EVERETT — Nurse Katy Roth is supposed to have three to four patients. But she always has five or more, sometimes up to eight on day shift, when patient needs are higher.
In 22 years of nursing, she told The Daily Herald, “I’ve never experienced the patient loads that I experience now, this last year.”
On Thursday, she told state senators it can lead to tragic results.
“Last week I had a patient who died on my shift, and he should not have,” she said.
Roth testified in favor of Senate Bill 5236, which would reinforce hospital staffing committees, as well as meal and rest breaks. It also would direct the Department of Labor and Industries to create minimum hospital nurse staffing levels by 2027.
Frontline workers and their administrators are largely divided on minimum staffing levels — often called ratios — as an effective approach to solving the staffing crisis. On Thursday, 13 frontline nurses testified in support, including several from Providence Regional Medical Center Everett. The bill had 5,700 signatures in support, with 1,000 opposed.
Michelle Lundstrom, chief nursing officer at Providence in Everett, said Friday she worries about the lack of available nurses and the loss of flexibility.
“In Snohomish County, we are severely under-bedded for both acute care and post-acute care,” Lundstrom said. “And if we were to implement this bill tomorrow, with the workforce that we have today, we would have to close even more beds. What that does for our patients — it reduces access to care.”
Providence Everett is the largest hospital in Snohomish County, accounting for nearly 75% of non-psychiatric discharges in 2021, according to state Department of Health data. For the Snohomish County residents who needed hospital care in 2021, just under half received care at Providence.
Roth chose to be a nurse after being inspired by the way nurses took care of her grandmother at the end of life. She has worked at Providence hospitals in Washington state for 18 years, most recently nine years in the float pool in Everett. She loves the variety of work as she covers shifts across many units.
But this last year has pushed her to consider leaving. Many others already have. Roth said since the pandemic, nurses have left due to compassion fatigue, ethical and emotional burnout, and overall mental health strain.
“We have a staffing matrix or staffing plan that had been submitted to the Department of Health. We’re not following it ever anymore, no matter what unit I go to,” Roth said.
Lundstrom doesn’t dispute the short-staffing that multiple nurses have described recently to The Herald. She said even with four years to add to the workforce and meet minimum ratios, hospitals need more solutions to address the workforce shortage, such as more nursing faculty, an easier path for out-of-state nurses to get licensed, student loan repayment and tuition assistance. State lawmakers are considering some bills this session that could help.
‘These challenging staffing conditions’
Statewide, about half of surveyed health care workers said they are likely to leave health care in the next few years. Of those under age 50, about 44% said they’d likely leave. Three unions representing the sampled workers commissioned the survey of 1,200 workers, 60% of them nurses.
Short-staffing is the major driver of this possible exodus — with 68% of all the respondents saying it is a primary reason. Even more — 80% — of those under 50 say short-staffing is a primary reason they might leave, according to an analysis provided by the WA Safe + Healthy campaign.
Nearly 80% of health care workers feel burned out, while 45% say they feel unsafe.
Everyone could be affected by short staffing, Roth said, if they or their loved ones cannot receive attention they need. To protect privacy, health care professionals must use caution sharing specific patient stories.
Roth shared a hypothetical scenario from an acute cardiac unit:
“I’m supposed to have three patients and maybe I have five patients,” she said. “And one of my patients belongs in the ICU, but there’s no beds and she’s in respiratory distress and needs frequent monitoring, advocacy, oxygen titration. She’s on high-flow oxygen — in respiratory distress. I also then have four other patients with cardiac issues and I can’t get out of the room, for example, because she needs that much attention.”
Roth is also on the hospital’s safety committee, which means reviewing the patient safety plan and any safety issues. She chose her words carefully about “sentinel” events — a type of “adverse” or avoidable event that results in death or serious physical or psychological harm.
“I am aware of sentinel events that have happened under these challenging staffing conditions,” she said. “Several of them that I’m aware of, and have witnessed even.”
Lundstrom, from Providence, said the hospital investigates every incident “that didn’t go the way that we wanted.” Without knowing specifics of cases mentioned by nurses at the hospital, she said, “I can tell you that we’ve not had any findings of anything that was related to staffing.”
‘I’m really hopeful’
The Washington State Hospital Association and hospital leaders have testified against Senate Bill 5236 at two hearings in 2023, as well as a similar bill in 2022. Hospital leaders who oppose the bill question if mandated minimum staffing levels will bring nurses back to the field and improve patient safety.
Are enough out there?
Or will hospitals remain short-staffed, resulting in turning away patients?
Four years away from a possible staffing standard, the Washington State Hospital Association has analyzed data to suggest that just under 3,000 licensed nurses are interested and ready to work. The Washington State Nurses Association analyzed different data from the state, with different assumptions, concluding that up to 16,000 licensed nurses could be available to work.
None of those numbers account for projected new nursing grads and retirements, which could be significant, according to the Washington Center for Nursing.
To meet the demand for nurses in hospitals, the state would need a total of 6,100 nurses, according to a 2021 survey. Nurses say that poor staffing leads to a reinforcing cycle of people quitting, higher patient loads and more people quitting. So, they argue, better staffing should work in the opposite direction.
But Lundstrom asked: “The challenge and the concern that we have from health care professionals is if we implement these strict ratios, what happens when they don’t come back?”
Hospital leaders at Providence also oppose the bill because it would stifle the flexibility to continue developing an innovative, team-based approach to nursing, as the hospital system is experimenting with elsewhere. In this model, the certified nursing assistants, licensed practical nurses and registered nurses work together, taking on the most responsibility they are capable of and licensed to do, while caring for each unique patient. Lundstrom said both patients and staff report positively on the team model.
“I’m really hopeful that through partnership and collaboration with our frontline caregivers, our hospital teams will get back to a place where we feel that again,” she said, meaning feeling like a team that loved coming to work. In Everett, the hospital is training nursing assistants on the job, as they have also been in short supply.
Lundstrom also worked in California hospital emergency departments, with staffing ratios, and saw ambulances backed up and hospitals “on divert,” unable to meet the ratios to staff all the beds. While research has supported improved patient outcomes with nursing ratios, she cites comparative research suggesting California does not currently have better outcomes than Washington.
The Senate bill directs the Washington State Institute for Public Policy, a nonpartisan public research group, to study minimum staffing standards in other jurisdictions.
‘The care my patients deserve’
Sara Gering quit her job at Providence Everett, but she didn’t quit nursing. She could no longer manage what she said was an unsafe patient load in the ICU and other units where management sent her.
She said each nurse is supposed to have a maximum of two patients in the ICU, but routinely had three in the past six months or so. In other units, she had five to seven patients. On Thursday, she told state senators she had watched “patients suffer needlessly and even die avoidable deaths due to the unsafe staffing conditions, which hospitals refuse to address and seek to normalize.”
Gering heard from nurse friends about better staffing in another ICU, so she just started work there in early February.
“When safe staffing ratios are maintained, I know I can come to work and give the care that my patients deserve. I’m able to spend time with them, getting to know them as individuals,” Gering said. “That is the nursing care that every person deserves, and nurses want to be able to give.”
Kelli Johnson has worked as a nurse for 10 years, the past three in the emergency department at Providence Everett. She has been talking to public officials for her patients and herself wherever possible this past year: the state, Snohomish County and the city of Everett.
“If we can’t get legislators to heed the concerns that nurses are trying to share with them about what’s happening at the bedside,” Johnson said, “it doesn’t bode well for the future of health care.”
She feels excited about the minimum staffing levels in Senate Bill 5236, and that it would continue hospital staffing committees, remove a hospital CEO’s ability to reject the staffing plan, and provide some teeth. As things stand, she said her staffing committee recommended changes for the emergency department. But hospital administrators did not adopt it, leaving nurses with the prior year’s plan and a pile of frustration.
Johnson had spent at least four hours of her day off this week, and countless hours over the past few years, advocating and organizing for safe staffing standards. She said of the bill: “If we get it passed, it will all be worth it.”
Sen. June Robinson, D-Everett, sponsored Senate Bill 5236. She told The Herald: “We have to come out of here with legislation that protects the work environment for nurses. How far we are going to get is still a question.”