EVERETT — Dana Robison, a labor and delivery nurse at Providence Regional Medical Center Everett, has seen patients in labor waiting on a bench in the hallway.
“I tell them, ‘If you think your baby’s coming out, yell real loud,’” she said.
According to nurses, it’s just one of many examples of a daily crisis at the Everett hospital.
Providence nurses in Everett are now preparing to strike if they can’t reach a deal over staffing by the next contract meeting Nov. 3.
Last week, most of the hospital’s nearly 1,400 nurses voted to authorize a strike. About 97% of votes were in favor. Nurses are demanding higher pay on shifts when the hospital doesn’t adhere to its staffing plans.
Nurses intend to give Providence two weeks notice before a strike, which would be the first for nurses since 1999.
“I think 100% of the nurses will walk out,” said Julie Bynum, a nurse at Providence for 18 years. “This is unprecedented.”
Providence and the nurses’ union have been in negotiations since April. The hospital is asking nurses to reconsider, citing its offer for 20% raises over three years to bring wages on par with Swedish Edmonds.
“This is unfortunate news given months of bargaining with the union and the latest competitive contract proposal, which honors our valued nurses,” Providence spokesperson Erika Hermanson said.
Nurses agree they need competitive pay, but said raises aren’t enough. They want a contract that encourages Providence to better staff the hospital.
“We are trying to recognize the additional care nurses must give,” said Evelyn Orantes-Fogel, a union worker helping the nurses with negotiations. “The units are understaffed due to vacant positions and, in our opinion, Providence has done little to fill these vacant positions.”
Providence Everett has hired more nurses this year compared to last year and retention rates are improving, said Michelle Lundstrom, the hospital’s chief nursing officer. The hospital would rather pay hiring bonuses than premiums to current nurses, she said Thursday.
Rethinking patient care
Providence Everett has lost over 600 nurses since 2019, forcing the hospital to shut down 100 beds. The hospital has hired some nurses back, Lundstrom said, but “in a perfect world” should have about 400 more.
Nurses are often stressed and rushing to complete tasks, orthopedic nurse Trevor Gjendem said. He said any mistake while dosing medication could be disastrous.
“You often leave your shift like, ‘What just happened? What did I just do?’” he said during a nurse town hall last month. “Leadership will say we made it through the night and no one died. Is that the standard?”
Nurses have called on Providence to regulate the number of patients assigned to each nurse, saying nurses should not have more than four patients at a time. Lundstrom said ratios are an outdated model.
Last year, state lawmakers rejected a bill that included nurse-to-patient ratios and enforced breaks. An amended bill that lawmakers passed this April requires nurse participation in staffing plans and issues penalties if hospitals fail to comply with those plans. It goes into full effect in 2027.
Darcy Jaffe, safety and quality director for the Washington State Hospital Association, said the days of putting most of the workload on registered nurses is coming to an end.
The workforce has changed, she said. More nurses work part-time, and hospitals need to hire more nurses to do the same work. The association doesn’t recommend mandated nurse-to-patient ratios because it’s too restrictive, she said.
A ‘new’ model
Lundstrom said the hospital is exploring ways to distribute work to other staff.
Providence is piloting a “Co-Caring” model based on its success at Covenant Medical Center in Lubbock, Texas. The Texas hospital reported a 73% decline in nurse turnover since the Texas switching to the model in 2021.
Under the model, nurses are paired with an aide each shift, and they divide tasks to care for six patients. Aides take on vitals, blood sugar checks, bathroom assistance and other tasks to help free more time for nurses.
Experts say the model is a rebrand of a team nursing model common until the 1980s. It can only work if aides are well-trained and supported, said Joanne Spetz, director of the Institute for Health Policy Studies at the University of California.
“There are a lot of ways in which it could go horribly awry,” Spetz said. “If you have a lot of turnover, nurses are constantly having to retrain people. Nurses also need to have clear guidelines on what tasks are appropriate to delegate.”
Providence Everett, one of eight pilot locations in the Pacific Northwest region, began the program in the spring.
Nurse Aaron Warnock said being paired with an aide helps with communication regarding patient needs. But the benefits depend on the day, he said.
“All aides are different,” he said. “It’s not in their practice to know what’s going on, and this is something they didn’t sign up for.”
Warnock said aides may not be well-trained to take on new tasks — and if something happens to his patient, his nurse’s license is on the line.
A key to the Texas hospital’s success has been virtual nursing, where nurses work remotely and check on patients using cameras in the hospital rooms. They take on time-consuming tasks, such as admissions, discharges, transfers and other non-hands-on work. The remote position also allows hospitals to hire outside their region.
The pilot at Providence Everett doesn’t include virtual nursing, at least for now. Lundstrom said leadership is focusing on the contract negotiations, then will look into buying equipment such as cameras and video screens.
A decision to invest in virtual nursing equipment would be “head-scratching,” Warnock said, since the hospital could invest that money toward a proven method of care: in-person nurses.
“It’s uncharted waters,” he said.
‘It’s a little rocky’
Warnock said caring for more than four patients has been unsafe, resulting in “many close calls.”
He remembers one patient who “looked terrible,” while their vitals were fine. Warnock’s intuition told him something was wrong, but he didn’t have time to investigate, he said.
“Every day, it’s an ethical dilemma of what gets our attention,” he said.
The patient had sepsis and died within 24 hours, Warnock said.
Evidence shows team nursing models can be harmful to both nurses and patients, said Karen Lasater, associate professor of nursing for the Center for Health Outcomes and Policy Research at the University of Pennsylvania.
“Despite hospitals pitching it as this new innovative model, it’s something that’s been tried and tested for decades and consistently fails,” she said.
Lasater studies hospital care models and their effects on patients and nurses. She said less care from registered nurses is associated with higher patient mortality, more hospital-acquired infections, longer stays and poor patient satisfaction. Nurses also report dissatisfaction because they’re removed from the patient and their work is more fragmented, she said.
It’s concerning that patients don’t know they are part of a pilot, Warnock said, and nurses don’t want the co-caring model to continue. Management has asked for feedback through anonymous surveys and monthly staff meetings, but nurses say they don’t feel listened to, Warnock said.
“We’ve consistently given negative reviews,” he said. “They are either dismissive or say they had no idea.”
Lundstrom said the pilot is going well. Feedback has been “really good” about more admission and discharge nurses helping to manage workloads. The hospital is also training more nurses to help the aides, she said.
Warnock also said it can be hard to provide in-the-moment feedback when management asks nurses how they’re doing on shift, especially if they’re new to the job.
“You don’t have time to elaborate and say, ‘This sucks, we’re killing people over here,’” he said.
Lundstrom said there was resistance to the model at the Texas hospital, too, but she had not heard from Everett nurses saying the model is unsafe.
“It’s a little rocky right now,” she said. “We are going to get to the other side.”
Proven care methods
Angela Korneev, who has worked at Providence for just over two months, said leadership tells new nurses to expect at least six patients. But that’s not what she was taught in school.
“I was taught the second you have more than five, it takes away from other people’s care,” she said.
Korneev said at her previous job in Colorado, each nurse had an aide and rarely had more than five patients. They tried a model similar to what Providence is piloting, she said, but it didn’t work.
In addition, patients in Everett are much sicker and there’s more to manage, she said.
“I feel like I run the entire 12 hours,” she said. “I’ve never worked another job where I felt so much pressure.”
Providence and other hospitals have, in part, blamed a national nurse shortage for staffing woes. Experts say otherwise.
“The idea that there is a nursing shortage is factually untrue,” Lasater said. “We’ve never had more nurses in this country.”
In 2022, about half of Washington’s 101,239 registered nurses with active licenses were employed in the state, according to data from the Washington Center for Nursing. In Snohomish County, 8,533 registered nurses, 616 advanced registered nurse practitioners and 815 license practical nurses were licensed for work in 2021, according to a report from the center.
Younger nurses can fill the gap created by early retirements during the pandemic, Lasater said, but only if they’re not burned out first.
“What is true is that there’s not enough nurses who want to work under the conditions that hospitals are providing for them,” she said.
This year, a union survey of health care workers in Washington showed nearly half of workers plan to leave the profession in the next few years if conditions don’t improve.
California law has mandated nurse-to-patient ratios across the state for over 20 years. Research has shown California’s ratios correlate with nurse satisfaction, Spetz said.
Lasater said team nursing models are largely a cost-saving measure to substitute registered nurses with lower-wage nurses, and resistance to nurse-to-patient ratios is financially motivated.
“It would be costly for them upfront,” Lasater said. “On the budget sheet, it looks like nursing is an expense to the hospital that doesn’t bring in revenue. The reality is, no one would come to a hospital if they didn’t need nursing care.”
Research shows staffing ratios are ultimately cost-saving to the hospital, Lasater said, as patients are less likely to have long stays, be readmitted or die. One study in Australia published in 2021 showed staffing ratios improved conditions so much the upfront investment paid for itself.
In the short term, Lasater said, hospitals need to build trust with their nurses and focus on evidence-based solutions. The majority of nurses don’t believe patient safety is a priority for leadership, she said, and nurses don’t trust their leadership to respond when nurses say there’s a patient safety problem.
“When you’re in a hospital, that’s your money your spending and the risk you’re taking,” nurse Kelli Johnson said during the town hall. “It’s your fight more than us, because we can leave.”
Providence leadership is prepared for nurses to strike, Hermanson said.
“We will bring in highly qualified nurses to care for our patients,” she said, “and serve the needs of our community.”