Oregon might cap how many patients can be assigned to a single hospital nurse or nursing assistant

A bill that would require hospitals in Oregon to follow minimum staffing standards for nurses and certified nursing assistants now has strong odds of passing.

After weeks of negotiations with the state’s nurses union, the Oregon Association of Hospitals and Health Systems announced they will drop their opposition and support a compromise version of the bill.

It’s a major reversal for a group that had initially warned that ratios — the nurses union’s top priority — could force hospitals to cut back their services.

In turn, the nurses union is throwing its political weight behind several of the hospital group’s bills, including one that would exempt hospitals and health systems from state regulations meant to limit the growth of health care costs to about 3% a year.

If HB 2697 passes, it would overhaul Oregon’s nurse staffing law and make the state one of the first in the nation to cap how many patients can be assigned to a single nurse. In another first, it also caps the number of patients assigned to certified nursing assistants, lower paid workers who help move patients and provide hands-on personal care.

The Oregon Nurses Association won the support of hospital leaders by agreeing to amendments which haven’t been posted publicly yet.

According to the union, the biggest compromises came in emergency care and psychiatric care. Hospital leaders argued they would be unable to meet the staffing ratios for these types of care that the union had proposed in its original bill.

In the original bill, nurses working in a psychiatric unit could be assigned a maximum of five patients. The compromise version doesn’t include a minimum ratio for psychiatric care.

Emergency department nurses have been some of the loudest voices pushing for staffing ratios, arguing they are being forced to care for more patients at a time than is safe. The Oregon Nurses Association had originally proposed a minimum of one nurse for every three patients in the emergency department.

The compromise version of the bill will allow hospitals to assign up to four patients to emergency department nurses, on average, during a shift, with a hard maximum of five patients per nurse. Emergency department nurses working with trauma patients — people who have been in a severe car crash or are suffering a bullet wound, for example — could be assigned no more than one patient at a time.

Those proposed standards could be weaker than what is in place currently at some individual hospitals, where staffing committees have set three patients as the maximum.

Matt Calzia, director of nursing practice for the statewide union, said hospitals and legislators raised valid concerns about how they would comply with emergency department staffing ratios when mass casualty events occur. More broadly, emergency departments are required by law to stabilize any patient who comes in their doors.

“We did have to build in some flexibility for the hospitals,” Calzia said. “That said, we’re also deeply concerned that’s where we’re seeing some of the highest rates of turnover.”

For nurses working in most parts of the hospital, including the general medical-surgical inpatient units that employ the greatest numbers of people, the staffing ratio would be 1-to-5 when the new law first goes into effect in June 2024. In June 2026, it will drop to 1-to-4.

Calzia said hospitals wanted more time to meet that standard, given the current very tight labor market, and ONA agreed.

Certified nursing assistants will be required to care for, at most, seven patients during a day shift and 11 on a night shift.

Rural hospitals, which have the hardest time recruiting staff, will be able to request a waiver from the Oregon Health Authority, which would allow them to exceed the maximum ratios if they can get agreement from their internal staffing committee.

The compromise includes a schedule for phased implementation of the biggest changes. If the bill passes, rulemaking would begin Sep. 1, 2023. The ratios would go into effect June 1, 2024. New staffing committees would start in December 2024, and state enforcement of the law, which will be complaint-driven, would take effect in June 2025.

The two groups have agreed to work together on initiatives targeting some of the biggest operational problems for hospitals. Those include $56 million in funding requests for clinical training for nursing students and nurse educator pay, and a task force to study how to deal with patients who stay in hospitals longer than necessary due to trouble finding a place to discharge them.

The chart below shows the ratio of patients to nurses by department as included in the amended bill.