When the bank he worked at for two decades moved its headquarters to Minnesota, Richard Botterill decided it was time for a new career. At 52, he enrolled in nursing school.
Fifteen years later, he’s an emergency room nurse and chair of the Oregon Nurses Association’s bargaining unit at Providence Portland Medical Center. Work for Botterill looks like this: stabilizing one patient who’d been maced and can’t see, determining if another had a stroke and stabilizing that patient, then on to a third in tachycardia (an abnormally fast heartbeat), all in the span of a few minutes.
“It’s gotten to the point where every day is an intense day,” Botterill says. “Every day, you’ve got people running from one end of the hospital to the other.”
How many people are on staff at any given time makes a big difference in patient care, which is why Botterill and his fellow union officers at the Oregon Nurses Association find themselves battling Providence Portland. They say Providence is routinely violating laws that mandate a given nurse-to-patient ratio, even though that now means accruing fines of up to $5,000 per day.
“They are fighting tooth and nail to prevent what I think is an appropriate level of staffing, in each of the different units we serve around the hospital,” Botterill told the Northwest Labor Press. “On a recent day we had 27 patients and one certified nursing assistant (CNA), for the entire floor. The law calls for a maximum of seven (patients per CNA). That’s poor patient care.”
Patient care is the calling for nurses like Botterill. It’s why they stay in jobs where the stress is high and the hours are long. Health care unions have spent years fighting for laws to mandate that hospitals don’t overwhelm staff with excessive patient loads, and have won passage of one bill after another.
Some version of a health care staffing law has been in place since 2001, Oregon Nurses Association Director of Professional Practice Christy Simila told the Northwest Labor Press. The 2001 law mandated a random audit of at least 7% of the state’s hospitals to check that they had a written staffing plan for nursing services.
In 2015, a new staffing law, Oregon Senate Bill 469, created committees made up of equal numbers of direct-care nurses and managers. The committees worked well, Simila said, but there was no real enforcement mechanism. The Oregon Health Authority (OHA) found violations year after year at multiple facilities but didn’t take enforcement action, even though the law said OHA “may” assess civil penalties for noncompliance.
So in 2023, lawmakers passed House Bill 2697, changing “may” to “shall” when it came to OHA issuing civil penalties to enforce the staffing ratio requirements.
Hospital executives called the bill an unfair burden, especially on rural facilities, and insisted that $5,000-per-day fines were excessive. But in a compromise with the unions, they got some flexibility to adjust staffing ratios if workers and management agreed, and the bill passed. The compromise also changed the mechanism for enforcement from audit- to complaint-based, lowered some penalties, and added a warning before fines could be levied.
The bill made Oregon the first state in the nation to establish statutory nurse-to-patient ratios and the first to set ratios for certified nursing assistants. Hospitals were given two years to comply with the law before fines could be applied, which meant no real enforcement until June 1, 2025.
When the deadline passed, ONA encouraged its members to file complaints whenever they saw a violation. That’s exactly what happened. Since June, more than 2,200 complaints have poured in. Most of them have been against OHSU, Providence Portland Medical Center, Asante Rogue Regional Medical Center, and Sacred Heart Medical Center Riverbend. Simila said that pattern indicates that most Oregon hospitals are complying with the law — and that a few clearly aren’t.
“A lot of hospitals are doing a good job coming into compliance,” Simila said. “Nurses are getting breaks without having to use the buddy system, where they double up patient assignments so one nurse could take a break. That unsafe practice is no longer happening for the most part. But some hospitals are trying to find loopholes to undermine the law.”
Some hospitals are undermining the staffing committee process, Simila said, misrepresenting the required ratios as prescriptive, rather than as a maximum patient assignment. Just as not every nurse comes with the same experience or skill and not every patient has the same needs, it needs to be the staffing committees that figure out the best ratios. Some hospitals are trying to avoid CNA ratios by assigning nurses to “tasks” instead of patients, or leaving some patients without a CNA at all. And in some cases, hospitals have been misrepresenting the law to nurses, for example suggesting they have a two-hour grace period during which they’re allowed to operate outside a staffing plan without that being a violation.
The point of staffing laws is to ensure that patients are cared for effectively — and to keep nurses from burning out and quitting, which they did en masse throughout the COVID-19 pandemic. Applications to nursing schools remain anemic today, Botterill says.
Botterill works in the emergency room at Providence, which is often well staffed. When it isn’t adequately staffed, the results aren’t good for patients no matter how the staff decide to manage the shortage. Sometimes staff close down entire assignments of the ER, which curtails the number of available beds and lengthens the time patients spend in the waiting room before they can be seen and treated.
“The worst wait I’ve seen is eight hours, but it’s not unusual for wait times to be in the four-hour range,” Botterill says. “Patients will leave, either home or to another hospital, or by the time they do get back to a room they’re very grumpy. When we get really busy and have a full waiting room we’ll go to ‘ambulance divert,’ notifying the ambulance company that right now we’re not taking ambulances and they have to go find another hospital to take their patients. All this translates into poorer care.”
“Staffing has a huge impact on the quality of care patients receive,” Simila said. “There’s tons of research showing for each additional patient a nurse cares for, there’s more potential for more adverse outcomes. It also really ties into the well-being of the nurse. If they’re having to take care of more patients than they feel is safe, it can add to moral distress, burnout. Thirty percent of nurses leave their job within the first year.”
The Oregon Health Authority has issued few penalties for violations of the law since June, as it investigates those complaints that have come in. Simila said about 200 of the complaints filed since June have been looked into so far. The first substantiated violation gets a warning, followed by a $1,750 fine for a second violation, then $2,500. Each subsequent penalty is $5,000 in a four-year period. Then it resets.
“It’s very frustrating,” Botterill says of some hospitals’ reluctance to properly staff their facilities. “I got into this because I wanted to do something that made a difference. Most of the nurses I work with are there because it’s a calling. I love what I do and the people I do it with.”
