Oregon lawmakers in 2023 passed a groundbreaking hospital staffing law aimed at curbing nurse burnout, slowing turnover and ensuring safer patient care.

Hailed as a major victory by both nurses and hospitals, the law was expected to stabilize the state’s health care system, strained by years of understaffing and high patient loads.

But more than a year after the law began to take effect, nearly 5,000 Providence hospital nurses are still on a strike, largely over the very issues the law was supposed to fix. Some even argue workloads have gotten worse since the law took effect.

Hospitals, meanwhile, say they’ve been dinged for violations of the law when they say they’re following it to the letter.

The dispute, now central to the largest health care strike in Oregon’s history, highlights how the compromise law has been plagued by disagreements in implementation, and why lawmakers might need to go back to the drawing board — at least, after tensions ease.

Staffing issues

House Bill 2697, enacted in 2023, made Oregon the second state to require hospitals meet minimum nurse-to-patient ratios, and the first to set those ratios in statute.

The law’s sponsors aimed to improve patient safety, alleviate workloads and address longstanding staffing challenges that were leading to employee burnout and early retirements.

“During the pandemic, hospitals were struggling to find enough nurses to work,” said Rep. Travis Nelson, D-Portland, a registered nurse and one of the law’s chief sponsors. “What we knew was that working conditions and wages were a big part of the reason why nurses were leaving the bedside.”

The law set specific nurse-to-patient staffing ratios across hospital units. For example, nurses working in the intensive care unit cannot be assigned more than two patients at a time. The law also introduced minimum staffing levels for certified nursing assistants — a first in the nation for support staff.

But HB 2697 also beefed up an existing staffing law that required hospitals to develop staffing plans through committees made up equally of nurses and management. The new law kept the committees but introduced a key change: If a staffing committee couldn’t reach an agreement after 60 days of mediation, the hospital would be required to stick to the nurse-to-patient ratios laid out in the new statute.

The law also created a process for nurses to file complaints if hospitals fail to meet staffing standards and charged the Oregon Health Authority with enforcement. Fines for violations of the law won’t begin until June under the phased implementation established by the Legislature.

The Hospital Association of Oregon, which represents the state’s hospitals, initially opposed establishing minimum staffing ratios, saying it could worsen the state’s hospital capacity crisis by requiring beds be left empty.

After months of negotiations, hospitals and the nurses’ union reached a compromise, agreeing to higher nurse-to-patient ratios in some areas than the union had originally proposed.

Nurses unions cast the law as a hard-fought victory, and hospitals as a reluctantly accepted compromise.

Clash over implementation

Oregon’s hospitals and nurses, though, have been deeply divided over how to interpret standards in the law.

Kyle Cook, a surgical oncology nurse at Providence Portland Medical Center and a member of the union bargaining team, said the hospital had staffing plans in place before the law took effect. After the law took effect, he said, Providence threw out the old agreements and began discussing new ones. In the meantime, Cook said, the hospital reverted to the lower staffing ratios prescribed in the new law.

“It’s just been reductionary instead of the spirit and letter of the law, which says staffing plans should remain the same or better,” Cook said.

Providence, however, said it has added 570 union nursing positions since the law was enacted. Changes to written staffing plans, the health system said in a statement, were made to comply with the new legal requirements.

“In practice, most of our units are staffed at levels that exceed the nurse-to-patient ratio” laid out in the new law, Providence said in its statement.

The health system added that most staffing plans across its eight Oregon hospitals, have been approved by nurse staffing committees with majority votes.

The Hospital Association of Oregon, an industry group that counts Providence among its members, says the state’s hospitals are following the law as written. They say the law isn’t working in part because the Oregon Health Authority is overreaching in its enforcement.

“The law, as it is being implemented by OHA, is inconsistent with what hospitals agreed to,” Sean Kolmer, the hospital group’s executive vice president of external affairs, wrote in an email. “The agency isn’t using nurse-to-patient ratios as the dispute resolution in units where these ratios apply — an approach that was essential to hospitals’ support and to the effectiveness of this law.”

The Oregon Health Authority this month found Providence in violation of the law because it failed to establish staffing plans for units at two of its hospitals, Providence Portland Medical Center and Providence Seaside Hospital, by the time that part of the law took effect in June 2024.

Providence says it’s complied with the laws. The health system said the complaints arose just days after the deadline to implement staffing plans. Providence said it has since submitted a staffing plan for its Seaside hospital and that it’s using the staffing levels laid out in HB 2697 at its Portland hospital while its staffing committee remains at an impasse.

Nelson, the bill cosponsor who previously served as vice president of the Oregon Nurses Association, said hospitals are “trying to change the narrative” of the law to justify reduced staffing. He said the law sets a limit on the number of patients assigned per nurse.

“When we passed the law, we were pretty clear in stating that those ratios were intended to be minimums, not the standard,” Nelson said. “But that’s not the way some hospitals have taken it.”

Kolmer said hospitals supported the staffing law on the condition that the nurse-to-patient ratios would serve as a fallback when a staffing committee couldn’t reach a consensus for a unit where statutory ratios apply. His group wants the Legislature to revise the law to make that clear.

Legislature may revisit

Rep. Rob Nosse, D-Portland, another chief sponsor of HB 2697 — and a former bargaining official for the Oregon Nurses Association before he was elected to the Legislature — acknowledged that the law leaves room for differing interpretations. He suggested the Legislature might need to revisit the law to provide greater clarity — though no notable amendments are yet before the Legislature in the lawmaking session that began this month.

“No law is ever perfect,” Nosse said. “We could introduce legislation to make it clearer, but changing a law in the middle of a major conflict is tricky.”

Kolmer, from the Hospital Association, said the organization “is in active conversation with our members, other advocacy organizations and legislators about necessary fixes needed to the hospital staffing law.”

Nelson, meanwhile, said he thinks the law “is working as intended by and large” but agrees there is room for improvement. He agrees that revisiting the law during the strike might not be a good time given “feelings of mistrust from both sides.”

“At the end of the day, the hospital is the employer and they could make moves to work with their health care workers and agree to meaningful collaboration,” Nelson said. “I think that would go a long way towards resolving a lot of the disputes.”

Two other sponsors of the bill, Sen. James Manning, D-Eugene, and Sen. Deb Patterson, D-Salem, did not immediately return messages.

For now, Providence and its nursing staff are battling over staffing ratios not in the committees laid out in state law, but at the bargaining table. Both hope to write their favored interpretation of the state staffing law into their next labor contract.