The Washington Legislature declared in 2017 that ensuring there are enough nurses in hospitals was “an urgent public policy priority” to protect patients and assure safe working conditions. The Legislature, for the first time, required hospitals to submit annual nurse staffing plans to the state Department of Health.

The next year, when Swedish Health Services submitted its hospitals’ plans for the first time, the health care provider noted it had just made some cuts.

“There were specific staff reductions” in nursing units, including in labor and delivery, neonatal intensive care and the IV nursing team, Swedish CEO Guy Hudson and Chief Nursing Officer Margo Bykonen wrote in December 2018. “These changes were based on operational business decisions for the organization.”

A year later, staffing levels are one of the key grievances cited by 7,800 Swedish nurses and health care workers whose three-day strike has forced the hospital system to fly in replacement workers, postpone elective surgeries and close its emergency departments in Ballard and Redmond and its labor and delivery rooms in Ballard. The strike is scheduled to end at 7:30 a.m. Friday, even though the two sides have not come to an agreement, with Seattle Mayor Jenny Durkan and King County Executive Dow Constantine expected to be on hand to show support for the employees.

Along with the cuts, Swedish has hundreds of nursing positions open, creating a vacancy rate higher than other major hospitals in the Seattle area.

Back in 2018, individual nursing units at various Swedish campuses made 35 specific staffing requests, according to the state filing, mostly asking for more nurses on specific shifts. Management denied at least 19 of those requests.

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For instance, the emergency department at Swedish Cherry Hill asked for the equivalent of 2.2 more full-time nurses to staff overnight shifts. Management responded: “Patient volume in the Emergency Department does not warrant an additional 2.2 FTE. Reallocation of resources can be considered to provide additional support where warranted but will be based on supporting data.”

Of course, staffing plans are no guarantee of actual staffing.

Swedish has 900 open positions, including almost 600 nurses, at its seven campuses, one of the figures frequently cited by the striking union, Service Employees International Union (SEIU) Healthcare 1199NW.

That’s a vacancy rate for nurses of about 6.3%, Swedish said.

Both the University of Washington Medical Center and Harborview Medical Center on Thursday said they had a vacancy rate among nurses of about 5%. Seattle Children’s hospital says its nursing vacancy rate is under 4.5%.

Tiffany Moss, a Swedish spokeswoman, attributed their vacancy rate to “just fewer people going to school for nursing and graduating with degrees.”

Swedish said their last contract proposal included about 200 new full-time positions.

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Robin Wyss, secretary-treasurer of 1199NW, said that although they have wage disputes with Swedish, nurses are leaving (the union says about 1,000 health care workers quit or retire from Swedish each year) for other reasons.

“When people are leaving, it’s not really because of money. It’s because if you have eight patients when you’re supposed to have four, because you’re covering for someone else, and somebody falls or someone gets hurt. That’s traumatizing,” Wyss said. The union stressed that its staffing concerns were for all health care workers it represents at the hospital, not just nurses.

Alina Vyas, a telemetry nurse at Swedish First Hill, said in her unit the standard nurse-to-patient ratio is 1:4. Until about a year ago, patients who just had a major incident — such as a stroke — or a major procedure got more attention, with a 1:3 nurse-to-patient ratio. But that’s been cut, Vyas said.

“It has an impact on so many different levels; the stress level is incredible,” Vyas said. Patients end up missing scheduled showers, or their walks down the hall become fewer, she said. “Because you have to do more with a little bit less, something has to give.”

She also said the patient population has changed considerably in her 20 years at the hospital. Swedish First Hill serves a lot more homeless patients than before — which has added to challenges.

“When people say there’s a nursing shortage, there’s a reason,” she said. “It’s not nurses not going into nursing, it’s nurses getting burnt out, leaving nursing.”

The number of new nurses passing the national licensure exam has risen steadily every year since 2012.

Lizette Vanunu, a charge nurse in the intensive-care unit at Swedish First Hill, said her unit’s staff was cut by one nurse and one nursing assistant in 2018. The nurse-to-patient ratio is supposed to be 1:2 in the ICU, Vanunu said, but a lot of the time they don’t make it.

“It’s not safe for one nurse to cover four sick patients in the ICU,” she said. “When we’re short, what happens is I beg for nurses to stay another four hours. A lot of times we don’t take breaks.”

There is a string of literature linking higher nursing-staff levels with better outcomes at hospitals.

A 2016 study in the Journal of the American Medical Association found hospitals with above-average nursing staff levels had lower death rates and similar costs, when compared to hospitals with lower staffing levels.

Only one state in the country, California, mandates specific nursing-staff levels in hospitals. A 2010 study found the California law resulted in hospital nurses there caring for one fewer patient, on average, than nurses in other states.

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“When nurses’ workloads were in line with California-mandated ratios,” the study found, “nurses’ burnout and job dissatisfaction were lower and nurses reported consistently better quality of care.”

Matthew McHugh, a professor of nursing at the University of Pennsylvania who’s studied nursing staffing levels, said nurses are the “surveillance system” of a hospital, spending time with and watching patients, gathering information and assessing whether care is proceeding as it should.

And while he said there are always labor shortages around nursing, he disputed that it’s particularly acute at the moment.

“We are producing more and graduating more RNs than ever in the history of the country,” McHugh said. “My guess is if you look in your own market of Seattle, some hospitals are staffed far better than others.”

Correction: A previous version of this story included a higher nursing vacancy rate for Swedish, that was an in-apt comparison with other area hospitals. The previous figure, provided by Swedish, covered the medical system’s seven campuses and 115 clinics, and counted nursing positions filled by temporary or traveling nurses as vacant. The updated figure covers just the seven campuses and counts positions filled by temporary or traveling nurses as filled.