SB 5344 — Concerning nursing fatigue.

S-1760.3SUBSTITUTES-0412.2SENATE SENATE BILL 5344State of Washington66th Legislature2019 Regular SessionBySenateSessionBySenators Health & Long Term Care (originally sponsored by Senators Cleveland, O'Ban, Hobbs, Takko, Mullet, Palumbo, Rivers, Wellman, and Hunt)READHuntRead FIRSTfirst TIMEtime 02/21/19.AN01/17/19.Referred ACT Relating to staffingCommittee committeeson andHealth limiting& theLong totalTerm numberCare.AN ofACT hoursRelating nurses can work across all health care settings to sixtynursing hoursfatigue; in a week;

amending RCW 70.41.420, 70.41.425, 18.79.200, 18.79.210, and 18.79.210;49.28.140;

creating a new section;

and providing an expiration date.BEdates.BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF WASHINGTON:NEWWASHINGTON:Sec. SECTION.  Sec.

INTENT.(1) The legislature finds monitoring and assessing whether nurses are able to receive their meal and rest breaks as specified by law and where applicable, a collective bargaining agreement, and monitoring the use of prescheduled on-call and call-back rates for nurses is an important component of mitigating nurse fatigue and operating a hospital effectively.

However, the legislature also finds that mandating rigid constraints on how hospitals provide breaks, or how they use prescheduled on-call and overtime does not allow the flexibility needed to work collaboratively to find solutions that work for complex care environments.

Further, they may jeopardize quality care and patient safety, by interrupting care transitions, creating barriers to communication, and preventing safe staffing for critically important procedures.(2) Hospital nurse staffing committees have been in place since 2008, and were granted additional authority in 2017 to increase monitoring and accountability and address nurse staffing issues collaboratively and at the local level.

Collaboration between direct care nurses, other staff, and management is a hallmark of the culture of safety found in organizations that successfully lower the incidence of adverse events while carrying out complex and hazardous work.(3) Therefore, the legislature intends to address the concern of nurse fatigue by building on the work of existing nurse staffing committees which all hospitals must have in place pursuant to law.

This approach will address staffing concerns at the individual hospital level in order to ensure local patient care needs can be considered and quality and safety of care maintained.

These nurse staffing committees shall have new obligations to collect, maintain, and review data on missed meal and rest breaks and the use of prescheduled on-call.

The nurse staffing committees will also have a new requirement to establish a complaint process for missed rest breaks.

If complaints are not addressed at the local level, the state department of health is granted the power to investigate the operations of the hospital's nurse staffing committee.(4) The legislature further intends to address nurse fatigue by addressing the total number of hours a nurse works, especially for nurses with multiple employers or who work in multiple care settings.

A maximum hours of weekly work for registered nurses is established to ensure nurses can provide safe and effective care to patients.Sec.

2.

((and))(ix)and(ix) Regular review of aggregate data on missed meal and rest breaks and development of strategies to enable registered nurses to take meal and rest breaks as required by law or the terms of an applicable collective bargaining agreement, if any, between the hospital and a representative of the nursing staff.staff;(b) Semiannual review of the staffing plan against patient need and known evidence-based staffing information, including the nursing sensitive quality indicators collected by the hospital;(c) Review, assessment, and response to staffing variations ((or)), concerns, or complaints presented to the committee on a quarterly basis if variations, concerns, or complaints are presented.(4) In addition to the factors listed in subsection (3)(a) of this section, hospital finances and resources must be taken into account in the development of the nurse staffing plan.(5) The staffing plan must not diminish other standards contained in state or federal law and rules, or the terms of an applicable collective bargaining agreement, if any, between the hospital and a representative of the nursing staff.(6) The committee will produce the hospital's annual nurse staffing plan.

To facilitate this requirement, the hospital must record when an employee misses a meal or rest break;

and(x) Regular review of call-back rate for nurses activated and called in to work during prescheduled on-call shifts and develop an understanding of trends contributing to call-back rates;(b) Semiannual review of the staffing plan against patient need and known evidence-based staffing information, including the nursing sensitive quality indicators collected by the hospital;(c) Review, assessment, and response to staffing variations ((or)), concerns ((presented to the committee)), or complaints.(4) In addition to the factors listed in subsection (3)(a) of this section, hospital finances and resources must be taken into account in the development of the nurse staffing plan.(5) The staffing plan must not diminish other standards contained in state or federal law and rules, or the terms of an applicable collective bargaining agreement, if any, between the hospital and a representative of the nursing staff.(6) The committee will produce the hospital's annual nurse staffing plan.

3.2.

((or))(iv)(((A))) Follow the nursing personnel assignments in a patient care unit in violation of RCW 70.41.420(7)(a) or shift-to-shift adjustments in staffing levels in violation of RCW 70.41.420(7)(b);(v)70.41.420(7)(b); Collect and review aggregate data on missed meal and rest breaks;

or(vi)or(v) AppropriatelyProvide respondmeal toand complaintsrest submittedbreaks toas therequired nurseby staffinglaw committeeor regardingthe patternsterms of missedan mealapplicable collective bargaining agreement, if any, between the hospital and resta breaks.(((B)))(b)(i)representative of the nursing staff.(((B)))(b)(i) The department may only investigate a complaint under ((this subsection (1)))(a)(iv),(1)))(a)(iv) (v), or (vi)(v) of this subsection after making an assessment that the submitted evidence indicates a continuing pattern of unresolved violations of RCW 70.41.420(7)(a)70.41.420(7) (a) ((or)), (b), or (c) that were submitted to the nurse staffing committee excluding complaints determined by the nurse staffing committee to be resolved or dismissed.

The submitted evidence must include the aggregate data contained in the complaints submitted to the hospital's nurse staffing committee that indicate a continuing pattern of unresolved violations for a minimum sixty-day continuous period leading up to receipt of the complaint by the department.(((C)))(ii) The department may not investigate a complaint under ((this subsection (1)))(a)(iv),(1)))(a)(iv) (v), or (vi)(v) of this subsection in the event of unforeseeable emergency circumstances or if the hospital, after consultation with the nurse staffing committee, documents it has made reasonable efforts to obtain staffing to meet required assignments but has been unable to do so.(((b)))(c) After an investigation conducted under (a) of this subsection, if the department determines that there has been a violation, the department shall require the hospital to submit a corrective plan of action within forty-five days of the presentation of findings from the department to the hospital.(2) In the event that a hospital fails to submit or submits but fails to follow such a corrective plan of action in response to a violation or violations found by the department based on a complaint filed pursuant to subsection (1) of this section, the department may impose, for all violations asserted against a hospital at any time, a civil penalty of one hundred dollars per day until the hospital submits or begins to follow a corrective plan of action or takes other action agreed to by the department.(3) The department shall maintain for public inspection records of any civil penalties, administrative actions, or license suspensions or revocations imposed on hospitals under this section.(4) For purposes of this section, "unforeseeable emergency circumstance" means:(a) Any unforeseen national, state, or municipal emergency;(b) When a hospital disaster plan is activated;(c) Any unforeseen disaster or other catastrophic event that substantially affects or increases the need for health care services;

4.3.

Nurses acting within the protocols of their delegation authority are immune from liability for any action performed in the course of their delegation duties.(viii) Nursing task delegation protocols are not intended to regulate the settings in which delegation may occur, but are intended to ensure that nursing care services have a consistent standard of practice upon which the public and the profession may rely, and to safeguard the authority of the nurse to make independent professional decisions regarding the delegation of a task.(f) The nursing care quality assurance commission may adopt rules to implement this section.(4) Only a person licensed as a registered nurse may instruct nurses in technical subjects pertaining to nursing.(5) Only a person licensed as a registered nurse may hold herself or himself out to the public or designate herself or himself as a registered nurse.(6)(a) A registered nurse may not perform direct clinical nursing care for compensation for more than a cumulative sixty hours in a week, regardless of health care setting, except for direct clinical nursing care that:(i) Occurs because of an unforeseeable emergent circumstance;

The beginning and ending day and time of the week may be defined and adjusted by the nurse, except that the beginning and ending day and time of the week may not be adjusted for the purposes of evading the requirements of this subsection.(iii) NoAn singleemployer healthis carenot setting may be held responsible for tracking the total cumulative hours worked of a registered nursenurse.Sec. across all health care settings.(iv) For purposes of this subsection, "health care setting" means a hospital, clinic, nursing home, laboratory, office, or similar place where a health care provider provides health care to patients.Sec.

5.4.

and(b) IfAttest applying for a license to practice as a registered nurse, attest at the time of application that he or she will not provide direct clinical nursing care under his or her license for compensation for more than the time permitted by RCW 18.79.260(6).(2) The commission shall use existing paper or electronic licensing systems for an applicant to attest to the requirement under subsection (1)(b) of this section.Sec.

6.5.

6.

RCW 49.28.140 and 2002 c 112 s 3 are each amended to read as follows:(1) No employee of a health care facility may be required to work overtime.

Attempts to compel or force employees to work overtime are contrary to public policy, and any such requirement contained in a contract, agreement, or understanding is void.(2) The acceptance by any employee of overtime is strictly voluntary, and the refusal of an employee to accept such overtime work is not grounds for discrimination, dismissal, discharge, or any other penalty, threat of reports for discipline, or employment decision adverse to the employee.(3) This section does not apply to overtime work that occurs:(a) Because of any unforeseeable emergent circumstance;(b) Because of prescheduled on-call time.

If an employee on prescheduled on-call is activated and working a shift immediately before or after a regularly scheduled twelve-hour shift, a health care facility must use reasonable efforts to find a replacement for the employee if he or she indicates he or she is fatigued and needs to be replaced;(c) When the employer documents that the employer has used reasonable efforts to obtain staffing.

An employer has not used reasonable efforts if overtime work is used to fill vacancies resulting from chronic staff shortages;

or(d) When an employee is required to work overtime to complete a patient care procedure already in progress where the absence of the employee could have an adverse effect on the patient.Sec.