Need for nurses gets more acute: Some worry about lapses in care at area hospitals

by Lisa Rapaport, Sacramento Bee

September 2, 2001

Sacramento-area hospitals have hundreds of vacant nursing positions and struggle daily to find enough nurses to work understaffed shifts.

Local hospitals are short more than 750 nurses, and it would take every new nurse California State University, Sacramento, can graduate over the next eight years just to fill existing vacancies.

The tight labor market has led to an increase in salaries, as well as health and pension benefits, on-the-job skills training and tuition reimbursement programs as hospitals compete for staff.

Despite hospitals' best efforts, however, the shortage keeps growing.

The result, according to dozens of nurses interviewed by The Bee, is that hospitals have opened themselves up to lapses in patient care that happened when staffing was low.

The first things to go are less critical tasks, such as bathing patients and changing bandages, nurses said.

As these interactions fall away, nurses spend less time in each room and start to miss subtle changes in patient conditions.

"At first, the icing-on-the-cake stuff doesn't get done, like the baths, and at first you cope OK, but then it can get so busy you worry about what will happen next," said Julie Meylor, a cardiac surgery intensive care nurse at Mercy General Hospital and a contract negotiator for the California Nurses Association.

In the rush to do more faster, nurses say, mistakes can happen. Lab tests get mislabeled. Medications come late. Call lights go unanswered. Patients get misdiagnosed. Infections, bedsores, falls and other preventable complications result.

Even at UC Davis Medical Center, where nurses work under some of the best staffing conditions in the country, there are times when the work can become too much.

"Sometimes, the simple fact is we don't have enough people and you just have to deal," said Stacey Munoz, a pediatrics nurse at the medical center.

In the rush to keep up with critical patient needs, some nurses worry that the nurturing part of patient care that lured them to the profession will fall by the wayside.

For Marian Ignatyev, a pediatrics nurse at the medical center, such hands-on care is critical to the job of helping patients get better.

Ignatyev's rounds began one recent morning as she eased a feeding tube out of a girl's nose, patted a damp cloth over her flushed face, steadied a cup of water in her hands, offered lip balm, then promised to come back soon for a bath and shampoo.

Between rounds, Ignatyev would cuddle a baby while scribbling notes in patient charts, tug another child along the corridor in a red plastic wagon as she moved from room to room, and attend to a terrified mother whose boy kept coughing up blood.

But she never was able to get back to help the girl bathe and untangle her hair.

"I do all that I can; I always want to do more than I can," said Ignatyev, still settling in at her first job since graduating a year ago from CSU Sacramento.

As cost pressures drive hospitals to set staffing with an eye on their bottom line, administrators find they must weigh their best estimate of how many nurses are needed on each shift against the knowledge that overstaffing is a luxury they can't afford.

This leaves managers scrambling to add extra staff when a nurse calls in sick or they get a sudden influx of patients.

"At least once a week, if not more, I am on the phone asking a nurse to come in and do the above and beyond," said Lynn Sandoval, a nurse manager in medical/surgical and telemetry units at Kaiser Permanente South Sacramento Medical Center.

"It's hard, especially when you know that somebody has already put in their full schedule and then I call them at home, but I still have to tell them the situation and ask if there is any possible way they can come in."

Managers and shift supervisors everywhere say calls like this have become an unavoidable part of their jobs as a scarcity of nurses makes it harder and harder for them to staff shifts without using temp agencies or asking employees to work overtime.

Under current staffing systems, managers have the flexibility to adjust nurse assignments as patient needs change over the course of a day, said Karen Smith, a charge nurse on a cardiac care unit at Mercy General Hospital in Sacramento.

One recent morning, Smith began her shift on the phone, looking for an extra nurse.

Her unit would soon get three patients fresh from surgery and she didn't have enough nurses on duty to treat them. Calls to temp agencies yielded no results, and Smith couldn't find a staff nurse to come in.

To avoid overwhelming her staff, Smith cut back on the number of patients her unit accepted.

"I look at what patients I have, if anybody can be transferred or how soon I can facilitate a discharge," Smith said.

It's a situation many nurse managers now face daily, one of the many stress-inducing exercises in nursing that experts say can lead to early burnout.

Some nights, emergency room nurse John Kanas has to keep ambulances at bay outside while every bed on the unit is full and patients in gurneys line the halls. As charge nurse at Sutter Roseville Medical Center, Kanas stands at the ambulance entrance and directs paramedics to keep their passengers in the rigs until he can decide which patients inside he can move aside or pull off a monitor to make way for someone waiting beyond the doors.

"Our patients can pile up on us when there's no place to transfer them in the hospital and there aren't enough nurses to staff the beds," Kanas said.

It's not by design. Hospitals supervisors can make their best estimate on what staffing levels are needed and still come out short-handed.

"Sometimes we have beds available that are not staffed because it's hard to guess when patients come," said Barbara Nelson, chief nurse executive for Sutter Roseville.

While ratios will take much of the guesswork out of staffing, local hospital executives say the new law won't make it any easier to tinker with staffing as patient needs change.

On intensive care and other critical units where the state has long required nurses to treat no more than two patients, however, nurses say ratios make their jobs easier.

Cindi Breaux, a post-surgery recovery room nurse at Methodist Hospital in Sacramento, has been on the job 26 years and attributes her longevity in the profession to the staffing conditions on her unit.

"I don't worry much about staffing because on my unit the state mandates a certain number of nurses," Breaux said. "That lets me do a job I love and take the time as I'm changing bandages or passing out pills to really see what my patients need. That's why I stay in nursing."

The Bee's Lisa Rapaport can be reached at (916) 321-1005 or lrapaport@sacbee.com.

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Need for nurses gets more acute: State's struggling to decide on the right staffing levels

by Lisa Rapaport, Sacramento Bee

September 2, 2001

They touch the skin and test for tone and texture. They change bedsheets and bandages, dispense pills and medical advice, and monitor vital signs.

Few professions are more personal than nursing. Yet, despite the need for such care, California health-care authorities have found it almost impossible to determine how many nurses are necessary to handle a rapidly growing number of patients.

In the two years since California passed the nation's first law mandating how many hospital patients each nurse can treat, state officials have struggled to put real numbers into the regulations.

Complicating the task is an exodus of talent. Each year, hospitals across the United States see growing numbers of nurses retire and quit.

And even as California establishes minimum staffing numbers, the nurse in charge of writing the ratios isn't sure they will work.

"There is no evidence that simply increasing the number of nurses will improve patient care," said Gina Henning, the public health nurse who is leading ratio efforts at the California Department of Health Services.

The ratio law, which takes effect Jan. 1, ordered state Health Services officials to figure out how many patients nurses can safely handle in various hospital units, from labor and delivery to emergency care.

The law was fought over several legislative sessions, fueled by concerns that managed-care cutbacks were compromising patient care and driving good nurses from their jobs.

At the time, the California Nurses Association said ratios were the only way to improve working conditions and the quality of hospital care.

The California Healthcare Association, meanwhile, said hospitals would not be able to locate or pay for enough nurses to comply with additional staffing required by the ratios law.

After the first version of the ratios bill stalled in committee and the next incarnation was vetoed by then-Gov. Pete Wilson, nurses union officials said they removed numbers in the third go-round to increase their odds of getting the bill signed.

Since the law passed, the ratios debate has escalated as the Department of Health Services weighs nurse staffing proposals submitted by roughly a dozen interest groups.

Not surprisingly, ratios proposed by hospitals and nurses differed wildly.

The 37,000-member California Nurses Association, for example, suggested a nurse-to-patient ratio of 1-to-3 in emergency rooms. The hospitals recommended 1-to-6.

For medical/surgical units where most patients recover from procedures, the California Healthcare Association, which represents 500 hospitals and health systems, suggested a 1-to-10 minimum. The nurses offered a 1-to-3 figure.

"There's no scientific way to come up with the ratios," said Joanne Spetz, a researcher with the Public Policy Institute of California. "They're going to have to make a decision about what is politically tenable."

Currently, the state only mandates ratios in critical units such as intensive care, where nurses can treat no more than two patients.

When the ratios come, they will require hospitals to hire more nurses, and fast.

Sacramento-area hospital administrators say they fear mandated staffing levels won't reflect a national and even global scarcity of nurses. They say health-care providers will drain limited financial resources to compete for additional staff.

"In any work shortage, we are faced with people who want a little different schedule or a little better pay, and we're in a situation where they can walk across the street," said Shelly McGriff, chief nurse executive for Sutter Medical Center in Sacramento.

Starting salaries in Sacramento area hospitals average about $21.50 an hour. Nurses on the job five years receive around $25 per hour. Per diem nurses can see hourly wages two or three times these amounts.

To hire enough nurses to comply with union-backed ratios, each hospital in the state would see labor costs climb by an average of $2.32 million a year, the Public Policy Institute of California estimated.

Hospitals may see a less dramatic increase in payroll expenses if they replace overtime and temporary shift workers with full-time staff nurses.

On average, hospitals in the state spend about $1 million annually on temp agency nurses, the California Healthcare Association said.

Union activists see the high overtime and per diem bills as a sign that hospitals could afford to add additional full-time nurses.

"There are enough nurses out there. If just half the registered nurses that work part time would agree to work one extra shift, hospitals would have no trouble meeting the ratios," said Rose DeMoro, executive director of the California Nurses Association.

The nurses union insists that high mandated staffing levels will reverse the shortage by making nursing a more attractive career.

If hospitals require too little staff, the California Nurses Association warns, overworked nurses will refuse to work in hospitals.

Many are already refusing.

Nurses are leaving the profession faster than the state can locate or educate replacements. Meanwhile, demand for nurses grows as California's population expands and ages.

California expects a minimum shortfall of 25,000 registered nurses by 2006. The number could soar when the ratios take effect.

The state has 276,074 licensed registered nurses, the Bureau of Registered Nurses reports. Not all work, and not all are employed in hospitals.

By 2010, 40 percent of registered nurses nationwide will be over the age of 50, nearing retirement at the same time as the first of 78 million baby boomers, creating a potential shortage of 400,000 nurses, according to federal labor statistics.

While the state's registered nurse work force is rapidly aging, California's primary supply system -- two-year and four-year programs at community colleges and state universities -- is graduating only about 5,000 nurses a year.

Just to keep pace with the state's growing and aging population, hospitals will need every graduate plus an additional 4,000 nurses each year, said Jan Emerson of the California Healthcare Association.

At a time when most of the state's hospitals are operating in the red and profitable facilities use investment income to offset losses from patient care, hospitals don't have the cash to compete for staff, Emerson said. "Hospitals may do everything they can to recruit under these conditions and it may not be enough," Emerson said.

While no cure exists for the state's financially beleaguered hospitals, mandatory staffing ratios should increase the amount of time nurses spend at the bedside, said Jim Ryder of the California Nurses Association, the union behind the law.

"Nurses need to be in the rooms enough to change bed linens and give baths," Ryder said. "That's the time they're able to touch the patient, see the texture and tone of skin, look at the input and output of liquids, and make a true assessment."

But as the state searches for the right ratios, Robyn Nelson, head of the California State University, Sacramento, nursing program, cautioned that it will take far more than a staffing law to put a meaningful dent in the state's nursing shortage.

"We can prepare more nurses, but hospitals have to create the environment that will keep them in nursing," Nelson said. "They have union issues, small profit margins and shrinking reimbursements from health plans and the government, so they don't have enough staff to deal with the acuity and then they have morale problems that stem from this. There is no easy fix."

The Bee's Lisa Rapaport can be reached at (916) 321-1005 or lrapaport@sacbee.com.

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EDITORIAL: The opinion of the Mercury News

Nursing profession needs better care

Improved working conditions will lure nurses back to hospitals
State must set standards to ensure that staffing levels are adequate

A POPULAR poster on the walls of under-staffed, badly managed work places proclaims: ³The beatings will continue until morale improves.²

Many of California's hospital nurses feel that's the policy where they toil. As conditions worsen, more registered nurses refuse to work in hospitals, choosing other health-care jobs or even leaving the profession entirely. The resulting under-staffing means heavier work loads and more mandatory overtime. Then even more nurses give up the fight.

The Legislature sought to end this downward spiral two years ago when it enacted a law calling for mandatory ratios of nurses to patients in acute-care hospitals. The law gave the state Department of Health Services two years to come up with the exact numbers for medical-surgical floors, pediatric units and psychiatric wards. (Ratios already exist for the most critical care areas, such as intensive care and burn units.)

Hospitals argued, before and after passage of the law, that they don't have enough money to pay extra nurses, and even if they did, there aren't enough nurses to go around, since staffing shortages are a chronic problem.

However, nurses, legislators and many patients have concluded that current care levels are so dangerously low that nursing levels must be increased, regardless of cost. Health care costs in California are already low compared to other states; and some of the increase will be offset as hospitals pay less for overtime and for registry nurses hired by the day.

As for the staffing shortage, there's plenty of evidence that there's no shortage of nurses at all. National and state studies show plenty of nursing school graduates, and also plenty of nurses leaving the profession due to job-related stress. The shortage is of nurses willing to work in hospitals. Improved working conditions will lure them back, as happened when the state of Victoria, Australia, adopted nurse-to-patient rules.

What should the ratios be? And should they include licensed vocational nurses, or just registered nurses, who have significantly more training? For medical-surgical beds, the California Nurses Association, which represents 38,000 registered nurses, wants one R.N. for every three patients. The hospital industry trade group wants a 1:10 ratio, which would change nothing.

Health care giant Kaiser Permanente surprised both groups in July by throwing its considerable weight behind a 1:4 ratio (counting a ³nurse² as either a registered or licensed vocational nurse). This is the same ratio proposed by the Service Employees International Union, which represents both kinds of nurses. The California Nurses Association, which pushed through state Sen. Sheila Kuehl's legislation in 1999, claims Kaiser is seeking a lengthy transition period that would ignore the law's requirement for ratios to be in place by January 2002, and would just let the problem get worse.

The extra expense for more nurses will be considerable; the California Public Policy Institute estimates the average cost per hospital for a 1:4 ratio at $1.3 million a year, and Kaiser expects to spend between $120 million and $200 million a year statewide to achieve that level. But if we want good care when we're most in need of it, we have to pay for it.

Setting standards for health care is difficult. There's no consensus on what level of care provides the best balance of competence and cost, whether it's nursing staff for a coronary unit or number of hospital beds for a city. Rural hospitals face special challenges. But the Legislature passed, and Gov. Davis signed, the bill calling for ratios only after convincing proof that staffing levels had dipped to unacceptable lows. The state must respond by setting those levels high enough that hospital care in California sets the standard of excellence that patients justifiably expect.

© 2001 The Mercury News

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Local nurses to rally at Capitol

by Jane Futcher, Marin Independent Journal

September 4, 2001

Nurses from Marin General, Novato Community and Kaiser hospitals will rally in Sacramento Thursday to press for strong nurse-to-patient ratios under California's 1999 Safe Staffing Law.

The rally, called by the California Nurses Association, will be followed by a public hearing at which nurses will share their experiences in hospitals around the state.

"Nurses are getting burnt out. I'm just exhausted some nights," said Sue Egisti, a Marin General Hospital nurse of 32 years, who plans to attend the rally along with more than 30 busloads of California nurses. "I come home thinking and praying that I haven't missed anything."

For several years, nurses' advocacy groups have clashed with hospital lobbyists on the proposed ratios, which will be determined in the next few weeks by the state Department of Health Services. The new ratios are set to take effect in January.

Across the board, nursing groups have proposed lower nurse-to-patient ratios than the California Healthcare Association, which represents 450 public and private hospitals in the state. For example, the nurses' association has proposed a ratio of one nurse to three patients on medical-surgical wards while the healthcare association backs a ratio of one nurse to 10 patients on those units.

Novato Community Hospital nurse Janet Andersen said the safety of patients and nurses is the reason she'll go to Sacramento on Thursday.

"This is not really about just the nurses. The battle is and remains for the patients," Andersen said. "They deserve safe health care and that's what this is really about. We can't accomplish this if the nurse is currently working her second shift in 24 hours, and she has 10 patients and she is covering one or two licensed vocational nurses who also have 10 patients. But this is what is currently the practice. If we don't change this, it will continue to be the practice, and the whole system will continue to deteriorate."

The Safe Staffing Law, the nation's first requiring minimum nurse-to-patient ratios in hospitals, was written by state Sen. Sheila Kuehl, D-Los Angeles, who will preside over the public hearing Thursday.

In anticipation of the impending start date of Jan. 1 for new ratios, officials for Kaiser Permanente Medical Center, the state's largest private health care system, announced in July they will back a union-supported ratio of one nurse to four patients in main medical and surgical wards even if the state decides on a higher ratio. Kaiser also requested a "transition period" of up to five years to implement the new guidelines due to the statewide nursing shortage.

Kaiser Permanente vice president MaryAnn Thode estimates that Kaiser could pay as much as $200 million a year more to hire nurses to comply with its proposed ratio of one nurse to four patients.

"Kaiser obviously believes we need ratios. I applaud them for that," Egisti said. "New nurses in this area will be enticed to work there because they won't have as many patients to care for."

The CNA objects to Kaiser's request for a delay in implementation.

"The hospital's argument is the nursing shortage," CNA spokeswoman Liz Jacobs said. "It's our contention that the nurses are there but don't want to work in acute care settings."

Kathie Graham, a spokeswoman for Marin General Hospital that, like Novato Community Hospital, is a Sutter Health affiliate, said nursing administrators at the Sutter hospitals are working together to develop a position on appropriate staffing ratios.

She said Marin General, like many hospitals, has based its nurse staffing levels on acuity - individual patient needs and the severity of illness. But, she said, "we're certainly going to be responsive to the legislation."

"Marin General absolutely supports safe staffing," Graham said.

Jacobs and the CNA argue that nurses now working in outpatient offices or in part-time positions will return full-time to hospital nursing if stronger ratios are implemented. In the long run, they say, patients, nurses and hospitals will benefit.

"In this day and age when the patient population is sicker and the length of stay is shorter we see patients repeat," said Cindy Daly, a Novato Community Hospital nurse who will join about 10 of her Novato colleagues in Sacramento. "Patients go home and they're back by the evening, and I think that's directly related to staffing. There is data to support that the fewer patients a nurse has, the shorter the length of stay and the better the outcome."

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Press Release
September 5, 2001

'No progress' on Staffing, Patient Care Quality
Oakland Children's Hospital Nurses Taking Strike Vote

Registered Nurses at Children's Hospital in Oakland are voting today, September 5 on whether to authorize a strike at the facility.

The 640 RNs, who are represented by the California Nurses Association, have been in negotiations with Children's management for five months. Nurse negotiators report that due to management intransigence the two sides have been unable to reach a new collective bargaining agreement.

The biggest stumbling block to concluding a new contract has been Children's management's refusal to agree to improve nurse-to-patient staffing. Moreover, the nurses charge, the situation has been made worse by a recent pattern of shifting RNs from units where they are critically needed to units where the ratios are legally mandated such as Intensive Care. The result, they says, it to leave the other units short-staffed, thus threatening to undermine the quality of care given patients.

"The RNs at Children's are serious about improving staffing so that we can provide quality patient care," said Martha Kuhl, RN. "During negotiations management has refused to address any of the staffing proposals we have raised in bargaining. Hospitalized patients are sicker, needing more time and attention from caregivers. Instead nurses at Children's, as elsewhere, are seeing their assignments increasing, leaving less time for each patient."

Kuhl added that a large group of Children's Hospital RNs will participate in the CNA-sponsored nurses' rally set for tomorrow in Sacramento calling on state regulators to set safe staffing ratios in keeping with California's new Safe Staffing law.

Of major concern for the nurses is their desire to upgrade the retirement benefits portion of their contract. At no additional cost to the hospital, the nurses say, they could be enrolled in a pension plan far superior to what they currently have. This, they say, would go a long way toward helping recruit and retain bedside RNs, thus alleviating the current nursing shortage. Management, however, has insisted on its own retirement proposal, which falls far short of what is needed.

"We also want to secure a livable pension for RNs so that we can attract nurses both to Children's and to the profession," said Kuhl. "So far the hospital has not come close to what other Bay Area employers are offering. This will mean that nurses will not choose to work at this hospital and conditions will deteriorate further."

"The stance the Children's administrators have taken in this situation can only be regarded as provocative," said CNA Executive Director Rose Ann DeMoro. "They seem to want to make a bad situation worse, to exacerbate the problem the RNs are seeking to resolve, that is the threat to patient care quality. This is a disservice to the nurses, the patients and the community."

For more information: Debra Grabelle 510-701-0192 / Carl Bloice: 510-273-2249.
Strike vote result will be available at 5:30 p.m. today.

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