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USA: Nurses Organize to Protect Patients

by Michael J. BerensChicago Tribune
December 20th, 2000

HAYWARD, Calif. -- Faces drawn from fatigue, eyes droopy, swollen and red, the 50 registered nurses gathered in the sparse meeting room, coffee cups tipped for yet another caffeine rush. They came to share stories and console each other about how their critically ill patients are all too often victims of substandard nursing care, resulting in unnecessary pain or injury.

"I feel so guilty," said a newly hired nurse in her early 30s, lowering her head and closing her eyes. "We're so short-staffed. Every time I go home I wonder if someone is going to die because I wasn't there."

The nurses at Kaiser Permanente Medical Center talked of being so overwhelmed they delivered too much medicine to patients. They complained that care was delayed to gurney-bound patients wheeled into hallways instead of rooms because too few nurses were on duty.

"What should we do?" a veteran nurse asked Kay McVay, president of the California Nurses Association, one of the nation's most aggressive nurses unions.

McVay told the anxious nurses to create a daily report of every case of bad or delayed care linked to insufficient staffing levels. "We'll take your experiences to the public," she said. Besieged by inadequate staffing, nurses are pushing their calls for reform into the public spotlight. From raucous street rallies to private meetings, the primarily female profession is circumventing a code of silence that, in some hospitals, still mandates that nurses should not speak to a superior unless spoken to first.

California is ground zero for this new, aggressive activism. This fall, the California Nurses Association, based in Oakland, about 30 miles north of Hayward, held the nation's first training school to teach nurses and patients how to become activists.

The Tribune reported in a three-day series in September that a majority of hospitals nationally have significantly reduced registered-nurse staffs. Since 1995, at least 1,720 patients have died and 9,584 others were injured in cases linked to overwhelmed or inadequately trained nurses.

Pushed by activist nurses, California lawmakers this year adopted an unprecedented law that will require hospitals to maintain minimum levels of nurse staffing.

Though a majority of nursing advocates generally recommend a ratio of one nurse for eight patients on general hospital floors, hospitals routinely order nurses to care for 15 patients or more, according to U.S. Department of Health and Human Services records. The California law represents the first government mandate to dictate staffing decisions within privately operated hospitals.

Hospital officials say patients receive the highest standard of care and that staffing is maintained at safe levels.

In a testament to the growing influence of the nation's 2.6 million registered nurses, legislators in two dozen states, including Illinois, have begun to draft similar staffing laws. Recently published research has found evidence that patients suffer fewer complications when more nurses are on duty.

"I don't know a nurse who would leave anyone they love in a hospital alone," said Tricia Hunter, executive director of the California branch of the American Nurses Association. She said nurses in dozens of states have formed volunteer "buddy groups" to maintain 24-hour vigils for their families and friends.

At some Chicago-area hospitals, registered nurses sometimes implore families to stay overnight with sick relatives because they cannot guarantee patient safety amid inadequate staffing on some shifts.

In Rhode Island, dozens of nurses marched in the streets this year--not for more money but for more nurses to be added to hospital staffs and an end to mandatory 16-hour shifts, which they say have resulted in sloppy, reckless care.

"In every city there is a momentous battle being waged for patient safety," McVay said. "Nurses are witnessing unnecessary death and injury because hospitals want to save a few dollars by eliminating patients' lifelines: registered nurses."

The activism is spreading. More than 350 nurses, including three representatives of the Illinois Nurses Association, gathered for four days of workshops and panel discussions at a new School for Nurse Activists and Patient Advocates, organized by the California nurses group.

Nurses and patients were shown how the 32,000 members of the California Nurses Association encouraged patients to publicly recount their experiences. Additionally, the association set up a 24-hour public hotline. The strategy is being copied by at least a dozen other nurses associations.

At the nurses meeting at the Kaiser Permanente Medical Center, Jim Ryder, a California Nurses Association leader, outlined a strategy that is as unorthodox as it is controversial: Nurses agreed to fill out brief, daily reports involving every instance of substandard care linked to inadequate staffing. The cases, which will not reveal patient names or any other identifier, will be put into a database and released next year, Ryder said.

The nurses allowed the Tribune to attend the meeting at Kaiser Permanente with a condition that the identities of those quoted would be protected.

The nation's largest nurses' associations maintain that a majority of facilities have unnecessarily squeezed staffs in pursuit of higher profits.

Even the upper ranks of the traditionally staid American Nurses Association have been spurred into a more demonstrative form of protest. Last month, association President Mary Foley was arrested after blocking the entrance to a hospital in Washington, D.C., where nurses were on strike to end what they said was excessive, mandatory overtime used to compensate for inadequate nurse staffing.

At the heart of the dispute: How many patients can be assigned to a registered nurse before safety is compromised?

California lawmakers have been the first to attempt an answer, earlier this year passing the nation's first law to establish nurse-to-patient ratios.

In one case presented to legislators, a 55-year-old cardiac patient died after a 10-hour wait in an Oakland emergency room on Jan. 10, 1997, while waiting for a bed at another Kaiser Permanente Medical Center.

Although the facility had empty beds, there weren't enough nurses on duty to provide care, according to the Health Care Financing Administration, a division of the federal Department of Health and Human Services.

But legislation so far has offered only elusive promises of an answer. State officials have until 2002 to establish staffing ratios.

For the last decade, hospital industry lobbyists had fended off dozens of attempts to regulate staffing levels in California, Illinois and a dozen other states.

In comparison, federal lawmakers have established nurse staffing requirements for the politically fragmented nursing home industry. Nursing homes are required to have at least one registered nurse on duty at all times; in the past, many facilities employed only aides on certain shifts.

Wary of the domino effect in other states, members of the American Hospital Association vow to vigorously oppose any government-backed efforts to wrest control of hospital management decisions.

Staffing ratios are the equivalent of trade secrets at many hospitals. Even the AHA doesn't ask its members to disclose specific numbers.

The hospital association argues that staffing levels must remain fluid, subject to variables that include the number of patient admissions and severity of illnesses. Citing overwhelming evidence to the contrary, California lawmakers sided with nurses and patients who described cost-cutting decisions that were affecting patient care.

A key to winning the law, nurses acknowledge, was urging nurses to go public and recruiting patients to lobby legislators.

James and Dawn Gadd of Sunnyvale were among the first to step forward. Their story was not one of unusual accidental death. Instead, their experience revealed a more common, systematic breakdown of patient care.

The Gadds testified in support of the staffing bill by recounting the last months of life of their 7-year-old son, Jesse, who was losing his front teeth when cancer claimed his life in early 1998.

"The registered nurses literally ran between patients. Many gave up their lunches and breaks to help patients," Dawn Gadd said. "Nurses were clearly overwhelmed.

"Most of the time, an untrained nurse's aide was sent to provide care. They often didn't know the medications or understand the nuances of care," she said.

Working in shifts, the parents said they assumed the role of nurses, trying to ease the final days of pain for their son.

"I was too scared to leave my son alone in the hospital," said Dawn Gadd. "There were so many little errors that we caught."

Nurse aides sometimes would attempt to administer inaccurate dosages or provide medicines in the wrong sequence or at the wrong time of day, which can cause severe complications.

"It's frightening to think what could have happened if we weren't there," she said.

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