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
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
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
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
"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
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
"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:
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
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
"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
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,"