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Integrity, Stewardship, Spirituality, Imagination, Respect, Excellence and Compassion. Those are St. Anthony's guiding lights -- except when it comes to nurses. They receive their own, more detailed set of guidelines on how to interact with patients. Under a recently adopted program known as "Person First," the nurses were told that they need to "sense people's needs before they ask, take the initiative to put customer's needs first, and go the extra mile to satisfy them" -- and to do it all using a script approved by hospital management.
"I'm sorry this has caused you concern. Let me take care of that right now for you," nurses are supposed to tell patients who bring up a problem. "I'm glad you brought this to my attention. Is there anything else I can do for you? I have the time."
Of course, some problems even a caring nurse can't solve; there's a script for that scenario, too.
"I'm sorry this has caused you concern. This is not my area of expertise. I will find the right person who can help you with this. Before I leave, is there anything else I can do for you? I have the time."
There's even a pre-approved method for following up.
"Did the doctor see you about that concern? Before I leave, is there anything else I can do for you? I have the time."
Just to make sure the nurses adhere to the script in their interactions with patients, the St. Anthony staff was told there would be a "secret shopper" planted among the patients. They were warned that nurses who are not appropriately "positive" could lose their jobs. "They told us our customer-satisfaction level was down and it was our fault and we need to work on it," says one St. Anthony's nurse who asked to remain anonymous for fear of retribution. "It's so demeaning to treat nurses that way. I've been nursing for years; I know how to talk to patients."
But the most offensive part of the script for many St. Anthony nurses is the final assurance that they "have the time" to care for the patient.
"You don't have the time; it's a lie," says another hospital veteran. (A St. Anthony spokesman says the purpose of the Person First initiative is to "take us to the next level in increasing patient-satisfaction rates and make us the health-care provider of choice in the state.")
The frustration over feeling insulted by hospital management isn't limited to St. Anthony nurses. At hospitals all over Denver, exasperated nurses are speaking out about exhaustive workloads that make it almost impossible to provide proper care for patients, saying they've become the victims of cost-cutting managers trying to wring more labor from an overwhelmed staff. It's gotten to a breaking point for dissatisfied nurses, many of whom are leaving the profession, resulting in a national and local nursing shortage. In Denver alone, more than 900 nursing positions are currently unfilled. And nurses point to a New England Journal of Medicine study published last year that found that for every one patient over a normal load a nurse has to care for, the overall death rate among patients increases by 7 percent.
In a largely female profession that traces its roots to the nun-like sense of mission fostered by Florence Nightingale, rabble-rousing doesn't come easy. Unions are now targeting hospital workers, but in Colorado, they've had limited success so far. Just three years ago, a union drive failed at St. Anthony, in large part because the hospital hired an out-of-state union-busting firm to intimidate nurses. But a major effort is now under way to create a union among nurses at Denver Health, the huge public agency that provides much of the care to Denver's uninsured residents, and many of the nurses involved say they've had enough and are ready to shake things up.
"There are things that nurses see that we simply can't get anyone to do anything about," says Denver Health nurse Jack Elston. "I've despaired of getting these issues addressed. There are so many obstacles, but I know we can bring these issues up at a union contract negotiation."
Elston is the last person you would imagine as a hospital nurse and a union supporter. For many years, the 58-year-old was a criminal attorney, but eventually, he grew to hate his profession, yearning for a career in the medical world, something he could do to help people. He decided to study nursing -- he was too old to get into medical school -- and the self-described Reagan Republican became an RN in 1995. He worked for a nursing agency for several years after moving to Denver from South Dakota and took temporary assignments at many of the large hospitals around town. He's seen and done it all at most of Denver's major medical centers -- and at each place, nurses were treated with similar indifference.
"They give you a message that your input is not important and you have to do what we tell you," Elston says. "But this is the 21st century; it's not Appalachia, and I'm not a coal miner."
Two years ago, Elston took a job in the psychiatric wing at Denver Health (formerly Denver General) hospital. He was excited because it catered to the poor, had many well-regarded departments and was the best trauma center in Denver. "As a psych nurse, you manage the milieu," he says. "You have to keep the explosive patients from assaulting each other. You're dealing with people severely disabled from mental illness. They can be very loud and angry. We get kicked, hit and spat upon."
But even though the job can be stressful, it's also rewarding, and Elston enjoys seeing patients start to emerge from their delusions and get steered into reality. "Our job is to stabilize them on medications and get them back into therapy. Watching these people change from the acute phase is gratifying."
Sometimes getting there is difficult, though, and not having enough nurses on the floor can be frightening and dangerous for their colleagues. "When you have too many patients, the situation gets dangerous both for the patient and the nurse," Elston says. "In a locked psych facility, there are assaults. The patients sometimes can't control their conduct."
A few weeks ago, a delusional patient on Elston's floor disconnected her roommate's oxygen tank and put it in the corridor, where it began hissing and was at risk of exploding. Such incidents wouldn't be a job-related hazard if the hospital were set up with piped oxygen, says Elston, who adds that he'd like to be involved in discussions with the architects of Denver Health's $148 million addition voters approved last month. He thinks that if nurses brought their direct experience to the planning, hospital administrators and designers would get a better idea of how to solve simple problems and of what does and doesn't work. But he sees no sign of that happening.
"It's like there's a black hole between us and management," Elston says.
That's a common refrain among Denver nurses. They say hospitals now require them to care for so many patients at one time, it's almost impossible to provide quality nursing, especially since only the most fragile patients are being left in hospital beds. Hospitals tend to send more stable patients home earlier in order to cut costs.
"You work harder and people are sicker," says a Denver Health nurse who has been in the field since the 1970s. "They used to have people come in the day before surgery, then decided that wasn't cost-efficient. Now it's like assembly-line health care. We used to have four or five patients; now you might have seventeen. You work in twelve-hour shifts and then don't get a break. It's not good for patients or nurses."
"What satisfies you is when you walk out at the end of the day and know your patients are safe, they got their meds, and you were able to talk to them," Elston says. "But if you're overwhelmed, you walk out thinking, 'Did I give those 2 p.m. meds?' You think, 'My God, I hope I didn't kill somebody today.'"
The Colorado Board of Nursing is all too familiar with these fears. The board frequently gets calls from nurses concerned that they might make a mistake and harm a patient, potentially costing them their license. "What we're hearing from nurses is that there's not enough people in the profession to safely provide care," says Dr. Pat Uris, director of the board. "What they're wondering is, 'If I go to work and make an error because the staffing is short, could I lose my license?'"
The answer is yes. Uris tells the nurses that, as licensed professionals, they're responsible for what they do on the job. But that puts nurses in a bind: If they refuse an assignment because they think the staffing level is dangerous, they can be accused of abandoning their patients and fired.
"They're in a tough situation," Uris says. "It's so hard for them to walk away when they know there's no one there to replace them."
Registered nurses (RNs) must have a nursing degree from a university or college. They supervise licensed practical nurses (LPNs), who handle some of the routine parts of patient care. Even though the law treats nurses as professionals who are legally liable for their conduct, many nurses say they are not treated accordingly by hospital managers.
"I feel disrespected by the administration of the hospital," says Mike Kingsbury, a Denver Health nurse. "If a majority of doctors came forward and said, 'This is a problem,' it would be addressed overnight. It's almost like they treat us like we're stupid. Nursing is a traditionally female-dominated profession, and nurses tend to go along with things, but I'm not used to being treated like that."
Kingsbury says the pressures put on nurses wind up harming patients, who don't get the care they should.
"If you have ten patients, you have six minutes per hour for every patient, and a lot of them wind up getting neglected. We can all tell you stories about bad outcomes as a result of this. I see what's happening to my patients on a regular basis. People go into this profession to help people; they're idealistic. We want to take care of patients physically and emotionally. Now it's the least common denominator. You just give them their medications and try to keep them alive."
Professor Mary Blegen of the School of Nursing at the University of Colorado Health Sciences Center has collected data from nurses at fifty hospitals across the country as part of her research into working conditions. She's found that nurses love the parts of nursing that attracted them to the field -- spending time with patients, being able to provide hands-on help to sick people -- but are deeply frustrated over other aspects of the job. "They like the work they do; what they don't like is not having much say in the decisions hospitals make," Blegen says. "Nurses are professionals, but they get treated like assembly-line workers. That works if you're making widgets, but not if you're treating people who are very ill."
Nor do they like knowing that executive salaries at hospitals, such as Denver Health, have skyrocketed while they are under pressure to do more with less. ("A Healthy Paycheck," June 27, 2002). Dr. Patricia Gabow, Denver Health CEO, saw her paycheck increase from $218,026 in 1996 to $426,030 in 2002; over the same period, the former nursing director's salary swelled from $72,188 to $167,906. "One of the things that set the nurses off was the executive salaries," Elston says. "When the manager comes striding down the corridor in an Armani suit and you're being told to conserve syringes, it makes you mad."
In February, more than fifty Denver Health nurses signed a letter that went to every nurse in the hospital announcing an organizing drive to create a union. Within a few months, a majority of Denver Health's approximately 800 nurses had signed cards saying they wanted to be represented by the Service Employees International Union (SEIU), Local 105.
Because Denver Health is a public-sector organization, it's not covered by federal labor laws, which exempt government agencies. A private hospital faced with an organizing drive would come under the purview of the National Labor Relations Board, but at Denver Health the union has to gain recognition from the hospital's nine-member governing board. As a result, Lynette Pitcock, director of SEIU's Metro Denver Nurse Alliance, thinks Denver Health will be easier to organize than a private hospital would be.
"A public hospital is more accountable," Pitcock says. "They can't spend a couple million on a union-buster."
Three years ago the SEIU was involved in an effort to unionize nurses at St. Anthony's two area hospitals. St. Anthony hired Kansas City-based Management Science Associates, a firm that specializes in battling union drives in the health-care industry, and soon the nurses were deluged with anti-union propaganda and forced to attend meetings warning them about the dangers of forming a union.
"The only reason we were trying to organize was to have a voice," says Bernie Patterson, a St. Anthony nurse who was active in the union drive. "Our Catholic, non-profit hospital hired a consulting firm and spent millions to fight us. It was really ugly."
Patterson's group eventually had to withdraw its petition for an election because many of the nurses who originally supported the union were frightened away. "Even the nurses who believed we needed a voice were losing their confidence," she says.
St. Anthony spokesman Scott Chase says the hospital believed having a union would hinder communication among its workforce.
"We wanted to foster a good relationship between management and the nurses and address their concerns directly, and not through a third party," says Chase. "We educated the nurses on our desires so they could make an informed decision. Ultimately, the nurses didn't see any value in a union and didn't support it."
Chase declined to reveal what St. Anthony spent to hire its anti-union consultant, but he scoffed at the idea that it had cost the hospital millions. "It's a very standard practice for a company going through a union campaign to bring in a company like that," he says.
Now the SEIU is targeting Denver Health and hoping that will be a crucial first step in organizing all the hospitals in Denver. "Our long-term goal is to build a health-care union in Denver," Pitcock says. "We have nurses all over the city who would like to form a union."
Today the only Denver health-care organizations that are organized are Kaiser Permanente and the Department of Veterans Affairs. The United Food and Commercial Workers Union Local 7 represents the nurses at Kaiser, while the SEIU represents the Kaiser LPNs and pharmacists; the VA nurses are represented by United American Nurses, an affiliate of the American Nurses Association.
But Denver Health has no intention of going quietly, and nurses there are meeting with resistance from hospital administrators. "They've developed a new policy that says you're not allowed to talk about the union on hospital grounds," Kingsbury says. "The administration is putting out memos saying to write up your employees if they talk about the union."
The union is now lobbying the Denver Health board to allow nurses to vote on whether they want to be represented by the SEIU -- something they have been asking for since April.
"The board is telling us to wait until July," says an exasperated Kingsbury. "I think the board has pretty good intentions, but why should we have to wait until July?"
In an effort to mollify its employees, Denver Health has established a "nurse council" that is supposed to gather suggestions from nurses and pass them on to managers. Establishing such a council is a typical move by hospitals fighting a union: They point to the nurse council as a way for nurses to speak to management without a union. Denver Health has also raised its nurses wages by 7.7 percent (the average full-time Denver Health RN now makes $54,000) and added 106 nursing positions to reduce the patient load.
"It was a significant budget decision, but we felt we had to move forward on adding to our nursing staff," says hospital spokeswoman Bobbi Barrow.
The personnel committee of the Denver Health board is now studying the unionization effort and will issue a recommendation to the full board in the next few weeks, Barrow says. But in a prepared statement given to Westword, the agency said it "fully recognizes all employees' constitutional right of association; they are not precluded from joining an association or union, as long as it is done on the employee's own time."The statement goes on to note that as a public agency, Denver Health is not covered under the National Labor Relations Act. "Employees of [Denver Health] have no right under current law to collective bargaining," says the statement. "A vote for unionization would only be possible if approved on a purely voluntary basis by the board."
Kingsbury says the recent improvements in wages and staffing are an attempt by the hospital to undercut the union campaign. He adds that money is not the main issue for most of the nurses; in a survey of Denver Health nurses conducted by the union, issues such as short staffing and working conditions were ranked as more important than money.
"It's not like we're greedy," says Kingsbury. "We have to save this profession."
The SEIU is following the example of unions in California, which have organized nearly half the nurses in the state. SEIU and the California Nurses Association each represent tens of thousands of nurses, and they've succeeded in making nurses a force to be reckoned with in the Golden State.
One of their biggest accomplishments was gaining approval for a 1999 law that sets nurse-to-patient ratio standards for general, psychiatric and special hospitals. The law also bans hospitals from having unlicensed employees perform traditional nursing duties such as giving medicine or assessing treatment. But since the law has been phased in over the past several years, it's still not clear what the overall impact will be. However, Pitcock thinks it shows what unified nurses can achieve. "It's exciting what's going on in California," she says. "They've really started to make major improvements in standards."
In Colorado, nurses have been supporting legislation that would set nurse-to-patient ratios at the state and federal levels. They were particularly interested in a bill by Representative Mike Cerbo introduced in the last legislative session that would have established such standards. Although the bill didn't pass, many nurses expect to see a more fully developed proposal next year. "We agree with the concept, but we need more time to discuss it," says Paula Stearns, executive director of the Colorado Nurses Association, adding that setting a ratio is tricky because hospitals that have to hire more RNs may cut back on nursing assistants and other support staff.
Patterson traveled to Washington D.C. last month with several other local SEIU activists to lobby for a national standard of one nurse to every five patients. "We just want to make patient care safe," Patterson says. "We're not just doing this for ourselves; it's for our patients. We feel the legislation would help the nursing shortage. If nurses don't feel their licenses are on the line every day, they'll come back."
But hospitals are fighting the nurses' proposal to set legal "safe staffing" levels, arguing that the nursing shortage makes it impossible to hire more nurses. The issue is complicated, Blegen says. "Anytime you bring in externally mandated ratios, it's a problem. What should the ratio be? If you put the ratios into effect and there aren't enough nurses, the hospital will have to close beds. And, of course, the costs will go up."
The one overwhelming reality facing both hospitals and nurses is that there simply aren't enough nurses. Nationally, it's estimated 168,000 nursing jobs are going unfilled, and as the population ages, the demand for nurses will only increase. It's estimated that by 2010, Colorado will need another 7,392 nurses.
Despite the dire need, hospitals say they can't find nurses to hire; nurses say the working conditions are what keeps them away. "Young nurses are overwhelmed at the complexity of the job," Elston says. "I see so many who are burned out in two years. I don't believe nurses are disposable; they're not like tissues you throw away. We have only one nurse on our floor of childbearing age; they're all old like me. What is the future of nursing?"
"I made a decision that I didn't want to work in a hospital," says Melody Wrobel, a nurse who works at an outpatient facility for the Mental Health Corporation of Denver. "I think the hospital nurses love the field; they're just absolutely frustrated and exhausted. I know a lot of nurses who aren't in nursing anymore. A friend said, 'To hell with this; I can go be a bartender.'"
The shortage is being driven by two factors: dissatisfied nurses leaving hospitals and fewer young women entering the profession. About fifteen years ago, with the advent of managed care, hospitals came under extraordinary pressure to cut costs and began slashing nursing staffs. As a result of the increased workloads, many nurses feel that hospitals have become their own worst enemy, constantly hiring new nurses and then watching them walk out the door.
"After nurses work for a year, they get out," Patterson says. "They get tired and burn out."
When Patterson lobbied for national legislation, she told lawmakers that "the nursing shortage did not cause understaffing -- understaffing caused the nursing shortage."
Everyone seems to have a story of a good nurse being mistreated by hospital management and leaving. Elston says one nurse he worked with had seventeen years' experience and then went through a bitter divorce. "She told them I need time off, I need to take six weeks to get my head together. They said, 'We can't do it,' and she quit. It seems to me that after seventeen years, a nurse is entitled to a sabbatical, especially under those circumstances. She was doing a great job. What did they gain by losing her?"
"The attitude is, 'If you don't like it, you can leave,'" Kingsbury adds. "What's happened is people have voted with their feet and gone out of the profession."
The people who are most affected by overwhelmed nurses are those who have the hardest time speaking up: seriously ill patients.
Wrobel is still upset over a situation she encountered five years ago, when her father was in a local hospital dying of kidney failure. He was incontinent and needed to be changed.
"I was trying to get him help one day, and I couldn't find a nurse. I found an aide and said, 'Please help me.' She said okay and then left for thirty minutes."
Wrobel decided she had no choice but to change her father herself.
"I wasn't going to let him lie there in his own stuff. He was so modest; my dad would never let me see him nude. He was all doped up on pain medication, but there was a point where he looked at me, and I could tell he was saying, 'I'm sorry.' I was so angry at that hospital."
Now Wrobel is working with the Denver Nurse Alliance, lobbying for legislation to change hospital working conditions.
"I want to change other people's experiences," she says.
