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Internal Bleeding 

St. John's Mercy Medical Center alienated their RNs when they turned to less experienced caregivers to save money. Now they're paying for it.

It's morning in a sixth-floor hallway of St. John's Mercy Medical Center, and tray tables and housekeeping carts wait side by side like racehorses at the gate. Women in every imaginable version of a uniform mill about indistinguishably, each nametag a blur of small print topped by a big bold first name. One's in heels, carrying a clipboard. Another wears slacks and a cotton print top that looks like a little kid's pajamas. Most wear turquoise, navy or maroon scrubs, the easy-care colors uncompromisingly bright. They're all moving fast, in and out of rooms like actors in a French farce. Suddenly a woman in white -- white skirt, white hose, white jacket -- appears, stethoscope around her neck. "Ah, Nurse!" a patient calls, relief in his voice.

What the patients don't realize is that the women in scrubs who sometimes empty their trash cans are registered nurses, too, often with more than a decade of experience. It's all a bit confusing, because the patient-care associates (PCAs) -- who have only two months' training, and often came from housekeeping -- wear the same scrubs and give the lion's share of the care.

Patients loyal to St. John's their entire lives remember the days when Sister Isidore Lennon -- a feisty Sister of Mercy who immigrated from Ireland and compromised on nothing -- walked the floors making sure "her" nurses were up to par. But everybody knows those days are gone: Health care's changing, cutting corners to keep up with managed care. That's why patients are so relieved to see the crystal award on display in the lobby, naming St. John's Mercy Medical Center one of the nation's "Top 100 Hospitals."

What they don't know is that this much-touted 1998 award was bestowed by two management-consulting companies, and most of its "benchmarks" measure bottom-line efficiency, the kind you get when you shift tasks from RNs to un-degreed, lower-paid assistants, then replace experienced nurses with entry-level nurses and make them responsible for overseeing -- without much support or much time to give direct physical care -- more acutely ill patients with shorter durations of stay.

You get awards that way. But you also get once-loyal nurses mad enough to unionize.

It all started with something called patient-focused care -- which nurses promptly nicknamed "profit-focused care." Experienced RNs found themselves forced to reapply for their jobs; full-time nurses lost their guaranteed hours; certain benefits dissolved; "care teams" were heavy with pinch-hitting, barely trained technical assistants. "Staffing used to be based on the patients' acuity, their needs," says Joan Skurat, an RN at St. John's for 12 years. "Now it's all numbers."

The hospital implemented patient-focused care in 1996, galvanized by threats of managed care, decreased Medicare reimbursements and a harsh health-care climate in which an oligarchy of megasystems fight to survive. St. John's brought in a consulting firm -- PFCA Inc. of Atlanta -- to reconfigure the patient-care staff into "teams." Such a positive word: Managers vowed that nurses would soon be spending more time with patients. Newly hired hospital president Mark Weber announced in a June 1996 Q&A for employees, "We are reorganizing our work force so that RNs are only doing things that require their expertise."

"They bought a framework that was sold to us by an outside company," sums up Karen Prade, an RN in the neonatal intensive care unit (NICU) who's been at St. John's 11 years. "They would do these time studies and say, 'OK, it takes five minutes to start an IV.' At first, they were having PCAs put in urinary catheters after a one-day training course." Nurses describe a slew of "incidents" --"A man was getting his blood drawn and the PCA forgot to remove the tourniquet"; "Another PCA hooked a nose-feeding tube to an IV" -- and swear there were more frequent infections and complications.

A staff physician, asking not to be identified, recalls "several instances where I said, 'My God, I can't believe this person is allowed to take care of patients.' One patient was on a blood-thinner, and his IV was leaking blood onto the floor, and the patient-care associate was frozen on the spot; she just kept staring at it. (The patient) told me he asked her what she was going to do, and she didn't say anything, and he said, 'Are you afraid of blood?' and she essentially said yes. He said, 'Why don't you just get a towel and put pressure on it?' and told her what to do. Later he asked me, 'Who are these people?'"

Now, when new PCAs are hired, they receive eight weeks of basic training, minimum -- but that only "evolved," as administrators put it, after RNs protested. The RNs, meanwhile, found themselves passing out food trays and stocking supply carts. "My new assignments included cleaning out the dayroom," recalls Nancy Cook, a psychiatric nurse who's since left the hospital. "One day I was scraping melted cheese out of the microwave, and I looked up and here's one of the psych techs sitting down charting." She sighs. "They didn't have the training, and they didn't have the humanity. One came from the gardening crew. One didn't want to lay hands on the people -- some needed to be toileted or cleaned or dressed, and this person simply did not do it. We were told to be tolerant."

Jody Miller, an ER nurse who's since left St. John's, says "after the first wave, we started noticing that we couldn't get our patients out of ER because there was no one upstairs to accept them. Meanwhile, the hospital was starting to ask us to draw blood, do EKGs and give respiratory treatments, because they were getting rid of the respiratory therapists."

Today, conditions vary dramatically, depending on the area of the hospital and how smoothly its teams function. Kerry Thacker, who's worked at St. John's almost 24 years, heard two patients saying, "This is just the worst floor!" and wanted to tell them, "'I'm sorry. You are getting the thrift treatment.' We're a medicine floor, and the average age of the patients is 70. They have multisystem breakdowns -- kidneys, lungs, heart, diabetes. They are on Medicare, so the hospital gets reimbursed less for their care. And each PCA has 10 patients to take care of."

St. John's chief nursing executive, Christine Crain, still insists that patient-focused care was a necessary improvement.

"The history of it is that we were getting feedback from our patients and from the physicians about the lack of continuity, that they would see as many as 50 or 70 different faces of people coming in to provide some element of care for them," says Crain.

So this wasn't a cost-cutting effort? "Let me -- " she blurts, determined to tell the story in a certain order. "So as we were looking at that information in terms of how to meet their needs with more consistent caregivers," she resumes deliberately, "we were exploring how we could do that better, and at the same time, health care was being faced with some significant challenges in terms of economics, managed care, decreased reimbursement. The public was telling us that health care was too expensive. So we came up with a system of care delivery that's team-based."

What, specifically, might that mean? Joan Kretschmer, who's been at St. John's for 15 years, says that before patient-focused care, her 24-bed ambulatory-care unit had four nurses on days, four on evenings and three on the night shift. Now they have three nurses on days, three on evenings and two on nights. They used to have at least one nursing assistant around the clock, with a second overlapping in heavy times. Now there's no overlap, and no PCA at night. The unit secretary's hours have been reduced, too, forcing the RNs to enter doctors' orders into the computer and answer phones, as well as respond to call lights all night. "We also no longer have lab techs coming in to draw blood, central service stocking the supplies for us twice a week, or an efficient housekeeping system that cleans the bed stat if you need it," adds Kretschmer. "Everything has shifted onto nursing. We're expected to clean the room, empty the trash and strip the bed before housekeeping even comes in to sanitize it, and you might wait an hour for a 'stat' bed to be sanitized."

Crain admits, "There is a challenge with housekeeping. We have experienced some vacancies. Nurses do pitch in. And I know that sometimes that can be a burden." But Kretschmer's concerns don't end there: "The ER is backing up with patients. And doctors are skipping the ER because it's so crowded, so we do a lot of triaging.

"I come home beat up," she finishes. "Sometimes it's 1 a.m. before I get out of there" (she's supposed to leave at 11:30 p.m.) "because I won't go off and leave the night shift if they're in obvious distress. Some nights I just pray, 'Don't let anybody go bad on me, because I am stretched so far I will miss it.'"

Last April, Dr. Farrin Manian, an expert in infectious diseases on staff at St. John's Mercy Medical Center, published an article in the New England Journal of Medicine asking, "Should We Accept Mediocrity?" He didn't mention his hospital by name, but he did enumerate consequences of patient-focused care: "Experience in basic health care services such as drawing blood and starting intravenous lines doesn't seem to matter much anymore, and in fact may be detrimental to one's future job security.... Important information such as vital signs, medications, and status of the intravenous site is no longer predictably documented in the patients' charts.... Changes in patients' clinical status (e.g., new onset of chills or changes in mental status) are not necessarily recognized by the nurse's assistants, nor are additional vital signs measured."

Manian summarized the problem neatly: "Those who hire non-nurse patient care workers to do nurses' jobs at lower wages seem to have underestimated the importance of the basic nursing skills required for recognizing when something is wrong. These skills cannot be acquired overnight, and yet miraculously anyone interested in taking vital signs and working in the health care field seems to have become qualified."

Have managed care and other economic pressures done as much damage as administrators anticipated? "Yes, absolutely," says Crain. "It has been a significant challenge to provide for the care of patients with decreasing reimbursements."

Yet according to a June 29, 1998, article in Modern Healthcare ("Market Pressures? Say What?"), hospitals in St. Louis "expected to have to defend against healthcare reform, managed care, cutbacks in federal reimbursements and declines in utilization. So they cut costs internally.... But healthcare reform never happened, and managed-care penetration stalled at about 25 percent of the market." Meanwhile, the hospitals had learned to negotiate en bloc, and they were so well-connected with the religious and corporate communities that there weren't "too many outsiders or bit players stirring up trouble or asking rude questions."

In 1994, right before the big reorganization of care, St. John's Mercy Medical Center (including a hospital in Washington, Mo., and other profit centers) reported $330.4 million in revenue. The next year, St. John's president was asked to resign and was replaced by Weber, a business-focused administrator who'd cut his teeth at Barnes Hospital. Then St. John's merged into the Unity Health System, now one of the region's four major systems, second only to BJC Health System in size and profitability. Unity is sponsored by the Sisters of Mercy Health System-St. Louis, itself the 14th-largest nonprofit health system in the U.S. "Mercy values" are still intended to rule -- although in March, the Sisters of Mercy ceded control of the system's day-to-day operations to laymen.

For the fiscal year ending June 1997 (the most recent data available), St. John's Mercy Medical Center reported revenues of almost $347.5 million and "excess" of $21.6 million. This December, when that Top 100 Hospitals award was announced, an article in Modern Healthcare characterized the winners as hospitals that "were able to do more with less. Compared with all U.S. hospitals, they employed 18 percent fewer staff members per 100 adjusted patient admissions, their occupancy rates were 22 percent higher, and they were 38 percent more profitable." St. John's made the list, the article reported, because of decreased lengths of stay and decreased expenses per discharge. "Profitability also outpaced the benchmarks: a cash-flow margin of 21.6 percent for the medical center vs. the 15.6 percent benchmark."

Obviously managed care was a challenge.
But maybe they overreacted.

St. John's recent management decisions aren't uniquely awful, they're typical. Nurses just aren't prepared to accept the new, numbers-driven version of patient care as inevitable. The general estimate is that 15-17 percent of the nation's RNs are already unionized, and campaigns are springing up in every major city, with about a dozen major unions competing for their business. But here in St. Louis, the St. John's nurses -- if they succeed -- will be the first to unionize. And if the St. John's nurses do organize, other health-care workers at the hospital -- and nurses at other hospitals -- are hoping for "a domino effect."

"St. Louis is one of the top 10 or 15 health-care markets in the country; it's right up there in terms of the pace and scope of change," notes Richard Sanders, national director of organizing for the American Nurses Association. "The nurses have been responding to it on their own for a long time." Now about a dozen major unions are competing for nurses' business. Sanders pauses, then says delicately, "Depending on the outcome at St. John's, we would be eager to start working with their nurses again."

The general public doesn't care which union the nurses choose -- we just want to know whether they'll strike. "The chances of that ever happening are pretty slim," says pro-union Lisa Nesler, a part-time RN in neurosurgery, "but when there is a health-care strike, it's not like there's a work stoppage. You cross the picket line. They scale things down, eliminate elective surgeries but still do traumas. It's not like nurses walk off the job and shut the doors."

Sanders says there's one strike per 100 negotiated contracts, so there's about a 1 percent chance of a strike. "I can't say there is no risk. But federal labor law governing health care is different than other industries because of the delicate, critical nature of the job. You have to give 10 days' notice before you can even do an informational picket, and federal mediators have to be involved."

The first attempt to organize at St. John's came back in 1984, when a group of nurses banded together for mutual support. "Management got so threatened, they gave everybody a 13 percent raise we didn't ask for," recalls Kathrine Metze Geldbach, a longtime psychiatric nurse. "Then they crucified the leaders. And we weren't even trying for collective bargaining!"

In 1996, spurred by the staffing changes of patient-focused care, the nurses did ask the Missouri Nurses Association (MONA) to help them unionize. The hospital promptly hired Industrial Relations Inc. (IRI) of Detroit, popularly known as a union-busting firm. Asked how much this counter-campaign cost (it's usually a pretty penny), St. John's PR manager Bill McShane says it was not a campaign. "IRI was brought in to educate management and employees about union organizing," he explains. "Financial arrangements are considered proprietary information."

IRI's visible tactics were innocuous: "They organized focus groups for employees to come in and talk," says Geldbach, "You were told it was to get your suggestions, but really it was to get a line on who might be pro-union." (At Warren Schools Credit Union in Detroit, IRI focus groups unearthed the invaluable information that employees didn't like the lighting in the parking lot.)

Geldbach fell for the focus-group shtick herself. Of course, she was tired: "They gave me a triple assignment. I was in charge of patients in full leather restraints, six suicidal borderlines who run around slicing at their wrists with plastic silverware, and patients who couldn't breathe after shock treatment. And in the middle, my boss would say, 'Metze, get your ass in here.' They ambushed people when they were harried: 'Get your things; we will be leaving the floor.' You thought you'd been fired, and it would be some silly meeting or other. They just wanted to keep us jumpy. And they did."

Miller remembers "looking to the nuns, going, 'Ladies! What happened to the Mercy values here?' But, as they frequently reminded us, we were employees at will. Some girls started seeing copies of their charting show up in their mailbox written over in red, 'You did this wrong,' reviewing stuff months later just to let you know they were watching you."

What IRI hadn't done was educate hospital managers about how labor law forbids interrogation, intimidation, harassment and coercion.

Another early union supporter, Nancy Cook, had worked in psych for 12 years. Four months after the MONA campaign began, she "walked in and found myself transferred to a geriatric unit. The head nurse wouldn't even talk to me about it." On another occasion, Cook says she was summoned from a busy floor and grilled by the director of nursing about the union. "At one point they made the comment that the hospital would never negotiate," recalls Cook. "That's illegal."

Hers was one of the cases cited in a 1996-97 complaint to the National Labor Relations Board. Nurses claimed that the hospital had "interfered with, restrained and coerced its employees in the exercise of their rights," making threats, discriminating against union organizers.

St. John's only penalty was to post a notice for two months, spelling out the labor law and promising to comply. They did so -- in tiny 12-point type.

Inside a year, the MONA campaign ran out of money, steam and courage. So the core organizers, still determined, interviewed the AFL-CIO. And it turned out that the AFL-CIO, a powerful organization whose industrial base is flagging, was just as interested in health care as health care was in them.

A group of St. John's nurses chose the AFL-CIO United Food & Commercial Workers (UFCW) Local 655, and on a rainy day in April of 1997, they announced their campaign, passing out sopping-wet handbills. They'd already gathered quite a few nurses who'd sat out the first campaign. "What pushed me over the edge was seeing the way they were trying to drive the older, higher-paid nurses away," says Kerry Thacker. "I'd see individuals targeted and punished, taken off committees they'd served on for years. And then it was my turn."

She realized how little recourse she had when she got into trouble for violating patient confidentiality -- a coworker was being treated in the hospital and, out of concern, she mentioned this fact to other nurses. "A few weeks later, my manager came in on her day off, and I got what's called a 'major counseling' -- meaning, one more incident and you're terminated. And if you talk about it to anyone else, you're terminated."

Several nurses understood that to be the policy -- Darlene Crafton, a St. John's nurse for 22 years, says she was told she was "in big trouble for violating confidentiality because I talked about my counseling." Yet, according to Crain, nurses are free to divulge details of their own counseling. It's patient confidentiality the hospital guards -- a good idea, but one that's been pushed so hard that many nurses are scared to talk specifically about anything connected to patient care, even without names.

The UFCW campaign's been fervent, and though they need only 30 percent to file for an election, workers estimate they've already gathered signatures from more than half of the nurses. They can't learn the official total until they file, at which time the hospital must release a list and negotiate which categories of nurses will vote. Any day now (symbolically, the nurses are hoping for the first week of May, which is National Nurses Week) the UFCW will file, and once the procedural wrangling ends, St. John's nurses will decide by secret ballot whether to unionize.

This time around, the fight's been milder, subdued by the presence of a powerful national union. Experience helped, too -- now the administrators know their legal limits, and the nurses know their rights. "The first time we leafleted the hospital, security said, 'You can't do that,' and I said, 'Oh yes we can,'" recalls Prade. "We didn't know we had a right to be there until the UFCW told us." On another occasion, a supervisor approached nurses who were passing out union literature (perfectly legal outside patient-care areas) and asked them to leave, telling them it was "very unprofessional." They refused.

Overall, though, the hospital's treading carefully -- Crain says they consult frequently with their labor lawyers to avoid doing anything illegal. The union's worst complaints are gray-area anecdotes: a manager who's "individually asking people in her department how they stand on the union"; a Unity van driving by the UFCW headquarters at meeting time; administrators offering half-truths and dire speculations.

The RNs found templates for most of management's rhetoric in Confessions of a Union Buster by Martin Jay Levitt (Crown, 1993): "Assure them they can come to you with any complaint, and let them know you'll really listen.... Warn them that once the union takes over it's out of your hands. From that moment on there will be no more flexibility.... Tell them that they won't be able to speak for themselves, and you won't be allowed to answer."

Sure enough, Nesler says, "Head nurses have approached people, saying, 'When the union comes in, we won't be able to talk to you like this.' People hear that and go, 'Oh my God, you mean I wouldn't be able to go talk to Jan?'" One hospital memo warned that a union "can do whatever it wants, despite the wishes of the employees." Last year, administrators put out a "fact sheet" pointing out that UFCW Local 655 has expenses of $14.2 million, etc., etc., and warning employees, 'You may lose the fellowship and sense of community among employees ... you may lose control of your personal relationship with management." Then they gave blanks for people to fill in: "When I need a day off, I ___. When I want to coordinate my vacation with my spouse's and my kids' school schedule, I ___. When I have a concern and want to talk with my supervisor, I ___."

Asked whether such portents are accurate -- whether snakes will grow from the heads of union organizers and relationships will harden into stone -- Crain says, "All of that becomes part of a negotiated contract, so it's hard to speculate." Asked if any anti-union nurses attend the union meetings (union supporters rattle off lists of suspected spies), she repeats the question musingly, then says, "The invitations are sent to everybody. I don't know who goes to the meetings. But I would expect that there might be some folks. We've encouraged people to get both sides."

They're getting only fragments of the union side, supporters argue; they hear a few bits out of context, and management gets a skewed report. Still, their presence is technically legal. "The problem is, there are nurses in the gray area -- not managers, but former managers, or loyal to people in management," explains Skurat. "They stick out like a sore thumb."

What the RNs really resent, though, are the parties.
"The day before the big UFCW meeting, the administration ordered pizzas for the entire hospital," says Prade. "The summer of the MONA campaign, we all got to go to Six Flags." Skurat recalls an ice-cream social last May -- one month after the union kickoff -- with the theme "We're a Hit!" bolstered by a jukebox in the cafeteria and beaming administrators. It was a great example of what Confessions of a Union Buster called "anti-union good times sponsored by a chastened and caring management." Then there was the 1998 Christmas party. A surgeon -- wearing a suit that day instead of scrubs -- made a casual comment about the union, teasing that the employees might owe this especially nice spread to their looming presence. He was approached immediately by security guards. Nurses heard that the guards later apologized, explaining that they thought he was a union agitator. But administrators insisted that he "was not asked for identification because he was making comments about the union but because it was not clear that he was a SJMMC/Unity Health employee. Contrary to SJMMC policy, he was not wearing his name badge."

Christmas may have been dampened, but in February, St. John's made up for it. To celebrate the Top 100 recognition, they hosted a Top FUN Hundred Winter Barbecue for all employees, complete with a pie-eating contest ("Be ready to get messy!" the flyer urged) and a limbo contest ("How low can you go?")

That's precisely what the nurses wanted to know.
"They are milking that award for all it's worth," groans Prade. "Just the other day they were passing around $100,000 Bars on little pushcarts with tablecloths. We had a baby dying that day, and I thought, I could sure use a little help here instead of a candy bar."

The highest authorities of the Roman Catholic Church have consistently spoken for unions as a right fundamental to human dignity, a way for workers, in the words of Pope John Paul II, "to defend and promote their interests and to contribute in a responsible manner to the common task." Yet last June, Sister Mary Juliane Carey, vice president for mission integration at St. John's Mercy Medical Center, wrote the RNs, "In light of recent organizing activities ... I would like to share with you our position on unions in health care, which is based on Catholic Church teachings." In essence, she argued that they already recognized workers' dignity but believed that, as a hospital, they would "best serve the common good by maintaining our mutual relationships, free from another party's intervention."

Such rhetoric pulls at faithful employees' heartstrings, and the union supporters' frank criticisms anger and embarrass them. When the St. Louis Post-Dispatch quoted nurses saying the hospital's housekeeping was slipping, you would have thought someone had accused the entire staff of illegitimate pregnancy. "We all need to learn to pick up our own messes," wrote a chastened staffer, and Crain fired off a letter saying, "I am especially offended by attacks on our quality of care and cleanliness." (One RN responded tartly, "We are sorry Chris Crain is offended by statements regarding lack of cleanliness. Maybe she and other administrators should come out of the office to patient-care areas.")

A few months ago, administrators produced a video, Something Special, to answer nurses' questions about unionization. One after another, administrators talk of strained workplaces, rigidity, injustice and risk. "The people of St. John's Mercy have created a special working environment," the narrator intones. "A union has no place at St. John's Mercy. Not then. Not now. Not ever." There's footage of a smiling nun hugging a nurse and a paean to the Mercy values: dignity, justice, service, excellence and stewardship (and they don't mean the union kind).

The video closes with Weber, the hospital president, recalling an encounter on the elevator with a nurse who'd tried three times to make it through a snowstorm. She finally made it, and covered her floor all weekend. "She'd been working I don't know how many hours straight," he says, awed, "but she took the time to stop and, not complain, but tell me it was worth it because of the mission."

Crafton says, "If you didn't see the video screening, you'd meet one-on-one with your supervisor and watch it together, and if you didn't do that, they sent it to your home. After one session, supervisors said, 'We can have an open discussion; just feel free to say whatever you want,' and one woman stood up and said she was for the union and the supervisor said, 'I am deeply offended.'"

Crain insists that the answers to all problems lie "in the heads and the minds of the nurses who work here." Why is it that so many nurses don't share her confidence? "That's somewhat confusing to me," she admits. "When I look at the care that's provided here, the overall system, I believe that it's a very fine one." Does she think the nurses will vote to unionize? "I believe that they will make the best decision for nursing," she replies firmly, "which would be to not (unionize)."

Many agree already. "There are people who are part of the problem and people who are part of the solution throughout life, and the people who are not part of the solution are the people who are doing this," snaps Marsha Kenison, an oncology nurse who opposes the union. "They are always looking for something different that is not there. They think they have bad patient ratios." The agitators forget, she adds, that "this is a business. It's a hospital, but it's also a business."

"I had two people from the union come to my house, knock on my door and call me by name," continues Kenison. "I felt real invaded." Does she think the union will win? "It's a fear. I'm going to find it very difficult to work under a union. I'm not going to have the voice I have now, and I'm going to have less money because I'm going to put it out in union dues. Quite honestly, I think everything is going to be worse, because you will have people controlling your destiny that have no idea what you do."

Jessica Winning, a charge nurse in the burn center who's worked at St. John's for 13 years, doesn't think the union has a chance. "If you are willing to work and document your complaints, the system works," she says. "Maybe if the issues they were striving for had to do with salaries and benefits, maybe I could see where they were going. But this isn't even a money issue. This has to do with staffing and ratios and the climate of health care. No union is going to change the way we get reimbursed. (Insurers) are the ones pulling the strings."

Prade sums up other anti-union positions she's heard: "For some it's financial. 'St. John's isn't going to listen anyway, so why should I pay someone money?' Some are afraid the administration's going to find out they're doing this and get rid of them. Some are traditionalists; they don't believe in nurses and unions, ever. And some are just major suck-ups. Then there's all the negative stuff: 'If we get a union, we won't be able to work anywhere else'; or 'If the food workers go on strike, we are not going to be able to work, either.' They are taking industrial rules about foremen and applying them to nursing. People say the union will tell us to strike -- no! We vote on that. And we're having enough trouble getting 50 percent to vote on this -- how in the world do you think we're going to get a two-thirds majority (what most nurses' union contracts require to strike)?"

The hospital's basic argument is that a union can't do anything about staffing or patient care, because those are management issues. Unions can only tackle workplace issues -- benefits, salaries and so on. But in nursing, trying to disentangle money and workplace issues from the quality of nursing care is like trying to draw only plasma from a patient's arm. Pro-union nurses have heard of unions' getting staffing increased, minimum nurse-to-patient ratios established, policies changed, workplace conditions improved and, above all, patient-care committees established: committees of elected -- not handpicked -- nurses, to whose concerns the hospital must respond within a specified time.

In short, the nurses want a voice, and they want answers when they speak. "You can fill out quality-improvement forms until you are blue in the face," sighs Prade, "and they will say, 'We are looking into that.' If they say anything at all."

Crain says there are "multiple examples where their concerns and suggestions have been acted upon. There was a request that full-time status be 72 hours instead of 80 hours; that change was made last summer. We have rooftop parking on the garage, and they asked if on the weekends that could be used, so we changed that and they can certainly park on top. In terms of clinical examples, there was an identified need to standardize the pediatric emergency carts. And the nurses on one of the areas identified a need for more telemetry. There are many avenues where we have demonstrated that we do listen."

She offers the Nurse Executive Council -- established during the MONA campaign -- as an example of RNs participating, voluntarily and influentially, in decision-making. But Prade -- the only union supporter on the council -- says members are handpicked by their managers, and she was only invited to serve after she pointed out that no one was representing her unit. "Rather than dealing with staffing issues, they are arguing about how crash carts should be set up," she says. "When someone from human resources came to talk to us, I did ask a question about the (freshly eliminated) career ladder. At the start of the next meeting someone said, 'I was really ashamed of our behavior last time -- we had guests.'"

Frustrated by politesse, martyrdom and new name tags that blurred any distinction between RNs and PCAs, nurses from St. John's successfully lobbied the state Legislature for a bill stipulating that RNs' credentials be prominently displayed on their name tags. On Oct. 26, 1996, a hospital Q&A promised that "in the near future, the name badge format will be changed to enlarge the RN credential." Then MONA went away. And the next time the nurses asked about changing the name tags, they were told that the new law made "no mention of the type size of the credentials. We have always displayed credentials in the name badge and will continue to do so."

Recently the badges were redone yet again -- this time removing any job specification from the PCA badge and wiping out any extra credentials of registered nurses (such as "B.S.N.," indicating a full four-year nursing degree). The informal, stewardessy first name stayed bold; no chance of a respectful "Ms." or "Mrs." or "Nurse Jones." The "RN" ... stayed small.

As for uniforms, administrators say the nurses wanted scrubs. "Sure we did," agrees Marge Herbert, who's worked in gynecology for 15 years. "That was before they went into patient-focused care. And at first, nurses were going to wear certain colors of scrubs, so you could still tell the difference."

Administrators purchased "nursing recognition pins" to quiet the clamor. And just recently, when hospital executives wrote to warn nurses that the union could have a negative effect on St. John's, the salutation was quite distinct: "Dear Professional Registered Nurse."

After professionalism, which appears and vanishes like a hologram on a cheap ring, comes the grievance policy, written in lemon juice and visible only under heat. According to Herbert, "They stopped distributing employee manuals to people years ago, and the grievance procedure is certainly not publicly known."

Asked whether there's an employee manual that outlines a nurse's grievance rights, Crain repeats the question, softly puzzled. "We have a human-resources manual, in which the grievance policy is clearly outlined. Each of the managers has it. (Nurses) can access it through the HR department." They'd better watch their timing, though. "If some nurse who is overwrought happens to blow up and use a four-letter word, she's fired," says Crafton, referring to a specific termination of a 17-year employee. "This woman knew about the grievance policy because she'd been a supervisor in the past, but when she wanted to exercise her rights, they said, 'You cannot, because you have been terminated.'"

The policies that are clear to all parties are the ones removing benefits. With patient-focused care, the hospital stopped offering shift differentials (higher pay as an incentive to work evenings or nights), as well as long-term-service days and two paid days a year for continuing education. Crain points out "newly identified sources of funds" for such education: The hospital donated its cut of Life Uniform sales, and the physicians offered money from their own research fund.

"The reason we got upset was nursing care," says Prade. "But as they continue to take away and take away and they put out anti-union literature saying, 'What can the union promise you?' it's real hard to sit and listen. They claim they are losing money because of managed care, but they are a not-for-profit institution that makes millions in profit every year. And they constantly redecorate. The new admitting area has Corian countertops, wood-paneled walls -- it's gorgeous. They told us they built a new corporate building for Unity -- with a fountain and a running track, yet -- with a $40 million surplus from cash reserves. And then they say there's no money to improve staffing."

Overall, is patient-focused care working? "We have teams that are at different points in their evolution," Crain says carefully. "The creation of the PCA role was a consolidating of some of the other tasks that folks assisted the nurses with: traditional nurse-assistant tasks, some of the phlebotomy.... It was an attempt to have the majority of the patient's care needs met by that group of caregivers."

She sees the shift as a way for nurses to become less task-oriented and more managerial. "It is our responsibility to participate in the care by using our critical-thinking skills, analyzing the data and helping to certainly provide the care for patients but also direct the care." Do the nurses have enough time with their patients to give -- or direct -- quality care? "I do believe here that the nurses -- I personally monitor staffing here on a very consistent ongoing basis, and I believe that our staffing patterns and ratios are absolutely adequate," she replies. "There may be isolated situations here and there, but the nurse-to-patient ratios are better today than they were in '93-'94, because the folks that are left here are sicker."

Maybe she means the ideal ratios -- because if the actual, current ratios were that good, St. John's wouldn't be looking to fill more than 150 RN vacancies, plus almost 90 PCA posts, and they wouldn't have created more than 110 new RN positions in the past year. They're struggling to rebound, especially because the average daily patient census is up to 528, a 7 percent increase since 1995.

Peggy Palermo, a critical-care nurse at St. John's for 15 years, says the ratios are misleading anyway, because nurses are doing more secretarial work, lab work and housekeeping work. "You can't spend any time doing patient teaching or preventive treatment," she notes, "and we don't keep charts and records the way we used to, noting every detail or warning sign. We don't even have time to fill out incident reports when something goes wrong." You also have to measure ratios on the bad days, not just smooth them into an average, she adds, because "there's no longer any nursing staff to pull in. We're below skeleton."

Crain swears the overall turnover rate hasn't increased, and the overall level of nursing experience hasn't dropped significantly. A few months ago, she distributed a video detailing recent recruitment efforts. Was it convincing? "I suppose if you hadn't been at St. John's for a while, it might have been," acknowledges Herbert. "But all these things have been said before. During the MONA campaign, they staffed up too, but afterward, things deteriorated again."

Thacker worries about inexperience, noting that 21 of the 48 RNs on her floor have been there for less than a year. "We've had nurses taken out of training because of staffing necessity. And those fresh out of orientation are training new orientees." Prade says "in peds (pediatrics), if you've been there a year you're an old-timer. In mother-baby, we had one girl who said, 'I've only been there a year and I'm orienting new people.'" (Those new people, incidentally, start at $12.68 an hour; long-timers at the top of the pay scale make $24.12 an hour.)

"Certainly new nurses do require training," concedes Crain, pointing out that the hospital has excellent educational programs. "We all started as a new nurse at some point." That's slim comfort, though, to those who depend on them. "There has been a mass exodus of some really good nurses," notes a physician. "We have a lot of new faces, relatively inexperienced, taking on the patient care."

The other training issue involves nurses assigned to "float" to a shorter-staffed area. D.J. Gross works in the mother-baby area, a happy, cheerful unit that's "probably the best-staffed in the hospital. It's the PR area, and we have an excellent department. But we get pulled to the NICU or peds or gyn.... You need to know where things are; you need to know the routine. With a contract, we could specify that we want adequate training, so we don't endanger any patients and run the risk of losing our license. It's just a very uneasy feeling you have when you are taking care of someone and you are not really sure what you are doing."

Prade, who's in the NICU, says, "They will pull in a maternity nurse who never really did babies. We try to give her the easiest cases, but there are times those babies are actually getting sick and that nurse doesn't know how to pick up the subtle signs." Conversely, when Prade was "floated" to pediatrics, she found herself taking care of "a 13-year-old, two days post-op with a spinal fusion. I am so far out of my league here."

Crain points out that "there was a time when nurses floated to multiple areas." (Granted, patients were less sick in those days.) "Now we are structured into care centers, groups of similar patients; we have identified and established networks that nurses float to, to ensure that the competency they need is appropriate for the needs of the patients." In other words, if you're a neonatal nurse you should already know how to take care of that teenager with the spinal fusion.

Jessica Winning echoes Crain's point: "We are pulled within a sister network. They may have changed where they put their IV bottles, but for the most part I feel very comfortable. I have not been given an assignment that I personally cannot handle."

But judging from the question in one of the hospital Q&A newsletters, not everyone's as calm as Winning, or as experienced. "What is the criteria for being a charge nurse?" the writer asked. "Our area is frightening. There are many night shifts where the combined RN experience is six months!" The reply was that administrators knew of no such area, unless the writer was talking about nights when someone was "floated" to the area. "To be a primary charge nurse, six months of experience is required."

Cost-cutting has meant cheaper supplies (sutures that break faster) and different priorities. Nurses say that when a patient dies, there's new pressure to whisk the body away and make room for a new patient, instead of decorously sealing the room for a while. "We're often sent prisoners," notes one nurse, "and recently they put a prisoner who was shackled to the bed with a guard in the same room with a regular patient who happened to be aphasic, totally alert but unable to speak. The nurse on duty objected, but they said they had to fill that bed."

RNs get furious when they talk about such practices -- but later they agonize over what they've said, afraid of hurting co-workers' feelings or slighting the head nurses they do respect. "People say, 'Oh, you are going to make people hate St. John's,'" sighs Prade. "No! We're just trying to improve the care!"

This union push is, in the end, not so much a battle for workers' rights as it is a crusade -- for old-fashioned patient care and for nurses' long-ignored dignity. In many ways, they've been their own worst enemies -- even the feminists refer to each other as "girls," and they joke self-consciously about being "good" and "sweet" and "co-dependent." Kretschmer's quick to explain the "nursing psychology" they feel administrators exploit: "Nurses will bend over backwards; they will stretch and they will cover." She pauses. "I am to the point where I am no longer able to do that. I can only stretch so far. And I don't feel safe.

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