Enough Nurses?

On July 6, during the day shift in Unit 2100  at Christus-St. Vincent Regional Medical Center, a nurse cared for two patients labeled high acuity—medical parlance for seriously ill.

The nurse deemed one patient, who'd just undergone foot surgery, as "non-compliant." Another patient for whom the nurse cared "was an IV drug user."

The drug user, reported the nurse, had "made arrangements to meet someone at the hospital to bring him drugs."

The drug user's escape from the unit went unnoticed. His nurse was on a rapid response call for one patient while trying to monitor a separate patient's "continuous bladder irrigation emergency."

"After both previous emergencies were under control," the nurse later wrote, "I went to the front entrance of the hospital and found the IV drug user patient almost outside. I needed to call security as the patient would not return to his room."

On May 11, during the day shift, seven nurses, two nursing assistants and a secretary watched over 34 patients in Unit 2100.

That's four beds short of the unit's capacity.

Four call lights had been left on for 30 minutes without a response from hospital employees.

Meanwhile, a surgeon instructed that a postoperative patient should get out of bed three times a day. But the patient's nurse left a note for the surgeon saying that task was impossible. The  patient "required coaxing" and moderate assistance to get out of bed, "which took 20 minutes."

"Because of short staffing, no one had time to get this patient out of bed more than once," wrote a nurse on the unit, "and once to the bedside commode."

Another patient in Unit 2100, on June 4, could have only wished for a bedside commode.

The patient "had a 'fecal accident' because no one was available to take the patient to the bathroom," a nurse reported later.

These are just a few stories told in anonymous nurse reports  provided to SFR by District 1199NM of the National Union of Hospital and Health Care Employees, the union that represents nurses and other employees at Christus St. Vincent, along with hospitals across the state.

Tension between management and the union has been simmering since the two parties entered into a collective bargaining agreement in August, 2011. The agreement abated a strike by nurses over alleged staffing shortages at Santa Fe’s largest hospital. Having too few staff, nurses say, seriously compromises patient care. It can lead to harder hospital stays and even preventable death.

Yet two years later, nurses say the staffing problem persists. And as the expiration date on the collective bargaining agreement approaches—July 31, 2014—union nurses have been alleging that Christus St. Vincent has been violating its own staffing standards etched into the contact. The hospital disagrees.

Hard data about staffing levels is sorely  absent from the contentious debate.

But union leaders say hospital memos obtained by SFR indicate the benchmark for staffing levels at Christus St. Vincent are below staffing levels of 60 percent of peer hospitals.

A hospital document states its benchmark for the amount of hours nurses spend with patients daily is at the 40th percentile of that of peer hospitals, meaning that 60 percent of comparable hospitals are more robustly staffed with nurses and other auxiliary unit employees.

Previously, Christus St. Vincent pegged its hours-per-patient day benchmark at the 50th percentile, according to hospital documents and nurses.

But the hospital appears to have lowered the bar for the current fiscal year.

The hospital refused to grant SFR an interview with any top managers for this story, then  declined to respond directly to a series of written questions. Instead, spokesman Arturo Delgado issued a general statement.  The hospital’s nurse staffing levels “are based on patient acuity” and “national benchmarking standards,” he writes in an email Monday.

“When benchmarking,” Delgado writes, “we look at hospitals of similar size and scope at our hospital.”

Delgado would not provide SFR with a nurse-to-patient ratio at the hospital, but he writes that hours of care per patient day, the hospital’s projected census, the skill of the staff and severity of patient conditions all factor into deciding staffing levels.

“At Christus St. Vincent Regional Medical Center,” he writes, “we are proud of the hard work and dedication demonstrated by our nurses, and staff, on a daily basis. Patient safety and patient satisfaction are always our first priority.”

He adds that it is “unfortunate that union leadership would choose to disparage the hospital and the wonderful care our staff provides each patient, every day.”

On June 10, the union took the unusual step of lodging a complaint with the state Department of Health, which has regulatory authority over New Mexico hospitals.

The union asked the department’s Health Facility Licensing  and Certification Bureau to investigate whether the alleged staffing shortages represented a danger to the “health, safety, or welfare” of the patients and staff at the hospital.

Like many states, New Mexico doesn’t mandate a nurse-to-patient ratio for hospitals.

State regulations say that an “adequate number” of professional registered nurses “shall be on duty at all times to meet the nursing care needs of the patients.”

The number of “nursing personnel for all patient care services of the hospital,” the regulations say, “shall be consistent with the nursing care needs of the hospital’s patients.”

“The ratio of licensed nursing personnel to patients,” reads another section of the administrative code, “shall be determined by the acuity of patients, the patient census, and the complexity of care the must be provided.” (A patient census is the number of patients in the hospital).

In response to the union complaint, DOH conducted a site visit of Christus St. Vincent on July 11 and concluded the hospital was in compliance with “applicable regulations.”  However, it noted several deficiencies in patient care.

Among them: the hospital “failed to ensure that medical records were accurately written and that documentation was completed promptly following patient falls” that occurred between June 1 through July 1. DOH surveyors also found that the hospital “failed to ensure” that medical records of three active inpatients who required turning or repositioning every two hours were kept.

According to DOH documents, there was no immediate documentation of a patient fall on June 23, other than “a retroactive charting or a late entry nursing note in the medical record,” logged the next day. The “late-entry” note by the nurse, states DOH documents, said the patient had been transferred to a new room in the evening “to be more visible” from the nursing station.

“[B]ut at the time of the fall,” states the DOH document, “there was nobody at the nursing station, due to staff being busy with other patients.”

Christus St. Vincent said in plans of correction that it will begin auditing charts and “re-educating” nurses.

“The complaint was unsubstantiated,” the DOH investigative report says of the union’s allegations. “There are no federal or state specific ratios identified for staff/patient ratios at present time,” writes DOH spokesman Kenny Vigil in an email to SFR.

Delgado writes that the department review was not based on the July visit alone, but that investigators “reviewed 6 months of hospital staffing and outcome data and determined that union leadership claims of compromised patient safety were unsubstantiated.”

The hospital called DOH’s visit “unannounced.” (Vigil says DOH “does not let a facility know beforehand about a site survey.”) But the union alleges Christus St. Vincent staffed up for DOH’s visit. It filed the complaint on June 10 and the investigation occurred roughly a month later.

The union’s “staffing insufficiency reports” from that time period show nurses expressing surprise that units were overstaffed.

“Overstaffed!” reads one report filed by a nurse on the Behavioral Health Unit on July 8. “Why—DOH?” The unit, according to the report, had a nursing assistant when the required staffing grid didn’t call for a nursing assistant.

“Staffed up 1 [registered nurse] and 1 Unit Secretary,” reads a report filed July 10 from Unit 2100. “DOH at CSV.” The nurse listed one extra registered nurse working on the unit, along with one extra secretary.

“[F]ull compliance of staff,” reads another July 11 report from the Rehab Unit.  The unit had eight employees, according to the report, caring for 18 patients.

Days later, on July 12, five hospital employees—three nurses and two nursing assistants—cared for the same number of patients. “Short 1 RN,” reads a union report. “Short 1 Unit Secretary as Unit Secretary made to sit for 12 hours. Unit secretary states it was obvious they staffed up for DOH. DOH never came to Rehab to visit with staff.”

The union has been collecting the staffing insufficiency reports since at least January. The reports, however, are difficult to independently verify.

They don’t reveal any names of patients or of nurses making them, and they’re meant to further the union’s goal to “present statistical and other relevant data to lawmakers to help them pass legislation that mandates safe staffing levels,” according to the union’s website.

Union officials say they believe the reports are coming from a small number of nurses, but they declined to say how many of Christus St. Vincent’s nurses are dues-paying union members. Meanwhile, the hospital won’t say how many people it employs or address  specific allegations in the reports, including the target time for staff to respond to a patient call light.

Yet the reports detail dates of incidents, the required staff working at the time of the incidents, the actual staff working during the incidents, the number of patients during the shift, the units where incidents occurred and the effect that alleged insufficient staffing had on patients.

The anonymous reports still provide a rare glimpse into the operations of a hospital that has tried to stifle nurses from publicly talking about their experience inside the units.

The hospital filed a grievance with the National Labor Relations Board accusing the union of violating contractual clauses in the collective bargaining agreement that prevent nurses from entering into a strike or a lockout.

An attorney for Christus St. Vincent accused the union, in a letter, of undertaking an “illegal corporate campaign” in violation of contractual language that states the union shall not engage in “concerted action where the purpose or effect is to interrupt, interfere with, impair, impede or obstruct any phase of CSVRMC’s operations or business.”

The letter further alleged the union violated a clause that the parties “agree to cooperate with one another” in the furtherance of their mutual interests.

The hospital’s evidence?

Nurses were bypassing the work of a contract-sanctioned staffing committee by communicating with “constituencies outside of the medical center concerning the establishment of mandatory staffing ratios at CSVRMC,” including lawmakers, the media and the public.

The letter followed a vote-of-no-confidence petition against hospital executives circulated by the union. Dozens of hospital employees signed the petition and some gave interviews to local media alleging staffing shortages.

“...[T]he Union and its agents have published, caused to be published, or distributed a multitude of false and defamatory statements in petitions, flyers, newspaper interviews, website postings, and various other media,” reads the letter, “attacking CSVRMC as engaged in and promoting practices that endanger the lives and safety of patients.”

Fonda Osborn, president of the union, replied in her own letter to the hospital’s attorney that she was “disappointed, but not surprised, that your client had chosen to use oppressive tactics to silence lawful activities” such as the right to seek redress of grievances from one’s government.

“We understand and share the hospital’s desire to keep certain matters internal; that ethic has its place in any institutional setting,” Osborn wrote. “But, in this instance, the hospital’s insistence on secrecy must be sublimated to patient care.”

A labor board arbitrator concluded early this year that union employees had not violated the anti-strike clause in their agreement nor had they engaged in illegal or defamatory speech.

“Testimony indicated that the right to speak out against practices potentially affecting patient care is an ethical obligation of the nursing profession,” an NLRB arbitrator wrote in January. The hospital’s grievance was dismissed “as lacking demonstrated merit.”

Around the same time, the union and hospital management entered into a settlement in which the hospital agreed to provide the union with data showing the number of patients and nurses at the hospital, allowing the union to evaluate whether the hospital is properly staffed.

The August  2011 collective bargaining agreement established the nurse staffing committee to “develop, implement, and maintain a written nurse staffing plan.” The staffing committee is composed of 10 members—half management, half union nurses. Management breaks any tie votes. It composes new staffing plans partly based on algorithms that determine how many hours nurses spend caring for patients per day.  The hospital has been arguing that the algorithms show it has been using more staff than necessary.

A November 2011 hospital document, for instance, shows that, based on the hospital’s algorithms, only two out of 18 units were understaffed. The document showed the hospital benchmarked staffing levels at the 50th percentile.

But hospital reports from June and August show the hospital lowered its 2014 benchmark to the 40th percentile, and that three units in the hospital  —critical care, maternity and nursery—didn’t even meet that benchmark.

On Monday, Aug. 26, Diane Spencer, a clinical nurse with 16 years under her belt at St. Vincent, met with the nurse staffing committee.

“Our goal was to be an average hospital,” she says of the 50th percentile staffing benchmark. “[B]ut wouldn’t you want to be one of the best hospitals in the state?”

Spencer tells SFR that management didn’t inform the staffing committee of its plans to drop the benchmark staffing levels to the 40th percentile.

Delgado, the hospital spokesman, refused to respond to specific questions about why the benchmark was dropped.

He writes in a prepared statement that the hospital has “seen significant increases in the quality of care and in out patient satisfaction scores.”

“[A]nd we will continue to work hard to ensure our scores and quality outcomes continue to improve,” he writes.

A state legislator last year introduced a measure to address the issue, but  other lawmakers stalled the proposed Safe Staffing Act, carried by Rep. Christine Trujillo, D-Bernalillo. It would have required hospitals to establish a nurse staffing committee, composed of six nurses, a nurse manager and “any other qualified person as determined by the hospital.” The  bill would have charged committees with establishing staffing plans for hospital units. The union lobbied for the bill while the hospital opposed it.

“A hospital shall formulate and adopt an algorithm for maintaining nursing staffing levels determined by the committee,” the proposed legislation reads, “which may require the hiring of additional nurses.”

It would have also required hospitals to report data on staffing and patient levels to the Department of Health—which would then post that data on its website for public inspection.

There's also no federally mandated nurse-to-patient ratio.

“We don’t have nurse-to-patient ratios in our standards,” says Elizabeth Zhani, media correspondent for The Joint Commission, a hospital accreditation agency.

Trujillo’s state proposal was similar to federal legislation Sen. Barbara Boxer, D-California, introduced last spring. The law would penalize hospitals that fail to maintain a minimum nurse-to-patient ratio, and prescribes minimum ratios for acute-care units.

Peer-reviewed research doesn’t definitively link higher staffing levels to better patient outcomes. But patient outcomes  are difficult to measure because of the diversity of circumstances under which they occur.

Barbara Mark, a registered nurse and professor at the University of North Carolina at Chapel Hill’s School of Nursing, led a 2012 study of the impacts of a California state law that  increased nurse-to-patient ratios in certain hospitals. The study found that after the California legislation was implemented, some hospitals experienced a decrease in rates of failure to rescue—patients dying after complications—and that infections due to medical care increased “significantly” in certain hospitals.   That could be because having more nurses leads to better detection, not because of an actual increase in infection.

Her research also indicated that mandating nurse-to-patient ratios also negatively impacted the bottom line of hospitals, where financial performance and charity care decreased after the legislation went into effect.

Mark tells SFR that research still hasn’t shown what a good nurse-to-patient ratio looks like, because other factors in the hospital—not just the number of nurses—impact quality of care.

Too many nurses working a unit can  be problematic as well, she says, because a nurse might assume another nurse is covering a task. Mark concludes there’s a “sweet spot” at the top of a bell-curve that would mark the ideal number of nurses. But that “sweet spot” is still unknown to researchers.

“It’s really difficult to parse out clean and clear relationships,” she says. “But as I said, there does seem to be some fairly convincing evidence on the whole that better nurse staffing is associated with decreased mortality and decreased failure to rescue.”

It’s been roughly five years since Texas-based Christus Health purchased St. Vincent Regional Medical Center—the state’s first hospital—which had been sinking in debt.  Christus says it owns more than 40 hospitals and health facilities in seven US states and six states in Mexico. In 2010, the latest year for which its tax information was available, Christus reported that it pulled in $498 million in revenue and ended the year on a positive financial note—a $2.9 million profit. The previous year, Christus Health was operating at a $20 million loss.

Its mission, according to its website, is “to extend the healing ministry of Jesus Christ.”

Observers note Christus is eyeing to expand that mission. This year, Alex Valdez, formally the CEO of the hospital, moved to Christus Health’s newly created position: president of international advocacy.

In Santa Fe, Christus has already expanded, snapping up the Physicians Medical Center on Rodeo Drive in 2011. A local nonprofit corporation affiliated with Christus St. Vincent, SVHsupport, paid $14.8 million for the purchase.

As a 2013 Health Status Profile conducted by Santa Fe County and Christus St. Vincent shows the hospital, with 268 beds, is “the largest hospital facility north of Albuquerque and the region’s only Level III trauma center.” The second largest county hospital is the 19-bed Physicians Medical Center that Christus St. Vincent purchased. The only other hospital in the county is Santa Fe Indian Health Service Hospital, with four beds.

When the union began collecting insufficiency reports, they began mostly as dry notes of how many employees worked on a unit. Nurses writing them mostly commented that their unit was short-staffed and logged the staffing levels.

But as time passed, the reports have grown richer in detail.  Union president Osborn tells SFR that the reports are intended to “notify management” of staffing insufficiencies.

“They could always say they didn’t know,” she says, “but then we could say ‘Well, you did know because we sent you these documents.”

“We have people that fall,” wrote an employee about the June 27 day shift in unit 3200, “…because one person…cannot properly care for 15 patients.”

“Vital signs are vital,” wrote the nurse, “and we can’t even get those because it takes 2 hours to get all 15 patients’ vital signs.”

When the nurse complained to the manager, the manager advised the nurse to skip patient baths “because vitals are more important.”

“So is skin, I thought,” the nurse wrote. “There’s too much wrong on our floor. It’s to the point where I and my coworkers dread work.”

“Daughter of a patient observed that the RN was moving quickly from one patient room to another to fulfill patient needs,” reads a June 18 report from the day shift of Unit 2100, the medical-surgical unit. “Daughter stated: who can I talk to that you need more staff?”

A nurse from the same unit detailed a “positive note” from the day shift on May 26, saying that because of “appropriate staffing” the nurse was able to: provide holistic care for a patient with a new diagnosis of HIV; get a patient out of bed three times who “had no motivation to participate in his care”; get “my morbidly obese patient out of bed” three times to a chair and bedside commode; to provide therapeutic spiritual care by having time to talk with patient regarding his goals for the hospitalization and how to achieve them; and take care of a “confused patient who kept trying to get out of bed independently because he was restless and anxious.”

But most of the reports don’t focus on the positive.

“This place has become an unsafe environment for patients and staff,” wrote one nurse in June. “Nurses are at constant risk of losing their licenses. I would not bring anyone in my family here because I know there is not enough staff to take good care of my loved ones. :(. Patients are not safe here anymore.”

Mark, the researcher, argues that whatever the staffing levels of a hospital, it’s important that “patients have some information about what the staffing level ratios are in the hospitals where they’re being treated” and that “nurses themselves be actively involved in creating those ratios.”

Unfortunately, she says, information sources like the Medicare compare website—which allows consumers to compare hospitals—does not have data on nurse-to-patient ratios.

“So patients are going to have to be active advocates,” she says, “for their own health and safety in the hospitals where they receive treatment.”

Santa Fe Reporter