Photos by Alan Lessig / The Detroit News Emily Minard of the Visiting Nurses Association checks patient Sherry Kurtiz in Kurtiz's home. "The most frustrating part was not giving care I thought the patients needed," Minard said of working in hospitals.

Stressed nurses quit, hurting patient care

Poor pay, conditions leave hospitals strapped for help

Emily Minard, 23, graduated from the University of Michigan School of Nursing in April 2000. She got a job at a hospital but quickly burned out, overwhelmed by the chaotic environment. She now works in home health care.

By Sarah A. Webster / The Detroit News

    DETROIT — Kelly Stimac says that if she had been allowed to do the job properly, she would still be working as a nurse.

    But what she once saw as a dream career became a nightmare. Every day became a race with too little time to treat too many patients.

    One day still haunts her. Stimac struggled to give one patient blood, while another began having a heart attack and yet another strained to breathe on a respirator.

    “It was just impossible,” said Stimac, who now reviews medical records for a Berkley law firm. “You couldn’t take care of people as needed. Staffing was terrible. I would come home and cry for hours.”

    Her solution was painful but simple: she quit.

    She is not alone. Thousands of other nurses are abandoning the once highly regarded profession.

    The exodus is aggravating a nationwide shortage of nurses and compromising patient care in many health care facilities nationwide.

    Many nurses openly say they are demoralized. They complain of low pay, long hours, large patient loads and being treated condescendingly. In the era of managed care, they say hospital administrators are putting profits over people — both workers and patients.

    Hospitals are struggling to keep nurses at the bedside and find new recruits. But services are quietly being reduced or restructured for lack of workers. Many nurses who remain on the job say they are being pushed to do more than ever — more than is safe.

    “Quality is impacted,” said Ada Sue Hinshaw, dean of the University of Michigan School of Nursing. “When the ratio of nurses drops below a certain level, more people die, there are more errors. I think patients need to know what they are walking into.”

    At least one local death is allegedly linked to low nurse staffing. And several patients interviewed by The Detroit News say their care was inadequate because of a dearth of nurses. Hospitals deny the charges.

    The crisis is likely to get worse. As the nursing workforce ages, more are retiring. And more women, who constitute about 90 percent of nurses, are seeking opportunities in less stressful professions.

    Without major changes in work conditions, such as mandated staffing levels, the shortage is expected to widen. The nation now has about 125,000 vacant nurse positions. The federal government projects that will increase by threefold to sixfold in the next two decades.

    In Metro Detroit, there are more than 2,000 registered nursing jobs vacant. Most of the area’s major health systems report 100 to 300 openings for nurses.

Kelly Stimac used to work as a full-time nurse. Now, she works in a law office.

    The situation is similar throughout the state. Despite lucrative signing bonuses — up to $10,000 in some cases — for new recruits, vacancy rates among Michigan hospitals range from 8 percent to 35 percent of the nursing staff,

    “The current supply of nurses is not meeting the demand and need for nurses in Michigan, and the situation is going to get worse,” concluded a recent report by Public Sector Consultants, a Lansing-based firm that studied the RN deficit for the Michigan Department of Consumer and Industry Service.

    A survey of 1,600 local nurses indicates the quality of care is being jeopardized:

* Fifty-four percent of Metro Detroit nurses said they “would not feel confident having someone close to them receive care in the facility in which they work.”

* A third of nurses said inexperienced staff miss patient symptoms.

* More than a fifth of nurses said patients are suffering more injuries while 27 percent said there are more medication errors.

* Nearly two-thirds said they cannot promptly respond to patient requests for help.

    Nationally, the nursing shortage is already so bad that it has been upgraded from a health crisis to a security concern as well.

    Legislators evaluating the country’s preparedness for terrorist events after Sept. 11 have received reports from health experts who said the nation does not have enough nurses now — let alone in cases of mass casualties.

    “The issue takes on a new urgency given the war effort,” Mary Foley, president of the American Nurses Association, told members of the U.S. House of Representatives.

Dark tunnel

    The RN shortage is most acute in hospitals, which employ 60 percent of nurses and rely on them for a variety of services.

    Already, as much as 10 percent of hospital medical patients may be suffering as a result of ebbing nurse staffing levels, according to the federally funded study of 5 million medical records by Harvard and Vanderbilt universities.

Robert Tyrer of Whitmore Lake said nurses failed to aid him at University of Michigan Hospital in January when his heart monitor went off, chanting, "Warning, irregular heartbeat." He left the hospital without checking out.

    When extrapolated for Michigan, where 1.2 million patients were admitted to hospitals last year, more than 124,000 patients could be affected. And that doesn’t account for the more than 22 million patients seen on an outpatient basis or treated outside of hospitals.

    The study, released in April, found a strong and consistent relationship between low nurse staffing levels and urinary tract infections, pneumonia, lengths of stay, upper gastrointestinal bleeding, shock cases and “failure to rescue” incidents, which is when a patient has a change in symptoms and nobody is there to respond to monitoring equipment or observe a problem and take appropriate action.

    Although that study was completed this year, co-author Peter Buerhaus, a nursing professor at Vanderbilt in Nashville, emphasized the research was based on data from 1997 — about the time staffing levels began to thin out.

    “Things have gotten worse, not better,” he said.

    While hospitals defend the care they provide, nurses said they were not surprised by accidents and oversights. On the contrary, many nurses agree they are delayed in providing basic care, like feeding, and missing symptoms. Surveys show that more than 40 percent of local nurses say they go home exhausted, discouraged and worried about their patients’ safety.

    “The nursing shortage has impacted so much that probably our duties are easily doubled, and there doesn’t appear to be any relief in the mid-term future,” said Sandra Sulflow, a nurse and union leader at Mt. Clemens General Hospital.

    “Not only is there not any light at the end of the tunnel, the tunnel is getting darker and darker. There’s massive depression of morale.”

Staffing debate

    Don Potter, president of the Southeast Michigan Health & Hospital Council, said quality is preserved by closing down units when there aren’t enough RNs to staff them. But that increases the possibility that patients who need care could ultimately be turned away.

    “Henry Ford Hospital will tell you they’ve got at least 50 to 100 beds in mothballs because they don’t have enough nurses to staff them. The same is true at others in town,” Potter said. “You don’t understaff a unit and put your people and employees at risk.”

    But nurses often don’t agree with administrators about what constitutes understaffing under the variety of staffing models used, which involve mixes of aides and other support staff.

    In fact, 67 percent of Metro Detroit nurses reported they worked with inadequate staffing “in both number and skill levels,” according to the Michigan Nurses survey.

    Skill has become a critical issue, RNs say, as hospitals fill holes in schedules with nurses from temporary agencies or by shifting nurses between units with disregard for experience.

Stretched too thin

    Many nurses complain that night shifts, when patients are presumed to be sleeping, are stretched perilously thin.

    Maryann Trombley, a legal nurse consultant in Macomb County, reviews malpractice cases in which she sees nurses put in maternity units without training on how to read fetal heart monitors.

    When a nurse can’t recognize a fetus is in distress and needs a speedy birth, complications like cerebral palsy can result.

    “Unfortunately, a lot of that is occurring,” said Trombley, who quit nursing in 1998 after 22 years.

    She left because understaffing challenged her ability to provide quality care and she objected to management’s admonishments not to tell patients the truth.

    “We were repeatedly told by administration never to tell a patient we were short-staffed,” Trombley said.

    Other nurses also said that happens. Some nurses explained that hospitals and nursing schools give this directive because they don’t want nurses to increase patient anxiety. But many feel patients have a right to be informed of the risks today.

Impact on patients

    “The nurses would tell me they were short,” said Jenny Huschka, who recently gave birth to her second child at Beaumont Hospital, Royal Oak. She noticed that the nurse assigned to help her delivery was simultaneously assisting a patient next door.

    “I wouldn’t say it was just terrible,” she said, “but definitely they were short people.”

    However, Beaumont spokeswoman Colette Stimmell said that facility is never understaffed. “It could be the patient’s perception of the situation and obviously her nurse’s perception,” she explained.

    Aside from reports of irritable, hurried nurses, hospital patients complained they didn’t get their medicines delivered on time or sometimes not at all.

Nursing, a once-proud tradition, has become a career some seek to avoid. Edie Mares, with younger daughter Mary, says her older daughter went to college this fall with one warning: Become a nurse "over my dead body."

    Marc Beitner of Oak Park said nurses at an Oakland County hospital forgot to order his heart and blood pressure medication during an overnight stay and gave him an insulin injection without food while he was partly sedated.

    He credited his girlfriend with preventing a potentially deadly event by recognizing the problem and feeding him.

    “My experience is, yeah, the nursing shortage is having an effect,” Beitner said.

    Others said that nurses were so busy they couldn’t respond promptly to emergency calls from patients. And it is not always clear if poor patient care is linked to the growing RN shortage.

    For example, Robert Tyrer, 48, of Whitmore Lake said no nurses came to his aid at the University of Michigan hospital in January when his heart alarm began chanting: “Warning, irregular heartbeat.”

    “I’m gasping for air, my heart was doing flip-flops and hurting, and nobody was coming into the room,” recalled Tyrer.

    In a panic, he reached up to a knob on his IV and increased the saline solution into his veins, which Tyrer said eased his pain. He also said that his urinal was not emptied and he was left lying in his own vomit throughout the night.

    Angered by what he considered to be neglect, Tyrer walked out of the hospital the next morning without being discharged.

    Like most patients, Tyrer doesn’t know if his registered nurse was caring for too many patients that night or whether she was tired from working overtime.

    U-M spokeswoman Kara Gavin said that Tyrer received high-quality care and that his nurse was assigned to only three other patients.

    Medical records, which Tyrer agreed to have released, supported several parts of his story, including that he vomited and that his urinal was not emptied between 11 p.m. and 6 a.m.

    The records do not reveal whether his heart monitor sounded an alarm, but Gavin agreed that fact would have been recorded by a nurse.

Not my child

    While better nurse staffing levels have been proven to improve care, nurses say their workloads keep getting heavier. More patients, fewer aides and voluntary and mandatory overtime have become the bane of nursing.

    What’s more, in an era of too-few nurses, scheduling has become a nightmare. Nurses never know when their shifts will end. Others said they aren’t permitted to use earned vacation time.

    Nurses say they never know what to expect at work. The number of patients they must care for is usually in flux based on changing systems of patient severity and support staff. Most area hospitals and nurses could not outline a typical RN-to-patient ratio.

    “It depends on who comes to work,” said Eusebia Aquino-Hughes, a nurse at Providence Hospital and Medical Centers in Southfield.

    Nurses say they are run ragged trying to protect patients — skipping meals and breaks.

    “If we make it to the bathroom twice a day, it’s a good day,” Aquino-Hughes said.

    Still, some nurses say their jobs remain rewarding.

    “I wouldn’t give it up for anything,” said Aquino-Hughes, who finds spiritual fulfillment in nursing. “This is where I’m going to retire.”

    For others, however, the stress is unbearable. Many nurses have dropped down to part-time status, found easier nursing jobs or simply quit — aggravating the shortage.

    Caring and gentle nurses are getting a harder edge in this new environment. Tension, distrust and unionization are on the rise.

    Nurses report increased infighting as they vie for the best schedules, and nurse-patient relationships have become strained. Nurses report an increase in work place violence from patients, their families and co-workers.

    Hospital administrators are being viewed with more suspicion. Edie Mares, who has been a Beaumont nurse for 21 years, said it’s a struggle to trust administrators and push herself to work harder when money is spent on new buildings rather than the nursing staff.

    “I really want to believe these people are not cruel and inhumane and don’t want us to be working under these conditions,” she said.

    Reliable old sources of nurses are drying up quickly in this contentious environment. Once a proud tradition, a new call has swept nursing: “Not my child.”

    Mares, whose own mother and sister are nurses, hears her peers say that all the time. Her eldest daughter went off the college this fall with a warning.

    “Over my dead body would she be a nurse,” Mares said. “I love the job. It makes you feel so good. But when you can’t do the job ... ”

    You can reach Sarah A. Webster at (313)222-1463 or swebster@detnews.com.