You may have noticed signs popping up in rear windows, on bicycle baskets and in homes around Missoula. White lettering against a cherry-red background reads, “We Support the ER Nurses at Community Hospital.” The implication, of course, is that somewhere, support for Community Medical Center ER nurses is lacking.
Earlier this year, management of Community’s Emergency Department announced that the department needed to make changes to staffing and schedules. An independent study and software analysis showed that labor costs were too high. Data also showed that nursing schedules were out of sync with patient flow. So the Emergency Department drew up a plan to match nursing hours and schedules with the study results.
Changes included modifying some shifts from 12 to 8 hours, or moving start and stop times. In February, management called a meeting about the “restructuring.” Maria Gurreri, a Community nurse and past president of the Montana Nurses Association Local #15, attended.
“We are protected under our [union] contract,” explains Gurreri. “[Management] can’t change our hours or our working conditions or our wages without mutual agreement.”
“Mutual agreement” is a phrase woven liberally throughout the union’s contract with Community. It means that changes to the nurses’ hours and schedules can take place as long as both parties consent. At the meeting, says Gurreri, management asked what they could do if the nurses would not agree to the restructure.
Answered Gurreri: “You’re pretty much stuck.”
But management didn’t feel stuck. In March, they polled the affected nurses—10 of the 26 who work in the emergency room. “The attached staffing plan,” read the poll, “is for your consideration relative to ‘mutual agreement.’” Not one of the 10 nurses polled agreed to the changes.
But management hadn’t necessarily polled the nurses for their feedback.
“It’s a formality,” says Gurreri. “It’s a formality to say, ‘we asked them if they wanted to do it’ to see if they could get mutual agreement, and they didn’t.”
Management felt it didn’t really need “mutual agreement.” In mid-April, the Emergency Department laid off six ER nurses.
Then, the hospital offered the nurses new positions in line with the restructure.
It was an illegitimate layoff, say union leaders, disallowed by the contract.
The nurses circulated a petition throughout the hospital to gauge the level of support. “We, the RNs at CMC, have serious concerns regarding management’s unilateral restructuring of RN positions within the Emergency Department,” it read. “We are concerned that if this issue is not resolved appropriately, similar unilateral shift changes will occur throughout the various departments at CMC.”
Within three days, 139 registered nurses had signed, and one had sent support via e-mail, says Don Judge, the labor-relations negotiator contracted by the union. Other employees—who were not registered nurses—also wanted to sign, but union leaders, afraid of retribution, advised them against it, according to Judge.
On May 14, 2004, the Montana Nurses Association (MNA) filed Unfair Labor Practice charges with the National Labor Relations Board against Community’s management.
“It’s not something you do frivolously,” says MNA Executive Director Claudia Clifford. “It’s a lot of work.” The complaint states that Community made “unilateral changes to the terms and conditions of employment of the bargaining unit.” Community laid off nurses, eliminated positions, changed shift times, reduced the number of hours worked per shift, and failed to lay off workers by seniority, according to the complaint. The charges allege specific retaliation against three nurses for union-related activities. The charges are the first filed by MNA against Community in at least a decade.
The union complaint and the Emergency Department’s attempts to bring schedules and costs into line with consultants’ recommendation have created a rift between Community and the MNA Local Unit #15. At Community, at least two nurses who say they were laid off illegitimately in order to accommodate the restructuring—nurses with years of experience—are taking their leave of the hospital instead of accepting new positions. Another has sought counseling for duress. And the tension has rippled to the hospital across town. At St. Patrick Hospital, nurses are on edge. They wonder if their jobs, too, are in jeopardy when union contracts appear to be so easily skirted. And while the union is at odds with the hospital, its own members are not altogether unified. A contingent of ER nurses feels misrepresented by the union. One nurse plans to withdraw her membership before the end of the contract year on Sept. 30. She believes five of her coworkers will join her.
The labor clash is loud, but some nurses worry that, labor issues aside, the staffing changes will compromise patient care. Management, not surprisingly, disagrees. So does the ER nurses’ professional organization, the Emergency Nurses’ Association.
Don Judge, former executive secretary of the Montana State AFL-CIO, is the labor relations advocate working on behalf of the union. For 30 years, he has been a labor advocate in the Big Sky State. Judge, who wears a trim white beard and calm demeanor, has seen a lot of labor abuses, but recent activity at Community stands out in his mind. “I would say that management’s actions are among the most blatant that I’ve seen in 30 years working in the labor movement,” he says.
The restructure, according to Community, is legitimate. Community’s legal counsel reviewed the contract, says Jan Perry, vice president of patient care services, and found management’s actions to be within the contract. “We’re not going into this blind,” says Perry.
Community, which sits on a 45-acre campus near Fort Missoula, is a 146-bed hospital employing a total of 838 full-time employees, including 322 nurses. Pressure between the union and the hospital started building last year, when Community expanded the duties of technicians working in the ER. The union, which represents 13,000 registered nurses across the state, reported the practice to the Board of Nursing, which put a stop to it.
When disputes arose between MNA and CMC in the past, says MNA’s Executive Director Claudia Clifford, “They were always able to work them out.” Not now. “This spring has not worked out so well,” says Clifford.
Kate Steenberg, MNA president, is a nurse at St. Patrick Hospital. “The perception is starting to be that if you are a big enough annoyance, or impede the direction that administration wants to take, you can lose your job at Community,” she says. Management’s approach, she says, was “You’ll do what I say or get laid off.” It’s partially from a self-interested perspective that she and other nurses at St. Pat’s support Community’s nurses. If it can happen at Community, she says, nurses wonder if it can happen elsewhere. The union had presented multiple alternatives that would not require lay-offs, but the alternatives didn’t go far. Instead of reaching a compromise, six nurses, including three union leaders, were laid off.
“To have that go so wildly wrong,” says Steenberg, “is sort of shocking.”
Here’s what isn’t shocking: The health care industry is hurting. Community Medical Center is no exception. Over a year ago, says CEO Tom Moser, Community brought in consultants. “They looked at how we compared with high-performing hospitals across the United States.” What did the consultants find? “When you look at our overall labor costs, we are higher than high-performing hospitals,” says Moser.
The hospital is a not-for-profit corporation and not accountable to shareholders. As such, says CFO David Richhart, Community considers itself accountable to the citizens of Missoula. “At the end of the day,” he says, “we answer to the community.” The question, says Richhart, is, “Why does it cost you so much more?”
There’s another question, and it’s one that no one wants to ask, says Steenberg: How will the staffing changes affect patient care? Recent nursing graduates are being hired into the ER. The nursing hours in total have dropped. Since last year, technicians are doing more work in Community’s ER.
“A nurse is a nurse is a nurse is a nurse,” says former local MNA President Gurreri. Technicians, she believes, are not trained to provide the kind of care that a nurse is licensed to provide. Last year, Community augmented its position descriptions of technicians, “unlicensed assistive personnel,” to include duties such as drawing blood and inserting IVs. In the field, it’s a technician’s job to do so, but inside the hospital, by law, technicians are not allowed to perform certain duties. The union alerted the Board of Nursing. The board halted the practice, but launched a task force to consider future duty expansions.
Corky Vincent, a Community ER nurse, doesn’t believe that technicians’ duties were curtailed over issues of patient safety.
“It threatened a couple of nurses,” she says.
She herself had welcomed the extra help, especially when patients were in dire need of medication. Prior to the curtailment, a technician could draw blood and insert an IV while Vincent delivered meds. Instead, Vincent recently had to spend 10 to 15 minutes with each patient drawing blood and starting an IV “before I could give the patient the medication that they needed.” She saw personnel who were qualified to help her relegated to changing bedsheets. It frustrated her.
“We had the person there who was qualified to do that, who was trained to do that, could not do that,” she says.
Ronnie Mitchell, who was laid off in April, was another ER nurse who says the extra help was sorely needed and appreciated. As Missoula grows, he says, Community sees more and more patients. “We were being swamped,” he says. Then, along came additional staff who knew how to draw blood and start an IV. “That’s real handy-dandy,” Mitchell says.
Mitchell, however, isn’t keen on having recent nursing graduates working in the ER. Neither is Gurreri. It’s “obvious,” says Gurreri, that you don’t hire inexperienced registered nurses for the ER. The split-second assessments and snap decisions that clinicians must make in the ER require skills that take time to acquire and perfect, she says. Book learning isn’t enough. She fears that the addition of less experienced nurses into the ER will compromise care.
Patricia Howard is president-elect of the Emergency Nurses’ Association (ENA), a national organization of professional emergency room nurses. The national nursing shortage, she says, has driven many hospitals to start hiring recent graduates into the emergency room. It’s a practice that has become common over the past several years.
“I can tell you that many years ago, it was not,” she says.
With extensive one-on-one orientation, she says, new graduates can be effective in the ER.
“In many ways, [hiring new graduates has] actually been a positive for us,” she says. “We’ve been able to mold their skills.”
Fresh nurses bring in “a new set of eyes” to look at old ways of doing things. Howard, in her quick southern accent, says “nationally, we are in the worst nursing shortage in the time that I’ve been a nurse.” However, even if the nursing shortage turns around, she would support having a combination of experienced nurses and recent graduates in the emergency room.
Vincent has worked with one of Community’s two new RN graduates. She describes the nurse as “very competent, very astute, very aware.” Tim Stahl, another ER nurse, believes that personality plays a large role in an individual’s ability to work in the ER—not necessarily experience. “Some people are cut out to do it and some aren’t,” he says.
Some senior nurses are alarmed at the sight of new graduates in the ER. While they exhibit genuine concern for patient care, their pride seems wounded, too, to see that nurses new to the profession can take the jobs they worked long to earn.
Mitchell, 53, has worked at Community ER for seven years, minus a couple months in the ICU unit.
“For me, this is the pinnacle of my career,” he says of the ER. “You work your way up to hone your skills.”
Administrators like Medical Director Greg Moore and Patient Care V.P. Perry believe that the changes will turn Community’s ER into a model to be emulated. The Emergency Nurses’ Association designed a software program that calculates recommended staffing levels based on the timing of emergency room visits and patient acuity, among other information. Community plugged in its data. An analysis recommended an ideal staffing level of between 10 and 11 full-time nurses. Management has chosen to staff at 14.7 full time nurses. It’s a drop from the 18.9 full-time nurses in 2003, but still almost 50 percent above the recommendations of ENA, which both nurses and managers point to as the organization that sets the standard.
Now, the ER has more nurses on duty during the evening, when more patients come through the door. It’s a set-up that nurse Vincent calls a “no-brainer.” She saw the restructure work beautifully one recent evening when the usual patient influx came through the door. The ER had four nurses on duty.
In contrast, Moore describes staffing prior to the restructure:
“When you have four nurses in the morning and no patients,” says Moore, “that’s not optimal care…This morning there is one patient in the ER…I was here at six. And there’s only been one patient in the ER from six to eight.”
Some nurses don’t seem overly impressed with data. “You can data yourself into never-never land,” says Mitchell. He asks what he is supposed to do when patients show up unexpectedly. He wonders if he’s supposed to show them the data chart and tell them they’re not supposed to be here now, so he can’t take care of them.
“If that happens [to] one patient,” says Gurreri, “that’s too often.”
While she, like Mitchell, is outraged by the alleged labor violations, both also say they are sympathetic to management’s need to watch the bottom line.
In fact, accountability to the bottom line in health care hasn’t always been standard practice. Historically, says Moser, who has been in the business over the past 20 years, “health care was not as sophisticated in terms of how we managed the business.
“We are in a very caring profession,” he says. Health-care professionals must strike the balance between the desire to serve and the economics of delivering health care, he says.
Community is changing not because it’s in imminent financial danger, says Moser. Rather, he says, it’s a continuous process of being “good stewards” of the public’s money. “If you don’t respond to changes in the market,” says Moser, “you could find yourself in trouble down the road.”
“Complacency,” agrees Moore, “is the death of hospitals. While costs increase about 5 percent each year, reimbursements from Medicare and Medicaid, which account for roughly half of the hospital’s payments, increase only about 2 percent each year. The hospital needs to show anywhere between 3 and 5 percent productivity improvement each year, says Moser. He won’t disclose where the hospital now stands along that continuum, but says, “We have not seen the types of improvements that we could have seen.”
The changes in the Emergency Department are expected to save $200,000 annually, says Moore.
But finances and labor contracts aren’t the only considerations. Montana state law is a factor, too. By law, nurses are required to report to the Board of Nursing when they believe that management is making decisions that jeopardize patient safety. “There are two sides to that,” says union negotiator Judge. “One of them is a recognition that it’s the nurse who makes those decisions, not necessarily the doctors, and not necessarily the administrator who takes a look at it and says, ‘well, we have enough staff out there.’” The other side, he says, is “if they report it, clearly the question becomes: ‘Is management going to get on their case because they’re reporting management for being understaffed?’ It’s a rock and hard place.”
And nurses aren’t necessarily the best negotiators. Mitchell wishes the hospital had simply waited until next year’s contract negotiations instead of allegedly violating the one it had. He says that nurses typically enter the field because they have a maternal nature. And, he says, they can make poor union negotiators because they are not prepared to walk away from the patients. Judge agrees. “Nurses are not like other trade unionists,” he says. “They just want to go to work and do their jobs and take care of people.”
This time is different.
“In this case, they have just been pushed so far by management, they felt they had no choice but to make waves.”
Some feel it’s the union that has pushed too far. Corky Vincent is an old hat at nursing but a new union member. “I’m a rookie with the union,” she says. “I have been horribly underwhelmed with the union at this point.” She pays around $360 annually for her membership. And she feels misrepresented. Not only did the union not solicit her input, she says, she believes it has been overly aggressive in its dealings with the hospital. She was taken aback, she says, when, earlier this year, a union leader declared “war” on the hospital. The union, she says, has had meetings that she knows nothing about. She plans to withdraw her membership. Five of her colleagues plan to do the same, she says. Stahl also has complaints with the union’s response to the restructure. Not once, he says, did union leaders ask him how he felt about it. While the specific changes directly affected neither his nor Vincent’s schedules, “We’re still involved in the daily function of the department.” And the union, he says, “should be keeping us aware of what they’re doing.”
Both union members and Community administrators seem caught off guard by their broken relationship. They will attempt to resolve the unfair labor practice charges over the next couple months through a grievance process. If unresolved, the charges will be arbitrated.
Dissent will die down, believes Stahl, if the restructure serves its stated purpose: to help the hospital help nurses deliver better care.
“We want to stress we’re not trying to put the hospital down,” says Gurreri. “We all work there. We’re proud to work there. We want to continue to be proud to work there, and one of the reasons we’re proud to work there is we give quality patient care, and we’re feeling like that’s being jeopardized.”
Meanwhile, two experienced nurses have turned in resignations. Others have accepted positions with fewer hours. Some say they are looking at other professions.
Mitchell is in counseling. He discusses the changes at Community in an animated way, jumping up from a bench to drive home a point. He says that he likes to sing to patients or “goof around” with them. In his gesticulations, it is easy to imagine him belting out a Broadway tune to a patient. Briefly, though, he pauses and quiets. He sits back into the bench. He had no intention of leaving Community, he says. After seven years in the ER, he considered his coworkers family. With little warning, he says, he lost them. “How do I grieve this?” he asks.
The changes aren’t easy on management, either.
“This is hard,” says Perry. “This is hard work.” She considers the staff her friends. “We are affecting people’s lives.”