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Wednesday, 05 March 2008 00:00

Nurses at HRMC caught in downward spiral

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Over-worked and underpaid. It’s a complaint most in America could wage against their boss. But at Haywood Regional Medical Center, it was just the tip of workplace complaints.

Interviews in the last week with several nurses across multiple departments portray a hostile workplace where concerns were stifled, the rank-and-file felt devalued and top management was over-bearing. That led to high turnover among nurses over the past two years.

To compensate, the hospital brought in more traveling nurses and new hires. Nurses were also forced to work mandatory overtime. It is possible that the high turnover in nursing, which reduced the ranks of the more experienced nurses, could have landed the hospital in its current crisis.

“The bedside nurse was stretched and stretched and stretched,” said Stephanie Adamavich, a nurse at Haywood for 15 years, including ICU. “When you stretch your nursing so thin, mistakes happen. That is just the reality.”

The loss of the hospital’s Medicaid and Medicare status — followed quickly by private insurers as well — was largely pinned on errors by nurses in administering medication, according to a cadre of inspectors over the past month. In the wake of the failed inspections, the community has lauded the excellent patient care provided by the nursing staff, something nearly everyone who has been to the hospital can attest to.

Interviews with seven nurses in ER, ICU, Labor and Delivery, and Outpatient Surgery revealed similar stories about workplace deterioration. Only one of the nurses was willing to share her name, but the recurring themes in their stories were consistent and pronounced, enough so that the newspaper suspended it policy against anonymous sources to share some of what they described.

Hospital administration was reluctant to answer questions about nursing for this article. Instead, they are limiting interviews with the media to mostly positive news about the plan and commitment to get the hospital back on track.

“That was then. This is now,” said Al Byers, the acting CEO. “I have got to focus on the future here. I can’t go back and analyze everything.” Byers worked alongside Rice for years as the chief operating officer, as did the other top administrators still in charge.

 

A new boss

Nurses attribute their negative workplace environment first and foremost to the leadership of former CEO David Rice, who resigned in the wake of the crisis last week. Nurses say they felt like a replaceable commodity rather than valued as people.

These feelings hit a new low under the reign of Shirley Harris, who was hired as the director of nursing last February. Harris was recruited from Wyoming, flown back and forth every week on the hospital’s dime and given living quarters here. Harris resigned last week. The hospital claimed her contract was over, but others believe her exit was due to the crisis. (The hospital would not share what her compensation was despite it being public record and instead referred the request to hospital attorneys.)

Harris’ marching orders were to overhaul “the culture of nursing” at the hospital, according to Rice at the time she was hired.

Initially, some nurses put hope in Harris to clean up the way things ran. They hoped she could be a new liaison between the rank and file staff and Rice’s administration, or provide an outlet for nurses to raise concerns without feeling threatened in their job.

But instead, the changes made by Harris did the opposite. Many nurses felt more oppressed and more demoralized. Nurses say the changes were so fast and furious, with rules being created and rescinded daily, that it created chaos.

“I think some of her decisions were unpopular,” said Nancy Freeman, hospital board chairman.

Eileen Lipham, a hospital vice president, agreed.

“There was concern there was a lot of change going on and you could see there was some moral issues as a result,” Lipham said.

But Rice continued to tout Harris as a needed agent of change that would whip nursing into shape. As a result, she was given full authority.

Harris was a big fan of memos. If she had a grievance with one nurse talking on a cell phone, rather than addressing the problem with that nurse she peppered the entire staff with a memo.

“We had memos taped all over the ICU walls,” Adamavich said.

Nurses felt like Harris created busy work, like a new form nurses had to fill out every time they walked a patient down the hall for exercise.

Policy changes in scheduling were the most hated, however, and led to mass resignations by nurses. The hospital lost more than 60 nurses between April and July of last year after a litany of new policies went into effect. The ER alone lost eight of its 10 part-time nurses.

Once nurses started leaving, it made things worse on those who remained. They were forced to work overtime. When nurses were sick or had to stay home with sick kids, it got harder to find co-workers to pick up their shifts.

As a result, nurses continued to leave. Five more ER nurses have left or are leaving since the beginning of the year. It marks a 50 percent turnover in the ER nursing staff in less than a year.

The workplace at Haywood Regional didn’t become suddenly untenable under Harris. But to many, Harris was the final straw.

At one time last year, the hospital had 27 positions posted on its help wanted board in the hospital. With so much turnover, training for new hires was paramount. But some nurses felt training was not long enough. Some nurses asked for more time in orientation, but the requests weren’t granted.

 

Traveling nurses

When questioned about nursing, Rice consistently pointed to the hospital’s nurse-to-patient ratio as comparable to national standards. But that ratio was achieved by placing nurses in roles they were at times unfamiliar with. Nurses from the regular patient floors would be pulled over to ICU to work shifts despite not being fully trained in ICU nursing.

To fill the gap of departing nurses, the hospital also relied on a high ratio of traveling nurses and agency nurses. Agency nurses are contracted through a regional nursing agency and pinch-hit for a shift here and there. Traveling nurses come from all over the country to work a 13-week stint. Often, their travel and accommodations are paid for. They cost 30 percent more in payroll than the hospital’s in-house nurses.

Travelers and agency nurses are usually competent nurses, but they don’t know the individual hospital. They don’t know where extra supplies are kept. They don’t know the paperwork. They don’t know the doctors. They don’t know the computer system. And they don’t know medication protocols of the hospital.

Travelers train alongside an in-house nurse for sometimes as little as two shifts before getting a full patient load of their own.

“A travel nurse may be a very good nurse and a competent nurse, but they don’t know the system so they need a resource,” Adamavich said. Adamavich would often take on the sickest patients since she didn’t know the skill set of the travelers, the agency nurses or the nurses sent down from another floor to help in ICU.

But on top of her own patients, Adamavich had to serve as a resource to the travelers and floaters and new hires who don’t know their way around as well. She said nursing support staff was trimmed — the people who answered phones and stocked supplies — putting even more workload on nurses.

Last summer, following the resignations of many part-time nurses, 15 percent of the nurses in the ER were travelers. Hospital-wide, however, it has been around 10 percent in recent months.

By comparison, Harris Regional Hospital in Sylva had no travelers on staff as of January, following a steady decline in their use over the past year.

 

Mandatory overtime

One of the new policies implemented by Harris was mandatory overtime. Most full-time nurses worked three 12-hour shifts a week. Harris required nurses to work four shifts a week to fill gaps.

By the fourth shift in a week, nurses said they were tired and less able to concentrate.

Harris also tried to nip the number of people calling in sick. She made a rule that if you called in sick one weekend, you had to work the next one to make it up. That didn’t work for mothers who had rotating weekend childcare duties. It also didn’t account for nurses already working a full load the following week, creating 60-hour work weeks for nurses trying to make up sick time.

At one point, Harris required a doctor’s note if nurses called in sick. Nurses simply came to work sick rather than pay to go to the doctor to get notes. That rule was later rescinded.

Nancy Freeman, hospital board chairman, said Harris was trying to make the nurses more accountable for their shifts.

“We have had and continue to have a lot of problems with nurses calling and then leaving us short-staffed,” Freeman said.

However, it alienated the legitimately sick as well as those who possibly took advantage of calling in sick.

Previously, nurses felt their home life was taken into account when creating schedules. Offering flexible schedules helped retain nurses in an otherwise competitive market. Nurses said they performed better when their work schedules met the needs of their family obligations. Under Harris, that wasn’t the case. Nurses felt like they were enslaved to work whenever and however much they were told.

“A lot of times nurses got to where they wouldn’t answer the phone,” said Freeman. “There was no reliable way to bring them in in times of short staffing.”

 

Bye-bye part-time pool

Before the nursing shake-up, the hospital had a pool of part-time nurses that worked an irregular number of shifts. Some might work just two shifts one month, but eight the next. They were like in-house pinch-hitters. They could pick and chose whether to take a shift when called.

In exchange for the flexibility, they weren’t guaranteed a certain number of hours. A nurse in the part-time pool might get three shifts a week — but also might get none. It was a convenient arrangement for nurses who couldn’t commit to a regular shifts due to other jobs or childcare duties.

Harris didn’t like the system, however, and wanted to standardize shifts worked by the part-time pool. She wanted the nurses to work a consistent number of shifts and become regular part-time employees. So she made a new rule. Nurses in the part-time pool had to work at least two shifts every pay period.

Some were retired and couldn’t work that much and still qualify as being retired. Others had childcare conflicts. Others simply didn’t want their schedules written in stone.

In the end, the rule jeopardized a critical pool of nurses for all departments in the hospital. Nurses simply dropped out rather than meet the rule.

Byers, acting CEO, said Harris was trying to standardize scheduling and hopefully push the part-time pool into working more regular shifts. Such a strategy is one thing if there was a glut of nurses in the marketplace, but instead there is a national and regional nursing shortage, with the outflow of nurses to neighboring hospitals or to work in doctor’s offices a long-standing problem.

Freeman said the hospital board was not aware of just how unhappy Harris’ policies had made nurses, or the number of resignations it was prompting.

“Clearly not all their issues were identified and brought to the board level,” Freeman said. Freeman said some of Harris’ policies may need to be reassessed.

 

Weekender program

Another scheduling change killed a long-standing and popular program called the weekender program. Theoretically, it was harder to get people to work weekends — defined as Friday, Saturday and Sunday. The weekender program offered nurses more money to work five out of six weekends, a common incentive at hospitals to satisfy otherwise hard to fill shifts.

Harris took away the extra pay that went with working weekends. Only she made it effective immediately and didn’t tell the staff. Many nurses didn’t know until they got their paychecks and they were less than usual.

 

Cost-cutting measures

Nurses felt like Harris’ role was to cut costs in nursing. The hospital, which had been consistently profitable for years, began losing money in the spring of last year. The hospital finished its fiscal year ending in September $1.9 million in the hole. For a hospital that typically made $2 million a year, the loss was significant.

The hospital cut 36 positions last summer to stem the losses, mostly in non-nursing areas. But it was not an unreasonable assumption by nurses that Harris’ was looking for ways to save money.

“She told us she was there to trim the fat,” Adamavich said.

Shortly after Harris’ arrival, Rice bragged at a hospital board meeting about the money Harris was saving. Rice added that Harris was not only saving money on nurses, but improving quality of care provided by nurses. Hospital board members did not question the two seemingly mutually exclusive goals.

In outpatient surgery, nurses were barred from working overtime. Nurses’ hours were added up every Thursday, and those who were over had to clock out early on Friday to avoid even a minute of overtime.

Christmas bonuses also went the way of cost-cutting measures, with a bonus of only $50 compared to the normal $400.

 

A new leaf

As the new rules mounted, morale sank. Nurses knew their work was suffering but felt silenced. They felt their jobs were at stake if they complained about their work conditions. Worse, they felt they could not complain about issues of patient care. Nurses were told that they were replaceable, lending to the climate of fear for their jobs.

When something went wrong, nurses could fill out incident reports — a sort of internal mechanism to track mistakes, theoretically to learn from them and prevent them from happening again. But somehow, the incident reports seemed to disappear into a black hole and weren’t acted on.

Some nurses said they were nervous when inspectors came — not so much about performing their duties, but that they would be punished if they cooperated with the inspectors.

With Rice gone, those left in charge say they are opening the door of communication and working to reverse the top-down operating style of Rice. Instead, they are reaching out to the rank-and-file.

“We are taking an approach of listening to and supporting our nurses more than ever,” said Robin Tindall-Taylor, the communications officer.

Adamavich said that is already coming across.

“Administrators are coming to us and talking to us and asking us what can be done. This is already totally different than what we working under and I am so excited,” Adamavich said, complementing Lipham in particular. “There is communication now.”

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