Debbie Cuaresma has been a registered nurse for the past 22 years, witnessing first hand the changes that have roiled the health care system in Southern California and the state, especially over the past decade.
She has had to care for ever needier patients, as managed care gatekeepers have kept all but the sickest out of hospital beds. She has found herself floated to wards where she has felt unskilled because of a shortage of co-workers. She has worked 12-hour plus shifts dead tired.
It's not the same as when she started.
"I used to go home feeling, "I made a difference today," said Cuaresma, now a cardiac unit nurse at St. Vincent Medical Center in Los Angeles.
"Now, I wonder, "What did I miss? Could I have done any better?"
Unlike many of her colleagues who have left the hospital setting for seemingly greener pastures elsewhere, Cuaresma has stayed. But now she is a member of the California Nurses Association, which organized the hospital's registered nurses in 1998 capitalizing on such discontent.
That campaign was among the first for the association in Southern California since the early 1990s. And it turned out to be more than a hint of what was to come.
Over the past two years, the CNA, and its rival, the Service Employees International Union, have organized seven Los Angeles County hospitals, and others regionwide. The CNA only represents registered nurses while the SEIU largely represents lower skilled workers, but also RNs.Elections scheduled
Indeed, within the next few weeks, SEIU elections are planned at three Los Angeles area hospitals, including one for RNs at Northridge Hospital Medical Center and technical, service and maintenance workers at California Hospital Medical Center in downtown Los Angeles.
The industry maintains that the nurses are mistaken if they think the unions are going to quickly improve conditions that it acknowledges are difficult.
"I think the world of nursing is often very, very demanding and exhausting," said Mary Dee Hacker, chief nursing officer at Childrens Hospital Los Angeles, which remains non-union. "Many nurses are trying to find an answer. But the answer is not found in a quick fix."
While the nurses have various specific gripes with individual hospitals, the underlying complaints by the unions are consistent against all of them: They contend that fewer nurses are being forced to work longer hours to take care of greater numbers of patients who are sicker than ever.
"Registered nurses more than anyone I know never take any breaks," said Beth Kean, the CNA's statewide organizing director. "This has had a dramatic impact, to where they have gone from loving their jobs to being stressed out."
There's a reason for this.
A report completed by the California HealthCare Foundation found that the median operating margin for Southern California hospitals fell into the red in 1999, after a five-year decline.
Among the factors cited for that decline are the high penetration of managed care, stingy government reimbursements and growing numbers of uninsured patients leading to high rates of uncompensated care.
And nurses, perhaps more than any other hospital workers, have absorbed the cost-cutting prompted by such financial pressures.
"They have been viewed as a commodity," said Bram Briggance, associate director of the California Workforce Initiative, a think tank that studies the state's health-care workforce. "If you need more, go to the registry."
Even industry officials agree that hospitals have in many ways created the conditions for today's organizing campaigns, which also seek for nurses a greater voice in hospital affairs.
Jan Emerson, vice president of external affairs for the California Healthcare Association, the industry trade group, said administrators cut back on nurses when managed care swept the state a decade ago.
Looking at rapidly shrinking revenues from insurers, many administrators believed that savings could be gained by having lower paid workers do some of the less skilled jobs traditionally done by nurses, such as changing bed sheets or passing out meals.
"Let RNs only do the jobs that RNs are licensed to do," Emerson said. "Nurses were laid off."
But those layoffs came right before a boom in the state's economy and corresponding population growth. Moreover, hospitals indeed found themselves handling every sicker patients under the managed care model.
"It took a few years to prove the model was flawed. Now we are playing catch up," Emerson said.
But while the hospital industry may understand what some of the causes of the nurses grievances in general, it doesn't mean it believes a unionized workforce is the answer to those problems.
Many hospitals have fought the unions tooth-and-nail during the campaigns prompting complaints to the National Labor Relations Board. The hospitals also have been criticized for hiring firms that assist administrators in fighting off the unions.
That criticism has been leveled at Catholic Healthcare West, the large Oakland-based chain that has been the primary target of both the CNA and the SEIU. The system disputes the charges the firms are union busters. It has seen four of its hospitals in the county organized by the CNA this year alone.
All told the two unions have organized over 3,600 RNs since 1998 in Los Angeles County, but still only about 12 percent of nurses are organized in Southern California, where union penetration historically has been lower.
While labor and industry agree that a shortage of nurses is a fundamental reason for the unhappiness among working nurses, they deeply dispute how to improve working conditions by attracting more.
Studies show that the average age of California nurses is 47 and rising, as fewer young people enter the profession to replace the ones that leave. Thirty years ago if a women wanted to enter health care, nursing was the obvious choice. Now there's medical school.
But the unions contend that the number of nurses in the state actually grew 5.4 percent from 1996 to 2000, and the reason there is a shortage in hospitals is because nurses now prefer to work outside the hospital setting.
The union's argument won out in 1999 when Gov. Gray Davis signed a "Safe Staffing" bill requiring the state Department of Health Services to set specific nurse-patient ratios.
But the battle was far from over as the two sides lobbied the agency this year for radically different numbers. The hospital industry wants ratios that set bare minimum standards giving them greater staffing flexibility, while the unions have sought far tougher ones. The state is expected to issue its proposed numbers some time this month.
Moreover, the two sides waged another legislative fight over a bill that would outlaw mandatory overtime for hospital workers.
Emerson said the industry plans to lobby Davis to veto the measure should it pass the Legislature. She also fears that the industry will be left with no choice but to close down beds should the state come out with tough nurse ratios.
"The unintended consequence would be that hospitals would have to be forced into considering taking beds out of service," she said.
Of course, some hospitals have tried to find other ways to keep their nurses, even in the face of difficult financial times. Take Childrens Hospital Los Angeles, the prestigious East Hollywood pediatric hospital.
Neither the CNA nor the SEIU have organized the hospital, even though Hacker, the chief nursing officer, acknowledges hearing "rumbling" among nurses.
Hacker says one reason nurses may be happier is an expensive internship program it puts all its new nurses through, which the hospital says is unique at six months in length and with it $25,000 cost per nurse.
But it claims spectacular results. The hospital is now retaining over 80 percent of its nurses after two years, while it once lost 40 percent in the first year alone.
"There is a nursing shortage no matter what the unions tell you. There is also an inadequately prepared workforce for what nurses have to do," Hacker said. "The way to address these things are places where they can grow and become educated to do this work. We are trying to create that kind of place at Childrens Hospital."
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