When she rushed her mother to a Wichita, Kan., hospital, an emergency room doctor quickly sized up the older woman as another pneumonia case. Her breathing was labored and pneumonia patients filled the emergency room.
But 61-year-old Shirley Keck didn't have pneumonia. As she lay in a hospital room all but ignored, she was suffering from a common type of heart failure that filled her lungs with fluid.
As Keck deteriorated over several hours, Hartman begged Wesley Hospital nurses for help.
"It was total chaos. Everybody was tired. Everybody was totally overworked," Hartman recalls. "As the breathing got worse, I'd ring the button. Nobody came."
It was Feb. 8, 1998 — a Sunday night, when hospital staffs are leanest. There were just two registered nurses and two nurse aides for 42 patients on Keck's floor, fewer than half the staff the hospital's own guidelines required.
"I'm going to die," Shirley Keck told her daughter.
She did, but was resuscitated and lingered for four years — depressed, paralyzed except for one arm and unable to talk because a stroke during the ordeal had caused brain damage.
Her family sued and won a $2.7 million malpractice settlement from Wesley Hospital in July 2000. Two years later, Keck died.
The hospital and Keck's attorney, Bradley Prochaska, say it's the first malpractice decision specifically pinned on inadequate nurse staffing. He has filed a similar suit involving a 38-year-old quadriplegic woman.
At first, Hartman was furious with the nurses. Now, she's joined their cause, speaking out about the need for more nurses at the bedside.
"If another family doesn't go through this, the nightmares I've had," she says, "that's all I can ask for."
In New Jersey and states across the country, nurses unions are pushing hospitals and lawmakers for limits on patient loads.
For example, nurses at Englewood Hospital and Medical Center in northern New Jersey two years ago won a contract limiting workloads generally to no more than a half-dozen patients per nurse — enforceable through arbitration.
RN Stephanie Orrico says Englewood is mostly meeting the rules. Before, it wasn't uncommon for medical/surgical nurses to have patient ratios of up to 1-to-15, she says.
"You tell me what kind of care those patients were getting," Orrico says.
Hospitals are trying to recruit and keep more nurses, with good reason: Too few nurses can cost patients their health and sometimes their lives, study after study shows.
A shortage of nurses is a factor in about one-fourth of patient injuries or deaths in hospitals, according to the Joint Commission on Accreditation of Healthcare Organizations' 2002 report.
The prestigious Institute of Medicine says long work hours and fatigue contribute to errors. Its November 2003 report recommends a ban on nurses working longer than 12 hours a day.
A 2002 study by Harvard and Vanderbilt university researchers, examining millions of 1997 hospital cases, found preventable deaths and patient complication rates were up to nine times higher in hospitals where the most care was given by licensed practical nurses and aides, not better-trained RNs.
For each additional patient over four assigned to a nurse, the risk of dying after surgery rose 7 percent, according to a 2002 survey of 168 Pennsylvania hospitals by Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.
"The fewer patients a nurse cares for, the better the outcome in general," says Aiken.
Nurses say their workload and paperwork do not leave enough time to comfort, educate or even thoroughly assess patients. Many of the most experienced nurses leave for easier jobs at drug or insurance companies, leaving ever-greener nurses at the bedside.
"You're just thrown in the deep end ... too many patients, too many tasks," says RN Alison Goodman, whom Wesley Hospital fired 3½ years ago after she repeatedly filed complaints about unsafe RN staffing levels and gave her reports to attorney Prochaska.
Hospital spokeswoman Helen Thomas says Goodman was fired for breaking patient confidentiality rules.
In another Kansas hospital, busy young mother Karin Meade was left paralyzed from the neck down due to inadequate care by nurses swamped with too many patients, Prochaska claims. Meade and her husband, Peter, are suing Olathe Medical Center, where he took her on June 14, 2001, after a chiropractic treatment tore an artery lining.
That caused small blood clots; some broke free, causing several mini-strokes, according to Prochaska. He says nurses didn't notice because for 28 hours none did the neurological checks required every four hours to see if Karin Meade was coherent and able to move and feel her limbs. Despite nurses' notes in her chart about slurred speech and a severe headache — classic stroke signs — no one intervened.
Spokeswoman Kate Eller says Olathe Medical Center does not discuss pending lawsuits.
Peter Meade has moved his wife to a group home in Chandler, Ariz., outside Phoenix, near her parents. He visits her daily and is modifying the house he lives in so she can move in.
"She's still in the I-can't-believe-this-has-happened-to-me stage," he says.
Hospitals generally say they haven't hired more nurses because they are in short supply. They also blame financial pressures, such as technology costs and cuts in government and insurance reimbursements. Most oppose hard-and-fast limits on how many patients nurses may handle.
"Mandating a number doesn't make those nurses appear," says American Hospital Association spokeswoman Amy Lee. "We feel that is trying to force what needs to be flexible into a one-size-fits-all model."
The New Jersey Hospital Association supports the goal of optimal nurse-to-patient ratios but strongly opposes mandated ratios, said spokesman Ron Czajkowski. Fixed ratios don't allow hospitals to make adjustments based on the experience level of nurses or the number of support workers on duty each shift, he said.
"You can't have the same standards for a 120-bed hospital in Salem County and a 600-bed hospital in Bergen County," Czajkowski said, adding that ratios could be financially disastrous for hospitals.
Finding enough qualified RNs will remain tough: The U.S. Department of Health and Human Services projects the current shortage of a few hundred thousand RNs could hit 750,000 by 2020, as aging Baby Boomers need more care and the nursing work force gets older.
But in Washington and states from New Jersey to Oregon, nurses' unions are ramping up battles for new laws or contracts setting minimum nurse-patient ratios.
Local unions have been fighting for — and increasingly winning — contracts that limit patient loads or that put nurses on committees that set staffing guidelines. It's a key issue this year in contract talks for nurses in at least 12 New Jersey hospitals.
Last October, nurses at University Hospital in Newark won a contract setting ratios of one nurse per two patients in ICU and seven in medical/surgical, or general, units.
Several unions have held lengthy strikes over staffing ratios, including one that began Nov. 14, 2002 at Northern Michigan Hospital in Petoskey, Mich. Some nurses have temporarily taken jobs as far away as Hawaii rather than cross the picket line, which has endured through two frigid winters.
"It's difficult for a lot of people to believe that nurses would make that sacrifice for their patients," says Sharon Norton of Teamsters Local 406. "They know not only is the patients' safety in jeopardy, their licenses are on the line and they're not willing to take it anymore."
Many nursing groups are looking to California as a model for nurse ratios.
In January, it enacted the nation's first hard-and-fast ratios, ward by ward. An RN may care for six patients at most, and only four in the ER and two in critical care units.
Six other states — Florida, Kentucky, Nevada, Oregon, Texas and Virginia — have enacted staffing regulations but not ratios, and 18 states introduced some staffing legislation last year, according to the American Nurses Association.
The California Nurses Association says its survey of nurses at 111 of the 450 acute care hospitals found 68 percent were complying or had improved staffing by late January.
"While some significant problems remain, the progress made to date is very encouraging," says the union's president, RN Deborah Burger.
The not-for-profit Kaiser Permanente system, with 28 California hospitals, hired about 3,000 more RNs to meet the new rules, gave nurses more say on policy and improved training for nurses and managers, says Marilyn Chow, vice president for patient care services. That reduced turnover significantly.
"We thought it was the right thing to do. It's all about patient safety," Chow says.
Many hospitals, including the three-hospital LibertyHealth system in northern New Jersey, are recruiting and training more foreign-born nurses. LibertyHealth did so with a $500,000 grant from the Plainsboro, N.J.-based Robert Wood Johnson Foundation, the country's biggest health care philanthropy, which also is funding efforts to expand nurse training.
Health-care giant Johnson & Johnson of New Brunswick, N.J., has devoted more than $25 million since 2002 to fund nursing scholarships and improve nursing's image through ads. J&J spokeswoman Kristen Smith says the company also is funding fellowships to train more nursing school faculty — a pool that, like the nurses, is too small and fast approaching retirement.
Experts say the union, hospital and foundation efforts are helping entice former hospital nurses back and draw new people into nursing. Applications at many nursing schools are up so much that students are turned away for lack of space or teachers.
The weak economy, hefty retention bonuses and a big pay jump also are big draws.
In New Jersey, for example, RN salaries rose 25 percent in three years to a statewide average of $29.42 per hour, while the statewide vacancy rate for RNs dropped from nearly 14 percent to 9 percent, says Barbara Tofani, director of the Center for Nursing and Health Careers at the New Jersey Hospital Association.
The center presents programs on health-care careers to schoolchildren. It also works with hospitals on retention strategies, ranging from mentorships to employee appreciation efforts.
"Hospitals are listening now to their staff nurses," Tofani says.