Twin Cities nurses using ward-closing power
Nurses at several Twin Cities hospitals are using an unprecedented clause in their union contract to close units to new admissions when they become too busy to efficiently handle.
Published May 27, 2002
From the moment Joan Johnson arrived for her 7 a.m. nursing shift, she knew it was crunch time at Mercy Hospital in Coon Rapids.
The "house" was filling up fast, though there were still some empty beds on Station 2 East, the 45-bed unit that Johnson oversees.
But on that first Saturday in May, she wasn't eager to take any more patients: The day shift was short three nurses and a nurse's aide.
So, for the next five hours, her entire unit was officially closed to new admissions. Any incoming patients would have to wait until she got more nursing help -- which didn't arrive until noon.
In the past year, she and other registered nurses have closed inpatient units hundreds of times in the metropolitan area, bolstered by a unprecedented clause in their union contracts. Hammered out a year ago in the face of threatened or actual strikes, the clause gives nurses at six metro-area hospitals the power to freeze admissions temporarily to their units if staffing reaches unsafe levels.
The clause is a first for a nurses union contract.
According to the American Nurses Association, no other contracts in the United States give nurses such a right.
So Twin Cities nurses have become, in effect, a test case; one that other hospitals throughout the Twin Cities area and the nation are watching.
Hospital officials insist that it's more of a nuisance than a danger to the patients who are left in limbo. It generally means that they're stuck in emergency rooms, recovery rooms or other temporary quarters longer than usual, or if necessary, shuttled off to other hospitals.
There's no sign that patients have suffered harm because of admission delays, according to Arnie Rosenthal, director of the state Office of Health Facility Complaints. "For patients, as long as they get good care, it probably doesn't matter where they are," he said.
It can, however, unnerve doctors and occasionally fluster hospital administrators. Yet, by most accounts, just the power to say "no" has brought a measure of relief to the pressure-cooker atmosphere that helped fuel last year's nurses strike in the Twin Cities.
For Johnson, who's been a nurse at Mercy for 23 years, turning away patients is a new experience.
"Since the new contract language, it really has empowered the . . . nurses on the unit," she said. "This way, I don't allow more patients in than we can safely care for."
It's not an everyday occurrence, but the language is getting a workout.
At Abbott Northwestern in Minneapolis, hospital records show that nurses closed units at least 170 times between August and March -- sometimes for 90 minutes, sometimes for entire 8-hour shifts.
At Fairview Southdale Hospital in Edina, officials counted 62 closings from September through April.
At Mercy, no one has kept a running total. But on May 4, half of its eight wards -- including behavioral health and critical care -- were closed by nurses for part of the day shift, according to Vince Rivard, the hospital's spokesman. It was, officials say, highly unusual, and by 3 p.m. all were reopened. But it showed, as nurse Johnson put it, "we're all sort of in this predicament."
Easing the strain
Nurses have been clamoring for some way to ease the strain caused by chronic shortages of nurses and other hospital workers around the country. They argue that staffing is often dangerously low, leaving too few nurses to care for too many patients.
But it was only last year that their frustration boiled over into a full-blown labor dispute in Minnesota. Last spring, the Minnesota Nurses Association made staffing a central issue in contract negotiations for almost 9,000 nurses at 13 hospitals. In response, some of the hospitals set up committees to study the problem.
Some, though, went further. Last May, four hospitals owned by Allina Hospitals & Clinics agreed to give nurses a say in closing patient wards -- the first nursing contracts in the country to do so, according to the American Nurses Association. The contract applied to Abbott, Mercy, United Hospital in St. Paul and Phillips Eye Institute in Minneapolis.
Then, in June, Fairview Health Services offered virtually the same language to striking nurses at its Southdale and Riverside hospitals, as part of a deal to end a 23-day walkout.
No one claimed it was an ideal solution. But in a crunch, supporters say, closing units can buy nurses time to regroup, call in reinforcements or finish up with the patients they have.
"Sometimes you just need a little breather to catch up," said Sandy Thimmesch, a nurse in charge of a 54-bed unit at Fairview Southdale. "That's where it's been very successful. To give us room to get caught up before the next wave of patients come."
In practice, hospitals say this isn't entirely new.
"It truly was happening before on an informal basis," said Jeanne Jacobson, a Fairview vice president. This just formalized the process, she said, setting guidelines on when and how it should be done. "So this isn't a huge change."
Kathy Wilde, vice president of patient care at Mercy, agrees. "We've always done it," she said. "I think that the charge nurses [who oversee each unit] really felt that they had that ability before."
But many nurses say the new rule has made it much easier. In the past, they say, many charge nurses were afraid to ask, and supervisors often vetoed their requests.
"We can communicate with the administrators a lot easier, and they're willing to listen," Jackie Hanson, who runs a 54-bed medical unit at Southdale. "If we feel we have to close a unit, they'll close the unit."
In the past, the message was often quite the opposite, said Jane Ekerberg, a charge nurse at Southdale's intensive care unit. "They wanted us to make room, no matter what," she said.
Some say that still happens at times; and that nurses themselves feel torn about turning anyone away. "We're very aware of the fact that there's a patient that needs to come into the hospital," said Pat Swenson, a charge nurse at Abbott. "It's not that we don't want to take care of [them]. It's that we have concerns about how well we're taking care of the patients that we have."
For some doctors, it's been a tough adjustment. "Physicians love to grumble," said Dr. Stephen Remole, the chief of cardiology at Mercy. "And here they are seeing some of their precious control moving over to the nursing staff."
At Mercy, he said, some colleagues worried that the closures would make it tougher to admit patients, and undercut their ability to get patient referrals. Yet "we all want what's right for the patient," he said. "I don't want my patient transferred to a unit that just took six admissions and can't handle it."
In practice, he said, the delays have been minimal. "We can almost always find a place to put them within a couple of hours," he said. "You're going to have crunch times where you've got to do some creative shuffling."
To hospital administrators, the answer isn't just hiring more nurses -- because the nurses shortage is getting worse. In late 2001 -- after Twin Cities nurses won 20-percent pay hikes over three years, there were 3,260 openings for registered nurses in Minnesota, according to a state job vacancy study. That's up from 2,900 nurse vacancies the year before.
The big push now is efficiency -- finding ways to move people in and out of the hospital more quickly, to free up beds. That's prompted hospitals to re-invent themselves in subtle ways.
At Mercy, for example, heart specialists have changed their morning routine to check on their healthiest, rather than sickest, patients first, so that they can send people home earlier and make room for new admissions. At the same time, says administrator Wilde, Mercy is considering creating a temporary holding area to house overflow patients for up to four hours.
If that kind of thing helps control the flow of patients, then the nurses say they're all for it.
"Patients don't get the benefit when you have to turn them away," said Carrie Mortrud, a nurse and union representative at Abbott. And hospitals lose money, too, she said. "It behooves all of us to work on this situation."
-- Maura Lerner is at email@example.com