Critical Condition 

Mary Flemming is the kind of nurse every hospital patient wants to see at the bedside: a seasoned specialist who can slip a needle in your arm before you even know it's in. As an IV nurse specialist at Fletcher Allen Health Care, Flemming is one of the nurses they call in for the "difficult access" patients: the neonatals, the pediatric chemotherapy patients, the elderly with collapsed veins, anyone for whom getting stuck with a needle might be a painful, or even life-threatening, complication.

Should you be sick enough to require her services, however, you'll be lucky to get her. Specialized nurses like Flemming, and all nurses, are in short supply.

It's a dangerous situation. Last week the Journal of the American Medical Association reported on a study by researchers at the University of Pennsyl-vania that confirmed what nearly everyone in the nursing profession has known intuitively for years: The more patients a nurse is responsible for, the more likely they are to die from complications, even after routine surgery.

The relationship between nurse-patient ratios and patient outcome isn't news to Flemming, or the hundreds of other nurses at Fletcher Allen who voted to unionize earlier this month. They see the consequences of a national nursing shortage every day. At any given time, Fletcher Allen's IV team is responsible for covering more than 400 patients throughout the hospital. Ten IV nurses could handle it, according to Flemming. But Fletcher Allen typically has seven on the job. One day last week, there were only three.

That may explain why a very ill woman had to wait several hours for Flemming recently. The patient, a breast-cancer survivor, had only one arm that could tolerate a needle, and it was all black-and-blue from previous failed attempts at an IV. "She was very sick, and very afraid," recalls Flemming, who quickly and painlessly started a line and told the patient's doctor that she would need an IV nurse for all future needles.

"Nurses, by and large, are smart, they're hard workers, they care, they take an interest in what they do," says Flemming. "But sometimes you want to run from the profession after a while because you feel like it's hopeless, like being in a really bad marriage."

The nursing shortage is hardly a new phenomenon, or confined to Fletcher Allen. Between 1995 and 2001 the number of nursing school graduates taking the national licensure exam dropped by nearly 29 percent; as early as 1998, Vermont's hospitals were feeling the effects. The U.S. Department of Health and Human Services now estimates that by 2020, more than 1.7 million nurses will be needed nationwide. But if current trends continue, only 635,000 will be available. Fletcher Allen's current nurse vacancy rate is 10 percent.

This dearth comes at a time when the demand for nurses has never been higher, as baby boomers enter retirement age. Furthermore, patients who years ago would have died of certain diseases are now living longer due to improved drugs and better technologies, which has only made their care more complex.

Meanwhile, health-care facilities increasingly focus on bottom-line priorities, relying more and more on their nursing staffs to deliver patient care -- nurses typically make up three-quarters of a hospital's work force. It's safe to say that nursing has never been more physically, intellectually or emotionally demanding.

"Today when people are admitted to the hospital, they are really admitted for nursing care," says Betty Rambur, dean of the College of Nursing and Health Sciences at the University of Vermont. "If they didn't need nursing care, they would be outpatients."

The nursing profession has always experienced cyclical fluctuations, but the current shortage is particularly acute. This is due to discouraging trends at every stage of the process, from an inability to attract young people into a profession with stagnant wages, to a severe shortage of nursing faculty, to greater numbers of nurses leaving the profession earlier.

At the same time, Vermont's nursing population is itself growing older. At 46, Flemming is a year younger than the median age of Vermont's nurses. Seventy-five percent of them are over the age of 40.

Yet, despite her 25 years of experience, Flemming earns only $5 more per hour than a new graduate entering the profession. "If you're a really, really good RN who's really, really seasoned and savvy, you're making relatively little more than people new to the profession," says Rambur. "In no other sector of our society would we expect or allow that."

A blue-ribbon panel commissioned two years ago to address Vermont's nursing shortage revealed that the wages of other health-care professionals, such as physical therapists, have all risen in the last decade. But Vermont's nurses have seen no real increase in their pay since 1992. So when the shortage hit, hospitals began turning to traveling nurses to fill those vacancies -- typically young, unmarried nurses who consider it an opportunity to travel and work in a variety of medical settings.

"Travelers" are contracted through national nursing agencies for three- to six-month stints. They don't get benefits from the hosting hospital, but are often paid better than the more experienced staff nurses they work with. Living allowances and signing bonuses -- which can amount to thousands of dollars -- add to the itinerant appeal.

"The only reason we use 'travelers' is when we can't fill those positions," says Mary Botter, chief nursing officer and senior vice president for patient-care services. Botter admits that this stopgap measure costs the hospital about one-and-a-half times what a full-time nurse costs. She couldn't say how much Fletcher Allen spends annually on travelers, but one estimate puts it between $7 million and $8 million last year.

"There isn't a magic wand that will create more nurses," says Botter. "We have to be focusing on two things: One is, how do we attract more people into this profession and, two, how do we create environments that will support nursing practices?"

Neither is an easy task. Some say that Vermont's current nursing shortage isn't due to any lack of licensed nurses in the state. Rather, it's a lack of nurses willing to work in today's nursing environment -- a trend borne out by a federal study released in August. The increasing corporatization of health care, in which business people are making clinical-care decisions, has resulted in cutbacks in equipment and resources, flat wages and deliberate staff shortages. Nurses say all of these contribute to an overworked and stressful nursing environment.

One nurse who worked for many years at Fletcher Allen recalls the arrival six years ago of West Hudson Group, a consulting firm brought in to "streamline" hospital operations. In the style of classic industrial engineering, consultants followed nurses around with clipboards and stopwatches as they performed their various duties, counting the number of steps between nurses' stations and patients' beds, then crunched the numbers to determine the most cost-effective way of operating.

The result: Several hundred nurses were laid off. Within six months, the hospital was approaching many of those same nurses to return to work as "per diems" -- staff nurses who do not work set schedules or receive any benefits.

"Nursing didn't create this problem, the industry of medicine has," says Flemming, who recalls how the IV team alone lost 25 percent of its staff in that round of cuts. "If nurses made a decent salary and continued to make a good amount of money with their years of experience, we'd have more nurses who could see more of a reason to stay there."

Not surprisingly, Flemming was one of the 672 nurses who voted in favor of unionizing the hospital's nursing staff. Upcoming contract negotiations with Fletcher Allen -- the state's largest health-care employer -- will set the bar not only for other Vermont nurses but other health-care workers throughout the region. While union organizers are calling this Vermont's biggest labor victory in 40 years, Flemming is realistic that real change, like healing, will be a slow process.

There are other reasons for hope. This fall, the Freeman Nurse Scholars Program at UVM, the only merit-based scholarship program for nurses in the nation, contributed to a nearly 20 percent increase in nursing applications, which will more than double the number of nursing graduates within two years. Fortuitously, UVM recently filled several nurse faculty positions that had been vacant for several years.

But it will take a lot more work to create an environment that attracts the numbers of ambitious young women and men who will be needed in the years ahead.

Flemming is not holding her breath. "My daughter, who's in college in Montreal, said to me, 'Mom, sometimes I think I want to go into nursing,'" she says, "and I said, 'Jen, don't do it. My daughter is a powerful person and I wouldn't want to see her in a powerless profession."