It seems it must have been another era, many generations ago; but Florene Todd-Moore can remember a time when the list of nurses waiting to work at Cook County Hospital was long.
That was in the early 1980s, before massive federal health-care cutbacks and an upswing in critically ill patients. Now at least 130 nursing jobs at County remain vacant, and the hospital is losing nurses at the same rate it hires them. Meanwhile the flow of patients has increased.
The result has been more overtime for nurses like Todd-Moore (some regularly work 16-hour days), a greater dependency on higher-paid temporary nurses, a labor showdown, and closed beds at County, the only Chicago-area hospital that meets the health needs of the poor.
"You can't have nurses working so many hours; it's not good for the patients and it's not good for the nurses," says Todd-Moore, who works with premature babies. "This is a serious problem; we aren't crying wolf."
County officials admit a shortage but try to downplay its urgency. "There is a national shortage of nurses, it's not just at County," says Wanda Robertson, the hospital's director of public affairs. "I don't think it's affecting the quality of health care. As for staff morale, that varies with people. One nurse might say, 'Yes, morale is bad,' another, 'No.' We try to do the best that we can."
The union charges that some hospital officials are more concerned with public relations than health care. And in a desperate attempt to highlight the shortage, County's nurses--members of the Illinois Nurses Association--staged a one-week protest: from September 30 to October 6, they refused to work any overtime. Hospital officials responded by canceling nonemergency surgeries and hiring more temporary nurses.
Union officials say they have no plans to stage another protest. But the action left each side feeling a little bitter toward the other, and there is no solution in sight.
"We gave the hospital notice so they had time to prepare," says Todd-Moore. "They closed beds and took in less patients. If you were coming in for, say, a removal of a mole, your operation was put off for another six months. X rays were put off. Everything got backed up. We made our point; if we had kept the boycott up, we'd only be hurting our patients. Now I hope everybody's ready to concentrate on the problem."
The shortage has a multitude of sources, including Reagan and Bush administration cuts in health-care benefits. As the federal government reduced coverage for indigent health care, more and more inner-city hospitals either closed or refused to take care of the uninsured. For County--an enormous facility located at 1835 W. Harrison--that only meant a longer line of patients.
Every week, thousands of people wait as long as eight hours to see a nurse or doctor at County's outpatient clinic. In 1988, according to the nurses' union, there were 36,000 admissions at County, and the average number of days spent in the hospital was six.
"They used to say County was just for the poor, but that's not the way it is anymore," says Todd-Moore. "The cost of health care has gone up so much that all sorts of working people come here now. If you have high blood pressure and your medicine costs $35 a month and you're living on $500 a month, you're going to come to County and sit in that clinic and wait eight hours because you don't have a choice. Where else are you going to go? Who else will take you?
"At County we also get the sickest, poorest people. County turns no one down. No matter how sick you are, no matter how bad you look or how bad you smell, we get you and we take care of you."
In recent years the number of critically ill patients--who require more nursing care--has increased in many hospitals.
"People in hospitals are sicker because we have the technology to keep people alive longer," says Susan Bennett, the union negotiator who represents County's nurses. "That's good, but it also means we need more nurses to service the sick. The number of critical-care beds has quadrupled; they require one nurse for every one and one-half beds."
The result, says Bennett, is that everywhere "the demand for nurses exceeds the supply." At County there are currently 1,046 staff nursing positions budgeted, but only 915 (or 86 percent) are filled.
"Our vacancy rate has been about the same for several years," says Sandy Peter, County's nurse recruiter. "That's not much higher than the national rate. But it means our managers have to spend a lot of time juggling staff. And we have to recruit that much harder."
But the recruiters' target group is smaller than it once was. Many college-educated women today are pursuing higher-paid professions than nursing, like law, real estate, and business.
"When other professions were closed to them, many women became nurses or teachers," says Robertson. "But women have more choice, and that means less of them will be nurses. We either have to attract more men to the profession or become more competitive with these other higher-paying professions."
County pays its starting nurses $13.39 an hour, or roughly $27,000 a year; a nurse with 20 years' experience can make about $41,500 a year without any overtime. In contrast, a first-year corporate lawyer can expect to make about $70,000. Though County's salaries have traditionally been competitive, they're not keeping pace with the highest-paying hospitals in the scramble to get nurses.
"Many hospitals are employing big hard-sell campaigns to hire nurses; some hospitals are offering thousands of dollars in bonus money to nurses who work weekends or nights," says Peter. "Our salaries are competitive. And we offer work opportunities that no hospital in the country can match. But I have to admit that we can't offer that big bonus money."
And for reasons even its administrators can't explain, the hospital clings to rules and regulations that make hiring difficult. There's a ban, for instance, on hiring experienced nurses at the prevailing wage.
"We have a 12-step wage system, but all nurses above step 3 get paid a step-4 wage; it doesn't matter if you've got 5 years or 53 years in the field," says Peter. "We had one nurse who worked in our burn unit for 15 years. When she left she was making about $19 an hour. When she wanted to come back, the hospital offered her $14.61. She wanted to work here, but she had no choice. She wound up working at another hospital; the difference in salary was just too great."
To help meet the demand for nurses, County has turned to temporary agencies that charge at a rate of about $37.50 an hour; of that, the nurses themselves receive about $30. Last year County spent some $5 million on temporaries.
Temporaries not only cost more than staff nurses but they're less likely to establish long-standing relationships with patients.
"We'd like to have more staff nurses, but let's face it, being a temporary nurse has its advantages," says Peter. "They get paid more, for starters. And they have flexibility. When I was a staff nurse, I worked every other weekend and half the holidays for years. Temporaries can control their schedules. They are in a position to say, 'Thank God it's Friday.'"
The typical way to compensate for the nursing shortage is to pay existing nurses overtime; this year the hospital will pay $15 million in overtime wages for nurses.
"Every day they ask you 'Do you want to work overtime?' And every day we do," says Todd-Moore. "You got people working 16-hour days. That's too many hours, even for a workhorse. You're going to get tired. Tempers will run short. You can't give each patient as much time as you'd like. In the nursery we've got 25 nurses for 63 patients--and I know darn well you need 35. But you can't quit; you can't refuse to work the overtime. Your patients need you."
All sides agree that to hire more nurses, County has to market itself aggressively as a hospital with a mission.
"We can't expect the nurses who want to work in gleaming suburban hospitals," says Elaine Williams, cochairman of the nursing local at the hospital. "This is an old hospital in an antiquated building. But I wouldn't work anywhere else because there's nowhere else that patients will need me as much."
It's a theme echoed by Peter and other nurses.
"I have a say in the health care of these patients," says Todd-Moore. "I'm the closest thing these babies have to a mother. I watch them gain their strength until they leave the nursery. I have one mother who comes back with her boy and says, 'This is your first mother.' That boy is five years old now. He calls me every Mother's Day and Christmas. I can't describe how good that makes me feel. I couldn't give that up."
A shortage of funds, however, undercuts any recruitment efforts. About $109 million of County's $288 million budget comes from the county board, and the rest comes from medicaid and medicare reimbursements. President Bush proposes to cut federal health-care payments, and local politicians are unlikely to make up the difference if it means raising taxes.
"I worry about the recession that's just around the corner, because when times get hard, the poor get hit the hardest," says Todd-Moore. "We're not looking for more money. If we wanted money, we'd take the overtime or become temporaries. That's not the issue. We're fighting for our patients and our sanity. We want for them what we would want for ourselves--quality health care."
Art accompanying story in printed newspaper (not available in this archive): photo/Bruce Powell.