Patience, and patients: Nursing shortage felt in local ER

By Emily Richmond

Friday, July 13, 2001 | 4:53 a.m.

Troy Repuszka reaches down to tighten the knot on one of her running shoes, a stethoscope dangling from her neck. She straightens, tugs on the hem of her tropical-print scrub top and reaches for a stack of medical charts.

There are four patients assigned to her care in the emergency room at Sunrise Hospital and Medical Center, and dozens more are waiting their turns in the crowded lobby. It's a Friday, and Repuszka, a registered nurse, is five hours into a 12-hour shift.

"It's a full house out there," she says, peering through the double doors to the waiting area. "Good thing we like it busy."

Nurses in the United States are in short supply. Nevada has the worst nurse-to-population ratio in the nation, with just 520 nurses per 100,000 people, according to a study released in February by the Health and Human Services Department. The national average is 782 nurses per 100,000.

It's a shortage that is only expected to get worse, the Nevada Hospital Association warned in a March report.

"The nursing shortage in Nevada increasingly jeopardizes the ability of health care providers to provide timely access to health care services and, thus, represents a growing threat to the state's public health," the report said.

When the vacancy rate for registered nurses reaches 8 percent, it's considered a crisis, said Doreen Begley, who is in charge of nursing topics for the Nevada Hospital Association. The national vacancy rate is 9 percent. Nevada's is 13 percent.

Nevada will need an another 662 nurses each year through 2008, according to the report. The state's six nursing programs expect to graduate 277 students this year. Assembly Bill 78, passed during the recent legislative session, provides funds from the tobacco settlement for nursing scholarships. The bill also calls for the state's University and Community College System to develop plans to double capacity at its nursing programs.

Nursing programs in Northern Nevada have 42 slots and 83 qualified applicants had to be turned away last fall. No applicants were turned away because of lack of space in Southern Nevada. Most Nevada nursing students last year were between the ages of 27 and 32, Begley said.

Older students are more likely to move out of state to find a program that will accept them, rather than wait for an opening in their area, Begley said.

"Once they leave the state it's very, very difficult to get them to come back," Begley said.

Repuszka's ER patients often include tourists who have overindulged in alcohol, homeless people with nowhere to go for treatment and locals who don't feel well enough to wait for an appointment with their regular doctors. There are no victims of car wrecks or other serious accidents -- those patients by law must be taken to University Medical Center, which has the area's only trauma center.

"This can be a pretty scary town," says Repuszka, who came from Canada five years ago for her job at Sunrise. "People come for the excitement and wind up overloading. Then they end up here."

A friend told Repuszka about the dire need for nurses in America and suggested that she try Nevada. Her husband took an early retirement package from his job with the Canadian government and moved his family south. Repuszka had returned to college while in her late 30s, and this was her first nursing job. She arrived in Las Vegas for an interview and was hired the same day.

"I can't imagine how fast they're trying to hire people now," Repuszka said.

Her regular schedule is between 36 and 40 hours a week, and she gets time and a half for overtime. Her salary of $26.26 an hour is set by Service Employees International, her union.

To earn her pay, Repuszka rotates throughout the ER, monitoring patients in the critical ward and keeping watch over people placed on psychiatric hold by the courts. She also takes her turn at the front desk, where the sick and injured are prioritized by a triage nurse.

On this Friday, Repuszka is responsible for a cluster of four examining rooms, which are divided by curtains instead of walls.

Repuszka takes a plastic bag of saline into Room 34, where 18-year-old Danielle Richvalsky is being treated for stomach pains. Repuszka and the doctor suspect appendicitis, but they aren't sure. The young woman's pain may stem from a broken back, the result of a car accident nearly two years ago. Richvalsky wears a back brace over her hospital gown.

"We're still waiting for the doctor to check out the results from your CAT scan," Repuszka tells Richvalsky, hooking the fresh bag of saline solution to the IV pole. "How's the pain?"

"Still there," Richavalsky says, managing a smile. "I don't want it to be appendicitis."

"Well, we'll have to wait and see a little bit longer, so hang in there. OK?" Repuszka says.

Dr. Ikram Khan, a general surgeon at Sunrise, stops by the ER to talk to Repuszka about Richvalsky. He reviews Repuszka's notes and agrees that a second round of diagnostic tests is needed.

"We don't want to operate on a healthy 18-year-old," Khan says, seated in a chair at the nurses' station. "Let's be completely sure here."

Repuszka reaches into a supply cart next to the nurses' station and picks up a syringe and tiny plastic vials. She pulls back the curtain to Room 35, where a woman from Los Angeles is stretched out on an examining table, one hand cupped protectively over her stomach. The woman in her early 30s is just five weeks pregnant and fears she may be suffering a miscarriage.

Carrying the woman's urine sample into a small anteroom, Repuszka dons gloves and dips a small strip into the container. It's one of hundreds of pregnancy tests performed each week in the ER. Every woman between 18 and 60 is tested.

A few minutes later the test shows the woman's hormone levels are elevated, indicating she may be in the early stages of pregnancy. The patient had told Repuszka that she has been trying to have a baby for more than five years.

"We'll have to keep our fingers crossed for her," Repuszka said, sighing.

There are 40 beds in ER, including 16 in the critical unit, which has one nurse for every three patients. Sunrise Hospital has openings for 198 nurses, ranging from part- to full-time positions. Most of those slots are being filled by traveling nurses supplied by staffing agencies, Sunrise spokeswoman Ann Lynch said.

In another bed in ER, a patient has been waiting for several hours to be transferred to a regular room. Why the delay? It's another symptom of the nursing shortage, Repuszka said.

The ER is supposed to be a way station, where patients are stabilized, diagnosed, treated and either released or moved to another ward. When the flow is interrupted, the dominoes begin to fall. The lines grow longer in the waiting room. The patient-to-nurse ratio rises. And, eventually, the ER must close its doors.

"Our goal in the ER is get 'em in and get 'em out," Repuszka said. "It's frustrating for everyone involved when we have a backup because there aren't enough nurses to take care of the patients upstairs."

For years nursing was considered a female vocation, which has made it a tough sell as a career choice for men, Begley said.

Also, women now have more options when it comes to careers and fewer are choosing nursing, she said.

"We want the profession of nursing to reflect the faces of the patients we care for," said Begley, a registered nurse. "We care for every area of the population, but our ranks simply don't reflect that diversity."

If the United States, and Nevada in particular, are going to rebound from the shortage, the perception of what a nurse is must be broadened to include men and minorities, Begley said.

The problems aren't limited to encouraging newcomers to the profession. The average age of nurses on the job continues to climb, and many are opting for early retirement, Begley said.

More than half of Nevada's registered nurses with active licenses are older than 46; the national average is 45, according to a report by the General Accounting Office, Congress' investigative arm. In 1980 52 percent of registered nurses were reported to be younger than 40. Today, that figure is fewer than one out of every three nurses. Nurses younger than 30 were 25 percent of the total in 1980, compared with 9 percent last year.

It's just before 2 p.m., and Repuszka is deciding what to do with two plastic iced tea bottles filled with whiskey.

The bottles were confiscated from a homeless man brought in for treatment of heat prostration and acute alcoholism.

"Can't we just dump it out in the sink?" another nurse says.

"I don't think we're allowed to," Repuszka replies. "It's his private property."

A call to the hospital's legal department confirms Repuszka's suspicions. The booze must be put away for the man's eventual release.

"Kind of ridiculous, isn't it?" Repuszka says, studying the Nestea labels on the 20-ounce bottles. "But it's his, so we'll hold on to it."

Encounters with the homeless are frequent in ER. In one case a man in a wheelchair was so dirty his clothing encrusted his skin. Repuszka and another nurse ended up scrubbing him for nearly two hours -- wheelchair and all -- in a decontamination shower.

"When we were finished the man kissed my hands and said, 'Thank you, thank you,' " said Repuszka, her face softening at the memory. "I just felt so bad for him. Where was he supposed to go?"

An elderly man is brought in on a stretcher by paramedics and shifted to the bed in Room 36 -- Repuszka's station. He tells her he called 911 after his right arm suddenly went numb.

Repuszka knows such numbness could be a sign of a stroke. She asks the man to smile, demonstrating with her own broad grin. Good news: There's none of the telltale, one-sided droopiness that often accompanies strokes. The man is also able to extend his arms straight ahead and keep them there, even with his eyes closed.

"Do you know what day it is today?" she asks the man, wrapping a blood-pressure cuff on his left arm.

"It's Friday," he answers.

"That's right, and what year is it?" Repuskza says.

"Uh, 2000, right?"

"Close," she answers with a smile. "It's 2001. Do you know who's president?"

"Not that Clinton fellah anymore, he got into trouble," the man answers, drawing a chuckle from Repuszka.

The phone rings. The tests results are back, and it's conclusive: Richvalsky has acute appendicitis. Repuszka crosses the hall to give the patient the news. There's no operating room available, so Richvalsky will stay in ER for now.

Many nurses are leaving because of job dissatisfaction and frustration over staffing shortages by hospitals, said Gay Howard, national coordinator for the union's Nurses' Alliance.

In a survey of 237 registered nurses in Nevada, the union found 66 percent believed inadequate staffing had contributed to serious medical errors. Some hospitals are using the nursing shortage as an excuse for not having adequate staffing levels, Howard Howard said.

The union, which represents nurses nationwide, found similar complaints in other states as well. Nevada nurses surveyed also reported not having enough time to assess and monitor patients, and 46 percent said at least once a week a patient's treatment was delayed or a medication dosage was missed.

"We know patient care is suffering," Howard said.

In May nurses set hundreds of pairs of thick-soled white nurses' shoes on the steps of the nation's Capitol. Sen. Harry Reid, D-Nev., was there for the demonstration and promised to support legislation that would ease the crunch.

"Our nurses are being forced to work too many hours of overtime," Reid said. "Mandatory overtime should not be used as a substitute for adequate staffing levels. We set limits on the number of hours airline pilots, air traffic controllers, train engineers and truck drivers can work before their fatigue reaches hazardous levels. We should do the same for nurses who are responsible for critically ill patients."

Reid has proposed federal funding for educating and training nurses. A second bill would require hospitals that accept federal funds to post nurse-to-patient ratios.

To make their concerns public, some nurses have resorted to one-day walkouts, such as one June 26 at the Washoe Medical Center in Reno, or to prolonged strikes.

In the United States, nurse strikes have become more common, with unions using them as leverage to negotiate better salaries and working conditions. At Stanford Medical Center in Palo Alto, Calif., a nine-week strike last summer crippled schedules for out-patient surgery and even forced the temporary closure of ERs.

Such tactics can leave deep scars in the community, Begley said. Not only do the nurses divide themselves from the rest of the medical staff, but they make it more difficult to attract newcomers to the profession.

"We shouldn't be airing our dirty laundry in public," Begley said. "We need to have fewer people in the profession bad-mouthing it so much."

At Stanford administrators offered group-counseling sessions for the nurses and physicians so that they could talk out their frustration and anger after the strike.

Cynthia Bunch, Nevada Nurses Association's spokeswoman, said her profession hasn't been vocal in any arena and that strikes are a last resort.

"For nurses to take a step this drastic, they have to be pushed," Bunch said.

When nurses quit, it's because of understaffing and mandatory overtime -- things that compromise patient safety, Bunch said.

"The more nurses that leave the less that remain on units to care for patients," Bunch said. "That's the true root of our current nursing crisis. Hospitals haven't truly valued the nurses they already had."

During strikes hospitals must rely on staffing agencies to provide temporary workers. U.S. Nursing, a national organization, was offering $40 an hour plus bonuses to traveling nurses willing to cross the picket line at the Washoe Medical Center.

"Strike-breaking nurses have to be very brave," Bunch said. "You're walking into a job where you don't know the facility or the staff, and if something goes wrong, it's your license on the line."

As the clock closes in on 6 p.m., Repuszka reassures a middle-age man that his cancer-striken mother will be carefully watched until she can be moved to a hospice later that evening. The man's manner is curt, almost abrasive. He tells the nurse he doesn't want his mother subjected to unnecessary tests. Repuszka just smiles, tries to reassure him and asks that he move out to the lobby before using his cell phone.

It's normal for the tension level to be high in ER, for both staff and patients, Repuszka said. She knows that fear and the unfamiliar surroundings can make people short-tempered. She doesn't take it personally.

"There are days when you go home after 12 hours and feel like screaming," she said, running her fingers through her shoulder-length brown hair. "But most days I feel respected by the doctors, and the other nurses and the patients. I feel like I'm helping people."

Two scrub nurses arrive in ER to wheel Richvalsky upstairs for her appendectomy. As her bed is wheeled past the nurses' station to the elevator, she raises her head from the pillow and scans the room for signs of the nurse who has been by her side for 11 hours.

"Wait, wait, 'bye, Troy," Richvalsky calls out. Her face crumples into tears when Repuszka dashes over from the other side of ER.

"You'll do great, don't worry," Repuszka says, smoothing back Richvalsky's hair and hugging her. "I'll see you soon."