The Double Standard

According to the nurses’ union, UVM-MC spends more than $11 million per year on its top fifteen administrators, including $2 million for CEO John Brumsted and $1 million for hospital president Eileen Whalen. When strike supporters gathered outside the hospital complex last week, they could see construction crews working on a $189 million addition to the medical center. Management is making plans to acquire more local physician practices and smaller hospitals, both in Vermont and neighboring upstate New York. During the walkout, Whalen reported spending $3 million on six hundred replacement nurses provided by Autumn Consulting Services, a Colorado-based firm whose niche market is strike breaking.

In contract talks before the strike, management negotiators consistently defended the medical center’s pay inequity. Nurses were informed that, for the purposes of setting executive compensation, UVM puts itself in the same big league category as Yale New Haven hospital, the Mayo Clinic, and Massachusetts General Hospital in Boston, which is affiliated with Harvard Medical School and Partners Healthcare.

On the other hand, RN compensation is determined “by comparing what RNs are paid in hospitals in rural Maine and New Hampshire,” reports Tristin Adie, a nurse practitioner active in the union. “So there’s one standard for hospital administrators and another for RNs, even though our hospital wouldn’t exist without RNs and NPs.”

The VFNHP estimates that six hundred of its members have not gotten a raise in nine years. According to the union, UVM-MC faces high RN turnover and a nursing shortage because Vermont ranks forty-seventh out of fifty states in RN pay levels. The issue of money is directly connected to nurse recruitment and retention and patient safety.

In any hospital, registered nurses and nursing assistants make up the largest percentage of the labor force because patients are not admitted to hospitals unless they need nursing care; and today, with more technological interventions and intensive monitoring, they need more than ever before.  Nurse practitioners play an increasingly important role in the delivery of hospital and clinic services, due to a nationwide shortage of primary care physicians and strict resident duty hour restrictions.

Whether on hospital wards or in outpatient clinics (like the ten operated by UVM-MC), adequate nurse staffing is a critical factor in patient safety and quality care. Understaffing has been linked to increased hospital infections, deaths from treatable complications, and poor pain management. As John Buchanan, Tanya Bretherton, and I wrote in Safety in Numbers in 2008:

When a nurse doesn’t have time to turn a patient in bed, that patient can develop an excruciating and costly bedsore. When a nurse can’t give prescribed medication on time, a patient may develop a serious infection or suffer from unremitting pain. When a nurse is running among eight different rooms, that nurse will not have time to notice a subtle change in a patient’s condition that indicates a catastrophe is about to happen.

It also means that nurses are rushed past educating patients about how to stay healthier.

“I have no time for following up with patients because we can’t recruit enough other NPs [since] this hospital pays so much less than its regional peers,” Adie told me. “Because of my workload, I wake up in the middle of the night because patients haven’t been called with the results of labs or imaging tests.  There are days when I leave the hospital an hour beyond my scheduled time because I need to do follow up.”

Among those out-of-state RNs rallying behind the VFNHP last week in Burlington were members of the Massachusetts Nurses Association. The MNA is sponsoring a ballot measure this fall that would limit the patient loads of Bay State hospital nurses. California is currently the only state in the nation with minimum nurse-to-patient staffing ratios. When other state legislatures have tried to follow suit, powerful hospital industry associations have blocked passage of all similar bills. This has forced unionized RNs, like those represented by VFNHP, to seek contract language limiting how many patients can be assigned to a nurse at the same time.

Sicker Patients, Fewer Nurses

Both in bargaining and past legislative fights over staffing levels, the industry has argued that ratio requirements would add unnecessary costs, deprive management of flexibility in making work assignments, and would result in hospitals laying off nursing assistants if they were forced to hire more RNs. But what’s really at stake is a “cost control” model that first took hold in the 1990s and has dominated health care ever since. As Safety in Numbers showed in 2008:

The shift to a cost control approach to managing illness, injury, and disease has been thoroughgoing and is now all-pervasive. This approach shortens patients’ length of time in the system (particularly as inpatients) [. . .] As patients get sicker, however, more nurses are not assigned to meet their increased requirements for care.

The cost control model guarantees profits for hospitals and insurers by pushing patients out of the hospital earlier — making them sicker in the long run — and pushing nurses to do more with less. That’s what administrators are arguing for when they reject safe staffing.

In this way, the Vermont nurses’ insistence that the choice is between “patients” and “profits” isn’t just a slogan. It’s an empirical description of what is blocking quality patient care in Burlington and beyond.

On its website, the UVM Medical Center proudly advertises its new $189 million addition, housing more patient beds and specialty clinics, as a “a better space for our patients — enhancing quality, privacy and healing.” In the absence of a new contract that provides better pay and conditions for nurses, their union negotiators question that management claim. Says Adie: “When we asked at the bargaining table who was going to staff the new facility, they said they had no staffing plans as yet.”

As MacMillan warned her colleagues during the strike, “We have an extended, protracted struggle ahead. We are in a power struggle with very powerful people who have deep pockets.” During their first walk-out ever, the Burlington nurses took a big step toward leveling that playing field with a strong showing of internal solidarity and community support. Hopefully, their fight will show results when bargaining resumes on July 24.