By Christopher Williams,Staff Writer

After working eight years at Maine’s largest hospital, Joanne Donnellan quit to save her own health.

Feeling overworked, Donnellan said she always punched out after her eight-hour nursing shift cringing at the thought of things left undone.

For years, her dreams were troubled by patients left in limbo and rounds unfinished. Even when she left to take a job as a home care nurse, her hospital nightmares continued.

It was only when she left nursing entirely three years ago that she started sleeping soundly.

Now, Donnellan keeps current on hospital nursing conditions through former colleagues. They flock to her East Baldwin kennel to drop off their dogs and share tales of woe.

Things have not improved, they say.

“It’s gotten a lot worse,” a floor nurse still working at MMC confided over lunch recently.

The problem

Maine, like many states, suffers from a nursing shortage.

There are more than 1,000 nursing vacancies across the state today. By 2020, that number is expected to multiply five-fold. The shortage comes despite the fact that a report several years ago showed more licensed nurses worked in Maine in non-nursing jobs than in any other New England state.

Some say that proves what they already knew: A lack of nurses is not the problem. Rather, it’s their unwillingness to put up with the heavy workload at many Maine hospitals, fearing for their patients’ safety.

Not only are nurses required to tend sicker patients, they’re also responsible for the actions of their support staff.

Since the advent of managed care in the 1990s, hospitals have been discharging patients earlier – a three-day stay for open-heart surgery, same-day discharge for a mastectomy.

That means that from a nurse’s perspective, every hospital patient requires high-level medical attention pretty much constantly.

Nurses have done what they can to meet the growing demands.

“We were so used to being frazzled and behind that we just adjusted and just worked our tails off and made sure everything got done,” Donnellan said, “even if we stayed hours after we were supposed to be done. And we were exhausted.”

Even nurses who flee hospitals for home care jobs are finding little refuge. Those patients are sometimes so sick they really belong in a hospital, say the nurses who tend to them.

Deb Kerr of Lovell worked as a home care nurse since 1992. She left earlier this year, calling the position “untenable.”

“I just felt I couldn’t do the job I had been hired for,” she said. “I felt I was put in a precarious situation.”

Her patients demanded far more care than she could offer during her scheduled hours. When she complained to her bosses, they downplayed the problem, she said.

She refused to visit certain patients, fearing their conditions were so unstable they were in danger. Even her best efforts would have been lost on them, she said.

She said she often coached family members on how best to get a home care patient re-admitted to the hospital. Knowing that hospital administrators and insurance companies might balk, she would advise the families to seek alternate hospitals.

Now working at a private nursing home, Kerr, 49, said she is ready to leave the nursing field altogether. When her son finishes college, she plans to switch to a different job in medicine, one that doesn’t involve caring directly for patients.

More than half of the nurses she worked with in both hospital and home care settings have done just that, she said.

“It becomes a dilemma of conscience,” she said. “Can you really become part of this?”

Burn out

Roughly 20,000 nurses are licensed in Maine. But a 2002 study showed that in Maine more of those licensed nurses are working in non-nursing jobs than in any other New England state, said Patricia Philbrook, who heads up the Maine State Nurses Association. Actual numbers were not available.

Philbrook, a working nurse, said the health care industry created the nursing shortage about 10 years ago. Anticipating cuts to federal health care programs, hospitals put in place hiring freezes. Nursing graduates couldn’t find jobs. As enrollments dropped in nursing programs, they lost their institutional support. Now they need to rebuild, Philbrook said.

Over time, demand rose. But the few nursing programs in the state couldn’t keep pace. Although there are more programs today, they still can’t keep up with the demand.

In fact, the outlook for filling that gap is dim, said Jane Kirshling, dean and professor of nursing at the University of Southern Maine.

As baby boomers get ready to retire at record rates, fewer nurses will be taking their places. That, coupled with an expected explosion in Maine’s elderly population, has health industry officials worried.

Maine had 13 nursing programs graduating 570 students last year, about twice more than the previous year. But it’s not nearly enough, say nursing executives at Maine hospitals.

Maine’s Department of Labor calculates 1,097 annual nursing vacancies statewide, three-quarter of those due to retirement or other reasons. That shortfall is expected to grow to 5,211 by 2020.

A bill carried over to this session of the Maine Legislature proposes to pump $1.7 million more into nursing programs across the state, an effort aimed at boosting the number of nursing student slots.

While acknowledging the problem of a nursing shortfall as patients get sicker, Kirshling said the results of a different survey of 15,000 Maine nurses who describe why they no longer practice is encouraging, despite the 2002 New England study cited by Philbrook. Kirshling’s numbers show more RNs in Maine working as nurses than the national average. The reason most cited for leaving the profession is retirement, not burnout, she said.

Ratios

Although experts agree there is no magic ratio of nurses to patients, one thing is clear: the greater the number of patients each nurse must care for, the worse the medical outcomes of the patients.

A University of Pennsylvania report showed that for every nurse added to tend surgical patients, fewer patients died.

Patients who undergo common surgeries in hospitals with the worst nurse staffing levels have as much as a 31 percent greater chance of dying, according to the national study that was published in “The Journal of The American Medical Association.”

California recently passed a law mandating maximum ratios for certain nursing positions at its hospitals. As a result, fewer nurses are expected to leave their jobs and fewer patients should die, according to a 2002 study in the AMA magazine.

The study says: “The shortage of hospital nurses may be linked to unrealistic nurse workloads. Forty percent of hospital nurses have burnout levels that exceed the norms for health care workers… One in five hospital nurses report they intend to leave their current jobs within a year.”

Linda Aiken, a registered nurse and professor at the University of Pennsylvania, said the leading reasons for burnout are lack of administrative support and too-heavy workloads.

Half the states in the nation have pending legislation that would prescribe nurse-to-patient ratios. Maine is not one of them.

Two years ago, a bill that would have required Maine to model its nursing ratios on California was referred to a governmental task force.

Philbrook said it’s probably time to reintroduce the measure.

No one interviewed by the Sun Journal could cite nurse-to-patient ratios at Maine hospitals.

Times have changed

Five years ago, Martha Riehle would have agreed with the MMC nurses who argue they are understaffed.

Back then, that hospital’s associate chief nursing officer said, “I couldn’t have had this conversation and said, ‘Oh, yeah, I’m comfortable'” with staffing levels. “We were not in great shape.”

The hospital had overlooked increasing patient acuity (seriousness of a patient’s condition) when scheduling nursing rotations.

“We should have been doing it,” she said. “We didn’t.”

That changed with the hiring of a new chief nursing officer, who introduced a different method for measuring nursing needs.

“She has made a phenomenal difference,” Riehle said.

Now, a team of workers, from RNs to administrators, meets to set nurse-to-patient ratios in any given ward at any given time.

MMC’s vacancy rate for nursing positions has plunged to about 1 percent now, she said. The hospital has applied to the American Nurses Association for status as a national model for nursing quality, a rigorous process that takes years to achieve.

‘Adapt and adjust’

In early 2000, nurses at MMC and Lewiston’s Central Maine Medical Center explored forming unions.

In both cases, some nurses complained their hospitals were understaffed and nurses lacked a voice in changing staffing levels. In the end, nurses at both hospitals decided against organizing.

Staffing levels have not been a problem at CMMC for the past two decades, said Sharron Sieleman, vice president for nursing. While declining to provide hard numbers, she characterized the ratios as “very, very good.”

Nurse-to-patient ratios are hard to pinpoint because they are always just a snapshot in time, she said.

“You have to change all the time to adapt and adjust,” she said. Those adjustments are made by nurses working each shift. If they see the need to call in additional staff, they can.

As for recruiting and keeping qualified nurses, Sieleman said CMMC benefits from its association with nursing programs in the area, including its own nursing school.

“That’s worked very well for us,” she said.

She points to a statistic that has many hospitals envious: more than one-quarter of CMMC’s staff has worked at the hospital for at least 20 years.

At St. Mary’s Regional Medical Center, administrators have injected greater flexibility in nursing schedules. That change is expected to put more nurses on floors where the sicker patients need more attention, said Mary-Anne Ponti, who heads up nursing there.

She said she worried most about the expected exodus of nurses in the coming years. A statewide survey predicts Androscoggin County is poised to lose the second greatest percentage of its nursing workforce, behind Aroostook County.

“We’ve got a lot of longevity staff here and that’s a wonderful thing,” she said. And she hopes it stays that way.