Nurses Deal With Dispute, Ward Reality : Medical: They worry that short staffing at the county hospital may lead to tragedy, and that a new contract gives them no power to stop it.

The morning sky is still gray when three nurses gather in a tiny corneroffice at the Ventura County Medical Center.

“We have a call from a patient who has been frequently seen in ER (emergency room),” night shift supervisor Meliba Ocibillo informs her relief at 6:45 a.m. “He has threatened to come over and shoot us.”

That’s not all: Nine women are in labor, an overflow ward has been opened on the third floor, and the thermometers on 3 West ward are reading high.

A glance at a computer printout shows nurse supervisor Darla Lowery that the obstetrics ward might need more nurses, but the surgery units are overstaffed.

Lowery, a beeper strapped to her black sweat pants, sets off on her rounds, ready to see what the day shift holds.

Beyond the rhetoric of the nurses’ bitter dispute with the county lies the reality of the county hospital, where administrators scramble to get the nurses they need and send home the ones they don’t. And where nurses worry that short staffing will one day lead to tragedy, and that terms of a new contract imposed on them give them no power to stop it.

In part, what Ventura County is experiencing is the paradox of health-care reform. The movement, on one hand, offers nurses more responsibility and respect by turning over many doctors’ tasks to highly trained nurses. At the same time, the cost-cutting initiatives have led to layoffs and pay cuts.

In Ventura County, the dispute has taken on nasty overtones. After a frustrating year of layoffs, slashed salaries and stalled contract negotiations, the nurses threatened to strike. The county responded by forcing them to accept a pay and benefits package that they had already rejected at the negotiating table.

“I think a lot of nurses are feeling that their rights are not being respected,” says Maria Lafitte, a senior registered nurse at the hospital. “Sometimes we have to stand up for our rights.”

Hospital administrators say they mean no disrespect. Instead, they say they need the new compensation package--and the latitude it provides in sending nurses home when the wards are empty--in order to survive financial cuts. “I need some flexibility,” said Darlene Betker, director of nursing at the hospital. “If I don’t have flexibility. I will have to have layoffs. I don’t want layoffs. Layoffs are horrible. But I can’t have people here picking up salaries when there is no work.”

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Betker moves quickly down the third-floor corridor, speaking to the nurses gathered at their stations. She walked these floors as a nurse for most of her 45-year career. Now she does the rounds each morning to check on her staff.

Down the hall from her office, she finds nurses huddled around a tape-recorder, jotting down comments that the night shift left on each patient in the ward. Around the corner, nurses ready a handful of patients for surgery. Upstairs, the neonatal unit prepares a seriously ill, premature baby for transfer to UCLA Medical Center.

Betker stops by the emergency room to check on the threat they received earlier. As it turns out, the call came from a mentally ill patient the nurses knew. They dispatched paramedics and police to pick him up and lock him into the county’s psychiatric in-patient unit.

At 8:30 in the morning, the emergency room is virtually empty. The surgery units upstairs are also quiet.

Until last week, the state had refused to authorize any elective surgery for poor patients, explains James Holden, the doctor who runs the general surgery unit. Elective surgery doesn’t mean face-lifts and nose jobs. It means gall bladder operations, slipped discs and other surgery that Ventura County’s poor residents need.

“Basically, Medi-Cal’s position is that if you aren’t dying from it, it’s not an emergency,” Holden says. The state has started to approve operations again, but the hospital for now is still using only two of its three operating rooms.

That means excess nurses on the floor.

Holden supports one of the most contentious elements of the county’s compensation package for nurses: sending nurses home when they’re not needed.

“Nobody wants to send people home,” he said. “And I personally don’t want to see the nurses’ pay cut. But we need to do something.” Nurses say they do not object to the idea, just the policy as written by the county. The California Nurses Assn. argued for a “comp-time bank” that would allow nurses to save excess hours and be paid for them on days when they were sent home, said Helen Horn, an assistant director with the union.

Horn said the nurses also want limits on the policy, which allows the hospital to dismiss nurses when they are “not immediately necessary.” That term should be defined more precisely, she contended.

“I know they say that,” Betker responded. “That’s what I’m paid to do is to make those kind of judgments. When I send somebody home, I’ve got to make sure that I am not putting any patient at risk, that I’m covered.”

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Darla Lowery’s beeper sounds at 10:45 a.m., and the day shift nursing supervisor heads toward the obstetrics ward.

“We’re going to need to call in another nurse if that’s OK with you, Darla,” obstetrics nurse Sharon Madonna says breathlessly.

Two women have delivered their babies. Another seven are still in labor. Six women are in recovery and three others are hospitalized in an attempt to stop premature labor. Six nurses are handling the floor.

“It’s just too much,” Madonna said.

Lowery authorizes another nurse, as the unmistakable wail of a woman in labor rises from a room nearby.

For all the talk about laying off and sending home nurses, administrators still find themselves scrambling for nurses in some units. Obstetrics fluctuates daily, if not hourly. Other critical-care units, including intensive care and telemetry, are chronically understaffed, nurses say.

“On the weekends, they’re down to such a skeleton crew that one sick call can throw the whole place,” said intensive care nurse Sheila Raives, who serves on the union’s negotiating team.

Nurses say staff reductions and cost-cutting measures can threaten lives in these units.

On some occasions, administrators have floated nurses who lack adequate training into intensive care or telemetry, both of which require monitoring complex machines, Raives said. In one instance, a nurse made a medication error that did not harm the patient but alarmed other nurses, she said.

Nurses contend that when staffing is short in the critical-care units, the nursing supervisors downgrade the level of care required by changing their assessment of a patient’s condition, or acuity.

Betker vehemently denies any such activity. “The whole acuity system is based on the registered nurse’s direct assessment of the patient,” Betker said. “I don’t do the assessment. No one in the nursing office does the assessment.”

She also denies any unsafe staffing practices, pointing out that the state and hospital set specific requirements for critical-care units.

Earlier this year, the California Nurses Assn. submitted about three dozen complaints to state health licensing officials, charging that nurses had been assigned in ways that could threaten patient safety.

The Department of Health Services Licensing and Certification confirms that investigators looked into complaints, but cannot release results until the investigation is completed.

Betker said the state brought four investigators to review her records in January, and adds: “I want to tell you, there wasn’t a shred of proof.”

This spring, Betker clashed with the intensive care nurses over providing a lunch hour. The nurses, who then worked from 6:45 a.m. to 3:15 p.m., wanted 30 minutes off in the middle of the day but needed qualified workers to relieve them.

“I don’t have a bagful of ICU nurses that I can just plug in there willy-nilly,” Betker said.

So she did away with the lunch break and changed the shift hours to 7 a.m. to 3 p.m. “Lunch relief is by operational availability,” Betker said, recalling eating at her post during her 12 years as a critical-care nurse.

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Nurse Practitioner Brenda Robinette rushes down the hall with a minutes-old baby boy who is breathing too fast and grunting. Respiratory difficulty, she tells the nurses as she brings the infant into the neonatal intensive-care unit at about 11:15 a.m.

Nurse Specialist Debbie Lao places baby Gabriel in an Isolette and attaches monitors to his tiny chest. She swabs his wrist with a cotton square as big as his hand, and then tries to draw the blood.

Little Gabriel screams at the touch of the needle, his cheeks growing pinker and healthier with each wail.

“Happy Birthday,” Robinette coos into the Isolette. “Welcome to ICU.”

As a nurse practitioner, Robinette is trained to evaluate the baby, prescribe certain medications and perform a set of procedures without a doctor’s permission. Lao, as a nurse specialist, also has special expertise in dealing with sick babies.

As part of his health care reforms, President Clinton is looking for such highly trained nurses to deliver many of the services now provided by doctors. Already, Ventura County uses nurse practitioners to run many of its public health clinics.

“The nurses are really a key part of health-care restructuring,” said Judith Overmyer, co-chairwoman of the local nurses’ union. “You’re going to be hearing a lot more from nurses.”

So nurses found it frustrating when contract negotiations dissolved into a debate on pay cuts and layoffs, Overmyer said. “We had all these big ideas that we wanted to talk about, and we got down and dirty from the start,” she said.

What’s more, nurses fear that the new compensation plan will give administrators latitude to fire senior nurses. The plan provides for layoffs by unit, rather than by seniority. Betker said nurses will still retain their seniority rights.

Betker said she also was disappointed with the negotiations, the first she has participated in during her long career. But she said the financial changes were an economic necessity.

“It may make people feel better to represent me with two horns and a tail, but the fact is I have to survive; we have to survive,” she said.

By 3 p.m., Betker and Darla Lowery are back in the tiny third-floor office, this time briefing nurse supervisor Denise Stewart on the shift ahead.

Nurses have shut down the overflow ward on the third floor but are still seeking a bed for one patient. Baby Gabriel is breathing well in neonatal intensive care and could soon be moved to the regular nursery.

Two babies have been born during the day shift, but two more expectant mothers arrived, bringing the total back to nine women in labor.

Vonnie Haller, clinical manager for the obstetrics unit, rushes into the room and asks for more nurses. “There’s five on the schedule tonight,” she said. “I can’t do it with five.”

Stewart agrees to find someone, and starts the new shift looking for a nurse.