Week of 10.24.08
Transcript: Nurses NeededBRANCACCIO: It was a U.N. Secretary General who once said: "constant attention by a good nurse may be just as important as a major operation by a surgeon." But attention from a nurse is getting harder to come by...part of the health care mess that is not getting as quite much attention as the battle over health insurance. America is running 100-thousand nurses short and it's set to get a lot worse...a situation, according to statistics, that affects your chances of getting out of the hospital alive. Come with me inside a busy hospital and watch nursing problems and some nursing solutions play out. Bill gentile produced our report.
Don 't get lost in this web of medical gear. It's keeping this terribly injured young woman alive. But it's all just tubes and wires without the nurse by the bedside.
MARY GRACE SAVAGE: Do you know my name? I'm Mary Grace. We've met a few times but very briefly. . and you've met a lot of people, so I'm not gonna hold you to that. Can you lift up your arms for me? What do you think? Get 'em up?
BRANCACCIO: Mary Grace Savage is a veteran nurse at New York's biggest hospital, the New York Presbyterian Hospital System. She's been here for 31 years.
MARY GRACE SAVAGE: Am I touching your nails sweetie?
BRANCACCIO: In this neurological intensive care bed is 25 year old Nicole Marquez, a dancer and actress who moved to New York from Mississippi to follow a dream of someday performing on Broadway. This is Nicole before the accident that put her here. She's in the hospital because of a terrible fall. Locked out of her apartment, she apparently tried to climb down to an open window - from the rooftop. She fell five stories behind the building and was not found until the next day. Nicole broke her neck...broke her back, pelvis, ribs; punctured a lung. Mary Grace and a team of nurses are working to help Nicole get back on her feet.
MARY GRACE SAVAGE: That's all her new mechanical pieces in there. See all that stuff? Her screws and wires and ankles and framework supporting all the things that had burst.
BRANCACCIO: Doctors visit Nicole daily and doctors did the surgery to re-assemble her broken body. Popular culture often depicts the work of doctors heroically. What is too often overlooked, however, is the essential role of nurses, who in the case of Nicole Marquez, care for their patient constantly. And by constantly, we mean constantly... monitoring, managing, responding day and night.
You strike me as someone who wouldn't hesitate at all, that if you saw something you didn't make sense on a chart or if you heard something that conflicted with something else you know about the patient, you'd probably say something about it, right?
MARY GRACE SAVAGE: Absolutely. That's my job
BRANCACCIO: It's something that has to be encouraged. You see that as your job
MARY GRACE SAVAGE: Absolutely.
BRANCACCIO: It's nurses who keep the communication flowing with Nicoles's family and friends. With Nicole they patiently run through the alphabet to figure out what she wants to say.
MARY GRACE SAVAGE: A, B C D, D? You want Daddy to come? Sure...She wants daddy.
LARRY MARQUEZ: Hey hey hey. How you doing?
MARY GRACE SAVAGE: There we go, there we go.
BRANCACCIO: Nurses are the engines inside hospitals everywhere. Nothing moves without them. Too bad there aren't enough Mary Grace's. America's troubled healthcare system is currently running about one hundred thousand nurses short. This shortage is on track to get much worse as the population gets older - and sicker. A U.S. government study says that within a dozen years, the national shortage could increase to more than one million. There are some fascinating reasons for this and some interesting proposed routes out of the crisis. It is literally and precisely a matter of life and death: a study in the Journal of the American Medical Association found that the more patients there are per nurse, the greater the risk that patients will die. Other studies have underscored the connection between nursing quality and how well patients do. If there's all this demand, how come not enough nurses? First of all, it's clearly not a career for the faint of heart.
MEGAN STACK: Where'd Gabe go?
BRANCACCIO: Ask Megan Stack, a kidney transplant nurse at New York Presbyterian. The patients Megan sees are part of a growing population of acutely ill, older people who often show up at the hospital with multiple problems.
MEGAN STACK: I've been a nurse here for about two years. I work with renal patients so I do uh, renal failure, I do renal transplant, and I do dialysis.
BRANCACCIO: As you watch her in action you can see Megan has a job that requires stamina and the ability to think, quite literally, on her quick-moving feet.
MEGAN STACK: 23 A is going for renal ultrasound. They're calling.
BRANCACCIO: One of her patients may be having a heart attack and it's up to her to formulate a rapid response. It is not just about fetching supplies. Nurses do a lot of what many of us think that only doctors do.
MEGAN STACK: She had a cardiac event so I can't let her go off the unit. Thanks, bye.
Home? No. No one's going home today.
BRANCACCIO: Stack's says she's managing the strain...but for how long?
MEGAN STACK: Unfortunately clean supply is a nice place to take a deep breath when you're feeling a little overwhelmed which I am, and you look for things that seem to always be moving. I think that's everybody, everywhere though. And it's not here but I got a deep breath, so...
BRANCACCIO: Across the country a lot of nurses find that continuing strain just too much. Renee Nicol served as an emergency room nurse for ten years at the Beaver Medical Center just outside of Pittsburgh. During that time, thousands and thousands of people in terrible crisis came through. Working in the E.R. is one of nursing's toughest assignments and over the years she's dealt with a lot of abuse from patients who are not at their best when they come in.
RENEE NICOL: Scratched, slapped, punched...spit at, called every name in the book...names I didn't know what it was. You know, so that's...you just get tired of it.
BRANCACCIO: But it was the life and death issues that got to Renee. Watching too many people die. One night a young woman was brought in from a car wreck.
RENEE NICOL: It was a very, very bad, 3 am trauma arrest. And um I had already worked there for 12 hours. Um...I stayed to help my co-workers work this arrest. It was a young lady. And um, we worked on her for two hours and she did not make it. So I came home and you know, it was just very...she was younger than me, you just feel like sense of loss, just senseless. Senseless death. I thought, you know, I'm very sensitive. I thought I don't want to see this anymore. I just really don't want to see all that anymore. So I needed to make a change.
BRANCACCIO: She ended up taking a job with a major insurance company and will now offer medical advice to patients - over the phone. There are tens of thousands of nurses like Renee who will cut short their careers in active care. Even more are scheduled to retire in the next decade. So the challenge for hospitals is to keep nurses from leaving and to bring new nurses in to the bedside.
WILLIE MANZANO: My first job, my very first job as a registered nurse, I think I cried every other night. And that was a long time ago.
BRANCACCIO: It's Willie Manzano's ultimate responsibility to recruit between 60 and 70 new nurses...every single month. She's senior vice president and chief nursing officer at New York Presbyterian Hospital.
WILLIE MANZANO: Well we've done a lot in terms of recruitment activities. So we have put together internship programs that really bring in nurses into the institution and we provide them with six months to one year internship programs in critical care.
BRANCACCIO: Unlike doctors, nurses don't often get internships or residency programs. They do here at New York Presbyterian. It's the city's busiest hospital. It includes five campuses and about 4,500 nurses. Together they handle at least 2 million patient visits a year. Alison LeBlanc, from Massachusetts, and Joannie Welsh, from Missouri are both fresh out of nursing school. We met them on the first day of their year-long residency at New York Presbyterian's burn unit.
ALISON LE BLANC: I'm documenting that he did it himself.
BRANCACCIO: It's nurses like these that Willie Manzano is working so hard to recruit and to retain.
ALISON LE BLANC: I was stressing over nothing.
ANDREW GREENWAY: Yes, you were.
BRANCACCIO: Today, Joannie is working with Patrick Bourke, a more experienced nurse on the unit.
JOANNIE WELSH: We're going to change his dressings on his burn on his right lower extremity.
BRANCACCIO: Andreas Krenmeir burned his leg on a motorcycle exhaust pipe.
PATRICK BOURKE: And then we're going to wrap it and Curlex and cover it... We're going to secure it with this kid of...
JOANNIE WELSH: This is called spandage. Some of the other hospitals that I looked at did not have the critical care classes that I was given and the extensive orientation so that gives you a huge amount of time to really gain those skills that you didn't have a chance to in your nursing school. So that's huge for any new grad. Um, actually a lot of new grads look at the orientation program more than they look at salary and benefits and things like that.
BRANCACCIO: Nurses wear masks and gowns to protect patients from deadly infection. Joannie and Alison are the beneficiaries of a system in which more experienced nurses guide and orient them, on and off the floor, through their residency.
JOANNIE WELSH: Ok. Nice work.
BRANCACCIO: Today Alison is working with Shelly Ann Matthieu, a veteran nurse who's been working in the burn unit for 18 years.
ALISON LE BLANC: Do you want to take this?
BRANCACCIO: Their patient is 19-year-old William Calderon. At work in a restaurant, Calderon dropped hot grease on his feet. He's just had a skin graft and a team of nurses wraps his feet to protect them.
SHELLY ANN MATTHIEU: You need to keep that graft straight....keep your foot straight. Because even when you think you're keeping that foot straight when you go to sleep we don't know what we do.
BRANCACCIO: It's part of Alison's continuing, on the job education.
SHELLY ANN MATTHIEU: The Curlex stretches and allows him to move like when you wrap a burn dressing like that it's to allow him to do physical therapy and move. This, it cannot move so when they wrap that up it just really immobilizes.
Frank Costello is a nurse who's been working in the burn unit for over 20 years. He's a senior nurse and one of the reasons that new and veteran nurses stay. He teaches, inside and outside the classroom, to keep nurses apace with developments in the field. He's part of the hospital's effort to retain nurses at every stage of their careers.
FRANK COSTELLO: So with those numbers, with respect to the low cardiac output, you would deem that shock to be what? Hyper bulimic...
BRANCACCIO: Remember Megan Stack from kidney transplant? She and Frank are from different hospital units, but she's here to benefit from his knowledge and expertise.
FRANK COSTELLO: Joannie's one of our new nurses....
BRANCACCIO: In the tank room, Frank works with Joannie to wash a patient's burned foot.
FRANK COSTELLO: And I find it most enjoyable to be at the bedside to teach...to go over things. And sometimes you teach by not even speaking. You teach by doing. I think you, you try to be for them somewhat of a role model that they want to also continue in the profession and be the best they can.
Now take another adaptic.....another one of these. I think there are two of these...
You're going to make mistakes. And you're going to, but you're going to learn from them. And so every day, I always tell them, look back, look back two weeks ago, where you were and look where you are now. And in two weeks ahead, you're going to find that you've progressed more. And then eventually, eventually, you'll get to a point where you'll feel somewhat, somewhat comfortable, but then don't ever become comfortable.
ALISON LE BLANC: As of right now, I'm always thinking about, like, did I miss something...
JOANNIE WELSH: Yeah.
ALISON LE BLANC: ...did I do something wrong?
JOANNIE WELSH: Even, even when we're on the unit, because we are new grads, we're constantly doing something, because we're not as efficient as somebody that's been here, say, twenty years. Like Andrew.
BRANCACCIO: Retaining nurses like Joannie and Alison is critical. About 25 percent of new nurses in the U.S. drop out in the first year. Willie Manzano says mentoring and special classes have dramatically cut the dropout rate at New York Presbyterian, and reduced it well below the national average. And where does nursing pay fit into all of this?
WILLIE MANZANO: I'd be the first one to argue, let's pay them great amounts of money. At the end of the day, that's not what's going to keep them here. It's really structures, systems, and support that we put in place to make the nurses feel that this is where they belong and where they can feel fulfilled, both personally and professionally.
BRANCACCIO: New York Presbyterian works hard to solve its' nursing challenges. But the fact is that this hospital's gain is some other competing health care facility's loss. Remember, there aren't enough nurses in America.
MARY NAYLOR: We prepare nurse advanced practice nurses...
BRANCACCIO: And few people understand that better, and the possible solutions, as well as Dr. Mary Naylor. She's a professor and a researcher at the University of Pennsylvania School of Nursing in Philadelphia.
MARY NAYLOR: If there was ever a time in the history of this country when one thought about the match between a profession and the changing needs of people in the country um, this is the time. We have this great growth in our society of people living longer uh, but they are also living with more chronic conditions, more health care needs than ever before, and we have a, a rise each year in the need for nurses.
BRANCACCIO: In theory, the law of supply and demand should swoop in to fix this disconnect.
I would have thought the market took care of this if there's a major significant demand for nursing talent, then you'd think that there would be schools across the country willing to take them in, train them up, and they become nurses.
MARY NAYLOR: It is not at all that kind of an issue. Um the, the real issue is that there are schools across the country but they don't have enough faculty to prepare these nursing students. Uh, last year, about seventy schools, seventy percent of the schools in this country reported that they could not accept qualified applicants into the programs, because they didn't have sufficient numbers of faculty to teach these students.
BRANCACCIO: You got that? Not enough nursing teachers, in large part because a person with the skills and experience to teach can make a lot more money either as a senior nurse at a hospital or working for, say, a pharmaceutical company.
It's another piece that contributes to this huge shortage of nurses.
MARY NAYLOR: Really, it is an historic proportion and the real fundamental issue is, I don't think everybody gets it.
BRANCACCIO: What Naylor says people don't "get" is that the nursing shortage is part of a broad U.S. health care crisis that will not be resolved with disconnected local and regional solutions.
MARY NAYLOR: What we don't have is a coordinated effort to bring all of those solutions, all of those best practices, um, to make them immediately available to everyone throughout this country.
BRANCACCIO: When it comes to national solutions there are lots of efforts on the table to improve patient access to care - but the major bill passed just this week by the senate finance committee offers no extra funding for nursing education. That means that, even if reform manages to provide coverage to millions of uninsured Americans, there won't be enough nurses to care for them. Health care experts say there are good arguments that dealing smartly with nursing in America could save money. Willie Manzano at New York Presbyterian says this point is much debated but she sees cost versus savings when it comes to nurses this way.
WILLIE MANZANO: The investments That you make to ensure that you have the right staff, the right number of people, really will save lives because you're preventing complications, you're preventing medical errors and you're also making sure that you have the right people who can take care of their patients every single day. And so to me, it's not a cost.
BRANCACCIO: Nicole Marquez, the dancer, now has been hospitalized for nearly a month. She and her family, that's her mom there, understand the powerful connection between her nurses, her care and her outcome.
MARY GRACE SAVAGE: Hey. Hi!
BRANCACCIO: The breathing equipment has been removed from her mouth and Nicole now can speak.
MARY GRACE SAVAGE: You said my name! It is....isn't it though! You have to breathe to talk.
SUSAN MARQUEZ: Nicole that's great.
NICOLE MARQUEZ: I love you mom. Wow. I never knew how wonderful that would sound.
SUSAN MARQUEZ: Wow is right.
BRANCACCIO: Nicole's mom has been at her side day and night for weeks.
BRANCACCIO: Susan this is a big hospital in a big city. It could be very impersonal. I don't know what her patient number is, it could be.....
SUSAN MARQUEZ: Could be. It's not.
BRANCACCIO: It's not your experience.
SUSAN MARQUEZ: Not at all. Not at all.
BRANCACCIO: To what extent would you say the nursing staff have been integral in making it not impersonal?
SUSAN MARQUEZ: That is the key component. Absolutely. The nurses have been spectacular. From the night we first got here and it was the fear of the unknown for us we didn't know her condition, we're in a strange place, we're in a strange city, right off the bat, the nurse is the one who was right there with us, walking us through everything.
BRANCACCIO: You've gotten to know them.
SUSAN MARQUEZ: Oh, gotten to love them. Yeah. We love them. Hmm.Hmm.
BRANCACCIO: For the first time since the accident, Nicole can sit up. And her doctors have told her that she's well enough to make the trip to a rehab center back home.
SUSAN MARQUEZ: We have to stay in touch with everybody because they're our new family. They've taken care of us.
NURSE 1: I'm going to miss you so much.
SUSAN MARQUEZ: I'm going to miss you, too.
NURSE 2: We'll miss you here but we're looking forward to you coming back in a year. That's right, we're coming back to party. Party time when you come back.
BRANCACCIO: The day after doctors told her she could leave, Nicole returned with family and friends to Jackson, Mississippi. We first broadcast this story one year ago. Since then, Nicole has been working through intensive rehab in Mississippi to get her strength back. Just a few weeks ago, she decided to pay a visit to the hospital back in New York.
NICOLE MARQUEZ: Houah, I'll show you my dance, it goes a little something like this...
BRANCACCIO: Just a year ago, doctors and nurses feared that this talented young woman would never walk again. She's still on the road to recovery.
NICOLE MARQUEZ: I went from here. Now I can do the wave.
DOROTHY: Oh my goodness!
BRANCACCIO: But Nicole knows that without the nurses who have cared for her she might not be here at all.
NICOLE MARQUEZ: I had a lot of people supporting me along the way but there's no way I'd be talking to you right now if it wasn't for those ladies. I'm standing here. My heart is beating. I'm getting better and better and better. All of that is due to them.
BRANCACCIO: You can get updates on Nicole Marquez's journey toward health and you'll also find a fascinating journal kept by nurse Joannie Welsh as she documented a week of her busy life in the burn unit. It's all on our website. Pbs.org is where you can check in. And that's it for NOW. From New York, I'm David Brancaccio. We'll see you next week.
Video: Interview: Nursing from Hospital to Home
In Your State: Nursing Excellence
Patient Update: Nicole Marquez
A Week in the Life: Nurse Joannie
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