Critical care 

For nurses in Montana, Missoula hospitals are their profession’s Promised Land. \nBut for how long?

There are many treacherous spots along Highway 35 as it snakes along the shores of Flathead Lake. Carla Langlois’ least favorite is Yellow Bay, a steep hill with a cliff to the west that drops off into the cold water. A few years ago the hill almost took her life as she was returning home from her nursing job at Missoula’s Community Medical Center. Though it was daylight, an ice storm had left patches of black ice on the road. Coming up the hill, Langlois’ Nissan four-by-four hit one of these patches and her truck began to fishtail.

“I knew I was going over the side,” she says. “I just had to decide whether to go headfirst or the other way around.”

Langlois knew going over headfirst meant the end, so she cut the wheel and swung the truck’s backend around. After a blur and a screech, she realized she was in the cab—and still alive. She was almost standing on the brake pedal, the front wheels gripping the road, the rear wheels hanging over the edge. Jamming the truck into low gear, she slowly ground forward and back onto the road. The truck’s back end was totaled–both tires blown out.

All this for a 100-mile commute from Bigfork through wind and rain, snow and ice to work as a nurse in Missoula.

“To tell the truth,” she says soberly. “I thought about not doing it anymore.”

Twice a month something during Langlois’ commute scares her silly, but she has kept at it.

“You spend one third of your life at a job,” says Langlois. “You’d better love that job.”

There are other hospitals closer to her home—Langlois worked at St. Joseph Medical Center in Polson before switching to Community—but the benefits of working in the Garden City are hard to resist. She has nothing bad to say about her experience at St. Joseph, but the rural hospital simply couldn’t compete with the wages, working conditions, and facilities in Missoula.

“When I decided not to work in Polson anymore I wasn’t sure what I was going to do,” says Langlois. “Then I went shopping in Missoula with a girlfriend of mine who had worked in Polson with me, and on the way home she pulled into the parking lot of Community and said, ‘Get out of the car. You’re filling out an application.’”

By the time Langlois got home, there was a message on her answering machine asking her to come in for an interview. That was seven years ago.

“I do miss being one of only two nurses in the building at night [at St. Joseph],” she says. “But the demands and responsibilities were a lot higher because you didn’t have all these people you could go to for support. You were it.”

Langlois’ husband owns a successful business in Bigfork, so she doesn’t work for the money—although she says the pay is great—but because she loves it.

“Their [Community’s] priority is the patient,” she says. “They’re our family when they come in the door, and that’s what makes me stay there. That’s what makes me drive down there.”

Langlois’ fondness for her work is shared by many of her co-workers who say that Missoula is the best place in Montana to be a nurse. Or, as one nurse put it: “This is our profession’s Promised Land.”

Making the pilgrimage
Like Langlois, many nurses around the country have been persuaded into frightful commutes. They battle congestion from the suburbs, jam into subway trains or drive hundreds of miles to work at bigger, better hospitals. The nurses at Community and St. Patrick Hospital are no exception. Both facilities have staff members who regularly commute from Polson, Ronan, Hamilton, Thompson Falls, and even farther. Community nurse Linda Batchelder routinely makes the 150-mile trek from her home in Bozeman to Missoula.

“With our two Montana seasons, winter and construction,” she says. “It always takes at least three hours.”

Still, for the last two years, a couple of times a month, Batchelder has been making the drive. She usually works three overnight shifts in a row, spends two nights with a friend and then returns home after her third shift. The commute has definitely gotten her acquainted with Montana’s unique weather.

“When it’s one o’clock and I can’t see my car in the driveway because of snow, that’s when I know I can’t make it,” she says. “But I think only two times in two years I haven’t made it.”

Batchelder says there are three things that make her drive manageable: The road crews do a great job, the scenery never gets old, and the rock ’n’ roll of Elvis Presley and Neil Diamond always keeps her toes tapping.

Batchelder and Langlois’ journeys may sound extreme, but a growing number of nurses are traveling long distances to bring home a bigger pay check, work in a more relaxed atmosphere or practice a medical specialty not found in other hospitals. This means that smaller hospitals, like St. Joseph in Polson, are forced to work harder recruiting nurses—even without the resources to do so. Rural hospital often advertise in national nursing journals and major newspapers, but those ads tend to lose their impact when placed next to one offering a bigger salary and a $4,000 signing bonus.

Out of the trenches
A few years ago, Kim Davis [not her real name] moved to Missoula from a city roughly two and half times the size of Missoula. There, Davis spent five years working as a nurse in a regional hospital not much bigger than St. Pat’s, the larger of Missoula’s two hospitals. There, she did what she believed all of America’s nurses do.

“I would work 12 hours without a bathroom break or a lunch break, and I would do this six or seven days straight,” she says. Davis didn’t complain about the conditions because there was no one to complain to. This was just the life of a nurse. Or so she thought.

“It wouldn’t be unusual to have a precipitous delivery in a room with no doctor and no nurse, or wait three or four hours in the ER,” she says. “We heard of a record of a 33-hour wait to be seen in the emergency room,”

For many Americans, Davis’ stories conjure up the blood-and-guts image of nurses portrayed on television and in the movies. Her daily reality was treating HIV-positive patients high on crack with multiple gun shot wounds, or armed guards, sometimes with dogs, patrolling the hospital because of gang skirmishes in overcrowded waiting rooms.

Needless to say, when she began at Community, things were different.

The war zone ER waiting room was replaced with something that resembled an upscale dentist’s office: comfy, cushioned chairs placed between green plants and end tables with neatly fanned magazines. In fact, nothing at Community seems to fit the world Davis was accustomed to. Here, nurses, doctors and patients walk the clean, calm halls smiling and chatting. There are no crowds of unattended patients or frenzied medical workers, and the smell of the cafeteria’s daily special—blackened salmon with roasted potatoes and vegetables—has replaced the antiseptic hospital smell.

St. Pat’s has a similar tranquil feel. It provides the same cutting-edge medical technology of a Denver or Salt Lake City hospital—including western Montana’s only cardiac surgery and invasive cardiology programs, and the area’s most advanced cancer treatment facility—without all the urban problems.

Beyond the physical differences, the second thing Davis noticed was her paycheck. At her old job, a nurse’s starting wage was $13.50 an hour. Community starts its nurses at $16.69 an hour, St. Pat’s at $18.05.

“Everyone [from home] told me to expect a 15 percent pay cut when I came up here,” says Davis. “I was shocked.”

With her experience and Community’s greater shift differentials (making a better hourly rate for working a less desirable shift, like nights), Davis’ pay actually increased about 20 percent. So why were wages so low at a larger, more urban facility? Davis has a theory.

“It was all the middle management people who were getting paid plenty of money for just sitting around,” she says. “They would just keep cutting and cutting and cutting nurses and not hire new nurses because it was too much trouble, or they didn’t want to be paying the big sign-on bonuses.”

Davis guffaws when she compares the pains she endured at her old job with her current situation.

“You were just expected to work overtime,” she says. “At one hospital here in Missoula you can’t work more than one eight-hour shift without getting overtime, which is great.”

Although Davis admits that she occasionally misses the variety of cases she saw at her former job, cases you don’t see in a rural setting dominated by auto and agriculture accidents, “I don’t think there’s anything I miss,” she laughs. “People up here don’t know how good they got it.”

Look for the union label
One of the main reasons Davis and other Montana nurses love their work has to do with changes enacted by the Montana Nurses Association (MNA). While only about 1,700 of Montana’s approximately 10,000 are members of the MNA, both St. Pat’s and Community’s nurses are represented by the 90-year-old union. Much of the draw to Missoula is due to MNA involvement in the local hospitals.

Davis says she was never a big fan of unions, but the MNA may have changed her mind.

“Personally, I think the people here in Missoula should be kissing the ground that the Montana Nurses Association walks on,” she says. “They’ve kept the situation a whole lot better here.”

In other states, finishing a 12-hour shift doesn’t necessarily signal the end of a workday. Nurses can work their usual shifts, only to have a charge nurse pounce as they pull out their car keys to head home. It doesn’t matter if the nurse has an appointment for a haircut, has to pick up her kids from school or is just plain exhausted. If there is no one else to cover the shift, the charge nurse can crack the whip and there is not much the nurse can do if he or she wants to stay employed.

In Montana, MNA has made it impossible for nurses to endure that kind of hardship. They have bargained to outlaw mandatory overtime, one of the primary causes of nurse burnout and, according to the American Nurses Association, something that has an enormous impact on quality of care.

Missoula hospitals still ask their nurses to work overtime. But if happy hour or a hike to the “M” sounds more appealing than the extra dough, a nurse can simply refuse. Montana is one of only five states where unions have bargained to prohibit mandatory overtime, although another 18 have legislation in the works to do the same.

In addition, the MNA has also set up professional conference committees, which give nurses a greater voice in expressing their grievances to hospital administrators. Whereas many hospitals have similar staffing committees, they are often ineffective tools of change, says MNA Labor Director Todd Thun.

“They really don’t have teeth,” he says. “They’re paper tigers.” But the MNAs committees can bite. If a dispute at the committee level goes unsettled it can move to collective bargaining—something the hospitals try to avoid. But Thun says this is rare. Just getting the nurses, doctors and administrators talking is usually enough to resolve the dispute.

Although some nurses complain that the MNA doesn’t always look out for its older nurses, most agree that the union has dramatically improved nursing conditions—something that helps shield Missoula from the national nursing crisis.

The question is, for how long?

The dwindling numbers

Community’s Vice President of Patient Care Services, Connie Huber, and St. Patrick Hospital’s Vice President of Nursing, Joyce Dombrouski, both agree that Missoula hasn’t experienced major repercussions from the national nurses shortage. Huber says that Community has no staffing problems, and Dombrouski says her shortage—a vacancy rate that hovers between 2 and 3 percent—is “a natural amount.”

Even if the two administrators are underestimating their deficiencies (as many local nurses suggest they are), neither hospital even approaches the national average. A year ago the American Hospital Association found that there were 126,000 nurse vacancies in U.S. hospitals, which roughly translates into a 15 percent vacancy rate. That number is only expected to grow as the population of nurses ages.

According to findings from a national survey of registered nurses, the average age of an RN is 44, with RNs under 30 representing only 10 percent of the total nurse population. Just five years ago the average RN was 42.5.

Langlois, Batchelder and Davis, who are all over 40, see this reality.

“We basically have this work force of older, more experienced nurses who are burning out or quitting or getting ready to go into retirement, and they’re not being replaced,” says Davis. “There is a crisis looming out there and I don’t know whether it’s being addressed.”

The logical solution would be for nursing schools to pump out more graduates. But the problem is compounded by a shortage of faculty at nursing schools.

For example, last year one nursing school in Nevada received 82 applications from qualified candidates for the fall semester, but had room for only 48 students, according to a report in the Reno Gazette-Journal.

This trend was confirmed in a recent survey by the American Association of Colleges of Nursing, which found that more than a third of the nation’s nursing schools turn down qualified applicants due to faculty shortages.

Still, even if those graduating nurses agree to work longer shifts and more days, it may not help. Young nurses have a tendency to leave the profession after just a few years.

“Less people are going into it and more people are getting out because it’s not real glamorous,” says Davis. “Everyone wants to make money and not work. Everyone wants to stock broke or dot.com, whereas nursing requires a certain level of education and empathy for other people. Everybody wants to retire early now.”

For younger nurses who want to stick with the profession but still retire early, there is the option of becoming a traveling nurse.

Traveling nurse agencies have been around for decades but never have hospitals been as reliant on them to fill staffing holes as they are now. A hospitals’ dependence on traveling nurses is usually an indication of desperation, so the travelers come at a price.

“I’ve looked at traveling,” says Alice Donovan [not her real name], a 20-something nurse who works in the Intensive Care Unit at St. Patrick Hospital. “I’ve spoken with some representatives and they told me, ‘We’ll pay your housing from $800 to $1,200 a month depending on where you’re living,’ and they’ll pay $300 for travel.”

The money doesn’t end there.

“They offer a referral bonus, so if another nurse signs on with the travel plan I would get a couple thousand dollars,” she says. “And sign-on bonuses are anywhere from $500 up to $10,000.”

For younger nurses, the allure of making $70,000 to $90,000 a year has tempted many to leave the world of permanent jobs.

“There is a section of nurses, a lot of young nurses, who have been drawn by those very, very high salaries,” says Dombrouski. Nicole Shields is a former St. Pats nurse who has transitioned from hospital to agency work. When Shields’ husband finished his graduate degree at the University of Montana last May and found work on the East Coast, she decided against a permanent position.

Quickly snapped up by Supplemental Health Services Limited, a worldwide health services staffing agency, she was placed in a matter of weeks at a hospital one hour from her new home. The $35,000 a year she made in Missoula became close to $80,000, plus a monthly housing stipend of $1,000. But the small fortune traveling nurses make is sometimes offset by the chilly reception they can receive from coworker and superiors.

“Hospital big-wigs kind of treat you differently in orientation,” she says. “They are all smiles and interested in what floor you are working on. Then when they find out you’re a traveler their demeanor changes and they move to the next person.”

Shields hasn’t felt much animosity from the permanent nurses yet. But she hasn’t worked with many either.

“The last night I worked,” she says, “The charge nurse was the only regular RN. The other four, including me, were agency [nurses].”

Permanent, local nurses often consider traveling nurses “scrubs,” who are only in it for the money and not committed enough to become part of the community. This is one reason many St. Pat’s nurses hope the shortage never forces the hospital to use the travelers, which they came close to doing a few months ago.

“We were all ready to have them come in but didn’t have to use them,” says Dombrouski. “We were working on both internal and external solutions, and the internal one worked out.”

Community has already begun using traveling nurses. Huber says this isn’t indicative of increasing staffing problems, as less than 3 percent of their nurses are travelers. But there are those who wonder how long it will be until Missoula relies as heavily on travelers as hospitals elsewhere in the country.

What the future holds
When asked what the Missoula nursing scene will look like in 20 years, there are a variety of opinions—almost all of them bad.

“Right now Montana is about five years behind,” says Kate Steenberg, a St. Pat’s nightshift charge nurse, referring to the national nurses shortage.

Steenberg, who is also co-president of MNA local #17 and president-elect for the state organization, sees evidence of the national dilemma in the growing deficit of critical care nurses, radiology techs and pharmacists. Huber also sees similar indications at Community.

“There are two or three areas where it takes us a little longer to recruit than it used to,” says Huber. Specialty nursing areas, like operating room, obstetric nurses, and radiology techs, are both fields where it has been harder to recruit than in years past.

Unlike Community, St. Pat’s doesn’t report recruiting difficulties. “However, one of our challenges we have is to make sure we retain the people we currently have,” says Dombrouski.

Higher out-of-state wages, she says, have made it challenging to retain staff. It’s been a challenge they’ve overcome for now, but she fears it will be harder to deal with in the future.

“Some places have offered $5,000 and $10,000 signing bonuses, we haven’t had to do that and we don’t want to do that because it’s not fair to the nurses here,” says Dombrouski. “Would we? Well, I never say never.”

Community has not needed to institute sign-on bonuses either, but they have begun to reimburse some employees for moving expenses.

“Money’s not the answer,” says Steenberg. “Unless you can improve some of the working dynamics in hospitals better, things are only going to get worse.”

Steenberg believes that the greatest elixir for the nursing shortage won’t be sign-on bonus or better shift differentials—though those do help—but by showing the public how amazing and dynamic the nursing profession can be.

“The public has this 1950s image of working where it’s all ‘Yes, doctor’ and ‘No, doctor,’ and they just trot around and give shots,” she says. “If I were an adolescent girl I would think, ‘Why do I want to do that?’ But if I could take them with me to the workplace and show them how I help the heart doctor crack the chest in the room or something like that, I think there would be some girls who say, ‘Cool! That rocks!’”

Yet the stereotypes endure. And while showing kids the rib spreader may excite some into pursuing a career in nursing, it still may not be enough to reverse the impending shortage.

It is difficult to say what Missoula health care will look like in the future, but as the city grows it moves further from the world of rural medicine and closer to the world of the metropolitan battlefield ER.

Missoula is now recognized as the medical hub of western Montana, a place where people have come to expect the highest medical care available. But like the town’s population of nurses, Missoula’s general population is growing older. Missoulians 65 and over have gone from being 8 percent of population in 1990 to 10 percent in 2000, and those numbers will only climb in the next decade. With fewer nurses and more people in need of care, greater demands will be put on people like Huber, Dombrouski and the MNA. Creative solutions will be needed to keep in place the Promised Land so many have worked so hard to create.

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