Death and mayhem visit Kansas City's biggest hospital chain.

Impractical Nursing 

Death and mayhem visit Kansas City's biggest hospital chain.

Leslie Remington wept as she worked the night shift. The nine patients on her floor needed attentive care as they recovered from surgery or awaited operations. The registered nurse knew she was failing them. Tears welled in her eyes and tumbled down her cheeks.

Some of the patients were confused, writhing or yelling, but Remington had no time to comfort anyone. In each room, as she took a patient's vital signs -- blood pressure, temperature, pulse and respiration -- she quickly looked at dressings and incisions, listened to the patient's lungs, heart and stomach and worried about the ailing people she hadn't visited yet. Patients kept pushing buttons, and Remington or the licensed practical nurse working with her answered each call light as quickly as they could.

A nauseated patient yelled that he needed medication. Before Remington could finish other pressing chores and run to the desk for his medicine, the man had vomited on himself and his bed. She cleaned him up, and then another call light came on.

She hurried up and down the long hallway between half-empty storage rooms and the front desk, hunting such basic supplies as washcloths and thermometers. Because of a shift change at Research Medical Center, some of the sick had gone two or more hours without seeing a nurse before Remington or her one assistant could get to them. "There's a lot that could have happened to that patient alone in that room," says Remington's close friend, Karen Hutten, an LPN. "They could be on the floor, they could be bleeding. They could be dead."

When Remington finally finished taking vitals, she had to prep a patient for a colonoscopy. His bowels had to be clean so doctors could see what they were doing as they "scoped" him the next day. The elderly patient was senile and confused; the prep consisted of several enemas. It was really a full-time project, but Remington could devote only brief periods to the chore. Each time the patient had a bowel movement in the bed -- which was often -- he and the bed had to be cleaned.

All the while, call lights clicked on, and patients moaned or called out.

"It was like all I did was run, run, run all night long. People had to wait for pain medicine. People had to wait for nausea medicine. There were things I know I needed to do for these patients -- like change dressings and change IV sites [to prevent infection] -- and I just couldn't get to it. It was so sad for me. It was a horrendous night."

The next night, Remington started her shift already exhausted and drained. She and the LPN again worked feverishly all night and just couldn't get caught up even enough to fill out paperwork, which falls to them because the unit has no secretary at night. They didn't have ten minutes for a bathroom break or a sandwich during the twelve-hour shift.

Remington went home that second morning, called in sick for the following evening and slept for fourteen hours straight. When she woke up, she told her husband that she was going to quit her job. "After that night I said, 'I just can't take another night of this,'" she says. But her income is important to her family, so she still plans to work a few shifts each month at the hospital.

Remington looks like the quintessential nurse. Her hands are slim and cool, perfect for delivering a glass of ice water or wrapping a bandage. She has short, chestnut-brown hair, a warm smile and a slightly reserved manner.

Since she was a child, she has wanted this career. As soon as her own children could get along without constant mothering, she took up nursing classes at Penn Valley Community College. She graduated nine years ago and was hired on at Research Medical Center, which had an excellent reputation for giving new nurses thorough training. Over the past few years, the hospital's nursing standards have crumbled, she says.

"Since I started working there, I've seen the care go so far down the tubes," Remington says, looking discouraged. "I have high standards, and I can't deal with how we're forced to do it now."

Research, a busy urban hospital on Kansas City's east side, is the largest of fifteen hospitals run by Health Midwest, which in ten years has grown into a local health care behemoth, controlling about 40 percent of the hospital beds in the metropolitan area. The chain has 12,000 employees and 3,157 beds. And thousands of upset nurses.

Nurses United for Improved Patient Care, which is run out of a small office in Raytown, for three years has been waging a campaign to unionize Health Midwest hospitals, one by one. Unionized nurses hope to persuade finance-focused Health Midwest executives to do something about severe understaffing, lack of basic supplies and faulty equipment.

As of this past spring, Nurses United had tried and failed to unionize the chain's visiting nurses but succeeded with Lee's Summit Hospital and the shiny suburban Menorah Medical Center in Overland Park. A fourth vote came earlier this month as nurses at the Medical Center of Independence voted on whether to unionize.

One evening in May, three uniformed nurses and a few union organizers stationed themselves near an escalator at the Hyatt Regency Crown Center Hotel. They handed out bright orange flyers to beautifully coiffed, bejeweled women in designer dresses and their escorts in expensive suits. The revelers were attending an awards dinner for Karen Pletz, a prominent member of Health Midwest's board of directors. Pletz, who is a vice chairwoman of the Greater Kansas City Chamber of Commerce and CEO of the University of Health Sciences, was being honored with the Spirit of Kansas City Award for compassionate service.

The awards banquet attendees graciously accepted the fliers, which featured a cartoon drawing of a bedraggled nurse collapsed in a chair, gasping, "All we want is a voice!" The Nurses United flier congratulated Pletz for her spirit and civic leadership. "But, unfortunately, OUR spirits are much lower because at Health Midwest: Patient care is suffering due to cuts in supplies and reduced support staff. Health Midwest is spending precious health care $$ on antiunion consultants to intimidate union supporters."

The nurses doled out leaflets for about twenty minutes before a hotel security guard approached them, threatening to call police if they didn't leave immediately. He snatched a stack of fliers from a nurse's hand.

"He was pretty red-faced and angry with us," says Hutten. The nurses left quietly. As Hutten pulled out of the parking lot, she passed a Kansas City police cruiser that was just pulling in and a Crown Center security vehicle.

A few weeks later, in June, when nurses showed up at the Adam's Mark Hotel to hand out leaflets outside a $125-a-plate fundraising gala for two Health Midwest hospitals that was to feature a speech by Ted Kennedy Jr., they stayed 45 minutes before security guards kicked them off the property. By the time nurses left, eight police officers and a paddy wagon had arrived, and cops told nurses they had to stand on the street -- but they'd be ticketed if they blocked traffic. Several newspaper reporters, a photographer and camera crews for WDAF Channel 4 and KSHB Channel 41 descended on the hotel.

Nurses United has also held rallies, such as the April gathering outside Health Midwest's headquarters on Meyer Boulevard where 35 nurses marched, waving signs: PATIENTS NOT PROFITS. UNION BUSTING IS DISGUSTING. HONK IF YOU LOVE NURSES. But union leaders say that showing up where wealthy Health Midwest board members schmooze has become a favorite in-your-face tactic.

"I think it's really starting to get on their nerves!" Nurses United union organizer Joyce Krawczyk says conspiratorially. "When the nurses show up at the fancy dinners and golf tournaments Health Midwest board members are a part of, there are a lot of other prominent community members there too. And so the Health Midwest board member is really kind of being publicly humiliated." Court records suggest that nursing care at Health Midwest hospitals can be deadly. When Marcy McCullough checked into Research Medical Center with a broken right femur in the spring of 1999, her husband and five grown children expected that she would have routine surgery and then leave the hospital, perhaps on crutches. But something went terribly wrong.

Surgeons repaired the 65-year-old woman's broken bone, then stitched up her thigh and sent her off to recover. For the pain, nurses gave her a patient-controlled morphine pump. With the push of a button, McCullough could get a dose of the narcotic painkiller.

If the pump had been in good condition, a mechanism would have prevented the groggy patient from accidentally giving herself an overdose of the powerful, addictive opiate. Apparently, that safeguard wasn't working. Too much morphine coursed into her bloodstream.

As McCullough lay in her hospital bed, she took a turn for the worse. She started to feel nauseated, then vomited several times. Her blood pressure plummeted. She began gasping for air. Drowsy, she slipped further and further from consciousness. When harried nurses finally discovered the problem, they tried to arouse McCullough with a sternal rub, a painful knuckles-to-chest massage used to wake somnolent patients. When that failed, they called in a doctor.

It was too late. McCullough was brain dead.

Last year, McCullough's husband and children filed a civil lawsuit in Jackson County Circuit Court for damages in excess of $75,000 against Research Medical Center and Health Midwest. The family also named five nurses as defendants in the lawsuit -- giving life to nurses' fears that they may be held legally liable for Health Midwest's shortcomings.

Like several other plaintiffs in lawsuits recently filed against Health Midwest, the McCullough family contends that poor nursing care led to the patient's untimely death. Scheduled for jury trial in August, the lawsuit also claims that the hospital is at fault for not supervising employees and for neglecting to provide adequate nurse staffing.

"Mrs. McCullough died because those nurses were not properly monitoring her and checking her status regularly, post-op, like they're supposed to," says Brian McCallister of The McCallister Law Firm in Westport. But a nurse who was named in the suit says anonymously that it would be "very accurate" to say that inadequate staffing and poor equipment contributed significantly to McCullough's death.

Local malpractice attorney Samuel Cullen, who represents another family that is suing Health Midwest, says he gets frequent calls from people considering litigation against Health Midwest. "Every week, those calls involve the quality of care provided by nursing staff. One recurring theme is the inattention paid to patients by nurses and infrequent visits to patients' rooms by nursing staff," he says.

And he talks to nurses in the Health Midwest system. Those nurses are afraid, he says, and they want to know what is their own legal liability -- and the possibility of having their nursing licenses revoked -- when they are forced to provide substandard care to their patients under "pressure from the hospitals."

The many nurses across the Health Midwest system who spoke with the Pitch confirmed that they fear being sued. "All the time. It's something nurses talk about all the time," says Toyia Tyson, an intensive care nurse at Overland Park Regional, a hospital that Health Midwest took over two years ago on a lease. Tyson knows at least one nurse who has been named in a lawsuit.

"But most of all," Tyson says, pausing gravely, "we worry about our patients."

It wasn't always like this. Ten years ago, when Health Midwest was just forming, nurses didn't have to worry constantly.

Mary Nash, a registered nurse who has worked for sixteen years in the intensive care unit at the Medical Center of Independence and now leads union organizing efforts there, remembers that the hospital used to be "friendly, nurse-oriented and patient-oriented." But about a year after Health Midwest took over, the changes started, and in the past two years there have been "major changes."

Formerly, MCI staffed hospitals according to an acuity system, which means that nurse-to-patient ratios were determined by how sick the patients were and how much direct care they needed, Nash says. But under Health Midwest, managers implemented a grid system, which dictates a set number of nurses to care for a certain number of patients, depending on the unit. Nash and most nurses believe that staffing by grid is accounting-focused, not patient-focused, and does patients a disservice. The American Nurses Association last year published "Principles for Nurse Staffing," which calls for an acuity system, recommending that staffing should be based on "analysis of individual and aggregate patient needs."

Health Midwest officials refused the Pitch's requests for interviews with its managers; in faxed answers to some questions, they claimed that "staffing is determined based on the severity of a patient's illness or injury plus number of patients on a unit, type of unit and availability of nurses." But all the Health Midwest nurses who spoke with the Pitch, including several who for a time worked in management, say the company assigns nursing staff based on a grid, not an acuity system.

"There are a lot of complex issues that go into critical care, and the grid is just numbers," Nash says. In her unit now, one nurse is automatically assigned two critical-care patients. If the unit is short-staffed, an ICU nurse may be given a third patient. That is "not a safe thing. If your staffing is short and you're across the hall and your ICU patient suddenly goes bad, you could miss that," Nash says.

ICU nurses deal with the most severely ill patients, mostly people in unstable condition who have cardiac or respiratory problems that need close monitoring. Many of them are on intravenous drips of powerful drugs, and they have bedside heart monitors. Some have a "swan-ganz catheter," which measures the pressure in the heart. They need almost constant care. Tyson, the ICU nurse at Overland Park Regional, says that before Health Midwest took over, managers took patients' acuity very seriously. Critically ill patients could have one-to-one care or even two nurses to one patient. The charge nurse on the unit dealt only with staffing, work flow and emergency patients, but under Health Midwest the charge nurse has a patient load and still must respond to emergencies. While she's gone, the staff nurses have to watch her patients.

Hospitals say there just aren't enough nurses available -- some Health Midwest nurses report that the company is offering signing bonuses of up to $6,000 for new graduates -- but nurses say that if Health Midwest managers listened to their concerns, more experienced nurses would not be so quick to leave. In Nash's unit last year, nurses repeatedly requested meetings with the vice president of patient services, who told them if they didn't like it at Health Midwest, they could look for other jobs. Three nurses on her unit transferred to other less-demanding units after that meeting.

Nurses in labor-and-delivery units say that in the past they cared for one patient in labor, but now they care for two. Barb Chamblin, a labor-and-delivery nurse at Menorah Medical Center who saw four of her colleagues resign in frustration in the month of June alone, says managing more than one birth invites disaster.

"When they get into the active labor phase, which means that things are really happening and changes are occurring rapidly, it really impacts you because of the danger, the liability if you don't consistently monitor those changes. You can really jeopardize the safety of the baby in utero. You have to watch the fetal heart monitor, you have to do IV drips. It's a real balancing act." Nurses can watch the progress of more than one patient at the front desk, where monitors for all patients are located, but they cannot keep an eye on one patient from another patient's room.

Staffing problems have posed ethical dilemmas to some nurses as they fill out paperwork. Sometimes doctors order vital signs taken every hour and a nurse just can't get to it. Nurses now commonly give a patient a timed medication two or three hours late. Nurses then face the dilemma of whether to record the truth or fudge the paperwork. Malpractice attorney Cullen says he has seen an increase in what is called "dry labbing" -- making up numbers. "They just write down numbers. They know the patient's in there; they think the patient's okay, so they just make up vital signs and write them down," he says.

Cullen represents the family of Queen Caldwell, a 44-year-old woman who entered Baptist Medical Center in May 1999, complaining of fever and weakness. An emergency room doctor diagnosed her with dehydration and sepsis, a severe infection in which bacteria get into the bloodstream. Doctors sent her to a medical floor with orders that nurses should check her vital signs every hour, but nurses let hours pass without checking them. After she died, her husband sued the hospital for failure to monitor and treat Caldwell.

The case has yet to go to trial.

Staffing isn't the only area where the chain has cut spending. Nurses allege that under Health Midwest's management it is more difficult to get needed supplies and that getting equipment repaired is difficult.

Health Midwest refused to give the Pitch specifics on how it meets hospitals' equipment needs, giving only a vague faxed statement that "every nursing unit has supplies readily available ... many times the problem is in 'communication.'" Health Midwest has implemented a "hot line" for supply shortages, the fax says.

Nurses at many Health Midwest hospitals say that the chain has reduced the amounts of some supplies that are available on a given day. When those supplies are gone, nurses have to make do or "beg, borrow and steal," says Tyson, whose supervisor had to send someone to Menorah Medical Center to pick up isolation gowns when Overland Park Regional ran out one recent day.

Health Midwest's system of doling out equipment and supplies seems to be centered on cost. Remington remembers that on her unit several years ago, spare IV equipment was kept in the hall so nurses could grab it as needed. They could set up a room with necessary equipment before the patient arrived so there would be no interruption in treatment. Now, to make sure the patient gets charged for use of the equipment, nurses must wait until a patient has arrived on the unit to even order an IV machine because they need the patient's bar-coded sticker (which arrives with his or her chart) to order the machine.

"The charge issue outweighs the patient-need issue," Remington says. She remembers one instance in which the unit was expecting a patient who had "a serious drip going on -- she was on heparin, which is a blood thinner, so she needed an IV machine." The patient waited for more than an hour to get her IV machine once she arrived.

Health Midwest now uses a centralized supply system, and nurses have to fax in requests for supplies as they run out. Frequently, faxes don't go through, nurses say, and it can take hours to get the needed supplies. Most nurses can name long lists of supplies that their units have run out of recently: syringes, IV start kits, dressings, surgical tape, needles, soap, shampoo, toilet paper, chest tubes.

Tyson, the ICU nurse at Overland Park Regional, remembers a recent day when her unit ran out of latex gloves. "That just blows your mind," she says. "How can a hospital run out of gloves? That's like a restaurant running out of Coke. Good grief!"

Chamblin, the labor-and-delivery nurse, says her unit was down to its last infant breathing tube when she called for more, but she couldn't get them delivered that night. Her unit sometimes runs out of sanitary pads for new mothers. "It's an irritating issue that goes on. It's embarrassing that you can't even provide something as basic as pads in the OB unit. The hospital supply system has been mismanaged. It's an ongoing problem."

Other cost cuts have created problems in Chamblin's unit. Health Midwest does not provide janitorial services at Menorah through the night, even though doctors perform emergency cesarean sections at all hours. One night, Chamblin's boss asked her to clean a bloody, contaminated operating room because two women were waiting to have c-sections. Chamblin refused to leave the bedside of her patient, who was still under anesthesia. After two hours and several calls by nurses and doctors to the daytime nursing supervisor's home, a manager finally came in and cleaned the OR.

Dale Blystone, a registered nurse at Lee's Summit Hospital, remembers the Thanksgiving weekend that her intensive care unit went two days without chest tubes. Then one night last winter, Blystone found that all critical IV fluids, such as lidocaine and dopamine, had been removed from the unit. After nurses complained, the drugs were returned to the unit.

One day last January, Remington found that blood sugar monitoring strips for diabetics were running low and were on back order until March. Diabetics must have blood sugar monitored four times a day, and nurses use the strips constantly. Instead of seeking another source for the strips, hospital managers tightened control over the strips and doled out just a few at a time. Remington found herself taking the elevator two floors down to the laboratory several times a day to get more strips. Nurses say they regularly have to leave their patients to go up or down several floors to the hospital pharmacy when it fails to deliver the drugs they need for their patients.

Some nurses even resort to buying supplies to bring in so they can care for their patients. Remington has brought shampoo to work so she could wash a patient's hair, and nurses at some hospitals have brought baby formula for parents.

Inadequate equipment also causes problems at hospitals. Nurses at almost all Health Midwest hospitals say at least a third of their hospital beds do not work, and many will not move into the head down, feet up position that doctors need to administer certain drugs or insert certain IVs. Hutten says her unit's beds creak and squeak and "make outrageous noises," and Remington says nurses have complained about the beds for years. The hospital finally ordered 62 new beds, which were distributed between two units, but managers told nurses that was "all they could afford." Blystone recently saw a bed collapse under a postsurgical patient, who "grabbed his stomach" and then had to sit propped in a chair for 45 minutes while maintenance fixed the bed.

Health Midwest, like other health care chains around the country, has asked nurses to be understanding and has blamed problems on "upheaval" in the health care industry. "The reality is that we are being requested to provide services to more patients, while our costs are increasing and our reimbursement from the government is decreasing," says a letter Lee's Summit Hospital CEO John L. Jacobsen sent last summer. He asked registered nurses to "keep in mind the pressures that our industry faces."

Top Health Midwest CEO Dick Brown even sent an open letter to nurses in June 2001, cajoling them with tales of the financial hardships faced by the industry. Shortages of health care workers and of patients able to pay for health care services "make it difficult to deliver the high-quality health care we all want to provide," he wrote. "Frustration is a daily companion for many in our industry."

Many Health Midwest nurses were outraged when amid such claims of a budget squeeze, Brown himself accepted a $450,000 raise from the board of directors to put his salary at $1.3 million a year. Board members reportedly gave the raise partly to reward Brown for cutting costs. In addition, sources have leaked information to union organizers indicating that Health Midwest is spending about $2 million on antiunion consultants and attorneys. After cutting six vice president positions, Health Midwest reported $2.2 billion in total revenues for the year 2000. But its executives say they fear the health care chain will be hit with losses of up to $40 million for 2001. In an effort to avert such losses, the company has hired a high-dollar consultant to perform a study of its operations as part of a streamlining initiative known as Project Delta.

Union organizers complain that Health Midwest's financial woes might not be so bad if not for a bloated management budget. Health Midwest has refused union organizers' call for full disclosure of finances, and its IRS filings are ambiguous. In 1998 filings, Health Midwest reported that 27 percent to 45 percent of its total spending went to management expenses, as opposed to patient care. But after hearing flack from union officials, the company claimed in 1999 that it spent just 10 percent on management costs, a figure more in line with other area hospitals' figures. And nurses complain that two-thirds of the Health Midwest board members have backgrounds in business, not health care.

The company's financial status is complex, but Health Midwest itself does have nonprofit status, meaning that members of its board of directors do not receive a salary and that profits go back into the hospitals themselves. The company takes in about $400 million in tax dollars for care of Medicare and Medicaid patients every year and receives a healthy share of tax breaks. Health Midwest avoids federal taxes through its nonprofit status, which requires its hospitals to provide "significant health care services to the indigent." But some of Health Midwest's hospitals report spending as little as 1 percent of their revenues on indigent care

Health Midwest also has a for-profit arm, the Health Midwest Ventures Group, which produces income from a variety of subsidiaries, including HMOs, a bill-collection agency that specializes in health care but contracts to other industries, a physicians' network, a diagnostic laboratory and a company that works with employers to prevent workplace injuries. Most Health Midwest hospitals have fundraising foundations that collectively raise tens of millions of dollars each year.

Last year the American Nurses Association surveyed 7,300 nurses across the country, most of them hospital nurses, and found that 75 percent felt that the quality of nursing care had declined in the previous two years in their workplace. Nearly 70 percent said that quality of care has declined because of inadequate staffing, and many reported skipping meals and breaks to care for patients. More than half said they felt "exhausted and discouraged" when leaving work and said they were "discouraged and saddened by what they couldn't provide for their patients." And more than 26 percent said they were "frightened for their patients." Like all of the Health Midwest nurses who talked with the Pitch, 41 percent said they would not feel comfortable having someone close to them hospitalized in their workplace.

The current shortage of nurses arises from many factors, one being the rise of managed care in the 1990s, causing hospitals to streamline, merge and close facilities to create greater cost-effectiveness. That meant many nurses were out of work, and many found other careers. Surveys from the U.S. Department of Health and Human Services show that out of 2.7 million registered nurses in the United States, nearly half a million do not work in nursing.

Health Midwest nurses say their complaints go ignored while management spends its money on staggering raises for high-level managers and slick feel-good ploys, such as a recent Gallup survey of half of Health Midwest's employees in which a $3,500 dream vacation was given to a lucky clerk, chosen at random from among poll participants. The winner was pictured on a Health Midwest "Special Bulletin," beaming broadly as a senior vice president gave her a cake and balloons. The bulletin announced in April that Gallup would spend "the next six weeks" compiling the results of the survey and that results would be shared with employees. Nearly three months later, employees have heard nothing about the poll results. "I am sure it is because no one had anything good to say," one nurse says.

Some nurses who are now union supporters -- including Remington -- have tried to bring about change by accepting promotions into management. Remington, after a yearlong stint in management, concluded that the only power she had to help the nurses was to "bring bagels or help out on the floor." Because of tight budget constraints, she could do nothing to increase staffing and could do little about the shortage of supplies or faulty equipment. Remington was hesitant at first, but she started going to union meetings and quickly became a strong supporter, even joining a nurses' picket outside the Health Midwest headquarters.

Formerly a night supervisor, Dale Blystone attended many management meetings for her unit at Lee's Summit Hospital and saw firsthand Health Midwest's focus on cutting costs. "What you saw and heard was the dollar: 'We need to cut supplies; we need to cut staffing on the floors; the nurses need to be more productive.'" The budget focus got so bad that the head nurse assigned a unit secretary to "keep track of every single item." The secretary would lock up supplies such as thermometers, and then on Blystone's shift, a night shift, the nurses couldn't have access to supplies they needed.

Blystone also got involved in union organizing, acting as a leader at Lee's Summit hospital, drumming up support for the union, handing out leaflets and speaking at meetings. Nurses there, in April 2000, decided by twelve votes to unionize. Health Midwest at that time issued a statement predicting that contract negotiations would be "lengthy and difficult," a statement that has proven true. The company's lack of cooperation in negotiations has raised the ire of union organizers, who, in what they acknowledge is an unusual move, have agreed to no negotiation ground rules with Health Midwest. They would not agree to limit the size of their negotiating team or to keep negotiations private.

"The company wants to kill us," says organizer Cathleen McCann, who has been in Kansas City for a year helping the nurses organize. A slim, twenty-something redhead, she furrows her brow when talking about the negotiations. "We don't trust them. They've lied about us, they've committed unfair labor practices. They've been very clear that they don't want a union."

At first, the nurses did not set out to form a labor union. They just knew they wanted to "do something" about the problems that were making them harried and cranky on the job and, many felt, putting their patients' lives in danger. In 1999, the same year McCullough died, nurses were talking in hushed tones at work and on the phone after hours about what they could do. Early on, they recognized that nurses across the Health Midwest chain were experiencing the same crises at work and that they needed to band together. At first, they considered filing a lawsuit against the company. They called attorney after attorney, most of whom said they could not help because they had ties to Health Midwest.

Finally, they reached a lawyer who agreed to represent them but told them it wasn't a lawsuit they needed -- it was a union. Not exactly notorious hellraisers, the nurses at first shied away from that idea, envisioning nasty strikes and picket-line shouting matches. But several leaders, including Teresa Barnett, a registered nurse who works in the recovery unit at Menorah Medical Center, persuaded others that a union was their best means for making changes.

In June of 1999, the nurses had their first meeting -- in Barnett's living room. They decided they needed more information and help organizing, so they started interviewing labor unions and in the fall of that year chose the Federation of Nurses and Health Professionals (a branch of the American Federation of Teachers) to represent them. The nurses hope to have completed union votes at all the Health Midwest hospitals within five years.

Nurses and the AFT labor organizers assigned to Kansas City say they have endured an onslaught of expensive attempts by Health Midwest to thwart their efforts -- including the hiring of Management Science Associates, an Independence-based firm notorious in labor circles as a "union buster" that even brags on its Web site that it has an 85 percent success rate of winning union elections in favor of the company.

Going up against Health Midwest is "brutal," Barnett says. "This is not easy. If we felt that we were treated with dignity and respect and that our patients' lives were important to the company -- I can't name one worker who'd put themselves through this. It's grueling."

So far, negotiations have involved Lee's Summit Hospital and Menorah Medical Center, where nurses voted in December 2000, by 34 votes, to unionize. During the first three union drives, nurses lodged more than 150 unfair labor practice charges with the National Labor Relations Board against Health Midwest. Nurses charged that hospital managers had threatened them with arrest and loss of their nursing licenses if they voted in support of a union.

While more nurses quit Health Midwest weekly, the ones who have dedicated themselves to unionization efforts say they believe they can make changes by combining their power. They say experienced nurses are desperately needed to stay and train the new graduates and to provide competent care for patients.

On a sunny June morning, Mary Nash stands outside the employee entrance at MCI, a steely look in her clear blue eyes. She hands out union information, encouraging her fellow nurses to show up for the July 2 and 3 union vote at MCI. She ignores a few disparaging comments from antiunion nurses and smiles and jokes with supporters.

MCI managers have been stepping up the pressure in the past few days, pulling harried nurses off their shifts for one-on-one meetings to "talk" about the union and tell them that the newly organized nurses at Menorah and Lee's Summit haven't seen any improvements. The union could vote to strike, management tells them, and then their families could be left without their nursing income. This tactic spooked a few single mothers who had been strong supporters, and union organizers are rushing off to their houses to talk to them even as Nash stands outside MCI.

This is Nash's final push before the vote. After a few hours, she goes home to wait. The union is her last hope. If the vote fails, she's not sure what she'll do. In her late fifties, she has only a few more years until retirement; nevertheless, she often considers getting out of nursing. But she thinks the union can win. It has good support.

On the night of July 3, the second day of voting, nurses begin filing into the MCI cafeteria for the vote count at about a quarter to 8. One side of the room is for management; the other side is for nurses. The nurses' side fills up quickly and crowds out the management side.

The nurses are whispering as they pass around a pink sheet of paper that ostensibly has been circulated by hospital managers. "See what this union can really do for you and patient care," it reads. "Wait and see the contract that Lee's Summit Hospital gets, then make your choice before you are stuck with nothing for three years also. JUST VOTE NO."

"And as I walked in there, they were sittin' there bitchin' about work stuff -- again!" whispers a brunette nurse in pink lipstick -- no doubt talking about anti-union coworkers.

"So what's the buzz today?" a union organizer asks a heavy-set nurse in an angel T-shirt.

"Just waitin'. We're nervous!"

A woman in a suit and a few men in dress shirts and ties, wearing pagers on their belts, file in and sit in seats reserved for management.

Nurses smile and rub their hands together anxiously.

Then a man in a dark suit and sunglasses tries to persuade newspaper reporters to leave the room. He is a representative from the National Labor Relations Board, the neutral federal agency overseeing the vote. "I've talked to both sides, and they both feel it would be better if you left," he says in a hushed voice.

"That's not true!" a union organizer chimes in.

The NLRB representative narrows his eyes and strides away, talking into his cell phone, and comes back fifteen minutes later with Health Midwest's attorney in tow to kick two reporters and a photographer out of the hospital.

After about half an hour, a huge group of nurses rushes out of the back entrance of the hospital screaming, whooping and group hugging.

"We did it! We did it!" they shout.

Organizer McCann rushes out, wearing a pink shirt and black capri pants, talking into her cell phone. "Yep. Mary Nash's numbers were right! We kicked their asses!"

The unofficial tally is 93 to 47 votes -- and organizers knew the company had stacked the vote with antiunion nurses from other hospitals too, perhaps hoping to tie up the process in lengthy NLRB hearings.

"That's 15 percent of the list they screwed with," says one organizer, jubilant that the nurses prevailed anyway. In fact, this is the largest margin the nurses have won by yet.

A middle-age nurse with short ash-blond hair starts sobbing and hugging her coworkers. "We have a unity now," she says, choked up. "Maybe now they'll sit down and listen to us."

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