The nurses at the San Ramon Regional Medical Center pride themselves on working for a small community hospital and providing excellent care to their patients. But within the last two weeks, some nurses encountered two patients they didn't want to treat. One needed pain medication after an appendectomy; the other needed treatment for a respiratory infection. The nurses' reluctance to get involved wasn't due to some aversion to the sensitive conditions in question. It was because the patients were children, and they're not pediatric nurses.
Although both patients were successfully treated, the nurses worry that this situation was merely a harbinger of what is to come. The hospital, which primarily treats adults, plans to earmark four beds in its medical surgical unit for pediatric patients. To prepare for the change, the hospital has instructed its nurses to take a crash course in pediatrics -- an idea that's gone over like a ton of bricks. Nurses say the limited training they're being offered -- a three-hour online course and four hours of classroom instruction -- is dangerously insufficient and unethical. "How safe is that for our community and the patients coming here, and how safe is that for our licenses?" asks registered nurse Debbie Lurie, who has worked at San Ramon for more than four years. "It's not that I don't want to take care of pediatric patients, it's that I don't want to do it under these circumstances."
In January, 35 of the 42 nurses in the medical surgical unit signed a petition to the hospital's CEO saying they were "dismayed by the efforts of this administration to force us to become pediatric nurses overnight without proper training."
Union organizers claim that the lack of training for the pediatric program is just another case of ill-advised penny-pinching by the hospital's parent company, Tenet Healthcare Corporation, the nation's second-largest for-profit hospital chain. Tenet has recently come under government scrutiny for its financial practices. In January, the Justice Department announced it was suing Tenet for as much as $500 million for allegedly overcharging on Medicare reimbursements. And the company recently settled ten lawsuits by plaintiffs who claimed the chain was price-gouging uninsured patients. Tenet recently announced it will change its Medicare reimbursement practices and will no longer charge uninsured patients full list price for medical procedures. But it also has been sued by the Congress of California Seniors, which claims the corporation overcharges for prescription drugs. Meanwhile, in January, the state Senate held its own hearings on allegations that Tenet was overcharging for workers' compensation fees.
The local pediatrics debate also is being played out against an intensely political backdrop. Last October, San Ramon's nursing staff voted to unionize by a 56 percent margin. Organizer Beth Kean of the California Nurses Association contends that hospital management put extreme pressure on the nursing staff during the union drive, including sending a supervisor who was impersonating a nurse to an organizing meeting and firing a nurse for putting up a union flyer on a public bulletin board. The nurse was reinstated after a public outcry, and the charges were investigated this winter by the National Labor Relations Board, which issued a complaint. The hospital is appealing the unionizing vote to the labor board, which is expected to hold hearings in March. In the meantime, the union's ambiguous status at the hospital means it is unable to bargain on behalf of the staff, and the union is hammering on the pediatric training issue as a timely example of why its intervention is needed.
Although many of San Ramon's employees welcome the hospital's plan to admit younger children, the nurses and the hospital's management disagree sharply over how much training is needed to care for them. Critics emphasize that taking care of children is very different than treating adults. There are different practices for dosing drugs, administering oxygen, setting up IV lines, and performing lifesaving techniques. There also are different rules for interpreting vital signs such as blood pressure and respiration rate; nurses are worried that without much previous experience, they won't be able to know when something is amiss. Sick kids can go rapidly from stable to critical condition, and nurses are afraid they might overlook the warning signs. "Those children can turn on a dime," Lurie says.
But Kim Burch, the hospital's business development director, says the hospital is being very careful to ensure that the new program will provide the appropriate care for children. She says caring for kids will primarily be the responsibility of designated pediatric nurses, who will be given additional training. The remaining nurses, she adds, are simply being asked to take these seven hours of basic training so that they can render assistance if necessary. Burch did not know whether the designated pediatric nurses will be recruited from the existing San Ramon staff or hired from outside.
Yet many nurses say seven hours isn't close to enough preparation. "Their proposal for care would be laughable if it wasn't dangerous," says Martha Kuhl, the treasurer for the California Nurses Association, who has been a pediatric nurse at Children's Hospital Oakland for more than twenty years. Kuhl compares San Ramon's proposal to her own hospital's training standards for nurses new to pediatrics: four to six weeks of hands-on training for medical and surgical nurses, and eight to twelve weeks for a critical-care nurse. Each new staffer is assigned a more experienced partner and they make their rounds together.
Some of the San Ramon nurses say they would prefer this kind of hands-on learning -- after all, an online course can't simulate what it's like to care for an actual child. "It's like reading a magazine article and taking a quiz at the end," Lurie says. Some say that they aren't even getting their seven hours' worth. "I went through the whole module, I read every word, clicked on every window possible, and it ended up taking me a total of two hours and twenty minutes," says San Ramon nurse Heather Coder of the online training. Coder says she still does not feel adequately prepared for pediatric work. Asked what might make her feel more comfortable, she envisions something more like the training San Ramon nurses were given several years ago when the hospital opened a new program for cardiac patients. For that program, nurses were given a four- to six-week training that included six-hour lectures, trips to other facilities to witness surgeries and post-op care, and the implementation of a partner system. "The pediatric population is also a special population, and we should at least have training that's similar to the training we had for the cardiac program," Coder says.
Although San Ramon Regional Medical Center has historically been an adult-centered hospital, the suburbs around it have a sizable youth population. "About 22 percent of the population in our immediate service area is under the age of fourteen," Burch says. Last May, San Ramon took a step toward serving a younger clientele by contracting with Children's Hospital Oakland to provide 24-hour in-house pediatricians at the San Ramon facility. "With the additional pediatrician support in the hospital, it makes sense for us to be able to take care of routine pediatric admissions in our community," Burch says.
The way it currently works, if a patient under age three does come into San Ramon, he or she is routed to the intensive care unit because that unit has the highest nurse-to-patient ratio. This arrangement doesn't seem to have pleased anybody. Some of the ICU nurses are uncomfortable treating very young patients; Burch says that transferring critical patients to other hospitals is distressing for both the kids and their parents; and recent surveys by the Department of Health recommended that the pediatric patients be grouped together by the acuity of their condition, rather than by age.
Consequently, there have long been plans to start a pediatric unit at San Ramon. In 1996, the state legislature approved a bill carried by former Walnut Creek assemblyman Richard Rainey that created a partnership between San Ramon Regional Medical Center and Children's Hospital Oakland by allowing the Oakland hospital's license to cover satellite facilities within a 25-mile radius. At that time, the plan was to create a seven-bed pediatric unit at San Ramon that would have been entirely staffed by Children's Hospital employees.
The unit never materialized, and some staff from Children's are surprised that San Ramon now plans to have its current employees treat pediatric patients. "I was kind of shocked when I heard that San Ramon was opening a pediatric unit," Kuhl says. "I was like, 'We're supposed to be the nurses there.'" After all, she says, it would be a desirable job placement for the pediatric nurses who commute to work at Children's Hospital from all over the Bay Area -- some from as far away as Modesto and Fairfield. How ironic, she points out, that the nurses who might like to work San Ramon's pediatric program aren't being invited to do so, and that the San Ramon nurses who are uncomfortable treating children may find themselves having to do it instead.
Kean alleges that Tenet is treating adult and pediatric nurses as interchangeable so that it doesn't have to pay to staff two different kinds of programs. "They don't want the expense of hiring pediatric nurses," she says. "They want fewer nurses to do more things." Of course, seven hours of pediatric training is cheaper than six weeks of it. Kuhl calculates that a beginning nurse earning $30 an hour who goes through six weeks of on-the-job training would collect about $5,700 in wages. That's not counting the cost of paying her benefits, hiring instructors, or providing course materials.
Hospital officials at San Ramon say they aren't rushing anything, and that when the pediatric program is ready to take on new patients in a few months, both the hospital and its nursing staff will be ready. "We're committed to providing quality medical care to the children in this community, and we think this is a positive," Burch says. But some of their employees insist they'll need more preparation before they will feel ready to treat severely sick kids. "All of my co-workers are really great and I would trust them with my mother's life," Coder says, "but I don't think anybody feels comfortable enough yet to have a child's life in their hands."
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