A Team To Play On
An array of improvements has boosted satisfaction among nurses on Bayview's Med A and Med B

Maria Koszalka, left, confers with Med B's patient care manager, Janet Kelly. When Kelly took the unit's reins less than two years ago, only three of 25 nursing positions were filled by Bayview employees. Today, more than half are on the medical center's payroll.

Three years ago, Maria Koszalka faced a shortage within a shortage. Like her counterparts at nearly every other hospital in the country, the vice president for patient care at Johns Hopkins Bayview Medical Center was struggling to find-and keep-nurses. The problem was evident even on the glamour units: the intensive care and other specialty areas. But on the medicine floors, where most of the medical center's patients receive care, only a handful of nurses were true Bayview employees. More than half the positions were filled by temporary agency nurses.

Koszalka, who co-chairs the committee on workplace issues for Maryland's nursing shortage commission and is president-elect of the Maryland Organization of Nurse Executives, wasn't about to leave her own turf in disarray. To zero in on the issues troubling Bayview nurses, she asked them to take a satisfaction survey in February 2001. Then, results in hand, she set out to reshape medicine nursing at Bayview.

What had been frustrating the medicine nurses the most, says Koszalka, was feeling that, as fewer nurses were available to shoulder the workload, those remaining had little control over their schedules, little say in how the unit functioned, and, as a result, little control over their lives.

Among Koszalka's first moves was splitting the unwieldy, 72-bed Zieve Medical Unit in two. The decision not only made sense geographically-a bank of elevators forms a natural division between what are now known as Med A and Med B-but it also allowed patients with similar care needs to be grouped together. (Today, those with cardiovascular or pulmonary disorders go to Med A; oncology and renal patients, to Med B.) Equally important, each unit would now be run by its own patient care manager. Furthermore, a $207,000 grant from Maryland's Health Services Cost Review Commission (one of several awarded to help hospitals in the state find ways to cope with the nursing shortage), meant Koszalka could put some clout behind other new ideas.

Med A became the pilot unit for the grant. There, a ratio of one nurse for every six patients was set, and extra agency nurses were brought in to make it stick. Also, nurses were given four-channel portable telephones, allowing them to stay at the bedside and still be instantly in touch with each other, with physicians, and with departments such as pharmacy and labs. And on both units, Koszalka encouraged the patient care managers to focus on building staff morale and teamwork.

"My first impression," says Robin Reid, who signed on to lead Med A in June 2001, "was of a very warm nursing staff absolutely thirsty for direction." Reid, formerly director of inpatients at Union Hospital in Elkton, Md., now has nurses doing their own scheduling around an every-third-weekend-on rotation. A simple bulletin board with staff members' names and photos promotes camaraderie and helps everyone know who's who. And the phones have been a hit, with physicians as well as nurses. In less than two years, says Reid, her nurse turnover rate has plunged from 40 percent to 11 percent, and the vacancy rate has dropped from 56 percent to 36 percent. "Now people are asking to work here," she says. "including some of the agency nurses."

Results of Koszalka's second nursing survey, conducted in September 2002, confirm the turnaround. In the first survey, the top complaint centered on the perception that managers didn't recognize a debilitating workload. Last fall, it was managers' fairness, effectiveness and relationships with staff that got the highest marks.

"Nurses like spending time with patients-that's why they became nurses," says Lisa Nummi, Bayview's director of emergency and medicine nursing. "When they can't do that, they're going to find someplace where they can. What's been done here is almost miraculous. We're building a team people want to play on."

-Mary Ann Ayd

Champion of Champions   David Hellmann " I learned when I was an intern that it was often the nurse who knew more about the patient than I did," says David Hellmann. "I always tell young doctors, 'If you want to be a really good physician, talk to a nurse.'" To prove his point, Bayview's chairman of medicine includes nutrses when he rounds with students and house staff twice a week. Not long ago, he says, a residengt noted that one patient was uncommunicative. A nurse sunsequently joined the discussion without having heard this comment. In her presentation, she said the patient was scared, and if you asked a lot of questions, he wouldn't answer. But, she added, if you got him talking about his work and his family, he'd tell you anything. The resident, says Hellmann, looked a little sheepish, but also enlightened. "What's so remarkable for physicians at Hopkins is that they're asked to be part of something special," Hellmann continues. "What I want to do is create an environment that does for nursing what Hopkins does for physicians. The reason nurses want enough staffing, medications arriving on time, clean floors, is so they can spend their time on nursing. I don't control staffing or pharmacy or cleanliness. But can influence how physicians incoprorate nurses. Let's make nurses not simply employees but an intrinsic part of this wonderful fabric we call Hopkins Medicine."