Even at 8 a.m., June 2 was blazing hot outside Mission Hospital. Few trees lent little shade at the entrance to the complex.
But the registered nurses who gathered that morning for a rally with National Nurses United are used to being on their feet for long periods of time in uncomfortable conditions.
About 50 RNs and their supporters, including a doctor wearing scrubs who had just completed a night shift, rallied to raise awareness about alleged dangerous conditions at Mission Hospital, which is owned by HCA Healthcare.
Greg Lowe, president of HCA’s North Carolina Division, has previously acknowledged a national nursing shortage. However, Mission’s RNs allege HCA management is letting staff decrease to unsafe levels through attrition as a cost-cutting measure and the result is unsafe nurse-to-patient ratios. The understaffing also means RNs are unable to take meal or bathroom breaks, they say.
Mission’s RNs have raised alarms about unsafe staffing for years, says Hannah Drummond, an emergency room nurse who spoke at the June 2 rally. Mission RNs began holding rallies after HCA bought Mission in 2019; gatherings in August 2020, October 2021 and April 2022 warned of unsafe staffing numbers.
“I’ve even talked to Sam Hazen, the CEO of all of HCA, about some of our concerns,” Drummond, the chief nurse representative at National Nurses United for Mission, tells Xpress.
“It’s gone up the ladder,” Drummond continues. “We’re just tired of waiting for them to get it together to act.”
A turbulent history
HCA, a for-profit company based in Nashville, purchased nonprofit Mission for $1.5 billion in 2019. Shortly thereafter, community members alleged patient care declined.
Health care professionals and former patients described long patient waits and diminished cleanliness. In February 2020, Asheville Mayor Esther Manheimer, Buncombe County Commission Chair Brownie Newman and State Rep. Brian Turner co-signed a letter to the Asheville Citizen Times stating, “[R]educed care for low-income patients, increased patient risk, and dismissing important practice groups that have provided outstanding service to Mission — are simply unacceptable and must be corrected.”
HCA responded in a March 2020 statement to Carolina Public Press, “There have been no cuts to our bedside nursing positions. We are aggressively recruiting for RNs and nurse support positions such as certified nurse assistants, health unit coordinators, patient care technicians and a variety of other nurse support roles.”
RNs employed at Mission announced their intention to pursue labor representation in March 2020. Six months later, RNs at Mission voted for representation by NNU, the largest nurse’s union in the country. Nearly 1,400 workers voted, and over 70% voted in favor of the union, according to CPP reporting. (NNU represents approximately 12,000 nurses at 20 hospitals owned by HCA Healthcare, according to NNU’s communications director Lucy Diavolo.)
The approximately 1,500 RNs at Mission who joined NNU ratified their first union contract in 2021; it expires in July 2024. (Xpress requested a copy of the contract from RNs and NNU but was unable to view it by press time.) According to the AFL-CIO, the contract included guaranteed breaks, a ban on mandatory overtime, hospital-provided personal protective equipment and testing and wage increases of up to 17%.
Yet at the June 2 rally, Mission staff alleged continuing problems.
The gold standard
Sixteen states address nurse staffing via legislation or regulations, according to the American Nurses Association, a professional organization that advocates for nursing standards. (Health care organizations can implement safe staffing levels as well. Nancy Lindell, director of public and media relations for HCA Healthcare North Carolina Division, did not respond when asked if HCA has a policy on staffing ratios.)
There are different approaches to nurse staffing. In 2019, ANA updated its guide to nurse staffing to advocate for flexible staffing that takes into account a nurse’s experience. California and Massachusetts have legislation on minimum nurse-to-patient ratios. Massachusetts requires one nurse per one or two patients in intensive care units, depending on a patient’s stability.
NNU, the union representing Mission RNs, worked with California legislators to codify nurse-to-patient staffing ratios into law, which its booklet Your Guide to Joining the RN Movement calls “the gold standard.” Susan Fischer, an RN at Mission for 17 years, calls the ratios established in this legislation “the safest possible way to take care of patients.” RNs at Mission tell Xpress they find many units are understaffed.
The gold standard recommends one nurse per two patients in intensive care; Fischer says colleagues tell her Mission has one nurse for two or three intensive care patients.
The trauma department of the emergency room should have one nurse per patient, according to the gold standard. Fischer says colleagues tell her Mission has two patients per nurse.
The psychiatric department should have one nurse per six patients, according to the standard. Fischer tells Xpress her colleagues have had seven patients per nurse. And in the neonatal intensive care unit, which should have one nurse per two patients, Fischer says nurses are assigned as many as four patients at a time.
When asked via email June 8 to respond to the allegations “regarding nurse-to-patient ratios that [RNs] feel are too high and what they say are insufficient time for meal breaks/bathroom breaks,” Lindell responded the same day with a statement.
“Mission Hospital continues to heavily recruit and offer robust sign-on bonuses,” the statement read. “Staffing at Mission Hospital is reviewed every four hours and staffing resources are shifted to respond to changes in patient acuity, sometimes placing charge nurses into care roles to best support our patients and staff.
“Like every hospital in the country, we are having to respond to the shortage of trained health care providers with innovative solutions such as: international nurses, alternative care delivery models, and academic partnerships — including the recent announcement of funding additional faculty members at three local colleges and university for their nursing education programs and opening the Galen College of Nursing in Biltmore Park.” Lindell also sent a press release about HCA funding nursing education.
Allegations of no breaks
Despite the NNU contract language requiring guaranteed breaks, RNs at the June 2 rally say they have to forgo bathroom and meal breaks due to understaffing. While speaking with Xpress, Drummond noted her colleagues’ chanting in the background. “Right now, they’re chanting about wanting a break,” she said. “I have had one lunch break since I [began working] the ER. One 30-minute break!”
When asked how HCA ensures RNs are able to take breaks, Lindell responded June 23: “Like any unit-specific staffing decision, immediate patient care needs are a consideration when scheduling break and meal periods. The hospital encourages all caregivers to take rest or meal periods during their shifts and to work with other caregivers to ensure the safe transition of patient care needs during these times.
“In addition to providing incentives for picking up additional full shifts, nursing departments offer staff the ability to pick up additional hours through partial shifts of varying lengths known as ‘helping hands’ shifts.”
Fischer, who works on night shifts, says she can usually eke out 15 minutes to eat but doesn’t take a formal break. She says the only time when she’s not on her feet is when she is working on patients’ charts.
“Charting and sitting at the desk is my break because I actually get to sit down for a moment,” she says. With her packed patient load, she can’t easily take a bathroom break either. “The point when my bladder is ready to burst is when I go,” she says.
On June 23, the careers page on HCA’s website listed over 230 RN openings at Mission Hospital in Asheville and an additional 50 open RN positions at other Mission locations in Western North Carolina. Lindell did not respond to Xpress’ question about the current number of nursing staff at Mission.
For now, RNs at Mission will have to make it work.
“It’s very disheartening, it’s very upsetting,” Fischer said at the rally. “And it’s because we’re overworked and overwhelmed.”