Every Saturday from 7:30 in the morning to 8 at night, nurse Megan Murphy keeps an eye on the blipping cardiac monitors and tiny intravenous tubes hooked up to fragile infants in the special care nursery at Prince George's General Hospital.
On Sunday mornings at 7:30, she is back at the hospital in her pink scrub suit with a stethoscope draped around her neck, ready to put in another 12-hour shift in the high-pressure intensive care unit for newborns.
The hours are grueling but there's a reward for Murphy: 36 hours of pay for 24 hours of work, along with five free weekdays in which to pursue her PhD in philosophy.
For Prince George's Hospital there's also a payoff: Dozens of nurses want to work weekends, making a significant dent in the hospital's battle against a chronic nursing shortage.
Although the nursing shortage is a persistent national problem, suburban Maryland hospitals are trying to conquer it with solutions ranging from flexible hours and better pay to improved fringe benefits and in-hospital college courses.
At Prince George's Hospital, for example, more than 30 percent of the hospital's 400 nursing slots were unfilled a year ago, said Robin Hagaman, administator of the county-run hospital in Cheverly.
Through a variety of new techniques, including "flextime," an in-hospital substitute pool and the weekends-only plan, the hospital drastically cut its vacancy rate, so that there were almost no openings for RNs as of the end of August, Hagaman said.
While local hospitals seem to be winning some skirmishes in the battle to recruit and retain nurses, suburban Maryland hospitals still are having more hiring problems than hospitals in other parts of the state.
A survey by the Maryland Hospital Association earlier this year found that 18.5 percent of the nursing positions in the Maryland suburbs of Washington are vacant, compared to a statewide shortage of 13.6 percent. The survey also found that more nurses leave their jobs in the Washington area, where there is a 32 percent annual turnover rate, compared to a 22.4 percent turnover rate statewide.
Richard Wade, a vice president of the hospital association, attributes the more serious nursing shortage in hospitals in the Maryland suburbs of Washington to the competition with hospitals in Washington and Northern Virginia.
In area hospitals, the shortage occasionally forces administrators to close beds in intensive care units and delay elective surgery because of insufficient staff. And for nurses, the high vacancy rate creates almost daily situations in which they are shorthanded and unable to provide top-notch patient care.
"It's not the way they taught you to nurse when you were in school," said Cheryl Kemp, a part-time night nurse at Holy Cross Hospital in Silver Spring. "When you're a student, you have time to really look at a patient, talk to a patient and assess their needs. Now you don't have time. You're just concerned with the bare essentials."
Hospital administrators contend the nursing shortage has not created unsafe situations for patients. But many nurses say privately there have been some scary nights, traditionally the hardest shifts to staff, when they have felt dangerously close to trouble because there were not enough nurses on units with critically ill patients.
The American Hospital Association predicts the nursing shortage will become worse in the next few years as nursing school enrollments continue to slip and as the demand for nurses grows, a result of increased hospital admissions, longer hospital stays, more complex medical technology and an aging population that probably will need more and more hospital care.
At the root of the problem, the National Commission on Nursing found in recent hearings throughout the country, is a long list of professional woes: low pay, undesirable hours, stressful working conditions, tense nurse-doctor relationships, a lack of autonomy and a lowly image of the nurse as "handmaiden to the physician."
Compounding the problem, experts say, is the wider variety of career choices open to women. While nursing competes with those new career options, hospitals vie with each other, with other health care institutions and with private physicians for the limited supply of nurses.
In this area, where the shortage generally is considered to be more severe at city hospitals, nurse recruiters from 22 hospitals in Northern Virginia, suburban Maryland and the District have banded together to produce a brochure and advertising extolling the virtues of working as a nurse in metropolitan Washington. Once a year, the association holds a mammoth nursing fair, which all its members attend in an effort to sign up nurses.
"One more new nurse to the area, we'll be happy to get, instead of fighting for every nurse who comes to town," said Angela Sweetin, vice president of the Washington Metropolitan Nurse Recruiters Association.
Nevertheless, job-hopping is common as nurses look for the best pay and the best hours, and local nursing directors say they constantly check the competition, to avoid losing nurses to other hospitals.
With low salaries one of the most common complaints from nurses, hospital administrators are starting to upgrade pay scales.
The average starting salary in Maryland for a newly graduated RN with no experience is about $14,000 a year, according to Richard Wade of the Maryland Hospital Association.
Several area hospitals already are way ahead on the salary scale, at least for starting pay. Holy Cross Hospital pays new nurses $16,400 a year, said Mark Smith, director of human resources. Other suburban Maryland hospitals offer comparable starting salaries, although they lag behind some hospitals in Washington and Northern Virginia that pay new nurses more than $17,000 a year for day shifts.
While salaries for newcomers are improving, bedside nurses quickly reach their top pay, area nursing directors say. At Shady Grove Adventist Hospital in Rockville, a new nurse receives $7.69 an hour, or about $16,000 a year, while a nurse with several years of experience can earn only $9.15 an hour, or about $19,000 a year, said Judith Smith, vice president for patient care.
To remedy this situation, several hospitals are creating "clinical ladders" designed to boost salaries for experienced nurses with medical specialties such as emergency, surgery or intensive care. At Prince George's General Hospital, a specialized nurse with seven years experience can earn up to $23,234, said Patricia Noble, director of nursing.
Despite the contention of several nursing groups that higher pay is the answer to the nursing shortage, a recent study by the Maryland Hospital Association argued that flexible working hours can be just as important as money in attracting nurses.
"For the nurse who is raising a family or going to school full or part-time, these kinds of arrangements can mean the difference between remaining in the nursing profession, staying home, or finding other employment which better suits their personal situation," said Richard Davidson, president of the hospital association.
Prince George's Hospital has been experimenting with flextime since January, and hospital administrators say the "make-your-own-hours" system has dramatically reduced both the vacancy rate and the turnover rate, which dropped from 67 percent in January to about 30 percent today.
The philosophy at Prince George's is "you tell us when you want to work and we'll fit you in somehow," said administrator Robin Hagaman.
One of the most popular plans at Prince George's is the "weekend alternative" program, in which day shift nurses can work 24 hours on weekends and get paid for 36 hours, and night nurses can receive 40 hours of pay for 24 hours of work.
Some of the nurses working on the weekend plan are students like Megan Murphy, who uses her five days off to take graduate courses at Georgetown University. Others are like Phyllis Callaway, a nurse in the newborn unit and the mother of two children, who saves on babysitting costs by working weekends when her husband can care for their children.
Prince George's Hospital offers low-cost child care to its employes, an option that is gaining popularity in Northern Virginia as a way of luring nurses. But hospital officials say they can't use the child care center as a nurse recruiting device because there is such a long wait for a space in the program.
Nurses shopping for a job in suburban Maryland have plenty of other perks to choose from. Sunday want ads promise benefits such as tuition reimbursement for advanced education, improved health and medical insurance and free parking. Many local hospitals use their suburban location as a drawing card for nurses unwilling to work in the city.
Montgomery General Hospital in Olney starts a program this month in which nurses seeking a bachelor's degree can take American University courses at the hospital. Suburban Hospital in Bethesda offers Bowie State College courses on the hospital grounds.
Some hospitals, including Suburban, are even paying a bounty to employes for each nurse they help recruit. At Shady Grove Adventist, an employe can receive a $100 bonus for each nurse recruited, if the nurse stays three months, said Judith Smith.
When all else fails and hospitals are left with empty slots, as most are, they turn to employment agencies to provide nurses on a temporary basis.
Temporary firms pay nurses as much as $14 an hour, considerably higher than the $9 an hour many experienced nurses earn. The pay discrepancy is a bone of contention with some nurses, who argue that full-time staff should receive as much as substitutes
Because temporary agencies bill hospitals as much as $25 an hour for the services of their nurses, several hospitals have set up their own substitute systems.
Before setting up its own "on-call float pool" a few months ago, Prince George's Hospital spent $300,000 a month on temporary nurses, or almost a quarter of its total nursing budget, said Robin Hagaman. Once the hospital created its in-house pool, agency costs dropped to $110,000 a month, he said.
Not only are agency nurses expensive, but hospital administrators say they organize their own pools because they want nurses who are familiar with their procedures.
"We feel these agency nurses are more prone to make more errors," Hagaman said. Also, "when you put an agency nurse and a hospital nurse side by side, it's almost like grease and water. They don't mix. There's resentment on the part of the hospital nurses because they know how much we pay the temporary nurses and how much we pay them."
Hagaman said Prince George's pays its own part-time float nurses $12 an hour, which is competitive with agency rates.
While local hospital executives search for immediate solutions to the nursing shortage, the Maryland Governor's Commission on Nursing Issues is looking for a long-term cure. State Delegate Marilyn Goldwater of Montgomery County, an RN who chairs the commission, said the panel will hold hearings around the state this fall on nursing problems and it will issue some legislative recommendations next year.