About 60 women a month gave birth at the county medical center when labor and delivery nursing specialist Liz Llewelyn began working there more than 22 years ago.
Today, more than 200 women a month deliver at the hospital, but the nursing staff has not grown with the patient load.
Hospital administrators are struggling to maintain staffing levels in an environment that gives nurses an incentive to leave.
Now, Contra Costa County finds itself forced to bargain for cutbacks that could send the already harried nurses looking for better paying and more promising jobs.
"We run out of nurses," Llewelyn said. "You can't get any backup."County Jail nurses say they can come in for a regular shift and find themselves assigned to a double shift.
Records show that nurses work long hours to cover staffing gaps. Studies suggest they suffer more injuries than in years past. Some of that is from overwork and some is from lifting obese patients, an increasingly common experience.
Now the county is talking about withdrawing one of the attractions of the public service job.
In contract talks with the nurses' union, Contra Costa negotiators have proposed making them wait 15 years instead of five to begin qualifying for retiree health benefits.
"I call it the bag lady retirement program," Llewelyn said. "For a part-time person, it would take 30 years to become vested."
Under the gun to cut spending, the county is hoping to back away from a generous retirement benefit that cost $ 179 million last year for all retired employees.
Nurses are in high demand across the country. Pay and benefits in the private sector are enticing them out of county hospitals and public health clinics everywhere. Contra Costa County pays about $ 10 an hour less than private Bay Area institutions employers like Sutter Health and Kaiser.
The county pays first-year registered nurses $ 33.89 an hour, lower than the Bay Area prevailing wage of $ 40. Kaiser East Bay pays $ 39.82, Alta Bates/Summit $ 38.47.
"These are one of the employee groups where we are totally at the mercy of the market," said supervisors' chairman John Gioia of Richmond.
"Every single one could go out tomorrow and get another job -- and often, a higher-paying job," he said. "The way it's always been, the private sector offers higher pay and the public has better benefits. Now, the private sector is starting to pay better benefits. We have less leverage."
The county's conundrum: It must cut back on spending, including benefits, but it has to keep a minimum number of skilled nurses.
Public acute-care hospitals and small private hospitals are scrambling to meet the state's minimum nurse-patient ratios of 5-to-1.
A UC San Francisco study last year predicted a statewide shortage of more than 20,000 nurses by 2012.
Beyond the immediate problem of cutting an attractive benefit, many of the county's health care employees are approaching retirement, another drain on the difficult-to-replace staff members. Hospital administrators nervously note that county-employed nurses average 51 years in age.
The stakes are higher now that voters have rebuked Gov. Arnold Schwarzenegger's attempt to dispense with minimum nurse-to-patient ratios.
Few large county hospitals are able to meet the 5-to-1 requirement, said Barbara Patton, vice president of the Camden Group, a Southern California consulting firm specializing in hospital operations.
"We're at a critical juncture," said hospital administrator Jeff Smith. "I'd venture to say there are crises at every turn. The biggest we have is the nursing and departure at a time when the patient population is increasing. We push our nurses to the limit."
Some 100 of Health Services' 450 nurses will retire in the coming three to five years, Smith said.
Other hospitals attract nurses by spending more money. The county does it by promoting itself as a gratifying mission for those who care.
"Attracting people is difficult to do," Smith said. "It requires careful, strategic planning. It requires management expertise. We can't pretend the labor market isn't what it is."
The county employs 2,000 people in its hospitals and clinics and 3,000 in all of health care services.
Those who seek county care are increasingly needy. Yet resources are diminishing, Smith said. Bariatric, or morbidly obese, patients are becoming more common.
"This is the new generation of kids you're hearing about, Llewelyn said. "They have heart disease, they have diabetes, they're on all kinds of drugs to manage it."
In addition to indigent patients, the county hospital is treating more people who had insurance but lost it, Llewelyn said.
Sonia, who is forbidden by the Sheriff's Office policy to reveal her last name, has seen the staffing sink from six night-duty nurses two years ago to three today at the County Jail in Martinez. Double shifts help stretch the staff.
"It's horrible on my shift," she said. "We've totally trimmed to the bone."
They still have to react to the people under their care. Drunken driving checkpoints and warrant sweeps can bring an influx of inmates, some with serious medical conditions, who have pacemakers or are on kidney dialysis or are clinically depressed.
Hospital critical care nurse and union negotiator Kip Norwood calls "a doozy" the weekend that brought in a woman with a severe leg infection and multiple organ failure. Both she and a patient in cardiac crisis "are doing quite well now," partly due to the expertise of a seasoned, specialized nursing staff, the nurse union negotiator said.
The county is willing to bump up the entry salaries by about 10 percent to attract new staff members but nothing to retain midcareer specialists, Norwood said.
The trend away from retirement benefits and toward benefits more appealing to young nurses is common throughout the industry, Patton said.
"The newer nurses -- a 25-year-old-- is looking at other things," she said. "Salary. And they are going to be starting families, so they're interested in flexibility in hours."
The county's most recent offer includes the retirement health benefit change and a two-year wage freeze, with a 2 percent cost-of-living wage in the third year.
The union is seeking more time off, better staffing ratios and better pay.
"We could say, 'Pay us what they pay at Kaiser,' but we know that's not going to happen," Norwood said.
"What we're looking for is the things that make it easier to be at the bedside."
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