Becky Hartman will tell you how crucial it is for a hospital to have enough nurses.

When she rushed her mother to a Wichita, Kan., hospital, an ER doctor quickly sized up the older woman as another pneumonia case. Her breathing was labored and pneumonia patients filled the emergency room.

But 61-year-old Shirley Keck didn't have pneumonia. As she lay in a hospital room all but ignored, she was suffering from a common type of heart failure that filled her lungs with fluid.

As Keck deteriorated over several hours, Hartman begged Wesley Hospital nurses for help.

"It was total chaos. Everybody was tired. Everybody was totally overworked," Hartman recalls. "As the breathing got worse, I'd ring the button. Nobody came."

It was Feb. 8, 1998 - a Sunday night, when hospital staffs are leanest. There were just two registered nurses and two nurse aides for 42 patients on Keck's floor, fewer than half the staff the hospital's own guidelines required.

"I'm going to die," Shirley Keck told her daughter.

She did, but was resuscitated and lingered for four years - depressed, paralyzed except for one arm and unable to talk because a stroke during the ordeal had caused brain damage.

Her family won a $2.7 million malpractice settlement from Wesley Hospital in July 2000. Two years later Keck died.

The hospital and Keck's attorney, Bradley Prochaska, say it's the first malpractice decision specifically pinned on inadequate nurse staffing. He has filed a similar suit involving a 38-year-old quadriplegic woman.

At first, Hartman was furious with the nurses. Now, she's joined their cause, speaking out about the need for more nurses at the bedside.

"If another family doesn't go through this, the nightmares I've had," she says, "that's all I can ask for."

Dire need

Across the country, nurses unions are pushing hospitals and lawmakers for limits on patient loads. And hospitals are trying to recruit and keep more nurses, all with good reason: Too few nurses can cost patients their health and sometimes their lives, study after study shows.

? A shortage of nurses is a factor in about one-fourth of patient injuries or deaths in hospitals, according to the Joint Commission on Accreditation of Healthcare Organizations' 2002 report.

? The prestigious Institute of Medicine says long work hours and fatigue contribute to errors. Its November 2003 report recommends a ban on nurses working longer than 12 hours a day.

? A 2002 study by Harvard and Vanderbilt university researchers, examining millions of 1997 hospital cases, found preventable deaths and patient complication rates were up to nine times higher in hospitals where the most care was given by licensed practical nurses and aides, not better-trained RNs.

? For each additional patient over four assigned to a nurse, the risk of dying after surgery rose 7 percent, according to a 2002 survey of 168 Pennsylvania hospitals by Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.

"The fewer patients a nurse cares for, the better the outcome in general," says Aiken.

But nurses say their workload and paperwork leave too little time to comfort, educate or even thoroughly assess patients. Many of the most experienced nurses leave for easier jobs at drug or insurance companies, leaving ever-greener nurses at the bedside.

"You're just thrown in the deep end ... too many patients, too many tasks," says RN Alison Goodman, whom Wesley Hospital fired 3? years ago after she repeatedly filed complaints about unsafe RN staffing levels and gave her reports to Prochaska.

Hospital spokeswoman Helen Thomas says Goodman was fired for breaking patient confidentiality rules.

Supply and demand

Hospitals generally say they haven't hired more nurses because they are in short supply. They also blame financial pressures, such as technology costs and cuts in government and insurance reimbursements. Most oppose hard-and-fast limits on how many patients nurses may handle.

"Mandating a number doesn't make those nurses appear," American Hospital Association spokeswoman Amy Lee says. "We feel that is trying to force what needs to be flexible into a one-size-fits-all model."

Finding enough qualified RNs will remain tough: The U.S. Department of Health and Human Services projects the current shortage of a few hundred thousand RNs could hit 750,000 by 2020, as aging Baby Boomers need more care and the nursing work force gets older.

But nurses' unions are battling for laws or contracts setting nurse-patient ratios. Several unions have held lengthy strikes over staffing ratios, including one that began Nov. 14, 2002, at Northern Michigan Hospital in Petoskey, Mich. Some nurses have temporarily taken jobs as far away as Hawaii rather than cross the picket line, which has endured through two frigid winters.

On the rise

Many nursing groups are looking to California as a model for nurse ratios.

In January, it enacted the nation's first hard-and-fast ratios, ward by ward. An RN may care for six patients at most, and only four in the ER and two in critical care units. The not-for-profit Kaiser Permanente system, with 28 California hospitals, hired about 3,000 more RNs to meet the new rules.

Six other states - Florida, Kentucky, Nevada, Oregon, Texas and Virginia - have enacted staffing regulations but not ratios, and 18 states introduced some staffing legislation last year, according to the American Nurses Association.

Many hospitals are recruiting and training more foreign-born nurses. And Johnson & Johnson has devoted more than $25 million since 2002 to fund nursing scholarships and improve nursing's image.

Experts say the union, hospital and foundation efforts are helping entice former hospital nurses back and draw new people into nursing. Now applications at many nursing schools are up so much students are turned away for lack of space or teachers.

The weak economy, hefty retention bonuses and a big pay jump also are big draws.

In New Jersey, for example, RN salaries rose 25 percent in three years to a statewide average of $29.42 per hour, says Barbara Tofani, director of the Center for Nursing and Health Careers at the New Jersey Hospital Association. It works with hospitals on retention strategies, ranging from mentorships to employee appreciation efforts.

"Hospitals are listening now to their staff nurses," Tofani says.