When you're a nurse offering critical care, you see sad things...cruel things...scary things.

"Like the 22-year-old I cared for who'd just come home from war, only to get testicular cancer and die from chemo complications," says Kathy Montanino, an R.N. of 20 years in Riverside County. "Or the 13-year-old killed by a drunk driver, the mom stabbed by her kids, another mom beaten so badly by her husband that she couldn't hold her head up in bed.

"You can't pay someone to do this job."

Clearly, Kathy does this job for other reasons. She tears up as she remembers these and other patients.

"When I started college, I thought I wanted to be a psychologist," says Kathy, "but when I took courses like anatomy and physiology, nursing just clicked. I saw it as giving part of my spirit to people when they're in their worst moments. I think I was particularly well-equipped because I came out of a troubled family. I got married and then had kids when I was only 16. I have a completely nonjudgmental bedside manner."

And with that thoughtful bedside manner, Kathy provides care that leads to hopeful outcomes, too, not just sad and scary.

"Like the 28-year-old heroin addict who came in with sepsis from dirty needles. A year later, I got a letter from her that she was clean and attending college. We still keep in touch. And the 19-year-old who vomited clumps of blood after giving birth. She had a bleeding ulcer that had never been diagnosed. As she lay there intubated and sedated for several days, I would lay the baby on her chest to breastfeed. She recovered fully, went to dental school and her boy is now four. They visit us at the hospital every year to thank us for saving her life."

Very early in her career, though, Kathy noticed staffing issues in her hospital. She began her career in the Telemetry unit, where nurse-to-patient ratios should not go above four patients per R.N.

"But I didn't stay. The lack of nurse assistants and other support staff in the Telemetry Unit was dangerous. I thought about going to E.R.," says Kathy. "But I was offered a position in a program in the Intensive Care Unit where I shadowed and learned from an experienced ICU nurse for three months. It was a great opportunity and included rigorous coursework at the same time. I've been in ICU ever since."

Today, that three-month program has been slashed to only six weeks, is open to new grads and no longer requires the master nurse's recommendation before the trainee is released to work on the unit.

"I'm what they call a preceptor in that program, meaning I'm one of the experienced nurses taking a new nurse under my wing. I have real concerns with the program. A lot of us veteran nurses have brought up concerns. Cutting this important training time in half is a disservice to everyone: the patients, the new nurses and the rest of us on the unit," says Kathy. "The bottom line is: it's dangerous. And then there's the other bottom line--the financial one: the hospital doesn't want to pay two nurses--the trainer and the trainee--for the full three months."

For Kathy, nurses working on a unit without the proper competencies is just one of the staffing issues that concerns her. Sometimes there just aren't enough nurses and support staff on the floor.

"Here's just one example: I had a woman who'd come out of open heart surgery. These patients need a lot of coaching and coaxing to get out of bed and move. It's critical that they open their lungs to prevent pneumonia," says Kathy. "But, I had another patient who was much more critically ill and required a lot of my attention. And because we also didn't have sufficient Physical Therapy staff to help make sure my first patient moved, she ended up with pneumonia and an intestinal condition called ileus. I have no doubt that those secondary illnesses were directly caused by short staffing. It broke my heart. It was so unnecessary."

But finally, the main staffing concern for Kathy is simply having the time and resources to be there for patients and their families. Like the husband Kathy comforted as his wife died of cancer. "You really comforted me. I hadn't laughed in three months. I just was not ready to say goodbye to my best friend of 50 years," he told Kathy. Or the mom whose 18-year-old daughter was brain dead after a motorcycle accident. Kathy carefully walked the mom through all the signs, explaining that her daughter was no longer in that body.

"It was the worst pain in her life, but she was able to find enough peace to make the decision to donate her organs. I helped her to celebrate her daughter's contribution. I sat with her and cried. She wanted me there in the Operating Room when they disconnected her from life support and donated her organs. I was with the mom and two sisters. It's something I'll never forget," says Kathy. "This is why I care so much about staffing. Nurses can't give that care if we're so task-oriented, hurried and without resources."