When it was reported on March 1 that 20 patients at St. Luke's hospital had suffered "reportable" pressure ulcers during the course of a year, Susie Moss took it personally.

Moss is a registered nurse in the intensive care unit at St. Luke's. She knew most of those pressure ulcers had occurred in her unit.

"I work with a really great team of people that really, truly care and provide excellent care, skilled care, to these people," Moss said last week. "And when I reflect back, (it is not) that nurses neglected the patients."

St. Luke's isn't blaming its nurses for the pressure ulcers. Jessica Stauber, a spokesperson for the hospital, said in a statement that equipment has been identified as a contributing factor, and the hospital is working with its vendors to address the problem.

Moss identified the equipment as expensive new beds in the ICU. But she's not convinced the problem lies only with equipment.

"I think it's irresponsible of us not to consider that it's possible staffing may have played a role in the development of those pressure ulcers," she said. "If we increase staffing, will we see a drop in pressure ulcers? I heavily believe that we would."

Moss and two other nurses - another from St. Luke's and one from Essentia Health-St. Mary's Medical Center - met with a reporter last week to express concern about what they say is a shortage of nurses and nursing assistants in their facilities. They say they are working extra hours and extra shifts. They say they're getting help from fewer available nursing assistants, who often are pulled away from assigned duties to help care for the most needy patients.

"The night shift almost never has an aide," said Breanna Diedrich, a registered nurse in the orthopedics unit for St. Luke's. "Today, we had one aide for 30 patients on my floor."

The Minnesota Nurses Association, which facilitated the meeting, said other nurses were eager to talk. The number was kept small at the reporter's request, and one Essentia nurse had to cancel out at the last minute.

Although Moss initially reached out to the News Tribune, the nurses' union said their Essentia members have similar concerns. The same report that found the 20 pressure ulcers at St. Luke's found two pressure ulcers at St. Mary's, each leading to serious injury, and a fall at St. Mary's that also led to serious injury.

Administrators at the two hospitals said they are doing everything they can to provide adequate staffing, but acknowledge it's a challenge.

"We are asking nurses to work overtime," said Cindy Kent, chief nursing officer for Essentia Health.

Essentia has hired 83 nurses for its Duluth hospitals since January, she said, although some of those were transfers from one unit to another.

"It's getting harder to hire staff in all disciplines - not just nursing," Stauber wrote. "We continue to innovate ... to maximize our success in recruiting and hiring qualified applicants."

But what the hospitals are doing hasn't been enough, said Chris Rubesch, a registered nurse in the post-coronary care unit at St. Mary's.

"My patients need staff to take care of them," Rubesch said. "Ultimately, I feel like it's the hospital's responsibility to make sure that there are licensed, well-trained nurses to provide that care."

There's no single number, such as a ratio of patients to nurses, that would demonstrate the understaffing that the nurses claim they're faced with. Instead, each unit comes to an agreement with management about the necessary "grid," or patient-to-nurse ratio, for their area of responsibility, the nurses said. In the ICU, a nurse is needed for every two patients, Moss said, and some patients require all of a nurse's attention. A nurse in orthopedics can cover 8-14 patients, Diedrich said.

Falling short of the grid is "a regular occurrence," Rubesch said.

"As is often the case on my floor and many others at both hospitals, if you don't have the staff to fill those grids, well, the patients keep coming," he said.

To help meet the need, Rubesch routinely works extra shifts, he said. Moss, who is scheduled for 12-hour shifts, has expanded those to 16 hours more often than not.

A unit's grid doesn't change if patients are sicker, Diedrich said, even though sicker patients require greater care.

Rubesch agreed.

"What I've seen just in the five years that I've been on my floor is that we are seeing patients who are sicker across the board," he said.

Kent said Essentia is working aggressively to hire nurses.

In addition to previously existing programs - nurse internships, offering positions even before nursing students graduate, a residency program for nurses interested in working in the ICU and tuition reimbursement - Essentia offered an off-site hiring event for registered nurses a couple of months ago, Kent said. It has a similar event scheduled next week for nursing assistants. And the health system is doubling down to interview all registered nurse applicants for its Duluth hospitals within the next two weeks.

"We are realizing that with our high volumes we need to be really creative to make sure that anyone who wants to work with Essentia Health has a really good experience with our hiring process, and also that we do it as quickly as possible," Kent said.

Stauber wrote that a particular challenge with nurses is that so few choose to work full time. Of St. Luke's 610 registered nurses in hospital patient care units, 489 work 32 hours per week or less.

"While we respect this choice, it does add to the challenge," Stauber wrote.

St. Luke's has implemented more 12-hour shifts based on staff requests, she wrote.

The hospital also introduced four-hour shifts for nursing assistants, since so many of them are also going to school, Stauber added. And it offers a tuition reimbursement program to encourage nursing assistants to stay at St. Luke's while in school.

Adam Kamp, a labor relations specialist for the Minnesota Nurses Association, acknowledged the efforts.

"I will say that we appreciate that both of the hospitals are trying to hire up to their census," he said. "We just want them to do more."

Regarding pressure ulcers, St. Luke's follows best practices, Stauber wrote, turning and repositioning patients who are at risk for skin breakdowns. In addition, one unit - at the initiative of nurses - recently has gone further by repositioning all patients every two hours during the first 24 hours of their stay, regardless of their risk.

The hospital is responding to the issue, Diedrich agreed.

"I believe that the hospital is reacting in a positive manner toward these incidents," she said. "But again, you need people to do that. You need RNs and aides and LPNs to do all these things."