Hospital To Nurses: Your Injuries Are Not Our Problem | KUER 90.1

Hospital To Nurses: Your Injuries Are Not Our Problem

Feb 18, 2015
Originally published on February 25, 2015 3:09 pm

The case of Terry Cawthorn and Mission Hospital, in Asheville, N.C., gives a glimpse of how some hospital officials around the country have shrugged off an epidemic.

Cawthorn was a nurse at Mission for more than 20 years. Her supervisor testified under oath that she was "one of my most reliable employees."

Then, as with other nurses described this month in the NPR investigative series Injured Nurses, a back injury derailed Cawthorn's career. Nursing employees suffer more debilitating back and other body injuries than almost any other occupation, and most of those injuries are caused by lifting and moving patients.

But in Cawthorn's case, administrators at Mission Hospital refused to acknowledge her injuries were caused on the job. In fact, court records, internal hospital documents and interviews with former hospital medical staff suggest that hospital officials often refused to acknowledge that the everyday work of nursing employees frequently injures them. And Mission is not unique. NPR found similar attitudes toward nurses in hospitals around the country.

Documents from Cawthorn's court case tell her story.

It was in the afternoon on her 45th birthday. A large patient had just had a cesarean section, and Cawthorn was helping move her from the gurney onto her bed — a task that nursing employees perform thousands of times every day.

"She kind of had one cheek on the bed, one cheek on the stretcher, and we [were] trying to help her," Cawthorn says. To demonstrate, Cawthorn bends her knees and crouches, keeping her back straight. She extends her arms like railings, as though she's holding them out for the patient to grip.

"And the second she grabbed on, almost instantaneously I felt like hot tar was just going down my spine, into my butt," Cawthorn says.

By the time she left work that day, she could hardly walk — or drive. Her husband had to lift her out of her car and carry her into their home, and lay her on the floor. Cawthorn could see the birthday flowers and pink cake her family had made on the dining table. "And I'm just on the floor, in tears," says Cawthorn, "in so much pain."

Cawthorn took painkillers and made it back to work the next morning, and reported the injury to her supervisor. Then she hurt her back again barely a week later when she lifted another patient. She injured her back a third time a few days after that. And nine months later, Cawthorn herself became the patient in the hospital where she worked: She had a "lumbar interbody fusion," an operation in which the surgeon built a metal cage around her spine.

State laws require companies to cover employees' medical bills when they are injured doing their jobs. Companies also have to pay workers' compensation to support injured employees while they're missing work — and missing their paychecks.

But officials at Mission refused to help Cawthorn. According to court documents, the hospital's own medical staff concluded that she was hurt moving patients. But the hospital's lawyer disagreed, arguing that Cawthorn actually hurt her back partly while lifting a dinner casserole out of her oven.

Mission hospital officials also said that as a result of Cawthorn's back injury she was no longer fit to work. Cawthorn and her husband say she was lying in her hospital bed two days after back surgery, when a hospital representative walked into her room and handed her a document. It announced that Mission was terminating her job.

"They actually saved themselves the postage," Cawthorn says, looking as if she's about to cry. "And I was so emotionally destroyed. Nursing's not just a job. It's who you are."

As Cawthorn and her husband, Tucker, talk about her painful saga, they're sitting at home in a small town about a 30-minute drive from Asheville. The refrigerator is covered with photos of their family, which show a dramatically different Cawthorn than the woman sitting now at her dining table.

The woman in the photos taken six and seven years ago, just before she got injured, is fit and healthy-looking. But on this day, she has arms like sticks, and dark patches under her eyes. She and her husband say she lost 40 pounds after she got hurt — and only recently has been able to regain 7 of them. Cawthorn says for the first three years after the incident, just the thought of how it changed her life and how officials at Mission responded was so painful that she couldn't talk about it.

"I would just cry," Cawthorn says. "I'd cry, and cry and cry."

There's no evidence that Mission's employees get injured more than staff do at other hospitals. As NPR's Injured Nurses investigation reveals, hospitals are not generally required to make their injury statistics public, so it's difficult to compare them. NPR also found that officials at most hospitals across the country have failed to do much about the epidemic of back and other injuries that affect their nursing staff.

Researchers in the health care industry say there are a few main reasons why.

One reason is money.

"It's been a tough couple decades for the hospital industry," says Daniel McChesney, co-founder of DeciBio, a health care industry research firm.

Nursing employees have very likely been getting hurt moving and lifting patients for as long as there have been nurses and patients. But studies by the U.S. government and university researchers in the 1990s began showing that hospitals can prevent many of those injuries, if hospital administrators invest enough time and money. They have to buy special equipment to move patients, such as powered ceiling hoists, and they have to conduct intensive training for the staff.

Some hospitals have purchased a limited amount of equipment and conducted some staff training, researchers say, but most have not taken aggressive steps to protect their nursing staff — partly because they are preoccupied with other problems.

"Their revenues have been stagnant or dropping and the costs have been going up," McChesney says.

Consider just a few of those costs. Many hospitals have to spend millions of dollars on measures to prevent patients from getting infections, says Bruce Vladeck, former administrator of Medicare and Medicaid. The federal government does not reimburse hospitals for treating patients who acquire infections on their watch.

Under federal laws, hospitals also have to computerize their medical records. That can cost "at least tens of millions of dollars in a large hospital system, and in some instances hundreds of millions of dollars," says Vladeck.

James Collins, a research manager in the Division of Safety Research at the National Institute for Occupational Safety and Health, says that safety and health officers in hospitals have told him frustrating anecdotes: They've tried to persuade their bosses to launch major campaigns to prevent nurses from getting hurt lifting patients, but their pitch goes nowhere.

Collins says safety directors tell him, " 'Just when I think I've got the CEO sold that we need [to spend] the funds for this comprehensive safe patient lifting program, in comes the chief of surgery describing the latest laser to improve his surgical outcomes.' " Collins says the surgeons inevitably get the money — which is often good news for patients — but the proposal to protect nursing employees goes "back at the end of the line."

Finances aside, some researchers say there's a social and political reason that protecting nurses is often not a top priority.

"Hospital administrators — too many hospital administrators — view nurses as second-class citizens," says Suzanne Gordon, author of Nursing Against the Odds. Gordon, who has been writing books about health care issues for 30 years, gives workshops at hospitals about the dynamics among administrators, physicians and nursing employees. She points to the ways that television and movies portray nurses as one way to understand their lack of status in society.

For instance, in the movie Meet the Parents, the protagonist, Greg, meets his girlfriend's family and their doctor friends:

"Greg's in medicine too," the girlfriend's father tells them.

"Oh, really?" they exclaim. "What field?"

"Nursing," Greg answers.

And everybody laughs.

"No, really," one says. "What field?"

It's just a Hollywood comedy, but Gordon says nurses don't have much clout partly because of gender. Ninety percent of nursing employees are women, while almost 70 percent of physicians are men, according to Department of Labor statistics.

And Gordon sees another troubling issue: Hospital administrators and the medical industry have traditionally devalued nurses.

"Historically," Gordon says, "hospital administrators viewed nurses as a disposable labor force" — even though there have been cyclical nursing shortages.

So, when hospitals cut costs, nursing staff is often among the first to go. For example, there have been layoffs in recent years at hospitals including the University of Massachusetts Memorial Health Care, Children's Hospital and Clinics of Minnesota, and Kaiser Permanente in California.

That's the national context in which the battle between Cawthorn and Mission Hospital played out in North Carolina. Cawthorn says she'll never forget the day that one of Mission's administrators told her that the hospital was not responsible for her back injury and would not cover her medical bills or workers' compensation. "I was so mad," Cawthorn says. "I was yelling at her, 'What is going on?' "

Ask Joshua Klaaren, a physician's assistant who worked in Mission's staff health clinic for six years, until late 2012. Klaaren says it was "pretty common to see nurses and [nurses' assistants] who have hurt their back, who have pulled their back with managing patients, moving patients, lifting patients, sliding patients. It [was] very, very, very common." Klaaren and his fellow occupational health specialists would conclude that those employees had been injured on the job.

But Klaaren says it also was "commonplace" for hospital officials to ignore what their occupational medical staff said. In fact, Klaaren and other medical specialists from Mission's staff clinic — who talked only on condition that we withhold their names, for fear of retaliation — told NPR that whenever they examined injured employees, they were required to fill out a form with the employee's name, date of injury, and diagnosis, followed by a section with two boxes: "In our opinion, injury or illness is" or "is not work related."

Hospital officials ordered the occupational health staff not to check either box, Klaaren and other sources told NPR. Instead, hospital administrators filled them out — even if they had not seen the injured employee.

The doctor who ran the staff health clinic, J. Paul Martin, warned Mission's executives for years that the hospital was mistreating injured employees, according to dozens of internal hospital emails and other documents obtained by NPR. The doctor's emails went to Mission's vice president and general counsel, the chief of staff, a member of the board of directors, and others.

One of the doctor's emails warned that the way the workers' compensation department was operating "shakes the very foundation of quality and patient safety." In another email, Martin called a decision by the workers' compensation department "mean-spirited." Martin, the hospital's top occupational health specialist wrote: "I cannot stand by and watch our employees treated that way."

Hospital executives told Martin, in effect, that these issues were not his concern, according to the documents. Martin declined to be interviewed for this story.

But there are public court records that scold Mission Hospital for mistreating injured employees. Every state has a workers' compensation court, so injured employees can appeal if a company won't help them. North Carolina's court — the North Carolina Industrial Commission — and the state Court of Appeals have ruled repeatedly in recent years that Mission Hospital refused to help injured nurses and others despite clear evidence that they got hurt on the job.

For example, the court ruled in 2002, in the case of an injured employee named Jennifer Rosenfelt, that Mission's refusal to cover some of her medical care was "based upon stubborn, unfounded litigiousness." The court ruled in 2004, in the case of another injured employee named Jeanne Chellis, that hospital officials "acted in bad faith" by not sharing evidence.

In Cawthorn's case, the workers' compensation court declared in 2011 that the way key officials at Mission Hospital treated her "constitute[d] fraud" — because they refused to pay her workers' compensation benefits "when they knew she was entitled to the same." In 2012, judges on the workers' compensation court got so upset with Mission in the case of an injured employee named Cathy Goff — they said the hospital had given the court information that was "not credible" and even "false" — that they said Mission should be investigated for fraud.

"What is particularly disturbing is that this is a hospital," says Douglas Berger, who served as a judge on the state workers' compensation court for 10 years. "This is a hospital who you would think, out of all the corporate actors, would be the most sensitive to treating injured workers fairly and decently."

Berger, now a lawyer in private practice, says he doesn't know why Mission's officials treated injured employees that way, but he says companies that don't support injured workers often do it for a simple reason.

"The view is, for every dollar I prevent going to a worker, that's more dollars for the company," Berger says. "Every [penny] I spend on a worker is less money I can spend elsewhere in the hospital."

Mission Health's own reports show that the corporation has been spending millions of dollars to expand its business. During the past decade, Mission has taken over or merged with five other hospitals. It has taken over doctors' practices, and other medical firms. A Mission spokesman told a national meeting a few years ago, "We're kind of the 500-pound gorilla" in the region. Someone recorded that and leaked it, along with other unguarded comments. The spokesman resigned.

Ron Paulus, Mission's CEO, told NPR that he didn't know about the workers' compensation cases involving Cawthorn and other employees when he took over in 2010. But he says as soon as he learned about them, he told his staff to forget the past and focus on creating a compassionate culture at Mission.

"Whatever is the truth or not the truth about all this different stuff, staff injuries — from the standpoint of, first, the humanity of that injury — these are family members, part of our team," Paulus says. "We want people to be productive and effective." That requires them to be healthy, he says.

Paulus says he has launched new training programs for the staff. He hired an outside consultant to analyze how hospital officials have handled workers' compensation cases since he took over — and Paulus says that Mission got a glowing report.

NPR asked for a copy of the report, but a spokesman for the hospital declined, saying, "This report is for internal use only and is not provided to third parties."

Paulus also says that the hospital has spent a "significant" amount of money to buy machines that move and lift patients, so the nursing employees can save their backs. "When you look at nurses and patients," says Paulus, "nurses have the most interaction with patients of any caregiver on the team. And nurses are ... the most trusted people in all of health care. So when I think about how I look at care delivery within Mission Health, nurses are front and center."

Five nurses and other medical employees who still work with Mission, or worked there long after he took over, say that perhaps Paulus has changed the message "at the top." But they haven't seen much sign of change taking place at the hospital.

It's been almost seven years since Cawthorn injured her back lifting patients. She's still shaky sometimes when she walks. But she and her husband say her saga damaged more than her physical health: The way Mission Hospital treated her also broke part of their spirit.

"I really thought that I was someone to Mission," she says. "I had poured my life into nursing. And when I got hurt, I meant nothing. I was absolutely nothing to the hospital."

NPR's Robert Benincasa, Lydia Emmanouilidou, Samantha Sunne and Barbara Van Woerkom contributed reporting and research to this story.

Copyright 2015 NPR. To see more, visit http://www.npr.org/.

Transcript

AUDIE CORNISH, HOST:

Hospitals could be dramatically reducing the rate of injuries incurred by nurses. But an NPR investigation finds protecting staff in this way is rarely a top priority. As we've been reporting this month, tens of thousands of nursing employees get debilitating back and arm injuries every year from lifting and moving patients. NPR's Daniel Zwerdling has the next installment of our investigation.

DANIEL ZWERDLING, BYLINE: We're going to tell you now about the case of Terry Cawthorn at Mission Hospital in Asheville, N. C. NPR obtained court records and other evidence about Cawthorn and other workers' admission. And they give a rare glimpse of how some hospital officials have refused to acknowledge that the everyday work nursing employees do - the way they lift and move patients - that work frequently injures them. Cawthorn had been a nurse at Mission Hospital for more than 20 years.

TERRY CAWTHORN: I was one of the hardest working nurses you would ever meet.

ZWERDLING: And you don't have to take Cawthorn's word for it. Her supervisor testified under oath that Cawthorn was one of the best.

TERRY CAWTHORN: Never missed work, came in early, stayed late - I loved being a nurse.

ZWERDLING: On this afternoon, we are talking at Cawthorn's home in a small town outside Asheville. The refrigerator is covered with photos of her family. And they show Terry Cawthorn before the injury. She looked fit, radiant. Today, her arms are sticks. She has dark patches under her eyes. She and her husband say she's lost 33 pounds since she got injured.

TERRY CAWTHORN: The first three years, I couldn't even talk to somebody about it. I would just cry. I'd cry and cry and cry.

ZWERDLING: Have you noticed how Cawthorn sometimes talks slowly? It's because she's in constant pain and she takes high doses of prescription narcotics. Terry Cawthorn ended up taking legal action against Mission Hospital. And court documents tell the story. It was afternoon on her 45th birthday - 2008. A large patient had just had a cesarean section, and Cawthorn was helping move her from the gurney onto her bed.

TERRY CAWTHORN: And she kind of had one cheek on the bed, one cheek on the stretcher. And we had it tilted and things, trying to help her. I'm just going to show you, because we are taught this in nursing school. This is a position...

ZWERDLING: And to demonstrate, Cawthorn bends her knees. She keeps her back straight. And she extends her arms like railings for the patient to grip.

TERRY CAWTHORN: And the second she grabbed on, almost instantaneously I felt like hot tar was just going down my spine into my butt.

ZWERDLING: Cawthorn says by the time she left work, she could barely walk.

TUCKER CAWTHORN: I saw the car drive up on top of the hill.

ZWERDLING: That's Cawthorn's husband. Tucker is a big man.

TUCKER CAWTHORN: I went up the hill, and she could not get herself out of the car. So I wedged myself under her legs and her back, and I eased her out of the car as best I could. And I carried her down the sidewalk into the house - laid her down on the floor.

ZWERDLING: Cawthorn took painkillers and made it back to work the next morning. She reported she was hurt. Then she hurt her back again barely a week later when she lifted another patient. She injured her back a third time a few days after that. And nine months later, Cawthorn became a patient in her own hospital. She had major back surgery called a lumbar interbody fusion. She shows me the x-ray. There's a metal cage around her spine.

TERRY CAWTHORN: Pretty wild to think that that's true to size.

ZWERDLING: Now, state laws say that when an employee is injured badly enough on the job, their company has to pay their medical bills and workers' compensation. But officials at Mission refused. Court papers showed that the hospital's own medical staff concluded that Cawthorn got hurt moving patients, but the hospital argued, no, she hurt her back partly by lifting a casserole out of her oven. And hospital officials said as a result of Cawthorn's back injury, she was not fit to work.

TERRY CAWTHORN: They actually saved themselves the postage and brought the paper that I was let go.

ZWERDLING: I want to get the timing right. You are literally lying in the hospital room two days after major back surgery.

TERRY CAWTHORN: Right.

ZWERDLING: Someone from Mission Hospital comes to your room and gives you the paperwork saying goodbye. Your job is finished.

TERRY CAWTHORN: Yeah. I was so emotionally destroyed. Nursing's not just a job. It's who you are.

ZWERDLING: There's no evidence that Mission's employees get injured more than staff do at other hospitals. But we're focusing on Mission in this story because we got an unusual look inside this one hospital's culture. We obtained court documents and internal hospital emails. We talked to medical staff who treated injured employees. Of course, remember, Mission's not the only hospital with injured nurses. Officials of hospitals across the country have failed to do much about the problem. And industry researchers say there are a few main reasons why. The first is money.

(SOUNDBITE OF VARIOUS NEWS BROADCASTS)

UNIDENTIFIED WOMAN #1: Tonight's top story - a healthcare crisis in the Berkshires.

UNIDENTIFIED MAN #1: The North Adams Regional Hospital is shutting down.

DANIEL MCCHESNEY: It's been a tough couple decades for the hospital industry.

ZWERDLING: Daniel McChesney is co-founder of an industry research firm called DeciBio. Studies started showing decades ago that hospitals can prevent nursing injuries if they're willing to invest time and money. They have to buy special equipment to move patients. And they have to do intensive training for the staff. But McChesney says most hospital executives are preoccupied with other problems.

MCCHESNEY: Their revenues have been stagnant or dropping, and the costs have been going up.

ZWERDLING: Talk about hospitals' costs - they have to prevent infections and computerize their records. And that can cost millions of dollars. They need to invest in new technology. Some hospitals are buying up other hospitals to get bigger and maybe better. So James Collins says no wonder nurses' injuries fall between the cracks. Collins is a research manager at the CDC, the Centers for Disease Control and Prevention. He studied nurses' injuries, and he says safety directors in hospitals have told him, look, we've tried to convince our bosses our hospital needs to prevent nurses from getting hurt lifting patients. But they tell Collins...

JAMES COLLINS: They say when I think I've got the CEO sold that we need to expend the funds for this comprehensive, safe patient-lifting program, in comes the chief of surgery describing the latest laser to improve his surgical outcomes. And he gets the check, and then we're back in the end of the line trying to get out funds next year.

ZWERDLING: To protect the nursing staff.

COLLINS: Right.

ZWERDLING: And some researchers say there's one more reason why protecting nurses is not often a top priority.

(SOUNDBITE OF FILM, "MEET THE PARENTS")

ROBERT DE NIRO: (As Jack Byrnes) Hey, hey, look who's up.

TERI POLO: (As Pam Byrnes) Hi, sweetie.

BEN STILLER: (As Greg Focker) Hi.

JAMES REBHORN: (As Dr. Larrry Banks) You must be Greg.

ZWERDLING: Did you see "Meet The Parents?" In this scene, Greg - he's played by Ben Stiller - Greg meets his girlfriend's family and their doctor friends.

(SOUNDBITE OF FILM, "MEET THE PARENTS")

DE NIRO: (As Jack Byrnes) You know, Greg's in medicine, too, Larry.

REBHORN: (As Dr. Larrry Banks) Oh, really? What field?

STILLER: (As Greg Focker) Nursing.

(LAUGHTER)

REBHORN: (As Dr. Larrry Banks) That's good. No, really, what field?

STILLER: (As Greg Focker) Nursing.

ZWERDLING: OK, that movie's just a comedy. But Suzanne Gordon says that hospitals and the medical industry have traditionally devalued nurses.

SUZANNE GORDON: Hospital administrators - too many hospital administrators - view nurses as second-class citizens.

ZWERDLING: Gordon's been writing books about nursing issues for 30 years.

GORDON: Historically, hospital administrators viewed nurses as a kind of disposable labor force.

ZWERDLING: Gordon says it's partly because of gender - 90 percent of nursing staff is women. And that's partly because of class. Nurses and nursing assistants don't have much institutional clout, so when hospitals cut costs...

(SOUNDBITE OF NEWS SEGMENT)

UNIDENTIFIED MAN #2: Children's Hospital and Clinics of Minnesota is laying-off nurses.

ZWERDLING: Nursing employees are some of the first to go - except during cycles when there's a nursing shortage. And that brings us back to Terry Cawthorn and Mission Hospital in North Carolina. Remember, court documents show that Mission's own medical staff concluded that Cawthorn injured her back moving patients. She had surgery with metal plates and screws. But one of the hospital's officials basically told her, no, we're not responsible for your injury. And the hospital fired her.

TERRY CAWTHORN: I was so mad. I was yelling at her going you can't do this to me. What - what is going on?

ZWERDLING: After the break, we'll take you to Mission Hospital and we'll tell you what was going on.

(SOUNDBITE OF MUSIC)

CORNISH: We're going to return to our story about a nurse named Terry Cawthorn and Mission Hospital in Asheville, N. C. As NPR's Daniel Zwerdling has been reporting, hospitals across the country haven't done very much to protect their nursing employees from getting hurt. Nurse Terry Cawthorn was injured so badly she had to have a gruesome back surgery. Leaders at Mission Hospital insisted they weren't responsible, and they fired her. Daniel picks up the story.

ZWERDLING: Our investigation found that officials at Mission Hospital often refused to acknowledge that nurses and other staff kept getting hurt doing their jobs - just talk to the medical staff who treated them.

JOSHUA KLAAREN: My name is Joshua Klaaren. I'm a physician assistant, and I worked at Mission Hospital.

ZWERDLING: Joshua Klaaren worked in the employee health clinic admission for six years. He left in late 2012. When nurses and nursing assistants got hurt, when any worker's admission got hurt, they would go to see Klaaren and the other clinic staff. That's what Terry Cawthorn did.

KLAAREN: It's pretty common to see nurses and CNAs who have hurt their back, who have pulled their back with managing patients, moving patients, lifting patients, sliding patients. It's very, very, very common.

ZWERDLING: Did you personally examine employees at Mission Hospital - nurses and others - who you felt were injured at work, that they probably did deserve workers' compensation, but then the hospital denied?

KLAAREN: Yes, that was commonplace.

ZWERDLING: Commonplace?

KLAAREN: Yes.

ZWERDLING: NPR has obtained dozens of internal emails from Mission Hospital. And they show that the doctor who ran the employee health clinic kept warning executives for years our hospital is mistreating injured employees. Those emails went to the hospital vice presidents and the general counsel and a member of the board of directors. But hospital officials basically told the doctor this is not your concern.

We called the doctor. His name is J. Paul Martin. He declined to be interviewed for this story. But there are public court records that scold Mission Hospital for mistreating injured workers.

DOUGLAS BERGER: What is particularly disturbing about this situation is this is a hospital.

ZWERDLING: Douglas Berger was a state judge for 10 years. He served on North Carolina's workers' compensation court. Every state has a workers' comp court so injured employees can appeal if a company refuses to help them. North Carolina's court has ruled over and over again that Mission Hospital refused to help injured nurses and others who got hurt on the job. Just read the cases - in 2002, 2004, 2006, 2011, again in 2012. Berger wrote in one decision that the hospital's refusal to cover an injured employee's medical care was based upon stubborn, unfounded litigiousness.

BERGER: Stubborn, unfounded litigiousness? They were acting in bad faith.

ZWERDLING: The courts said officials made a conscious attempt to mislead Terry Cawthorn so she wouldn't understand that she deserved workers' compensation. They said that's fraud. And the court ordered Mission to pay penalties to punish them. Berger says he can't read the minds of Mission's executives, but companies that don't support injured workers often do it for a simple reason - money.

BERGER: The view is, for every dollar I prevent going to a worker, that's more dollars for the company. Well, every money I spend on a worker is less money I can spend elsewhere in the hospital.

ZWERDLING: And Mission's own reports show that the company has been spending millions of dollars to expand its business.

(SOUNDBITE OF NEWS SEGMENT)

UNIDENTIFIED MAN #3: CarePartners Health Services announces this morning it will merge with Mission Health.

ZWERDLING: Over the past decade, Mission has taken over or merged with five other hospitals. It's taken over doctors' practices and other medical firms. Mission's own spokesperson told a national meeting a few years ago we are kind of the 500-pound gorilla in the region.

UNIDENTIFIED WOMAN #2: You have a phone call. It's a pre-op.

ZWERDLING: I went to see the chief executive officer who runs Mission Hospital. His name is Ron Paulus. He's a doctor. To get to his office, you walk into the huge main building through the lobby and up to the executive floor. Paulus says, look, when he took over Mission back in 2010, he didn't even know about all those court cases involving injured employees. But he says as soon as he heard, he essentially told his staff forget the past. We are establishing a new culture here.

RON PAULUS: Whatever is the truth or not the truth about all this different stuff, staff injuries, from the standpoint of, first, the humanity of that injury - these are family members, part of our team. But also, because we want people to be productive and effective, so yes, these are very important.

ZWERDLING: Paulus says to make sure that everybody gets that message, he launched new training programs for the staff. He hired an outside consultant to analyze how has the hospital handled worker's compensation cases since Paulus took over. He says Mission got a glowing report. And he says the hospital has spent what he calls a significant amount of money to buy machines that move and lift patients so nursing employees can save their backs.

PAULUS: When you look at nurses and patients, nurses have the most interaction with patients of any caregiver on the team. And nurses are the most trusted. So when I think about how I look at care delivery within Mission Health, nurses are front and center.

ZWERDLING: After I met with Paulus, I talked with a handful of nurses and other medical staff who still work with Mission or who worked there long after he took over. And they said maybe Paulus has changed the message at the top, but we haven't seen much change. And remember that outside report that Paulus commissioned which he said shows that Mission is doing a great job handling injured employees? Will you give me the copy of this outside independent review?

PAULUS: I don't have a copy of that, and I'll discuss that internally.

ZWERDLING: The hospital spokesperson emailed me later. They will not give me the reports.

TERRY CAWTHORN: That is how the top of the screw is, so it's got...

ZWERDLING: Back at Terry Cawthorn's house - this nurse who worked at Mission for more than 20 years - has better days and worse days. She helps her husband Tucker with his bookkeeping. He repairs air conditioners. She's sometimes shaky when she walks. But they say she's lost more than her health. They say the way Mission Hospital treated her broke part of their spirit.

TERRY CAWTHORN: I really thought that - that I was someone to Mission. And when I got hurt, I meant nothing. I was absolutely nothing to the hospital.

TUCKER CAWTHORN: This - this change has been incredible so far as our lives go. When she was telling her story a while ago and she started (crying) - she started with the day she got injured. It still breaks my heart, because that's the day that changed (crying) - changed our lives.

ZWERDLING: Meanwhile, Mission reports it's still expanding. The company is opening new clinics in two counties and is building a new center for doctors in telemedicine. The company's CEO says it's all designed to take better care of patients. Daniel Zwerdling, NPR News.

CORNISH: Next week, the surprising hospital that is spending millions to prevent nursing injuries. Transcript provided by NPR, Copyright NPR.