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John Peter Smith hospital's emergency room is part of a state-of-the-art medical pavilion, open less than a year. But conditions in the ER's "green room," as described recently by one nurse, sounded more like those of a one-doctor hospital in the middle of an epidemic.

"There were a couple of times when I thought patients were going to start a riot in there," nurse Joe Snow said. "It's like you're taking care of a small town with only two nurses and one technician at a time. ... One man can't take care of an entire army."

The "green room" is where patients whose ailments have been deemed not immediately life-threatening are sent to be screened while they wait for further treatment ... and wait and wait.

Snow, who has worked in the ER for almost five years, described angry patients complaining that their conditions were worsening after waiting as long as 15 or 16 hours to see a doctor. He said he's seen as many as 80 patients parked there with only two overwhelmed nurses to attend to them. Then there are the patients who somehow slip through the cracks of initial triage evaluations and end up waiting in the green room when they should have gone straight to an ER bed. He talked about conditions so overcrowded and stressful that more than a dozen nurses quit their jobs in the first two months after the new emergency room opened, for fear that they would lose their licenses if something happened to a patient due to the overcrowding and woefully inadequate staffing.

He didn't expect a Sunday tea party when he signed up to work at a county hospital ER, Snow said, but he never imagined it would be so disorganized. "I understood that when we first moved, there would be growing pains," he said. "I thought that it would be bad, but it was worse than I ever expected."

Snow and other JPS emergency room nurses have been so frustrated and scared by ER conditions that they did something that nurses may have never done before in a Fort Worth hospital: They organized so that they could speak as a group. And then they took public action.

In recent weeks, the nurses drafted a petition asking for more staff to be assigned in the green room. And last month, they mailed the petition to management, signed by 28 of the hospital's 55 ER nurses.

They didn't do it without fear. In fact, one petition organizer said every ER nurse he spoke to supported the petition's aims; the ones who declined to sign did so out of fear for their careers. Every nurse interviewed by Fort Worth Weekly for this story said that people in their profession live with the constant threat of retaliation if they raise concerns. In Texas, they have a phrase for one such tactic. It's called being "Group One'd," referring to the name of an organization that does background checks on hospital employees and, so nurses believe, is responsible for blacklisting anyone who speaks up.

So why did the nurses step forward this time? Not because conditions at JPS' emergency room are worse than they've ever been; problems there are somewhat legendary.

In part, it was due to the arrival of new CEO Robert Earley, who took the reins at the public hospital and cleaned house. Under his leadership, they felt they might be listened to. Earley, still in his honeymoon period as the CEO, has promised change, and some of the nurses who signed the petition see it as a way to test his sincerity.

But the other part of the equation reaches beyond JPS, to a statewide and national movement. Elsewhere in Texas and around the country, groups of nurses are acting together to work for better patient care, better pay, and better hospital staffing and against what they see as unfair treatment by hospitals. They're fighting via legislation, lawsuits, petitions, and - even in right-to-work states like Texas - through unionizing.

At JPS, the ER nurses are working with an organization called the National Nurses Organizing Committee, a California-based nurses' advocate group. Many of the ER nurses are members of the group, which is helping them organize and deal with management. The NNOC does help nurses unionize, but it's also a professional organization that advances nurses' concerns through legislation and provides support to nurses who are advocating for patient safety, as is the case at JPS.

NNOC officials are quick to point out that although the JPS nurses are not yet seeking to form a union, they are acting collectively as a union would. In a state where many leaders view unions only slightly more favorably than the Communist Party, NNOC officials say that is a huge step forward.

In California, a law passed a few years ago mandates a patient-to-nurse ratio of 4 to 1 in hospitals; a similar bill is being considered by the Texas Legislature. At a hospital in Houston, the first nurses' union in Texas has been formed.

Last February, three of the nation's biggest nurses' unions combined their efforts and converged on North Texas. The NNOC, along with the California Nurses Association and the Massachusetts Nurses Association, are in the process of merging into the United American Nurses-National Nurses Organizing Committee, which will boast a combined 150,000 members.

According to Shum Preston, a spokesperson for the NNOC, Texas has become the epicenter for the nurses' union movement. He said there are 10,000 nurses participating in some form of activism in the state. There have already been three marches on the state capitol, with somewhere between 300 to 600 nurses turning out each time to advocate for a better work environment. In their efforts to mobilize Texas nurses, the NNOC has lobbied legislators, sponsored online petitions, run phone banks, and held nurse-led community meetings.

"Texas is one of the hot spots for nurse organizing. It may be because conditions in Texas hospitals tend to be particularly oppressive compared to the national average, based on what I've heard," he said. "It's an exciting time for nurses in Texas."

But it's a tough row to hoe for nurses. Those interviewed for this story said they fear reporting agencies that they believe function like the healthcare profession's own mafia. Organizations like Group One are often used by managers as a way to keep nurses in line and get them to work in conditions that might be unsafe, nurses said. In some cases, a black mark on a nurse's Group One report can be career-ending. Even Group One officials acknowledge that managers use the company as a threat, though they said they discourage that. And union-busting law firms employed by hospitals have made fortunes from tracking union activity and opposing it at every turn.

Patients who show up in John Peter Smith's ER are first evaluated by a triage nurse. If their health problems are critical, they go straight to an ER bed. Those whose complaints don't seem to be immediately life-threatening are diverted to the green room. For example, if a patient comes in with chest pains, but an EKG examination determines that it is not a heart attack, that patient goes to the green room and receives x-rays, lab work, and a variety of other tests and surveys that don't require a doctor. The patients are then seen in order of severity of their problems, according to protocol.