Nurse, Interrupted

It's May 13, the day after Florence Nightingale's birthday, and as part of the annual celebration of Nurses' Week--established in part to commemorate Nightingale's role in the development of professional nursing--members of the Massachusetts Nurses Association have asked me to speak to a group of registered nurses (RNs) at the University of Massachusetts Memorial Health Care Campus in Worcester. Usually, such events are upbeat--occasions for flowery praise of America's largest predominantly female profession, which is also the largest profession in the health care system. Not today. The 30 or so middle-aged nurses who straggle into a bare auditorium look like they're attending a wake.

In a sense, they are. These RNs entered the profession with high expectations and a strong sense of purpose several decades ago, but the field they work in is no longer either patient- or nurse-friendly terrain. The health care system has changed, and nurses like the weary ones at this event feel they are unable to fulfill their historic mission of caring for the sick. "Nurses are simply exhausted," explains Kate Maker, an RN for 16 years, who works on an intensive care unit (ICU). "Patients can't survive without our services. But today we can't give them those services" because they are sicker, and there are more patients for each nurse to take care of.

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In the ongoing public debate about the quality of market-driven medicine, most criticism has focused on the deterioration of physician autonomy and of the doctor-patient relationship under "managed care." But health care cost cutting and competition are having an ever-more damaging impact not just on doctors but on the nation's 2.6 million RNs.

Hospital restructurings and downsizings have slashed bedside nursing staff--the backbone of the hospital--and have replaced RNs with poorly trained and poorly paid nursing assistants. Those RNs who remain at the bedside must now care for greater numbers of sicker patients who are assembly-lined through the hospital in shorter and shorter periods of time. Ironically, in an era when much attention is focused on the problem of medical errors, nurses no longer have time to be patients' 24-hours-a-day early-warning and early-intervention system. They no longer have time to get to know patients and respond to their needs. Even as the medical system as a whole becomes increasingly impersonal, nurses can no longer provide the level of comfort and compassion they once did.

The consequences of cuts in nursing care are extremely serious. Patients who could recover, don't. Preventable complications escalate. Some patients die. Moreover, as nurses are stretched too thin in the hospital and as patients are denied expert nursing care at home, the burden of care is shifted to unpaid, ill-prepared family caregivers.

Largely because of current conditions, veteran nurses are leaving the field and potential new entrants are being discouraged from joining the profession. Just as the population is aging and in need of more nursing care, the nation now faces a new nursing shortage.

More Patients, Fewer Nurses

As hospitals compete for managed care contracts and try to gain clout with insurers, cost cutting is moving more and more money away from the bedside. Faced with lower fees from both HMOs and Medicare, hospitals are desperate to save money. Since RNs represent 23 percent of the hospital work force and are the biggest share of labor costs (and are only 10 percent unionized), downsizing RN staff has become an irresistible cost-reduction strategy.

Over the past decade, hospitals have turned to expensive consultants who assure anxious hospital CEOs that their product is just like any other easily definable, measurable commodity. Change the production process, make operations more efficient, replace expensive employees with cheaper ones, and help those who remain to be more productive--you'll save money without sacrificing quality, consultants say.

Hospitals have thus downsized their RN staffs through layoffs or by attrition. They have also replaced RNs, who in 1996 earned on average $37,738 plus benefits, with unlicensed assistive personnel (UAPs), who earn 20 to 40 percent less.

No states regulate the education of nurse assistants. So someone with no high school diploma and a few hours of on-the-job training may change sterile dressings, insert urinary catheters, or clean tracheostomy tubes. Meanwhile these nursing assistants are actually practicing under the supervising RN's license; under state licensure rules, the RN can be held responsible for any mistakes made by aides working under his or her direction--and can lose his or her license as a result of those mistakes.

To make sure workers are productive, hospitals may also cross-train janitors, housekeepers, transport workers, and security guards to do nursing work. (That person changing your tracheostomy tube may be a janitor!) Studies report that hospital nursing staffs, which once consisted of 85-95 percent registered nurses and only 5-15 percent aides, are now only 80, 70--sometimes 50--percent registered nurses and up to 50 percent aides.

Hospitals often dispute nurses' claims that restructuring has resulted in fewer nurses at the bedside. The American Hospital Association (AHA) , for example, contends that the number of RNs employed in hospitals actually rose from 858,909 in 1992, to 901,198 in l997. But the association does not take account of where in the hospitals RNs are working. Hospitals provide the AHA only with aggregate FTEs (full-time equivalent positions), a number that includes all RNs regardless of whether they're involved in providing direct care or have purely administrative functions, such as dealing with insurance companies.

"Hospitals now have a cadre of RNs who are taking care of the charts, not the patients," says Jean Chaisson, a clinical nurse specialist at the Beth Israel Deaconess Medical Center in Boston. "On a floor with fewer RNs spread thinner, when I'm busy rushing one patient to the operating room, these case managers or utilization reviewers are not there to help make sure another patient isn't falling on the floor."

Besides, even according to the AHA's own statistics, when RN FTEs are calculated on a per-admission basis--reflecting the volume of patients and intensity of the patients' needs--their number declines slightly. This report explains that there are "fewer RNs particularly in markets with high managed care penetration."

Nurses like Chaisson tell us that their workload has increased and that they may be taking care of two or three times the number of patients they took care of in the past--perhaps 10 to 16 patients on medical surgical floors or three to four patients in ICUs.

The Institute for Health and Socio-Economic Policy (IHSP) recently analyzed 18.2 million California hospital discharge records and other data collected from state agencies and the hospital industry for the California Nurses Association. Between 1994 and 1997, there was an 8.8-percent increase in the average number of patients for which an RN cared, a 7.2-percent decrease in the number of RNs employed, and a 7.7-percent jump in the number of patients per staffed bed between 1995 and 1998.

The New York State Nurses Association reported similar findings when it surveyed its state's RNs. Twenty-two percent of the nurses who responded said they were responsible for 10 or more patients. Hospital surgical nurses reported an average patient load of 9.4 patients, and critical care nurses, 3.14 patients. Forty-six percent of the nurses said they couldn't provide the level of nursing care patients needed.

What Jane Smith faces when she gets to work at night on an orthopedic floor in a southern community hospital is typical for today's restructured nurse. (Note: Some of the names in this article have been changed). With only one aide, she routinely cares for up to 20 frail, elderly patients who have just emerged from the operating room after having total hip or knee replacements. Her patients are completely immobilized and may be in excruciating pain. Smith has to take their vital signs frequently, draw their blood, and every few hours inject drugs (such as pain relievers, or heart or ulcer medications) into their veins.

It is now well-known that insufficient pain medication jeopardizes a patient's ability to heal. It is also well-known that pain medication should be administered well before patients are turned or do their physical therapy. But Smith says, "If you have a really heavy patient load, you don't have time to do it. They ask for pain medication, and I tell them I'll be there as soon as I can. I recently had five patients in a row who needed meds, and I had to put them on a list. You run in there and give them meds, and get a pain scale, and ask if there's anything you can do and they'll say, 'You're too busy. I don't want to ask you.'"

Orthopedic surgeon William Marshall works with Jane Smith and shares her frustrations. Because nurses are so overloaded, he says, "you order a unit of blood at 6:30 in the morning, and you find out that at 5:30 in the evening it still has not been given. You find patients [who were] calling for medicine for pain, and it wasn't given to them until an hour-and-a-half later."

Marshall says that "cuts to the bone" are driving individual nurses to despair. "There are people with whom I've worked for 10 or 15 years," he explains with mounting distress, "and I find them in tears, saying, 'I can't stand it anymore. I'm going to leave.'"

Sicker Patients, Busier Nurses

Another cost-cutting measure--shortened length of hospital stay--is changing the nature of patient needs and making it more difficult for nurses to minister to them.

For almost every operation, treatment, or diagnostic procedure requiring hospitalization, length of stay has been shortened. Although getting patients out of the hospital and back home is touted as a wonderful thing for patients, it actually makes it harder to care for those who are hospitalized.

In the past, people came into the hospital for surgery the day before their operations and stayed in the hospital until they were well on the road to recovery. Today, the 91-year-old woman who is on Jane Smith's unit (after a hip replacement operation) does not come in the day before surgery for tests, but arrives at the hospital on the day of the operation. Nor will the woman remain in the hospital until she recovers. She's out in three days. Which means she is much sicker while she's in the hospital, as are all the other patients nurses care for.

When length of stay is so truncated, the hospital becomes like a Midas muffler shop. Forty to 50 percent of the total patients admitted to a hospital may be discharged in 24 hours. Barbara Norrish of Samuel Merritt College, Department of Nursing, and Thomas Rundall of the University of California, Berkeley's, School of Public Health have demonstrated that patients' shortened length of stay increases nurses' cumulative patient load. "A typical nurse may come onto her unit at 7:00 in the morning and take care of seven patients with an aide," says Norrish. "But four of those patients are discharged at noon, and four new patients are admitted at 1:00 p.m. The nurse manager who sees the patients at 1:00 p.m. will argue that the nurse only has seven patients. But she doesn't; she has 11."

Plus, with all these admissions and discharges, activity on the unit--not just at the bedside--also escalates with nurses spending as much time talking to home care agencies, rehabilitation facilities, nursing homes, or family members, negotiating the hand-off of the patient, as they do for direct patient care.

Erica Wilson, who works in an oncology clinic in a prestigious teaching hospital in a major metropolitan area in the Northeast, is a case in point. In her clinic, the same number of RNs now see more patients than ever before. Half of Wilson's patients are on experimental treatments. She must spend more time reviewing treatment plans and double-checking calculations of drug dosages. Because the side effects of experimental drugs aren't well-known, those drugs must be infused more slowly. Wilson also has to closely monitor patients, respond to any hint of an adverse reaction, and review with patients complex schedules for chemotherapy.

Many of her patients now take highly toxic drugs--drugs that used to be administered in a hospital or clinic--at home. If they experience side effects, they call the clinic. Wilson must leave patients to respond to these calls. At the same time, patients who have been discharged from the hospital while they are still ill are bringing more serious problems to the clinic. And the increased volume of sicker patients leads to more clinic emergencies like cardiac and respiratory arrests. As a result of the volume and acuity of patients, "things are being missed," she says. "If we aren't making major mistakes, it's by the skin of our teeth."

Such heavy caseloads don't only detract from patient care; they erode the quality of the nurses' working life. Harried RNs say they have no time to go to the bathroom, eat lunch, or have a cup of coffee much less get off the unit to attend essential educational seminars.

One stressed-out emergency room nurse explains that she has more than once almost fainted because she can't find a moment in her eight-hour shift to get a bite to eat. Another RN tells me she won't drink tea or coffee on the job because caffeine just makes her go to the bathroom, and she has no time to take a toilet break. More say they suffer from stress-related illnesses, like ulcers, colitis, and hypertension. Because they are unable to get help turning and moving patients, many report back injuries.

According to the Bureau of Labor Statistics, 700,000 health care workers suffered an injury or illness in 1996--twice as many as were reported in 1990. The rate of injuries surpassed that of manufacturing, construction, and mining, which are well-known high-hazard industries. Of the 91 categories of workers the Bureau of Labor Statistics measures, RNs ranked fourth in days lost at work due to nonfatal illnesses and injuries. Only "stock handlers and baggers," "freight and stock material handlers," and "laborers/construction workers"--all primarily male--had more illnesses and injuries. In Minnesota, between 1990 and 1994, when restructuring efforts reduced nursing by 9.2 percent, there was a 65-percent increase in RN work-related injuries and illnesses.

Nurses' morale is also plummeting because of an increased use of "floating" and mandatory overtime, scheduling practices that nurses have long deplored as unsafe to patients and demeaning to nurses. When nurses float, they are moved from the unit where they usually work to one with which they may not be familiar. For example, if a cardiac nurse calls in sick or goes on vacation, managers may send an oncology nurse to replace him or her. "Would you ask an ear, nose, and throat doctor or dermatologist to cover cardiology for the day and expect high quality care?" Jean Chaisson asks. "I don't think so."

Today, after an exhausting 8- or 12-hour shift, a nurse may also suddenly learn that he or she has to work an extra 8 or 12 hours. For a largely female work force with child care and family responsibilities, this is particularly onerous.

"You work from 3:00 in the afternoon to 11:00 at night. You have arranged for someone to take care of your kids," says Kate Maker, a nurse at the University of Massachusetts Medical Center in Worcester. "So at 10:00 you're told you have to work mandatory overtime. Well, just like the hospital can't pull nurses out of the sky to suddenly work 11 to 7, we can't pull babysitters out of the sky at 11:00 at night to take care of our kids. We're put in the terrible position of having to choose between abandoning our patients and abandoning our children." If RNs protest that these assignments are unsafe for their patients, they are often warned that refusing the assignments will constitute "patient abandonment"--a charge that can lead to a disciplinary action by the state Board of Registration in Nursing.

Perhaps more than anything else, nursing morale has bottomed out because RNs say they no longer have time to really "care" for their patients. "Before, I was able to sit in a room and teach patients about their care and listen to them," an ICU nurse in the Midwest told me. "But today, you can't have any kind of interaction with patients. You don't have time to talk with them, or hold their hand, or be with them. Today, we only have time to take care of their tubes." This nurse eventually left the hospital.

Losing Nurses, Losing Lives

Not surprisingly, patients and their family members are feeling the side effects of the disorganization of nursing care. Madge Kaplan is the Boston-based Health Desk editor for National Public Radio's Marketplace show. Last winter, her 81-year-old father had a stroke and was hospitalized at a major northeastern teaching hospital. He then spent a total of three months in its inpatient and rehabilitation units. The medical aspects of his care, Kaplan explains, were excellent.

But Kaplan adds, "If my father or the three other patients in his room needed to go to the bathroom, if they needed to reposition themselves to eat a meal, if they needed help in adjusting their position in a wheelchair, if they needed help unwrapping utensils to eat a meal, that help was not forthcoming."

It was "tragic," Kaplan says, to watch "these frightened, frail elderly patients push themselves to the limit of their energy to get someone to pay attention to them. Pleading with someone to get a glass of water or to wipe someone up when they had spilled something on their bed."

Kaplan, like Jane Smith's patients, understood that the nursing staff were overwhelmed. "Nurses seemed to have their hands full--so much so that I always came away feeling that staff seemed tense, stretched, and in no mood to engage with patients and the people visiting them."

Although boosters of market-driven health care insist that "consumers" like Kaplan and her father will vigorously advocate for themselves when they don't get the service they expect, neither complained to hospital administration. Why? Because when people are sick, vulnerable, and totally dependent, they are loath to alienate those who hold their lives in their hands.

Patients do, however, register their concerns when they are not immediately dependent on their hospital for care. In l996, the AHA sent its members a confidential report entitled "Reality Check: Public Perceptions of Health Care and Hospitals." The report summarized data gathered in focus groups with 300 patients in 12 states plus an opinion survey of another 1,000 patients. "The key indicator that people referred to as a measure of quality of their hospital care," the report stated, "was the nurse."

The report went on to say that those surveyed

hold a strong belief that skilled nurses are being systematically replaced by poorly trained and poorly paid aides. Their perspective on the "thinness" of hospital nurse staffing was reflected in a universally mentioned experience: "If I hadn't stayed in the hospital room with my mother, child, or spouse, they would never have gotten the correct medication or care on time." People believe the profit motive is behind the reduction in nursing care. They are angry at the reversal in health care priorities this represents.

In the face of patient and nurse complaints, the hospital and insurance industries often argue that nurses have not proven their worth and that their critical role in patient care has not been scientifically documented.

Nothing could be further from the truth. While nursing's contributions--like those of other predominantly female occupations--have hardly received the kind of research attention devoted to the highly male medical profession, there is, in fact, a considerable body of scientific literature that explains what nurses do and why it is critical to patient health.

Jeffrey H. Silber and his colleagues at the University of Pennsylvania School of Medicine are studying an important variable in determining patient mortality--what they call "failure to rescue." These researchers report that among hospitals with comparably adjusted case mixes, some are better at "rescuing" patients than others. Working with researchers Linda Aiken and Julie Sochalski of the University of Pennsylvania School of Nursing, they have identified the critical factors in patient rescue. Hospitals need to have enough educated staff who recognize a problem when they see it. Those staff must be with patients enough of the time and must have enough status and authority in the institution to mobilize resources and deal with crises. Nurses, the researchers explain, are the educated eyes-on/hands-on, 24-hour-surveillance-and-intervention system in hospitals.

When, as other recent studies confirm, hospitals employ enough educated nurses and give them ample time with patients, patients have fewer urinary tract infections, falls, pneumonias, and bedsores. And they are less likely to die. When Aiken and her colleagues analyzed the care of AIDS patients, they documented that "an additional 0.5 nurse per patient per day--or an additional nurse for every six patients on each eight-hour shift--would be expected to reduce the likelihood of [patients] dying by roughly one-third."

In October, Michael Rie, an anesthesiologist and intensive care physician at the University of Kentucky, presented a quality-assurance analysis of ICU readmissions in one university hospital. (The data were collected in response to findings that the average length of ICU stay for patients with respiratory problems was longer than that suggested by a nationally accepted benchmark.) The study found that patients at low risk of death and/or readmission to ICU--who had been discharged to regular hospital floors--were being readmitted at a seemingly elevated rate. Patients with a predicted low risk of death, 10 percent, had an actual mortality rate of 24 percent.

When investigators explored why patients were readmitted to the ICU, they discovered that 80 percent of these patients had potentially preventable ICU readmissions. The problem was they weren't receiving enough basic respiratory care on non-ICU floors. A plausible inference is that there weren't enough staff in this hospital to suction patients' lungs and help them cough.

Not only is this endangering patients' health and sometimes their lives; it's not even cost-effective. In this particular hospital, for example, the nonlabor costs for the ICU readmission of only 79 patients was $1.6 million--or 35 percent of the cost of their entire hospitalization. If labor costs were added to this figure, it would be two to three times as high. (This points to the need not just for better staffing but also for intermediate care units that provide a level of services less intensive than in ICUs but more intensive than on general care floors.) The fact that cutting nursing services doesn't save money is confirmed in other studies about hospital restructuring.

Laying off RNs and replacing them with aides works only for so long. Eventually hospitals have to hire additional RNs. But today, when they try to fill vacancies, many hospitals are finding it more and more difficult to attract new recruits. In a report on the new nursing shortage, even the AHA concludes that "RN Dissatisfaction May Be Driving the Current Shortage in Hospitals."

This increasingly well-publicized dissatisfaction with working conditions and concern about the quality of patient care is driving young women and men away from studying nursing in the first place. In an era of low unemployment, especially when women have more career options than ever before, why would anyone want to spend the time and money involved in getting a nursing education for the privilege of being part of a cheap, disposable labor force? And why would more men decide to enter a "women's profession" that even women are finding unattractive? It is hardly surprising that the number of young people interested in entering four-year nursing programs has been steadily declining over the past four years and fell by 5.5 percent in 1998.

What Can Be Done

For the past several years, nurses have tried to focus public attention on the erosion of their working conditions. This summer, both Massachusetts and California passed whistle-blower bills. And after intense pressure from the California Nurses Association, California Governor Gray Davis recently signed the first safe-staffing law anywhere in the country (and he did it despite the opposition of the state's hospital industry). This measure requires that, by the year 2002, the state Department of Health implement safe nurse-to-patient ratios and limit the floating of nurses between units.

But while legislation like California's can help alleviate the nation's persistent nursing crisis, it is only a short-term solution. Many other, more fundamental changes need to be made in both the financing and delivery of health care. As long as we have a job-based, employer-dominated private health insurance system in which billions of dollars are siphoned off every year for unnecessary advertising, marketing, and administrative costs (not to mention insurance and drug company profiteering), those who provide hands-on care will always be starved for resources.

But though national health insurance is a necessary first step toward improvement, it is not in itself a sufficient condition for quality nursing care. Even if America eventually provides tax-supported coverage as Canadians have had since the 1970s, nursing care may still be a cost-cutting target (as it has been in Canada lately) if the value that nurses add to the health care system is not recognized.

In other words, despite recent curbs on physician autonomy and specialist referrals, most people--even under the degraded conditions of managed care--regard medically necessary care as an entitlement. There is, however, no parallel conception of necessary nursing care. If such a concept did exist, the training and deployment of nurses and the organization of nursing care within hospitals would be seen as no less important to patient outcomes than medicine's role in diagnosis and treatment. The dangers of both radically reduced hospital stays and insufficient nursing care in other settings would be more widely understood. And there would be better pay for and treatment of nurses as well as greater social recognition and respect.

Our contract with RNs would be, in effect, that we must care about them if we want them to care for us. ¤

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