Hospitals are finding themselves in bidding wars for managed-care contracts and many are responding by reducing nursing staffs to cut costs. A preliminary study of a survey of nurses finds that cutbacks are taking place in most hospitals and that patient care is being reduced. An advertisement appeared in several national and California newspapers, Alongside pictures of nurses standing with their uniform and the best shoes for nurses, at the bedside of acutely was the following statement: “Hospitals and HMOs are cutting care to make record profits. Patients are paying the price. Just ask any registered nurse who provides direct care.”
The ad launched a California Nurses Association (C.N.A.) campaign called “Patient Watch.” It is an attempt to reach out to patients and families and elicit Congressional action to address what nurses–and increasingly many physicians–feel is a trend that is literally endangering the lives of thousands of patients: Responding to market pressures, hospitals are “restructuring” or downsizing. By pitting hospitals against one another in the bidding for managed-care contracts, the new lords of the health care market–insurers and H.M.O.s–are winning drastic discounts, often below the hospitals’ actual costs. To make up their losses, hospitals are cutting their nursing staffs, which represent about 28 percent of hospital labor costs.
Competition, says John O’Brien, C.E.O. of the Cambridge Hospital and chairman-elect of the Massachusetts Hospital Association, is forcing hospitals to “squeeze down on our costs at every possible level.” O’Brien is a longtime supporter of single-payer health care and a vocal critic of competition. “Nursing has been hard hit. Nursing is the backbone of the hospital. But the pressures we’re putting on our nurses are inordinate. I’m doing it like everyone else is. It certainly can’t continue.”
Reducing Nursing Staffs to Cut Costs
Nearly three-fourths of American hospitals of every kind–private nonprofits, for-profit hospital chains, public hospitals, small community and large teaching hospitals–are engaged in or developing plans for “restructuring.” The American Nurses Association conducted a survey of nursing layoffs. Preliminary findings of the yet-unpublished study report on data provided by 1,835 nurses from all fifty states. Seventy percent of the respondents said their employers were cutting back on staffing by leaving vacated positions unfilled, 66 percent said hospitals had laid off nurses or were planning to do so, and 45 percent said that the use of unlicensed assistive personnel (U.A.P.s) was increasing. Three-quarters of the nurses in hospitals with reduced nursing staff said patient care had eroded and more than two-thirds said patient safety was compromised.
These nurses are being replaced with lower-wage and less-skilled employees, like nursing assistants and technicians who may have no health care background and yet are asked to make complex nursing decisions. Aides are not required to meet any educational or licensing requirements. Nurses who remain at the bedside must now care for more patients and supervise these techs as well. Moreover, they are legally responsible for any mistakes the U.S.P.s make.
In Massachusetts and California, which have the highest penetration of managed care in the country, this trend is increasingly common. Boston’s prestigious nonprofit Brigham and Women’s Hospital laid off more than forty registered nurses. The hospital wiped out its entire continuing care department, laying off seven clinical nurse specialists, one nurse practitioner, and one staff educator. They were replaced by less expensive social workers who had no formal medical education. Brigham and Women’s nurses are now required to work mandatory overtime and have had to give up the kinds of flexible scheduling arrangements that had been marked improvements in their working conditions and job satisfaction.
When Brigham and Women’s announced its historic merger with Massachusetts General Hospital, the heads of those two institutions–each of whom earned close to a million dollars that year–announced even further staff cuts. They trumpeted that they were going to cut 20 percent of their budgets, which could entail the loss of at least 4,000 hospital jobs. At Massachusetts General, nurses’ anecdotal reports suggest that vacated positions aren’t being filled and that many units are understaffed. Massachusetts General and Brigham and Women’s are hardly struggling hospitals. These nonprofit hospitals have constructed palatial new facilities, added redundant and unnecessary services, hired outside consultants, and spent enormous sums buying up primary physician practices, as well as on advertising and marketing.
In California, R.N.-to-patient ratios have declined precipitately. Even in critical-care units–developed specifically to provide intensive nursing care–staffing has suffered, nurses say, as hospitals try to game the system to slash costs. Some hospitals, nurses report, have renamed units to disguise the intensity of patient needs. In others, patients may be transferred out of critical care units prematurely just to reduce the number of R.N.s employed in those units.
Deborah Bayer, a staff nurse in the critical care unit at Children’s Hospital in Oakland, said that the hospital replaced 20 percent of its medical surgical R.N.s with aides on a one-to-one ratio. (The hospital recorded a $6.2 million profit and has finished construction of a large ambulatory care center.) These aides were given eleven days of training before replacing R.N.s with years of schooling and bedside experience. On medical surgical floors, says Bayer, administrators insist that because nurses now have “helpers,” they can carry a caseload of five or six patients, sometimes even six or seven patients, rather than three or four.
Even the nonprofit H.M.O. Kaiser Permanente is now developing a radical redesign of its health care delivery system, referred to as the Gateways Operational Planning Project. The literature on the project presents a design that faithfully mirrors industrial mass-production techniques. The process of patient care is broken down into its constituent parts. Each moment of the patient’s day is plotted in advance and each fragment of care is assigned to a different assembly-line worker. Nurses are replaced by “multi-skilled caregivers,” most of whom will be lower-paid aides. Streamlined to move along a well-oiled factory conveyor belt, patients will have less and less contact with skilled nurses. Those nurses who remain in the hospital will function not as repositories of intimate knowledge about and connection with the patient but as detached managers who supervise less educated and less experienced members of the “care team.”
Periodic attempts to de-skill nurses have long concerned members of that profession. But today, this trend is particularly dangerous. Patricia Benner, professor of physiological nursing at the University of California at San Francisco School of Nursing, says “there is no one in a hospital today who is not in that hospital because they are very sick. We rarely put patients in hospitals just for observation. We rarely put patients in hospitals just for observation. We rarely admit them prior to surgery and we discharge them faster after their surgeries. This means that the acuity level of patients is far higher than it used to be and that most of these patients have conditions where there is very little room for error. They need instantaneous interventions and great skill.”
Less Costly Aides, Not Expensive Nurses
Administrators claim that their new policies are intended to help patients by liberating nurses from unnecessary tasks so they can spend more time doing “real nursing”–redefined as managing the patient from afar. Less costly aides, not expensive nurses, should be the ones taking temperatures, giving bedpans and feeding patients, insist administrators and insurers. Again, most nurses argue vehemently against this corporate redefinition of their profession. “Administrators tell us that you don’t really need nurses to change a baby’s diaper or feed a baby. Aides can do that, and we can stand back and assess the patient, devise a plan of care and supervise the aide who carries it out,” says Bayer. But how, she asks, can you evaluate patients if you no longer have the relationship with them over time that is the hallmark of nursing?
When she’s feeding a baby, Bayer explains, she’s engaged in a whole series of complex cognitive activities. “I’m learning if the baby has the energy to suck. I’m determining what her color is while she’s sucking. When I’m changing a baby I’m diagnosing that baby’s condition. Does he cry out in pain when I touch him? What does his skin look like? Babies can’t verbally tell you how they feel. How you learn is through interactions around their bodily care.”
In the Orwellian doublespeak of corporate-driven health care reform, this denial of critical care is recast as “patient-driven” or “patient-centered care.” The results, however, are often far from “patient-centered.” According to the C.N.A., a labor and delivery nurse at a Berkeley hospital related the following incident: “On a very busy night when we were already understaffed, a patient whom we didn’t know showed up and said she was in labor. The ward clerk directed her to a room and notified the charge nurse of her arrival. The patient used the bell twice to complain that she was in pain and needed a nurse, but the ward clerk could not find anyone free who could see her. When the patient had been there about twenty to thirty minutes, her husband came out to say that she had to push. Our ward clerk called two of us and said it was an emergency, so we left our patients and ran to the new patient’s room. When we arrived, she had delivered a very small baby into the toilet, head first. The baby was too small to survive and died of prematurity.”
Similar stories are now surfacing in hospitals and are reminiscent of the horrors of the nursing crisis when a critical shortage of nurses resulted in significant problems with patient care. Take the case of a 72-year-old man who was diagnosed with lung cancer. The man was well-insured, and his family included several health care professionals who should have been able to get him the very best treatment. He was admitted to a large teaching hospital to have a lung removed. The operation went extremely well, and the surgeons announced that he was making a remarkable recovery. When he left the recovery unit for a general medical surgical floor, his physicians believed he could be discharged a day early. Unfortunately, the hospital had targeted the medical surgical floor for drastic cuts in its nursing staff. The patient developed pneumonia, which went undetected and untreated until it was too late. He died three days later.
Stunned at the outcome, one of his family members, who is a nurse, said, “At the end, he was surrounded by all this incredible high-tech medical equipment. But the tragic thing was that all he needed was the most rudimentary piece of medical equipment–a stethoscope–and a nurse who had the time and experience to check on him, listen to his chest and hear the unmistakable wheezing of pneumonia. If he had gotten that kind of routine attention, he would probably be alive today.”
Research studies documenting what happens when nursing care is eliminated are beginning to appear. Boston College nursing professor Judith Shindle-Rothschild studied nurses’ working conditions and patient care in a geographical cross section of Massachusetts hospitals. The numbers of R.N.s decreased and unlicensed personnel increased. In the same study, 43 percent of nurses polled reported recent increases in unsafe staffing levels, and nurses reported fifteen patient deaths because of inadequate staffing. One of these occurred in a sub-acute unit; because of understaffing, no one responded when an alarm light sounded on a patient’s respirator, signaling that the patient was going into respiratory arrest. The patient died. In another incident, a patient who had been disconnected from a respirator died because not enough nurses were on duty. Six patients committed suicide while unattended.
A clear sign of the seriousness of the problems in hospitals is that a number of physicians are speaking out to defend nursing. Traditionally, physicians have downplayed nurses’ importance. But Dr. John Merritt O’Donnell, chairman of the Department of Surgical Intensive Care at The Lahey Clinic outside Boston, points out that in medical and surgical intensive care units, nurses constantly re-evaluate patients and “recognize the most subtle changes in vital signs, mental status and sophisticated monitors that may herald a catastrophic event. Their role has become even more crucial recently because the dramatic reduction in residency training programs has depleted the number of interns and residents previously providing twenty-four-hour-a-day in-hospital coverage. Physicians now, more than ever, rely on nursing assessments and recommendations when making diagnostic and therapeutic decisions. There are certainly deserving targets for cuts–physician spending, pharmaceuticals, hospital middle management and insurance. But don’t cut nursing care.”
Not only does competition eliminate expert nurses at the bedside, it also deprives patients of nursing care through the dramatic acceleration of the trend toward early hospital discharge that began with the introduction of controls on Medicare payments. The United States now has the shortest length of hospital stay of any industrialized country–a development that has done nothing to curtail soaring health care costs. Patients in this country stay in hospitals 20 to 40 percent fewer days than in countries with single-payer systems. Managed care groups have embraced early discharge with religious fervor: They discharge patients from the hospital much more quickly than traditional fee-for-service plans.
“You would not believe what people are going home with today,” Dr. Ruth McCorkle, American Cancer Society Professor of Nursing at the University of Pennsylvania School of Nursing and a researcher on the home care needs of cancer patients, exclaims with undisguised outrage. “We’re doing mastectomies on an outpatient basis. Mastectomies!” She pauses, almost with disbelief. “Women are going home with complex dressing changes, with drains from their wounds, with injections they have to give themselves. Men are going home after prostate surgery with inadequate education about the consequences of their surgery. And I haven’t even gotten to the emotional needs of these patients, who are faced with life-threatening illnesses and whose bodies may have been dramatically altered.
“In our ongoing study of testing nursing interventions in elderly postsurgical cancer patients, a fifth of our sample has deep-vein thrombosis [blood clots in the leg]. Out of that group, four have been re-admitted with pulmonary emboli [clots that travel from the leg to the pulmonary arteries, where they can cause instant death!. This means we’re getting them out of the hospital so fast that we’re forgetting the fundamentals about the dangers of blood clots after surgery and the need for nurses to initiate walking with supervision after surgery.”
“Taking care of patients today is an exercise in frustration,” says Martha Griffin, almost in despair. A nurse for twenty-four years who works as a cardiac thoracic critical-care nurse at Brigham and Women’s Hospital, Griffin reports that over the past year and a half, some patients having open-heart surgery are now being discharged after four to five days, rather than six to ten. “Patients used to leave the hospital because they were ready to leave. Now the goal is to get them out, to move patients along the continuum, whether they are ready to go or not. We used to send people home with things that a patient or family member could take care of. Today we’re sending people home who need complicated wound care. They have stitches in their chest and leg where they were cut open or drains were put in. They have staples in their chest. They have wounds with a high risk for infection. They go home with physical therapy referrals because they can’t get out of bed alone. They have complicated drug regimens. What we are doing is turning the home into a hospital.”
Hospital administrators and insurance executives rationalize away their responsibilities to patients and families. After a Boston Globe editorial criticized Harvard Community Health Plan’s newly mandated labor and delivery policy–which forces women to leave the hospital twenty-four hours after a normal vaginal delivery–several of its medical directors responded in a letter to the editor: “The Globe may believe there is no substitute for an extra day free of worries about preparing meals, housekeeping or childcare, but that is not what medical coverage is supposed to provide, especially in this era of grave concern about the rising costs of health care.”
The directors of one of the most prominent H.M.O.s in the nation are explicitly segregating treatment from the process of recovery and coping. “It is as though they are saying that their only job is to extract the baby from the womb, and then their responsibility to the patient is over,” commented Joan Lynaugh, associate dean and director of graduate studies at the University of Pennsylvania School of Nursing. “Our health care system has never done very well with the concept of convalescence,” Lynaugh continued, “but when people who run a community health care plan explicitly argue that we shouldn’t plan for the fact that people who are ill are tired and weak and can’t get out of bed and need help with activities of daily living–when they say that it is not our job to care for the sick–then we have to ask, What is their job, what are they taking our money to do?”
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