Nursing is at the center of a shift in hospital care

August 07, 1994|By Patricia Meisol | Patricia Meisol,Sun Staff Writer

Nurses were in such demand when DeeDee Franke graduated from nursing school in 1981 that hospitals courted her with offers of cars and tuition reimbursement. Now, as occupancy rates fall and hospitals worry about the bottom line, nurses are finding their jobs disappearing.

But unlike other down cycles Ms. Franke has witnessed, this one affects not only nurses' livelihoods but the way care is delivered inside hospitals.

In hospital after hospital, both nurse managers as well as floor nurses are being winnowed out in favor of less skilled -- and cheaper -- personnel, many of them unlicensed, who work under the direction of a staff nurse.

The changes already have led to thousands of layoffs in cities such as Boston and San Francisco. In Washington, D.C., hospitals are laying off nurses by the hundreds. In Baltimore, the change is occurring gradually as vacancies go unfilled.

The restructuring of hospitals and the change in the nursing labor force comes at a time when hospital profits nationally are at an all-time high and when hospitals are spending freely on mergers, acquisitions and high-tech facilities to attract patients.

"What is happening is unlicensed aides are performing direct patient care in some hospitals. The hospitals are reconfiguring their staff mix so there are fewer RNs and more aides," said Erin Eckles, a labor specialist for the American Nurses Association.

"What we're seeing is a lot of downward substitutions," she said. "It's a fundamental shift in the way care is going to be provided, and an initial displacement of nurses."

Ironically, hospitals spent the past decade building primary care nursing teams in response to literature that showed the quality of care is directly related to patient-nurse ratios. In the late 1980s, many Maryland hospitals wouldn't hire a licensed practical nurse (LPN).

Now "they are minimizing the role of the nurse," said one long-time nurse at Sinai, one of at least a dozen Maryland hospitals that are reducing management and redesigning jobs. Besides Sinai, they include St. Agnes, Greater Baltimore Medical Center, Mercy, St. Joseph, the University of Maryland Medical Center and Johns Hopkins.

At the University of Maryland, for instance, one clinical nurse manager is now overseeing both the pediatric and maternity units. Those units attract up to 900 patients with problems ranging from cancer to AIDS. Mercy, which already employs licensed practical nurses, isn't hiring unlicensed professionals but it expects jobs will be reduced as they are redesigned.

"We are going to see how the (new) patient model works in terms of service, quality, and cost," said Amy Freeman, senior vice president for patient care services at Mercy.

At the same time that the nurse-to-patient ratio is increasing, tighter restrictions on hospital admissions means the average patient is sicker.

The trend has set off alarms among medical professionals. It has also led Congress to initiate a study by the Institute of Medicine, a division of the National Academy of Sciences, documenting the shift and its impact on quality of care.

"The consumer makes the assumption that when you go to the hospital, the care is safe," said Dr. Mary Virginia Ruth, assistant dean for professional services at the University of Maryland School of Nursing. "You can no longer make that assumption," she said.

The aides replacing nurses, she said, often don't have the observation skills or knowledge base to pick up on complications and respond to medical situations quickly. "Mistakes are more ,, and hidden," she said. "It's hard to get statistics on when a patient falls out of bed."

For instance, the professor cited her own experience as a guardian for a 92-year-old woman in a hospital intensive care unit. First she found the patient had been left sitting up for three hours after surgery. Then the patient was left untreated for constipation for four days. The problem was remedied, but it happened again four days later, she said.

Catherine Crowley, assistant vice president of the Maryland Hospital Association, defended the shift, saying that the majority of tasks being delegated to aides in Maryland hospitals involve activities of daily living that nurses don't really need to do.

"Others are routine, predictable procedures that, based on the condition of the patient and the skill of the technician, can be safely delegated," said Ms. Crowley, head of the MHA's center for nursing education. "In fact, hospitals are spending a lot of time working with nurses to develop that skill of delegation."

Unlike earlier experiments with a team approach, today there is much more evaluation of the patient and the care giver to see whether the technician has the required skill for that patient, Ms. Crowley said.

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