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.
