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PHILADELPHIA - It was oddly quiet in the predawn, artificial light of the hospital as nurse Sandy Pincik arrived for work. As usual, she came 15 minutes early, so she could organize a little before things really took off at 7.

Doctors huddled with nurses in the hall, discussing the day's treatment plans. Soon, they would head for their offices or operating rooms, and then the floor would belong mostly to nurses like Pincik.

Pulling a flowered smock out of her bag, she put it on over her white T-shirt and draped a purple stethoscope around her neck. She grabbed a pile of pens, a clipboard and a box of supplies and put them on a movable writing stand in the corridor.

A low-key woman with wavy, light-brown hair and magenta nail polish, Pincik would be responsible for five beds - four patients so far this day - and would help out with five others.

She and Jean Smyth, another registered nurse, work as a team to cover 10 beds on Thomas Jefferson University Hospital's 7 North, a unit that treats people recovering from urologic surgery, kidney or liver transplants, or medical problems associated with dialysis.

A thousand small duties

Pincik's day would revolve around making sure those patients got everything they needed, from ice and new sheets to CPR. It would be a day filled with a thousand small duties, tasks few would notice - unless they didn't get done.

Complaints about modern, cost-conscious medicine are everywhere these days.

Patients are warned that their doctors, their hospitals and their .. insurance companies make more money by providing less treatment. They read about hospital layoffs and predictions of more to come and wonder if enough people will remain to take care of them.

Nurses, who have been among the most vocal critics, argue loudly that hospitals have compromised care by increasing nurses' workloads and replacing them with cheaper, lesser-skilled employees.

A national survey of 7,500 nurses last year by Boston College nursing professor Judith Shindul-Rothschild found that more than a third would not recommend a family member receive care in their institutions. And nearly 70 percent reported having less time for basic nursing care and nearly 75 percent less time to comfort and talk to patients. Nonetheless, only 14 percent rated the quality of the places where they worked as poor.

Nursing employment statistics do little to clarify the debate. The American Hospital Association says the number of RNs working in hospitals has continued to rise, even though the number of patients has fallen.

Linda Aiken, a University of Pennsylvania nurse researcher who has studied the AHA statistics, said the number of RNs working in inpatient care has declined in recent years. But when the number of patients, their length of stay, and the severity of their illnesses were taken into account, she noted, the number of nurses remained relatively constant, at least through 1994.

The number of other caregivers, meanwhile, fell significantly, Aiken said. That might account for the perception among nurses that they are working much harder.

Quality shows decline

The quality of hospital care, according to early research, has shown no decline. Still, it is common to hear former patients complain that their nurse seemed harried, that he or she took forever to come when the call button was pressed. These patients might be well now, but they feel bad about their hospital stay, they say.

Most patients have little idea what the nurse is doing when he or she is not with them, and few have had enough hospital experiences to compare today's care with that given before costs were such an issue.

Jefferson, saying its nursing care is as good or better than ever, welcomed a request to have a reporter follow one of its nurses. Several other hospitals refused.

Sandy Pincik's day, therefore, may not be typical of what nurses in other hospitals experience. But it is a window into what life is like for a nurse at a major teaching hospital in 1997. And it reveals the pivotal role of employees, who as Pincik puts it, do "everything."

By 7:20 a.m., the night nurse was filling in Pincik on the status of her patients.

Mark Pannapacker, a young man recovering from a kidney-stone operation, thought he had passed another stone overnight.

Jerry Singleton, a dialysis patient admitted with fluid around his heart, was being prepared for surgery the next day.

Pincik would have to draw blood from Kevin Margaret Scharff, a post-transplant patient who had come in with pneumonia.

And the fourth patient would be going home if tests showed him to be free of infection.

Although for most of this day, Pincik's primary responsibility was only four patients - she usually has five and sometimes as many as eight - she would spend as much of her eight-hour shift on paperwork and the phone as she would in their rooms. In a modern hospital, hands-on time at bedside is only part of a nurse's workday.

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