Lifeline of Nurses Thinning

Two months before their 7-year-old son, Jesse, died of cancer, James and Dawn Gadd folded their frustrations into a two-page letter.

Kaiser doctors and nurses “are kind, courteous and helpful,” the couple wrote to Kaiser Foundation Health Plan last December. But the nurses, they said, are impossibly overworked--”literally running between patients,” dashing “between beeping IV pumps” on the Santa Clara oncology ward.

Nurses did their best, even skipping breaks and meals to attend patients, but Jesse, through cycles of surgery, infections and nauseating chemotherapy, was too often left in the hands of unskilled aides, wrote his parents, both longtime Kaiser members.

Besieged by soft-tissue tumors, Jesse would have died in any case. But the Gadds argued that more nurses might have made his stays less painful and frenzied; more of them might have eased the strain on his parents, powerless to do much more than comfort him.

Kids like Jesse are often “tired, sick, vomiting and afraid,” wrote the Gadds, who never left their son alone over 20 months of hospitalizations. “[Registered nurses] need to be given the time to provide more than just . . . medications.” Kaiser’s excellent reputation is endangered, the couple said, by “the appearance . . . that Kaiser is putting money before patients’ needs.”

Kaiser, a pioneer in managed care and the nation’s largest health maintenance organization, says it does not have a systemic problem in its nursing care. It is, however, not alone in drawing complaints from patients--or RNs themselves--about the pinch on registered nursing. In California and elsewhere, many hospital RNs are stretched thin and working double-time to compensate.

There have been nursing shortages before, but this one, critics say, is different: It was fostered by the forces of managed care, and has primarily affected specialty areas in which experienced and highly trained nurses are most in demand. In the early 1990s, many veteran RN positions were cut back and replaced by cheaper unlicensed or lesser-trained staff just as hospital patients began to be admitted sicker and discharged quicker.

It’s not just pillow fluffing and soothing words that are lacking. Sometimes, critics say, patient health and safety suffers. Nurses report that patients have fallen; they’ve gone without pain medication; they’ve been mis-medicated. A 1997 study showed fewer RNs means longer hospital stays and more complications such as bedsores and infections.

Some nurses say their profession, with its proud history of patient advocacy, is in critical condition.

“There’s the old common-sense adage, ‘You don’t run with the scissors,”’ says Boston nurse activist Barry Adams, who was fired after complaining about working conditions at a hospital-based nursing home. “When a nurse has 10 patients, 15 patients, it is not conducive to safe nursing practices. When you’re . . . just pouring pills, just one wrong pill can be the end. Do you know how quickly [wrongly administered] penicillin can kill somebody?”

It’s as though nurses are leaning over patients on an accelerating conveyor belt, says Judith Shindul-Rothschild, an assistant professor at Boston College’s nursing school. Each “speedup”--a term adopted from manufacturing-- “brings them closer to the brink of chaos.”

Hospital industry advocates acknowledge that nurses are busier--but deny that patient care has suffered.

Kaiser assigns nurses according to a system based in part on nurses’ input, says Joann Zimmerman, who oversees nurses in the South Bay area. The system is “not 100%” but makes room for “teaching time” and “comfort time.” The Gadd family’s experience, she said, may have been colored by Kaiser’s prolonged contract negotiations with nurses--now resolved--which temporarily deflated staff morale.

But critics say the troubles afflicting nursing are widespread. According to health care author Suzanne Gordon, they reflect the country’s devaluation of a female-dominated profession devoted to the process of “care” as opposed to dramatic “cures.”

Healthy people judge medical care by doctors and their devices, but hospitalized patients quickly learn that RNs are their lifeline, she and others said. It is they who bring the pain medication on time (or not), who take patients for post-surgical walks, who act as confidantes, and, at times, as outspoken advocates.

“Somebody needs to be a voice for patients” when they are too sick to speak for themselves, said Adeline Justeson, a pediatric nurse at Santa Monica-UCLA Medical Center.

Managed Care, Training Blamed

Veterans of the nursing profession have a sense of deja vu. Once a decade, they say, a shortage of nurses occurs, usually a few years after a severe glut is declared.

But the current dearth, some critics say, didn’t emerge from natural economic ebbs and flows. It was created, they say, when managed care squeezed payments to hospitals, and consultants scoured the wards for anything expendable. RNs, often the bulkiest item on the labor budget, were among the first to get pink slips.

This shortage is different in another way: With 2.2 million practicing RNs--more than ever before--the nation has no general shortfall. But in some regions, including California, the reservoir of experienced and specialized hospital nurses--trained in critical care, for example, or oncology--is seriously low.

And, at least in some parts of California, hospital RNs in general are in short supply. Three California regions--Contra Costa County, San Jose and Orange County--have among the lowest number of hospital RNs per capita in the nation. Many nurses now are working outside hospitals, often in outpatient clinics and home health care.

The increasing complexity of medicine has boosted demand for RNs with bachelor’s degrees and advanced training. But education has fallen behind; nursing schools have closed or cut programs.

Meanwhile, some nurses complain of being temporarily assigned, or “floated,” to unfamiliar hospital units. Others chafe at overseeing less qualified aides, who are not trained, as RNs are, to interpret vital signs or to spot more subtle signs of patient deterioration.

Unlicensed aides sometimes receive as little as a few weeks’ training, while RNs generally have two- to four-year degrees. But such aides are far less expensive, drawing about half an experienced RN’s salary or even less.

In time, some experts expect the nursing shortage to extend to hospital RNs of every stripe, nearly everywhere. The nursing work force is aging--the average age in California is 47--and many are bent on retirement. Others are changing career tracks, leaving the bedside. Young women now have an array of attractive career options outside nursing.

Some doctors say patients already are worse off.

One Los Angeles obstetrician said mistakes by nonspecialized nurses in a Cedars-Sinai Medical Center intensive care unit “directly contributed” to a patient’s miscarriage.

According to the doctor, one nurse, a “floater” from another unit, incorrectly transcribed a medication intended to keep the doctor’s patient, a pregnant woman, from going into pre-term labor. A fill-in night shift nurse, from a nursing temp agency, did not notice the error. The patient went unmedicated and lost her baby.

“It’s a lot cheaper to hire bodies than it is to hire skilled people, but it’s completely, clearly dangerous,” said the doctor, who says he wrote a letter to Cedar’s complaining about the handling of the medication.

Cedar’s officials declined to discuss the case, saying it is confidential and is under internal investigation. Chief nursing officer Linda Burnes-Bolton says Cedar’s has hired more than 200 RNs this year and is “cross-training” nurses to work in different units. She said Cedar’s nurses work “very, very hard” to ensure that patient care is never compromised.

Politically Active Nurses Emerging

Cautiously, sometimes at their peril, nurses are speaking out. Pockets of this profession filled with nurturing souls--once taught in school to avert their eyes from doctors’ direct gazes, and to give physicians’ their seats at the nurse’s station--are embracing activism.

A much larger segment is quietly disenchanted. The public isn’t happy, either. Consider:

* A nationwide survey of 7,560 nurses published in the American Journal of Nursing in November 1996, found that two in five nurses would not want a family member treated where they worked. Three-quarters reported not having enough time to educate or comfort patients and family members. More than one in eight said they were likely to leave nursing.

A focus-group survey prepared for hospital chief executives by the American Hospital Assn. found the public sees nurses as the “key indicator” of hospital quality.

People strongly believe that “skilled nurses are being systematically replaced by poorly trained and poorly paid aides,” the report states. They “believe the profit motive is behind the reduction in nursing care. They are angry at the reversal in health care priorities that this represents.”

* In California and a few other states, collective bargaining is becoming more aggressive and widespread.

Nurses have traditionally shunned unions as “unprofessional;” many vow never to “walk out” on patients. Yet, in some regions, union campaigns and contract negotiations have seen some success, especially when the focus was defined as patient care rather than simply compensation.

The most remarkable achievement may have been a contract hammered out by the California Nurses Assn. and Kaiser in Northern California earlier this year. The nurses got a good raise. But the agreement also contained a novel provision under which RNs would be appointed “quality liaisons”--watchdogs over patient care--at Kaiser’s Northern California operations. The agreement, heralded as a national model by one mediator, cemented nurses’ place within the organization as patient advocates.

* An increasing minority of nurses is becoming politically active or going public with their concerns about patient care.

In dramatic testimony before his state’s legislature in February, Boston activist Adams endorsed a whistle-blower protection bill for health care workers. He recalled his impressions in July 1996, when his normal load of six patients at Youville Healthcare Center, a hospital-based nursing home in Cambridge, Mass., doubled.

“I remember the wounded and embarrassed look on patients’ faces after they fell, slipping in their own urine and feces while trying to get to the bathroom [by] themselves . . . . I found a new graduate practical nurse in a hurry preparing a syringe with 50 times the [proper] dose of a medication . . . and a young woman telling me she had not had her surgical dressing changed in two days.”

After complaining to supervisors, Adams said, he was fired. A National Labor Relations Board judge later ruled he was a victim of retaliation.

In a statement, Youville vowed to appeal, saying Adams’ termination was not related “in any way” to the patient care issues he raised.

Meanwhile, the American Nurses Assn. and various state associations are pursuing other legislation. A federal “patient safety” bill would make hospitals’ RN staffing ratios public. In California, a CNA-backed bill is seeking to limit the number of patients per RN, depending on the patients’ illnesses, and to prohibit unlicensed employees from providing nursing care. California law now mandates that RNs take care of a maximum of two patients in critical care settings, but leaves other staffing levels up to hospitals, based on patient’s “acuity.”

The bill is opposed by the hospital industry, which contends that existing regulations are sufficient.

But legislation isn’t the only route to change. Former nursing professor Laura Gasparis-Vonfrolio started a magazine. It’s called Revolution: The Journal of Nurse Empowerment. She thought about calling it Evolution, she said, “but we don’t have that much time.”

Expressing her frustrations in writing represents a toned-down approach for Vonfrolio. She says she was fired from her first nursing job, in the 1970s, after she struck a doctor who had punched her when she refused to give what she considered a dangerous injection.

Her magazine, which has steadily gained attention among nurses, does not have a nurturing tone. Critics call it shrill. But it captures the anger--sometimes in bold lettering--that segments of the nursing population feel.

“It’s time to . . . rise up off our haunches and create an environment that no longer wounds us!” Vonfrolio urged in one issue.

Another activist group came together in cyberspace last August. It’s called the Florence Project, named after nurse Nightingale, who, despite her soft historical image, is remembered by this 550-member group as “the original nurse activist.” They met via e-mail, then formed an alliance--and a World Wide Web site--to promote a health system “not motivated by economic gain.”

‘Primary Care’ Nurses a Vanishing Breed

Amid all this turmoil in health care, there are nurses who thrive.

Pat Brownstein, for example, loves her job--even if it is hectic and sometimes misunderstood as medical drudgery. “It’s not just about bedpans,” she explains.

For Brownstein, 47, a veteran of 25 years, it is about patient contact.

On a recent Monday, she race-walked through most of her 12 1/2-hour shift at UCLA Medical Center, answering her four patients’ call lights, warming meal trays, changing beds, dispensing drugs, filling out charts, taking orders from medical residents close to half her age. Still, she found time to advise and reassure the bed-bound.

At one point, she looked in on a cancer patient, 63 years old, hospitalized for the first time. He was scared. The cancer had ambushed him; the only hints for months were a drippy nose and a dogged headache. By the time surgeons cut into him, it was too late to save his eye or the bones beneath.

Doctors had whisked through on rounds, reporting they “got it all.” The patient, his face half-covered in gauze, wondered in their wake: How can they be sure?

After explaining the importance of wound irrigation, Brownstein paused over the bedside. A while back, she said, a friend of hers had the same surgery--and the very same fears. “She’s still around,” Brownstein stressed. “When they tell you that, believe it.”

Somehow, in less than five minutes, she had the man and his wife talking excitedly about a much-dreamed-of trip to Yellowstone.

Brownstein still has occasion to practice the kind of A-to-Z nursing that many other hospitals are phasing out. It’s called “primary care”--in which the RN takes thorough charge of a patient throughout his or her stay.

Critics complain that nurses like Brownstein are a vanishing breed. Managed care, they say, increasingly has fostered a more fragmented system, in which RNs essentially become remote supervisors rather than direct care providers.

Of course, hospital nurses don’t have to stay put. With proper training, RNs can advance to positions as nurse practitioners, case managers, administrators and more.

Yet author Gordon worries that such professional “advances” mean stepping back from the bedside, where she believes true nursing, however unglamorous its image, begins. She supports further education of nurses but bemoans devaluation of the traditionally female, care-taking role.

Dawn Gadd, Jesse’s mother, doesn’t know about that. But she knows her son could have used more RNs at his bedside.

“These kids need you to come in and sit with them, even play a game with them, something short. The nurses really wanted to do that. . . . They really did try to do everything they could for the family. But how much can you do when a patient down the hall needs you and the machine’s beeping?”