March-April. 2000 Vol.1 - No.2
http://www.revolutionmag.com/newrev2/engineering.html
By Don DeMoro
Don DeMoro, director of the Institute for Health & Socio-Economic Policy, has authored numerous studies critiquing health care industry policies, including "California Health Care: Sicker Patients, Fewer RNs, Fewer Staffed Beds" (1999) and "A Methodological Critique of the East Bay Hospital Capacity Study" (2000).
The health care industry and its proponents, including investment banks and management consulting firms, have had much to say in recent years about the origins of RN shortages and solutions. However, nearly all of their analysis has focused on causes that leave the industry itself invisible and devoid of responsibility for its own role in causing the nursing shortage.
Nursing shortages are certainly not a new phenomenon. Like other market and labor trends, the supply of nurses has historically been uneven, and nurses have entered or re-entered the workforce to stave off national crises of care.
But the nursing shortage that has grabbed headlines across the country in recent years, and left scores of unfilled vacancies on hospital bulletin boards, is unique and threatens to be far more enduring.
Increasingly, trends indicate that many RNs simply have lost trust in the industry; they've left the hospital setting and they are not readily coming back.
The health care industry and the numerous management consultants it employs have a catalog of explanations for the current shortage.
They cite an aging workforce - the average age of RNs is now 46 - and opportunities for women in other professions as long-closed doors in business, law and other male-dominated venues begin to slowly crack open. They note drops in nursing school enrollments and declining graduation rates. They blame the "invisible hand" of the market, which in supposedly neutral fashion dictates supply and demand, as well as changes in medical technology and patient care trends that require fewer nurses.
Not coincidentally, the industry analysts paint these factors as beyond their control. Notably absent from these clarifications is any recognition or accountability for the industry's own actions.
An assessment can begin with a brief look back at the last major nursing shortage in the mid-1980s. As noted by Judith Shindul-Rothschild, RN, assistant professor at the Boston College School of Nursing, that shortage was reversed when hospitals abandoned fragmented models such as team nursing and turned to primary care nursing, which enabled RNs to provide a patient's total care. The result was what Shindul-Rothschild calls a "renaissance in nursing," and RNs returned to the workforce.
Within a few years, however, virtually everything had changed. Nursing care no longer was prioritized as the health care industry had begun to systematically deskill, displace and deprofessionalize nursing.
Guided by market-driven goals of cost-cutting and profit-making rather than assurance of quality care, corporate health care firms began to implement restructuring programs in the corporate, clinical and technological arenas.
On the corporate level, large-scale mergers and acquisitions intended to increase market share and build economies of scale resulted in an unprecedented concentration of health care resources in the hands of a shrinking number of very large companies.
In the past six years, mergers and acquisitions have consumed an astonishing $453 billion in health care, concurrent with a rise in profits and executive stock portfolios, resources that could have been better spent elsewhere ......
(See Slide Show)
The binge was fueled by a 1994 change in U.S. anti-trust law (ironically, the only major change adopted by Congress in response to the Clinton administration's 1993 health care plan) that granted extraordinary latitude to merging health care corporations, reputedly to encourage competition.
The anti-trust law was reflective of the increased political clout of the industry. It was also a harbinger of vigorous lobbying against any policy legislation, including scores of health care reform proposals, that would inhibit its corporate expansion and profit generation.
Similarly the industry was successful in manipulating tax laws - for example, shifting assets from for-profit to non-profit entities to avoid taxation and regulations, such as moving patients to hospital units or other areas with lesser regulatory oversight.
To accumulate the cash needed for their expansion, and to pay off the staggering debt load they incurred, hospital corporations increasingly turned to squeezing labor costs - and nursing care in particular, their main source of expenditures.
At the bedside, management consulting firms like McKenzie, Booz Allen & Hamilton, American Practices Management (APM), Andersen Consulting and the Hunter Group, were paid hundreds of millions of dollars to implement work redesign models.
Carrying pleasing-sounding names such as Patient Focused Care or Population Based Care, the re-engineering was premised on models first introduced in the manufacturing sector of the economy and forced onto the health care workplace and direct caregivers.
The emphasis was on "just-in-time" production techniques that cut staff to dangerously low levels and only provided care for patients when they reached the periphery of crisis and presented a legal liability if they were not treated.
At their core, the redesign plans were intended to deskill and disempower direct caregivers. Most of the models featured the carving up of the care process into assorted "tasks," and shifting RNs away from hands-on patient care to serve as "team leaders" of unlicensed assistive personnel who would perform the tasks. It would mean replacing direct care RNs with unlicensed staff and RNs with advanced degrees who would supervise them.
New technologies also played a major role in the deskilling process, such as computerized diagnostic and treatment protocols that some institutions began to use in areas from bedside care to telephone advice.
Large numbers of RNs were simply laid off - Kaiser Permanente alone laid off 1,600 RNs in Northern California from 1994 to 1997, and a 1997 survey by the California Board of Registered Nursing found that 5 percent of respondents had left nursing due to downsizing.
Health care had been "transformed," the industry and its consultants proclaimed. With fewer RNs ostensibly needed in hospitals, hospital-based education and training programs for RNs were dropped. As hospitals signaled to nursing schools that fewer nurses were needed, education curricula and expenditures were cut back. Enrollments in entry-level bachelor's degree programs had fallen by 4.6 percent in the fall of 1999, although advanced degree programs were growing, according to the American Association of Colleges of Nurses. The Boston College School of Nursing was among the healthiest programs, with admissions flat rather than declining, Shindul-Rothschild said.
The restructuring programs had a huge economic cost. Kaiser Permanente alone spent about $100 million in only one year on its top four consultants - enough to insure at least 80,000 people.
Results for patients also have been disastrous. In an examination of more than 18.2 million patient discharge records from 1993-1997, a study by the Institute for Health & Socio-Economic Policy found that the proportion of patients admitted to a hospital in a given year who were well enough to be discharged home dropped 5.2 percent.
Industry attempts to limit admissions and reduce costs have forced many patients to seek the ER as their only means of access to a hospital bed of any kind. California ERs now account for almost 34 percent of all hospital admissions statewide.
And hospital-based errors leading to the deaths of up to 98,000 Americans every year have become a national scandal. Notably, the Institute of Medicine, which produced the findings, studied every conceivable variable except RN staffing ratios and deteriorating patient care conditions to explain the shocking numbers.
Patients are sicker than ever, and there are fewer RNs at the bedside.
Some states, such as New York, Massachusetts and Pennsylvania, have experienced steadily declining numbers of full-time RNs, coupled with a rising uninsured population. As more patients use the emergency room as their entry point to health care, RNs struggle with higher nurse-to-patient ratios and higher acuity levels of patients.
Click here to view charts of RN numbers in
Massachussetts, New York and Pennsylvania
In Maryland, the nursing shortage is reaching epidemic proportions. Dr. John Burton, director of geriatric medicine at Johns Hopkins Bayview Medical Center told a Baltimore Sun reporter that the staffing problems are "having a dramatic impact, and it's likely to get worse. We're headed for a crisis." Maryland hospitals are suffering nurse vacancy rates of 10 percent to 12 percent, with some hospitals facing a 20 percent shortage. The Professional Staff Nurses Association of Maryland, which represents nurses in six of the state's 55 institutions, reports that complaints on unsafe assignments or mistakes have doubled since the beginning of the new year.
Although Maryland hospitals are offering higher salaries and extra benefits like tuition or day care provisions, they aren't finding takers. The state's Board of Nursing reports that the number of registered nurses available for work dropped by about 2,300 from 1998 to 1999.
In other states, hospitals are also offering signing bonuses of $6,000 or more, seemingly to little avail.
A closer look yields disturbing information. According to the American Hospital Association, the number of California full-time employed hospital RNs peaked at about 63,700 in 1994 and has not quite attained that level since. But figures obtained from the California Board of Registered Nursing this year reveal that 266,800 RNs are licensed statewide and, of that number, about 248,000 are actively licensed.
So, where have all the nurses gone?
"All you have to do is talk to a direct care nurse to find out what the conditions are like," said Echo Heron, RN, and author of Tending Lives: Nurses on the Medical Front. "Forced overtime, working double shifts, having far too many patients to care for, then being asked to 'delegate' your work to a person with very little training, well, it all adds up. The hours. The strain. The stress on you, not to mention your family.
"And too many RNs feel that they aren't safe and their patients aren't safe," Heron said. "When nurses are overworked and exhausted, run ragged by too many patients, mistakes happen."
A Maryland nurse, who refused to give her name to a reporter for the Baltimore Sun for fear of losing her job, said that a nurse missed a very unsafe cardiac arrhythmia with one of her patients because she was busy with another one. Yet a number of Maryland hospitals assign ICU nurses three patients instead of the standard ratio of one nurse to two ICU patients.
Nurses across the nation are extremely concerned about the quality of care in their hospitals. A survey conducted by Fingerhut Granados Opinion Research revealed that 66 percent of RNs believe that "staffing levels are inadequate at the place where they work." Sixty-nine percent of them worried that "patients aren't getting the care they need." And 75 percent of RNs were concerned that "because of short staffing, a mistake affecting a patient will occur."
If we look at the evidence, we are forced to a conclusion about the nursing shortage.
Nurses are losing trust in their institutions and in their management. They are losing trust in the entire health care industry.
Nurses see speed-up at the expense of patient care while executives in the hospital chains where they work sit on wealth undreamed of only a few years ago. They see inner city hospitals closed while the companies shift services to more affluent communities, and they see the most vulnerable patient populations, including the poor, seniors, and some minorities, medically redlined and deprived of needed care.
They see ever-decreasing lengths of stay while acuity levels skyrocket, and sicker patients moved to the new patient dumping ground of "sub-acute" care. They see implementation of computer programs that reduce skills to tasks and unlicensed staff performing increasingly complex procedures.
They have so little faith in hospitals today that increasing numbers will not even recommend hospitals they work in to family members because they are not sure the facility will care for them properly.
"Our profession is mostly women, and it's true that there are more alternatives for women wanting professional careers," says Shindul-Rothschild. "But then, those slots aren't being filled by men, either. So you have to ask the question, 'Why aren't men coming into the field?' Whether male or female, people aren't entering the profession because of money. The salaries are competitive. And during the last nursing shortage in the '80s, nurses came back to the profession. We aren't seeing that happen today. So that leads me to the conclusion that it must be the working conditions."
Despite the negative consequences of the transformation of health care the past few years, the industry is gearing up for a new stage of deskilling and restructuring programs. They will be prompted by industry attempts to cope with the huge debt load created by the mergers and acquisitions, fallout from the 1997 cuts in Medicare reimbursements, and the recent wave of pharmaceutical mergers and the resulting increases in formulary prices as HMOs seek to pass costs to hospitals.
Most critically, the industry will use the excuse of the devout refusal of actively licensed RNs to enter a workplace they consider unsafe for themselves and their patients.
The mysterious workings of the market and employment opportunities for women elsewhere can not begin to explain the current shortage of RNs.
More likely, the industry shortage is a self-inflicted wound brought about by years of market- and industry-led restructuring programs that led to indiscriminate downsizing, increased patient complaints about the quality of care, deteriorating RN-to-patient ratios, and most critically, a marked loss of RN trust.
Just as the industry has created this crisis, it can help to resolve it. The industry can do its part to alleviate the RN shortage by adopting in word and practice a few simple principles:
* Value patients as human beings and not as "covered lives."
* Rather than expending resources fighting RNs and patients on safe staffing ratios, use those resources to enhance the ratios. The market is not able to set ratios that are safe for patients or that will assure adequate numbers of RNs.
* Trust in the professional judgment and skills of the bedside nurse to advocate for the patient.
* Terminate all contracts with management consultant deskilling programs and invest those hundreds of millions into preventative care and improving nurse-to-patient ratios.
* When RNs testify that many health care restructuring programs are a form of patient endangerment - listen.
* Accept that a profession dominated by women can and should earn a living wage commensurate with skills and dedication.
* Promote direct caregiver role models as opposed to nurse executive models. The archetypal nurse executive may appeal to an MBA student but is decidedly less appealing to those who value nursing as a noble and hands-on calling.
* Adopt RN work schedules that allow RNs some semblance of a normal life.
* Provide RNs with adequate retirement and health benefits.
* Provide increased funding for RN scholarships.
* Expand educational and training opportunities for generalist RNs to learn specialty skills, and for LPNs, LVNs and aides to become RNs.
* Work with nursing unions on projects to develop new programs for the future of nursing.
Most importantly, do whatever it takes to restore the traumatic loss of RN faith in the industry that they see as having forsaken both them and their patients in the pursuit of private wealth over and above public health.
That trust must be earned. It cannot be purchased with sign-on bonuses and certainly not with broken promises. The path back to that lost trust will be difficult. Common decency, an industry reaffirmation of the centrality of patient health in its mission and a commitment to the nursing profession that has made the industry one of the wealthiest in the nation demand it.
Click here to read how
nurses are fighting back against short staffing
