Readers Digest article on nursing and patient's risk wiith non-licensed personnel

[nurs4kids]

I thought this was good publicity and a pretty well written article. This is from the September's issue of Reader's Digest .

How Hospitals Are Gambling With Your Life

By Andrea Rock

Reader's Digest

It was no routine inspection. The investigator who showed up at the Santa Rosa, Calif., hospital that June morning three years ago wasn't interested in checking for germs on table counters. Anonymous reports had come to her agency, the state's department of health services, claiming the hospital was endangering the lives of surgical patients. "We all had to go meet with the official, one at a time, in private," says a nurse who is on the hospital staff. "It created quite a stir. But a lot of people were relieved because they knew what was happening was wrong."

The official quickly uncovered the truth: An unlicensed assistant was performing surgical procedures, including suturing deep-tissue wounds and placing pins in bones. "Patients had no idea that the person doing these things could be an assistant without even a college education," the staff nurse says. Although the hospital denies that patient care was ever compromised, a quick end was put to the assistant's illegal operating career. Too bad it didn't put an end to the story. A survey the following year by the California Healthcare Association revealed that unlicensed staff was assisting in surgery in at least 20 California hospitals.

If you think this sounds a little scary, you're in for an even bigger fright. For what unfolded in California is only a symptom of something far more serious. In a six-month investigation, Reader's Digest has uncovered evidence that your health-even your life-is being put at risk in the last place you'd expect. In hospitals, doctors' offices and outpatient clinics, the person you may have the most contact with is not a physician or a nurse. It could easily be someone whose medical education consists of a few days or weeks of training, much of it provided on the job. It's someone who may not even have a high school degree and who, not long before, might have been cleaning tables in the hospital cafeteria.

The full price we are paying for this amateur care is tough to know because so many incidents are shrouded in secrecy. Lawsuits stemming from medical-staff errors are usually settled out of court, and then hushed up by gag orders.

Most of the nurses and aides contacted by Reader's Digest were willing to speak only if their names were not used. Several acknowledged that they'd been in situations where unqualified nursing care endangered a patient's health, yet they wouldn't discuss details for fear their employers would punish them.

Among those interviewed was a former aide in a Pennsylvania hospital, who spoke bluntly about her trials as an unlicensed assistant: "I often felt like I had a patient's life in my hands, and I was wondering, 'What do I do here?' I would be scrambling to take vital signs and respond to patients' calls. Then I'd try to evaluate what were the urgent things I should get a nurse for and what I could take on myself. It was wrong because I'm an aide, not a nurse."

Changing Roles for Aides

It used to be that the duties of unlicensed aides were limited to tasks that required little training, such as taking patients' temperatures, bathing them or helping them move from bed to chair. But during the past decade, pressures to slash costs have changed the aide's job, sometimes radically.

Nowhere was the money squeeze tighter than in hospitals, where Medicare payments were falling even as competition heated up for managed-care contracts. To boost their bottom line, hospitals hustled in management consultants who told them, among other things, to cut labor costs.

You didn't have to be a brain surgeon to figure out the next step: Unlicensed aides typically make $10 an hour, compared with $21 for registered nurses. So hospitals and clinics began hiring more "unlicensed assistive personnel," as they were called, who took on new duties previously carried out by registered nurses or licensed practical nurses (trained to a lesser degree than RNs). Inevitably, too many aides wound up in situations where they were dangerously over their heads.

Early one January morning in 1996, a woman in Hayward, Calif., called her doctor's clinic complaining of symptoms that were classic for an abdominal aortic aneurysm -- an extremely dangerous swelling of the artery that carries blood from the heart. Unknown to her, the medical-advice phone line was manned by unlicensed assistants.

She called four more times during the day, yet the aides decided she didn't need immediate attention. Not until late in the afternoon was the woman allowed to see a doctor, and by then it was too late. The aneurysm ruptured while she was being prepared for emergency surgery, causing her to suffer an excruciating death.

Horror stories like this shouldn't surprise anyone, given the wrenching changes in nursing staffs. According to Peter Buerhaus, senior associate dean for research at Vanderbilt University School of Nursing, some 100,000 unlicensed aides were hired by hospitals from 1995 to 1996, half of whom were let go the following year. Their numbers then remained relatively stable through 1999 -- the last year for which Buerhaus has solid calculations. To come up with his figures, he had to use U.S. Census surveys, since no one tracks the nationwide employment of aides in hospitals anymore.

"The American Hospital Association stopped collecting data on unlicensed aides in 1994, and a lot of nurses think they did it on purpose because they didn't want the public to know what was happening," says Christine Kovner, a nursing professor at New York University.

This suspicion is unfounded, says AHA Senior Vice President Rick Wade. He maintains that survey questions about the number of aides and other support staff hired by hospitals were eliminated for a practical reason. Confusing and inconsistent job titles, he says, made the task of identifying aides too cumbersome.

RNs Overworked, Stretched Thin

As for RNs, tens of thousands were cut by hospitals in the mid-1990s and then added back, according to Buerhaus. Lost in the shuffle were untold numbers of experienced nurses who, not coincidentally, made the most money.

Amid this staff turmoil, RNs have had to face additional burdens. Many find themselves hostage to huge piles of paperwork that can keep them from checking on their patients. "We're required to do much more documentation than ever before, both for managed care and for legal reasons," says Sandy Eaton, an RN at Quincy Medical Center in Quincy, Mass. "On one floor there is a ten-page paper that must be filled out each time a patient is admitted. And since only RNs are allowed to complete all those forms, they spend less and less time with patients."

Then there's the matter of the patients themselves. In trying to cut costs, hospitals have been quickly releasing all but the sickest patients, and RNs say they're bearing the brunt of it. Already stretched thin, they're now caring for people who have been shuffled out of the Intensive Care Unites (ICUs) onto other floors of the hospital.

As an RN with 30 years' experience describes the situation at her California hospital: "Patients who are still on ventilators or cardiac monitors are being moved out of ICUs to floors where there's one nurse for every five or six patients, rather than one nurse for every two patients as they would have in ICU -- the only place where I'd feel comfortable leaving a family member alone these days."

Even her daughter's presence at the bedside couldn't help 61-year-old Shirley Keck, who was hospitalized with a diagnosis of pneumonia in February 1998 at Wesley Medical Center in Wichita, Kan. Keck's condition steadily worsened, according to the later testimony of her daughter, Becky Hartman. Eventually, her mother "was ripping at IVs, drenched in sweat, literally gasping for breath," says Hartman.

Keck's daughter testified that for three and a half hours she begged for more help, but it appeared to her that her mother's nurse was always in a hurry. Hartman recalled hearing the nurse "bark out that they were understaffed, had been working six days a week, twelve-hour days, and that she could only get to one person at a time." According to Hartman, the severity of Keck's condition was missed by this nurse and others on the hospital staff who entered the room. Hartman also stated that at one point someone who appeared to be a nurse came into the room to check Keck's vital signs. When Hartman began asking questions, she testified, the woman told her that "she was sorry, but she was from pediatrics and they were short-handed. She would let the nurse know I was concerned."

Finally, Hartman put in a frantic call to her father, who was home ill himself. Returning to the hospital room, she was met by a nurse who said a chaplain was waiting for her. Her mother had gone into near respiratory arrest, but Hartman was told that "they had worked hard and saved her." "Saved her?" Hartman replied. "You did this to her!"

By then Keck's oxygen-starved brain was permanently damaged, according to a suit brought against Wesley by the Keck family. Keck's attorney asserted that under the hospital's own guidelines, at least five RNs, two licensed practical nurses and four aides should have been on duty. In fact, he contended, there were only four RNs, no LPNs and three aides to care for Keck and 41 other seriously ill patients.

The hospital has denied all liability, maintaining that the staffing of nurses and other professionals met appropriate standards, and that the staff was not negligent in monitoring and treating Keck. The hospital further claimed that the fault lay with doctors who misdiagnosed Keck and did not order proper treatment -- a charge the doctors denied. Last year, Wesley settled for $2.7 million.

Whether the issue is distracting paperwork or chronic understaffing, one result is clear: When you ring that call button, the odds have jumped that an unlicensed aide will come through the door.

Some health care experts think that the problems posed by these unlicensed aides are greatly exaggerated. "We've tried to reduce costs without affecting quality," says Michael Waters, a former chairman of the board of governors at the American College of Healthcare Executives. "Hospital errors do take place, but they are rare. I believe hospitals are very safe places to be. I don't want to see unlicensed aides doing things they're not qualified to do -- but you don't need an RN to change sheets or empty bedpans."

Hugh Greeley, a consultant to hospitals on medical-staffing issues, suggests reasons why nurses are raising concerns about these aides. "The nursing profession believes this is a serious issue," he says. "But it also believes that hospitals should be staffed with a greater ratio of nurses per patient, and that these nurses should be paid more."

In any case, Greeley says, there's no cause for worry in nationally accredited hospitals, because they don't allow aides to perform tasks that could endanger a patient's life.

That's not the experience, however, of a respiratory therapist who worked in an Arizona hospital. He says that over his 20-year career he has seen numerous patients nearly die because of the incompetence of unlicensed aides. "One time I went to check on a seriously ill patient whose oxygen mask had been taken away by an aide at lunchtime and left off for an hour," says the therapist. "His color was hideous and his lips were blue. If I hadn't come in, he might well have died."

It's also not the experience of Dr. Gordon Schiff, director of clinical quality research for the department of medicine at Cook County Hospital in Chicago. "I've seen cases of patients with heart problems and drug side effects that were not recognized in a timely way, because the first-line caregivers were poorly trained and poorly paid aides," says Schiff. "Multiply those cases across the country and you have tens of thousands of preventable errors each year that result in serious harm to patients."

Most unlicensed assistants, of course, are doing the best job they can, and for paltry wages. But too often their assignments bear no relation to their past experience.

"My husband had four-vessel heart-bypass surgery in March 1999, and when he had only been out of surgery thirty-six hours, his heart monitor was being read by people who just a month earlier had been in the dietary and housekeeping departments," says Kay McVay, president of the California Nurses Association.

She isn't exaggerating: McVay learned this from nurses in the ICU. It's common for hospitals to take workers from departments such as housekeeping and cross-train them to provide direct patient care, says Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania. In fact, other researchers say, those workers may go from mopping floors to taking blood pressure after just a few days of training.

A 1996 report by the Institute of Medicine, an affiliate of the National Academy of Sciences, revealed that most unlicensed assistants have no more than a high school degree -- and nearly one in five is lacking even that.

"When the person who interacts most with patients also has the least education, you'd better train them well and supervise them closely," says Mary Wakefield, director of the Center for Health Policy, Research and Ethics at George Mason University.

Lack of Standards

A nurse's aide who works at an Illinois hospital told Reader's Digest that her training for nursery duty consisted of a week-long orientation program and working for a month alongside a fellow nurse's aide. At times she's been left alone with a roomful of newborns, which makes her nervous. "I worry because if a baby suddenly starts choking or is not breathing, we are not qualified to handle that," she says.

Are hospitals like hers just ignoring national standards for training aides? Not really. There aren't any. Just check out the conclusion of medical experts in the Institute of Medicine report: "No accepted mechanism exists either to measure competency or to certify in some fashion that ancillary nursing personnel have attained at least a basic or rudimentary mastery of needed skills." Translation: 50 different hospitals could have 50 different ways of training their aides -- none of which may be adequate.

It's left to each state, individually, to regulate training, and most don't bother. The result is that overwhelmed aides either worry themselves sick or switch out of their jobs.

A former hospital aide in Pennsylvania told Reader's Digest that she was given a two-week training course on how to take blood pressure and other vital signs. During her first year on the job in 1996, there were two registered nurses, four licensed practical nurses and two unlicensed aides caring for 30 patients. But starting in 1997, the staff was cut so dramatically that often only one registered nurse and two licensed practical nurses worked with her to cover the same 30 patients.

"I was in the room with patients more than the nurses were," the aide said. "I did things I wasn't trained for, like taking out catheters and IVs, but the nurses asked me to because they didn't have time."

Increasingly scared that she'd harm someone, the aide transferred to a different department within the hospital. Judith Shindul-Rothschild, associate professor of nursing at Boston College, says that aides like this one are right to feel nervous, as should their supervisors. "It's hard to tell what the aides don't know," she says. Nancy Casazza, a 53-year-old RN in Walnut Creek, Calif., concurs: "If a patient with abdominal pain is feeling chilly, an aide might give him a blanket without taking his temperature or mentioning it to anyone. Yet that chill could be a precursor to septic shock, which can quickly cause death."

Did an aide's misstep cause a nearly fatal illness in the case of Archie Mayton? In the autumn of 1998, the tall, soft-spoken 66-year-old showed up at a walk-in clinic in Oak Ridge, Tenn., for a flu shot and a cortisone injection in the hip for his arthritis -- both routine procedures. Over the next week his hip began to swell and ache.

Worried, Mayton was taken by his wife to the hospital, where doctors quickly realized he was ill from a serious infection. One of the doctors suggested that Mayton be hospitalized, but agreed to treat him and then send him home with medication. A few days later, however, Mayton was back in the hospital in even worse shape. His kidneys soon stopped working, and a nephrologist was rushed in to get them going again.

Hospital surgeons cut an incision from Mayton's hip to his knee to discover the full extent of the infection. By now, it had spread to his bloodstream. The doctors urgently treated him and gave him more medication. It took nine months of painful recuperation, says Mayton, but eventually he healed. "It was a terrible time," says Mayton's wife, Janet.

The Maytons contacted their lawyer, who uncovered something stunning when she took depositions: The clinic's nursing staff was made up solely of unlicensed assistants -- including the woman who administered the shot.

"We were shocked and so angry," says Janet Mayton. Adds Archie: "I'm a barber and I have to have a license for what I do, so it never occurred to me that people would be allowed to do medical work without a license."

He has filed suit against the clinic, Park Med Ambulatory Care, alleging negligence in giving the shot. Attorneys for Park Med, which denies "any and all liability for Mr. Mayton's alleged injuries," say the clinic and its staff "acted appropriately at all times." They point out that, in Tennessee, it's legal to use unlicensed aides as office nurses and allow them to give shots. They also dispute "the nature and extent of [Mayton's] injuries and the cause of the infection," and assert that Mayton himself "greatly contributed to his injuries" by declining to be admitted the first time he went to the hospital.

Mayton, meanwhile, says he is living with pain and muscular weakness. "Lots of days I don't really feel good," he says.

What's In Store

If things don't change soon, there could be many more Archie Mayton-like lawsuits in the years ahead. For two storms are converging, with patients almost sure to be caught up in the tempest.

First, hospital executives may well be forced to hire even more unlicensed aides, because they're still under the gun financially, both from managed care and a slashing of Medicare reimbursements (cut by about $40 billion over five years beginning in 1998).

Second, it's predicted that the number of experienced RNs will significantly shrink as retirements and resignations fuel a serious nursing shortage. According to a recent University of Pennsylvania study, 40 percent of hospital nurses say they are unhappy with their present jobs, and one in five say they plan to quit within a year.

"I used to love being a nurse," says Nancy Casazza, the RN from Walnut Creek. "But now I only work four days a month in an ER because I hated being put in situations where I didn't have time to hold a patient's hand or give adequate care. There are nurses out there who would come back if conditions improve, but we're just waiting to see."

It could be a long wait.

Nothing is in the works that would hold aides to high nationwide standards. The Patient Safety Act, which would force hospitals to reveal how many aides and nurses they employ -- and the impact on patients -- has been hung up in Congress since 1995.

At least hospital whistle-blowers may get legal protection, thanks to the Patients' Bill of Rights-managed -- care legislation that could eventually get traction on Capitol Hill. Just ask Barry Adams how badly that's needed.

An RN in Boston, Adams was fired for saying, among other things, that unlicensed aides were making errors that could cost the lives of patients. Among the incidents he reported: "I was about to give a diabetic patient an insulin shot when I noticed she was eating a piece of candy. She told me the other nurse, who actually was an unlicensed aide, had suggested she have a piece of sugarless candy rather than food because she'd been vomiting since the previous day -- a fact that the aide never reported to nurses." Had Adams given the patient her insulin as ordered, he says she might have gone into a coma. In 1997 an administrative judge ruled that Adams had been fired unlawfully by hospital officials aiming to both silence and punish him. Two years later a Massachusetts whistle-blower law was on the books. Only a few other states -- California and New Jersey among them -- have similar statutes.

As a patient, your surest protection is your own insistence -- or that of your family -- that you get the care you deserve. Learn which procedures are best performed by RNs, and if you won't be able to monitor your own care, try to make sure that a family member or friend is on hand as your advocate.

Jean Gaddy Wilson of Marshall, Mo., knows how crucial this can be. She was constantly at her husband's bedside during his frequent hospitalizations following a kidney transplant. "I've had to change dressings myself that were left on my husband for twenty-four hours, even though the doctor ordered they be changed at least three times a day," she says. "Patients who don't have family members with them in the hospital are treated just like inventory sitting on a shelf."

Not that anyone is suggesting you avoid hospitals when you need serious medical treatment. But times have changed, and you should realize patients are, in a very real sense, guinea pigs.

"Boeing would never roll out a totally redesigned jet and fly it, untested, with a full load of passengers. But in many cases, that's what's happening with our nursing care," says George Mason's Mary Wakefield.

There's not a person who knows what the full consequences of this experiment will be. The aides themselves, though, have already seen enough. "I've worked in an oncology unit for twelve years," says a nurse's aide in California, "and it's changed so much. I really worry about the patients. It's just not fair the way they're being treated. Patient care is lousy -- and it's getting worse every day."

[P_RN, ADN, RN]

https://allnurses.com/forums/search.php?s=&action=showresults&searchid=9235&sortby=lastpost&sortorder=descending

Several folks have made comments on this article.

The use of UAP is here to stay as long as they can get someone to do it. Face it to the clipboard room $9 an hour equals 3 UAP for every RN (they don't have to hire). :\

[nurs4kids]

Guess I missed a few posts, prn. Impressed with your use of the board, love the link above..thanks. I didn't quite see it from the perspective of a LPN, and once again we are slicing our own necks arguing over petty issues. This article was NOT written to inform the public on job descriptions of RN's and LPN's. It did, at one point, mention that these tasks should not be carried out by untrained personnel and lists LPN's as trained.

"hospitals and clinics began hiring more "unlicensed assistive personnel," as they were called, who took on new duties previously carried out by registered nurses or licensed practical nurses (trained to a lesser degree than RNs). Inevitably, too many aides wound up in situations where they were dangerously over their heads"

The point behind the article is to point that we need LICENSED personnel performing assessments and making the judgement calls, not aides. I love CNA's, but I totally agree with the article. We will always need aids to help with patient's care, but not to independantly care for a patient.

As long as nursing (LPN and RN) continues to pick at the petty points of every piece of publicity and fog over the big picture, nursing will continue to suffer. We MUST leave our own inferiority complexes out of the issues!

[P_RN, ADN, RN]

N4 I absolutely agree!! There is no reason for the good to be destroyed from the inside like a cancer. We need to stand shoulder to shoulder instead of turning our backs on one another.

LPNs are great. I can't think of a one that I have worked with that I wouldn't trust my life to.

I have worked with some good UAP, but face it someone sick enough to be in hospital is entitled to the best that can be found. That best is a licensed person!

The UAP-(and I am NOT counting student nurse technicians (by any title their employer gives them) as UNLICENSED....they are PRE-licensed personnel) has not much to lose, not much to gain. We have a lot to lose and hopefully a lot to gain.

[oramar]

My SIL was a trained medical assistant. She went to a dialysis clinic to work. She quickly found herself dealing with life and death situations that she felt ill equipment to meet. The RNs at the clinic were spread very thin. Being a intellegent person my SIL realized someday someone would be killed or injured due to her lack of knowledge. She said she could not live with the fear. She now works for post office.

[oramar]

I did a post once about a friend who is a medical records clerk in a doctors office. The doctor started to take her in to assist with exams. She was running into situations that made her feel in over her head. She called me up to ask for advice. I told her "nope, I couldn't help, tell the doctor to hire a nurse". I figured she was not working off of my license.