Cost Cuts Cited : Nursing: A Profession That’s Ailing

At least half a dozen times a day, Esther Warwick, a 120-pound, 5-foot, 2-inch nurse at Los Angeles’ Cedars-Sinai Medical Center, must struggle to move incapacitated patients who can be as much as twice her weight.

When Warwick went to work at the hospital, there were about 120 assistants at the hospital to help with such tasks and do other routine things such as wash and bathe patients. But no more.

“When I came here they were just laying off the nursing assistants,” she said. “It was a big change . . . from having someone help you to doing it alone.” These days, she said, “We’re rushed so much that sometimes I don’t get to spend the amount of time with patients that I’d like to.”

Physically Grueling

Although popularly perceived as an altruistic job in which practitioners mostly help rehabilitate patients, nurses say that their profession has increasingly become a physically grueling and emotionally exhausting one in the last four years as hospitals such as Cedars-Sinai have come under pressure to cut costs.

As the federal government, insurance companies and private employers have looked for ways to control medical costs, hospitals have moved swiftly in the last three years to treat patients quicker, trim overhead and reduce staff.

Not only must harried nurses often make do with less support but, increasingly, they must also cope with treating older and sicker patients as well as devastating new diseases such as AIDS, acquired immune deficiency syndrome.

Facing Burnout

The nation’s 1.8 million nurses “are facing burnout day in and day out, particularly when they are not getting the emotional reward of spending time with recuperating patients,” said Joel M. Bergenfeld, chief executive officer of Century City Hospital. “There’s no question in my mind that nurses are bearing the brunt of cost containment.”

The stresses began shortly after 1983 when Congress enacted legislation that changed the way the federal government paid hospitals for treating Medicare patients.

Under the new rules, a hospital is paid a fixed sum for the treatment of each ailment covered by Medicare. If a hospital treats a patient for less than the government fee, it can keep the difference. If it spends more, the hospital must suffer the loss.

Since Medicare fees make up about 40% of a hospital’s revenue, the incentives under the new system are obvious: the less a hospital spends, the more it profits. Usually that means shorter--and more intensive--hospital stays, which have fallen to an average of about seven days from 7.6 days in 1982, according to the American Hospital Assn. in Chicago.

“Since 1983 the patients in the hospital are much sicker and the hospital has become a much more stressful place because patients require constant monitoring,” said Margretta Styles, president of the American Nurses Assn. and professor of nursing at the University of California, San Francisco.

“All these people were thinking of was how to cut costs,” mused Styles, referring to the federal government architects of controlling hospital costs. “No one was thinking about the impact on nurses. It has really come back to haunt us.”

The legacy of cost controls has not been all bad news for nurses. The new climate of efficiency has led to some changes--such as computerized record-keeping and redesigned work stations--aimed at making some nursing jobs easier. And Richard Schweiker, the father of hospital cost control and U.S. secretary of health and human services from 1981 to 1983, said the economy measures have worked.

“Cost containment has done a good job of slowing down health care costs . . . and producing more efficiency,” said Schweiker, who is now president of the American Council of Life Insurance in Washington. But he said: “Nurses shouldn’t be made the scapegoat. I think that’s unfortunate if that’s the case.”

Plight of Nurses

The plight of nurses, however, may soon command the attention of consumers and health experts as a potentially long-term nursing shortage begins to take hold.

The number of job openings for registered nurses in hospitals more than doubled from 6.5% of the work force to 13.6% between 1985 and 1986, according to the AHA. The vacancies have sent health care executives, such as Century City Hospital’s Bergenfeld, as far away as London in search of nurse recruits.

That shortage, experts say, has been exacerbated by a narrow salary range that discourages nurses from spending a career in the profession. The average starting salary of hospital staff nurses in November, 1986, was $20,340, according to the American Nurses Assn. The average maximum salary for hospital staff nurses that year was $27,744.

Stressful Environment

The nurses who are signing up are finding hospitals a much more stressful environment. The casual bedside chat with patients that nurses once enjoyed has taken a back seat to more pressing matters.

Fear of medical malpractice litigation, for example, has produced more forms and paper work. Technology has produced more sophisticated tests to administer and interpret. And fewer aides have meant that nurses must struggle more often to do such things as push heavy gurneys and rush from room to room to bathe and move patients.

Hospitals say such changes have lowered costs and increased efficiency. But nurse Frank Ignacio said in his case administrators went overboard. He said officials at Hollywood Presbyterian Medical Center increased the work load so much that he was forced to take an eight-month medical leave of absence, starting last September, because of emotional and physical stress.

‘Cost Containment’

“When I came here in 1982 the ratio of nurses to patients (at Presbyterian) was about 1 to 3, which is ideal,” said Ignacio, 32. “Then after cost containment it went to 1 to 4. Now it’s about 5 or 6 to 1.

“I can’t tell you how many times I had to forgo my 30-minute lunch break because patients needed assistance,” Ignacio said. “And the patients were so sick it just became so depressing. It was affecting me emotionally and physically.”

Sari Weiner, a vice president at Presbyterian, conceded that nurses at Presbyterian must care for more patients but she said the work load is manageable.

“Of course it’s stressful to have (nursing) vacancies in your unit,” Weiner said. “But the people committed to caring for patients and clinical excellence are the people who are going to be able to manage.”

Care Is Compressed

Under the new system, the same care is frequently compressed into a shorter period of time. “Five years ago, if you had a baby you were probably in the hospital four days,” explained Connie Curran, executive director of the American Organization of Nurse Executives.

“The first day you were in labor, the second day you were feeling a lot better and the third and fourth day nurses were spending time with you teaching you things like how to feed and care for your baby,” Curran continued.

Now, “chances are you are not going to be in the hospital for days three and four,” Curran said, “and in a lot of cases you probably won’t stay for even two days.”

Experts said they don’t know whether the increased hustle and bustle is leading to more mistakes on the job. But at a time when hospital admissions are dropping both nationally and in California, complaints against all nurses in California rose 26% during the year to a record high 390 complaints for the 12 months ended June 30, 1986, according to the Board of Registered Nurses.

Board officials said better reporting and a 17% rise in the number of nurses since 1982 account for much of the increase in complaints. Yet other experts see a relationship between hospital economy measures, increased workload and nursing errors.

‘Feels Like a War Zone’

“Nurses are working double shifts and working overtime,” said Joyce Berger, director of Highland Hospital in Oakland. “I would say we are rapidly approaching a crisis point.” In the hospital today, Berger said, “it feels like a war zone.”

For some patients, such as Jay Freedberg, a Canoga Park electrical engineer who recently entered a San Fernando Valley hospital after having his left leg amputated in 1980, it simply seems some nurses don’t care as much any more.

“I had a situation where I rang the (nurse call) bell and waited three hours,” said Freedberg, 49, who was hospitalized for four days in March to check complications in his right leg. “It turned out that the bell was not working properly. I had to get out of bed--against my doctor’s orders--and walk to the nursing station. Their reaction was very complacent.

‘I Could Have Died’

“When I was in the hospital for the amputation, the hospital (staff) response time was much better,” Freedberg said. “This time I wasn’t critically ill but if I was, I could have died.”

Modern nursing began in the mid-19th Century when Florence Nightingale, the daughter of a wealthy Italian family, moved to England and began caring for the sick. Nightingale revolutionized nursing when she and a group of assistants went to Turkey during the Crimean War and began showing British authorities that skilled nursing care and improved sanitary conditions could greatly reduce the death rate of wounded British soldiers.

Today, registered nurses generally must complete college-level degree programs that can vary in length from two to five years. They take courses in anatomy, physiology, nutrition and psychology, among other things, and learn the latest in clinical technology.

‘Can Be Gratifying’

“It can be gratifying work,” said Richard Fraser, a nurse who coordinates the cardiovascular surgical intensive care unit at Encino Hospital.

Yet while many nurses, particularly those who work on specialized units, such as those devoted to pediatrics or diabetes, derive great pleasure from their jobs, others do not.

Said Martha Cerny, a 55-year-old career nurse who works in the medical surgical unit of the Medical Center of North Hollywood: “I’ve advised my daughter in college not to go into it. It’s a physically demanding job; you are on your feet all the time. Nursing is definitely not a job you can make a career out of.”

So far there does not appear to be any exodus from the profession. Rather, experts said, enrollment is down in nursing schools and many nurses are finding brighter career opportunities outside the hospital. More nurses are opting to work in doctors’ offices or for home health care agencies, which care for recuperating patients after they are discharged from the hospital.

Some experts, such as Roxane Spitzer, vice president of nursing at Cedars-Sinai, blame the media’s alleged negative portrayal of the profession in part for driving potential candidates away. She said, for example, that nurses are often portrayed on television as alluring sex objects with little job responsibility.

“I sent a letter to the producers of the Bill Cosby show suggesting that his son (Theo) become a nurse,” Spitzer said. “I think that would help improve the image of nursing.”

But nursing’s negative image is not entirely a media creation. Its reputation for long hours and low pay is earned.

Observed Stephen Bloomberg, a Beverly Hills urologist who frequently works with nurses when he performs surgery in area hospitals: “I think that nurses have one of the most difficult jobs in the work force . . . and the least appreciated. It’s a tremendous change from how they were regarded 20 or 30 years ago.”