Nurse Registries Hailed, Assailed by Hospital Staffs

It is 6:45 a.m., and the medical reinforcements are arriving at Kaiser Permanente’s towering Panorama City hospital.

Half a dozen nurses and attendants in sensible shoes and collarless white shirts, part of a small army of temporary medical workers brought in each day to staff Southern California hospitals during a continuing nursing crisis, sign in near the bustling emergency room.

“We need them to function,” said Anita Zermeno, operating room nursing supervisor. But while most of the temporaries are capable, Zermeno said, some have such limited abilities that she must give them easy assignments. She also orders a staff nurse to watch over them, which she said is galling since a temporary nurse is paid at least $5 an hour more than a staff nurse.

“Here comes someone getting the big bucks and all they can do is a hysterectomy,” Zermeno said. “Give me a break.”

40% of Staff

A national nursing shortage has made a number of medical facilities reliant on agencies, commonly known as registries, that supply temporary nurses and attendants. In some hospitals at times, 40% of the nursing staff is from outside registries, while the figure is as high as 80% in some nursing homes, health-care specialists said.

Some hospital officials now see the registries, once considered a solution to staff shortages, as a part of the problem. Critics said that registries are competing with institutions for nursing school graduates and are draining off staff nurses by offering pay that hospitals cannot match.

Members of an association of state nursing homes grew so frustrated that they persuaded Assemblyman Gerald N. Felando (R-San Pedro) to introduce legislation that would put the agencies out of business--even though without them many hospitals and nursing homes would have trouble staffing their facilities. Felando put the bill, sponsored by the California Assn. of Health Facilities, on hold after the registries rose up in protest.

“If I had my druthers, they would not exist,” Donna Robinson, associate director of nursing at Olive View Medical Center in Sylmar, said of the registries.

Experts say the nursing shortage was brought on by a changing business climate that has made traditionally male-dominated careers more attractive to women who ordinarily might choose nursing as a vocation.

At the same time, some nurses are deciding against the long hours and pressure of working on a hospital staff. If they go to work for a registry, they can pick and choose from the jobs offered. They can turn down a job if they don’t like the hours or the hospital. If they feel like taking a vacation, they can just go.

They also earn more money because hospitals pay premium rates to the registries for skilled nursing personnel, although the difference in wages is partly offset by the health benefits offered to hospital staffs.

A registered nurse is paid $15 to $17 an hour to work in a nursing home, while registries may pay upward of $27 an hour. Olive View, a public hospital run by Los Angeles County, pays $573.50 to the registry for a nurse to work a single, 12-hour shift on the weekend in critical care.

“Our business is doing very, very well now,” said Pat Donohoe, vice president of business development for NSI Home Health Care.

The industry as a whole is booming, according to health-care observers. Hospital nursing supervisors said they get several calls a week from new registries springing up. “It’s a gas war out there,” Penny Hammer, nursing supervisor at Valley Presbyterian Hospital in Van Nuys, said of the competitive market.

Figures on the usage of registry nurses at hospitals demonstrate the importance of registries to the delivery of health care.

Rising Costs

In the 1986-87 fiscal year, Los Angeles County paid $1 million for temporary nurses at its six public hospitals, including Olive View. In the previous fiscal year, the figure was $3.3 million. This year, it is expected to soar to $12 million, officials said.

The University of California’s teaching hospitals have seen a similar growth pattern. UCLA Medical Center spent $2.4 million for registry nurses in the last nine months of the 1986-87 fiscal year, according to figures gathered by the California Nurses Assn. That amount nearly tripled last fiscal year, to $6.1 million.

All this has put the nurse who is looking for work in an advantageous position. “Every registry in town is fighting to get that nurse,” said Carmen Baker, regional director of STAT Nurses Registry, which has an office in Granada Hills.

The increasingly competitive market among registries has caused some of them to begin offering benefits and even bonuses and vacations to nurses to encourage them to sign up. Several agencies have resorted to hiring nurses over the phone, without checking their credentials, some hospital officials say.

This has led to problems. Hammer said one agency sent a nurse attendant who was unable to take a patient’s temperature. The attendant, it turned out, had never worked at a hospital before. “I called the registry. They had not checked her references. They just put her to work,” Hammer said.

Dangerous Errors

In other cases, Hammer said, nurses have showed up in clothes so dirty that they had to be sent home to change. One temporary nurse administered a potentially fatal dose of medication to a patient, Hammer said. The patient survived.

And another nurse assistant at Valley Presbyterian cursed a patient who was complaining of pain. “She said, in effect, ‘It’s in your head.’ She fired four-letter words off” at the patient and at the hospital and walked off the job, Hammer said.

Despite the criticism, however, nursing supervisors agree that the vast majority of registry nurses are skilled professionals who know their jobs as well as most staff nurses.

“We screen very carefully,” Baker said. “The nurses that we send out are highly qualified.” Before sending a nurse on a job, STAT checks to see that the nurse has at least one year of hospital experience, as well as experience in cardiopulmonary resuscitation and a nursing license.

“The mama-and-papa registries are the ones that are hurting us,” Baker said. “When we refuse a nurse, they sign up with the mamas and papas who are working out of their homes.”

Chip Baker, director of human resources for ARA Living Centers, a large nursing home company in California, said there are many “fly-by-night” agencies.

Horror Stories

Jean Orr, chief of the state Bureau of Personnel Services in Sacramento, has heard the horror stories. Although her office is supposed to regulate the industry, the vast majority of registries are not required to file papers with her, or are operating outside the law. Only 50 agencies are registered with her office, she said.

“You can find 50 in any community of Southern California right now,” she said.

By law, nursing agencies must register with her office only if they require employees to pay them a fee to work. Many are paid directly by hospitals. Then there are others that operate without required licenses, she said.

“If you’ve got white shoes and a clean white shirt, you can be a nurse’s aide and open a registry,” she said. “There is a whole unregulated industry out there. No one really has a handle on it.”

Hospitals Blamed

In the eyes of Rose Ann De Moro, assistant director for collective bargaining of the California Nurses Assn., the hospitals have only themselves to blame for the situation. Hospitals would be better able to hang on to staff nurses if they paid them more and gave them more freedom in setting their hours, she said.

“Hospitals are making registries a very appealing place to go,” she said. “It’s not like registries are out there trying to overthrow the hospitals.”

Now nurses are feeling their power. “You’re seeing a whole different kind of nurse these days,” said Shirley Hamill, associate director for the Western United States of Upjohn Health Care Services, which operates a nursing agency. This new crop of nurses is more assertive, she said.

Nursing agencies “give them another option to keep them in the hospitals,” said William York, executive director of AMI Health Care Staffing, a nursing agency.

Problem Worsens

But spokesmen for health-care facilities say just the reverse is happening--nurses are being drained from the hospitals. Registries have “worsened the situation,” said David Helmsin, a spokesman for the California Assn. of Health Facilities, which represents nursing homes. Registries “are like vultures almost, feeding on a big problem.”

The agencies have not only forced hospitals to compete with them for nurses, but with one another, critics say. Hospitals with bad reputations, or in poor areas, may find it difficult to locate even a temporary nurse on some days.

Robinson at Olive View said it can take as many as 44 phone calls to find a nurse. Then, “it’s not unusual for a registry to call two hours before” a shift begins “and say, ‘Nurse Jane Doe cannot work for you.’ We do a little checking and we find Nurse Doe is at Northridge” Hospital Medical Center, Robinson said.

The situation is magnified in nursing homes, which run on slim financial margins because they depend more heavily on government reimbursement. They cannot afford to pay nurses what acute-care hospitals pay. As a result, keeping staff becomes difficult.

Changing Staff

Nursing home officials said some facilities are run almost entirely by employees of registries, which may change daily. A nurse on the floor only one day may not notice signs that a patient is deteriorating, officials say.

State law requires three hours of nursing care per patient a day. It also requires that a registered nurse be on duty at all times at larger facilities.

Nursing homes have trouble attracting required ancillary staff, which include nurse’s aides, and hire registry personnel at up to $20 an hour for jobs that normally pay about $5 an hour.

The result is a strain on budgets. The cost of registry employees for ARA’s 30 California nursing homes doubled from 1987 to 1988, and there is a chance that it will double again this year, officials said.