Ailing Profession : Nurses Hurt by Recession and the Hiring of Less-Educated Medical Assistants

THE REGION —  Registered nurse Cindy Keen loved the parts of her job at City of Hope National Medical Center that had nothing to do with taking blood or giving medication. The parts such as knowing how to take a 6-year-old cancer patient’s mind off the tumor that left her tiny stomach swollen by playing her favorite video or offering her a favorite food.

Keen, who lost her job following a contentious two-week strike in June, worries that she won’t find another nursing job like that. At worst, she fears, she will find no work at all.

In a dramatic change from six years ago, when a severe nursing shortage caused nationwide panic, Keen and 46 other nurses from the Duarte hospital whose jobs were filled by replacements are struggling to find steady work.

These nurses’ dilemma reflects a nationwide downturn in the nursing industry, caused by twin factors: the recession and a movement by hospitals toward hiring less-educated staffs, including licensed vocational nurses and unlicensed assistants, said Arthur A. Sponseller, a senior vice president of the Hospital Council of Southern California.

In the mid- and late-1980s, frantic hospitals were flying in nursing recruits from abroad. Newspapers bulged with help-wanted ads for nurses, and competing hospitals tried to outbid each other to woo new hires.

That was a time when the percentage of unfilled slots for registered nurses averaged 21% per hospital in California. By 1991, the most recent statistics available, the vacancy rate in California was 9%, according to the American Hospital Assn., a trade group in Chicago.

At Southern California hospitals, new hires totaled 22.5% of registered nursing staffs in 1987; that figure dropped to 12.8% in 1992, according to the Hospital Council of Southern California’s survey of 100 acute hospitals.

The turnaround means that, to make ends meet, some of the replaced City of Hope nurses are refinancing their homes, dipping into their children’s college funds or abandoning the business for new fields.

Pediatric nurse Keen is scrambling for work as a temporary replacement nurse through a registry that hospitals notify when they are short-staffed. Every morning, she gets awakened by a 5 a.m. telephone call that usually tells her there’s no work for the day. For a nurse who thrives on a human touch--she used to take home the clothes of sick children and wash them if their families weren’t around--the change is jarring.

“It’s degrading, to say the least,” said Keen, a 25-year nursing veteran. “I do have some expertise. . . . No one seems to care. No one seems to want it.”

Meanwhile, her husband, who owns a pool maintenance service, supports the family, which includes their two teen-agers.

About 80% of the City of Hope’s 450 registered nurses walked off the job on June 15 after contract negotiations failed to resolve disputes over job descriptions and time off. A week later, hospital officials started hiring permanent replacements, saying that they did not want to jeopardize patient care in a potentially prolonged strike. Fifty-one of the striking nurses were replaced because the others returned to work before replacements could be hired; and four of the replaced nurses have since been rehired.

But the 47 remaining are finding that where once they could have had their pick of jobs, the pickings are now slim.

Nurse Gloria Diaz, who worked in the bone marrow oncology unit, is “waiting for the bank to write me a foreclosure note.”

Her husband lost his aerospace job in March. The couple will have to pull their 11-year-old son out of private school to make ends meet. The couple also have two girls, ages 7 and 6.

“I thought this would be a lifetime place of work for me,” said Diaz, 40, a 19-year nursing veteran who applied unsuccessfully for work at seven hospitals.

The nursing shortage gave her a false sense of security--and now the move toward less trained health-care workers leaves her embittered.

“I can do the work that an aide or an LVN can do, but an LVN or aide can’t do what I do,” she said. “It’s become a business. It’s just a trend of the time. Everything now comes down to how much it costs and how much will (hospitals) gain from it.”

Nurse Ruby Allen, 32, is refinancing her family’s La Crescenta home while she looks for work and cares for her 1-year-old daughter. She’s relying on her husband’s income as a manager of a door manufacturing company.

Allen feared that the hospital was trying to force registered nurses into supervisory roles.

“I didn’t become a nurse to become a supervisor of LVNs and aides,” she said. “The bedside nursing thing is being taken away from the RNs.”

City of Hope nurses had walked out partially because of a management proposal to change job descriptions in their contract. They believed that the hospital was opening the door to cut back on registered nurses by hiring unlicensed workers, some of whom would have no high school diploma and only a few weeks’ training, said nurse Kathy Patane of the California Nurses Assn., which represented striking workers.

Meanwhile, the replaced RNs are finding that the only nursing jobs they can find are ones they’d rather not take, such as the overnight shift in a nursing home, she said.

“The RN at the bedside is going to be a novelty,” Patane said. “You’re going to find overqualified people looking for jobs that at one time they would never thought of applying for.”

Hospital officials deny that they intend to push out RNs, saying they want only the right to update job descriptions annually, based on changing needs.

But nurses point to a handout from a hospital training seminar last fall on a proposed “Partners-in-Practice” plan to team registered nurses with licensed vocational nurses, nursing students and unlicensed assistants. The team-nursing system “provides critical relief to the issue of RN scarcity,” the handout said.

Under such a system, registered nurses supervise assistants, who take over non-medical duties such as making beds, delivering meals and moving patients. Other assistants--licensed vocational nurses and technicians--relieve registered nurses of some medical duties, such as drawing blood or taking a temperature.

Hospitals can save millions of dollars each year by beefing up their staffs with licensed vocational nurses and other assistants instead of registered nurses. At the University of California, San Francisco, a similar system saves the two campus medical centers about $3 million annually; at UCI Medical Center, the savings is about $1.5 million, according to officials at the facilities. In both cases, the savings is roughly 3% of the total budget.

The movement started as a way to deal with the ‘80s nursing shortage, which was one of the most serious in U.S. history.

But City of Hope officials said their aim was not to save money and that a partnership system does not necessarily call for fewer registered nurses.

“What we were interested in doing is looking at the Partners-in-Practice model as a mechanism to enhance professional practice,” said Rebecca Ropchan, the hospital’s vice president of nursing.

Ropchan said that details for the Partners-in-Practice plan had never been finalized. The plan, which was scheduled to begin in July, was delayed while hospital officials dealt with the strike. She declined to provide details on how the plan would work.

“I wish I could be more specific, but because we haven’t implemented anything yet, I can’t give you any concrete examples,” she said.

Locally, administrators at San Gabriel Valley Medical Center, Huntington Memorial Hospital and Inter-Community Medical Center said they are developing plans to begin team-nursing systems. Administrators at Methodist Hospital in Arcadia and Pomona Valley Hospital Medical Center said they are considering such a system.

The woeful economy has also forced hospitals to review their staff budgets as bed counts steadily drop, meaning less income. In the San Gabriel Valley, the fourth-quarter occupancy rate dropped from about 56% in 1990 to 52% in 1992, according to the Hospital Council of Southern California.

Experts say that most hospitals can no longer afford a staff of all registered nurses.

“The public can no longer expect an RN will do certain things for them,” said Nancy Potash, nurse manager of acute pediatrics at UCLA Medical Center. “They can expect an RN will check to make sure things are done right.”

Advocates say the Partners-in-Practice system frees nurses from routine tasks to concentrate on the patient’s medical care. Critics say hospitals are skimping on registered nurses and forcing the remaining ones to spend little time with patients--time that they use to pick up subtle changes in breathing, skin color and other red flags that unlicensed workers are not trained to notice.

A bill pending before the state Assembly would limit the role of unlicensed hospital workers in patient care to work that requires no medical knowledge. The California Nurses Assn. has lobbied for the bill.

But some nurses embrace the trend toward using less-educated aides.

“It makes my job so much easier,” said Lee Ann Bruhn, a UCLA Medical Center pediatrics nurse, who heads a partnership team. “I can concentrate more on patient care . . . I can have time to do teaching and discharge planning and making the patient stay the best possible without having to worry about getting all the beds changed and baths done.”

The move is toward efficiency, not an underhanded scheme to show registered nurses the door, said Dr. Ben Shwachman, president of the Los Angeles County Medical Assn. and a Covina anesthesiologist.

“There is no goal . . . to phase out nurses or RNs,” he said. “That simply is not so.”