Condition: Critical : They usually shun activism. But threats to patient care and their profession have pushed nurses over the edge and onto sidewalks in protest.

TIMES HEALTH WRITER

In Washington, 5,000 nurses march down Pennsylvania Avenue to protest nursing layoffs.

In Redwood City, Calif., nurses picket a hospital after administrators trimmed R.N. jobs.

And in Illinois, nurses hold a public hearing to discuss whether firing dozens of hospital nurses is hurting patients.

So Los Angeles County nurses were not alone in their bold actions taken last week to protest massive cutbacks in the public health-care system.

"The nursing profession is an advocacy profession--we are always advocating for the patient," says Patricia Lopez, an OB-GYN nurse practitioner at Roybal Comprehensive Health Center in Los Angeles. "Since we are the ones who see what [layoffs and clinic closures] do to the patients directly, that translates to action. We can't stand to see the level of care reduced."

But, perhaps for the first time in their storied history, registered nurses are also standing up for themselves and the future of their profession.

"You rarely see this kind of action," says Sara Foer, a spokeswoman for the American Nurses Assn. (ANA), of the sickout by L.A. County nurses. "There have been very few nurses' strikes. But these people have been pushed to the edge."

Indeed, history has shown that nurses favor quiet activism over ruffling feathers, says Bonnie Bullough, a professor of nursing at USC who has studied the field for 40 years.

"They don't come forward easily; they're really pretty shy. It takes an extreme happening to get them to come forward," she says. "They have always felt that their focus should be patient care. So they have not been active in the broader political arena."

Their engagement in political activism may be changing, however, because nurses now see two threats: what they say is the decline of patient care because of the shift to managed care and the decline of their profession.

"Every state is reporting layoffs of nurses and the increasing use of part-time and less-skilled employees," says Anna Gilmore, director of labor relations for the Washington, D.C.-based ANA. "We've never seen hospitals go to the lengths they have today with laying off nurses and replacing them with lower-paid workers."

Nurses often refrain from typical labor-union tactics such as strikes or sickouts out of concern for their patients, Gilmore says.

"These nurses must be very, very concerned to take this kind of step. It's not taken lightly or without concern for their patients," she says.

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Calling in sick as a form of protest is not without risk, others say. Nurses are bound by a professional code that demands they do nothing to compromise patient care. Some members of the County Board of Supervisors criticized county nurses for endangering the lives of patients.

"Nurses, in particular, are in a position of responsibility with respect to the day-to-day health of their patients," says Ellen H. Moskowitz, an associate for law at the Hastings Center, a medical ethics think tank in Briarcliff Manor, N.Y. "That doesn't mean, to me, that nurses ought to be prohibited from striking or taking other labor actions. But any decision should take into account their primary responsibility, which is patients."

The traditional view of nurses as individuals who put others' needs before their own has led to a reluctance among nurses to even join labor unions. Only about 17% of the 2.2 million R.N.s nationwide belong to unions, the ANA says.

"Even when nurses began to unionize in 1971, many came to unionization with a lot of doubts," Bullough says. "Many thought it was self-serving, that they should be patient-oriented. They have this guilt about thinking of themselves. I think it's only this time, because it involves their own welfare and their patients' welfare, that they are coming forward."

But layoffs of registered nurses--who earn an average of about $34,000 a year--are widespread in the United States, ANA officials say. Various estimates show that 200,000 to 300,000 nurses may lose their jobs this decade as hospitals and clinics look for ways to cut costs.

"As hospitals are restructuring, nurses are being laid off or replaced with unlicensed personnel, such as nurses' aides and nurses' assistants," the ANA's Foer says. "The person who is faced with layoff is the staff nurse--the R.N. who works at the bedside."

Nurses who hold advanced degrees or training, such as nurse practitioners, nurse anesthetists and midwives, are more likely to keep their jobs because they are performing duties once held by higher-paid physicians, Foer says. About 100,000 R.N.s nationwide hold advanced degrees or training.

But even these nurses are subject to layoffs and often have to accept lower salaries to land another job.

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Part of the ANA's mission is to alert R.N.s to nursing jobs that may be in demand, such as home health care, private practice or advanced-practice nursing. But Foer says the organization is fighting to preserve the need for the "bedside" nurse primarily out of concern for patient care.

Always considered a mainstay of health care, hospital staff R.N.s are now having to prove their worth, experts say.

"We are trying to conduct more research to show that nurses at the bedside really protect the patient; that more nurses means shorter length of hospital stays, fewer complications and readmissions," Foer says.

Hospital admissions have been shrinking over the past decade as health-care providers emphasize the use of more economical home-based or outpatient care whenever possible. But that trend conflicts with the use of less-skilled hospital caregivers, says Gilmore, the ANA labor relations director.

"Hospitals are taking care of patients who are much sicker and for fewer days. But they're trying to provide care with a minimally skilled person," she says.

A survey of ANA members released earlier this year showed that nurses are seeing more medication errors, patient falls and less efficient hospital service.

Whether the trend in use of less-skilled personnel is eroding the quality of patient care is even the focus of a study by the government-sponsored Institute of Medicine.

Indeed, Los Angeles County nurses say their protest was motivated as much for their patients as themselves.

"The message we're trying to put out is, 'What about the patient? What about the public?' " says Rosie Martinez, a public health nurse at Olive View Medical Center, a county facility in Sylmar. "We are a highly skilled profession. When they try to put in nurses who are less skilled, we see this as an important advocacy issue. We want patients cared for properly."

Lopez says that after she was notified of Roybal's closing (which is now in doubt with the federal financial aid package promised by President Clinton on Friday), she could barely look her patients in the eye.

"It was devastating," Lopez says. "We are the ones who will see what the cuts will do to patients directly. We can't stand to see the level of care decline. We have to be able to face ourselves in the mirror."

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Darlene Moore began working for the county 38 years ago as a licensed practical nurse. She continued to study, eventually earning her R.N. and nurse practitioner degrees. Although she was not served a layoff notice by the county, she often thinks of the numerous opportunities she could have had in the private sector.

But Moore says many of the county nurses want to care for the disadvantaged and under-served people who are drawn there.

"It's about treating someone who smells as if they had just climbed out of a garbage can with the same respect and dignity as a wealthy person," Moore says. "We feel like we are advocates for the poor. I've had patients calling me this week saying, 'Darlene, what is going to happen to me?' "

Moore, a specialist in treating diabetics at County-USC, says she is particularly worried about the threatened closure of a clinic at the hospital that serves pregnant diabetic patients. Pregnant women with diabetes must be carefully monitored to avoid giving birth to babies with serious health problems or birth defects, she says.

"I have a 200-patient caseload," Moore says. "My function is to keep them out of the hospital. But if these patients don't have clinics to go to, the hospitals will be flooded.

"That is what this is all about: My patients and their families and keeping them as healthy as possible."

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