Hospital Nurses Feel Pain of Health System’s Restructuring

It was midnight on May 15 and Kathie Gayle had just finished caring for no fewer than 11 seriously ill patients during her nursing shift at Inglewood’s Centinela Hospital Medical Center.

When Gayle, a licensed vocational nurse, left that night, her legs ached so badly and her ankles were so swollen that she wondered how she would manage the walk across the parking lot to her car. But things were to get worse.

When she showed up for her next shift, she was told she would be in charge of giving medications to 22 patients--in a unit of geriatric patients, with whom she had limited experience. A maternity nurse, used to working with newborns and their mothers, Gayle immediately thought of the things that could go wrong.

She wasn’t used to administering the types of medications the elderly patients were getting. Some of the patients had suffered heart attacks or experienced kidney failure. Others had advanced diabetes, while still others required intravenous feeding or machines to help them breathe.

Trained nurses can tell from the color or shape of a pill whether it’s the right one, but Gayle wondered if she would recognize a mistake if one was made by the pharmacy. She also feared she might miss a warning of patient distress, such as a change in breathing pattern or skin coloring.

It was then that Gayle decided to end her six-year job with the hospital. She walked back out the doors and has not returned.

“I said this is crazy, no one should have to work like that,” the nurse said. “They wanted us to do the work of three nurses.”

Now she treats patients in their homes as a home health-care nurse.

Gayle is one of the casualties in the massive restructuring of the country’s medical system set in motion by the shift to managed care. Almost overnight, the restructuring has changed the world of nursing and patient care within the nation’s hospitals.

Whether they leave voluntarily or are forced out, nurses who staff hospital wards are among those feeling the biggest impact as hospitals across the nation wrestle with the demands of managed-care medicine by downsizing, restructuring and laying off thousands of health care workers in the process.

In a survey of the executives who run 681 acute-care hospitals, the accounting firm Deloitte & Touche said that more than one-third reduced their staffs in 1995. The same report said morale among hospital workers was at its lowest since the surveys began in 1989.

“What our members are saying, on a daily basis, is, ‘I just can’t keep up anymore,’ ” said Kit Costello, president of the 25,000-California Nurses Assn. Most, she said, are trying to cope and have not reached the point of walking away from their jobs.

With competition for managed-care contracts forcing cost containment, and advances in technology and surgical procedures shortening hospital stays, hospitals are faced with empty beds and declining revenues.

*

Hospitals reporting a decline in nurses say the drop-off mirrors a reduced number of patients. They also say the need to downsize and contain costs has led to an increase in support staff for nurses and a more defined role for registered nurses.

These nurses’ assistants perform vital medical tasks that registered nurses traditionally do, such as taking blood pressure and electrocardiogram readings, as well as chores like cleaning bed pans and giving baths, which nurses also have done.

“We are much smarter now,” said Susan Harris, spokeswoman for the California Hospital Assn. and a registered nurse. “We are using highly trained professionals, the RNs, to do work that nurses should do, like working with families, planning discharge needs, educating patients. They don’t need to be passing food trays, making beds, turning on the TVs. Those things others can help with.”

Still, the thinning of the nursing ranks, at a time when managed care is keeping all but the sickest patients out of hospitals, has raised questions about the quality of care in hospitals and whether they are being adequately staffed.

Critics say the unlicensed or less experienced health care workers who are taking over jobs once handled by nurses often have only a few weeks training before being sent out to the wards, where they work under the direction of registered nurses. These workers come from a wide variety of backgrounds, but mostly from other jobs in the health-care industry, according to interviews with hospital administrators and nurses’ assistants. For some, the jobs are a step up from housekeeping or patient transportation services, for others a stop-gap job leading to nursing or medical school.

Just how many hospital staff nurses have lost their jobs is unknown.

National job statistics kept by the American Hospital Assn. show that there was a 2.5% increase in the number of registered nurses last year. The problem is that nurse staffing data include outpatient clinics, a strong growth area for nursing jobs, and consequently do not reflect the decline in hospital nursing positions.

*

Concerns in Congress about the complaints by nurses unions that staffing is at dangerously low levels led to a 22-month study of the adequacy of nurse staffing by the Washington, D.C.-based Institute of Medicine, which is part of the National Academy of Sciences. In the study released earlier this year, the researchers found they could not get enough data to answer the questions.

“Hospitals say the number of nurses is actually increasing,” said Charlene Harrington, a professor and researcher at the University of California San Francisco School of Nursing, who worked on the study. “But nurses at the bedside appear to be decreasing. It is very hard to get data.”

A Chicago-based placement firm for nurses and other health industry workers, Challenger, Gray & Christmas, said in its annual survey of the hospital industry that hospitals eliminated the jobs of 23,075 doctors, nurses, technicians and others between 1993 and 1995. During the first five months of 1996, the survey said, another 8,169 layoffs were announced. There was no breakout on the number of nurses who lost their jobs.

“There is no question that there is real pressure on registered nurses and licensed vocational nurses,” said John Challenger, a vice president of the firm.

The trend is a marked departure from the 1980s, when dollars flowed freely into hospitals and there was such high demand for nurses that industry observers said they could write their own ticket.

“Some nurses want things to run the way they did in the 1980s,” said Ted Braun, a spokesman for Santa Monica-UCLA Medical Center. “Unfortunately, times have changed and hospitals have had to change with them. Every hospital in Southern California is facing the same challenge. You can’t staff one nurse for each person except in the critical care unit. That doesn’t mean patients aren’t getting quality care.”

In Southern California, Kaiser Permanente has been among the largest hospital chains to announce cutbacks. Systemwide, Kaiser said, it has eliminated 2,000 jobs in its 10 Southern California hospitals since 1993, about 800 of them nursing positions.

At Kaiser’s huge medical center on Sunset Boulevard in Los Angeles, administrators say there has been a 30% drop in patients in the last three years and a corresponding 20% drop in the nursing staff. The implication is that nurse staffing actually has improved.

At UCLA, there are 650 full-time positions for nurses, down about 60 job slots from five years ago, university officials said. At the same time, the number of unlicensed staff in nursing wards, known as care partners, has grown from 30 to 120. The way the university sees it, there is more staff on the floor and, since each care partner works under the direction of a registered nurse, there is the same level of expertise.

“The care today is just as good as it was five years ago,” said Heidi Crooks, UCLA’s director of patient care services. The California Nurses Assn., however, contends that UCLA is targeting its most experienced nurses, who are earning the highest salaries, for layoffs--depriving patients of an invaluable amount of experience.

Critics of the changing staffing patterns say they have led to a decline in quality because they deprive patients of valuable skills.

“As a way of cutting costs, hospitals replace nurses with less-skilled people,” said job placement specialist Challenger. “Inevitably there is a decline in quality.”

“There is no question that quality is being compromised,” said nurses’ association chief Costello.

The exhaustive Institute of Medicine study found that, on the basis of a limited number of studies, “the quality of hospital care has not suffered,” although it said that there were not enough data available to answer that question with certainty. The researchers said they were “shocked by the lack of current data relating to the status of hospital quality of care on a national basis.”

Nurses unions in California keep track of staffing problems by urging their members to fill out complaint forms that are filed with local hospitals. Both the California Nurses Assn. and the Service Employees International Union report a rising number of complaints.

*

A nurse who worked in the labor and delivery unit at Kaiser Foundation Medical Center in Los Angeles in February sounded similar to Centinela nurse Gayle in one complaint.

“My conscience won’t let me sleep,” she wrote in a copy of the complaint obtained by The Times. The nurse, whose name was blacked out, said that during one shift in the labor and delivery room in February she was “put in a very scary, dangerous situation and patient care was compromised.”

During that shift, she wrote, she was left alone with five patients, each in a critical stage of labor.

“There was no way I could watch all five patients alone, with a breech in active labor and two preterms and a labor patient and a patient having fetal distress that hadn’t even been admitted yet,” the nurse said. Finally help arrived, and there apparently weren’t any patient complications. But the incident shook up the nurse, who wrote, “I have never felt like quitting like I did Thursday night.”

Administrators at the hospital, known as Kaiser Sunset, say they look into each complaint. It is unknown what action, if any, they took in the case of the nurse’s complaint. One nurse caring for five patients in the labor and delivery unit is far short the hospital’s guidelines. The guidelines call for a maximum of one nurse for every two patients in delivery, but the ratio is supposed to be one nurse for each patient who is acutely ill or in the second stage of labor, and one for each case in which there is fetal distress.

Kaiser officials say they are rarely caught short-handed, but the Service Employees International Union contends that short staffing is much more common than the hospital admits. Investigations initiated by the state Department of Health Services led to the filing of two complaints against Kaiser Sunset for not meeting minimum staffing requirements on several occasions during 1995. Kaiser officials say they have corrected the problems that led to the complaints.

Bud Pate, a Kaiser official, acknowledged that “a lot of complaints” were filed with the state, but blamed them on union activity. “We feel we have had ample staff [at Kaiser Sunset], well qualified and trained,” he said.

Nurses for years have been pushing the Legislature, unsuccessfully, for clearer definitions of exactly what constitutes adequate staffing. Except in critical care, where there is a mandate of one nurse to each one or two patients, state law is vague on exactly how many licensed nurses should be in a hospital ward at any particular time. The law requires hospitals to establish consistent guidelines for staffing based on such determinants as the severity of patients’ illnesses.

But the law is subject to wide interpretations and has long been a matter of controversy among nurses and hospitals.

*

This year, two initiatives are on the November general election ballot that supporters say would protect patients and satisfy many of the complaints nurses have by requiring minimum staffing levels. One of the initiatives is backed by the Service Employees International Union, the other by the California Nurses Assn. The initiatives would leave the setting of standards up to state regulators.

It is unclear whether either of the initiatives would have helped solve the problems that confronted nurse Gayle.

Gayle said the pressure she felt during her last shift was caused by both the large number of patients and the system of “floating” nurses from one ward to another when staffing shortages develop. In moving from the maternity to the geriatric unit, she said, she felt out of place, even though she had been assigned there as a “float” nurse on other occasions.

Here, Gayle came in conflict with basic hospital policy. At Centinela, as well as other hospitals, nurses are required to work wherever they are assigned. With modern-day pressures on hospitals, it is often hard to predict which wards will be packed with patients and which will have relatively light loads.

Centinela administrators said assigning one nurse to deliver medications to 22 patients, as Gayle was, is not at all unusual. “We determined that her assignment that night was really a very easy assignment,” said Centinela nursing supervisor Margo Perusse. She said other nurses had been able to handle dispensing medications to that many patients with no problem.

But Gayle feared that any number of things could go wrong.

“This is not safe, I explained,” Gayle said. “Then they told me, ‘You have a choice. We will let you come back to the unit, providing you give care, or you can go home. But be advised if you go home, you don’t have a job.’ ”

Gayle said that was when she decided to go home.