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StumbleUponOverworked and Stretched Thin
As for RNs, tens of thousands were cut by hospitals in the mid-1990s and then added back, according to Buerhaus. Lost in the shuffle were untold numbers of experienced nurses who, not coincidentally, made the most money.Amid this staff turmoil, RNs have had to face additional burdens. Many find themselves hostage to huge piles of paperwork that can keep them from checking on their patients. "We're required to do much more documentation than ever before, both for managed care and for legal reasons," says Sandy Eaton, an RN at Quincy Medical Center in Quincy, Mass. "On one floor there is a ten-page paper that must be filled out each time a patient is admitted. And since only RNs are allowed to complete all those forms, they spend less and less time with patients."
Then there's the matter of the patients themselves. In trying to cut costs, hospitals have been quickly releasing all but the sickest patients, and RNs say they're bearing the brunt of it. Already stretched thin, they're now caring for people who have been shuffled out of the intensive care units (ICUs) onto other floors of the hospital.
As an RN with 30 years' experience describes the situation at her California hospital: "Patients who are still on ventilators or cardiac monitors are being moved out of ICUs to floors where there's one nurse for every five or six patients, rather than one nurse for every two patients as they would have in ICU -- the only place where I'd feel comfortable leaving a family member alone these days."
Even her daughter's presence at the bedside couldn't help 61-year-old Shirley Keck, who was hospitalized with a diagnosis of pneumonia in February 1998 at Wesley Medical Center in Wichita, Kan. Keck's condition steadily worsened, according to the later testimony of her daughter, Becky Hartman. Eventually, her mother "was ripping at IVs, drenched in sweat, literally gasping for breath," says Hartman.
Keck's daughter testified that for 3 1/2 hours she begged for more help, but it appeared to her that her mother's nurse was always in a hurry. Hartman recalled hearing the nurse "bark out that they were understaffed, had been working six days a week, twelve-hour days, and that she could only get to one person at a time." According to Hartman, the severity of Keck's condition was missed by this nurse and others on the hospital staff who entered the room. Hartman also stated that at one point someone who appeared to be a nurse came into the room to check Keck's vital signs. When Hartman began asking questions, she testified, the woman told her that "she was sorry, but she was from pediatrics and they were short-handed. She would let the nurse know I was concerned."
Finally, Hartman put in a frantic call to her father, who was home ill himself. Returning to the hospital room, she was met by a nurse who said a chaplain was waiting for her. Her mother had gone into near respiratory arrest, but Hartman was told that "they had worked hard and saved her." "Saved her?" Hartman replied. "You did this to her!"
By then Keck's oxygen-starved brain was permanently damaged, according to a suit brought against Wesley by the Keck family. Keck's attorney asserted that under the hospital's own guidelines, at least five RNs, two licensed practical nurses and four aides should have been on duty. In fact, he contended, there were only four RNs, no LPNs and three aides to care for Keck and 41 other seriously ill patients.
The hospital has denied all liability, maintaining that the staffing of nurses and other professionals met appropriate standards, and that the staff was not negligent in monitoring and treating Keck. The hospital further claimed that the fault lay with doctors who misdiagnosed Keck and did not order proper treatment -- a charge the doctors denied. Last year, Wesley settled for $2.7 million.
Whether the issue is distracting paperwork or chronic understaffing, one result is clear: When you ring that call button, the odds have jumped that an unlicensed aide will come through the door.
Some health care experts think that the problems posed by these unlicensed aides are greatly exaggerated. "We've tried to reduce costs without affecting quality," says Michael Waters, a former chairman of the board of governors at the American College of Healthcare Executives. "Hospital errors do take place, but they are rare. I believe hospitals are very safe places to be. I don't want to see unlicensed aides doing things they're not qualified to do -- but you don't need an RN to change sheets or empty bedpans."
Hugh Greeley, a consultant to hospitals on medical-staffing issues, suggests reasons why nurses are raising concerns about these aides. "The nursing profession believes this is a serious issue," he says. "But it also believes that hospitals should be staffed with a greater ratio of nurses per patient, and that these nurses should be paid more."
In any case, Greeley says, there's no cause for worry in nationally accredited hospitals, because they don't allow aides to perform tasks that could endanger a patient's life.
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