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TwitThisLack of Standards
That's not the experience, however, of a respiratory therapist who worked in an Arizona hospital. He says that over his 20-year career he has seen numerous patients nearly die because of the incompetence of unlicensed aides. "One time I went to check on a seriously ill patient whose oxygen mask had been taken away by an aide at lunchtime and left off for an hour," says the therapist. "His color was hideous and his lips were blue. If I hadn't come in, he might well have died."It's also not the experience of Dr. Gordon Schiff, director of clinical quality research for the department of medicine at Cook County Hospital in Chicago. "I've seen cases of patients with heart problems and drug side effects that were not recognized in a timely way, because the first-line caregivers were poorly trained and poorly paid aides," says Schiff. "Multiply those cases across the country and you have tens of thousands of preventable errors each year that result in serious harm to patients."
Most unlicensed assistants, of course, are doing the best job they can, and for paltry wages. But too often their assignments bear no relation to their past experience.
"My husband had four-vessel heart-bypass surgery in March 1999, and when he had only been out of surgery thirty-six hours, his heart monitor was being read by people who just a month earlier had been in the dietary and housekeeping departments," says Kay McVay, president of the California Nurses Association.
at the She isn't exaggerating: McVay learned this from nurses in the ICU. It's common for hospitals to take workers from departments such as housekeeping and cross-train them to provide direct patient care, says Linda Aiken, director of the Center for Health Outcomes and Policy ResearchUniversity of Pennsylvania. In fact, other researchers say, those workers may go from mopping floors to taking blood pressure after just a few days of training.
A 1996 report by the Institute of Medicine, an affiliate of the National Academy of Sciences, revealed that most unlicensed assistants have no more than a high school degree -- and nearly one in five is lacking even that.
"When the person who interacts most with patients also has the least education, you'd better train them well and supervise them closely," says Mary Wakefield, director of the Center for Health Policy, Research and Ethics at George Mason University.
A nurse's aide who works at an Illinois hospital told Reader's Digest that her training for nursery duty consisted of a week-long orientation program and working for a month alongside a fellow nurse's aide. At times she's been left alone with a roomful of newborns, which makes her nervous. "I worry because if a baby suddenly starts choking or is not breathing, we are not qualified to handle that," she says.
Are hospitals like hers just ignoring national standards for training aides? Not really. There aren't any. Just check out the conclusion of medical experts in the Institute of Medicine report: "No accepted mechanism exists either to measure competency or to certify in some fashion that ancillary nursing personnel have attained at least a basic or rudimentary mastery of needed skills." Translation: 50 different hospitals could have 50 different ways of training their aides -- none of which may be adequate.
It's left to each state, individually, to regulate training, and most don't bother. The result is that overwhelmed aides either worry themselves sick or switch out of their jobs.
A former hospital aide in Pennsylvania told Reader's Digest that she was given a two-week training course on how to take blood pressure and other vital signs. During her first year on the job in 1996, there were two registered nurses, four licensed practical nurses and two unlicensed aides caring for 30 patients. But starting in 1997, the staff was cut so dramatically that often only one registered nurse and two licensed practical nurses worked with her to cover the same 30 patients.
"I was in the room with patients more than the nurses were," the aide said. "I did things I wasn't trained for, like taking out catheters and IVs, but the nurses asked me to because they didn't have time."
Increasingly scared that she'd harm someone, the aide transferred to a different department within the hospital. Judith Shindul-Rothschild, associate professor of nursing at Boston College, says that aides like this one are right to feel nervous, as should their supervisors. "It's hard to tell what the aides don't know," she says. Nancy Casazza, a 53-year-old RN in Walnut Creek, Calif., concurs: "If a patient with abdominal pain is feeling chilly, an aide might give him a blanket without taking his temperature or mentioning it to anyone. Yet that chill could be a precursor to septic shock, which can quickly cause death."
Did an aide's misstep cause a nearly fatal illness in the case of Archie Mayton? In the autumn of 1998, the tall, soft-spoken 66-year-old showed up at a walk-in clinic in Oak Ridge, Tenn., for a flu shot and a cortisone injection in the hip for his arthritis -- both routine procedures. Over the next week his hip began to swell and ache.
Worried, Mayton was taken by his wife to the hospital, where doctors quickly realized he was ill from a serious infection. One of the doctors suggested that Mayton be hospitalized, but agreed to treat him and then send him home with medication. A few days later, however, Mayton was back in the hospital in even worse shape. His kidneys soon stopped working, and a nephrologist was rushed in to get them going again.
Hospital surgeons cut an incision from Mayton's hip to his knee to discover the full extent of the infection. By now, it had spread to his bloodstream. The doctors urgently treated him and gave him more medication. It took nine months of painful recuperation, says Mayton, but eventually he healed. "It was a terrible time," says Mayton's wife, Janet.
The Maytons contacted their lawyer, who uncovered something stunning when she took depositions: The clinic's nursing staff was made up solely of unlicensed assistants -- including the woman who administered the shot.
"We were shocked and so angry," says Janet Mayton. Adds Archie: "I'm a barber and I have to have a license for what I do, so it never occurred to me that people would be allowed to do medical work without a license."
He has filed suit against the clinic, Park Med Ambulatory Care, alleging negligence in giving the shot. Attorneys for Park Med, which denies "any and all liability for Mr. Mayton's alleged injuries," say the clinic and its staff "acted appropriately at all times." They point out that, in Tennessee, it's legal to use unlicensed aides as office nurses and allow them to give shots. They also dispute "the nature and extent of [Mayton's] injuries and the cause of the infection," and assert that Mayton himself "greatly contributed to his injuries" by declining to be admitted the first time he went to the hospital.
Mayton, meanwhile, says he is living with pain and muscular weakness. "Lots of days I don't really feel good," he says.
If things don't change soon, there could be many more Archie Mayton-like lawsuits in the years ahead. For two storms are converging, with patients almost sure to be caught up in the tempest.
First, hospital executives may well be forced to hire even more unlicensed aides, because they're still under the gun financially, both from managed care and a slashing of Medicare reimbursements (cut by about $40 billion over five years beginning in 1998).
Second, it's predicted that the number of experienced RNs will significantly shrink as retirements and resignations fuel a serious nursing shortage. According to a recent University of Pennsylvania study, 40 percent of hospital nurses say they are unhappy with their present jobs, and one in five say they plan to quit within a year.
"I used to love being a nurse," says Nancy Casazza, the RN from Walnut Creek. "But now I only work four days a month in an ER because I hated being put in situations where I didn't have time to hold a patient's hand or give adequate care. There are nurses out there who would come back if conditions improve, but we're just waiting to see."
As a patient, your surest protection is your own insistence -- or that of your family -- that you get the care you deserve. Learn which procedures are best performed by RNs, and if you won't be able to monitor your own care, try to make sure that a family member or friend is on hand as your advocate.
Jean Gaddy Wilson of Marshall, Mo., knows how crucial this can be. She was constantly at her husband's bedside during his frequent hospitalizations following a kidney transplant. "I've had to change dressings myself that were left on my husband for twenty-four hours, even though the doctor ordered they be changed at least three times a day," she says. "Patients who don't have family members with them in the hospital are treated just like inventory sitting on a shelf."
Not that anyone is suggesting you avoid hospitals when you need serious medical treatment. But times have changed, and you should realize patients are, in a very real sense, guinea pigs.
"Boeing would never roll out a totally redesigned jet and fly it, untested, with a full load of passengers. But in many cases, that's what's happening with our nursing care," says George Mason's Mary Wakefield.
There's not a person who knows what the full consequences of this experiment will be. The aides themselves, though, have already seen enough. "I've worked in an oncology unit for twelve years," says a nurse's aide in California, "and it's changed so much. I really worry about the patients. It's just not fair the way they're being treated. Patient care is lousy -- and it's getting worse every day."
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