Across the nation, hospitals are cutting back on registered nurses-and delegating some of their chores to aides who average only two to six weeks of training. No one knows how many RNs have been lost or how the trend will affect patients. The scant available evidence comes mainly from nurses’ groups that have a stake in the status quo. But health workers do seem worried. Of 1,800 who were polled recently by the American Nurses Association, 68 per-cent said their RN staffs had been cut in the past year, through attrition or layoffs. And two thirds of those reporting cutbacks thought the changes were jeopardizing patients. Doctors are voicing similar concern. “If I were really worried about one of my patients, I would set my alarm and go check myself,” says Dr. Christopher Greeley, a pediatric resident in Nashville, Tenn. “Some of the people I’m relying on to be my eyes and ears have less training than the person running the slushy machine at 7-Eleven.”
Hospital administrators say they’re merely trying to adapt to a changed market. Hospital admissions have plummeted since the early 1980s, when insurers began treating inpatient care as the costly luxury it is. The shift has put many institutions out of business and forced survivors to cut expenses wherever they can. Nurses, as the largest group of hospital employees, are an obvious target for savings. The idea isn’t to do away with them, administrators say, but to deploy them more efficiently – by hiring $15,000-a-year “care associates” to handle mundane tasks, such as changing linen, bathing patients and helping doctors with routine technical procedures. As Barry Horn of Berkeley’s Alta Bates Medical Center explains, “I don’t need to take a nurse out of commission to assist in a spinal tap. The assistance it requires is simple.”
The problem, critics say, is that these aides are performing feats for which they’re unqualified. State and national nurses’ associations have been particularly outraged by reports that unlicensed attendants are handling catheters in cardiac patients at UCLA Medical Center and suturing surgery patients at some of California’s Kaiser hospitals. “They shouldn’t be doing invasive procedures,” says Grady, the Boston intensive-care nurse. “Many don’t even know to bring an unstable vital sign to somebody’s attention.” UCLA and Kaiser both acknowledge letting unlicensed aides perform these drills, but both defend the practice, saying that doctors are always on hand to supervise. “We think it’s very clear that this is legal,” says Frances Ridle Hoover, director of ambulatory care and cardio-diagnostic services at UCLA.
Aside from anecdotes, there is little evidence that the move away from RNs has harmed patients. A few studies have found that hospitals with low nurse-to-patient ratios have slightly elevated mortality rates. And nurses at Boston College noted in a 1994 survey that nursing staffs had been cut at several Massachusetts hospitals where patients later died in mishaps. “This should tell us that we have to be very careful,” says study leader Judith Shindul-Rothschild. But there is no direct link between the cutbacks and the deaths. As Massachusetts Hospital Association spokesman Andrew Dreyfus says, any number of factors could have contributed.
The nurses’ concerns are no doubt parochial in part. “One has to wonder whether this has more to do with traditional union work protection than with real concern about patient care,” says Mark Speare, associate director of the UCLA Medical Center. For years, he recalls, RNs disdained many of the tasks they’re now fighting to keep. Yet no one denies that nursing cuts could have dire effects. “Somewhere down the line,” says Horn of Alta Bates, “the dollars could dry up to the point where care will be affected.” Where that point lies is anyone’s guess. The Institute of Medicine, a federal advisory group, may help clarify the hazards in a forthcoming study of hospital nursing trends. But if the nurses’ associations expect to save the status quo, they’re sure to be disappointed. The revolution is already here. The question is how happily it will play out.
