story by Tracy DeCroce
photo by Greg Stempel (Fireframe)
Lisa Morrow was a registered nurse who opted to take severance pay when layoffs came down the pike at Virginia Mason Hospital. After eight years at the hospital, Morrow said that recently the "staffing ratios were getting scary." On evening shifts in the cardiac step down unit, where many patients were just a day out of open-heart surgery, Morrow would be responsible for six to seven patients, plus be in charge of the floor. In addition to checking in on her patients, she would be dealing with admissions, transfers, discharges and administrative details such as cleaning rooms and getting supplies. She said it became increasingly rare to get a 15-minute break on her eight-hour shift even one night a week.
The work had become so stressful, Morrow said, that when presented with the option to leave she considered changing professions. She said she wanted to get out before experiencing the disaster that she felt was imminent.
"You're not only taking care of sicker patients, you're taking care of more sicker patients," Morrow said. "It was just a matter of time before something terrible was going to happen, and I wasn't going to be able to get to it. I didn't want that on my conscience, or my record."
The sweeping changes in the health care industry are dramatically impacting the work climate and job stability for nurses. They are at the front lines of the changing health care industry, and many don't like what they see. Nurses at Washington's hospitals have experienced unprecedented layoffs, severe reduction in hours, decreases in the number of Registered Nurses attending patients and immeasurable uncertainty about a profession that just years ago offered security, good pay and flexibility.
The nastiness bred by changes that hospital managers say are necessary in these increasingly competitive economic times has left scores of nurses embroiled in bitter bargaining disputes. The following list shows a sampling of nurses and some social workers presently working with expired contracts in the Puget Sound area:
- 1,500 at Group Health Cooperative
- 800 at Providence Medical Center
- 400 at Highline Community Hospital in Burien
- 400 at Stevens Memorial Hospital in Edmonds
- 400 at Valley Medical Center in Renton
If these negotiations reach impasse- a point after which an outside mediator fails to bring the parties to a compromise- then management can impose its version of the contract and nurses have the option to strike. Glen Goldstein, executive vice president of the Local 1199 nurses union, said that the magnitude of nurses with unratified contracts shows that hospitals are attempting to make radical changes on the backs of their workers.
"The fact that so many nurses are without contracts speaks to the hard-line stands hospital management is taking with regard to substantial cuts for the RN workforce," said Goldstein, whose union represents 6,500 nurses statewide, including 5,000 at major Seattle hospitals.
Everyone involved with health care speaks to the changes brought by managed competition - changes that most agree have been foreseeable over the past five years. Managed competition is forcing hospitals to reevaluate their spending practices and to implement cost-containing measures in order to survive in a shrinking medical market. For some time, insurance companies have been gearing up for changes that might leave only a few of them standing.
The result has been fewer patients with less coverage staying shorter periods in the hospital. For example, Seattle patients spent 117,663 fewer days in the hospital from January to July in 1994 than during that same period in 1992, said Beverly Jacobson, president and CEO of the Seattle Area Hospital Council, a trade organization representing 19 hospitals.
Hospitals have responded by scaling back administrative and managerial positions sometimes up to 33 percent, Jacobson said. But with nurses accounting for 60 to 70 percent of the hospital workforce, the primary care providers can't be spared, administrators say.
"When patient volumes go down, we try to make reductions on the administrative side, but ultimately you have to look at the people on the front lines," said Sally Wright, a spokeswoman for Swedish Medical Center, which laid off 280 nurses or approximately one-fifth of its nursing staff this summer.
But union leaders and nurses don't buy that line.
"It's a manipulation of what health care reform is supposed to be about," said Steve Carr, the public relations coordinator for the Washington State Nurses Association, which represents 14,000 nurses. "It's real curious to me that they use the language of health care reform to justify the disregard to nurses."
Part of the issue, Jacobson said, has to do with how much nurses' salaries have risen in recent years. Not long ago, hospitals were so desperate for nurses they embarked on a recruitment effort that drove up salaries. Today, an RN with a two-year degree can start at $35,000 a year, Jacobson said. RNs with five years experience are earning $63,000 on the average, she said.
Union officials are quick to counter, however, with gross examples of managers living off the fat of the land. Reports this summer of Valley Medical Center administrator Rich Roodman's $98,000 bonus on top of his $273,000 salary sent nurses into a rage. Some 400 nurses remain without a contract at that hospital.
The effect on nurses' lives has been substantial. Andronetta Owen, 42, was one of the Swedish casualties. Owen used to earn $22 an hour as a home health and hospice nurse, a job that entails working in people's homes, checking heart rates and lung activity, changing dressings, and keeping in touch with doctors. The goal of home care is to teach the patient to monitor his or her own care and to know when to call the doctor.
A divorcee raising two boys, ages 4 and 7, Owen had been a nurse for 21 years and had never before been laid off. This time, she did not think she would be at risk because home health and hospice has been expanding as more people receive out-patient care. Owen was given the choice of taking severance pay and looking for a job elsewhere or putting her name on a recall list and working in the meantime on per diem status, which is on-call and without benefits. Owen chose the latter because she felt she was in a good position to be recalled.
Since then, she has found it difficult to get the hours she needs to pay the bills. In addition, she must plan for her child care- committing $45 in advance- on days when she is scheduled to work, and runs the risk of being called and told that the hospital does not need her.
"You don't know in the morning when you get up whether you'll be working or not," she said.
The recall process at Swedish is intricate and, consequently, slow, said spokeswoman Wright. Of the 280 nurses laid off, more than half chose to take severance pay. Another 120 nurses, Owen among them, put their names on the recall list. As part of the layoffs, nurses had the opportunity to rebid for the positions that the hospital had decided to continue staffing. Nurses who stayed with the hospital were offered four weeks of retraining if they were qualified and capable of working in a different position, Wright said.
After the rebidding, 70 positions were left unfilled for two reasons, Wright said. Either nurses didn't want those jobs because they were nights, weekends or part-time shifts or because the nurses on the recall list weren't qualified for the available positions. Those posts were opened to housewide transfers, allowing nurses in other Swedish positions to transfer into them. This often creates a domino effect throughout the hospital. Then, those on the recall list have a shot at the remaining posts. The last resort is conducting an outside search.
So far, the recall process has placed at least 27 nurses in the 70 open positions and as of a couple of weeks ago, perinatal and critical care units were advertising outside, Wright said.
"We're making an effort to use our own nurses when we can," she said.
Like several nurses and union representatives interviewed for this story, nurse Owen supports the move towards national health coverage for all Americans. But she is skeptical about the level of integrity on the part of those involved in the process.
"Yes, I am in favor of it," Owen said. "But I think it will have all the problems inherent to the character of our people. We're all concerned with our own financial security, and I think it needs to be weighed with the whole ethics of the process. I think the priorities need to be evaluated by people who are really versed in the ethics of the whole system, and that relates to the impact on the community, the individual, the family, the whole picture."
Most hospitals currently are restructuring nursing units. This is a process that takes a variety of forms specific to a given hospital and which targets specific nursing units, said Jacobson of the Seattle Area Hospital Council. Some examples are team approaches, involuntary transfers, unit merging and skill mix changes.
In many cases, such as with skill mix changes and team approaches, the idea is to put RNs in the role of managing, planning and assessing, leaving other jobs requiring less skill and training to be handled by less-trained nurses, aides or orderlies. A team might consist of a mix of RNs, clinical nurse practitioners, licensed practical nurses and certified nurse assistants, Jacobson said.
Ironically, hospitals moved away from such models years ago in order to favor a primary care approach-giving RNs the responsibility for the direct care of the patients.
"Now we're moving back," Jacobson said. "And the reason we can is because of the efficiency of technology. All of this is done to get the most appropriate person doing the most appropriate care in the most appropriate setting."
One of the first strategies at Swedish Medical Center was merging units, said spokeswoman Wright. In maternity care, for example, post partum care used to be handled separately and by different nurses than delivery. Now, the hospital is looking at labor, delivery and recovery all in the same room, handled by the same nurse. In this case, labor and delivery nurses got the job while the less-skilled post partum nurses were the ones laid off, Wright said.
Barbara Heimbigner, an RN who acts as co-chairwoman of the WSNA local chapter at Sacred Heart Medical Center in Spokane, has seen restructuring potentially destroy nurses' career paths. Last month, Sacred Heart management forced seven critical care and intensive care nurses to accept new placements or face termination for insubordination. In this "deployment" (a management term), the nurses were shuffled on short notice into holes created by attrition and took a pay cut in the process, Heimbigner said.
"What it did is change their careers," said Heimbigner. "It's like if you asked a cardiac surgeon to deliver your baby."
Administrators said that nurses must be willing to be flexible to keep on top of the changes. "They're going to have to make some changes and use some additional skills as we go to integrated systems," Jacobson said.
But even Jacobson admits: "It's not an easy time for nursing. I'm an RN myself."
Many RNs, though theoretically being moved into positions of greater authority, are not in favor of restructuring. Among other concerns, a recent U.S. Supreme Court ruling changed the traditional employee classification of RNs under the National Labor Relations Act. The court ruled that RNs can be classified as supervisors, thus losing the right to organize and engage in collective bargaining.
But more than that, nurses said, they fear the reduction of RNs to patients and see less qualified people with very little training assuming the direct care that RNs consider their ultimate responsibility. They fear complications, even disaster and have grave concerns about patient care and safety. They also worry about the loss of individualized attention for patients, and with it the education patients need to cope with their diseases and their lives.
"One of the important things with children is the fear they have," said Heimbigner, who works in the Pediatric Intensive Care unit at Sacred Heart. "One of the things they respond really well to is someone holding them. As we get less people in the hospital there's less time to hold them. I think nurses in oncology will feel the same-less time to be able to hold their hands and talk about death. That's going to be lost."
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Administrators, however, said that patient satisfaction has gone up as a result of restructuring. Northwest Hospital in north Seattle monitors all units where the hospital introduces mixed teams, said Irene Artherholt, vice president for clinical services.
"As we made changes, we did so with an eye on measuring patient satisfaction," Artherholt said. "We felt it was important to listen to patients and nurses."
Patient brochures contain satisfaction surveys, which are analyzed quarterly. In addition, Northwest has developed several tracking systems over the past four years for monitoring and recording truthful patient opinions, Artherholt said. For many patients, unlicensed personnel such as aides and orderlies responded more quickly to patients' immediate needs such as helping them to the bathroom or moving their beds, she said.
Many RNs at Northwest initially found it difficult to integrate the unlicensed personnel into their work routine, Artherholt said. In response, the hospital trained the RNs to delegate duties in order to free them up for higher-skill tasks.
"They felt they couldn't delegate responsibility, so they didn't and felt burdened," she said. "The magic that has to happen is to integrate this unlicensed personnel so that the RN can focus on things they were trained to do."
Part of the conflict stems from a difference between what RNs and hospital managers consider appropriate and necessary action. Beyond giving up individualized attention to patients, RNs, to varying degrees, are being forced to give up their own job security. Administrators said RNs must be more flexible in order to adjust to the industry changes. But, in many cases, RNs neither trust nor support management's rationale for disrupting the nursing balance.
So where does that leave the thousands of individual nurses who have devoted themselves to a care-giving profession that could potentially be pulled out from under them? For many, they are in a quandary, wondering how to adjust, whether to stand their ground or to simply leave the profession.
Morrow, the RN who was laid off from Virginia Mason, never thought she would return to nursing. But since May she has been dividing her time between a home hospice service and per diem work at the public Harborview Medical Center. She said there's been so much opportunity that she could be working seven days a week if she wanted to.
The change for Morrow has been a positive one, as the different setting has helped renew her perspective and revitalize her commitment to nursing as a career. Nevertheless, Morrow sees those in the profession now as the ones weathering the storm. Like many nurses who are trying to stay positive, Morrow can visualize the rainbow through the clouds. But neither she nor most of her colleagues think they can reach that end without making their voices heard over the thunderous rumblings of this storm called health care reform.
"When it all shakes down, I think there's going to be a really good role for nurses," Morrow said. "But I think we need to toot our horns now because hospitals are making a lot of stupid mistakes."
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Contents on this page were published in the October/November, 1994 edition of the Washington Free Press.
WFP, 1463 E. Republican #178, Seattle, WA -USA, 98112. -- WAfreepress@gmail.com
Copyright (c) 1994 WFP Collective, Inc.