Nursing on the Edge

by Harold Stearley

Therapeutic Misadventures	When the space shuttle Challenger exploded, NASA's Mission Control termed it a "major malfunction." When civilians were killed during the bombing of Iraq, the military called them "collateral damages." The terminology used to mask disasters is fascinating; referring to individuals as nameless groups reduces human life to simple, clean numbers. The medical industry is no exception. An error in medicine which debilitates or kills is dubbed a "therapeutic misadventure." The man in Florida who had the wrong leg amputated, the Michigan woman who had the wrong breast removed, the Boston journalist killed by four times the correct dosage of chemotherapy, the patient who was disconnected from his ventilator by mistake and suffocated -- all simply therapeutic misadventures. Once admitted to the hospital, you stand an 18 to 30 percent chance of experiencing an adverse drug event, and 14 percent of all inpatient deaths are generated by these drug complications. All told, 60,000 to 140,000 people die each year just by following doctor's orders and taking their prescribed medications. Using the higher figure, more people are dying under a doctor's care than from violent crime, high risk sexual behavior, or motor vehicle accidents -- combined. The elderly are particularly at risk: 70 percent of physicians treating Medicare patients failed an examination on the proper way to prescribe medications to seniors. Complications, many life-threatening, occurred in 88 percent of elderly patients taking three or more prescription drugs. Prescription drugs also account for 32,000 hip fractures annually by making elderly patients dizzy or sedated. What's preventing you from becoming one of the estimated 180,000 patients who die each year in a therapeutic misadventure? Chances are good that it will be an alert Registered Nurse -- that is, if your hospital still has one available. Hospitals nationwide are laying off registered professional nurses and support staff. In their place, proponents of managed health care are attempting to create generic health care workers. These multi-skilled workers are unlicensed, minimally-trained employees who perform any range of medical procedures: Nursing, respiratory therapy, x-ray imagining, EKGs, physical therapy -- and, of course, housekeeping. The same person emptying the trash one minute could be making life-and-death decisions the next. Ironically, such systems bear the name "Patient-Centered Care" because they are supposed to decrease the present fragmentation of services provided in the hospital.
How much do they make?	But the true purpose of this change is to fatten the bottom line. Health care is an annual $1,000,000,000,000-plus industry that enjoys profits of 20 percent or more. As nursing positions are eliminated, an ever-growing bureaucracy has emerged. We presently have nearly two hospital administrators for each inpatient bed in this country -- whether that bed is filled or not. The average hospital spends about 28 percent of all of its resources on administration. And the next time you hear a CEO blame expensive staff salaries for those staggering hospital bills, consider this: the actual cost of labor has dropped by 11 percent since 1992 -- as administrative costs and salaries have risen. During the same period, hospital administration has grown by 180 percent. Who loses, as dollars are shifted from nursing to administration? It's probably going to be you, the patient. If your hospital is typical, the floor nurse on duty is caring for 17 other patients besides yourself -- and hospital administration may be planning to double the number of patients seen by the nurse. While statistics support retaining more professionals, institutions employing various managed care strategies have sought professional staff reductions ranging anywhere from 10 to 50 percent. There are over a dozen current research articles which show the more RNs at the bedside, the lower the morbidity and mortality, the higher the patient's compliance rate with treatments and medications, and the lower the costs for those patients. Patricia Prescott, RN, Ph.D., a nursing professor and researcher from the University of Maryland, documented specifically that higher RN-to-patient ratios decreases patient morbidity and mortality by as much as 5 to 10 percent. A study conducted by national health care consulting firm E.C. Murphy compared the staffing structures of 281 general acute care hospitals in the U.S. and determined that hospitals which reduce their staffs by eight percent or greater were more than 400 times as likely to show increases in patient morbidity and mortality.
PFC: "Patient-Focused Care" or "Profit For Corporation?"	But under the guise of reducing costs to the consumer, the hospital corporations have begun to cut indiscriminately. Business analysts -- the same analysts which make assembly lines more productive -- were fully welcomed into the unpredictable, no two patients (products) alike, industry of health care. Booz-Allen and Hamilton, Incorporated pioneered the Patient-Focused Care (PFC) concept. This international management and technology consulting firm services large corporations and banks -- a far cry from the delivery of compassionate humanistic services. Other corporations and consultants have jumped on the bandwagon, and restructuring is in full swing across the country and internationally. As a result, the prescribed treatment for our hospitals' ailments could prove to be more fatal than the disease. Corporate ideology seems based on one concept: reduction of staff. The newest approach to staff cutback in a hospital environment is to employ "multi-skilling and cross-training." What this amounts to is "de-skilling" or stripping away professional boundaries; and the only way this can be effectively, and completely, accomplished is through "de-licensing" our complex skills. Administrators are moving fast. They are creating college programs for "certified multi-skilled health care practitioners." Employer groups are lobbying legislatures for removal of licensure requirements. After fighting for years to expand our roles as nurses, to achieve reasonable RN/patient ratios, and to provide "total patient care," we are now witnessing the dismantling of our profession, as well as the professions of all other licensed or certified therapists and technicians. Ironically, managers state that this will elevate our role, and eliminate the so-called unskilled tasks which we perform. Those in administrative circles don't seem to understand that we chose nursing to be at the bedside, to provide both skilled and unskilled tasks, to make contact with all aspects of our patients -- this contact is an intuitive part of us, the part that makes contact, and the part that heals. The few of us which remain after the slash and burn of PFC will be restricted to directing the actions of robotic technicians and keeping the assembly line running. And you, Dear Patient, will be the product on that assembly line.

Harold Stearley, R.N., B.S.N., A.S.B., CCRN, has held various clinical and supervisory positions over his twenty-one year career, and has helped develop innovative programs for several hospitals. He is a member of Sigma Theta Tau, and was named in "Who's Who in Nursing" and "Who's Who in America." His freelance writing appears regularly in the local press in Missouri, and his articles have been featured in Nursing, Nursing Administrative Quarterly, Nursing Economics, and The Missouri Nurse. He holds positions on the Editorial Board of The Missouri Nurse and on the Staff Nurse Editorial Advisory Board for The American Nurse.

Portions of these essays have previously appeared in other forms in REVOLUTION, The Journal of Nurse Empowerment.

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