Nurses Feel the Pinch

"Today we're facing an issue called "quality," and at stake is the very survival of our profession — and the health of this country as well. It's past time for us to focus on what we do best — advocate for the patients. We need to use every forum and every avenue available to us to assert the simple fact that only professional, licensed nurses can provide safe and comprehensive care, no matter what the setting. We have to get the word out that 'costs' are being used to drive changes in health care that are bad for sick people, bad for hospitals, and bad for all the citizens of this country." 

Kathy Sackman, RN,
Co-Chair of United Nurses of America
(UNA)/AFSCME

Because Congress did not (and is not planning to) pass meaningful health care reform legislation, private forces are acting on their own to dramatically transform our delivery system. Health care accounts for one-seventh of our economy, and it is a big business reaching beyond acute care to home care nursing facilities, mental health, children's services and MR/DD.

The choice was never between change and maintaining the status quo, but by whom, when and how changes will be made. Change is taking place in every market — urban or rural, small town or big city — and in every practice setting. These changes are determining where people receive care, who provides that care and how the care is paid for.

HOSPITALS RELY ON NURSES

...BUT AIDES' ROLES ARE GROWING

The pressure to cut costs is now being used at the bargaining table. Nurses are seeing jobs disappear through attrition or layoff, seeing their jobs redesigned (often without their participation) and their direct care duties performed by lower-paid, often scantily-trained and less-skilled personnel. Witness the advent of such euphemisms as "patient focused care" or "care partners," where a few nurses "manage" care by teams of aides (who may include ward secretaries and housekeepers) who feed and bathe patients, check vital signs and do other "routine" chores. These chores are often spilling over to more invasive procedures, such as suctioning, catherizations, tube feedings and blood draws.

There is a new crop of management consultants offering "redesign" models to hospitals. Painting a sharp contrast to the Bureau of Labor Statistics projections referred to in Chapter 4, these "hired guns" say that if patient-focused care systems were enacted across the board, the switch could replace 100,000 nurse jobs and save $2 billion a year or more. Not only do they claim they can cut hospital staffs by a third, but they also try to create "incentive" compensation systems with bonuses instead of pay increases — all dependent on the performance of the institution and determined by the employer.

Several recent studies carry the corporate agenda further along toward its logical conclusion:

Institute of Medicine Report on the Adequacy of Nurse Staffing: Nurses throughout the country were anticipating that this report would identify the grave consequences and quality implications of reducing the number of nurses and changing the staffing skill mix in the delivery system. While the report did an excellent job of describing the risks and problems in the current system, it declined to make firm conclusions and recommendations regarding acute care staffing. The report strongly advocated the need for research to substantiate the link between nurse staffing, quality outcomes, work-related injury and stress and organizational performance.

The report also stated that while the current number of nurses (approximately three million RNs, LVNs and LPNs) may be adequate, their mix of education and training may not meet either current or future demands. The document did not find evidence of massive reductions in RN staffing in hospitals, but did acknowledge that the impact of managed care needs to be closely monitored.

The IOM report called for an increase in advanced practice nurses to assume the role of "case manager" and for procedures to certify the competence of nurse assistants who will deliver more and more direct care. And it suggested that the "harmful and demoralizing" effects of these changes could be offset if management involved nursing personnel in work and staffing redesign.

The IOM appeared more comfortable dealing with the nursing home industry, which has more regulation, data and oversight. There was a firm recommendation to increase RN staffing from an eight-hour to a 24-hour minimum, an increase which necessitates a boost in the number of clinical specialists and nurse practitioners specializing in geriatric care.

Health and safety was another area of clear data and firm recommendations. On-the-job injuries, such as back injuries and needle wounds, are on the rise — 52% in hospitals and 62% in nursing homes, since 1980 — at a time when private industry injury rates have been stable or have declined.

The Pew Commission Reports: The Pew Charitable Trusts are seven funds established by the founder of Sun Oil. In part, Pew's stated goals are to promote the health and well-being of the American people, strengthen disadvantaged communities, and enhance the ability of educational institutions to train health care practitioners

Two 1995 Pew reports dealing with supply and regulation have sparked much needed controversy and debate about the future of the health care industry, regulation, skill-mix and education. In the first, entitled "Critical Challenges: Revitalizing the Health Professions for the 21st Century," Pew perceives that the health care system in general will be:

• Better managed with integrated services and financing
• More accountable to those who purchase and use services
• More inclusive in defining health, and more concerned with education, prevention and managing care

According to the Pew report, this demand-driven system will lead to the following realities:

• Closure of approximately half of the nation's hospitals, and the elimination of perhaps 60% of the hospital beds
• Massive expansion of primary care in ambulatory and community settings
• A surplus of 150,000 physicians, 250,000 nurses and 40,000 pharmacists
• Consolidation of the over 200 allied health professions into several multi-skilled disciplines

Pew offers a number of specific recommendations for nursing itself, asserting that there is a need for the nursing profession to recognize the value of multiple entry points to professional practice but distinguish between the practice responsibilities of these different levels of nursing, (i.e., BSN degree for case management and Masters degree for advanced practice). Pew also advocates a reduction in the number and size of nursing education programs by 10-20%, as well as integration of education and the highly managed systems of care that model flexible work rules and work re-design.

The second key Pew report is entitled, "Reforming Health Care Workforce Regulation." If the first document was aimed at identifying the "what," this second report seeks to spell out the "how" with respect to regulatory practice acts. Taken at face value, these recommendations are logical and long overdue.

According to the second document, the current regulatory environment offers protection for the profession and not the public, restricts innovation and change, provides minimum sanctions for incompetent practitioners and limits entry and mobility. "Fixing" the regulatory system, designed to protect the public, could result in the dismantling of the regulatory environment. Those with the money to lobby state and federal legislators, such as the American Hospital Association and for-profit providers and insurance companies, make arguments for no licensure or facility-based certification (institutional licensure) on the basis of outcome measures, accreditation, reduced cost and increased consumer satisfaction.

As sensible as the reforms may appear to be, the biggest regulatory issue facing nurses is not addressed by the Pew taskforce: The delegation of nursing duties to unlicensed providers while retaining licensed nurse responsibility for the outcomes. Although assessment functions cannot be delegated, tasks from charting to patient education to increasingly invasive and complex procedures are now on the auction block in many states.

One rationale given for dismantling the regulatory environment is the increased use of practice parameters to guide medical and nursing practice. These models are seen as a substitute for the need to regulate practitioners because they regulate practice.

These parameters, also known as practice protocols or "appropriateness reviews," often take the form of so-called decision-trees — if the answer is "yes," go to question 2; if "no," go to pathway B — which are used to determine whether the presenting conditions and prior history warrant the physician's recommended treatment. These are typically applied to the use of tests to determine a diagnosis (MRI), for complex conditions (CHF), expensive treatments (open heart surgery), or for those procedures which have a known history of over-utilization (i.e., C-section and arthroscopies).

These protocols have a sound medical base and have been used in the past for peer review. As they come to dominate practice, they will cut costs and allow non-medical or unlicensed practitioners to make treatment decisions by following a "recipe."

Summary of the Ten Recommendations

1. States should use standardized and understandable language for health professions regulation and its functions to clearly describe them for consumers, provider organizations, businesses, and the professions.
2. States should standardize entry-to-practice requirements and limit them to competence assessments for health professions to facilitate the physical and professional mobility of the health professions.
3. States should base practice acts on demonstrated initial and continuing competence. This process must allow and expect differenct professions to share overlapping scopesof practice. States should explore pathways to allow all professionals to provide services to the full extent of their current knowledge, training, experience and skills.
4. States should redesign health professional boards and their functions to reflect the interdisciplinary and public accountability demands of the changing health care delivery system.
5. Boards should educate consumers to assist them in obtaining the information necessary to make decisions about practitioners and to improve the board's public accountability.
6. Boards should cooperate with other public and private organizations in collecting data on regulated health professions to support effective workforce planning.
7. States should require each board to develop, implement and evaluate continuing competency requirements to assure the continuing competence of regulated health care professionals.
8. States should maintain a fair, cost-effective and uniform disciplinary process to exclude ncompetent practitioners to protect and promote the public's health.
9. States should develop evaluation tools that assess the objectives, successes and shortcomings of their regulatory systems and bodies to best protect and promote the public's health.
10. States should understand the links, overlaps and conflicts between their health care workforce regulatory systems and other systems which affect the education, regulation and practice of health care practitioners and work to develop partnerships to streamline regulatory structures and processes.

Source: Pew Health Professions Commission Taskforce on Health Care Workforce Regulation