THE NEW HANDS-OFF NURSING

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Rebecca Strunk suffered increasing discomfort as she lay recovering from a hysterectomy at the Christ Hospital in Cincinnati, Ohio. Again and again, the 46-year-old mother of two complained of pain in her upper abdomen, and again and again the people who came into her room to care for her wrote down "incisional pain" on her chart, although the incision was in her lower abdomen. Finally, after three days, as her temperature spiked and her blood pressure plummeted, Strunk's doctors suspected the truth: her bowel had been nicked in the surgery, and she was succumbing to a massive infection spawned by leaking feces. Two days later she died. And last week Strunk's survivors announced that they had agreed to accept $3 million from the hospital in full settlement of a wrongful-death suit.

Some 20,000 patients are killed every year by infections they pick up in America's hospitals. What made Strunk's case particularly significant was her husband's contention that Strunk died largely because the hospital staff members to whom she described her distress were not registered nurses but "patient-care technicians" who lacked the expertise to interpret her complaints. In 1994, the year of Strunk's operation, the Christ Hospital had turned to what management consultants call "patient-focused care," a system in which such bedside tasks as taking vital signs and answering call buttons are performed by unlicensed personnel who report to an R.N. Registered nurses must complete at least two to four years of postsecondary education and pass state licensing exams. Patient-care technicians are trained for a matter of weeks, and their competency is judged solely by the employer.

"The de-skilling of the personnel on the floor is really alarming," warns Dr. David S. Rubsamen, a California physician and lawyer whose Professional Liability Newsletter instructs doctors on how to avoid and defend malpractice suits. "Nursing involves all kinds of subtle perceptions. If you say, 'I'm coughing. I feel anxious' to a registered nurse, that means pulmonary embolism. Try that on a para-something-or-other who's been trained for six months." Nevertheless, patient-focused care is becoming the staffing pattern of choice throughout the country. Facing reduced reimbursements from Medicare, Medicaid and managed-care plans, hospitals must cut labor costs to survive. And nurses don't come cheap.

They used to. Nursing was long regarded not as labor but as a labor of love, and women--the profession remains 96% female--were expected to serve selflessly, lifting 200-lb. patients all day and working nights and weekends up to their elbows in blood and pus. In 1987 staff nurses, on average, made $22,000 to start and $30,000 after 20 years on the job--often less than (male) hospital maintenance workers with eighth-grade educations. Then in the late 1980s a severe nursing shortage gave the profession the leverage to win compensation commensurate with skill. Today the average staff nurse's salary is about $35,000; at New York City's Presbyterian Hospital, a nurse with 20 years' experience earns $71,250--a big blip on any cost-containment radar screen.

This year Presbyterian's contract negotiations with the nurses have broken down over language that would allow the replacement of 350 of the hospital's 1,500 R.N.s with unlicensed technicians. The hospital says it has no plans to do this, but simply wants "the flexibility to operate in today's market," explains spokesman Robert de Luna. So, apparently, did Boston's prestigious Brigham and Women's Hospital, where nurses had to threaten a walkout last week to win assurance that R.N.s will not be replaced by unlicensed personnel. Similar showdowns can be expected nationwide, says Beverly Malone, president of the 180,000-member American Nurses Association, because "what happens on the coasts has a big influence on what happens throughout the country."

On the West Coast, unions and consumer groups have put two versions of a Patient Protection Act on November's ballot. Propositions 214 and 216 would require the state to enforce minimum staffing levels for licensed personnel at all medical facilities and would protect whistle-blowing health-care workers from being fired. Similar measures have been introduced throughout the country, from the U.S. Congress to the Cincinnati city council, but nowhere does the battle loom larger than in California. A coalition led by the health-care industry and the Chamber of Commerce has mounted a multimillion-dollar ad campaign to defeat the initiatives.

Also set for November is the trial of a consumer-fraud lawsuit filed by the California Nurses Association against the 508-bed Alta Bates Medical Center in Berkeley. The suit claims that the hospital enforced a gag rule on its employees to "cover up the essential nature" of its patient-focused care plan. Viki Ardito, Alta Bates' acting vice president of patient-care services, calls the lawsuit frivolous: "It's about maintaining the union's people and their dues."

The Institute of Medicine, a congressionally chartered advisory body, reported in January that it was "shocked by the lack of current data relating to the status of hospital quality care." Nurses report that as they are taken from the bedside to supervise less skilled personnel, medication errors, patient injuries, infections and bedsores are on the rise. In preliminary results of an American Journal of Nursing survey conducted this spring by Judith Shindul-Rothschild, assistant professor of nursing at Boston College, almost 2 out of 5 nurses said they would not want a member of their own family to be cared for in the hospital where they work.

Of course, their jobs are on the line, so the nurses may be biased. With the burgeoning emphasis on outpatient care, the nation's total number of hospital beds fell from 1.7 million (80% occupied) in 1965 to 1.2 million (70% occupied) in 1992. Between 1983 and 1993 the number of registered nurses per 100 patient admissions actually grew, from 80 to 105. Nurses argue that an ever sicker inpatient population requires ever more nursing, because the less gravely ill are never admitted and those on the mend are quickly shown the door. But hospital management sees a large number of high-priced R.N.s as the wrong prescription for survival in a shrinking market: "Models like patient-focused care are the way health care's going to go," says Alta Bates' Ardito. "That's the way it's going to be delivered. The unions are defying gravity." Of course, defying gravity has a way of getting someone hurt. The question now is, Will patients take the fall?