This is hospital business these days - at least as characterized by a recent New York Times article. The major story in the Business Section on January 29, 1995, was about the survival (to date) of the California Pacific Medical Center in San Francisco. Since 1991, this hospital has laid off 35% of its 4,300 employees, including 68% of its senior managers. The census for its licensed 1,067 beds has run about 280. Hospitals have become cost centers - financial drains where patients are sent only as a last resort, which they must leave as quickly as they can.
This picture is not unusual nationwide, as managed care takes hold; hospitals are increasingly becoming integrated health companies, part of a large corporation. The promise of managed care as initially conceived was to promote cost-effective, prevention-oriented care. It was supposed to prevent millions of dollars being spent every year on unnecessary care in this country. There is little doubt that dollars are being saved. Profits are up for the hospital/health insurance industry (Burda, 1994).
But what is happening to the quality of care in hospitals? It goes without saying that the main reason people must be hospitalized is to receive nursing care; they are too ill or their treatment is too complex to be managed at home. Yet, hospitals continue to target RNs for layoffs. A national survey of hospitals by Modern Health Care revealed that 27% planned to lay off nurses in the next year, an increase from 19% in 1993. Not long ago, it was common for RNs to comprise 90% of the work force involved in direct patient care. Today that skill mix is often down to between 65% and 70% (ANA, 1995b).
At a February 1995 press conference, ANA released findings from a survey of 1,835 nurses nationwide (ANA, 1995a). They found that reduction in the number of RNs in hospitals was causing unsafe conditions for some patients, and massive workloads for the RNs who remain. Increased use of unlicensed assistive personnel (minimally skilled workers with as little as 4 to 6 weeks of training) to provide patient care is becoming commonplace, reported by 44% of the respondents. The respondents also reported more medication errors, increases in patient falls and fractures, longer waits for routine care, and earlier readmission and re-injuries resulting from inadequate patient education.
What is nursing education doing to respond? Clearly, the day-to-day practice of the clinical teacher has been profoundly affected by these changes. My colleagues who teach students in acute care settings report that the changes of the last 6 months in nurse staffing are taking enormous tolls on the clinical education of students. Faculty find themselves actually doing essential care that simply would not be provided were they not there, being another set of clinically skilled eyes and ears for the nurse too busy to notice changes in patients' status. They find themselves being much more active in interpreting the nursing practices witnessed by the students, so students understand what is acceptable practice, and what the circumstances may be that have contributed to the practices they are observing. The safety net afforded by having students pair with experienced nurses is simply not there.
Our response must be on several levels. In the short run, we need new strategies for managing clinical teaching in acute care settings. While a major paradigm shift in nursing education is occurring, it's not finished yet. We still sense an enormous obligation to help our students learn nursing practice in acute care settings, despite our goals in teaching community-based primary care practices. We need to develop ways to help our students critically evaluate and reconcile the promises of work restructuring and the realities they see in practice. With our students, we could begin to form alliances with community leaders, to inform the public about the effects of managed care on quality of care in hospitals, and to develop report cards of hospitals in our local communities as a public service (as ANA has proposed).
In the long run, we must continue our movement toward new paradigms for nursing education. We have little history to guide us in this move; the stakes are high; the need for innovation is greater than ever before. Let us be not frantic, but thoughtful, caring, and committed.
- American Nurses Association. (1995a). The 1994 layoffs survey conducted for the ANA. McLean, VA.: Decision Data Collection, Inc.
- American Nurses Association. (1995b). Safety and quality of patient care in hospitals: Talking points. Washington, DC: Author.
- Burda, D. (1994). A profit by any other name would still give hospitals the fits. Modern Healthcare, 18, 115.