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Update on nursing employment
Update on nursing employment Author: Polly Gerber Zimmermann, RN, MS, MBA, CEN, Chicago, Illinois
n c e r t a i n t y looms all around c o n c e r n i n g the s h a p e of future nursing employment. Nationwide, hospital employee morale has hit a n e w low a c c o r d i n g to 81% of the r e s p o n d e n t s in the 1995 hospital h u m a n resource survey c o n d u c e d by Deloitte & Touche. The r e s p o n d e n t s attribute their gloom to u n c e r t a i n t y about health care reform (92%), c h a n g e in job d u t i e s (58%), and layoffs (41%). 1 What is actually currently h a p p e n i n g in this e v e r - c h a n g i n g arena, and w h a t are the r e s p o n s e s ?
U
m a n y as 450, not 120, a c u t e i n p a t i e n t b e d s per 100,000 people will be n e e d e d , 2 and that there is too m u c h concern about r e g i s t e r e d nurse job loss in light of an A m e r i c a n Hospital A s s o c i a t i o n survey e s t i m a t e that there was actually a n a t i o n w i d e 3.5% rise in hospital e m p l o y m e n t of r e g i s t e r e d nurses from March 1994 to March 1995. 7 Regardless, most agree there is a general shift in e m p l o y m e n t toward c o m m u n i t y and outpatient settings with a projection of 612,000 more r e g i s t e r e d nurses n e e d e d in home health by the year 2000. s
Future hospital predictions Most planners p r e d i c t that there will be significantly less n e e d for i n p a t i e n t hospital beds. On the basis of the existing health m a i n t e n a n c e organization (HMO) data, they forecast that only 120 acute i n p a t i e n t b e d s will be n e e d e d for every 100,000 people. This is a significant reduction from the current n u m b e r of 358 b e d s p e r 100,000 people. 2 T h e s e c h a n g e s are e x p e c t e d to be e x p e r i e n c e d m o s t noticeably in the n o r t h e a s t region and the psychiatric service lines. 1 Nurses n e e d to take notice of this prediction b e c a u s e two thirds of the nations' 2.2 million nurses are now employed by hospitals. 3 The loss of hospital jobs for r e g i s t e r e d nurses is p r e d i c t e d to n u m b e r 200,000 to 300,000 jobs, and possibly even 500,000, a c c o r d i n g to E d w a r d O'Neil, h e a d of the University of C a l i f o r n i a - S a n F r a n c i s c o C e n t e r for Health Professions and the Pew Health Professions CommissionS, 4 Echoing a similar m e s s a g e , the Service Employees International Union e s t i m a t e s 1 million hospital jobs will be lost to "restructuring" by t h e year 2005. 5 The h o s p i t a l - b a s e d labor force in the Chicago area has already b e e n r e d u c e d by 15% to 20% in the last few years. 6 However, not all agree with this sobering future forecasting. Some nursing leaders cite the following points: (1) HMO subscribers are healthier and do not reflect the general population, (2) the population as a whole is aging, and (3) the m o v e m e n t toward universal a c c e s s to health care would increase the n e e d for health care services. It has b e e n p r e d i c t e d that as Polly Gerber Zimmermann is staff nurse III, Emergency Department and Occupational Health, Swedish Covenant Hospital, and associate nurse, American Airlines Occupational Health, Chicago, Illinois. For reprints, write PollyGerber Zimmermann, RN, MS, MBA, CEN, 4200 N. Francisco, Chicago, IL 60618. J Emerg Nurs 1996;22:917-22. Copyright 9 1996 by the Emergency Nurses Association. 0099-1767/96
$5.00 + 0 18/9/75481
ED-specific effects Some e m e r g e n c y nurses feel a s e n s e of job security b e c a u s e there will always be a c c i d e n t s and emergent needs. Some think there will actually be an increase in ED staffing n e e d s as a result of n e w developments, such as c h e s t pain observation centers or i n c r e a s e d holding times in the e m e r g e n c y d e p a r t m e n t to c o m p e n s a t e for d o w n s i z e d critical care units. Others are less certain about the ED's prospects. They believe that m a n a g e d care will s u c c e e d in educating a n d directing the ambulatory patients a w a y from the e m e r g e n c y d e p a r t m e n t . The A m e r i c a n Hospital Association's Society for Ambulatory Care Professionals latest report i n d i c a t e d that ED visits n a t i o n w i d e have d e c r e a s e d 1.9%. 9 This is the first decline in national ED c e n s u s since 1985. The c a u s e of this n a t i o n w i d e decline is attributed to m a n a g e d care, increase in primary care, c h a n g i n g patterns in specialty care, and competition from urgent care providers, ambulatory care centers, and p h y s i c i a n offices. 9 The effects are also u n e v e n across the United States. The Pacific region of the country reported that ED visits d e c r e a s e d by 13.9%. In contrast, the East and Central regions h a d a slight increase, apparently b e c a u s e m a n y p a t i e n t s in the inner-city and rural areas still use e m e r g e n c y d e p a r t m e n t s for n o n u r g e n t care. 9 Off the record, m a n y e m e r g e n c y d e p a r t m e n t s report a trend of m a i n t a i n i n g a similar census b u t e x p e r i e n c i n g an increase in a c u i t y and higher admission rates. Some have had difficulties when they downsized their staff a c c o r d i n g to general predictions only to have their own institution's c h a n g e s be less d r a m a t i c or less rapid than expected. Nonurgent ambulatory p a t i e n t s remain a significant portion of any ED p a t i e n t base. The layperson August 1996 317
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often lacks the discernment to accurately determine the urgency of his or her condition (i.e., that their sharp chest pain is costochondritis rather than a heart attack). In one study the physician researchers identified that only 56% of the ED patients needed immediate care, yet nearly 90% of the patients themselves honestly believed they needed "to see a doctor immediately. ''1~ How this ongoing dilemma is ultimately resolved remains to be seen.
The managed care factor Managed care and its policies continue to have a large influence on registered nurse staffing needs. Currently, 7 of 10 workers in large firms receive health care through m a n a g e d care plans (27% at HMOs, 29% at preferred provider plans, and 14% at point-ofservice plans). 11
Some experts warn that a r e s u l t i n g "me-first" c u l t u r e is b e i n g b r e d in t h e staff.
Currently nearly one in five Americans is now a member of an HMO. lz Already at the mark of 54 million total members nationwide, 13 total HMO membership, according to the Interstudy project, will reach 58.5 million to 66 million members by 1997.12 However, a backlash against HMOs has b e g u n as some members experience perceived treatment postponement, denial, inadequate physician time, and lack of preventative services. 11 A survey by the Robert Wood Johnson Foundation found that sick people enrolled in m a n a g e d care plans have significantly more complaints about quality than similar patients in traditional fee-for-service plans. 12 Public concern about quality of m a n a g e d care is continuing to mount. Responses include increased legislation (as seen in the actions against too rapid p o s t p a r t u m discharge), requirements for quality reporting and ratings, and direct contracting by companies with providers. 13 Some emergency departments have contracted with HMOs to see their afterhours patients. The final outcomes of this factor are still being shaped.
Mergers: The newer unknown The r e c e n t r a m p a n t consolidation of hospitals through mergers and acquisitions is one of the newer "unknown" cards. In addition to the elimination of departments and consolidation of services, hospital 315 Volume 22, Number 4
mergers and acquisitions rose 44% between 1994 and 1995.14 One in five U.S. community hospitals actually changed ownership in the last 2 years. 5 The fact that this widespread trend is basically unregulated raises some concerns. The Joint Commission on Accreditation of Healthcare Organizations does look at results through "sentinel events" such as poor patient outcomes, but there are few rules concerning the criteria or procedures for a merger. 5 These changes often result in staff "surpluses" as departments consolidate and institutional priorities change. Sometimes everyone in a department is forced to reapply for the fewer jobs now available. Mergers are often troublesome because four equally important aspects are not given proper attention: people, structures, politics, and organizational culture. 15 One manager recently involved in a merger "divorce" related the inherent, but not initially perceived, difficulties. The style of the communitybased, team-focused, informal, nonreligious small hospital clashed with the corporation-owned, hierarchy-based, formal culture of their "partner," a large religious hospital. For example, the smaller hospital wanted to deal with "surplus" staff through retraining and attrition, whereas the other (larger) hospital wanted to activate layoffs. Then, unexpectedly, a new chief executive officer with some different approaches b e c a m e involved halfway through the process.
Current layoff picture for registered nurses According to a 1995 Modern Healthcare survey, 36% of hospitals are planning to reduce staff, and that rate of reductions is accelerating a m o n g those intending to reduce their staff. Ten percent of hospitals making staff cutbacks are planning to target 15% or more of their workforce by the end of this year. 1 According to a 1994 hospital h u m a n resources survey, 27% of downsizing hospitals are specifically targeting registered nurses. 16 Data from APM (American Practice Management, a consulting firm used by many hospitals) show that 87% of 52 hospitals using APM's services cut registered nurse positions as a result of their suggested redesigns. 3 Personal experience underscores the phenomenon of reducing the numbers of registered nurses. More than two thirds of an American Nurses Association (ANA) nationwide convenience sample of registered nurses reported that they have seen reductions in registered nurse staffing where they work. 17 Not surprisingly, 71% of nurses in another survey believed their own job security was "very shaky. ''is This number is significantly higher than 49% of the general population worried about losing their job. 19
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N u r s e s a r e also c o n c e r n e d a b o u t their often limi t e d i n v o l v e m e n t a s t h e s e crucial p a t i e n t c a r e d e c i s i o n s a r e m a d e . T h e U n i v e r s i t y of M i c h i g a n M e d i c a l C e n t e r r e s t r u c t u r i n g p l a n calls for r e g i s t e r e d n u r s e e l i m i n a t i o n s , w i t h future d e c i s i o n s a b o u t b u d g e t c u t s to b e m a d e b y a four-physician, t h r e e - a d m i n i s trator (nonnursing) t e a m . M a n a g e m e n t at C o l u m b i a P r e s b y t e r i a n M e d i c a l C e n t e r in N e w York is d e m a n d i n g t h e i r r i g h t "to r e p l a c e RNs w i t h u n l i c e n s e d p e r s o n n e l " d u r i n g c o n t r a c t n e g o t i a t i o n s . 2~ R a t h e r t h a n b e i n g p e r c e i v e d a s h e a l t h care l e a d e r s for t h e d e c i s i o n s a n d c h a n g e s , m a n y n u r s e s feel c o m p l e t e l y r e m o v e d from t h e p r o c e s s .
Effects of the layoff tumult on the involved people C h a n g e from r e s t r u c t u r i n g a n d d o w n s i z i n g is e x p e c t e d to h a v e an i n f l u e n c e on morale. This is often r e g a r d e d a s a t e m p o r a r y b u t n e c e s s a r y p a r t of t h e p r o c e s s . But a n u n e x p e c t e d e n d p r o d u c t , a c c o r d i n g to s o m e experts, is a r e i n f o r c e m e n t of c o r p o r a t e b u r e a u c r a c y , r a t h e r t h a n its p r o j e c t e d elimination. T h i s is a t t r i b u t e d to t h e d i s s o l u t i o n of t h e o r g a n i z a t i o n ' s effective informal c o m m u n i c a t i o n c h a n n e l s ) 9 S o m e e x p e r t s w a r n t h a t a r e s u l t i n g "me-first" c u l t u r e is b e i n g b r e d in t h e staff. This i m p e d e s e m p l o y e e s ' abilities to w o r k c o o p e r a t i v e l y a n d creatively. 19 T h i s a t t i t u d e follows t h e a f f e c t e d people. R e s e a r c h e r s t r a c k e d i n d i v i d u a l s w h o h a d b e e n laid off b u t w e r e n o w r e e m p l o y e d ("the s u c c e s s stories"). T h e y f o u n d t h a t t h e s e i n d i v i d u a l s c o n t i n u e to s p e n d " e n o r m o u s a m o u n t s of time" looking for n e w j o b s r a t h e r t h a n i n v e s t i n g t h e m s e l v e s in t h e e n h a n c e m e n t of their n e w c o m p a n y . 19 T h e r e is also c o n c e r n a b o u t t h e effect on t h e h e a l t h c a r e e x e c u t i v e s at t h e "helm" of c h a n g e . M a n y a r e r e p o r t i n g a s a p p i n g of their vitality, "a loss of their spirit." A c c o r d i n g to one expert, t h e c a u s e is t h a t t h e important values that motivated and attracted peop l e ' s initial i n v o l v e m e n t to h e a l t h c a r e are n o w o b s c u r e d . This e x p e r t ' s p o i n t is h o w often do you h e a r d i s c u s s i o n s a b o u t w h e t h e r t h e n e w m e r g e r or c h a n g e s will result in real value b e i n g a d d e d to t h e p o p u l a t i o n ' s h e a l t h ? 21
The answer i s . . .
?? If all t h e i n f o r m a t i o n s e e m s c o n f u s i n g a n d conflicting, y o u c a n b e a s s u r e d t h a t you h a v e correctly u n d e r s t o o d t h e situation. O n e ED n u r s e m a n a g e r summarizes, " E v e r y o n e is l o o k i n g for 'THE A N S W E R . ' You h a v e a g r a s p of reality w h e n you finally realize t h a t no one k n o w s for sure." M i n u s a crystal ball, m a n y staff n u r s e s r e t a i n a n o p t i m i s t i c v i e w t h a t t h e r e will a l w a y s b e e m p l o y m e n t for n u r s e s in s o m e form. E m e r g e n c y n u r s e s are k n o w n for their e x c e l l e n c e in m a k i n g r a p i d a s s e s s -
m e n t a n d a n a l y z i n g c o m p l e x s i t u a t i o n s . T h e s e useful abilities effectively transfer into other n u r s i n g s p e cialties or s e t t i n g s . The B u r e a u of L a b o r S t a t i s t i c s projects a 25% i n c r e a s e in t h e total n u m b e r of jobs for r e g i s t e r e d n u r s e s b y t h e y e a r 2005. This p r e d i c t i o n t a k e s into consideration technologic advances, an aging population, t h e n e e d to r e p l a c e e x p e r i e n c e d r e g i s t e r e d
This attitude follows the affected people. Researchers tracked individuals who had b e e n laid off b u t w e r e n o w reemployed ("the success stories"). They found that these individuals continue to s p e n d " e n o r m o u s a m o u n t s of t i m e " l o o k i n g for n e w jobs rather than investing t h e m s e l v e s in t h e e n h a n c e m e n t of t h e i r n e w c o m p a n y .
n u r s e s , a n d t h e shift in d e m a n d from h o s p i t a l s to o u t p a t i e n t facilities. It is n o t e d t h a t in an "evolving system," registered nurses "may rotate among employment settings." Obtaining advanced degrees for t h e f u t u r e ' s i n c r e a s e d s u p e r v i s o r y roles a n d e x p a n d e d s e t t i n g s is e n c o u r a g e d b y b o t h the Bureau of Labor S t a t i s t i c s a n d t h e I n s t i t u t e of M e d i c i n e comm i t t e e 7, 22
Managerial preventive measures H o s p i t a l s try to d e a l w i t h t h e c h a n g e s t h r o u g h crea t i v i t y 23 (see "Avoiding R e g i s t e r e d N u r s e Layoffs: T h r e e H o s p i t a l s S h a r e H o w It's Done," p a g e 323). M a n y t a k e a p r o a c t i v e r e s p o n s e a g a i n s t n u r s i n g layoffs b y c r e a t i n g their o w n u n i q u e b l e n d of familiar s t r a t e g i e s . A l t h o u g h the "solutions" m a y not s e e m desirable, t h e y h a v e p r o v e n to b e m o r e effective a n d p a l p a b l e t h a n t h e alternatives.
1. Avoiding surplus hiring R u n n i n g "lean a n d m e a n " a v o i d s e x p e n s i v e , "just-incase" staffing. E x a m p l e s i n c l u d e i n d e p e n d e n t floati n g critical c a r e (STAT) nurses, z4 m a n d a t o r y on-call s t a t u s to m e e t t h e i n c o n s i s t e n t n e e d s of t h e n i g h t shift, 25 a n d a n i n t e r m i t t e n t u s e of a n overflow unit, staffed b y on-call nurses. 26
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4. Retraining for new settings "I a m a R e g i s t e r e d N u r s e " Pins Available The "I am a Registered Nurse" pin is available from the Illinois Nurses Association, Attn: Judy Nykiel, 300 S. Wacker Drive, Suite 2200, Chicago, IL 60606 (312-360-2300), for $3 each or 2/$5 plus $1 for shipping/handling. A gold-and-purple registered nurse tie-tac pin (measuring 3/4 x 3/4 inch), created by the American Nurses Association, can be purchased from the Illinois Nurses Association for $15 plus $1 shipping and handling. This pin is also available from Jim Coleman, Ltd., 970 E. Northwest Highway, Mt. Prospect, IL 60056; (800) 335-1560, fax (847) 398-0043. The price is $13.99 for state nurses associations/ANA members, $15.99 for nonmembers plus $2 shipping/handling.
Parkland Memorial Hospital in Dallas dealt with fluctuating, seasonal staff needs in the summer through freezing a m a n a g e m e n t nurse position and using the monies saved for an increase in staff nurse hours. The newly created, successful trial program offered a bonus of $1200 to each registered nurse who worked nine extra shifts. (Registered nurses are exempt and do not qualify for overtime pay.) In addition, management staff continues to take call duty for critical staffing shortages, and the infrequent use of an adjacent overflow holding area during high volume. 26
2. Flexible hours New full-time employees at Baptist Hospital in Miami are all hired with the understanding that they will be scheduled and paid for 64 to 80 hours in a 2-week pay period, determined by the hospital's staffing needs. They still receive full-time benefits, but the hospital now has the flexibility to deal with the fluctuating seasonal census. 3. Cross-training Intrafacility floating nurses between similar units, after orientation and training, is a familiar strategy. In addition, cross-training for tasks formerly provided b y ancillary d e p a r t m e n t s keeps nurses at the patients' bedsides. For example, nurses can, once again, obtain arterial blood gas studies, nebulizer treatments, phlebotomy, and electrocardiograms (ECGs). This could mean even better patient care because it allows ongoing clinical evaluation of the patient while the task is being performed without delay. 320
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Purging underutilized specialties or closing units has been described as a current response by up to 35% of nurses in one survey. 18 Moving these hospital nurses into community and outpatient settings is a common strategy for larger networks. For example, Stanford University Hospital moved many of its eliminated inpatient staff nurse positions to the expanding home health and ambulatory services. 27 Using its own College of Nursing, RushPresbyterian-St. Luke's in Chicago is retraining many of its inpatient nurses in certificate programs. Covered by tuition reimbursement, new employment opportunities include their home health business (which grew from 70,000 to 200,000 visits a year), case management, occupational health, and the institution's own HMO. 27
5. Keeping compensation in check Although it is not a popular change, most staff members eventually agree that wage freezes or benefit reductions are preferable to unemployment. Beth Israel in Boston has avoided layoffs, despite sharp nursing b u d g e t cuts, with a 1-year w a g e freeze and by designating all registered nurse positions as salaried.
The important values that motivated and attracted p e o p l e ' s initial i n v o l v e m e n t to h e a l t h c a r e a r e n o w obscured.
In one survey, 39% of nurses surveyed reported that no overtime is being authorized, and 27% no longer have the weekend 12/12 (Baylor) shifts, is Even more universally, 52% of nurses reported benefits-usually medical or educational p a y m e n t s - - h a v e been reduced and 43% said their pay increases were lower, is
Reinforcing nursing's vital role Registered nurses need to continue to reinforce the importance of the registered nurse credential. The intensifying acuity of hospitals' patients only further emphasizes that registered nurses, with their critical thinking and decision-making abilities, are essential. "Hospitals are becoming big ICUs," says Michael Evans, PhD, vice president of patient care at Presbyterian Hospital of Dallas. "Ten years ago, no
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one w o u l d h a v e t h o u g h t a b o u t h a v i n g an u n l i c e n s e d p e r s o n c a r i n g for a n i n t e n s i v e care p a t i e n t . N o w t h a t ' s [level of acuity] b e c o m i n g no different [than] a n y w h e r e in a hospital. ''3 A n i n s i d i o u s t r e n d is t h a t of c o n s u l t a n t s advoc a t i n g c h a n g e s in s t a t e p r o f e s s i o n a l l i c e n s e l a w s to allow c o l l a p s i n g of d i s t i n c t p r o f e s s i o n a l c a t e g o r i e s b y 50% to allow m o r e " b r o a d e n i n g " of d u t i e s . This p r o p o s e d c h a n g e is s e e n a s a w a y to g i v e m o r e lati t u d e in job r e d e s i g n . 5 S o m e i n s t i t u t i o n s w a n t all staff m e m b e r s , r e g a r d l e s s of t h e i r c r e d e n t i a l s , to b e d e s i g n a t e d a u n i v e r s a l "health c a r e worker."28 S o m e r e g i s t e r e d n u r s e p o s i t i o n s in Illinois h a v e b e e n " r e d e s i g n e d " to p a t i e n t c a r e t e c h n i c i a n (PCT) s t a tus, a p o s i t i o n a n d c o m p e n s a t i o n p r e v i o u s l y g i v e n to l i c e n s e d p r a c t i c a l n u r s e s in t h a t i n s t i t u t i o n . O f f e n d e d t h a t t h e RN d e s i g n a t i o n after t h e i r n a m e w a s s m a l l c o m p a r e d w i t h t h e i r PCT title, t h e y w e r e offered s a m e - s i z e d RN n a m e t a g s after i n v o l v i n g t h e Illinois N u r s e s A s s o c i a t i o n (INA) a n d t h e s t a t e D e p a r t m e n t of P r o f e s s i o n a l R e g u l a t i o n . 29 S o m e n u r s e s w e l c o m e g i v i n g a w a y s o m e of t h e i r r e s p o n s i b i l i t i e s to o t h e r s o u t of a s e n s e of collegiality or t h e d e s i r e to m a k e t h e i r w o r k l o a d easier. Others, h o w ever, b e l i e v e t h e y a r e " s h o o t i n g t h e m s e l v e s in t h e foot" b y d o i n g that. T h e y s u s p e c t t h a t t h e p o w e r t h a t p h y s i c i a n s h a v e s u c c e s s f u l l y h e l d in t h e h e a l t h c a r e a r e n a is r e i n f o r c e d t h r o u g h t h e i r s t a u n c h a d h e r e n c e to t h e n e c e s s i t y of t h e MD c r e d e n t i a l for m a n y t a s k s a n d r e s p o n s i b i l i t i e s . In c o n t r a s t , o n e s u r v e y f o u n d t h a t 85% of r e s p o n d i n g ED r e g i s t e r e d nurses had personally witnessed unlicensed assisted personnel performing nursing functions (assessing, triage, giving phone advice, extensive c o u n s e l i n g , d i s c h a r g i n g ) , b u t 32% d i d n e t t h i n k t h a t w a s a p r o b l e m , s~ N u r s e s n e e d to c o n t i n u e to p u b l i c l y reinforce a n d p r o m o t e t h e n e c e s s i t y of their r e g i s t e r e d n u r s e qualifications. O n e n u r s e m a n a g e r w e a r s a s i m p l e blacka n d - w h i t e 31/2 x 11/2-inch p i n t h a t s t a t e s "I a m a R e g i s t e r e d Nurse." Her m o s t i n t e r e s t i n g c o m m e n t s c o m e n o t from t h e p a t i e n t s , as s h e e x p e c t e d , b u t from h o s p i t a l staff. "Staff from m a n y different d e p a r t m e n t s tell m e t h e y h a d n e v e r t h o u g h t before a b o u t w h y m a k i n g t h a t p u b l i c i d e n t i f i c a t i o n is so important." (See t h e b o x on p a g e 320 for o r d e r i n g information for r e g i s t e r e d n u r s e i d e n t i f i c a t i o n p i n s a n d tie tacs.)
I n s t i t u t e of M e d i c i n e C o m m i t t e e on t h e A d e q u a c y of N u r s e Staffing in H o s p i t a l s a n d N u r s i n g H o m e s 7 f o u n d t h a t t h e r e w e r e insufficient d a t a to d e c i d e w h e t h e r h o s p i t a l s a r e a d e q u a t e l y staffed or if p a t i e n t c a r e is suffering. T h e y i n d i c a t e t h e r e is a s e r i o u s lack of m o n i t o r i n g s y s t e m s or c o m p l e t e d r e s e a r c h to d e t e r m i n e w h a t c o n s t i t u t e s a "safe skill mix" or h o w different m i x e s m a y c h a n g e o u t c o m e s . Therefore all r e g i s t e r e d n u r s e s n e e d to s u p p o r t r e s e a r c h t h a t c a n help p r o v e t h e w o r t h w e k n o w w e p o s s e s s . S o m e v i e w s h r i n k i n g t h e r e g i s t e r e d n u r s e role t h r o u g h e l i m i n a t i o n or r e p l a c e m e n t w i t h l e s s e r skilled w o r k e r s a s t h e solution to t o d a y ' s h e a l t h c a r e c o n c e r n s . T h e effects of t h a t a p p r o a c h r e m i n d m e of
One s u r v e y found that 85% of r e s p o n d i n g ED r e g i s t e r e d n u r s e s had p e r s o n a l l y witnessed unlicensed assistive personnel performing nursing functions ( a s s e s s i n g , triage, giving p h o n e advice, e x t e n s i v e c o u n s e l i n g , discharging), but 32% did not think that w a s a problem.
Keeping the registered nurse in the skill mix
a p a r o d y I o n c e h e a r d . It p o k e d fun at t h e w a y an effic i e n c y r e d e s i g n e x p e r t m i g h t criticize S c h u b e r t ' s Unfinished S y m p h o n y (P. Cournoyec; p e r s o n a l c o m m u n i c a t i o n , 1995). T h e e x p e r t w o u l d no d o u b t s a y that there were considerable times when certain i n s t r u m e n t p l a y e r s h a d n o t h i n g to do, or t h a t t h e r e were too m a n y violins playing identical notes at once, or that p a s s a g e s h a d b e e n r e p e a t e d unnecessarily. The whole p i e c e could h a v e b e e n s h o r t e n e d . . . and the c o m p o s e r would h a v e h a d time to finish the symphony! N u r s e s , like a p r o p e r l y o r c h e s t r a t e d p i e c e , p e r form a n i r r e p l a c e a b l e , e s s e n t i a l p r o f e s s i o n a l art. But it is o n l y w h e n n u r s e s truly a p p r e c i a t e a n d b e l i e v e in t h e i r o w n v a l u e t h a t t h e y c a n t h e n a r t i c u l a t e a n d "sell" it to p o l i c y m a k e r s a n d t h e p u b l i c a t large.
D e s p i t e e x a c t l y w h a t , how, or w h e n t h e c h a n g e s occur, r e g i s t e r e d n u r s e s k n o w from e x p e r i e n c e e x a c t l y h o w vital t h e role of t h e n u r s e is for q u a l i t y p a t i e n t care. T h e r e is a n e c d o t a l i n f o r m a t i o n a b o u t skill m i x c h a n g e s a f f e c t i n g q u a l i t y a n d s a f e t y of p a t i e n t care. H o w e v e r , t h e 1996 r e p o r t b y t h e federal
I thank Donna Potter, RN, CEN (Kent County Hospital), Nancy Highduke, RN, CEN, and Teresa Meyers, RN, CEN (Parkland Memorial Hospital), Craig McCal], RN, MS, MBA, CEN (Baptist Hospital of Miami), and Kathy J. Horvath, RN, MS. and Susan Stengrevics, RN, MS (Beth Israel, Boston), for their input into this article. August 1996 321
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References 1. Moore JD. Morale hits new low. Mod Healthc 1995; 25:52, 53, 57. 2. Nursing96 Editors, Curtin LL. Job security, clearing away the myths. Nursing 95 1995;25:46-7. 3. Lumsdon K. Faded glory. Hosp Health Netw 1995;69:30-5. 4. American Nurses Association. Major job losses foreseen in shift to managed care. Am J Nurs 1995;95:73-5. 5. Kauffold MR Merger fallout. RNs fight for survival as corporate couplings cause job collapse. Chicago Tribune, NursingNews 1996, March 20:1. 6. Kauffold MR Toughing out the merger surge. Chicago Tribune, NursingNews 1996, March 20:3. 7. American Nurses Association. IOM panel demands proof that cuts hurt care. Am J Nurs 1996;96:67, 70. 8. Mills ME, Tilbury MS. Restructuring: safety, quality and cost--nursing administration's perspective. Nursing Policy Forum 1995;1:17-9. 9. Montague J, Pitman H. Currents: emergency care. Hosp Health Netw 1996;70:14. 10. American Hospital Association. Currents. Hosp Health Netw 1995;69:20. 11. Kotulak R, Gorner R Medicine aches with HMO fever. Chicago Tribune 1996, April 14:sect 1, col 2:1, 16. 12. Meyer H, Solovy A, Hagland M. Beyond HMOs. Hosp Health Netw 1996;70:33-54. 13. Montague J, Pitman H. Currents: managed care. Hosp Health Netw 1996;70:14. 14. Montague J, Pitman H. Currents: mergers--the center of the storm. Hosp Health Netw 1996;70:10. 15. Bolman LG, Deal TE. Merger meltdown. Healthcare Forum J 1994;37:(6):30-6.
16. Burda D. Layoffs rise as pace of cost-cutting accelerates. Mod Healthc 1994:24:33, 34, 36, 38. 17. American Nurses Association. Cuts in RN staff keep escalating--ANA sees patient safety at stake. Am J Nurs 1995;95:69, 72. 18. Meissner JE, Carey KW. How's your job security? Nursing 94 1994;24:33-8. 19. Leana CR. Why downsizing won't work. Chicago Tribune, 1996, April 14;sect 10:14-18. 20. American Nurses Association. In brief. Am Nurse 1996 ;April/May:6. 21. Pryor KT. Take this job and love it? Hosp Health Netw 1996;70:28, 30. 22. American Nurses Association. How jobs are projected to grow/1994-2005. Am J Nurs 1996;96:70. 23. Zimmermann PG. Avoiding registered nurse layoffs: three hospitals share how it's done. J Emerg Nurs 1996;22:323-7. 24. Zimmermann PG. Use of "stat" nurses in the emergency department. J Emerg Nurs 1995;21:325-37. 25. Zimmermann PG. "On call" staffing. J Emerg Nurs 1993;19:529-31. 26. Zimmermann PG. Holding areas/observation units: d~j~ vu all over again. J Emerg Nurs 1996;22:307-10. 27. American Nurses Association. Top med centers grow more adept at shaving staff. Am J Nurs 1995;95:73-4. 28. Curtin LL. Comrade healthcare workers...? Nuts Manage 1995;26:7-8. 29. Kauffold MR RNs protest job rewrites. Chicago Tribune, NursingNews 1996, March 20;2. 30. Zimmermann PG. Nursing's perceptions of the effects of unlicensed assistive personnel in hospital emergency departments [thesis]. Chicago: North Park College, 1996.
T h e JOURNAL OF EMERGENCY NURSING welcomes the submissions of unsolicited manuscripts a n d e n c o u r a g e s c a l l s to d i s c u s s p o t e n t i a l a r t i c l e s .
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n c e r t a i n t y looms all around c o n c e r n i n g the s h a p e of future nursing employment. Nationwide, hospital employee morale has hit a n e w low a c c o r d i n g to 81% of the r e s p o n d e n t s in the 1995 hospital h u m a n resource survey c o n d u c e d by Deloitte & Touche. The r e s p o n d e n t s attribute their gloom to u n c e r t a i n t y about health care reform (92%), c h a n g e in job d u t i e s (58%), and layoffs (41%). 1 What is actually currently h a p p e n i n g in this e v e r - c h a n g i n g arena, and w h a t are the r e s p o n s e s ?
U
m a n y as 450, not 120, a c u t e i n p a t i e n t b e d s per 100,000 people will be n e e d e d , 2 and that there is too m u c h concern about r e g i s t e r e d nurse job loss in light of an A m e r i c a n Hospital A s s o c i a t i o n survey e s t i m a t e that there was actually a n a t i o n w i d e 3.5% rise in hospital e m p l o y m e n t of r e g i s t e r e d nurses from March 1994 to March 1995. 7 Regardless, most agree there is a general shift in e m p l o y m e n t toward c o m m u n i t y and outpatient settings with a projection of 612,000 more r e g i s t e r e d nurses n e e d e d in home health by the year 2000. s
Future hospital predictions Most planners p r e d i c t that there will be significantly less n e e d for i n p a t i e n t hospital beds. On the basis of the existing health m a i n t e n a n c e organization (HMO) data, they forecast that only 120 acute i n p a t i e n t b e d s will be n e e d e d for every 100,000 people. This is a significant reduction from the current n u m b e r of 358 b e d s p e r 100,000 people. 2 T h e s e c h a n g e s are e x p e c t e d to be e x p e r i e n c e d m o s t noticeably in the n o r t h e a s t region and the psychiatric service lines. 1 Nurses n e e d to take notice of this prediction b e c a u s e two thirds of the nations' 2.2 million nurses are now employed by hospitals. 3 The loss of hospital jobs for r e g i s t e r e d nurses is p r e d i c t e d to n u m b e r 200,000 to 300,000 jobs, and possibly even 500,000, a c c o r d i n g to E d w a r d O'Neil, h e a d of the University of C a l i f o r n i a - S a n F r a n c i s c o C e n t e r for Health Professions and the Pew Health Professions CommissionS, 4 Echoing a similar m e s s a g e , the Service Employees International Union e s t i m a t e s 1 million hospital jobs will be lost to "restructuring" by t h e year 2005. 5 The h o s p i t a l - b a s e d labor force in the Chicago area has already b e e n r e d u c e d by 15% to 20% in the last few years. 6 However, not all agree with this sobering future forecasting. Some nursing leaders cite the following points: (1) HMO subscribers are healthier and do not reflect the general population, (2) the population as a whole is aging, and (3) the m o v e m e n t toward universal a c c e s s to health care would increase the n e e d for health care services. It has b e e n p r e d i c t e d that as Polly Gerber Zimmermann is staff nurse III, Emergency Department and Occupational Health, Swedish Covenant Hospital, and associate nurse, American Airlines Occupational Health, Chicago, Illinois. For reprints, write PollyGerber Zimmermann, RN, MS, MBA, CEN, 4200 N. Francisco, Chicago, IL 60618. J Emerg Nurs 1996;22:917-22. Copyright 9 1996 by the Emergency Nurses Association. 0099-1767/96
$5.00 + 0 18/9/75481
ED-specific effects Some e m e r g e n c y nurses feel a s e n s e of job security b e c a u s e there will always be a c c i d e n t s and emergent needs. Some think there will actually be an increase in ED staffing n e e d s as a result of n e w developments, such as c h e s t pain observation centers or i n c r e a s e d holding times in the e m e r g e n c y d e p a r t m e n t to c o m p e n s a t e for d o w n s i z e d critical care units. Others are less certain about the ED's prospects. They believe that m a n a g e d care will s u c c e e d in educating a n d directing the ambulatory patients a w a y from the e m e r g e n c y d e p a r t m e n t . The A m e r i c a n Hospital Association's Society for Ambulatory Care Professionals latest report i n d i c a t e d that ED visits n a t i o n w i d e have d e c r e a s e d 1.9%. 9 This is the first decline in national ED c e n s u s since 1985. The c a u s e of this n a t i o n w i d e decline is attributed to m a n a g e d care, increase in primary care, c h a n g i n g patterns in specialty care, and competition from urgent care providers, ambulatory care centers, and p h y s i c i a n offices. 9 The effects are also u n e v e n across the United States. The Pacific region of the country reported that ED visits d e c r e a s e d by 13.9%. In contrast, the East and Central regions h a d a slight increase, apparently b e c a u s e m a n y p a t i e n t s in the inner-city and rural areas still use e m e r g e n c y d e p a r t m e n t s for n o n u r g e n t care. 9 Off the record, m a n y e m e r g e n c y d e p a r t m e n t s report a trend of m a i n t a i n i n g a similar census b u t e x p e r i e n c i n g an increase in a c u i t y and higher admission rates. Some have had difficulties when they downsized their staff a c c o r d i n g to general predictions only to have their own institution's c h a n g e s be less d r a m a t i c or less rapid than expected. Nonurgent ambulatory p a t i e n t s remain a significant portion of any ED p a t i e n t base. The layperson August 1996 317
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often lacks the discernment to accurately determine the urgency of his or her condition (i.e., that their sharp chest pain is costochondritis rather than a heart attack). In one study the physician researchers identified that only 56% of the ED patients needed immediate care, yet nearly 90% of the patients themselves honestly believed they needed "to see a doctor immediately. ''1~ How this ongoing dilemma is ultimately resolved remains to be seen.
The managed care factor Managed care and its policies continue to have a large influence on registered nurse staffing needs. Currently, 7 of 10 workers in large firms receive health care through m a n a g e d care plans (27% at HMOs, 29% at preferred provider plans, and 14% at point-ofservice plans). 11
Some experts warn that a r e s u l t i n g "me-first" c u l t u r e is b e i n g b r e d in t h e staff.
Currently nearly one in five Americans is now a member of an HMO. lz Already at the mark of 54 million total members nationwide, 13 total HMO membership, according to the Interstudy project, will reach 58.5 million to 66 million members by 1997.12 However, a backlash against HMOs has b e g u n as some members experience perceived treatment postponement, denial, inadequate physician time, and lack of preventative services. 11 A survey by the Robert Wood Johnson Foundation found that sick people enrolled in m a n a g e d care plans have significantly more complaints about quality than similar patients in traditional fee-for-service plans. 12 Public concern about quality of m a n a g e d care is continuing to mount. Responses include increased legislation (as seen in the actions against too rapid p o s t p a r t u m discharge), requirements for quality reporting and ratings, and direct contracting by companies with providers. 13 Some emergency departments have contracted with HMOs to see their afterhours patients. The final outcomes of this factor are still being shaped.
Mergers: The newer unknown The r e c e n t r a m p a n t consolidation of hospitals through mergers and acquisitions is one of the newer "unknown" cards. In addition to the elimination of departments and consolidation of services, hospital 315 Volume 22, Number 4
mergers and acquisitions rose 44% between 1994 and 1995.14 One in five U.S. community hospitals actually changed ownership in the last 2 years. 5 The fact that this widespread trend is basically unregulated raises some concerns. The Joint Commission on Accreditation of Healthcare Organizations does look at results through "sentinel events" such as poor patient outcomes, but there are few rules concerning the criteria or procedures for a merger. 5 These changes often result in staff "surpluses" as departments consolidate and institutional priorities change. Sometimes everyone in a department is forced to reapply for the fewer jobs now available. Mergers are often troublesome because four equally important aspects are not given proper attention: people, structures, politics, and organizational culture. 15 One manager recently involved in a merger "divorce" related the inherent, but not initially perceived, difficulties. The style of the communitybased, team-focused, informal, nonreligious small hospital clashed with the corporation-owned, hierarchy-based, formal culture of their "partner," a large religious hospital. For example, the smaller hospital wanted to deal with "surplus" staff through retraining and attrition, whereas the other (larger) hospital wanted to activate layoffs. Then, unexpectedly, a new chief executive officer with some different approaches b e c a m e involved halfway through the process.
Current layoff picture for registered nurses According to a 1995 Modern Healthcare survey, 36% of hospitals are planning to reduce staff, and that rate of reductions is accelerating a m o n g those intending to reduce their staff. Ten percent of hospitals making staff cutbacks are planning to target 15% or more of their workforce by the end of this year. 1 According to a 1994 hospital h u m a n resources survey, 27% of downsizing hospitals are specifically targeting registered nurses. 16 Data from APM (American Practice Management, a consulting firm used by many hospitals) show that 87% of 52 hospitals using APM's services cut registered nurse positions as a result of their suggested redesigns. 3 Personal experience underscores the phenomenon of reducing the numbers of registered nurses. More than two thirds of an American Nurses Association (ANA) nationwide convenience sample of registered nurses reported that they have seen reductions in registered nurse staffing where they work. 17 Not surprisingly, 71% of nurses in another survey believed their own job security was "very shaky. ''is This number is significantly higher than 49% of the general population worried about losing their job. 19
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N u r s e s a r e also c o n c e r n e d a b o u t their often limi t e d i n v o l v e m e n t a s t h e s e crucial p a t i e n t c a r e d e c i s i o n s a r e m a d e . T h e U n i v e r s i t y of M i c h i g a n M e d i c a l C e n t e r r e s t r u c t u r i n g p l a n calls for r e g i s t e r e d n u r s e e l i m i n a t i o n s , w i t h future d e c i s i o n s a b o u t b u d g e t c u t s to b e m a d e b y a four-physician, t h r e e - a d m i n i s trator (nonnursing) t e a m . M a n a g e m e n t at C o l u m b i a P r e s b y t e r i a n M e d i c a l C e n t e r in N e w York is d e m a n d i n g t h e i r r i g h t "to r e p l a c e RNs w i t h u n l i c e n s e d p e r s o n n e l " d u r i n g c o n t r a c t n e g o t i a t i o n s . 2~ R a t h e r t h a n b e i n g p e r c e i v e d a s h e a l t h care l e a d e r s for t h e d e c i s i o n s a n d c h a n g e s , m a n y n u r s e s feel c o m p l e t e l y r e m o v e d from t h e p r o c e s s .
Effects of the layoff tumult on the involved people C h a n g e from r e s t r u c t u r i n g a n d d o w n s i z i n g is e x p e c t e d to h a v e an i n f l u e n c e on morale. This is often r e g a r d e d a s a t e m p o r a r y b u t n e c e s s a r y p a r t of t h e p r o c e s s . But a n u n e x p e c t e d e n d p r o d u c t , a c c o r d i n g to s o m e experts, is a r e i n f o r c e m e n t of c o r p o r a t e b u r e a u c r a c y , r a t h e r t h a n its p r o j e c t e d elimination. T h i s is a t t r i b u t e d to t h e d i s s o l u t i o n of t h e o r g a n i z a t i o n ' s effective informal c o m m u n i c a t i o n c h a n n e l s ) 9 S o m e e x p e r t s w a r n t h a t a r e s u l t i n g "me-first" c u l t u r e is b e i n g b r e d in t h e staff. This i m p e d e s e m p l o y e e s ' abilities to w o r k c o o p e r a t i v e l y a n d creatively. 19 T h i s a t t i t u d e follows t h e a f f e c t e d people. R e s e a r c h e r s t r a c k e d i n d i v i d u a l s w h o h a d b e e n laid off b u t w e r e n o w r e e m p l o y e d ("the s u c c e s s stories"). T h e y f o u n d t h a t t h e s e i n d i v i d u a l s c o n t i n u e to s p e n d " e n o r m o u s a m o u n t s of time" looking for n e w j o b s r a t h e r t h a n i n v e s t i n g t h e m s e l v e s in t h e e n h a n c e m e n t of their n e w c o m p a n y . 19 T h e r e is also c o n c e r n a b o u t t h e effect on t h e h e a l t h c a r e e x e c u t i v e s at t h e "helm" of c h a n g e . M a n y a r e r e p o r t i n g a s a p p i n g of their vitality, "a loss of their spirit." A c c o r d i n g to one expert, t h e c a u s e is t h a t t h e important values that motivated and attracted peop l e ' s initial i n v o l v e m e n t to h e a l t h c a r e are n o w o b s c u r e d . This e x p e r t ' s p o i n t is h o w often do you h e a r d i s c u s s i o n s a b o u t w h e t h e r t h e n e w m e r g e r or c h a n g e s will result in real value b e i n g a d d e d to t h e p o p u l a t i o n ' s h e a l t h ? 21
The answer i s . . .
?? If all t h e i n f o r m a t i o n s e e m s c o n f u s i n g a n d conflicting, y o u c a n b e a s s u r e d t h a t you h a v e correctly u n d e r s t o o d t h e situation. O n e ED n u r s e m a n a g e r summarizes, " E v e r y o n e is l o o k i n g for 'THE A N S W E R . ' You h a v e a g r a s p of reality w h e n you finally realize t h a t no one k n o w s for sure." M i n u s a crystal ball, m a n y staff n u r s e s r e t a i n a n o p t i m i s t i c v i e w t h a t t h e r e will a l w a y s b e e m p l o y m e n t for n u r s e s in s o m e form. E m e r g e n c y n u r s e s are k n o w n for their e x c e l l e n c e in m a k i n g r a p i d a s s e s s -
m e n t a n d a n a l y z i n g c o m p l e x s i t u a t i o n s . T h e s e useful abilities effectively transfer into other n u r s i n g s p e cialties or s e t t i n g s . The B u r e a u of L a b o r S t a t i s t i c s projects a 25% i n c r e a s e in t h e total n u m b e r of jobs for r e g i s t e r e d n u r s e s b y t h e y e a r 2005. This p r e d i c t i o n t a k e s into consideration technologic advances, an aging population, t h e n e e d to r e p l a c e e x p e r i e n c e d r e g i s t e r e d
This attitude follows the affected people. Researchers tracked individuals who had b e e n laid off b u t w e r e n o w reemployed ("the success stories"). They found that these individuals continue to s p e n d " e n o r m o u s a m o u n t s of t i m e " l o o k i n g for n e w jobs rather than investing t h e m s e l v e s in t h e e n h a n c e m e n t of t h e i r n e w c o m p a n y .
n u r s e s , a n d t h e shift in d e m a n d from h o s p i t a l s to o u t p a t i e n t facilities. It is n o t e d t h a t in an "evolving system," registered nurses "may rotate among employment settings." Obtaining advanced degrees for t h e f u t u r e ' s i n c r e a s e d s u p e r v i s o r y roles a n d e x p a n d e d s e t t i n g s is e n c o u r a g e d b y b o t h the Bureau of Labor S t a t i s t i c s a n d t h e I n s t i t u t e of M e d i c i n e comm i t t e e 7, 22
Managerial preventive measures H o s p i t a l s try to d e a l w i t h t h e c h a n g e s t h r o u g h crea t i v i t y 23 (see "Avoiding R e g i s t e r e d N u r s e Layoffs: T h r e e H o s p i t a l s S h a r e H o w It's Done," p a g e 323). M a n y t a k e a p r o a c t i v e r e s p o n s e a g a i n s t n u r s i n g layoffs b y c r e a t i n g their o w n u n i q u e b l e n d of familiar s t r a t e g i e s . A l t h o u g h the "solutions" m a y not s e e m desirable, t h e y h a v e p r o v e n to b e m o r e effective a n d p a l p a b l e t h a n t h e alternatives.
1. Avoiding surplus hiring R u n n i n g "lean a n d m e a n " a v o i d s e x p e n s i v e , "just-incase" staffing. E x a m p l e s i n c l u d e i n d e p e n d e n t floati n g critical c a r e (STAT) nurses, z4 m a n d a t o r y on-call s t a t u s to m e e t t h e i n c o n s i s t e n t n e e d s of t h e n i g h t shift, 25 a n d a n i n t e r m i t t e n t u s e of a n overflow unit, staffed b y on-call nurses. 26
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4. Retraining for new settings "I a m a R e g i s t e r e d N u r s e " Pins Available The "I am a Registered Nurse" pin is available from the Illinois Nurses Association, Attn: Judy Nykiel, 300 S. Wacker Drive, Suite 2200, Chicago, IL 60606 (312-360-2300), for $3 each or 2/$5 plus $1 for shipping/handling. A gold-and-purple registered nurse tie-tac pin (measuring 3/4 x 3/4 inch), created by the American Nurses Association, can be purchased from the Illinois Nurses Association for $15 plus $1 shipping and handling. This pin is also available from Jim Coleman, Ltd., 970 E. Northwest Highway, Mt. Prospect, IL 60056; (800) 335-1560, fax (847) 398-0043. The price is $13.99 for state nurses associations/ANA members, $15.99 for nonmembers plus $2 shipping/handling.
Parkland Memorial Hospital in Dallas dealt with fluctuating, seasonal staff needs in the summer through freezing a m a n a g e m e n t nurse position and using the monies saved for an increase in staff nurse hours. The newly created, successful trial program offered a bonus of $1200 to each registered nurse who worked nine extra shifts. (Registered nurses are exempt and do not qualify for overtime pay.) In addition, management staff continues to take call duty for critical staffing shortages, and the infrequent use of an adjacent overflow holding area during high volume. 26
2. Flexible hours New full-time employees at Baptist Hospital in Miami are all hired with the understanding that they will be scheduled and paid for 64 to 80 hours in a 2-week pay period, determined by the hospital's staffing needs. They still receive full-time benefits, but the hospital now has the flexibility to deal with the fluctuating seasonal census. 3. Cross-training Intrafacility floating nurses between similar units, after orientation and training, is a familiar strategy. In addition, cross-training for tasks formerly provided b y ancillary d e p a r t m e n t s keeps nurses at the patients' bedsides. For example, nurses can, once again, obtain arterial blood gas studies, nebulizer treatments, phlebotomy, and electrocardiograms (ECGs). This could mean even better patient care because it allows ongoing clinical evaluation of the patient while the task is being performed without delay. 320
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Purging underutilized specialties or closing units has been described as a current response by up to 35% of nurses in one survey. 18 Moving these hospital nurses into community and outpatient settings is a common strategy for larger networks. For example, Stanford University Hospital moved many of its eliminated inpatient staff nurse positions to the expanding home health and ambulatory services. 27 Using its own College of Nursing, RushPresbyterian-St. Luke's in Chicago is retraining many of its inpatient nurses in certificate programs. Covered by tuition reimbursement, new employment opportunities include their home health business (which grew from 70,000 to 200,000 visits a year), case management, occupational health, and the institution's own HMO. 27
5. Keeping compensation in check Although it is not a popular change, most staff members eventually agree that wage freezes or benefit reductions are preferable to unemployment. Beth Israel in Boston has avoided layoffs, despite sharp nursing b u d g e t cuts, with a 1-year w a g e freeze and by designating all registered nurse positions as salaried.
The important values that motivated and attracted p e o p l e ' s initial i n v o l v e m e n t to h e a l t h c a r e a r e n o w obscured.
In one survey, 39% of nurses surveyed reported that no overtime is being authorized, and 27% no longer have the weekend 12/12 (Baylor) shifts, is Even more universally, 52% of nurses reported benefits-usually medical or educational p a y m e n t s - - h a v e been reduced and 43% said their pay increases were lower, is
Reinforcing nursing's vital role Registered nurses need to continue to reinforce the importance of the registered nurse credential. The intensifying acuity of hospitals' patients only further emphasizes that registered nurses, with their critical thinking and decision-making abilities, are essential. "Hospitals are becoming big ICUs," says Michael Evans, PhD, vice president of patient care at Presbyterian Hospital of Dallas. "Ten years ago, no
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one w o u l d h a v e t h o u g h t a b o u t h a v i n g an u n l i c e n s e d p e r s o n c a r i n g for a n i n t e n s i v e care p a t i e n t . N o w t h a t ' s [level of acuity] b e c o m i n g no different [than] a n y w h e r e in a hospital. ''3 A n i n s i d i o u s t r e n d is t h a t of c o n s u l t a n t s advoc a t i n g c h a n g e s in s t a t e p r o f e s s i o n a l l i c e n s e l a w s to allow c o l l a p s i n g of d i s t i n c t p r o f e s s i o n a l c a t e g o r i e s b y 50% to allow m o r e " b r o a d e n i n g " of d u t i e s . This p r o p o s e d c h a n g e is s e e n a s a w a y to g i v e m o r e lati t u d e in job r e d e s i g n . 5 S o m e i n s t i t u t i o n s w a n t all staff m e m b e r s , r e g a r d l e s s of t h e i r c r e d e n t i a l s , to b e d e s i g n a t e d a u n i v e r s a l "health c a r e worker."28 S o m e r e g i s t e r e d n u r s e p o s i t i o n s in Illinois h a v e b e e n " r e d e s i g n e d " to p a t i e n t c a r e t e c h n i c i a n (PCT) s t a tus, a p o s i t i o n a n d c o m p e n s a t i o n p r e v i o u s l y g i v e n to l i c e n s e d p r a c t i c a l n u r s e s in t h a t i n s t i t u t i o n . O f f e n d e d t h a t t h e RN d e s i g n a t i o n after t h e i r n a m e w a s s m a l l c o m p a r e d w i t h t h e i r PCT title, t h e y w e r e offered s a m e - s i z e d RN n a m e t a g s after i n v o l v i n g t h e Illinois N u r s e s A s s o c i a t i o n (INA) a n d t h e s t a t e D e p a r t m e n t of P r o f e s s i o n a l R e g u l a t i o n . 29 S o m e n u r s e s w e l c o m e g i v i n g a w a y s o m e of t h e i r r e s p o n s i b i l i t i e s to o t h e r s o u t of a s e n s e of collegiality or t h e d e s i r e to m a k e t h e i r w o r k l o a d easier. Others, h o w ever, b e l i e v e t h e y a r e " s h o o t i n g t h e m s e l v e s in t h e foot" b y d o i n g that. T h e y s u s p e c t t h a t t h e p o w e r t h a t p h y s i c i a n s h a v e s u c c e s s f u l l y h e l d in t h e h e a l t h c a r e a r e n a is r e i n f o r c e d t h r o u g h t h e i r s t a u n c h a d h e r e n c e to t h e n e c e s s i t y of t h e MD c r e d e n t i a l for m a n y t a s k s a n d r e s p o n s i b i l i t i e s . In c o n t r a s t , o n e s u r v e y f o u n d t h a t 85% of r e s p o n d i n g ED r e g i s t e r e d nurses had personally witnessed unlicensed assisted personnel performing nursing functions (assessing, triage, giving phone advice, extensive c o u n s e l i n g , d i s c h a r g i n g ) , b u t 32% d i d n e t t h i n k t h a t w a s a p r o b l e m , s~ N u r s e s n e e d to c o n t i n u e to p u b l i c l y reinforce a n d p r o m o t e t h e n e c e s s i t y of their r e g i s t e r e d n u r s e qualifications. O n e n u r s e m a n a g e r w e a r s a s i m p l e blacka n d - w h i t e 31/2 x 11/2-inch p i n t h a t s t a t e s "I a m a R e g i s t e r e d Nurse." Her m o s t i n t e r e s t i n g c o m m e n t s c o m e n o t from t h e p a t i e n t s , as s h e e x p e c t e d , b u t from h o s p i t a l staff. "Staff from m a n y different d e p a r t m e n t s tell m e t h e y h a d n e v e r t h o u g h t before a b o u t w h y m a k i n g t h a t p u b l i c i d e n t i f i c a t i o n is so important." (See t h e b o x on p a g e 320 for o r d e r i n g information for r e g i s t e r e d n u r s e i d e n t i f i c a t i o n p i n s a n d tie tacs.)
I n s t i t u t e of M e d i c i n e C o m m i t t e e on t h e A d e q u a c y of N u r s e Staffing in H o s p i t a l s a n d N u r s i n g H o m e s 7 f o u n d t h a t t h e r e w e r e insufficient d a t a to d e c i d e w h e t h e r h o s p i t a l s a r e a d e q u a t e l y staffed or if p a t i e n t c a r e is suffering. T h e y i n d i c a t e t h e r e is a s e r i o u s lack of m o n i t o r i n g s y s t e m s or c o m p l e t e d r e s e a r c h to d e t e r m i n e w h a t c o n s t i t u t e s a "safe skill mix" or h o w different m i x e s m a y c h a n g e o u t c o m e s . Therefore all r e g i s t e r e d n u r s e s n e e d to s u p p o r t r e s e a r c h t h a t c a n help p r o v e t h e w o r t h w e k n o w w e p o s s e s s . S o m e v i e w s h r i n k i n g t h e r e g i s t e r e d n u r s e role t h r o u g h e l i m i n a t i o n or r e p l a c e m e n t w i t h l e s s e r skilled w o r k e r s a s t h e solution to t o d a y ' s h e a l t h c a r e c o n c e r n s . T h e effects of t h a t a p p r o a c h r e m i n d m e of
One s u r v e y found that 85% of r e s p o n d i n g ED r e g i s t e r e d n u r s e s had p e r s o n a l l y witnessed unlicensed assistive personnel performing nursing functions ( a s s e s s i n g , triage, giving p h o n e advice, e x t e n s i v e c o u n s e l i n g , discharging), but 32% did not think that w a s a problem.
Keeping the registered nurse in the skill mix
a p a r o d y I o n c e h e a r d . It p o k e d fun at t h e w a y an effic i e n c y r e d e s i g n e x p e r t m i g h t criticize S c h u b e r t ' s Unfinished S y m p h o n y (P. Cournoyec; p e r s o n a l c o m m u n i c a t i o n , 1995). T h e e x p e r t w o u l d no d o u b t s a y that there were considerable times when certain i n s t r u m e n t p l a y e r s h a d n o t h i n g to do, or t h a t t h e r e were too m a n y violins playing identical notes at once, or that p a s s a g e s h a d b e e n r e p e a t e d unnecessarily. The whole p i e c e could h a v e b e e n s h o r t e n e d . . . and the c o m p o s e r would h a v e h a d time to finish the symphony! N u r s e s , like a p r o p e r l y o r c h e s t r a t e d p i e c e , p e r form a n i r r e p l a c e a b l e , e s s e n t i a l p r o f e s s i o n a l art. But it is o n l y w h e n n u r s e s truly a p p r e c i a t e a n d b e l i e v e in t h e i r o w n v a l u e t h a t t h e y c a n t h e n a r t i c u l a t e a n d "sell" it to p o l i c y m a k e r s a n d t h e p u b l i c a t large.
D e s p i t e e x a c t l y w h a t , how, or w h e n t h e c h a n g e s occur, r e g i s t e r e d n u r s e s k n o w from e x p e r i e n c e e x a c t l y h o w vital t h e role of t h e n u r s e is for q u a l i t y p a t i e n t care. T h e r e is a n e c d o t a l i n f o r m a t i o n a b o u t skill m i x c h a n g e s a f f e c t i n g q u a l i t y a n d s a f e t y of p a t i e n t care. H o w e v e r , t h e 1996 r e p o r t b y t h e federal
I thank Donna Potter, RN, CEN (Kent County Hospital), Nancy Highduke, RN, CEN, and Teresa Meyers, RN, CEN (Parkland Memorial Hospital), Craig McCal], RN, MS, MBA, CEN (Baptist Hospital of Miami), and Kathy J. Horvath, RN, MS. and Susan Stengrevics, RN, MS (Beth Israel, Boston), for their input into this article. August 1996 321
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References 1. Moore JD. Morale hits new low. Mod Healthc 1995; 25:52, 53, 57. 2. Nursing96 Editors, Curtin LL. Job security, clearing away the myths. Nursing 95 1995;25:46-7. 3. Lumsdon K. Faded glory. Hosp Health Netw 1995;69:30-5. 4. American Nurses Association. Major job losses foreseen in shift to managed care. Am J Nurs 1995;95:73-5. 5. Kauffold MR Merger fallout. RNs fight for survival as corporate couplings cause job collapse. Chicago Tribune, NursingNews 1996, March 20:1. 6. Kauffold MR Toughing out the merger surge. Chicago Tribune, NursingNews 1996, March 20:3. 7. American Nurses Association. IOM panel demands proof that cuts hurt care. Am J Nurs 1996;96:67, 70. 8. Mills ME, Tilbury MS. Restructuring: safety, quality and cost--nursing administration's perspective. Nursing Policy Forum 1995;1:17-9. 9. Montague J, Pitman H. Currents: emergency care. Hosp Health Netw 1996;70:14. 10. American Hospital Association. Currents. Hosp Health Netw 1995;69:20. 11. Kotulak R, Gorner R Medicine aches with HMO fever. Chicago Tribune 1996, April 14:sect 1, col 2:1, 16. 12. Meyer H, Solovy A, Hagland M. Beyond HMOs. Hosp Health Netw 1996;70:33-54. 13. Montague J, Pitman H. Currents: managed care. Hosp Health Netw 1996;70:14. 14. Montague J, Pitman H. Currents: mergers--the center of the storm. Hosp Health Netw 1996;70:10. 15. Bolman LG, Deal TE. Merger meltdown. Healthcare Forum J 1994;37:(6):30-6.
16. Burda D. Layoffs rise as pace of cost-cutting accelerates. Mod Healthc 1994:24:33, 34, 36, 38. 17. American Nurses Association. Cuts in RN staff keep escalating--ANA sees patient safety at stake. Am J Nurs 1995;95:69, 72. 18. Meissner JE, Carey KW. How's your job security? Nursing 94 1994;24:33-8. 19. Leana CR. Why downsizing won't work. Chicago Tribune, 1996, April 14;sect 10:14-18. 20. American Nurses Association. In brief. Am Nurse 1996 ;April/May:6. 21. Pryor KT. Take this job and love it? Hosp Health Netw 1996;70:28, 30. 22. American Nurses Association. How jobs are projected to grow/1994-2005. Am J Nurs 1996;96:70. 23. Zimmermann PG. Avoiding registered nurse layoffs: three hospitals share how it's done. J Emerg Nurs 1996;22:323-7. 24. Zimmermann PG. Use of "stat" nurses in the emergency department. J Emerg Nurs 1995;21:325-37. 25. Zimmermann PG. "On call" staffing. J Emerg Nurs 1993;19:529-31. 26. Zimmermann PG. Holding areas/observation units: d~j~ vu all over again. J Emerg Nurs 1996;22:307-10. 27. American Nurses Association. Top med centers grow more adept at shaving staff. Am J Nurs 1995;95:73-4. 28. Curtin LL. Comrade healthcare workers...? Nuts Manage 1995;26:7-8. 29. Kauffold MR RNs protest job rewrites. Chicago Tribune, NursingNews 1996, March 20;2. 30. Zimmermann PG. Nursing's perceptions of the effects of unlicensed assistive personnel in hospital emergency departments [thesis]. Chicago: North Park College, 1996.
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