Special Report: The Crisis In Nursing

By Christine Gorman

-- December 1986. New York City. A patient at Montefiore Medical Center could have died when his tracheal breathing tube fell out. Reason: no one on the understaffed night shift heard the respirator alarm go off.

-- February 1987. Los Angeles. Six days after being released from the Los Angeles County-University of Southern California Medical Center, a 39-year-old woman dies from complications suffered in a hospital-bed fire. Her family's contention: harried nurses discovered the accident only after she had suffered burns on 40% of her body.

-- January 1988. Louisville. For a time, by astonishing coincidence, none of the city's eleven hospitals can accept critically ill or injured patients. Reason: available beds in intensive-care units cannot be filled because not enough nurses are on duty.

From New York to Los Angeles, the nation's hospitals are locked in the grip of what could become the worst nursing shortage since World War II. Overworked and abysmally paid, growing numbers of America's 2 million registered nurses, 97% of whom are women, are trading in their bedpans for law books, ledgers and briefcases. The exodus of the exhausted comes at a time when nursing schools are reporting dramatic declines in enrollment and veteran nurses are loudly objecting to their working conditions. Paradoxically, however, there are more nurses employed now than ever before. Thanks to increasingly complex medical technology, an aging patient population and the worsening AIDS epidemic, the demand for nurses has never been greater.

Alarmed by gathering signs of a health-care disaster, Secretary of Health and Human Services Otis Bowen recently convened a special commission in Washington to find ways to revitalize the nursing profession. Almost simultaneously, retired Admiral James Watkins, the chairman of the presidential AIDS panel, called for federal programs to attract half a million more nurses by 1991 to treat AIDS patients and others who are chronically ill. Nurses on the job bluntly admit that patients entering U.S. hospitals these days may be risking their lives. "You should be worried if you or someone in your family has to check into a hospital," warns Mary Helen Clark, an intensive-care nurse at Einstein-Weiler Hospital in the Bronx. "There is not enough staffing to cover shifts. Patient care is compromised all the time."

In desperation, nurses have taken to the streets to protest. In January, 3,200 nurses staged a 3 1/2 day strike against the Los Angeles County public- hospital system. Hospitals in the New York City area have endured two strikes and four sick-outs in the past eight weeks alone. "You have to be deaf, dumb and blind not to know that there's a dangerous situation," says Emergency Room Nurse Renee Gestone, who picketed Brooklyn's Lutheran Medical Center last week. Adds fellow Striker Pat Stewart: "Some of the doctors are saying that we are morally wrong to go on strike, but is it any more morally wrong than if we are stretched out thin, giving bad care?"

"Who wants to go into nursing these days when there are so many better opportunities for women?" asks Adriene Barmann, 27, a cancer nurse at Mount Sinai Medical Center in Miami Beach. For most registered nurses, the average beginning salary is $21,000, yet 30-year veterans regularly earn less than $30,000. Duties range from starting intravenous lines and bathing patients to such menial tasks as fixing TVs and taking out the garbage. Hospitals routinely require 50- and 60-hour workweeks. Little wonder, then, that enrollment in nursing schools has plummeted 20%, to less than 200,000 student nurses, since 1983. During that period, four of the nation's top nursing schools have closed their doors.

At the same time, advances in medical technology have dramatically increased nurses' responsibilities. Consider the neurological intensive-care unit of Chicago's Cook County Hospital. Cocooned in a bewildering array of intravenous lines, tubes and machines, each patient is desperately ill; 30 nurses are required to monitor and care properly for a group of nine patients around the clock. "Things can change rapidly," explains Mary O'Flaherty, the unit's nurse coordinator. "One moment a patient's intracranial pressures, blood pressure and cerebral-profusion pressure can be fine. The next moment you can start hearing bells."

Patients now require more attention outside the intensive-care unit as well. As part of a long overdue campaign to control soaring medical costs, most patients are released from the hospital faster, but the ones who remain are sicker -- and usually older. The number of elderly patients has almost doubled in the past two decades. Result: more nurses are needed for fewer patients.

The AIDS epidemic has only made a bad situation worse. In New York City, AIDS patients already take up 9% of all available hospital beds. "Caring for AIDS patients is different from caring for any other sick person, make no mistake," says Donna Stidham, a senior nurse at the 20-bed AIDS unit of Sherman Oaks Community Hospital in Los Angeles. These patients tend to be sicker, their illnesses less predictable and their families more difficult to handle. Experimental treatments require close attention and study. "It's going to make everyone face the nursing shortage," says Jeanne Kalinoski, an AIDS nurse at a major New York City hospital. "If you have a heart attack in the emergency room, you might not get a bed because of the number of AIDS patients."

Officially, of course, the shortage has not really endangered people's lives. "Often the level of T.L.C. that a patient expects -- the back rub, the hand holding -- doesn't get done in today's intense environment," says Allan Anderson, president of Lenox Hill Hospital in Manhattan. "But I don't think there is any evidence that the quality of hospital care has deteriorated."

Nurses tell more troubling tales. Some are required to "float" into sections of the hospital where they have no experience; others must work beyond the point of exhaustion with no backup. Cook County Hospital's O'Flaherty contends that it is not at all unusual for a nurse to be confronted with two patients requiring emergency attention at the same time. Once on the scene, of course, nurses are legally liable; they cannot refuse to work, however impossible the situation. The only recourse for many is to fill out a form protesting the assignment. This does not absolve them if something goes wrong, but it proves that the hospital knew about the situation. "Someone in the hospital fills out a form every night," says Einstein-Weiler's Clark.

What is the solution? Trying to attract young nurses by offering higher starting salaries is a first step. But the cost of constantly having to train new nurses drains the resources of virtually every major medical center. The money might be better spent on creating incentives for experienced nurses to stay. "Nurses who are competent and show potential for professional growth ought to be able to double their salaries in ten years and triple them by retirement," argues Judith Ryan, executive director of the American Nurses' Association, based in Kansas City. "That would make us competitive with other professions."

Many health-care experts believe the entire concept of nursing and the traditional role of the nurse must be radically redefined. For too long the medical community has depended on nurses as a source of cheap but versatile labor. "We need to define the professional nature of nurses more precisely and assign other people to positions where a nurse's professional and scientific background is not essential," says Dr. David Skinner, president of New York Hospital. It does not take a nursing degree, for example, to deliver a pill to a patient. Houston's M.D. Anderson Hospital sometimes uses medication technicians, not R.N.s, to dispense drugs to patients after nurses have verified the dose. Says Connie Curran, vice president for health-care management and patient services at the American Hospital Association (AHA) in Chicago: "Hospitals that are using registered nurses to answer telephones and do an incredible amount of paper work should hire a secretary and use nurses to nurse."

Naturally, such a revamped job description means more responsibility -- and more respect. Nurses are often the first to spot trouble, make sense of a patient's confusing symptoms or suggest a needed change in treatment. Yet acting on such observations has traditionally been the physician's purview. R.N.s must become full-fledged members of the team and be expected to engage ! in the medical give-and-take about patients' well-being. That role is never in doubt on the AIDS ward at Sherman Oaks Community Hospital, where doctors and nurses find themselves depending on one another to battle the deadly disease. Beth Israel Hospital in Boston has retained its reputation for first-rate care with an innovative program that gives each nurse primary responsibility for one or two patients.

Even so, nurses are not quite blameless in this crisis. If they want to be taken seriously in an era of high-tech medicine, they are going to have to get serious about educational norms and standardize training programs. Currently, students can choose to take an R.N. exam after completing courses that last from two to five years. And the pressure is on to expand less rigorous programs in order to produce more nurses. Says Paula Castonguay, a nurse recruiter at the University of Texas Medical Branch at Galveston: "It worries me that not only are we not going to have enough nurses, but the ones we get are going to be less qualified."

The medical community can no longer afford to chew up its nurses and spit them out. "The old attitude toward nurses -- 'work long, work late, work hard' -- is just not going to attract people," says Debbie Davenport, a Los Angeles nurse. Agrees the AHA's Curran: "Nurses aren't content to be the housewives of the hospital anymore." Nor should they be.

With reporting by Barbara Dolan/Chicago and Jeannie Ralston/New York