Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: SUNDAY, November 27, 1994 TAG: 9411290016
SECTION: BUSINESS PAGE: F1 EDITION: METRO
SOURCE: SANDRA BROWN KELLY STAFF WRITER
DATELINE: LENGTH: Long
So, they have been reassigned to 9 West, a medical-surgical unit.
For almost three days, the pediatric unit ("pic-u") was empty of patients, and nurses scheduled for duty there "floated" to a variety of other departments, including the Roanoke hospital's nursery, obstetrics, pediatrics and medical-surgical wards.
Some used a portion of their annual personal time off, which the hospital administration encourages when there is no work.
Since insurance companies began pushing for lower costs, more outpatient surgery and shorter in-hospital stays, no hospital can afford to let nurses sit and wait for patients. Nowhere is this more obvious than in Carilion Health System, which operates Roanoke Memorial Hospital and Community Hospital of Roanoke Valley and accounts for more than 70 percent of the hospital in-patient admissions in the Roanoke Valley. It employs 9,500 people throughout its system and 5,600 in the Roanoke Valley.
As part of a system faced with a growing presence of managed health care, which monitors when and how long a patient can use a hospital, the Carilion nursing staffs are being squeezed from all sides.
Nurses are being asked to return to being generalists after having been asked to specialize. They have lost some of the extra differential pay for working unpopular weekend shifts, and are being asked through quality management programs to manage themselves on staffing.
On Oct. 1, Carilion eliminated the additional pay that was given nurses who were asked to work on short notice; weekend on-call pay, which had been $3 an hour for some specialties, was set at $2 an hour. Carilion also has eliminated the Baylor Plan, whereby some nurses who worked 32 hours on weekend and holiday shifts were paid for 40 hours.
Hospitals no longer need ways to entice nurses onto their staffs because there's no longer a shortage of RNs. Cutbacks throughout the country have assured a near-oversupply. Once upon a time, hospitals in larger communities stole nurses from Roanoke by paying incentive bonuses. These days there are no such bonuses.
Carilion also did away with sign-on bonuses for nurses, although it has kept bonuses for some specialists that are still in short supply, such as physical and occupational therapists.
Roanoke Memorial is even doing away with the scholarships it used to ensure that it would have enough nurses. RMH president Houston Bell Jr. said the financial support will be continued for students already in a program, but no new awards are planned.
Nurses said they feel they are the main victims of the cost-consciousness.
"I'm dedicated to nursing. I love nursing. That's what I'm supposed to be in, but the frustration of seeing the hospital look at the bottom line - which is money - is not where the nurses or doctors are looking," an RN said. "Our perspectives are different. I realize the hospital has to make money to stay in business. Health care professionals, their bottom line has never been money. That's not why we're health care professionals."
But this is the age of the generalist.
Nurses have had to take on broader duties, including some formerly assigned to specialists such as IV Therapy teams, who specialize in sticking patients for intravenous therapy, and phlebotomists, who draw blood samples. They also have ended up doing some work formerly done by orderlies.
On the other side, secretaries have been trained to take blood pressures and nursing assistants know how to suction mucous from trachea tubes.
Reassignment of staffers when a department is not busy is the most frightening part of the change to nurses, especially those who have spent years in one specialty.
"My concern is that when I'm pulled into an area where I don't have the expertise and qualifications," a Community Hospital nurse said, "what if a patient dies? Not only would it devastate me, but I'd be in the position of being responsible. If I go to court, a judge is going to say: 'What would a reasonable nurse have done? A reasonable and prudent nurse would not have accepted the job,''' she said.
Hers is not an unexpected response, according to author David M. Noer, a vice president for training and education at the Center for Creative Leadership in Greensboro, N.C.
In his book, "Healing the Wounds," Noer wrote:
"Layoffs are intended to reduce costs and promote an efficient, lean and mean organization. However, what tends to result is a sad and angry organization, populated by depressed survivors."
According to an article in Healthcare Financial Management magazine, Noer and others contend that massive work force reductions cause "survivor sickness," in which those left behind feel "violated" and become "angry, depressed, anxious, fearful, and skeptical."
Certainly, the following excerpts from one Roanoke Memorial nurse's letter to the newspaper show that reaction. She asked that her name not be used for fear that it could affect her job.
"So much is spent on convincing the public that 'Carilion Cares,' and yet behind the scenes are nurses like myself, angry, frustrated and scared.
"Angry because the patients are being neglected and charged for it! We are frustrated because staffing is cut to minimum and below minimum. Patients are not being turned properly [every two hours for those unable to turn themselves]. We're frustrated because we don't have time to do range of motion [moving or exercising limbs], frustrated because they are dying all alone and we only have time to run in and check for respirations. We don't have time to feed them slowly and listen to their needs," she wrote.
The nurse said supervisors "can't or won't" show management what the nursing needs are and won't authorize overtime to keep an area from being understaffed.
"It would seem that keeping overtime costs at 2 percent or less is of greater importance than qualified nurses caring for patients in the critical care environment," the health care worker said in her letter." Don't use my name," she added. "I don't want to lose my job."
The "floating" of nurses is a concern for supervisors, too. Staffing guidelines say that nurses must be trained in an area of reassignment or be asked to do only those tasks they are trained in. They have the right to refuse the reassignment.
"I don't expect nurses from labor and delivery to go into the medical-surgical unit and run things, but they can help," said Beth Cullum, Community vice president for nursing.
Nor does Cullum, a trained nurse, expect every nurse to like the changes.
"I'm not going to say all nurses are 100 percent happy. But do I have a staff committed to excellence? Yes," she said.
Cullum came to Community in September 1993 from the Greenville, S.C., hospital system. She is part of the "new" Community Hospital, which came under the wing of Carilion Health System in a 1990 merger with Roanoke Memorial Hospital.
She holds a bachelor's degree in nursing from Duke University and a master's degree from the University of Massachusetts. Like all health care workers, she knows that there is a limit to how lean a staff can be before it adversely affects patient care.
Community is nowhere near the danger point, she said.
"I'm not worried yet because I see so much opportunity for us still," Cullum said.
Before Cullum arrived, nursing staff members didn't go beyond "their own area." But there's a new philosophy, she said: "We're here for Community Hospital."
Her aim, she emphasizes, is to create collegiality and get employees to "drop the turfs."
There are too many specialists anyway, she said.
"We even have specialists within cardiac intensive care."
The trimming at Community began before Cullum's arrival, but she gives it her blessing. Hospitals, like most businesses these days, don't speak in terms of numbers of employees but of full-time equivalents, or FTEs. Cullum has helped eliminate 113 FTEs.
She also has helped put in place a program called "shared governance," which not only gives nurses more say in how patients are treated but also gives them responsibility for staffing.
A recent suggestion to cut a nurse manager position came from the team of which the manager was a member.
The nurse whose job was eliminated has taken a nonmanagement position at Community; she gets to keep her nurse manager salary for a year.
So far, Cullum said, Community has been able to find positions in the Carilion system for almost everyone who lost a job there. When orderly positions were cut, the hospital paid for three workers to retrain as nursing assistants.
Cullum said the intention is to not lose experienced staff members.
This year, Cullum took 80 registered nurses from Community to Rockledge, a stone mansion Carilion owns and uses for workshops in South Roanoke, to talk about collaborative practice and shared governance. Both are terms for giving nurses greater responsibility for patient care, staffing needs, performance and education.
"I told them I wanted them to commit without reservation," she said.
When one nurse asked Cullum, "Are you actually going to ask the staff to 'marry' Community Hospital?" Cullum's answer was "yes."
The pressures on the nursing profession are complex, Cullum said.
For example, eight nurses usually work each shift in Community's labor and delivery department. If there are no patients, but the potential of some at any time, "How many do you send home?" Cullum said.
The challenge for hospitals is to see if they can deliver care at the price insurance companies want to pay, said Dorman Fawley, president of Community Hospital.
But the challenge also is to make certain the quality of care stays high, he said.
Fawley was recruited two years ago to run Community after its longtime president retired. He has three master's degrees, including one in hospital management, which he used to teach at Johns Hopkins Medical School.
"I can lower the costs, but I think there is a point of diminished return," Fawley said. "I worry about patient care."
by CNB