ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Sunday, November 17, 1996 TAG: 9611190064
SECTION: EDITORIAL PAGE: 3 EDITION: METRO
COLUMN: BETTY STROTHER
SOURCE: BETTY STROTHER EDITORIAL WRITER
In the new health-care era, how do hospital patients fare?
THEY WOULDN'T want anyone they cared about to be in a Carilion hospital now, the four women agreed, unless they could sit at the bedside of their loved one the whole time. They don't trust the nursing care - though all are registered nurses at Carilion hospitals.
It's not the work their fellow RNs do that worries them. It is the work they will not be doing under a re-engineered "inpatient care delivery model" that Carilion Health System eventually will put in place in all of its 14 hospitals, including Community and Roanoke Memorial in the Roanoke Valley.
Many nursing chores traditionally done by RNs will be delegated to "clinical partners" - licensed practical nurses and (unlicensed) nursing assistants. Inserting catheters, changing IV dressings, taking vital signs are among the tasks on a long list of "patient care activities" deemed appropriate for clinical partners.
Simple tasks, the RNs agreed, which most people could learn quickly. But will nursing assistants - whose duties traditionally have been to give baths and empty bedpans - understand the significance of a change in a patient's vital signs? Know what danger signs to look for when changing a dressing? Recognize those warnings when they see them?
That knowledge of pathophysiology is what RNs spend years in training to acquire.
Precisely, said Beth Cullum, Carilion's vice president for nursing. It does not take an RN's skill to perform the task. It does take her judgment to assess the wound. So, while an RN (a professional partner) is providing care appropriate to her skill level, she can take a look at the wound while her clinical partner handles the bandaging.
But what if an RN can't be in the room right then?
Again, Cullum said, determining whether it's necessary to be there - and, if so, planning the day's work so she can be - are part of developing the nursing plan, one of an RN's key responsibilities.
The four nurses (who insisted on anonymity) had come down to the newspaper a couple of days earlier to air their fears - about their patients' well-being, and about their own accountability for tasks they feel they will be forced to delegate whether they are comfortable doing so or not. "We have no voice. We're robots."
What they are is part of a trend: Many hospitals across the nation have cut licensed nursing staff and shifted some of their bedside duties to lesser-trained, lower-paid, unlicensed aides, usually to save money.
And lowering costs is part of what is driving Carilion's re-engineering, Cullum admitted. But quality of patient care remains the highest priority. The goal of re-engineering is to put the focus of care on the patient, she says.
Before the new "patient-care model" was designed - by teams involving more than 100 employees - an assessment of Carilion's operations found that care is fragmented, with patients seeing 15 to 21 different care-givers in a 12-hour period. Patients put up with delays and duplication of effort because of hospitals' centralized, compartmentalized structure. And, on average, nurses spend more than 40 percent of their time on tasks that could be delegated to less-skilled workers (a figure that obviously is debatable).
Patient-focused care will involve changing far more than nursing jobs. Some centralized departments, from registration to EKG to physical and occupational therapies, will be shifted to patient-care units. There, all of the patient-care partners - administrative (i.e., unit clerks) and support (i.e., housekeepers) as well as professional and clinical partners - will work as a team to give coordinated care. That's the plan, anyway.
Besides lowering the cost of care, Carilion expects the restructuring to allow patients and their families to establish relationships with their care givers, tests to be turned around more quickly and physician's orders carried out more efficiently. And RNs, hospital officials said, should be able to spend more time on direct patient care: not on checking vital signs, but on planning and coordinating the care, educating and counseling the patient, as well as administering medication and handling complex treatment. They will have greater accountability and responsibility for managing the process of delivering health care.
"This is absolutely raising the bar, increasing their professionalism," Cullum said.
The four nurses didn't see it that way. "Nursing schools have tried to make nurses more specialized, and now we're taking a giant step back," one lamented.
"Who's running us are people who don't know what nursing is about," warned another. "They've never been in a position where if you made a mistake, someone could die."
Nurses already are stressed. Short-staffing means many are working mandatory overtime, and are stretched thin on their longer shifts. And with managed care ensuring that only the sickest patients are admitted to begin with, the average patient requires more care than before.
These problems, Cullum and Carilion spokeswoman Shirley Holland explained, are the result of a patient census 10 to 15 percent higher than this time last year. "We are responding, making sure the resources are there." But the pressure that employees have been under recently is not the result of the new care-delivery model, which is not yet being used at either of Carilion's Roanoke hospitals, said Cullum. "They have more assistance in the [new] care model than today."
More assistance - for which the RNs will be accountable. The four nurses are not at all sure they want to be when it comes to the work of unlicensed staff. (The hospital gives four to six weeks of training to clinical partners.)
"Nurses have been assigning tasks for a long time," Nancy Durrett, executive director of the Virginia Board of Nursing, said by phone. "There is not a list of things nurses can and can't do." Rather, licensing standards hold them accountable for deciding what care to assign to others. The language is intentionally broad, both to allow for evolving technology, and for a more basic reason.
"Sometimes a task can be nursing or not nursing," Durrett said, "depending on the condition of the patient" and who is being assigned to handle the task in what kind of unit. In an orthopedic unit, where the patient is a young man with two broken arms who simply needs someone to get food to his mouth, feeding is not a nursing activity. Delegating that job to an aide is perfectly appropriate.
In a stroke unit, where brain damage may have affected a patient's swallowing reflex, feeding involves knowledge, skill and judgment. It is nursing. Making those distinctions will be daily decisions for RNs.
Will this work?
Unfortunately, little objective research has been done on the overall impact of staff restructuring on quality of care - partly because hospitals don't want to share their data. As hospitals reorganize, they will have to be open - about licensed/unlicensed staff ratios, infection rates, readmission rates, morbidity rates - before the public can judge the success or failure of what is, really, one gigantic experiment.
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