The New Nursing Universe

Despite the promises of the restructurers, it took only a few years for nurses working at the bedside to recognize that hospitals facing a variety of financial pressures would try to solve them by downsizing the nursing work force and extracting as much productivity as possible from those who remained at the bedside. Nurses would soon be laid off and hospitals would not fill vacant positions. Since most hospitals lose between 10 and 12 percent of their RNs annually, the failure to fill vacant positions could eventually result in a significant reduction in the number of RNs. As promised, hospitals also changed the “skill mix” of RNs—that is, how many nurses are actually involved in hands-on patient care. This made perfect economic sense. In 1992 RNs earned an average of $37,738 per year, while the average staff nurse earned $35,212. Unlicensed assistive personnel (UAPs) may earn 20–40 percent less than RNs, and licensed practical nurses (LPNs) also earn less than RNs. Both groups may receive no decent benefits. In their restructuring many hospitals therefore replaced RNs with less expensive staff.1 “In a cost-competitive system, persons with the lowest level of training who can do the job are employed, under the assumption that higher training leads to greater compensation.”2 In 1984, 68 percent of all RNs in the United States worked in hospitals. By the year 2000 that figure had fallen to 59 percent.3 One study cited in a report released by the Institute of Medicine in 2004 showed that the nursing staff in hospitals had declined by 7.3 percent between 1981 and 1993. Another stated that the “use of multiskilled workers who are not RNs to perform such activities as making beds, giving patients baths, positioning patients too ill to position themselves, performing electrocardiograms, and drawing blood was identified as a core feature of redesign initiatives by 61 percent of 360 hospital nurse executives surveyed in 1995.”4

Nurses immediately began to worry about RN substitutes who were assigned nursing duties. No states regulate the education of nurse assistants. “No national standards exist for minimum training or certification of ancillary nursing personnel employed by hospitals. . . . Thus, they vary widely in educational attainments and in their training for simple nursing or quasi-nursing tasks. Furthermore, no accepted mechanism exists either to measure competency or to certify in some fashion that ancillary nursing personnel have attained at least a basic or rudimentary mastery of needed skills.”5

The result? Someone with no high school diploma and few hours of on-the-job training could be changing sterile dressings, inserting urinary catheters, or cleaning tracheotomy tubes. The RN still on the job would have to supervise this nursing aide, while doing all patient assessments and documentation himself. Meanwhile the nurse’s assistants would actually be practicing under the RN’s license. Under state licensure rules, the RN can be held responsible for any mistakes made by aides working under his direction—and can lose his license as a result of those mistakes. Early in the restructuring process, Janie Storr, a member of the Service Employees International Union who worked at Providence Hospital in Seattle, Washington, expressed nurses’ concerns about working with poorly educated aides. She described taking care of seven acutely ill patients with complex medical needs—one patient with an amputated leg, high blood pressure, and paralysis due to a stroke; another with Alzheimer’s, back pain, and incontinence; an elderly alcoholic with a fractured arm—while struggling to monitor a certified nursing assistant who, after only forty hours of training, was asked to take the blood sugar levels of patients on the unit. One evening, the assistant was assigned to a diabetic patient. When he reported to Storr a few hours after he’d seen the patient, he causally remarked, “Oh, I forgot to mention this to you, but I didn’t think it was important. The blood sugar in room such and such is relatively low, but that’s okay because the patient is sleeping.” In fact, the patient was in a diabetic coma.

Or there was the patient with a head injury who was admitted to Storr’s unit from the ER. When he arrived in the emergency room he told staff that he wanted to die. Shortly thereafter, a nursing assistant brought him up to the floor where Storr works. Two days later, Storr discovered that the potentially suicidal patient had a stash of Tylenol, sedatives, tranquilizers, and psychotropic medications in a plastic bag in the drawer of his bedside table. How did these get here? Storr asked the patient. Oh, he remarked blithely, the patient had brought them with him to the hospital 255 and the nursing assistant who wheeled him up to the unit had simply put them in his drawer.6

Nurses aren’t opposed to working hard or working with aides, Storr insisted. Aides are supposed to be there to help nurses by monitoring patients and advising the nurse of any significant changes in a patient’s status. But how is an untrained aide going to recognize a significant change when he or she sees it? That takes years for nurses to learn. Another element of restructuring—the cross-training that we discussed in the previous chapter—has also disturbed nurses. Again to save money, other hospital workers were trained, sometimes minimally, to pitch in and do nursing duties in their downtime. Thus when not busy with their primary job, maids, janitors, transport workers, kitchen workers, physical therapists, or other hospital staff would change sterile dressings or insert tracheotomy tubes. Similarly, if a nurse has a moment to breathe, she might be asked to do transport work, or social work, or housekeeping. At the same time, hospitals also laid off workers who actually helped nurses get through the day. Linda Aiken and her colleagues found that nurses were spending a great deal of their time giving patients food trays and then picking them up because food service staff had been laid off. Nurses were pitching in doing housekeeping duties because housekeepers were laid off or had to fetch blood products or lab specimens, or shuttle patients around the hospital because transport workers or lab staff were reduced.7 If a unit secretary job was eliminated, then nurses had to answer the phone.

In 2003 I talked to one hospital vice president of nursing who told me that his hospital was now dealing with what he described as the “umpteenth” consultant in a decade of restructuring. This time the message was simple: don’t cross-train or adjust skill mix, just eliminate nurses’ jobs. He managed to convince the hospital CEO and CFO not to cut any more RN positions. Instead, they cut the jobs of one hundred housekeepers. “The place is a mess,” he said, “and nurses have to do housekeeping work.”

Whether they have been downsized or “rightsized,” nurses tell us that their workload has increased and that they may be taking care of two or three times the number of patients they took care of in the past—perhaps ten to sixteen patients on medical surgical floors, and three or four patients on ICUs. In California, nurses lobbied successfully for safe nurseto- patient ratios because they were able to document this increase in workload. For example, the Institute for Health and Socio-Economic Policy analyzed 18.2 million California hospital discharge records and other data collected from state agencies and the hospital industry. Between 1994 and 1997 there was “an 8.8 percent increase in the average number of patients for which an RN must care; a 7.2 percent decrease in the number of RNs employed; and a 7.7 percent jump in the number of patients per staffed bed between 1995 and 1998.” Indeed, during this period California, a pioneer in managed care, ranked second-lowest nationwide (after Washington State) in the ratio of registered nurses to patients. 8

“The nursing problem surfaced most dramatically in California,” Alan Sager, a health care economist at the Boston University School of Public Health explains, “because California was near bottom of nurses per thousand people and has been cutting back on health care spending for past 20 years. Hospital spending was one-sixth, or 16.6% per person below national average, in 2002. In a state where the cost of living is very high, they’re spending one-sixth less per person. The cost of living in Los Angeles is 42 percent above the U.S. average.”9

In 1999 the Minnesota Nurses Association released yet another study confirming these trends. The report revealed that 70 percent of nurses surveyed said they were “unable to perform fundamental valuable duties of nursing . . . on a timely basis.”10

When nurses complain about too much work for too few nurses, hospitals insist that the number of RNs working in the industry has not declined. One study found that between 1990 and 1996 the number of hospital nurses had actually increased by 15 percent.11 But these numbers tell a complicated story. When hospitals count the number of RNs they employ, they include everyone who has an RN after their name, no matter where they are working. Administrators, utilization reviewers or discharge planners, nurses working in outpatient settings, clinical specialists, and nurse practitioners supplementing the work of medical residents—all will be listed on the books as part of the nursing work force, even though some are not delivering patient care on a hospital unit and cannot, therefore, help ease the burden of their stressed-out nursing colleagues on those units. “Hospitals now have a cadre of RNs who are taking care of the charts, not the patients,” said Jean Chaisson, describing what happened when she was still working at the Beth Israel Deaconess during its merger. “On a floor with fewer RNs spread thinner, when I’m busy rushing one patient to the operating room, these case managers or utilization reviewers are not there to help make sure another patient isn’t falling on the floor.”

At the end of the 1990s, Jane Smith* gave me a detailed description of what it was like for nurses and patients in the restructured hospital. Smith is an orthopedic nurse who worked nights in a Southern community hospital. She told me she routinely cared for eleven or twelve, and sometimes sixteen to twenty, frail, elderly patients who had just emerged from the operating room after having total hip or knee replacements. Her patients 257 were completely immobilized and could do nothing for themselves. Some were in excruciating pain. Smith took frequent vital signs to make sure they did not develop postsurgical infections, pneumonias, or internal bleeding that could lead to cardiac arrest and death.12 She helped them walk so they didn’t develop blood clots in their legs and shifted their positions so they didn’t develop bedsores, which is a serious risk of immobility for 11 to 13 percent of hospital patients under seventy-nine years of age.13 She also drew blood for tests and, every one to two hours, pushed intravenous medications (such as pain relievers, or heart or ulcer medications) into their veins and monitored their responses.

Over the past decade, doctors and nurses have drawn attention to the scandalous underutilization of pain medication for postsurgical patients. Due to extensive educational efforts, most health care workers today understand that insufficient pain medication jeopardizes a patient’s ability to heal. They also know that pain medication should be administered well before patients are turned, given a bedpan, or do their physical therapy. But Smith said, “If you have a really heavy patient load you don’t have time to do it. They ask for pain medication and I tell them I’ll be there as soon as I can. I recently had five patients in a row who needed meds, and I had to put them on a list. You run in there and give them meds, and get a pain scale, and ask if there’s anything you can do and they’ll say, ‘You’re too busy. I don’t want to ask you.’ ”

Dr. William Marshall* works with Jane Smith and shares her frustrations. In fact Marshall, an orthopedic surgeon, was the one who introduced me to Smith and to the problems of nurses in his hospital. He had heard a column I did for Public Radio International when I was a commentator for its show Marketplace. Concerned about the nursing crisis in his hospital, he shared his experiences with me. Because nurses are so overloaded, “You order a unit of blood at six thirty in the morning and you find out that at five thirty in the evening it still had not been given. You find patients calling for medicine for pain and it wasn’t given to them until an hour and a half later.”

Marshall said “cuts to the bone” were driving individual nurses to despair. “There are people with whom I’ve worked for ten or fifteen years,” he explained with mounting distress, “and I find them in tears, saying they can’t stand it anymore, they’re going to leave.”14

Patient Acuity and Cumulative Workload

One of the things that makes the contemporary nursing workload so difficult to deal with is the fact that with decreases in patient length of stay and pressure to enhance patient “throughput,” nurses’ duties have actually increased. This increase in intensity of nursing workload is created by a phenomenon called heightened patient acuity.

When patients stayed in the hospital for longer periods of time, they were generally easier to care for because they were less intensely ill. Over a decade ago, for example, a patient having surgery would be admitted to the hospital the day before his operation for tests, observation, and perhaps some education. After surgery, the patient would be permitted to convalesce before he was discharged. This meant that the average nurse might be taking care of one patient who needed little monitoring or pain and symptom management—the patient admitted the day before surgery or the patient fully stabilized and about to be discharged—as well as several patients who were acutely ill following their procedure. The nurses’ caseload would be balanced with high- and low-acuity patients. Today, surgical patients are admitted the same day as their surgery. When they are out of the OR, they are discharged as soon as they no longer have a temperature or a tube inserted in their bodies. Thus patients in the hospital for all sorts of treatments have very intense needs.

Consultants who teach hospitals how to downsize nursing staff often insist that if patients are staying on a unit for shorter periods, it’s only logical that they need fewer nurses to care for them. “When consultants crunched the numbers, they would tell VPs of nursing that a decrease in patient length of stay—from, say, five days to three days—for some particular patient population would mean that nurses could be cut from ten nurses for five days to six nurses for three,” Joanne Disch, a former vice president of nursing, explains.

“Looking at it from a numerical point of view, the consultants, unfamiliar with the realities of patient care, saw a decrease of 40 percent in length of stay, which to them translated into 40 percent fewer nurses. What they didn’t understand was that decreasing the length of stay could actually mean patients needed more nurses per day for the shortened stay. Cutting the length of stay involved cutting precisely those days in the hospital when patients needed less nursing care.

“Someone would say, ‘But that’s not how it works,’ ” Disch continues, “and the consultants would respond, ‘Well, you’re going to cut 40 percent of the work.’ Then you explain that you can’t apply lockstep financial analysis, and they would tell nurse executives, ‘Well, you’re just protecting nursing, you’re being unrealistic, and you’re not willing to change.’ ” On its website, the travel nurse agency UltimateNurse maintains a variety of chat rooms. On one of them nurses posted their concerns about patient acuity systems: “Don’t you just LOVE those acuities!! I work in the ER, and if a patient states he/she has arm pain, its a low acuity, even if this arm pain turns out to be a massive MI [myocardial infarction, or heart 259 attack]. They take their numbers/acuity from the stated complaint vs the final diagnosis!! Keeps the staffing ratio down.”

A labor and delivery nurse explained that “we do 800–900 deliveries a year, and so are fairly busy. Our staffing is based on our acuity system. Approx. a year ago, our hospital incorporated the Van Slyke model of acuities. Since that time our nurse/patient ratio has taken a turn downhill! It is so frustrating! When we complain to the nurse managers that our acuities do not adequately reflect what is going on, we get a ‘canned’ answer of: ‘Yes it does, the time studies you did prove that.’ The time studies were done prior to initiating the Van Slyke model. . . . I am so afraid that something bad will happen with the bare bones staffing we have the majority of the time! . . . I have been in nursing 20 years, and this is the worst it has ever been!”15

These nurses believe that systems for measuring patient acuity don’t reflect the realities of contemporary patient care. In the United States, at least, “data on all Medicare hospital admissions for 1985–97 showed an annual increase in the complexity of cases treated in acute care hospitals as measured by the Medicare case mix index, while a review of patient data for all payers and all acute care general hospitals in Pennsylvania during 1994–97 revealed that the severity of illness of patients admitted to those hospitals increased in the aggregate by 4.5 percent over the fouryear period.”16

When length of stay is truncated, the hospital and other health care facilities become like a Midas Muffler shop. Norrish reported patient turnover rates sometimes as high as 40–50 percent over an eight- to twelve-hour period.17 For the nurse, there is thus no downtime in the day and no ability to get a few minutes to catch one’s breath, take a lunch or coffee break, or even go to the bathroom.

Erica Wilson* works in the oncology clinic of a prestigious teaching hospital in the Northeast. She describes how increased patient acuity has affected her working life. In her clinic, the same numbers of RNs now see more patients. Half of Wilson’s patients are on experimental treatments. She must spend a great deal of time reviewing treatment plans and double-checking calculations of drug dosages. Because the side effects of experimental drugs aren’t well known, drugs must be infused more slowly. She must also monitor patients closely, so that she can respond to any hint of an adverse reaction, and then go over with the patient the complex schedules for administering chemotherapy.

A great deal of medication administration is now outsourced to the home, and patients are now instructed on self-administration of highly toxic drugs that nurses used to administer in the hospital or clinic. If patients have side effects, they call the clinic. Wilson must leave her patients to respond to these calls. At the same time, patients who have been discharged from the hospital while they are still ill are bringing more serious problems to the clinic. The increased volume of sicker patients also leads to more clinic emergencies like cardiac and respiratory arrests. As a result of the volume and acuity of patients, “Things are being missed,” she says. “Bloods that need to be drawn aren’t. For example, you didn’t realize that the patient needed a specific blood draw that day and they didn’t get it even though the study required it. If we aren’t making major mistakes, it’s by the skin of our teeth.”

Nurses thus complain that they cannot attend to basic patient needs. They have trouble getting medications to patients on time, and they can’t get patients to the bathroom or walk them as they should. They do not have time to make sure that the patients are not lying in feces or urine, which puts them at risk for skin breakdown and bedsores, and they do not have time to manage patient’s pain adequately. In 2004 a nurse in Pennsylvania told me that she and two RNs and two LPNs share twenty-nine patients on a multipurpose unit that mixes geriatric patients with pediatric patients. She recently was responsible for a woman with a raging blood infection who had permanent feeding and breathing tubes and was in four-point restraints because she kept trying to pull the tubes out. To turn her or bathe her required at least three nurses and at least a half an hour. But how could three nurses find the time to do this when they had to care for twenty-eight other patients, all equally sick and demanding? Nurses often tell us that they don’t even have time to take one of the most important measures used for infection control—hand washing. This is a particularly significant and alarming problem. It’s estimated that about two million patients a year in the United States develop hospitalacquired infections and about eighty thousand die of those infections.18 Hand washing is one of the most important ways that nurses and doctors and other health care workers prevent the spread of infection inside the hospital.

Proper infection control doesn’t just involve sticking your hands under the faucet and slapping on a little soap. Nurses are supposed to wash their hands thoroughly before and after patient contact. Atul Gawande, a surgeon, describes the process. “First you must remove your watch, rings, and other jewelry” (which are notorious for trapping bacteria). “Next, you wet your hands in warm tap water. Dispense the soap and lather all surfaces, including the lower one-third of the arms, for the full duration recommended by the manufacturer (usually fifteen to thirty seconds). Rinse off for thirty full seconds. Dry completely with a clean, disposable towel. Then use the towel to turn the tap off.”

If you become an ace and manage to do all this in a minute, imagine, 261 Gawande and hand-washing experts ask, how many times you touch a patient and how much time you’d have to spend washing your hands. Not to mention the damage that all this contact with strong soap does to the skin of the nurse or doctor. Although hospitals are now using alcohol rinses and gels, which may be somewhat quicker and less irritating, each additional patient the nurse cares for increases the hand-washing burden. Do nurses all wash their hands in the appropriate manner? When Gawande checked out his hospital in December 2003, he found that even with the new gels, 30 percent of the staff were not complying with hand-washing routines.19

More patients to care for. More meds to monitor. More time spent washing your hands. Sicker patients to comfort. These aren’t the only extra burdens nurses bear today. Shortened length of stay also increases what researchers Barbara Norrish and Thomas Rundall call nurses’ cumulative patient load. “A typical nurse may come onto her unit at seven in the morning and take care of seven patients with an aide,” says Norrish. “But four of those patients are discharged at noon, and four new patients are admitted at 1:00 p.m. The nurse manager who sees the patient at 1:00 p.m. will argue that the nurse only has seven patients. But she doesn’t. She has eleven.”

What is true of the speeded-up process of care for each individual nurse also applies to the unit itself. With more admissions and discharges, activity on the unit also escalates. Units feel more chaotic because with more patients, there are more people taking care of them. Nurses will have to deal not just with one or two doctors per four or five patients, but with multiple doctors dealing with multiple patients, all having different and sometimes contradictory suggestions about what to do about the patient. (The cast of characters is even larger in teaching hospitals with their interns, residents, fellows, and postdocs.) Nurses will have to confer with more social workers and more occupational, physical, and respiratory therapists. There will be more discussions with nutrition staff, and with transporters, pharmacy techs, and unit secretaries, if the unit still has one. Nurses will spend more time talking to home care agencies, rehabilitation facilities, nursing homes, or family members negotiating the handoff of the patient. Hospitals argue that there are now “case managers” or social workers to manage the patient’s discharge. But nurses have to provide them with the information needed to care adequately for patients leaving the hospital. And of course, more family members and friends will ask nurses pressing questions about their loved one’s condition. Many nurses have told me that when they raise these issues with nurse managers or higher-level hospital administration they get little support.

“The business people have taken over and they staff strictly by the numbers,” said one nurse in the Midwest. “When you express concerns that patient acuity is higher, they say, ‘You have six patients and two RNs, what’s the problem?’ If you point out that there are problems when there are more admissions or acuity rises, and ask what will happen if . . . , they say, ‘We don’t staff for what-ifs.’ ”

Enforcing Throughput

While nurses are juggling all these demands, they are under escalating pressure to get the patient out of the hospital—or discharged from a rehab hospital or even home care. Indeed, nurses today are asked to become enforcers of the very “throughput” that they feel jeopardizes the patients they care for and makes their job so frustrating. When length of stay is truncated, it is not the insurance company executive or utilization reviewer, hospital administrator, government bureaucrat, or MD who actually gets the patient out of his hospital bed. It is the nurse. Marie Heartfield, a senior lecturer in nursing at the University of South Australia, has studied the work of nurses on short-stay units. Heartfield began her study because of intellectual curiosity and personal experience. She herself had had surgery and was sent home far earlier than she would have been in the past. She found that she had much more pain than she’d anticipated and that nurses were not much help in managing that pain.

What is happening to patients and nurses in this new environment? she wanted to know. So she turned her investigative lens to a short-stay surgical unit in Australia, as well as to the preadmission unit where patients were given education prior to their surgery. Heartfield found that in both preadmission and on the actual short-stay unit, nurses were being asked to ignore the totality of patients’ needs and responses in the interest of throughput. When they talked to patients in their preadmission interviews, Heartfield says, nurses often treated patients who were anxious about surgery or anxious about their potential diagnoses (if they were having breast cancer surgery, for example) as though they were not really sick at all. “It was as though the nurses were processing goods in a supermarket rather than engaging with people who were having surgery and who were understandably nervous about it.”

Heartfield says she found the same thing on the short-stay unit. Nurses were constantly manipulating filled and unfilled beds, not patients. Patients would come in and go to surgery and the bed they were in was freed for another patient. The nurse would then get another patient who might then go to surgery, and another would come in. If patients returned from surgery to the unit, they were expected to stay no longer than two days. 263 They were defined as short-stay patients, not as people with a particular condition or problem. If the patient expressed concerns about the length of their hospital stay, Heartfield says, the nurses were not encouraged to consider those concerns.

“One man in my study was middle-aged. He had come in to have surgery on his shoulder and was only supposed to stay for one night. He made it quite clear that he didn’t think a one-night stay would be very good for him because he would have limited mobility after the surgery. He told the nurses that he lived by himself and felt that a two-night stay would be more appropriate. After the surgery he was in a lot of pain, and had virtually no mobility in his shoulder.”

Under the new model, this patient was not defined as someone with a complex set of physical needs, who would face difficulties once he was outside of the hospital. “Because it was just a shoulder he shouldn’t be requiring any hospital services. His problems had been localized to his shoulder and did not include living his life after having surgery on that shoulder.”

To keep their jobs, nurses have adapted to the model. Privately, however, many complain about these issues to their unit managers and toplevel administrators. Most say they get nowhere. Work smarter, not harder, they are told. Learn to delegate and prioritize. “How do you prioritize between a patient in shock and someone in ventricular tachycardia, or a patient in ventricular tachycardia and one who’s in cardiac arrest?” an ICU nurse asked.

RNs also worry about what happens to patients when they are sent home. They know that patient care is now being outsourced to illequipped relatives—family members who are now asked to provide professional-level nursing care in the home. As a number of studies have shown, family caregivers of the elderly and chronically ill often pay for providing help to their loved ones with loss of income, loss of job, and sometimes loss of their own health and well-being.20

The Disappearance of In-House Education and Support

The stresses that nurses experience today are further aggravated by cutbacks in the kind of clinical education and staff development that hospitals often provided both veteran and new RNs. Like physicians, nurses need a period of apprenticeship or orientation after they graduate from nursing school to help them master the complexities of actual practice. Our society doesn’t build a standard period of apprenticeship training— an internship or residency stage in the workplace—into nursing education, as it does for doctors. Two reports, in 1996 and 2001, indicated that a majority of RNs had not been sufficiently prepared to take care of patients’ needs in a rapidly evolving health care system in which there were constant advances in technology, treatment, and medications.21 Because of this, hospitals must provide some sort of orientation and ongoing education that allows novice nurses to develop a high degree of competence. Rather than throw them directly into the fray, many hospitals used to provide new nurses with a period of orientation—perhaps six, eight, or twelve weeks in which they attend orientation sessions and work with a more experienced nurse (in nursing jargon that RN is called a “preceptor”). If enough experienced nurses were employed on units, and patient loads permitted, nurses could also expect help from more experienced nurses with whom they can discuss patient care issues.

In many hospitals busy staff nurses, whether novices or experts, also received help and support from clinical nurse specialists, nurses like Marion Phipps or Jean Chaisson. These nurses had master’s degrees and specialized in a particular area of nursing. They would often run staff development programs and educational sessions for floor nurses. If they were unit based, they were available to give nurses advice and seek out the latest research on a variety of different clinical issues.

Like physicians, nurses also depend on continued education to stay abreast of new developments in both nursing and medicine. They have to learn about new treatments and medications and about new research produced by both disciplines. Indeed, in order to maintain their licenses, nurses are required to collect a certain number of continuing education units (CEUs) every year. Many nurses benefited from hospital “in-services”— education provided in the hospital, sometimes even on their unit—that helped them keep current.

In order for nurses to take advantage of educational opportunities, hospitals not only have to provide teachers and speakers, they have to give nurses time off to attend educational or professional meetings. This, in turn, depends on the indirect resource of adequate nurse staffing levels on a particular unit. Doctors are able to attend a grand rounds or a conference outside the hospital because on-call doctors cover for them and because nurses remain behind to take care of their patients. But who will replace nurses who leave the bedside to advance their knowledge? Certainly not doctors. Other nurses will. If there are not enough nurses on a unit to replace a nurse who wants to go to an educational session, she won’t be able to leave. Similarly, if hospitals don’t allocate resources for clinical specialists, there will be no unit-based help for the busy nurse. Cost cutting has led hospitals to eliminate not only nursing staff but also staff education and development programs. Many hospitals have scaled back their orientation programs for newly hired nurses and on- 265 going in-service training and continuing education programs for nurses as a result of financial pressure.22 When hospitals were under pressure to cut costs, nurse executives and managers felt they were in a terrible resource bind. “Nursing leaders faced with draconian budget targets felt they didn’t want to cut direct caregivers or nursing assistants,” explains Joanne Disch, a former nursing executive and a current professor of nursing. “Faced with these kinds of budget targets that were pretty dramatic, a lot of people felt that it would be better to cut educational resources than to cut staff.”

What happens when nurses don’t get properly educated or oriented? The first days Carol Lincoln* spent on the job are an example. After graduating from nursing school, she took a position as a staff nurse at a major hospital in Toronto. Lincoln was sent to a unit that was short-staffed. No one expected or welcomed her. Most important, no one had time to orient her. She felt that the nurse who was assigned to introduce her to the unit was furious that she had to take on this burden on top of all her other responsibilities. “And she let me know it in no uncertain terms,” Lincoln says.

Just to get this novice out of her hair, she sent her off for her first onthe- job patient contact—preparing dead bodies for shipment to the hospital’s morgue. “I had never seen a dead body,” Lincoln shuddered. “We don’t do cadavers in nursing school. I had no idea how to provide postmortem care. I didn’t know how to wrap a body and no one told me and I couldn’t find any protocols that could help me. So there I was, in this room with one dead patient on a bed, and one live patient behind a flimsy hospital curtain. I had to battle to try to lift and shift this literally dead weight without alarming the living patient who was only a few feet away.” Although the more experienced nurse finally took pity on Lincoln and suggested that she help her with lighter tasks, her day didn’t get any better. What was “light” to her was heavy to a novice like Lincoln. She was asked to set up the intravenous pumps that deliver fluids and patients’ medications. But she didn’t know how they worked, and the experienced nurse was too harried to give her the comprehensive lesson she needed. She didn’t understand the Cardex system used to record patients’ medication needs and care plans. As her shift was coming to an end and she was ready to breathe a sigh of relief, the nurse asked her to fill up a tub for a man who was dying of AIDS. She went into the bathroom only to discover that she was dealing not with a normal tub but a special hydrosonic tub whose sides had to be covered with gel before the patient bathed in it. When she mastered that maneuver and began to fill it with water, the nurse peeked in the door and asked her to help with another patient. Leaving the room, Lincoln shut the door behind her. “The unit was a madhouse,” she says. “I went with her to her patient. And then on to the next thing. Phones were constantly ringing, nurses were being paged every which way. As the chaos increased, we answered one phone and heard a frantic voice on the other end of the line. It was the cardiac care unit, the unit just below ours. ‘What the hell’s going on up there?’ they screamed. ‘The ceiling down here is falling in and water is flooding the unit.’ ”

“Oh my god,” Lincoln thought, as she hung up the phone and raced over to the bathroom. “I opened the door and water streamed out into the hallway. I had left the tub on and shut the door and forgot about it because of the crush of other responsibilities. I was . . . well, how can I describe it? mortified, humiliated. And also very, very angry.” “You don’t come out of nursing school ready to start on an understaffed unit. I should have been oriented,” Lincoln says. Training was what she determined to get.

The next morning, Lincoln went to the nurse manager and begged her to let her spend the next five shifts with no patient load, following a veteran nurse and just absorbing and learning. She agreed, with one caveat. “She told me they couldn’t pay me, that I’d have to work for nothing.” The two came to an agreement: Lincoln would work seven shifts and get paid for only two.

With that week of training complete, Lincoln felt more secure. Over the next eleven months her skills improved, but the situation in her hospital deteriorated as more nurses were laid off and patient loads increased. Since Canada was experiencing widespread hospital “restructuring,” Lincoln was unable to find more satisfying work. Lincoln followed many other Canadian nurses who went to the United States during the 1990s because of the lure of better pay. What she didn’t understand was that positions in U.S. hospitals were vacant because similar hospital restructuring was taking place in the United States. When she spoke to the vice president of nursing in the U.S. hospital trying to woo her down to Texas, Lincoln was surprised to learn that she was being interviewed for a head nurse position on the cardiology unit. She told the nurse executive that she’d had less than a year’s experience as a nurse with none of it in cardiology. Lincoln’s reservations were dismissed, and she was told that the hospital would provide her with a few weeks of training for the position. She nonetheless refused to take the job and was hired as a staff nurse on another unit.

For years, nursing students have complained about the education they receive from veteran nurses in the clinical setting. Restructuring only exacerbates the problem. And the rudimentary introductions new nurses receive in the restructured workplace don’t bode well for future retention. 267 Many hard-won new recruits to nursing—students in nursing schools— report that generally they are not warmly welcomed when they enter hospitals, long-term care facilities, clinics, and other health care settings for clinical experience and contact. During these “clinical rotations” or “clinical placements,” students are supposed to watch and question experienced nurses and help them care for patients. Today, these experienced nurses have little time to teach students and respond to what seems to be a relentless barrage of questions.

Teaching, like orienting the new nurse, is something a nurse racing between multiple, increasingly sick patients can ill afford, and many nurses make it quite clear that they do not appreciate this extra load. They aren’t paid extra for teaching students, and their caseloads aren’t adjusted accordingly. Harried nurses who lack teaching experience may not bother to conceal their resentment about this extra duty that has been placed on their shoulders.

Katherine Harris, who is now a labor and delivery nurse in western Massachusetts, says that when she was a student she had some nurses who were nice to her and a lot who weren’t. “You go in there and think that you’re there to help them out. But in fact, I see—now that I’m a nurse myself and work with students—that students aren’t a help. They’re an extra burden. They have nothing but questions and take up nothing but time.” A student at the University of Toronto School of Nursing echoed these sentiments. What she found was not help but a disgruntled nurse who made her feel completely unwelcome.

When I was recently asked to lecture to a fourth-year class of bachelor’s students at a nursing school at a state university in New England, I asked the students to write about their experiences learning to be nurses. The question was entirely neutral and did not specifically solicit negative comments. While many of the students remained committed to their choice of career, the majority were disheartened by their workplace encounters. “My experience on a med-surg (medical-surgical) floor last semester was very difficult,” one student wrote. “All of the nurses, and I mean all of them, were not open and understanding with us. We students received negative attitudes and a lot of harshness every time we went to clinical. This really impacted the way I worked with my patients because I was constantly thinking about how, for example, one nurse yelled at me earlier or gave me a dirty look after I asked a simple question. I was always nervous on the floor and scared to death to ask questions or ask for help. I would get nauseated before each clinical day because I knew what the response would be from the nurses when we arrived in the morning.”

What is perhaps even more disturbing are the lessons that students learn about the realities of patient care in the era of cost cutting. Nurses, by their example, cannot teach students how to give patients thorough evaluations, take needed time to deliver and monitor treatments and administer medications, and—this is particularly distressing to students— take the time to educate them and listen to their patients’ concerns and assuage their anxieties. What nursing students seem to learn is how to rush in and out of rooms and deliver just the basics in the shortest amount of time possible.

In an interesting essay, one of the students described her own experiences as a patient when she’d recently had her appendix out. She felt she got good care because the nurses in the hospital had worked with her when she worked in the same hospital as a nursing assistant. What stunned this young woman was the way the nurses treated her roommate, a patient who required much more care than she did. “Most of the staff ignored her call bells but would come running as soon as I rang mine. Eventually I would ring in for her as well. I could easily sense the impatience in everyone’s voices when they spoke to her.”

One student summed up the frustration her classmates conveyed: “I have often had to rush into a room, do the care and rush out. Not stopping to talk or do the extra things. I have often gone home crying because I could not do all I wanted, all I thought these elderly patients deserve.” These new nurses and nursing students would have benefited greatly from the assistance of clinical nurse specialists. The clinical specialist was one of the great innovations of the 1970s and 1980s, when nursing academics and hospital management recognized the need for unit- or hospital-based education and support for working nurses. This particular nursing job, however, was one of the casualties of cost cutting and restructuring. During the 1990s, clinical specialist positions were either reduced or eliminated. Indeed, in the mid to late 1990s, it became almost a vogue for clinical specialists to go back to school to become nurse practitioners. “In the mid-1990s, with the advent of HMOs and consultants like the Hunter Group, clinical specialists were laid off in huge numbers. No one had ever before experienced anything like this,” says Kathleen Dracup, who was a cardiac clinical specialist and professor at UCLA School of Nursing during this period. “People looked around and saw that the promise was that nurse practitioners were going to have the job security of the future. So schools of nursing developed post-master’s programs for people who had master’s degrees, such as clinical specialists, so they could get an NP degree. In 1995, there were about twenty-five thousand NPs in the United States; now there are over a hundred thousand. Part of that was fueled by clinical specialists transforming themselves into NPs.”

Medicare also helped fuel the exodus, Dracup adds. At about the same 269 time clinical specialists were being laid off, Medicare began to reimburse nurse practitioners for their work. All of this, she comments, sent a big message that nurse practitioners could find employment and reimbursement while clinical specialists couldn’t even get a job. The message took. “There was galloping motion toward NPs,” Dracup explains. The problem, Dracup says, is that the role of the NP is very different from the role of the clinical specialist. “Clinical specialists are defined as supporting systems of care. They work with nurses to support nurses, do research, and help hospitals gear up for Joint Commission accreditation. (The hospital accreditations that Medicare requires are done by the Joint Commission on Accreditation of Healthcare Organizations.) Nurse practitioners spend their days doing very different things. They work one-toone with patients, often as physician substitutes or sometimes in collaboration with physicians.”

Jean Chaisson’s professional voyage over the past decade illustrates what has happened to the role of clinical nurse specialist. When I began to write about Chaisson for my book Life Support, she was practicing at the Beth Israel Hospital in Boston. Chaisson spent four days a week working as a clinical specialist, teaching nurses about the latest developments in medical treatments and nursing care and advising nurses and doctors about how to provide better care for patients. Because she wanted to be close to nursing practice, she spent one day a week delivering direct care to patients. When her hospital merged with the New England Deaconess in 1996, the cost squeeze was on.

Unit managers had been instructed to cut costs. They felt, Chaisson said, that having a nurse available to teach and support RNs was a luxury they could no longer afford. So clinical specialist positions were cut and nurse managers, whose workload had also increased (a typical nurse manager would, under restructuring, manage two or perhaps even three units rather than one), would be asked to provide clinical support to nurses while simultaneously doing twice as much managerial work.

Chaisson didn’t immediately lose her job as a clinical specialist. Instead the balance of her work week shifted. She worked one day a week as a clinical specialist and four days as a staff nurse. During what soon became known as the “mangled merger” between the two hospitals, the newly combined institution was hemorrhaging money. More and more clinical specialists were laid off. Chaisson stopped doing clinical specialist work and worked as a staff nurse.

The hospital had always used clinical specialists to run educational sessions. With money drying up for staff education and clinical specialists losing their positions, there was less and less emphasis on education, Chaisson explains. And the hospital began to cut back on the kind of daylong programs it used to run. These dealt with important subjects like skin and wound care, arrhythmias (irregular heart rhythms), renal failure, and other clinical issues. The hospital also offered lunchtime seminars— for example, a seminar for a geriatric interest group where nurses could come once a month and get an hour’s worth of CEUs. With the departure of the clinical specialists, those programs began to disappear. Floor nurses were so overloaded with patients that they might be unable to attend the more meager fare that was offered instead.

By 2003, when I visited the Beth Israel Deaconess, a new nurse administrator was trying to reverse some of the problems caused by the merger and was starting to rehire clinical specialists. From conversations I had with the clinical specialist on the ICU as well as with a new staff nurse, it seemed, however, that the mandate of the clinical specialist had changed. Rather than planning care and conducting ongoing education to refine and expand nurses’ knowledge, the nurse educator’s role seemed to be far more limited. Her mission, said the clinical specialist, was to orient new nurses quickly to the ICU and get them out on the floors as speedily as possible.

In its 2004 report, Keeping Patients Safe, the Institute of Medicine (IOM) states that nurse education in hospitals and other health care facilities has suffered during cost cutting and does not provide the ongoing support nurses need. And if hospitals have skimped on training for nurses, who at least had a basic education in nursing school, what was even more alarming was that they were also failing to educate the nursing assistants who were now being asked to do many nursing tasks. The IOM report also noted that in the reengineering schemes not enough initial training and retraining was given to the nursing assistants who were supposed to lighten the load of the registered nurses that hospitals employed.23 How then could nursing assistants—who may not even have had a high school education and who were not covered by any state or federal regulations— be safely left with significant patient responsibilities if they didn’t have the training to fulfill them?

In fact, because nursing education and staff development has been so truncated, some unions have stepped in to fill the gap. Dorothy McCabe, the director of the Department of Nursing and Career Services of the Massachusetts Nurses Association (MNA), which provides continuing education for RNs, says that before cost cutting the MNA offered sporadic continuing education programs. “Now we now offer about twenty courses on clinical subjects, like lab values and cardiac arrhythmias, and many of them are filled—and not only with nurses who are MNA members. Fifty percent of the attendees are not MNA members. They’re coming because so many hospitals have done away with staff education de- 271 partments and clinical specialists. In fact, I worry about RNs and their patients when our courses are filled.”

Working Longer

In the spring of 2004 I went to visit an exhibit at the American Textile History Museum in Lowell, Massachusetts. The museum is a monument to American fabrics and to the workers whose sometimes backbreaking labor produced them. On display were photographs of female workers who toiled in the textile mills of Lowell during the latter part of the nineteenth century. One glass case exhibits a letter written to a mill official in 1867 and signed by dozens of mill workers. It reads as follows: “To the treasurer of the Appleton Corporation. We, the undersigned operatives in your employ, believing that 11 hours a day is inimical to our best moral & physical interests, would most earnestly request you to reduce the term of labor from 11 to 10 hours per day & your petitioners as in duty bound will ever pray.”

This petition, written over a hundred years ago, captures the struggle workers have waged—and thought they’d won—for the eight-hour day and the forty-hour week. While workers in other countries are fighting for even greater reductions in the workday and workweek, nurses are being asked to go back more than a century in time and devote more and more of their weekly—and daily—waking hours to their work. A paradoxical combination of employer demand, nurses’ fear of retaliation and job loss, failure to pay nurses an adequate wage, and nurses’ own voluntary accommodation to poor working conditions has resulted in an epidemic of overwork in the North American nursing profession. This epidemic includes four interrelated phenomena—so-called voluntary overtime work, longer shifts, mandatory overtime, and lack of flexible work schedules. All of these problems are another way that the new ruthless economy, to use Head’s term, is infiltrating nursing.

In the new global economy, when cost cutting and downsizing take place, those who remain on the job are asked to work longer and harder. Indeed, some form of overtime work is a central cost-cutting strategy in the world of downsizing. That’s because, in the “rightsized” workplace, only the labor force—not the amount of work itself—has been rightsized. The amount of work actually remains the same or increases. When, for example, the automobile work force was downsized in the 1990s, the number of cars that workers were expected to produce didn’t diminish to accommodate the reduction in force; the worker was asked to produce even more with much less. Similarly, in spite of predictions of huge numbers of hospital closings and diminishing numbers of patients, the hospital and health care work place is dealing with more patients, and, as we’ve seen, more acutely ill patients.

Using overtime as a routine way to staff a hospital floor enables employers to increase worker productivity while simultaneously cutting labor costs. They do this by encouraging employees to work more overtime or by mandating them to do so. After all, it’s more cost-effective to ask one worker to spend more time on the job doing the work of two or three workers than to hire those extra workers and incur the costs of their salaries, benefits, and job training.

As cost cutting proceeded during the 1990s and into the twenty-first century, hospitals cut their nursing budgets and many other expenses. “Some of the efforts to squeeze hospitals have been justified by evidence of wasteful practices,” Alan Sager says. “But most hospitals today are run in a pretty lean way and on a pretty lean mixture. Nonetheless they are still under pressure to continue cutting costs.” Sager and other critics of market medicine, like physician researchers David Himmelstein and Steffie Woolhandler, argue that this is because cost-cutting efforts have not addressed the real sources of waste, which “are clinical and administrative— unnecessary surgery, incompetent care, defensive medicine, all of which raise cost without clinical benefit. Then there are all the mountains of unnecessary paperwork,” says Sager, “which also raise costs without clinical benefit. Again, those two forms of waste are not under hospitals’ control, so hospitals squeezed on the revenue side continue to try to squeeze the costs that they can control—e.g., nursing.” Like other workers in the United States, nurses usually agree to take on large amounts of overtime work because their real wages have stagnated and they simply can’t make it on their salaries. Thus, Michael Smith has argued, “the decline of real wages partially renders moot the question of whether an employer actually requires overtime; many workers consider overtime mandatory because they need the extra pay to maintain their standard of living.”24

In addition to financial concerns, nurses’ socialization makes them particularly susceptible to overtime: it is difficult for them to resist appeals for self-sacrifice. When a manager insists that their patients need them, or they know their refusal to work will add an even heavier burden on their colleagues, it’s hard for them to say no. When workers don’t accept overtime work on a voluntary basis, many employers mandate them to work an extra few hours or an extra shift. If workers refuse, they may lose their jobs or face discipline. With mandatory overtime, Smith writes, “workers lose the ability to weigh the loss of leisure and family time against the added income. Instead, they are often forced to chose between working 273 overtime and losing their jobs.”

Here’s how it works in the hospital. After an exhausting eight- or twelve-hour shift, a nurse may suddenly learn that she has to work an additional eight or twelve hours. For a largely female work force with child care and family responsibilities, this is particularly onerous, not to mention unsafe, because a weary nurse will be far less alert. “The problem is worse for us at night,” explained Kate Maker, a nurse at UMass Memorial Hospital in Worcester, Massachusetts. “You work from three in the afternoon to eleven at night. You have arranged for someone to take care of your kids till you come home. So at ten o’clock, you’re told you have to work mandatory overtime. Well, just like the hospital can’t pull nurses out of the sky to suddenly work eleven to seven, we can’t pull baby-sitters out of the sky at eleven at night to take care of our kids. So we’re put in the terrible position of having to choose between abandoning our patients or abandoning our children.”

In some states, if RNs protest that mandatory overtime assignments are unsafe for their patients, they may be told that any refusal to accept the assignment will constitute “patient abandonment.” This is a particularly cynical use of a serious and important category of work place violation. To protect patients, a nurse who accepts a patient assignment by reporting to work can be disciplined and potentially lose her license if she walks off the job and thus willfully abandons her patients. This charge can lead to a disciplinary action by the state Board of Registration in Nursing. But patient abandonment only exists when the nurse has accepted the patient assignment and then abandons her vulnerable charges. It is a retrospective, not a prospective act. If she says, “No, I am too tired to work tonight,” thus refusing mandatory unscheduled overtime, she is not abandoning a caseload of patients she has accepted.

Even nursing students learn how dangerous it can be to refuse a mandated extra shift. One nursing student described an incident that occurred while she was doing her clinical placement. When all the nurses gathered for report, she expected to hear them discussing medical and nursing diagnoses. Instead they were talking about a colleague who’d been fired. What had happened to this woman? she wondered. The nurse had been ordered to work mandatory overtime because another nurse had called in sick. The nurse refused. “Even though she needed to pick up her kids from daycare, the supervisor fired her, saying that she wasn’t a ‘team player.’ Apparently a year earlier that same nurse had been instrumental during a code. Not a team member, what does that mean?” Given these pressures, it is not surprising that nurses report an epidemic of overtime, both mandatory and voluntary, over the past decade. When the American Nurses Association surveyed 4,826 nurses in 2001, almost 70 percent said they work mandatory or unplanned overtime each month, some as many as three or four times per month. When they were asked about planned overtime, “the total percentage of nurses working some form of overtime rose by more than 10 percent. . . . More than half of the nurses (51.7 percent) work anywhere from one to sixteen hours of overtime, and only 20.2 percent work no overtime at all.” Many said they work between forty and sixty hours a week, with the average nurse in the survey working as much as ten hours beyond the usual forty-hour workweek. Almost 12 percent said they worked sixty-one to eighty hours a week.25

In another report “61 percent of nurses surveyed said they had noted an increase in overtime or double shifts during the past year. Forty-eight percent said that ‘the amount of overtime required’ had increased.”26 The use of mandatory overtime has added to nurses’ discontent and fueled the exodus of nurses from hospital work. This in turn created greater demand for fewer nurses to work harder and longer. In an ever-downward spiral, hospitals found it harder to attract new recruits. Mandatory overtime as a solution to nursing shortages only exacerbated the problem.

And Longer Still

Overtime work is such a serious problem in part because of longer shifts. Ten or twenty years ago, most nurses in hospitals worked eight-hour shifts. To give twenty-four-hour care to patients, the standard hospital working day was divided into three eight-hour shifts. A group of nurses would arrive at seven in the morning and work until three. Another group of nurses would arrive to relieve them and work the evening shift, from three until eleven. These would be relieved by the night shift, who would work from eleven to seven.

Because they have to juggle work and family—or because they found the work so unsatisfying and preferred to get it over with as quickly as possible so they could have more free time for themselves—some nurses have turned back the clock on a century of labor law reform (as well as a growing body of literature documenting the relationship between fatigue, error, and poor judgment, not to mention irritability and poor communication in the workplace) and work three back-to-back twelve-hour shifts. Before cost cutting, some hospitals would pay them a full-time salary for thirty-six hours of work.

Today, studies and surveys have shown, fewer and fewer nurses work the standard eight-hour day, and more and more are working three back to-back twelve-hour shifts. Whether they choose these schedules volun- 275 tarily or not, many find they are staying at work even after their shift is over because they simply have too much work. The American Nurses Association survey found that the majority of nurses were now working between forty-one and sixty hours per week, with some working as much as eighty hours a week.27

Anne Rogers, a sleep researcher at the University of Pennsylvania School of Nursing, is the principal investigator of a study funded by the Agency for Healthcare Research and Quality to investigate the impact of nursing working hours on patient safety. In the heated debate about resident and physician working hours, Rogers explains, there have been many studies (about thirty) on physician work hours. Data on hours have been correlated with patient safety problems such as errors in medication orders, operations on the wrong limb, and poor judgments about patient care. There have been no studies, however, of nurses’ work hours. “We don’t know what hours nurses work, nor do we know the effect on patients,” Rogers comments.

To rectify this problem, researchers asked four hundred nurses randomly selected from the American Nurses Association, and five hundred from the American Association of Critical Care Nurses to keep a diary for twenty-eight days. They were to note when they slept, when they worked, when they were scheduled to work, if they made errors, if they were drowsy at work, if they fell asleep, if they worked overtime, and why. Researchers have collected data on ten thousand shifts.

Rogers explained that data on the first 5,300 shifts worked by the ANA nurses revealed “the majority of nurses no longer work traditional day evening or night shifts. About 60 percent of nurses in the first sample worked twelve hours. In the sample of critical care nurses, 86 percent were on twelve-hour shifts. Since hospitals are no longer willing to pay nurses who work thirty-six hours a full-time salary, they are also asking nurses to come in to do an extra four-hour shift to make up the difference.” But twelve hours, the researchers discovered, is not the full duration of many nurses’ working day. Some nurses—a small minority—were scheduled to work twenty consecutive hours. More troubling is the fact that most nurses simply can’t get their work done during their scheduled shift. “Every nurse in our sample,” Rogers said, “worked extra at least once during the twenty-eight-day period. Only one out of five days could they count on getting out on time. The nurses are averaging fifty-five minutes extra every single day they work.”

Although these nurses were staying late to finish their work, they were probably not being paid for this overtime. The Fair Labor Standards Act mandates that workers be paid overtime, but workers have to put in for that overtime in order to receive their pay. Rogers and others report that nurses are not going to their employers and requesting their overtime pay. According to Rogers, one study has shown that some don’t want to ask managers for extra pay because they worry about some form of employer retaliation or feel they’d be accused of being “too slow.” In the latter case, the inability to finish work would not be blamed on the characteristics of the workplace—increased workload and patient acuity—but on the characteristics of the worker. Some nurses may simply be unaware of labor laws mandating that they be paid for anything they do in the workplace: reporting on the condition of patients to another nurse taking over for the next shift, documenting their work in a chart, or finishing up with phone calls or other patient care activities after they finish their shift. “All of this is working time,” says labor lawyer Robert Schwartz, author of Your Rights on the Job.28 “Reporting time, charting time, that is working time.” But it will only be paid as working time if the employer exercises his or her rights.

Hospital workloads also lead nurses to contribute their unpaid labor to the hospital bottom line, as they increasingly work through breaks and lunch. Again, under state and federal laws and union contracts, nurses must be offered breaks and cannot be required to work through them. The nurse can volunteer to work through her breaks, but then the employer has to pay the nurse for those breaks or she must be permitted to leave work thirty or forty-five minutes earlier, depending on the amount of break time allotted.

Today, however, most nurses are working through lunch and getting no compensation for it. “On 63 percent of shifts, nurses didn’t get a lunch break or a break relieved of patient care. They may have had a lunch break but they spent it answering call lights. Ten percent of these nurses didn’t get lunch breaks at all, no matter how long their shift,” Rogers reports. Ten states have laws stipulating that workers have to have a thirtyminute lunch break, but nurses in those states were not getting their legally mandated breaks and lunch periods. In forty states there are no laws mandating lunch breaks, but laws do stipulate that if you work on your lunch break, you should be paid. These nurses were not paid for the time they took from their breaks. In June 2004, after an investigation by the U.S. Department of Labor, the UMass Memorial Medical Center was forced to pay 367 of its nurses $614,449 in back wages because the hospital didn’t pay them wages for their breaks even though they worked through them.29

“So,” Rogers comments, “middle-aged women (the average age of nurses in the sample, like nurses in general, was forty-five) are working eight, ten, twelve hours without any break from patient care responsibili- 277 ties and then staying when their shift ends because they can’t get their work done.”

Not surprisingly, Rogers adds, many of these nurses were sleepdeprived. Some nurses didn’t get enough sleep because they were doing other things. Some had heavy family responsibilities at home. Many of these nurses, for example, were taking care of elderly relatives, young children, or both. Many reported not getting enough sleep, being drowsy at work, or even falling asleep at work. While this is often a problem for nurses who work at night, many nurses were having trouble staying awake during the day.

Not only are nurses working without being paid for it, but their salaries overall have stagnated. Although nurses have not been encouraged to focus on the monetary rewards of the profession, the stagnation in wages, at a time when the job has become more hectic and demanding, has contributed to a flight from bedside nursing into administrative positions and even into other professions. “Since 1992,” Julie Sochalski writes, “nursing wages on average have done no better than keep pace with inflation in the general economy. After adjustment for inflation, RNs saw no increase in purchasing power of their annual earnings during most of the 1990s.” Similarly, Robert Steinbrook reports that “in recent years, wages for registered nurses have been relatively flat as compared with the rate of inflation. In 2000, the average annual salary of a registered nurse employed full-time was $46,782. Between 1980 and 1992, real annual salaries for registered nurses increased by nearly $6,000. Between 1992 and 2000, however, they increased by only about $200.”30

During the early 1990s, when demand for nurses was low, it is perhaps not surprising, Sochalski notes, that nursing wages didn’t rise. But even after hospitals started chasing nurses, “RNs who did not seek additional education or promotion to higher positions received wages that rose at decreasing rates with experience. Wages paid to hospital staff nurses who graduated twenty years earlier were only 10 percent higher than wages paid to those who came into nursing ten years earlier.” This pattern, Sochalski speculated, would encourage new candidates to the profession to view bedside nursing as a career trap and to believe that “the only way to realize salary gains is to pursue more education or leave the bedside for other jobs, such as administrative positions.”31

Economist Barbara Bergmann has done some research on the issue of nurses’ salaries. Like Sochalski, she wondered why, in a market economy, nurses wages haven’t risen enough when there is a recognized shortage. One reason, she believes, is that hospitals in many metropolitan regions implicitly agree not to compete with one another to raise wages. Hospitals do this, Bergmann argues, by informally exchanging information about the salaries they pay nurses, which essentially limits wage increases. Indeed, in 1994, the Department of Justice brought an antitrust suit against the Utah Society for Healthcare Human Resources, an organization controlled by Utah hospitals, for doing just that. “In 1996, the Federal Trade Commission issued a joint statement of policy outlining what kind of information sharing hospitals may engage in, so as not to violate antitrust laws,” Bergmann says. “It would be interesting to know whether these guidelines are being followed. I suspect they aren’t.”

Nurses’ wage stagnation is part of a larger pattern of the stagnation of middle-class wages in the United States. Simon Head argues that there is a connection between broader reengineering in the economy and the income inequalities that the United States experiences. “Data for the economy as a whole provides strong circumstantial evidence of a causal link between technological change in the form of reengineering and ERP (enterprise resource planning), and the stagnation of most U.S. wages and benefits.”32

Hot and Cold Running Nurses

Nurses’ morale has also plummeted because of the increasing use of floating— another hospital staffing practice nurses have long deplored. “Floating” means moving nurses from the unit where they usually work to another nursing unit that is short-staffed. For example, if a nurse calls in sick, is out on vacation, or on maternity leave, managers will send an oncology nurse to a cardiac unit to replace her, or a cardiac nurse might be floated to a surgery unit. While floating a nurse on an occasional basis to deal with patients that she is relatively unfamiliar with may not be a terrible burden, floating as a routine practice is part of a larger deskilling of educated professionals that decreases morale, and, nurses say, is unsafe for patients. “Would you ask an ear -nose-and-throat doctor or dermatologist to cover cardiology for the day and expect high-quality care?” Jean Chaisson asks.

This is precisely what many hospitals ask nurses to do on a daily basis. Over a decade ago, nurses would usually work on units that specialized in a particular health problem. Hospitals might have a float pool of nurses that would supply a nurse to another unit in an emergency. Today, hospitals use floating as a routine staffing strategy both to avoid hiring additional permanent nurses and to deal with the shortage the lack of new recruits creates.

Susan Davis* told me how nurses in her teaching hospital are constantly floated between units. Davis, a nurse manager, said that the hospital tries to match the nurse’s skills to the unit to which he has been as- 279 signed. But sometimes a nurse may be asked to work with an unfamiliar group of patients. “A nurse coming into the hospital to work won’t know where she may be working,” Davis said. “She knows where her home base is, but if that floor isn’t too busy, he or she may be floated to another floor. The possibility of working with people you don’t know, patients you don’t know, and units you don’t know is always there.”

Today, hospitals want the flexibility not only to float nurses but also to float patients. If a unit has a full complement of patients and nurses, but a new patient needs to be admitted to that unit, the patient may be sent to a floor where a bed is free and a nurse is available to staff it. Davis explained that decisions about patient placement are based on available resources rather than patient need. Either the patient may be sent someplace where nurses have little expertise but a lot of free beds, or the nurse may be sent to a unit where there is a surplus of patients about whose conditions she has little expertise.

Again, this reflects the nineteenth-century notion that a nurse is a nurse is a nurse. It also suggests that managers may assume that nurses don’t need any expertise of their own because they can always rely on the expertise of the physician, or can get a quick catch-up on how to care for an unfamiliar group of patients by checking the clinical pathways or care maps. Nursing work is destabilized by another practice that hospital restructurers have imported from manufacturing industries. Like just-intime supplying of auto or stereo parts, we now have just-in-time staffing in the hospital. “Every manager who’s responsible for living within a budget wants the budget to be as flexible as possible,” Alan Sager explains. “In health care that means as the amount of care you have to give goes up you can hire more people and buy more IV solution, and as the amount of care goes down you can adjust your costs accordingly. Today no hospital wants to pay to staff beds that are empty, that don’t have patients in them. Managers want to match staffing and cost to patient census and therefore revenue. If the patients are there, they are generating revenue. They don’t want to staff empty beds which are not generating revenue.”

Just as health care managers try to control the length of patient stay in the hospital, they also try to control the duration of the length of a nurse’s stay in the hospital. They do this by denying many RNs the predictability of a fixed schedule. Using patient acuity systems, nurse managers are told that they have to “flex” their work force up and down as patients either fill or vacate hospital beds. At midnight before the following day of work, nurse managers check the midnight census of patients on a particular unit. Then they look at planned discharges and predictable admissions. With the help of computerized patient acuity systems, they decide how many nurses they need for the next day. If the patient census looks like it might be low, a nurse who was scheduled to work might be called at home and told not to come in to work. She is told to take a vacation or personal day and absorb the loss of income. This is a reversal of the scheduling of vacation and personal time, which is usually chosen by the worker, subject to the employer’s okay. If the patient census looks like it’s going up, managers will frantically call nurses and beg them to come in and forego whatever plans they may have made for their day off. No matter how senior she is, the nurse is vulnerable to these appeals.

“They count your volume at midnight, which is your lowest volume, and you’re staffed to your average daily volume,” oncology nurse manager Maureen O’Keefe* explains. “So my midnight census might be eighteen. But you can be pretty sure that from nine in the morning till seven at night I might have twenty-one. Then you play with the numbers and say, this is the amount of discharges I’m going to have over the unit. How many am I going to assign to each unit and therefore how much staffing is going to be built on it? You have this much money in the budget. How are you going to divvy it up?”

According to Susan Davis, “On our unit, we go over with physicians on the day before how many patients we think are going to need dialysis and how many apheresis (a blood treatment process) and we try our best to identify those who might need it. Then we always have four or five patients who come in unexpectedly. If those four or five patients don’t materialize, nurses have to go home early. Yet if we get ten unexpected patients, we stay until they’re done, which means we may stay till midnight. We are expected to flex up and down, but we are never allowed to breathe a sigh of relief and say, ‘Okay, now maybe we can get a chance to go over policies for the future, or do some education, or just some reading to improve our own knowledge.’ ” Under this new system, Davis says, the nurses she works with are conceptualized as machines connected to a bed with a person in it. If the bed no longer has a person in it, then, of course, the tool should be turned off so it doesn’t consume any more electricity. In this case, the tool is of course a human being who is paid by the hour. When the tool goes home, it’s not paid. “Nurses are given an option of a day without pay, vacation time, or comp time,” Davis explains. “But we experience bumps in census on a daily basis. In fact, we can experience low census for a month at a time so it’s possible for a nurse to lose a day a week.” She says that when she and the nurses she works with raise their concerns to upper management, “their response is, ‘Don’t complain, we could float you to another unit.’ If we say we don’t know how to work on another unit, they say, ‘We’ll teach you.’ ” “In how many minutes?” she asks.

This doesn’t happen only on a daily basis. Sometimes it can happen on 281 an hourly basis. Luisa Toffoli, a nurse manager in Adelaide, Australia, is conducting a study of the use of flexible schedules and their impact on nurses and managers. In their attempt to shift nurses in and out of the hospital, Toffoli says, start times will be staggered, nurses will be asked to leave the hospital, or managers will implore a nurse to come in for only a few hours. “Please come in and help the patients,” the manager begs. “Most times it’s ‘Please come in and help your colleagues, they’re really up against it.’ Sometimes, depending on how the manager relates to staff, it’s ‘Come and help me, I’m drowning.’ ”

And managers literally are drowning, she says, because the number of nursing hours per patient day is constantly being benchmarked downward with hospitals arbitrarily reducing nursing hours per patient day. The number, she says, never goes up.

In response to these pressures, nurses may adopt a shift-work mentality toward their employment. In the early stages of her study, Toffoli says, she found that nurses started to talk about their work differently. Before the new restructuring, only managers or administrators spoke about nursing hours. “All of a sudden nurses on the ward were talking about nursing hours and actively seeking to reduce the hours. They’d ring up and say, ‘Oh look, the place is quiet, I’ll go early. Get someone else to start later and I’ll start earlier.’ So all of a sudden the nurses at the ward level were organizing their lives in terms of nursing hours. I found that disturbing. Nurses were still talking about patients, but patients were in the background now. Nursing hours came to the foreground.” Rather than viewing the nurse as a shift worker, this reconfiguration of nursing, as a mathematical calculation of predictable hours per patient in a bed, turns the nurse into an hourly worker. She is not a professional who can determine how she controls her working day once she arrives in the workplace. She becomes a mechanical robot fulfilling a certain number of predetermined tasks, set not by the doctor but by the patient acuity system or clinical path. If the clinical path or patient acuity system determines that X patient gets only so many hours of nursing care, the nurse is not free to decide that the patient needs a little more of this—say, more teaching about how to take the twentyfour medications he may be going home with, or how to adjust his diet to newly diagnosed diabetes. Or maybe she needs a little bit more of that—a conversation about her anxieties because she just lost a breast to cancer and is concerned that her husband will no longer find her attractive. Nurses don’t have time to do this because they no longer have any downtime. This, in spite of the fact that downtime, as any nurse will tell you, is often some of the most valuable time in the workplace. Just because nurses don’t have direct patient duties, or occasionally empty hands, doesn’t mean they have empty heads. They could be learning about new treatments and research. They could be sitting on committees planning or improving care. They could be doing one of the most important things of all—meeting with doctors and other clinicians or health care workers to develop interdisciplinary teamwork. But none of this can happen if the nurse is scurried out of the hospital the moment a patient is discharged. When nurses had more predictable work schedules, they could try to plan when to run errands or take care of family responsibilities. Now their work and professional lives are both unpredictable, which may leave them little energy for planning care or further study.

This trend is exacerbated by a so-called innovation that some U.S. hospitals are using to convince nurses that they have a more flexible approach to nurses’ shifts. In some hospitals, managers are now running on-line auctions on which nurses can bid against each other for the shifts they would like to work. The Spartanburg Regional Healthcare System in South Carolina began an on-line auction that allows nurses to bid on extra shifts. Nurses bid against one another and the one who bids less gets the shift. The hospital says this gives nurses better pay and more control over their work and cuts down on the use of temporary nurses.

How, one wonders, can nurses sitting at a computer betting against one another claim the status of a professional? How can managers confronted by a constantly shifting cast of winners—and losers—plan the mix of expertise and experience necessary to staff floors? In this kind of scheduling, some nurses may receive more favorable shifts than others, but is this the best way to equitably distribute the shift work involved in patient care? Rose Ann De Moro, executive director of the California Nurses Association argues that these kinds of “innovations” treat patients like “widgets on an assembly line and nursing as casual labor,” while Virginia Treacy, the executive director of District Council 1 of JNESO in New Jersey, said of the bidding program at Our Lady of Lourdes in Camden, New Jersey, it’s “Keep them down. Keep them dumb. Keep them divided.”33

When I asked Patricia Benner, a nursing researcher, about this trend, her first comment was a distressed “Oh my god!” Then she explained her response. “This is a logical extension of the market model. There’s no vision of a community of practice where people are assigned because of how well they work together, where they can learn from one another, it’s all like these interchangeable parts and you create an institution that’s inhos- 283 pitable, or alien to the complexity of the work.”

Given the nature of nursing work today, it is perhaps not surprising that so many newly graduated nurses and nursing students say they are profoundly discouraged by the lack of encouragement they receive from veteran nurses. New nurses as well as nursing students uniformly report that the experienced nurses they work with tell them they’re crazy to go into nursing. Often discouraged because their friends and families have questioned their decision to go into nursing rather than medicine, they find it difficult to deal with the fact that bedside nurses seem to be reinforcing broader societal attitudes toward the profession.

One of the reasons experienced nurses are having so much trouble in the workplace is that it’s hard to find nurses who want to work in hospitals or giving direct care in other settings. If new recruits are discouraged from sticking around, that won’t help already stressed-out veteran nurses. Yet, it’s hard to tell overburdened experienced nurses to contain their disaffection when they feel so overwhelmed and often betrayed, not just by hospitals but also by nursing management and somehow nursing itself. As one nurse put it, if you feel the hospital thinks you’re just another shovel, then why not shovel yourself right out of the institution—the profession— altogether? Which is precisely what a lot of nurses are doing. They believe the crisis is so deep and so pervasive that there is nowhere to run and nowhere to hide.

Reproduced from Nursing Against The Odds, by Suzanne Gordon.  Copyright © 2005 by Suzanne Gordon.   Used by permission of the publisher, Cornell University Press.