Nurses were in such demand when DeeDee Franke graduated from nursing school in 1981 that hospitals courted her with offers of cars and tuition reimbursement. Now, as occupancy rates fall and hospitals worry about the bottom line, nurses are finding their jobs disappearing.
But unlike other down cycles Ms. Franke has witnessed, this one affects not only nurses' livelihoods but the way care is delivered inside hospitals.
In hospital after hospital, both nurse managers as well as floor nurses are being winnowed out in favor of less skilled -- and cheaper -- personnel, many of them unlicensed, who work under the direction of a staff nurse.
The changes already have led to thousands of layoffs in cities such as Boston and San Francisco. In Washington, D.C., hospitals are laying off nurses by the hundreds. In Baltimore, the change is occurring gradually as vacancies go unfilled.
The restructuring of hospitals and the change in the nursing labor force comes at a time when hospital profits nationally are at an all-time high and when hospitals are spending freely on mergers, acquisitions and high-tech facilities to attract patients.
"What is happening is unlicensed aides are performing direct patient care in some hospitals. The hospitals are reconfiguring their staff mix so there are fewer RNs and more aides," said Erin Eckles, a labor specialist for the American Nurses Association.
"What we're seeing is a lot of downward substitutions," she said. "It's a fundamental shift in the way care is going to be provided, and an initial displacement of nurses."
Ironically, hospitals spent the past decade building primary care nursing teams in response to literature that showed the quality of care is directly related to patient-nurse ratios. In the late 1980s, many Maryland hospitals wouldn't hire a licensed practical nurse (LPN).
Now "they are minimizing the role of the nurse," said one long-time nurse at Sinai, one of at least a dozen Maryland hospitals that are reducing management and redesigning jobs. Besides Sinai, they include St. Agnes, Greater Baltimore Medical Center, Mercy, St. Joseph, the University of Maryland Medical Center and Johns Hopkins.
At the University of Maryland, for instance, one clinical nurse manager is now overseeing both the pediatric and maternity units. Those units attract up to 900 patients with problems ranging from cancer to AIDS. Mercy, which already employs licensed practical nurses, isn't hiring unlicensed professionals but it expects jobs will be reduced as they are redesigned.
"We are going to see how the (new) patient model works in terms of service, quality, and cost," said Amy Freeman, senior vice president for patient care services at Mercy.
At the same time that the nurse-to-patient ratio is increasing, tighter restrictions on hospital admissions means the average patient is sicker.
The trend has set off alarms among medical professionals. It has also led Congress to initiate a study by the Institute of Medicine, a division of the National Academy of Sciences, documenting the shift and its impact on quality of care.
"The consumer makes the assumption that when you go to the hospital, the care is safe," said Dr. Mary Virginia Ruth, assistant dean for professional services at the University of Maryland School of Nursing. "You can no longer make that assumption," she said.
The aides replacing nurses, she said, often don't have the observation skills or knowledge base to pick up on complications and respond to medical situations quickly. "Mistakes are more ,, and hidden," she said. "It's hard to get statistics on when a patient falls out of bed."
For instance, the professor cited her own experience as a guardian for a 92-year-old woman in a hospital intensive care unit. First she found the patient had been left sitting up for three hours after surgery. Then the patient was left untreated for constipation for four days. The problem was remedied, but it happened again four days later, she said.
Catherine Crowley, assistant vice president of the Maryland Hospital Association, defended the shift, saying that the majority of tasks being delegated to aides in Maryland hospitals involve activities of daily living that nurses don't really need to do.
"Others are routine, predictable procedures that, based on the condition of the patient and the skill of the technician, can be safely delegated," said Ms. Crowley, head of the MHA's center for nursing education. "In fact, hospitals are spending a lot of time working with nurses to develop that skill of delegation."
Unlike earlier experiments with a team approach, today there is much more evaluation of the patient and the care giver to see whether the technician has the required skill for that patient, Ms. Crowley said.
There were 53,560 registered nurses and 9,939 practical nurses in Maryland as of June 30. No figures are available on the change in nurses' work places or the ratio of RNs or LPNs to unlicensed care givers, but the shift is expected to be dramatic when the numbers are calculated in the next year or two.
Experts believe it will be five years before patients realize care has changed, says Sister Mary Jean Flaherty, dean of the School of Nursing at Catholic University of America in Washington, D.C.
"I see a lot of assistants who have maybe three, four, even six months on-the-job training. But my concern is, they are not really able to deliver care under the reform system because they will be treating only very sick people," she said.
The American Nurses Association, meanwhile, has begun a consumer education campaign featuring a brochure, "Every Patient Needs a Nurse," that lists questions patients should ask before hospital admission. It is also trying to force hospitals to make public their nurse-patient ratios and skill levels.
Meanwhile, the Maryland Board of Nurses revised regulations about what non-licensed staff can do as of July 5, dropping a laundry list of "don'ts" in favor of giving the nurse in charge the authority to delegate after judging the patient's needs and the technician's skills.
"One of the dangers is, you can go too far and delegate too much," said Donna M. Dorsey, executive director of the Maryland State Board of Nursing. "One of the biggest problems with delegation is that nurses don't understand what it is and many times they don't understand they are responsible," she said. More than 700 nurses showed up this summer for the board's conference to teach nurses how to delegate, she said.
The board is hearing more complex complaints and more of them, Ms. Dorsey said, but so far, they don't indicate a wholesale drop in the quality of care.
Ironically, nurses continue to be in demand. "There are plenty of jobs available -- the problem is, look at where the jobs are available and look at nurses," said Ms. Dorsey.
This fall, the University of Maryland will stage a conference to help hospital nurses make the transition to other settings, including jobs at insurance companies, managed care companies, and doctors' offices. Nursing schools also are changing their curriculum to prepare nurses to work in the community.
Ms. Franke, who entered the profession 13 years ago, was ahead of the curve -- she started a home health service two years ago, sold it to a hospital, and now visits patients at home through the Visiting Nurse Association of Baltimore.
"I think nurses are beginning to realize you have to have a skill mix," she said.