Arlington, Mass. -- ACROSS AMERICA, hospitals -- in a rush to restructure -- are reducing costs by cutting nursing care instead of trimming administrators' salaries or curtailing expensive construction and redundant technology. As a result, patients are at risk.
In an American Hospital Association survey conducted in June, 71 percent of hospitals said they were restructuring. And A new study by the New York State Department of Health predicts that 3,000 registered nurses will lose jobs their jobs in New York hospitals between 1995 and 1997.
When hospitals downsize, registered nurses are often replaced with "unlicensed personnel."
This year, the American Nurses Association surveyed 1,835 hospital nurses in 50 states. Seventy percent of those polled said their employers were cutting staffs by leaving vacated positions unfilled; 66 percent reported layoffs or plans for them and 45 percent said the use of unlicensed personnel was increasing.
Three-quarters of the nurses in hospitals with reduced staffs said patient care had eroded, and more than two-thirds thought patients' safety had been compromised.
State licensing boards do not regulate the education of unlicensed personnel brought in to take the place of nurses. There are no requirements on the amount of training for unlicensed personnel and other staff "cross-trained" to do nursing work, including housekeepers, maintenance people, central supply and other workers.
Training may vary from a few hours to six weeks. The unlicensed nurse substitutes may have no education in health care or even have a high school diploma. Yet, in many hospitals, they now insert catheters, read electrocardiograms and change sterile dressings.
Not only do registered nurses have to take care of more and sicker patients in less time than before and supervise untrained technicians, but also they are legally responsible for mistakes the aides make.
One major Eastern hospital discontinued its six operating-room head-nurse positions. These nurses supervised the cleaning staff in the operating rooms.
One result, a nurse told us, is that equipment such as the heart and lung machine used in cardiac bypass surgery is not always properly cleaned between operations. One result is that in some three-month periods post-surgical infection rates have almost doubled.
Are some hospitals ignoring research on the importance of proper nursing care? A study by Linda Aiken, a professor of nursing at the University of Pennsylvania, reported 7.7 percent lower mortality rates for Medicare patients hospitalized in medical centers known to provide good nursing care than in centers that do not place a high priority on such care.
Judith Shindul-Rotschild, assistant professor of nursing at Boston College, compared nursing practice and patient care in a number of Massachusetts hospitals in 1989 and 1994, surveying 928 and 856 nurses, respectively.
In 1989, only two nurses reported difficulties in providing safe care because of inadequate staffing of registered nurses. In 1994, with the number of registered nurses reduced and unlicensed personnel on the rise, 363 nurses reported such difficulties.
In 1989, no nurses reported deaths that resulted from inadequate staffing levels; in 1994, nurses reported 15 such deaths.
A number of doctors are beginning to protest.
At John L. Doyne Hospital in Milwaukee, Dr. George B. Haasler, chief of general thoracic surgery at the Medical College of Wisconsin, is concerned about the replacement of registered nurses with nursing assistants.
"We see problems that are very complex -- the sickest patients referred to us from other institutions," he said. "Every member of the care team has to be as educated as possible.
"Nursing assistants do not have the same educational background as nurses, who have from two to four years of education that concentrates on assessment skills and the biological sciences.
"You can't just make a blanket statement that, to cut costs, nursing assistants can do the same kinds of things that nurses do, because they can't."
Dr. John Merritt O'Donnell, chairman of the department of surgical intensive care at the Lahey Clinic, in Burlington, Mass., said: "Nurses are the foundation of our health care system.
"Cutting labor costs by decreasing the nursing work force is irrational and naive. There are certainly deserving targets for cuts -- physician spending, pharmaceuticals, middle management and insurance. But don't cut nursing care."
Suzanne Gordon is writing a book about nursing. Ellen D. Baer is a visiting professor of nursing at New York University. They wrote this for the New York Times.