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PHILADELPHIA - It was oddly quiet in the predawn, artificial light of the hospital as nurse Sandy Pincik arrived for work. As usual, she came 15 minutes early, so she could organize a little before things really took off at 7.

Doctors huddled with nurses in the hall, discussing the day's treatment plans. Soon, they would head for their offices or operating rooms, and then the floor would belong mostly to nurses like Pincik.

Pulling a flowered smock out of her bag, she put it on over her white T-shirt and draped a purple stethoscope around her neck. She grabbed a pile of pens, a clipboard and a box of supplies and put them on a movable writing stand in the corridor.

A low-key woman with wavy, light-brown hair and magenta nail polish, Pincik would be responsible for five beds - four patients so far this day - and would help out with five others.

She and Jean Smyth, another registered nurse, work as a team to cover 10 beds on Thomas Jefferson University Hospital's 7 North, a unit that treats people recovering from urologic surgery, kidney or liver transplants, or medical problems associated with dialysis.

A thousand small duties

Pincik's day would revolve around making sure those patients got everything they needed, from ice and new sheets to CPR. It would be a day filled with a thousand small duties, tasks few would notice - unless they didn't get done.

Complaints about modern, cost-conscious medicine are everywhere these days.

Patients are warned that their doctors, their hospitals and their .. insurance companies make more money by providing less treatment. They read about hospital layoffs and predictions of more to come and wonder if enough people will remain to take care of them.

Nurses, who have been among the most vocal critics, argue loudly that hospitals have compromised care by increasing nurses' workloads and replacing them with cheaper, lesser-skilled employees.

A national survey of 7,500 nurses last year by Boston College nursing professor Judith Shindul-Rothschild found that more than a third would not recommend a family member receive care in their institutions. And nearly 70 percent reported having less time for basic nursing care and nearly 75 percent less time to comfort and talk to patients. Nonetheless, only 14 percent rated the quality of the places where they worked as poor.

Nursing employment statistics do little to clarify the debate. The American Hospital Association says the number of RNs working in hospitals has continued to rise, even though the number of patients has fallen.

Linda Aiken, a University of Pennsylvania nurse researcher who has studied the AHA statistics, said the number of RNs working in inpatient care has declined in recent years. But when the number of patients, their length of stay, and the severity of their illnesses were taken into account, she noted, the number of nurses remained relatively constant, at least through 1994.

The number of other caregivers, meanwhile, fell significantly, Aiken said. That might account for the perception among nurses that they are working much harder.

Quality shows decline

The quality of hospital care, according to early research, has shown no decline. Still, it is common to hear former patients complain that their nurse seemed harried, that he or she took forever to come when the call button was pressed. These patients might be well now, but they feel bad about their hospital stay, they say.

Most patients have little idea what the nurse is doing when he or she is not with them, and few have had enough hospital experiences to compare today's care with that given before costs were such an issue.

Jefferson, saying its nursing care is as good or better than ever, welcomed a request to have a reporter follow one of its nurses. Several other hospitals refused.

Sandy Pincik's day, therefore, may not be typical of what nurses in other hospitals experience. But it is a window into what life is like for a nurse at a major teaching hospital in 1997. And it reveals the pivotal role of employees, who as Pincik puts it, do "everything."

By 7:20 a.m., the night nurse was filling in Pincik on the status of her patients.

Mark Pannapacker, a young man recovering from a kidney-stone operation, thought he had passed another stone overnight.

Jerry Singleton, a dialysis patient admitted with fluid around his heart, was being prepared for surgery the next day.

Pincik would have to draw blood from Kevin Margaret Scharff, a post-transplant patient who had come in with pneumonia.

And the fourth patient would be going home if tests showed him to be free of infection.

Although for most of this day, Pincik's primary responsibility was only four patients - she usually has five and sometimes as many as eight - she would spend as much of her eight-hour shift on paperwork and the phone as she would in their rooms. In a modern hospital, hands-on time at bedside is only part of a nurse's workday.

Pincik began her day zipping from patient to patient, from phone to computer to patient file. Most of the tasks were short, but she rarely finished one without being interrupted by a phone call or questions from nursing students helping on the floor.

She drew blood from the still-sleeping Scharff, then dropped it off in a pneumatic tube that would take it to the lab. She called a doctor to see whether the dialysis staff could take a blood sample from Singleton, saving him a needle stick. She took vital signs. She checked Pannapacker's pain medication orders and called dietary to stop his breakfast tray, on orders from his doctor. She asked a student to change Pannapacker's dressing. She made Singleton's bed and checked how much he had had to eat and drink (fluid balance is important in dialysis patients). She talked with her colleague Smyth about a post-op patient due in later in the day.

There was just time for a friendly "How ya doing?" in most of the rooms. She asked Scharff if she felt more like eating today. She asked Pannapacker, who worked for a medical case-management company, if he thought he might need a nurse when he returned home, and he said he thought that would be unnecessary and expensive. She asked Singleton about his scheduled trip to the OR, so his dialysis again could work properly.

The conversations were brief and to the medical point, no chitchat about the weather or the holidays, but brief as her contact with them was, her patients seemed satisfied with their care. There were no long waits for attention and no one seemed to want more hand-holding.

The little tasks

By 8:45, Pincik thought she had things well enough under control to start doing the little things that make her feel good about being a nurse.

She began going from room to room, making sure everyone had fresh ice, a task that might also be done by a nursing assistant.

Seeing that Smyth was busy, she ducked into 24, Daisy Lake's room. Lake, a friendly 57-year-old from Glassboro, Pa., was one of Smyth's patients. She had had kidney stones removed, a relatively routine operation, a few days earlier but was a complicated patient because she was paralyzed from the waist down.

She wanted coffee, so Pincik hurried to the pantry down the hall to fetch it. Getting coffee might seem a mundane task for a woman only months from a master's degree, but Pincik likes doing it and knows that every contact with a patient might tell a nurse something important.

She filled the cup, picked up sugar, cream and Sweet 'N Low, and headed back to Lake's room. What happened next is why critics say deskilling is a bad idea.

Pincik gave Lake the coffee and handed her a spoon.

"Can you put it in there for me?" Lake asked, motioning toward the coffee cup. "I'm afraid to move."

She told Pincik that her arm hurt. In an instant, Pincik switched from waitress to nurse. This was a clue that something was wrong, the kind of clue, nursing advocates say, lesser-trained employees might miss.

Pincik looked at Lake's IV arm. It was swollen. She touched the puffy skin. It was warm. She turned off the IV pump. No blood drained back into the tube. The IV had come loose. "I'll be right back," Pincik said as she went to get supplies to start a new IV.

Lake had been getting fluids and antibiotics through the tube. Failure to fix it not only would keep her from getting the treatment she needed but could lead to a badly swollen and painful arm.

Pincik, 34, became a nurse in 1986, during the nursing shortage, when some hospitals were offering signing bonuses and lots of other perks to attract RNs. In a few years, though, everything had changed.

Big employers had grown exasperated by skyrocketing health-insurance costs. They demanded cost control and got it from HMOs and other managed-care insurers, who began scrutinizing health expenses like never before. Insurers pressured hospitals to send patients home more quickly, leaving empty beds and unwieldy payrolls.

Between 1986 and 1992, the length of the average hospital stay fell from 7.1 to 6.5 days. Before long, the same hospitals that had fought to attract nurses were making headlines with layoffs or transferring staff to their new home-care departments.

At the same time, medical improvements were allowing doctors to save older, more critically ill patients. That, combined with the shorter hospital stays, left hospitals with sicker and sicker patients. As Penn's Aiken put it, hospitals have become "giant intensive-care units."

Feeling more harried

All these changes were making nurses feel more harried.

Two years ago, like most hospitals in the city, Jefferson looked at its declining admissions and the projections of more to follow and decided to "restructure" its staff. Its goal was to reduce its $500 million budget by $75 million within four years, CEO Tom Lewis said.

Although it has retained a heavier emphasis on RNs than many hospitals, Jefferson reduced its nursing staff through attrition. Broader responsibilities for nurses allowed it to reduce staff in other areas, such as respiratory therapy and phlebotomy. Since then, staffing has increased as the hospital lured several high-volume physician practices.

Jefferson also has a slightly smaller percentage of RNs caring for patients. In the 1980s, RNs, who make about $45,000 a year, would have provided 100 percent of the nursing care in ICUs and intermediate units. Today, they make up 90 percent of the staff in ICUs and 85 percent in intermediate units. On acute-care general units, they make up 80 percent of the staff, 5 percent less than before. LPNs, nursing assistants, and techs make up the difference.

On this day, along with Smyth and Pincik, an LPN was on the unit, as were several nursing students. A nursing assistant had called in sick.

The hospital had learned from patient surveys, in which less than 10 percent had voiced complaints, that patients often felt unprepared for discharge. Now nurses put more emphasis on teaching patients what they need to know at home, and the more experienced nurses, like Pincik, are responsible for coordinating treatment and discharge planning with other hospital departments. At least in theory, having everything more organized should allow the hospital to send people home more efficiently.

After Pincik finished with Lake, she returned to her own patients, ping-ponging between rooms and charts, moving so quickly she could disappear into a room or around a corner in the time it took to glance over a shoulder and back.

Piles of paper work

At least half of her working day was spent with paper rather than patients. Unpleasant as it is, paperwork always has been a significant part of nurses' jobs, Pincik and nursing leaders said. With so many different caregivers involved with any one patient, the charts and other forms are the primary means of communication.

The paperwork also is important when hospitals seek accreditation, a key hurdle for prestige and insurance reimbursement. Increasingly, in the era of managed care, it is used to justify bills or longer hospitals stays.

Standing at the portable desk in the hall, Pincik explained a new discharge planning form to Smyth. Then she filled out forms describing in detail the treatment the man in Room 21 was getting. He had been evicted, and she wanted the people at the shelter where he was going to know how to care for him.

Pincik's day was winding down. In a few minutes, Smyth would get a new patient, a man who had just finished penile-prosthesis surgery. Another patient, who had had his bladder removed, was due in Pannapacker's room.

Pincik stripped the beds in her two empty rooms and emptied urinals. (The housekeeping staff doesn't touch human wastes.) She checked on Scharff and Polidor. Singleton was still in dialysis.

At 3, she turned her patients over to the night nurse. For the most part, her patients said they were satisfied with their care.

But Pincik didn't leave. Working a 12-hour shift this day, she spent the next four hours helping other nurses and working on scheduling and other paperwork. It was night when she left the hospital for the dark streets outside and the trip home.

Pub Date: 7/12/98

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