Hospitals are strapping on more work, skimping on training and trying to stuff contract concessions through. And the health-care reform bill could make things worse
February 10, 2010 |
Hospital work is thought to be recession-proof. No matter what the economy, people get sick and need care.
The work is there, but at a cost: hospital workers and researchers say some hospitals are churning through a round of reorganization, strapping on more work, skimping on training, and trying to stuff contract concessions through.
Increased hospital workloads are linked to bad economies: the last big push started in the early '90s downturn, says Judy Shindul-Rothschild, who researches nursing at Boston College.
That episode was about "de-skilling": management consultants substituted lower-cost, less-skilled workers for higher-cost nurses. Today's squeeze is especially strong at hospitals with many uninsured and underinsured patients. Worse, Shindul-Rothschild says, the national health care reform now stuck in Congress might intensify the problem.
Do More With Less
When Temple University Health System closed its Northeastern Hospital in Philadelphia last year, patients flooded into the flagship Temple facility, overloading the ER. Patients sit in wheelchairs while nurses scramble to evaluate them and find increasingly scarce rooms.
"You have to just push, push, push," said Patty Eakin, a Temple emergency room nurse and president of the Pennsylvania Association of Staff Nurses and Allied Professionals, a union for health-care workers. "It's exhausting and worrisome. You always wonder if you did enough."
The pressure for "patient turnover" is higher, she said, while the number of hands on deck hasn't changed -- Temple hasn't hired more staff.
In Kalamazoo, Michigan, critical care nurse Shawn Shuler sees similar problems developing at Borgess Medical Center. The Michigan Nurses Association won a staffing system in the hospital's 2006 contract that assigned nurses based on how sick patients were, a ratio that could be as high as one-to-one.
But with the state's economy in a tailspin and Borgess bleeding money, the facility cut training for new nurses in half and lowered the number of nurses per shift. In certain units, if one patient requires a nurse's full attention, the other now takes all the rest, regardless of how sick they are.
Shuler, who heads the local union, says the overwork and disorientation quickly drive new hires out. The hospital lost 52 critical-care nurses last year.
Even as a matter of a hospital's financial self-interest, squeezing workers makes little sense, Shuler says. Patient complications that develop when overworked staff miss a problem cost the hospital more than a proper staffing policy would. Management has refused meetings with the union for seven months.
In Philadelphia, Temple (unsuccessfully) sought to fine the union $250,000 if a worker spoke out about hospital conditions. Temple has demanded a "non-disparagement" clause -- along with wage freezes and 50 percent pension cuts -- in talks since the September contract expiration. Nurses are saving up, anticipating that a strike is inevitable.
Hospital bosses hate workplace actions that interfere with their carefully manufactured image, said Marsha Martin, a nurse and local union president at a University of Florida hospital. Administrators at her facility still bring up a 15-year-old "brown ribbon" action, the "don't shit on me" campaign, which resisted management's reorganization scheme in the consultant-crazed '90s.
Nurses handed out ribbons and cards with their demands to patients and staff. They blanketed the hospital. "It lasted two days," said Martin, until administrators halted mandatory OT.
Follow the Misleader
Cost-cutting and ballooning workloads are creating more problems for patients, too. Inexperienced nurses thrown into unfamiliar jobs at the Michigan hospital insert chest tubes incorrectly. Falls, bed sores, and failures to rescue patients are all up.
Having too many patients makes it hard to "pick up on signs and symptoms that should have been picked up on," Shuler said.
Shindul-Rothschild said rising rates of complications for patients indicate a pervasive problem at some hospitals.
She says "caregivers of last resort," hospitals that serve large populations of uninsured and underinsured patients, are laying off advanced-practice nurses who train workers and track effectiveness. Budget-strained hospitals are reducing headcount, she said, at the cost of losing veterans best suited to battling systemic patient problems like infection and fall rates.
Those difficulties could worsen under the health-care reform bill, she said. As it stood in mid-January, the national legislation resembled a 2006 Massachusetts law that forced most of the population to secure insurance and provided some subsidies to do so.
Those subsidies came from an "uncompensated care pool" in Massachusetts, state reimbursements that "last resort" hospitals previously had relied on to cover the cost of treating many uninsured patients.
The reimbursements disappeared but patients kept coming -- and now, many had substandard insurance that wouldn't pay for adequate treatment. The "last resort" hospitals had to eat more costs and began to cut services and overload workers.
"The health care dollar can only be divided so many ways," Shindul-Rothschild said, noting that both Massachusetts and the nation have yet to tackle the "real inefficiencies in the system": insurers that capture one-third of health care spending.
"If we don't find a way either at the state or federal level to once and for all put the private insurance companies out of business," she said, "we will see more of these cyclical efforts to squeeze the workers who provide care."
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