Kaiser Nurses Speak out on Health Care Restructuring
The health care industry is going through a major transformation. Hospitals use words like “patient focused care,’’ claiming they are attempting to keep the costs of health care down and improve patient care. But in fact they are restructuring health care using the industrial model of “scientific management.” Instead of employing skilled nurses to provide one-on-one patient care, the hospital corporations are attempting to create health care factories where patients are moved along “care paths” like cars down an assembly line. The nurses at Kaiser Sunset in Los Angeles spoke to the Dragon about what they are witnessing from the hospital floor.
Critical care path
Kaiser released “critical care paths” describing a time line for the procedures that a patient is to receive for a particular condition. The care path is based on the critical path analysis model used by assembly line manufacturers, according to Rhonda Goode, president of the Local 535 Kaiser Sunset Chapter. Although some of the nurses feel that some standardization is a good thing, others describe it as “cook book medicine.” When a patient doesn’t progress as fast as the path prescribes, the nurses have to fill out the back of a form justifying why the patient “fell off” the path.
There is a lot of resentment toward what some nurses refer to as “the little yellow brick road.” Cardiac surgery unit nurse Cindy Battle points out, “Instead of filling out the form, we could be caring for the patient, but if you don’t fill out the form they yell at you and write you up. Everybody is a number. But someone who is 60 pounds overweight is going to take longer to heal then someone who runs five miles a day.”
The care path is enforced by discharge planners, who make sure that care is being provided based on the DRG (diagnostic related guidelines). These planners have no medical licenses and are not trained to evaluate individual patients, yet their job requires them to force doctors and nurses to justify any extra care a patient receives or to explain why a patient is still in the hospital.
Intensive care nurse Betsy Kawahira witnessed a heated argument between a discharge planner and a doctor, who had to justify keeping a patient who was recovering from a cervical laminectomy [a spinal cord operation] in the hospital a day longer than prescribed in the plan—that the patient was blind and unable to walk was not reason enough for the planner.
Other nurses told the Dragon that doctors have confided to them their fears of being fired if they don't go along with the care path.Fast track—speed-up
The care path is just the first stage. Fast tracks are experimental care schedules designed to get patients out of the hospital even faster. Although nurses agree that getting patients out of the hospital and back into their normal surroundings in a shorter time is a favorable goal, many feel that fast tracking is nothing more than medical speed up—increasing productivity at the cost of patient comfort and even health. Nurses told the Dragon this policy has caused many patients to be sent home in marginal conditions, forcing them to return later when their conditions worsen.
“Before, you would do everything you could do, so that when patients went home you knew they would be okay,” according to Battle. “Now we send them home with antibiotics and tell them to come back in a week. I have a problem with that.” She tells of one patient with an irregular heart beat that couldn’t be controlled by meds, “We gave the heart a shock and it went back to a normal rhythm. They released the patient a few hours later. Before, we would have kept him for 24 hours, because the heart rhythm can revert back in eight hours.”
Sonia Nahhas, a nurse in the intensive care unit, has complained to her supervisor several times about decisions that she feels are not in the best interest of her patient. For example, she explained that there is a push to move patients out of the intensive care unit (ICU), where the staffing ratio of nurse to patients is high, to the definitive observation unit (DOU), where the ratio is lower. “A lot of times we’ll have a patient on a ventilator who is still coughing and has a lot of secretion and phlegm. We’ll tell the doctor we don’t think the patient looks good, but the doctor will say the patient doesn’t have a fever and the ventilator numbers are okay according to the fast track parameters. So they’ll extubate the patient early so they can get him out of the ICU and into the DOU. Then 24 hours later the patient will return because he can’t breath and we’ll have to re-hook him up.
“Forcing the body to breath before it is ready can compromise a patient’s health, especially elderly patients or patients with heart or lung problems. . . . We need to look at the patients to see if they are ready instead of just looking at blood tests and x-rays. I feel the fast track parameters are not based on what is good for the patient.”
One of the effects of the fast tracking has been to shift the burden of care from the hospital to the patients and their loved ones. Patients are sent home with hospital equipment still in them, and part of the nurse’s job is to teach the patient or the family how to use the equipment. According to neonatal nurse Flora Gianan, “Not only do we have to fill out the care path, the acuity order, the nursing care plan, and the nurse’s note and teach basic nursery skills in a shorter period of time, if the baby has to go home with a monitor or a gastrostomy tube, we must teach the mother how to take care of the tube.” Gianan worries about many of the babies she feels are sent home too soon.“ Before, we had different criteria; I worry about them now. But I tell the parents to return if anything goes wrong. We teach them what to look for and then stress that if anything seems wrong, to bring the baby back to the clinic. That is the only way you can feel good about what is happening and feel that you have done your service to them.”
Post-natal intensive care nurse La Netta Fitzhugh is even more outspoken. “I had a patient tell me ‘if I wanted to be a nurse I would have gone to medical school.’ We are pushing on the public that they are going to have to be nurses and doctors, that they have to dress wounds, operate respirators, do suctions, even feed their babies through g-tubes if the baby isn’t eating. They are going to have to stay home or hire a nurse. We’re changing their lifestyles. A lot of people don’t know how to dress an oozing wound and because of that, patients are coming back a week later with bad infections.”
Reducing nurses Kaiser’s real goal
The real intent of the restructuring is to lower costs by reducing the number of employees. To do this, Kaiser has laid off nurses and increased the number of patients they have to attend. Nurses feel Kaiser has cut staffing so low it has created a dangerous situation by compromising nurses’ ability to give good quality care.
According to Nahhas, “I enjoy helping people and that is what is frustrating, because I can’t do that now. With the new fast track, I don’t have time to give them the right care. We just try to do the best we can, but that is not necessarily good. I may have two patients that both require a lot of attention to stabilize physiologically. One of them may not get all the attention he needs because I’m busy trying to keep the other patient from dying.”
No extra hands
Carolina Short, a nurse in CSU, explains further, “Early extubation [getting the patient off the respirator] can be good for the patient; however the patient’s condition is still just as critical. But as soon as you remove the tubes, the patient-to-nurse ratio goes from one-to-one to two-to-one. You have to look at the whole unit. All the nurses are doubled up with patients, the patients are still critically ill, but if something goes wrong there aren’t any extra hands. What happens if all the nurses are doubled up with patients and then a patient’s heart stops beating? You call for help, but none of the other nurses can leave their patients, because all of their patients are critical too.”
Certain departments have mandated patient-to-staff ratios, such as the ICU. To cut costs, Kaiser Sunset recently closed one of its three ICU units and then opened a DOU, where they could have a higher patient-to-nurse ratio. Nurse Leila Valdivia works in the recovery room, where patients from the operating room are wheeled in on gurneys and closely monitored until they have stabilized enough to be taken to their room in the ICU. The recovery room is intended as a way station, where patients would normally stay for a very short period of time, but the ICU shutdown has caused a back-up of patients in the recovery room, creating what Valdivia feels is an almost inhuman situation.
“Patients are supposed to be in the recovery room only long enough for them to wake up and for us to take them off the monitor. The gurneys are hard and the lights are bright. The patients aren’t supposed to be lying there for six to eight hours. I had one patient who was there at the end of my shift who was still there when I came back the next day; he had been there for 18 hours. The patients are in pain from their incisions. Their neighbors are throwing up. There’s no privacy to use the bed pan because the patient next to them is only 18 inches away. Those who want to eat can’t even eat, even though they may not have eaten since the day before.
“The patients will complain, ‘I don’t understand. They knew about my surgery for weeks; they knew I was supposed to have a bed.’ And what am I supposed to tell them? In nursing school they were adamant that we are patient advocates. What are we supposed to do when the administration creates policies that are in conflict with our role as nurses? The administration seems to feel that it is okay to let patients deal with their discomfort as long as they aren’t flipping out. Patients tell me that they are going to drop their membership as soon as they get out of here, and the next day in a staff meeting the managers complain that membership is dropping. What do they expect?”
Death of a profession?
Some of the best nurses are talking about quitting because they feel they can’t give the patients the quality of care they deserve and that the nurses want to give. They feel the ship is sinking.
Betsy Kawahira, a nurse for over 20 years, expressed the feeling of many nurses: “I used to enjoy working at Kaiser because we were able to give good quality care. Now, under the name of cost containment, it is quantity rather than quality. With the cutbacks in staffing and high acuity levels, I can’t keep up; it’s too stressful. We don’t have the support staff we need to help us do a safe job. Instead of three nurses to turn a patient, now we have to try with two. Nurses are hurting their backs and shoulders, getting carpal tunnel injuries. Management has created a dangerous situation, both for patients and for nurses.”
La Netta Fitzhugh, another veteran nurse explained, “I got into nursing almost 20 years ago because I enjoy taking care of people. I feel I have the special skill of listening to people, especially people who might feel intimidated by the health care system: poor people, people of color, and people with a difficult grasp of the English language. I believe in treating patients the way I would want my children treated. I pledged to myself that the day I couldn’t deliver top quality care to my patients, I would leave nursing. I worry that day is coming.”
Debbie Pointevint, an ICU nurse, says, “I feel they treat us like nurses are a liability. We are the ones at the bedsides, not the administrators. They make decisions based on studies and statistics. I would like to see them try to come on the floor and take care of patients the way they prescribe. Kaiser spends so much money on consultants you would think they could figure it out.”
Is all this pain necessary?
Kaiser says it has to make these changes to control costs, but last year Kaiser’s profits increased by 20.8 percent from the year before. They made profits of $815 million in 1994 Their net worth in 1993 was more than $9.7 billion. They are making record profits, even though they are supposed to be a non-profit corporation. There is absolutely no reason for the pain these cutbacks are causing.
Nurses go on the offensive
The union has encouraged nurses to fill out “patient care notification forms” documenting what they feel are unsafe procedures. As a result of this campaign, the California State Department of Health and Human Services cited Kaiser for inadequate staffing levels. The union has forced Kaiser to begin taking the union’s demands for protecting patient care and improving staffing levels more seriously.
What nurses can do:
If you feel you are given an assignment which endangers your patient, fill out a patient care assignment notification form (available from your union Steward), present it to a nurse manager, and request a response. If the problem continues, file a grievance. Notify the union and send a copy of your complaint to the California Department of Health Service.
Nurses should know the Nurse Practice Act and the Board of Registered Nursing regulations and advisories. According to the Nurse Practice Act, staff nurses independently evaluate orders, treatment and procedures, and have an affirmative duty to protect patients by notifying nurse managers of unsafe assignments or other problems that arise in patient care. Nurse managers are liable for making unsafe assignments and may be reported to the Board of Registered Nursing at (916) 322-3350.