Internal Bleeding

St. John's Mercy Medical Center alienated their RNs when they turned to less experienced caregivers to save money. Now they're paying for it.

It's morning in a sixth-floor hallway of St. John's Mercy Medical Center, and tray tables and housekeeping carts wait side by side like racehorses at the gate. Women in every imaginable version of a uniform mill about indistinguishably, each nametag a blur of small print topped by a big bold first name. One's in heels, carrying a clipboard. Another wears slacks and a cotton print top that looks like a little kid's pajamas. Most wear turquoise, navy or maroon scrubs, the easy-care colors uncompromisingly bright. They're all moving fast, in and out of rooms like actors in a French farce. Suddenly a woman in white -- white skirt, white hose, white jacket -- appears, stethoscope around her neck. "Ah, Nurse!" a patient calls, relief in his voice.

What the patients don't realize is that the women in scrubs who sometimes empty their trash cans are registered nurses, too, often with more than a decade of experience. It's all a bit confusing, because the patient-care associates (PCAs) -- who have only two months' training, and often came from housekeeping -- wear the same scrubs and give the lion's share of the care.

Patients loyal to St. John's their entire lives remember the days when Sister Isidore Lennon -- a feisty Sister of Mercy who immigrated from Ireland and compromised on nothing -- walked the floors making sure "her" nurses were up to par. But everybody knows those days are gone: Health care's changing, cutting corners to keep up with managed care. That's why patients are so relieved to see the crystal award on display in the lobby, naming St. John's Mercy Medical Center one of the nation's "Top 100 Hospitals."

What they don't know is that this much-touted 1998 award was bestowed by two management-consulting companies, and most of its "benchmarks" measure bottom-line efficiency, the kind you get when you shift tasks from RNs to un-degreed, lower-paid assistants, then replace experienced nurses with entry-level nurses and make them responsible for overseeing -- without much support or much time to give direct physical care -- more acutely ill patients with shorter durations of stay.

You get awards that way. But you also get once-loyal nurses mad enough to unionize.

It all started with something called patient-focused care -- which nurses promptly nicknamed "profit-focused care." Experienced RNs found themselves forced to reapply for their jobs; full-time nurses lost their guaranteed hours; certain benefits dissolved; "care teams" were heavy with pinch-hitting, barely trained technical assistants. "Staffing used to be based on the patients' acuity, their needs," says Joan Skurat, an RN at St. John's for 12 years. "Now it's all numbers."

The hospital implemented patient-focused care in 1996, galvanized by threats of managed care, decreased Medicare reimbursements and a harsh health-care climate in which an oligarchy of megasystems fight to survive. St. John's brought in a consulting firm -- PFCA Inc. of Atlanta -- to reconfigure the patient-care staff into "teams." Such a positive word: Managers vowed that nurses would soon be spending more time with patients. Newly hired hospital president Mark Weber announced in a June 1996 Q&A for employees, "We are reorganizing our work force so that RNs are only doing things that require their expertise."

"They bought a framework that was sold to us by an outside company," sums up Karen Prade, an RN in the neonatal intensive care unit (NICU) who's been at St. John's 11 years. "They would do these time studies and say, 'OK, it takes five minutes to start an IV.' At first, they were having PCAs put in urinary catheters after a one-day training course." Nurses describe a slew of "incidents" --"A man was getting his blood drawn and the PCA forgot to remove the tourniquet"; "Another PCA hooked a nose-feeding tube to an IV" -- and swear there were more frequent infections and complications.

A staff physician, asking not to be identified, recalls "several instances where I said, 'My God, I can't believe this person is allowed to take care of patients.' One patient was on a blood-thinner, and his IV was leaking blood onto the floor, and the patient-care associate was frozen on the spot; she just kept staring at it. (The patient) told me he asked her what she was going to do, and she didn't say anything, and he said, 'Are you afraid of blood?' and she essentially said yes. He said, 'Why don't you just get a towel and put pressure on it?' and told her what to do. Later he asked me, 'Who are these people?'"

Now, when new PCAs are hired, they receive eight weeks of basic training, minimum -- but that only "evolved," as administrators put it, after RNs protested. The RNs, meanwhile, found themselves passing out food trays and stocking supply carts. "My new assignments included cleaning out the dayroom," recalls Nancy Cook, a psychiatric nurse who's since left the hospital. "One day I was scraping melted cheese out of the microwave, and I looked up and here's one of the psych techs sitting down charting." She sighs. "They didn't have the training, and they didn't have the humanity. One came from the gardening crew. One didn't want to lay hands on the people -- some needed to be toileted or cleaned or dressed, and this person simply did not do it. We were told to be tolerant."

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