1. Todd, Betsy MPH, RN

Article Content

We enter the 21st century as workers in the most expensive health care system in the world. Yet despite our country's trillion-dollar-a-year investment, nurses struggle to provide safe, supportive, decent care.


The drastic reshaping of our hospitals over the last six years has been accompanied by a great deal of rhetoric about hospital "missions" and "patient-focused care." Yet the consultants who've directed the changes either don't understand or are willfully ignorant of the intricacies involved in delivering safe care. Even medical and nursing administrators, who by virtue of their clinical expertise should know better, have become preoccupied with survival in the marketplace-leading to what one author calls a "fatal distraction" from the real business of health care: caring for patients and improving the quality of care.1


The disruption of the work of the hospital has been mind-boggling. Many of the clinical double checks that have always been integral to safe care have been discarded. The communication necessary for good care has become more difficult as staffing in all departments is cut to the bone. Frequent floating and part-time (lower paid) personnel (no matter how expert) foster discontinuity of care. Job descriptions have been rewritten so that fewer people now handle more tasks. Try as we might, we simply can't make up for drastic cuts in nursing and in pharmacy, social service, dietary, physical therapy, and clerical staffing.


Most nurses take their responsibilities very seriously. And though we may be extremely stressed by this Brave New Hospital, our patients may literally die from it.2-4 So we cope-with increased patient loads and sicker patients. We work through breaks and take paperwork home to complete on our own time. We attempt to teach and supervise minimally trained personnel who have been brought in to replace RNs. Nurse managers cover additional units for indefinite periods of time (without additional pay, of course).


Like hospitals, home care agencies have been downsized, leaving fewer RNs to care for far more complicated cases. Often, family members and friends become "caregivers of last resort."


The bottom-line accounting methods designed to assess the costs and benefits of all of this don't take into account patient suffering. Nor do they appreciate the fear and anxiety (and guilt, when a loved one fails) felt by family caregivers-or their lost income from unpaid leave or jobs lost when they are thrust into this role. Overworked nurses and unpaid family members have been pressed by dedication and love to cover gaping holes in the system. Investors in managed care companies and their CEOs reap enormous profits from our labor, with the CEOs being among the most highly compensated executives in the country.


As in any crisis, some good things have come out of profit-driven health care. Many hospitals have increased their computer capacity, a move that may improve care in the long run. Experience shared between merged institutions has uncovered "best practices" that will raise clinical standards. Nurse practitioners have greater opportunities in and out of hospitals. And mergers and fear of losing "market share" have forced some academic medical centers to provide more care to the minority communities the centers are supposed to serve.


These, however, are tiny bright spots. U.S. health care is crumbling. What can be done?


In June 1999, the ANA House of Delegates endorsed universal health care, pointing to it as the only viable solution to our complex problems. Asserting that "health care is a fundamental human right," the delegates emphasized that "the single-payer mechanism [for a universal health care system is] the most desirable option" for reform.


As we work toward universal health care, we need to continue our "everyday rebellions"5 and take every opportunity to articulate why expert clinical care, teaching, emotional support, and the continuity of care we provide are essential to the public's health and to individual patients. Our role should not be to carve out a niche in a system that fails our patients; instead, we should help create a new system of care that preserves the dignity, autonomy, and health of both patients and health care workers.




1. Schiff G. Fatal distraction: finance vs vigilance in our nation's hospitals [editorial; comment]. J Gen Intern Med 2000;15(4):269-70. [Context Link]


2. Thomas EJ, et al. Hospital ownership and preventable adverse events [see comments]. J Gen Intern Med 2000;15(4):211-9. [Context Link]


3. Garg PP, et al. Effect of the ownership of dialysis facilities on patients' survival and referral for transplantation [see comments]. N Engl J Med 1999;341(22):1653-60. [Context Link]


4. Kovner C, Gergen PJ. Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image J Nurs Sch 1998;30(4):315-21. [Context Link]


5. Mason DJ. AJN's century of everyday rebellions. Am J Nurs 1999;99(10):7. [Context Link]