As a member of the Professional Performance Committee at Marin General Hospital I see reports regularly on an increasing number of untoward incidents and near-misses that are occurring as the registered nurse-to-patient ratio decreases. For example, x-ray technicians that instill intravenous medications during radiology procedures; a patient whose urethra was cut into by a house tech who was called upon to insert a urinary catheter and did not have the background to know that urine output should be expected; intensive care and coronary care patients who are "bumped" to other units not because their status is improving, but because the hospital refused to staff adequately in the critical care units.
These incidents are happening because the hospital mandated that unlicensed assistive personnel may, under the direction of an RN, perform these tasks because the hospital saves money by not staffing critical care and other units with the previous nurse-to-patient ratio. To quote an article in The Nation magazine: "RN-to-patient ratios have declined precipitately."
Once upon a time "simple nursing tasks" were feasibly delegated under the model of team nursing. The team consisted of various categories of RNs, LVNs, CNAs, all of whom were licensed or certified by the State of California for the roles and duties for which they were trained or prepared, not by the employer who stands to gain from utilizing the lowest possible pay category of employee. In those days, the patient population was vastly different from today's. In the words of Patricia Benner, professor of physiological nursing at the University of California at San Francisco School of Nursing, "There is no one in a hospital today who is not in that hospital because they are very sick. We rarely put patients in hospitals just for observation. We rarely admit them prior to surgery and we discharge them faster after their surgery. This means that the acuity level of patients is far higher than it used to be and that most of these patients have conditions where there is very little room for error. They need instantaneous interventions and great skill."
Registered nursing staff has been slashed and unlicensed assistive personnel placed up to 50% of the RNs at MGH over the last two years. These aides were given 10 or so days of training before replacing RNs with years of schooling and bedside experience. These unlicensed personnel cannot provide appropriate care. When airlines seek to improve their bottom line, they do not replace pilots with ground maintenance crews. When local governments seek to effect cost savings, they do not replace police officers with "highly trained" crossing guards. Only RNs have both the substantial multi-disciplinary scientific knowledge base and the technical skills for safe patient care.
This proposition is dismissed by hospital administrators as "anecdotal" and "unsubstantiated by research." But research studies documenting what happens when RN nursing care is eliminated or decreased have appeared. By last year thirteen recent studies on nursing care documented that hospitals with a higher percentage of RNs have lower morbidity and mortality rates. By this year, even non-nursing and non-healthcare journals are carrying reports of alarming patient outcomes.
We should not blame the new categories of employees for these changes, nor demean the valuable services they can perform. I have always valued the contributions of the technicians, aides, LVNs, CNAs, dieticians, unit clerks, therapists, housekeepers, etc. On a hospital-wide basis we all functioned together to deliver high-quality patient services. I welcomed the support that these people provided. The issue is one of replacement by others of critical RN functions for the acutely ill and fragile patients.
It is a serious ethical dilemma for a hospital, in the interest of presumed cost savings, to substantially increase the level of risk to which patients will be subject. It is a serious ethical dilemma for the hospital to replace licensed professional nurses, pharmacists, therapists, laboratory personnel with unlicensed aides. It is a serious ethical dilemma for a hospital, in the interest of modernization, competition, or managed care goals, to decrease to levels of safe, competent patient care. I am not saying that all nursing care must be done only by RNs. There is a place for a judicious skills mix. But RNs do not want to be responsible for increased morbidity and mortality of patients who are entrusting their care to unlicensed personnel inadequately prepared and nominally under our supervision and direction.