At least half a dozen times a day, Esther Warwick, a 120-pound, 5-foot, 2-inch nurse at Los Angeles' Cedars-Sinai Medical Center, must struggle to move incapacitated patients who can be as much as twice her weight.
When Warwick went to work at the hospital, there were about 120 assistants at the hospital to help with such tasks and do other routine things such as wash and bathe patients. But no more.
"When I came here they were just laying off the nursing assistants," she said. "It was a big change . . . from having someone help you to doing it alone." These days, she said, "We're rushed so much that sometimes I don't get to spend the amount of time with patients that I'd like to."
Although popularly perceived as an altruistic job in which practitioners mostly help rehabilitate patients, nurses say that their profession has increasingly become a physically grueling and emotionally exhausting one in the last four years as hospitals such as Cedars-Sinai have come under pressure to cut costs.
As the federal government, insurance companies and private employers have looked for ways to control medical costs, hospitals have moved swiftly in the last three years to treat patients quicker, trim overhead and reduce staff.
Not only must harried nurses often make do with less support but, increasingly, they must also cope with treating older and sicker patients as well as devastating new diseases such as AIDS, acquired immune deficiency syndrome.
The nation's 1.8 million nurses "are facing burnout day in and day out, particularly when they are not getting the emotional reward of spending time with recuperating patients," said Joel M. Bergenfeld, chief executive officer of Century City Hospital. "There's no question in my mind that nurses are bearing the brunt of cost containment."
The stresses began shortly after 1983 when Congress enacted legislation that changed the way the federal government paid hospitals for treating Medicare patients.
Under the new rules, a hospital is paid a fixed sum for the treatment of each ailment covered by Medicare. If a hospital treats a patient for less than the government fee, it can keep the difference. If it spends more, the hospital must suffer the loss.
Since Medicare fees make up about 40% of a hospital's revenue, the incentives under the new system are obvious: the less a hospital spends, the more it profits. Usually that means shorter--and more intensive--hospital stays, which have fallen to an average of about seven days from 7.6 days in 1982, according to the American Hospital Assn. in Chicago.
"Since 1983 the patients in the hospital are much sicker and the hospital has become a much more stressful place because patients require constant monitoring," said Margretta Styles, president of the American Nurses Assn. and professor of nursing at the University of California, San Francisco.
"All these people were thinking of was how to cut costs," mused Styles, referring to the federal government architects of controlling hospital costs. "No one was thinking about the impact on nurses. It has really come back to haunt us."
The legacy of cost controls has not been all bad news for nurses. The new climate of efficiency has led to some changes--such as computerized record-keeping and redesigned work stations--aimed at making some nursing jobs easier. And Richard Schweiker, the father of hospital cost control and U.S. secretary of health and human services from 1981 to 1983, said the economy measures have worked.
"Cost containment has done a good job of slowing down health care costs . . . and producing more efficiency," said Schweiker, who is now president of the American Council of Life Insurance in Washington. But he said: "Nurses shouldn't be made the scapegoat. I think that's unfortunate if that's the case."
Plight of Nurses
The plight of nurses, however, may soon command the attention of consumers and health experts as a potentially long-term nursing shortage begins to take hold.
The number of job openings for registered nurses in hospitals more than doubled from 6.5% of the work force to 13.6% between 1985 and 1986, according to the AHA. The vacancies have sent health care executives, such as Century City Hospital's Bergenfeld, as far away as London in search of nurse recruits.
That shortage, experts say, has been exacerbated by a narrow salary range that discourages nurses from spending a career in the profession. The average starting salary of hospital staff nurses in November, 1986, was $20,340, according to the American Nurses Assn. The average maximum salary for hospital staff nurses that year was $27,744.
The nurses who are signing up are finding hospitals a much more stressful environment. The casual bedside chat with patients that nurses once enjoyed has taken a back seat to more pressing matters.