Debt-ridden Denver health system to stretch staff with technicians

Public hospitals are in deep financial trou- ble. Short on funds and nurses, they are des- perately seeking revenue and ways to stretch overworked staff. Philadelphia’s and St Louis’s city hospitals are closed, Detroit’s has been sold, and New York City is experimenting with ways to keep its 17-hospital system afloat. Cook County Hospital employees in Chicago have had payless paydays.

In Denver, the City Council approved a plan Sept 8 to stretch staff with technicians. About 70 of the 349 beds at Denver General Hospital have been closed most of the year due to a nursing shortage, and $3.4 million has been lost on an annualized basis.

Proposed by John Sbarbaro, MD, deputy director for medical affairs, three levels of un- licensed health care technicians would take on a wide variety of functions, many now per- formed by nurses. They could perform such duties as assessing and teaching patients, administering medications, observing re- sponses, and evaluating results of lab tests. Although formally trained and certified techni- cians would be incorporated, the technician levels do not require any formal education, not even a high school diploma. Dr Sbarbaro said they would be governed by tests and “perfor- mance standards,” but no details were offered. Emphasis is on on-the-job training. Techni- cians would work not only in the hospital but also throughout the city’s health system, which includes satellite clinics and the Visiting Nurse Service.

a Legislation

In the operating room, technicians II and Ill could prepare patients for surgery, position them, and scrub for both “routine” and “com- plex” procedures. Technicians 1 1 1 could also “assist on operations which may be extensive and complex or of considerable or prolonged duration.” Assist is not defined. In a prelimi- nary proposal, the technicians would have been permitted to circulate, but this was later removed.

General qualifications for the technician I are the “ability to read and write compound and complex sentences, using cursive style and proper end punctuation, employing adjec- tives and adverbs sufficient to be able to read and write instructions and reports regarding patient’s condition, treatment, and care.” They must also be able to add, subtract, multiply, and divide, “react effectively, calmly, and ra- tionally in a stressful environment,” and “es- tablish effective working relationships.” Tech- nicians II and Ill must have experience at the next lower level.

Flexibility, upward mobility for nurse aides, and jobs for the community were among Dr Sbarbaro’s reasons for the proposal.

“The creation of training and new job oppor- tunities in an area reserved for licensed health personnel will open the door of opportunity and hope to hundreds of presently unemployed people,” said Ron Thompson, a neighborhood action coordinator. Another consumer advisor described the plan as “culturally sensitive.”

Dr Sbarbaro also sees technicians as a solu- tion to problems in recruiting and retaining nurses. After a staff nurse told the City Council about research demonstrating RNs are more productive than nonprofessional nursing per- sonnel, Dr Sbarbaro countered that, “Our turnover is highest in nursing, and our training

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Vel Garner, RN, testifies before the Denver City Council.

costs are highest in nursing." He maintained that technicians are "our most stable work force" because they are trained in the commu- nity.

AORN joined alarmed nurses in lobbying against the proposal. Executive Director Jerry G Peers, RN, wasoneof 20 nurses testifying at a public hearing July 14.

Speaking for the city-employed nurses' as- sociation, Cathy Chandler, RN, assistant head nurse in surgical intensive care, said techni- cians were not the answer to nurses' problems at Denver General. "We have tried better scheduling. Salaries need to be more competi- tive. We would appreciate clerical assistance but not this type of fragmented nursing care."

Council members questioned the nurses sharply about solutions to the budget crisis. One councilman asked Chandler if nurses were "featherbedding" in opposing the plan. "The bottom line is economics," another said. "Hasn't it occurred to you we might not be able to afford you any more?"

Nurses protested that even routine patient

care required knowledge of anatomy, physiol- ogy, and a wide variety of other disciplines. They pointed out the complex health problems of high risk patients served by the hospital. They questioned the legal liability of physi- cians and nurses who would supervise the technicians. They argued that their nursing care would be eroded as they spent more time training and supervising unskilled personnel.

Dr Sbarbaro skirted the legal question, say- ing physicians could extend their licenses over anyone they chose. "This is what physicians do in their private practice," he said, without explaining how this kind of supervision could be expected on an acute care unit 24 hours a day.

Nurses were unable to dissuade the council members, who passed the plan with only one dissenting vote. "Common sense tells me you don't need a lot of education to perform many of these tasks," one said, lauding Dr Sbarbaro as "innovative."

The Denver technician plan, in which an in- stitution develops its own training and creden- tialing program for health workers is a type of institutional licensure-a practice nursing has strongly opposed. Nursing has taken the posi- tion that individual licensure or certification is better assurance of accountability. With no education or credential from outside the Den- ver system, technicians would have no indi- vidual accountability and no way to demon- strate their skills are transferable.

Are roles for technicians expanding elsewhere? "The issue comes up periodically but has always died out," said Ruth Lewis, RN, director of the Department of Nursing Practice for the American Nurses' Association (ANA). For example, psychiatric technicians have been licensed in some states but gradually this is diminishing. In New York, a bill that would have permitted nonlicensed personnel to ad- minister medications in the state's youth pro- grams died in committee.

In New York City hospitals, roles for physi- cians' assistants (PAS) are expanding to fill gaps left by new restrictions on the entry of foreign medical graduates. At St Barnabas Hospital, PAS provide nearly 80% of care once provided by physicians, the New York Times reports. Montefiore Hospital is training PAS to act as first assistants and provide much of the care for surgical patients that has been

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provided by surgical residents. The 80 who have been trained are estimated to be earning from $18,000 to $25,000 a year after training.

Are the borders of health care responsibility shifting? Will more hospitals in financial trouble turn to technicians and PAS? There is no ques- tion that the financial problems of public hospi- tals are a spreading disease. For many of the poor, they are the last resort. These are the “medically indigent”-those who are too poor to pay for their own care, have no insurance, and do not qualify for government help through Medicaid or Medicare. Medicaid is the gov- ernment’s health assistance program through the states, covering primarily those who are aged, blind, disabled, or receiving Aid to Families with Dependent Children. Many poor people and families do not f i t in these categories. Medicare is paying only about 40% of costs for the aging, the New England Jour- nal of Medicine reports (July 3).

Last year, Denver General Hospital took care of 45,000 indigent patients and had 250,000 indigent outpatient visits. State and local governments, pressured by inflation, may not be able to pick up the slack for these pa- tients. In 1979, New York City provided $254 million in free care to uninsured patients, according to the New York Times. An esti- mated two-thirds of emergency room and out- patient visits there were provided free.

Where can these hospitals turn for help? Uncle Sam is the obvious source. In June, the US Department of Health and Human Services (HHS) announced a national demonstration project and a program to aid two New York City hospitals. Rep Charles Rangel (D-NY) has held national hearings. Sen Jacob Javits (R-NY) introduced two bills that would provide emergency grants to hospitals and amend the Medicaid and Medicare laws to assist some hospitals with uncollected bills. Similar legisla- tion is likely to be introduced in the new Con- gress.

What can nurses do? First, they must edu- cate the public about nursing. In their delibera- tions, the Denver City Council could not under- stand the connection between basic education and daily patient care. They looked bewildered when nurses talked about “care planning” and a “knowledge base.” Some plainly viewed nursing education as a luxury the public could not afford.

Nurses must learn about health economics. Arguing for quality patient care is laudable, but how will we as a society pay the bills? Do we have the will to reform the Medicare and Medicaid systems? Will we support a national health insurance system that will cover the poor who do not have health insurance now? Will we pay more local taxes to support our public hospitals and make them better places for nurses to work? Nurses must help public officials in answering these questions.

W The US House passed its version of the health manpower bill Sept 3, including the Nurse Training Act. The vote was 368-8. The no votes were cast by James M Collins (R- Tex), Daniel Crane (R-Ill), Philip Crane (R-Ill), William E Dannemeyer (R-Calif), James E Jef- fries (R-Kan), Richard Kelly (R-Fla), Lawrence P McDonald (D-Ga), and Ronald E Paul (R- Tex).

In mid-September, the Senate was still dragging its feet, although a committee had approved a bill. If they do not vote and work out their differences with the House by the end of the year, the bills will die.

The nursing programs were in decent shape, but the American Nurses’ Association was vigilant against possible cuts in funding levels.

Patricia Patterson Associate editor

Correction Clifford Jordan, RN, is professor of nursing at the School of Nursing, University of Pennsylvania, Philadelphia. He was incorrectly identified in the article, “Educators take a new look at perioperative nursing,” AORN Journal (September 1980) as associate professor and director of graduate programs in nursing.

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