Hahnemann boosts use of registered nurses in bid to improve care

In a move that defies conventional wisdom, Hahnemann University Hospital is replacing less expensive workers with people who are paid more.

Michael Halter, the hospital's chief executive officer, believes that ultimately the change will earn Hahnemann more money and customers, and create a more loyal staff when the labor market becomes competitive again.

Halter said a pilot study done on one nursing unit found that using all registered nurses to care for patients instead of a combination of nurses and nursing assistants led to higher-quality care, and greater patient and nurse satisfaction. As a result, the entire hospital is transforming to the all-RN model. Halter thinks the move will pay off financially as insurance companies change reimbursement policies to reward quality.

"I believe it'll help us grow," Halter said. The idea, he said, originated with nurses. It has been tried on two units and will begin on a third next week. He expects the entire transition to take six months to a year. Until now, it has been possible to move certified nursing assistants (CNAs) on those units to other jobs, but Halter said layoffs will soon be required.

The hospital has 600 registered nurses and will hire 50 to 60 more. Nurses make from $35 to $50 an hour while aides make about $25, Halter said.

But the union that represents 75 CNAs who likely will lose their jobs is mobilizing to fight the change. The CNAs, whose contract with Hahnemann expires in July, plan to picket starting Tuesday afternoon.

"It's a bad situation and they are in for the fight of their life," said Henry Nicholas, president of District 1199C of the American Federation of State, County and Municipal Employees (AFSCME). "We are not going to let this go down."

Nicholas said that when nursing assistants are gone, patients will have to wait longer for a bedpan or help with dinner.

He called the decision to stop using CNAs "union busting" and said the hospital has a responsibility to employees who have served it well, often for decades.

"There is no legal question. It's a moral question," he said. "It is unjust to throw these people out who have been there for 50 years and beyond just on a humbug."

A hospital spokeswoman denied the change was intended to break the union and said many other union workers would remain. Halter said he was doing what he considered best for patients.

"I care about these people," he said of the CNAs. "They are good people, but my responsibility is really to the patient, because they come in and they turn their care over to us."

Matthew McHugh, a nursing professor at the University of Pennsylvania who studies health policy and outcomes, said aides took on more nursing work during the 1980s and 1990s in response to a shortage of nurses and to pressure from managed-care companies to lower costs. While cost remains an issue, the tight economy has made it harder for RNs, especially those without bachelor's degrees, to find jobs.

McHugh said evidence suggests that patient outcomes are better when hospitals employ higher proportions of RNs, especially when the nurses have more advanced training. More important, though, he said, is that hospitals foster a culture that encourages employees to get more training, have good communication among nurses, physicians and managers, have enough people to do the work, and provide nurses with the tools they need.

Magnet nursing status, a credential bestowed by the American Nurses Credentialing Center, is an indicator of those qualities, he said. Hahnemann is a magnet hospital.

Neither Halter nor McHugh expects large numbers of hospitals to do away with nursing assistants. "I don't know that it will necessarily be a trend," McHugh said, "but I think it could be successful for individual hospitals."

Under Hahnemann's existing system, each nurse had five or six patients. Nursing assistants had no set number, but Halter said they had about 10 patients each. In the all-RN model, each nurse will have three or four patients and a unit will have a charge nurse with no patients of her or his own to help with patient flow.

As part of the new model, when one shift ends and another begins, nurses will "hand off" patients at the bedside. That means patients will learn firsthand how they are doing, a step that should reduce confusion and improve education. That information might reduce re-admissions.

"The biggest complaint we get from patients is, 'I don't know what's going on and I feel like I'm a prisoner,' " Halter said, and the handoff at least addresses the first part of that.

Halter said he found results of the pilot study convincing. The percentage of nurses who said they could complete their work during their shift rose from 37 before the pilot to 74 after, reducing overtime payments. Fewer patients got bedsores or had trouble with blood thinners. The number of emergencies at the bedside was nearly halved - a sign, Halter believes, that nurses were identifying problems before they got out of hand. Fewer patients fell. Patient satisfaction rose, especially with pain control.

One might think that nurses would balk at doing more menial work, such as changing diapers or taking temperatures. But many nurses have long argued that the more time they spend with patients, the quicker they notice when things are going awry. They see skin problems when giving a patient a sponge bath or notice weakness while helping someone to the bathroom. An all-RN model removes the middleman - the nursing assistant - who had to recognize a problem and then tell a nurse about it.

"We're there for the hard part, the fun part, the dirty parts," said Laura Picariello, a nurse in one of the all-RN units. "We do it all."

"A lot of us got into nursing to help patients," said Brian Emery, a nurse on the 17th-floor unit where the pilot was conducted. "It's not really about doing bed baths vs. acute-level skills."

Orien Smith, an Elkins Park woman whose 61-year-old father, Calvin, was in Hahnemann last week to have a catheter placed for dialysis, said the staffing change was a noticeable improvement. The father likes knowing who his nurse is every day and the daughter likes knowing that "whoever I'm talking to is his nurse." She also thinks the care is "more compassionate because you kind of build a rapport with the person."