Registered nurses from across the country went to Washington DC last week to urge Congress to take action to fix the nation’s broken health care system by enacting Medicare for All.

RNs from California, Florida, Illinois, Kansas, Maine, Maryland, Massachusetts, Michigan, Minnesota, Texas and Washington DC urged Congress to enact Medicare for All.

While our nation’s health care system has incredibly capable nurses and other health professionals, and boasts a variety of other advantages like the highest spending per person in the world, we don’t get the outcomes we should.  Far too many go without health care when they need it.  Our nation ranks behind 19 industrialized countries in preventable deaths among those under age 75.   

In our for-profit health care system, too often patients’ needs seem to take a back seat to corporations’ efforts to build their bottom line.  42,000 Americans will die this year for lack of health coverage, or about 1 per 1,000 uninsured people.  Nurses know all too well that patients face financial barriers to care – even with insurance.  Over one-third of people report going without care or not filling a prescription due to cost, which is dangerous and can lead to unnecessary suffering, dramatically increased costs of care, and even death.  Paul Holland, a nurse working at St. Louis University Hospital told staff for Senator Claire McCaskill (D-MO) about one patient who was forced to put off necessary treatment until she qualified for Medicare years later, which may well have led to her death.

NNU Co-President Deborah Burger, RN, and other health care advocates made the case for Medicare for All to staff for Rep. Raul Grijalva (D-AZ).

These are among the reasons that National Nurses United advocates for Medicare for All.  Nurses envision a more equitable world, where patients get the care they need without going broke.  As part of the Nurses Campaign to Heal America, RNs went to Capitol Hill in Washington DC last Thursday to tell members of Congress that our patients need a system that puts them first. 

Working with health care and consumer advocates, we visited dozens of Senators and Representatives of both political parties to tell them that the nation needs a change.   Vikki Averegan and Sylvia Nell Searfross of Texas had a great conversation in the office of Rep. Beto O’Rourke (D-TX) that produced concrete suggestions from the congressman’s staff to help make that change possible – they suggested we continue our activism and speak up for better health care at town halls and by writing letters.

Under a single payer health care system, everyone can get the care they need while the nation saves nearly $600 billion per year by slashing overhead and negotiating lower drug costs with providers.  Beyond financial savings, streamlining the payment system would free up substantial nurse time and other health care professional time that could be spent caring for patients.  

Two thirds of Americans support a national health program that covers everyone, and nurses were proud to speak up for this important step toward a health care system that puts the needs of patients first.

RN Kim Anderson of Chicago and a team of Illinois nurses urged staff for Rep. Mike Quigley (D-IL) to support Medicare for All.

Nurses also joined Sen. Bernie Sanders (I-VT) for a conversation about single-payer, improved Medicare for All at a summit with advocates Wednesday.  We discussed how our health care system needs more than tinkering, that it needs an overhaul so that it enhances the clinical judgment of RNs and doctors and other caregivers in order to serves patients effectively. As patient advocates we can create a health care system offering universal access.  We discussed how nurses and others reject a system where access is based on ability to pay, so are continuing our efforts to ensure that everyone gets the care they need.

Why you should be wary of “FRANK”

Noticed how little in the healthcare debate we hear one word that should be at its center – care?

Nurses have noticed, and are alarmed at worrisome changes now putting patients at risk.

A new video from National Nurses United starring the decidedly non-personal “FRANK” is a humorous or not so humorous glimpse into one of the most troubling mutations.

Largely away from the media focus on websites and insurance markets, hospitals, with a helping hand from insurers and other corporate interests, are, dramatically altering your ability to get the care you need.

They’re even re-defining what it means to be sick.

For those reasons and more, NNU has launched a public advocacy campaign as an alert about sweeping changes in the healthcare delivery system that are occurring far outside the media spotlight, but frighteningly real to nurses and many patients alike.

To highlight these startling mutations, NNU is sponsoring radio ads, videos, legislation, and holding rallies, marches and other street actions across the country to warn patients and communities what they may face the next time they are at their most vulnerable.

One of the biggest dangerous developments is the proliferation of unproven medical technology.

“FRANK” and company shine a light on computer care at the bedside with only a modicum of hyperbole.

You may think “Frank,” as in “Formatted Recognition Analysis, Non-Human Konclusion,” bears little resemblance to reality.

But every day RNs see “clinical decision” type systems on which hospital executives are spending hundreds of millions of dollars that spit out an instant diagnosis, prognosis and treatment protocol that may bear little correspondence to your actual condition and treatment need.

Increasingly, the computers rely on a concept known as “population health,” in which the diagnosis, prognosis and treatment recommendations are based on factors common to a broad swatch of similar people.

When the patient in our “Personalized Care” ad asks for a registered nurse – not the computer and its algorithms – the hospital executive blandly explains the algorithms “tell us what disease you should have based on what other patients have had.”

“That makes no sense. I’m not other patients. I’m me!” our patient says crying out for help.

“Look it’s not all about You!” the executive retorts. “We’ve spent millions on algorithms, software, computers.”

So, you’re only as sick, as someone else with a similar symptom, regardless of what other health problems you may have. And your outlook for recovery, and what care, if any, you receive, is increasingly determined by others that fit your “profile,” not your own health status.

Thus the crux of this trend with individualized care fading away as hospitals spend instead on experimental medical technology.

Much of the medical technology is being promoted as the cure all for everything that ails our broken healthcare system from medical errors to how to cut healthcare costs.

Too often technology fails on all those counts. Unsafe staffing is a far more common cause of medical errors, and, as noted, when hospitals spend millions, even billions system-wide, on unproven technology, they are driving up costs, not cutting them.

Unfortunately, there are substantial federal financial incentives within the 2009 stimulus bill. The federal government has handed out more than $23 billion in incentive payments to hospital implementing Electronic Health Records systems, which are linked to the bedside computers, since 2011, it was reported last week.

It’s worth emphasizing that the device manufacturers and other industry lobbyists pushed for the federal handouts, as the Washington Post noted, “in a sophisticated, decade-long campaign to shape public opinion and win over Washington’s political machinery.”

Our video has a happy ending, when an actual RN, Bonnie Castillo, enters the room and tells the hospital billing director, “FRANK,” and “Steve,” the “highly cost-effective computer technician” to “Move! Now!,” get out of the way and get human help.

Other ads in this campaign talk about the hospital’s emphasis on collecting your bill and then working to kick you out the door as quickly as possible, and the essential role of having an RN at the bedside.  Check out the whole series here.

The ads are a reminder that “when it matters most, insist on a registered nurse.” That’s one way to respond to the latest assault wave on care from a depersonalized system that is far more focused on its profits than your care.

Leading nurse and healthcare union organizations in 12 countries in the Americas, Africa, Asia, Australia, and Europe held coordinated actions marking international “Nurses Week” (May 6-12) with a call to step up efforts to promote patient safety, protect health care services, and ensure access to health care for all with a common theme of “Health Care is a Human Right.”

The actions included calls to enact measures to stop the privatization of health services and protect patient safety, including the passage of legislation for safe staffing laws. Nurses also took action against the harmful health effects of climate change, and made a call for enactment of the Robin Hood tax on trades of stocks, bonds and other financial instruments to raise needed revenue for basic human needs.

In each country, the actions were led by affiliates of Global Nurses United, an international federation of nurses and healthcare worker unions across the globe formed in June last year in San Francisco. Leaders of the organizations pledged to work together to resist austerity measures and promote health care as a right for all people.

What follows is a visual recap of GNU actions around the world for which we received photographic or video documentation. In addition to those pictured there were also actions in:

Guatemala: The Sindicato Nacional de los Trabadores de Salud de Guatemala held a picket in Guatemala City at the Congress of the Republic demanding passage of the Robin Hood Tax to protect public health care services.

Dominican Republic: The Sindicato Nacional de Trabajadores de Enfermeria held marches in the cities of Santo Domingo, Santiago, Barahona and San Pedro de Macorís demanding a bigger budget for public health and against the privatization of health services.

South Korea: The Korean Health and Medical Workers Union organized a national tour that began last week and will continue until May 23 in opposition to health care privatization and the Trans-Pacific Partnership Agreement (TPPA) along with the announcement of a new study emphasizing the need for improved staffing.

Korean Health and Medical Workers’ Union

Brazil: The Federação Nacional dos Enfermeiros organized nurses, healthcare workers and students for a five-day encampment at the Minas Gerais Legislative Assembly to protest poor working conditions. Nurses and nursing students also mobilized at the national capital in Brasilia and participated in a public hearing to push for national legislation to reduce nurses’ working hours.

In Brasilia, Brazilian nurses and nursing students were honored for their work, especially for their fight for the regulation of working hours.

Australia: The Queensland Nurses Union staged workplace activities in 137 hospitals and aged-care facilities across Queensland, and the New South Wales Nurses and Midwives Association organized actions in New South Wales.

NSWNMA Celebrates International Nurses Week

Queensland Nurses Union Nurses & Midwives’ “flash mob” dance in Brisbane in celebration of International Nurses Day

Kenya: The Kenya National Union of Nurses joined the national mobilization for May Day with their banner proclaiming: We Dare to Care!

Canada: The Canadian Federation of Nurses Unions organized a national “wear white” protest campaign to push for safe staffing and defend patient safety, along with workplace protests and street rallies and the and Fédération Interprofessionnelle de la santé du Québec organized actions to support nurses and other health care professionals across Quebec.

United Nurses of Alberta at the Peace Bridge in Calgary on International Nurses Day

South Africa: DENOSA, the Democratic Nursing Organisation of South Africa, is holding events, under the theme “Nurses: A Force for Change, A vital Resource for Health,” across the country through May 29. [http://www.cosatu.org.za/show.php?ID=8755]

DENOSA nurses at International Nurses Day celebration in Soweto.

Honduras: The Asociation Nacional de Enfermeras/os Auxiliares de Honduras held marches across the country including Tegucigalpa where, dressed in white uniforms, union members and allies carried placards with messages to President Juan Orlando Hernández: “Mr. President, do not ignore the nurses,” and another banner denounced the shortage of drugs with “In the San Felipe hospital’s drug crisis: no anesthesia for surgery, no pain killers!”

Asociacion Nacional de Enfermeras y Enfermeros Auxiliares de Honduras

Find more great fotos of the Tegucigalpa action here >>

United States: National Nurses United marked the Global Day of Action with mobilizations and activities in Chicago, Illinois, Washington, DC, Sacramento, California, and various locations in Florida, Minnesota, Texas and Maine.

Chicago, IL: RNs rally to demand closure of the polluting “Petcoke” (Petroleum Coke) plant.

Read more at the links below: 

Rallying at Koch-owned Facility, Nurses Experience Petcoke Pollution Firsthand >>

In Chicago, Nurses Take Up Fight Against Petcoke Piles >>

Washington DC:  RNs rally to push for passage of safe staffing legislation in district hospitals

Sacramento, CA: 500 RNs converge on the state Capitol to press for passage of bills that would improve patient care and workplace safety.

Ireland: Irish Nurses and Midwives Organisation launched a safe staffing campaign at their 3-day 95th annual delegate conference.

Philippines: The Alliance of Health Workers staged a Health Workers’ Day action on May 7 in Manila to stand up for health care workers and public health care and protest the proposed Trans-Pacific Partnership Agreement (TPPA). The agreement would open up to foreign investors the purchase of 72 hospitals, which will lead to price increases and further deprive Filipinos access to affordable care. When new owners acquire the hospitals all the workers can be terminated.

See wonderful pictures and learn more about this action here >>

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After learning this morning of the second major oil leak in L.A. in less two months, some of the newest members of CNA rushed to the scene to offer assistance and assess the health risks associated with a gushing leak coming from a ruptured above-ground pipeline.
 
The newly elected Bargaining Team nurses from USC Verdugo Hills had a scheduled meeting less than half a mile from the spill at the CNA Glendale office to prepare for negotiations with management of the recently unionized hospital. Sandy Mulcahey, RN and Erica Beltran, RN arrived to find a massive cleanup underway. The nurses gathered information from LAPD and LAFD officials, who thanked the RNs for their assistance.
 
Mulcahey described the smell in the area as “a heinous, burned rubber stench.”
 
Beltran, describing the surrounding air quality, said, “It’s bad even for someone like me, with healthy lungs. When the wind kicks up, it hits you in the face and it hurts. It really hurts. So my mind immediately goes to the children living nearby, the elderly, people with asthma, someone with chronic pulmonary disease. If they’re close enough, this could potentially them send to an E.R.”
 
When asked what role RNs have with regard to the environment, Beltran said, “We take an oath to be patient advocates, and our patients don’t have to just be in a hospital. They’re here in the community. It’s our duty to take preventative measures to make sure our environment is safe.”
 
Mulcahey answered, “The list is endless.”

Federal Government Orders MedStar Washington Hospital Center to Provide Critical Staffing, Health, and Safety Information to Nurses

The National Labor Relations Board, a federal agency, has found that MedStar Washington Hospital Center violated federal law by refusing to provide nurses and our representatives with copies of the 2012 AHRQ Survey on Patient Safety Culture, copies of the current staffing plans for each unit, and daily deviation from the established staffing plans. Rather than work with nurses collaboratively to improve staffing and patient safety at the hospital, management claimed confidentiality and wasted thousands of dollars to wage a failing legal battle to withhold the information.

This second decision follows the September 11, 2013 ruling of Judge Arthur Amchan, an administrative law judge of the National Labor Relations Board.

Judge Amchan ruled that the hospital must provide the requested information to National Nurses United.

Instead of accepting the ruling, providing the information, and beginning to address nurses’ serious concerns about staffing, health and safety, management appealed the ruling to the National Labor Relations Board in Washington.

By appealing, management prioritized concealing their safety record above all else. Management has wasted thousands of dollars diverting money that should be earmarked for care and improvements to their attorneys in a shameless attempt to hide the truth about their safety record.

The decision orders management to post a notice acknowledging violation of federal labor law. Further management has been ordered to cease and desist from refusing to bargain collectively with National Nurses United, and interfering with, restraining, or coercing employees. A full copy of the decision can be found at www.nursesunited.org

Their first Facility Bargaining Council meeting will take place Wednesday, May 21, at 5:00pm in the True Auditorium at Washington Hospital Center. RNs are invited to attend for a discussion about winning improvements in our next round of contract negotiations.

The slippery slope for patients, nurses, and doctors posed by robots in healthcare

By: RoseAnn DeMoro, Executive Director of National Nurses United

For patients needing dialysis or care for acute kidney failure, there’s a new doctor in the nephrology ward at St. Joseph Hospital in Eureka, Calif. Meet the doc on a stick.

It’s not a scene from “Star Trek” or the latest X-box video game. And, like the smooth-sounding, but ominous “Hal” computer running the spaceship in “2001: A Space Odyssey,” those side effects might be a killer.

Eureka RNs have noticed an immediate impact. Dr. “doctor on the lamp post” can sort of see the patient, but can’t offer hands-on care, has trouble getting around, and doesn’t hear so well. So it’s up to the RN to babysit the machine, wheel it around, and clinically assist the remote doctor with patient communication and physical assessments. (The company name “InTouch Health” should be listed in the dictionary somewhere between “deceptive” and “Are you kidding me with this?”)

For RNs, it means more time away from other patients on often already short-staffed units. Involvement with this process at the patient’s bedside will take considerable time, “during which a nurse’s other assigned patients have no nurse available to meet their needs,” says St. Joseph RN Katherine Donahue

Further, “the robot doctor is very impersonal for the patient. It undermines the hands-on ability for the doctor with the patient, and if the electronic equipment malfunctions it can compromise the medical record,” Donahue added.

Computer-driven errors from the trillions of dollars the healthcare industry is spending to develop, market, and profiteer from in the not-so-brave new world of medical technology. That’s not a concern, right?

Or as Hal the computer states right before killing the human passengers and pilots, he is “foolproof and incapable of error.”

Problems with the machines might be a surprise to the consultants and industry executives, not to mention the politicians who enacted financial incentives to promote rapid expansion of medical technology as key components of the Affordable Care Act, and the 2009 budget stimulus bill before that.

But nurses have long been aware of the downsides for quality care and human healthcare employment, deriving from computerized diagnostic and prognostic protocols, and other skill-debasing and displacing mechanical overlords.

At the dawn of the healthcare restructuring wave of the early 1990s, the California Nurses Association’s research department was sounding the first warnings of the implications of turning nurses and other hospital personnel and the nursing process itself into digital bits, of how individual patients need individualized care, and of how the machines can and do actually fail.

We cited the example, told in a PBS special, “The Thinking Machine,” of artificial intelligence researcher Doug Lenat describing his rusting 1980 Chevy to a skin disease diagnostic system as a lark. It concluded that the patient had measles.

For a more recent anecdote, consider Hal’s great-grandfather, Watson, developed by an IBM research team and rolled out with great fanfare on the quiz show “Jeopardy.”

Viewers watched in awe as Watson steamrolled its human competitors, until they got to the “Final Jeopardy” question: “What U.S. city’s largest airport was named for a World War II hero; its second largest, for a World War II battle.” Watson answered promptly, “Toronto,” (uh, that’s in Canada), while the overmatched humans got it right, “Chicago.”

That story made lots of news. But less recalled is follow-up explanation from the lead IBM research investigator who concluded that the “category names were tricky,” only minimally suggesting an “expected answer,” and “the way the language was parsed provided an advantage for the humans and a disadvantage for Watson,” as reported by Steve Hamm in a blog for “Building a Smarter Planet.”

Or, in a nutshell, all the problems nurses, CNA and NNU have reported with computerized protocols – substituting digitalized systems that don’t necessarily respond to the diverse, complex health problems faced by real patients for human professional judgment, the ability to think and analyze.

Watson went on to a better life in, you guessed it, healthcare. Last month IBM announced that Watson will be making utilization management decisions for lung cancer treatment at Memorial Sloan–Kettering Cancer Center in conjunction with insurance giant WellPoint. IBM Watson’s business chief boasted that 90 percent of nurses in the field who use Watson will follow its guidance, reports Forbes magazine.

While RNs have long been the Cassandras on technology, many doctors have been late to the game and been in the forefront of cheerleading for how the Watsons and telemedicine practitioners are the solution for medical errors, improving overall quality, and cutting healthcare costs.

A physician walking the rounds in a hospital might only see five or 10 patients a day. Put that same doctor at a desk with a computer monitor miles or continents away, and they might see 300 patients a day. How many doctors do you think the CEOs will need in this future?

One last example from the retail grocery industry. When product scanners were introduced, a lot of checkers thought it would make their jobs easier. It did, required fewer of them and downsized their skills as well.

Today, walk into any Safeway and notice the growing number of fully automated check-out registers with no live workers and no ability to respond to individual problems – in other words, just another grocery commodity. That’s what the doc behind the doc on the stick might give a little more thought to.

How nursing scripts and patient satisfaction surveys project a fantasy of care, not real care

By: RoseAnn DeMoro, Executive Director of National Nurses United

“Hello, Mr. Smith. My name is Joanne. I am your nurse. Are you experiencing any pain today? No? That’s good. Do you need help getting to the bathroom?” (check script) “Can I fluff your pillow, bring you a magazine, turn on your TV, move your water bottle closer?”

(check script) “I am so happy to be of service, this is all part of the excellent care we provide here at Happy Homes Medical Center and Resort.”

“We know you have choices when you go to the hospital, thank you for choosing Happy Homes.” (check script) “You will be receiving a survey from us after you leave Happy Homes, and I hope you will remember this excellent service when filling it out. Have a nice day, Mr. Smith.”

If this scenario seems far fetched, you’re probably not a nurse who has worked in a hospital recently. Strict adherence to scripts derived from exorbitantly paid consultants like the Studer Group and Press Ganey for every interaction between the RN and her patient is increasingly a job expectation.

Can’t recall it all? Not to worry, the hospital will provide acronyms and “important key words,” also known as the “Five Fundamentals of Service,” to help RNs remember their script, helpfully reinforced by their managers, as we noted in a 2010 NNU CE home study course and feature story (National Nurse, October, November 2010).

Scripting is one element, another is “rounding,” guaranteeing that every nurse document a visit to every patient at least once every hour, even if the nurse checks on the patient more frequently, as is typically the case, or misses the hour by a few minutes because another patient happens to be coding.

And, what happens if you fail to meet the scripting and rounding requirements? For the nurse, especially in a non-NNU hospital, it can lead to docked pay or other discipline. For the hospital, it can lead to reduced Medicare reimbursement, for which it will certainly exact punishment on the nurses.

Welcome to the not-so-Brave New World of faux patient satisfaction.

About 15 years ago, during an earlier wave of hospital restructuring, we told the story about a hospital where nurses being required to put lip gloss on a patient to improve their color before a family visit so that family members would think their loved one was receiving appropriate care. Even as the hospital was replacing RNs with unlicensed personnel, all that mattered was the perception of care.

As the years have evolved, so have the reengineering methods. And the hospitals have an added incentive to substitute service and the appearance of care for the actual delivery of quality care.

It pays. A lot. The Centers for Medicare and Medicaid Services announced last October that patient satisfaction survey results will be one significant factor in determining Medicare reimbursements, and for those executives lucky enough to meet the contrived guidelines, bonuses.

To make matters worse, patient satisfaction surveys are fully integrated into the 2010 Affordable Care Act, through healthcare quality initiative measures.

Are the nurses, doctors, and other staff constantly smiling? Check. Are there plants in the hospital lobby? Check. Attractive artwork on the walls? Check. Soothing music in the elevators? Check. An espresso machine in the cafeteria? Double check. Free wi-fi in hospital rooms and lounges? Triple check. And are the nurses scrupulously following those scripting and rounding demands? Checkmate.

If this sounds like something out of Disneyworld or the hotel and hospitality industry, that’s not a coincidence. Hospitals now use the same consultants and the same formulas. Call it Goofy on steroids.

Consultant-driven reengineering blueprints are destructive enough in the service and entertainment industry. In healthcare they can be deadly.

Witness a study, “The Cost of Satisfaction,” just published in February in the Archives of Internal Medicine. Correlating patient satisfaction surveys with outcomes, the study said the risk of death for the most highly satisfied “healthy” patients was 44 percent higher than their less “satisfied” counterparts. The article sparked a bevy of medical blogs and news accounts with titles like, “Do you like your doctor? It could be the death of you,” and a furious rebuttal from Press Ganey statisticians arguing the surveys are “here to stay.”

Just making the patient happy, with inappropriate care for example, has no bearing on quality of care, wrote columnist Theresa Brown, RN, in a March 14 New York Times commentary aptly headlined “Hospitals Aren’t Hotels,” and echoed by William Sullivan, MD in a March 20 article in Emergency Physicians Monthly titled, “Dying for Satisfaction.”

Nurses don’t need these high-priced consultants or CMS or the ACA to determine how to improve quality at the bedside. Studies have long documented that safe RN staffing, especially mandated RN-to-patient ratios, and other measures that reinforce professional nursing judgment and the application of an RN’s clinical expertise and experience have far greater impact on positive patient outcomes.

Indeed, nurses increasingly see that the patient satisfaction scam, and the scripting and rounding that accompanies it, are closely associated with hospital industry restructuring aimed at deskilling, displacement of RNs, and automating RN interactions with patients.

They interfere with nursing care, undermine the culture of safety, can lead to increased medical errors, and subject RNs to intimidation, offensive scrutiny, and discipline from managers for not following the consultant’s script and doing enough to artificially inflate patient scores.

It’s a safe bet that when Disney executives themselves are in the hospital, they’d rather have safe nursing care than a potted plant at the bedside.

How the ACA is restructuring care and nursing itself

By: RoseAnn DeMoro, Executive Director of National Nurses United

With all the clamor over website woes during rollout of the Affordable Care Act, much less attention has been paid to changes in the delivery of healthcare that will have far-reaching, adverse effects on healthcare quality and access long after the signup problems are a distant memory.

As we have said, some components of the ACA are clearly welcome, especially the Medicaid expansion in those states where the governors are not standing with pitchforks in the door to block health coverage for the working poor. Yet there’s plenty of trouble in the fine print, especially on the care delivery side.

For RNs, these changes are achingly apparent. Just ask Kaiser Permanente RNs who have spent much of the fall protesting cuts in hospital and patient services that Kaiser executives paint as the face of future healthcare. Much of this latest wave of hospital and healthcare restructuring was, of course, wreaking havoc before enactment of the ACA.

However, financial incentives buried deep in the new healthcare law add a whiff of healthcare restructuring on steroids. The ACA rewards hospitals and insurers for shifting care delivery out of the hospital, regardless of patient need, stepped-up use of labor- and skill-displacing technology, gimmicks like patient satisfaction surveys, the transfer of more costs onto patients and workers, and other worrisome trends.

To get the full picture, I strongly encourage those who are able to attend one of our educational offerings, “What Does the ACA Mean for RN Patient Advocacy? The Bedside From the Bottom Line,” “RN Patient Advocacy in an Ecological Context,” both now open for registration on the NNU website, or one that will start soon, “Keeping Sight of Patient Protection: Insurance & Patient Care After the Affordable Care Act.”

Like those bad Halloween movies, the worst abuses long associated with managed care are back. Private health insurers, and hospital chains like Kaiser that are also insurers, or hospitals that form their own integrated networks through the new Accountable Care Organizations (ACOs) have an economic incentive to restrict care.

Other insurers simply pass along their financial risk to providers, who then, to boost their own revenues and profits, shift the burden onto patients through steeper co-pays, require cash up front before administering care, determine if patients are a payment risk using medical credit scoring, and hound patients for payment afterwards.

Hospitals also set cost reduction targets by limiting patient access to hospital care, increasing out-of-pocket expenses for patients, and targeting RNs.

The latest wave of the restructuring emphasizes two interrelated objectives: eroding the patient advocacy role of RNs through deskilling, displacement, and division, weakening the ability of RNs to act collectively.

Fewer patients are admitted, held in “observation units” up to 24 hours then sent home, and pushed out the door prematurely to lesser-staffed, lesser-regulated sites or home.

Kaiser, for one, has reduced its average daily census by 11 percent the past four years. They’re not alone. Henry Ford Health System in Detroit had a 6 percent drop the first seven months of this year, Modern Healthcare reported in August. Health consulting firm Sg2 predicts a national 3 percent drop in inpatient admissions the next five years, coupled with a 17 percent growth in outpatient services.

Hospitals overall, note our researchers at the Institute for Health and Socio-Economic Policy, have profit margins of 35 percent for elective outpatient services, compared to just 2 percent for inpatient care.

Kaiser, a national model, is seeking to move 1,000 RNs out of hospital care to other settings in Northern California alone, thus dispersing RNs and undercutting their ability to act together to fight for patients, while closing hospital services in a number of facilities, as seen in an array of cuts which have outraged seniors in Manteca, Calif. and the closure of pediatric care in Hayward, Calif.

In a 2012 Health Week presentation in Copenhagen, former Kaiser CEO George Halvorson said that in the near future, “for most people the home will be the primary site of care” dominated by in-home monitoring, self-care, and increasingly “cheap.”

That will increase the burden on families, especially women. A Gerontologist study in 2012 predicted an up to 15 percent likelihood of adverse events for home care patients in drug side effects, falls, and equipment malfunctions, and a huge increase in levels of stress and strain for the new home caregivers.

For RNs, the restructuring wave hits in multiple other ways as well. Technology is used to displace, not enhance, professional skill; to increase surveillance of nurses; and to routinize care by chopping it up into discrete, factory assembly line-type parts.

If managers can fragment and standardize the nursing process, they can automate it with technology, and intensify the workload with speed-up and short staffing. Sound familiar?

NNU RNs are heroically challenging these trends, and it is a major reason why we continue to campaign for a more humane healthcare model, not based on maximizing profit, but on ensuring a single standard of excellence in quality care for all. But it is going to require all of us; everything we represent is at stake.

RNs from Doctors Medical Center (DMC) are fighting to keep this critical facility open. Nurses are urging Contra Costa County Board of Supervisors to assume authority of DMC, which has 79 percent of the hospital beds and 60 percent of the emergency care in the region. Closure would be a healthcare catastrophe! Sign the petition to save Doctors Medical Center in San Pablo!

On May 12, International Nurses Day and Florence Nightingale’s birthday, nurses around the world will rally in support of the declaration, “Healthcare is a Human Right,” as part of a day of action organized by Global Nurses United, an international network of nurses’ unions, including National Nurses United.

When GNU leaders came together to establish the network in 2013, they pledged to work together to guarantee the highest standards of universal healthcare as a human right for all. This ambitious agenda is the legacy of the many giants in the history of nursing who dreamed big and organized with others to realize those dreams. As we prepare for the day of actions on May 12, we pause and reflect on that legacy, to remember the values and the deeds of some of our predecessors.  

Florence Nightingale (1820-1910) is credited as the founder of modern nursing, and despite this, public awareness is often limited to her work tending to the wounded in the Crimean war. In fact, she was an expert statistician and developed groundbreaking data visualization tools to advocate for changes in military and other health policies. The so-called ‘Lady with the lamp’ shed more light on health practices through her skill at collecting, evaluating, and analyzing data than with any lamp she carried while at the warfront.

Mary Seacole (1805-1881) was born in Jamaica and drew on the Creole medical remedies she learned from her mother, particularly in the treatment of tropical diseases. She organized a response to a cholera outbreak in Panama, noting, “I believe that the faculty have not yet come to the conclusion that the cholera is contagious, and I am not presumptuous enough to forestall them; but my people have always considered it to be so…” Rejected for volunteer service in the Crimea, Seacole self-funded her travels and established a hybrid business/service project that sold supplies to support the provision of health services at the front. Seacole overcame many barriers as a woman of color to provide medical care where it was sorely needed.

Nazaria Lagos (1851-1945) was appointed as the first president of the Red Cross in Dueñas, Iloilo, in 1897, under the auspices of the Catholic Church and the military government, both aspects of Spanish colonial rule in the Philippines. Soon after, she and her family joined the Philippine movement for independence from Spain and Lagos organized a rebel hospital on her family’s remote hacienda. Since medicine and drugs were not available, she gathered local medicinal plants and recruited traditional healers and nurses from the Red Cross to assist with the hospital. After Spain ceded the Philippines to the United States, the hospital continued to operate until US troops occupied Illoilo and burned down the hacienda as punishment. Today Lagos is highly honored in the Philippines for using her skills as a healer and organizer to support the revolution at great risk to herself and her family.

Lavinia Dock (1858-1956) was a pioneer in nursing education and a political activist in the suffragist and other movements. In the 1907 American Journal of Nursing, Dock admonished her fellow nurses to get involved: “I am ardently convinced that our national association will fail of its highest opportunities and fall short of its best mission if it restricts itself to the narrow path of purely professional questions and withholds its interest and sympathy and its moral support from the great, urgent, throbbing, pressing social clams of our day and generation.” Dock walked her talk and was arrested and jailed numerous times for her activism. Despite subsequent gains in women’s rights, her questions to her peers are still relevant today: “As the modern nursing movement is emphatically an outcome of the general woman movement and as nurses are no longer a dull, uneducated class, but an intelligent army of workers…What is to be our attitude toward full citizenship?  Shall we be an intelligent, enlightened body of citizens, or an inert mass of indifference?”

Lillian Wald (1867-1940) invented the practice of the “public health nurse” and the concept of public health policies in general. Wald opened the Henry Street Settlement House in New York City to provide healthcare and other services to immigrant women and other residents living in poverty in the Lower East Side. Then, and still today, Henry Street’s range of health, educational and cultural programs, manifest Wald’s holistic vision. The Wald Circle, made up social workers, female trade unionists and active suffragists, advocated extensive social reforms including protective legislation for children. Although Wald’s activism angered some of Henry Street’s wealthy donors, she refused to be intimidated or stop her organizing.  

Cecilia Makiwane (1880-1919) was raised in what was known at the time as, the British Cape Colony. In 1903 Makiwane was one of the first black students to be admitted to the colonial nursing college and then became the first black woman in South Africa to be licensed as a nurse. She participated in the first women’s anti-pass campaign, an early pre-cursor to the South African Anti-Apartheid Movement. Before this campaign, women had not been actively resisting the regime and the uprising, particularly because it was multi-racial, greatly alarmed authorities. Makiwane and the over 5000 women who were part of the campaign, many of whom were arrested and jailed, showed great courage and foresight in challenging the status quo more than 80 years before the dismantling of apartheid. 

Each one of these women embodied the courage and commitment that is at the heart of nursing today:

• They were visionary and ahead of their time
• They were expert in the development of health sciences and social policy 
• They recognized how human health connects to social justice and planetary health
• They were advocates, organizers and facilitators – creating systems and organizations to make change and address human needs
• They overcame discrimination, borders and financial restraints to accomplish their goals

Let their memory be a tonic and inspiration as together we confront contemporary challenges and move forward towards quality healthcare for every human being on this planet.

Happy International Day!