Why Nurses Leave The Bedside: A Bedside RN's Perspective
Produced with the considerable assistance of webmisstress Pye
Topic: Introduction 
Part of and Intro to Chapter Two: The Health Care Industry and Nurses Within It
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It  is impossible to discuss the nursing shortage without examining  power in  the Health Care Industry and within that group, the hospitals which are the main employment setting of RNs
See Relevant Page Hospitals and Hospital Stats

Hospitals  and Public Health account for >88%  of nurse employment venue [See Nursing Stats, Employment Settings] . Public health involves in its numbers the significant Hospital based Certified Home Care Agencies  [CHHAs]  answering to the more powerful hospital management to which they are wed. 
There are 5,801 registered hospitals in the US, and 987,440 Total staffed beds involved in  US registered Hospitals, according to The American Hospital Association 2001 annual survey. [The number breakdown, and identification of  profit and non-profit identification amongst them is given their own page-See Hospitals and Hospital Stats
The Powers in Health Care
The Health Care Industry has been for-profit driven since the 1960s [see For-Profit Health Care and its evolution].   Still reeling from DRGs Footnote Three initiated in the 80s,  hospitals were hit with the managed care era in the 1990s; Both severely curtailed hospital profits. Among the economic powers in modern health care are: 
  • A)  HMOs -Health Maintenance Organizations- some of which have been around for decades
  • B)  Large Conglomerate Hospital & Health Care Facility Chains rising in power in the 80s
  • C) MCOs-Managed Care Organizations [whose prominence is linked to  excesses of the for-profit nature of health care and the anticipated but failed Clinton Health Care Reform] 
  • D) The Pharmaceutical Industry [which found itself restricted by in-hospital formularies attempting to cap pharmaceutical cost, but  who weathered the change by expanding  R & D endeavors thus bringing  essential drugs to market, in which  manner they have maintained profit through innovation.  The enormous cost of R&D is passed on to the pharmaceutical   customers, including hospitals, while pharmaceutical corporate profits remain insanely enormous ] ; and, finally, 
  • E) a new tier to management superceding the hospital CEO, the Consultant Firms, who assisted not for profit hospitals to change their direction in the 1970s , helped create the management present in hospitals as we know them today, and who, in the 1990s, had newly powerful  niche as a result of managed care and the chaos and disarray  resultant in our nation's hospitals. 
The economic powers above listed compete with nurses for the slice of pie alloted each from the health care coffer pie. As a result, nursing is often shifted to the bottom of the list in salary and benefit adjustment by the nation's hospitals,  although comprising 70% of the nation's hospitals resource pool and being the primary service sought by any patient admitted to a hospital. 
The CEO in context of this study:
The power of Hospital CEOS of large conglomerate facility chains exceeds the CEO of the  local hospital, or local  consortium of hospitals regionalized to a service area and sometimes a part of the large conglomerate chain. The average salary of hospital CEOs has its own dedicated page within this site.   The local hospital or its regional consortium tier CEO now appears subjugated to the Consultant Firms voluntarily accessed through corporate board approval and the  hospital CEOs request to assist that CEO in meeting their job description. Consultants are summoned to evaluate and re-define the business plan for a hospital, and  often provide interim management in addition to the management already in place, all at great cost to the entity to which they are summoned. The leaders in Consulting further function as pundits, exerting influence and direction throughout the industry. See dedicated pages entitled Hospitals and Hospital StatsHospital CEOS,  and the Consultant Firms, all with dedicated pages and part of this Chapter's Table of Contents.

Hospital Boards of Directors always include MDs and often an MD practicing in the facility is on  the board; sometimes  the  CEO is in fact an MD.  MDs also serve as CEOs of HMOs [see Kaiser] and on the boards of all the powers in modern health care outlined above. Nurses are seldom on Boards of Directors, and in the few instances when present, are decades away from bedside practice [see Tenet] . 

Nurses, who constitute 70% of a hospital's labor resource,  as a group can be defined as the profession which all hospital patients seek thus representing the primary economic impetus to any hospital [see  footnote one  ] , and they experienced increases in their salaries in the 1980s [see graph] as a result of the last crisis shortage in the 1980s, itself merely a part of the longstanding nursing shortage evident since the post WWII era. Enrollment in nursing schools escalated in the early 1990s. From a management perspective, as a result of both  increased nursing school enrollment and a perception that the market force had not only been met but apparently over estimated, nurses seemed a logical group from whom  to squeeze further efficiencies in the 1990s; Efficiencies, give backs  and salary suppresion were encouraged. Efficiences, give backs and salary suppresion redefined nursing practice and the economic benefit for the work performed; They also seriously undermined the tenuous improved nursing image gains of the 80s, proving just how weak the gains fueling improved image were. 

The redefining resolutely erradicated a fragile, improved image gained by  improved salaries, enhanced work environment,  and implied improved voice of nurses in the hospital hegemony , mitigating the assumption continued response to market demand would occur tomstregnthen and firmly establishing the new  image. Management soundly reversed the woefully temporary, mismanaged, and misperceived nursing glut  of the mid 1990s;  The effect of  intent , philosophy and decisions regarding nursing and  nurses underscored a willingness to seriously try nursing's expendability and this frighteningly recent effect can not, and should not, be underestimated. Ultimately management sacrificed nurses and nursing, diminished the number of persons willing to pursue the career, and negatively affected the number nurses able and willing to perform the job [see nursing stats]. Management, in direct opposition to their job description,  diminished the reality and image of hospitals, nursing's primary employment venue.   Nurses began to come forward with the conditions, demands, and fear for patient safety that the changes entailed and their complaints were addressed in the nation's newspapers, thus affecting both   the image of nursing and the image of hospitals to those outside the system. 

Meanwhile in the pharmaceutical, HMO and MCO arena enormous profits were being generated. On an annual basis,  hospital upper tier management continued to receive handsome salary increases,  additional bonuses and enhanced benefit packages. By 1994 nursing literature was discussing "short staffing" while the industry denied its existence. By 1995 RN union activity was on the rise and by the late mid 90s, nursing strikes frequently in the news. By year 2002 anti-unionizing efforts were in full swing while nurses themselves continue to exhibit struggle between pro and anti-union mentality. [See RN unions]. 

While nurse salaries have been viewed as contributing to erosion of  hospital profits, nurses can in fact be seen as the primary profit generating service offered by Hospitals and CHHAs . In short, nursing services are the prism through which all other profits are derived  [see Sister Roy and her nursing model] .  The expert suppresion of this reality by an at best unenlightened or misguided, and at worst, sinister and bullying managerial tier  is possible only through collusion of nursing and nurses. As a professional group, nurses are often viewed and/ or are presented as "not in it for the money" [footnote two ] .They suffer from  poor image, , are recognized as lacking voice in the hegemony depending on them, report  unremitting stress in their work days, exhaustion, burn out , and  a sense of helplessness sometimes obfuscating to  martyrdom-  poor self image playing a role in this transformation. 

It is the purpose of this chapter to review the profits, stance towards nursing, board composition and CEO  salaries of:  The major hospital/health care facility chains;  the largest HMOs and MCOs;  the largest Pharmaceutical Corporations;  and the leading Consultant Firm [which both extablishes the practices of the individual hospitals to which they are summoned, and serve as pundits to the industry].   The average salary of hospital CEOs over time is also addressed.  What appears obvious is that  in the dynamic health care industry there are many slices of  coffer pie. Indeed, efficiencies must again be addressed. The difficult question, given the for-profit nature and public trading of the large chain facilities, MCOs,  consultant firms,  and pharmaceuticals [and the demands for ever increasing economic performance by  their shareholders]  is how. For that, see Response to the Alpha Factors

Footnote One: Sister Calista Roy 
For those nurses who are familiar with the Roy Model of Nursing, the irony may not be  lost. Within the greater framework of 
her adaptation model, Sister Calista Roy conceived of the hospital as a nursing facility where people come for nursing care. Accepting this sub textual concept involves an understanding that if the  patient wanted a doctor, they would go to the doctor's office, while a hospital provides implicit promise of nursing care; What people receive, or expect to receive in a hospital, are nurses able to oversee and attend to their care, assist in their procedures, provide sound and thorough nursing assessment,  respond to change in their status and adjust treatment appropriately, advocate for their recovery and treatment, manage the equipment involved in their care, and instruct them on how to manage their illness or injury in the post hospitalization period. What a bedside nurse does is act as a central referrer, according to Sister Calista. If the patient develops additional symptoms during the hospital stay, the nurse contacts the appropriate physician for a treatment modality change before further harm can occur and then she evaluates the response to the change in treatment plan initiated in response to her assessment. If the patient is coping poorly, she refers to social work. If the patient is unable to mobilize, she assures PT is involved.  If the patient develops new symptoms apart from the admitting diagnosis, she refers to the appropriate specialty MD or assures that referral is made by the treating primary physician, , etc, etc.. In this model, the role of nurses in hospitals is paramount, and it follows that the role of management should be seen as supportive to its essential personnel. Instead, because of tremendous pressures exerted in the managed care era, the opposite took hold in the 1990s with management taking a hostile position to the nurses that are the heart and function of the hospital the managers steward.

Footnote Two
"A voluntary hospital is a nonprofit community facility operating under religious or other
                             voluntary auspices. Ultimate responsibility for all that takes place at the hospital rests with its
                             board of trustees, generally selected from the community's business and professional people,
                             who serve without pay. To manage the hospital, the trustees appoint a paid administrator. 

                             Proprietary hospitals are commercial establishments. They are profit-making institutions. Of
                             course, working for profit does not necessarily make a hospital bad, any more than being
                             nonprofit ensures quality care. Proprietary hospitals are owned by corporations or, less often, by
                             individuals such as doctors who practice at the hospital. Hospital corporations usually own a
                             chain of institutions located in several states, and they often own nursing homes or other types
                             of health care facilities as well. 

                             Government-supported hospitals, like all tax-supported institutions, sometimes have to curtail
                             services when budgets are cut. Also, they may not measure up to other hospitals in terms of
                             comfortable accommodations and the availability of private rooms. "

Footnote Three: DRGs are Diagnosis Related Groupings, and their advent signified a change in payment to hospitals from payment by the day  to payment by the diagnosis. As a result, where formerly it was profit inducing to keep a patient in the hospital, it became, with DRGs, profitable to discharge them at the first possible moment, and impossibly expensive to keep them beyond a time frame established by the hospital relevant to the DRG and its payment schedule to them. The nation's physicians, the primary admitting and discharging entites of the hospital systems,  had to become comfortable with this change, and were strongly marshalled by hospital management in complying with the economic bottom line of the DRG mandate within their own hospital systems. The inducement to increased profit through discharge before, or by,  the alloted time frame of the DRG led to what many [patients, nurses, patient advocacy groups and MDs included] felt  was premature discharge of individual patients in need of care beyond that available in the communities to which they returned, and before the time frame which would have been provided under the more familiar former payment structure.

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