Tuesday, September 16, 2008
Nurse Deficit? Affluent Patients Hire Their Own
By ABIGAIL ZUGER
Published: April 16, 2002
Mary M. Baker's elderly mother is thinking of having back surgery, and Ms. Baker has already decided that when the time comes, her mother will not be lying in a hospital room all alone. ''She's a retired nurse and she never complains,'' Ms. Baker said. ''I'm definitely having someone in there with her.''
This is more than just a doting daughter talking: Ms. Baker is a nurse herself, and president and chief executive of Chicken Soup Plus, a nursing agency in Sacramento. When she hires a private nurse for her mother, she will be joining what she feels is an emerging trend: hospitalized patients employing nurses of their own rather than relying on the hospital nursing staff.
Private nurses have been available for hire in hospitals for decades, markers of affluence much like household servants. Now, though, they are working in a different world. Shortages of staff nurses plague hospitals across the country. Even in those that are fully staffed, surveys have repeatedly shown, nurses are taking care of more patients and sicker patients than ever before, with far less time to nurse each patient assigned to them.
Headlines repeatedly broadcast hospitals' dangers, and patients generally know for themselves just how unpleasant a stay in one can be. Some researchers fear that worried patients and their families may begin to view private nurses less as a luxury than as a prudent and sensible precaution.
But by hiring private nurses, they say, patients may simply be exchanging one set of problems for another, entrusting their care to nurses unfamiliar with a hospital and its routines and leaving themselves potentially vulnerable to mishap.
There is no centralized data on how many private duty nurses and nurse's aides, sometimes called ''sitters,'' work in hospitals. Further, little consensus can be found among those in the business as to whether their services are increasingly in demand.
Deborah Yanicelli, manager of the Manhattan office of Access Nursing Services, an agency that supplies private nurses to hospitals, often ones known for attracting well-heeled patients, says her volume of requests has increased considerably, up by perhaps 15 percent over the last four months.
''The reputation is that you're taking a risk in the hospital,'' she said. ''Some people with means just want to make sure everything will be O.K.''
In contrast, a representative of the nurse registry at Greenwich Hospital in Greenwich, Conn., one of the wealthiest communities in the country, noted no increase in demand. Neither did Mark Baiada, president of Bayada Nurses, a large private nursing agency based in New Jersey and serving 11 states.
''That market isn't really growing like crazy,'' Mr. Baiada said, in contrast to the demand for home care nurses for recently discharged patients, which is soaring. ''You're in the hospital for such a short time now that you're discharged before you can blink,'' he said. Dr. Lorraine Mion, director of geriatric nursing at the Cleveland Clinic Foundation, said the demand for private nurses at her hospital was no different than usual. ''Still, it's an interesting question,'' Dr. Mion said. ''You can certainly see it happening someday.''
Economic considerations may be blurring the picture: private nurses are expensive. Those who can afford them may frequent affluent hospitals where the perceived need for them is still not great. No insurance plans cover the cost, and hospitals will finance a private attendant only when a patient is at a high risk of life-threatening harm if left alone: an actively suicidal patient, for instance. Otherwise, the fee for a private nurse, which may run from $20 an hour for a practical nurse or aide to $75 an hour for an experienced registered nurse, must be paid by the patient or family.
The money buys the confidence that a patient will not have to wait for the basics of nursing care, like help with eating or navigation to the bathroom. Bedbound patients will be repositioned frequently to help them avoid developing bedsores, and postsurgery patients will be reminded to do their breathing exercises.
Private nurses supply extra pairs of hands to untangle intravenous lines and arrange pillows; they guard against falls and keep water pitchers full. They can clarify the purpose of new medications and review discharge instructions.
But even when private nurses are highly experienced registered nurses, they generally cannot dispense medication, administer transfusions or chemotherapy, or write notes that become a part of the hospital record. These activities are the legal responsibility of the staff nurses, and hospitals will not allow them to be delegated. The result is that hospital and private nurses must collaborate in the patient's care -- an arrangement that may or may not work out. Jane Laffend, a bank trust officer in Philadelphia, spends much of her workday coping with the medical needs of elderly clients. When her elderly aunt was taken to a New York emergency room with abdominal pain last winter, Ms. Laffend hired a private registered nurse for her without thinking twice.
''She was in the E.R. for three days waiting for a bed,'' Ms. Laffend said, ''lying on a gurney with no pillow at first, no blanket, only two nurses for a roomful of critically ill patients. A terrible situation. Having that nurse for her was very beneficial. It meant she didn't have to wait for a bedpan, for anything.''
But the bad side, Ms. Laffend said, was that once her aunt was convalescing in a regular ward, she developed no rapport at all with the floor staff nurses, who may ignore and even resent patients who hire outside help.
''The sense you get from them is that if you don't trust me, then all right, so much for you,'' Ms. Laffend said. ''All in all, it was better for her psychologically to have someone there. If it was better over all, I don't know.''
Nursing scholars agree that private nurses may smooth over rough spots in hospital care, but at a cost.
Dr. Claire Fagin, an emeritus professor of nursing at the University of Pennsylvania, said: ''In general they don't know the setting, they're not that sophisticated, they don't have a relationship with the hospital or the doctors. It's not a good scenario, but it may be better than being on your own.''
Dr. Linda Aiken, a nurse who directs the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, said: ''Our research suggests that the quality of care provided by nurses who are not part of the hospital staff is not as good. There are so many things they are unfamiliar with: the other members of the hospital staff, the doctors, location of equipment.'' When Phyllis Barber's 92-year-old mother was hospitalized in Tucson for intestinal bleeding, Ms. Barber, in New York City, hired a nursing aide to stay with her overnight.
''It was a terrible experience,'' Ms. Barber said. Her mother was awakened in the middle of the night for a blood test, was disoriented from sedation, fought with the staff nurses and ultimately tried to call 911 from her bedside phone. A doctor finally canceled the blood test and calmed everyone down.
And the aide? ''She was just sitting there,'' Ms. Barber said, not getting involved, not helping at all. ''Next time I'll get a private R.N.,'' she said. ''It's very expensive, but it's worth it to have someone who can communicate with the nurses on the staff.''
Nurses themselves suggest that in the long run, a patient's interests may be best served not by hiring private nurses, but if at all possible, working out a closer relationship with the hospital staff nurses instead.
When friends or family members ask Dr. Aiken of Penn how best to smooth a hospital stay, her first suggestion is that they research the hospitals and their nursing staffs, she said.
First, they should try to choose hospitals that have been designated ''magnet'' hospitals by the American Nurses Credentialing Center, a subsidiary of the American Nurses Association, Dr. Aiken said. Nursing services in these hospitals have adequate staffing and are configured to perform at their best, she said, and her research suggests patients fare far better in them than elsewhere. The magnet program is barely 10 years old, however, and only 47 hospitals have been recognized nationwide. Failing that, Dr. Aiken suggests that prospective patients find out if they will have a primary nurse responsible for their care once they are admitted, then contact that nurse and interview her ''just as they would a doctor.'' ''Hiring a nurse is something one should resort to only after exploring other options,'' Dr. Aiken said. ''If patients and family are explicit about what's needed, staff nurses are pretty wonderful,
accommodating people and will try to respond.''
Dr. Mion of the Cleveland Clinic said that often there was no substitute for friends and relatives to reassure patients and represent their interests. ''Private nurses may be more for the anxious person who needs immediate attention,'' Dr. Mion said.
For her own friends and family, her major recommendation is that a family member be around as much as possible, especially when an elderly patient is fresh from surgery, or newly transferred from intensive care. ''It helps to have a familiar face,'' she said.