Subject: The Shadowy World Of "Temp" Nurses Date: Published: 11/1/91 (478 lines) Source: Wall Street Journal. Copyright Dow Jones & Co. Inc. Danger in White: The Shadowy World Of `Temp' Nurses ---- By Walt Bogdanich {This article is excerpted from the new book, "The Great White Lie," by Walt Bogdanich, a staff reporter in the Washington bureau of The Wall Street Journal.} It promised to be such a grand adventure. See sunny Florida. Live near the ocean, experience a life that seemed so distant and so bountiful to a single mother of three living in the dirt-poor town of Plumerville, Ark., population 700. This dream of a better life visited Sharon Aussler one day in May 1987, when she picked up a copy of the Arkansas Democrat. Her eye stopped at classified section 73. And there it was: "ATTENTION ALL NURSES. RN's & LPN's needed. RN's $16 to $18 per hour plus housing. LPN's $12.50 hour with temporary housing, free travel for all." At age 23, Ms. Aussler's life had been marked by fitful starts and stops. Since late in her teens, however, she always had a vocation to fall back on. She was a nurse, a licensed practical nurse. In past years, that would have guaranteed her a lifetime of options, but times were changing. As hospitals faced sicker patients and used more complex medical equipment, many no longer wanted LPNs, who had less formal training than registered nurses. LPNs often got relegated to depressing nursing home care. A wave of excitement washed over Ms. Aussler as she dialed the number listed in the ad. At the other end of the line, she found a pleasant-sounding voice belonging to Julie Monahan, president of All Care Nursing Service of Boynton Beach, Fla., in Palm Beach County. "There's a big shortage of nurses in South Florida," Ms. Monahan explained. "We're kind of close to Miami, but it's not like `Miami Vice.' ... You'll make $12.50 an hour." Ms. Monahan also promised to reimburse Ms. Aussler for her flight down, plus she would arrange a place for her to stay. At the time, Ms. Aussler could hardly have imagined what awaited her. All Care Nursing was part of a shadowy, burgeoning industry providing day-labor nurses to thousands of medical facilities across America. Although many agency nurses were competent, sometimes excellent, administrators rightfully felt queasy hiring unknown and unpredictable contract laborers. But hire them they did. With one in every eight nursing jobs in hospitals vacant -- one in five in New York City -- agencies promised a quick fix, one less worry for administrators already facing federal cost controls, empty beds, more competition, and the onset of AIDS and crack. Temps had further appeal because hospitals didn't pay them benefits, and unlike regular employees, they did not have to be carried on the payroll when patient occupancy dropped. But by succumbing to the quick fix, administrators soon entered a vicious circle: The more they relied on temps, the more they ignored the underlying causes of their nursing shortage, such as poor pay and overwork. And the more they ignored those causes, the more permanent staff nurses they lost, requiring more and more temps. Like a junkie with a growing habit, hospitals often found one supplier inadequate. Soon, individual hospitals were turning to 10, 15, even 20 agencies to meet their growing demand. One midsized Florida hospital used temps to fill 140,000 hours in 1988, while others commonly tapped contract labor for 30,000 or 40,000 hours annually. By the late 1980s, more than half of all big-city hospitals in the U. S. were kept afloat by temp agencies, providing everything from pharmacists to nurses' aides. The agencies could be as ephemeral as the faceless workers they provided, opening and closing like floating crap games. Palm Beach County hosted 60 agencies, more or less, depending on which month one did the counting. Free of virtually any government regulation, some set up shop with little more than a telephone and a Rolodex. The willingness of administrators to gamble on temp nurses of unknown quality was emblematic of the most turbulent, disruptive decade in the history of American hospitals -- a decade when government decided once and for all to end gluttony in the halls of healing, yet health care costs soared from 9% to 12% of the gross national product; a decade in which researchers stunningly concluded that 7,000 patients had died from negligence in New York State hospitals in just one year, yet the medical community called for less outside scrutiny rather than more; a decade that began with the Reagan administration pushing competition as a solution to high hospital costs, yet ended with influential corporations calling for national health insurance. Temp agencies found Palm Beach County particularly inviting. Because residents flooded in and out depending on the season, patient loads at the dozen or so regional hospitals fluctuated widely. By helping hospitals vary staffing levels, agencies had more business than they could handle, giving rise to the birth of new agencies. One area hospital, during one seven-month stretch in 1989, bought labor from 20 different agencies bearing such names as Angels in White, Nurse on Call and Team Nursing. Complaints rolled in from doctors and nurses about the quality of the labor some temps provided. "After they worked a shift, you would question where they got their nursing credentials," said Sue Bradford, nursing director at Delray Community Hospital. Patients never knew that the nurse injecting a needle into their vein was as much a stranger to the hospital as to them. When hospitals discovered an unsuitable worker, they merely told the sponsoring agency not to send that person again. "We simply just took the posture that as long as it's not happening at my facility, what do I care? " said Peter Faron of Palm Beach Regional Hospital. Sharon Aussler stepped into this world, after leaving her children with relatives, just before the July 4 holiday when she arrived in Boynton Beach and met Julie Monahan. Ms. Monahan's casual dress cast her as an unlikely chief executive of an agency with $6 million in annual gross income. Her attire, according to an All Care customer, was your standard "flip-flops and shorts, that sort of thing." Her appearance, however, belied a keen business mind and a competitive edge. She battled bigger nationwide agencies on even terms by playing tougher and smarter. With only so many nurses in Palm Beach County, she devised a strategy of using newspaper ads to target nurses in economically depressed areas in Arkansas, Alabama, Louisiana, Tennessee, and North Carolina. By the late 1980s, All Care was one of the biggest agencies in Palm Beach County. Sharon Aussler was a recruit who would depend heavily on All Care for help in adjusting to her new life in Florida. She had no car, no place to live, little money, and at least initially no local friends. All Care functioned as her umbilical cord to the world, providing at times everything from local transportation to cheap lodging. Ms. Aussler actually lived in All Care's headquarters, located in a modest one-story house in a semi-residential neighborhood several blocks from doctors' offices and Bethesda Hospital. Most nurses who lived here -- Ms. Monahan also provided living quarters elsewhere in the city -- were given beds in a larger room, while others stayed elsewhere in the house, which included another room, a kitchen, two bathrooms, and an office that served as All Care's nerve center, filled with file cabinets, desks, and telephones. A house that an upper-middle class family of four might find comfortable instead provided shelter for as many as 18 people, according to one former All Care employee. Ms. Monahan said the most was "probably 10 or 11." Even so, that didn't include the office staff that often labored from dawn until 1 a.m., smoking cigarettes, typing, running the photocopying machine, and working the phones. Ms. Aussler signed a three-month work agreement with All Care and got her first assignment when an overnight shift needed filling. All Care put Ms. Aussler to work without, she said, either testing her nursing knowledge or administering any other screening exams. (Ms. Monahan terminated an interview before she could be asked about that allegation.) Ms. Aussler's first job turned out fine, but there was something about Ms. Monahan that didn't seem quite right. Soon after arriving at All Care, she was sitting with some fellow nurses, when Ms. Monahan suddenly appeared. "You are here to work," Ms. Aussler said Ms. Monahan told her. "If you go to the beach, I want to know it. And I want to know exactly which beach you go to." Standing up to Julie Monahan might sound simple; it was anything but. "Julie had a very, very strong personality," said John Roylance, who worked for All Care as a nursing assistant in the early 1980s. Ms. Monahan could be most generous, or very nasty, he said. But there was another element to her personality that stood above all the rest. "There's no polite way to put it: Julie has a mouth like a longshoreman," Mr. Roylance said. "I was brought up in Hoboken {N. J. } and I'm familiar with longshoremen." (Ms. Monahan denied ever directing abusive language at any employee, although she acknowledged that she occasionally swears.) Sharon Aussler disliked her cramped housing, but she didn't mind it as much as she might have under different circumstances. That was because in the beginning she spent little time there. When not working, she usually slept. When not sleeping, she worked. And there seemed to be a lot more of the latter than the former. With hospitals spending so much money on temps (JFK Medical Center in Palm Beach County doled out $1.7 million for temp nurses during one four-month period), Ms. Monahan eagerly sought to get her share. In 1988, All Care filled 23,725 eight-hour nursing shifts at area hospitals. About half of All Care's shifts were in nursing homes. To meet the demand, Ms. Monahan tried to squeeze as much as possible from her stable of workers. And when that wasn't enough, her workers say she squeezed some more. "We were not asked do we want to go to work, we were told we had to go to work," Ms. Aussler said. Nurses worked 16-hour days and 20-hour days. Even worse, the shifts were often strung together one after another, a nightmare seemingly without end. "There were people sleep walking, sleep talking," Ms. Aussler said. "I was sleeping in the bathrooms in {medical} facilities. I was sleeping on the floors, anywhere I could catch a nap I would do it. I was not the only one." Weary nurses would help each other, one watching the floor while the other slept. When Ms. Aussler finally did collapse in exhaustion at home, there always seemed to be someone kicking her bed, telling her to get up and begin the whole process all over again. "I was never Sharon, I was always a whore, or a bitch, or a slut, or a c-," Ms. Aussler recalled. "I did not come to Florida to be treated like a dog. I came to Florida to make a life for me and my three kids.... At least a dog can run somewhere." Sometimes Ms. Aussler would sit with her roommates and cry in frustration. (Ms. Monahan said nurses could have left any time they cared to, even though they had signed work agreements.) Working 80 or more hours a week took an immense toll on the nurses, not to mention their patients. Ms. Aussler said she was so tired she sometimes couldn't read a patient's medication record. And if she couldn't understand it, she did nothing, figuring no medication was better than an overdose. "I got to the point where I would skip some patients just to be done," she recalled. Sometimes she decided who got medicine and who didn't by how much work was involved. A patient on a heavy regimen of medication got nothing. A patient requiring only one or two pills got them. This haphazard triage system developed because agency nurses were judged, in part, on their ability to cover a certain number of patients in a certain period of time. A tired nurse who moved too slowly might not be asked to return. Ms. Aussler's conduct was guided not by nursing's noble mission, but a cold, crass assessment of her own self-interest, which she explained this way: "A patient, if he doesn't know his name, can't tell anybody if he had his medicine or not." Ms. Aussler didn't feel good about what she was doing, and she said other nurses felt the same way. "I put myself and a lot of patients in jeopardy," she said, although she doesn't know if anyone was harmed. (Ms. Monahan said she was shocked to hear Ms. Aussler say she was too tired to give medicine to patients. "I wasn't her shadow," Ms. Monahan said. "Did All Care send her out when she was too tired to do her job? I have no idea. I just can't believe she would do that.") Hospital officials knew that temp nurses were showing up for duty exhausted from other shifts, but they felt powerless to stop it. By the time they recognized the problem, it was too late; their patients needed care, and a tired nurse was better than no nurse. One day in a private moment, a temp named Becky Seibert confessed something to Sharon Aussler: Although she was a licensed practical nurse, she had been working as a registered nurse. About a week before Christmas in 1987, Ms. Seibert said Julie Monahan came to her with an unusual request. "Can you work this evening as an RN? " she asked. "This nursing home needs an RN on the premises." "But I'm not an RN. What do I do? How do I do this? " "Just scribble RN after your signature and do your job." (RNs must meet more rigorous educational standards than LPNs and carry greater responsibilities for patient care. RNs evaluate a patient's condition, then devise and manage a plan of care. An LPN merely carries out an RN's orders.) Ms. Seibert said Ms. Monahan discussed how to camouflage the RN notation that was supposed to follow her signature. By signing a sloppy RN, Ms. Seibert could later deny, if necessary, that she wrote it. She practiced scribbling RN several times on a scratch sheet of paper. "That's fine," Ms. Monahan observed. Later, through her lawyer, Ms. Monahan denied that she ever knowingly sent out a worker to fill a job without the proper license. Now, Ms. Seibert suggested that Ms. Aussler should do it, too. "Sharon," she said, "you can do it. Just go in and act like you know what you're doing. I've been a nursing supervisor. There's nothing to it." Ms. Aussler was shocked. "Becky, what are you going to do if a patient codes {needs to be resuscitated}? " she asked. "You might have to start an IV, push medicine through the IV. We're not licensed to do that." "I'm going to dial 911," Ms. Seibert said, a retort better suited to a Mel Brooks movie than a medical facility. Ms. Seibert said she eventually posed as an RN for about a half-dozen shifts in several medical facilities. As she bent the rules, she began to wonder about others who worked beside her -- like the LPN who didn't seem to know how to do a simple tube feeding. It was almost as if she had never done it before, Ms. Seibert thought. Ms. Aussler had also heard of some strange goings on. Besides Becky Seibert, two other LPNs told her they had posed as RNs, Ms. Aussler said. She also suspected, although she had no specific proof, that certain individuals were posing as certified nurses aides, or CNAs. Her first tip: They could hardly speak English. "There is no way I felt they could even pass CNA school," she said. "When you say go give a bath and they tell you, `Me don't speak no English.' If you're a nurse's aide you got to know when somebody tells you go give a bath." Some CNAs merely showed up for work, grabbed a blanket and laid down. CNAs were supposed to do more than just clean patients. They should know how to take a patient's vital signs, such as temperature and blood pressure. Ms. Aussler, however, saw temp CNAs who could do neither. "I had a nurse's aide from All Care give me a 110 temp," she said. Sharon Aussler couldn't have been happier to see the final days of her three-month All Care contract winding down. Before she actually walked out the door, however, she reached a big decision; she would make one dramatic attempt to get even. It was early October 1987 -- two nights before she was to leave -- when Ms. Aussler made her move. Waiting until the office closed and the nurses were asleep, she walked into All Care's file room. It was after 1 a.m. As she stopped at the office's personnel files, her mind flashed to the stories she had heard of unqualified people being sent out on assignment. Now, she had come to copy their records. Two days later, at dawn, she gathered up her things, including the copied documents, and left All Care for good. Ms. Aussler anonymously shipped her records to the Department of Professional Regulation, the administrative arm of the Florida Board of Nursing. She would later say she turned over the documents not just for revenge, but for other nurses as well. "I don't want anybody to have to go through what I went through," Ms. Aussler said. "You go to nursing school to be a professional, to care for people." Working for All Care, she said, made her lose sight of that commitment. The state filed an administrative complaint against Julie Monahan, RN, accusing her of unprofessional conduct. In response, Ms. Monahan provided investigators with a sworn statement in which she said her business "lends itself to a high probability of dealing with disgruntled independent contractors and the possibility of making bookkeeping errors." Ms. Monahan admitted that Becky Seibert "may have been incorrectly billed as an RN on three or four occasions," but, she added, that couldn't be confirmed because certain records weren't available. Ms. Monahan also said another LPN was possibly billed as an RN but that the nurse in question denied working beyond her license. Above all, Ms. Monahan told investigators that she never knowingly sent an unqualified worker into the field. At any rate, on Oct. 12, 1989, at the Howard Johnson Downtown Hotel in Orlando, Ms. Monahan came forward to plead her case before a meeting of the Florida Board of Nursing. The complaint included the serious allegation that Ms. Monahan "on numerous occasions...placed persons in positions for which they were not qualified." Once the hearing began, however, the state quickly dropped this allegation for lack of evidence. That left only billing errors. Ms. Monahan's lawyer, Donald Orlovsky, began her defense by pointing out that she did business with more than 100 hospitals and nursing homes, and employed 500 nurses. With that out of the way, Mr. Orlovsky got to the point. "The background of the investigation was initiated under precarious, at best, circumstances," he said. "It was initiated anonymously by a disgruntled employee, we believe." He then submitted a letter to the board from a nurse, Bessie Tikker, which he said suggested that someone had altered All Care's records before delivering them to state regulators. "I have statements from members of the community detailing their views of Ms. Monahan as a businesswoman and her agencies," Mr. Orlovsky continued. "Uniformly, they regard her as honest, a person of integrity, a person with professional significance in nursing, a philanthropist, and a nursing teaching advocate." (The state couldn't counter those statements because, according to government records, investigators didn't know Ms. Aussler's identity and therefore couldn't produce her as a witness. The state also failed to locate and interview Ms. Seibert.) Mr. Orlovsky downplayed the six apparent billing errors. "The errors in question, if they occurred, amounted to no more than $100. They took place in a volume of business that involved 46,000 shifts." Bonnie Phipps, an investigator with the Department of Professional Regulation, concurred that most of the people she talked to, including officials at hospitals and nursing facilities, said Ms. Monahan was a fine citizen. After a few preliminaries, the following exchanges took place between Ms. Monahan and several questioners. QUESTIONER: Ms. Monahan, can you tell us what you think occurred in the specific six cases? MONAHAN: I hope I don't cry. QUESTIONER: You're doing good. Take some water. MONAHAN: I have a letter here. Jesus, I'm sorry (Ms. Monahan cries). QUESTIONER: That's all right. You're doing good. MONAHAN: It is brought to my attention this week what happened. I'm sorry (Ms. Monahan cries). QUESTIONER: That's all right. Drink some water if you want to... MONAHAN: ...I thought I had been framed, you know. A nurse came in and told me, she had seen them doing it, and -- I'm sorry. God, I'm crying. QUESTIONER: .... Have you worked very hard to get where you are today? MONAHAN: You bet. QUESTIONER: ...It's not beyond the scope of reality, I don't think, to anyone sitting here that there are going to be the possibility of some errors, and the fact is that you have undoubtedly dealt with those in an appropriate manner or you wouldn't be held in the esteem that you are by the community. MONAHAN: Sir, I have installed a computer and I also put everything under lock and key. QUESTIONER: You'll love the computer. By the hearing's end, the Florida Board of Nursing enthusiastically gave Ms. Monahan a clean bill of health. All charges were dismissed. Meanwhile, a different and more far-reaching attack on temp agencies was quietly playing out back in Palm Beach County. Periodically, the heads of various hospital nursing departments got together to discuss their mutual problems, including temp agencies that dumped poor quality workers on them while charging high prices. From these meetings sprang an idea: Why don't area hospitals band together and say in effect, "We won't buy any temps from agencies that don't meet our qualifications"? With the help of the South Florida Hospital Association, nine hospitals solicited bids from area agencies, then selected eight agencies as "preferred providers." All Care wasn't one of them. Agencies not selected were understandably unhappy and filed an antitrust lawsuit against the hospital association and the hospitals. The hospitals, recognizing their potential liability, probed aggressively into the backgrounds of the agencies. And, unlike the state of Florida's timid regulatory effort, the hospitals didn't conduct a narrow, low-budget investigation. Spearheading their probe was the Miami law firm of Mershon, Sawyer, Johnson, Dunwody & Cole. It hired a tenacious private investigator named Tom Whiteman to track down ex-employees of All Care, as well as other agencies. He quickly hit paydirt. Based on records they had obtained and Mr. Whiteman's spadework, the hospitals filed court papers in the antitrust suit charging that Ms. Monahan orchestrated a scheme -- which she denied -- whereby "individuals with absolutely no nursing training were recruited and ...sent to hospitals and misrepresented to be trained health care personnel. License credentials were forged and altered and untrained persons were provided with answers to medicine tests and other skills tests, all so these individuals could avoid detection. In short, All Care, through its owner Julie Monahan, took every conceivable step to deceive hospitals ...without the slightest regard for the welfare of the patients for whom these untrained individuals were caring." The law firm, for example, obtained sworn testimony that All Care had sent out a secretary, a construction worker and a commercial spray-painter to render nursing care. But Ms. Monahan's lawyer, Helen McAfee, said Mershon, Sawyer counseled the hospital association in setting up a preferred provider organization that allegedly violated antitrust laws and now was "throwing dirt" because it had neither the facts nor the law on its side. As the year 1990 came to an end -- a full nine months after Mershon, Sawyer filed public papers in court alleging gross misconduct by All Care -- state regulators still hadn't bothered to investigate those charges. The same couldn't be said of the federal government, however. It disclosed that it was conducting an investigation of certain Palm Beach County hospitals on the grounds that they may have violated federal antitrust laws when they tried to control the quality and pricing of temp agencies. The hospitals denied the charges. As for Sharon Aussler, she continues to work as a nurse, although she said she will never feel the same about her profession. "I did the right thing a long time ago to stop what was going on at All Care," she said, "and nothing happened." --- Copyright 1991 by Walt Bogdanich. From the forthcoming book THE GREAT WHITE LIE by Walt Bogdanich to be published by Simon & Schuster Inc. Printed by permission. --- Corrections & Amplifications ALL-CARE Home Health Services Inc., headquartered in Lauderhill, Broward County, Fla., has no connection with All Care Nursing Services Inc. of Boynton Beach, Palm Beach County, Fla., which was the subject of a Nov. 1 excerpt from the new book "The Great White Lie." Similarly, All Care Registry Inc. of New York is not affiliated with or related to the Boynton Beach firm. (WSJ Nov. 14, 1991) 911101-0053 [This article is made available here by Dow Jones Co. for the personal and non-commercial use of callers to this bbs, in the hope that it will be of some help to those who are suffering from the disease and others who are seeking to help them.]