When I was 38 years old, I had my first child and went to the hospital expecting a lot of care from my friend the doctor. What I discovered was nursing. It was my nurses who got me through my labor and delivery. My nurses who sorted out my plumbing problems and taught me how to deal with my newborn.

I have spent the past decade writing about nursing and spent three years with three nurses at Boston's Beth Israel Hospital. Those experiences are recounted in my book Life Support: Three Nurses on the Front Lines. In it I describe nursing as a tapestry of care, a tapestry woven through nurses' daily contact with patients, through attending to patients' physical needs, administering high tech treatments, monitoring patients' responses to those treatments, helping educate patients about how to live with their illness, dealing with family members, and finally, helping patients die with some measure of comfort and dignity. We think of machines, medications and surgery as the life supports in our health care system. But it is, in fact, the relationships nurses and other caregivers forge that are one of the most powerful therapeutic tools in health care.

Consider some of the facts. Today vast resources are being funneled away from the bedside and to the pockets of CEOs and shareholders. In l996, the CEOs of the eight largest for-profit HMOs in the United States earned on average seven million dollars a year. Malik Hassan, CEO of Foundation Health Plan earned $17.9 million and controlled $164 million in stock, while the lowest earner on the scale was Larry House of Med Partners who earned $2.5 million a year and controlled only $108 million in shares.

Meanwhile money spent on advertising and marketing has skyrocketed. Between 1968 and 1993, the administrative and clerical sector of health care grew by 692%. In l968, administrative occupations comprised 18.1% of healthcare FTE's and 27.1% in l993. In l968, nursing personnel comprised 40.6% of FTE's and 36.3% in l993. One sees concrete evidence of this trend whenever one opens a morning paper, or watches television in the evening, or visits a physician's office. The amount of advertising for health care companies has grown dramatically. The New York Times and other major newspapers constantly run full page ads -- at up to $75,000 a shot -- for hospitals and health care companies that proclaim their "caring;" prime time television has spots proclaiming the virtues of competing companies.

And any patient walking into a physician's office is struck by the number of staff sitting behind a glass partition whose time is exclusively devoted to figuring out which insurance form to fill out for which patient, which blood or urine test to send to which lab (depending on what deal a particular insurer has worked out with what particular laboratory); which drugs can be prescribed to which patient (depending on the drug formulary the company uses);if the patient can be sent to a specialist and which one (depending on MCO policy); how many days a patient can stay in the hospital; and where that patient will be sent post hospitalization -- to home or to one of the new so-called sub-acute facilities in this burgeoning industry that has grown thanks to market driven managed care.

Meanwhile patients in hospitals are being sent home quicker and sicker -- and thus denied expert nursing care when they need it -- through dramatic reductions in the average length of hospital stay and through dehospitalization -- not allowing patients to go into the hospital when they may need to. As economist Uwe Reinhardt has pointed out, "Between l980 and l995 total inpatient admissions per thousand population and average length of stay declined by about 20 percent each; consequently, inpatient days per thousand declined by about 40 percent." Although this is supposed to be saving us money, as Reinhardt points out during the same period real per capita spending on hospital in-patient care rose by nearly 53 percent.

Because managed care has resulted in many nursing lay-offs, and has shortened length of stay and runs patients through the system so quickly, the patients are much sicker. At the same time, nurses are now dealing with extremely high nurse-to-patient ratios. Some nurses on general medical or surgical floors may be dealing with eight to ten patients on the day shift or up to fifteen at night. Intensive care nurses who used to do one-to-one nursing are now caring for two and three extremely ill patients. And of course, patients are routinely sent home while they are very unstable and the burden of their care is put on the shoulders of ill-prepared family caregivers at home.

This latter phenomenon is very distressing because people pay for nursing care in their insurance premiums and now they are asked to deliver that care themselves in the home, as well as bear the financial (lost pay when they take time off work, lost promotions and even lost jobs), emotional and physical consequences of delivering that care themselves.

It is no wonder that those who are sick increasingly report that they have been sent into no-care zones both in the hospital and at home. The American Hospital Association and the Boston based Picker Institute, for example, sent out questionnaires to 37,000 patients and held 31 focus groups with patients in 12 states. In a publicly released report, "Eye on the Patient," the two groups reported that almost 33 percent felt they were sent home from the

hospital too early. Thirty percent said that, when discharged, they were not warned about possible danger signals related to their condition. Thirty-seven percent were unsure about when they could resume daily normal activities. Between 23 and 29 percent reported problems with continuity of care or lack of coordination between various providers. One quarter wanted more emotional support. Twenty-three percent cited insufficient information and education about their condition.

From the point of view of nursing, however, the findings released in a report privately circulated by the American Hospital Association are more interesting. This document, entitled "Reality Check," said the following:

"The key indicator that people referred to as a measure of quality of their hospital care was the nurse. They hold a strong belief that skilled nurses are being systematically replaced by poorly trained and poorly paid aides. Their perspective on the 'thinness' of hospital staffing was reflected in a universally mentioned experience: 'If I hadn't stayed in the hospital room with my mother, child or spouse, they would never have gotten the correct medication or care on time.' People believe that the profit motive is behind the reduction in nursing care. They are angry at the reversal in health care priorities that they believe this represents."

The backlash against mismanaged care is strong indeed. There are efforts to repeal the ERISA loophole, to enact Bills of Rights for patients, among many other challenges to our market driven system. Our ability to construct a viable, rational health care system that spent money on patients not profits would be enhanced if more patients and families, health policy experts, and political representations truly understood the contributions nurses make in our health care system. Managing care is a worthy goal. But mismanaged care is not only affecting patients ability to get high quality medical care, it is making it very difficult for them to get the kind of high quality nursing care which makes high quality medical care possible.

In the early days of the American hospital, patients were afraid to enter those venerable institutions because they were terrified they would leave dead. It was the development of modern nursing that in fact made hospitals safe for patients. Today, we are truly going back to the future. More and more patients are afraid to go into the hospital because the nurses are either not there or unable to do their job.

It is time we recognized that health care is a collaboration between medicine and nursing. Managed care is not only making it difficult for patients to gain access to good medical care, it is denying them access to high quality nursing care. What is needed is serious reform of the market system (in my view what is truly needed is a universal health care system).

But no reform will be complete if it targets only medical care -- choice of physician and specialist, emergency room treatment, medication of choice, etc. It must also target policies like radical reductions in length of stay, replacement of nurses by poorly-trained and poorly-paid aides, cuts in home care services, and the increased nurse-to-patient ratio that makes it impossible for nurses to weave the tapestry of care that is the real life support in health care.