It is enraging but not particularly surprising that our health care system is failing the most essential of its workers. Nurses are the keystone holding up our rickety and raggedly uneven health care system. We desperately need more of them, but we have created a health care system — indeed, a broader society — that, as if by design, devalues them and takes them for granted.
Like workers in other female-dominated professions in the care economy, nurses are spoken of, often with a whiff of condescension, as heroes. But just like teachers, social workers, health aides, day care workers and mothers, we sure don’t treat them that way.
In the early days of the COVID-19 pandemic, America’s nurses were rightly praised for the central role they played. But nurses are burned out. Many are simply leaving the profession. Thousands across the country are doing what the nurses at Montefiore and Mount Sinai in New York City did last week: go on strike.
Their No. 1 demand is not more pay or better benefits, the traditional stuff of labor negotiations. Instead, they want hospitals and nursing homes to hire more nurses and commit to set ratios of patients to nurses, something institutions have long resisted, in order to reduce their workload and increase patient safety.
In a major victory for the nurses union, Mount Sinai and Montefiore medical centers, two of the biggest in New York, agreed last week to do just that, ending the strike in three days.
Given how heavily regulated and bureaucratic America’s health care system is, it may come as a surprise that hospitals aren’t legally required to have a certain number of nurses on hand per patient — especially since similar rules are in place in other highly regulated industries. Federal regulations require a strict minimum number of flight attendants on each flight depending on the type of aircraft. If the airline is even one short, the plane remains on the tarmac.
Yet nurses in an intensive care unit, a cancer ward, an emergency room or a labor and delivery ward can routinely find themselves juggling many more patients than common sense would suggest they could care for, never mind best practices recommended by medical experts. One striking nurse I interviewed last week told me that he routinely had to juggle 15 to 20 patients, significantly more than the recommended number. Only California regulates the ratio of nurse staffing in every hospital unit. Efforts to expand this practice elsewhere have failed.
This is not a problem created by the pandemic. For years, America has been grappling with a nursing crisis, which is now peaking just as our health care system faces perhaps the biggest challenge in its history: the relentless care needs of the aging baby boomer generation.
Yet at precisely this moment, when demand for health care is surging and pay for nurses is rising, tens of thousands of nurses have already fled the profession. Even before the pandemic, surveys showed that roughly half of nurses reported experiencing burnout and one-fourth were planning to leave their job in the next year. Now it is about one-third. By 2025, the U.S. health care system could be short as many as 450,000 nurses.
We have known for a long time that inadequate nurse staffing leads to more patient deaths. In a 2002 peer-reviewed study, researchers found that each additional patient assigned to a hospital nurse increased the likelihood of premature death by 7%. And yet understaffing is the rule, not the exception.
How did we get here? America spends more on health care per capita than any other developed nation, but what we get in return is a highly uneven set of health outcomes. We pride ourselves on leading scientific advancement of medicine, and the quality of specialists who treat serious illness requiring advanced care is envied the world over.
But the United States is near the bottom of the list of developed nations on some of the most common health problems, like asthma, diabetes and heart disease. It is a scandal that America’s maternal mortality rate is more that double that of many other wealthy nations. There are many factors that lead to these poor outcomes — many of them systemic, like poverty and racism. But a major reason we are sicker and live shorter lives on average than people in other rich nations is our lack of access to the kind of basic, primary care and monitoring that is the bedrock of nursing.
“It’s not a sexy thing, but that’s really what we do day in and day out: Control the traffic and be the beacon for problems, and get the right people in the room when something’s going wrong,” said Christopher Friese, a professor of nursing at the University of Michigan.
Hospital administrators say they are desperate to hire more nurses. Mount Sinai and Montefiore, for instance, have hundreds of openings they have not been able to fill. Part of the problem is that there just aren’t enough nurses who want to work in hospitals, largely for the reasons I’ve outlined: overwork and a feeling of futility from not being able to provide adequate care. This leads to a vicious cycle, as nurses flee jobs in hospitals or the profession altogether early in their careers, making it all the more difficult to attract new ones.
Hospitals operate under the brutal and confounding economics of U.S. health care. Medicare and Medicaid reimbursement rates are set by the government and, according to the hospitals, don’t cover the actual cost of care. Private insurance companies negotiate to pay as little as they can, frequently creating perverse incentives that skew care toward expensive, high-tech testing and procedures and away from the labor-intensive basics of primary care. So when it is time to cut costs, administrators inevitably look at labor, and nurses almost always make up the biggest workforce, said Alexi Nazem, a physician and the CEO of Nomad Health, a health care staffing company. Our system treats nurses more as a cost center than a value creator so that the goal in too many cases becomes as few nurses as possible caring for as many patients as possible.
That is incredibly shortsighted, said Linda Aiken, a professor of nursing at the University of Pennsylvania. In 2021, she and a group of researchers published a study examining proposed legislation in New York that would require hospitals to meet minimum nursing staffing ratios. They studied a group of Medicare patients in New York and found that better staffing ratios could have prevented more than 4,000 deaths and saved upward of $700 million in medical costs over a two-year period — a conservative estimate, given the scope of the study.
But the hospital industry lobbied hard against the proposed bill, arguing that hospitals need more staffing flexibility. According to the Healthcare Association of New York State, an industry group, 4 of 5 hospitals in the state are either losing money or operating on unsustainable margins.
“Hospitals are pretty much driven by their balance sheet, and not over the long term,” Aiken said.
The version of the New York legislation that ultimately passed did not include fixed staffing ratios, mandating instead that a committee of nurses and hospital administrators work together to set ratios. If they cannot agree, the law permits the hospital to unilaterally impose its own staffing plan.
This is a real missed opportunity. Like many caring professions, nursing has long been undervalued and taken for granted. It is not a coincidence that these jobs, like so many others that involve caring for others, are performed overwhelmingly by women, though the number of male nurses has been growing.
Gabriel Winant, a labor historian at the University of Chicago who has written a book about health care, said that the failure to value care work of all kinds hurts everyone: “The only way in our society people get access to care is: one, a woman does it for free through the family; or two, an industry figures out how to make money off of it.”
The pandemic showed us all how frayed and unsustainable our systems of care are. Nurses sit at the top of the care hierarchy, and they have a big role to play in transforming the way we value care work, Winant said.
“We could imagine nurses at the leadership of a broad, small-D democratic coalition or movement for higher quality care for all,” he said.
We spend a lot of time in our politics talking about the need for meaningful jobs that support a middle-class life. It is hard to imagine a more meaningful job than nursing. But to get people interested in doing this job and sticking with it for the long haul, we need to invest in making it sustainable as a long-term career, imbued with the respect and dignity it deserves. Our lives depend on it.
Lydia Polgreen is a columnist for The New York Times.
