Our health care system is failing its most essential workers.

It is infuriating but not particularly surprising that our health care system is failing its most essential of workers. Nurses are the keystone holding up our rickety and inequitable health care system. We need more of them, but we’ve created a health care system—really, a broader society—that, by design, devalues ​​and takes them for granted.

Like workers in other female-dominated occupations in the care economy, nurses are talked about, often with condescension, as heroes. But like teachers, social workers, health aides, day care workers, and mothers, we certainly 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 Montefiore and Mount Sinai nurses in New York City did last week: Go on strike.

Their No. 1 demand isn’t higher wages or better benefits, the traditional stuff of labor negotiations. Instead, they want hospitals and nursing homes to hire more nurses and commit to capping the ratio of patients to nurses, something the institutions have long resisted, to reduce their workload and Patient safety can be increased.

In a major victory for the nurses union, Mount Sinai and Montefiore Medical Center, the two largest in New York, agreed to do the same last week, ending the strike in three days.

Given how heavily regulated and bureaucratic the US health care system is, it may come as a surprise that hospitals are not legally required to have a certain number of nurses per patient – ​​especially when in other highly regulated industries. Same rules apply. 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 less, the plane stays on the tarmac.

Yet nurses in an intensive care unit, a cancer ward, an emergency room or a labor and delivery ward may routinely find themselves juggling many more patients than common sense suggests they can care for. Never mind the best practices recommended by medical experts. One striking nurse I interviewed last week told me that she regularly has to juggle 15 to 20 patients, far more than the recommended number. Only California regulates the proportion of nurse staffing in each hospital unit. Attempts to extend this practice elsewhere have failed.

This is not a problem created by the pandemic. For years, America has been grappling with a nursing crisis that is now looming large as our health care system faces perhaps the greatest challenge in its history: the need for continued care for the aging Baby Boomer generation.

Yet at this time, as the demand for health care increases and salaries for nurses increase, tens of thousands of nurses have already fled the profession. Even before the pandemic, surveys showed that nearly half of nurses had experienced burnout and one-quarter were planning to leave their jobs in the next year. Now it’s down to about a third. By 2025, the US health care system could face a shortage of 450,000 nurses.

We have long known 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 chance of premature death by 7%. Yet staff shortages are the rule, not the exception.

How do we reach here? America spends more on health care per capita than any other developed nation, but what we get in return is a highly unequal set of health outcomes. We pride ourselves on pioneering scientific advances in medicine, and are admired around the world for the quality of our specialists who treat critical illness requiring advanced care.

But the United States ranks near the bottom of the list of developed countries for some of the most common health problems, such as asthma, diabetes, and heart disease. It is a scandal that America’s maternal mortality rate is double that of many other wealthy countries. There are many factors that lead to these poor outcomes – many of them systemic, such as poverty and racism. But a major reason we are sicker and live shorter lives on average than people in other wealthier countries is our lack of access to the kind of basic, primary care and monitoring that is the basis of nursing.

“It’s not a sexy thing, but it’s really what we do day in and day out: Control traffic and be the beacon for problems, and get the right people in the room when something’s going wrong,” Christopher Friese Said, a professor of nursing at the University of Michigan.

Hospital administrators say they are desperate to hire more nurses. For example, Mount Sinai and Montefiore have hundreds of open spaces that they haven’t been able to fill. Part of the problem is that there are not enough nurses who want to work in hospitals, largely for the reasons I’ve outlined: overwork and a sense of futility from not being able to provide adequate care. This leads to a vicious cycle, as nurses leave hospitals or the profession altogether early in their careers, making it even more difficult to attract new ones.

Hospitals operate under the brutal and complex economics of American health care. Medicare and Medicaid reimbursement rates are set by the government and don’t cover the actual cost of care, according to hospitals. Private insurance companies negotiate to pay as little as they can, often creating perverse incentives that draw attention toward expensive, high-tech tests and procedures and away from the labor-intensive basics of primary care. So when it comes time to cut costs, administrators inevitably look to labor, and nurses almost always make up the largest workforce, said Alexei Nazem, a physician and CEO of health care staffing company Nomad Health. Our system treats nurses more as a cost center than a value creator so that in many cases the goal becomes nurses caring for as many patients as possible.

It’s incredibly short-sighted, said Linda Aiken, 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 a minimum nursing staffing ratio. 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 more than $700 million in medical costs over a two-year period – given the scope of the study. A conservative estimate.

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 out of 5 hospitals in the state are either losing money or operating on precarious margins.

“Hospitals are largely driven by their balance sheets, and not over the long term,” Aiken said.

The version of the New York law that eventually passed did not include a fixed staffing ratio, instead a committee of nurses and hospital administrators work together to determine the ratio. If they can’t agree, the law allows the hospital to unilaterally impose its staffing plan.

This is a real missed opportunity. Like many caring professions, nursing has long been underestimated and taken for granted. It is no coincidence that these jobs, like many other tasks involving caring for others, are largely performed by women, although the number of male nurses is increasing.

Gabriel Winant, a labor historian at the University of Chicago who has written a book about health care, said that the failure to value all types of care work hurts everyone: “The only way to care for people in our society is The way is: one, a woman does it for free through family; or two, an industry figures out how to make money out of it.

The pandemic showed us all just how fractious and unsustainable our care systems are. Vinant said nurses sit at the top of the care hierarchy, and they have a big role to play in changing the way we value care work.

“We can envision nurses leading a broad, small-D democratic coalition or movement for high-quality care for all,” he said.

We spend a lot of time in our politics talking about the need for meaningful jobs that support middle-class life. It’s hard to imagine a more meaningful job than nursing. But for people to be interested in doing this work and staying with it for the long term, we need to invest in making it sustainable as a long-term career that deserves respect and dignity. Our life depends on it.

Lydia Polgreen is a columnist for the new York Times,


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