Opinion | America’s Nursing Crisis


When the Covid-19 pandemic hit New York this spring, Jessica Fink wanted to help. She’s been a nurse for 15 years, and she moved from Delaware to serve at Stony Brook University Hospital on Long Island.

Ms. Fink told me she was “ready to contribute,” to care for Covid patients. But once she got to Stony Brook, where she worked in the I.C.U., she “felt very alone.”

“We were so overloaded,” Ms. Fink said, that the hospital “couldn’t meet the demands.”

During her three months at Stony Brook, Ms. Fink sometimes had more patients than felt safe. I.C.U. care grew to seem “futile.” Because of the pain patients experienced from hands-on care and being on ventilators, she described herself as “a human torture device.” She knew that her care physically hurt patients and in her experience, offered little benefit: “Most of the patients I didn’t see getting better.”

Nurses come to work to care, help and heal. But there has been so little care, help and healing for them during the pandemic. News reports have documented unsafe levels of nurse staffing, a continuing lack of personal protective equipment and an overwhelming number of patient deaths. Some nurses quit their jobs because they felt that hospital administrators did not care whether they lived or died.

I’ve worked as a nurse for a decade and written about what my fellow nurses experience on the job. I worry for America’s nurses, and I am angry. The problems they face are inflicting a deep and lasting wound.

For Ms. Fink, it all came to be too much. Now, almost eight months after leaving Stony Brook, she no longer wants to work in the I.C.U. and is studying to become a nurse practitioner. “I’m going into primary care to keep people out of the hospital,” she said.

If the problems nurses experience aren’t remedied, the United States could end up with a severe shortage just as the need for nurses is growing significantly. The Bureau of Labor Statistics projects that an average of nearly 176,00 registered-nurse positions will need to be filled every year through 2029. I doubt that the country can meet that need.

The shortage was predicted even before the coronavirus pandemic. Aging baby boomers create a larger population of patients in need of care, and a large number of nurses over 50 will retire soon. Nursing schools don’t have enough faculty to expand the nursing work force.

Work-environment issues — and insufficient staffing, in particular — also contribute to the problem. A recent survey by NurseGrid revealed that the percentage of nurses reporting that they are suffering from burnout has doubled during the pandemic, to more than 60 percent in December from 25 percent in April.

And while 68 percent of nurses were worried about insufficient staffing in the first weeks of the pandemic, NurseGrid found that nearly 80 percent said that a shortage of nurses was their “key challenge” in providing quality care.

As Myra Taylor, a nurse in Pittsburgh who has been at the bedside for 20 years, told me: “Going into the pandemic, we were not prepared. We never had enough nurses and support staff. We never increased the nurses.”

If you haven’t done the job, it is probably hard to understand how awful it is to “work short” — without enough nurses on the floor. Because nurses cannot be in two places at once, every additional patient assigned to a nurse can create a clinical moral dilemma: Should I keep monitoring the patient who just started chemotherapy or leave to help a frail patient go to the bathroom without falling? The more patients any nurse has, the more the ability to care for each of them will be compromised. Multiple studies have shown that those compromises can and do lead to patients dying who would not have otherwise.

A January study of Veterans Affairs hospitals published in JAMA Network shows that overloaded Covid I.C.U.s last year were “consistently and independently associated with Covid-19 I.C.U. mortality.” The authors did not focus on causes, but they listed staffing as one of two explanations that warrant further investigation. Covid I.C.U.s have reported nurse-to-patient ratios as high as one to four, rather than the recommended one to one or two.

At Stony Brook, Jessica Fink said she had four patients sometimes. I asked her whether some patients died in the I.C.U. because nurses were overworked and she said yes. “People are not getting the best care because we’re overloaded,” she said.

But even if patients receive the best possible care, many of them die of Covid. And the nurses feel their patients’ deaths.

Hunter Marshall, a 33-year-old nurse who cared for Covid patients in New Mexico and as a traveling nurse in San Diego, had worked in hospice earlier in his career. He thought this experience would help him process grief. Instead, he found himself deeply upset. “Watching so many people die alone — that’s not normal,” he said.

An I.C.U. nurse in Pennsylvania who asked that I not reveal her name because she fears reprisals from her hospital, said of Covid, “It’s probably going to end my career.” The emotional wall that nurses maintain to avoid being engulfed by tragedy, she said, is “getting thin with all the deaths.”

Research indicates that many Covid nurses have most likely advanced beyond burnout and are now suffering from “moral injury,” a term typically applied to combat soldiers that the Department of Veterans Affairs defines as a response to “acting or witnessing behaviors that go against an individual’s values and moral beliefs.”

Ashley Bartholomew, a nurse who lives in El Paso and worked in a Covid I.C.U., described the “sense of hopelessness” she experienced at work. She said she felt moral injury “from the hospital, patients and politicians.”

For Ms. Bartholomew, the betrayal occurs in the hospital and also among people in the community who do not take Covid seriously. “It’s moral injury when I leave a hospital bursting at the seams and all the bars and stores are full of people,” she said, her voice rising with indignation.

Frontline nurses bear physical burdens as well. The coronavirus vaccine has increased some nurses’ sense of safety on the job but has not completely relieved their fear of bringing the virus home to their families or of contracting it themselves. An American Nurses Foundation survey from December found that a majority of nurses are overwhelmed and exhausted. Nurses may barely get to eat, drink or see the whole face of a colleague for the 12 hours (or more) of every shift they work.

The risk nurses face from Covid of course includes death, but also a life forever changed by the virus. Jill Hansen, a 43-year-old Utah nurse, healthy and athletic with no known comorbidities, contracted Covid while working in an I.C.U. and ended up needing a double lung transplant. A colleague, Holly Pike, started a GoFundMe campaign to support Ms. Hansen’s three children and help pay her medical bills. On Jan. 20, Ms. Hansen received a transplant, and she recently left the hospital. “It’s still a long road she’s on,” Ms. Pike said, and the five-year survival rate for a lung transplant hovers around 50 percent.

Ms. Hansen’s tragic case serves as a metaphor for nursing after Covid: determined to heal, but in dire need of financial, technical and emotional support to make it possible.

The bulk of the failure to support nurses in the United States comes down to money. Nurses are the largest labor group in hospitals but do not bring in revenue the way physicians do. So many hospitals look at firing them to cut costs. But this corporate calculation is shortsighted: It fails to consider the ensuing patient harm.

A 2020 report from the Healthcare Financial Management Association, a 64,000-member industry group, shows that having enough nurses in hospitals can save money. Fully staffed hospital floors tend to have fewer costly adverse events such as medication errors, falls, hospital-acquired infections and patient deaths. Having enough nurses also guarantees a higher quality of care, buttressing hospitals’ reputations and indirectly increasing their income.

Still, firing nurses remains a favored way for hospitals to try to improve their bottom line. Reporting by The New York Times found that 36 of America’s 60 largest hospital chains have laid off, furloughed or cut the pay of staff members to save money during the pandemic, despite receiving government bailout funds meant to help hospitals avoid such cuts.

The problem isn’t only money, though: Nurses’ labor often seems invisible. A study found that nurses were used as sources in just 2 percent of quotations in articles about health care in September 2017, down from an already meager 4 percent two decades earlier. A doctor colleague who worked closely with nurses his entire career told me that until he read my book “The Shift,” he had no idea what nurses do all day.

The nurses I spoke to feel this disregard, especially now. The Pennsylvania nurse said she has seen hospital management show little concern for nurses during the Covid crisis.

“Nobody ever says to the staff, ‘How are you doing?,’” she said. “Nobody cares.” Mr. Marshall said, “The illusion that the institutions that employ us ever cared about us is shattered.”

The profession has to change if we want to have enough nurses in the future. Federally mandated staffing ratios or other legislation for safe staffing needs to become law.

We also need to find creative ways to bring more nurses into the work force, as S.E.I.U., a union whose members include health care workers, has done in Washington State. The union partners with job training programs and hospitals to help minimally skilled health care workers become nurses.

“We are looking at career pathways. How can a housekeeper become a nurse?” said Jane Hopkins, a nurse and executive vice president of S.E.I.U. Healthcare 1199NW.

Limited capacity at nursing schools currently restricts the number of new nurses, so funding is needed for additional faculty and to make nursing school more affordable. And nurses need guaranteed mental health support, including paid time off, to treat their moral injury and possible PTSD. Hospital management must recognize and honor nurses’ value.

Nursing itself also needs to transform. Ms. Hopkins calls out nursing schools and hospital nurses for systemic racism that makes it harder for Black nurses to succeed. Too many nurses embrace the hospital hierarchy and link seniority with authority, leading to nurse-on-nurse bullying. The American Nurses Association, while admirably focusing on nurses’ mental health, is not calling for meaningful enough work environment improvements in response to nurses’ challenges during the pandemic. Unions are standing up for change, but it is dispiriting that our national nursing organization is not.

It saddens me to admit this, but I doubt that I will ever return to the health care front lines. I’ve worked in oncology and hospice, and seen suffering and death. But the hardest thing for me was the increasing focus in health care on profits and billing. The World Health Organization’s new definition of burnout includes feelings of “cynicism related to one’s job.” Knowing the system cared more about money than patients ruined nursing for me. The nurses who’ve worked through during the pandemic exhibit a similar cynicism.

People go to the hospital because they need the care of nurses. Without them, there is no care. But nurses are not an infinitely elastic resource; they’re people, many of whom are exhausted, traumatized, barely holding themselves together. It’s time to really see and care for them.

Theresa Brown is a nurse and the author of “The Shift: One Nurse, Twelve Hours, Four Patients’ Lives.” This essay was supported in part by a grant from the National Institute for Health Care Management Foundation.

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