Cokie Giles is passionate about her career as a nurse; she just wishes her workplace didn’t make it so hard to do her job. The nurses at her hospital in Bangor, Maine, are stretched to a breaking point—with too many patients, constant stress, and marathon half-day shifts. With the thin staff grinding away at full capacity, there’s basically no emergency backup for the nurses themselves: “There is no leeway for [a coworker’s] child breaking their leg on the way to school in the morning,” she said, “or the things that happen in life.”
“When you went into nursing to help people and to be a caregiver,” Giles told The Nation, “and you find you can’t do that, it’s very frustrating.”
The breakneck pace of Giles’s workplace reflects what medical authorities are calling a nationwide “nursing shortage.” The United States has nearly 4 million nurses—more than one-seventh of all the nurses in the world—yet, somehow, that’s still not enough. As baby boomers age, analysts have been warning that a lack of qualified nurses could lead to overburdened hospitals and a higher risk of neglect and errors.
But the nurses on the front lines of our health care crisis say that the idea of a “shortage” doesn’t tell the whole story, and the canard of a labor market crunch shouldn’t distract policy-makers from the more systemic gaps at work. The problem isn’t that there aren’t enough nurses; it’s that—given hospital budget cuts, increased patient loads, and the profit incentive of too much of our health care system—there aren’t enough sustainable nursing jobs, with living wages and supportive work environments.
Many clinics, hospitals, schools, and nursing homes are today chronically understaffed, and it’s clear that many deficits in today’s health care system tie into a lack of access to skilled nursing care. The American Nurses Association estimates that, from 2018 through 2022, registered nursing will have more job openings nationwide than any other profession. But there is a steady influx of nurses entering the field. When there are staffing problems, advocates say the real problem is that employers just aren’t willing to fund a fully staffed workforce.
Labor advocates therefore view the crisis in nursing care as an artificial scarcity, induced by a system that fails to invest adequately in its human resources. “They prefer not to be hiring as many registered nurses because of the salaries that registered nurses command,” said Gerard Brogan, director of nursing practice at the union National Nurses United (NNU). “There is a thought within the industry that registered nurses can be easily replaced by lesser-qualified, lesser-educated, hence lesser-paid, workers,” such as less-credentialed certified nursing assistants.
Amid massive funding gaps and punishing workloads, turnover rates among nurses are as high as 37 percent in some areas. Yet it’s not necessarily low pay that drives nurses away: Salaries in large cities start at around $70,000 annually—solidly middle class. Job quality is a deeper problem: About 16 percent of nurses report feeling burnt-out at work. Forty-one percent say they feel a lack of engagement at their workplace, suggesting that many nurses feel alienated, demoralized, and unsupported on the job. Nurses also experience inordinate rates of trauma and violence at work.
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Giles said that she had seen many greener nurses getting pushed out by unbearable stress. “They’re just starting out their career,” she said, but “a lot of them are leaving the nursing profession. They just don’t feel it’s going to be worth it to work under that pressure, going home every day crying because they can’t finish the work that they have to do. That’s where we end up having so many difficulties with keeping staff.”
Some states have weighed mandates for nurse-to-patient staffing ratios to ensure safety for their patients and sustainable workloads for their nurses. Setting a standard workload for nurses working in hospitals—a policy that California pioneered in 2004—helps ensure not only an optimal level of care for each patient but also stability in nurses’ working conditions and a consistent workflow. Some hospitals have undertaken initiatives to promote safe staffing levels in their own operations. Studies have shown that staffing ratios lead to improved patient outcomes and workforce morale, while also curbing health care costs.
Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania, has conducted research revealing that under the safe-staffing ratio law, California hospitals saw lower patient mortality rates compared to other states with higher patient loads per nurse. In a 2013 study on a Medicare program, higher nurse staffing levels correlated with a roughly 25 percent drop in the program’s penalties for excessive hospital readmissions. Higher staffing rates correlated with better job quality and with lower rates of dissatisfaction and burnout at work. The findings paralleled similar studies in Canada, the UK, and Belgium (all of which, not coincidentally, have universal health care programs).
But although instituting staffing ratios may seem intuitive for maintaining a sustainable nursing-care workforce, politics often gets in the way. Massachusetts last year weighed a ballot measure that would follow California’s system of mandatory nurse staffing ratios for hospitals. Despite a robust state-based health plan, the referendum narrowly failed—thanks in large part to a massive opposition campaign from the hospital industry that seeded public doubt about the cost of the reforms.
Aiken argues that understaffing issues are not simply a mismatch of demand and supply in the job market but rather the product of systematic suppression of labor costs in a system that invests much less in the health care workforce than in its administrative bureaucracy. “I think it’s just very tempting for hospitals to look at that labor budget and say, ‘What difference does 100 [nurses] make in our big institution?’ But 100 nurses might be able to generate a million dollars to do some other priority that we have.” What hospital administrators neglect, she says, is that “Health care is about people taking care of people.”
The real problem with nursing care, then, is that profits are too often prioritized over patients, and over the labor rights of critical workers. That’s why nurses on the front lines of the health care crisis are also at the forefront of the fight for single payer.
Though the politics of staffing ratios can get muddled on the state level, the current Medicare for All proposals, introduced in the House by Pramila Jayapal and in the Senate by Bernie Sanders, would establish clear staffing standards for health care practitioners across the country—Jayapal’s bill specifically addresses nurse-to-patient staffing ratios. For their part, nurses are coming out swinging for Medicare for All: It’s no coincidence that NNU was one of the first health care unions to officially endorse single payer. At the same time, nurse advocates have foregrounded the workforce needs that will come in the wake of a massively expanded health care program. They have pushed to ensure that the single-payer plan would combine staffing mandates with commensurate investment in nursing care, along with collective-bargaining rights.
Carmen Comsti, NNU’s regulatory policy specialist, said that under single payer the federal government would wield its purchasing power to control prices and ensure that health care providers support sustainable staffing levels. When negotiating contracts, the government would tell providers, “‘If you don’t meet [the standards], you’re not going to get our money.’ And the entire concept of Medicare for All is that the government is using their leverage across the nation, because there’s a single risk pool of patients.” Universal care could mitigate the vast regional disparities in labor conditions that currently result from funding disparities, because every provider in the system would be required to adhere to national standards.
The nurses’ unions are not alone: Although the American Medical Association has historically opposed the idea of single payer, workers inside and outside the health care sector are aligning behind Medicare for All. Today, single payer has been endorsed by many unions, including the National Education Association, United Auto Workers, United Steelworkers, and many state federations of the AFL-CIO. The umbrella group Labor Campaign for Single Payer describes Medicare for All as “a powerful alternative to the austerity policies being foisted on America’s workers.” The push for single payer as a core component of a more comprehensive social welfare system links the interests of health care workers with the social needs of the communities they serve.
To Brogan, supposed “nursing shortages” can be traced back to shortsighted decision making by health care administrators. While nurses are focused on patients’ experience, he argues, for managers, whose business interest is at odds with the duty of care, “the patients are an abstract. They literally are data on a sheet of paper. They’re not an abstract to the nurse. We have, as nurses, an intimate relationship with the patient. We see them as human beings.” But to do their job right, nurses need a system that sees them as human as well.
