This article was reported with the support of a fellowship from the Alicia Patterson Foundation.
Jessica Wheeler works the night shift as an oncology nurse at Wilkes-Barre General Hospital in northeastern Pennsylvania—but her patients are usually wide awake. “When they have a new cancer diagnosis or they’re going to have a biopsy in the morning, they don’t sleep,” says the 25-year-old Wheeler (which is not her real name). “They’re scared.” Other patients are in their final hours of life, surrounded by grieving family. What she wants is to be there to comfort them, to talk them through those difficult hours, to hold their hands and attend to their pain. But, mostly, she can’t.
According to hospital policy, night nurses on her floor should care for no more than six and a half patients, but they typically have ten. When things go bad with one or two, the floor quickly tips into chaos.
Wheeler recalls one night when she had a patient who couldn’t breathe and several others under her care. “I called the supervisor to ask for anybody—a nursing assistant, anybody! And I didn’t get it, and my patient ended up coding.” Another night, Wheeler had a post-op patient who required constant attention; the patient was confused and sick, and she soon escaped her restraints and pulled out her drains, spraying fecal matter all over the wall. Early the next morning, her heartbeat became irregular just as another patient was dying. “Those nights are scary,” Wheeler says. “I think I’ve seen everybody on our floor cry.”
Another young nurse describes a shift when she had only been on the job a few months and was saddled with ten patients, including one whose incision was leaking badly, requiring her to administer blood all night long. “I was drowning,” the nurse says. She called for help multiple times, but it never came. At the 7 am shift change, she confused two patients’ blood-sugar numbers and medicated the wrong one.
Wilkes-Barre was not always this out of control. For decades, it was a nonprofit community hospital serving the onetime coal town. It was bought in 2009 by what is now the nation’s largest for-profit healthcare chain, Tennessee-based Community Health Systems, which operates 207 hospitals in twenty-nine states. The Pennsylvania Association of Staff Nurses and Allied Professionals (PASNAP), the nurses’ union, counts fifty-one fewer nurses since the CHS acquisition, a reduction of more than 10 percent—and that’s on top of the elimination of dozens of nursing aides and secretaries. The nurses are not only juggling more patients, says Fran Prusinski, a critical-care nurse who’s been at the hospital for thirty years, but “they have to change the linens, empty the garbage and answer the phones.”
Some of the job’s intensity is due to broad national trends in healthcare. The rise of HMOs and cost-cutting in the 1990s mean patients who are stable and ambulatory—some nurses call them “walkie-talkies”—are now quickly released, so those left in the hospital tend to be sicker and harder to care for. “The patients we’re taking care of on a general medical floor now were the patients twenty years ago we took care of in an ICU [intensive-care unit] with a 2-to-1 patient-to-nurse ratio,” says Elaine Weale, an ER nurse who’s been at the hospital for thirty-three years. “Now that nurse may have five patients, six patients, seven patients.” And as technology has advanced, gravely ill patients who once would have died are now being kept alive, requiring constant care.
But the crush of work these nurses face also exemplifies a hidden side of the recent economic recovery: in industry after industry, speedups are turning work into a hazard, with increasing numbers of injuries and dangerous levels of stress. While 18.6 million people remain underemployed, millions of others are working more hours, and more intensely, than ever. This is especially true in certain industries, from oil refineries to retail to publishing, where federal data shows labor productivity has risen at double or more the national rate. A 2010 survey of people registered with Monster.com found that 53 percent of respondents had taken on additional duties since the start of the recession because co-workers had been laid off—almost all of them without any additional compensation. A 2010 report from the Center for American Progress and the Hastings Center for WorkLife Law found that overwork was a particular problem among professionals: 14 percent of women and 38 percent of men were working more than fifty hours a week. But it has become common in industrial occupations as well. “When time and a half for overtime was established by federal law, that was really a job-creation measure, so it would cost less to hire a new worker,” says Mike Wright, the United Steelworkers’ director of health and safety. “But starting in the late 1970s, the cost of benefits exceeded that extra pay cost, and it became cheaper to work your existing workers harder.”
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American workers do work longer hours than we did a generation ago, according to some analyses, and hundreds more per year than our counterparts in France or Germany—the equivalent of six to eight extra weeks a year. We top the Eurozone nations in productivity by 18 percentage points. “Every month the BLS [Bureau of Labor Statistics] releases its worker-productivity numbers, which measure output per labor hour worked,” says Celeste Monforton, a former Occupational Safety and Health Administration (OSHA) staffer. Montforton, now at the George Washington University School of Public Health, points out that the numbers “go up every month. And that’s because businesses are not hiring new workers; they’re just expecting the old workers to work more, and spitting them out after they get injured.” Some of these gains come from the adoption of new technologies, but others just come from pushing workers harder.
A 2013 survey of its own union reps by the United Steelworkers, which represents such blue-collar industries as oil and steel, found that production pressures, the increased pace of work and increased workloads topped workplace health concerns—outstripping more obvious risks such as poorly maintained equipment. When the reps were asked to give an example of a health or safety problem that had gotten worse over the past year, understaffing led the list. The jobless recovery, in other words, is sustained in part by aggressively overworking those with jobs.
Take the meatpacking industry. By age 39, Juan Martinez, who worked at a Cargill beef processing plant near Omaha, had hands so disfigured from making repetitive cuts that he could no longer work; he is now surviving on disability. He still experiences pain so intense it feels like nails are being hammered into his fingers. His crew had to slice up 4,600 twenty- to thirty-pound pieces per shift. In the four years he was at the plant, from 2003 to 2006, the number of people at his station dropped from eight to six or seven, while the parts kept coming. Since they couldn’t keep up with the line when someone took a bathroom break, supervisors responded by simply denying break requests. “There are people who would pee in their pants,” he told me, “because they didn’t give them permission to go.”
Another meatpacking worker, whom I’ll call Porfirio, worked on the kill line at XL Four Star Beef (now JBS) in Omaha for twenty-seven years. When he started, he says, they killed 1,000 cattle in a ten-hour shift; now they kill 1,100 in eight and a half hours. At night, when he goes to bed, his hands hurt so much that he has trouble falling asleep; when he wakes up in the morning, he can’t move them at all. Everyone talked about popping enormous doses of Tylenol; some talked about pressure so intense it left them depressed. “The Speed Kills You,” a 2009 report from the nonprofit organization Nebraska Appleseed, was based on a survey of 455 meatpacking workers; it cataloged a range of injuries, from cuts, falls and fractures to musculoskeletal and repetitive-strain injuries, attributed mainly to “uninterrupted line speed.” Three-quarters of respondents said line speed had increased in their plant over the past year.
Line speeds in meatpacking and poultry are federally regulated for food safety only, not worker safety. Last year, the USDA proposed to raise the cap on poultry line speeds from 140 to an almost unimaginable 175 birds a minute, even though hand and wrist injuries were already rampant in the industry. A government study of one poultry plant in March of this year found that 41 percent of the workers already exceed safe limits for hand activity, and 42 percent showed evidence of carpal tunnel syndrome.
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Whether the USDA recognizes it or not, the costs of overwork extend beyond the growing army of exhausted, shattered or broken workers. Few of the meatpackers I spoke with in Nebraska had paid sick days, so they routinely handle meat while sick with colds or with fingers infected so badly they’ve lost their nails; one organizer told me there are foods he’ll no longer eat after seeing the inside of the plants. “If it were slower, we could do the work more carefully,” one longtime Cargill worker says, “and the food would be safer to eat.”
Speedups, like those at the plant or the hospital, have produced some of the most spectacular industrial disasters in recent years. The BP oil spill in the Gulf of Mexico in 2010 was caused, in part, by intense production pressures that had entire crews working twelve-hour shifts without a single day off for weeks on end; hundreds of maintenance tasks, and a key cement inspection in the well that exploded, had been skipped to save time and money. The spill’s final effects on marine life and coastal communities may not be known for years.
The catastrophic explosion at Massey Energy’s Upper Big Branch coal mine in West Virginia in 2010 killed twenty-nine people. Inspectors found that basic safety measures, such as controlling dust, had been routinely sacrificed in a relentless focus on the production of coal; one miner had even been suspended for sounding the alarm about poor ventilation—a factor in the explosion. A 2008 Las Vegas Sun investigation into a spate of construction-worker deaths on the Strip found that multibillion-dollar projects going up at a dizzying pace, with contractors facing steep penalties for missing deadlines, had made skipping basic safety practices routine. The Walmart driver who hit comedian Tracy Morgan in June, killing his companion, was speeding, according to police, and had not slept in twenty-four hours; he’d already been working for thirteen and a half hours (of a maximum of fourteen, a new federal cap) and may have been rushing to make his final delivery rather than taking the nap he desperately needed.
But nowhere is the effect of worker speedups on the general population more evident than at hospitals like Wilkes-Barre. Numerous studies over the past decade have shown that higher patient-to-nurse ratios are strongly correlated with medical errors and worse health outcomes, including more patient deaths. A 2007 study by the Agency for Healthcare Research and Quality found that each additional patient assigned to a nurse above optimal levels was associated with an increased risk of 7 percent for pneumonia and 53 percent for respiratory failure. A 2010 study led by Linda Aiken at the University of Pennsylvania, based on survey data collected after implementation of a California law capping patient-to-nurse ratios, found that Pennsylvania hospitals would have 10.6 percent fewer surgical deaths if they were to match California’s ratios. This likely has implications for the growing Ebola epidemic: according to a national survey released in October by National Nurses United (NNU), 60 percent of nurses say their hospital doesn’t reduce their patient load to accommodate caring for an “isolation” patient. Whether it’s Ebola or tuberculosis, says Terry Marcavage, a staff rep for PASNAP and a former practical nurse, “you can have the best plans, but if you don’t have the people in place to carry out the plans, what good is the plan?”
A report released last December by a Pennsylvania state agency found that in almost every hospital in central and northeastern Pennsylvania, mortality rates for key procedures had dropped or held steady between 2007 and 2012, except at four hospitals—including Wilkes-Barre General. There, data showed higher than expected mortality rates for four of the sixteen procedures studied. A hospital spokesperson claimed that documentation skewed the data, but ER nurse Weale sees the poor outcomes as the result of “an unsafe environment” produced by “less nurses doing more care for sicker patients.”
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Last July, when I visited the hospital, the nurses were on strike, for themselves and for their patients. Despite a year and a half of bargaining, they had seen no movement on their key demand: adequate staffing. Temperatures were in the high 80s, and an exhausted, sweaty group of organizers were sprawled out in the modest house with vinyl siding that served as the union’s headquarters during the prolonged contract negotiations. By the union’s estimate, Community Health Systems had spent at least $1 million on agency nurses to staff the hospital during their two job actions. (CHS told investors it spent $10 million on strike-related costs in 2013 alone.)
I sat down with Wheeler and a few other young nurses in their 20s—most of whom work nights, when patient loads are highest—and asked when they’d last had time to take a lunch break. “I don’t think I’ve ever,” Wheeler said, but then recalled a day last December when she was rotated to another floor and got to take her full thirty minutes. It’s the only lunch break she’d taken in two years on the job.
Not surprisingly, higher patient-to-nurse ratios are associated with higher levels of nurse burnout, job dissatisfaction and turnover. These days, Marcavage says, lots of new hires don’t even last a year.
“It’s too hard,” says Danyelle Lishon, who became a nurse in February. “There’s only four of us, and if one person leaves the floor—” The others finish her thought: then there are only three nurses to care for up to thirty-nine patients. Though no one manages to take it, a lunch break is automatically deducted from the nurses’ pay. As for the paperwork required to get paid for that half hour—who has time to fill it out? (A collective-action lawsuit is pending against Wilkes-Barre General over the hospital’s habit of neglecting to pay nurses for those phantom lunch breaks.)
“We don’t take breaks,” Wheeler says. “We don’t pee. I go a lot of twelve-hour shifts without peeing.” I ask whether they get urinary-tract infections, and Wheeler laughs: “I just got over one.”
Among the nurses, the understaffing has created an epidemic of ulcers, migraines, depression and insomnia. “There are so many nurses on Xanax, Ativan or antidepressants,” says Weale. It has also caused a wave of back injuries. Helen Guilford, a critical-care nurse on the night shift for the past twenty-seven years, says most of her patients are on ventilators and many of them are sedated, requiring constant lifting and boosting without the proper assistance. “It’s just a very heavy load,” Guilford says. When she gets home after a shift, she routinely ices her knees and ankles and takes Tylenol and Celebrex, an anti-inflammatory. Last year she had surgery for two back injuries, including a herniated disc. The procedure involved a bone graft, the fusing together of two discs, and the insertion of several rods and screws. She is out on medical leave as of October 7 after injuring her back again after the surgery. According to the Bureau of Labor Statistics, being a nurse or a nursing aide are two of the top six occupations for musculoskeletal injuries.
PASNAP has been trying for years to push a California-style law through the Pennsylvania legislature that would mandate safe staffing levels. But the state’s private-hospital lobbying group, the Hospital and Healthsystem Association of Pennsylvania, whose political-action committee enjoys the support of CHS’s local subsidiary, Commonwealth Health, insists that hospitals be allowed “complete flexibility” on staffing. “I hear from the hospital association a lot, and they say, ‘We’re very concerned with patient safety, but for the love of God don’t pass this bill,’” says State Senator Daylin Leach, who reintroduced the staffing-level bill in March 2013. “If this were ever placed on the calendar for a vote, then the full wrath of God would be unleashed upon the Pennsylvania legislature.”
In September, the Wilkes-Barre nurses finally reached a settlement, winning better health benefits and union protections, but no guarantees on better staffing—only a professed commitment to dialogue.
This pattern of bargaining is typical for CHS, according to Chuck Idelson of NNU, which represents nurses at six CHS hospitals in California, West Virginia and Ohio. The chain, he says, is “ferociously opposed to the union” and has taken “a very hard line in negotiating.” In three of these hospitals, NNU attorneys had to seek federal injunctions to force CHS to the bargaining table over safe staffing and other issues. These so-called 10(j) injunctions are quite rare, and a quarter of those issued nationally in 2013 and 2014, according to NNU attorneys, were issued against CHS. In one case, a federal district-court judge took the unusual step of ordering CHS to pay the union’s negotiating expenses. “That showed you what a wanton violator of labor law they are,” Idelson says.
After nurses from two CHS-owned hospitals in Watsonville and San Diego County, California, spoke at a rally last winter protesting CHS’s latest acquisition, both were fired. (“Unfair labor practice” charges are pending.) CHS fired another union activist, at Affinity Medical Center in Ohio, and then went to the Ohio Board of Nursing to attempt to get her license revoked. The complaint was rejected, and Affinity was forced to reinstate her.
Like Wilkes-Barre General, Affinity was acquired by CHS in 2009. And just as at Wilkes-Barre, the number of nurses at Affinity has dropped by more than 10 percent since the takeover, despite a major expansion of the ER. Support staff have also been slashed. “Now they have nurses emptying trash, wiping down IV poles, even dusting,” says Michelle Mahon, NNU’s regional staff rep, echoing the old-timers at Wilkes-Barre. “It’s like the 1900s.” Understaffing has gotten so bad in the mental-health unit that severely ill patients often go unobserved, leading to one nurse getting choked and another battered so badly that she ended up with several fractured ribs.
It’s not that CHS hospitals can’t afford to ease their nurses’ workloads. An NNU analysis of federal Medicare cost data for the fiscal year ending in January 2012 found that hospitals, on average, were charging Medicare $331 for every $100 of total costs. But many CHS hospitals charge double that, putting them among the most expensive in the country. The number at the Watsonville hospital is $737; at Wilkes-Barre General, it’s $638. Wilkes-Barre General and CHS both declined to respond to detailed questions.
Partly due to pricing practices like these—and perhaps also due to fraudulently billing government health programs, the subject of a $98 million settlement in early August—CHS brought in $13 billion in profits in 2013. Its top five executives all pulled in compensation packages worth more than $2.3 million that year. CHS chief executive Wayne Smith received $8.8 million.
In our increasingly polarized economy, it seems, squeezing workers to the breaking point is just another way to maximize gains at the top. But we’re all absorbing the cost of doing business, if not in broken backs and ribs and shattered sleep, then in unsafe food and roads and hospitals. Little in our regulatory system takes on the risks of work speedup. “During a fatality investigation, OSHA doesn’t ask the question why: Why was the guard off the machine?” Celeste Monforton says. “And it’s typically off the machine because they can operate quicker without it.” She circles back to the Massey mine explosion, which she helped investigate: “The technical way it happened was the coal dust exploded—but the cause was the production pressures, the way the company had no respect for the workers’ lives.”