Hospitals are using the nursing shortage to stiff health care workers

Nurse taking off face shield

Nurse taking off face shield

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[The article below was published on the Jacobin website on 5th December 2021. It is reproduced here exactly as it appeared originally (apart from the links). Although it refers to the situation of workers in the United States health service I believe there are enough parallels with the situation in Britain (where the National Health Service has been subjected to a creeping privatisation for decades) to warrant its publication on this blog. The insidiousness and machinations of capitalism know no borders. Something which most workers don’t accept and refuse to act in a united manner – within their own country and internationally.

In Britain all the ‘tinkering around’ made by successive governments (really since just after it was established) of the NHS has always been with the excuse that this would make the service better but the reality has been the opposite. The ruling establishment found the idea of something that benefited the majority of the population an anathema and they were able to get away with the gradual dismantling of the structure of the NHS by moving more and more of the money making aspects towards private hospitals and clinics. People in the UK would still get treatment for ‘free’ – but the costs society had to pay now have to take into account the profits for the shareholders.

When it came to medical staff this meant that private companies were getting their skilled workers for free. They have never contributed anything for the training of these (British) nurses and doctors – all the cost for which was (and is) carried by the State. And if there was a shortage then they would scour the world for those skilled practitioners – as, shamefully, did/does the NHS. That meant that the poorer countries of the world spent huge amounts in educating such medical staff but would never get the benefits of that investment.

Lack of investment in the education and training of these medical staff in Britain, the poor conditions under which they are expected to work, coupled with the lack of availability of such skilled workers from other parts of Europe (due to the UK leaving the European Union) and the rest of the world (due to the pandemic) means that staffing levels in British hospitals are way below what is required to run an efficient service which serves the population without abusing the staff.

As with many of the negative aspects of British society (for example, the level of poverty and inequality) these shortages in hospitals were not caused by the pandemic but were merely exacerbated and exposed by the arrival of the covid virus.

And the ‘success’ of the virus has been, in part, due to the fact that the health systems in the vast majority of the countries of the world had been struggling to deal with everyday issues and was woefully inadequate when it came to deal with the extra pressures caused by the pandemic. This shortage of staff, facilities and equipment, together with a population with a high number of ‘vulnerable’ people were the reasons the deaths have been so high.

The call in Britain since early in 2020, from the Buffoon and his government, has been to ‘Save the NHS’ – a NHS they had been instrumental in weakening since its foundation. That ‘saving of the NHS’ has meant the closure of society on a number of occasions (and another is almost certainly due in the UK in the next few days) with a huge cost to society and especially for the poorest and most vulnerable. By ‘saving’ by inadequate investment in the health service in the past the government has spent an unimaginable amount of money to prevent society from rising up and throwing the incompetents out of the country.

Although that money came from nowhere the population will still be expected to clear the ‘debt’. How that will pan out will have to be seen. It will be interesting if those people who stood on their own doorsteps on various occasions since March 2020, banging their pots and pans in support of the NHS and the other ‘essential workers’ (who are the non-essential workers?) will remember this and make sure that public services get the funding they require, not just to deal with ‘normal’ times but for the next pandemic. It’s becoming increasing certain that (as with disastrous weather conditions due to the climate emergency) such a likelihood is not a matter of if but when.]

Hospitals are using the nursing shortage to stiff health care workers

by Heather Rust

Rather than materially address the underlying issues of the nursing shortage crisis, health care providers are exploiting it in order to further consolidate power at the top of industry hierarchies – and break the power of organized labor below.

There’s no shortage of articles about our nationwide nursing shortage. Everywhere, foreboding headlines paint a dire picture of a health care system stressed by a skyrocketing number of patients and a dwindling number of nurses able to care for them.

But there are no attendant articles about hospital corporations, public health systems, and politicians rising to meet this shortage. One would expect hospitals to be aggressively recruiting and retaining as many nurses as possible with competitive pay, safe working conditions, and attractive benefits. But industry-wide labor disputes throughout the pandemic indicate that the opposite is true.

Industry bosses’ refusal to address this labor shortage by granting nurses even the most basic rights and protections — despite our nation’s major health systems making billions in surplus over the course of the pandemic — suggests that this crisis in nursing isn’t a crisis for everybody.

In fact, for decades hospital corporations, obsessed with profit over all else, have been cutting staffing levels while putting increased stress and unrealistic demands on the workers who remain.

The result is an impossible situation in which workers are pushed to do more with less, leading to nurses and other health care workers leaving the field due to stress and an inability to provide adequate care for their patients.

When staffing is cut to the bone by health care companies looking to line their pockets, patient care suffers, often with devastating consequences. Researchers have shown that, after controlling for patient and hospital characteristics, each additional patient assigned to a nurse increases the odds that one of those patients will die by 7 percent.

Fewer nurses means worse outcomes for patients — but it also means lower labor costs, less union power, and more profit for hospital corporations. Their response to the current nursing shortage demonstrates that this is a trade-off they’re more than willing to make.

The Generational Shift

There are some objective conditions fueling this staffing crisis. The average age of registered nurses in this country is around fifty years old, and the nursing profession won’t be spared in the mass exodus of baby boomers from the workforce. A 2017 study speculated that around 1 million of the 3.8 million registered nurses in the United States will leave the workforce by 2030.

This timeline has since been accelerated by COVID-19. A survey of nurses in Washington found that around a quarter of nurses in the state either retired or are thinking about retiring earlier than planned because of the stress brought about by COVID.

And this trend isn’t limited to the boomer generation. According to studies released earlier this year, between 20 and 30 percent of health care workers in general — and two in five nurses in particular (43 percent) — are thinking of leaving the profession entirely.

But a generation of aging and retiring workers doesn’t just mean fewer nurses — it also means more patients. As boomers exit the workforce, they’ll be entering our nation’s health care programs and facilities en masse.

Even without the need to account for massive historical contingencies like a pandemic, the 276,000 or so registered nurses projected to be added to the ranks of the labor force over the next decade cannot keep pace with the astronomical growth in the number of people needing care.

It makes sense given this context that the demand for nurses and other health care workers would be intense. And compared to other sectors, health care is actually growing as an industry. Today care workers account for one in seven jobs nationwide. The Bureau of Labor Statistics predicts the employment of registered nurses will grow 9 percent from 2020 to 2030, and employment of health care workers in general will grow by 16 percent over the same period, which is much faster than average for all other occupations.

As these numbers indicate, nurses clearly provide an essential social value. Whether they are appropriately valued in return is another question. Nurses today face increasing workloads, more stressful cases, worse nurse-to-patient ratios, chronic understaffing, higher risks of workplace violence, stagnating wages, and fewer resources.

Despite these conditions, hundreds of thousands of people every year still decide to pursue nursing as a career. But the damage wrought on our public institutions by privatization and the profit motive affects education as much as it does health care. In 2019, nursing schools turned away 80,407 qualified applicants from nursing programs due to an insufficient number of faculty, clinical sites, classroom space, and clinical preceptors, as well as budget constraints.

The nursing shortage, then, doesn’t seem to stem from a mysterious loss of interest in nursing as a practice, but from this gap between the increasing social demand for care and the physical stress and economic marginalization of the people and public institutions that perform it.

Management by Stress

In the United States, health care is treated not as a publicly provisioned good but as a commodity. Its function isn’t to make the general population well but to make a small sliver of this population wealthy.

Given the profit motive in US health care, it’s no surprise that health care corporations are making decisions based on their bottom lines, not on what is best for patients. In a field where physical bodies matter more than anything else, staffing constitutes a major portion of hospital operating expenses, making up roughly 50 percent of total operating costs. Given the tremendous cost of labor to hospital operations, executives are always looking for ways to decrease staffing and the costs associated with employing workers.

Many hospitals have found a solution in so-called lean production. This management strategy, originally developed in Toyota auto factories, is premised on cutting staffing to the bare minimum and forcing the remaining workforce to work harder — in the case of nursing, overburdening workers and subjecting patients to terrifyingly unsafe conditions. Because of the importance of increasing the exploitation of individual workers in this model, critics like Mike Parker have called it “management by stress.”

The results of management by stress in health care have been predictable. Overwhelmed by impossible expectations, suffering patients whom they cannot do enough to help, and a lack of breaks and vacations, nurses and other health care workers are leaving the bedside in droves.

Meanwhile, US health care corporations made $180.7 billion in profit in 2019, and are projected to make $197.8 billion in profit by 2024. These companies unsurprisingly made a windfall in the first year of the COVID-19 pandemic.

But despite these profit windfalls, all health care positions except physicians have seen slow or negative median wage growth over the past decade. And while the care economy as an industry is growing, real wages lag far behind this sectoral growth as horizontal mergers and consolidations among corporations are creating a situation in which a smaller handful of buyers of a product (in this case, nurses’ labor) can dilute competition and exert more control over wages and productivity. The Biden administration’s massive bailout of big hospital chains has only accelerated this massive sectoral consolidation.

The tight workplace control resulting from corporate consolidation, lean production, and its attendant union-busting practices means that nurses aren’t just seeing stagnating wages — they’re also seeing rapidly deteriorating working conditions. An aging population and higher acuity patients, coupled with decades of funding cuts across the board, has only made these poor conditions worse.

The pre-COVID nursing situation was already unstable. For many, the pandemic made it completely untenable.

Let’s start with the grimmest reality related to the nursing shortage: over 1,200 nurses have died from COVID-19. While the proximate cause of these deaths was obviously the disease itself, the ultimate cause was the decision by those in power not to allocate society’s vast resources toward the basic maintenance of human life.

Many of these deaths were avoidable. Very few of them occurred in well-funded academic medical centers, while the vast majority took place in shamefully underfunded facilities like nursing homes, hospices, and prisons.

Another irony at the heart of the nursing shortage is that by April 2020, barely a month into the pandemic, 1.4 million US health care workers had already lost their jobs. The nurses that didn’t die or get laid off faced a dramatic increase in the number and severity of sick patients, rapid changes in protocols, severe understaffing, and shortages of personal protective equipment — plus the emotional toll of being frontline workers during a pandemic, often serving as substitute caregivers for dying patients whose families were unable to visit hospitals because of COVID-related security measures.

While nurses were deemed “essential” for their pandemic-related labor, these nominal accolades didn’t translate into any real material investment in helping them do their jobs.

Shortage or Strategy?

So what are health care corporations doing in response to the nursing shortage? In essence, they’re using it as a pretext to accelerate changes in the way that nursing labor is performed and compensated.

Where providers are hiring new nurses, they’re skimping on training with predictable results. Without the resources to support them, these hiring sprees are putting increased pressure on the more experienced staff. “We’re actually hiring excessively,” Kelley Cabrera, who works as an emergency department nurse in the Bronx, told Jacobin.

“Except wages are not attractive, so we’re only attracting new grad RNs. Staff is all quitting because of the pay and conditions, so there’s nobody to train all the new hires.” Cabrera added that agency staff, who are not permanent workers but instead hired on an as-needed basis, “are training new nurses. And the few non-agency staff left, like myself, are refusing to train anyone else because conditions are so bad and it’s unsafe. And it’s also not worth the $12 an hour to do it.”

On the other side of this dynamic, new grad hires are thrown onto the floor before being properly trained, leading to unsafe conditions, burnout, and early departures from bedside nursing. A new grad labor and delivery nurse who requested anonymity told Jacobin, “When we were hired, we were promised a certain amount of training and support, but that was immediately walked back.

Management said, ‘We just don’t have the staff for that.’ Of the eight new grads I started with, three left bedside nursing entirely within six months because they felt too unsafe.”

This massive imbalance between experienced and inexperienced nurses creates a vicious cycle: experienced nurses don’t have the time to train new nurses and take care of their patients, which has a bottlenecking effect on the patient population of a given facility, which then creates even more work for the experienced nurses, which then makes more experienced nurses leave, which further exacerbates this imbalance. “At a certain point, there’s only so much we can do, and ramming a unit with new grads who are being rushed off orientation doesn’t help anyone,” said Cabrera.

Rather than providing sufficient support to these experienced nurses to encourage them to stay, health care corporations instead divert funding toward big sign-on bonuses and agency staff.  Agency staff, also known as travel nurses, are independent contractors who are hired through staffing agencies that act as middlemen between workers and health care facilities. They are nonunion workers without benefits who are compensated at many times the hourly rate of staff nurses who hold permanent jobs at the same facilities, some of which are union, others not.

In many cases, hospitals utilize agency staff to maintain lean staffing, which means employing as few staff as possible — and bringing in outside workers to fill in gaps only when it’s considered absolutely necessary. The result is that permanent workers are required to do the same job with fewer staff, inevitably leading to worse patient care and increased stress for those workers left to do an impossible job.

While hospitals pay agency nurses significantly higher hourly wages than those nurses they employ on a permanent basis, it’s often more profitable to cycle travel nurses and leave full-time positions unfilled due to the high cost of benefits and the desirability of being able to change staffing levels at will.

As facilities implement leaner and leaner models of staffing, many nurses have noted with suspicion that the so-called nursing “shortage” is occurring alongside a massive rise in nonpermanent agency hires. Nurses across the country have also recently observed health care facilities posting job openings they have no intention of filling. This way, the facilities can blame the shortage on workers’ refusal to work while diverting the money that would have gone toward filling these positions toward agency staff.

“Management is using the ‘shortage’ to justify contracting out (these jobs to agency staff) and increasing the registry budget but not wages and benefits,” said one nurse in California who requested anonymity.

While agency staff get paid at much higher hourly rates than traditional nurses, facilities see them as a long-term investment. “Working at a union facility,” asked Consuelo Vargas, a bedside nurse in Illinois who recently stepped back from the profession due to low morale, “how do we have a union if at least half of the nurses are nonunion agency RNs? Working at a public hospital where employees pay in to a pension fund, what happens to the pension fund when nurses are leaving and the hospital is outsourcing environmental, transporters, CNAs, and RNs, and none of these individuals pay into the fund? What happens to union hospitals?”

A nurse in New Jersey echoed this sentiment, saying that his facility’s justification of the shortage as a way to hire more agency staff is “an intentional move to weaken labor. Talk in the break room has been a mixture of ‘We don’t get treated well’ to ‘I should become an agency or traveling worker too.’”

Marty Harrison, a nurse at Temple University Hospital in Philadelphia and member of the Pennsylvania Association of School Nurses and Practitioners, also said that her employer embraced the opportunity this shortage provides. “They would be perfectly happy if all of us problematic union members quit and they got to start over with 1,500 new RNs. They would love to staff, as necessary, with 100 percent agency.”

While the nursing shortage has nuanced origins — shifting population demographics; cuts in public health funding; decades of austerity budgets at the municipal, state, and federal levels; the increasing privatization and commodification of health care; and the unprecedented stress placed on workers and our health system by COVID — its trajectory seems clear. Rather than materially address the underlying issues of this crisis, providers will instead exploit it in order to further consolidate power at the top and break the power of organized labor from below.

The shortage is a serious crisis for nurses and patients alike, and employers are choosing to make it an inevitable one.

“Destroying the notion of a unit-based, full-time job with benefits would be a worthy investment at virtually any cost in their minds,” Harrison said. “Never waste a good crisis!”

So what’s the solution? In health care, just like most industries, the improvements in working conditions, pay, benefits, and patient care that have been won over the years are the direct result of courageous workers who said enough to the perverse profiteering of hospital corporations that value the dollar more than human life.

If American health care is going to be reformed to serve patients above all else, it will be through the commitment and organization of rank-and-file workers who are unwilling to tolerate the status quo any longer.

About the author

Heather Rust is a nursing student in New York and a member of Democratic Socialists of America.

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The creeping privatisation of public space


Kingstown, St Vincent - bus station transformed into bar and restaurant

Kingstown, St Vincent – bus station transformed into bar and restaurant

It now seems that in virtually every country throughout the world not only is the basic infrastructure of a country being privatised and being controlled by capitalists from who knows where but also public space is being appropriated by a growing army of small traders of every kind.

This was turned into a ‘theory’ of development by one of the arch proponents of monetarism and neo-liberalism, the Peruvian Hernando de Soto, way back in the early ’90s. His argument was that by allowing unfettered and unrestricted freedom for people to enter the market place they would provide for themselves and in the process give a push to the economic development of the country.

This is starting to appear in some of the metropolitan countries but is almost a virus in an increasing number of countries throughout the world. In the European context this is especially evident in Albania, ‘the third world in Europe’. With the destruction of the socialist economic structure the country has virtually reverted to the pre-revolutionary, pre-liberation feudal relationships to production and distribution.

What this form of economy does is use the public infrastructure for private gain and in the process both degrade that infrastructure and deny it to those of the public who might wanted to have made use of facilities created for the benefit of all.

It will come as no surprise that the same is happening in the Caribbean islands where you have some of the richest people in the world rubbing shoulders (but only metaphorically) with some of the poorest.

An example is the bus station next to the market, right beside the sea in the main town of St Vicente, Kingstown, in the Windward Islands.

At some time in the recent past the local authorities must have decide to establish a ‘proper’ bus station, making entry and exit of the buses a fluid and organised affair (rather than the organised chaos that is the norm) as well as providing safe and relatively comfortable places for passengers to wait. This included benches and shades against the searing Caribbean sun. That plan must have looked good on paper and the reality was probably quite impressive at the start. But at some time the petite bourgeoisie invaded that space and took it over.

What possibly started as providing food and drink facilities to those waiting for their bus has now developed to such a stage that the people friendly bus shade has been taken over by the traders and woe betide anyone who might want to use those facilities as if they belonged to all.

For what has happened is that the shade has been extended by all types of material, from wooden boards or corrugated sheets of iron to plastic or more substantial tarpaulins. Any number of ramshackle tables and benches have appeared and the prime area has become a mecca for local fast food or rum shacks (those places where the local ‘blow your head off’ 84% rum is decanted from large containers into smaller bottles, depending upon the budget of the customer).

Electricity is needed for these businesses and so what was designed as public lighting has been broken into and the power supply diverted to satisfy the demands of the refrigerators and lighting of these cafes and bars. Gas needed for cooking comes in bottles and they end up breaking the paving stones so carefully placed there in the first place. Rubbish accumulates and this adds to the general degradation of the area. And there is never any investment in repair of this infrastructure, not by the so-called entrepreneurs who are making their profit from them nor by the local authorities, and why should they? Just to see it degraded once more.

This exists in a situation where there is obviously some sort of official sanction of such activity. In the town of Grenville, the second city of Grenada, outside the meat market there is a sign painted on the wall, by order of the health authorities, that vending of any kind is prohibited due to potential health hazards. As you can imagine under this painted notice there was a whole string of people selling a diverse variety of products.

This was not surreptitious trading that you come across in certain places, e.g., outside the Duomo in Florence where the traders selling posters melt into the crowd at the merest hint of the police. In Grenville the meat market is a literal stone’s throw from the local police headquarters.

Now this attitude could be described as churlish, being hypercritical of those people who are merely trying to make a living. This is, indeed, the approach that de Soto takes when anyone criticises his ‘theory’.

But it goes much further than that. In other parts of the world I’ve walked past women sitting at the roadside with a small pyramid of tomatoes (not more than 6 or 7) and that’s all they are trying to sell. I have gone past them some hours later and they are still there. Rather than be a method to reduce unemployment and create wealth these practices only serve to disguise a massive problem of underemployment as well as being psychologically demoralising when hours are spent with no financial reward forthcoming.

But this idea of a ‘free market’ only exists if the powers that be consider it worth while promoting. There was a case recently of a semi-official street fruit and veg stall being given the heave-ho when they were trying to trade just across the road from a Tesco Metro store in the centre of Liverpool.

Now I’m the last person who would defend the right of these Liverpool shopkeepers to challenge the economic power of a huge world retailer but this idea of a ‘free market’ promoted so positively in many of the poorest parts of the world would find itself under attack if it were to challenge the big players.

The reason it is promoted is that, in itself, such activity only feeds dreams that the poor have of one day being rich and has no impact upon the real development of any country. Whilst they live with that dream they don’t think of collective action that might have a longer term impact upon their futures. And as a by-product they degrade what belongs to all making the argument for more investment in the public sector, as opposed to the private, all that more difficult.

‘Privatisation’ of Parc Guell?

Information Board Parc Guell

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‘Privatisation’ of Parc Guell?

The Barcelona municipal council are considering charging admission for entry into Parc Guell, one of Antonio Gaudi´s gems, in order to get more money from visiting tourists, without improving access or services.  This is opposed both by tourists and the local residents.

Parc Guell, to the north of Barcelona, is the green area which offers one of the iconic panoramic views of the city below as well as being the place to see some of Antonio Guadi’s unique designs. If you haven’t yet been able to visit the park then you´d better do so soon if you don’t want to pay.

‘There’s money in them there hills’, according to the municipal government, now in the hands of the CiU party, the right-wing Catalan nationalist party. Every day thousands of tourists visit the park, most seemingly wanting to have their picture taken beside the dragon – which has become the symbol for the park itself. It pains the local grandees that so much money is virtually flowing out of the open gates.

So many people want to visit the area so why not charge them?

Many of the residents around the park are against this virtual privatisation as it would affect them directly and they are also angry that an increasing amount of the park has been paved over, presumably because that makes it cheaper to maintain.

As far as I can remember the park was accessible at all times but when I visited yesterday (the first time for more than 10 years) I was surprised at the substantial gates that prevent access after sunset. This restriction on access would have been instituted by the previous ‘socialist’ local government – who had had control of Barcelona City Council continuously since the death of Franco in 1975 – so a change of government would not necessarily mean a change of policy, if payment is introduced in the near future.

Especially in the peak summer months of July and August Barcelona is teeming with tourists and, as in so many other cities throughout the world, tourism is vital to the local economy. But as is becoming increasingly the case elsewhere, instead of being open and welcoming to visitors the main emphasis seems to be on how to milk them even more.

So far this policy has not had an adverse effect on tourism where surcharges have been introduced already for the mere temerity to want to visit the place, as has happened in Venice. Perhaps people will be prepared to pay ever more to see these places, perhaps not. But it is sad to read, yet again, that politicians consider that almost everything has a price. Don’t be too concerned about the pickpockets operating on the Rambla, it’s the bandits in the town hall who are after every cent you have.

It’s good that the local residents are against charging for entry to Parc Guell. However, one of the lines in their little poster to be seen in the vicinity of the park I find disconcerting. They talk about the ‘poor management of the affluence of visitors’. Does this mean that they don’t care where the tourists are fleeced as long as it doesn’t directly involve them?

March 2014 Update.

It was with a great deal of annoyance that I received the news that you now have to pay for entrance into the park. It was on the day before leaving Barcelona that I was told by Catalan friends that payment was now required to visit the Gaudï structures part of the park, the green space that is the majority of the area is still free to enter.

So the struggle against the privatisation of yet another public area has been lost. I know that the local people were against it but the state, whether local or national, and the greedy and avaricious will never give up until they lose their influence and power. They will always grind us down by their sheer determination to win – we, all too often, give in.

Not having visited Barcelona for more than I year I had missed out on the arguments. I’m sure I’d read that Güell himself had left the park to the people of Barcelona but by maintaining that the green spaces are still freely accessible and by employing a high-flying and expensive lawyer, together with a right-wing administration and judges with fingers in many lucrative pies the privateers have been able to get around whatever he might have desired a hundred years ago .

Not only do you now have to pay there is also a limit of 800 people visiting a day and if you arrive too late you might have a long wait.

Opening times:

25th October – 23rd March 08.30 – 18.00

24th March – 24th October 08.00 – 21.30

Entrance Fees:

Adults €8.00

Child (7 – 12)/Over 65/Disabled €5.60 – Under 7 free

Tickets can be bought at the ticket vending machines at Lesseps and Vallcarca Metro stations and at various ATMs close to the park, or at the park entrance itself.

7th March 2014

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