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As the COVID-19 pandemic stretches into its third year, providing patient care and services has become increasingly challenging for nurses and healthcare workers. Vaccine hesitancy and lack of access continue to drive surges of illness that overwhelm the healthcare system and care providers. The addition of these extraordinary stresses, on top of long-term problems due to profiteering and the resulting inadequate staffing, has created a crisis of epic proportions.
Moral injury is now far too common, and healthcare professionals are questioning how much more they can endure. As Patricia Pittman explained in the Spring 2021 issue of AFT Health Care in “Moral Injury: From Understanding to Action,” moral injury is a systemic problem. It demands collaborative, systemic solutions—including reallocation of resources in the healthcare industry to focus on patient care, healthcare for all, and providers’ working conditions.
Here, we learn from two longtime nurses—Barb Pomasl, a recently retired ICU nurse who is on the bargaining team for the Wisconsin Federation of Nurses and Health Professionals (AFT Local 5000), and Bill Garrity, the president of University Health Professionals (AFT Local 3837) and an emergency department nurse in Connecticut—about how the worsening strain in their workplaces has impacted their view of the future of the profession.
Then, the articles by Rebecca Kolins Givan and by Peter Lazes and Marie G. Rudden explore the kinds of collective action you as frontline unionized workers can take now to fight for your patients, for your profession, and for a healthier and safer world for everyone.
–EDITORS
Editors: The enormous challenges we see bedside nurses and other healthcare workers facing now existed pre-pandemic and have only been exacerbated in the last two years. Can you talk about these challenges from your lived experiences?
Barb Pomasl: I’ve been in nursing for 37 years, and most of that time was spent in the intensive care unit (ICU) of Aspirus Langlade Hospital, a 25-bed critical access hospital in northern Wisconsin. We are the only hospital in all of Langlade County, and the employees are part of the community. Not a day or even a shift goes by without seeing a patient who is somehow related to or knows a staff member. So we have a vested interest in the hospital. But the hospital does not invest in us.
We have been fighting for the same issues—safer working conditions (which are also patient care conditions) and adequate wages—for years. Yet, hospital management continues to be more concerned with lining their pockets than with what our patients and the people who care for them need. They were already cutting back our staffing before the pandemic so that they could improve their “productivity”; to me that translates into cutting staff to make more money. Of course, a hospital must be fiscally responsible to survive, but patients suffer when we cannot care for them safely or when we struggle to give them the standard of care we were trained to provide; this is not acceptable.
We have given our all to our patients for years, and Aspirus has repeatedly demanded more while cutting our supports from under us. We started bargaining for our upcoming contract in October 2021, which has been difficult and demoralizing. By February (when this issue was going to press), management had only offered us a 2 percent increase—meanwhile, between 2019 and 2020 alone, when frontline workers were risking our lives and health for our patients, executives earned between 12 and 27 percent increases.1 We are simply asking to be paid fairly and respected as professionals, but we are treated as if neither we nor the work that we do every day matters. This is emotionally, mentally, spiritually, and physically exhausting, and there is only so much we can take. I am only 59 years old, but I retired at the end of 2021. I had to do it for the sake of my mental health. I still fight for nurses as part of the bargaining team, but I feel guilty every day for leaving my patients and my coworkers behind in that environment.
Bill Garrity: I have been a nurse for 32 years, and 25 of those have been with the state of Connecticut. When I started, I was doing bone marrow transplant and oncology nursing, and then I spent about five years in the emergency department (ED) before I was elected president of University Health Professionals (UHP). I am in my sixth year as president, and I am also the AFT Connecticut divisional vice president for public employees working with the State Employees Bargaining Agent Coalition.
Every one of us has felt the toll of our working conditions through this pandemic, whether it be the loss of a family member, problems with the consolidation of healthcare facilities and systems, or just dealing with immoral people who keep asking us to do more with less. Many of our members just cannot handle it anymore. I have actually had suicide prevention talks with my own members.
I am afraid to think of where healthcare is headed because of privatization. Hartford HealthCare, which is the big guy here in Connecticut, has been eliminating services from smaller hospitals to send the money-making procedures to Hartford Hospital (“the mothership,” as we call it here). And patients are paying the price. I lost my father-in-law in January because of this. He had a heart attack in the middle of the night, and the local EMS took him to New Britain General, a satellite of Hartford Hospital. He would have been better served at Hartford Hospital, which has the most extensive cardiac services, but it could not take him because of the omicron surge. While he waited for days in the ED at New Britain for a transfer to another hospital, he developed a fever—and he died waiting for a procedure that could have saved his life.
We see this kind of thing more and more in healthcare as big conglomerates take over and essential services are moved from smaller community facilities to regional giants. I don’t see an end in sight. Instead, I hear management talking about capping nursing salaries because of the expense, while agencies for travel nurses are extorting money from hospitals that could be used to pay nurses appropriately.
We are also in contract negotiations (as of February, when this issue was finalized for press). Management originally offered a 1 percent increase for a three-year contract. Of course, there was no hazard or pandemic pay, despite the fact that we endure mandatory overtime and an on-call system. They just keep demanding more and more from us without valuing our work or the toll that it is taking professionally and personally.
Barb: This is not rocket science. Pay nurses what we deserve and increase staffing so we can take care of our patients and do our jobs properly. Most hospitals have the money. During our bargaining, Aspirus’s lawyers told us, “It is not an inability to pay you; it is an unwillingness to pay you.” How does that make us feel? It is no surprise that many of us cannot continue working in that environment.
Editors: Can you share a few details about the challenges nurses have been facing?
Barb: Nursing is a huge job to begin with, but when the pandemic started, suddenly we were expected to do everything. We absorbed all of the other disciplines because no one else was allowed into COVID patients’ rooms. Therapies, dietary, maintenance, housekeeping—we were doing it all. I never ended my shift on time because I knew that my patients needed hands-on care and I was doing as much as I could for them. You cannot change the standard of care during a pandemic. If you are not doing the right things, people are going to die.
Bill: And caring for patients has become more challenging because acuity levels are more significant and staffing ratios are even worse. During the worst surges, our ICU ratios tripled—not just in our health system, but around the state. So an ICU nurse who should have had one patient too often had three. And while the hospital tried not to have nurses caring for COVID-positive and COVID-negative patients simultaneously, that was impossible in many units.
Barb: On top of this, we were dealing with uncertainty about our own safety. Early in the pandemic, hospital protocols for personal protective equipment (PPE) were changing every single day and sometimes within the same day. Sometimes the changes would be posted on Friday afternoon at four o’clock after management left, so there was no one to answer our questions.
Bill: In the hospitals where my members work, many managers and administrators were not there to begin with; they were working from home while we were risking our lives. And where were the Joint Commission and the Occupational Safety and Health Administration when we needed them to answer questions and provide guidance? When we were being told to save all of our N95s in paper bags or to wear the same PPE when going from one patient to another, where were they to step in and say, “This is completely inappropriate”? This is not the good infection control that we were taught.
There were so many other changes from one day to the next with poor or no planning. Management would open an overflow COVID floor without people to staff it, then pull staff from other units to work the floor but give them no equipment. We quickly got tired of hearing them say “Just do your best.” We were the ones at the bedside when things went wrong due to the hospital’s failure to plan or to give us the resources we needed.
More recently, a challenge arose over COVID testing for staff. In one of our hospitals, some staff who got COVID had PCR test results that were still positive after five days. Management’s answer was to try different tests until the result is negative so we can bring staff back to work earlier. These decisions make no sense.
Editors: You both have been in nursing for a long time. How were working conditions different for bedside nurses 30 years ago, before the rise of corporatization and profiteering in healthcare?
Bill: We move patients in and out of care much more quickly now than 30 years ago. I started out on a 34-bed orthopedic unit, on night shift with a 12-patient assignment. That sounds like too many, but on any given night, some of my patients were waiting for surgery the next morning, and others were staying with us for up to a week after their surgery, so while the patient load was high, the work was very manageable. Now procedures like total hip or knee replacements are almost same-day surgeries, so patients are in and immediately out. In fact, because the recovery time is so much shorter, sometimes the hospital is forcing these patients out before they have all the anesthesia out of their systems.
Everything is about acuity and moving patients faster and faster. In the ED, we are measured by “door-to-balloon” times to save patients, and in some of our best-case scenarios we are under 20 minutes. This means that a patient is on a table for a procedure to clear their heart or a vessel in their brain within 20 minutes of coming through the emergency room door. That’s the kind of result the hospital is looking for, and the pressure it puts on healthcare workers is brutal because the demand has not been met with adequate staffing levels. This type of pressure is why we have nurses who are committing suicide or thinking about suicide.
Barb: I first started on the medical-surgical unit night shift, and we could have up to 18 patients. But like Bill’s, some needed very little; they were pre-op or prepping for a colonoscopy. Patients also stayed longer, so we had time to get to know their unique needs. Over the years, patients have gotten sicker and sicker, but they are in the hospital for much less time. We are expected to get them better and get them discharged quickly. It is much more work—and dramatically harder—to care for patients this way. It requires expertise, particularly the ability to read patients and know what they need much faster.
Bill: This is where hospitals are often dishonest about staffing needs. They will say, for example, that an oncology nurse can care for up to 6 patients. Well, at any given minute, that nurse may have 5 patients, but during a 12-hour shift they will actually care for 14 different people: 1 existing patient who stays, 4 who are discharged, 3 who are admitted, and then 6 who need care while a coworker takes a lunch break. But the hospital will claim that staffing is adequate because not all of that nurse’s 8 patients were there at the same time, and the additional 6 were only while briefly covering for a coworker. Management needs to think more carefully about what such claims mean for patient care.
In obstetrics, some administrators want to consider mother-baby couplets as a single patient. Giving a nurse nine patients in this case means they are actually caring for nine mothers and nine babies. It is an impossible expectation.
Barb: Having safe and reasonable patient-nurse ratios is so important, but so is acuity, which I think is a much more accurate way to assign patients, especially in the ICU or ED. Lowering the ratio means little if the hospital does not take care of the employees it has to ensure they are satisfied and stay to provide the excellent care they always have.
The hospital’s refusal to see this underscores that while we have improved patient care significantly in the last 30 years, what has not really changed much is the treatment of nurses. When I started out, nurses were seen as subservient. If a physician was around, we were expected to get up and let them have our chairs. And we have been subjected to verbal abuse from patients and families for years.
It is unacceptable to treat us this way. Yet, because we are professionals, it’s tough to get nurses to walk away. We stay past our shifts, stay through the abuse, without support from our employers, until we just burn out. A nurse reached out to me some time ago to tell me that she had clocked out after 18.5 hours. According to our state law, you cannot work more than 16 hours. When I asked why she stayed, she said, “I couldn’t leave. My work wasn’t done.” And that is exactly what the healthcare system expects from us. This job uses nurses up until there is nothing left.
Barb: I think the public needs to be more aware not only of what a nurse does but also that nursing is a profession, and we have a lot of education. We do so much more than pass out medication. We are the last line of patient advocacy. If something is going wrong with a patient, it’s the nurse who knows about it, not the physician who saw the patient briefly. We read labs and know what can be expected to change in the patient’s condition based on the results. We oversee all aspects of their care. If a physician orders an incorrect dose, the nurse is one of the people most likely to catch it and correct it.
I also wish more people knew how much assessment and monitoring a nurse is continually doing for each patient—so increasing our patient load has serious consequences. Adding just one patient to the workload increases the risk of patient mortality by 7 percent2 —but it’s common for hospitals to increase the load by two or three patients, especially for night-shift nurses.
Bill: I wish more people knew the burden nurses are carrying. We love caring for our patients, but it is dangerous work. In addition to the unsafe patient loads, you never know what situation you are about to walk into with any given patient. Not long ago, a younger nurse who I was training asked me to help her deal with an intoxicated, combative patient who was climbing out of bed in the ED. I approached him, put my knees right up against his, and tried to get him to calm down and lie back. Then the nurse realized he had a gun, and he started to reach for it. I jumped on the bed to hold him down, and another nurse called our in-house police. Thankfully, they arrived immediately and took control of the weapon and the situation.
Sharing this incident stresses me out even now. Nobody should have to experience that. But some hospitals do not even have security—yet another key issue in the systemic short staffing we are suffering.
Editors: You have both seen nurses leave the bedside in recent months as a result of these challenges—some of whom have been in the profession for decades, just as you have. What is lost in nursing and in patient care when longtime nurses leave?
Bill: What is lost is our institutional knowledge. Longtime nurses know the history of our hospitals and our units. When new managers come in and try to make changes without understanding the reasons certain practices have been established, it is important to have someone who was there the first time that change was suggested to keep mistakes from being repeated.
We also have considerable union knowledge that helps us look out for each other. Younger nurses can be easily manipulated by management if they do not know their contract, but that is more difficult with experienced nurses. Right now, between myself, my first vice president, and my chief steward, we have over 70 years of union knowledge with which to help our members. My first vice president is retiring this year, and I am dreading the loss of that invaluable knowledge.
And then we also have very significant patient care knowledge. The large corporate hospitals love to use the “See one, do one, teach one”3 adage for precepting new nurses, but when seasoned nurses leave, the task of precepting can fall to someone who has only been in the job for months. Without our experience, new nurses may know the theories of patient care, or they may know policies and procedures, but they do not know the ways care is actually delivered at the bedside.
Barb: So much patient care knowledge is lost. With 37 years of experience, I am able to tell when a patient is declining much earlier than a nurse who has only been practicing for a year or two. We had to temporarily close our ICU in October 2021 because we could not staff it. We moved ICU patients into the ED, but ED nurses are not trained to be ICU nurses. Management said, “Just go down and show them. See one, do one, teach one.” But it does not work that way. Now that I have retired, all of the ICU nurses have fewer than five years of experience. I recently spoke with a new nurse who graduated last June and is already burning out, questioning why she is in this field, because there is no one left with the experience to help her when patient care grows challenging. Newer nurses cannot teach what they don’t know.
Ideally, those of us with decades of experience would not leave but would transition into teaching roles, providing the training at the bedside that is lacking in nurse preparation today. But that would mean a reallocation of resources that, so far, hospitals have been unwilling to do. When I retired, I offered to stay on at Aspirus Langlade to do orientation and train some of the newer ICU nurses who were coming in. Management was not interested; they were too focused on the money an “extra” nurse would cost them.
Editors: What changes do you need to see in healthcare before you’ll recommend nursing to others as a great profession?
Bill: I don’t know that I could tell someone that this is a great job anymore. Too much would have to change. We would have to see an end to privatization and profiteering and a meaningful investment in patient care and providers’ working conditions, including fair wages and national staffing legislation that includes accountability. For now, I have to have uncomfortable conversations with my members. As a union leader, I have to tell them that nurses are here for the patients and the benefits, but we are not here for the pay. I have to tell them that if they want more money, they can take a travel contract—but they will be burned out in a few years. The system has been designed this way and must be completely redesigned.
Barb: The entire healthcare system needs major reform. My heart breaks for our young nurses. My granddaughter is 28, and she did not listen when I warned her not to go into nursing. She works at the same hospital I did, in our medical-surgical unit, and I can hardly bear to think of everything she will have to live with in this profession over the next 30 years.
Of course, that is only if she stays and the environment doesn’t change. I do not see how she will be able to stay long because the money is not in the right place. Profit, not patient care, is the center of healthcare. We need a radical shift in priorities to remember that we are here for the patients, not to line executives’ and investors’ pockets. Until this shift happens, patients and frontline staff will continue to suffer the consequences.
Endnotes
1. B. Knebel, “Nurses and Healthcare Workers at Aspirus Langlade Hospital Deserve Fair Pay and Safe Staffing, ‘Bed Shortage’ Is Actually a Shortage of Nurses and Health Professionals Willing to Be Disrespected by Corporate Healthcare,” Paramenino, January 26, 2022.
2. L. Aiken et al., “Nurse Staffing and Education and Hospital Mortality in Nine European Countries: A Retrospective Observational Study,” The Lancet 383, no. 9931 (May 24, 2014): P1824–30.
3. S. Kotsis and K. Chung, “Application of See One, Do One, Teach One Concept in Surgical Training,” Plastic and Reconstructive Surgery 131, no. 5 (May 2013): 1194–1201.
[Photo credits: FREDERIC J. BROWN / Contributor / AFP / Getty Images; Nathan Howard / Getty Images; Nic Coury / Bloomberg via Getty Images]