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Christina, a licensed practical nurse in Louisville, Kentucky, contacted the World Socialist Web Site after reading of a young Ohio nurse driven to suicide by the abusive conditions in the for-profit healthcare system. She described worsening conditions over her more than four decades as a nurse: chronic understaffing and burnout, the malignant presence of insurance and profit in healthcare decision-making, and the devastating impact of the COVID-19 pandemic on nurses. Her name has been changed to protect her anonymity.

“Healthcare as a whole has become very hostile for workers,” Christina told the WSWS. “You have no support from management. The documentation is impossible to maintain while doing your job.”

“I am an agency nurse,” she explained. “I go into many healthcare settings and can see so much that other nurses, who may be limited to one area, cannot see.” She is often hired by nursing homes for short-term contracts, sometimes for only a few hours or a single shift. Christina has been contracted to work in the ICU, surgery, orthopedics, women and children’s care, and more. 

Supervisors sometimes have little medical knowledge and are unable to answer nurse questions. “On the weekends or holidays, someone has to be a supervisor. You are supposed to have at least one RN on hand. You rarely see an RN in the building. Most ‘on-call’ people are not in the building. You are supposed to text them if you have a problem, and try to understand each other through text, which may lead to a phone call. And they’ll have someone like the housekeeper supervisor, maintenance supervisor, social worker as the supervisor. It takes the whole team to run a hospital, including housekeeping, maintenance—but the whole point of this team is to provide healthcare to the patient. You just have no support. A maintenance worker cannot give you medical direction.” 

Understaffed and overwhelmed

Nurses are overwhelmed by workloads, Christina said, and conflicts are common. “Because they don’t have enough nurses, management pit the staff against each other. It becomes ‘I don’t want to do it and you’re not going to make me do it,’ so it comes down to who has the biggest voice. Who has the backbone, who’s going to say, ‘I’m not doing this,’ and there’s no management to say, ‘No, this is the way it needs to be.’” 

This level of conflict has only fueled the exodus of full-time staff nurses to agency work, where nurses are not required to be on-call. Agency workers may walk into a facility and work a four-hour shift with no strings attached—a relationship that undermines continuity of patient care but benefits the hospital industry’s bottom line because it relieves administration of providing insurance and retirement plans for a growing segment of its workforce.

“When I started agency work decades ago, it was to fill in for someone on family leave or when an illness struck a facility,” Christina stated. “You almost needed another full-time job. It was hard to survive off of contract work. 

“As a contractor, you don’t get any of the benefits, but you get flexibility and more money. When COVID hit, people started leaving their full-time positions and there was no one to fill those spots. It got to the point where you have hospitals with 50 to 60 percent short-term agency temp nurses. When it comes to critical times, management can’t guarantee they will have enough nurses to come in to work.” 

“It used to be that before you could be a contractor, you had to go through all these tests,” she said. “But half the agencies will let you take the test five times before you pass it. The agencies need the workers, they can’t make money if their workers don’t pass the test.” Christina felt this state of affairs could only be addressed by eliminating contractor positions across healthcare. She pointedly supported striking California nurses, noting that she had received calls to travel there to fill in for $100 a day but refused. “There is a reason they went on strike! I don’t want anything to do with that mess. We need a strike here. Part of the reason they are on strike is they don’t have enough help and support. It’s management, it’s insurance, it’s state-level problems. It’s policy.”

Christina described a byzantine and impossible-to-maintain computerized documentation system within Louisville hospitals, which nurses are expected to continually update. “There is a lot of paperwork, and training does not prepare you. School teaches you how to do an assessment on a patient, but not how to document it. 

“There is a saying that ‘nurses eat their young,’ because the more experienced nurses resent having to show new nurses how to do their work. It’s not intentional. But if you have a workload that is so heavy and you don’t have support from management to get you through, and you have doctors that are barking at you, throwing charts and hanging up the phone, downright disrespecting you in front of everyone, how are you going to assist the nurse beside you when you’re stressed out trying to do your own job? You’re starting your day with a fight and then expected to go in and treat your patients with a smile.

“You want to sit down and take a break? Nine times out of 10 you’re not going to get it,” Christina stated. “You can say, ‘I’m going to take a break,’ and you’ll hear, ‘Yes, but I need you to do this, this and this right away.’ How can you take a break when you have to hang this IV, start this g-tube feeding, and this man just got out of the shower, and you need to re-dress his wounds? You get in at 6 a.m. and haven’t had a bite to eat.

“They’re telling you to do these things, but you don’t have any equipment.” Nurses are sent scrambling throughout the hospital in search of supplies. “Nurses are not supposed to be responsible for the supplies, but management has made us responsible for them. If you hire someone off the street as an orderly and they know nothing about nursing, how will they know what you need when you ask for four-by-four gauzes or 60cc syringes, how could they possibly get our order right? 

“If I need an oxygen canulate for a patient having trouble getting enough air, do you really have time to go running around to find a nasal canulate? But you find yourself doing that day after day after day.

“When I started in nursing, I didn’t have to think about not having what I needed or run around a building for supplies. I’ve had to get in my car and go to another hospital or another nursing home to find equipment that we need—things that we use every day, we’ve had to get in our cars and go look for it. It may take hours to go across town and get it, and we still have to get back there to take care of our patients.”

“COVID is not over”

“The COVID pandemic really broke my spirit,” Christina said. “It took my love for nursing away quite a bit. I can vividly remember the first time we were told about COVID in a healthcare setting. We were told, ‘This is some kind of virus. We don’t know what it does or where it came from.’

“They said, ‘We will provide you with equipment.’ We didn’t have anything that we needed. It doesn’t matter that everyone in the country needed it. We should have had it all along. There were many times we had to don masks and gloves, so we should have had it all along. 

“Instead, they said: We’re going to give everyone one gown and one mask. When you’re done with your mask, put it in a paper sack with your name on it and put it on this shelf. And when you come back the next day, you take that same mask and put it on. So, we said, ‘How long do we have to wear this one mask?’ They said, ‘We’ll let you know.’ For at least 13 hours a day, for a week, we were wearing these masks.

“Then one young lady said, ‘What happens if we start getting symptoms?’ The supervisor said, ‘What do you mean, what do you do?’ She said, ‘If I wake up with a fever and a cough, what do I do?’ He just said, ‘Don’t come here. Anyone else have a question?’ It was like they didn’t care what happened to us because we would just be replaced. 

“We were going to work with this little equipment taking care of these patients, and management didn’t care about us or the patients. They tried to convince us that all the ‘extra’ stuff was not necessary. It was necessary, because the healthcare workers were spreading it! It wasn’t our fault; it was because of management. We had no choice. 

“I walked out of that place. I could not do that. I said, ‘You don’t give a darn about us or the patients, as long as your operations keep going.’ And they wanted those COVID patients in there because of the money. 

“They wanted double, triple documentation for COVID patients. They eliminated the people who used to do documentation and put that on the frontline workers. If you didn’t document it, you didn’t do it. The more I say I did for this person, the more money the hospital gets from insurance companies.” 

“COVID is still here. It is not over,” she stated. “You don’t have a choice of whether you work with COVID patients, or even knowing the diagnosis before you go in and start taking care of patients. You still don’t have proper equipment to take care of them, they’re not left in isolation, it’s treated like the common cold and it’s in the ventilation system. I came into work and found I had four COVID patients—why did I not know this? Where’s my N95 mask and glasses? Management has nurses documenting COVID patients being treated in isolation when they’re going to dialysis and eating in the dining room.”

Tyranny of the insurance industry

Christina explained that the documentation system in place sets nurses up to falsify paperwork. “They put the steps into the computer system so that the nurse has no choice but to click it off [to advance through the system]. A nurse might have five patients that they have to click off every hour. How could that be possible? But that’s how they get their money. There’s no way possible that nurses can do a third of the things they are required to enter into the documentation. And if something were to happen, the first thing they do is go into the system. ‘It says right here that you did this. Why did you click it?’ It lets the hospital off the hook and puts the blame on the nurses. It’s all about money.

“Nobody talks about it until something goes wrong and there needs to be a fall person. Someone is to blame. It’s chaos. I’ve seen nurses cry, just drop their keys and leave without waiting for the next shift to replace them.

“The healthcare industry is not going to correct this itself,” Christina said. Acknowledging the closure of rural hospitals and massive social crisis in the cities, she stated, “I don’t think they can close the urban hospitals, but I feel like a lot of outpatient clinics are not going to exist. I’ve seen it get worse and worse. That’s going to put an even greater burden on the larger hospitals. The trauma centers are getting a lot of victims of one-on-one robberies and crimes, overdoses, motor vehicle accidents out of control. We see a lot of people hit while they’re walking down the side of the road because it’s always congested. People are getting hit by cars daily. Trauma centers are overwhelmed by these things at a higher rate than we ever had before.”

“I hear, ‘Oh, you’re just old school, you think things should be a certain way.’ Well, that’s right. Things should be a certain way. There are rules, policies, procedures. People’s lives are in our hands! 

“It’s all about money. I can get a patient that is acute and needs immediate care. The first question is ‘What’s their insurance?’ It’s inhumane and it’s getting worse. The healthcare industry wants us to do whatever we have to do so they can get their money. It’s profit.”