By LINDA H. AIKEN
Nursing and Sociology professor
The Covid-19 pandemic has exposed strengths in the nation’s health care system – one of the greatest being our awesome nurses. But it also exposed many weaknesses, foremost among them chronic nurse understaffing in hospitals, nursing homes and schools.
More nurses have died of job-related Covid-19 than any other type of health care worker. The more than 1,140 U.S. nurses who lost their lives in the first year of the pandemic knew the risks to themselves and their families. And yet they stayed in harm’s way.
They cared for their fallen co-workers. They went to New York from around the country to fight on the front lines in the first Covid surge. Nurses from Northwell Health in New York returned that support by deploying to the Henry Ford Health System in Detroit in December when Covid surged there.
We celebrate nurses now. We call them heroes. But if we value their sacrifices and want them to be there when we need them, we must prevent a return to the poor pre-pandemic working conditions that led to high nurse burnout and turnover rates even before Covid.
As a nurse with extensive clinical experience in hospitals, I found it nearly impossible to guarantee safe, effective and humane care to my patients. And so I established the world’s leading research center on nursing outcomes to understand the causes of nurse understaffing in the U.S. and abroad and to find solutions to the problem.
DEATH IN THE ICU
I was looking through the window of a Covid Intensive Care Unit (ICU) when I realized I might see someone die. I didn’t even know who she was. But I was filled with immense grief as she edged closer to death by the hour. What I didn’t know yet was that by the time I left two days later, at least three patients would be dead.
The vaccine offers hope, but the sad truth is that the virus continues its brutal slaughter in ICUs like this one in Phoenix. The only people allowed in are health care workers. They’re overworked and underpaid in a deluged hospital.
I wanted to know what it is like for them now, after a year of witnessing so much death. Eager to show us their daily reality, two nurses wore cameras so that for the first time we could see the ICU through their eyes. “Unless you’re actually in there, you have no idea,” one said. “Nobody can ever even imagine what goes on in there.”
This ICU contains 11 of the hospital’s sickest Covid patients. Most are in their 40s and 50s. And they are all on death’s door. It’s an incredibly depressing place. In my video, I blurred the patients’ faces to protect their privacy. But I also worried that blurring would rob them of their humanity.
The family of a patient who was rapidly declining allowed her face to be shown. And they readily told me about her. Her name is Ana Maria Aragon. She’s a school administrator and a 65-year-old grandmother. Sara Reynolds, the nurse in charge of this ICU organized a video call with Ana’s family to give them a chance to be with her just in case she didn’t make it. “It just breaks my heart when I hear families saying goodbye,” she said.
IT’S THE NURSES
You might expect the doctors to be running the show. But it is really the nurses who are providing the vast majority of the care – giving baths, rubbing on foot lotion, shaving the men, cleaning up after bowel movements.
Working 12-hour-plus shifts, isolated in this windowless room, the nurses survive by taking care of each other, and by finding small doses of levity. The patients spend most of their time on their stomachs because it makes it easier to breathe. But the nurses have to turn them often to prevent pressure sores.
It’s unfathomable to me that these nurses have gone through that every single week, sometimes every single day for an entire year. I assumed the nurses must block out all the deaths to be able to keep going, but they don’t. They grieve every single one.
“I’ve always loved being a nurse. It’s what I’ve always wanted to do,” said one. “And these last couple months, it’s definitely made me question my career choice.”
What makes their situation so tragic is that many of these nurses hide their trauma, leaving them feeling isolated and alone. “We’re the only ones that know what we’re going through,” she added. “I don’t really want to tell my family about everything because I don’t want them to feel the same emotions that I feel. I don’t want them to know that I carry that burden. I’m Mom. I’m strong. I can do anything. And I don’t want them to see that.”
Leadership in the pandemic hasn’t come from elected officials or spiritual guides but from a group that is underpaid, overworked and considered secondary, even in their own workplaces. As so many others have dropped the ball, nurses have worked tirelessly out of the spotlight to save lives, often showing more concern for their patients than for themselves.
I worry their trauma will persist long after we re-emerge from hibernation. Covid’s legacy will include a mass PTSD on a scale not felt since World War II. This burden should not be ignored.
Nevertheless, we find ourselves too often with a shortage of nursing care. Many decades of research reveal two major reasons:
- Poor working conditions, including not enough permanent employer-funded positions for nurses in hospitals, nursing homes and schools.
- Failure of states to enact policies that establish and enforce safe nurse staffing; enable nurses to practice where they are needed, which is often across state borders; and modernize nurse licensing rules so that nurses can use their full education and expertise.
Training more nurses cannot solve these problems. But more responsible management practices in health care, along with better state policies, could.
Not only are states not requiring safe nurse staffing, but individuals also do not have the information and tools they need to pick hospitals and nursing homes based on nurse staffing or to advocate better staffing at their hospitals and nursing homes.
Ninety percent of the public in a recent Harris Poll agreed that hospitals and nursing homes should be required to meet safe nurse staffing standards. But powerful industry stakeholders such as hospital and nursing home organizations and often medical societies are strongly opposed and usually defeat legislation.
The New York State Legislature was the first in the post-pandemic era to fail to approve proposed safe nurse staffing standards for hospitals. The bill didn’t pass, despite compelling evidence that the legislation would have resulted in more than 4,370 fewer deaths and saved over $720 million over a two-year study period through shorter hospital stays.
TIME FOR CHANGE
We need influential champions taking on special interests so that states will make policy changes that are in the public’s interest. AARP is using its clout to advocate nurse-friendly policies. But health insurers and companies such as CVS, Walgreens and Walmart that provide health care have been on the sidelines.
While we long to go back to pre-Covid life, going back to chronic nurse understaffing in hospitals, nursing homes and schools would be a big mistake. We owe nurses and ourselves better health care resources.
The so-called nurse shortage has become an excuse for not doing more to make health care safe, effective and patient-centered. State legislators must do their jobs. Health care leaders must fund enough positions for nurses and create reasonable working conditions so that nurses will be there to care for us all.
Linda H. Aiken is a professor of nursing and sociology and the founding director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.