There’s no polite way to say this: The U.S. health care system failed the American people during the Covid-19 pandemic. Unless we admit to the failures — like not having enough nurses in hospitals — we are bound to repeat them.
The U.S. spends considerably more on health care per capita than any other country in the world, with a total bill exceeding $4 trillion in 2020. U.S hospitals alone spent close to $1.3 trillion in 2020 and still failed to employ enough nurses — even before the pandemic — to provide safe and effective care.
In the midst of the pandemic, hospital leaders have blamed everyone but themselves for not having enough nurses. They blamed a national nurse shortage when nursing schools are graduating close to 180,000 new nurses every year, a 250% increase since 2000, suggesting the problem is not supply but objectionable working conditions. They blamed nurses for leaving the profession in droves, even though less than 5% of nurses say they plan to leave nursing — though more than 20% say they intend to leave their hospital jobs. Hospitals blamed supplemental staffing agencies for driving up nurse salaries, even complaining to the Federal Trade Commission and to Congress.
And hospital leaders conveniently overlook the fact that many hospitals furloughed nurses without pay after the first wave of Covid-19, after they had risked their lives to care for tens of thousands of critically ill Americans. Such labor practices do not engender employee loyalty.
High nurse turnover rates in hospitals do indeed show that nurses are leaving their employers, which gives an exaggerated perception of nurse shortages. These departures are understandable, since 47% of bedside nurses were experiencing high job-related burnout and one-third were dissatisfied with poor working conditions before the pandemic emerged.
But staffing agencies are meeting the need for an organized way to deploy nurses to the hardest-hit places, and without them patient outcomes could be worse. If such agencies did not exist, we would have had to invent them to move nurses nationally during the pandemic.
Other countries are also having problems attracting and retaining nurses. But none have as many nurses as the U.S. does, nor do they spend as much as the U.S. to end up closing in on 900,000 deaths from Covid-19 as we write this; and with families separated from their loved ones when they were sick and dying; nurses, doctors, and other clinicians experiencing life-altering burnout and stress; hospitals rationing care; and emergency departments in chaos.
It is past time for the federal government to step in with strategic and specific interventions to eliminate chronic understaffing and nurse shortages in hospitals permanently, not just during Covid. There’s no need for new legislation — the federal government can use its existing authority under Medicare to require safe nursing staffing.
In the federal system of government, the states are responsible for licensing health care facilities and health care providers. However, the deep pockets of hospital interests work against state legislatures passing regulations to assure adequate nurse staffing. In Massachusetts, hospital groups reportedly spent $25 million to defeat a 2018 general ballot initiative to require hospitals to meet standards for safe nurse staffing. No state has successfully passed such standards since California did so in 1999. Under the California regulation, patients in that state’s hospitals on average receive three hours a day more nursing care than patients in other states.
Studies in New York and Illinois estimate that minimum hospital nurse staffing standards would save thousands of lives — just among people covered by Medicare — each year. Even so the New York State legislature failed to pass safe patient-to-nurse ratios for hospitals last year after experiencing the brunt of the Covid-19 emergency.
A recent Harris poll showed that more than 90% of the public want nurse staffing standards in hospitals, but states are not getting it done.
The federal government has a potent policy vehicle to address nurse shortages in hospitals: the rules of Medicare participation. The U.S. Supreme Court just upheld a Covid-19 vaccination mandate for employees in organizations participating in Medicare using this authority. Similarly, in 1964, the federal government succeeded in racially integrating the nation’s hospitals almost overnight and without much fanfare by threatening to withhold federal funding in the soon-to-be enacted Medicare program.
The federal government can require hospitals participating in Medicare to adhere to specific quality standards, including safe nurse staffing standards. There is precedent, as Medicare already requires nursing homes receiving Medicare reimbursement to meet a minimum nurse staffing standard. Two decades of research and experience with California’s mandated nurse staffing levels offer an excellent guide to setting minimum standards for hospitals participating in Medicare, which is basically all hospitals.
In the U.S. hospitals are big business. It is time to change how they conduct that business. For decades, the hospital industry has failed to voluntarily implement safe nurse staffing and failed to police those hospitals that commonly violate evidence-based staffing norms.
Changes to Medicare can help solve the otherwise intractable problem of nurse understaffing in hospitals. The U.S. has the nurses. Americans deserve their care.
Linda H. Aiken is a registered nurse, a senior fellow at the Leonard Davis Institute of Health Economics, and a professor in the School of Nursing and the Department of Sociology at the University of Pennsylvania. Claire M. Fagin is a registered nurse and a professor and dean emeritus at the University of Pennsylvania’s School of Nursing.
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