But now that I am actually working, I am dealing with a lot of speed-up, just like everywhere else. I spend my days running around so much that I can barely think. There is more to do than we can possibly get done, so I need to just decide which tasks have to be done to keep something terrible from happening, and forget about the rest. Its like my head isn’t up long enough to see the results of our work. My contact with patient is sometimes negative, because I am so stressed. I end up having to convince patients that this is the best I can do for them now, since I need to move on. It’s very tough.
It’s not always like this. I do sometimes have really good interactions with patients, and sometimes find I can take really good care of patients despite everything. But the negative interactions, and the feeling that I don’t have the time to take care of patients the way I feel I should, are there enough that I often feel worn down, a little more each time.
The speed-up has come because hospitals and the health care system in general are getting squeezed hard. It seems like there has been a constant stream of cuts and threatened cuts to Medicare and Medicaid. There are either direct cuts, or changes to the rules that amount to cuts. Some of the rules seem reasonable on paper: for example, “value-based purchasing,” which means in part that hospitals with high rates of patients being readmitted within 30 days for the same conditions are reimbursed at lower rates. It seems reasonable, but in reality, many of our patients, especially those from poorer communities, are sicker, they have less resources, and they have less ability to manage their care at home. Even the best hospital care will not prevent early readmission for many of these patients. So hospitals in poorer areas are going to be hit hardest by this rule. The result will be less staff, less resources and worse care.
There are a million and one ways that nurses are expected to do better, to do more with less. We are constantly given new rules and requirements, at the same time as we are seeing fewer nurses on every shift, and that translates to less time to meet all the old and new requirements. At some levels, people understand this is a problem, but at the top level, they are not being honest about the impossibility of this situation.
Some of my co-workers have been in the job for a long time. People talk about how things used to be, and how the nurse to patient ratio was better. In the past, management was more flexible, so you had more options to deal with problems, such as if you were short-staffed. Now, management is more rigid and you have to deal with what you have, even if it is unsafe for patients.
We talk with each other in the break rooms, to some extent – and if there is an activity, such as if the union has a lobbying day or protest, people will participate if they can. There is a lot of complaining about how things are so unreasonable.
I am pretty open about my politics at work to some extent. People see me as someone who will speak up or raise issues. We talk about issues related to race and class, and how decisions are made that favor the hospitals in rich neighborhoods, or how we need to raise taxes on the wealthy. We even talked some about Occupy, a lot of people said they supported it even if they didn´t participate directly. But I don’t talk about more radical politics in my workplace. It would just be so far out of context, it would not be relevant or helpful.
I can imagine that it might be possible to make marginal changes to the system as it is, but not without a huge fight. There have been so many cuts, and from so many different angles. And the pressure to keep cutting is so great.
Even Obamacare is all about cutting costs. It is built into the process of the Act that there is a process of squeezing the system more and more, and to pay less and less per patient, even if more patients are covered. Usually, that means worse and worse care, especially for lower income patients.
If we had a single payer system – a truly single payer system without a secondary insurance option – there would then be strong incentives to finance health care in a way to get decent care for everyone. But even in the countries that now have a national health care system, they are facing similar problems due to a decrease in public investment in health care. Single payer would be an important step, but not the end of the fight.
We can fight for smaller reforms, and may even have some victories, such as in California, where they won improvements in staffing ratios. That was a really impressive and important victory. We should be fighting to do the same in other states. But there are a lot of obstacles to doing the kind of organizing we would need in my workplace to get to a place where it seems more likely we could win these kinds of reforms.
First, there is the isolation. We mostly work alone, and have to keep our heads down and our minds focused to get our work done and avoid missing something that could harm a patient.
Second is the nature of the work. We have a lot of hierarchical relations with other workers, so that can create a lot of conflict and get in the way of building solidarity. This is built into the ways that things are structured. As nurses, we rely on other staff – technicians, aides, etc., to help us take care of our patient. They all have a role, but the buck stops with the nurse. If things are not getting done that we need to get done, we fear for our patients, our job and our license. So we have a strong incentive to push ancillary staff in one way or another, to come down on them when things don’t get done fast enough, and they have a strong incentive to push back.
A third challenge is the nature of our shift work. This decreases the opportunities to talk to people. Lunch breaks are all over the place, and you can’t always control your break time since it depends on what’s going on with your patients. Many people commute a long way to work, so it isn’t realistic that they would come in for a meeting or an action on their day off.
Fourth, people believe that we are here for the patient, and so they tend to have mixed feelings about what we can or should demand and what actions we should take to push for our demands.
Finally, people often accept the limits they are presented with. They think, “management says this is all there is, so that is all we can do.”
On the other hand, there is a fairly widespread feeling that the management at the top doesn’t care about us or our patients. They say they care, but we know all they care about is the bottom line and making themselves work good. The front-line workers see management as the enemy a lot of the time. It is easy to generate a sense of us versus management. This sounds a bit contradictory, because on the one hand I am saying people just accept what they are told – and then on the other hand I am saying they are able to see the boss as the enemy. The truth is, I think people have contradictory consciousness about their place in the health care system, and their role as workers. Hopefully, this creates possibilities for organizing.
All these obstacles and more must have been present in California, and the California nurses have somehow overcome them to win impressive victories, including safe nurse-to-patient ratios. In a few places, at least, nurses have been fighting back. This gives me hope for organizing in the rest of the country.