I wrote this in reply to an analysis by a radical. Edits appreciated.
“[University of Pittsburgh Medical Center’s Presbyterian Hospital’s Chief Medical Officer Loren H.] Roth says that improving the quality of care may also mean challenging a bedrock belief: that each patient is unique and that doctors must bring individualized judgment to each case. This view "has a kind of appeal to it for both the profession and patients," says Roth, "but it is not so." Most illnesses and injuries can best be treated by standardizing care, he argues. The goal is to ‘industrialize every process we can.’” Medicine’s Industrial Revolution, Business Week. The bold and italics are mine.
The nursing shortage is all over the headlines. It is a common discussion in the popular discourse, and has driven many (myself included) to pursue work in health-care and rethink how it impacts our lives. The crisis is real and the severity frightening. Yet the causes remain clouded in illusions, obfuscation, and partial truths. Revolutionaries alike have failed to either question or investigate the situation thoroughly enough. To this end, I hope to unearth some facts about the nursing shortage in hopes that we may correct the misinformation, and organize more effectively in health care.
The Daily Standard
The standard analysis in the corporate media and even most radical analyses goes as follows:
1. The nursing shortage is being caused by an aging baby boom population who are retiring across the next decade, and who will put a new burden on the health system both in their health care needs and as retiring nurses.
2. The education system we have for training nurses in insufficient to meet the expanded demand of the retiring baby boom generation.
3. Advances for women translated into the freedom to work better jobs and consequently leave nursing.
A typical portrayal of the shortage may be taken from a CBS News story Nursing Shortage In Critical Stage (Jan. 17, 2003), where they claim “There is a major reason for the shortage. Ever since the mid-’80s, young people [should read women] have been choosing more lucrative careers. At the same time, the nurses we do have are getting older; the average age is now 45. Just as the baby boomers are starting to need more care, the pipeline is running dry, and it’s going to get much, much worse.” An interview with a revolutionary nurse yields a similar analysis. M. Treloar gives three factors: 1. Shortage of nursing professors 2. Shortage of nursing education programs 3. The need is expanding.
This is of course no joke. Studies have shown that, “the ratio of potential caregivers to the people most likely to need care, the elderly population, will decrease by 40% between 2010 and 2030. Demographic changes may limit access to health care unless the number of nurses and other caregivers grows in proportion to the rising elderly population.” The population shifts due to the baby boomer generation is one important factor precipitating this situation. These facts are illuminated in light of fewer young people entering nursing each year. “The average age of the RN population in March 2004 was 46.8 years of age, up from 45.2 in 2000. The RN population under the age of 30 dropped from 9.1% of the nursing population in 2000 to 8.1% in 2004.” Confusing as this seems, we will make more sense of it below.
Education of course plays a role in this, in that if we can’t train enough new workers, we are going to have problems. “U.S. nursing schools turned away 41,683 qualified applicants from baccalaureate and graduate nursing programs in 2005 due to insufficient number of faculty, clinical sites, classroom space, clinical preceptors, and budget constraints. Almost three quarters (73.5%) of the nursing schools responding to the 2005 survey pointed to faculty shortages as a reason for not accepting all qualified applicants into entry-level nursing programs.” Part of these facts are explained by faculty shortages and lack of educational infrastructure, but it doesn’t account for why less young people are entering the field.
All of these things are true and important, yet missing the most crucial points. We should add that:
1. The health care corporations, in unison with broader attacks on living conditions and social organization, set out to transform the health care industry to become more productive for the interests of capital. The effects of these changes have had two major and ongoing effects. (i) They have sought to minimize the amount of work that employees with professional or skilled work must do, in favor of proletarianizing the hospital. This means that there should be minimal doctors in favor of (Amongst other changes) an expanded nurse population with productivity as high as possible (and likewise maximized unskilled hospital staff). In effect, the demand for nurses was expanded by industrialization and capitalist restructuring. (ii) The changes themselves have made the work intolerable for huge numbers of workers, who are leaving health care in droves. Whatever level of community health system existed is being and has been dismantled in favor of the centralized mass hospital and market consolidation. There work is concentrated amongst staff meticulously planned to extract labor at high rates leading to work overloads, shortages, and damaging stress. In short the restructuring and capitalist management of health care is driving nurses away from the profession.
2. Perhaps the most missed factor is the return of baby boomer nurses. With the increased opportunities for women came a natural exodus from the under-compensated work of nursing. Yet with restructuring bringing about renewed demand for nurses which the existing labor pool couldn’t fill, pay rose. This attracted former nurses back to work in high numbers. Yet it is precisely these nurses who will retire within the next decade. In short, the crisis due to restructuring and working conditions was averted partially and temporarily, but will only worsen as such a pool is no longer available.
The evidence for my claims is not hard to find. The business press, government publications, and the unions all agree that nurses are leaving the field, retention is low, and that working condition deterioration due to restructuring is a major factor. A study of five different nations found that over 40 percent of hospital nurses reported being dissatisfied with their jobs. One out of three nurses under the age of 30 is planning to leave her or his hospital nursing job within the next year according to that study (Source: Nurses’ reports of hospital quality of care and working conditions in five countries. Health Affairs, 2001, 20, 43-53.). According to an April 2001 study, The Nurse Shortage: Perspectives from Current Direct Care Nurses and Former Direct Care Nurses recorded that one in five nurses are contemplating leaving patient care for reasons other than retirement within the next five years. Worse still, after graduation some nurses never enter the profession, prefering to pick other work. A study by Julie Sochalski, PhD, FAAN, RN, at the University Of Pennsylvania School Of Nursing, found that more than four out of every 100 female nurses were not working in nursing after graduating. That number is nearly twice as high for new male nurses. (See Health Affairs, September/October 2002 edition, for details.)
In broad outline the transformation within health care reflects a worldwide capitalist trend of the past few decades. Emboldened by their perceived freedom to dismantle the social welfare schemes formerly used to attempt to pacify workers; all over the world capital has seized infrastructure like the health care systems, and transformed these institutions to consolidate both economic and social control in hopes of diffuse worker struggle and extracting more value. Though privatization receives a great deal of commentary and fanfare, this process in health care remains latent in the United States. More pointedly the working class resistance to the restructuring, both through work actions and abandoning the industry deserves more attention. Yet this is all clear in the publications of the business press and the State. More important than what is missed is how we should move forward.
To this end, we should organize as workers within health care together community organization to force our desires upon capital, and shatter their plans for using our suffering and ill health as a place to produce value. I see three ways we can intervene positively in this direction: 1. Organize against funding cuts to existing services through an industrial organization of workers taking direct action with the communities affected by the cuts. 2. Couple direct struggle against the companies and the State with demands for services provided to the huge numbers who lack such and improvements in the existing care and working conditions. 3. Work towards universal health care that is administered directly by community councils. The suffering capital imposes can’t bring about our liberation. If we can demystify its processes, and show the possibility of securing a more meaningful human existence, we can create ruptures. Through taking action together, we can transform health care and the social relations around us.