I have been a nurse for 31 years and applaud the new graduate speaking out. But here is the deal: Equaled only by the flaming disregard that most hospital administrations have for what nurses actually do, is the blinders that nursing instructors are wearing as to what nurses actually face in the workplace today. They ill-prepare the new grad for what she/he will be forced to deal with if they want to actually work in a hospital today.
With few exceptions,the pay is low, there are limited effective standards capping hours of work and these jobs offer limited benefits, provide poor working conditions, have no union representation, and are insecure. With forced mandatory overtime we are given the opportunity to put in long extra hours each week, often keeping us away from interacting with our homes or personal life for weeks at a time. Does this picture not fit the model of the nineteenth-century sweatshop with long hours, low wages, and unsafe working conditions? It is hard to believe that this economic environment can coexist in the modern world with our sleek cities like Atlanta where I work, a prosperous stock market, and high-tech jobs.
As young grad nurses find themselves working extremely long hours in an effort to climb their career ladders, they only find themselves burned out early. As professionals, especially the more creative and brilliant ones, have found out, their nursing school instructors have failed to adequately prepare them for the shock of finding the medical profession transformed into an industry where profits are made from sickness and sick people; forces they only too late dimly perceive but which have forced them to take on at times multiple jobs to patch together a career, while struggling to provide themselves with health and retirement benefits.
We could simplistically blame the managed health care employer for this state of affairs, because it is easy to see who holds the power in this personal dynamic. But if we take a closer look, it is the individual competitiveness embedded in the medical field today that has a dark side; competition breeds winners and losers, and the market, by itself, does not care how they are distributed. It does not matter if competition makes a few winners extremely wealthy while a large number of losers become relatively poor, as long as average wealth increases.
As nurses we provide our employers with tremendous value at a low cost. Low wages and long hours is the mortar which holds hospitals together. Nursing has always drawn the short-straw: it is only within the last years that we have drawn the short straw to subsidize the prosperity of managed health care. It suggests limits to which this kind of competition may push the losers in this field--the nurse. We do not have the power to raise wages substantially or working conditions and we are caught in a race to the bottom.
Whether you realize it or not, nursing is a labor-intensive industry and providing medical care is a commodity in this day and age of managed health care, subject to intense competitive pressure. As long as public policy supports this kind of unbridled competition between hospital services as a blanket solution to our social and economic problems, the problem becomes more complex than a simple struggle between management and labor. In our effort to mix government regulation with market institutions we are throwing the baby (in this case the new grad) out with the bath water.
The new grad today sees people they graduated with in college, have weekends and holidays off, time with their families and not working like dogs every day of their lives. In essence, they see their friends having a life. So what could possibly be there for them to stay in hospital nursing? Went we went to managed health care, it only intensified the lousy working conditions nursing has labored in for years. At the time, we only asked but two questions: Does the policy of managed health care lower prices and improve services, and is that a benefit to the average consumer? But there are other questions:
- How does the policy affect wages? How does it influence hours and working conditions? Does it structurally alter the terms of competition to favor one group over another? This matters from a social perspective. We are individuals in pursuit of personal material goods and a society in pursuit of broader goals that require maintenance of both individual and community rights.
- Does this policy promote or undermine institutions that provide training and maintain standards? Does it encourage or discourage long-term investment in skills? Does it promote the high road or the low-road to skilled nursing care?
- How does the policy affect safety and health? Does competition create an unhealthy work environment and put workers at greater risk of occupational illness or injury? Does the policy make our hospitals safer or more dangerous to be a patient in them? Who pays the cost for the added risks?
- Since this policy has been implemented, will we eventually need new regulations and incur additional costs to ensure the public safety and welfare? Do the market incentives that promote cheaper health care actually encourage optimal allocation of those funds?
To our discredit, nurses have been sweating their labor since the days of Florence, in the name of "its the moral and noble thing to do". Only now, can managed health care make money off of that ingrained practice. Three general conditions characterize sweatshops.
- First, the wages are so low that they are below subsistence. These wages are so low that if you are a single parent you are unable to support your family well enough to maintain the family's current class position and skill level and reproduce that level in succeeding generations. This leads to sweating your labor to reach target earnings levels.
- The second necessary condition of sweatshop conditions as found in the sweatshops of the early 19th century, is overwork, a natural extension of low wage rates, in order to make ends meet. Nursing encourages nurses to extend their work day and extend their work week. Many nurses work the equivalent of two or three full-time jobs. With no real penalty either for assigning nurses long hours of work, there is no disincentive to discourage use of nurses to the maximum extent allowed by law or human endurance. The low-wage rate, encouraged nurses to become complicit in this regime, sweating their labor to reach their desired earnings threshold. When I started nursing, eight hour days were the norm. About 17 years ago, 12 and 14 hour days became commonplace and with forced mandatory overtime, 18 hour days are not uncommon now.
- And the third condition of sweating your labor involves unhealthy conditions of work. How many out there work 12 hours with a short break? Some nights in ICU, we work 12 hours non-stop without a break. I mean I think of those women with sewing machines in sweatshops at the turn of the century, crammed into small, poorly lit and ventilated rooms, exposed to high levels of poisonous chemicals, dangerous machinery, and delibitating effects of fatigue. Couple that with the newest trend, labor market churning and skilled labor shortages and we might as well be back in 1900 rather than 2000.
The problem is, is that when the young new grad comes in and complains about the way things are, and the working conditions, we point the finger and call them "Generation W" with the "W" standing for whine. At the turn of the century workers in successful sweatshops collaborated in the sweating process and this condition holds for nursing today. We have sweated our labor for so long, and have been so successful at it, while providing excellent nursing care under the most extreme of conditions, we are hard pressed to know how to duplicate that into the generation pressing to take our place in the nursing workforce of today. In fact, new grads have no desire to duplicate those work conditions. And to top it all off, Administration, clueless beings that they are, cannot understand themselves how we can not duplicate our work philosophy into the new, younger nurse. And in fact, it looks like many of the "older" nurses are getting fed-up also and leaving nursing at the rate of 12,000 a year, never to return. Low wages, carrying few if any retirement benefits, and poor working conditions have created serious consequences for our industry, for employees and for the unsuspecting public.
In an effort to problem-solve this crisis, Administration has decided once again not to improve working conditions or work on retention factors to retain the nurses they have. While complaining about a severe labor shortage, they continue to hire the lowest wage they can find from wherever they can find them, which drives wages down further throughout the labor market and exacerbates the skilled nursing shortage. The overall effect is to crank wages down tighter, paradoxically making the job less desirable.
This unfettered market for nursing labor from the third world nations produces a continuous and destructive slide that will threaten nursing instead. Managed health care simply cannot recruit, hire, train and retain nurses who can both do the job, pass stringent drug tests and have the education and know-how to do their job--work performed under difficult conditions at the wages companies are willing and now, able to pay. The continual infusion of new employees into the business of nursing in the hospital, however temporary can break any work situation. Nursing, it seems, has a seemingly inexhaustible well of new grads, even if it grinds them up and spits them out a fearful rate. Now our industry is embarking on a new project: to permanently replace this situation with nurses from far-flung communities, willing to work for less. At the same time that Administration complains about a severe labor shortage, they continue to hire the lowest wage workers they can find from wherever they can find them, which drives wages down further throughout the labor market and exacerbates the skilled nursing shortage. As long as the market for nursing remains unstable, someone will take that low-wage nursing job--if only on a temporary basis. As wages drop, it becomes irrational for individual workers, to invest in their human capital--what they have built up in skills and marketablity over years working in the business. This furter devalues their labor and ends up attracting to nursing those workers with the fewest employment alternatives, mainly from third world nations.
I wonder if Administration will ever wring their hands over the trap in which they see themselves, a trap they set themselves, unable to raise wages or working conditions to the level needed to attract the kind of nurses they want and need.
[This message has been edited by RunningSoLate (edited September 27, 2000).]