A Public Hospital Nurse Explains Our Miserable Health Care System
"None of the people who say 'that’s they way things are' would accept their own children being treated that way."
More than three months ago, the union contract covering thousands of nurses who work for New York City’s public hospitals expired. These nurses, who make up the backbone of the city’s health care system, are fighting for better staffing levels and for equal pay with their counterparts at private hospitals—who earn nearly $20,000 more per year for the same work. Adding to this financial insanity is the fact that the City of New York paid $1.2 billion to a private firm last year to provide (non-union, out of town) “travel nurses” to fill staffing gaps at the city’s hospitals. For a fraction of that money, the city could raise wages for the nurses it already has and bolster staffing directly, the union says.
What is this job really like? And what does it tell us about America’s health care system? To find out, I spoke to Joe (not his real name), a nurse in a psychiatric ward at one of the city’s public hospitals, who asked to be kept anonymous. He is active in his union’s ongoing fight to win a fair contract.
When you came out of nursing school, did you consciously decide to get a job in a public hospital?
Joe: I wanted to work in a public hospital. I was born in New York City. The idea of working in my neighborhood really meant something to me. I like the idea of walking to work, just as a huge quality of life increase. But also, that my patients could be my neighbors. I like that as a Richard Scarry-type idea. And also the accountability. Even when I’m tired, I’m like, “Hey, this is someone I can see at the corner store.”
You work in the psych department. Did you choose that?
Joe: I did. It was a combination of, I really enjoy talking to patients, and the connection that you get with them. And that the intervention can be just talking—being a mensch can be an intervention! I like that. And I noticed that my classmates who were hyper competitive Type-A hated it. So I thought, if they hate it, maybe it’s something I should consider.
What’s a typical day for you?
Joe: The days can change rapidly. I work in inpatient, so the average stay is around two and a half weeks. We do have a psych emergency room. Some people do it and love it, they love the action and the speed. But that’s not for me. In psych, one nurse will get medications for all the patients. That’s the majority of the job. If there’s a crisis, you’re giving a stat dose. It could be the classic “Five and Two”—shorthand for five milligrams of Haldol, two milligrams of Ativan.
Who are your patients, primarily? How do people get there?
Joe: It’s not rich people. I’ll say that off the bat. There’s some people who are homeless. It’s people who can’t afford to go to a really high end facility. If they’re minors, then typically either a parent called them in, or a guidance counselor or someone. It can range from suicide attempts, sometimes a panic attack, to schizophrenia getting worse, or sometimes that appearing for the first time.
It’s mostly poor or working class. A lot of people who live in the neighborhood. Most people have either Medicaid or no insurance. So if you’re a private hospital, you don’t make money off of that. NYU [for example] is known for sending people next door to Bellevue. Once they realize— “We’re not gonna make money off this guy. Send him next door!”
What’s the staffing like in your hospital? How is the workload?
Joe: In our contract, the ratio [of patients to nurses] is seven to one. But it’s generally not that. A lot of people work short. And the consequences for that depend on where you are. I have friends who work in the emergency department—I forget what their contract ratios are—but they’re having upwards of 13 patients, solo. And then someone goes on break because they might need to use the bathroom or something like a human being, and all of a sudden you have over 20 patients, in the emergency room. I’ve heard stories about patients coming in needing bloodwork, and six or seven hours they’re walking out. And outcomes are worse. For every additional patient a nurse has, the mortality rate rises significantly.
In psych, you have to be medically stable in that unit. It’s not necessarily life and death—but it’s generally that, instead of getting better, some patient was traumatized. It’s tough to isolate, “This was just due to staffing,” because psych nursing is so interdisciplinary. So even if you have enough nurses but your doctors are spread too thin, [patients] are still suffering. If you don’t have enough staff overall, people are gonna be getting more medication. And your mindset changes too: From, “How do I help my patients?” to “Okay, I have 11 more hours of my shift. How do I get through this?” When your ratios are worse, your care is worse.
Nurses are leaving. A lot of people are watching these current negotiations to see if they can stick around.
It’s really similar to teachers, right? People wash out of the profession because the state refuses to fund it.
Joe: You’re put in a position to fail. And you can’t help but feel you’re failing the people you’re trying to serve. The burnout rate is high. Sometimes you can either just become kind of immune to what you see, or you start thinking worse of your patients. It’s just a natural reaction.
To open up the activity rooms, for example, you need a staff member. If they’re short on staffing, you can’t open it up. I’ve seen fights break out because there’s not enough playing cards, or things like that. Eric Adams is not coming down to visit a bunch of mentally ill people, right? They’re not gonna get mad at him. Nurses and nurse techs are on the unit 24/7. So if you’re gonna get mad at someone, you’re gonna get mad at the person who’s there.
Are there still a lot of travel nurses working in your hospital?
Joe: Yeah. And they’re not unionized, but in some specific capacities they have more rights than we do. It’s infuriating. For example, they’re not allowed to be a charge nurse—running assignments, things like that. So they can’t be left alone on a unit. I can be left alone. Even a travel nurse who’s been in the field 15 years, they’re gonna have at least one coworker. And while we’re getting better benefits, that’s true, they’re getting at least double our hourly rate. I have friends who do side gigs, so they get the ads. For the same hospital they work in!
They’re saying they’re trying to hire nurses. But it doesn’t get to the heart of it, which is: you’re asking [regular nurses] to do a harder job for less money. Patients are sicker, because in this country, the privatized health care system means that you get the health care that you can afford. So patients are sicker physically and psychologically. Every one of my patients could be diagnosed with complex PTSD. Worse schooling, less secure home environment. Their treatments are more complicated and more difficult. There’s more comorbidities. They tend to not have as good a relationship with providers and medicine, which makes sense. But it makes the work more difficult. So you’re doing more difficult work for less money.
Personally—this isn’t an official position—but personally I think what they’re trying to do is just do what they did to the restaurant in Goodfellas. You try to turn everything into Uber. On the public side, they’re trying to break the union and Uberize it. That’s one model. You get a gig economy worker. And on the private side, you get concierge medicine. You’re either a VIP, or you get the Uber driver.
Your union is really trying to get the community involved in this fight now.
Joe: The response from the hospital police and the NYPD to some of the actions so far has been pretty telling. I wasn’t too surprised, but it was still shocking, if that makes sense. How much hostility and how much violence. The one that I was at nobody really got hurt, but just escalating, picking fights, shoving people unnecessarily. And then just playing the victim—pushing people into the way of patients and then yelling, “You’re getting in the way of patients!” That kind of stuff.
And the police are another public union, in your same city.
Joe: Yeah. They got a lot of people to do a lot of overtime. So they have money for some things, right?
Does it feel like the nurses you work with who worked through the Covid pandemic are a little traumatized by that?
Joe: Nursing is a female dominated field. It’s a very tough field. I think hardly any of my coworkers would describe themselves as traumatized. But I would say that they’ve been through horrendous trauma. There’s no way it didn’t affect them. I mean, people lost their best friends at work—died, in some cases, from the work conditions they were in. And now they’re working in worse conditions than before, when this thing hit. I don’t know how that doesn’t affect you as a human being.
Has being a nurse made you more in favor of Medicare for All?
Joe: I was definitely in favor of it before. But if I wasn’t before, I don’t know how I would not be now. I don’t know how you look at this and say it’s okay. I don’t mean to aggrandize what I do for a job. It’s a job, right? Because “nurses are heroes,” that can be harmful. But [for patients], someone’s mom isn’t there—they got us. To see how they’re treated by the city is such an insult. I refuse to accept that “that’s just the way things are. That’s an inevitability.” It’s not. None of the people who shrug and say “that’s they way things are” would accept their own children being treated that way. My parents wouldn’t allow me to be treated the way my patients are.
When people say, “You think public healthcare is so great? Well in Canada, they have to wait.” You don’t have to wait now? Have you ever tried to get a doctor’s appointment? It’s hell. You’re waiting!
If we were to sit down and try to come up with a system that extracted misery as much as possible, we couldn’t do a better job.
This interview has been edited for length and clarity. Joe’s union, NYSNA, is having a number of public protests in the coming week that anyone can attend. Full information can be found here.
More
I had a piece in The Guardian yesterday about the problem with organized labor’s extremely early endorsement of Joe Biden’s reelection. I also had a very dumb piece in Defector this week which consists primarily of inside jokes about yogurt and the Jacksonville Jaguars. The interview with Joe touched briefly on the lack of solidarity that police unions display to every other union; if you want to read me ranting angrily on this topic at greater length, see here.
The WGA strike is still going on. After you attend the NYSNA protest, you can come support a WGA picket line on either coast. Here is all the info. It’s fun and you will love it.
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I didn't fully appreciate the role of nurses until I was undergoing aggressive cancer treatment. When I had serious reactions to immunotherapy, 8-10 nurses were immediately there, some for the hours it took to stabilize me. I can't really imagine Joe's role in a psychiatric unit with the sheer unpredictability of that patient set. It's unconscionable that Joe and his colleagues are reduced to being a cost to be managed and that patients' well-being of subject to the willingness of hospitals/hospital management to ensure they're cared for so long as it doesn't cost much.
I worked with public insurers as HMOs were being pushed. It was all about throughput (utilization). The trade-off was level of care. And when doctors and nurses got backlogged the patient experience was like being caught in a traffic jam - you couldn't see what started it but boy was it bad.
I worked inpatient psych in Colorado through the pandemic. Recently moved. Joe described my experience to a T but the nurses in CO are not unionized so it’s just jumping place to place trying to get better pay or benefits or stay in one hospital and try to change the culture from within. The profit motive really has no place in healthcare. All that money health care insurance companies have should be spent on care. Just cut them out of the equation