Hospitals have made sure they hire JUST ENOUGH nurses to cover shifts and no more. With covid hitting, this blew out the number of nurses needed resulting in a lot of "I know you've already worked 60 hours, but can you do another 20? we are short!".
Rather than hiring permanent people or upping salary, Hospitals have instead elected to just use travel nurses and an extreme premium so as to avoid any salary increases.
The fix is one that Hospital admins don't want. Pay your nurses more and hire more than the minimum to cover shifts so a nurse being out sick doesn't result in another working a 80 hour week.
So, instead it's been day old pizza with superhero stickers.
I look at academia which is rife with money sloshing around, and see undergraduate classes are taught by grad students who make ~30k a year who are basically the Nurses of the academic world and treated like garbage. The justice system is dysfunctional, courts systems are overwhelmed and understaffed so criminals just enter and exit like a revolving door, and police is basically useless because the best they can do is taxi criminals into the system that automatically spits them out again, while they take the brunt of public criticism for how they are forced to deal with a problem that is mostly beyond their scope.
In all of these cases it seems like the bottom if falling out of these institutions, and the responsibilities have fallen on their respective janitors to deal with it when the solutions need to come from places that have been incentivized to create the mess in the first place.
https://www.jerrypournelle.com/reports/jerryp/iron.html
"In any bureaucratic organization there will be two kinds of people:
First, there will be those who are devoted to the goals of the organization. Examples are dedicated classroom teachers in an educational bureaucracy, many of the engineers and launch technicians and scientists at NASA, even some agricultural scientists and advisors in the former Soviet Union collective farming administration.
Secondly, there will be those dedicated to the organization itself. Examples are many of the administrators in the education system, many professors of education, many teachers union officials, much of the NASA headquarters staff, etc.
The Iron Law states that in every case the second group will gain and keep control of the organization. It will write the rules, and control promotions within the organization."
These are all jobs where people sign up for the job. Whether it’s altruism or genuine passion. They’re willing to compromise and put up with less pay and harder working conditions.
But because they’re willing to compromise, these people are pushed to their limit. With not only low pay and shit conditions, but higher-ups which actively exploit their altruism and passion. “If you don’t work, patients / children are going to suffer!” coming from the same beaurocracy which created the situation where a) they suffer or b) you work extra hours.
They’re being pushed past the limit in fact, which is why there’s now a nursing and teaching shortage despite these actually being popular fields. A lot of people want to work these professions, they just don’t want the jobs.
He nicked it from Robert Michels, who wrote about the Iron Law of Oligarchies in 1911: https://en.wikipedia.org/wiki/Iron_law_of_oligarchy
I was reading some old Analog magazines the other day, and man, Pournelle was one deranged man in his "non-fiction".
It's possible this dichotomy works in theory only. Being generous, it's possible they just disagree about the goals of the organization.
Note that the strict formulation of this law (ie. "in _every_ case..") is profoundly anti-democratic in that it assumes no democracy can ever exist or function. Of course, I hope your household provides a good counter example (if not, then you should seek outside support).
Anyway, for those of us who still believe in democracy, it has long been recognised that the cost of it is that everyone has to be a adult who takes responsibility for basic things in life like maintaining the social fabric of the institutions you belong to in order to prevent them from being taken over by sociopaths.
So the question is, will we support medical professionals in doing this? In the UK, before COVID, when junior doctors went on strike to try and remedy the situation, the media denounced them as enemies of the people and they were completely crushed by the state (with the help of their own professional organisations like the BMJ). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4902702/
why is this such a common story across pretty much every single industry? There's more people in the country than 10, 20, 30 years ago. More customers, more money. Why do they think they can handle more work with less workers whose salary is less when adjusting for inflation?
In the academia that contains money sloshing around, the only grad students teaching are the ones who want to.
In the academia that doesn't contain money sloshing around, it's a different story.
But the truth is, no one in academia is making bank from academia directly -- not the grad students, certainly, but also not the adjuncts, or even the professors. You have to look higher up the chain (or, I guess, laterally?) for that. (Yes, there's the caveat that some faculty make good use of their prestigious affiliations or professional connections to increase income from outside of academia.)
Staying when you want to leave indicates there's enough compensation to 'make it worth it' at least versus whatever shitty alternatives you have. Leaving when you want to stay, to me, would be a much bigger indicator that nurses who want to stay in the profession can't because of wage/benefits/conditions issues.
I think the conclusion of this sort of economic thinking is basically: Give your employees just enough money that they can keep they keep their head above the water but not enough to flourish, and just enough pressure/responsibility that they don't have energy to do anything else, but not too much that they have a complete mental breakdown that leaves them with the conclusion that they should leave your industry at any cost.
When you spent a lot of time and money into a specialized and demanding career, I imagine it practically very difficult to actually change your career, even if it's killing you. It's probably even worse if you have familial obligations. You likely do not have time or energy to better your situation after hours, and if you quit, you potentially resign yourself (perhaps) to many years of destitution while you accumulate the necessary knowledge to do something else. I would not be surprised if many people just bear bad conditions because the cost to do anything else worth one's time is simply too high.
Many people don't have even a little optionality.
Another interpretation is that the economy is a tool for exploiting people. For example, human beings are inherently of the opinion that human decency is good, they want to be functioning members of society, they care about the wellbeing of others, and if they are paid crap and treated like garbage, they will endure that, even to the point of great personal cost, emotional distress, mental illness, alcoholism, and even death. But as long as they don't quit, then everything is fine.
If you want to see an indocator of terrible compensation - check why pretty much noone (at least here) wants to be a nurse.
Profession is rapidly aging because new ppl are not joining. And they are not joining because work is hard and pay is terrible.
The whole Healthcare system if we dont get robots in place fast is going to crumble soon like a house of cards.
People don't 'switch careers' when they've spent years getting good at it. What they do instead is sit around posting on HackerNews and fucking the dog in all sorts of other ways.
Do you realize the irony of it all? This place gets like 1/10th the traffic on weekends. That's not a coincidence.
In healthcare I get the feeling that a lot of workers feel stuck in that there are many patients and people depending on them, and to leave would sort of be like abandoning them while increasing the burden on ex-cowoerkers.
Not necessarily. The "transaction costs" of switching careers are huge. If you want to make comparable money to nursing, you probably need training in something else, which likely requires a period of low or no income, possibly years of schooling or other training, etc.
It's hard to switch careers after 30 -- not always impossible, but certainly hard to revert back to the lifestyle of a 20-something for some time. People may stick it out despite unhappiness.
Doesn't mean compensation is adequate.
The criminal justice system may be overwhelmed, but its reaction certainly isn't to just let criminals "exit like a revolving door". The US is still incarcerating people at 10x the rate of other wealthy countries.
Nurses being overworked is simply due to there not being enough nurses. It matters little if there's too much bureaucracy somewhere, or if too much money is spent on pharmaceuticals (about twice as expensive as anywhere else) or if doctors make too much money or if the US has a uniquely unhealthy population.
yes but this begs the obvious question of "why?", which either leads to the immediate thoughts of
1. not enough people want to be nurses 2. companies don't want to hire more nurses
I'm assuming #1 is false, so #2 is the go-to conclusion, at least on the high level. I'm sure I'm missing some more nuanced #3/4/5 explanations, but it does seem to ultimately come down to money that isn't being spent (be it maliciously or simply due to not having the budget).
What some people will call government waste - other people will call ethical employee treatment... sure there are a lot of other sources of inefficiency outside of your comment - but complaining about overpaid government bureaucrats is essentially advocating for the same race-to-the-bottom that has stagnated wages in large parts of the labour pool.
Hah, wasn't it UCLA who recently got excoriated for advertising for grad students to teach undergraduate classes with this stellar line:
"This is an uncompensated position"?
You're delusional. America has more people in jail, serving longer sentences, than _any country in history_.
Here: https://www.cnn.com/2018/06/28/us/mass-incarceration-five-ke...
My mom was a nurse, my aunt was a nurse, my sister is a nurse and my best friend’s mom is a nurse. I really can’t believe anyone continues to be a nurse given the insane working conditions these folks have to put up with. Twelve hour shifts, overflowing with patients, watching newcomers earn more than seasoned veterans… When I compare it to my laid back software engineering job it’s like I’m living in an entirely different universe. The hospital industry is a hugely demoralizing place.
On top of that, they also hire as few orderlies and nursing assistants as possible, so the nurse doesn't even have anyone to offload things to, and ends up having to do more work on more patients.
This has been a problem well before the pandemic.
It's a trope among nurses that they are so busy they don't have time to use the bathroom, let alone eat lunch.
Source: My wife is a nurse, most of her friends are nurses, and she left the profession ~a year before the pandemic because of exactly these issues.
He kept getting vacation requests denied due to lack of staffing, yet if he asked if they were looking to hire, the answer was always No.
He was super lucky and had some early cryptocurrency investments pay off big, so he decided he was done with it retired. He said that he loved helping people as a nurse, but not at the cost of his own physical and mental health, having to work 60-80 hours/week. If he ever gets back into it, he would establish at the interview phase that he works 50 hours/week tops, and that vacation "requests" are not requests, but notices.
Like what did you expect to happen? We're not stupid.
At all jobs, vacation time was almost never a problem. Maybe that's more the case now that I'm a freelancer, though. I just announce when I won't be available, and although we do try to plan things so that we never have the entire team gone at the same time (unless the company as a whole plans for that; Christmas breaks are often like that), they always accept my absense. It's really notifications, rather than requests.
But this is Netherland. We've got quite a different work culture than the US does.
As someone who worked in hospitals to help redesign their processes, this one piqued my interest.
For every project I worked on (and I mean literally every one), the team lead wanted to jump to the solution that they just need the ability to hire more people. In the rare instances where they were able to convince hospital admins to do so, it never fixed the problem. Not once.
Why? Because it never addressed the root causes. They needed to take a process-oriented approach. There's a saying that adding more people to a broken process makes things worse. You can hide a lot of quality issues with inventory; if you have a requirements for 100 widgets a day and you have a crap process that only makes 10 quality widgets, you can meet your goal by increasing throughput 10x, but nobody thinks that would be a good approach. It's the same with injecting more staff onto a broken system. If the system causes nurses to spend disproportionate amounts of time on admin work and not on direct patient care, it may be better to look at your admin processes rather than just hire more nurses.
It's natural when people to feel overwhelmed to think the solution is to just hire more people, but it's almost always better to hold off on hiring until the system/process is fixed.
Edit: I'm curious about the downvoting. I think it would help illuminate the conversation if you could explain where your disagreement lies. I'm basing my statements on actually tracking when hiring was increased to the levels desired and metrics did not improve.
The problems are caused by a "just in time" approach to staffing, where you have exactly enough people to cover the shifts at bare minimum. What solution would you suggest other than more people? They are not saying to throw more nurses at patients simultaneously, they are saying to hire more nurses so existing ones aren't bound to spent the entire week stretching themselves across the hospital.
Also, I think you are being downvoted because you are applying software engineering rules to medicine.
>What solution would you suggest other than more people?
It obviously depends on the situation but most of the time it comes down to reducing process waste. That may be automation through software where a nurse was hired specifically to only generate reports 40 hours a week, to re-designing a layout that minimizes travel time for nurses when they are delivering to patients. My experience with the staffing situation is that managers did not know how to staff to meet the needs of their patient loads and just revert to simple heuristics that left them understaffed at some times while being overstaffed at others.
Here, better traffic design is necessary. And room alternative, more efficient forms of traffic (public transport, bikes).
I do think nursing (and many similar fields) do need to hire more people, but I also suspect they have to redesign how nurses work. Less overhead, more focus on the core of their work. Streamline the processes, especially the administrative side, and not expect them to fill in for many other kinds of work at the hospital. Get separate specialists for that.
I get the impression that the same is often true for teachers, academics and cops: too much focus on administration, which takes the focus away from the reasons they chose these jobs in the first place. Streamline the administrative process, or have dedicated administrators help them with the boring stuff, so the nurses, teachers and cops can focus on the actual content of their jobs.
If it's because it provides more patient care beyond what a nurse can provide in a good system, it might be a valid point. But if it's because the system is fundamentally broken, I'm skeptical that hiring more people will actually fix anything. From personal experience, it will only create a lag that will require the same need for more hires down the road.
I'm a UK doctor working in the field, always looking to optimise processes while keeping quality.
Email is in my profile.
The problem is that they had two consecutive shifts.
The alternative is that the hospital hires enough people so they can schedule them such that everybody has time to go home relax and sleep after they are done with a shift.
Then I open my recruiter inbox and I see like 20 new B2C healthcare startups.
It really feels like the entire economy is designed to prevent problems being solved. Some people in healthcare are making massive amounts of money and the quality of life of everyone that performs the actual work has taken a nosedive when it was already a really crappy situation.
Sans the covid anomaly, immigration has never been higher in Western nations. The issue isn't restrictive migration. It's that we're not treating nurses well. That means fewer people pick this career, and more nurses leave prematurely. Suggesting that we need to import more nurses is only admitting that migrant nurses are willing to work for worse pay and worse working conditions, and I don't think that's fair to anyone.
In case people want an idea of what travel nurses made during COVID...
https://khn.org/news/highly-paid-traveling-nurses-fill-staff...
> In April, she packed her bags for a two-month contract in then-COVID hot spot New Jersey, as part of what she called a “mass exodus” of nurses leaving the suburban Denver hospital to become traveling nurses. Her new pay? About $5,200 a week, and with a contract that required adequate protective gear.
> Months later, the offerings — and the stakes — are even higher for nurses willing to move. In Sioux Falls, South Dakota, nurses can make more than $6,200 a week. A recent posting for a job in Fargo, North Dakota, offered more than $8,000 a week. Some can get as much as $10,000.
But it also isn't an option for everyone. Many don't have the flexibility to switch to travel nursing. For example, you may not be able to get a nearby contract and may not be able to travel (e.g. because you have children). Plus, traveling isn't an option for new nurses without experience, who now have to work in hospitals that are hemorrhaging experienced nurses to traveling AND have worse staffing ratios than ever.
> The $5200/wk rate is more likely 3 or 4 12-hour shifts
3 or 4 12 hour shifts a week is normal for salaried nurses. $5200/wk isn't. It's over double.
> which pay outrageously but often require a full week of 12-hour shifts or something similar with the expectation the nurse will only do one week then recover.
I'm not sure what you're trying to say. Yes, it may be a full week of 12 hour shifts, but it's still a much higher pay. And if you get the next week off, it's a fantastic deal.
For context, pre-pandemic, I knew a nurse who often would do this schedule for her salaried job - she requested it as she liked having a full week off.
What I mentioned elsewhere: Travel nurses have a lot more control over the contracts they take. They can work fewer hours per year and still make significantly more. They may have stretches of long hours in a given contract, but annually they work less.
What happens is they'll accept a few weeks (or 2 months) of long hours, and then take a month off and relax. As you can imagine, if they're getting paid $6000/week, they can easily take a lot of time off and still get paid more annually than their salaried counterparts (while overall working fewer hours per year).
I can agree that executive compensation is exorbitant, but do not agree that "MBA types" (what does that even mean?) have no value add. There's nothing inherent with being in the health care industry that translates directly into administering a (large) business. Why would you think doctors or nurses would be good at that?
I agree that Doctors and Nurses would likely be poor administrators - however the disparity in income is incomprehensible in healthcare.
Anecdotally, I know a travel nurse who works in pediatric ICUs (PICUs). One shift a couple months ago, the overnight staff on her unit was >80% travelers. And this is in peds units that aren't as affected by COVID, because ~1/2 of the patients are cardiac babies with congenital heart issues. The only case I can see for not paying staff more to increase retention is that they can respond to a dip in cases over the summer, but that can't possibly be an 80% decrease in patients. Maybe they're waiting until travel rates come down to offer an increase in pay so their 1.2x salary offer is more enticing in comparison to the travel rates, but the current system is ridiculous financially. I did mention that we've seen first-hand that hospitals can afford to pay nurses $4k/week, though, and I'm sure I'm not the only one who noticed.
This is a two-edged sword. If you hire more than you need, the nurses' hours will be cut during normal situations and they won't make enough money. If hospitals don't cut extra hours and instead keep the staff on the clock, a public scandal will erupt surrounding well-paid medical professionals sitting around doing nothing.
I don't think that's true. Increasing the amount of nurses means simply increasing the amount of care. If you have twice as many nurses, you'll have twice as much care for your patients. No way nurses would be sitting around doing nothing.
They employ on-call, PRN, contract nurses, etc to fill in the gaps which mostly works in non-pandemic situations.
Hearsay from the nurses I know: a large hospital near me has a separate budget line item for full time nurses vs. travel nurses or other "mercenery" roles. This incentive system will never create the best patient care, but I suppose that's not really the goal.
With additional nuance that this kind of thing used to be protected a bit by the additional guard of a pharmacist. The automated dispensary changed those criminally liable people into a checkbox bypass that this nurse (and from the sounds of it, the rest of them by effect of policy) regularly bypassed.
https://khn.org/news/article/radonda-vaught-fatal-drug-error...
On an individual basis, nurses are overworked because they choose to be and their employers allow for it. The standard work week is 3 12 hour shifts, which is much less than most professionals work. Like a retail or warehouse worker, they are expected to clock out as soon as possible and leave when the shift ends. Those of us with salary jobs knows how difficult that can be in our arrangements and how much "free" work we end up performing. They get paid premiums for everything; night, weekend, etc. And since they're hourly, they typically LIKE the overtime and signup for it as much as possible. They also might work FT at one hospital and pull extra shifts at another hospital on a PRN basis. These things are very common. Just like in a retail environment, people typically LIKE to work holidays so long as it's voluntary because it's 1.5x pay (or more?).
> Rather than hiring permanent people or upping salary, Hospitals have instead elected to just use travel nurses and an extreme premium so as to avoid any salary increases.
This makes no sense. Capacity is the problem, paying more for the same capacity does not solve the problem. Hospitals try very hard to avoid overtime and the travel nurses due to the cost. It's also a very elastic model to balance and a lot of flex (non Full Time) folks are needed to fill the gaps and manage cost somewhat.
> The fix is one that Hospital admins don't want. Pay your nurses more and hire more than the minimum to cover shifts so a nurse being out sick doesn't result in another working a 80 hour week.
That is the current system. The problem is usually time. If someone calls in sick, they do it an hour before their shift starts. They usually can solve for this. Either they call from their roster or a supervisor level person with an active RN license steps into the clinical side that day. Staffing at 2x just in case everyone calls in makes no sense. Staffing at 5x just in case a pandemic hits makes no sense.
Hospitals barely make money as it is, I don't see how this is a sustainable solution. Paying more does not create capacity in this industry.
It's also important to note that "nurse" is a very generic term. For example, ICU nurses is a very distinct type of nurse that has been dealing with COVID first hand (caring for vent patients). They are the ones you hear about making $150-200/hour in COVID times. It is difficult to become an ICU nurse. It hasn't been possible for a surgical nurse to pivot to ICU nurse in these times so the labor pool has been rather fixed, or shrinking due to natural churn and inability to onboard new folks. It would be akin to suggesting why does some [insert super specific domain expertise] developer make $1M/year at FAANG when they could hire a PHP coder for $15/hour on a freelance website. There is no immediate/cheap substitute for the experience and knowledge that the expensive developer has, so they cost more. This is happening in nursing where some are thriving while many actually got furloughed early on in the pandemic.
My personal opinion on the matter, is one only has to look at the demographics of an average nurse. It's become quite "old" and like other industries, the boomer's retiring is causing a labor issue. The handful of nurses that made 5-10 years of salary since Q1.2020 are now ready to retire early as well. I don't blame them.
The problem is – and this may be very bizarre in a society as capitalistic as the US – healthcare should not be beholden to making a profit.
Rehabilitating people is clearly "valuable" to the economy in that without people to participate in the economic system, a debt-based economy collapses; I'd argue that healthcare is much more valuable to capitalism than is reflected on a balance sheet of paper costs/revenues/profits, and yet a system such as ours has absolutely no way in its current form to price that in (sure, in an academic defense you could wave hands that "positive externalities" such as these should be priced in to the model, but it's clear with the racket the medical industry has found itself in that will never happen practically).
The main issue profit-seeking conflicts with is that whole rehabilitating/healing/saving people is an intrinsically good thing to do, and that letting people who have full lives to live die or suffer is an intrinsically bad thing to do.
What's not sustainable is that healthcare has to survive within the confines of a system that is many times in complete opposition to it. Other otherwise-capitalist countries have at least tried to insulate their healthcare industry from market forces, meanwhile the US has just wrapped it in another layer of capitalism with its insurance market.
Capacity is generally limited by staffing, not space or actual beds. When hospitals report how many "beds" they have available, they're generally not talking about the furniture.
What you need to realize is that nursing salaries in the US are NOT uniform. From what I've seen in past discussions about it is they range anywhere from $20/hr -> $100k/year. The $100k/year are usually achieved only in cities and generally only by travel nurses.
The majority of nurses, that I've seen, are clocking in at 50->60k yearly salary.
Sort of like saying "Oh, that google dev makes $300k a year. How much more do devs in the US need?"
"Sysadmin" seems the most readily comparable title in IT, going from "I push software to Windows PCs" to "I manage supercomputer clusters."
And the answer to that is "how much is Google worth?" If your business relies on the efforts of software engineers to design and build your primary products, they should have the primary equity in the company. So no, even Google developers aren't paid nearly enough...and they're certainly overworked, regardless of how much they make.
While $100K/year is not the norm throughout the country, it is normal in my city (non-SV). Travel nurses made a lot more during COVID.
From my conversations, pay is not the reason they are considering leaving. Working conditions are.
Something something freemarket no longer applies when it comes to paying peons?
It never did.
They will bear a lot of that, because these people care for their patients and leaving a job because of bad circumstances also means leaving their patients behind with those bad circumstances.
Which is not something that comes easy to everybody who makes "helping others" such a big part of their work motivation.
To be honest, I am amazed that Canada has a healthcare system left.
Decades of mismanagement and underinvestment aside, almost any Canadian healthcare worker can cross the border and instantly see a substantial pay bump and increase in QoL.
I do imagine within the next 20 years, Canadian healthcare is going to look vastly different. Like something from an emerging market, where sure there is universal healthcare, but you generally avoid it if you have the means.
For example, I have to pay $9000 a year BEFORE my insurance starts covering healthcare costs. (at $5000 my insurance starts paying out and I owe 10% of the bill). My insurance does not cover medicine costs at all.
Besides they need their health workers too.
This seems perfectly consistent with econ101. Prices for something is high, so we need more supply.
