Illustration by Liam Eisenberg.

In the early hours of July 26, 2021, about 200 nurses began to assemble outside of Community First Medical Center in Chicago. Inside, the hallways were lined with patients. But all day, in 90-degree heat, the nurses stayed outside, on strike. They set up tents and handed each other water. Patients and other community members came by to give them food. When the hospital wouldn’t let the nurses inside to use the bathrooms, nearby businesses opened their doors. “The whole neighborhood was behind us,” said Kathy Haff, a registered nurse who’s worked at the hospital for 30 years.

The pandemic had exacerbated the already very poor conditions at Community First. After an investment bank bought the hospital in 2014, the management started to cut back on staff and slash benefits, reducing the head count even further as people left. Disinvestment led to huge supply snarls, sometimes leaving nurses without enough IV fluid or even linens, Haff said. Over 90 percent of Haff’s coworkers voted to unionize in December 2019. “They felt like they couldn’t do their jobs and take care of people,” she said. Once the pandemic hit, nurses—and patients—were at even greater risk. There was so little personal protective equipment that nurses were bringing in their own gowns and masks. Three of Haff’s fellow nurses died of Covid, including one who told her daughter that she believed she was going to die because there wasn’t enough PPE. “She was a real great nurse,” Haff said quietly. “She was coming in and working nonstop until it got her.” The Occupational Health and Safety Administration eventually levied fines of over $13,000 for the hospital’s lack of protections.

So when Community First dragged its feet over the union’s first contract negotiations, the nurses went on strike. Management was “shocked,” Haff said. “It made them realize we were serious and we weren’t going away.” After the July strike, the hospital kept stalling, so the nurses threatened to do it again, for even longer. Management finally yielded to the pressure, and the nurses ratified their first contract, securing wage increases, benefits that had disappeared under the new ownership, and safety protocols for Covid.

Haff ties the community’s support for the nurses to the pandemic. “People finally appreciate our role,” she said. “All these things are now being brought to the forefront because people never realized all these years how hard it was. Now they’re seeing it’s always been this way.”

As the pandemic pushed our health care system to the brink of collapse, images of overworked nurses were plastered all over the media. But difficult working conditions existed long before Covid. What’s changed is that nurses have decided to fight back, with a wave of strikes and labor organizing sweeping across the industry. There were 76 strikes in health care between January 2021 and mid-April 2022 alone, including a nearly year-long strike last year at St. Vincent Hospital in Massachusetts over unsafe staffing, which may be the longest nursing strike the country has seen in at least three decades. But despite the fierce labor activism and a new public interest in the plight of essential workers, nurses are still at a breaking point.

Overcapacity: With hospitals still short-staffed, many patients are waiting to transfer from ambulances to ERs or from ERs to inpatient rooms.(Jae C. Hong / AP)

In a survey that Karen Lasater, an assistant professor at the University of Pennsylvania School of Nursing, happened to conduct in the weeks right before the pandemic started in the United States, she found that nurses were already struggling because of insufficient staffing at their hospitals. Over half said they were experiencing high levels of burnout, and one in four planned to leave their employer.

When the pandemic hit, hospitals were caught off guard. Few had adequate personal protective equipment. “As we were getting ready to fight the virus, we did not understand we were about to fight an administration, too, for basic things like PPE,” said Mawata Kamara, a registered nurse at San Leandro Hospital in California. It was the first time in her more than decade-long career that she had to reuse an N95 mask. (“Despite unprecedented challenges, we have maintained good staff-to-patient ratios, adequate PPE in spite of global supply shortages, and excellent care,” a representative of San Leandro Hospital said in response to a request for comment.)

Many nurses, unsure how to protect their families when they returned home from work, came up with elaborate protocols. Falguni Dave, a registered nurse at Cook County Health in Illinois, went so far as to move out of her home for over a month and live in an apartment to prevent bringing Covid back to her older in-laws and her husband, who is diabetic. “The physical need to be able to touch and hold your family members when you come home from work” went unmet, she said. At the same time, a wave of acutely sick people suffering from Covid flooded emergency rooms across the country. “I don’t even know how to describe the amount of people who died and got sick,” said Maureen Kryszak, a registered nurse who has worked at Catholic Health’s Mercy Hospital of Buffalo for over a decade. Across the country, nurses contracted Covid and died by the thousands. Some left their jobs to shield themselves and their families from the virus. Hospitals, which had been cutting back on staff for years, couldn’t marshal enough employees to care for all their patients.

Without adequate staff and with an exponentially increasing number of deeply sick patients, the nurses’ workload became crushing—and it hasn’t let up, even as the country has acted as though it can move on from Covid. When we spoke in early February, Kryszak said her emergency room was “so overwhelmed” that patients couldn’t be transferred to other floors. They’re left in beds in hallways or, worse, in chairs. “We are bursting at every seam,” Kryszak said. (JoAn Cavanaugh, Mercy’s director of public relations, said, “Mercy Hospital of Buffalo has been challenged by staffing shortages and supply chain issues that have affected hospitals and businesses across the county over the past two years,” adding, “Mercy Hospital has seen a marked improvement in staffing [in March].”)

The conditions are similar at Kamara’s hospital. “It’s like playing checkers,” she said, constantly moving patients into rooms and into hallways, back and forth, trying to accommodate everyone coming in the doors. One patient with dementia, she said, recently had to be moved in and out of their room three or four times because the hospital didn’t have enough space. Management “create[s] these situations” by failing to adequately staff every department, Kamara said. “It’s just poor management in an environment where it’s literally life and death.”

Katie Johnson, a registered nurse at the Longview-Kelso Kaiser Permanente medical office in Washington, said she and her coworkers are forgoing breaks to care for more patients and staying late to finish their charts after they’re supposed to go home and rest. “If my patient needs medication and I also need to go to the bathroom, I’m going to pick my patient,” she said. The nurses avoid drinking water during their shifts so they don’t need to use the bathroom as often. When she’s at home, Johnson struggles to relax. “There’s that feeling of going home and wondering if you let a patient down. Even though you know that you’re giving good care, there’s always a part of you that’s wondering, ‘What if it wasn’t enough?’ or ‘Did I forget something?’” She has a hard time decompressing and even sleeping. “We’re just hanging on by a thread.”

“I honestly hate ‘burnout’—the word doesn’t even begin to describe what you’re really feeling,” Johnson said. (A Kaiser Permanente representative noted that the pandemic “has impacted the nursing profession across the country,” adding that the company “is committed to remaining an employer of choice through market-leading pay and benefits.”)

Brittany Smith, a registered nurse at Doctors Hospital of Manteca in California, cares for people before and after surgery. During almost every shift, she said, there are more patients per nurse than there are supposed to be under state law. “We are working in the most unsafe conditions I have ever worked in,” Smith said. She cares for six to eight people at a time who have had strokes or heart attacks as well as others who are having mental health issues or going through withdrawal, all of whom require frequent monitoring. Smith typically works three days in a row, putting in 12½-hour shifts, and in February she couldn’t take a single break, not even to eat a meal, often not even to use the bathroom. Working like that takes a toll on “mind, body, and soul,” she said. “You go home and your entire body hurts. You get nauseous because you haven’t eaten all day.” She frequently gets headaches and “brain fog” that makes it difficult to think. “That’s scary for the patients, when the nurse can’t think straight because they have no fuel in their body.”

“It’s horrendous—I don’t know how else to say it,” she added. (Smith’s hospital did not respond to a request for comment.)

The load got to be so much for Falguni Dave that she decided to take a pay cut to go from being a charge nurse in the medical-surgical unit to a bedside nurse in the ICU. “It was becoming too overwhelming to be the charge nurse and have to take on a full load of patients,” she recalled. “It felt like I wasn’t providing the best care for my patients.” (A representative for Cook County Health said that it has hired more than 1,300 nurses during the past two years and is “actively recruiting” for more than 300 open nursing positions.)

In the early months of the pandemic, many hospitals postponed elective surgeries. But most have resumed scheduling them, overbooking to make up for lost time, and it’s been busier than ever for the elective and outpatient surgeries that registered nurse Jack Trudell works on at UW Health in Wisconsin. Last fall, management decided to have people stay overnight in the recovery room because there weren’t enough beds elsewhere. “It didn’t feel like we were keeping the promise made to people,” Trudell said. “It just didn’t feel safe.” The stress has taken a toll on him. Years ago, he said, one of his children passed away, and he had a panic attack shortly after. He had his second panic attack recently. While driving with his wife, “all of a sudden things were moving way too fast,” he said. Trudell pulled over and let his wife drive. The next day he managed to drive himself to work, but when he started getting a report on his first patient, “it was like I didn’t hear the words,” he said. He ended up missing a week of work, and he still worries he could have a panic attack on the job. (UW Health press secretary Emily Kumlien noted that the pandemic “has put a strain on every health system and hospital in the country,” adding that the hospital has “always prioritize[d] the safety of our patients and our staff.”)

The emotional toll of caring for Covid patients still echoes. Kryszak remembers her first Covid patient, a man who had been grocery shopping and came in feeling short of breath. He later died. There are the elderly people who die alone, people begging her for the vaccine when it was too late. She’s had many sleepless nights. Days when she can’t eat. Days when she can’t bring herself to talk to her family. “You can’t get some of the visions out of your head, some of the people asking for help,” she said. She’s suffered chest pains and headaches and has experienced her heart racing. “There’s days you get out of bed and you just don’t know how you’re getting up to go back—other than you know there’s someone else there that needs help.”

Dave recently cared for an unvaccinated Covid patient in the ICU for three days, 12 hours each day, who kept telling her they were scared. On the last day, the patient had to be intubated and then died holding Dave’s hand. “I came home and I cried, because there was nothing I could do, even though I did everything in my power to possibly help,” she said.

Unprotected: Nurses at Kaiser Permanente in South San Francisco, Calif., rallied for better standards for health care workers as the pandemic began in March 2020.(Lea Suzuki / The San Francisco Chronicle via Getty Images)

The extreme workload and physical and mental anguish nurses are experiencing is a potent combination that has led to a number of strikes, protests, and union-organizing campaigns. All the nurses I spoke to said the main motivation was to secure better staffing to keep their patients and coworkers safe. Their own pay and benefits, while important, were secondary.

Kryszak had never been on strike before the pandemic, nor had many of her coworkers. But when they couldn’t make any progress on lowering nurse-to-patient ratios in their new contract, they went on strike in October for over a month. Though everyone worried about being able to pay their bills and keep their health insurance during the strike, 96 percent of the union voted in favor. Other departments struck with them. “We took an entire hospital out,” she said. It worked. The contract they eventually signed gives the hospital a year to meet staffing goals across all departments, making theirs the first union contract outside of California that enshrines nurse-to-patient ratios. That “will set a precedent for hospitals across New York and beyond,” her union said.

Dave hadn’t been on strike before, either; it had been decades since nurses at her hospital had walked out. But when management failed to address staffing in contract negotiations, her union decided to walk out in June. It was only a one-day strike, but it was “empowering,” she said. Within 24 hours, management met with the nurses and agreed to many of their demands.

In late 2020, while Kamara and her coworkers at San Leandro in California were pushing for staffing ratios in their new contract, management tried to get rid of a nurse advisory group. “We felt disrespected, we felt unheard, we felt gaslighted,” Kamara said. So they went on strike for five days in October of that year. During all five days of the strike, “the picket line was full,” she said. In the end, they got what they wanted: “We walked away with a contract with no takeaways.”

Many nurses decided to unionize during the pandemic. Doctors Hospital is small, and before the pandemic, Smith said, “it felt like a really family-like environment.” That family started talking to each other in the hopes of improving things at the hospital. Last September, 94 percent of the nurses there voted to join the California Nurses Association.

For Trudell, the UW Health nurse, trying to persuade his coworkers to unionize has been a way to cope with the emotional distress he feels. “It just felt like I’m taking part in something that’s taking that control back,” he said. “Whether I never got a raise again, having my profession back, my voice back, and that kind of respect back, I’d take that.”

Their patients are also likely to benefit. “There’s a substantial body of evidence to suggest that nurses’ unions contribute quite a bit to quality care,” said Ariel Avgar, a professor at Cornell University’s School of Industrial and Labor Relations who has studied health care. One study found that patients in unionized hospitals in California were 5.5 percent less likely to die from heart attacks. Another found unionized hospitals outperform nonunion ones on 12 of 13 patient outcomes.

“It seems like nurses are finally realizing that they’re important and they have rights and we are a force,” said Haff, the Community First nurse. “It’s about time. It should have been like that a long time ago.”

Yet despite these bold actions and even a number of unionization and contract wins, most nurses I spoke with said little has actually changed. Even those who secured concessions and agreements from management through strikes said that they have yet to be implemented.

Even after the contract victory in late 2020, staffing is still too low at Kamara’s hospital, she said. The Friday before we spoke in early February, she worked her shift from 3 am to 11 am, and her team was so shorthanded that she didn’t have a single break. When it was time to leave, only one nurse out of four showed up for the next shift. She said her manager tried to guilt-trip her into staying. “This is your job, to make sure that the emergency room is staffed,” Kamara remembered thinking. Still, it’s “morally distressing” to leave patients and coworkers in that situation, she admitted. “It makes me angry. It makes me want to keep fighting even more.”

Haff’s hospital still hasn’t committed to staff ratios, and the things the union did secure in the contract are being implemented only intermittently. The strike and subsequent contract were just a first step: “We have to hold them accountable,” Haff said. “We’ve got a long way to go.” (In response to a request for comment, Community First chief operating officer Faisal Master and chief nursing officer Dina Lipowich said the contract “literally tracks the language of the Illinois Nurse Staffing Improvement Act of 2021,” but noted that the hospital’s budget is “generally tied to the financial state of affairs of the State of Illinois, because a large percentage of the hospital’s funding comes from the State of Illinois.” They claimed that the investment bank’s ownership “ultimately saved over 1,000 jobs” and that the supply shortages were not specific to the hospital.) Johnson, the Kaiser Permanente nurse, said that there are still hundreds of open, unfilled positions at her hospital. Despite hiring benchmarks being enshrined in her union’s contract, Kryszak believes that staffing levels are actually worse than before the strike thanks to people leaving, and that the hospital won’t meet the deadline of January 2023. “The more short-staffed we are, the more people leave,” she said. “Something has to be done somewhere.”

On the picket line: Nurses at St. Vincent Hospital in Worcester, Mass., went on strike for nearly a year, the longest nursing strike in at least two decades.(Joseph Prezioso / AFP via Getty Images)

The nightmarish conditions nurses have faced during the past two years are a heightened version of the tough conditions they’ve always endured. They often work long shifts, sometimes at odd hours. They face high rates of violence at the hands of patients. But one factor tops the list and has been getting worse for decades: a simple lack of enough staff on hand to adequately care for all of the patients in a hospital. Kryszak has worked at her hospital for over 10 years. “Staffing has always, as long as I’ve known it, been an issue,” she said. “Sometimes it feels like nothing more than an assembly line.” Unionized nurses have a way to push back when given patient loads that they feel are unsafe: signing Assignment Despite Objection forms codifying their dissent, which shifts responsibility to management in the case of adverse outcomes. Even before the pandemic, signing them had become a nearly everyday occurrence for many of the nurses I spoke to.

The health care industry blames a so-called nurse shortage. But that explanation warps reality. The number of people passing their nursing licensing exam has grown steadily since 2002, with 184,500 in 2021, an increase of 13,000 over 2019. It’s “a false narrative that nurses are leaving the profession,” said Lasater, the University of Pennsylvania professor. “What is happening is nurses are saying they plan to leave their employer.” The nurses I spoke with said the problem is that hospitals aren’t offering working conditions and benefits that keep people on the job. Without more support from management, Smith said, there’s been a “mass exodus” of nurses from her hospital. “This staffing crisis is not because we don’t have enough nurses. It’s because nurses can’t work in these conditions any longer.”

Staffing levels fluctuate wildly among facilities; in some, nurses are assigned as many as 10 patients at once. Better staffing levels would help alleviate the workloads, but that’s not the only benefit. “Bad working conditions lead to bad patient care,” said Avgar. “Better working conditions lead to better patient care.” One study found that each additional patient assigned to a nurse increased the likelihood of a patient dying and also increased the rate of burnout among the nurses. On the flip side, hospitals with more nurses have lower rates of mortality and fewer readmissions.

But with the ever-spiraling costs of US health care, many hospitals are “under tremendous financial strain,” Avgar said. As they have become increasingly focused on their bottom line, it’s fallen to nurses to demand safer, better care. “Hospitals are often very short-sighted in their thinking about this,” Lasater said. “They only see nursing as an expense rather than [appreciating] everything they do to save money and increase efficiencies in care.”

The irony is that while there’s an up-front cost to hiring more nurses, the investment pays off in the long run. One study found that if hospitals in Illinois stuck to a ratio of four patients to each nurse, they would not only avoid nearly 1,600 deaths but also save over $117 million a year thanks to shorter patient stays. In New York, according to a similar study, that would save 4,370 lives and $720 million over two years. “In truth, nurses are the revenue generators of hospitals,” said Lasater, who was the lead author of these studies. A study in Australia found that increasing nurse staffing more than paid for itself in savings.

“By virtue of choosing this profession…nurses make an ethical commitment to patients,” Lasater said. “Hospitals have taken advantage of that and have long put nurses into these impossible working conditions because nurses will continue to show up.”

The dynamic is inseparable from gender. More than 85 percent of registered nurses are women. “Nursing is still viewed as women’s work,” noted Lisa Huebner, a professor of women’s and gender studies at West Chester University in Pennsylvania and the author of Catheters, Slurs, and Pickup Lines: Professional Intimacy in Hospital Nursing. “The notion of a nurse being naturally caring—it’s because we’re thinking women are naturally caring.” In her research, she found that hospital administrators and managers saw care as something inherent to nurses’ personalities, not an important facet of their professional responsibilities. “If we are constantly talking about care as just something [women are] naturally good at, it’s not going to require any other resources, time, staffing, expertise. It should just naturally happen,” Huebner said. It’s easier, then, to cut back on staffing and resources for nursing if it’s assumed they’ll keep doing their best to care for patients.

Johnson’s hospital implemented a “lean model” as far back as 2018, she said. “We went into this pandemic in a shortage that we already had by their making,” Avgar noted that the same is true throughout the industry: “What we’re seeing in health care during the pandemic is the price of not investing in the system well before the pandemic.”

First responders: Nurses cared for thousands of sick and dying people in the early months of the pandemic, and many say the stress still lingers.(Frederic J. Brown / AFP via Getty Images)

Individual, hospital-by-hospital organizing can chip away at poor conditions and inadequate staffing, but the problem is too big to leave to nurses alone. One way to take the burden off nurses would be for the government to step in and require hospitals to have enough staff to ensure good care. But only one state, California, currently mandates staffing ratios.

Some states have tried to join California, but they’ve met stiff resistance from the health care industry. “The stakeholder group that has actively lobbied against safe staffing mandates are hospitals,” Lasater said. In Massachusetts, voters shot down a ballot measure that would have enshrined nurse-to-patient ratios in law after a campaign backed by a hospital association spent $24.5 million opposing it. New York considered staffing-ratio legislation, but after hospital associations “pushed back really strongly,” Avgar said, lawmakers ended up only requiring hospitals to form committees on the issue. Illinois has also considered a safe staffing bill that hasn’t yet become law.

A national solution could be achieved relatively quickly if the political will were there. Medicare already requires the hospitals that it reimburses—which is nearly all of them—to meet quality standards. It could use that same authority, Lasater argued, to require that they meet staffing levels that ensure quality care. “But they don’t do it,” she said. A Senate bill that would require all hospitals to comply with specified ratios hasn’t gotten any traction this year.

Avgar said he senses a “possible change in the air” after the last two horrific years. According to Lasater, “the pandemic blew open the doors of hospitals in a way that hasn’t happened, really, over the last several decades.” Public awareness of the importance of nursing is higher than ever.

But Avgar also fears that the country will have a short memory. The public enthusiasm for essential workers that inspired people to bang on pots and pans in the early days of the pandemic has long since faded, and the federal funding for Covid testing and treatment for the uninsured and for antibody treatments meant to keep patients out of hospitals has expired, raising the risk of even bigger surges in cases. “There’s a narrow window of opportunity,” Avgar said. “Can unions, policy-makers, [and] workers capitalize on that to create sustainable long-term change?”