By Lauren Coleman-Lochner

Fallout from the nursing shortage that’s plaguing U.S. hospitals got so bad that 16% of the nurses at one western Pennsylvania facility left last year, and 220 of those remaining staged a five-day walkout that halted elective surgery.

Sandra Harrison, an operating room nurse who’s spent her 39-year career at ACMH Hospital, teared up as she recounted working without even a lunch break and years of missed family and events. Her colleague, Stephanie Barrett, is exhausted from doing two, three and sometimes four jobs at a time. “I think pretty much almost everybody has considered, if not leaving health care altogether, taking a different path in nursing,” Barrett said. “I don’t know anybody who hasn’t.”

The nurses said during the March walkout they’re tired of caring for too many patients in 160 beds with too few people. About 5,000 nurses in Palo Alto, California won a new contract after going on strike last month, citing similar complaints.

The rebellions reflect the exhaustion and frustration that’s led to a national wave of nurses quitting even as the need has surged. It predates the pandemic, and it’s not likely to get better by itself: The U.S. forecasts an annual average of 194,500 openings for registered nurses through 2030.

Hospitals and nurses agree there’s a shortage of bedside nurses, and that it’s bad for the patients. Sometimes they die as a result. What the two sides don’t agree on is the solution.

Nursing groups say conditions worsened by the pandemic existed for years, and the cure is to set minimum staff levels. Hospitals say mandates can magnify shortages and deny them control of their largest expense as they fight for their own survival. The idea nevertheless is gaining traction.

“It is important if we want to reduce fatalities, if we want to eliminate harm, the kinds of accidents that can happen in hospitals,” said Illinois Rep. Jan Schakowsky, who’s pushing a national bill to set minimums. “We know that patients do better. Mortality is significantly decreased.”

Costs Spike

The American Hospital Association’s nursing affiliate has called mandates “a static and ineffective tool that cannot guarantee a safe health care environment or quality level,” and said they don’t account for variables such as how sick patients are.

What’s more, hospitals say they can’t afford mandates. The pandemic battered their already-tight finances, shutting down elective surgery and spiking costs for labor and supplies. The association figures the outbreak cost members at least $400 billion.

Consulting firm Kaufman Hall said a third of U.S. hospitals were losing money last year, and Harold Miller, an adjunct professor and former associate dean at Carnegie Mellon University, estimated at least 40% of U.S. rural hospitals, about 800, are at high or imminent risk of closing. That’s on top of 104 from all regions that shut in the past four years, according to the Medicare Payment Advisory Commission.

The federal funding programs now winding down gave hospitals some breathing room but didn’t fix underlying issues like inadequate government reimbursements, said Diane Rafferty, managing director at the Alvarez & Marsal turnaround firm. “You’re going to see hospital closures,” she said.

That probably means more pressure to cut staff, but fewer nurses mean more deaths. “We’ve been saying this for 30 years and the findings are irrefutable,” said Linda Aiken, a University of Pennsylvania professor who researches the issue. A year-long study she co-authored found mortality for 201,493 Illinois Medicare patients rose 16% for each added person nurses had to oversee. A 4-to-1 patient ratio would have saved about 1,595 lives and $117 million, in part by shortening stays, the paper concluded.

States have earmarked billions of dollars for retention payments, signing bonuses and education assistance. Still, hospitals sometimes must pay temp agencies hundreds of dollars an hour to fortify their ranks. Nurses at ACMH said recruits sometimes sign on and leave after a short time.

Moral hazard plays a role in the turnover, said Gerard Brogan, nursing practice director at the National Nurses United union and its California chapter. It’s the distress nurses feel because they can’t do their best for their patients.

Barrett, 36, says she’s already considered a senior nurse in her ACMH unit after only six years. She often finds herself watching heart monitors and caring for patients in hallways, some held in the ER for days because beds weren’t available. “I’ve had 15 patients at one time,” she said.

Rural Care

The hospital’s hometown, Kittanning, population 3,789, is the seat of Armstrong County, a mix of farms and old coal and oil towns. It’s flanked by the Allegheny River, with a handsome courthouse on a hill and gourmet coffee that would stand up in New York and Seattle, but also a downtown dotted by vacancies and a Dollar General store.

“Health care in rural Pennsylvania is a major issue,” said John Fetterman, the lieutenant governor and US Senate candidate, who saw the hospital in his small town close when he was mayor. He called minimum staffing “fundamental to patient safety, fundamental to prevent nurse burnout.”

But staffing “is one component of the issue and one component of the solution,” said Rafferty, who holds degrees in nursing and healthcare administration and served as an interim hospital CEO.

Cutting Back

For example, she said, hospitals may cut back on other items like equipment to meet mandates, and some in California have eliminated staffers who did tasks like bathing patients, leaving registered nurses to do them.

As for retention, Rafferty said nurses today have other options such as telehealth and management, not to mention other career choices. To keep nurses in the field, hospitals need to provide mentoring and career paths, she said. Affiliations with nursing schools would help, too.

ACMH didn’t respond to requests for comment. Pennsylvania’s hospital association opposes the staffing bill, saying state and federal laws exist to ensure patient safety and that setting mandates amid a shortage could force shutdowns, said spokesman Liam Migdail. His group says the state averages vacancies of 27% for nurses who directly care for patients.

California Mandate

While Pennsylvania is one of a handful of states weighing staffing laws, California is the only state that passed one. Annual turnover has been a fraction of other states’ since the law was enacted in 2004, and nursing injuries and patient re-admissions plunged too, Brogan said.

“It’s saving hospitals money,” he said, citing a Robert Wood Johnson Foundation study estimating costs to replace and train a nurse at $40,000 to $85,000. But because executive turnover is so frequent, “we’re in the short-term profit zeitgeist.”