# Why is the Field of Nursing So Toxic?



## OrchidSugar (5 mo ago)

This profession comes up often in discussions of bullying, abuse, power plays, interpersonal conflict, and burnout. Why is that? And is this a uniquely American phenomenon?

Edit: Even pre-pandemic.


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## Warp11 (Jul 13, 2016)

Are there any areas of nursing you want to discuss? E.g. ER vs. Palliative care. The demands would be quite different.


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## DOGSOUP (Jan 29, 2016)

You might wanna check out Nurse Hate is just Corporate Propaganda at r/antiwork if it is still up.


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## OrchidSugar (5 mo ago)

Warp11 said:


> Are there any areas of nursing you want to discuss? E.g. ER vs. Palliative care. The demands would be quite different.


I'm not familiar with the different disciplines, but would be open to learning about them. I know nothing.


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## OrchidSugar (5 mo ago)

DOGSOUP said:


> You might wanna check out Nurse Hate is just Corporate Propaganda at r/antiwork if it is still up.


Post got deleted, but I can see comments


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## recycled_lube_oil (Sep 30, 2021)

Competitive environment? I have never worked in Nursing but taking these things you mention:



> bullying


Not sure what you mean by bullying. But have had managers (in non-nursing and also I am not even mentioning when I was in the military) who have regulary asked emloyees questions like "Why the fuck do I even employ you" in front of the whole office and in front of visitors.



> , abuse,


No comment, have seen shit in the army which would be classed as abuse. Have seen shit in civvi land classed as abuse which made me want to abuse the person making the allegation as it was pathetic.



> power plays


Is this not normal anywhere? Even outside the workplace.



> , interpersonal conflict


This probably is just a side product of anywhere you work with other people. And I am going to guess that Nursing is quite a stressful job anyway. Sp the stress will affect people differently.



> , and burnout.


I know from experience that this is not limited to nursing.



> Why is that? And is this a uniquely American phenomenon?


This sounds like it could be a UK workplace, so doubt it is limited to across the pond. My question, whydo you think nursing would be exempt from normal working conditions?

As someone who has worked military/finance/betting industry/more finance (ugh)/public sector/social care, I would say this is normal.

In companies that are profit driven, mainly finance, I would say it is even worst. You do learn how to navigate office politics though, it is good for personal development. I have also heard that working in legal, can be quite horrific (the perks and pay exist for a reason).

But yeah, burnout sucks. I experienced it in my last job on a regular basis and my leave was just spent dreading going back to work. It was great (sarcasm).


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## OrchidSugar (5 mo ago)

recycled_lube_oil said:


> Not sure what you mean by bullying. But have had managers (in non-nursing and also I am not even mentioning when I was in the military) who have regulary asked emloyees questions like "Why the fuck do I even employ you" in front of the whole office and in front of visitors.


What I mean by bullying is exactly as you described. I can only go from stories I have heard:

Shift manager controlling the schedule in such a way that certain individuals are overworked and under-rested
Assigning holidays to the same folks over and over, based on favoritism
Yelling, verbal humiliation, and degrading behavior in public and private
Groups of people working in teams to harass or ostracize one individual
Attempts at covertly sabotaging a colleagues work




recycled_lube_oil said:


> No comment, have seen shit in the army which would be classed as abuse. Have seen shit in civvi land classed as abuse which made me want to abuse the person making the allegation as it was pathetic.


Yes. I think the army is an inherently toxic environment to work in. That's clear. Are you of the mindset that since you suffered greatly without speaking up, someone who suffered less should also suffer without speaking up?



recycled_lube_oil said:


> Is this not normal anywhere? Even outside the workplace.
> I know from experience that this is not limited to nursing.


I'm wondering if there are some things that are unique to the nursing profession, because from my perception, the stories of toxic workplace behaviors seem more prevalent in this industry than in certain others, like tech, customer service, marketing, teaching, etc. 

I'm not arguing that toxic behaviors don't exist elsewhere. I'm asking if there is something unique to the field of nursing that makes the pattern more easily recognized and highly vocalized.



recycled_lube_oil said:


> My question, whydo you think nursing would be exempt from normal working conditions?


So once something has been normalized, does that mean we must never question or attempt to improve it ever again?


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## JennyJukes (Jun 29, 2012)

I've worked in care as well as being based in a hospital (working on the social side e.g. homelessness rather than medical) and I've always said care attracts the best and worst people. Honestly met the most caring, wonderful people in care on one hand but the slyest bullies on the other hand too.

There are several reasons it gets a reputation of being bitchy and toxic I guess:

1) Care and nursing means long hours for very little reward. When I worked in the hospital, I was absolutely shocked at some of the attitudes towards homeless people or those with mental health issues or addictions. I thought, how are you a nurse?! I could understand though because they had very limited resources and got a lot of abuse from people with social issues. Also, most of them train on the medical side and don't get full training on dealing with people with additional social issues. That's a full time profession in itself which they're not trained to deliver. It's a lot to ask someone and it's only natural they are burnt out and get a bit jaded. This is partly why I was brought in to give specialised advice and assistance. It let them do the medical side and I took over the social side. It's too much to expect from one person IMO. 

2) Many nurses go through University and training together so know each other for a very long time, plus spend most of their time with them because of their long hours. Families get annoyed at each other after a while, so why not nurses? Also, they work on really difficult cases and have to really get to know each other and trust each other. There's bound to be a few that can't get along well but have to spend so much time with each other, and that conflict and bad feelings toward another can build up.

3) Nursing is predominantly woman and many women love to gossip. It's a form of social bonding. As above, they spend so much time with each other, they know each other's business and which buttons to press. It seems high school stuff but I've seen it in different professions, I've even heard of it in my boyfriend's work (engineering), I think toxicity and gossip can be found anywhere, some are just more covert.

4) At least where I live, care doesn't require qualification (but nursing does of course), so it's an easy career for anyone to get into. There's always a need for carers too, so I've seen some work places employ people they probably never should have (with one being fired from a previous role and another actually being struck off the register).... I was shocked when I saw my high school bully was a carer, but I suppose she needs to make a living too, even if she doesn't really _care_. Does make me laugh when I see people who made my life hell become mental health nurses or post "mental health matters" but people do grow up after all.


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## DOGSOUP (Jan 29, 2016)

OrchidSugar said:


> Post got deleted, but I can see comments


Ok as I recall some of the comments were very informative too. Also one thing to consider is nursing being a female dominated field, so that probably impacts the way power plays and interpersonal conflict emerges and is dealt with. (As @JennyJukes just pointed out as I write this).


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## Sily (Oct 24, 2008)

I worked with nurses for 25 years. I was in no way a nurse myself. These are my observations on why stress and pressure transfers over to toxicity—

1. Some of the nurses work with asshole doctors.
2. Nurses were checked and rechecked on their duties.
3. Nurses make mistakes (they are human) and sometimes people die.
4. Long hours.
5. Double shifts.
6. Too many duties.
7. Dealing with too much crap 💩, blood, broken bones, vomit 🤮 and death during the day.
8. Patients who are rude or crazy or don’t want to be there.
9. Doctors don’t do their jobs, or physical therapists, or other professionals.
10. They have to do mostly everything the doctor says. I THINK in the past I have seen doctors screw up and nurses having to cover mistakes. I always had the impression in nursing school it was beat into nurses, to always cover, for the doctor.
11. Lastly, physical abuse and emotional abuse from patients.
12. I FORGOT one - - ->>> the Director of Nursing was a Commander. Very hard on her nurses.


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## OrchidSugar (5 mo ago)

That's a thorough reply. Thank you.



JennyJukes said:


> At least where I live, care doesn't require qualification (but nursing does of course), so it's an easy career for anyone to get into. There's always a need for carers too, so I've seen some work places employ people they probably never should have [...] I was shocked when I saw my high school bully was a carer, but I suppose she needs to make a living too, even if she doesn't really _care_.


I hate that. When you see your bully doing a job that requires empathy. Rip. But I think you're right. Sometimes we end up in jobs that are not well suited because we need to pay bills and survive. So we are grateful for what we can get.



JennyJukes said:


> Also, most of them train on the medical side and don't get full training on dealing with people with additional social issues. That's a full time profession in itself which they're not trained to deliver.


Just for those of us who don't know the lingo. Would you say the following definition is what you mean by "carer"? I'm also wanting to make sure we're talking about the same job description across different countries. 

"Care Coordinators facilitate conversations between interdisciplinary Care Teams (including Patient Navigators, Care Coordinators, primary care physicians, and additional health care providers) and expedite client services referrals."

Would you say it's someone performing case management and social services?



JennyJukes said:


> Many nurses go through University and training together so know each other for a very long time, plus spend most of their time with them because of their long hours.





JennyJukes said:


> Nursing is predominantly woman and many women love to gossip. It's a form of social bonding.


I think the working together with the same cohort over a long time can definitely facilitate social bonding teams or gangs, depending on the day. I do often hear a lot about travel nurses and newbies experiencing a rough go with bullying.


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## Necrofantasia (Feb 26, 2014)

OrchidSugar said:


> This profession comes up often in discussions of bullying, abuse, power plays, interpersonal conflict, and burnout. Why is that? And is this a uniquely American phenomenon?
> 
> Edit: Even pre-pandemic.


Being overworked by the sick, the ignorant and the vulnerable while being a woman makes for a bad combo.


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## MsMojiMoe (Apr 7, 2021)

I just got out of the hospital a few days ago…I had to get my gallbladder and stones removed..I was there for 5 days.

i can’t mention anything about the actual business but the other patients ( bc I had roommates), it was shocking how they behave. I worked retail/customer service a long time ago, never again, but this reminded me how ppl act towards the workers.

i had one roommate at a time…there were curtains that separated us…total of two roommates while I was there

both roommates were older women, who were in their late 60s, with UTI …now I guess this effects older women differently than younger ones…and it can cause confusion…but, idk

both women acted like they were 5 years olds…constantly lying and complaining, no regard for me either…like why they had TVs in rooms ( one for each of us)… this lady wouldn’t turn off her tv even when she kept falling asleep in front of it ( I was force for 19 hours…the second lady didn’t watch tv, thank goodness)…and she wouldn’t turn it down…they asked her to be mindful of her roommate ( me), and she was like that’s okay…zero care about others, no it’s not okay….. She might need surgery the next day so no water or food…but had her daughter sneak food for her…( ppl and their food, the other roommate did this too…and while I was walking I heard a nurse ask another nurse if a doctor had cancel a patients surgery, bc the patient told her that he did, so they can have food…like these ppl are older and don’t they get it, or do we just become entitle liars in our 60s or maybe it could be from the illness but can UTI really cause ppl to act like this)…like this woman is in her 60s acted like a little child, lying , sneaking and having temper tantrum’s to get their way…
she constantly yell at 5he nurses in particular this one that was Asian, even telling her to go back home…like wow, the nurse kept her cool tho…at one point, the lady peed and poop bag got stuck, her poop was thick, and the nurse had to weave it thru these tubes.. ( I could only hear and smell this) …but the lady just kept berating the nurse, telling her she is doing it wrong, and she has been doing it herself for 15 years and your not suppose to use alcohol pads but soap an$ water…and would have a fit screaming for other nurses etc, finally the nurse said would you like to do it…and she said, no very quietly … I wouldn’t have the patients for this kind of behavior from adults…She also would yell at this particular nurse for anything (she yell at everyone) …like the nurse was trying to take her vitals, and the lady kept yelling at her, you can’t just give ppl meds, and the nurse was like I’m not, I’m checking your vitals..she wanna to call the cops again….it was a nightmare…I was a.ways taught to respect elders but how can one respect such behaviors.

both women were also very big, and couldn’t turn themselves over…so every twenty mins they wanted to be moved, and would start yelling at the top of their lungs, both.. so this wasn’t an isolated instance …either would push the call help button, I had to keep doing it for them…one lady wanna to call the cops bc her phone died and the nurses didn’t plug it i for her yet..( but she couldn’t bc her phone was dead but kept threatening it) it was only 10 mins…they have other patients ….

this isn’t even the half of it…like I hope it was the illness that was causing these behaviors( which could of been) but I don’t get how adults can act like this if not…like how does confusion make you act like this or are ppl really this entitle and ungrateful …I was shame that adults can act like this, no regard or care for their care givers or anyone…just someone to yell at. It reminded me so much of retail.

So don’t know the business side but the patient side is awful how they are treated…I would burn out the first month. I couldn’t handle that. It was hard just being a patient and having to witnesses it for 5 days…I couldn’t wait to get home.


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## Squirt (Jun 2, 2017)

MsMojiMoe said:


> both roommates were older women, who were in their late 60s, with UTI …now I guess this effects older women differently than younger ones…and it can cause confusion…but, idk


When I worked at a customer-facing job, there was an older lady who was a regular. One day she came in and was extremely disgruntled and disoriented. It shocked me because usually she was so sweet and easy to help. She was acting like a different person and ended up storming out. After another week or so, she came back and apologized for what happened, and told us she had a UTI that apparently came along with psychological effects where she was having hallucinations and couldn't remember things (that she'd never heard of until after she went to the doctor). She was still shaken from the experience after getting medical treatment, but no longer as confused or angry.

It doesn't really make it any easier to handle, but it is very possible that at least some of that behavior was due to the infection.



> *Psychological UTI Symptoms*
> The main effect of a UTI on a senior’s mental health is delirium. The U.S. Library of Medicine defines delirium as a mental state in which a person is confused, disoriented and unable to think or remember clearly. The following symptoms of delirium are commonly seen in older adults with UTIs. However, they may not all be present, and they may fluctuate over time.
> 
> Any sudden change in mental status
> ...


UTIs Cause Unusual Behavioral Symptoms in Elders - AgingCare.com


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## 98403942 (Feb 10, 2021)

Vulnerable customers.


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## MsMojiMoe (Apr 7, 2021)

Squirt said:


> When I worked at a customer-facing job, there was an older lady who was a regular. One day she came in and was extremely disgruntled and disoriented. It shocked me because usually she was so sweet and easy to help. She was acting like a different person and ended up storming out. After another week or so, she came back and apologized for what happened, and told us she had a UTI that apparently came along with psychological effects where she was having hallucinations and couldn't remember things (that she'd never heard of until after she went to the doctor). She was still shaken from the experience after getting medical treatment, but no longer as confused or angry.
> 
> It doesn't really make it any easier to handle, but it is very possible that at least some of that behavior was due to the infection.
> 
> ...


yeah, I read all about it while in the hospital, trying to understand….that’s why I did mention it….bc it really could be from the illness…but wow, it’s shocking And so extreme….It’s hard to understand how, but it seem to really affect older ppl differently. if it is from the illness, it’s a little more tolerable bc you know it isn’t their fault, but if not is really is disappointing we could treat others like that esp when they are trying to help you.
thanks, for your story with it, it soften my heart a bit knowing this was from the illness and not how the person really is.


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## Squirt (Jun 2, 2017)

MsMojiMoe said:


> yeah, I read all about it while in the hospital, trying to understand….that’s why I did mention it….bc it really could be from the illness…but wow, it’s shocking And so extreme….It’s hard to understand how, but it seem to really affect older ppl differently. if it is from the illness, it’s a little more tolerable bc you know it isn’t their fault, but if not is really is disappointing we could treat others like that esp when they are trying to help you.
> thanks, for your story with it, it soften my heart a bit knowing this was from the illness and not how the person really is.


I mean, I’d be having the same trouble. That’s hard. What a taxing stay, on top of going through surgery yourself. Hope you are doing well, btw.


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## recycled_lube_oil (Sep 30, 2021)

OrchidSugar said:


> What I mean by bullying is exactly as you described. I can only go from stories I have heard:
> 
> Shift manager controlling the schedule in such a way that certain individuals are overworked and under-rested
> Assigning holidays to the same folks over and over, based on favoritism
> ...


Sounds like "here is my 4 weeks notice" situation.



> Yes. I think the army is an inherently toxic environment to work in. That's clear. Are you of the mindset that since you suffered greatly without speaking up, someone who suffered less should also suffer without speaking up?


No I have no issues with them speaking up. However.... there is a phrase "Think about who you are complaining to". As someone who has been in the army, do you really honestly think I am the person to complain to about the terrible hardships of civilian life? Like, lets be serious. At best I will offer to write your resignation letter for you.

Also, from an employers perspective, it does me favours as I can navigate the shit and not give a f**k.



> I'm wondering if there are some things that are unique to the nursing profession, because from my perception, the stories of toxic workplace behaviors seem more prevalent in this industry than in certain others, like tech, customer service, marketing, teaching, etc.
> 
> I'm not arguing that toxic behaviors don't exist elsewhere. I'm asking if there is something unique to the field of nursing that makes the pattern more easily recognized and highly vocalized.


I think its more shocking when its Nurses. I can't explain why, but Nursing dosn't strike me as somewhere I would expect to be toxic if I were naive.



> So once something has been normalized, does that mean we must never question or attempt to improve it ever again?


You can do whatever you want. But when talking about strikes and workplace revolutions, please leave me alone as I generally have work to do and in all honesty people refusing to work and complaining all the time, hey it makes me look better. So yes, by all means carry on. Whatever works for you.


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## OrchidSugar (5 mo ago)

recycled_lube_oil said:


> No I have no issues with them speaking up. However.... there is a phrase "Think about who you are complaining to". As someone who has been in the army, do you really honestly think I am the person to complain to about the terrible hardships of civilian life? Like, lets be serious. At best I will offer to write your resignation letter for you.


I can’t really speak to their intent, but it’s possible that they are trying to connect with you in another way. Not as an army man, but as a fellow concerned citizen, taxpayer, stakeholder, or something else. They don’t realize how pointless it is to discuss these issues with you because they don’t know you well enough yet.



recycled_lube_oil said:


> I think its more shocking when its Nurses. I can't explain why, but Nursing dosn't strike me as somewhere I would expect to be toxic if I were naive.


Shocking or no, communities have a vested interest in the people who care for their health to not be violent, burnt out, enraged, and harmful to others.



recycled_lube_oil said:


> You can do whatever you want. But when talking about strikes and workplace revolutions, please leave me alone as I generally have work to do and in all honesty people refusing to work and complaining all the time, hey it makes me look better. So yes, by all means carry on. Whatever works for you.


Hell yeah brother. Don’t engage with that kind of content if it upsets you. And if you meet anyone who insists on talking about it, may be best to just plug your ears until you can get away from them. You and this kind of person could never ever be compatible.


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## chad86tsi (Dec 27, 2016)

OrchidSugar said:


> What I mean by bullying is exactly as you described. I can only go from stories I have heard:
> 
> Shift manager controlling the schedule in such a way that certain individuals are overworked and under-rested
> Assigning holidays to the same folks over and over, based on favoritism
> ...


Absent actual examples, I see nothing here that does not exist in other work fields. I'm curious what drove the decision to pin this toxic behavior to one single work field...


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## Deezzee (Nov 25, 2011)

chad86tsi said:


> Absent actual examples, I see nothing here that does not exist in other work fields. I'm curious what drove the decision to pin this toxic behavior to one single work field...


I guess the ultimate irony is that nursing is a caring profession – if you can't display basic decency to your co-workers/subordinates, how are you going to provide a certain standard of care to the patients?

For a person acting in bad faith, nursing (without counting doctors) hardly sounds like the most appealing industry to get rich quickly. If someone wants to go on a power trip, they would join the military or law enforcement, where they would be explicitly granted authority to exert force and dominance over other people.


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## chad86tsi (Dec 27, 2016)

Deezzee said:


> I guess the ultimate irony is that nursing is a caring profession – if you can't display basic decency to your co-workers/subordinates, how are you going to provide a certain standard of care to the patients?
> 
> For a person acting in bad faith, nursing (without counting doctors) hardly sounds like the most appealing industry to get rich quickly. If someone wants to go on a power trip, they would join the military or law enforcement, where they would be explicitly granted authority to exert force and dominance over other people.


What little toxic conduct I saw from Nursing staff rarely found it's way to those in their care, though I did see poor care delivered as well. Toxic work stuff I saw mostly revolved around survival/boundaries/turf-war kind of behaviors, and that's not uncommon in most fields where there is big money, pressure, and high stakes. 

The truly excellent nursing staff never batted an eye at this garbage and just did their jobs. It takes a special kind of soul to rise to this level, and not all qualify.


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## OrchidSugar (5 mo ago)

I'm dropping this article here. So I can read it later...

*How a Sprawling Hospital Chain Ignited Its Own Staffing Crisis*
Ascension, one of the country’s largest health systems, spent years cutting jobs, leaving it flat-footed when the pandemic hit.


* *






By Rebecca Robbins, Katie Thomas and Jessica Silver-Greenberg
This article, the third in a series on nonprofit hospitals, was reported from Joliet, Ill., Grand Blanc, Mich., and New York.

Dec. 15, 2022
At a hospital in a Chicago suburb last winter, there were so few nurses that psychiatric patients with Covid were left waiting a full day for beds, and a single aide was on hand to assist with 32 infected patients. Nurses were so distraught about the inadequate staffing that they banded together to file formal complaints every day for more than a month.
About 300 miles away, at a hospital outside Flint, Mich., similar scenes were unfolding. Chronic understaffing meant that patients languished in dried feces, while robots replaced nursing assistants who would normally sit with mentally impaired patients.
Both hospitals are owned by one of the country’s largest health systems, Ascension. It spent years reducing its staffing levels in an effort to improve profitability, even though the chain is a nonprofit organization with nearly $18 billion of cash reserves.
Since the start of the pandemic, nurses have been leaving hospitals in droves. The exodus stems from many factors, with the hospital industry blaming Covid, staff burnout and tight labor markets for acute shortages of staff.

But a New York Times investigation has found that hospitals helped lay the groundwork for the labor crisis long before the arrival of the coronavirus. Looking to bolster their bottom lines, hospitals sought to wring more work out of fewer employees. When the pandemic swamped hospitals with critically ill patients, their lean staffing went from a financial strength to a glaring weakness.
More than half of the roughly 5,000 hospitals in the United States are nonprofits. In exchange for avoiding taxes, the Internal Revenue Service requires them to offer services, such as free health care for low-income patients, that help their communities.

But The Times this year has documented how large chains of nonprofit hospitals have moved away from their charitable missions.
Some have skimped on free care for the poor, illegally saddling tens of thousands of patients with debts. Others have plowed resources into affluent suburbs while siphoning money from poorer areas.https://www.nytimes.com/interactive...on=CompanionColumn&contentCollection=Trending

And many have cut staff to skeletal levels, often at the expense of patient safety.
At a single hospital in Northern California, the sprawling nonprofit hospital chain Providence laid off dozens of medical staff in 2017 and 2018, resulting in long waits for crucial care. At a Washington State hospital that is part of CommonSpirit Health, another giant nonprofit chain, years of belt-tightening reached a breaking point in October when an overwhelmed nurse called 911 dispatchers, who sent the fire department to help care for patients.









Ascension’s Genesys hospital in Michigan.Credit...Dieu-Nalio Chéry for The New York Times


Ascension, which runs 139 hospitals, among the most of any chain in the United States, is emblematic of the industrywide movement to keep labor costs low.
As recently as 2019, Ascension was trumpeting its success at reducing its number of employees per occupied bed, a common industry staffing metric. At one point, executives boasted to their peers about how they had slashed $500 million from the chain’s labor costs. In the years before the pandemic, they routinely refused requests to hire more medical workers or fill open jobs, according to current and former hospital administrators and employees.
The yearslong effort — a combination of widespread layoffs and attrition — rarely attracted public attention. But it left Ascension flat-footed for Covid.
During surges in the coronavirus, Ascension repeatedly reduced its capacity by more than 500 beds nationwide because it did not have enough workers. In Michigan alone late last year, the chain had 1,100 nursing vacancies. The head of an Ascension hospital in Baltimore last year blamed staffing shortages for the emergency room being dangerously overcrowded.
To understand how Ascension’s strategies affected patients, The Times focused on two hospitals, St. Joseph in Illinois and Genesys in Michigan, where nurses belonged to unions that tracked staffing cuts and kept detailed logs of what they said were unsafe conditions. The Times reviewed more than 3,000 pages of those logs and interviewed 70 current and former nurses, executives and other employees at Ascension hospitals.
Nurses said that Ascension’s downsizing had stark consequences.









Nurses at Ascension hospitals filed formal complaints warning about inadequate staffing.


Patients lingered for hours on gurneys with serious, time-sensitive problems. Surgeries were delayed. Other patients developed bed sores — gaping wounds that for frail patients can be deadly — because they were not repositioned often enough.
“You feel awful because you know you’re not turning these patients,” said Jillian Wahlfors, a nurse at Genesys. “You know they’re getting their meds late. You don’t have time to listen to them. They’re having accidents, because you can’t get in fast enough to take them to the bathroom.”
Nick Ragone, an Ascension spokesman, denied that cost-cutting contributed to staffing shortages during the pandemic. Such a claim, he said, “is fundamentally misguided, misleading and demonstrates a lack of understanding of the impact of Covid-19 on the health care work force.” He also said Ascension offers superior care that “has been improving over time” and that the hospital provides free treatment for many low-income patients.
Unlike some rivals, Ascension avoided layoffs early in the pandemic, and Mr. Ragone said the chain has more employees relative to patients than many of its peers. From December 2015 to June 2021, he said, Ascension’s ratio of bedside nursing capacity to its discharged patients has increased by 64 percent, with staff increasing and discharges holding roughly steady.
Academics who study hospital workforces cautioned that the metric makes Ascension’s staffing conditions seem better than they are. For example, the ratio’s increasing number of nurses over time at least partly reflects Ascension having added about 17 hospitals, while the data on discharges does not include outpatients, even though nurses are spending more and more time caring for them.
Daily business updates The latest coverage of business, markets and the economy, sent by email each weekday. Get it sent to your inbox.

Because it is difficult for outsiders to verify such industry-supplied data, hospitals can use it to serve their own purposes.
“The complexity and the lack of transparency, all of these things make it impossible to try and figure out exactly what’s going on,” said Linda Aiken, a professor at the University of Pennsylvania School of Nursing, who has conducted large surveys of hospital staff. “That’s why we ask nurses.”

*A Ministry, Not a Business*









A statue of St. Francis of Assisi outside an Ascension hospital in Illinois.Credit...Taylor Glascock for The New York Times


Ascension was created in 1999 through the merger of two networks of hospitals, many founded in the 1800s by nuns who ministered to the poor.
The combined hospital system swiftly became a juggernaut, its profits soaring sixfold in its first decade. (As a nonprofit, Ascension describes this figure as “excess of revenues and gains over expenses and losses.”) By 2010, Ascension’s $15 billion in revenue rivaled that of companies like General Mills and Gap.
Today, Ascension operates in 19 states, mostly in the South and the Midwest. It serves about six million patients.
By many measures, Ascension is rich.
In addition to its billions in cash, it runs an investment company that manages more than $41 billion. Last year it paid its chief executive, Joseph Impicciche, $13 million.
Because of its nonprofit status, Ascension avoids more than $1 billion a year in federal, state and local taxes, according to the Lown Institute, a health care think tank. Until the pandemic, Ascension was consistently profitable, earning hundreds of millions a year. The past year was a rare exception: Because of the stock market downturn and soaring labor costs, Ascension lost $1.8 billion.
Ascension and its executives have powerful incentives to be as profitable as possible. The more money the chain makes, the more its executives get paid. (Mr. Ragone said that a larger proportion of executives’ pay is based on other factors, like delivering high-quality care.) And stronger financial metrics allow the chain to borrow money at lower interest rates, enabling it to buy new hospitals and add services.

Executives have described their profit-seeking strategies as key to the hospital system’s stability and its mission of serving the poor and vulnerable.
“We are a ministry,” Anthony Tersigni, Ascension’s previous chief executive, said in 2007. “We’re not a business.” (Mr. Tersigni now leads Ascension’s investment arm, a job that paid him $11 million his first year.)
Four former executives who joined Ascension from other nonprofit hospital systems said the profit-driven culture surprised them. There were few conversations, they recalled, about how profits could be used to advance Ascension’s charitable mission. The pressure to reach financial targets struck them as more befitting a for-profit company.
“Their whole approach to the finances was right out of the Wall Street playbook,” said William Weeks, who until his retirement in 2019 was the chief operating officer of a five-hospital chain that Ascension owns in Oklahoma.
For example, Ascension charged its hospitals management fees, which covered the cost of centralized services like human resources, that were so high that they sometimes drove hospitals into financial peril.
In Washington, Ascension charged tens of millions of dollars in fees to Providence Hospital, which largely served poor, Black patients. The district’s attorney general investigated whether Ascension’s fees were excessive. In response, the chain in 2018 agreed to forgive $130 million of debt owed by the struggling hospital, which by then was being downsized into an urgent care center.
But the heart of Ascension’s business strategy was cutting costs.
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*A Late-Night Phone Call*
In 2010, Dr. Michael Schatzlein, who had spent years at a for-profit hospital chain, was hired to run a handful of Ascension hospitals in Tennessee and Alabama.
“The idea was to bring what I’d learned about containing costs through improving efficiencies to a mission-driven organization,” he said.
It was a tumultuous time in the health care industry. The federal government was reducing the amounts that Medicare paid hospitals to care for older patients. Plus, the coming rollout of the Affordable Care Act created deep uncertainty about hospitals’ financial prospects.
Around 2013, Ascension executives made a series of projections that showed that, over the next five years, their costs were expected to outpace their revenue by more than $5 billion.
To close that anticipated gap, Ascension turned to its biggest expense: labor. That year, the chain laid off thousands of workers, including medical staff.
Dr. Schatzlein, who by then had been promoted to run more than a dozen hospitals, was asleep at the JW Marriott in Indianapolis, where he was attending an industry conference with other Ascension executives. A phone call woke him. He was asked to come to a meeting downstairs, where executives decided they had to lay off thousands of workers across Ascension.
For Dr. Schatzlein, that meant axing about 3 percent of the staff, or about 1,000 nurses and other employees, in his hospitals. “I felt horrible about it,” he said. “My entire career was based on avoiding across-the-board layoffs.”

Across its network of hospitals, Ascension set individual financial targets, and executives whose hospitals did not achieve their goals would not get bonuses, according to three former executives. Keeping staffing low was one of the easiest ways to get paid, since labor costs make up about half of a hospital’s expenses.
Ascension also closely tracked the number of nurses on duty relative to how many patients were treated in each hospital unit. Managers felt pressure to require fewer nurses to handle more patients. Some had to show they were hitting productivity targets before they could hire more workers, according to current and former Ascension employees.
Ascension began showcasing its initiatives to cut labor costs. At a 2015 industry conference, two Ascension executives gave a presentation titled “Successful Labor Optimization Efforts” that detailed their tactics, which they said had saved nearly $500 million in just three years.
In Michigan and Illinois, Ascension lobbied against legislation that would have required minimum nurse-to-patient ratios. The measures never became law. In the following years, staffing levels at Ascension hospitals in those states were routinely below what the bills would have required, according to nurses at those hospitals.
Ascension’s fears about looming financial shortfalls never came to pass. Over the five years in which Ascension executives had projected the $5.2 billion loss, the system instead earned $2.7 billion in profits.
Even so, it continued to cut workers.
*Running for Supplies*









Ascension’s St. Joseph is the only hospital in Joliet, Ill.Credit...Taylor Glascock for The New York Times


When the pandemic hit, nurses at St. Joseph, the only hospital in Joliet, Ill., were overwhelmed and feared for the safety of patients, according to state inspection records and thousands of pages of formal complaints that nurses filed with the hospital warning about unsafe conditions.

“Every day it’s unsafe staffing!!!” one nurse wrote in June 2020, underlining “every day” four times.
Nurses said they had been finding themselves in such situations more and more since 2018, when Ascension took over St. Joseph.
Shortly after the acquisition, St. Joseph employed 791 nurses. That number has since dropped by 23 percent, according to the Illinois Nurses Association, which represents the hospital’s nurses and has clashed with Ascension’s management over pay and other issues.
The staff reductions were largely the result of nurses leaving to pursue better pay and working conditions elsewhere. Ascension then left many vacant jobs open, though some slots were filled by nurses on short-term contracts, employees said. Nurses at St. Joseph generally make between $29 and $52 an hour and can earn multiples more working for medical staffing companies.
Mr. Ragone said that St. Joseph’s number of employees per occupied bed went up 6 percent between 2018 and 2021. But that figure partly reflects Ascension having reduced its capacity. The data also includes many employees who do not treat patients. Mr. Ragone would not provide data specific to nurses.
Some of the nurses’ grievances have been substantiated by state authorities.
In April 2021, Illinois health inspectors cited St. Joseph for failing to care for patients who needed to be regularly repositioned. The inspectors found that some patients developed bed sores after they were not moved for as much as 20 hours, despite doctors’ orders that they be shifted often.
Since then, the problems have intensified.
In January 2022, as the Omicron wave pummeled the Chicago area, groups of nurses signed the formal complaints on more than 130 occasions.

At the beginning of the month, an entire shift of eight nurses in one unit signed a complaint that there was only one nurses’ aide available for 32 patients with Covid, most of them on oxygen. The complaint said a supervisor told the nurses that the entire hospital was short-staffed.
At the end of the month, no one showed up to staff the surgical supply room. When two patients needed emergency surgery, nurses were left to gather instruments themselves. One surgery was delayed, and a nurse had to abandon a 100-year-old patient to run for supplies.
One night in October, nurses in St. Joseph’s intensive care unit learned that they would have to care for four patients each — double the industry standard. The hospital had to divert ambulances from delivering patients until more nurses arrived.
Four nights later, nurses in the emergency room refused to clock in because they were being asked to care for 11 patients each, instead of the recommended four.
“It was inevitable,” said Jillian Moffett, who was among the nurses who protested the staffing levels. “One of these days someone was going to put their foot down and say, ‘I’m not taking this anymore.’”
*The Rise of the Robots*









Ascension replaced some nurses’ aides with robotic devices that monitor and communicate with patients.Credit...AvaSure


In 2019, Ascension received an award from a company called AvaSure. The “AvaPrize” was bestowed upon the hospital chain because of its embrace of a new cost-cutting innovation: robots.

Traditionally, Ascension, like other hospitals, sent nurses’ aides into the rooms of patients who needed close supervision. Left untended, these patients, many with dementia or psychiatric illnesses, might get out of bed and hurt themselves.
But in the years before the pandemic, some Ascension hospitals switched course. Going forward, they would generally assign nurses’ aides only to patients who were deemed at high risk of dying by suicide.
For other patients, aides would be replaced by AvaSure’s “TeleSitters.” By 2019, Ascension had installed 450 of the robots in more than 50 of its hospitals. The devices — essentially a video camera mounted on a metal pole — send live footage to an off-site command center, where workers talk to patients through speakers in the machine.
In marketing materials, AvaSure boasts that the TeleSitter — which is used by about 1,000 hospitals nationwide — allows workers to monitor the movements of up to 16 patients at once.
Its website features the testimonial of a top nurse at a Texas hospital that started using AvaSure devices during the pandemic. He said they would enable someone like him to “do three shifts in the E.R. and then do a shift at home using this.”
AvaSure cites research showing its robots reduce dangerous falls. And some Ascension officials said the TeleSitters were invaluable during the pandemic. “Somebody had eyes on those patients,” Maureen Chadwick, an Ascension executive, said at an event this year.
But at Ascension’s Genesys hospital in Michigan, nurses said patients, many of them already disoriented, were confused by the disembodied voices coming from TeleSitters. There were sometimes not enough robots — which nurses derided as “sitters on a stick” — to go around.

And when workers at the command center 80 miles away called the hospital about wayward patients, there were often no secretaries at Genesys available to answer the phones.
Ascension had cut those jobs.
*16-Hour Shifts*









Stephanie Bates, a nurse at Genesys hospital, said she refused orders to work extended shifts so that she can care for her children.Credit...Dieu-Nalio Chéry for The New York Times


Patients enter Genesys through a four-story atrium decorated with greenery and rock pools. Inside, the 400-bed hospital is reeling from years of downsizing.
In 2018, Ascension had laid off workers, including at least 500 in Michigan — even as the chain that year reported profits of $2.2 billion. Genesys, one of a handful of unionized Ascension hospitals, avoided those layoffs. Instead, administrators froze hiring.
That freeze eventually thawed. Even then, vacant positions were rarely advertised online.
Since the hiring freeze was imposed, the number of permanent nurses working at Genesys has fallen by roughly 30 percent, according to the Teamsters union that represents the nurses.
Ascension partially filled that gap by hiring temporary nurses, and Mr. Ragone said Genesys’s employees per occupied bed increased 12 percent between 2018 and 2021. (Like St. Joseph, Genesys reduced its patient capacity, which contributed to the rise in the staffing ratio, and Mr. Ragone would not provide data about the hospital’s nursing staff.)
Yet nurses said that to keep things running, Genesys demanded they work 16-hour shifts, threatening to fire some who refused because of exhaustion or child-care commitments. Hospitals commonly require nurses to work past their scheduled shifts as an emergency stopgap, such as during a blizzard. But at Genesys, nurses said, the tactic is used to make up for chronic understaffing.

Stephanie Bates, a Genesys nurse who works a 12-hour shift ending at 11:30 p.m., said that multiple times a week, she is ordered to work until 3:30 a.m. She said that she refuses so that she can care for her young children early in the morning. Other nurses echoed her experience.
On at least four occasions this year, managers have written in nurses’ employment files that refusing to work 16-hour shifts “is not in line with our value of dedication,” according to internal disciplinary records reviewed by The Times.
Nurses in nearly every unit at the hospital said in interviews that they were regularly required to care for more patients than allowed under their contract — restrictions that are supposed to ensure the safety of patients. “You just try to do damage control your whole shift,” said Stephanie Atchley, a Genesys nurse. “It just all snowballs into very poor care.”
Dr. Dale Hanson, a physician who treats patients at Genesys, said that most days, there are not enough nurses, resulting in prolonged hospital stays for his patients. Some get marooned in the emergency room because of nursing shortages in other parts of the hospital.
Dr. Hanson blamed Ascension’s aggressive cost-cutting, which he said has resulted in “miserable” conditions for patients and staff.
*‘Someone Is Going to Die’*









Jill Bruff, an I.C.U. nurse at Genesys, said she regularly finds patients lying in dried feces.Credit...Dieu-Nalio Chéry for The New York Times


Even as the pandemic has waned, nurses at St. Joseph and Genesys said, there remained so many unfilled positions that they felt like they were working in a perpetual crisis.

As of this month, 24 of the 52 night-shift positions in Genesys’s medical and surgical intensive-care units were listed as unfilled, and 17 of the open jobs had yet to be advertised, according to the hospital’s internal tally, which The Times reviewed.
Jill Bruff, a nurse who works in those I.C.U.s, said that about once a week, she arrives for her night shift to find patients who had been lying in their own feces for so long that the excrement had dried. On one recent occasion, Ms. Bruff said, the nurse working before her cried when she explained that she had not had time to clean up a soiled patient.
“That patient shouldn’t ever had to sit for that long, and that nurse shouldn’t have had to cry because she felt so awful,” Ms. Bruff said. Four other nurses said their patients have had similar experiences as a result of understaffing.
Mr. Ragone said that “the publication of an assertion from an unsubstantiated claim that our dedicated nursing staff would allow a patient in the I.C.U. to be left improperly unattended, without evidence, is irresponsible.”
Nurses at St. Joseph in Illinois also were at their breaking point.
“MAKE THIS BETTER ASCENSION. SHAME ON YOU!!!” one nurse wrote in a formal complaint in June. The nurse described a chaotic scene in the emergency room where there were not enough nurses or beds for seriously ill patients.
“Someone is going to die if this continues,” another nurse wrote in July, “and there is no indication that anyone is concerned.”
Susan Beachy and Sheelagh McNeill contributed research.

Rebecca Robbins is a business reporter covering the pharmaceutical industry. She joined The Times in 2020 and has been reporting on health and medicine since 2015. @RebeccaDRobbins
Katie Thomas is an investigative reporter who has been writing about the business of health care since 2012. @katie_thomas
Jessica Silver-Greenberg is an investigative reporter on the Business desk. She was previously a finance reporter at the Wall Street Journal. @jbsgreenberg • Facebook
A version of this article appears in print on Dec. 16, 2022, Section A, Page 1 of the New York edition with the headline: Big Hospital Chain’s Cuts Ignited Its Staffing Crisis.


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