Nurses have been front and center of every medical crisis, and after the COVID-19 pandemic, nurses were recognized as frontline heroes.
However, more nurses are stepping up and admitting that although they were able to save lives, the pandemic exacerbated unequal workplace conditions, which made their job harder, longer, and more stressful.
As a result, a safe space nurses joined to advocate for their needs was nurse unions.
Nurse unions have existed since the 20th century, but it wasn’t until 2005 that union membership among nurses started to increase, according to a 2010 article in the Journal of Clinical Nursing.
Since then, more nurses have become advocates to eliminate workplace violence, uneven nurse-to-patient ratios, and unfair hiring practices within the healthcare system. This is certainly true with the recent strikes in New York, California, Minnesota, and the U.K.
Strikes for Safe Staffing and Fair Contracts
Although hospital executives and management have set standards such as how many nurses can be hired and what benefits they get, nurse associations like National Nurses United (NNU) have fought to protect nurses’ safety when these contracts don’t reflect nurses’ needs in the workplace.
One issue that has been a significant cause of nursing strikes across the U.S. is safe staffing.
Many hospitals are faced with uneven nurse-to-patient ratios, which diminishes the quality of care among patients. This leaves nurses to make up for the lack of staff in hospital units through increased hours and fewer mandated breaks–and in turn, that can lead to more medical errors.
California is the only state to have mandated minimum nurse-to-patient staffing ratios in all hospitals. Therefore, many would think that having a law to prevent understaffing already existed. Still, according to the President of National Nurses United, Zenei Triunfo-Cortez, RN, this was not the case.
Zenei Triunfo-Cortez, RN, is the President of National Nurses United
“Since beginning my nursing career, we have always fought for safe nurse-to-patient ratios. It was a lot of work, persuasion, and real-life stories about what happens to us every day in our work life that helped us show legislators that we need this because this is what’s happening in our lives day in, day out.”
However, there is no nationwide federal law for safe staffing. Triunfo-Cortez and other union nurses at NNU are looking to change that. In other affiliate states with NNU, nurses who are part of the organization also hold rallies to build awareness of the need for safe staffing and legislative laws protecting nurses’ right to organize.
“We will not stop until working conditions are a lot better for all of our nurses, no matter which state you are in, and it doesn’t matter which area of practice you are in. We’ll make sure that our nurses are well provided for in all areas,” says Triunfo-Cortez.
Ethnic Minorities and Nurse Unions
Nurses from minority backgrounds make up almost 20% of registered nurses, according to the American Association of Colleges of Nursing. Sadly, their representation among the nursing community compared to the population of BIPOC Americans remains small.
Many nurses of color feel discouraged in their workplace if their fellow nurses don’t look like them, so it’s no surprise that they can leave their jobs faster if they don’t receive support when they’re overworked.
Julia Barcott, the chair of economic and general welfare at the Washington State Nursing Association (WSNA), has seen this happen in her workplace. Barcott is an ICU nurse at the Astria Toppenish Hospital in Toppinish, Washington, an area with a large population of Hispanic, Filipino, and Indigenous tribes. She adds how she mentored four Hispanic and Indigenous bilingual nurses who experienced understaffing during the COVID-19 pandemic.
Julia Barcott is the chair of economic and general welfare at the Washington State Nursing Association
“They went to college together, got their nursing degrees, and all wanted to serve their communities. They stuck it through the pandemic,” says Barcott. “Then, when things didn’t get better after the pandemic slowed, they realized that the hospital wouldn’t address the staffing issues. They were continuing to go on as if the pandemic was still here.”
Barcott explained that these nurses eventually left their jobs, despite receiving sign-on bonuses.
“You want to have racial equity and have people that look like yourself if you’re a patient that understands your customs and beliefs,” says Barcott. “These four young women were like that. They were a huge asset.”
Chronic workplace conditions such as these are some of the reasons why nurses of color join unions. However, systemic racism has also factored into why BIPOC nurses can be disillusioned with the profession. Dealing with discrimination as a nurse in the early 90s is why Triunfo-Cortez, a Filipina, decided to become involved with unionizing.
“I was applying for a transfer and was bypassed because the manager told me she could not hire more Filipinos. And so, at that moment, I thought, why should you look at the person’s ethnicity? You have to be looking at the qualifications, right?” says Triunfo-Cortez. “And so I became involved thinking that nurses need to speak up because this is modern history, and there’s still apparent discrimination happening.”
When nurses of color get involved with unionizing, they provide unique views on chronic healthcare challenges that others may not have. BIPOC nurses can also gain more accurate representation in a healthcare system where white-dominated opinions can be at the center.
Nursing Shortages Don’t Exist
While nursing unions can help bring awareness to unfair nurse-to-patient ratios and workplace violence, they also bring light to long-held beliefs about the healthcare system–like nursing shortages don’t exist.
“What we have is not a staffing shortage, but a shortage of nurses who do not want to work under unsafe working conditions because we do not want to be blamed for bad outcomes of our nursing care,” says Triunfo-Cortez.
Barcott mentions that some people with nurse licenses aren’t practicing as a nurse at all because of understaffing.
“There’s like 150,000 nurses in Washington. Less than half of those are working right now, but many of them are the ones that have active licenses. They are not willing to work in the conditions that are occurring now,” Barcott says. “They would rather not work as a nurse or take time off because they’re burned out, or they go do something different.”
Hospital executives and management often think of profits and business expenses more than the harmful conditions nurses experience daily. Some employers believe that to solve this retention problem. Then they need to direct more funds toward hiring new nurses.
For example, Barcott explains that it costs around $100,000 to orient a new nurse over six months. However, when hospital management and financial officers don’t address chronic workplace issues, these nurses leave faster, causing this cycle to repeat.
Nursing unions see this issue, which is why many lobby for legislation for fair staffing and safe workplace practices.
In Washington, the WSNA pushes for state laws to be passed supporting safe staffing standards, enforced rest breaks, and functional staff committees. Like the WSNA and the NNU, the New York State Nurses Association (NYSNA) educates union nurses on worker rights. It helps them bargain for health benefits, higher wages, and paid holidays.
Using Unions to Make a Difference
When nurses of all demographics sit at the table to discuss fair workplace conditions, everyone, including patients, benefits from a better quality of care.
“It’s uplifting to know that most of our nurses are real and true patient advocates, not just by word, but in action as well,” says Triunfo-Cortez. “When you think alike and know that your goal and your mission are the same, then you will do everything in your power to achieve those goals because we know that if we all work together towards a common goal, it would be for the betterment of everyone.”
After the pandemic, more people now see that nurse unions exist and are here to stay. People not working in healthcare are picking up protest signs, while hospital management sees that there’s strength in numbers.
“I think that’s why membership is starting to go up in a lot of areas where essential workers were put in that position because that was the only that’s the only way we can collectively band together and express the needs of our patients. And it was only a matter of time,” says Barcott.
Healthcare is likely to be one of the most significant issues facing legislators as they return to Jones Street for the 2023 long session, and a record number of nurses who are members of the North Carolina Nurses Association (NCNA) will be helping guide important healthcare policy decisions as members of the North Carolina General Assembly (NCGA).
With four nurses in the House and one in the Senate, legislators from across the state will have plenty of opportunities to talk with subject matter experts from both sides of the aisle on various bills that impact healthcare.
Nurses and Members of the NC General Assembly
NCNA member Rep. Carla Cunningham, RN, BSN, D-Mecklenburg, is a hospice nurse from Charlotte. She is the longest-serving nurse at the General Assembly, entering her sixth term in the House since she was elected in 2012. She begins 2023 as a Vice Chair of the Health Committee and a member of the Appropriations, Health, and Human Services; Appropriations; Commerce; Energy and Public Utilities; Rules, Calendar, and Operations of the House, and Wildlife Resources committees.
NCNA member Sen. Gale Adcock, RN, MSN, FNP-BC, FAANP, FAAN, D-Wake, is a family nurse practitioner from Cary. She is the first-ever nurse to serve in the Senate, starting her first term after spending four terms in the House. She has been assigned to the Health Care; Appropriations on Health and Human Services; Commerce and Insurance; and Transportation committees.
NCNA member Rep. Donna White, RN, R-Johnston, is a public health nurse from Clayton. She is in her fourth term in the House, having first been elected in 2014. She is a Chair of the Health and Appropriations, Health and Human Services committees and a member of the Appropriations; Education – Community Colleges; Environment; Families Children and Aging Policy; and Local Government committees.
Rep. Diane Wheatley, RN, R-Cumberland, is a critical care nurse from Linden. She is in her second term in the House, where she will serve as a Chair of the Pensions and Retirement committee, Vice Chair of both the Education – Community Colleges and Education – K-12 committees, and a member of the Health; Appropriations; Appropriations, Education; and Environment committees.
NCNA member Rep. Diamond Staton-Williams, RN, BSN, MHA, CMAC, NE-BC, D-Cabarrus, is a care manager from Harrisburg. She is one of the new faces on Jones Street, having been elected to her first term in November after serving on the Harrisburg Town Council since 2017. She is a member of the Appropriations; Appropriations, Capital; Disaster Recovery and Homeland Security; Environment; Federal Relations and American Indian Affairs; and UNC Board of Governors Nominations committees.
These five nurses bring a wealth of healthcare experience to their respective chambers. NCNA encourages its fellow legislators, constituents, and lobbyists to take advantage of this session’s invaluable knowledge base.
Nurses often talk about the importance of nurses being at the table in an elected office where policies are made, and here’s a chance for 50 nurses to get the skills they need for a seat at the table.
Healing Politics invites nurses and midwives interested in seeking elected office to apply to attend its inaugural Campaign School for Nurses and Midwives on May 24-27, 2023, at Duke University’s Sanford School of Public Policy in Durham, N.C.
Healing Politics will provide intensive and practical training to 50 nurses and midwives to run for elected office.
In addition, nurse legislators and campaign operatives with experience in fields ranging from fundraising to digital strategy will provide instruction.
The organization believes more nurses – as superb communicators, empathetic listeners, and persistent builders – should run for political office to attain better health for all.
The program will begin on Wednesday evening, May 24, with a welcome/networking reception and run Thursday, Friday, and Saturday. All meals are included as the program runs from morning until evening.
“All across our country, people are hurting. They need help. The good news is that getting that help just got a lot easier… This cross-government effort has been years in the making and comes at a crucial point to help address the mental health crisis in our country, especially for our young people.”
—FCC Chairwoman Jessica Rosenworcel
The Saturday, July 15 launch of the three-digit 988 line—which will provide Americans experiencing mental health crises with access to trained counselors—could be a significant step forward for public health in the US. The product of a three-year joint effort by the U.S. Department of Health and Human Services (HHS), the Federal Communications Commission (FCC), and the U.S. Department of Veterans Affairs (VA), the 988 Suicide & Crisis Lifeline will eventually supersede the 10-digit National Suicide Prevention Lifeline (1-800-273-8255).
The new line offers a more direct, robust, and flexible path for people seeking assistance with mental health issues. John Draper, executive director for the National Suicide Prevention Lifeline, told Yahoo Life this week that 988 is for anyone who is grappling with a debilitating emotional storm (or is worried about a loved one in such a situation) and has much broader applications than the 911 “what is your emergency?” line. As Draper describes it, 988 is a resource anyone can text or call when they feel “so overwhelmed by their experience [and] their feelings that it impairs their ability to get through the day.” It covers virtually any mental health crisis and people are urged to call well before they reach a gun/pills on the table situation.
Health and Human Services Secretary Xavier Becerra sees the new line as an important step in addressing the mental health crisis gripping the country in the wake of the two most stressful years in most Americans’ living memory: “988 is more than a number, it is a message: we’re there for you. Through this and other actions, we are treating mental health as a priority and putting crisis care in reach for more Americans. Thereis still much work to do. But what matters is that we’re launching, 988 will be live. We are looking to every governor and every state in the nation to do their part to make this a long-term success.”
However, it will take time to recover from 13 years of not-very-enthusiastic government support. Many states have not yet allocated funds for the 988 program and only 20 have even partial legislation in the works to implement the line. Draper says they are prepared for this: “In the event that [a local call center] is unable to answer the call because they lack the resources, we are providing at the national level backup services… So in the event that the local centers are unable to take those calls or those chats or texts, somebody will be there to take them. It’s a matter of holding on, maybe for just a little bit longer, and we’ll answer.”
“Recent investments made in the Lifeline have already resulted in more calls, chats, and texts answered even as volume has increased, but we know that too many people are still experiencing a suicidal crisis or mental health-related distress without the support they need,” said Miriam E. Delphin-Rittmon, Ph.D., the HHS Assistant Secretary for Mental Health and Substance Use and leader of SAMHSA. “Over time, the vision for 988 is to have additional crisis services available in communities across the country, much the way emergency medical services work. The success of 988 depends on our continued partnership with states, as the federal government cannot do this alone. We urge states and territories to join us and invest further in answering the call to transform our crisis care response nationwide.”
Vets’ fingers have a shorter walk
VA administers the Veterans Crisis Line through the Lifeline’s national network. Because of VA’s partnership with the Lifeline, the Veterans Crisis Line is affected by this transition to a new number. Veterans and their loved ones can now Dial 988 then Press 1 to reach the Veterans Crisis Line.
“988 has been a long time coming and will serve as a critical resource during a crisis when every second counts. The new, shorter number will help ensure Veterans have easier access to the Veterans Crisis Line,” said VA Secretary Denis McDonough. “This launch is a whole-of-government approach in line with the President’s call to prioritize mental health by strengthening access to crisis services, and preventing Veteran suicide, our top clinical priority.”
A bull market for a mental health crisis line
In 2021, the Lifeline received 3.6 million calls, chats, and texts. That number is expected to at least double within the first full year after the 988 transition.
The United States had one death by suicide every 11 minutes in 2020, according to the Centers for Disease Control and Prevention. Suicide was the second leading cause of death for young people aged 10-14 and 25-34. From April 2020 to 2021, more than 100,000 people died from drug overdoses. Studies have shown that after speaking with a trained crisis counselor, most Lifeline callers are significantly more likely to feel less depressed, less suicidal, less overwhelmed, and more hopeful.
The 10-digit Lifeline number 1-800-273-TALK (8255) will continue to be operational after July 16 and will route calls to 988 indefinitely. Veterans, service members, and their families can also still reach the Veterans Crisis Line with the current phone number 1-800-273-8255 and Press 1, or by chat or text to 838255.
On June 24, 2022, the U.S. Supreme Court overruled Roe v. Wade, the landmark 1973 decision that established the nationwide right to choose an abortion.
For decades, the rancorous debate about the ruling has often been dominated by politics. Ethics garners less attention, although it lies at the heart of the legal controversy. As a philosopher and bioethicist, I study moral problems in medicine and health policy, including abortion.
Bioethical approaches to abortion often appeal to four principles: respect for patients’ autonomy; nonmaleficence, or “do no harm”; beneficence, or providing beneficial care; and justice. These principles were first developed during the 1970s to guide research involving human subjects. Today, they are essential guides for many doctors and ethicists in challenging medical cases.
Patient autonomy
The ethical principle of autonomy states that patients are entitled to make decisions about their own medical care when able. The American Medical Association’s Code of Medical Ethics recognizes a patient’s right to “receive information and ask questions about recommended treatments” in order to “make well-considered decisions about care.” Respect for autonomy is enshrined in laws governing informed consent, which protects patients’ right to know the medical options available and make an informed voluntary decision.
Some bioethicists regard respect for autonomy as lending firm support to the right to choose abortion, arguing that if a pregnant person wishes to end their pregnancy, the state should not interfere. According to one interpretation of this view, the principle of autonomy means that a person owns their body and should be free to decide what happens in and to it.
Abortion opponents do not necessarily challenge the soundness of respecting people’s autonomy, but may disagree about how to interpret this principle. Some regard a pregnant person as “two patients” – the pregnant person and the fetus.
One way to reconcile these views is to say that as an immature human being becomes “increasingly self-conscious, rational and autonomous it is harmed to an increasing degree,” as philosopher Jeff McMahan writes. In this view, a late-stage fetus has more interest in its future than a fertilized egg, and therefore the later in pregnancy an abortion takes place, the more it may hinder the fetus’s developing interests. In the U.S., where 92.7% of abortions occur at or before 13 weeks’ gestation, a pregnant person’s rights may often outweigh those attributed to the fetus. Later in pregnancy, however, rights attributed to the fetus may assume greater weight. Balancing these competing claims remains contentious.
Nonmaleficence and beneficence
The ethical principle of “do no harm” forbids intentionally harming or injuring a patient. It demands medically competent care that minimizes risks. Nonmaleficence is often paired with a principle of beneficence, a duty to benefit patients. Together, these principles emphasize doing more good than harm.
Although 97% of unsafe abortions occur in developing countries, developed countries that have narrowed abortion access have produced unintended harms. In Poland, for example, doctors fearing prosecution have hesitated to administer cancer treatments during pregnancy or remove a fetus after a pregnant person’s water breaks early in the pregnancy, before the fetus is viable. In the U.S., restrictive abortion laws in some states, like Texas, have complicated care for miscarriages and high-risk pregnancies, putting pregnant people’s lives at risk.
Justice, a final principle of bioethics, requires treating similar cases similarly. If the pregnant person and fetus are moral equals, many argue that it would be unjust to kill the fetus except in self-defense, if the fetus threatens the pregnant person’s life. Others hold that even in self-defense, terminating the fetus’s life is wrong because a fetus is not morally responsible for any threat it poses.
Yet defenders of abortion point out that even if abortion results in the death of an innocent person, that is not its goal. If the ethics of an action is judged by its goals, then abortion might be justified in cases where it realizes an ethical aim, such as saving a woman’s life or protecting a family’s ability to care for their current children. Defenders of abortion also argue that even if the fetus has a right to life, a person does not have a right to everything they need to stay alive. For example, having a right to life does not entail a right to threaten another’s health or life, or ride roughshod over another’s life plans and goals.
Justice also deals with the fair distribution of benefits and burdens. Among wealthy countries, the U.S. has the highest rate of deaths linked to pregnancy and childbirth. Without legal protection for abortion, pregnancy and childbirth for Americans could become even riskier. Studies show that women are more likely to die while pregnant or shortly thereafter in states with the most restrictive abortion policies.
Other marginalized groups, including low-income families, could also be hard hit by abortion restrictions because abortions are expected to get pricier.
Politics aside, abortion raises profound ethical questions that remain unsettled, which courts are left to settle using the blunt instrument of law. In this sense, abortion “begins as a moral argument and ends as a legal argument,” in the words of law and ethics scholar Katherine Watson.
Putting to rest legal controversies surrounding abortion would require reaching moral consensus. Short of that, articulating our own moral views and understanding others’ can bring all sides closer to a principled compromise.
When Dr. Roy Guerrero, a pediatrician in Uvalde, Texas, testified before a U.S. House committee Wednesday about gun violence, he told lawmakers about the horror of seeing the bodies of two of the 19 children killed in the Robb Elementary massacre. They were so pulverized, he said, that they could be identified only by their clothing.
In recent years, the medical profession has developed techniques to help save more gunshot victims, such as evacuating patients rapidly. But trauma surgeons interviewed by KHN say that even those improvements can save only a fraction of patients when military-style rifles inflict the injury. Suffering gaping wounds, many victims die at the shooting scene and never make it to a hospital, they said. Those victims who do arrive at trauma centers appear to have more wounds than in years past, according to the surgeons.
But, the doctors added, the weapons used aren’t new. Instead, they said, the issue is that more of these especially deadly guns exist, and these weapons are being used more frequently in mass shootings and the day-to-day violence that plagues communities across the nation.
The doctors, frustrated by the carnage, are clamoring for broad measures to curb the rise in gun violence.
Weeks after the Uvalde school shooting, what steps the country will take to prevent another attack of this magnitude remain unclear. The House on Wednesday and Thursday passed measures aimed at reducing gun violence, but approval in the Senate seems uncertain at best.
Many physicians agree something substantial must be done. “One solution won’t solve this crisis,” said Dr. Ashley Hink of Charleston, South Carolina, who was working as a trauma surgery resident at the Medical University of South Carolina in 2015 when a white supremacist killed nine Black members of the Mother Emanuel African Methodist Episcopal Church. “If anyone wants to hang their hat on one solution, they’re clearly not informed enough about this problem.”
The weapons being fired in mass shootings — often defined as incidents in which at least four people are shot — aren’t just military-style rifles, such as the AR-15-style weapon used in Uvalde. Trauma surgeons said they are seeing a rise in the use of semiautomatic handguns, such as the one used during the Charleston church shooting. They can contain more ammunition than revolvers and fire more rapidly.
Overall gun violence has increased in recent years. In 2020, firearm injuries became the leading cause of death among children and adolescents. Gun-related homicides rose almost 35% in 2020, the Centers for Disease Control and Prevention reported in May. Most of those deaths are attributed to handguns.
A study recently published by JAMA Network Open found that for every mass shooting death, about six other people were injured. Trauma surgeons interviewed by KHN said the number of wounds per patient appears to have increased.
“I feel we are seeing an increase in the intensity of violence over the past decade,” said Dr. Joseph Sakran, a trauma surgeon at Johns Hopkins Hospital in Baltimore. He cited the number of times a person is shot and said more gun victims are being shot at close range.
Survival rates in mass shootings depend on multiple factors, including the type of firearm used, the proximity of the shooter, and the number and location of the wounds, said Dr. Christopher Kang of Tacoma, Washington, who is president-elect of the American College of Emergency Physicians.
Several recent shootings have left few survivors.
The perpetrator of the Charleston massacre shot each of the nine people who were killed multiple times. Only one of those people was transported to the hospital, and, upon arrival, he had no pulse.
Last year, shootings at three Atlanta-area spas left eight dead — only one person who was shot survived.
The chaos at a mass shooting scene — and the presence of an “active” shooter — can add crucial delays to getting victims to a hospital, said Dr. John Armstrong, a professor of surgery at the University of South Florida. “With higher-energy weapons, one sees greater injury, greater tissue destruction, greater bleeding,” he added.
Dr. Sanjay Gupta, a neurosurgeon who is chief medical correspondent for CNN, wrote about the energy and force of gunshots from an AR-15-style rifle, the type also used in the recent mass shooting in Buffalo, New York. That energy is equal to dropping a watermelon onto cement, Gupta said, quoting Dr. Ernest Moore, director of surgical research at the Denver Health Medical Center.
Medical advances over the years, including lessons learned from the battlefields of Iraq and Afghanistan, have helped save the lives of shooting victims, said Armstrong, who trained U.S. Army surgical teams.
Those techniques, he said, include appropriate use of tourniquets, rapid evacuations of the wounded, and the use of “whole blood” to treat patients who need large amounts of all the components of blood, such as those who have lost a significant amount of blood. It’s used instead of blood that has been separated into plasma, platelets, and red blood cells.
Another effective strategy is to train bystanders to help shooting victims. A protocol called “Stop the Bleed” teaches people how to apply pressure to a wound, pack a wound to control bleeding, and apply a tourniquet. Stop the Bleed arose after the 2012 shooting at Sandy Hook Elementary School in Newtown, Connecticut, where 20 children and six adults were killed.
The CDC, which in the past two years has been able to conduct gun research after years of congressional prohibitions, has funded more than a dozen projects to address the problem of gun violence from a public health perspective. Those projects include studies on firearm injuries and the collection of data on those wounds from emergency rooms across the country.
For some doctors, gun violence has fueled political action. Dr. Annie Andrews, a pediatrician at the Medical University of South Carolina, is running as a Democrat for a seat in the U.S. House on a platform to prevent gun violence. After the school shooting in Uvalde, Andrews said, many women in her neighborhood reached out to ask, “What can be done about this? I’m worried about my kids.”
Dr. Ronald Stewart, chair of surgery at San Antonio-based University Health, told KHN that the people shot in Uvalde had wounds from “high energy, high velocity” rounds. Four of them — including three children — were taken to University Hospital, which offers high-level trauma care.
The hospital and Stewart had seen such carnage before. In 2017, the San Antonio hospital treated victims from the Sutherland Springs church shooting that left more than two dozen dead.
Two of the four Uvalde shooting victims have been discharged, University Health spokesperson Elizabeth Allen said, and the other two remained hospitalized as of Thursday.
It will take a bipartisan effort that doesn’t threaten Second Amendment rights to make meaningful change on what Stewart, a gun owner, called a “significant epidemic.” Stewart noted that public safety measures have curbed unintentional injuries in car crashes. For intentional violence, he said, progress hasn’t been made.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.