Aaron Habrack works as a nurse in the medical intensive care unit (MICU), which serves some of the sickest patients at Robert Wood Johnson University Hospital. The job is stressful, but rewarding, he says. What makes it frustrating—and potentially life-threatening to patients—is that he often finds himself responsible for more patients than he believes is safe.
In the MICU, he says, there should be no more than two patients per nurse, though the ratio might be one-to-one with some patients—such as those on ventilators or dialysis—or even two nurses to a patient. This may be more costly, but according to Habrack, keeping these ratios low is best for the health and safety of the hospital’s patients.
Habrack is one of 1,700 nurses on strike at the New Brunswick hospital, which is one of New Jersey’s primary trauma facilities and the flagship its largest hospital and health care company, RWJBarnabas Health. The nurses, who are represented by the United Steelworkers union, have been on strike for more than eighty days. Their primary demand is enforceable nurse-to-patient ratios that will protect both nurses and patients.
“When I have my two patients, the way our unit is set up, I can actually sit at my desk and there are windows into the patients’ rooms,” he tells The Progressive during a rally on the campus of neighboring Rutgers University. “I can have a visual on both of my patients. I can see and hear in the rooms at all times while I’m working. If they give a third patient to me, now I have a third patient that is removed from my desk that I’m not able to give that consistent monitoring to, so I’m constantly back and forth.” He said this means there are moments when each patient is not directly monitored.
This forces a dangerous “triaging,” he says, that strains the ability of nurses to give their patients proper attention and “creates an environment where we start to have to prioritize tasks that should not need to be put into triage, [choosing] between if I hear a ventilator alarm and an IV pump alarm.”
“I have to think in my head ‘what could that be going off,’ ” he adds, “and is that more important than attending to this ventilator in the room. It becomes a much more demanding mental stack to balance.”
Management has responded to the striking nurses’ demands with guidelines and overtime pay; they also won an injunction limiting the workers' actions on the picket line.
Hospital spokeswoman Wendy Gottsegen said in a statement in late September that the hospital offered “two, separate options for ending the strike—either accepting the hospital’s offer from August 2 that would have ensured the state’s highest staffing standards and nurse compensation or agreeing to enter binding arbitration. The union rejected both.”
The hospital offer, according to its website, included a three-year pay increase of 15 percent, plus “ample overtime” to address staffing shortages. Hospital officials claim they already pay the nurses more than other hospitals in the state and that their staffing levels are consistent with other New Jersey facilities.
Nurses say the offer was inadequate because it contained loopholes that would allow the hospital to shortchange staff by, for example, not paying overtime to cover shortages when they call in sick.
The nurses’ strike in New Brunswick is part of a larger national wave of labor actions by healthcare workers that recently won big gains. California and Massachusetts, according to Nurse Journal, have enshrined patient ratios in state law. Massachusetts law now “limits nurses to one patient in the intensive care unit,” with exceptions, while California staffing rules define “the number of patients nurses may oversee in each hospital unit.” Nine other states use nurse-led committees “to review staffing challenges” and set ratios.
The ratios are important, says Cathy Kennedy, president of the California Nurses Association, because they protect both the nurses and the patients. California’s rules have been in place since 2004 and they have “reduced the number of patient deaths in our state,” she tells The Progressive.
“Patients are no different in the state of California than any other state across the United States,” she says. “So, federally, nationally, we see that it’s important for nurses to be working in safer working conditions.”
Lower patient to nurse ratios, she explains, allow nurses to spend more time with each patient, while preventing what Kennedy calls “moral distress, or moral injury.”
“I went into nursing because I really wanted to care for patients,” she says. “It’s something that I wanted to do. And it’s difficult, when at the end of the day, you feel like you didn’t do your best. And I hear nurses constantly saying that the day was horrific, they get in their car, they start crying, they don’t know what to do.”
The COVID-19 pandemic was an eye opener, Kennedy recalls, reminding everyone that there is an infrastructure that needs to be maintained, but that the corporate model and the consolidations in the healthcare industry have failed at this.
“COVID taught us a lot,” she says. “That was unbelievable. And we’re not out of this pandemic yet. But at the peak, where we saw millions of patients and people die, not only our family members, but also nurses, other health care workers, physicians, because we did not have what we needed to protect ourselves.”
Rebecca Kolins Givan, an associate professor of labor studies and employment relations at Rutgers who studies labor issues in the healthcare field, says nursing strikes are almost never about pay. They are “about patient care.”
“And for nurses, that comes down to staffing,” she says. “They know very well the difference between the care they can provide if they are assigned to cover more patients than is safe or reasonable.”
Research backs this up, she says, highlighting that “you can’t provide the highest level of patient care that patients clearly deserve and that nurses want to provide without sufficient staffing.”
“That has been the critical issue in nurse bargaining for quite some time,” she says. “The nurses in New York who went on strike, and those who came close to going on strike, want really strong staffing language. The New Jersey nurses are basically saying, ‘we should have—for our patients, for our ability to provide quality care—we should have enforceable staffing levels’.”
According to Givan, this is true for most hospital jobs. About 85,000 workers in the Kaiser Permanente health care system, for example, conducted a three-day walkout in five states and the District of Columbia, which ended with what the Coalition of Kaiser Permanente Unions described as “a historic agreement” that will “will set a higher standard for the health-care industry nationwide.”
The Kaiser workers sought and won better pay, which is expected to help retain staff, and a minimum wage for health care workers. The feeling behind the strike, as Matt Swanson put it at the close of the three-day walkout, was that health workers had been hearing, during the height of the COVID pandemic, that they were front-line heroes, but they were not receiving much in the way of tangible rewards. Swanson, an organizer with the Service Employees International Union (SEIU) in Oregon, says that executives at Kaiser—like executives elsewhere—were being rewarded as hospital revenues grew, but workers saw their pay stagnate and nurses and other workers leave. This created staffing shortages that could compromise care and further stress workers.
“You have these executives who maybe didn’t come out of health care, executives who have prioritized the wrong things,” he says. Growing revenues were not being invested in improving care, but were funneled into the stock market where they could generate even more profit, or they were used to buy up other hospitals and health systems. The response from workers, he says, is “ ‘Hey, what about us? What about the folks who are providing care? We need more support on the job, we need more staff to be hired.’ ”
Nurses are fed up. They are striking, Givan says, because the corporate model in health care encourages austerity.
Carol Tanzi, a twenty-five-year veteran nurse at Robert Wood Johnson and a lead organizer with the union, says this dynamic is at the center of negotiations in New Brunswick, which have turned into a “power struggle.”
“The dynamic [pits] the people who are trying to make billions of dollars in profits and keep it in their pockets against the people who are in the hospital taking care of people and who are trying to preserve the real idea of what a nurse is supposed to do,” she says.
According to Tanzi, nurses would prefer to take care of patients and would rather have remained on the job. But they had no choice, she says. So they walked off the job.
“What better show of advocacy than doing that, making such a personal sacrifice to get our voices heard,” she says.
Dozens of nurses on the picket lines offer a similar analysis. They say that the corporate model of health care, and the consolidation of facilities within fewer and fewer companies, interferes with their ability to provide quality of care, even as most nurses spend extra time treating patients and making sure their departments run well.
Will Mumford, a neuroscience nurse, explains that he often works longer than his scheduled twelve-hour shifts, getting to work an hour or more early and often staying well after his shift ends. He does this because he is committed to his patients, but staffing shortages place extra burdens on nurses and are driving some away.
“It sucks to always feel like you’re shortchanging the people,” Mumford tells me, “even if you’re putting in 150 percent. A lot of us don’t take lunch, don’t take breaks, we work constantly and still stay late and chart afterwards, because we’d rather do as much patient care as we can and make it up on our time.”
Jeff Balo, a cardiovascular intensive care nurse, says staffing ratios are important to maintain the standard of care expected by the hospital, the patients, and the nurses themselves. When there are shortages, “[nurses] have to be able to prioritize what is the best thing for the patients.” Balo explained that this often means making choices about who may be sickest and who needs the most attention. On an ICU floor, where patients may be on lifesaving devices, these decisions can be the difference between life and death.
Staffing ratios are supposed to be set to allow nurses to manage crises, but corporate care models are asking nurses to take on higher patient loads, which reverberates back on patients.
“Nurses should be able to function properly, safely, and have enough time to be able to take care of our patients. The only way that’s going to happen is if the ratios (of patient to nurse) are lower . . . . In an emergency situation, if I’m unable to get over there, and God forbid, if that patient dies, it looks like a reflection on my care where I'm not set up for success by the actual system itself.”
Nurses are fed up. They are striking, Givan says, because the corporate model in health care encourages austerity, which in turn leads hospitals to hire fewer nurses and support staff as a way of managing costs on a ledger sheet—though not the costs to patients.
“What we see in health care is these ostensibly nonprofit providers that act like for-profits,” Givan says. “When you look at their strategies, they seem to be revenue maximizing. When you look at executive compensation, they look like for-profit executive compensation. When you see their marketing budget, it doesn’t look like a nonprofit. It looks like a for-profit that’s trying to maximize market share.”
The industry, Kennedy says, is making millions of dollars, and hospitals are “looking at more profit over patients.”
“We’re saying, ‘you need to put money into the infrastructure,’ ” she says. “This is about the ability to make sure that patients who pay for their care, their insurance and things like that, are provided the care that they absolutely deserve. And even those that cannot afford it, they should still be afforded comprehensive quality and safe patient care.”