I actually think that this is just one example of many across a ton of disciplines where people like Nurses basically are forced to deal with costs and responsibilities offloaded onto them from above the responsibility chain. Resources are eaten up at the top of the chain to their benefit and costs are offloaded down the chain until it reaches people like Nurses at the end of the line who have to deal with it because there is nobody else to offload it to. There is no shortage of people wanting to be nurses (in some places it is extremely competitive), and there is a huge demand for nurses based on shortages everywhere, but somehow we are in a situation where nurses are overworked because they are short staffed.

I look at academia which is rife with money sloshing around, and see undergraduate classes are taught by grad students who make ~30k a year who are basically the Nurses of the academic world and treated like garbage. The justice system is dysfunctional, courts systems are overwhelmed and understaffed so criminals just enter and exit like a revolving door, and police is basically useless because the best they can do is taxi criminals into the system that automatically spits them out again, while they take the brunt of public criticism for how they are forced to deal with a problem that is mostly beyond their scope.

In all of these cases it seems like the bottom if falling out of these institutions, and the responsibilities have fallen on their respective janitors to deal with it when the solutions need to come from places that have been incentivized to create the mess in the first place.

I think this is due to Pournelle's Iron Law of Bureaucracy:

https://www.jerrypournelle.com/reports/jerryp/iron.html

"In any bureaucratic organization there will be two kinds of people:

First, there will be those who are devoted to the goals of the organization. Examples are dedicated classroom teachers in an educational bureaucracy, many of the engineers and launch technicians and scientists at NASA, even some agricultural scientists and advisors in the former Soviet Union collective farming administration.

Secondly, there will be those dedicated to the organization itself. Examples are many of the administrators in the education system, many professors of education, many teachers union officials, much of the NASA headquarters staff, etc.

The Iron Law states that in every case the second group will gain and keep control of the organization. It will write the rules, and control promotions within the organization."

Nurses, teachers, charity workers, IEPs, game devs.

These are all jobs where people sign up for the job. Whether it’s altruism or genuine passion. They’re willing to compromise and put up with less pay and harder working conditions.

But because they’re willing to compromise, these people are pushed to their limit. With not only low pay and shit conditions, but higher-ups which actively exploit their altruism and passion. “If you don’t work, patients / children are going to suffer!” coming from the same beaurocracy which created the situation where a) they suffer or b) you work extra hours.

They’re being pushed past the limit in fact, which is why there’s now a nursing and teaching shortage despite these actually being popular fields. A lot of people want to work these professions, they just don’t want the jobs.

This is the same reason why startups often phrase what they are trying to do as "change the world" and not "become filthy rich" to their employees.

I think most startups (at least originally) did start out as ‘change the world’. When you find out that changing the world is kinda hard, ‘become filthy rich’ starts to sound like a good alternative.

They'd be structured differently if they were truly about changing the world, instead of just being vehicles for wealth accumulation.

Absolutely. And you'd see much less hypergrowth mindset, and a willingness to go slow, steady, and do it right.

How would the structure change?

Not a single professional investor does so on the basis of “change the world”. Maybe “create a monopolized market”, that’s a changed world.

You're just falling for the propaganda.

As a startup person, I like the startups where the spiel is “Get filthy rich by changing the world” the most. As long as I get to partake in the riches.

I've had good rapport with those who are honest about their startups being businesses, as they're usually also the same types who understand that working for them is just a job, and that a job at a startup comes with its own risks, as well.

People that go out of their way to say that their startups have a higher mission make me uneasy. I don't know if they're just trying to convince others that they're running something other than for-profit businesses driven by expected returns on investment for investors, or if they truly believe it themselves. It's either borderline manipulation or delusion, and neither are something I want to hitch myself to.

I can think of a couple of companies whose public face represents "Get filthy rich by changing the world". Tesla, for one. Maybe SpaceX too.

Oh, no, that reads like I just turned into a Musk fanboy. Surely there's got to be some non-Musk company that I can add to that list?

> Surely there's got to be some non-Musk company that I can add to that list?

Biotech startups? Develop a cure for horrible disease X (save lives, give people a few more years with their families, etc–feels good?)–and then get rich selling that cure.

I think Blue Origin's messaging is in principle similar to SpaceX (Bezos wants to save the environment by moving manufacturing to orbit, etc.) It is just that SpaceX rather obviously delivers on that message, and has grown rich delivering; Blue Origin hasn't delivered much yet, and it is hard to grow rich prior to delivery–but maybe, give them a few more years, they'll finally get their act together, and they'll become more SpaceX-like.

It seems to be the case that if you give someone a bunch of money, they'll stop wanting to change the world for the better. There are thousands of billionaires who could each end hunger and homelessness but have chosen not to.

The resources available to nation states dwarf those of billionaires, and it’s they’re specific actual job to do it, yet they too have failed to end hunger and homelessness. Bill Gates has sunk untold billions into humanitarian aid and its a drop in the ocean.

Eventually, you start looking into why the governments fail to end hunger and homelessness. Then, people start calling you a tankie.

Because hunger and homeless ness were of course unknown under Stalinism.

https://en.wikipedia.org/wiki/Mass_killings_under_communist_...

I'm not seeing anything about homelessness in the article you linked to. Just for perspective, here's the opposite side of the coin: https://en.wikipedia.org/wiki/Anti-communist_mass_killings

As a regular person, I like startups where the spiel is "Have a fabulous life and be pretty comfortable while doing things that even after some serious devil's advocacy seem as if they might make the world a better place".

I was impressed when I met the founders of Gaikai (a zero-day network game distribution system later bought by Sony), and asked them what the goal was. Answer: "Buy an island". Honesty has its merits.

I had a VP at a large company who was sharing her background. When she talked about her failed start up she said "we did it cause we wanted to be MILLIONAIRES... and that didn't work out so here I am".

It was funny and personable. Still one of the better VPs I remember.

Bit of a false distinction to me.

Because how to get filthy rich is by changing (improving) the world.

Hahahaha you are so funny!

Oh, my sweet summer child.

It's one way to do it, not the only or simplest one? And once someone had done it, they tend to transition a bit to exploitation mode because why not (they think)? Is my impression

Yeah - the problem is that "a dream fuffilling job" without major filtering like med or law school effectively has a "virtual compensation" from desirability of the job. We see the reverse for (potentially literally) shit jobs or in ill repute. The economy accounts for your feelings but it cannot care about them.

Pretty sure most ppl become nurses for other reasons

They become nurses because it's a relatively easy (two years at a CC) to become an RN, and the pay is pretty good.

It's easy on the body, compared to similar paid blue collar jobs, like union construction. And it seems better than office work.

Durning the AIDS crisis a lot of nurses--who could quit did. They quit because many were legitmetly scared.

Hospitals got worried, and told their marketing departments to throw out the word, "We need nurses!". Most smaller hospitals had a hard time keeping qualified egos (The Medical Doctor), and they couldn't be bothered besides doing just the bare minimum.

Let's not forget their are many classifications of nurses (RN, LVN, etc., and porely trained Candy Stripers, or cheap help, hospitals (especially union controlled) use instead of nurses. Some are not porely trained though, but nursing unions don't like competition. I'm not berating unions. Moneynot spent on help seems to go to administrators anyway.)

(I went to school with nursing students. Most were divorced. Most were around mid 30's. This was in the 90's. Now nursing is a good path to middleclass for immigrants.)

"They become nurses because it's a relatively easy (two years at a CC) to become an RN, and the pay is pretty good."

That is no longer the case and many now require 4 year bachelor programs to be hired as RN nurses. My wife has her bachelors in nursing and runs an ER and the hiring requirements includes a bachelors degree in nursing and not a 2 year degree.

I had no idea that Pournelle was claiming credit for that!

He nicked it from Robert Michels, who wrote about the Iron Law of Oligarchies in 1911: https://en.wikipedia.org/wiki/Iron_law_of_oligarchy

I was reading some old Analog magazines the other day, and man, Pournelle was one deranged man in his "non-fiction".

Leo Laporte would have him on a variety of his TWIT podcasts from time to time. I considered once coming up with a drinking game where you'd drink every time Jerry would have a sentence that included, "..when I wrote about...", but I realized you'd kill yourself.

Politically he was somewhat to the far right of Atilla the Hun

That wasn't as apparent when he was a BYTE columnist for many years but boy his website sure turned into "old man yells at clouds" although he did have serious health issues in his later years.

As somebody with experience at NASA, this made me chortle. I would NOT characterize the average civil servant that I worked with as "devoted to the goals of the organization." That includes the lowest level field organizations. Unfortunately, for the average employee, it eventually gets treated like any other job.

It's possible this dichotomy works in theory only. Being generous, it's possible they just disagree about the goals of the organization.

That’s the point. The second group, those who only care about the existence of the organisation, and the power/money it provides to them, have taken over at NASA.

As a result only those who act to increase the power/wealth at the expense of all else, such as the original goals of the organisation, get promoted and hang around. The end result, an organisation that achieves very little, and consumes huge amounts of resources, full of people who really don’t care about the fundamental goals of the organisation.

Ok, I see your point and think you're right. The quote distinguished between scientists/technicians and management. I met many in the former group who cared little about the goals of the organization, but to your point, they had been within the organization a long time.

I don't think the technician/management dichomoty is a good proxy. There are people from both groups who care about the goals more than the organization, but they not the people being given power.

Anyone who has visited planet earth and spent time here is well aware of that. The task is to prevent these people from taking and holding power.

Note that the strict formulation of this law (ie. "in _every_ case..") is profoundly anti-democratic in that it assumes no democracy can ever exist or function. Of course, I hope your household provides a good counter example (if not, then you should seek outside support).

Anyway, for those of us who still believe in democracy, it has long been recognised that the cost of it is that everyone has to be a adult who takes responsibility for basic things in life like maintaining the social fabric of the institutions you belong to in order to prevent them from being taken over by sociopaths.

So the question is, will we support medical professionals in doing this? In the UK, before COVID, when junior doctors went on strike to try and remedy the situation, the media denounced them as enemies of the people and they were completely crushed by the state (with the help of their own professional organisations like the BMJ). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4902702/

>The task is to prevent these people from taking and holding power.

And for that I completely blame the 'right' thinking, honest, hardworking nerd types - even when given the reins to power they will often not take it, because it is uninteresting work, compared the cool gadget/problem they are working on.

> in order to prevent them from being taken over by sociopaths.

Every institution has already been taken over by sociopaths. That's why it's called an "iron law", and not a mere concern.

> Every institution

+ "that is so large so there's a pyramid to climb and a bunch of sociopaths who start climbing".

Smaller orgs can get away, can avoid the iron law.

But a big country is a bit doomed

Funny you should mention unions. They seem like the only vehicle (imperfect as it may be) the first group has to keep the second group in check.

They definitely are, as long as the union itself isn't compromised by that second group.

In a healthy marketplace, walking to another job works as well.

Do we have a healthy marketplace? Specifically for nurses?

I certainly doesn’t seem it.

You just explained something I saw on many establishing subreddits!

Here's the original author: https://en.wikipedia.org/wiki/Iron_law_of_oligarchy

Thanks for the link, I'll check it out.

That's why you need unions

> There is no shortage of people wanting to be nurses (in some places it is extremely competitive), and there is a huge demand for nurses based on shortages everywhere, but somehow we are in a situation where nurses are overworked because they are short staffed.

why is this such a common story across pretty much every single industry? There's more people in the country than 10, 20, 30 years ago. More customers, more money. Why do they think they can handle more work with less workers whose salary is less when adjusting for inflation?

Owners and operators have learned that they can keep the lights on by running their businesses with skeleton crews and, at the same time, reap the rewards of lower costs as profits.

Covid was also used to exploited the issue further and as an excuse for horrible service and skeleton crews.

During covid Business owners saw that the consumer was willing to take it so they will continue to run on skeleton crews as long as the consumer takes it.

Sure the consumer will complain but they are still using their money to buy from skeleton run places.Partly because most industries nowadays are Oligarch control and what one does the other does as well and the consumer has lost their control of the marketplace.

We are living in a world where the big guys have the majority control of the market place and the market want's skeleton crews.

This is seen across the board in all big business run industries. However with nursing, especially in the ER and the ICU that are now running a skeleton crew the consequence is your health and even your life. Until the big healthcare providers,insurance industry, hospitals, doctors , etc start to get sued over low staffing as the cause of death nothing will change and they know how to document to prevent such a case.

> reap the rewards of lower costs as profits

yeah...or stay in business because their prices aren't 10x their competitors.

The anti-capitalism is strong on HN these days...

I don´t know much about nursing specifically but it is actually interesting to account for how many customers served per employee and how many there are at the bottom of the organization. If you are earning next to nothing and are doing 200 widgets per minute a 10 fold salary increase wouldn't change the cost of the product per customer. If there also is a large profit margin the desire to keep wages down is more of a fetish than the sensible choice it is at the other end of the spectrum.

Depending on the type of job you also get a different "product" depending on how much you pay and you might not be able to measure it. Employees cut corners in the least visible way and do not brag about extra effort if they are paid well enough.

This[0] was a fun read.

>Nursing care services are the most intensely used hospital services by acute hospital inpatients yet are poorly economically measured [...] >Nurses are an anomaly in the current inpatient billing system. Rather than bill for the actual services provided to the patient or the amount of time spent providing nursing care, the cost of nursing is embedded into the line item for room and board, which is the same fixed cost for every patient receiving the same level of care within a particular institution. In other words, all patients cared for on a given unit are billed the same room and board charge regardless of the actual amount of nursing care the patient utilized during that hospitalization.

[0] - http://frogfind.com/read.php?a=https://www.ncbi.nlm.nih.gov/...

> If you are earning next to nothing and are doing 200 widgets per minute a 10 fold salary increase wouldn't change the cost of the product per customer. If there also is a large profit margin the desire to keep wages down is more of a fetish than the sensible choice it is at the other end of the spectrum.

It depends on what portion of the cost of production is materials vs capital costs vs labor. You're presuming that labor is a small portion of the cost of production, which is probably true if you're selling them for $10. If it's an extremely low cost item, like plastic washers, labor can still be a significant part of the production costs. It also depends on whether you carry that down the supply chain, since part of your material cost is someone else's labor costs.

> Nursing care services are the most intensely used hospital services by acute hospital inpatients yet are poorly economically measured

This doesn't strike me as utterly insane. Most treatment prices should include the cost to have a nurse deliver it. The tiers of rooms should roughly approximate the amount of nursing care required outside of treatments. It's not perfect, but it might be better on the net than having nurses spend more time on the patient chart to add billing items.

I.e. it might be overall better to not have a specific line item for "rolled patient over to prevent sores" that the nurse has to enter in, and then billing has to argue with insurance about whether a roll was needed or not. It might be cheaper for everyone to figure out the average cost of providing nursing per tier, add a profit margin, and charge everyone that.

I'm not saying it is better, but it seems at least plausible.

> If there also is a large profit margin the desire to keep wages down is more of a fetish than the sensible choice it is at the other end of the spectrum.

I'm consistently surprised by misunderstandings of supply and demand.

There is a labor market. It's relatively free, all things considered. Sometimes companies conspire to keep prices down (see: high tech antitrust lawsuit/settlement) but usually the thing that keeps wages low isn't business owner collusion it's the availability of workers accepting work with a low wage.

Sure, all things being equal business owners would like to pay less for labor. They'd also like to pay less rent, less for insurance, lower taxes, etc. And sometimes they want to pay less than anyone is willing to accept, and sometimes instead of raising wages they rant about it on Twitter or in opinion pieces or whatever.

But that doesn't get them employees!

>usually the thing that keeps wages low isn't business owner collusion it's the availability of workers accepting work with a low wage.

But if you have a labor shortage and low wages at the same time, that means that workers accepting work with a low wage aren't available, but the employers are keeping wages low anyway. (And in this context, poor working conditions amount to "low wages" because they decrease the value of the job to the employee.)

In capitalism, "labor shortage" means "the employers had better pay their employees more, or else they won't have the employees to compete against other employers who will pay more".

I don't think we disagree, but what you describe is not necessarily a result of collusion -- maybe the business just doesn't work with higher-paid workers (i.e., product costs more than market is willing to pay) and scales with number of workers, in which case the owner might take whatever workers they can get at cost X, but can't hire any at cost X+1.

Only a profit-averse business owner would turn away revenue-exceeding-costs work merely because it involves paying workers more -- that business will likely not last super long unless there are special circumstances in play.

I think 'we have to exploit our workers to stay competitive' is a bigger argument against capitalism than 'I choose to exploit my workers because it gives me more profits'.

Attrition sucks money. It is just not on the spread sheets for the bean counters.

They don't think they can handle more work with fewer workers. It's just a profit squeeze, and someone else pays the price.

Because it's more profitable to have a single person that works 80 hours and one desperate for a job than 2 that work 40 hours.

Because they really can in many cases from more automation, better tools, and better processes and understanding. The demand also doesn't neccessarily increase linearly with the population.

in many cases there is room for automation. I'm not quite confident we are at the level of an Auto-Doc assisting/replacing nurses yet, though. Nurses being thrown into multiple duties for 1.5x standard full time work seems to suggest that one or all of the above factors are not being met.

>The demand also doesn't neccessarily increase linearly with the population.

for elastic goods, no. But medicine is about as inelastic a product as you can get.

> academia which is rife with money sloshing around

In the academia that contains money sloshing around, the only grad students teaching are the ones who want to.

In the academia that doesn't contain money sloshing around, it's a different story.

But the truth is, no one in academia is making bank from academia directly -- not the grad students, certainly, but also not the adjuncts, or even the professors. You have to look higher up the chain (or, I guess, laterally?) for that. (Yes, there's the caveat that some faculty make good use of their prestigious affiliations or professional connections to increase income from outside of academia.)

I don't disagree nurses DESERVE to be paid more (I'm not sure if the economics bear out but they're certainly as WORTHY as many other professions), but wouldn't the fact that these nurses continue to work in nursing despite considering leaving bolster the argument even further that they are receiving adequate compensation?

Staying when you want to leave indicates there's enough compensation to 'make it worth it' at least versus whatever shitty alternatives you have. Leaving when you want to stay, to me, would be a much bigger indicator that nurses who want to stay in the profession can't because of wage/benefits/conditions issues.

> Staying when you want to leave indicates there's enough compensation to 'make it worth it' at least versus whatever shitty alternatives you have. Leaving when you want to stay, to me, would be a much bigger indicator that nurses who want to stay in the profession can't because of wage/benefits/conditions issues.

I think the conclusion of this sort of economic thinking is basically: Give your employees just enough money that they can keep they keep their head above the water but not enough to flourish, and just enough pressure/responsibility that they don't have energy to do anything else, but not too much that they have a complete mental breakdown that leaves them with the conclusion that they should leave your industry at any cost.

When you spent a lot of time and money into a specialized and demanding career, I imagine it practically very difficult to actually change your career, even if it's killing you. It's probably even worse if you have familial obligations. You likely do not have time or energy to better your situation after hours, and if you quit, you potentially resign yourself (perhaps) to many years of destitution while you accumulate the necessary knowledge to do something else. I would not be surprised if many people just bear bad conditions because the cost to do anything else worth one's time is simply too high.

It also cues your organization up for a failure cascade. You don't have workers who want to stay, you have workers who are forced to stay. As soon as they can leave, you're not going to lose "1 or 2" you're pretty likely to use a substantial plurality since whatever changed probably changed for all of them at the same time. Can your organization survive with 50% of the staff giving 4 weeks notice at the same time?

Just sue them to prevent them from being able to quit.

https://www.latimes.com/business/story/2022-01-24/wisconsin-...

Wow that's basically indentured servitude. We are going back a 150 years in time!

> Can your organization survive with 50% of the staff giving 4 weeks notice at the same time?

Yes, you hire them back at travel nurse rates, while you lobby for your state legislators to ban your employees from doing any work if they quit.

What we're seeing play out is essentially the Dead Sea Effect, but in Nursing.

https://medium.com/geekculture/the-dead-sea-effect-d71df1372...

That conclusion would be fallacious, although many on both sides believe it. For one it ignores both growth potential and relative costs. High productivity workers can and do utterly dominate in ways which more than make up for it. And miserable employees are mercurial in quality at best relative to happy and motivated ones.

I recall hearing about one desert conflict "gratuitous" allocation of several times the prior typical water per day resulted in outsized military performance. I think it may have been the Six Day War. But Silicon Valley is basically the exemplar of that business model as they specifically go with a very high COL area in the world's richest country instead of mass outsourcing. Even assuming that the actor is a heartless and selfish bastard what truly matters first is net profit.

It is the same fallacious false economy seen both among slaveowners and the Soviet Union. That the labor is free or already paid for so don't worry about its efficiency.

The caring professions are quite a special case. The worse things get, the more carers care.

They are not like computer programmers who can make an industrial process be 10,000x faster. They cannot magically care 10,000x more, no matter how relaxed and comfortable they are.

Furthermore, as they are pushed closer and closer to failure, the collapse in patient care standards does not result in a collapse in profit. People aren't going to not seek medical treatment, it's a basic human need, sometimes a life or death need.

So we're back to the question: does that mean they should be exploited and milked of all their caring, at the same time the standard of care collapses, because the economic incentives reward that?

And that is fundamentally a moral/humanitarian question in which you have to make an adult moral judgement.

Employers are going to pay the minimum wages they can in order to retain sufficient workers. They obviously aren't going to voluntarily pay extra just so that employees can flourish.

There are a lot of jobs openings available to someone with an RN certificate and some experience. Unemployment in that group is close to zero. They don't all work in direct patient care roles.

It looks like you accidentally "did a communism" by arguing for nationalizing health and putting patient-care considerations above market considerations :)

Communism never has worked and never will work. We should just set legal minimum standards for patient care quality. Hospitals can then do whatever they need to comply with those standards, including setting nurse wages at whatever the market dictates.

Thanks Ayn Rand, a more astute reader might see the meme phrase, the scare quotes, the smiley, and see the obvious humorous intention :)

But I'll go ahead and explain the joke. There is a long history of the private sector using the spectre of communism (or socialism, or "big government" or "nanny state") as a canard to prevent sensible policies eg. anything that would improve patient care, even if it were at minuscule costs and will use that canard to justify lobbying aggressively to prevent it. And if they cannot obstruct legislative action then they switch to defunding the state bodies which enforce the regulations as an exercise in "cost cutting" because "the state is wasting your hard earned taxes!!" etc.

Hope you have a better rest of your day.

Edit: I mean, once you have set a regulation, and established a body to police it, you have already interfered with the market, so even what you are suggesting could be described as having "done a communism"

>Edit: I mean, once you have set a regulation, and established a body to police it, you have already interfered with the market, so even what you are suggesting could be described as having "done a communism"

Exactly, remove regulations from health care. I'm dead serious. Regulatory burden on nurses and health care workers are insane. It's completely plausible the net effect would be far more people saved than lost, due to greater access to healthcare and lower burdens to achieving outcomes.

Which specific regulations would you propose to remove? Everyone loves the idea of reducing regulatory burden but they always fail to give specifics.

For example, hospitals spend a lot of money complying with CMS reporting rules on iatrogenic harm such as bed sores and secondary infections. Should they stop doing that?

> Everyone loves the idea of reducing regulatory burden but they always fail to give specifics.

You're right, apologies for not being specific.

>Which specific regulations would you propose to remove?

Specifically, all of them.

>Should they stop doing that?

Object to framing of the question. Hints at a false dichotomy. Desirable outcomes can be achieved without precisely following a regulation.

I love it. Libertarians and similar always like to say "communism sucks, can not work, can never work, is a completely broken model"... when the reality is that 1) they _dislike_ the model (which doesn't make it broken), and/or 2) that communism, like many systems, works well, until annoying corrupt humans wanting money, power or both start interfering with the ecosystem.

The second point is entirely accurate. It's one of the major factors that makes communism, socialism, untenable in many ways.

What's hilarious / frustrating is how these same people think that humans in a libertarian utopia won't be corrupt, won't want for money and power, and as a result, "Sure, remove all regulation - the market will get more efficient! It certainly won't end up like the railroads in the 19th century, or something out of an Upton Sinclair novel!"

I choose free markets BECAUSE everyone is corrupt, not the other way around. Regulators, who are third parties to the transaction beholden to neither those seeking health care nor those offering it, are the most susceptible to corruption. Regulators need eliminated to reduce corruption, amongst other things.

It's always the regulators isn't it?

Never the supplier using ill gotten capital from predatory business practices to lobby or perpetrate regulatory capture.

Nope, it's always those pesky regulators sticking their hands out. Never those Captains of Industry! Paragons of Humanity and Unquestionable Beings of Moral Fiber and Impeccably Ethical Manner!

>everyone is corrupt

What part of that didn't you understand? Where did I say the captains of industry aren't corrupt. I said "everyone."

The consumer has the power to voluntarily spend or not spend with a particular health care provider for the vast majority of health care decisions. Their providers are beholden to the customer.

The regulator, on the other hand, is not beholden to the customer this way. The regulator, are typically integrated as part of government and thus not only are they unbeholden to the customer but they also are part of the same entity as men with guns who can use violence to achieve their ends. They are nearly always unelected and only in the loosest sense does the customer have any control -- no one seriously votes for their senators / representative based on who they approve of in say the FDA (can 99% of voters even name a single regulator in say the FDA?) -- that vote is dominated by other even more important issues you need your representative for. These regulators are effectively an ultimate source of corruption, backed by guns and only in the most tangential sense accountable to consumers but with wide latitude to control industry in ways that harm the consumer.

Yes everyone is corrupt, including the 'captains of industry' and even the 'consumer' but regulators make things massively worse. Regulators create an amplification effect of corruption.

Many can't afford to not work due to debt/rent/child support payments. If you don't pay rent you lose the apartment and the weekend parenting time. Miss the child support payments which were being taken from paycheck and child support enforcement takes driver license and starts process to take the car that is in your name.

Many people don't have even a little optionality.

That's actually my point. IF they are able to meet their obligations in nursing and their job is literally such a superior option to all the alternatives that they don't have 'optionality' then it's a weird flex to be angry at your one best(least bad) option that actually pays your rent and child support. Be angry that the alternatives aren't as good as the nursing gig you have.

I definitely feel for those paying child support, because 'imputed income' means you must pay at whatever rate the judge thinks you can make the best money at. You can never take a more relaxing lower paying job, because it will result in your imprisonment. Those people really have no future in the US -- their only option to throttle back their income is suicide, leave the country, or wait to go to jail. I blame society for the existence of these debtor's prisons, not nursing employers.

Seems you understand the more income -> more support trap. Mandatory overtime is considered in support calculations. That sets high water mark so going back to 40/hours week does not lower payments. I learned the hard way, and last employer I regularly sent email to boss thanking them for opportunity to work voluntary overtime. I would subpoena the boss's response of 'yes' for evidence in child support hearing to only use 40/hours week. The courts and county child support enforcement are wicked and liars.

Yes that never made the slightest sense to me. As someone married with a kid, when I get a raise or bonus it goes to my retirement -- not as a change in quality of life for a child who already has food/shelter/education. The kid still gets the same amount now as when I made significantly less. The idea that a kid needs more money because you worked overtime is quite possibly one of the dumbest ideas I've ever heard. At best it's simply backdoor alimony.

But the counter to that is, just because you work a minimum wage job and can't afford much child support, doesn't mean that what you can afford is enough to raise the child well. I expect it's very hard to say "the child needs _this_ much in order to be raised well" and then scale up from 0 to that amount as the parent makes more money. But you also can't just decide how much the child needs and then make the parent pay that much no matter how much they make. So the compromise is to base the amount paid on the amount the parent makes, and not really cap it. This has the benefit of allowing low earning parents to pay less, at the cost of high earning parents paying more (than is really needed).

>But you also can't just decide how much the child needs and then make the parent pay that much no matter how much they make.

This is basically how it works when you're married, though, at least in my family. Whether I'm unemployed or my work life is booming, the child cost the same for me as when I'm not. During bad times I liquidate my engineering tools / spend from savings / go into debt / sell my vehicle to take care of my kid if needed. On the flip side during the good times the extra money goes into investments and retirement. The amount I need to take care of the kid is fixed, with the amount I spend having virtually nothing to do with the amount I make. My level of personal real spending has changed very little since I got my first near minimum wage job after leaving home at 18; and definitely not linearly with my salary (at best I eat out more now, but that's because I'm busier making money). When the kid came they've always been a relatively fixed cost -- or at least unaffected by our salaries.

My kid would not be effected the slightest, better or worse, for my wage unless I was stuck below ~$12/hr for an extended time, so maybe it would make more sense to take a variable amount up to say $12/hr and then just a fixed price after that.

>doesn't mean that what you can afford is enough to raise the child well

Really depends. Some children grow up in situations where money is scarce but nonetheless have fulfilling childhoods that lead them towards success. It's also worth noting parents who can provide other things in lieu of money -- such as a homestead where they grow their own food and build their own house is perfectly acceptable in a marriage but somehow not acceptable as part of child support enforcement. It doesn't make sense.

>This has the benefit of allowing low earning parents to pay less

Again this is an odd choice. When I am making nothing, I still contribute half to the family costs. When I'm making 6 figures, my half stays the same. Both my wife and I have a deal where we pay half the costs. That way there is no resentment that someone is paying more just because they make more. It happens to be my wife makes significantly more money than me, but we still pay 50/50 costs of child and other bills with the remainder going into our own unshared accounts. It would be extraordinarily selfish and greedy of me for me to demand my wife to pay more simply because she makes more money, yet if we divorced this is precisely what the judge would order in many states. No matter how nasty the divorce I would simply return her share of her savings along with anything over half for spending of the child -- to not do so would make me a vile and greedy person who cowardly uses the violence of the state to unjustly take from others.

In our case the cost of the child is about 6-8% of our current salaries; so as you can see from child support calculators, about half of the money calculated by child support worksheets would be entirely for the lolz of the judge.

>So the compromise is to base the amount paid on the amount the parent makes

Unfortunately this isn't how it works, as above alluded. Once you make a certain amount it becomes your 'imputed income'. Once you set the precedent you can earn a maximum, the judge expects that to be your income you're capable of. You pay based on that higher amount whether you relax back to a lower paying job or not. In this way you're set up into a trap where if you try to get a higher paying job to save up to pay off years of child support, you're stuck in an even more fucked position and meanwhile if your kid is like mine and has a relatively fixed cost then the rest is bled off as backdoor alimony as a reward to your ex-spouse for divorcing you.

Well it depends what you think the purpose of economies is. One idea is that human beings are just a type of animal, and the economy is a social system which is supposed to incentivize the kind of behaviours that you want humans to do. If you want humans to be nurses, then the economy had better reward that.

Another interpretation is that the economy is a tool for exploiting people. For example, human beings are inherently of the opinion that human decency is good, they want to be functioning members of society, they care about the wellbeing of others, and if they are paid crap and treated like garbage, they will endure that, even to the point of great personal cost, emotional distress, mental illness, alcoholism, and even death. But as long as they don't quit, then everything is fine.

Most of those ppl cannot leave due to various obligations.

If you want to see an indocator of terrible compensation - check why pretty much noone (at least here) wants to be a nurse.

Profession is rapidly aging because new ppl are not joining. And they are not joining because work is hard and pay is terrible.

The whole Healthcare system if we dont get robots in place fast is going to crumble soon like a house of cards.

The US has lots of people interested in nursing and not enough infrastructure to turn them into nurses:

https://www.npr.org/sections/health-shots/2021/10/25/1047290...

The work is hard, but the pay is well above many other jobs and there are jobs everywhere.

Im in Eastern Europe so situation here is complete opposite.

+ emigration of nurses to Germany

That's not how the real world works.

People don't 'switch careers' when they've spent years getting good at it. What they do instead is sit around posting on HackerNews and fucking the dog in all sorts of other ways.

Do you realize the irony of it all? This place gets like 1/10th the traffic on weekends. That's not a coincidence.

Are you familiar with the US? I don't see how you can in good faith argue that if people don't like what they have to do and/or what they get paid for it, they can just go do something else.

There's also the consideration that nurses don't leave, because they can see that patient care standards are not good, and they worry that if they leave, their colleagues will be forced take up the slack, employers won't replace them (since the colleagues took up the slack), and they will reward themselves for having found a way to "improve efficiency."

There are, of course, onlookers who are unable to even perceive the moral dimensions that normal human beings take for granted. Perhaps they were beamed down from the mothership just yesterday? The prevalence of psychopathy among human beings cannot be as high as it would appear from the average internet message-board, can it?

I am not really specifically making an argument on their salaries, I guess I am saying that Nurses are in the position where they have the least leverage in the system so they end up bearing a lot of the responsibilities that should be held elsewhere while having a disproportionate amount of resources allocated to them.

In healthcare I get the feeling that a lot of workers feel stuck in that there are many patients and people depending on them, and to leave would sort of be like abandoning them while increasing the burden on ex-cowoerkers.

> Staying when you want to leave indicates there's enough compensation to 'make it worth it' at least versus whatever shitty alternatives you have

Not necessarily. The "transaction costs" of switching careers are huge. If you want to make comparable money to nursing, you probably need training in something else, which likely requires a period of low or no income, possibly years of schooling or other training, etc.

It's hard to switch careers after 30 -- not always impossible, but certainly hard to revert back to the lifestyle of a 20-something for some time. People may stick it out despite unhappiness.

Doesn't mean compensation is adequate.

America is full of terrible jobs now. Just terrible. There has been a degradation of job quality with outsourcing, amazon, you name it. This may be why nurses don't leave.

But hasn't that always been the case, where 80% of the jobs were unsatisfactory in some way or another. Be it pay, conditions, co-workers, management/boss, hours, commute time, etc... Not just America, but most industrialized countries.

>America is full of terrible jobs now.

At what point in time did America have better jobs? A lot of people may reference the glory days of 70s and 80s manufacturing, but those jobs went from bad to good with the power of unionization. There was no free lunch.

This reads too much like a generalization of the standard complaints about management and their stupid meetings, the basic thesis of that web comic that was neither funny nor true, Dilbert.

The criminal justice system may be overwhelmed, but its reaction certainly isn't to just let criminals "exit like a revolving door". The US is still incarcerating people at 10x the rate of other wealthy countries.

Nurses being overworked is simply due to there not being enough nurses. It matters little if there's too much bureaucracy somewhere, or if too much money is spent on pharmaceuticals (about twice as expensive as anywhere else) or if doctors make too much money or if the US has a uniquely unhealthy population.

>Nurses being overworked is simply due to there not being enough nurses.

yes but this begs the obvious question of "why?", which either leads to the immediate thoughts of

1. not enough people want to be nurses 2. companies don't want to hire more nurses

I'm assuming #1 is false, so #2 is the go-to conclusion, at least on the high level. I'm sure I'm missing some more nuanced #3/4/5 explanations, but it does seem to ultimately come down to money that isn't being spent (be it maliciously or simply due to not having the budget).

The obvious #3 is "nurses are doing too much non-nurse stuff" which relates to both #1 (job is annoying and not what I want to do) and #2 in a way (they are not hiring non-nurses and/or investing in equipment, tools, etc).

I was introduced to the Dilbert comic strip while working in the Bay Area in the '90s. Customer's rep literally pulled me aside and asked how I could work for my boss. Said "this is your boss!"

Dilbert wasn't a webcomic, it was in the paper.

The pillars of society are police, healthcare workers, and teachers. Except in America, where the pillars are, according to salaries, CEOs.

Not just America but pretty much everywhere. I'm Finnish, and when I read about problems of American nurses it all seems pretty much identical to what is going on in my country, except maybe for some legal problems. Low pay, angry patients, lack of resources and bad IT seem universal.

The universal part is human greed, and I’m just not sure if we’re going to survive long enough to get over that.

Greed, combined with kindness and agreeableness, but in different people

And, the pillars of government are college coaches. Ha

And yet the government budgets rise dramatically year after year.

The government is one of the few places where you can get a job in your twenties and retire comfortably in your 60s having made a decent, but certainly not outstanding, amount of money with consistent raises and cost of living adjustments.

What some people will call government waste - other people will call ethical employee treatment... sure there are a lot of other sources of inefficiency outside of your comment - but complaining about overpaid government bureaucrats is essentially advocating for the same race-to-the-bottom that has stagnated wages in large parts of the labour pool.

I complain about getting a lifetime pension after 20 years of service. A career is 22-65 or 43 years.

(Most) Bureaucrats don’t get a pension after 20 years, so that’s a bit of a red herring.

https://en.m.wikipedia.org/wiki/Federal_Employees_Retirement...

That might be the case for federal, but a lot of state employees like teachers can get substantial retirement after 20 years.

Please don't conflate State Public Employee retirement systems with State Teacher retirement systems. They each have their own rules.

The teacher retirement systems I know of have rules like (age + years_worked)>=80 ==> full pension benefits.

Retiring after 20y will earn you a smaller monthly and is only possible (under that rule-of-80 above) if you start teaching at age 40. Teachers are much more likely to retire after 25+y (age_start=30, age_retire=55).

It's not that they're paid too much. It's that they do too little useful work.

A relative of mine works for a state level LEO targeting financial crimes - they've spoken often about how "smaller government" advocating politicians have repeatedly hamstrung the organization when it tries to go after large corporations. They've still managed to do good work going after smaller scale offenders that fleece investors - but I wouldn't put the blame on those employees for doing work you don't find useful... it's mostly up to politics.

That's the whole point. Powerful proponents of small government want to do anything and everything with no consequences. They've duped a lot of less-wealthy suckers into believing that having fewer public services will benefit them somehow, and/or that the only thing standing in the way of personal success is the government. They talk a lot about figures like word count in legislation and other easy to understand concepts (even to folks with low education).

Any govt office, focusing on the US here, seems to have a huge back log and understaffed like the IRS, Immigration services, DMV etc. For e.g. earliest appointment I can get is perhaps a month or two out. A huge backlog and understaffed makes a case of overworked employees. Surely, they are doing work, and so I can only think that by "they do too little useful work", you mean that the work itself that they do is of little use. Are they? Seems like getting my driver's license or tax refund is pretty useful, no?

It's actually not sure that they are doing work. There are backlogs because the employees and management are slow, inefficient, and don't make changes that would be made by a private organization either staying up to date or being replaced by a competitor.

(There are complexities and counter-examples that moderate this generally true statement.)

This is just victim-blaming.

Defund the organisation to point of total chaos and near-collapse. Blame employees for collapse in work quality.

Here are some more generally true statements:

Increase profits and improve efficiency by cutting out maintenance tasks and firing the people who do them. Blame accidents or outages on employees, customers, bystanders.

People die? Company goes bust? Who cares? Even if there are consequences, the executives/officials to blame have already taken the money and moved on to the next thing. You can't prosecute them or get the money back (unless they were stupendously dumb and got directly involved and stayed on 'til the bitter end and centres of power were so affected that prosecutors can't ignore it: see Theranos, Enron, etc.).

Theranos and Enron went bust. Government bureaucracies never go bust.

Governments are overthrown and reformed at scale "all the time". Perhaps about as often as often as corporations relative to their number and sizes.

Even without governments being overthrown, government agencies get deeply reorganized fairly often; often for reasons of politics rather than efficiency, but nevertheless.

As often? Come on.

Yeah, when was the last time the US gov got overthrown. Or Brazil or Germany or France, UK ... "All the time"?

Otherwise good points I think, @scaramanga:

>>> cutting out maintenance tasks and firing the people who do them. Blame accidents ... Who cares? ... You can't prosecute them

We don't share preconceptions (I see multiple problems at multiple levels of public org charts, and in the electorate), but I see and appreciate why you might have that priority.

While I myself am frustrated with the bureaucracy and inefficiencies of govts, but I am not sure if its entirely fair to compare a govt with a private company/org - at least based on the scale they operate on and the profit motive, which make it very different.

> It's actually not sure that they are doing work. > (There are complexities and counter-examples that moderate this generally true statement.)

Guess, based on that I cannot really have a counter argument here :)

> Guess, based on that I cannot really have a counter argument here :)

Hah, sorry. If you don't qualify a general statement, you'll get jumped on by people supplying the qualifier for you. I wish it weren't like that.

Relative size is a good point, certainly. We can look to several huge companies to see frustrating interaction points (hence my qualifier.)

From what I understand, queueing theory would say a backlog that doesn't go away but also doesn't keep growing means you're staffed to just barely keep up on average.

It's not given that the queue backlog is staying even, but you would also have to factor the externalities of better or worse performing offices into the queueing analysis. Slower government workers have consequences like the public giving up and bothering to add to the queue, and occasionally, lawsuits due to failure to perform a required task, legal cases being a less desirable budget spend than bureaucratic staffing.

Parents point is that there must be slack in a system in order to have a stable queue size.

But slack can also be perceived as waste, which can be cut.

And if your budget is cut, you are likely to see that slack as "first thing on the copping block" with the consequence that the queue begins to expand. But most systems have natural buffers which delay catastrophic failure. By that point there have been elections, you have retired, etc. and someone else is left holding the bag.

At that point you can blame the organisation for being "slow", or "inefficient", and then you can cut it's funding further, or destroy it outright or maybe outsource it to the private sector.

Then the private sector can drive profits by asset stripping and cutting safety or vital maintenance work, then when the whole system collapses, you can hold the taxpayer hostage by demanding a bailout of the, presumably vital, service (or you can renationalise it), and the whole cycle starts again.

Welcome to our planet, enjoy your stay, it's likely to be a brief one :)

Ah, if that was their only point, then I should have pointed out that a better operating department can achieve a lower waiting time with the same degree of slack. I understand the utilization rate tradeoff and that's not the issue.

I'm glad you've enjoyed writing your comments--like your style. :)

Ah sorry, slightly misinterpreted, my understanding was that without slack you cannot stabilize queue sizes which makes OP incorrect(?)

Yeah, more efficient nodes can delay that effect, but it seems that in real world system the existence of buffers means that consequences are delayed in ways that have significance (across careers, elections, etc) and those factors tend to dominate.

yw, nice that anyone reads it, without that i'd just be another mad shouty bloke on the internet, maybe i still am :)

We all are. :)

I've worked public and private sector and know plenty of people in both and I've not noticed a huge difference in the number of people just coasting vs those who really try to make a difference.

What makes you think government is that much worse than the private sector in this regard?

> What makes you think government is that much worse than the private sector in this regard?

Sure a lot of people coast in the private sector, hiding in the corners of their organizations. But if the business allows too much of that to happen, they go bust. In government, they just go get a tax increase.

They do not go bust, they just find ways to bilk their employees, or customers, or the general public, or they find a way to make the government nanny them by shredding regulations or what not.

You seem to think that people cannot escape the consequences of their actions, and that consequences arrive swiftly and fairly. But I should think a quick look around the world we actually live in will disabuse you of that notion in short order. Especially when it comes to gigantic centres of power with vast reserves of cash and well protected revenue streams.

And if you've worked in any tech company, you've probably already seen that the people who coast do not "hide in corners" they make up an entire class, called "management", especially "middle management", they're front and centre because they have no productive work to do so they can devote the majority of their time to extravagant displays justifying their existence and their elevated positions and compensation.

One place I worked, was a Big Company providing overpriced services to other Big Companies. There were loads of low skilled IT workers, taking too long, making mistakes. Adding a BA and/or PM to drive every project when a competent dev could've done it solo a few years ago. But when you keep getting issues, you keep adding process and now every job is 1000+ hours.

But eventually the work got done and we kept getting work because Big Companies buy from other Big Companies. You're not going to risk tendering to a 3 man office who gets it done faster, cheaper, better because if it doesn't happen questions will be asked. Unfortunately there are a lot of talented small businesses out there but they just don't get the work due to this.

Do that enough, and Big Corp gets overtaken by a smaller, nimbler company that does better. See the book "The Innovators Dilemma" for one aspect of this.

Which Big Corp though? The provider or the consumer? The dilemma is, this all feels like a bit of a Boy's Club where they all agree to just help each other and ignore the little people. Not always formally, it's just how things work out. They have an interest in maintaining the status quo and ignoring upstart-startups.

Of course, eventually yes it's impossible to ignore the value gap. But I've seen companies threaten to leave but keep paying the bills for many years because in a big company, it's not really anyone's problem in particular and it's easier to just keep going along to get along. One example we had was B2C email communications, there are so many cheaper more capable players out there but they just got us to do it because we did other stuff for them.

> this all feels like a bit of a Boy's Club where they all agree to just help each other

Come on. They often try to sue each other out of business, get the government to declare competition illegal, "cut off their air supply", "knife their baby", etc.

> because we did other stuff for them

There you go. Not because of the goodness of their hearts.

Not if they are competent at building moats.

Big Companies today are not the same Big Companies of yesterday. There is constant churn at the top. The ones at the top today are all newish companies.

Companies go bust all the time. One of the corporations I've worked for simply disappeared (Data I/O). Corporations disappear all the time. Remember RCA? No? How about Kmart? Sears? Kodak? Tektronix? Novell? Lotus? Wordstar? AOL? Zilog? Myspace? Zenith? Curtis-Mathis? RCA was once the biggest corp in the world.

I've known people in every corporation I've worked for who accomplished nothing and were not managers. I was often given the job of trying to turn whatever they did into something useful. Everybody knew who they were. I remember one person, we'll call "Smith". "Smith" would check in code, and it was always so bad that someone else would have to redo the whole thing. After a while, the term "smith-code" became a generic term for code that was worse than nothing.

How bad can you be that your name becomes a generic term for useless work?

"Smith" eventually got laid off. The team was relieved.

Sure, I was imprecise, I mean, they do not necessarily go bust. And even if they do, it can be delayed by decades, even centuries, by techniques that are too numerous and well known to list here.

I've known a few Smith's in my time, one thing they all had in common was the protection of a manager who had no interest in the quality of Smith's work, as long as Smith would take his side in any disputes. When the consequences became too great, the manager would suddenly understand the problem and approve the minimum of changes to fix it, while taking credit for the work. Smith would not complain about this slight because he understood the nature of the transaction.

Edit: btw. congrats getting rid of your Smith, these people can be very difficult to dislodge. Presumably your guy did not have the protection of a manager.

None of those companies have gone bust though. RCA got purchased and integrated by/into GE, Kodak filed bankruptcy but still exists with a significant number of employees, Tektronix is currently a fortune 500 company, Novell is now owned by Micro Focus, Lotus was never that big of a company, but they still exist and are doing pretty poor but still sell cars, AOL still exists and is owned by Yahoo, MySpace still exists and is owned by an advertising company and the other 2 or 3 I've never heard of.

The Lotus that the GP refers to is probably Lotus Development Corporation / Lotus Software, the makers of the hugely popular Lotus 1-2-3 spreadsheet from the 80s. It's still around-ish: it was owned by IBM until 2017 then was sold to the Indian company HCL Technologies for $1.8 billion. Pretty good for a company thought to be two decades obsolete!

Zilog was the maker of the Z80 microprocessor that powered a huge number of games consoles and simple computers in the 80s. Also still around - its parent company was acquired for $750 million.

I had to look up Curtis-Mathis because it wasn't a thing in the UK.

And MicroPro / WordStar International does seem to be legitimately dead: acquired by SoftKey who were acquired by Mattel who have since gotten rid of all the associated brands.

Who uses Lotus 1-2-3 today? Nobody.

Yeah, I know they didn't literally go bust, some company always winds up buying the remaining value in the company, as its trademarks and IP have value.

But in any practical sense, they ceased to exist. (I meant Lotus of 1-2-3 fame, not car fame.)

Tektronix didn't go bust. It was acquired for $2.8b in 2007 with 4,000 employees and is now part of an umbrella corporation that trades as NYSE:FTV.

Their scopes are still for sale and still good.

You're right, I thought I'd remembered they'd gone bust.

> part of an umbrella corporation

meaning their former glory is gone. When I was starting out Tektronix was a very big deal in computers and electronics. I haven't even heard their name in 20-30 years.

You're right too. Their former glory is gone, I never knew how much bigger they were before until I looked up more of their history today.

> and see undergraduate classes are taught by grad students who make ~30k a year

Hah, wasn't it UCLA who recently got excoriated for advertising for grad students to teach undergraduate classes with this stellar line:

"This is an uncompensated position"?

> courts systems are overwhelmed and understaffed so criminals just enter and exit like a revolving door,

You're delusional. America has more people in jail, serving longer sentences, than _any country in history_.

Don't know why you're being downvoted on this. It's simply a fact. Is it because you didn't provide a citation?

Here: https://www.cnn.com/2018/06/28/us/mass-incarceration-five-ke...

This. So much this. In so many fields, it's actually hard to find one where this is not the case.

The rules nurses have to deal with around things as asinine as taking PTO are AMAZING. They’re required to put in PTO requests months in advance and the hospital can and will say “Sorry, denied. We don’t have enough people…” As they are intentionally creating skeleton crews of nurses to wring every ounce of profit out of the business.

My mom was a nurse, my aunt was a nurse, my sister is a nurse and my best friend’s mom is a nurse. I really can’t believe anyone continues to be a nurse given the insane working conditions these folks have to put up with. Twelve hour shifts, overflowing with patients, watching newcomers earn more than seasoned veterans… When I compare it to my laid back software engineering job it’s like I’m living in an entirely different universe. The hospital industry is a hugely demoralizing place.

The hospital I work at requires physicians to file their schedules 8 months in advance. The only deviation from that is for emergencies. Unofficially there’s a lot of flex for them, but that’s the official administration line.

Yeah, my mom was a small town nurse it was the same even there. I gave them a bit more slack because it was a hospital serving like 2000 people (so not really a high profit place) but even there, there was a lot of last minute "Oh no! People didn't show up for their christmas shifts, could you come in please!"

In cases I'm familiar with, they aren't hiring JUST ENOUGH nurses, they are hiring AS FEW NURSES as they can get away with. More like half as many as they should. IIRC, nurse-to-patient ratio should be around 1:5, but it can often be more like 1:10 or worse.

On top of that, they also hire as few orderlies and nursing assistants as possible, so the nurse doesn't even have anyone to offload things to, and ends up having to do more work on more patients.

This has been a problem well before the pandemic.

It's a trope among nurses that they are so busy they don't have time to use the bathroom, let alone eat lunch.

Source: My wife is a nurse, most of her friends are nurses, and she left the profession ~a year before the pandemic because of exactly these issues.

This ended up being the last straw for one of my friends who was a nurse.

He kept getting vacation requests denied due to lack of staffing, yet if he asked if they were looking to hire, the answer was always No.

He was super lucky and had some early cryptocurrency investments pay off big, so he decided he was done with it retired. He said that he loved helping people as a nurse, but not at the cost of his own physical and mental health, having to work 60-80 hours/week. If he ever gets back into it, he would establish at the interview phase that he works 50 hours/week tops, and that vacation "requests" are not requests, but notices.

That describes me, though in tech. Trying to step back in to tech and recently had interview. After I explained parenting time schedule, HR guy said everbody works 60 hour weeks every week so there is not a role for me.

Yeah the incredulous looks I get when I turn down gigs at "unlimited" PTO positions are just wild.

Like what did you expect to happen? We're not stupid.

"Unlimited" gets a bad rap.

At the place I'm at right now, we have an unlimited policy and I've got 25 days of PTO planned over the course of the year that's all been approved.

But yeah...I do know not every place is that good about it.

I believe there's studies showing that unlimited PTO policies actually result in people taking less time off, especially in competitive environments. The theory is people don't want to be viewed as "the guy" who takes more time off than anyone else. I'm not sure that's a good thing. There's less of that pressure when it's earned PTO.

Its just corpspeak for "we don't want to commit to you getting time off or a possible slight payout"

This is so weird to me. I've always said I work 4 days, 32 hours, and that has almost never been a problem. I've once spoken to a prospective employer that really wanted 40 hours, and although the job sounded really interesting, 40 hours was not an option for me.

At all jobs, vacation time was almost never a problem. Maybe that's more the case now that I'm a freelancer, though. I just announce when I won't be available, and although we do try to plan things so that we never have the entire team gone at the same time (unless the company as a whole plans for that; Christmas breaks are often like that), they always accept my absense. It's really notifications, rather than requests.

But this is Netherland. We've got quite a different work culture than the US does.

That sounds perfectly fair actually. You explained you can't work 60 hours a week and he explained it's not the role for you. Complete honesty and the choice was made not to do the deal. You shouldn't get special hours or treatment for being a parent.

I agree with you, and I wanted them to know my needs so we all succeed. Hilariously the guy never asked my pay needs (low) and talked to me about the top of the pay range. I didn't care to correct him since the expectation was overtime all the time for everybody. Looks like a management culture I don't want to struggle against, so I can look elsewhere.

Look into state government IT. Low pay, but you'll never work over 40 hours a week.

>The fix is one that Hospital admins don't want. Pay your nurses more and hire more

As someone who worked in hospitals to help redesign their processes, this one piqued my interest.

For every project I worked on (and I mean literally every one), the team lead wanted to jump to the solution that they just need the ability to hire more people. In the rare instances where they were able to convince hospital admins to do so, it never fixed the problem. Not once.

Why? Because it never addressed the root causes. They needed to take a process-oriented approach. There's a saying that adding more people to a broken process makes things worse. You can hide a lot of quality issues with inventory; if you have a requirements for 100 widgets a day and you have a crap process that only makes 10 quality widgets, you can meet your goal by increasing throughput 10x, but nobody thinks that would be a good approach. It's the same with injecting more staff onto a broken system. If the system causes nurses to spend disproportionate amounts of time on admin work and not on direct patient care, it may be better to look at your admin processes rather than just hire more nurses.

It's natural when people to feel overwhelmed to think the solution is to just hire more people, but it's almost always better to hold off on hiring until the system/process is fixed.

Edit: I'm curious about the downvoting. I think it would help illuminate the conversation if you could explain where your disagreement lies. I'm basing my statements on actually tracking when hiring was increased to the levels desired and metrics did not improve.

You're describing Brook's Law from The Mythical Man-Month. It was an observation of collaboration in software engineering specifically, and it cannot be applied universally to every industry. Really, anything that is highly parallel (medicine, teaching, stocking shelves, waitstaff, deliveries) can benefit from hiring more people until you reach saturation, and medicine isn't there or we wouldn't be having the conversation.

The problems are caused by a "just in time" approach to staffing, where you have exactly enough people to cover the shifts at bare minimum. What solution would you suggest other than more people? They are not saying to throw more nurses at patients simultaneously, they are saying to hire more nurses so existing ones aren't bound to spent the entire week stretching themselves across the hospital.

Also, I think you are being downvoted because you are applying software engineering rules to medicine.

It's interesting because they aren't software engineering rules. If anything, they are industrial engineering rules that pre-date software and certainly older than the mentioned book from 1975. The approach I was using was developed specifically for healthcare and with great effect in some organizations. I know this is HN, but I think it's an error to assume everyone is coming at a problem from a software perspective.

>What solution would you suggest other than more people?

It obviously depends on the situation but most of the time it comes down to reducing process waste. That may be automation through software where a nurse was hired specifically to only generate reports 40 hours a week, to re-designing a layout that minimizes travel time for nurses when they are delivering to patients. My experience with the staffing situation is that managers did not know how to staff to meet the needs of their patient loads and just revert to simple heuristics that left them understaffed at some times while being overstaffed at others.

> re-designing a layout that minimizes travel time for nurses when they are delivering to patients.

I think talking about micro-optimizations like this misses the forest through the trees.

It's neat and cool. Fun to wring out those last bits of efficiency. But the fact you even need to discuss it shows how hiring adequate amount of bedside staff is the absolute last thing any medical system will do.

> revert to simple heuristics that left them understaffed at some times while being overstaffed at others

Showing that they were better than modern day automated shift planning.

I will submit that if your hospital floor staff is not 50% idle on your average given fully-staffed boring day, you are understaffed. Only extremely exceptional events should cause your staff to be booked 100%. When it happens it should be root cause analyzed and be immediate cause for executive concern.

The trope of card playing nurses should be true, because of all industries there are - you want surge capacity in healthcare. Both physically speaking in terms of warm bodies available, as well as mentally speaking in brains not being stressed to their max the entire shift.

I understand these ideas don't end up with maximal efficiency. I am likely naive as well - but it's pretty clear that hospital systems are being operated in an intentional manner to keep staffing cut to the bone right up until the point the system or people break.

This doesn't just hold true for healthcare, it's endemic in a lot of service industries where the bottom tier employees are expected to live in service of the profession and take up all the slack from above.

There's a general rule of thumb that I have about any business: if it "looks busy" and people are running around, yelling into phones, unavailable for questions, etc., it's probably either understaffed or ineffectively organized. A workplace where things aren't visibly moving is one that is ready to make plans and respond to events smoothly. The productivity rate is somewhat independent of the "busyness rate" since there are a huge number of ways to stop work from needing to be done in the first place.

However, this seems to be unsatisfying to modern management styles. Apparently if you aren't running the employees into the ground like an Amazon warehouse, you're "leaving something on the table".

>I think talking about micro-optimizations like this misses the forest through the trees.

It may be different in practice than you are imagining. It's been years so I don't have the exact numbers, but something on the order of 10-20% increased patient throughput in radiology of a major metropolitan hospital that provides for an underserved community. (Keep in mind, it's not just nurses who have to traverse hospitals but patients. Many of them are old or lack mobility, so the changes are compounded.) I don't consider that "micro" but you may have different expectations. As a comparison, I don't think nurses would think a 20% increase in staffing is trivial, but my preference is to measure at the patient level, because that is the outcome I'm most concerned with.

>Showing that they were better than modern day automated shift planning.

Can you explain? I'm not following this statement. I was involved because it wasn't working.

>you want surge capacity in healthcare.

I agree. But like all complicated systems, you rarely get something for nothing. The trope in healthcare is you can choose between quality, cost, and access, but you only get to choose two. Lots of slack in the provider supply side is great for surge capacity, but it generally comes at the expense of cost. That's difficult when many of the same people who complain about the lack of providers also like to point out the cost of healthcare. I would prefer to take system-level view so we aren't essentially just shifting the waste around in the system and instead work to cut it out completely. In this case, excess capacity isn't waste but a desired measure of resilience. But I do think it needs to be measured and managed. My experience has been that nurse managers will just constantly increase the slack in the system rather than address the other issues.

And I absolutely agree there are issues, across many industries, where JIT thought-processes are short-sighted. COVID, and prior to that, Fukashima, has demonstrated this error. There are certain critical systems that we do not want operating at maximum input/output efficiency. If the staffing issues I've referenced were consciously framed in that sort of pragmatic, data-driven argument, I would be the first to stand behind it. But often they were really coming from a "we're-overwhelmed-and-don't-know-what-else-to-do-so-just-hire-more-people" perspective.

I'm suddenly reminded of traffic. For a long time, governments tried to fight traffic congestion by adding more lanes. Traffic is highly parallel, so this should work, right? But it doesn't. Traffic grows to fill up those additional lanes and you're stuck with the same congestion.

Here, better traffic design is necessary. And room alternative, more efficient forms of traffic (public transport, bikes).

I do think nursing (and many similar fields) do need to hire more people, but I also suspect they have to redesign how nurses work. Less overhead, more focus on the core of their work. Streamline the processes, especially the administrative side, and not expect them to fill in for many other kinds of work at the hospital. Get separate specialists for that.

> If the system causes nurses to spend disproportionate amounts of time on admin work and not on direct patient care, it may be better to look at your admin processes rather than just hire more nurses.

I get the impression that the same is often true for teachers, academics and cops: too much focus on administration, which takes the focus away from the reasons they chose these jobs in the first place. Streamline the administrative process, or have dedicated administrators help them with the boring stuff, so the nurses, teachers and cops can focus on the actual content of their jobs.

I would say streamlining is definitely preferential to do first and sometimes hiring staff afterwards. If the latter is done first it can quickly result in administrative bloat. I often wonder if that's part of the issue with higher education and contributes to some of the increased costs in recent decades.

i think that argument works a lot better in a field where they arent bullying people into working overtime near constantly

Perhaps. But again, why is the overtime needed?

If it's because it provides more patient care beyond what a nurse can provide in a good system, it might be a valid point. But if it's because the system is fundamentally broken, I'm skeptical that hiring more people will actually fix anything. From personal experience, it will only create a lag that will require the same need for more hires down the road.

if the overtime isnt needed let people go home after 6 hours each day

I think maybe I'm miscommunicating the point. Yes, if overtime isn't needed people should be sent home. Hospitals agree on this; they don't want to pay overtime if it's not needed.

The issue I'm pointing to is that sometimes it's "needed" because of a bad process, like when there is redundant work. Sometimes it's needed because the system needs slack to compensate for disruptions in system dynamics. Sometimes it's "needed" because "that's how we've always done things." Point being, if it's needed, it should be because it contributes directly to better patient outcomes rather than bad processes.

My contention is that if you reduce redundant work, staffing levels will be reduced to match to go back to the current equilibrium of overwork.

And that seems to speak to his point exactly. The problem isn't that there isn't enough staff. It's the management is performing badly at scheduling or some other process. The internal problem needs to be fixed before hiring is increased.

The issue is that you hold this as axiom valid across industries. Since your personal experience with IT projects was that process was always issue, therefore when nurses say the hospitals need to hire more nurses, you assume they must be wrong. And you also completely ignore industry specific realities - like there being surge of patients due to covid.

Having excess capacity is necessary and should be a consideration to build a resilient system. It's not about trying to get to 100% efficiency, it's about managing to what you care about and resiliency can be one of those items.

It's hard to adequately staff to that level when the systems/processes are largely unmanaged. By definition, an unmanaged process doesn't know how much nursing gets spent on each element, from patient care to admin work. So it becomes just a guess as to how many you need; when people work in unmanaged processes they tend to feel overwhelmed and the knee-jerk reaction is to hire more people. And often when you add more people to an unmanaged process, the inefficiency can compound, leading you to feel like you need more people to fill the continuing gaps.

Hiring more people can be part of the solution. But you need to understand and manage the process first to get to the right answer.

How do you know the process is not managed? That is fascinating thing here - the argument is not that "I looked at nursing work in hospital and it was unmanaged" it is "I worked on IT project and since it was unmanaged, I am 100% convinced the same situation is in hospitals".

Maybe you meant to respond to someone else, but if you look through the chain of comments, they track back to a post where I was referencing personal experience in healthcare. This included projects redesigning processes where nurses were an integral part of the service.

My position is precisely that "I looked at nursing work in hospital and it was unmanaged." (not in every instance, of course, but certainly in those relevant to this conversation)

If you're interested in chatting about this sort of stuff, let me know.

I'm a UK doctor working in the field, always looking to optimise processes while keeping quality.

Email is in my profile.

My Daughter was born on the winter solstice this year. We had a broken sink in our hospital room and someone came by to fix it. He had a trainee with him. Who was mentioning that he was scheduled to work New Years Eve and then again the next day on New years day. A 3rd shift followed by an immediate 1st shift. He was casually talking to the guy training him and mentioned that had to be a mistake. The guy in charge said something like "what did I tell you. They don't care about you". I sure felt angry for both of them at that moment.

Hospitals operate 24×7. Someone has to work those shifts. Usually it ends up being the employee with the least seniority. What's the alternative?

The problem is not that they had to work on those days.

The problem is that they had two consecutive shifts.

The alternative is that the hospital hires enough people so they can schedule them such that everybody has time to go home relax and sleep after they are done with a shift.

My first year at the movie theater I had to work Christmas Eve, Day, New years eve and day, all for minimum wage. People are just more entitled now a days.

Did you go home and sleep between working on on new years eve and new years day? If yes then what you had is not what the complaint is about.

"My life was hard, so your life should be hard as well."

Yeah, let's keep not evolving as a species.

A good friend of mine couldn't get a single 3 day weekend approved (so one day of PTO) several months in advance.

Then I open my recruiter inbox and I see like 20 new B2C healthcare startups.

It really feels like the entire economy is designed to prevent problems being solved. Some people in healthcare are making massive amounts of money and the quality of life of everyone that performs the actual work has taken a nosedive when it was already a really crappy situation.

I think this gets it a bit backwards. There has been a shortage of nurses for decades, and it’s getting worse. This is exacerbated by an aging population and restrictive immigration policies. Travel/agency nurses were supposed to be load balancers for a system with variable demand for labor, but for a variety of structural reasons agencies began to pay nurses more. This has prompted a landslide of nurses moving into agency work. Labor costs have risen accordingly, but fundamentally that’s driven by the shortage of supply. If you talk to administrators they will tell you that they hate relying on agencies but they have no viable alternatives. They can’t raise wages because they have little/no control over their own cost structure thanks to the screwed up way healthcare in the US works, and most hospitals are barely scraping by. There are no easy answers to this one, and blaming it on shortsighted administrators (of which there are many!) misses the larger context.

>This is exacerbated by an aging population and restrictive immigration policies.

Sans the covid anomaly, immigration has never been higher in Western nations. The issue isn't restrictive migration. It's that we're not treating nurses well. That means fewer people pick this career, and more nurses leave prematurely. Suggesting that we need to import more nurses is only admitting that migrant nurses are willing to work for worse pay and worse working conditions, and I don't think that's fair to anyone.

> Rather than hiring permanent people or upping salary, Hospitals have instead elected to just use travel nurses and an extreme premium so as to avoid any salary increases.

In case people want an idea of what travel nurses made during COVID...

https://khn.org/news/highly-paid-traveling-nurses-fill-staff...

> In April, she packed her bags for a two-month contract in then-COVID hot spot New Jersey, as part of what she called a “mass exodus” of nurses leaving the suburban Denver hospital to become traveling nurses. Her new pay? About $5,200 a week, and with a contract that required adequate protective gear.

> Months later, the offerings — and the stakes — are even higher for nurses willing to move. In Sioux Falls, South Dakota, nurses can make more than $6,200 a week. A recent posting for a job in Fargo, North Dakota, offered more than $8,000 a week. Some can get as much as $10,000.

Travel nursing is definitely a great way to turn the tables if you can do it. The money you can make is clearly quite high! I fully support those nurses using travel nursing to get greater pay.

But it also isn't an option for everyone. Many don't have the flexibility to switch to travel nursing. For example, you may not be able to get a nearby contract and may not be able to travel (e.g. because you have children). Plus, traveling isn't an option for new nurses without experience, who now have to work in hospitals that are hemorrhaging experienced nurses to traveling AND have worse staffing ratios than ever.

These contracts are likely emergency contracts, which pay outrageously but often require a full week of 12-hour shifts or something similar with the expectation the nurse will only do one week then recover. I've seen this for COVID peaks and when a hospital's entire nursing staff is planning to strike. The $5200/wk rate is more likely 3 or 4 12-hour shifts.

I'm not sure I follow:

> The $5200/wk rate is more likely 3 or 4 12-hour shifts

3 or 4 12 hour shifts a week is normal for salaried nurses. $5200/wk isn't. It's over double.

> which pay outrageously but often require a full week of 12-hour shifts or something similar with the expectation the nurse will only do one week then recover.

I'm not sure what you're trying to say. Yes, it may be a full week of 12 hour shifts, but it's still a much higher pay. And if you get the next week off, it's a fantastic deal.

For context, pre-pandemic, I knew a nurse who often would do this schedule for her salaried job - she requested it as she liked having a full week off.

What I mentioned elsewhere: Travel nurses have a lot more control over the contracts they take. They can work fewer hours per year and still make significantly more. They may have stretches of long hours in a given contract, but annually they work less.

> 3 or 4 12 hour shifts a week is normal for salaried nurses. $5200/wk isn't. It's over double.

It's a normal shift schedule, and they pay travel nurses much more than staff nurses to work the same shift schedule. These are typically 3 month contracts, but not always.

> I'm not sure what you're trying to say. Yes, it may be a full week of 12 hour shifts, but it's still a much higher pay. And if you get the next week off, it's a fantastic deal.

I don't disagree, but a lot of people do not want to work (or feel like they can't provide good care for) 12 hours every day for a week.

Ah I see - we're in agreement!

How many working hours are in those weeks?

I haven't found concrete figures, but from what I've read, they do often work more hours during the contract. However, travel nurses in general have far more control over their schedule than regular salaried nurses. A salaried nurse cannot refuse to work, but travel nurses routinely say "No" to contracts if they don't like the pay or the hours.

What happens is they'll accept a few weeks (or 2 months) of long hours, and then take a month off and relax. As you can imagine, if they're getting paid $6000/week, they can easily take a lot of time off and still get paid more annually than their salaried counterparts (while overall working fewer hours per year).

I replied to the parent, but the highest quotes are probably emergency contracts for 5 or 7 shifts of 12 hours but only for a week. Longer contracts are often 3 months at 3 or 4 shifts per week.

Executive hospital pay is ridiculous AND the executives are often times just some MBA type without any real value add. How about you chop up their comp between the nurses - would be a start. Nurses are the lifeblood of the hospitals for anyone who has had the unfortunate circumstances of having to spend any time there.

>Executive hospital pay is ridiculous AND the executives are often times just some MBA type without any real value add.

I can agree that executive compensation is exorbitant, but do not agree that "MBA types" (what does that even mean?) have no value add. There's nothing inherent with being in the health care industry that translates directly into administering a (large) business. Why would you think doctors or nurses would be good at that?

The administrative side typically doesn't actually understand the technicality of administrating care and many times are MBA business types who administer a business as if its is commodity without understanding the true nature of the business (from their overconfidence generated from their degree and their lack of understanding the nature of the problems through distillation and non-technical understanding). This MBA culture is similar to tech/prod relationship in tech companies. Thus they provide little value add and get paid unfair amounts for their relative value.

I agree that Doctors and Nurses would likely be poor administrators - however the disparity in income is incomprehensible in healthcare.

I would add that travel nurses are treated better in a lot of ways. Staff nurses must attend certain meetings and training aimed at standardizing care and improving outcomes. The travelers don't have to attend. Travelers can take off pretty much any time they want as long as they know before they sign the contract. Sure, they're considered "outsiders" by some staff and sometimes get the less enticing patient assignments, but for those drawbacks, they get paid 4x (I've seen 3-8x staff rates, but 4x seems common) plus a housing stipend as long as their location is more than some distance (I think 40 miles iirc) from their "home" location. Why would anyone be a staff nurse?

Anecdotally, I know a travel nurse who works in pediatric ICUs (PICUs). One shift a couple months ago, the overnight staff on her unit was >80% travelers. And this is in peds units that aren't as affected by COVID, because ~1/2 of the patients are cardiac babies with congenital heart issues. The only case I can see for not paying staff more to increase retention is that they can respond to a dip in cases over the summer, but that can't possibly be an 80% decrease in patients. Maybe they're waiting until travel rates come down to offer an increase in pay so their 1.2x salary offer is more enticing in comparison to the travel rates, but the current system is ridiculous financially. I did mention that we've seen first-hand that hospitals can afford to pay nurses $4k/week, though, and I'm sure I'm not the only one who noticed.

Yeah, anecdotally, experienced nurses were fed up in the mid-1980s.

Do you have anything I can see about that, or did you just know people who were fed up and retired then.

I just knew people who were fed up and retired then.

> Hospitals have made sure they hire JUST ENOUGH nurses to cover shifts and no more.

This is a two-edged sword. If you hire more than you need, the nurses' hours will be cut during normal situations and they won't make enough money. If hospitals don't cut extra hours and instead keep the staff on the clock, a public scandal will erupt surrounding well-paid medical professionals sitting around doing nothing.

> a public scandal will erupt surrounding well-paid medical professionals sitting around doing nothing

I don't think that's true. Increasing the amount of nurses means simply increasing the amount of care. If you have twice as many nurses, you'll have twice as much care for your patients. No way nurses would be sitting around doing nothing.

That's not how healthcare works. That it is does not function that way is why free-at-point-of-use public healthcare systems are capable of working.

Not sure why you're being downvoted, but the idea that doubling nurses doubles the amount of patient care shows an ignorance of the healthcare system. "Patient care" is a nebulous term and needs to be further defined in that statement. Do you now get two catheters instead of one? Or get your vitals taken twice as often? Both double patient care but only one is relevant.

I could definitely imagine nurses having twice as much time to carefully read my charts, or twice as much time to sleep at night and be well rested so they don't fuck things up, or being able to come by and help with something twice as quickly

That would provide better patient outcomes, I agree. Whether hiring more nurses translates to actually doubling that, is another question. To be clear, I'm not saying that increased staff is not part of the solution; it's just been my experience that it's rarely the sole part (or often even the majority part) of the solution.

It's because it would actually double the amount of care on most floors, because they're usually at 60% of the staffing they need as a start because they've been able to get away with that for years.

That doesn't really answer the question. "it would actually double the amount of care". It would double the amount of staff hours. How those staff hours are used is a measure of patient care and not all hours are equally relevant to the patient.

As an example, if we assume you are a software engineer and you double your work hours, will you double your code output? Probably not, just like it's not a 1:1 translation of nurse hours to patient care.

Comments like this are showing just how much you don't understand maintaining a service level based care, and are stuck in thinking in terms of producing a product.

Combined with willfully ignoring that basically all floors are intentionally understaffed and have been for years.

I can tell you from my years in healthcare that many of the people who think they know how the system works only have a very myopic understanding and they usually are the one's who have the most confidence that their simple solution will fix the problem. Unfortunately, there's a lot of nuance in complex systems like healthcare.

We probably agree about the staffing levels to an extent, but I would be curious to hear the staffing estimation methodologies used in your experience.

Yeah, I agree. You sound like many healthcare admins I've worked with and for.

I'm not sure its the flex in this argument you think it is.

I wasn't healthcare admin and most of my department was staffed with nurses. But we were very data oriented and it helped buffer us from emotional responses to problems.

I have no doubt your emotionally detached analysis decided the floors were adequately/overstaffed since the nurses hadn't all quit yet or gone on strike.

I mean they clearly are still working there, they can always do a bit more to cover right?

I think you are are either misinterpreting my stance or transferring an argument from your personally experience. Also, you may want to revisit the HN guidelines[1]

My position is not that they were always adequately staffed, but that in my experience increasing staffing did not fix the problems as expected because the problems were rooted in more systemic issues. As I've stated elsewhere staffing may be part of the solution but rarely a panacea. Also, my stance is that fixing the systemic issues will help them do less non-patient-centered work so they can focus more on being a healthcare provider, where they are the most valuable.

[1]https://news.ycombinator.com/newsguidelines.html

Thank you for your thoughtful responses, you seem to be the only person here with experience trying to solve the actual problem in a data driven way

At the rate that healthcare charges in the US, hospitals can more than afford to keep X+1 or +2 needed nurses around in three 8-hour shifts. They just don't.

Not even close. Most hospitals have trouble staying afloat as is. And there are disciplines within nursing, so you'd have to overstaff by quite a bit more such that closer to 2x is a backup but leads back to the GP's point.

They employ on-call, PRN, contract nurses, etc to fill in the gaps which mostly works in non-pandemic situations.

Reading threads like this really hammers home most of HN have never worked in health care. Hospitals BARELY make their budget. 1% over cost of doing business is considered a really good year for my institution.

Also if I never have to hear people complain about bloated admin budgets in education and healthcare ever again it’ll be too soon. Those admins aren’t sitting around on their thumbs—they’re dealing with the ridiculous legal and administrative system the insurance companies and government have created. Those people are absolutely critical for the institution to exist.

This seems to be highly bifurcated, like so much in the US, between the haves and the have-nots. But overall I don't think it's fair to say "Hospitals BARELY make their budget." As usual, the whole system is broken. There are some hospitals with a wealthy customer base with full-ride insurance who can bill obscene amounts and profit massively, and then there are some hospital systems with uninsured and underinsured customer bases who are just scraping by.

I looked up my local hospital network, UCHealth (Colorado, there are many UCHealths it would seem), and their EBITDA in 2021 was 16.6%. Mayo Clinic posted 1.2 billion dollars in _operating profit_ in 2021, and also have a gigantic investing arm with several billion dollars under management.

Then we look at networks like Spectrum in Michigan, who posted only a 3.6% margin, or Henry Ford, with a negative operating margin offset by investment income, and it becomes clear that _some_ hospitals barely make their budget while _others_ rake in dollars.

It’s the same economics that create food deserts in some places and Whole Foods in others. Or how banks don’t exist in poorer neighborhoods despite being profitable on others. There is no incentive to allow one to subsidize the other. It happens with health networks that are mission based but otherwise, not usually. Try balancing out your research with the taxpayer funded public hospitals, it’s a train wreck.

> bill obscene amounts and profit massively

Profit how? Your 2 examples of UCHealth and Mayo Clinic are both non-profits.

Non-profits generally use substantial income in excess of revenues for expansion, just like many for-profit organizations. Excess revenues can also be absorbed in salary and other compensation or cost increases, usually top down of course. The main difference is that non-profit organizations are prohibited by law from making distributions to owner-shareholders. They can spend excess revenues in any number of other ways, starting with the furniture for example.

How badly is the entire industry mismanaged if hospitals have to charge thousands-to-millions of dolllars for treatments? There is no possible way that is just barely supporting facilities+medical staff+reasonable administration+liabilities if other countries can do it at tiny fractions of our price.

Instead, the story as I've heard it seems to be similar to education: massive administrative overhead permitted by fundamentally broken insurance billing.

Sure I may not know healthcare but they really need to fix their shit.

I agree it needs a reboot but it’s highly politicized and the things they reform usual cause more and more administrative burdens and thus costs.

The sad truth is labor in America is incredibly expensive. Healthcare is extremely labor intensive. And everything else is expensive too. We don’t pay the came cost from the source for things like drugs, medical supplies, etc. A thing that cost $100 in another country costs $1000 in the US. That’s from the manufacturer who can control what price they charge. It’s capitalism doing it’s thing. But we also have a ton of middle men. Insurance, brokers, wholesalers, distributors, and on and on. All of who need a margin of profit and maintains some level of administration overhead. So when people here say administrators and too bloated and over paid, it’s really the supply chain that is deep and prices that are uncontrolled.

Even parts of this thread exemplifies how difficult it is to get agreement on what the problem/solution even is. People are complaining that healthcare is too expensive others saying nurses need to be paid more or have hospitals increase staffing. These ideas are in complete opposition.

Hospitals have been paying 4x staff rates for travel nurses for multiple years now, though.

I’ve never seen that even before the pandemic. 1.5x-2x is normal for all the usual reasons a contractor cost more. Taxes, benefits, agency that needs a margin, etc.

I’m guessing if you’ve seen that is hyper localized to some place/issue.

1.5x isn't a real increase in staff rates if all it accounts for is taxes and benefits that the employer covers for regular employees anyway. It is like certain government employees who complain about being paid too little when the actual cost of their compensation in many cases is through the roof.

The situation is so bad that regulation or standard practices encouraging employers to document compensation figures instead of quasi-mythical salary figures would do a lot of good to reduce confusion in this area.

All in, it's still averages about 20-30% more expensive in a normal operating environment (before pandemic and all the subsequent issues). This is significant on the largest expense line item and considering it's controllable to a degree.

You can pay people fixed monthly salary + overtime hours. You don’t need to cut their hours and their pay, though that’s often the choice that employers make.

Exactly, choosing to cut hours or pay due to a lull in business is a choice made by the employer. It's not like these hospitals are sputtering along right at the fringe of solvency and one bad choice will bankrupt them - private health providers tend to make pretty comfortable profit margins and the fact that they can pay such outrageous surge prices for travel nurses is a pretty clear proof of how much they have to spare.

Many hospitals literally are sputtering along right at the fringe of solvency. This is particularly a problem with non-profit hospitals in poor and rural areas. Summer have shut down in recent years, and the pandemic is accelerating that trend.

https://www.beckershospitalreview.com/finance/12-latest-hosp...

Some hospitals are sputtering right along, and a list of 12 isn't a great piece of evidence that those hospitals (many of which are run by regional organizations which are essentially consolidating patient pools into a central location) are being run effectively - especially if these hospitals are paying 10k/week for travel nurses.

If there's a location that isn't profitable to operate a hospital in then the hospital will probably fail. America is the country still clinging to market-driven healthcare services and the market can be a cruel mistress.

And all that doesn't at all erode the fact that nurses are paid pauper's wages at extremely profitable hospitals - some tech companies are going out of business, some probably closed their doors today... that doesn't mean that all engineers are expected to work for 60hrs/week at $15/hr.

That article was just a recent example. If you search around you can find many other hospitals which have closed down or gone through bankruptcy in recent years.

https://www.gpb.org/news/2022/04/08/wellstar-closing-er-hosp...

https://www.post-gazette.com/opinion/editorials/2022/04/04/c...

In 2020 the US median salary for an RN was $75K. That was well above the median household income. Hardly pauper's wages.

Most hospitals are not extremely profitable. In fact the majority are run by governments or non-profit organizations.

https://www.kff.org/other/state-indicator/hospitals-by-owner...

Tech companies will pay engineers as little as they can get away with. Expectations have nothing to do with it. Wages are set by the market.

> Rather than hiring permanent people or upping salary, Hospitals have instead elected to just use travel nurses and an extreme premium so as to avoid any salary increases.

Hearsay from the nurses I know: a large hospital near me has a separate budget line item for full time nurses vs. travel nurses or other "mercenery" roles. This incentive system will never create the best patient care, but I suppose that's not really the goal.

for those that aren't aware, a while here reads as at least 40 years, and it gets worse every year, especially the last 10 or so.

With additional nuance that this kind of thing used to be protected a bit by the additional guard of a pharmacist. The automated dispensary changed those criminally liable people into a checkbox bypass that this nurse (and from the sounds of it, the rest of them by effect of policy) regularly bypassed.

I always wanted to understand how hospitals get away with treating their employees like that. In any other industry, people would not accept it. This is the industry where (arguably) I'd want people to be _most_ relaxed and _least_ overworked because human lives and wellbeing is on the line. Why don't airlines do that to their pilots? Should there be similar regulation in nursing?

Same reason game developers get treated like shit compared to many other developers. People are willing to put up with more shit to do a job they find rewarding.

So you are saying it's stockholm syndrome?

Not at all. I'm saying people consider all aspects of a job when choosing whether to leave which includes pay, working conditions, personal satisfaction from doing the job... Healthcare people probably like the feeling of helping people in need and are willing to accept the tradeoff of worse working conditions over choosing another job which does not have as much personal satisfaction of helping people but better working conditions.

Game developers are likely the people who love video games and so are willing to put up with the worse working conditions in order to work on the games they love.

That makes a lot of sense, thanks!

and now nurses are apparently solely responsible for medical errors and will not be supported by their employer. the cause of which appears to be related to #3 in GP above where overrides are a regular occurrence and quickly loose meaning if you have to do it multiple times per day.

https://khn.org/news/article/radonda-vaught-fatal-drug-error...

I always thought it was insane how nurses, a health profession, are forced into so many unhealthy habits, like working long hours with little sleep and with difficult access to healthy meals while they are working.

This is a problem in other health professions like medicine (at least during the training phase), and pharmacy.

Yes and No.

On an individual basis, nurses are overworked because they choose to be and their employers allow for it. The standard work week is 3 12 hour shifts, which is much less than most professionals work. Like a retail or warehouse worker, they are expected to clock out as soon as possible and leave when the shift ends. Those of us with salary jobs knows how difficult that can be in our arrangements and how much "free" work we end up performing. They get paid premiums for everything; night, weekend, etc. And since they're hourly, they typically LIKE the overtime and signup for it as much as possible. They also might work FT at one hospital and pull extra shifts at another hospital on a PRN basis. These things are very common. Just like in a retail environment, people typically LIKE to work holidays so long as it's voluntary because it's 1.5x pay (or more?).

> Rather than hiring permanent people or upping salary, Hospitals have instead elected to just use travel nurses and an extreme premium so as to avoid any salary increases.

This makes no sense. Capacity is the problem, paying more for the same capacity does not solve the problem. Hospitals try very hard to avoid overtime and the travel nurses due to the cost. It's also a very elastic model to balance and a lot of flex (non Full Time) folks are needed to fill the gaps and manage cost somewhat.

> The fix is one that Hospital admins don't want. Pay your nurses more and hire more than the minimum to cover shifts so a nurse being out sick doesn't result in another working a 80 hour week.

That is the current system. The problem is usually time. If someone calls in sick, they do it an hour before their shift starts. They usually can solve for this. Either they call from their roster or a supervisor level person with an active RN license steps into the clinical side that day. Staffing at 2x just in case everyone calls in makes no sense. Staffing at 5x just in case a pandemic hits makes no sense.

Hospitals barely make money as it is, I don't see how this is a sustainable solution. Paying more does not create capacity in this industry.

It's also important to note that "nurse" is a very generic term. For example, ICU nurses is a very distinct type of nurse that has been dealing with COVID first hand (caring for vent patients). They are the ones you hear about making $150-200/hour in COVID times. It is difficult to become an ICU nurse. It hasn't been possible for a surgical nurse to pivot to ICU nurse in these times so the labor pool has been rather fixed, or shrinking due to natural churn and inability to onboard new folks. It would be akin to suggesting why does some [insert super specific domain expertise] developer make $1M/year at FAANG when they could hire a PHP coder for $15/hour on a freelance website. There is no immediate/cheap substitute for the experience and knowledge that the expensive developer has, so they cost more. This is happening in nursing where some are thriving while many actually got furloughed early on in the pandemic.

My personal opinion on the matter, is one only has to look at the demographics of an average nurse. It's become quite "old" and like other industries, the boomer's retiring is causing a labor issue. The handful of nurses that made 5-10 years of salary since Q1.2020 are now ready to retire early as well. I don't blame them.

"Hospitals barely make money as it is, I don't see how this is a sustainable solution. Paying more does not create capacity in this industry."

The problem is – and this may be very bizarre in a society as capitalistic as the US – healthcare should not be beholden to making a profit.

Rehabilitating people is clearly "valuable" to the economy in that without people to participate in the economic system, a debt-based economy collapses; I'd argue that healthcare is much more valuable to capitalism than is reflected on a balance sheet of paper costs/revenues/profits, and yet a system such as ours has absolutely no way in its current form to price that in (sure, in an academic defense you could wave hands that "positive externalities" such as these should be priced in to the model, but it's clear with the racket the medical industry has found itself in that will never happen practically).

The main issue profit-seeking conflicts with is that whole rehabilitating/healing/saving people is an intrinsically good thing to do, and that letting people who have full lives to live die or suffer is an intrinsically bad thing to do.

What's not sustainable is that healthcare has to survive within the confines of a system that is many times in complete opposition to it. Other otherwise-capitalist countries have at least tried to insulate their healthcare industry from market forces, meanwhile the US has just wrapped it in another layer of capitalism with its insurance market.

I tend to agree with majority of this but it’s another can of worms altogether. It’s also an alternative reality nowhere near existing. In reality, no profit means no healthcare at all so these happen to be important considerations.

> Capacity is the problem

Capacity is generally limited by staffing, not space or actual beds. When hospitals report how many "beds" they have available, they're generally not talking about the furniture.

They are absolutely talking about actual physical beds. The bed is licensed by the state and inspected by a regulator and is an indication of how many patients can stay in the hospital. As as been shown these years, they can and will pay what is needed, finding qualified people is the hardest part.

If a hospital has 200 beds but only enough nurses to staff 100 of them, they have "100 beds".

Maybe to you, but officially you have 200 beds at 50% occupancy. If needed, nurses can be added by other means. For example, the army, FEMA, etc. will ship in nurses and just need to know if the bed is physically there and certified for use.

> For example, the army, FEMA, etc. will ship in nurses

Might ship in more nurses, and until they do, the beds that can't be staffed don't count towards capacity.

> 50% occupancy

Having the capacity to staff those beds is not the same as the beds being occupied. Beds are occupied by patients, not nurses.

Do you actually know what you’re talking about or trying to argue towards what a view you “feel” is the right thing?

I happen to work at a healthcare company that reports number of beds and did receive FEMA sourced labor during the pandemic in some of our rural hospitals that were short staffed and literally do not have the physical labor pool to tap into.

I think you’re discussing how you like to interpret the metrics of beds and occupancy but it’s not how it’s actually discussed in the industry.

ED nurse here. Of course n=1: "can be added" doesn't means "will be added". Our ED regularly boards admitted patients to the point we have a single resuscitation room left for new patients checking in or coming in via EMS. Plenty of rooms and physical beds in the hopsital, and by official metrics hallway beds are counted in "beds available". We did have National Guard present for some time, but it was non-clinical warm bodies to sit with patients on suicidal precautions, stock supplies, etc. No extra clinical staff. Though they were incredibly helpful and lightened the load, they did not enable more beds to be available.

It makes sense to the $250k/year hospital chief bureaucrat (not a medical person) and the Pres. and board accept that the extra contractor pay is just short term.

So are pandemics if you look at it that way

It was great for revenue. Hospitals got paid for using Remdesivir, which has no approved medical use anywhere worldwide and had a test on Ebola virus patients halted because it was killing faster than the Ebola virus. https://www.cms.gov/medicare/covid-19/new-covid-19-treatment...

' October 22, 2020, the FDA approved remdesivir (Veklury) for the treatment of COVID-19 for adults and certain pediatric patients requiring hospitalization '

That stuff is lethal. https://www.fiercebiotech.com/biotech/gilead-mulls-repositio...

Hospitals receive very little revenue for administering remdesivir. It's not a material item on their financial statements.

This shows $5.5 billion for Remdesivir in USA in 2021. This drug has no approved medical use and is ridiculously harmful to life.

https://www.drugdiscoverytrends.com/50-of-2021s-best-selling...

' Veklury (remdesivir) Gilead Sciences $5,565,000,000.00 COVID-19 requiring hospitalization '

And it is administered via IV, so add maybe $1000 for the IV procedure.

This discussion indicates about $75,000 which is easy profit when the patient is already on the bed and intubated. https://www.jdsupra.com/legalnews/cms-hikes-payment-for-covi...

It doesn't even work for helping recovery. Literally poison with no medical use anywhere for anything. Another drug company and hospital emergency payday.

Can't edit my other comment but also wanted to note that they added the clawback provision, which is a common tactic. What this does is allows them to add any type of payment scheme they want, and they can decide later if it was abused. So, if medical professionals are prescribing a drug with no medical value, they can decide that was fraud later and recoup the funds. It may be 5 or 10 years later but they often do this type of thing, hospitals are aware of that risk, and it would be rather cavalier/criminal to significantly abuse it for financial gain. It could even result in criminal charges, lost medical licenses, etc.

It’s hard to tell but these things have been rolled out quick with a broad approach of; don’t give any hospital any reason not to admit a sick patient during the pandemic. Normally a patient in outlier territory would have a hard time finding a long term acute care location if they were likely to lose the LTAC money. So they quickly instituted various add on and kicker “bonuses” such that nearly no patient would loss the LTAC money.

LTAC companies, in capitalism, would simply not accept patients if they thought they were too sick to make money on. Accepting parients put them out of business. The government wants hospitals to admit as many patients as they can in a health crisis. So , I feel this was more of a case where they acted quick and broad and didn’t actual think much about whether the drug was valid. If doctors want to prescribe it, it shouldn’t bankrupt the hospital where they work. The clinical value is up to the medical professions to figure out.

> Hospitals barely make money as it is

They aren't supposed to.

Yeah. That's just like, your opinion, man.

It doesn't match up to the reality of the US's "system"

57 percent were nonprofit and nearly 19 percent were controlled by a state, county or city government so most aren't [0].

[0]: https://www.beckershospitalreview.com/rankings-and-ratings/1....

What’s that? We’re intentionally filtering wealth to the top? You don’t say…

From a Canadian stand point you American nurses are already highly paid. My brother works in the US and was recently thinking of coming back to work closer to where he grew up. The best deal he could get here was $20usd less then what he makes there. So on top of making $20 more then a nurse here he is also making it in USD. He is making huge amounts of cash as a nurse down there. How much more do nurses need?

> How much more do nurses need?

What you need to realize is that nursing salaries in the US are NOT uniform. From what I've seen in past discussions about it is they range anywhere from $20/hr -> $100k/year. The $100k/year are usually achieved only in cities and generally only by travel nurses.

The majority of nurses, that I've seen, are clocking in at 50->60k yearly salary.

Sort of like saying "Oh, that google dev makes $300k a year. How much more do devs in the US need?"

"Nurse" is a pretty broad title when popularly thrown about, given that it spans from LPN to DNP and med-surg/clinic to ICU.

"Sysadmin" seems the most readily comparable title in IT, going from "I push software to Windows PCs" to "I manage supercomputer clusters."

> Sort of like saying "Oh, that google dev makes $300k a year. How much more do devs in the US need?"

And the answer to that is "how much is Google worth?" If your business relies on the efforts of software engineers to design and build your primary products, they should have the primary equity in the company. So no, even Google developers aren't paid nearly enough...and they're certainly overworked, regardless of how much they make.

> relies on the efforts of software engineers to design and build your primary products, they should have the primary equity in the company.

The average tenure at Google is 4 years. This means that most current Google's have joined when the company was already at sky high valuation. They made incremental improvements to the product line. But arguing that they should own the majority of the shares is just ridiculous. Think about it: if google had made no new development in the last 4 years, how much would it still be worth ? The answer is: not as much as today, but probably quite a lot.

Current employees thus deserve a part of the pie, as they are the one tending for it. But when they joined the pie was already very nice, and they had 0 impact on that. Not with their work nor their investment, so they can't claim that part for themselves.

https://www.sfgate.com/news/article/Highest-paying-jobs-in-S... reports Registered Nurses as getting $150k/year in San Francisco, and $83k nationally.

> The $100k/year are usually achieved only in cities and generally only by travel nurses.

While $100K/year is not the norm throughout the country, it is normal in my city (non-SV). Travel nurses made a lot more during COVID.

From my conversations, pay is not the reason they are considering leaving. Working conditions are.

He was an icu nurse not a travelling nurse and not in a big city. Washington state I forget the city but it wasn’t a big city like Seattle.

>How much more do nurses need?

Something something freemarket no longer applies when it comes to paying peons?

> Something something freemarket no longer applies when it comes to paying peons?

It never did.

The nursing labor market is so fluid, so much turnover, it operates much more like a commodity exchange where prices are concerned. This doesn't apply to people to refuse to change employers so incentivizes short term rate chasing

Apparently quite a bit if 90% hate their jobs

Nursing, just like many other social oriented professions, attract a lot of people for the right reasons, like wanting to help other people, yet too often that well-meaning motivation is then exploited to the maximum by overworking and underpaying these people.

They will bear a lot of that, because these people care for their patients and leaving a job because of bad circumstances also means leaving their patients behind with those bad circumstances.

Which is not something that comes easy to everybody who makes "helping others" such a big part of their work motivation.

It's the game developer of health care.

People get into it because they love it, and then have their love exploited for profit by businesses masquerading as social charities.

Some hospitals and clinics do great philanthropic work. There are also a lot that don't, but have the same cross over their door.

Without starting values and locations (COL) you can’t compare values in this way.

Canada is generally more expensive and taxes more (especially when you factor in sales taxes and such).

To be honest, I am amazed that Canada has a healthcare system left.

Decades of mismanagement and underinvestment aside, almost any Canadian healthcare worker can cross the border and instantly see a substantial pay bump and increase in QoL.

I do imagine within the next 20 years, Canadian healthcare is going to look vastly different. Like something from an emerging market, where sure there is universal healthcare, but you generally avoid it if you have the means.

>Like something from an emerging market, where sure there is universal healthcare, but you generally avoid it if you have the means.

Already happened. It's impossible to get a primary care physician in the Maritime provinces and in BC.

here in germany nurses make 15€ And in switzerland nearly the double. I can understand their frustration and those who can leave or get new jobs.

Something that should always be considered is US healthcare is an expensive nightmare. Public healthcare is a HUGE benefit that I think a lot of outside of US people underestimate. (And no, nurses don't get free healthcare from their hospitals. They have the same terrible insurance everyone else gets).

For example, I have to pay $9000 a year BEFORE my insurance starts covering healthcare costs. (at $5000 my insurance starts paying out and I owe 10% of the bill). My insurance does not cover medicine costs at all.

I wonder if "free government healthcare" would increase your tax liability by more or less than $9000

They are looking into getting nurses from the Philippines and Africa. Works for the UK maybe but there's a huge language barrier for the rest of Europe.

Besides they need their health workers too.

In Germany's defense, at least, Switzerland has some of the most insane wages in the world, and the cost of living there is equally high.

A friend of mine is working in bern and his salaray is 7400 franken. Minus taxes that are nothing (10% or so) and health care ( insane 120 franken.. i pay 600€ in germany) there is much left. Apartments are around 1000-2000, food etc is another 1000… blablabla point is he can safe much more money per month than more german workers make after taxes.

>you American nurses are already highly paid. [...] How much more do nurses need?

This seems perfectly consistent with econ101. Prices for something is high, so we need more supply.

They use the extra money here to pay for healthcare.