Wearing red t-shirts and clutching signs that read “patients before profits” and “safe staffing saves lives,” over a hundred nurses march in a line the morning of Sept. 1 in front of Oakland’s Kaiser Permanente. This is the day after their contract with their employer expired.

The California Nurses Association announced Aug. 23 that 22,000 Kaiser nurses in northern California and Los Angeles would hold informational pickets to bring attention to the need for a new contract, with 500 health workers RSVPing to the Oakland demonstration.

Northern California and Los Angeles Kaiser nurses have been bargaining for a new contract since June without making any major progress, according to a CNA and National Nurses United press release.

Elena Jahouah, registered nurse at Kaiser Oakland, insists the hospital’s administration is prioritizing profit over the well-being of health workers and patient care.

“Nurses are retiring, getting sick, leaving, dying, and this is not just at Kaiser — this is across the nation at all healthcare systems," Jahouah said. "This profession has been put under enormous strain, so it really makes very little sense to me that Kaiser would be so toxic to their nurses.”

Holding a sign that says “There’s no Kaiser without nurses” in front of Kaiser Oakland Medical center, Jahouah says that health workers made little to no progress in contract negotiations with Kaiser higher ups. While thousands of nurses in the state work without a contract, mental health problems plague employees in the field.

Northern California and Los Angeles Kaiser workers are frustrated about the lack of response from upper management regarding issues around staffing. Nov. 5 marks the date where union members will decide whether or not to strike on the week of Thanksgiving.

According to the National Academy of Medicine, 25 to 54% of nurses and physicians experience symptoms of burnout.

UC San Diego researchers found that nurse suicide rates were significantly higher compared to the rest of the general population in 2014. This disparity has only increased in recent years with hospitals overflowing with patients due to the pandemic.

In addition to a rising demand for nurses, much of the stress Kaiser Oakland nurses face is tied to chronic understaffing. Much of these issues around understaffing are likely due to structural flaws within Kaiser, according to frontline workers.

Jahouach says that Kaiser expanded middle management throughout the pandemic, including assistant nurse managers and other administrative positions, rather than adding more bedside staff.

The registered nurse also mentions that Kaiser seems to be more profit-driven in recent years, and that business executives who rely on a lean staffing structure have replaced physician and nurse leaders.

“When COVID hit, it exposed how terrible that model is for American healthcare," Jahouah said. "We didn't have the masks we needed, we didn't have the supplies we needed to keep our patients safe or to keep our nurses and doctors safe.”

Now almost three years into a pandemic, nearly every department is still short of staffing and more resources are often needed for patient care.

Understaffing: A healthcare catastrophe

One of nurses’ main complaints has to do with a relatively new system for assessing patient illness.

Kaiser switched over from a GRASP system — General Responsibility Assignment Software Patterns — to an epic acuity system in 2018, an alternative that gives nurses less control over measuring the illness of patients. This acuity system lacks transparency around staffing, according to frontline workers at Kaiser.

Watkins feels that the GRASP acuity system was more fair when it came to adequately staffing nurses according to the patient care that was needed. While this new epic acuity system measures work by points per patient, the GRASP system was used to measure the number of tasks per nurse.

The prior workload nursing measurement system would have a nurse assign points based on the task they are responsible for during their shift. With the GRASP system, a nurse could account for a patient who may require more points based on their combative behavior, language barriers, or any other issues that may complicate patient care.

The epic acuity system counts points based on nursing documentation. If the nurse does not have time to document a task, that task will not be accounted for, but there will still be a great deal of work for the nurse assigned to the task. According to Robin Watkins, registered nurse at Kaiser Oakland and union representative, the new workload nursing measurement system is supposed to be kept in check through frequent meetings with nursing and administrative members.

“We just haven't made any progress since this system was integrated into Kaiser," Watkins said. " We saw the inadequacies of the system when they first rolled it out. We tried to work with the employer to try to get them to adjust it to make it work for nurses.”

In the epic acuity system, each patient is assigned a number of acuity points, a measurement of patient illness; however there are no guidelines around how many points each nurse should handle on their shift.

This makes it easier to manipulate staffing, as there is no maximum number of points for each nurse.

The northern California Kaiser nurses created a contract that addresses Title 22, which covers nurse-to-patient ratios and how to adequately staff for different levels of needed care. The contract that health workers are negotiating pushes for more transparency around the way the current epic acuity system is used.

Employees, union representatives, and upper-management come together for Professional Practice Committee meetings once a month. Watkins, who has worked in the intensive care unit at Kaiser for 12 years, says that conversations around Kaiser’s epic acuity system are usually deceptive during these meetings.

“We just want them to do the right thing," Watkins said. " Since we switched over to an acuity system, it’s gotten worse over the last couple years to the point where it seems like they use it in a way that’s not transparent.”

The intensive care unit nurse of 12 years says that there has not really been much effort to enforce rules around staffing. Watkins felt more confident in the prior acuity system that more nurses would be called in when needed.

Finding a solution

Tamie Cline, president of the Oregon Nurses Association, says that many hospitals in her state also face major issues around understaffing. Cline, a registered nurse for 20 years, insists that many hospitals’ management have been forcing too many patients on nurses for years.

One solution to the current staffing crisis is investing more in the education system, according to Cline, which will add more nurses to the field at a faster rate.

According to the American Association of Colleges of Nursing, student capacity at many nursing schools is limited due to a shortage in teaching faculty. In 2019, nursing schools turned away more than 80,000 applicants in the U.S. due to a shortage of resources, specifically a scarcity in educators and a lack of classroom spaces.

“It's not that we don't have people out there who don't want to be nurses," Cline said. "We don't have the ability to get them through nursing school or open spots for them to apply.”

While the demand for nurses grows, thousands of healthcare workers retire or leave the field per year. The 2020 National Nursing Workforce Survey found that one-fifth of the respondents were planning on retiring before 2025.

The U.S. Surgeon General Vivek H. Murthy released a warning in May around healthcare worker burnout and the need for immediate action to diminish nurses’ growing moral injury. The advisory ended with an additional call for more research on the mental health status of healthcare workers.

“We have a moral obligation to address the long-standing crisis of burnout, exhaustion, and moral distress across the health community," read the advisory. " We owe health workers far more than our gratitude. We owe them an urgent debt of action.”

With no new contract in place, northern California and Los Angeles Kaiser nurses are anticipating a strike in the coming weeks.