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From New Yorker

From Vox

Burnout, vaccine hesitancy, and plum traveling gigs are making it harder for hospitals to hire the nurses they need.

Covid-19 may no longer be surging widely across the United States, but America’s hospitals are still experiencing a staffing crisis that is putting critical care for patients in jeopardy.

Hospitals all over the country are struggling, especially those in lower-population areas. A new survey of rural hospitals from the Chartis Group, provided to Vox in advance of publication, reveals how deep the problem runs. Nearly 99 percent of rural hospitals surveyed said they were experiencing a staffing shortage; 96 percent of them said they were having the most difficulty finding nurses.

Almost half of the hospitals in the survey said staffing problems had prevented them from accepting new patients in the past 60 days. One in four hospitals said that a lack of nurses had forced them to suspend certain services, including, according to Michael Topchik, national leader of the Chartis Center for Rural Health: newborn delivery, chemotherapy, and colonoscopies. Another one in five said they were considering it.

“The pandemic has maxed out these hospitals,” Topchik told me, “which means they are unable to provide services vital to the community.”

Hospitals have gotten a lot better at handling Covid-19 surges. They have more weapons at their disposal — antiviral drugs and monoclonal antibodies — and better understand which techniques are effective at preventing the disease from getting worse. Roberta Schwartz, chief innovation officer at Houston Methodist Hospital, told me while her hospital started shutting down services immediately during the first pandemic wave, they were able to absorb more than 700 Covid-19 patients during the most recent summer wave without compromising their other operations.

But as flu season looms and cold weather threatens another Covid-19 surge, two trends that would fill up hospital beds again, the staffing crisis isn’t easing.

According to a September study commissioned by the American Hospital Association, the average cost of labor expenses for each discharged patient has grown by 14 percent in 2021 — even as the number of full-time employees has dropped by 4 percent.

Hospitals, both rural and urban, are feeling the squeeze. Their workforces are burned out. Some staff members are still reluctant to take the Covid-19 vaccine, even as some facilities start to impose mandates. And they are facing competition from traveling nursing companies that are offering better and better benefits to lure nurses away from permanent full-time jobs.

With some services being shut down, patients in underserved areas may have to travel hours to larger facilities — hospitals that are experiencing their own staffing challenges and often run at near 100 percent capacity already.

“There are nursing shortages nationwide, which means many hospitals can’t staff all their beds,” Karen Joynt Maddox, assistant professor of medicine at Washington University in St. Louis, told me. “The big referral centers … chronically operate at or above capacity, so any bumps in volume put additional strain on the system.”

Why many American hospitals have a staffing crisis

Burnout among the health care workforce remains acute 20 months into the pandemic. About half of medical workers reported feeling burnout during 2020, according to a study from the American Medical Association. Almost half of ICU nurses said in another survey earlier this year that they were considering leaving the profession.

Nine in 10 rural hospital leaders said their concerns about staff burnout had increased over the course of 2021. In other words, the staffing crisis is getting worse, not better.

“The workforce is burnt out. The workforce is leaving,” said Beth Feldpush, senior vice president at America’s Essential Hospitals. “The human capacity is more of an issue than physical capacity.”

The average age of a nurse in the United States is 50; some of those workers decided to retire early rather than push on through the most difficult working conditions of their career.

”This is mental anguish,” Schwartz said. “We have an aging workforce. Some of them might have worked another year or two, but with a pandemic, nope.”

Vaccine hesitancy could end up making this difficult situation worse. Only about 25 percent of the rural hospitals surveyed by Chartis are instituting a vaccine mandate (some of which have not yet taken effect), but, among those, about one in four expect a significant percentage of their staff — 5 percent or more — not to comply with the mandate.

For some of them, that would mean an automatic termination and another job opening that the hospital needs to fill.

But that’s when the third problem squeezing hospitals complicates things: It’s getting harder to hire and retain nurses because many of them can earn a higher salary working as a traveling nurse, hired for a temporary period by a hospital facing a staffing crunch — and willing to pay the rising prices commanded by those workers.

As NBC News reported last month, permanent nurses at rural hospitals make on average about $1,200 per week. These days, some travel nursing firms are offering their workers more than $5,000 per week.

“This has been a huge shift for many folks,” Mary Beth Kingston, chief nursing officer at a health system serving Illinois and Wisconsin, said in a panel discussion on the staffing crisis hosted by the AHA. “People are leaving their place of employment because this is a chance to increase their salary in a major way.”

Traveling nurses have played an important role in the pandemic. Hospital leaders say that, in essence, they needed to increase their workforce by 20 percent to handle Covid-19 surges, and the travel firms helped to supply that excess staffing. In the Chartis survey, more than half of the hospitals said their use of travel nurses had increased “significantly” during the pandemic, even though most of them used those workers only “rarely” prior to the current crisis.

But that increase in demand has allowed travel nursing firms to offer those higher salaries and more generous benefits, which can lure nurses away from permanent employment. Hospital leaders describe a situation in which full-time nurses and traveling nurses are sitting side by side at a nursing station, with the latter telling the former how much money they are making in this new role.

In the Chartis survey of rural health systems, hospital leaders named “more financially lucrative opportunities” as the No. 1 reason for their nurses leaving, followed by pandemic burnout and retirement.

There isn’t an easy solution to the nursing crisis. The worrisome trends actually predate the pandemic; in 2018, a study in the American Journal of Medical Quality projected more nursing shortages to appear from 2016 to 2030, concentrated particularly in the South and the West.

The aging workforce is part of the problem, and not enough students are enrolling in nursing school to offset those losses, according to the American Association of Colleges of Nursing.

There are some provisions in Democrats’ pending Build Back Better legislation to support the health care workforce by forgiving loans for medical education, incentivizing more doctors and nurses to practice in underserved areas, and providing more funding to hospitals that run graduate education programs.

But hospitals don’t believe it will be enough. They are preparing for a world in which Covid-19 is endemic, a regular part of the medical calendar — and their staffs are still overstretched.

“They are concerned with the overlap of a winter surge and more flu circulating,” Feldpush said. “They do not expect to see any alleviation in staffing shortages or costs.”

I guess I’ve always thought of freedom as an activity, not a condition. There’s a tendency, especially in our culture, to think of freedom as “freedom from.” To be free is to not be tyrannized by some outside power, and that’s fine, but it’s incomplete. You can be free of tyranny, but if you’re destitute, if you’re abandoned, if you don’t have agency because your most immediate needs aren’t being met, you’re not free in any meaningful sense. I say all that because it’s why I think we’re obliged to care about the condition of other people if we believe in freedom as a universal right.

Ok, that’s the end of my rant, I promise.

Sebastian Junger

No, you’re absolutely right. I didn’t go into these contemporary issues in America in my book, because the issue of freedom, it doesn’t change that much over the ages. I was trying to write a book about what allows humans to maintain their autonomy in the face of a more powerful group. Throughout history, very disempowered and often very mobile groups were able to evade or outfight larger dominant groups that wanted to oppress them. The extraordinary thing about humans, unlike any other mammal, is that a smaller individual or a smaller group can actually outfight a larger one. I wanted to understand how that worked. How do we maintain our autonomy in the face of a more powerful group?

Sometimes that more powerful group is your own government. The labor movement 100 years ago, there were totally disenfranchised foreign workers working in the textile mills in Massachusetts, and they faced down the National Guard and the corporations and the government, and they got the laws changed.

One of the ways they did that was incorporating women into their ranks. Once you put women on the front line of a protest, the cops often do not dare use mass violence. They’re way more willing to do that against men. As one frustrated policeman said in Lawrence, Massachusetts, in 1912, he said, “One good cop can handle 10 men. But it takes 10 cops to handle one woman.” That changed the tactical dynamic on the streets that allowed those protests to succeed.

But let me just add to that: What I was saying about freedom from an enemy or freedom from oppression within your own society, those are the classic conservative and liberal concerns. Conservatives are concerned with an outside threat, and liberals, they’re much less worried about outsiders. In fact, they’re often quite open to them culturally. What they’re worried about is internal unfairness. If you take those two concerns and you marry them together in one society, you have a society that can both protect itself and run a fairly equitable system. Either one by itself wouldn’t work very well.

There’s actually a lot of data. There’s a wonderful book, I’m looking at it right now on my bookshelf, Our Political Nature, by Avi Tuschman. Maybe you know it. He collects all the studies that show that our political predilections are partly hereditary. About 50 percent of the variance of our political opinion comes from our genetics, it’s inherited. That to me means that a basically conservative or liberal viewpoint had to have been adaptive in our evolutionary past. When they’re in roughly equal measure within a society, you’re at this sort of sweet spot where you can defend yourself and you’re running a society that’s fair and therefore stable.

Sean Illing

This theme of the importance of groups, of community, of solidarity, was at the heart of your last book, Tribe, which was about combat soldiers and the transition back to “normal” life. Soldiers come home and that intensity is gone, the sense of immediate and overwhelming purpose is gone. Even the title of your documentary about the hike, The Last Patrol, gestures at this longing to recapture the emotional intensity of war. Was that something that was clear to you from the outset, or did this part of it become clear once you were out there on the road?

Sebastian Junger

No, I knew how it would work out there. I mean, listen, the interesting thing about having to find water is that it creates the proper value for water. If you can just get water by turning on a faucet, it doesn’t have any value. If you have to go looking for it, suddenly water has value. Suddenly being warm has value, being safe has value.

I know that the only way to survive and function effectively in a raw environment like that, particularly the semi- industrial one that we were in, which had all kinds of social threats as well, it was to be in a small group that was quite loyal to itself, and where people were willing to do very hard things to make sure everyone was okay.

Since I wrote Tribe, I had this thought: “How do you define ‘tribe’?” It’s one of those elusive words, like freedom. You try to define it, and then it sort of squirts to the side and you’re like, “No, that’s not it either.” You can’t quite pin it down. And I was like, “This is ‘tribe.’ I will make sure that whatever happens to you will happen to me too. We’re going through this together.”

This small group that I walked with along the railroad lines, that’s very much how we were. At one point we had a 110-degree heat index, and one guy really started falling out. We were all carrying 50, 60 pounds on our back, even 70 sometimes if we were loaded up with food. We had to get where we were going. One of us said to the guy who was falling out, “Listen, man, I’ll take your pack.” He put 60 pounds on top of 60 pounds, and strapped it on and walked that way until the guy who was having trouble felt a little better and took his pack back. That’s “what happens to you, happens to me.” We’re in this together.

What I would say about Tribe, in the third chapter, I talk about soldiers because that’s the most immediate current topic that the public is familiar with. But actually, in the beginning of the book, I’m talking about how community works, and why the tribal community has always been so appealing.

Along the American frontier, there are many, many cases of young people, young Americans, absconding to the Natives. Running off to join the Natives. As Benjamin Franklin himself lamented, there were no examples of Native peoples going in the other direction. This is a white Christian society that thinks it’s superior, but people were sort of voting with their feet, as it were, and all of the migration was towards the tribal. You didn’t have the church breathing down your neck, you weren’t behind the plow 12 hours a day plowing up some rocky field. You didn’t have these awful sexual and social mores of colonial society.

Interestingly, all the way on the other side of the world, the Great Wall of China has always been thought of as having been built to keep out that sort of barbarian horde, the nomads on the steppe that invaded mainland China, invaded the Chinese empire and didn’t destroy everything. Obviously that was an element, but what many historians now think is that the wall was also there to keep people, impoverished Chinese farmers, from fleeing to nomadic society.

Nomadic society is always more equitable, more egalitarian than sedentary, agricultural society, where you can accumulate wealth and pass it on through generations. The beginnings of class structure start with agriculture. What the early Chinese were trying to do is keep their own people from absconding to the native peoples across the wall as well.


To hear the rest of the conversation, click here, and be sure to subscribe to Vox Conversations on Apple Podcasts, Google Podcasts, Spotify, Stitcher, or wherever you listen to podcasts.

As a culture, we are currently obsessed with looking back at the stories of the wronged women of the ’90s and the ’00s. The revisitation is sometimes pegged to the premiere of Framing Britney Spears, the New York Times documentary that argued earlier this year that Spears was unfairly targeted by a predatory media, but it would be more accurate to say that Framing Britney Spears is the culmination of a longer, ongoing trend of looking backward.

The popular podcast You’re Wrong About, which began in 2018, built its name in part on debunking cultural myths about women like Anna Nicole Smith and Monica Lewinsky. Tonya Harding was the subject of an Oscar-winning film in 2017, and an acclaimed 2019 documentary revisited Lorena Bobbitt. Hardly a month seems to go by these days without a cultural artifact informing us that we all got it badly wrong when we made one particular woman the butt of a global joke 20 years ago.

Part of this reconsideration seems to come from how drastically the cultural norms around feminism and misogyny have shifted over the past few decades, especially after the tumultuous upheaval brought on by the Me Too movement in 2017 and 2018. We veered out of one decade where snickering over nonconsensual upskirt photos was a perfectly normal late-night comedy joke into another in which revenge porn has a name and a criminal sentence attached to it. It’s natural, in the wake of such a rapid shift, to want to look back with wide and blinking eyes: Wow. We really all said some things then that we never would today, didn’t we?

And as the baby boomers begin to age out of their long-held positions as cultural gatekeepers, millennials have begun to take their place. With that changing of the guard comes enough accumulated cultural power that those who grew up in the ’90s and ’00s can indulge in a preoccupation with the decades of their childhood, and with how retrograde they can appear in hindsight.

“For me, it was kind of a rite of passage to look at stories that I remembered adults reporting on when I was a child and then seeing just how bad of a job they’ve done some of the time,” Sarah Marshall, co-host of You’re Wrong About, told Vox earlier this year. “We just abused women for sport in the media, and I feel like that’s generationally something important to look at. What was in the media and the bloodstream when you were a child? How were the adults who were in charge of the culture then maybe not doing as good a job as you would like to try and do now?”

Enter Diana, literally hounded to her death by a ravenous tabloid press. The tragedy of Diana’s story makes her a perfect fit for our current moment of reexamination. But there’s an added wrinkle to Diana’s story that no one else has, one that makes her especially ripe for revisitation this year.

Meghan Markle is a walking, talking reminder of Diana’s legacy

One of the signs that Diana is having a moment is that the women’s retailer Anthropologie has what is clearly a full Diana-themed section on its website this fall, complete with a Diana-look-alike model. But interspersed among all the photographs of shaggy blonde pageboy haircuts and classic English riding boots, there are photos of another model whom Anthropologie seems to believe goes with Diana: a woman who bears a striking resemblance to Meghan Markle, the daughter-in-law Diana would never live to see.

 Anthropologie

Anthropologie’s Diana section features a Meghan Markle look-alike model.

Meghan Markle, who knows her way around a publicity narrative as well as Diana did, has repeatedly aligned herself with Princess Diana in the time since she and her husband Prince Harry left the royal family in 2020. In a much-discussed interview with Oprah this March, Meghan and Harry explained that much like Diana, Meghan had faced intense mental health struggles upon joining the royal family.

“What I was seeing was history repeating itself,” Harry said, adding, “When I’m talking about history repeating itself, I’m talking about my mother. When you can see something happening in the same kind of way, anybody would ask for help.”

The pair said they relied on the money Harry inherited from Diana to support themselves as they withdrew from the royal family, and Meghan compared their decision to talk to Oprah to Diana’s infamous choice to go public about her discontent with her marriage to Prince Charles. Throughout the interview, Meghan wore a diamond bracelet that had belonged to Diana.

Meghan and Harry offer a potent reminder of the power of the Diana story: the tale of a beautiful princess trapped within an unfeeling royal system, driven slowly toward despair, is a killer narrative arc in any decade. But they also offer a valuable new twist on the old tale.

Diana was caught in a loveless marriage, and Charles was both unable and unwilling to support her in the way she needed to be supported. But Meghan and Harry have made it clear that they are facing their own trials and tribulations together, as partners — so when Meghan needed to leave the royal family, Harry left with her.

They’re offering the public a rare chance to redeem the memory of the virgin sacrifice whose life we destroyed. So while pop culture remains committed to constantly revisiting the details of what happened to Diana and why, Harry and Meghan offer us a chance to retell the Diana story yet again — this time with a happy ending at last.

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