Last December, the omicron variant was tearing through the D.C. region. Cases surged to the highest levels ever recorded, and more people were hospitalized with the virus than at any other point in the pandemic. Healthcare workers, overworked and depleted, felt abandoned as they responded to a fourth COVID wave, this time without the appreciative yard signs, front porch cheers, or financial support of previous surges.

Twelve months later, at the end of 2022, healthcare workers now face a “tridemic” of flu, RSV, and COVID, while the same staffing problems that defined the past three years of the pandemic persist. It’s left hospitals overwhelmed, workers run down, and patients at risk.

But there is a difference this year. Local workers, buoyed by the momentum of union negotiation wins and the broader labor movement mobilizing across different industries this year, are stepping up the fight for better staffing and increased compensation.

“What I really want, obviously, is better retention and better staffing,” says Charlene Garcia, an emergency department nurse at Washington Hospital Center. “But also compensation … and above all, safety.”

Over the course of this year, local nurses and healthcare workers staged protests, unified with other unions and labor associations for support, and at one point, held a strike to get their demands met. With more D.C.-area nurses re-entering into contract negotiations in 2023, labor leaders and workers say this type of direct action will continue until they feel they’re paid what they deserve, and working in an environment that values both them – and most importantly – their patients.

“Workers need to be active and fight,” says Edward Smith, the executive director of the DC Nurses Association, a branch of National Nurses United that represents nurses at local hospitals. “I think we’re seeing a new generation of activists demanding that ‘I want my rights, I want to be respected. I want to be treated with dignity.’”

‘We can’t close our doors’

Garcia has worked in Washington Hospital Center’s emergency department for nearly six years, half of those spent witnessing COVID’s toll on her coworkers and patients. While she says hospital overcrowding was a longstanding issue in the emergency department prior to the pandemic, the past three years only exacerbated the problem. Healthcare workers – particularly nurses – are leaving, often due to low wages, burnout, or a combination of both, and hospitals are struggling to recruit and keep new hires.

“Some nurses, they’ve seen trauma over these years,” Garcia says. “They leave the bedside, they try to do other things. And I don’t blame them – you do what’s best for you, best for your home life.”

Earlier this month, news circulated widely that Washington Hospital Center had no beds available, with wait times of up to 17 hours in the emergency department — a fact that scared and frustrated residents, but a reality that is not uncommon in her department, according to Garcia.

When there are no beds left on an emergency floor, patients are “boarded,” meaning they’ve been admitted and are assigned a nurse, and they’re given care either in the waiting room, hallway, lobby, or another area until a bed becomes available. Garcia says she’s seen some patients wait multiple days for a bed, and while she provides the best care she can, without a bed, there are certain things (like a shower, or a place to brush their teeth) the nurses just can’t give them.

“Sometimes it can take less than 30 minutes to get a bed or it can take 25 hours, two days, three days – even a whole week,” says Garcia. “I’ve seen patients discharged in the hallway in the emergency department because we never even had a bed to give them that whole time … we’ll have patients that we have to change in the hallway. It can be very frustrating.”

Garcia says the boarding problem can be directly tied to the department’s staffing crisis, where sometimes one nurse is taking care of between seven and ten emergency patients at a time. Ideally, she’d only be taking care of four patients. She says that of the nurses that she started working with six years ago, only 10% remain at Washington Hospital Center.

The nursing staffing crisis is not unique to Washington Hospital Center, or even to the D.C. region. It’s also not a new problem, but a crisis that’s only grown over the past three years, worsening when COVID and other viruses surge and overwhelm health systems. Among Garcia’s top concerns going into 2023, when National Nurses United (the union representing WHC nurses) will renegotiate its contract, is a commitment from management on filling vacancies.

“We can’t close our doors, and we’ll never say no to anyone – people need help and we’re here to give it, but we need the appropriate staffing,” Garcia says.

Delays in solutions

In D.C., Mayor Muriel Bowser created a task force earlier this year, led by local officials and management of the region’s major hospitals, to figure out solutions for the healthcare worker shortage. The group met several times between May and September to discuss rebuilding the city’s healthcare workforce, and was expected to release a set of recommendations for the city and hospital management to guide and inform new policies. The report was supposed to come out in November, but despite the urgency of the issue, as of Dec. 22, the task force’s website reads it will be “coming soon.” A DC Health spokesperson told DCist/WAMU that the recommendations are currently undergoing “internal reviews to ensure that the strategies and investments necessary to address the current supply and demand challenges.” They did not say when the report will be formally presented to the mayor and the public.

D.C. officials have also acknowledged the strain on hospitals – particularly emergency rooms – in this most recent triple wave of COVID, flu, and RSV infections. At a press conference earlier in December encouraging residents to get flu shots, Deputy Mayor for Health and Human Services Wayne Turnage said that DC Health, along with members of Bowser’s administration, would be meeting with the D.C. Hospital Association – a group that represents the region’s largest hospitals – that week to discuss any potential actions that could alleviate the burden on emergency rooms and decrease wait times. (A spokesperson could not comment directly on what was discussed in the meeting, but told DCist/WAMU that D.C. leaders “agreed to receive a letter from DCHA that will outline their requests for solutions” that could help resolve the situation in the region’s emergency rooms.)

“The city’s acute care hospitals are facing what really is a perfect storm … there is a persistent shortage of staff that began developing prior to the pandemic, especially among nurses,” Turnage said at the press conference. “What this means is that hospital administrators are not able to staff all of the licensed beds in their hospitals, creating a significant reduction in capacity in some of our large and small hospitals.”

During that press conference, Turnage blamed the overflowing emergency rooms on patients showing up with non-severe illnesses and injuries, saying this “spikes the demand for services from staff that are already overburdened, and hospitals that are already understaffed.” Yet Turnage and Sharon Lewis, the interim DC Health director, did not provide any detail on what potential solutions Bowser or D.C. Health officials were considering to alleviate the burden on hospitals. When asked if they were considering declaring a public health emergency – a move that could shore up certain resources – Lewis said it wasn’t currently an option. (Several states have called on President Biden to declare a national emergency in the face of the tridemic surge.)

Garcia, the emergency department nurse, says that fall and winter are always busy, and it’s not up to the hospital to determine what may or may not be an emergency for someone. Additionally, underinsured or residents without insurance at all may not have a primary care doctor to rely on, or an urgent care location that’s convenient and accessible.

“I think sometimes people are like ‘yeah, I would love to go to an urgent care, but I don’t have the insurance to pay for it,’ and in the emergency department we can sign them up for Medicaid, Medicare, whatever they need,” Garcia says. “I also feel like some patients, they don’t really understand primary care or maybe they didn’t understand their discharge instructions very well, or they misinterpreted something. Maybe we just need to help them and get them in the right scenario – in the right place to be able to continue their continuity of care.”

Direct actions bring small wins 

While 2022 is ending with many of the same problems that characterized the healthcare workforce at the year’s start, labor experts say that these issues ignited national and local union efforts, pushing healthcare workers to demand they be paid and treated as “essential.”

“We’ve come through a really profound moment for people who work in the healthcare industry, especially nurses,” says Joseph McCartin, a labor historian with Georgetown University. “What we started to see over the course of 2022 is a lot of desire on behalf of nurses to have their essential role properly recognized.”

And it’s not just nurses demanding change. Last month, resident physicians at Children’s National Hospital held a demonstration as their union, Committee of Interns and Residents, a branch of the Service Employees International Union, negotiated a new contract with the hospital amid an overwhelming surge in RSV cases. Like every other hospital system, resident physicians and fellows reported being stretched thin, overworked, and underpaid. On Dec. 7, the unit ratified a new contract with the hospital, securing pay increases of 12.5% over the next three years, and a mental health stipend of $5,000. They fell short, however, of winning a safety cap that would limit the number of patients per resident.

Dr. Lydia Lissanu, a first-year resident who came out on a rainy night in November to demand better working conditions, told DCist/WAMU in an interview that she prioritized joining a unionized program when looking at residencies. And although they didn’t get everything they wanted in the contract, she’s proud of the wins that they were able to secure. She also sees a newfound strength in her coworkers — and potential to unify with all levels of staffing, from fellows, to nurses, to doctors.

“One of the things that I really wanted to impart to my peers is: you have so much more power than you think do,” Lissanu says. “It’s really, really easy within the structure of medicine to feel like just the bottom of the wheel and just another cog, and the entire system would collapse without residents, so I think people realize that collectively, and that’s why we got the wins that we got.”

According to Becker’s Hospital Review, more than 18 healthcare worker strikes took place across the U.S. this year. In September, more than 15,000 nurses in Minnesota walked off the job for three days, marking what is believed to be the largest private sector nurses’ strike in U.S. history. Locally, more than 300 Howard University Hospital nurses, pharmacists, and social workers went on strike for one day in April, as contract negotiations stalled between Adventist Healthcare, the company that manages Howard University Hospital, and the D.C. Nurses Association. The strike followed a protest in January during the omicron surge when nurses called on hospital management to fill the roughly 100 vacant nursing positions.

During the protest and the strike that followed last spring, hospital workers won support from other labor groups like the Metro Washington Labor Council, lawmakers like Councilmember and then-mayoral candidate Robert White, and Howard University students and faculty. Smith says that building coalitions and bringing others into the union’s push is a key part of organizing, and something he’s seen grow stronger in 2022 as unionization drives took off in a national context.

“The days of labor calling a rally and only 10 people showing up, I think they’re over,” Smith says. “I think there’s a tide turning.”

The pressure worked – at least in part. DCNA reached an agreement with Adventist in May, and while it did not include nurse-patient ratios (or a regulation that would dictate how many patients one nurse can take care of at a time), it did bring small victories for the nurses, like mandated monthly meetings between union leaders and a hospital staffing committee to discuss how to fill vacancies and boost worker retention. According to Smith, management has been cooperative at these meetings – a “major piece” of negotiations for DCNA.

Back to the bargaining table 

While the Howard nurses’ contract is set until 2024, the D.C. Nurses Association and National Nurses United are aiming for progress in 2023.

As a nurse at Washington Hospital Center, Garcia is represented by National Nurses United, which will enter negotiations with the hospital for a new contract next year. Garcia says she’s willing to take action — including walkouts, pickets, or strikes — to get her demands heard. Namely, she wants better compensation – which she says would help retention – and increased safety precautions, like metal detectors. Overall, she said she mostly just wants to be able to do her job as well as she can, something she can’t do when she’s treating patients from a hallway.

“We’re so understaffed that I am having multiple patients, that it’s so unsafe I can’t even give the proper care that they need to get,” she says.

Anne Strauss, a labor representative for National Nurses United, said they’ll likely bring up nurse-patient ratios again during negotiations (as they have in the past), but they expect to run into pushback from management.

“Although we absolutely propose that and have tried to negotiate that, it’s very hard, if not impossible, to get the hospital to agree to something like that,” she says.

There is no standard for nurse-patient ratios across the U.S., and California is the only state with a law mandating how many patients different nurses can legally take care of at one time – a result of lobbying by National Nurses United. Usually, hospitals or hospital associations (organizations that represent the interests of hospitals in the region) issue guidelines, but they’re not mandatory. National Nurses United’s local efforts did succeed in getting Washington Hospital Center to reserve certain “resource” or “charge” nurses on shifts – meaning a nurse assigned to a shift for the sole purpose of assisting other nurses. Strauss and Smith with DCNA also want to push the D.C. Council to pass a law regulating patient-nurse ratios in the city, and they hope to get legislation introduced in the next year.

Unionized nurses at Children’s National Hospital will be up for a contract renewal in mid-2023, so negotiations will start sometime early next year. Smith would not comment on the specifics of what may be negotiated, but said retention and pay equity will be chief among the union’s demands. Meanwhile, even though nurses at Howard secured mild gains this year, he says the contract is only good as long as management holds to it.

“You can have a strike, you can get a contract, but if you don’t keep following up and keep fighting for your rights, you’re gonna lose them,” he says.

After more than two decades in organizing, Smith says 2022 felt like a turning point in labor organizing to him, against a national backdrop of unionization drives at places like Chipotle, Starbucks, Amazon, and other businesses. Locally, 2022 saw union drives at bookstores, food retailers, and by government employees. He says that part of what feels different about this current moment is the vigor among younger employees, and a commitment to their fellow workers.

“I really think there’s hope in labor that there wasn’t a lot of in the 90s and 2000s,” Smith says. “I’ll tell you that it seemed like too many older people were just too happy in their jobs in the union and just went along to get along kind of thing. I think that’s changing.”