Contributor – Vincent Derby
The privatization of healthcare has shifted the focus from clinical excellence to the prioritization of shareholder equity. Meline (2025) found that for-profit hospitals invest less into nursing services, leading to higher nurse-to-patient ratios, 4.7 to 6.8 at non-profit versus for profit respectively (Muir et al, 2025), resulting in a lesser amount of lower quality care. This creates time constraints, significantly reducing the nurse’s ability to identify and intervene in the care of a deteriorating patient. This cultivates a systemic environment where preventable mortality becomes an expected outcome. For-profit hospitals have a significantly lower quality of care and safety outcomes, measurable by safety grades of 53.6% for non-profit facilities when compared to 33.8% at for-profit facilities (Muir et al., 2025).
The foundation of healthcare relies on trust in the social contract between the system and the patient. The patient is completely reliant upon the care and services provided to them by the hospital. They are at the mercy of the system. Healthcare is designed with an explicit understanding and expectation of the system to heal, remove barriers to healing, and create a setting that fosters safety and protections from error. The for-profit model allows systemic corners to be cut to reduce the “cost of doing business” (nurses salary, nurse-to-patient ratio, equipment) protecting the shareholders from the stressors of the moral ambiguity of the day-to-day operations of the hospital. The nurse’s duty is to operate with total clinical vigilance without disruption by the constraints of the for-profit limitations. The current social contract is being morphed into something that represents a structural collapse under the weight of self-imposed constraint. These concessions have destroyed the patient and the nurse’s trust in the healthcare system. The normalization of the legal obligation to prioritize profit over people is associated with a degradation in nursing care resulting in lower patient safety and worse outcomes.
The most relevant theoretical framework to view this shift in paradigm through is the grand theories that are taught in school as an authoritative imperative of how to conduct one’s nursing practice. One such Grand Theory that is distorted through the current methodology of nursing is that of Imogene King. The understanding that is taken away from reading her theories is that there are a few key traits that are essential to adhering to King’s theories. The first of which is presence. When a patient is declining, experienced nurses often sit and talk to the patient about what symptoms they are feeling, and how it is affecting them. Additionally, it allows them to have more time in the room to use focused assessment skills to figure out what is happening and what the next steps should be.
A second trait of focus of King is perception and an ability to read the room. This helps to identify any hesitations, anxieties, or tensions between family members. This is essential for fully understanding the patient. The third trait is the ability to communicate on the level of the patient. For example, the meds aren’t just named off; the purpose is explained in common language. The better one understands the patient, the better you can be attuned to the subtleties in patient care. King’s view of nursing insists on being an autonomous expert on the patient. These ideas highlight commonly accepted traits in her theories to explain the aspects of nursing that are the most marginalized into obsolescence, proving that Imogene King’s model of nursing is not dying, but has been killed but the for-profit hospital system.
The problem with the current model of healthcare is that all the autonomy and time to provide care as described in these grand theories have been systematically removed from the nursing toolbox. The current model of healthcare has moved to a profit over people system. This creates a system where costs are cut to protect the investors’ money, and the fastest way to save money is to underpay nurses and overload the assignments with inflated nurse to patient ratios. When the nurse has their time stripped away from them, this directly impacts the quantity of care that can be provided as well as the quality of care.
With a six-patient assignment, after the mandatory breaks you are forced to take, operational tasks like med pull, and the hours of charting required for each patient, you roughly have six minutes to spend with each patient per hour, leaving you with an impossible amount of time to practice the standards of King’s theory. This loss of time also strips the autonomy of critical thinking from most nurses because they don’t have the time to think independently; they are forced to run around as task-oriented drones. Their days are unflinchingly rigid if there is any hope of getting all the care done for the patient. This creates a severe level of burnout for the nurses which creates a level of disengagement from the work and creates a system where they are forced to always be walking backwards out of the room to get to the next task.
This intersection of the degradation of autonomy, loss of time, and burnout creates a system where a nurse is forced to operate in a manner that is boiled down to the defeatist mentality of “Here’s your meds, I hope you don’t die.” This is not conducive to developing a truly healing relationship with a patient. This new healthcare model is responsible for breaking down the social contract between the hospital and the nurse, and therefore the nurse and the patient. This distrust and decrease in ability to provide care could play a large part of why there are so many instances of violence in the hospital from verbal altercation to physical violence.
To argue that the current care window is sufficient to provide the quality of care described by King, is to move the functional and philosophical answer to “what nursing is?”. To argue that this view is too chronological is to separate time from function. When these concepts are divorced, the construct of nursing moves from one being a holistic caretaker toward a view of nursing where a nurse becomes a unit of labor. When viewed as a unit of labor, time is minimized as a self-preservation technique. To argue that this is an adaptation in the evolution of nursing is to ignore the concept of “negative evolution”, where non-beneficial traits gained are disadvantageous. Furthermore, the argument that operational tasks can be combined, carrying multiple patients’ medications at once, is institutional scaled normalized deviance from safety standards.
The argument that this is generalization and politically targeted would be to ignore the clinical isomorphism that is being displayed currently in healthcare. While the for-profit numbers are troubling, the non-profit numbers are not to be interpreted as good. Those numbers are simply better. The non-profit numbers are less evidence of superiority; but could be viewed as the market demands slowly pulling both models to a point of singularity in failure. This is described by Clegg and Bailey (2008) as coercive isomorphism and represents a survival mechanism that creates negative results for the public in order to remain economically relevant.
The healthcare machine is directly responsible for the nursing shortage. These current operational standards are forcing nurses of all experience levels through perpetual cycles of moral distress and moral injury. The quickness to name the phenomenon as burnout is an exercise in blame shifting; it trivializes moral injury as burnout and cites a need to develop personal resilience. With the current trajectory, without a systemic change, it can be theorized that nursing shortages will continue, and the healthcare system is setting itself up for a systemic structural collapse related to the prioritization of capitalistic impulses.
To prevent this structural collapse, nursing needs to become a rewarding career again. The three-day work week isn’t even the benefit it once was; with the current committee demands, continuing education, constant requests to pick up extra shifts, and mental recovery days needed after these shifts, the work week is significantly longer than the promise. For nursing to remain a viable career, the work-life balance needs to be restored. The demands on the job need to be re-evaluated, or the nursing pool will continue to decline. Nurses want to be able to focus on their patients; they want the time to provide the level of care that matches the reason they were called to the profession. However, without a change to the structure and morality of healthcare, no amount of money will save the field of nursing if the cost is the integrity of your soul.
References
Institutional isomorphism. (2008). In S. R. Clegg & J. R. Bailey (Eds.), International encyclopedia of organization studies (Vol. 4, pp. 679–681). SAGE Publications. https://doi.org/10.4135/9781412956246.n233
King, I. M. (1981). A theory for nursing: Systems, concepts, process. John Wiley & Sons.
Meline, J. (2025). For-profit hospitals invest less in nursing services. University of Pennsylvania: Leonard Davis Institute of Health Economics. https://ldi.upenn.edu/our-work/research-updates/for-profit-hospitals-invest-less-in-nursing-services/
Muir, K. J., Sliwinski, K. S., Golinelli, D., McHugh, M. D., & Lasater, K. B. (2025). Hospital ownership type correlated with investments in nursing services: Evidence from Illinois. Medical Care, 63(8), 594–599. doi: 10.1097/MLR.0000000000002148.
About Vincent Derby
Vincent Derby is a Registered Nurse with a decade of acute care experience across diverse clinical settings. Having served as a travel nurse during the height of the COVID-19 pandemic, he witnessed firsthand how temporary crisis measures hardened into the new operational status quo. Currently pursuing his Master of Science in Nursing (FNP) at the University of Colorado Colorado Springs, Vincent writes to challenge the systemic degradation of the nursing profession and the erosion of patient care.