All Tristin Kate Smith ever wanted to do was help people. As a high school student, she enrolled in a neighboring school district in order to help older adults in nursing homes.
But bit by bit, life as an emergency nurse for the 28-year-old Ohio native deteriorated.
When she and her colleagues told hospital management of their work struggles during the Covid-19 pandemic, including long hours and insufficient support, they were told to enroll in online courses.
“The compliments, the pizzas, the ‘thank you’ letters gradually had less meaning to me,” she wrote in a letter titled Letter To My Abuser last March.
“You ignore us while we beg on our hands and knees. We get a pizza party and free pens for being ‘healthcare heroes’.”
Tristin wrote how she lived in constant fear of someone walking into the facility she worked at with a gun and shooting the place up.
In July, her father, Ron Smith, found her dead in her home from a self-inflicted injury.
“She told me she would cry before she went to work,” he said. “Sometimes she would even get physically sick.
“She’d tell me: ‘Dad, there is no help.’ She said the only breaks she’d get were when she’d grab her sandwich on the way to the bathroom and get a few bites. I told her she needed to start thinking about a different career.”
Tristin’s struggles with working in healthcare went viral after Smith published her letter in an Ohio newspaper in October.
But Tristin was far from alone. Female nurses in America take their own lives at nearly twice the rate of the wider female population. Harassment of health workers has more than doubled since 2018, according to the US Centers for Disease Control.
Former nurses interviewed by the Guardian recounted being asked to do 10 to 20 hours of at-home administrative work monthly, adding to their job-induced stress.
“When I read Tristin’s story, I thought of how so many times I found nurses in the break room just crying,” said Janet Michaelis, an Ohio-based nurse who worked in emergency rooms for 19 years. “They’re just distressed because they feel like they are failing.
“I [would] tell them: ‘It isn’t you. This is not possible. Don’t think that you’re wrong.’”
All this is happening at a time when profits at many non-profit healthcare organizations, which account for 60% of all healthcare providers nationwide, are soaring.
The American Nurses Association (ANA), a national organization with 4 million members, has blamed “cost-cutting decisions” for fueling a nursing staffing crisis.
Jennifer Mensik Kennedy, president of the ANA, said the negative workplace effects associated with staffing shortages require “meaningful and lasting solutions to be implemented immediately: eliminating mandatory overtime, enforceable workplace violence prevention plans, providing mental health and wellness resources for nurses [and] transparency of nurse reimbursement.”
Tristin worked for a time at Kettering Health, a healthcare provider at the center of a fraud scandal that saw former senior executives allegedly using company funds for non-business purposes.
Kettering operates 15 hospitals and more than 120 outpatient facilities in the region. It is the second-largest employer in south-western Ohio. Its senior leaders are some of the highest-paid non-profit workers in the midwest, making more than $2m annually in a region where per-capita income is $32,600.
The organization’s former CEO, Fred Manchur, has been accused of misusing organizational and charitable funds to travel and remodel his home. Emails sent by the Guardian to Kettering Health asking if the organization had moved to ease nurses’ workloads since the pandemic were not answered.
But Kettering isn’t an outliner. The CEO of Kaiser Permanente, a major non-profit healthcare provider that operates in eight states and Washington DC, earned more than $13m in 2022. The CEO of Ascension Health Alliance earned more than $11m the same year.
While legislation to establish a nurse-patient ratio was reintroduced in Congress in March 2023, change at the federal level has been painfully slow, nurses’ advocates say.
That has forced some states to act on their own. In Oregon, a law establishing a nurse-patient ratio is set to go online in June. Further ratio reductions, along with fines for violating organizations, are expected to take effect in 2025 and 2026.
California has a staffing mandate in place for 20 years that, studies suggest, has helped reduce mortality rates among patients while lowering burnout and job dissatisfaction rates among nurses.
For Ron Smith, getting a similar ratio law in place in Ohio is now his main goal. He said he and other family members mailed Tristin’s letter to state senators and countless hospitals around the country, but had received little in the way of a response.
He recalled that when Tristin would come home from her nursing job, she was unable to sleep properly because she was lying in bed asking herself if she did everything right.
“The general public does not know what nurses are going through,” he said.
“Tristin’s letter is an agenda of what needs to be addressed. It’s an action list.”
In the US, you can call or text the National Suicide Prevention Lifeline on 988, chat on 988lifeline.org, or text HOME to 741741 to connect with a crisis counselor. In the UK and Ireland, Samaritans can be contacted on freephone 116 123, or email jo@samaritans.org or jo@samaritans.ie. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org.
