By Angela Archer, MSN, RN
Nurses are called the backbone of health care. The phrase is praise, but it also exposes a problem: backbones carry the weight when the rest of the system is failing. Nurses are expected to recognize social needs, prevent harm, manage complex technology, advocate for vulnerable populations, address inequities, and influence policy (Han & Kim, 2024; National Academies of Sciences, Engineering, and Medicine [NASEM], 2021). Yet the systems that depend on nurses often fail to provide the staffing, authority, safety, compensation, education, and policy preparation needed for that work (American Hospital Association [AHA], 2025; Costa et al., 2024; Rainbow et al., 2024). Nurses are not weak; they are structurally unsupported. The problem is not inadequate resilience. It is a system that relies on nursing responsibility while limiting nursing power.
Vulnerability is not the same as fragility. It can develop when people carry high responsibility with limited control. Krieger (2008) argued that structural analysis should identify the levels, pathways, power relationships, and accountability involved in the production of harm. In nursing, those pathways include staffing, workplace safety, professional authority, education, and access to decision-making. Their effects can become visible as injury, burnout, fatigue, sleep disruption, moral distress, and mental health strain (Rainbow et al., 2024). These outcomes are not evidence of insufficient resilience. They are warning signs that the conditions of care are affecting the people expected to provide it.
Structural vulnerability also begins before nurses enter the workforce. Clinical judgment and patient safety must remain central to nursing education, but policy education, legislative advocacy, community organizing, and political skills are not always taught. Han and Kim’s (2024) systematic review found that nurses’ policy participation is shaped by the interaction of individual, professional, organizational, and sociopolitical barriers and facilitators. Nurses cannot be expected to influence policy when preparation, mentorship, protected time, and organizational encouragement are inconsistent.
Hospital workforce decisions make the problem perceptible. Costa et al. (2024) argue that the nursing workforce crisis is not merely a recruitment problem; chronic understaffing, moral injury, poor working conditions, and underinvestment drive nurses away. The AHA (2025) reports a first-year RN turnover rate of 22.3% and identifies physical demands and insufficient staffing as major risk factors for turnover. Still, nursing is often treated as a labor cost to control rather than as a clinical foundation to protect (Laskowski-Jones, 2023). When budgets are balanced by thinning nursing capacity, the hidden costs return as turnover, delayed care, preventable harm, and lost expertise.
Labor action makes nursing’s structural position difficult to ignore. Strikes are often discussed as disruptions, but they may also signal that pathways for addressing staffing, safety, compensation, and workplace authority have failed (Costa et al., 2024; Krieger, 2008). When nurses reach the point of withholding labor, the issue is rarely only wages; it is also whether health systems will listen to the clinical expertise of the workers most responsible for patient monitoring, safety, and advocacy (Rainbow et al., 2024). In July 2026, Brigham and Women’s Hospital reported that a Massachusetts Nurses Association work stoppage was affecting the hospital, although the hospital remained open and planned to continue patient care through emergency preparedness plans and temporary nurses (Brigham and Women’s Hospital, 2026). The deeper question is why nurses so often must reach a crisis point before systems respond.
Nursing’s structural position is also shaped by gender, professionalization, and public image. Gunn et al. (2019) found that education, health, labor-market, gender, and welfare-state policies influence nursing’s autonomy, recognition, resources, and participation in decision-making. Because nursing remains a predominantly female profession, it also carries the historically rooted social and financial devaluation of caring work. Godsey et al. (2020) documented nurses’ perceptions of an inconsistent professional brand image. When nursing is portrayed through compassion and self-sacrifice rather than expertise, leadership, and policy influence, admiration may not translate into professional authority (Godsey et al., 2020; Gunn et al., 2019).
To be sure, health systems face financial, operational, and workforce limitations. Staffing standards can reduce flexibility, and labor actions can disrupt care. When nurses are exhausted, injured, silenced, or excluded from decisions, their capacity to provide safe care and advocate effectively for patients may be reduced (Costa et al., 2024; Rainbow et al., 2024). Recognizing nurse vulnerability does not place nurses above marginalized communities; it acknowledges that structurally unsupported nurses have less capacity to advocate alongside them.
The answer is not to ask nurses to become more resilient. Nursing programs should incorporate policy, advocacy, social determinants of health, and community engagement. Health systems should use evidence-based staffing, protect nurses from workplace violence, provide meaningful shared governance, and include frontline nurses in decisions about technology, budgets, workflows, and care redesign. Nurses have already shown that they can carry broken systems. The better question is whether health systems, policymakers, and society will give them the authority to redesign those systems. Health equity requires nurses to be empowered in the rooms where staffing, budgets, technology, and policy are decided.
