Some jobs prepare you for anything.
That’s how Julia Smith felt about working at Petty Island on the Delaware River, where she repaired machinery and loaded freight on and off a giant barge bound for Puerto Rico. At 23, she felt ready to problem-solve her way through whatever hit her.
Seafaring wasn’t the long-term future Smith had in mind, though: She had always wanted to work in medicine. The first step on that path was nursing school, which she finished just a few weeks before the first coronavirus case landed in the Philadelphia region.
Upon graduating, Smith took a job in a step-down unit at the 371-bed St. Mary Medical Center in Langhorne, one of Bucks County’s largest employers and its main trauma center. She had heard that working in that unit, where patients require a high level of observation and care, would prepare her for critical care — a sought-after field in nursing, for which experience is how you qualify. She figured step-down would be an exciting, fast-paced place to apply the lessons she’d learned in nursing school by caring for patients with a variety of conditions.
Just as she was gaining her sea legs — beginning to learn how the hospital worked, getting to know her colleagues, being assigned her own patients without a supervisor — the floor began flooding with COVID-19 patients. Smith found her education was of little use.
“Being new, you go off of your ABCs,” Smith said. “There’s no set nursing concept with this. This is something that we weren’t taught.”
New nurses often rely on experienced colleagues to help guide them through the protocol in different situations. But with a new disease, there were little those mentors could offer, either.
“No one knew what was going on, how to treat them, what we should do,” Smith recalled.
Nursing is a career that’s been plagued by burnout for decades, while at the same time it soars in popularity. For those who were on the cusp of their nursing careers in 2020, short staffing, less-than-normal supervision, and mismanagement exacerbated by the pandemic led many to question the future of the profession.
During the first wave of cases last spring, hospitals had limited personal protective equipment and throngs of patients in critical condition. That meant supplies were rationed and nurses like Smith were the ones designated to go into the rooms where COVID-19 patients were quarantined, to check vitals, and respond to their needs.
Under normal circumstances, those rounds can be brief and nurses can care for multiple patients at a time. But it was common for the patients in the step-down unit to have such low oxygen levels that Smith said she wasn’t comfortable leaving the bedside — she needed to stay and monitor, in case they got worse. As Smith would sit, masked and robed up, watching one high-needs patient, the lists of tasks for her other patients would mount quickly. There was little chance for relief because her colleagues were stuck by the bedsides of their own patients.
Doctors and physician assistants would rarely enter the rooms, she said, unless they were performing critical procedures like intubating patients, to cut down on the risk of catching the virus. As call buttons went unanswered, the list of needs grew, and nurses like Smith were stuck in rooms.
As a brand-new nurse, Smith was regularly responsible for up to four patients at a time who needed high levels of care — a normal patient load for a new nurse in that situation might have been half that.
Potential for earlier burnout
Short staffing is not a new problem among hospital nurses, and the pandemic has made it worse.
“Chronic understaffing in hospitals and chaotic and inefficient work environments put nurses in a very poor position to be able to respond to the COVID surge because they were already reaching deep inside themselves in the normal context of care,” said Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing.
In part, that’s because the level of care required for COVID-19 patients is so high. Normally, nurses are assigned a mix of patients whose needs vary in intensity to make their caseloads manageable. When everyone has COVID, the workload for each patient becomes much greater.
Short staffing is closely linked to nursing burnout, a phenomenon the field has long contended with and which experts fear the pandemic will exacerbate. Half of new nurses report feeling burned out, but 45% of all nurses do.
“Many nurses don’t end up being able to do a decades-long career because the level of burnout is so high,” said Rebecca Givan, a labor studies professor at Rutgers University who specializes in health care. She predicted that new nurses would likely deal with accelerated burnout as they deal with staffing challenges and increased physical and emotional stresses.
A recent study in New York and Illinois found that high nurse burnout before the pandemic was associated with substantial numbers of avoidable deaths among patients that didn’t have to die.
Burnout has an impact on hospital costs, as well. The greater the nurse burnout rate at any given hospital, the longer the length of patient stays, which costs hospitals more. It’s also expensive to lose staff: Replacing each nurse who leaves for a better-managed hospital can cost as much as a full year of a nurse’s salary.
At St. Mary, experienced nurses were leaving the hospital in droves. Some were out sick or caring for sick family members. Others were afraid they were stretched so thin they might make a mistake, putting their nursing licenses at risk. More just decided to retire early.
The experienced nurses who did stay didn’t have time to mentor or help the new nurses the way they normally would, said Smith. That meant that on top of learning everything about COVID on the fly, she was groping around in the dark for some of the bedside manners that come with years on the job.
“The anxiety of not being able to breathe and feeling like a drowned fish is tremendous,” Smith said.
Less support for young nurses, and for their patients
Where nurses usually support families who can directly offer their kin a sense of comfort, visitation during the pandemic was restricted, meaning the nurse was often the only go-between communicating with family and patients.
“We have a lot of people who’ve lost their wives and husbands, and we don’t unfortunately have time to provide that care for them,” Smith said. “To tell them it’s worth living. It’s worth moving past this and getting better and going home to your grandchildren and family.”
Smith had her own family to contend with, too. At home in Bensalem, she worried about infecting her parents, with whom she lived. She was so exhausted after work, she would just retreat to her room most days. Before shifts, she took virtual courses as prerequisites for medical school. She’d text with her colleagues who worked overnight to get a sense of what she was in store for, and how short-staffed she could expect it to be on the floor.
Even offers of double pay, then triple to encourage people to pick up extra shifts began to fall flat, said Smith. No incentive was enough when you were physically too tired to work.
“It didn’t get better with time, it got worse with time,” she said.
The 800 nurses at St. Mary had organized a union last year, in part to fight for better staff-to-patient ratios. After a year of negotiations and no contract, burned out and with few options remaining, the nurses walked off the job for two days in November.
For Smith, the same protections that had been afforded to her by her union as a dock worker apply at the hospital, only instead of protecting loss of freight, now she was protecting loss of life. Her dad and brother, longtime members of the seafarers union, joined her on the picket line.
The pandemic has brought a surge in labor organizing among nurses nationwide, largely focused on improving staff-to-patient ratios that nurses say prevent burnout and allow them to deliver the care their patients need. In the Philadelphia region, St. Mary was one of two new nurses unions that ratified contracts during the pandemic. More still fought for staffing requirements in updated contracts.
A month after the walkout, hospital management at Trinity Health, which owns St. Mary, struck a deal with the nurses. The new contract included a tiered pay increase over five years and “enforcement mechanisms to ensure that the hospital hires and schedules enough nurses to meet its staffing guidelines, and that the guidelines cannot be changed without prior discussion with the nurse union representatives.”
At the time, St. Mary management praised the agreement. “We look forward to working together to fulfill our shared mission to be a transforming and healing presence for those we serve,” hospital president Dr. Lawrence Brilliant said in a statement.
St. Mary management did not immediately respond to questions from WHYY News more recently about how the new staffing requirements have manifested since the contract was signed.
In February, Pennsylvania lawmakers introduced legislation that would require safe staffing in hospitals across the state, to prevent nurses from fighting one-off battles like these. Only California has state-mandated ratios, but many states have proposed similar bills.
By the time the contract was ratified, Smith’s honeymoon period at the hospital was long over. The varied experience she hoped she’d get responding to all sorts of conditions and diseases turned out to be all COVID, all the time. She felt her growth had been stunted.
Yet Smith was called upon to help the newest class of nursing school graduates acclimate to the floor. It seems that a year navigating all this was enough to make her the expert.
“Yes I’ve had some experiences over the past year, but that was hard to hear,” she recalled. “You need to be a resource for these new nurses — and I’m like, ‘But I’m a new nurse!’”
Still, she finds it rewarding to be able to answer the questions.
Aiken, from Penn’s School of Nursing, is optimistic that new nurses will stay the course. Her research has shown that it’s not the intense, high-stakes clinical conditions that cause burnout — in fact, the life-and-death nature of the work is what attracts them to the job in the first place.
In that sense, Aiken hopes caring for COVID patients will make nurses feel like they are doing valuable work. But, she said, for them to stay, their employers will have to treat them that way too.
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