‘Nursing Is in Crisis’: Staff Shortages Put Patients at Risk

“When hospitals are understaffed, people die,” one expert warned as the U.S. health systems reach a breaking point in the face of the Delta variant.,

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Cyndy O’Brien, an emergency room nurse at Ocean Springs Hospital on the Gulf Coast of Mississippi, could not believe her eyes as she arrived for work. There were people sprawled out in their cars gasping for air as three ambulances with gravely ill patients idled in the parking lot. Just inside the front doors, a crush of anxious people jostled to get the attention of an overwhelmed triage nurse.

“It’s like a war zone,” said Ms. O’Brien, who is the patient care coordinator at Singing River, a small health system near the Alabama border that includes Ocean Springs. “We are just barraged with patients and have nowhere to put them.”

The bottleneck, however, has little to do with a lack of space. Nearly 30 percent of Singing River’s 500 beds are empty. With 169 unfilled nursing positions, administrators must keep the beds empty.

Nursing shortages have long vexed hospitals. But in the year and half since its ferocious debut in the United States, the coronavirus pandemic has stretched the nation’s nurses as never before, testing their skills and stamina as desperately ill patients with a poorly understood malady flooded emergency rooms. They remained steadfast amid a calamitous shortage of personal protective equipment; spurred by a sense of duty, they flocked from across the country to the newest hot zones, sometimes working as volunteers. More than 1,200 of them have died from the virus.

Now, as the highly contagious Delta variant pummels the United States, bedside nurses, the workhorse of a well-oiled hospital, are depleted and traumatized, their ranks thinned by early retirements or career shifts that traded the emergency room for less stressful nursing jobs at schools, summer camps and private doctor’s offices.

“We’re exhausted, both physically and emotionally,” Ms. O’Brien said, choking back tears.

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Cyndy O’Brien, an emergency room nurse at Ocean Springs Hospital. “We are just barraged with patients and have nowhere to put them,” she said.Credit…Rory Doyle for The New York Times

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A Covid patient under treatment at Ocean Springs Hospital, part of the Singing River nonprofit health system, which has 169 unfilled nursing positions.Credit…Rory Doyle for The New York Times

Like hospital leaders across much of the South, Lee Bond, the chief executive of Singing River, has been struggling to stanch the loss of nurses over the past year. Burnout and the lure of financially flush health systems have hobbled hospitals during the worst public health crisis in living memory.

With just over a third of Mississippi residents fully vaccinated, Mr. Bond is terrified things will worsen in the coming weeks as schools reopen and Gov. Tate Reeves doubles down on his refusal to reinstate mask mandates. “Our nurses are at their wits’ end,” Mr. Bond said. “They are tired, overburdened, and they feel like forgotten soldiers.”

Across the country, the shortages are complicating efforts to treat hospitalized coronavirus patients, leading to longer emergency room waiting times and rushed or inadequate care as health workers struggle to treat to patients who often require exacting, round-the-clock attention, according to interviews with hospital executives, state health officials and medical workers who have spent the past 17 months in the trenches.

The staffing shortages have a hospital-wide domino effect. When hospitals lack nurses to treat those who need less intensive care, emergency rooms and I.C.U.s are unable to move out patients, creating a traffic jam that limits their ability to admit new ones. One in five I.C.U.s are at least 95 percent capacity, according to an analysis by The New York Times, a level experts say makes it difficult to maintain standards of care for the very sick.

“When hospitals are understaffed, people die,” said Patrica Pittman, director of the Health Workforce Research Center at George Washington University.

Oregon’s governor has ordered 1,500 National Guard troops to help tapped-out hospital staff. Officials in a Florida county where hospitals are over capacity are urging residents “to consider other options” before calling 911. And a Houston man with six gunshot wounds had to wait a week before Harris Health, one of the country’s largest hospital systems, could fit him in for surgery to repair a shattered shoulder.

“If it’s a broken ankle that needs a pin, it’s going to have to wait. Our nurses are working so hard, but they can only do so much,” said Maureen Padilla, who oversees nursing at Harris Health. The system has 400 openings for bedside nurses, including 17 that became vacant in the last three weeks.

In Mississippi, where coronavirus cases have doubled over the past two weeks, health officials are warning that the state’s hospital system is on the verge of collapse. The state has 2,000 fewer registered nurses than it did at the beginning of the year, according to the Mississippi Hospital Association. With neighboring states also in crisis and unable to take patient transfers, the University of Mississippi Medical Center in Jackson, the only Level 1 trauma unit in the state, has been setting up beds inside a parking garage.

“You want to be there in someone’s moment of need, but when you are in disaster mode and trying to keep your finger on the leak in the dike, you can’t give every patient the care they deserve,” said Dr. LouAnn Woodward, the medical center’s top executive. With staffing shortfalls plaguing hospitals coast to coast, bidding wars have pushed salaries for travel nurses to stratospheric levels, depleting staff at hospitals that can’t afford to compete. Many are in states flooded with coronavirus patients.

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Workers sanitized a Covid field clinic in the parking garage of the University of Mississippi Medical Center. Credit…Rory Doyle for The New York Times

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Dr. LouAnn Woodward, the top executive at the University of Mississippi Medical Center. “When you are in disaster mode and trying to keep your finger on the leak in the dike, you can’t give every patient the care they deserve,” she said.Credit…Rory Doyle for The New York Times

Texas Emergency Hospital, a small health system near Houston that employs 150 nurses and has 50 unfilled shifts each week, has been losing experienced nurses to recruiters who offer $20,000 signing bonuses and $140-an-hour wages. Texas Emergency, by contrast, pays its nurses $43 an hour with a $2 stipend for those on the night shift. “That’s ridiculous money, which gives you a sense of how desperate everyone is,” said Patti Foster, the chief operations officer of the system, which runs two emergency rooms in Cleveland, Texas, that are over capacity.

Ms. Foster sighed when asked whether the hospital offered signing bonuses. The best she can do is pass out goody bags filled with gum, bottled water and a letter of appreciation that includes online resources for those overwhelmed by the stress of the past few weeks.

Business has never been better for travel nurse recruiters. Aya Healthcare, one of the country’s biggest nurse recruitment agencies, has been booking 3,500 registered nurses a week, double its prepandemic levels, but it still has more than 40,000 unfilled jobs listed on its website, said April Hansen, the company’s president of work force solutions. “We’re barely making a dent in what’s needed out there,” she said.

There were more than three million nurses in the United States in 2019, according to the Bureau of Labor Statistics, which estimates 176,000 annual openings for registered nurses across the country in the next few years. But those projections were issued before the pandemic.

Peter Buerhaus, an expert on the economics of the nursing work force at Montana State University, is especially rattled by two data points: A third of the nation’s nurses were born during the baby boom years, with 640,000 nearing retirement; and the demographic bulge of aging boomers needing intensive medical care will only increase the demand for hospital nurses. “I’m raising the yellow flag because a sudden withdrawal of so many experienced nurses would be disastrous for hospitals,” he said.

Many experts fear the exodus will accelerate as the pandemic drags on and burnout intensifies. Multiple surveys suggest that nurses are feeling increasingly embattled: the unrelenting workloads, the moral injury caused by their inability to provide quality care, and dismay as emergency rooms fill with unvaccinated patients, some of whom brim with hostility stoked by misinformation. Nurses, too, are angry — that so many Americans have refused to get vaccinated. “They feel betrayed and disrespected,” Professor Buerhaus said.

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Oxygen tanks being delivered to the emergency room at the University of Mississippi Medical Center.Credit…Rory Doyle for The New York Times

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Patti Foster, left, chief operations officer at Texas Emergency Hospital, and Cassie Kavanaugh, the chief nursing officer for the hospital’s network. “I don’t know how much more we can take,” Ms. Kavanaugh said.Credit…Michael Starghill Jr. for The New York Times

Increasing the nation’s nursing workforce is no easy task. The United States is producing about 170,000 nurses a year, but 80,000 qualified applicants were rejected in 2019 because of a lack of teaching staff, according to the American Association of Colleges of Nursing.

“We can’t graduate nurses fast enough, but even when they do graduate, they are often not prepared to provide the level of care that’s most needed right now,” said Dr. Katie Boston-Leary, director of nursing programs at the American Nurses Association. Newly minted nurses, she added, require on-the-job education from more seasoned ones, placing additional strains on hospital resources.

Some of the proposed remedies include federal policies that can stabilize the profession, including financial assistance to help nursing schools hire more instructors and staffing-ratio mandates that limit the number of patients under a nurse’s care.

“This simplistic notion that the labor market will just produce the number of nurses we need just isn’t true for health care,” said Professor Pittman of George Washington University. “Nursing is in crisis, and maybe the pandemic is the straw that will break the camel’s back.”

The crisis is on full display at Texas Emergency Hospital, which has been treating patients in hallways and tapping administrators to run specimens to the lab. In recent days, 90 percent of those admitted to the hospital have tested positive for the coronavirus. Short on ventilators, and with hospitals in Houston no longer able to take their most critically ill patients, officials have been contemplating the unthinkable: how to ration care.

On Friday, Cassie Kavanaugh, the chief nursing officer for the hospital’s network, was dealing with additional challenges: Ten nurses were out sick with Covid. She had no luck renting ventilators or other breathing machines for her Covid patients. Many of the new arrivals are in their 30s and 40s and far sicker than those she saw during previous surges. “This is a whole different ballgame,” she said.

Ms. Kavanaugh, too, was running on fumes, having worked 60 hours as a staff nurse over the previous week on top of her administrative duties. She was also emotionally wrought after seeing co-workers and relatives admitted to her hospital. And her anguish only mounted after she stopped at the grocery store: Almost no one, she said, was wearing masks.

“I don’t know how much more we can take,” she said. “But one thing that hit me hard today is a realization: If things keep going the way they are, we’re going to lose people for sure, and as a nurse, that’s almost too much to bear.”

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