Voices from the front lines
Even as the threat of COVID recedes, hospital staff face multiple crises
COVID-19′s deadly grip has eased. Lockdowns and school closures are distant memories, and many people have resumed some semblance of their pre-pandemic lives.
Inside hospitals, however, reality remains fraught. Front-line workers continue to weather crisis after crisis, from supply shortages, to a mental health epidemic, to an influx of patients sicker from delaying care. Many nurses are still grappling with their personal trauma after serving on the front lines of the pandemic.
While front-line workers return to hospitals day after day, there are fewer of them. By some estimates, nearly one in five health care workers quit their jobs during the pandemic. More may follow. A survey of Massachusetts nurses taken in March and April found that 33 percent planned to leave sooner than originally anticipated, and 25 percent planned to reduce their hours because of the stress and demands of the pandemic.
Those who remain are facing new challenges, as they pick up work left behind by their colleagues.
For a month this summer, The Boston Globe collected voice memos from six nurses as they worked their shifts, to better understand what it is like inside hospitals right now. Exhausted, dealing with problems outside of their control, many cling to small moments of victory. Others count down the hours till they retire.
For now, they keep showing up to do their vital work.
The floor was short staffed. Again. Leilani Hover knew it before she even arrived. On each of her days off, her phone had pinged with voicemails asking her to come in for extra shifts. The notes filled her with dread.
Hover had been many things in her lifetime. A short order cook, a waitress. She did title searching and then worked at the post office. When she discovered nursing 13 years ago at age 40, she realized she had found a way to care for others that she had been searching for her whole life.
Initially, going to work felt exciting and awe inspiring. But the pandemic changed that. The demands of the past two-and-a-half years had been extraordinary; her efforts never seemed enough.
On this day, Hover had expected to have at most two patients. But the floor didn’t have a charge nurse who can oversee the team and hop on to assignments as needed, or a crisis nurse, who often acts as an extra pair of hands. Without them, there weren’t enough people on the floor to respond to a cardiac arrest. Someone would have to come from the emergency room to assist with the intricate dance of CPR, medications, and more. In those moments, it was all hands on deck. That night, she knew, there was a chance that a critical pair of hands would be late.
Hover waited anxiously through her 12-and-a-half-hour shift for such an alert, tensing every time there was an overhead page. “Code…” her breath caught in her throat, stopping her from her tasks. Don’t be code blue. The codes instead cycled through a rainbow of other colors, carrying with them meanings aimed at the knowing few, like notes passed in school. It didn’t help her relax.
The patient had to be moved. Hover had just arrived for her shift, and already there was chaos. Orders to transfer the patient to another floor had been pending all day. By nightfall, the other parts of the hospital were backing up. Soon, Hover was juggling the transfer of her first patient, getting the room cleaned, caring for another intubated patient, and trying to coordinate where a third patient would go.
“It’s just such a cascade of events,” Hover said. “It’s a constant.”
At work, Hover could lock her emotions behind a mask of professionalism. But outside of the hospital, the emotions bubbled to the surface. She avoided talking about the job. Otherwise the words would catch in her throat and force tears to the corners of her eyes.
She’d think of the patients, coming and coming with COVID years before. She remembered the hours pumping their hearts through their chests, performing CPR, the patients’ ribs cracking from the force of her palms. Or she’d think of their deaths, mouths propped open with plastic tubes.
She had begun to push off invitations to social events, preferring the quiet of her house, tending to the needs of her garden. There she could care for something without alarms sounding, without terror.
“I can’t even share with my family, because I don’t want them to know,” she said.
The psychiatric area of the emergency department was teeming with people. One patient had been there for days waiting for a geriatric psychiatric bed. Others were suicidal. Some were struggling with schizophrenia and hadn’t regularly been taking their medication. One had a history of being violent toward staff.
Nurses can look at a patient’s medical record to see if they have a history of assault, but most don’t need to. The staff had seen these patients before.
A security officer told Ellen MacInnis that one of her patients had been violent in the past, and as she entered the room, she moved cautiously. Because it can soften the edges of a difficult encounter to speak to someone at eye level, instead of towering over them as they lie in bed, she pulled up a chair. Yet she was careful to ensure it wouldn’t be in her way should she need to escape.
Violent patients used to bother her, but she had come to understand there was heartbreak and need behind a person’s outbursts. Sometimes, violence was a way of communication, and MacInnis was willing to listen.
Caring for suicidal patients was more challenging. Each was supposed to have a sitter to ensure they didn’t harm themselves. But there weren’t enough nursing assistants, health workers, and ED technicians on the floor, so each assistant monitored two or more patients at a time.
For many, COVID had exacerbated mental health struggles and disconnected them from sources of support. So they showed up in the ER, grappling with substance use disorders or struggling with unseen demons and traumas that MacInnis could not fix. For others, the services they needed were unavailable in the ER. “That’s one of my frustrations as a nurse,” she said. “I have patients sitting there in front of me, and there is really nothing I can do for them.”
MacInnis heard an overhead page for the anesthesia team to come to the ICU to intubate a patient so sick as to need a machine to breathe for them. She knew instinctively the patient had been hers, and her heart sank.
The emergency department had tried for hours to help the older man breathe better, even putting him on high-flow oxygen. When he was taken to the ICU, he had begun to improve. Yet his congestive heart failure and likely pneumonia were too much for his lungs without mechanical help. Intubation marked a setback, one extra hurdle the patient would have to overcome. Despite all the hospital’s work and effort, she didn’t know if he would survive.
Survival wasn’t always the goal. MacInnis knew from her 33 years in the profession that sometimes nursing was about walking someone as gently as possible to death, helping them understand and prepare for what was coming. One of her other patients that night was experiencing end-stage pancreatic cancer. The goal for now was to manage the man’s pain.
MacInnis helped position him in the bed and gave him some medication. She rubbed his shoulders to distract his body from pain. The man knew he wasn’t going to survive. As she placed a blanket over his frail frame, the man thanked her.
“I really trust you,” he said. His body settled into stillness, and he drifted off to sleep.
MacInnis quietly left his room.
“That’s a victory,” MacInnis said. “That’s a good day.”
Claire O’Connell’s unit was well staffed for the holiday. Doctors, realizing they could get time in the operating room, had tacked on a few extra cases for the day. The patients cycled in and out of O’Connell’s unit, where they were prepped and managed before and after surgery.
The day ran smoothly, but it wasn’t like most days. Usually doctors were eager to get patients into the OR quickly, pushing the nurses to work faster. Other times, the doctors would come in and interrupt O’Connell as she was talking to a patient, which she felt was rude.
The relationship between nurses and doctors had frayed since COVID, when she was sent into sick patients’ rooms while doctors seemed to do all they could to stay on the other side of the glass.
Much of those early months of COVID still stuck with her. O’Connell remembered the day she was called to work in the COVID ICU, her name echoing over the overhead PA system. It felt like being called from the crowd to compete in the Hunger Games, impersonal and cold. “Anyone wanna go for me?” she joked. No one said yes.
O’Connell had always wanted to be a nurse, like her mother. As a child, she had watched her get dressed for work — a white dress cinched around the waist and buttoned to the collar, carrying a white, starched cap with a black velvet ribbon. The job initially held that magic for O’Connell, but since the pandemic, nursing had lost its mystique. Now, she wanted to be in the hospital as infrequently as possible.
Colleagues wanted to decrease their hours, too, but the hospital couldn’t accommodate them. Managers said they would only be able to let nurses work less after they staffed up more, but O’Connell doubted that day would ever come. (In a statement, Brigham and Women’s said it is committed to allowing staff to reduce hours when possible without impacting patient care.)
So nurses took steps back in the ways that they could. They stopped taking extra shifts, despite earning time-and-a-half and an incentive bonus the hospital offered. Some called out sick when the burdens became too much. Others left entirely. O’Connell didn’t blame them. She could sense they were on the brink
Emergencies were fast coming from other floors to the intensive care unit, and new admissions were streaming in. There seemed to be a new emergency every hour. Joan Ballantyne herself darted between the rooms of two patients, one in respiratory distress, the other with a breathing tube snaked down her trachea.
“It’s just nonstop,” she said.
In between emergencies, Ballantyne ventured to the supply room. The previous week, she couldn’t find blood tubes, each manufactured for specific tests. Earlier in her shift, linens were in short supply. Now it was the stickers that affixed the cardiac monitors to patients that allowed her to check their heart rates. The stickers had to be changed and moved daily so patients’ skin didn’t break down.
The minutes ticked by as she looked in the usual spots, then began a stressful scavenger hunt. Perhaps they had fallen behind a shelf? Maybe they had been misplaced? A laundry list of other to-dos cycled in her head as she looked.
Exasperated, Ballantyne left the room without the stickers.
“You can never just say all right,, I’m going to go and get this,” she said. “You say I have to see if I can find this.”
She made a mental note to tell the next shift nurse. Maybe she’d have better luck hunting them down.
The patient wiggled his fingers, and his face transformed with joy. A stroke had immobilized one side of his body. But little more than a day later, the synaptic connections in his brain had began to function enough that his body moved again.
This morsel of progress sent the three nurses in the room into cheers. They asked him to perform the movements again and again, celebrating the return of his function and hope. Maybe they were ridiculous, cheering and clapping accomplishments so subtle the patient could only rustle his sheets. But it was a joyous moment, the kind that counterbalanced the heartache, sadness, and stress. Nursing was like a gemstone in that way. The lightness and the darkness could sit so close, oscillating with the mere flick of a wrist. Amid the pressure and stress, it could be beautiful.
That night, sitting in her car in her driveway, Ballantyne felt buoyed. “I don’t think you experience stuff like that in other professions,” she said. “It’s not for everyone. It’s really hard, and really difficult at times … but it was a good day.”
On the way into work, Rachel Fournier felt tense, worried about what the day might bring. She wondered what kind of patients would be on the psychiatric floor where she worked, and how well staffed they’d be to handle them. Four years into her job as a nurse, she still had a bright-eyed optimism most days, but the unknowns were eating away at her positivity.
At the morning team meeting, Fournier heard a familiar refrain — discharging patients had become much more difficult. Many inpatient beds and outpatient support programs were closed due to widespread staffing shortages. Partial hospitalization programs were few and far between, and therapists had lengthy wait lists. Some programs shifted to telehealth, which was inaccessible to some and uncomfortable for others.
COVID had exacerbated all of it. But the pandemic had an especially profound effect on those struggling with homelessness, upending their already fragile lives. In the summertime, when many shelters closed, patients found themselves sleeping in fields or taking shelter behind stores. They couldn’t access their medication. When they did, sometimes it was stolen.
Discharging patients struggling with homelessness was among the most challenging aspects of her job. She could set them up with outreach workers, but resources were few and far between. There were years-long waits for affordable housing. Residents in her own town of South Hadley had bristled fiercely at the suggestion of mixed income housing. She had seen the difference stable housing could make for a patient and was at a loss how to help someone without it. The patients left the hospital and fell through the safety net like sand.
“Without stable housing, different parts of their lives crumble,” she said. “Unfortunately there is not a lot we can do.”
Many days, Fournier was tasked with coordination, a chess game of discharges and admissions. But today there weren’t many people to move. She would have time to sit with patients in their rooms, find out more about who they were beyond scribbled notes in a medical record.
Those days were her favorites. Fournier remembered once offering to help a patient struggling with homelessness untangle her matted hair. She worked conditioner into the patient’s brunette mane, untwirling it knot by knot with a comb, gently, patiently. Her hair unburdened, the woman showered. Fournier remembered her emerging from the washroom transformed.
Those were the shifts that helped Fournier feel as though she were making a difference.
Some days the job demanded more of her than she thought she could give, requiring her to act as a nurse and a social worker, family therapist, and case manager. But at the core of it, nursing still lit her up inside. It was all she had longed to be.
Two patients on the unit had tested positive for COVID, and the specter of anxiety and stress returned to the floor.
COVID had generally been difficult to manage on the geriatric psychiatric unit, where Judith Laguerre had worked for 16 years. Patients, confused already, didn’t recognize the nurses who had come to care for them dressed in masks, gowns, and gloves. The protective equipment also muffled nurses’ words, adding to patients’ confusion and fear. Some, suffering from mental health issues, refused to accept there was a pandemic at all.
The positive tests brought back other memories. Laguerre remembered the shame she felt in those early days, as the world looked on at the uneven toll the pandemic took on Black and brown communities because of systemic disparities .
She remembered lying in bed, sick with COVID herself, just as the world was waking up to its presence. Bleary-eyed and weak, wrestling with pain and tingling that reverberated through her body, she had looked upon her own mortality and assessed her odds of survival as akin to a coin flip.
Once recovered, she vowed to use her voice to speak up for change, advocating for action on the lack of personal protective equipment and opening up about what nurses of color were going through at work. When she saw a fellowship to address racial disparities in Alzheimer’s care, she jumped at it.
Laguerre still felt bites of lingering pain, a parting gift from the infection. It greeted her some days alongside the aches of the job, of muscles sore and stretched and feet that some evenings felt like lead.
The man was scheduled to be discharged back to his home, an event that normally would be cause for celebration. So often, elderly patients were sent somewhere else after the hospital — a nursing home, a rehabilitation center.
But the happy task turned more challenging, as the man’s family arrived early and were impatient to leave. They had had complaints throughout his lengthy stay, and Laguerre noticed they were particularly hostile when the staff were Black.
As Laguerre worked in the room, the family began packing up the man’s things. They couldn’t find a T-shirt.
“That’s how it is in these places,” a family member said within earshot of Laguerre. “Things tend to disappear.”
Racism could be commonplace. Some patients would take medication only from white nurses. Some would question out loud why there were so many Black workers there.
Laguerre remembered once seeing a woman silently choke, air and sound blocked inside her panicked face. Laguerre rushed over and attempted the Heimlich maneuver, but it didn’t work. Realizing she was choking on peanut butter, Laguerre took her finger to scrape the woman’s throat, clearing it for air. The woman gasped, and with that first gulp of oxygen, spat out the words — “Don’t touch me, [racial slur].”
The name calling wasn’t the worst part. Laguerre believed the system itself perpetuated that kind of abuse, by not allowing space for Laguerre and others to speak out about it.
Some days she wondered how she could be an advocate for patients when she struggled to be an advocate for herself.
“We can forgive patients. They are sick. They are old. We can forgive family. They are coming and leaving. We will not see them again,” Laguerre said. “But when we talk about the system, or co-workers, it’s hard. It can be harder than the work itself.”
But Laguerre believed in leaving things behind, dropping the moments of anguish, savoring instants of joy.
They had a saying at work, that you could choose to laugh or cry.
“But we end up laughing, because we would cry often and wouldn’t be able to do the job,” Laguerre said.