People come to Shelly Hughes to get better. Most patients at the Washington State long-term-care facility she works at are there for the express purpose of getting well enough to go home. In a typical year, she would rarely see cases of “failure to thrive,” the technical term for a sharp and sudden decline in health. But last year, multiple people who were expected to make a full recovery went into rapid decline: They refused to eat, drink, or move, and then died.
She blames isolation, in part. Her facility has dramatically limited inside visitors since the start of the coronavirus pandemic, and employees wear full personal protective equipment, which makes communication difficult, especially with patients who are hard of hearing or have dementia. “Everyone that you see is basically a spaceman with no face,” she told me. She used to be able to comfort scared and lonely patients not just with her words, but with body language and facial expressions. Now she’s resorted to exaggerated gestures and writing questions down on a pad of paper.
Hughes and her co-workers are also trying to provide care while significantly understaffed, tending to far more patients than they should. Every shift has open slots, putting a greater burden on those who come in to work. “You physically do not have the caregivers and the nurses and social workers in the building to be able to sit and talk with people in a way that makes them feel like they’re not alone,” she said. “You feel really helpless.”
It’s made Hughes consider whether she can stay in her job for only the second time in nearly a decade. The other time was eight years ago, right after she miscarried twins. The facility was severely short-staffed, and she had been picking up a lot of extra hours. “I really blamed the work for my miscarriage,” she said. She got through it and decided to stay.
This time might be different. “I love my job, and I want to keep doing it for as long as I can,” she said. But, she added, “I know that there is an expiration date on this job or me.”
No one has endured the past year unscathed, but America’s health-care workers have witnessed the worst of it while trying to keep the rest of us healthy and safe. They’ve fought for PPE, and with patients and visitors who refuse to wear masks. They’ve watched their patients give birth alone, suffer alone, die alone. Hundreds of thousands got sick themselves, and many more lived with the daily worry of bringing the virus home to their loved ones. Many began to wonder if it’s worth it. “People are definitely looking for greener pastures,” says Rob Baril, the president of SEIU 1199 New England, a union chapter that represents about 25,000 nursing-home employees, home health aides, and other health-care workers.
Many of the facilities that employ these workers already struggled with retention given the low pay and high workload. “Pre-pandemic, this was a workforce that in many ways was very fragile and underappreciated and underpaid,” Rachel Werner, the executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania, told me. Baril estimates that about 80 percent of his members are women, and that 80 percent are Black or Latino. And because their work is associated with the work that women are expected to do at home for free, it’s long been undervalued. “It’s a workforce that’s quite invisible, easy to dismiss,” Werner said. “It doesn’t have a lot of political capital or clout.”
Now the stakes are even higher. “You can’t get people to go risk their lives for $15 an hour,” Baril told me. Chronic understaffing became an acute crisis last year, as people got sick or feared for their safety if they came to work; one in five nursing homes was short on staff last summer. But workers without paid sick leave faced financial ruin if they had to stay home to quarantine or recover from COVID-19.
It was a vicious cycle. Take nursing homes: COVID-19 outbreaks were significantly more common in facilities that didn’t offer paid sick leave. Sky-high turnover rates helped spread the disease far and wide. So far, more than 1,800 nursing-home staff and 130,000 residents have died of COVID-19. At one facility in Connecticut, Kimberly Hall North, which has 150 beds, the state reported in May that 40 patients had died; Baril said that one employee had died and another had brought the disease home to her mother, who died. The long-term-care system “has historically been held together with duct tape and spit,” Werner said. “The pandemic revealed how fragile that system is.”
In a recent report published by the Department of Health and Human Services’ Office of Inspector General, hospital administrators said increased workloads and the trauma of caring for COVID-19 patients have left staff “exhausted, mentally fatigued, and sometimes experiencing possible PTSD.” That has led to even higher turnover than normal—38 of the 296 hospitals surveyed faced a critical staffing shortage. One Texas hospital saw its annual nurse turnover rate jump from 2 to 20 percent, according to the report. A hospital network reported an increase in life-threatening central-line blood infections—an increase it attributed to a lack of staff and the fatigue of those who were working.
Hospitals don’t expect the crunch to ease after the pandemic fades, but instead to worsen, because so many people have been deterred from entering the industry. One hospital that usually recruits new nurses from its teaching hospital graduated only 100 in 2020, yet had 200 open positions. Several of Hughes’s co-workers have quit; many have left the medical field altogether. Hughes tries to persuade them to instead take a leave of absence so they could come back. “So far no takers,” she said.
Melanie Arciaga worked her last shift as a registered nurse at Harborview Medical Center, in Seattle, on April 3, 2020. Back then, her hospital’s PPE was often locked up; nurses had to request it each time they needed it. New patients were tested for COVID-19 as they were admitted, but if they tested negative, no extra precautions were then taken.
At the end of that last shift, Arciaga had to take the vital signs of a patient whose roommate had just developed respiratory symptoms. The only protection she had was a pair of gloves; she wasn’t wearing a mask or eye protection. The patient coughed, “and I felt it [go] straight into my face and my eyes,” she told me. She was too busy to give it much thought until she overheard another nurse say that the roommate had tested positive for COVID-19. There wasn’t much Arciaga could do, so she finished her charts, went home, and went to sleep.
She woke up to a voicemail saying that the patient who’d coughed on her had tested positive. Less than 48 hours later, she was in pain “from head to toe,” she said. “It felt like nails driving through my fingers, my toes, my foot, my head.” One night, her husband later told her, she woke up and said to him, “Just kill me right now. I can’t have this pain anymore.” When her husband drove her to the emergency room, he refused to leave the parking lot—he thought she was going to die in the hospital. She had a fever for nine days and the pain lasted for two weeks.
Nearly a year later, Arciaga still has an acute burning sensation in her nose. Her lungs didn’t heal until January; she had to pause every so often to cough while we spoke over the phone in early March, and she still gets short of breath. “I think this is going to be my new norm,” she said.
She wants desperately to go back to working in the hospital, but can’t tolerate wearing a surgical mask for more than two hours without intense coughing spells. “I feel really, really bad because they’re really, really short-staffed,” she said. “I just feel so helpless.”
She’s also furious. Before she was forced to stop working, she had been fighting for adequate PPE—and her colleagues are still fighting. Hospitals and nursing homes were notoriously flat-footed at the start of the pandemic, but even as recently as November, more than 80 percent of National Nurses United members reported reusing at least one type of single-use PPE such as masks. Arciaga likened herself and her co-workers to soldiers. “You’re throwing me into a war, fighting a battle without a gun, without shoes, without a helmet, no armor.” She’s become afraid to go outside and be around other people. The first time her husband made her leave the house, they drove to the ocean, with just a stop for gas, and she gripped his hand in fear the whole time. “I still have some sort of PTSD,” she said.
When I asked Adarra Benjamin, a home health and personal-care aide in Chicago, to sum up the past year, all she could get out was, “Panic, panic, suspense.” Eventually she added, “Every day is like a waiting game to see if someone gets sick.” Because she works in people’s homes, she’s lost most of her clients and income this year. She wants to take on more clients as they become willing, but worries she’ll be exposed to COVID-19.
After months of seeing co-workers, patients, and others engage in risky behavior, Bartie Scott, a nurse practitioner in Fayetteville, Tennessee, is similarly at the end of her rope. The week after Thanksgiving, one 70-year-old woman who came to her clinic to get a COVID-19 test after her co-workers had tested positive admitted that, despite feeling under the weather a few days before Thanksgiving, she had eaten her holiday meal at a restaurant with her daughter. Her test was positive.
Scott has tried to ignore the people around her not wearing masks, but when she recently had to wait in a crowded room with two men who weren’t, she couldn’t stay silent anymore. She asked them to wait somewhere else, but instead of leaving, other people jumped in to defend them. “It’s like a slap in the face,” she told me. It feels like “a personal insult.”
“On the surface, I tell myself I’m keeping it all together,” she said. But “underneath, I’ve been kind of angry.”
In the fall, Shelley Hughes started adding an extra night to her weekly schedule to help ease the staffing shortage at her facility. But it took a toll. “I felt like I was dying,” she said. “It just felt like all of the life and energy was gone.” She went to work, came home, and was capable of doing nothing else—not playing the piano, cuddling with her puppy, or any of the other activities she had been using to distract herself. Her relationship with her husband suffered. She finally got blood work done and was diagnosed with hypothyroidism right before New Year’s. Her doctor suggested that stress from work was a trigger.
In some places, the trauma of this year has resulted in large-scale political change. In February, the Virginia legislature passed a law mandating five days of guaranteed sick leave for home health-care workers. Adarra Benjamin’s union was able to secure paid sick leave—a benefit they’d never had before—for home health workers who contract COVID-19. She hopes the union can secure even more improvements, such as a higher minimum wage and sick-leave benefits that will remain after the pandemic subsides.
All 25,000 of Rob Baril’s union members are currently negotiating new contracts. Long-term-care workers are fighting for a base wage of $20 an hour, good health insurance, and retirement benefits. “I’ve never seen our membership so angry. They just feel that they’ve been violated,” he said.
Others have less fight in them. Hughes’s union contract is up this year, and normally she’d be trying to get her co-workers energized to fight for better pay. This year she’s preparing them to “beg,” she said—not with bosses, but with lawmakers. Workers are planning a rare team-up with management to plead with the Washington State legislature to devote more funding to long-term care. In past contracts, the union has won guaranteed raises and increased sick and vacation time from management. This year Hughes will be relieved if the company doesn’t try to claw any of that back.
Only recently have health-care workers had a glimpse of a different future. When I spoke with Bartie Scott in March 2020, her greatest fear was bringing the virus home to her 75-year-old ex-smoker husband. But on Christmas Eve she got a call saying that if she could get to the health department within an hour, she could get her first vaccine dose. “Boom, I was out of there in my dirty clothes,” she said. When I spoke with her more recently, she had received both shots and her husband had gotten one. “We made it,” she said.
They’re lucky. According to The Guardian and Kaiser Health News, at least 3,600 U.S. health-care workers have died of COVID-19. After Hughes got her first vaccine shot, in February, she sat in her car and cried. “It was relief,” she explained. But it was also “sadness for the people that are already gone and didn’t get a chance to get it.”