Soon after the COVID-19 pandemic began last spring, Christine Choi, DO, a second-year medical resident at Harbor-UCLA Medical Center, volunteered to enter COVID-19 patient rooms. Since then, she has worked countless nights in the intensive care unit in full protective gear, often tasked with giving the sickest patients and their families the grim choice between intubation or near-certain death.
“I’m offering this guy two terrible options, and that’s how I feel about work: I can’t fix this for you and it sucks, and I’m sorry that the choices I’m giving you are both terrible,” Choi told the Los Angeles Times’ Soumya Karlamangla about one patient encounter.
While Choi exhibits an “almost startlingly positive attitude” in her work, it’s no match for the psychological burdens placed on her shoulders by the global pandemic, Karlamangla wrote. When an older female COVID-19 patient died in the hospital recently, her husband — in the same hospital with the same diagnosis — soon began struggling to breathe. Sensing that he had little time left, Choi held a mobile phone at his bedside so that each of his children could come on screen to tell him they loved him. “I was just bawling in my [personal protective equipment],” Choi said. “The sound of the family members crying — I probably will never forget that,” she said.
It was not the first time the young doctor helped family members say goodbye to a loved one, and it would not be the last. Health care providers like Choi have had to work through unimaginable tragedies and unprecedented circumstances because of COVID-19, with little time to dedicate to their own mental health or well-being.
It has been nearly a year since the US reported what was believed at the time to be its first coronavirus death in Washington State. Since then, the pandemic death toll has mushroomed to nearly 500,000 nationwide, including 49,000 Californians. These numbers are shocking, and yet they do not capture the immeasurable emotional weight that falls on the health care providers with the most intimate view of COVID-19’s deadly progression.“The horror of the pandemic has unfolded largely outside public view and inside hospitals, piling a disproportionate share of the trauma on the people whose work takes them inside their walls,” Karlamangla wrote.
Experts are deeply concerned about the psychological and physical burdens that providers must bear, and the fact that there is still no end in sight. “At least with a natural disaster, it happens, people get scattered all over the place, property gets damaged or flooded, but then we begin to rebuild,” Lawrence Palinkas, PhD, MA, a medical anthropologist at USC, told Karlamangla. “We’re not there yet, and we don’t know when that will actually occur.”
Sixty-eight percent of providers said they feel emotionally drained from their work, 59% feel burned out, 57% feel overworked, and 50% feel frustrated. The poll asked providers who say they feel burned out what contributes most to that viewpoint. One doctor from the Central Valley wrote:
“Short staffed due to people out with COVID. I’m seeing three times as many patients, with no time to chart or catch up. Little appreciation or contact from my bosses. I have never had an N95 [mask]. The emotional toll this pandemic is taking. Being sick myself and spreading it to my wife and young kids. Still not fully recovered but needing to be at work due to physician shortages. Lack of professional growth, and a sense of lack of appreciation at work and feeling overworked. The sadness of the COVID-related deaths and the stories that go along with the disease. That’s a lot of stuff to unpack.”
For one female doctor from the Bay Area who responded to the CHCF survey, the extra burdens of the pandemic have been unrelenting: “Having to work more, lack of safe, affordable, available childcare while I’m working. As a single mother, working 15 hours straight, then having to care for my daughter when I get home. Just exhausted with no days off. So many Zoom meetings all day long. Miss my family and friends.”
It is unclear how the pandemic will affect the health care workforce in the long term. For now, the damage “can be measured in part by a surge of early retirements and the desperation of community hospitals struggling to hire enough workers to keep their emergency rooms running,” Andrew Jacobs reported in the New York Times.
One of the early retirements Jacobs cited was Sheetal Khedkar Rao, MD, a 42-year-old internist in suburban Chicago. Last October, she decided to stop practicing medicineafter “the emotional burden and moral injury became too much to bear,” she said. Two of the main factors driving her decision were a 30% pay cut to compensate for the decline in revenue from primary care visits and the need to spend more time at home after her two preteen children switched to remote learning.
“Everyone says doctors are heroes and they put us on a pedestal, but we also have kids and aging parents to worry about,” Rao said.
Working Through Unremitting Sickness and Death
In addition to the psychological burden, health care providers must cope with a harsh physical toll. People of color account for most COVID-19 cases and deaths among health care workers, according to a KFF issue brief. Some studies show that health care workers of color “are more likely to report reuse of or inadequate access to [personal protective equipment] and to work in clinical settings with greater exposure to patients with COVID-19.”
“Lost on the Frontline” provides the most comprehensive picture available of health care worker deaths, because the US still lacks a uniform system to collect COVID-19 morbidity and mortality data among health care workers. A year into the project, the federal government has decided to take action. Officials at the US Department of Health and Human Services cited the project when asking the National Academies of Sciences, Engineering, and Medicine for a rapid expert consultation to understand the causes of deaths among health care workers during the pandemic.
The National Academies’ report, published December 10, recommends the “adoption and use of a uniform national framework for collecting, recording, and reporting mortality and morbidity data” along with the development of national reporting standards for a core set of morbidity impacts, including mental well-being and psychological effects related to working through public health crises. Some health care experts said the data gathering could be modeled on the federal government’s World Trade Center Health Program, which provides no-cost medical monitoring and treatment for workers who responded to the 9/11 terrorist attacks 20 years ago.
“We have a great obligation to people who put their lives on the line for the nation,” Victor J. Dzau, MD, president of the National Academy of Medicine, told Jacobs.
Dressed in blue scrubs and carrying a stethoscope around her neck, an oncology nurse in Salem, Ore., looked to the Grinch as inspiration while suggesting that she ignored coronavirus guidelines outside of work.
In a TikTok video posted Friday, she lip-dubbed a scene from “How the Grinch Stole Christmas” to get her point across to her unaware colleagues: She does not wear a mask in public when she’s not working at Salem Hospital.
“When my co-workers find out I still travel, don’t wear a mask when I’m out and let my kids have play dates,” the nurse wrote in a caption accompanying the video, which has since been deleted.
Following swift online backlash from critics, her employer, Salem Health, announced Saturday that the nurse had been placed on administrative leave. In a statement, the hospital said the nurse, who has not been publicly identified by her employer, “displayed cavalier disregard for the seriousness of this pandemic and her indifference towards physical distancing and masking out of work.”
“We also want to assure you that this one careless statement does not reflect the position of Salem Health or the hardworking and dedicated caregivers who work here,” said the hospital, adding that an investigation is underway.
Salem Health did not respond to The Washington Post’s request for comment as of early Monday.
The nurse’s video offers a startling and rare glimpse of a front-line health-care worker blatantly playing down a virus that has killed at least 266,000 Americans. It also has been seen in some coronavirus patients, some on their deathbeds, who still refuse to believe the pandemic is real.
The incident comes at a time when Oregon has continued to see a spike in new coronavirus cases and virus-related hospitalizations. Just last week, the state’s daily reported deaths and hospitalizations rose by 33.3 and 24.2 percent respectively, according to The Post’s coronavirus tracker. At least 74,120 Oregonians have been infected with the virus since late February; 905 of them have died.
The clip posted to TikTok on Friday shows the nurse mocking the health guidelines while using audio from a scene in which the Grinch reveals his true identity to Cindy Lou Who.
Although the original video was removed, TikTok users have shared a “duet” video posted by another user critical of the nurse, which had more than 274,000 reactions as of early Monday.
Soon after she posted the clip, hundreds took to social media and the hospital’s Facebook page to report the nurse’s video and demand an official response from her employer. Some requested that the nurse be removed from her position and that her license be revoked.
Hospital officials told the Salem Statesman Journal that the investigation is aiming to figure out which other staff members and patients have come in contact with the nurse, who works in the oncology department.
But for some, the hospital’s apologies and actions were not enough.
“The video supplied should be evidence enough,” one Facebook user commented. “She needs to be FIRED. Not on PAID leave. As someone fighting cancer, I can only imagine how her patients feel after seeing this news.”
The hospital thanked those who alerted them of the incident, emphasizing that its staff, patients and visitors must adhere to the Centers for Disease Control and Prevention guidelines.
“These policies are strictly enforced among staff from the moment they leave their cars at work to the moment they start driving home,” hospital officials told the Statesman Journal.
On her day off not long ago, emergency room nurse Jane Sandoval sat with her husband and watched her favorite NFL team, the San Francisco 49ers. She’s off every other Sunday, and even during the coronavirus pandemic, this is something of a ritual. Jane and Carlos watch, cheer, yell — just one couple’s method of escape.
“It makes people feel normal,” she says.
For Sandoval, though, it has become more and more difficult to enjoy as the season — and the pandemic — wears on. Early in the season, the 49ers’ Kyle Shanahan was one of five coaches fined for violating the league’s requirement that all sideline personnel wear face coverings. Jane noticed, even as coronavirus cases surged again in California and across the United States, that Levi’s Stadium was considering admitting fans to watch games.
But the hardest thing to ignore, Sandoval says, is that when it comes to coronavirus testing, this is a nation of haves and have-nots.
Among the haves are professional and college athletes, in particular those who play football. From Nov. 8 to 14, the NFL administered 43,148 tests to 7,856 players, coaches and employees. Major college football programs supply dozens of tests each day, an attempt — futile as it has been — to maintain health and prevent schedule interruptions. Major League Soccer administered nearly 5,000 tests last week, and Major League Baseball conducted some 170,000 tests during its truncated season.
Sandoval, meanwhile, is a 58-year-old front-line worker who regularly treats patients either suspected or confirmed to have been infected by the coronavirus. In eight months, she has never been tested. She says her employer, California Pacific Medical Center, refuses to provide testing for its medical staff even after possible exposure.
Watching sports, then, no longer represents an escape from reality for Sandoval. Instead, she says, it’s a signal of what the nation prioritizes.
“There’s an endless supply in the sports world,” she says of coronavirus tests. “You’re throwing your arms up. I like sports as much as the next person. But the disparity between who gets tested and who doesn’t, it doesn’t make any sense.”
This month, registered nurses gathered in Los Angeles to protest the fact that UCLA’s athletic department conducted 1,248 tests in a single week while health-care workers at UCLA hospitals were denied testing. Last week National Nurses United, the country’s largest nursing union, released the results of a survey of more than 15,000 members. About two-thirds reported they had never been tested.
Since August, when NFL training camps opened, the nation’s most popular and powerful sports league — one that generates more than $15 billion in annual revenue — has conducted roughly 645,000 coronavirus tests.
“These athletes and teams have a stockpile of covid testing, enough to test them at will,” says Michelle Gutierrez Vo, another registered nurse and sports fan in California. “And it’s painful to watch. It seemed like nobody else mattered or their lives are more important than ours.”
Months into the pandemic, and with vaccines nearing distribution, testing in the United States remains something of a luxury. Testing sites are crowded, and some patients still report waiting days for results. Sandoval said nurses who suspect they’ve been exposed are expected to seek out a testing site on their own, at their expense, and take unpaid time while they wait for results — in effect choosing between their paycheck and their health and potentially that of others.
“The current [presidential] administration did not focus on tests and instead focused on the vaccine,” says Mara Aspinall, a professor of biomedical diagnostics at Arizona State University. “We should have focused with the same kind of ‘warp speed’ on testing. Would we still have needed a vaccine? Yes, but we would’ve saved more lives in that process and given more confidence to people to go to work.”
After a four-month shutdown amid the pandemic’s opening wave, professional sports returned in July. More than just a contest on television, it was, in a most unusual year, a symbol of comfort and routine. But as the sports calendar has advanced and dramatic adjustments have been made, it has become nearly impossible to ignore how different everything looks, sounds and feels.
Stadiums are empty, or mostly empty, while some sports have bubbles and others just pretend their spheres are impermeable. Coaches stand on the sideline with fogged-up face shields; rosters and schedules are constantly reshuffled. On Saturday, the college football game between Clemson and Florida State was called off three hours before kickoff. Dodger Stadium, home of the World Series champions, is a massive testing site, with lines of cars snaking across the parking lot.
Sports, in other words, aren’t a distraction from a polarized nation and its response to a global pandemic. They have become a constant reminder of them.And when some nurses turn to sports for an attempt at escape, instead it’s just one more image of who gets priority for tests and, often, who does not.
“There is a disconnect when you watch sports now. It’s not the same. Covid changed everything,” says Gutierrez Vo, who works for Kaiser Permanente in Fremont, Calif. “I try not to think about it.”
Sandoval tries the same, telling herself that watching a game is among the few things that make it feel like February again. Back then, the coronavirus was a distant threat and the 49ers were in the Super Bowl.
That night, Sandoval had a shift in the ER, and between patients, she would duck into the break room or huddle next to a colleague checking the score on the phone. The 49ers were playing the Kansas City Chiefs, and Sandoval would recall that her favorite team blowing a double-digit lead represented the mightiest stress that day.
Now during shifts, Sandoval sometimes argues with patients who insist the virus that has infected them is a media-driven hoax. She masks up and wears a face shield even if a patient hasn’t been confirmed with the coronavirus, though she can’t help second-guessing herself.
“Did I wash my hands? Did I touch my glasses? Was I extra careful?” she says.
If Sandoval suspects she has been exposed, she says, she doesn’t bother requesting a test. She says the hospital will say there aren’t enough. So instead she self-monitors and loads up on vitamin C and zinc, hoping the tickle in her throat disappears. If symptoms persist, which she says hasn’t happened yet, she plans to locate a testing site on her own. But that would mean taking unpaid time, paying for costs out of pocket and staying home — and forfeiting a paycheck — until results arrive.
National Nurses United says some of its members are being told to report to work anyway as they wait for results that can take three to five days. Sutter Health, the hospital system that oversees California Pacific Medical Center, said in a statement to The Washington Post that it offers tests to employees whose exposure is deemed high-risk and to any employee experiencing symptoms. Symptomatic employees are placed on paid leave while awaiting test results, according to the statement.
“As long as an essential healthcare worker is asymptomatic,” Sutter’s statement read, “they can continue to work and self-monitor while awaiting the test result.”
Sandoval said employees have been told the hospital’s employee health division will contact anyone who has been exposed. Though she believes she’s exposed during every shift, Sandoval says employee health has never contacted her to offer a test or conduct contact tracing.
“If you feel like you need to get tested, you do that on your own,” she says. Sandoval suspects the imbalance is economic. In September, Forbes reported NFL team revenue was up 7 percent despite the pandemic. Last week Sutter Health reported a $607 million loss through the first nine months of 2020.
Sandoval tries to avoid thinking about that, so she keeps heading back to work and hoping for the best. Though she says her passion for sports is less intense now, she nonetheless likes to talk sports when a patient wears a team logo. She asks about a star player or a recent game. She says she is looking forward to the 49ers’ next contest and the 2021 baseball season.
Sometimes, Sandoval says, patients ask about her job and the ways she avoids contracting the coronavirus. She must be tested most every day, Sandoval says the patients always say.
And she just rolls her eyes and chuckles. That, she says, only happens if you’re an athlete.
The pandemic put nurses on the front lines of the battle against COVID-19 and caused shifts in the way they provide care.
During this year, nurses have adapted to increased adoption of telehealth and virtual patient monitoring, as well as constantly evolving staffing needs.
These factors — and others, such as the physical and emotional conditions nurses have faced due to the public health crisis — are sure to affect nursing in the years to come. Here, 10 healthcare executives and leaders share their predictions for nursing in the next five years.
Editor’s note: Responses were edited lightly for length and clarity.
Beverly Bokovitz, DNP, RN. Vice President and Chief Nurse Executive of UC Health (Cincinnati): In the next five years, as we continue to encounter a national nursing shortage, I expect to see additional innovative strategies to complement the care provided at the bedside.
One of these strategies will be some type of robot-assisted care. From delivery of medications to answering call lights — and completing simple tasks like needing a blanket or requesting that the heat be adjusted — we will see more electronic solutions. These solutions will allow for a better patient experience and help to exceed the expectations of our patients as customers.
Of course, nothing can take the place of skilled and compassionate bedside care, but many tasks could be automated — and will be — to supplement the professional nursing shortage.
Natalia Cineas, DNP, RN. Senior Vice President and Chief Nurse Executive of NYC Health + Hospitals (New York City): Nurses will continue to play a vital role in addressing the health inequities and social determinants of health among vulnerable populations as the nursing workforce itself becomes more diverse and inclusive. As the largest segment of the healthcare workforce — with some 4 million nurses active in the U.S. — nurses represent the faces of the communities in which they serve. As America becomes a more diverse and inclusive society, so too will the nursing profession become more diverse and inclusive. Currently, industry estimates indicate that between one quarter to one-third of all U.S. nurses identify as a member of a minority group, with between 19 percent and 24 percent of U.S. nurses identifying themselves as Black/African-American; 5 percent to 9 percent identifying themselves as Hispanic; and about 3 percent identifying themselves as Asian. The percentage of minority nurses has been rising steadily for the past two decades and is expected to continue to climb in the coming years.
Blacks and underserved minority populations face numerous genetic, environmental, cultural and socioeconomic factors that account for health disparities, and the impact is particularly visible in the areas of cardiovascular disease, diabetes, pregnancy and childbirth mortality, and cancer outcomes, as well as the enormous toll of the current novel coronavirus global pandemic, where communities of color have been among the hardest hit populations.
In New York City alone, statistics compiled by the city’s health department show Blacks and Hispanics together account for 65 percent of all COVID-19 cases; represented 70 percent of all hospitalizations due to COVID-19; and, sadly, 68 percent of all deaths caused by COVID-19. As demonstrated during this pandemic, in the future, technology such as telehealth and virtual patient monitoring will play a major role in the care of patients. There will be a vast need to address social determinants of health by educating and providing resources to allow utilization of this technology such as using “wearable tech” to monitor ongoing health issues, such as high blood pressure, diabetes, heart conditions and other chronic illnesses.
Ryannon Frederick, MSN, RN. Chief Nursing Officer of Mayo Clinic (Rochester, Minn.):Nursing research will experience extraordinary demand and growth driven by a realization that both complex and unmet patient needs can often be best served by the role of a professional registered nurse. Nurses are uniquely positioned to implement symptom and self-management interventions for patients and their caregivers. Significant disruption in healthcare, including increasing use of technology, will lead to a dramatic shift to understand the role of the RN in improving patient outcomes and implementing interventions using novel approaches. Nursing researchers will provide a scientific body of evidence proving equivalent, if not better, patient care outcomes that can be obtained at a lower cost than traditional models, leading to an even greater demand for the role of the professional nurse in patient care.
Karen Higdon, DNP, RN, Vice President and Chief Nursing Officer of Baptist Health Louisville (Ky.):The value of nursing has never been more apparent. Nurses have led the front line during this pandemic. In the next five years, we must be flexible and creative in establishing new models of care, specifically around roles that support nursing, such as assistant and tech roles. Creating roles with clear role definition, that are attractive and meaningful for nursing support will help build consistent, high-quality models for nursing to lead. This consistency, along with IT capabilities that enhance workflow, will better allow nurses to work at the top of their scope.
Karen Hill, DNP, RN. COO and Chief Nursing Officer of Baptist Health Lexington (Ky.): 2020 was declared the “Year of the Nurse” and this reality has never been more true than realizing the personal and professional sacrifices of nurses in dealing with issues surrounding the pandemic. The next five years will require nursing professionals to be flexible to address new, unknown emerging issues in all settings, to be open to new opportunities for leadership in hospitals, schools and communities and to use technology and telehealth to provide safer care to patients. Nurses need to evaluate our practices and traditions that are value-added and leave behind the task orientation of the past. We need to honor our legacy and create our path.
Therese Hudson-Jinks, MSN, RN. Chief Nursing Officer and Chief Patient Experience Officer at Tufts Medical Center and Tufts Children’s Hospital (Boston):Over the next five years, I expect that the support and retention of clinical nurses will become the top priority of every CNO and executive team, given nurses’ direct impact on supporting the business of healthcare. This will be particularly critical because there will be a concerning shortage of experienced clinical nurses as a result of advancing technologies increasing complexity in care, additional nurse roles created outside traditional areas, fierce competition for talent between large healthcare systems, aging baby boom workforce retiring at higher rates year over year, and a lack of sufficient numbers of PhD-prepared nurses working in academia and supporting higher enrollments.
I also believe that CNOs will be laser-focused on creating the practice environment that enhances retention of top, talented clinical nurses, and we will put a greater emphasis on the influence of effective nursing leadership in reaching that goal. In addition, I fully expect that nurses will be seen more as individuals with talents and experience than ever before — not just a number on a team, but rather a professional with specific, unique, talents that are highly sought after in competitive markets.
Finally, I anticipate that nursing innovation will blossom, given the exposure of the “innovation/solutionist superpower” within nurses during the pandemic. Philanthropy will grow exponentially in support of nursing innovation as a result.
Carol Koeppel-Olsen, MSN, RN. Vice President of Patient Care Services at Abbott Northwestern Hospital (Minneapolis): During the COVID-19 pandemic nurses have been working in difficult physical and emotional conditions, which may lead to significant turnover after the pandemic resolves. Nurses have a commitment to serving others and will persevere until the crisis is past; however, when conditions improve, many nurses may decide to pursue careers outside acute care settings. A possible turnover, coupled with a service economy that has been devastated, may result in large numbers of former service workers seeking stable jobs in nursing. Hospitals will have to be nimble and creative to onboard an influx of new nurses that are not only new to the profession but new to healthcare. Tactics to onboard these new nurses may include the use of retired RNs as mentors, instructor-model clinical groups in the work setting, job shadowing and aptitude testing to determine the best clinical fit.
Jacalyn Liebowitz, DNP, RN. Senior Vice President and System Chief Nurse Officer of Adventist Health (Roseville, Calif.): Over the next five years, I see nurses providing more hospital-based care in the home using remote technology. Based on that shift, we will see lower-acuity patients move into home-based care, and higher-acuity care in hospitals will increase. With that, hospital beds will be used at a different level. My bold prediction is that we will not need as many beds, but we will need higher acute care in the hospitals.
Nurses will learn differently. As we are seeing now, nurses have not been able to train in the traditional way. They are already using more remote technology to educate, onboard and orient to their roles. It looks and feels vastly different, and nurses need to be comfortable with that.
As for patient care, I think data that can be gleaned from wearable biometrics, and the use of artificial intelligence will help predict patient care on a patient-by-patient basis. Nurses will work with AI as part of their thought process, instead of completely focusing on their own judgment and assessment.
I also believe we are going to face a nursing shortage post-COVID for a few reasons. Due to the emotional and physical toll of responding to a pandemic, some nurses will decide to retire, and another group will leave based on the risks that go hand-in-hand with the profession.
As for patient care, we are going to collaborate differently. There will be more video conferencing regarding collaboration around the patient. And I think in the future we will see that the full continuum of care will include a wellness plan.
Debi Pasley, MSN, RN. Senior Vice President Chief Nursing Officer of Christus Health (Irving, Texas):I believe the demand for nurses will become increasingly visible and newsworthy throughout the pandemic. This could drive increases in salaries and numbers of qualified candidates seeking nursing as a profession in the medium and long term. The shortage will, however, continue to be a factor, leading to more remote work options to both supplement nursing at the bedside and substitute for in-person care.
Denise Ray, RN.Chief Nursing Executive of Piedmont Healthcare (Atlanta): Nursing schools will need to focus on emergency management and critical care training utilizing a team nursing model. While nursing has become very specialty-driven, the pandemic has demonstrated gaps in our ability to adapt as quickly utilizing a team model where nurses lead and direct care teams. By implementing a team model and enhancing education in the areas of emergency management and critical care, nursing can adapt quickly to the ever-changing environment.
Also, communication with patients and families will take on different dimensions with wider use of tele-therapeutic communication. Nurses will be leaders and liaisons in the process, connecting physicians, patients and patient families virtually.Nurses will play a key role in integrating patient family members as true patient care partners— making sure they have the information they need to serve an active caregiving role for their family members during and after hospitalization. We’ll also see more nurses becoming advanced nurse practitioners, playing an expanded role in all healthcare settings.