National Nurses United (NNU), staged a protest in front of the White House on Thursday, May 7, 2020. Area nurses stood among 88 pairs of white shoes, representing the number of nurses known to have died by that date of COVID-19, according to the union.
In an ideal world, C., would only have one patient during a 12-hour shift as a labor and delivery nurse at Medstar Washington Hospital Center — but these days, that's almost never the case.
Especially when she's assigned a patient in active labor or with an acute condition, she says it's safest for everyone if she can direct all of her attention on one person. But C., who is a recent nursing school graduate and is using only her first initial to protect her employment, says she may have up to four patients in her care on any given shift.
"If you have one nurse and you're responsible for two patients, sometimes three, what does that mean to the patients' care? What does that mean to the baby? How are you doing interventions?" C asks. "It's impossible, basically, to make sure that they're getting the quality care and that they're feeling seen."
Similar situations are playing out in hospitals across the region as the D.C.-area confronts a nursing shortage. This nationwide issue predates the pandemic but has been exacerbated by COVID-19's emotional and physical toll on healthcare workers. Nurses are burnt out after working through the past three years, often without adequate pay or pandemic safety protections, causing many experienced nurses to leave their bedside roles for positions with more flexible hours, or leave the profession entirely. Moreover, those vacancies aren't getting filled, which nurses say is putting both staff and patients at risk.
"The older nurses, they're tired. They've been basically looked over and they've been screaming [since] before the pandemic, 'we were already stretched thin," C. says. "So then you add this catastrophe on top of that – they don't feel supported, and so they're leaving."
The D.C. Nurses Association, a union representing nurses in the D.C. area, conducted a survey of its members this summer and found that inadequate staffing was a major issue for more than 95% of those surveyed. Respondents worked at hospitals across the District, including United Medical Center, Children's National Hospital, and Howard University Hospital and 80% said that they work more than one shift a week with insufficient staffing on their unit.
"We don't call it a nursing shortage, we call it a shortage of nurses who are willing to work in these kinds of conditions," says Edward Smith, the executive director of the D.C. Nurses Association.
Numerous studies have found that lower patient-nurse ratios lead to higher survival rates and better outcomes. In a 2018 study of in-hospital cardiac arrest at more than 75 hospitals in Pennsylvania, New Jersey, Florida, and California, the odds of survival were five percent lower for each additional patient per nurse on medical-surgical units.
There is no one standard practice or set of guidelines for nurse-patient ratios in the U.S, despite it being one of the most crucial aspects of ensuring patient safety. In most states, these ratios are determined by the hospital or hospital associations (organizations that represent the interests of hospitals in a region), but exist more as recommendations than rules. California is the only state in the U.S. with a law on the books, which mandates that the highest number of patients a nurse can be assigned in departments like medical/surgical, psychiatric, and postpartum is six. Other types of care, like emergency room traumas, intensive care, and labor and delivery requires a maximum of two patients for every nurse.
This lack of regulations, according to many nurses, has fallen on their shoulders.
"At least once a day, we're understaffed," says Richie Alexander, who has worked at Washington Hospital Center's ortho-trauma floor for six years. Alexander says they regularly have to take care of five patients at a time even though it really shouldn't be more than four. "[This] makes it difficult to do standard care as well as a holistic approach to patient care. Instead of being able to spend time with our patients, learning about the whole patient, we just look at the clinical picture which is unfortunate, because there's more to it than just why the patient is there."
According to Alexander, an appropriate amount of nurses per shift would mean that each nurse could spend around 15 minutes each hour with a patient. When the floor is short-staffed, however, that time can drop to ten minutes which "just doesn't give patients enough time with their nurses."
Staffing shortages can have life-threatening consequences, especially in emergency situations. One 2018 study found that when nurses in trauma centers cared for three additional patients in 24 hours, the time for diagnostic evaluation doubled, from approximately half an hour to one hour. In emergency situations, this kind of delay can be a matter of life and death.
Chris Riley, a D.C. resident, experienced this first-hand when horrible stomach pains sent him to the emergency room at Sibley Memorial Hospital earlier this month.
What started as nausea in the middle of the night turned into "excruciating" pain on his right side around 8:30 a.m. Certain that something was seriously wrong, Riley arrived at the ER around 9 a.m. For hours, he sat as staff members walked around the waiting room, apologizing to those waiting for the delay. Around 1:30 p.m. he was finally admitted to a room. By 5:00 p.m., he was receiving an emergency appendectomy.
"The surgeon came and saw me the next morning, and he said the surgery went really well but the condition of my appendix, at the point when they took it out, was in an extremely bad state," Riley says. "He said that I was very lucky that they got it out when they did, because it was getting very close to bursting."
Though he's unable to say for certain, Riley suspected the extraordinary delays were because "they just did not have the staffing for the amount of people needing care."
Beyond its impact on patient-care, short staffing can also create unsafe environments for nurses themselves.
Samantha, a nurse at Comprehensive Psychiatric Emergency Program (CPEP), an acute psychiatric facility run by D.C.'s Behavioral Health department, says that over the past two years, they've lost around seven nurses and two supervisors – a significant percentage of staff at a small facility with just 16 beds (a reduction due to the pandemic). With only two nurses on staff at a time, that means Samantha is sometimes responsible for up to eight patients at a time – often while they're undergoing an acute mental health crisis. (CPEP also has mental health counselors and other psychiatric staff on-site.)
"With insufficient staffing – it's dangerous, it's very dangerous. It could be anything from getting kicked, spat on, people taking feces and throwing it at you, people actually trying to beat you... it really gets very serious," Samantha says. "It's a labor of love, but it's getting really, really challenging. You have to think about your life and your health, and sometimes that's going to take precedence over your livelihood, unfortunately."
As her fellow nurses have left CPEP in the past few years, Samantha says those hired to fill the vacancies haven't lasted long either — she suspects because of the unsafe environment. Having worked as a nurse in various settings for 17 years, Samantha says some of the newer hires lack experience in psychiatric care. She says that in many cases, a fearful nurse can be more of a danger on a shift than having no nurse at all.
"They're not experienced in dealing with this type of patient population, and sometimes that can be dangerous," Samantha says. "Working with folks who don't have the experience and are fearful, it can almost be a liability more than an asset."
High turnover isn't just occurring in psychiatric care, but nearly all healthcare fields across the U.S. With more and more experienced nurses retiring (55% of registered nurses are over 50) younger nurses, who are more likely to move around and change jobs frequently, are left to fill the vacant positions.
But the nursing pipeline is shrinking in the younger generation — not because of a lack of interest in the profession but because there aren't enough faculty members willing to teach prospective nurses. According to the American Association of Colleges and Nursing, more than 90,000 qualified applications were declined in 2021 because there were simply not enough faculty members to staff classes and programs. Like the shortage of clinical nurses, the dearth of nursing faculty can be attributed to multiple overlapping factors: an aging faculty pool, less attractive salaries in academia versus clinical practice, and retirements among current faculty.
The boom in travel nursing during the pandemic has also contributed to the shortage of both clinical nurses and nurses to teach them. A blessing and a curse, travel nurses are brought in by an outside agency help a floor or unit stay above water when staffing is low. But they also tend to make more than the nurses employed by a hospital system, despite doing the same amount of work. While nursing pay varies significantly, by some estimates travel nurses earn on average about $88 an hour compared to registered nurses making an average of $39 per hour.
Alexander, who works at Washington Hospital Center, says it's a "vicious" cycle: without adequate staffing, conditions are unsafe but it's hard to attract new hires until things get safer.
"We're short-staffed, but we want to be safe," Alexander says. "And we can't do that unless we get more staff, but that staff doesn't want to work there."
A spokesperson for the DC Hospital Association, which oversees 13 local hospital systems in D.C., told DCist/WAMU in an email that the group is working with its members to retain existing nurses and attract new hires by reviewing current pay structures, and offering signing bonuses. The spokesperson didn't, however, offer any concrete steps that hospitals have already taken.
Aware of the severity of the staffing crisis among the city's healthcare workers, D.C. Mayor Muriel Bowser created a task force earlier this year. Led by local healthcare and government officials (including management of major hospitals), they've met a handful of times to address rebuilding and strengthening the city's healthcare workforce. Mark LeVota, the executive director of the D.C. Behavioral Health Association who sits on the task force, is working on recommendations regarding retention and recruitment that will be sent to Bowser in the coming weeks and, he hopes, implemented at the city's hospitals.
"People can't self care their way out of burnout, but they do need time for self care, they do need time to rest," says LeVota. "We're really going to have to have more conversations as an entire healthcare industry about how we help people rest, how we make sure that their shifts aren't too long, how we make sure that we're not asking people to do overtime too frequently, how we find other ways to make sure that the people just have the time that they need."
While DCNA has made gains in the past year for workers – this past April, the union reached a deal with Howard University Hospital for a contract that protects senior professionals' compensation – the demands of many local nurses are still not being met. Samantha, for her part, wants hazard pay for the risks she incurs by working as only one of two nurses for 16 patients at CPEP – but says her requests haven't gone anywhere. C. says that the hospital recently cut the rate for incentive bonuses, which are offered when a nurse picks up an extra shift, and that her complaints have also led nowhere.
"[Management's] response is, 'oh everybody's short,'" C says. "That's not a valid excuse. It goes back to, of course, the dollar – when you put profits over people, you end up in situations like this."