Amy, an ICU nurse, is considered a veteran in her busy hospital in Athens, Ga. As older nurses have hemorrhaged from the unit during the pandemic, less experienced nurses often look to her for guidance on things like how to fix a monitor, manage a drug dosage, locate extra supplies, or decipher a doctor’s handwriting. Though this informal leadership can be a heavy burden as the unit grapples with ventilated COVID-19 patients, it doesn’t come with a title or pay boost.
Amy is just a few years out of nursing school herself. She’s doing the best she can, she says, but after operating at near constant-crisis for two years now, her limited experience can only go so far.
“It’s babies teaching babies. With five years, I’m one of the most experienced staff,” said Amy, who asked to be identified by a pseudonym and the hospital where she works not be named for fear of retaliation from management, which she says has happened when other staff spoke to journalists. “Every shift, we’re just barely making it.”
What Amy is managing in her ICU during the pandemic has been daunting to seasoned nurses with two or three times her experience: overwhelming patient loads caused by spiking virus case rates, shifting protocols, thin staffing, and widespread burnout, exacerbated in some pockets in the South stemming from vaccination resistance. “We are missing care points that used to be a standard, but that we haven’t been able to do because we don’t have the staff to pay attention to that,” Amy says.
Many of the more experienced nurses have left their jobs, if not the profession altogether. As the Omicron hospitalization surge has crushed hospitals across the country, in Athens — which serves as a medical hub for 17 surrounding rural counties — her hospital has had periods of being too full to accept new patients. Not because there aren’t enough beds per se, but because there aren’t enough nurses to staff them.
Amy’s reality is supported by new data. Since the pandemic began in spring 2020, unemployment has soared for nursing positions — in part because of early-pandemic layoffs, but mostly due to nurse resignations. Even before the pressures of record-breaking hospitalizations, the nursing industry was already facing high rates of burnout that disproportionately impacted female healthcare workers.
Over the last two years the number of registered nurses nationwide dropped by 100,000. For licensed practical nurses and nursing assistants, the decreases were 25,000 and 90,000, respectively. People of color left the field at disproportionately high rates.
The South has been hit particularly hard. Mississippi lost 2,000 nurses in 2021; hospitals in Tennessee had 1,000 fewer staff compared to the beginning of the pandemic; Texas recruited 2,500 nurses from outside the state, though it wasn’t enough to meet demand; and, Louisiana had over 6,000 unfilled nursing positions open before the Delta variant caused a surge in cases, just as Hurricane Ida was hurtling toward the state and displacing hundreds of healthcare workers last September, according to data from the American Nurses Association.
The problem has only gotten worse as the Omicron variant has pushed COVID-19 hospitalizations to record highs across the country, which have just recently begun receding in some parts of the South but are still hitting daily records in others. (notes: are only expected to get worse in the South.)
There was already a nationwide nurse shortage. Compounded by the pandemic, the effects of that shortage are magnified in the South, by factors including disproportionately high rates of chronic illness, persistent poverty, low-wage jobs, and statehouse-driven health policy decisions.
Amy says the result is a team of younger, inexperienced staff who are already at risk of burnout themselves while their compassion fatigue takes over as shifts become Groundhog Days of death and hopelessness. And worst of all, she says, it’s preventable. At her ICU and across the nation, almost all of the sick and dying COVID patients are unvaccinated.
Sicker patients — both unvaccinated patients with COVID, and those who delayed care during the pandemic and now need a higher level of care — have filled ERs for too long, overflowing into hallways and ambulance bays, spilling into all aspects of health care.
“I know exactly what I'm walking into every day – a COVID-land with no support,” Amy said. Pre-COVID, her ICU shifts were challenging, but there was always hope. After nearly two pandemic years, the energy from innovative treatments and the adrenaline of racing toward a cure is gone. “I know exactly what's going to happen. All of them are going to be intubated, vented for weeks, and some will die long deaths,” she said. “It’s become monotonous and taken out a lot of the joy.”
Every one of the dozen nurses The Fuller Project and Reckon interviewed for this story pointed to ongoing hospital pain points that, though present before the pandemic, have been exacerbated by month after month of constant crisis.
There are simply too few nurses to care for the surging need. “We’re sprinting every day,” Amy said, “And you just can't maintain that.”
“No raises, bonuses, or hazard pay”
On top of the mental strain, the stubbornly low wages many receive feel like “a slap in the face,” says Brittany*, who recently left her position in Mississippi for a higher-paying traveling agency position. (She asked to be identified by a pseudonym for fear of retaliation when she returns to her home hospital in Jackson.)
Nurse pay has remained relatively flat for the last decade, and only ticked up slightly during the pandemic, according to recent Health Affairs research, but least so in the South where care has always demanded more. Mississippi staff are paid among the lowest in the country — with a $28.67 average hourly wage (behind only South Dakota, at $28.73) — about $10 hourly shy of the national average.
“The hospital won’t give us raises, bonuses, or COVID (hazard) pay,” said Brittany, who is currently working in Louisiana through the agency. “And then you have a neighboring state who’s offering $126 an hour and a $1,000 stipend to pay for housing during the week, versus your $30 job at home.”
Amid these pay gaps, expressions of gratitude, she said, have started to ring hollow. “I don't care about the healthcare hero signs anymore because the hospitals have shown that they don't care about us,” she said. “If you really think that we are the heroes that you say we are and we are a vital part of the healthcare community, then pay us what we’re worth,” she said.
Instead of higher pay, the new COVID wave has been met with fewer staff, who are asked to do more under constant crisis conditions and peak hospitalizations.
The underlying causes of financial stress in the hospital system predate the pandemic. For one thing, Mississippi has among the highest rates of uninsured people in the nation — four of the five states with the lowest levels of insured people are in the South. People without insurance are more likely to seek care in emergency departments because they lack other options.
For another, over the past 10 years, Southern states have seen the most hospital closures — in part due to decades of providing uncompensated care — so staff see a tighter, sicker squeeze on resources. Across the country the Southern states, Texas, Tennessee, and Georgia lost the most hospitals.
Mississippi is not far behind. Because its hospitals are so taxed, Mississippi in early January entered crisis standards of care — an emergency intervention tool employed by the state health department to spread the burden across hospitals by revolving new ICU patients to different facilities around the state. It’s meant to be short-term, but is still in place a month later. Mississippi has among the lowest vaccination rates, stalled at 50%, and has seen the highest death rate across the pandemic.
Hospital administrators and public health advocates in this region have long said they need federal and state financial help to prop up their hospitals and health systems. Expanding Medicaid allows people with low incomes to sign up for federal health insurance, and research shows it helps hospitals stay open because they’re reimbursed for care that would otherwise be given for free. Studies also show having more people insured not only saves states money, but also saves lives by expanding access to preventive care, like cancer screenings, and helps people get acute care faster when it’s needed. Of the 12 states that have not expanded, almost all are in the South.
Capacity a misnomer for staffing
Meanwhile, most Southern state policymakers have done little to address the issues.
Quite the contrary: Legislatures, particularly in the South, have slashed public health budgets, and with it staffing, over the last decade. Due to state budget cuts, local health department spending has plummeted by almost 20% since 2010 and staffing dropped at the state and local level by nearly 40,000 jobs.
Despite generally having higher need — more poverty, chronic illness and uninsured folks — cuts have been deepest in the South. Louisiana’s health agency spends the least per capita: $32 per person; at $37, Tennessee isn’t far behind. Delaware spends the most per person, along with other Northeastern states, at $263.
These spending cuts have exacerbated nursing shortages, not just piling more responsibilities on those who have stayed, but also compromising care, nurses say.
No federal law regulates the number of patients a nurse can be responsible for at any given time, known as nurse ratios. Standards vary by unit and patient need, but American Nurses Association standards of care and research recommend that each nurse be responsible for one patient in an ER setting, two in an ICU setting — though research shows that COVID patients necessitate one patient per nurse, and at most, five in a rehabilitation setting.
Texas is the only Southern state to address nursing ratios by law, mandating hospitals have committees to standardize staffing ratios. (California is the only state nationwide to require a minimum nurse ratio on every unit.)
In Mississippi, Brittany points out that the growing ratios are dangerous for nurses and diminish patient care. “In some cases the hospital tries to present it to you as about patient care — ‘it's for the best’,” she said. “But is it really for the best if I’m supposed to have a 1:2 patient ratio and you have a third patient on a vent? Are they really getting the care?”
Brittany says messaging that hospitals are short on available beds clouds the reality. “The hospitals are not running out of beds, they're running out of nurses,” she said. “You can transport patients all day long and put them in rooms all day long, but if you don't have a nurse to carry out doctors’ orders, what good is a bed going to do for a patient?”
In early January, South Carolina hospitals experienced some of the worst shortages in the nation, with 36% of facilities reporting “critical staffing shortages” — a term not defined federally, but left up to internal policy and facility needs. In 2018 South Carolina already had the fewest nurses per capita, at 7.9 per 1,000 residents, one of just four states to have a ratio lower than 10 per 1,000, including Texas.
In North Carolina, where the nurse ratio is slightly better than the U.S. average at 12 nurses per 1,000 residents, an interactive tool is being used to model current and future nurse shortages across the state. Emily McCartha, a researcher at University of North Carolina’s Sheps Center for Health Services Research, who helped develop the tool, says the data will start pointing toward policy solutions. “We will also have to work on retention of current staff and potentially coaxing folks that have exited the field to return,” she said.
‘Without nurses there is no health or healthcare’
In the meantime, many nurses in the South say they just want to be heard and their plight recognized. But even that can be elusive.
Last September, Ernest Grant, president of the American Nurses Association and a North Carolina-based nurse by trade, sent the country’s top health official an urgent letter asking for the national nursing shortage to be declared a public health crisis — and for funding to be allocated to help.
In the letter, Grant told U.S. Department of Health and Human Services Secretary Xavier Becerra, “ANA is deeply concerned that this severe shortage of nurses, especially in areas experiencing high numbers of COVID-19 cases, will have long-term repercussions for the profession, the entire health care delivery system, and ultimately, on the health of the nation.”
“Without nurses there is no health or healthcare. We are the backbone,” Grant said in an interview with The Fuller Project and Reckon. “But as we continue to drive more and more away, that care system is going to implode on itself if it hasn't already in some places that are implementing crisis care standards.”
In his letter to Becerra, Grant pointed out that Southern states have among the worst nursing shortages.
Grant says Becerra has yet to respond. At publication time, HHS had not replied to queries about it from The Fuller Project and Reckon.
Meanwhile, young nurses like Amy, the ICU nurse in Georgia, feel stuck. With $100,000 in nursing school debt, leaving the field and returning to bartending, which she did before becoming a nurse, isn’t feasible. For now, she’s resigned to cope with what comes her way in the ICU.
“This doesn't have to be this way. And this isn't a situation we’ve electively signed up for. I’m not a martyr, I don’t want to be a martyr,” she said. “I also think it got the hospital out of (accountability) when we would be complaining and they were like, ‘But look at all the community support you have and look at all the little thank you, nurses notes from first graders.’ It’s not a solution.”