ST. LOUIS — In early 2020, COVID-19 patients began streaming into the Barnes-Jewish Hospital intensive care unit where Garrett Ambuehl worked.
Some of the normal support staff were pulled back to limit the risk of exposure, leaving Ambuehl and other nurses with more responsibilities, and less help. They cleaned patient rooms. They wore the same masks for weeks on end. They cared for patients who passed away without family present. And they began quitting.
“The tally just kept going up,†Ambuehl said. The quality of care, he said, started to dip.
Then he left, too.
The medical ICU on the eighth floor of the Central West End hospital was the first COVID ward at the busiest hospital in the state. And, over the course of the pandemic, as many as 90 of the unit’s 140 nurses and health care workers quit, transferred or otherwise left the unit, according to interviews with nurses and managers who worked there. Eventually, ICUs across the region faced the same relentless wave of patients, and the same demoralizing wave of employee departures.
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“This is the highest turnover that we have ever seen in nursing,†said Denise Murphy, the top nurse in the BJC HealthCare system, which owns Barnes-Jewish. “It’s not just a BJC or even a regional crisis, it’s a national crisis.â€
BJC officials estimated turnover in the ward closer to 75, said it was constantly rehiring, and that patient care remained “exceptional.†But they also acknowledged “high turnover in these high intensity environments.â€
“I had thousands of nurses across the health system every day, not just doing their jobs, but helping people die without their family,†Murphy said, choking up as she spoke. “This hurts, and I understand why they hurt. I do. And I understand why they’re angry and I understand why they’re leaving. I don’t want them to, but ... my God, I understand.â€
The pandemic hit ºüÀêÊÓƵ in March 2020. Within weeks, hospitals were caring for nearly 500 people sick with the virus. Hospitals rationed masks and gowns. And for two years, health care workers were hit by unrelenting waves of virus patients. The worst spikes came in the winters. And even when infections receded, the hospitals were still filled with the non-COVID patients whose care had been postponed.
As the crisis dragged on, health systems across the country began to struggle with staffing. Attrition has risen at all of the region’s major health systems, officials said.
Ondrea Williams, regional vice president of patient care services and chief nursing officer of SSM Health ºüÀêÊÓƵ, another of the region’s largest hospital systems, recalled speaking to a young nurse who worked in a COVID ICU. Over the course of a shift, a third of the patients in the 12-bed unit died. The nurse said she had chosen her career because she wanted to help people, and she’d understood that not everyone would survive, Williams remembered. But the scale of COVID-19 was beyond anything she could have expected.
“I would liken it to having like a mass casualty almost on a daily basis,†Williams said.
“Day after day after day.â€
A crisis hits
Barnes-Jewish, Murphy said, “really took the brunt of the pandemic.â€
The nurses interviewed for this story worked in a 34-bed medical ICU at Barnes-Jewish Hospital. The unit was technically two, divided by a small hallway, with 24 beds on one side, and 10 on the other.
Elsewhere on the campus, there are specialized ICUs dedicated to areas like neurology, surgical trauma or bone marrow transplants. This ICU was more generalized, treating patients with ailments from pneumonia to strokes to overdoses to kidney or liver problems.
In early 2020, it became Barnes-Jewish Hospital’s first dedicated COVID-19 unit.
The first wave of infections hit that spring. Staff quickly went from treating two COVID-19 patients to dozens.
Nurses worked entire shifts without eating or going to the bathroom. With housekeepers told not to enter COVID-19 patient rooms unless absolutely necessary, nurses even cleaned floors and wiped down counters. At the end of their shifts, some went to hotels, rather than their own homes, to reduce the risk of spreading the virus to their families.
“We didn’t know what this was,†said one former staff nurse in the ICU, who spoke on the condition of anonymity. “We didn’t know what it would do.â€
They spent longer stretches of time in patient rooms, when possible, to avoid having to change their personal protective equipment, which was running in short supply. When they needed something, they banged on the door to get the attention of a runner who could bring supplies.
Meanwhile, hospitals had canceled or delayed non-emergency “elective†procedures, and hospital revenue was dropping, fast.
All three of the region’s major health systems scrambled to cut costs, and all three furloughed workers: SSM furloughed about 5% of its workforce without pay for 13 weeks, citing a 50% decline in patient volumes. Mercy said it would temporarily layoff thousands and cut an undisclosed number of jobs. BJC furloughed some workers, cut pay by 10% for some managers and by 20% for executives, said Murphy, the chief nurse executive.
It was a terrible time, Murphy said. But BJC avoided layoffs, and was able to continue people’s health benefits while they were furloughed. Most returned to normal salaries within eight weeks, Murphy said.
“We did the best we could,†Murphy said.
One day in May of 2020, Melissa Cahill, a former assistant nurse manager, responsible for managing day-to-day operations and staffing in the ICU, received a letter notifying her that her salary would be cut 10%.
Cahill’s husband lost his job. He received a small severance package, she said, but the family had three kids, and needed to keep up with mortgage payments and other expenses. After work and on the weekends, Cahill started picking up shifts working for the grocery delivery service Instacart.
She didn’t feel supported or valued. She often received little or no warning about decisions coming down from leadership.
Cahill said she had every intention of spending the rest of her career at Barnes-Jewish. Instead, in November 2020, she left. She thinks that by that point in the pandemic, about 60 other nurses who worked in the unit had quit.
Cahill is now a manager in a 24-bed cardiac unit at a small, community hospital in Florida.
Unless health systems start doing more to retain nurses, patients will never get the quality of care they had before, Cahill said.
“I don’t think it is sustainable,†Cahill said. “The world of health care will never be the same.â€
‘A tough equation’
Like countless other hospitals across the country, as the pandemic progressed Barnes-Jewish began to lean more heavily on short-term nurses contracted through staffing agencies, often referred to as “travel nurses,†or “travelers.â€
Travel nurses typically work at hospitals on 13-week contracts. With health systems across the nation competing for the critical help, the hourly rates for travelers rose substantially. As a result, staff nurses were often working alongside travel nurses who made dramatically more money than them.
While Cahill was making $38 to $45 an hour at Barnes-Jewish Hospital, she said, agency nurses were making $140 to $150 an hour.
“We needed them, so we had to pay the asking price,†said another former assistant nurse manager, who spoke on the condition of anonymity. “I’m not complaining. … But it just seems like there’s no incentive for your core staff to stay.â€
National Nurses United, the largest nurses’ union in the U.S., that hospitals haven’t done enough to improve working conditions and adequately staff units. The union represents nurses at one local hospital: SSM Health ºüÀêÊÓƵ University Hospital.
“The challenge is the retention,†said Marchelle Vernell, a nurse who works in interventional radiology at ºüÀêÊÓƵ University Hospital, and serves as NNU’s chief nurse representative for the hospital.
Vernell said she believes that hospitals need to adequately staff units, listen more to nurses’ input, and do more to ensure nurses feel appreciated for their dedication.
“I don’t think we feel valued,†Vernell said.
But hospitals are now acting to keep nurses: SSM increased wages for frontline staff last year. The Mercy health system has added loyalty pay, said Senior Vice President and Chief Nursing Officer Betty Jo Rocchio. “With every great tragedy, there’s an opportunity to come out better on the other side,†Rocchio said. “Now’s the time to really listen to what they need.â€
And in March, BJC invested $50 million in raising nurse salaries across the system. The starting hourly rate for a nurse just out of school rose to $28 from $25.50, BJC said.
Plus, the health system is hiring more workers in roles that can support nurses, like patient care technicians, who perform less technical tasks, like taking vital signs or helping move patients, Murphy said. It is also using more virtual patient monitoring, so one technician can watch 10 patients electronically.
“I wish we could have given every one of our nurses triple what the agency was making. I wish we could have done that. That’s not sustainable for a health system or a hospital,†Murphy said. “It’s a tough equation.â€
People in the industry say the demand and prices for travel nurses are now beginning to decline.
Before COVID-19, a travel nurse’s hourly rate may have been $70 to $75, though it would vary depending on the position, said Dennis George, CEO of APS, an Overland Park, Kansas-based company that provides support services to hospitals including staffing, consultation and purchasing.
During the peak of COVID-19, the rates were in the $150 to $160 range, he said. Now, they’re more often in the $120 to $140 range, and hospitals are trying to negotiate them down, gradually.
It’s all too late for Ambuehl, the Barnes-Jewish medical ICU nurse.
Ambuehl left the hospital in February to become a travel nurse. He said the decision was more related to his personal life than to BJC. But as he got closer to leaving, he felt he needed to speak up in some way.
On his last day at the hospital, he sent an email to BJC officials, urging them to pay executives less and frontline workers more.
“Let me be clear, I am not suggesting that a redistribution of excess executive wages would amount to a huge increase for nurses, respiratory therapists, and other bedside staff when spread across the board,†he wrote. “But it would amount to fairness, and it should certainly happen as the current system is grossly unfair and wildly out of alignment with BJC’s purported values.â€
In a recent interview, Ambuehl said he suspects hospital administrators are hoping the nurses who’ve left will “all come home.â€
“And nurses are holding out, hoping they’ll get paid fairly,†Ambuehl said. “But who’s going to win that?â€