Late one Saturday in the fall of 2020, an elderly man hospitalized with COVID-19 asked nurse Michael Bulger for a shave. He was too weak to do it himself, and the few days’ worth of stubble had grown itchy beneath his oxygen mask.
With more and more new patients who’d contracted the coronavirus, Bulger’s floor at the Plano hospital where he works had filled to capacity. Still, he told the man he’d try to shave him but couldn’t make any promises. “Well, I’m going to meet my maker tomorrow morning,” the man said. “I want to look good when I get there.”
So, Bulger got a razor and gave his patient the best barber shop-style shave he could around his layers of personal protective gear. By dawn, the man’s blood oxygen level had plummeted to around 70%, but he pulled his oxygen mask off. He didn’t want it anymore. He only wanted Bulger to stay by his side until the end. An hour and a half later, he died. “After a while, it became kind of a daily thing,” Bulger said. “You come in and wonder which ones aren’t going to be there when you leave tomorrow morning.”
He estimates he’s performed CPR more times in the past two years than he had during his previous 11 years as a registered nurse. Throughout a typical five-night span, he would perform CPR at least six times and could almost guarantee that by that point the patient would not revive. It’s a physically and emotionally taxing process, using his whole body to pump someone’s heart for them, often punctuated by the sound of ribs cracking beneath the force of chest compressions.
He was working from 60 to 75 hours per week. The hospital offered a $40 per hour bonus on top of overtime pay to incentivize nurses to pick up extra shifts amid the ceaseless tide of patients flowing through the doors. Many of Bulger’s fellow nurses declined because they had “nothing left,” he said. Memories like this are not distant for nurses like Bulger. President Joe Biden may have declared the pandemic over, but Texas is still seeing upward of 1,075 new confirmed cases a day, with a daily average hospitalization rate of 283 patients for Dallas County as of Oct. 2.
More troublesome still, nurses are assaulted on all fronts these days, both literally and figuratively. They’re burned out and suffering deep psychological scars from the pandemic. This has sparked a mass exodus of workers from the field, foisting more work on those who remain. Violence against nurses has also radically increased in the last few years, in part thanks to the pandemic, and nurses say minimal workplace protections leave them to face the danger alone.
Psychiatric nurse practitioner Sandra Risoldi knows the risks well. Years ago, she was having trouble with a disturbed patient whom she could not calm down. Risoldi asked her supervisor to step in and take over, but the supervisor refused. When Risoldi tried to go back into the room, the patient kicked the door at her, which she had used as a shield to block him back into the room. “He probably would’ve smashed my head to pieces on the ground,” Risoldi said. “He was jumping over things to try to get out.”
Today, Risoldi is a psychiatric nurse based in Florida and the founder and president of Nurses Against Violence Unite, which advocates for a safer workplace for nurses. She travels the country teaching seminars to fellow nurses on spotting the warning signs in a potentially violent patient, how to deescalate and how nurses can best defend themselves. She structures her seminars as therapeutic experiences for nurses to work through the trauma of the violence they’ve already faced and without receiving the help they needed. “Everybody has a breaking point,” she says. “What more do you want?”
Between the start of the pandemic and October 2021, nearly one in five healthcare workers quit, according to a study by the survey research company Morning Consult. In March, the nursing hiring platform Incredible Health said that more than a third of nurses surveyed planned to call it quits by the end of this year. Almost half of those planning to leave cited burnout and high-stress work environments as the primary reasons, with benefits and compensation listed second. While in Texas sign-on bonuses as high as $10,700 were offered as incentives to hire more nurses, salaries in the state have stagnated, falling behind the national average of $82,750 by 4% at $79,120.
"You come in and wonder which ones aren’t going to be there when you leave tomorrow morning." - Michael Bulger, nurse
The pay is not enough to compensate for the physical and mental toll of an increasingly dangerous profession. The American Nurses Association (ANA) says that one in four nurses have been physically assaulted on the job, with 13% of overall missed workdays caused by workplace violence. The Occupational Safety and Health Administration (OSHA) places the risk of violence against healthcare workers at four times greater than that of any other industry. Violent incidents have steadily spiked throughout the pandemic, but only between 20% and 60% are reported, according to ANA.
Risoldi travels the country teaching seminars on preventing violence. The cornerstones of her program are understanding, awareness, recognizing escalation and conflict resolution. She trains nurses to meet patients and seek out what immediate concerns and needs might cause agitation. Risoldi says to follow the trail of anxiety.
She uses her organization to fill in the educational gaps that leave nurses vulnerable to potential violence and to fight for legislation to combat the problem. Within the medical field, Risoldi wants to break down the barrier between physical health and mental health. She also wants hospitals to employ more mental health professionals and provide one per floor as opposed to one per building.
A 2018 state report on workplace violence against nurses found that only 48% of those surveyed rated their hospitals as very safe, and only 48.5% knew whether their hospitals had violence prevention programs. The ANA calls the overall attitude toward workplace violence in healthcare “Just Culture,” that accepts injuries to nurses as “just part of the job” and treats violent incidents as routine occurrences that workers have to deal with on their own. Hospital employee manuals, codes of conduct and other regulatory documents at the facility and state levels across the nation often lack clear definitions of what workplace violence is, which allows incidents to be swept aside if they’re not deemed severe enough.
Only a handful of states have legislation on the prevention and management of workplace violence, and OSHA has no requirement for healthcare organizations to implement prevention programs. Only voluntary guidelines exist. Victims often don’t report incidents for fear of retaliation or concern that the incident will be counted against them as poor job performance.
In November 2020, a Texas Senate bill to combat violence against healthcare workers failed to become law.
Louis Kidd, a house supervisor at HCA Mainland Hospital in Texas City, said HCA has prevention protocols in place, but when pressed for specifics, he could offer only reaction plans for violence already occurring. He said he might be called to address a violent situation and would then call for security or police.
At many hospitals, including HCA and the Plano hospital where Bulger works, problem patients are handed off to male nurses when they’re available. Kidd said patients typically aren't as troublesome to male nurses.
Bulger, who stands at 6 feet tall and is powerfully built from his years on the Dallas Warriors Hockey team as a right wing and goalie, has often been called on to help control potentially violent patients. On one occasion an aggressive male patient got between one of Bulger’s female coworkers and the door of his room. “She was essentially trapped,” Bulger said. He stepped inside and asked if there was something they needed help with.
Seeing Bulger, the man immediately backed down, letting the other nurse escape.
Bringing male nurses in to handle problem patients and calling for security are all well and good, but Bulger pointed out that at his hospital, security might be several floors away, and much damage can be done in the time it takes for them to arrive. “It’s really hard to police that,” he said, “because if somebody gets angry and just goes off, that violence has already happened.”
One of the obstacles to change in the field is, as Risoldi calls it, a culture of learned of helplessness among healthcare workers. Nurses don’t seek help when they need it because they assume a certain level of violence is just part of the job. With minimal protections, Risoldi said, nurses fear that admitting they’re not OK will lead to their removal from the floor should they be deemed unfit to work.
The shortage of nurses in some ways is feeding the rise in workplace violence. Hospitals overrun with patients during each wave of the pandemic coupled with the loss of burned-out nurses spelled longer wait times in ERs and left admitted patients feeling ignored. Frustration made people agitated and angry, pushing them closer to the likelihood of lashing out. Desperate family members, not allowed to see hospitalized loved ones in their last moments, caused the brunt of the disruption that Bulger remembers during the height of the pandemic.
To compensate for the loss of permanent staffers, more hospitals are turning to medical staffing agencies. These firms represent travel nurses who work under contract, jumping from one medical facility to the next to fill in the gaps. Travel nurses often make as much as three times the regular hospital pay, plus room-and-board. It’s a lucrative deal for those seeking the pay and benefits they feel are equal to their efforts, but it siphons permanent staffers from hospitals
Those not signing on to travel nursing agencies are switching hospitals altogether for higher pay. Bulger is switching to a different hospital in the Plano area for an $11 per hour boost over his current pay. Four or five of his colleagues who also chose to stay in healthcare all switched departments in search of less draining workloads. (Bulger spoke on the condition that we not name his employer.)
The nurses who’ve chosen to stay in the profession for now are feeling the same pressures that have driven others to leave. But they stay on not just because they want to, but because they feel they must. Continuing to work in nursing does not mean they’re spared the burnout that forced others out. A nurse from the progressive-care unit at HCA Mainland, who spoke on the condition of anonymity, said they love their profession and feel obligated to their community. “I feel like I make a difference and if I’m not there, who else is there?” the nurse said via text message.
A Mayo Clinic study on burnout in healthcare defines it as “affective and cognitive changes, including emotional exhaustion, depersonalization and cynicism and diminished feelings of personal efficacy resulting from chronic occupational stress.” On a neurological level, burnout diminishes the prefrontal cortex region of the brain, reducing motivation and communication skill and increasing unprofessional behavior. Burnout hurts the rest of the body, too, raising the risk of hypertension, cardiovascular disease and suicide. Studies from the past two years found that nearly a quarter of healthcare workers reported likely post-traumatic stress disorder, a mental condition that develops after experiencing or witnessing terrifying events, and 57% of those screened for it met the criteria to be diagnosed.
The brain’s ability to repair itself means that with stress relief, the damage can be undone. But the repetitive nature of trauma in this job doesn’t leave room for the kind of break needed to heal.
“When you’re surrounded by that trauma for a long time, it’s hard to break out,” Risoldi said. “It almost becomes like an addiction. The addiction of the nurse wanting to take care of this patient to make sure they live. … It’s like you’re molded to make sure the patient is number one, and you’re always the sacrificial lamb.”
On a rare slow night, her supervisors wanted to send her home, but she chose to stay to support the only other two nurses, she recalled. Within 15 minutes, three vehicle accident victims arrived, one of whom, the nurse said, “was a severe trauma that we had to fight hard to keep alive.” Ideally, it should’ve been all-hands on deck for that patient, but it was only one nurse and the trauma surgeon.
“The surgeon was literally helping me hang blood because he was the only set of hands available as we worked on this actively dying patient,” she said. “That’s not something he should have ever had to do, but we didn’t have the people we needed.”
She feels more confident in her skills now a year into the job but is “exhausted by the needless obstacles placed in our way.”
On typical busy nights at the Galveston hospital, when there might only be one bed available, the ER nurse said her team isn’t allowed to go on saturation, meaning they can’t tell emergency medical services not to arrive with more patients unless they absolutely must. The decision isn’t up to her or her team. It belongs to executives who’ve never worked an ER shift. “Those things cost them money,” she said, “and our mental health is much easier to spend.”
Kidd, the HCA house supervisor, says his facility is holding its own right now, but called staffing the ER “just a crapshoot” amid a major loss of staff to travel nursing agencies. He defended the current staffing ratio at the hospital of one nurse for every six patients as a standard. But there are no legally defined nurse-to-patient ratios in any state but California, which set the ER ratio at one nurse to four patients. National Nurses United recommends an even lower ratio of one to three.
The Texas Board of Nursing has no authority over staffing ratios, calling the issue a “workplace/employment matter,” which is true under state law. Since 2009, Texas requires hospitals to implement and enforce written nurse staffing policies to “ensure adequate numbers of nurses with skill levels to meet the level of patient care,” leaving it up to hospitals to decided what that means.
The Texas Center for Workplace Studies estimates that by 2032 the state will need 291,872 more nurses than the 400,000 working here as of 2021. Based on current employment trends, the state could fall short of meeting that demand by about 57,000 nurses. According to this year’s retention and staffing report by NSI Nursing Solutions, for the first time ever the national turnover rate for RNs, meaning the rate at which employees leave their organization, exceeded the overall hospital staffing turnover rate, jumping up by 8.4% over 2021 to a 27.1% average.
Risoldi looks at the problem a little differently. “We don’t have a nursing shortage,” she said. “We have nurses that are tired of being treated terribly.”