By Mark Kreidler

It was a little more than three weeks ago that COVID patients began filling up the intensive care units at both Bakersfield hospitals where Mary Lynn Briggs works. It had happened before, but this felt different.

“The majority of patients we’re seeing are in their 20s and 30s, and we’ve never seen that before,” Briggs said. “And in the past, although so many people who were in the ICU with COVID died, we also saw patients who survived — even went back to work. But these last three weeks, everybody has died.”

This is the brutal surge of the novel coronavirus that experts have long predicted, as some of the most severe cases fueled by the fast-moving Delta variant finally become hospitalizations. Both hospitalization and ICU admission rates in California have experienced massive upticks in the past month, including double-digit increases over the past seven days.

For many nurses, though, it isn’t merely the numbers that chill. This is also a flashback to the very worst of any COVID period, including the end of 2020 and the first several weeks of this year. And some of them fear a darker turn — including working at hospitals that will be slow to address the biggest issues, like staffing.

“It’s a little bit of a PTSD feeling, to be honest,” said Brenda Chavez, an RN in the Centinela Hospital Medical Center emergency department in Inglewood. “We’re just kind of holding our breath: Is this going to be even more severe than before?”

*   *   *

From a nursing perspective, 2020 was a year of battle. COVID itself was an immense challenge, but from the outset of the virus’s arrival in the U.S., nurses also dealt with issues they might never have imagined confronting. Up and down California, nurses sometimes pleaded with and picketed their own hospitals for adequate amounts of personal protective equipment, including masks and even disposable gowns, and for enough staff to do their jobs the way they needed to be done.

Those concerns certainly haven’t abated. While PPE appears to be mostly under better control, there are suggestions that some hospitals may again face shortages. And the nurses at Centinela, where Chavez works, conducted an informational picket just last week to air their concerns over inadequate staffing. Erica James, a nurse in the ER, said the need was “especially dire as COVID-19 cases once again surge.” (Disclosure: The nurses quoted in this story are members of the California Nurses Association, a financial contributor to Capital & Main.)

It’s a national issue. But in the complex field of nursing, what is national can quickly become local, and it demands a local response.

When hospitals in any given area or region find themselves facing staffing shortages, they often tap into a national network of so-called travel nurses, who do just that: Accept a short-term assignment at a hospital or group, move to that area and help fill out a thin staff. But COVID has generally meant emergencies in multiple areas of the country at the same time, with travel nurses sometimes offered signing bonuses and enhanced pay to choose one assignment over another.

In the wake of staffing issues, PPE shortages and the sometimes helpless feeling of working with terribly ill or dying COVID patients, nurses have begun leaving the ranks. Although firm numbers aren’t known, the anecdotal evidence is strong.

“As the months progressed last year, and especially in November and on, I began to notice that our nurses were leaving,” said Chavez, who has worked at Centinela for 2 ½ years. (The CNA says that in 2020 alone, Centinela lost 226 nurses, about half the total number currently working at the hospital.) “So we’re trying to be more vocal about getting short-staff problems fixed, because we already saw what happened in November, December and January.”

Chavez said nurses were told last month that staffing was being thinned due to “low census,” meaning that fewer ER beds were in use. “But we have had an ER waiting time of multiple hours, plus ambulances waiting in line with patients,” she said. “At times we don’t have enough staff to help each other with patients.”

*   *   *

In Bakersfield, Briggs works in the ICU at two Mercy hospitals. She noted that “by about the second COVID surge,” staffing levels were at issue, even with travel nurses being brought in. California law requires hospitals to provide one nurse for every two patients in ICUs, but Briggs said that on several occasions Mercy has had a ratio closer to 3:1. (The state has issued temporary waivers to those ratios more than once during the pandemic, but a spokesperson for Mercy maintained that ratios “did not exceed 2:1” at either of its Bakersfield hospitals.)

Now comes the next wave of the virus, and Briggs, who works the night shift, said it is sending younger and sicker patients her way, often while she and her colleagues deal with staffing shortages. A year and a half of wrenching work for the nurses is nowhere near finished, while burnout stands on the fringes of the conversation.

Both Briggs and Chavez said they’ve made efforts to guard against becoming emotionally overwhelmed. Chavez began meeting with a therapist, anticipating what will happen over the next several weeks. That includes caring for patients who refused to wear masks or be vaccinated.

“People maybe don’t realize that compassion fatigue is a real thing,” Chavez said. “We have to take care of each other and take care of ourselves as nurses so that we can stick this out and care for our patients.”

That grind may continue for months, in part because the staffing issues aren’t likely to be resolved soon. And reinforcements might not be so quick to arrive.

“We had two cohorts of new (nursing) graduates in the ICU in 2020, and they came in facing this situation, in these circumstances, with no experience to back them up,” Briggs said. “Most of them have already left.”

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The rapidly escalating surge in COVID-19 infections across the U.S. has caused a shortage of nurses and other front-line staff in virus hot spots that can no longer keep up with the flood of unvaccinated patients and are losing workers to burnout and lucrative out-of-state temporary gigs.

Florida, Arkansas and Louisiana all have more people hospitalized with COVID-19 than at any other point in the pandemic, and nursing staff is being stretched thin.

In Florida, virus cases have filled so many hospital beds that ambulance services and fire departments are straining to respond to emergencies. Some patients wait inside ambulances for up to an hour before hospitals in St. Petersburg, Florida, can admit them — a process that usually takes about 15 minutes, Pinellas County Administrator Barry Burton said.

One person who suffered a heart attack was bounced from six hospitals before finding an emergency room in New Orleans that could take him in, said Joe Kanter, Louisiana’s chief public health officer.

“It’s a real dire situation,” Kanter said. “There’s just not enough qualified staff in the state right now to care for all these patients.”

Michelle Thomas resigned as a manager of the emergency department of a Tucson, Arizona, hospital three weeks ago after hitting a wall.

“There was never a time that we could just kind of take a breath,” Thomas said Tuesday. “I hit that point … I can’t do this anymore. I’m so just tapped out.”

She helped other nurses cope with being alone in rooms with dying patients and holding mobile phones so family members could say their final goodbyes.

“It’s like incredibly taxing and traumatizing,” said Thomas, who is unsure if she will ever return to nursing.

Miami’s Jackson Memorial Health System, Florida’s largest medical provider, has been losing nurses to staffing agencies, other hospitals and pandemic burnout, Executive Vice President Julie Staub said. The hospital’s CEO says nurses are being lured away to jobs in other states at double and triple the salary.

Staub said system hospitals have started paying retention bonuses to nurses who agree to stay for a set period. To cover shortages, nurses who agree to work extra are getting the typical time-and-a-half for overtime plus $500 per additional 12-hour shift. Even with that, the hospital sometimes still has to turn to agencies to fill openings.

“You are seeing folks chase the dollars,” Staub said. “If they have the flexibility to pick up and go somewhere else and live for a week, months, whatever and make more money, it is a very enticing thing to do. I think every health care system is facing that.”

Texas Gov. Greg Abbott on Monday directed state officials to use staffing agencies to find additional medical staff from beyond the state’s borders as the delta variant overwhelms its present staffing resources. He also has sent a letter to the Texas Hospital Association to request that hospitals postpone all elective medical procedures voluntarily.

Parts of Europe have so far avoided a similar hospital crisis, despite wide circulation of the delta variant, with help from vaccines.

The United Kingdom on Monday had more than 5,900 COVID-19 patients in hospitals, but the latest surge has not overwhelmed medical centers. As of Tuesday, the government said 75 percent of adults have been fully vaccinated.

The same was true in Italy, where the summer infections have not resulted in any spike in hospital admissions, intensive care admissions or deaths. About 3,200 people in the nation of 60 million were hospitalized Tuesday in regular wards or ICUs, according to Health Ministry figures.

Italian health authorities advising the government on the pandemic attribute the relatively contained hospital numbers to the nation’s inoculation campaign, which has fully vaccinated 64.5% of Italians 12 years of age or older.

The U.S. is averaging more than 116,000 new coronavirus infections a day along with about 50,000 hospitalizations, levels not experienced since the winter surge. Unlike other points in the pandemic, hospitals now have more non-COVID patients for everything from car accidents to surgeries that were postponed during the outbreak.

That has put even more burden on nurses who were already fatigued after dealing with constant death among patients and illnesses in their ranks.

“Anecdotally, I’m seeing more and more nurses say, ‘I’m leaving, I’ve had enough,’” said Gerard Brogan, director of nursing practice with National Nurses United, an umbrella organization of nurses unions across the U.S. “’The risk to me and my family is just too much.’”

COVID-19 hospitalizations have now surpassed the pandemic’s worst previous surge in Florida, with no signs of letting up, setting a record of 13,600 on Monday, according to the Department of Health and Human Services. More than 2,800 required intensive care. At the height of last year’s summer surge, there were more than 10,170 COVID-19 hospitalizations.

At Westside Regional Medical Center in Plantation, Florida, the number of COVID-19 patients has been doubling each week for the past month, wearing down the already short staff, said Penny Ceasar, who handles admissions there.

The hospital has converted overflow areas to accommodate the rise in admissions. Some staffers have fallen ill with COVID-19.

“It’s just hard. We’re just tired. I just want this thing over,” Ceasar said.

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In early 2020, when the coronavirus began making it difficult for many people around the world to breathe, hospitals became a central front against a disease that, more than a year later, has killed nearly 4 million human beings and counting.

At one hospital in Mission Viejo, Calif., a team of nurses and doctors were recruited for what became the Isolation Intensive Care Unit. Many volunteers at Providence Mission Hospital had come from cardiac and surgical intensive care units, where they deal with death and trauma each day.

Launched in March 2020, the isolation unit would come to be known as “Tip of the Spear,” a military term used to describe a group doing dangerous work. Many nurses who would spend countless hours with patients, helping them return to health or helping them say goodbye to family, got tattooed with spears, hash marks and a heart.

Today, those nurses speak of forming deep bonds and of the joy in helping some deathly sick patients survive. But they also can’t forget horrific and heart-breaking experiences that are very much still with them, even months after the hospital’s special unit shut down as cases in California dropped sharply.

With little knowledge of how to treat patients, and amid enormous personal risks, these nurses had leaped into the abyss. They will never be the same.

To capture the reality that the horrors of COVID-19 will be with us for years to come, even as many countries move beyond the pandemic, Associated Press photojournalist Jae C. Hong turned to an unusual form of photography not typically used in the context of reporting the news. He employed a special exposure technique in photographing 10 nurses in areas of the isolation unit, now empty.

First, Hong made pictures of each nurse. Then he asked them to step aside and shot images of the same background. By using a multiple exposure function, he made the images overlap. The result: pictures that create the feeling that the nurses are both there, in the photo, in the present — and also somewhere else.

Here are their pictures, and the experiences they are wrestling with to this day:

___

Anthony Wilkinson still thinks about those 30 hours — the ones when three patients died.

The first was a woman who had been on a ventilator for weeks. One day, her oxygen levels dropped sharply and an emergency team began CPR. One lung ruptured, so a doctor inserted a tube in it to begin removing the blood. Then the other lung collapsed. There was no saving her.

That day, the family of a second patient being cared for by Wilkinson decided to withdraw care. The person had been hanging on with the help of a ventilator and medicines.

“You try to keep somebody alive, but their body is decomposing,” says Wilkinson, 34.

Just when Wilkinson’s team was bagging up the body of the second person who died, another patient’s bowel burst. The patient was in a Rotoprone bed, a cage-like, cylindrical structure that rotates patients to improve circulation. “We had to open the cage and bang on his chest. His lungs were already so filled with pressure from the ventilator,” Wilkinson says.

Hours later, the patient died.

Wilkinson says the ICU team and his wife, also a nurse, helped him get through days like that. It also helped that he became a father during the tough year, which allowed him to leave the ICU ward and go home and do “dad stuff.”

The memories, however, linger: “I don’t know if I’ve unpacked a lot of the blood and all the stuff we did to save people’s lives.”

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During brutal days at the hospital, Christina Anderson and other nurses would scream or cry together, knowing that at home it would be hard for their families to understand what they were going through.

Still, there was no such thing as leaving their work at the hospital. The stress carried over to loved ones at home who were curious, worried, struggling to understand. Anderson’s 12-year-old would ask: “Mommy, how many lives did you save today?” Or: “Mommy, how many people died today?”

People died and people recovered. But most days, patients were somewhere between the living and the dead.

One of Anderson’s most vivid memories was when five patients were in RotoProne beds. They were in the “bay,” an open post-operative room that could be seen through the window of the anteroom, where nurses would put on personal protective equipment before going in.

Periodically the hospital’s CEO would visit the wing. One day, Anderson asked him if he had seen the bay lately. He had not, so she took him to the anteroom to have a look.

“Oh my God,” she recalled him saying.

“It hit me,” she says, “that what we were seeing and experiencing and how we were treating these incredibly sick patients was anything but normal.”

___

Debbie Wooters, an ICU nurse for 15 years, vividly remembers a man who had just retired and made big plans with his wife. They had placed an offer on a house out of state. They’d planned to travel.

Each day in the hospital, he got worse. Eventually, he was placed on a ventilator. He died a few days later.

“Instead of looking forward to a new beginning, we were FaceTiming his wife so he could say goodbye and thank her for the lifetime of memories,” Wooters says.

Learning they would be put on ventilators frightened many patients. And naturally so: There were numerous stories of people who had been intubated and never survived. Wooters remembers a patient who “looked at me and said, through his gasping breath, ‘I don’t want to die.‘”

“I explained to him that he was in the best hands and we will fight like he was our own family,” she says.

The ICU unit was isolating, not just for patients but for nurses as well. While keeping people alive was the main job, the nurses also needed to keep patients motivated or, when the chance of survival looked less likely, provide comfort.

“There were countless patients that we sat with, talked to, and touched so they knew they weren’t alone while dying,” Wooters says. And then there were the times they connected patients to families via their phones. “The cries and devastation heard,” she says, “was unbearable.”

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There were days Lisa Lampkin didn’t eat, drink water or go to the bathroom during her shift. The reason: Going in and out of the isolation unit took time.

It wasn’t just putting on and taking off gowns, gloves and masks, as with regular ICUs. It also required intense hand scrubbing and cleaning her air-purifying respirator, which resembled an astronaut helmet and had its own air system. Then she had to put it back on, scrub her hands again and climb back into the gown and the rest of her gear.

“What was once a 30-second ordeal was now a two-minute ordeal,” says Lampkin, a nurse for 20 years. “And in nursing, minutes are valuable. We remained in the room for hours to allow our patients to have those precious minutes.”

The extra time was needed to overcome communication barriers. Masks and shields muffled words, making it hard for nurses and patients to understand each other. It didn’t help that the patients struggled to breathe, which made talking that much harder.

At the end of each day, Lampkin would weep with joy for making it through her shift without a wave of new patients, or weep with sorrow for all that her patients were enduring.

“I would go home, try to sleep,” she says. Then she would “wake up to the reality of this pandemic again.”

___

While Elisa Castorena remembers many patients who died, she prefers to focus on happy memories such as working with other nurses to bathe bed-ridden patients while listening to music and joking with them.

Sponge baths gave nurses a chance to assess patients’ skin, give their arms and legs some motion exercises and help relieve pressure points.

“I think what I loved the most about bathing the patients was seeing them all fresh and clean and knowing they got much needed tender loving care,” says Castorena, 40, who has two young children and is married to a police officer.

She also cherishes a memory of caring for a man in his 60s who came to the brink of death and survived—because he “stayed positive.” As his condition went from bad to worse over the course of several weeks, the man needed to be intubated, sedated and put in a RotoProne bed.

Slowly, he began to show improvement. He was given a feeding tube and a tracheostomy, eventually managing to speak a few words through a talking valve.

“He told me he had faith in us and he knew if he stayed positive, he was going to make it out of the hospital alive,” Castorena says.

Castorena gradually learned other things about him. For example, he owned a mechanic shop in San Clemente that her family had frequented for years. When she learned the man’s son was a firefighter, she remembered that the mechanic shop had patches from many fire departments on the wall.

Months after he was released, Castorena visited the shop and her old patient. He still had some minor symptoms but had recovered enough to work. Castorena gave him a patch from her husband’s police department to add to his wall.

___

As an ICU nurse the last five years, Jamie Corcoran got used to seeing death. She dealt with it by remaining detached.

With COVID-19, detachment wasn’t possible.

Months after the special unit closed, Corcoran can still visualize a board in the COVID ward with the initials of each patient that the team lost.

“I can remember every single name and face with their initials on that board,” says Corcoran, 31. “Every single one.”

The death of a man in his 20s still haunts her. Sick at home for over a week before going to the hospital, once there the man began showing signs of organ failure.

One night, when Corcoran was helping the man get repositioned in bed, he told her he felt afraid. The man was clearly declining, but there was still hope he could improve. If anything, his youth was an advantage.

The next night, at the beginning of Corcoran’s shift, the man stopped breathing. He was put on a ventilator and given various drips to try to revive him. Nothing worked. Within a few hours, his pulse was gone and a “code blue” was called. A half hour of CPR and defibrillation were unsuccessful.

A co-worker said a brief prayer and the team began cleaning up. Shortly thereafter, the room was clean. It was, Corcoran says, as if nobody had been there.

“But,” she says, “for many months after that, those of us that were in that room were left still trying to find the pieces of our hearts that were lost in that room.”

___

A few months ago, Nikki Grecco and other nurses commemorated the anniversary of the first death in the COVID ward.

Grecco vividly remembers the man and how he died. He was in his mid-60s, married with two daughters in their 20s. One day, Grecco sensed that something was wrong and called in a doctor. The man was showing signs of distress and a team frantically tried to stabilize him. It was too late; he was bleeding out internally and had lost his right lung and part of his left.

The man’s wife was at his bedside when he died.

“I have never felt so defeated as I did in that moment,” Grecco says.

Grecco, 34 and the mother of two young children, says being married to a pulmonary nurse practitioner helps because he knows the stresses and rigors of ICU work.

Still, the memories rush back and can overwhelm. Sometimes the trigger can even be a moment on a TV medical drama like “Grey’s Anatomy” or “The Good Doctor.”

“Their portrayal of what it was like in a COVID ICU is pretty close,” says Grecco, adding that often she has to “fast forward through a few episodes because some hit too close to home.”

___

Driving to work, Cathy Cullen sometimes tears up when thinking about what she and the other nurses endured.

Outside the hospital, “Thank you” statues put up early in the pandemic still stand. Seeing the display can unleash a flood of emotions, as can memories that fellow nurses share over text messages.

An ICU nurse for 31 years, Cullen has experienced a lot of death and heartache. Still, she doesn’t know how to relate the experience of taking care of extremely ill patients to anything else.

“The birth of my children and marriage aside, being a part of this team, this endeavor, and this pandemic is by far the greatest, worst, most rewarding, most painful thing I have ever done in my life,” she says.

Many of her memories are of awful things, like the time her team lost three patients in a single day or walking by a refrigerated truck every morning and knowing that it full of bodies because the hospital morgue was full. But there were also the wins, and it’s those she tries to focus on.

One of Cullen’s earliest patients was a young woman in her 20s, the age of one of her own daughters. The young woman was terrified, particularly when her breathing became so labored that the only option was a ventilator.

“Please don’t let me die,” Cullen remembers her saying.

The patient’s mom and her sisters would provide thumb drives with all kinds of music — hip hop, classical, classic rock, 80s dance beats. Even though the patient was sedated, the nurses would play the tunes and hold up a phone so family could look and her and speak over Facetime.

After several months and many close calls, the young woman made it.

“She was one of the victories that we celebrated,” Cullen says — “literally jumping up and down in happiness.”

___

There is a scene that replays in Jill Shwam’s head each day: an 11-year-old boy screaming while his mother, in her early 40s, doesn’t respond as doctors try to save her.

The woman had Type II diabetes but otherwise was healthy. After being very sick and on a ventilator, she recovered enough to start breathing on her own.

One day, while speaking on the phone with her son, the woman’s breathing became more labored than usual.

“You need to say goodbye,” Shwam remembers saying as the woman’s oxygen levels dropped sharply. The woman told her son: “I hope this isn’t the last time I talk to you. I have to go.”

Within 20 minutes, the woman was back on a ventilator and began experiencing what nurses and doctors call a “second storm” of the disease. Her heart rate spiked, her blood pressure tanked, and assorted intravenous drips made no difference.

Within 24 hours it was clear that most likely the woman wouldn’t survive, so her son was allowed to be by her bedside. As the woman “coded” and doctors and nurses worked frantically on her to no avail, her son wailed.

Shwam, 40, had seen a lot of trauma and death as a cardiac nurse, but this shook her to the core.

“I think about her a lot,” says Shwam, crying softly. “I think about them a lot.”

___

Verlin Frazier still remembers watching a woman walk between RotoProne beds to reach — and say goodbye to — her husband.

It was Spring 2020, just as COVID-19 started hitting California hard. The unit was full, and there were six people in the bay. Three of them were in RotoProne beds, including this man, a recently retired firefighter.

His body was shutting down. It was clear he would die before the night ended. Nurses had held his hand and rubbed his forehead. Now it was time for his wife to say goodbye. Watching her do that, after having walked between “five of the sickest patients in the hospital,” hit Frazier hard.

“I remember biting my tongue and cheek, holding my breath, anything to prevent myself from bursting into tears,” says Verlin, 34.

To make it worse, Verlin wasn’t able to console the wife because just as she was saying her goodbyes, another patient in the bay began deteriorating and needed attention.

Within a few months, Verlin saw a pattern in many of the sickest patients, which still sticks with him. A patient would struggle to speak simple sentences to family members on the phone. In the background, nurses and respiratory therapist would frantically prepare for intubation.

Then, says Verlin, the familiar words: “Stay strong,” or “They are going to take great care of you,” or “You are going to be home soon.”

“There was always an `I love you,’ which was where I usually had to pull the trigger in ending the phone call,” he says, “because they were deteriorating so fast that even talking was making it worse.”

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As the coronavirus pandemic surges across the nation and infections and hospitalizations rise, medical administrators are scrambling to find enough nursing help — especially in rural areas and at small hospitals.

Nurses are being trained to provide care in fields where they have limited experience. Hospitals are scaling back services to ensure enough staff to handle critically ill patients. And health systems are turning to short-term travel nurses to help fill the gaps.

Adding to the strain, experienced nurses are “burned out with this whole (pandemic)” and some are quitting, said Kevin Fitzpatrick, an emergency room nurse at Hurley Medical Center in Flint, Michigan, where several left just in the past month to work in hospice or home care or at outpatient clinics.

“And replacing them is not easy,” Fitzpatrick said.

As a result, he said, the ER is operating at about five nurses short of its optimal level at any given time, and each one typically cares for four patients as COVID-19 hospitalizations surge anew. Hospital officials did not respond to requests for comment.

But the departures are not surprising, according to experts, considering not only the mental toll but the fact that many nurses trained in acute care are over 50 and at increased risk of complications if they contract COVID-19, while younger nurses often have children or other family to worry about.

“Who can actually work and who feels safe working are limited by family obligations to protect their own health,” said Karen Donelan, professor of U.S. health policy at Brandeis University’s Heller School for Social Policy and Management. “All of those things have been factors.”

Donelan said there is little data so far on how the pandemic, which has killed more than 231,000 people in the country, is affecting nursing overall. But some hospitals had a shortage even before the virus took hold, despite a national rise in the number of nurses over the past decade.

With total confirmed coronavirus cases surpassing 9 million in the U.S. and new daily infections rising in 47 states, the need is only increasing.

Wausau, Wisconsin-based Aspirus Health Care is offering $15,000 signing bonuses for nurses with at least a year of experience and hiring contract nurses through private staffing companies to handle a surge in hospitalizations that prompted the system to almost quadruple the number of beds dedicated to COVID-19 patients.

Aspirus, which operates five hospitals in Wisconsin and four in small communities in Michigan’s Upper Peninsula, also is moving nurses around between departments and facilities as hot spots emerge, said Ruth Risley-Gray, senior vice president and chief nursing officer at Aspirus.

Outside help still is needed, in part because some nurses have gotten sick from or were exposed to the cornavirus during the current wave, which “came with a vengeance” starting in August, Risley-Gray said. At one point in mid-October, 215 staffers were in isolation after showing symptoms or being exposed to someone who tested positive, and some are just starting to return to work.

Aspirus recently was able to hire 18 nurses from outside agencies, and may need more if the surge continues.

Because the pandemic is surging just about everywhere in the country, hospitals nationwide are competing for the same pool of nurses, offering pay ranging from $1,500 a week to more than $5,000, said April Hansen, executive vice president at San Diego-based Aya Healthcare, which recruits and deploys travel nurses.

She said demand for their services has more than doubled since early in the pandemic when the greatest need was in hot spots like New York and New Jersey and then moved to southern states. In recent weeks the virus has been spiking across the country, with the new hot spots in places like the rural upper Midwest and southern-border communities such as El Paso, Texas.

Now placing nurses where they’re needed is “like a giant game of whack-a-mole,” said Hansen, whose company has about 20,000 openings for contract nurses.

In North Dakota, where infection rates are exploding, hospitals may cut back on elective surgeries and seek government aid to hire more nurses if things get worse, North Dakota Hospital Association president Tim Blasl said.

In Texas, Gov. Greg Abbott recently announced he was sending 75 nurses and respiratory therapists to El Paso to help handle the city’s surge. Wisconsin Gov. Tony Evers, meanwhile, issued emergency orders making it easier for nurses from elsewhere to practice in his state and for retired nurses to come back.

“This has been a challenge, and we’ve been pleading with the community members to protect themselves and others,” by wearing masks and social distancing, said Aspirus’ Risley-Gray, who said the positivity rate among community members tested by Aspirus rose from under 10% in September to 24% last week.

To combat the emotional toll and fatigue that comes with caring for COVID-19 patients, including just donning and removing protective equipment all day, Aspirus has been giving nurses microbreaks and quiet places to get away and collect themselves when they feel overwhelmed.

Travel nurses say the need at small hospitals tends to be greater than at larger facilities.

Robert Gardner, who’s currently assigned to a hospital in a small town about 20 miles west of Atlanta, said he did search and rescue in the Coast Guard during Hurricane Katrina and the pandemic is “a lot worse.”

He worked at a large New Jersey hospital when that state was swamped by the virus in the spring, and now worries that flu season could bring further chaos to hospitals. But he’s determined to stick it out, no matter what.

“It’s not even a question,” Gardner said. “Nursing is a calling.”

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After years of similar attempts, the state legislature passed AB 890, sponsored by Assembly Member Jim Wood, D-Santa Rosa. The bill has been reshaped significantly since its introduction, including the addition of a requirement that NPs work for three years before they can practice on their own.

Advocates for the bill say removing these practice limitations will improve health care access in the state’s rural and underserved areas, while attracting and retaining more nurse practitioners (NPs), which are registered nurses with masters or doctorate degrees and additional training. But physician groups such as the California Medical Association strongly lobbied against the bill, saying NPs do not have adequate training to practice independently, and that the move would exacerbate health care disparities by creating a two-tiered system of doctors and NPs.

Those on both sides of the debate shared one thing: their positions were reinforced by their distinct experiences during the pandemic.

“The pandemic has really brought to life the issues we see in our practices,” said Patti Gurney, the president of the California Association for Nurse Practitioners. “In the past, when these shortages and disparities and inequities were brought up, it was easier to dismiss the need for change. But not so much now.”

A clinic’s capacity stalled

For nurse practitioner Alexa Colgrove Curtis, who works in primary care and psychiatry in Nevada City, the existing requirement of physician oversight has kept her from seeing some psychiatric patients over the past several months.

Curtis had been working under the supervision of her clinic’s psychiatrist, treating patients experiencing addiction and recovery as well as co-occurring disorders such as anxiety and depression.

In May, the psychiatrist left for a position in an urban setting. In general, it’s a challenge to attract psychiatrists to areas where many patients are uninsured or have Medicaid, said Curtis, who is also the assistant dean of graduate nursing at the University of San Francisco.

The clinic is still operating under a supervising medical director, but that physician isn’t trained in psychiatry so that limits Curtis’ practice, too. Until they find another supervising psychiatrist, she’s not able to serve an at-risk population amid a pandemic that’s exacerbating problems such as alcohol and drug misuse and suicide.

“We had a behavioral health crisis prior to COVID and that’s just escalated, and we need to provide as much access as we can,” she said.

While the pandemic has relaxed restrictions and made it easier to reimburse telehealth, it’s hard to find someone with the bandwidth and willingness to supervise someone in a different community, Curtis said.

Then there’s the cost. “If funds were unlimited, we could pay a king’s ransom to have someone tele-supervise, but that, to my mind, is not the most cost-effective method we have to provide quality care,” she said.

With a doctorate degree and a certificate in psychiatric mental health along with decades of training in places such as adolescent health centers and federally qualified health clinics, Curtis said she feels confident practicing on her own. And, if there’s a case outside her areas of expertise — such as a patient with depression who isn’t responding to treatment — she can refer that patient to a psychiatrist.

For now, she is focusing on her family medicine patients, leaving those psychiatry patients to either forgo care or seek it elsewhere.

Facing uncharted medical waters

On the other side of the debate, the pandemic has also reinforced opposition to the legislation.

When COVID-19 flooded emergency rooms in the spring, physicians had to pull on years of training and diagnostic skills to work on the fly, said Dr. Vivian Reyes, an emergency medicine physician and the president of the California American College of Emergency Physicians, which opposed the legislation.

COVID-19 patients were suddenly appearing in emergency departments with strange findings like “frostbite” on extremities and there were no established protocols for treatment.

“We were figuring this out while we were seeing patients, taking what we knew from training and translating it into how we might treat this disease,” Reyes said. “Without this level of training, I think it could have been a different experience. Patients might not have received the same level of care.”

In the emergency department, the mix of patients requires the diagnostic ability that comes from physician’s lengthy training of four years in medical school and at least three in residency, she said. That extensive experience helps her with uncommon cases such as diagnosing a life-threatening aortic dissection for a patient who only described a fleeting pain in her chest.

Reyes agrees that health access is clearly a concern, but she questions the move to expand the role of nurse practitioners.

“If you live in a rural system, you don’t need a higher level of care?” she said. “To me, that doesn’t sound right, especially when there are alternatives like telemedicine.”

Next steps

The legislation still needs Gov. Gavin Newsom’s signature before becoming law — he has until Sept. 30 to decide. The measure would not take effect until Jan. 1, 2023.

If enacted, the bill would add California to the about two dozen other states in which nurse practitioners can practice independently, including West Coast neighbors like Washington and Oregon.

The change is in line with the broader goals of the Affordable Care Act, which aimed to increase access to care in medically underserved areas, said San Francisco-based health consultant Jason Lee of ECG Management Consultants. The pandemic shone a light on those needs.

“The weaknesses in our health networks has been revealed through COVID for sure,” he said. In some underserved areas, “we were already feeling there weren’t enough providers, so even a small demand puts a strain on the provider base in those areas.”

-Kellie Schmitt

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