Nurses Concerned About Insufficient Staffing in the COVID-19 Respiratory Care Unit at St. Joseph Hospital

Cropped photo of the entrance to St. Joseph Hospital’s Emergency Room, where potential COVID-19 patients enter the hospital and are triaged according to need. [Photo by Ryan Hutson]

Nurses at St. Joseph’s Hospital in Eureka have complained that staffing levels are dangerously low in the COVID care section of the hospital–this, they say, affects both the staff and the well-being of the patient.

Nurses usually work a 12-hour shift in the RCU (Respiratory Care Unit), which they refer to as the ‘COVID Unit’, and report not being given additional help, even when caring for COVID-19 patients entails a great deal of additional attention to detail.

One nurse who works periodically in the RCU tells about one of the more difficult days that they have had where an elderly patient required additional assistance, but there was no help available to the single nurse on duty.

“I had this patient, he was very very confused.,”  the nurse related, “and he… kept trying to get out of bed- so I did have to deal with those circumstances and it took me 45 minutes to feed him a meal…while you can’t even attend your other patients.”

The nurse explained further,

 ….Because nobody is coming in to help me and this guy is incontinent and he’s peeing the bed, he’s pooping the bed- I have nobody to help me turn this completely confused guy that can’t follow directions….  You would normally have another nurse to help you pull the patient up and turn them, and I told the charge nurse,… “I cannot do a skin assessment by myself.”  And she just sort of shrugged her shoulders and put her arms up like, you know, and said that she wasn’t going to come in and help me with this patient- and not just for the skin assessment.

The RCU nurse explained this specific day, unfortunately was not  an uncommon experience on the second floor in the Covid care unit. Other nurses we spoke to agreed.

Between each COVID patient, the nurses have to donn and  doff (put on and take off a variety of protective equipment), every time they leave a room or enter a new room.  This nurse estimated that a nurse would need to enter each patient’s room a minimum of about six – ten times per shift, and must re-doff and re-donn each time.  If all four of the designated RCU beds are occupied, this added safety routine- totally necessary to guard against spread of the COVID-19 disease- becomes a marathon of caregiving.  

Nursing COVID patients  is frequently done under stressful circumstances where the pressure to perform is palpable, and the inherent risk involved becomes a juggling act for many nurses who take on the duty of working the Respiratory Care Unit at St. Joseph in Eureka.  

One of the nurses we spoke to explained that being the exclusive caretaker during a 12-hour shift in the “COVID Unit” is exhausting, but also explained that the staffing minimums for this particular unit seemed to fall short and could harm patients.

On October 5th, CNA union members picketed outside St Joseph Hospital in Eureka, calling for astaffing plan for the recently installed Telemetry Unit on the second floor, which does treat COVID-19 patients. [Photo by Ryan Hutson]

Staffing minimums at Providence St. Joseph Hospital in Eureka are not being met within the RCU, according to sources with direct knowledge interviewed for this article.  Adding to the worry, some local nurses have declined to be quoted, citing fears of work-place retaliation such as having reduced working hours or being sent home without pay, or worse, being let go all together.  

According to several employees of St. Joseph Hospital we spoke to, if a staff member were to refuse an assignment in one of the units where COVID-19 patients are treated -for example in the Respiratory Care Unit (RCU) or the Telemetry Unit also on the ‘med-surg’ 2nd floor- they have been sent home for the day without pay, and may face repercussions from management, and others have been admonished by their nurse managers for requesting an aide to assist them in the RCU with the treatment of the COVID-19 telemetry patients (patients using heart monitoring technology which requires specific expertise).  

According to local RNs who were consulted for this article, caregivers who have been working through the pandemic are taking on long hours at St. Joseph’s and also coping with a shortage of designated helping hands.

A cropped screenshot (from a video interview during a union picket at St. Joseph’s) of a letter providing notice of an “investigatory meeting” which “could result in discipline” issued by a nurse manager to a nurse who was sent home without pay, following their request for an assistant in the recently created Telemetry Unit- dated October 5th, 2020.  This new unit, opened in October, also serves COVID-19 patients when needed.

One nurse we spoke to explained the way work assignments to the RCU are selected, being largely sourced from a group with specific expertise in acute care such as in the ER or ICU.  The  nurse explained, “I am an RN, and I work in the resource pool, which is more commonly known as the ‘float pool’ which, we cover all the areas of the hospital depending on our background. And so a lot of the float pool is used to staff this COVID Unit- ‘Respiratory Care Unit’ is what we are supposed to call it-”

The nurse described the way ‘the COVID unit’ is situated on the second floor of St. Joseph Hospital.  “They sectioned off part of the second floor,” the nurse explained, “and it’s sectioned off with plastic sheeting and big signs, you know, to make sure you’re- to be authorized to go in there.  It’s one of the med-surg floors.”

The nurse went on to call attention to the ratios of staffing that are expected with units containing high-acuity patients such as on the med-surg floor, or in the Intensive Care Unit, where a minimum of two qualified RNs are expected to be available per unit according to the ratios outlined by CA law.  The nurse said, with a hint of incredulity, “And they even staff it as if it is one whole unit, yet, nobody is allowed to come onto the unit, because then they’re considered contaminated and they can’t go help any other patients on that floor…”

While the RCU is located amidst the med-sug unit and the Telemetry unit also on the second floor, the RCU COVID unit is unique due to it being effectively separated from other areas, and as its own unit – which is functionally separated from the adjacent med-sug and telemetry units – it would require an additional set of qualified hands according to CA’s staffing minimum standards.  

The nurse also spoke about the requirements for working in this particular unit, noting that the safety protocols are far more involved than if they were to be assigned to a different but equally serious unit, such as the Progressive Care Unit, or the Intensive Care Unit, for example, where telemetry care and post-surgery care is provided.  At the time of this interview, the RCU held four separate ICU beds, which are situated individually in negative pressure rooms, which prevent the airflow from those rooms from seeping into the surrounding space- a measure that is required when dealing with highly infectious pathogens, but also a standard ICU room feature.  

 Screenshot of video tour of Humboldt County’s so far unused Alternate Care Site: Redwood Acres, Eureka, California which shows a simplified example of the PPE donning and doffing routine that is critical in ensuring the safety of frontline caregivers.  

The nurse explained,

The unit was bigger at first, and there was a lot of help. They had somebody making sure you’re donning and doffing your PPE appropriately.”  The experienced nurse continued, “But also, they were a helping hand to get supplies for you, because once you put all your equipment on, and you go in your [COVID] room, there isn’t anybody to help and hand you any supplies.  So you have to completely undress, you know, sterilize, get what you need, re-dress up, and go back in the room- for a cup of water, or a spoon, or just, you know menial things- because you’re the only person on that floor.

As the pandemic has fluxed, so has the number of beds allotted to the various units that accommodate COVID-19 patients.  At first, there were as many as eight beds prepared, but when the need for those beds dissipated over the spring and summer, the RCU was created and tapered down to a four-bed unit, which St. Joseph staffs according to census.  

The nurse explained how the specific COVID-19 RCU has evolved over the many months since the spring.  “Before, there were more beds, and the unit kept on shrinking and shrinking because there weren’t – thank goodness- very many COVID patients.  So now it’s down to a four-bed unit so that you would never need- according to St. Joes’ administration- that you would never need more than one nurse to staff those four patients.”  

They went on to compare the staffing rate in the ‘COVID unit’ to comparable units, and the staff to patient ratio provided in those.  

“The ratios are the same as- so, you can have four telemetry patients – four patients on a monitor in the PCU (Progressive Care Unit), well, in the Respiratory Care Unit the ratio is the same. They do not change the ratio at all; they don’t look at the donning and doffing and consider that in the ratio.  It’s the same as it is on any other floor.  And you have no charge nurse or secretary, so you are entering all your own stuff on the computer.”  

NNU Flier showing a breakdown of proposed staffing standards to be adopted on a federal level, configured to match CA’s existing Title 22 staffing requirements.

According to Title 22, which outlines regulations and standards for hospitals like St. Joseph, there should be a 1:2 ratio of caregivers to patients in a Respiratory Care Unit, such as the designated space for COVID-19 patients.  Since the RCU is actually located on the already staffed second floor med-surg unit, nurses working the RCU alone are told that the charge nurse on the second floor is the second set of hands- although as a matter of practice, they are not specifically available to the COVID unit unless they are assigned to that unit.  

Screengrab from Title 22, Division 5 

 With the added routines of donning and doffing the Personal Protective Equipment, and the sanitization drills that staff must do as a matter of necessity, more time is dedicated to these tedious but critical tasks.  This is even more cumbersome when there is only one nurse to staff the RCU.  

Expressing frustration the nurse told us, “So, they like to say, ‘Oh yeah, you have help- you have all this staff on the second floor,’ even though nobody is allowed to help you.  The charge nurse might basically just help with staffing… the administrative part.  There’s no hands-on help from anybody.”   

Unable to wait for a possible second pair of hands when something is needed urgently, they confirmed that working solo in such a high-maintenance unit presents a problem, sometimes multiple times in a shift.  Rather than be able to stay contained in the area restricted to COVID-19 care, this nurse confirmed that without a second pair of hands, they have to choose between leaving the contaminated COVID-19 area and getting what they need -a medicine, a utensil, a blanket, a glass of water or anything they don’t have stocked or already in the room- or staying in the RCU and trying to do without.

The nurse explained, “So, I just get it, and… I can’t wait- I can’t call a charge nurse and say ‘I need two items.’  It takes way too long to get items- I mean, it’s more stocked now, but you still to have to go over to that second floor sometimes and grab things” 

As this nurse detailed the troubling aspects of donning and doffing and attempting to handle multiple high risk or critical care COVID-19 patients, they repeatedly expressed  concern for their patients’ level of care.  In expressing worry about the potential for exposure of the virus into other areas of the hospital, the point was repeatedly made by each nurse that chose to provide input for this article that safety and care are inextricably linked, and that the obvious solution according to each of them, was to increase the level of staffing in each unit that is responsible for coronavirus patients.  Each person interviewed or quoted in this article maintained that a second nurse and an aide would solve the problem, as well as meet the minimum staffing requirements outlined by Title 22.

The California Nurses Association has taken the position that staffing ratios directly affect patient care in a serious way.  The nurses union has lobbied to institute more controls and oversight on staffing procedures for many years, insisting that “allowing hospitals to set staffing levels that are primarily budget driven, while not setting up a system of accountability, has created a threat to patient safety.” 

Emails sent from CNA union representative Ian Seldon obtained while researching for this article reflect communications requesting additional support for the nurses working in St. Joseph Hospital.  One of these emails notices union member nurses of a planned informational picket in response to the knowledge that – according to the email – a staffing waiver had been requested, indicating that the hospital was applying for permission to make adjustments to the already insufficient staffing levels during the pandemic.  

Cropped screenshot of a union organizer’s email to local union members notifying them of a planned picket in August, due to a breakdown in communication between hospital management and union reps.  August 4th, 2020 email.

The local representatives of California Nurses Association have been advocating on the behalf of nurses for better staffing conditions and more PPE access since the start of the pandemic.  As far back as March, CNA had been citing staffing ratio concerns among other topics related to workplace and patient safety in negotiations with hospital administration, getting mixed results.  

When local union nurses were called to vote on whether or not to strike at the start of the year- back in February- the answer was a resounding “yes”.  So far, a full strike has been successfully avoided, but remains an option for union members in an emergency. This flier was distributed, laying out the points in favor of such a drastic action, if necessary.

CNA/NNA union flier distributed to union members, promoting the option of a strike as a negotiating tool for local healthcare workers.  

An email the next day proclaimed a small victory, the ability to legally strike if they decided it was needed.  The CNA email reads in part, “Congratulations Eureka Nurses – You had incredible turnout yesterday – more than a super-majority turned out with just a week’s notice – and 98.5 percent of you said YES to give your Nurse Negotiation team the power to call a strike if necessary.”

Another email from August informs union members that a strike was planned and noticed to the hospital administration.  This 10-day strike was narrowly averted, and the union reps called off the strike when some progress was made, opting to focus on the coronavirus response.  Seldon’s email describes the status of the negotiations:  

Email from CNA union representative of June 8th, 2020 describing points of contention in negotiations with St. Joes’ administration in a ‘bargaining update’.

Most recently, a December 15th press conference held by CNA raised the alarm over staffing ratio compromises, with CA Nurses insisting that a ‘new rule’ may allow hospitals to violate safe staffing standards- which they say “will lead to more death and suffering of both patients and health care workers”.  The press release states a startling statistic, noting “California’s multi-billion hospital industry fought for years to block the state’s landmark safe staffing law, and then tried to overturn it, even though studies have shown the California law has resulted in up to 14% fewer patient deaths than in comparable hospitals, assured nurses more time to spend with patients, and kept nurses at the bedside far longer.”

Screenshot from the virtual press conference where CNA & NNU union members advocate for “safe staffing” in opposition to for-profit hospitals circumventing staffing minimums in the midst of a pandemic surging along side the regular flu season.  December 15th, 2020. 

While union advocates are working behind the scenes to secure better working conditions, frontline caregivers are feeling the brunt of the pandemic fatigue.  Echoing statements provided by other interviewees, one nurse explained, “The thing that I’m most concerned of- and I think everyone else is most concerned of, is our patients’ safety- because we have had many many times, confused patients that are very at risk for climbing out of bed and falling.” 

Thinking back to a specific day that caused them to feel exasperated, and which in large part spurred this interview, Nurse continued, 

And so they have these bed alarms that go off if the patient is exiting the bed- and you can put on the bed.  And if you’re in another one of your patient’s rooms, with your [capper] helmet on and everything else, you can kind of maybe hear that alarm, but it can be any patient on the entire second floor, so you can’t even – you don’t even know if it’s your patient getting out of bed and hurting themselves – and it’s going to take you how long to get to that patient?  

Say you were in the middle of toileting your other patient in the other room, so you have to finish that.  You can’t just leave them on the toilet because they are at high risk for falling, right?  So you have to finish your task.  So, you have to take your equipment off, sterilize your capper, go to the other room and donn, before you can even help that other patient. There’s nobody else answering their call light, and nobody’s allowed to go in and help that other patient.

They acknowledged that unfortunately, in the absence of a staff member to ‘watch’ a patient as a bedside caregiver or ‘besitter’, they have had to use the alternative bed alarms to help monitor patients, because they are unable to closely monitor their multiple patients at once. They said, “So that’s my main complaint is patient safety, and nurse safety- for that matter.”

One nurse pointed out that missing a break is a regular and problematic occurrence which not only affects the staff members who become exhausted and risk becoming fatigued in the long run, but also has a direct consequence for patients.  The nurse explained,

“…I didn’t get my first break, it was a quarter after five, even though the shift ends at six – so it was a quarter after five, and one of the directors came and offered me an afternoon break you know, A second break of the day even though the shift is almost over. And I said ‘well, my patient needs to be fed, and it took me 45 minutes to feed him lunch, so will you be able to go and feed my patient?’ – because I knew what the answer was going to be, and she said no.  And I said ‘well then I guess I don’t get an afternoon break..’ and she kind of just looked at me.  

Another nurse, who was reluctant to go on the record for press, citing concerns for her job security with the hospital, but she did want to make something in particular known to the public.  She was clear about the bottom line being safety and that the quality of care given to patients depended on the level of safety afforded not only to staff at the hospital, but to the patients as well.  The example of sitters, or bedsitters was a top priority. She told us,

So basically they are getting on us about an increase in patient falls, but they won’t even staff us appropriately… they wouldn’t even approve overtime for more help, despite the fact that they received so much money…. Some days there is no break nurse, no aides and no unit secretary- it’s scary.  The charge nurse has to give us our breaks and there’s at least one time we didn’t get them at all… there was one day that I know of at least, that the “Respiratory Unit” -which is what they call the second floor now- didn’t have a charge nurse or break nurse or unit secretary or any aides. It was insane… Someone fell that day.

She went on to say that having help, such as a nurse’s aide or bedsitters available, is nearly a constant issue, affecting the work flow and daily routine of nurses in the COVID unit negatively.  The nurse continued,

We need sitters like almost every day- which is someone to watch the unstable patients, so that also takes our help away- the managers are straight up telling us the increase in falls is our fault, but it’s pretty much impossible to be with five patients at once which is how many we each have and why we depend on aides.  There are also incontinent people who will end up with pressure ulcers or severe skin breakdown if they don’t get cleaned up, but with no aides all we can do is our best to get to them all… Some days we have enough aides, and they will pull them off the floor to “take temps” at the front door… it’s absolutely insane right now.  

I’m not privy to all the administrative reasons for this crap but it’s really frustrating to see how much money that they have received but won’t put patient safety first… .

As a result of the Cares Act, which supplied funds to various businesses at the start of the pandemic, including for-profit healthcare systems and hospital conglomerates like Providence St. Joseph Health, which secured over 24 million dollars in Coronavirus relief money.  

An art installation depicting Sisters of Orange, the nuns who founded St. Joseph Hospital, in Eureka at the start of the 1918 Influenza pandemic. [Photo taken December 21st, 2020 by Ryan Hutson.]

Taking into account the additional safety measures needed to take care of the COVID care area the extra PPE being worn, the donning and doffing, the separation from other units and additional helping hands, the inherent risk involved with infectious disease- in addition to the existing staffing minimum requirements per Title 22 in California, nurses say they are in a difficult position, having to compromise their own safety in order to provide the best care they can amidst a pandemic where the goal post moves almost as frequently as COVID-19 cases are counted.

Because the hospital staffs according to census, the total bed count in the units which contain COVID-19 patients is able to change slightly with the flow of incoming cases.  Largely, nurses and local healthcare officials agree that the majority of cases recently flowing into the local ER at St. Joes are not COVID-19, but seasonal flu or other emergency matters that quickly fill up hospital beds. While the county is now including ICU capacity data in the county’s COVID-19 dashboard for the first time in the pandemic, it remains unclear exactly how the patients are cohorted within the hospital care setting.  While COVID-19 patients are treated in the RCU as well as in the ER at times, in addition to the recently created Telemetry Unit, the concern remains that in the absence of sufficient staffing ratios, an inadequate staffing plan could result in unhealthy  outcomes for patients  

And the nurses we talked to are worried. They spoke out to us because as one said,  “[We] want to see our staff safe, our patients safe and get[ting] the help they need.”

Screenshot from Humboldt County COVID-19 Dashboard- December 18th, 2020

At the time of publishing, the media liaison and communications director for St Joseph Health in Eureka did not reply to our email requests for input on this article.