Jamille Cabacungan’s shift as charge nurse in UCSF’s medical-surgical unit began with bad news: Just seven of her nine nurses showed up. When a patient’s oxygen fell dangerously low, Cabacungan dropped her paperwork to stabilize the person. When two patients needed security monitoring but no safety attendants were available, she borrowed two nursing assistants and left just one to help 31 patients with toileting, meals and hygiene. When she begged bed-control not to send in another patient, she was refused because the ER was backed up.
That’s when, on a chilly day in February, Cabacungan broke down in tears.
“I just remember feeling ultimate defeat. There was no help!” she said. Her colleagues wrapped their arms around her. “It makes you question what you signed up for as a nurse. I still want to take care of people, but in that moment I just wanted to quit.”
Nurse Jamille Cabacungan stands outside the hospital at UCSF’s Parnassus campus on March 10 in San Francisco. She and many other nurses say they are frustrated by job conditions that have led to a statewide nursing shortage in hospitals.
Lea Suzuki/The ChronicleShe isn’t alone. Understaffing at Bay Area hospitals predates the pandemic, but two years of COVID-19 have made it worse. All told, hospitals in California are short the equivalent of more than 40,000 full-time nurses, a UCSF study reported in August. That’s almost 14% fewer than needed, a shortage the researchers expect to last until 2026 when enough nursing students graduate to match pre-COVID levels.
Older nurses are leaving the profession faster than new ones can begin, and many in mid-career say they can’t wait to leave, the study found. The researchers don’t say exactly why so many nurses are pulling back, but many around the Bay Area offered one surprising explanation: frustration with hospitals.
“They are choosing not to work in hospitals,” said Chuleenan Svetvilas, a Bay Area spokeswoman for National Nurses United, the nation’s largest nursing union.
Svetvilas described a vicious cycle, where nurses like Cabacungan feel they don’t have enough help — and others describe some structural sexism — all leading to greater dissatisfaction, then to more nurses leaving, then to feeling stretched even thinner.
Stories abound about such tensions: A nurse who had to lie on top of a patient — for seven minutes — because no one was around to help her stop him from trying to pull out his breathing tube. An emergency department that routinely turns away ambulances because there aren’t enough nurses to staff the beds. A nurse denied workers compensation for a damaged shoulder after a decade of lifting patients, while other professions with largely male first-responders qualify for the benefit.
Bay Area hospitals have seen a rise in complaints about such working conditions during the pandemic — including staffing levels so low that nurses believe patients are endangered.
Cabacungan filed one about the day that brought her to tears.
Jamille Cabacungan, a UCSF nurse, wears a button that reads “Safe Staffing Saves Live.” Dissatisfaction with working conditions appears to be behind a nursing shortage in hospitals statewide.
Lea Suzuki/The ChronicleIn theory, dangerous shortages shouldn’t happen in California, which limits the number of patients a nurse is supposed to be responsible for on any shift. The maximum is five, with fewer in departments with more seriously ill people.
Nurses who believe the staffing level is too low for patient safety on a given day, or that it creates other problematic working conditions, can file a complaint with their union and employer called an “assignment despite objection.” Hospitals say they don’t track these “ADOs.” But unions keep a close eye on them.
UCSF
2020: 1,216 complaints
2021: 1,764 complaints
Increase: 45%
Stanford Health Care
2020: 46 complaints
2021 190 complaints
Increase: about 400%
Lucile Packard Children’s Hospital
2020: 86 complaints
2021 105 complaints
Increase: 22%
Sources: California Nurses Association, RN Professional Practice Committee at UCSF, and the Committee for Recognition of Nursing Achievement
Bay Area hospitals say they comply with those requirements.
“UCSF prides itself on meeting or exceeding those state-mandated ratios,” a spokeswoman emailed, noting that staff retention rates there are also good. UCSF hospital officials declined to be interviewed.
Stanford Health also declined an interview request but wrote: “Our nurse-patient staffing has at all times exceeded the minimum standards set by California law, and in most cases exceeds our own staffing plans,” throughout the pandemic. Stanford’s nursing staff has grown by 36% in three years, while Lucile Packard Children’s Hospital, also at Stanford, increased its nurses by more than 24%. In all, the hospitals have 1,163 more nurses than in 2019.
Leah McFadden, a nurse in Stanford Health’s surgical trauma unit, agrees that nurse-to-patient ratios have held steady. But she said that has been achieved through constant overtime requests and being badgered to fill in for absent colleagues at the last minute.
“I get text messages almost daily for the ICU, for day and night shifts, because they’re short,” McFadden said. “It’s not sustainable.”
At Stanford, more than 1,300 nurses say they may quit within five years. That’s 41% of the 3,255 nurses who responded to a survey from their union, the Committee for Recognition of Nursing Achievement.
Statewide, the UCSF study found that hospital nurses worked nearly four hours less per week in 2020 than in 2018, dropping from an average of 37 hours to 33. And the percentage of nurses working in any setting — including nursing homes, home health care and doctors offices — fell from 60% to 53% in the same time.
“Employers need to redouble their efforts to retain registered nurses,” the researchers concluded.
Nurses in labor negotiations with San Francisco General Hospital, Sutter Health, Stanford Health and Lucile Packard Children’s say they couldn’t agree more.
Dana Pullman, an ICU nurse at San Francisco General, rallies for safe staffing on March 10. She said she had to restrain an agitated patient alone for seven minutes because no one was available to help.
Nanette Asimov/The ChronicleHundreds of nurses waved signs outside Stanford Health last week, demanding more part-time options and better working conditions, while Sutter nurses have rallied throughout the Bay Area. Dozens also gathered recently in front of San Francisco General, calling out their dissatisfaction with staffing levels.
Dana Pullman, an ICU nurse at the city-run hospital, described a recent ordeal with a patient who awoke agitated from sedation and tried to pull out his breathing tube.
“I had to physically hold this man down,” she said. “I was yelling out for help — but no one was around.”
Seven minutes passed before someone was able to help her. By then, the man had pulled out the IV tubes delivering his medication. “It was an unsafe situation,” Pullman said.
Another sign of understaffing is how often a hospital has to turn away ambulances headed for the ER because there are too few nurses to staff the beds. It’s a “canary in the coal mine” for dysfunction, says a recent study in the New England Journal of Medicine Catalyst.
San Francisco hospitals typically turn away 12% of ambulances. But San Francisco General turns away 60%, the worst rate in the city, according to the San Francisco Emergency Medical Response database. The next highest rate, 18%, is at UCSF.
The San Francisco Department of Public Health said San Francisco General was “significantly impacted by the pandemic,” although the hospital has had the worst rate since at least 2011.
Health officials said they often send ambulances to other hospitals to maintain the necessary nurse-to-patient ratios. But as the city’s only hospital with a full range of care for trauma victims, they still accept every trauma patient and those with a heart attack, stroke or serious burns.
At a labor rally on March 10, nurses at San Francisco General say a shortage of nurses means the ER has to routinely turn away ambulances.
Nanette Asimov/The ChronicleNurses say they are also ticked off that if they get injured on the job, state law doesn’t assume they qualify for workers compensation, as it does for firefighters and police, most of whom are men.
“It’s ridiculous that they’ve just been given that, and we have to now fight for it,” said UCSF nurse Christine Thomas, who woke up with excruciating shoulder pain one morning in 2020.
“I’m an orthopedic nurse, and my shoulders are a body part I use frequently,” she said. “We’re lifting, reaching, ambulating patients, you name it.”
Nancy Uschersohn, a nurse at Lucile Packard Children’s Hospital, rallies outside Stanford Hospital in Palo Alto on March 9. Nurses are in labor negotiations with Packard and Stanford Health.
Lance Yamamoto/Special to The ChronicleBut when she requested workers compensation for her shoulder, which needed surgery, she was told that because the injury wasn’t tied to a specific incident, “it was just wear and tear — and that I’m just getting old,” said Thomas, who was then 37.
An exception for health care workers who get COVID-19 expires this year. State Sen. Dave Cortese, D-San Jose, wants to eliminate the expiration and expand the range of health care workers’ injuries and illnesses presumed to be job-related. His bill, SB213, is making its way through the Legislature.
Opposing the bill is the University of California Office of the President, which oversees UCSF and five other UC hospitals.
“I’m not blind to what’s happening in the industry,” said Alicia Minutoli, a nursing student at City College of San Francisco.
“I’ve had people ask me, are you sure you want to be a nurse? What about the burnout? Have you heard about how nurses are treated at work? What about COVID!”
She credits her instructor Joyce Coffey, a veteran nurse at Sutter Health, with sharing a passion for nursing — but never sugar-coating the problems.
Yet Minutoli, who is studying pediatric oncology, hasn’t wavered.
“When I’m in the hospital setting, I feel that I’m right where I need to be,” she said. “Nursing is, without a doubt, a calling for me.”
Nanette Asimov is a San Francisco Chronicle staff writer. Email: [email protected] Twitter: @NanetteAsimov
