Fear, stress, sadness and frustration are rampant among Montana's thousands of nurses and other front-line health care workers, some have told the Missoulian, as they work under duress in the midst of the deadly coronavirus pandemic.
Almost all nurses in Montana been denied hazard pay in negotiations with their employers across the state. Turnover rates are higher than usual as some of these healthcare workers decide that even though they're passionate about caring for people in desperate times, the physical danger and mental anguish just isn't worth it anymore.
"It's feeling burnt out," explained Jeff Notar, an intensive care unit nurse at St. Patrick Hospital in Missoula. "The things that go along with that are apathy and a lack of caring. That in and of itself is really hard to deal with. I'm an introspective person so I don't feel good that I feel that way. There's just a heightened level of stress with a virus you don't want to catch and you don't have a whole lot of treatments for."
Notar contracted the virus in December.
"There's no doubt in my mind it came from work, but I can't prove it," he said. "A lot of us had exposure to one patient in particular."
Notar and another ICU nurse at St. Pat's who believes she contracted COVID-19 at the hospital, and who asked to remain anonymous, confirmed to the Missoulian that 15-20 ICU nurses at the hospital have contracted the virus, and about eight got it in a single cluster in December.
"I don't know if the ventilation blew the wrong way or what, but we all tested positive within a week of each other," Notar said. "A couple nurses passed it on to a family member or two."
In interviews with the Missoulian, nurses across western Montana have described watching as hundreds of their colleagues contracted the virus. In a profession dominated by women, many with families and young children at home, nurses also say there's isn't enough of a financial incentive to quarantine every time they feel sick. And after months of watching people suffer, struggle to breathe and die alone, nurses that spoke to the Missoulian also described feelings of outrage and disgust that Gov. Greg Gianforte has decided to rescind the statewide mask mandate (although the mandate will remain in effect in Missoula County).
It's all taking a toll on mental health.
"Dealing with the ICU, we're seeing the worst responders to the virus out of all patients," Notar explained. "If that's all you see, then you think 'if I get this, that's going to happen to me.' Am I going to end up on a ventilator? My mental health is tenuous. A lot of us are feeling tenuous."
He said the hospital's medical administration has been supportive about ensuring everyone is getting mental health treatment if they need it, but the contract negotiations in the midst of the pandemic were "super stressful."
"There's a higher degree of burnout now than there's ever been," he said. "I think people are a little apathetic about the contract, because the contract is one of the easiest things to remove from the mind to free up bandwidth to deal with work."
Unlike other professions, in health care, workers can never stop thinking about the virus, Notar continued. It's nonstop at work, he said, and then they have to take even more precautions at home in order to make sure they're not bringing it to work.
"It's COVID overload," he said. "It's the stress of wearing gear, the stress of the job, the stress of getting the virus and wondering if the gear is working or if this guy coughing right next to me, literally coughing in my face, is giving me a big hit of coronavirus."
At St. Patrick Hospital, nurses now have to do more work because they're covering phlebotomy tasks and cleaning rooms, too.
"To get through a day you have to expend two times the units of work," he said. "Some days it's three or four units of work. But we're getting the same time off, the same amount of vacation, the same amount of sick pay. The total amount of work is higher and the stress is higher. And I would say the repercussions for failure are higher, too. Then you want to throw in the interaction with family members of patients."
Notar said the cumulative toll of seeing so much death is a burden.
"I watch these people that are struggling to breathe all day long," he said. "It's not humane to watch people struggle to breathe for 12 hours, to see eyes get wide when they get a little anxious because they can't breathe, or they can't breathe because they're anxious."
He said in normal times, there's more than one nurse in a room to help a person feel comfortable.
"Now you have to watch them struggle alone," he said. "And we don't have as many other therapies. It takes longer to get into a room to try to minimize exposure. It all just takes longer and is more complicated. There's a lot to it."
Vicky Byrd, the CEO of the Montana Nurses Association, said her organization represents about 3,000 nurses in Montana in 30 local units across the state. She said that in every hospital in Montana that has had contract negotiations since the pandemic began, none were able to negotiate hazard pay. The U.S. Department of Labor defines hazard pay as additional financial compensation for performing hazardous duty or work involving physical hardship.
"The only place that received hazard pay was the Montana Department of Public Health and Human Services," Byrd said. "We are getting workarounds, memorandums of understanding in place, so they are getting time-and-a-half and extra pay in exchange for coming in for their seventh or eighth shift in a row. But none of them have hazard pay."
Nurses are under significant mental and physical duress during the pandemic, she explained.
"Nurses are really resilient and strong, but they're tired and they are being overworked," she said. "They are rationing Personal Protective Equipment, and that doesn't sit well. They're getting called every single day on their days off and many are being asked to work harder and longer hours."
Providence spokeswoman Stacy Rogge said the hospital recognizes the critical nature of burnout. St. Pat's provides an assistance program providing support for personal and work-related problems, a confidential Behavioral Concierge Program with same-day appointments, a peer-to-peer support system, tele-spiritual health counseling and other services. The hospital also provides paid pandemic administrative leave when applicable for exposure or symptoms, added pay benefits for those who've missed work due to COVID exposure, and emergency day-care benefits. Its in-network medical insurance covers 100 percent of COVID-19 treatment through March 31, 2021, for enrolled caregivers and their dependents.
Byrd said about 16% of nurses in Montana have contracted COVID-19. The fatigue of constantly wearing PPE for long shifts, months on end, is also taking a toll.
"Some nurses are getting mouth sores and lip sores from the N95 masks," she said.
She said there's been an increase in nurses choosing to quit or retire this year.
"Some nurses have chosen to retire," Byrd said. "The average age of a nurse is over 50, and it might even now be 55. It's really an older workforce. They are most at-risk, and many have preexisting conditions. You throw in diabetes and heart issues and cancer and we have got a real issue. The whole nation is understaffed. All 50 states are crying for staff. It ain't gonna do no good to rob Peter to pay Paul. Staffing is always an issue and it's exacerbated by the pandemic."
Young nurses have entered a trial-by-fire this year, she noted.
"Now we have brand new nurses coming into the workforce and burning them out," Byrd said. "Being a new nurse, can you imagine in this pandemic, you and your coworkers are working 6,7 or 8 days in a row? And you're brand new? It takes resilience. We try to offer as much professional development and as much support as we can."
Rogge said in anticipation of the COVID surge, Providence-St. Patrick Hospital began the use of nurse “travelers” in Oct. 2020. The State of Montana offered the use of statewide nurse travelers in Dec. 2020 — paid for through disaster funding. Currently, the U.S. National Guard continues to provide support services at St. Pat’s.
Byrd said that because the majority of nurses are women, the burden of child care at home often falls on them.
"My niece is a nurse, and she works the night shift at a local facility," Byrd said. "I told her to call me every day. I told her it's OK to say 'no' to extra shifts. Take care of yourself. Many are trying to take care of family or trying to school kids at home. It's the perfect storm."
Byrd said the Montana Nurses Association vehemently disagrees with Gov. Gianforte's decision to rescind the mask mandate.
"We will push back on that," she said. "We will encourage everybody to embrace science and evidence and data because nurses and health care workers are taxed. That will not improve things. Social distancing and washing hands and putting on a mask are simple things we can do to take care of each other."
Byrd said Gianforte's decision to rely on "personal responsibility" is destined to fail.
"We know personal responsibility doesn't work," she said. "Look at state lawmakers showing up to work and refusing to wear masks. It doesn't set a good example for any citizens. Are those lawmakers going to turn down a ventilator when they need it? I can say that because I'm an RN. They're coming in to our community here. I live in East Helena. I don't want them taking my mom and dad's ventilator because they chose not to wear a mask."
Jeff Notar, the ICU nurse at St. Pat's, said nurses at St. Pat's have negotiated an extra $6 per hour for working extra shifts, but that's below the extra $15 per hour given to nurses in Great Falls.
"The hospital administration didn't want to discuss anything about coronavirus during negotiations," he said. "That put us in a position where we have a contract that doesn't consider the unique situation of being in the middle of a pandemic. Negotiating in the middle of a pandemic super sucks. We were stressed out. But the administration was not interested in budging."
Rogge said the hospital "does not offer hazard pay based on any one particular patient's diagnosis (or suspected diagnosis); however, our facilities do have a variety of pay incentives that are offered to caregivers, including 'extra shift incentive' pay for picking up extra shifts in times of greater patient volume, or bonuses for taking additional on-call shifts or extra shifts in general.
"We have regular dialogue with our nurses about pay, incentives and benefits during the pandemic," Rogge said. "We have provided extra shift incentives for nurses and staff."
Notar said Missoula nurses have noted that they make less than nurses in Anaconda, and many are tempted to take other jobs with less stress and higher pay.
Notar also recalled that during the initial lockdown in March, the hospital was "grossly" overstaffed. But because the contract the nurses had negotiated didn't include anything about the virus, the hospital couldn't cancel shifts. So the hospital asked the nurses to approve a new contract that would allow the hospital to cancel shifts when the hospital was overstaffed.
"Of course nobody voted for it, because to our detriment, the administration had refused to discuss coronavirus during contract negotiations," Notar said. "Maybe if they had, they could have helped themselves, too. It kind of goes both ways."
Notar said he couldn't believe that Gov. Gianforte would rescind the mask mandate.
"I'm speechless," he said. "I'm absolutely speechless. That follows suit in keeping with the continuing politicizing of masks. It's an insult to grocery store workers, it's an insult to people on the front line, even though I hate that phrase. It's an insult to people that have died of coronavirus. It's an insult to the health care system and an insult to people's health."
Notar compared mask wearing to other simple but effective death prevention measures.
"If we removed the seat belt law, people would keep wearing seat belts," he said. "But the sad reality is sometimes people have to be told what to do. People will do things that are deleterious to their health. Kids that are 14 would go buy cigarettes without laws. Wearing a mask is no more an infringement on rights than wearing underwear. I have to wear one for 12-and-a-half hours and a face shield every day. I don't think Greg's helping anybody out."
Notar said some hospitals in Montana are "overrun" with COVID patients and the problem could get worse.
Notar's colleague, a nurse who asked to not be identified, said she recently took another less-stressful job due to the anxiety this year.
"The patient that triggered my eventual departure from the ICU was cognitively impaired and nonverbal and had contracted COVID due to community spread within his group home," she told the Missoulian. "He could not understand what was happening, and he was also unable to communicate aside from nonverbal indicators of extreme panic. The fear was confounded by our need to wear protective equipment, which is inhuman and was rightfully perceived as scary. The innocence of high-risk patient populations is something that we all need to think about when COVID precautions are not followed."
She contracted COVID in December, she believes at work, and said her family was frightened.
"It is one thing for a Montanan to take a self-perceived risk, but we are all in this together," the nurse said. "When I mask and distance, it is for my mother-in-law caring for her elderly mother," she said. "It is for my friend's 2-year-old daughter, who has been undergoing chemotherapy and is immuno-compromised. It is for my kids and family and everyone I do not know. We all need to come together as a community to help our neighbors make it through the pandemic."
The nurse said watching people die is a regular part of the job, but it's more traumatic during the pandemic for both the patient and the nurse.
"One of the largest contributors to the traumatic components of COVID is related to the sadness expressed either verbally or physically by the patients," she said. "This, in part, is related to quarantining away from their loved ones and the distress caused by the uniquely terrifying dying process secondary to COVID. When patients are hospitalized, they do not have regular human interactions such as hugging, holding hands, making their dinner, petting their dog, going outside for fresh air."
The nurse said physical touch during the last moments of life is taken for granted when there's not a pandemic.
"Even when COVID patients are dying, their loved ones cannot touch them," she said. "The entire process of PPE creates a two-glove barrier between the patient and others," she said. "While families are saying goodbye, it is through an N95 mask, a gown, a face shield, and two pairs of gloves."
Nurses take on an additional emotional burden when someone who can't be near family is dying, she explained.
"When you read about these people passing and the statistics, it can be dehumanizing," she said. "But when you see how hard it was for them to pass, how long that struggle took, and the emotional ramifications of it ... they are spending days and weeks away from their family. It's not like they just have a heart attack and die. Before COVID, the family could be there for people passing. There was a whole process for the community to be able to support them and their families."
She said the virus is "alienating" and that means nurses play the role of family in the last moments now.
"We, as nurses, are helping them," she said. "When they pass, it feels like a relative is passing. You insert yourself in their family. You are the voice for their family. The empathy is different than what it had been before COVID."
This is the first of a two-part series looking at how nurses in Montana have been affected by the coronavirus pandemic. Read the second part in Monday's Missoulian.