ATLANTA - Carey Mullis believes she was put on this earth to nurse. But she's not sure whether she can take the pandemic's toll in her South Georgia hospital anymore.
COVID-19 has turned Georgia's chronic nursing shortage into a crisis. As exhausted staff bear the crushing fourth wave building from the delta variant, many COVID-19 nurses with long experience are quitting, moving to calmer jobs or barely hanging on.
In a state that already had one of the nation's lowest ratios of nurses to population, job postings for nurses jumped by double-digit percentages in each of its regions in 2020, then jumped again. About 11,000 nursing positions across the state sit vacant, according to the nursing job service Vivian. More than 1,700 of those are in intensive care units.
It's not close to over: A recent survey by Vivian found 43% of nurses nationwide are considering leaving health care.
As cases soar, hospitals and staff once again describe treating patients in meeting rooms, hallways and any available space. Yet they are having to scale back services for lack of staff.
Hospitals from Piedmont Henry County to Phoebe Putney in Albany to Augusta University Health have halted elective surgeries. Marietta's Wellstar Kennestone regularly closes sections of its emergency department for lack of nurses, according to staff.
When replacement nurses can be found, they're often new graduates or temps from other states or countries like the Philippines, as desperate hospitals pay top dollar to staffing companies scouring the globe.
In the midst of it all, something has changed: a tired public, younger victims, shattered hopes that the pandemic was ending. The applause of spring 2020 has faded. Patients and their families can get angry, sometimes citing misinformation about the virus or barking when asked if they're vaccinated.
The only no- or low-cost way to stop turnover is to treat nurses with more kindness and respect, an Emory researcher said. But people's tempers are short.
At Colquitt Regional Medical Center's emergency room in Moultrie, it's all very personal for Mullis.
"I can't blame the people who have left, and I can't even say that I haven't considered leaving many times lately," Mullis said. "We're giving all we have to these people, and sometimes they're just not making it. Lately it's been 20- and 30-year-olds, not just the elderly people it's just been so much, back to back to back."
A vicious cycle
Georgia has 141,000 nurses licensed, a number that has stagnated for a decade, growing only slightly as the population surged, according to research led by Jeannie Cimiotti, an associate professor in Emory's School of Nursing.
Even before the pandemic, those who stayed in the profession were often exhausted and felt powerless in workplaces that too often failed to help them or ignored their ideas about improving patient care, Cimiotti said. Health care systems have balked at spending money to hire more nurses, and decades of advocating for state-mandated workload limits have failed.
Burnout poses risks to patients, she said. Nurses can experience fatigue, struggle to concentrate and have trouble making decisions. Research shows that hospital-acquired infections and other health problems can increase.
The Georgia Center for Nursing Excellence works with state officials to identify staffing trends. In 2020, there were 8,000 more job openings for Georgia than the year before, said the center's CEO, Pat Horton.
"There's a shortage everywhere we look," she said.
Shortages create a vicious cycle, further exhausting the remaining nurses.
"They are in the battlefield for our patients right now," said Georgia Board of Nursing President Tammy Bryant. "There's not enough of them. They're being burnt out. You know, we thought we had this under control as we got to fall; and now we're back in the second upswing. So they're tired now."
Gov. Brian Kemp has put hundreds of millions of dollars into hiring contract staff, but Georgia is competing with other Southern states that are also deluged with COVID-19 cases. Under Georgia's state of emergency order, the nursing board has issued temporary permits to get nurses in the field more quickly and for retired nurses to come back. Including permits solely for the purpose of administering vaccines, those total 10,766.
None of it has solved the shortage. And it's hamstringing every health care provider, not just hospitals.
"We're in a staffing crisis," said Neil Pruitt, CEO of PruittHealth, one of the largest long-term care providers in the Southeast. Pruitt said he had resorted to a pilot program of bringing in nurses from the Philippines, which he said costs about $40,000 per nurse just to make the hire. PruittHealth has had to limit admissions at some of its nursing homes because it can't hire enough frontline workers to adequately staff the facilities.
Nearly a dozen state contractors were already assigned to Coffee Regional Medical Center as the current surge from the delta variant hit. Worsening conditions forced them to request an additional 24, said Vicki Lewis, its president and chief executive officer.
The patient census has run over capacity for days on end. Some two-thirds of the patients in the 98-bed hospital tested positive for COVID-19, and nearly all of them were unvaccinated. Severe pneumonia is common among those patients, and last week, the Georgia State Patrol rushed borrowed ventilators to their door.
South Georgia State College and Wiregrass Georgia Technical College are training new health care workers to pitch in at Coffee Regional. Enrollment at nursing schools across the state seems to be holding steady or doing well, officials said, perhaps driven by a desire to help or the new prominence of a solid profession.
But how many of those students will graduate, especially given the complications of getting clinical experience, is an open question. In March 2020, many hospitals barred nursing students from entering their doors because they didn't have enough masks to protect them from the virus, and their schools had trouble finding protective gear.
One local nursing class started with 30-some students, said Tonia Garrett, Tift Regional Medical Center's chief nursing officer. Six stayed on course for graduation.
As Garrett spoke of Tift's situation last week, the hospital had run out of beds, and two dozen patients were stuck in the ER waiting for admission. Twenty of her nurse managers and nurse educators had stepped out of offices and gone back to the front lines to fill in staffing holes. The COVID-19 patient count is near Tift's previous peak, with no sign of slowing.
"It's just amazing how quickly that this is escalating," Garrett said.
She understands she can't keep every nurse. Her fallback is to try to at least keep them working for her health system if they leave the front lines and to rotate other nurses in. Tift also encourages therapy groups for nurses to talk about what they've been through.
"Those nurses that were in ICU this time last year that are still there, that's the ones that have struggled the most emotionally," Garrett said.
Hospitals say they put safety as paramount and staff accordingly, but critics say some of the blame for nurse attrition lies with hospitals themselves.
Gerard Brogan, a nurse and director of nursing practice at the union and professional organization National Nurses United, maintains that in recent decades, hospitals have cut registered nursing staff to boost their bottom lines. Experienced leaders and go-to experts disappeared as less expensive health care workers such as licensed practical nurses and certified nursing assistants shouldered more of the work. During short-term surges, hospitals brought in in high-priced visiting nurses.
This approach doesn't work in a global pandemic where hospitals across the nation are scrambling for nurses.
"We've been railing against this for many years, knowing as the hospital industry does that there will be a pandemic," Brogan said. "It was never a question of if, it was a question of when."
'Nurses coming and crying'
Joey Ellerbee, a nurse who lives in Woodstock, has been the nurse thrust into leadership as his hospital got swamped. When the pandemic had lulled, some employees were furloughed. Now that the lulls have turned back into waves, he realized many of his coworkers never returned.
"I don't know where they're at," he said. "I guess they all left nursing, I don't know. Because it's bad everywhere across the country, and if they all went to travel (as contract nurses), then why is it still so bad all across the country?"
Ellerbee was promoted to charge nurse in Wellstar Kennestone's emergency room. On good days, filling in to treat patients, with great teammates, there was nothing better, he said.
There hasn't been a good day in months.
As the hospital wards overflow, the ER becomes a holding zone for patients requiring a bed, even though they're not specially designed to keep staff safe from COVID-19. Hospitals try to house those who test positive in special negative-pressure rooms that suck away air contaminated by virus droplets.
The stress from that is compounded at times by the change in patient attitudes.
"It's not like the beginning, when everybody was understanding, and they saw what we're going through and dealing with," Ellerbee said. "Now it's like they're pissed off because they're sitting here wondering why they can't get a room."
He recently transferred out, to the intensive care unit meant for patients who've been wounded, for example in crashes or violence.
Back in Moultrie, Carey Mullis' supervisor is watching to see what she does. Mullis has been open with her boss, Toni Leigh Bullard, especially in the last two weeks, coming to her in tears.
"She's fabulous. She really is one of our strongest nurses," Bullard said of Mullis.
"We've dealt with a lot of death throughout our times, not just with COVID it's the defeat now that you see. You know you've seen nurses coming and crying, or leaving work crying. Just because they don't feel like they can do enough. It's devastating.
"You walk through the nurses' station and you hear it every day," Bullard said: "'I'm not sure how much longer I could do this.'"