For weeks, Kelly Stanton wasn't sleeping. She lay in bed gripped with the anxiety of having to go to work at a Washington, D.C.-area hospital not knowing whether she might bring home the coronavirus to her husband and their three children.
It was inevitable, she thought. She wasn't protected.
Stanton, a nurse for 28 years, had seen federal safety protocols for health care workers begin to crumble amid the pandemic by early March.
Guidelines from the Centers for Disease Control and Prevention regarding personal protective equipment, or PPE, changed consistently. At Stanton's hospital, nurses were told that they would have limited access to an already low stockpile of protective equipment and were being asked to reuse single-use masks multiple times, she said.
"Never in my time as a nurse have I seen this," she said. "It was a position I could never have imagined I'd be in, even in my wildest dreams."
Each time a safety regulation changed, she said, she began to feel more like "a sheep sent to slaughter" than a front-line nurse, and she started agonizing between her job and her family.
By late March, the risks weighed too heavily, and Stanton submitted her resignation.
"It was an extremely difficult decision, but as a mother and wife, the health of my family will always come first," she said. "In the end, I could not accept that I could be responsible for causing one of my family members to become severely ill or possibly die."
As COVID-19 has infected more than 1 million Americans, nurses working on the front lines with little protective support have made the gut-wrenching decision to step away from their jobs, saying that they were ill-equipped and unable to fight the disease and that they feared for not only their own safety but also that of their families.
Many of these nurses, who have faced backlash for quitting, said new CDC protocols have made them feel expendable and have not kept their safety in mind, leaving them no choice but to walk away from a job they loved.
'We're not cannon fodder. We're human beings.'
As the nation took stock of its dwindling medical supplies in the early days of the pandemic, CDC guidance regarding personal protective equipment quickly took a back seat.
Supplies of N95 masks, which had previously been the acceptable standard of protective care for both patients and medical personnel, were depleting, so commercial grade masks, surgical masks and, in the most extreme cases, homemade masks, such as scarves and bandannas, were all sanctioned by the CDC — which didn't return a request for comment — to counter the lack of resources.
Nurses, among other health care workers, were expected to pivot and adapt with no evidence to the view that new guidelines would provide any significant protection from a novel and contagious disease.
"Things they were telling us we had to now do, you would've been fired if we did that three weeks before," Stanton said. "How is this suddenly OK?"
There had been warning that a pandemic was coming, she said. "Hospital administrators, states and the federal government should have stockpiled PPEs. All three failed."
COVID-19 patients had only slowly started trickling in, but Stanton could see where things would head. It was almost guaranteed that nurses would be at risk under those conditions, she said.
"We're not cannon fodder. We're human beings," she said.
In many respects, nurses who have had to treat COVID-19 patients with little or no protection, especially in the early days of the pandemic, have become collateral damage.
Nearly 10,000 health care workers on the front lines, including nurses, have tested positive, according to a preliminary survey the CDC conducted from February to April.
Because data collection has been slow and not comprehensive and many people with COVID-19 have been asymptomatic, actual numbers are likely much higher.
At least 79 nurses have died from the coronavirus, the American Nurses Association, which has been independently tracking reports, said Thursday.
"There are huge ethical dilemmas that nurses are now facing," said Liz Stokes, director of the American Nurses Association Center for Ethics and Human Rights.
"Just imagine having to make decisions every day on whether you're going to fulfill your professional obligation to care for patients versus sacrificing your personal safety or even that of your family because you're in a situation where you don't have adequate resources."
Nurses have a duty to their patients, but they also have a duty to themselves under the nursing code of ethics, Stokes said. Those are equal obligations, and if you feel morally torn, you have to make the decision that's right for you, she said.
Stokes added that it's also important to be thankful for the nurses who have decided to step away because they recognized that they weren't in the best situation physically or mentally to provide care.
'No, we didn't sign up for this'
For Rebecca, a nurse in the Albuquerque, New Mexico, area who didn't want her full name used for fear that she won't be rehired, the writing was on the wall when she saw a member of her hospital management collect all N95 masks from her floor and lock them in a cabinet in early March, before the country went into full-blown crisis.
"It's really demoralizing to see someone lock them up in front of you knowing that you might need one of those," she said. "The whole scene was very symbolic of how all this was going to go down. And it was a bad sign for what's to come."
Rebecca, who has been a nurse for four years, said that communication and infrastructure began to break down fairly quickly and that nurses were expected to make terrible compromises.
Masks were rationed to one per week and sometimes shared. Only nurses who dealt with patients who tested positive for COVID-19 were given an extra N95 mask, even if the patient showed symptoms.
During one 16-hour shift, Rebecca was repeatedly in close contact with a patient who later tested positive — and she wasn't wearing a mask.
"I knew it was something I could no longer handle," she said. "I know my limitations."
Rebecca quit in mid-April, one week after she tested negative for COVID-19 after exposure to the patient.
Since quitting, she has been sensitive to the criticism many nurses like her have faced for stepping away during a pandemic. That's why many of them have kept their decisions private, she said.
It's especially hurtful when she reads comments on social media that nurses shouldn't raise complaints because they "signed up for this."
"We didn't sign up to be sacrificial lambs. We didn't sign up to fight a deadly disease without adequate resources," she said. "We're told we're soldiers. Well, you don't send soldiers to war without a gun and expect them to do their job, but you are doing that to us."
The sentiments have been shared by thousands of other nurses who feel they are also being put in dangerous environments.
Last month, the New York State Nurses Association, representing more than 3,000 nurses, filed three lawsuits against the New York State Health Department and two hospitals over the health and safety of nurses treating COVID-19 patients.
Among other things, the lawsuits call out the state for not providing appropriate protective equipment for nurses, not properly training nurses deployed from hospital units and not providing safe enough working conditions for high-risk employees.
While the Health Department declined to comment directly on the lawsuit, it did say it was "deeply grateful for the ongoing efforts of New York's health care workers to reduce the spread of COVID-19 by testing people who may be infected and treating those who are most in need."
Quitting has been on the minds of many nurses, said Cara Lunsford, a nurse who founded Holliblu, an online community for nurses.
According to a survey conducted by Holliblu, 62 percent of over 1,000 respondents said they are planning to quit either their jobs or the profession altogether.
"They didn't sign up to go into work and be unprotected from an invisible enemy, and the pressure is really starting to mount for a lot of nurses," Lunsford said.
This is an unprecedented time, and nurses weren't trained to be soldiers or handle biological threats with little protection and resources, she said. And if they leave for their sanity or safety, they shouldn't be treated as defectors.
Constantly being anointed a "hero" by the public also hasn't helped the added pressure, Rebecca said. While it's a nice gesture, it gives the connotation that you should be risking yourself without help and that if you don't you're a "coward."
She added that several colleagues reached out to her about wanting to quit after she left but that many just don't have the option.
"I've realized that I'm very fortunate that I had a choice," she said. "A lot of nurses have student loans, car loans, and they are single parents. They can't quit, and that bothers me, because they are being taken advantage of right now."
'It was one of the most difficult decisions of my life'
Kate, who didn't want her full name used for privacy, quit her job at a Virginia hospital in April after she was pulled from her floor as a post-anesthesia care unit nurse and reassigned to critical care after only four hours of training.
Throughout her hospital, protective equipment was siphoned for COVID-19-positive patients, but with testing not fully widespread, she never knew whether someone was infected, and worse she, didn't know whether she was bringing it home.
Kate would go directly to the attic and quarantine away from her husband and children after getting home from work. But the emotional toll was high, and she could no longer be away from her 1- and 3-year-old children.
She knew she had to walk away from her job.
While putting her family first has got her through the painful decision, she still feels tremendous guilt for leaving.
"It's not just a job, it's a calling, and to walk away from it is extremely difficult and painful." she said. "I wish I could have stayed with my patients. It's not like I didn't want to be there."
Had masks been available and pre-pandemic precautions preserved, "without a doubt I'd still be working," Kate said.
Stokes, of the American Nurses Association, said: "One of the issues that we are trying to emphasize is that nurses must be supported in whatever decision they make, whether they take the risk or choose not to take the risk to protect families.
"It's a heart-wrenching decision, and many nurses have expressed that they feel sadness and sorrow that they are leaving their colleagues and patients. It's a difficult decision, and that in itself can be emotionally traumatic."
Stokes believes the psychological consequences of putting nurses in these dilemmas will be profound and long-lasting. She predicts high levels of post-traumatic stress disorder and secondary trauma syndrome trailing the pandemic.
"Nurses were already burned out before, and this pandemic might push many of them completely out," she said.
The mental health toll on medical workers was put into sobering perspective after New York City emergency room doctor Lorna Breen died by suicide. A hotline created by physicians to help doctors deal with the anxiety of combating the crisis said it averages up to 20 calls a day. Another hotline, For The Frontlines, has also been set up as a 24-hour resource for other health care and essential workers.
"I would anticipate increased apprehension possibly extending into anxiety or mood problems," said Dr. Sheetal Marri, a psychiatrist, referring not only to nurses who continued to work but also to those who stepped back. "These effects will impact the way nurses and other health care professionals will deal with workplace health hazards even after this pandemic is over."
Stanton said she would like to return to nursing but only once guidelines are restored and she can feel safe going to work again. While she is taking this time to focus on her family, she still misses her job.
"I loved being a nurse. You do it because you care, you want to help people," she said. " But right now, nurses don't feel like heroes. We feel expendable."
If you or someone you know is in crisis, call the National Suicide Prevention Lifeline at 800-273-8255, text HOME to 741741 or visit SpeakingOfSuicide.com/resources for additional resources.