On March 31, Florida emergency room nurse Naomi Moya took a big risk. Though her hospital didn’t allow staff to wear N95 masks when treating patients who were not diagnosed with the coronavirus, Moya brought one from home and put it on to protect herself.

A supervisor noticed the N95 right away and ordered her to remove it.

“I have my own supply,” Moya recalled saying. “It’s protection for me and you and my coworkers and the community and my family when I come home.”

The impasse was polite, but both sides held firm. Thus, at the height of a pandemic, when there’s a shortage of nurses, Moya stepped away. She and the hospital agreed that she would go on unpaid leave.

Clinicians across the country are weighing similar choices when their hospitals lack the protective gear they believe they need to care for patients. A New Jersey doctor said she left her urgent care position because of safety concerns. “This is an unstable situation with a novel coronavirus with a company that could be protective but is not being adequately protective,” she said.

In North Carolina, Angela Allen said she watched warily as the coronavirus spread, waiting for her hospital to do something to protect the staff. Administrators considered the psychiatric unit where she works as a nurse “low risk,” Allen said. By mid-March, she said she asked for the staff to be tested for the coronavirus, so they could also be sure to avoid infecting the patients, and her manager said that wasn’t necessary. “If we can’t rule out that we are carriers then we have to assume that we are,” Allen said. “And if you’re not giving us the right equipment to at least protect our patients, then I can’t do my job.”

Allen said she didn’t quit but took a leave of absence and hasn’t been back since March 19.

ProPublica spoke to 15 doctors and nurses from New Jersey to California to North and South Carolina who said their administrators have normalized poor infection control practices — putting them at risk and likely spreading the virus. A study published Tuesdayby the Centers for Disease Control and Prevention found that health care workers are getting infected at high rates, which also makes them a source of transmission.

ProPublica and others have reported on staff who were suspended or fired for bringing their own gowns and masks and other protective equipment, or speaking up about it. But clinicians are saying there’s an even deeper problem. The conditions are so unsafe they’re being forced to choose between their livelihoods and risking their lives — and that means some are walking away.

Moya works at AdventHealth Heart of Florida, a 193-bed facility in Davenport, near Orlando.

AdventHealth did not respond to ProPublica’s questions about Moya. But it said in a statement that it does not have a shortage of N95 masks or other gear. Its statement said staff are not allowed to wear masks unless they are issued by the hospital, to ensure they are medical-grade and properly fitted. The N95 masks are provided to staff who care for suspected or known COVID-19 patients, the statement said.

Lowering Infection Control Standards

In the upside-down world of American health care in the era of coronavirus, a nurse in an N95 is often considered both safe and defiant.

N95 masks are superior to surgical masks for coronavirus protection, but like many hospitals, AdventHealth Heart of Florida has restricted their use.

But the policy doesn’t account for the spread of disease by people who have not yet tested positive or who aren’t showing symptoms, Moya knew.

“We know the disease process,” Moya said. “I don’t know who may be infected or not.”

The United States was caught so unprepared for the pandemic that hospitals don’t have enough N95 masks and other important gear. So facilities have been lowering their infection control standards — and demanding compliance from staffers.

Moya had been prepared. She purchased her own N95 masks, and on that final day of March she put one on under the surgical mask AdventHealth had given her.

When she was told to remove it, she got called to the office of the emergency department director, she said, who told her if she wore the N95 other staff would also want one. Also, the hospital didn’t want patients to feel scared by seeing everyone in a mask, Moya recalled the director saying.

Moya is known for her calm demeanor, according to a nurse who works with her. She speaks English, Spanish and American Sign Language and is nonplussed by even the most aggressive patients.

The problem isn’t just a lack of supplies, Moya and other clinicians who spoke to ProPublica said. The administrators are not acknowledging the hazards, causing a breakdown of trust.

“They know this is real and that people are dying,” Moya said of her administration. “Would you send a firefighter into a burning building without appropriate gear?”

The Joint Commission, which establishes quality and safety standards for hospitals, accredits AdventHealth. It put out a statement on March 31 — the same day Moya went on leave — supporting clinicians bringing their own face masks, including N95s, to work. “It is better to allow staff the opportunity to enhance their protection, even if the degree of that increased protection is uncertain,” the statement said.

Moya said she went on unpaid leave at great cost, having to defer her mortgage and car payments. She wants to return to her job. AdventHealth is a large organization that operates in nine states. It should be aware of the Joint Commission’s recommendations, she said. It’s also a Christian organization that pledges to “extend the healing ministry of Christ,” she said. So it should do better at the command to “love thy neighbor,” she said, when it comes to protecting its staff and patients.

Clinicians Getting Silenced

Most of the clinicians who spoke to ProPublica would not speak on the record because they feared retaliation. They said their administrators have been changing policies to try and adapt to the pandemic. But the rules are often not consistent with what’s known about the virus.

A nurse in northern New Jersey said her hospital is reassigning staff to units for which they may not have adequate training. One supervisor suggested that refusing an assignment could result in a complaint against the nurse’s license, the nurse said. “My problem is they feel like they own us or something,” the nurse said.

Kate McLaughlin, a nurse who runs the advocacy organization NJ Safe Ratios, said she has heard of hospitals threatening to file complaints against nurses’ licenses if they quit or refuse to take assignments they consider unsafe. The intimidation “will make nurses reconsider whether they should come back to the bedside,” she said.

The widespread nature of retaliation against health care workers who complain about the lack of personal protective equipment led to the creation of Beacon, a nonprofit advocacy organization in Massachusetts. Dr. Sejal Hathi, a co-founder of the group and a resident at Massachusetts General Hospital, said Beacon sent a letter Thursday to hospitals that had suspended or fired workers, demanding fair treatment and threatening legal action if they didn’t respect the rights of their staff. Health care workers are being forced to choose “between professional duty and personal safety,” Hathi said. “Those are competing ethical and existential obligations.”

Allen, the North Carolina nurse, works in a unit that’s part of the emergency room at Mission Hospital in Asheville. She has launched a website, The Unmasked RN, to give voice to nurses around the country who believe they are being muzzled. “We have executives making medical and scientific decisions without consulting the people who went to school for this,” she said.

April Creamer, a behavioral health technician who works with Allen, said she is also thinking about leaving Mission Health because of the conditions. She’s been told the hospital has N95 masks, but the management doesn’t think they’re necessary in the psychiatric unit, she said. “For a while they were not providing us with any protection,” Creamer said. “They were ignoring the fact that COVID is a real thing.”

Mission Health spokeswoman Nancy Lindell said in a statement that “all our departments are appropriately equipped with hygiene supplies for both our staff and patients.” She did not address the specific concerns raised by Allen and Creamer.

Many hospital executives say publicly they have the gear to keep their staff safe. But then their workers say they are not getting what they need.

Mark O’Halla, president and CEO of Prisma Health in South Carolina, gave a reassuring message in an April 8 video. “We have plenty of personal protective equipment to cover all of our employees and team members across the system,” he said.

But two Prisma Health nurses who spoke to ProPublica said that has not been the case. Both the nurses said they have not been given N95 masks for use throughout their shifts and that staff have not been allowed to bring them from home. They said nurses have resigned because of the lack of protective equipment. Others were sent home with threats that they would be fired. Still others are looking for other jobs, the nurses said.

Prisma Health told ProPublica in a statement that it “is able to provide the appropriate personal protective equipment for treating suspected or confirmed COVID-19 patients.” Prisma has “sufficient stock of surgical masks” which are “deemed appropriate for COVID-19 patient contact excluding aerosol generating procedures,” the statement said.

Rick Boothman, who retired as chief risk officer for the University of Michigan Health System in 2018, said the coronavirus crisis is cracking open the fissures that sometimes exist between hospital administrators and clinicians. Health care providers are remarkably resilient, he said, and that’s allowed administrators to be too cavalier with them. “It’s unethical and immoral to shove somebody into harm’s way when that’s not what they signed up for,” Boothman said.

The administrators should be up front with the clinicians and tell them that they’re sorry, but the resources are limited and the challenge is at the doorstep, Boothman said. The leaders should tell the staff that they see that the safety situation is not optimal, he said, but that nobody will be pushed into an avoidably dangerous situation. Such an approach would build trust and be well received by doctors and nurses, he said.

“I think you’d find an amazing number of people who would step up and not complain,” Boothman said.

---