On the frontlines of the pandemic, 2020 was a brutal year for nurses.

Nurses were put in “positions where they had to choose between the calling of taking care of patients and putting their loved ones at risk,” as Alyssa Boldt, a relief charge nurse on a COVID-19 floor at Sacred Heart Medical Center, described it.

The vaccines brought a sense of relief for nurses like Boldt who had weathered the uncertain first few months with the disease. Nurses had continued to treat patients through COVID waves, despite having to reuse personal protective equipment and live with the fear they could be bringing home a virus with no cure to their own families after every shift.

Now, Boldt’s primary concern is staffing.

“The stressor now is the fear of the nursing shortage, the hemorrhaging nurses are doing from the halls of hospitals for many reasons that may not just be COVID, but that COVID uncovered,” Boldt said. “COVID has really revealed a lot of issues with the health care system and how providers on the frontlines operate and are treated.”

The statewide and nationwide nursing shortage existed long before the pandemic began, but the stress of the past year has led some nurses to rethink their careers .

It’s been a year and a half since nurses have formed the frontline of care for patients fighting COVID-19, and as the latest surge threatens already crowded hospitals, staffing shortages are continuing to contribute to capacity issues as the delta variant drives virus transmission rates higher.

Boldt said some of her colleagues have left nursing altogether, while others have left the hospital setting for a less stressful medical environment in clinics and other settings.

This pattern was captured in a survey of just more than 400 nurses statewide, published by the Washington Center for Nursing, that sheds light on how exhausting the experience has been for nurses.

The survey found that 51% of nurses were laid off or furloughed at some point during the pandemic; 49% of the nurses surveyed actually got COVID-19 last year; and 42% are considering or have made plans to leave nursing altogether.

Clint Wallace, a rapid response and ICU nurse at Sacred Heart Medical Center who has been a nurse for more than two decades, decided to go back to school to be a nurse practitioner as a result of the pandemic.

He’s still working at the hospital, but when he finishes school, he will likely use his new certification in a clinic or practice that is not as intense as the hospital.

Wallace has thought a lot about the nursing shortage.

“I don’t have an answer; I wish I did,” he said. “Maybe more money would help to incentivize more young people to become nurses because, bottom line, that’s what we need, is more people with their nursing license.”

While the Center for Nursing report is not intended to be comprehensive, nurses and advocates agree the past year has brought a higher level of stress and anxiety to the profession, as well as exacerbated the existing nursing and staffing shortage.

“They have been laboring through and now are exhausted; they are physically exhausted because there aren’t enough of them, so they’re picking up extra shifts and they’re emotionally drained,” said Diane Sosne, president of SEIU Healthcare 1199NW.

The stress of the pandemic at work also came home as frontline workers tried to keep their families safe, Sosne said.

“We’re at the point now where the nurses are leaving,” Sosne said. “They may have hung in there during the worst of it and now you’re saying to yourself, ‘Oh my gosh, there’s delta. I thought we were coming out of this and now we’ve got to worry about that.’ ”

Some hospitals are offering generous sign-on bonuses for new hires, as well as referral bonuses for nurses who refer a new nurse who gets hired.

The fatigue is setting in just as hospitals are at their busiest time of year, then the delta variant hit. Hospital patient loads statewide and nationwide are surging, with both COVID and non-COVID cases, and transferring patients elsewhere can take days. Daily hospitalizations for COVID-19 in Washington are approaching levels not seen since December.

The pandemic also disrupted nursing education, which is vital to ensuring there are new graduates entering the workforce. In-person clinicals, which is where soon-to-be nurses hone skills and learn how to put practices into action, were canceled at the start of the pandemic, and simulations and virtual learning took over.

The report from the Center for Nursing found that this affected some students, who felt like they didn’t get the necessary in-person experience they need.

“We did move to some virtual and simulated clinical training, more than our typical program,” said Anne Mason, associate dean at the WSU College of Nursing.

WSU split nursing students into pods, so they had clinical simulations with the same group of students all semester long. Mason said there were fewer clinical options, since rotations like the ICU were not available due to the pandemic. This fall, Mason said in-person clinicals should be back to operating fairly normally, however.

Frankie Manning, outreach coordinator at the Mary Mahoney Professional Nurses Organization, said the Center for Nursing survey did not surprise her, based on what she’s heard from nurses in the past year.

“The whole issue of how do we provide mental health support to people who are in very stressful situations,” Manning said.

With no family members allowed to visit COVID-19 patients, nurses often played the role of not just caregiver, but moral support in patients’ dying moments.

“How do we provide an emotional response going forward to support communities and people doing the frontline work?” Manning said.

With the potential for more nurses to burn out and leave the profession, Manning wonders if as many nurses would have left if they had the support they needed.

“That’s the question we have to ask ourselves as we move forward in the scheme of things, because it’s a heavy lift when you’re asking people to do not only major physical work, but also mental work, without support,” Manning said.

Boldt said her group of best friends, which includes a lot of nurses, is part of what keeps her going, and the current mood of nurses still on the frontline feels like the depression stage of Kubler-Ross’s stages of grief.

“We had this hope laying in front of us, and this modern miracle that this vaccine is, and when we were offered it, many of us took that opportunity,” Boldt said.

She wishes the community could also embrace the vaccine, while getting their questions answered in a compassionate way.

“I wish there was a way that the community could recognize and validate the fears that folks have who don’t want to take the vaccine and compassionately walk alongside those people and offer them the means to look at the information that’s true and validated scientifically and guide them through the fears they have in ways that would reassure them that this vaccine is safe and effective,” Boldt said. “Because it’s become so polarized that I think everyone is afraid to identify the nuance.”