David Joel Perea called from Maine, Vermont, Minnesota and ultimately Nevada, always with the same request: “Mom, can you send tamales?”
That’s how Dominga Perea knew where her 35-year-old son was. And she would ship them overnight.
David Perea, a traveling nurse, had “a tremendous work ethic,” routinely putting in 80 hours a week, according to his brother Daniel.
But when Perea took a job at Lakeside Health & Wellness Suites — a Reno, Nevada, nursing home that has received dozens of safety citations since 2017 from the federal Centers for Medicare & Medicaid Services — his mother was “scared silly.”
During his stint at Lakeside, nearly one-fifth of its residents were infected with COVID-19, according to state health records.
Lakeside’s “top priority is the safety of those who live and work in our facility,” a spokesperson said.
When her son didn’t respond to her text on April 6, Dominga Perea knew something was wrong.
Her son had COVID-19. He died days later.
As coronavirus surges across the country, health care systems continue to suffer critical shortages, especially among non-physician staff such as nurses, X-ray technicians and respiratory therapists.
To replenish their ranks, health facilities have relied on “travelers” like Perea. Health staffing agencies have deployed tens of thousands nationally since March’s early outbreaks in the Northeast.
Now, the virus is tearing through rural areas — particularly in the Great Plains and Rocky Mountain states — and stressing the limited medical infrastructure.
Rural hospitals largely have relied on traveling nurses to fill staffing shortages that existed even before the pandemic, said Tim Blasl, president of the North Dakota Hospital Association.
“They find staff for you, but it’s really expensive labor,” Blasl said. “Our hospitals are willing to invest so the people of North Dakota get care.”
The arrangement presents risks for travelers and their patients. Personnel ping-ponging between overwhelmed cities and under-served towns could introduce infections. As contractors, travelers sometimes feel tensions their full-time colleagues do not. Frequently employed by staffing agencies based thousands of miles away, they can find themselves working in crisis without advocates or adequate safety equipment.
In 2020, the upsides of their jobs — freedom and flexibility — have been dwarfed by treacherous conditions.
Now, the ranks of travelers are thinning: The work is exhausting, bruising and dangerous. Thousands of front-line health workers have gotten the virus and hundreds have died, according to reporting by KHN and The Guardian.
On April 17, Lois Twum, a 23-year-old traveling nurse from New Orleans, was one of four passengers on a flight to New York’s John F. Kennedy Airport.
When the self-described “adventure-seeking adrenaline junkie” arrived for her first shift at Columbia University’s Irving Medical Center in New York, she said she was assigned four patients on a COVID-19 unit. Intensive-care nurses typically care for two or three patients.
As these “constantly crashing” patients required resuscitations and intubations, “There was practically no one to help,” Twum said, because “everyone’s patient was critical.”
The hospital did not respond to requests for comment on workplace conditions and treatment of travelers.
As hospital employees got sick, quit or were furloughed amid budget cuts, travelers picked up the slack. They were redeployed, Twum said, assigned more patients as well as the sickest ones.
“It was like we were airdropped into Iraq,” Twum said. “Travelers, we got the worst of it.”
On social media and in email groups, recruiters for travelers circulate photos of sun-splashed skylines or coastlines emblazoned with dollar signs, boasting salaries two or three times those of staff nurses. They promise signing bonuses, relocation bonuses and referral bonuses. They make small talk, ask about travelers’ families and suggest restaurants in new cities.
But when it comes to navigating workplace issues, “These people can just disappear on you,” said Anna Skinner, a respiratory therapist who has traveled for over a decade. “They are not your friends.”
Caught between the hospitals where they report for duty and remote staffing agencies, their worker protections are blurred.
For instance, under the federal Occupational Safety and Health Act, providing protective equipment is the staffing agency’s responsibility — but the travelers who spoke with KHN said agencies rarely distribute any.
Perea’s family members said they believe he did not have adequate PPE. His employer said it was the nursing home’s responsibility to provide it.
“It is up to each of our clients to provide PPE to our staff while they are working assignments through MAS,” said Sara Moore, a spokesperson for Perea’s agency, MAS Medical Staffing.
Sometimes, travelers are assigned to emergency rooms or intensive-care units despite having little experience in the areas in which they now must work. Skinner, a pediatric specialist, said she landed in adult ICUs when deployed to the University of Miami Health System in April. She received an hour of orientation, she said, but “nothing could have prepared me for what I had to deal with.”
Over five weeks, she said she intubated one patient after another, suctioned the blood pouring into patients’ lungs and out of their noses and mouths and dealt with families who were aghast, angry and afraid.
Under that stress, Skinner said she couldn’t sleep and lost weight.
The Miami hospital did not respond to requests for comment.
Travelers often face “incredibly onerous” hurdles to the overtime, sick leave or worker’s compensation they are entitled to under the federal Fair Labor Standards Act, said Nathan Piller, a lawyer with Schneider Wallace Cottrell Konecky, an employment and business litigation firm.
Even the number of hours they can count on working is out of their control, Skinner said. Contracts reviewed by KHN authorize travelers to work a set number of hours, but only a fraction of those hours are guaranteed, and they must be approved by on-site managers. The guaranteed hours might be compensated at rates hovering around minimum wage and require working holidays, which are not uniformly recognized.
The terms can be “modified from time to time during employment,” according to the contracts.
In 2018, AMN Healthcare, one of the country’s largest travel nursing agencies, agreed to a $20 million settlement for wage violations involving nearly 9,000 travelers. Violations “appear fairly commonplace across the industry,” said Piller, who worked on the settlement.
Skinner said travelers are left to advocate for themselves to managers they might have just met — and “complaining just isn’t an option.”
KHN reviewed travel nursing contracts issued by Aya Healthcare, a large staffing agency, and found that any disputes — wrongful-termination claims, claims of discrimination, harassment or retaliation, wage claims and claims for violation of federal, state or other laws or regulations — must be settled out of court, through arbitration.
Representatives of the Service Employees International Union, the American Nurses Association and the National Nurses United said their members have been suspended or fired from traveling worker agencies for speaking to the news media, posting on social media or otherwise voicing concerns about unfair practices.
Matthew Wall, a longtime traveling nurse, knows this all too well. In July, two days into his assignment at Piedmont Henry Hospital in Stockbridge, Georgia, Wall said he reported to hospital administrators “undeniably unsafe” conditions for himself and patients, including inadequate PPE, long hours and high patient-to-staff ratios.
Instead of addressing his concerns, Wall said the hospital — which is under investigation by the federal government for workplace safety issues after another traveling nurse died of COVID-19 in mid-March — canceled his contract.
“Travelers are treated like dog chow,” Wall said. “The second you become a liability, they dispose of you.”
“We continue to closely follow Centers for Disease Control and Prevention guidelines paired with our best practices in patient care and safety for all,” said John Manasso, a hospital spokesperson, who declined to comment on Wall’s case.
Some see an impossible choice.
“We all know, if not for us, these patients would have no one,” Twum said. “But watching each other get sick left and right, it makes you wonder: Is this worth my life?”
Skinner took a job as a staff nurse in Aspen, Colorado.
After his current contract in New Orleans ends, Wall is planning a break from nursing.
Traveling registered nurse David Perea on April 6 — the day he was hospitalized with COVID-19. He died on April 19.
Daniel Perea via KHN
Dominga Perea finally received a text back the night of April 6: “Don’t panic, Mama, I have the COVID.
“Pray for me.”
She saw David over FaceTime on Easter.
“He struggled even eating mashed potatoes” she said, “because he couldn’t breathe.”
The next morning, he was put on a ventilator. He never woke up.
Months later, Lakeside hadn’t filled Perea’s position.
“Ideal candidate must be a caring individual dedicated to providing high quality care,” the job listing read, and “able to react to emergency situations appropriately when required.”
Contributing: Matt Volz
KHN (Kaiser Health News) is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
