Burnout is stalking the country’s nursing homes. Even as the coronavirus peaks yet again, remaining staffers are worn out, often fed up with the companies they work for, and yet many say they are holding on because their patients need them and have no one else to look out for them. Still, never far from their thoughts is the knowledge that they, too, could be felled by the disease.

And unlike the ambulance drivers and hospital workers who have struggled to save lives during the pandemic, many say they feel no love from the outside world. If a hospital was a home to heroes, a nursing home, in the popular imagination, seemed to have become a place where bodies were found stacked in a closet.

“The people in the community have no idea what we are going through,” said Rebecca Rufial, a licensed vocational nurse in Paris, Tex., who works a 12-hour shift every night, in charge of two halls with 40 to 50 patients, helped by two nursing assistants. “And no one cares, either.”

Allyson Stanton, a social worker in Howard County, Md., said, “It’s frustrating and sad — and overwhelming, because there’s just too much to take on.”

Staffers everywhere tell of fellow employees who have left their jobs out of anger, fear or illness. In late May, as the pandemic was spreading out from the Northeast, 14 percent of nursing homes nationally reported a shortage of nurses; that number has remained steady, a Washington Post survey of Medicare data shows. The number of facilities reporting a shortage of nursing aides has risen, to nearly 18 percent, or about 3,000 nursing homes.

The number of infected staffers has increased steadily all these months, to a total of more than 260,000 as of Nov. 15. And nursing-home companies have had few alternatives to turn to — despite the billions of dollars funneled into the system through emergency federal funds. Temporary employment agencies are not big enough to fill the gaps. In a business with a history of shortages and high turnover, there is no deep bench of retired nurses and aides willing to come back to work.

All this puts more of a burden on those who remain — who have worked month after month with often inadequate supplies. Some have sent their children to live with relatives or ex-spouses. Inevitably, some are cracking under the strain.

At first the adrenaline was flowing, with days running together. Making do. Feeling confusion, sorrow, determination. When covid-19 hit nursing homes in New York in March, in Kentucky in April, in Texas in July — it was like a five-alarm fire for the nurses and aides and cooks and technicians who kept the places running, even as residents sickened and died around them.

But no one can maintain that pace.

“Mental, physical and emotional stress” was how Imee Villavicencio, a registered nurse in Manhattan, described it. “And exhaustion.”

“Grueling. Disheartening,” Rufial said. “Nurses are giving their all day after day attempting to accomplish an extraordinary amount of tasks, with no end or relief in sight. We are so busy with other things that we are missing small things with residents that could possibly prevent bigger issues from happening. Day after day, it’s the same overwhelming and far-reaching set of responsibilities we keep clocking in to.”

“This has been the worst eight months of a lot of our lives,” said Ruthie Fishman, director of a “memory care” group of homes for dementia patients in Montgomery County, Md.

With coronavirus cases spiking nationally, Maryland is among at least 22 states that are once again barring most family visits indoors, as they did in the spring, trying to tamp down on contagion but demoralizing residents and putting further burdens on staff.

Last year, before the pandemic, a survey found that 30 percent of nurses in nursing homes met the definition of burnout. Half of all nurses said that in their previous shift, they had been unable to make time for a comforting talk with a patient; nearly a third said they had been unable to ensure adequate patient surveillance.

One of the authors of that study, Elizabeth White of Brown University, is doing a follow-up looking at the effects of covid-19, the disease the virus causes. She expects the numbers to be worse.

“There were significant challenges in the workforce to begin with, and then we threw a pandemic on top of it,” she said. “We can expect this is going to have a significant impact on people wanting to leave.”

A hospice nurse in Michigan who asked not to be identified so as not to jeopardize her current job, quit because she was angry at the way her employer had pressured her to return to work when she contracted the coronavirus herself. The nurse said she was shaken by the distress of the residents, and infuriated by the understaffing and emphasis on cutting costs at the nursing homes she visited.

“It’s just the most horrible thing to see someone suffering like that,” she said of the patients with the disease. “I can’t think of a worse way to die.”

And she hated to see nursing home companies exploit the dedication of their health-care workers. “They really do take advantage of the culture of nursing, which is fairly meek,” she said.

Dedication was all Michelle Thompson knew. She was a low-paid assistant responsible for dispensing medicines at a nursing home called Signature Healthcare at Summit Manor, in Columbia, Ky. Unmarried, 58 years old, a diabetic with high blood pressure, she was determined to carry on when the coronavirus entered the facility.

“It was just all scary at the beginning,” recalled her sister, Denise Carver. “Nobody knew what was going on.”

Thompson volunteered to work with the patients who had fallen ill.

“We tried to talk her out of it,” said her mother, Marlene Iames. “She said, ‘No, these people need me, and it’s my job, and I’m going to try to help them. If I don’t do it, who else is going to do it?’ ”

Thompson told her family that staffers hadn’t been provided with enough face masks or proper personal protective equipment. For a week or maybe two, she kept working. On April 17 she was running a fever, thought it was the flu and called in sick. Her supervisor accused her of slacking and, Carver said, told her to come in. Thompson refused. On April 18, she learned she had tested positive for the coronavirus. On April 21, she went to the hospital, where her kidneys failed and doctors put her on a ventilator. She died April 30.

Summit Manor is part of the Signature Healthcare chain, which received $23 million in emergency federal funding to combat the disease. As of Nov. 1, there had been 71 confirmed cases of covid-19 at the facility, with another 32 suspected. Sixteen residents have died of the disease, as well as Thompson and another employee.

Officials at the nursing home and at the Signature Healthcare headquarters in Louisville did not respond to repeated requests for comment.

Carver said it seems like everybody in Adair County, population 18,656, knew of someone who died at Summit Manor.

‘I’m crying silently’

At the nursing home where she works on Manhattan’s Upper West Side, Imee Villavicencio began to feel sick on March 19, with congestion and a cough but no fever. She was out sick for seven days, but seemingly recovered and returned to work as a charge nurse on one floor. By then the pandemic was raging through the city, and not sparing the nursing home (which she asked The Washington Post not to identify so as not to cause difficulties at work).

“The day-by-day work is hard both mentally and physically,” she wrote in a sort of contemporary Facebook diary, which she shared with The Post. (Spelling and punctuation have been corrected.) “I cried every day feeling so hopeless ... Colleagues die, my co-workers get sick one by one ... My patients die ... body bag after body bag ...

“Every time I go inside the room of a covid patient ... I feel very scared ... Every time I FaceTime a family member to say their final goodbye to my dying patients ... I’m crying silently and choking ... I can’t wipe my tears because of the face shield.

“I remember vividly, one of my patients is dying ... gasping for air while I’m adjusting her IV line ... She opens her eyes ... grabs my forearm and said, ‘I’m afraid! Don’t leave me.’ At the back of my mind ... I can’t stay here ... I’m exposing myself too long ... I was telling myself don’t be stupid ... get out ... you gave the [morphine] already ... it will comfort her ... but I can’t. I can’t let this woman die scared and alone ... I can’t do that as a human being. I stayed with her until she took her last breath. ..

“I have a phobia with ambulance sirens ... that sound associated with crisis and death. ... The whole first week of April I was so fatigued. The precaution I took, name it and I did it. Showering 3 times daily, bagging of my scrubs/shoes etc. ... I thought the fatigue is just exhaustion from work.”

It was more than that. On April 3, she developed body pain and extreme exhaustion, then “coughing, difficulty of breathing, chills, diarrhea chest pain, nose bleed, etc.” It was covid-19. At one point she was sure she would pass out, and she was worried no ambulance would come for her in time because of the crush of calls in the city. A friend, a doctor, put her on steroids and antibiotics.

And she recovered.

“It’s like a nightmare,” she says now in a phone interview. She returned after 20 days to a nursing home in a state of extreme crisis. Seventy-four residents and one employee died there. She has had a difficult time shaking the trauma of seeing so many people in her care get sick and die.

“They become our daily life,” she said. “Some have been here 6 to 10 years. Losing them in a short period of time, one by one, it’s really hard.”

She was caring for 36 patients, assisted by four aides. She was working 16 to 17 hours a day.

One day she and a colleague walked into the dementia ward wearing full protective equipment, and one of the residents, looking up, guessed that it was a Halloween party.

In April, she said, she thought about quitting. Villavicencio, who is 38, grew up and got her training as a registered nurse in the Philippines. She moved to New York in 2006 and has lived there ever since. She is unmarried and shares an apartment with three other nurses. Her mother, now retired, and two sisters are also nurses, and also in New York.

“In April, it was so scary,” she said, especially because she has asthma. “There were moments when I got sick I thought I was going to die.” Should she go back to work? And what would her family do if she died?

But then she thought of her patients. “Who’s going to help them if I don’t?”

For a couple of months she saw a counselor, and that helped. “If I didn’t, I thought I might lose my mind.”

Today she has no regrets about staying on. But there’s been a strange dynamic at the nursing home: The last suspected case among residents was recorded the week of June 21, as the pandemic began to ease throughout New York. But cases among staff have continued in all the months since. In May, there had been 40 confirmed cases among employees. By October, that figure had doubled, to 81.

“You still get a little burned out physically,” Villavicencio said. “I know I can protect myself. But in the back of your mind, you’re still scared. It’s like always you’re working on the edge. There’s an uncertainty. That’s how I feel, whenever I go there.”

No applause for nursing home staff

Last spring, New Yorkers began leaning out of their windows every evening at 7 to make noise in appreciation for the EMTs, hospital nurses and doctors who were struggling to save lives. Soon that appreciation for those on medicine’s front lines had spread across the country and permeated the media.

Nursing home staffers noticed and felt left out.

“Nursing home workers are underpaid, overworked, they’re often immigrants,” said Fishman, director of the memory-care homes in suburban Maryland. “They got no applause. We didn’t have the support. It was easier to say these places were just bad. ‘Oh, my God, look at this nightmare that’s nursing homes.’ It’s easier to stomach than to say those places were doing the best they could.”

White, the Brown University researcher, said that as part of her survey this summer respondents were asked open-ended questions, and again and again nursing home employees said how much they resented the way the media was portraying their work.

“We were really blown away by how many of those who responded to this brought that up,” she said. “There’s been a lot of blame placed on nursing homes, and it’s important to understand the effect this has on people who work in them.”

All this makes it that much harder to replace those workers who have left, much less increase staffs to handle the extra work. States have been sponsoring fast-track online courses for prospective certified nursing assistants, but they have yet to make a dent in the endemic staff shortages.

Pay remains low: about $10 to $12 an hour for a certified nurse aide.

Patients and families blame the staff when the coronavirus erupts in a building, believing, often with some justification, that employees have become infected by community spread where they live and shop, said Rufial, in Texas.

“When I go to the store, NO ONE is wearing a mask,” she wrote in an email. “When I pick up food to go, NO ONE is wearing a mask ... and NO ONE is being held accountable for it here in the big red state of Texas. Regardless if I’m wearing my mask (which gets u enough dirty looks) if no one else is, then I’m pretty vulnerable to whatever they are breathing out. If no one is required to wear a mask, how are we supposed to remain safe for our patients?”

With staffing short, there often aren’t enough nurses or aides to lift or turn a bedridden patient properly. “The unsafe lifting, changing, bathing, transferring is breaking down our bodies, and breaking down our residents,” Rufial wrote. Some go two weeks without a shower because there isn’t enough help, she said.

“Our residents are not faring well, as we have had many decline in overall health status, some to the point of death. They are disheveled, unnourished, and lonely. I feel like I’m sprinting through rooms with barely a hello, and they FEEL that from all of us. We've not had resources to attend to their needs or changes in condition, causing increased falls, injuries, infections, and deaths.”

Rufial got sick herself over the summer, with shooting pains between her shoulder blades and dizziness so bad “I like to fell out of my chair,” she said in a phone interview. It was several days before she could get a coronavirus test, and it came back negative. She plunged back in, working a 12-hour night shift on the dementia hall at Brentwood Terrace nursing home, owned by a company called Diversicare that received more than $37 million in federal emergency money.

“I feel in the depths of my soul, man, that I was made to care for people,” she said. “But it’s going to get horrible. We’re fixing to lose a lot more patients. I get to think about that the rest of my life.”

Diversicare acknowledges that it has been challenging to keep fully staffed.

“Many staff have become ill or had to quarantine due to exposure, while also having to provide more one-on-one care to reduce possible spread of the virus. This puts significant strain on our workforce, particularly in our smaller communities, like Paris, where there is a shortage of health-care workers generally,” Nick Lamkin, chief legal and risk officer for Diversicare, wrote in an email.

He continued: “We are doing everything we can to support our caregivers and staff on the front lines. At Brentwood Terrace alone, we have added sign-on bonuses, hired temporary team members, increased wages for those who work on our covid unit, temporarily brought in staff from other markets, and put in place a special bonus plan. We do not believe that patient care has suffered at the center; in fact, we currently have no covid-positive residents at the facility.”

Federal aid, he wrote, has been a vital lifeline. “Our costs, with regard to PPE, testing and staffing have been extraordinary and have only increased as the virus has spread across the country, resulting in increasing demand by all health-care providers and sectors for supplies and more frequent testing."

He added: “We are very proud of the team in Paris and their dedication to our residents and patients. They are our health-care heroes, and we are grateful for all that they do every day.”

Joel Jacobs contributed to this report.