Women in labor diverted to hospitals they’ve never set foot in, call buttons left blinking, and early-morning C-sections bumped to the afternoon: That’s the reality for birthing patients at the world-renowned UCSF Medical Center at Mission Bay, according to the nurses who care for them.

Despite a reputation for providing specialized, high-quality care and treating the most complex and risky cases, the facility struggles with chronic understaffing, inadequate training, and poor management that jeopardize patient safety, nurses say. The unit, which delivers about 2,500 babies each year, often doesn’t have enough nurses to staff the floor, forcing them to work overtime after a 12-hour shift with few breaks — or none at all.

“The nurses are working as hard as possible to prevent mistakes and errors from happening and to give excellent care to patients,” said Claire Zukin, a nurse who has worked at the birth center for more than eight years. “But when we have been working for the last 15 hours ... our cup is empty.

“We want to be able to bring excellence and energy and compassion to taking care of our patients,” she added. “But when we are chronically understaffed, it is difficult to do that.”

The UCSF birth center is no outlier. Years after California led the nation by mandating minimum staffing ratios, nurses statewide say (opens in new tab) those standards aren’t enough to keep up with increasingly complicated patient needs. 

UCSF Health, the parent organization that manages the Mission Bay medical center, defended its staffing.

“Despite ongoing national nursing shortages, we meet California’s mandated nurse-to-patient ratios and staffing standards, with a dedicated nurse for every patient,” it said in a statement.

Nurses say they’ve asked the hospital to hire more nurses and provide staff with better training on how to care for patients with complex conditions — like sickle cell anemia and substance abuse disorders — but little has changed. Now, they are calling on patients and the public to join them in demanding that UCSF hire more staff and improve nurse education.

At a rally Friday afternoon, a few dozen nurses in red T-shirts gathered on a turf hill outside the hospital in Mission Bay. Several gave speeches demanding adequate staffing, security, and leadership.

“On a daily basis, pretty much, we don’t have the adequate coverage that we need to make sure that not only are patients getting the care that they need, but also that our nurses are able to take rest and eat,” Amanda Peters, a nurse, said at the rally. 

Her colleague Jen Lindberg said she works 16-hour shifts with no breaks. Afterward, she feels exhausted. 

“Our work is very physically demanding,” Peters agreed. “Most of us deal with chronic pain issues.”

UCSF said it is working to recruit more nurses and supplement staffing with traveling nurses.

“We respect the role of our nurses and the importance of their voices, and we make staffing decisions based on patient needs and clinical judgment,” it said in its statement.

Zukin doesn’t buy it.

“I think the university doesn’t want to hire more nurses,” she said. “There are a lot of people who would love to work at UCSF. It’s a great place to work in a lot of ways, but the university is not prioritizing hiring staff … despite the fact that our patient population is one of the most complex patient populations to care for in the Bay Area.”

Zukin said the unit is typically short-staffed during the day, so night-shift nurses end up staying for four extra hours, or those who are off are called in to work. When there aren’t enough nurses to staff labor rooms, patients are told to go to a different hospital to deliver their babies.

If there aren’t enough nurses to staff an operating room — or if other, more emergent and urgent labor situations are happening — a C-section scheduled for 8:30 a.m. may not be performed until 1 or 2 p.m. That leaves patients, who are unable to eat ahead of surgery, waiting in the triage room, unsure of when they’ll go for surgery and meet their babies.

“It’s very distressing for people,” Zukin said.

Challenges persist after delivery, when nurses are typically assigned to three rooms — each with a mother and baby. Zukin said that when there are patients with preeclampsia, sickle cell anemia, mental illness, or other severe conditions, a ratio of 1 to 3 is not safe.

“That may mean that they require more nursing time and attention, careful monitoring, and in those situations when we’re short-staffed, we have to take three rooms anyway,” she said. “We believe that our patients deserve much higher levels of care, much more attention than having us split between three high-level complex patients.” 

And nurses are treating those kinds of patients more frequently. Because UCSF is an academic research institution, the medical center conducts specialized procedures and often cares for patients transferred from elsewhere in the Bay Area and even out of the state. At the same time, Zekin said, nurses haven’t received adequate training to appropriately care for a patient population that is becoming more complex.

There is just one nurse educator in the unit for around 180 nurses, according to Zekin.

“We don’t have anybody coming in and educating us, for instance, on things like increasingly severe mental health disorders that people are presenting with while they’re pregnant and postpartum,” she said.

Night-shift nurse Erin Zezulak described a recent incident in which a patient gave birth while on a 5150 hold. Child Protective Services seized the infant soon after, she said, provoking extreme distress in the new mother. The patient ended up staying in the department for two weeks, whereas she would have been better served in a psych ward, Zezulak said.

“We have many patients like that that wind up staying for months because of behavioral or substance abuse or other issues,” Zezulak said, adding that caring for those patients goes beyond what maternity ward nurses are typically trained for. “We’re trying to do that as birthing center nurses.”

Zukin said nurses have raised their concerns with management for years via email and in meetings. The issue came to a head in January, when nurses issued a vote of no confidence in the unit’s nursing director, DeeDee Pubien. The university removed Pubien as a result and appointed an interim director in her place. But after three weeks, that person was removed without explanation. It took the university two months to name another interim nursing director.

Pubien did not respond to a request for comment. 

That left nurses with just two assistant managers — one on the day shift and one on nights — to go to with concerns about patient care and safety, as well as security situations that put patients and staff at risk.

“We were navigating high-risk and challenging situations without leadership,” Zukin said. “Issues with patients and patient family members who were being unsafe and needed to be escorted out, things like that.” 

Metal detectors were recently delivered to the center’s lobby, Zukin said, but they haven’t been set up. Although there is a security guard, and wristbands are needed to access the unit, patients and visitors aren’t screened for weapons.

“There continue to be security incidents … that make us want metal detectors,” Zukin said. She said she couldn’t provide details about those incidents.

A representative for UCSF did not respond to questions about the metal detectors, the requests for more training and a policy on treating sickle cell anemia, or why the department was left without a director for two months. The hospital said it has launched a national search for a permanent director for the birth center.

For nurses in the unit, help can’t come soon enough.

“The public has this perception that UCSF is the best of the best, and the nurses are trying to deliver that care,” Zukin said. “We really do give excellent care, but at the end of the day, when you’re stretched thin, and you haven’t had a break, and it’s been eight hours, and you need to respond to a critically urgent situation like a hemorrhage or an emergency C-section, you have to put everything else aside and take care of the patient. It’s much easier to take excellent care of a patient in those situations when you have had a break.”