Career Guidance

‘One of the most emotionally draining jobs in the hospital’: Why ‘sitters’ are such a hard role to fill

A nurse was walking by a room in the emergency department of Baystate Franklin Medical Center in Greenfield in October when she saw something that made her scream for help.

A patient who had been deemed a high risk for suicide had tied a bedsheet around their neck, according to three department nurses familiar with the incident. They insisted that no identifying details about the patient be shared because of federal privacy laws.

Several nurses raced into the room and frantically cut through the sheet with scissors. The patient was unharmed, but the episode left nurses shaken. The patient was supposed to have received constant monitoring by a staffer known as a “sitter” or “patient observer,” but had been left alone.

Simple arithmetic explains why. There were four other suicidal patients in the department at the time and only one sitter on duty because of a shortage of such employees, said the three nurses, only one of whom agreed to be identified because of fear of reprisals.

With many hospitals struggling financially, the job they have the hardest time filling is a thankless, often unnoticed, but critical one: sitters, who protect people at risk of harming themselves or others. Nearly half the sitter jobs in the state are vacant, far above the vacancy rate for other positions, according to a recent survey by the Massachusetts Health & Hospital Association. That’s up from less than one-third of sitter jobs going unfilled in 2022.

“We need more people in these roles,” said Suzanne Love, one of the three Baystate nurses and a union leader. “I’ve been bringing this up to management for years.” Love wasn’t on duty during the incident but was briefed afterward.

Heather Duggan, a spokesperson for Baystate Health, the largest health system in Western Massachusetts, declined to discuss the episode or the job of sitters, citing patient privacy.

Visitors to hospitals may not be aware that some employees are paid to keep a constant watch on patients with mental illness, dementia, substance abuse problems, or medical conditions that put them at high risk for complications or falls. But sitters, while they may be almost invisible and are often paid barely above minimum wage, play an important role in maintaining safety.

That’s particularly true for those watching psychiatric patients, who may pose a danger to themselves or others in an instant if they don’t receive “one-to-one” monitoring. The demand for such monitoring has surged in recent years, experts say, because the pandemic exacerbated mental health issues.

“I would describe this job as one of the most important jobs in the hospital regarding patient care and patient safety, and it is one of the most emotionally draining jobs in the hospital as well,” said one of the three nurses at Baystate Franklin, who began her career as a sitter.

The nurse, who was not on duty during the suicide attempt but was briefed by co-workers afterward, said that as a sitter, she had to sit within 18 inches of patients deemed at high risk of harming themselves or others. She also had to accompany them to the bathroom.

She often went home with scratches and bruises on her body inflicted by patients with dementia, who can become anxious or confused at the hospital, she said. She was paid about $19 an hour, $4 above the current minimum wage.

Sitters are entry-level positions, and the low pay and challenges of watching patients at risk for harming themselves or others for hours prompt many employees to leave for other jobs, said Sam Melnick, a spokesperson for the hospital association.

The jobs website Indeed recently advertised sitter positions in Massachusetts with starting pay of $16 to $26 an hour.

Hospitals typically require sitters to have a high school diploma or equivalent certification, Melnick said. Once they are hired, he said, hospitals provide training, including in how to de-escalate conflicts.

Hospitals would like to offer better pay to sitters, Melnick said, but as behavioral health employees, their work is inadequately reimbursed by health insurers.

“This is a high-need position that hospitals are working hard to fill,” he added.

Lora Pellegrini, chief executive of the Massachusetts Association of Health Plans, which represents more than a dozen insurers, disputed that insurers are to blame for sitters’ low wages. She said that insurers generally bundle reimbursements for nurses, aides, and sitters and that “hospitals have full discretion to allocate their resources within these bundled payments.”

The stress of the job is another reason sitters have a high vacancy rate, according to a counselor at Cambridge Health Alliance who sometimes works overtime as a sitter in the emergency department. The employee, who insisted on anonymity because of the sensitivity of the subject, said CHA prohibits sitters from touching patients except under extreme circumstances. If a patient becomes a danger, sitters are expected to summon hospital public safety officers, nurses, or other employees. It sometimes takes five such employees to restrain the patient, the counselor said.

David Cecere, a spokesperson for CHA, said his hospital doesn’t have a shortage of sitters, adding that none earn less than $20 an hour. As for the challenges of managing difficult patients, he said, all sitters receive training in de-escalating tense situations and keeping people safe.

Regardless of the cause, the state’s sitter shortage frequently provokes complaints by nurses.

Since December 2023, nurses at Saint Vincent Hospital in Worcester, Framingham Union Hospital, and Leonard Morse Hospital in Natick have filed at least 30 complaints that patients failed to receive one-to-one monitoring, according to the Massachusetts Nurses Association union. Tenet Healthcare, a for-profit, Dallas-based company, owns the three hospitals.

Katie Murphy, president of the Massachusetts Nurses Association, addressed a nurses demonstration in 2024 outside Framingham Union Hospital to highlight their complaints alleging dangerous conditions, which the hospital's owner disputed.Pat Greenhouse/Globe Staff

Following many of those complaints and others by nurses, the federal Centers for Medicare & Medicaid Services notified Saint Vincent in February that deficiencies in staffing and care had led to a finding of “immediate jeopardy,” a designation reserved for situations that put patients at risk of serious injury or death.

Such a finding puts a facility on track to lose Medicare and Medicaid funding unless the deficiencies are quickly addressed. Carolyn Jackson, Saint Vincent’s embattled chief executive, submitted her resignation the same week of the CMS finding. The threat of losing those funds was removed days later when the state approved Saint Vincent’s report of the changes it had made and planned to make.

Shelly Weiss Friedberg, a spokesperson for Tenet, said last month that the hospital chain provides appropriate staffing for jobs, including sitters. Most of the nurses’ complaints were “unfounded,” she said, and reflected a union campaign to influence contract negotiations.

As the October suicide attempt at Baystate Franklin illustrates, the stakes for failing to observe a patient are high. And some patients left without sitters are less fortunate than that one.

In 2021, a 31-year-old man who had failed to take his antipsychotic medications became combative in the emergency department at Carney Hospital, which was owned by the financially troubled for-profit system Steward Health Care. Gilberto Melendez-Brancaccio was given medications to calm him and had his arms and legs placed in restraints. When his oxygen levels plunged to dangerously low levels, he also received a breathing mask.

Gilberto Melendez-Brancaccio.

A sitter was assigned to monitor him, but the employee was also watching two other patients. Melendez-Brancaccio was left alone. No one noticed when his heart stopped and he died, according to federal investigators who reviewed his case.

Melendez-Brancaccio’s aunt, Catherina Brancaccio, of Quincy, said she has no doubt that her nephew, whom she helped raise and who had studied graphic design, would still be alive if a sitter had kept him under constant watch.

“They assigned a sitter for a whole bunch of people,” said Brancaccio. “How is she supposed to manage a whole bunch of people? They totally dropped the ball.”

Melendez-Brancaccio’s mother filed a wrongful death lawsuit in 2023 against Carney Hospital and several clinicians there. A state judge stayed the case because Steward collapsed in a spectacular bankruptcy, and Carney closed.

More than four years after her nephew’s death, Catherina Brancaccio still mourns the loss of Melendez-Brancaccio.

“They left him alone,” she said. “With four-point restraints, rule number one is you never leave them alone.”