Caregiving and Health Care Worker Burn Out—It's Time to Fix the System

Healthcare workers at every level have weathered hellish conditions. Not that things were perfect before the coronavirus—America's healthcare system has always had its flaws. But it took a pandemic for the public to see just how deep the fault lines run. One in four healthcare workers have considered leaving their job since COVID hit in early 2020, and one in 10 have resigned, a Morning Consult poll reveals.

Adding the Stress of COVID

If COVID had been contained from the start and managed more effectively, it might have been just another fire to snuff out. But here we are.

"I worked for 20 hours yesterday. My body and spirit are broken." So begins an oncology nurse's account of life in a hospital that's losing staff, where in the scramble for beds, someone with fever, cough, and shortness of breath lands in a unit occupied by immunocompromised patients. It's enough to bring the frustrated RN to tears. "My anxiety is high, my mental health is in the toilet. I hope and pray we never have to live through a time like this again."

In a different hospital, another nurse, already on edge, braces for the next wave of illness: "I'm trying to mentally prepare myself. But my heart is broken at how broken the system is right now."

These insider confessions plucked from a digital bulletin board, reveal what it is to be in nursing during the COVID era. Nurses are "angry," "stressed," and "exhausted." They're afraid of exposing family members to the virus. They're frustrated that some patients, even "on their own death beds, unable to breathe," remain in denial about the existence and severity of the virus.

The Psychological Damage Is Widespread

Forty-six percent say their mental health has worsened, the polling firm reports. Seventy-four percent of emergency medicine physicians surveyed by Medscape last summer say their burnout has intensified. Physician suicides, already double the rate of the general population prior to the pandemic, are expected to soar once the 2020 death toll is tallied.

No doubt many caregivers are drawn to careers in health care because they're motivated to make a difference in people's lives, heal the sick, and minister to the dying. It can be stressful on a normal day. But COVID amped up the level of burnout way beyond what anyone anticipated.

The consequences are concerning not only for the well-being of the healthcare workforce but for patient care.

Heightened Risk of Patient Safety Incidents

Clinician burnout is associated with a heightened risk of patient safety incidents, poor quality of care, ineffective provider-patient communications, and reduced patient satisfaction, according to a 2019 report from the National Academies of Science, Engineering, and Medicine on clinician burnout.

"This is a crisis like we've never seen," Mary Jo Kreitzer, PhD, professor of the School of Nursing at the University of Minnesota, tells Health. "How do we give health care professionals, at the right time, an opportunity to even process their experience?"

Time To Take Stock

If ever there were a moment to take stock of where we've been and how we got here—and how to make sure it doesn't happen again—it's this one.

Here's what pushed some doctors and nurses to their breaking points, why some low-wage healthcare workers are afraid to voice their concerns, and what healthcare leaders must do to repair the damage.

Carol Pak-Teng, MD, fully expected 2020 to be her best year ever—until COVID upended everything. "The level of trauma just skyrocketed," the New Jersey ER doctor tells Health. She found herself in a depressive episode beginning last March—and she got COVID later that month. Her staff suffered from insomnia, depression, uncontrolled anxiety, and recurrent, intrusive thoughts—symptoms consistent with post-traumatic stress disorder (PTSD), says Dr. Pak-Teng.

Clinicians are trained to jump in whenever a natural disaster strikes, but COVID has been overwhelming and unrelenting. "In a normal year, we don't see heavy things," explains California-based emergency and radiology nurse Sarah Wells. Even in normal times, witnessing traumatic events can cause PTSD, she says, because you're "taking on some of that trauma."

The Emotional Strain

Of course, 2020 was anything but normal. Clinicians maneuvered day after day in full PPE, flipping patients in respiratory distress to help them breathe. They worked extra shifts to cover for colleagues who had fallen ill, resigned, or died and struggled to save patients despite limited resources and bandwidth. Health caregivers witnessed unimaginable suffering.

Critical Care Nurse Heather Donaldson, who sees COVID patients at Sacramento's UC Davis Medical Center, recalls so many heartbreaking moments, like the gravely ill gentleman who, in a video chat with family, needed supplemental oxygen after every few words. "Emotionally, you'd have to be an absolute monster not to feel for these people," she says.

The Physical Toll

The fallout was evident even early in the pandemic. Hospital nurses caring for COVID patients last spring had more severe insomnia, fatigue, feelings of depersonalization, post-traumatic stress, and psychological distress than their co-workers with no direct contact with coronavirus patients, a Journal of Clinical Nursing study published last November revealed. Nurses clocking more than 40 hours a week and skipping 30-minute breaks to rest exhibited worse outcomes.

Study coauthor Linsey Steege, PhD, associate professor in the School of Nursing at the University of Wisconsin–Madison, spoke with nurse leaders who told her "there's no 'more drawer'"—no more nursing assistants to pick up the slack, no more space for nurses to nap. And that has implications for nurses' well-being and for patient care. "What we are asking of health care professionals, in many contexts, is just not sustainable," she tells Health.

Critical Shortages of Health Caregivers

Before COVID, researchers were forecasting critical shortages of doctors and nurses, particularly in certain regions of the country. COVID upped the ante. Hospitals desperate to fill ICU nurse positions were paying travel nurses $2,000, $5,000, and even $7,000 a week in 2020, one placement company reported. At the same time, many hospitals reduced staff positions or cut workers' hours in 2020 to offset sharply higher COVID-related expenses and plummeting revenue.

That belt-tightening continues today. Adam Kellogg, MD, who helps run the residency training program in emergency medicine at Baystate Health in Springfield, Massachusetts, says senior residents who are preparing to graduate can't find jobs. He's never seen residents as stressed and burned out as they are now.

Aspiring doctors and nurses seem undeterred. The Association of American Medical Colleges says applications for the 2021 academic year rose 18% from the same time a year earlier—which some observers have dubbed the "Fauci effect" (after the nation's top infectious disease doctor, Anthony Fauci, MD, whose leadership during the pandemic may have inspired some young people to pursue a degree in medicine).

Enrollment in entry-level bachelor's degree nursing programs rose 5.6% in 2020, says the American Association of Colleges of Nursing. Anna Valdez, PhD, professor and chair of nursing at Sonoma State University in Northern California, hasn't seen any COVID-related dip in applications. She thinks people may not appreciate what nurses have gone through because many aren't speaking up.

An intensivist specializing in the care of critically ill patients at a major medical center in Arizona (and who requested anonymity in order to speak freely) expects a huge exodus of talent from the bedside. Without a massive support system for healthcare workers, the most experienced doctors and nurses will leave, she predicts. "They were burnt out before COVID."

Others Experience Burnout Too

Nurses and doctors don't work alone. A lot of other people—from EMTs and lab techs to medical assistants, nurses aides, and orderlies—are putting their lives at risk.

According to the nonprofit Brookings Institution, seven million Americans hold down low-paid jobs assisting doctors and nurses. These jobs include providing direct care to individuals and handling food, housekeeping, and janitorial services. Most are women, about half are either Black or Hispanic, and their median wage is just $13.48 an hour.

Why don't we hear from them as often as we do doctors and nurses, who often appear in news interviews and viral social media posts? Many are simply afraid of losing their jobs.

Chelsey Aguiar, a certified nursing assistant (CNA) at a hospital in Massachusetts, often agrees to work additional hours or pull a double shift. On two recent days, she was the only CNA on a floor with 12 patients and two nurses. "That is not enough help at all. We're just so overwhelmed," she tells Health.

She recently had a major panic attack after working eight days in a row without a break. "Watching people die, watching people being taken off ventilators…(bringing) bodies to the field morgue…It's been a lot," she says.

The Need for Worker Protections

Aguiar, who makes $16 an hour, would like to see stronger worker protections because if she gets sick and uses up her sick pay or needs to quarantine, she's not covered. A spokeswoman for 1199SEIU United Healthcare Workers East—Massachusetts confirms that most healthcare workers were excluded from the emergency sick leave provision in the CARES Act, the stimulus package signed into law last March. She says the union is part of a coalition pushing the state legislature for emergency paid sick time.

Lori Porter, CEO of the National Association of Health Care Assistants, tells Health that one of her members, a CNA in a nursing home, developed a blood clot in her lung after having COVID. By Porter's account, the woman's employer pressured her to return to work or lose her seniority. Since she had run out of sick pay and could not afford to take medical leave, she felt she had no choice.

COVID has made matters much worse for CNAs: "They're sick, they're dying,…and if they miss a shift, they don't get a paycheck," Porter says.

Of the more than 3,400 US healthcare workers who have died from COVID-19 to date, more than half are non-physicians and non-nurses, per the Guardian/Kaiser Health News tracking project, "Lost on the Frontline."

A Lack of Leadership

On a Friday in December, a group of doctors huddled over Zoom to talk about depression and burnout in medicine. One chat room participant expressed disappointment in her organization's lack of leadership on the issue. Was she really supposed to "yoga" her way to wellness?

For many years, health organizations focused on fixing people instead of fixing systems. Jaime Hope, MD, the meeting moderator and an attending physician at Beaumont Health in Royal Oak, Michigan, tells Health that this is victim blaming. If you are tired or burned out, the thinking goes, "it's because you didn't do enough yoga, not that the system is stacked in a way that makes it difficult and exhausting and scary to do your job," explains Dr. Hope, who is all in favor of using self-care strategies—just not in lieu of workplace reforms.

Self-care Efforts

A growing number of programs are aimed at helping healthcare workers manage the pandemic's psychological toll. Right before COVID hit, Lindsay Espejel, a registered nurse, and a medical student began training a group of nurse leaders in Houston in a peer-support model called "Healing Circles." The idea is to create a safe space for nurses to share their thoughts and feelings. Nurses might talk about the loss of a patient or the angst of trying to reach a COVID patient's family members, only to learn that the person's relatives passed away from COVID, too. It's an opportunity to "digest those traumas" among compassionate listeners and give a sense of belonging, Espejel explains.

Individual-focused strategies, like mindfulness training and stress management, as well as interventions involving small group discussions "may be beneficial and can be an effective part of larger organizational efforts," according to the National Academies' report.

On their own, though, these strategies don't sufficiently address clinician burnout, it says. That's where systemic changes come into play, from small workarounds giving providers more scheduling flexibility to sweeping changes targeting the culture of medicine.

Caregivers Need To Discuss Their Mental Health Too

"Physicians are trained to be stoic and strong and not show weakness," Dimitrios Tsatiris, MD, a psychiatrist practicing in Ohio, tells Health. It begins in residency when doctors-in-training typically clock 80-hour workweeks. That's an area for improvement, he says. What's more, doctors shy away from openly discussing their mental health. "We're worried about the consequences that could have on our medical licensure."

Where the Health Care System Has Made Progress

Are health systems rising to the challenge? Have they made progress? Some more than others, Tait Shanafelt, MD, chief wellness officer of Stanford Health and a national thought leader on healthcare worker well-being, tells Health. As a first step, he urges organizations to really listen to what their people say they need. That resonates with Kreitzer, who had an opportunity to review one institution's plan for supporting nurses during COVID. Though well-intentioned, it was filled with "gimmicky things," she says, like elevating stories of heroism and springing for pizza. "What I said to them was, 'Have you gotten any input from nurses?'" They had not.

Will caregivers who braved this once-in-a-century pandemic decide to walk away or recommit? Hard to know at this point in the pandemic. COVID's toll on the healthcare workforce will likely be studied for years to come.

At least now, with vaccines in use, there's room to breathe. When Health spoke with Michelle Drew, the Wilmington, Delaware-based doctor of nursing practice and certified nurse midwife had just received her first dose and was looking forward to her second. "It's been 295 days since I've hugged my parents, and so the idea that soon I may be able to (do that) has me giddy."