Covid-19 is roaring back for a third wave. The first two substantially increased feelings of moral injury and burnout among health care workers. This one is bringing burnover.
Health care systems are scrambling anew. The crises of ICU beds at capacity, shortages of personal protective equipment, emergency rooms turning away ambulances, and staff shortages are happening this time not in isolated hot spots but in almost every state. Clinicians again face work that is risky, heart-rending, physically exhausting, and demoralizing, all the elements of burnout. They have seen this before and are intensely frustrated it is happening again.
Too many of them are leaving health care long before retirement. The disconnect between what health care workers know and how the public is behaving, driven by relentless disinformation, is unbearable. Paraphrasing a colleague, “How can they call us essential and then treat us like we are disposable?”
It is time for leaders of hospitals and health care systems to add another, deeper layer of support for their staff by speaking out publicly and collectively in defense of science, safety, and public health, even if it risks estranging patients and politicians.
Long before the pandemic emerged, the relationships between health care organizations and their staffs were already strained by years of cost-cutting that trimmed staffing levels, supplies, and space to the bone. Driven by changes in health care reimbursement structures, systems were “optimized” to the point that they were continually running at what felt like full capacity, with precious little slack to accommodate minor surges, much less one the magnitude of a global pandemic.
We are now facing a convergence of two cataclysms: the abject failure of preparedness driven by the dogma that market forces can best shape health care, and the catastrophic failure at the highest levels of leadership in the U.S. to adequately address and control the pandemic. Health care workers are left to manage in the ensuring chaos feeling disposable, devalued, and demoralized.
Wearing a mask — the best prevention against a pathogen for which there are no curative therapeutic measures — is optional in 26 states. Pandemic isolation fatigue is real and large gatherings are increasingly common. Thanksgiving celebrations will likely fuel the spread of Covid-19. Deborah Birx’s uncharacteristically sharp warning to the White House, “We are entering the most concerning and most deadly phase of this pandemic,” adding that, “… an aggressive, balanced approach … is not being implemented,” belies her grave concern.
In the absence of leadership from elected and appointed officials, those at the coalface of care — doctors, nurses, respiratory therapists, social workers, transport specialists, cleaners, dining service workers, and others — are a bucket brigade trying to staunch a pandemic wildfire.
Hospitals are grasping for solutions to support their strained workforces. Recharge rooms, tranquility tents, and peer support programs, drawn from various initiatives in other environments, are popping up everywhere. Some hospitals have carts with snacks, tea, water, and anti-fog goggle spray — tokens to remind their staff, amid the taxing trials of their work, that leadership cares. And yet levels of distress, which were already high before the pandemic, are rising.
Instead of more resilience strategies, which health care workers already understand are symbolic trinkets, what they need is to know who truly has their backs in this fight.
In March, clapping for essential workers was a powerful signal that individuals and communities were grateful for the efforts of those at most risk. But those expressions of gratitude, when co-opted by marketing departments, left health care workers skeptical of their authenticity and cynical about future such efforts on their behalf. Were the expressions of gratitude and support genuine, or were they intended to create good glossies for hospital fundraising? Does the mental health of workers really matter, or does it just make good copy? No matter how well-intended those efforts of support were, they often further eroded trust between staff and organizations, rather than fostered it.
As a crisis looms, it is not possible to deliver a just-in-time resilient community. Creating a deep-seated, meaningful, mutually supportive relationship between an organization and its workforce takes time. Healthy communities build reserves of trust, goodwill, respect, and caring they can call on during crises. Such efforts must be in place before a crisis hits and extended long after it resolves. Otherwise, building the community is another drain on resources already stretched to the breaking point.
There is an epidemic in this country of not listening to those in distress. Health care leaders must stop offering solutions before getting deeply curious about the problem and asking staff what they need. Administrators and clinicians must be equal partners at the tables where decisions affecting care are made and where resources are allocated.
Supporting health care workers’ mental health is not just about supporting individuals as they cope with unimaginable situations. It is also about improving the environment, processes, policies, and cultures of institutions and their communities. It is about recognizing and clearing away bureaucratic barriers to make it as easy as possible for staff to do exceptionally difficult jobs.
Health care workers want to see the leaders of their institutions, particularly the country’s largest health care systems, loudly, publicly, and collectively advocate for the aggressive, balanced approaches Birx alluded to. They want their leaders to spend an hour on rounds with them seeing — and feeling — the realities they face and working collaboratively on solutions, rather than offering a hospital-branded bottle of water.
For months, health care workers have been trying to put out the fire of this pandemic bucket by bucket. They have been waiting for the public to realize the enormity of the threat and to accept the necessity of simple sacrifices for the greater good: wearing a mask, physical distancing, and avoiding large gatherings. They have been waiting for elected leaders to call the country together and ask them to rise above their individual interests. They have been waiting for someone to see the enormous and growing risk that health care workers face.
That isn’t happening, and they are losing hope. They are tired, the wind is against them, and their voices are getting hoarse. Still reeling from the burnout of the first surges, they are watching COVID-19 cases soar and imagining the very real threat of pandemic burnover.
The fire trucks and water drops that might stop pandemic burnover are the simple measures each individual can do to limit transmission. If health care leaders loudly, insistently, and collectively call for these measures, it will be a statement of solidarity with their workforce and the first step to rebuilding trust, embracing collaboration, and, most importantly, to saving the lives of health care workers and the public.
Wendy Dean is a psychiatrist and president and co-founder of the nonprofit organization Moral Injury of Healthcare. Simon G. Talbot is a reconstructive plastic surgeon at Brigham and Women’s Hospital, associate professor of surgery at Harvard Medical School, and co-founder of Moral Injury of Healthcare. The views expressed here are the authors and do not necessarily reflect the viewpoints of their employers.