We survived the pandemic’s early days with purpose-fueled adrenaline. Working in the epicenter of the first Covid-19 outbreak in the U.S., two of us (R.H. and K.H.) scrambled to transition as many patients as possible to telemedicine, but still worked on site in the hospital. Soon afterward, T.N. was on the frontlines as highly infectious patients flooded her intensive care unit. Our caseloads grew, and we worried about bringing Covid-19 home from the hospital and infecting vulnerable family members. Encouraged to engage in self-care, we walked and connected with colleagues. Eventually the pandemic took its toll, causing burnout, insomnia, anxiety, and grief.
Mounting evidence shows we aren’t alone.
A survey of more than 500 health care workers and first responders published this week in the Journal of General Internal Medicine, co-authored by two of us (R.H. and K.H.), found that a substantial majority of respondents reported experiencing clinically significant psychiatric symptoms, including post-traumatic stress disorder (38%), depression (74%), anxiety (75%), and recent thoughts of suicide or self-harm (15%).
Too many health care workers are suffering from burnout and beyond, yet they’re less likely to receive psychiatric care due to barriers like difficulty accessing care, stigma, and “heroic” health care worker myths.
This mental health burden is compounding health care labor shortages and threatening quality of care. Half of the participants in the survey reported that the pandemic had reduced the likelihood of remaining in their field. Psychiatric symptoms — especially PTSD — increased the odds of respondents considering leaving their current profession and reporting trouble completing work-related tasks. The current degree of suffering in health care workers is already impeding the country’s ability to treat Covid-19, conditions left unaddressed during the pandemic, and rising anxiety and depression.
The survey suggests certain experiences were especially associated with emotional distress and burnout. The volume of critically ill patients respondents worked with and workers’ risk of Covid-19 exposure both played a significant role, as did the heartache of patients dying from Covid-19.
Even when patients survive, treating Covid-19 can be excruciating. As one respondent wrote: “People begging for your help. I feel so evil and dirty having to place a BiPap [breathing machine] on a patient begging me not to. They don’t like it and cry and beg for me to let them die. I must put patients in restraints to keep them from pulling out their tubes. They cry for me to let them go. It’s like a bad horror movie.”
But it was factors promoting demoralization — such as feeling unsupported by one’s workplace, or being asked to take unnecessary risks when better options were available — that were the most strongly associated with burnout and psychiatric symptoms. As one respondent plainly put it: “Our hospital doesn’t care about us. We’re disposable.”
Not all demoralization is directly workplace-related. One of us (T.N.) was surprised to find her mental health worse when the risk of contracting Covid-19 decreased, thanks to the availability first of sufficient personal protective equipment and then the arrival of vaccines. Why? Proliferating disinformation suggesting that health care systems offer lifesaving care to make money has led some of her patients to protest getting necessary medical treatments. Many participants in the survey echoed those sentiments, saying it’s distressing when political leaders and community members flout — or outright demonize — public health measures: “The worst thing is dealing with incredible stress at work, and then realizing no one really cares… It’s very disheartening when the community doesn’t do its part. I feel betrayed.”
Challenges aren’t evenly distributed among health care workers. Those of color carry a higher burden of Covid-related stress leading to burnout and other problems. Essential non-clinicians, like environment services employees, also have high levels of pandemic stress and exposure, but are often overlooked and less empowered to advocate for themselves within their health care systems. In the survey, nurses reported particularly high rates of PTSD symptoms (42%), while emergency medical services (EMS) workers reported the highest levels of depression symptoms (83%) and thoughts of suicide or self-harm (24%). These findings reflect what we are seeing. Nurses have left T.N.’s intensive care unit, saying they can’t bear holding up another iPad for patients’ loved ones to say goodbye.
Health care workers were suffering burnout and more before the pandemic. And there are worrisome trends among educators and other worker groups, too. Indeed, the U.S. in general is experiencing rising anxiety and depression. The U.S. needs sweeping investment in psychiatric disorder prevention and treatment. A critical step in that pursuit is ensuring the well-being of the health care workforce through structural and cultural changes:
- Better access to evidence-based psychiatric treatment, including paid sick leave and explicit supervisor encouragement. Insurance should facilitate preference- and need-matched care. Outreach to workers who may be experiencing particularly acute distress, such as EMS personnel, is needed.
- More protection and support for workers by health care leaders, from addressing staffing shortages to prioritizing transparent, honest, bidirectional communication that centers frontline workers’ concerns, is needed, along with realistic leave and staffing policies, such as for parents with quarantined children. Factors like systemic racism that compound stress for health care workers of color must be addressed.
- Unequivocal support for science-backed measures by political leaders, including vaccines and masking.
Like our colleagues across the country, we continue to weather pandemic stressors. T.N. remembers to believe in herself, even when some of her patients don’t. She also doubled her antidepressant, and finds sharing her struggles with others helpful, hoping it will reduce mental health stigma. We cultivate gratitude, savoring working alongside our patients, whether it’s helping someone leave the ICU or recover from PTSD. We tend to our well-being by going for long runs or meditating.
But we now know that self-care alone can’t restore the well-being of the health care workforce, and hope everyone — politicians, health care leaders, and communities — will come together to mend the fabric of our health care system.
Rebecca Hendrickson, a psychiatrist and acting assistant professor, and Katherine Hoerster, a clinical psychologist and associate professor, are clinician researchers at VA Puget Sound Health Care System, Seattle Division, and the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine. Hoerster is also adjunct associate professor in the Department of Health Systems and Population Health at The University of Washington School of Public Health. Thanh Neville is an ICU physician and researcher at UCLA Health and medical director of the UCLA 3 Wishes Program. This essay represents the personal views of the authors and does not necessarily reflect those of their employers.
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