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Burnout among nurses, physicians and other healthcare workers was a pervasive problem even before the onset of the COVID-19 pandemic, but now that the U.S. has been living with the coronavirus for over a year, some on the front lines are starting to bow to the pressure.
This was exemplified in a recent survey from the American Nurses Foundation, which found that the pandemic is causing 92% of nurses to consider leaving the workforce. Nearly half cite insufficient staffing as one of the primary reasons.
In some ways, it was a crisis waiting to happen. The healthcare system wasn't prepared for a public health crisis of this magnitude, and the crisis highlighted fractures that had been building within the industry.
Properly trained staff were needed to address patients with a new and formidable virus, and these staffs were in short supply. The sheer volume of patients was overwhelming.
Add to that the lack of personal protective equipment at the start of the pandemic, and nurses didn't feel safe. Many still don't, and it's become clear that a better approach to staffing would go a long way toward addressing healthcare workers' mental and physical health needs.
Anne Dabrow Woods, a practicing critical care nurse practitioner at Penn Medicine and chief nurse of health learning, research and practice at Wolters Kluwer Health, said that in an effort to better support critical care staff some hospitals started shuffling around staff to fill some of the gaps.
But many hospitals and health systems are still playing catch-up, and most still have a long way to go before the burnout issue is properly addressed.
"We're starting our fourth wave of COVID, and nurses are tired," said Woods. "They feel that not only did their health systems fail them in many cases – there's a feeling health systems weren't there to support them with their equipment or the education they needed, or with the staffing."
This is borne out in the numbers for both nurses and physicians alike. Clearly, the pandemic is taking a toll on the mental and emotional wellbeing of physicians, with female physicians and those in critical care and infectious disease reporting the highest burnout rates during the public health emergency, according to findings from a December physician burnout report from Medscape.
Burnout and the stress of the pandemic – including factors such as personal risk, social distancing and financial uncertainty – appeared to diminish physicians' overall work life happiness, with only 49% reporting they were happy in 2020, versus 69% pre-pandemic. More than one-third (34%) reported feeling unhappy last year, compared with 19% in 2019.
Nurses report similar trends, with 47% in the ANF survey reporting that work is negatively affecting their wellbeing. A new approach is needed, and staffing is a good place to start.
A BETTER WAY TO STAFF
According to Woods, the health systems that have most successfully made headway on this front have made an effort to cross-train staff. They have taken staff from areas such as progressive care and trained them to work in the critical care unit. They've also trained med/surge nurses to work on telemetry units – all to move staff around more efficiently, based on where the patients are and their level of need. That's been key to moving the needle.
"The nursing shortage will get worse," said Woods. "You have to develop a multi-specialty nurse who is competent to work in other areas – upscaling nurses so they feel competent and confident."
The healthcare system also needs to change how it onboards new nurses, said Woods. It needs to work with educational institutions to bring in practice-ready nurses. It needs to invest in staff-development instructors or nurses in professional development who are in charge of training staff.
Investing in these positions and in this training can allow nurses to work in multiple units, thereby giving them more leeway to take time off to recharge and spend time with their families, for instance.
"People are not meant to work seven, 10 days in a row," said Woods. "You can't keep up with that pace. They're exhausted, and they can't make decisions when they're so tired they can't think straight.
"When people have time off, they can invest in their wellbeing. We need to start thinking about the wellbeing of our workforce. We need flexible scheduling patterns, give time off and invest in things that can really make a difference."
That ties into another issue with nurses and caregivers: mental health. Just 3.1% of respondents in the ANF survey felt like their employer invested in their mental health, or understood that the staff had responsibilities outside of the workplace.
Many provide employee assistance, but often that's not enough, said Woods: Health leaders need to walk down to the front lines to see the situation for themselves.
"Leaders need to be on the floor and see what's going on," she said. "It's about getting the mental health folks up on the units so they can see what's happening.
"Then ask the staff, 'What can we do that would be helpful to you? Is it having a counselor? Is it days off? Is it understanding you have responsibilities outside the workplace, and what can I do to help you with that?' It's those types of things."
These actions communicate to staff that leadership is engaged and concerned about their health. Leaders can then take it to the next level by offering sufficient child care, something that was lacking at the start of the pandemic, when nurses and clinicians often stayed in hotels, rather than going home to their families for risk of virus exposure.
Meanwhile, support staff can help make sure that nurses are secure in their finances and in terms of supplies for their families, like food.
Even prior to the pandemic, burnout among healthcare professionals was a widespread public health concern, with some studies reporting burnout for more than 50% of clinicians. Aside from staffing, perhaps the factor that could change things the most is the current campaign to get Americans vaccinated.
"The vaccines protect you from getting really sick, when otherwise you may need hospitalization," said Woods. "Getting shots into arms is the first step. That's going to give us a reprieve, so we're not going to see as many critically ill patients. That's a good first step."
In the long term, systems that are changing the culture to focus on workforce wellbeing will be the most successful in clawing their way back from the pandemic.
"Staff are feeling overworked, unsafe and undervalued," said Woods. "They're going to burn out, and they're going to leave the institution and the profession. Now is the time for health systems to step up and invest in employee wellbeing, cross-training, and asking staff what they need to feel good."