Health workers know what good care is. Pandemic burnout is getting in the way
The desperate and frantic pace of hospital work in 2020 in New York, the epicenter of the U.S. pandemic at the time, was more chaotic than anything intensive care nurse Matthew Crecelius had ever seen. "It was like watching a bomb go off in slow motion," he says.
He was caring for double the usual number of critically ill patients and navigating hospital halls that looked more like construction zones, with giant fans and plastic tubing blowing a deafening level of extra ventilation. He couldn't hear his patients, or see them through the giant wooden doors of the negative pressure chambers.
"You shout out to somebody, 'Hey, can you check on my other people?' " he says. " 'I can't even see a monitor; I don't know how they're doing.' "
Once, while Crecelius tended to one COVID-19 patient, another ripped off his oxygen mask, triggering a heart attack. Alarms blared. Crecelius rushed to the room, swathing himself in a new gown, to try to revive the man -- who died clutching a photo of his daughter. As other nurses rushed in to help, other unattended patients started to crash.
Crecelius says he can recall numerous moments like this one, when the crush of work and burnout among health care staff had a direct impact on patient care.
"That plays out again and again, day by day, at many hospitals, and in my opinion, I think it's getting worse," says Crecelius, a traveling contract nurse who has worked in a dozen hospitals since the pandemic began.
Many health care workers surveyed say they feel burnt out and that is impacting patient care. The prolonged battle against COVID-19 has left many doctors, nurses, medical assistants, respiratory therapists and others on the front lines of care exhausted and overwhelmed, fueling greater levels of burnout that were already high. The advent of vaccines against the coronavirus sparked hope of a return to normal — only to be dashed by the latest surge of cases, driven primarily by people who aren't vaccinated.
Medicine is a team sport. ... How many clinicians need to be experiencing burnout until we see an effect on quality?
Burnout is a common term many associate with sheer exhaustion. But the World Health Organization says it's also characterized by greater cynicism and reduced effectiveness at work. It was a huge problem in health care long before the pandemic. But now the short staffing and the crushing and unpredictable workload is contributing to epidemic levels of burnout.
"It's not good for their mental health; it's not good for the work environment. There's increased chance for mistakes, medication errors," says Ernest Grant, a specialist in burn care and president of the American Nurses Association. Many fellow nurses he talks to say they're at the end of their rope, which Grant says presents a hazard for any patient needing urgent care right now. "There is no health without nurses," he says.
Caregivers under extreme stress
But just how much burnout affects patient care is very hard to gauge. Multiple studies have linked burnout to lower quality of care. But many of those studies rely mostly on subjective measures, such as patient surveys and self-reporting by nurses and doctors. So drawing a cause-and-effect connection isn't easy.
What happened to Carolyn Dewa in California illustrates why.
After her father was hospitalized in April with cancer, Dewa had a hard time reaching his physicians. Pandemic-related restrictions at the hospital limited when family could visit, and the sheer volume of patients left the staff no time to call the family with updates or to explain treatments.
At one point, doctors treating Dewa's father halted his anti-stroke medication, thinking his throat might be too constricted to swallow the pills. "No one asked me," says Dewa, who had been taking care of her father before the hospitalization and knew he was still able to eat and swallow.
As doctors rushed between patients, she says, they were relying more than usual on numbers and charts to make decisions about how to care for each person.
A short time later, her father died of a stroke.
A painful irony that only adds to Dewa's grief: As part of her work as a professor at the University of California, Davis, she studies the effect of burnout on medical care. "I know what good care is supposed to look like," she says.
Speaking from a personal perspective, Dewa adds, she does feel burnout cost months of her beloved dad's life. But she also recognizes the extreme stress his caregivers were under. It would be very hard, she says, to pinpoint objectively how much that burnout contributed to his death.
"Medicine is a team sport," Dewa says. "So can you attribute it to one clinician? How many clinicians need to be experiencing burnout until we see an effect on quality?"
Not enough staff, no empty beds
Clearly, one huge problem is a shrinking field of seasoned professionals in medicine. Since the pandemic's start, some health care workers have retired early and many say they're considering leaving the field.
Crecelius, the traveling ICU nurse, says that increasing reliance on less-experienced health workers can hurt patients. At the small Michigan hospital where he works now, he recently discovered that a nurse on a previous shift had inadvertently put a heart attack patient on the wrong medication.
It's really a game of dominoes where the doctor is just emotionally devastated because they can't fix it.
"She's a newer nurse and doesn't know this is completely inappropriate. Had someone more experienced been here, we would have been able to catch that," he says.
Crecelius says he used to think of such incidents as teaching moments. These days, he has no time or energy to mentor. He just complains to his colleagues, about his colleagues.
That shortness of time, staff and fuses can fuel still more burnout.
Recently in Indianapolis, for example, a combination of the latest surge in COVID-19 cases and a dire shortage of staff meant all the acute-care beds across the region were full. Lindsay Moore-Ostby, a family doctor in the city and member of the advocacy group Physicians for Patient Protection, says one doctor dealing with that crisis tried to transfer a patient, personally calling every hospital within several states — around 40 hospitals — she recalls.
This doctor was "trying desperately to find a bed for a patient who needed ICU care," Moore-Ostby says. At that point, the doctor told her: " 'Now I'm spending time trying to make this transfer happen — so, what if I can't provide the care I need to the other patients who need me?' "
"It's really a game of dominoes," adds Moore-Ostby, "where the doctor is just emotionally devastated because they can't fix it."
A few months into the pandemic, Moore-Ostby started her own concierge practice, cutting back on her roster of patients. She did so, she says, primarily because having no time to talk to patients robbed her of what had led her to the profession in the first place.
"That little bit of time connecting with the patients — that's what they like, that's what they need and deserve," she says. "And it's what I love about medicine."
Solutions are in the details
As the problem of burnout multiplies, some health care systems are trying to find solutions – discovering they often are found in the small details of the work.
For much of this summer, Tampa emergency doctor Damian Caraballo couldn't staunch the flow of unvaccinated COVID-19 patients coming in. Nor could he stop the stampede of co-workers — nurses, EMTs, and lab techs — who kept leaving, making the pace of work more frantic for those who remained.
"Even things as simple as registration; we're short registration people, and that puts a delay on everything," Caraballo says. The average waiting time in his ER ballooned to over 10 hours. "So it has a downhill effect."
"People keep saying, 'What is the one thing we can do?' There is no one solution. There are many.
On balance, the pandemic has made all the normal bureaucratic hassles of the medical system that much more grating, Caraballo says. But he can also point to recent changes that have made a difference: His hospital started allowing remote monitoring of some COVID-19 patients.
"I've been able to send people home" if they have sufficient internet connectivity, says Caraballo, who is a member of patient-advocacy group Physicians for Patient Protection. Florida also recently relaxed rules about where patients could receive IV infusions of monoclonal antibodies to treat COVID-19, a move that also eased Caraballo's patient load. "All those things would take stress off the hospital because we wouldn't have to admit these patients."
Certainly, chronic short-staffing and overwork are huge factors intensifying burnout. But better management can also help alleviate it, even under extreme conditions, says Christina Maslach, a psychologist at the University of California, Berkeley, whose Maslach Burnout Inventory is the basis of the World Health Organization's definition of the workplace syndrome.
"We have to get past this notion that the job is what it is and you can't fix it, you can't change it, you just have to deal with it no matter what," Maslach says.
Often it is a collection of irritants at work that make people feel undervalued, disregarded and eventually burnt out, she says: "Little stuff. What are the chronic pebbles in your shoe?"
She says the fixes, therefore, are often small and targeted.
One of the most common complaints health care workers talk about, Maslach says, is a perfect example: not having a functioning copier.
That might seem minor, she says. But what makes the broken Xerox so toxic is that it taps into a simmering rage that health care staff universally bemoan: The byzantine paperwork and insurance forms that suck up their after-hours and weekends. So having to hunt down a copier that isn't out of ink or jammed doesn't just make the patient backlog worse, it ignites an existing fury within.
Maslach says she's seen huge morale boosts just from hospital management buying a new copier. In addition to making the work faster, "it gives people the sense they are being listened to, that they're being taken seriously," she says.
And she says combating burnout means identifying and tackling these kinds of problems that plague the workplace.
"People keep saying, 'What is the one thing we can do?' " she says. "There is no one solution. There are many."
Implementing staff ideas for fixes
Often the best suggestions come from those who do the work.
Massachusetts General Hospital realized that early in the pandemic.
As the nation's supply of rubber gloves ran critically low, a triage nurse came up with an idea for a plexiglass wall at a patient's bedside. It had arm holes cut into it, where a set of sleeve-like rubber gloves could be attached. That way, caregivers could slide their arms through and adjust a patient's oxygen line or check a pulse — it was quicker and safer and didn't require a new pair of gloves.
"I thought it was a great idea, so we implemented it very quickly," says Ali Raja, executive vice president of emergency medicine at Mass General. "And the triage staff absolutely loved it."
One of the things they loved about it, Raja says, is that adopting staff ideas gave them a sense of agency over their work lives. "Implementing as many ideas as possible — especially if they're not very expensive — can definitely not only acknowledge the staff's expertise and what they're going through, but quite honestly can give you some really good solutions that the leadership just won't have thought of, because they don't have boots on the ground."
He says staff came up with other ideas: to set up a COVID triage unit outdoors in the ambulance bay and to give iPads to patients, so they could more readily communicate with staff, who then didn't have to suit up in personal protective equipment.
Another critical way of fighting burnout is addressing the mental health challenges that come with it. Officially or unofficially, many hospitals and workers talked about the importance of camaraderie.
Some hospitals converted waiting rooms left vacant because of visiting restrictions, into staff lounges or to be used for peer counseling. Talking about the difficulties of managing work and life sometimes led to staff volunteering to cover for one another in family emergencies.
"I've been asking my friends for help when I've needed it," says Raja, and his co-workers urged him to seek therapy for the first time. "That's not something I would've been willing to do, but the fact is, so many of my colleagues have acknowledged that same burnout and told me how much that helped."
ER doc Damian Caraballo says he encourages the same at his hospital in Tampa: "Offer moral support for them. In the short term, I think that's the best we can do."
For the most part, there are not too many quick ways to solve burnout, he says. It doesn't help knowing the crush of work these days is largely preventable; two-thirds of patients he sees are people with COVID-19 who didn't get vaccinated — even though they could have — often young people. That fact, combined with staff shortages, " it just creates this really tough environment that makes burnout even worse," Caraballo says.
Losing passion for the field
The worst part, say health care workers like traveling nurse Crecelius, is that burnout is robbing them of their sense of purpose — making it harder to care about the work itself.
"Last year this time, I had a greater sense of 'This is kind of my duty,' " says Crecelius, who says he's always had an instinct to run toward disaster — wherever help is most needed. While working in the hotspots during the early months of the pandemic, he says, he told himself: " 'I'm able, I'm young; I can make a difference. Let's go and see if we can put this fire out.' "
In those days, he donned a kind of emotional armor, he says — muscling through shifts during which he lost patient after patient, then prepared them for the morgue.
Then, on a road trip this summer in an RV he built with his wife, Crecelius was standing in line at a grocery store, waiting to buy bananas and yogurt, when he glanced at a tabloid with a cover story about the pandemic.
"And it had a picture of someone loading zipped-up bodies onto a truck," he remembers. "I lost it."
He trembled as he looked at the picture, flooded with memories of volunteering to load bodies into the morgue. He thought of the families he'd helped say goodbye, holding a phone to the ear of his patient.
The work feels different to him now, Crecelius says. Though he's a fifth-generation nurse, he is looking to switch careers.
"Now that there is a vaccine, people aren't getting it," he says. Nursing has changed for him. "I'm not interested anymore."
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