The ramifications of health care worker burnout

0:00:02.8 Dr. Rob Davidson: I'm an emergency physician for the past 20 plus years in West Michigan, working in a small rural emergency department. A lot of people still are unvaccinated and will likely never get vaccinated in our area in the patients that I served. And so that's been a unique challenge. I just had a person yesterday that came in with classic symptoms, diagnosed with COVID-19 and told the PA who was taking care of him, I don't believe that's true, but yet was willing to be admitted to the hospital, had low oxygen, had all the symptoms, the X-ray, everything else. That is something I've never experienced. When you tell someone they have a heart attack, they accept they have a heart attack and they accept the treatment for it, and you go on your way. But the politicization and the social identity aspect of COVID has just been probably the most stressful part, the volumes, the cases, the sickness. It's tough moment to moment, but you do your shift, you go home, that's part of life being an ER doc, you're okay with it. It's just that social part of it that has been so strange and so frustrating, and I think has added to the burnout for so many people.

0:01:05.2 Speaker 2: That was Dr. Rob Davidson, a long-time physician and a recent graduate of the University of Michigan School of Public Health where he earned his Master of Public Health. For him and thousands of his fellow healthcare workers, COVID-19 has been non-stop for two years and counting. We want to understand what that's doing to our healthcare workforce, from dealing with illness themselves to experiencing burnout or even leaving the field all together. We'll explore the ripple effects of COVID's impact for these workers and what potential solutions exist. Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important health topics, stuff that affects the health of all of us at a population level, from the microscopic to the macro-economic, the social, to the environmental, from cities to neighborhoods, states to countries, and around the world. Richelle Webb Dixon is Senior Vice President and Chief Operating Officer at Froedtert Hospital in Milwaukee. She's also a graduate of Michigan Public Health. She started her position at Froedtert in May 2020 in the early months of the pandemic.

0:02:24.4 Richelle Webb Dixon: And so it was very interesting to be new, and to be in a new city, and to learn a new system all while you're still trying to meet the needs of a pandemic that none of us knew what the next day was going to bring. In the midsts of the pandemic, so if you look at May 2020 and beyond, we didn't have staffing issues, because as a system, we shut down our ambulatory operations. We had individuals who were willing to work and their home location was closed. So we were very thankful to be able to use staff from across the system to meet the needs at our acute care hospitals. As the pandemic continued on and we begin to open back up our inventory operations, that staff that we depended on to meet the needs of our patients in different ways on the acute care campuses wasn't there. They needed to go back to their home locations. And so from a staffing perspective, if you asked me the question, "What was the difference with COVID?" I would say it depends on where we were in the pandemic. Early on, we had no staffing issues. Coming out of it now in 2022, we have the same staffing shortages as most other hospitals across this country.

0:03:34.9 RD: And part of that is, at this point, people are fatigued. We thought this is gonna last a couple of weeks, a couple of months at best, and here we are two years down the road. Others have decided that while it might have been their life calling, at this point, they wanna try something different. And then the third, we're realizing that healthcare isn't immune to the great resignation. People really are retiring and just deciding that they've done this for X amount of years, and now it's time to go enjoy their life or be closer to family. So current date, today in 2022 and part of 2021, our staffing concerns are real. Like most other hospitals across the country, we use travelers to fill in gaps, and we continue to do so. Thankfully, I think we see the light at the end of the tunnel as our COVID numbers continue to decline. And hopefully the goal for us is to retain the staff that we have, as well as attract others to come work at Froedtert, because this is a great place to be.

0:04:33.0 S2: Leadership at Froedtert realized early on, they would have to streamline decision-making.

0:04:38.9 RD: Froedtert had a plan to implement virtual visits within the next three years. So this is in 2020, they would have done it by 2023. When the pandemic hit, they were able to, because they had the infrastructure built and they were in that planning process, they were able to do it within a week. So we went from a three-year plan to is up and implemented in five days. And that really is because all the resources were focused on what needed to be done, streamline decision-making, and that everybody executed on what the action of the day would have been. One of the other changes we made when we talk about COVID and how we responded to COVID was our approach to where we put patients. So early on in the pandemic, if you had COVID, we had dedicated units. So only those teams dealt with treating the patient.

0:05:33.5 RD: And while it was great, we were still learning. We had some of the best metrics in terms of treating COVID patients and getting them out in terms of with the stay. What we recognize is that staff retired, because that was their every day all day. At some point in the summer of about '21, we made the change to say, "COVID is here, it's with us." And so our expectation is, no matter where that patient is across our facility, that our staff need to be able to treat COVID positive patients. And so we went from dedicated units to it's what we do every day. If that patient is positive for COVID, you know how to dress appropriately with your PPE and then treat that concern as well as anything else that may have happened. And so what that did for us in terms of our staffing was it normalized it. So we didn't have staff that only dealt with COVID, but we assume if you come work in healthcare that everybody is gonna be accountable and responsible to care for that patient as they come through the door.

0:06:28.8 S2: While business operations adapted to COVID's enduring presence, the reality was many individuals pined for the way that things once were.

0:06:37.0 RD: When we found ourselves almost a year into it, I think people just felt some type of fatigue and wanting that human touch. They wanted things to go back to normal. And what we needed to say was, "This is our new normal." Things were not gonna be the way they were pre-March 2020. They were gonna be different.

0:06:56.1 RD: And so our response to that was to say, "How do we take care of our staff differently? How do we meet the needs of staff who are struggling? Who are showing up every day because this their calling, this is their mission, but yet may not wanna go home?" Right? May not want to bring that chance that they would infect someone at home to their loved ones. And so we had to respond to our staff differently. Part of that was we had contracts with local hotels, so if you worked and didn't wanna go home, we pay for you to stay in the hotel. One of the other services that were important for us was to insure that they had access to EAP, the Employee Assistance Program. They've always had access, but we needed to make it a little bit more real.

0:07:40.3 RD: So if you were in the COVID unit when we had those, the amount of deaths that you experienced, and you may have been the only person in that room, was enormous. So we literally have that EAP representative on the floor in real time to lead that team, not just that nurse, but that team through a session. "How do we help you talk about what you're experiencing? And help you understand and place it where it needs to be so you can continue your work?" When we looked at our numbers and the number of deaths that one unit had seen, it tripled from the number of deaths that they had seen the year before. That's a lot for any one person, let alone the entire department, which is also, I think part of the impetus for us to say, "COVID is everybody's business." And so we couldn't just assume that this one unit was gonna take care of everyone. The numbers were increasing and the amount of resources needed just would not have allowed that. But then how do we partner with you differently as our staff to make sure that as you deal with COVID, as you deal with everything else that's going on, that you have visible support to help you talk through what you're experiencing so you don't carry it with you? 

0:08:56.8 RD: And that was probably the difference for us, is that EAP literally was everywhere, in-person, talking, holding sessions, trying to help people deal with what they were experiencing. If they didn't want the group session, we increase the number of in-person one on one sessions that were had as well.

0:09:15.0 S2: The American Hospital Association recently cited research from 2021 showing alarming findings. Throughout the pandemic 44% of nurses, nearly half, reported experiencing physical violence. And 68%, almost seven in 10, reported experiencing verbal abuse.

0:09:33.1 RD: Being in healthcare for as long as I have been, you knew that there was some violence that happened. But it got heightened in the midst of the pandemic. And so many may ask the question, "Why?" And I think people were isolated. And as they're coming out, not anybody's coming out with good manners. And so what we're seeing is, I think, some clinical pieces, whether you're mad at wearing a mask or not. People's feelings about whether COVID's real or not. People's feelings about being cooped up, or they're upset about our visitor policies. So a number of things I think have been triggers for individuals, no excuse though for the violence that we're receiving. And I equate it when people talk to me about, "Well is this new?"

0:10:16.1 RD: It's not new. But think about it too with the airlines. You have a lot of the airlines coming out saying, "We're experiencing high levels of violence, and it will not be tolerated." Same thing with the hospital system. This isn't going to be tolerated, and we're gonna work with our colleagues from across the country to do something different. One of the main things you'll see when you come in to our hospital is that kindness heals. That we will not tolerate verbal nor physical violence of any kind. That's important because what we recognize is our nursing staff had a high tolerance for violence. And we asked them not to. We asked them to consider that it was not part of the job, that you did not get into nursing to get hit, kicked, or harmed. And so once we shifted that thought process, the accountability for them to keep themselves safe, and for us to make sure they had the resources that we keep them safe was heightened. Now mind you, we'd already been working on a lot of this. But because the patients and family members, unfortunately, who were coming into our hospitals were exhibiting more violent behavior it heightened our response and awareness.

0:11:27.0 RD: So one of the things we did that came out of the COVID was we could put a flag in a patient's chart. And that was important for us, and it's a very thoughtful manner of how we do that. But that was important to say that if this patient exhibited violent behavior in the inpatient setting, how am I allowing my team member, my colleagues on the outpatient setting to know that they need to be prepared for that? We know this patient created problems on the inpatient, and we never warn the outpatient when they do their follow-up visit. So it allowed us, again, from a team perspective, from a network perspective, to say that violence isn't just inpatient, but if it happens everywhere, how are we all made aware and all have the same strategies to ensure that we keep each other safe? 

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0:12:15.1 S2: Christopher Friese is a Professor of Nursing at the University of Michigan School of Nursing, and a professor of Health Management and Policy at the School of Public Health. An oncology nurse by training, his research focuses on cancer care delivery and increasing safety for both patients and health care workers on the job.

0:12:33.5 Christopher Friese: So I think what's really important is there's clearly greater awareness and concern for the plight of healthcare workers, especially nurses, after what we've seen over the two few years. So nurses have been delivering extraordinary care in hospitals, schools, they've been serving their communities all throughout this pandemic with really no relief. And what that has shown us is that they are at risk for substantial burnout, what we call emotional exhaustion, being tired of being in the workplace, etcetera. We've actually had data, for about the last two to three years, that working conditions, particularly for nurses, was going in the wrong direction for a period of time. Some of those trends were there before the pandemic, but certainly the pandemic kind of exposed the fault line of that. For a hospital nurse, something to recognize is that the work we do is very complicated. We have the physical care that we may have to deliver to a patient, whether that's addressing their wound from their surgery, making sure that their drains or tubes are working properly, if they've had surgery, to make sure either stuff's going in or out in the right way, administering medications to make sure that infections are prevented, or pain's controlled or nausea's controlled, or if someone's having low blood pressure, that we give the right fluids to kinda, "tank them up."

0:13:53.6 CF: So it's a lot of that physical care, but what people probably don't understand is the behind the scenes what I call air traffic control. A, checking physicians' and others' orders to make sure that it's safe for the patient, that they didn't order something that's contraindicated, or the patient's not gonna be able to tolerate, or the patient has an allergy to. Letting a physician know, "Hey, I gave that medication, and the pain's no better, what's our next plan?" Alerting them when we see that the patient is deteriorating and getting what we call the Rapid Response Team around a patient who's in trouble. And the sooner we do that, the more likely they are to make it through that encounter. All the way to preparing patients for discharge, making sure they understand how to take their medications, monitor their wounds, etcetera. And then of course helping patients have a peaceful death and supporting family members and loved ones who are left behind.

0:14:48.4 CF: So what you see on TV is a lot of the physical skills of doing these very specific procedures, and that's of course a big part of it. But this whole function of air traffic control, of who needs to be helping the patient, "Is our treatment working? What do we need to adjust?" helping patients and families understand that, I think that's the hidden work of nursing that doesn't always maybe make it easy on a TV show. But it's so important, and that's the stuff that falls away when we're... We don't have an adequate number of nurses to care for patients. It's that surveillance function, that air traffic control that becomes so much more difficult when we're running short. Patients are still getting medications and treatments, but all this other piece of the care is kinda missing when we don't have the right folks at the table to care for our loved ones.

0:15:40.2 S2: What are some of the biggest issues faced by nurses? 

0:15:43.2 CF: So we've been surveying nurses in my research lab for over a decade. And some of the consistent themes that nurses tell us have been troubling them in their workplaces is really this issue of I call running lean. So healthcare operations, for a large part hospitals but other sectors of healthcare as well, have really tried mathematically, if you will, to deliver healthcare services in the most efficient manner possible. It's expensive to do, it's a large part of the budget, nurses are not really paid for the services they deliver, they're a cost center to a hospital or any other health system. So a lot of hospitals and other settings really have tried to say, what's the least amount of employees we can have in a clinical environment to deliver care safely and run with that? And I think what we saw is running lean for so long has its consequences. That when we don't have slack in the system, when we don't have extra people around to help us when things get difficult, when things get difficult, it's gonna be really, really tough.

0:16:45.6 CF: One of the things I'm really trying to encourage many of my colleagues who are in leadership and executive positions is to really dive back in, to sit down with the clinicians and really listen carefully to what their concerns are and really drive their future planning, and their future strategy, and their healthcare settings to meet the needs that their front line is telling them. And that's been disconnected for... Before the pandemic, but certainly the pandemic has also exposed that. And then I think the other thing to think about is there's been a strong emphasis on quality improvement approaches informed by management and operations research. And that's really important. We wanna be as efficient as we can. The potential downside of this is this is not a perfect system, and there can be a lot of unpredictability in patient care needs that a mathematical model doesn't always help us with.

0:17:37.5 CF: And so I think that piece needs to come back, and we need to be able to have a process whereby clinicians on the front lines can call some of their shots and say, "We need to surge some extra support here and now," we need to be able to do that. And we need to have the people in our system who can step in and do that. One of the things, curiously in the very beginning of the pandemic that just baffled me, was many health systems furloughing clinician workers. I thought to myself, "We're just at the beginning of this pandemic," and I understand the need to keep the lights on and keep the finances going, I understand all that, but to send a message to healthcare workers that, "We don't need you right now," I think that was chilling to me, and I think that has bore out that maybe that was probably not the right decision.

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0:18:33.3 CF: One of the things we need to talk about sadly is self-harm and death by suicide among healthcare workers. So in 2021, myself and a few other colleagues published a paper that showed that death by suicide among healthcare workers, particularly female registered nurses, was twice the rate of the general population. We actually had these numbers, and they were rising, and this trend was observed before the pandemic hit, the latest data was 2017. So the paper was published during the pandemic, and several chief nursing officers reached out to me and said, "We are seeing this. We are very concerned about our nurses. What do we need to be doing differently to really make sure that they have the support they need, that we can recognize if someone's in trouble?" etcetera.

0:19:16.2 CF: Now, thankfully, we've done some consultation and given some folks some tools. Number one is listen to your employees. The other thing that's really exciting is some legislation just got passed, the Lorna Breen Act, some of you may have seen that. So this is federal legislation that actually has a large grant mechanism for research and outreach specifically for healthcare workers on mental health issues. It's one of the first examples we have.

0:19:40.3 CF: Very specific programs for mental health support for health care workers. And I think that will be helpful in peeling back that potential stigma. A lot of healthcare workers don't really wanna disclose that they have a problem, they're having difficulty. So I'm hoping that these programs will help healthcare workers realize it's okay to seek help. Just like you ask your patients to go for help, it's time for you to go for help. And also customize the services to meet the needs of healthcare workers, nurses, physicians, and others. So that's a really exciting development.

0:20:15.3 S2: What can we do to support the nurses and other health care workers in our lives? 

0:20:20.7 CF: Nurses are always the first ones in, in a time of conflict. We talked about the pandemic a lot today, I was also struck by the extraordinary video and imagery of nurses caring for kids with cancer in the Ukraine. And setting up neonatal ICUs in the subway in Kiev. So nurses don't leave. We are there for all of life's crises, and that is our call and our function. So it's really powerful. And so what are some ways that people can help? With four million of us, it's likely that each of us has a loved one, a family member, a friend, a neighbor who's a nurse. Don't be afraid to ask them how they're doing. Because of HIPAA and privacy concerns, they're not often likely to talk about their work, but we can do that in an anonymized way and talk about our stressors and how things are going. And we don't always need our friends and family members to solve our problem, but to listen to us and say, "Wow, that was really hard." And, "That's really tough."

0:21:18.4 CF: And those family members know us, right? And they know when we're off and when we might need a little bit of extra help and support. Checking in with your loved ones who are nurses to say, "How are you doing? I really wanna learn more." And every setting has its opportunities for volunteers or donations or other things that will ease the burden of nurses, and so people will know that. And that's always very heartening.

0:21:42.7 CF: I think the message to healthcare executives, leaders of systems that employ nurses, whether it's hospitals or otherwise, listen carefully to your nurses. Think about ways that you can act upon the issues that they are bringing to you. Good example, during the pandemic, we cut back urgently on the amount of required documentation that nurses had to complete on every patient because we just had to. And we did that, and I'm not aware of any patient harm that follow that, and in fact, nurses were very pleased that they could complete their charting faster. And guess what? Now that's all back, the old stuff is back and we're adding more, that's the wrong approach. We need to streamline documentation. We need to reduce onerous burdens, regulatory burdens, on nurses, etcetera. And so I would say listen carefully to you own nurses and scrub their daily work carefully for the things that are not focused on patient safety or their own safety. And really think carefully about adding new things to their workload, because if you add more stuff that surveillance detection, air traffic control function goes down. You can't just keep adding.

0:22:52.4 CF: So that's the message for the executives, and I think for each other, really important point, we know when our peers and our colleagues are not in a good place. And I think we need to develop better tools to help our peers who might be in trouble or might be having difficulty to say, "Boy, today was really tough. Do you wanna talk about that? Do you wanna think about reaching out to a professional and having a conversation?" Etcetera. And the thing I will tell you is in my own experience, I had life trauma, I went to see this therapist for a while and stuff came up about my work that was not even in my brain when I walked into those encounters. And so having a professional thoroughly walk you through the process of thinking about your work and thinking about what your stressors are is incredibly powerful.

0:23:40.9 CF: And you may personally not be in a position to feel like you need it, but if you're hearing that from peers and colleagues who are saying, "Hey, this is about you, we wanna make sure you're in a good place." I think that's exciting. One of the things that the Breen Act that we talked about is setting up support resources from professional organizations outside of your employer. So there's less stigma and less concern about privacy, you can go and do this in a confidential way outside of your employer. So I think those are some things to do, and I think the other piece is, nurse to nurse, is to be gentle with each other.

0:24:14.5 CF: I often say this to a new graduate who I'm following after they've cared for somebody for eight or 12 hours and they'll apologize it for something that didn't get done. The thing I always say in the hospital is, "That's why this is a 24/7 business. We don't expect to get it all done. You did the best you could for the eight or 12 hours, I'm not here to second guess you." And giving each other that grace, and that patience, and that gratitude to say, "Hey, thanks for keeping it together for eight or 12 hours, I've got this. Go home. Take a rest. Take care of yourself. Thank you for what you did." I think having a little bit of grace and a little bit of gratitude will be helpful for all of us moving forward.

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0:25:11.5 S2: Thanks for listening to this episode of Population Healthy from the University of Michigan School of Public Health. We're glad you decided to join us and hope you learn something that'll help you improve your own health or make the world a healthier place. If you enjoyed the show, please subscribe or follow this podcast on iTunes, Apple Podcast, Google Play, Stitcher, Spotify, or wherever you listen to podcast. Be sure to follow us at U-M-I-C-H-S-P-H on Twitter, Instagram, and Facebook, so you can share your perspectives on the issues we discuss, learn more from Michigan public health experts, and share episodes of the podcast with your friends on social media. You're invited to subscribe to our weekly newsletter to get the latest research news and analysis from the University of Michigan School of Public Health visit publichealth.umish.edu/news/newsletter to sign up. You can also check out the show notes on our website, population-healthy.com for more resources on the topics discussed in this episode. We hope you can join us for our next edition where we'll dig in further into public health topics that affect all of us at a population level.

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