The extreme stress brought on by the healthcare industry’s response to the COVID-19 pandemic has highlighted what should always be a concern: the need to care for the psychological well-being of physicians, nurses, and other healthcare workers.

The pandemic response has taken stress to new levels in facilities and communities. The emergency physician who served as medical director at a New York City hospital committed suicide. Her family told media outlets that it was prompted by the strain of working day after day with the onslaught of COVID-19 patients. A New York City paramedic also killed himself the same week, with the family reporting the stress of responding to coronavirus calls as the cause.

Not only is caring for employees’ well-being the right thing to do, but it also directly affects the quality of care they provide patients. The issue has been studied in the context of clinician understaffing and other stressors, notes Robert Morton, BA, ARM, CPHRM, CPPS, assistant vice president of patient safety and risk management for The Doctors Company, a medical malpractice insurer in Napa, CA.

Nurses’ vigilance and adherence to infection control practices, as well as their dedication to other quality of care issues, erodes when they are understaffed and do not feel they have the support of management, Morton says. Quality of care can be diminished when nurses, physicians, and others are overworked, forced to work with inefficient systems, and burdened with administrative requirements.

Situational awareness can suffer and clinicians can falter on their observance of patient safety practices like hand hygiene and cross-checking patient information. Overstressed clinicians are likely to record higher rates of error.

The Agency for Healthcare Research and Quality offers a Care for the Caregiver Program Implementation Guide here.

Nurses Show Signs of Stress

The COVID-19 response has brought a range of stresses to nurses, some expected and some surprising, says Linda Roney, EdD, RN-BC, CPEN, CNE, assistant professor and undergraduate nursing program director at the School of Nursing and Health Studies at Fairfield University in Connecticut.

Roney says her nursing school already was addressing the problem of workplace stress and how it can affect the care delivered by nurses. Two years ago, she began to hear stories about how faculty members were concerned about the stress level of nursing students.

The school began a holistic health initiative that is purposeful in including pedagogy. The focus is on caring for the caregiver, offering wellness initiatives, and preparing emerging nurses for the stresses they would encounter on the job. In March, Roney heard from nursing graduates about the challenges they faced from the pandemic.

“Some of the challenges are what would be expected from, for instance, a pediatric nurse being transferred to work in an adult ICU [intensive care unit]. What wasn’t expected was that we would hear from so many nurses who were being furloughed from their positions,” Roney says. “These nurses were in a position of wanting to help, yet they couldn’t work their full-time hours. This was a new type of stress that they didn’t expect when they came out of nursing school.”

Research has shown a direct link between the well-being of frontline healthcare employees and patient outcomes, Roney notes. “This was a problem pre-COVID-19 and well documented. Now, we’re in a situation where nurses of all types are being tasked to take care of the sickest patients, with protocols evolving sometimes over the course of a shift,” Roney notes. “It’s more important now than ever to consider the effects on the care they are able to deliver to patients.”

Employers should work to reduce the immediate impact of the COVID-19 pandemic on nurses and other clinicians. Roney adds that it is important to consider the long-term effects, too. The stresses faced by some employees could linger longer after the high volume of COVID-19 patients diminishes and healthcare workplaces return to normal.

“What will be the longstanding impact on their physical and mental well-being? We don’t really know yet, but this is something we should watch for and not just decide at some point that the crisis is over and our employees are back to their normal selves,” Roney suggests. “In many cases, those employees were stressed to begin with. There is a good chance that for some, the COVID-19 response is going to leave them with effects that will affect them and their patients for a long time.”

Roney recommends instituting a program that includes regular communication with staff members, including rounding, and the generous use of employee assistance programs.

Creeping Burnout

Cognitive overload and burnout already were serious problems for healthcare professionals. The COVID-19 response is highlighting just how bad those threats are, says M. Bridget Duffy, MD, chief medical officer of Vocera Communications in San Jose, CA, which provides communication services to healthcare organizations.

“Numerous studies have demonstrated how provider burnout is directly linked to quality and safety,” Duffy says.1,2 “Those who have emotional exhaustion, fatigue, and burnout have higher incidents of adverse events, medication errors, and bad outcomes in operating rooms.” Research clearly indicates that the doctor or caregiver experience is directly related to the patient experience, she says.3 If the doctor or nurse has nothing left to give, the patient experience and satisfaction score typically goes down in most institutions, Duffy says.

Nurses on Suicide Missions

Duffy has heard nurses share stories from the frontlines where COVID-19 outbreaks were widespread and other nurses were brought in from elsewhere to handle the volume. They refer to that as “suicide missions.”

“They don’t know whether they will survive flying in to help their peers in the trenches. It’s truly a heightened state of anxiety. How does one do their best work under those conditions?” Duffy asks. “To hear it referred to like that I think is unprecedented.” One of the biggest stressors for clinicians is how they have been robbed of some of the personal interactions with patients and family members, which are critical to making their work feel meaningful and to cope with some of the negative aspects of the jobs, Duffy says. She recalls one story in which a physician was stricken with COVID-19. His nurses went in the room twice a day to help him FaceTime with his wife, who could not visit.

But as the surge hit hospitals and the patient-to-nurse ratios jumped to 6:1 and then as high as 10:1, nurses could no longer find time for even that kind of interaction. “There isn’t time for a nurse to hold up a phone and help someone FaceTime with a loved one, much less the horrific times when patients die alone because their loved ones can’t be at their bedside,” Duffy says. “Some caregivers have taken to printing a big photo of themselves and hanging it from their name badge, trying to give some humanity back as they provide care at the bedside while wearing masks and all this other equipment that creates a barrier between the two human beings.”

Many nurses are forced into palliative care roles when they are not prepared. The sudden onslaught of so many dying patients will have lasting effects on them, Duffy says.

“I’m sure there will be cases of post-COVID post-traumatic stress syndrome. We will have a whole generation of doctors and nurses of all ages who will have stress that will have to be addressed on the other side of this,” Duffy predicts. “This will be one of the most important topics that we have to address after this. The virus and the experience of those who fought it may frighten people from entering these professions. We will have to make changes to assure the physical and mental well-being of our healthcare workforce.”

Benefits to Organization

The effects of the pandemic on physician and nurse well-being must be monitored and addressed in the coming months and years, says Gary Price, MD, MBA, FACS, practicing physician and president of The Physicians Foundation, a nonprofit in Boston that supports physicians and educates the public about the challenges they face.

Physicians and nurses commit suicide and are at a higher risk of doing so than the general population.4,5 In addition to lower satisfaction scores and more errors, burned out physicians and nurses tend to retire earlier, he notes.6,7

“From the institution’s standpoint, the most important point is that preventing physician burnout leads to better care of patients,” Price says. “It protects a critical asset for any organization that hires physicians. It is going to be significant to their bottom line, not only because of the cost of replacing a physician they lose to burnout but also the difficulty of finding a physician to replace someone who leaves.”

The issue of physician burnout is receiving more attention than in the past. Price added that COVID-19 is both a blessing and curse in that it is drawing attention to the negative effects of burnout while also possibly making the problem worse.

Organizations seeking to address burnout should start by publicly identifying the issue as important and implementing communication channels, Price offers.

Changes to working conditions can begin with addressing frustrations with the electronic medical record and, at least during the COVID-19 response, providing better access to personal protective equipment (PPE), he says.

Facilitating better communication among healthcare workers can help alleviate feelings of isolation and show that colleagues are feeling the same stresses, Price says.

Zoom Calls Help

Zoom meetings were part of the solution when the effects of COVID-19 began to show quickly in those who belong to Physician Performance, a 2,900-member association in Woburn, MA, comprised of different types of provider groups, including large faculty practice, community health centers, and solo and small group independent practices.

Executive Director Deb Schoenthaler says one of the first signs of stress was the physicians’ requests for information about how to respond. They were unusually stressed by the uncertainty of the pandemic’s scope, how they should respond, the lack of PPE, and other issues, she says.

“It was important for us to set up an independent communication channel that could support those physicians, particularly those in one- or two-person practices, with updates on things that were changing in clinical care but also just getting them information about changes in payor reimbursement, coding requirements, and related issues,” Schoenthaler says.

The physicians were candid about their concerns about a possible decline in patient care quality, not only because of the social distancing restrictions but also due to everyone’s stress, Schoenthaler adds.

One of the first steps was to create a weekly Zoom call to communicate across a group of about 350 physicians. The process was daunting at first because of the technological challenge in communicating to so many people in a live format.

“We weren’t quite sure how it was going to work out, but it’s been an amazing experience working with them. We usually have at least one or two people from a majority of the practices participating,” Schoenthaler reports. “We wanted to use these Zoom meetings ... to help them understand how to triage their patients as they began to close their offices and needed to direct their patients to the correct site for care.”

Physician Performance helped the physicians determine the best way to divert patients for care when their offices closed, whether that was sending them to urgent care or an emergency department. Participants also discussed best practices for setting up phone contacts with patients and the use of telemedicine for those who chose that path.

The availability of testing was another hot topic, in addition to how accurate it was and when it was appropriate to use the scarce tests.

Further, reimbursement issues were a big worry. The calls included discussions of the requirements for billing with the new or increased use of phone contacts or telemedicine.

“There were really two major stresses: how were physicians going to care for their patients amidst all these changes, and how were they going to survive financially,” Schoenthaler says. “As the crisis continued and we had these weekly calls, we started to include subject matter experts in topics like palliative care and gerontology. The goal was to provide supportive tools that would help bring down their stress levels and ensure that their patients still received quality care.”

The calls also allowed physicians to collaborate and share ideas about how to cope with the crisis. This was important, Schoenthaler says, because physicians collaborate extensively in normal times, relying on each other to inform and discuss options.

“Their world suddenly got much smaller. They were not able to stop by another physician’s office and chat about a problem for five minutes,” she says. “The Zoom meetings gave them the opportunity to share across all of the participants. If one has found a great way to do outreach to elderly patients, that physician can share it with others.”

Another healthcare company is using telemedicine to provide care for stressed employees. VITAS Healthcare, a Miami-based company that provides end-of-life care, offers the service free of charge, says Diane Psaras, chief human resources officer.

VITAS partnered with a telemedicine provider to provide 24/7 access to virtual healthcare appointments with board-certified physicians from home via phone, an app, or on the web.

“When our employees are feeling well and confident, and their families have the medical support they need, they can focus on providing the best possible hospice care amidst one of the most challenging times our nation has ever faced,” Psaras says.

Caution with Hero Title

A frontline healthcare worker’s burnout can directly affect more people than the condition would for those who work in other professions, according to Jarrett Jedlicka, vice president and principal for healthcare with Ceridian, a company in Minneapolis that provides human capital management.

A clinician who is overly stressed, exhausted, or worried will be carrying out tasks every day at work, sometimes hundreds of times in a shift, which could directly affect the health of another person, he argues. That means caring for the well-being of clinicians is about more than just that employee, he adds. “There is such a focus on the patient, but what can get lost is that there is another factor that has so much effect on how the patient fares — that is the caregiver,” Jedlicka says. “We have a society that is so consumer-driven that sometimes we lose sight of how critical the health of that caregiver can be. First responders are all taught to protect themselves first because they can’t be of help to anyone else if they get hurt. As organizations, we can overlook that sometimes.”

Jedlicka notes that even the current trend of praising healthcare workers as heroes can be detrimental. “Hero as a recognition is great. But hero also implies that these people are superhuman and don’t need to be cared for,” Jedlicka says. “We have to be conscious that these are real people with lives outside of what they’re doing in the hospital. We need to be careful not to create these unrealistic expectations that this RN [registered nurse], doctor, dietician can just go nonstop all the time. You can call them heroes, but remember that they’re really human.”

The COVID-19 response is drawing even more attention to the risk of burnout among healthcare providers, and Jedlicka hopes there will be a lasting benefit after the pandemic subsides.

“In unprecedented times, there is an unprecedented opportunity for greatness,” he says. “People are rising to the challenge, but we also need to think about the structural changes that are needed to support our caregivers. To deliver top quality care, our caregivers need to receive top quality support.”

(Editor’s Note: The American College of Emergency Physicians eulogized Lorna Breen, MD, FACEP, on April 27. EMT John Mondello took his own life on April 24. Learn more about him here.)

REFERENCES

  1. Patel RS, Bachu R, Adikey A, et al. Factors related to physician burnout and its consequences: A review. Behav Sci (Basel) 2018;8. pii: E98. doi: 10.3390/bs8110098.
  2. Yates SW. Physician stress and burnout. Am J Med 2020;133:160-164.
  3. Panagioti M, Geraghty K, Johnson J, et al. Association between physician burnout and patient safety, professionalism, and patient satisfaction: A systematic review and meta-analysis. JAMA Intern Med 2018;178:1317-1330.
  4. Farmer B. When doctors struggle with suicide, their profession often fails them. National Public Radio, July 31, 2018.
  5. Davidson JE, Proudfoot J, Lee K, et al. A longitudinal analysis of nurse suicide in the United States (2005-2016) with recommendations for action. Worldviews Evid Based Nurs 2020;17:6-15.
  6. Shin J, Kim YJ, Kim JK, et al. Probability of early retirement among emergency physicians. J Prev Med Public Health 2018;51:154-162.
  7. Blakeley JA, Ribeiro VE. Early retirement among registered nurses: Contributing factors. J Nurs Manag 2008;16:29-37.

SOURCES

  • M. Bridget Duffy, MD, Chief Medical Officer, Vocera Communications, San Jose, CA. Phone: (888)-986-2372.
  • Jarrett Jedlicka, Vice President & Principal – Healthcare, Ceridian, Minneapolis. Email: jarrett.jedlicka@ceridian.com.
  • Robert Morton, BA, ARM, CPHRM, CPPS, Assistant Vice President, Patient Safety and Risk Management, The Doctors Company, Napa, CA. Phone: (800) 421-2368.
  • Gary Price, MD, MBA, FACS, President, The Physicians Foundation, Boston. Phone: (202) 591-4015.
  • Diane Psaras, Chief Human Resources Officer, VITAS Healthcare, Miami. Phone: (855) 539-1012.
  • Linda Roney, EdD, RN-BC, CPEN, CNE, Assistant Professor, Undergraduate Nursing Program Director, School of Nursing and Health Studies, Fairfield University, Fairfield, CT. Phone: (203) 254-4000, ext. 2763. Email: lroney@fairfield.edu.
  • Deb Schoenthaler, Executive Director, Physician Performance, Woburn, MA. Phone: (781) 528-2828.