By Melinda Young
Emerging research about the pandemic’s toll on healthcare workers shows it is leading to disturbing levels of stress, burnout, anxiety, and other problems.
- Hospital case managers had to become frontline nurses to care for COVID-19 patients, adding to their stress and the possibility of post-traumatic stress disorder.
- Case managers need help building their resiliency as the crisis continues.
- Doctors and nurses who performed at a high level felt more supported by the hospital administration. Their perceived organizational support was higher.
Research on the effects of the COVID-19 pandemic on nurses, physicians, and other healthcare workers across the world shows disturbing levels of anxiety, depression, stress, burnout, and suicide.1-3
The authors of one study estimate the prevalence of burnout among registered nurses in the United States to range from 35% to 45%. The authors concluded that nursing burnout due to COVID-19 threatens the stability of the healthcare workforce.1
Results of another U.S. study revealed nurses have experienced isolation, anger, betrayal, grief, exhaustion, loss, denial, and feelings of helplessness as the pandemic surges and strains on personal protective equipment (PPE) supplies forced them to work under risk of infection.2
Nurses from a hospital in Wuhan, China, reported high levels of depression, anxiety, and insomnia during the pandemic. They also noted higher levels of post-traumatic stress disorder (PTSD) symptoms when compared with a stable period.3
As the pandemic continues to push hospitals and healthcare workers to the limit, case management leaders need to help their employees improve resilience and engage in self-care.
“The pandemic is not letting up,” says Ellen Fink-Samnick, LCSW, CCM, CRP, principal of EFS Supervision Strategies in Burke, VA. “Some states have no hospital beds, and rural communities are drowning from decreased availability of hospitals from hospital closures over the last decade.”
Hospital case managers are exhausted and working at maximum levels of stress. “They have been watching colleagues get sick and die, and they have been dealing with what I term ‘collective trauma,’” Fink-Samnick says. “There are many people who have seen more deaths in a day than they should have to see in an entire career.”
Case managers’ roles changed fundamentally during pandemic surges in 2020. Those who continued case management and care transition work had to adjust to meeting patients through telehealth because they were not allowed into COVID-19 patients’ rooms. Others were furloughed or laid off because of pandemic-related cutbacks. There also were RN case managers who were told they could keep a job, but they would need to switch from case management to bedside nursing for COVID-19 patients, Fink-Samnick explains.
“Some nurses were petrified and filed actions with their union or refused to come into work,” Fink-Samnick says. “They were filing complaints with OSHA [Occupational Safety and Health Administration], and this was occurring all over the country. People were petrified they were going to bring this virus home to loved ones.”
COVID-19-related complaints made to OSHA grew from 25 on April 20, 2020, to 10,350 on Nov. 15, 2020. (More information is available at: https://www.osha.gov/enforcement/covid-19-data.)
OSHA complaints often focused on the lack of PPE and adequate cleaning. For example, a complaint filed in May 2020 stated a hospital did not provide N95 or equivalent respiratory protection to staff working with COVID-19 patients. Another complaint said the hospital ran out of gowns and asked staff to wear patient fabric gowns and separate fabric sleeves for direct patient care. (A copy of the complaint is available at: https://www.osha.gov/sites/default/files/Closed_Federal_and_State_Plan_Valid_Covid-19_Complaints_through_May_10-Receipt_Date_release.pdf.)
“People felt very threatened, and a lot of people made the decision to leave their job,” Fink-Samnick says.
For case managers still on the job, the question on their mind is what the new norm will be like, she notes. “Just as people get used to having the new norm, it shifts again.”
Healthcare professionals can suffer from PTSD, but they are not prepared for this, even though they are exposed to trauma — particularly when a crisis occurs.
“In the military, they prepare for PTSD because they know people will be on the frontlines, and they prepare the whole family,” says Keith Doram, MD, MBA, FACP, adjunct associate professor of medicine at Loma Linda (CA) University School of Medicine. “They don’t do that in healthcare.”
People reach their breaking point when confronted with stressors they cannot predict and stressors they cannot control. “The typical healthcare worker is constantly interrupted in clinical work and has competing demands with no off times,” Doram explains. “In healthcare, we’re trying to create a healing experience at the same time our workers themselves need healing.”
A case manager’s resiliency depends partly on the person’s workplace environment and work support network, he notes. One goal is to create an environment in which staff can maintain resiliency despite the crisis and other conditions of their work. But this requires both attention to self-care and actions that enhance resiliency, as well as the right ingredients in the workplace environment, Doram says. (See story on how case managers can build resilience in this issue.)
Case management leaders need to build resilience in themselves and in their staff. Crises, such as the pandemic, often are times when new leaders arise. Case management supervisors can look for employees who are more proactive, resilient, and willing to find creative solutions to emerging problems.
“Think about who the more proactive people are, and put them in leadership positions,” suggests Mike Crant, PhD, MBA, professor of management and organization at the University of Notre Dame. “Acknowledge that a crisis by definition has high levels of uncertainty; it’s the wild West. Tell people, ‘We can’t give you guidance on everything. You have to figure things out for yourself.’ Say, ‘That’s OK — we want you to do that. Don’t wait for us to tell you what to do.’”
Doctors and nurses who performed at a high level felt more supported by the hospital administration, and their perceived organizational support was higher, Crant says, based on his research in Wuhan, China, about how healthcare professionals handled the emerging pandemic.4
“They felt the hospital had their backs and felt deeply about them,” he adds. “Those who struggled felt less supported.”
When proactive and resilient employees face a crisis, such as the pandemic, they thrive, Crant says. “The crisis did not totally destroy their sense of well-being.”
Case management leaders can demonstrate support for their staff by encouraging self-care. For example, case managers should incorporate a 15-minute walk into even their busiest of days. They need to stay engaged in exercise, including tai chi and yoga, and eat nutritious foods when possible. “Don’t grab those fast-food meals,” Fink-Samnick says. “Try to socialize, even if it’s a virtual happy hour. I have one friend who reaches out to me every two weeks just so we can see each other.”
Even if case managers are exhausted by the end of the day and want to be alone, they should try to engage in at least one social interaction. “People who isolate are going to be more prone to health issues, substance use, and suicidal ideation, so they need to push themselves,” Fink-Samnick explains. “Do one five-minute chat by picking up the phone, or maybe chat with colleagues about something that is not work-related.”
Pet adoptions have increased during the pandemic. This is another way for people to receive nurturing and support. “Some people have gone in another direction and taken certifications and tried new things to engage their brains,” Fink-Samnick says. “Everyone needs to cope in their own way.” Other self-care activities include relaxing pastimes, such as coloring on paper or electronically. Case management leaders can recommend staff use their hospitals’ employee assistance programs when they need short-term counseling.
Case managers should focus on sleep hygiene to ensure a better night’s rest, including moving electronic devices out of the bedroom, or at least not on the bedside table. It also helps to avoid social media sites before bed, or to avoid spicy and caffeinated foods and beverages, Fink-Samnick says. “Don’t get into a toxic conversation with a partner or girlfriend, or into a social media rant before you go to sleep,” she adds. “There needs to be some sort of relaxing routine.”
There are additional sleep tips available online at the National Sleep Foundation’s website: https://www.thensf.org/10-sleep-tips-sleep-quality/. For example, they recommend setting a regular sleeping schedule, listening to music or reading a book before bed, and making sure the bedroom is cool and quiet. It also recommends turning off electronics and dimming lights on digital clocks.
- Janeway D. The role of psychiatry in treating burnout among nurses during the COVID-19 pandemic. J Radiol Nurs 2020;39:176-178.
- Iheduru-Anderson K. Reflections on the lived experience of working with limited personal protective equipment during the COVID-19 crisis. Nurs Inq 2020;e12382.
- Cai Z, Cui Q, Liu Z, et al. Nurses endured high risks of psychological problems under the epidemic of COVID-19 in a longitudinal study in Wuhan China. J Psychiatr Res 2020;131:132-137.
- Chen N Yi-Chen, Crant M, Wang N, et al. When there is a will there is a way: The role of proactive personality in combating COVID-19. 2020. Article in pre-print. https://www.dropbox.com/s/l639jt2nltnr5x2/Proactive%20Personality%20and%20COVID-19%20preprint%20version.pdf?dl=0