Since the COVID-19 pandemic forced a shutdown in the United States, nurses, case managers, and other healthcare professionals have faced high levels of stress, burnout, and occupational trauma.

  • A year after the pandemic began, more than half of nurses said they have felt exhausted within the previous two weeks.
  • In New York City, clinicians experienced high rates of psychological symptoms, including 57% reporting acute stress, according to a study.
  • Too often, case managers and other leaders put on a strong front and do not share with their staff the uncertainty and challenges of a crisis, instead of talking about how everyone can work together to get through it.

Research shows healthcare workers are suffering from extremely high levels of stress, burnout, post-traumatic stress disorder (PTSD), and occupational trauma. These existed before the COVID-19 pandemic, but have worsened over the past year and a half of the world in crisis.

“We have a workforce in a dysfunctional dance with patients — no one can escape the stressors of what they’re going through,” says Ellen Fink-Samnick, LCSW, CCM, CRP, DBH-C, principal of EFS Supervision Strategies, LLC in Burke, VA. She spoke about resilience, occupational trauma, and social determinants of health at the Case Management Society of America’s 2021 Virtual Conference, June 7-10.

Collective, infused trauma has created a toxic work situation for many healthcare professionals. “It hits the workforce head-on; they feel it, whether they are case managers, utilization management, or reviews,” she adds.

In normal times, when case managers are stressed or experiencing burnout, they can take a day off or go on vacation. Even when these time-outs were available during the pandemic, they were not enough to help people regain their energy and emotional equilibrium.

“The pandemic was not a one-and-done thing,” Fink-Samnick says. “We have now been living with this for [18] months, and it’s still going on with people unsure about these latest waves. We’ve never stopped.”

Collective occupational trauma can create an all-encompassing cycle in which the workforce has no way to escape professional and personal stressors.1 “People are tired and burned out,” Fink-Samnick says. “When you look at collective occupational trauma, think of it in the context of PTSD. You have got a little stress, and that contributes to trauma and the shared experience of what’s going on.”

In a survey assessing the effect of COVID-19 after one year of the pandemic, 51% of nurses said they experienced exhaustion within the past 14 days. Another 43% said they felt overwhelmed, 37% felt irritable, and 36% said they were anxious or unable to relax. One in seven nurses said they felt numb.2

The survey, conducted by the American Nurses Foundation, also revealed one-third of nurses said their work has no meaning, and 30% were sad. Nearly as many also said they wanted to quit their jobs.

“Folks hit the breaking point where they can’t work,” Fink-Samnick says. “Across every discipline, substance use is up, suicidal ideation is up, PTSD is up.”

The traditional priority in healthcare organizations is the patient. Nurses and other staff are expected to keep going — no matter how tired they are, no matter how challenging the circumstances.

But, the big lesson from the pandemic’s relentless assault on healthcare workers is that organizations will need to shift their focus to their staff, truly supporting them, nurturing them, and taking care of them, Fink-Samnick says.

One study of New York City clinicians, conducted during April 2020, revealed high rates of psychological symptoms. Nearly half of the physicians, nurses, and others screened positive for psychological symptoms, including 57% for acute stress, 48% for depressive symptoms, and 33% for anxiety symptoms. Researchers concluded these healthcare workers, especially nurses and advanced practice providers, experienced COVID-19-related psychological distress.3

“Mental health issues of the workforce have escalated,” Fink-Samnick says.

What can healthcare organizations do about it?

“It is the elephant in the room,” she says. “If you ask organizations if they’re doing something, of course they say they are. Everyone is well-intended and wants to fix it and to stop employers from pushing staff to the max.”

But there remains a healthcare work culture of doing everything possible for patients and putting employees’ needs on the back burner.

From an individual case management director’s perspective, the first step is to acknowledge their own fear and uncertainty. “Too often, leaders feel they must put a strong face forward and tell their staff it’s going to be all right,” Fink-Samnick says. “It’s the little kid syndrome, where you’re told everything is going to be all right, and you believe it until you’re into adolescence.”

Instead, leaders should acknowledge the challenges and uncertainty and promote the idea that “We’re all in this together.”

“Let’s sit down and talk about what ideas we all have to get through this and see what it means to identify the physical manifestations of stress,” Fink-Samnick suggests. “Go up to a staff member and say, ‘You look exhausted; you look no good today, so why don’t you go home?’”

But the first step is to build a workplace culture in which it is acceptable to acknowledge exhaustion and stress and to make it OK to take a break from it. “Until you build that culture and people can show they’re a little vulnerable, feeling crispy around the edges, no one will do it,” Fink-Samnick says.

Case management leaders also can work to build morale and resilience among their staff. “We hear everyone has to be resilient, but what do you do to get there?” she asks. “Organizations need to make sure they’re coming across in a way that shows their staff they’re prioritizing their health, safety, and well-being. Maybe do one-on-one checks with colleagues and have staff put reminder items on the calendar for self-care, and you — as a leader — can ask, ‘Did you do it? I want to make sure you prioritize you.’”

Leaders also can consistently check on their teams, repeating this for more than just one or two weeks. (See steps to save staff’s mental health in this issue.)

“When we put a new initiative in place, everyone looks at it, but over time the novelty wears off,” Fink-Samnick says. “We need to provide ongoing, consistent support.”

Case management directors also need their own support system to prevent burnout, and this also may take a culture change. “Too often, leaders do not accept support from other people,” Fink-Samnick says. “They think, ‘If I stop, I won’t be able to start again.’”

What would help leaders is support and communication with other leaders, whether they are in case management or another area. “They can do cues with each other around things like sleep hygiene,” Fink-Samnick says. “Organizations need to create a culture where people can talk about their mental health, and it’s not a dirty word.”

One tactic is to use the emotional personal protective equipment (PPE) model. This is shorthand for giving staff emotional/behavioral health equipment. Healthcare professionals affected emotionally by the pandemic can find information about therapists in their area at: emotionalppe.org. All services provided through the Emotional PPE Project are free of charge, the website states.

The new lesson for healthcare organizations is to learn how to support staff for the long haul and not just for the short-term. “This is a constant theme. If you want a sustainable case management workforce, then you need to support their health and mental health,” Fink-Samnick explains. “The more stress they endure, the more exacerbation of chronic illnesses and autoimmune disorders — the more those ramp up.”

Case managers’ mental health should be assessed as part of the normal performance appraisal. “Some organizations are assessing staff burnout as part of their performance metrics,” Fink-Samnick says. “How burnt out is staff, and how is it impacting workforce performance and quality of care?”

The pandemic and its terrible mental health toll on healthcare providers is an opportunity for organizations, healthcare leadership, and professional disciplines to step up and acknowledge that good mental health of the workforce is a mandate, Fink-Samnick says.

“By addressing that, you’ll better improve and inform healthcare quality,” she adds.


  1. Fink-Samnick E. 10 ways to tackle collective occupational trauma and restore resilience. PACES Connection. Feb. 23, 2021.
  2. American Nurses Foundation. Pulse on the Nation’s Nurses COVID-19 survey series: Year one COVID-19 impact assessment. February 2021.
  3. Shechter A, Diaz F, Moise N, et al. Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic. Gen Hosp Psychiatry 2020;66:1-8.