Infection Preventionists Experiencing Burnout, Moral Injury Amid Pandemic
‘We are no exception — infection preventionists are definitely struggling’
Infection preventionists (IPs) are suffering along with their coworkers as an epidemic of burnout and job turnover roils the healthcare system amid an ongoing pandemic. According to a survey in press by the Association for Professionals in Infection Control and Epidemiology (APIC), 70% of IPs meet the criteria for “high stress” and 65% have symptoms of burnout, says Ann Marie Pettis, RN, president of APIC.
“We partnered with the Ohio State School of Nursing to do a survey study of our members,” she says. “We reached out to about 6,000 members and got just under 1,000 responses — a 15% response rate. Those that screened positive for depression were 22%, and 30% screened positive for anxiety.”
As this report was filed, the survey article was slated for publication in an upcoming issue of the APIC journal, the American Journal of Infection Control.
“We are no exception — IPs are definitely struggling,” Pettis says “I think one of the main reasons we are seeing the burnout and exhaustion is that [the pandemic] has gone on so long. People didn’t really anticipate that we would be dealing with this coming up on two years. It seems like every day you think you are going to get a semblance of normalcy, [and] something else comes along. Right now, it is [COVID-19 vaccine] mandates and determining religious exemptions. IPs are still right in the thick of it trying to work with those who are on the frontlines. Their stress and emotional health have definitely taken a hit.”
In that regard, the Centers for Medicare & Medicaid Services has set a Jan. 4, 2022, deadline for millions of healthcare workers in a wide variety of medical settings to be immunized against COVID-19 or their employers could face penalties and loss of reimbursement. (See “CMS Issues Mandatory Vaccine Rule for Healthcare Workers.”)
SARS-CoV-2 necessarily has been the predominant infection control issue, but IPs were distraught at seeing the traditional array of healthcare-associated infections (HAIs) rising during the pandemic chaos. As Hospital Infection Control & Prevention reported recently, several critical HAIs — including high-mortality bloodstream infections — skyrocketed during the pandemic in 2020, as IPs had insufficient resources and staff, while many were pulled from normal duties to work on COVID-19 tasks. (See Hospital Infection Control & Prevention, September 2021.)
“We have seen the results with the HAIs around the country going up,” Pettis says. “Both the staff and the IPs have had to focus so much on all the chaos around COVID. This is something that has been very difficult for IPs to deal with. [HAI prevention] is our mission — that’s our wheelhouse — it’s all about protecting patients.”
The collateral damage includes the relationships IPs carefully built with staff to collaboratively prevent HAIs, she adds. “The trust that we worked to have with staff has been challenged throughout the pandemic because of all the shifting of requirements and recommendations,” Pettis says. “That takes a toll.”
A Decline, but Little Relief
The pandemic has fallen off somewhat from the recent delta variant surge, but it persists and there still are millions of Americans unvaccinated. Consider that 89% of U.S. counties reported high (73%) or substantial (16%) transmission as of Nov. 1, 2021.1 That is down from Oct. 8, 2021, when 96% of counties were reporting high (90%) or substantial (6%) transmission. In a sign of continuing futility, only 64 counties in the nation — 2% — report “low” transmission of COVID-19 in the most recent data. Genomic surveillance indicates the delta variant is being found in about 99% of sequenced SARS-CoV-2.
As the pandemic endures, healthcare workers are leaving their chosen profession in droves. In particular, nurses report a cascade of negative emotions and are leaving the field in an exodus expected to worsen with resignations to avoid COVID-19 vaccine mandates. Employment in healthcare is down by 524,000 jobs since February 2020, with nursing and residential care facilities accounting for about four-fifths of the loss, the Bureau of Labor Statistics reported recently.2
“One of the biggest stressors has been staffing, whether it is people out sick or taking early retirement,” Pettis says. “That leads to closed-down units and closed-down beds.”
A widely cited estimate by the Association of American Medical Colleges (AAMC) projects that the United States will face a shortage of between 54,100 and 139,000 physicians by 2033.3 That projection was made before the pandemic, which likely will accelerate the trend. In any case, the demographics of a graying America translate to more physicians retiring as more of the population ages. There are multiple prepandemic reports of physician burnout and depression, and things certainly have not improved in the current environment. One physician, who cited the “damning effect” of the healthcare system’s failure to prioritize wellness for caregivers, put it bluntly: “Doctors are twice as likely to die by suicide as their own patients.”4
According to a survey by the American Nurses Foundation (ANF) that netted responses from 22,215 nurses from Jan. 19 to Feb. 16, 2021, nurses feel such intense emotions as “betrayed” (12%), “guilty” (11%), and “like a failure” (10%).5 Nurses reported more than one emotional state, as the highest percentage answers exceeded 100%: exhausted (51%), overwhelmed (43%), irritable (37%), and anxious (36%). Only 1% of respondents felt suicidal, but that still is 222 nurses thinking of taking their own lives.
These are the classic symptoms of burnout, although some prefer the term “moral injury or moral distress,” a condition somewhat similar to that experienced by soldiers in combat. In general, moral injury occurs in a person who witnesses, participates in, or fails to prevent some harmful event. This event might be well beyond their power to stop, but their ethics and moral code are violated, and they are harmed emotionally.
“Nurses, for example, may have too many patients to care for at one time,” says Alyson Zalta, PhD, associate professor of psychology at the University of California Irvine. “While they are taking care of one patient, they realize a patient is coding in another room.”
The term burnout could be interpreted as an individual lacking resiliency, but moral distress captures the larger forces of a systemic breakdown, she adds.
“There is moral distress in watching the dumpster fires we have seen so many times in this pandemic,” said Susy Hota, MD, MSc, FRCPC, medical director of infection prevention and control at Toronto General Hospital.
Speaking at IDWeek 2021, a virtual conference held Sept. 29-Oct. 4, 2021, she added, “[For example], when we have ideas and thoughts on what should be done, but we are not in control of that decision-making. Sadly, sometimes the recommendations that we make do not align with the hospital priorities right now, and that can be frustrating.”
Moral Distress and Activism
In shifting the framing of the mental health crisis from the worker as an unresilient victim to the larger occupational damage done by the healthcare system, “Moral distress can be a platform for activism,” Hota said.
“[Know] the things that are important to you, speak up, and do not sit on the sidelines,” she added. “This can be an outlet for not letting it eat away at you. A lot of this is about prevention. I think that is why we keep emphasizing the ‘prevention’ in infection prevention and control. It’s actually important in your own life.”
Although the pandemic has been mentally disturbing to healthcare workers in general, infection control and healthcare epidemiology have some unusual job aspects that contribute to burnout.
“Decisions we make around policies for infection prevention and control actually may affect thousands of people,” Hota said. “That’s a big emotional burden that we carry. Some of those policies that we set, we just can’t quite effect the change that is required for them to be effective. All we can do is try to influence people to change their behavior and affect their thinking. That can be mentally exhausting and involve a lot of repetition, which also could contribute to burnout.”
Data collection and discussion is needed for identifying trends and adverse events, but in the raw emotions exposed by the pandemic, numbers may seem dehumanizing.
“We talk about cases and rates all the time,” she said. “That’s how we describe epidemiologically what is happening, but we don’t talk about the people behind those rates. That causes some depersonalization that can erode our empathy.”
Interestingly, by the nature of the job, IPs and epidemiologists actually can contribute to burnout in other healthcare workers, she noted.
“By trying to be highly reliable we often will work toward standardizing processes through algorithms or checklists,” Hota said. “The problem is we are taking away the autonomy of the clinical decision-makers. That can contribute to burnout and a sense of lack of control in other clinicians. Moreover, by trying to do audit and feedback — by trying to give people a sense of how well they are doing with processes — we’re kind of imposing another source of oversight and control over clinical practice.”
Although necessary, antibiotic stewardship and restricting certain antimicrobials during pandemic times may have a similar negative effect on clinicians.
“A lot of what we do to facilitate these processes for stewardship and other infection prevention and control initiatives are integrated into electronic medical records, which we know from multiple surveys are a source of stress,” she said “This can contribute to burnout of our colleagues as well. We should be mindful to try to reduce these burdens as much as possible.”
In an unrelenting pandemic, the sheer repetitive nature of the work can blur aspects of the job that may once have brought joy. “Sometimes it feels like Groundhog Day,” Hota says, using the movie as a metaphor. “Outbreak meeting after outbreak meeting, and there is only so much of that you can take. I don’t know what the solutions are, except maybe having a recognition of what your limits are and making sure you have enough [support] in your system so can put things off or have other individuals help.”
This kind of support requires an institutional commitment to wellness, a foundation that includes people modeling healthy behaviors and talking about their experiences.
“We can’t address this problem until we can talk about it — until we can understand it,” Hota said. “Having engagement and work culture surveys are really important to understand how big the issue is, and what factors need to be addressed.”
IPs and healthcare epidemiologists see their prime mission as patient safety, and, thus, administrators underfund their programs at the peril of those admitted for care.
“In healthcare epidemiology in particular there is connection between burnout and patient safety and medical errors,” Hota said. “It is very clearly an emerging problem. So, make that connection between what your targets are in infection prevention and control, and what you need to actually get there in terms of support and people. Try to be motivated and continue advocating for the resources we need. Use this as an opportunity to actually improve the conditions in which we work.”
Foster a culture of inclusion, respect, and stability, she said. “Really commit to having a positive work environment just in your day-to-day work,” she added.
This individual effort can be supported by group meetings, particularly among nurses who are on the frontlines.
“Some hospitals are offering support groups and therapeutic groups to allow nurses to get together and talk to each other on company time,” Zalta says. “I think it is really valuable to communicate that the psychological heath of the nursing workforce is something that organizations care about. Encouraging peer support for nurses to be able to talk about their experiences is really important.”
One of the major barriers is the enduring stigma of seeking mental health, which both physicians and nurses fear could affect their licensing or alter their standing with superiors if there is a breach in confidentiality.
“Stigma is unfortunately still quite prevalent,” says Liselotte Dyrbye, MD, an internist at the Mayo Clinic in Rochester, MN.
Dyrbye found in research that was done before the pandemic that 38% of nurses reported symptoms of burnout and 40% had substantial indicators of depression.6 Noting that burnout is the direct result of job demands that exceed job resources, she cited the need for healthcare administrators who can “provide people with a positive work environment and with leaders who are really skilled at building teams. Nearly all the solutions lie in the work environment. We really need system-level solutions.”
Public health officials are asking for solutions. The Center for Disease Control and Prevention’s National Institute for Occupational Safety and Health (NIOSH) published a request for information, asking for “interventions to prevent work-associated stress, support stress reduction, and foster positive mental health and well-being among the nation’s health workers.”7 As this report was filed, the deadline to submit comments was Nov. 26, 2021.
NIOSH asked for input on programs and interventions, including “how stigma associated with seeking mental healthcare is addressed, and how health workers are encouraged to participate. In your experience, how does the workplace benefit from implementing interventions or offering services to health workers to prevent/reduce work-related stress?”
An anonymous commenter to the NIOSH request for information, who reported experiencing post-traumatic stress disorder after four tours in Iraq, may have tapped into some of what healthcare workers are feeling in writing, “I’ve had some very bad experiences, and some included near death. I know it’s hard for some people to understand, but at the same time it’s also extremely hard to be able to explain and to feel comfortable doing so. But I think half the battle is being able to come forward and at least try to explain or understand. Because I know myself if you are comfortable with talking to someone that will actually listen to you, it’s a great feeling to be able to unload some of your feelings and thoughts, stress, anger, and frustration. Nobody is perfect, but everyone deserves their happiness. It’s just a very difficult journey at times.”
- Centers for Disease Control and Prevention. COVID data tracker. COVID-19 integrated county view. https://covid.cdc.gov/covid-data-tracker/#county-view
- Bureau of Labor Statistics. The employment situation — October 2021. https://www.bls.gov/news.release/pdf/empsit.pdf
- American Association of Medical Colleges. The complexities of physician supply and demand: Projections from 2018 to 2033. Published June 2020. https://www.aamc.org/media/45976/download?attachment
- Adibe B. Rethinking wellness in health care amid rising COVID-19-associated emotional distress. JAMA Health Forum 2021;2:e201570.
- American Nurses Foundation. COVID-19 impact assessment survey – The first year. https://www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/what-you-need-to-know/year-one-covid-19-impact-assessment-survey
- Kelsey EA, West CP, Cipriano PF. Original research: Suicidal ideation and attitudes toward help seeking in U.S. nurses relative to the general working population. Am J Nurs 2021;121:24-36.
- 86 Fed Reg 53306 (Sept. 27, 2021)
Infection preventionists (IPs) are suffering along with their coworkers as an epidemic of burnout and job turnover roils the healthcare system amid an ongoing pandemic. According to a survey in press by the Association for Professionals in Infection Control and Epidemiology, 70% of IPs meet the criteria for “high stress” and 65% show symptoms of burnout.
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