Health care workers: Isolation, uncertainty and a risk for burnout during COVID-19 crisis

Health care workers: Isolation, uncertainty and a risk for burnout during COVID-19 crisis

Phoenix ICU nurse Neva Farmer has not hugged her 8-year-old son in more than two months.


Farmer, like many other health care workers in Arizona, is living away from her family while she works on the front lines of the COVID-19 pandemic. COVID-19 is the illness caused by the new coronavirus, and there’s no end to the pandemic in sight.


In a recent Kaiser Family Foundation poll, 45% of adults in the U.S. reported that their mental health has been negatively affected because of worry and stress over the virus.


For health care workers, stress is heightened. Burnout has long been a problem for physicians and nurses, but COVID-19 is adding serious risk factors.


In addition to the regular hardships that go along with the job, health care workers who are caring for COVID-19 patients are living with a threat that never goes away — the worry of contracting the virus themselves or what many say is worse, passing it along to their families.


Many spend long days wearing much more personal protective equipment than in the past. The equipment can feel hot and uncomfortable and make interactions with patients to feel less personal.


There are no statistics on how many have reached a level of burnout to date. But more than two months after Arizona Gov. Doug Ducey declared a state of emergency over COVID-19, hospital leaders are rushing to intervene before the emotional and physical toll on health care workers reaches crisis levels.


Watching fearful patients with COVID-19 get put on ventilators and seeing some of them die can be traumatic. And the virus is capricious — patients seem to be doing well, only to suddenly take a turn for the worse.


“Burnout is real. Compassion fatigue is real,” said Mario Valadez, who is senior director of mission integration for Dignity Health’s Chandler Regional and Mercy Gilbert Medical Centers. “What has been so challenging is not only are you having to deal with the realities of COVID-19 when you go to work but you also have to deal with it when you go home. There is no kind of escaping it, and that has been a challenge for everyone.”


Rachel Basham, a Phoenix-area emergency department nurse, said the ICU at her hospital is full and almost all of the patients are positive for COVID-19. Two patients are connected to an external lung known as ECMO, or extracorporeal membrane oxygenation.


“One huge and very helpful thing that I will hope comes out of this is some better staff mental health support because I think we’re going to need this, especially looking that this is going to be going on for a while,” Basham said. “I think that’s going to be a really necessary evolution to the trauma and just the difficulties that we’re all encountering.”


Some hospital and health care systems in Arizona say are stepping up resources to support their workers. Dignity Health has done check-in calls to see how workers are doing, and several hospitals have pop-up shops with groceries and items such as toilet paper and hand sanitizer for their workers.


Arizona cases of COVID-19 as of Friday exceeded 15,600, with 775 known deaths, according to numbers released by the Arizona Department of Health Services.


As of Friday, 796 patients were hospitalized in Arizona with suspected or confirmed COVID-19. The number of hospitalized patients has not been declining over time.


While COVID-19 cases in Arizona have not reached a worst-case scenario capacity that state officials had once feared, health providers remain braced for more cases, particularly now that social distancing measures have been relaxed at the state level.

A sense of threat all the time

Dr. Nicholas Vasquez, an ER physician who treats COVID-19 patients at a Phoenix-area hospital, has seen at least eight fellow health care workers get sick with COVID-19 and said bringing home the infection to his family is a constant worry.


Vasquez has an elaborate decontamination ritual that involves getting taking off his scrubs in his family’s garage. Other colleagues are living in hotels, away from their loved ones, he said.


The Harvard Global Health Institute defines physician burnout as a condition in which physicians lose satisfaction and a sense of efficacy in their work. Health care leaders across the country are increasingly worried about it as the COVID-19 pandemic continues.


On Friday, the California-based National Organization for Arts in Health launched a GoFundMe campaign to help bring free art programs to health care workers struggling with anxiety and other symptoms that could lead to burnout in the wake of the pandemic.


“We’re starting to see some impact now, but the consensus is that burnout rates and the numbers of people leaving clinical work are about to jump beyond anything we’ve ever experienced,” Dr. Alan Siegel, an organization board member and family physician, said in a written statement.


“Offering enhanced, immediate options to help health care workers cope with anxiety and avoid burnout is critical.”


Medicine is three parts — one part a calling, one part a profession and one part a business, Vasquez said. The tension between those three can sometimes lead to frustrations, he said.


Some patients are overwhelmed by their situation whether it’s trauma, chronic illness, poverty or all three, Vasquez said. They are resistant to any help, no matter how much effort health providers make. That can lead to health providers developing what’s often known as “compassion fatigue,” or a diminished ability to feel compassion for others.


“I think that’s where burnout starts,” Vasquez said.”When you start losing the part of the job that is the calling, that is the caring for people and you are just there to do the business or the profession.”

Chaplains increasingly minister to staff

Burnout and stress were already issues for doctors, nurses and other front line health workers prior to the COVID-19 pandemic.


A 2019 report from the Harvard Global Health Institute deemed physician burnout a public health crisis, and a national survey of 743 physician assistants released on Tuesday found one in five of those surveyed said they are “definitely burning out” during the pandemic, with one or more symptoms of burnout, such as emotional and physical exhaustion.


The American Academy of Physician Assistants survey found that in addition to regular stress of the job, there are new anxieties with COVID-19, including a shortage of personal protective equipment and pay cuts.


“What’s unique about coronavirus is it’s the first time where we’ve had to contemplate our own mortality and the threat the patient in front of us poses to our family. That’s a new thought for us,” Vasquez said. “Some of us have moved out of our own homes, and we all have elaborate decontamination rituals when we get home.”


At the outset of the pandemic, Dignity Health in Arizona called its employees individually to see how they were faring, Valadez said.


Dignity officials asked employees basic questions like how their families are doing, whether they are sleeping well, and whether they have groceries.


“Coronavirus has done so much to create separation and distance,” Valadez said. “What we are really challenged with is how we create human connection in spite of the fact that this virus has caused so much distance and disruption.”


Connection with the staff is part of that ministry, he said.


Prior to the pandemic Dignity’s chaplain ministry in the East Valley was about 25% to staff and the rest to patients and families. It has since gone up to 50% to 60%, he said.

‘You are hoping to save every life and you can’t always do that’

Physicians and nurses in the U.S. and all around the world have always run a high level of burnout, which is why addressing it is going to be a “very big” issue for Dignity Health moving forward, said Dr. Keith Frey, chief medical officer for Dignity Health in Arizona.


“It does take a toll on us now that we are eight weeks into this. It’s intense, it’s stressful for my colleagues,” Frey said.


“We really have to pay attention to how we support our colleagues, help them build a resilient life, the ability to continue to do what they do so very well, but not let them get to the point where they run their battery down where it’s to their own harm.”


Dignity Health is a division of Chicago-based CommonSpirit Health, which is the largest Catholic health system in the U.S., and Frey is leading the national company’s program on physician burnout and wellness.


“In health care, you are hoping to save every life and you can’t always do that,” Frey said. “We want to attend to the fatigue that people have when they see people so devastated by the outcome of COVID.”


Banner Health, which is Arizona’s largest health system, has been stepping up supports for workers with gestures like giving them meals, arranging virtual social gatherings and forging partnerships with local hotels for workers who need to live away from their families, said Dr. Marjorie Bessel, who is Banner’s chief clinical officer.


“We’ve had coaching supportive calls for people to be able to call in and talk about what’s happening, talk about the stresses and strains that they have,” she said. “We have a whole myriad of activities. … By the time I get to the end of this year, the types of programs I have in place for those activities before COVID and after COVID will probably be significantly augmented.”


Bessel said the intensity of the work and extra PPE workers wear can create stress for workers, as can taking care of a colleague who is ill with COVID-19.


“That’s the person that maybe was working next to you last week and now they are here in your hospital, potentially very ill, and that can add quite a bit of strain.”


On the flip side, responding to situations like a pandemic is what health care workers are trained for, and it’s fulfilling a calling, Bessel said.


“We hear from folks who say things like ‘I’ve never felt more aligned with my purpose in life than really being called into action for people who really need me,'” Bessel said.


Health care workers are needed by patients and the community in a way that is above and beyond how they may feel in their day-to-day work, she said.


“We’d like to think that we say a lot and celebrated them even before COVID, but they are hearing more from us how much we appreciate them, how much we appreciate them being here for all of us,” Bessel said.


“There’s both sides and as we continue to work through this and have subsequent waves it will be interesting to see what the statistics show. Some people may continue to feel very much aligned with their purpose and not have burnout issues. And others may feel more of those stressors that have been more difficult for them at these times.”

‘Here Comes The Sun’ marks recovery

Valleywise Health nurse managers Chanté Neal and Regina Villa say there’s no clear answer to how long their staff will be caring for COVID-19 patients. Right now, Valleywise Medical Center in Phoenix typically has between 20 and 30 COVID-19 patients and half of them are in the ICU, and extremely ill.


“Nobody knows how long this will last,” Neal said. “There’s always that uncertainty in the air. There’s still a lot of uncertainty and fear around this for everyone, so that alone is a big stressor.”


Given visitor restrictions that remain in place at most hospitals, health care workers can find themselves in a dual role of caregiver and support system.


Nurses will often spend several 12-hour shifts taking care of the same COVID-19 patient, and they get to know the patients well.


“They are the patient’s everything. They are the only resource they get to see,” Neal said. “We have a Spirit Team and one of the things they did was put together a COVID discharge song. When they do recover, we play the song overhead.”


The song is The Beatles’ “Here Comes The Sun” and it can be heard throughout the hospital, she said.


“The patients will cry, the nurses will cry,” Neal said. “The staff claps and cheers as the patient rolls down the hall and ‘Here Comes The Sun’ plays overhead on the paging system. It’s just really cool and it’s a reminder that all the hard work going into taking care of these patients is paying off.”


Seeing patients who have recovered and who go home is in itself an invaluable morale boost, Neal said.


“It reminds them why they chose to do what they are doing,” Villa said. “Our patient population is underserved to begin with. We are kind of like the safety net hospital for the Valley. … Our passion is truly to care for all people, it doesn’t matter who you are and we tell our staff that.”


Villa said she likes to remind her staff that they are serving during a historical time, and that this is their time to shine. She also reminds them that they are all in it together.


“This is the time when people really need us most,” she said. “It’s a lot of pressure but it’s very rewarding. And when that song comes overhead — I’ve been in meetings, I’ve been in break rooms and I’ve been at the nursing station — it goes off and all the staff just stop and we say ‘yay.'”


Arizona health care workers are doing their best to adapt to the situation.


Neva Farmer, an ICU nurse, said she has a strong support system, including fellow nurses, which helps her manage the stress.


“We didn’t train for this part of it. COVID is completely new for all of us,” she said.


Vasquez, an ER physician, said the assumption now in the emergency department is that everyone is COVID-19 positive.


“I no longer touch my patients as much. Before I’d shake hands, I’d sit down, I’d examine them much more closely,” he said. “I’ve had to curtail those exams and that handshaking to where we just say hi now and walk in with a mask and gloves. It’s made it more stilted. It’s harder to connect to them.”


Until there’s a vaccine available against COVID-19, Vasquez does not see a clear end to current practices.


“For many of my brethren and for my family, this has become the new normal,” he said.




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