Healthcare worker burnout: from bad to worse

Healthcare worker burnout is associated with symptoms of exhaustion, depression, insomnia, post-traumatic stress disorder (PTSD), or other mental health symptoms and is considered a national crisis and priority by the United States Surgeon General. ^{Reference Murthy1} About 50% of physicians reported symptoms of burnout prepandemic and burnout increased as the pandemic evolved. ^{Reference Murthy1,Reference Shanafelt and Noseworthy2} Burnout drives turnover in healthcare professions. ^{Reference Shanafelt and Noseworthy2,3} The American Nurses Foundation reported that 31% of nurses under 35 expressed the intent to leave and 35 to 45% of all nurses are experiencing burnout. ^3,4 There are several factors that led to increased burnout during the pandemic. Healthcare workers were afraid of infecting family members and were challenged by ongoing changes in pandemic-driven patient care protocols. ^{Reference Lluch, Galiana, Doménech and Sansó5} Healthcare workers faced an increase in workloads and inadequate supplies. ^{Reference Galanis, Vraka, Fragkou, Bilali and Kaitelidou6} Other reported drivers of burnout include decrease in social support, increased periods of isolation, and inadequate rest. ^{Reference Galanis, Vraka, Fragkou, Bilali and Kaitelidou6} Nurses reported moral distress from the poor prognosis of their patients. An increase in stress occurred from nurses who reported inadequate support from leaders and a lack of teamwork. ^{Reference Guttormson, Calkins, McAndrew, Fitzgerald, Losurdo and Loonsfoot7} There is a direct correlation between burnout and patient outcomes. This extreme level of stress and psychological pressure resulted in PTSD, anxiety, insomnia, and depression symptoms among healthcare workers. COVID-19 aggravated burnout that already existed within the healthcare systems prepandemic. ^{Reference Copanitsanou, Fotos and Brokalaki8} Providers are not exempt. Physicians experiencing burnout can suffer substance abuse, depression, suicidal ideation, decreased self-care, and increased risk for motor vehicle crashes. ^{Reference West, Dyrbye and Shanafelt9} All healthcare disciplines suffered the negative consequences of the pandemic.

Healthcare worker burnout impacts patient care and further demoralizes them. Patients experience longer recovery times when providers suffer from depersonalization. ^{Reference West, Dyrbye and Shanafelt9} Medical errors increase stress on healthcare workers worsening burnout symptoms. ^{Reference West, Dyrbye and Shanafelt9} Moral injury from errors deepens the existing symptoms of burnout. ⁴ Thus, burnout causes a decrease in quality care, an increase in medical errors, increased recovery times for patients, and lower patient satisfaction scores. Burnout is associated with lower healthcare productivity. ^{Reference West, Dyrbye and Shanafelt9} Healthcare workers are more effective when burnout is minimized.

COVID-19, patient safety and healthcare infection prevention

Patient safety is the top priority in patient care as first, do no harm is the primary tenet of medicine. Healthcare workers suffering from burnout pose an increased risk of accidental harm to patients. ^{4,Reference West, Dyrbye and Shanafelt9} Failure to minimize avoidable harm increases the risk of patient and family suffering caused by death, disability, increased cost, and longer length of stay. ^{Reference Safety10} Healthcare organizations maximize patient safety through targeted processes of care measures, technologies, and desired behaviors to mitigate the risk of adverse events. ^{Reference Safety10} Healthcare workers experiencing burnout may suffer from greater depersonalization, be less connected with a safety mission, and may be more prone to errors and breaks in safety protocols (Table 1).

Table 1. Key Factors for Healthcare Worker Wellness, Resilience, Patient Safety, and Infection Prevention

The Centers for Disease Control and Prevention reported a surge in healthcare-associated infection (HAI) during the COVID-19 pandemic (Figure 1). ¹¹ These include a higher incidence of ventilator-associated events (VAE), central line-associated bloodstream infections (CLABSI), catheter-associated urinary tract infections (CAUTI), and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia when comparing pandemic years to the most recent year prior to the pandemic.

Figure 1. Quarterly National SIRs for select HAI types, 2019-Q1–2021-Q3¹¹.

The proportionate impact of HCW burnout on HAI outcomes remains undefined, though Cimiotti et al reported that nurse burnout was significantly associated with an increased risk for urinary tract infections and surgical site infections. ^{Reference Cimiotti, Aiken, Sloane and Wu12} Various studies demonstrate that burnout is associated with heightened risks for patient safety incidents, though not specifically HAIs. ^{Reference Hall, Johnson, Watt, Tsipa and Healthcare Staff Wellbeing13–Reference Garcia, Abreu, Ramos, Castro, Smiderle, Santos and Bezerra15} We argue that the unique HCW burnout experienced during the COVID-19 pandemic, coupled with factors outlined below, created a “perfect storm” of conditions that made patients increasingly vulnerable to HAIs during this period.

Various forces potentially drove the HAI increase during the COVID-19 pandemic. Hospital-associated infections likely heightened secondary to changes in hospital procedures resulting in increasing intravenous (IV) tubing length. ^{Reference Blake, Giuliano, Butterfield, Vanderveen and Sims16} This was done so IV medications could be changed outside of patient rooms, and to allow nurses to bundle care to decrease overall personal protective equipment (PPE) usage. Staffing shortages played a role in increasing HAIs rates secondary to staff fatigue and burnout, resulting in greater reliance on third-party agency staffing. ^{Reference McVey, von Wenckstern and Mills17,Reference Zhou, Lai, Wan, Zhang and Tan18} Agency nurses may be less knowledgeable of institution-specific safety culture awareness and hospital-specific HAI prevention techniques. ^{Reference Stone, Pogorzelska, Kunches and Hirschhorn19,Reference Mitchell, Gardner, Stone, Hall and Pogorzelska-Maziarz20}

Individual and organizational wellness and the path toward resiliency

No single intervention exists to minimize burnout and heighten healthcare worker wellness. There are various individual and organizational strategies to promote resiliency and decrease burnout. ^{Reference Lluch, Galiana, Doménech and Sansó5} Individuals can use self-guided coping mechanisms to reduce signs and symptoms of stress. This includes mindful activities, physical activity, meditation, and reflection. ^{Reference Maresca, Corallo, Catanese, Formica and Lo Buono21–Reference De Simone, Vargas and Servillo23} Organizational strategies are more impactful at reducing the overall signs and symptoms of burnout within systems. ^{Reference De Simone, Vargas and Servillo23,Reference Naegle, Kelly and Embree24} Organizational strategies include improving and reducing workloads, workflows, increasing flexibilities of schedules to improve work-life integration, provide opportunities for advancement, to bring meaning in work, promote collegiality within the organization to increase social support, and to decrease the stress of the organization as a whole. ^{Reference Shanafelt and Noseworthy2,Reference De Simone, Vargas and Servillo23} For example, a positive work environment for front-line providers includes supportive leadership, the ability to balance a work schedule, professional autonomy, adequate resources, and opportunities to professionally advance. ^{Reference Copanitsanou, Fotos and Brokalaki8}

Various professional and government organizations endorse wellness enhancement tools. The American Hospital Association published a Well-Being Playbook 2.0 to serve as an executive guide for hospital leaders. ²⁵ The Institute for Healthcare Improvement toolkit, titled, Guide to Promoting Health Care Workforce Well-Being During and After the COVID-19 Pandemic serves a similar purpose. ²⁶ The Office of the Assistant Secretary for Preparedness and Response that serves under the Health and Human Services published tips for resiliency strategies and workforce retention, Creating a Caring Workforce Culture: Practical Approaches for Hospital Executives. ²⁷ The U.S. Surgeon General made HCW burnout top five priorities. ^{Reference The28} Additional research is needed on the direct impact of hospital-acquired infections and burnout.

A multi-path approach is required to minimize HCW burnout, maximize resilience of the workforce, and maximize patient safety. First, healthcare systems must prioritize the recognition of burnout including depersonalization, emotional exhaustion, and personal lack of accomplishment, and prepare for future pandemics and global health crises. ^{Reference Galanis, Vraka, Fragkou, Bilali and Kaitelidou6,Reference James, Hudon, Merrick, Olson, Hanes and Scanlan29} Healthcare workers must be aware that their organization is working to improve and provide a healthy professional environment to feel supported. ^{Reference Reitz, Terhorst and Smith30} Addressing burnout cannot be done on the individual level alone. ^{Reference Shanafelt and Noseworthy2,3} Organizations must assess HCWs regularly to identify dimensions of burnout and well-being. ^{Reference Shanafelt and Noseworthy2,Reference James, Hudon, Merrick, Olson, Hanes and Scanlan29} Professional engagement or worker motivation is a healthy way to reduce burnout and increase safety within an organization. ^{Reference James, Hudon, Merrick, Olson, Hanes and Scanlan29,Reference Mossburg and Dennison Himmelfarb31} Healthcare organizations must also consistently provide mental health support to their workforce. ^{Reference Murthy1}