Burnout among all stripes of healthcare workers — including infection preventionists (IPs) — has become a dire situation warranting national action. Accordingly, the Centers for Disease Control and Prevention (CDC) and the National Institute for Occupational Safety and Health (NIOSH) have released new research and emphasized available resources to raise awareness for an ambitious “system change” in healthcare delivery.
Dubbed “Impact Wellbeing,” the national campaign provides hospital leaders with evidence-based resources to improve workplace policies and practices to reduce burnout and ease access to mental health counseling.1
“To label our current and longstanding challenge a ‘crisis’ is an understatement,” said Casey Chosewood, MD, MPH, director of the Office for Total Worker Health at NIOSH, at a recent press conference. “We’re calling on employers to take this information to heart and take immediate preventive actions. We know from previous research that organizational, systemwide interventions are more effective than individually focused interventions, or those that rely on the worker to take the initiative to address their own mental health concerns. We don’t want to just treat workers who are suffering, we want to prevent that harm to all workers in the first place.”
The Association for Professionals in Infection Control and Epidemiology (APIC) was ahead of the curve on this, doing membership surveys and hosting webinars to help IPs during the pandemic.
“We are glad to see the CDC focusing on this,” says Pat Jackson, RN, MA, CIC, FAPIC, president of APIC. “One thing we know is burnout is significant in IPs — there is no question. We found that out before this CDC study.”
In that regard, a study published last year found that among 926 respondents to a survey of 6,000 IPs, 65% reported burnout, with 30% experiencing anxiety and 22% experiencing depression.2 (See Hospital Infection Control & Prevention, September 2022.)
“IPs who worked shorter shifts and had more organizational wellness support had better well-being outcomes,” the authors concluded. “Organizations must fix system issues that result in poor health and invest in workforce wellness.”
‘They Really Can’t Do Any More’
Again — nothing against yoga and mindfulness meditation — but burnout and related mental health problems increasingly are seen less as an individual weakness and more as a systems breakdown.
“Many people felt that healthcare workers were sort of immune to some of these challenges,” Chosewood said. “They’re an incredibly resilient workforce, but at the end of the day, health workers are human. And they’re telling us, as we listen to their stories, that they really can’t do any more, and that we must address the system — the longstanding systemic issues. Healthcare workers really see their work as a calling, so they’re some of the last to complain. But it’s time for us to really bring important attention to this critical issue.”
As part of that, the outdated myth of healthcare heroes that can and must meet every challenge should be recognized for what it is: an insidious paradigm for occupational and, ultimately, patient harm.
“The more attention we place on this the better, but we have to actually make the changes,” Jackson says. “For so long in healthcare, it was all about ‘we just have to weather the storm, buck up, and make it through.’” We are realizing now that this is not really a noble thing. It’s hurting our mental health. It’s not helping patient care. We know with burnout we see more medical errors, increases in hospital-associated infections [HAIs] and turnover among staff.”
In addition to compromising healthcare workers and reducing overall patient safety, burnout drives increasing healthcare costs, meaning system changes to reduce staff burnout will offset some of the massive expenditures driven by this trend.
For example, a single central-line-associated bloodstream infection costs an average of $48,108 (range, $27,232 to $68,983).3 The cost of replacing physicians ($500,000) and nurses ($40,000) hit hospital budgets hard.4 Increased medical errors set off a spiral of expenses, from increased length of stay to looming litigation. It makes financial and common sense that a fully staffed infection prevention department not only would lessen IP burnout but enhance their ability to reduce it in their colleagues.
Yet, the power of prevention always has been a difficult argument to win, and many IP programs have been chronically understaffed for years.
‘We Think Our IPs Need Help’
To make the case for needed staff, APIC is developing an IP staffing calculator, hoping it will replace the outmoded but seminal studies on this critical issue: SENIC (one IP per 250 occupied beds) and the Delphi study (0.8 IP to 1 IP per 100 occupied beds).5,6
“With this calculator, you will be able to plug in different metrics — you have this many beds, but how many of them are ICU [intensive care unit] beds? How many are surgical beds? What is the volume of your blood cultures?” Jackson says. “You will plug all this in, and it will tell you if you are staffed [appropriately] or not well staffed. We think that our IPs need help and we are hoping this will be used by administrators.”
The IP staff calculator likely will go through a beta phase with test users before being officially released later in 2024.
Currently, hospitals are dealing with staffing shortages beyond IPs, which increases burnout by those working long shifts to cover for their colleagues. This in turn makes it more likely they will burn out and leave their post — worsening the situation in a vicious cycle.
Highlights from a recent CDC Vital Signs report on healthcare worker burnout included survey results from the National Opinion Research Center’s General Social Survey, specifically the quality of work life module.7 The analysis showed that 46% of health workers often felt burned out in 2022, an increase of 32% from 2018. “Intentions by health workers to change jobs also increased, with 44% in 2022, reporting they were likely or very likely to look for a new job in the next year,” Chosewood said at the press conference. “In comparison, other [non-healthcare] worker groups reported a decrease in job turnover. I think that this speaks to the uniqueness of the healthcare setting, as it really struck healthcare workers hard.”
It was not clear from the survey results whether those planning to leave their current jobs would remain in healthcare or leave the field entirely, he noted. Anecdotally, there are indications that they are “not just jumping from hospital to hospital,” he said, raising concerns that some plan to leave the profession altogether, he added.
Assess Local Situation with NIOSH Tool
As part of the Impact Wellbeing campaign, NIOSH is urging hospitals to start with their Well-Being Questionnaire, which was developed by the agency to help facilities identify gaps in their wellness programs and target improvements. The questionnaire assesses five domains of worker well-being, taking a holistic approach to a complex problem:8
• Work Evaluation and Experience
• Workplace Policies and Culture
• Workplace Physical Environment and Safety Climate
• Health Status
• Home, Community, and Society
“[The NIOSH questionnaire] is really the first of its kind to look at and measure many aspects of worker well-being, including their physical health, the workplace climate, and their interactions with peers, coworkers, and managers,” Chosewood said. “It’s a very simple, 15-minute, 68-item survey that gives organizations a lot of very valuable information. We would recommend it as a very good starting place to measure the well-being of health workers in any environment.”
NIOSH also has posted a “Leadership Storytelling Guide,” inviting hospital leaders to talk publicly about getting help for their own mental health concerns and encouraging staff to do the same. “Sharing your own story can offer profound benefits to your workforce by combating stigma, normalizing mental health challenges, and empowering employees to seek help,” NIOSH said.9
In any case, the involvement of leadership is critical, lest healthcare workers’ calls to action fall by the wayside.
“Clearly, there is a role for more participation by workers in the decisions that are being made in their work environment,” Chosewood said. “They really need to have more of a voice, more agency, more of a role in day-to day decision-making at that first-line level. We need to do a better job of increasing training for supervisors and managers, increasing flexibility, modeling and encouraging people to take time off, assuring adequate staffing, and building labor and management cooperation efforts.”
Mental Health Stigma, License Fears
A critical role for hospital leadership is to ensure healthcare workers have access to counseling without concerns about confidentiality or job security. Some clinicians have avoided mental health therapy out of fear it could affect their medical license.
“There still tends to be quite a bit of stigma associated with admitting that you have depression or are seeking help,” Debra Houry, MD, chief medical officer at the CDC, said at the press conference. “As a health worker, you’re supposed to sort of be above those concerns. But in truth, it’s critical that people feel comfortable getting the help they need.”
There are ongoing efforts to remove these kinds of medical licensing questions, particularly regarding past incidents that no longer apply to clinicians’ current status.
Another issue was healthcare worker “harassment,” which the CDC and NIOSH found was rampant in 2022. Indeed, broadly defined harassment of healthcare workers in this time period was “epidemic,” Houry said.
“Organizations really have the responsibility to create safer, healthier environments with zero tolerance of harassment to the extent that’s possible,” she said. “[Actions needed include] increasing training and resources for people who experience harassment, making sure that staff development issues are responsive to these challenges, certainly taking harassment complaints seriously and acting upon them, and being transparent to staff when claims of harassment and acts of harassment actually do occur.”
The definition of harassment was very broadly defined in the survey. It could be angry exchanges between staff, bullying, or patients and their family members acting in a threatening manner.
Jackson said APIC would consider adding medical licensing concerns and harassment on an upcoming IP membership survey now that this CDC/NIOSH data has established a baseline.
Suicidal Ideation; ‘the Thing with Feathers’
Burnout is a relatively benign word to describe the issues it can lead to, including suicidal ideation. A recently published study identifies an increased risk of suicide — compared to non-healthcare workers — in registered nurses, health technicians, and healthcare support workers in the United States.10 The suicide rate per 100,000 non-healthcare workers was 12.6, compared to an overall rate in healthcare personnel of 14.1. Elevated risk was identified in healthcare support workers, who had a suicide rate of 21.4 per 100,000 people. Registered nurses had a rate of 16 per 100,000 people, and health technicians followed closely with a 15.6 per 100,000 people suicide rate. Although they are trying to diversify and bring in people with different training, the vast majority of IPs are registered nurses (RNs).
The study analyzed data from about 2 million workers who were American Community Survey (ACS) participants from 2008 through 2019. “Heightened suicide risk for registered nurses, healthcare support workers, and health technicians highlights the need for concerted efforts to support their mental health,” the authors concluded.
Yet, as poet Emily Dickinson noted, “Hope is the thing with feathers.” There are ways up and out of this situation, but they require hospital management and healthcare personnel working together to redefine their work culture.
“Our analysis also showed places where there is hope that we can improve the outlook for this workforce,” Chosewood said. “Importantly, the Vital Signs report noted that poor mental health outcomes are less common when working conditions are positive, and where health workers have the potential to thrive. Supportive work environments had a positive impact on health workers. For example, the data show that depression symptoms were halved when health workers could take part in workplace decisions.”
Shared decision-making builds trust in management and increases worker compliance with duties. Designing work and policies to support employees can help workers feel safe and protect their mental health.
“It’s important for healthcare leaders to know that solutions don’t necessarily require a major financial investment,” Chosewood said.
Historically, healthcare has not been an early adopter of new concepts to design a better work environment and a healthy culture, Chosewood said. However, the telework needed in the pandemic removed the burden of daily commuting, and many departments — including infection control — have now gone to a hybrid model, allowing some work to continue at home.
Abigail Cunanan, MS, MLS(ASCP), CM, CIC, an IP in the Inova Health System in Falls Church, VA, described at the APIC 2023 conference the hybrid model her department has developed.
Essentially five IPs in a 923-bed hospital have developed a system to have one work-at-home day per week and they take turns as three-day weekends come up on a rotating basis. Staff working at home are in communication with those on site and have pre-selected work that can be done beyond the hospital. This system can lead to longer work hours for some days, but the benefits of a healthy work-life balance are a tonic against burnout.
“We started at the end of October [2022 and] there have been favorable responses about maintaining work-life balance, health and well-being support, remote work productivity, and retention for the next year,” Cunanan said.
REFERENCES
- The National Institute for Occupational Safety and Health (NIOSH). Impact Wellbeing. Last reviewed Oct. 12, 2023. https://www.cdc.gov/niosh/impactwellbeing/
- Melnyk BM, Hsieh AP, Mu J, et al. Associations among infection prevention professionals’ mental/physical health, lifestyle behaviors, shift length, race, and workplace wellness support during COVID-19. Am J Infect Control 2023;51:62-69.
- Agency for Healthcare Research and Quality. Estimating the additional hospital inpatient cost and mortality associated with selected hospital-acquired conditions. Last reviewed November 2017. https://www.ahrq.gov/hai/pfp/haccost2017-results.html
- symplr. The cost of burnout in healthcare. Published July 22, 2021. https://www.symplr.com/blog/the-cost-of-burnout-in-healthcare#:~:text=Burnout%20in%20healthcare%20carries%20a,staff%20RN%20turnover%20costs%20%2440%2C038
- Haley RW, Culver DH, White JW, et al. The efficacy of infection surveillance and control programs in preventing nosocomial infections in US hospitals. Am J Epidemiol 1985;121:182-205.
- O’Boyle C, Jackson M, Henly SJ. Staffing requirements for infection control programs in US health care facilities: Delphi project. Am J Infect Control 2002;30:321-333.
- Nigam JA, Barker RM, Cunningham TR, et al. Vital Signs: Health worker-perceived working conditions and symptoms of poor mental health — quality of worklife survey, United States, 2018-2022. MMWR Morb Mortal Wkly Rep 2023;72:1197-1205.
- The National Institute for Occupational Safety and Health. NIOSH Worker Well-Being Questionnaire (WellBQ). Last reviewed Aug. 4, 2021. https://www.cdc.gov/niosh/twh/wellbq/default.html
- Health Action Alliance. Workplace mental health: Tips for sharing your story. https://uploads-ssl.webflow.com/6010e149d9130a63e7b78adb/627337662f2037642ee7f0ce_Tips%20for%20Sharing%20Your%20Story.pdf
- Olfson M, Cosgrove CM, Wall MM, Blanco C. Suicide risks of health care workers in the US. JAMA 2023;330:1161-1166.
Burnout among all stripes of healthcare workers — including infection preventionists — has become a dire situation warranting national action. Accordingly, the Centers for Disease Control and Prevention and the National Institute for Occupational Safety and Health have released new research and emphasized available resources to raise awareness for an ambitious “system change” in healthcare delivery.
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