By Gary Evans, Medical Writer
Although infection preventionists (IPs) have experienced documented mental and physical exhaustion and burnout during the pandemic, at the 2022 conference of the Association for Professionals in Infection Control and Epidemiology (APIC) they were urged to stay connected and strong.
In its first live conference since the pandemic set in, the APIC meeting in Indianapolis was grief-tinged at times, but ultimately rallied IPs forward after years of fighting the COVID-19 pandemic.
APIC President Linda Dickey, RN, MPH, CIC, choked up a little in thanking her infection control colleagues at the University of California Irvine but told conference attendees the priorities of the meeting were “rejuvenation, staying connected, and encouraging one another.”
Among many other things, IPs have been beleaguered but resilient subject matter experts who have tried valiantly to get out correct information regarding vaccines, infection control guidelines, and other critical aspects of the pandemic response to patients, staff, and their communities.
“Last month, I was at a conference where FDA (Food and Drug Administration) Commissioner Robert Califf said he believes misinformation could become our leading cause of death,” Dickey said. “It’s sometimes hard to connect the dots between the effects of misinformation, such as not getting vaccinated, and the effects on others.”
To illustrate this, she cited the case of a 33-year-old a mother of two who presented at a Spokane, WA, area emergency room earlier this year with sepsis as the result of pneumonia. No beds were available, and none could be found in area hospitals to provide the continuous dialysis care the patient needed. She died in the emergency room 20 hours later.
“A newspaper article noted that the lack of specialty-care beds, which had been impacted by the number of COVID-19 admissions, had contributed to her death,” Dickey said. “Her father, a former journalist, wrote in her obituary, ‘Please get vaccinated against COVID-19. Your actions really do affect others.’”
Although IPs have been a large part of the effort to debunk myths about the vaccines being unsafe, public health has been undermined in a politically divided country.
“We have over 1 million Americans dead of COVID-19 — most dying after a vaccine was available,” said Janet Haas, PhD, RN, CIC, who received APIC’s lifetime-achievement Carole DeMille award at the conference.
“Where you stand on the political spectrum is not important,” she said. “The fact that we are not working together to fix these problems is. It’s scary, and it’s inconsistent with our American values and can-do spirit.”
As a balm against despair, and also as a call to action, Hass urged IPs to intentionally approach each day with positivity. The current situation “requires us to speak out and create a better world,” she said.
By the same token, “Don’t tolerate negativity,” she urged. “When you hear negative comments or innuendo about a person, a group, or an appropriate process, don’t let it pass,” she told APIC attendees. “We have seen what happens when people are allowed to continue obnoxious or dangerous paths. Intervention takes courage, but it makes things better and safer for everyone.”
Long Hours, Unhealthy Habits
IPs have been ground down during the pandemic, much as their colleagues in other specialties have, with many of them abandoning wellness efforts, exercise programs, and drinking more often after work, according to a new study.1
Significantly, the study was published in APIC’s peer-reviewed journal and was based on a survey of their members. The lead author of the paper is Bernadette Mazurek Melnyk, PhD, chief wellness officer and dean of the College of Nursing at Ohio State University.
“[IPs] have struggled just like the other professions,” she says. “During the pandemic, a lot of people quit exercising as much as they used to, they ate unhealthier, and they increased their alcohol intake. Those types of activities definitely changed in IPs. When you think about these figures, it’s pretty staggering. Almost 17% of IPs were using alcohol four or more times a week. These are ways that people are coping, but what that is going to mean for our population is that two, three, five years from we are going to see more chronic disease, diabetes, high blood pressure.”
A random sample of APIC members were emailed a survey assessing mental and physical well-being, lifestyle behaviors, and perceived worksite wellness support. A total of 926 IPs responded. Data were collected in July and August 2021.
“About two-thirds were exercising less than usual and eating less healthy than usual,” Melnyk said. “Three-fourths were sleeping less than usual.”
Depression was reported by 22% of respondents; anxiety was reported by 30%; and 65% reported they had symptoms of burnout and emotional exhaustion.
“Frontline and practicing IPs and IP administrators and directors had more negative mental health impacts than IPs in other roles,” the paper concludes. “IPs with organizational wellness support were less likely to report negative COVID-19 impacts.”
In contrast, a direct relationship was found between working longer hours and worsening physical and mental health symptoms, particularly among IPs who worked shifts of nine to 11 or more hours.
“The longer the work shift, the poorer mental and physical outcomes,” Melnyk says.
“People are so burned out after 10 hours of work they are not able to have full mental engagement. Studies have shown poorer health outcomes and more medical errors made. But those IPs who said their worksite supported their wellness had better outcomes. This perceived wellness support in [work] culture is critical for folks, and I’ve seen that in all my other studies.”
Moral Injury and Burnout
Melnyk did not look for “moral injury” in her study, but it is emerging as a distinct syndrome that has been identified in combat soldiers and now in healthcare workers.2
Duke researchers compared the occurrence of “potential moral injury” (PMI) between post-9/11 military combat veterans and healthcare workers surveyed during the COVID-19 pandemic. Surveys of the combat veterans were done in 2015 through 2019; healthcare workers were assessed for signs of PMI in 2020 and 2021. The comparative groups included 618 veterans deployed to a combat zone after Sept. 11, 2001, and 2,099 healthcare staff working in healthcare during the COVID-19 pandemic.
Researchers looked for two common triggers of moral injury: “other-induced” (disturbed by others’ immoral acts) and “self-induced” (harm caused by violating one’s own code of ethics and morality). The results revealed that 46% of post-9/11 combat veterans and 51% of healthcare workers experienced other-induced PMI. Self-induced moral injury was reported by 24% of the soldiers and 18% of the healthcare workers, according to lead author Jason Nieuwsma, PhD, a clinical psychologist at Duke University in Durham, NC.
“Moral injury is distinct from burnout,” he says. “Burnout is something that has been looked at a fair amount among healthcare workers preceding the pandemic and then, certainly, during the pandemic. It tends to describe a feeling of exhaustion and depletion. Moral injury certainly involves some of those feelings, but it is defined or described more by a sense of either participating in something that went against your moral conscience or witnessing something that went against what you thought was right. There is perhaps even a feeling like you were betrayed, or that you saw somebody else do something that went against what you feel like is right.”
One of strongest triggers for moral injury in soldiers is the killing of noncombatants. Healthcare workers experienced strong feelings during events such as forced rationing of care or enforcing “cruel policies” like having to tell visitors they could not see their loved ones as they were dying, he says.
Isolation, one of the common symptoms that manifest in soldiers, now is being followed over time in healthcare workers, Nieuwsma says.
“One of the things that we see among veterans, regardless of whether your moral injury is induced by another, a result of a betrayal, or self-induced, is it can lead to isolation and cutting off from other people,” he says. “This is either because you feel like other people can’t be trusted or because you feel like you’re a bad person and don’t deserve to be around other people. Isolation is one of those behaviors that can then exacerbate lots of different mental health problems.”
Although Nieuwsma did not specifically study IPs in relation to moral injury, it is arguable that many have felt some self-induced or institutional harm to the degree they had to violate their own values and core mission to prevent healthcare-associated infections (HAIs).
These infections increased dramatically during the chaos of the pandemic. IPs frequently were pulled into COVID-19 duties and rounds, and compliance enforcement of infection control practices too often went by the wayside.
“We know from the literature that there’s been an increase in healthcare-associated infections as we pivoted our attention away from preventing HAIs into responding to the pandemic,” said Sarah Smathers, MPH, CIC, FAPIC, infection prevention and control director at the Children’s Hospital of Philadelphia. “As IPs, we were the owners of how to safely care for our infected patients.”
The IP’s Tale
At the onset of the pandemic, she had a bit of a “savior complex,” Smathers said at an APIC session. “I was working so hard to fix everything that was happening in my hospital, everything that was going on in my kids’ schools related to COVID and lockdown, and then also everything in my community.”
This effort included texting and email as well as social media as people sought Smathers and other IPs out for pandemic guidance.
“They always started off, ‘I know you’re so busy but … ,’” she said. “And I really felt this duty to respond to everybody. I really thought it was my privilege to help people and to reassure others.”
IPs in general really answered that call to help in any way that they could; for example, in navigating a safe return to school.
“I did a PPE (personal protective equipment) training with our teachers as they went back to take care of students who needed special services,” Smathers says. “We also had many IPs who answered the call to help our sports and entertainment industry safely return. We had vaccination clinics that we staffed or stood up, and not just for our healthcare workers but for our communities in general.”
These good deeds did not go unpunished, however, as overextended IPs began suffering physically and mentally.
“I was pushing myself past the point of exhaustion and burnout,” Smathers said. “That was leaving me with some physical symptoms of headaches and dizziness. I was having a lot of memory loss and forgetting words. There was this moment that I recall driving home, looking at my blind spot and seeing a car there. My brain couldn’t catch up and think fast enough, and I started to go into that lane anyway. That was the moment I said I’m working too hard. I need to pause and rest. I need to think about my own recovery.”
Although viewed as subject matter experts by many staff members, IPs also were seen to some degree as gatekeepers by other healthcare workers.
“They saw us as the face of the pandemic,” Smathers said. “They had some anger and frustration. They saw us as the people who had the things that they needed and that they couldn’t get, whether it was testing early on or vaccines later. That was a real hard [place] to be in.”
As the pandemic continued, institutional priorities began to shift to staffing challenges and financial losses.
“We felt like those resources that we had at the beginning of the pandemic were pulled away to deal with those other important issues,” she said. “It felt to some of us like we were left behind to carry on the response, but with less support.”
This situation was compounded by the personal challenges many IPs faced.
“Some of us have lost loved ones,” Smathers said. “We’ve cared for sick family members. We’ve navigated these school closures or childcare needs for our families. I’m here to tell you, it’s not just you — it’s not just infection preventionists. COVID-19 has really impacted all of us in society.”
Parents of young children had a particularly difficult time when schools closed during the early lockdowns. In Smathers’ case, she was swamped at work when schools closed, and her university professor husband suddenly had to work from home.
“He was conducting labs out of our kitchen, while our children were homeschooled and left to be kind of independent in their bedrooms,” she said. “My daughter, who was in third grade at the time, did pretty well. My son was in first grade. We would often find him under the covers in his bed or in the dog crate. That was an incredibly challenging time to be a parent.”
IPs Leaving Field
The predicted mental health aftershock of fighting those waves of SARS-CoV-2 has hit healthcare workers even as the pandemic has continued.
“Now it’s still dragging on two years later, not everybody has come back to the office,” she said. “But what they predicted is true, that people are feeling the low morale, they’re hyper-stressed, they have a general fear, and everything we knew about work is really gone. Those old easy connections, brainstorming and collaboration, it’s all a little bit harder in the remote world or the hybrid world. Some people have chosen to remain full-time remote because of the stressors of going back.”
Others in fields across the board have left their jobs, including IPs, who actually were short-handed prior to the pandemic, Smathers said. She co-authored a 2019 study that found a 25% vacancy rate in infection prevention departments.3
“This was a surprising finding because, at the time, it was much higher than the national nurse vacancy rate of 9%, indicating that there was a challenge in IP staffing prior to the pandemic,” she said.
Resignations are being exacerbated by older, baby boom IPs retiring as their careers wind down. “I know a few IPs who have said that they’ve helped their organizations through the worst part of the pandemic and now it’s time for them to rest and they have gone into a well-deserved retirement.”
The fight goes on, seemingly still on the terms dictated by a highly mutable virus. IPs must hold the line with what they have and restock their profession as APIC creates academic and training pathways into the field. All this is occurring during an ongoing pandemic and the “collective trauma” that is being inflicted on healthcare.
Part of the reason for the difficulty stems from the pandemic unfolding as a recurrent onslaught, rather than a natural disaster that is linked to one moment in time, Smathers notes. “This pandemic has really been chronic and prolonged,” she said. “The start date has been different for people across the world and across our country, and there’s really no clear end date in sight.”
REFERENCES
- 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 2022; Jul 13:S0196-6553(22)00337-6. doi: 10.1016/j.ajic.2022.04.004. [Online ahead of print].
- Nieuwsma JA, O’Brien EC, Xu H, et al. Patterns of potential moral injury in post-9/11 combat veterans and COVID-19 healthcare workers. J Gen Intern Med 2022;37:2033-2040.
- Gilmartin H, Reese SM, Smathers S. Recruitment and hiring practices in United States infection prevention and control departments: Results of a national survey. Am J Infect Control 2021;49:70-74.
Infection preventionists experienced exhaustion and burnout during the COVID-19 pandemic. However, at the 2022 conference of the Association for Professionals in Infection Control and Epidemiology, they were urged to stay connected and strong.
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