By Gary Evans, Medical Writer
Some healthcare workers are hanging by a thread as thin as a suture. Others have fallen — due to COVID-19, workplace violence, or by their own hand. Many have fled healthcare as if it were a burning building. Perhaps, more appropriately, a burned-out building. Too many healthcare workers today are described as anything but well. Mentally, they are at the end of the tether: burned out, morally injured, compassion fatigued, with some depressed to the point of suicidal ideation.
“Caring for people who are sick can be intensely stressful and emotional,” said Debra Houry, MD, chief medical officer at the Centers for Disease Control and Prevention (CDC). “Exposure to human suffering takes an immense toll.”
Houry recalled her days as a harried emergency department clinician at a recent press conference held by the CDC and its sister agency, the National Institute for Occupational Health and Safety (NIOSH).
“You do everything you can to save a life,” Houry said, but those lost battles echo long after the incident. “I still remember some of the tough patient cases I had, where I gave the bad news about an advanced cancer diagnosis to a working spouse or the time I was unable to resuscitate a young toddler after a car crash,” she said. “After a shift like this, I would have to put on a good front and take care of my own family. In doing this, I didn’t always pay enough attention to my own wellness needs.”
These conditions preceded the pandemic but were inestimably intensified by it, as healthcare workers saw patients dying while fearing for their own lives and worried about exposing their families at home.
“You add to that things like COVID-19, where you have a new virus before we had vaccines, the stress on the healthcare system just pushed it to the brink — really to the tipping point,” Houry said. “Our nation’s health workers are suffering, and we must act.”
The CDC and the NIOSH released new research and emphasized available resources as they tried to raise national awareness of a dire situation.
“To label our current and long-standing challenge a ‘crisis’ is an understatement,” Casey Chosewood, MD, MPH, director of the Office for Total Worker Health at NIOSH, said at the 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.”
‘Impact Wellbeing’
Dubbed “Impact Wellbeing,” the new 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
A key component is the NIOSH Worker Well-Being Questionnaire, which was developed by the agency to help healthcare facilities identify gaps in their wellness programs and target improvements.2 The questionnaire assesses five domains of worker well-being, taking a holistic approach to a complex problem:
- 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, co-workers, 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 has also posted a “Leadership Storytelling Guide” to “help hospital leaders talk publicly about getting help for their own mental health concerns and encourage 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. This is a critical moment to share the resources available at your organization and a powerful opportunity to announce new company action to improve workplace mental health.”3
The involvement of leadership could bring a call to action for staff and management. “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, Licensing Fears
A critical role for hospital leadership is to ensure healthcare workers can access 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 tends to be quite a bit of stigma still associated with admitting that you have depression or seeking help,” Houry said. “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.”
The Dr. Lorna Breen Heroes Foundation developed three basic steps to ensure healthcare workers can access care without fear of licensing entanglements:
- Audit all licensure and credentialing applications, addendums, and peer review forms.
- Change any invasive or stigmatizing language around mental health.
- Communicate these changes to the workforce and assure clinicians that it is safe for them to seek care.4
The foundation is named for Lorna Breen, MD, an emergency physician at NewYork-Presbyterian/Columbia University Irving Medical Center, who committed suicide in April 2020 after contracting COVID-19. Breen’s death led to a new federal law, the Dr. Lorna Breen Health Care Provider Protection Act, which provides funding for mental health education and wellness campaigns — including the CDC and NIOSH Impact Wellbeing initiative.
Other physician suicides occurred during the pandemic, of course, including a painful one described by Jesse Ehrenfeld, MD, president of the American Medical Association. (For more information, see the related story in this issue.)
“Two years ago, a dear friend of mine, a medical school classmate, an emergency room physician in California who was working tirelessly on the front lines throughout COVID, took his own life,” Ehrenfeld said recently at the National Press Club in Washington, DC. “He was an energetic and loving soul, a brilliant, caring doctor who felt the weight of the pandemic on his shoulders, and he struggled to get out from under it. I knew he struggled, but I didn’t know how to help him, and he didn’t know how to ask for help. I’m still deeply troubled by his death, just as I am haunted knowing that there are thousands of people in his community who can no longer receive his care.”5
In addition, a recently published study revealed the elevated suicide risks of non-physician healthcare workers, including registered nurses, health technicians, and healthcare support workers.6 (For more information, see the related story in this issue.)
Harassment and Threats
Highlights from a recent CDC Vital Signs report7 on healthcare workers included some survey results from the National Opinion Research Center’s General Social Survey — specifically, the quality of work life module.
“The number of days U.S. health workers reported their mental health was not good in the past 30 days increased more than other workers between 2018 and 2022, the timespan before and after the start of the COVID-19 pandemic,” Chosewood said. “Health workers were also more likely than other workers to report negative changes in their working conditions during this time. Notably, health workers reported the largest increase in being harassed at work compared to other workers.”
Indeed, broadly defined harassment of healthcare workers in this 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 noted. “[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.”
Hospital Employee Health asked the speakers to clarify the nature of harassment in more detail. “Harassment really is sort of a constellation of negative exposures, negative work experiences,” Chosewood explained. “It could be anger between patients and staff, or between co-workers. Bullying, negative comments, really unfortunate interactions between people all would represent forms of harassment. For the purposes of this study, it not only included those interactions between workers, but also potentially from family members to workers, or from patients to workers.”
In addition, there were widely reported incidents when public health officials were threatened or harassed, Houry added. “In the healthcare setting, it could be threats of violence from patients [or] family members upset about a long wait,” she said. “Just those frustrations, but it increased — it nearly doubled during this time.”
Almost Half of HCWs Leaving Current Job
Specifically, the analysis showed that 46% of health workers reported often feeling 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 explained. “In comparison, other 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, Chosewood noted. Anecdotally, there are indications that they are “not just jumping from hospital to hospital,” raising concerns that some plan to leave the profession altogether, he added.
“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 half 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 was not an early adopter of new concepts to design a better work environment and a healthy culture, Chosewood noted. However, the telework needed in the pandemic removed the burden of daily commuting, and many systems have now gone to a hybrid model allowing some work to continue at home.
“I think 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. 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.”
REFERENCES
- National Institute for Occupational Safety and Health. Impact Wellbeing. Last reviewed Oct. 12, 2023.
- National Institute for Occupational Safety and Health. NIOSH Worker Well-Being Questionnaire (WellBQ). Last reviewed Aug. 4, 2021.
- Health Action Alliance. Workplace mental health: Tips for sharing your story. 2023.
- Dr. Lorna Breen Heroes’ Foundation. Remove intrusive mental health questions from licensure and credentialing applications: A toolkit to audit, change, and communicate. May 3, 2023.
- American Medical Association. AMA president sounds alarm on national physician shortage. Oct. 25, 2023.
- Olfson M, Cosgrove CM, Wall MM, Blanco C. Suicide risks of health care workers in the US. JAMA 2023;330:1161-1166.
- Nigam JAS, 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.
Some healthcare workers are hanging by a thread as thin as a suture. Others have fallen — due to COVID-19, workplace violence, or by their own hand. Many have fled healthcare as if it were a burning building. Perhaps, more appropriately, a burned-out building. Too many healthcare workers today are described as anything but well. Mentally, they are at the end of the tether: burned out, morally injured, compassion fatigued, with some depressed to the point of suicidal ideation.
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