High rates of COVID-19 burnout could lead to shortage of health-care workers
by Robert Maunder, Professor of Psychiatry, University of Toronto; and Gillian Strudwick, Scientist and Assistant Professor, Institute of Health Policy, Management and Evaluation, University of Toronto
Burnout occurs in many occupations, but health care exposes its professionals to unusual types of stress, including moral distress.
During the pandemic’s third wave, researchers interviewed nurses to see how their perceptions had changed over the preceding year. Early in the pandemic, nurses had reported optimism about supporting one another through the pandemic, but by the third wave, this had been replaced by anger and exhaustion.
One source of resentment was how employers were managing a depleted workforce. Clinical psychologist Dana Ménard found that incentives for new hires caused anger among those who had been on the front lines for a year with no retention rewards. Vicki McKenna, president of the Ontario Nurses Association, expressed concerns about staffing, telling a reporter, “I fear that it is going to be devastating to the workforce. I’m very worried about the future of the nursing workforce.”
Meanwhile, other sources warned of a potential shortage of nurses. “Canadian nurses are leaving in droves,” ran a Globe and Mail headline.
Appreciating what is happening to these nurses and how to respond hinges on understanding burnout, which may be the primary occupational hazard of health-care work. This is especially true in a pandemic. Burnout, as it is typically measured, has three components: emotional exhaustion, depersonalization (indifference or emotional distance) and a diminished sense of professional achievement.
Burnout occurs in many occupations, but health care exposes its professionals to unusual types of stress, including moral distress. This arises when professionals feel constrained from providing the best care. Examples include situations when care may be too aggressive at the end of life, or when one health-care worker is concerned about care provided by another. Moral distress has increased during the pandemic due to scarce resources and the inability to comfort families.
Consequences of burnout
Burnout is bad for everyone. It is associated with diminished safety and quality of care for patients, and mental health problems and poor quality of life for professionals.
For the health-care system, burnout is associated with absenteeism, reduced productivity and thoughts of leaving one’s job. During a time when nurses and doctors are in short supply, we cannot afford to lose more because of burnout.
Burnout is rising
Burnout was common before COVID-19 and is now rampant. For example, rates of severe emotional exhaustion were often in the range of 20 to 40 per cent prior to the pandemic, with higher rates in intensive care units and emergency medicine. Compare that to Canadian surveys later in the pandemic reporting rates of 62 per cent, 63 per cent and 72 per cent.
It should be no surprise that working in health care during a pandemic that is unprecedented in our lifetimes has increased burnout.
In addition to risking their own health, many health-care professionals have been, for example, working longer hours and are often understaffed if colleagues are in quarantine or ill. Many maintained their full-time job while their children were unable to attend school. They must also manage uncertainty as policies change and a virus mutates, while providing care to critically ill individuals who chose not to be vaccinated.
Burnout may deplete the health-care workforce
Surveys of health-care workers reveal an extraordinary challenge. A survey of members of the Registered Nurses Association of Ontario found 43 per cent were considering leaving, more among those who felt burnt out. Another Canadian study reported 50 per cent of nurses surveyed intended to leave.
Signing bonuses for new nurses, which angered the nurses Dr. Ménard’s team interviewed, suggest that the intention to leave is translating into action. Indeed, reports of shortages related to pandemic burnout continue to appear in the news.
Since understaffing is both a cause and consequence of burnout, the health-care system may be entering the downward spiral of a particularly vicious circle.
The solution should match the problem. Evidence indicates that burnout is more a consequence of work conditions than of the workers’ vulnerabilities: of long hours, high workload, moral distress and violence and abuse in the workplace, among other systemic problems.
And yet, most research studying interventions to prevent and reduce burnout focuses instead on individuals by teaching things like coping skills and stress reduction techniques. Although providing individual interventions may be moderately helpful, as the sole response to an occupational hazard, it is perverse — like teaching the residents of a flood zone how to swim instead of elevating their homes or helping them to move.
The health-care system urgently needs system-level measures that protect its professionals from harm, and compensate them for hazards. These may include manageable hours, adequate time off, appropriate staff-to-patient ratios and workplace safety measures. Some organizations will try to recruit new health professionals to manage shortages, but recruitment into a harmful environment is not sustainable.
Which brings us to leadership. Evidence supports the value of leadership in reducing burnout in health care, especially leaders who are transparent, ethical, respectful, reflective and informed. We need health-care leaders who are committed to protecting the health of providers and organizations as well as patients. System level support is needed to prevent the COVID-19 pandemic from causing an exodus of professionals from health care.