“It’s weird, the PTSD — it’s when you don’t expect it,” she says, composing herself.
Nurses, doctors and other health care team members train to handle disasters that last perhaps a few days. But the pandemic doesn’t function like other disasters, with predictable phases and a clear end; new waves of illness constantly reset the clock. And the stress of giving prolonged, intense care for a new, lethal and fast-spreading disease has lasted longer for Seattle’s health care workers than anyone else in the U.S.
Even with case levels simmering instead of surging, COVID-19’s impacts linger in care workers’ compounding fatigue and in the bodies of the increasing number of long haulers adding to the workloads.
Ann’s weariness extends beyond her work. She’s so tired of being alone, of being afraid, of wearing a mask — and of going to the grocery store and seeing people bare-faced.
“You look at them and you just wanna throw something at ’em, ’cuz that’s insane,” she says.
The stress and trauma are contributing to worrisome trends in mental health that have people in the industry concerned about not only their colleagues’ well-being, but the future of medical care itself.
‘Sprinting in a marathon’
Many health care workers enter the field with the optimistic goal of helping patients turn corners, but COVID-19’s lethality and unpredictability have turned that expectation upside down.
“We have residents who have seen more death in their last year of their residency than many doctors have seen in their entire career,” says Dr. Christopher Bundy, the executive medical director of the Washington Physicians Health Program.
And with the multiple waves of illness, they’ve experienced false summits and no idea of when they might actually relax.
“They started sprinting in a marathon, [and the virus kept] moving the goal posts,” says Dr. Arpan Waghray, chief medical officer of Providence Behavioral Health and executive medical director at Swedish. He expects to see an increased level of diagnosed post-traumatic stress syndrome in health care workers over the next one to three years. “You're finishing over and over again. … I don't think the impact is going to go away,” Waghray says.
Typically, relationships with colleagues offer some form of camaraderie and support. But many forms of bonding are off the table for now. Samantha Conley, a neuroscience acute care nurse at Harborview who sits on a staffing committee, can’t chat over lunch with co-workers about the hard things she’s seen, or meet colleagues’ kids or spouses. “I hadn’t realized how important those things were until I couldn’t do them anymore,” she says.
Health care workers with families are especially overwhelmed, Conley says. The pandemic is straining their relationships at home, and work usually means a long day of being short-staffed. “Somebody you need is not going to be there, and you’re just going to have to make do, when it feels like it’s been a year of making do,” she says.
Though trauma is widespread, many nurses and doctors Crosscut spoke with say stigmas about mental illness and mental health in the medical field complicate hospitals’ efforts to assess it and intervene. Not only do physicians and nurses fear looking vulnerable, but some health workers worry that seeking help might damage their employability. Licensing and credentialing often require people to answer questions about their history of mental illness, and workers are skeptical of whether using company resources will result in notes in their permanent file.
“Nurses, we know the importance of mental health, because we see it. We have a lot of patients who have mental health issues. But it's really hard for nurses to turn that around and shift it towards ourselves and our own mental health,” says Casie L., a critical care nurse at a Puget Sound hospital.
“During times of crisis, we're trained to put ourselves last,” says Bundy of the Washington Physicians Health Program, “in the service of performance.”
There’s a dearth of large-scale research about how health care workers’ perceived stress levels and mental health risk factors have trended over the course of the entire pandemic, but researchers in Washington state like Dr. Rebecca Hendrickson are trying to fill in those gaps.
Hendrickson, a UW Medicine faculty member who usually studies PTSD and the behavioral impacts of repeated trauma in veterans at the VA Puget Sound Medical Center, started researching COVID’s impacts on health care workers’ mental health when physician colleagues around the country started talking about the pandemic with the same language she hears in her patients who are veterans. She recently presented initial, non-peer-reviewed results to colleagues on a study conducted since September into mental health trends in health care workers and first responders.
The national study involved more than 500 health care workers and first responders who answered a COVID-exposure questionnaire and filled out 10- to 20-minute online surveys with write-in and multiple choice questions. The surveys exposed clear links between negative mental health outcomes and COVID-related stressors like volume and intensity of care, perceived risk to workers and their families, and demoralization with work.
Levels of distress were significantly higher than she predicted. Over 75% of respondents’ answers put them in the clinical range for PTSD, depression, anxiety and insomnia. While the survey wasn’t meant to diagnose anyone, Hendrickson was alarmed to see about 75% of people surveyed falling into the clinical range for depression and anxiety, and a third of people for PTSD symptoms. Reports of thoughts of suicide or self-harm were also high. Previous large surveys show 3-4% rates in the general population, but this survey shows 12% of healthcare workers and 19% of first responders report having these thoughts.
Demoralization — feeling as though your work doesn’t matter, that you aren’t appreciated and that the work you do provide is futile — was the strongest predictor of nearly every mental health outcome.
And the symptoms are getting worse among Hendrickson’s study subjects, 20% of whom say they have lost family members or close colleagues to the virus. Rates of PTSD and depression symptoms have increased roughly 50% and 23% respectively over the course of a few months.
“People as busy as health care workers can deal with overwhelm, but when you combine that busy-ness with a lot of uncertainty and fear, that's the recipe for developing PTSD,” Bundy says.
Not everyone who endures chronic stress and trauma will respond by developing mental illness. But when those conditions are also accompanied by widely reported feelings of demoralization, they can lead to burnout, which carries its own risks.
“People are feeling guilty that they haven't been able to give the best care, or the care that they think the patients deserve, because they're so busy with tasks and just kind of overwhelmed by all the demands that are placed on us, which just keep growing. They never take anything off of our plate; they just keep adding to our plate,” says Casie L. “I’m definitely seeing more nurses burn out.”
Conley, the neuroscience nurse, says the overwhelming circumstances affect how she interacts with colleagues and patients. When one irritable patient began screaming at her, she found her usual emotional resiliency absent and was brought to tears. "I just couldn't keep it together,” she says.
Burnout has been a recognized problem in the medical field for decades: MedScape data show 42% of physicians nationwide felt burnt out already at the beginning of 2020. There was a temporary reprieve in burnout at the beginning of the pandemic. All of a sudden, frontline workers felt purpose and value. But the rates have bubbled back up. Dr. Alka Atal-Barrio, chief medical officer at the Everett Clinic, says surveys show about 30% of clinicians at Everett are burnt out as of October — down from 47% a few years ago — but burnout indicators increased between May and October.
Many doctors and nurses want to take time off of work to truly separate themselves from the trauma and recover. Vaccines offer some light at the end of the tunnel, but with possible surges always on the horizon, many of them can’t disconnect.
“The burnout comes in when it's all the time — when you find that you're taking that stress and overwhelm home with you, and it's affecting your life outside of work,” says Dr. Anne Browning, assistant dean for well-being at the University of Washington School of Medicine, and founding director of the Resilience Lab.
Various hospitals in the region have launched mental health and wellness programs ranging from online portals that direct employees to articles and self-care modules, to full-on conversations with peers in both one-on-one and group settings, to employee assistance programs providing access to formal mental health care with counselors. Many say the peer-to-peer offerings have been the most helpful.
“It’s hard to come home to your nonhealth care spouse and share what you’ve been through in the hospital. It’s not the same as sharing it with another doctor, nurse or health professional,” says Bundy.
MultiCare’s Code Lavender employee support program saw a nearly 50% increase in use, with just over a thousand employees using it in 2020. UW’s peer support program saw more than 600 request for peer support in its first 13 months. In Providence’s 120,000-person system, a virtual platform for therapy with a trained therapist has been used more than 5,000 times, and a program that directs people to tiered online resources based on self-reported stress levels has been used more than 14,000 times.
“We've tried to create a superlow barrier to support, which can even be [as] informal as a hallway conversation, to midlevel triage with supportive conversations with a professional, to ongoing support with professionals in the clinical setting,” UW’s Browning says.
But taking advantage of those resources remains a constant challenge. None of the doctors or nurses Crosscut spoke with who are unaffiliated with those programs had used employer-provided wellness services; only one knew anyone who had shared that they had.
“How are our members going to do webinars on stress when they’re already tired and work six days a week and have to go home and look after their families?” says Jane Hopkins, a registered nurse and executive vice president of SEIU Healthcare 1199NW, who served on President Joe Biden’s Transition COVID-19 Advisory Board. Providence Behavioral Health’s Waghray says that in order for these programs to work, they need to be automatically made a part of the workload, be accessible anywhere and be opt-out.
But the conditions that lead to mental health problems, and especially to burnout, require more solutions than mental health care.
Doctors and nurses still want many of the things people like Stanford researcher Tait Shanfelt, an expert in health care worker mental health, found during eight listening sessions with 69 health care workers during the first week of the COVID-19 pandemic in the U.S. Shanafelt summarized their needs in a heuristic: “hear me, protect me, prepare me, support me, and care for me … and honor me.”
Washington state professional organizations representing nurses and medical professionals, as well as local unions, have advocated for a host of support mechanisms in the pandemic beyond wellness programs: everything from adequate personal protective equipment and staffing, to overtime pay, to time off for workers who can’t find child care, to memorandums of understanding on timely COVID testing that keeps more nurses on the floor instead of in quarantine, to more employer responsibility for employees who fall ill on the job. Politicians at the national level have introduced things like the Dr. Lorna Breen Health Care Provider Protection Act, named in honor of a New York City emergency room physician who died by suicide during the pandemic. The act would distribute money through the Department of Health and Human Services to support burnout prevention training and provide mental health resources.
“It's not just sitting on a computer and looking at a workshop that's going to make our members’ lives better,” Hopkins says. “I think hospitals, even unionized hospitals, will have to fight really hard for really important things.”
Nurses have had to fight hard to be heard. Conley says her staffing committee’s interactions with the Harborview administration have become more contentious over her two years in it. They’ve had a nursing shortage for a long time, and lack assistant staff to help get patients to the bathroom, eat or turn them in bed so they don’t get pressure ulcers.
“The idea that we would come to the administration and say, ‘Hey, here's what our patients really need in order to be safe, well cared for, improve — to have them say, ‘No, we don't think that's important. We're not even going to bargain with you?’ That just felt really painful, at a time when they put up signs outside the hospital that say ‘Heroes work here.’ But you don't listen to the heroes. It feels like they're saying they value us on the one hand, but not acting like it,” Conley says.
To meet all of the needs suggested by research and directly requested by health care workers and their advocates, self-care and therapeutic services are only a start. All of the people Crosscut spoke with stressed that the conditions creating a need for self-care are systemic and environmental. Suggesting otherwise risks blaming employees for their struggles.
“If the most resilient people in your whole population are burning out in their work environment, that's a canary in the coal mine problem, right? It's not the canary, it's the coal mine,” Bundy says. “We can encourage people to do [self-care] without at the same time absolving the system from its responsibility to create work environments that are also healthy.”
Samantha Conley, a neuroscience acute care nurse at Harborview who sits on a staffing committee, tries to find silver linings when she's experiencing chronic work stress in the pandemic. “I just try to remind myself, ‘Look how lucky you are, Sam! You’re not in one of those beds. You’ve got great support, a secure job.' But often, it’s tough times still for a lot of us.” (Courtesy of Matt Krzycki/SEIU Healthcare 1199NW)
Hospitals have been hosting town halls and small group conversations to improve transparency within and access to leadership, as well as to make employees feel heard. Browning, the assistant dean, says UW’s biweekly town halls with chief nursing and medical officers have been helpful. “I think it’s really humanized our leadership, in showing just how hard it has been to be a leader trying to make decisions in real time and to give folks a chance to apologize, if a decision or piece of communication didn’t work out the way they wanted.”
Atal-Barrio says town halls and daily huddles between leadership like herself and small groups of staffers have been essential. “I'm a believer in transparency,” she says. “I do not coddle my team. They are leaders in and of themselves. And I trust them to lead like I lead, and they do a great job.” She thinks it’s time to bring back in-person meetings and social events that foster connection.
Casie L. recognizes the efforts hospital administrations are making, but says the staff still feels those efforts are superficial.
“I don't even really think they know what nurses do. It's more than just, you know, cleaning up poop, which is what my kids think I do,” Casie L. says. “It’s all the critical thinking that has to happen as we manage all these life-saving medications that these people are on, and the ventilators, and dealing with families and trauma. We wear a lot of hats that I think people don't realize we do.”
For some, the best way to boost morale is simple: Pay frontline workers more.
Atal-Barrio says the Everett Clinic protected jobs and salaries through 2020; it offered recognition pay for people on the front lines, and covered child care expenses when day cares were closed. All providers' salaries were guaranteed for the first six months of the pandemic.
Casie L. says her ICU’s bonus pay system for extra shifts has helped make people feel valued. “I know a lot of nurses wanted hazard pay, which was never even really looked at. I think a lot of nurses felt dissed that way. So that has helped,” she says.
But for most people, the need to feel heard, valued by managers and administrators and that they can depend on their colleagues for emotional support trumped everything.
The UW is developing a recovery plan to support employees as the pandemic winds down. It involves staggered vacations and training peer supporters in how to help people process trauma.
There’s a lot of fear that nurses have been moving so quickly for so long that they haven’t had space to process their feelings — and that they’ll need support when the time comes. “We're not at the point where we can talk about how hard things are. We're at the point where we're just getting through the hard things,” Conley says.
In Hendrickson’s research into PTSD, she has found that the real symptoms of the illness rear their heads for many people when they finally disconnect from the battle and reenter “the real world.”
“Every once in a while when I'm sitting in my car on the rare occasions we have rush hour traffic it'll hit me. I don't know, I don't spend a lot of time reflecting on it just because there was nothing I could have done about any of this. It was just awful,” Ann K. says.
“There are definitely parts of my life that I don’t want to talk about … and I’m not going to be ready to talk about those things for a long time,” says Dr. John Lynch of Harborview.
Leaving the industry
Despite the plans to help people improve their mental health and avert burnout, many employees are already leaving health care. Washington State Nursing Association nurse representatives report that at multiple local hospitals’ intensive care unit floors, each has lost up to a dozen nurses leaving either for different units, to retire or to leave the profession altogether.
Atal-Barrio is concerned about losing employees, and her clinic is preparing for this, she says. In the clinic’s past, she says, people never really retired. But that has changed: These days, they’re retiring earlier than they may have initially planned to. Everett’s 2020 attrition rate was 4% — below its 9% benchmark — but Atal-Barrio is concerned about how often she’s hearing people are too tired, or that they can't keep working at this pace.
“Workers are telling you they can’t afford to feed their kids or send them to college, or pay their mortgage,” Hopkins says, noting that her members from Black, Asian/Pacific Islander and low-income families have been struggling most, financially and physically. “We have given you all of our lives, and you need to do better by us.”
“Nurses mostly want to know that their concerns are being heard,” Ann K. says. If they aren’t? “They will start looking for a place to work.”
Ann says other nurses are always asking her when she’ll retire so they can have her job. She made a conscious decision to leave the floor for an office years ago. She was done coming home with poop on her shoes and being spit on. She knows a few nurses working on their master’s degrees so they can find another job that doesn’t involve bedside work.
Hendrickson’s research so far shows a relationship between the volume of people who report that they are considering leaving health care and the volume of psychiatric symptoms and demoralization linked to the COVID response.
“We’re already living at the edge in terms of the volume of patients and need that health care workers are trying to meet, so I absolutely think we should be concerned that if people actually leave the field at the rates they say they're thinking about it, it would be a big problem. It puts our whole system at risk,” Hendrickson says.
Conley has considered life beyond Harborview. “I said I'm never gonna leave. They're gonna have to shut the doors on me. But, you know, the need for health care workers right now is so high. I can go and someone would take me and I can work somewhere where it's less stressful [and better paid],” she says. Some of her co-workers have already changed job functions or moved to different hospitals.
“Our jobs that we used to love, I don't know that they're ever coming back,” Ann K. says. “ I remember somebody telling me, ‘Oh, you're a nurse — you signed up for this. I'm like, ‘No, I did not. I did not sign up for the plague.’ ”
“I've got this great picture of my great aunt in her nursing uniform, and she was a nurse in 1918. She looks very unhappy.”