Conjure a memory of Central Oregon deep summer triple-digit heat thick with hazy smoke and humidity. Now imagine you're working a 12-hour shift in the designated outdoor COVID tent where you aren't allowed to keep a water bottle with you and full Personal Protective Equipment is required at all times—aka sticky plastic full-body garb. This was the mid-pandemic recurring Groundhog-Day nightmare that Alison Fountain, a Central Oregon-based urgent care nurse, found herself in off and on over the last 18 months.
Now imagine amplifying the incubi. Cue the PPE shortage.
"It caused a whole other level of burnout," Fountain laments. "Being told to reuse masks that have already been worn for over 12 hours, trying to re-sanitize a single-use mask and give it to other caregivers, and being given protective gowns that on the box says, 'not to be used for isolation against viruses' was a complete joke."
It's no wonder Fountain (and so many other health care professionals) are feeling burned out.
Fountain says burnout feels like, "A dread of going to work. Waking up in the morning before a shift and throwing a fit before heading out the door. Being tired most of the time (both physically and mentally). Hiding a negative-trending attitude really well. My internal dialogue is one of a negative nature these days—which is not who I usually am."
When Jen Rainey, an Oregon-based oncology physician's assistant, was confronted with the reality of working during a shortage of adequate PPE, she and her health care co-workers felt like single-use masks themselves: disposable.
"If you don't feel protected or safe where you work, even though you know you're a valuable resource, it's not a good feeling. People felt like they were busting their butts for patients, but extra efforts were lost in the distraction of COVID," Rainey said.
To boot, Rainey's particularly vulnerable oncology patients need both reassurance and close monitoring in the face of COVID. In the current setting of widespread staff shortages throughout the health care system, providers are not necessarily set up for increased patient volume. Rainey says transitioning to telemedicine early in the pandemic was particularly challenging.
"At the start of COVID I always wondered, did I miss something on that call, or would I have gotten something different if it was an in-person meeting? Though telemedicine has been necessary, it has contributed to provider burnout. A lot of us hadn't done much telemedicine before COVID and we had to figure out how to give good care and keep patients at home." On top of this she has seen a huge spike in daily phone calls—which she must return, in addition to her regular responsibilities.
These are not Rainey's preferred methods of meeting with patients and not what she was expecting or anticipating when she got into medicine.
Rainey says burnout looks like, "Feeling overwhelmed to the point you can't solve easily fixable problems anymore. Compassion fatigue. Losing trust in the leadership of the organization you work for. Entire team apathy, as opposed to just a provider occurrence. It's an entire health care team thing. It's easy enough to rally around an individual experiencing burnout and help them out. But when the team as a whole is burnt out, that is hard to recover from."
For Christina McKeown, a hospital nurse who formerly lived in Central Oregon, COVID burnout looks like extreme fatigue, lack of enthusiasm for work that she would have typically loved and feelings of hopelessness. To sum it up, McKeown says, "Heaven knows those of us in medicine have been through the wringer."
Ileana Bourland, licensed acupuncturist, herbalist and owner of Heal Grow Thrive Medicine, had to shut down her practice in March 2020 when national COVID restrictions were first put into play.
“If you don’t feel protected or safe where you work, even though you know you’re a valuable resource, it’s not a good feeling. People felt like they were busting their butts for patients, but extra efforts were lost in the distraction of COVID.”—Jen Rainey
"I was very concerned about my patients who use acupuncture and massage for pain management. Many would otherwise take opiates or other medication and still have to go to the ED [emergency department] or urgent care for help with their pain. My stress was very high as I learned how to navigate Governor Kate Brown's and the Oregon Health Authority's rapidly changing guidelines regarding COVID safety. In mid-April 2020, we were able to reopen for emergency, physician-referred patients only. I was thrilled to be able to open our doors, but I was plagued with the stress of trying to get it right." Emergency, physician-referred patients are typically disadvantaged financially and otherwise, and/or veterans.
The National Center for Biotechnology Information published a paper in 2020, "Burnout in Healthcare Workers: Prevalence, Impact and Preventative Strategies," defining it as such: "Burnout is a work-related stress syndrome resulting from chronic exposure to job stress. The term was introduced in the early 1970s by psychoanalyst Herbert Freudenberger and has subsequently been defined by Christina Maslach, et al, as consisting of three qualitative dimensions which are emotional exhaustion, cynicism and depersonalization, reduced professional efficacy and personal accomplishment."
Clearly not outliers, many of the experiences Fountain, Rainey, McKeown and Bourland express are defined in this paper, and bolstered by a recent poll from Kaiser Family Foundation and The Washington Post, which found that six out of 10 health care workers are currently struggling with mental health issues as a result of the pandemic. More than half say they are burned out as a response to chronic stress at work.
Dr. Angelina Montoya, who's practiced psychiatry in Bend since 2005 and is a member of the Deschutes County Medical Society, has counseled a number of health care providers in various positions including nursing, physician assistant and physician. From these visits she has gleaned, "I would characterize their concern not so much as burnout but more as feeling overwhelmed with work. The difference is this: none of the health care professionals ever discussed NOT working or going to a different type of work. It is more a sense of trying to be more tolerant, more available to their patients, but at times feeling crushed by the serious and unrelenting nature of the work, and at times, the disappointment of not being able to be more available to family, friends."
Perhaps more serious burnout is happening than is totally revealed or clear in counseling sessions. Fountain and McKeown noted that although the health care organizations they were employed by offered some form of employee assistance for stress management, health care staff could be reluctant to use these resources and to be entirely honest with a counselor.
"I have never used these services," shares Fountain. "I know there are quite a few of us that are concerned to talk about things like burnout and compassion fatigue to somebody that is a part of the organization that we work for."
Though pandemic conditions and demands have undeniably stressed the health care system (and more imperatively its staff) to the brink of spontaneous combustion, many conceded the components for ignition were long present before COVID. Five years prior to the pandemic, a Mayo Clinic study entitled, "Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014" concluded that burnout and satisfaction with work-life balance in United States physicians worsened in the study period and that more than half of U.S. physicians were experiencing professional burnout.
If the top of the food chain (doctors) are feeling the heat in the kitchen, it seems a reasonable inference that the sous chefs and waiters (nurses, physicians assistance, etc.) are probably sweating bullets two-fold. After all, sh*t trickles downhill.
Urgent-care nurse Fountain's pre-COVID experiences went like this: "When I was working night shift in a busy ER, we were short staffed most nights, ran constantly through the shift as there was a steady stream of patients coming in and a revolving door at the ambulance bay of trauma patients and medical emergencies. It was not uncommon for patients to wait in the waiting room for six-plus hours just to be seen and I'm sure you can imagine that with those wait times, the patients were definitely not in the best of moods when they got back to a hospital room," she described. "The amount of verbal abuse us nurses took from patients was beyond what most could imagine. So on top of verbal abuse from patients, the stress of multiple traumas and medical emergencies, watching people die, comforting family members and caring for the mentally ill in crisis, we did not get breaks or lunches. Of course, we would reach burnout. In fact, three years into my nursing career, I was burnt crispy and didn't want to continue."
“I know there are quite a few of us that are concerned to talk about things like burnout and compassion fatigue to somebody that is a part of the organization that we work for.” -Alison Fountain
Others agree that this is nothing new.
"Provider burnout was a huge problem before the pandemic," explains Rainey. "Existing failings in health care were brought to light during COVID. I work in a rural area and there just aren't enough bodies to handle significant extra stress on the local resources. The pandemic has only highlighted the fact that health care has problems that aren't being addressed adequately."
In 2018, the Central Oregon Medical Society began to address health care burnout through the Oregon Wellness Program. In early 2020 Montoya was invited to participate, which is where she gained her aforementioned insights about those working on the front lines in health care. OWP includes eight free, totally confidential, psychological counseling sessions in 12-month intervals to physicians, physician assistants (also going by the name physician associates as of May 2021, by a vote of the American Academy of PAs) and nurse practitioners. In addition, COMS hosts monthly to quarterly practical and informational talks on health care burnout and how to combat it as an individual. Since 2012, when the first partner program began, more than 300 physicians have taken advantage of the program, completing more than 1500 visits.
This programming is independent of any singular provider or health care organization, which could alleviate some of the concerns Fountain shared about disclosing compassion fatigue directly to another employee (mental health specialist or not).
Present pandemic burnout stop gaps
In NCBI's study, it was also found that burnout, "is [still] not clearly defined and there is no consensus on the diagnosis. There is an agreement that burnout in medicine is harmful to the professional, the institution, and the patient." So how can health care administration and the powers that be intervene, triage and contain a powder keg that is difficult to define?
Rainey, the PA, who also holds a master's in public health, suggests health care organizations do more to repair trust with care teams.
"Employee appreciation does not look like surprise donuts in the break room or mental health webinars. Send someone from leadership to look at workflow issues. If you want to show me you appreciate my time, you are going to sit down with me and talk about what the issues are—but those conversations aren't always happening with leadership. And that doesn't tend to be the culture of medicine."
In addition, Rainey wants leadership to recognize there are other critical people on the team outside of doctors, like receptionists and those making patient contact. "In my experience pre-pandemic, I was hearing a lot about specifically provider burnout, but all the team members are important to workflow and need to be heard when it comes to burnout."
Up to 80% of health care jobs are held by women, according to the Bureau of Labor Statistics, which means women are staffing the frontlines of medicine and suffering these stresses disproportionately.
An Oregon Health & Sciences University study published in June in the journal Health Affairs titled, "Cultural And Structural Features Of Zero-Burnout Primary Care Practices" broadly concurs with Rainey's prescription for addressing burnout.
"Although much attention has been focused on individual-level drivers of burnout in primary care settings, examining the structural and cultural factors of practice environments with no burnout could identify solutions. ... Efforts to prevent burnout in primary care may benefit from focusing on enhancing organization and practice culture, including promoting leadership development and fostering practice agency."
Currently, Fountain has noticed the most impacting stress factor, and perhaps most solvable, is an "increase in patient volume with less staff."
Fountain shares, in addition to upping staffing numbers, she and her colleagues want to see equality in bonuses. "Often substantial sign-on bonuses are being offered to nurses. But what about all of us that are currently working through this mess? To incentivize and keep the nurses that continue to show up? I think that needs to be addressed as well. Retention bonuses or something would be appreciated instead of seeing that someone that will soon be working beside you is being offered up to a $10,000 bonus—not going to lie, that kind of hurts."
McKeown, the hospital nurse, echoes that.
"We desperately need more support for medical workers. Fair wages to retain hospital staff, regular wage increases to accommodate for cost-of-living increases, coverage to allow nurses to be able to get a lunch or take a mandatory break—sometimes we can't get to the restroom in a 12-hour shift because we are so busy—and plans in place to deal with staffing shortages during these unprecedented busy times."
Not unlike Central Oregon, the West and the nation's current fire season, drought conditions in health care are persisting, with no end in sight.
"Frequently, what I tell [Oregon Wellness Program participants] is what they already know but maybe need to be reminded of. They are human. They are normal in feeling grief and anger and hopelessness at times, just as they are normal in feeling a sense of elation and a sense of accomplishment when they have helped heal. In our health care training, we are steered more to focus on the BEST outcome, and while that is often the most frequent outcome, it is not every outcome. That is when it is important to be able to tolerate our disappointment, learn from it, and keep going." Perhaps easy to say, but hard to do, when you're a nurse that isn't allowed to keep a water bottle with you or use the bathroom for 12 hours.
Note: Health care workers employed in Oregon experiencing burnout, wanting to talk about burnout or looking for solutions to burnout may want to attend the 2021 Oregon State of Reform Health Policy Conference in Portland in October.