“We Are in a War”: Mitigating Burnout in COVID-19
Trigger warning: Sections of this blog examine the negative impact that COVID-19 may have on health care professionals and/or contain war references. Readers should examine their emotional state prior to reading and skip to different sections as desired.
To the palliative care teams and health care professionals across the nation fighting to support patients and families during the COVID-19 pandemic—we see you. We have read your stories, observed your sacrifices and heroism, and heard your calls for help.
One of the most consistent concerns you have shared is how fighting COVID-19 is accelerating burnout in yourselves and your teams. Many health care professionals have likened this effort to combat. Given the scope of the pandemic and all of the factors surrounding it, the hard truth is that it may be impossible to avoid some level of burnout or long-term trauma. However, there are strategies to normalize what you are feeling and mitigate the impact of this stress. Given the parallels to combat, we spoke with military and health care experts to better understand which strategies palliative care team leaders and individuals should prioritize during this time. These include maintaining basic activities of daily living, remaining in the present, managing expectations for ones’ self, and developing a buddy system (please see complementary resource outlining just the stress mitigation strategies). Before that, we examine the COVID-19-related factors that are accelerating burnout, and ways in which your organizations should provide support.
COVID-19 Factors Accelerating Burnout
Burnout is defined as “a syndrome characterized by high emotional exhaustion, high depersonalization (i.e., cynicism), and a low sense of personal accomplishment from work.” Standard factors contributing to professional burnout include sustained high caseloads, time pressures, and insufficient job resources. And the consequences of burnout in health care include damage to the individual professional, adverse events in patient care, and a strain on organizations.
Unfortunately, burnout is not a new challenge in health care. Prior to the pandemic, a high percentage of doctors and nurses across disciplines were reporting symptoms. And palliative care teams have felt this even more acutely, with diminishing programmatic resources and a looming workforce shortage.
The COVID-19 pandemic both exacerbates the pre-existing causes of burnout and adds its own stressors. Palliative care teams in particular are navigating a delicate balance of supporting their patients and families, their colleagues, their loved ones, and themselves. Here are some examples of the novel factors in COVID-19 accelerating burnout among palliative care professionals:
- Patient Volume. The overwhelming number of patients and the severity of their needs are requiring palliative care teams to deliver care outside of their established patterns. This includes operating in new roles and settings, and stretching staff-to-patient ratios.
- Nature of Illness. As COVID-19 is highly contagious, can lead to severe outcomes, and has no universal treatment, the prevalent public health strategy is social distancing. Yet it is precisely during serious illness and extreme stress when connectedness is psychologically critical. In observing social distancing guidelines, palliative care professionals must deliver serious news to patients and families remotely, including that loved ones may not be able to see each other again in person before the patient dies. The high mortality rates associated with COVID-19 mean that palliative care providers must deliver this news more frequently than ever before, increasing the likelihood of secondary traumatic stress. Additionally, both “patient volume” and “nature of illness” considerations can challenge palliative care professionals’ feeling of integrity in their work and/or make them feel that they are delivering inadequate care.
- Resource Scarcity. The contagious nature of COVID-19 means that all health care professionals are dealing with the fear, stress, and grief of anticipating or seeing loved ones, friends, and colleagues become ill. This is exacerbated by well-documented shortages of personal protective equipment (PPE) in health care settings across the nation. Additionally, while it is outside of the purview of palliative care to make triage decisions, the scarcity narrative has crept into all aspects of care. This creates significant pressure to get the words in difficult discussions “right,” so that they do not increase patient and family suffering. (Please see VitalTalk’s resources, also featured prominently in CAPC’s COVID-19 Response Resources toolkit.)
- Incomplete Information and Uncertainty. Given the novelty of COVID-19, best practices on how to medically manage it are changing every day. This creates a constant need to monitor sources for updates and micro-changes that could save a patient’s life. Not only is this time-consuming, but it can undermine providers’ confidence in their own professional judgement. This ever-changing medical knowledge base is also accompanied by a deluge of institutional and governmental policy guidance that, while generally intended to reduce burden, can be confusing and overwhelming. And yet despite all this information overload, there are still so many unknowns—among the most demoralizing is how long the pandemic will last.
- Additional External Factors and Anticipation of the Future. The COVID-19 pandemic has decimated the global economy and is challenging the sustainability of health care organizations and providers who are stepping up to meet the need. While the U.S. government continues to develop policies to stabilize the situation, the damage is already being felt. Meanwhile, many health care providers are anticipating a secondary surge in patients—not only those whose needs have been triaged during this period, but also a new cohort of seriously ill patients who may exhibit (as-yet-unknown) long-term consequences of surviving COVID-19.
What you are facing during this global pandemic is overwhelming. It is normal and justified to feel stress, fatigue, sadness, anger, guilt, or any other constellation of negative emotions. You are not alone. The challenge facing you now is how to navigate these feelings past the threshold at which you would normally stop, in order to continue meeting the needs of patients with serious illness, and their families.
While this blog is primarily intended for palliative care teams and individual health care professionals, much of their ability to remain grounded during this time depends on institutional/organizational support. Leadership must take certain actions to create a healthy environment for workers, which include procuring PPE and other necessary resources; mitigating risk for vulnerable health care workers; facilitating child and elder care; and supporting mental and physical health, etc. Providing these resources not only supports employees, but it increases efficiency and reduces burden on departments or teams to focus on general wellness. This allows leaders to focus on individualized needs, and frees up more time for teams to deliver patient care.
Many institutions are showing incredible leadership in this regard. Organizations such as Mount Sinai Health System and Hackensack Meridian Health have identified and/or procured resources to help meet employees’ basic, psychosocial, and mental health needs, including child care, transportation, food, and spiritual and emotional support. They have consolidated relevant clinical guidelines, education, and HR information into a “one stop shop,” and regularly share this with staff through all available channels. And they host recurring town halls or similar meetings to provide updates and answer employee questions in real time. We recognize that these strategies may not be easily replicated outside of health systems or large hospitals; however, some relevant materials such as care guidelines can be found online and may be appropriate for use.
Finally, all health care professionals may be faced with difficult decisions as the number of COVID-19 cases rapidly increases across the country. The need to care for an unprecedented volume of seriously ill and dying people under conditions of scarcity can lead to moral distress and burnout. One of the most protective actions all health institutions/organizations can take is to establish a clear, system-wide plan to allocate resources that is based on widely accepted legal and ethical principles. No professional—especially palliative care clinicians—should make these decisions as individual judgments. Every state has different regulations and laws governing decisions to withhold or withdraw various life support technologies. The state’s Department of Health and the legal services office in your organization can provide guidance.
Team and Individual Stress Mitigation Strategies
While there are legitimate problems with using ‘war’ as metaphor, including in the context of this pandemic, the circumstances palliative care teams are facing have some profound similarities to those on the front line in combat. Therefore, while conducting research for this blog, we interviewed several health care and military experts on strategies to limit the negative mental impact of fighting COVID-19 (see "Acknowledgements" below). The following quotes deeply resonate with what health care workers are up against, particularly when the strategies move to “survival.”
Finding time to make life feel normal was very important in a combat zone . . . [feeling] a semblance of normalcy in a long-term period of chaos is so important to reminding yourself that you’re a human being.
Survival depends on the people around you, who you are in the trench with. You get strength from each other.
Little things become ‘adaptability Band-Aid’s’ that can cultivate resilience.
While reviewing the strategies, keep the following considerations in mind (and apologies for the clichés):
- Although no one knows the duration for sure, caring for patients and families with COVID-19—and its aftermath—will be a marathon, not a sprint.
- If we do not care for ourselves, there will not be anyone left to care for the patients. We must take the time to recharge for ourselves, and come together as teams to take care of our colleagues.
- Wellness is an individualized concept. Not all strategies discussed herein will work for everyone. Identify 1-2 that will work best for you, but do not forego the basics of eating, sleeping, and hygiene
Although the window for preparation is closing rapidly as the number of confirmed COVID-19 cases grows, there may still be an opportunity to be proactive, depending on the palliative care team’s location and patient volume. The best thing palliative care leaders can do to preserve the wellness of their teams is to create structural boundaries that will limit overextending providers later on:
- Work with organization leadership on where palliative care will be maximally effective.
- Set concise, actionable criteria for triaging the most appropriate patients for your services. This is particularly critical for smaller programs that might have one physician or nurse practitioner, and are then suddenly called to staff an entire hospital, ED, or ICU.
- Think “outside the box” regarding care delivery. Should you embed staff within a certain unit? Set up a peer-to-peer and/or patient-facing telemedicine palliative care hotline?
- Understand what “stretch” case load your team can accommodate.
For larger programs, we suggest developing a strategy for how to channel COVID-19 response-related information. One program created a centralized email inbox monitored by key personnel. This not only ensures that communication is systematically received, but also limits the amount of “noise” that team members are subject to.
If time and resources allow, it may be worth exploring if there are any opportunities to increase the capacity of your nonpalliative care specialist colleagues in communication and basic symptom management. CAPC is providing free access to relevant courses in its COVID-19 toolkit. That said, some teams have reported that once COVID “arrives,” it is too late for this approach.
Beyond proactively structuring the palliative care program for a COVID-19-specific response, revisit and reinforce existing strategies for team health. These include defining the team’s mission and culture; building resilience and team health into the team’s processes and strategic plan; fostering connection and communication; and celebrating joy and sharing grief. See CAPC’s toolkit, Building and Supporting Effective Palliative Care Teams (particularly “Team Health and Resilience”), for more information.
For individual professionals, it is a good time to become familiar with available mental health resources (see the list of numbers under the section, “Danger Signs”), potentially establishing a relationship with a provider, or developing an action plan with your existing provider.
As the number of COVID-19 cases increase, palliative care team leaders should create or expand opportunities to reduce isolation among staff, even virtually. Standard team meetings should include new “check points,” including embedding moments of pause for relaxation, breathing, or other mindfulness practices. It is also helpful to periodically start meetings by checking in with each team member about how they are doing, potential concerns with loved ones, family illnesses that need navigation, child care issues, or modifications that need to be made for the next week. This reminds the team that their ultimate responsibility is to themselves and their loved ones, and that this pandemic does not strip them of their identity or needs.
Many programs have established recurring drop-in faculty and staff support sessions, led by social work and/or spiritual professionals on the team. Some spiritual leads have circulated non-denominational prayers that can be used for both patients and the individual provider. (Reminder: since social workers and chaplains often default to providing emotional support to the team, so they must make sure to have their own outlet.) And one program recently established a “Departmental Pause to Remember”—a short weekly memorial service for staff to reflect and honor those who have been lost.
Program leads should also set aside time and space for debriefing particularly traumatic incidents. The clinical stress debriefing approach can provide a useful frame for both allowing providers to discuss their experiences while also incorporating the facts of the situation.
Programs can establish formal buddy systems that enable peer-to-peer connections between staff, or individuals can seek out a buddy directly. This person does not need to be a mentor, but rather someone who directly understands the conditions in which the other is working and with whom they can be vulnerable. Buddies should get into the practice of regularly checking in on each other, as they go to work or decompress after a shift. Relatedly, small palliative care teams should identify a “sister team” to periodically check in. These connections can be in or out of the health system or organization. If unable to locate another program, national organizations like CAPC, AAHPM, and HPNA provide discussion platforms and office hours that already exist. CAPC has opened COVID-19 Virtual Office Hours to anyone seeking connection throughout the duration of the pandemic.
Team leaders should reinforce the expectation that time off on the schedule is time off (except in extreme emergencies), and individuals should do their best to adhere. During a crisis, brains can enter “flight, fight, or freeze” mode and people might find it scary to disengage, lest they miss something. But this means no time to decompress and recharge, when finding times of normalcy is essential for sustainability in the long haul. We suggest engaging family and friends to help hold oneself accountable for carving out non-work time.
As circumstances with COVID-19 become more stressful, individuals should communicate anything—particularly clinical gaps—that is causing undue distress to their supervisor(s). Team leaders may have tools and/or be able to identify creative solutions to address needs; for example, exploring options to procure cameras so that staff can visualize their patients, despite a solid door. Even if the gaps remain unfilled, sometimes the act of trying to improve care can help mitigate feelings of distress or inadequacy.
Finally, avoid unhealthy coping mechanisms—whether junk food, tobacco, alcohol, drugs, etc. Individuals should forgive themselves if they do indulge, but then make sure to find their way back to healthful strategies
For this section, we are speaking directly to you—the individual health professional reading this piece.
Caring for your patients, their families, and your colleagues may take every reserve that you have, and no one knows when this pandemic will end. After a certain point, you may enter “survival mode.” Getting through the days and weeks to come will require lowered expectations—just keeping your head above water.
If survival is where you find yourself, please remember that you are not alone. Many people beat themselves up for not coping perfectly, and then enter a downward spiral of negative thoughts. Given the immensity of the situation, simply doing the next right thing is the best many of us can hope for. Anxiety and grief in a global pandemic is an appropriate response. And under pressure, many of us are more resilient than we give ourselves credit for. Veterans noted that part of what kept them going was that there was no other option.
Beyond this, the idea of ‘self-care’ may seem impossible right now, but even in survival mode, the basics (ADLs) are non-negotiable: eat (as healthily as you can, but do what you need to do), hydrate, and sleep. Take a shower; walk if you can. Avoid alcohol or illicit substances.
Then, keep looking for moments of mindfulness. Maintaining an orientation towards the present can help keep you grounded when you start spinning in your mind. Some suggestions include:
- Remember that you are alive—that there is breath and a life force in you; this can be as simple as a single deep, calming breath.
- Literally shake your body out. Our bodies can store trauma and intense experiences, which the simple act of shaking can release (see the work of Peter Levine and Bessel Van der Kolk).
- On your way to work, set an intention for the day; e.g., “Today, I am going to lead by example” or “Today, I am going to make someone smile.”
- Find opportunities for gratitude; e.g., the patients being extubated and discharged today, the way your team is coming together. One veteran noted that, while in combat, the people around him were the only thing that kept him going, and remained grateful for their existence even decades later.
- Return to your values and purpose—remember why you got into this work in the first place, and why you are here doing this.
There is some research to suggest that your perception of stress can contribute to the physical impact it has. To the extent that you can, re-frame your physiological response in a way that is positive, i.e., your body is helping you rise to the challenge, it could support longer-term resilience.
And finally, do not work beyond a certain threshold. One program said the absolute maximum is six days of consecutive work. An employee must stop after that. And again, time off must be time off, even if that looks like spending the entire day in bed.
Here are some additional resources on this topic:
Acknowledging that the threshold for stopping is much higher during this unprecedented crisis, there may come a time when it is absolutely necessary to stop. Everyone should know at this point, but it bears repeating: DO NOT GO TO WORK IF YOU ARE EXHIBITING SIGNS OF ILLNESS.
Otherwise, the symptoms of burnout can be complex and may not look the same in everyone. However, experiencing one or more of the following either to an intense degree or over a sustained period of time should be a warning sign:
- Sadness, depression, or apathy
- Easy frustration
- Blaming of others, irritability
- Lacking feelings, indifference
- Inability to focus
- Isolation or disconnection from others that impacts your relationship to a troubling extent (while it is normal to be more irritable with loved ones, it is worth noting if you are lashing out, or finding yourself nearing emotional or physical abuse)
- Inappropriate humor, such as using gallows humor with patients and families
- Poor self-care (hygiene)
- Tired, exhausted, or overwhelmed; alternately, insomnia but then not feeling tired
- Feeling like:
- A failure
- Nothing you can do will help
- You are not doing your job well
- You need alcohol/other drugs to cope
- Thinking unsafe thoughts, such as looking for physical or emotional scapegoats (e.g., “If only something could happen to me, then I would not be well enough to work”), or considering self-harm
If the above feel familiar to you, you may be experiencing true and sustained burnout; you must press pause and seek help. While most health care professionals will feel some degree of guilt if they do not “show up,” extended time in this state risks doing significant harm—not only to your patients and colleagues, but also yourself and your loved ones. This may be where the “buddy system” can be incredibly helpful, since they may recognize changes in you before you recognize them in yourself.
A note to early-career health professionals: to address significant workforce shortages, governments and employers have moved up the timeline for certain providers to be able to practice. This is critical, and we are so grateful to you for your willingness to serve. That said, you must take extra care to monitor for the signs and symptoms of burnout, and seek help early and often. When this pandemic ends, you will remain the future of health care in this country.
There are many free mental health resources that health care professionals and individuals can access:
- Disaster Distress Helpline 1-800-985-5990, or text “TalkWithUs” to 66746
- National Suicide Prevention Lifeline 1-800-273-TALK (8255)
- SAMHSA National Helpline 1-800-662-HELP (4357)
- National Institute of Mental Health Crisis Text Line 741741 (text “HELLO”)
- National Alliance on Mental Illness 1-800-950-6264
- Veteran Crisis Line 1-800-273-TALK (8255) and press 1, or text to 838255
- Some state health departments are establishing volunteer networks of local mental health professionals (e.g., NY Mental Health Electronic Help Center); visit your state health department website to learn more
Looking to the Future and Gratitude
Your ability to recover from this pandemic will depend on many factors, including personal resilience, any direct impacts on yourself and loved ones, and external systems and structures that will change in untold ways before it is over. There will eventually be a time to examine issues of post-traumatic stress (or growth) and moral injury, and how one might begin to cobble oneself back together. Suffice it to say that many will need the support of mental health professionals to address lingering depression, anxiety, and psychological distress—but recovery is possible.
In the meantime, we hope that the following message will bring you some comfort. The response to this pandemic has brought out some of the best in humanity, ranging from the work you are doing on the frontlines, to people caring for each other in ways small and large. And not only will this end, but the gravity of the pandemic has exposed gaps in the health care system that impact populations across the board. This will provide a strong foundation for a much-needed systems change. We are already seeing significant changes in how health care is delivered, from new technologies, to streamlining of burdensome requirements at an accelerated pace. The learning from this could result in lasting transformation.
And finally, we want to thank you. Your heroism and grace transcends this pandemic. As this nation’s health care system battles chaos and buckles under the weight of need, you are the ones who make the time to bring peace—through managing unmanageable symptoms and through clear and honest communication, amidst so much uncertainty. You are the light in the health care system that ensures that patients and families do not have to walk this journey alone. Without you, the fight against COVID-19 would not be possible.
While they might already be hearing this, there is a reason—beyond money—that people go into health care. Hopefully that calling can sustain them and allow them what they need to be resilient. Because it is unprecedented to have things like refrigeration trucks for bodies. As someone who doesn’t have medical know-how, I’m so grateful for every person in the health care system who put in that time to be able to meet the need today. I’m grateful for everyone from the palliative care teams, to the phlebotomists, to the janitors—I’ve long said that hospitals would shut down without their janitors, because infection control—ESPECIALLY in this moment—is so big. I’m grateful for everyone in the system.
- Beckman AL, Gondi S, Forman HP, Health Affairs: “How to Stand Behind Frontline Health Care Workers Fighting Coronavirus” (link)
- Centers for Disease Control and Prevention: “Emergency Responders: Tips for Taking Care of Yourself” (link)
- U.N. Office for the Coordination of Humanitarian Affairs, Inter-Agency Standing Committee on Mental Health and Psychosocial Support in Emergency Settings: “Briefing Note on Addressing Mental Health and Psychosocial Aspects of COVID-19 Outbreak” (particularly pp. 15-16) (link)
- U.S. Department of Health and Human Services: “A Guide to Managing Stress in Crisis Response Professions” (link)
- U.S. Department of Veterans Affairs: “Managing Healthcare Workers’ Stress Associated with the COVID-19 Virus Outbreak” (link)
Thank you to the following people who contributed their expertise and reflections to inform the writing of this blog:
- Edward Boone, Veteran, US Army
- Reverend Sarah Caine, MDiv, Chaplain, First Lieutenant
- Katie DeMarco, DNP, MSHS, MSN, APN-C, FNP-BC, ACHPN, Clinical Supervisor, Institute of Pain and Palliative Medicine, Hackensack Meridian
- Amy Frieman, MD, MBA, FAAHPM, Chief Wellness Officer, Hackensack Meridian
- Howard Hering, Veteran, US Army
- Adrienne Kilby, LCSW-C, Geriatrics Social Worker
- Rabbi Edith M. Meyerson, DMin, BCC, Assistant Professor, Brookedale Department of Geriatrics and Palliative Medicine