The Exacerbation of Burnout During COVID-19: A Major Concern for Nurse Safety.

The United States and many other countries around the world are experiencing a pandemic that has not occurred to this extent since the 1918-1919 Spanish Flu. The virus has created a public health crisis and led to many challenges for health care providers and health care systems. As I write this column, many health care providers are on their way to New York to assist the nurses, respiratory therapists, and doctors who are exhausted there. The Federation of State Medical Boards has made a joint announcement that they are working together to ensure that they “will continue to explore ways to support qualified health care professionals as they respond to this evolving national emergency.” That statement highlights the immense need for crossing state lines for doctors, nurses, pharmacists, and other health care providers during this national emergency. Thousands of other nurses, doctors, respiratory therapists, and so many others are working non-stop to care for COVID-19 patients, while concurrently determining how to meet the needs of their other patients. As fellow nurses, we have lived, shared, or heard these experiences.

However, the reality of the health care environment before the arrival of COVID-19 presents some concerns. The frequent discussion in the media has focused on the number of ventilators and hospital beds, but often lacking in the discussion is the number of available nurses, doctors, respiratory therapists, and other qualified health care providers. We should be concerned about not only the number of qualified professionals, but also the number of “healthy” individuals who can care for sick patients and operate these complicated ventilators. In regard to the discussion of healthy, I am implying mentally and physically, not “burned out.”

Burnout has been recognized by the World Health Organization and is only related to the workplace. Additionally, burnout is triggered by extended workplace stress which is not managed effectively. Burnout is a stress response, much like post-traumatic stress syndrome and is a concern for nurses. In fact, just in July 2019, The Joint Commission released a Quick Safety Advisory of Combating Nurse Burnout in response to recent studies on increasing burnout among nurses. Their advisory highlighted that 15.6% of nurses reported burnout and that emergency room nurses were at a higher risk. Furthermore, nurses had reported in surveys that only 5% of health care organizations were assisting staff with burnout. The Advisory presented multiple suggestions to health care organization's leadership and management teams to develop mindfulness and resilience in their employees. The Joint Commission also noted that organizations needed to remove barriers to nurses' work flow, staffing, and workplace environment concerns. This Joint Commission advisory was sent to organizations 6 months before COVID-19. Hopefully, organizations had started some resilience programs and addressed some of these concerns.

The association between suicide and burnout is unknown; however, it has been understudied among nurses. A recent study was completed and published recently in the Archives of Psychiatric Nursing. The study, based on data from 2014, found nurses had a significantly higher rate of suicides. Female nurses had a suicide rate of 11.97 per 100,000 person-years, and male nurses had a suicide rate of 39.8 per 100,000; both were significantly higher compared with women and men in the general population (7.58 and 28.2 per 100,000 person-years, respectively, P < .001). Retired nurses and nurse anesthetists were at a higher risk than the general population. Additionally, nurses were statistically and significantly different compared with the general population with mental health history, treatment for mental health problems, having previous suicide attempts, leaving a suicide note, and having physical health problems. Unlike the general public, nurses were most likely to use pills as the method of suicide. The most common medications used were benzodiazepines and opioids.

So as COVID-19 impacts nurses, we may expect nurses to be at a higher suicide risk. Organizations should be considering this possibility and consider ways to assist health care workers dealing with burnout and feeling intense stress from COVID-19. Some organizations are already starting support programs. For example, weekly video conferencing sessions are offered for peer groups to discuss various issues affecting them. Some of the discussion questions include the following: What worries you? How are you feeling? What are you experiencing now? How are you processing all of this? Zoom has been used in these formats. The following tips for these sessions have been offered by one organization. First have a moderator, then ask everyone to turn on their cameras (if possible). Open Zoom chat function, so participants can mention items, and moderators can discuss with the group. If more than 15 people are participating, then consider using Zoom breakout rooms. Acknowledge each person as they join the Zoom meeting. There are also some tips for the moderator. These include the fact that psychological safety is key. It may take time for participants to open up. Resist the urge to “fill the silence” if there are lulls. Let conversations unfold naturally. Try to focus more on emotions rather than clinical details or how to fix the problem.

Now that COVID-19 is here, what should frontline health care providers do to decrease their risks of burnout? The stress comes from pressures regarding procedures that must be followed: constant awareness and vigilance regarding infection control procedures; physical strain of protective equipment (dehydration, heat, and exhaustion); and physical isolation (cannot touch others). Be alert for burnout signs: irritability, anxiety, disengagement, exhaustion, and low mood. , If you start to notice these signs, then take some time for breaks. Even short breaks of 10 minutes are helpful. Health care workers need to understand there are situations that are out of their control. , Kelly Blasko, the clinical psychologist and lead for mobile health clinical integration at the Defense Health Agency Connected Health, even recommends using your watch if possible as a reminder to take these breaks. Keep your workplace positive by good teamwork and positive reinforcement. Here are a few applications that can be used to decrease stress. Virtual Hope Box contains personalized tools to help you with positive coping, through relaxation, distraction, and connecting to others in a time of need. Breathe2Relax teaches diaphragmatic breathing to de-escalate stress. Provider Resilience App offers self-assessments and stress reduction tools along with a dashboard to track your daily resilience rating. Headspace is a meditation and sleep app that can have a positive impact on health professionals' personal and professional lives.

Nurses are at the forefront of this COVID-19 crisis, as they are with many health care issues. Nurses and its leaders must also be aware that there are physical and emotional needs that need to be handled. Nurses must learn to make their personal health needs more of a priority as well. The American Nurses Association started a campaign that any nurse can join. Research has shown that nurses tend to be less healthy than most Americans. The goal is to improve nurses' personal wellness in five areas: nutrition, rest, quality of life, physical activity, and safety. The Healthy Nurse, Healthy Nation found that 70% of the nurses put their patient's safety, wellness, and health before their own. Twenty-four percent (24%) of the nurses reported their general health as fair to poor. When asked about if they got the emotional support they needed, 24% responded always, and 38% said usually, leaving 36% with needing more emotional support. The nurses were also asked about their top 10 work hazards, and 79% reported work stress. Stress can be managed.

Now is the time to support health care providers. We can each do this in a variety of ways. Be alert for burnout in yourself and your peers. Those health care workers who were on the frontline should expect a period of readjustment. Here is a link to a PDF for health care providers: https://www.ptsd.va.gov/covid/COVID19ManagingStressHCW032020.pdf. Together we will get through this health crisis.