Protecting Healthcare Workers: Caring for the Caregivers

Working in health care has always had its risks and challenges: exposure to infectious diseases, long hours, shift work, back injuries, violent physical assaults and the emotional toll of witnessing human suffering. These demanding working conditions exact a toll of those providing direct patient care (physicians, nurses, therapists, technicians), but also affect emergency responders, long-term care staff, public health workers, and others who provide support services in our nation’s health care organizations.  [Just now recalling my college summer job in housekeeping at a local hospital, where I saw pain, sadness, and worry in patients’ rooms on a daily basis.]

The statistics bear that out. OSHA reports that more workers are injured in the healthcare and social assistance industry sector than any other. This industry has one of the highest rates of work related injuries and illnesses and it continues to rise.

But even though healthcare has always been a high-risk occupation, it wasn’t until the early 1990’s during the AIDS epidemic, that OSHA finally issued its bloodborne pathogens standard. Aside from the short-lived COVID-19 emergency temporary standard, issued in 2021, the agency has so far done little else to address hazards in healthcare, although OSHA is progressing on standards to protect healthcare workers from infectious diseases and workplace violence.

The COVID pandemic has only exacerbated health and safety challenges faced by healthcare workers. Studies and surveys have found high levels of stress, anxiety, exhaustion, and burnout in health care workers during the pandemic (for example, see here, here, here, here). These impacts have enormous costs. One study estimated the societal costs of health care worker burnout in the U.S. to be $4.6 billion!  Our providers are worn out.  And worn out, stressed out exhausted healthcare workers cannot be good for patients.

Adding to the burnout were the thousands of healthcare workers who died from COVID-19, many because of the shortage of adequate personal protective equipment, especially N-95 respirators, and the CDC’s errant recommendation that surgical masks would adequately protect healthcare workers.

Adding to that tragedy is the fact that we no accurate count of the number of healthcare workers who died from exposure to COVID-19 in the workplace.

A  national survey of clinical and non-clinical staff conducted in the early days of the pandemic found the following:

Proportion of Respondents Reporting Burnout, Intent to Leave, and Work Overload by Role Type*

*Table 2 from Rotenstein LS, Brown R, Sinsky C, and Linzer. M. The Association of Work Overload with Burnout and Intent to Leave the Job Across the Healthcare Workforce During COVID-19. Gen Intern Med 38(8): 120-127, 2023
**Non-clinical staff included housekeeping, administration, receptionists, schedulers, lab or X-ray technicians, finance, food service, IT support, and researchers without a clinical role.

The public health workforce has also experienced significant losses. Data from a nationally representative survey of state and local government public health agency workers in 2021 revealed that approximately 40% intended to leave their jobs within the next five years. Of those, 76% began thinking about leaving since the start of the COVID-19 pandemic.
Clearly, the COVID pandemic further strained and exhausted our healthcare and public health workers, and it has taken yet another toll on their mental health (see here, here). The tragic death of Dr. Lorna Breen, medical director of the emergency department at New York-Presbyterian Allen Hospital, was a window into the immense pressure and demands faced by our health care providers in the onslaught of the pandemic.

Dr. Breen died by suicide on April 26, 2020 (read more about it here, here, here). After contracting and recovering from COVID herself, Dr. Breen returned to her ER and hospital overwhelmed with incredibly sick patients, limited personal protection, insufficient supplies (including oxygen), and not enough help. Though depressed and despondent over the situation, she did not seek help for fear that it would impact her career It was a wake-up call that led to the creation of the Dr Lorna Breen Health Care Provider Protection Act (more here, here). Signed into law in 2022, the Act has funded $103 million across 44 organizations to implement evidence-informed strategies that reduce and prevent suicide, burnout, mental health conditions, and substance use disorders.  Read more about what the grantees are doing here.

The American Journal of Public Health has just published a supplemental issue entitled Health Worker Mental Health: From the Current Crisis to a Sustainable Future.  The special issues was conceived and sponsored by NIOSH and the CDC, with support from the American Rescue Plan Act which included funding for research, interventions, training, and education in response to the mental health crisis unfolding due to the COVID-19 pandemic.

The issue includes articles that explore trends in mental health and well-being, evidence-based interventions and call for additional research, leadership and change at the organization, state, and national levels.

Work: A Social Determinant of Health

Employment provides both benefits and risks to working people. As such, work is recognized as an important determinant of health (see here, here, here).  Exhaustion and emotional burnout in our nation’s health care workers certainly takes a toll on their health and wellbeing. It also can impact patient care (e.g., increased risk for medical errors, lower-quality care) and be costly for the organizations that employ them (e.g., absenteeism, turnover; increased insurance costs).

It doesn’t have to be this way. There’s no mystery around the psychosocial work factors that can impact workers’ mental health and well-being; they include excessive job demands, low control over work, harmful supervisory and managerial practices, ineffective or lack of communication, bullying, and incivility (See here, here, here).  And there’s plenty of information on how to create a healthy work environments (here, here, here).  In 2021, NIOSH created a Health Worker Mental Health Initiative to safeguard and promote the mental health of health workers. It includes a 5-part plan to raise awareness of the issue and urge employers to take action, with a focus on primary prevention. NIOSH Director Dr. John Howard and CDC official Debra Houry write about it here.

Empowering Workers: The Union Solution

Forming a union is one sure-fire way to enhance worker health and wellbeing – and improve patient care. They give workers more control over their pay, benefits, and working conditions. Unions collective workers’ concerns and demands and counter the enormous power of employers.  The Economic Policy Institute reports that:

• On average, a unionized worker earns 2% more in wages than a peer with similar education, occupation, and experience in a nonunionized workplace in the same industry. And in states where union density is high, nonunion workers also benefit as their employers must compete to attract and retain the workers they need.
• Union workers are more likely to have better employer-sponsored benefits including health insurance, retirement, paid sick leave.
• Unions improve workplace health and safety and empower workers to report unsafe conditions without fear of retaliation.
• Unions increase civic engagement and have broader community benefits, such as voter mobilization and turnout, and worker-friendly public policy (e.g., minimum wage).

And the U.S. Department of Treasury notes that unions strengthen the middle class and grow the economy at large (see here).

But forming a union has been a struggle for health care workers. Health care systems are notorious for their anti-union campaigns and activities (see for example here, here, here, here, here, here). An aside: take a look at Labor Lab for a union-buster tracker and other useful resources.

Health Worker Mental Health Affects All of Us

Our health care system is under duress and is exacting a huge toll on those who provide and support the delivery of health care and public health services. They are always there for us, and we need to be there for them.

On the micro level, let’s remember their stressful workload and have patience when our providers are running late. And then thank them and their staff for their care. Thank the assistants, housekeepers, and food service workers if you visit a friend or loved one in a nursing home or assisted living facility. And then let’s support their unionizing efforts and advocate for policies, programs, and practices that protect and promote the health and wellbeing of this critical workforce  – in their organizations and at the local, state, and national levels.

We’re not only doing it for them, but for us and our families as well.  The best guarantee of quality healthcare – and we will all be in need of quality healthcare at some point – is healthy, contented healthcare workers.

We need to do a better job.

Addendum: Highlights from Selected Articles

• An early look at what the 44 grantees funded by HRSA under the Dr Lorna Breen Health Care Provider Protection Act are doing to decrease burnout among health workers and trainees (see here).
• An initiative in Virginia resulted in a law requiring the removal of overly broad and invasive questions about health workers’ mental health and past mental health conditions from the  state licensing process for all licensed health care workers (see here).
• A 2022 e-mail survey of registered nurses in Michigan collected information on burnout/exhaustion, thoughts of self-harm, and overall wellness on a scale of 0 to 10.  93.6% of responding practicing nurses reported exhaustion that exceeded the Oldenburg Burnout Inventory scale’s established cut point of more than 2.25. Nearly 10% reported thoughts about self-harm. And the respondents mean overall wellness rating was 6.2, with younger nurses reporting poorer well-being. The article also reports on workplace factors associated with emotional exhaustion and suggests intervention strategies (see article here).
• Behaviors of immediate supervisors and those in leadership positions are associated with worker well-being, safety climate, teamwork climate, burnout, job satisfaction, and intent to leave. Thus suggesting leadership development as a possible primary prevention approach to mitigate health worker stress and optimize work environments. Article presents a leadership development framework (see here).
• Caregiving responsibilities are associated with adverse physical and mental health outcomes.  A secondary analysis of the 2019 California Health Interview Survey (CHIS) found: 1) both US-born and immigrant caregivers were more likely to report severe psychological distress than noncaregivers; 2) the relationship between caregiver and care recipient was not significantly associated with the likelihood of severe psychological distress; 3) proximity to care recipient (i.e., where the care recipient resides) was a key predictor of severe psychological distress among both US-born and immigrant caregivers; and 4) immigrant caregivers were significantly more likely to report severe psychological distress that US-born caregivers. Authors recommend that mental health resources and policies tailor interventions to the specific needs and circumstances of caregivers (see here).
• An initiative in Virginia resulted in a law requiring the removal of overly broad and invasive questions about health workers’ mental health and past mental health conditions from the  state licensing process for all licensed health care workers (see here).

___________

Cover photo by Earl Dotter.