Health workers battle COVID-19 and burnout

For Colleen McGuinness, a registered nurse in the critical decision unit of the emergency department at UMass Memorial Medical Center, the hardest COVID-19 moment came while setting up a call for a comatose patient and her family.

“I entered the patient's room and started dialing up the video call,” McGuinness wrote in an email. “As I was dialing, I turned to the patient, and she took her last breath right in front of my eyes. I immediately stopped the call, because I knew if I witnessed my loved one pass like that, it would be traumatizing to witness.”

In an interview, McGuinness elaborated on her experiences

“COVID for me was the most terrifying experience I ever had in my life,” McGuinness said. “It was just awful watching people every day take their last breath. ... It was a war zone.”

The war continues. 

Meanwhile, the frontline troops are tired: emotionally and physically burned out from long shifts, changing protocols, extra work, donning and doffing extensive personal protective equipment, and the constant fear of bringing a deadly virus home with them. 

“It’s actually kind of surreal,” Karen Richard, a registered nurse with HealthAlliance in Leominster, said. “It’s exhausting on a lot of different levels. It’s taking an emotional toll on you, and it’s taking a physical toll on you, and you come home and try to put it out of your mind so you can be a good parent and good partner...but it’s really difficult.”

That toll is documented by turnover.

“On a phone call earlier, a nurse manager who’s worked here 35 to 40 years said she’s never experienced turnover like she has over the past year,” said Christopher Navis, a registered nurse and director of clinical practice and patient safety at UMass Memorial Medical Center.

A hospital spokesman said the hospital does not release information on personnel actions, so it’s difficult to say how many employees have left due to COVID-19. 

But anecdotal examples are easy to find. 

Maureen Horan, a registered nurse at UMMC, said 20 people in her intensive care unit, including personal care assistants, nurses and secretaries, have left since March, choosing a transfer, retirement or early retirement.

“Staff has not even come back to work — they just called and said not coming back,” said Martha Diaz, an RN at UMass Memorial. “The degree of mental, physical and emotional exhaustion among staff has gone up, absolutely. ... I try to be optimistic and find a solution, but this one I’m having trouble with.”

At St. Vincent Hospital, more than 100 nurses have left the facility for other hospitals with better conditions, pay and benefits, according to the Massachusetts Nurses Association. 

This turnover has led to nurses reporting regularly filling in on extra shifts and being “mandated,” or told to stay beyond their shift to ensure appropriate staffing levels. 

And still the number of patients grows.

“We’re burned out because we’re scared we can’t take care of patients safely,” said Heather Zenkus, an RN on the dedicated COVID Unit at St. Vincent Hospital. Zenkus was among hundreds of nurses picketing for more staffing and PPE on Tuesday. “That’s why we’re out here today.”

COVID-19 and constant fear

UMass Memorial Nurse Bernard Waigi has a routine when he comes home from a shift on a COVID-19 floor.

First, he strips off all of his work clothes in the basement. Then he goes to a designated bathroom to shower. Then he cleans the bathroom and dresses in clean clothes. And then — and only then — will he hug his three little children. 

“Every time I go to work I’m always afraid and praying that I do enough to keep myself safe and my coworkers safe, and it’s so emotionally draining because you don’t want to bring it back to the family,” Waigi said.

Other nurses described similar routines.

Richard said that nurses have been wiping shoes and equipment down with bleach before going home; keeping extra shoes in their car (Waigi also doesn’t let his kids in the car he uses to commute to work); stripping their work clothes off in the garage; washing clothes separately from their family and staying in hotels. 

“One of the nurses I work with ended up staying in an RV on her parents' property because she was concerned about bringing it home,” Richard reported. “I think all of us have had some family members or extended family members who don’t want to go near you, so you’re almost ostracized sometimes. It’s such a bizarre situation.”

The routines reflect what nurses described as one of the chief stressors of COVID-19: fear.

Tener Veenema, a contributing scholar at the Johns Hopkins Center for Health Security and a professor of nursing and public health at the Johns Hopkins Bloomberg School of Public Health, noted COVID-19 is a “novel coronavirus” that is airborne and easily transmissible. 

The unknown

“In the first wave there were far more unknowns than knowns,” said Dr. Steven Bird, professor of emergency medicine at UMass Medical School and clinician experience officer at UMMC. This included such important unknowns as how easily the virus was transmissible and what treatments worked or did not work. Plus, there was no immediate hope of a vaccine.  

In other words, this wasn’t a flare-up of a disease that had been researched, for which treatments had been tested and approved, and that the general public had heard of. This was something altogether new - and dangerous.

“You are dealing with patients who are very scared of this disease,” Waigi said. “Many don’t know how they got it, you have family members calling and trying to visit when they can’t."

Registered nurse Diaz said that this fear and uncertainty has made it difficult to care for patients, contributing to burnout.

“Part of the stress and burnout for nurses is dealing with the uncertainty,” Diaz said. “We don’t know yet what the long-term effects of this illness are going to be for those who are fortunate to survive and for the other diseases, we do have pathways, clinical pathways and algorithms we follow, and now we’re just starting with the algorithms (for COVID-19).

That uncertainty also manifests in what nurses described as a constantly changing work environment — procedures and policies that can change by the day, different protocols depending on supervisors, changing numbers of patients and staff — all of which adds to caregiver stress.

“Most people go to work and they kind of know how their day is going to go, and we don’t have that anymore,” Richard said. “Now, it’s kind of like prepping yourself to go to battle because you walk into work and you don’t know what to expect.”

This uncertainty is gearing up again as another wave of COVID-19 arrives. While nurses and hospital leaders generally agreed that they have a better sense of how to effectively treat the virus this time around, nurses were less sure that wave two would be any easier than it was in the spring. 

“I think that when it first came, there was a lot of uncertainty about procedures and how to do this and how to do that, but we now have the whole PPE thing down, we know kind of the things that you need to have with you when you go into the room so you don’t have to go back out and come back in, and the procedures if you have to transport a patient for a test or discharge a patient with COVID, we have that worked out,” Richard said. “But that being said, this is worse, we are seeing a lot more positive patients ... it seems to me, in my opinion, that it’s worse this time, there are more patients this time.”

There also seems to be less goodwill.  

The rally to defeat COVID-19

When COVID-19 first arrived this spring, it found a community mobilizing to fight it.

Sewing groups made masks. Schools and businesses donated PPE. It seemed like there was a race among biotech companies, manufacturers and researchers to find the best way to produce ventilators and other medical equipment. In fact, there was such demand for PPE donations and volunteers that the state designated an online portal to help.

“It was really refreshing and frankly, nice, when in the first wave there was an outpouring of support for health care workers,” Bird said. “People made cards — we still have them around the hospital — people donated PPE, donated food, and I think that health care workers really felt appreciated because we were putting our health at risk as we were helping patients.”

It has not continued.

“Now that has all but disappeared, and I think that a lot of caregivers now are feeling like they are taken for granted,” Bird continued. “We’re beginning to see increasing amounts of violence again to patients and families, which was unheard of or unthinkable during the first wave.”

Moreover, there is less staffing help.

Unlike in the spring, hospitals are not shutting down most clinics or canceling elective procedures. Thus, the nurses and PCAs that were freed up and able to be redeployed to COVID units are no longer available in many cases, nurses said. 

“We don’t have as much help as we did the first time, and it’s very difficult, people are tired,” Horan said.

Moreover, with the highly infectious nature of COVID and the requirement of PPE when in contact with any COVID-19 patient, nurses said many ancillary services have been discontinued. 

PPE repetition

“It seems like the only people who can go into the rooms are nurses and PCAs, because they want to save the PPE, no one else can go in there,” said Diaz. “So we have to transport patients, have to strip our own beds, bring in our own trays, we’re losing transport, maintenance, dietary, a lot of the support system.”

And since donning and doffing PPE is so important and yet time-consuming — Richard described her PPE as consisting of a gown, two pairs of gloves, booties, either an N95 mask and eye protection and a cap over head, or a full face respirator providing eye protection — nurses make sure to “cluster” their care. 

“You want to limit your exposure in the room, so you cluster your care, and try and do as much as you can do when you go in there so you don’t have to go in there as often,” Diaz said. 

But it’s tiring, hot (several nurses noted that the negative-pressure rooms of COVID-19 patients are hotter than normal), and uncomfortabe.

“It’s a lot of plastic,” Richard said. “But we will put that stuff on for the 500th time that night if you think they need something.”

Inevitably, something comes up.

“The temptation to run into a room real quick - just put a mask on, because you just have to press a button - that happens all the time,” said Horan. “But you can’t do it, you have to protect yourself.”

Hospital and response to stress 

You also can’t do it because Dr. Kimi Kobayashi, chief quality officer at UMMC, keeps a close eye on the PPE of nurses and other frontline caregivers. 

“I think I am really worried about post-traumatic stress disorder and caregivers,” Kobayashi said in an interview last month. “ ‘PPE Fatigue’ we call it - when caregivers are unable to keep their vigilance up and we see it in less PPE adherence.”

Navis, the director of clinical practice and patient safety, also has his eye out — starting a PPE Promotion Program or “P3 Program” where nurse education safety specialists reward caregivers for proper PPE adherence with free coffee cards and stickers.

“We started doing rounds, visualizing what we are doing for PPE and how compliant we are, and what are the barriers,” Navis said. “Right now, it’s been a very positive program, and we’ve gotten really good feedback and people are happy to see we’re out there and taking this very seriously to make sure everybody has what they need to protect themselves.”

But PPE Fatigue is a symptom. Addressing the underlying issue of burnout or PTSD is, as Navis acknowledged, “a really difficult thing to navigate.”

“We have people that are working within the organization and taking care of very sick COVID-positive patients, and they go home and there’s nothing normal with their family life,” Navis said. “It’s just all around you.”

But Navis said UMMC is trying. 

Administrators are talking to staff, have a weekly publication to share resources available such as the hospital’s Employee Assistance Program, and the hospital promotes healthy lifestyle choices for employees, he said.

Bird, the chief wellness officer, added that the hospital has set up a “Caring for the Caregiver” committee. The idea is to learn from the first wave about how to best help with stress, potential burnout and mental health issues. The committee has started a peer support network, offers resources for child care, as well as given out free coffee.

“It seems like a small token,” Bird said of the coffee. “But it was really well-received and we’re looking at redoing that.”

St. Vincent Hospital

St. Vincent Hospital did not respond to questions for this story but issued a statement.

“From day one of this pandemic, we have prioritized the safety and well-being of our staff, and we remain focused on that,” a hospital spokesman said. “We have the necessary resources, capacity and supplies in place to safeguard our employees, and appropriately care for our patients. Our hospital is safe, and we encourage people not to delay care.”

But while Bird said nothing was off the table for the Caring for the Caregiver committee, he acknowledged there is no silver bullet to eliminating caregiver burnout.

“I wish there were one, two or three things we could do that would definitely have an impact, but healthcare is complicated and UMass Memorial Healthcare is varied,” Bird said. “Creating a single-best solution is not likely to be fruitful.”

Nurses interviewed, however, had a common suggestion.

“One thing leadership can do is ask the staffing what they can do rather than just arbitrarily make changes,” Diaz said, noting that her unit is in the midst of being changed to a surveillance unit. “What they need to do is communicate with staff rather than just each other through their boardrooms and their zoom meetings.”

Horan agreed. 

“Come down to the troops and ask what they need and give it, ask ancillary staff, PCAs," Horan said. 

She was among several nurses who commended PCAs as the unsung heroes in the pandemic. 

“Help is really what we need, the staffing,” Horan continued. “My manager is trying, she is hiring people, but they need time to get trained.”

St. Vincent nurses, who are in the midst of contract negotiations they hope will lead to more staffing, said the same.

“I’m hoping management begins to not just talk at us, but listen and make some changes that are collaborative, we want them not only to listen but to hear us,” RN Dominique Muldoon said. “We want them to hear us when we say to them we cannot take care of patients in this fashion and we need you to step in and make some changes to help us. We need help.”

The hardest calls…

But almost unanimously, nurses interviewed said that the hardest part of the pandemic involved the circumstances McGuinness described earlier: the final calls.

“Not being able to be with someone, not being able to say goodbye, we know that is so difficult,” RIchard said. “We know full well that that could be our family member in that bed, and you don’t forget that.”

Indeed, they don’t. And they won’t for a long time.

“It has been awful, sad, and depressing,” said Lori Pannozzo, an RN in the ICU at St. Vincent Hospital. “I truly didn’t realize it affected me until (wave one) was over."

In fact, the moment she realized she was burned out and experiencing post-traumatic stress disorder came not in the hospital but at home watching a television show. 

A nurse was facetiming with the wife of a dying COVID-19 patient because the wife couldn’t visit the hospital. 

“I started bawling,” Pannozzo said. “That incident was dead on.”