Front-line care workers have been called heroes throughout the coronavirus pandemic. Many of them don’t feel like it.
Instead, they feel besieged and traumatized not only by the suffering and death they’ve witnessed, but by a health care system they believe is showing it doesn’t value them, a disjointed and ineffective governmental response, and members of the public who deny the reality of all that suffering and death.
Tragedy is part of the job for medical providers, but the relentlessness of the coronavirus outbreak is more than most have ever seen, said Nina Wells, a doctor of nursing practice and the president of the Service Employees International Union Local 121RN in Pasadena, California.
“It is the vicarious trauma that is never-ending with this pandemic. And it’s from all angles, not just the disease itself. It’s from the poor management, the lack of supplies, the lack of staffing ― it just goes on and on,” Wells said. “You get up and you do it again, day after day, without any reprieve, without any resources — for the most part — and it’s just mental cruelty.”
There have been more than 6.7 million confirmed cases of COVID-19 in the U.S. and over 198,000 deaths, according to data compiled by Johns Hopkins University. While some of those deaths occurred at home, the rest happened in hospitals, nursing homes and other facilities where doctors, nurses and other staff are the only witnesses to patients’ final, lonely moments.
“You can say we’re ‘heroes’ ― I don’t particularly like that term ― but we’re definitely not treated as such,” said Erin McIntosh, a nurse in Riverside, California.
The mental health effects of the pandemic on health care workers can already be measured.
A Physicians Foundation survey released this month found that 58% of doctors now say they frequently experience burnout, up from 40% two years ago. Half of physicians during the pandemic have had feelings of “inappropriate anger, tearfulness or anxiety,” 30% report feelings of hopelessness, 8% say they have contemplated self-harm and 18% are drinking or using drugs more.
Yet the same survey found that just 13% of doctors have sought mental health care during the pandemic. Not only do health care workers face the same limited access to mental health care services as everyone else, but the culture of medicine creates pressure to not admit to struggling,
Lonely Deaths And Nightmares
McIntosh works as a “code blue” nurse, which means she’s called in when a patient is in serious trouble. In a typical month, she said, her hospital has 30 to 50 code blues. In April, there were more than 70.
“I was just seeing patient after patient crashing and coding. We had a lot of deaths in the hospital and it did affect me,” McIntosh said. “I’m seeing a lot of that in our field, a lot of mental health issues related to what we’ve been put through these last six months.”
In April, McIntosh holed up at a hotel so she wouldn’t risk infecting her family. During that time, she had a persistent nightmare that her husband caught COVID-19 but there was no ventilator available for him. In another recurring nightmare, she said, “I’m hearing code blue after code blue after code blue and I can’t get to the patients. It definitely has a toll.”
One incident has stuck with McIntosh. She intended to pay a brief visit to a COVID-19 patient who appeared to be stable. The woman asked her to stay and talk. She was isolated from friends and family and just wanted some company. McIntosh chatted with her for about 40 minutes. An hour later, the patient died.
“That really hit home with me that not only are these patients dying ― they’re dying alone and lonely,” McIntosh said. “That’s just my one example. What about all these other patients that are in the rooms with closed doors, with no visitors, alone? That’s not a good feeling.”
Health care providers can feel tremendous guilt that they weren’t able to do more, wondering if the huge numbers of patients, inadequate staffing and complexity of safety procedures meant they didn’t get to someone they could have saved if somehow they had been quicker, McIntosh said.
They also carry intense anxiety about getting sick themselves and passing on the virus to co-workers, patients and their own families.
Nearly 1,200 health care workers in the United States have died because of COVID-19, according to a tally from Kaiser Health News and The Guardian. Two of them worked at McIntosh’s hospital; their deaths are the subject of an ongoing lawsuit.
“I have seen so many co-workers fall ill,” McIntosh said. “We all know people that have lost someone.”
Compounding that grief is what McIntosh sees as mismanagement inside the hospital. As in many facilities around the country, personal protective equipment like masks is in short supply at her workplace. Directives from administrators about what safety equipment and procedures nurses should follow have contradicted her training and experience. Her hospital cut back on staff even as the high volume of COVID-19 patients demanded more resources, she said.
“That was just an eye-opener to me and made me feel like, as a nurse, I wasn’t valued. It’s all about the almighty dollar,” McIntosh said.
Meanwhile, she is confronted by people ― including some of her own relatives ― who refuse to believe the pandemic is real or to wear masks, and who want the country reopened.
“It’s a real slap in the face for those of us who have worked day in and day out, tirelessly trying to save lives,” McIntosh said. “That’s easy for people to say, but when you’re there looking at someone’s face, holding their hand, FaceTiming their loved ones ― you cannot know how much that hurts.”
It’s all making her wonder if she can carry on. “When I first became a nurse, my first job, I felt so empowered and so valued because I was making a difference in people’s lives. I don’t know that I necessarily feel that anymore, and I think that’s what a lot of people are feeling,” she said. “Nurses are leaving the profession in droves.”
The pandemic has merely worsened what was already a “crisis” of health care worker burnout, said Aisha Terry, an emergency physician in Washington, D.C. Terry also serves on the board of directors of the Irving, Texas-based American College of Emergency Physicians.
Research before the pandemic found that as many as half of doctors reported being burned out, and other studies found up to 20% of nurses and emergency physicians experience symptoms of post-traumatic stress disorder. The rate of suicide among doctors is more than double that of the general public. The Physicians Foundation survey found that more than one-fifth of doctors know a fellow physician who died by suicide.
Matters have gotten worse half a year into a pandemic, Terry said, but the underlying reasons that health care workers suffer from mental health problems have persisted for a long time.
“The problem is environmental and systemic,” Terry said. “Health care is increasingly business-oriented and profit-driven, which inherently competes with patients’ best interests and creates ethical conflicts for physicians.” Knowing that financial and other constraints can prevent medical providers from offering the best care causes a “moral injury” to them, she said.
What’s more, admitting to or seeking mental health care is deeply stigmatized in medicine. Doctors and nurses aren’t supposed to show weakness or admit that the stress of their work is affecting them, even during extreme circumstances like a pandemic.
“The culture that we train in and work in sometimes perpetuates a mentality wherein the toll of dealing with this kind of repetitive trauma to our mental health is minimized as just a part of the job,” Terry said.
In addition, some states require physicians to disclose mental health diagnoses and treatments when applying for or renewing a medical license. This further discourages them from seeking help when they need it, she said.
‘The Hero Thing Just Gets Buried’
Jennifer Casaletto, an emergency physician in Charlotte, North Carolina, said there has been no escape from the pandemic and the stress it creates. Normally, she can separate her negative experiences at the hospital from the rest of her life. Not now, she said.
“This is one of those things that you don’t avoid by leaving work. It’s everywhere,” said Casaletto, who is president-elect of the American College of Emergency Physicians’ North Carolina chapter. “It’s hard to limit your engagement even though you know you need to.” Her husband, Jacob Debelak, is also a hospital-based physician and both treat COVID-19 patients.
Like McIntosh, Casaletto has grown frustrated with the spread of misinformation and disinformation about the virus and with people in her community who refuse to cover their faces and take other precautions.
“Having neighbors and friends almost working against us is hard,” Casaletto said. “The ‘hero’ thing just gets buried because of the amount of folks who are saying it’s a hoax and who aren’t willing to care for their neighbors and who don’t believe any of the science. It just is really difficult to say, ‘What do you think I gain by this being a hoax?’ I gain nothing.”
The stress that can lead to mental health problems affects more than doctors and nurses. Trece Andrews works in the laundry at a nursing home in St. Clair Shores, Michigan. She said her employer was “very dishonest” in the early weeks of the pandemic, telling workers that no residents would be stricken with COVID-19. The employer was wrong. Residents fell ill, and then so did employees, Andrews said.
Just like medical professionals, Andrews and her co-workers face risks to their health and the health of their families. Although they aren’t treating patients, they’re in close proximity to them and to the doctors and nurses who care for them. Approximately 40% of COVID-19 fatalities in the U.S. have been nursing home residents, according to a New York Times analysis.
These conditions have led a number of Andrews’ fellow workers to quit their jobs, and their replacements often don’t stick around once they realize the dangers. This turnover and short-staffing are undermining residents’ care, Andrews said.
“When you guys put your parents and grandparents in a home, you want quality care for them. So if they don’t get better or change some of this stuff that’s going on in this particular industry, it’s going to take from the care and the well-being of these residents,” Andrews said.
The American College of Emergency Physicians, the American Medical Association and other medical organizations have called for states to relax the requirements that doctors disclose their mental health histories. The emergency doctors group also supports bipartisan Senate legislation that would study health care workers’ mental health and create assistance programs. The bill is named after Lorna Breen, a New York physician who died by suicide in April.
While these workers await relief from the pandemic and help from their employers and the government, Casaletto also pleads with the public for help.
“It’s all of our responsibility to protect the most vulnerable of society as well as our own families, to make sure that we are taking this seriously, that we are wearing masks when we’re in public, and that we’re washing our hands frequently,” Casaletto said. “Please let us help you. And please know that we are there and have your back.”
CORRECTIONS: A previous version misidentified Jennifer Casaletto and Nina Wells. Casaletto is president-elect of the American College of Emergency Physicians’ North Carolina chapter, not the national group. Wells is a doctor of nursing practice, not a nurse practitioner.
If you or someone you know needs help, call 1-800-273-8255 for the National Suicide Prevention Lifeline. You can also text HOME to 741-741 for free, 24-hour support from the Crisis Text Line. Outside the U.S., please visit the International Association for Suicide Prevention for a database of resources.