Burnout and distress are rife in the largest study yet of frontline workers’ pandemic experiences.
Thousands of frontline health workers say their mental health is suffering due to the COVID-19 pandemic, reporting burnout, depression, and PTSD – and some doctors plan to ditch medicine as a result.
These are among the early findings of the ongoing nationwide COVID-19 Frontline Health Workers Study, which at the time of writing had attracted more than 9,000 responses to questions on the mental, physical and social impacts of the pandemic.
In an analysis of the first 5,000 responses, nurses were most strongly represented but just under 2,000 respondents were doctors, of whom 900 were hospital consultants and 300 were GPs, said co-lead Associate Professor Natasha Smallwood.
“Participants were asked whether they believed they had experienced any mental health conditions since the pandemic began and so far, 62% said they have experienced anxiety, 58% have experienced burnout, 27% have experienced depression, and 5% say they’ve experienced PTSD,” said Professor Smallwood, who is a respiratory physician at Royal Melbourne Hospital.
“It’s interesting because there have been studies showing a lot of the general population has had anxiety, but for us as frontline workers, the fear is amplified because you’re putting your life on the line and potentially infecting your families, which adds to what’s already a high-stress job.”
About 85% of respondents so far were from Victoria, but responses have come from every state and territory, Professor Smallwood said.
She suspects the study is the largest of its kind, with the closest being a survey of 5,000 people in China working at a single hospital.
Their survey also includes several clinical scales for aspects of psychological health, including resilience, generalised anxiety disorder, the Patient Health Questionnaire, Impact of Events Scale, and the Abbreviated Maslach Burnout Inventory, but the results of these have not yet been analysed.
The responses have also included around 5,000 entries in the free-text sections of the survey, Professor Smallwood said.
“We haven’t yet quantified this, but there have been a small number of respondents, including doctors, who chose to write – as this is not a survey question – that they are giving up their job because of their experiences during the pandemic,” Professor Smallwood said.
“There have been a variety of reasons given, including perceived lack of support either from their organisation or the government, and junior doctors who said they haven’t had enough control around rosters.
“If you don’t have the ability to choose if you care for COVID-19 patients, or how you deliver that care, it’s quite overwhelming for people in the time of a killer pandemic.
“Another reason that has been well reported is a fear of infecting their family – they’ve been seeing the experiences of colleagues internationally, of people dying. Working in health is definitely a vocation, but for many people this pandemic has just been too much.”
These are a few of the responses received:
- “Less often do I look forward to work. Almost every day I think about how much I don’t want to be a nurse and how life would be easier in so many other jobs. Not letting family and relatives be with their sick relatives is the hardest thing about COVID-19.”
- “I’m glad to have had this chance to serve the community at such an important time. But I’m tired and I’m sad and I miss the joyful life I led before it came.”
- “To whoever is reading this, please take care of yourself and people you love and care for. That includes family, friends, patients, anyone.”
Guilt was also a recurrent theme, Professor Smallwood said.
“There was one comment from a pregnant healthcare worker who said they had asked not to treat COVID-19-positive patients for fear of getting sick, but they felt guilty and said it was a daily challenge to stand their ground.
“Another said, ‘We’re all exhausted. I was burnt out pre-pandemic and now feel so guilty about wanting to leave medicine but will stay because I feel I need to, not because it’s what’s best for me.’”
“Among the people who said they have temporarily stopped working on the frontlines, for physical or mental health reasons, they say how guilty they feel – all because they want to protect themselves and their families.”
Coping mechanisms
To manage their mental health, a quarter of participants said they had increased their exercise level, a quarter said they were practising yoga or meditation, and 14% said they were using some form of mental health related app.
However, 26% also said they were consuming more alcohol to cope during the pandemic, and most of the cohort said they had not sought professional help for their psychological distress.
“Among our respondents, 75% have not used a formal program: they have not seen a doctor or psychologist, and they’ve not used one of the professional support programs that are either longstanding or have been put in place to support them during the pandemic,” Professor Smallwood said.
“Unfortunately, I’m not surprised. People worry about the stigma associated with this, and I think many health professionals have it ingrained in us that because our jobs involve dealing with death and dying we just have to cope with it, and this mentality is showing quite clearly in this crisis – people are not seeking help when they need it.”
While most people felt they had received adequate training around the use of PPE, more than half said they wanted further training still, which Professor Smallwood suggested may reflect the level of uncertainty around transmission of the SARS-CoV-2 virus.
“The vast majority, well over 50%, also reported that they are ‘worried’ or ‘very worried’ that they will infect their family,” Professor Smallwood said.
“Roughly 10% had had to self-isolate because of potential exposure, and about 2% reported having had COVID-19.”
Many respondents raised concerns for the wellbeing of junior doctors, particularly in Victoria, but Professor Smallwood said she was also struck by the number of senior male clinicians and leaders who wrote that they were also struggling.
“Without being too gender-biased, that’s a group I had assumed would cope quite well because they’re used to leadership and tend to have a good ability to cope in a crisis, but this is such a different type of crisis – this study has underscored the fact that everybody is experiencing this pandemic, and some degree of disruption,” she said.
The study authors also introduced a measure of moral injury to the survey.
“Moral injury is a relatively new concept, which is about being unable to provide care as you would normally because of a change in circumstance. Most health professionals choose their careers because they want to help others and moral injury has been quite well described in places such as Italy and New York for example, where they haven’t had enough ICU beds and had to decide which patients get the best chance of survival,” Professor Smallwood said.
“In our survey, participants have described incidents with patients who are too afraid to come to hospital or go to primary care. Some also struggle with fact that when people die of COVID-19 they die alone.
“Participants recount stories about people dying on their own, of not being able to get a priest, some patients not having adequate pain control – and health workers are really distressed.”
Next steps
The team has applied for funding for deeper qualitative research with a subset of the cohort, then plans to develop a series of recommendations for government and medical professional bodies on how health workers can be better supported in the future.
Counselling and psychological support independent of the hospital or organisation, support around childcare and home-schooling, and structured team debriefing were among the most common suggestions arising from the responses so far, Professor Smallwood said.
“Some people expressed a fear that if they admitted feeling anxious and burnt out at their workplace, they might be the first to lose their job.
“Others said they see the distress of colleagues and end up being each other’s counsellors, and while they think they would all benefit from having to formally debrief, they don’t have time to do it.”
The number of respondents itself is remarkable considering healthcare workers are typically reluctant to talk about adverse effects on their mental health, Professor Smallwood said.
“We only opened the study in early September and thought it would take us four months to get 7,000 responses, so it’s just been extraordinary.
“You don’t get that volume of participation unless people have been really touched by something and I think that’s key, they’ve been so affected by COVID-19.”
She said the findings had not been entirely bleak.
“We should never forget that sometimes crises really do unite people. For example, one group is doing a virtual walk from Queensland to Tasmania – the staff have found it quite fun competing and said doing a shared team activity has been helpful for their mental health.”
