The stories Natasha Charleston heard were haunting.

As a crisis response program coordinator and vocational case manager with Coventry, which was acquired by Mitchell Genex in 2020, Charleston knew her skills in managing emergency situations and helping people cope with trauma could be of use to more than her employer during the COVID-19 pandemic.

She began volunteering with the Northern Illinois Critical Incident Team, counseling health care workers who were struggling with their mental health as a result of the pandemic.

Nurses told her of working 16-hour shifts only to come back after a short break to find four of their patients had passed. Others expressed anxiety about bringing the virus home to their families. Self care routines lapsed as hours increased and gyms, yoga studios and other wellness businesses closed in the name of public health.

“These are health care professionals who have had to deal with death on a larger scale. It’s always difficult coping with death, but they’ve been forced to keep going based on the sheer numbers of patients who needed their services,” said Charleston, CRC, LCPC, CISM. “And there was a lack of time and ability to really use outlets to cope with this kind of stress.”

While the COVID-19 pandemic has taken a toll on the mental health of workers from all walks of life, doctors, nurses and others involved in professions whose primary concern is caring for someone else were particularly affected.

A survey of 1,119 health care workers conducted between June and September of 2020 found that 93% of health care workers reported feeling stress, 86% reported feeling anxiety and 76% reported exhaustion and burnout.

“These guys and gals were very secluded; they just had each other. So they had feelings of loneliness, and again, that the weight of the world was just on their shoulders,” Charleston said.

This mental crisis is nothing new, however. Before the pandemic, systematic factors contributed to high rates of compassion fatigue, burnout, depression and suicide amongst those in caring professions and health care workers in particular.

As vaccination rates climb and the end of the pandemic gets closer, it may be time to reevaluate some of the systematic factors that put health care workers at an increased risk for conditions like anxiety, depression and burnout.

New technologies are also stepping in to help determine what types of activities are increasing stress for clinicians.

Pre-Pandemic, Compassion Fatigue Plagued the Caring Professions 

Even before the pandemic, those in caring professions were at an increased risk for workplace stress conditions like burnout and mental illnesses including depression, anxiety and suicidal thoughts or ideations.

Defined as jobs that involve caring for others, the caring professions range from those in childcare and education to medical professions like doctors and nurses.

Natasha Charleston, CRC, LCPC, CISM

These types of workers often conceptualize themselves as caregivers, and consequently, they can experience compassion fatigue, especially when facing situations like the COVID-19 pandemic, where they may not be able to prevent sickness or death.

“They describe it as a calling, that they’re called to this type of work,” Charleston said. “And when you show up and want to help solve the problem, if the problem is someone suffering and dying before your eyes, and you can’t save them, that hits home.”

Similar to burnout, compassion fatigue is a combination of physical and emotional symptoms, including a loss of purpose, a preoccupation with trauma, and physical tiredness and isolation that arise when the stress of caring for others becomes too much.

Though the condition’s prevalence varies by profession and type of caregiving, studies have found that compassion fatigue can affect somewhere between 7.3% and 40% of ICU workers and a 2006 study found that nearly 50% of Colorado county child protection staff suffered from the condition.

Health Care Professionals at Risk 

Health care professionals in particular are at risk of experiencing compassion fatigue and burnout due to the high stakes and fast-paced nature of the caregiving work they do.

Doctors and nurses treating critically ill or injured patients know every choice could be the difference between life and death for the people they’re treating.

“They are faced with these rising pressures to not only deal with these life and death situations, but [also] the pressures to produce better outcomes at lower costs,” said Tammy Bradly, vice president of clinical product development at Coventry.

If left untreated, the feelings of loneliness, isolation, exhaustion and a preoccupation with trauma that are common symptoms of compassion fatigue and burnout can escalate into more severe mental illnesses like depression, anxiety or even lead to suicide.

“Research has shown that they are at increased risk for suicide,” said Trish Harmon, risk control consultant at CNA Insurance. “The number of physicians who commit suicide every year is equal to one medical school graduating class.”

Doctors die by suicide at almost double the rate of the general population, with most estimating that between 300 to 400 physicians commit suicide each year, though that figure has been questioned due to the difficulty of establishing reliable statistics.

Lori C. Harbert, MSW, LCSW, director of health and well-being, BluePearl

Still, there’s no question that a high number of physicians are struggling with mental illness and these problems often start early. A 2019 paper published in the journal Missouri Medicine reports that 20% of medical residents met the criteria for depression and 74% met the criteria for burnout.

Charleston, who has counseled nurses, respiratory therapists, cleaning staff and others who work in medical facilities, noted nursing staff and people working in non-medical roles in hospitals struggle with their mental health as well.

Data from the National Violent Death Reporting System shows that of the more than 159,000 suicides that occurred between 2007 and 2018 nearly 2,400 involved nurses.

As with other professions, women are at greater risk for suicide. A study from the University of Michigan found that female nurses are nearly two times more likely to die by suicide than women at large.

The issue is not just limited to those providing care to humans. Veterinarians are also at high risk of depression, anxiety and suicide due to compassion fatigue, burnout and high exposure to euthanasia.

One veterinarian told Lori C. Harbert, MSW, LCSW, director of health and well-being at BluePearl, a veterinary health system, that she had 15 euthanasia appointments in one day.

“The intensity and emotional impact of the human animal bond is very real,” Harbert said.

“Veterinarians and perfectionism go hand and hand—expectations of self and the standards they strive for at times are not balanced.  Add in extensive financial debt and the human animal bond you have the perfect emotional storm. ”

Veterinarians are 3.5 times more likely to commit suicide than members of the general population, a 2019 CDC study that looked at suicide amongst veterinarians between 1979 and 2015 found. During that time period, almost 400 veterinarians died by suicide.

“Many veterinary professionals report trouble sleeping, increased anxiety and depression. The more emotionally overwhelmed a person becomes the harder it is to set boundaries that support individual self-care,” Harbert said.

As with medical providers, suicide rates were higher amongst women, with 326 female veterinarians committing suicide compared to 72 of their male counterparts.

A Systematic Issue 

Though often framed as an individual problem, the mental health crisis in the health care sector is largely driven by systematic issues.

Doctors, nurses, veterinarians and other health care professionals work long hours, have a high administrative workload and labor in close proximity to death and dying. As work hours rise, so does the risk of burnout.

The odds of physician burnout rise by three percent for each additional hour doctors work past a normal 40 hour work week, the American Medical Association reports. With 57% of physicians reporting they work 71 or more hours per week and another 50% saying they work 61-70 hour weeks, this statistic indicates that the risk of burnout amongst doctors is high.

“More recently, there’s an acknowledgement and identification that the root cause is predominantly systemic,” Harmon said.

“Excessive documentation associated with the electronic medical record is an important factor and the emphasis on productivity quotas and metrics, such as having to produce and see many patients in a certain timeframe.”

Long work hours are likely to be a staple of medical systems for years to come, however, as the U.S. is currently facing a physician shortage.

In just over a decade, the American health care system is expected to face a shortage of between 54,100 and 139,000 primary and specialty care physicians, according to the Association of American Medical Colleges which has provided data on the issue for six years.

Burnout, compassion fatigue, depression and anxiety all contribute to this shortage as these conditions can cause health care workers to leave their jobs and seek new career paths.

Health care workers leaving the profession creates more stress for those who choose to stay in the industry, however, as there often aren’t enough new graduates to fill their roles.

“While individual personality traits like resiliency and a physician’s ability to handle stress do play a role, it’s the environment that has exacerbated it,” Harmon said.

Trish Harmon, risk control consultant, CNA Insurance

COVID-19 only worsened these pre-existing problems by requiring many in the health care field to work longer hours and treat more patients in order to battle the pandemic. ERs were filled by COVID patients and some hospitals had to turn people away because there simply weren’t enough beds.

“Physicians have had to make difficult clinical decisions with the scarcity of ventilators and personal protective equipment, as well as being separated from family members, it’s just been very difficult, so yes, the pandemic has certainly impacted burnout,” Harmon said.

While veterinarians did not see an influx of COVID-19 patients, the pandemic pet adoption boom meant that they too saw an increased workload that contributed to higher stress levels.

The strain has continued even now that we are more than a year into the pandemic. During one week in March of 2021, seven veterinary professionals committed suicide.

“COVID’s impact has been universal to all human beings and the response of many was to add additional family members. I regularly hear, ‘he or she is my COVID dog,’ ” Harbert said.

“For the veterinary community, this created a surge in the number of animals needing medical attention. This only compounded the stress that was already being felt by our veterinary community. The outcome has been going from simply being tired to overwhelmingly exhausted.”

Mental Health Resources

Currently, there are a number of resources available for those in the health care sector who are struggling with mental health.

The American Psychiatric Association offers a confidential physician support line for clinicians to use if they feel the need to talk about their mental health, and many employers offer benefits like employee assistance programs (EAPs) that can offer support to those struggling with burnout or compassion fatigue.

The existing stigma around mental illness in all parts of society is especially strong amongst health care workers, because they conceptualize themselves as caregivers and not people who need to be taken care of.

“Physicians do not like to acknowledge their own symptoms or admit that they can be affected by burnout, and really oftentimes refuse to seek help, and this leads to an increased risk of depression, anxiety, and even suicidal ideation,” Bradly said.

“When I’m working with ICU, the intensive care unit and emergency room nurses, they consider themselves the toughest of the tough,” Charleston added. “And the truth is that they may not very well be comfortable asking for any sort of counseling or supportive services.”

Consequently, Charleston and Bradly recommend health care systems make EAPs and other mental health related benefits easy for doctors and nurses to access so they don’t have to spend a lot of time researching services or asking for help.

In addition to making services easily accessible, appointing a chief wellness officer can signal to health care employees that mental health needs to be taken seriously and further help reduce the stigma by having a company employee dedicated to ensuring clinician wellbeing.

“We really need to look at the bigger picture, and the first step is leadership commitment. If you don’t have leadership commitment in an organization, the initiative won’t be as successful,” Harmon said.

“If you have leadership commitment and you’ve appointed a chief wellness officer, you’re making a statement to your physicians that we care about your health and wellness and that this is important to us”

On the pet medicine side, the American Veterinary Medical Association offers a number of resources on mental health, self care, wellness and compassion fatigue that serve as a starting off point for vets in need.

Tammy Bradly, vice president of clinical product development, Coventry

“This profession has an inherent emotional base and as veterinary professionals, who are overwhelmingly empathetic human beings, it is important to know it is OK to feel the emotion,” Habert said.

“That part of the profession will not change but how you handle the emotion is what you can have control over. The AVMA and MVH4you.com provide a plethora of resources.”

New technologies are also attempting to track physician stress levels and determine the causes of clinician burnout.

Wearable heart rate monitors are being used to study the connection between the amount of time doctors spend working in the inboxes connected to patients’ electronic health records (EHR) and their stress levels.

Researchers from Kaiser Permanente found that clinicians who worked in their ERH inboxes outside of normal work hours experienced higher average stress durations. Those who worked in ERH inboxes after hours felt stress for 80 out of 243 total work minutes.

It also found clinicians were most stressed during the first hour of work, the early afternoon and the early evening. Forty-two outpatient clinicians from five separate medical facilities participated in the study.

This research builds up previous studies which demonstrated a link between EHR inboxes and physician burnout. A 2019 study found that physicians who receive high amounts of EHR inbox messages are 40% more likely to suffer from burnout.

“That’s where a lot of the burnout is coming from,”  Bradly said. “They don’t feel that they are able to spend the time and take care of their patients because they’re too busy doing documentation and other things that are required.”

To help manage this stressor, health care providers should consider allocating time in a physician’s day for responding to ERH messages and discourage providers from responding to non-urgent messages outside of work hours.

These tools could go a long way in helping address some of the systemic issues that are contributing to struggles with depression, burnout and anxiety amongst those working on the health care side of the caring professions.

“If you don’t fix the occupational and environmental factors, you’re still going to have an issue,” Bradly said.

“During the pandemic, it’s been impossible to fix environmental and occupational issues because you just do not have enough healthcare workers. So everyone was pulling double, triple duty. So those are two key elements that we, over the past year, really haven’t been able to address. Hopefully we can begin to now.” &