Data from the third NurseGrid survey was recently released, showing that nurses’ sense of well-being has significantly declined throughout the pandemic. Notably, rates of self-reported burnout swelled to 61 percent, a sharp increase from 25 percent in September. The December survey results also show that more than 20 percent of nurses report that they plan to leave bedside nursing or leave nursing entirely by 2021.

The recent data compiles survey answers from December 9-18, 2020. The aim of the third survey was to update the first two surveys (completed in April and September of 2020) and draw out trends in nurses’ mental health as the pandemic continues to rage.

NurseGrid is an application widely used by nurses across the country to access work-related information, such as scheduling and communicating with co-workers. It was used as a platform for the survey in collaboration with the Association of periOperative Registered Nurses (AORN). The sample size for the third survey was 10,017 nurses.

The three NurseGrid surveys bring out changes in nurses’ main concerns throughout the progression of the pandemic. In April, the survey showed nurses mainly concerned about shortages of PPE and ventilators, whereas in December a majority of nurses reported concerns centered on shortages of nurses and ICU beds. However, PPE remains a concern with only 42.7 percent of surveyed nurses reporting an adequate supply of PPE. Many nurses are still forced to reuse hospital-provided PPE or purchase their own PPE.

While the research included in this article relates to nurses, nurses are just one subset of the health care workforce. Health care workers function as a team, and COVID-19 has affected everyone, from environmental services to staff physicians to transport workers.

On a Facebook group of certified nurse assistants (CNAs), a recent discussion of burnout brought the aforementioned data to life. All names have been changed to protect their identities.

Grace, a CNA at a long-term care facility, wrote: “Every day we’re expected to do more in less time. Getting more and more short staffed by the day. There’s a big division between nurses and CNAs at my workplace, the aides get treated like crap. ... We have mandatory overtime. We’re in low census, but it seems like the highest resident count we have ever had because all the residents we have are in need of so much help.”

Another CNA, in the same Facebook thread, added: “Burnout is everywhere. I might be looking into a career change. I love what I do ... but I feel like I’m not making a difference.” Others in the discussion expressed a similar desire to leave their jobs or careers entirely.

Burnout is a phenomenon characterized by emotional exhaustion, lack of motivation and feelings of frustration. In the 1980s, researchers Christina Maslach and Susan E. Jackson were the first to quantify burnout, developing a scale called the Maslach Burnout Inventory (MBI). The MBI is widely used today in multiple variations. Maslach’s definition of burnout is widely understood today as a state of mind developed over time in response to excessive stress at work, characterized by feeling emotionally drained, having a detached response to other people and lacking interest in improving work performance.

While greatly exacerbated by the COVID-19 pandemic, the issue of burnout among health care workers is not new. A theoretical review published in 2020 summarized findings from 91 different peer-reviewed papers on burnout in nurses from 1976 to 2019. Authors found that high workload, value incongruence, low control over the job, low decision latitude, poor social climate/social support and low rewards are predictors of burnout.

The entire review can be read here, but for the purposes of this article, only a few of the theorized causes of burnout—patient requirements, value congruence and workload—will be discussed.

Four of the reviewed papers investigated the relationship of burnout to patient characteristics/requirements. Overall the papers found that nurses were more likely to report being emotionally exhausted and growing cynical when taking care of suffering patients or patients with complex needs. Caring for a high number of patients, who are dying or have decided to withdraw life-sustaining treatment, was also shown to result in higher burnout scores.

Seven of the eight studies on value congruence—the extent to which a person’s personal principles line up with the requirements of the job—showed an inverse correlation with burnout. Low value congruence tended to predict burnout, in accordance with the MBI.

High workload has a high association with the development of emotional exhaustion. Twelve of the 13 studies that focused on high workload found this connection. Poor staffing levels, often causing high workload for those nurses left on the floor, was also independently shown to predict burnout in 12 of the 15 studies focused on staffing.

The voices of health care workers confirm that COVID-19 greatly exacerbated conditions that research has shown may lead to burnout. In Facebook discussions, health care workers described witnessing high rates of death, being overwhelmed by the care of very complex patients in COVID ICUs, feeling ethically and morally exhausted as they are unable to care for patients properly due to lack of time or staff, working longer hours with less staff and taking on higher patient loads. In many cases health care workers must take on the additional role of support or comfort for scared, lonely and dying patients unable to see family members as a result of restricted visitation.

In a respiratory therapist (RT) group on Facebook, Martha, a retired respiratory therapist from Kansas with over 40 years’ experience, described the workday for an RT before COVID-19. “We [RTs] are always multitaskers—in any given day we work ED, NICU, ICU, med-surg, oncology, PACU, etc. There are maybe 3–4 staff members or even just one person sometimes covering all those areas. We run the gamut of the hospital or facility every day. ... Our daily patient loads per shift consist of many patients sometimes 30–40 different patients per shift that we each see multiple times per shift.”

During COVID-19, Martha described the additional challenges that arose: “On top of all this we added COVID patients which just preparing to see (due to PPE) was time consuming, and the level of care they take is enormous. Yes, we are burnt out. We added intensive COVID patients to our already extensive list for the shift. RT’s are tired, just as is the rest of the team.”

In her comments she insisted that the entire hospital staff was affected by the additional stress brought on by COVID-19—from environmental services, laundry workers and kitchen staff to nurses and transport workers.

Martha closed her statement: “Hardest of all, [RTs] are too many times the last voice a patient hears before we extubate them and let them go. So after all the other things we do, end of life care is added to the list—we are seeing/doing way too much of that and it takes a toll. Covid just added to the myriad of reasons healthcare workers burn out.”

Jamie, a CNA, expressed similar feelings of emotional and physical exhaustion. “I’m really burnt out. So overworked and underpaid. We’re having to work one aide to 30–40 residents a day ... and having to help other units as well because it’s been so hard on all of us that many are so tired and overworked that people are calling off or quitting. Most of us are so anxious before we go into work ... we feel sick and dizzy.”

Jamie works in a nursing home and stated that with the onset of COVID-19, staffing became much worse as co-workers fell ill or quit in order not to put their families at an increased risk of contracting the deadly virus.

She also described how patient care suffers as a result of COVID-19 and burnout of health care staff, a phenomenon which is backed by the results of the aforementioned theoretical review. Evidence from 17 of the included studies pointed to the negative effects of burnout on patient care. Areas of patient care including safety, adverse events, medication errors, patient falls, patient dissatisfaction, and family complaints are possibly increased on units or in facilities where staff suffer from high levels of burnout. This, in turn, has the potential to further increase burnout, disturbing health care workers who joined the medical field to help patients.

“The residents seem to be weaker and like they’re giving up because they don’t have anything to look forward to now that families aren’t allowed in,” Jamie wrote.

“Even housekeeping isn’t getting done because nobody wants to go into sick people’s rooms to clean and there is nobody in laundry anymore so rags and clothes etc. aren’t getting washed. We’re wiping people with pillowcases and sheets. It’s quite sad really. I feel like before COVID all of us were at least not overworked. Being overworked on top of being underpaid on top of no staff is killing us and making the patients suffer.”