Connie Nugent MLS
Corresponding author: Connie Nugent
Contact Information: Connie.Nugent1@gmail.com
DOI: 10.12746/swrccc.v8i36.769
Pressure pushing down on mePressing down on you
Every health care worker, especially those in hospitals, would identify with the lyrics sung by David Bowie and the rock group Queen in their 1981 song “Under Pressure.” Months of dealing with the COVID-19 pandemic have increased pressure on businesses, schools, and families, but health care workers face unrelenting and often unrelieved stress and anxiety.
At the beginning of the pandemic, the U.S. health care system was unprepared, and deliberate disinformation and obfuscation from the federal government contributed to the lack of basic medical equipment, personal protective equipment, and medicines. States found themselves competing with one another, scrambling for ventilators and PPEs wherever they could be located. The government’s undermining of medical experts and the Centers for Disease Control promoted the fallacy that COVID-19 was not serious and that basic safety precautions could be ignored.
Ten months into this pandemic, COVID-19 cases have increased, hospitals are stretched to the limit, and physicians, nurses, respiratory therapists, and other clinicians are exposed on a daily basis to the coronavirus while undergoing extreme workloads. According to Dr. Tait Shanafelt, health care professionals experience “the same societal shifts and emotional stressors faced by all people” but they also face “moral dilemmas and a rapidly evolving practice environment that differs greatly from what they are familiar with.”1
Shanafelt et al. surveyed health care workers, including residents and fellows, regarding their concerns and classified their responses into five generic categories: Hear Me, Protect Me, Prepare Me, Support Me, and Care for Me.1
Hear Me: Physicians and nurses are uncertain that hospital leaders appreciate their concerns. Survey results indicate that the most frequent request of respondents is “honor me” and that the process starts with leadership.1 State and national leaders are remote, but local hospital department chairs, division chiefs, and administrators should make themselves visible and accessible and should invite and seriously evaluate input from house staff and nurses. Shanafelt emphasizes, “The importance of simple and genuine expressions of gratitude for the commitment of health care professionals and their willingness to put themselves in harm’s way for patients and colleagues cannot be overstated.”1
Protect Me: A primary concern of all health care workers is exposure to the coronavirus, becoming infected, and/or transmitting the virus to family members.1 An NBC news feature pointed out that the lack of PPEs has caused some nurses to quit. When nurses at one hospital had limited access to PPE and were told to reuse single-use masks, one nurse complained that she “felt like a sheep sent to slaughter.”2 Liz Stokes, director of the American Nurses Association Center for Ethics and Human Rights, said that nurses have a duty to their patients, but also to themselves, and that they now face ethical dilemmas.2
The Guardian and Kaiser Health News reported in August 2020 that more than 900 front-line American workers have died from the coronavirus and its complications. Many who died lacked adequate PPE; some died due to inadequate safety measures at work.3 By October 2020, the median age for medical staff infected with COVID was 57, compared with 78 in the general population.4 An adequate supply of PPE, safe working conditions, immediate access to testing if needed, and restricting older health care professionals to non-COVID patients can reduce the risk of infection.
Allowing time for COVID recovery is essential. Some infected doctors and nurses feel the pressure to return to work too soon. The Health Professionals and Allied Employees Union reported that many of its members who contracted the coronavirus said they had to return to work while they were still symptomatic. Union president Debbie White remarked, “What we learned in this pandemic was employees felt disposable. Employers didn’t protect them, and they felt like a commodity.”5
Prepare Me: Health care workers are often asked to serve in areas for which they are not adequately trained.1 Due to a shortage of beds in some hospitals, COVID patients may be housed not only in a medical ICU, but in a coronary ICU, in a surgical ICU, or even temporarily in a pediatric ICU. Cardiologists may be asked to care for COVID patients, and non-ICU nurses may be pulled to work in an ICU. Without adequate training in pulmonary and critical care, health care professionals may experience heightened stress and anxiety. Programs that provide basic knowledge in critical care and access to experts can increase self-confidence in those who are non-specialists.
Support Me: Cases of COVID-19 are increasing across the United States, leading to overburdened and understaffed hospitals and increasing workloads for already stressed hospital workers.1 Months of caring for COVID patients in ICUs exact a toll on physicians and nurses, and on residents and fellows who often bear the brunt of inflexible schedules and heavy patient loads. Gulati and Kelly report, “In a challenging healthcare environment, physicians face additional risk factors including burnout, moral injury, and post-traumatic stress disorder.”6 Moral injury occurs when a clinician faces an ethical dilemma, e.g., regarding triage or withdrawing life support or deciding whether or not to work without adequate PPE. Gulati and Kelly suggest establishing a hospital-based COVID-19 Clinical Ethics Committee that health care workers can consult on a confidential basis, and physician peer groups can visit via teleconferencing to discuss pressing issues.6 It is imperative that hospitals recognize and support the physical and emotional needs of health care workers, including locations for proper rest and relaxation.
Care for Me: Health care professionals are uncertain that hospitals will actually take care of them and their families should quarantine be necessary.1 Some physicians and nurses may want to live apart from their families while caring for COVID patients, and hospitals could provide suitable nearby lodging. Assistance with childcare should reduce family anxiety.
It’s the terror of knowing what the world is aboutwatching some good friends screaming
“Let me out!”
Listen.
That screaming you hear comes from working mothers who are trapped in a perfect storm: the terror of their world includes the pandemic, a divisive cultural atmosphere, having to work from home, lack of adequate child care, online school for kids, shouldering most of the family responsibilities, with an overall fear of infection. It is no wonder that many of them feel as though they are running in place, living the old folk saying, “The hurrieder I go, the behinder I get.” In Lewis Carroll’s 1871 novel Through the Looking-Glass, and What Alice Found There, Alice meets the Red Queen who runs at awe-inspiring speed without advancing an inch. She instructs Alice, “It takes all the running you can do, to keep in the same place. If you want to get somewhere else, you must run at least twice as fast as that.”7 Working mothers know exactly how this feels.
Carroll, Lewis. Through the Looking-Glass, and What Alice Found There. London: Macmillan and Co., Ltd., 1871.
Consider the stress and anxiety of physicians and nurses during the pandemic. Now consider that those who are women may also be mothers. Co-author of the new 2020 Women in the Workplace Report by LeanIn.org and McKinsey and Company, Marianne Cooper maintains, “not only are mothers doing way more at home than fathers during the pandemic, but mothers are also more than twice as likely as fathers to worry that their performance is being judged negatively because of their caregiving responsibilities.”8 She explains that the American beliefs in “the ideal worker” and “the good mother” often undermine working mothers. The ideal worker is completely devoted to the job, depending on others to take care of the family. The good mother is completely devoted to her family and to the needs of her children. The two are of course incompatible.
The pandemic poses risks for physicians and nurses who are mothers. Women in other types of jobs may be able to work from home and juggle childcare while doing so. Health care workers do not have that luxury. Pennsylvania orthopedic surgeon Kate Deisseroth faced a dilemma when her twins’ school went online. Her colleagues took some of her work and supported her decision to consult with patients from home, but she realized that surgery and childcare had consequences, “As a surgeon, you can’t take a year or two off and go back in, so it would be kind of the end of that career.”9 She resorted to looking for a nonclinical job with fixed hours.
Although many female health professionals consider leaving hospital jobs due to extreme workloads and/or fear of infection, some can’t quit; they may be single parents, have student loans, etc. Recognizing that some face criticism or backlash for their decisions to leave their jobs during the pandemic, Liz Stokes, of the American Nurses Association, points out that “nurses must be supported in whatever decision they make…Nurses were already burned out before, and this pandemic might push many of them completely out.”2 Psychiatrist Dr. Sheetal Marri warns, “These effects will impact the way nurses and other health care professionals will deal with workplace health hazards even after this pandemic is over.”2
Poet Robert Frost (1874–1963) examined issues over which a person has no control in his poem “Acceptance.”10
When the spent sun throws up its rays on cloud
And goes down burning into the gulf below,
No voice in nature is heard to cry aloud
At what has happened. Birds, at least, must know
It is the change to darkness in the sky.
Murmuring something quiet in her breast,
One bird begins to close a faded eye;
Or overtaken too far from his nest,
Hurrying low above the grove, some waif
Swoops just in time to his remembered tree.
At most he thinks or twitters softly, “Safe!
Now let the night be dark for all of me.
Let the night be too dark for me to see
Into the future. Let what will be, be.”
Light changes to darkness in the sky, but the birds do not cry aloud at its coming; they accept its presence and endure it. COVID-19 is the current darkness facing health care professionals. According to a survey on the prevalence of burnout of health care workers during the pandemic in Japan, a workload reduction, an increase in staff, hazard pay, educational resources, childcare support, counseling, and expressions of appreciation and respect can alleviate stress and anxiety and perhaps reduce burnout.11
Keywords: COVID-19, coronavirus, pandemic, anxiety, physicians, nurses, burnout
Song lyrics: “Under Pressure.” David Bowie and Queen (J Deacon, B May, F Mercury, R Taylor). In the album Hot Space, published by EMI-Elektra, 1982.
Article citation: Nugent C. Anxiety. The Southwest Respiratory and Critical Care Chronicles 2020;8(36):70–73
From: Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
Submitted: 10/6/2020
Accepted: 10/9/2020
Reviewer: Gilbert Berdine MD
Conflicts of interest: none
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.