Work Environment and Health Care Workforce Well-Being: Mental Health and Burnout in Medically Underserved Communities Prone to Disaster

Abstract

Health care workers (n = 71) completed an online survey or participated in one of five focus groups. Clinical cutoff scores revealed concerning levels of depression (16%), anxiety, and burnout (49%). Qualitative responses (n = 172) yielded two themes: work environment and well-being. Addressing burnout requires an ecological systems mindset, which accounts for complex stressors present in individual providers’ lives (large-scale disasters and personal stressors), agency-level factors (scheduling and workload), and larger social and contextual administrative factors (allocating time for self-care through scheduling and billing codes). (Am J Public Health. 2024;114(S2):S156–S161. https://doi.org/10.2105/AJPH.2023.307478)

STUDY OBJECTIVE

Approximately 50% of health care providers have symptoms of burnout,¹ and many leave prior to retirement because of the excessive exhaustion caused by prolonged work-related stress.² Environmental work factors, such as overworked systems, lack of autonomy, administrative overload, and workplace isolation, contribute to stressful work environments and an “us (providers) versus them (administrators)” dilemma.^3,4 In addition to the work environment, threats to overall well-being, such as mental health and life stressors, play a reciprocal role in burnout. Rarely is it one stressor that affects mental health and burnout. Rather, disasters, community crises, or life adjustment events lead to complex stressors that can exacerbate preexisting mental health concerns or deplete coping mechanisms. The COVID-19 pandemic required health care providers and support staff to work longer hours in high-stress situations, increasing preexisting burnout.⁵ However, the pandemic did not occur in isolation as other life stressors, such as disasters and negative community events, further affected provider well-being.^6,7

Research or Assessment Questions

The combination or coexistence of mental health problems and complex stressors, both personal and work related, can lead to burnout.⁸ Many scholars have discussed the theoretical implications of provider mental health⁹; however, there is a need for more input from the health care workforce on what type of mental health services would improve well-being. The purpose of this study was to investigate the mental health and burnout of the health care workforce in areas prone to natural disasters. Specifically, we explored in depth how complex stressors affected their work–life balance.

Participants, Sample, Geographic Location, Setting, and Year of Study

Seventy-two health care workers from two health care systems in southeastern Louisiana completed an online survey via Qualtrics (n = 51) or participated in five focus groups (n = 21) between June and December 2022. The ages of participants were as follows: 15% were aged 20 to 29 years, 39% were 30 to 39 years, 30% were 40 to 59 years, and 16% were 60 or older. The majority were married or living with someone in a marriage-like relationship (69%) and identified as female (78%; 22% male) and White (57%; 28% Black or African American, 5% Asian, and 10% Hispanic/Latinx). Thirty-nine percent made less than $50 000, 41% made between $50 000 to $90 000, and 20% made more than $90 000. Of the participants, 4% were in allied health, 18% in behavioral health, 10% in medicine, 26% in nursing, 14% in public health, 14% in health administration, 11% were support staff, and 3% were missing data. Table 1 provides the frequency and percentages of life adjustments or stressors, mental health, and burnout.

TABLE 1—

Percentage of Participants’ Life Stressors, Mental Health, and Burnout: Louisiana, 2022

	Health Care Workers (n = 51), No. (%)
Life stressors
New job/career	21 (41)
Social isolation	20 (39)
Move	18 (35)
Behavioral health problems	17 (33)
Financial problem	13 (26)
Other stressors	12 (24)
Death or illness of a close friend or family member	12 (24)
Disaster	11 (22)
Loss of income	9 (18)
Unemployment	4 (8)
Childbirth or adoption	2 (4)
Legal trouble	2 (4)
Mental health
Anxiety	13 (26)
Depression	8 (16)
Burnout
Probably no burnout (< 10)	11 (22)
Mild burnout (10–13)	15 (29)
Moderate burnout (14–17)	12 (23)
Severe burnout (18–22)	8 (16)
Very severe burnout (≥ 23)	5 (10)

Note. Data are from the quantitative survey (n = 51). A cutpoint of ≥ 3 was used to determine clinical significance of anxiety (mean = 1.9; SD = 1.7; α = 0.85) and depression (mean = 1.3; SD = 1.7; α = 0.85). Minimum burnout score was 8, and maximum was 40 (mean = 15.0; SD = 7.1; α = 0.91). Depression and anxiety rates for administrators were 14% and 14%, respectively. Anxiety was higher for providers (27%), and depression for providers (16%) was close to that of administrators. Moderate to severe burnout was 42% for administrators and 50% for providers.

METHODS

Health care entities were chosen based on a convenience sample of administrative requests for help with provider well-being in disaster-prone locations. Participation was voluntary; surveys were anonymous to encourage disclosure, and identifying information was not collected. Focus groups were held online using Zoom technology and lasted 60 minutes to one hour and 60 minutes. Prompts were developed by the focus group leaders and in collaboration with the administration and included the following: How has the COVID-19 pandemic changed the work situation in positive and negative ways? What does burnout look like in the organization? What challenges do you see in the work environment? What do you do to take care of yourself? Zoom recordings were transcribed, and ATLAS-ti qualitative software (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) was used to group data into 262 unique pieces of phrased data (i.e., responses). Two researchers reviewed the codes and themed them accordingly. Fifty-one participants completed the online survey and answered brief validated scales on mental health, including anxiety and depression (Patient Health Questionnaire-4)⁹ and a subscale on burnout.¹⁰

KEY FINDINGS

Two themes were identified: work environment and well-being. Responses were grouped by administration versus provider or staff. Table 2 presents the themes, subthemes, and quote examples by participant type.

TABLE 2—

Qualitative Quotes Supporting Themes and Subthemes of Work Environment and Health Care Workforce Wellbeing

Theme: Work Environment (172 Responses)
	Administration (Responses = 25)	Staff (Responses = 26)
Adaptability	So I think it’s a combination of a lot of things that make us able to get to the other side … we’ll do whatever it takes to get to the next milestone … to get back functional.	We’ve shown over and over again over the last 3 years, you can throw a lot … at us and we’re going to make it to the other side. We might be raggedy and tired and beat down, but we will be on the other side every single time.
	And what does that take? It takes commitment, it takes the ability to be able to make the hard decisions and push your employees to make them better because it’s going to make the work that we do out in the community stand out just that much.	That sort of added flexibility I think has helped for at least staff that can work remotely. So I’d say that’s become a positive.
	Administration (Responses = 5)	Staff (Responses = 25)
Workload and staffing	So I think we have a different staffing landscape now than we’ve had before … regarding [paid time off] with being out sick or my kids being out sick; can I get some more time so that we can go on vacation?	They set that minimum, but also having a maximum too … a cap … of the patients that you have … if I had to do 15 notes in a day then … I’d be there until 9:00 at night doing notes.
	…challenges of trying to assure that we’re getting that right balance for the mission and then also meeting the needs of the staff.	I think what most people may feel is that burnout comes when the tasks are at 10 and then 10 minutes later tasks are at 50.
Scheduling	Administration (Responses = 0)	Staff (Responses = 24)
	…	It’s like, ‘Oh, hey, you have an opening on your schedule; can you talk to this random person that you’ve never met before, and they’re suicidal’?
	…	My schedule, I have no opening next week, not even if one of my patients calls in sick needing to be seen. I have nothing available, and that makes me sad because you know what I end up doing? Okay, you can come at 12:00. That’s my lunchtime. And I’m using my catchup time when I’m checking labs.
Incentives	Administration (Responses = 24)	Staff (Responses = 14)
	So our goal is always to look for the best way to take care of our employees. I find that is the best strategy for retention.	I’ve been doing it for 10 years, and it just takes one patient who is grateful to keep me working where I am. You know what I mean. That’s what makes me keep doing what I’m doing because I think that I make a difference.
	We know that the pay is near the top, but it’s not just that. It is a nice new desk.	Keep the pay competitive. I mean, for the type of work that we’re doing, there’s a lot of places—fast food chains— that pay close to what some of us are making, if not more.
Policies and procedures	Administration (Responses = 8)	Staff (Responses = 21)
	We have a handful of providers who will communicate with one another, but if many more can get on board I think that’ll help the workflow.	So, communication is the key. If you don’t communicate then everything’s gonna be chaos.
	We always talk about that. Let’s make sure that our staff has the correct tools to do what they need to do. And the right number of people to do it.	That’s just how they do it and this is just what they do, but this is not the overall policy. If we’re all going to be collaborating and working together and doing the same jobs then we all need to be doing the same steps in the process.

Theme: Well-Being (90 Responses)
Mental and behavioral health	Administration (Responses = 10)	Staff (Responses = 9)
	I can tell that [they are] overloaded. You know, [they] don’t put it on me or do anything like that, but I can tell that it’s too much.	So, I know for me it’s irritability, feeling short, loss of focus, and also just feeling super fatigued.
	We notice a decline in their [employees’] attitude about work, their productivity.	[Patient] was scared to death. And that still haunts me a little bit. I guess I have a little PTSD from that.
Loneliness	Administration (Responses = 7)	Staff (Responses = 7)
	The importance of having colleagues, that your work isn’t just you individually, that it’s how you connect with other people. And I think having virtual options makes it harder to do that.	I was pretty stressed out just because I felt disconnected from my people. And that, after a while, took a toll.
	And then as time goes on, it’s the question of how do you keep people connected within the organization and within their team when they are not physically in the same location and how do you work through that?	I was lonely. I’m stuck by myself. This isn’t fair.
	Administration (Responses = 3)	Staff (Responses = 28)
Self-care	I am fairly unskilled at that [self-care].	I know I need to do better, though, so I can prioritize myself.
	That’s an area [self-care] in which we are not good.	So, I think it’s very important for everyone to practice it [self-care] or at least be open to making space for it in their lives and stuff.
	Administration (Responses = 16)	Staff (Responses = 10)
Complex stressors	COVID is, it’s kind of a national thing … affecting everyone. But when you start talking about the differences between Hurricane Ida and the COVID-19 pandemic, it’s one thing to say that this was done during the daytime and it worked. But when you have to bring it home in the evening and deal with it, it consumes your daytime and your nighttime. I think it took a toll on the staff as a whole.	I don’t know how much of it is, ‘Oh it’s COVID, it’s work’ versus how much of it’s me just adjusting.
	COVID was more of a slow burn. It was a change in how we operated in our offices, but it didn’t change our offices and our locations. [Hurricane] Ida changed peoples’ locations drastically.	The dust was settling from COVID, we had like the new norm, and then [Hurricane] Ida kind of uprooted everybody.

Note. Data are from the focus groups (n = 21).

The work environment theme yielded 172 responses. Subthemes within work environment included adaptability, scheduling, workload and staffing, incentives, and policies and procedures. Scheduling appeared to be the largest complaint because of its impact on daily routines; for example, multiple schedulers without clinical knowledge, lack of a screening process, and overscheduling. Scheduling adequate time for notes, consultation, and patient visits may seem intuitive, but as reported by the providers, it is not consistent. Differing from providers, administrators discussed staffing challenges and providing resources such as disaster pay and additional paid time off. Staff noted the inability to take time off because they come back to a hectic workload, and the need for clearly communicated policies and procedures with feedback loops to ensure two-way communication.

The well-being theme yielded 90 responses. Subthemes within well-being included mental and behavioral health, loneliness, self-care, and complex stressors. Among both administrators and providers, many noted being stressed; however, the administrative responses were more focused on workforce mental health and productivity, whereas providers focused on their own symptoms. For loneliness, responses were evenly split among administrators and providers, and many reported the shifting of office space and culture as contributing to isolation. Feelings of isolation were reported because of increased virtual work and displacement due to the hurricane. Regarding self-care, providers noted the importance of activities such as vacations and travel, prayer, environmental escape, massage, journaling, hobbies, and leaving work at work. Another difference between administrators and providers was the number of self-care responses, with only a few administrators noting the importance of self-care. Complex stressors or the cumulation of challenges were noted by all. Specifically, Hurricane Ida, which occurred in August 2021, was very stressful at the provider and administrative levels.

EVALUATION, TRANSFERABILITY, AND ADVERSE EFFECTS

In the current study, 16% and 25% met the cutoff for clinically significant depression and anxiety, respectively, which are consistent with health care workforce rates found in other studies.³ Provider anxiety rates were almost double those of administrators and were about the same for depression. Further, almost half (49%) reported moderate to very severe burnout, which is similar to findings from other studies¹⁰ and compounded preexisting pandemic burnout.¹¹ Qualitative responses revealed that burnout is not siloed; rather, it is a balance of work environment and personal well-being that not only changes over time but requires an understanding of administrative structure, provider effectiveness, and staff efficiency. Administrators were more focused on the incentives they provided, as this was their solution to retention. However, retention is only one part of burnout, and other organizational efforts are needed—specifically, scheduling, workload, and staffing.

Improved work environment alone is not enough to change burnout; provider well-being and work–life balance are also contributors.¹² Participants noted access to mental health and office connectedness to combat loneliness as ways to improve their well-being. Staff were also astutely aware of the importance of self-care and how it is the intention behind small acts that can pay off. One provider noted that “sometimes … at work … I need two minutes for myself. I just step out and I tell everybody I’m coming right back … take a little breathing and then go back inside.” Another noted that “it’s not always like these big things that you have to do to make yourself feel special. Sometimes it’s the little things that you do daily that you have that intention.” Although we did not have a particular question on natural disasters, respondents were clear that a recent hurricane affected their well-being. Allostatic load, or the cumulative burden of mental and physical health stressors,¹³ can vary by person, but the compiling of stress and life events will eventually take a toll.

SCALABILITY

The health care workforce represents a group of dedicated and compassionate individuals. In recent years, additional stressors and several tragic and high-profile situations highlighted the degree to which burnout is affecting health care providers and the health care workforce. These findings offer an important first look into the similarities and differences among administration and providers regarding burnout and workforce retention in disaster-prone regions. Given demographic and cultural differences, a one-size-fits-all approach will not address the burnout situation. Similarly, geography, politics, and work environments are likely to differ. This study’s voluntary nature increases the likelihood of bias selection (i.e., participants wanted to share personal experiences); however, their responses may also indicate that, because of multiple disasters, this population is exposed to more challenges. Basic research techniques employed in this study can be utilized by administrators to individualize plans specific to their workforce. Further, large-scale and more generalizable studies can help identify plans or structures that may be a good starting point for addressing common issues, such as scheduling, communication, and well-being.

PUBLIC HEALTH SIGNIFICANCE

Administrators and staff noted the dedication and commitment to their work, but communication and listening from both parties are needed. Clinics and hospital systems could make the most impact by improving scheduling with provider input and then communicating changes directly to staff. Collaborative scheduling will help autonomy and workload, both known contributors to burnout.² Normalizing and adding access to mental health supports, especially in disaster-prone regions, will also improve well-being; many staff noted that they did not have a place to access services. Telehealth and artificial intelligence may be cost-effective ways to support provider mental health, while maintaining anonymity and avoiding the stigma of accessing service where they work.¹⁴ Similarly, creating scheduling and billing codes for dedicated self-care time may help engagement in self-care activities and provide the basis for a return on investment that can be compared with retention rates. The findings highlight the urgent and immediate need to alleviate the growing risk of burnout by implementing system changes and interpersonal supports, and by improving work–life balance informed by administrative and provider perspectives.