The Role of Psychiatry in Treating Burnout Among Nurses During the Covid-19 Pandemic

Abstract

The prevalence of burnout among US registered nurses ranges from 35 to 45%. In one study, nurses had twice the rate of depression compared with other health care professionals. Owing to the Covid-19 pandemic, burnout is a major threat to the stability of the workforce on the front lines. Consultation-liaison (C/L) psychiatry can provide assistance through liaison meetings, stress management programs, and curbside consults to help reduce the risk of burnout. Narrative medicine programs, mindfulness-based stress reduction, and meditation apps are additional means to alleviate stress. Given the current challenges facing C/L psychiatry and the mental health field in general, there is an urgent need to overcome stigma and financial barriers to make treatment readily accessible.

While the term burnout was popularized by Graham Greene in his novel, “A Burnt-Out Case” in 1961, initial health care research was carried out by Freudenberger and Maslach in the nineteen seventies (Freudenberger, 1974; Maslach, 1976). Burnout syndrome is included in the recent 11th revision of the ICD as an occupational phenomenon (WHO, ICD-11, 2019). It is a syndrome, most commonly diagnosed using the Maslach Burnout Inventory, that results from chronic workplace stress that has not been adequately managed (Maslach et al, 1996). It is characterized by exhaustion, negative feelings or cynicism related to one's job, and reduced professional efficacy.

Recent studies indicate that the prevalence of burnout among US registered nurses (RNs) ranges from 35 to 45% (Dyrbye, Shanafelt, & Sinsky, 2017; Li et al., 2018; Moss et al., 2016). Nurses are more likely to have higher levels of stress, get less sleep, and are more likely to be overweight than the general population (Eanes, 2015; Lee et al., 2011; Melnyk et al., 2013; Thacker et al., 2016).

Compassion fatigue is a type of burnout that more often affects nurses because of the constant emotional connection they have with their patients. Secondary traumatic stress stems from unanticipated events such as the loss of a patient or a medical error. These work-related conditions if left unmanaged can lead to depression, which as opposed to burnout, is felt in all areas of life. Letvak et al. (2012) studied depression among RNs and found almost twice the rate compared with those in other professions.

In a 2016 review of 36 articles, Brandford and Reed summarized the predictive and protective factors related to depression in nurses. The main predictors were women who were younger, less experienced, single or divorced, those working more shifts, exposed to workplace trauma or violence, with a lack of support, with diminished role boundaries, and with overall lower job satisfaction. Protective factors included being older, married, having more experience and higher job satisfaction, self-efficacy, sense of optimism, and learned resourcefulness (Brandford and Reed, 2016). There is a higher rate of suicide among nurses, with higher rates of mental illness and previous suicidal history. Benzodiazepines and opioids are the most commonly used substances in nurse suicides (Davidson et al., 2019).

Current Covid-19 environment

For decades, health care facilities have been facing fiscal pressures. These are now reaching catastrophic levels given the Covid-19 pandemic. There are widespread cuts in pay, jobs, and hours for nurses and doctors as a result Levy, 2020, Silver-Greenberg, Drucker, & Enrich, 2020. As care has moved more and more to the outpatient setting, hospital providers are being bombarded with treating only the sickest, most challenging, complex cases. Owing to ever-decreasing length of stays, there is a constant pressure to move patients quickly from admission to discharge. Owing to the increased pace along with staff shortages, nurses and doctors are feeling as if they can never do enough to keep up with the runaway demands.

With the sudden surge of the Covid-19 pandemic, many institutions that were already feeling the aforementioned constraints are now forced to operate under battlefield conditions. Given the high mortality rate that many have experienced working with Covid-19 patients, the lack of proper personal protective equipment, and the stress of being urgently deployed to medical intensive care units and Covid wards, even when feeling unprepared to do so, burnout is a major threat to the stability of the workforce on the front lines (Cabrera, Karamsetty, & Simpson, 2020). In one large study, female nurses providing front-line care to Covid-19 patients in China were found to have the highest levels of depression, anxiety, insomnia, and distress (Lai et al, 2020).

For many, ethical issues have arisen over the conflict of wanting to serve versus the fear that they will either contract the illness themselves and/or infect their families. With patient families not allowed to visit their dying relatives, staff are being called on to initiate painful online or phone conversations. Similar to what veterans endure, many health care professionals serving on the front line are experiencing trauma that could lead to post-traumatic stress disorder (PTSD) and burnout. This has created a massive need for mental health services not only in the short term to address staff burnout but for the millions affected by the pandemic (Cabrera, Karamsetty, & Simpson, 2020; Pfefferbaum & North, 2020; Rajkumar, 2020).

The role of psychiatry

Psychiatrists and mental health professionals routinely work with patients and staff suffering from burnout and PTSD. Consultative-liaison psychiatry (C/L psychiatry), dating back to the mid 18th century, is that branch of psychiatry that specializes in the interface between general medicine/surgery and psychiatry. George Engel, MD, and others in the mid nineteen seventies are credited with promoting the biopsychosocial model and accelerating its integration into modern-day medicine (Bourgeois & Sharpe, 2020; Engel, 1977; Schwab, 1989). C/L psychiatry is charged, as part of their liaison function in hospital and clinic settings, with creating programs that address caregiver stress and burnout. Typically these take the form of weekly or monthly interdisciplinary meetings with other medical-surgical departments that provide support and guidance when working with the most challenging, high-risk patients.

Common areas of collaboration include psycho-oncology, pain management, cardiology, morbid obesity and bariatric surgery, poorly controlled diabetes, high-risk OB, burn units, transplant services, and many others. Sometimes these groups are run by the medical service, where a mental health worker is employed as a regular member of the team.

This intervention alone has been demonstrated to lessen the impact that doctors and nurses face when having to treat patients without the necessary support from psychiatry/mental health services (Bourgeois & Sharpe, 2020; Wood et al., 2014). They provide a safe outlet to express their anxieties, fears, grief, and hopeless/helpless feelings in addressing the mental health needs of their patients. This can reduce stigma and encourage others to also seek out help. In overcoming their sense of isolation, staff begin to appreciate their unique contribution as a member of the health care team.

C/L psychiatry meetings can also serve as a safe place to express concerns over the demands of the workplace and to brainstorm with their colleagues about how to work together in a more effective way. Staff can leave feeling renewed and more optimistic knowing that they are part of a proactive process that is addressing many of their fears and concerns.

For example, being confronted with an acute psychiatric disturbance in the medical setting can be traumatic for many staff, who are untrained in providing mental health care. C/L psychiatry can bring in innovative solutions to help bridge the gap if properly funded. By supporting staff and patients doing timely curbside and formal consults, they can educate and support staff on how to better address the mental health needs of their patients. By attending rounds or forming liaison meetings described previously makes them an essential member of the team. This can substantially lower the stress level and help to prevent burnout.

Current challenges faced by psychiatry

What makes this time a particularly dire situation is that psychiatry and social work departments are routinely underfunded and strained, so are unable to keep up with the demand to support their medical colleagues. The insurance industry plays a major negative role, as reimbursement levels are routinely substandard for mental health, making it difficult for administrators to risk hiring the additional needed staff. In the United States, in spite of Parity laws aimed at ensuring equitable care for the mentally ill, insurance companies have increasingly been taken to court over violating these laws (CMS 2008; Xu et al, 2018).

Owing to the limited staff available, a lunch hour continuing medical education series that focuses on a range of relevant mental health issues can be presented to many medical staff live or provided online. The topics include coping with death and dying presented jointly with palliative care and hospice, management of common psychiatric emergencies, psychopharmacology, diagnosis and treatment of depression, anxiety, PTSD, dementia, or psychosis. As well staff can be trained to improve their communication skills when working with difficult patients and families, to learn to recognize early warning signals, and how to deescalate a crisis. In the end, the goal is for C/L psychiatry departments to establish good working relationships with staff that keep communication lines flowing and allow for team building.

Additional means to alleviate stress

Other ways that mental health professionals can help to relieve or prevent burnout include initiating journal clubs that use articles as a spin off for discussion of difficult cases.

Narrative medicine get-togethers, such as the AfterWards program at Johns Hopkins Hospital, is an opportunity for participants to be with their colleagues from other departments and be offered the opportunity to express their feelings through an exploration of literature, art, music, and writing (Khazan 2015). There has been continued growth of these programs, which also help clinicians develop better communication skills. Examples include the Keck School of Medicine (University of Southern California), the Lewis Katz School of Medicine (Temple University) and the School of Professional Studies (Columbia University).

Stress management programs are usually offered by mental health staff and can consist of only one or two sessions, an 8- to 12-week program or open weekly sessions, where mindfulness-based stress reduction (Luken and Sammons, 2016), cognitive behavioral skills, self-care, yoga, tai chi, and overall wellness can be taught. The Stress Management and Resiliency Training program, which blends web-based interventions with independent reading and facilitated discussions, was found to decrease anxiety, stress, and burnout among nurses suffering from burnout at 3-month follow-up (Magtibay et al, 2017). These programs have been found to prevent and lessen the impact of burnout (Almen and Lisspers, 2019; Rowe, 2000; Stier-Jarmer and Schuh, 2016). Radiologists and staff report a dramatic increase in stress as a result of the Covid-19 pandemic. Fessell and Chernis report on the effectiveness of using “micropractices” to prevent burnout and for emotional wellness. These include brief mindfulness breathing exercises along with other self-awareness techniques (Fessell and Cherniss, 2020). In addition, countless numbers of apps such as Calm and Headspace are readily available to learn and practice stress management.

These programs and apps offer a combination of the following approaches:

• 1.Cognitive restructuring and reframing
• 2.Stress management and relaxation skills
• 3.Yoga/tai chi, mindfulness meditation
• 4.Grief counseling
• 5.Brainstorming around ways to change workplace and workload
• 6.Writing workshops
• 7.Music and art therapy
• 8.Learning communication skills
• 9.Building workload and organizational management skills

Summary and conclusions

C/L psychiatry and the entire mental health community is there to help prevent and treat the ever-increasing crisis of burnout that is striking many of our colleagues during the Covid-19 pandemic.

In addition to the group-based modalities described previously, mental health professionals are there to offer individual treatment for those staff suffering from a mental illness that is not improving in spite of attending one of these programs. Warning signs include worsening depression with increasing isolation, apathy and lack of interest, substance/alcohol abuse or dependence, suicidal thoughts, post-traumatic stress symptoms, phobias, panic attacks, hypochondriasis, intrusive generalized anxiety or obsessions, and insomnia. As burnout can include a multitude of these overlapping symptoms, it is often necessary for staff to have easy access to these services so that an accurate diagnosis and treatment plan can be established. Treatment can include psychiatric medication and individual psychotherapy and if necessary appropriate referrals for a higher level of psychiatric care.

Employee assistance programs (EAPs) need to be enhanced and be made readily available to staff especially during this crisis. These unfortunately only offer a few sessions though before a referral is given.

Barriers to treatment include the stigma of acknowledging that treatment is needed. Sadly the “macho culture” still prevails within health care, where it is seen as a weakness to admit that one needs help. In addition, health care professionals feel compelled to help at all costs, so admitting that they are not up to the task is considered to be taboo. Because of this, they may be reluctant to confront their superiors to work toward effecting positive change in the workplace.

Other barriers include lack of health insurance that offers ample mental health coverage without a burdensome high deductible or copay. In addition finding the right professional whether it's a social worker, psychologist, or psychiatrist can be challenging even for those in the health care field.

Either way, studies show that initiating treatment either through accessing an EAP, joining a group program, engaging in enhanced self-care, and/or seeking out individual treatment with a therapist or psychiatrist can prevent burnout. Hopefully by all working together, we will overcome the obstacles that prevent easy access to essential mental health care.