Burnout, Anxiety, and Depression: the Pandemic and Implications for Healthcare Workers

Hello, I’m Dr. Carlo Carandang with AnxietyBoss.com. Today, we will talk about burnout, anxiety, depression, the pandemic, and implications for healthcare workers. I gave this presentation on April 2021 to nurses at a webinar sponsored by FindaTopDoc.

Pandemic and Effect on Society

So let’s talk about the pandemic and its effect on society. So people keep saying that we’re going to be experiencing a new normal but there’s nothing normal about this pandemic and how it’s affecting us. Really what’s going on is an evolutionary change that’s nothing we’ve seen before. So what’s happening is you’re experiencing profound social, occupational, economic and political changes. And what’s significant about this pandemic is that there is no end in sight- the future is unknown and uncertainty is pervasive. In addition, there’s this breakdown in communication, as us wearing masks hides our non-verbal communication, so it further isolates us from one another. When we’re not in lockdown, then we’re hiding behind masks and we’re missing out on our human need to communicate with each other. So the masks in itself actually hides us from each other, further isolating us from each other. So the pandemic has been quite detrimental for us social beings who need to communicate with one another.

Pandemic and Effect on Healthcare Workers

So let’s talk about the pandemic and its effect on healthcare workers. So healthcare workers are exhausted- they’re exhausted physically, mentally and emotionally. And with regards to the crisis, it’s just there seems to be no end in sight- the crisis is now chronic and the thought of future waves is just more than what workers can bear. So burnout from the pandemic and the consequences of it will become more apparent in the coming years and I’m afraid you’re going to see large numbers of people who actually leave healthcare because of the strain that that it has taken on our health care system and its workers.

Before I get into defining what burnout is and the consequences of burnout, I want to also let you know there’s only so much that individuals can do but with regards to the mental health and physical well-being of healthcare workers. It’s really the duty of hospitals and public health authorities to ensure that their health care workers are not exposed to the virus. It’s also their duty to maintain the mental health of their health care workers. Also I would say that doctors need to advocate to hospital executives for the well-being of their staff, because doctors let’s be honest- you can’t do your jobs without health care workers; you can’t do your jobs without the nurses; you can’t do your jobs without the clerks; you can’t do your jobs without the people who are assisting you in surgery; you can’t do your jobs when no one’s following your orders, right? So doctors- you have to advocate for your healthcare workers- you have to do it this- you have the power and you have to advocate for your workers in hospitals. You need to do a better job of protecting your workers and ensuring their mental health- it’s your duty. So let’s get with it!

Duty of Hospitals and Public Health Authorities

The rest of the talk is going to be about how the individual can help prevent burnout, but there’s a duty of hospitals and public health authorities to ensure the mental health of their health care workers, while at the same time protecting them from contracting the Covid virus. So with regards to how to affect change at a hospital administration level, I would recommend that you unionize, so that the union can advocate on your behalf. As I mentioned before, please align with your doctors so that you can affect change to support better working conditions for healthcare workers. Again, doctors can’t treat patients without healthcare workers. So that’s just the reality- doctors, get out there and advocate!

So the public has immense respect for health care workers- they really appreciate that you go out there every day and you risk your lives to help those who are suffering from this from this virus, this disease. So what you can do is try to get the public behind your cause because they are sympathetic to you, and if you get the public behind your cause then soon the hospital executives and the public health authority will be forced to comply. So get the public behind you because they already have immense respect and gratitude to you- okay, that’s enough with regards to institutional and societal duties to healthcare workers.

What You Can Do to Address Burnout

Let’s now talk about how you can help yourselves to prevent burnout. So before we go into how to prevent it you got to know what it is. So burnout is commonly referred to as being stressed out. So burn out is a result of exposure to mounting stressors, be it from your job, be it with relational problems, be it financial problems. So burnout is when these stressors overwhelm your capacity to cope with them. So you wouldn’t get burnout if you had adequate coping skills to deal with the stressors. However once the stressors overwhelm you and it overwhelms your ability to cope with them, then this could lead to burnout. So if you continue to have all this stress and you don’t get proper help, then you can develop burnout which is also known as being stressed out. So with burnout, this is equivalent to an adjustment disorder where you start to have symptoms of anxiety and/or depression, but it is not full-blown anxiety disorder or major depressive disorder yet. All right- so here’s a flow chart- going to break out my laser pointer. So in this burnout flow chart here are the stressors. So again the stressors could be job pressure, relational problems, illness in the family, child rearing, looking after elderly parents, financial burden. So the normal things that families go through these are called stressors. So ideally you’d have support- you’d have adequate coping skills- you’d had a stable mental health to actually deal with all these things. However, with mounting stressors, it overwhelms your coping skills, then this turns into stress. Then pretty soon, once it lasts a long time or becomes more frequent, the stressors can lead to burnout, also known as stressed-out. Clinically, this is known as an adjustment disorder. So if it continues, the burnout could lead to significant mental illness such as anxiety disorders and depressive disorders, and the unfortunate outcome of both of these if you’re burnt out, if you have burnout, or if you have anxiety/depression, that this ultimately leads to departure from your job due to disability. Or you know in worst cases, due to a progression of these disease states, some cases lead to suicide- and you don’t hear about suicide a lot amongst healthcare workers, but it happens, you know depression untreated could unfortunately lead to suicide. So there’s pretty significant implications for burnout and if you don’t deal with it, you can have departure from your job and then you can suffer ultimately from significant mental illness such as anxiety disorders and depression. So with regards to burnout and adjustment disorder, if you continue to have all the stress and you don’t get the proper help, then you can develop burnout as I showed you on the previous flow chart. Again, clinically, burnout is the equivalent of an adjustment disorder where you start to have symptoms of anxiety and/or depression, but it’s not full-blown anxiety disorder or depressive disorder yet. So it’s really important to deal with the stressors you’re facing every day when you’re treating patients being exposed to the virus when you go to the hospital every day and the strain this is taking on your mental and emotional well-being. If that gets too overwhelming, burnout, which is also an adjustment disorder, can easily occur in your circumstances.

What are the Symptoms of Burnout?

So what are the symptoms of burnout or adjustment disorder? Well, it’s basically you just look at the symptoms of anxiety and depression and you’ll find the symptoms of burnout. So really these are what you see- when I’m treating patients with anxiety and depression, this is what you see when people have anxiety disorders and depressive disorders. So burnout shares the same symptoms such as irritability, fatigue, insomnia, poor concentration, poor appetite, anxiety, depression, anhedonia- where you’re not finding pleasure in things anymore, negativity, social isolation and poor job performance- and then fantasies of quitting. So these are some of the symptoms of burnout, and if you want to detect the early signs of burnout- if you want to see if you might be on the road to burnout, this could look like being frequently absent from work, being constantly late for work, your work performance has decreased significantly, you have a pattern of mistakes or minor accidents, you have a lack of energy, lack of enthusiasm, you can have emotional outbursts in the workplace, and you might have unwarranted complaints toward the workplace co-workers and administration. However, as I mentioned before, those complaints against administrations are most of the time well-founded- do not let the hospitals and the public health authorities off the hook- they’re responsible to ensure that you are protected from disease, contracting disease from your patients, and they’re responsible for your emotional and mental well-being. So I’m talking about these unwarranted complaints- when it’s beyond what’s reality. Another way to detect early burnout is that you’ll see repeated complaints from coworkers or from patients about the care that the healthcare worker has provided. So these are some early signs to detect burnout.

Burnout Can Lead to Anxiety and Depression

So when you have burnout, then you are at risk for the development of an anxiety disorder or major depressive disorder. So anxiety and depression are really two sides of the same coin. So if you don’t get help for burnout, then you may develop an anxiety disorder and/or depression. So which one develops depends on how you think about your stressors. So here’s this flow chart- let me get my pointer out. So here’s chronic stress. So if you continue to experience chronic stress, which turns into burnout (which is also called an adjustment disorder clinically) then this could either progress into an anxiety disorder or depressive disorder. So how it actually differentiates is really how you think about it. So when you have stressors and you’re burnt out- if you’re thinking “I’m going to fail and something bad will happen”- this type of thinking can lead to anxiety disorder, and if you’re thinking “all is hopeless” or “I’m useless” then this could lead to depression. So what develops, anxiety versus depression, really falls to how you’re thinking about your stressors and dealing with it. So these are some of the thought patterns that may occur which leads to these different states.

Development of Anxiety Disorder

So with the development of anxiety disorder, then this could actually develop from this negative cycle of anxiety. So here’s a trigger and this is the stressor. So this could be real or imagined danger. So this trigger or stressor can lead to thoughts about the stressor: “I feel bad, so it must be bad- I can’t cope.” “Something terrible is going to happen” and then this could lead to feelings of being anxious and fearful and then you might have physical symptoms of anxiety- you know lump in the throat, butterflies in the stomach, constant muscle strain, headaches- those type of things and then these feelings can then lead to behaviors where you avoid or escape to try to deal with your negative feelings and your negative thoughts and you try to cope by doing things that help you feel better or make you feel safe. Then this then leads back to more negative thoughts, more negative feelings, and it just feeds into one another with this vicious cycle of anxiety.

Development of Depression

And here is the negative cycle of depression. So it starts here with the trigger, which in this case can be job stress, then this leads to thoughts of hopelessness, that you’re useless, and I can’t handle distress, then the negative thoughts induced depressive feelings, feeling blue, sad, and then these depressive feelings then leads to avoidance. So the behaviors can include isolation, withdrawing and putting off work deadlines, being late for work, or just withdrawing from work entirely. And then these behaviors then maintain the thought that all is hopeless, then it continues this negative cycle of depression. It’s a vicious cycle actually, because it just keeps getting worse and worse every time it goes around.

Resilience

So how do resilient people handle stress? Because you know not everyone reacts to stressors the same way. So those of you that are burnt out may wonder how those around you who are being exposed to the same stressors are actually handling it and appeared to be doing well. So the answer is that these people are probably resilient in the face of such stressors. So there are multiple ways to have resilience in the face of stressors and adversity. So the first thing is a positive attitude. So thinking negatively makes you feel sad and bad. So having a positive attitude will put you in a better mood to deal with things better no matter how distressful. People who are resilient also have hope for the future. So they are optimistic and have hope that things will improve despite a temporary setback that will help them climb out of the hole they’re in. So another thing that resilient people have is that they see failure as constructive feedback. So resilient people see failure as a way to learn from the mistakes they made that contributed to the failure. So in times of crisis resilient people take this as an opportunity to learn and develop. So it’s an opportunity to change for the better. Resilient people also deal with challenges as they happen. So they don’t delay in dealing with complex problems or challenges. Procrastination only leads to delays that can make the situation worse. Resilient people also lower their expectations. So if you have high expectations of yourself and others then you will be disappointed most of the time, as you and other people can’t be perfect or have a positive outcome all the time. So the key for resilient people is to aim for average and if the outcome is above average then you will be that much more satisfied, and if the outcome is below average then you don’t have far to reach the average or good enough outcome. So lowering expectations is another thing that resilient people do. Also, resilient people are flexible. So people who are resilient are flexible in their thinking and flexible in interactions with people. So they let things slide- they don’t sweat the small stuff. So save your energy for more difficult challenges. Resilient people also focus on things that they can control. So resilient people don’t worry about the things they can’t control. So just focus on what you can do- if it’s something external to you, like the hospital administration, there’s things you can do to affect change at that level as I mentioned before. Okay, but there’s other things you can’t control, so why focus on them? Another thing that that resilient people do is that they regulate their emotions. So resilient people are steady with their emotions even when things around them become chaotic and are out of control. So regulating emotions is very important. So there’s different ways to do this- I’ll mention this later, but things such as meditation, yoga, progressive muscle relaxation- these kind of things help quiet your mind, if you’re having problems regulating your emotions. Some of these self-care techniques do actually quiet your mind.

How to Deal with Burnout, Anxiety and Depression

So burnout anxiety and depression. So how do you deal with it once you get to the point you get burnt out or you get anxiety or you get depression. Right- again burnout is an anxiety disorder- it’s clinical- this is what mental health professionals treat- we treat all these things right. So the first line of therapy is psychotherapy- go to a therapist. Each one of you healthcare workers has an employer with an employee assistance program. So these programs are set up for you to help you when you have clinical problems such as adjustment disorder, anxiety and depression. So go see a therapist- take advantage of your EAP program and get the help you need. So get on with a therapist if you’re experiencing these things. Cognitive behavioral therapy and short-term psychodynamic therapy are both effective for dealing with anxiety and depressive disorders. Also, when it comes to the point where your anxiety disorder or depressive disorder such as major depressive disorder are becoming more prominent and it’s not responding to psychotherapy, then at that point you may need to see a psychiatrist and the psychiatrist then has different medications such as SSRIs and SNRIs to help deal with your anxiety and/or depressive disorders.

Q&A

Now I’m going to go into questions and answers- I was hoping to do this in person for live conferences, but unfortunately with the pandemic here we are- we are doing things virtually. So I was asked to do this talk for a nursing association to help them to help health care workers with dealing with burnout and stress. So unfortunately this has to be done virtually. So I was asked to pre-record this and here’s some questions that the organizer had from their constituents.

So the first question: what are some practical everyday techniques healthcare professionals can implement to avoid burnout? So self-care is very important- you have to quit isolating. I know you’re out there slogging away in the hospitals treating patients, but you do have to focus equally on your self-care- on what you eat- on exercise and doing things that make you feel good. So get a massage, go get your hair done when if it’s safe to do so from a health public health perspective. So go out there and do the things for self-care, and if you’re isolating and if you’re on lockdown then there’s things you can do at home to actually affect self-care such as working out at home, exercising at home, and socializing with people, like what we’re trying to do right now through video conference. You can also try relaxation techniques such as yoga, meditation, diaphragmatic breathing and progressive muscle relaxation. So all these techniques are- I’ll point you to a website at the end where all these techniques are listed in a video and a guide, a step-by-step guide through videos to help you with some of these relaxation techniques. So at the end, I’ll give you that website. You can also reach out to family and friends. Please take mental health days or go on vacation to recover. So if you are getting stressed out on any particular day for any particular reason, take a mental health day, or take a vacation to recover and lastly the advice is that a previous slide on resilience- what resilient people do- just copy what they do and pretty soon you could be a resilient person that deals with stressors adequately. So you could function at your job better and you can have stable mental health and emotional well-being.

The second question: many health care professionals have expressed feelings of grief from the losses of the pandemic- how can we overcome this? Well you see you got your health care professionals who are treating patients who are dying and who have died and or are on critical support and need your services day in and day out. So I would recommend that within your hospital settings that you form support groups for healthcare workers to debrief with colleagues on these feelings you have that you don’t have time to debrief because if you keep it all inside you’re going to burn out and you’re going to have anxiety and depression. So anxiety disorders and depressive disorders are classified as internalizing disorders- internalizing meaning it’s stuff that comes from your thoughts- it’s stuff that comes from inside you. So the stressors are external, but they are called internalizing disorders because it’s stuff that occurs inside you- your thoughts, your emotions, how you actually decide to make choices about behaviors which are helpful or not. So one way to deal with internalizing disorders that come from the inside is to start to expressing how you’re feeling to others that actually are experiencing the same thing and pretty soon what happens is that that catharsis occurs from actually just letting it out. So that’s why we do it- it seems trivial to just say go talk about it but that’s really the work- to talk about it with others going through the same things- and really your colleagues are the ones that can support you the best. When you go home to your family, they don’t really understand what’s going on- they might have an idea what might be occurring but they’re not the ones treating patients; they’re not the ones having to deal with hospital administrators not protecting you; they’re not the ones having to risk their lives every day being exposed to this potentially lethal virus; they’re not the ones seeing other family members suffer loss when the virus kills their loved ones. So your colleagues are the best source of support at work because they’re experiencing the same thing. So get out there and form support groups with your colleagues and hold these frequently. So debrief with colleagues after each event that shakes up your medical unit. So if you have a loss, a death on your unit, then debrief with your colleagues- and not just from a Mortality & Morbidity (M&M) point of view, but from a point of view that this is hard for you; this is hard for the staff to handle. So let’s check in with one another and make sure everyone’s okay and if someone’s not okay then we all support that person. Another thing you can do is go see a counselor. If you’re on lockdown a lot of therapy now is being conducted online. And lastly you could just take off time from work to recover. So maybe you need to go take a few sick days- maybe you need to go on short term disability- but take time off to recover because if it’s affecting you then you should talk to your manager/hospital administration and they should not blink an eye when you ask for it.

Another question: how to deal with family members who do not understand the stresses and burdens nurses face? As I explained before in the previous question, nobody else is going to understand what you’re dealing with unless they’re in your shoes. So your colleagues are really in the best position to understand what you’re going through and therefore that’s the road to you getting help is just being with people who understand. So you do have to go home to your family who really don’t understand what you’re dealing with and what’s happening. They’re probably seeing some of the effects of the trauma- this vicarious trauma that you’re experiencing through being exposed to the virus, risking your life, being exposed to people who are dying from this. So it may help actually for them to tell them what vicarious trauma is- that although others are experiencing the trauma and loss, because you are a direct provider care provider for those who are experiencing loss and trauma, that then becomes vicarious trauma to you because it’s as if you’re experiencing it, because you’re so intimately involved with the care of that patient and family. So explain what that is to them- explain that your patient’s loss is your loss too. So it’s not like any other job where you can just leave it at work- healthcare workers can’t leave it at work because what they do is so emotionally draining, especially this pandemic and especially when they’re dealing with all these losses. So it would also help to label your state. So if you’re burnt out, just say so and explain your need of compassion on their part to recover. So just state that “I’m stressed out and I’m burnt out from work and I need space to recover,” that in itself can let your family members know that they need to back off and provide support when you ask for it. Lastly, an important thing is to set boundaries at work to help avoid bringing these stresses home. Because you know at the end of the day, it’s unfair to expect workers to do their jobs and then have to take it home. So as healthcare workers, you can’t just do your job and then go home and then leave it at work- it doesn’t happen that way. We’re human- we absorb all of these stressors and we have to have a way to wring them out- we can’t keep them inside if we keep these stressors inside. When we don’t deal with it adequately it leads to anxiety and depression and then pretty soon it leads to you dropping out of work- soon you need help from a psychiatrist. So you want to avoid having to see the psychiatrist. So what you can do then is to set boundaries at work to help avoid bringing those stresses home. So for instance, if you’re a therapist at the hospital and they keep bombarding you with patients, most healthcare workers will just say yes- they won’t say no. So I know of healthcare workers that when they’re asked to see more patients, they just go ahead and see them and double-book their appointment schedule just so they could accommodate and be helpful because we are in the helping professions. So we have a hard time saying no- just say no and if it’s a resource issue and if there’s a big waiting list, at the end of the day for the individual health care worker, that’s not your problem. Your responsibility is your family and it’s really up to you to ensure that you don’t go home and take it out on them, because that’s what it feels like to them. So I’m just trying from the other side- I’m trying to be supportive, but it’s really up to the individual health care worker to set boundaries at work and say no. Health care workers just set boundaries- the problem of too many patients- that’s really not your problem- that’s the hospital’s problem- they need to hire more people- they need to get out from their offices and maybe help you guys out at the front line. So that huge wait list and the amount of work that you need to do is not really your problem- it’s the hospital administration’s problem and it’s your job to ensure that you can do your job to the best of your abilities and you can’t do the job to the best of your abilities if you keep saying yes- So say no. So that when you’re seeing a patient you can give 100% to that patient- because if you’re getting overbooked and you’re having to see more and do more and work overtime- guess what- each patient you see after that point on when you’re burnt out, you’re not giving them 100% of you. So don’t get to the point where you get burnt out- set boundaries at work- say no.

Another question- how to overcome fatigue, anxiety and burnout to excel at work? So again you can engage in self-care as I mentioned in previous slides. Try to come to terms with uncertainty. So people are worried about the future, but the future is uncertain- even the clinical researchers and public health officials don’t know what the future is going to be- they can make some predictive modeling to see how this pandemic’s going to go, but at the end of the day, people don’t really know what’s going to happen. So you really have to come to terms with uncertainty and you can’t worry about it too much. So it’s one of those things you can’t hang your hat on. So just come to terms with uncertainty and follow what your public health authorities say. So those kind of things can actually help make things more certain now if everybody followed what the public health officials were saying- maybe we wouldn’t have all these waves that are coming. But in the meantime, we have to come to terms with uncertainty- take mental health days as needed- you may need to go on short term disability- you may need to see a counselor and if you have anxiety and or depressive disorder you may need to see a psychiatrist.

I’m going to state this last one carefully because we have to come to grips with what’s going to happen. Look folks- you healthcare workers are tired- you’re exhausted and there’s future waves coming and there’s some of you that are overwhelmed and seeing your emergency rooms and your medical units overfilling with Covid patients and more are coming. So the thought of future waves are just unbearable right now- you’re exhausted: physically, emotionally, mentally. So if it’s really coming to the point where you’re getting burnt out, and you’re really not wanting to go back to work because of the enormous strain that’s put on you as a healthcare worker, then you may need to consider switching to another career. I’m going to say this because the worst thing that can happen to you is to not have choices. So if you feel like the only thing you can do is be a healthcare worker, and I can do nothing else, then it gives you the feeling of being trapped. I just want to give you permission if you’re getting burnout and it’s occurring for too long and especially if this is resulting in an anxiety disorder or depressive disorder, then maybe it’s time to consider switching, and you may need to leave the healthcare field altogether. So even just considering that allows you to have a choice, and when you have choices then you don’t feel trapped. I’m just saying consider it, if you’re at the point where you’re burnt out or you have anxiety or depression.

Take Home Message

So the take home message- stress and burnout, if it becomes severe and chronic, may transform into anxiety and/or depression- therefore, it is important to deal with stress and burnout and to cope with it effectively. The pandemic has caused profound changes in the social, occupational, economic, and political domains. It is very important your hospital has a duty to protect you from exposure to deadly pathogens and has a duty to ensure your mental health. Please align with your unions and please align with doctors to advocate for better working conditions. And for those relaxation techniques and self-care techniques that I mentioned earlier, you can find out more at AnxietyBoss.com. Thank you for listening.