Even as the low case numbers for COVID-19 have ticked grimly upward in New Jersey and throughout the nation in recent days, the state’s hospitals and health care workers up and down the line have been coming to grips with a post-pandemic world and the new problems it presents. Chief among these pressing concerns is that of the mental and physical toll the crisis has taken on the men and women who staff the state’s sprawling health care system.
“People are fatigued, they’re worn down,” says Kelly L. Gilrain, director of psychological services at Cooper University Health Care, headquartered in Camden. “The elasticity is no longer there. The high anxiety of the pandemic has passed, but things are not going back to normal. The old normal is no longer normal.”
The state, like the nation and the world, was devastated by the coronavirus outbreak of 2020. As of July, New Jersey has had more than a million cases of COVID-19, resulting in more than 26,500 deaths since the pandemic came to the state, according to Worldometer. Nationwide, there have been almost 35 million cases; worldwide, there have been over 4.1 million deaths due to COVID.
Hospital capacities and hospital staffs were pushed to the breaking point in the last year and a half. A survey conducted earlier this year by the data intelligence company Morning Consult found that over 10% of health care workers worldwide have left their jobs since the pandemic outbreak. The same survey also found that a quarter of health care workers have considered leaving.
And while life in New Jersey, which was hit so hard by the virus last spring, returns to some semblance of normalcy, for the health care workers who were on the front lines, that journey back to “normal” is just beginning.
‘It’s been a war.’
“It’s been a war for hospitals and health care workers,” says Dr. Mark Rosenberg, chairman emeritus of emergency medicine at St. Joseph’s Hospital in Paterson and president of the American College of Emergency Physicians. “A long, hard-fought war. We are over the worst of it, but we are not out of it yet. What we are seeing now, in a large number of physicians, but also throughout all hospital staff, is PTSD.”
Post-traumatic stress disorder, or PTSD, is a psychological designation coined in the late 1970s to describe states of mental and physical stress in soldiers who experienced combat in Vietnam. The term replaced earlier designations like “shell shock” and “battle fatigue,” and was soon used to describe the problematic conditions of civilians who survive natural and manmade disasters, like 9/11, Hurricane Katrina and, now, COVID-19.
Rosenberg says the coronavirus—with its rapid spread, lethal potency and, for a long time, no vaccine—assailed and sorely tried medical institutions and individual health care workers alike. The pandemic also exacerbated existing problems at local hospitals.
“In the midst of the crisis, Medicare proposed cuts to emergency room physicians’ pay,” Rosenberg says. “You call these people heroes one minute, and the next minute you’re cutting their pay. Would the military cut soldier’s pay in the middle of a war? And how do you think the soldiers would feel about it?”
Rosenberg says his organization and others fought the proposed changes to the fee schedule and managed to stall them. But the possibility looms and creates one more worry for doctors dealing with COVID and its aftermath. Of course, doctors are not the only health care workers with worries.
‘Unprepared.’
“Most of the state’s hospitals were just not prepared for the pandemic,” says Barbara Rosen, RN, first vice-president of HPAE, New Jersey’s largest health care union, representing 14,000 nurses and other health care workers. “What many of our members now feel is a lack of confidence in their employers.”
Rosen says many hospitals lacked sufficient personal protective equipment (PPE) for their frontline staff, causing equipment to be re-used against safety protocols and causing many caregivers to supply their own PPE.
“Our health care workers were unnecessarily exposed to the virus,” Rosen says. “We lost seven members to the disease. I’d say between 20 and 25% of our members contracted the virus. That’s my stab at the figure. Hospitals do not have to release that information. That’s another problem we want addressed.”
Rosen says caregivers were obliged to work when sick, quarantine periods were cut short, contact tracing was lacking in many cases, and whistleblowers were terminated.
“Many of our nurses have left the profession,” Rosen says. “In one of our hospitals, the staff has gone from 430 to 310. A lot of our frontline workers slept in garages and rented rooms for fear of infecting their families.”
Last year, HPAE published a white paper laying out in more detail the manifold problems Rosen sees in the industry, as well as proposed solutions.
“Our survey,” the report reads in an opening summary, “returned by 1,100 HPAE health care workers, gave us a frontline picture of the shortcomings of our pandemic response and the impact those gaps had on not only the workers, but on the care they provided and on the public’s safety. It shows us what our nurses and health care workers learned: they were largely alone, with little consistent guidance from state or federal agencies; policies in their health care institutions were based more on economics than public safety; and there was even less enforcement of existing laws to protect them as they went through their day. Seeking to protect patients, they were left unprotected.”
“Now we are looking at a lot of PTSD among our members,” Rosen says.
Facing death.
On top of concerns about job security, proper equipment, proper procedures, self-exposure to the virus and possibly exposing loved ones, there was the constant, manifest horror of the deadly disease.
“The mindset of the health care worker is focused on the people they are serving,” says Dawn Gelsi-Collins, director of culture and engagement for the Inspira Health Network, which operates three medical centers in southern New Jersey. “They are go-go-go when at work. They were exuberant in reacting to the first wave of the pandemic. But it soon went from this exuberance to holding the hands of dying patients, who were otherwise dying alone, without loved ones near.”
Gelsi-Collins noted the case of a respiratory therapist who became the surrogate loved one for so many terminal patients that his peers saw the need to dissuade him from the practice.
“People told him to take care of himself,” she says.
Dr. Rosenberg points out that, under relatively normal conditions, ER caregivers don’t witness a lot of death. They deal with patients’ immediate complaints and send them on to other doctors and departments. But during the pandemic, regular ER visits were down and many ER rooms were used to house COVID patients, many of whom would die.
“Patients were now dying, and dying alone, in ERs,” Rosenberg says. “Physicians and other ER staff who did not often see death now saw death regularly.”
There were over 400 suicides among physicians during the pandemic, and many were ER doctors, Rosen says.
“PTSD is exactly that,” he says. “Post-traumatic, after the fact. People are really, really tired. That’s why we need to be providing counseling and other help to people who are stressed out, who are feeling the stress of the job.”
Building resilience.
Banita Herndon, RN, is an emergency room nurse and has been on the frontline throughout the COVID-19 pandemic at University Hospital in Newark.
“In the beginning of the pandemic, we did not have a great deal of education in how to deal with it,” Herndon says. “You had to get your mind set before going to work that you were going to be dealing with patients with the COVID virus. You had to treat everything in the safest way, but you also had to keep your mind off worrying, keep things in perspective. My goal was always to go in there and take care of my patients. That is what I was there to do. And now things have changed, but we’re still in this struggle. My goal is still the same.”
Herndon has not complained of PTSD. Rather, she is the epitome of the engaged, can-do caregiver. She embodies the attitude that health care experts and hospital leaders are seeking to preserve, promote and rescue from burnout.
“There’s professional pride and an esprit du corps here in health care,” says Dr. Anthony L. Rostain, chair of psychiatry and behavioral health at Cooper University Health Care. “If people think they are not delivering the care they should be delivering, anxiety and depression can set in.”
Rostain partners with Cooper’s Kelly Gilrain to lead the hospital’s Resiliency Resources Team, which was set up to address the increased stress, anxiety and traumatic grief facing health care workers due to COVID-19. UPAE’s Rosen, in criticizing the pandemic responses of numerous New Jersey hospitals, noted that some hospitals dealt well with their staff’s needs and concerns, and Cooper was one of them.
Rostain was recruited by Cooper to work on creating a culture of staff wellness and mutual assistance before the coronavirus outbreak, so the groundwork for a resilience team was in place when the crisis came.
“We were fortunate to have Dr. Rostain come to Cooper,” Gilrain says. “A team of us came together at once to respond to the crisis. We went around the hospital and met with different groups of workers throughout the day, hearing of their fears, the threats to their roles, and just how overwhelmed they felt from this COVID thing. The response to our initial efforts was great. Everyone wanted to meet and talk. The phone rang off the hook.”
The team provided support, education and skill-building through resiliency workshops, peer support groups, and digital content. The peer support groups connected physicians, nurses and the many other health care workers in the system to their colleagues. The team developed a digital library and wellness intranet site to address topics like coping skills at work and maintaining a healthy lifestyle while under stress.
“We’re changing the culture and that takes time,” Gilrain says. “It’s more than individual resilience but a culture of resilience, of team effort and peer support. It’s a culture where it’s OK to say you’re not OK.”
Rostain and Gilrain have appealed to the hospital to consolidate all the staff wellness programs under one head, and Cooper has responded by hiring someone to do just that.
“They put their money where their mouth is,” Gilrain says.
“Now we can study the data our efforts have produced, see what works and make the necessary improvements going forward,” Rostain says.
What now?
Necessary improvements to meet current and future health care needs brought to light by the pandemic are on the minds of many in the medical profession.
“We need statewide standards in how to deal with such crises,” UPAE’s Rosen says. “We need better plans, better staffing and better legislation. And we want a seat at the table when the new plans and laws are being determined. Because, you know, when you don’t have a seat at the table you end up being the meal.”
Dr. Rosenberg is among those pushing for passage of the Dr. Lorna Breen Healthcare Providers Protection Act, currently before a U.S. Senate committee, which is named in honor of an ER doctor who took her own life during the pandemic. Among other things, the law calls for a greater effort to identify and treat anxiety, stress and burnout among health care workers and to provide job security for caregivers who are afflicted with PTSD.
“We really are all in this together,” Rosenberg says. “I don’t want to get political, but the vaccines are now available, and they work. It upsets me that there are a lot of people who won’t take care of themselves. If I have to send my team back into that war zone, it will be very tough.”