In fall 2020, Seattle therapist Shelley Green started taking appointments with health care workers whose lives had turned profoundly bleak during the COVID-19 pandemic. 

Green had faced her own stresses. She’d given birth in spring 2020, during some of the most uncertain days of the pandemic in Washington. And as a member of the health care community, she felt fortunate she could do her teletherapy work from the comfort of her home. For a small group of health care workers without that luxury, she decided to offer her therapy services free of charge.

She listened to their fears. They were terrified of bringing the coronavirus home and accidentally killing a family member. As the months wore on, she heard their disillusionment. Some were so ill-supported at work, by their communities and by public officials, she said, that they felt they were being “left to die.”

These days, Green hears their anger. 

They feel disrespected, even ridiculed, by those most at risk for getting sick or needing their care: people who won’t wear a mask or refuse to get vaccinated. 

Mental health resources from The Seattle Times

Green’s clients’ experiences fit with startling new research. Repeated exposure to sickness and death, and a sense of fear and anxiety that’s rippled across the medical and first-responder communities during the pandemic, is crippling the mental well-being of many people in these vital workforces, according to a new study published Thursday in the Journal of General Internal Medicine and led by Dr. Rebecca Hendrickson, a physician and researcher at VA Puget Sound Health Care System and assistant professor of psychiatry and behavioral medicine at University of Washington School of Medicine.

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More than half of frontline health care workers — and about 40% of first responders like firefighters and paramedics — say the pandemic has decreased their willingness or ability to stick with their careers. 

One in five nurses say it’s “not at all likely” they’ll still be working in their field in five to 10 years; about 17% of first responders say the same. Of the four pro bono clients Green has worked with, only one is still in the job they had pre-pandemic, she said. 

Being a trusted caregiver — and then feeling helpless in that role — has caused serious feelings of loss and despair. 

“Everyone is quitting,” said Laura Wood, a social worker at Swedish Cherry Hill in Seattle, adding that nurses, emergency department technicians, respiratory therapists and social workers are leaving “left and right.” “Our staff is so burned out. We’re just so tired.”

But the research offers some hope: Even if someone experienced lots of pandemic-induced stress, a supportive work environment made a big difference.

People who felt their employer was looking out for them, or didn’t ask them to take unnecessary risks, did much better than those who felt unsupported, the research suggests.

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“We don’t need to protect people from every aspect [of their jobs],” Hendrickson said. “If you can increase the amount of support people have … you can make a really big difference in people’s experiences and people’s ability to recover and cope effectively with the trauma they’re experiencing as part of their job.”

Red flag

Early in the pandemic, Hendrickson was struck by how health care workers in the pandemic’s epicenters — Italy, then New York City — described their sleep. 

Even though they were exhausted, they struggled to drift off. When they finally did, their days haunted their dreams. Nightmares were common. They’d often awake in a panic. 

“This was concerning,” she said. Anecdotes from health care workers sounded eerily similar to reports from combat veterans she worked with at the VA. This particular brand of sleep disturbance put people at risk for persistent, long-term symptoms like anxiety, depression and PTSD, Hendrickson said. It was of particular concern to Hendrickson, because it signaled that health care workers might continue to have symptoms even after pandemic stresses subsided. 

The crushing stress on health care workers was well-documented early in the pandemic. Large, international studies on health care workers’ well-being were published in major research journals. An ER doctor’s suicide made national news. Millions of people blew whistles and banged on pots and pans to honor health care workers and their sacrifices. 

What wasn’t clear, Hendrickson realized, were the specific parts of pandemic life that led some but not others to experience psychiatric symptoms — and why it could be difficult for certain frontline workers to bounce back when daily stressors ended.

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From September 2020 to February 2021, Hendrickson and her colleagues recruited 510 first responders across 47 states to answer those questions. The researchers didn’t formally diagnose the participants, but asked them to complete four standardized psychiatric assessments, a pandemic-specific questionnaire and questions about their professions. Although much of the study took place before vaccines were widely available — and health care workers found themselves treating COVID-19 patients who chose not to be vaccinated — Hendrickson is now enrolling more participants and following up with earlier participants to see if anything has changed for them.

In general, the more pandemic-related stressors someone experienced, the greater their psychiatric burden and likelihood of leaving their profession, the researchers found.

Participants’ pandemic experiences were tied to symptoms of depression, anxiety, insomnia and post-traumatic stress disorder. Feelings of demoralization, in particular, predicted high levels of psychiatric symptoms and disinterest in their careers.

More than 12% of the health care workers, and nearly 20% of first responders, reported thinking about hurting themselves, or that they would be better off dead, at least several days during the past two weeks. Paramedics had a uniquely high prevalence of these types of harmful thoughts, suggesting that they in particular might benefit from mental health support.

“It was just kind of overwhelming and a red flag,” Hendrickson said. “We have an urgent need to address these issues both because there’s just a really high level of suffering and distress … and we have a moral obligation as a society to address this type of suffering in people who have worked hard to protect all of us during this pandemic.”

Care for caregivers

Wood, who assesses depressed and suicidal emergency-room patients, has a unique window into health care workers’ trauma.

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“Because that’s my specialty, my coworkers will come and share their troubles with me,” Wood said. 

Her colleagues care for COVID-19 patients who are sick and dying alone. Some have called out sick, fearing the trauma they’d return to on their next shift. Those who ultimately decided to quit have symptoms ranging from insomnia, to suicidal thoughts, to overwhelming feelings of sadness, anxiety and depression, she said. 

Wood, an executive board member for the health care union at Swedish, said the facility recently added a new mental health benefit at the union’s urging. Staff and their family members now have access to online mental health care and get 25 free visits each year. “You can see someone that same day or the next day,” she said. “It’s really increased the access.”

The notion that the health care workforce needs better support isn’t new, said Elaine Walsh, an associate professor at the University of Washington School of Nursing, but “it’s come to a head and really come to a moment of crisis.” 

In addition to mental health care access, systemic changes like ensuring workers get to take breaks — and that breaks are truly restful — would also help, Walsh said. Staffing shortages at the Cherry Hill facility for example, have made it difficult for staff to take time off, Wood said.

Giving workers free parking or other perks, Walsh said, could also make a difference. Making sure workers have a way to give employers feedback about their needs also helps build trust, Hendrickson said. To fight burnout, health care workers here are also lobbying for retention bonuses and incentive pay for employees who take extra shifts. 

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Green, the therapist, said employers also have a responsibility to train workers to recognize so-called secondary trauma — when someone is exposed to a traumatized person or their experiences. As caregivers, there’s a culture and expectation that first responders and health care workers push through: They move to the next room, handle whatever the next person needs, take it home with them, and get up the next day to do it again.

Often, people in the health care field don’t acknowledge the toll this mindset has on mental health, and how it can make it harder for people to do their job well, Hendrickson said. Of the clients she’s worked with, Green said, many don’t realize this kind of trauma has a name.

“She was like, ‘It’s just so hard for us. We’re always the last ones to seek what we need because we see ourselves as providing what other people need,’” she said of one person she had talked with.

Recently, when talking with a nurse friend, Green encouraged her to look for a therapist among a growing network of mental health providers who have stepped up to provide free care.

Her friend’s response was similar to one she’d heard from others — one plagued with concern that what they’d experienced wasn’t bad enough — that they weren’t “traumatized enough by this pandemic to get care on someone else’s dime.”