Australia’s healthcare workers are reporting that they are exhausted and burnt out after the pandemic wrought profound change to their work practices. As the health crisis continues, how can the quality of care be sustained? By Karen Willis and Natasha Smallwood.
Healthcare workers suffering exhaustion and burnout
The Australian healthcare system is held in high regard internationally, scoring well on access, equity and outcomes. Although no system is perfect, until now there has been a general assumption that if you need care in Australia, particularly emergency care, you will get it. So it is shocking to read that intensive care beds are full, that there is trouble recruiting the highly skilled doctors and nurses needed to work in intensive care units, Covid-19 medical wards and emergency departments, and that paramedics are at breaking point. How has it come to this?
The strains on the healthcare system during the past 12 months have been immense. As Mark Putland, director of emergency medicine at Royal Melbourne Hospital, says: “It’s been a big journey. It started with a genuine fear that you might die from coming to work. Then there was the exhaustion from constantly changing guidelines and procedures. We built what we thought was a model of care that was ready to respond. But then we found that the workforce was decimated through furloughing, and we have had to rearrange everything again on the fly and make do.”
For most of us, the daily grind of Covid-19 is evident in news reports, as we listen to “the numbers” and adjust our emotions accordingly. The road map out of restrictions provides matter-of-fact information about the anticipated surge of cases and deaths. Expressed as numbers, these reports cannot capture the feelings of mental distress among healthcare workers who are exhausted and emotionally burnt out. Associate Professor Putland says healthcare workers have mixed emotions: “On the one hand, they now feel like they can see to the other side of this, to a time when they can socialise again with family and friends; on the other hand, the anticipation of the overwhelming volume of work that is about to happen is horrifying.”
Australia’s health system has been reliant on the flexibility of its workforce – shiftwork, casual banks, many healthcare staff choosing part-time work or working in multiple settings. This has changed radically in the past year. Strategies to minimise the spread of the virus mean staff can no longer work across multiple sites. Covid-19 testing and vaccination hubs have required a massive investment of staff who are no longer available to work in their usual settings, such as hospitals. Private-sector staff redeployed to the public setting and some public patients sent to private facilities add to restrictions on the availability of elective procedures.
As outbreaks occur, staff who are exposed, or potentially exposed, must be furloughed – taken out of the workforce for 14 days, isolated and tested until there is a negative result. Those who contract the virus are away from work for substantial periods of time.
Covid-19 causes ongoing disruption to workforce availability. One of the authors of this piece, Dr Natasha Smallwood, is a front-line worker. She describes an ordinary week:
“On Monday night my daughter developed a cough, sore throat and other flu-like symptoms – first thing Tuesday morning my husband took her for a Covid-19 test. My husband and I are both front-line senior doctors. While we waited for the test results, neither of us could risk going to work. If we went into the hospitals we work at and our daughter’s test turned out to be positive, we did not want to risk inadvertently exposing colleagues and patients to Covid-19.
“So consultations were rescheduled to telehealth. Fine for those patients who did not need a physical examination; not fine for those who need to be seen in person. That’s how easy it is to wipe out two senior clinicians for two days, in an overstretched, overburdened workforce that is surging for the anticipated Covid-19 wave.”
Simply put, the workforce flexibility that has supported the healthcare system is no longer there.
Stories about the pressures staff experience in the health system are now emerging day by day. They echo the findings from research we conducted investigating the psychosocial impacts of Covid-19 on the front-line health workforce during the second wave of the pandemic. At that time, we found that 70.9 per cent of our sample of 7846 health workers reported emotional exhaustion and 40 per cent had moderate to severe symptoms of post-traumatic stress disorder. Anecdotally in their free text responses, many healthcare workers wrote about leaving the workforce – young people at the beginning of their careers were rethinking their choices; older, experienced specialists or senior staff were considering early retirement. Others were wanting to stay in healthcare, but not at the front line.
Additional staff trained to work with Covid-19 patients during the second wave of the pandemic are no longer willing to do this work – such is the exhaustion and trauma of work in a crisis that is not a one-off event but a long and hard slog. As Putland says, “There are people amongst us suffering a kind of PTSD. Some are finding it hard to work, especially those who got Covid, so they are saying, ‘I can’t do it anymore.’ ”
Alongside emotional exhaustion and burnout, the reasons healthcare workers want to leave the profession are varied. Many feel unsafe and worry about passing the virus onto their loved ones. Others feel the work they do is not valued.
There is concern about the rationing of care and difficult choices. This leads to moral distress – the requirement to act in a way that goes against core values. For some healthcare workers, moral distress is felt as they contemplate working in a health system where services will be rationed, as is the concern about ICU bed availability. For others it is about the delivery of safe care or high-quality care – for example, the proposal that nurses in ICU must care for double the number of patients they do normally.
The distress of health workers was evident in our survey, as health workers described holding up iPads so families could say goodbye to loved ones who were dying alone, or being the only person in the room comforting frightened patients. While many health workers were grateful for the technology that enabled farewells via iPads or mobile phones, they were also distraught at the lonely deaths they witnessed.
Health workers have written extensively about what it is like to treat patients with Covid-19 and there are common themes throughout. Some have used graphic descriptions to highlight the importance of getting vaccinated – describing suffering from Covid-19 as feeling like “you can’t get enough oxygen” or feeling “like you are drowning”. They are shocked at what they witness. The most dramatic is the rapid deterioration of patients.
Patients this year are much younger and unvaccinated. They are fearful about presenting to hospital for any reason, including Covid-19, and so are sicker when they are admitted. Alarmingly, whole families, including children, may have the virus.
Recent calls by front-line healthcare workers, particularly nurses, for “hazard pay”, or what the Victorian branch of the Australian Nursing and Midwifery Federation calls a PPE allowance, have been controversial. Detractors argue that healthcare workers are “doing what they signed up for”. But did they sign up for this level of risk; for work conditions where they are in hot, uncomfortable personal protective equipment for an entire shift, unable to have a drink of water or go to the toilet for several hours; where they feel as if they are letting down their colleagues if they can’t work additional shifts?
These healthcare workers want recognition and to be valued for the work they do on the front line. Valuing staff increases the likelihood of retaining them, and attracting back those who have left the workforce.
Like all of us, those in front-line healthcare have put their lives on hold during the pandemic. Putland says: “In normal life, with all its challenges, during a short crisis, you can pause everything; but in long-term crises like this these all still happen and have to be managed in the background. Last year we pretended that all the life events could wait, but they can’t. We knew it wasn’t a sprint, but we expected there would be a finish line. We have had to change our expectations, try for a more sustainable approach, accept that we just need to put one foot in front of the other.”
Even when we reach 80 per cent of the population fully vaccinated, the world of healthcare will have changed. We need to examine what this means for a healthcare system that was already stretched before the pandemic. The road towards “Covid normal” healthcare will require vision from healthcare leadership, especially with a workforce that is exhausted, where patients have delayed seeking care and therefore are sicker and more complex to treat, and where there are longer waiting lists for procedures that were delayed due to the pandemic.
If the Australian health system is to remain one of the best in the world, this road will begin with supporting and valuing front-line staff.
This article was first published in the print edition of The Saturday Paper on September 25, 2021 as "Care trauma".
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