Early in the Covid-19 pandemic, when much of U.S. society shut down, health workers put their own safety on the line and kept going to work to care for patients. Although their communities initially banged on pots, cheered from their balconies, and put up thank-you signs, the pots have long since stopped clanging. Expressions of gratitude have too often been replaced by hostility, anger, and even death threats toward health workers, as health misinformation has exploded, eroding trust in science and public health experts. Yet doctors, nurses, pharmacists, social workers, respiratory therapists, hospital security officers, and staff members of health care and public health organizations continue showing up to battle the pandemic and its sequelae — long Covid, mental health strain, widening health disparities, and 2 years’ worth of deferred care for myriad conditions.
The toll on our health workers is alarming. Thousands of them have died from Covid. More than half of health workers report symptoms of burnout,1 and many are contending with insomnia, depression, anxiety, post-traumatic stress disorder, or other mental health challenges.2 An intensive care nurse in Miami told me, “There was a point when I could no longer contain the heartbreak of everyone I lost.” He stopped counting after his 135th patient died from Covid in the pandemic’s first year. Caring for patients has always been emotionally and physically demanding, but as one Missouri physician told me, “There is only so much we can give. We are people, too.”
Burnout manifests in individuals, but it’s fundamentally rooted in systems. And health worker burnout was a crisis long before Covid-19 arrived. Causes include inadequate support, escalating workloads and administrative burdens, chronic underinvestment in public health infrastructure, and moral injury from being unable to provide the care patients need. Burnout is not only about long hours. It’s about the fundamental disconnect between health workers and the mission to serve that motivates them.
These systemic shortfalls have pushed millions of health workers to the brink. Some 52% of nurses (according to the American Nurses Foundation) and 20% of doctors (Mayo Clinic Proceedings) say they are planning to leave their clinical practice. Shortages of more than 1 million nurses are projected by the end of the year (U.S. Bureau of Labor Statistics); a gap of 3 million low-wage health workers is anticipated over the next 3 years (Mercer). And we face a significant shortage of public health workers precisely when we need to strengthen our defenses against future public health threats. Health worker burnout is a serious threat to the nation’s health and economic security.
The time for incremental change has passed. We need bold, fundamental change that gets at the roots of the burnout crisis. We need to take care of our health workers and the rising generation of trainees.
On May 23, 2022, I issued a Surgeon General’s Advisory on health worker burnout and well-being, declaring this crisis a national priority and calling the nation to action with specific directives for health systems, insurers, government, training institutions, and other stakeholders. The advisory is also intended to broaden awareness of the threat that health worker burnout poses to the nation’s health. Public awareness and support will be essential to ensuring sustained action.
Addressing health worker well-being requires first valuing and protecting health workers. That means ensuring that they receive a living wage, access to health insurance, and adequate sick leave. It also means health workers should never again go without adequate personal protective equipment (PPE) as they have during the pandemic. Current Biden administration efforts to enhance domestic manufacturing of PPE and maintain adequate supplies in the Strategic National Stockpile will continue to be essential. Furthermore, we need strict workplace policies to protect staff from violence: according to National Nurses United, 8 in 10 health workers report having been subjected to physical or verbal abuse during the pandemic.
Second, we must reduce administrative burdens that stand between health workers and their patients and communities. One study found that in addition to spending 1 to 2 hours each night doing administrative work, outpatient physicians spend nearly 2 hours on the electronic health record and desk work during the day for every 1 hour spent with patients — a trend widely lamented by clinicians and patients alike.3 The goal set by the 25×5 initiative of reducing clinicians’ documentation burden by 75% by 2025 is a key target.4 To help reach this goal, health insurers should reduce requirements for prior authorizations, streamline paperwork requirements, and develop simplified, common billing forms. Our electronic health record systems need human-centered design approaches that optimize usability, workflow, and communication across systems. Health systems should regularly review internal processes to reduce duplicative, inefficient work. One such effort, Hawaii Pacific Health’s “Getting Rid of Stupid Stuff” program, has saved 1700 nursing hours per month across the health system.5
Third, we need to increase access to mental health care for health workers. Whether because of a lack of health insurance coverage, insurance networks with too few mental health care providers, or a lack of schedule flexibility for visits, health workers are having a hard time getting mental health care. Expanding the mental health workforce, strengthening the mental health parity laws directed at insurers, and utilizing virtual technology to bring mental health care to workers where they are and on their schedule are essential steps.
Fourth, we can strengthen public investments in the workforce and public health. Expanding public funding to train more clinicians and public health workers is critical. Increased funding to strengthen the health infrastructure of communities — from sustained support for local public health departments to greater focus on addressing social determinants of health such as housing and food insecurity — advances health equity and reduces the demands on our health care system. The recent announcement by the Centers for Disease Control and Prevention of $3 billion in grant programs to support public health infrastructure, data systems, and workforce is the type of investment that’s needed.
Fifth, we need to build a culture that supports well-being. It’s time to break the traditional silence surrounding the suffering of health workers. As gratifying as our work is, it can also be profoundly isolating, especially when we feel we can’t let our colleagues know if we’re not OK — a feeling that millions of health workers, including me, have had during our careers. Culture change must start in our training institutions, where the seeds of well-being can be planted early. It also requires leadership by example in health systems and departments of public health. Licensing bodies must adopt an approach to burnout that doesn’t punish health workers for reporting mental health concerns or seeking help and that protects their privacy. Finally, many health workers still face undue bias and discrimination based on their race, gender, or disability. Building a culture of inclusion, equity, and respect is critical for workforce morale.
Making these changes won’t be easy. But they are essential and urgent. They require key stakeholders to step up and do their part. The government can ensure continued focus and accountability by supporting a National Health Care Workforce Commission to drive coordinated federal action and by collaborating with state and local governments and the private sector on a national agenda for health worker well-being. The Joint Commission can add worker well-being measures to institutional accreditation standards. And health system leaders must make worker well-being a measurable priority, with accountability at the highest level of the organization, and include health workers in designing and implementing a comprehensive well-being strategy.
Despite years of inaction, there are hopeful signs that this time can be different. At the federal level, the Dr. Lorna Breen Health Care Provider Protection Act of 2022 and billions of dollars in funding from the 2021 American Rescue Plan will provide new infrastructure and resources to strengthen programs affecting health worker well-being. These resources are supporting increased mental health services, health workforce expansion, loan-forgiveness programs for health professionals, more robust public health infrastructure, and well-being education programs for health workers. President Biden has called for billions of dollars in additional funding to sustain these investments.
Outside government, the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience has boosted stakeholder engagement and commitment with its National Plan for Health Workforce Well-Being. Various health systems are establishing executive-level positions with the charge, resources, and authority to institutionalize comprehensive agendas for health worker well-being. Finally, a rising generation of health workers are using their voices at work and in educational institutions, professional associations, and the public square to advocate for organizational and policy changes that address burnout. They understand that when their well-being and the health security of their communities are at stake, silence is not an option.
As a nation, we cannot allow ourselves to fail health workers and the communities they serve. We must build on these steps, boldly taking on entrenched interests, bureaucratic inertia, and the status quo. Health workers throughout the country have told me they are reaching their breaking point — that “something has to change.” They are right. May our country never forget our moral obligation to care for those who have sacrificed so greatly to care for us.
Funding and Disclosures
Disclosure forms provided by the author are available at NEJM.org.
This article was published on July 13, 2022, at NEJM.org.
1. Prasad K, McLoughlin C, Stillman M, et al. Prevalence and correlates of stress and burnout among U.S. healthcare workers during the COVID-19 pandemic: a national cross-sectional survey study. EClinicalMedicine 2021;35:100879-100879.
2. Bryant-Genevier J, Rao CY, Lopes-Cardozo B, et al. Symptoms of depression, anxiety, post-traumatic stress disorder, and suicidal ideation among state, tribal, local, and territorial public health workers during the COVID-19 pandemic — United States, March–April 2021. MMWR Morb Mortal Wkly Rep 2021;70:1680-1685.
3. Sinsky C, Colligan L, Li L, et al. Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med 2016;165:753-760.
4. Columbia University Department of Biomedical Informatics. Report from the 25 by 5: symposium series to reduce documentation burden on U.S. clinicians by 75% by 2025. 2021 (https://www.dbmi.columbia.edu/wp-content/uploads/2021/08/25x5_Executive_Summary_V2.pdf).
5. Ashton M. Getting rid of stupid stuff. N Engl J Med 2018;379:1789-1791.
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