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Transcript

AARON ORLOWSKI, HOST

Nurses are burned out. At the same time that they’re exhausting themselves tending to patients with COVID-19, a culture of disease denial and anti-vaccination is precluding us from actually staunching this tide of death. A war like this is not what they signed up for.

How are nurses suffering as the pandemic drags on? And what do they need from all of us to prevent more of this trauma?

From the University of California, Irvine, I’m Aaron Orlowski. And you’re listening to the UCI Podcast. Today, I’m speaking with Candace Burton, who is an associate professor of nursing at UCI.

Professor Burton, thank you for joining me today on the UCI Podcast.

CANDACE BURTON

Thanks a lot, Aaron. It’s nice to be here.

ORLOWSKI

So you’re working on a study right now about what has been happening to nurses during the COVID-19 pandemic, and you’ve been talking to them about their experiences. So what are they telling you?

BURTON

If I repeated what they’re actually telling me, I think we would all just break down in tears. The answer to that question is that they’re telling me a lot of really terrible things, that they are really struggling, that this has been worse than anything they’ve ever experienced before. And maybe one of the most key pieces to that is that right now nurses are everything to everybody in the hospital because of the precautions and the fact that nurses need to be so intimately involved with patients who are so terribly ill. There are no family members allowed. There are no chaplains or other support people allowed in the room. So we’re kind of multiple people in one nurse body right now.

ORLOWSKI

So what prompted you to start this study? And when did you start it?

BURTON

We really started the study four or five months ago. And kind of what prompted this was a conversation that I was having with one of my doctoral students who is graduated now. But she’s also the director of critical care and emergency services at a hospital, and she was telling me about some of the awful things that have been going on because they were in a really underserved area. And there were a lot of really sick people. And then it turned out that we had a colleague over in psychology who was interested in this phenomenon called moral injury, which kind of goes along with something that’s fairly well known in nursing called moral distress, which is when as a nurse, you know what needs to be done, but for whatever reason you can’t do it. And the concept of moral injury takes that a step further to actually being emotionally damaged by that. And so we were starting to think, you know, I bet this is probably some of what’s going on right now with our workforce. And so we wanted to get in there and see.

ORLOWSKI

Yeah. What other situations does this type of moral injury or moral damage arise, kind of in a more general sense? What are the parallels for the experience that these nurses are going through?

BURTON

I’ve heard a lot of the nurses I’ve spoken with and a lot of other people describe it in terms of being at war or being in combat or fighting a battle. And I know that there has been some similar work done at the National Center for PTSD up in Palo Alto with combat vets around this kind of thing, where there is no good choice in a given situation, but you have to do something, and then maybe you do something that you don’t want to do, or that you later regret, or that you wish you hadn’t done. And so I think that’s probably the one that comes to mind immediately, which is pretty disturbing.

ORLOWSKI

And these really difficult experiences — what feelings are these prompting for nurses? How is their emotional state really affected by that?

BURTON

Some of them are really struggling. A lot of them are really struggling. A lot of us are really struggling, I should say. Because it’s not just one nurse, it’s all of us. You know, I think there’s a lot of just exhaustion, just emotional and physical exhaustion, from just going flat out for so long with such incredibly sick patients and difficult circumstances. I’ve heard words like “hopelessness,” “depression,” “anxiety.” And more recently, I think we’re starting to see a lot of anger that things are not getting better, that there seem to be things that could be done that could make this better, that aren’t being done, that the public is no longer as invested in stemming the tide of the pandemic as we were early on. And that nurses are continuing to carry this unbelievable burden without relief, without support, without attention, really. There’s a lot of anger.

ORLOWSKI

How has the experience that these nurses are going through changed in the last 18 months? I mean, this has been a long pandemic so far, and there must have been ups and downs and different waves. But so how have things changed over the course of that time?

BURTON

You know, I think at the beginning we were all terrified. Everybody was terrified. It didn’t matter whether you were a nurse, an administrator, a physician, somebody on the street, we were all pretty terrified of what this thing was, and what it was going to do. And you know, some pretty radical steps were taken. Here in California, we went on complete stay-at-home for a while. And I think people were really nervous about it and frightened. And then the vaccines came along and there was this idea that this was the great panacea and that everything was going to be okay. And so at first there was a great deal of enthusiasm for the vaccines. I actually helped run our vaccine clinic at UCI when we first opened up with our students and our nursing faculty. And it was one of the most exciting things I’ve ever done because people were just so happy to be getting the vaccine. And I think that has tapered off. There’s a saying that it’s not a sprint, it’s a marathon. And I think people thought that this was a sprint to get to the vaccine. And then once we did it would be okay and we’re still in the middle of a marathon and we’re not done yet.

ORLOWSKI

So when you are talking to these nurses, I don’t know if you’re able to offer them any advice or anything, but what do you recommend that they do with these really difficult emotions in this time, with that depression and that anger?

BURTON

You know, that’s a really great question. And we have actually started asking the nurses in our study, what are you doing to handle this? But I’ll tell you I came into this research for a couple of reasons. One being that my background as a scientist and researcher is in stress and trauma. And so obviously there was a lot of stress associated with the perspectives of nurses involved in this. And so I wanted to be part of trying to figure out, okay, what can we do with that? And as I got further into the research and listened to more and more of the nurses talk, I started to think how similar their stories sounded to me to the stories I’ve heard from people who have been in abusive relationships, people who have experienced assault and violence, because they really were taking a lot of responsibility on themselves.

And I finally just started saying to them, as we were wrapping up some of the interviews, I would say, “Listen, I just, I need to tell you, this is not your fault. That this was not anything you could have done something about. You were presented with an impossible situation and you did the best you could.” And so I think hearing that and acknowledging that this is trauma, that this is painful, difficult, impossible-to-bear stuff has been a good first step. And the second thing I think has been helpful is really encouraging nurses to have compassion for themselves in this situation. We’re very good as nurses, as a profession, we’re very compassionate toward patients, even patients we don’t particularly like. We’re very good at being compassionate toward patients and families and the people we work with. We are not so good at doing it for ourselves because we’re supposed to be the strong ones who do it for everybody else.

And so when I have talked to nurses, I’ve said, “Look, you can’t — one of my favorite quotes is you can’t pour from an empty cup. So you have to fill your cup somehow so that you can continue to do this. And when you fill your cup, it means taking care of yourself, and making sure that you’re getting what you need.” And part of what’s come out in this study is that we can’t make nurses responsible for their own wellbeing in this. That there’s not enough lavender or candles or scented bath salts in the world to relieve this, that we have to look at this as a systemic problem, too. And then we have to realize that this is a workforce that is in jeopardy.

ORLOWSKI

Well, I want to talk about that more in a little bit. But how has the experience of nurses, who you said are playing every role in these hospitals from chaplain to loved one to everything in between, how’s it different from that of what doctors are experiencing? Because doctors are also part of the crucial care staff.

BURTON

I don’t want to say that any member of the interdisciplinary team that is required to look after a COVID patient is any more or less necessary than any other. I think the big difference is that for physicians and other types of providers, they’re in and out all day. Nurses are with those patients sun up to sundown. Or, sundown to sun up, frankly. And we’re intimately involved with them. And nurses are the ones who hear it when the patient is asking for their family, saying that they can’t breathe, saying that they’re afraid. And other providers go in and out of the room and they go somewhere else. But, for example, one of the things that the nurses have been telling me about is that when you have these really sick, sick patients who are at this very high acuity level of care, you spend hours in the room with one patient, and you have no idea what’s going on with your other patient while you’re in there, because you can’t see out of the room and you can’t hear anything because of all the equipment and the negative pressure that’s required to keep the virus contained. And so sometimes they would come out of their room and something terrible had happened to their other patients. And there was no one to do anything about it because everybody else was in a room with their patient.

ORLOWSKI

So many patients and not enough nurses to look after them.

BURTON

Exactly. And it’s just a very intimate type of relationship. And I use that word very intentionally because we do spend so much time with these people. We become, you know, attached to them. And it’s terrible to see someone that you’ve come to know, and maybe to care about in some way, get sicker and sicker and then maybe die.

ORLOWSKI

Well, you mentioned that this experience, that the nurses are describing it as a war or a long battle. And some nurses sign up for combat duty. But is that what all of these nurses signed up for? I mean, is this the type of extremely intense experience that they thought they were going to have when they decided to become a nurse?

BURTON

I can almost guarantee you that it was not. I went to nursing school. I certainly wouldn’t have been prepared for anything quite like this. You know, there was nothing — people keep using that word “unprecedented.” And I keep thinking, can we get back to precedented times? That would be good. This is unprecedented. We had no idea how to prepare for this. We had no idea how to prepare new nurses for this. And what’s been interesting is that a lot of the nurses that I’ve talked with, the ones who have been in practice longer say that they’re so grateful that this was not their first experience with nursing because they have all of the years where nursing was the best job in the world to sustain them through this. Whereas some of the newer nurses are just so frustrated and exhausted. I talked to one nurse who was literally hiding those little things of protein shakes in the pockets of her scrubs and slurping on them as she ran from room to room because she was working so much and so hard for so long that she was losing weight.

ORLOWSKI

Oh wow. Well, it seems like this is kind of a two-part war. You know, one part is against the COVID-19 disease itself. And then the other is with this culture of disease denial or anti-vaccination, which is making the first war a lot worse, because it keeps on going. So how is that dynamic affecting nurses?

BURTON

It’s deeply frustrating. And as I was saying earlier, I think that’s where a lot of the anger is coming from, and a lot of the distress. Because it’s so obvious to those of us who have been in the direct care environment and seeing what this is like, and worked with people who are sick and dying from this, that it doesn’t have to be this way. That there are ways to protect ourselves, stem the tide, flatten the curve, whatever you want to say. And the idea that some folks are choosing deliberately not to engage in behaviors that could prevent them from having to suffer that is really demeaning and distressing.

ORLOWSKI

I mean, a person’s behavior, their choice to not protect themselves extends to these care providers who are already suffering.

BURTON

Yeah. I mean, we have well over 600,000 deaths in this country from COVID. Something like 30 percent of those have been healthcare providers. And then I think maybe 12 percent of those have been nurses. So this is our lives.

ORLOWSKI

Well, you mentioned earlier that the experiences that the nurses are going through and their comments reminded you of similar research that you had done previously looking at abusive relationships and abusive situations. So what are some of those similarities or differences, in your view, between the previous types of abusive situations that you’ve studied and this current tragedy?

BURTON

I think the biggest is probably this sense of having no control over the situation. That’s something I’ve heard a lot from people who’ve been in violent situations. That they had no control over the situation, and that they could only do whatever it took to keep themselves alive. And I’ve had that conversation with survivors of sexual assault, where they’re saying, “You know, I shouldn’t have gone there, I shouldn’t have had a drink, I shouldn’t have worn this dress, blah, blah, blah, blah.” And I say, “You know what? You survived. You — whatever this person was going to do, they were going to do, and you are alive to tell me about it. And that’s what’s important.” And so that feeling of having no control, of being in an absolutely life-threatening situation and being unable to do anything about it, I think is probably the biggest similarity. And then sort of secondary to that is the guilt and shame of feeling like you weren’t doing what you could have done, that you weren’t doing the best job you could do to take care of someone, that maybe that patient died because you weren’t there five minutes earlier, which is not a reasonable perspective, but in times of great stress and trauma, we’re not always reasonable people.

ORLOWSKI

And that’s where you’re able to hopefully sometimes say, at least to the individuals that you’re speaking to, “You know, this is not your fault.”

BURTON

Exactly.

ORLOWSKI

Well, I don’t want to put the onus on the nursing profession as the group of people that needs to make a change, but are there changes that you think that the profession as a whole could make to lessen or prevent this kind of trauma?

BURTON

I think there are a few things that we could do. I have done some work on trauma-informed care and particularly around teaching trauma-informed care to nursing students because, well, we don’t. You know, it’s interesting, I was just actually working on a paper on this for academics coming back to the classroom this fall. My colleagues, and I have also done a paper on how to teach trauma-informed care practices to nursing students. I think that in the process of working on those two papers, we kind of found out that that content has never really been attended to in most healthcare types of curricula. And so that I think is the first thing that we have to do. We have to recognize that none of us is getting out of this unscathed. There is not a person who can call themself a nurse or a nursing student who is coming out of this unscathed. And if we don’t start taking a universal precautions approach to trauma, we are going to see a lot of loss in a profession, both of actual people in the profession, the actual workforce, but also compromised health, mental health problems, you know, difficulties with productivity and function, generally, because there’s only so much a person can really take. And that’s different for everybody. Some people can take quite a lot more than others. But there is a limit.

ORLOWSKI

What do nurses need from all of us right now? Just the general public, listeners, as we seek to prevent this trauma, and as we seek to help them heal from it?

BURTON

I think the first thing is please wash your hands and wear a mask. That’s what every nurse would say right now if you said to them, “What would you like to say to the public?” They would say, “Wash your hands, wear a mask, get the shot if you haven’t. And even if you have gotten the shot, wash your hands and wear a mask.” Because with the variants, you know, the delta now the lambda and mu coming out, it’s just impossible to predict the course. We know that the vaccines offer good protection against everything we know about so far, including some of these other variants. And so it doesn’t make sense not to get the shot at this point, if you want to protect yourself and protect others from this disease. I think that’s the first thing.

And it’s interesting because one of the things that surprised me was the nurses started saying pretty quickly on in this study, “Don’t call me a hero. I’m not a hero.” One of them said to me, “I’m not a hero. A hero saves lives. I’m not saving lives right now.” And I thought that was really poignant and unfortunate that that particular nurse didn’t see themselves that way. Because I do think that there have been some very heroic things done by the nursing workforce to get us through all of this. But I think it was very trendy for a while to celebrate nurses and call us heroes and send food and send little gifts and stuff like that. And now it seems like people have determined this is business as usual. But as we were just discussing, the fact that this is not what we signed up for, it’s not business as usual. And so the difficulty, I think, with reconciling that, and with trying to talk about this to anybody who hasn’t been in the trenches with us as nurses, it’s really difficult. And so I hope that if there are folks listening who know nurses who have nurses in their families, that they will be willing to just listen, and not try to fix it, and not tell them they don’t want to hear about it because it’s too depressing, or tell them that they don’t believe them, but that they will just be willing to hear them out.

ORLOWSKI

Professor Burton, thank you so much for joining me today on the UCI Podcast.

BURTON

It’s been a pleasure, Aaron, thank you.

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