How the Pandemic is Taking a Toll on Rhode Island’s Front-Line Health Care Workers

On a Wednesday morning in February, the neonatal intensive care unit at Women and Infants Hospital is a bubble of calm, a quiet oasis in the otherwise bustling hospital complex bordering Providence’s Jewelry District. Everything about the space is designed to evoke a sense of peace for parents navigating a stressful time, from its green and beige walls to the nurses speaking in hushed but confident voices as they walk the halls. In a room at the end of the hall, where staffers gather to start their day, a whiteboard lists the needs of patients while a Pinterest-worthy sign charges them with their most important task: “Keep the tiny humans alive.”

Here, more than in other areas of the hospital, decorations and personal touches indicate that many of the patients will be here several months before they are ready to go home. Private rooms, once filled with grandparents and cousins, are now restricted to parents due to pandemic visitation policies. Sometimes, even that small comfort goes away. In one room, a nurse in full personal protective equipment cradles a child whose mother tested positive for COVID-19 a few days before.

“This family can’t come visit, so the nurse is taking on that role,” says Karen Dreyer, a nurse who has worked in the NICU for twenty-four years.

Despite the serene exterior, the department faces unique stresses not encountered in other areas of the hospital. Every so often, a phone in Dreyer’s hand goes off to signal a potentially complicated birth is happening in the delivery area. Some families spend weeks or even months in the NICU waiting for their child to gain the strength to go home. Nurses become a part of that recovery, often receiving Christmas cards or birthday party invitations for years after. For those who don’t make it, the grief is a shared experience.

“The whole staff takes it hard,” Dreyer says. “It’s such a tight community here, so when that happens, it hits everybody.”

The hospital holds debriefings and offers chaplain services, but often the greatest comfort after a child’s death is discussing it with each other. Dreyer calls these conversations therapeutic, giving nurses the opportunity to share their grief with others who understand. Emily Breguet, an assistant nurse manager with three children of her own, recalls one night shift when NICU staff was struggling to care for two critically ill newborns. She was relieved to see one of her fellow nurses arrive at 3 a.m. to join the fight.

“Both those kids died within an hour. And if I hadn’t had her, I don’t know what I would have done,” she says.

Like other health care workers, NICU staff has faced the additional challenge of working amid the constant threat of COVID-19. Danielle Buzzell, a nurse with severe asthma who has worked in the NICU for seventeen years, says the hardest part for her has been wearing an N95 mask at all times while working. She recalls the early weeks of the pandemic when she would strip down hazmat-style and shower before greeting her children after work. Even now, she says, her kids don’t race up to her for a hug and a kiss when she gets home.

“The very beginning, I thought this was the year I was going to die,” she says. “I have young children at home, so we were afraid. But we have a calling, and we are all these babies have. We’re very specialized in our training, and so we came and we did it.”

When she received her first COVID-19 shot the day after Christmas in 2020, she was so relieved she cried.

“This is a calling to be a NICU nurse. If we didn’t show up to work, if we just quit, who would they have?” she asks.

Like with physicians, the factors leading to burnout and staff shortages among nurses began long before COVID-
19. As far back as 2012, researchers predicted a shortage of between 300,000 and 1 million nurses across the country by 2020. The reasons for the shortage are complex and include longer lifespans, the retirement of baby boomer nurses and limited capacity in nurse education programs. Trish Criner, a Kent Hospital nurse and president of United Nurses and Allied Professionals Local 5008, recalls when local hospitals could mandate overtime based on staffing needs. When she started working in 1994, she says, it wasn’t unusual to have to cancel weekend plans because of last-minute staffing mandates.

“I was getting mandated like once a week at some points,” she says. “A lot of people forget what it was like. It was hell, but you know what, it was part of the job. It was part of the job and if you wanted to be a nurse, you really don’t know when you’re going to go home. That was that.”

Rhode Island banned mandatory overtime in hospitals for nurses and nurse’s assistants in 2008, but the job, like most in the medical industry, still takes a heavy emotional toll on employees. In the early weeks of the pandemic, colleagues in Criner’s unit at Kent Hospital found themselves caring for a longtime co-worker who had fallen ill with COVID-19. The woman, an intensive care unit nurse and secretary for more than forty years, eventually succumbed to the disease surrounded by her fellow staff members. When she entered the room to care for her, Criner says, she had trouble equating the patient before her with the co-worker she knew and loved.

“There’s always a little bit of numbness, especially if you’re a seasoned nurse, because in general you see a lot of death throughout your career,” she says. “You learn how to separate, and your mind automatically does that. And then with COVID, the profound sadness and the ugliness of it, that kind of numbs you even further.”

Today, she says, younger nurses have more tools to advocate for themselves in the workplace, including stronger union advocacy and a greater acceptance of mental health needs. Raquél Pérez, a nurse who graduated from the University of Rhode Island in 2017, says that following the start of the pandemic, many of her friends reevaluated where they fit in the profession and whether they want to continue in their current roles. Though most still work in nursing, she says, individuals are placing greater emphasis on self-care, and the expectation of health care workers always putting other’s needs before their own is changing.

“I always remind people we’re human beings first and we’re nurses second,” she says. “I can’t say if I think these conversations would’ve been as common or as put out here before the pandemic. I think there’s definitely this sense that we’ve moved to make sure the people who are taking care of other people are taken care of, too.”

As the pandemic has raised more awareness of the challenges faced by front-line medical workers, health care organizations are taking note. At Miriam Hospital, Collins has been an advocate for expanding the availability of transcendental meditation resources among staff. The program initially started as a pilot for nurses sponsored by Heal the Healers Now, a national initiative that launched in April of 2020 to try to reduce burnout by training health care workers in transcendental meditation. As of March, the program had expanded to train ten staff doctors and offer training to all newly hired nurses. The hospital dedicates regular space for meditation and offers group sessions where staff members can meditate together.

“I saw a poster to recruit people to do it, and it’s something I had heard of and wanted to do,” Collins says. “I did the training myself and saw the difference it really made, especially after these last two years of constant pandemic, really feeling like it’s continued trauma. We get through one wave and then we just have to do it again.”

The transcendental meditation program runs alongside the hospital’s other integrative therapy offerings, including yoga and massage. Collins, who spent the first three months of the pandemic living in his finished basement for fear of exposing his family to COVID-19, says health care workers can sometimes be too resilient in their  approach to their work. Front-line workers have been taught to push through difficulty, often leading to frustration and employees feeling on edge down the line. If these feelings are not addressed, he says, the situation can lead to burnout and staff leaving the industry.

“That just puts more work on everybody else, because you can’t just go to the grocery store and pick up a new doctor or a new nurse,” he says.

According to Lisa Abbott, senior vice president for human resources and community affairs at Lifespan, the state’s largest hospital group, clinician burnout was already an epidemic long before COVID-19 swept across the country. Beginning in 2017, the organization hired a consultant to conduct a survey and develop recommendations for preventing burnout in staff. The results, published as a study in the American Journal of Medicine, included everything from meeting basic needs — ensuring clinicians have time to use the bathroom and access to healthy snacks — to safeguarding more complex needs such as publishing or teaching as an actualization of their work.

Following some changes, she says, the organization began to see modest improvements. Then, COVID-19 disrupted every-
thing.

“What I tend to say is when COVID first hit, people were running on adrenaline. When the second wave hit, people were running on fumes. And when the third wave hit, people ran away,” she says.

Dr. Bradley Collins using one of the meditation rooms at Miriam Hospital. Photograph courtesy of Lifespan.

“What I tend to say is when COVID first hit, people were running on adrenaline. When the second wave hit, people were running on fumes. AND When the third wave hit, people ran away.” — LISA ABBOTT

Lifespan doubled down on its emotional and mental health initiatives, supports that became even more important as the pandemic inflamed an already brewing staffing crisis. As of March, Lifespan had about 2,300 vacancies across all its facilities, up from 800 pre-pandemic but down from about 2,600 at the height of the omicron surge. As hospitals find themselves increasingly in competition for a limited supply of workers, employee well-being has become as much about attracting new staff members as protecting the health of the ones already there. More recent efforts at Lifespan have included looking at how to expand on-site child care and investing $50 million in wage enhancement, primarily for clinically facing roles.

“That matters, but it’s not just about wages,” Abbott says. “Most of what I’m talking about doesn’t have to do with what we’re paying people, it’s the total value of being here. And I think over time as people are able to come up for air, it will start to really make a big difference. In fact, I’m counting on it.”

Some approaches to addressing burnout in health care have taken a less traditional approach. Dr. Judson Brewer is the director of research and innovation at the Mindfulness Center at Brown University and a top researcher in addiction psychiatry and habit change. In 2018, he helped develop an app that aimed to break the cycle of anxiety by offering mindfulness training in the form of daily exercises and check-ins. In one of the first pilot studies, which measured the app’s effects on physicians dealing with anxiety, researchers found a close link between anxiety and physician burnout. Furthermore, they discovered that participating in mindfulness training via an app could lower anxiety in physicians by as much as 57 percent.

“If you’re burnt out and exhausted, how are you going to have the energy to go and see somebody? It’s a vicious cycle,” Brewer says. “This is in part why we developed these digital therapeutics, because I wanted to help overcome some of those barriers to entry.”

Even as the app went to mass market, though, Brewer recognized it had limits in addressing burnout among physicians. In the study, the app had the greatest effect on callousness — a defense mechanism people develop to protect themselves from burnout — and the least effect on emotional exhaustion, a factor often outside a health care worker’s control. Brewer interpreted these results to mean that while app-based mindfulness training can help health care workers and employees in other high-stress jobs control their responses to the pressures around them, external help can only go so far in fixing the institutional factors that create the stressful conditions.

“An app is not going to fix a system, but it might help people free up their own individual energy to go and change the system,” he says.

On a national scale, too, the country is taking note. Earlier this year, Congress passed the Dr. Lorna Breen Health Care Provider Protection Act, which establishes grant funding to support behavioral and mental health services for front-line medical workers. Named for a Manhattan emergency room doctor who took her own life in the early weeks of the pandemic, the bill also requires the Department of Health and Human Services to encourage health care providers to seek support and disseminate best practices for improving mental health and preventing suicide among medical workers.

“I feel like there’s a lot more focus in the moment on this mentality of health care workers,” says Brooke Huminski, a Providence-based psychotherapist who has treated health care workers both before and during the pandemic. “I feel like the pendulum is moving. Is it moving fast enough?”

Helene Macedo loves cooking but finds it more difficult since losing her sense of taste and smell. photography by Alex Gagne.

At her home in Cranston, Helene Macedo has come a long way since October of 2020. She now works six-and-a-half hours at a time and has resumed going to the gym. She goes out to restaurants but orders only dishes she knows, relying on memory as a substitute for her still-absent sense of taste. Despite her struggle with long COVID, she has managed to avoid much of the long-term anxiety and depression so common in her industry, crediting her family with keeping her mind grounded even as her physical health deteriorated.

Last winter, about six months after returning to work, she watched as the latest wave of COVID-19 pushed an
already stressed industry close to breaking point. Entire units at Rhode Island Hospital once bustling with patients now sat empty because of a lack of employees to staff them. Every day, she says, her co-workers came into work with the feeling they were trying to hang on as long as they could. Some had already left to take more lucrative traveling assignments or out of frustration with their roles.

“There’s nothing worse than coming into work and feeling like you have barely been able to do what you need to do. You’re dealing with patients. You’re dealing with lives,” she says.

Like others, Macedo says she sees a new generation of nurses more focused on work-life balance. Younger health care workers are more willing to speak up for themselves or switch positions if a job doesn’t deliver what they need. Like her own struggle with COVID-19, the causes behind the health care industry’s staffing crisis are long and complex, and easy answers aren’t readily available; but until everyone sits down to focus on the problem, she says, nothing is going to get fixed.

Despite everything, she says, she isn’t ready to give up what she does.

“You never want to say it can’t get any worse, because we never thought we’d see where we’re at right now,” she says. “We all love what we do, so I think that’s sort of what keeps us coming back every day to do it. And just every day keep thinking something has to give so that we can see some glimmer of improvement.”

If you or someone you know is experiencing a mental health crisis or thoughts of suicide, call the 24/7 BH Link hotline at 401-414-LINK. Or you can use the Crisis Text Line and connect with a crisis coordinator within twenty-five seconds on average. Text HELLO to 741741, and communicate until you feel safe.