Burnout in Infection Prevention: The Silent Crisis We Must Confront

IP Lifeline From Infection Control Today

Having had a fulfilling career as an infection preventionist (IP), I am now a part-time PhD student and a full-time lecturer in infection prevention and control (IPC) at University College Cork, Ireland. I am passionate about my PhD subject matter—burnout in IPs—. I have suffered burnout throughout my career to date, just as you have, and it is time for us to acknowledge how we feel, what led us here, and how we can overcome it, so please step into my shoes for a moment and hear my story....

I recall my early career in IPC through rose-tinted glass when I worked as a nurse in infectious diseases at Northwick Park Hospital in London, England. I was young and zealous, and this was about the most exciting place I had ever worked. I learned everything I could about infectious diseases with some wonderful colleagues.

In 2001, I returned to my native Cork, Ireland, where I enthusiastically started my first IPC role. It was no easy feat as I dealt with some of the more draconian challenges of an older system that felt threatened, hostile, and resistant to change. This impacted my productivity and passion, causing me to feel disengaged and isolated at times. Nonetheless, I survived and achieved a great deal, but at what cost?

Fast-forward to 2019, and I had started a master’s in applied psychology as if I were preparing for an existential life crisis! Not really. I was subconsciously searching for a more positive way to address my own burnout, and it was working. Wow, my timing was perfect!

When COVID-19 struck, I was managing a large medical center. With this enormous existential threat bearing down on the world, I was thrown from the mundane tasks of a managerial role to absolute chaos, with months of scrambling for additional personal protective equipment (PPE) and supplies, putting our clinics online overnight, implementing infection control precautions, while also holding space for patients and colleagues who were fearful and stressed. I knew I did a stellar job because I understood crisis management inherently.

Bizarrely, I felt more alive and engaged than I had in a long time, in the sense that I felt completely in the zone managing an existential public health crisis. I quickly realized that I needed to be elsewhere, so, equipped with my experience in IPC, leadership, and applied psychology coaching, I returned to the frontline as an IPC nurse specialist in the hospital sector. I was also in the middle of my dissertation—a study on nurses’ experiences on the COVID-19 frontline, during which I was privileged to interview incredibly brave nurses. My findings were distressing, and it was harrowing to process, but I found myself relating to the fear, isolation, and distress that my colleagues were experiencing.

Before I delve deeper, it is important to understand how burnout is defined. Maslach¹ describes it as “a prolonged response to chronic emotional and interpersonal stressors at work,” characterized by 3 domains: emotional exhaustion, feeling distance from work, and reduced self-efficacy. Burnout is also a response to sustained work-related stress due to organizational and individual coping factors and personality type.

Patient mortality rates tend to be higher in hospitals with higher rates of staff burnout, and there is emerging research suggesting a strong link between burnout and the implementation of IPC measures,² which is a worrying trend for IPs. In fact, long before COVID-19, our mental health has been a concern; nurses who cared for patients with Ebola, SARS³, and MERS-CoV⁴ are known to have suffered considerable mental health challenges, including burnout.⁵

In a sense, the pandemic has merely given these challenges a platform, so it is timely that the World Health Organization (WHO) has crystalized workplace burnout by its inclusion in the 11th Revision of the International Classification of Diseases (ICD-11) as a phenomenon exclusive to occupational health.⁶ This development is critically important as ICD-11 now offers medics a guide for recognizing burnout, allowing the WHO to track burnout and other conditions that might coexist (eg, anxiety, moral injury). This also adds strength to my justification for examining burnout in IPs and is a major advance in supporting how we might design a solution. In addition, within the European Union (EU), addressing burnout is justified from a legal perspective (European Union Framework Directive on Health and Safety (89/391/EEC)),⁷ placing the onus on employers to manage burnout in a preventative manner by including binding policies over the traditional soft policies.

At the start of the pandemic, politicians, the media, and the public lauded us as superheroes in armor (PPE); people stood on their steps and lit candles for us as we joined the frontline, like soldiers going into battle. They nudged us on, and we were proud to serve, turning up every day to care for the loved ones of strangers. Support soon dwindled, and we were publicly villainised, disrespected, humiliated, and blamed for spreading infection and killing patients.

Five years on, the fallen angels and forgotten heroes feel cynical about the unrealistic expectations placed upon us as individuals. Where is our support now? Where was it then? Although the superhero label may have been an unintended consequence, it was nonetheless damaging and severely impacted our mental health while we tried our best to uphold the strong moral code and duty of care that was deep-rooted in us. We did our best, but our best just wasn’t good enough. It wasn’t good enough…then we were really hurting.

One nurse described her enormous guilt at choosing which patients she could save as there weren’t enough staff to care for them all. We had to put our emotions on hold for sustained lengths of time, or we would fall apart too soon, be broken, and be unable to return to work. Some of us had to purposely detach from our chaotic surroundings by hunkering down to shield ourselves from the emotional torment. One day at a time, one task at a time became familiar mantras, as did the potent use of metaphors, particularly war-like metaphors. Describing our trauma in metaphors helped us to make sense of it to cope. We likened our chaos to war zones, where we went into battle with all guns blazing.

We reached our capacity to cope with a sustained and lengthy pandemic. Research strongly suggests the nearer the frontline, the poorer the outcomes in terms of psychological wellbeing.⁸ My study strongly highlights the emotional effects on nurses due to fear, isolation, and feeling undervalued at work. One nurse shared that she was so afraid of dying herself that she rewrote her will before being redeployed, yet she went in there without question and pushed with her shoulder to the wheel, flanked by an army of nurses.

Another nurse felt so distraught with having to pack bodies into cadaver bags that she likened it to packing groceries at the store. Not only that, but those same patients died in their hospital beds, alone, scared, and away from their families. This had a profound effect on us and contributed to the extensive moral injury and sustained levels of burnout we endured. Sadly, neither I nor the nurses in my study received any form of resilience training during the pandemic and no psychological debriefing thereafter.

We, the IPs, are forgotten in all of this. There have been countless burnout studies on other health care workers and a mere handful on IPs. Some healthcare workers are destined to do great things, but what we did during COVID-19 was quite extraordinary. We may have weathered the same storm but were not all in the same boat, and the climate remains unstable. Our roles were unique in disease prevention, outbreak management, support and education, and generally keeping the show on the road with constantly changing guidelines. Today, what is certain is that the sustained stress and burnout that we suffer are our new reality. We are facing the endemic effects of burnout, high turnover rates, and an aging population of IPs.

On March 11, 2020, most of us knew that COVID-19 was our call to action. Most IPs in their lifetime never get to work through a global pandemic, but we did, and although what we endured placed our discipline into disarray, we have come away from this with an abundance of knowledge and strength. My PhD will leverage that knowledge to support IPs emotionally and psychologically through extended crisis events using the pandemic as a catalyst for change.⁹

My goal is to develop a burnout prevention model to bridge the gap between scientific research and the practical application of burnout interventions. One of my papers is the first global systematic review on IP burnout, which has started the clock ticking. This work is urgent because, as we all know, the next existential crisis is simmering on the horizon, and it will not sit and wait until it reaches boiling point.

To learn more, please see Sinéad’s systematic review protocol at https://hrbopenresearch.org/articles/7-69