Introduction

In May 2022, the Surgeon General of the United States (U.S.) released an advisory announcing the urgent need to address healthcare worker (HCW) burnout and resignation [1]. Burnout is defined as an occupational phenomenon by the 11th Revision of the International Classification of Diseases (ICD-11) and is “conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: feelings of energy depletion or exhaustion; increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and reduced professional efficacy” [2]. The challenges of the Coronavirus disease 2019 (COVID-19) pandemic have aggravated already high rates of HCW burnout in the U.S., with several studies estimating that around half of HCWs have experienced burnout during the pandemic [3, 4]. Current literature on burnout is largely focused on physicians and nurses, and data including other roles are less common. However, inclusion of other roles in research related to burnout and turnover is important, as over the next several years, it is expected that there will be a considerable shortage of HCWs in low wage positions [5] and in a study of over 20,000 U.S. HCWs, Certified Nursing Assistants (CNA) were among the groups with the highest levels of stress [3].

In addition to affecting individual HCWs themselves, HCW burnout has also been associated with decreases in patient safety, including higher rates of healthcare-associated infections [6]. Additionally, burnout is associated with increased rates of HCW turnover [7, 8], which leads to higher costs for healthcare systems as a whole. An estimated $4.6 billion are spent on burnout-related turnover for physicians alone in the U.S. each year [9]. To build a more resilient healthcare system overall, more research is needed on the causes of HCW burnout and possible interventions to address this urgent issue. The goal of this project was to gain insight on drivers behind HCW burnout and turnover during the COVID-19 pandemic through exploratory focus group discussions with both current and former CNAs.

Methods

From October 2022 to January 2023, eight virtual qualitative focus group discussions were held over Zoom with CNAs who worked in acute care hospitals during the COVID-19 pandemic. In order to obtain a broader understanding of factors affecting burnout and turnover among CNAs, both current and former CNAs were included in the focus group discussions. Participants were recruited by Rainmakers Strategic Solutions [10] in partnership with Focus Forward, a qualitative recruitment agency through multiple sources, including social media and outreach via professional organizations. Participation was voluntary and participants were compensated for their time. This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy (See e.g., 45 C.F.R. part 46, 21 C.F.R. part 56; 42 U.S.C. §241(d); 5 U.S.C. §552a; 44 U.S.C. §3501 et seq.). Participants provided verbal consent prior to the start of the focus groups. Per determination by the CDC’s National Center for Emerging and Zoonotic Infectious Diseases (NCEZID) Human Subjects Advisor, this qualitative assessment does not meet the definition of research under 45 C.F.R. 46.102(l) and IRB review is not required. NCEZID’s determination holds that the project did not require submission to CDC’s Human Research Protection Office as granting authority is delegated to the CDC Centers, Institutes, and Offices under CDC Policies SSA-2010-01 and SSA-2010-02.

Each focus group ranged from four to 10 participants and lasted approximately 30 minutes, with the discussion guided by a trained moderator [RC] utilizing open-ended prompts. Topics explored included challenges experienced as a CNA during the pandemic, what participants would change about their experience as a CNA during the pandemic, messages they would like to convey to management in their facility, what could have helped them continue to work as a CNA in an acute care hospital and motivations for continuing or leaving their career as a CNA. The focus groups were recorded with participant permission, transcribed and deidentified, and then coded across the discussions using an immersion-crystallization technique [11] as a group by a team of three coders [RS, RC, LB] with experience in qualitative coding. Codes were summarized using NVivo (released in March 2020) [12] and Microsoft Excel and reviewed as a group to ensure reliability. Consensus in assigned codes was reached through group discussion and codes were then categorized into corresponding themes. Participant demographic information obtained by Rainmakers Solutions during the recruitment process was also summarized overall and by current work status. After deidentification, authors did not have access to information which could identify individual participants.

Results

Of the 58 CNAs who participated in the focus groups, 33 (57%) worked in an acute care hospital during the COVID-19 pandemic and remained employed as hospital-based CNAs, while 25 (43%) were former CNAs who worked in an acute care hospital at some point during the COVID-19 pandemic but were no longer working in a healthcare setting. Of the 58 participants, 54 (93%) were female, and 41% were White, while 40% were Black or African American (Table 1). Twenty-one percent of the participants were of Hispanic, Latino/Latina or Spanish origin. The mean age of the participants was 39 years, and the participants had a mean of 12 years of experience as a CNA. The participants worked varying shifts, with 27 (47%) working primarily day shift and 20 (34%) primarily working night shift.

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Table 1. Demographics of participating certified nursing assistants working in acute care hospitals during the COVID-19 pandemic.

https://doi.org/10.1371/journal.pone.0290880.t001

Throughout the focus groups, five convergent themes emerged when participants discussed challenges experienced, what they would change about their experience working as a CNA during the pandemic, messages they would like to convey to management in their facility, what could have helped them continue to work as a CNA, and their motivations for continuing or leaving their career as a CNA (Table 2).

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Table 2. Convergent themes expressed by participating certified nursing assistants working in acute care hospitals during the COVID-19 pandemic.

https://doi.org/10.1371/journal.pone.0290880.t002

Discussion

During the COVID-19 pandemic, healthcare systems across the U.S. were faced with a surge of patients requiring care along with shortages of Personal Protective Equipment and staff [13]. Convergent themes that emerged across the focus groups included staffing challenges, a lack of respect and recognition in their facilities, the toll the job takes on CNAs both physically and mentally, a lack of facility leadership support for CNAs, and the need for better pay and incentives for CNAs.

The participants shared their experiences working in facilities with patient-to-staff ratios reported as high as 40 to 1 and the effect these ratios had on their day-to-day experiences as CNAs. The CNAs described that high patient-to-provider ratios were a factor that led them to consider leaving their job, potentially further exacerbating the issue. One CNA described that learning about high patient-to-staff ratios when applying to a job in a new facility would prevent them from wanting to work there. Staffing shortages also have been reported across healthcare facility types and worker roles both before and during the pandemic [14–17], with a qualitative study of nursing home staff also finding that staffing was a main concern for CNAs in long-term care settings [18]. In a survey of over 20,000 physicians and nurses in the U.S. during the COVID-19 pandemic, over half of nurses felt that staffing levels were not adequate to properly care for patients and improved nurse staffing was the intervention respondents felt was most important for improving their well-being [19]. While various studies have focused on the relationship between staffing ratios for Registered Nurses and patient safety [20], evidence to more clearly define staffing ratios for CNAs is very limited, and more research in this area is warranted. Understanding the implications for both patient safety and for HCW well-being should be included as part of further investigations.

The CNAs in this analysis also expressed that the mental and physical toll that being a CNA placed on them contributed to burnout. Across healthcare settings, CNAs provide essential care to patients, including turning, bathing, and feeding. As the role of a CNA often includes manual handling of patients and other tasks which can be physically taxing, the physical exhaustion experienced during their jobs was described as one reason that CNAs considered leaving their positions. The CNAs also described that facilities did not routinely offer mental health support, or that this support was not consistently offered for staff in all roles. Offering mental health support and resources to HCWs across all roles in facilities, especially considering the high rates of anxiety, depression, and Post Traumatic Stress Disorder seen in HCWs during the pandemic [21], might help address this issue. Several participants also described that they became morally uncomfortable with what they perceived as the decreased quality of care they were able to provide to patients due to limited staffing and resources. This sentiment is similar to the moral distress and moral injury that has previously been described in HCWs which stems from limitations outside of their control preventing them from being able to provide the care that they feel their patients need [22, 23]. These concepts should also be considered in addition to burnout when discussing interventions to improve the HCW experience and decrease turnover.

The theme of lack of respect and recognition for CNAs which emerged during the focus groups is concordant with a nationwide study that found that HCWs who felt valued by their facilities experienced lower rates of stress and burnout [3]. The U.S. Surgeon General Advisory also includes ensuring that workers know they are valued as one way that healthcare organizations can work to address burnout [1].

Specific suggestions for improvement at the healthcare facility level provided by the focus group participants included making CNAs feel valued by celebrating CNA week, upper management directly saying thank you to CNAs, improving wages and hazard pay, and giving discounts for essentials such as work shoes, scrubs, and parking. However, frequent pizza parties and impersonal thank you letters from management were spoken of negatively by participants. The participants also thought that debriefing with their peers after traumatic situations may improve their mental health. Several studies have shown the feasibility of debriefing interventions to support HCWs at risk for burnout, and additional research further exploring debriefing programs may be important in developing tools for prevention of HCW burnout in the future [24, 25]. The CNAs also desired to be included in conversations with facility leadership about improvements that could be made in their facilities. As suggested by one participant, having a lead CNA to act as a liaison between CNAs and facility leadership may provide the opportunity for CNA participation in workplace experience improvement. Creating a forum for CNAs to have regular contact with leadership to discuss their work experiences and opportunities for improvement may also serve to facilitate support for CNAs. Previous qualitative discussions with HCWs during the COVID-19 pandemic have also cited the importance of leadership who listen to and take action to address the concerns of frontline personnel [26] and a survey of over 30,000 U.S. HCWs found that favorable leadership scores were associated with lower odds of burnout [27].

Various interventions to address and prevent HCW burnout have been cited in the literature, including individual-level prevention measures (e.g., exercise, self-care training, and improved sleep) and organizational interventions, such as paid time off or inclusion of input from HCWs across various roles when making decisions that impact HCW policy and practice in facilities [1, 28]. Improving both individual and organizational factors is important for preventing burnout and supporting workers who are experiencing burnout.

Our study had several limitations. Participants represented a voluntary convenience sample and all data collected were self-reported. Data were also subject to recall bias and social desirability bias. Participants may not be representative of the overall population of CNAs in the U.S.; and therefore, generalizability of participant perceptions may be limited. Compared to the overall population of CNAs in the U.S., the sample of participants in our focus groups had an overrepresentation of CNAs from the South and West Regions of the U.S. and an underrepresentation of participants who were of Asian or Pacific Islander descent. Despite this, the overall demographics of our participants were similar to the overall population of CNAs in the U.S., with U.S. Census Bureau data estimating that in 2020, 89% of CNAs in the U.S. were Female, while 50% were White, 35% Black or African American, 5% Asian or Pacific Islander, 5% were people of other races, 4% people of more than one race, and 0.9% were American Indian or Alaskan Native [29]. As the CNA workforce largely consists of women and people of color, further research on workplace-associated inequities among CNAs (e.g., unequal access to mental health resources) is important as they may further exacerbate health inequities experienced by women and people of color overall. Additionally, it is also important to note that over 20% of CNAs in the U.S. are foreign-born and further research on inequities experienced by immigrant health workers may also be an important topic to consider, as this population is recognized as having their health and well-being disproportionately impacted by the COVID-19 pandemic [1]. Furthermore, when looking at potential differences between themes expressed by current and former CNAs during the focus groups, caution should be taken in interpretation due to the qualitative nature of these open-ended focus group discussions. While a somewhat higher proportion of former CNAs expressed the theme of the physical and mental toll of their jobs in comparison to current CNAs, and a somewhat lower proportion of former CNAs discussed pay and incentives as compared to current CNAs, these qualitative data should not be used as a basis for statistical comparison between the two groups.

In summary, focus groups with CNAs in acute care hospitals have shown that factors at the individual and organizational levels affect the HCW experience, contribute to burnout and turnover, and should be addressed to ensure a resilient healthcare system. The focus group participants and CNAs nationwide provided essential care to patients throughout the COVID-19 pandemic and, as such, should be included in activities to recognize their contributions and provided equal access to resources for support. Additionally, as literature related to HCW burnout largely focuses on nurses and physicians, more research is needed on factors leading to burnout among workers in other healthcare roles and developing evidence-based interventions to prevent burnout in these groups.

Acknowledgments

We want to express our sincerest gratitude to the participating CNAs who graciously shared their experiences working in healthcare and for their dedication in providing essential care to their patients under the most challenging circumstances.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.