Experiencing distress with staffing shortages, increased patient care needs, and visitor restrictions.

Over the course of the pandemic, in the hospital, there were fluctuations in staffing with strain due to shortages as well as increased workload and increased volumes of acutely ill (COVID-19 and non-COVID-19) patients. As one nurse shared “the staffing has gotten a lot worse, and it’s become overwhelming (T5)”, while another described their “workload has increased to a ridiculous demand [with] heavier patients, more discharges and admissions every day, and short staffed more frequently (T4)”. As a medical imaging technologist (T4) noted “work is getting more hectic right now as volumes increase and its lack of staffing and the hectic work environment that stresses me”. The increased workload as a result of staffing shortages and increase in patient volumes and complexity was further exacerbated, particularly for nurses, by having to provide education to redeployed or new staff. Shortages of staff occurred as a result of sick calls, recruitment challenges, and turnover with some participants sharing that nurses were leaving the organization for less stressful environments and better compensation. The following excerpts provide examples of this theme.

“Working in the ICU has put additional strains with the patient population, limited resources and increased teaching to unqualified staff. There is no financial compensation for nurses. It makes me feel ICU nurses are expendable and worthless. Short staffed or staffed to quota but with unqualified staff puts tremendous strain on the ICU nurse.” (T3 Nurse)

“The lack of staff has been incredibly difficult. So many sick calls, so many short staffed shifts. No one is applying for job postings. No one wanting overtime because everyone is so burnt out. We have yet a chance to breathe despite the numbers.” (T4 Occupational Therapist)

“Nurses aren’t growing as professionals. People have left the unit due to lack of growth, difficult assignments, toxic social unit environment and other personal reasons.” (T5 Nurse)

“It’s crystallized my retirement plans and likely will be earlier than pre-pandemic.” (T6 Physician)

Grappling with ongoing staffing shortages and heavy workloads evoked feeling stressed, burnt out, and upset. Some respondents also expressed feeling resentment and betrayal towards other staff that were taking sick time off or were no longer redeployed, with hospital management for not supporting staff more throughout the pandemic. As one nurse (T2) noted “I frequently feel upset and betrayed by them calling in sick because it makes us short-staffed for the shift, which in turn creates more stress on the rest of us who continue to come in to work regularly during this pandemic.” Others expressed feeling morally distressed and guilty about coming to work and not being able to provide quality care or when they themselves had to take a day off work due to being sick. For some respondents, their levels of exhaustion and burnout and managing within a crisis situation were impacting their ability to provide quality care. As a speech language pathologist noted “we were in a crisis situation, making quick decisions that have never before had to be made and those may not have always led the best outcomes but they always came from good intentions from all involved parties (T3)”. This theme is further illustrated in the following quotes.

“In the second wave patients have been coming in more sick than I can remember. The amount of time spent providing bedside nursing care for just 1 patient is increasing. I feel it is unsafe, for my patients, for myself. I feel taken advantage of, working in increasingly difficult circumstances with added pressure and urgency.” (T2 Nurse)

“With staff shortages and ongoing high caseload demands, I feel guilt at taking more than 1 day (a SICK day!) off work. Taking any planned time off is more stressful than being at work.” (T7 Nurse)

“Due to staffing demands and workload challenges, my role has shifted in responsibilities to work that I don’t feel passionate about, which created inner conflict for me that is challenging.” (T7 Social Worker)

More severe moral tensions emerged with some participants sharing that they felt they were abandoning their patients when they were redeployed, while others described having to compromise the care they were capable of providing. The toll of visitor restrictions also was observed to impact the care of both the patients and their care partners, as one participant described as "keeps them up at night”. This theme is further illustrated in the following quotes.

“The most difficult part of redeploying to another area of the hospital, was the sense that I was abandoning my own patients.” (T4 Social Worker)

“Very difficult to feel you are doing a good job when you are not providing the same amount to therapy that you were able to provide prior to the pandemic.” (T6 Occupational Therapist)

“What keeps me up at night is the cumulative effect of seeing the isolation and confusion of our patients, and their families throughout this pandemic, and the struggles they have with understanding what is going on.” (T3 Healthcare Personnel)

“I find the rules about patient visitors and care partners to be unfair, discriminatory, and inconsistently applied. This is very distressing in the clinical environment.” (T3 Physician)

Feeling devalued, unappreciated, and invisible due to lack of support and inequities.

Closely aligned with the first theme, feeling devalued and invisible due to lack of support and inequities emerged as further examples of tension and moral distress. This theme captures the feelings evoked from the lack of acknowledgement and response from both the organization’s leadership and government. This is illustrated as one nurse described that “support for staff working during the pandemic from senior hospital management [and] the government continues to be sporadic and patronizing (T3)”. They further added “being told verbally by everyone that they so thankful for your service and hard work, but then doing nothing concrete (increased pay, more resources) is disingenuous and makes me more depressed than if they had said nothing at all”. Others described feeling unsupported (e.g. having to take vacation days when being off due to a COVID-19 high risk exposure), unappreciated with having to do more with less, and emotional as noted by one nurse “it has been tiring, emotionally draining and feelings of being unsupported by some colleagues and management (T3)”. Further narrative excerpts exemplify this theme.

“Ongoing staff shortages has caused ongoing stress and burnout. The lack of notice by management or repercussions sets the tone that this is acceptable going forward and they don’t care about us.” (T4 Healthcare Personnel)

“There is no flexibility and nurses are not seen as humans, just pawns that are replaceable. They are tired of being treated like they are unimportant and are leaving in droves.” (T6 Nurse)

Over time, feelings of sadness, disillusionment. irritability, resentment, and apathy were experienced. For example, one healthcare personnel shared that COVID-19 created apathy in their department that resulting in them feeling “being bad at your job, unsatisfied (T4)”. Other narrative examples include:

“The expectations are high and it feels like management doesn’t really care that we are languishing on the frontlines. I don’t feel the government care about the toll this has taken on us. I feel wrung dry.” (T4 Occupational Therapist)

“I feel sad and disillusioned than ever before. I feel my manager and hospital just don’t care about protecting staff.” (T7 Nurse)

“I don’t feel valued by the organization. My ability to find my resiliency against the day to day stressors is now lacking and it comes out in my irritability at home too.” (T7 Nurse)

Fewer participants shared a counterview to not feeling supported as they shared their appreciation for what was described as “small things”, “little things”, and “small tokens” that the hospital leadership provided. This included providing free coffee and tea, wellness kits, t-shirts, and acknowledgement of people who exemplified the hospital’s values during open forums and emails as noted in the following quotes:

“The small things like the wellness initiative, tea robot makes a world of difference.” (T4 Resident)

“I appreciate the organizations commitment to supporting and recognizing staff-small tokens of thanks-sleep kits, t shirts, treats, values shout outs, town halls, daily communication.” (T5 Senior Manager)

Several inequities emerged over time that contributed to feelings of resentment, anger and hurt between various groups: those providing direct clinical service vs. those who did not (e.g. administrative staff, researchers); those seeing patients within the hospital vs. their counterparts in the community; or those receiving extra pandemic pay compared to those who did not. Allocation of personal protective equipment (PPE) and access to COVID-19 vaccines varied between patient facing physicians and staff in the hospital and those that were not patient facing.

For those not who perceived not having the same access to resources or deemed “essential” the perception of a “two-tiered system” emerged and generated feelings of being left out, unprotected, anxious, invisible, and overlooked. Participants also shared feeling burnt out as a result of not being replaced themselves, while other clinicians (e.g. nursing) were replaced. This theme is further elucidated in the following narrative.

“I understand that frontline workers are the focus, but demanding auxiliary staff like admins be on site, while not providing PPE or salary supports, makes people feel expendable and unappreciated. (T3 Administrative Assistant). The two-tiered system for clinical vs non-clinical staff contributed to my anxiety about getting sick and my sense that the organization did not value me or my work.” (T4 Administrative Assistant)

“When surge beds were introduced on the 3rd floor, nursing staff was augmented to accommodate the increased work load but not Allied Health staff–[there was] mixed messaging from upper management regarding treating staff fairly during these stressful circumstances.” (T4 Physiotherapist)

“Allied were omitted from pandemic pay even though we had just as much risk. We do not feel appreciated or valued. Instead of spending money on little gifts we would all prefer to be paid more or a bonus.” (T5 Dietician)

“Those of us in non-clinical positions lack a lot of emotional support. We have to navigate the resources available to us alone.” (T5 Research Personnel)

Polarizing anti- and pro-public health measures and incivility.

A constellation of emotions also emerged associated with the societal response to COVID-19. Respondents shared it is “frustrating”, “irritating”, “demoralizing”, “very stressing”, “overwhelming” and “disheartening” that there are those in society who are vocal about not believing the seriousness and impact of COVID-19. Particularly, respondents identified those who have protested against public health measures (e.g. wearing masks or face shields, social and physical distancing) or who have travelled during the second wave. For some respondents, this added to their level of fatigue and was “wearisome” as they continued their efforts in keeping themselves safe, the patients in the hospital safe, and their family safe. As one respondent noted that it was an “insult to many of our sacrifices at work and at home”. Collectively, this has resulted in what is referred to as “COVID fatigue and burnout and feelings of despair” and for some “feeling resentful”. This theme is further elucidated in the following narrative examples:

“It remains wearisome—the constant specter of dealing with the unknown and having to adapt to the next challenge, the sense of helplessness and the demoralizing feeling of doing the right thing at personal cost when colleagues and the community are not. I cannot but help feel resentful.” (T2 Resident)

“We sacrificed for 1 year and have achieved nothing. People are not abiding by the social measure put in place. I as a healthcare worker feel insulted by this.” (T3 Healthcare Personnel)

“It is hard to suppress judgement about people choosing not getting vaccinated, or not following public health directives. My well of compassion is empty at times. Then I feel a sense of failure at myself for feeling that way.” (T6 Nurse)

“The "freedom convoy protests" have significantly increased my stress level knowing that a portion of the population has no confidence in public health and science.” (T6 Physiotherapist)

“I find that I’ve been losing confidence in the public’s will to do what is right and to sacrifice a little more for the common good.” (T7 Occupational Therapist)

Over time, some respondents shared increasing difficulty being empathetic and compassionate for those who were not vaccinated and how this was impacting them and their ability to provide optimal care. Further, increasing examples of patient incivility resulting in emotional burnout were provided as one healthcare personnel shared “patients are back to pre-covid levels of frustration that they take out on staff and I am finding myself more emotionally burnt out as every day that we continue to live through this pandemic feels increasingly Sisyphean” (T5). Additional quotes illustrate this theme:

“It’s even more challenging to provide equal care to patients who aren’t cooperative and willing to accept your care. This is the most draining part of my job; working with patients and families who don’t appreciate your care.” (T4 Occupational Therapist)

“It’s increasingly difficult for me to have empathy for people who choose their physical comfort at the risk of endangering others.” (T5 Healthcare Personnel)

“We’re dealing with patients with COVID who are anti-vaxx. How do you find compassion for them when you’re so exhausted?” (T5 Nurse)

“Really nasty families/patients has really made me dislike work and society.” (T6 Physiotherapist)

“We have many more patient outbursts and episodes of violence than before the pandemic. I find myself becoming more weary as time goes on.” (T6 Physician)

“One of the most stressful parts of dealing with the pandemic has been dealing with visitors who are not compliant with PPE, not wearing masks, and who are angry with the visitor policies. Some interactions have left me shaken and upset.” (T7 Nurse)

Incivility was also experienced on a colleague-to-colleague level as noted by one nurse (T7) who shared “the main stress that comes from my workplace is not the patient population but from some of my colleagues who are either abusive, intrusive, and malicious”.