A Stanford-led study published on March 16 found that two out of three maternal and neonatal healthcare workers faced severe burnout during the pandemic. Through use of a survey, researchers found that burnout levels rose by over 40% since 2011, which could hurt patient outcomes and increase rates of medical error.

The study was a partnership between associate neonatology professor Jochen Profit and Bryan Sexton, associate professor of psychiatry at Duke. They launched the study in June 2020, surveying providers who attended a webinar on mental health. 

Profit, a practicing neonatologist, said the findings of the study make clear that institutions need to keep an eye out for the mental health of all their staff, not just the ones interfacing most frequently with COVID patients.

“In the NICU, we didn’t see our patients dying from [COVID], but nevertheless we saw this huge increase in burnout,” Profit said. “Institutions need to be mindful that it’s not just the folks in the emergency room or the adult ICUs who are suffering from this. This is almost like post-traumatic stress, and people’s mental health can be triggered by future events, so there’s going to be an ongoing need to support people.”

Sexton added that burnout often worsens the longer a person is exposed to the stressful stimulus: “The way burnout works is that it’s kind of cumulative; it’s like death by a thousand paper cuts,” Sexton said. “The longer you’re exposed to the sources of those paper cuts, the more you’re going to have to recover.”

The 288 respondents consisted primarily of nurses and physicians. In this sample, 66% reported severe burnout, and 73% were worried that burnout had increased in their coworkers. Nurses also reported higher rates of unprofessional behavior and difficulty concentrating than physicians. Over one-tenth of providers reported an increase in medical errors as well.

There are limitations to the study, which the authors acknowledge. First, there may be some selection and response bias present, as the sample consisted of attendees at a seminar about mental health who voluntarily chose to respond. Since the original 2011 study was from a decade prior, several other factors and events other than the pandemic may also have contributed to the sharp rise in burnout. Finally, the survey participants were from California and attendees of a conference, so the results may not be representative of all health workers in the United States. 

But even when accounting for these factors, the researchers are confident that the wellbeing of these healthcare workers has decreased during the pandemic — and if action isn’t taken now, this burnout will likely worsen with time.

A study 10 years in the making

Sexton and Profit met several years earlier, when Sexton gave a talk about the consequences of burnout in the medical community. Initially, Sexton had been working in aviation, using psychology to reduce flight errors and plane crashes. He wanted to see if he could apply what he had learned to patient care, where errors seemed much more prevalent. 

“My first job was at Johns Hopkins, and I was studying how safety culture, leadership and teamwork affect error rates and nurse turnover,” Sexton said. “I noticed one variable in particular that was able to predict patient outcomes.” 

The key variable was provider burnout, which could be assessed using a test called the Emotional Exhaustion Scale. The scale was first developed in the ’70s by Christina Maslach, professor emeritus of psychology at UC Berkeley. Sexton found that the scale performed better than any other tool in predicting infections, patient satisfaction, length of stays, medication errors and mortality. 

Soon after, he began giving talks about burnout. At one of those events, he met Profit, and the two quickly clicked with their shared research interests.

In 2011, Profit and Sexton pioneered the country’s first large-scale study to assess provider burnout in the neonatal intensive care unit. They surveyed providers across 44 neonatal intensive care units in California through the California Perinatal Quality Care Collaborative. 

“We looked at all providers, not just physicians,” Profit said, “because especially in the intensive care unit, healthcare is a team sport.” 

In this survey, they found that one-fourth of providers reported facing severe burnout. When the pandemic hit, they were curious as to how the pandemic might affect rates of burnout in maternal and neonatal medicine, parts of the hospital interfacing with lower numbers of COVID-19 patients.

At Stanford Medicine, Deirdre Lyell, professor of obstetrics and gynecology, confirmed that the pandemic was a new source of stress for maternal and neonatal doctors.

She said that Stanford obstetricians do about 4,500 deliveries per year, and have a total of 6,000 visits to the labor and delivery wards annually. During the pandemic, the numbers didn’t slow down, despite the added challenges posed by the virus: “Labor and delivery doesn’t pause for a pandemic,” Lyell said.

Pregnant people who were sick with COVID-19 posed a particular challenge, raising the anxiety of everyone involved — doctors, nurses and hospital staff — for potential transmission. 

Uncertainty about maternal-neonatal transmission created an additional challenge of isolating babies once they were born, and Lyell found that most COVID-positive mothers were reluctant to part with their newborns. The CDC later made clear that maternal-neonatal transmission of the virus was not common. 

There was also confusion on whether family members should be allowed in the delivery room to provide emotional support for the mother. Several other hospitals around the country banned visitors to labor and delivery, based on local public health guidelines, though Stanford allowed a support person to come into the room.

Lyell added that more knowledge about the disease and vaccine availability have made things slightly easier on healthcare providers as they became more aware of how to keep themselves and their patients safe. 

In looking towards the future, Lyell says that the best way to help the healthcare workforce is by respecting their guidance and knowledge. 

“People were so supportive when the pandemic hit, and we really appreciated that,” she said.

A previous version of this article misspelled the name of Deirdre Lyell. The Daily regrets this error.