Front-line fatigue: 'I don't want to lose my humanity' — CNAs weighed down by empathy exhaustion

Editor's note: This is the third in a series of stories looking at front-line fatigue among health care workers in Utah.

SALT LAKE CITY — Cole Squire vividly remembers walking past the rooms of the COVID-19 patients when he was working as a certified nursing assistant at University of Utah Health. He looked through the door windows, past hastily scrawled oxygen stats and medicine names written on the glass, to see the patients inside, most of them sedated, intubated and restrained. They were laying on their stomachs caught in a web of IVs and feeding tubes and monitors.

It seemed unreal, almost apocalyptic even.

After a long shift, he would go home to his loved ones who, despite his day of proving otherwise, would argue with him over misinformation that COVID-19 was no worse than a typical flu.

Squire began pursuing a career in medicine at age 16 because he felt like it was his duty to help people. When the pandemic hit, the 21-year-old CNA did not shy away from the work, despite being a full-time college student. He volunteered to help with COVID-19 testing on top of his already extended work hours. But on Sept. 8, he stepped away from medicine entirely and decided to move across the world to pursue a graduate degree in a vastly different field.

Why? What made him decide to leave after five years of working in health care, one and a half of which there has been a brutal pandemic?

He explained that his decision to leave came about because of the physical fatigue and burnout of working the long hours and exhausting shifts. But mostly it came from people in his state disrespecting and decrying health care workers who are still reeling from the mental blows the pandemic just keeps bringing.

"Having to do all of (the physical labor and mandatory overtime), it definitely takes a toll. Then you add the social aspect to it, and it will probably break you," Squire said.

"I did not sign up to be villainized. I came here to help people."

'A mass exodus'

Recent studies have shown that up to one third of American health care workers are leaving the profession in unprecedented numbers, resulting in a staff shortage, specifically among nurses and nursing assistants.

"It's not if we are having a mass exodus. It's we are having a mass exodus," Squire said.

Even employees like Squire who have been in the profession for a long time are choosing to leave, which is unusual, and hardly anyone is willing to take their places, explained Daedree Holmes Long, a CNA who works in Utah's Uinta Basin.

"After the first few days, brand new nurses are just like, 'What the hell did I get into here?' I don't think people realize because everyone is walking away," she said.

After elective surgeries were delayed the first time around, some hospitals let go of a portion of their staff. Squire was working in a cardiac unit, but University of Utah Health redirected him and other staff to help out in other areas of the hospital rather than letting them go. The hospital managed to avoid laying off or firing most employees. However, this came with its own set of difficulties. For instance, nurses and nursing assistants who are not used to an ICU setting were suddenly dealing with ventilators and medications specific to the ICU.

In nursing homes and assisted care facilities like the one Anne Ashworth works for, this shortage sometimes looks like two employees taking care of 16 residents with moderate to severe dementia, some of whom can't talk, some of whom are violent, and some of whom are incontinent.

"Picture two people trying to feed a group of 16 and trying to keep everyone in their chairs, not feeding each other or pulling their pants down and urinating in the middle of the dining room. And picture us not succeeding because of staffing shortages. It is so hard, feeling like there's not an end in sight. It's hard knowing you are giving subpar care to people because there simply is not enough of you to go around," Ashworth said.

In Long's rural hospital, there are already limited resources like oxygen concentrators as well as limited staff, and there's not another nearby hospital to divert patients to. Typically, they ship out severe cases, but at the moment, everywhere else in the state is full, including the bigger hospitals. Instead, the health care workers have to do their best despite knowing that their best might not be good enough.

"If someone comes in with chest pain and we have a full ER, we can triage the best we can and try to get to them but we just don't have the resources. The staff is limited. Physicians and nurses are limited. And you can only work so many hours for so many shifts without getting to an exhaustion point where you can make mistakes or miss things," Long said.

Squire recalled that he would sometimes spend time hunting down the last remains of some of the scarcer resources like gloves, sanitizing equipment and medical tape. The staff had to lock up their masks when they weren't in use because patients' families were taking them.

"This is insane," he told himself while searching through the storage area. "If this goes on anymore, I don't know what we are going to do."

'Boots on the ground'

Certified nursing assistant is an entry-level position that often revolves around helping patients to perform the basic actions of life like eating, bathing, using the toilet and walking. CNAs generally have a higher turnover rate because they are regularly dealing with bodily fluids and highly personal care. With COVID-19 cases, this sometimes looks like carrying in a breakfast tray while wearing full protective equipment or helping a patient say goodbye to their loved ones as they are about to be put on a ventilator, knowing there's a good chance they won't come off of it.

Long described her typical day: helping patients to wake up and use the bathroom, taking in breakfast trays, doing paperwork, checking supplies, helping patients shower, changing their linens, taking calls, monitoring heart rates, all while checking each patient's vitals every four hours.

"Some days I am just running from room to room, from call light to beeping noise," she said. "It's so hard to plan, so you really have to take it minute by minute."

"You are the boots on the ground. You get the most up close and personal with the patients," Ashworth explained. "And because this is an entry-level position, employers are competing with retail and hospitality, but often you're not making a ton of money, less than McDonald's and Lowe's."

During the height of the pandemic, Squire's management implemented on-call shifts for everyone on top of their other shifts. He would wake up at 4:00 in the morning, check to see if he had messages and then wait all day to be called on to come help, while only getting paid about half of what he normally made.

Protective equipment

After receiving a slew of emails from the hospital asking for help, Squire volunteered as a COVID-19 tester. He and his fellow volunteers stood outside under white tents as car after car pulled up to be tested. He wore black scrubs, covered by a thin, blue, plastic gown about the thickness of a grocery bag. Then he had regular gloves underneath incredibly thick cancer gloves meant for handling radioactive material. Then on top of that, he had on a powerful respiratory filter and a white hood over his head.

"One of the nurses said that they took a temperature gauge inside the gown underneath the white tents, it was like 106 degrees. And being in full protective gear makes it difficult to safely drink or use the bathroom," he said.

In an eight-hour shift, volunteers would test people in 650 to 700 cars, trying to get them to move as quickly as possible because the snaking lines blocked other businesses' parking. At the end of the shift, Squire would remove his protective gear to find his scrubs completely drenched with sweat. His hands were white and wrinkled like raisins. He had headaches and heat exhaustion. Eventually the people running the testing sites had to cut down the hours of the shifts because too many people were suffering from heat exhaustion and heat stroke.

Misinformation

After then-President Donald Trump got COVID-19 and finished treatment, Squire's patients on the cardiovascular floor in Salt Lake City started testing positive for the disease and had to be transferred to the COVID-19 units in the hospital. As they were being put on oxygen and showing symptoms of the novel coronavirus, they told Squire that COVID-19 was fake and not a big deal since Trump had recovered.

"(My co-workers and I) were hitting our heads against the walls, like, 'Are you serious? This is not true!'"

When he got home and tried to decompress from work, he was hit with a stream of misinformation — not just online, but from his friends and family members. One family member told him that people were overreacting about COVID-19 and that health care workers were purposefully misdiagnosing people with the virus or saying someone died from COVID-19 in order to somehow get more money. That particularly stung.

"The majority of us don't go into the medical field for money, and now we're being ridiculed saying we are just purposefully doing it to get funds and money," he said. "There were a lot of arguments, I'll be honest."

In the Uinta Basin, Long has been contacted by Utah Poison Control multiple times this week alone because people in the rural community are taking ivermectin, a dewormer for cows, sheep and horses whose use in humans the Centers for Disease Control and Prevention has specifically spoken out against, in an attempt to treat COVID-19. Long had to tell her husband to load up on ivermectin for their livestock because there is a shortage owing to people buying it to try to treat COVID-19.

Into the arena

When the pandemic first started, Squire felt like a hero. The community was celebrating health care workers and seemed to be recognizing their efforts. He ate free Krispy Kreme doughnuts for health care workers frequently. But then once the pandemic and the lockdown began to stretch out longer and longer, people nationwide and in Utah in particular started to push back.

"That's when we got to see the hostility from the general public. And 100 times worse were the politics surrounding COVID-19," Squire said. "As a medical professional, I've never witnessed this before. We're trained to deal with medical issues but now, all of a sudden, we are having to fight. We've been thrown into the political arena when we didn't even want to be."

On top of dealing with coronavirus patients and medical supply shortages, Squire and his co-workers also had to deal with "being used as tools in political campaigns," with "Utah senators and governors either downgrading us or praising us," he said.

What was particularly infuriating for Squire was that although politicians did not have medical or science experience or expertise, they were giving out medical advice and commenting on the situation like they were epidemiologists. Every time there was a protest, he said he and his co-workers would resign themselves to another wave.

"We often hear that freedom isn't free," Long said "Freedom for everyone comes at a cost. In this case, by choosing your freedom, you're taking away someone else's health or even life."

Long loves wearing her mask with her hospital name and logo on it in public because she hopes that people will see her with a mask and know that she is a health care worker that is still masking. As a mother of a child with fragile health and a relative of people with autoimmune disorders, she wants to do whatever she can to protect the vulnerable members of the community.

"Ninety-nine times out of 100, people are probably rolling their eyes at me," she said, but added that if it inspires even one person, it's worth it.

Empathy fatigue

When Long drives home after work, she goes over and over what happened during her shift, sifting through her worries and wondering if she set the bed alarm or if she remembered to chart the temperature change or report on the right patient.

"I'm just feeling overwhelmed because there's so much to do and so little time. Knowing that we can do the best we can and give it 110% on our shift and still somewhere the ball gets dropped," she said.

The mental load weighs on her so that even if she's physically exhausted, she will lie awake and think and stress for hours and wonder if she needs to become more calloused, if it would all be easier to deal with if she just hardened her heart. But at the same time, she thinks of the family members crying in the parking lot as their loved one gets wheeled by, or the COVID-19 patients crying and coughing alone in their rooms, and she feels a need to recognize that pain and suffering.

Because she lives in such a small community, she recognizes a name almost every shift. She sees her patients' names written in the local obituaries.

"You hear all this misery. Sometimes I don't feel like it computes. I get the kids to bed. And my husband's like, 'Go to sleep,' and I can't. I don't think I even know what I'm holding in," she said, fighting back tears. "I don't want to lose the empathetic side of me. I don't want to lose my humanity.

"The biggest issue of this pandemic is that a lot of people have lost their humanity. There are people who genuinely just don't care about the lives lost or how many kids are orphaned or the couples married 60 years who can't meet their great-grandchildren or about the 60-year-old who doesn't have a chance to enjoy retirement because they have every long haul symptom. I don't want to lose my compassion, my empathy. But part of me wonders if it would be easier on my heart if I did."

For Ashworth, it's like wading through knee-high water day in and day out.

"I'm not someone who gets angry very often, but it is hard sometimes to not get angry. Usually it's when I see people on my social media who feel so politically charged about it and try to equate it with the Holocaust. It makes me so angry. That anger is in its own way fatiguing," she said.

"It's not the same kind of exhausting as if you were sprinting on dry land. But it's the weight of constantly pushing through every day. The longer you keep moving forward, the more tired you get."

Non-COVID-19 patients

One of the most fatiguing things each CNA interviewed mentioned was the harm that is being done to patients without COVID-19 who may not be given full quality care because the hospitals and staff are overloaded.

"Those little things really help make the difference in helping people heal — those little acts of service. And that's being taken away," Long said.

She explained that health care has a clinical side and service side and patients need both of them to be able to heal and to improve. Long said that she loves to hear about people's hobbies growing watermelon or to see pictures of her patients' cats or horses. But that personal side is missing because there is just a need to focus on the clinical side, which is particularly difficult for other hospital patients admitted with mental illnesses.

"The pandemic has brought out every weakness we have in society. We've never seen anything like what we're experiencing now with mental illness and. substance abuse increasing significantly," she said.

In small hospitals and care facilities, there is not enough staff to be divided up between COVID-19 care and other care, which means that there is an increased risk of infection.

Who is left?

A few of Squire's co-workers left at the same time he did, and many more have left since. If you ask him if he regrets leaving, he will say that right now he does not at all. He is done.

Long said that she feels a huge privilege that she doesn't have to work in health care and can quit if she wants to, because she is no longer sure she wants to go into health care.

"The health care system isn't built for this kind of strain. This isn't worth not being happy," she said. "I don't think a lot of us care workers understand what has happened to us. I wonder in the decades to come if we identify with veterans with PTSD and the social backlash."

The health care industry continues to lose more and more employees. And Ashworth has seen many of her co-workers leave, scarred by losing so many patients during a COVID-19 outbreak in 2020. She does not blame them in the slightest.

But for Ashworth, who has only been a CNA in the care facility for a few months, she feels it is a "good trial by fire" for her and has solidified that she wants to be in health care.

"It's rewarding. I think I'll look back and be glad that I did this and that I helped," she said. "The call of health care and why you go into medicine — anyone who is wanting to help should become a CNA at least for a little while. There's such a capacity to give back."

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