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U.S. Surgeon General Advisory on Healthcare Worker Burnout Matches COVID-19 Experiences of Massachusetts Nurses and Exposes Failure of Healthcare Executives to Follow Recommendations

Surgeon General proposes ways to improve worker and patient health – including stronger workplace violence protections – that largely align with a survey of Massachusetts nurses released in May 2022

Despite the COVID-19 pandemic wreaking havoc on healthcare workers, staffing levels and patient care quality, executives often fail to listen to and support caregivers

CANTON, Mass. – An advisory distributed by the U.S. Surgeon General sounding an alarm about the COVID-19 pandemic worsening healthcare worker burnout and offering a series of recommendations echoes the traumatic experiences shared by nurses in the “State of Nursing in Massachusetts” survey released for National Nurses Week in May.

The advisory presents recommendations that match many of the solutions proposed by the Massachusetts Nurses Association (MNA), including stronger workplace violence protection, which the MNA and lawmakers on Beacon Hill have advocated for as part of legislation that has advanced in the House and Senate. Unfortunately, many of the recommendations from the Surgeon General and Massachusetts nurses have fallen on deaf ears in the executive suites and board rooms of the healthcare industry.

“The U.S. Surgeon General advisory on healthcare worker burnout highlights the trauma that has been inflicted on nurses and healthcare professionals by the COVID-19 crisis and the failure of healthcare executives to put people above profits,” said Katie Murphy, a practicing ICU nurse and President of the MNA. “The MNA joins with the Surgeon General in calling for solutions to address our broken healthcare system, including empowering the voices of caregivers, and protecting the health and safety of healthcare workers.”

“Unfortunately, still missing from the Surgeon General’s advisory and the failed response of healthcare executives are enforceable staffing standards that decades of peer-reviewed research have shown to reduce burnout and improve patient care quality,” Murphy said. “We hope the Surgeon General’s advisory will spur action in Massachusetts and nationwide to address the exhaustion and moral injury felt by nurses and healthcare workers who simply want to feel safe and supported while they pursue their passion.”

The advisory, “Addressing Healthcare Worker Burnout: The U.S. Surgeon General’s Advisory on Building a Thriving Health Workforce,” states in its introduction:

“Health workers, including physicians, nurses, community and public health workers, nurse aides, among others, have long faced systemic challenges in the health care system even before the COVID-19 pandemic, leading to crisis levels of burnout. The pandemic further exacerbated burnout for health workers, with many risking and sacrificing their own lives in the service of others while responding to a public health crisis. Promoting the mental health and well-being of our nation’s frontline health workers is a priority for the Biden-Harris Administration and a core objective of President Biden’s national mental health strategy, within his Unity Agenda.”

Many of the recommendations in the advisory align with priorities identified by the nurses and healthcare professionals of the MNA, and by the randomized survey of Massachusetts nurses conducted for “The State of Nursing in Massachusetts.” This breakdown summarizes those areas of alignment and illustrates ways in which healthcare executives have failed to act.

Protecting Healthcare Workers from Violence and Infection

Surgeon General Advisory

  • “Organizations, communities, and policies must prioritize protecting health workers from workplace violence and ensure that they have sufficient personal protective equipment.”
  • In a national survey among health workers in mid-2021, eight out of 10 experienced at least one type of workplace violence during the pandemic, with two-thirds having been verbally threatened, and one-third of nurses reporting an increase in violence compared to the previous year.”

State of Nursing in Massachusetts Survey

  • There was an 11-point uptick in nurses calling violence a “major challenge” from 2021 to 2022 and a 16-point increase from 2019.
  • 38% of nurses said workplace violence was such as challenge that it would impact their decision to leave the profession sooner.
  • 37% of nurses said a lack of PPE was a major challenge during the pandemic.

Efforts of MNA Nurses and Healthcare Professionals

  • On June 2, the day after a deadly shooting at a Tulsa hospital, Massachusetts lawmakers recommended that legislation filed on behalf of the MNA – An Act requiring health care employers to develop and implement programs to prevent workplace violence – be passed favorably out of committee and sent to House Ways and Means.
  • The House bill is very similar to Senate legislation bearing the same name that lawmakers advanced to the Senate Ways and Means committee on March 31.
  • The legislation, sponsored by Senator Joan Lovely and Representative Denise Garlick, would require healthcare employers to perform an annual safety risk assessment and, based on those findings, develop, and implement programs to minimize the danger of workplace violence to employees and patients.
  • In addition, the legislation would provide time off for health care workers assaulted on the job to address legal issues, allow nurses and healthcare professionals to use their health care facility address instead of their home address to handle legal issues related to an assault, and require semiannual reporting of assaults on health care employees to District Attorneys.
  • Following significant struggles with PPE availability and non-scientific PPE policies at Massachusetts healthcare facilities when the pandemic began, the MNA filed legislation that would require public reporting of PPE levels at healthcare facilities, and create a Joint Oversight Committee to determine the current personal protective equipment (PPE) supplies on hand at acute care hospitals and state-operated facilities to meet pre-crisis standards.
  • The MNA is also advocating at the State House for a bill that would presume that any frontline healthcare worker who contracts COVID-19 acquired it at work. It would also prohibit employers from requiring healthcare workers to use their own sick time, vacation time or other PTO to quarantine, treat or recover from COVID-19.

Healthcare Executives’ Failed Response

  • For many years, Massachusetts healthcare executives have pushed back against efforts to require a rigorous, consistent, and employee-informed standard to prevent workplace violence.
  • Without strengthened protections, healthcare workers have suffered from an epidemic of violence which has only worsened during the pandemic:
  • Last October, WBUR reported that two to three Massachusetts General Hospital nurses are assaulted every day.
  • In July 2021, a Lowell General Hospital nurse was severely assaulted in the emergency department, hit in the head with a fire extinguisher by a patient. Two months later, WHDH reported on a “troubling rise in patient violence” in Massachusetts emergency departments.
  • PPE decisions by healthcare executives and the government, especially during the first months of the pandemic, have been a well-documented failure:
  • Boston Herald, March 31, 2020: “Coronavirus in Massachusetts: Nurses ‘deeply disturbed’ by PPE protocols outlined in memo from state.”
  • Boston Globe, April 30, 2020: “Mass. nurses union balks at reused face masks”
  • Boston 25, May 13, 2020: “Mass. nurses saying no to decontaminated masks”
  •, May 27, 2020: “Nurses union calls out Steward Health Care for donating PPE amid apparent shortages for hospital staff”
  • WBUR, June 16, 2020: “Nurses Renew Calls To Stop Cleaning, Reusing N95 Masks”
  • Boston Globe, June 21, 2020: “‘It’s like pulling teeth’: There’s still a PPE shortage — and a second wave could send medical workers into crisis mode”
  • Becker’s Hospital Review, October 8, 2020: “FDA warns Battelle about mask sterilization system”
  • CBS Boston, January 17, 2022: “I-Team: Mass General Brigham Nurses Concerned About Limited Supply Of N95 Masks.”
  • 51% of nurses in the State of Nursing in Massachusetts survey said their employer did a fair or poor job providing PPE.
  • 68% of nurses said their employer did a fair or poor job helping with donning and doffing of PPE.

Burnout and Healthcare Workers

Surgeon General’s Advisory

  • “Even before the COVID-19 pandemic, health workers were experiencing alarming levels of burnout – broadly defined as a state of emotional exhaustion, depersonalization, and low sense of personal accomplishment at work. Burnout can also be associated with mental health challenges such as anxiety and depression.”
  • In 2019, the National Academies of Medicine (NAM) reported that burnout had reached “crisis” levels, with up to 54% of nurses and physicians, and up to 60% of medical students and residents, suffering from burnout.
  • The pandemic has since affected the mental health of health workers nationwide, with more than 50% of public health workers reporting symptoms of at least one mental health condition, such as anxiety, depression, and increased levels of post-traumatic stress disorder (PTSD). 

State of Nursing in Massachusetts Survey

  • 33% of MA RNs reported planning to leave nursing sooner than originally planned due to the stress of COVID. Among newer nurses with 0 to 5 years of experience, 37% are planning to leave sooner – the highest percentage of any experience group.
  • Newer nurses, with five years or less of experience, are more likely to leave the profession now, with 25% this year saying they plan to leave nursing within two years, up from 18% in that experience range last year and 10% in 2019.
  • Among nurses who said they will leave nursing sooner because of COVID, 99% said that they always or sometimes feel emotionally drained from work and 83% feel disengaged.

Healthcare Executives’ Failed Response

  • 59% of nurses in the State of Nursing survey reported a lack of hospital support with emotional challenges during COVID, up from 51% in March 2021. 79% of nurses planning to leave the profession reported this concern.
  • Nurses across age ranges, facility types and geographical areas in Massachusetts have reported in the State of Nursing survey for years that understaffing and having too many patients to care for at one time has taken a toll on them physically and emotionally and has led to increasing problems with patient care quality.

Empowering Healthcare Workers

Surgeon General’s Advisory

  • “Transform workplace culture to empower health workers and be responsive to their voices and needs.”
  • “We can begin by listening to health workers and seek their involvement to improve processes, workflows, and organizational culture.”

State of Nursing in Massachusetts Survey

  • 73% of nurses said their employer did a fair or poor job of involving frontline staff in COVID planning/response.

Efforts of MNA Nurses and Healthcare Professionals

  • The MNA represents more than 25,000 members working in 85 healthcare facilities, including 51 acute care hospitals, as well as a growing number of nurses and health professionals working in schools, visiting nurse associations, public health departments and state agencies.
  • This number has increased by 2,000 in recent years as the demand for healthcare workers has grown and the MNA has responded to requests from nurses and healthcare professionals to help them join the union and advocate for themselves and patients.
  • At the State House, the MNA has also advocated for various legislation that would require the state and healthcare employers to include the voices of union and non-union healthcare workers in decision-making, including around workplace violence, the preservation of essential services, and workforce development and patient safety.

Healthcare Executives’ Failed Response

  • Healthcare executives have dropped pizza off in the break room, left Hershey kisses on the nurses’ station and published glossy advertisements thanking “healthcare heroes,” but they have refused to give healthcare workers an equal seat at the table unless forced to by law or unionization.
  • The MNA has requested healthcare employers voluntarily recognize nurses and healthcare professionals seeking to unionize at facilities like the Berkshire VNA and Milford Regional Medical Center, but the consistent response is no. Healthcare executives would rather spend money better spent on patient care to hire consultants to fight their employees’ efforts to gain a stronger voice.

Staffing, Wages and Worker Support

Surgeon General Advisory

  • “Provide living wages, paid sick and family leave, rest breaks, evaluation of workloads and working hours, educational debt support, and family-friendly policies including childcare and care for older adults for all health workers.”
  • “Ensure adequate staffing, including surge capacity for public health emergencies, that is representative of the communities they serve. This is critical to protect and sustain health workers and communities.”

State of Nursing in Massachusetts Survey

  • 55% of nurses in the survey said understaffing is the biggest obstacle to providing quality care, and particularly for newer nurses, with 68% of nurses with 0 to 5 years of experience saying understaffing is the biggest obstacle they face.
  • The number of RNs who said they do not feel that they have enough time to provide patients with the care and attention each one needs jumped to a record high of 71%, up from 60% last year.
  • This connects with an alarming finding from the survey: The percentage of nurses who said this year that the overall quality of care in Massachusetts hospitals has gotten worse (83%) is higher by nearly 30 points than any other year.
  • Almost two-thirds (64%) of nurses said inadequate pay or benefits is a major challenge. This response is up from 48% reporting lack of pay or benefits in 2021 and 27% in 2019 – a 37-point increase in nurses having a concern about pay and benefits over three years.
  • 55% of nurses planning to leave the profession sooner said separation from their families during COVID was a major challenge.

Efforts of MNA Nurses and Healthcare Professionals

  • For decades, the MNA has advocated for safe staffing levels and enforceable patient limits at the local, state, and national level. The impact of how many patients a nurse is assigned at one time is one of the most studied topics in healthcare. Voluminous peer-reviewed evidence shows maintaining a safe patient limit helps shield nurses from burnout and protects the quality of patient care.
  • MNA legislation entitled The Workforce Development and Patient Safety Act would examine current nursing practice, including the impact on quality of patient care, the makeup of the current nursing workforce, and future needs of nursing care in the state.
  • Across Massachusetts, MNA nurses and healthcare professionals work together as union members to negotiate improved staffing levels, wages, benefits and working conditions.

Healthcare Executives’ Failed Response

  • Healthcare executives have spent tens of millions of dollars fighting against efforts to require safe staffing levels in Massachusetts, and countless more around the country.
  • At hospitals across Massachusetts, nurses have had to hold rallies, pickets, community forums and in some cases strikes and strike authorization votes to get healthcare executives to agree to staffing improvements and wage increases that are critical to nurse recruitment and retention.
  • 82% of nurses in the State of Nursing in Massachusetts survey said their employer did a fair or poor job of providing emotion support services.
  • 84% of nurses said their employer did a fair or poor job of providing time off to deal with working during COVID.
  • 89% of nurses said their employer did a fair or poor job of compensating nurses for efforts during the crisis.
  • 66% of nurses said their employer did a fair or poor job of providing childcare options.

“I have never seen nurses so demoralized by conditions at the bedside and how difficult it is to provide the kind of care our patients deserve,” said Murphy, the MNA President. “The coronavirus has made it even harder to be a healthcare professional dedicated to safe patient care, but the pandemic alone did not create these problems.

“One of the most concerning set of findings from this survey is the devastating impact current working conditions are having on our newly graduated and novice nurses, as these are the nurses who constitute the hope for the future of our profession,” Murphy said. “Nurses across Massachusetts join the U.S. Surgeon General in calling for improved staffing, pay and support services to address the healthcare profession’s intense stress and help recruit and retain the nurses necessary to provide safe patient care.”

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Founded in 1903, the Massachusetts Nurses Association is the largest union of registered nurses in the Commonwealth of Massachusetts. Its 25,000 members advance the nursing profession by fostering high standards of nursing practice, promoting the economic and general welfare of nurses in the workplace, projecting a positive and realistic view of nursing, and by lobbying the Legislature and regulatory agencies on health care issues affecting nurses and the public.