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Emotional Exhaustion Among US Health Care Workers Before and During the COVID-19 Pandemic, 2019-2021

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Is the COVID-19 pandemic associated with an increase in health care worker emotional exhaustion?

Findings  In this 3-year survey study with an overall sample of 107 122 responses from US health care workers before (2019) and twice during (2020 and 2021-2022) the COVID-19 pandemic, increases were reported in assessments of emotional exhaustion in oneself and in one’s colleagues overall and for every role; nurses reported increases each year, but physicians reported decreases in 2020 followed by sharp increases in 2021. Exhaustion score clustering in work settings was suggestive of a social contagion effect of exhaustion.

Meaning  These findings indicate that emotional exhaustion among health care workers, which was problematic before the pandemic, has become worse; increases in emotional exhaustion may jeopardize care quality and necessitate additional support for the workforce.


Importance  Extraordinary strain from COVID-19 has negatively impacted health care worker (HCW) well-being.

Objective  To determine whether HCW emotional exhaustion has increased during the pandemic, for which roles, and at what point.

Design, Setting, and Participants  This survey study was conducted in 3 waves, with an electronic survey administered in September 2019, September 2020, and September 2021 through January 2022. Participants included hospital-based HCWs in clinical and nonclinical (eg, administrative support) roles at 76 community hospitals within 2 large health care systems in the US.

Exposures  Safety, Communication, Organizational Reliability, Physician, and Employee Burnout and Engagement (SCORE) survey domains of emotional exhaustion and emotional exhaustion climate.

Main Outcomes and Measures  The percentage of respondents reporting emotional exhaustion (%EE) in themselves and a climate of emotional exhaustion (%EEclim) in their colleagues. Survey items were answered on a 5-point scale from 1 (strongly disagree) to 5 (strongly agree); neutral or higher scores were counted as “percent concerning” for exhaustion.

Results  Electronic surveys were returned by 37 187 (of 49 936) HCWs in 2019, 38 460 (of 45 268) in 2020, and 31 475 (of 41 224) in 2021 to 2022 for overall response rates of 74.5%, 85.0%, and 76.4%, respectively. The overall sample comprised 107 122 completed surveys. Nursing was the most frequently reported role (n = 43 918 [40.9%]). A total of 17 786 respondents (16.9%) reported less than 1 year at their facility, 59 226 (56.2%) reported 1 to 10 years, and 28 337 (26.9%) reported 11 years or more. From September 2019 to September 2021 through January 2022, overall %EE increased from 31.8% (95% CI, 30.0%-33.7%) to 40.4% (95% CI, 38.1%-42.8%), with a proportional increase in %EE of 26.9% (95% CI, 22.2%-31.8%). Physicians had a decrease in %EE from 31.8% (95% CI, 29.3%-34.5%) in 2019 to 28.3% (95% CI, 25.9%-31.0%) in 2020 but an increase during the second year of the pandemic to 37.8% (95% CI, 34.7%-41.3%). Nurses had an increase in %EE during the pandemic’s first year, from 40.6% (95% CI, 38.4%-42.9%) in 2019 to 46.5% (95% CI, 44.0%-49.1%) in 2020 and increasing again during the second year of the pandemic to 49.2% (95% CI, 46.5%-51.9%). All other roles showed a similar pattern to nurses but at lower levels. Intraclass correlation coefficients revealed clustering of exhaustion within work settings across the 3 years, with coefficients of 0.15 to 0.17 for emotional exhaustion and 0.22 to 0.24 for emotional exhaustion climate, higher than the .10 coefficient typical of organizational climate (a medium effect for shared variance), suggestive of a social contagion effect of HCW exhaustion.

Conclusions and Relevance  This large-scale survey study of HCWs spanning 3 years offers substantial evidence that emotional exhaustion trajectories varied by role but have increased overall and among most HCW roles since the onset of the pandemic. These results suggest that current HCW well-being resources and programs may be inadequate and even more difficult to use owing to lower workforce capacity and motivation to initiate and complete well-being interventions.

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Article Information

Accepted for Publication: August 2, 2022.

Published: September 21, 2022. doi:10.1001/jamanetworkopen.2022.32748

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Sexton JB et al. JAMA Network Open.

Corresponding Author: J. Bryan Sexton, PhD, University Tower, Ste 1510, 3100 Tower Blvd, Durham, NC 27707 (Bryan.Sexton@duke.edu).

Author Contributions: Dr Sexton had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Sexton, Adair, Proulx, Profit, Bae, Frankel.

Acquisition, analysis, or interpretation of data: Sexton, Adair, Proulx, Cui, Frankel.

Drafting of the manuscript: Sexton, Adair, Profit, Cui.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Sexton, Cui.

Obtained funding: Sexton.

Administrative, technical, or material support: Sexton, Adair, Proulx, Profit, Bae, Frankel.

Supervision: Sexton, Profit.

Conflict of Interest Disclosures: Dr Sexton reported receiving grants from Safe & Reliable Healthcare (who have a contract with Duke University to conduct secondary analyses on safety culture and workforce well-being data) during the conduct of the study; honoraria from the Virginia Hospital Association, the California Perinatal Quality Care Collaborative, the Georgia Hospital Association, Methodist Health System, UT Southwestern, Sutter Health, and the University of Rochester outside the submitted work. No other disclosures were reported.

Funding/Support: This work was funded by grants from the National Institutes of Health (R01 HD084679-01 to Drs Sexton and Profit) and Health Resources and Services Administration (1 U3NHP45396-01-00 to Dr Sexton). Funders provided partial salary support for Dr Sexton, Dr Adair, Dr Profit, and Dr Cui.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Our Stanford University colleague and collaborator, Daniel Tawfik, MD, provided helpful informal comments on an earlier version of this manuscript. He was not compensated for this contribution.

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