Nurses Are Burned Out. Can Hospitals Change in Time to Keep Them?

Calling It Quits is a series about the current culture of quitting.

One morning, in fall 2020, Francesca Camacho drove away from her 12-hour night shift as a critical care nurse at Rush University Medical Center in Chicago and tried to merge onto the highway. The day’s work, in her words, was “just very terrible.” This wasn’t uncommon at the time: The Cook County area was experiencing the highest levels of Covid hospitalization it had ever experienced, surpassed only by the Omicron variant wave the following year.

She was on the phone with her parents, a ritual she’d developed as a way to decompress after a shift, when she noticed what appeared to be a teenage driver in front of her.

“I remember thinking, What is this girl doing that justifies her not letting me in?” Ms. Camacho, now 27, recalled. “And I just felt this surge of rage.” She hung up the phone and screamed and cried for the rest of the drive home.

The next day, she asked her co-workers if anything similar had ever happened to them; they all said yes. Lunchtime therapy sessions with fellow nurses turned into professional therapy sessions. “It really was feelings of anger that I felt, and I think very deep underneath that was just terrible sadness about what I was seeing and what we were all going through,” she said recently.

Last August, she quit her job. She is now a first-year law student at Boston University and plans to use her law degree to advocate changes in the medical field.

Burnout has always been a part of nursing, an effect of long working hours in physically and often emotionally taxing environments. The Covid pandemic exacerbated those factors and added some of its own: understaffing, a rise in violence and hostility toward health care workers over masking mandates and an increase in deaths, particularly in the early months of the pandemic. In a study from the American Nurses Foundation, released last month, 57 percent of 12,581 surveyed nurses said they had felt “exhausted” over the past two weeks, and 43 percent said they felt “burned out.” Just 20 percent said they felt valued. (Those numbers were largely consistent throughout the pandemic.)

“Burnout and our current issues have been going on for decades,” said Jennifer Mensik Kennedy, the president of the American Nurses Association. “So what did we learn from the last couple of years? That we need to make sure that we implement programs and processes to decrease the burnout and to improve the work environment. Because Covid is not the last pandemic, or the last major issue to happen.”

For some, those well-intentioned changes may not come soon enough: Forty-three percent of those surveyed by the American Nurses Foundation said they were at least thinking about switching jobs. Some, like Ms. Camacho, have left the profession. Others are shifting roles.

Kelly Schmidt, 52, spent 25 years working in the newborn I.C.U. at a hospital near her home in San Anselmo, Calif. She was drawn to the job — she credits that to her mother’s work as a midwife and her own “innate sense to want to protect them and heal them” — and found herself doing whatever it took: riding in the back of ambulances, flying in transport planes over the Pacific or in helicopters through the Bay Area fog.

She loved her job, her patients and her co-workers, but over the years other challenges materialized. The transition from physical charts to electronic medical records took her away from her patients’ sides, and, just as the pandemic hit, a transition to a management role tasked her and a co-worker with overseeing more than 90 employees. As nurses themselves began to fall sick and quarantine, the stress grew and the healthy staff ranks thinned, and Ms. Schmidt said she “emotionally started feeling like a robot.”

Then, last May, she found herself on the bottom mattress of her daughter’s bunk bed, sick with Covid and quarantined from the rest of her family. She found herself reassessing the two-hour commutes, the emotional labor of the job, the compartmentalization. She saw a job listing for a nearby school nurse position, dusted off and updated her 23-year-old résumé and, on a Sunday night, applied. The district called her on Monday, interviewed her over a video call on Tuesday (“I practically was keeling over by then,” Ms. Schmidt recalled) and offered her the job by the end of the week.

“I don’t want people to think the job I left was a bad job,” she said. “It was just time for me to go. I’ve had other colleagues say, ‘I don’t want to leave my job hating it,’ so they retire early. I didn’t want to leave my job hating it. I wanted to leave on a high note. And now I have pictures of the helicopter on my desk and I can chitchat with the little kids and try to figure out if they’re sick or not.”

Some hospitals recognized there was a problem before the pandemic and tried to fix it. Kathleen Littleton, 35, of Baltimore, not only worked at Johns Hopkins Hospital (and received her master’s degree in nursing science at its university), but served as an instructor in the nursing school as well. The hospital utilized the research of Cynda Hylton Rushton, a clinical ethics professor at the nursing school, specifically “the Mindful Ethical Practice and Resilience Academy,” a program that focuses on mindfulness and meditation to combat burnout, with some success.

Then the pandemic hit and, Ms. Littleton recalled, there was, practically speaking, no time to think about mindfulness or meditation.

As the Johns Hopkins I.C.U. began to fill in spring 2020, Ms. Littleton’s mental health plummeted. By November she had transferred to the hospital’s labor and delivery wing, thinking it would be less stressful. Instead, she saw a handful of Covid-infected mothers go directly from C-sections to life support.

In October 2021, she left Hopkins for a travel-nurse job that paid her three times what she made at her previous role but also put her face-to-face with different tragedies: gunshot wounds, car accidents, stabbings, train crashes. She was regularly disassociating, she said, looking down at her hands and wondering whose they were. In the bath one day she envisioned the light above her falling into the tub and electrocuting her.

“Whenever people ask casually — like, ‘How are you doing?’ — nobody really wants to hear the answer,” Ms. Littleton said. “So much of what happens in the hospital, it’s almost impossible to describe to your friends or family members who aren’t involved in health care. And it’s hard to talk about mental health. In nursing, sometimes it’s frowned upon when people say, ‘Oh I feel so burned out.’ It’s almost like a shameful way to approach it.”

At her therapist’s suggestion, she checked off the days until her contract ended in May 2022. With the extra money she had saved from the pay bump she took an extended honeymoon through Spain, Portugal and the Netherlands. She now works for an insurance company doing health promotion and engagement.

“Now I’m finding myself just randomly making blueberry scones at 9:30 at night, or deciding with my husband to go see our friends play music at this bar spontaneously,” she said. “I’ve become much less … rigid.”

That said, she’s also in therapy for post-traumatic stress disorder, and, like every other nurse interviewed for this story, has felt some level of guilt for her decision to leave her job.

“I feel so guilty that I am not in the hospital still, and I also really mourn the loss of my critical care career,” Ms. Littleton said. “I’m disappointed not in myself — because it’s not fair to blame myself — but I’m really disappointed that I just can’t do it anymore.”

One thing that’s not an issue, Dr. Mensik Kennedy of the American Nurses Association said, is interest in the field. Conventional wisdom — and Dr. Mensik Kennedy’s own expectations — would presume that, with these intense levels of stress and burnout, interest in nursing would wane. Yet there were 60,000 qualified nursing applicants turned away from nursing schools this past year, according to the A.N.A.

As experienced nurses leave the profession, there are fewer and fewer opportunities for students to get the hands-on, in-hospital training that is necessary for the profession, which in turn leads to nursing schools not producing enough graduates to fill the gap. Fix the burnout and staffing issues, Dr. Mensik Kennedy said, and the infrastructure can once again support the necessary amount of new graduates needed to fill the nursing gap.

The most important way to start, she said, is to regularly measure nurses’ stress levels, to take action when they begin to climb and to change the glorification of working without breaks.

For Ms. Schmidt, the former N.I.C.U. nurse, that stress has eased with her new role. “It’s still hard work,” she said. “It’s still good work. I still am super busy. But it’s not always life and death.”