Essential and Invisible: Addressing Burnout for Low-Wage Frontline Workers during COVID-19

Background: Frontline and essential jobs such as medical and nursing assistants, food service workers, and housekeepers and janitors are often “invisible” when conceptualizing the essential healthcare workforce. These types of workers are not typically included in health workforce burnout literature. Frontline workers are more likely to be women, immigrants, and people of color. Frontline workers are also more likely to be in low-wage positions and experience heightened physical, mental, and financial hardship. As health systems continue to grapple with how best to provide services in this new COVID-19 era, addressing the needs of these essential workers and identifying best practices in supporting and preventing burnout is a critical way to continue the functioning and safety of care delivery. This study sought to understand the unique experiences of low-wage, frontline workers in hospitals to better understand their needs and identify strategies to best support them during COVID-19.

Methods: Interviews were conducted using a semi-structured interview guide over an e- meeting platform. Qualitative interviews explored the main sources of stress that contributed to feelings of burnout and strategies to help buffer these stressors and provide professional and personal supports All interviews were checked for accuracy and transcribed for thematic content analysis. Interviews focused on participants’ work and educational background; levels of burnout they experienced, COVID-19 resources provided by their employer; homelife and job security.

Results: Twenty low-wage, frontline workers from three states were interviewed including California (n=1), Colorado (n =5), and North Carolina (n=14). On average, workers had been in their jobs for 5.8 years (range 3 months to 20 years). Seven participants worked in environmental services (i.e., housekeeping), six in food services, five in patient transport, and two had front-desk roles. Themes emerged related to both perceived causes of burnout and protective factors against burnout. The four most prominent stressors contributing to frontline workers' sense of burnout were: (1) Changes in duties and being understaffed, (2) Fear of contracting COVID-19 and endangering others, (3) Desire for recognition, and (4) Lack of clarity around safety precautions and eligibility of resources. Protective factors that helped buffer stressors included: (5) Provision of extra paid time off or flexible, (6) Organizational efforts to provide mental health; (7) Self-coping strategies (i.e., family and community) and a sense of pride in their jobs.

Implications: This study offers perspective of a vital group of health system employees regarding experiences of stress and burnout, as well as buffers and supports during COVID-19. Respondents described feeling underappreciated despite having to do more in their jobs with less staff, and a heightened risk of their own safety. Clear communication on resources, PTO time for sick leave, mental health supports, and self-coping strategies were beneficial for participants. Given that the U.S. health system relies on thousands of low-wage workers to keep health systems cleaned, fed, and moving, identifying strategies to support this workforce is greatly needed.