"It's been full-on. We aren't just stretched, we're bled."
These are the words of practice nurse manager Tracey Morgan of Tiaho Medical Centre in Rotorua.
Morgan has worked on the frontlines of the pandemic response for the last two years and has advocated for nurses' rights since 2009.
"I believe mental health struggles have absolutely escalated," Morgan said.
"It really hit me today when someone told me I looked tired."
It comes as a legal and health expert has recorded widespread burnout in health workers in Australia and New Zealand.
Morgan said health workers weren't ready for the scale of the pandemic.
"We didn't know what hit us."
Morgan believed the strain on those workers was the result of a chain reaction of "layers on layers" of increasingly built-up issues.
She said nurses had faced ever-changing information, difficult logistics in finding supplies such as flu vaccines and protective gear, and frustrated patients - all while putting their own health at risk.
"We've got people screaming down the phone and banging on the door.
"We still needed to go home to our whānau."
From Morgan's perspective, there were no easy solutions.
"We haven't even had the opportunity to acknowledge what has happened."
All she asked of patients was patience and encouragement. Nurses would carry on going the extra mile for patients because "that's what we signed up for".
Tauranga Hospital respiratory and general physician Dr Johnnie Walker said the pandemic had changed hospital work "beyond recognition".
The need to isolate patients with respiratory difficulties, difficulties in getting supplies and shifts changes all took a toll before even returning home after working in "clouds of Covid."
"We had to train our kids not to hug us when we got through the door."
Walker encouraged the public to be kind to frontline health staff.
"You never know what someone is going through.
"A kind word or the offer of help would go a long way."
Walker said it was also important for hospitals to set up multiple systems to access different forms of mental health support services.
University of Melbourne School of Population and Global Health professor Marie Bismark said healthcare workers across New Zealand and Australia were exhausted.
"You can keep working on adrenaline for a few weeks but we're now years into the pandemic and the pressure is not easing off."
Bismark, a lawyer and medical doctor who grew up in Rotorua, has just published a book about the pandemic experiences of healthcare workers in Australia and New Zealand.
"What we're seeing is high rates of depression, anxiety and burnout among health workers.
"Perhaps the most worrying finding from our study was that in Australia one in 10 health workers has had thoughts that their life is not worth living."
She said long work hours were taking a physical toll but workers were also suffering moral injuries when waiting lists meant they could not provide the quality of care they wanted to.
"It's a difficult thing because we go into this job to care."
Participants in Bismark's study also said they found it "distressing" to enforce limited visiting hours and often faced verbal and physical abuse.
Bismark said individual resilience was not the issue.
"The problem is much deeper than lunchtime yoga classes. It's really a health and safety issue."
Bismark said many frontline health workers felt they could not take breaks because it would place a greater burden on their colleagues due to tight staffing.
"But people cannot keep going under this amount of stress," Bismark said.
"If you have a family member or friend who is a health worker, one of the most important things is to encourage them to take a break and take time off."
Signs of burnout to watch out for included emotional exhaustion, depersonalisation and a reduced sense of personal accomplishment.
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Bismark said health workers could also begin to lose some of the human connection in their jobs and see patients as numbers on their workload instead of human beings.
"People start to feel quite detached from their work. They feel like they're not doing a good job anymore."
Some solutions Bismark suggested were staying in touch with friends and family, exercising, decreasing alcohol intake and seeking professional help.
Bismark said support from colleagues and professionals with shared experience could help encourage frontline health workers to seek assistance.
Where to get help:
If it is an emergency and you feel like you or someone else is at risk, call 111.
For counselling and support
Lifeline: Call 0800 543 354 or text 4357 (HELP)
Suicide Crisis Helpline: Call 0508 828 865 (0508 TAUTOKO)
Need to talk? Call or text 1737
Depression helpline: Call 0800 111 757 or text 4202
For children and young people
Youthline: Call 0800 376 633 or text 234
What's Up: Call 0800 942 8787 (11am to 11pm) or webchat (11am to 10.30pm)
The Lowdown: Text 5626 or webchat
For help with specific issues
Alcohol and Drug Helpline: Call 0800 787 797
Anxiety Helpline: Call 0800 269 4389 (0800 ANXIETY)
OutLine: Call 0800 688 5463 (0800 OUTLINE) (6pm-9pm)
Safe to talk (sexual harm): Call 0800 044 334 or text 4334
All services are free and available 24/7 unless otherwise specified.