It is heartbreaking to hear about the emotional turmoil of health care clinicians who are fighting on behalf of COVID-19 patients. They are using their voices to tell us their raw and embattled stories of front-line challenges: being alone with dying patients, trying to use Facebook or other social media to allow family members to say their last goodbyes, crying out of frustration and desperation due to a lack of personal protective equipment, and expressing a fearful mistrust of the systems that are not protecting them and may even fire them for speaking out.
What we can also hear in their stories are the many ways that health care systems and governments have failed them. Hospital administrators and others must begin now to think about the short- and long-term mental health implications for this morally courageous group of nurses, physicians, and other front-line workers.
All of us in clinical practice have had to face the loss of patients, no matter what we tried to do to save them. Many of us remember those deaths down to the details, for the impressions they have made on our psyche. I remember a parent holding her child after he died and telling me that she had prayed that God would take him that night to end any suffering. Indeed, the child died that night. The sorrow and grief after a patient dies are experienced differently by each team member involved in a patient’s care.
Today this grief is cumulative. With about 1,000 US COVID-19 patients dying each day since April 1, the loss after loss of patients, including their colleagues, is overwhelming. Nurses and physicians are also grieving the loss of human contact with family and friends who often serve as a shield and sounding board for their day-to-day work-life experiences.
When the next group of COVID-19 patients are suffering and in need of help, there is no time for breaks to debrief, shed a tear, or comfort one another. How long can nurses and physicians last at this mentally and physically exhaustive pace? Not long, I suspect.
The ethics-related stress that nurses and other health care providers face is happening in real time before the public’s eyes as medical personnel are forced by overwhelming circumstances to withdraw or withhold certain treatments from patients whom they have been trained to provide with these very treatments. The ethical climate in many hospitals — formerly a carefully nurtured supportive environment — has quickly changed to that of a war zone. Data show that how nurses and others feel about the ethical climate of their workplace is a protective factor against their wanting to leave their jobs, as is the availability of adequate resources to help them deal with workplace stressors.
All nurses and physicians have experienced days when they were mentally and physically exhausted from caring for patients with complex needs, addressing staffing shortages, mediating disagreements on goals of care, or addressing some other clinical issue. But the relentless crush of patients with COVID-19 coming through hospital doors who need urgent care would exhaust anyone.
As the pandemic slows, hospital administrators, educators, researchers, and others must begin to develop and implement interventions to address the trauma and psychological damage sustained by health care workers on the front lines. They will live with the grief and moral residue (remembering their role in difficult decisions) that may surface at any moment, especially when they encounter an ethical challenge in caring for a future patient.
The National Academy of Medicine recently issued a list of “Strategies to Support the Health and Well-Being of Clinicians During the COVID-19 Outbreak.” Even before the COVID-19 pandemic, a report compiled by the academy raised significant concerns about the levels of clinician burnout, post-traumatic stress, depression, and suicide risks. The newly released strategies are intended to support clinicians and keep them engaged in the fight against COVID-19. Health care leaders and managers are asked to provide clear messages that clinicians are valued and to establish a blame-free work culture. Clinicians themselves are advised to stay connected to colleagues and practice self-care techniques. However, what will be needed soon are ways to identify and provide help to the individuals with invisible wounds among the many thousands of nurses, doctors, and other clinicians who accepted extraordinary risks on the public’s behalf during the pandemic.
Screening and early intervention are critical, as is destigmatizing a request for help from those who are trained to be providers of help. We must understand the extent of systems’ unpreparedness — how we got there and how to do better. And we need to examine closely the ethical challenges in patient care thrown at us by the pandemic and how future ethics training might help clinicians who must make unimaginable decisions. We need to get better at protecting those who are most valuable to protecting us.
Connie M. Ulrich is a professor of nursing and bioethics at the University of Pennsylvania and the Lillian S. Brunner chair at the University of Pennsylvania School of Nursing.