Burnout, compassion fatigue, and moral distress – we use these terms often when talking about the effects of nursing job stress. The COVID-19 pandemic has brought so much into perspective, including the trauma that those on the frontlines experience during ‘normal’ times. Now, as nurses and other clinicians are battling COVID-19, that trauma has increased exponentially.

Too often, use of the terms burnout and compassion fatigue leads us to believe that the problem is coming from within; that we are not strong enough to handle the issue at hand. In reality, a better term to use and understand is moral injury. This 2018 article in STAT clarifies the difference in terminology and why it is so important distinguish those differences.
 

The term “moral injury” was first used to describe soldiers’ responses to their actions in war…The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care (Talbot & Dean, 2018).

Solutions such as implementing self-care strategies, strengthening resilience, and employing better coping mechanisms are not to be minimized, however when institutional or social factors prohibit health care providers from providing appropriate care with adequate resources or safety precautions, solutions need to shift to remedying those factors. A meditation app won’t fix staffing issues. Debriefing sessions won’t secure adequate personal protective equipment (PPE). A yoga session won’t increase access to COVID-19 testing. Don’t get me wrong, there is value in these and other self-care strategies, but at this moment our health care providers are facing the worst of the worst, and help is needed.

Workload, schedules, staffing, inefficiencies, and lack of resources have been long-standing issues. Now, clinicians on the front line of the COVID-19 crisis are putting their physical and mental well-being on the line each and every day. Add in the acuity of the COVID-19 patients, witnessing patients dying without family and friends nearby, and the stress of watching life on the “outside” where others are questioning the reality of this virus and disregarding the important role that each citizen must play in putting an end to the pandemic. Our clinicians – those who we depend on at the most vulnerable times in our lives – are at risk.

How can we understand what clinicians are most concerned about? The easiest and best way is to simply ask. Last April, researchers held eight listening sessions with groups of physicians, nurses, advanced practice clinicians, residents, and fellows. The areas of focus were what health care professionals were most concerned about, what messaging and behaviors they needed from their leaders, and what other tangible sources of support they believed would be most helpful. Eight sources of anxiety were identified (Shanafelt, Ripp, and Trockel, 2020):

1. Access to appropriate personal protective equipment
2. Being exposed to COVID-19 at work and taking the infection home to their family
3. Not having rapid access to testing if they develop COVID-19 symptoms and fear of propagating infection at work
4. Uncertainty that their organization will support/take care of their personal and family needs if they develop infection
5. Access to childcare during increased work hours and school closures
6. Support for other personal and family needs as work hours and demands increase
7. Being able to provide competent medical care if deployed to a new area
8. Lack of access to up-to-date information and communication

It is eight months later, and for many, these issues remain. We have learned a lot about this virus and how it is transmitted. We have identified some strategies for supporting patients and treating the virus. We are so close to beginning vaccinations here in the U.S. Why are we still reusing PPE? Why don’t we have widespread testing for our workforce?

In August 2020, Preventing a Parallel Pandemic — A National Strategy to Protect Clinicians’ Well-Being was published in the New England Journal of Medicine. The authors call for five high priority actions at the organizational and national levels to protect our clinicians during and after this crisis (Dzau, Kirch, & Nasca, 2020):

1. Integrate the work of chief wellness officers or clinician well-being programs into COVID-19 “command centers” or other organizational decision-making bodies for the duration of the crisis.
2. Ensure the psychological safety of clinicians through anonymous reporting mechanisms that allow them to advocate for themselves and their patients without fear of reprisal.
3. Sustain and supplement existing well-being programs.
4. Allocate federal funding to care for clinicians who experience physical and mental health effects of covid-19 service.
5. Allocate federal funding to set up a national epidemiologic tracking program to measure clinician well-being and report on the outcomes of interventions.

Even before the pandemic, so many health care providers were experiencing burnout, compassion fatigue, and yes, moral injury. We can’t continue to ask so much of our frontline providers without giving them the resources and support they desperately need.

There is no simple solution, but we need leadership willing to focus on a culture of safety and ethics. Time is running out; we need to protect and support our clinicians. When the pandemic is a memory and COVID-19 is something we jot down in a patient’s history, we will still need nurses.

References:

Dzau, V.J., Kirch, D.K., & Nasca, T. (2020). Preventing a Parallel Pandemic — A National Strategy to Protect Clinicians’ Well-Being. New England Journal of Medicine, 383. https:///www.doi.org/10.1056/NEJMp2011027

Shanafelt, T., Ripp, J., & Trockel, M. (2020). Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic. JAMA, 323(21). https://www.doi.org/10.1001/jama.2020.5893

Talbot, S.G. & Dean, W. (2018, July 26). Physicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/