Nurse case managers increasingly see patients with worsening health and more chronic conditions. Dealing with critically ill patients has contributed to more symptoms of stress, anxiety, and depression among nurses and other healthcare professionals, research shows.1

Older, medically burdened patients are living longer, and sometimes in frailer conditions and with worse symptoms. All this is contributing to emotional health issues among healthcare workers, and COVID-19 has exacerbated the problem, says Alexander Wolf, DNP, RN, APRN, palliative care nurse practitioner with TriHealth in Cincinnati.

Training in palliative care can help nurses and case managers treat patients struggling with pain and chronic disease symptoms, he notes.

“Palliative care is about addressing all of these quality of life issues, communicating sensitively about a person’s goals, and helping them plan for an uncertain future,” Wolf adds. “It’s about helping them live the best they can, where they are now.”

Case managers, particularly those who handle workers’ compensation cases, are accustomed to taking care of catastrophically ill and injured patients, says Cynthia Bourbeau, RN, CRRN, CCM, CNLCP, rehabilitation nurse case manager, life care planner, and president and owner of Medical and Life Care Consulting Services, Inc. in Belchertown, MA.

“When people have those kinds of injuries and are severely impaired, and they need someone to be their hands and feet, we set up that care and help them have the best life they can,” Bourbeau adds.

The difference now is that case managers must find new resources or new ways to help patients access the care they need. Some of these patients were in case management before they tested positive for the virus, and now case managers have to take their infection into account, she says.

“This is what’s affecting their lives right now, so we make sure they get what they need for everything,” Bourbeau says. “We’re not providing direct care on COVID patients, technically, but we’re coordinating their care.”

Handling the pandemic’s effect on patients and how it has forced healthcare workers to follow stringent infection prevention and physical distancing guidelines when working with COVID-19 patients have added stress to case managers’ already stressful lives.

For instance, healthcare professionals have had to deal with many systemic problems in recent years. They spend a great deal of time filling out documentation and electronic medical records, says Bernadette Melnyk, PhD, APRN-CNP, vice president for health promotion and dean of the College of Nursing at The Ohio State University.

The pandemic has highlighted how important it is for healthcare organizations to focus on staff’s mental health and stress.

“My prediction is we’re going to have a tsunami of mental health problems among our healthcare providers during the rest of the pandemic and in the months following,” Melnyk says. “I think we’ll see a lot of post-traumatic stress disorder. We’re already seeing moral distress in these providers.”

Wolf has studied moral distress among critical care nurses, but the same issues can affect any healthcare professional who works with critically ill patients — particularly when they are infected with COVID-19 or at risk of serious illness if they become infected.

“‘Moral distress’ refers to situations where an individual has identified in their own mind the morally correct action to take, but they are unable to take it because of some perceived constraint,” Wolf explains. “Research shows that moral distress manifests itself in a number of ways, but it is linked to increased burnout among staff.”

As COVID-19 patients are discharged from hospitals with new chronic health issues — such as lung problems, severe weakness, muscle deconditioning, kidney failure, and other debilitating conditions — case managers’ jobs become more challenging. Often, patients were not sent to skilled nursing or rehabilitation facilities because some of these places would not accept COVID-19 patients. These frail patients often were sent home to their families.

“They’re often weak after being extubated,” Wolf says. “There are a number of patients who — in any other circumstance — should not be going home to their family’s care, but they are going home.”

Case managers often have to support these patients and their families, and help them emotionally prepare for a long and uncertain recovery period.

This is why it is important for healthcare organizations and leaders to support their staff and offer emotional health solutions, such as encouraging staff to learn cognitive-behavioral therapy interventions and mindfulness, Melnyk says.

A systematic review of studies about physician and nurse mental health revealed that healthcare systems need to promote their health with evidence-based interventions.2

For example, case management leaders could encourage their staff to learn mindfulness skills, such as gratitude practices and deep breathing exercises, Melnyk says.

“They can focus on getting up every morning and naming two people or things they’re grateful for,” she explains. “That works in studies.”


  1. Wolf AT, White KR, Epstein EG, et al. Palliative care and moral distress: An institutional survey of critical care nurses. Crit Care Nurse 2019;39:38-49.
  2. Melnyk BM, Kelly SA, Stephens J, et al. Interventions to improve mental health, well-being, physical health, and lifestyle behaviors in physicians and nurses: A systematic review. Am J Health Promot 2020;890117120920451.