The Darkest Hour: Little PPE, No Vaccine Led to Moral Injury
'I am an angel of death and comfort. That weighs on me.'
By Gary Evans, Medical Writer
A fascinating and disturbing study1 captures the emotions and attitudes of healthcare workers in 2020 when COVID-19 emerged. Personal protective equipment (PPE) was in short supply, and the first COVID-19 vaccines would not be available until the end of the year.
There was a general despairing feeling in this period that there was not “enough” of anything, including reliable information, says lead author Ye Kyung Song, MD, PhD, a psychiatrist at Duke University. “It was a scary time.”
As one healthcare worker told the researchers, “I felt like our lives were more disposable than our PPE was.”
Defining moral injury as “emotional distress resulting from events or transgressive acts that create dissonance within one’s very being,” Song and colleagues said this sense of discordance and compromised values “was not only experienced after a single moral dilemma, but also from working in morally injurious environments. Moral injury is strongly associated with medical errors, clinician burnout, and increased suicidal thoughts.”1
Healthcare workers were recruited to participate in a survey via email and social media in two phases of five weeks each: April 24 to May 30, 2020; and Oct. 24 to Nov. 30, 2020. In addition to demographic questions, the 1,344 respondents answered open-ended questions about their emotions and experiences. In both phases, the respondents were primarily nurses, nurse practitioners, and physicians. “Across separate cohorts of HPs [healthcare professionals] in 2020, the level of moral injury increased dramatically, and functional impairment from moral injury symptoms nearly doubled,” the researchers reported.
An Oral History
From the workers’ responses, Song and colleagues outlined themes of fear and fatigue, isolation and alienation, and (most intensely), betrayal. The researchers collected descriptions of this emotional trajectory from healthcare workers in their own words, including these examples:
- Fear and fatigue: “The greatest source of fear has been contracting COVID myself. I’ve become really kind of obsessive over cleaning everything I touch and washing my hands and not touching my face. I’m a healthy young person but that doesn’t seem to matter given the cases I’ve read about where young people are just as ill. It’s shaken my faith in medicine, it makes me feel vulnerable and scared, to be honest. It also makes me scared to give it to my husband, my parents, or anyone, really.”
- Isolation and alienation: “I am more distant with everyone. I avoid friends and family for fear of infecting them or exposing them to this as I feel that I am a carrier. I actively avoid my wife and now find ways to sabotage our relationship as my depression has hit new levels and I want her to leave and not witness this downward spiral.”
- Betrayal: “I felt as though we were being ‘offered up for slaughter’ by having to stay in a COVID-filled room with questionable PPE. Then I felt guilty for thinking of myself. But then what if I got COVID; I have a family. And then I felt horrible for the patient, alone except for me — their nurse who was worried about herself. The back-and-forth guilt and worry about wanting to protect myself. [I] felt like a pawn in a game by hospital administration. Wanting to fully care for the patient was exhausting. I’m sure I’m not the only one who was feeling that way. Our chaplain was a wonderful resource, but we needed debriefing from our leadership. Instead of debriefing, they opted to spend money on ‘healthcare heroes’ signs outside the hospital. It felt like a slap in the face. I became resentful toward administration and hospital leadership. It was as though it was taboo or uncomfortable for leadership to come and talk to us.”
Connection to Patients Broken
Across both phases, using PPE and social distancing measures in patient care contributed to estrangement from patients, with healthcare workers feeling the quality of care was compromised. “We can’t build a connection with our patients because we can’t spend the time to really care for them the way they deserve to be cared for [at the bedside],” a survey respondent said.
The constant donning and doffing of PPE contributed to the general chaos on the frontlines with COVID-19 patients. “We’re trying to help patients in one room but call bells are going off in another room, and you can’t get there,” one healthcare worker reported. “More than a few times, patients have crawled out of bed and fallen because you can’t get there fast enough.”
Many workers were deeply affected by the wrenching combination of being the last to see a patient die, even as others came into their care denying COVID-19 even existed.
“Honestly and personally, as a human being, that breaks my heart,” Song said. “I can’t imagine being the care nurse or the respiratory therapist — people who are around the bedside of patients saying with their dying breath, ‘I don’t have COVID. COVID is a hoax.’ At the end, some would ask if they could please get the vaccine, but was too late.”
Nurses held phones up to patients for a last conversation with loved ones, and were often the only other person in the room when the patient died.
“I didn’t let them die alone,” one survey respondent said. “I am an angel of death and comfort. That weighs on me.”
Another survey respondent described the combination of the chaos, death, denial, and misinformation as alienating and surreal. “[It was] like being on a game show. You’re put into crazy PPE that you have to keep on for prolonged periods of time, sometimes have to work in unknown environments with unfamiliar co-workers with extremely sick patients with doctors who might run out of options for their care. It was a harrowing experience.”
This crucible of care formed team bonds, but sometimes deepened divisions. A recent study revealed moral injury occurred in healthcare workers at a level heretofore seen only in combat soldiers.2 (For more information, see related story in this issue.)
“Healthcare workers felt very disturbed about having to enforce policies of visitors not being allowed to see their loved ones as they were dying,” says lead author Jason Nieuwsma, PhD, clinical psychologist at Duke.
Song’s study did not address this specific comparison in detail, but she said military jargon became common expressions from beleaguered healthcare workers. “What I find really striking is that the metaphors are the same — and they were used a lot,” she says. “People in healthcare were describing their experiences with words and phrases like the ‘front lines’ and ‘gearing up.’”
One healthcare worker told the researchers, “We pulled staff from all over the hospital and dumped them in these makeshift units. Nurses that were from all different specialties were all put together and expected to team-nurse. The stress was unreal, and the unit was like a battlefield.”1
Yet many found a sense of community with their co-workers through the experience of shared trauma and the common goal of providing patient care. While these “survivors” — as they saw themselves — remained, many nurses and their colleagues headed for the exit doors.
“Staff are leaving in droves, leaving us short-staffed and flexed up with our patients, causing even more stress over the already heavy workload with COVID patients,” one worker said in the survey.
There were longstanding nurse staffing issues, “but the pandemic just blew that open,” Song says. “This is anecdotal, but I have friends who are nurses who left the bedside because of COVID.”
The feelings of betrayal may resonate for some time, even as some hospitals try to improve conditions and retain employees. “I am not privy to the conversations where they are thinking of things they could do to improve morale and staff retention, but I’m not sure that hospitals are doing very much of anything to retain people,” Song says. “I think they are trying to hire as many new people as possible. They are giving these hiring bonuses, but are nurses going to be leaving a year later after they get their bonus? I don’t know.”
Workplace restructuring that places nurses’ emotional health as a high priority is needed to stanch the bleeding of the “great resignation,” said Anne Woods, DNP, RN, CRNP, chief nurse of Wolters Kluwer Health Learning.
“We have to build a better work environment,” Woods said at a recent webinar on the national nursing shortage.3 “It has to be safe, and we’re not going to have a safe work environment until we have an adequate number of competent nurses at the bedside to take care of our patients. That has to be done first.”
A persistent problem is the pandemic rising and falling in waves as surges aggravate staffing problems and other aspects of medical response. “When our patient numbers surge, we don’t have enough nurses because that’s not how we staff,” Woods said. “In hospitals today, we staff for the average census. You have these surges, and then you have a decline, a surge, then a decline. We have to teach nurses to work within these alternative care models.”
A team model is the best solution. The collaboration and flexible staffing options can prevent staff from becoming overwhelmed. “We need to really invest in our workforce. That means monitoring for stress, exhaustion, burnout, moral distress,” Woods said. “That means our leaders need to be up on the floor to see what the tone and the culture is of every unit. We all know that culture can be different from one hospital unit to another hospital unit.”
Efforts to remove stigma from mental health counseling (and remove any potential effect on medical licensing), to replenish PPE supplies, and to vaccinate for SARS-CoV-2 are improving the situation for healthcare workers. But moral injury is not something easily overcome — quite the opposite, says Song. Given the current situation with a surging omicron BA.5 subvariant, and the possibility that a new variant may arise, moral injury could be triggered to greater degrees again as the pandemic continues.
“I think the reasons for moral injury are a little different now,” Song says. “People in general in healthcare are fairly comfortable working with COVID now; the fear of catching the virus is not as big. But I think moral injury is something that is carried. It doesn’t go away, and it definitely won’t go away until there is an acknowledgement by the [healthcare] institutions that a harm was done.”
- Song YK, Mantri S, Lawson JM, et al. Morally injurious experiences and emotions of health care professionals during the COVID-19 pandemic before vaccine availability. JAMA Netw Open 2021;4:e2136150.
- Nieuwsma JA, O’Brien EC, Xu H, et al. Patterns of potential moral injury in post-9/11 combat veterans and COVID-19 healthcare workers. J Gen Intern Med 2022;37:2033-2040.
- Lippincott Nursing Center. Nursing’s wake-up call: Change is now non-negotiable. March 24, 2022.
A fascinating and disturbing study captures the emotions and attitudes of healthcare workers in 2020 when COVID-19 emerged. Personal protective equipment was in short supply, and the first COVID-19 vaccines would not be available until the end of the year. There was a general despairing feeling in this period that there was not “enough” of anything, including reliable information.
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