A highly infectious disease originating in Wuhan, China, coronavirus disease 2019 (COVID-19) has posed an unprecedented challenge, creating a host of stressors for health care providers in addition to clinical issues treating patients with this disease. In March 2020, the World Health Organization (WHO) declared COVID-19 to be a pandemic.1  By the end of June 2020, there were more than 500 000 deaths and 11 million infected persons globally. Severe acute respiratory syndrome coronavirus 2, the virus that causes COVID-19, can spread rapidly; health care workers need to protect themselves as well as their families. Complicating this, at the beginning of the outbreak, there were shortages of personal protective equipment (PPE) for health care workers in the United States and elsewhere.

In addition to managing the clinical issues surrounding treating patients with COVID-19, clinical staff have been impacted by numerous ethical dilemmas including restricted visitation, particularly at end of life. Nurses feel the impact of being the only person with a patient at the end of his or her life while coordinating online visits with family who are not allowed to be present. The moral distress created by the pandemic is unlike anything seen by health care workers. Particularly at this time, there must be a program at each facility to care for the caregivers. The COVID-19 pandemic will have long-lasting psychological impacts on health care workers, putting them at risk for future issues with moral distress or posttraumatic stress disorder.

Resource Concerns

Shanafelt et al2  conducted focus groups with health care workers to identify and understand their sources of anxiety related to COVID-19. The researchers identified 8 sources of anxiety2 :

  • access to appropriate PPE

  • exposure to COVID-19 at work and taking the disease home to their families

  • lack of rapid access to testing if they develop symptoms and fear of the virus spreading at work

  • uncertainty that their organization will support/take care of their personal and family needs if they contract COVID-19

  • access to childcare during increased work hours and school closures

  • support for other personal and family needs as work hours and demands increase (eg, food, hydration, lodging, transportation)

  • ability to provide competent medical care if the health care worker is deployed to an unfamiliar work area (eg, nonintensive care unit [ICU] nurses having to function as ICU nurses)

  • lack of access to up-to-date information

Health care workers have raised awareness about inadequate supply of ventilators and PPE, as well as about the need for sufficient nursing staff to care for patients. Hospitals have had to adapt to these staffing and resource challenges, creating surge plans that push patient care outside the usual mode of practice. Some of these plans have included a team nursing approach with trained (ICU) nurses and non-ICU nurses working together as a team to care for patients.3 

Burnout

Before the pandemic, clinician burnout was already a widespread problem.4  Pandemic-related risks to health care workers in light of that reality include physical and emotional harm that some are calling a “parallel pandemic.”5, 6  Before the pandemic, health care workers reduced the risk of burnout by spending time with family and friends. With increased work hours during the pandemic, the toll of emotional exhaustion, and the risk of infecting their families, health care workers lose full access to that outlet. Health care workers worried about infecting their families have been self-isolating, which can result in depression, insomnia, and feelings of isolation.6 

Albott et al7  describe burnout as a multifaceted response to job stress with symptoms that include exhaustion, cynicism, and inefficacy. In areas with high COVID-19 infection, clinicians are exposed to high rates of death, dying, and trauma and may feel unable to provide appropriate care because of insufficient information regarding this disease. Burnout causes a loss of physical, cognitive, and emotional energy as well as ineffective coping strategies, negative attitudes, and a feeling of disengagement from work.7  My prior discussion touched on how staff have needed to balance their duty to patients and concerns for their health and family. To date, there is at least 1 reported physician suicide, purportedly from the trauma, stress, and burnout of caring for patients with COVID-19.8 

Resilience

Resilience has been defined as “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress.”9  In order to develop resilience, health care workers need to feel safe by having appropriate PPE, getting adequate nutrition and rest, and having organizational support in the form of transparent communication as well as a manageable workloads.9  In addition to clinicians’ current high risk for burnout and low workplace morale, they are grieving the loss of so many patients to COVID-19. Health care organizations must develop strategies to support health care workers and help increase their resilience. “Care for the Caregiver” programs should be in place to address short-term stress and support long-term resilience.

Organizational Activities to Support Health Care Workers

Lai et al10  surveyed doctors and nurses in China, who reported high rates of symptoms of depression, anxiety, insomnia, and distress. Staff who experienced this psychological burden were primarily nurses, especially women, who were directly engaged in the diagnosis of COVID-19 and caring for and treating affected patients.

Leaders of health care organizations need to support clinicians treating patients with COVID-19, by ensuring staff get what they need to care for patients, being visible to answer questions, and listening to staff concerns, especially during times of high stress and high patient volume. Staff should be allowed to debrief during times of high stress; organizations should ensure that a support program to assist with this is in place. Staff should also be given frequent breaks and be allowed to step away from the high-stress environment. Experts from the American Psychological Association suggest that staff be offered training on wellness and resilience techniques, including mindfulness, relaxation, and cognitive behavioral therapy–based healthy thinking.9  Organizations and health care workers must recognize the symptoms of stress and address them early. Health care workers need to be encouraged to communicate their distress and seek help from professionals in the organization through support and employee assistance programs.

These are unique times and abnormal circumstances for health care workers. The American Association of Critical-Care Nurses has a position statement, Moral Distress in Times of Crisis, which lists suggestions for health care institutions. Recommendations include providing adequate supplies and equipment for staff protection, establishing evidence-based policies for allocation of scarce resources, ensuring administrators are accessible, providing tools to help clinicians recognize moral distress, and offering critical stress debriefings and protocols for end-of-life care, to name a few.11  Caregiver wellness must be a priority in order to avoid burnout and, even worse, posttraumatic stress disorder in the future.

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Footnotes

The author declares no conflicts of interest.