How Can I Survive This?

Abstract

Worldwide, health-care professionals are experiencing unprecedented stress related to the coronavirus disease 2019 pandemic. Responding to a new virus for which there is no effective treatment yet and no vaccine is beyond challenging. Moral distress, which is experienced when clinicians are unable to act in the way that they believe they should, is often experienced when they are dealing with end-of-life care issues and insufficient resources. Both factors have been widespread during this pandemic, particularly when patients are dying alone and there is a lack of personal protection equipment that plagues many overburdened health-care systems. We explore here, guided by evidence, the concept and features of moral distress and individual resilience. Mitigation strategies involve individual and institutional responsibilities; the importance of solidarity, peer support, psychological first aid, and gratitude are highlighted.

Worldwide, clinicians are experiencing unprecedented stress related to the coronavirus disease 2019 (COVID-19) pandemic. Patient care is necessarily altered in substantial and challenging ways. Health-care professionals (HCPs) themselves are being infected and, at least temporarily, isolated, and unable to work. Some are dying: in Italy, by mid-April, the numbers of physicians who died fighting the virus surpassed 100.¹ Medical journals and the media reveal their distress calls:

“I sat overwhelmed and helpless; they just kept calling, and every time I cringed. What will we do? I have never in my 15-year career felt so helpless.” Chicago, Ill.²

“Older patients are not being resuscitated and die alone without appropriate palliative care, while the family is notified over the phone, often by a well-intentioned, exhausted, and emotionally depleted physician with no prior contact. Lombardia region, Italy”³

“(…) we have lost the intimate connection with our patients at their most vulnerable points; felt powerless in the face of the very real fear felt by patients, trainees, and our colleagues alike; and, worst of all, have been left unprotected.” Bronx, NY⁴

Such distress is an indication of the significant psychological reactions being experienced by clinicians on the frontlines of this pandemic.

Sources of anxiety have been identified as (1) access to appropriate personal protective equipment (PPE), (2) exposure at work and possibility of infecting their family, (3) slow access to testing if symptomatic and fear of propagating infection at work, (4) uncertainty that their organization will take care of them and their families if the infection develops, (5) childcare availability, (6) support for basic necessities if workload increases (food, hydration, lodging, transportation), (7) ability to perform if relocated (eg, non-ICU nurses working as ICU nurses), and (8) need for clear and up-to-date information and communication.⁵ Studies are revealing the toll of such anxiety. For example, a cross-sectional study in 21 ICUs in France found reactions such as fear of being infected, inability to rest, inability to care for family, struggling with difficult emotions, regret about the restrictions in visitation policies, witnessing hasty end-of-life decisions, indications of anxiety, depression, and peritraumatic dissociation.⁶ Worldwide, HCP emotional distress or burnout related to practice in response to the pandemic has been assessed as high, particularly for nurses, and associated with lack of personnel or resources and with poor communication from supervisors.⁷

Our analysis of what these and other published studies have found has prompted us to conclude that some HCPs, beyond the physical and psychological burdens of COVID-19 treatment and care, are experiencing what is known as moral distress as they face the moral dilemmas and ethical issues this pandemic presents.⁸ Moral distress is the angst that professionals in diverse fields experience when they have identified what they believe to be the right course of action but are unable to act upon it.^{8 , 9} They may experience frustration, anger, guilt, physical symptoms, and anxiety as they perceive threats to their moral integrity.10, 11, 12, 13 Moral distress is distinct from other types of distress because it involves the violation of one’s core moral values.¹⁴ Personal and institutional constraints, such as those that prevent us from caring as we believe we should,¹ are causes of moral distress with perception and context keys to understanding it.^{8 , 13}

As Khoo and Lantos¹⁵ describe, “HCPs must deal with decisions about the allocation of scarce resources that can eventually cause moral distress and may affect one’s mental health.” Providers offering critical medical care within a stressed health-care system may be at elevated risk for the development of moral injury, a concept well-studied in the military and a parallel construct of moral distress in health care. As a consequence, HCPs are susceptible to posttraumatic stress disorder during and after the COVID-19 pandemic.¹⁶

In this review, we briefly explore the features of moral distress within the pandemic context and individual resilience, institutional responsibilities, and the importance of solidarity, peer support, and gratitude as mitigating tools. What follows is based on best evidence.

Moral Distress During a Pandemic

Two frequent triggers of moral distress that are described in the literature in nonpandemic times are end-of-life conflicts,^{17 , 18} along with issues related to provision of suboptimal care related to lack of resources.^{19 , 20} It is not a stretch to conclude that we are indeed witnessing and experiencing moral distress during this exceptional times.^{6 , 18 , 19 , 21} On the theme of end-of-life care, nothing has been so distressing than witnessing patients dying alone due to the visitation restriction policies⁶ and lack of personnel to dedicate time and resources for proper palliative care and support to grieving families. As one clinician said: “We’re still trying to figure out how to give these patients a ‘good’ death. Watching patients spend their remaining days isolated and alone is devastating.” Seattle, WA ²²

At the institutional level, scarce resources are a major cause of moral distress,⁶ which is exemplified by inadequate staffing (many isolated due to possible contamination), PPE shortage,⁷ scarcity of mechanical ventilators and ICU beds, and HCPs without appropriate training looking after critically ill patients, and on it goes. “All of us, whether being flooded by a surge of patients, hindered by an ossified and fragmented health-care system, or constrained by a lack of effective therapies, shared a sense of helplessness in the face of COVID-19.” Burlington, NC ²

Many HCPs have considered abandoning their profession due to moral distress,^{18 , 23} but thankfully, workers who were interviewed during this pandemic report the opposite, literally reaching beyond their physical capacity, to the point of offering to cover extra shifts.²⁴ Many have come out of retirement to work at the bedside, which is a positive response that has arisen despite the lack of resources and limited protection available.

Addressing Moral Distress During COVID-19

The recognition of moral distress involves an important paradigm shift; a shift away from considering the distressed HCP as simply exhausted, too emotional, unable to take the heat of practice, or simply in need of a break toward a view that it is an alarm signal from a conscientious person practicing in problematic contexts.²⁵ The former perspective implies that the problem resides within the individual, whereas the latter recognizes that the practice setting or the organization environment can be the issue. In fact, the interaction between the HCP and the work environment is fundamental to resolving this puzzle. Fortunately, moral distress may function as a catalyst for changes when properly addressed.¹⁹ How can individuals who are experiencing moral distress resolve or mitigate it?

Identify It and Raise Your Concerns

All practitioners, regardless of discipline or professional ranking, should be able to raise their concerns of conscience and their moral struggles freely in critical times.⁴ It is important first to identify the particular moral conflict that is causing the distress and analyze it. For example, is it a “decision about withdrawal of ventilation on a patient who deserves few more days”? “Is it about a patient dying alone as his wife sits outside the ICU doors and cannot say goodbye”? Addressing such moral conflicts may involve struggles to be heard, to be respected, and to be trusted and will require seeking common ground.¹⁹ In institutions in which a culture of ethical questioning is endorsed and promoted, there will be less unresolved moral distress, even during times of extraordinary challenge.^{5 , 19} A triage officer or a committee to guide decisions about who gets into the ICU or who will qualify for a ventilator has been proposed and implemented in many centers as a way to reduce the burden of decision-making for frontline clinicians.^{21 , 26}

Self-Examination

In our research on moral distress, professionals have said such things as, “When I go home, I don’t just feel like a bad nurse, but like a bad person.” Recognizing that one is experiencing moral distress has proved to be helpful, promoting more positive self-reflection. When you “check in with yourself,” do so with empathy, compassion, and forgiveness.^{27 , 28} When you are experiencing moral distress, reach out to an ethicist at your institution who can assist you to address the ethical dilemmas and conflicting situations that you are confronting. A further strategy is to arm yourself with knowledge about hospital policies and the science behind COVID-19 management.29, 30, 31

With Courage, Share Experiences

“Courage is the commitment to begin without any guarantee of success.”(von Goethe). Fortitude and moral courage need to be part of our armamentarium as professionals; that is, being prepared to make tough decisions and confront the uncertainties associated with our resolve to do the right thing, while recognizing the consequences we may face.³² A sense of being a member of a team promotes such courage. “Feeling fear and acting anyway”: moral courage is a means to triumph over fear with practical action.³³ One should share experiences at team meetings, even if they may seem to portray your frustration, weakness, distress, sense of unfairness, or sense of guilt. Ethics-based rounds, by enabling better comprehension of the nuances of a particular dilemma, have been shown to have positive effects on moral distress reduction.³⁴ An example of such initiative is the well-known “Schwartz rounds program,”^{35 , 36} which facilitates communication and offers structured peer support.²⁹ It is evident in this pandemic that professionals, even though they are dealing with PPE shortages and serious risks to their health, continue to care and advocate for their patients with courage.^{4 , 24}

Moral Resilience and Moral Distress: How Do Resilient People Cope?

During this pandemic, resilience in aid of survival appears as a necessity. It is definitely useful in addressing moral distress. How do we develop it? One definition of resilience is “the ability of an individual to respond to stress in a healthy, adaptive way, such that personal goals are achieved at minimal psychological and physical cost.”^{37 , 38} The foundation for resilience is adequate self-care: ensuring adequate rest, exercise, cultivating spirituality, meditation, and the practice of personal interest and hobbies outside of the work environment.^{39 , 40} However, in the midst of a hectic shift in the ED or ICU, opportunities for rest are elusive, and exercise and hobbies seem wishful thinking.⁴¹ When possible, nevertheless, find some ways of dedicating time for oneself, even a walk or run outdoors can bring significant relief. Such self-care is an ethical response because it increases the chance that anxiety, compassion fatigue, burnout, and posttraumatic stress experiences can be avoided, allowing one to continue to practice.^{29 , 39 , 42}

Rushton¹⁴ has characterized moral resilience as a way to mitigate moral distress: “…choosing how one will respond to ethical challenges, dilemmas, and uncertainty in ways that preserve integrity, minimize one’s own suffering, and allow one to serve with highest purpose.” As we discuss later, the words “choosing” and “purpose” are central to this response. Highlighting the altruism of being able to work as HCPs during this pandemic and serving the greater good will help HCPs to be reminded of their purpose.⁴³ Such personal approach is complementary to interventions at the organizational level.

Strategies to Cultivate Personal Resilience In The Midst of COVID-19

“Everything can be taken from a man but one thing: the last of human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way”. (V. Frankl)⁴⁴

A practical approach to cultivate resilience involves three components⁴⁵:

Acceptance of the Present Reality

A constant theme of this pandemic is the tragedy incurred as HCPs are forced many times to choose the least hurtful outcome among two equally devastating ones. Accepting the harsh reality that is this pandemic, with its unfairness and horrendous suffering, is required until we have new means to fight it.⁴⁶ Resilient people refrain from wishful thinking and move to accept external realities.⁴⁰ A common mistake is to think that only optimistic people can overcome suffering and develop resilience. Always seeing the bright side may be helpful, but our optimism should not distort our sense of reality. As Orbinski⁴⁷ wrote, describing physician’s humanitarian action: “While I am sometimes optimistic, I try always to be hopeful.” Resilient people see the situation with no illusions or pretensions; they are practical and realistic. They are not overwhelmed by emotion but are able to rebalance the mind. A resilient person reframes the suffering in a different narrative to release the grip of this suffering. As Rushton explains, it is a decision that we have to make for ourselves.¹⁴

We must focus on what is relevant and important, keeping ourselves informed by our organizations and by reputable sources, to understand the reality that we face. During the severe acute respiratory syndrome epidemic, professionals reported that proactive education before the surge of cases was associated with an increase in resilience and a decrease in anticipatory anxiety.³¹

A Strong Belief That Life Is Meaningful

We can learn from the wisdom of those who have gone before and survived extraordinarily troubling times. In his book “Man’s Search for Meaning” Frankl⁴⁴ wrote that “true existential meaning stems out of three sources: (1) accomplishments and creative activities (solving a problem or creating something); (2) experiencing something or someone inspiring; and (3) identifying value in unavoidable suffering.”

The creative solutions and great accomplishments shown by many hospitals who have tripled their ICU capacity in a matter of days, transforming operating rooms into ICUs,⁴⁸ hospitals being built in weeks, car manufactories making ventilators, all very inspiring initiatives. The love and gratitude shown to HCPs by the public (clapping from balconies or flashing car lights), the support shown by medical students (running errands or babysitting children for HCPs), the warm company of a loved one after an exhausting shift put our world in perspective. Those are examples of creativity, sources of renewal, and inspiration in difficult times.

Witnessing unavoidable suffering and loss is a reality of practice, although we may ask “why” and “when is this going to stop?” In pandemic times, for every tragedy we see, another may appear. But this is our challenge. Together, with compassion, we take action, create our own story, and reaffirm our purpose and the impact we can have and make a difference.²⁴ By doing so, perspectives on suffering are changed.

The Ability to Improvise and Adapt

In crises, the outcome of rigorous training is revealed. The team unites; years of preparation show their worth.³¹ Improvisation and invention are shaped safely by knowledge and experience. Adapting to change, HCPs “show their face” by attaching their own photos to their gowns and by using mobile devices to allow families to virtually say goodbye to dying loved ones.^{49 50} The risks are high, but we understand them and can respond.

Institutional Role in Staff Wellbeing

Sustaining and improving clinicians’ wellbeing must come from the institutions where we practice.⁵¹ Institutions need to recognize and validate the experience of moral distress and create a sense of cohesion to sustain increasing pressures (“we are in this together,” “we have your back”).²⁹ Most measures to mitigate moral distress and promote HCPs wellbeing are in fact focused on institutional measures.⁵² Many of the reasons for anxiety brought up by Shanafelt et al⁵ and by the survey with HCPs in France⁶ revealed important systemic issues that could be mitigated with proper institutional interventions: the “fear of being infected” being minimized by proper equipment, training and simulations; the “inability to rest” by devising better call schedules and increased rotations; the “regret about the restrictions in visitation policies” by modifying visitation allowances according to the community viral surges and more compassionate approach; and the “witnessing hasty end-of-life decisions” by having proper ethical guidelines and respectful and open discussions with the HCPs who are involved directly in care.

Streamlining lines of communication can improve accuracy and consistency of information flow, which is an issue raised during this pandemic.⁷ The 2003 severe acute respiratory syndrome epidemic showed us that hospital leadership, infection control services, and professional bodies must provide honest information, frequent updates, and acknowledgment of uncertainty when required.^{43 , 53} Plans and institutional processes for procurement of supplies must be clear and transparent, especially when shortages are real. Communication tools can be used (eg, Team STEPPS⁵⁴) to objectively seek patients’ goals of care and ascertain who might benefit from palliative care.

At times of overwhelming patient volumes, management needs to make certain that shifts are distributed evenly, based on workload and not just hours toiled, all organized with the participation of frontline workers. Other important initiatives are how to reconfigure space, how to provide safe staffing levels, the proper use of supplies, and care processes in the setting of a pandemic.^{55 , 56} Disability facilitation and sick leave are extremely important elements of prudent institutional response, in parallel with professional emotional support facilitation with no cost to the employee.

It has been shown that institutions can promote HCP wellbeing by organizing 1 hour/week (paid time) for communal experience discussions, incorporating elements of mindfulness, reflection, and information sharing.^{57 , 58} Such practices, along with efficient leadership, will enhance the power that flows from a shared sense of moral purpose.^{53 , 59} Table 1 gives additional measures to support staff during the pandemic.

Table 1.

Interventions That Might Be Useful to Mitigate Mental Distress in the ICU Relevant to the Coronavirus Disease 2019 Pandemic

Environmental interventions •Promoting healthy work environment: personal protection equipment training, simulation on donning and doffing •Provide devices/tools to allow for virtual communication with families Communication training, appropriate staffing, meaningful recognition •ICU self-scheduling/time off and hiring extra personal, extra compensation •Limit the maximum number of days worked consecutively, shorter rotations •Support groups •Cognitive-behavioral therapy, institutional absorbing costs Team-based interventions •Team debriefings; “Schwartz rounds,” promoting the use of psychological first aid •Use of structured communication tools; CPR simulation while wearing shields and n-95 masks to enhance understanding and close loop communication •Team-building and interpersonal skills training; purpose focus and recognition of staff’s roles and performance •Regular leadership rounds; “check-ins” and huddles (situational awareness) Practitioner-focused interventions •Stress reduction training •Relaxation techniques •Time management, endorsing mobile Apps that promote time-management •Assertiveness training •Meditation •Work-life balance measures: hobbies, family, and social activities •Self-care measures: ensuring adequate rest, exercise, healthy eating habits Interventions to mitigate risk factors •Palliative care consultations; training on virtual contacts with families •Ethics consultations •Establishing goals of care for every patient in the ICU; advance directives promotion •Family care conferencing within 72 hours of ICU admission, with the use of virtual methods

Adapted from Moss M, Good VS, Gozal D, Kleinpell R, Sessler CN. An official Critical Care Societies collaborative statement-burnout syndrome in critical care health-care professionals: a call for action. Chest. 2016;150(1):17-26.

Peer Support

HCPs, especially physicians, are known notoriously to neglect support and external help, even when they recognize that there is trouble. It may be that this “conspiracy of silence” is in part due to a perceived stigma associated with seeking help, given that it may appear to indicate an inability to cope. This attitude persists, despite significant attitude change and the reality that physicians who receive support from their colleagues or spouse are more successful in achieving wellness.³⁹

Solidarity is a powerful tool in a pandemic. Teams working together in common tasks as “communities of practice”⁶⁰ allow for the creation of reflective space for recognizing and sharing experiences of vulnerability that arise during practice. Through shared wisdom and knowledge, a supportive environment (real or virtual) can be created, governed by a common interest in providing good care, regardless of hierarchical or disciplinary differences. Discussion may reduce a clinician’s sense of isolated responsibility, promoting resilience and opening dialogue.⁴⁰ Greater resilience may in turn have a positive effect on how clinicians cope with the stress of their challenging work.⁶⁰

Initially, it is important to identify a trustworthy colleague or a group for peer support and to ensure a safe environment in which to talk. Helpful coworkers will have the emotional capacity for supportive conversation and the ability to set aside personal reactions for a time. Then you may do the same for them. The challenge is to listen to one another without trying to fix the situation. It takes suspending judgment, generous listening, acknowledging, validating, normalizing, and reframing. The incentive is having an opportunity to speak the truth together while respecting each other’s views.

Self-care can be accomplished with others, for example using social media. Colleagues can post humor or uplifting messages and self-care suggestions to one another. You can be honest about your experiences and difficulties and give others permission to voice theirs. “You seem anxious, are you okay?” “How can I support you right now?” Validation of one another is helpful: ”I really appreciate you.”⁶¹

Psychological First Aid (PFA): A Tool For Difficult Times

Most people will not experience the development of a serious mental issue after a disaster or emergency, such as this pandemic. Some HCPs can have strong reactions after dealing with such difficult situations, but most will recover on their own. The recovery from the pandemic surge situation will be better if people feel safe and connected to others during the crisis; if they have social, physical, and emotional support and if they feel like they can help themselves and their community.

“PFA is a humane, supportive response to a fellow human being who is suffering and who may need support. It involves the following themes: (1) providing practical care and support, which does not intrude; (2) assessing needs and concerns; (3) helping people to address basic needs (for example, food and water, information); (4) listening to people, but not pressuring them to talk; (5) comforting people and helping them to feel calm; (6) helping people connect to information, services and social supports; and (7) protecting people from further harm.”⁶²

According to the World Health Organization, any HCP can be a PFA provider without any prior mental health education.^{53 , 62} Table 2 describes PFA actions with examples for pandemic times. Note that PFA is not “psychological debriefing” because it does not necessarily involve a detailed discussion of the event that caused the distress experienced. HCPs who experience continued symptoms of distress a month or more after working in a hectic ICU or ED, however, may benefit from professional psychological intervention. If an individual’s reaction is extreme, formal intervention can be beneficial, and the institution should facilitate that.⁶³

Table 2.

The Four Main Actions in Psychological First Aid and How It Can Be Applied to the COVID-19 Pandemic

Four Principles of Psychological First Aid	Application to the Coronavirus Disease 2019 Pandemic: Examples
Prepare
Learn about the crisis event.	Connect with reliable source of information about the pandemic.
Learn about available services and supports.	Discuss with managers and institutional support system.
Learn about safety and security concerns.	Get proper training on personal protection equipment and help others to be trained; provide simulation.
Action principles
Look
Check for safety.	Be part of the coaching team to keep colleagues safe during personal protection equipment donning and doffing.
Check for people with obvious urgent basic needs.	Take time daily to observe people and how they are coping.
Check for people with serious distress reactions.	Be aware of your surroundings for signs of stress and extreme reactions of anxiety and fear.
Listen
Approach people who may need support.	With respect, offer your ears and your time. Do not force people to talk; look for a quiet and private place. Emphasize self-care.
Ask about people’s needs and concerns.	Are you OK to go home? Are you concern about your family? Facilitate coronavirus disease 2019 testing.
Listen to people and help them to feel calm.	Normalize people’s response; what are expected reactions, emphasizing the altruism of working during pandemic.
Link
Help people address basic needs and access services.	Help to provide home transportation, grocery shopping, childcare, water, and lunch at breakrooms with proper distancing.
Help people cope with problems.	Assure safety on patient care, organize brief open discussions before and after shift; facilitate duty days/shifts adjustments.
Give information.	Share knowledge: offer tips about how one can protect family members. Be honest: if you don’t know, tell them that “you are going to find out the answers.”
Connect people with loved ones and social support.	Be aware of people with stress and connect them with local support systems and their family (with their permission).

Adapted from World Health Organization, War Trauma Foundation, World Vision International. Psychological First Aid: Guide for Field Workers. Geneva: WHO Press; 2011.

Gratitude

“Remember that in any man’s dark hour, a pat on the back and an earnest handclasp may work a small miracle.” Brigadier-General S.L.A Marshall, 1950.⁶⁴

Recognition of each other’s contribution to the COVID-19 response is significant to team support. Recognize a team member for a successful intubation, the cleaning services for preparing a room for a new patient, a unit clerk for quickly processing a new admission; it can make a difference in their day, which is especially true when it comes from management. According to Emmons,⁶⁵ gratitude means an affirmation of goodness. When we look at life as a whole, gratitude inspires us to identify the good, even amid chaos. It is not ignoring complaints, burdens, and hassles, but rather acknowledgment that others help us achieve the goodness in our lives.⁶⁵

Conclusion

Moral distress is inherent to pandemic times. Using strategies to increase our resilience and our ethical engagement with one another, within an environment of mutual support and solidarity, we can address morally distressing experiences in meaningful ways. As clinicians, we want to provide the best care we can, even under the horrific pressures of a pandemic. Our institution will have a fundamental role to play in sustaining our ethical practice and supporting our commitment to care for patients in the most effective and compassionate way possible.