A blueprint for leadership during COVID-19

As of the end of June 2020, there were over 10 million confirmed COVID-19 cases and more than 500,000 associated deaths worldwide.^1,2 The healthcare system is under tremendous pressure, rapidly adapting to population health needs while taking steps to address a host of urgent issues: shortages of personal protective equipment (PPE); distribution of limited resources; ethical dilemmas; and the integration of specialty consultation services, such as palliative care, to address clinical emergencies, including pain and symptom exacerbation.^3-8 Add to this the pervasive public context of social distancing, quarantining, and self-isolation and there are certain to be healthcare workers across disciplines deeply impacted by the immeasurable consequences of stress and fear.

Nurses comprise 59% of the healthcare workforce, with close to 28 million nurses worldwide delivering about 90% of health services.⁹ In the US, there are 4 million nurses working across acute care and community settings, among others.¹⁰ Nurses spend a higher proportion of time in contact with patients than other disciplines; this face-to-face interaction raises nurses’ risk of viral transmission and exposes them to the emergent suffering of patients and their families, who are confronting unprecedented health challenges during the COVID-19 pandemic.

Nurses are also facing a host of changing practice considerations, including redeployment to new roles and/or responsibilities, increased work times and pressures, fear of virus transmission and illness, complex patient and family dynamics, strained inter-disciplinary team communication, and difficult ethical issues in the delivery of care.^11,12 (See Changing practice considerations.)

Changing practice considerations¹².

• More work: There’s a noted increase in shift lengths, consecutive shifts, and on-call times; rest periods are likely insufficient.

• Fear surrounding safety and health: Healthcare worker infection rates are increasing and hundreds of clinicians have died, there are increased shortages of and restrictions on the use of PPE, and some employees have been threatened with termination if they speak publicly about work conditions.

• Isolation: Healthcare workers continue to isolate and enact social distancing in their personal lives; some are distancing from their immediate family to decrease risk of transmission, reducing the amount of emotional, spiritual, and physical support received from loved ones.

• Threats to livelihoods: Many organizations are reducing hours, salaries, and roles due to cancellation of elective procedures and nonurgent care delivery, many institutions aren’t offering crisis pay despite conditions, and many healthcare roles are being terminated across settings.

• Risk of redeployment: Individuals are being asked to take on responsibilities they may not be trained for, increasing the risk of trauma.

• The unknown, unclear, and uninformed: A lack of clear, transparent information from policy makers and leaders decreases confidence in system-level factors; much about disease transmission and pathophysiology remains unknown and there are no answers about the duration of the health crisis.

• New technology: The uptake and navigation of telehealth are time-consuming; there’s a learning curve, with a lack of clarity about reimbursement mechanisms for services rendered in this forum.

• Rising moral residue: All healthcare workers are at substantial risk for moral distress in the face of difficult clinical and ethical decisions that will have long-term impacts.

In addition, COVID-19 may impact nurses’ personal lives in several ways, such as death or illness of a loved one, childcare issues, overburdened financial obligations, shifting responsibilities, and anxiety about exposing family members to the virus.¹³ Ultimately, rapid and intelligent investment in nursing is needed at policy and leadership levels to ensure strategic workforce optimization in all specialities and at all levels.^14,15

Although experts are providing recommendations to assuage provider exhaustion, there continues to be a gap related to pragmatic policy shifts specific to the needs of nurses that can be rapidly achieved.¹⁶ This article discusses burnout and moral distress among nurses during the COVID-19 pandemic and suggests institutional policy recommendations to support nurses not only during this crisis, but also during future pandemics and health disasters to promote health system resilience and maintain quality patient outcomes.

Burnout

Burnout is more than stress or fatigue—it’s a feeling of over-whelming exhaustion, cynicism, and low self-efficacy resulting from chronic work strains.¹⁷ The World Health Organization classifies burnout as an occupational phenomenon due to its fundamental connections to the workplace.¹⁸ A poor work environment characterized by job demands outweighing job resources is the primary cause of burnout; for nurses, this translates into decreased autonomy, strained working relationships with colleagues, lack of support from management, and insufficient resources and staff.^19-21

Estimates of nurse burnout within the US range from 35% to 45%.^22,23 The COVID-19 pandemic has exacerbated the realities of poor work environments, which may lead nurse burnout rates to grow exponentially as hospitals ask nurses to work under potentially extreme conditions.

Burnout has been linked to job dissatisfaction, depression, and even suicidal ideation.^24-26 However, the effect of burnout isn’t isolated to the individual experiencing it. Nurse burnout has also been associated with absenteeism and turnover affecting workforce stability.^27,28 Burned out clinicians aren’t only more likely to leave their jobs, but also nursing or healthcare entirely.²⁹ Perhaps most concerning are the consequences of clinician burnout on patient care. Two systematic reviews found that clinician burnout was linked to a higher incidence of medical errors, lack of communication, and poor quality and safety.^30,31

Although not every hospitalized patient with COVID-19 will require ICU care and ventilator support, they all require high levels of nursing care. Nurses have distinctive considerations given their workload, clinical responsibilities, and increased patient exposure time. Hospitals can support nurses during the COVID-19 pandemic by reinvesting in the work environment to make additional resources available, enabling nurses to deliver the highest quality of patient care.

Moral distress

During the COVID-19 pandemic, many clinicians are struggling to balance their obligations to care for patients with their personal responsibilities to their own health, especially when adequate PPE is unavailable. They’re unsure how and where to share their concerns because of fear of retaliation. Others are challenged by the shift from a primarily patient-centered ethical frame-work to one that prioritizes swift triage and the allocation of scarce resources to those most likely to benefit. They witness the impact of frightened patients without the support of their loved ones and the reality that some will die alone given visitor restrictions nationwide. Still others are concerned about the risk of spreading the virus to their families and communities, or the risks of redeployment to unfamiliar settings.

The consequences of these questions, along with emotional and spiritual exhaustion, is known as moral distress or, in extreme cases, moral injury. Moral distress is the anguish that arises from knowing what we ought to do but not being able to act on it because of constraints that imperil the integrity and well-being of clinicians.³² It’s a contributing factor to burnout, which has implications for the stability of the healthcare workforce.¹⁹

If we view moral suffering along a continuum, moral injury is the most corrosive form of moral suffering, involving high-stakes situations where our integrity has been violated and our moral core eroded.³³ Moral injury may be recognized retrospectively when we realize that our conscience has been violated, our well-being has been chronically depleted, or our typical protective mechanisms have become disabled.³⁴

Moral residue comes from unmet obligations that persist even when we do the best we can in a constrained environment, often provoking a sense of moral failing.³⁵ When moral distress accumulates, it’s likely carried into the next situation and builds over time.³⁶ Some clinicians may become overwhelmed with this emotional burden or become angry or morally outraged—a predictable and justified response to a core ethical value being violated.³⁷ This can lead some to become even more exhausted or leave the healthcare profession at a time when there are already critical shortages of all types of clinicians. Recent evidence suggests that two-thirds of nurses are considering leaving their jobs or the profession because of the pandemic.³⁸

The COVID-19 pandemic invites us to consider how to provide the greatest resources to those patients most likely to benefit, but it doesn’t erase the ethical obligation to care for patients with as much skill and compassion as possible. The optimal response will require collaborative approaches to create the boundaries of ethically permissible actions within the context of a pandemic and a space for diverse responses to be held by the community within and outside of healthcare. Healing the moral wounds of the pandemic will require us to restore personal and relational integrity while leveraging our moral resilience.³³

Recommendations

The National Academy of Medicine (NAM) has released strategies to support clinicians’ health and well-being.³⁹ Although these are important recommendations, encouraging nurses to exercise some of these suggestions, such as taking breaks or reporting their concerns, may be unrealistic without giving them the support, safety, and resources to do so. We’ve further adapted NAM’s strategies with concrete recommendations to support nurses during the COVID-19 pandemic.

Create a COVID-19 taskforce with a strong nursing presence.

CNOs and directors of nursing have the required experience and direct contact with clinical nurses and nurse managers. Including nursing leaders on the taskforce ensures that we advocate for the concerns and obstacles nurses are facing at the bedside and create strategies to support frontline clinicians. The taskforce shouldn’t only discuss resource allocation of technology (such as ventilators, extracorporeal life support, and ICU beds), but also the necessary nursing staff needed to operate such technology without compromising the health of the workforce or patient safety. Additional concerns that the taskforce should address include PPE rationing, disinfection protocols, and how staff on the bench can be retrained for intelligent and safe redeployment.

Key stakeholders, including clinical nurses and nurse managers, should be invited to participate on resource allocation and triage committees. Clinical nurses are an important source of human capital and institutional knowledge and can discuss why certain policies or expectations may not translate effectively into practice.

Make top leadership accessible to clinical nurses.

Nursing executives and hospital leadership should round regularly on units to meet with nurses, understand barriers and facilitators to best practices, and engage nurses in strategic problem-solving to address concerns. When staff members don’t feel that their concerns are acknowledged, it erodes their sense of trust and engagement within the organization. Instituting a continuous feedback loop between leadership and staff is necessary to address these valid feelings. To ensure transparency and address social distancing, efforts should be made to encourage remote meetings, forums, and townhalls.

Intelligently and safely redeploy clinical staff on the bench to units.

Under regular circumstances, nurses often feel unable to leave their patients for sufficient recuperation time during their shift. Not having enough staff and support to complete the necessary care or take breaks during the day leads to nurses feeling overextended and eventually results in burnout. We recommend that hospital leaders find ways to redeploy staff on the bench to support units that are particularly strained.

Hospitals across the US have canceled elective surgeries to save beds for patients with COVID-19. OR and perioperative nurses can be redeployed as unit resource nurses to help floor nurses with critical tasks that can’t be delegated to unlicensed assistive personnel (UAP). A resource nurse doesn’t need to take a patient group but can help with admission assessments and screenings, starting I.V. lines, drawing labs and blood cultures, bathing and patient hygiene, toileting, ambulation, and taking vital signs. This approach ensures that nurses on the bench aren’t furloughed or laid off and provides opportunities for nurses to work on units without the burden of taking on an unfamiliar patient population.

In addition to sharing workload, the availability of a resource nurse gives unit clinicians the support needed to realistically take breaks during their shift. To further support staffing needs, physical therapy assistants and/or technicians could be retrained as UAP to help with delegated tasks, such as bathing, ambulation, and vital signs measurement. Unit secretaries can be used to support charge nurses and nurse managers with the logistics of patient admissions, transfers, and discharges. Redeploying staff is a systemic way to distribute the workload and create breaks for rest, nourishment, and relief from the intensity of the COVID-19 response.

Create a culture of transparent communication.

Hospital leaders should institute frequent rounding by infection control personnel to answer nurses’ questions about virus transmission and provide updates on CDC recommendations for best practices.

We also recommend that infection control personnel and hospital leadership determine their plans for rationing and allocation of PPE, instituting clear guidelines for use and reuse (such as how masks are saved and sanitized). Bringing this information directly to nurses increases transparency and helps alleviate fears about becoming sick or potentially infecting a family member.

Foster well-being with strategic advocacy.

Clinical nurses have been confronted with a unique combination of challenges during the COVID-19 pandemic, bearing witness to unusually high numbers of patients suffering and dying, supporting sick patients in communicating with their families, and feeling ethically compromised in the face of scarce resources. To address this abrupt shift in how care is delivered, hospitals should make mental health services available to clinical nurses to manage their anxiety, fear, and grief. Ethics consultant availability and open forums to discuss ethical challenges can help lessen the burden associated with these decisions or help nurses reconcile their feelings of moral distress.

Healing from the effects of the pandemic can’t rest on the shoulders of those at the frontlines. It will take commitment from healthcare leaders, government officials, and private citizens to dismantle the systemic factors that have created the conditions for moral distress. Legislation such as the proposed Essential Workers Bill of Rights, which advocates for higher wages, universal paid sick leave, protection for whistleblowers, and corporate accountability for meeting responsibilities to employees, is an encouraging start.⁴⁰ In the meantime, nurse managers and other leaders should document the ongoing prevalence of moral distress and burnout and use the results to focus resources and interventions.^19,39

A shift toward well-being

During the COVID-19 pandemic, the healthcare workforce is vulnerable to a number of debilitating factors, including severe resource constraints; significant increases in workplace expectations; and mental, emotional, and spiritual exhaustion. The intersection of these elements is likely to result in increasing rates of burnout and moral distress. Nurses—the most prevalent healthcare workers with the highest proportion of direct patient care time—require distinct considerations to protect and sustain them throughout the pandemic and in the event of future health crises. Rapid policy changes at institutional levels can promote a culture shift toward well-being and sustain the nursing workforce throughout the precariousness rendered by COVID-19. NM