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Posted on June 15, 2020 at 9:00 AM

by Christine Grady, RN Ph.D., and Connie Ulrich, Ph.D. RN FAAN

In Shakespeare’s Hamlet, Claudius famously notes “When sorrows come, they come not single spies, but in battalions.” Today, during the coronavirus pandemic, we are seeing and hearing “battalions” of sorrow reflected on the faces and in the voices of nurses and other healthcare workers, as well as from patients and families across the global community. Nurses and other healthcare workers are often working under grueling workplace conditions. They are physically and mentally exhausted from the complexity of care needs for COVID-19 patients, from staffing shortages, inadequate personal protective equipment (PPE), medicines, and life-sustaining technologies, from witnessing firsthand racial-based disparities, from being alone with dying patients without the support of patients’ families, anguishing over necessary but tragic ethical decisions, and harboring mistrust of a broken system that was meant to protect them.   These challenges are steady, complex, and exceptional.

Each day when they go to work, they put their own health and lives at risk.  Despite the lack of a rigorous system for collecting these data, estimates as of June 2020 are that close to 600 healthcare workers, including nurses, doctors, paramedics, nursing home workers, hospital janitors, and administrators have died from COVID-19; likely an underestimateAs Rosenbaum noted, a fundamental tension exists between effectively caring for our COVID-19 patients and caring for our other patients, ourselves, our families, and our communities. Widespread uncertainty, anxiety, and sadness remain.  Overlaying worry about the effects of the virus are well-founded concerns about other aspects of healthcare provider well- being.  Nurses and others have to manage being over-stretched and exhausted along with the moral distress associated with experiencing unavoidably tragic choices and mishaps that they will have to live with. Their moral distress grows as clinical challenges magnify and they are not able to stop patients from dying even when they are doing the best they can providing appropriate care.  Some are isolating themselves from their own loved ones to protect them.  Some healthcare workers have been asked to take a cut in pay or hours or are being furloughed or reassigned to units outside of their usual practice. They are worried about legal liability from bending standards of practice, wonder if they can say no to unsafe practices, and how to articulate their concerns about the influence of politics and economics on humanistic caring ideals. Some might wonder how we expect nurses and others to continue, or young people to aspire to these professions.

Yet, intrepid nurses, doctors, and other healthcare workers continue on a daily basis to provide quality care for patients with and without COVID-19 and to save lives, even in these times of crisis.  We see acts of moral strength and courage, persistence in focusing on caring for patients, and saying no or demanding more help when conditions are unsafe or will compromise patient care, even at risk of being suspended or reprimanded for their actions.  Competence, compassion, and grit are hallmarks of the healthcare provider ethos.  Yet, competence, compassion, and grit can be taxed by insufficient personnel or support and organizations in disarray.

How should we be helping healthcare workers caring for patients during this public health pandemic emergency, and heal in its aftermath?  Healthcare institutions have a responsibility to do everything that they can to garner the staff and resources necessary to provide good patient care and provide adequate protective equipment to mitigate risk to their healthcare staff.  In addition, nurses and other front line providers need regularly updated information, including training and guidance on best practices, data on clinical course and patient outcomes, institutional and regional policies and procedures, and transparency about limited resources and decisions. Creative ways to provide services and support to patients and staff using technologies, even from a distance, can be helpful.  Teamwork is indispensable, and although crises sometimes brings teams together towards a common goal, inclusivity and respect for all members of the team is essential.  Maximal and creative utilization of supportive services, such as palliative care, bioethics consultation, spiritual care, and others available in many institutions should be encouraged.  Staff should be offered regular breaks, access to meals, temporary housing when possible, and time off.   As time goes on, we must strive to find ways to support the brave staff who continue to provide care in the best way that they can, and ways to heal the wounds and moral distress and anguish of those who had to make or abide by agonizing decisions about care or watch family, friends, or colleagues suffer.  This must also include mental health resources to address the relived anxieties and worries when faced with haunting memories of choices made and losses incurred.

The societal value of nurses and other front line providers is immeasurable. There is no patient care or effective use of healthcare infrastructures without them. Their creativity, moral strength, and professional and personal resolve in the face of adversity is something we should long remember and celebrate.  Nurses comfort dying patients at life’s end, hold patients hands and show compassion for patients in isolation, work extra hours and shifts to cover unit shortages, endure personal risk in the workplace, use their voices to demand resources and change to protect themselves and their patients and families, and continue to go to work every day facing many ethical uncertainties before them. For this, we all should be thankful, and just as we learn more about the pathogenesis, natural history, and health disparities of COVID-19 and more about vaccines, drug and non-drug treatments that will save lives, we also need to learn from nurses and others on the front lines who serve the public so admirably with unmatched strength of character and expert clinical skills under devastating circumstances.

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