Moral Injury Among Health Care Workers in the Intensive Care Units during COVID 19 Pandemic.

Eduardo E. Chang*, Esther Segura¹

1. Senior Patient Liaison, Methodist Hospital, Houston Texas.

Corresponding Author: Eduardo E. Chang, M.D., M.B.A., Clinical Assistant Professor of Medicine, University of Texas Medical Branch, Texas.

Copy Right: © 2021 Eduardo E. Chang. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: December 11, 2021

Published Date: December 18, 2021

Objective: Letter to the editor

Conflict of Interest: None.

MeSH: Moral Injury, Burn Out, Critical Care, Nursing, Intensivist, Respiratory Therapist, Post Traumatic Stress Disorder, Nursing Shortage, depression, occupational stress, Health workforce.

The coronavirus pandemic has placed high stress on all healthcare workers. A large number of admissions and increased mortality. Treating multiple patients with very poor outcomes has increased the level of anxiety and post-traumatic stress syndrome among nurses, therapists, physicians, and support staff. The increased media coverage and the daily bombardment of news, clinical reports and public opinions ranging from vaccination to healthcare policies create an information overload that has never been present in our intensive care units.  Families bring their loved ones for a perceived “cure” or “therapy”; they have a myriad of questions and high expectations for a virus that continues to kill thousands every day. The United States of America approaches close to 800k deaths at the time this letter has been written. More deaths due to COVID 19 than the American civil war. Families upon bringing their loved ones to our intensive care units have consulted Dr. Google and want us to follow treatments that have no scientific validity but are the current trend on the internet. Medical personnel treat symptoms and provide therapies derived from multiple centers around the world, that have scientific validity. The combination of pressure from the family, limited treatment for a new disease in addition to the many gravely ill patients create an atmosphere of recurrent stress and psychological pressure for the healthcare worker. The Concept of “suck it up” from their superiors just makes the situation worse, forcing the healthcare worker to quit making the current shortage of health care providers even more pronounced.

What most people call “burned out” are cases of moral injury, the concept of moral injury comes from the history of war.  This is defined as the intense psychological distress which can follow actions or lack of them which strongly clash with the individual’s moral or ethical code.

Moral injury can cause strong feelings of shame, frustration, sadness, or anger.  It was the feeling described by soldiers that returned from war. In the context of health care providers, it is created by an act of commission, the act of omission, or an act of betrayal.  Some healthcare workers are not affected, some become affected as they are exposed to recurrent loss of life and unrealistic expectations from family, patients, and administrators in treating a disease with no cure and high mortality when decompensated and in respiratory failure.

Healthcare workers invest a large amount of their youth and career studying how the body works as well as how to execute the art of healing.  They have a set of moral values, and they care about humanity. After all, not harm are the words we all say more than once throughout our careers.  Having trained to provide the best care disregarding race, gender, and economics of the individual, to provide comfort, treat pain, and extend human life.  During the COVID 19 surges, healthcare staff has been asked to take another shift, to work nights and weekends and face a relentless enemy in the ICU who can’t be cured and fights back when you stabilize a patient. Faced with patients that are afraid of this new disease, they place their lives in your professional hands, compounded with families that you can’t please or provide a positive outcome, the uncertainty strains one’s fortitude. This along with the increased number of prolonged-term critical patients that remain in intensive care units at the same time with minimal progress.

Before COVID 19, critical care providers and staff in the United States were limited in numbers. They were forced to deal with the needs of many healthcare systems, matrices, financial expectations, and constraints of growing computer-based electronic medical records (EMR). This electronic record has transformed the health provider-patient relationship and converted it into a template-driven interview.  This technology that is wonderful to track matrix and progress also took away time and part of the doctor-patient relationship which had been the hallmark of medicine for millennia. The most important thing in the encounter became to enter the orders, set up the power plants and fill information in the templates.  This information is required for billing, chart completion, and to prevent litigious situations. Leaving less time for patient care as electronic chart completion is time-consuming.

As the health care providers continue to be exposed to unrealistic expectations from our health care system.  Faced with a disease with no cure, high mortality, and unrealistic expectations from families. Many quit and were replaced by temporary workers. Hospitals in America relied on travel staff both nurses and physicians to fill the thinning ranks within the ICU. This lowers the morale of nurses and physicians as the new travelers may get paid double or more than the person who has been present for decades, adding to the psychological injury of the fatigued healthcare worker. 

In a post-COVID 19 world, medicine in America needs to change. The societies of critical care nursing and societies of critical care medicine have projected a large exit of practitioners and nurses that want to leave the profession.  The attrition diminishes the number of good people that sacrificed their youth, time, and family to provide bedside care for our critically ill; they need to be protected and listened to. There needs to be a means of providing moral support to assist them and allow for staff retention.

Moral injury is what front-line healthcare workers are suffering.   Many nurses and physicians in the ICU suffer the symptoms of burnout, exhaustion, cynicism, and decreased productivity. Many physicians in this pandemic in America have reported at least one of the above symptoms.   This pandemic has stressed the American medical system. 

The problem is larger than burned-out providers, the system itself is broken.   What the front-line workers are experiencing is moral injury.  In essence, when the provider sees actions that are perpetrating, failing to prevent, or bearing witness to actions that transgress deeply held beliefs. The moral injury that we are witnessing in our hospitals is equivalent to seeing someone being killed over and over in the field of battle. With time some will adapt, and others may develop the equivalent of post-traumatic stress disorder (PTSD).  What many nurses and physicians are experiencing is the failure to consistently meet patients’ vital needs, to save lives. No one goes to school for 15 years to be an intensivist in America or 6 to 8 years to be an ICU nurse to see people die over and over for a prolonged period. Intensive care medicine trains one to be prepared for the possibility of the patient’s death, but a consistently high number of deaths for patients that have been on the unit for at time months is different.

Before COVID most hospitals in American had been driven by profit, competition and improving offered services. They all look at financial considerations, electronic health records, filling out the matrix for quality improvements while practicing legal protective medicine. COVID pushed a very broken system into a situation where over 50 percent of ICU care nurses are considering quitting.  An already limited medical specialty field has many physicians retiring, pursuing other areas of medicine or business.  This group of professionals are highly educated and can change careers. These fields were already short on staff before COVID 19 and will remain short-staffed in the years to come.

The everyday grind of failing to deliver what you want, which is to see patients get better. To have the betrayal of patients dying and then explain this to families that had unrealistic expectations.  Family members do not understand issues such as COVID 19 related shock or sepsis that currently has no active cure. It is a repetitive psychological trauma that the frontlines are seeing and will continue to experience in the ever-changing pandemic world that we live in.

There is no immediate solution to the agony these frontlines are seeing in intensive care units around the world. But perhaps a bit of empathy and some understanding of their situation is needed from hospital administration and our fellow man. Nurses, respiratory therapists and physicians take over a decade of school and training to achieve the competencies needed to work in an ICU. No one sacrifices so much in personal time and effort to then quit without cause.

Our hospital and health field leaders need to recognize that the new casualty of this pandemic is the frontline workers.

To find a skilled nurse that can perform multiple skills simultaneously for 12 hours and troubleshoot a patient minute to minute is a challenge. These specialized nurses can run 3 to 4 vasoactive medications for shock, multiple intravenous pumps, run a computer proning system, recognize hemodynamic patterns, run a hemodialysis machine, recognize patterns of distress on a ventilator, speak to physicians and other therapists and coordinate patient care in multiple patients in a day.

The time to allow healing in our front liners needs to start today. The first step is to recognize that there is an epidemic among the ranks of healthcare professionals.  Empathy and acknowledgment by hospital leadership are the beginning of a road towards recovery.