Resources For Frontline Workers Struggling With Moral Injury & Mental Health Amid COVID-19
The residual effects of COVID-19 on the mental health of nurses will not be gone as the pandemic dies down. Many will have to manage the ongoing psychological effects of working as healthcare workers, and as “soldiers” in our battle against the coronavirus. More than ever before, COVID-19 has exposed how our healthcare workers are at an increased risk of mental health struggles.
In New York, where the COVID-19 impact has been felt the most in the United States, two COVID-19 frontline healthcare workers have committed suicide: emergency medical technician, John Mondello, and emergency physician, Lorna Breen.
Suicide has always been an "unspoken" secret within the healthcare profession. But the extreme COVID-19 workplace conditions are breaking down our healthcare workers faster than ever, increasing the risk of healthcare worker suicide. Front line health care workers - many who are bearing increasingly higher levels of moral injury every day- are losing both their lives and mental health as they save us from the virus.
Long before COVID-19 made landfall in the US, nurse suicide rates were already higher than in the general public. Also, physicians and other healthcare professionals are known to be at a much higher suicide risk.
The purpose of this article is to help those who might be struggling with mental health and those who are concerned with their loved ones fighting on the front lines of the COVID-19 pandemic.
Moral injury to healthcare workers on the front lines
Healthcare workers are often publicly referred to as soldiers going into battle, and moral injury is repeatedly being called a culprit for increased risk of mental health issues.
The Moral Injury Project at Syracuse University defined the condition as: "the damage done to one's conscience or moral compass when that person perpetrates, witnesses, or fails to prevent acts that transgress one's own moral beliefs."
Symptoms of moral injury can include shame, guilt, depression, remorse and a sense of being "psychologically and/or spiritually damaged and an inability to forgive oneself for perceived violations of one's moral code."
It makes sense then that soldiers in battle would experience moral injury. But it may be harder for someone who works outside of direct patient care to understand why healthcare professionals would experience moral injury since their goal is to save lives, not take them. But the injury is still there, especially when patients deteriorate, suffer, or die after nurses have set their well-being aside to save them.
Craig Spencer, Emergency Medicine MD at New York-Presbyterian, tweeted about his experiences that may help explain the moral injury that healthcare workers face. "It's not just the volume of patients that's hitting us. It's the severity. Respiratory arrest. Respiratory arrest. Respiratory arrest. Each takes 6-8 professionals. Nurses, respiratory techs, ER docs, anesthesiologists. Each takes an hour or more. Back to back. All shift."
"We're all being asked to do things we've never done before. Run a code as your goggles fog & you can't decipher the vital signs on the monitor. Try to predict which COVID patient will crash if you send them home. And which won't."
Spencer talked about conversations with family members, listening as they sob, knowing they won't be able to say goodbye as they stop the drips and turn off the ventilators. "Someone starts saying a prayer. You can't help but cry. This isn't what we do. You stand by. You wait. This isn't what we do. You stand by. You wait. Time of death: 7:19 pm."
Fear exacerbates moral injury
A lack of respirators remains a concern for some. Many healthcare workers have felt scared about infecting patients with COVID-19, especially as many have been forced to work without the proper personal protective equipment (PPE). Some healthcare workers have been fired for trying to wear their own masks after their employers would not provide one for them.
The lack of proper PPE has caused healthcare workers to fear they could accidentally infect their family at home with COVID-19, especially older family members or those who are immunocompromised.
Alice Benjamin, Clinical Nurse Specialist, ER Nurse, and medical correspondent from San Diego says, "There is an influx of patients that is way beyond what you've previously been used to. And then you couple that with fear of getting infected, bringing it home to your family and actually even dying from it. That's enough to put anyone in a state of situational depression and anxiety."
In talking about the government's response to healthcare worker distress, Benjamin added that "some politicians have said that after this is over, we want to make sure we have therapy and counseling for our healthcare providers. Well, that's PTSD. We need to be on the proactive side."
Healthcare workers at higher risk of mental health issues
Jessica Gold, MD and assistant professor of psychiatry at Washington University, explains that especially during COVID-19, medical professionals' "calm surface appearance is the only armor they have left. Underneath it, many health care workers are barely keeping it together. They are anxious and afraid. They aren't sleeping, and they find themselves crying more than usual."
The feeling of doom is more pronounced because of the lack of PPE. Dr. Gold states, "personal protective equipment is critical to protecting health care professionals' physical and mental well-being."
Also, processing one's feelings takes time, which healthcare professionals in the middle of an epidemic don't have. Many at the frontlines are working long shifts with few breaks and little sleep in-between. They are just trying to survive.
We have learned from studies during the SARS epidemic that quarantine has a profound effect on the mental health of health care workers. It leads to an increased risk of acute stress disorder, alcohol abuse, and depression. Even three years later, the PTSD of healthcare workers was more severe than the general public. Many healthcare workers never returned to work.
A new study from China shows high rates of anxiety and depression in healthcare workers for Wuhan, China. Of more than 1200 healthcare workers, 50% reported at least minor depression, 14% of doctors and 16% of nurses reported moderate or severe depression, and 34% of all the healthcare workers reported insomnia. Those at highest risk were women and those at the center of the epidemic in Wuhan.
Facts about suicide in the United States:
According to the Centers For Disease Control (CDC):
- Suicide is the 10th leading cause of death in the United States.
- One person dies by suicide every 11 minutes.
- In 2017, 10.6 million American adults seriously thought about suicide, 3.2 million made a plan, and 1.4 million attempted suicide.
- People who have experienced violence, including child abuse, bullying, or sexual violence, are at higher risk for suicide.
Warning signs of suicide
A person considering suicide may talk about ending their life or express feelings of hopelessness. Suicide warning signs from the CDC include:
- Feeling like a burden
- Being isolated
- Increased anxiety
- Feeling trapped or in unbearable pain
- Increased substance use
- Looking for a way to access lethal means
- Increased anger or rage
- Extreme mood swings
- Expressing hopelessness
- Sleeping too little or too much
- Talking or posting about wanting to die
- Making plans for suicide
Mental health screening for healthcare workers isn't happening - But It Should Be
Healthcare workers are not being screened for mental health risks the way patients are. Benjamin stated that it is impossible to look at someone and tell if they are suicidal without a mental health and suicide assessment, which is something that nurses and doctors perform regularly on patients.
"We have these systems in place for patients that we treat. But what about us?" she said. "In hindsight, I'm going to say that we've done a poor job - and not for nurses - but the healthcare industry in general with helping to screen and maintain the mental health of our healthcare providers. There's already research about ICU fatigue and what that does to the nurses and the physicians in the ICU."
"I keep hearing that nurses are soldiers," Benjamin added. “But you don't send the soldiers into war without the proper equipment or guns or armor. I appreciate the analogy because I believe that it's meant with kindness and it's meant to celebrate us. However, I've been a nurse for 23 years. I know my job is to take care of people who can't otherwise take care of themselves. I've never looked at myself as a soldier, per se. We're there to care for people, and I just think that this whole situation has really shed some light on how broken and unprepared our healthcare system is when it comes to emergencies."
The CDC recognizes that COVID-19 can take an emotional toll on healthcare providers, and you may experience reactions and symptoms as a result of exposure to other's individual's traumatic experiences.
Here are tips from the CDC to reduce secondary traumatic stress reactions:
- Acknowledge that secondary traumatic stress can impact anyone helping families after a traumatic event.
- Learn the symptoms, including physical (fatigue, illness) and mental (fear, withdrawal, guilt).
- Allow time for you and your family to recover from responding to the pandemic.
- Create a menu of personal self-care activities that you enjoy, such as spending time with friends and family, exercising, or reading a book.
- Take a break from media coverage of COVID-19.
- Ask for help if you feel overwhelmed or concerned that COVID-19 is affecting your ability to care for your family and patients as you did before the outbreak.
Healthcare workers urgently need crisis counselors available on staff to help them manage mental health issues during the pandemic - Where are they?
Crisis counselors are able to help with emotional support, provide trustworthy guidance, and allow our healthcare workers to be more resilient. This would help dramatically with burnout and those suffering with moral injury. It would also help our healthcare workers continue to give optimal patient care.
Nurses have been expected to work in highly exhausting and stressful situations, often until they are completely run down or they start to show symptoms of having the virus. At the time of writing this article, I could not find a single hospital in the U.S. with on-site crisis counseling for healthcare workers during the pandemic. As this crisis has reached a breaking point in some facilities, it seems that on-site counseling would be an obvious step to help nurses and other healthcare workers who desperately need it.
We continue to hear speeches about how we need to help our frontline caregivers with mental health “after’’ the pandemic is over. But we are missing the point. Our healthcare professionals need mental health available - now - in the workplace, while they are fighting this crisis. The moral injury is happening now.
Mental Health Resources
If you know someone at immediate risk of self-harm, suicide, or hurting another person:
- Call 911 or the local emergency number.
- Stay with the person until professional help arrives.
- Remove any weapons, medications, or other potentially harmful objects.
- Listen to the person without judgment.
- If you or someone you know is having thoughts of suicide, a prevention hotline can help. The National Suicide Prevention Lifeline is available 24 hours a day at 1-800-273-8255.
Watching loved ones struggling with mental health issues during the COVID-19 crisis can make anyone feel helpless. Here are resources for loved ones, coworkers, and family members who may notice their frontline workers might be struggling with mental health.
National Suicide Prevention Lifeline
A national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress. They are "committed to improving crisis services and advancing suicide prevention by empowering individuals, advancing professional best practices, and building awareness."
- 800-273-8255 (available 24/7)
- Online chat: https://suicidepreventionlifeline.org/chat/ (24/7)
Other mental health hotlines and discussion communities:
- SAMHSA National Helpline: 1-800-662-HELP (4357) Disaster distress helpline - free, confidential, 24/7, 365-day-a-year treatment referral and information service (in English and Spanish) for individuals and families facing mental and/or substance use disorders.
- Mental Health America: This site has a free, online mental health discussion community. Discussion topics include mental health concerns, support for family and friends, and coping with mental health stigma.
- Crisis Text Line: Text “HELLO” to 741741. This hotline is available 24/7 throughout the U.S. This line is for anyone in any type of crisis, and will connect you with a crisis counselor who will provide support and information.
Mental health apps and virtual support:
- X2: a mental health app for individual people or businesses that helps reduce anxiety and depression with online chat. Their mission is to “provide affordable, quality mental health support, regardless of income or location.”
- Mind Shift: a mental health app for anxiety for young adults that focuses on avoiding anxious feelings and changing how you think about anxiety
- CBT Thought Record Diary: an app to record negative and distorted thinking patterns, identify negative thinking, and reevaluate your thoughts. It helps to gradually change thinking patterns and approaches to situations causing anxiety.
- Talkspace Online Therapy: an app for people who can’t afford a therapist but need to talk. You are able to text a trained therapist as often as your need to and receive daily responses (prices range from $65- $99/week).
- Breathe2Relax: Created by the National Center for Telehealth and Technology, this app helps remind us to breathe and that we are OK. It teaches stress management through diaphragmatic breathing and lower “flight or flight” response. Helpful option for managing PTSD.
- Headspace: An app with hundreds of meditations for stress, anxiety, sleep, and focus. It helps to teach mindfulness in a few minutes every day.
- Calm: A mental health app with guided meditations, breathing programs, and relaxing music. Named by Apples as the 2017 iPhone app of the year.
- Ten Percent Happier: A mental health app that claims to make you ten percent happier with guided medications for anxiety, stress, parenting, sleep, and inspiration
- Woebot: A depression and anxiety reduction program built by Stanford psychologists with cognitive behavioral therapy tools they used with patients in clinic.
Or you can discover an app that is right for you with PsyberGuide, a“non-profit organization, with a mission to help consumers choose effective and accessible mobile health technologies.” This app reviews mental-health apps and digital tools. Each has a score for credibility, user experience, and even how transparent the apps are about data storage.