The consequences of coronavirus disease 2019 (COVID-19) continue to evolve, with approximately 8.2 million confirmed cases and 445,000 subsequent deaths worldwide as of June 17, 2020 (Johns Hopkins University, 2020). Discussion on leveraging the nursing role and promoting nurse leadership in this time of health system strain continues to emerge (Daly et al., 2020; Rosa et al., 2020). The long-term consequences on health care workers—particularly on nurses as the professionals who spend the highest proportion of direct patient contact time—is yet to be determined.
Similar to a patient experiencing the myriad dimensions of grief, many health care workers are going through their own stages of denial, anger, bargaining, depression, and—just maybe—acceptance (Kübler-Ross, 2011). The internal sense of courage discovered within nursing during COVID-19 has given new meaning to the World Health Organization designated 2020 Year of the Nurse and the Midwife. The nursing workforce is likely to experience high rates of burn-out, moral suffering, and attrition. In the face of moral adversity, there is a need for continued guidance on how to minimize these negative mental and emotional outcomes for nurses to maintain and enhance well-being, deliver quality patient care, and foster a culture of moral resilience (American Nurses Association, 2020; Rosa et al., in press).
Moral resilience is defined as the ability to preserve or restore integrity in response to various types of moral adversity (Rushton, 2018). The COVID-19 pandemic has created numerous types of moral adversity for frontline clinicians, including tensions created by allocation of scarce resources, such as personal protective equipment; medical equipment, such as ventilators or extracorporeal membrane oxygenation; treatment modalities, such as dialysis, blood transfusions, or medications; and clinician shortages in the face of escalating numbers of patients requiring COVID-19–associated care. Concurrently, many clinicians are confronted with new ethical challenges that call into question their ethical obligations to patients, their loved ones, and themselves as they consider the risk of exposure, illness, and death due to COVID-19.
Being able to confront these challenges without abandoning core values, personal commitments, and professional obligations is critical. In addition, nurses should be conscious not to exceed individual emotional or professional capacities in a way that inadvertently contributes to moral suffering, for stability and clarity is central to moral resilience. For many nurses, emotional exhaustion or overload will be unavoidable in the context of COVID-19. Although there are a number of system-level factors required to protect and promote the well-being of nurses, the system has fallen short again and again throughout the pandemic response. We want to empower clinical nurses to identify their own plan for well-being and self-preservation amid the consequences of the crisis and an uncertain future.
Preserving personal health integrity is strengthened by committing to self-regulatory skills and practices. Being able to attune to our inner mental and emotional experiences in the moment and to respond skillfully to what is in front of us creates the foundation for actions that are consistently informed by integrity. Unless health care organizations invest in systemic programs that enable these skills, the burden of responsibility falls to individuals.
Practices and Recommendations to Promote Staff Well-Being and Resilience
Using interventions offered by the integrative medicine (IM) department at a community-based hospital in Washington, D.C., we offer several concrete practices and recommendations to promote staff well-being and moral resilience. This IM department emerged from a pilot study offering acupuncture, yoga, and massage to patients with cancer undergoing disease-directed treatment. In approximately 2 years, the IM service has offered more than 5,500 visits to support patients with burdensome oncology-related and/or chronic medical symptoms and empower them in recognizing their own sense of self-efficacy and innate capacity to heal.
We cannot underestimate the influence of lifestyle on one's experience of health (Jonas, 2019; Kreitzer & Koithan, 2019). Finding time for self-care is challenging at baseline—never mind during a global pandemic. The IM department is aligned with work-place excellence strategies to provide employees the opportunity to attend meditation practice and receive acu-puncture, yoga therapy, or massage therapy without leaving campus. The weekly guided mindfulness meditation session allows a non-hierarchal space for hospital workers and patients. Allocating fiscal and human system-wide resources to provide services for staff self-care during the COVID-19 crisis is imperative, requiring nurse leader advocacy for necessary funds and innovative mechanisms to ensure staff access. If there is no time for self-care, patient care is almost certain to suffer.
For Now, Just Breathe
An IM clinician, also serving as a system champion for wellness, offers 15-minute breathing sessions three times per week via teleconference for anyone working within the health system. The program is called “For Now, Just Breathe.” This session is a reminder that no matter the intensity of work, one can momentarily focus on the breathing practice to intentionally regulate the parasympathetic nervous system and focus on “Rest, Digest, Repair,” countering the more common “Fight, Flight, and Freeze.” The sessions have normalized the need to take a break, to breathe, to nurture the importance of pausing during the craziness of the day and disrupt schedules to alleviate staff suffering. The role of Dr. Weil's breathing techniques, particularly the “4-7-8 technique,” has been invaluable to relax the mind, reduce stress and anxiety, and enhance focus (Gonzalez, 2016).
Finding the opportunity for gratitude may seem trite as the incidence of COVID-19 continues to swell. It is necessary to cry, scream, grieve, and express. Through it all, gratitude remains a simple yet powerful practice to heal, energize, and empower. It magnifies positive emotions by seeing what is present and turning off the mind to draining emotions, such as envy or resentment. Ultimately, seeing the goodness available in life, acknowledging where it comes from, and giving credit to its source is a practice (Emmons & Mishra, 2012). Researchers found that when health care workers reflected on at least three good things that happened in a given day, this reflection improved well-being, which might strengthen resilience (Rippstein-Leuenberger et al., 2017). Encouraging gratitude practices for teleconference attendees of the breathing sessions created a forum where staff shared heartwarming gratitude statements for self and others, inviting connection among participants, increased positivity, and self-compassion. Kindness and camaraderie have become more obvious as the team cares for each other, reminding them to pause, share, and reflect.
There is sure to be substantial and long-term nurse suffering throughout and beyond the COVID-19 pandemic. We must all commit to creating environments for each other to care for ourselves without guilt, worry, or strain. Taking our power back to preserve the workforce and ensure the continuity of care requires a culture of moral resilience. This culture shift starts with making time for ourselves in concrete ways; concentrating on our breath and the present moment; and expressing our pain while also focusing on the parts of our work that bring us joy and meaning. We must remind our systems that they are responsible for our well-being and advocate for policy change that supports clinical nurses across specialties. But in the meantime, we must focus on caring for ourselves and each other.
Harpreet Gujral, DNP, FNP-BC
Program Director and Nurse Practitioner
Sibley Integrative Medicine
Sibley Memorial Hospital
Johns Hopkins Medicine
Cynda H. Rushton, PhD, RN, FAAN
Anne and George L. Bunting Professor of
Professor of Nursing and Pediatrics
Johns Hopkins University
Berman Institute of Bioethics/School of
William E. Rosa, PhD, MBE, NP-BC, FAANP,
Robert Wood Johnson Foundation Future
of Nursing Scholar
University of Pennsylvania School of
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