Moral Distress, Building Resiliency, and Supporting Health Center Staff During COVID-19’s Winter Surge

Exhausted health care worker

Nine months into the COVID-19 pandemic and a time when positive cases and deaths are steadily increasing, community health center staff at all levels are grappling with a range of emotional, physical, and mental stress. Regardless of whether health center staff are working remotely or onsite, many are feeling overwhelmed, frustrated, fatigued, and burned out. Staff are also sensing sadness and grief for patients whom they have lost or who have lost family members and are experiencing a sense of helplessness that they are not doing enough for their patients or staff.  Additionally, not being able to deliver the care one believes is good and right can create a moral dilemma that is experienced as moral distress.

Moral distress and moral injury are emotions and bodily changes (i.e., insomnia or loss of appetite) that accompany a disconnect between what you believe is right and good and what you are able to do or what you see happening around you.   

As Grace Wang, MD, MPH, a family physician at International Community Health Services in Seattle, Washington, explains: “Our work in the health center is part of the overall health system. We sometimes find ourself in situations where we know what to do and we want to do the right thing but we can’t. This is very difficult and takes its toll.”

1. Name it.   
2. Find time to talk about it.
• Carve out time during team meetings to discuss the situation causing you moral stress
• Task specific team members to facilitate conversations about challenging and frustrating situations that are at the root of moral distress  
3. Recognize early clues such as:
• Use of words ‘should’ or ‘ought’ are important clues that values are at stake
• Emotions that range from anger to guilt and shame
• Knowing the right thing to do but experiencing constraints to doing it

4. Educate clinical teams about preventative strategies including: 
• Buddy up to watch out for each other
• Create a safe place to talk
• Develop team cues for asking about and acknowledging moral distress

5. Try team exercises in Conversations About Moral Distress and Moral Injury   
Adapted from the presentation, “Taking Care of the Compassionate Care Team: Conversations About Moral Distress and Moral Injury,” by Gerri Lamb, PhD, RN, FANN, Arizona State University for Advancing Interprofessional Practice, Education and Research, March 26, 2020.    

Supporting Team Wellness
Great efforts by leadership teams, staff managers, and directors at health centers and their affiliated health care systems and hospitals are underway to support team wellness and build resiliency at both individual and group levels. Several examples shared by Jessica Wallace, PA, at Denver Health’s Montbello Family Health Center, include:

  • Senior leadership providing clear, transparent, and regular communication and sincerely acknowledging how hard people are working.
  • Medical leadership keeping everyone informed with daily COVID-19 updates
  • Staff utilizing RISE, or Resilience in Stressful Events, for access to resources that can help them face stress in their work environment. (The program was developed by Johns Hopkins University and went live at Denver Health earlier this year prior to the COVID-19 pandemic.)
  • Expanding RISE peer/volunteer-run support groups

Primary Care Associations (PCAs) are also doing their part to help reduce some of the workloads and pressures at health centers in their states. Lori Dumke, MSN, RN, Director of Clinical & Quality Services, Community Healthcare Association of the Dakotas, says that CHAD is trying to take as much off the health centers’ plates as possible and on several fronts, such as:

  • Providing free behavioral health counseling and resources via phone, text, Facebook messenger, and email
  • Distributing updates from each state’s 3 weekly COVID-19 meetings because health center staff do not have the time to participate
  • Sharing of policies and procedures discussed during monthly Quality Improvement Group meetings so that health centers can learn from each other and do not have to reinvent the wheel
  • Hosting COVID-19 response scenario planning sessions during the summer before COVID-19 rates sharply increased in both North and South Dakota.

Building Resiliency
Building resilience can help many healthcare providers and staff manage the many challenges and stresses they are facing professionally and personally.

In the recent University of New Mexico’s Project ECHO COVID-19 Global Learning Collaborative presentation, Managing Stress and Burnout during the COVID-19 Pandemic, Jeff Katzman, MD, Professor, University of New Mexico, Department of Psychiatry, highlighted several ways health care teams can build resiliency individually and as a team.

These recommendations include:

  • Make a plan (e.g., What if I get the virus, what if a family member gets the virus, etc.) Turn to that plan instead of fear
  • Have calm and transparent conversations
  • Limit the news
  • Honor genuine emotions and find people to validate them
  • Identify passivity and fatigue and do something

There is no question that the COVID-19 pandemic is testing health centers unlike any other time in history. However, health centers and their staff can and are responding—from the top leadership on down to peer support groups and there are a wide range of resources to help health centers strengthen their current strategies and approaches. If you or your health center needs guidance in addressing moral distress, building resiliency, team wellness, and other behavioral health challenges, contact CMO@NACHC.org.