For Christina Nester, the pandemic lull in Massachusetts lasted about three months through summer into early fall. In late June, St. Vincent Hospital had resumed elective surgeries, and the unit the 48-year-old nurse works on switched back from taking care of only COVID-19 patients to its pre-pandemic roster of patients recovering from gallbladder operations, mastectomies and other surgeries.
That is, until October, when patients with coronavirus infections began to reappear on the unit and, with them, the fear of many more to come. "It's paralyzing, I'm not going to lie," said Nester, who's worked at the Worcester hospital for nearly two decades. "My little clan of nurses that I work with, we panicked when it started to uptick here."
Adding to that stress is that nurses are caught betwixt caring for the bedside needs of their patients and implementing policies set by others, such as physician-ordered treatment plans and strict hospital rules to ward off the coronavirus. The push-pull of those forces, amid a fight against a deadly disease, is straining this vital backbone of health providers nationwide, and that could accumulate to unstainable levels if the virus's surge is not contained this winter, advocates and researchers warn.
Nurses spend the most sustained time with a patient of any clinician, and these days patients are often incredibly fearful and isolated, said Cynda Rushton, a registered nurse and bioethicist at Johns Hopkins University in Baltimore.
"They have become, in some ways, a kind of emotional surrogate for family members who can't be there, to support and advise and offer a human touch," Rushton said. "They have witnessed incredible amounts of suffering and death. That, I think, also weighs really heavily on nurses."
A study published this fall in the journal General Hospital Psychiatry found that 64% of clinicians working as nurses, nurse practitioners or physician assistants at a New York City hospital screened positively for acute distress, 53% for depressive symptoms and 40% for anxiety — all higher rates than found among physicians screened.
Researchers are concerned that nurses working in a rapidly changing crisis like the pandemic — with problems ranging from staff shortages that curtail their time with patients to enforcing visitation policies that upset families — can develop a psychological response called "moral injury." That injury occurs, they say, when nurses feel stymied by their inability to provide the level of care they believe patients require.
Dr. Wendy Dean, co-founder of Moral Injury of Healthcare, a nonprofit organization based in Carlisle, Pennsylvania, said, "Probably the biggest driver of burnout is unrecognized unattended moral injury."
In parts of the country over the summer, nurses got some mental health respite when cases declined, Dean said.
"Not enough to really process it all," she said. "I think that's a process that will take several years. And it's probably going to be extended because the pandemic itself is extended."