Distressed Work: Chronic Imperatives and Distress in Covid‐19 Critical Care

Abstract

This ethnographic study introduces the term “distressed work” to describe the emergence of chronic frictions between moral imperatives for health care workers to keep working and the dramatic increase in distress during the Covid‐19 pandemic. Interviews and observant participation conducted in a hospital intensive care unit during the Covid‐19 pandemic reveal how health care workers connected job duties with extraordinary emotional, physical, and moral burdens. We explore tensions between perceived obligations of health care professionals and the structural contexts of work. Key findings cluster around the moral imperatives of health care work and the distress that work engendered as work spaces, senses of vocation, patient and family interactions, and end‐of‐life care shifted. While the danger of working beyond limits has long been an ordinary feature of health care work, it has now become a chronic crisis. Assessing this problem in terms of distressed work and its structural contexts can better address effective, worker‐informed responses to current health care labor dilemmas.

Support for clinicians with moral loss after the pandemic

“…When clinicians’ agency is constrained or undermined, as occurred in the pandemic, a sense of moral disorientation arises involving a loss of coherence between their sense of moral identity and imposed workplace requirements 1. As clinical ethicists working in large metropolitan hospitals in Australia we observed loss of moral identity and agency, moral distress, and moral injury among clinicians (box 1).…”

“…For example, delaying cancer surgeries and stopping cancer screening services because of government mandated restrictions was frustrating and distressing for staff who believed the long term consequences and burdens for these patients were greater than the benefits of preventing covid infections 15. Staff were redeployed, their responsibilities were changed, and in some situations they lost professional control over care decisions 135612…”

“…A UK mixed-methods survey study of 257 NHS staff in a single organisation and a US based qualitative study both found that staff burnout and moral distress were linked to loss of control of their work through imposed redeployment and new working patterns 15. A Chinese survey study similarly concluded that a substantial proportion of clinicians in the region were at risk of moral injury symptoms, and that clinicians caring for patients with covid-19 experienced a 28% greater risk than their colleagues caring for other patients 12.…”

“…These studies highlight that being required to care for patients in ways that conflicted with fundamental health ethics values of patient centred care was distressing for clinicians, inducing feelings of shame and guilt and a loss of moral identity 1416. When clinicians are prevented from doing what they believe is right for their patient by a workplace authority (eg, health administrators or governments) their moral distress may lead to an erosion of trust in self and in leadership,17 feelings of professional powerlessness,5 and loss of professional integrity to be able to perform their role in accordance with their values 1. While many of the underlying factors causing distress among healthcare staff were present before the pandemic and are likely to continue as health systems face backlogs and workforce shortages, the intense and large scale disruption caused by covid-19 greatly worsened the situation, tipping clinicians into a state of moral loss.…”

“…Much of the focus on the state of health services since the height of the pandemic has been on healthcare financing, workforce shortages,12 and physician burnout 345. Less attention has been given to the physical, psychological, and moral distress healthcare workers experienced because of increased and changed work demands,6 personal protection requirements,7 and isolation from peers and workplace supports 4.…”