The first years of the COVID-19 pandemic had a severe impact on the mental health of nurses, who were already struggling with low morale owing to low pay and understaffing. For many, the mental strain of working through the pandemic crisis did not end with the politicians' expedient claim that the pandemic is ‘over’ (even as the coronavirus continues to mutate, infect and kill). Although many celebrate the freedoms of the end of lockdown policies and mask mandates, those who bore, and continue to bear, responsibility for nursing critically ill patients through times of crisis are often left alone and unsupported to cope with the toll it has taken on their lives and mental health.
Among the costs for healthcare staff at the frontline of COVID-19 care are post-traumatic stress disorder (PTSD) and moral loss or moral injury. PTSD, suicidal ideation and suicide were recognised as risks to nurses on the frontline from the start of the pandemic (Chidiebere Okechukwu et al, 2020). Gabra et al (2022) found that nurses on the frontline of care for COVID-19 patients were significantly more likely to experience PTSD compared with other nurses (P=0.025). This was associated with the intensity of working during the crisis with inadequate breaks and a lack of institutional support.
Moral loss may be defined as a betrayal of what is considered right in a high-stakes situation (Walton et al, 2020). Delany and McDougall (2023) explained that moral loss occurs, for example, when a nurse must deny a family the right to visit their dying relative or when a nurse holds a dying patient's hand while the family is ‘present’ only via tablet computer.
The effects of PTSD and moral loss can continue long after the crisis situation is over. Nurses who experience PTSD or moral loss through their care for COVID-19 patients need much better support and acknowledgement than they currently receive.
Andrew Ridgway is a registered general nurse who worked in an intensive care unit (ICU) during both waves of the pandemic. The extreme experience of nursing in the shadow of so much illness and death – experiencing sorrow and fear, as well as love, loyalty and humour – remain with him.
His trust offered inadequate support, and to help cope with the intensity of his experiences, he resorted to writing poetry during the darkest days, jotting down notes of his feelings and memories after his shifts:
‘The world looks strange
Through the same eyes
So many finals
So many silent goodbyes
‘But everything changed for me
In such a short time
But not to be seen
Is the largest of crimes.’
Ridgway was profoundly changed by his experience of COVID-19 nursing. But the present is almost more difficult to bear because of the widespread expectation to ‘return to normal’ and to ‘put the pandemic behind us’. This constant demand denies those who experienced the most intense pain the right to grieve, to reflect and to heal.
Ridgway has now published a collection of his poems, which he hopes will help others to connect with their own experiences of the pandemic and work through their pain in their own way (Ridgway, 2022).
As much as we might wish to put the past behind us, ‘we beat on, boats against the current, borne back ceaselessly into the past’, to quote F Scott Fitzgerald in The Great Gatsby (1925). Without due reflection and acknowledgement, the traumas of the past will haunt the present and may create new terrors.
PTSD can kill, and the moral loss associated with the pandemic was experienced not only by nurses but also by all those dismayed by the deceit of politicians who claimed to lead us through those times.
We may not understand for a long time to come the full impact of these experiences on our society.
Ridgway's raw poems offer his readers a chance to connect with their own experiences of the pandemic and feel less alone. Sometimes, reading how someone else has dealt with their suffering, and with the very particular situations of moral loss that so defined the pandemic, can help us come to terms with our experiences of COVID-19 for ourselves.
We owe it to those nurses such as Ridgway who give so much to the care of others in desperate times at least to acknowledge the pain of their sacrifice. As Ridgway notes: ‘not to be seen is the largest of crimes.’
‘Those who bore responsibility for nursing critically ill patients through times of crisis are often left alone and unsupported to cope with the toll it has taken on their lives and mental health’