Another grim milestone has been reached during the COVID-19 pandemic; close to 1 million deaths from COVID-19 were reported in the United States, more than in any other country in the world.1

We do not have to look far for evidence of collateral damage suffered by the frontline health care workforce from the COVID-19 pandemic. These providers come with resilience, commitment, and acceptance that the conditions they work under will be challenging. However, the COVID-19 pandemic has been unprecedented in the toll it has taken on the health care workforce.

Moral distress and moral injury in frontline health care providers are similar to that experienced by combat veterans. In the case of the pandemic, critical care providers who were found to be at higher risk for symptoms of moral injury were younger in age, spent less time in practice, and had higher levels of anxiety and depression as well as burnout.2

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This level of stress and anxiety is also reflected in the results of an online survey conducted by The Clinical Advisor between January 7 and March 3, 2022. The survey accompanied my article COVID-19 and Moral Injury: a Mental Health Pandemic for Frontline Health Care Workers.3 A total of 478 nurse practitioners (NPs) and PAs responded to the survey.

The first question asked about symptoms of COVID-19-related moral injury; 90% of respondents acknowledged they have experienced symptoms such as insomnia, depression, anxiety, panic attacks, posttraumatic stress disorder (PTSD), and suicidal thoughts (Question 1).

Respondents who reported these symptoms were then asked if they had sought professional help from a mental health professional. Sixty-five percent (n=297) said no and 35% (n=161) said yes. (Question 2). When asked, “Has mental wellness and the emotional wellbeing of you and your colleagues been a priority of your employer,” 81% of respondents said “no” (Question 3).

The immediate challenge going forward is to identify what strategies and interventions need to be put in place to provide a safety net and salvage a critically injured health care workforce. The potential loss is already present as clinicians are choosing to leave the health care profession. Many of those who can are deciding to retire. Others are pursuing other clinical care settings outside of critical care.

Recognition in this area must include the need for targeted therapeutic interventions and support for those experiencing moral injury to prevent functional impairment as a result of depression, anxiety, and PTSD.

What Do Health Care Workers Want?

Shanafelt et al conducted a study of the expectations and needs of health care workers (physicians, nurses, advanced practice clinicians, residents, and fellows) during the first week of the pandemic at one hospital in New York City.4 The authors identified the following 5 requests of their employer: hear me, protect me, prepare me, support me, and care for me.

These “asks” have not changed over the course of the pandemic. For example, when The Clinical Advisor readers were asked to provide comments to the survey, some respondents cited work from home, availability of wellness coaches, online zoom peer-support meetings, and counseling as morale boosters. Others expressed frustration at being asked to work longer hours for less pay in unsafe environments.

Hear Me

In the study by Shanafelt et al, “hear me” was one of the top requests respondents had of their organizations. Their ask was to have input and feedback and be assured their voices were being heard and they were being included in the decision-making process addressing the challenges of the pandemic.4

Respondents to The Clinical Advisor survey also noted:

“Superficial things [have been offered] like having counseling and listening sessions but no real change. Less staff and same expectations for metrics as prepandemic when staffing was always lean. Now we work with half the staff for double the patient visits per day.”

“They have tried and clearly want to support us, but I don’t think they really know what to do.”

Protect Me

Many health care workers also lacked access to sufficient personal protective equipment (PPE) and testing. If they did become ill, many health care workers who responded to the survey and in the study by Shanafelt et al questioned whether they could ask for and be given the needed time off with understanding and support and without judgment. Changing policies and lack of communication left some to wonder about support from leadership.4

A survey respondent wrote: “Employers push us to see more patients each day because of COVID-19 to help keep [the patients] out of the emergency departments. They push [us to work] more with fewer staff members and then send messages to take care of our mental health, but they don’t support this in actions.”

Prepare Me

Most health care providers on the frontline have never experienced anything like the overwhelming challenges they faced with COVID-19 patients. These included changing protocols, shortages of PPE and supplies, feelings of powerlessness and hopelessness, inability to provide the standard of care to their patients, and overwhelming numbers of patients dying alone, separated from their families.

Their “ask” was for management and leadership to provide them with training and resources, to give them permission to ask for help, and for leadership to communicate honestly and with transparency.4

Support Me

The expression that the pandemic is a marathon and not a sprint has been repeated many times. Self-care is frequently overlooked. However, when frontline health care workers ask for support they are also asking for recognition of their own physical, mental, and emotional limitations; they ask for time off, the need for “rest” in order to reset. Frontline health care providers face not only demands at work but the challenge of meeting personal and family needs.

Their “ask” is for leadership to make a difference by recognizing their limitations and supporting them as they seek help professionally and personally. For some, the reluctance to seek help from mental health professionals may be related to determination to be self-reliant or fear of judgment or stigma. The survey results showed 90% of respondents were experiencing stress-related symptoms but only 35% reported seeking help from a mental health professional.

“There is the acknowledgment of the huge emotional burden and burnout. There are people we can reach out to if we need help. But being understaffed and having wages locked has caused me to seriously consider retiring early,” noted one respondent.

Care for Me

Early on in the pandemic, nurses and frontline health care providers were hailed as heroes. As the pandemic has entered its third year, they do not feel like heroes. They cope with the moral distress of not being able to provide the care they want to for patients and families and the conflict between what they want to do and can do.5

For many clinicians, what is needed is an expression of gratitude, recognition of their commitment to go “above and beyond.” Humanness, support, and empathy is needed from leadership at a very personal level for the sacrifices they have made. A need to not be taken for granted.6

“Some programs have been provided but all online resources, nothing to support leaders on the frontline of health care,” said one survey respondent. Another wrote: “They try to give us breaks and incentives, however, there are just too few workers and too much work with little compensation.”

School Nurses Affected by Moral Injury

One respondent to the survey said: “School nurses are being forced to tell families to send kids to school when they know it is not a safe environment. To tell kids to return on day 5 when they know children test positive on day 8, to not be able to keep up with contact tracing because numbers are too high. Not ‘frontline’ but severely impacted.”

Another wrote: “We have been expected to work past our contracted hours, weekends, holiday breaks. We have been expected to let parents and staff members verbally assault us over policies that have been in place by local, state, and federal health agencies. No one cares if there will be plenty of nurses to care for them or their loved ones until there is not.”

Finally, there is empowerment in an expression of recognition and gratitude that honors frontline clinicians’ commitment to the work they do and compassion for those they take care of. Messages of gratitude are carried forth by the media and the public. Frontline providers also need to hear that same gratitude expressed with empathy and sincerity by management and leadership.6

“Pizza is not enough,” wrote one respondent. Clinicians need to know those same leaders hear them and will respond to their need to be heard, protected, prepared, supported, and cared for as they continue to put themselves on the frontlines during the COVID-19 pandemic.4

Catherine R. Judd, MS, PA-C, CAQ-Psy, DFAAPA, is an assistant clinical professor in the Department of Physician Assistant Studies at the School of Health Professions, The University of Texas Southwestern Medical Center, Dallas, Texas.


1. Coronavirus Resource Center. COVID-19 data in motion. Johns Hopkins University of Medicine. Accessed March 2, 2022.

2. Mantri S, Lawson JM, Wang Z, Koenig HG. Prevalence and predictors of moral injury symptoms in health care professionals. J Nerv Ment Dis. 2021;209(3):174-180. doi:10.1097/NMD.0000000000001277

3. Judd CR. COVID-19 and moral injury: a mental health pandemic for frontline health care workers. The Clinical Advisor. Accessed March 2, 2022.

4. Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA. 2020;323(21):2133-2134. doi:10.1001/jama.2020.5893

5. Hossain F, Clatty A.  Self-care strategies in response to nurses’ moral injury during COVID-19 pandemic.  Nurs Ethics. 2021;28(1):23-32. doi:10.1177/0969733020961825

6. Horan KM, Dimino K. Supporting novice nurses during the COVID-19 pandemic. Am J Nurs. 2020;120(12):11. doi:10.1097/01.NAJ.0000724140.27953.d1

7. Singer T. Klimecki OM. Empathy and compassion. Curr Biol. 2014;24(18):R875-878. doi:10.1016/j.cub.2014.06.054