DURHAM, N.C. — Years into the pandemic, doctors and nurses are reporting symptoms that resemble those experienced by men and women in the military after tours of duty. And thirteen North Carolina counties are reporting a high risk of COVID-19 as the virus shows no signs of giving health care professionals a break. 

What You Need To Know 

A phenomenon called moral injury showed up in health care workers during and after the pandemic 

Moral injury is what experts describe as a transgression against one's own moral code 

Watching someone die without the ability to intervene can lead to feelings of helplessness 

Post traumatic stress disorder is a condition where a person has difficulty recovering from a terrifying event, either as a victim or a witness.

While many health care workers may have the nightmares and other symptoms of PTSD, they're also dealing with something equally troubling and complex called moral injury.

Feelings of helplessness, guilt and anger that come with following protocols may violate a person’s sense of right and wrong.

Duke University Hospital’s Dr. Elizabeth Hankollari said there were many days where she felt a behavioral shift in herself and colleagues when some outcomes were far beyond her control.

“Something that made us feel like we may have to make decisions that otherwise we wouldn’t be making. That might be contrary to what our personal beliefs and value systems would be, which would be to help everyone with whatever we have,” the doctor said.

Suiting up for the work shift against a deadly virus during a public health disaster day after day, month after month, year after year, takes its toll on even the toughest professionals.

"Then you add the physical exhaustion of being at work more. The uncertainty at work, which is really stomach churning in a way. When you walk into work you can feel the difference, I can remember after it was declared a pandemic and an emergency — you could see it at work," Hankollari said.

Hankollari is the medical director of internal medicine at Duke University Hospital for the non-critical care COVID-19 unit.

"This is why doctors, nurses and pharmacists and everyone in health care works for … we want to be able to step up in a crisis,” she said.

The medical director is part of a nationwide trend regarding work schedules in the heart of the pandemic. Medical systems around the world, much less America, have widely reported increased hours on the job for nurses and doctors working the frontlines.

“At the end of the day, if you have people who are used to doing a certain amount of work, and then you increase their workload while increasing their stress and anxiety outside of work — which my workplace could not control — I think you are just going to get more burnout, and I think we have definitely seen that,” she said.

COVID-19 also turned health care professionals into enforcers, banning visitors from bedsides when families needed them most.

"I think there were definitely times, especially when we were struggling with things, watching patients die by themselves, alone in the hospital without family being able to visit them,” she said.

All the personal protective equipment in the world can’t protect the heart.

While guidelines offered physical protection from the novel coronavirus, health care workers are human. An uncontrollable situation could spiral into a state of persistent grief and shame.

This self-transgression was first reported by clinicians in combat veterans who had returned home from war. The battle-hardened serviceman often spoke of feelings of powerlessness when they followed a command that broke from their own moral code.

"You saw this side of the pandemic that other people didn’t see and know about and you have to carry that with you and by the way you better get back to work — so don’t sit there and mull it over too long because you have other patients to see —you get a page about someone whose oxygen is dropping in room 10, and you have to go over and see them,” she said.

The American Psychiatric Association defined moral injury in medicine as a moment or moments in the course of providing care when a clinician must make a choice that goes against their core beliefs. Watching a patient die alone is a traumatic experience that may create deep emotions of shame and isolation in that health care worker.

"My family, who was not in medicine, just would not understand how I felt when I came home that day, and I had a patient that died and their family wasn’t able to be with them. That felt so wrong,” she said.

The American Association of Critical Care Nurses recently surveyed more than 6,000 nurses. Two-thirds reported that their pandemic experiences caused them to consider leaving the profession. The doctor said it’s hard to come back to work when the sick and suffering you care for don’t like the advice you are offering – such as unvaccinated patients or people who don't even believe in COVID.

"The kind of anti-vaccine sentiment that we heard. It really made us feel like the public, our patients and family sometimes didn’t…it made it feel like they didn’t trust us and that was really hurtful,” the doctor said.

Hannkollari said she remembers seeing the long looks on the faces of nurses in her unit.

"I remember one day sitting at my workstation after a patient had passed away, and I felt like, how can I go back to work right now?’" she asked aloud.

Another component of moral injury can be the persistent fear of infecting family members. The doctor even mentioned how her young daughter wondered about her mother’s health.

"I found out later she would say, ‘Mommy, I was afraid you were going to get COVID and die,’ which is hard to hear from an 8-year-old or 7-year-old or however old she was when this all started. She didn’t share that with us because I think she even sensed that mommy’s under a lot of pressure and stress, and I don’t want to bring something up that might make that worse,” she said.

Specialists in behavioral and mental health believe there are many ways to better care for the people – nurses, doctors, and more – who are providing the care in the future.

“We were not just doctors but we were — I don’t want to say victims of the pandemic — but we were facing all the same uncertainty as everyone else in society."

Some other reasons for moral injury could be hospital staff panicking about a shortage of resources, like personal protective equipment. Hankollari said thankfully that she didn’t experience that at her workplace.