Experiences of staff providing specialist palliative care during COVID-19A multiple qualitative case study

Abstract

ObjectivesTo explore the experiences of, and impact on, staff working in palliative care during the COVID-19 pandemic.DesignQualitative multiple case study using semi-structured interviews between November 2020 and April 2021 as part of the CovPall study. Data were analysed using thematic framework analysis.SettingOrganisations providing specialist palliative services in any setting.ParticipantsStaff working in specialist palliative care, purposefully sampled by the criteria of role, care setting and COVID-19 experience.Main outcome measuresExperiences of working in palliative care during the COVID-19 pandemic.ResultsFive cases and 24 participants were recruited (n=12 nurses, 4 clinical managers, 4 doctors, 2 senior managers, 1 healthcare assistant, 1 allied healthcare professional). Central themes demonstrate how infection control constraints prohibited and diluted participants’ ability to provide care that reflected their core values, resulting in experiences of moral distress. Despite organisational, team, and individual support strategies, continually managing these constraints led to a ‘crescendo effect’ in which the impacts of moral distress accumulated over time, sometimes leading to burnout. Solidarity with colleagues and making a valued contribution provided ‘moral comfort’ for some.ConclusionsThis study provides a unique insight into why and how healthcare staff have experienced moral distress during the pandemic, and how organisations have responded. Despite their experience of dealing with death and dying, the mental health and well-being of palliative care staff was affected by the pandemic. Organisational, structural, and policy changes are urgently required to mitigate and manage these impacts.

Moral distress amongst palliative care doctors working during the COVID-19 pandemic: A narrative-focussed interview study

“…22 –24 During the COVID-19 pandemic, existing challenges were magnified while new constraints were imposed leading to increased levels of moral distress. 4,8,25 This study found that the limited visitation policy, PPE and physical distancing restrictions had a large impact on staff. Facial recognition and lip-reading are important for interpersonal reassurance in distressed patients and the presence of family and friends is well-known to benefit patients with delirium and dementia.…”

“…The moral distress doctors described had varying effects but at its worst, caused feelings of guilt and ineffectiveness, which supports previous research into the effects of moral distress. 8,22 Experiencing moral distress can lead to what is termed moral residue, the lingering emotional wound that can result, 27,28 or moral injury which has been defined as the profound psychological distress that follows when a person’s moral or ethical code is violated by actions, or lack of actions, taken. 29 The potential for moral injury is evident in the doctors’ accounts and may have profound consequences on their professional and personal well-being.…”

“…5 Studies in palliative care have shown an increase in anxiety and psychological distress amongst healthcare workers, 6 and a struggle to communicate and connect effectively with patients due to work pressures and national restrictions. 7 An emerging consideration in this context is moral distress, 8,9 which occurs when a person is prevented from taking the action that they believe to be morally right, 10 and has been shown to be prevalent amongst healthcare workers during the pandemic. 4 This study aims to present the narratives of palliative care doctors practicing during the pandemic and facilitate understanding of their experiences.…”