‘Moral injury’: Hospital staff resigning over stress of enforcing visitor bans


Dr Danielle Ko

The challenge of enforcing pandemic visitor restrictions has led widespread “moral injury” and even resignations of some hospital staff, the clinical ethics lead at Austin Health says.

While patients in palliative care have always been allowed visitors at the health service in Melbourne’s north, strict rules were imposed early in 2020, reducing access for palliative patients and effectively banning outsiders for the rest.

There were always some exemptions and restrictions eased over time, although patients are still limited to four visitors per day in most cases. Suspected or confirmed cases of COVID-19 can have one visitor daily in full PPE, provided nursing staff agree.

Nevertheless, doctors and other staff are still struggling with the emotional rollercoaster of managing patient requests to see their loved ones, says Dr Danielle Ko, who is also a palliative care consultant at the Austin Hospital.

“At various times over the last two years, there have been days when I feel fine about the visitor policy and others where I’ll be in tears,” she says.

“And that continues because there’s a really considerable burden on staff decision making even with a clear policy.”

Speaking at the RACP congress in Melbourne last month, Dr Ko stressed she was not arguing for a free-for-all, nor did she criticise the decision to impose restrictions during the pandemic.

“There are no ‘right’ decisions around visitor restrictions,” she said.

“These are ethical dilemmas because we’re facing equally unappealing paths forward and dealing with ongoing aggression from frustrated families.”

However, it was hard to overstate the anguish felt by frontline staff as they were confronted by distressed patients and their family and friends, Dr Ko said.

“All the visitor restrictions caused distress, not only for the dying patients. If you have a loved one and you have to drop them off at ED and don’t know what’s happening, of course you want to be with them.”

“And that anger and frustration from patients is totally understandable,” she said. “So you would take it, because you could actually relate and think ‘if I was in that position, I would also feel that way’.”

Dr Ko said this distress was acutely felt in palliative care, despite its greater flexibility on visitors compared with the rest of the hospital.

“Many of the palliative care staff have considerable moral injury and quite a few staff have quit, citing the visitor restrictions as one of the biggest factors,” she told the conference.

“The time spent enforcing and discussing visitor restrictions has been phenomenal. At times, junior officers spent at least half their days taking about visitor restrictions, why they were in place and why people couldn’t see their loved ones as much as they wanted to.”

“They were exposed to a lot of very sad and angry families.”

Visitor bans in other wards presented other challenges, not least because of the increased stakes on decision making around the transition to end-of-life care.

A particular focal point for this was the hospital’s nursing unit managers, although even junior doctors occasionally found themselves faced with huge moral questions, Dr Ko said.

“There are people in the cancer wards for instance, who look like they are about to die and can either come good again or deteriorate suddenly,” she said.

“Doctors, including juniors had to ask ‘should I make them end of life so they can have visitors or continue treatment which doesn’t look like its working?’ If you don’t call it, and the patient dies earlier than expected, their loved ones will never get the chance to say goodbye in person.”

“I can’t even imagine the number of staff who are still living with those decisions.”

“I am a senior doctor and have seen a lot of dying patients, but even so it can be difficult to predict when someone is at end of life. I had two patients whose death came more quickly than expected. As a result, families were not around when they died and that is something I carry with me every day.”

Junior staff on Austin Hospital’s palliative care units sometimes spent half their days discussing visitor restrictions, Dr Ko says.

Reflecting on the past two years, Dr Ko stressed restrictions had been well supported by hospital staff at the beginning of the pandemic given the then-shortages of PPE and lack of vaccines.

“Staff were pretty happy about shutting visitors out, notwithstanding we knew it was horrible to do and didn’t feel right,” she said.

“But as things changed, with vaccines reducing the risk to staff and as we were allowed to do more in life, there was a lot of moral distress.”

“I would feel bad for the patients and their families. Struggling with these decisions myself, and watching the considerable burden on my colleagues even with a clear policy was hard to watch.”

“Then when restrictions first eased, the poor security staff and the frontline staff became completely overwhelmed and people were waiting hours.”

Nevertheless, she said there had been some positives, adding it was the first time that staff safety became codified as a top priority for the health service.

Formal systems were also put in place to move decisions on visitor restriction exemptions out of the hands of frontline staff, allowing them to focus on patient care, Dr Ko said.

“We learned we really need a clear and transparent policy, with regular review to ensure it’s proportionate,” she said.

“You need efficient escalation processes, and people need to know who to escalate to in a timely manner. You need fair exemption processes and timely communication to staff and patients.”

Dr Ko said failures to give staff time to prepare for changes led to a “predictable spike in aggression”.

“We also learned the importance of providing a forum for staff to express their distress and understand their reasons. This was helpful, even if we didn’t have any definitive answers,” Dr Ko said.

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