Federal Practitioner

The COVID-19 pandemic presented stressors for patients and health care professionals alike, and the prevalence of health care practitioner burnout and dissatisfaction has risen dramatically.^1,2 This, in combination with an increasingly virtual interface between patients and care teams, has the potential to lead to increased depersonalization, anxiety, distress, and diminished overall well-being among clinicians.^1,3 Within the Veterans Health Administration (VHA), women’s health primary care practitioners (PCPs) are specially trained clinicians thatprovide comprehensive care to women veterans. Data suggest that women’s health PCPs may experience higher rates of burnout and attrition (14% per year) compared to general PCPs in VHA.⁴ Burnout among PCPs, especially those working at VHA, is well known and likely related to poor interdisciplinary team structure, limited administrative time, high patient complexity, and isolation from additional resources (eg, rural settings).^4-7 Increased clinician burnout is associated with poorer quality of care and worsening quality of the doctor-patient relationship.⁸

The medical humanities can act as a countermeasure to clinician burnout.^9,10 Studies have demonstrated that physicians who participate in the medical humanities are more empathic and experience less burnout.^11,12 Engaging with patient stories through listening and writing has been a source of fulfillment for clinicians.¹³ Despite the benefits of narrative medicine, programs are often limited in scope in small face-to-face group settings during elective time or outside work hours.¹⁴ The COVID-19 pandemic presented significant challenges to implementing such programming. The VHA is a large health care system with many rural locations, which further limits the availability of traditional small-group and face-to-face trainings. Few studies describe large-scale medical humanities training in virtual learning environments.

NARRATIVE MEDICINE EVENT

To improve satisfaction and engagement among PCPs who care for women veterans, we developed, implemented, and evaluated a large-scale, virtual, interprofessional narrative medicine event aimed at achieving the following: (1) gain a deeper appreciation of the impact of deployments on women veterans; (2) describe the social and emotional challenges faced by women veterans returning from deployment (reintegration); (3) identify strategies to support veterans during reintegration; (4) apply narrative medicine techniques on a large-scale, virtual platform; and (5) assess clinician engagement and satisfaction following participation. We hypothesized that clinician satisfaction and appreciation would improve with a better understanding of the unique complexities of deployment and reintegration faced by women veterans. Utilizing a novel, humanities-based intervention would lead to strong engagement and interaction from participants.

Setting

A 3-hour virtual session was conducted on November 15, 2022, for an interdisciplinary audience. This included physicians and trainees in medicine and behavioral health, nurse practitioners, social workers, dieticians, nurses, and clinical support staff. The training was advertised via emails through established mailing lists and newsletters, reaching a large interdisciplinary VHA audience 90 days prior to the event. This allowed potential participants to dedicate time to attend the session. The training was open to all VHA employees, with no inclusion or exclusion criteria for either the training or the evaluation. The training was delivered within existing space utilized for continuing medical education in women’s health.

For the session, the 93-minute documentary Journey to Normal (jtninc.org) was chosen because it focused on the impact of deployment on women veterans and their experiences when returning home. The film follows the stories of several women veterans through combat and reintegration. The screening was split into 2 segments given the emotional impact and length of the documentary.

A facilitator opened the session by reading a series of reflective prompts centered on women veteran deployment, reintegration, and the stressors surrounding these transitions. The initial prompt served to familiarize participants with the session’s interactive components. Additional prompts were interspersed and discussed in real time and were chosen to mirror the major themes of the documentary: the emotional and psychological impact of deployment and reintegration for women veterans. Short responses and word cloud generation were used and debriefed synchronously to encourage ongoing engagement. Participants responded to prompts through anonymous polling and the chat function of the virtual platform.

During intermission, we introduced My Life, My Story (MLMS). MLMS is a VHA initiative started in 2013 that, with the veteran’s permission, shares a piece of a veteran’s life story with their health care practitioner in their medical chart.¹⁵ Evaluation of MLMS has demonstrated positive impacts on assessments of patient-clinician connection.¹⁶ The MLMS goal to improve patient-centered care competencies by learning stories of veterans aligned with the overarching goals of this program. Following the film, participants were given 10 minutes to respond to a final reflective prompt. The session ended with a review of existing VHA resources to support returning veterans, followed by a question-and-answer session conducted via chat.

We used the Brightcove virtual platform to stream this program, which facilitated significant interaction between participants and facilitators, as well as between participants themselves. In addition to posing questions to the session leaders, participants could directly respond to each other’s comments within the chat function and also upvote/downvote or emphasize others’ comments.

Evaluation

The evaluation schema was 2-fold. Because this session was presented as a part of the national VA Women’s Health webinar series, a standard evaluation was dictated by the VHA Employee Education System. This survey was electronically disseminated and included questions on occupational category and overall satisfaction, plus 9 standard evaluation questions and 4 program-specific questions tied to the workshop objectives. The standard evaluation questions assessed participant satisfaction with the training, satisfaction with the training environment, and appropriateness of the content. The programspecific questions asked the participants whether the session met the stated learning objectives. All questions used a 5-point Likert scale (1, strongly disagree; 5, strongly agree). Descriptive statistics were used for analysis. Individual chat messages and spontaneous replies were analyzed as a surrogate measures of audience engagement. A qualitative analysis of participants’ final reflections to assess for attitudes related to patient care, empathy, and burnout following participation in this curriculum is forthcoming.

A total of 876 participants attended the virtual setting and 525 (59.9%) completed the immediate postevaluation survey. Respondents represented a variety of disciplines, including 179 nurses (34.1%), 100 social workers (19.0%), 65 physicians (12.4%), and 10 physician assistants (1.9%), with < 10% comprising counselors, dentists, dietitians, pharmacists, physical therapists, and psychologists. Nearly all participants reported satisfaction with the learning activity, would recommend it to others, and felt it advanced their knowledge, attitudes, and skills to better contribute to their VHA interprofessional team for patient care (Table 1). Similarly, participants reported a highlevel of agreement that the program satisfied the session-specific objectives. In response to an open-ended question on the standard VA evaluation regarding overall perceptions of the training, free-text responses included such statements as, “I think this should be mandatory training for all VA [clinicians]”; and “This webinar [opened] my mind to the various struggles women veterans may encounter when [they] return to civilian life and [increased] my understanding of how I could support.”

More than 1700 individual chat messages and > 80 spontaneous replies between participants were recorded during the interactive session (Table 2). Spontaneous quotes written in the chat included: “This is the best film representing the female veteran I have ever seen;” “Powerful and perspective changing;” “Thank you for sharing this incredible film;” and “I needed this to remind me to focus on woman veterans. Although our female veteran population is small it will remind me daily of their dedication, recognizing that there are so many facets of making the ultimate sacrifice.” Several participants said such programming should be a mandatory component of VA new employee orientation.

DISCUSSION

Clinician burnout diminishes empathetic patient-physician engagement. Patients’ stories are a known, powerful way to evoke empathy. This session provides one of the first examples of a straightforward approach to delivering a medical humanities intervention to a large audience via virtual platform. As measured by its high engagement, participant satisfaction, and narrative evaluations, this model was successful in evoking empathy and reinforcing the core VHA values for patient care: integrity, commitment, advocacy, respect, and excellence.

Rates of burnout and disengagement among PCPs are high and increased during the COVID-19 pandemic.² This curriculum used a synchronous, narrative-based approach during work hours to address burnout. Lack of empathy is a cause and consequence of burnout and disengagement. Narrative approaches, especially those evoking patients’ stories can evoke empathy and help counteract such burnout. This curriculum demonstrates one of the first large-scale, narrative-based, virtual-platform approaches to utilizing patients’ stories for positive clinician impact, as evidenced by the extensive participation, engagement, and satisfaction of participants.

Individuals interested in implementing a similar program should consider common barriers, including time constraints, advertising, and clinician buy-in. Several key factors led to the successful implementation of this program. First, partnering with established educational efforts related to improving care for veterans provided time to implement the program and establish mechanisms for advertising. The VHA is a mission-driven organization; directly tying this intervention to the mission likely contributed to participant buy-in and programmatic success. Further, by partnering with established educational efforts, this session was conducted during business hours, allowing for widespread participation.

A diverse group of VHA clinicians were actively engaged throughout the session. Chat data demonstrated not only numerous responses to directed prompts, but also a larger extemporaneous conversation among participants. Additionally, it is clear participants were deeply engaged with the material. The quality of participant responses demonstrates the impact of narrative stories and included a new respect for our shared patients, a sense of humbleness as it relates to the women veteran experience, and a sense of pride in both the VHA mission and their roles as a part of the organization.

This session did not end with traditional take-home skills or reference handout resources typical of continuing education. This was intentional; the intended take-home message was the evoked emotional response and resultant perspective shift. The impact of this session on patient care will be examined in a forthcoming qualitative analysis of participants written reflections.

Limitations

Some participants noted that the chat could be distracting from the film. Others described that virtually attending the session allowed increased opportunity for interruption by ongoing patient care responsibilities, resulting in diverted attention. Many participants were granted protected time to attend this continuing education session; however, this was not always the case. Additionally, this evaluation is limited, as 40% of participants elected to not complete the postevent survey. The individuals who choose to respond may have been more engaged with the content or felt more strongly about the impact of the session. However, the volume of chat engagement during the session suggests strong participant involvement. The analysis was also limited by an electronic survey which did not allow more granular assessment of the data.

This session also raised an ethical consideration. The film evoked very strong emotional responses which, for some, were challenging to attend to personally in a large-scale virtual environment. Established clinician resources were highlighted during the session that were available for any participant who needed additional support. Participants were also encouraged to step away and process their emotions, if needed. Future interactions of this session might consider improved interparticipant chat management and upfront warnings about the emotional impact of the film accompanied by proactive dissemination of resources for participant support. One example of such resources includes breakout rooms facilitated by trained counselors. Prompts might also be adjusted to allow for more guided interparticipant engagement; facilitation can be brief as participants’ responses often carry the conversation.

CONCLUSIONS

This study shows that a large-scale, virtual medical humanities intervention is not only possible but well received, as evidenced by both quantity and quality of participant responses and engagement. The narrative approach of hearing patients’ stories, as portrayed in Journey to Normal, was found to be satisfying and appreciated by participants. Such an intervention has the potential to evoke empathy and help counteract burnout and disengagement among clinicians. This study directly aligned to the greater mission of the VHA: to improve quality medical care for all veterans, including women veterans, a subset population that is often overlooked. Organizations beyond the VHA may wish to leverage virtual learning as a mechanism to offer medical humanities to a wider audience. To optimize success, future programs should be tied to organizational missions, highlight patient voices and stories, and utilize platforms that allow for participant interactivity. Through virtual platforms, the medical humanities can reach a broader audience without detracting from its impact.

The COVID-19 pandemic presented stressors for patients and health care professionals alike, and the prevalence of health care practitioner burnout and dissatisfaction has risen dramatically.^1,2 This, in combination with an increasingly virtual interface between patients and care teams, has the potential to lead to increased depersonalization, anxiety, distress, and diminished overall well-being among clinicians.^1,3 Within the Veterans Health Administration (VHA), women’s health primary care practitioners (PCPs) are specially trained clinicians thatprovide comprehensive care to women veterans. Data suggest that women’s health PCPs may experience higher rates of burnout and attrition (14% per year) compared to general PCPs in VHA.⁴ Burnout among PCPs, especially those working at VHA, is well known and likely related to poor interdisciplinary team structure, limited administrative time, high patient complexity, and isolation from additional resources (eg, rural settings).^4-7 Increased clinician burnout is associated with poorer quality of care and worsening quality of the doctor-patient relationship.⁸

The medical humanities can act as a countermeasure to clinician burnout.^9,10 Studies have demonstrated that physicians who participate in the medical humanities are more empathic and experience less burnout.^11,12 Engaging with patient stories through listening and writing has been a source of fulfillment for clinicians.¹³ Despite the benefits of narrative medicine, programs are often limited in scope in small face-to-face group settings during elective time or outside work hours.¹⁴ The COVID-19 pandemic presented significant challenges to implementing such programming. The VHA is a large health care system with many rural locations, which further limits the availability of traditional small-group and face-to-face trainings. Few studies describe large-scale medical humanities training in virtual learning environments.

NARRATIVE MEDICINE EVENT

To improve satisfaction and engagement among PCPs who care for women veterans, we developed, implemented, and evaluated a large-scale, virtual, interprofessional narrative medicine event aimed at achieving the following: (1) gain a deeper appreciation of the impact of deployments on women veterans; (2) describe the social and emotional challenges faced by women veterans returning from deployment (reintegration); (3) identify strategies to support veterans during reintegration; (4) apply narrative medicine techniques on a large-scale, virtual platform; and (5) assess clinician engagement and satisfaction following participation. We hypothesized that clinician satisfaction and appreciation would improve with a better understanding of the unique complexities of deployment and reintegration faced by women veterans. Utilizing a novel, humanities-based intervention would lead to strong engagement and interaction from participants.

Setting

A 3-hour virtual session was conducted on November 15, 2022, for an interdisciplinary audience. This included physicians and trainees in medicine and behavioral health, nurse practitioners, social workers, dieticians, nurses, and clinical support staff. The training was advertised via emails through established mailing lists and newsletters, reaching a large interdisciplinary VHA audience 90 days prior to the event. This allowed potential participants to dedicate time to attend the session. The training was open to all VHA employees, with no inclusion or exclusion criteria for either the training or the evaluation. The training was delivered within existing space utilized for continuing medical education in women’s health.

For the session, the 93-minute documentary Journey to Normal (jtninc.org) was chosen because it focused on the impact of deployment on women veterans and their experiences when returning home. The film follows the stories of several women veterans through combat and reintegration. The screening was split into 2 segments given the emotional impact and length of the documentary.

A facilitator opened the session by reading a series of reflective prompts centered on women veteran deployment, reintegration, and the stressors surrounding these transitions. The initial prompt served to familiarize participants with the session’s interactive components. Additional prompts were interspersed and discussed in real time and were chosen to mirror the major themes of the documentary: the emotional and psychological impact of deployment and reintegration for women veterans. Short responses and word cloud generation were used and debriefed synchronously to encourage ongoing engagement. Participants responded to prompts through anonymous polling and the chat function of the virtual platform.

During intermission, we introduced My Life, My Story (MLMS). MLMS is a VHA initiative started in 2013 that, with the veteran’s permission, shares a piece of a veteran’s life story with their health care practitioner in their medical chart.¹⁵ Evaluation of MLMS has demonstrated positive impacts on assessments of patient-clinician connection.¹⁶ The MLMS goal to improve patient-centered care competencies by learning stories of veterans aligned with the overarching goals of this program. Following the film, participants were given 10 minutes to respond to a final reflective prompt. The session ended with a review of existing VHA resources to support returning veterans, followed by a question-and-answer session conducted via chat.

We used the Brightcove virtual platform to stream this program, which facilitated significant interaction between participants and facilitators, as well as between participants themselves. In addition to posing questions to the session leaders, participants could directly respond to each other’s comments within the chat function and also upvote/downvote or emphasize others’ comments.

Evaluation

The evaluation schema was 2-fold. Because this session was presented as a part of the national VA Women’s Health webinar series, a standard evaluation was dictated by the VHA Employee Education System. This survey was electronically disseminated and included questions on occupational category and overall satisfaction, plus 9 standard evaluation questions and 4 program-specific questions tied to the workshop objectives. The standard evaluation questions assessed participant satisfaction with the training, satisfaction with the training environment, and appropriateness of the content. The programspecific questions asked the participants whether the session met the stated learning objectives. All questions used a 5-point Likert scale (1, strongly disagree; 5, strongly agree). Descriptive statistics were used for analysis. Individual chat messages and spontaneous replies were analyzed as a surrogate measures of audience engagement. A qualitative analysis of participants’ final reflections to assess for attitudes related to patient care, empathy, and burnout following participation in this curriculum is forthcoming.

A total of 876 participants attended the virtual setting and 525 (59.9%) completed the immediate postevaluation survey. Respondents represented a variety of disciplines, including 179 nurses (34.1%), 100 social workers (19.0%), 65 physicians (12.4%), and 10 physician assistants (1.9%), with < 10% comprising counselors, dentists, dietitians, pharmacists, physical therapists, and psychologists. Nearly all participants reported satisfaction with the learning activity, would recommend it to others, and felt it advanced their knowledge, attitudes, and skills to better contribute to their VHA interprofessional team for patient care (Table 1). Similarly, participants reported a highlevel of agreement that the program satisfied the session-specific objectives. In response to an open-ended question on the standard VA evaluation regarding overall perceptions of the training, free-text responses included such statements as, “I think this should be mandatory training for all VA [clinicians]”; and “This webinar [opened] my mind to the various struggles women veterans may encounter when [they] return to civilian life and [increased] my understanding of how I could support.”

More than 1700 individual chat messages and > 80 spontaneous replies between participants were recorded during the interactive session (Table 2). Spontaneous quotes written in the chat included: “This is the best film representing the female veteran I have ever seen;” “Powerful and perspective changing;” “Thank you for sharing this incredible film;” and “I needed this to remind me to focus on woman veterans. Although our female veteran population is small it will remind me daily of their dedication, recognizing that there are so many facets of making the ultimate sacrifice.” Several participants said such programming should be a mandatory component of VA new employee orientation.

DISCUSSION

Clinician burnout diminishes empathetic patient-physician engagement. Patients’ stories are a known, powerful way to evoke empathy. This session provides one of the first examples of a straightforward approach to delivering a medical humanities intervention to a large audience via virtual platform. As measured by its high engagement, participant satisfaction, and narrative evaluations, this model was successful in evoking empathy and reinforcing the core VHA values for patient care: integrity, commitment, advocacy, respect, and excellence.

Rates of burnout and disengagement among PCPs are high and increased during the COVID-19 pandemic.² This curriculum used a synchronous, narrative-based approach during work hours to address burnout. Lack of empathy is a cause and consequence of burnout and disengagement. Narrative approaches, especially those evoking patients’ stories can evoke empathy and help counteract such burnout. This curriculum demonstrates one of the first large-scale, narrative-based, virtual-platform approaches to utilizing patients’ stories for positive clinician impact, as evidenced by the extensive participation, engagement, and satisfaction of participants.

Individuals interested in implementing a similar program should consider common barriers, including time constraints, advertising, and clinician buy-in. Several key factors led to the successful implementation of this program. First, partnering with established educational efforts related to improving care for veterans provided time to implement the program and establish mechanisms for advertising. The VHA is a mission-driven organization; directly tying this intervention to the mission likely contributed to participant buy-in and programmatic success. Further, by partnering with established educational efforts, this session was conducted during business hours, allowing for widespread participation.

A diverse group of VHA clinicians were actively engaged throughout the session. Chat data demonstrated not only numerous responses to directed prompts, but also a larger extemporaneous conversation among participants. Additionally, it is clear participants were deeply engaged with the material. The quality of participant responses demonstrates the impact of narrative stories and included a new respect for our shared patients, a sense of humbleness as it relates to the women veteran experience, and a sense of pride in both the VHA mission and their roles as a part of the organization.

This session did not end with traditional take-home skills or reference handout resources typical of continuing education. This was intentional; the intended take-home message was the evoked emotional response and resultant perspective shift. The impact of this session on patient care will be examined in a forthcoming qualitative analysis of participants written reflections.

Limitations

Some participants noted that the chat could be distracting from the film. Others described that virtually attending the session allowed increased opportunity for interruption by ongoing patient care responsibilities, resulting in diverted attention. Many participants were granted protected time to attend this continuing education session; however, this was not always the case. Additionally, this evaluation is limited, as 40% of participants elected to not complete the postevent survey. The individuals who choose to respond may have been more engaged with the content or felt more strongly about the impact of the session. However, the volume of chat engagement during the session suggests strong participant involvement. The analysis was also limited by an electronic survey which did not allow more granular assessment of the data.

This session also raised an ethical consideration. The film evoked very strong emotional responses which, for some, were challenging to attend to personally in a large-scale virtual environment. Established clinician resources were highlighted during the session that were available for any participant who needed additional support. Participants were also encouraged to step away and process their emotions, if needed. Future interactions of this session might consider improved interparticipant chat management and upfront warnings about the emotional impact of the film accompanied by proactive dissemination of resources for participant support. One example of such resources includes breakout rooms facilitated by trained counselors. Prompts might also be adjusted to allow for more guided interparticipant engagement; facilitation can be brief as participants’ responses often carry the conversation.

CONCLUSIONS

This study shows that a large-scale, virtual medical humanities intervention is not only possible but well received, as evidenced by both quantity and quality of participant responses and engagement. The narrative approach of hearing patients’ stories, as portrayed in Journey to Normal, was found to be satisfying and appreciated by participants. Such an intervention has the potential to evoke empathy and help counteract burnout and disengagement among clinicians. This study directly aligned to the greater mission of the VHA: to improve quality medical care for all veterans, including women veterans, a subset population that is often overlooked. Organizations beyond the VHA may wish to leverage virtual learning as a mechanism to offer medical humanities to a wider audience. To optimize success, future programs should be tied to organizational missions, highlight patient voices and stories, and utilize platforms that allow for participant interactivity. Through virtual platforms, the medical humanities can reach a broader audience without detracting from its impact.

The COVID-19 pandemic presented stressors for patients and health care professionals alike, and the prevalence of health care practitioner burnout and dissatisfaction has risen dramatically.^1,2 This, in combination with an increasingly virtual interface between patients and care teams, has the potential to lead to increased depersonalization, anxiety, distress, and diminished overall well-being among clinicians.^1,3 Within the Veterans Health Administration (VHA), women’s health primary care practitioners (PCPs) are specially trained clinicians thatprovide comprehensive care to women veterans. Data suggest that women’s health PCPs may experience higher rates of burnout and attrition (14% per year) compared to general PCPs in VHA.⁴ Burnout among PCPs, especially those working at VHA, is well known and likely related to poor interdisciplinary team structure, limited administrative time, high patient complexity, and isolation from additional resources (eg, rural settings).^4-7 Increased clinician burnout is associated with poorer quality of care and worsening quality of the doctor-patient relationship.⁸

The medical humanities can act as a countermeasure to clinician burnout.^9,10 Studies have demonstrated that physicians who participate in the medical humanities are more empathic and experience less burnout.^11,12 Engaging with patient stories through listening and writing has been a source of fulfillment for clinicians.¹³ Despite the benefits of narrative medicine, programs are often limited in scope in small face-to-face group settings during elective time or outside work hours.¹⁴ The COVID-19 pandemic presented significant challenges to implementing such programming. The VHA is a large health care system with many rural locations, which further limits the availability of traditional small-group and face-to-face trainings. Few studies describe large-scale medical humanities training in virtual learning environments.

NARRATIVE MEDICINE EVENT

To improve satisfaction and engagement among PCPs who care for women veterans, we developed, implemented, and evaluated a large-scale, virtual, interprofessional narrative medicine event aimed at achieving the following: (1) gain a deeper appreciation of the impact of deployments on women veterans; (2) describe the social and emotional challenges faced by women veterans returning from deployment (reintegration); (3) identify strategies to support veterans during reintegration; (4) apply narrative medicine techniques on a large-scale, virtual platform; and (5) assess clinician engagement and satisfaction following participation. We hypothesized that clinician satisfaction and appreciation would improve with a better understanding of the unique complexities of deployment and reintegration faced by women veterans. Utilizing a novel, humanities-based intervention would lead to strong engagement and interaction from participants.

Setting

A 3-hour virtual session was conducted on November 15, 2022, for an interdisciplinary audience. This included physicians and trainees in medicine and behavioral health, nurse practitioners, social workers, dieticians, nurses, and clinical support staff. The training was advertised via emails through established mailing lists and newsletters, reaching a large interdisciplinary VHA audience 90 days prior to the event. This allowed potential participants to dedicate time to attend the session. The training was open to all VHA employees, with no inclusion or exclusion criteria for either the training or the evaluation. The training was delivered within existing space utilized for continuing medical education in women’s health.

For the session, the 93-minute documentary Journey to Normal (jtninc.org) was chosen because it focused on the impact of deployment on women veterans and their experiences when returning home. The film follows the stories of several women veterans through combat and reintegration. The screening was split into 2 segments given the emotional impact and length of the documentary.

A facilitator opened the session by reading a series of reflective prompts centered on women veteran deployment, reintegration, and the stressors surrounding these transitions. The initial prompt served to familiarize participants with the session’s interactive components. Additional prompts were interspersed and discussed in real time and were chosen to mirror the major themes of the documentary: the emotional and psychological impact of deployment and reintegration for women veterans. Short responses and word cloud generation were used and debriefed synchronously to encourage ongoing engagement. Participants responded to prompts through anonymous polling and the chat function of the virtual platform.

During intermission, we introduced My Life, My Story (MLMS). MLMS is a VHA initiative started in 2013 that, with the veteran’s permission, shares a piece of a veteran’s life story with their health care practitioner in their medical chart.¹⁵ Evaluation of MLMS has demonstrated positive impacts on assessments of patient-clinician connection.¹⁶ The MLMS goal to improve patient-centered care competencies by learning stories of veterans aligned with the overarching goals of this program. Following the film, participants were given 10 minutes to respond to a final reflective prompt. The session ended with a review of existing VHA resources to support returning veterans, followed by a question-and-answer session conducted via chat.

We used the Brightcove virtual platform to stream this program, which facilitated significant interaction between participants and facilitators, as well as between participants themselves. In addition to posing questions to the session leaders, participants could directly respond to each other’s comments within the chat function and also upvote/downvote or emphasize others’ comments.

Evaluation

The evaluation schema was 2-fold. Because this session was presented as a part of the national VA Women’s Health webinar series, a standard evaluation was dictated by the VHA Employee Education System. This survey was electronically disseminated and included questions on occupational category and overall satisfaction, plus 9 standard evaluation questions and 4 program-specific questions tied to the workshop objectives. The standard evaluation questions assessed participant satisfaction with the training, satisfaction with the training environment, and appropriateness of the content. The programspecific questions asked the participants whether the session met the stated learning objectives. All questions used a 5-point Likert scale (1, strongly disagree; 5, strongly agree). Descriptive statistics were used for analysis. Individual chat messages and spontaneous replies were analyzed as a surrogate measures of audience engagement. A qualitative analysis of participants’ final reflections to assess for attitudes related to patient care, empathy, and burnout following participation in this curriculum is forthcoming.

A total of 876 participants attended the virtual setting and 525 (59.9%) completed the immediate postevaluation survey. Respondents represented a variety of disciplines, including 179 nurses (34.1%), 100 social workers (19.0%), 65 physicians (12.4%), and 10 physician assistants (1.9%), with < 10% comprising counselors, dentists, dietitians, pharmacists, physical therapists, and psychologists. Nearly all participants reported satisfaction with the learning activity, would recommend it to others, and felt it advanced their knowledge, attitudes, and skills to better contribute to their VHA interprofessional team for patient care (Table 1). Similarly, participants reported a highlevel of agreement that the program satisfied the session-specific objectives. In response to an open-ended question on the standard VA evaluation regarding overall perceptions of the training, free-text responses included such statements as, “I think this should be mandatory training for all VA [clinicians]”; and “This webinar [opened] my mind to the various struggles women veterans may encounter when [they] return to civilian life and [increased] my understanding of how I could support.”

More than 1700 individual chat messages and > 80 spontaneous replies between participants were recorded during the interactive session (Table 2). Spontaneous quotes written in the chat included: “This is the best film representing the female veteran I have ever seen;” “Powerful and perspective changing;” “Thank you for sharing this incredible film;” and “I needed this to remind me to focus on woman veterans. Although our female veteran population is small it will remind me daily of their dedication, recognizing that there are so many facets of making the ultimate sacrifice.” Several participants said such programming should be a mandatory component of VA new employee orientation.

DISCUSSION

Clinician burnout diminishes empathetic patient-physician engagement. Patients’ stories are a known, powerful way to evoke empathy. This session provides one of the first examples of a straightforward approach to delivering a medical humanities intervention to a large audience via virtual platform. As measured by its high engagement, participant satisfaction, and narrative evaluations, this model was successful in evoking empathy and reinforcing the core VHA values for patient care: integrity, commitment, advocacy, respect, and excellence.

Rates of burnout and disengagement among PCPs are high and increased during the COVID-19 pandemic.² This curriculum used a synchronous, narrative-based approach during work hours to address burnout. Lack of empathy is a cause and consequence of burnout and disengagement. Narrative approaches, especially those evoking patients’ stories can evoke empathy and help counteract such burnout. This curriculum demonstrates one of the first large-scale, narrative-based, virtual-platform approaches to utilizing patients’ stories for positive clinician impact, as evidenced by the extensive participation, engagement, and satisfaction of participants.

Individuals interested in implementing a similar program should consider common barriers, including time constraints, advertising, and clinician buy-in. Several key factors led to the successful implementation of this program. First, partnering with established educational efforts related to improving care for veterans provided time to implement the program and establish mechanisms for advertising. The VHA is a mission-driven organization; directly tying this intervention to the mission likely contributed to participant buy-in and programmatic success. Further, by partnering with established educational efforts, this session was conducted during business hours, allowing for widespread participation.

A diverse group of VHA clinicians were actively engaged throughout the session. Chat data demonstrated not only numerous responses to directed prompts, but also a larger extemporaneous conversation among participants. Additionally, it is clear participants were deeply engaged with the material. The quality of participant responses demonstrates the impact of narrative stories and included a new respect for our shared patients, a sense of humbleness as it relates to the women veteran experience, and a sense of pride in both the VHA mission and their roles as a part of the organization.

This session did not end with traditional take-home skills or reference handout resources typical of continuing education. This was intentional; the intended take-home message was the evoked emotional response and resultant perspective shift. The impact of this session on patient care will be examined in a forthcoming qualitative analysis of participants written reflections.

Limitations

Some participants noted that the chat could be distracting from the film. Others described that virtually attending the session allowed increased opportunity for interruption by ongoing patient care responsibilities, resulting in diverted attention. Many participants were granted protected time to attend this continuing education session; however, this was not always the case. Additionally, this evaluation is limited, as 40% of participants elected to not complete the postevent survey. The individuals who choose to respond may have been more engaged with the content or felt more strongly about the impact of the session. However, the volume of chat engagement during the session suggests strong participant involvement. The analysis was also limited by an electronic survey which did not allow more granular assessment of the data.

This session also raised an ethical consideration. The film evoked very strong emotional responses which, for some, were challenging to attend to personally in a large-scale virtual environment. Established clinician resources were highlighted during the session that were available for any participant who needed additional support. Participants were also encouraged to step away and process their emotions, if needed. Future interactions of this session might consider improved interparticipant chat management and upfront warnings about the emotional impact of the film accompanied by proactive dissemination of resources for participant support. One example of such resources includes breakout rooms facilitated by trained counselors. Prompts might also be adjusted to allow for more guided interparticipant engagement; facilitation can be brief as participants’ responses often carry the conversation.

CONCLUSIONS

This study shows that a large-scale, virtual medical humanities intervention is not only possible but well received, as evidenced by both quantity and quality of participant responses and engagement. The narrative approach of hearing patients’ stories, as portrayed in Journey to Normal, was found to be satisfying and appreciated by participants. Such an intervention has the potential to evoke empathy and help counteract burnout and disengagement among clinicians. This study directly aligned to the greater mission of the VHA: to improve quality medical care for all veterans, including women veterans, a subset population that is often overlooked. Organizations beyond the VHA may wish to leverage virtual learning as a mechanism to offer medical humanities to a wider audience. To optimize success, future programs should be tied to organizational missions, highlight patient voices and stories, and utilize platforms that allow for participant interactivity. Through virtual platforms, the medical humanities can reach a broader audience without detracting from its impact.

On March 11, 2020, the World Health Organization designated COVID- 19 as a pandemic.¹ Pandemics have historically impacted physical and mental health across all populations, but especially health care workers (HCWs).² Nurses and other HCWs were profoundly impacted by the pandemic.^3-8

Throughout the pandemic, nurses continued to provide care while working in short-staffed workplaces, facing increased exposure to COVID-19, and witnessing COVID—19–related morbidity and mortality.⁹ Many nurses were mandated to cross-train in unfamiliar clinical settings and adjust to new and prolonged shift schedules. Physical and emotional exhaustion associated with managing care for individuals with COVID-19, shortage of personal protective equipment (PPE), risk of infection, fear of secondary transmission to family members, feelings of being rejected by others, and social isolation, led to HCWs’ increased vulnerability to psychological impacts of the pandemic.^8,10

A meta-analysis of 65 studies with > 79,000 participants found HCWs experienced significant levels of anxiety, depression, stress, insomnia, and other mental health issues, such as posttraumatic stress disorder (PTSD). Female HCWs, nurses, and frontline responders experienced a higher incidence of psychological impact.¹¹ Other meta-analyses revealed that nurses’ compassion satisfaction, compassion fatigue, and burnout levels were significantly impacted with increased levels of burnout among nurses who had a friend or family member diagnosed with COVID- 19 or experienced prolonged threat of exposure to the virus.^12,13 A study of 350 nurses found high rates of perceived transgressions by others, and betrayal.⁸ Nurse leaders and staff nurses had to persevere as moral distress became pervasive among nursing staff, which led to complex and often unsustainable circumstances. ¹⁴ The themes identified in the literature about the pandemic’s impact as well as witnessing nurse colleagues’ distress with patient mortality and death of coworkers during the early phase of the COVID-19 pandemic compelled a group of Veterans Health Administration (VHA) nurses to form a research team to understand the scope of impact and identify possible solutions.

Since published studies on the impact of pandemics on HCWs, including nurses, primarily focused on inpatient settings, the investigators of this study sought to capture the experiences of outpatient and inpatient nurses providing care in the US Department of Veterans Affairs (VA) Sierra Pacific Network (Veterans Integrated Service Network [VISN] 21), which has facilities in northern California, Hawaii, and Nevada.^15-19 The purpose of this study was to identify the impact of COVID-19 on nurses caring for veterans in both outpatient and inpatient settings at VISN 21 facilities from March 2020 to September 2022, to inform leadership about the extent the virus affected nurses, and identify strategies that address current and future impacts of pandemics.

METHODS

This retrospective descriptive survey adapted the Pandemic Impact Survey by Purcell et al, which included the Moral Injury Events Scale, Primary Care PTSD Screener, the Patient Health Questionnaire-2 for depression, and a modified burnout scale.^20-24 The survey of 70 Likert-scale questions was intended to measure nurses’ needs, burnout, moral distress, depression and stress symptoms, work-related factors, and intent to remain working in their current position. A nurse was defined broadly and included those employed as licensed vocational nurses (LVN), licensed practical nurses (LPN), registered nurses (RN), nurses with advanced degrees, advanced practice registered nurses (APRNs), and nurses with other certifications or licenses.

The VA Pacific Islands Research and Development Committee reviewed and approved the institutional review board-exempted study. The VISN 21 union was notified; only limited demographic information and broad VA tenure categories were collected to protect privacy. The principal investigator redacted facility identifier data after each facility had participated.

The survey was placed in REDCAP and a confidential link was emailed to all VISN 21 inpatient and outpatient nurses during March 2023. Because a comprehensive VISN 21 list of nurse email addresses was unavailable, the email was distributed by nursing leadership at each facility. Nurses received an email reminder at the 2-week halfway point, prompting them to complete the survey. The email indicated the purpose and voluntary nature of the study and cautioned nurses that they might experience stress while answering survey questions. Stress management resources were provided.

Descriptive statistics were used to report the results. Data were aggregated for analyzing and reporting purposes.

RESULTS

In March 2023, 860 of 5586 nurses (15%) responded to the survey. Respondents included 344 clinical inpatient nurses (40%) and 516 clinical outpatient nurses (60%); 688 (80%) were RNs, 129 (15%) were LPNs/LVNs, and 43 (5%) were APRNs. Of 849 respondents to provide their age, 15 (2%) were < 30 years, 163 (19%) were 30 to 39 years, 232 (27%) were 40 to 49 years, 259 (30%) were 50 to 59 years, and 180 (21%) were ≥ 60 years.

The survey found that 688 nurses reported job satisfaction (80%) and 75% of all respondents (66% among inpatient nurses) reported feeling happy with the care they delivered. Both inpatient and outpatient nurses indicated they could rely on staff. Sixty percent (n = 516) of the nurses indicated that facility management considered workplace health and safety and supervisors showed concern for subordinates, although inpatient nurses reported a lower percentage (Table 1).

Two hundred fifty-eight nurses (30%) reported having nurse colleagues who died and 52 (6%) had ≥ 3 colleagues who died. Among respondents, 292 had ≥ 3 patients who died after contracting COVID-19 and 232 (27%) had a significant person in their life die. More than one-half (54%; n = 464) of nurses had to limit contact with a family member who had COVID-19. Most nurses reported concerns about their colleagues (91%), were concerned about bringing COVID-19 home (82%), and stayed away from family during the pandemic (56%) (Table 2).

A total of 593 nurses (69%) reported feeling overwhelmed from the workload associated with the pandemic, 490 (57%) felt frustrated with role changes, 447 (52%) were stressed because of short staffing, and 327 (38%) felt stressed because of being assigned or floated to different patient care areas. Among inpatient nurses, 158 (46%) reported stress related to being floated. Coworker absenteeism caused challenges for 697 nurses (81%) (Table 3).

Nurses suggested a number of changes that could improve working conditions, including flexible scheduling (54%) and more hours of leave, which was requested by 43% of outpatient/inpatient nurses and 53% of inpatient alone nurses. Access to COVID-19 testing and PPE was endorsed as a workplace need by 439 nurses; the need for access to PPE was reported by 43% of inpatient-only nurses vs 29% of outpatient/inpatient nurses. The need for adequate staffing was reported by 54% of nurses although the rate was higher among those working inpatient settings (66%) (Table 4).

Four hundred sixty-four nurses (54%) felt tense and irritable at home because of work and 447 had ≥ 1 symptoms of burnout (Table 5). In terms of moral distress, > 30% of nurses witnessed morally incongruent situations, 10% felt their own moral code was violated, and > 30% felt betrayed by others (Table 6). Among respondents, 16% to 21% of nurses reported depressive symptoms (eAppendix). About 50% of nurses intended to stay in their current position while 20% indicated an intention to leave for another VA position.

DISCUSSION

This study identified the impact of COVID-19 on nurses who work in VISN 21. The survey included a significant number of nurses who work in outpatient settings, which differed from most other published studies to date.^15-19 This study found that inpatient and outpatient nurses were similarly impacted by the COVID-19 pandemic, although there were differences. A high percentage of nurses reported job satisfaction despite the personal and professional impact of the pandemic.

Caring for veterans can result in a therapeutic relationship with a deep appreciation of veterans’ service and sensitivity to their needs.²⁵ Some nurses reported that they feel it is a privilege to care for veterans.

Most nurses who participated in this study felt they could rely on their colleagues and were concerned about their health and wellbeing. Kissel et al explored protective factors for nurses during the pandemic and found participants often reported that their coworkers were positive safeguards.¹⁷ At least 50% of respondents reported that management considered workplace safety and was concerned about their welfare. Previous research has found that a positive working organization that promoted safety and concern for staff were protective factors against stress among HCWs.²⁶ A literature review of 3 coronavirus outbreaks illustrated the support from supervisors and colleagues promoted resiliency and reduced stress disorders.³

Similar to other studies, study respondents experienced profound losses, including the deaths of colleagues, patients, and family. In 2021 Howell reported that HCWs experienced increased stress, fear, anxiety, and other negative emotions following news of colleagues’ deaths from COVID-19.²⁷ Kissel et al reported that nurses frequently described pandemic-related physical and psychological harm and witnessing distress that they had not been previously exposed to.¹⁷

Our findings illustrate the tightrope nurses walked while caring for patients and concerns about the health of their colleagues and family. Consistent with our findings, Howell found that HCWs were afraid of contracting the infection at work and then unknowingly giving it to others such as patients, coworkers, and household members. ²⁷ Murat et al reported that some nurses chose to live separately during the pandemic to avoid spreading COVID-19 to relatives.¹⁹ Several researchers found that concerns about family and children were prevalent and led to fear, anxiety, and burnout among nurses.^18,28,29 Shah et al suggested that nurses experiencing death in the workplace and within their family may have resulted in fear and anxiety about returning to work.²⁹ Garcia and Calvo argued that nurses may have been stigmatized as carriers of COVID-19.¹⁶ In addition, the loss of prepandemic workplace rituals may have impacted performance, team connection, and functioning, and led to increased turnover and decreased attachment to the organization.³⁰

This study described the significant workplace issues nurses endured during the pandemic, including being overwhelmed with additional and/or multiple roles and frustrated and stressed with role changes and short staffing. Nurses endorsed workplace challenges in the context of coworker absenteeism and reassignments to different areas, such as intensive care units (ICUs).¹⁷ Researchers also reported that displaced team members experienced loneliness and isolation when they were removed from their usual place of work and experienced distress caring for patients beyond their perceived competency or comfort.^17,31 Nurses also experienced rapid organizational changes, resource scarcity, high patient-to-nurse ratios, inconsistent or limited communications, and the absence of protocols for prolonged mass casualty events.¹⁷ These challenges, such as significant uncertainty and rapidly changing working conditions, were shared experiences suggested to be similar to “tumbling into chaos,” and likened to the overwhelming situations faced during patient surges to a medical “war zone.”¹⁷

Study respondents indicated that nurses wanted better access to critical supplies, PPE, and COVID-19 testing; more flexible scheduling; longer leave times; and staffing that was appropriate to the patient volumes. These findings aligned with previous research. Howell found that HCWs, especially nurses, worried about childcare because of school closures and increased work hours.²⁷ Nurses felt that hospital support was inaccessible or inadequate and worried about access to essential resources.^17-19,27 Studies also found excessive workloads, and many nurses needed mental or financial assistance from the hospital in addition to more rest and less work.^18,28 An editorial highlighted the potential adverse effects that a lack of PPE could have on staff ’s mental health because of perceptions of institutional betrayal, which occurs when trusted and powerful organizations seemingly act in ways that can harm those dependent on them for safety and well-being.³²

Consistent with other research, this study found that a majority of nurses experienced significant burnout symptoms. The number of nurses reporting symptoms of burnout increased during the pandemic with ICU nurses reporting the highest levels.^17,33 Soto-Rubio et al emphasized that working conditions experienced by nurses, such as interpersonal conflict, lack of trust in administration, workload, and role conflict, contributed to burnout during COVID-19.³⁴ Other studies found that nurses experienced burnout caused by uncertainty, intense work, and extra duties contributed to higher burnout scores.^18,19 It is not surprising that researchers have indicated that nurses experiencing burnout might display depressive and stress-related symptoms, insomnia, and concentration and memory problems.¹⁹

The results of this study indicate that one-third of participating nurses were experiencing moral distress. Burton et al described COVID-19 as an environment in which nurses witnessed, experienced, and at times had to participate in acts that involved ethical violations in care, institutional betrayal, and traumatic strain.⁹ Of note, our findings revealed that both inpatient and outpatient nurses experienced moral distress. Interestingly, Mantri et al found that COVID-19 increased moral injury but not burnout among health professionals, which differed from the results of this study.³⁵

The findings of this study indicate that many nurses experienced depressive symptoms. A systematic review found a similar percentage of HCWs experienced depression while caring for patients with COVID- 19, though a Chinese study found a higher percentage.^36,37 Previous research also found that the most difficult aspect of the COVID- 19 pandemic for nurses was coping with mental disorders such as depression, and that many experienced difficulty sleeping/ had poor sleep quality, believed a similar disaster would occur in the future, were irritated or angered easily, and experienced emotional exhaustion.^15,19 The long-term mental and physical ramifications of caring for individuals with COVID-19 remain unknown. However, previous research suggests a high prevalence of depression, insomnia, anxiety, and distress, which could impair nurses’ professional performance.²⁹

This study reported that a majority of nurses intended to stay in their current position and about 20% intended to leave for another position within the VA. Similar findings conducted early in the pandemic indicated that most participants did not intend to quit nursing.¹⁹

This study’s findings suggest the COVID-19 pandemic had an adverse impact on VISN 21 nurses. It is critical to develop, implement, and adopt adequate measures as early as possible to support the health care system, especially nurses.¹⁸

Implications

Before the COVID-19 pandemic, discussing burnout and moral anguish was common, primarily in critical care.¹⁴ However, these experiences became more widespread throughout nursing settings during the pandemic. Nurse leaders have been identified as responsible for ensuring the environmental safety and personal well-being of their colleagues during and after pandemics.¹⁴

Studies of HCW experiences during COVID-19 provide many insights into future preparedness, strategies to best handle another pandemic during its acute stage, and techniques to address issues that might persist. This study and others suggest that comprehensive interventions in preparation for, during, and after a pandemic are needed. We break down strategies into pandemic and postpandemic interventions based on a synthesis of the literature and the research team’s knowledge and expertise.^{3,14-16,27,29,36,38-44}

Pandemic interventions. During a pandemic, it is important that nurses are adequately cared for to ensure they can continue to provide quality care for others. Resources supporting emotional well-being and addressing moral distress offered during a pandemic are essential. Implementing meaningful strategies could enhance nurses’ health and wellbeing. It is essential that leaders provide nurses a safe work environment/experience during a pandemic by instituting meaningful resources. In addition, developing best practices for leadership are critical.

Postpandemic interventions. Personal experiences of depression, burnout, and moral distress have not spontaneously resolved as the pandemic receded. Providing postpandemic interventions to lessen ongoing and lingering depressive, burnout, and moral distress symptoms experienced by frontline workers are critical. These interventions might prevent long-term health issues and the exodus of nurses.

Postpandemic interventions should include the integration of pandemic planning into new or existing educational or training programs for staff. Promotion and support of mental health services by health system leadership for nursing personnel implemented as a usual service will play an important role in preparing for future pandemics. A key role in preparation is developing and maintaining cooperation and ongoing mutual understanding, respect, and communication between leadership and nursing staff.

Future Research

This study’s findings inform VHA leadership and society about how a large group of nurses were impacted by COVID-19 while caring for patients in inpatient and outpatient settings and could provide a basis for extending this research to other groups of nurses or health care personnel. Future research might be helpful in identifying the impact of COVID-19 on nursing leadership. During conversations with nursing leadership, a common theme identified was that nurses did not feel that leadership was fully prepared for the level of emergency the pandemic created both personally and professionally; leadership expressed experiences similar to nurses providing direct care and felt powerless to help their nursing staff. Other areas of research could include identifying underlying factors contributing to burnout and moral distress and describing nurses’ expectations of or needs from leadership to best manage burnout and moral distress.

Limitations

Experiences of nurses who stopped working were not captured and information about their experiences might have different results. The survey distribution was limited to 2 emails (an initial email and a second at midpoint) sent at the discretion of the nurse executive of each facility. The study timeline was long because of complex regulatory protective processes inherent in the VHA system for researchers to include initial institutional review board review process, union notifications, and each facility’s response to the survey. Although 860 nurses participated, this was 15% of the 5586 VISN 21 nurses at the time of the study. Many clinical inpatient nurses do not have regular access to email, which might have impacted participation rate.

CONCLUSIONS

This study identified the impact COVID-19 had on nurses who worked in a large hospital system. The research team outlined strategies to be employed during and after the pandemic, such as preplanning for future pandemics to provide a framework for a comprehensive pandemic response protocol.

This study adds to generalized knowledge because it captured voices of inpatient and outpatient nurses, the latter had not been previously studied. As nurses and health care organizations move beyond the pandemic with a significant number of nurses continuing to experience effects, there is a need to institute interventions to assist nurses in healing and begin preparations for future pandemics.

On March 11, 2020, the World Health Organization designated COVID- 19 as a pandemic.¹ Pandemics have historically impacted physical and mental health across all populations, but especially health care workers (HCWs).² Nurses and other HCWs were profoundly impacted by the pandemic.^3-8

Throughout the pandemic, nurses continued to provide care while working in short-staffed workplaces, facing increased exposure to COVID-19, and witnessing COVID—19–related morbidity and mortality.⁹ Many nurses were mandated to cross-train in unfamiliar clinical settings and adjust to new and prolonged shift schedules. Physical and emotional exhaustion associated with managing care for individuals with COVID-19, shortage of personal protective equipment (PPE), risk of infection, fear of secondary transmission to family members, feelings of being rejected by others, and social isolation, led to HCWs’ increased vulnerability to psychological impacts of the pandemic.^8,10

A meta-analysis of 65 studies with > 79,000 participants found HCWs experienced significant levels of anxiety, depression, stress, insomnia, and other mental health issues, such as posttraumatic stress disorder (PTSD). Female HCWs, nurses, and frontline responders experienced a higher incidence of psychological impact.¹¹ Other meta-analyses revealed that nurses’ compassion satisfaction, compassion fatigue, and burnout levels were significantly impacted with increased levels of burnout among nurses who had a friend or family member diagnosed with COVID- 19 or experienced prolonged threat of exposure to the virus.^12,13 A study of 350 nurses found high rates of perceived transgressions by others, and betrayal.⁸ Nurse leaders and staff nurses had to persevere as moral distress became pervasive among nursing staff, which led to complex and often unsustainable circumstances. ¹⁴ The themes identified in the literature about the pandemic’s impact as well as witnessing nurse colleagues’ distress with patient mortality and death of coworkers during the early phase of the COVID-19 pandemic compelled a group of Veterans Health Administration (VHA) nurses to form a research team to understand the scope of impact and identify possible solutions.

Since published studies on the impact of pandemics on HCWs, including nurses, primarily focused on inpatient settings, the investigators of this study sought to capture the experiences of outpatient and inpatient nurses providing care in the US Department of Veterans Affairs (VA) Sierra Pacific Network (Veterans Integrated Service Network [VISN] 21), which has facilities in northern California, Hawaii, and Nevada.^15-19 The purpose of this study was to identify the impact of COVID-19 on nurses caring for veterans in both outpatient and inpatient settings at VISN 21 facilities from March 2020 to September 2022, to inform leadership about the extent the virus affected nurses, and identify strategies that address current and future impacts of pandemics.

METHODS

This retrospective descriptive survey adapted the Pandemic Impact Survey by Purcell et al, which included the Moral Injury Events Scale, Primary Care PTSD Screener, the Patient Health Questionnaire-2 for depression, and a modified burnout scale.^20-24 The survey of 70 Likert-scale questions was intended to measure nurses’ needs, burnout, moral distress, depression and stress symptoms, work-related factors, and intent to remain working in their current position. A nurse was defined broadly and included those employed as licensed vocational nurses (LVN), licensed practical nurses (LPN), registered nurses (RN), nurses with advanced degrees, advanced practice registered nurses (APRNs), and nurses with other certifications or licenses.

The VA Pacific Islands Research and Development Committee reviewed and approved the institutional review board-exempted study. The VISN 21 union was notified; only limited demographic information and broad VA tenure categories were collected to protect privacy. The principal investigator redacted facility identifier data after each facility had participated.

The survey was placed in REDCAP and a confidential link was emailed to all VISN 21 inpatient and outpatient nurses during March 2023. Because a comprehensive VISN 21 list of nurse email addresses was unavailable, the email was distributed by nursing leadership at each facility. Nurses received an email reminder at the 2-week halfway point, prompting them to complete the survey. The email indicated the purpose and voluntary nature of the study and cautioned nurses that they might experience stress while answering survey questions. Stress management resources were provided.

Descriptive statistics were used to report the results. Data were aggregated for analyzing and reporting purposes.

RESULTS

In March 2023, 860 of 5586 nurses (15%) responded to the survey. Respondents included 344 clinical inpatient nurses (40%) and 516 clinical outpatient nurses (60%); 688 (80%) were RNs, 129 (15%) were LPNs/LVNs, and 43 (5%) were APRNs. Of 849 respondents to provide their age, 15 (2%) were < 30 years, 163 (19%) were 30 to 39 years, 232 (27%) were 40 to 49 years, 259 (30%) were 50 to 59 years, and 180 (21%) were ≥ 60 years.

The survey found that 688 nurses reported job satisfaction (80%) and 75% of all respondents (66% among inpatient nurses) reported feeling happy with the care they delivered. Both inpatient and outpatient nurses indicated they could rely on staff. Sixty percent (n = 516) of the nurses indicated that facility management considered workplace health and safety and supervisors showed concern for subordinates, although inpatient nurses reported a lower percentage (Table 1).

Two hundred fifty-eight nurses (30%) reported having nurse colleagues who died and 52 (6%) had ≥ 3 colleagues who died. Among respondents, 292 had ≥ 3 patients who died after contracting COVID-19 and 232 (27%) had a significant person in their life die. More than one-half (54%; n = 464) of nurses had to limit contact with a family member who had COVID-19. Most nurses reported concerns about their colleagues (91%), were concerned about bringing COVID-19 home (82%), and stayed away from family during the pandemic (56%) (Table 2).

A total of 593 nurses (69%) reported feeling overwhelmed from the workload associated with the pandemic, 490 (57%) felt frustrated with role changes, 447 (52%) were stressed because of short staffing, and 327 (38%) felt stressed because of being assigned or floated to different patient care areas. Among inpatient nurses, 158 (46%) reported stress related to being floated. Coworker absenteeism caused challenges for 697 nurses (81%) (Table 3).

Nurses suggested a number of changes that could improve working conditions, including flexible scheduling (54%) and more hours of leave, which was requested by 43% of outpatient/inpatient nurses and 53% of inpatient alone nurses. Access to COVID-19 testing and PPE was endorsed as a workplace need by 439 nurses; the need for access to PPE was reported by 43% of inpatient-only nurses vs 29% of outpatient/inpatient nurses. The need for adequate staffing was reported by 54% of nurses although the rate was higher among those working inpatient settings (66%) (Table 4).

Four hundred sixty-four nurses (54%) felt tense and irritable at home because of work and 447 had ≥ 1 symptoms of burnout (Table 5). In terms of moral distress, > 30% of nurses witnessed morally incongruent situations, 10% felt their own moral code was violated, and > 30% felt betrayed by others (Table 6). Among respondents, 16% to 21% of nurses reported depressive symptoms (eAppendix). About 50% of nurses intended to stay in their current position while 20% indicated an intention to leave for another VA position.

DISCUSSION

This study identified the impact of COVID-19 on nurses who work in VISN 21. The survey included a significant number of nurses who work in outpatient settings, which differed from most other published studies to date.^15-19 This study found that inpatient and outpatient nurses were similarly impacted by the COVID-19 pandemic, although there were differences. A high percentage of nurses reported job satisfaction despite the personal and professional impact of the pandemic.

Caring for veterans can result in a therapeutic relationship with a deep appreciation of veterans’ service and sensitivity to their needs.²⁵ Some nurses reported that they feel it is a privilege to care for veterans.

Most nurses who participated in this study felt they could rely on their colleagues and were concerned about their health and wellbeing. Kissel et al explored protective factors for nurses during the pandemic and found participants often reported that their coworkers were positive safeguards.¹⁷ At least 50% of respondents reported that management considered workplace safety and was concerned about their welfare. Previous research has found that a positive working organization that promoted safety and concern for staff were protective factors against stress among HCWs.²⁶ A literature review of 3 coronavirus outbreaks illustrated the support from supervisors and colleagues promoted resiliency and reduced stress disorders.³

Similar to other studies, study respondents experienced profound losses, including the deaths of colleagues, patients, and family. In 2021 Howell reported that HCWs experienced increased stress, fear, anxiety, and other negative emotions following news of colleagues’ deaths from COVID-19.²⁷ Kissel et al reported that nurses frequently described pandemic-related physical and psychological harm and witnessing distress that they had not been previously exposed to.¹⁷

Our findings illustrate the tightrope nurses walked while caring for patients and concerns about the health of their colleagues and family. Consistent with our findings, Howell found that HCWs were afraid of contracting the infection at work and then unknowingly giving it to others such as patients, coworkers, and household members. ²⁷ Murat et al reported that some nurses chose to live separately during the pandemic to avoid spreading COVID-19 to relatives.¹⁹ Several researchers found that concerns about family and children were prevalent and led to fear, anxiety, and burnout among nurses.^18,28,29 Shah et al suggested that nurses experiencing death in the workplace and within their family may have resulted in fear and anxiety about returning to work.²⁹ Garcia and Calvo argued that nurses may have been stigmatized as carriers of COVID-19.¹⁶ In addition, the loss of prepandemic workplace rituals may have impacted performance, team connection, and functioning, and led to increased turnover and decreased attachment to the organization.³⁰

This study described the significant workplace issues nurses endured during the pandemic, including being overwhelmed with additional and/or multiple roles and frustrated and stressed with role changes and short staffing. Nurses endorsed workplace challenges in the context of coworker absenteeism and reassignments to different areas, such as intensive care units (ICUs).¹⁷ Researchers also reported that displaced team members experienced loneliness and isolation when they were removed from their usual place of work and experienced distress caring for patients beyond their perceived competency or comfort.^17,31 Nurses also experienced rapid organizational changes, resource scarcity, high patient-to-nurse ratios, inconsistent or limited communications, and the absence of protocols for prolonged mass casualty events.¹⁷ These challenges, such as significant uncertainty and rapidly changing working conditions, were shared experiences suggested to be similar to “tumbling into chaos,” and likened to the overwhelming situations faced during patient surges to a medical “war zone.”¹⁷

Study respondents indicated that nurses wanted better access to critical supplies, PPE, and COVID-19 testing; more flexible scheduling; longer leave times; and staffing that was appropriate to the patient volumes. These findings aligned with previous research. Howell found that HCWs, especially nurses, worried about childcare because of school closures and increased work hours.²⁷ Nurses felt that hospital support was inaccessible or inadequate and worried about access to essential resources.^17-19,27 Studies also found excessive workloads, and many nurses needed mental or financial assistance from the hospital in addition to more rest and less work.^18,28 An editorial highlighted the potential adverse effects that a lack of PPE could have on staff ’s mental health because of perceptions of institutional betrayal, which occurs when trusted and powerful organizations seemingly act in ways that can harm those dependent on them for safety and well-being.³²

Consistent with other research, this study found that a majority of nurses experienced significant burnout symptoms. The number of nurses reporting symptoms of burnout increased during the pandemic with ICU nurses reporting the highest levels.^17,33 Soto-Rubio et al emphasized that working conditions experienced by nurses, such as interpersonal conflict, lack of trust in administration, workload, and role conflict, contributed to burnout during COVID-19.³⁴ Other studies found that nurses experienced burnout caused by uncertainty, intense work, and extra duties contributed to higher burnout scores.^18,19 It is not surprising that researchers have indicated that nurses experiencing burnout might display depressive and stress-related symptoms, insomnia, and concentration and memory problems.¹⁹

The results of this study indicate that one-third of participating nurses were experiencing moral distress. Burton et al described COVID-19 as an environment in which nurses witnessed, experienced, and at times had to participate in acts that involved ethical violations in care, institutional betrayal, and traumatic strain.⁹ Of note, our findings revealed that both inpatient and outpatient nurses experienced moral distress. Interestingly, Mantri et al found that COVID-19 increased moral injury but not burnout among health professionals, which differed from the results of this study.³⁵

The findings of this study indicate that many nurses experienced depressive symptoms. A systematic review found a similar percentage of HCWs experienced depression while caring for patients with COVID- 19, though a Chinese study found a higher percentage.^36,37 Previous research also found that the most difficult aspect of the COVID- 19 pandemic for nurses was coping with mental disorders such as depression, and that many experienced difficulty sleeping/ had poor sleep quality, believed a similar disaster would occur in the future, were irritated or angered easily, and experienced emotional exhaustion.^15,19 The long-term mental and physical ramifications of caring for individuals with COVID-19 remain unknown. However, previous research suggests a high prevalence of depression, insomnia, anxiety, and distress, which could impair nurses’ professional performance.²⁹

This study reported that a majority of nurses intended to stay in their current position and about 20% intended to leave for another position within the VA. Similar findings conducted early in the pandemic indicated that most participants did not intend to quit nursing.¹⁹

This study’s findings suggest the COVID-19 pandemic had an adverse impact on VISN 21 nurses. It is critical to develop, implement, and adopt adequate measures as early as possible to support the health care system, especially nurses.¹⁸

Implications

Before the COVID-19 pandemic, discussing burnout and moral anguish was common, primarily in critical care.¹⁴ However, these experiences became more widespread throughout nursing settings during the pandemic. Nurse leaders have been identified as responsible for ensuring the environmental safety and personal well-being of their colleagues during and after pandemics.¹⁴

Studies of HCW experiences during COVID-19 provide many insights into future preparedness, strategies to best handle another pandemic during its acute stage, and techniques to address issues that might persist. This study and others suggest that comprehensive interventions in preparation for, during, and after a pandemic are needed. We break down strategies into pandemic and postpandemic interventions based on a synthesis of the literature and the research team’s knowledge and expertise.^{3,14-16,27,29,36,38-44}

Pandemic interventions. During a pandemic, it is important that nurses are adequately cared for to ensure they can continue to provide quality care for others. Resources supporting emotional well-being and addressing moral distress offered during a pandemic are essential. Implementing meaningful strategies could enhance nurses’ health and wellbeing. It is essential that leaders provide nurses a safe work environment/experience during a pandemic by instituting meaningful resources. In addition, developing best practices for leadership are critical.

Postpandemic interventions. Personal experiences of depression, burnout, and moral distress have not spontaneously resolved as the pandemic receded. Providing postpandemic interventions to lessen ongoing and lingering depressive, burnout, and moral distress symptoms experienced by frontline workers are critical. These interventions might prevent long-term health issues and the exodus of nurses.

Postpandemic interventions should include the integration of pandemic planning into new or existing educational or training programs for staff. Promotion and support of mental health services by health system leadership for nursing personnel implemented as a usual service will play an important role in preparing for future pandemics. A key role in preparation is developing and maintaining cooperation and ongoing mutual understanding, respect, and communication between leadership and nursing staff.

Future Research

This study’s findings inform VHA leadership and society about how a large group of nurses were impacted by COVID-19 while caring for patients in inpatient and outpatient settings and could provide a basis for extending this research to other groups of nurses or health care personnel. Future research might be helpful in identifying the impact of COVID-19 on nursing leadership. During conversations with nursing leadership, a common theme identified was that nurses did not feel that leadership was fully prepared for the level of emergency the pandemic created both personally and professionally; leadership expressed experiences similar to nurses providing direct care and felt powerless to help their nursing staff. Other areas of research could include identifying underlying factors contributing to burnout and moral distress and describing nurses’ expectations of or needs from leadership to best manage burnout and moral distress.

Limitations

Experiences of nurses who stopped working were not captured and information about their experiences might have different results. The survey distribution was limited to 2 emails (an initial email and a second at midpoint) sent at the discretion of the nurse executive of each facility. The study timeline was long because of complex regulatory protective processes inherent in the VHA system for researchers to include initial institutional review board review process, union notifications, and each facility’s response to the survey. Although 860 nurses participated, this was 15% of the 5586 VISN 21 nurses at the time of the study. Many clinical inpatient nurses do not have regular access to email, which might have impacted participation rate.

CONCLUSIONS

This study identified the impact COVID-19 had on nurses who worked in a large hospital system. The research team outlined strategies to be employed during and after the pandemic, such as preplanning for future pandemics to provide a framework for a comprehensive pandemic response protocol.

This study adds to generalized knowledge because it captured voices of inpatient and outpatient nurses, the latter had not been previously studied. As nurses and health care organizations move beyond the pandemic with a significant number of nurses continuing to experience effects, there is a need to institute interventions to assist nurses in healing and begin preparations for future pandemics.

On March 11, 2020, the World Health Organization designated COVID- 19 as a pandemic.¹ Pandemics have historically impacted physical and mental health across all populations, but especially health care workers (HCWs).² Nurses and other HCWs were profoundly impacted by the pandemic.^3-8

Throughout the pandemic, nurses continued to provide care while working in short-staffed workplaces, facing increased exposure to COVID-19, and witnessing COVID—19–related morbidity and mortality.⁹ Many nurses were mandated to cross-train in unfamiliar clinical settings and adjust to new and prolonged shift schedules. Physical and emotional exhaustion associated with managing care for individuals with COVID-19, shortage of personal protective equipment (PPE), risk of infection, fear of secondary transmission to family members, feelings of being rejected by others, and social isolation, led to HCWs’ increased vulnerability to psychological impacts of the pandemic.^8,10

A meta-analysis of 65 studies with > 79,000 participants found HCWs experienced significant levels of anxiety, depression, stress, insomnia, and other mental health issues, such as posttraumatic stress disorder (PTSD). Female HCWs, nurses, and frontline responders experienced a higher incidence of psychological impact.¹¹ Other meta-analyses revealed that nurses’ compassion satisfaction, compassion fatigue, and burnout levels were significantly impacted with increased levels of burnout among nurses who had a friend or family member diagnosed with COVID- 19 or experienced prolonged threat of exposure to the virus.^12,13 A study of 350 nurses found high rates of perceived transgressions by others, and betrayal.⁸ Nurse leaders and staff nurses had to persevere as moral distress became pervasive among nursing staff, which led to complex and often unsustainable circumstances. ¹⁴ The themes identified in the literature about the pandemic’s impact as well as witnessing nurse colleagues’ distress with patient mortality and death of coworkers during the early phase of the COVID-19 pandemic compelled a group of Veterans Health Administration (VHA) nurses to form a research team to understand the scope of impact and identify possible solutions.

Since published studies on the impact of pandemics on HCWs, including nurses, primarily focused on inpatient settings, the investigators of this study sought to capture the experiences of outpatient and inpatient nurses providing care in the US Department of Veterans Affairs (VA) Sierra Pacific Network (Veterans Integrated Service Network [VISN] 21), which has facilities in northern California, Hawaii, and Nevada.^15-19 The purpose of this study was to identify the impact of COVID-19 on nurses caring for veterans in both outpatient and inpatient settings at VISN 21 facilities from March 2020 to September 2022, to inform leadership about the extent the virus affected nurses, and identify strategies that address current and future impacts of pandemics.

METHODS

This retrospective descriptive survey adapted the Pandemic Impact Survey by Purcell et al, which included the Moral Injury Events Scale, Primary Care PTSD Screener, the Patient Health Questionnaire-2 for depression, and a modified burnout scale.^20-24 The survey of 70 Likert-scale questions was intended to measure nurses’ needs, burnout, moral distress, depression and stress symptoms, work-related factors, and intent to remain working in their current position. A nurse was defined broadly and included those employed as licensed vocational nurses (LVN), licensed practical nurses (LPN), registered nurses (RN), nurses with advanced degrees, advanced practice registered nurses (APRNs), and nurses with other certifications or licenses.

The VA Pacific Islands Research and Development Committee reviewed and approved the institutional review board-exempted study. The VISN 21 union was notified; only limited demographic information and broad VA tenure categories were collected to protect privacy. The principal investigator redacted facility identifier data after each facility had participated.

The survey was placed in REDCAP and a confidential link was emailed to all VISN 21 inpatient and outpatient nurses during March 2023. Because a comprehensive VISN 21 list of nurse email addresses was unavailable, the email was distributed by nursing leadership at each facility. Nurses received an email reminder at the 2-week halfway point, prompting them to complete the survey. The email indicated the purpose and voluntary nature of the study and cautioned nurses that they might experience stress while answering survey questions. Stress management resources were provided.

Descriptive statistics were used to report the results. Data were aggregated for analyzing and reporting purposes.

RESULTS

In March 2023, 860 of 5586 nurses (15%) responded to the survey. Respondents included 344 clinical inpatient nurses (40%) and 516 clinical outpatient nurses (60%); 688 (80%) were RNs, 129 (15%) were LPNs/LVNs, and 43 (5%) were APRNs. Of 849 respondents to provide their age, 15 (2%) were < 30 years, 163 (19%) were 30 to 39 years, 232 (27%) were 40 to 49 years, 259 (30%) were 50 to 59 years, and 180 (21%) were ≥ 60 years.

The survey found that 688 nurses reported job satisfaction (80%) and 75% of all respondents (66% among inpatient nurses) reported feeling happy with the care they delivered. Both inpatient and outpatient nurses indicated they could rely on staff. Sixty percent (n = 516) of the nurses indicated that facility management considered workplace health and safety and supervisors showed concern for subordinates, although inpatient nurses reported a lower percentage (Table 1).

Two hundred fifty-eight nurses (30%) reported having nurse colleagues who died and 52 (6%) had ≥ 3 colleagues who died. Among respondents, 292 had ≥ 3 patients who died after contracting COVID-19 and 232 (27%) had a significant person in their life die. More than one-half (54%; n = 464) of nurses had to limit contact with a family member who had COVID-19. Most nurses reported concerns about their colleagues (91%), were concerned about bringing COVID-19 home (82%), and stayed away from family during the pandemic (56%) (Table 2).

A total of 593 nurses (69%) reported feeling overwhelmed from the workload associated with the pandemic, 490 (57%) felt frustrated with role changes, 447 (52%) were stressed because of short staffing, and 327 (38%) felt stressed because of being assigned or floated to different patient care areas. Among inpatient nurses, 158 (46%) reported stress related to being floated. Coworker absenteeism caused challenges for 697 nurses (81%) (Table 3).

Nurses suggested a number of changes that could improve working conditions, including flexible scheduling (54%) and more hours of leave, which was requested by 43% of outpatient/inpatient nurses and 53% of inpatient alone nurses. Access to COVID-19 testing and PPE was endorsed as a workplace need by 439 nurses; the need for access to PPE was reported by 43% of inpatient-only nurses vs 29% of outpatient/inpatient nurses. The need for adequate staffing was reported by 54% of nurses although the rate was higher among those working inpatient settings (66%) (Table 4).

Four hundred sixty-four nurses (54%) felt tense and irritable at home because of work and 447 had ≥ 1 symptoms of burnout (Table 5). In terms of moral distress, > 30% of nurses witnessed morally incongruent situations, 10% felt their own moral code was violated, and > 30% felt betrayed by others (Table 6). Among respondents, 16% to 21% of nurses reported depressive symptoms (eAppendix). About 50% of nurses intended to stay in their current position while 20% indicated an intention to leave for another VA position.

DISCUSSION

This study identified the impact of COVID-19 on nurses who work in VISN 21. The survey included a significant number of nurses who work in outpatient settings, which differed from most other published studies to date.^15-19 This study found that inpatient and outpatient nurses were similarly impacted by the COVID-19 pandemic, although there were differences. A high percentage of nurses reported job satisfaction despite the personal and professional impact of the pandemic.

Caring for veterans can result in a therapeutic relationship with a deep appreciation of veterans’ service and sensitivity to their needs.²⁵ Some nurses reported that they feel it is a privilege to care for veterans.

Most nurses who participated in this study felt they could rely on their colleagues and were concerned about their health and wellbeing. Kissel et al explored protective factors for nurses during the pandemic and found participants often reported that their coworkers were positive safeguards.¹⁷ At least 50% of respondents reported that management considered workplace safety and was concerned about their welfare. Previous research has found that a positive working organization that promoted safety and concern for staff were protective factors against stress among HCWs.²⁶ A literature review of 3 coronavirus outbreaks illustrated the support from supervisors and colleagues promoted resiliency and reduced stress disorders.³

Similar to other studies, study respondents experienced profound losses, including the deaths of colleagues, patients, and family. In 2021 Howell reported that HCWs experienced increased stress, fear, anxiety, and other negative emotions following news of colleagues’ deaths from COVID-19.²⁷ Kissel et al reported that nurses frequently described pandemic-related physical and psychological harm and witnessing distress that they had not been previously exposed to.¹⁷

Our findings illustrate the tightrope nurses walked while caring for patients and concerns about the health of their colleagues and family. Consistent with our findings, Howell found that HCWs were afraid of contracting the infection at work and then unknowingly giving it to others such as patients, coworkers, and household members. ²⁷ Murat et al reported that some nurses chose to live separately during the pandemic to avoid spreading COVID-19 to relatives.¹⁹ Several researchers found that concerns about family and children were prevalent and led to fear, anxiety, and burnout among nurses.^18,28,29 Shah et al suggested that nurses experiencing death in the workplace and within their family may have resulted in fear and anxiety about returning to work.²⁹ Garcia and Calvo argued that nurses may have been stigmatized as carriers of COVID-19.¹⁶ In addition, the loss of prepandemic workplace rituals may have impacted performance, team connection, and functioning, and led to increased turnover and decreased attachment to the organization.³⁰

This study described the significant workplace issues nurses endured during the pandemic, including being overwhelmed with additional and/or multiple roles and frustrated and stressed with role changes and short staffing. Nurses endorsed workplace challenges in the context of coworker absenteeism and reassignments to different areas, such as intensive care units (ICUs).¹⁷ Researchers also reported that displaced team members experienced loneliness and isolation when they were removed from their usual place of work and experienced distress caring for patients beyond their perceived competency or comfort.^17,31 Nurses also experienced rapid organizational changes, resource scarcity, high patient-to-nurse ratios, inconsistent or limited communications, and the absence of protocols for prolonged mass casualty events.¹⁷ These challenges, such as significant uncertainty and rapidly changing working conditions, were shared experiences suggested to be similar to “tumbling into chaos,” and likened to the overwhelming situations faced during patient surges to a medical “war zone.”¹⁷

Study respondents indicated that nurses wanted better access to critical supplies, PPE, and COVID-19 testing; more flexible scheduling; longer leave times; and staffing that was appropriate to the patient volumes. These findings aligned with previous research. Howell found that HCWs, especially nurses, worried about childcare because of school closures and increased work hours.²⁷ Nurses felt that hospital support was inaccessible or inadequate and worried about access to essential resources.^17-19,27 Studies also found excessive workloads, and many nurses needed mental or financial assistance from the hospital in addition to more rest and less work.^18,28 An editorial highlighted the potential adverse effects that a lack of PPE could have on staff ’s mental health because of perceptions of institutional betrayal, which occurs when trusted and powerful organizations seemingly act in ways that can harm those dependent on them for safety and well-being.³²

Consistent with other research, this study found that a majority of nurses experienced significant burnout symptoms. The number of nurses reporting symptoms of burnout increased during the pandemic with ICU nurses reporting the highest levels.^17,33 Soto-Rubio et al emphasized that working conditions experienced by nurses, such as interpersonal conflict, lack of trust in administration, workload, and role conflict, contributed to burnout during COVID-19.³⁴ Other studies found that nurses experienced burnout caused by uncertainty, intense work, and extra duties contributed to higher burnout scores.^18,19 It is not surprising that researchers have indicated that nurses experiencing burnout might display depressive and stress-related symptoms, insomnia, and concentration and memory problems.¹⁹

The results of this study indicate that one-third of participating nurses were experiencing moral distress. Burton et al described COVID-19 as an environment in which nurses witnessed, experienced, and at times had to participate in acts that involved ethical violations in care, institutional betrayal, and traumatic strain.⁹ Of note, our findings revealed that both inpatient and outpatient nurses experienced moral distress. Interestingly, Mantri et al found that COVID-19 increased moral injury but not burnout among health professionals, which differed from the results of this study.³⁵

The findings of this study indicate that many nurses experienced depressive symptoms. A systematic review found a similar percentage of HCWs experienced depression while caring for patients with COVID- 19, though a Chinese study found a higher percentage.^36,37 Previous research also found that the most difficult aspect of the COVID- 19 pandemic for nurses was coping with mental disorders such as depression, and that many experienced difficulty sleeping/ had poor sleep quality, believed a similar disaster would occur in the future, were irritated or angered easily, and experienced emotional exhaustion.^15,19 The long-term mental and physical ramifications of caring for individuals with COVID-19 remain unknown. However, previous research suggests a high prevalence of depression, insomnia, anxiety, and distress, which could impair nurses’ professional performance.²⁹

This study reported that a majority of nurses intended to stay in their current position and about 20% intended to leave for another position within the VA. Similar findings conducted early in the pandemic indicated that most participants did not intend to quit nursing.¹⁹

This study’s findings suggest the COVID-19 pandemic had an adverse impact on VISN 21 nurses. It is critical to develop, implement, and adopt adequate measures as early as possible to support the health care system, especially nurses.¹⁸

Implications

Before the COVID-19 pandemic, discussing burnout and moral anguish was common, primarily in critical care.¹⁴ However, these experiences became more widespread throughout nursing settings during the pandemic. Nurse leaders have been identified as responsible for ensuring the environmental safety and personal well-being of their colleagues during and after pandemics.¹⁴

Studies of HCW experiences during COVID-19 provide many insights into future preparedness, strategies to best handle another pandemic during its acute stage, and techniques to address issues that might persist. This study and others suggest that comprehensive interventions in preparation for, during, and after a pandemic are needed. We break down strategies into pandemic and postpandemic interventions based on a synthesis of the literature and the research team’s knowledge and expertise.^{3,14-16,27,29,36,38-44}

Pandemic interventions. During a pandemic, it is important that nurses are adequately cared for to ensure they can continue to provide quality care for others. Resources supporting emotional well-being and addressing moral distress offered during a pandemic are essential. Implementing meaningful strategies could enhance nurses’ health and wellbeing. It is essential that leaders provide nurses a safe work environment/experience during a pandemic by instituting meaningful resources. In addition, developing best practices for leadership are critical.

Postpandemic interventions. Personal experiences of depression, burnout, and moral distress have not spontaneously resolved as the pandemic receded. Providing postpandemic interventions to lessen ongoing and lingering depressive, burnout, and moral distress symptoms experienced by frontline workers are critical. These interventions might prevent long-term health issues and the exodus of nurses.

Postpandemic interventions should include the integration of pandemic planning into new or existing educational or training programs for staff. Promotion and support of mental health services by health system leadership for nursing personnel implemented as a usual service will play an important role in preparing for future pandemics. A key role in preparation is developing and maintaining cooperation and ongoing mutual understanding, respect, and communication between leadership and nursing staff.

Future Research

This study’s findings inform VHA leadership and society about how a large group of nurses were impacted by COVID-19 while caring for patients in inpatient and outpatient settings and could provide a basis for extending this research to other groups of nurses or health care personnel. Future research might be helpful in identifying the impact of COVID-19 on nursing leadership. During conversations with nursing leadership, a common theme identified was that nurses did not feel that leadership was fully prepared for the level of emergency the pandemic created both personally and professionally; leadership expressed experiences similar to nurses providing direct care and felt powerless to help their nursing staff. Other areas of research could include identifying underlying factors contributing to burnout and moral distress and describing nurses’ expectations of or needs from leadership to best manage burnout and moral distress.

Limitations

Experiences of nurses who stopped working were not captured and information about their experiences might have different results. The survey distribution was limited to 2 emails (an initial email and a second at midpoint) sent at the discretion of the nurse executive of each facility. The study timeline was long because of complex regulatory protective processes inherent in the VHA system for researchers to include initial institutional review board review process, union notifications, and each facility’s response to the survey. Although 860 nurses participated, this was 15% of the 5586 VISN 21 nurses at the time of the study. Many clinical inpatient nurses do not have regular access to email, which might have impacted participation rate.

CONCLUSIONS

This study identified the impact COVID-19 had on nurses who worked in a large hospital system. The research team outlined strategies to be employed during and after the pandemic, such as preplanning for future pandemics to provide a framework for a comprehensive pandemic response protocol.

This study adds to generalized knowledge because it captured voices of inpatient and outpatient nurses, the latter had not been previously studied. As nurses and health care organizations move beyond the pandemic with a significant number of nurses continuing to experience effects, there is a need to institute interventions to assist nurses in healing and begin preparations for future pandemics.

Discussion

The patient’s violaceous papule on the nose with an apple jelly appearance is consistent with lupus pernio—a cutaneous form of sarcoidosis associated with respiratory involvement. Lupus pernio disproportionately affects African Americans, which further supports this diagnosis.¹ Lupus pernio is characterized by violaceous, indurated plaques predominantly on the face. It has a strong association with systemic sarcoidosis and often involves the lungs and other organs, as seen in this case. The laboratory results support this diagnosis. Hypercalcemia is a common systemic manifestation of sarcoidosis due to increased production of 1,25-dihydroxyvitamin D by activated macrophages with granulomas.² Elevated chitotriosidase, an enzyme produced by macrophages, is another biomarker of sarcoidosis reflecting granuloma burden.³

The differential diagnoses included Langerhans cell histiocytosis (LCH), discoid lupus erythematosus, granulomatosis with polyangiitis, and granuloma annulare. However, these diagnoses did not fully align with the entirety of the patient’s clinical presentation and laboratory findings. LCH is a rare neoplastic disorder characterized by the abnormal proliferation and accumulation of Langerhans cells, a type of dendritic cell involved in immune response, in various tissues such as the skin and bone. Dermatologic findings in LCH include brown/purple papules and an erythematous papular rash rather than the violaceous plaques/papules in lupus pernio. LCH can have lung involvement; it typically presents with nodular or cystic changes in the upper lobes as opposed to the bibasilar opacities seen in this case.

Discoid lupus erythematosus presents with characteristic round, erythematous, scaly plaques on the cheeks, scalp, and ears. This is different from the apple jelly appearance seen in this case and does not present with systemic granulomatous involvement.

Typical manifestations of granulomatosis with polyangiitis, formerly known as Wegener’s granulomatosis, include renal disease, upper and lower respiratory tract involvement, or necrotizing vasculitis. Cutaneous manifestions of granulomatosis with polyangiitis typically include purpura or ulcers rather than the violaceous plaques seen in lupus pernio. Patients with granulomatosis with polyangiitis would also present with nonspecific systemic symptoms such as fever, weight loss, and malaise, which are not depicted in this case.⁴

Granuloma annulare is a benign condition that often presents with annular plaques that are skin-colored rather than violaceous. These plaques are often found on the hands and feet rather than the face. This condition also lacks the systemic manifestations seen in this case.

In primary care, encountering violaceous papule and plaques on the face, especially on the nasal alae or ear, should be concerning for possible lupus pernio, particularly in high-risk populations such as young African Americans. These lesions generally have a more indurated “deep” and “doughy” appearance and can result in scarring, distinguishing them from other types of cutaneous sarcoidosis. An apple jelly appearance seen on diascopy with a glass slide can further support the diagnosis. While the lesions are typically asymptomatic, patients may be concerned about potential cosmetic disfigurement. Given the potential for scarring and the association with systemic sarcoidosis, a dermatology referral is recommended for further evaluation and management.

A detailed patient history, physical examination, and laboratory exams are essential to accurately diagnose lupus pernio. Biopsy of a skin lesion, serum markers, and imaging studies were utilized to help assess systemic involvement and further confirm diagnosis in this patient. Following the diagnosis, the patient was started on his current regimen of prednisone, methotrexate, and hydroxychloroquine, which are standard therapies for managing both cutaneous and systemic sarcoidosis.

This case shows the importance of recognizing lupus pernio, a distinct form of cutaneous sarcoidosis, in patients presenting with characteristic skin lesions and systemic involvement. It is essential to differentiate it from other granulomatous and inflammatory skin conditions to ensure appropriate management and prevent complications.

Federal Practitioner thanks the Association of Military Dermatologists (militaryderm.org) for their assistance in developing the Image Challenge. Submissions based on photographs, radiography, or any other visual medium are welcomed.

Discussion

The patient’s violaceous papule on the nose with an apple jelly appearance is consistent with lupus pernio—a cutaneous form of sarcoidosis associated with respiratory involvement. Lupus pernio disproportionately affects African Americans, which further supports this diagnosis.¹ Lupus pernio is characterized by violaceous, indurated plaques predominantly on the face. It has a strong association with systemic sarcoidosis and often involves the lungs and other organs, as seen in this case. The laboratory results support this diagnosis. Hypercalcemia is a common systemic manifestation of sarcoidosis due to increased production of 1,25-dihydroxyvitamin D by activated macrophages with granulomas.² Elevated chitotriosidase, an enzyme produced by macrophages, is another biomarker of sarcoidosis reflecting granuloma burden.³

The differential diagnoses included Langerhans cell histiocytosis (LCH), discoid lupus erythematosus, granulomatosis with polyangiitis, and granuloma annulare. However, these diagnoses did not fully align with the entirety of the patient’s clinical presentation and laboratory findings. LCH is a rare neoplastic disorder characterized by the abnormal proliferation and accumulation of Langerhans cells, a type of dendritic cell involved in immune response, in various tissues such as the skin and bone. Dermatologic findings in LCH include brown/purple papules and an erythematous papular rash rather than the violaceous plaques/papules in lupus pernio. LCH can have lung involvement; it typically presents with nodular or cystic changes in the upper lobes as opposed to the bibasilar opacities seen in this case.

Discoid lupus erythematosus presents with characteristic round, erythematous, scaly plaques on the cheeks, scalp, and ears. This is different from the apple jelly appearance seen in this case and does not present with systemic granulomatous involvement.

Typical manifestations of granulomatosis with polyangiitis, formerly known as Wegener’s granulomatosis, include renal disease, upper and lower respiratory tract involvement, or necrotizing vasculitis. Cutaneous manifestions of granulomatosis with polyangiitis typically include purpura or ulcers rather than the violaceous plaques seen in lupus pernio. Patients with granulomatosis with polyangiitis would also present with nonspecific systemic symptoms such as fever, weight loss, and malaise, which are not depicted in this case.⁴

Granuloma annulare is a benign condition that often presents with annular plaques that are skin-colored rather than violaceous. These plaques are often found on the hands and feet rather than the face. This condition also lacks the systemic manifestations seen in this case.

In primary care, encountering violaceous papule and plaques on the face, especially on the nasal alae or ear, should be concerning for possible lupus pernio, particularly in high-risk populations such as young African Americans. These lesions generally have a more indurated “deep” and “doughy” appearance and can result in scarring, distinguishing them from other types of cutaneous sarcoidosis. An apple jelly appearance seen on diascopy with a glass slide can further support the diagnosis. While the lesions are typically asymptomatic, patients may be concerned about potential cosmetic disfigurement. Given the potential for scarring and the association with systemic sarcoidosis, a dermatology referral is recommended for further evaluation and management.

A detailed patient history, physical examination, and laboratory exams are essential to accurately diagnose lupus pernio. Biopsy of a skin lesion, serum markers, and imaging studies were utilized to help assess systemic involvement and further confirm diagnosis in this patient. Following the diagnosis, the patient was started on his current regimen of prednisone, methotrexate, and hydroxychloroquine, which are standard therapies for managing both cutaneous and systemic sarcoidosis.

This case shows the importance of recognizing lupus pernio, a distinct form of cutaneous sarcoidosis, in patients presenting with characteristic skin lesions and systemic involvement. It is essential to differentiate it from other granulomatous and inflammatory skin conditions to ensure appropriate management and prevent complications.

Federal Practitioner thanks the Association of Military Dermatologists (militaryderm.org) for their assistance in developing the Image Challenge. Submissions based on photographs, radiography, or any other visual medium are welcomed.

Discussion

The patient’s violaceous papule on the nose with an apple jelly appearance is consistent with lupus pernio—a cutaneous form of sarcoidosis associated with respiratory involvement. Lupus pernio disproportionately affects African Americans, which further supports this diagnosis.¹ Lupus pernio is characterized by violaceous, indurated plaques predominantly on the face. It has a strong association with systemic sarcoidosis and often involves the lungs and other organs, as seen in this case. The laboratory results support this diagnosis. Hypercalcemia is a common systemic manifestation of sarcoidosis due to increased production of 1,25-dihydroxyvitamin D by activated macrophages with granulomas.² Elevated chitotriosidase, an enzyme produced by macrophages, is another biomarker of sarcoidosis reflecting granuloma burden.³

The differential diagnoses included Langerhans cell histiocytosis (LCH), discoid lupus erythematosus, granulomatosis with polyangiitis, and granuloma annulare. However, these diagnoses did not fully align with the entirety of the patient’s clinical presentation and laboratory findings. LCH is a rare neoplastic disorder characterized by the abnormal proliferation and accumulation of Langerhans cells, a type of dendritic cell involved in immune response, in various tissues such as the skin and bone. Dermatologic findings in LCH include brown/purple papules and an erythematous papular rash rather than the violaceous plaques/papules in lupus pernio. LCH can have lung involvement; it typically presents with nodular or cystic changes in the upper lobes as opposed to the bibasilar opacities seen in this case.

Discoid lupus erythematosus presents with characteristic round, erythematous, scaly plaques on the cheeks, scalp, and ears. This is different from the apple jelly appearance seen in this case and does not present with systemic granulomatous involvement.

Typical manifestations of granulomatosis with polyangiitis, formerly known as Wegener’s granulomatosis, include renal disease, upper and lower respiratory tract involvement, or necrotizing vasculitis. Cutaneous manifestions of granulomatosis with polyangiitis typically include purpura or ulcers rather than the violaceous plaques seen in lupus pernio. Patients with granulomatosis with polyangiitis would also present with nonspecific systemic symptoms such as fever, weight loss, and malaise, which are not depicted in this case.⁴

Granuloma annulare is a benign condition that often presents with annular plaques that are skin-colored rather than violaceous. These plaques are often found on the hands and feet rather than the face. This condition also lacks the systemic manifestations seen in this case.

In primary care, encountering violaceous papule and plaques on the face, especially on the nasal alae or ear, should be concerning for possible lupus pernio, particularly in high-risk populations such as young African Americans. These lesions generally have a more indurated “deep” and “doughy” appearance and can result in scarring, distinguishing them from other types of cutaneous sarcoidosis. An apple jelly appearance seen on diascopy with a glass slide can further support the diagnosis. While the lesions are typically asymptomatic, patients may be concerned about potential cosmetic disfigurement. Given the potential for scarring and the association with systemic sarcoidosis, a dermatology referral is recommended for further evaluation and management.

A detailed patient history, physical examination, and laboratory exams are essential to accurately diagnose lupus pernio. Biopsy of a skin lesion, serum markers, and imaging studies were utilized to help assess systemic involvement and further confirm diagnosis in this patient. Following the diagnosis, the patient was started on his current regimen of prednisone, methotrexate, and hydroxychloroquine, which are standard therapies for managing both cutaneous and systemic sarcoidosis.

This case shows the importance of recognizing lupus pernio, a distinct form of cutaneous sarcoidosis, in patients presenting with characteristic skin lesions and systemic involvement. It is essential to differentiate it from other granulomatous and inflammatory skin conditions to ensure appropriate management and prevent complications.

Federal Practitioner thanks the Association of Military Dermatologists (militaryderm.org) for their assistance in developing the Image Challenge. Submissions based on photographs, radiography, or any other visual medium are welcomed.

Express Scripts, the contractor that manages the pharmacy benefit for Tricare, the military health insurance program, announced in 2021 that after a 5-year absence, CVS Pharmacy was once more in the network. In 2023, CVS had the largest profits of any pharmacy chain in the United States, about $159 billion, and generated a quarter of the overall revenue of the US pharmacy industry.¹ Tricare officials heralded the return of CVS as a move that would offer US Department of Defense (DoD) beneficiaries more competitive prices, convenient access, and overall quality.²

DOJ Files Lawsuit Against CVS

In December 2024, the US Department of Justice (DoJ) filed a lawsuit alleging that CVS violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA).^3,4 The United States ex rel. Estright v Health Corporation, et al, filed in Rhode Island, charged that CVS “routinely” and “knowingly” filled invalid prescriptions for controlled substances violating the CSA and then billed federal health care programs for payment for these prescriptions, a breach of the FCA.⁵ The DoJ alleged that CVS pharmacies and pharmacists filled prescriptions for controlled substances that (1) lacked a legitimate medical purpose; (2) were not legally valid; and/or (3) were not issued in the usual course of medical practice. ⁶ CVS contests the charges and issued an official response, stating that it disputes the allegations as false, plans to disprove them in litigation, and has nonetheless fully cooperated with the investigation.⁷

The allegations involved prescriptions for drugs like opioids and benzodiazepines, primary culprits in the American overdose epidemic.⁸ The complaint notes that the prescriptions were early refills in excessive quantities and included what has been called the “holy trinity” of dangerous medications: opioids, benzodiazepines, and muscle relaxants. ^5,8 Even worse (if that is possible), as the complaint outlines, CVS had access to data from both inside and outside the company that these prescriptions came from notorious pill mills and were hence unlawful and yet continued to fill them, leading the DoJ to file the more serious charge that the corporation “knowingly” violated the CSA and “prioritized profits over safety in dispensing controlled substances.”^5,6

The Unholy Trinity

The infamous members of what I prefer to call the “unholy trinity” are a benzodiazepine, often alprazolam, an opioid, and the muscle relaxant carisoprodol. The combination amplifies each agent’s independent risk of respiratory depression. The latter is a schedule IV medication with an active metabolite, meprobamate, that also has this adverse effect. All 3 drugs have high abuse potential and, when combined, increase the risk of fatal overdose. The colloquial name holy trinity derives from the synergistic euphoria experienced when taking this triple cocktail of sedative agents.⁹ This pharmacological recipe for disaster is the house specialty of pill mills: infamous storefront practices that generate high profits and exploit persons with chronic pain and addiction by handing out controlled substances with little clinical assessment and even less oversight.¹⁰

When the Means Become the End

The DoJ allegations suggest that the violations resulted from “corporate-mandated performance metrics, incentive compensation, and staffing policies that prioritized corporate profits over patient safety.”⁶ If the allegations are true, why would a company reinvited by Tricare to serve the nation’s heroes seemingly engage in illegal practices? While CVS has not responded in court, their statement argued that “too often, we have seen government agencies and trial lawyers question the good-faith decisions made by pharmacists while a patient waits at the pharmacy counter, often in pain.”⁶

The DoJ complaint offers a cautionary warning for the US health care system, which is increasingly being micromanaged in the pursuit of efficiency. Like many practitioners in and out of the federal system, I get a cold chill when I read the word productivity. “CVS pharmacists described working at CVS as ‘soul crushing’ because it was impossible to meet the company’s expectations,” the complaint alleges, because “CVS set staffing levels so low that it was impossible for pharmacists to comply with their legal obligations and meet CVS’s demanding metrics.”⁵ Did top-down mandates drive the alleged activities by imposing unattainable performance metrics on pharmacists, offering incentives that encouraged and rewarded corner-cutting, and refusing to fund sufficient staffing to ensure patient safety? This may be what happens when the means (efficiency) become the end rather than a mechanism to achieve the goal of more accessible, affordable, high-quality health care.

Ethically, what is most concerning is that leadership intentionally “deprived its pharmacists of crucial information” about specific practitioners known to engage in illegal prescribing practices.⁶ CVS did not provide pharmacists with “information about prescribers’ prescribing habits that CVS routinely collected and reviewed at the corporate level,” and even removed prescriber blocks that were implemented at Target pharmacies before it was acquired by CVS.⁵ The first element of informed consent is providing patients with adequate information upon which to decide whether to accept or decline treatment. ¹¹ In this situation, however, CVS allegedly prevented “pharmacists from warning one another about certain prescribers.”⁶

If true, the company deprived frontline pharmacists of the information they needed to safely and responsibly dispense medications: “The practices alleged contributed to the opioid crisis and opioid-related deaths, and today’s complaint seeks to hold CVS accountable for its misconduct.”⁶ Though the cost in human life that may have resulted from CSA violations must absolutely and always outweigh financial considerations, the economic damage to Tricare from fraudulent billing and the betrayal of its fiduciary responsinility cannot be underestimated.

A Corporate Morality Play

CVS is not the only company, nor is pharmacy the only industry in health care, that has been the subject of watchdog agency lawsuits or variegated forms of wrongdoing, including violations of the CSA and FCA.^10,12 As of this writing, the DoJ case against CVS has not been heard, much less adjudicated in a court of law. It is ironic that both the DoJ claims and the CVS rebuttal describe the manifest conflict of obligation that pharmacists confront between protecting their livelihood and safeguarding patients’ lives as suggested in the epigraph that has been attributed to the 19th-century British physician and medical educator Peter Mere Latham. It is a dilemma that a growing number of health care practitioners face daily in a vocation becoming increasingly commercialized. It is all too easy for an individual physician, nurse, or pharmacist to feel hopeless and helpless before the behemoth might of a large and looming entity. Yet, it was a whistleblower whose moral courage led to the DoJ investigation and subsequent charges.¹³ We must all never doubt the power of a committed person of conscience to withstand the pressure to mutate medications into poison and stand up for the principles of our professions and inspire a community of colleagues to follow their example.

Express Scripts, the contractor that manages the pharmacy benefit for Tricare, the military health insurance program, announced in 2021 that after a 5-year absence, CVS Pharmacy was once more in the network. In 2023, CVS had the largest profits of any pharmacy chain in the United States, about $159 billion, and generated a quarter of the overall revenue of the US pharmacy industry.¹ Tricare officials heralded the return of CVS as a move that would offer US Department of Defense (DoD) beneficiaries more competitive prices, convenient access, and overall quality.²

DOJ Files Lawsuit Against CVS

In December 2024, the US Department of Justice (DoJ) filed a lawsuit alleging that CVS violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA).^3,4 The United States ex rel. Estright v Health Corporation, et al, filed in Rhode Island, charged that CVS “routinely” and “knowingly” filled invalid prescriptions for controlled substances violating the CSA and then billed federal health care programs for payment for these prescriptions, a breach of the FCA.⁵ The DoJ alleged that CVS pharmacies and pharmacists filled prescriptions for controlled substances that (1) lacked a legitimate medical purpose; (2) were not legally valid; and/or (3) were not issued in the usual course of medical practice. ⁶ CVS contests the charges and issued an official response, stating that it disputes the allegations as false, plans to disprove them in litigation, and has nonetheless fully cooperated with the investigation.⁷

The allegations involved prescriptions for drugs like opioids and benzodiazepines, primary culprits in the American overdose epidemic.⁸ The complaint notes that the prescriptions were early refills in excessive quantities and included what has been called the “holy trinity” of dangerous medications: opioids, benzodiazepines, and muscle relaxants. ^5,8 Even worse (if that is possible), as the complaint outlines, CVS had access to data from both inside and outside the company that these prescriptions came from notorious pill mills and were hence unlawful and yet continued to fill them, leading the DoJ to file the more serious charge that the corporation “knowingly” violated the CSA and “prioritized profits over safety in dispensing controlled substances.”^5,6

The Unholy Trinity

The infamous members of what I prefer to call the “unholy trinity” are a benzodiazepine, often alprazolam, an opioid, and the muscle relaxant carisoprodol. The combination amplifies each agent’s independent risk of respiratory depression. The latter is a schedule IV medication with an active metabolite, meprobamate, that also has this adverse effect. All 3 drugs have high abuse potential and, when combined, increase the risk of fatal overdose. The colloquial name holy trinity derives from the synergistic euphoria experienced when taking this triple cocktail of sedative agents.⁹ This pharmacological recipe for disaster is the house specialty of pill mills: infamous storefront practices that generate high profits and exploit persons with chronic pain and addiction by handing out controlled substances with little clinical assessment and even less oversight.¹⁰

When the Means Become the End

The DoJ allegations suggest that the violations resulted from “corporate-mandated performance metrics, incentive compensation, and staffing policies that prioritized corporate profits over patient safety.”⁶ If the allegations are true, why would a company reinvited by Tricare to serve the nation’s heroes seemingly engage in illegal practices? While CVS has not responded in court, their statement argued that “too often, we have seen government agencies and trial lawyers question the good-faith decisions made by pharmacists while a patient waits at the pharmacy counter, often in pain.”⁶

The DoJ complaint offers a cautionary warning for the US health care system, which is increasingly being micromanaged in the pursuit of efficiency. Like many practitioners in and out of the federal system, I get a cold chill when I read the word productivity. “CVS pharmacists described working at CVS as ‘soul crushing’ because it was impossible to meet the company’s expectations,” the complaint alleges, because “CVS set staffing levels so low that it was impossible for pharmacists to comply with their legal obligations and meet CVS’s demanding metrics.”⁵ Did top-down mandates drive the alleged activities by imposing unattainable performance metrics on pharmacists, offering incentives that encouraged and rewarded corner-cutting, and refusing to fund sufficient staffing to ensure patient safety? This may be what happens when the means (efficiency) become the end rather than a mechanism to achieve the goal of more accessible, affordable, high-quality health care.

Ethically, what is most concerning is that leadership intentionally “deprived its pharmacists of crucial information” about specific practitioners known to engage in illegal prescribing practices.⁶ CVS did not provide pharmacists with “information about prescribers’ prescribing habits that CVS routinely collected and reviewed at the corporate level,” and even removed prescriber blocks that were implemented at Target pharmacies before it was acquired by CVS.⁵ The first element of informed consent is providing patients with adequate information upon which to decide whether to accept or decline treatment. ¹¹ In this situation, however, CVS allegedly prevented “pharmacists from warning one another about certain prescribers.”⁶

If true, the company deprived frontline pharmacists of the information they needed to safely and responsibly dispense medications: “The practices alleged contributed to the opioid crisis and opioid-related deaths, and today’s complaint seeks to hold CVS accountable for its misconduct.”⁶ Though the cost in human life that may have resulted from CSA violations must absolutely and always outweigh financial considerations, the economic damage to Tricare from fraudulent billing and the betrayal of its fiduciary responsinility cannot be underestimated.

A Corporate Morality Play

CVS is not the only company, nor is pharmacy the only industry in health care, that has been the subject of watchdog agency lawsuits or variegated forms of wrongdoing, including violations of the CSA and FCA.^10,12 As of this writing, the DoJ case against CVS has not been heard, much less adjudicated in a court of law. It is ironic that both the DoJ claims and the CVS rebuttal describe the manifest conflict of obligation that pharmacists confront between protecting their livelihood and safeguarding patients’ lives as suggested in the epigraph that has been attributed to the 19th-century British physician and medical educator Peter Mere Latham. It is a dilemma that a growing number of health care practitioners face daily in a vocation becoming increasingly commercialized. It is all too easy for an individual physician, nurse, or pharmacist to feel hopeless and helpless before the behemoth might of a large and looming entity. Yet, it was a whistleblower whose moral courage led to the DoJ investigation and subsequent charges.¹³ We must all never doubt the power of a committed person of conscience to withstand the pressure to mutate medications into poison and stand up for the principles of our professions and inspire a community of colleagues to follow their example.

Express Scripts, the contractor that manages the pharmacy benefit for Tricare, the military health insurance program, announced in 2021 that after a 5-year absence, CVS Pharmacy was once more in the network. In 2023, CVS had the largest profits of any pharmacy chain in the United States, about $159 billion, and generated a quarter of the overall revenue of the US pharmacy industry.¹ Tricare officials heralded the return of CVS as a move that would offer US Department of Defense (DoD) beneficiaries more competitive prices, convenient access, and overall quality.²

DOJ Files Lawsuit Against CVS

In December 2024, the US Department of Justice (DoJ) filed a lawsuit alleging that CVS violated both the Controlled Substances Act (CSA) and the False Claims Act (FCA).^3,4 The United States ex rel. Estright v Health Corporation, et al, filed in Rhode Island, charged that CVS “routinely” and “knowingly” filled invalid prescriptions for controlled substances violating the CSA and then billed federal health care programs for payment for these prescriptions, a breach of the FCA.⁵ The DoJ alleged that CVS pharmacies and pharmacists filled prescriptions for controlled substances that (1) lacked a legitimate medical purpose; (2) were not legally valid; and/or (3) were not issued in the usual course of medical practice. ⁶ CVS contests the charges and issued an official response, stating that it disputes the allegations as false, plans to disprove them in litigation, and has nonetheless fully cooperated with the investigation.⁷

The allegations involved prescriptions for drugs like opioids and benzodiazepines, primary culprits in the American overdose epidemic.⁸ The complaint notes that the prescriptions were early refills in excessive quantities and included what has been called the “holy trinity” of dangerous medications: opioids, benzodiazepines, and muscle relaxants. ^5,8 Even worse (if that is possible), as the complaint outlines, CVS had access to data from both inside and outside the company that these prescriptions came from notorious pill mills and were hence unlawful and yet continued to fill them, leading the DoJ to file the more serious charge that the corporation “knowingly” violated the CSA and “prioritized profits over safety in dispensing controlled substances.”^5,6

The Unholy Trinity

The infamous members of what I prefer to call the “unholy trinity” are a benzodiazepine, often alprazolam, an opioid, and the muscle relaxant carisoprodol. The combination amplifies each agent’s independent risk of respiratory depression. The latter is a schedule IV medication with an active metabolite, meprobamate, that also has this adverse effect. All 3 drugs have high abuse potential and, when combined, increase the risk of fatal overdose. The colloquial name holy trinity derives from the synergistic euphoria experienced when taking this triple cocktail of sedative agents.⁹ This pharmacological recipe for disaster is the house specialty of pill mills: infamous storefront practices that generate high profits and exploit persons with chronic pain and addiction by handing out controlled substances with little clinical assessment and even less oversight.¹⁰

When the Means Become the End

The DoJ allegations suggest that the violations resulted from “corporate-mandated performance metrics, incentive compensation, and staffing policies that prioritized corporate profits over patient safety.”⁶ If the allegations are true, why would a company reinvited by Tricare to serve the nation’s heroes seemingly engage in illegal practices? While CVS has not responded in court, their statement argued that “too often, we have seen government agencies and trial lawyers question the good-faith decisions made by pharmacists while a patient waits at the pharmacy counter, often in pain.”⁶

The DoJ complaint offers a cautionary warning for the US health care system, which is increasingly being micromanaged in the pursuit of efficiency. Like many practitioners in and out of the federal system, I get a cold chill when I read the word productivity. “CVS pharmacists described working at CVS as ‘soul crushing’ because it was impossible to meet the company’s expectations,” the complaint alleges, because “CVS set staffing levels so low that it was impossible for pharmacists to comply with their legal obligations and meet CVS’s demanding metrics.”⁵ Did top-down mandates drive the alleged activities by imposing unattainable performance metrics on pharmacists, offering incentives that encouraged and rewarded corner-cutting, and refusing to fund sufficient staffing to ensure patient safety? This may be what happens when the means (efficiency) become the end rather than a mechanism to achieve the goal of more accessible, affordable, high-quality health care.

Ethically, what is most concerning is that leadership intentionally “deprived its pharmacists of crucial information” about specific practitioners known to engage in illegal prescribing practices.⁶ CVS did not provide pharmacists with “information about prescribers’ prescribing habits that CVS routinely collected and reviewed at the corporate level,” and even removed prescriber blocks that were implemented at Target pharmacies before it was acquired by CVS.⁵ The first element of informed consent is providing patients with adequate information upon which to decide whether to accept or decline treatment. ¹¹ In this situation, however, CVS allegedly prevented “pharmacists from warning one another about certain prescribers.”⁶

If true, the company deprived frontline pharmacists of the information they needed to safely and responsibly dispense medications: “The practices alleged contributed to the opioid crisis and opioid-related deaths, and today’s complaint seeks to hold CVS accountable for its misconduct.”⁶ Though the cost in human life that may have resulted from CSA violations must absolutely and always outweigh financial considerations, the economic damage to Tricare from fraudulent billing and the betrayal of its fiduciary responsinility cannot be underestimated.

A Corporate Morality Play

CVS is not the only company, nor is pharmacy the only industry in health care, that has been the subject of watchdog agency lawsuits or variegated forms of wrongdoing, including violations of the CSA and FCA.^10,12 As of this writing, the DoJ case against CVS has not been heard, much less adjudicated in a court of law. It is ironic that both the DoJ claims and the CVS rebuttal describe the manifest conflict of obligation that pharmacists confront between protecting their livelihood and safeguarding patients’ lives as suggested in the epigraph that has been attributed to the 19th-century British physician and medical educator Peter Mere Latham. It is a dilemma that a growing number of health care practitioners face daily in a vocation becoming increasingly commercialized. It is all too easy for an individual physician, nurse, or pharmacist to feel hopeless and helpless before the behemoth might of a large and looming entity. Yet, it was a whistleblower whose moral courage led to the DoJ investigation and subsequent charges.¹³ We must all never doubt the power of a committed person of conscience to withstand the pressure to mutate medications into poison and stand up for the principles of our professions and inspire a community of colleagues to follow their example.

During their 12-hour shifts, registered nurses (RNs) in Arizona and Arkansas perform many of the same tasks as RNs in Wisconsin and Wyoming: Assessing patients, monitoring vital signs, administering medications, and charting records to provide the best patient care. The work might be similar, but there are vast differences in the number of RNs in each state.

In states like Idaho, Utah, and Nevada, which have the lowest number of nurses per capita, there are as few as 7 nurses per 1000 residents, compared with South Dakota and the District of Columbia, which have double the number of nurses than underserved states — giving them the highest number of nurses per capita.

Even states with the largest number of nurses per capita are not immune to the nursing shortage. The National Bureau of Labor Statistics estimates that there will be 195,400 job openings for RNs from 2021 to 2031.

So, what makes it easier for some states to recruit and retain RNs than others?

 

States With the Highest Number of Nurses Per Capita

South Dakota

RNs per 1000 residents: 15.79

Average wage: $67,030 or $32.23 per hour

Average rent in Sioux Falls: $1192 per month

The Midwestern state has more miles of shoreline than Florida, herds of wild buffalo, the highest summit east of the Rockies, and more nurses per capita than all other states . Healthcare is one of the major industries in the Mount Rushmore State.

Haifa Abou Samra, dean and professor at the University of South Dakota School of Health Sciences, Vermillion, isn’t surprised that RNs want to call the state home. 

“South Dakota is a nice place to live,” Samra said. “[The] schools are wonderful. If people are growing families, there is support; neighbors support their neighbors, and it’s a relatively safe community.”

South Dakota has 19 approved nursing education programs that graduated 878 RNs in 2022. Scholarships and student loan forgiveness programs have helped attract qualified RNs, and collaborations between education and industry have been instrumental in addressing the nursing shortage, Samra told this news organization.

Even though RNs earn less than the median wage ($87,070 per year/41.38 per hour), South Dakota has a low cost of living and no individual income tax, which helps stretch those earnings.

 

District of Columbia

RNs per 1000 residents: 15.39

Average wage: $105,220 or $50.59 per hour

Average rent in Washington, DC: $2485 per month

After a shift at some of the top-ranking hospitals in the nation, RNs working in the compact capital region can explore museums, monuments, and cultural sites; walk along the banks of the Potomac River; or grab a bite at award-winning restaurants.

Washington, a top-ranking metro area because of its growth, high wages, and access to economic opportunities, is also home to several top-tier hospitals and some of the best healthcare in the nation, and RNs who want to pursue continuing education have access to top-tier universities.

Nurses in Washington, DC, might make some of the highest wages in the nation, but the region also has the second-highest cost of living in the United States, with average rents topping $2400 per month and an average home price of $594,337.

 

North Dakota

RNs per 1000 residents: 12.99

Average wage: $74,930 or $36.03 per hour

Average rent in Fargo: $1051 per month

North Dakota projects a 10.4% increase in employment for RNs, which is higher than the national average, and the state has implemented several strategies to address chronic nursing shortages. The Nurse Staffing Clearinghouse connects nursing school graduates with local employers and created a statewide nursing staffing pool for in-state recruitment of travel nurses.

But it’s not just plentiful job opportunities and a low cost of living that attract nurses to the Peace Garden State. The state and its largest cities, Bismarck and Fargo, hold several “best of” accolades, including nods for the safest places to live and among the Best Places to Raise a Family, giving it high marks for quality of life.

Sure, the winters are cold, but the outdoor recreation can’t be beaten. RNs can bundle up and see the bighorn sheep in the Badlands at Theodore Roosevelt National Park or explore expansive terrain for skiing, snowboarding, and snowmobile trails.

 

States With the Lowest Number of Nurses Per Capita

Nevada

RNs per 1000 residents: 7.92

Average wage: $96,201 or $46.25 per hour

Average rent in Las Vegas: $1478 per month

Despite a projected 23% job growth for RNs between 2020 and 2030, the state has struggled to fill open positions. It might be the higher-than-average cost of living (9.7% higher than the US average) or higher-than-average crime rates that make RNs reluctant to gamble on a job in the Silver State. But there are some big wins for nurses in the state.

Salaries are higher than the national average, there is no state income tax, and some of the lowest property taxes in the nation. Thanks to new legislation, RNs with student loan debt won’t have to bet on black at the casino to make their payments. The Health Equity and Loan Assistance Program is a new initiative that offers up to $120,000 in loan repayment assistance to providers, including RNs, who commit to working in underserved and rural areas across the state for 5 years.

The state also has incredible attractions, from the neon lights and over-the-top architecture in Las Vegas to iconic red rock canyons, stunning state parks, and landmarks like Hoover Dam and Lake Tahoe.

 

Utah

RNs per 1000 residents: 7.05

Average wage: $79,790 or $38.36 per hour

Average rent in Salt Lake City: $1611 per month

Healthcare is one of the biggest employers in Utah, and nurses are the most in-demand healthcare workers in the state. But below-average wages and a cost of living that is a whopping 28% higher than the national average could be some reasons that the Beehive State is struggling to attract nurses.

A high number of job vacancies mean higher patient-to-nurse ratios, creating additional stress for a workforce prone to burnout. Much of the state is rural, public transportation is inadequate, and poor air quality causes frequent haze and smog.

The challenges are offset by some big benefits: Utah has been ranked as the “best state” thanks to the strong economy, infrastructure, and quality education — and it doesn’t hurt that Utah is home to myriad outdoor recreation opportunities and the stunning scenery at landmarks like Bryce Canyon and Arches National Park.

Moreover, Utah is hustling to boost its RN workforce. The University of Utah, Salt Lake City, has increased enrollment by 25% and hired additional faculty to help boost the nursing workforce — and those who work in hospitals and health clinics across the state benefit from a flat 4.55% individual income tax rate.

 

Idaho

RNs per 1000 residents: 7.02

Average wage: $80,130 or $38.53 per hour

Average rent in Boise: $1646 per month

Although the nursing workforce in Idaho has increased, it still ranks as the lowest in the nation. Teresa Stanfill, DNP, RN, executive director for the Idaho Center for Nursing, said that the number of new nurses is too low to replace the number of retiring nurses.

The state introduced loan repayment programs that award up to $25,000 to cover student loan debt, and hospitals and health systems often offer sign-on bonuses and relocation packages to attract RNs. But long winters, an isolated location, and limited cultural options can make it harder to attract nurses to the state.

It’s easier to recruit RNs to suburban areas like Boise, Meridian, and Nampa, but rural parts of the state struggle, Stanfill added. The nursing shortage is among the reasons that 11 hospitals and emergency departments closed in 2024, and healthcare organizations slashed services across the state.

Idaho has a lot to offer RNs, from small-town charm, reasonable cost of living, and gorgeous landscapes that make it one of the top 10 fastest-growing states in the nation. Collaboration between industry leaders and nursing programs is focused on finding creative solutions to boost the nursing workforce in Idaho.

A version of this article first appeared on Medscape.com.

During their 12-hour shifts, registered nurses (RNs) in Arizona and Arkansas perform many of the same tasks as RNs in Wisconsin and Wyoming: Assessing patients, monitoring vital signs, administering medications, and charting records to provide the best patient care. The work might be similar, but there are vast differences in the number of RNs in each state.

In states like Idaho, Utah, and Nevada, which have the lowest number of nurses per capita, there are as few as 7 nurses per 1000 residents, compared with South Dakota and the District of Columbia, which have double the number of nurses than underserved states — giving them the highest number of nurses per capita.

Even states with the largest number of nurses per capita are not immune to the nursing shortage. The National Bureau of Labor Statistics estimates that there will be 195,400 job openings for RNs from 2021 to 2031.

So, what makes it easier for some states to recruit and retain RNs than others?