Employing Greek Tragedy to Help Medical Professionals Cope with COVID

Frontline medical workers continue to confront unprecedented professional and personal challenges of the COVID-19 pandemic. From their own inadequate access to personal protective equipment to facing impossible decisions about allocating limited lifesaving resources among their patients, clinicians have experienced feelings of betrayal, anger, and fear.

Now, by combining one of the pandemic’s newest forms of communication – the Zoom webinar – with the ancient art of Greek tragedy, an innovative project is reaching frontline medical workers who may be struggling in isolation, providing them the opportunity to name and communalize their experiences, connect with colleagues, and access available resources.

Theater of War for Frontline Medical Providers – developed by Theater of War Productions, the Johns Hopkins Berman Institute of Bioethics, and the Johns Hopkins Program in Arts, Humanities & Health – presents dramatic readings by acclaimed actors of scenes from ancient Greek plays for audiences of frontline medical providers to open up powerful dialogue about difficult subjects. In a paper published by The Lancet on July 23, the project’s organizers write “we have found that presenting scenes from ancient tragedies about complex ethical situations for frontline medical providers generates an open, non-threatening space in which health personnel can begin to process, interrogate, share, and bear witness to experiences of loss, betrayal, grief, and other forms of moral suffering during the COVID-19 pandemic.”

Theater of War for Frontline Medical Providers events begin with a live reading of scenes carefully curated to address themes and issues that medical providers may be facing during the pandemic, such as personal risk, abandonment, deferred grief, deviation from standards of care, helplessness, and complicity in creating suffering. After the performance, the actors are replaced by four panelists—a diverse group of front-line medical providers—who respond to what they heard in the plays that resonated with their own experiences of caring for patients during the pandemic. After the panelists’ remarks, a skilled facilitator prompts the audience to join the discussion with a series of questions encouraging reflection and dialogue about themes raised by the plays. The discussion provides an opportunity for the medical workers in the audience to take center stage, sharing the impact of COVID-19 on their lives and finding solace in the community of their peers.

The project premiered on May 24, with 417 clinicians from the Baltimore area logging onto Zoom for a performance featuring Frances McDormand, Jesse Eisenberg, David Strathairn, and Frankie Faison. In a post-performance evaluation, 93% of respondents reported that the program offered new insights about their experience during COVID; 92% said the program made it easier to talk about difficult subjects related to COVID. Following that success, the Arts in Health Initiative of the Laurie M Tisch Illumination Fund provided a grant to fund 10 performances of the project in New York City.

The first of these performances, focusing on the EMS/first responder community in NYC will take place Thursday, July 30, at 7 p.m. While focusing on EMS professionals, this first performance will be open to the general public. To register, please visit: www.towems.eventbrite.com. Cast members will include: Anthony Almojera, Vice President of New York City’s Uniformed EMS Officers Union; Amy Ryan, whose credits include “The Office,” “Birdman,” and “Gone Baby Gone;” and Chad Coleman from “The Wire” and “The Walking Dead,” among other credits.

Other actors confirmed to participate in upcoming performances include McDormand, Strathairn, Faison, Eisenberg, and David Zayas. The next two performances will be:

August 19, noon-2 p.m.
Lincoln Medical Center, Bronx
Featuring Frances McDormand, Jesse Eisenberg, David Zayas, Frankie Faison

September 16, noon-2 p.m.
Lenox Hill Hospital
Manhattan Eye, Ear, and Throat
Lenox Health Greenwich Village
Cast TBA

“Ancient tragedies provide a new entry point for clinicians to process moral suffering generated by the pandemic,” wrote Theater of War Artistic Director Bryan Doerries and Berman Institute faculty Cynda Rushton, Jeremy Greene and Gail Geller in The Lancet. “While individual cognitive reframing can be helpful in the treatment of traumatic disorders, there is also a role for collective social interventions in responding to collective trauma. Ancient Greek plays about chronic and terminal illness, moral distress, the challenges of witnessing suffering, and end-of-life care can be used to forge a common vocabulary for openly engaging doctors, nurses, students, and other health-care professionals in creating constructive dialogue, fostering understanding, compassion, and a renewed sense of community.”

In Fight Against COVID-19, Nurses Face High-Stakes Decisions

As the number of confirmed COVID-19 cases accelerates in the United States, nurses on the front lines of the health care response have found themselves in unprecedented positions, making high-stakes decisions for patients and their own personal lives.

“We in uncharted territory in response to the magnitude of the pandemic,” says Cynda Rushton, a professor at the Johns Hopkins School of Nursing and Berman Institute of Bioethics known as an international leader in nursing ethics. “It’s a time of great stress and uncertainty, and nurses are rising to the challenge.”

Two weeks ago, Rushton—author and editor of Moral Resilience: Transforming Moral Suffering in Healthcare (Oxford University Press, 2018)—helped create the Frontline Nurses Wikiwisdom Forum, a virtual safe space where nurses can share their challenges and experiences during COVID-19.

“We know that nurses are the backbone of American health care, and often its heart and soul,” the site says. “The COVID-19 pandemic is testing all of us, but nurses are on the front lines. This space will be available 24/7 until America exits this crisis. Join us. Share your knowledge, experience, and challenges about working on the front lines of a pandemic. We know you are overworked, understaffed, possibly heartbroken and anxious, but always courageous. Feeling part of a community, even a virtual one, can help.”

In a wide-ranging Q&A with the JHU Hub, Professor Rushton discusses the pandemic’s impact on the nursing profession, the ethical challenges it poses, and reasons for hope among the turmoil. 

Read the full story here.

Q&A with Cynda Hylton Rushton: Examining Clinician Burnout

By Danielle Kress
Published courtesy of Johns Hopkins School of Nursing

In Fall 2019 the National Academy of Medicine released a new report, Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being.

Cynda Hylton Rushton, PhD, RN, FAAN, the Anne and George L. Bunting Professor of Clinical Ethics in the Johns Hopkins Berman Institute of Bioethics and the School of Nursing, was one of only two nurses selected to serve on the committee preparing the report. As a forerunner in helping nurses overcome the burden of burnout, Rushton played a key role in bringing forth evidence-based recommendations for addressing this problem in the future.

Rushton shares some inside perspective into burnout, the committee’s findings, and what this means going forward.

Why was a committee needed to explore burnout among health professionals, which the committee defined as physicians, nurses, pharmacists, dentists, nurse practitioners, and physician assistants?
Burnout, a state of emotional exhaustion, cynicism and decreased personal accomplishment, remains a significant problem for clinicians across the country. On a daily basis, clinicians are struggling to balance the needs of an increased number of sick or injured patients and populations dealing with comorbidities and severe illnesses, the intersection of patient care and technology, documentation requirements and mounting pressure to do more with less. When these factors collide, there becomes a gap between the way clinicians want to practice and the way they actually are. These threats to integrity can result in moral distress and lead to burnout.

Overall, clinicians are drained physically, mentally, and emotionally and their well-being degraded. The committee was charged with examining the scientific evidence regarding the causes and consequences of burnout and identifying evidence-based systemic solutions.

How much is burnout really affecting clinicians?
Among nurses, 35-45 percent experience some form of burnout, with comparable rates among other providers and higher rates among physicians. It’s important to note that burnout has been viewed as an occupational hazard rather than a mental health diagnosis. It is not a few days or even weeks of depletion or exhaustion. It is the cumulative, long-term distress and suffering that is slowly eroding the workforce and leading to significant job dissatisfaction and many leaving their professions. In some instances, serious health concerns and suicide can result.

What about the impact on patients?
Patient care can suffer when clinicians withdraw or are not fully engaged in their work. Moral distress, long hours, negative work environments, or organizational inefficiencies can all impact a clinician’s ability to provide what they feel is quality, safe patient care. Likewise, patients are impacted when health care organizations are unable to attract and retain competent and compassionate clinicians.

What does this mean for nurses?
As the largest sector of the health care professions, nurses have the most patient interaction and are at the center of the health care team. Nurses are integral to helping patients to holistically respond to their health conditions, illness or injury. If nurses are suffering from burnout and moral distress, the whole care team and the patient, will experience serious consequences when nurses’ capacities to adapt to the organizational and external pressures are eventually exceeded.

What is one of the most important takeaways from the NAM report on burnout?
Burnout is a complex and pervasive problem that impacts all members of the health care team, health care organizations, and the public. Bold and comprehensive reforms are needed to stem the tide of burnout. No longer is it justified for individual clinicians to be responsible for remediating the serious systemic contributors to burnout that undermine clinical practice.

The consensus report calls for a systems approach to clinician wellbeing that engages point-of-care clinicians, key stakeholders, professional societies and organizations, regulatory bodies, insurers, and policy makers to design comprehensive solutions. Reforms that impact the structure, organization, and culture of health care are urgently needed.

What can be done to address this widespread problem?
To effect sustainable change, strategic actions and organizational changes that address the underlying contributors to burnout must be developed, implemented, and evaluated. That includes health system leadership, dismantling systemic barriers to providing safe and quality care, and supporting the resiliency and integrity of frontline clinicians and learners in the health professions.

Increased investment in a comprehensive research agenda is vital to understanding the effectiveness and impact of systemic solutions. We need to look at the health care team in its entirety and understand that strengthening each part will improve job performance and patient care and satisfaction and contribute to healthier work environments.

How has your MEPRA program been innovative in this area?
At Johns Hopkins, I have led the development and implementation of the Mindful Ethical Practice and Resilience Academy (MEPRA). The Academy includes a foundational curriculum, community of practice, retreats, and unit-based Champion initiative. The goal is to build moral resilience among frontline nurses who face ethical challenges from issues related to resource allocation and ineffective communication to patient suffering and care coordination within the organization, and to foster systemic solutions.

The results have been substantial so far. The Academy is truly resonating with frontline nurses and giving them renewed confidence in what they do and why they do it. We’re witnessing a ripple effect, seeing how newly enabled nurses are speaking up and helping others on the health care team with some of the tools and skills they learned through the program. The academy goes beyond individual skills to engage frontline nurses in designing solutions to cultivate a culture of ethical practice in health care.


Additional Resources:

Gail Geller, ScD, MHS

In addition to her work in genetics, Dr. Geller’s other substantive areas of scholarship include the use of complementary and alternative medicine (CAM), the role of palliative care in chronic diseases, and the medical socialization process.  She received one of the highly coveted NIH “challenge” grants to explore the integration of palliative care in the management of children, young adults and families affected by chronic, life-threatening disorders (muscular dystrophy and sickle cell disease). She received a prestigious Kornfeld Fellowship to explore the intersection of bioethics and CAM. She has served as co-director of the educational component of the Johns Hopkins CAM Center, ethics representative on the Data Safety & Monitoring Board of the National Center for Complementary & Alternative Medicine (NCCAM), and adjunct faculty at the Tai Sophia Institute in their Master’s Program in Transformative Leadership and Social Change.  For 15 years, she co-directed the required Integrative Medicine course for Hopkins medical students, and the Healer’s Art elective. Several of the grants onwhich she has served as PI, Co-PI or Co-I have focused oncultivating respect, trust, empathy, wonder, and tolerance forambiguity among current and future health professionals. The unifying themes that animate her work are communication and decision-making under conditions of uncertainty, and the intrapersonal, interpersonal and social/cultural forces that influence moral development, attitudes and behavior. 

Dr. Geller also has longstanding interests in ethics education. She served as Co-Deputy Director of the Greenwall Fellowship Program in Bioethics & Health Policy until 2012, and now, as the Berman Institute’s Director of Education Initiatives, she oversees the Hecht-Levi Fellowship Program in Bioethicsand the Masters in Bioethics . Dr. Geller has occupied several educational leadership positions in the SOM.  She was involved in the revision to the undergraduate medical curriculum that took place in 2009. Currently, she co-directs the “culture of medicine” core theme which includes horizontal strands of particular relevance to ethics, professionalism and social justice. In addition, she directs the Scholarly Concentrationcalled the HEART (Humanism, Ethics, and the ‘Art’ ofMedicine), teaches in the “Medical Humanities & Social Medicine” elective, serves on the Advisory Board for the Center for Medical Humanities & Social Medicine, and directs the Program in Arts, Humanities & Health.  She is a  member of the School of Medicine’s Admissions Committee.   

Dr. Geller has served on the Board of Directors of the American Society for Bioethics & Humanities, the scientific review panel for the ELSI Program (Ethical, Legal and Social Issues) at NIH’s National Human Genome Research Institute, the Advisory Board of the Center for Genetics Research Ethics and Law (CGREAL) at Case Western Reserve University, and the IOM Committee on the Review of Omics-Based Tests for Predicting Patient Outcomes in Clinical Trials. She was a Consultant to the Ethics Working Group of the National Children’s Study, the Informed Consent Working Group of the Secretary’s Advisory Committee on Genetic Testing (SACGT), the CDC’s Program in Public Health Genetics, and the Presidential Advisory Committee on Human Radiation Experiments. She is a Fellow of the Hastings Center. 

Joseph A. Carrese, MD, MPH, FACP

Joseph Carrese, MD, MPH, FACP is Professor of Medicine at the Johns Hopkins University School of Medicine, a member of the Division of General Internal Medicine at the Johns Hopkins Bayview Medical Center, and a core faculty member of the Johns Hopkins Berman Institute of Bioethics.

Dr. Carrese’s scholarship focuses on clinical ethics and professionalism, with a particular interest in medical education, examining ethical issues in the context of cultural diversity and clinical ethics consultation. Dr. Carrese’s peer-reviewed articles have been published in leading medical and bioethics journals, such as JAMA, BMJ, CHEST, Academic Medicine, the Hastings Center Report, the Journal of General Internal Medicine, the Journal of Clinical Ethics, the American Journal of Bioethics and Medical Education. Dr. Carrese has been a visiting professor at several academic medical institutions and he has been invited to speak at many national and international meetings.

Dr. Carrese was on the Board of Directors for the American Society for Bioethics and Humanities from 2012-15. In 2012 Dr. Carrese was a founding Board member and Chair-elect of the Academy for Professionalism in Healthcare (APHC). From 2013-2015 he was Chair of the Board of Directors of APHC and he was the immediate past-Chair 2016-18.

Dr. Carrese received a National Award for Scholarship in Medical Education at the Society of General Internal Medicine annual meeting in April 2008 for his body of work in the area of clinical ethics education. From 2009-2014 Dr. Carrese was a member of the ASBH standing committee on Clinical Ethics Consultation Affairs (CECA) and in October 2011 he received the ASBH Presidential Citation Award for his work on this committee. Dr. Carrese is a Fellow of the Hastings Center.

Dr. Carrese is Chair of the Ethics Committee at the Johns Hopkins Bayview Medical Center, Chair of an Institutional Review Board at the Johns Hopkins School of Medicine, and primary care doctor to a panel of patients seen at the Bayview Medical Offices internal medicine clinic on the Johns Hopkins Bayview Medical Center campus.

Dr. Carrese graduated from Williams College and the University at Buffalo School of Medicine. He completed a fellowship in the Robert Wood Johnson Clinical Scholars Program at the University of Washington in Seattle, where he studied medical ethics and anthropology. Dr. Carrese joined the faculty at Johns Hopkins in 1994.

Mark T. Hughes, MD, MA

In addition to his work in ethics, Dr. Hughes is co-developer and associate editor of the Internet Learning Center, an Internet-based curriculum utilized by medical residency programs across the nation. From 2005 to 2009, he was a facilitator in the course Curriculum Development in the Longitudinal Johns Hopkins Bayview Faculty Development Program, and he is co-editor of the book “Curriculum Development for Medical Education,” now in its third edition. Dr. Hughes previously served as a core faculty member in the Florence R. Sabin College in the School of Medicine. He has been an associate editor for the Journal of General Internal Medicine and was coordinator of the End-of-Life Interest Group for the Society of General Internal Medicine..

Mary Catherine Beach, MD, MPH

Dr. Beach is on the editorial board for Patient Education and Counseling and on the Advisory Board for Communication in Medicine. At Johns Hopkins, Dr. Beach serves as co-chair of an Institutional Review Board (IRB), Course Director of the Scholarly Concentrations Program (a course spanning 2 years in the School of Medicine curriculum that guides students through a mentored scholarly project), and Director of the TL1 Predoctoral Clinical Research training program (a year-long interdisciplinary program).

Zackary Berger, MD, PhD

Dr. Berger is Associate Professor in the Johns Hopkins Division of General Internal Medicine and Core Faculty at the Johns Hopkins Berman Institute of Bioethics, with joint appointment in the Johns Hopkins Bloomberg School of Public Health. With an active practice in primary care internal medicine at Johns Hopkins, Dr. Berger focuses his clinical, educational, and research work, as well as his widely read publications for the lay public, on the ways in which shared decision making in the doctor-patient encounter might be in conflict with medical evidence and the political, social, and psychological realities of the patient.

Dr. Berger teaches residents in their internal medicine clinic and medical students on the wards at Johns Hopkins Hospital, and is part of a Berman faculty team which teaches bioethics to residents in a number of Johns Hopkins specialty programs. He is also staff physician at the Esperanza Clinic Health Center, a free clinic serving undocumented Spanish-speaking immigrants.

Dr. Berger is the author of two books for the lay public on doctor-patient communication and on patient preference in the context of medical evidence.

Cynda Hylton Rushton, PhD, RN

Dr. Rushton’s seminal work on nurse suffering and moral distress was selected for inclusion in the U.S. Nursing Ethics History project chronicling the evolution of nursing ethics in the United States. As part of her RWJ Fellowship, she also tested an intervention to reduce moral distress and burnout by cultivating resilience in nurses working in critical care, oncology and neonatal/pediatrics.  Dr. Rushton is currently designing, implementing and evaluating the Mindful Ethical Practice and Resilience Academy (MEPRA) to build moral resilience in novice nurses.  Her forthcoming book, Moral Resilience: Transforming Moral Suffering in Health Care, to be published by Oxford University Press aims to transform current approaches for addressing moral distress by focusing on innovative methods to cultivate moral resilience and designing a culture in health care that supports ethical practice.

Dr. Rushton is also an internationally recognized expert in ethics and palliative and end-of-life care. In 2001, she received the American Association of Critical-Care Nurses Pioneering Spirit Award for her work in advancing palliative care across the life-span.  Dr. Rushton was appointed by Maryland’s governor as the first chair of the State Council on Quality Care at the End-of-Life and served from 2002-2008. She has provided leadership to a variety of national projects focusing on palliative and end-of-life care, including the National Nursing Academy on Palliative and End-of-Life Care Open Society Institute (PDIA), an innovative, experiential interdisciplinary communication training model (HRSA), the Initiative for Pediatric Palliative Care (IPPC) a research, education and quality improvement project, the End of Life Nursing Education Consortium (ELNEC) and the Upaya Institute’s Being With Dying Professional training program.  Dr. Rushton served as a member of the Institute of Medicine’s Committee on Increasing Organ Donation and as a consultant to the IOM’s project “When Children Die.” She also served on the board of directors of the Coalition to Transform Advanced Care (CTAC). She led (with Dr. Gail Geller) an international collaboration to improve the lives of children affected by life-threatening neuromuscular diseases and a related project, focusing on the ethical issues faced by neuromuscular clinicians.

In 2008 and 2014, Dr. Rushton was honored as one of Maryland’s Top 100 Women.  She is also an American Academy of Nursing’s Edge Runner and in 2014 received the Milestone Award for Bioethics Leadership from the Centre for Health Care Ethics at Lakehead University. Dr. Rushton is a Fellow of the Hastings Center and the American Academy of Nursing.

Dr. Rushton received her Master’s of Science in Nursing, with specialization as a pediatric clinical nurse specialist, from the Medical University of South Carolina. She completed her undergraduate degree in nursing at the University of Kentucky and received a doctorate in nursing at the Catholic University of America, with a concentration in bioethics. Dr. Rushton is the recipient of three post-doctoral fellowships: a Robert Wood Johnson Nurse Executive Fellowship (2006-2009), a Kornfeld Fellowship in end-of-life, ethics and palliative care (2000), and a Mind and Life Institute Fellowship in Contemplative Science (2013-2014).