On March 27, 2020, my commentary raising questions on how to protect the nursing workforce in the Covid-19 pandemic was published online in Women’s Healthcare.1 The commentary called for legislative interventions to provide personal protective equipment for all nursing personnel. In addition, a brief overview on maintaining personal mental health during this unprecedented global pandemic was presented, hoping for early identification and interventions for emotional or mental health problems. Despite these calls for action, the emotional and mental health of frontline workers, including nurses and nurse practitioners (NPs), have been in the background of the Covid-19 pandemic. Another commentary from March 20, 2020, warned of loss of life of frontline healthcare professionals including nurses, NPs, physicians, and first-line responders including emergency medical technicians, paramedics, and medical technologists.2 Washington Post journalists reported a lack of an official tally of the number of health professionals who have succumbed to Covid-19.3 On June 17, 2020, however, the journalists reported that 77,700 healthcare workers had tested positive for the coronavirus. Data from a June 20, 2020, article reported over 600 frontline healthcare workers in the United States had died from the coronavirus.4 The number of Covid-19 patients that nurses and NPs care for every day throughout the United States, as well as the sadness of colleague deaths, are having an overwhelming impact on the mental health of nurses and NPs.
Covid-19’s wrath: emotional well-being and mental health
As nurses and NPs are in the trenches fighting the Covid-19 battle, the design and implementation of rigorous studies on the emotional and mental health of nurses and NPs caring for patients, families, and communities adversely affected by Covid-19 to prevent and treat emotional and mental health problems have yet to emerge. But there are glimpses of what will need to be studied to best help nurses and NPs who have or will experience emotional or mental health problems directly related to their roles in the pandemic. No team of nurses or NPs have been untouched by this pandemic, which changed the focus of their work so quickly. One day, nurses and NPs were employed in their comfort zone providing high quality care to the patients they serve. The next, everything was flipped upside down, and the word “deployed” became the new assignment.
They were deployed from a comfort zone caring for chronically ill, medically complex children to the fast-paced pediatric intensive care unit that was also accepting “young adults” to the age of 50 years who were diagnosed with Covid-19. Suddenly, and without warning and minimal preparation to care for these patients, deployments became the new norm. Emergency room nurses and NPs who thrive in fast-paced environments were overrun with critically ill patients, who one minute were talking with them and the next minute gasping for air requiring immediate intubation and ventilatory assistance. More deaths than anyone could imagine occurred in such a short span of time—day shift, night shift—Covid-19 attacked again and again. Relentless, ruthless, unyielding….day after day, night after night. Clinical practice guidelines and clinical evidence to combat this horrid viral enemy were and are nonexistent. Nurses, NPs, patients, and families thrive on hope—hope ignites resilience—feelings of hope and the corresponding resilience were also thwarted by this virus.
What has emerged from studies investigating healthcare workers are increased depression and depressive symptoms, anxiety, psychological distress, and poor sleep quality.5 Another study reported additional symptoms including stress, insomnia, denial, anger, and fear in addition to anxiety and depressive symptoms.6 Further evidence that mental health problems abound is supported by a study that compared 1,200 frontline healthcare workers in China providing care to Covid-19 patients to workers in secondary roles. The investigators reported that frontline healthcare workers experienced higher levels of mental health symptoms when compared to those in secondary roles.7 In New York City (NYC), the epicenter of Covid-19 in the United States, 57% of healthcare workers screened positive for acute stress, 48% for depressive symptoms, and 33% for anxiety symptoms. In each screen, a higher percentage of nurses and NPs screened positive when compared to attending physicians.8
Thus, Covid-19 has not only invaded the physical health of patients of all ages and populations but it has also assaulted the emotional and mental health of nurses, NPs, and all healthcare providers. When and how can the healing begin?
Emotional and mental health: healing must begin
Covid-19 has the upper hand. Until a definitive effective treatment is established for Covid-19 or until a safe, effective vaccine is available, Covid-19 will remain in command of our emotional and physical lives. This is uncharted territory for nurses, NPs, and all healthcare providers, and in fact, for all individuals in this country and globally. Recent guidelines and strong recommendations from the Centers for Disease Control and Prevention are attempts to control the impact of the virus on the physical well-being of each individual and community. To maintain physical health, the new norm is to wear face masks in public spaces, maintain social distance, frequent handwashing, and astute awareness of environmental cleanliness.
Mental health is intricately connected to our physical health. Thus, the question to consider is: “What strategies can be implemented that will successfully return the control of our emotional and mental health to our personal self?” A study examining the mediation effect of resilience on social support and mental health with 1,472 healthcare workers from Jiangsu Province, China, at the peak of the Covid-19 outbreak was conducted. The investigators reported that resilience partially mediated the effects of social support on the mental health of these healthcare workers.9 Strategies to build resilience are part of the tool kit of every nurse and NP. We help our patients build resilience. Now, it is time to apply these principles to ourselves.
Researchers examined the concept of vicarious trauma in which healthcare providers caring for Covid-19 patients would manifest patient symptoms, eg, loss of appetite, irritability, fatigue, and sleep disorders, as they sympathized with the symptoms displayed by their critically ill patients.7 Early recognition of vicarious trauma as a phenomenon impacting the emotional and mental health of nurses and NPs allows for early implementation of workplace mental health strategies including system-wide social and emotional support systems. Acknowledging the nurses and NPs’ personal experience of “feeling the pain” of those suffering with Covid-19, and scheduling time to talk and reflect on these experiences, may be an effective strategy for nurses to personally cope with their emotions.
In addition, there are calls for new intensive systemic psychological services, interventions, and support to be implemented in hospitals nationwide to manage the mental healthcare needs of frontline medical staff working with Covid-19 patients.10 These psychological services need to be designed, implemented, and evaluated for effectiveness in prevention and treatment, with specific planned outcomes or goals to restore the emotional and mental health of those adversely affected by caring for Covid-19 patients.
Social media sites provided personal experiences and stories of Navy personnel including Navy nurses, NPs, and physicians deployed to NYC to work in NYC hospitals alongside NYC nurses, NPs, and physicians during the height of the Covid-19 pandemic. These nurses were a team. It was clearly evident that they supported one another throughout their deployment. Simply from observing interactions on social media, it seemed that the unwavering support was foundational to their individual and team successes, and was an essential component in their emotional well-being.
Nurses in NYC reported that physical activity including exercise was the most common coping behavior used to support their personal emotional and mental health. In addition, access to an individual therapist with online self-guided counseling was also an effective healing strategy.8 NYC nurses, NPs, and other healthcare frontline responders were honored by the people of NYC each night at 7 pm—at the change of shift—with a resounding round of applause. Such acts of kindness and regard for their efforts were so appreciated, and perhaps with each night of applause, fostered their resiliency to continue to battle the virus. Only when nurses and NPs become engaged in re-establishing control of their own emotional and personal mental health can healing begin and the resilience of each individual in the nursing workforce prevail.
Donna Hallas is Clinical Professor and Director of the Pediatrics NP program at New York University Rory Meyers College of Nursing in New York, New York. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.
References
- Hallas D. Nurses, nurse practitioners, and nurse midwives on the front lines of COVID-19: How do we protect the nursing workforce? Women’s Healthcare. Online. March 27, 2020. https://tinyurl.com/y8njo7tz.
- Mandrola J. COVID-19 and PPE: Some of us will die because of the shortage. Medscape. March 20, 2020.
- Babb K, Shammas B, Cha AE. Fallen on the front lines. Hundreds of health-care workers lost their lives battling the coronavirus. Washington Post. June 17, 2020.
- Crist C. Almost 600 US healthcare workers have died from COVID-19. Medscape Nurses. June 9, 2020.
- Vindegaard N, Benros ME. COVID-19 pandemic and mental health consequences: systematic review of the current evidence. Brain Behav Immun. 2020 May 30.
- Torales J, O’Higgins M, Castaldelli-Maia JM, Ventriglio A. The outbreak of COVID-19 coronavirus and its impact on global mental health. Int J Soc Psychiatry. 2020;66(4):317-320.
- Otu A, Charles CH, Yaya S. Mental health and psychosocial well-being during the COVID-19 pandemic: the invisible elephant in the room. Int J Ment Health Syst. 2020;(14):38.
- Shechter A, Diaz F, Moise N, et al. Psychosocial distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic. Gen Hosp Psychiatry. Online. June 16, 2020.
- Hou T, Zhang T, Cai W, et al. Social support and mental health among health care workers during coronavirus disease 2019 outbreak: a moderated mediation model. PLoS One. 2020;15(5):1-14.
- Zaka A, Shamloo SE, Fiorente P, Tafuri A. COVID-19 pandemic as a watershed moment: a call for systemic psychological health care for frontline medical staff. J Health Psychol. 2020;25(7):883-887.