THE DISEASE CAUSED by the novel coronavirus, coronavirus disease 2019 (COVID-19), had infected nearly 15 million people as of July 21, 2020. By that date, COVID-19 was responsible for over 610,000 deaths worldwide, including over 140,000 deaths in the US alone.1 Along with this incalculable loss, the outbreak has had devastating effects on the mental health of people with COVID-19, their families, and the community at large. Healthcare workers face tremendous stress, both emotionally and physically, from the grueling work hours and the threat of contracting the virus at work.
The combination of fatigue and the pressure to keep working despite the threat of contracting the illness contributes to evolving mental health problems that are likely to emerge from the pandemic. These problems add pressure to operational teams that focus on supplies, finances, and the epidemiology of this lethal virus.2 This article addresses the potential mental health issues for healthcare workers that may emerge from this pandemic as well as treatment options and self-care activities that promote recovery.
COVID-19 and mental health
Nurses working on the front lines of the COVID-19 pandemic may experience various mental health problems. Here are a few examples:
- Chronic stress. Nurses are continuously fearful of contracting COVID-19, infecting others, encountering prejudice from the public due to working as a nurse, and dealing with inadequate supplies of PPE.3 Stress becomes chronic when it is overwhelming and cannot be resolved, resulting in relationship, health, and sleep problems.4-7 People with chronic stress experience intense emotions that can feel overwhelming and result in thinking negatively.8 Nurses on the front lines in COVID-19 hotspots report feeling like a graduate nurse again, filled with uncertainty and worry.9
- Acute stress disorder. Nurses with acute stress disorder may have trouble sleeping, worry constantly, and experience persistent negative thoughts about their role in the traumatic event, such as thinking “I should have done more to help.”10 When we experience trauma, we detach from the memory. We ignore our emotions to protect against the pain, but these emotions reappear over time and impact our lives.11 The nurse may respond to a minor irritation as if it were a life-threatening event.12 Nurses may feel they are in a dreamlike state that impacts their ability to think, process their emotions, and respond appropriately to situations.13 Signs and symptoms of acute stress disorder may last for up to 30 days.14 If symptoms persist for more than a month, posttraumatic stress disorder (PTSD) is diagnosed.14
- PTSD. Nurses are not strangers to caring for critically ill patients who die.10 However, the number of patients dying amid a surge in COVID-19 cases is causing healthcare workers to feel powerless, which can lead to PTSD. For example, more than 27,000 New York City residents died in a 6-week period in March and April when the city experienced a huge COVID-19 surge; this was six times the average.15
PTSD has unexpected, long-lasting, and devastating effects. PTSD can develop after direct or indirect exposure to a traumatic event, such as hearing about a traumatic event involving a family member, friend, or colleagues; experiencing similarities to the original traumatic event; or reliving hidden memories of the traumatic event. Those with PTSD experience recurrent intense and disturbing thoughts and feelings stemming from one or more traumatic events.12,16,17 People may relive an event through flashbacks or nightmares, and they may feel sadness, fear, anger, and detachment or estrangement from other people.17 People who experience PTSD may avoid situations that remind them of their trauma.17
Individuals with PTSD may not understand what triggers their PTSD-related reaction. For example, watching a TV program in which a patient dies with breathing difficulties may evoke painful feelings and memories of a patient dying from COVID-19. A medical drama that brings back thoughts and feelings connected with the original trauma is a trigger, or an event that results in a distressing reaction.17
People with PTSD may have ongoing negative thoughts and feelings about themselves or others, such as fear, horror, anger, guilt, or shame. They may also have a much lower interest in activities they had previously enjoyed.17 Many traumatized individuals have a robust and unconscious inclination to go inward, often to re-experience their distressing thoughts, painful memories, and uncomfortable sensations.18 They may have an exaggerated, startled response to certain situations and develop problems with concentration and sleep.7
For healthcare professionals, acknowledging personal needs is of paramount importance.19 Nurses who are unaware of their needs and prioritize colleagues and patients over themselves are at a substantial risk for developing mental health issues.20
Consider the example of palliative care nursing. Nurses in palliative care are surrounded by death, yet they find the work both professionally and personally satisfying.21 By being aware of their feelings and personal triggers, they can develop protective coping mechanisms (for example, discussing upsetting situations with fellow nurses).22 Sharing feelings with colleagues has been found to reduce stress.7
The nursing team's role
Nurses' roles in caring for patients with COVID-19 are being recognized worldwide. In the spring of 2020, at the height of the COVID-19 spike in New York City, the collective cheer for frontline health workers at 1900 was a nightly ritual that showed solidarity and support to our healthcare staff.23
Working on the COVID-19 front lines has been described as caring for patients on a battlefield. Working together in this fight leads to a great camaraderie between team members, and these bonds between team members matter.24 Healthcare workers focus on meeting the needs of patients, solving problems, and finding solutions for PPE shortages. They want to provide quality care because it is the right thing to do.
Nurses are showing exceptional commitment and a strong sense of duty in these times.26 However, they are constantly feeling anxious about protecting themselves and their families from infection during the pandemic. Nurses are unique human beings like everyone else; some enjoy the adrenaline rush while others struggle.
When nurses struggle personally, we tend to be critical of our colleagues or management, and withdraw from others. Such a change in personality is often an indicator of struggle.
It is often a team member who will notice that you are not your usual self and may be struggling with anxiety and stress. Asking yourself or a colleague three simple questions can raise awareness about a possible problem:
- Am I ok? Are you ok?
- Do you feel you cannot give anymore?
- Do you feel your work is ineffective?26
If you are struggling, speak with your colleagues, acknowledging those feelings and thoughts in the first instant. If you feel you are not performing effectively in your workplace, talk with your manager and state your opinions on being ineffective. Everyone has limits, and sometimes just taking a week off might be sufficient.
Nurses who continue to feel this way should discuss it with their primary healthcare provider and their employer, and review the options available. Some nurses may want the support of a counselor. It is a strength to realize that you are struggling with your mental health and need help.
Early psychological intervention does make a difference.27 Each of us has a limit to stress, and it is important not to compare your stress levels to those of another person. There is strength in being vulnerable and showing our thoughts and emotions. Brown defines vulnerability as uncertainty, risk, and emotional exposure.28
Topping off emotional reserves
Nurses on the COVID-19 front lines are plagued by drained emotions, loneliness, and fear. These are normal reactions to an unfamiliar, uncertain environment. Transitioning away from work at the end of the day is essential for nurses to top off their emotional reserves.
Tiredness and difficulty falling or staying asleep are the most troublesome parts of working a shift pattern in the best of times.29 Getting enough sleep is crucial to mental health; poor sleep patterns impair decision-making abilities and the ability to process information.30 In addition, nurses must take care of themselves and treat themselves as they would care for their patients. Nurses must ensure that they are eating right, are hydrated, and are getting adequate sleep.
Gaining understanding about the risk factors and ways of protecting yourself is invaluable. A range of supports may be available from your employer or your professional organization.31,32 Senior managers within the healthcare facility need to be seen and listen to staff concerns on the front line to encourage an atmosphere of mutual trust and respect.25 Acknowledging the emotional cost of your job can help destigmatize this problem for one another.33
If you have had a particularly stressful day, acknowledging and discarding any negative thoughts or feelings can help improve sleep quality. Having a ritual to signal the end of work is essential. Here are some suggestions:
- Take a shower. Visualize all the worries of the day disappearing down the drain.
- Write down any thoughts or feelings in a notepad.
- Watch a favorite TV program.
- Read a book.
- Listen to your favorite music.
- Contact a friend.
- Write down three things you were grateful for today.
When you go to bed, ensure your bedroom is cool and dark. Turn your awareness to your breathing and notice where you feel it, whether in and out of your nose, or the rise and fall of your abdomen. Doing this for a couple of minutes helps relax your body.29 Having a routine for bed creates a pattern in our brain, so when we do certain things, we are telling ourselves it is time for bed.34
As we learn new skills and work with new colleagues, we must be gentle with ourselves and our team. We need to acknowledge our challenges and celebrate the victories, however small. Hugs can instill a feeling of safety and comfort, but hugging each other is now impracticable. When we hug ourselves, we release oxytocin, the feel-good hormone.22 If you need support, hug yourself.
Preparing for night shift
Preparing for the night shift varies from person to person. Personal responsibilities may include caring for children or older relatives. Speaking with senior staff about preparing for the night shift is a useful way of developing a routine. Every person will have a unique way of preparing for night shifts. It is important to try what works for you, which may include:
- sleeping later in the day before the first-night shift rotation.
- resting for an hour before work.
- having a shower before you start your shift, reducing the water temperature to awaken your senses.
- wearing sunglasses when returning home to reduce the amount of sunlight exposure.
- going to bed when you arrive home.
- getting out during daylight hours for a short period wherever possible.
Eating food during the night has an impact on our metabolism.35 A light meal is advisable, before or at 0100, as it could affect your alertness in the second part of the night shift.36
The COVID-19 pandemic is an unprecedented event in our lifetimes that will have untold mental health implications for nurses and other healthcare professionals on the front lines, both in the short and long term. As of the time of this writing in July 2020, COVID-19 cases have again risen sharply across the country, especially in southern and western states. Although scientists and healthcare professionals know more about the disease and how to treat it now, nurses in current COVID-19 hotspots will still be treating patients with a serious and rapidly spreading disease while possibly contending with shortages of PPE, equipment, and treatments.37 Nurses will need to receive support from their team, practice optimal self-care strategies, take measures to replenish their emotional reserves, and learn how to transition mentally from work to home after their shift. Recognizing stress and learning how to cope will help nurses protect their mental health as we move forward during this pandemic.
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