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Strategies to improve nurses' stress response during the COVID-19 pandemic

Meehan, Carolyn D. PhD, RN; Schlamb, Cheryl D. DNP, CRNP; Nair, Julie McCulloh PhD, RN, APHN-BC, CCRE

Author Information
doi: 10.1097/01.NURSE.0000803484.15041.ba
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Pandemics have historically impacted nurses both physically and mentally, and the current pandemic is no exception.1 The COVID-19 pandemic has resulted in many healthcare challenges such as inadequate staffing to meet increased workloads, nurses assuming new roles, and insufficient or lacking personal protective equipment (PPE). Nurses are increasingly isolated from family, friends, and their communities due to fears over their ability to spread the virus and infect susceptible contacts. Nurses also deal with fear of becoming a fatality as they watch coworkers and patients succumb to this virus. These factors, among many others, contribute to increased stress levels, job burnout, and sustained mental duress that profoundly affect the overall wellness of nurses amid the pandemic.2 This article examines strategies for nurses and leaders to identify stressors, practice self-care, and develop healthy coping skills.

A 2020 survey found that 2% of nurses nationwide plan to leave the profession, translating to the potential departure of approximately 60,000 nurses.3 This is an alarming number considering the shortage of nurses in the US even before the pandemic. Some survey respondents said they plan to change roles or specialty areas. Nevertheless, 85% of the nurses surveyed said their nursing plans have not changed and provided statements to reflect this sentiment, such as “Nurses don't jump ship” and “I am more committed than ever to nursing.”3 This follows reports suggesting that most nurses are resilient and able to navigate the stressors from the pandemic.3

However, according to Selye's Stress Theory, resilience alone may not be enough to protect nurses from acute stress disorder (ASD), which is characterized by acute stress reactions that may occur within a month following a person's exposure to a traumatic event (e.g., serious injury, threatened death, or sexual violation). ASD symptoms include dissociation, negative mood, avoidance, and arousal.4 As one survey respondent said, “There will be long-term effects of the stress and trauma that will affect the profession for years to come.”3 Nurses who are continually exposed to one or more traumatic events may develop ASD, which can progress to posttraumatic stress disorder (PTSD), which is defined as “experiencing repeated or extreme exposure to adverse details of traumatic events.”5 Limited data tracked from previous pandemics, disasters, and terrorist attacks provide evidence that nurses exposed to acute stressors, particularly when working in an area of higher acuity over a longer period, are at greater risk for PTSD.5 Data on the impact of gender or marital status on the incidence of PTSD are conflicting, but research does suggest that younger nurses and those with less experience are at higher risk when exposed to high-acuity units for a prolonged period.5,6

Amid the COVID-19 pandemic, nurses of all experience levels are exposed to an unparalleled number of mortalities and patients who are critically ill. Novice nurses are particularly susceptible to moral distress due to their inability to deliver care as instructed in their undergraduate nursing education.7 They are forced to learn under severe conditions, and some may not be receiving adequate support either in the workplace from peers or through their social networks. The sustained exposure to acute stress, combined with caregiver burden, may lead to a systemic stress response experienced by nurses at an unprecedented rate. As a result, nurses are now considered a vulnerable population during this pandemic.6

Nurses will benefit from comprehensive education and support on identifying and managing stressors and other mental health concerns.8 Promoting the awareness of these mental health concerns among nurses and their employers may lead to actions that improve mental health outcomes and provide nurses with a sense of hope and recovery. For example, education on stress management techniques that can be utilized during this period could provide nurses with additional coping strategies. What nurses have used in the past may not be an option during COVID-19. Local and national pandemic-related regulations implemented to prevent COVID-19 transmission have also restricted individuals from engaging in their normal daily activities. As such, nurses may need to adapt and explore new activities and healthy coping strategies to better manage their stress levels.9

Identifying symptoms of stress

Common manifestations of acute stress include physical, behavioral, and psychological signs and symptoms. Examples of physical symptoms might include fatigue, lack of energy, and lack of sleep. Behavioral symptoms such as social isolation, irritation, anger, withdrawing from others, neglecting responsibility, and the hidden use of drugs and alcohol may be present. Psychological symptoms such as sadness, anxiety, feelings of helplessness, hopelessness, impaired memory, and concentration may also be experienced.6

With or without a preexisting mental health diagnosis, nurses still report higher levels of acute stress, anxiety, depression, hyperarousal, hypervigilance, vicarious traumatization, and negative thoughts.8 As a result, a higher percentage of anxiety disorder diagnoses are expected and may be persistent postpandemic. The symptoms of an anxiety disorder are severe and may result in panic attacks that impair a person's ability to engage in activities of daily living. Those diagnosed with an anxiety disorder may experience persistent and excessive fears that inhibit their ability to work or maintain relationships.8

During COVID-19, nurses also report feelings of loneliness related to social isolation. By adhering to social distancing restrictions, nurses may not interact in person with family and friends for months. Additionally, the fear of interacting with nurses caring for patients with COVID-19 expressed by friends and family further diminishes their social connections and increases their risk of social isolation.9

Nurses are also experiencing sleep disturbances that may be linked to anxiety and fear.2 Other predominant concerns are related to finances and childcare during the pandemic, with nurses finding themselves as the sole financial provider in their family and/or their child's teacher.

Nurses caring for patients with COVID-19 have reported feelings of inadequacy. While nurses are often called heroes, some nurses reported feeling uncomfortable because they do not feel they can deliver care as required or in accordance with national and institutional policies.8 They report concerns over insufficient PPE and a lack of or changing national guidelines for the care of patients with COVID-19.7 These feelings of inadequacy combined with the significant increase in the rate of mortality associated with COVID-19 is leading to an increased risk for compassion fatigue that is described as an overwhelming feeling of negativity that the nurse cannot escape. Compassion fatigue during the pandemic can occur because of repeated exposure to caring for patients with COVID-19 which is considered by many to be a traumatic experience.2

Nurses must conduct a self-assessment to check for any of the above combination of stress symptoms. If nurses identify that they are experiencing symptoms, they should consider seeking the help of a professional for evaluation and treatment.6,7

Coping strategies and self-care

The first step of understanding acute stress and compassion fatigue is self-awareness. Nurses can utilize protective mechanisms to improve mood, well-being, and reduce stress. Some modalities include physical activity, religion or spirituality, and the incorporation of meditation and intentional breathing. Routine yoga practice produces mental clarity and quietness, increases body awareness, relieves chronic stress, relaxes the mind, centers attention, and improves concentration. Complementary therapies include the use of aromatherapy, acupressure or acupuncture, or energy therapies, such as reiki.10 Self-care may look different during the pandemic, but these modalities are still possible to use while maintaining infection prevention precautions. (See Self-care tips.)

At the organization level, leaders must create and promote a culture of self-care among healthcare workers during the pandemic. Team building should be utilized with daily debriefing and huddles that integrate humor and promote awareness and relaxation. Some agencies use oasis rooms as a relaxation space to decompress and provide caregiver wellness.11

Organizational interventions should be offered as a forethought. Healthcare agencies should look to the tech industry and replicate supportive work environments for employees. Examples of tech companies' offerings include dining, fitness, medical, laundry, daycare, restaurants, and retailers. All the listed services are located at the worksite, providing employees with free food, fitness options, and reduced rates for childcare and retail options. Employee-assistance programs should be offered to assist in linking nurses with appropriate mental health providers for either short-term or long-term interventions. An example of an intervention is telehealth which is an excellent venue during the pandemic that provides mental health support for at-risk nurses in the privacy of their home. Organizations also need to provide programs to educate staff on peer identification of persons experiencing a mental health concern or crisis. Nurses respond to each other because they can easily identify and relate to common issues and similar situations. The development of peer support groups is not just a promising idea, but vital during this unprecedented time.6,8,9

Nursing leadership needs to understand the unique needs of nurses during the pandemic. All nurses need to feel heard, valued, and connected to their nursing leaders regardless of their generation and experience level. Amid the pandemic, nurse leaders should evaluate employee well-being and work environment via staff surveys, observation, and institutional data. Current employee feedback and other sources of data can be used to design strategic programs aimed at addressing staff concerns. Additionally, nurse leaders must not forgo recognition practices that demonstrate to staff that their work is acknowledged and appreciated. Staff recognition is linked to decreased rates of organizational attrition; therefore, staff recognition practices should also be reevaluated or reimagined, particularly in this unprecedented time.7 Nurse leaders must understand that a nurse's sense of being heard and valued is linked with higher performance, satisfaction, and retention rates.7 Nurses who feel undervalued by their leaders, may leave their existing position or worse, leave the nursing workforce. Nursing leaders that assess their employees' well-being, work environment, and provide equitable distribution of resources and staff recognition may cultivate a healthier and well-balanced workforce.11,12 It may be necessary at this time to provide nurse leaders with education on disaster/emergency response so they can mentor future nurses in similar situations.

Health policy

Healthcare policy makers need to focus on the creation and allocation of funds for the mental health and well-being of frontline healthcare workers. Nurses make up most of the healthcare workforce and it is anticipated they will need long-term mental health assistance due to PTSD and other mental health challenges. The Coronavirus Aid, Relief, and Economic Security Act funds released by the Federal Government and given to individual states are meant to partially offset the costs that will be required to care for affected nurses.13 The judicious use of these funds will offer support to nurses now and in the postpandemic world.

The COVID-19 pandemic has significantly resulted in increased stress, social isolation, fear, and trauma among nurses. The literature suggests this may result in nurses leaving the profession and potentially experiencing PTSD. Nurses must learn to identify stressors and practice self-care. Organizations and nurse leaders create a healthy work environment by providing resources and opportunities to promote nurses' self-care, peer support, and mental healthcare interventions. These strategies could conceivably increase nurse retention at a time when the nursing workforce is at a premium

HELPFUL RESOURCES:

SAMHSA's Disaster Distress Helpline (crisis counseling and support for emotional distress)

1-800-985-5990

National Suicide Prevention Lifeline

1-800-273-TALK

National Domestic Violence Hotline

1-800-799-SAFE

SAMHSA National Helpline (alcohol and substance use disorder)

1-800-622-HELP

National Institute for Occupational Safety and Health

1-800-CDC-INFO (1-800-232-4636)

www.cdc.gov/niosh/topics/healthcare/default.html

SELF-CARE TIPS

  • Join social media nursing support groups.
  • Keep a routine.
  • Consider safe socialization.
  • Exercise outdoors.
  • Try activities such as:
    • meditation and mindfulness
    • writing/journaling
    • cooking
    • arts and crafts
    • music
    • gardening

REFERENCES:

1. Huremovic D. Brief history of pandemics. www.ncbi.nlm.nih.gov/pmc/articles/PMC7123574/.
2. Shechter A, Diaz F, Moise N, et al. Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic. Gen Hosp Psychiatry. 2020;66:1–8.
3. Spader C. 2020 nursing trends and salary survey results. 2020. www.myamericannurse.com/2020-nursing-trends-and-salary-survey-results/.
4. UpToDate. Acute stress disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis. 2021. www.uptodate.com/contents/acute-stress-disorder-in-adults-epidemiology-pathogenesis-clinical-manifestations-course-and-diagnosis
5. Carmassi C, Foghi C, Dell'Oste V, et al. PTSD symptoms in healthcare workers facing the three coronavirus outbreaks: what can we expect after the COVID-19 pandemic. Psychiatry Res. 2020;292.
6. Stelnick AM, Carleton RN, Reichert C. Nurses' mental health and well-being: Covid-19 impacts. Can J Nurs Res. 2020;52(3):237–239.
7. Horan KM, Dimino K. Supporting novice nurses during the COVID-19 pandemic. Am J Nurs. 2020;120(12):11.
8. Nelson SM, Lee-Winn AE. The mental turmoil of hospital nurses in the Covid-19 pandemic. Psychol Trauma. 2020;12(S1):S126–S127.
9. American Nurses' Association. Covid-19 legislative, regulatory, advocacy update. www.nursingworld.org/practice-policy/work-environment/health-safety/disaster-preparedness/coronavirus/what-you-need-to-know/legislative-and-regulatory-advocacy/covid-19-legislative-regulatory-and-advocacy-update/.
10. Bruns DP, Kraguljac NV, Bruns TR. Covid-19: facts, cultural considerations, and risk of stigmatization. Clin Pract. 2020;31(4):326–332.
11. Hofmeyer A, Taylor R, Kennedy K. Knowledge for nurses to better care for themselves so they can better care for others during the Covid-19 pandemic and beyond. Nurse Educ Today. 2020;94:104503.
12. Salvant M, Wycech J, Alexander A, et al. Comparing opinions on meaningful recognition: do views of trauma nursing leaders and staff align. J Trauma Nurs. 2020;27(2):121–127.
13. Department of Health and Human Services. Cares act provider relief fund general information. www.hhs.gov/coronavirus/cares-act-provider-relief-fund/index.html.
Keywords:

COVID-19; mental health; nurses; stress; wellness

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