Dealing With COVID-19 Post-Traumatic Stress

Strategies for Preserving the Nursing Workforce and Supporting all Vital Frontline Personnel

Therese A. Fitzpatrick, PhD, RN, FAAN; Nancy M. Valentine, PhD, DSc(hon), MPH, FAAN, FNAP President


Nurs Econ. 2021;39(5):225-238, 250. 

In This Article


Taking the opportunity to evaluate these strategies is another area where organizations and professional associations can partner to explore how best to conduct research. There are several initiatives launched by professional associations.

  • ANA (2017) has established a Building Strength through Resilience Committee and launched a Health Nurse, Healthy Nation program.

  • American Nurses Foundation (2020) established a well-being initiative.

  • National Academy of Medicine (2017) Action Collaborative on Clinician Well-Being serves as a comprehensive resource for planning organizational change.

We need to ask ourselves: what more can we do to build on the work that has been done in a crisis? Where can we go from here? Building a framework for interventions can be a place to start and everyone needs to get involved. This requires a multiprong approach and community effort. Imbedding wellness within an organization is not as simple as assigning it to a lead person.

Focus on the Individual

Not everyone is the same. Staff are at all different levels of need at any given time. Develop a screening process that allows for customized interventions. This can include utilizing apps that assess mental health and provide feedback to the individual.

Using a public health approach, people can be categorized in three general groups (primary, secondary, tertiary) with differing levels and approaches to intervention:

   • Resilience training at the primary level is focused on self-awareness, coping, and communication skills.

   • Secondary screens for burnout and provides resources and support for nurses; and

   • Tertiary interventions target nurses where their ability to function has been surpassed and need help and a plan for returning to work. What we know from PTSD work in the Veterans Administration is that intervention is critical. People who have gone through a traumatic event can often experience insomnia, low self-esteem, a host of unpleasant thoughts that often lead to increased anxiety and depression, feeling numb to emotions. Getting help as soon as possible is critical.

   • Every individual needs a self-care routine, which should be reinforced by all organizations. In a first-person account, Avadhani (2021) mentions her self-care routine of daily treadmilling and meditation saved her early on, so she had the strength to carry on. Eventually, as she worked through the many lonely months, the stroke of insight she eventually gained was recognition that no matter how much she suffered, the spouses and families were hurting worse. Her role was to help them as much as possible and she resolved to stay the course.

Avadhani is a good example of the impact of a routine to focus on self allows for the opportunity for daily regrouping, processing events, and reflection on life and personal health. Tips of how each staff member has developed a wellness routine might be a good topic for a staff meeting, for example.

For managers and leaders, it is important to acknowledge that stress is often not visible but is manifested in behaviors. Therefore, people need understanding, not judgment. This is not a prescription and varies by person. Generally, be more attentive to what is going on in people's personal lives, realizing everyone has a back story of concerns.

Personal resilience can be strengthened by fostering:

Realistic optimism. Optimism is only about 25% inheritable, with other factors affecting overall positivity, such as working in an organization that cares about employees.

   • Emotional awareness and control over emotions.

   • Self-efficacy: setting goals and moving forward to meet them.

   • Connections with others are vital.

   • Care for personal well-being.

Focus on Team Efforts for Generating Creative Ideas and Enthusiasm

Northwell Health System Nurses' Choir. Featured on the audition for America's Got Talent 2021. Their rendition of the song "Stand by Me" is truly unforgettable. Received Howie's Golden Buzzer. Very inspiring. These 18 (out of 18,000) nurses in the system portrayed their energy, message, and desire to reach others and shared their message with the world. This performance no doubt had a ripple effect throughout the system. Support such grass roots efforts to use talents to deal with adversity (NBC, 2021).

Massachusetts General Hospital Buddy System. Patterned after the military, staff are paired so they have someone to check in with each day. Reduces the impact of isolation (Walters, 2021).

Rush University Medical Center Wellness Response Team. Headed by a chaplain, the team rounds regularly on units to check in with staff on the frontlines and offer support (Stevens, 2021).

Aurora Health Chief Spiritual Officer. Job scope includes well-being and the sustainability of the workforce as well as work in the community and oversight of ethics functions.

Focus on the Organization

Authentic leadership assessment. There is no substitute for strong, capable, and trusted leadership. Work with senior leadership teams may be needed to develop their skills and resilience. Crisis brings out the best in capable leaders and is a litmus test for those not up to the challenge. Organizations with mature and wise leaders no doubt fared better than those where fragmentation and lack of genuine respect for the workforce is evident to the rank and file. Love your staff and respect them and it will be returned. Live by the Golden Rule.

Be transparent and let staff know that you, as a leader, understand what they are experiencing as you and your family are seeking some of the same supports that you are recommending to others. Let people know you want them to get vaccinated because you want them and their families to be safe. Such disclosures lower barriers and recognize seeking support is a human experience.

This approach can work magic as it is a sign of strength, not weakness, which gets to the heart of the stigma that needs to be erased. Building interventions into the fabric of the workforce begins at the top and carries through to orientation of new employees and the workforce overall.

Education for the senior executive team and board members. Chapter 10 of the new The Future of Nursing 2020–2030 report is an in-depth review of the many factors that contribute to distress within the profession and offers a comprehensive outline of potential interventions. For those not in the nursing profession, it is an educational overview of factors that need to be addressed to change the work environment (National Academy of Medicine, 2021).

For those tasked with developing a systems approach to improving the workplace, read Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being (National Academies Press, 2019).

Revisit the organization's mission statement and strategic plan. Is staff well-being part of the overall fabric of goals and objectives for creating a healthy community for all employees? If not, it must be addressed by senior leaders as a way of recognizing this is a population health issue that requires population health interventions involving all stakeholders. Emphasize the business case for wellness – less absenteeism, turnover, increase engagement, improvement in quality scores, etc. – in addressing why it is imperative to rethink how the organization addresses employee needs.

If the mission statement and strategic plan already incorporates employee well-being, revisit the strategies and work on measurement of outcomes, such as keeping voluntary turnover low and tracking why staff leave the organization. Track employee feedback on feeling supported and respected. Focus groups and well-being councils are being adopted to gain feedback and give a voice to all caregivers. Measurement of burnout is needed, along with other sources of feedback, to plan interventions.

Educate managers. They are the frontline of defense and must know how to intervene and use coaching methods to develop staff and address concerns.

Scan the environment for strategies and tactics that can be adopted. Review existing strategies that can be adopted such as these relatively low-cost interventions:

   • The Psychological Personal Protective Equipment checklist is a tool for promoting mental health and well-being that can be owned by individuals and unit managers (Institute for Healthcare Improvement, 2021).

   • Peer-to-peer training such as the Mental Health First Aid for Workplace offered by the National Council for Mental Wellbeing (2021). This approach is used in 25 countries and 2.5 million have been trained. The power of peer outreach can be tapped with such a program.

As part of the overall strategic plan, strengthen communication and perhaps include CEO broadcasts that emphasize employee well-being, dignity of work, and highlights everyday heroes to reinforce appreciation and gratitude.

Organize a framework. Gallup offers a Well Being at Work structure and training. This structure lays out five areas of well-being and guides organizations on how to achieve a whole person balance between career, social, financial, physical, and community, rather than overreliance on policies and perks. The role of leaders is to communicate the importance of mission (Gallup, 2021a). Gallup also published Ten Well Being Practices to Guide Leaders, which is worth reviewing and using as a benchmark for assessing the current state of an organization and serving as a guide for instituting new practices (Gallup, 2021b).

In addition, implementation of programs with existing evidence-based structures and processes is worth considering. Examples include:

   • Fostering the American Nurse Credentialling Center's (2019) Magnet Recognition Program® to build a strong and capable organization for nurses and the organization. As of 2021, 561 (8.9%) of hospitals achieved Magnet designation, so there is room to grow.

   • Conducting Schwartz Rounds allow for discussion of complex clinical situations using a facilitator to foster participation and understanding of the psychological aspects of the work. Schwartz Rounds are grand rounds style events that focus on a case or a theme related to the emotional impact of patient care that care team members experience. An interprofessional panel is facilitated to share their experiences, and then the discussion opens to comments from audience participants. It is a valuable way to reflect on subjects that may not be typically discussed in a group forum (The Schwartz Center for Compassionate Healthcare, 2021).

   • Adopting the American Association of Critical Care Nurses (2018) Healthy Work Environment Standards can improve outcomes for patients, nurses, and healthcare team. Standards include skilled communication, true collaboration, effective decision-making, appropriate staffing, meaningful recognition, and authentic leadership.

   • Participating in the DAISY Awards program fosters recognition of individual excellence. The DAISY Foundation (n.d.), created to express gratitude by a family that experienced extraordinary nursing, is considered the leader in meaningful recognition of nurses.

   • Tapping into the programs that are offered by professional associations (e.g., STTI Healthy Workplace awards program). Sigma's Healthy Work Environment Awards recognize and honor clinical facilities and academic settings that have demonstrated commitment in promoting healthy work environment and have demonstrated excellence in healthcare outcomes in both health care delivery and academic settings (Sigma Theta Tau, 2021).

   • Learning from others and adopting strategies used as effective interventions in other industries. For example, mandatory check-ins are routinely done for police when an untoward event occurs. Clearly, COVID-19 was such an event. I asked a nurse if she would attend a discussion with a counselor during COVID, and she said no. But asked if it was mandated, her answer was yes, since she knew everyone would have to attend.

   • Exploring new technologies, such as Even Health (2021), an innovative IT platform for building emotional strength. This app allows employees to access information and education on wellness and, most importantly, the opportunity to join discussion groups via technology-supported masking of voice recognition, free of stigma, to tell their story and gain feedback and support from others across the organization in a private manner. Adoption of such an app can be complementary to existing employee assistance programs and gives employees freedom to control access and use.

   • Expanding implementation of best practices beyond a given workplace, taking evidence-based work and systematically implementing it across many health systems, is a novel approach to advancing the spread of best practices that give staff and nurse leaders a chance to influence change (Caruso et al., 2019; Johansen et al., 2019; Johansen et al., 2020).

In general, be on the hunt for novel solutions and be part of groups that are addressing such interventions. One example is the Lee Kum Kee Center for Health and Happiness at the Harvard T.H. Chan School of Public Health (n.d.) where they are studying resilience among workers across industries.