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

Highlights and Trends

Let's look at the numbers providing evidence for this unprecedented call to action. People in health care are leaving via retirements, escaping routines, cutting back hours, working for agencies where they can get flexible schedules, or leaving the field earlier than expected to pursue other options. This is a trend across all industries. It is a turning point for many workforces. What will stem this tide?

For nurses, baseline stresses have been known for years. Stress among nurses is not new. Of course, there are many rewards as well, otherwise, nurses would not stay in the field. Despite the frustrations, most do continue to work. But let's put a spotlight on what needs to change.

What are some of the highlights and trends? Long before COVID hit, many studies documented burnout and factors that lead to nurses leaving the profession due to stress, unfulfilled expectations of the profession, or some combination. Let's look at a few examples.

Work-related Stress

Some stress is related to the work itself – systems, policies, and procedures that are part of the standard operating procedures of an institution. For example, work stress can be related to staffing patterns (often the top complaint among staff), coworker conflict and bullying behavior, management conflict, workflow redundancy, copious documentation requirements, continuous support given to families and coworkers, and direct patient care activities. All these organizational factors and extra tasks add up to significant formal and informal overtime (Happell, 2013; Work Related Stress, 2020).

In addition, psychological pressures involved in the care process, such as moral distress issues regarding difficult choices clinicians make in providing care, are present. These dilemmas are often focused on the individual provider feeling powerless to provide quality care, which generates conflict and leads to more stress.

During COVID, nurses reported great moral distress and compassion fatigue in caring for patients which entailed painful procedures, turning, and intubation. Inflicting so much pain and seeing so many patients die nonetheless was torturous for clinicians and patients. Many asked, was the pain and eventual death worth the care involved and pain endured by the patient?

Clearly, the pandemic brought new challenges in how to deal with multiple technologies, PPE shortages for staff and scarce ventilator resources for patients, deep fear of contagion from job to family and community, and loss suffered with daily waves of death in the workplace.

Even nurses working far from a COVID intensive care unit (ICU), such as in a neonatal ICU, had to support frantic parents virtually and at the same time worried about preemies not being able to see a human face for months as nurses wore shields, masks, and glasses as part of protective gear. Nurses in ambulatory care settings often saw the first wave of cases before admission and those in long-term care and assisted living cared for patients who were both vulnerable to the virus and socially isolated. Such daily experiences bring up many moral questions that often cannot be answered in the moment.

Nurses may also express disgust and cynicism with the healthcare system. Fed up with care fragmentation, lack of political will on the part of politicians, and lack of responsiveness of leaders, nurses I reached out to for feedback said they were done with the profession. Very disheartening to hear. When I suggested strategies for bringing issues to the attention of key individuals, one individual stated she had written letters to politicians and attempted to play an active role, but in her mind, to no avail.

External Stressors

Other stressors are more external, often related to patient interactions. Nurses typically work in very dynamic settings and are in close contact with the public in many roles. An interesting study by the Robert Wood Johnson Foundation (2015) examined violence against nurses in emergency departments. Often, violence is seen as part of the job. However, in related studies, three in four nurses experienced verbal or physical abuse such as yelling, cursing, grabbing, scratching, or kicking from patients and visitors (Speroni et al., 2014). Three in 10 nurses reported physical abuse. More education is needed to prepare nurses on how to anticipate violence and protect themselves, as well as to enact laws to make assault of a healthcare professional a criminal activity. Considering the shocking reports of violence among airline passengers toward flight attendants and society-wide escalation of violence during the pandemic, such violence will undoubtedly impact healthcare personnel too.

As a result of such stressors, staff burn out is common. A study of physicians and nurses indicated more than 40% of physicians in family medicine, emergency medicine, and general internal medicine and more than 50% of physicians in critical care units reported burnout syndrome (BOS) (Moss et al., 2016). In a meta-analysis of studies of nurses in ICUs, 25%-33% reported severe cases of BOS and a whopping 86% exhibited one or more symptoms of BOS; namely emotional exhaustion (73%), followed by a lack of personal accomplishment (60%), and depersonalization (48%) (Reith, 2018). Nurses working in units where there is a negative culture reported the highest level of symptoms. Burnout can be contagious. So, the culture of an organization does matter as does the quality and dedication of leadership; these go hand in hand. (Moss, 2016; Reith, 2018; Shah et al., 2021).

Personal Stress

Not all stress is work related. A dividing line between work and personal life does not exist, particularly when it comes to emotions. It is a blended experience. While doing my PhD thesis at Brandeis University, I learned from nurse study participants they often carry many personal and family-related burdens. My study, "Stress, Alcohol and Psychoactive Drug Use Among Nurses in Massachusetts," used a survey instrument to elicit a large data bank of information that assisted in estimating the incidence and prevalence of at-risk behaviors among nurses who participated. The goal of the study was to survey a large sample of nurses and use responses to calculate those at risk for alcohol and drug abuse. In analyzing questions related to stress factors, most stress was related to personal and home problems, rather than work. Nurses also reported high levels of alcohol and drug abuse within their family systems. These complex issues and emotions are brought into the work environment and merge with the daily routine and become difficult to separate (Valentine, 1992).

I conducted this study because I was interested in impaired nursing practice. I previously encountered impaired nurses in my first leadership role as director of nursing in a large metropolitan hospital. Having worked on an earlier Harvard-sponsored naltrexone clinical trail study with hard core addicts, I was shocked to see how addiction affected capable nurses. Clearly, I was naïve and learning "on the job" that addiction can strike any group. However dramatic each nurse addiction case might be, I looked at their situation with compassion and wanted to change policies and practices associated with how impaired nurses are treated. My personal and professional goal was to get nurses treatment and return to practice, not be tossed out permanently, which is all too common.

This view was not popular or embraced by my peers at the time. They thought I was naïve to have such notions and brash to be speaking out about alternative approaches. They believed impaired nurses did not exist in their organizations. One day I got a frantic phone call from a revered nurse leader who asked for my advice in dealing with a nurse who was highly thought of but who had recently been confronted about drug use and had gone missing. The managers and coworkers were afraid she might commit suicide. I gave her my advice and luckily all worked out well. That experience won that leader over, but she never talked about it openly with others. Perhaps the shame of having an impaired nurse was thought to be a poor reflection on the nurse leader as well. Another example of how even talking about such problems is very difficult.

Nurse Suicide

Through my professional experience as a nurse executive and given the data collected for my thesis, I recognized women, nurses in particular, often assume caregiver roles within their families, carry personal problems with them into the job. Instead of organizations dealing directly with these issues with prevention strategies, placing emphasis on treatment and believing that most can return to work and be successful once fully engaged in treatment, nurses are typically fired and many never practice again or, worse, commit suicide because of job loss, humiliation, and the eventual untoward outcome of their illness. No other group of healthcare professionals are treated this harshly. Suicide, whether related to substance abuse or not, cannot be dismissed as rare.

Nurse suicide has received little attention and is relevant to our current situation where we can expect all mental health issues to increase. Here are some pre-COVID statistics.

"Using the 2005–2016 National Violent Death Reporting System dataset from the Centers for Disease Control, it was found that male and female nurses are at a higher risk for suicide, confirming our previous studies," reports Judy Davidson, DNP, RN, research scientist at UC San Diego. "Female nurses have been at greater risk since 2005 and males since 2011. Unexpectedly, the data does not reflect a rise in suicide, but rather that nurse suicide has been unaddressed for years" (Carr, 2020, para. 2; Davidson et al., 2020).

The World Health Organization reports that one person dies every 40 seconds by suicide. It is the 10th leading cause of death in the United States, occurring at a rate of 13 per 100,000 persons.

While overall mortality rates are decreasing in the United States, the suicide rate is rising. Davidson and colleagues (2020) found female nurse suicide rates from 2005–2016 were significantly higher (10 per 100,000) than the general female population (7 per 100,000). Similarly, male nurse suicides (33 per 100,000) were higher than the general male population (27 per 100,000) for the same period. Sidney Zisook, MD, UC San Diego, Davidson's coauthor, states, "Opioids and benzodiazepines were the most commonly used method of suicide in females, indicating a need to further support nurses with pain management and mental health issues. The use of firearms was most common in male nurses and rising in female nurses. Given these results, suicide prevention programs are needed" (Carr, 2020, para. 5).

How can we use these data to inform our actions? From an organizational and policy perspective, many health systems and state boards of nursing deal with serious mental health issues that lead to impairment among nurses in a punitive manner, which is a dramatic example of how we simply do not tolerate mental health problems among nurses in the workplace.

I am hopeful COVID will be the tipping point to change this perspective. Many people will exhibit problems and need assistance along a broad spectrum of mental health issues. Instead of viewing impaired nurses in a separate category, we have the opportunity to reset our perceptions and view stress and mental health among staff along a continuum of experience; some having mild or moderate reactions to stressors, while others have more serious outcomes, such as PTSD and associated impairment.