Covid‐19: Supporting nurses' psychological and mental health

"I broke down and cried today. I cried of exhaustion, of defeat. Because after 4 years of being an ER nurse, I suddenly feel like I know nothing" (Sydni Lane, USA, Instagram and Facebook). (Fick , 2020) “It's an experience I would compare to a world war” Roberta Re, Italy. (Giuffrida, 2020) “we're on our knees here, and it's really difficult and we're all trying the best we can and we don't feel… we feel like we could be doing more, and I know we can't … we're staying away from our families and we're putting ourselves in danger to try and save other people's loved ones, it feels like a losing battle but it's not, we've all got hope and we're all trying to do what we can.” (Shirley Watts, UK ICU Nurse, BBC news 04 April 2020) As the coronavirus disease 2019 (COVID-19) pandemic takes hold, nurses are on the front line of health and social care in the most extreme of circumstances. We reflect during a moment in time (week three of lockdown in the UK and week 5/6 across Europe) to highlight the issues facing nurses at this unprecedented time. At the bedside 24 hr a day seven days a week, in similar outbreaks, nurses have had the highest levels of occupational stress and resulting distress compared with other groups (Cheong & Lee, 2004; Maunder et al., 2006; Nickell et al., 2004). Nurses are already a high-risk group, with the suicide rate among nurses 23% higher than the national average (ONS, 2017). Despite this, the RCN (Royal College of Nursing in the UK) has reported that nurses feel “repeatedly” ignored by their employers when they raise concerns about their mental health (Mitchell, 2019). A focus on personal responsibility for psychological health and well-being and an overemphasis on nurses being “resilient” in the face of under-staffing and often intense emotional work is consistently challenged by nurses and nurse academics (Traynor, 2018). Treating resilience as an individual trait is seen to “let organisations off the hook” (Traynor, 2018), yet has often been the focus of organisational strategies to date. This does not work at the best of times and certainly is not appropriate now in these most difficult of circumstances. Here, we discuss the stressors and challenges and present evidence-informed guidance to address the physical and psychological needs of nurses during the COVID-19 pandemic. We stress the importance of peer and team support to enable positive recovery after acutely stressful and emotionally draining experiences, and outline what managers, organisations and leaders can do to support nurses at this most critical of times. The high prevalence of COVID-19 in the general population of many countries, its novelty and highly infectious nature, and the associated morbidity and mortality rates are placing an unprecedented demand on health and social care services worldwide. In addition to the admission to hospital of high numbers of critically ill patients, care demands on nurses and care assistants have also increased in the community, in care homes and in learning disability and mental health services. These demands must be met by an already-depleted workforce (+44,000 RN vacancies in the UK pre-COVID-19) and one that is further depleted at this time due to infection, self-isolation and family responsibilities in the face of the crisis. The nature of care itself and new ways of working are potentially highly stressful for staff. Nurses are not only experiencing an increase in the volume and intensity of their work, but are having to accommodate new protocols and a very “new normal.” For instance, many mental health services have transformed almost overnight from providing face-to-face care and treatment to a predominately virtual service of telephone or video consultations. In many other areas, nurses are adjusting to providing end-of-life care more frequently and often in the face of more rapid deterioration than they are used to. Isolation rules mean the presence of family at the bedside is rarely possible. Nurses are therefore frequently standing in for family members and facilitating remote access for loved ones. Established nurse–patient ratios are under strain. In ITU in the UK, for instance, staff-patient ratios of one-to-one are changing to ratios of one ITU nurse to six or more patients, with the shortfall being made up by staff without ITU experience. To boost the nursing workforce, many countries have also fast-tracked their final-year nursing students to join the nursing register early and have encouraged retired colleagues back to practice (Jackson et al., 2020). Many nurses have been redeployed, working in new specialities or in higher acuity areas. All of these factors are likely to be adding stress for existing staff, with additional implications for the well-being of new members of the team. Evidence from studies on COVID-19 and other infectious respiratory disease outbreaks reflects high concern among nurses for personal or family health in the face of direct contact with a potentially deadly virus and the stress of balancing this concern with the ethical obligations of continuing to provide care (Jiang, 2020; Khalid, Khalid, Qabajah, Barnard, & Qushmaq, 2016; Kim & Choi, 2016; Nickell et al., 2004). Other stressors evident from research to date include concerns about shortages of staff and of personal protective equipment (PPE), navigating an unfamiliar setting or system of care and lack of organisational support (Kim, 2018; O'Boyle, Robertson, & Secor-Turner, 2006; Shih et al., 2009). Additionally psychological conflicts between healthcare workers' responsibility to care for the ill and their right to protect themselves from a potentially lethal virus were reported (Chen, Wu, Yang, & Yen, 2005). Our own anecdotal sources in the UK and Europe endorse these findings for COVID-19 as (at time of writing) we approach the peak of the pandemic, but also raise the possibility of other stressors including moral distress resulting from treatment decisions based on finite resources, the lack of access to antigen or antibody testing for most front-line staff, and the discomfort and fatigue resulting from long shifts spent wearing full PPE. On social media, nurses speak of crippling tiredness after long shifts with sore faces after so many hours in masks, as well as communication barriers with colleagues and patients when wearing full PPE; nurses often cannot hear patients, and patients can struggle too; not being able to see nurses' faces or hear what is said. Nurses also speak of the difficult ethical and moral judgements that are being taken in hospitals; care homes and the community throughout the world. They tell of experiencing stigma in the wider community, being perceived as a threat to the safety of others and as “disease-carriers.” As the number of COVID-19 patients grow, there will be increasingly stringent rules about who can be offered ventilation, with one doctor suggesting “soon many of our own staff would not meet the criteria” (Anon & The Guardian, 2020). Reflecting on the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) COVID-19 guidelines for the criteria that doctors and nurses should follow, the moral philosopher Yascha Mounk reflects: “If you are an overworked nurse battling a novel disease under the most desperate circumstances, and you simply cannot treat everyone, however hard you try, whose life should you save?” (Mounk, 2020). Nurses are likely to experience moral and ethical conflict with the potential for stress and moral distress or moral injury (Bridges et al., 2013; Greenberg, Docherty, Gnanapragasam, & Wessely, 2020; Morley, Ives, Bradbury-Jones, & Irvine, 2019). These stressors are present across settings in health and social care, and relevant to all members of the nursing team, including care assistants and temporary members of the team drafted in from their studies or from retirement. There is also an emerging narrative of guilt and some of potential shaming among nurses and students who are unable to contribute to direct patient care due to their own high risk and vulnerability to coronavirus. Nurses and their unions are speaking up about the lack of testing for front-line staff and the variation in access to PPE. Nationally and internationally it appears there is wide variation in access to PPE and the Royal College of Nursing in the UK and its counterparts across the world have been campaigning for adequate PPE for nurses suggesting the nursing voice has been side-lined in the relevant debates (Ford, 2020). In many countries, the focus has been on acute and intensive care; however, nurses in the community and mental health and learning disability settings may also have inadequate access to PPE. The UK priorities for PPE distribution and testing are being interpreted as further discrimination against nurses who do not work in acute physical health settings, leading to further anger that some lives appear to matter less. A failure to protect nursing staff adequately is causing anger and frustration, making nurses feel unsafe at work, while they are risking their own health and fearful of transmission to their families. Unless nurses feel well supported by their organisations and governments, that anger may linger after the crisis potentially causing some to leave the profession. It would be difficult as a nurse not to have strong emotional reactions to the COVID-19 virus and its impact on one's work (fear, anger, frustration, worries). Such fear and anxieties are normal, as are the intense feelings evoked when nurses feel unable to care for patients as they would have otherwise. Nurses and healthcare or nursing assistants, in acute, community mental health and social care settings are having to make extremely difficult decisions from one moment to the next. They are having to be very creative about new ways of working with very ill patients with mental health needs or learning disabilities or dementia. Legal frameworks to support the continuation of care at times of mental health crises such as (in the UK) potential temporary amendments to the Mental Health Act 1983 and the Coronavirus Act 2020 which enforce isolation; place further strain on therapeutic relationships and the delicate balance between nursing care and restrictive practice. In situations where compliance with social distancing and isolation with COVID-19 is low on the list of priorities for people in receipt of care, nurses are having to weigh up human rights, safeguarding and infectious disease protocols all of which may potentially conflict. There are some good signs that health systems are recognising how important it is to support healthcare staff. In the UK, NHS staff have been given free access to more than 1,500 specialists, online therapy and group counselling sessions and will receive practical and financial assistance as well as specialist bereavement and psychological support. Volunteers from charities including Hospice UK, the Samaritans and Shout are staffing phone and text helplines. The NHS is also offering free access to support from Apps such as Headspace, UnMind and Big Health for healthcare staff and their families to include guided meditation and tools to battle anxiety and help with sleep problems. This is a good start, but these services rely on the individual seeking help, and this may well not be sufficient. Investment in a range of supportive measures that do not just place the onus on the individual is almost certainly necessary. Supporting nurses practically and psychologically is essential to preserving their health in the short and long term, particularly when occupational stress levels are so high. Ensuring psychological well-being requires a layered response, with different components at different times, comprising strategies aimed at prevention through to treatment, and strategies/actions at different levels, from organisational and team/ward responses to those aimed at individual self-care and peer support. Response to the specific unprecedented challenge of COVID-19 will also need a flexible strategy as needs and requirements are likely to change over the course of the pandemic response. Furthermore, nurses working outside acute hospitals, working autonomously or in dispersed teams across large geographical areas can find accessing support challenging. Having reviewed the literature and gathered intervention resources from a variety of sources, it is evident that there is much to learn from other similar crisis situations such as SARS, MERS and Ebola. The evidence base in this area is considered weak, and most research is observational or has focussed on early interventions after major incidents and once the crisis has passed (Billings et al., 2020). From a nursing perspective, few studies consider nursing outside of hospital walls. In Figure 1, we present strategies and interventions aimed at supporting nurses' psychological well-being during the COVID-19 crisis. This guidance is led by best-available evidence, underpinned by theory (see Figure 1), expert opinion and models used in the military, as well as experiences from other countries and other infectious disease outbreaks (Watson, 2020; Watson, Brymer, & Bonanno, 2011; Watson et al., 2013). Below, we highlight physiological and safety needs; peer support; team support; and the roles and needs of managers and leaders as well as long-term recovery support needs. While at work and outside of work, nurses should prioritise their own well-being as much as possible, paying attention to meeting their essential needs for drinks, food, rest and sleep, and building in rest and comfort breaks (Cole-King & Dykes, 2020). At times of crisis, human physiological and safety needs come to the forefront—adequate food, shelter, rest, sleep and safety needs for example (Kenrick, Griskevicius, Neuberg, & Schaller, 2010). Recent interviews with medical staff (including nurses) treating COVID-19 in a hospital in Hunan Province support this (Chen et al., 2020). A detailed psychological intervention package (online course to deal with psychological problems; a psychological assistance hotline; and group interventions) encountered obstacles, as staff were reluctant to participate. Staff reported not needing a psychologist at this time, as they were concerned with more immediate worries including not wanting their families to worry; more rest without protective and support and with anxiety and The psychological intervention measures were therefore to include a place to and of their work to with families to to psychological problems; and access to staff for psychological the rest areas to to staff and and provide support (Chen et al., 2020). In countries with the threat of the from the there are from nurses for adequate PPE; and access to the right for psychological support with the wider evidence base that early with more intense for example psychological can be & & Wessely, 2009). on the work of Watson (Watson, 2020; Watson et al., we know that to the healthcare work is by stress may be the to it and stigma can be an to for often do not prioritise good care of recognising it may on or they fear the team without after nurses cannot after health are to after others and not are therefore likely to need others and to to of For week a of a of for a nursing team who had not had a for more than Figure for strategies and interventions for individual and peer support. the pandemic, nurses may be working with people who are not their team therefore need to support other and find ways to help new members feel and as as (see Figure with more colleagues can help support colleagues who have from have been or are final-year students who are in the numbers or in some countries have been early et al., needs to be so that the people are not support and should be so that is not seen as an for organisations they are not providing adequate psychological or other support. All members of the and access to support during and after the In the for Care (Bridges et al., 2018), nurses and healthcare assistants the of nursing teams in to in on This other that the of for members to learning and social support for nurses difficult work with Staff in the an to meet to in on well-being the safety and other evidence at the and of shifts can also help to social support for other (see Figure In times, there is evidence that group such as can team and increase for colleagues and patients et al., 2018). to psychological safety in our that staff by members should not be staff should have had the to and a difficult or experience to protect staff from et al., 2009). as to all in the and face to may not be the at the of the pandemic. The of Care in the UK is therefore their in to in has the of but in a virtual to be in existing teams across the with by of and for a time of an with present 2020). These sessions are being in practice and in and other teams in the few and we to with our students at the of these will A from studies of members of the is that team and leaders and their is highly with mental with a reported in mental health between who perceived themselves as having a good or et al., There is therefore much managers and leaders can do to support nurses in their teams and organisations (see Figure for strategies and guidelines also and communication is as well as and access to physiological and safety needs (Billings et al., 2020; & Dykes, 2020). It is also important that nurses support for so that they have the to support others and are able to good to decisions and access to a are particularly important for where they can through the difficult decisions they are having to make in to COVID-19 They will need their healthcare and to on during the pandemic. or seeking a for peer support is therefore Evidence it is important not to what are and anxieties in such and situations and stress and that needs change over time (Billings et al., 2020). to highly or resilience and do not long-term psychological Greenberg, & Wessely, 2005). some will in most these without the need for interventions Wessely, & is evidence of staff experiencing stress after infectious disease outbreaks for example et al., that does not mean all staff will experience mental health it will be important to the psychological needs of the nursing workforce the of the pandemic, so that in teams and across organisations as well as across we can learn and make nurses have access to adequate support in the recovery to a of nurses with psychological or in the of the acute staff may be on some may have staff colleagues have or family members there has been time to and some may have or guilt (Cole-King & Dykes, 2020; et al., It is important that interventions do and are to individual at and groups should be early or detailed could an and psychological is now with A of research has the of the of as a in of long-term for a of psychological may in et al., et al., 2009). to treatment for those staff who of mental health such as therapy and and which are to be in et al., may be may be for this, and it will be important that there is of access and that this is to nurses as well as other members of the healthcare team. to this unprecedented some resilience is but nurses need their their the and the to support with and and front-line staff throughout Europe is to and some nurses at the of and of such as and other There are also of teams in and in and intensive care to but a this is not nurses also need to feel their needs are for and that they are with adequate PPE equipment in all settings where health and social care are being They need access to rest good peer and team support and leaders that will to care for well after the pandemic is As who have nurse well-being for it is to see the increased focus on healthcare staff yet that it takes a pandemic to its critical staff will need but resilience must be seen as an individual it is a and organisational Evidence from the the resilience of the team appears to be to the between team members than the psychological or of et al., The resilience is now as staff can feel it is to staff are and psychologically lack of resources or ethical and emotional challenges as in nurses can feel it is their they have not the adequately or been This is not this be an to the and emotional strain that nurses on of and not only through this crisis but after it is all health care is back to support for nurses' well-being will critically While COVID-19 particularly high stress on there is very in the guidance that not relevant to staff well-being and when the pandemic is we to the guidelines being used to support for nurses and nursing the We are to our colleagues for their support in the of this to who had the for guidance and through the different levels of while being with are also due to the colleagues who on the and for evidence and