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International research on the experiences of nurses during outbreaks of infectious diseases highlights how their mental and wellbeing is affected by caring for patients in stressful and challenging situations
Within the current coronavirus pandemic and against a backdrop of a pre-existing shortage of nurses in the UK, it is crucial to consider the issue of mental health and how to support nurses. This article uses the concept of emotional labour as a vehicle for a discussion of how best to understand the unique challenges faced by nursing staff in all care settings. Care is the central pivot around which nursing revolves and, as such, is dependent on an emotive response to support patients during critical stages of Covid-19 infection.
Citation: Graham Y et al (2020) How a pandemic affects the mental health of the nursing workforce. Nursing Times [online]; 116: 8, 20-22.
Authors: Yitka Graham is head of the Helen McArdle Nursing and Care Research Institute and associate professor of health services research, University of Sunderland; Ann Fox is executive director of nursing, quality and safety, Sunderland Clinical Commissioning Group and visiting professor, University of Sunderland; Jeanette Scott is executive director of nursing, quality and safety, South Tyneside Clinical Commissioning Group and visiting professor, University of Sunderland; Melanie Johnson is executive director of nursing and allied health professionals, South Tyneside and Sunderland NHS Foundation Trust and visiting professor, University of Sunderland; Catherine Hayes is professor of health professions pedagogy, University of Sunderland.
The coronavirus pandemic has challenged UK healthcare services at a time when there is already a shortage in nursing workforce numbers, as a result of demands on the NHS and unfilled vacancies (Appleby, 2019). With a vacancy rate of more than one in 10 across the UK (Buchan et al, 2019), there is an exponentially increasing burden and pressure on the existing workforce. As a result, acknowledging the need to support the mental health and wellbeing of nurses in all care settings has never been more important.
The nursing profession has embedded within it an ethos of compassionate care, with the workforce engaged on an everyday basis in intense and sustained emotional and psychological interactions with patients and their families and carers, often under exceptionally challenging conditions (Kinman and Leggetter, 2016). For many nurses, underlying politics and the history of traditional organisational hierarchies still have the potential to negatively affect elements of their work today (Feeley et al, 2019) – for example, perceptions and views of the status of nurses among other health professionals and profession-based silos, which can lead to exclusion and lack of opportunity for interprofessional collaboration (Braithwaite et al, 2016; Weller et al, 2014).
These issues may, unsurprisingly, make nurses vulnerable to stress and can lead to feelings of compassion fatigue with the duties they perform (Mason et al, 2014). Compassion fatigue is best defined, in these circumstances, as a state of physical and mental exhaustion caused by a depleted ability to cope with one’s everyday environment (Cocker and Joss, 2016), which may lead to reduced levels of resilience and burnout, resulting in an overall poor quality of life, both personally and professionally.
Compassion fatigue, burnout and compassion satisfaction were identified as key factors influencing nurses’ health-related quality of life in a research study of 1,521 Spanish nurses. The study’s authors recommended that healthcare organisations should actively implement programmes to support nurses’ emotional wellbeing and offer protection against negative variables, such as fatigue and burnout (Ruiz-Fernández et al, 2020). In a study of emergency care nurses, support of nurses by management staff was found to be conducive to high levels of compassion satisfaction, while lower levels of support resulted in burnout and compassion fatigue (Hunsaker et al, 2015).
Implications of Covid-19
Covid-19 is a newly identified disease, and evidence is still emerging on its pathophysiological impact and epidemiology, and the demographical implications of the pandemic. The Chinese government has studied the mental health and wellbeing of the frontline healthcare workforce in Wuhan, identifying factors leading to long-term suboptimal mental health status, including stress, anxiety, depressive symptoms, insomnia, denial, anger and fear. These factors are associated with, and correspond to, the high risk of potential infection with the virus and inadequate protection against contamination, overwork, physical and mental exhaustion, discrimination, isolation, complex patient care, and a lack of contact with families. The impact of these mental health issues will not only affect healthcare workers in the present fight against Covid-19 but may also affect their long-term health status (Kang et al, 2020a). Strategies to ameliorate the effects on staff include redeploying staff from other regions and establishing shift systems that allow workers time to rest and to take turns in high-pressure roles.
The first published study examining the mental health of nursing and medical staff based in Wuhan in the wake of the pandemic found that, of the 994 staff studied, 37% had experienced sub-threshold mental health incidents, 34% had mild disturbances, 22% had moderate issues and 6% had severe disturbances. Young women experienced a higher burden of mental health issues compared with older females and males in the study cohort (Kang et al, 2020b). In terms of support, 36% had accessed psychological materials (for example books), 50% accessed media (for example text messages on self-help coping methods), and 17% had sought counselling or psychotherapy. There was little access to formal mental health service provision, but this was nevertheless perceived as an important resource. Further recommendations emphasise the importance of supporting the mental health and wellbeing of all frontline healthcare workers during the pandemic (Kang et al, 2020a).
While acknowledging differences in healthcare systems, the validity of the findings to the UK workforce in terms of universal similarities in human experience make these aspects of global research invaluable. The World Health Organization has recognised the impact of Covid-19 on levels of mental health and wellbeing and issued specific advice on the provision of proactive support to health professionals (WHO, 2020).
Studies on the wellbeing of nurses and other healthcare workers during other pandemics have been examined. A study in Hong Kong identified four salient themes based on the instabilities and vulnerabilities facing emergency nurses in the management of emergent infectious diseases. The themes were resource constraints, threats of cross infection, ubiquitous changes and lingering uncertainties that may affect nurses’ abilities to perform outbreak-response duties (Lam et al, 2019) (Table 1).
Within the literature on severe acute respiratory syndrome (SARS), a Taiwanese study of 1,257 healthcare workers found differences in mental health across two phases of the outbreak. In the initial phase (rapid spread of virus), 81% experienced anxiety and excessive worry, 68% experienced depression and associated negative impact on family relationships, 62% experienced somatic symptoms and 50% experienced sleep problems, underpinned by perceived threats to life and vulnerability amidst a high level of uncertainty. In the repair phase (infection brought under control), 83% experienced depression and poor family relationships, 78% experienced somatic symptoms, 77% experienced anxiety and excessive worrying, and 54% experienced sleep problems. In the repair phase, there were higher rates of depression compared with higher levels of anxiety experienced in the initial phase. The reduction in anxiety was thought to be the result of the virus being under control and recognition that the disease was preventable. The high levels of depression, likely the result of the mental health impact of SARS, were proposed to be a contributing factor for 120 nurses (8% of participants) tendering their resignations during this phase (Chong et al, 2004).
An investigation into emotions, stressors and coping strategies of healthcare staff during the MERS-CoV outbreak in Saudi Arabia found that ethical obligations to their professions were rooted in an obligation to continue to work despite fears of safety. It also found that maintaining a positive attitude, improvement in health status of infected colleagues and reduced transmission of disease among staff owing to protective measures led to reduced fear and sustained them throughout the epidemic (Delgado et al, 2017).
A 2006 study investigated the influence of nurses’ perceptions of the possibility of SARS infection in relation to their dedication to nursing and their employer, and the consequences for intention-to-leave in the period following the SARS outbreak (Chang et al, 2006). Findings showed that nurses who believed themselves to be at risk of infection when caring for patients with SARS had a positive effect on the relationship between commitment to nursing, their employer and their intention to leave. This commitment to remain in the nursing profession in times of crisis highlights the need to support nurses by ensuring that personal protective equipment is available and used, and to inform and educate on infectious diseases such as SARS, as an integral part of training for staff (Chang et al, 2005). These are key points of learning from previous pandemics, which can be transferred to the current management of Covid-19 infection in UK healthcare practice.
Emotional labour and the nursing profession
The term emotional labour was coined by Hochschild, who defined it as “having to induce or suppress feeling in order to sustain the outward countenance that produces the proper state of mind in others” (Hochschild, 2012). It refers to having to display or deliberately obscure emotions at work, owing to perceived expectations that society may have of that profession. Within nursing, there is an onus on staff to both optimally deliver compassionate care and manage their own emotions to be able to alleviate suffering in patients and their families (Strazdins, 2000). Occupations that require emotional labour have three common characteristics: intensive contact with the public, the need to evoke an emotional state in others and a set of explicit or implicit rules concerning the types of emotions shown that are deemed to be suitable or unsuitable when in contact with others (Kinman and Leggetter, 2016). Studies have shown emotional labour to be fundamental to the nursing profession, with dissonance, as a result of ‘surface acting’ in day-to-day practice, a potential contributing factor to stress and burnout (Delgado et al, 2017), and that nurses early in their career are at higher risk compared with those at the mid or later career stage (Cho et al, 2006).
Studies have shown contributing factors to increasing personal resilience in the workplace include support networks, personal attributes and the ability to organise work for personal resilience (McDonald et al, 2016). Recommendations from a literature review into resilience in nursing suggested education on how to build resilience should be built into nursing curricula and incorporated into mentorship schemes outside the individual nursing environments within which staff work (Jackson et al, 2007).
The challenge of working in the current pandemic is likely to have an enduring impact on the mental health and wellbeing of healthcare staff across the globe. While the validity of research findings from other countries differs in terms of context and culture, the universality of human experience is generalisable and should be widely shared across nursing practice.
Ensuring that the welfare of nursing staff across all settings remains at the forefront of workforce planning has never been more important during the current pandemic. There is already a national recruitment and retention crisis across the nursing sector, which has the potential to be exacerbated in the light of negative outcomes relating to loss of life and reported lack of PPE availability.
With no vaccine currently available, there is an ongoing reliance on social distancing to protect healthcare staff from contracting Covid-19 and keep the NHS functioning. This has implications for nurses’ mental health and wellbeing. The valiant efforts made by nurses during Covid-19 echo the compassionate nature of the profession, with some paying the ultimate price. Those who are at the central heart of caring and saving lives as an integral part of multidisciplinary teams across the world need and deserve the assurance that, as a priceless part of our society that is often undervalued, they will be afforded all the protection they need, mentally, physically and emotionally.
- The shortage of registered nursing staff in the UK had reached a critical level prior to the emergence of Covid-19
- The environmental, psychological and emotional impact of Covid-19 care affects nurses’ personal health and wellbeing
- Compassion fatigue and burnout are key predictors of suboptimal mental health in nursing staff
- Key lessons from international nursing experience and healthcare research have the potential to inform the UK response
- Managing the emotional labour of nursing during the coronavirus pandemic is a challenge in relation to supporting optimal mental health
- The NHS mental health helpline is 0300 171 3000 (text 85258) and is open between 7am and 11pm every day.
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