Along with incalculable loss, the coronavirus (COVID-19) outbreak has had devastating effects on the mental health of people with COVID-19, their families, and the community at large. Healthcare workers face tremendous stress, both emotionally and physically, from the grueling work hours and the threat of contracting the virus at work.
This article addresses the potential mental health issues for healthcare workers that may emerge from this pandemic as well as treatment options and self-care activities that promote recovery.
COVID-19 and Mental Health
Nurses working on the front lines of the COVID-19 pandemic may experience various mental health problems. Here are a few examples:
Nurses are continuously fearful of contracting COVID-19, infecting others, encountering prejudice from the public due to working as a nurse, and dealing with inadequate supplies of PPE.(1) Stress becomes chronic when it is overwhelming and cannot be resolved, resulting in relationship, health, and sleep problems.(2-5) People with chronic stress experience intense emotions that can feel overwhelming and result in thinking negatively.(6) Nurses on the front lines in COVID-19.
hotspots report feeling like a graduate nurse again, filled with uncertainty and worry.(7)
Acute stress disorder.
Nurses with acute stress disorder may have trouble sleeping, worry constantly, and experience persistent negative thoughts about their role in the traumatic event, such as thinking “I should have done more to help.”(8) When we experience trauma, we detach from the memory. We ignore our emotions to protect against the pain, but these emotions reappear over time and impact our lives.(9) The nurse may respond to a minor irritation as if it were a life-threatening event.(10) Nurses may feel they are in a dreamlike state that impacts their ability to think, process their emotions, and respond appropriately to situations.(11) If signs and symptoms of acute stress disorder persist for more than a month, posttraumatic stress disorder (PTSD) may be diagnosed.(12)
Nurses are not strangers to caring for critically ill patients who die.(8) However, the number of patients dying amid a surge in COVID-19 cases is causing healthcare workers to feel powerless, which can lead to PTSD. PTSD can develop after direct or indirect exposure to a traumatic event, such as hearing about a traumatic event involving a family member, friend, or colleagues. Those with PTSD experience recurrent intense and disturbing thoughts and feelings stemming from one or more traumatic events.(10,13,14) Nurses with PTSD may relive an event through flashbacks or nightmares, and they may feel sadness, fear, anger, guilt, shame and detachment or estrangement from other people.(14) Many traumatized individuals have a robust and unconscious inclination to go inward, often to re-experience their distressing thoughts, painful memories, and uncomfortable sensations.(15) They may have an exaggerated, startled response to certain situations and develop problems with concentration and sleep.(5)
The nursing team’s role.
When nurses struggle personally, we tend to be critical of our colleagues or management and withdraw from others. Such a change in personality is often an indicator of struggle. It is often a team member who will notice that you are not your usual self and may be struggling with anxiety and stress. Asking yourself or a colleague three simple questions can raise awareness about a possible problem:
• Am I ok? Are you ok?
• Do you feel you cannot give any more?
• Do you feel your work is ineffective?(16)
If you are struggling, speak with your colleagues, acknowledging those feelings and thoughts in the first instant. If you feel you are not performing effectively in your workplace, talk with your manager and state your opinions on being ineffective. Everyone has limits, and sometimes just taking a week off might be sufficient.
Nurses who continue to feel this way should discuss it with their primary healthcare provider and their employer and review the options available. A range of supports may be available from your employer or your professional organization.17,18 Some nurses may want the support of a counselor. It is a strength to realize that you are struggling with your mental health and need help.
Early psychological intervention does make a difference.(19) Each of us has a limit to stress, and it is important not to compare your stress levels to those of another person. There is strength in being vulnerable and showing our thoughts and emotions. Brené Brown defines vulnerability as uncertainty, risk, and emotional exposure.(20)
Topping off emotional reserves.
Nurses on the COVID-19 front lines are plagued by drained emotions loneliness, and fear. These are normal reactions to an unfamiliar, uncertain environment. Transitioning away from work at the end of the day is essential for nurses to top off their emotional reserves. If you have had a particularly stressful day, acknowledging and discarding any negative thoughts or feelings can help improve sleep quality. Having a ritual to signal the end of work is essential.
Here are some suggestions:
• Take a shower. Visualize all the worries of the day disappearing down the drain.
• Write down any thoughts or feelings in a notepad.
• Watch a favorite TV program.
• Read a book.
• Listen to your favorite music.
• Contact a friend.
• Write down three things you were grateful for today.
The COVID-19 pandemic is an unprecedented event in our lifetimes that will have untold mental health implications for nurses and other healthcare professionals on the front lines, both in the short and long term. Although scientists and healthcare professionals know more about the disease and how to treat it now, nurses in current COVID-19 hotspots will still be treating patients with a serious and rapidly spreading disease while possibly contending with shortages of PPE, equipment, and treatments.(21)
Nurses will need to receive support from their team, practice optimal self-care strategies, take measures to replenish their emotional reserves, and learn how to transition mentally from work to home after their shift. Recognizing stress and learning how to cope will help nurses protect their mental health as we move
forward during this pandemic.
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2. Mariotti A. The effects of chronic stress on health: new insights into the molecular mechanisms of brain-body communication. Future Sci OA.
3. American Psychological Association. How stress affects your health. 2019. www.apa.org/helpcenter/stress-facts.
4. Heidt T, Sager HB, Courties G, et al. Chronic variable stress activates hematopoietic stem cells. Nat Med. 2014;20(7):754-758.
5. Kabat-Zinn J. Full Catastrophe Living. 15 th anniversary ed. New York, NY: Piatkus; 2004:249.
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7. Gonzalez D, Nasseri S. ‘Patients have panic in their eyes’: voices from a Covid-19 unit. The New York Times. 2020.
8. Hayes C. Coronavirus: front-line NHS staff ‘at risk of PTSD’. BBC News. 2020. www.bbc.com/news/uk-52258217.
9. Muller R. Trauma and the Struggle to Open Up. New York, NY: WW Norton & Company; 2018:33.
10. Van Der Kolk B. The Body Keeps the Score. London: Penguin; 2014:156-157, 166.
11. Bolton EE, Jordan AH, Lubin RE, Litz BT. Prevention of posttraumatic stress disorder. In: Gold SN, ed. APA Handbooks in Psychology. APA Handbook of
Trauma Psychology: Trauma Practice. Washington, DC: American Psychological Association; 2017:483-497.
12. Psychology Today. Acute stress disorder. 2019. www.psychologytoday.com/ie/conditions/acutestress-disorder.
13. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
14. American Psychiatric Association. What is posttraumatic stress disorder? 2020. www.psychiatry.org/patients-families/ptsd/what-is-ptsd.
15. Levine P, Blakeslee A, Sylvae J. Reintegrating fragmentation of the primitive self: discussion of “somatic experiencing.” Psychoanal Dialogues.2018;28(5):620-628.
16. Highfield J. Am I OK? Intensive Care Society. 2020. www.ics.ac.uk/ICS/Education/Wellbeing/ICS/Wellbeing.aspx.
17. World Health Organization. Coronavirus disease (COVID-19) outbreak: rights, roles and responsibilities of health workers, including key considerations for occupational safety and health. 2020. www.who.int/publications/i/item/coronavirus-disease-(covid-19)-outbreak-rights-roles-and-responsibilities-ofhealth-workers-including-key-considerations-foroccupational-safety-and-health.
18. American Association of Critical-Care Nurses. Well-being Initiative. 2020. www.aacn.org/nursingexcellence/well-being-initiative.
19. World Health Organization. WHO guidelines on conditions specifically related to stress. 2013. www.who.int/mental_health/emergencies/stress_guidelines/en.
20. Brené Brown. Vulnerability. 2020. www.brenebrown.com/definitions.
21. Frank S. As coronavirus slams Houston hospitals, it’s like New York “all over again.” The New York Times. 2020.
BY Gráinne Ráinne Clancy, BN, MIACP; D’Arcy D. Gaisser, DNP, MS, RN, ANP-BC; and Grace Wlasowicz, PhD, RN, PMHNP-BC, ANCC NP. This article has been adapted for space and originally appeared in the September 2020 issue of Nursing © 2020 Wolters Kluwer Health, Inc. This risk management information was provided by Nurses Service Organization (NSO), the nation's largest provider of nurses’ professional liability insurance coverage for over 550,000 nurses since 1976. The individual professional liability insurance policy administered through NSO is underwritten by American Casualty Company of Reading, Pennsylvania, a CNA company. Reproduction without permission of the publisher is prohibited. For questions, send an e-mail to firstname.lastname@example.org or call 1-800-247-1500. www.nso.com.