Keywords
Key points
- •Women comprise majority of the US nursing workforce.
- •Nurses experience a higher prevalence of certain neuropsychological disorders than the general public.
- •The coronavirus disease 2019 pandemic disproportionately affected health-care workers, particularly nurses.
- •Increased prevalence of depression, anxiety, posttraumatic stress disorder, and workplace violence may be contributing to nurses leaving the field.
- •Hospital administrators and government agencies must implement policies and practices and adapt the workplace environment to attract and retain nurses.
Introduction
In March of 2022, The American Nurses Foundation (ANF) published some alarming results of an impact survey of nurses in the United States (US). More than 12,000 nurses participated. More than 50% of those nurses completing the survey planned to leave or were considering leaving their position, an increase of about 20% from the prior year.
1
It was evident from the numerous concerns noted that the emotional and physical stress of working as a nurse throughout the coronavirus disease 2019 (COVID-19) pandemic has taken its toll.This pandemic has disproportionately influenced health-care workers and particularly bedside nurses. Numerous studies around the globe have demonstrated an increased prevalence of various neuropsychological disorders among nurses during the last 2 years, including depression, anxiety, and other stress-related conditions such as posttraumatic stress disorder (PTSD).
2
This is further exacerbated by workplace violence (WPV) toward nurses, which has been increasing for more than a decade but dramatically increased during the pandemic.- Sun P.
- Wang M.
- Song T.
- et al.
The Psychological Impact of COVID-19 Pandemic on Health Care Workers: A Systematic Review and Meta-Analysis.
Front Psychol. 2021; 12https://doi.org/10.3389/fpsyg.2021.626547
3
- Ramzi Z.S.
- Fatah P.W.
- Dalvandi A.
Prevalence of Workplace Violence Against Healthcare Workers During the COVID-19 Pandemic: A Systematic Review and Meta-Analysis.
Front Psychol. 2022; 13https://doi.org/10.3389/fpsyg.2022.896156
Hospital administrators, government agencies, and the health-care system at large must act judiciously to improve the working conditions for nurses before the next pandemic when a severe nursing shortage would put the health and safety of the US population at high risk.
History
Nursing is this nation’s largest health-care profession, with nearly 4.2 million registered nurses (RNs) nationwide.
1
It is historically, and currently, still, a female-dominated profession, with more than 80% of the US RNs being women.4
Not only do women dominate the profession but they have also historically been its most significant contributors.Female pioneers in the nursing field, such as Florence Nightingale, made indisputable contributions to both nursing and the health-care profession. Nightingale’s approach to caring for patients revolutionized how nurses practiced through her implementation of disease prevention measures, including an emphasis on handwashing and other hygiene practices.
Many might view nurses as the exemplar of Carl Jung’s Caregiver archetype: selfless and self-sacrificing, always putting their patients first, making their rounds when they should be eating or taking a much-needed break, as embodied by the “Lady with the Lamp” so famously did nearly 2 centuries ago during the Crimea War. However, even these infinitely selfless caregivers must have a breaking point.
Nightingale, perhaps Jung’s quintessential caregiver, would have been appalled by the lack of progress in conditions under which many nurses found themselves during the COVID-19 pandemic: frequently faced with a lack of personal protective equipment, inadequate support, longer shifts due to personnel shortage, inadequate staffing, living in isolation from friends and family, abusive patients and family members, fear of falling ill to the same virus plaguing their patients, watching patients and colleagues succumb to COVID-19, all of which resulted in an excessively stressful workplace environment. Unsurprisingly, many of these issues have been cited as reasons for nurses leaving or planning to leave their positions.
5
- Shah M.K.
- Gandrakota N.
- Cimiotti J.P.
- Ghose N.
- Moore M.
- Ali M.K.
Prevalence of and Factors Associated With Nurse Burnout in the US.
JAMA Netw open. 2021; 4https://doi.org/10.1001/jamanetworkopen.2020.36469
Background
Before the onset of the global COVID-19 pandemic in 2020, there was already a nursing crisis in the US nursing shortages have been a somewhat cyclical societal issue during the last century with various causes. Frequently, the shortage boiled down to either supply or demand.
6
During the Great Depression, for example, increased use of the health-care system led to heightened demand for nurses rather than an actual reduction in the number of nurses. During World War II, the US military ciphered tens of thousands of nurses from the civilian sector to join the war effort. This nursing shortage was very much a supply problem.The Institute of Medicine published the landmark report “The Future of Nursing” in October 2010. The report called for doubling the number of nurses with doctoral degrees and increasing the percentage of nurses with baccalaureate degrees in the workforce to 80%.
7
According to the most recent workforce survey referenced above conducted by the National Council of State Boards of Nursing, only 64.2% of RNs is educated/trained at the baccalaureate or graduate level.1
The current nursing workforce falls far short of the report’s recommendations, and the situation is projected to worsen. According to The Registered Nurse Workforce Report Card and Shortage Forecast for the US, a nationwide shortage of RNs is anticipated to persist between 2016 and 2030, with the western and southern states being the most affected.8
One factor contributing to the shortage is simply a matter of demographics. The US population is aging; nearly one-third is aged older than 58 years. Both patients and nurses alike are getting closer to retirement age. Nearly half (47.5%) of all RNs is now aged older than 50 years.
9
Although a significant percentage of the population is close to retirement, research shows that the “choice” to retire is not always voluntary. Between 2010 and 2018, an analysis of data from a high-quality longitudinal survey from the University of Michigan suggests that most of those who hold career jobs in their 50s will get pushed out of those jobs before official retirement age.
10
Senior staff nurses are not immune to this nationwide phenomenon. However, whether these older nurses leave voluntarily or involuntarily, younger nurses can advance by moving into positions that pay more and may offer more fulfillment. These tend to be administrative positions that take them away from the bedside, resulting in fewer nurses left in direct patient care, thereby increasing the workload for those remaining and accelerating burnout and more departures.6
The term “burnout” is often used to describe the reason for the mass exodus from bedside nursing. However, the term does not adequately encapsulate the mental health crisis that has plagued the nursing profession since the first human cases of COVID-19 were reported in Wuhan City, China, in December 2019.
The Evidence
Depression
The World Health Organization (WHO) defines depression as “persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities. It can also disturb sleep and appetite. Tiredness and poor concentration are common.
11
According to the latest data from the WHO, approximately 5% of adults worldwide suffer from depression.12
In the US, 8.1% of adults aged 20 years and older experienced depression in a given 2-week period during 2013 to 2016.13
The prevalence of depressive symptoms in US adults climbed more than 3-fold higher compared with prepandemic levels.14
Depression seems to affect women more than men. Some sources note that women are nearly twice as likely to be diagnosed with depression as men.
15
The reasons are multifactorial and complex and may involve reporting bias but there is also evidence for biological and psychosocial causes. With women representing more than 80% of US nurses, depression in this profession is essentially an epidemic of female caregivers.Nursing is a stressful, demanding, and taxing profession with higher rates of depression linked to job stress.
16
One study published well before the pandemic showed that nurses experience depressive symptoms at a rate twice as high as individuals in other professions.17
There is a paucity of data specifically on the prevalence of depressive symptoms of US nurses during the pandemic, however.In a meta-analysis involving nearly 30 countries, including the US, the authors examined the prevalence of stress, depression, anxiety, and sleep disturbance among nurses during the COVID-19 pandemic.
18
Included were 93 cross-sectional studies of 93,112 nurses demonstrating high proportions of the symptoms mentioned above. The aggregate prevalence of depression was 35% among nurses during the COVID-19 outbreak.18
This rate is higher than that of the general population in the US and around the globe during the same time frame.Younger nurses may experience even higher rates of depression than their senior counterparts. In the previously cited survey by the ANF, it was found that, during the pandemic, of nurses aged younger than 35 years, 43% reported feeling depressed. In contrast, about one-fifth of nurses aged older than 55 years reported feeling depressed.
1
Anxiety
Anxiety may be defined as feeling tense, worried, or having ruminating thoughts, as well as experiencing physical changes such as increased rapid heart rate or blood pressure.
19
According to the WHO, the prevalence of anxiety disorders worldwide is approximately 3.4%.20
In 2019, before the onset of the pandemic, the prevalence of anxiety in the United States was even higher than global rates at about 8%.21
As with depression, anxiety disorders are more common among women than men: 4.6% compared with 2.6% at the international level.20
Early in the pandemic, the prevalence of anxiety among the US population nearly tripled.
22
In the meta-analysis noted above conducted by Al Maqbali and colleagues, the pooled prevalence of anxiety was 37% among nurses.18
Similar to depression, this rate was significantly higher than the general population.Again, younger nurses noted even higher rates of anxiety than depression based on the ANF survey, with 66% of nurses aged younger than 35 years reported feeling anxious, although still a significant rate of 35% of nurses aged older than 55 years also reported anxiety.
1
The prevalence of anxiety and depression, stress, and sleep disturbance was higher during the COVID-19 pandemic than reported during the previous Middle East respiratory syndrome coronavirus (MERS) and severe acute respiratory syndrome (SARS) epidemics.
18
One might postulate that these higher rates could be related to the different natures of the viruses themselves. For instance, although MERS and SARS have a higher fatality rate, COVID-19 is far more infectious, spreading easily from person to person, even in the absence of symptoms. This high infectivity rate changed the way nurses and the population as a whole lived their lives.Another significant difference between MERS/SARS and COVID-19 is the sheer number of lives lost due to COVID-19. Since 2012, 858 deaths have been attributed to MERS.
23
During the 2003 SARS outbreak, there were 8098 confirmed cases worldwide, with 774 deaths. In the US, only 8 people had laboratory evidence of SARS-associated coronavirus infection.24
The most recent statistics reported by the WHO demonstrate more than 615 million confirmed cases of COVID-19 worldwide, with more than 6.5 million deaths.
25
More than 1 million of these deaths were in the US.26
During the first year of the pandemic, more than 3600 health-care workers in the US lost their lives to the virus; 1 in 3 deaths (32%) were nurses.23
More US nurses lost their lives to COVID-19 than the entire world population lost to either SARS or MERS. This a shocking statistic and one which cannot be overlooked when discussing the state of mental health of our nurses.Posttraumatic Stress Disorder
The term “burnout” is often used when citing reasons for nurses leaving the profession. It is worth taking a moment to understand this term better. Based on the International Classification of Diseases 11th Revision (ICD-11) released this year, “burnout” is defined as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. Three dimensions characterize it:
- •Feelings of energy depletion or exhaustion;
- •Increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and
- •Reduced professional efficacy.”27
Burnout is not a medical diagnosis. Moreover, although many nurses may have experienced job burnout before the pandemic, what many have experienced since 2020 is not burnout but rather PTSD.
PTSD can occur in people who have witnessed or experienced a traumatic event. The American Psychiatric Association explains that “people with PTSD have intense, disturbing thoughts and feelings related to their experience that last long after the traumatic event has ended. They may relive the event through flashbacks or nightmares; they may feel sadness, fear, or anger; and they may feel detached or estranged from other people. People with PTSD may avoid situations or people that remind them of the traumatic event, and they may have strong negative reactions to something as ordinary as a loud noise or an accidental touch.”
28
During the COVID-19 pandemic, nurses involved directly with patient care often witnessed not just a single traumatic event but multiple traumatic events, sometimes on the same day. Many witnessed not only the deaths of their patients but also colleagues, family, and friends. Due to visitor restrictions during the pandemic, most patients died without loved ones around them—their nurse was the only one present when they left this earth.
In one study of nurses working in acute care settings during the pandemic in the US, 58.7% were at risk for developing PTSD.
29
A similar study found 47% at risk for PTSD, which, although a lower rate than the study mentioned above, is still higher than veterans of Vietnam, The Gulf War, or Operation Iraqi Freedom, according to the US Department of Veterans Affairs.- Hernandez J.M.
- Munyan K.
- Kennedy E.
- Kennedy P.
- Shakoor K.
- Wisser J.
Traumatic stress among frontline American nurses during the COVID-19 pandemic: A survey study.
Traumatology. 2021; (Published online August 16)https://doi.org/10.1037/trm0000320
30
, 31
, 32
- Byon H.D.
- Sagherian K.
- Kim Y.
- et al.
Nurses’ Experience With Type II Workplace Violence and Underreporting During the COVID-19 Pandemic.
Workplace Health Saf. 2021; (21650799211031233)https://doi.org/10.1177/21650799211031233
Although the mental health of nurses worsened during the COVID-19 pandemic, it alone is not to blame for nurses leaving the profession in mass. Other endemic issues have not been comprehensively addressed and have been left to fester within the health-care system for decades. Insufficient staffing and a workplace environment negatively influencing one’s health and well-being are 2 of the most common reasons nurses want to leave their current positions.
1
Feeling unsupported by an employer during the pandemic, a lack of trust in an employer, the need for a higher income, and a poor organizational response to COVID-19 are additional reasons for wanting to leave.1
However, incivility and a complete lack of respect for this nation’s largest caregiver group is an epidemic that has infiltrated our hospitals and clinics but is often overlooked.Workplace Violence
Bullying and incivility toward nurses are something that has likely been around as long as the nursing profession itself. Senior nurses bullying new recruits is seen by some as a rite of passage in the profession. Physicians bullying nurses has become a societal norm exemplified in what seems like nearly every medical drama on television. Although bullying and incivility have no place in any professional environment, WPV is a shocking reality faced by members of the health-care field every day.
The most common health-care environment-based assault is one in which the perpetrator is a member of the public with whom the nurse interacts during the course of their regular duties. This is known as Type II WPV. According to the US Bureau of Labor Statistics 2020 data, nurses experience a high rate of Type II WPV.
31
Reported rates are likely lower than actual rates. The complexities of reporting lead to underreporting, which, in turn, results in underestimating the extent of the problem. Since hospital administration is unaware of the full magnitude of the issue, there may be minimal effort to address it.33
Being a hospitalized patient during the pandemic was both physically and psychologically straining, particularly early on when there were still so many unknowns about the virus itself and providers were unsure how to best treat the disease. The fear alone may have been overwhelming, causing patients to act out either verbally or physically toward caregivers. Fever, electrolyte imbalances, hypoxia, and other components of the disease process could lead to delirium, causing patients to behave in ways they usually would not act when healthy. Families and visitors of patients also experienced increased levels of stress.
Nurses’ poor mental health, increased workload, inadequate staffing, and lack of support all contributed to an increase in vulnerability, which could exacerbate both WPV and its underreporting.
33
,34
For instance, it has been demonstrated that unmet patient health-care needs and requests are a risk factor for Type II WPV. It is possible that these issues were made worse by staffing shortages and reduced hospital capacity during the COVID-19 pandemic.- Byon H.D.
- Sagherian K.
- Kim Y.
- Lipscomb J.
- Crandall M.
- Steege L.
Nurses’ experience with type II workplace violence and underreporting during the COVID-19 Pandemic.
Workplace Health Saf. 2021; (216507992110312)https://doi.org/10.1177/21650799211031233
35
An alarming 66% of nurses during the pandemic said they experienced increased bullying at work compared with before the pandemic.
36
Incivility and bullying were predominately identified as coming from patients and their families.1
About 33% of nurses said they had experienced violence in their workplace, and it does not stop at the hospital doors—nearly a quarter of nurses reported bullying outside of work, and 12% reported violence outside of work.36
This is consistent across different surveys.Discussion
Numerous measures have already been implemented to address the mental health crisis involving our nation’s health-care workers, including those created by individual hospital systems and new organizations born out of the pandemic. Some examples include the following:
- •The Lorna Breen Health Care Provider Protection Act—The bill was named after an assistant professor of emergency medicine at Columbia University Vagelos College of Physicians and Surgeons who died by suicide in April 2021. Its purpose is to help create training programs focused on well-being and behavioral health and a national campaign encouraging health-care professionals to seek support and treatment.
- •“Don’t Clock Out”—Friends and colleagues of Michael Odell, a critical care nurse who died by suicide in January 2022, founded the not-for-profit as a peer support community and mental health resource for nurses.
However, the problem does not seem to be a lack of resources but rather that the resources already in place are not being used. According to one survey, 72% of nurses have access to mental health services but 90% never take advantage of these services.
37
The reasons behind this are multifactorial. The stigma surrounding mental health is a significant deterrent for many to seek help. There might be fears regarding professional licensing if one were to report that they were seeking help for a mental health disorder.Regarding WPV, there were already several initiatives introduced before the pandemic by various organizations to decrease its prevalence.
- •2015—American Nurses Association (ANA) concluded deliberations and issued a new position statement on incivility, bullying, and WPV.
- •2016—Occupational Safety and Health Administration issued a Request for Information soliciting information on the topic of WPV.
- •2019—H.R. 1309 (Workplace Violence Prevention for Health Care and Social Service Workers Act, 2019) was introduced by US House of Representative Joe Courtney. This bill, if passed, would require a comprehensive WPV prevention plan be developed and implemented by covered employers in the social service and health-care sectors.
- •2019—ANA launched the #EndNurseAbuse campaign to increase awareness of WPV against nurses.
Yet, despite these efforts, bullying and incivility increased dramatically during the pandemic.
36
There is still no current nationwide to protect health-care workers from WPV. Representative Courtney’s bill was introduced to the senate in May of 2022 but no further action has been taken.Summary
The COVID-19 pandemic has drawn attention to many of the inadequacies of the US health-care system. When it comes to addressing critical issues such as the mental health of its largest group of providers, nurses, and ensuring that health-care workers have a safe environment in which to work, most efforts have fallen short. Many nurses are leaving hospital-based careers, whereas some are leaving the field altogether. Hospital administrators and government agencies must implement policies and practices and adapt the workplace environment to attract and retain nurses by focusing on their safety and the intersection of their work demands and mental health to avoid a potential demographic crisis in the next decade. Unless we act quickly and comprehensively to address the issues that matter to nurses, the next pandemic could be far more deadly, not because the virility of the next virus is higher but because we will have fewer caregivers to save us.
Disclosure
The author has no relevant financial or nonfinancial interests to disclose. The author has no conflicts of interest to declare relevant to this article’s content. The author certifies that she has no affiliations with or involvement in any organization or entity with any financial interest or nonfinancial interest in the subject matter or materials discussed in this article. The author has no financial or proprietary interests in any material discussed in this article.
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Published online: February 20, 2023
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