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How COVID-19 is affecting nurses’ mental health, and what to do about it

There are so many reasons to feel anxious about coronavirus, but help is out there

  • Anxiety about patients, the possibility of infecting family members and the financial impact of the pandemic are being felt by many nurses
  • Using social media can be positive in so many ways, but destructive and panic-inducing too
  • Advice on healthy coping mechanisms – and the habits to avoid
 Neil O'Connor
Taking breaks when possible during shifts is important Picture: Neil O'Connor

It seems inevitable that caring for patients in the high-stakes context of COVID-19 will take its toll on the mental health of nurses.

A public health emergency on this scale makes the threat personal for nurses, as well as one they manage professionally: with inadequate and insufficient personal protective equipment (PPE) reported in many areas, nurses are anxious about their own welfare and that of their families.

And, of course, nursing staff have died.

But nurses report for work in the most challenging of circumstances anyway, because that is the job.

The potential legacy for nurses’ mental health

As nurse Justin Walford puts it: ‘There is the fear – fear we will become infected or we will infect our families; that our colleagues will become sick or the stories we hear from other countries will become our stories.’

Writing for Nursing Standard, the emergency department senior practice development nurse describes what must be a common anxiety: ‘After a shift, you start to wonder whether that shortness of breath, headache or other vague symptom is anything to worry about.’

Read Justin Walford's article here

The potential legacy for nurses' mental health should not be underestimated.

‘We were already a depleted workforce that was showing signs of fragility,’ says RCN professional lead for mental health Catherine Gamble.

‘Managing your stress and psychosocial well-being during this time is as important as managing your physical health’

WHO guidance

‘Nurses hold the fort and they’re just expected to go on and on. We really have to invest in psychological support, not just during the outbreak but onwards,’ she says.

Here, we consider some of the issues preying on the minds of nurses in this pandemic and explore ways to help ease the psychological burden and promote mental health.

As a nurse, is it normal to feel anxious and worried about coping with the pandemic?

Feelings of stress among healthcare workers are likely and are no reflection on their ability to do the job, the World Health Organization (WHO) says.

It has issued guidance on COVID-19 and mental health that recognises the particular needs of healthcare workers. Crucially, it puts their mental well-being on a par with their physical health.

‘We are going to have to provide psychological support to all staff involved in this’

Nicki Credland, British Association of Critical Care Nurses

The guidance states: ‘Feeling stressed is an experience you and many of your colleagues are likely going through; in fact, it is quite normal in the current situation. Managing your stress and psychosocial well-being during this time is as important as managing your physical health.’

A healthcare professional looking visibly tired and worried at work
Picture: iStock

How can I promote mental well-being in my team?

Guidance for managers to help support their team's mental health includes:

  • Ensure all staff receive good quality communication and accurate updates
  • Rotate workers from high-stress to lower-stress functions
  • Partner inexperienced workers with more experienced colleagues – buddying helps to provide support, monitor stress levels and reinforce safety procedures
  • Initiate, encourage and monitor work breaks. Implement flexible schedules for workers who are directly affected or have a family member affected
  • Ensure staff know where they can access mental health and psychosocial support services
  • All of the above applies to you as an individual too – managers who are role models of self-care are able to mitigate stress

Source: WHO COVID-19 guidance

What are some of the particular anxieties facing nursing staff?

Worries and uncertainties about personal safety and the lack of PPE, workload, case complexity, skills mix, and loved ones’ health are among a vast range of stressors that cut across professional settings, but are perhaps most clearly seen in intensive care units (ICUs).

British Association of Critical Care Nurses chair Nicki Credland told Nursing Standard recently: ‘We are going to have to provide psychological support to all staff involved in this, particularly to ICU nurses, staff who will have the stress of looking after very complicated patients in increasingly high volumes, and staff who don’t traditionally work in the ICU.’

Many nurses – mental health and community staff among them – have to deal with the stress of caring for patients and service users even while provision of PPE is inadequate.

The RCN’s Ms Gamble says: ‘Mental health is the last port of call and not prioritised. This patient group has the highest likelihood of getting coronavirus because they are physically unhealthy too, and they may not understand social isolation.’

View our COVID-19 resource centre

Mitigating the danger of ‘moral injury’ and PTSD

Freelance journalist Stephanie Jones-Berry writes:

King’s College London professor of defence mental health Neil Greenberg warns that, without careful supervision, clinicians could experience conditions such as post-traumatic stress disorder (PTSD) and depression as a result of the COVID-19 pandemic and difficult care decisions.

Professor Greenberg says the threat of ‘moral injury’, defined as the psychological distress that stems from actions, or the lack of them, that violate someone’s moral or ethical code, will be a danger for all healthcare staff.

He tells Nursing Standard that nursing students and those who have less experience in working in traumatic situations might be particularly at risk.

‘We know people most at risk haven’t encountered these situations before and haven’t had any space to think about them.’

Situations where decisions have to be made, such as choosing which patients to ventilate, due to a lack of equipment, might later elicit feelings such as shame, guilt and disgust.

These symptoms can contribute to the development of mental health difficulties, including depression, PTSD, and even suicidal thoughts, he says.

Frank discussions with clinical leads about the likelihood of these situations occurring and a briefing on moral injury, will be key to prevention, as will good supervision and the opportunity to talk through decisions in settings such as Schwartz rounds, Professor Greenberg advises.

Read more from Professor Greenberg and colleagues, writing in the BMJ

A man and a woman sitting on a sofa talking to a nurse via a video phone app
Virtual social contact with family and loved ones can provide support Picture: iStock

The Mental Health Foundation recognises the fact that going into work when most of the population is working from home will increase anxiety among healthcare staff.

‘It will feel unusual and may add to the anxiety you feel, or that loved ones feel for you,’ says the charity in its COVID-19 guidance.

NHS Employers is aware that health service staff are worrying about the safety of family and friends, particularly if they have caring responsibilities for loved ones in at-risk groups.

‘Staff may be dealing with patient deaths, and with sick and/or dying family members and friends,’ it says.

Added to these factors, many nurses will be experiencing sudden financial insecurity if their partners have lost their jobs or face redundancy or reduced income because of the UK lockdown.

Are concerns about your finances affecting your mental health?

There are organisations ready to offer nurses support if they have financial worries, including:

  • Cavell Nurses Trust Charity dedicated to supporting nurses, midwives and healthcare assistants in times of hardship
  • RCN Lamplight Support Service Open to non-members as well as members of the RCN
  • Turn2us Charity that helps people in financial need gain access to welfare benefits, charitable grants and other financial help

Coping mechanisms for nurses during the pandemic

 iStock
Exercise can aid relaxation and mental
well-being Picture: iStock

Psychological well-being and management of stress levels are as important as physical health, says the RCN, echoing the emphasis WHO places on healthcare workers' mental health.

The college advocates healthy lifestyle strategies including staying hydrated, maintaining healthy eating and sleeping patterns, and keeping up social contact with your support networks, even if that contact is virtual.

It advises sticking with strategies that have worked well for you in the past, rather than trying to learn new ones. These might include deep breathing, taking regular exercise, practising mindfulness, relaxation techniques or simply talking to a colleague or friend.

It is also important to remember to take regular breaks, says the college.

‘Take your at-work breaks whenever you can and don’t feel guilty about taking your days off,’ it says.

Slow the cycle of stress: stop, breathe, then think

The Intensive Care Society has produced practical guidance that can be applied across the workforce.

It says: ‘Stop, breathe, then think – slowing your breathing slows the stress cycle and re-engages your frontal lobes, then you can think.’

Other tips, include:

  • Consider your psychological energy levels and the need to ‘fill up’ after emptying the tank
  • Be aware of your ‘bandwidth’ and that it may take longer to think things through and make sense of them if you are feeling overwhelmed
  • Beware of using dramatic language that could panic your colleagues

Source: Intensive Care Society

Is this a helpful coping strategy?

WHO cautions against a temptation of resort to ‘unhelpful coping strategies’, including using tobacco, alcohol or other drugs.

‘In the long term, these can worsen your mental and physical well-being,’ it says.

And sometimes, the simplest ideas are effective. Staff at Bradford Teaching Hospitals NHS Foundation Trust for example, have come up with this coping mechanism:

What should employers do to support nurses’ mental health?

WHO makes the point: ‘Keeping all staff protected from chronic stress and poor mental health during this response means they will have a better capacity to fulfil their roles.’

 iStock
Alcohol may seem like a good idea,
but is not a helpful coping strategy
Picture: iStock

NHS Employers advises: ‘Organisations may want to review their support for staff and expand provision where possible.’ This support could include debriefs, trauma risk management (TRiM), Schwartz rounds and deployment of existing in-house clinical psychology teams.

South West London and St George’s Mental Health Trust recognises its staff are likely to need enhanced support and has set up a staff helpline.

‘We’re going to be available until around midnight,’ says Catherine Gamble, who in addition to her RCN role is head of nursing practice, education and research at the trust two days each week. ‘If you get home late and have had a really challenging shift, you have someone to talk to.’

At Barts Health NHS Trust in London, the chaplaincy is stepping up the pastoral support it offers the workforce, by opening a dedicated, round-the-clock staff hotline.

‘If you need a chat or a prayer, we are here for you,’ deputy head of chaplaincy Tasha Critchlow wrote in a tweet to promote the service. ‘We don’t have any answers, but we are good listeners.’

‘This is a crucial time for employers to support staff’

For Compass, a mental health services provider, having good mental health and well-being strategies in place is already proving invaluable in supporting its staff through the challenges of the pandemic.

‘It’s inevitable that staff will be worried,’ says project manager Emma Tymon, one of the organisation’s 11 volunteer mental health champions.

‘They’re going to work, and they know that risk has increased, while the anxieties of our service users have also risen. If you’re already experiencing a mental health issue, that will be intensified by the current situation.’

The organisation, which is a provider of school nursing, and mental health services for children and young people, among other services, has embedded the six core standards recommended by the 2017 independent, government-commissioned review of employers and mental health.

‘It includes encouraging open conversations about mental health and the support that’s available,’ says Ms Tymon.

Practical steps employers can take

Among the practical steps Compass is taking is to ensure key messages are clearly communicated.

‘Normal staff responsibilities are changing to make sure we’re meeting the needs of our service-users and responding to the current climate. It may mean working very differently,’ says Ms Tymon. ‘The clearer you are as an organisation about what you require, the less it feeds any anxieties.’

Staff are worried about putting themselves at risk when they are meeting clients face to face, she says. ‘We’re using different ways of working, such as virtual, whenever possible.’

‘This is a crucial time for a good employer to show how they are supporting their staff,’ says Ms Tymon.

Is social media fuelling my anxieties?

Nurses who use social media will be aware of its value as a forum for information-sharing, celebration, consolation and – crucially with mental health – as a valve for letting off steam. A quick browse through Twitter using the #CovidSupportForNurses hashtag for example, shows how supportive nurses can be of each other.

But while social media is invaluable in keeping people connected, the RCN’s counselling service suggests limiting your exposure if you find it heightens anxiety levels. You could consider:

  • Muting key words that trigger worries or negative feelings.
  • Unfollowing or ‘snoozing’ hashtags, individuals or groups.
  • Setting boundaries for how much and when you do social media browsing.

NHS Forth Valley community mental health nurse Leanne Patrick writes in Nursing Standard: ‘As healthcare professionals, we should be all the more mindful of the impact our social media posts may have on colleagues and the public. Anxiety is catching and endless messages of doom are unhelpful.

‘Healthcare professionals have a sense of purpose and meaning in this pandemic. It will likely carry us through the darker days’

Leanne Patrick, NHS Forth Valley

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Constant social media use can add
to stress levels Picture: iStock

‘Some trusts are already at 50% staff absence rates, and it only takes a cursory glance of social media to see that this is partly comprised of fearful asymptomatic staff.'

Read Leanne Patrick's full comment here

In its guidance on mental health self-care during the COVID-19 pandemic, the Mental Health Foundation agrees that ‘rumour and speculation can fuel anxiety’. In contrast, ‘having access to good quality information about the virus can help you feel more in control,’ it adds.

To reduce levels of anxiety, the RCN also recommends seeking information and news updates from trusted sources at one or two set times each day, rather than in a constant stream.

As Ms Patrick adds: 'We must strike the balance between documenting this crisis and using our influence to motivate political action, and being participants in a parallel pandemic of panic.

‘Healthcare professionals have a sense of purpose and meaning in this pandemic. It will likely carry us through some of the darker days to come.’

‘I’ve lost my purpose as a student, but I’m trying to keep busy’

Nursing student Francesca Hufton
Nursing student Francesca Hufton

‘Students are facing uncertainty and feel nervous, not knowing what to expect,’ says Francesca Hufton, a second-year mental health nursing student at Canterbury Christ Church University.

‘A lot of nursing students are mature too, so they have family responsibilities, including home schooling.’

Ms Hufton has experienced mental health issues herself and COVID-19 is affecting her. ‘I’ve lost my biggest protection factor – my work,’ says Ms Hufton. ‘But I’m trying to keep busy.’

She has joined the hundreds of thousands who have signed up to the NHS Volunteer Responders scheme, where she will be phoning those who are living in social isolation and feel lonely.

‘As we’re not able to go into university and can’t be on placement anymore, I feel I’ve lost a bit of my purpose,’ she says. ‘This gives me something I can do.’

Lynne Pearce is a health journalist

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