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
Nurse wearing a face mask walks away from a hospital building, looking downcast

Nurses’ emotional well-being is being challenged like never before by coronavirus, so finding coping strategies is essential

  • Anxiety about patients, the possibility of infecting family members and the financial impact of the pandemic are still being felt by many nurses
  • Eight in ten nurses in a Nursing Standard survey said their mental health has been affected by COVID-19
  • Advice on healthy coping mechanisms – and the habits to avoid
Picture: iStock

Month after month of working in the high-stakes environment of COVID-19 has had a huge impact on the mental health and well-being of nurses.

Eight out of ten nurses responding to a Nursing Standard survey told us their mental health had been affected by the pandemic, while six in ten said their physical health was suffering. The survey, in November 2020, had 1,650 nurse participants.

Long hours caring for patients, fears about contracting the virus, separation from loved ones, and redeployment – the pressure on nurses has been unrelenting since March last year.

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 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 described what must now 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.

‘The unprecedented demand on nursing staff during the pandemic is having a huge impact on their own wellbeing,' says RCN general secretary Dame Donna Kinnair.

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

WHO guidance

‘The nurses I speak to every day tell me they have no fuel left in the tank and their resilience is being seriously tested. It's vital that support is available where and when it is needed, and that managers encourage and support staff to seek help,' 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.

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

‘Nursing staff need help now to deal with unimaginable levels of anxiety and stress’

Donna Kinnair, RCN

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?

The sheer scale of patient mortality, exhaustion, personal safety worries, 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 hearing of numerous stories about staff being off sick, needing mental health counselling and being diagnosed with post-traumatic stress. We have also heard of staff who have been sectioned under the Mental Health Act.

‘Nurses are suffering the brunt of the COVID-19 pandemic. They are physically and mentally exhausted. Particularly, within critical care, there are significant levels of post-traumatic stress evident, which is extremely worrying. This is simply not sustainable’

The RCN’s Professor Kinnair adds: ‘Nursing staff need help now to deal with unimaginable levels of anxiety and stress, but there must also be a long-term plan to tackle problems, like PTSD, which may occur.’

View our COVID-19 resource centre

Mitigating the danger of ‘moral injury’ and PTSD

RCNi features editor 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

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.

Many nurses told the Nursing Standard survey that, because they work in healthcare, they felt the need to be extra-cautious about social mixing. Worry about taking the virus home or passing it to older or vulnerable relatives was a constant source of anxiety for some.

One respondent described how she was ‘socially cut off from family, church activities and friends’.

A ward sister told us: ‘I am suffering feelings of isolation from the rest of my family, especially the grandchildren. Working on a respiratory ward has placed me squarely on the front line and I am very aware of the possibility of passing on the virus to those I love.’

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

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. Since the start of the pandemic, quiet zones, ‘welfare cafés’ and PPE marshals have been introduced by NHS to support staff.

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.’

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.

Kettering General Hospital NHS Foundation Trust teamed up with the community to set up a café for staff, called the We Care Café.

The café was designed as a space for staff to decompress, socialise, access peer support, and talk to ‘active listeners’ who signpost staff to other services, if needed.

‘It’s a place where you can have a proper break,’ says nutrition nurse specialist Trish Alga who visits the café regularly. ‘Also, there is usually someone to talk to on the counselling side if you feel the need to speak about something that has concerned you.’

A dedicated NHS staff mental health helpline, set up in 2020, offers nurses psychological support and signposts staff to services including practical and financial assistance, as well as specialist bereavement support, through volunteers from charities such as Hospice UK and the Samaritans.

The phone line 0300 131 7000 is open from 7am-11pm every day, while the text service, open 24 hours a day, is available by texting FRONTLINE to 85258.

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.

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.

As mental health nurse Leanne Patrick wrote in Nursing Standard at the start of the pandemic: ‘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, mental health nurse

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

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 pointed out: '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.

‘As nursing students, we try to support each other, and university has been good too’

Nursing student Francesca Hufton
Nursing student Francesca Hufton

‘We went back to university in September, but most of our lectures are online, which is challenging,’ says Francesca Hufton, a third-year mental health nursing student at Canterbury Christ Church University.

‘Some students with children have managed to get extensions on their assignments because of the difficulties with home schooling. At home it can be hard to engage and you have to be very organised.’

Ms Hufton has experienced mental health issues herself and COVID-19 is affecting her. ‘My own mental health has been very up and down,’ says Ms Hufton. ‘It's my final year and there is a lot of responsibility and expectations.

'I think everyone is struggling, although we try to support each other, and the university has been good too.’

‘I started a 13-week placement in September on a mental health ward, which I really enjoyed. It also really helped with my studies – without it, things would have been much harder.

‘I’ve just heard I’ve got a job working with people with eating disorders – I haven’t felt this happy in a long time.’

Lynne Pearce is a health journalist

Further information

This article was first published on 8 April 2020