The impact of stress on the mental health of nurses during COVID-19.

How is stress affecting nurses?

It does not come as a shock that stress levels are higher now amongst the general population than they were before the COVID-19 pandemic. However for nurses, whose role in normal circumstances is a high stress job, this increase in stress during COVID-19 is having a huge impact on them. Research has shown that during the pandemic, nurses have consistently reported more anxiety, stress and depressive symptoms (Shreffler, Huecker & Petrey, 2020). This research was carried out during COVID-19 so is very relevant and discussed staff working in multiple wards and areas, so really helps to give us an idea of just how much of an impact stress is having on nurses. Further results from this research found that these symptoms were higher amongst staff on ‘usual wards’ than in frontline or critical care units. Similarly, levels of burnout were also lower in the frontline and critical care units staff. This could be down to many factors, including the normal pressures in these units ordinarily being higher, so this may mean these staff have more ability to cope and higher resilience in the current pandemic, as well as these staff being provided with feedback and information more often.

The impact of stress can contribute to mental health difficulties, and in the healthcare profession, things like burnout, anxiety and depression are not uncommon. All is not lost though, as there are many protective factors for stress which can help contribute to better mental health, including having strong resilience and good coping abilities. But how can nurses develop resilience and coping abilities? And just how much of a negative impact can stress have nurses working during the pandemic?

The impacts of stress on health

Stress can be defined as the degree someone feels unable to cope in the face of pressured situations. Work related stress has been shown to have a multitude of effects on those working in the healthcare field during the current pandemic including: anxiety, depression, exhaustion and burnout (Neto et al, 2020). Not only do these factors have a huge impact on our physical and mental health, these factors also affect the ability to successfully carry out job roles effectively. Stress can lead to poor decision making, lower performance, less efficiency and decreased motivation, which can all have detrimental effects on nurses and the patients they are treating. During the current COVID-19 pandemic, stress levels are exceptionally high which is understandable but severely negatively affecting the mental health of professionals.

Stress impacts mental health in many ways. Stress can develop into mental health problems such as anxiety, depression or panic disorders. More drastically, stress has been linked to major depression, self harm, suicide and suicidal thoughts. Due to this it is important to have support and coping mechanisms in place to help buffer against stress. Resilience and effective coping abilities are great supports that buffer against stress and its effects and will be discussed later.

Research into the impact of stress on the mental health of nurses during the pandemic can be criticised for not investigating the long-term impacts of this stress. This is because of COVID-19 being a very recent pandemic, research is still emerging in the area. Research is studying a relatively new and evolving subject, so it’s important to take this into account when looking at the research on the impacts on nurses. However, research can compare the effects of stress with past pandemics to give an of the kinds of issues faced. Studies looking at the impact of COVID have tended to focus on the impacts of stress during the first few months of the pandemic, looking at the short term effects. With the recent introduction of the vaccines and further developments in the pandemic research needs to focus on these areas in relation to the impact of stress on nurses to see how these changes have affected them. It could be that in the long term, staff are finding ways to manage this stress so it has less effects on them, the news of vaccines have given some hope to nurses and helped to elevate some of the stress, or it could be that the buildup of stress over the past year of the pandemic has led to burnout amongst nurses, and news of people returning to a more ‘normal life’ bring anxiety about rising cases in the future. Further research needs to focus on these areas to get a wider view of the effects of stress on nurses.

Without appropriate support and buffers, constant stress can lead to burnout. Burnout is a combination of physical, emotional and mental exhaustion often arising from the impact of stress. Nurses are at an increased risk of burnout during the pandemic through the higher levels of stress being faced. Some news articles are stating that nurses are questioning whether they still want to work in the field after the pandemic is over, due to just how much of an impact it is having on them physically and mentally. Research suggests that 30-50% of physicians and as high as 70% of nurses are affected by burnout (Bridgeman, Bridgeman & Barone, 2018). This figure was amongst staff pre-pandemic, but it is only likely to have grown during COVID-19 with the extra pressures on staff in the workplace. There are however, things that can help buffer against this stress and burnout, by managing the external pressures and developing emotional resilience for example.

The importance of coping abilities and social support

One of the buffers to stress are coping abilities. These are the skills we use to help us deal with stressful situations, for example, practicing relaxation techniques, exercising regularly, having resilience, engaging in hobbies, support networks and taking time to reflect. Social support is also a very important factor and buffers against stress and burnout (Rehman, Bhuttah & You, 2020). However, during the pandemic the levels of social support we have access to has dropped massively. With not being able to meet friends and some nurses isolating away from their own family and vulnerable relatives to protect them from the virus means access to this all important social support is very limited. With the many protective factors of having good levels of social support clear, it is important to try and preserve some level of social support, whether this is in the form of keeping in regular contact with family and friends virtually, and also all important work colleagues, which during these times can be vital sources of support and comfort, as well as knowing first hand the effects of working throughout the pandemic.

The role of resilience

Resilience is how able we are to recover from difficulties and challenges. Coping abilities and resilience work together to buffer against stress and as a result mental ill health. In tough times, resilience is seen as coping and not thriving (O’Dowd et al, 2018). This is important when we look at coping abilities and resilience together. If we aren’t coping then we aren’t likely to have that all important resilience. This research looked at physicians and asked them what helps them cope in stressful times. Some similarities emerged including spending time with friends and family and having a good level of social support. This is important for both resilience and coping abilities as mentioned previously. This research has its limitations in terms of application as it was conducted before the pandemic, things like spending time with others is now much harder, and some healthcare workers are even living away from their own family in a bid to help protect them from the virus. The research does have merit though, it’s important to have systems in place to help buffer against stressful times and developing emotional resilience is a big part of this. Naeem, Irfan & Javed (2020), stated there is an urgent need to build resilience to help protect people from trauma, isolation and help people cope during the pandemic due to the many benefits resilience serves.

Some key skills that can help develop resilience include: use relaxation techniques, build your support network, find a good work-life balance and developing hobbies amongst others. Through meta analysis, it was found that specific resilience training is of great benefit to those working in the healthcare profession (Cleary et al, 2018). Resilient people are also more likely to ask for help and support, and receiving this help makes them more resilient. This is very important when looking at interventions to help nurses working during the COVID-19 pandemic.

Support for nurses

Despite many of the interventions available focusing mainly on general stress faced before COVID-19, there are some showing to be particularly positive and valuable when applied to the current pandemic. There are some issues around how effective and generalisable they are in terms of the impacts during COVID-19 though, as it is still relatively new and specific interventions are currently being developed. Recently, one such intervention has been developed through IAPT (improving access to psychological therapies) named the Homerton Covid Psychological Support (HCPS) pathway. This intervention aims to provide support for frontline healthcare professionals through the pandemic. The intervention aims to address some of the mental health difficulties being faced by those working on the frontline (Cole et al, 2020). This should go a way to helping provide support for frontline healthcare professionals throughout the pandemic and to help address some of the mental health difficulties that develop from the stress experienced by nurses working on the frontline. This intervention addresses not only distress faced from the start of the pandemic but to also offer support for the months and years that follow. This is a huge benefit as it does not just focus on the short term effects of stress on mental health, but also the more developing and long term impacts. The Homerton support pathway has three phases. The support pathway can be accessed at any of the phases and can also go through the phases from one to three. The first includes screening and self-help, the second includes group-based interventions and digital support systems, the final phase includes high intensity psychological support.

Some research suggests that mindfulness based interventions also show promising results in helping with the effects of stress on mental health (Klein et al, 2019). Furthermore, therapies including mindfulness-based cognitive therapy (MBCT), the use of mindful self-compassion (MSC) and also acceptance and commitment therapy (ACT) all reduce stress and burnout levels. Therefore these kinds of mindfulness interventions would be useful to incorporate into training and support offered to nurses, especially during the pandemic to help provide skills to buffer against stress and its effects.

In summary, stress can have huge impacts on the mental health of nurses working during the COVID-19 pandemic. It can lead to burnout and various mental health conditions. Fortunately, there are things nurses can do to help buffer from these effects including building resilience, social support and coping abilities. There have also been significant developments in terms of interventions, with the Homerton COVID psychological support pathway being developed especially to provide help and support for healthcare professionals during the pandemic. With research developing all the time hopefully more COVID specific interventions to provide support for healthcare staff will be developed in the near future. These should prioritise giving nurses the tools needed to improve the areas of coping abilities and resilience. We have seen these to be important aspects of reducing stress, even through trauma and high stress work environments, such as those being experienced during the current pandemic.

References:

Bridgeman, P. J., Bridgeman, M. B., & Barone, J. (2018). Burnout syndrome among healthcare professionals. American Journal of Health-System Pharmacy, 75(3), 147–152. https://doi.org/10.2146/ajhp170460

Cleary, M., Kornhaber, R., Thapa, D. K., West, S., & Visentin, D. (2018). The effectiveness of interventions to improve resilience among health professionals: A systematic review. Nurse Education Today, 71, 247–263. https://doi.org/10.1016/j.nedt.2018.10.002

Cole, C. L., Waterman, S., Stott, J., Saunders, R., Buckman, J. E. J., Pilling, S., & Wheatley, J. (2020). Adapting IAPT Services to Support Frontline NHS Staff during the Covid-19 Pandemic: The Homerton Covid Psychological Support (HCPS) Pathway. The Cognitive Behaviour Therapist, 1–25. https://doi.org/10.1017/s1754470x20000148

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