You can mark the toll of the COVID pandemic on nursing in multiple ways, from the tragic loss of nursing lives to the impact on nurses’ mental health. You can also count the impact in the number of nurses leaving the profession, a trend that may have long-lasting effects on nursing.
In a new study, the International Council of Nurses (ICN) says that 20% of its National Nurses Associations (NNAs) reported an increased rate of nurses leaving the profession in 2020. Some 90% of the NNAs are somewhat or extremely concerned that heavy workloads, insufficient resourcing, burnout, and stress related to the pandemic response are among the drivers, according to a policy brief.
Nurses and other HCPs–some wearing only gauze masks–treat Covid patients in Brazil.
ICN Chief Executive Officer Howard Catton said in a press release that the new data shows that difficulty in retaining experienced senior nursing staff, an effect of the pandemic that was expected to occur in the long term, is happening right now.
“The COVID Effect on the global nursing workforce, coupled with the current shortage of six million nurses and a further four million heading for retirement by 2030, could see the global nursing workforce of 27 million nurses being depleted by ten million, or even halved,” Catton is quoted as saying. ICN refers to the COVID-19 Effect as a form of mass trauma affecting the world’s nurses.
The ICN says it has recorded nearly 3,000 COVID-related deaths among nurses in 60 countries. In all likelihood, says ICN, that figure underestimates the death toll due to incomplete monitoring.
On a positive note, in the ICN survey 74% of NNAs reported their countries have committed to increasing the number of nurses, and 54% of countries have committed to improving the retention of currently employed nurses.
Identifying Burnout
At the same time, a new study published in JAMA Network Open finds that burnout represents a significant problem among U.S. nurses who leave or are considering leaving their job. The research used data from the 2018 National Sample Survey of Registered Nurses, well before the pandemic.
The study (“Prevalence of and Factors Associated with Nurse Burnout in the U.S.”) discovered that among the roughly 420,000 nurses who reported leaving their job in 2017, 31.5% reported burnout as a reason. Working in a hospital, as opposed to other settings, was associated with higher odds of identifying burnout in a decision to leave or consider leaving.
“Health systems should focus on implementing known strategies to alleviate burnout, including adequate nurse staffing and limiting the number of hours worked per shift,” the article notes. Further, with the increasing demands placed on frontline nurses during the pandemic, “these findings suggest an urgent need for solutions to address burnout among nurses,” the report warns.
The consequences for nursing during the COVID-19 pandemic are serious and potentially long-lasting. Such are the conclusions of a major news report from the National Council of State Boards of Nursing (NCSBN).
Among the findings:
Over the past two years, approximately 100,000 registered nurses (RNs) left the workforce during the COVID-19 pandemic due to stress and burnout. This number represents a portion of the workforce NCSBN would not have expected to leave.
Another 610,388 RNs reported an “intent to leave” the workforce by 2027 due to stress, burnout, and retirement.
Some 188,962 additional RNs younger than age 40 reported similar intentions.
About one-fifth of RNs nationally are projected to leave the healthcare workforce.
“The data is clear: the future of nursing and the U.S. healthcare ecosystem is at an urgent crossroads,” says Maryann Alexander, PhD, RN, FAAN, NCSBN chief officer of nursing regulation in a press release. The research was gathered from a biennial nursing workforce study conducted by NCSBN and the National Forum of State Nursing Workforce Centers.
In normal conditions, the NCSBN would anticipate that some 150,000 RNs would have left the workforce during the last two years, due largely to planned retirements, as well as normal pursuit of education and career change, says Brendan Martin, PhD, director of research at NCSBN in an interview. But the data revealed that 330,000 RNs had departed, combining retirements and those who left the workforce due to stress and burnout.
“In terms of looking retrospectively, we were really floored by that number,” Martin says. With an aging population and an increase in patient demand related to COVID-19, “just treading water and maintaining current staffing levels isn’t sufficient. And so the fact that we have any drop-off, let alone double the number we would anticipate, was really problematic.”
COVID the “Accelerant”
The COVID pandemic, says Martin, brought to light enduring nursing workforce issues. “Many of the issues that are confronting the workforce are long-standing issues. The pandemic itself wasn’t necessarily the driver of a lot of the stress, of a lot of this burnout. It was the accelerant,” Martin says.
The research shows that feelings such as being emotionally drained, fatigued, and burned out were most pronounced in nurses with ten or fewer years of experience. That drove an overall 3.3% decline in the nursing workforce during the past two years, the NCSBN report says.
The number of younger nurses planning to leave poses a special problem suggested Martin. “We’re relying on them to essentially step into more leadership roles to form the backbone of the workforce for the next 30 to 40 years and to really mentor the folks coming up through the ranks.”
Currently, says Martin, there are about 4.6 million licensed RNs in the U.S., with a little over 900,000 licensed practical and vocational nurses.
Solutions from Many Stakeholders
Addressing this problem will take cooperation from many stakeholders, Martin notes. “The impacts of the pandemic were so wide-ranging and so widespread that there isn’t a single key stakeholder that needs to be involved,” he says. “Everybody needs to get involved because it’s about how we educate our future nurses. It’s about how we onboard our new career entrants. It’s about how we support our current workers. And then it’s also about how we leverage the expertise, the built-up knowledge, and the acumen of the older nursing cohort.”
“With intentional policy, there’s a potential to get ahead of the curve and to blunt the impact of some of the things that we’re seeing with intents to leave,” according to Martin. “But more important than that, if we change the way that we mentor new nurses entering the workforce, if we give them the appropriate support and the funding if we talk about mental health services for current nurses, I think that there’s a real potential to build a more resilient workforce. If we make this a more sustainable and enriching environment, I think we’re going to rebound. I really strongly believe that, and I think the research supports it.”
Resilience of Nurses
On a positive note, “We saw a larger proportion of licensed nurses employed in nursing and at the bedside than we have in past and recent cycles,” says Martin. “It was really the resilience of nurses, basically going into the heart of the storm, so to speak, during the COVID period. We saw that come up in the data. That’s not news to anyone. That’s long-standing, how dedicated nurses are to their craft.”
The week before Brian Colvin was scheduled for shoulder surgery in November, he tested positive for covid-19. What he thought at first was a head cold had morphed into shortness of breath and chest congestion coupled with profound fatigue and loss of balance.
Now, seven months have passed and Colvin, 44, is still waiting to feel well enough for surgery. His surgeon is concerned about risking anesthesia with his ongoing respiratory problems, while Colvin worries he’ll lose his balance and fall on his shoulder before it heals.
“When I last spoke with the surgeon, he said to let him know when I’m ready,” Colvin said. “But with all the symptoms, I’ve never felt ready for surgery.”
As the number of people who have had covid grows, medical experts are trying to determine when it’s safe for them to have elective surgery. In addition to concerns about respiratory complications from anesthesia, covid may affect multiple organs and systems, and clinicians are still learning the implications for surgery. A recent studycompared the mortality rate in the 30 days following surgery in patients who had a covid infection and in those who did not. It found that waiting to undergo surgery for at least seven weeks after a covid infection reduced the risk of death to that of people who hadn’t been infected in the first place. Patients with lingering covid symptoms should wait even longer, the study suggested.
But, as Colvin’s experience illustrates, such guideposts may be of limited use with a virus whose effect on individual patients is so unpredictable.
“We know that covid has lingering effects even in people who had relatively mild disease,” said Dr. Don Goldmann, a professor at Harvard Medical School who is a senior fellow and chief scientific officer emeritus at the Institute for Healthcare Improvement. “We don’t know why that is. But it’s reasonable to assume, when we decide how long we should wait before performing elective surgery, that someone’s respiratory or other systems may still be affected.”
The study, published in the journal Anaesthesia in March, examined the 30-day postoperative mortality rate of more than 140,000 patients in 116 countries who had elective or emergency surgery in October. Researchers found that patients who had surgery within two weeks of their covid diagnosis had a 4.1% adjusted mortality rate at 30 days; the rate decreased to 3.9% in those diagnosed three to four weeks before surgery, and dropped again, to 3.6%, in those who had surgery five to six weeks after their diagnosis. Patients whose surgery occurred at least seven weeks after their covid diagnosis had a mortality rate of 1.5% 30 days after surgery, the same as for patients who were never diagnosed with the virus.
Even after seven weeks, however, patients who still had covid symptoms were more than twice as likely to die after surgery than people whose symptoms had resolved or who never had symptoms.
Some experts said seven weeks is too arbitrary a threshold for scheduling surgery for patients who have had covid. In addition to patients’ recovery status from the virus, the calculus will be different for an older patient with chronic conditions who needs major heart surgery, for example, than for a generally healthy person in their 20s who needs a straightforward hernia repair.
“Covid is just one of the things to be taken into account,” said Dr. Kenneth Sharp, a member of the Board of Regents of the American College of Surgeons and vice chair of the Department of Surgery at Vanderbilt University Medical Center.
In December, the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation issued these guidelines for timing surgery for former covid patients:
• Four weeks if a patient was asymptomatic or had mild, non-respiratory symptoms.
• Six weeks for a symptomatic patient who wasn’t hospitalized.
• Eight to 10 weeks for a symptomatic patient who has diabetes, is immunocompromised or was hospitalized.
• Twelve weeks for a patient who spent time in an intensive care unit.
Those guidelines are not definitive, according to the groups. The operation to be performed, patients’ medical conditions and the risk of delaying surgery should all be factored in.
“Long covid” patients like Colvin who continue to have debilitating symptoms months after 12 weeks have passed require a more thorough evaluation before surgery, said Dr. Beverly Philip, president of the society.
Now that covid has been brought to heel in many areas and vaccines are widely available, hospital operating rooms are bustling again.
“In talking to surgical colleagues, hospitals are really busy now,” said Dr. Avital O’Glasser, medical director of the outpatient preoperative clinic at Oregon Health and Sciences University in Portland. “I’ve seen patients with delayed knee replacements, bariatric surgery, more advanced cancer.”
At the beginning of the pandemic, surgical volumes dropped dramatically as many hospitals canceled nonessential procedures and patients avoided facilities packed with covid patients.
From March to June 2020, the number of inpatient and outpatient surgeries at U.S. hospitals was 30% lower than in the same period the year before, according to McKinsey & Company’s quarterly Health System Volumes Survey. By May 2021, surgical volumes had mostly rebounded, and were just 2% lower than their May 2019 totals, according to the May survey.
Oregon Health and Sciences University clinicians developed a protocol a year ago for clearing any patient who had covid for elective surgery. When obtaining patients’ medical history and conducting physical exams, clinicians look for signs of covid complications that aren’t readily identifiable and determine whether patients have returned to their pre-covid level of health.
The pre-op exam also includes lab and other tests that evaluate cardiopulmonary function, coagulation status, inflammation markers and nutrition, all of which can be disrupted by covid.
If the assessment raises no red flags, patients can be cleared for surgery once they have waited the minimum seven weeks since their covid diagnosis.
Originally, the minimum wait for surgery was four weeks, but clinicians pushed it back to seven after the international study was published, O’Glasser said.
“We are still learning about covid, and uncertainty in medicine is one of the biggest challenges we face,” said O’Glasser. “Right now, our team is erring on the side of caution.”
At Memorial Sloan Kettering Cancer Center in New York, doctors don’t follow a specific protocol. “We’re taking every patient one at a time. There are no hard-and-fast rules at this institution,” said Dr. Jeffrey Drebin, chair of surgery.
Clinicians work to find a balance between the urgency of the cancer surgery and the need to allow enough time to ensure covid recovery, he said.
For Brian Colvin, whose right rotator cuff is torn, delaying surgery is painful and may worsen the tear. But the rest of his life is on hold, too. A sales representative for an auto parts company, he hasn’t been able to work since he got sick. His balance problems make him reluctant to stray far from his home in Crest Hill, Illinois, the Chicago suburb where he lives with his wife and 15-year-old son.
Some days he has more energy and isn’t as short of breath as others. Colvin hopes it’s a sign he’s slowly improving. But at this point, it’s hard to be optimistic about the virus.
A new CDC study adds to the growing body of real-world evidence (outside of a clinical trial setting) showing that COVID-19 mRNA vaccines authorized by the Food and Drug Administration (FDA) protect health care personnel (HCP) against COVID-19. mRNA vaccines (Pfizer-BioNTech and Moderna) reduced the risk of getting sick with COVID-19 by 94% among HCP who were fully vaccinated. This assessment, conducted in a different study network with a larger sample size from across a broader geographic area than in the clinical trials, independently confirms U.S. vaccine effectiveness findings among health care workers that were first reported March 29.
“This report provided the most compelling information to date that COVID-19 vaccines were performing as expected in the real world,” said CDC Director Rochelle P. Walensky, MD, MPH. “This study, added to the many studies that preceded it, was pivotal to CDC changing its recommendations for those who are fully vaccinated against COVID-19.”
Data for this assessment come from a network covering 500,000 HCP across 33 sites in 25 U.S. states, providing additional robust evidence that mRNA vaccines are effective against symptomatic illness in real-world conditions.
The assessment compared vaccination status of participants who tested positive for SARS-CoV-2, the virus that causes COVID-19 (cases) with vaccination status of those who tested negative (controls). Among the 1,843 participants, there were 623 cases and 1,220 controls. Vaccine effectiveness estimates were calculated by comparing the odds of COVID-19 vaccination in cases and controls. The large sample size in this study allowed for a precise vaccine effectiveness estimate with narrower confidence intervals than earlier CDC findings published March 29.
Understanding vaccine effectiveness among HCP is important because they are at higher risk for exposure to SARS-CoV-2 through patient interactions. Vaccination of HCP protects them and their patients against COVID-19 and ensures continuation of critical health care services.
The assessment found that COVID-19 symptomatic illness was reduced by 94% among HCP who were fully vaccinated, defined in this study as seven or more days after receipt of a second vaccine dose, and by 82% among those who were partially vaccinated, defined in this study as 14 days after receipt of dose one through six days after dose two. These findings support CDC’s recommendation that everyone should get both doses of an mRNA COVID-19 vaccine to get the most protection.
This assessment is part of CDC’s comprehensive strategy of using complementary methods to understand how COVID-19 vaccines are working in different populations and real-world settings. On May 12, CDC expanded COVID-19 vaccination recommendations to include adolescents 12 years through 15 years of age under the U.S. Food and Drug Administration’s Emergency Use Authorization. These adolescents are now authorized to receive the Pfizer-BioNTech COVID-19 vaccine. CDC has several surveillance networks that will continue to assess how well FDA-authorized COVID-19 vaccines are working in real-world conditions in people of different age groups, including children and adolescents.
Are you experiencing the Covid-19 Effect? As the COVID-19 pandemic continues to ravage populations across the globe, nurses are facing a form of mass trauma that could have effects far into the future, according to a new report from the International Council of Nurses (ICN). The ICN refers to this trauma the “COVID-19 Effect.”
Preliminary findings of a new survey of the ICN’s 130-plus National Nurses Associations (NNAs), coupled with studies by the NNAs and other sources, suggest that the COVID-19 Effect is “a unique and complex form of trauma with potentially devastating consequences in both the short- and long-term for individual nurses and healthcare systems they work in,” according to a press release.
The mass trauma of the COVID-19 Effect results from both the deaths and infections experienced among nurses, as well as mental health consequences. At the end of December 2020, the cumulative number of reported COVID-19 deaths in nurses in 59 countries was 2,262, says the ICN. That compares with 1,097 in August and 1,500 in October.
Brazil, the United States and Mexico have the highest number of reported COVID-19 nurse deaths. More alarming, the ICN says that the figure of 2,262 is likely a significant underestimate, due to the absence of a systematic, standardized global surveillance system.
Also at the end of December 2020, more than 1.6 million healthcare workers were infected with COVID-19 in 34 countries. The ICN notes that in many countries, nurses were the biggest healthcare worker group to have COVID-19.
A Massive Mental Toll
Besides the tremendous physical cost to the nursing workforce, the COVID-19 Effect has inflicted a huge mental burden. ICN’s survey revealed that close to 80% of the NNAs that responded received reports of mental health distress from nurses working in the COVID-19 response. The report quotes studies from China, the U.S. Spain, Brazil, and other countries documenting nurse stress, anxiety, exhaustion, and burnout.
The COVID-19 Effect, states the report, is a complex phenomenon that is intertwined with various issues including persistently high workloads, increased patient dependency and mortality, burnout, inadequate personal protective equipment, the fear of spreading the virus to families and relatives, an increase in violence and discrimination against nurses, COVID-19 denial and the propagation of misinformation, and a lack of social and mental health support.
One response to nurses’ mental health concerns came from the American Nurses Foundation. In May, in partnership with other major nursing organizations, it launched the Well-being Initiative — a set of resources to help nurses manage the stress and overcome the trauma caused by COVID-19.
Future Fallout
The pandemic may have devastating consequences in the long term, suggests the ICN. Previously, the ICN projected a global shortfall of more than 10 million nurses by 2030 but now says that the COVID-19 Effect could increase that number to as high as 14 million nurses in the future.
“Such a shortfall would impact all healthcare services in the post-COVID-19 era to such an extent that I would argue the health of the nursing workforce could be the greatest determinant of the health of the world’s population over the next decade,” says Howard Catton, ICN CEO, in the press release.
