On Tuesday, the ANA American Nurses Foundation (the Foundation) released new survey findings from nearly 12,000 nurses nationwide, revealing that younger nurses are struggling more with mental health challenges and that nurses are experiencing an increase in workplace violence as the nation enters year three of the COVID-19 pandemic.
Mental Health and Workplace Violence
Nurses’ mental health and well-being has been and remains a pressing issue, with the ongoing stressors of the pandemic taking a significant toll on younger nurses. Nearly half of nurses surveyed under age 35 said they have sought professional mental health support since March 2020. Of the survey respondents under age 25, 69% say they have been suffering from burnout, which is more than double than those older than 25 (30%). Additionally, nurses under age 25 (47%) and nurses between 25- 34 (46%) consider themselves as being not or not at all emotionally healthy compared to nurses over the age of 55 (19%) and were more likely to have experienced an extremely traumatic, disturbing, or stressful event due to COVID-19. The number of workplace violence incidences against nurses are on the rise, according to the survey. Specifically, 2/3 of nurses surveyed said they have experienced increased bullying at work while 1/3 of nurses report increased incidents of physical violence at work.
“Mental health challenges endured by nurses is a serious ongoing dilemma that will have long-term impacts on the profession as this younger generation of nurses have been hit the hardest, as noted in the survey. As we think about the future of nursing, this is particularly disturbing because nurses are our most valuable resource in health care, remaining a constant force in the recovery efforts to end this relentless pandemic by administering COVID-19 vaccines, educating communities, and providing safe and quality patient care to millions. The key to ending this pandemic is having and sustaining a robust nursing workforce operating at peak health and wellness,” said Foundation Board of Trustees President, Wilhelmina M. Manzano, MA, RN, NEA-BC, FAAN. “The Foundation continues to be committed to providing resources and the necessary support to all nurses through the Well-Being Initiative and the Coronavirus Response Fund for Nurses. We need to ensure nurses are consistently and completely protected and supported. There is too much on the line.”
Lack of robust support systems feeds staffing crisis
Among respondents who say that their organization is experiencing a staffing shortage (89%), more than half (53%) say that it is a serious problem. Younger nurses are leaving their current positions and roles in increasing numbers. According to the survey findings, nurses ages 25-34 and 35-44 were more likely to change positions than nurses over age 55. Similarly, 60% of nurses under age 25 and 57% of nurses 25-34 do not believe their organization cares about their well-being and generally feel unsupported. The lack of support and work negatively affecting their mental health and well-being were major contributing factors to this sentiment of younger nurses who were more likely to experience negative and unhealthy emotions.
“As we enter the third year of this incessant pandemic, the survey findings are even more alarming than what we found in the survey done last year. It’s extremely disheartening that we are still seeing and hearing about the same issues nurses have been burdened with since the start of the pandemic in 2020,” said Foundation Executive Director, Kate Judge. “Nurses are still struggling with mental health issues, feeling unsupported, and suffering from severe burnout and post-traumatic stress because of their sustained response to the COVID-19 pandemic. The nurse staffing shortage has had a domino effect on the profession and it’s only going to worsen if we don’t address the chronic, underlying work environment issues. The Foundation continues to work tirelessly on behalf of the nation’s nurses who deserve our full support and respect for their efforts in improving public health and pulling our nation out of the grip of this pandemic.”
Nurses cannot solve the longstanding challenges facing the profession alone. It is imperative that the Administration and all other stakeholders utilize all available authorities to address these issues and collaborate with nurses to forge a path forward to ensure a strong nursing workforce now and in the future.
The full survey results and findings are available online (PDF).
*Data collected through a non-incentivized survey administered by the American Nurses Foundation. Between January 8 – January 29, 2022 – 11,964 nurses completed this survey. *
For nurses who commit suicide, job-related problems likely play a major role in that tragic decision.
Such is the conclusion of a study of 203 nurses known to have job problems prior to death by suicide between 2003 and 2017 published in the April 2021 issue of the Journal of Nursing Regulation.
“Nurses who lose a nursing position or leave the profession because of substance use, mental health issues, or chronic pain are at risk for nurse suicide,” the article noted.
In a previous longitudinal study of nurse suicide, “one of the things that came out pretty clearly was that nurses were more likely to have a known job-related problem prior to death,” said Judy E. Davidson, DNP, RN, MCCM, FAAN, lead author of the project. Davidson serves as nurse scientist, UC San Diego Health Sciences and research scientist, UC San Diego School of Medicine, Department of Psychiatry.
The danger zone: situations known to increase risk of nurse suicide
Of the 203 nurses studied, nearly all were out of work or in the process of losing their position as a nurse, the study notes. The researchers analyzed narratives about the 203 nurse suicides written by medical examiners and law enforcement personnel. Using natural language processing and thematic analysis, the researchers discovered three main reasons for the suicides.
“Nurses with substance use disorder are treated inequitably to others in the world. Nurses are treated differently and inequitably, and it often leads to death.”
—Judy E. Davidson, DNP, RN, MCCM, FAAN
First, a nurse could have a serious mental health issue. “Their mental health problems were not controlled to a point where they could continue working,” said Davidson. Largely, the nurses suffered from depression.
Second, nurses could suffer from uncontrolled chronic pain leading to them no longer being able to function as a nurse and having to leave their job. That could lead to financial ruin, a destroyed family and a sense of having no way out, noted Davidson.
“Obviously we should be able to do a much better job at controlling people’s pain,” Davidson said. “There are many different types of way you can express yourself as a nurse, and there are desk jobs that nurses could do. The whole issue of undertreated pain is definitely actionable.”
Third, nurses who die by suicide related to job loss may suffer from the mental health issue of substance use disorder (SUD). This cause is “really problematic for the profession and this is where we have a lot of work to do,” said Davidson.
“Nurses with substance use disorder are treated inequitably to others in the world,” according to Davidson. “Nurses are treated differently and inequitably, and it often leads to death.”
If the nurse doesn’t get help prior to being found on the job impaired or prior to diverting medications, then the nurse often loses his or her job at the point of identification, Davidson noted. “What we need to do is to be able to identify these nurses earlier in the course of their disease. Substance Use Disorder is a disease that is incremental in nature; it doesn’t happen overnight. And there are points in time when these people could be identified earlier, encouraged and motivated into treatment to prevent issues such as being found impaired in the workplace.”
When states have mandatory reporting requirements, those requirements prevent this from happening and drives these issues underground, Davidson said. “Nurses end up progressing in their disease to the point where they’re so far gone by the time they’re identified that it ends up being treated as a criminal issue instead of a disease-focused issue.”
Confidential prevention programs can save lives
One method to stop the progression from mental health issues to suicide involves a program for suicide prevention tested at UCSD in partnership with the American Foundation of Suicide Prevention and replicated nationally. A nurse, physician or other hospital worker is sent a request to fill out a survey in an anonymous encrypted program. If the respondent scores moderate to high risk, a therapist, who is also anonymous, will contact the person through encryption over the computer. The healthcare worker can then have anonymous online counseling, be referred to a psychiatrist or psychologist for maintenance therapy while remaining anonymous, or break anonymity and engage in traditional counseling.
“We’ve sent hundreds of doctors, nurses and hospital workers over the years into mental health treatment without anyone in the organization knowing who they are,” Davidson said. The employee’s manager will not know the reason why they took leave to get treatment.
Through this program, UCSD refers roughly 40 to 60 nurses a year into mental health treatment, including the disease of substance use disorder (SUD), Davidson said. “It works beautifully and is very cost-effective.”
Losing one’s “identity as a nurse”
“The nurse cracks when their identity as a nurse is threatened. It just breaks them.”
—Judy E. Davidson, DNP, RN, MCCM, FAAN
In another warning about the effects of job issues on nurse suicide, a study published in the November 2021 issue of the American Journal of Nursing found that burnout – which has become rampant during the COVID pandemic – was strongly associated with suicidal ideation among nurses. “Compared with other U.S. workers, nurses are at higher risk for suicidal ideation, and nurses with such ideation are more reluctant to seek help than those without it,” the report said. “Burnout contributes to the risk of suicidal ideation.”
The events leading to job loss are largely modifiable, concluded Davidson and colleagues in the Journal of Nursing Regulation article. Alternative-to-discipline (ATD) programs, it notes, would benefit from standardization, national oversight, consistent use of non-disciplinary measures, and focus on treatment while the nurse was temporarily removed from the workplace. Removal of license could be reserved only for those who are refractory to treatment, it notes.
At a core level, suggested Davidson, these nurse suicides have to do with a loss of identity. “The nurse cracks when their identity as a nurse is threatened. It just breaks them,” Davidson said. “We break our nurses by firing them when they have the disease of substance use disorder. We discard them from the profession where we could instead be healing them. We could preserve the workforce by focusing on earlier identification, motivating nurses into treatment on leave using anonymous programs like the one tested at UCSD, instead of breaking them by taking their jobs and licenses.”
For more information about starting an anonymous encrypted screening program at your organization, contact the American Foundation of Suicide Prevention: https://afsp.org/interactive-screening-program
The National Institute of Mental Health reports that mental illness costs the United States over $300 billion annually, with one in five adults experiencing some sort of mental health condition each year. As a growing number of frontline workers report experiencing mental health issues ranging from anxiety and stress to PTSD and MDD, organizations such as the National Alliance on Mental Health (NAMI) have launched guides that specifically target healthcare professionals. While the pending Lorna Breen Act offers hope in its aims to make help more readily available for physicians and nurses, you should NOT wait.
When left untreated, mental health issues can exacerbate into life-threatening illnesses. One of these five tested, accessible, treatment options could help you feel better and function more effectively:
1. Cognitive Behavioral Therapy
Cognitive-behavioral therapy (CBT) is a form of psychotherapy that is focused on changing behavior and thought patterns in order to relieve symptoms and problems. CBT can be used to treat a wide range of mental health disorders, including depression, anxiety, and certain addictions. During CBT, a professional counselor or therapist will work with you to create specific goals based on your situation. These goals can focus on decreasing symptoms or changing behaviors that may be contributing to symptoms such as anxiety or depression. The counselor will also work with you on discovering personal vulnerabilities and stressors that may contribute to your symptoms.
2. Intensive Outpatient Programs
Intensive outpatient programs can be a great option for those who want to quit drinking or taking drugs but don’t need intensive treatment. In an iop program, patients come to a rehab facility several times per week, where they participate in group and individual therapy sessions. These programs typically last from 1-4 months.
The advantage of an intensive outpatient program is that patients do not have to stay at a rehab facility during their recovery, allowing them to go to work or school while in treatment. Since these programs are less structured than inpatient options, they may not be as effective for some people with severe drug and alcohol abuse issues.
3. Mindfulness-Based Stress Reduction
Incorporating a variety of stress reduction techniques into your day can go a long way in keeping you healthy, happy, and prepared for life’s stressors. This is where mindfulness comes in. Mindfulness is gaining popularity as a stress-reduction technique as it works for almost anyone.
Research has also shown that MBSR training can improve sleep quality, enhance productivity and even improve symptoms of chronic illness like diabetes and rheumatoid arthritis. If you want to take advantage of mindfulness training but aren’t sure where to start, then consider taking an online class or hiring an instructor for one-on-one coaching.
4. Pharmacological Therapies
Pharmacological therapies are another option front-line workers can use to treat their mental health concerns. Work with your doctor to find the best pharmaceutical treatments for your lifestyle. While these therapies are an effective way to treat mental health, be wary of your reliance on them.
Antidepressants in particular can be habit-forming and in some cases may not even work for everyone that uses them. If you suffer from depression, anxiety, or any other mental illness, be sure to speak with a doctor about all of your options. In many cases, pharmaceuticals should be the last resort. For example, depression can be treated by talk therapy alone. More advanced mental health disorders such as psychosis or schizophrenia will likely require a variety of therapies to bring symptoms under control over time.
5. Interpersonal Psychotherapy
Interpersonal psychotherapy, or IPT, is designed to help individuals adjust to stressful life situations. A therapy session may include discussions of emotional reactions, problem-solving techniques, and other cognitive exercises designed to make it easier for you to effectively manage your feelings. You’ll also learn how to better recognize signs of distress in yourself and others.
There are three main phases of IPT: crisis intervention, acute stabilization, and prevention. There are typically 10 one-hour sessions during each phase of IPT treatment. Oftentimes IPT is used as a form of treatment for PTSD symptoms after an emergency occurs on the scene or at home in the form of critical incident stress debriefing.
Everyone deserves mental health care, regardless of their financial situation or employment status. Front line workers should take these five ideas into consideration to care for their mental health.
- If you have thoughts about suicide or you are in crisis, call the National Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255). The ANA has also assembled some resources for nurses suffering from suicidal ideation here.