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. *
Demanding that the hospital industry invests in safe staffing and that President Biden fulfills his campaign promise to protect nurses and prioritize public health, National Nurses United (NNU), the largest RN union in the United States, is calling for nurses to take part in actions across the country on January 13. Among the activities planned for this Thursday, the NNU will conduct a national virtual press conference at 1.00 PM EST and hold a candlelight vigil in Washington, D.C. for nurses who lost their lives to Covid-19.
“This is a vicious cycle where weakening protections just drives more nurses away from their jobs.”
—Zenei Triunfo-Cortez, RN, President, NNU
A perfect storm is brewing, according to NNU nurses. The Biden administration has “ripped away critical protections“ from health care workers and the public, the Centers for Disease Control (CDC) has weakened Covid isolation guidelines, and the Occupational Safety and Health Administration (OSHA) plans to withdraw critical Covid protections for health care workers—right when the Omicron variant is exploding across the country and hospitalizations are skyrocketing. The NNU states that leaving nurses unprotected by the government and by profit-driven hospital employers which have failed to invest in safe staffing and critical health and safety protections, has created unsafe working conditions that are driving nurses out of the profession.
Nurse retention will rise when hospitals set safe staffing levels
NNU President Zenei Triunfo-Cortez, RN suggests that the nurse staffing crisis—while it may have been exacerbated by the pandemic—is primarily a consequence of hospitals prioritizing dollars above human lives. In a statement, Triunfo-Cortez said, “As we enter year three of the deadliest pandemic in our lifetimes, nurses are enraged to see that, for our government and our employers, it’s all about what’s good for business, not what’s good for public health. Our employers claim there is a ‘nursing shortage,’ and that’s why they must flout optimal isolation times, but we know there are plenty of registered nurses in this country. There is only a shortage of nurses willing to work in the unsafe conditions created by hospital employers and this government’s refusal to impose lifesaving standards. So this is a vicious cycle where weakening protections just drives more nurses away from their jobs.”
NNU conducted a survey of thousands of registered nurses across the country from October to December 2021. Of the nurses who responded, 83 percent said at least half of their shifts were unsafely staffed, and 68 percent said they have considered leaving their position. RNs say nurses would stop leaving the profession if hospitals immediately improved working conditions by increasing staffing levels and followed nurses’ advice to grow the pool of available nurses. According to nurses, hospitals must actively hire permanent staff nurses and consider a wider range of educational qualifications; stop canceling nurses; properly cross-train current staff nurses so that they are competent to work in other departments, especially critical care, and institute optimal occupational health and safety protocols to protect nurses, other health care workers, and patients.
Schedule for Thursday, Jan 13
What: Virtual press conference, featuring national nurse stories
When:Thursday, Jan. 13, 1 p.m. ET/ 10 a.m. PT
Who: Registered nurses from across the United States
Nurses also call on the CDC to strengthen isolation guidelines for health care workers and the public, and on OSHA to institute a permanent Covid health care standard without delay. On Jan. 5, NNU joined leading labor organizations and unions representing the country’s nurses and health care workers to petition the United States Court of Appeals for the District of Columbia Circuit to order OSHA to issue a permanent standard and to retain the emergency temporary standard until the permanent standard goes into effect. Without the protections of a permanent standard, RNs emphasize that the health and well-being of nurses, other health care workers, patients, and the general public is in grave danger.
“Everyone will need medical care at some point in their lives, and when our loved ones are in the hospital, we want nurses to be able to deliver the focused care that all patients deserve,” said Bonnie Castillo, RN, NNU executive director. “But the working conditions that our employers and the federal government are telling nurses and health care workers to endure are both grossly unfair and unsustainable, and we are standing up on Jan. 13 to say, ‘Enough!’ We need permanent protections based on science, and we need them now because when nurses and health care workers aren’t safe, we cannot keep our patients safe.”
The San Leandro Hospital emergency department, where nurse Mawata Kamara works, went into lockdown recently when a visitor, agitated about being barred from seeing a patient due to covid-19 restrictions, threatened to bring a gun to the California facility.
It wasn’t the first time the department faced a gun threat during the pandemic. Earlier in the year, a psychiatric patient well known at the department became increasingly violent, spewing racial slurs, spitting toward staffers and lobbing punches before eventually threatening to shoot Kamara in the face.
“Violence has always been a problem,” Kamara said. “This pandemic really just added a magnifying glass.”
In the earliest days of the pandemic, nightly celebrations lauded the bravery of front-line health care workers. Eighteen months later, those same workers say they are experiencing an alarming rise in violence in their workplaces.
A nurse testified before a Georgia Senate study committee in September that she was attacked by a patient so severely last spring she landed in the ER of her own hospital.
At Research Medical Center in Kansas City, Missouri, security was called to the covid unit, said nurse Jenn Caldwell, when a visitor aggressively yelled at the nursing staff about the condition of his wife, who was a patient.
In Missouri, a tripling of physical assaults against nurses prompted Cox Medical Center Branson to issue panic buttons that can be worn on employees’ identification badges.
Hospital executives were already attuned to workplace violence before the pandemic struck. But stresses from covid have exacerbated the problem, they say, prompting increased security, de-escalation training and pleas for civility. And while many hospitals work to address the issue on their own, nurses and other workers are pushing federal legislation to create enforceable standards nationwide.
Even so, Michelle Wallace, chief nursing officer at Grady Health System in Georgia, said the violence is likely even higher because many victims of patient assaults don’t report them.
“We say, ‘This is part of our job,’” said Wallace, who advocates for more reporting.
Caldwell said she had been a nurse for less than three months the first time she was assaulted at work — a patient spit at her. In the four years since, she estimated, she hasn’t gone more than three months without being verbally or physically assaulted.
“I wouldn’t say that it’s expected, but it is accepted,” Caldwell said. “We have a lot of people with mental health issues that come through our doors.”
Jackie Gatz, vice president of safety and preparedness for the Missouri Hospital Association, said a lack of behavioral health resources can spur violence as patients seek treatment for mental health issues and substance use disorders in ERs. Life can also spill inside to the hospital, with violent episodes that began outside continuing inside or the presence of law enforcement officers escalating tensions.
A February 2021 report from National Nurses United — a union in which both Kamara and Caldwell are representatives — offers another possible factor: staffing levels that don’t allow workers sufficient time to recognize and de-escalate possibly volatile situations.
Covid unit nurses also have shouldered extra responsibilities during the pandemic. Duties such as feeding patients, drawing blood and cleaning rooms would typically be conducted by other hospital staffers, but nurses have pitched in on those jobs to minimize the number of workers visiting the negative-pressure rooms where covid patients are treated. While the workload has increased, the number of patients each nurse oversees is unchanged, leaving little time to hear the concerns of visitors scared for the well-being of their loved ones — like the man who aggressively yelled at the nurses in Caldwell’s unit.
In September, 31% of hospital nurses surveyed by that union said they had faced workplace violence, up from 22% in March.
Dr. Bryce Gartland, hospital group president of Atlanta-based Emory Healthcare, said violence has escalated as the pandemic has worn on, particularly during the latest wave of infections, hospitalization and deaths.
“Front-line health care workers and first responders have been on the battlefield for 18 months,” Garland said. “They’re exhausted.”
Like the increase in violence on airplanes, at sports arenas and school board meetings, the rising tensions inside hospitals could be a reflection of the mounting tensions outside them.
William Mahoney, president of Cox Medical Center Branson, said national political anger is acted out locally, especially when staffers ask people who come into the hospital to put on a mask.
Caldwell, the nurse in Kansas City, said the physical nature of covid infections can contribute to an increase in violence. Patients in the covid unit often have dangerously low oxygen levels.
“People have different political views — they’re either CNN or Fox News — and they start yelling at you, screaming at you,” Mahoney said.
“When that happens, they become confused and also extremely combative,” Caldwell said.
Sarnese said the pandemic has given hospitals an opportunity to revisit their safety protocols. Limiting entry points to enable covid screening, for example, allows hospitals to funnel visitors past security cameras.
Research Medical Center recently hired additional security officers and provided de-escalation training to supplement its video surveillance, spokesperson Christine Hamele said.
In Branson, Mahoney’s hospital has bolstered its security staff, mounted cameras around the facility, brought in dogs (“people don’t really want to swing at you when there’s a German shepherd sitting there”) and conducted de-escalation training — in addition to the panic buttons.
Some of those efforts pre-date the pandemic but the covid crisis has added urgency in an industry already struggling to recruit employees and maintain adequate staffing levels. “The No. 1 question we started getting asked is, ‘Are you going to keep me safe?’” Mahoney said.
While several states, including California, have rules to address violence in hospitals, National Nurses United is calling for the U.S. Senate to pass the Workplace Violence Prevention for Health Care and Social Service Workers Act that would require hospitals to adopt plans to prevent violence.
“With any standard, at the end of the day you need that to be enforced,” said the union’s industrial hygienist, Rocelyn de Leon-Minch.
Nurses in states with laws on the books still face violence, but they have an enforceable standard they can point to when asking for that violence to be addressed. De Leon-Minch said the federal bill, which passed the House in April, aims to extend that protection to health care workers nationwide.
Destiny, the nurse who testified in Georgia using only her first name, is pressing charges against the patient who attacked her. The state Senate committee is now eyeing legislation for next year.
Kamara said the recent violence helped lead her hospital to provide de-escalation training, although she was dissatisfied with it. San Leandro Hospital spokesperson Victoria Balladares said the hospital had not experienced an increase in workplace violence during the pandemic.
For health care workers such as Kamara, all this antagonism toward them is a far cry from the early days of the pandemic when hospital workers were widely hailed as heroes.
“I don’t want to be a hero,” Kamara said. “I want to be a mom and a nurse. I want to be considered a person who chose a career that they love, and they deserve to go to work and do it in peace. And not feel like they’re going to get harmed.”
COVID-19 vaccines are highly effective in preventing symptomatic illness among health care workers in real-world settings.
The study, published in the New England Journal of Medicine, found that health care personnel who received a two-dose regimen of Pfizer–BioNTech vaccine had an 89% lower risk for symptomatic illness than those who were unvaccinated. For those who received the two-dose regimen of the Moderna vaccine, the risk was reduced by 96%.
The researchers also found that the vaccines appeared to work just as well for people who are over age 50, are in racial or ethnic groups that have been disproportionately affected by COVID-19, have underlying medical conditions and have greater exposure to patients with COVID-19.
The vaccines’ effectiveness was, however, lower in immunocompromised people.
“That this study demonstrated the effectiveness of the Pfizer–BioNTech and Moderna COVID-19 vaccines to protect health care workers — people who worked tirelessly and at great potential risk to care for their friends and neighbors — is a major statement to address any remaining skepticism about the importance of everyone getting vaccinated,” said Dr. David Talan, a professor of emergency medicine and of medicine and infectious diseases at the David Geffen School of Medicine at UCLA, and the study’s co-lead author.
The project, Preventing Emerging Infections through Vaccine Effectiveness Testing, or PREVENT, was conducted with researchers from the University of Iowa’s Carver College of Medicine. The study evaluated nearly 5,000 health care workers — 1,482 who had tested positive for COVID-19 and displayed symptoms of the disease and 3,449 who had COVID-19–like symptoms but had tested negative for the disease. The participants were from 33 U.S. academic medical centers, including Olive View–UCLA Medical Center in Sylmar, California.
All of the participants completed surveys covering their demographic information, job type and risk factors for severe disease from COVID-19, as well as their vaccination status.
Other findings include:
A two-dose regimen of either of the mRNA vaccines reduced the risk of illness by 95% among Black and African American people, 89% among Hispanic people, 89% among Asian or Pacific Islander people, and 94% among American Indians and Alaskan Native people, compared to unvaccinated people.
Of all those who received a single dose of either of the two-dose mRNA vaccines, the risk of illness was reduced by 86% among Black and African American people, 82% among Hispanic people, 80% among Asian or Pacific Islander people, and 76% among American Indians and Alaskan Native people compared to unvaccinated people.
For people who are obese or overweight, a two-dose regimen reduced the risk of illness by 91%; among the same group, partial vaccination reduced the risk by 76% among partially vaccinated compared to unvaccinated.
For people who have hypertension, a two-dose regimen of either mRNA vaccine reduced the risk of illness by 92%, and partial vaccination reduced the risk by 83% among partially vaccinated compared to unvaccinated.
For people who have asthma, a two-dose regimen of either mRNA vaccine reduced the risk of illness by 91%, and partial vaccination reduced the risk by 78% among partially vaccinated compared to unvaccinated.
For immunocompromised people, the risk of illness was reduced by 39% whether they received a single dose or two doses of either mRNA vaccine.
Sixty-two people in the study were pregnant at the time they were surveyed. Vaccination was 77% effective in preventing symptomatic COVID-19 illness among pregnant people who had received at least one dose of one of the mRNA vaccines.
Because of the relatively short time period of the study — from December 2020 to May 2021 — the research does not address how long vaccines continue to provide protection against COVID-19. In addition, data was collected before the emergence of the delta variant, so the vaccines’ effectiveness today may be different than they would be against earlier variants.
PREVENT is a collaboration between EMERGEncy ID NET — a CDC-supported network led by Talan that comprises 12 U.S. emergency departments and focuses on studying emerging infectious diseases — and a previously assembled group of sites that worked under Project COVERED, another CDC-funded effort to assess the risk to emergency department providers of acquiring COVID-19 through direct contact with patients and to determine ways to mitigate that risk.
National Nurses United’s (NNU) new nationwide survey of more than 5,000 registered nurses reveals that employers must do more to be fully compliant with the Occupational Safety and Health Administration (OSHA) emergency temporary standard (ETS) and to implement optimal standards to protect nurses and other health care workers from Covid-19.
This survey is the sixth national survey of nurses during the pandemic by NNU, the nation’s largest and fastest-growing union of registered nurses. Most of the requirements for the ETS went into effect on July 6 and all requirements went into effect on July 21. The ETS is the first-in-the-nation enforceable federal Covid-19 standard, which nurses have fought for since the beginning of the pandemic. The ETS includes requirements on personal protective equipment (PPE), patient and visitor screening, and employee notification within 24 hours of the employer becoming aware of the exposure.
“We are more than 18 months into the pandemic, yet hospitals are still not doing enough to ensure the safety of nurses, patients, and other health care workers. Covid cases are surging to their highest levels yet in some areas of the country, and some ICUs are over capacity.
Nurses need optimal personal protective equipment. Health care employers must notify nurses as soon as possible when they are exposed and make it easier for RNs and other health care workers to get tested.”
—NNU Executive Director Bonnie Castillo, RN
NNU’s latest survey reveals that nurses still face problems with access to testing, being notified in a timely manner when they are exposed, inadequate respiratory protection, unsafe staffing, mental health, and workplace violence. RNs also reported inadequate Covid screening and testing rates for patients who enter or are admitted to a health care facility and a decrease in dedicated Covid units compared to the last survey (March 2021).
More than 75 percent of hospital nurses are not being notified of exposures to Covid in a timely way. Only 23 percent of hospital RNs reported timely notification of exposure by their employers, down from 31.6 percent reported in March 2021. Prompt notification is essential for hospital infection control.
Access to testing is an issue at some hospitals. About 41 percent of RNs at hospitals reported that any staff who asks for testing has access; nearly 20 percent said access to testing is limited at their facility, and 7 percent said testing is not available where they work. Of the nurses who answered additional questions on employer testing, 58 percent said that only staff who are symptomatic can get tested, a troubling statistic as scientific research has found that about half of all Covid transmissions are from asymptomatic and pre-symptomatic individuals who were infected.
Not all patients and visitors are screened for Covid. Only two-thirds of hospital RNs report that all patients are screened for Covid-19 signs and symptoms before or upon arrival at the facility. Less than a third of hospital RNs reported that every patient is tested for Covid before or upon arrival at the facility. For visitors, screening and testing was reported to occur at even lower rates: Only 53 percent of hospital RNs report that every visitor is screened for Covid-19 signs and symptoms before or upon arrival at the facility and a mere 4 percent of RNs reported that all visitors are tested for Covid before or upon arrival. Screening for Covid-19 symptoms, in combination with reliable diagnostic testing and screening for recent exposure history, is necessary to effectively identify and isolate individuals who may be infectious to prevent spread of the virus within health care facilities.
Hospital nurses are still not provided optimal PPE when caring for Covid-positive patients or patients suspected of having Covid. About 61 percent of hospital RNs reported wearing a respirator for every Covid-positive patient encounter, down from nearly 75 percent in our March 2021 survey. In addition, only 40 percent of hospital RNs reported that respirators are worn when they are caring for patients who are suspected of having Covid or whose tests results are not completed; and about 62 percent reported using surgical masks for patients suspected of having Covid or awaiting test results. All nurses should be wearing a respirator for every encounter with a Covid-positive or suspected Covid-positive patient, in addition to eye protection, isolation gown or coveralls, and medical grade gloves.
Nurses diagnosed with Covid have faced lasting symptoms. Nearly a quarter of RNs who contracted Covid experienced symptoms from zero to three months, a third had symptoms lasting three to nine months, 12 percent had symptoms lasting nine to 12 months, and 12 percent more than a year. The most common symptoms reported included tiredness or fatigue, joint or muscle pain, memory or concentration difficulties, headaches or migraines, and difficulty breathing or shortness of breath.
Short staffing remains a persistent problem in hospitals, with more than 57 percent of RNs reporting that staffing has gotten slightly or much worse, up from 47 percent of nurses in our March 2021 survey. Also, nearly half of hospital RNs (49 percent) reported that their facility is using excessive overtime to staff units.
Covid-19 is still having a deep impact on the mental health of hospital nurses, who continue to face moral distress and moral injury at work:
Nearly 42 percent of hospital RNs fear they will contract Covid.
Slightly more than 50 percent are afraid they will infect a family member.
More than a third (35.1 percent) are having more difficulty sleeping.
More than half (53.5 percent) feel stressed more often than before the pandemic.
About 42 percent feel sad or depressed more often than they did before the pandemic.
More than a third feel traumatized by their experiences caring for patients.
Hospital RNs reported an increase in workplace violence. About 31 percent of hospital RNs said that they faced a small or significant increase in workplace violence, up from 22 percent in our March 2021 survey. RNs attribute the increase in workplace violence to decreased staffing levels, changes in the patient population, and fewer visitor restrictions.
NNU’s four surveys in 2020 covered hospitals’ lack of preparedness for Covid-19 (March); government and employers’ disregard for nurse and patient safety (May); the devastating impact of reopening too soon (July); and hospitals’ and health care employers’ lack of preparation for the fall/winter surge, despite more knowledge about the dangers of the virus and effective measures to prevent spread (November). The fifth survey (March 2021) highlighted the continuing disregard that hospitals and health care employers show for the safety of nurses and health care workers, more than one year into the pandemic.
The sixth survey results were gathered from both NNU unionized nurse members as well as non-union nurses in all 50 states plus Washington, D.C. and Puerto Rico. The results cover the period June 1 to July 21, 2021.
