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Nurses in Crisis: A Mental Health Pandemic

Perspectives from an RCC who also works as a registered nurse and registered psychiatric nurse.

By Amanda Burns, RCC, RN, RPN

 

Note: The beginning sections of this article are also featured in Nurses in Crisis: A Mental Health Pandemic, published in the Spring 2022 issue of BCACC’s Insights magazine.

 

The morning alarm sounds off, and once again, another busy shift is waiting for the nurse. “Sue” checks her phone and sees numerous notifications from the hospital, alerts for anyone to come to fill yet another vacant shift. Managing her frustration, she takes a deep breath, kisses her kids goodbye, and heads off to work.

An ICU nurse’s work uniform is now layered with the addition of personal protective equipment. Despite her years of experience, the surge of COVID patients instills a fresh sense of anxiety and urgency in her to manage the patient’s complex needs while avoiding infection. She is used to managing complicated medical equipment, but today she must consider a new piece of equipment: a personal iPad that her patient’s family has delivered.

She eventually accomplishes the setup after fumbling with Wi-Fi connectivity troubles. She elevates her patient so he can view the photographs of his loved ones on the small screen. This isn’t a typical visit; no outsiders are allowed, but since the patient’s condition is deemed terminal, this is the only way for them all to share a goodbye.

The nurse tries to move out of the screen to allow the private virtual meeting. The patient attempts to hold the device himself, but his body is weak and trembling. The nurse has no option but to witness and inject herself into this very private meeting and manage the intrusive feelings that wash over her. She holds her patient and the iPad as the messages of love and grief are shared over a small screen. With the absence of much-needed physical contact from his loved ones, she tries to enhance these goodbyes by gently stroking the patient’s skin, trying to translate the love of his family physically.

The nurse struggles to compose her own emotions and remain the steadfast caregiver he deserves and requires. There is no time to process what the nurse is experiencing as there is much more to do. She is mentally, emotionally, spiritually, and physically exhausted when the shift is over. She has a brief opportunity to share her experience with arriving colleagues. Still, she is halted by the awareness that she must not burden the nurses who are just starting their shift. She must also try to leave the day’s events behind as she heads home, peels off her uniform in the garage, and slips into the shower before greeting her family with what little “care” she has left to give.

Mental health challenges among nurses

The COVID-19 pandemic has moved from months to years. Health care professionals, the frontline warriors in this pandemic, await the opportunity to exhale. The feeling is described as waiting for a building fire to burn out, a car accident to come to a stop, an earthquake to find its completion, but the end has not come with the pandemic. The largest group of health care professionals impacted are nurses, including registered nurses, registered psychiatrist nurses, and licensed practical nurses. Psychological and physical work-related concerns are not new, and the added pressure of caring for those impacted by the virus is now further contaminating the mental health of many nurses.1,2

Nurses are first and foremost people with the same likelihood of having challenges with their mental health. The profession can increase the risk of these challenges occurring with routine exposure to trauma, violence, and suffering. In 2019, WorkSafeBC amended the Workers Compensation Act acknowledging mental illness as a work-related injury. This Presumptive Legislation for Work-Related Mental Health Injuries now includes nurses regulated by the British Columbia College of Nursing Professionals (RNs, RPNs, LPNs, and NPs).

A variety of circumstances influences nurses’ stress levels. Heavy workloads, lengthy shifts, fast pace, lack of physical or psychological safety, chronicity of care, moral conflicts, perceived job security, workplace bullying, and lack of social support are just a few examples. Burnout, depression, anxiety disorders, sleep difficulties, and other ailments might occur from the associated psychological anguish.3,4 Professionalism, quality of care delivery, efficiency, and general quality of life can all be harmed by work-related stress.5,6 While it is vital to identify and minimize these work-related risk factors to preserve mental health and well-being, progress is slow to non-existent. It is then up to the nurses to take care of themselves.

After the 7 o’clock cheers

A renewed sense of professional honour occurred initially during the pandemic. Recognition of the work frontline health care workers with the global and collective routine of setting aside time to bang pots, blow whistles, and cheer on frontline workers at 7 p.m. each night. Nurses who often felt unseen, unacknowledged, and misunderstood experienced a sort of pride in the call to action to join their coworkers during a time of crisis. But those cheers ended and are now replaced with a sense of helplessness, burnout, and vicarious trauma as the relentless demand continues, perhaps more intensely than before.

Reports aren’t looking good. The BC Nurses’ Union and researchers from the University of British Columbia School of Nursing worked on a study during the pandemic that looked at the mental strain associated with working as a nurse in diverse settings. The nurse sample had two to three times the national average of suicidal thoughts and attempts.7 According to a member poll conducted by the Canadian Federation of Nursing Union in January 2022, 94 per cent of nurses are experiencing symptoms of burnout, with 45 per cent claiming severe burnout and two-thirds of the nurses saying their mental health has deteriorated in the past year.8

Understanding the nursing culture

Canadian nursing dates back to the 1600s when nuns sacrificed their own lives for the good of others and were expected to do so. This mindset continues as the health care sector is viewed as service-oriented, with secondary importance to those providing that care.

Nurses can feel that the public expects nurses to care for patients at any cost, including the cost of their well-being and their families. Care is perceived as their calling, mission, and obligation, and, thus, they perceive their complaints and concerns are unvalued and, at times, in contrast to the symbolic giving nature of nursing as a service. This makes it difficult for nurses to reach out for support, as they often feel handcuffed to the idea of prioritizing others at the expense of themselves.

The nursing culture includes both protective factors and risk factors. The protective features identified by nurses include the advancement of care and healing for patients, continual learning and education, expertise in their chosen field, supportive peers who are often referred to as “work-wives,” “work-husbands,” and “work-family.” Nurses value their contribution to the healing journey or providing symptom management and emotional comfort in the absence of healing.

Risk factors for mental health challenges within the profession have more complexity. Similar to firefighters, nurses are a “band of sisters and brothers.” Nurses don’t want to be the “weak link” and be doubted by their peers, seen as incompetent or weak. Nurses are also familiar with the “eating their young” ideation which minimizes support and emphasizes the need to “suck it up” and “toe the line” to be accepted. The bullying behaviour, also known as lateral violence, can result in feelings of inadequacy and separation for a nurse. Younger or newer nurses may feel personally inadequate, starting a negative trend early in their careers. This culture of survival leads nurses to feel like they are often under tension, and those who struggle with mental health challenges feel like failures. The silencing only serves to fuel the stigma and shame, and the cycle continues.

Organizational trauma

The nursing culture is influenced by organizational trauma; the collective trauma of the group impacts the nursing profession collectively and individually. Organizations can suffer from trauma in the same way individuals do because of unhealed acute traumatic experiences and gradual, cumulative traumatization.9,10 Traumatization undermines an organization’s ability to respond to external and internal issues when trauma overpowers cultural structure and processes.11,12 Organizations are condemned to repeat their mistakes unless the impacts of organizational trauma and the resultant dynamics are appropriately addressed. But in the meantime, the nurse is negatively impacted as a member of these organizations.

Nurses are members of many organizational groups, including health authorities, unions, professional colleges, and associations. Nurses are pulled in many directions to balance employee roles, licensing regulatory body professional demands, and union member obligations. Unfortunately, these roles can conflict, leaving the nurse confused, overwhelmed, and scared.

Nurses fear being reported and disciplined by their regulatory body and losing their license if they share information about their mental health challenges. They worry about embarrassment from their employer and coworkers if they identify as proactive or responsive to their mental health issues. While the nursing unions highlight the areas of challenges in the workplace, the advocacy efforts emphasize traumatization and victimization to seek those improvements while minimizing resiliency. The early indoctrination of nursing norms from nursing training programs initiates ideations of submission, other-focus, and emphasize excellence and proficiency rather than growth.

Reframing clinician distress: Moral injury not burnout

Nurses become health care providers because they want to make a difference in someone’s life and swear an oath to that fact. But now more than ever, nurses are being asked to consider the demands of other stakeholders before the needs of the patients. Every time nurses are forced to make a decision that contravenes patient best interests, they feel a sting of moral injustice. Over time, these repetitive insults and moral traumas amass into moral injury.13

The correct description is critically important as it reframes the problem and potential solutions. Burnout has been used predominantly to describe health care providers’ distress. Burnout implies that the problem lies within the individual, who lacks the resources or resilience to cope with the workplace. This is frustrating for nurses as they are offered resilience training while the system remains unchanged. Nurses need to be acknowledged that the reactions they are experiencing are not the result of some personal failing or weakness but rather the double binds they face in the workplace as they try to prioritize healing over profit or imposed organizational rules.

Reframing self-care

Nurses are familiar with the concept of self-care and will encourage their peers to embrace this practice. The reality is that there is often a collective eye-rolling at the idea of self-care with the accompanying joke of associating the method with lavish trips and spa weekends that never occur. Alternatively, nurses may be numbing their emotions with substances and other forms of escapism. Nurses may feel they are “unloading” with their peers by using dark humour and “bitching” about the organizational failings and union deficiencies. They may feel they can’t unpack their thoughts and feelings with loved ones for fear of burdening them or being perceived as weak and uncaring.

Reframing self-care as a professional and personal responsibility highlights self-obligation rather than a frivolous indulgence for personal means. The term “self-full” can be an alternative language to highlight the benefits of feeling physically and mentally fit and a resiliency lens. Caring-for-self can present as a means of professionalism while capturing the essence of critical self-nurturing.

It is also possible that the concept of compassion fatigue has to be debunked. Nurses believe the idea that compassion has hazards is a sign that the very “tool” they need to offer exceptional care to their patients is also the one that is causing them to suffer. Gabor Maté shares that the real issue with the notion of compassion fatigue is the lack of compassion for ourselves.14 Nurses should be aware that current research suggests that compassion has benefits for the brain and heart, including the ability to reduce aging, improve relationships, and promote kindness.15,16, 17,18 Many experts believe compassion fatigue is actually a misnomer as if we correctly engage in genuine compassion.19 Emotional empathy can also shift into compassion empathy to minimize its fatiguing outcomes.20

Thank you to everyone who supports nursing during the pandemic and after it has passed. I am in the unique position of being an RN, RPN, and RCC. I continue to work in the hospital, and my private practice work focuses on health professionals and first responders.

Nurses are a feisty bunch. I have learned so much by being a nurse, having nurse colleagues, and being a nurse therapist. I am a proud member of the nursing profession and see firsthand what is getting in the way of nurses seeking this much-needed mental health care for both ourselves and our colleagues. The barriers are worthy of exploration to enhance understanding, shatter misinformation and faulty assumptions, and build a more robust and healthier nursing community.

 

Considerations for counsellors working with nurses:

  • Become occupational aware of the nursing culture.
  • Embrace a trauma-Informed and strength-based approach.
  • Normalize using mental health supports.
  • Incorporate a biopsychosocial lens for risk and protective factors.
  • Explore cultural barriers to enhance understanding and shatter misinformation and faulty assumptions.
  • Normalize trauma reactions to extremely abnormal circumstances.
  • Communicate that post-traumatic injury can lead to post-traumatic growth.
  • Reassure nurses that they are not alone in their struggles and not broken, weak, and damaged beyond repair.
  • Provide psychoeducation with neuroscience and brain-based benefits of modalities so nurses can link it to the already familiar emphasis of biological emphasis training.
  • Confidentiality is critical and a familiar concept in healthcare, but nurses need to be reassured that the therapist prioritizes privacy and discretion.
  • Assist with compassion training, so nurses can continue to feel empathy for others suffering while gaining the ability to feel positive emotions without feeling distressed.
  • Assist nurses to identify and explore the double binds they face at work (moral injuries).
  • Help the nurse understand how compassion and empathy differ neurobiologically.

 

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Amanda Burns is an RCC in private practice and also an RN and RPN in a major hospital. Amanda has a particular interest in supporting health professionals and first responders (selfmatters.ca).

 

 

References

1 Woo T, Ho R, Tang A, Tam W. Global prevalence of burnout symptoms among nurses: A systematic review and meta-analysis. J Psychiatr Res. 2020 Apr; 123:9-20. doi: 10.1016/j.jpsychires.2019.12.015. Epub 2020 Jan 22. PMID: 32007680.

2 Yoni K Ashar, Jessica R Andrews-Hanna, Joan Halifax, Sona Dimidjian, Tor D Wager, Effects of compassion training on brain responses to suffering others, Social Cognitive and Affective Neuroscience, Volume 16, Issue 10, October 2021, Pages 1036–1047

3 Khanal P, Devkota N, Dahal M, Paudel K, Joshi D. Mental health impacts among health workers during COVID-19 in a low resource setting: a cross-sectional survey from Nepal. Globalization Health. (2020) 16:89. doi: 10.1186/s12992-020-00621-z

4 Muller AE, Hafstad EV, Himmels J, Smedslund G, Flottorp S, Stensland SØ, et al. The mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: a rapid systematic review. Psychiatry Res. (2020) 293:113441. doi: 10.1016/j.psychres.2020.113441

5 Woo, T, et al (2020).

6 Yoni K. Ashar, et al, (2021).

7 UBC & BCNU. Psychological Health and Safety in the Workplace. https://www.bcnu.org/a-safe-workplace/mental-health-strategy/psychological-health-and-safety-in-the-workplace

8 CFNU, https://nursesunions.ca/wp-content/uploads/2022/02/Viewpoints_Survey_Results_2022_January_EN_FINAL.pdf?fbclid=IwAR2WMUt4VLJEu6nZSG2qg3Q9_0Sb0ArvlvKL0ndDFF1ysmadnhQF89L6L-U

9 Hormann S., Vivian P. (2017) Intervening in Organizational Trauma: A Tale of Three Organizations. In: Tirmizi S., Vogelsang J. (eds) Leading and Managing in the Social Sector. Management for Professionals. Springer, Cham. https://doi.org/10.1007/978-3-319-47045-0_11

10 Vizheh M, Qorbani M, Arzaghi SM, Muhidin S, Javanmard Z, Esmaeili M. The mental health of healthcare workers in the COVID19 pandemic: a systematic review. J Di

11 Hormann S., Vivian P. (2017).

12 Vizheh M., et al.

13 Dean, W., Talbot, S., & Dean, A. (2019). Reframing Clinician Distress: Moral Injury Not Burnout. Federal practitioner: for the health care professionals of the VA, DoD, and PHS36(9), 400–402.

14 Maté, Gabor. There is no compassion fatigue. https://www.youtube.com/watch?v=dI5hq5ZQ-W0

15 Dowling T. (2018). Compassion does not fatigue! The Canadian veterinary journal = La revue veterinaire canadienne59(7), 749–750.

16 Gerard, N. (2017), “Rethinking compassion fatigue,” Journal of Health Organization and Management, Vol. 31 No. 3, pp. 363-368. https://doi.org/10.1108/JHOM-02-2017-0037

17 Kirby James N., Doty James R., Petrocchi Nicola, Gilbert Paul, The Current and Future Role of Heart Rate Variability for Assessing and Training Compassion, Frontiers in Public Health, 5, 2017 https://www.frontiersin.org/article/10.3389/fpubh.2017.00040

18 Vizheh M, et al.

19 DeDecker J. “Compassion Fatigue” is a Misnomer: How Compassion Can Increase Quality of Life. Creat Nurs. 2020 Nov 1;26(4):246-252. doi: 10.1891/CRNR-D-19-00086. PMID: 33273129.

20 Bernhardt, Boris C., and Tania Singer, “The Neural Basis of Empathy,” Annual Review of Neuroscience (July 2012), 35 (1), 1-23.