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The Silent Mental Health Crisis: Nursing Throughout COVID-19

Katherine Carlton

Youngstown State University

NURS 6900: Healthcare Issues and Trends

Dr. O’Dell

September 28, 2022

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Abstract

The Coronavirus 2019 disease has brought to light the importance of the nursing profession. It

has also proven to show that there are flaws in the healthcare system. Historically, nursing has

always been an emotionally taxing job with the mental health of nurses often being neglected.

Currently, there is a nursing shortage with low retention rates. This has resulted in novice nurses

taking on the brunt of a pandemic at the start of their careers. With fewer staff members available

nurses are required to increase their workload, directly putting patients in danger. These flaws

are greatly affecting the mental health of nurses. Failure to recognize and work toward resolving

these issues will be detrimental to the entire healthcare system. By providing federally mandated

nurse to patient ratios the government can provide a safer environment for nurses to work in.

Hospitals should be promoting and providing mental health resources to their nurses so there can

be improvement in nursing staff retention.

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The Silent Mental Health Crisis: Nursing Throughout COVID-19

The world relies on nurses in a time of crisis. A nurse will be there for a patient on their

best days and their worst. A nurse will be there when a patient is dying to console the patient and

family. A nurse will be there when a patient is confused and potentially violent toward the nurse.

A nurse will be there when a patient has experienced domestic violence to help their patient’s

body and soul heal. One can quickly see that the mental and emotional workload on a nurse at

baseline is cumbersome. As the coronavirus disease 2019 (COVID-19) pandemic shook the

world, nurses once again responded. The consequence on responding nurses has not gone

unnoticed. Nurses who cared for COVID-19 patients have been found to exhibit psychological

distress, depression, anxiety, and posttraumatic stress disorder (Ayotte, Schierberl Scherr,

Kellogg, 2022). The mental health crisis currently affecting nurses cannot be ignored. COVID-

19 has put a spotlight on the flaws related to the healthcare system and the lack of support

available for nurses. The healthcare system was not prepared for the strain that would push

nurses past patient safety, therefore impacting their own wellbeing. Nurses will need help

achieving resilience in order to continue to care for others. This is critical in order to support the

mental health of current nurses and those to come.

Historically, nursing has never been an emotionally easy job. Dating back to 1856 the

mother of nursing herself, Florence Nightingale, came back from aiding the British soldiers in

the Crimean War angry over the lack of basic healthcare causing unnecessary death (Andrews,

2022). She was angry because she cared, and she knew that there was room for improvement.

This anger can be felt sweeping inpatient care units today. An anger resulted from wanting to

give the best patient care and to improve patient safety, but working with limited resources.

Another issue noted historically is that the mental health of caregivers was not viewed as
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important. Moving to World Warr II, prisoner of war United States Navy Nurse Dorothy Still

was liberated in 1945. Returning home, she was struggling with posttraumatic stress disorder.

She was told by her physician “those men were heroes, but Nurse Still was a woman and a nurse,

and therefore, did not suffer” (Le Beau Lucchesi, 2021). Mental health awareness has grown

drastically since 1945, but potentially there are echoing thoughts of this mindset.

Many of today’s current issues with nursing can place strain on a nurse’s mental health.

In order for there to be improvement in the system, one must fully understand the depth of the

emotional toll being put on today’s nurses. At large an issue in the nursing world is the current

nursing shortage. The nursing shortage is multifaceted some causes being an aging workforce,

increasing older adult population, increased acuity of patients, workplace dissatisfaction, limited

educators, and limited pay scales to name a few (Huston, 2023, p. 87). As the baby boomer

generation ages, this trend is expected to continue. There will be more patients to manage who

are living longer with multiple chronic issues, making their care complicated. Another aspect of

this is that the nurses from the baby boomer generation will be retiring. This will leave a lasting

impact as nursing units will be losing many of their experienced coworkers. COVID-19 has

understandably led to older nurses retiring early or relocating as they themselves would be at risk

for more severe complications then their younger coworkers (Huston, 2023, p.83). As a result,

novice nurses had to work through the complications of COVID-19 without as many seasoned

nurses to guide them.

Almost every nurse will admit their first year of being a nurse is scary and overwhelming.

The novice nurses of today came into their careers facing a pandemic, amplifying the

overwhelming experience of starting in this profession. New nurses are still learning how to

critically think and when to trust their instincts when something is wrong. They are also learning
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how to have difficult conversations with patients when they receive terrible news and how to be

assertive for a patient’s benefit. These novice nurses are adjusting to their careers in a time of

being short staffed with increased nurse to patient ratios. Further increasing the stress of their

work and increasing the danger to patients. “An increase in a nurses’ workload by one patient

increased the likelihood of an inpatient dying within 30 days of admission by 7%” (Aiken et al.,

2014). Many studies have been done reporting similar statistics. Factually, increased patient to

nurse ratios decreases the level of care and safety to a patient even if a nurse is experienced.

Nurses are being set up to feel disappointed in the limited care they are physically cable of

providing. Increased workloads have led to increased burnout and turnover intention (Nal et al.,

2022). The current state of nursing is not sustainable or realistic. One can observe this as the

national staff registered nurse turnover average in 2021 was a concerning 27.1%, up 8.4% from

2020 (Nursing Solutions Inc, 2022). With over a quarter percent of nurses leaving their staff

position, there is clearly a systemic issue. Nurses are feeling the burden of the care they are

giving and feeling like there is no relief coming. This calls for change in the legal system and the

hospital systems at large.

As mentioned, increased patient to nurse workloads greatly increases the stress amongst

nurses. It also can lead to an unnecessary higher patient mortality rate, leaving nurses to process

feelings of grief and guilt. One suggestion to aid this situation is to implement federally

mandated nurse to patient ratios. The state of California currently has state regulations in place

that mandate nurse to patient ratios. California has seen success from implementing such

protocol. Californian hospitals have seen a decrease in staff turnover, decrease in hospital

acquired infections, and increase in patient satisfaction (Anders, 2021). Although it may seem to

hospital systems that it would be more expensive to hire more nurses there must be consideration
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of the consequences if they do not address unsafe ratios. Thirty-five billion seven hundred

million to forty-five billion dollars a year are spent by hospitals due to hospital acquired

infections on inpatient units (Schmidt et al., 2019). Having more nurses on a unit will allow for

safer care. If a nurse has multiple patients assigned to them and one patient takes a drastic

medical turn for the worst, they must use their best judgement to prioritize their care. Meaning

they may not be able to do things such as turn their patient every two hours, which would reduce

the risk of a pressure related injury. Or the nurse may not be able to change a central line

dressing reducing the risk of a central line-associated bloodstream infection. Or the nurse may

not have time to collect a stool sample on a patient exhibiting symptoms of clostridioides

difficile therefore increasing the risk of infection being spread throughout the unit. These are all

things that will end up costing the hospital money. These are all things that will have a negative

impact on patient safety. These things result in the nurse going home feeling guilty they did not

have time to give the care their patients deserved. If there are not proper ratios, more than likely

the nurse will not be able to ask a coworker on the same shift to be able to help as they too will

have a heavy patient load.

Another financial reason for hospitals to encourage safer ratios is that it will increase the

amount of time a nurse is able to be available to their patients and spend time with them. Time

allows the nurse to create a trusting relationship, leading to better compliance with treatment

plans. These factors increase patient satisfaction which results in the hospital receiving greater

Medicare reimbursement (Liu et al., 2021). Patient satisfaction will also greatly increase nurse

satisfaction. There is a great deal of power in a nurse leaving their shift knowing they have done

everything possible to care for their patients. Most nurses choose the profession because they

enjoy helping people, and they receive a sense of accomplishment by doing so. One of the
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biggest ways to help improve the mental health of nurses is to provide an environment where

they can safely do their job.

With safe nurse to patient ratios there is more likely to be staff retention. Retention is

something that explicitly needs to be addressed within hospital systems in order to break the

current staffing cycle. As discussed, the novice nurses have started their career in an

unwelcoming time. Nursing schools do their best to introduce nurses to different fields of the

profession, however it is unrealistic for them to cover all scopes of practice. It is common for

nurses to start their career in a specialty that their school only briefly covered, which can be very

intimidating. One way to help retain new nurses is by providing them nurse educators who can

guide them through the start of their career (Jean & Briana, 2019). Although nurse educators

have become more common in teaching hospitals there still is not one for every unit or even at

every hospital. By having nurse educators on all units there would be a wide spread reduction of

stress. This would allow for new nurses to have a point of reference when they need to receive

education and help implement evidence-based practice amongst staff since medicine is an

evolving practice. With a reduction of stress from nursing school to real world nursing there can

be better retention, which will in terms lead to unit wide stress reduction. It is important to

advocate for hospitals to support their nurses with nurse educators and to help encourage their

current staff to become educators. One way hospitals can do this is by helping their current staff

pay for advanced degree programs.

There are so many resources hospitals could provide for their nurses to help them feel

supported throughout hard times. Another idea may be to have a mental health counselor

assigned to several units so nurses have a resource available to them. Potentially after the death

of a patient this counselor could check in with them and the unlicensed personnel on the unit to
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see if anyone needs grieving resources. They could also do a yearly or bi-yearly check in with

the nurses of their assigned units. Frequently hospitals have resources available, but they never

promote them to their nursing staff. A nurse does not often want to admit they need help, it may

be better if they had face to face time to encourage them utilizing the mental health resources

available. Another recommendation would be that when a new employee is hired to teach them

how to utilize mental health resources available. Potentially, new hires could be handed a

pamphlet with instructions with their employee handouts. Another option would be for hospitals

to provide support groups for nurses with a counselor there to mediate the conversation. This

would allow nurses to recognize that it is not surprising nurses are struggling given how difficult

their job is, it would remind them they are not alone in the struggle. As many nurses know,

prevention is the key to a better well-being. It would be helpful for nursing schools or hiring

hospitals to teach coping mechanisms and to prepare people for what it truly means to be a nurse.

It also may be helpful to have some kind of mental health counselor round units and provide

coping mechanisms as a refresher at set intervals during huddles. Nurses, just as any humans,

deserve to feel cared about. By promoting mental health resources more frequently and in a more

personable way there is a chance that stigmas, such as Nurse Still experienced, could be hushed.

The mental health crisis amongst nurses is not a linear issue. As addressed, there are

many issues that are currently impacting the mental health of nurses’ negatively. It will take

involvement of stakeholder such as politicians and hospital systems along with individual nurses

for these changes to be made. It will also take time for many of these issues to be resolved,

however some improvements could be made quiet quickly. The first step in this process is for

active recognition that nurses are real people with emotionally intense jobs. Hospitals have the

power to listen to their nurses and to loudly provide resources. Nurses have the power to speak
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up and rally together to create support groups. Yes, the pandemic has been extremely hard on

the nursing community, but the community can use this as fuel to improve.
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References:

Aiken, L. H., Sloane, D. M., Bruyneel, L., Van den Heede, K., Griffiths, P., Busse, R.,

Diomidous, M., Kinnunen, J., Kózka, M., Lesaffre, E., McHugh, M. D., Moreno-Casbas,

M. T., Rafferty, A. M., Schwendimann, R., Scott, P. A., Tishelman, C., van Achterberg,

T., Sermeus, W., & RN4CAST consortium (2014). Nurse staffing and education and

hospital mortality in nine European countries: a retrospective observational

study. Lancet, 383(9931), 1824–1830. https://doi.org/10.1016/S0140-6736(13)62631-8

Anders, R.L. (2021). Patient safety time for federally mandated registered nurse to patient ratios.

Nursing Forum, 56(4), 1038-1043. https://doi.org/10.1111/nuf.12625

Andrews, R. J. (2022). Florence Nightingale’s Data Revolution. Scientific American, 327(2), 78-

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Ayotte, B. J., Schierberl Scherr, A. E., & Kellogg, M. B. (2022). PTSD Symptoms and

Functional Impairment Among Nurses Treating COVID-19 Patients. SAGE Open

Nursing, 8, 1-8. https:doi.org/10.1177/23779608221074651

Huston, C. J. (2023). Professional Issues in Nursing: Challenges and Opportunities (6th ed.).

Wolters Kluwer.

Jean, S. C., & Briana, L. W. (2019). The Clinical Nurse Educator Role: A Snapshot in

Time. The

Journal of Continuing Education in Nursing, 50(5), 228-232.

https://doi.org/10.3928/00220124-20190416-09

Liu, L., Gauri, D. K., & Jindal, R. P. (2021). The Role of Patient Satisfaction in Hospitals’

Medicare Reimbursements. Journal of Public Policy & Marketing, 40(4), 558-570.

https://doi.org/10.1177/0743915620984723
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Le Beau Lucchesi, E. (2021) Frontline Fatigue. Discover, 42(6). 24-28.

Nal, M., Sevim, E., Bektas, G., Dirican, U., & Sahin, E. (2022) Medicating Role of Burnout in

the Effect of Nurses’ Workload on Turnover Intention during COVID-19 Pandemic.

Revista de Cercetare Si Interventile Sociala, 77, 37-50. https://doi.org/10.33788/rcis.77.3

Nursing Solutions Inc. (2022). NSI National Health Care Retention & RN Staffing Report.

https://www.nsinursingsolutions.com/Documents/Library/

NSI_National_Health_Care_Retention_report.pdf

Schmidt, R. N., Hunt, S., & Stapp, M. (2019). The Budgetary Impacts of Hospital-Acquired

Infections. Journal of Business & Behavioral Sciences, 31(1), 25-35.

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