The COVID-19 pandemic made an immediate impact on the nursing profession. Some nurses suffered devastating health consequences. Many nurses dealt with excessive on-the-job stress, well-founded fears of becoming infected and grief over seeing patients succumb to COVID-19 while isolated from their families.
Workplaces became risky and fraught with shortages of adequate personal protective equipment like masks. Hospital jobs abruptly changed, and nurses found themselves caring for patients outside their realms of expertise, often with minimal training.
Even as the pandemic begins to wane unevenly across the U.S., long-term fallout on the nursing profession is likely. Burnout may linger even after the situation returns to “normal.” For some nurses, conditions under which they worked may be the last straw that drives them away from bedside nursing. Yet, nursing schools are drawing more applicants.
Other positive glimmers — such as increased professional autonomy, leadership opportunities and career growth potential — have resulted from pandemic-based health care needs.
Below, nurses share their insights on the negative, positive and as-yet-unknown effects of COVID-19 on their professional peers.
New York City was at the epicenter of the pandemic when COVID-19 first hit the U.S. There, nurses caring for patients during this first wave experienced depression, anxiety and illness, according to a study published April 5, 2021, in the journal Nursing Outlook.
About one-quarter of nurses reported anxiety and 17% reported depression among nearly 2,500 nurses surveyed working in four hospitals in the NYU Langone Health system, according to researchers at NYU Rory Meyers College of Nursing. Anxiety and depression increased the more that individual nurses cared for patients with COVID-19. Younger nurses and nurses working in intensive care units were more likely to experience these mental health issues.
In addition, 13% of nurses reported having become infected with COVID-19. Nearly half of nurses had to self-isolate and nearly 20% lived in temporary housing that the hospital provided. Professional development and training, particularly in proper use of PPE, was one of the top helpful factors for caring for patients with COVID-19, according to study authors. Having a sense of mastery at work was the most protective against depression and anxiety.
Unfortunately, in many hospitals throughout the country, nurses often felt under-educated and under-trained to take care of COVID-19 patients. In numerous cases, the issue wasn’t just knowing how to safely put on and remove PPE — it was not having enough PPE to safely take care of patients.
To reduce the spread of COVID-19, hospitals severely limited nonessential or nonemergency treatment, shutting down clinics and many services. As hospitals rapidly created new ICUs and shifted specialty units to focus on patients with COVID-19, many nurses were abruptly thrust into unfamiliar patient care settings and roles — like pediatric nurses suddenly required to take care of adult ICU patients. And, of course, nobody was experienced in giving care to patients infected with the novel coronavirus.
“Just-in-time training” is used in fields like disaster medicine to rapidly get health care providers up to speed, in the moment and at their location, in basic principles, skills, procedures and safety measures to take care of patients in a crisis.
But instead of “just in time,” it was more a case of “too little, too late” when it came to COVID-19 preparation by health and hospital administrations, suggests Gerard Brogan, a registered nurse and director of nursing practice for the California Nurses Association/National Nurses United.
“In the American health care system there’s just-in-time staffing, just-in-time procurement of supplies,” Brogan says. “Well, what did that lead to? A paucity of personal protective equipment. That’s been one of the biggest stories of the year.”
The U.S. had plenty of advance warning about the pandemic, Brogan says. “Within the medical community, it’s been known for decades there will be a pandemic,” he says. “It’s never been a question of ‘if.’ It was always a question of ‘when.’ And, certainly those who make these decisions aren’t paying the price, of course. It’s the frontline workers who are doing that.”
Ernest Grant, president of the American Nurses Association, says PPE shortages represent the most immediate impact on the nursing profession. “It’s hard to believe, but it’s been over a year and nurses are still reporting that they’re having difficulty getting their PPE, or personal protective equipment, such as masks,” he says.
The necessity to reuse and resterilize face masks intended for disposal after a single use is a particular pandemic sore spot. Ongoing controversy as to whether it’s truly safe to repeatedly wear these masks — especially when working with known or potentially infected patients — has sown fear, anger and mistrust among some frontline health care providers.
Brogan recalls one of the many discussions he’s had with nurses over the issue: “This is absurd — a year ago, if I had reused an N95 mask, I literally would have been disciplined,” the nurse told him. “Now, I’m being disciplined if I don’t reuse an N95.”
To address the situation, nursing organizations have advocated for improved distribution chains and use of the Defense Production Act. The DPA is law giving the president emergency authorization to control domestic industries. Most recently, it has been used to maximize production of N95 respirator masks and speed up vaccine production in the U.S. to alleviate shortages.
Nurses who died of COVID-19 represent an irreversible loss from the pandemic. Whatever happens moving forward, their lives can never be replaced. Of the more than 3,600 health care workers who lost their lives to COVID-19 in the first year of the pandemic, nurses were the occupation most affected, accounting for 32% of those deaths, according to the Lost on the Frontline investigation, a joint effort of Kaiser Health News and The Guardian.
In October 2020, the Centers for Disease Control and Prevention broke down COVID-19-associated hospitalizations among health care personnel by specific occupation. Nursing-related occupations represented the largest proportion (36%) of health care personnel hospitalized with COVID-19, according to the CDC.
A new study focused on persistent effects. This research found that long COVID syndrome affected about 10% of health care workers, even some with initially mild symptoms. The study of previously healthy Swedish health care workers was published April 7 in JAMA. Symptoms included loss of taste and smell, fatigue and breathing problems which negatively affected their work, personal lives or both, months after being infected. Similar studies of U.S. health care workers are ongoing.
Ripe for Burnout
Nursing burnout and stress was already a problem before the pandemic. “Increasingly, nurses are having more and more tasks added to their to-do lists daily in hospitals,” says Jacqueline Nikpour, a graduating PhD candidate at Duke University School of Nursing and an incoming postdoctoral fellow at the University of Pennsylvania School of Nursing’s Center for Health Outcomes and Policy Research. “Then you just add the massive uncertainty — it goes beyond workload because you’re working in survival mode with COVID for months on end.” With cases decreasing, she says, “what you’re starting to see is more of a prolonged burnout.”
Early public support and gratitude expressed for nurses and other frontline health care workers may have eroded as the pandemic dragged on, Nikpour suggests. “Now, with the political debates about masks and vaccination, and people who are going out in large groups, nurses are saying, ‘COVID cases are still happening — I’m still seeing these patients every day,'” she says. “And there’s a lot of backlash from the public. Rather than it being, ‘Oh, you’re the health care heroes’ like it was a year ago, now it’s more, ‘This is what you signed up for.'”
In a nationwide survey of more than 9,200 registered nurses released in March 2021, conducted by National Nurses United, participants reported these mental health and emotional issues a year into the pandemic:
— Of hospital RNs, 43% have more trouble sleeping than before the pandemic.
— More than 61% feel more stressed.
— Anxiety has increased for 57% of these nurses.
— About half feel more sad or depressed.
— Nearly 60% say they fear they’ll contract COVID-19 and infect a family member.
Personal as well as professional lives have been strained, points out Robyn Begley, CEO of the American Organization for Nursing Leadership and chief nursing officer/senior vice president of workforce for the American Hospital Association.
“Throughout the pandemic, nurses have worked long hours while trying to simultaneously manage their personal lives at home, such as arranging child or elder care,” Begley says. “Many nurses shared concerns over bringing the virus home to their families.”
Job-related stress could have long-term as well as immediate effects, Begley adds. “We are concerned about the mental health and well-being of the nursing workforce,” she says. “Nurses have worked tirelessly caring for critically ill dying patients without having the time to grieve or practice self-care. We are particularly concerned about the number of nurses who may leave their current roles providing direct patient care or exit the nursing profession entirely.”
In the pandemic’s wake, the preexisting nationwide nursing shortage could get worse. Nikpour currently works on a research team at the Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill, as part of a partnership with the North Carolina Board of Nursing.
The team has created a supply-and-demand project of the state’s nursing workforce over the next 10 to 15 years. “We’re going to be releasing a model that demonstrates a shortage of up to and above 10,000 nurses across the state by 2033,” Nikpour says. “That’s pretty substantial. Now, you hope that things will be done to offset that by then.”
Nationwide, the shortage of registered nurses is expected to intensify with baby boomers aging and health care needs increasing, according to the AACN website.
The pandemic has produced some positives for the nursing profession. “There is greater recognition of the critical role that nurses play in fighting the pandemic — caring for patients while protecting and promoting the health of communities,” Begley says. “Nurses have taken on leadership roles in this work, while utilizing innovative strategies to promote health such as telehealth technology, which allows patients to receive care from the safety and convenience of their home.”
Rather than pushing students away from nursing careers, a recent survey showed an increase in applications to nursing schools, Begley notes.
Student enrollment in bachelor’s and graduate-level nursing programs all increased in 2020, according to data released on April 1 by the American Association of Colleges of Nursing. For bachelor’s programs to prepare new registered nurses, enrollment increased by nearly 6%.
However, there’s a downside: With persistent shortages of nursing faculty to teach students and of clinical sites for training, thousands of qualified applicants are being turned away from nursing programs at four-year colleges and universities, the AACN survey found. For example, more than 65,000 applicants were denied enrollment into entry-level nursing programs last year.
Yet, nurses are needed more than ever. The pandemic could represent an opportunity for nurses to move to career paths beyond inpatient hospital units, and expand their presence in outpatient care and more broadly in public health, Nikpour says.
Nurses are taking major roles in efforts to reduce disparities in health care access, delivery and outcomes that are related to social determinants of health. For example, Nikpour says, North Carolina has been rolling out a state referral program called NCCARE 360. The program aims to address root causes of health problems — such as meeting the unmet social needs of a mother living in older housing with lead paint, affecting her child who has asthma. Rather than accepting the status quo of the child requiring periodic emergency visits for asthma attacks, the program would tackle the toxic environment in which the family lives, refer the child to preventive care and improve his or her health.
“Nurses are really going to need to be a part of these programs,” Nikpour says. “Now, with increased focus on health equity, we’re starting to see some of those opportunities emerge as nurses are looking for employment in other settings.”
In light of the pandemic, advanced practice nurses realized an increase in their autonomy, with more ability to practice independently to meet the health care crisis.
“When the pandemic occurred, there was an emergency situation declared, which allowed more of what we call full-practice authority for the advanced practice nurses — nurse practitioners and clinical nurse specialists — to be able to do telehealth and telemedicine across state lines without fear of retribution,” Grant says.
Some states which had required nurse practitioners to practice in collaborative agreements with supervising physicians temporarily suspended those requirements, notes an August 2020 article in the American Journal of Nursing. In addition, the Centers for Medicare and Medicaid Services granted nurse practitioners approval to provide certain medical services in long-term care settings that previously were only provided by physicians, according to the AJN piece.
It will be difficult to unring the bell after the pandemic has passed, Grant suggests. “We’re not going to go back when this is over,” he says. “Because we’ve proven that we can do this stuff. And this is an emergency situation — imagine what we could do in a quote-unquote normal situation to really be able to advocate for your patients.”
People with chronic illnesses such as diabetes, arthritis and heart disease will continue with needs that must be met, Grant notes. “We’ve been able to achieve that through telehealth, telemedicine and other initiatives that have the public or the consumer feeling much more appreciative of the actions that nurses have been doing,” he says. “So I feel pretty certain that once this pandemic is declared over and nurses begin to want to declare more full-practice authority, the public will be behind us. Because we have proven that we can do it. So we should be able to move forward.”
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