Mental health strain appears to be a key contributor to nurses leaving or considering leaving the profession altogether—a crisis made worse by a pandemic that has disproportionately affected frontline health workers.
Accelerating Nursing, Transforming Healthcare, a study conducted by Johnson & Johnson earlier this year in partnership with the American Nurses Association (ANA) and American Organization for Nursing Leadership (AONL), examines the many professional, individual and workforce issues driving this crisis and maps a progressive path forward for the nursing profession. In addition to quantitative research (n=4000), 33 renowned nurse leaders and nurse advocates across the country were interviewed to dive deeper into the key areas highlighted in the study. The degree to which nurses have struggled personally while providing care for the sickest patients stood out as a common theme echoed across the interviews —along with critical it is for health systems to address nurses’ mental health and well-being, both for the individual nurse and the long-term sustainability of the profession.
“We have to pay very careful attention to the fact that nurses worked an amazing number of hours this past year to meet the needs of the organization,” said ANA Enterprise CEO, Loressa Cole, DNP, MBA, RN, FACHE, NEA-BC, FAAN, “and at some point, we have to recognize that if we don’t meet the psychological and emotional needs of the nurse, then that nurse is not going to be there.”
Fortunately, health systems are heeding the call and applying innovative strategies to support nurses’ mental health, from trauma-informed group sessions to mindfulness-based practices to song-writing. While much more still needs to be done for nurses and all frontline health workers, the increased attention to mental health is promising. Below are a few examples from our recent research that illustrate the participants’ insights, including their recommendations for how healthcare systems can more fully address mental health moving forward.
Recognize the trauma from COVID-19 and work to reduce the stigma surrounding mental health
Dr. Cole, who was previously chief nursing officer in a hospital that treated victims of a mass shooting, points out that COVID-19 is a traumatic stress fundamentally different from anything the nursing profession has experienced before. Despite periodic lulls, the trauma from the loss of lives has continued daily for nearly two years. Dr. Cole underlined that hospitals must first acknowledge this trauma, and then make sure nurses know what tools and support and resources are available to them. “We need to provide the time and the settings in which they can talk about what they're experiencing and feeling, and also give them the opportunity for rest when needed,” she said. “Many nurses are simply not taking the time right now to heal and recover, and they're not being encouraged to do so.”
The other critical part of supporting nurses in seeking mental health care is reducing the stigma associated with it, which is still a barrier, even among healthcare professionals. Cynda Rushton, PhD, RN, FAAN, the Anne and George L. Bunting Professor of Clinical Ethics in the Berman Institute of Bioethics and the School of Nursing at Johns Hopkins University, said she was surprised when she saw the data from a recent American Nurses Foundation survey, showing that only 24% of surveyed nurses accessed mental health services; of those who didn’t, 50% said didn’t feel they needed services and 36% said they thought they should manage it themselves.
“The current culture in nursing frames this as, ‘there's something wrong with you, that you are weak, that you are lacking,’ which is a huge issue,” said Dr. Rushton. “The message has to be, ‘you are resilient, we want to strengthen and support you, so that you can do what you want to do.’ Seeking help must be reframed as act of integrity, not of deficiency.”
Employ a range of resources to support nurses in processing their experiences
Organizational programs can play key roles in supporting nurses’ mental health—and some hospitals are beginning to offer a wider variety of them. David R. Marshall, JD, DNP, RN, FAAN, senior vice president and chief nursing executive at Cedars-Sinai in California, discussed several of its initiatives, including trauma-informed group sessions, known as “collective exhale,” in which 10 people meet in breakout rooms with spiritual care staff to guide conversation. “We started out with the question, ‘what’s your authentic story about COVID?’ Participants were able to share deeply, including the patients they lost, the fear they had of bringing COVID home to their families, and even issues like feeling numb to all the loss over so many months,” said Dr. Marshall.
Other initiatives included a “letting go” activity, where nurses wrote on dissolving paper something they wanted to let go of and placed it in a bowl of water to watch it dissolve. Nurses were also given the opportunity to work with songwriters, to create songs about their pandemic experiences. Dr. Marshall said all these activities were incredibly helpful to nurses processing their experiences.
Nurses may not be experiencing only burnout, but also various types of moral suffering, added Dr. Rushton. She discussed a Hopkins initiative, Mindful Ethical Practice and Resilience Academy, which supports nurses experiencing both burnout and moral suffering. The program offers six four-hour workshops over a 12-week period and focuses on five pillars—moral resilience, moral agency, moral sensitivity, moral discernment and reasoning, and moral action. The program has had significant results, including reductions in depression and anger, increase in resilience, and even a decrease in intent to leave one’s job. “It’s really about helping [nurses] remember why they’re doing their work,” said Dr. Rushton, “giving them specific skills on how to strengthen their connection to their values and integrity, and the communication skills, so they can speak up in ways that can be heard.”
Change structurally to support nurses’ well-being
Providing nurses with the tools and time to heal is clearly critical—but it shouldn’t all be on the nurse. Sharon Pappas, PhD, RN, NEA-BC, FAAN, Chief Nurse Executive at Emory Healthcare, noted that she’s actually been frustrated by the many offers she gets to teach resilience to nurses at Emory Healthcare. “Classical resilience training for nurses is important but not enough,” she said. “It’s not just looking at individual resilience, but also looking at work environments. Organizations need to change, too, making sure the work system is contributing to well-being.”
Deeper foundational shifts may be necessary—like implementing relational leadership, with a focus on building community in the context of a unit culture, Dr. Pappas added. This kind of connected leadership is especially important to counter what she calls the “transactional” attitude toward nurses, which may have been necessary to staff patient care units during the pandemic, but may have also had an unwanted side effect of making nurses feel interchangeable and disconnected from their home teams. “The unit leaders who engage in relational leadership have the most connected teams,” said Dr. Pappas, “who also remain connected to purpose. How we lead and make decisions is critical to well-being.”
Acknowledge that trauma existed before COVID in other forms, particularly for nurses of color
Finally, it’s important to keep in mind that the mental health strain many nurses are feeling may be layered upon existing trauma, especially for minority individuals. A number of participants brought up the fact that racism lingers in practice and in nursing school and needs to be acknowledged by the organization—and addressed.
Ena Williams, MBA, RN, Senior Vice President & Chief Nursing Officer, Yale New Haven Hospital, talked about the existing trauma minorities lived with before COVID. “When you think about the Black and Brown communities, who have carried the stress of racism and this constant state of pressure,” she said, “it doesn't matter what level you are in your career, in your life, how much money you have, or what title you have, it is always there. I think we're going to have to pay close attention to our minority leaders who are both leading in this heightened state of racial tension, as well as experiencing it personally. They're trying to lead, sometimes even in spaces that doesn't always welcome them. Minority leaders need allies more now than ever.”
Ms. Williams also discussed the group sessions her health system implemented, with the aid of a facilitator, to help nurses process their experiences. However, she urges leaders to listen to nurses to learn what they need. “Part of our job as leaders is to meet our teams where they are,” she said, “and not try to get ahead of them. Because they will lead us to the right places, and decision making.”
Nurses can help lead the way
Addressing nurses’ mental health and well-being for the long-term is an interdisciplinary issue—but as Ms. Williams mentioned, nurses themselves have many of the answers health systems are seeking. Dr. Rushton, who co-led the WikiWisdom report on frontline nurses, which includes recommendations on mental health, advised organizations to take appropriate time to listen to nurses’ needs. Dr. Rushton mentioned the fact that nurses repeatedly said, “listen to us. We have the answers, we know what to do, ask us—and really listen to us.”
We saw nurse’s capacity to generate answers around mental health during our recent NurseHack4Health hackathon on Building a Sustainable Workforce of the Future. One team, for example, came up with a digital tool that creates a “heat map” of high-anxiety units in the hospital to identify nurses who may be at greater risk of undergoing trauma in the future; another worked on a data-driven solution to combat burnout that includes a mindfulness app specifically designed for nurses, which not only aims to support individual nurse mental health, but anonymously aggregates information across health systems and beyond to try to understand how nurses are feeling on a larger level to facilitate system-wide changes that could improve the environment in which nurses practice. Nurses can and should continue to innovate and advocate for themselves and their colleagues—and be vocal about how their organizations can support their mental health and well-being, both now and in the long term.
Johnson & Johnson is committed to advocating for, elevating and empowering nurses to lead healthcare transformation and change human health for the better. The Accelerating Nursing, Transforming Healthcare research findings provide strong evidence of nurses’ capacity to move healthcare forward—and the need to support the nursing workforce in more comprehensive ways, to ensure its well-being over the long term. The Workforce of the Future chapter, along with our other two chapters, Care Delivery and Organizational Structure, touch on nurses’ mental health and well-being in various ways. We encourage you to explore the findings and join us as we work to help define a progressive path forward for the nursing profession.
