Jennifer Ricker, BSN, RN, CCRN, nurse manager of the medical intensive care unit at St. Joseph's University Medical Center in New Jersey, confronted the heartbreaking realities of COVID-19 stress one night in April.
Ricker had just responded to a code blue for a patient on the COVID-19 unit when another patient went into cardiac arrest. Within one hour, a total of five patients went into cardiac arrest. Three of them died.
"I reminded the nurses they had done everything possible to treat the patients," Ricker said, pausing to hold back tears. "As the next shift of nurses arrived, I said that their best work was all that was required, no matter what the outcome."
Ricker has been caring for patients for more than 16 years, and the sheer volume and acuity of the patients with COVID-19 has been like nothing she had seen in the past. They are often on ventilators and suffering from some combination of acute respiratory distress syndrome (ARDS), blood clots and heart failure. Nurses frequently titrate as many as eight medications for one patient.
Nurses were not only experiencing COVID-19 stress and trauma from patients dying, but a few also were grieving the deaths of family members who had contracted the disease. Others felt isolated because they were avoiding contact with children and spouses within their own homes or living in a hotel room provided by the hospital to reduce the risk of spreading the virus.
"Sometimes nurses just wanted someone to hug them, but that was not safe," she said.
COVID-19 stress can take a deep toll
Nurse leaders like Liz Stokes, JD, MA, RN, director of the Center for Ethics and Human Rights at the American Nurses Association, worry the psychological toll of the disease on healthcare workers could be the next pandemic.
"Even before COVID-19, nurses were already at risk of moral distress, compassion fatigue and burnout, and now they may be dealing with intense feelings of loss, grief and fear," she said.
Stokes urges hospitals to prepare for an increase in symptoms related to post-traumatic stress disorder, depression, anxiety and other mental health conditions among nurses.
The potential psychological consequences of the pandemic on healthcare workers surfaced in March amid reports that several nurses caring for COVID-19 patients had committed suicide in Europe.
"Nurses may not be processing their experiences during the crisis," Stokes said. "It's critical that organizations be proactive about supporting nurses to help them alleviate mental health symptoms."
In May, the American Nurses Foundation partnered with four leading nursing organizations to launch the Well-Being Initiative, which aims to help nurses manage their COVID-19 stress and overcome trauma. The program gives nurses access to digital mental health and wellness-related tools, including a smart phone app that connects nurses to an expert trained to provide support.
Using Zoom to reach nurses
At St. Joseph's University Medical Center, which is a Catholic institution, one form of support that benefited nurses was prayer from the pastoral department. The deacon regularly blessed the COVID-19 unit, which was a meaningful moment for the staff, Ricker said. When she noticed nurses were struggling after patients had died, Ricker invited the hospital's psychiatric crisis department to lead debriefing sessions, and sometimes she connected nurses with the hospital's crisis hotline.
In the early stages of the pandemic, Bridget Boeckman, APRN, supervisor of the critical care advanced practice providers at Nebraska Medicine in Omaha, helped her team of 32 nurse practitioners and physician assistants by calling each of them to ask how they manifested stress and what coping strategies they had in place.
"Some nurses said they didn't know how they reacted to stress, and it was a good chance for them to reflect on that," Boeckman said.
She also started a weekly Zoom hangout to provide a setting where nurses and advanced practice providers could share their experiences with one another.
One of the most difficult situations nursing staff and providers have confronted is their inability to build rapport with a patient's family members in person, Boeckman said. She experienced this recently when caring for a man in his 50s whose condition worsened rapidly in 24 hours. The patient needed to be intubated quickly, and she called the family via Zoom so they could see him before intubation.
"It's emotionally difficult knowing that this may be the last time the patient is conscious for weeks, or possibly the last time the family ever talks to him," Boeckman said.
Training nurses to support peers
During the pandemic, Bridget Ryan, BSN, RN, CCRN, assistant nurse manager of the medical ICU at ChristianaCare's Christiana Hospital in Delaware, relied on her training from the health system's Care for the Caregiver program, which helps identify signs that a nurse is struggling emotionally.
"Anxiety and fear can cause different reactions, and some people act out in anger, while others clam up or cry," she said. Nurses may be referred to Ryan for support, or she sometimes pulls a nurse aside in the moment if she sees these behaviors.
Ryan can take the nurse to the unit's OASIS (Opportunity to Achieve Staff Inspiration and Strength) room, which was designed by the health system's Center for WorkLife Wellbeing.
The room includes serene paintings, the sound of waves crashing, candles, a recliner chair and a throw rug to give staff a space for a mental break.
"I give them an opportunity to voice how they are feeling and let them know that what they experienced is very traumatic," Ryan said. "I remind them that it is OK to feel vulnerable."
At UCHealth hospitals in Colorado, one of the most successful forms of mental health assistance for nurses during the pandemic has been team support sessions offered by one of the hospital's psychologists. Nurse managers who feel their teams would benefit from a session contact the psychologist to initiate the process. So far, 73 teams have participated.
"Sleep disturbances are one of the first signs of PTSD, and the first half of the session is dedicated to giving them space to open up about their experiences," said Elizabeth Harry, MD, senior director of clinical affairs at UCHealth. "Then we offer coping tips, such as strategies for maintaining good sleep quality and quantity and deepening safe contact with family, friends and colleagues who can offer support."
The health system also launched a new buddy system in which nurses can sign up to partner with a colleague for support. The pairs receive a text each day with a check-in topic.
Programs such as this ideally will help nurses who might be struggling with COVID-19 stress not only at work, but also with the long-term ramifications of the pandemic at home, such as unemployed spouses, changes to school routines and the loss of loved ones.
"Our goal is to create a safety net and find people who are quietly suffering and withdrawing," Harry said. "That's why we are helping peers reach out to each other."
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