Last month, at the start of a fourth Covid-19 wave in the US, a nurse in a Seattle-area intensive-care unit announced her resignation on Twitter. “No amount of money could convince me to stay on as a bedside ICU nurse right now,” she wrote. “I can’t continue to live with the toll on my body and mind. Even weekly therapy has not been enough to dilute the horrors I carry with me from this past year and a half.”
The nurse, Sara, who asked to be identified by her first name so she could speak freely about her experiences at work, told Vox that she’s been offered incredible bonuses in exchange for extra hours. She said she could make an entire month’s mortgage payment just by working one extra shift, but has declined. “We’re not soldiers,” Sara said. “We’re not the saviors of humanity. We’re humans who have families and the need to take care of ourselves.”
In June, Julia Belluz wrote for Vox about the many structural barriers that prevent physicians from getting mental health treatment. It led to an outpouring of support, and a question: What about the nurses?
The roughly 3 million registered nurses (RNs) currently employed in the United States are, in Sara’s words, “the eyes and the ears and hands and feet of providing health care.” But nurses are leaving the profession at a staggering rate. According to a 2021 report from Nursing Solutions, the turnover rate for registered nurses last year was close to 20 percent. This leaves hospitals understaffed: About 10 percent of hospital RN positions were vacant last year, the same report found, perpetuating a cycle of burnout and likely worsening the quality of care for patients.
As an ICU nurse, Sara said the pressure and strain have felt unbearable. When Covid-19 arrived, she was often the only health care provider in the room with a critically ill patient, “feeling like this person’s life was completely in my hands, and it was up to me,” she told Vox. She said her own symptoms now mirror some of those of post-traumatic stress disorder: traumatic flashbacks, nightmares, uncontrolled moods, and crying.
Sara was able to carve out time to find a therapist and join a virtual support group, but she worries that many nurses don’t have the capacity to seek support on their own. “It feels like everybody’s running on fumes,” she said. “We need to make the barriers to accessing [mental health support] quite a bit lower because people are just so exhausted.”
The mental health of nurses was taxed even before the Covid-19 pandemic. Female nurses in particular were at twice the risk of dying by suicide as women in the general population, according to research published earlier this year. And that’s only “the tip of the iceberg,” said Christopher Friese, a professor of nursing at the University of Michigan and a co-author of the study. “What I worry about is the large number of nurses that we can’t even quantify, that are suffering in silence.”
Friese, who has practiced as a registered nurse for 27 years, spoke with Vox about the toll nursing can take on mental health, and what has to change for nurses to get the support they need. Our conversation has been edited for length and clarity.
“There’s real consequences for our nation’s health”
What have been some of the biggest strains on nurses, before the pandemic, that might put them at these greater risks for mental health challenges?
I think there are a couple of buckets to think about. The first bucket is their personal experience. Nurses are not only delivering care to the patients and their communities, but they’re also caring for their children, their family members, and loved ones. They take on an added caregiving role beyond their job. So I think we need to understand that better.
The second bucket is the workplace. The health care workplace has not been healthy for nurses for some time. We’ve known for over a decade that nurses have been concerned about their workloads. They’ve been concerned about the resources that they have to take care of patients or communities. And they are often the group that we add new tasks on to. So adding the electronic health record has placed that very heavy burden on nurses because nurses are sort of a catchall for all of that work. And we haven’t taken anything away from nurses. The only thing we’ve done is continued to pile on to their work.
And I think the final point that we need to be aware of, and I’ve certainly seen, is increased hostility in the workplace. Nurses more frequently are bearing the brunt of verbal and physical abuse from patients, patients’ family members, and some staff. And we have not created a safe environment to work.
Have you experienced some of these strains firsthand in your time as a clinical nurse?
Nursing is a very rewarding profession, but there are times when it can be very draining. I’m deeply worried by what I’m seeing. Despite all my experience, it is definitely harder work than it was when I started. It was getting harder before the pandemic, and the pandemic only exposed those fault lines where the system has not served nurses well.
Could you talk more about how Covid-19 might have impacted nurses’ mental health?
In our data, we had over 700 nurses die from suicide in the 2017-2018 period. That was an all-time high. So we were trending up, and then Covid-19 hits. They were dealing with these really risky clinical scenarios where we don’t have good information, early on in the pandemic. How do we protect people? Do people have the right protective gear?
There is also a unique combination of their personal health at risk, their loved ones’ safety, and then the societal split in our approach to this public health crisis, which you’re seeing right now. We have really good tools to protect our population — we have really effective and very safe vaccines. We’ve learned in this pandemic that masking and staying out of crowds is effective. And yet we have a swath of the population who is not doing that. And they’re in our ICU and they’re in our hospital beds, and nurses have to live with that duality.
The other thing we’re observing is staff shortage — either people have left the workforce, or they’re ill themselves, or their loved ones are ill and they’re caring for family members. Everybody’s picking up more work. That just perpetuates the cycle. We’re on a hamster wheel here, where nurses just can’t get off.
Are you worried about attrition from the nursing profession, especially from the added strain of the pandemic?
I’m deeply worried. I’m already aware of particularly experienced nurses who have left their clinical position, and you can’t really replace them, their decades of experience. Those are the folks who train our next generation and help support physicians and others. So it’s a real brain drain.
Then it creates this cyclical problem where you’re always running short. We have very clear evidence: when you don’t have enough nurses, patients have more complications, they’re more at risk of dying, etc. So there’s a direct connection to a healthy, fully staffed nursing workforce and public health. There’s real consequences for our nation’s health if we do not curb this crisis.
Access to mental health care isn’t just about health insurance
Do you find nurses tend to have good access to mental health care?
Most employed nurses have relatively good health insurance, so they probably have access on paper. But it’s very difficult for health care professionals — and especially nurses — to seek out mental health services because of the stigma we have in place. Nurses might be concerned that if they seek out mental health services and undergo treatment, that might jeopardize their employment.
There are numerous examples. As nurses are applying for positions and interviewing and going under intake questioning, they might disclose that they have a mental health condition or they’re taking medication. And leadership is questioning whether they’re suitable for those positions: Can they handle the pressure of that work? So that only makes it more likely that you’re not going to disclose and you’re not going to access services.
We need a really different kind of model for nurses. We all need mental health services that are safe, accessible, and confidential.
The final piece of that is the disciplinary process for nurses. Right now, if a nurse makes what is assessed to be a clinical error, we quickly go down the disciplinary route, and we don’t realize that there might be someone in trouble, a human being in front of us who needs care. Is this person well? Do they need help? And what kind of help? These should be the first questions we ask, and then we can get to the other things.
As my colleague Julia Belluz reported earlier this year, physicians often seem reluctant to get mental health treatment because in some states, and in some cases, they are worried it could jeopardize their medical license. Do nurses have similar disclosure requirements or licensing concerns?
I don’t know of boards of nursing that formally ask if you have a mental health diagnosis or you’re taking medication. But in a lot of the boards, you have these statements about “moral character.” Assessing one’s character can get wrapped into mental health very quickly in our country. So I think we really want to separate that out. We want people to feel comfortable knowing you can be an excellent nurse and also have a mental health condition. And we want to make sure that you’re getting the recommended treatment you need. It’s just like having diabetes or some other condition. We need to get that stigma out of mental health.
I appreciate there are many nurses who are very public about their struggles, but they’re the exception. And there’s nothing magical that would exempt nurses from having the same underlying health conditions — mental or otherwise — [as] the rest of the population.
Are you comfortable disclosing whether you’ve ever struggled with mental health issues as a registered nurse?
I wouldn’t say that I’ve had a crisis situation. I’ve certainly had stressful moments. I can vividly remember days on the unit even decades later. The work nurses do is physically demanding, and it can be emotionally taxing. It can also be very rewarding. But the kind of work we’re doing, with people’s lives in our hands in very fragile emotional states, you can’t just walk away from that. It sticks with you. I’m thankful that I’ve been able to navigate that, but there are certain events in my career that I will never forget and come back to haunt me.
Do you see your findings about suicide as a potential indicator for the risk of mental health challenges overall?
Below the surface of this is a much larger group of nurses who are, day-to-day, struggling with these issues. We may not even know they are in trouble or they are struggling, and we have no way to know whether they’re getting the help they need. The challenge is to make sure that we can keep them safe before they’re even contemplating suicide.
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We have the tools to take better care of nurses
It seems like physicians and their struggles may get more attention than nurses, even though there are so many more nurses in the country. Why do you think that is?
First, we have better data collected on physicians, so it’s a bit easier to track them over time. Their professional organizations have a fairly robust data set. It’s been a little harder to track nurses over time. We only do surveys of nurses. I think, too, the medical profession has done a better job of understanding this risk and developing unique programs for physicians.
One of the areas to think about is the power differential. Physicians tend to enjoy a relatively privileged place, particularly in the US, relative to other health care workers. So their concerns and issues more often reach prominence. We don’t have a lot of information about other demographic factors, such as gender or sexual identity, etc., but you could imagine that groups that are historically disadvantaged are going to be less likely to be heard on this issue.
There’s a ton of other health care professionals — respiratory therapists, pharmacists — who have been strained, too. And the challenge is to get good data on them. This is only the surface of what the problem may be. We don’t have the fundamental research to help us understand why these things are occurring.
Are there other barriers you see standing in the way of nurses getting mental health care?
We need a different model that is specific to nurses. I think that’s the missing piece. We have specific programs for veterans. We have specific programs for rural residents and adolescents. We don’t really have that for nurses, despite the really alarming data we presented.
We also don’t know the sequence of events. Is it the workplace that’s triggering this? The family environment? Unless we do some really basic registry work, we’ll never know the answer to that. So it limits our ability to help, without research, and that adds to the stigma. If we don’t know what we’re dealing with, then we can’t even let nurses know that there are greater risks and maybe they need to reach out.
How can we take better care of nurses?
We all have a family member or a loved one who’s a nurse. And I think oftentimes we don’t necessarily check in with them and ask them how they’re doing, how their day was. We know their work is difficult. Sometimes they’re not able to tell us a lot for privacy reasons. But checking in with loved ones who are nurses, making sure they know they’re valued. If a family member is struggling, making sure they know that is a normal thing and that seeking help is perfectly okay.
I think we also need to have a conversation as a nation about how we value nurses — and how we structure health care so that they can actually be the best nurse they can be for our patients and for our loved ones. Right now, it’s very transactional. We really need to think carefully, particularly after this pandemic: Can we redesign their work so that we take full advantage of their clinical skill? I think right now we’re not doing that.
The last thing would be to advocate for research on nurses. That has not been valued. Just like we want better understanding of diabetes and cancer, we want to have a better understanding of: Are nurses at risk, and what can we do to help them? We have the tools to do this.
Do we as a society want to put value on this? Do we want to try to better understand how we can have a healthy, safe nursing workforce? I think, for our loved ones, that’s the question. Because if we don’t, we’re going to be in big trouble.