Addressing mental and emotional health concerns experienced by nurses during the COVID-19 pandemic.

BACKGROUND: Nurses are the majority of the world's health work force and the frontline responders during pandemics. The mental/emotional toll can be profound if it is not identified and treated.
PURPOSE: In March 2020, with New York City as the epicenter of the COVID-19 pandemic in the United States, Columbia University School of Nursing organized support circles for faculty and students providing clinical care as a healing method to address trauma.
METHODS: Columbia University School of Nursing adapted guidelines and conducted Circles of Care to share, listen, and acknowledge the new challenges for nurses via Zoom. Analysis of these sessions produced major themes of concern for nurses.
FINDINGS: Between March 31 and May 31, 2020, we facilitated 77 sessions with 636 attendees. Eight major themes emerged: coping mechanisms, patients suffering and dying, feelings of helplessness, frustration with COVID-19 response, silver lining, disconnection from the world, the thread that holds nurses together, and exhaustion. DISCUSSION: This report offers insight into the mental/emotional outcomes of being on the frontlines. Addressing these issues is essential for the well-being of nurses and all health care providers for an effective pandemic response.

Introduction

Nurses are the majority of the world's health work force and the frontline responders during pandemics. They provide direct knowledge to the community, educating people about the agent causing the outbreak, how it is transmitted, and how it can be prevented. They provide contact tracing and dispel stigma. They diagnose and treat, often with inadequate personal protective equipment (PPE). They too often become infected and die. The mental and emotional toll during pandemic response, including isolation, stigmatization, and exhaustion can be profound and lasting if it is not identified and treated.

During the Ebola epidemic in Sierra Leone, Liberia, and Guinea from 2014 to 2016, nurses bore the highest death toll among the health work cadre. Oral histories of nurses and midwives who provided clinical care conducted by the Columbia University’s “On the Frontlines” project provided collective evidence of the trauma from daily shifts in Ebola Treatment Units where colleagues, family members, and thousands of people from the community died. Nurses told stories of exhaustion, burnout, and despair at the numbers of deaths they witnessed. They also had great pride in their contributions to the defeat of the outbreak and believed it was part of the nursing profession's ethical responsibility to respond. However, preliminary analysis of the oral histories indicates that these nurses had no recognition for their service nor any organized forms of healing to recover (Dohrn et al., 2020).

One key component to combatting a pandemic relies on maintaining a healthy workforce. This includes effective access to and use of PPE and structured support for the emotional well-being of those providing care. The World Health Organization (WHO) issued guidelines for mental health care for frontline responders, emphasizing that this time of crisis generates great stress, with particular ramifications for health care workers (WHO, 2020). A survey conducted by the American Nurses Association in nursing preparedness for the COVID-19 response found that 87% of nurses fear going to work, 36% have cared for an infectious patient without having adequate PPE, and only 11% felt well-prepared to care for a COVID-19 patient (American Nurses Association, 2020). These factors contribute to increased mental and emotional hardships for nurses and highlight the need for innovative mental health support during public health crises (Veenema et al., 2020).

In March 2020, with New York City becoming the epicenter of the COVID-19 pandemic in the United States, Columbia University School of Nursing's (CUSON) dean and its Office of Global Initiatives (OGI), Global Health Division, planned ways to address nurses’ mental and emotional needs. With faculty providing clinical services in-hospital to the escalating number of people stricken with COVID-19, and preparation for master's nursing students to enter the hospital under the supervision of nursing staff, we formulated a strategy to provide ongoing support to these nurses through “Circles of Care” as a healing method.

The Circle of Care adapts a practice of healing circles used by Native American peoples in the United States (Umbreit, 2003). Historically, a group of people gathered around a fire, a “circle of healing,” and passed a talking stick when a person wanted to speak. Undivided attention to listening to what someone expressed and the use of silence to focus on the present moment created conditions for everyone to acknowledge and respect what was shared, and in this process healing occurred. Groups such as global Healing Circles developed guidelines for initiating and conducting healing circles for nursing professionals with modules (Healing Circles, 2020). This method of bearing witness to stress and trauma has also been initiated with successful outcomes by health care teams in primary care settings (Mehl-Madrona & Mainguy, 2014).

Adapting from resources and guidelines for healing circles, CUSON described its purpose for its Circles of Care as a way “to create an environment of healing to share experiences as a nurse responding to the COVID-19 pandemic through telling, listening, and acknowledging the daily challenges we as nurses face. This will serve as a resource to prevent burn-out, find sustenance, energy and healing from others, and minimize long-term mental trauma" (Healing Circles, 2020).

Methods

Design

In mid-March 2020, the dean of CUSON and the Office of Global Initiatives recognized the severity of New York City becoming the epicenter of COVID-19 infections, hospitalizations, and deaths in the country and its impact on nurses on the clinical frontlines. As such, we built an initiative to address and support the mental and emotional strain on nurses. We adapted guidelines for conducting a Circle of Care, “On the frontlines of COVID-19: A circle for nurses providing clinical care to share, listen, and acknowledge our new challenges in our daily lives.” Given the “stay-at-home” restrictions in New York, all circles were conducted on Zoom (Zoom Video Communications, 2020). Participants had the option to have their cameras on or off during the circle to encourage a comfortable and conducive environment for each of them. This report summarizes observations and themes that emerged during the circle sessions.

Measures

Circle Guidelines

The guidelines, adapted from resources by Healing Circles, included a welcome and reading of the following agreements for each circle: One person signals to speak and no cross-talking or direct dialogue between two people; Silence is respected and participants can choose not to speak during the circle; To be mindful of time so that each member can share; To treat each other with kindness and respect; To listen with full attention to what a person speaking is saying as a way to give recognition, respect, and support with compassion and curiosity; To honor each other's unique ways to healing and to not presume to advise, fix, nor save one another; Speak about what each is witnessing as a nurse, challenges, concerns, and fears including reactions from family and friends. Participants are reminded to treat carefully what each member says in the safe space as the circle is confidential and to refrain from attributing statements to individual people when they are outside of this circle (Healing Circles Langley, 2018).

Data Collection

Circle Structure

CUSON rolled-out its Circles of Care for participation to all nursing faculty and nursing doctoral students who are in clinical practice, to current nurses at the major university-connected hospital who are enrolled in advanced clinical management and leadership master's program at CUSON, to students completing their master's nursing degree who are serving in a nurse technician role during COVID-19 response, to faculty and staff operating at ColumbiaDoctors Nurse Practitioner Group, and to student council leaders at CUSON (CUSON, 2020). The majority of the subjects were involved in the direct care for COVID patients. Circle sessions—dates, times, and Zoom details—were circulated via CUSON email listserve.

CUSON faculty in the master's programs were trained to be leaders for circles that held approximately 5 to 10 participants. The circle leaders were trained together by the same team using the same approach and guidelines. The leader guided the process and the participants in each circle. Each circle also had a host, a member from the Office of Global Initiatives (OGI), Global Health Division, to provide logistics, support to the leader, and keep note of emergent and consistent themes.

Each circle began with ringing of a bell by the Circle leader with instructions to take deep breaths. Circle leaders were encouraged to choose a prompt or share a personal story/poem to set the tone for the circle session and help foster discussion. After 30 to 60 minutes of participant engagement and discussion, the circle was closed. Circles were scheduled based on needs and requests, ranging from a single session to a weekly and bi-monthly basis.

Data Analysis

In the first five circles, leaders and hosts observed consistent themes emerging from each circle session. To ensure a general uniformity in the observations, the leaders and hosts discussed and agreed upon the identified emergent themes and their respective descriptions. From that point onwards, each member of the OGI team referred to the theme table to document and categorized the most salient points during each circle session. After the final circle in May 2020, the team merged their notes in Microsoft Excel (Microsoft Corporation, 2020) and organized the discussed information into eight main themes and related sub-themes over the course of the nine-week circle sessions. A theme was counted if it was mentioned at least once during a circle session. Frequencies of each theme and sub-theme from each circle were then tallied and totaled.

Findings

Between March 31 and May 31, 2020, we provided space and time for 77 Circles of Care sessions, with 636 attendees in the Circle spaces to process, reflect, and acknowledge their nursing experiences during their COVID-19 response. The mean size of each circle was 8.5 attendees (range: 0–65 attendees).

Eight major themes emerged from the circles. Frequencies of these main themes can be seen in Figure 1 and a percentage breakdown can be seen in Figure 2 . “Coping mechanisms and mental health” (17%), “Dealing with patients suffering and dying” (15%), and “Anxiety, fear, and feeling of helplessness” (15%), were most frequently mentioned in circle sessions. “Frustration with COVID-19 preparation and response” (13%), “Silver lining” (11%), “Disconnection from the world” (10%), “The thread that holds nurses together” (10%), and “Exhaustion” (9%) followed (Figure 2).

Figure 1

Frequency of Circle main themes from March 31 through May 31, 2020.

Figure 2

Percentages of Circle main themes from March 31 through May 31, 2020.

Subthemes exemplify each of the main theme categories as referred in Table 1 . Subthemes with the highest frequencies expressed by nurses and nursing students were “guilt related to seeing patients dying or suffering alone” (n = 35); “concern for COVID-19 exposure for self, family members, colleagues” (n = 35), “validation to their feelings via support circle and other means” (n = 31), “guilt related to not being able to be on the frontline” (n = 30), and “coping strategies are unique for everyone” (n = 30).

Table 1

Themes, Subthemes, and Examples

Themes and Bulleted Subthemes	Frequency (n)	Examples, Comments, and Quotes From Circle Participants
Dealing with patients suffering and dying• Guilt related to seeing patients dying or suffering alone.• Guilt related to not being able to be on the frontline• The sheer magnitude of the negative consequences due to COVID-19	n = 46n = 35n = 30n = 15	Witnessing people dying alone without family.“…the idea of human dignity just thrown out the window,”Older/vulnerable nurses expressing guilt for prioritizing their health“Never seen anything like corona”“This is the new norm”
Exhaustion• Difficult trying to gain a sense of “self”/balance•Completely physically and emotionally consumed with COVID-19	n = 30n = 17n = 13	Feelings of burnout: "my whole life has become the job, I barely see the sun and I have no routine."Feelings of being extra removed from natural environments, limiting the amount of time outside of the apartment to ensure safety
Disconnection from the world• Difficulties with “2D” or virtual learning•Mourning physical/face-to-face human connection and fellow students	n = 33n = 19n = 16	"I still feel like a student, hard to differentiate between school and work;” Missing out on milestones like graduation ceremony.Worried about their education (as students) and their future.Advantages of telemedicine however lack of in-person connection.
Anxiety/Fear/Helplessness• Triggering of prior negative experiences• Concern for COVID-19 exposure for self, family members, and colleagues. Vulnerability to infection for self and loved ones.• “Checking COVID-19 statistics/news constantly”• Concern/helplessness over patients’ fears• Unknown situation	n = 46n = 10n = 35n = 12n = 17n = 18	Triggers of experiences with other pandemics, 9/11, natural disasters.“A lot of people who died in the 9/11 died due to lack of personal protective equipment and we are now in the same boat""I feel like I have more control over the situation if I understand every part of it"With masks, patients can't see the nurses’ smiles and expressions of reassurance. "nurses are always trying to say to patient ‘I'm there with you’ however lack of touching makes that difficult”How long will this go on for and will it get worse?
Frustration with COVID-19 preparation and response• Lack of pandemic training/ direction/ protocol• Lack of PPE• Frustration with public not taking public health precautions seriously•Inadequate skills (particularly for students). Example: Not carrying weight at new unit as it is unfamiliar• Redeployment	n = 40n = 22n = 23n = 18n = 16n = 10	Fear of a second wave and unpreparedness.Assignment to units where nurses have not worked before; Missing area of care they are used to providing
Coping Mechanisms and Mental Health• Coping strategies are unique for everyone• Validation of participants’ feelings via support circle and other means	n = 54n = 30n = 31	Mental health of colleagues and peer-students; Passing of nursing and medical colleagues."All I want to do is sleep and be prepared for my next shift, I feel selfish in some ways in order to take care of myself"Emphasis on the importance of self-care and self-compassion."Support circle allows feelings to surface"
Silver lining•Hopefully this pandemic will address the weaknesses in our health care system in the future• Nurses are finding a purpose in the pandemic, opportunity to help• Moments of hope•Students are better prepared, gained valuable experiences	n = 36n = 15n = 12n = 15n = 19	"Nothing will ever be the same, we have to think about how to prepare for the unknown, how to manage people's expectations of what we can do”"COVID has exposed the flaws in the hospital system so hopefully, this triggers positive change in the future"Ways teams mark victories, like sending a patient home and playing music for their discharge."We were supposed to have [clinical] integration right now so it's been nice to have other nurses on the floor ask for us to help out - feels like I'm using my brain"
The thread that holds nurses together• “We're all in this together” / humanity• Nurses have been leaning on and supporting each other• Commitment to the nursing field	n = 31n = 11n = 23n = 19	“Very humbling to experience nurses on the floor."truly learned the model of a nurse""…the art of nursing, like comforting is more pertinent right now as the science portion of nursing is handicapped right now;""We are patient advocates right now especially because the patient's family can't be advocates"

The main theme of “Coping mechanisms and mental health” had the highest percentage out of all the main themes throughout the sessions (17%). As seen in Figure 3 , the subtheme breakdown for this main theme includes an almost equal percentage for “coping mechanisms are unique for everyone” (51%) and “validation of participants’ feelings via support circles and other means” (49%).

Figure 3

Subtheme percentage breakdown for main theme “coping mechanisms and mental health.”

Discussion

With the 636 participants, across 77 circles, we determined eight major themes and related subthemes that captured the experiences of nurses and student nurses responding to the COVID-19 pandemic. This report offers insight into the mental and emotional outcomes of being on the frontlines, which enables future research to be aimed at enhancing the student nurse environments and overall nurse well-being.

The significance of these findings can be examined in two major areas: (a) overall lack of pandemic preparedness; and (b) openings for new possibilities for provision of health care. Both of these areas impact the mental and emotional well-being of nurses and all health care providers.

Lack of Pandemic Preparedness

Considering the first, participants from the Circles of Care expressed in many ways the lack of pandemic preparedness. Nurses and nursing students in the circles expressed not having experience in providing care during a pandemic, which increased the levels of stress and fear. In an ongoing oral history project of nursing leadership in pandemics, nursing participants reported that lack of knowledge of the SARS-COVID 2 virus coupled with misinformation and lack of clear guidelines from federal authorities on modes of transmission, prevention, and treatment heightened the feelings of anxiety and fear (Dohrn et al., 2020). Witnessing the deaths of so many patients, alone and suffocating, nurses expressed feeling powerless and in conflict with our nursing education that promotes our physical being with the patients throughout the lifecycle, including death. Lack of preparedness resulted in diverting all energies to direct clinical care, pushing the mental and emotional well-being of the health care team to a low priority (Dohrn et al., 2020). The resulting survival mode took a toll on providers, exemplified by the tragic suicide of a leading Emergency Room physician at our institution's affiliated hospital. Overall, morale was tested on an individual and team level.

New Possibilities for Provision of Health Care

Clear recommendations for going forward emerge from the second consideration: openings for new possibilities for the provision of health care. Educationally, when the School of Nursing initiated simulation training for students in modes of transmission of the virus, PPE, ventilator use, and postmortem care, nursing students developed these skills, resulting in improved confidence in the hospital units, and reducing the emotional stress. When nursing leadership in the hospital redeployed palliative care nurses to the emergency departments, this situation eased. Furthermore, palliative care nurses connected dying people to their families electronically. New teams became solidified as the pandemic pushed open new doors for collective work. Nurses shared in the Circles their increased responsibilities in the ICUs as doctors and nurses renegotiated respective responsibilities in emergency response while adhering to safe practices. Many expressed that the hierarchical medical structure loosened as everyone needed to perform at their highest levels.

Shechter et al. (2020) surveyed health care workers in a large New York City medical center on the impact of psychological distress, especially nurses and advanced practice providers. The findings indicated that the availability of mental and wellness resources for health care workers is essential. Initiatives at CUSON that focused on creating spaces for emotional and mental well-being, such as the Circles of Care, allowed acknowledgement of feelings and the criticalness of self-care for our profession. Hospitals convened daily access to pastoral care to the units for group gatherings as well as individual needs. Mental health services such as counseling and support groups were available to nursing students. Student led relaxation programs such as yoga and meditation were also made available.

Lastly, nurses found increased respect and commitment for our profession. The recognition by the community with the daily 7 PM applause and banging of pots outside people's windows and the public and media's attention to nurses as heroes brought pride and self-respect to our role in saving lives (Newman, 2020). This enhanced the worth of the sacrifice being made daily by nurses on the frontlines, who were also becoming infected and seeing their colleagues die and often separated from their families to prevent possible transmission of the virus.

COVID-19 has forced various nursing schools globally to re-think strategies of including final-year nursing students in voluntary pandemic response and minimizing subsequent negative mental health impacts. The themes expressed by CUSON students and faculty providers in the Circles of Care are similar to those in recent literature on nursing and medical students providing care as a part of a pandemic response. Examples include feelings of fear and uncertainty, association of higher anxiety score with lack of PPE, and fear of infection (Collado-Boira et al., 2020; Savitsky et al., 2020). Furthermore, as observed in Figure 3, mental health, coping mechanisms, and validation of nursing students’ emotions during their COVID-19 response were salient topics of discussion. Thus, it is vital for nursing education to consider the impact of trauma-experiences of students during COVID-19, mitigation strategies for coping as well as nursing student preparedness and experiences of patient death and dying for potential future public health emergencies (Fowler & Wholeben, 2020; Galvin et al., 2020).

Limitations

Limitations to our Circles of Care approach include the utilization of Zoom over conducting sessions in-person. Although virtual sessions allowed for efficiency and safer communication in terms of preventing the spread of COVID-19, as well as the option to turn off the camera to encourage anonymity, in-person sessions may have been more conducive to open, personal communication between participants. Another limitation was the variability in circle sizes. Determining participants’ availability and scheduling the Circles of Care sessions to ensure adequate attendance proved to be challenging as many were navigating both nursing school and responding to COVID-19 at the clinical level. In addition, the variance in each leader's style is a limitation to be noted. Various prompts and topics initiated by the leader gave rise to different focus points within each circle. This may have impacted participant responses and in turn, theme frequencies. This too limits our ability to determine the reason behind the differences in theme frequencies. As the pandemic progressed with plateaus and surges, the list of themes may vary by its relevance and importance. For example, physical and mental exhaustion (i.e., burnouts) may have increased or became more prioritized over the other themes.

Conclusions

These findings have great value for future research and recommendations for policy guidelines. This pandemic has globally and nationally forced a rethinking of how health care teams can maintain and expand readiness for public health emergency response. Studies on the most effective ways to integrate nursing preparedness into nursing education and continuing professional education are needed as well as new models for teamwork that this pandemic has enabled. Policies for promoting and maintaining a healthy workforce, physically, mentally, and emotionally, need to be developed and implemented. This would strengthen the health workforce during pandemic response as well as overall improve our ability to provide safe and robust care going forward.

Author Contribution

All authors, JD, YF, RS, ED, LF, participated in the conceptualization, methodology, collection of this work. YF, RS, and ED were involved in the administration process. JD, YF, RS, and ED were responsible for the formal analysis. All authors were involved in the original manuscript preparation and review and editing process.