key: cord-0846430-i961e848
authors: Turale, Sue; Nantsupawat, Apiradee
title: Clinician mental health, nursing shortages and the COVID‐19 pandemic: Crises within crises
date: 2021-04-23
journal: Int Nurs Rev
DOI: 10.1111/inr.12674
sha: 25ea80ffbb437c9cfcc0af9856955b221a1a7893
doc_id: 846430
cord_uid: i961e848

Around the world, nurses are working under enormous pressure providing care to sick and dying patients during the pandemic. Many are faced with increased stress, and other negative effects on their mental health. They are also faced with the possibility of infection and death from COVID‐19. Before the pandemic there was a global shortage of nurses, but this is likely to be exacerbated by the increased demands of caring during COVID‐19 as well as the usual care of non‐COVID patients. One serious concern is that the pandemic and multitudinous effects on the nursing profession will exacerbate nursing attrition and their poor mental health into the future. Another serious concern is whether the profession will be able to attract sufficient numbers of nurses to care for populations into the future. Governments and health policymakers everywhere need to invest in nursing and health care and pay attention to the needs of health systems to ensure a healthy population. It is argued that without this, economies will not recover and prosper, and health systems will not be able to provide quality care.

Today, perhaps like never before, the world is facing a healthcare crisis because of the triple whammy of nursing shortages, the COVID-19 pandemic, and the incipient effects of these on the mental health of clinicians. The shortage is likely to be exacerbated due to the pandemic as well as other factors like nurse ageing and continuing nurse attrition. The shortage was deemed a global nursing crisis in 2002 and is a complex problem spanning major areas for action, including policy development and intervention, health sector funding, policy and planning for the workforce, nursing regulation, leadership, and nursing recruitment and retention (Oulton 2006) . Despite many calls to action for governments to deal with the shortages and the excellent strategies developed by the International Council of Nurses (ICN) and Nursing Now, in concert with the World Health Organization and others, we have yet to see real progress and investment in nursing. ICN reports that National Nursing Associations around the world have collaborated strongly and responded to the call for leadership to co-ordinate responses to the pandemic. But this is not enough. All governments need to step up to the mark with real investment in, and support of, the profession.

Reports from around the world tell of nurses, along with other health professionals, being exhausted. Many are dispirited after a year of caring for high patient workloads with COVID-19 and seeing too many people die, as well as trying to deal with the usual caseloads of people needing interventions. Many are fed up trying to manage their lives, juggling family and work responsibilities, working extra shifts because of the acute nursing shortages, and facing unresolved ethical issues in practice. Nurses have to deal daily with distancing from the ones they love, and with ... illness and death. And too often, nurses have had to put their excellent skills into situations that are new to them, in unplanned urgent situations outside of their usual scope of practice, not a new phenomenon in nursing. These critical issues will not be relieved until a significant number of the world's population is vaccinated, and more nurses are available to care for populations.

We need to find ways to support clinicians to have the necessary self-care while doing their job, and adequate staffing is essential for this. Hospitals were close to maximum capacity with severe nursing shortages (American Nurses Association, 2019) before the COVID-19 pandemic took hold. Many countries are suffering economic downturns due to the pandemic, but unless investment is made in the education of more nurses, and the ongoing training and support of current nurses, then economies will continue to suffer. It is simply untenable to expect that there will be economic prosperity and recovery in countries that do not have good population health and health systems, and this requires an adequate and competent health workforce.

There is no doubt that nurses are, for the most part, resilient creatures and have quickly adapted their skills to improve nursing practice during this pandemic, often making do with shortages. But innovation and willingness to do the hard work cannot continue without let up, without support, counselling, proper resources and recognition, and without significant investment in nursing and health care within and across countries. We simply cannot expect nurses to continue to 'make do' and especially when they are not being listened to, nor being adequately protected to carry out their work It is difficult to estimate the true effects on nurses because of the impacts of the pandemic, nursing shortages and scarcity of resources. And we cannot predict when this pandemic will end. We assume that with the ongoing pandemic and short-staffing many nurses not been able to take muchneeded leave to rest and recuperate. This will only compound the negative effects on their mental and physical health and well-being. Nurses already work unsociable shift work hours that have an existential and real impact on their lives. And the risks and fear of COVID-19 infection have not abated. Sadly, an unknown high number of nurses have been infected with the virus and at least 22 00 have died (ICN 2021). This figure will undoubtedly grow. A few studies have found that nurses are suffering from post-traumatic stress disorder, anxiety, high stress, depression or moral suffering, but there is an urgent priority for research funding to uncover the extent of the problem. Davidson et al. (2020) warned of the spike in suicide in nurses and physicians before this pandemic. Clearly, there is an urgent need for the promotion of mental health in the profession, including mental health screening and short and long-term psychological and social support (Jun et al. 2020 ). This will not only promote and sustain their well-being but also help to prevent their attrition from the workforce.

Nursing is a highly respected profession in many countries, but we do not yet know what the effects of the pandemic will be on the successful recruitment of more people into nursing in future. Will young people avoid nursing because of the risk to their health and well-being, scared to get infected and seeing the plight and hard work of nurses in the media? And will the rapid movement of nursing education to online learning assist or deter more people from entering nursing courses in the future? Of importance is that there may be an underestimation of new nurses in health systems, and we do not yet know the extent of the number of student nurses who have not been able to graduate due to interruptions to their studies throughout the pandemic.

We are yet to understand the extent of increased attrition from the global workforce due to the pandemic. Nurses have risen to the call to assist during these critical times and, in some countries, the number of nurses available to care has actually increased due to retired nurses recalling back to duty. Student nurses have also been asked to bolster the workforce. In this issue of INR, nursing colleagues from Lebanon report over 600 nurses leaving the country during COVID-19 but this was compounded by a massive explosive disaster. Said & El-Shafei (2021) in Egypt found there is a higher intent to leave the workforce among nurses with high stress caring for patients with COVID-19 in fever hospitals than in those of nurses working in general hospitals. It is important for researchers to uncover clear evidence world-wide about this to assist in workforce decision-making.

In our opinion, calling nurses heroes has not helped the professional image of nursing. They certainly are to be recognized and rewarded for the critical work they have done and continue to do. But many insist they are trying to do their job. Calling them heroes but expecting them to not have enough quality personal protective gear or to practice in poor working environments negates their ability to achieve what they are educated to do, and puts their lives at risk.

In conclusion, there is no doubt that nursing in the time of COVID-19 is having a profound effect on the mental health of nurses, especially clinicians on the front lines of the pandemic, and governments need to be seriously concerned with investing in nursing. Nurses everywhere need to give voice to these concerns in appropriate forums and at decision making tables. After all, the health of nations is dependent on the work of the profession, and we simply cannot afford to lose more nurses from the profession.

Fact sheet: Nursing shortage. Available at

A longitudinal analysis of nurse suicide in the United States (2005-2016) with recommendations for action

Protecting nurses and other healthcare workers tops ICN's agenda after WHO Executive Board meetings

Clinician mental health and well-being during global healthcare crises: Evidence learned from prior epidemics for COVID-19 pandemic

The global nursing shortage: An overview of issues and actions

Occupational stress, job satisfaction, and intent to leave: nurses working on front lines during COVID-19 pandemic in Zagazig City