key: cord-0917561-govpa3kj authors: Edmonson, Cole; Anest, Paulette; Gogek, Jim title: A Profession Disrupted: Looking Back to Go Forward date: 2022-03-16 journal: Nurse Lead DOI: 10.1016/j.mnl.2022.02.010 sha: a9ddaae194702a648c4ff60897c49d3d6e6aae1b doc_id: 917561 cord_uid: govpa3kj Nurses face unprecedented harms from the COVID-19 pandemic. A survey by AMN Healthcare found that registered nurses experienced significantly elevated levels of stress, burnout, and other challenges that led nearly 1 million to consider leaving nursing altogether. Despite the challenges, a confluence of positive factors present great confidence that the nursing profession can bounce back and become much stronger due to lessons learned and hardships overcome during the pandemic. There is near-universal awareness that solving the significant challenges to nursing is vitally important, because the health of the American people depends on the health of the nation’s nurses. Nurses face unprecedented harms from the COVID-19 pandemic. A survey by AMN Healthcare found that registered nurses experienced significantly elevated levels of stress, burnout, and other challenges that led nearly 1 million to consider leaving nursing altogether. Despite the challenges, a confluence of positive factors present great confidence that the nursing profession can bounce back and become much stronger due to lessons learned and hardships overcome during the pandemic. There is near-universal awareness that solving the significant challenges to nursing is vitally important, because the health of the American people depends on the health of the nation's nurses. T he years 2020 and 2021 were perhaps one of the most challenging times for nurses since World War II, with COVID-19 rampaging in all regions, no vaccine available, an uncertain supply of personal protective equipment, effective treatments scarce, and infection and death rates climbing precipitously from the infectious disease-including among nurses. Yet at the same time, student enrollment was surging at US schools of nursing. 1 These new nursing students surely knew about the risks they faced to their own health, and they knew about the stresses of the profession they were entering; it was a time of greatly heightened public fear widely disseminated through mass and social media and in interpersonal conversations. Yet, more people than ever wanted to become nurses. We might even speculate that more people wanted to become nurses because of the pandemic. This phenomenon of nursing school enrollment surging during a time of the greatest risk to the profession testifies to the strength, determination, quality, and resiliency of the people who become nurses. These factors provide great hope that the risks to nurses' mental health and wellbeing and the threats of nurses leaving the profession due to the intense stress of COVID-19 can and will be overcome. In addition, many health care organizations, professional organizations, and nurses themselves are dedicated to developing and implementing solutions to the challenges that arose for the nursing profession due to the intense stress and moral distress of working during the COVID-19 pandemic. The 2021 AMN Healthcare Survey of Registered Nurses by AMN Healthcare 2 includes unique data on the challenges faced by registered nurses who worked during the pandemic, along with information on resiliency and solutions. Responses to the 2021 Survey of Registered Nurses were collected between May 14, 2021, and May 21, 2021. AMN received a total 14,737 responses; data in the survey, which are reported in this article, were generated from 6562 survey responses by registered nurses in the United States who were active and practicing nurses in the past year and provided direct care to patients. The margin of error for the survey is ±1% at the 95% confidence level. It is the first survey to go KEY POINTS COVID-19 inflicted unprecedented harms on nursing. The AMN 2021 RN Survey showed significantly elevated stress and impacts. Most nurses are emotionally drained; nearly one quarter say they ready to quit nursing. A confluence of positive factors present confidence that the profession can bounce back. Commitment and action by health care and professional organizations and nurses themselves anticipates greater help in the future. beyond the daily stressors in health care and deep into how nurses are experiencing the sense of belonging in their workplaces and the greater societal issues of racism, sexism, homophobia, and discrimination. Survey respondents were 72% female, 9% male, 18% prefer to self-describe or not disclose, and 1% other categories. They were 39% Millennials, 37% Gen X, 22% Baby Boomers, and 1% Gen Z. Fifty-four percent of survey respondents had baccalaureate degrees, whereas 27% has associate's degrees, 12% master's degrees, 7% diplomas, and 1% doctoral degrees. Respondents were 57% White, 17% Black, 10% Asian or Asian American, 6% Latinx, 6% prefer not to disclose, 4% race or ethnicity not listed here, 1% American Indian or Alaska Native, 1% Middle Eastern or North African, and 1% Native Hawaiian or Other Pacific Islander. Respondents to 2021 RN Survey of Registered Nurses were more diverse than the national cohort of registered nurses, in which nearly three quarters of nurses are White. 3 According to the survey, 18% of RNs were diagnosed with COVID-19 by May 2021. Given that there are approximately 4 million RNs in the United States 4 this equates to approximately 720,000 nurses nationwide. The great majority of nurses-83%, or approximately 3.2 million nurses nationwide-had cared for patients with COVID-19. Sixty-five percent of all nurses said working during the pandemic raised their stress level "a lot" or "a great deal." Sixty percent said working during the pandemic impacted their work-life balance "a lot" or "a great deal." As a result of the pandemic, 63% of nurses felt emotionally drained, 57% felt burned out most days, 51% worried their job was affecting their health, and 39% often felt like quitting their jobs. Nurses who cared for patients with COVID-19 had greater stress and more negative consequences compared to nurses who did not treat patients with COVID-19. Among nurses who said they experienced a great deal of stress at work, 43% cared for patients with COVID-19 and 24% did not care for patients with COVID-19 (total percentages do not equal 100% because they involve comparisons of independent samples). Career satisfaction among nurses who cared for patients with COVID-19 was 7 percentage points lower. Satisfaction with quality of care was 9 percentage points lower. Nurses who cared for patients with COVID-19 were 8 percentage points less likely to encourage others to become a nurse. The 2021 Survey of Registered Nurses also found that approximately 23% of nurses said it was somewhat likely or extremely likely they would leave the field of nursing because of the COVID-19 pandemic. This frankly astonishing figure represents almost a million nurses, and clearly reflects the intense frustration of nurses practicing during the pandemic. Although it is unknown how many nurses would follow up on their stated desire to leave their profession, these data represent a clear warning that the well-being of nurses is at serious risk. Compared to other nurses, nurses who expressed a likelihood of leaving the profession had a significantly more negative outlook. They were more than 3 times more likely to feel burned out most days, 3 times more likely to feel emotionally drained, nearly 4 times more likely to worry their jobs were affecting their health, 2 times less likely to feel their voice is heard at work, and more than 3 times less likely to be satisfied with their job and career. The pandemic has created for nurses a particularly damaging emotional wounding known as moral distress. Moral distress is defined as the "psychological distress of being in a situation in which one is constrained from acting on what one knows to be right." 5 With moral distress, nurses and other health care professionals working in an environment where their core values feel violated can face frustration, anger, guilt, anxiety, withdrawal, and self-blame. 6 This in turn can result in increased burnout, turnover, negative perceptions about their institutions, withdrawal from patients affecting quality of care, and leaving their profession altogether. 7 A major source of moral distress for nurses has been the often ambivalent and sometimes hostile public attitudes toward vaccines, masks, and COVID-19 safety, including among patients in hospitals. Another factor related to the moral distress of some nurses, identified in the 2021 Survey of Registered Nurses, has been the critical issue of inclusion in the workplace. Sixteen percent disagreed when asked if they felt like they belong in their current workplace, and another 20% were uncertain. About a third disagreed or were uncertain when asked if they could express differing views and perspectives at work and whether all coworkers have equitable opportunities. These percentages were higher among nurses who did not identify themselves as White or heterosexual. Altogether, this signifies a large number of nurses who don't have a sense of belonging at their workplace, which can create harm, not only to nurses themselves, but also to health care organizations and patients. Despite the unprecedented pressures on nurses from the COVID-19 pandemic, a confluence of positive factors exists that present great confidence that the nursing profession can bounce back and become much stronger due to lessons learned and hardships overcome during these years of unprecedented difficulties. The fact that enrollment in nursing school was higher than ever during the pandemic testifies to the dedication and high quality of people entering the field. The continued high career satisfaction levels among nurses, undimmed by the pandemic, strongly suggests that those new nurses will also be satisfied and fulfilled by their career choices. Over the years, RN surveys by AMN Healthcare have shown persistently high career satisfaction among nurses. The 2021 Survey of Registered Nurses showed 81% of nurses were extremely satisfied or somewhat satisfied with their career of nursing. The percentage was the same in 2019 and only a couple percentage points difference in 2017 and 2015. In each year, "extremely satisfied" was the largest category. The commitment and action taken by health care organizations and professional organizations to improve the well-being of nurses anticipates greater support for nurses in the future. In a landmark report, The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity, the National Academy of Medicine's consensus recommendations directly address the issues of supporting the health and well-being of nurses and achieving health equity in the United States through strengthened nursing capacity and expertise. 8 Nursing organizations throughout the nation and the world are focused on identifying and responding to the pandemic's impacts on nurses. Nurses themselves show high interest in self-care, and in ensuring that their workplaces are more supportive and equitable for each other. The 2021 Survey of Registered Nurses includes evidence on nurse involvement in mental health and well-being programs and in self-care. Approximately 46% of nurses say they engage in activities or access resources to address their mental health and well-being at least twice a week, and nearly one quarter at least 4 times a week. Two-thirds take action at least once a week. However, one-third of nurses don't do anything to address their mental health and wellbeing. Nurses said that most health care organizations provide some type of mental health care and create a culture of support for their mental health. The most widely available support comes from employee assistance programs or EAPs. Nearly two thirds of nurses said that their health care organizations support a culture of wellness "a moderate amount," "a lot," or "a great deal." Fifteen percent said their organizations do not support a culture of wellness at all. At organizations that provide programs for mental health support, three quarters of nurses said those programs were "moderately effective," "very effective," or "extremely effective." Nearly 2 in 5 nurses have a post-shift ritual to transition from the rigors of professional duties to their personal lives. Detachment after work is an important predictor of health for nurses and other health care workers, resulting in reduced emotional exhaustion, depressed feelings, and sleep problems. 9 The 2021 Survey of Registered Nurses also included anecdotal comments from nurses describing their post-shift rituals to transition from patient care to personal life, which range from meditation, prayer, and loud music to talking on the phone to friends and family, bingewatching their favorite TV shows, and playing with their dogs. The pandemic's impact requires extraordinary efforts by organizations and the public to support the overburdened mind, body, and spirit of their nurses who have been working in extremely difficult environments and under unprecedented stress. The sobering percentage of nurses who are contemplating leaving their profession testifies to the hardships they face. Nurses are not only integral to the health care industry, but as the COVID-19 pandemic has shown, they are essential to the health and well-being of everyone. That's why solutions to the challenges faced by nurses are everyone's responsibility. A critical and immediate solution is universal COVID-19 vaccination to reduce the overwhelming patient burden on nurses. A monumental, yet avoidable, burden for nurses has been caring for patients with COVID-19 who have chosen not to be vaccinated. To support and respect nurses, the patient population needs to make every effort to stay healthy and out of the hospital, particularly during a pandemic. The American public, civic organizations, communities, and employers need to seriously consider this fact as part of their support for nurses. It should be noted that nurses overwhelming support immunization for COVID-19. According to a survey taken in July 2021 by the American Nurses Association, 90% were vaccinated against COVID-19 or planned to get vaccinated, and 91% were comfortable recommending COVID-19 vaccines. 10 This was significantly higher than the rate (70%) among all US adults at the time. 11 The Future of Nursing 2020-2030 report by the National Academy of Medicine provides clear recommendations on supporting the well-being of nurses: Conclusion 10-1: All environments in which nurses work affect the health and wellbeing of the nursing workforce. Ultimately, the health and wellbeing of nurses influence the quality, safety, and cost of the care they provide, as well as organizations and systems of care. The COVID-19 crisis has highlighted the shortcomings of historical efforts to address nurses' health and wellbeing. Conclusion 10-4: Coordinated and collaborative action at the individual and systems levels, encompassing individual nurses, educators, employers, health systems, professional organizations, and government agencies, is needed to promote nurses' health and wellbeing. 8 On the level of daily practice, many solutions are available for the proactive care of the mental health and well-being of nurses. The American Nurses Association Healthy Nurse, Healthy Nation program has partnered with health care organizations across the country in a long-range, multifaceted effort to improve the health of nurses, providing essential resources for coping with the stresses and hardships caused by working during pandemic. Some hospitals and health systems have stepped up efforts to provide nurses with new resources such as digital platforms accessible via smart phones that offer immediate access to mental health support. Programs for meditation, stress management, relaxation rooms, massage, and other therapeutic services have been launched by hospitals as sources of self-care to help nurses reduce mental and physical distress. 12 The Institute for Healthcare Improvement outlined a program of "psychological PPE" to promote mental health and well-being among nurses, providing recommendations and tactics for individual nurses and leaders. 13 Psychological PPE on the individual level: Limit staff time on site/shift Design clear roles and leadership Train managers to be aware of key risk factors and monitor for any signs of distress Make peer support services available to staff Pair team members together to serve as peer support in a "buddy system" Daily or regularly scheduled practices at the unit level can be very helpful in reducing stress on nurses. Such practices may include Schwartz Rounds, which are group reflective practice forums where nurses and other health care professionals discuss the emotional and social issues they face in caring for patients and families. Schwartz Rounds complement traditional rounds in broadening the care focus to include clinicians themselves in addition to patients. Leader rounding with clinical staff also can have a positive impact. Other purposeful practices that can be helpful to manage and reduce the daily stresses of nursing include debriefing, team huddles, and peer-supported stress first aid. Nurses benefit when self-care is promoted across personal, organizational, and professional levels. A movement is underway to embed nurse mental health and well-being support in nursing education, which is vital to developing a nationwide culture of support for caregivers. This follows the American Nurses Association Code of Ethics, which emphasizes the duty of the nurse to not only promote the health and safety of patients and populations but also their own health and safety. Evidence shows that nurse educators teaching self-care and resilience to nursing students and in residencies can be effective in helping to reduce burnout and exhaustion, 14 and in enhancing awareness of the importance of stress reduction and self-care. 15 Nursing education programs that include an emphasis on nurses' health and well-being can enable nursing students to better prepare themselves as they transition into practice. AMN Healthcare made tens of thousands of nurse assignments during the pandemic; many of them were multiple consecutive assignments caring for patients with COVID-19. Throughout the health care staffing industry, a historic mobilization of travel health care professionals helped to rush care providers to where they were needed most across the nation. In this environment, enhancing care for caregivers required an aggressive virtual approach. One area of rapid innovation by AMN during the pandemic was mobile technology for the health care workforce. A mobile application was developed to help nurses manage all business aspects of their work, whereas another supported clinical work, such as video conferencing and exchanging critical information with patients, their families, and colleagues. AMN Healthcare also provided: Free counseling for AMN caregivers and family members, including on-the-spot sessions through telehealth. Clinical Care Calls for peer support of clinicians by the largest and most experienced clinical team in the health care industry Training in psychological first aid for clinical team leaders AMN Healthcare also partnered with many organizations to advance nurse well-being, including: National Alliance of Mental Illness to promote awareness of mental health services and removing stigmas around mental health Schwartz Center for Compassionate Care to promote safe space Daisy Foundation to increase recognition of nurses and their impact, specifically with rural, historically underrepresented facilities and expansion to postacute care settings. American Organization for Nursing Leadership to increase the sense of belonging among nurses, along with diversity in leadership, nurse manager resilience education, and funding minority nurse researchers National Black Nurses Association to support diversity initiatives, youth programs and the organizations mission American Nurses Foundation to help fund the Reimaging Nursing Initiative and to expand the call for the initial 11 pilot projects for nurse-driven care models National League for Nursing to promote the Eradicate Racism from Nursing Education series for nurse educators and faculty The COVID-19 pandemic threatened a disruption in progress for the nursing profession due to hardships that are unprecedented in the modern era. However, the lessons from and responses to the pandemic are creating a positive imprint on the profession as health care and professional organizations focus new attention and expand capacities for caring for caregivers, empowering leaders, and creating positive practice environments to improve the wellbeing of nurses and their engagement in the workplace. There is a near-universal awareness that solving the significant challenges from the pandemic and other problems is of paramount importance to nursing, healthcare, and the nation, because the health of the American people depends on the health of the nation's 4 million nurses. Though the problems that nursing faces in the pandemic are extreme, solutions are available. The entire nursing community and its supporters must be bold, brave, courageous, and steadfast to follow the way to a healthier nation for nurses and the public. American Association of Colleges of Nursing. Student enrollment surged in U.S. schools of nursing in 2020 despite challenges presented by the pandemic 2021 Survey of Registered Nurses/nursing and the nation: extreme challenges, extraordinary impact National Sample Survey of Registered Nurses (NSSRN) NCSBN's Environmental Scan: A Portrait of Nursing and Healthcare in 2020 and Beyond What moral distress in nursing history could suggest about the future of health care Moral distress, moral residue, and the crescendo effect Looking at the positive side of moral distress: why it's a problem The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity What makes a good work break? Off-job and onjob recovery as predictors of employee health New survey data: nurses recommend COVID-19 vaccines and support mandates and boosters if recommended. ANA Enterprise Homepage, News Releases KFF COVID-19 vaccine monitor Healthy nurse, healthy nation: year four highlights 2020-2021 Psychological PPE": promote health care workforce mental health and well-being Evidence-based resilience intervention for nursing students: a randomized controlled pilot trial Teaching accelerated nursing students' self-care: a pilot project Chief Clinical Officer at AMN Healthcare in Dallas, Texas. Paulette Anest, MSN, RN, is Head of Clinical and Education Solutions at AMN Healthcare in