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Coping with emotional stress

By: Christine Pabico, PhD, RN, NE-BC, and Holly Carpenter, BSN, RN

Supporting nurses through unprecedented times.


  • In a survey with 18,000 respondents, 79% of nurses rated themselves at high risk for workplace stress.
  • High nurse burnout rates are linked to decreased job satisfaction, increased turnover, and negative patient safety and satisfaction impact.
  • Several initiatives have been launched to address nurse stress during the COVID-19 pandemic.

Even before the COVID-19 pandemic began, nurses reported high stress levels. (See Nurses and stress.) Now, healthcare organizations and nurses at all levels are struggling to handle the surge of patients. Nurses are seeing their own friends, families, and colleagues get sick or even die from the virus, and they’re working long hours at a much faster pace in an environment where much remains unknown. Many are overwhelmed, if not confused, by conflicting and changing recommendations, and they feel anger, fear, grief, and frustration over inadequate personal protective equipment and health inequities. Compounding these challenges is the economic impact on many businesses, including hospitals. With community services and elective hospital cases on hold, furloughs and layoffs are occurring across the nation.

Nurses and stress

In an ANA Enterprise Healthy Nurse, Healthy Nation™ survey, which had more than 18,000 respon- dents, 79% of nurses rated themselves at high risk for workplace stress. High rates of burnout are reported among nurses, and studies by Davidson and col- leagues (2020) and Kõlves and De Leo suggest that nurses are at higher risk of suicide than the general population.

High rates of burnout are linked to several negative consequences for healthcare organizations, including:
• decreased employee job satisfaction
• increased turnover
• negative impact on patient safety and satisfaction.

The many stress factors associated with COVID-19 will likely lead to an escalation of nurse burnout. In a survey conducted by the American Nurses Association (ANA) in mid-March to April, nurses were asked what their biggest concerns were. More than half said they were worried not only about protecting themselves, but also about protecting their families and keeping them safe. Receiving the right information and loss of financial stability also emerged as factors causing the most worry.

Studies show that nurses with high resilience have a significantly lower incidence of symptoms of post-traumatic stress disorder (PTSD), second victim syndrome, anxiety, and depression. (See Second victim syndrome and PTSD.) To foster resilience, all of us must open up the discussion and create opportunities to support and offer resources to nurses. Three programs—American Nurses Credentialing Center’s Pathway to Excellence® #EmotionsBehindtheMask campaign, Healthy Nurse, Healthy Nation™ (HNHN), and the Well-Being Initiative—are doing just that.

Emotions Behind the Mask

Nurses will always smile in front of patients and co­workers. However, we must remember that many of them are suffering from the emotional toll of the pandemic. Behind each nurse’s mask may be sadness, grief, worry, or anxiety. For this reason, Pathway to Excellence launched the #EmotionsBehindtheMask campaign to bring awareness to the heightened threat to nurse well-being. The campaign’s goals are to identify COVID-19’s impact on nurses’ emotional well-being, offer platforms to begin much-needed dialogue, and share valuable resources. Safeguarding clinician well-being is a must, and this campaign encourages everyone (you and those around you) to pause and take the time to get to know the emotions behind the mask.

Second victim syndrome and PTSD

Many nurses experience second victim syndrome and post-traumatic stress dis- order (PTSD) in response to the stress they experience in their work.

Second victim syndrome is the reaction—typically guilt—healthcare providers may experience related to unanticipated adverse events. As nurses and other clinicians witness multiple deaths over a short time (as during the pandemic), they may feel they aren’t doing enough.

Studies by Tajvar and colleagues and Danella and colleagues also show that nurses, especially those working in in- tensive care units (ICUs), have a high risk of developing PTSD, with some comparing it to soldiers in battle. Prevalence is high among nurses because they face daily traumatic events associated with severe illness, suffering, and death. A study conducted in the United Kingdom by Sanchez and col- leagues showed that indicators for PTSD in ICU nurses were as high as 48%. Even on the general nursing floors, 14% of nurses reported experiencing PTSD. Signs and symptoms of PTSD include:

• sleeping problems
• irritability
• nightmares
• severe anxiety.


Since its launch in May 2017, ANA Enterprise’s HNHN initiative has strived to improve the health of the nation by improving the health of its nurses. HNHN collaborates with and connects nurses, nursing students, healthcare organizations, nurse employers, schools of nursing, universities, nursing associations and organizations, and other interested parties on nurse health, safety, and wellness in five domains: nutrition, physical activity, rest, safety, and quality of life. Via an online platform (free to everyone at hnhn.org), emails, texts, and social media, HNHN offers participants multiple wellness resources, including inspiring challenges, the Healthy­Nurse® Survey, topical blogs, contests, discussion boards, newsletters, access to a meditation app, and more.

To further assist with nurse mental health issues during the pandemic, HNHN has added a comprehensive Mental Health Help For Nurses blog compiled by HNHN’s Strength through Resiliency Committee. The blog contains resources from around the nation to support nurses’ mental well-being. Recent challenges focused on meditation, sleep, and physical activity at home have been geared toward boosting pandemic wellness. Financial wellness, meaningful recognition of nurses, and pandemic coping tips also have been posted. HNHN continues to emphasize the importance of nurse self-care. Safe and healthy nurses supported and valued by their communities, employers, and associations and organizations are effective weapons against nurse burnout and stress.

The Well-Being Initiative

In May 2020, the American Nurses Foundation, through its Coronavirus Response Fund, partnered with ANA, the American Association of Critical-Care Nurses, American Psychiatric Nurses Association, and the Emergency Nurses Association to create the Well-Being Initiative to provide nurses with access to a comprehensive suite of free resources and tools to support their mental health and well-being. Virtual support programs are available for nurses to process their experiences in small groups, one-on-one, or through writing. The initiative also provides access to a wellness app and resources for seeking mental health support; it will continue to launch new programs in the future. Get more information here.

Don’t go it alone

Nurse stress is at an all-time high. To effectively meet the challenges of this pandemic with their mental well-being intact, nurses need support from other nurses, employers, associations, and other interested parties. Resilience must be built, and practical stress-coping methods provided and used. Comprehensive self-care is a must—it’s not selfish or self-serving. In fact, it’s an ethical duty as spelled out in Provision 5 of the Code of Ethics for Nurses With Interpretative Statements: “The nurse owes the same duties to self as to others, including the responsibility to promote health and safety.” Don’t go through this alone. Take advantage of peer and group support, open dialogue, employee assistance, mental healthcare, hotlines, and other resources that are available to help you.

Christine Pabico is the director of Pathway to Excellence® Program at the American Nurses Credentialing Center in Silver Spring, Maryland. Holly Carpenter is a senior policy advisor at the American Nurses Association in Silver Spring, Maryland.


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