Study: Critical Care Nurses’ Poor Mental Health Is Jeopardizing Patient Safety

May 17, 2021
A study by a large group of healthcare researchers is warning senior hospital leaders that they need to address the poor mental health status of critical care nurses, which they believe could be endangering patient safety

A new study of the mental health and the working conditions of critical care nurses (CCNs) in the U.S. healthcare system, based on an extensive nationwide survey, is pointing to systemic issues that could put patients at risk. According to an analysis created by a large team of healthcare researchers and that was published in the May issue of the American Journal of Critical care (AJCC), critical care nurses are at significant risk for burnout, with some of that risk spilling over into patient safety concerns.

The article, entitled “Critical Care Nurses’ Physical and Mental Health, Worksite Wellness Support, and Medical Errors,” looks at the intersection of those various elements it was written by a large team of researchers, led by Bernadette Mazurek Melnyk, Ph.D., APRN-CNP. The other authors are Alai Tan, Ph.D.; Andreanna Pavan Hsieh, M.P.H.; Kate Gawlik, DNP, APRN-CPN; Cynthia Arslanian-Engoren, Ph.D., RN, ACNS-BC; Lynne T. Braun, Ph.D., CNP; Sandra Dunbar, DSN, R.N.; Jacqueline Dunbar-Jacob, Ph.D., R.N.; Lisa M. Lewis, Ph.D., R.N.; Angelica Millan, DNP, CNS, NP Liana Orsolini, Ph.D., R.N.; Lorraine B. Robbins, Ph.D., R.N., FNP-BC; Cynthia L. Russell, Ph.D., R.N.; Sharon Tucker, Ph.D., APRN-CNS, NC-BC; and JoEllen Wilbur, Ph.D., APN.

The objective, the authors write in the article, was “To examine the associations among critical care nurses’ physical and mental health, perception of workplace wellness support, and self-reported medical errors.” With that in mind, they write that “This survey-based study used a cross-sectional, descriptive correlational design. A random sample of 2,500 members of the American Association of Critical-Care Nurses was recruited to participate in the study. The outcomes of interest were level of overall health, symptoms of depression and anxiety, stress, burnout, perceived worksite wellness support, and medical errors.”

And what did they find? “A total of 771 critical care nurses participated in the study,” they write. “Nurses in poor physical and mental health reported significantly more medical errors than nurses in better health,” while “Nurses who perceived that their worksite was very supportive of their well-being were twice as likely to have better physical health”—95 percent versus 55.8 percent.

For context, they note that, “In 2017, the National Academy of Medicine (NAM) launched the Action Collaborative for Clinician Well-being and Resilience in response to increased rates of burnout, depression, and suicide and their adverse effects on clinician well-being and patient safety. A national US study of 1,790 practicing nurses from 19 health care systems indicated that worse physical and mental health of nurses was related to a greater number of reported medical errors. That study was the first to demonstrate that depression was the leading predictor of medical errors among nurses. Furthermore, nurses who perceived greater support for wellness at their worksite had better physical and mental health outcomes. Yet that national study did not specifically examine health and medical errors of critical care nurses (CCNs) or the relationship of those factors to perceived wellness support.”

Further, “Critical care nurses are known to experience higher levels of stress than nurses in other specialties because of their complex clinical environment, which includes high patient acuity, increased use of advanced technology, and frequent exposure to loud alarms and fluorescent light sources. Their physical health is negatively affected by long shifts with limited breaks to rest properly, often resulting in sleep disruption, headaches, cardiovascular disease, gastrointestinal symptoms, and musculoskeletal disorders. The mental health of CCNs is also adversely affected by their work with critically ill patients, which includes frequent exposure to traumatic events and the need to regularly deal with ethical issues that arise.”

What’s more, “Research findings indicate that CCNs have high rates of posttraumatic stress disorder, burnout, anxiety, and depression.  One study showed a 24-percent prevalence rate of posttraumatic stress disorder in CCNs, compared with 15 percent in nurses working in other clinical areas.  Regarding burnout, a systematic review of 206 studies of CCNs indicated a prevalence ranging from 6 percent to 47 percent.  Additional prevalence studies have shown that 23 percent to 28 percent of CCNs report anxiety and 15 percent to 30 percent experience depression. In comparison, the 12-month prevalence rate of depression in the general US population is 10 percent. The rates of mental health problems in CCNs are expected to increase even further as the COVID-19 pandemic continues to amplify fears about contraction and transmission in addition to inconsistent availability of ventilators and personal protective equipment.”

With those findings from past studies in mind, the authors write that “This study used a cross-sectional, descriptive correlational design. The institutional review board at the study site deemed the study protocol exempt from the need for approval. Data were collected from August 31, 2018, through August 11, 2019. A simple random sample of 2,500 members of the American Association of Critical-Care Nurses (AACN) was recruited to participate in this study after the entire AACN membership was initially contacted and informed about the opportunity. The study survey was administered through Qualtrics, an online survey software program. An anonymous survey link was emailed or mailed directly to the AACN members; of the 2500 members contacted, 1139 agreed to participate (response rate, 45.6 percent). Once the email link or QR code was activated and before starting the survey, participants provided consent through an online consent form. Data gathered were anonymous and did not have any of the 18 HIPAA (Health Insurance Portability and Accountability Act) privacy rule identifiers. To examine the relationship among CCNs’ health, perceived worksite wellness support, and medical errors, we analyzed data only from participants whose primary role was in clinical practice.”

As they note, “Four questions from the Professional Quality of Life Scale (ProQOL) were used to assess burnout: ‘I feel worn out because of my work’; ‘I feel trapped by my job’; ‘I am not as engaged with my patients today as I used to be’; and ‘I believe I can make a difference through my work.’” Meanwhile, “Perceived workplace wellness support was assessed by asking ‘How supportive is your work environment of personal wellness?’ Participants rated this question using a Likert-type scale that ranged from 0 (not at all) to 4 (very much so). Medical errors were defined as ‘preventable adverse effects of care.’ Participants reported the number of medical errors they had made in the past 5 years. Response options were none, 1 to 2, 3 to 5, or more than 5.”

And what the researchers found was this: The CCNs reported suboptimal health, with 470 (61.0 percent) reporting a physical health score of 5 or lower and 393 (51.0 percent) reporting a mental health score of 5 or lower. A substantial proportion of nurses reported some degree of depressive symptoms (n = 304; 39.5 percent), anxiety symptoms (n = 409; 53.2 percent), and stress (n = 325; 42.2 percent). Only about a third of the nurses (n = 307; 39.8 percent) reported high professional quality of life. Nearly two-thirds (60.9 percent) of the CCNs reported having made medical errors in the past 5 years. For all of the health measures (physical health, mental health, PHQ-2, GAD-2, PSS-4, and ProQOL-4), the occurrence of medical errors was significantly higher among nurses in worse health than those in the better health categories. For example, 67.0% of the nurses with higher stress scores versus 56.5% of the nurses with no or little stress reported having made medical errors in the past 5 years.” What’s more, “The association between the nurses’ health measures and medical errors was sustained after adjusting for age, sex, race/ethnicity, marital status, education, and hours of work per day or shift. Compared with nurses reporting better health, those with worse health had a 31% (odds ratio [OR], 1.31; 95 percent CI, 0.96-1.78 for physical health) to 62 percent (OR, 1.62; 95% CI, 1.17-2.29 for depressive symptoms) higher likelihood of having made medical errors.”

Importantly, “The proportion of nurses with better physical health (self-reported physical health score ≥6) increased with higher perceived workplace wellness support: 32.9 percent, 38.0 percent, and 55.8 percent for not at all/a little, somewhat, and very much support, respectively. The same trend was also observed for all of the other health measures, including mental health, depressive symptoms, anxiety symptoms, stress, and professional quality of life.” Also, “The significant relationship between greater perceived support of wellness and better health held after adjusting for nurses’ age, sex, race/ethnicity, marital status, education, and hours of work per day or shift in the multiple logistic regression models. Compared with nurses whose workplaces provided little or no support, those whose workplaces provided greater support for wellness were more than twice as likely to have better personal health, with ORs ranging from 2.16 (95 percent) for better physical health to 8.96 (95 percent) for high professional quality of life. Nurses whose workplace provided some support also had higher odds of having better health and professional quality of life compared with those whose workplace provided little or no support after adjusting for other covariates in the model, with ORs ranging from 1.20 (95 percent) for better physical health to 2.96 (95 percent) for high professional quality of life. We found similar associations of health with medical errors and workplace wellness support when analyzing health measures as continuous variables.”

As a result, the article’s authors write that “This study’s findings provide support for a strong positive association between suboptimal physical and mental health in CCNs and the occurrence of medical errors. Nearly 40 percent of CCNs in this study reported some degree of depressive symptoms, and more than 50 percent reported anxiety symptoms, proportions that are higher than those that have been reported in other studies of CCNs (depression, 23-31 percent; anxiety, 18-20 percent). Unresolved depression can lead to suicidal ideation and action, which have been on the rise and occur at a higher rate in nurses than in the general population. Therefore, health care leaders need to implement screening programs that detect symptoms of depression in their clinicians so that evidence-based treatment can be made available. One successful program is the HEAR (Healer Education Assessment and Referral) screening program, which provides anonymous online depression screening and treatment referral and is patterned after a program developed by the American Foundation for Suicide Prevention.  Since its inception, the program has successfully identified a substantial number of suicidal nurses and connected them with treatment options.”

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