It was a bracing experience, if unsurprising, to read an article in the May issue of the American Journal of Critical Care, entitled “Critical Care Nurses’ Physical and Mental Health, Worksite Wellness Support, and Medical Errors,” written by Bernadette Mazurek Melnyk, Ph.D., APRN-CNP, and a team of 14 fellow researchers, nearly all of whom have nursing backgrounds. As I wrote earlier this week, the study provides strong evidence that the critical care nurses (CCNs) in the nation’s hospitals are not only seriously stressed these days; their precarious mental health—as described by the CCNs themselves—should give pause.
As the researchers explain in their article, their objective 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.
And here are some of the bracing statistics represented by the survey’s results: fully 61 percent of the CCNs responding to the survey reported a physical health score of 5 or lower, and 51 percent reported a mental health score of 5 or lower. Even more worrying, 39.5 percent reported some degree of depressive symptoms, 53.2 percent reported anxiety symptoms, and 42.2 reported stress. Only 39.8 percent reported high professional quality of life. And 60.9 percent reported having made medical errors in the past five years. Most importantly, the occurrence of medical errors was significantly higher among nurses in worth health. For example, 67 percent of the nurses with higher stress scores reported having made medical errors in the past five years, versus 56.5 percent with little or no stress. Importantly, even after the researchers adjusted for age, sex, race/ethnicity, marital status, education, and hours of work per day or shift, the connection remained strong. Indeed, compared with nurses reporting better health, those with worse health had a 62 percent higher likelihood, if experiencing depression, of having made medical errors.
Now, here’s where senior executives and leaders of patient care organizations come in: as the article’s authors write, “The proportion of nurses with better physical health increased with higher perceived workplace wellness support… 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.”
In other words, senior hospital and health system leaders can do something about this crisis: they can create the best working conditions possible, and can actively check in with their critical care nurses and do what’s possible in the context of this moment in U.S. healthcare, to support their mental and physical health. Here’s the thing: the authors of this article totally understand what’s been going on during the COVID-19 pandemic, which during much of last year made everyone working in inpatient hospitals feel as though they were working in MASH units just off the battlefield. What’s more, even as COVID cases are now declining significantly, and the worst of the pandemic appears to be over, nurses, physicians, and really, practically everyone working in hospitals, clinics, and health systems, is having to deal with longer-term effects of stress (not to mention that some clinicians and other healthcare workers actually have become physically ill themselves). The reports of mental health crisis have been harrowing, and a small number of physicians and nurses have taken their lives.
More commonly, significant numbers of nurses and physicians have told reporters and those conducting surveys that they’re strongly or moderately considering leaving healthcare already. And that is at a time when the nurse workforce is aging significantly, and we were already in an anticipated crisis around that issue.
There are multiple issues here. In an article published in the Health Affairs Blog on May 3, 2017 and entitled “How Should We Prepare For The Wave Of Retiring Baby Boomer Nurses?” Peter Buerhaus, David Auerbach, and Douglas Staiger wrote that, “Beginning in the early 1970s, career-oriented and largely female baby boomers embraced the nursing profession in unprecedented numbers following large increases in health care spending after the introduction of the Medicare and Medicaid programs. By 1990, baby-boomer registered nurses (RNs) numbered nearly one million and comprised about two-thirds of the RN workforce. As these RNs aged over the next two decades,” they wrote, “they accumulated substantial knowledge and clinical experience. The number of boomer RNs peaked at 1.26 million in 2008, and, after a brief delay in the early part of the current decade (likely associated with the Great Recession), the baby-boomer RN cohort began retiring in large numbers. Since 2012, roughly 60,000 RNs exited the workforce each year, and by the end of the decade more than 70,000 RNs will be retiring annually. In 2020, baby-boomer RNs will number 660,000, roughly half their 2008 peak.”
What’s more, Buerhaus, Auerbach, and Staiger wrote, “The retirement of one million RNs from the nursing workforce between now and 2030 will mean that their accumulated years of nursing experience leave with them. We estimate that the number of experience-years lost from the nursing workforce in 2015 was 1.7 million (multiplying the number of retiring RNs by the cumulative years of experience for each RN), double the number from 2005 (see Figure 1). This trend will continue to accelerate as the largest groups of baby-boomer RNs reach their mid to late sixties. The departure of such a large cohort of experienced RNs from the workforce means that patient care settings and other organizations that depend on RNs will face a significant loss of nursing knowledge and expertise that will be felt for many years to come.”
That article prompted a long series of very thoughtful comments from readers. One particularly thoughtful comment was this one: “There are some additional considerations as the baby boomer generation of nurses retire. Will lower experience mix of nursing staff lead to higher adverse events or worse patient outcomes? Will retirement of nursing faculty lead to a decrease in the number of new graduates which could add to the problem of local or even national shortages of nurse? Will there be pressure to increase wages of nurses or increase turnover in competitive environments where multiple hospitals compete for experience nurses? Will overall costs of nursing care, approximately 25 percent of hospital operating budget, decrease (assuming older nurses have higher salaries), and if so, will that provide opportunities to increase the number of nurses or would hospitals or other facilities use the nursing cost savings for other purposes?”
Well, yes—exactly all that.
And then came the catastrophe of the COVID-19 pandemic. Per that, one particularly thoughtful and interesting study was published online on March 15 in the journal AACN Advanced Critical Care, which is published by the American Association of Critical Care Nurses and is a sister publication to the American Journal of Critical Care.
Entitled “Experiences of Nurses During the COVID-19 Pandemic: A Mixed-Methods Study,” it was authored by Jenna A. LoGiudice, Ph.D., CNM, R.N., FACNM, and Susan Bartos, Ph.D., R.N., CCRN. The authors used a sophisticated combination of a survey, individual interviews, and data analysis, to identify major themes emerging from interviews with hospital-based nurses conducted as the pandemic was peaking. They found several major themes common among the 21 nurses they interviewed extensively. The first was the constant confusion at the height of the pandemic, as everything was moving fluidly, and hospital leaders were struggling with how to manage surging patient volumes and continuously evolving clinical protocols for caring for COVID patients. As one nurse told them, “There was a lot of confusion from [the] administration with changing guidelines, directions, [and] endless questions.”
And the authors write in their article that “The negative emotions, frustration, anxiety, and stress they each expressed stemmed from the unknown and from both the constantly changing protocols related to patient care and the continual changes surrounding proper use and allocation of PPE”—personal protective equipment. Second, the no-visitor policy, necessitated by the extreme potential for infection of the virus, meant that nurses were required to “provide not only the medical needs but also the emotional and mental support” to patients, especially those who were intubated. As everyone knows, many, many thousands of COVID patients died in ICUs with no physical access to their loved ones, and with nurses comforting them during their dying moments. “Nurses expressed the heavy emotional toll related to patients dying without their family present, and how they as the nurse did everything in their power to bridge the gap and to be the family,” as they told the researchers. Nurses also dealt with the constant fear of becoming ill with COVID themselves, or of spreading the virus to their loved ones. And they struggled with basic physical and mental exhaustion.
And now? We are in a situation in U.S. healthcare in which some of the most highly skilled nurses in the healthcare system, experienced critical care nurses, are collectively in a state of stress, distress and burnout. What can senior leaders of patient care organizations do?
It seems clear that the leaders of patient care organizations nationwide will need to perform some kind of well-being inventory of their clinicians right now—physicians, nurses, all clinicians—and of course, non-clinicians as well. But, focusing on this specific group of nurses, critical care nurses, senior organizational leaders will need to take decisive action and move both to support those CCNs now on staff, as well as, let’s face it, prepare for some to leave, including possibly leave the field together. And for those on staff now, they will need to take meaningful action to create the best working conditions possible, and, clearly, to provide mental health support to their CCNs.
It’s impossible to know what percentage of CCNs and other valuable clinicians might actually leave the field altogether or retire; at the height of the pandemic, the stress was so great that, naturally, many considered doing so. Now, as we begin to move towards something approaching a new normal, the acute distress might have passed; but longer-term burnout issues loom large—and won’t be going away anytime soon. So now seems like a very important time for leaders to find out what’s actually happening in their organizations, and to take decisive action—for every obvious reason.
