By Don Sadler
The past year-and-a-half has been a time unlike any that most nurses have ever seen due to the upending of the nation’s health care system by the COVID-19 pandemic. As a result, the health care profession has dealt, and is still dealing, with unprecedented levels of stress, anxiety and burnout among all nurses, including those in the OR.
Stress, depression, anxiety and even suicide were already high among health care workers before the pandemic, says Vangie Dennis, MSN, RN, CNOR, CMLSO, assistant vice president, perioperative services at Anmed Health. “We were dealing with two times the rate of suicide among physicians and over 20 percent of nurses were suffering from PTSD,” she says.
“The pandemic is presenting clinicians with even greater workplace hardships and moral dilemmas that are likely to exacerbate existing levels of burnout and related mental health problems,” Dennis adds. “How they cope with these emotions can affect their well-being, the care they give to others and the well-being of the people they care about outside of work.”
Looking back to the beginning of the pandemic, perioperative nurses shared the same type of roller-coaster emotions felt by all nurses, notes Phyllis Quinlan, Ph.D., RN-BC, the career coach for the Association of peri-Operative Registered Nurses (AORN).
“They were wondering, ‘Is this real? How can this be happening? And how am I going to care for patients and keep my family safe?’ ” says Quinlan. “These questions were soon replaced by the reality that their life and nursing practice were going to be seriously altered for an indefinite period of time.”
Most perioperative nurses were concerned about keeping the ORs open, the potential of deployment to a place beyond their comfort zone and skill competency, and the ever-looming chance of being furloughed. “Some spoke about being very unsettled while others were struggling with real fear,” says Quinlan.
“Still others struggled with what Dr. Brene Brown calls ‘comparative suffering,’ ” Quinlan adds. “Once they became aware of the enormity of what was being asked of their colleagues, they found themselves battling self-imposed guilt for not ‘suffering’ equally and feeling as though they got a ‘free ride.’ ”
Of course, there have also been nurses experiencing the grief and bereavement associated with the loss of a family member, friend or colleague to the pandemic. “There is no timetable for working through loss and grief,” says Quinlan. “It is a very personal experience that can be triggered long after the actual loss of a loved one.”
“We should not hesitate to offer specialized grief counseling before a staff member becomes overwhelmed,” Quinlan adds.
In thinking back to the beginning of the pandemic, Dennis says she initially thought COVID-19 was just another virus.
“I definitely was not prepared for the impact,” she recalls.
According to Dennis, experiencing or witnessing traumatic events impacts everyone differently. “Sometimes the stress can be managed successfully but other times individuals may experience clinically significant distress or impairment, such as acute and post-traumatic stress disorder or secondary traumatic stress,” she says.
“Compassion fatigue and burnout may also result from chronic workplace stress and exposure to traumatic events during the COVID-19 pandemic,” Dennis says.
A Myriad of Feelings
“Nurses are human too and have experienced a myriad of feelings and emotions during the pandemic,” says David Taylor, MSN, RN, CNOR, president of Resolute Advisory Group LLC. “Bereavement, isolation and fear have triggered many of the mental health conditions that have been reported as a result of the pandemic.”
“Unfortunately, some health care providers are managing their stress with increased levels of alcohol and drug use,” Taylor adds.
Taylor is concerned that we have yet to see the worst of these symptoms among nurses.
“Nurses suited up for work every day and continued to care for the sick,” he says. “I believe many of their emotional responses and symptoms due to the pandemic will be delayed and have a profound impact on the profession going forward. PTSD will plague some for years to come.”
According to Taylor, nearly 30 million surgical procedures were canceled or postponed worldwide because of the pandemic.
“As a result, many perioperative nurses stopped being OR nurses and began caring for patients with and without COVID-19 on inpatient units and in the ICUs,” he says.
“Many of these nurses who stepped up to the challenge during the crisis are now returning to their ORs and working harder than ever to help their organizations catch up with the backlog of elective procedures,” says Taylor.
Some nurses have not had a chance to process their grief or other mental and emotional strains as a result of the pandemic because the demands placed upon them are not over yet, Taylor adds. “I’m afraid many nurses will experience long-term effects as a result and each will process their stressors differently and at varying times,” he says.
High Stress Levels
Karen Reiter, RN, CNOR, RNFA, CASC, is the CEO of DISC Surgery Center in Newport Beach, California. She recalls the intense stress many nurses experienced at the onset of the novel coronavirus outbreak.
“At the beginning of the pandemic, the stress level among our nurses was high,” she says. “They were challenged with their children at home and wondering if it was safe to come to work and were they doing everything correctly to protect themselves and their family from the virus.”
Not surprisingly, her staff was also worried about whether the ASC would remain open or have to shut down.
“Money was definitely a big concern,” she says, but her facility remained open throughout the pandemic. “We also continued paying any full-time staff members who caught the virus for the entire time they were out sick, so their families were not harmed financially.”
Reiter says there were lots of tears over the past year as well as increased friction and fatigue among her staff. “We were desperately short staffed with nurses going out sick and our per diem staff who worked in the main hospitals no longer being available to us,” she says.
Some positive experiences did emerge from the ordeal.
“It created more of a team,” says Reiter. “We all pledged to live a certain way to reduce the risks to ourselves and each other. Also, one of our owners used his charity to charter a 747 to China and bought back 184,000 N-95 masks for use in our ASC, and then he donated the rest to hospitals.”
Dennis stresses the importance of holistic resilience when it comes to caring for oneself in the midst of these trying circumstances. “The question is: How do we care for ourselves so that we might be able to care for others?” she says.
“On an airplane they tell you to put the oxygen mask on yourself first so you can help others, but this goes against the grain for many nurses,” Dennis adds. “But if you don’t, there won’t be anything left in the tank. As nurses, we have to rest, recharge and sleep.”
There’s an important distinction between resilience and endurance, says Dennis.
“Endurance is the ability to withstand hardship or adversity over an extended period, while resilience is the ability to adjust to, recover or grow from it,” she explains. “While we’re in the midst of the intensity of the pandemic, it’s OK simply to endure.”
“But endless endurance leads to collapse,” says Dennis. “When we’re working this hard, resilience means coupling the intensity of our work with periods of relaxation and recovery.”
Dennis encourages nurses to make time for activities that allow them to disengage from the intensity and rejuvenate their mind and body.
“Sufficient sleep, healthy eating, regular exercise and moments of quiet all help balance out the stress of our work,” she says.
To help nurses cope with the stress, anxiety, burnout and other factors resulting from the pandemic, the American Nurses Foundation and a consortium of other health care organizations teamed up to create the Well-Being Initiative.
“This is a multi-tiered approach to support the mental health and well-being of America’s nurses who are on the frontline of diagnosing, treating and caring for the individuals and families impacted by the COVID-19 pandemic,” says Allison Nordberg, program director of the American Nurses Foundation.
The feedback provided by nurses who have participated in the Well-Being Initiative programs has been overwhelmingly positive.
“Nurses have reported that the programs have given them the opportunity to reflect and feel supported,” says Nordberg. “There are several multi-week programs which have been shown to decrease participants’ stress levels and have a positive impact on nurses even after the program concludes.”
More information about the Well-Being Initiative is available at nursingworld.org/thewellbeinginitiative.
Quinlan believes that the biggest emotional and mental challenge for perioperative nurses is trying to stay optimistic and resilient in the face of relentless and persistent uncertainty.
“We are not built for navigating uncertainty for this length of time,” she says. “While we are accustomed to powering through for days, weeks and on rare occasions even a month, this challenge has been ongoing for more than a year now and has taxed everyone to their limit.”
Dennis offers some suggestions to help OR nurses and perioperative nursing leadership cope with these challenges and increase their resilience.
“First, there has to be open communication among coworkers and their supervisors about the stress they’re feeling,” she says. “Everyone needs to feel free to talk openly about how the pandemic is affecting them professionally and personally.”
Other suggestions from Dennis include the following:
- Identify factors that cause stress and work together to identify solutions.
- Ask about how to access mental health resources in your workplace.
- Remind yourself that everyone is in an unusual situation with limited resources.
- Recognize that you are performing a crucial role in fighting this pandemic and that you are doing the best you can with the resources available.
- Increase your sense of control by keeping a consistent daily routine when possible – ideally, one that is similar to your schedule before the pandemic.
- Try to get adequate sleep and make time to eat healthy meals.
- Take breaks during your shift to rest, stretch or check in with supportive colleagues, coworkers, friends and family.
- Get as much exercise as you can and spend additional time outdoors.
- Engage in mindfulness techniques such as breathing exercises and meditation.
- If you are being treated for a mental health condition, continue with your treatment and talk to your provider if you experience new or worsening symptoms.
“Amidst adversity, there is always an opportunity to learn and grow,” says Dennis. “But after the pandemic ends, we do not simply want to return to the way things were before, which included more than one-third of nurses suffering from burnout and up to 20 percent reporting symptoms of PTSD.”
“We want to do better,” Dennis stresses. “We have challenging and important work to do, and the world needs us now more than ever.”