When the World Health Organization declared 2020 the Year of the Nurse and Midwife, I doubt that they envisioned what nursing would face in 2020 and into 2021. Nurses are the backbone of health care delivery, and it has never been more evident than with the unprecedented events that have occurred worldwide.

The unrelenting pressure experienced by many US nurses since early 2020 has been overwhelming and will have consequences into the foreseeable future. We must begin to name what nursing is experiencing as a form of complex trauma. When traumatic experiences are stacked upon one another without the time to process them, mental health concerns become paramount in assisting the profession to recover from the pandemic, and for some, added multiple natural disasters to their communities and homes just adds to the trauma.

The ICD 11 identifies complex trauma as occurring with a series of traumatic events eventually leading to one-to-many traumatic events, which put the person over their trauma threshold. The pandemic and the variants that are emerging fit that concept, especially for nursing.

In the early 2010s, nurses envisioned their profession as one that certainly had challenges when caring for the person who was ill. I doubt they thought about the unrelenting, day to day concerns that are involved with taking care of the world. I imagine that they did not see working in conditions that did not allow for adequate personal protective equipment, where families could not be with their loved ones, or where new and innovative ways had to be rapidly adapted to changing situations.

Complex trauma encompasses the criteria for PTSD (re-experiencing, avoiding and hypervigilance) and adds three additional areas of disturbance related to self-organization: emotional dysregulation, interpersonal difficulties, and negative self-concept. When working as a psychotherapist I encountered this fairly frequently, but not to the degree we are seeing with nursing in the past year or two. We need to call it what it is – complex trauma – to be able to identify what lessons we have learned and how we can mitigate the long-term consequences and preserve the nursing profession.

Studies are emerging which identify the emotional toll the pandemic has had on the nursing force, with one NurseGrid study indicating that 20% of the nurses participating in the survey were considering leaving the profession, retiring or switching to a different role in the next year.

In addition to the trauma associated caring for patients and family members who are themselves traumatized, nurses are reporting increases in depression, anxiety, and substance use. The supply of nurses is expected to have a deficit of around 10 million nurses worldwide. We must save our profession, especially our brothers and sisters that work in the frontlines. They have the building blocks for resilience and self-worth, and they need strategies which focus on healing the wounds that the pandemic has created. So, what have we learned so far and what do we need to do in the future?

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Responses are needed from organizational, educational, and personal perspectives, at a minimum.

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Organizations

·     Encourage supportive relationships among the team members

·     Assure that every nurse/employee takes breaks for eating, drinking, biological needs and steps away from the work environment at least once or twice per shift

·     Try to assure adequate time off from work wherever possible

·     Identify structures which are no longer working and develop new and innovative ways to assist nurses, and by extension families and patients

·     Provide safe spaces where nurses can support each other and find an empathetic ear

·     Provide for mental health care strategies adapted to the unique work environment

·     Explore programs that can be incorporated into the environment that promote resilience. An example is Resilience in Stressful Events (RISE).

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Educational Systems

·     Retention of students must be considered, and student fears allayed as much as possible

·     Promote self-care within the nursing student community/cohort

·     Utilize basic therapeutic strategies, like Cognitive Behavioral Therapy concepts, to encourage students to reframe what they are feeling, seeing, and experiencing

·     Relook at curriculum development to add in the new concerns, techniques and skills that are now being utilized. For instance: telehealth, epidemiology, and the lessons we are learning from this protracted pandemic.

·     Teach trauma informed care. A few resources can be found here.

‍Personal Strategies

·     Balance work and home life as much as possible

·     Try to stay in tune with co-workers and help identify the cues they each have which indicate that they are approaching their limits.

·     Debrief with co-workers after particularly stressful and traumatic days

·     Make a list of things that you enjoy doing and find relaxing and employ them when you feel tension rising. They can be simple things that can be done at work, like practicing deep breathing, running warm water over your hands, walking in the halls, physical exercise or punching a pillow if needed. Others are things to do on your days off – music, reading, journaling.

·     Become attuned to yourself – know when you are experiencing stress that gets in the way of providing quality patient care or functioning in your home environment

·     Enter therapy if you are feeling too overwhelmed

·     Practice mindfulness several times a day and just be in the moment

·     Other self-care resources can be found here and here.

·     What else can you think of that fits into your life?

Jean Watson, a nurse theorist, and professor, reminds us: “Nurses are a unique kind. They have this insatiable need to care for others, which is both their greatest strength and fatal flaw.”

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