Supporting nurses’ recovery during and following the COVID-19 pandemic
Intended for healthcare professionals
Evidence and practice    

Supporting nurses’ recovery during and following the COVID-19 pandemic

Jennifer Jackson Assistant professor, University of Calgary, Calgary, Alberta, Canada

Why you should read this article:
  • To understand the widespread effects of coronavirus 2019 (COVID-19) on healthcare staff

  • To implement elements of recovery that can support you during the COVID-19 pandemic

  • To learn how your organisation can aid your recovery during COVID-19

Research suggests that working during traumatic events can lead to deteriorating physical and mental health for nurses, a phenomenon that has been demonstrated during the coronavirus 2019 (COVID-19) pandemic. However, research has also shown that there are evidence-based strategies that can be used to assist nurses in their recovery from such events. Promoting awareness among individual nurses about the effects of COVID-19 enables them to adopt positive coping strategies, both on an individual and organisational level. This article details strategies including formal and informal debriefing, taking regular breaks, and using stress mitigation strategies during shifts. The article also discusses the potential for post-traumatic psychological growth. This acknowledges that while working in a healthcare environment during COVID-19 can be extremely challenging, it also enables nurses to experience personal growth such as the development of emotional intelligence. As nurses adapt to the ‘new normal’ of working during COVID-19, healthcare organisations should ensure that they provide nurses with the support that enables them to recover effectively.

Nursing Standard. doi: 10.7748/ns.2021.e11661

Peer review

This article has been subject to external double-blind peer review and checked for plagiarism using automated software

@JJackson_RN

Correspondence

jennifer.jackson1@ucalgary.ca

Conflict of interest

None declared

Jackson J (2021) Supporting nurses’ recovery during and following the COVID-19 pandemic. Nursing Standard. doi: 10.7748/ns.2021.e11661

Published online: 15 February 2021

Coronavirus 2019 (COVID-19) has had widespread effects that researchers and healthcare professionals are only just beginning to understand. Evidence suggests that nursing during extreme events can be profoundly stressful (Nukui et al 2018), and that nurses can experience regret and be ‘haunted’ by challenging experiences during their careers (Wolf and Zuzelo 2006, Von Arx et al 2018). This evidence indicates that nurses are likely to require support to recover from working during the COVID-19 pandemic. While data about the effects of the COVID-19 pandemic on nurses is still being widely examined, studies demonstrate that nursing during the pandemic is extremely challenging, but that some interventions, such as reasonable shift schedules, psychological support, and adequate personal protective equipment, can be used to support nurses (Huang et al 2020, Liu et al 2020).

During the COVID-19 pandemic there have been various stages, with some periods involving high numbers of cases and other periods involving a reduced demand for healthcare services. This means that during the course of the pandemic there may be opportunities for healthcare staff to engage in a period of recovery where the number of cases decreases or stabilises (Stewart 2020). It is important to consider how nurses can recover, and what recovery might entail, for both individual nurses and healthcare organisations. The COVID-19 pandemic has placed an unprecedented burden on many nurses, and there is a need to process these events. Similarly, nurses would benefit from organisational support to assist them in their recovery.

At present, there is no consensus on a research-based definition of recovery from COVID-19, beyond the physical recovery. However, some researchers have theorised that there are three phases of response from healthcare professionals to a crisis, with corresponding emotional and psychological states, including (Stewart 2020):

  • Preparation phase: anticipatory anxiety.

  • Active phase: heroics and surge to solution; disillusionment and exhaustion.

  • Recovery phase: recover and long-term psychological effect.

It could be argued that the notion of returning to ‘normal’ following the COVID-19 pandemic is not a useful concept, primarily because there were already challenges with the effective functioning of healthcare systems even before the pandemic. This means that the recovery process for nurses may not be straightforward. In addition, studies have identified that nurses do not feel prepared to manage disasters (Labrague et al 2018), and it is unlikely any individual was prepared for COVID-19. Therefore, it is reasonable that nurses will need to process their experiences and be supported following the COVID-19 pandemic.

This article examines the elements that might constitute a recovery process for nurses and how these can be implemented to manage the personal repercussions of COVID-19. It discusses several individual evidence-based strategies – such as awareness, debriefing, taking breaks and personal self-care – and organisational interventions that may support nurses to recover and adapt to the ‘new normal’ of working during COVID-19.

Key points

  • Evidence suggests that nurses are likely to require support to recover from working during the coronavirus 2019 (COVID-19) pandemic due to the challenging nature of the work

  • During the course of the pandemic there may be opportunities for healthcare staff to engage in a period of recovery where the number of cases decreases or stabilises

  • One significant action that nurses can undertake when seeking to recover from the COVID-19 pandemic is to reflect on how they have been affected. This reflection can incorporate the concept of awareness

  • Debriefing can be an important element of recovery for nurses, for example by talking informally with colleagues, or via a more formal arrangement with the organisation

  • Taking regular breaks at work and implementing personal self-care, for example ensuring adequate sleep, also form part of the recovery process

Awareness

One significant action that nurses can take when seeking to recover from the COVID-19 pandemic is to reflect on how they have been affected. This reflection can incorporate the concept of awareness, which involves the individual recognising how they are being affected by adversity (Jackson 2018, Jackson et al 2018). Awareness is vital to overcoming adversity, because it encourages people to take action (Jackson et al 2018).

During an event such as the COVID-19 pandemic, nurses can be attentive to the coping strategies they are using such as taking time away from work and relying on social support, and whether these strategies are effective. This awareness results in a process of ‘self-tuning’ or self-adjustment, which enables nurses to adapt their behaviour in a healthy way (Spreitzer et al 2005, Vinje 2007). Nurses have reported benefits from identifying their physical and mental reactions to stressors, thereby increasing their awareness of the effect of critical events (de Boer et al 2014). For nurses, taking time to reflect on the effect that the COVID-19 pandemic has had on them is a useful strategy when seeking to recover.

Debriefing

Debriefing can be an important element of recovery for nurses and it is vital that nurses and their colleagues talk about their experiences (de Boer et al 2014). Discussing personal experiences is a crucial intervention that supports mental health (Jackson et al 2018).

Debriefing can be formal or informal. Formal facilitated debriefing and peer support can be organised by healthcare organisations (Epp 2012, de Boer et al 2014). Research has shown that formal debriefing following life-threatening patient emergencies has multiple benefits for patient care and healthcare staff (Couper et al 2013). One hospital, for example, arranged for counsellors to be available onsite 24-hours a day during the COVID-19 pandemic, and cited this intervention as a significant factor in the effectiveness of their COVID-19 infection control procedures (Huang et al 2020). Other interventions include crisis phone lines, employee assistance programmes, and other types of formal counselling that nurses can be encouraged to use.

Informal debriefing opportunities include nurses taking time to talk to their colleagues, for example at the nursing station, at the start of a ‘huddle’ or before ward rounds. Nurses regularly provide emotional support to patients, and during events such as the COVID-19 pandemic they would also benefit from sharing this type of personal support with each other (Bridges et al 2013, Edward et al 2017). It is important that nurses can speak to each other informally, and that organisations support formal debriefing, as a means of support.

Taking breaks

Another evidence-based recovery strategy that nurses can use during the COVID-19 pandemic is to ensure that they take adequate breaks, which should involve them physically removing themselves from the work environment. It is imperative that nurses take breaks during their shifts. Taking short breaks is a recognised intervention aimed at supporting patient safety and staff well-being (Rogers et al 2004, Witkoski and Dickson 2010, Happell et al 2013). Nurses also use short breaks to provide each other with emotional support and debriefing (Cronin 2001). However, one study found that 95% of nurse respondents said that they often ‘skipped’ tea and coffee breaks during periods of short staffing (Al-Kandari and Thomas 2008). It is important that nurses work together with the support of management to ensure that all staff have a break during each shift.

In addition to breaks, it is important that nurses take adequate time away from work. This could include consecutive days off or a period of leave. Managers should be encouraged to arrange staff schedules so that each nurse receives consecutive days off wherever possible, since this supports a return to normal sleeping and waking patterns following shift work (Chung et al 2012). However, this is dependent on adequate staffing levels. Alongside reduced overtime, adequate staffing levels improve outcomes for nurses and patients across a variety of measures including reduced patient morbidity and mortality (Aiken et al 2011, Ball et al 2012, Ausserhofer et al 2014, Cho et al 2016). Time taken away from work will support nurses to sleep, reflect on their experiences, and engage in personal self-care strategies.

Personal self-care strategies

Nurses can also engage in self-care to support their recovery. While self-care is not a ‘cure all’ for working under challenging conditions (Traynor 2017), evidence has demonstrated that nurses benefit from self-care activities such as engaging in supportive relationships and activities outside of work. Supportive relationships are important, with evidence showing that spousal support contributed to improved nurses’ mental health following the Fukushima nuclear disaster in Japan (Nukui et al 2018).

Physical self-care strategies include taking adequate sleep, which for nurses has been linked with reduced levels of negative emotion, such as regret about clinical decisions following shifts (Scott et al 2014). Consecutive days off promote improved sleep, and managers should ensure that nurses have adequate time between shifts to recover physically and mentally (Chung et al 2012, Han et al 2014). According to a study of nurses in Thailand, some nurses have also reported that crying can provide an opportunity for catharsis and support following episodes of work stress (Pongruengphant and Tyson 2000).

While these personal self-care strategies will not entirely mitigate the effects of the COVID-19 pandemic, they can form part of an overall strategy for nurses’ recovery, particularly when supported by organisational interventions.

Organisational interventions

Managers have a central role in supporting nurses’ recovery from events such as the COVID-19 pandemic. They can provide nurses with time for reflection, arrange continuing education on COVID-19, support debriefing discussions, and manage staffing and shift patterns in a way that enables nurses to take adequate breaks.

Alongside these measures, there is significant evidence demonstrating that nurses benefit from interventions focused on their well-being (McDonald et al 2012, 2013, Houck 2014, Mealer et al 2014, Bridges and Fuller 2015, Riemer et al 2015, Vermeir et al 2016). For example, Mealer et al (2014) implemented a 12-week programme for critical care nurses, which included counselling, mindfulness and exercise. However, well-being interventions alone may be insufficient to reduce burnout and improve well-being among nurses, particularly in suboptimal working conditions (Taylor 2019). Nurse leaders should also be encouraged to ensure that adequate staffing levels and high-quality working conditions are in place, in conjunction with any well-being interventions.

There are also environmental factors that can enhance nurses’ ability to mitigate stress during shifts. For example, turning down the lights on a ward and limiting noise for a few hours during a shift results in a statistically significant decrease in nurses’ stress (Riemer et al 2015).

Another method for managing stress is for nurses to have an up-to-date knowledge of traumatic events such as the COVID-19 pandemic, and the potential effects on patients. One Japanese review found that increased education concerning radiation was linked to improved mental health for nurses responding to the Fukushima nuclear disaster (Nukui et al 2018). Nurses should be supported with continuing education about COVID-19, which may decrease their stress levels when nursing affected patients.

Post-traumatic growth

Following a traumatic event such as the COVID-19 pandemic, there is the potential for post-traumatic psychological growth. This can occur when individuals demonstrate an improved level of well-being following a traumatic event. For example, there has been evidence of post-traumatic growth such as increased emotional intelligence among nursing students (Li et al 2015), and increased life satisfaction among nurses (Itzhaki et al 2015), following working in stressful situations such as armed conflict zones (Lev-Wiesel et al 2009). One recent example of post-traumatic growth was demonstrated in a study of nurses working during COVID-19, who reported pride in having worked during the pandemic, and renewed gratitude for their personal well-being (Liu et al 2020).

Conclusion

Awareness, debriefing and taking adequate breaks during shifts have all been identified as effective strategies that contribute to nurses’ recovery following traumatic events. Applying these evidence-based strategies can contribute to nurses’ recovery during and following the COVID-19 pandemic. Additionally, nurses should be encouraged to use personal strategies such as sharing their experiences with colleagues, alongside organisational initiatives such as counselling programmes. There is also the potential for post-traumatic growth following nurses’ experiences of COVID-19, which may assist them in recovery and adapting to the new normal.

References

  1. Aiken LH, Cimiotti JP, Sloane DM et al (2011) Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Medical Care. 49, 12, 1047-1053. doi: 10.1097/MLR.0b013e3182330b6e
  2. Al-Kandari F, Thomas D (2008) Adverse nurse outcomes: correlation to nurses’ workload, staffing, and shift rotation in Kuwaiti hospitals. Applied Nursing Research. 21, 3, 139-146. doi: 10.1016/j.apnr.2006.10.008
  3. Ausserhofer D, Zander B, Busse R et al (2014) Prevalence, patterns and predictors of nursing care left undone in European hospitals: results from the multicountry cross-sectional RN4CAST study. BMJ Quality and Safety. 23, 2, 126-135. doi: 10.1136/bmjqs-2013-002318
  4. Ball J, Pike G, Griffiths P et al (2012) RN4CAST Nurse Survey in England. http://www.safestaffing.org.uk/downloads/rn4cast-nurse-survey-in-england (Last accessed: 27 January 2021.)
  5. Bridges J, Fuller A (2015) Creating learning environments for compassionate care: a programme to promote compassionate care by health and social care teams. International Journal of Older People Nursing. 10, 1, 48-58. doi: 10.1111/opn.12055
  6. Bridges J, Nicholson C, Maben J et al (2013) Capacity for care: meta-ethnography of acute care nurses’ experiences of the nurse-patient relationship. Journal of Advanced Nursing. 69, 4, 760-772. doi: 10.1111/jan.12050
  7. Cho E, Lee NJ, Kim EY et al (2016) Nurse staffing level and overtime associated with patient safety, quality of care, and care left undone in hospitals: a cross-sectional study. International Journal of Nursing Studies. 60, 263-271. doi: 10.1016/j.ijnurstu.2016.05.009
  8. Chung MH, Kuo TB, Hsu N et al (2012) Recovery after three-shift work: relation to sleep-related cardiac neuronal regulation in nurses. Industrial Health. 50, 1, 24-30. doi: 10.2486/indhealth.ms1305
  9. Couper K, Salman B, Soar J et al (2013) Debriefing to improve outcomes from critical illness: a systematic review and meta-analysis. Intensive Care Medicine. 39, 9, 1513-1523. doi: 10.1007/s00134-013-2951-7
  10. Cronin C (2001) How do nurses deal with their emotions on a burn unit? A hermeneutic inquiry. International Journal of Nursing Practice. 7, 5, 342-348. doi: 10.1046/j.1440-172x.2001.00319.x.
  11. de Boer J, van Rikxoort S, Bakker AB et al (2014) Critical incidents among intensive care unit nurses and their need for support: explorative interviews. Nursing in Critical Care. 19, 4, 166-174. doi: 10.1111/nicc.12020
  12. Edward KL, Hercelinskyj G, Giandinoto JA (2017) Emotional labour in mental health nursing: an integrative systematic review. International Journal of Mental Health Nursing. 26, 3, 215-225. doi: 10.1111/inm.12330
  13. Epp K (2012) Burnout in critical care nurses: a literature review. Dynamics. 23, 4, 25-31.
  14. Han K, Trinkoff AM, Geiger-Brown J (2014) Factors associated with work-related fatigue and recovery in hospital nurses working 12-hour shifts. Workplace Health and Safety. 62, 10, 409-414. doi: 10.3928/21650799-20140826-01
  15. Happell B, Dwyer T, Reid-Searl K et al (2013) Nurses and stress: recognizing causes and seeking solutions. Journal of Nursing Management. 21, 4, 638-647. doi: 10.1111/jonm.12037
  16. Houck D (2014) Helping nurses cope with grief and compassion fatigue: an educational intervention. Clinical Journal of Oncology Nursing. 18, 4, 454-458. doi: 10.1188/14.CJON.454-458
  17. Huang L, Lin G, Tang L et al (2020) Special attention to nurses’ protection during the COVID-19 epidemic. Critical Care. 24, 120. doi: 10.1186/s13054-020-2841-7
  18. Itzhaki M, Peles‐Bortz A, Kostistky H et al (2015) Exposure of mental health nurses to violence associated with job stress, life satisfaction, staff resilience, and post‐traumatic growth. International Journal of Mental Health Nursing. 24, 5, 403-412. doi: 10.1111/inm.12151
  19. Jackson J (2018) A grounded theory of the resilience process in postqualification nursing students. Journal of Nursing Education. 57, 6, 371-374. doi: 10.3928/01484834-20180522-09
  20. Jackson J, Vandall-Walker V, Vanderspank-Wright B et al (2018) Burnout and resilience in critical care nurses: a grounded theory of Managing Exposure. Intensive and Critical Care Nursing. 48, 28-35. doi: 10.1016/j.iccn.2018.07.002
  21. Labrague LJ, Hammad K, Gloe DS et al (2018) Disaster preparedness among nurses: a systematic review of literature. International Nursing Review. 65, 1, 41-53. doi: 10.1111/inr.12369
  22. Lev-Wiesel R, Goldblatt H, Eisikovits Z et al (2009) Growth in the shadow of war: the case of social workers and nurses working in a shared war reality. British Journal of Social Work. 39, 6, 1154-1174. doi: 10.1093/bjsw/bcn021
  23. Li Y, Cao F, Cao D et al (2015) Nursing students’ post-traumatic growth, emotional intelligence and psychological resilience. Journal of Psychiatric and Mental Health Nursing. 22, 5, 326-332. doi: 10.1111/jpm.12192
  24. Liu Q, Luo D, Haase JE et al (2020) The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study. The Lancet Global Health. 8, 6, e790-e798. doi: 10.1016/S2214-109X(20)30204-7
  25. McDonald G, Jackson D, Wilkes L et al (2012) A work-based educational intervention to support the development of personal resilience in nurses and midwives. Nurse Education Today. 32, 4, 378-384. doi: 10.1016/j.nedt.2011.04.012
  26. McDonald G, Jackson D, Wilkes L et al (2013) Personal resilience in nurses and midwives: effects of a work-based educational intervention. Contemporary Nurse. 45, 1, 134-143. doi: 10.5172/conu.2013.45.1.134
  27. Mealer M, Conrad D, Evans J et al (2014) Feasibility and acceptability of a resilience training program for intensive care unit nurses. American Journal of Critical Care. 23, 6, 97-105. doi: 10.4037/ajcc2014747
  28. Nukui H, Midorikawa S, Murakami, M et al (2018) Mental health of nurses after the Fukushima complex disaster: a narrative review. Journal of Radiation Research. 59, 2, 108-113. doi: 10.1093/jrr/rry023
  29. Pongruengphant R, Tyson PD (2000) When nurses cry: coping with occupational stress in Thailand. International Journal of Nursing Studies. 37, 6, 535-539. doi: doi: 10.1016/s0020-7489(00)00031-6
  30. Riemer HC, Mates J, Ryan L et al (2015) Decreased stress levels in nurses: a benefit of quiet time. American Journal of Critical Care. 24, 5, 396-402. doi: 10.4037/ajcc2015706
  31. Rogers AE, Hwang WT, Scott LD (2004) The effects of work breaks on staff nurse performance. Journal of Nursing Administration. 34, 11, 512-519. doi: 10.1097/00005110-200411000-0000
  32. Scott LD, Arslanian-Engoren C, Engoren MC (2014) Association of sleep and fatigue with decision regret among critical care nurses. American Journal of Critical Care. 23, 1, 13-23. doi: 10.4037/ajcc2014191
  33. Spreitzer G, Sutcliffe K, Dutton J et al (2005) A socially embedded model of thriving at work. Organization Science. 16, 5, 537-549. doi: 10.1287/orsc.1050.0153
  34. Stewart R (2020) How do we recover from COVID-19? Helping diabetes teams foresee and prepare for the psychological harms. Diabetic Medicine. 37, 10, 1655-1657. doi: 10.1111/dme.14360
  35. Taylor RA (2019) Contemporary issues: resilience training alone is an incomplete intervention. Nurse Education Today. 78, 10-13. doi: 10.1016/j.nedt.2019.03.014
  36. Traynor M (2017) Critical Resilience for Nurses: An Evidence-Based Guide to Survival and Change in the Modern NHS. Routledge, Abingdon.
  37. Vermeir P, Vandijck D, Blot S et al (2016) Communication Satisfaction and Job Satisfaction among Critical Care Nurses and the Impact on Burnout and Turnover Intention. http://www.cochranelibrary.com/central/doi/10.1002/central/CN-01407554/full (Last accessed: 20 January 2021.)
  38. Vinje HF (2007) Thriving despite adversity: job engagement and self-care among community nurses. https://bora.uib.no/bora-xmlui/handle/1956/2646 (Last accessed: 20 January 2021.)
  39. von Arx M, Cullati S, Schmidt RE et al (2018) “We won’t retire without skeletons in the closet”: healthcare-related regrets among physicians and nurses in German-speaking Swiss hospitals. Qualitative Health Research. 28, 11, 1746-1758. doi: 10.1177/1049732318782434
  40. Witkoski A, Dickson VV (2010) Hospital staff nurses’ work hours, meal periods, and rest breaks. A review from an occupational health nurse perspective. AAOHN Journal. 58, 11, 489-497. doi: 10.3928/08910162-20101027-02
  41. Wolf ZR, Zuzelo PR (2006) “Never Again” stories of nurses: dilemmas in nursing practice. Qualitative Health Research. 16, 9, 1191-1206. doi: 10.1177/1049732306292544

Share this page

Related articles

Views of specialist head and neck nurses about changes in their role
The Cancer Reform Strategy (Department of Health 2007)...

Chronic pain in breast cancer survivors
The 20-year relative survival rate for women diagnosed with...

Supporting delivery of the recovery package for people living with and beyond cancer
Survivorship is an important issue in cancer care in the UK....

An assessment of the value of music therapy for haemato-oncology patients
The aim of this service evaluation was to assess the value...

The role of lung cancer nurse specialists
A report published by the National Lung Cancer Forum for...