Nurses Are Superheroes, But COVID-19 Is Not the Only Villain

From yard signs to bus stop billboards, “Health care workers are heroes” is a ubiquitous slogan these days. As a nurse who spent nearly a decade working in the emergency room, I always tend to notice them. But what happens when that pat on the back starts to feel like a slap in the face? The annual observation of Nurses Week starting May 6 will likely garner the usual plastic gifts, maybe even a T-shirt and some cake, since it has been kind of a special year. But as the dust settles around the tragedy that was our pandemic response, I urge you to consider that the superhero cape feels more like a lead balloon for many. And too many of my colleagues continue dragging the heavy cape behind them while desperately trying not to lose sight of the healing work they set out to do.

Nurses do indeed have superpowers. Unfortunately, invisibility is one of them. The Woodhull Study Revisited found that nurses were cited as sources in only 2% of health news stories in 2017 and were never cited in policy-related health stories despite their expertise and significant contributions. Nursing is scientifically complex and often physically demanding, and involves much more skill and grit than a halo and wings. You can call nurses heroes or angels, but doing so reinforces a blind spot to the intellect, critical thinking, and trained skill they bring to their work. It also glosses over the challenges nurses face, the ethical dilemmas they stare down, the physical demands they overcome, and the abuse they endure daily. One in four nurses is assaulted at work, and up to 80% of workplace violence incidents affecting nurses go unreported. Many nurses suffer in silence as a result, knowing that others will not understand, or worse, will place the burden squarely back on their shoulders by saying they signed up for it.

The seeds of nursing burnout and looming shortages were planted well before COVID-19, as a result of an understaffed, industrial-style health care system that promotes color-by-numbers algorithm efficiency over critical thinking and interpersonal communication. Hospitals demand nurses take on too many patients, manage unrealistic medical record demands, and complete tasks with an efficiency that is not humanly possible, much less humane to our patients. Research has shown repeatedly that high nurse-to-patient ratios and poor nursing work environments correlate with increased patient mortality. It is not difficult to imagine, as a patient, that overworked nurses deliver worse care and ultimately more patients die as a result.

The COVID-19 pandemic has added insult to injury by forcing health care professionals to now also defy once unquestionable standards of the protective equipment required for oneself as a caregiver. Nurses have been forced to keep and re-wear masks that were previously determined to be safe for only a single use. They now have to use these sometimes multi-week-old masks to treat community members unwilling to wear a mask in public, but who now expect to be saved as they struggle to breathe.

Would you continue to show up for work, 13 hours at a time, sometimes days on end, if that was your experience? Did I mention bathroom and meal breaks are also not guaranteed? Nurses spent countless hours over the past year facing unprecedented levels of death and dying, strained to the maximum, amid a void of family support due to visitation restrictions. Going home after an impossibly long shift to social media photos of unmasked friends gathering, balking at the need to wear a mask or socially distance, strained relationships and pushed many nurses beyond a point of exasperation to sheer rage and desolation.

The time is now to publicly acknowledge the fact that suicide rates are higher among nurses than the general public (and proportionally even worse among physicians) due to high job demands, stress, stigma, and access to medication. Self-care tips and resiliency training have their place, but it is imperative to not place the burden of this problem solely on the individual. Nurses were already exiting the field at problematically high rates prior to COVID-19, with average turnover rates hovering around 17%, attributed primarily to burnout. It was recently reported that three in 10 health care workers are now considering leaving the profession. That type of exodus would prompt a continuing disaster long after the last COVID-19 vaccine is administered. Demand for nurses is projected to increase steadily in the coming years, but efforts to satisfy the shortages will instead be hobbled by a brain drain of experienced professionals.

If we want to stem the tide of nurses and other health care workers heading for the door, appropriate support from our institutions at the highest levels — both government and health care — needs to be organized and promoted as a top priority. Health care workers, and nurses in particular, need:

• Routine assessment of clinician well-being with interventions as needed
• Shared governance structures with a platform for nursing input into decision-making
• Increased transparency around safety policy, operational plans, and available resources
• Opportunities, including time, space, and training, for mental health support
• Proactive support to promote nurses’ personal health and safety, including their families
• Exploration of methods to reconnect staff to meaning and purpose in their work

Organizations such as the Institute for Healthcare Improvement are attempting to demonstrate best practices. And there are individual institutions trying to make a difference, such as the HEAR Program at UC San Diego. But the problem is too large and too dramatic for piecemeal solutions. Research and replication of what works, with implementation and accountability, is needed at the highest levels.

Our veteran community is one place to look, based on lessons learned and recent experience addressing the mental health fallout of extremely challenging professional environments. While not identical, there are similarities in the struggles faced by both service members and nurses. At least 3,000 nurses worldwide have been documented to have died of COVID-19 during the pandemic, with many more nurse deaths uncounted. More than ever before, nurses risk their life by showing up to work. After clocking in, a culture of selflessness and stoicism runs rampant in health care; it is all stiff upper lip and keep moving. And an underlying frustration or anxiety due to moral distress, or feeling powerless to practice with integrity due to institutional pressures and constraints, combined with a sense that the public cannot adequately understand the lived experience, runs across both veterans and nurses.

After United States military suicides hit a record in 2012, outpacing combat death, the Department of Veterans Affairs (VA) ultimately declared a suicide and mental health crisis among service members and veterans in 2013; landmark legislation followed in 2015 that devotes significant resources and attention to suicide prevention and mental health, including increased funding, research, programs, and communications. While the VA and Pentagon’s efforts to improve military mental health culture and services are far from perfect, the largest national institutions interacting with our service members and veterans have acknowledged the existence and impact of a mental health crisis within their ranks.

Too often baseline mental health support among health care employers boils down to providing a hotline phone number and self-care tips to promote resiliency. This is not sufficient support for the health care workforce of today. And it places an unfair onus on the individual to solve the problem. No amount of deep breathing and yoga practice can erase the suffering nurses have faced this past year. While there are always exceptional examples, history has demonstrated most employers are not intrinsically motivated to do more. The time has come for a proactive and multifaceted effort from the top down. It is time to recognize the magnitude of the problem within the health care workforce: Burnout, turnover, work environment, moral distress, and increased suicides and mental health crises require an equal magnitude of resources dedicated to a solution.

We must recognize nurses for their contributions and as fallible human beings, not heroes or angels or robots. Because the pain and trauma will not stay buried forever. A bipartisan coalition of co-sponsors led by Senator Tim Kaine, D-Va., re-introduced the Dr. Lorna Breen Health Care Provider Protection Act in March following the tragic suicide of an emergency physician last year. Her story and her struggle are familiar to most health care workers. The legislation is an effort to increase federal research, training, and grant funding focused on mental health resources for health care workers to avoid similar tragedies. But public support and pressure is needed for the legislation, which is currently being debated, to be enacted and impactful. Passing the Breen Act will help federal funding from the American Rescue Plan “be allocated in the most appropriate way to deal with the mental health needs of our health care professionals,” according to Kaine.

Hospitals are frequently shielded by patient privacy laws and draconian public relations employee restrictions that make it difficult for nurses to speak out about the conditions they face on the ground. Those who do, risk their livelihood as a result, as seen last year when employees were fired for sounding the alarm about working conditions and equipment shortages early in the pandemic. We have to acknowledge that the current system does not recognize or support our nurses as people, as individuals, as humans who put their lives on the line. Nursing can be an incredibly rewarding profession despite its demands, but even nurses have their breaking points.

So this year for Nurses Week, by all means, send the cookies. But don’t forget to thank a nurse properly by providing the support they need at the highest level. Stay informed and contact your representative to let them know this matters to you and your family.

Visit ENA 411 or the American Nurses Association RN Action Center.