What do you like about the Argument and Discussion sections of this paper?Discuss

Read the Argument and Discussion section in the paper: The Pandemic, Our Nurses and Their Crisis.

Respond to the questions below. You may use bullet points or short sentences – this assignment is not about your writing, but rather your critique of someone else’s writing against the assignment guidelines.

Your responses may be brief (2 to 4 thoughts per question), but include some level of depth to your response (something more than “it was good” or “it needed work”). Be as specific as possible.

Question 1: What do you like about the Argument and Discussion sections of this paper?
Question 2: What do you think could be improved in the Argument and Discussion sections?
Question 3: What specific feedback would you give this writer?  Consider the assignment guidelines, the writer’s ability to communicate ideas clearly and the paper format (grammar, spelling, APA).

The Pandemic: Our Nurses and Their Crisis
Writer Name
BNURS000: Translating Scholarly Knowledge into Nursing Practice
Name of Institution

During the current pandemic, a time of unknown certainty, registered nurses have been faced with unimaginable challenges globally. The rapid spread of Coronavirus, or COVID-19, has had negative impacts on the mental health and well-being of our frontline workers (Blake et al., 2020). From all over, nurses have raised their voices collectively to have their mental health concerns be addressed during this time of crisis. For example, voiced concerns are specifically related to moral distress, professional burnout, anxiety, fear, and frustrations with the public and their lack of knowledge pertaining to COVID-19 (Galehdar et al., 2020). Frustrations with medical institutions and their lack of prioritization on safety measures and thoughtful communication disseminated to its employees is also a topic of concern during the pandemic.

Nurses are starting to feel the weight of the pandemic through both somatic and psychological symptoms (Grabbe et al., 2019). These feelings are being reported by nurses of all genders, that come from a variety of nursing backgrounds, and with a range of nursing experience from new graduate to 20+ years. The topic of nurses feeling unsupported or underprepared during times of crisis is of importance as well (Buselli et al., 2020; Hennein et al., 2020; Galehdar et al., 2020). Nurses have reported being unable to take their breaks due to understaffing with the influx of COVID-19 positive patients. Moreover, an alarming increase of employee sick calls are documented due to the virus and/or other underlying factors such as compassion fatigue, professional burnout, and longer shifts being worked. Similarly, other reports such as feelings of management not listening or placing priority on their employee’s well-being has been mentioned across a few research articles as well.

With so much research identifying key psychological factors pertaining to our frontline workers mentality during the pandemic, there appears to be significantly more qualitative data compared to quantitative data available at this point in time. During further research, there were some potentially promising solutions discovered that are currently available and may answer the question of what really works for our nurses during times of crisis. For example, the UK has fast tracked an eDigital Learning package designed for its frontline workers. The program is an online module that consists of six sections with free access to all, even for the public who are also struggling. This program was created to facilitate learning about key psychological factors and their impacts on mental health during times of crisis, to normalize responses to these factors, and to stimulate help-seeking behaviors among its participants (Blake et al., 2020). In addition to an eLearning package, another study performed using a randomized controlled trial with The Community Resiliency Model® designed to promote employee well-being and decrease reported somatic symptoms in nurses by voluntarily attending a one-time three-hour class (Grabbe et al., 2020). Comparatively, there is a cross-sectional study that utilized interviews with nurses that addressed the effects environmental factors had on HCWs during a typical shift. For example, the distance between break areas and workstations, areas of privacy or for staff use only, access to natural light, and supplementary amenities for staff break rooms (Nejati et al., 2016).

The purpose of this paper is to address the reduction of negative outcomes in nurses by participation in current up-to-date evidence-based practices during unprecedented times, while also identifying the latest developed best practices that have been implemented to address the mental health and well-being needs of our nurses. With that in mind, among nurses who work in acute crisis situations, does participating in mental health best practices decrease negative outcomes in nurses versus those nurses who do not participate in best practices?

Review of the Literature

Introduction

It is imperative to gain a deeper insight as to why it is so crucial to address the mental health needs and well-being of nurses during a crisis situation. For the purpose of this literature review articles researched include publications from Australia, Canada, Italy, Iran, Norway, United Kingdom (UK), and the United States. Of these articles on nurse’s well-being during times of crisis, common themes emerged. For example, all researched studies have revealed there to be more female than male participants. According to a study conducted in Italy by Buselli et al. (2020), women display statically significant higher levels of secondary trauma symptoms (STS) than males, putting them at increased risk for developing symptoms of post-traumatic stress disorder (PTSD) (p. 9). This is an interesting finding as it shed light on how dominantly nursing is populated with women and alarming “as female HWs [health workers] have been reported to have higher rates of mental health morbidities compared with male HWs during the COVID-19 pandemic” (Hennein et al., 2020, p. 28). There has been limited information provided among the presented articles on transgender and non-binary participants. This may represent a possible gap in research regarding accurate data collected on gender.

Other demographic information obtained from the literature highlighted that nurses of Caucasian decent have higher affected rates than other ethnicities (Hennein & Lowe, 2020; Nejati et al., 2016). Due to a limited number of articles researched for this paper, this statistic may be inaccurate due to the lack of articles included from all other countries reporting in response to the pandemic. It is of note that for these studies, the mean ages of affected individuals ranged between 31 and 41 years old with an average work experience between 7 and 17 years in nursing. Continued research identified the educational background(s) of the participants included more bachelor’s degree and/or higher certificates awarded (Galehdar et al., 2020; Johnson et al., 2020).
Additionally, more frontline healthcare workers (HCWs), or those who provided direct care of COVID-19 patients, showed higher prevalence of the aforementioned symptoms than those who did not. One study conducted in Norway by Johnson et al. (2020), showed that 36.5% of their sample size of 1,773 healthcare and public service workers with direct patient contact were reported to have symptoms of PTSD, anxiety, and depression as compared to 27.3% of the HCWs working indirectly with patients during the pandemic (p. 6). In comparison, a study conducted in the United States by Hennein et al., (2020), of 588 frontline workers, 51.9% displayed psychological symptoms. Of those, 14% showed signs and/or symptoms of probable depression, 15.8% with probable anxiety, 23.1% with probable PTSD, and a shocking 42.6% with probable alcohol use disorder (AUD) (p.1). An interesting finding of note is that of all the articles cited in this paper, Hennein et al., (2020) is the only study that addressed the topic of AUD among HCWs.

With all the information pertaining to the negative condition nurses are finding themselves in, what is available to assist with promoting positive mental health practices and improved overall well-being? In the United States a study was performed by Grabbe et al. (2019) called the Community Resiliency Model®. Its main purpose was to promote nurse well-being and counteract the alarming rates of reported STS and burnout among the nursing community. This model has been used as a one-time resiliency intervention to drive self-care habits through “non-cognitive variants of mindfulness, which uses awareness of sensations in the body as a vehicle for emotional regulation” (Grabbe et al., 2019, p. 325). This randomized controlled trial has shown promising data when users actively implement the skills taught on self-awareness and emotional regulation during times of amplified stress. Furthermore, it demonstrates that decreased STS and somatic symptoms with increases in resiliency and well-being analyzed from pre-post training session surveys were achieved. To conclude, the model proposed by Grabbe et al. (2019) provides a direct connection between periods of increased “emotional stress” and use of sensory awareness tactics for self-preservation and reduction in somatic symptoms (p. 325).

Another promising intervention proposed by van Agteren et al. (2018) out of Adelaide, Australia, addressed the needs of nurses through a two-day resilience training program. The program was adapted from a well-known resilience training module first designed by TechWerks that delivers education through experienced trained professionals. This intervention was evaluated through a cohort study using pre- and post-mental health assessment to include baseline behaviors prior to training and one month following the conclusion of the course. Data from the study revealed notable increases in well-being and resilience. However, psychological measures for depression, anxiety, and PTSD rendered nonsignificant changes for depression, anxiety, and stress. As previously mentioned, this study offers promising insight to identifying and addressing key factors in people that may lead to more positive well-being outcomes. The invention provides a good starting point, or sturdy foundation, for research to continue to evolve and allow for discovery of potential best practices.

An intervention originally proposed out of Toronto, Canada, by Maunder et al. (2010) for the purpose of identifying an appropriate “Pandemic Influenza Stress Vaccine”, reveals that the use of a computer-assisted resiliency training module promotes positive mental health outcomes. The study is a randomized control trial that selects consenting participants into one of three modules; each being different lengths of time to complete. This utilizes “dose-finding” to assess which length of time per module works most successfully for improving mental health outcomes in HCW’s (Maunder et al., 2010). To substantiate the findings, the trial developed three training modules, identical in all components except in course length. Of the three lengths, 1.75 hours, 3 hours, and 4.5 hours, it was evident that participants of the 3- and 4.5-hour courses benefited the most from the program.

In summary, the intervention showed statistically significant data for increased pandemic-related self-efficacy, confidence in training and support, and positive interpersonal skills recorded by the participants. However, with further research it was discovered the Maunder et al. (2010) study had since retired their intervention due to the overwhelming amount of time and resources needed to keep up with the constant demands of technology evolution required for continued support of the intervention (R. Maunder, personal communication, February 18, 2020). For this reason, one might inquire the purpose of this article’s inclusion. Due to the unmistakable data that reveals positive outcomes from the study’s sample population, this intervention provides a fantastic foundation for continued exploration and development of real-time best practices that directly address the mental health needs of our HCWs.

Blake et al. (2020) out of the UK, proposed and designed a free, online digital learning package for HCW’s during the current COVID-19 pandemic. This study has more qualitative components than of the previously mentioned interventions, however the user satisfaction of the program after initial release is of particular interest. With further investigation, it was identified that this study provides feedback solely on the program and its components including usability, acceptability, and practicality, however, does not provide quantitative measures for overall level of depression, anxiety, PTSD, STS, or AUD of its participants either prior to or post use of the program.

It is important to note that aside from intervention resources identified in this paper, non-intervention-based research articles utilized cross-sectional survey-based approaches, including the same scales, PHQ-9 for depression, GAD-7 for anxiety, PC-PTSD for PTSD, and one article utilized the AUDIT-C for alcohol use disorder to assess and evaluate psychological measurement. This is significant because cognitive and somatic symptoms were analyzed and evaluated using the same tools to produce both qualitative and quantitative data. In sum, this consistency across studies strengthens the conclusions derived from the data of the collective articles.

Conclusion

There has been a growing amount of literature pertaining to nurses’ mental health and well-being since the start of the current COVID-19 pandemic. Multiple articles addressed the concern of reported increases in anxiety, depression, PTSD, and STS in nurses across all fields, ages, genders, and experiences. There is an explicit need to prioritize further research on the psychological effects of this crisis among HCW’s, and the call to action for rapid development of interventions that show statistically significant data based on evidence-based practice to promote improved metacognition and resiliency. As stated by Johnson et al. (2020), “Reducing dysfunctional metacognitions and increasing participants ability to reduce worry and rumination may therefore be an important asset during pandemics” (p. 9).

Argument

It is evident from the research that a nurse’s mental health and well-being are negatively impacted when working during a crisis. As stated by Johnson et al. (2020), “Increases in [PTSD, anxiety, and depression] symptoms are markedly higher than estimates from pre-pandemic populations, suggesting that this issue may be of major cause for concern” (p. 10). This is likely attributed to the increased demands placed on nurses and other frontline workers, such as “work overload and “voluntary” overtime demands” from management (Grabbe et al., 2019). This is a critically large impediment on a nurse’s ability to receive desired time off so to engage in self-care behaviors and regroup mentally, spiritually, and physically. Furthermore, when frontline workers are repeatedly exposed to traumatic situations, such as increased risk of contracting the disease, patient loss, lack of PPE, feelings of being under supported and/or overworked (Buselli et al., 2020; Hennein et al., 2020), the nurses themselves become a safety risk due to increased probability of medication errors or difficult decisions being made when not of sound mind.

In contrast, a theme emerged from more experienced nurses (in age and years in nursing) self-reporting more resiliency and lower rates of STS symptoms in times of stress and crisis as opposed to newer and youngers nurses (Buselli et al., 2020; Grabbe et al., 2019). Although that sheds some hope for the more experienced nurse, how does that help the generation of nurses behind them? While the question stands, it has been proven that even the experienced nurse in a trial sample can contribute to the findings lacking as a whole on providing statistically significant improvements on mental distress related to mood disorders, anxiety and stress (van Agteren et al., 2018). Given these points, an area of research to explore further is locating data on reports on the number of increased cases of HWCs with a new diagnosis of depression, anxiety, or PTSD, since the onset of the acute phase of the pandemic, and whether these two variables are directly correlated to each other. For instance, Johnson et al, (2020) claims that “pre-existing psychological diagnosis, higher levels of anxiety, and depression symptoms were associated with PTSD [symptoms]” (p. 9). Due to the difficulties in locating data on HCWs mental states and/or diagnoses prior to the start of COVID-19, data collected was limited on comparisons pre- and post- clinical measurement (Buselli et al., 2020, p. 9).

Furthermore, these studies utilized self-reporting techniques, such as surveys. An argument could be made that surveys are subjective assessment tools and may render the subsequent data biased in the participants responses and offer little to no distinction between actual pandemic related stress or stress related to being a HCW in general. It is true that psychological assessment on the impact anxiety, depression and PTSD have on an individual during crisis “may not always be aligned” with evaluations conducted from a mental health practitioner (Buselli et at., 2020). Nevertheless, surveys will continue to be used until development of a newer gold standard for measuring one’s mental health objectively has been identified.

Addressing our nurses and frontline workers mental health and well-being is critical during the present circumstances. Now we know the importance behind why we need these topics addressed, it is equally important to understand the research and literature that provides solutions. For the purpose of this paper, use of prescription drugs on psychological symptoms and disorders will not be discussed, instead, non-pharmacological interventions (NPIs) will be argued as the most promising interventions available in support of mental health and well-being management. For example, NPIs such as resiliency training, mindfulness, and psychological first aid, improve a nurse’s mental health and well-being (including but not limited to crisis situations).

To start, there have been promising results shown with resiliency training programs offered by both Grabbe et al., (2020) and Maunder et al., (2010). For example, Grabbe et al. (2020) designed a random controlled trial (RCT) utilizing The Community Resiliency Model ® (CRM) to teach its users self-regulation techniques during times of crisis. The purpose of CRM is to educate HCWs on the power of mindfulness and self-awareness of one’s own body sensations to promote emotional regulation. Having the skills needed to enhance sensory awareness can even lead to reductions in emotional distress (Grabbe et al., 2020). The article makes a point to address that CRM is not therapy, however, it is based on well-known psychotherapy approaches of somatic experiences. This is important to differentiate due to the level of stigma HCWs face when seeking “help”, as van Agteren et al. (2020) mentions the challenges faced by HCWs “surrounding mental illness and help-seeking” (p. 3) for fear of repercussions.

Another promising intervention designed by Maunder et al., (2010) also utilized a RCT to determine the effects of a one-time resiliency training course. The attractiveness of this intervention is that it is computer-based and upon completion continuing education (CEs) were awarded. Statistically significant data was gathered from two of the three groups, suggesting that medium to longer course lengths provide the most user support for mental health and well-being improvement. Both studies appear to have data that supports overall increases in its participants resiliency, well-being, positive interpersonal skills and confidence in training and support. By the same token, decreases in STS and somatic symptoms are also seen.

In support of the above mentioned, van Agteren et al., (2018) states that “providing basic psychological skills training to health service staff, is an intervention health service organizations can implement as a primary prevention strategy for the general workforce staff” (p. 1). Most importantly, Maunder et al., (2010) defines how an organization can utilize their study as it “is feasible and may facilitate improvement in psychological variables that predict resilience” (p. 6). When budgets are considered by health organizations and stakeholders it is critical to weigh proposed interventions based on applicability, practicality, and fiscally sound options. This makes the idea of a computer-based resiliency training program desirable as it can be completed in or outside work as well as cost reductions related to the self-directed approach of online learning.

To conclude, while CRM has been proved to promote resiliency and positive well-being, other modalities such as self-directed computer programs can produce similar results. For the Maunder et al. (2010) study the literature makes note to discuss the program measured only “mediators of stress-outcomes rather than direct measure of pandemic stress” (p.8). This is important to acknowledge as it sheds insight to whether the data provided answers the question of will this training actually address stress specifically related to crisis?

Discussion

As mentioned, studies have shown that nurses bear a great deal of psychological distress during the time of COVID-19 and its havoc wreaked on the community. In an article by Hennein et al. (2020), it can be concluded that with the “variability in mental health measures, additional studies are needed in the US that validate these findings and quantitively examine risk factors for these and other mental health morbidities” (p. 16). This is a valid point as another article supports this claim by providing supportive data that showed underlying mental health conditions are strongly correlated with development of signs and/or symptoms of PTSD, anxiety, depression, and STS (Johnson et al., 2020).

After conducting research on best practices to promote nurse’s well-being, I would take this data and propose a trial based on the Iowa Model of Evidence-Based Practice to Promote Quality care utilizing the CRM design. Although the program is not an online self-directed learning opportunity, it is a one-time 3-hour course that addresses the mental and physical symptoms produced by sudden onset of strong unregulated emotions. As I have compiled research pointing to positive outcomes for the organization, staff, and patients, which addresses the “knowledge and problem focused triggers,” I would present these findings to management to gauge their understanding and perceptions of the information provided.

Since this is my first time addressing an issue of this magnitude, I would also inquire and clarify from management what is already in place that is used to address nurse’s mental health, regardless of crisis situations or not. Additionally, can the existing program(s) show statistically significant data that supports no further changes need to be made at this time. On the other hand, if management cannot identify or claim the existing methods work, then I would move forward with permission to assemble a team to address HCWs mental health and place priority on incorporating the CRM model into practice change for the organization.

Once approved, my team and I would pilot the study utilizing two groups: Group A is the control, nurses who do not participate in the study, Group B is the variable, nurses who do participate. Sample population would include registered nurses of different backgrounds and are employed within the same organization. Other geographical data to be assessed but not required for trial participation includes gender, age, ethnicity, years of nursing experience, education background, and family status. Information regarding voluntary participation for the proposed study will be disseminated through all media modalities, such as work email(s), discussion boards, team meetings and huddles, organization intranet webpage, and corporate newsletters.
Because CRM occurs once, a pre- and post- interview will be conducted by the same person from the development team to assess the success of the program and/or areas of further research required such as limitations discovered during the trial. Furthermore, a follow up interview with the nurses who participated in trial will be critical to data collection at one month, three month, and six months post trial to adequately gauge whether the skills taught had any real-life practicality for its users.

Based on current data, this will incentivize organizations to provide treatments and training on mental health best practices during orientation to unit and periodically hold in-service sessions for staff to address the needs of staff and foster an environment keen on preventive care. Estimated improvements include decreased sick calls, interpersonal conflicts and increases seen in patient care and safety. Ways to achieve the proposed outcomes would be to provide mentor programs or “Champions of well-being” as a means for peer support. Additionally, management can incentivize staff with tangible means. For example, one extra paid sick day per calendar year would be awarded for participation in self-help seeking behaviors such as attending therapy or utilizing an employee assistance program to seek in-network providers. As a result, the collective organization will lead by example through a corporate-wide demonstration of a powerful movement to normalize self-care and mental health needs of its employees, resulting in staff who are encouraged and confident in their journey to seek treatment without worry of ramifications. To emphasize this claim, Hennein et al. (2020) states that participants of their study who began psychotherapy reported that it was “their most hopeful experience during the pandemic” as it enriched their mental well-being (p.12).
Furthermore, paid compensation would be provided while staff attended company training or care sought outside work. Currently at The Everett Clinic, they use a model called the “Nursing Professional Clinical Ladder”, where staff are incentivized through the use of “points” that are awarded towards certain aspects of the nursing profession. Such as, professional development, education and training, community involvement, and policy management. Each team member has the opportunity to earn rewards by participation in one of the four units of the program. There are several items within each unit to choose to participate in. For example, joining a committee within the community, presenting an in-service education or training session, or identifying areas of weakness within current policies and procedures; The list goes on. Once a specific number of points are earned, or milestone achieved, the staff member will receive a “bonus,” or additional pay, added to their current tiered salary scale.
It is hard to determine which interventions will work for who, as addressing mental health and well-being is not a “one size fits all” standard. The key to staff participation and retention is going to be a delicate balance between each department within the organization. Keeping in mind that resilience is the bridge to wellness, by working together and tackling the issue of our nurse’s holistic well-being, greatness can be achieved.
Conclusion

Our frontline workers have been fighting an uphill battle since the surge of the COVID-19 pandemic. The emotional and physical turmoil HCWs have had to endure during these unforeseen circumstances is an experience not one health care personnel will ever forget. Throughout this paper, a call to action has been discussed regarding the lack of mental health resources our HCWs desperately need and needed, even prior to the pandemic outbreak. Interventions have been researched, described, and discussed regarding the next steps to take in addressing the psychological impact on our nurses resulting from the current crisis. With all things considered, it is undeniable that among nurses who work in acute crisis situations, participation in mental health best practice(s), decreases negative outcomes in nurses compared to nurses who do not participate in best practices. Nurses have responded by the thousands that with more schedule flexibility to allow for additional time off from their clinical obligations, leaves “more time for spiritual practice, hobbies, exercise, healthy cooking, and self-reflection” to occur (Hennein et al., 2020).

To conclude, “Specific action on negative metacognition, worry, anxiety and depression may be a pathway forward to reducing PTSD symptoms” (Johnson, et al., 2020). Of the countless articles that describe, in detail, the negative impacts the COVID-19 pandemic has had on its frontline workers, both direct and indirectly, substantially less articles are published that specifically address current evidence-based interventions proven to be beneficial to a HCW’s mental state and well-being. The time for action is now, the psychological outcomes of our HCWs cannot wait. Now, more than ever, focused attention and prioritization need to be placed on our nurses, their mental health, and their well-being.

References
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Buselli, R., Corsi, M., Baldanzi, S., Chiumiento, M., Del Lupo, E., Dell’Oste, V., Bertelloni, C., Massimetti, G., Dell’Osso, L., Cristaudo, A., & Carmassi, C. (2020). Professional quality of life and mental health outcomes among health care workers exposed to Sars-Cov-2 (Covid-19). International Journal of Environmental Research and Public Health, 17(17), 6180. https://doi.org/10.3390/ijerph17176180
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Maunder, R. G., Lancee, W. J., Mae, R., Vincent, L., Peladeau, N., Beduz, M. A., Hunter, J. J., & Leszcz, M. (2010). Computer-assisted resilience training to prepare healthcare workers for pandemic influenza: a randomized trial of the optimal dose of training. BMC Health Services Research, 10(1). https://doi.org/10.1186/1472-6963-10-72
Nejati, A., Shepley, M., Rodiek, S., Lee, C., & Varni, J. (2016). Restorative design features for hospital staff break areas. HERD: Health Environments Research & Design Journal, 9(2), 16-35. https://doi.org/10.1177/1937586715592632
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