APHON Contacts the White House for Nursing Mental Health During COVID-19

May 19th, 2020

The President
The White House
1600 Pennsylvania Avenue, NW
Washington, D.C. 20500

Dear Mr. President:

On behalf of the undersigned organizations representing approximately 5 million of our nation’s nursing professionals, including advanced practice registered nurses (APRNs), we write to urgently request support for nurses serving on the frontline of our battle against the COVID-19 pandemic. We are gravely concerned about the psychological health and well-being of nurses and other front-line staff during the COVID-19 public health emergency, and ask the Administration to take these concrete steps to provide psychological first aid:

1) Direct federal disaster behavioral health agencies and staff to develop resources to aid nurses and other health care professionals during the COVID-19 public health emergency;
2) Activate U.S. Public Health Service (USPHS) Mental Health Teams and Service Access Teams to address the psychological impacts of COVID-19 on nurses and other health care professionals;
3) Deploy Military Disaster Mental Health teams and behavioral health servicemembers to heavily impacted areas to provide psychological assistance and care to civilian nurses and other healthcare workers.

We appreciate your Presidential Proclamations designating May 6th as National Nurses Day and May as National Mental Health Awareness Month. These proclamations recognize the impact that the COVID-19 pandemic is having on the mental and psychological health of nurses and their communities. As you know, nurses in many specialties are the primary providers of patient care, and their psychological health and well-being are essential to addressing the COVID-19 public health crisis. Nurses are not only
‘first responders’ but also ‘sustained responders’ for patients and their families,i which places them at greater risk for compassion fatigue, emotional exhaustion, burnout, depression, substance use disorders, and suicide.

Research has documented that nurses currently engaged in treating COVID-19, and earlier with severe acute respiratory syndrome (SARS) patients, report more severe degrees of psychological distress such as depression, anxiety, and insomnia than other healthcare workers.ii,iii Nurses are at significantly higher risk to complete suicide than the general population, with work-related stressors being a greater contributing factor.

iv,v In COVID-19 care, nurses are facing extraordinary workloads, often without adequate access to personal protective equipment (PPE). In recent surveys, nurses reported extreme to moderate concern about the safety of their family and friends (87%), about adequate testing (84%), and about access to PPE (75%).vi

The social isolation of quarantine measures contributes to loneliness and presents additional risks to nurses’ psychological health.vii High death rates, unique to COVID-19, increase “second victim” grief and despair; nurses are often the only person present as patients die alone without their loved ones. Among nursing staffs, recent graduates may be especially vulnerable to the extremes of the pandemic’s work environment. Adjustments in employment situations to meet the most immediate needs of care, can result in further unrest and feelings of inadequacy. Importantly, concerns related to the stigma of perceived weakness by being unable to meet demands or expressing the need for mental health support can present barriers to help.

According to the American Psychological Association, providing evidence-based interventions, such as Psychological First Aid (PFA) and Skills for Psychological Recovery (SPR), to those going through a crisis can increase resiliency and reduce anxiety. Therefore, there is an urgent need to reach all nurses, including APRNs, in their work settings to identify those experiencing extreme distress or nearing a crisis state and to provide them the tools and support they need to improve their psychological health and wellness. As they struggle to keep pace with the demands being placed on them, we ask the Administration to take the following steps to support nurses:
Direct federal disaster behavioral health agencies and staff to develop resources to aid nurses and other health care professionals during the COVID-19 public health emergency The federal behavioral health support led by the U.S. Department of Health and Human Services during disasters is typically oriented toward assisting in discrete areas. For the COVID-19 pandemic, we need to adopt a public health approach supporting frontline health care providers nationwide. This should include the provision of technical assistance, educational resources, and grants to build capacity for peer-to-peer psychological first aid training, and the immediate deployment of trained behavioral health responders.

Activate U.S. Public Health Service’s (USPHS) Mental Health Teams and Service Access Teams to address the psychological impacts of COVID-19 on nurses and other health care professionals The USPHS Mental Health Teams can be deployed in response to public health emergencies to carry out assessments and screenings for suicide risk, acute and chronic stress reactions, substance abuse, and other mental health disorders, and support the development of behavioral health training programs. The teams are also trained in the provision of psychotherapy, psychological first aid, crisis intervention, and other behavioral health interventions to prevent and treat mental illness and substance use disorders. We request the Administration immediately work with State leaders and activate these teams to provide urgently needed mental and psychological support for health care professionals.

Deploy Military Disaster Mental Health teams and behavioral health servicemembers to heavily impacted areas to provide psychological assistance and care to civilian nurses and other healthcare workers Armed Forces behavioral health professionals and servicemembers trained in psychological first aid could provide an urgently needed surge in treatment capacity to COVID-19 hotspots, and provide assessment, diagnosis, and treatment of mental health and substance use disorders among civilian nurses and other frontline staff. In addition to the direct provision of services, such a deployment would put ‘boots on the ground’ and boost morale. This would send a powerful signal to frontline providers about the importance of psychological well-being and combat the stigma associated with seeking help.

We believe these steps will save lives—both of nurses and the patients in their care, right now and after the national public health emergency is over. Research suggests the psychological impact of disease outbreaks and disasters on healthcare providers can last for several years.viii,ix

We urgently ask for your help to preserve and protect the profession for the sake of our nation’s future.

Thank you for taking action to address this critical issue. We look forward to working with you to overcome this crisis and strengthen our healthcare delivery system.

Most respectfully,

Academy of Medical-Surgical Nurses
Academy of Neonatal Nursing
American Academy of Emergency Nurse Practitioners
American Association for Men in Nursing
American Association of Critical-Care Nurses
American Association of Nurse Anesthetists
American Association of Nurse Practitioners
American Association of Post-Acute Care Nursing
American Cannabis Nurses Association
American College of Nurse-Midwives
American Holistic Nurses Association
American Nephrology Nurses Association
American Organization for Nursing Leadership
American Psychiatric Nurses Association
American Public Health Association, Public Health Nursing Section
American Society for Pain Management Nursing
American Society of Peri-Anesthesia Nurses
Association of Diabetes Care & Education Specialists
Association of Nurses in AIDS Care
Association of Pediatric Hematology/Oncology Nurses
Association of periOperative Registered Nurses
Association of Public Health Nurses
Association of Rehabilitation Nurses
Association of Veterans Affairs Nurse Anesthetists
Association of Women’s Health, Obstetric and Neonatal Nurses
Chi Eta Phi Sorority, Inc.
Emergency Nurses Association
Friends of the National Institute of Nursing Research
Gerontological Advanced Practice Nurses Association
Hospice Palliative Nurses Association
Infusion Nurses Society
International Association of Forensic Nurses
International Nurses Society on Addictions
International Society of Psychiatric-Mental Health Nurses
National Association of Hispanic Nurses
National Association of Neonatal Nurses
National Association of Nurse Practitioners in Women’s Health
National Association of Pediatric Nurse Practitioners
National Association of School Nurses
National Black Nurses Association
National Coalition of Ethnic Minority Nurse Associations
National Council of State Boards of Nursing
National League for Nursing
National Nurse-Led Care Consortium
National Student Nurses’ Association, Inc.
Nurses on Boards Coalition
Nurses Organization of Veterans Affairs
Nutrition Support Nurses Section, American Society for Parenteral and Enteral Nutrition
Oncology Nursing Society
Organization for Associate Degree Nursing
Orthodox Jewish Nurses Association
Pediatric Endocrinology Nursing Society
Preventive Cardiovascular Nurses Association
Society of Gastroenterology Nurses and Associates
Society of Pediatric Nurses
Society of Trauma Nurses
Wound, Ostomy and Continence Nurses Society

The Vice President
The Honorable Alex M. Azar II, Secretary of DHHS
VADM Jerome M. Adams, M.D., M.P.H., Surgeon General
Senate Majority Leader Mitch McConnell
Speaker of the House Nancy Pelosi
Senate Minority Leader Charles E. Schumer
House Minority Leader Kevin McCarthy

i Boyle, D. A. (2011). Countering compassion fatigue: A requisite nursing agenda. The Online Journal of Issues in Nursing, 16(1). ii Lai, J., Ma, S., Wang, Y., Cai, Z., Hu, J., Wei, N., … & Tan, H. (2020). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA network open, 3(3), e203976-e203976.
iii Nickell, L. A., Crighton, E. J., Tracy, C. S., Al-Enazy, H., Bolaji, Y., Hanjrah, S., … & Upshur, R. E. (2004). Psychosocial effects of SARS on hospital staff: survey of a large tertiary care institution. Cmaj, 170(5), 793-798.
iv Davidson, J. E., Proudfoot, J., Lee, K., & Zisook, S. (2019). Nurse suicide in the united states: analysis of the center for disease control 2014 national violent death reporting system dataset. Archives of psychiatric nursing, 33(5), 16-21.
v Davidson, J. E., Proudfoot, J., Lee, K., Terterian, G., & Zisook, S. (2020). A Longitudinal Analysis of Nurse Suicide in the United States (2005–2016) With Recommendations for Action. Worldviews on Evidence‐Based Nursing, 17(1), 6-15.
vi COVID-19 Survey Responses: Find Out What 32,000 Nurses Want You to Know About Treating COVID-19. (2020, April 24). Retrieved from https://www.nursingworld.org/~4987e5/globalassets/covid19/ana_covid19infographic_dataset1_20200424-final.pdf.
vii Holt-Lunstad, J., Smith, T. B., Baker, M., Harris, T., & Stephenson, D. (2015). Loneliness and social isolation as risk factors for mortality: a meta-analytic review. Perspectives on psychological science, 10(2), 227-237.
viii Wu, P., Fang, Y., Guan, Z., Fan, B., Kong, J., Yao, Z., … & Hoven, C. W. (2009). The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk. The Canadian Journal of Psychiatry, 54(5), 302-311. ix Galea, S., Rockers, P. C., Saydee, G., Macauley, R., Varpilah, S. T., & Kruk, M. E. (2010). Persistent psychopathology in the wake of civil war: long-term posttraumatic stress disorder in Nimba County, Liberia. American journal of public health, 100(9), 1745-1751.

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