Professional burnout has been a major problem over the 3 years of the COVID-19 pandemic, leading to decreased job satisfaction, increased turnover among nurses, decreased quality of care for patients, and a net decrease in the total healthcare workforce due to resignations and retirements. Nursing work in particular is intense, high-stress, and emotionally demanding; nursing students start to experience these stressors early in their clinical training. The usual stresses of clinical practice worsened during COVID-19, due to more fear of infection, more risk of secondary trauma from seeing patients suffer or die, more work as clinics are short-staffed, less support as colleagues are distracted by their own challenges, and greater isolation as providers felt their own experiences to be more anomalous. Paradoxically, the public perception of nurses as "heroes" during the pandemic might have made traumatic experiences even harder to talk about when nurses' sense of their own capabilities and experiences didn't match the widely-accepted story.
To mitigate the risk of burnout and mental health symptoms among nursing students, the University of Colorado College of Nursing (CU Nursing) developed an innovative co-curricular training program to teach students about the impact of stress and techniques to manage it. Results of the program were recently published in the Journal of the American Psychiatric Nurses Association. The course was launched in January 2021, relatively early in the course of the COVID-19 pandemic although after the most restrictive public health "lockdown" rules had been lifted. Nursing students, like other health care professionals, were still struggling with personal disease risk, secondary trauma, and lack of support; they also had anxiety due to staffing shortages and health facility closures that made it difficult to complete their required clinical placements, and many had concurrent pandemic-related challenges with mental health, family, and finances.
CU Nursing's stress impact course was based on a "deployment" model originally created by my colleague Laura McGladrey, and evolving out of her work with military and first-responder groups. The central concept was that nursing students were being deployed into a high-stress situation, where special resources and strategies would be needed to cope successfully. The course gave students tools such as:
- definitions to provide a common language for talking about stress injuries;
- a deployment model that empowered students to talk about their stress level with others;
- a stress continuum (from green through yellow to red) for students to assess their own stress level and changes in stress over time;
- a tool for making "green choices" that can reduce or prevent stress injuries, such as sleep, exercise, good nutrition, social connection, getting outdoors, avoiding distressing media, etc.;
- and a problem-solving approach to help students step back from situations when their stress level became extreme.
The course's effects were evaluated using pre/post surveys completed by students during the one-semester course. Students' initial scores on commonly accepted mental health screening measures showed that 5-10% had clinically significant levels of anxiety and depression and at least 20% had meaningful signs of trauma at the start of the program. Students said that the course increased their ability to feel calm, content, and hopeful, improved their sense of autonomy and connection with others, and increased their ability to manage both general worry and COVID-related stress. Importantly, they also reported significantly lower levels of professional burnout after participating in the course, which suggests that teaching students this type of content could help to address the severe health professional shortages seen during the COVID-19 pandemic.
From a Two Minds perspective, two of the most important contributions of the stress course seem to have been helping students to name their stress in order to deal with it proactively, and helping students to deepen relationships with their peers that are protective against mental health problems. Giving students vocabulary and tools as a common language for communicating about stress and coping was a way to build Narrative-mind structures that emphasize resilience. Additionally, they gave students a way to talk with others (another important function of the Narrative mind) about making healthier choices: e.g., "I'd like to attend that Zoom happy hour, but I need to make a green choice for myself and take a walk outside right now." Beyond the social dimension of the course, concrete coping suggestions included things like getting more exercise, limiting social media exposure, getting enough sleep, and going outdoors, all of which affect people by way of the Intuitive mind. (For high levels of stress, students were encouraged to go beyond these simple preventive measures by actively renegotiating commitments, seeking informal or formal help, or making other life changes). Furthermore, a sense of social connection or embeddedness in a community is a central human need that the Intuitive mind actively orients to and pursues. For many people that sense of connection was severely disrupted by multiple simultaneous changes during the COVID-19 pandemic, and we believe that the opportunity to speak with peers about stressful experiences was helpful to students in and of itself. Although the stress impact course started at a Narrative level (as all educational programs do), the coping tools provided in the course then engaged students' Intuitive minds in a powerful way. That Intuitive-mind focus might have been particularly important in helping students to feel calm, connected, and empowered, and in reducing burnout despite ongoing stressors related to COVID-19.
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