Sustained professional and personal effects of the COVID-19 pandemic are placing pediatric nurse practitioners (NPs) at high risk for burnout and anxiety, according to survey findings published in the Journal of Pediatric Health Care. The effects of COVID-19 are also seen in their patient population, with more than 70% of NPs noting increased reports of both child and parental mental health concerns.
“Urgent response is needed to address pediatric-focused APRN [advanced practice registered nurses] burnout and mental health needs with sustainable strengths-based and resilience strategies to ensure the nursing workforce has the necessary resources and support to address critical health challenges associated with mental health stressors and professional burnout,” said Jessica Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP, FAAN, National Association of Pediatric Nurse Practitioners (NAPNAP) Immediate Past President and coprincipal investigator, in an interview.
“This problem is, of course, multifactorial, with isolation, loss of safety net services, family stressors and trauma, and deferred care and services all compounding this issue across communities worldwide,” said NAPNAP Secretary and coprincipal investigator Jennifer Sonney, PhD, APRN, PPCNP-BC, FAANP.
Insufficient staffing is another factor affecting nurses’ stress, impacting job satisfaction, and driving many nurses to leave the profession, according to the American Association of Colleges of Nursing (AACN). Although nursing school enrollment recently increased by 5.1%, this rate is not growing fast enough to meet the projected demand for RN and APRN services, the AACN noted.
The study included 886 APRNs who responded to an anonymous online survey posted February 4 to March 10, 2021. Of these, 796 respondents (90%) completed the entire survey, 612 of whom (69%) were members of NAPNAP, 87% identified as female, and 89% identified as White. Most respondents (79%) reported pediatric NP primary care certification and 10% reported acute care NP certification (10%).
Three-quarters of respondents (73%) were fully vaccinated against COVID-19 at the time of the survey. The remainder of respondents received 1 dose (12%) or were waiting for vaccine access (6%); only 4% indicated no plan to receive the vaccine.
High Levels of NP Burnout, Anxiety Reported
Pediatric NPs expressed high levels of concern regarding professional burnout, nervousness or anxiety, and coping with stress. One-third of NPs (34%) indicated moderate or extreme concern regarding feeling professionally burned out, 25% for feeling nervous or anxious, and 15% for feeling depressed or hopeless.
Nearly 20% of respondents experienced the death of a loved one from COVID-19 disease, and 10% tested positive for the disease. Twenty percent of respondents reported moderate or extreme concern for their overall mental health.
One-third of respondents (34%) reported decreased work hours and 16% reported increased work hours during the pandemic. Decreased personal income was reported by 39% and increased income was reported by 6%.
“In addition to practicing clinicians feeling anxious or burned out, 70% of educator respondents in the study reported moderate or extreme concern with clinical training site availability, delaying the pipeline of new pediatric NP graduates from entering the workforce to increase patient access to care” said Dr Peck, who is also clinical professor at the Baylor University Louise Herrington School of Nursing in Dallas, Texas.
Barriers to Clinical Practice
Lack of accessibility of COVID-19 testing was the most commonly reported barrier with only 40% of respondents reporting COVID-19 testing availability in their practice setting. Responding to disinformation was the second most commonly reported barrier with 55% of respondents listing this as a moderate to extreme barrier.
Self-Care and Organizational Changes
Pediatric APRNs should prioritize personal well-being and self-care physically, mentally, emotionally, spiritually, socially, and culturally, Dr Peck said. “Thoughtfully limit media exposure to avoid retraumatization and continuous exposure to harmful narratives,” she said. “Engaging with professional and social support networks is a critical source of support to help nurture diverse perspectives and positive self-talk to reframe criticisms.”
The authors also suggest that favorable environments and organizational changes to practice environments may protect against burnout.
“Leaders in health care and academic organizations need to affirm the value of and regard for pediatric-focused APRNs in health organizations with enhanced role visibility, respect for professional contributions, equitable representation in research and scholarship efforts, and ensured psychological safety,” Dr Peck said. “Adopting well-being as an organizational value can normalize and support expressions of wellness-promoting behaviors.”
“Serving together as experts in pediatrics and advocates for children gives us courage and strength to keep working to find a way forward,” Dr Peck said. “While the care of nursing is loudly applauded, the voice of nursing lacks equal attention and respect. Nursing is a scientific profession of highly educated scholars, experts, leaders, and care practitioners ideally positioned to provide voice and influence for pandemic preparedness and response.”
According to Dr Peck, “Pediatric advanced practice nurses are ideally situated leaders at the epicenter of this global crisis, and must be involved in decision-making processes seeking prompt and effective solutions. Health leaders must assess and respond to pandemic-related trauma we have endured and prioritize sustainable programmatic efforts to cultivate holistic wellness.”
Nurses Need Reinforcements
In an opinion piece published in The Hill, Patricia McMullen, PhD, JD, CRNP, FAANP, FAAN, said that it should not have taken a pandemic to recognize the urgent need for more nurses in the workforce.
According to AACN’s report on 2019-2020 Enrollment and Graduations in Baccalaureate and Graduate Programs in Nursing, 80,407 qualified applicants were turned away from baccalaureate and graduate nursing programs in 2019 due to insufficient number of faculty, clinical sites, classroom space, and clinical preceptors, as well as budget constraints. A shortage of faculty and/or clinical preceptors was cited as the reason for not accepting all qualified applicants among nearly two-thirds of the nursing schools responding to the survey.
“Our nurses need reinforcements as soon as they’re ready to do the job,” Dr McMullen noted.
Strategies for managing moral distress are also needed during the COVID-19 pandemic. According to the AACN, moral distress occurs when clinicians know the correct action to take but are unable to take it, this is especially prevalent among nurses who care for critically ill patients and is also caused by inadequate staffing, value conflicts, challenging team dynamics, and duty conflicting with safety concerns.
“Whether stemming from internal or external factors, moral distress profoundly threatens our core values. It is distinct from other forms of distress experienced by nurses,” AACN stated.
Resources and a tool for recognizing and managing moral distress are available here.
Peck JL, Sonney J. Exhausted and burned out: COVID-19 emerging impacts threaten the health of the pediatric advanced practice registered nursing workforce. J Pediatr Health Care. 2021;35(4):414-424. doi:10.1016/j.pedhc.2021.04.012
American Association of Colleges of Nursing. Nursing Shortage. Updated September 2020. Accessed September 9, 2021. https://www.aacnnursing.org/News-Information/Fact-Sheets/Nursing-Shortage
McMullen P. We’ve asked so much of our nurses, it’s time to give them reinforcements. August 19, 2021. Accessed September 9, 2021. https://thehill.com/blogs/congress-blog/healthcare/568642-weve-asked-so-much-of-our-nurses-its-time-to-give-them
American Association of Critical-Care Nurses. Moral distress in nursing: what you need to know. Accessed September 10, 2021. https://www.aacn.org/clinical-resources/moral-distress