The pandemic has placed a spotlight on the mental health of nurses and threats to their overall sense of well-being. The World Health Organization (2018) defines mental health as a "state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community." Nurses, nurse educators, and nursing students everywhere experienced the catastrophic outcomes associated with the virus. The invisible work of nurses - compassion, sacrifice, and human connection - requires giving of self in ways not easily replenished. As a result, academic settings and health care organizations are placing a greater emphasis on mental health and wellness.
As nursing students transition into practice, they enter a profession where nurses report high levels of mental distress and burnout associated with job-related demands. Burnout reduces the quality of patient care, leads to increased error rates and greater mortality, and increases nurse turnover while decreasing overall levels of nurse productivity (Stephens, 2019). This jeopardizes patient care and creates a negative loop that can spread across the unit and organization (Melnyk et al., 2018).
Although the pandemic has certainly contributed to nurse burnout and psychological distress, these concerns were also reported in nurses prior to the pandemic. A 2018 study by the Advisory Board reported that one third of the more than 400,000 nurses surveyed planned to leave the profession, citing burnout as their primary reason (Advisory Board, 2021). Left unchecked, burnout can lead to increased rates of depression, anxiety, substance abuse, and suicidal ideation (Melnyk et al., 2021). It is well documented that feelings of stress and burnout are directly correlated to an increase in adverse health care events that negatively affect patient outcomes and contribute to nursing workforce attrition.
Approximately one out of every three new nurse graduates will leave their position within the first two years and the profession within five years (Kovner et al., 2014). Although a number of factors contribute to the decision to leave the profession, the most frequently cited are job-related strain, psychological demands, and burnout (Rudman & Gustavsson, 2010, 2012). Rudman and Gustavsson noted that 50 percent of new nurses demonstrated significant levels of burnout by Year 2, and 20 percent reported high levels of burnout accompanied by depressive symptoms at some point during their first three years of employment.
Patterns of behavior in nursing school, such as study burnout, exhaustion, disengagement, and depressive mood, are predictors of early career burnout, lower performance levels, and intent to leave (Jarden et al., 2021). These results suggest the importance of recognizing early signs of burnout and disengagement during nursing school and implementing prevention strategies to promote mental health and well-being in students. Nursing education can have a significant effect on students' overall sense of health (Spurr et al., 2021). Students (prelicensure and graduate) face a combination of social, psychological, physical, emotional, and family demands that compete with academic expectations and self-care. As a result, threats to well-being may include poor nutrition, lack of sleep, less exercise, social pressures, financial demands, clinical care demands, fragmented social networks, academic attrition, and concerns for personal safety (McConville et al., 2017). Nationally, nursing students reported high rates of anxiety, depression, suicidal ideation, and feelings of being overwhelmed by the demands of their program (Turner & McCarthy, 2017). These feelings can significantly reduce students' capacity to learn and predispose young students to mental health disorders. Consistent with Maslow's hierarchy of needs, basic needs must be met before a person can address psychological needs and progress to self-actualization (Maslow, 1987).
The health of the nursing workforce and ultimately of our nation is dependent on the mental health and well-being of nursing students. Addressing their mental health status and implementing strategies to mitigate threats to student well-being are a moral imperative, "something that must happen because it is the right thing" (Macmillan Dictionary, https://www.macmillandictionary.com/us/dictionary/american/moral-imperative). Nurse educators and academic leaders have a shared responsibility to contribute to a redesign of academic systems that focuses on prevention and integrates strategies to promote resilience and self-care in students (Slavin et al., 2014). The redesign should concentrate on reducing environmental stressors and integrating strategies to improve overall well-being. Graduation rates from a nursing program and percentage of first-time pass rates on licensure or certification exams are no longer sufficient as the gold standard for program success.
As nurse educators, we play a significant role in promoting a positive academic environment by considering the various aspects of students' lives and promoting a balance between environmental, mental, physical, and social relationships (Stanton et al., 2016). Developing an open, engaging, and interactive teaching style; fostering positive student and faculty relationships; balancing curricular demands; and demonstrating respect for and interest in students are essential initial strategies. Studies have reported that college students who have higher levels of resilience tend to evidence lower stress levels, less depression, and improved academic success (Van Hoek et al., 2019). Stress-reducing activities are highly associated with an increase in resilience and improved overall levels of performance and well-being.
The financial burden of education on students can have a significant impact on student well-being (Jones et al., 2018). Costs associated with nursing programs include required books, technology, supplies, uniforms, and travel to clinical sites. Students may struggle to afford adequate housing, food, social activities, reliable transportation, and health care, which can interfere with the time and energy needed to focus on studies. To reduce unwarranted costs, faculty can use online textbooks and free library resources, while also assisting with cost-saving strategies such as carpooling. In addition, prior to integrating academic software as a course requirement, it is important to regularly solicit vendor quotes and validate improvement in student learning.
Course delivery, design, workload, due dates, classroom climate, and teaching style can also significantly impact student stress, anxiety, and well-being. When classes are designed with student learning as the central tenet, motivation, enthusiasm, engagement, and overall learning improve. To create better learning conditions, educators should coordinate calendars across courses to minimize conflicting exam and assignment due dates, organize online classes using a similar design to help students focus on content versus course navigation, regularly review curricular content to eliminate redundancies or unnecessary (nice to know) information, and include active learning activities to increase engagement and create enthusiasm for learning. Students who understand the relevance, authenticity, and applicability of the subject matter to their chosen profession tend to be more engaged and motivated to learn.
Faculty may be the first to recognize when a student is struggling, noticing, for example, an increase in absenteeism, changes in behavior, disengagement, or a change in hygiene and dress. It is important to reach out to students who appear to be in distress and refer them to appropriate resources for help when applicable. Information on wellness resources, counseling services, and links to mental health care and suicide prevention hotlines should be readily visible on course online landing pages and published in student handbooks and syllabi for easy access. We must make a concerted effort to reduce the stigma associated with mental illness and distress and embrace the opportunity to support mental well-being as part of our teaching.
Academic leaders and nurse educators are positioned to advocate for a shift from an emphasis on treatment for mental illness to a focus on prevention and strategies to improve overall well-being and personal health (Di Placito-De Rango, 2018). The shift begins by openly creating a culture and climate of well-being and mental health in nursing schools, including the development of policies, behaviors, lessons, and activities to cultivate resilience, self-care, and coping strategies. These new norms can help to prevent burnout, fatigue, and depressive symptoms across academic and health care environments. The inclusion of self-care topics, resilience strategies, emotional regulation, and stress management activities must be infused across the curriculum with the role modeling of wellness behaviors in the classroom and routines that include evidence-based strategies to reduce stress, improve focus, and enhance overall sense of well-being. Students who actively participate in a variety of self-care activities throughout their nursing program will be better prepared to engage in wellness behaviors following graduation. Ultimately, students will develop a toolkit of self-care strategies and will be ready to face the challenges of entering an ever-changing and demanding health care environment.
The American Nurses Association, in conjunction with Healthy Nurse, Healthy Nation, encourages nurses to practice and role model healthy behaviors and offers an extensive list of resources and tips to promote nurse mental health (https://www.healthynursehealthynation.org). Nurse educators are encouraged to share these and other resources with their students and incorporate relevant content or activities into their courses. An additional resource is available on the Duke Center for Healthcare Safety and Quality website - a series of "bite-sized" wellness resources that can easily be adapted into academic classrooms and clinical environments (https://www.hsq.dukehealth.org/bite-sized-resources/). Study outcomes support the efficacy of these simple yet effective wellness activities to enhance the overall well-being of health professionals in response to the inherent demands of an unpredictable and demanding health care environment. An extensive list of publications is also available on the Duke Center website (https://www.hsq.dukehealth.org/publications/).
A holistic approach to preparing the future of our nursing workforce begins in academia. Nurse educators are called to collectively promote a culture of well-being in nursing programs and prepare students with the tools they need to promote self-care and resilience. Nursing students are the future of our nursing workforce and the health of our profession and the nation.
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