Nurses worldwide experience stress, loss, and violence

A first-of-its-kind study provides a snapshot of the substantial mental health burden on nurses around the world. Published in the journal International Nursing Review, the research documents the impact of three years of intense working conditions brought on by the COVID-19 pandemic.

“Our study describes how nurses are affected by stressors in their workplace and shows how the stress carries over into their home life. The personal losses from the pandemic complicate this picture as there could easily be lingering grief in a third of the workforce,” said Allison Squires, a professor at NYU Rory Meyers College of Nursing and the study’s lead author.

Stress and burnout among nurses working during the COVID-19 pandemic are well-documented, but most studies come from high-income countries. To address the gap in knowledge from other countries around the world, Squires founded the Global Consortium of Nursing and Midwifery Studies. The international research collaboration, which now includes nurses and other health professionals from 82 countries, is examining the long-term effects of the COVID-19 pandemic on the nursing workforce.

In the current study, the researchers surveyed 9,387 nurses from 35 countries between July 2022 and October 2023. They were asked about their mental health and other related factors, including loss, burnout, experiencing aggression from the public, access to mental health services, and self-care practices.

The researchers found widespread mental health challenges among nurses working during the pandemic, with rates of anxiety and depression ranging from 23% to 61%. Nurses consistently experienced more mental health symptoms at work compared to at home; the most common work-related issues were feeling tired (57%), anxiety (44%), and feeling overwhelmed (41%).

Rates of mental health issues varied widely among countries, likely reflecting cultural factors associated with psychological stressors or stigma related to mental illness. For instance, 69.9% of nurses in Brazil reported workplace-related anxiety, compared to 23.8% in Indonesia, while 80.9% of nurses in Turkey reported feeling overwhelmed at work, compared to 6.7% in Thailand.

Loss and public aggression were also identified as challenges to nurses’ mental health. Notably, 20% of nurses suffered the loss of a family member, 35% lost a friend, and 34% a coworker to COVID-19.

“The staggering personal losses of friends, family, and coworkers and their effects on nurses’ mental health should not be underestimated,” Squires and her coauthors write.

In addition, nearly half (48%) of nurses surveyed reported experiencing violence and aggression from the public due to their identity as a nurse—”an extremely concerning finding and ongoing health worker safety issue,” noted Squires.

Only 24% of nurses reported that their employers provided adequate mental health services, leaving many without support or relying on self-care strategies. Most nurses reported more frequently engaging in self-care—including exercise, spiritual practices, and leaning on family and other relationships—compared with before the pandemic.

“The increased engagement in self-care practices suggests that nurses, given the intensity of the pandemic’s working conditions, may have turned to these activities to cope with adverse mental health symptoms experienced at work,” said Squires. “However, promoting self-care will not address the scope of the problems we’ve identified; we need to develop targeted and accessible mental health support in order to foster a resilient nursing workforce.”

The researchers call on policymakers and healthcare organizations to increase mental health services available to nurses worldwide and address issues in the clinical work environment in an effort to support the psychological safety of nurses and other frontline workers.

“Given our findings, it is not surprising that we see nurses moving within the nursing workforce to lower stress roles, leaving their positions or countries for better working conditions, or leaving the profession altogether,” said Squires. “This poses a threat to health system sustainability worldwide, and the impact is likely to affect the most vulnerable systems that were already stretched and stressed to their limits prior to the pandemic.”

“This study supports what ICN has been reporting since the pandemic: we are seeing alarmingly high levels of stress and burnout in nurses across the world,” said Pamela Cipriano, president of the International Council of Nurses (ICN). “This is causing some nurses to leave the profession, which added to the aging workforce, will only exacerbate an already severe global shortage of nurses. We need governments to invest in nursing and improve working conditions and salaries in order to retain the nurses they have and attract more to the profession. ICN has published evidence to show that investing in nurses saves money, strengthens economies and saves lives.”