The Post Pandemic Future: Nursing in the Region of the Americas and Mental Health

As we move toward a post COVID-19 future, we must attend to the health and well-being of our healthcare workers...

As we move toward a post COVID-19 future, we must attend to the health and well-being of our healthcare workers, and specifically to nurses who make up the largest portion of the healthcare workforce. Throughout the world, nurses play a crucial role in achieving expanded access to primary healthcare (PHC) services, health promotion, disease prevention, and quality of care, without leaving anyone behind. Strengthening the nursing profession is essential to transform healthcare systems.

The transformative and impactful role of nurses has been highlighted throughout the COVID-19 pandemic. The health workforce has endured many particularly difficult challenges during this time, both professionally and in their personal lives, in the effort to respond to the needs of communities, patients, and families. As a result, many nurses and other providers are facing their own mental health challenges due to the prolonged response to address pandemic challenges.

Protecting mental health of providers has become an important lesson of the pandemic

Several areas in the Region of the Americas (hereafter referred to as the Region) have faced inequities and greater challenges, especially in countries that are considered low- and middle income. Increasing national investments in nursing in the Region is necessary and has been addressed by the Pan American Health Organization (PAHO). Protecting mental health of providers has become an important lesson of the pandemic and an essential and permanent component in the management of health systems and services. This article offers a summary of challenges in the Region of the Americas as leaders consider the best strategies to support a positive relationship that features resilience, adequate working conditions, and investments in the nursing profession for a post-COVID-19 future that protects workers’ mental health.

Nursing in the Region of the Americas
The report, State of the World’s Nursing 2020: Investing in Education, Jobs, and Leadership, published by the World Health Organization ([WHO], 2020), estimated that there are approximately 9 million nursing professionals in the Region of the Americas, which includes 35 member countries (see Table). These providers represent greater than 56% of the health workforce, yet 87% of the nurses are in three countries: Brazil, Canada, and the United States (WHO, 2020).

Table. Countries in the Region of the Americas

National Health Workforce Accounts (WHO, 2023). 

...this Region remains one of the most inequitable globally, with millions of people lacking access to comprehensive health services

Furthermore, this Region remains one of the most inequitable globally, with millions of people lacking access to comprehensive health services (e.g., preventive, and palliative care) (PAHO, 2014). In Latin America and the Caribbean (LAC) in 2020, estimated unemployment is 13.5%, poverty rate is 37.3% with extreme poverty of 15.5% (Economic Commission for Latin America and the Caribbean [ECLAC] & PAHO, 2020).

Strategic Directions for Nursing
In 2019, the PAHO, the WHO regional office in the Region of the Americas, presented the Strategic Directions for Nursing in the Region of the Americas, reflecting the ongoing commitment to strengthening nursing practice and education. Several goals were to empower nursing professionals, raise awareness, and acknowledge the role of nurses as transformative health agents for people, families, and communities (PAHO, 2019).

Recently, PAHO (2022c) launched the document “The Strategic Importance of National Investment in Nursing Professionals in the Region of the Americas.” This document aligns with the "Global Strategic Directions for Nursing and Midwifery 2021-2025" (WHO, 2021) and investigated unique challenges that have affected the ability of nurses to achieve their full potential and offered policy options and key actions to address these challenges in the short and long term. Examples of these actions included: investing in and standardizing nursing education and competencies; increasing the proportion and authority of nurses in senior health and academic positions; increasing the availability of health workers in the context of recruitment and migration and strengthening professional regulatory systems and contributing to interprofessional care.

Investment in nursing professionals in the Region of the Americas has proven insufficient.

Investment in nursing professionals in the Region of the Americas has proven insufficient. Post pandemic strategic efforts are needed to strengthen leadership and optimize the nursing workforce for an effective response to the health needs of the population. For example, strengthening public policies and management; increasing the number, retention and qualifications of registered nurses; improving regulation of and education for nursing practice; and expanding the labor market and professional roles have potential for a positive impact on health system performance and on the lives of people, families, and communities in this Region (PAHO & College of Nursing UIC, 2020; PAHO, 2022c).

The COVID-19 Pandemic and Provider Mental Health

Impact on Region of the Americas
The COVID-19 pandemic has had significant adverse impact in the Region of the Americas, with more than 175 million cases and 2.8 million deaths, by 25 August 2022. These numbers account for around 40% of all global cases while only 13% of the global population is represented by this region (Etienne, 2022; PAHO, 2022a).

Countries implemented non-pharmacological public health measures during the response to the pandemic, including lockdowns and school and business closures. These measures had varying effects on the social, economic, and cultural conditions of different population groups. In countries where access to health has been most affected by the pandemic, health professionals and caregivers have embodied the ideal response (PAHO, 2020). However, this response was not without a cost to the mental health of our healthcare workers as evidenced by multiple studies (Peñacoba et al., 2021; Bae et al., 2022).

In countries where access to health has been most affected by the pandemic, health professionals and caregivers have embodied the ideal response

As a result of the pandemic, 47% of countries in the Region experienced disruption in the health services in the area of mental health, neurological health, and substance use disorders. In 17% of the countries the disruption included greater than 50% of these services. Mental healthcare and psychosocial support for health workers were implemented as actions to mitigate disruptions in service delivery and promote service recovery in 63% of the countries (PAHO, 2022d).

The dedicated work of nursing professionals was critical in the response to the pandemic. For example, the positive impact by the work of nurses resulted in lower COVID-19 infection rates among residents in long-term care institutions in the United States of America (Figueroa et al., 2020) and has reduced mortality rates and hospital readmission for up to 30 days for patients in home treatment with use of oxygen and continuous telephone support (Banerjee et al., 2021). Remote and telehealth services have benefited remote communities (McCullough et al., 2020) and enabled respiratory system monitoring and support for rehabilitation and mental health in patients recovering from COVID-19 (Park et al., 2020).

Provider Mental Health
However, as previously mentioned, the health workforce has also suffered significant effects of the pandemic. A total of 1,827,112 COVID-19 cases among healthcare workers, including 9,159 deaths, have been reported to PAHO by 22 countries in the Americas in the period up to 12 May 2021. Even prior to the pandemic, mental health concerns related to stress in the workplace have been identified. In the PAHO (2017) Plan of Action on Workers’ Health 2015-2025, the issue of occupational hazards was addressed at the global level and action is deemed a great necessity. In this document five strategic lines of action were identified: 1) Develop and update legislation and technical regulations on workers’ health; 2) Identify, evaluate, prevent, and control hazardous conditions and exposures in the workplace; 3) Increase access to and coverage of health services for workers; 4) Promote health, well-being, and healthy work in the workplace; and 5) Strengthen diagnostic capacity, information systems, epidemiological surveillance, and research in the field of occupational diseases, injuries, and deaths. All of these strategies will be important for the future health of our workforce to ensure the health and well-being of those who care for others and also to eliminate extra expenditures and decrease migration due to burnout from those who see the risks as too high (Buchan et al., 2022; PAHO, 2017).

Even prior to the pandemic, mental health concerns related to stress in the workplace have been identified.

Response to Mental Health Concerns
The pandemic exposed chronic underinvestment in human resources for health (HRH) and a lack of information systems to report on HRH distribution, lines of care and professional categories, and composition and characteristics of interprofessional health teams. As health systems surged in capacity, countries faced challenges in the recruitment, deployment, protection, and retention of the health workforce, including providing psychosocial support to health workers on the frontlines (PAHO, 2021a).

Health worker safety and patient safety are interconnected.

Protecting providers’ mental health is an important lesson of the pandemic and an essential and permanent component in the management of health systems and services (PAHO, 2021b). Health worker safety and patient safety are interconnected. Health workers who are physically and psychologically healthy are less likely to make mistakes, which contributes to improved patient safety and quality health services (Institute of Medicine (US) Committee on Quality of Health Care in America, 2000). In the Region of the Americas there is a tremendous gap between the number of people who need mental healthcare and those who receive it, even with the current health workforce. Even pre-pandemic, this treatment gap was much higher in Latin America and the Caribbean than in North America (Kohn et al., 2018).

In the Region of the Americas there is a tremendous gap between the number of people who need mental healthcare and those who receive it...

In 2022, the PAHO addressed parallel actions for the groups that make up the health teams to ensure education in the following areas: mental health and psychosocial support (MHPSS); psychological first aid (PFA) and team care and support, emergency detection and referral systems to mental health. In this document, PAHO suggested several actions for countries to ensure availability of and access to mental health services for health workers in need. First, design specific mental health services for health workers or, in an integrated manner, for the rest of the population. These services should incorporate ethical principles, such as autonomy, confidentiality, and professional secrecy. It is important to have available professional providers who do not belong to the same work team as the colleagues to whom they provide care. Second, consider the possibility of offering support services and mental healthcare in remote modalities. Finally, consider the formation of self-management groups within work teams, with periodic follow-up meetings (PAHO, 2021b).

The document also addressed measures focused on health promotion (PAHO, 2021b). Several measures specifically targeted potentially helpful actions for health workers. These included: 1) Address basic needs; 2) Maintain a safe organization, with accountability and commitment from the highest level (including official statements, policies and bylaws, and the appointment of a health and safety specialist in the workplace); 3) Respect rest breaks and relief during work and between shifts; 4) Maintain a healthy diet; 5) Engage in physical activity; 6) Maintain contact with family and friends and 7) Avoid the use of tobacco, alcohol and other psychoactive substances to cope with the situation and 8) Use relaxation, breathing, and mindfulness techniques to manage stress (PAHO, 2021b).

For those who hold health management positions in the governmental or institutional sectors, whether public or private, the PAHO (2021b) document offered a number of suggestions:

• Adopt policies to promote health worker well-being and mental health and to prevent violence, harassment, and abuse of authority in the work environment.
• Effectively include mental healthcare for health workers in all intervention programs.
• Implement mental health monitoring and care systems in health institutions and organizations.
• Make mental healthcare services available to workers and volunteers.
• Consider the occupational burnout syndrome as an occupational disease, and ensure its detection and care.
• Encourage prevention and coping of stigma, discrimination, and violence, as well as fostering respect and appreciation for health workers, with and from the community and institutions.
• Implement effective communication strategies that promote health workers’ care and respect for their role, and reduce fear and blame in the general population.
• Adopt policies for public recognition of health workers and caregivers during the pandemic.
• Guarantee work schedules compatible with this healthy criteria, rest times, with team rotation systems in the first line of intervention; and consider the rotation of work teams.
• Consider the health workers' mental health a priority in the creation of job profiles, evaluation of competencies and performance indicators.
• (PAHO, 2021b, p. 3)

In 2022, PAHO also collaborated with the COVID-19 Health Care Workers (HEROES) study (NIH, n.d.), co-directed by two principal investigators of Columbia University’s Mailman School of Public Health and the School of Public Health, Faculty of Medicine, University of Chile. This was a multicenter prospective cohort study designed to assess the impact of the COVID-19 pandemic on the mental health of healthcare workers. The study reported data of healthcare workers from 11 countries, such as Argentina, the Bolivarian Republic of Venezuela, Brazil, Chile, Colombia, Guatemala, Mexico, Peru, the Plurinational State of Bolivia, Puerto Rico, and Uruguay (PAHO, 2022b).

The HEROES study findings showed high rates of depressive symptoms, suicidal ideation, and psychological distress in several countries of the Region.

The HEROES study (PAHO, 2022b) findings showed high rates of depressive symptoms, suicidal ideation, and psychological distress in several countries of the Region. As for depressive symptoms, between 14.7% and 22.0% of healthcare workers in most countries presented symptoms that led to suspicion of a depressive episode, with Chile accounting for the highest rate. The figures for suicidal ideation fluctuated between 5% and 15% of respondents, with the highest values in Chile and in the Plurinational State of Bolivia.

Regarding psychological distress, two groups in the HEROES study (PAHO, 2022b) presented relatively low values (12%-13.5%), while higher figures were observed in five groups, in which Colombia was the country with the highest values. Relevant associated factors included, at the individual level, having low social support and receiving economic support. At the family level, there was concern about infecting relatives. For those working with patients with COVID-19, factors included conflict with patients’ families, having to triage patients, and confidence in the management of the pandemic by the healthcare institution. In terms of working conditions, factors included changes in job duties and the presence of support networks at work. Finally, at the social level, factors included confidence in the government’s handling of the pandemic and stigma, or having experienced violence related to working with COVID-19 patients (PAHO, 2022b). Even though the professions of study participants were not identified, it is reasonable to suggest that similar findings would be found with just nursing participation, as nurses represent 56% of the health workforce.

Conclusion

As we move forward in a post COVID-19 pandemic world, strategies such as the ones mentioned above will only be effective with noted improvements in the care for the mental health of nurses who are caring for others. Nursing professionals are an integral part of the healthcare system. However, a resilient professional is needed to manage workplace stressors that can impact the physical and emotional aspects of well-being, and support quality care for communities, patients, and families. Improvement in the care of mental health for nurses is especially true when attempting to prevent migration from the workforce.

The mental health of our nurses must be a priority in the focus of our future efforts in healthcare workforce strategies.

Migration of nurses out of low- and middle-income countries, such as those included in the Region of the Americas, will continue to beleaguer the Region without concerted effort to build and support a resilient workforce of nurses. These nurses have faced not only the burdens placed upon them during the COVID-19 pandemic but also the weight of insecurities and inequities not commonly faced by their peers in wealthier nations. A positive relationship between resilience, adequate working conditions and investments in nursing is an important consideration for a post COVID-19 pandemic future, especially considering the inequities and treatment gaps noted among many low- and middle-income countries in the Region of the Americas. The mental health of our nurses must be a priority in the focus of our future efforts in healthcare workforce strategies.

Authors

Silvia Helena De Bortoli Cassiani, PhD, RN
Email: cassianis@paho.org
ORCID ID: https://orcid.org/0000-0003-0914-7511

Silvia Helena De Bortoli Cassiani, is a registered nurse and has been Regional Advisor for Nursing and Allied Health Technician in the Pan American Health Organization / World Health Organization in Washington, DC, since April 2013. Prior to her current position, she was dean of the Ribeirão Preto College of Nursing at University of São Paulo, Brazil. She holds a PhD in Nursing.

Bruna Moreno Dias, PhD, MHS, RN
Email: morenobru@paho.org
ORCID ID: https://orcid.org/0000-0002-7346-4848

Bruna Moreno Dias is a registered nurse and works as a consultant at PAHO/WHO. She holds a PhD and Masters in Health Sciences from the Ribeirão Preto College of Nursing at University of São Paulo, Brazil. She has worked in health institutions, in education and in the development of research on topics related to management of health services and nursing.

Rebecca Johnson, BSN, MBA, RN
Email: johnsonreb@paho.org
ORCID ID: https://orcid.org/0000-0001-8079-7029

Rebecca Johnson is a registered nurse and member of the PAHO internship and practicum program (July to Nov, 2022). She holds a Master’s in Business Administration. Her background includes work in the pediatric and emergency room setting along with education of baccalaureate prepared nurses.

Disclaimer: The authors hold sole responibility for the views expressed in this manuscript, which may not necessarily reflect the opinion or policy of the PAHO/WHO.