The seemingly never-ending pandemic, driven by unvaccinated high-acuity patients, has nurses suffering a cascade of negative emotions and leaving the field in an exodus expected to worsen with COVID-19 vaccine mandates.

According to a survey by the American Nurses Foundation (ANF) that netted responses from 22,215 nurses from Jan. 19 to Feb. 16, 2021, nurses feel “betrayed” (12%), “guilty” (11%), and “like a failure” (10%). Nurses reported more than one emotional state as the highest-percentage answers exceeded 100%: exhausted (51%), overwhelmed (43%), irritable (37%), and anxious (36%).Only 1% of respondents felt suicidal, but that still is 222 nurses thinking of taking their own lives.1

In a recent survey of 234 registered nurses in California, 15% of respondents reported thoughts of suicide in the previous month.

“That is extremely distressing,” says lead author Alyson Zalta, PhD, associate professor of psychology at the University of California, Irvine. While her paper awaits publication, Zalta previewed a few of the findings for Hospital Employee Health.

In addition to patient care challenges, the denial and politicization of COVID-19 have taken a toll on nurses. “Nurses have been in an impossible position within the context of this pandemic and the decisions they have had to make,” she says. “The way our society has responded to this event has really been pretty damaging for nurses.”

Rather than “burnout,” Zalta prefers to describe this damage as “moral injury,” a condition somewhat similar to that experienced by soldiers in combat. In general, moral injury occurs in a person who witnesses, participates in, or fails to prevent some harmful event. This event might be well beyond their power to stop, but their ethics and moral code are violated and they are emotionally harmed.

“Nurses, for example, may have too many patients to care for at one time,” Zalta says. “While they are taking care of one patient, they realize a patient is coding in another room.”

As a result of such conditions, 13% of the nurses surveyed said they plan to leave the nursing field, adding to an escalating national nursing shortage that threatens to undermine patient care.

“Turnover is a major issue and seriously compromises the health of the workforce,” Zalta says. “We’re certainly seeing that there are work place issues as well as the broader sociopolitical climate that are driving distress.”

Nearly 1 in 5 HCWs Have Quit

In another national poll of 1,000 healthcare workers conducted between Sept. 2 and Sept. 8, 2021, 18% said they had quit a job, and 12% said they were laid off. In addition, 19% said they were considering quitting and leaving healthcare altogether.2

Moreover, researchers who reviewed death records found nurses who quit or are fired for mental health issues, substance use, or chronic pain are at risk for suicide. The researchers selected nurse suicide cases for those who appeared to have a job-related problem prior to death, as coded on forms or described in investigation narratives.3 Although the study was based on pre-pandemic data, one of the authors concluded suicidal ideation was partly linked to the loss of “identity” as a nurse, a psychological detriment that could manifest more generally as more nurses leave their chosen field. (For more information, see the June 2021 issue of Hospital Employee Health.)

“Employment in healthcare is down by 524,000 [jobs] since February 2020, with nursing and residential care facilities accounting for about four-fifths of the loss,” the Bureau of Labor Statistics recently reported.4

Nursing is a compelling calling and is year in and out voted the most trusted profession. The COVID-19 pandemic has changed the equation, but it is initially surprising to see nurses willing to give up their careers rather than be vaccinated against SARS-CoV-2. Another wave of resignations already is forming as hospitals and healthcare facilities of all stripes move to mandate COVID-19 vaccination to meet new federal requirements. In the aforementioned ANF survey, 28% of nurses who were not yet vaccinated said they had no intention of doing so. Overall, 28% reported a desire to quit.1

Stigma, Refusal of Help

In another recently published survey of 7,378 nurses conducted from 2017-2018, 5.5% of respondents reported experiencing suicidal ideation within the past year. That is 403 nurses who were so distressed they experienced suicidal thoughts before the pandemic. Moreover, nurses with suicidal ideation were less likely to report they would seek help (72.6%) than those without these thoughts (84.2%).5

“There certainly are data out there that suggests emotional distress is very high in our frontline workers, the people who are really taking care of the COVID-19 patients,” says lead author Liselotte Dyrbye, MD, an internist at the Mayo Clinic in Rochester, MN. “It would not surprise me at all if suicidal ideation was more prevalent in nurses now than it was at the time of our study. I also would not be surprised if burnout was more common. Nurses who are burned out are more likely to have suicidal ideation.”

Some reluctance to seek therapy could be concerns about a board flagging their license or giving up confidentiality, she notes.

“The other obstacle is stigma, which is unfortunately still quite prevalent,” Dyrbye says. “Then, difficulty getting access. You might finally get an appointment with a mental health professional, but then you are scheduled first shift. It’s hard to find anybody to cover you because you are already short-staffed, and you need to go take care of your patients, which is your primary duty. That is really concerning because they need to go get care.”

There is a feeling among nurses that only others in their profession can relate to their stress and work conditions during the ongoing pandemic.

“Some hospitals are offering support groups and therapeutic groups to allow nurses to get together and talk to each other on company time,” Zalta says. “I think it is really valuable to communicate that the psychological heath of the nursing workforce is something that organizations care about. Encouraging peer support for nurses to be able to talk about their experiences is really important.”

To a considerable extent, nurses were predisposed to a mental health crisis, with higher divorce and burnout rates than the general public, well before SARS-CoV-2 emerged. Moreover, the crucial healing connection with the patient has largely been lost in today’s “mechanized” corporate medicine, says Jan Bonhoeffer, MD, an author and pediatrician at University Children’s Hospital in Basel, Switzerland. (See related story in this issue.)

“This has clearly been exacerbated during the pandemic,” he says. “The rates of depression, burnout have been skyrocketing in many countries. I feel this is way beyond the U.S. This is a global phenomenon. The data are just coming out now. We’re just gradually seeing this, and I believe we will continue to see it in the next few years to come — not only for healthcare professionals, but also for families.”

Similarly, Dyrbye found in her study (again, before the pandemic) that 38% of nurses reported symptoms of burnout and 40% had substantial indicators of depression. “This is directly related to work-related stress,” she says. “We know that the nurses on the frontline of the COVID-19 pandemic now are experiencing more work stress and certainly more burnout.”

Burnout is the direct result of job demands that exceed job resources. “There are many was to mitigate the high stress that nurses are experiencing,” Dyrbye says. “One is to make sure that there is adequate staffing so the patient load isn’t too overwhelming. Also, that they have adequate access to PPE [personal protective equipment] — that is another big factor. And providing people with a positive work environment with leaders who are really skilled at building teams. Nearly all the solutions lie in the work environment. We really need system-level solutions.”

NIOSH Request for Information

The CDC’s National Institute for Occupational Safety and Health (NIOSH) published a request for information, asking for “interventions to prevent work-associated stress, support stress reduction, and foster positive mental health and well-being among the nation’s health workers.”6 As this report was filed, the deadline to submit comments was Nov. 26.

“Health workers face many demands at work, which may include difficult working conditions, long work hours, rotating and irregular shifts, exposure to human suffering and death, and increased risks for personal exposure to disease and harm,” NIOSH stated. “The COVID-19 pandemic has exacerbated these challenges and contributed to new and worsening mental health concerns, including burnout, compassion fatigue, depression, anxiety, substance use disorders, and suicidal ideation.”

NIOSH asked for input on programs and interventions, including “how stigma associated with seeking mental healthcare is addressed, and how health workers are encouraged to participate. In your experience, how does the workplace benefit from implementing interventions or offering services to health workers to prevent/reduce work-related stress?”

An anonymous commenter to the NIOSH request for information wrote, “We are living in unprecedented times. I never thought I would see the day where nursing would be a profession that is literally shunned. Doctors and nurses walking off of their once-loved jobs due to stress and burnout. I worked frontline at a rural health clinic for over 1.5 years providing rapid COVID tests, and after that, vaccines. Overwhelm[ed] was not even close to how I was feeling. I could not quit because of my financial obligations, but I dreaded coming to work every day. It seemed as if no one cared at all. I was terrified for my safety as well as the safety of my loved ones. Working shorthanded along with stress was not the formula for a happy work environment. I would like to see administration openly appreciate staff and [put] more incentives in place to boost morale. Appreciation goes a long way.”

Dennis Smith, a healthcare pastoral care provider, wrote, “Peer support that is prompt, sensitive, and sincere has been helping people to take a few more steps in a better way as we continue through the pandemic. Employee assistance program support is beneficial. The ability of those who are walking with the same moccasins and in real time can be very powerful.”

Another commenter, Nolan Wessell, MD, an assistant professor of orthopedics at Colorado University Hospital, cited the expansion of workload and demand for productivity.

“Data suggest that healthcare providers today are tasked with completing three to five times the level of productivity compared with what was asked of them 30 years ago,” he wrote. “We need a system that better values all types of healthcare providers and ensures that they can function at the highest level of their training in order to ensure the long-term success of a system that is already overburdened and becoming more burdensome with each passing day.”


  1. American Nurses Foundation. Pulse on the nation’s nurses COVID-19 survey series: Year one COVID-19 impact assessment. February 2021.
  2. Galvin G. Nearly 1 in 5 health care workers have quit their jobs during the pandemic. Morning Consult. Oct. 4, 2020.
  3. Davidson JE, Ye G, Parra MC, et al. Job-related problems prior to nurse suicide, 2003-2017: A mixed methods analysis using natural language processing and thematic analysis. J Nurs Regul 2021;12:28-39.
  4. Bureau of Labor Statistics. The employment situation — September 2021. Oct. 8, 2021.
  5. Kelsey EA, West CP, Cipriano PF. Original research: Suicidal ideation and attitudes toward help seeking in U.S. nurses relative to the general working population. Am J Nurs 2021;121:24-36.
  6. National Institute for Occupational Safety and Health. Interventions to prevent work-related stress and support health worker mental health; request for information. Federal Register. Sept. 27, 2021.