Whenever the end does come and the final wave crashes on shore, it will carry with it a reckoning for the people who bore the heaviest burden of care in this pandemic, Canada's 440,000 nurses. (Renzetti 2021)

It is time to acknowledge what has been hidden inside Canada's healthcare system for decades but has become more visible during the COVID-19 pandemic: widespread stress, mental health problems and burnout in the nursing workforce. For the past 20+ years, repeated concerns about the mental health of nurses in Canada have been raised within many national reports, yet the rates have continued to rise.

In the 2001 report Commitment and Care: The Benefits of a Healthy Workplace for Nurses, Their Patients and the System, Baumann et al. discussed nurses quitting their jobs because they were physically and mentally exhausted. The 2005 National Survey of the Work and Health of Nurses (Shields and Wilkins 2006) found that among 19,000 nurses, 9% experienced clinical depression during the previous year – higher than the general population. Close to 20% reported that their mental health had made their workload difficult to handle, and just over 10% had taken time off for their mental health.

Fast-forward to 2019 and the survey conducted by the Canadian Federation of Nurses Unions (Stelnicki et al. 2020). As reported in this issue, the results are startling, with high numbers of nurses screening positive for a mental disorder, high rates of suicidal behaviours and burnout (Stelnicki and Carleton 2021). And all of this was before COVID-19 even arrived in Canada.

How Are Nurses Managing during the Pandemic?

During the COVID-19 pandemic, additional studies have shown its devastating toll on the country's registered nurses, nurse practitioners, registered psychiatric nurses and licensed practical nurses (registered practical nurses in Ontario). In a survey by Statistics Canada, 70% of healthcare workers reported worsening mental health as a result of working during the pandemic (Sandri 2021). One-third reported fair or poor mental health, with this number being higher among nurses at 37%. In a survey of 765 registered practical nurses across Ontario (WeRPN 2021), 96% said that their daily experiences at work had become "exponentially more stressful," with 83% reporting that their mental health had been adversely affected by their work and 71% reporting that they had experienced a "breaking point." Other studies have reported that mental health issues, such as insomnia, anxiety and depression, have been common among nurses practising during the pandemic (Crowe et al. 2021; Lapum et al. 2021).

Although it isn't possible to directly compare results across the years, they highlight the escalating enormity of the issue and the disturbing rates of mental health issues being reported by nurses. These rates will likely increase for some time to come, leading to the possibility of an echo pandemic, with widespread mental illness and mental health issues arising as a result of COVID-19 (Canadian Mental Health Association 2020).

When the editors of this journal discussed a special issue on nurses' mental health, we knew this was going to be an important area to feature. But we wanted to move beyond describing the problem to posing potential solutions. Therefore, we asked these questions: What is being done to support the mental health of nurses, and what has been found to be effective in these challenging times? During the pandemic, nurse leaders (Bookey-Bassett and Purdy 2021; García and Calvo 2021; Rosser et al. 2020) have recognized the need to be adaptable within contexts that have rapidly and repeatedly changed (Lapum et al. 2021). They have continually been asked to reach into their leadership toolboxes to find ways to support nurses while being subject to the same stresses. For this issue, we asked nurse leaders to share with us those solutions and strategies that have worked for them during the past year.

What Are Nurse Leaders Doing to Support Their Nurses?

Stelnicki and Carleton (2021) provide an outline of their research highlighting the mental health and organizational stressors experienced by nurses. Prior to the pandemic, nurses reported high levels of post-traumatic stress disorder and depression, with one in three nurses having suicidal thoughts. These levels are consistent with those found in public safety personnel, such as firefighters, paramedics and police officers, who are also regularly exposed to potentially traumatic events (such as severe human suffering and life-threatening illness) and significant workplace stress and violence and have high rates of burnout. Although some stressors cannot be prevented, others can be decreased or eliminated. Support from leaders is vital to help with this.

Next, we invited nurse leaders from Ontario (Jeffs et al. 2021; Lefebre et al. 2021; Ogilvie 2021; Velji and Brannon 2021), New Brunswick (Donovan 2021) and British Columbia (Chant 2021) to respond to the research and describe the strategies they used within their different contexts, including corrections, long-term care, mental health, acute care, home and community care and primary care. All discuss the inconceivable challenges faced by nurses and their unrelenting commitment to patients. Each paper then discusses the comprehensive, multipronged approaches used, including

• ensuring the safety needs of staff and patients;
• monitoring both internal and external environments through meetings, surveys and focus groups;
• streamlining goals, removing barriers and providing greater control over nurses' work by adapting or creating new documents, forms, processes and access to resources;
• communicating honestly and transparently through emails, online chats, memos, town halls, team meetings or daily huddles;
• encouraging teams to be creative in building more joy at work by celebrating achievements, showing appreciation and recognizing nurses;
• enhancing virtual wellness programs or resource hubs to provide rapid access to services that provided counselling, information or ready-to-use actionable tools; and
• offering education and coaching sessions to help build resilience while managing stress.

Innovations to Support Nurses' Mental Health

Although not resolving the underlying causes, the use of digital tools is an emerging field that is rapidly evolving to support mental health and enhance access to services. Strudwick et al. (2021) outline an array of digital tools, services and programs that may be of interest to nurses and nurse leaders. Specifically, they discuss a digital professional support group/virtual community of practice, digital mental health interventions available through mobile apps or Web-based resources and a database of resources made available online. Nurse leaders have an important role to play in moving the digital mental health strategy forward as digital mental health support may be one "tool" that nurses can draw upon during (and after) COVID-19 to support their needs.

The development of managers' skills in supporting mental health is an important need that ultimately benefits the entire workforce. Within a public health setting, Bhimani et al. (2021) identified the need to enhance the support and skills for managers to apply participative management practices and resiliency strategies within their teams. A survey to understand their leadership development needs identified four key areas: enhancing skills to support staff mental health and resilience, managing and motivating staff performance, improving leadership communication and managing virtual teams. A range of leadership development activities were implemented that included ready-to-use actionable tools and best practice interventions for resiliency development, such as mentorship and debriefing. Engaging further with them to encourage the use of newly learned practices, through meetings, one-on-one conversations and informal group conversations, was an important strategy for reinforcement.

Within a large mental healthcare facility, Limoges et al. (2021) examined how COVID-19 influenced healthcare providers' well-being, professional practice and interprofessional collaboration. They also examined what supports would assist them during the pandemic recovery period. Witnessing the impact of pandemic restrictions on patients was a significant source of stress and anxiety for the healthcare providers who participated. Moreover, they were eager to move to proactive strategies, such as participating in the redesign of health services, to support their own well-being as well as patients'. Lastly, with redeployment to other areas, participants reported developing a deeper understanding of other professional roles, which supported interprofessional collaboration and enhanced health services redesign. The findings and recommendations can assist leaders in addressing the mental health challenges arising from the pandemic.

The mental health of street nurses and their front-line colleagues has been further strained during the COVID-19 pandemic, with a concomitant spike in opioid overdoses and deaths among those experiencing homelessness and a lack of support from community agency partners due to pandemic restrictions. McMenemy et al. (2021) describe an innovative interdisciplinary and participatory research study currently being undertaken to develop and evaluate a multifaceted support program to promote the holistic (mental, physical, social and spiritual) well-being of healthcare providers. At the beginning of the pandemic, evidence-based interventions were implemented by Ottawa Inner City Health to support staff wellness. These included retreats grounded in a holistic approach to wellness and healing based in both Indigenous and Western traditions. Various challenges have been experienced during the COVID-19 pandemic, and the authors discuss how the retreats will be adapted to the pandemic context. This research is an important step in better understanding and supporting the often overlooked and forgotten front-line workers in Canada.

Conclusion

No matter the context, nurse leaders have stepped forward across Canada to develop multipronged approaches to support nurses' mental health during an unprecedented time. A sustained crisis demands leaders who are innovative and courageous in the solutions and strategies they use to support a nursing workforce already facing a mental health crisis. As we progress through the COVID-19 pandemic and move forward, there is much work to be done to help "the people who bore the heaviest burden of care" (Renzetti 2021) and keep the mental well-being of Canada's nurses visible. It is time to acknowledge the tsunami that has been forming for decades by continuing to create and bolster new strategies to enhance nurses' mental health. The Canadian Journal of Nursing Leadership will continue to disseminate ideas and strategies to keep readers aware of work taking place in this area. We invite you to submit the valuable work that you are doing in your context so that, together, we can create much-needed change.

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