At NWP we’re in the business of helping care for nurses’ wellbeing. In this blog series on depression, I explore how this common mental disorder manifests in nurses as well as information and advice for understanding it and treating it. In this article, we cover what depression is, how common depression in nursing is and what factors make this more likely.

What is depression?

In brief, depression is a psychological disorder in which the person experiences a range of psychological, physical and cognitive symptoms. The primary symptoms of the condition are persistent low or depressed mood and a feeling of lethargy and reduced interest in your normal day-to-day activities.

Depression differs from person to person and between different cultural contexts. So, your depression may look and feel very different to your colleague or friend’s.

Importantly, these symptoms aren’t just like being “down in the dumps” or “a bit sad or negative” about life. Depression is serious and goes beyond the transient woes and downturns we all experience from time to time.

Read our article “XYZ” for further information about the diagnosis of depression and how to spot it in yourself or one of your nursing colleagues.

What causes depression?

Depression is a complex, multifaceted psychological disorder that varies significantly from one person to another. In general, we know that there are a few key factors that increase or decrease someone’s risk for developing depression. It’s important to consider:

Biology – genetics (family history makes it more likely to develop it), poor diet with high sugar/high processed foods, reduced or too much sleep, lack of regular physical activity and exercise, other ongoing physical illnesses (e.g. hypothyroidism, cancer, chronic pain).

Social factors – upbringing and exposure to maltreatment, lack of social support, lower income, living in the densely populated area vs countryside, being single and not married, having a child with a disability or chronic condition, exposure to stressful events, nature of your job.

Psychological factors – personality characteristics, coping styles, resilience, stress vulnerability. 

Gender  – depression is approximately 1.7 times more likely in women than men, a robust finding in the literature which is thought to be due to biological differences rather than socioeconomic factors.

A combination of all these factors helps explain why any given person may become depressed.

How many nurses are depressed?

As nursing is a diverse profession with many different settings and specialities, it is not straightforward to answer this question. 

However, one leading review on this topic estimated that Registered Nurses are around twice more likely to develop depression than other types of workers (Brandford and Reed, 2016). 

Moreover, data summarised in a recent review in the UK titled, “The mental health and wellbeing of nurses and midwives in the UK” similarly suggests that rates of depression maybe around 30% in nurses for some nurses.

This represents a significant problem both for the individuals affected, the patients they treat, the organisations they work for and thus society as a whole.

Has COVID increased levels of depression in nursing?

The current context of COVID has meant that many nurses have been faced with additional stress in the working environment. 

Working in ICU and emergency settings is well known to increase nurses’ risk of developing psychological disorders. 

Therefore, with many nurses having been redeployed to work in frontline roles during the pandemic, it might be expected that rates of depression in nursing have increased. 

The literature paints exactly this picture. 

Olaya et al (2021) conducted a systematic review and meta-analysis of studies evaluating mental health complaints in healthcare workers. This basically means they took the data from previously published studies (57 studies, to be precise) and used statistical procedures to look at the picture as a whole.

The data were quite varied, coming from 17 different countries. They found the pooled prevalence of depression was 25% for nurses (vs 24% for doctors) but 43% for frontline professionals. 

Take that in for a second. Almost half of all frontline workers had developed depression in this huge sample of thousands of nurses.

And how does the prevalence of 25% for nurses, in general, compare with the rest of the population? According to a study by Bueno-Notival et al (2020) DOI: 10.1016/j.ijchp.2020.07.007,  the pooled prevalence of depression in the community was also 25%. 

This means that overall, nurses did not fare worse than the population at large during COVID, however, frontline nurses were almost twice as likely to be depressed.

Alarmingly, this 25% rate is still very high. Pre-pandemic, the prevalence of depression in adults was estimated to be just 3.44% in 2017. 

The takeaway here then is that the pandemic has led to a seven-fold increase in the rate of depression in both nurses and others in general. For frontline workers, this figure is over ten times higher.

Nurses have historically been more likely to experience depression than their other people and the impact COVID has had makes it more likely they will continue to experience this condition.

What causes depression in nursing?

In an effort to identify some more specific factors that lead to depression in nursing, Brandford and Reed (2016) identified in a systematic review the following as predictors of depression in nurses:

• Female gender (consistent with other research on depression in the general population)
• Younger age
• Single and/or divorced
• Fewer years of work experience
• Working in psychiatric, community setting and midwife settings.
• More acute settings
• Shift work
• Workplace violence or trauma
• Job strain
• Role overload (too much work for your pay grade)
• Role insufficiency (not getting enough out of your role)
• Diminished role boundaries (lack of clarity about your and others’ responsibilities)
• Lack of supervisor support
• Job insecurity
• Lack of reward
• Lower job satisfaction 

Whilst many of these are not specific to nursing, there are a few key ones that are more common to the profession, which make nurses more likely to experience depression. 

For example, working in hostile environments with harassment, bullying and incivility is common for nurses and not found in many other environments.

As is witnessing traumatic events. Moreover, shift work is uncommon in many other professions, yet is known to be detrimental to physical and mental health.

Thus, there are now many known factors that make it more likely a nurse becomes depressed. This has important implications for the prevention of depression.

In addition to these, the pandemic has put several additional specific stressors on nurses that have made the depression more likely to develop:

• Uncertainty and fear around the exposure of self and to others of COVID.
• Increased exposure to stressful and traumatic events.
• Increased stressogenic working environments (long working hours, restricted breathing from PPE).
• An interruption to some of the usual positive and protective factors of the nursing role such as physical touch with patients, being time-poor, not being able to bond with colleagues as easily.
• Consequential impact on positive lifestyle factors such as reduced sleep and impact on diet, social relationships.
• Social stigma (e.g. being labelled “COVID nurses”).

What factors protect against depression?

The good news is that current research has identified several factors which seem to be protective against depression. That is, if these are present, nurses are less likely to become depressed, and experience positive wellbeing:

• Older age
• Married
• More years of experience
• Positive evaluations and expectations toward self and others
• Higher job satisfaction
• Self-efficacy (the belief that you are in control of your life and confidence in skills and abilities)
• Optimism 
• Resourcefulness
• Positive ideation
• Regular exercise
• High level of perceived social support outside work.

There will be many more protective factors in addition to these, but this list is encouraging as it points towards potential targets for intervention at the individual and organisational level.

Naturally, some of these are easier to manipulate or promote, than others. 

For example, social support can be encouraged through workplace initiatives, positive psychological coping can be trained, and interventions can promote lifestyle changes such as increased exercise. 

It might be a bit unethical for organisations to encourage marriage, though….

Given the huge role that organisations have in shaping some of these risk/protective factors, there is a responsibility here to make changes and implement programs and training to benefit the mental health of nursing staff.

What does this all mean?

Nurses, like the world at large, have suffered psychologically throughout the pandemic. If you are a nurse who worked in a frontline role or had any exposure to COVID, there is an alarmingly high chance you may have developed depression in the past couple of years.

Pandemic aside, several nursing working environments make it more likely you are going to develop depression than someone else who is not a nurse. 

This route is far from set in stone, however, as there are many ways we can prevent depression. We will cover some of these in future articles at the Nurse Wellbeing Project.

If you’re concerned you have depression, there are many effective treatments out there and I recommend you book an appointment with your GP as soon as possible to discuss your options. https://doi.org/10.3389/fpsyg.2021.603553