In Their Own Words: How Nurses’ Tweets Capture COVID’s Psychological Toll
An analysis of Twitter activity shows that city by city, the rise in COVID-19 deaths elicits growing expressions of concern from nurses about their own mental health.
Nurses are fighting at the frontlines of the COVID-19 pandemic day and night. But they and other healthcare providers are also waging a battle against the psychological toll of the pandemic.
There have been many news articles reporting on the extreme anxiety, stress, and panic many healthcare providers are feeling as ICU beds fill, patients die daily before their eyes, and their own families find themselves no longer safe in their presence. Initial research from China, the first country hit by the COVID-19 pandemic, reports that healthcare workers (and particularly nurses) report high rates of depression, anxiety, insomnia, and distress symptoms. Alarms are being raised to say we must focus on the pandemic’s effect on the mental health of healthcare providers and get them the support they need.
While the news has spotlighted powerful testimonies from nurses across the country, there remains the question of how to gather better data to gauge frontline workers’ mental health during these unprecedented times. We turned to the rich data offered by Twitter to see what we could learn about the topics foremost in nurses’ minds.
As a widely used social media platform, Twitter offers accessible insights into their sentiments and concerns. By analyzing more than half a million Tweets by thousands of nurses in select cities since the start of the pandemic, we found that there has been a dramatic rise in the number of nurses Tweeting on topics related to mental health, and these rises correspond with spikes in COVID-19 deaths in their cities.
Data for millions of Tweets in eight cities can be explored in our online dashboard, but for this post we focused on three of them: New York, Seattle, and New Orleans, chosen for the differing timelines and trajectories of their pandemics.
Here’s what we learned.
1. Nurse’s Tweets increasingly reflect negative emotional sentiment, particularly in cities where deaths from COVID-19 have not yet peaked.
We pulled over 600,000 Tweets from 2,000 nurses in New York City, New Orleans, and Seattle and measured their sentiment and the prevalence of mental health related terms over the course of the pandemic so far.
Sentiment analysis is one way to measure how positive or negative Tweets are. Each word in a Tweet is assigned a positive, negative, or neutral score. For example, words like “scared,” “angry,” or “bad” would receive a negative sentiment score, while words like “happy,” “joy,” and “smile” would receive a positive sentiment score.
As shown below, we found that while average sentiment of nurses has declined everywhere since the end of January, it appears to be recovering among those in New York and Seattle, but in New Orleans it has continued to decline.
Comparing the numbers of new confirmed COVID-19 deaths (the second graph) to the variations in sentiment across New York, New Orleans, and Seattle shows just how differently the pandemic has affected these cities.
There appears to be a relationship between the number of COVID-related deaths in a city and its nurses’ Twitter sentiment.
We see that in Seattle, one of the earliest COVID-19 hotspots, sentiment began dropping in late February and remained low through much of March. However, as the number of new COVID-related deaths has stabilized, so too has sentiment — in fact, it appears to have improved in recent weeks.
In New York, COVID-related deaths did not start climbing until early March, and weekly deaths increased through the beginning of April. However, in recent weeks, the number of new COVID-related deaths appears to be dropping. This decrease appears to be followed by a stabilization in the Tweet sentiment of New York’s nurses.
In New Orleans, a rapid climb in COVID-related deaths towards the end of March coincided with a rapid drop in sentiment. Unlike in New York and Seattle, sentiment has not recovered yet in New Orleans.
2. Nurses are increasingly Tweeting about mental health.
Sentiment analysis is a powerful indicator of the overall trends in nurse’s feelings, but it cannot tell us what specifically about their Tweets is driving this decline in sentiment.
To better understand nurses’ Tweets, we homed in on specific keywords by creating a research-informed list of search terms. These were grouped into categories such as mental health, personal protective equipment (PPE), family, COVID disease, community support, and reopening. Creating this list was necessary, given the huge size of the data set, in order to investigate the changes in mentions of words more likely to be related to COVID-19. We then tracked how often these terms were mentioned, across the three cities, over time.
Of the top 20 most used terms on our list, 8 were related to mental health (i.e., feelings of stress or anxiety in some form) such as “hard,” “break,” “death,” etc. The chart below shows the counts of the top 20 terms in the three cities:
Given the high number of mental health-related terms, we dug deeper into Tweets indicative of mental health. We see that the prevalence of mental health related-Tweets has significantly risen over the course of the pandemic.
The graph below shows there is a sharp rise in mentions, from just 1,500 instances in the three cities at the beginning of the year (before COVID-19 reached the US) to a peak of 8,150 for the week of March 22.
How does this trend vary among our three focus cities? Just as with sentiment, mental health-related Tweets also appear to ebb and flow with the changes in COVID-related cases in each city.
Below, we see the number of mental health mentions among Tweets by city compared to their new confirmed COVID-19 cases. As might be expected, mentions are higher in Seattle than the other two cities for most of February and early March, coinciding with that city’s earlier peak in COVID cases. New York then overtakes Seattle and peaks in late March, which coincides with the period when the number of new cases begins rapidly increasing. Since the beginning of March, mentions in New Orleans have risen steadily, peaking the latest of the three cities, in the week of April 5.
We also observed changes in the specific mental health keywords nurses were using over time across the three cities, as the next graph shows. “Hard” has remained the most used word, on the rise for most of the pandemic, with mentions reaching a peak in the week of March 15. The word “break,” which was initially the second most popular, has ceded its position to “death,” which has become more prominent in recent weeks. As the death toll due to COVID-19 rises, it seems to be occupying more mindspace and dominating online conversations as well.
While it’s hard to gauge the specific topics nurses are discussing, the shifting popularity of certain terms highlights the dynamic nature of the pandemic’s impact on nurses’ feelings.
3. Increased discussion of mental health is accompanied by concerns around PPE and hospital equipment.
The lack of adequate equipment or supplies creates an incredibly frightening situation that contributes to the toll the pandemic takes on the mental health of health care workers. As shown above, PPE (personal protective equipment) was one of the most popular terms of our search list used by nurses. “PPE,” “ICU,” and “ventilators” all witnessed a steady increase in mentions from early March onwards and reached their peak in the 3rd week of March. Usage of “mask” peaked a week later. These trends capture the extent to which equipment shortages contribute to the daily stressors nurses face.
How can we support our nurses?
Nurses (along with doctors and other medical staff) are on the frontlines of caring for patients, their own families, and themselves as the COVID-19 pandemic continues to ravage the country. Protecting and addressing the mental health of nurses and other providers is critical at all times, but all the more so now. Healthcare professionals face immense threats to their physical and mental health, including patient loss, job stress, safety fears, and a lack of equipment and resources.
We recognize that Twitter analysis has its limitations, in particular that Twitter users are a self-selecting group. While the above analysis cannot serve as the sole evidence base for overarching policy recommendations, we believe that it substantiates anecdotal media reports, offers valuable insights into the day-to-day concerns of nurses, and paints a vivid picture of the toll of this pandemic on our frontline healthcare workers. As their Tweets and testimonies tell us, the pandemic is taking a toll, and it’s time we pay attention and take action.
First, the need to provide adequate personal protective equipment for health care workers has been well documented in the press and requires a coordinated effort at the federal, state, local, and facility levels. Equipping providers with the supplies and equipment they need is essential for both their physical and mental health.
Second, supporting provider mental health requires actions at many levels. Various activities have been proposed, and resources developed, to help healthcare providers dealing with COVID-19 support their own wellbeing, e.g. exercising, journaling, making time for family and friends, and engaging in hobbies. Nonetheless, many healthcare professionals cannot prioritize self-care due to the demands of their work. They need support from their institutions and leaders to do so.
At the institutional level, Mt. Sinai hospital in New York has created avenues to support basic needs (childcare, transportation, and food), psychosocial needs (supportive counseling, support groups, self-care activities, and confidential support), and mental health needs. State and federal governments can also play a role by enacting policies to protect nurses and other healthcare professionals. United States of Care has outlined a policy agenda to support healthcare workers emotionally, physically, mentally, and financially through and beyond the crisis. The agenda focuses on sustaining healthcare system capacity and the workforce needed through extra financial support to healthcare workers, workforce expansions, and investments in health systems and supplies.
Beyond their own well-being, we must remember that provider mental health also impacts patient care outcomes. The best patient care comes when providers have adequate self-care. So, as the pandemic continues, there is a need for deeper understanding of provider mental health to inform support mechanisms.
Thousands of healthcare providers are fighting on the front line against COVID-19. The concerns that many of them are voicing through their social media presence are a clear call to all of us — to work together to provide them the support they need.
- The American Medical Association has developed a resource for managing mental health during COVID-19 which provides strategies for healthcare workers to cope with the stress and anxiety that come from being on the frontlines of the COVID-19 pandemic. The guide includes a number of mental and behavioral health resources for healthcare workers.
- The American Psychological Association provides concrete strategies for individual healthcare professionals to help manage their own stress during COVID-19.
- Health Leads USA details how healthcare providers and hospital leaders can support self-care and create individualized self-care plans for each healthcare worker.
- Headspace is offering free access to its online meditation services to all healthcare professionals through December 31, 2020.
This work was made possible by everyone at the Surgo Foundation, including but not limited to (in alphabetical order): Yael Caplan, Grace Charles, Rahul Joseph, Hannah Kemp, Danielle Schmutz and Sema Sgaier