The most disruptive force in the ICU work environment this century has been the coronavirus pandemic 2019 (COVID-19). Over the past two years, that disruption has been very evident as ICU staffs around the globe were overwhelmed by the influx of critically ill patients in urgent need of advanced interventions. In March 2020, New York City was hit by the first major COVID-19 spike in the United States. The New York state governor made a desperate appeal to all health care providers to help New York as hospitals became overwhelmed. As the surge continued, ICU nurses started to feel burnout, emotional fatigue, compassion fatigue and moral distress. They also expressed an intent to leave.1–3Since then, hospitals in the United States are competing to hire temporary ICU nurses. They have been offering skyrocketing weekly rates to incentivize nurses into working in difficult and uncertain environments.4
ICU nurses were caring for patients with the life-threatening severe acute respir syndrome coronavirus 2 virus (SARS-CoV2) virus. Patients often did not have adequate personal protective gear (PPE). Many loved ones self-quarantined in order to avoid the spread of the virus to their loved ones.1, 3These nurses saw the pain and fear of patients who were also separated from their families. ICU nurses used tablets to facilitate video calling between patients and their families. However, this was difficult because nurses shifts were short-staffed and nurses had to keep up with almost daily changes to PPE protocols.3The first New York surge was so chaotic that many families were not notified of their deaths for hours or days. Hospitals had to transport the dead in refrigerated trucks to keep the death rate down.5The COVID-19 epidemic caused severe psychological, physical and moral injuries to ICU nurses. ICU nurses were under pressure to keep working despite being fatigued, burnout, or showing symptoms of the virus.3
1 WORK ENVIRONMENT & MENTAL HEALTH
Evidence of COVID-19’s effect on the mental health and well-being of ICU nurses is rapidly mounting. A PubMed search that was conducted in December 2021, using the terms nurse, work environment COVID, mental health, and mental health returned scores of citations describing pandemic-associated anxiety and depressive symptoms, moral injuries, burnout, and the need for psychosocial support among nurses. These reports came from many countries, including China and Australia, Iran, Cyprus and the United Kingdom. This demonstrates the widespread mental impact of the pandemic. Khajuria et.al. conducted a large international study about the mental health of health care workers in 41 nations.6Depressive symptoms were strongly associated with being a nurse, working as an ICU nurse and not having the proper PPE. However, health care workers who had received psychological support were less likely (Khajuria) to report depressive symptoms or hopelessness.
Since decades, nurses have been studying the relationship between nurse outcomes and the work environment.7American Association of Critical Care Nurses developed the Healthy Work Environment (HWE), based upon the best evidence linking work environment aspects to nurse outcomes.8This HWE model is composed of six standards: effective communication, true collaboration and effective decision-making. It also includes meaningful recognition and authentic leadership. [HWEAT].8, 9The HWEAT can be used for comparing changes in the work environment and ICU nurse outcomes.9
1.1 Mental health
During the COVID-19, nurses reported adverse mental health outcomes such as anxiety, depression and moral injury, as well as risk for suicide.1, 10–13Female nurses were twice as likely to commit suicide than the general population.14Even one nurse’s suicide can have devastating effects on the unit or institution where she worked.15
1.2 Moral distress and moral injuries
Some of the mental health problems that ICU nurses experienced during the COVID-19 epidemic are the result of moral distress and moral injury (MI).16MD has been described as the psychological distress nurses feel in relation to morally difficult situations.2MI in nurses is still a relatively new concept. MI was first discovered in military veterans who were forced to do something that was against their deeply held moral beliefs, often in high-stakes situations like combat.12, 17MI in nurses is the psychological, behavioural and spiritual aftermath of nurses violating, failing to act on, witnessing or causing a violation their deeply held moral beliefs.3, 18–20As nurses witnessed the final goodbyes of a dying patient to their family via videocall, they may have suffered MI. They were sometimes forced to follow restrictive visitor policies or had no choice but to care for their patients.3In these situations, hospitals in the United States may have to establish crisis standards of care to guide the allocation of scarce resources.21In these circumstances, nurses are required to withhold or withdraw interventions that would otherwise be provided. This could lead to moral violations and anxiety, as well as depression, associated with MI. MI and MD can threaten the stability of ICU nurses as nurses are forced to leave their jobs in less stressful positions or even leave the nursing profession altogether.
1.3 A tragic case: Dr. Lorna BREN
Although Dr. Lorna Breen was not a nurse, her suicide in April 2020 was one of the first signs of the mental health effects of the COVID-19 pandemic.22Dr. Lorna Breen worked as an emergency room physician during the peak of the New York City surge. After contracting COVID-19, she tried to return to work for a few days but was overwhelmed by physical exhaustion and the suffering around her. Dr. Breen resisted seeking help as she was more concerned over the stigma of seeking psychotherapy than about her own health. Her family lobbyed the United States Congress for funding research into the impact of the COVID-19 epidemic on the mental health and well-being of healt hcare professionals. In 2022, $140million in grants will be distributed by health systems to support mental health training programs and to identify strategies that prevent suicide, burnout, depression, and other mental health conditions. The funds will be used to raise awareness about mental health and to fund research into the effects of COVID-19 on mental health of health care professionals.23
As tragic as Dr. Breen’s suicide was, it also brought to light the need for professionals to recognize the impact of their work environment on mental health. Her legacy promises to integrate mental health as a measure for a healthy work environment. The ICU nursing community is especially aware of the suicide risk because female nurses were twice as likely to commit suicide as the general population before the pandemic.14Work-related stress and mental illness are two of the main risk factors for suicidal behavior. ICU nurses seem more affected by COVID-19 than other COVID-19 patients.14, 24To support ICU nurses’ mental health, creative and deliberate interventions must occur at both the hospital and unit levels.
2 MENTAL HEALTH EXEMPLARS – UNITED STATES
These three examples of programs in the United States are designed to promote mental health and well being of health care professionals. The first two examples were in place prior to the pandemic. While the third one was developed during it.
2.1 UCSD HEAR Program
After a series of suicides at the medical school, the University of California at San Diego (UCSD), launched the Healer Educational Assessment and Referral Program (HEAR) in 2010.15The program was designed to inform medical students about mental issues and encourage them participation in a confidential web-based, online mental health assessment. The assessment was created in collaboration with American Foundation for Suicide Prevention. Since then, it has been implemented on more than 60 medical schools across the country. [AFSP].15, 25After the suicide of a nurse, the HEAR program at UCSD was extended for nurses in 2016. An evaluation of the participation of nurses in the online screening program over three years revealed that 527 of them opted to take part. 48 of them were found to be at high risk of suicide. One hundred seventy six received just-in time support from therapists. 98 accepted referrals to additional follow-up care. The program now includes group emotional debriefing sessions that take place after difficult incidents. These sessions are well attended and monitored by nurses.15
2.2 Ohio State University BEST program
The Ohio State University James Comprehensive Cancer Center’s Brief Emotional Support Team (BEST), training grew from a similar program 2 years ago to support trauma patients. The BEST program is managed by a psychiatric mental healthcare clinical nurse specialist (CNS). It emphasizes peer-to–peer psychological first aid and crisis intervention training.26 By 2021, over 700 employees had completed BEST training. As the pandemic erupted, the workplace culture of wellness first was credited with having a protective impact on employees.
2.3 Providence My Mental Health Matters
Providence Health System, a network of 52 hospitals across the Western United States, has over 120000 employees. Recognizing that the stress caused by the COVID-19 pandemic was affecting the workforce, Providence developed a range of mental health services for all employees, including individual telehealth visits.27, 28Lyra, a digital application that connects employees with previously difficult to access mental health care, allows employees to access the care. After completing an online survey employees are matched with either licensed mental health providers or a mental health coach based on their risk stratification. Appointments can be made within 48 hours and are covered with no out of pocket costs for up 24 sessions.
3 CONCLUSION
Although it is not known how the COVID-19 pandemic has affected ICU nurses, it has clearly had a profound effect on the mental health and well-being of ICU nurses. According to the American Nurses Association (ANA), nurses are required to practice self-care as a duty.29It is possible for ICU nurses to leave the United States due to mental health concerns resulting from the pandemic. Administrators and nurses in ICU must work together to address mental health threats in the workplace environment. This will ensure that the ICU nursing workforce is retained and sustained.24The relationship between the nurse environment and outcomes such as burnout, emotional exhaustion or compassion fatigue, moral distress, turnover, and intent to leave was well established before the pandemic.30
Three innovative programs were described in the United States that could be replicated around the globe to support and monitor nurse mental health and well being. Further research is needed to determine the relationship between mental health-targeted programmes and nurse perceptions regarding the work environment. A healthy work environment can increase nurse satisfaction and retention when it is implemented according to the AACN model.31The AACN validated the Healthy Work Environment Assessment Tool, (HWEAT), as a tool that can be used to conduct this type of research.8, 32To attract and retain skilled staff, it is essential to address the work environment and the impact it has on ICU nurses’ mental health. These efforts are vital to the health and well-being of nurses. They are the foundation of strength and resilience in the nursing profession.
