The most disruptive force to the ICU environment in this century’s century has been the coronavirus disease 2019 COVID-19 pandemic. 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. New York City, New York was the epicenter of the first major COVID-19 increase in the United States in March 2020. The New York state governor made a desperate appeal to all health care providers to help New York as hospitals became overwhelmed. The surge continued and ICU nurses experienced burnout, emotional exhaustion and compassion fatigue, as well as moral distress and turnover.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 often used tablets to facilitate video calls between patients, their families, and their loved ones. However, even this mode of communication was difficult due to the fact that nurses shifts were not well staffed and nurses were trying to keep up to date with nearly daily changes to PPE protocols, treatment regimens, and other information.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 unimaginable physical, psychological, 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 ENVIRONMENTAL AND MENTAL HELF
Evidence of COVID-19’s impact on ICU nurses’ mental health is rapidly growing. A PubMed search in December 2021 with the search terms nurse, work environment and COVID yielded scores citations that reported pandemic-associated anxiety, depression, moral injury, burnout, and the need to provide psychosocial support for 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.6It was found that depressive symptoms were strongly linked to being a nurse, working at the ICU, and not having proper PPE. However, those who received mental health support were less likely than others to report feeling hopeless or depressed (Khajuria).
Nurses have studied for decades the relationship between work environment and nurse outcomes.7American Association of Critical Care Nurses (AACN), developed the Healthy Work Environment model (HWE). It is based on the best evidence linking elements of the work environment with nurse outcomes.8This HWE model includes six standards: skillful communication, collaboration, effective decision making, effective decision-making and meaningful recognition. The Healthy Work Environment Assessment Tool can measure these standards. [HWEAT].8, 9The HWEAT can help you correlate changes in your work environment with ICU nurse outcomes.9
1.1 Mental health
Nurses during COVID-19 reported negative mental health outcomes, including anxiety, depression, moral injury, and risk of suicide.1, 10–13Female nurses were already twice as likely to commit suicide as the general population.14Even one suicide of a nurse can have severe consequences for the unit or institution in which it was employed.15
1.2 Moral distress or moral injury
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 is often 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 violated their deepest 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 committing a grave violation of 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 Dr. Lorna BREN: A tragic case
Although Dr. Lorna Bren did not become a nurse, she was one of many early symbols of the mental impact of COVID-19 on the mental health of health care workers in the United States. She committed suicide in April 2020.22Dr. 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 was reluctant about seeking help because she was more concerned with the stigma of seeking psychological treatment than her own well-being. Her family lobbyed the United States Congress for funding research on the impact on the mental health and well-being of healt hcare workers of the COVID-19 epidemic. Starting in 2022, $140 million worth of grants will be distributed to health system and training programs to help identify strategies to prevent suicide, burnout, and mental health conditions. They also promote job satisfaction and the well being of health care professionals. The funds will also be used to raise awareness and fund research on COVID-19’s impact on mental health.23
As tragic as Dr. Breen’s death was, it also brought to light the need for professionals to recognize the impact of their work environment on mental health. Her legacy will be the integration of mental healthcare as a measure to a healthy workplace. The ICU nursing community knows that suicide is a real risk. Female nurses were twice as likely as the general population to attempt suicide before the pandemic.14Two of the most significant risk factors for suicide include work-related stress, and mental health problems. ICU nurses seem to have experienced these two major risk factors disproportionately during COVID-19.14, 24To support ICU nurses’ mental health, creative and deliberate interventions must occur at both the hospital and unit levels.
2 MENTAL EXEMPLARS FROM 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 death of a nurse, HEAR at UCSD was extended in 2016 to nurses. The online screening program was a three-year retrospective assessment that showed 527 nurses participated in the program. 48 of them were found to be at high risk of suicide. One hundred seventy-six received support from therapists in an emergency situation, and 98 were referred for further treatment. 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 is a network consisting of 52 hospitals located in the Western United States and employing over 120000 people. Recognizing the impact of COVID-19 on the workforce, Providence created a variety of mental health services that all employees can access, 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 are usually available within 48 hours. They can also be covered with no extra costs up to 24 sessions.
3 CONCLUSION
Although the cumulative impact of the COVID-19 epidemic on ICU nurses is not known, it has clearly had an important impact on the mental well-being and mental health of ICU nurses. According to the American Nurses Association (ANA), nurses are required to practice self-care as a duty.29It is possible that ICU nurses in America are leaving because of mental health concerns that they experienced during the pandemic. To retain and sustain ICU nurses, administrators and clinical nurse must collaborate to address mental health concerns in the work environment.24The relationship between nurse outcomes and the work environment, including burnout and emotional exhaustion, compassion fatigue and 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 workplace and its effect 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.