Throughout the COVID-19 pandemic, nurses – particularly those working intensive care units (ICUs) – played a pivotal role in the care of patients, (Labrague and Santos, 2021). The health emergency that followed the emergence of a novel and highly contagious strain of severe acute respiratory syndrome (SARS) coronavirus (SARS-Cov-2), led to significant and rapid change to global healthcare systems, resulting in unprecedented workload and uncertainty for healthcare workers. This included nurses who were placed under extreme stress when dealing with the rapid influx of COVID-19 patients to ICU and facing exposure to the virus (Fernández-Castillo et al, 2021).
A global pandemic was announced in March 2020 (Bolina et al, 2020). In June 2020, the International Council of Nurses (ICN) reported that more than 600 nurses had died worldwide as a result of COVID-19, the largest group of health professionals infected with the disease (ICN, 2020). The high incidence of infection in the workplace at the height of the pandemic inevitably led to psychological and mental health issues such as compassion fatigue, depression, anxiety, stress, burnout and post- and peri-traumatic stress disorder among ICU nurses (Lai et al, 2020; Hacimusalar et al, 2020; Schwerdtle et al, 2020; Gordon et al, 2021; Labrague and Santos, 2021). Indeed, it is arguable that ICU nurses experienced greater despair and anxiety than any other clinician (Mo et al, 2020; Heesakkers et al, 2021).
To better understand the factors related to the psychological and mental health consequences of the COVID-19 pandemic for ICU nurses, a qualitative narrative review of the contemporary literature was undertaken.
Method
A structured literature search was carried out between March 2022 and August 2022. Online databases (CINAHL, Scopus, Ovid and Google Scholar) were searched using specific keywords [‘impact’ OR ‘effect’ OR ‘the influence’] AND [‘mental health’ OR ‘psychological’] AND [COVID19] AND [‘Intensive care unit’ OR ‘ICU’] AND [‘nurses’ OR ‘nursing staff’ OR ‘nursing workforce’] AND [‘Pandemic’] AND [‘ICU Nurse’]. The PICo (Population, Interest and Context) was used to determine the research question and establish the eligibility criteria.
Inclusion criteria included: all papers published worldwide about the experiences of ICU nurses during the COVID-19 pandemic, qualitative studies, articles in English, articles were peer reviewed, and published from 2018 until August 2022. Exclusion criteria included: grey literature, quantitative studies, non-English-language articles, non-peer-reviewed articles, and papers published before 2018.
The Critical Appraisal Skills Programme (CASP) (2018) was employed to judge the quality of the studies and their relevance to the topic of inquiry. Thematic analysis was subsequently undertaken, guided by Thomas and Harden (2008). The synthesis consisted of three stages: line-by-line coding of text, the generation of descriptive themes, and finally the development of analytical themes (Thomas and Harden, 2008). The process of analysis identified four key themes:
- Isolation
- Workload
- Clinical preparedness and lack of protocols
- Fear.
Findings
Theme 1: isolation
The notion of isolation and psychological ill-being is supported by a wealth of existing studies confirming that there is a link between isolation and mental health issues such as anxiety and depression (Brown et al, 2021; Wilkialis et al, 2021).
The theme of isolation was prevalent throughout the reviewed studies, which can be subcategorised in several ways. First, during the pandemic, ICU nurses were physically isolated from other hospital departments for the purposes of infection prevention and control. This type of isolation contributed to feelings of separation and psychological distress (Montgomery et al, 2021). Second, ICU nurses experienced social isolation on account of hospital staff avoiding them due to fear of contracting the virus (Fernández-Castillo et al, 2021). Related to this, studies by Moradi et al (2021) and Hu et al (2021) found that the need for reduced contact with family members – to protect loved ones – contributed to feelings of isolation among ICU nurses. A study by Sezgin et al (2022) reported that, due to contact with COVID-19 patients, ICU nurses felt that they were socially excluded from wider society. Third, as observed by Fernandez-Castillo et al (2021) and Levi and Moss (2022), ICU nurses experienced psychological isolation when they were left alone with deteriorating patients.
The themes from the literature suggested that wearing personal protective equipment (PPE) contributed to feelings of isolation (Montgomery et al, 2021; Muz et al, 2021). Wearing PPE meant that nurses were unable to recognise each other and communicate effectively, often to the detriment of the therapeutic nurse-patient relationship, leading to isolation and professional disconnect (Fernández-Castillo et al, 2021).
The study by Montgomery et al (2021) found that stress and isolation were mitigated by strong teamwork and camaraderie when working in ICU during the pandemic. This was the only study that used the sociological concept of a ‘community of fate’, which refers to collective action by a group of people as an organised response to a crisis. The results of this study emphasised the significance of social and organisational support structures and perhaps offer a direction for future empirical inquiry.
Theme 2: workload
As alluded to above, during the pandemic organisations were required to optimise resources, resulting in the deployment of staff to areas of critical need (Vera San Juan et al, 2022). The restrictions imposed to limit the spread of COVID-19 resulted in a reduction in the number of available health professionals, for example, where some staff were required to shield, this required nurses to work longer hours to fulfil patient care (Fernández-Castillo et al, 2021). In addition, the volume of patients, and the inexperience of ICU nurses who had never previously cared for COVID-19 patients – and were often having to do so without peer support – added to greater workloads and longer shifts, increasing emotional strain (Chegini et al, 2021; Fernández-Castillo et al, 2021). Studies by Montgomery et al (2021) and Sezgin et al (2022) found that ICU nurses experienced an increase in psychological issues and anxiety as a result of working longer shifts, they were unable to take comfort breaks, and were often denied annual leave.
Each of the reviewed studies highlighted a range of issues related to workload, which added to the psychological burden faced by ICU nurses at an already clinically demanding time (Fernández-Castillo et al, 2021; Moradi et al, 2021).
Theme 3: clinical preparedness and lack of protocols
The theme of clinical preparedness, or lack of, and an absence of protocols was evident across the reviewed studies and the lack of preparedness arguably added to psychological distress among ICU nurses. A lack of organisational policies, such as the allocation and use of PPE, and ever-shifting protocols resulted in an increased psychological burden among ICU nurses (Chegini et al, 2021; Montgomery at al, 2021; Muz et al, 2021). A study by Khajuria et al (2021) reported that staff who had not been issued appropriate PPE were more than twice as likely to report depressive thoughts. Likewise, staff who had not received adequate training for their role were more likely to report mental health issues (Galehdar at al, 2020).
A further concern related specifically to the lack of end-of-life care protocols. Some of the studies reported that nurses had experienced deep sadness after watching patients die of COVID-19, particularly in the absence of a loved one (Fernández-Castillo et al, 2021; Montgomery et al, 2021; Hu et al, 2021; Catania et al, 2021; Gordon et al, 2021). The work by Montgomery et al (2021) acknowledged the lack of clarity regarding procedures relating to end-of-life and after-death care in the first wave of the pandemic and how this had contributed to psychological injury. However, none of the studies reviewed were able to identify any strategies on how this could be addressed or suggest protocols to avoid such situations in future. Therefore, further empirical studies must be undertaken to facilitate the development and subsequent evaluation of protocols to establish a well-informed workforce with the requisite knowledge and skills to cope with end-of-life care.
Theme 4: fear
The theme of fear was abundant throughout the reviewed studies (Moradi et al, 2021; Chegini et al, 2021; Labrague and Santos, 2021). Studies by Danielis et al (2021) and Sezgin et al (2022) found that ‘fear of the unknown’ increased ICU nurses' anxiety, along with a fear of death, due to witnessing a large number of patients dying. In addition, studies revealed that concerns about transmitting the virus to family members and the associated fearfulness impacted on the nurses' home lives, creating a sense of domestic distress. Studies by Moradi et al (2021) and Hu et al (2021) found that many nurses opted to stay in hospital accommodation during the pandemic for fear of passing on the virus to friends and loved ones.
Healthcare workers who had never previously provided critical care encountered difficulties when trying to acclimatise to unfamiliar clinical practices and processes. Indeed, basic nursing tasks such as recording therapeutic observations or washing patients felt overwhelming to some, particularly redeployed staff without critical care experience, which added to the psychological burden (Montgomery et al, 2021).
Finally, social networks and repeated media coverage were cited in the literature as contributing to fear during the pandemic, with the dissemination of conflicting information, particularly in relation to COVID testing in the first wave of the pandemic, adding to distress among nurses, healthcare workers and the wider population (Bhagavathula et al, 2022; Garfin et al, 2020).
The findings in this theme are significant, since it is accepted in the literature that unmanaged fear and anxiety can have consequences beyond those of poor mental health and psychological ill-being. Studies have shown that fear can result in poor job satisfaction and work performance, leading to marked absenteeism and increased staff turnover (Labrague and Santos, 2020; Lee, 2020). Arguably, fear must be abated or, at the very least, minimised during times of crisis if a stable and resilient nursing workforce is to be maintained. To mitigate this in future, Mubarek et al (2021) made the case that health education can reduce fear and anxiety and therefore build psychological capital. There is a limited number of empirical studies that have explored this further and Mubarek et al's (2021) study offers a new direction for future empirical endeavour.
Discussion
Analysis of the literature has offered key insights into factors that contributed to ICU nurses' psychological and mental health during the COVID-19 pandemic. It would seem that isolation and workloads were significant contributory factors. These, coupled with a lack of clinical preparedness and organisational protocols, as well as fear, added to psychological distress among ICU nurses. Furthermore, as Khajuria et al (2021) observed, a lack of wellbeing and mental health resources for staff during the pandemic added to psychological distress.
Nonetheless, the global response to the COVID-19 pandemic had a number of positive outcomes, including the speed with which new systems were implemented and change effected in the NHS. Furthermore, many of the studies reported that staff expressed feeling a great sense of responsibility in their job roles throughout the pandemic, fostering a shared feeling of purpose that extended across vocations and hierarchies (Bailey and West, 2020; Fernández et al, 2020; Fernández-Castillo et al, 2021). The findings from the narrative literature review also revealed other positive outcomes, such as nurses becoming self-directed learners by gaining proficiency in clinical skills related to the acutely deteriorating patient (Danielis et al, 2021; Montgomery et al, 2021), leading to fulfilment and job satisfaction (Fernández et al, 2020).
These last findings offer a more nuanced insight into the outcomes of the pandemic and, perhaps, a new direction for consolidation of learning should a future global health crisis occur. Indeed, there is some evidence from the literature suggesting that lessons were learnt from previous pandemics. For example, according to Munnoli et al (2022), the knowledge distilled from the flu pandemic in 1918 informed the global response to the COVID-19 pandemic. However, Wong et al (2005), who examined the psychological impact of the SARS outbreak among healthcare workers, identified numerous issues related to moral distress and psychological injury (Wong et al, 2005), which suggests that attention to the psychological needs of the healthcare workforce had been overlooked.
Nevertheless, the emergent data post-pandemic is encouraging (Brahmbhatt et al, 2022; Marcassoli et al, 2023). This includes the evolution of healthcare practices: for example, enhanced health literacy, the use of innovative technologies and the worldwide connections that have been made as a result of the COVID-19 pandemic, which may position the global health economy in a favourable position should there be a future health pandemic.
It is hoped that the findings from this review can help inform future practice aimed at protecting the psychological wellbeing of ICU nurses. A number of recommendations are provided, forging a potential path for future research inquiry.
Recommendations
Training, policies and education
It is vital that healthcare leaders provide the required support for ICU nursing staff throughout emergency situations through training, policies and evidence-based education (Labrague and Santos, 2020). The findings from this narrative literature review suggest that it is timely to provide and regularly revise policies and guidance at both local and national level to enable nurses working in ICU to be better prepared to care for patients in difficult circumstances or crises such as the COVID-19 pandemic.
The authors therefore recommend providing staff with training specific to COVID-19 care pathways and ensuring they are up-to-date with infection control measures. In order to accomplish this, a variety of platforms, such as video technologies, webinars and social media platforms, can be used (Labrague and Santos, 2020). Specific policies in regard to PPE and end-of-life processes will reduce the associated stress and uncertainty, helping to enhance the psychological wellbeing of nurses. While it is acknowledged that the emergence of protocols was dynamic during the pandemic, there is a paucity of studies that have evaluated them post-pandemic.
Wellbeing
The challenge of achieving a balance between workforce demands and staff wellbeing is never easy. However, the authors recommended that hospital leaders assess risks early on to identify nurses' psychological and mental health needs. There is mounting evidence acknowledging the value of support and buddy systems as a way of connecting nurses who are socially or psychologically isolated (Schneider and Schneider, 2020). Regular peer support meetings should be held, particularly for those who worked in COVID-19 cohort ICUs (Georger et al, 2020; Shen et al, 2020; Crowe et al, 2021).
Similarly, the use of clinical supervision provides an opportunity for peer support and, as Heesakkers et al (2021) observed, can offer relief from stress and reduce mental strain. Furthermore, due to the association between perceived stress and anxiety and post-traumatic stress disorder (PTSD), access to psychological assistance and mental health resources should be readily available to ICU nurses.
It is important to note that the long-term consequences of the COVID-19 pandemic on psychological and mental health are not fully understood (Kathirvel, 2020). The Royal College of Nursing has called for extra support for staff experiencing long COVID, in recognition of the psychological impact this has on nurses. Indeed, there are emerging digital strategies to improve the post-pandemic health and wellbeing of nurses, which provide a range of approaches to support and foster psychological wellbeing among those worked during the pandemic (Feng et al, 2022).
The explosion of empirical research ensuing from the pandemic has provided new insights to help inform future nursing practice that will hopefully engender an informed, clinically proficient and less fearful workforce.
Limitations
The study was limited by the fact that data collection in the studies reviewed took place over short durations. Furthermore, it is accepted that many of the studies were undertaken in countries with healthcare systems different from that of the UK NHS.
Conclusion
The COVID-19 pandemic caused disruption to the normal order of society, creating significant psychological pressures on individuals and communities (Feng et al, 2022). Crucially, the pandemic had a significant effect on the mental health and psychological wellbeing of ICU nurses (Heesakkers et al, 2021). This narrative review has discussed factors that led to mental health issues and psychological ill-being among ICU nurses during the pandemic, offering some insights into the contributory factors.
The psychological wellbeing and mental health of the healthcare workforce should be a major public health concern beyond the COVID-19 pandemic if healthcare systems are to function effectively (Lewis, et al, 2021). Accordingly, the findings of this review may contribute to the development of effective responses to future global crises by providing insight into the problems faced by, and the needs of, ICU nurses in the UK healthcare system. The authors acknowledge that future empirical research will offer new insights into the long-term psychological and mental health issues that have affected ICU nurses as result of the COVID-19 pandemic. Therefore, if lessons are to be learnt, it is perhaps timely to reflect on what has gone before, harness the learnings and work towards rebuilding the mental health and psychological wellbeing of the healthcare workforce.
KEY POINTS
- Nursing patients with COVID-19 during the pandemic was a challenging experience for intensive care nurses, which impacted on their psychological wellbeing and mental health
- The psychological and mental health needs of the nursing workforce must be protected with appropriate psychological, social and organisational support
- Further empirical research is needed to investigate the long-term psychological and mental health impact of the COVID-19 pandemic on nurses
CPD reflective questions
- What were the key factors associated with psychological injury among ICU nurses during the COVID-19 pandemic?
- How does the article's recommendations and implications adequately protect the nursing workforce for future waves and other pandemics?
- How might healthcare leaders prepare for future pandemics to ensure the mental health and psychological wellbeing of ICU nurses?