Has COVID-19 taken a heavier toll on the mental health of ICU nurses?

During the COVID-19 pandemic, intensive care units (ICUs) have had to undertake the heaviest burden, which pushed them globally beyond their limits while delivering care to the most severe cases of COVID-19. Patients hospitalised in the ICU due to COVID-19 require significantly more nursing time including monitoring and titration, mobilisation and hygiene activities (Bruyneel et al., 2021). Moreover, ICU nurses have had to provide humanistic care for COVID-19 patients who are deprived of seeing their family members. As a result, nursing workload in the ICU increased significantly during this period (Lucchini et al., 2020, Reper et al., 2020). Long and tiring shifts, isolation, lack of personal protective equipment, fear of transmitting the disease to their loved ones as well as disrupted private lives increasingly render healthcare professionals chronically exhausted. ICU staff also witnessed many patient deaths and hasty end-of-life decisions, despite their hard efforts (Azoulay et al., 2020). Struggling with COVID-19 on the front line and trying to do their best amidst these circumstances have put a heavy burden on the mental health of ICU professionals.

In this issue of Intensive & Critical Care Nursing, Heesakkers et al. (2021) report the results of a national cross-sectional survey concerning the impact of the first COVID-19 surge and associated risk factors on the mental well-being of ICU nurses. The reported prevalence of anxiety, depression and posttraumatic stress disorder (PTSD) were 27.0%, 18.6%, and 22.2%, respectively, and the need for recovery was positive. These findings are relatively “less alarming” than those reported by a Canadian study examining the mental health status of Critical Care Registered Nurses engaged in direct patient care during the initial phase of the COVID-19 pandemic. The Canadian participants reported clinical concern for (23%), probable (13%) and significant (38%) symptoms of PTSD as well as mild-to-severe depression (57%), anxiety (67%) and stress (54%) (Crowe et al., 2021). A recent study from France reported symptoms of anxiety, depression, insomnia and peritraumatic dissociation in 50.4%, 30.4%, 37.8% and 32% of frontline healthcare providers, respectively, with the highest rates in nurses (Azoulay et al., 2020). Although the results may show variations depending on the health policies of the countries, they point out to the fact that ICU nurses suffer intense psychological burden.

In the present study, working in an academic hospital, fear of infecting relatives, and having insufficient numbers of colleagues were independently associated with increased levels of psychological symptoms, whilst having had a break for a holiday since the first surge of COVID-19 were independently associated with reduced depression symptoms and need for recovery (Heesakkers, et al. 2021). In the Canadian study, most participants reported concerns over contracting COVID-19 or taking the virus home to their families. Some participants reported trying to stay connected with family members and friends via only telephone calls and video chats. Some reported feelings of stigmatization by friends and family members for working in the COVID unit as well as feelings of being isolated and shunned (Crowe et al., 2021). Taking into account the wide array of factors adversely affecting the mental health of ICU nurses, it would have been worthwhile mentioning what percentage of nurses had children or elderly persons at home deprived of being looked after, along with the impact of this separation on their mental health, given that three-quarters of ICU nurses were female in the present survey. Failure to meet caring responsibilities for the household would impose further distress on ICU nurses and merit search for potential solutions.

A limitation of the study by Heesakkers et al. (2021) is that other ICU staff were not investigated. A global cross-sectional survey performed between March 18 and April 1, 2020, evaluated the prevalence of anxiety across a broad range of healthcare workers (HCWs) supporting patients with COVID-19. Of the 1416 participants, 26.2% were nurses. Anxiety was significantly more common among nurses as compared with physicians, and among female staff as compared with male staff (Cag et al., 2021). Likewise another study from Italy reported higher levels of anxiety and PTSS among nurses than among physicians (Di Tella et al., 2021). Additionally, the readers would have benefited more if the authors had described their healthcare systems in the Netherlands in some detail, addressing the impact of working in an academic hospital.

It is understandable that, particularly during the first surge of the pandemic, there was a higher workload not allowing HCWs to connect or rest as well as other uncertainties such as overwhelming and unclear communication, rapidly changing policies and information, and inadequate personal protective equipment (Cag et al., 2021, Crowe et al., 2021, Elbay et al., 2020, González-Gil et al., 2021).

The present study (Heesakkers, et al., 2021) provides important data as to the impact of the first surge of the COVID-19 pandemic on the mental health of ICU nurses and related risk factors. Our experience-derived strategies both to protect and restore the mental well-being of ICU staff during the COVID-19 pandemic are presented in Table 1 . Experiences gained from the first COVID-19 wave will guide us in future waves of the COVID-19 pandemic and other possible infectious disease pandemics. Better recognition of the pathogenesis and course of the disease and better protection from transmission through vaccination of healthcare professionals and the population at large will hopefully alleviate the mental health burden of the pandemic.

Table 1

Strategies to protect mental health of ICU staff amidst the COVID-19 pandemic.

Strategies	Suggestions
Improving working conditions of ICU staff	- Increasing the number of staff- Ensuring optimal nurse-patient ratios- Regulation of weekly working hours- Making necessary arrangements to facilitate the use of leaves and holidays
Ensuring the safety of healthcare workers in terms of COVID-19 transmission	- Supply of adequate and appropriate personal protective equipment- Adequate supply of liquid soap and hand sanitizer- Rapid completion of COVID-19 vaccinations of healthcare workers
Ensuring regular training	- Efficient sharing of up-to-date and clear protocols
Mental health interventions	- Arrangement of online group / staff meetings to alleviate sense of isolation and to provide a channel for ventilation of emotions- Screening and early identification of mental health problems among staff by a psychiatry liaison team- Easy access to mental health services- Encouragement to seek help from mental health professionals

Authors’ contributions

Every author participated to write this publication and approved the content.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.