Mental preparedness for prolonged periods of high workload - What did we learn from the covid-19 pandemic?

The COVID-19 pandemic did not only have an enormous impact on the wellbeing of intensive care unit (ICU) patients and their family members, but also on nurses’ wellbeing. The surge of COVID-19 patients, scarcity of protective equipment, anxiety surrounding an unknown virus and the shortage of personnel due to loss of (mentally) ill personnel and colleagues that left their job causing a deterioration in working conditions, moral dilemmas and stress. The marathon length of the pandemic with high frequency and intensity of distressing events led to increased symptoms of burnout, anxiety, depression and post-traumatic stress disorder (PTSD) among ICU clinicians (Azoulay et al., 2020, Bruyneel et al., 2021, Crowe et al., 2021, Heesakkers et al., 2021, Kok et al., 2021, Meynaar et al., 2021, Şanlıtürk, 2021).

For decades, clinicians’ mental wellbeing has been high on the agenda. Increased working hours, nurse-patient ratio, high workload and feelings of failure in patient treatment during the COVID-19 pandemic increased the urgency to enhance the mental resilience of healthcare professionals to be prepared for long-lasting pandemics. Mental illness has a tremendous impact on the lives of individuals, including shame, burden for their family and lose of work including financial consequences. Also, its societal and financial impact is enormous, with a shortage of healthcare professionals as worst-case scenario. Mental illness is a horrible human ache especially since it is preventable (Linzer and Poplau, 2021).

With no clear end of the pandemic and uncertainty about new virus variants, interventions to protect the wellbeing of healthcare professionals, and especially of nurses, are of utmost important to avoid a further exodus of valuable and high qualified ICU nurses. Healthcare organisations should be better prepared for future crises, including increasing nurses’ mental resilience.

There are several interventions to increase nurses’ mental preparedness (Table 1 ). Creating more awareness for self-care is of utmost importance to keep nurses mentally and physically in good health. While nurses often have an altruistic character, they also need to take care of themselves. Being prepared for working under difficult crisis circumstances, nurses should be trained to better take care for themselves, how to relax (e.g., mindfulness), and how to monitor one’s own health to create a better work-home balance.

Table 1

Interventions to increase mental preparedness.

Interventions	Description
Emphasize the importance of self-care	Create more awareness for self-care, including attention for a healthy work-home balance, how to relax and how to monitor your own health
Quick communication about new insights	Improve communication channels for efficient communication about new insights and knowledge and update in guidelines and protocols
Support from colleagues and management	Arrange peer support, developing briefing and debriefing procedures, social team activities
Reflection rounds, ethics consultation	Organise ethical discussion meetings for reflection
Reduce workload in pandemic situations	Generate a flexible pool of healthcare professionals prepared for temporarily working in the ICU; scaling down nursing care
Structural system changes	Increase number of nurses working in the ICU; empower nurses, and improving employment conditions
Empower nurses	Embrace nurse’s role in policy decision making in the hospital and in the media

Feelings of stress and uncertainty during a pandemic crisis can be reduced by quick communication about new insights regarding the disease and its treatment. More knowledge increases feelings of control and self-efficacy and has an inversed association with moral distress (Kok et al., 2021). Examples to communicate swiftly are blogs and vlogs, daily newsletters via email or intranet site, closed WhatsApp groups, and quick updates of protocols and guidelines.

Furthermore, support from colleagues and management is effective to mitigate moral stress. Setting up peer support mechanisms including the needs and wishes of ICU healthcare professionals (Kok et al., 2020) and brief and debrief procedures before and after difficult situations is helpful (Heesakkers et al., 2021) to reduce the impact of moral stressful situations on mental health. Additionally, reflection rounds and ethics consultations can be introduced and set up supported by ethicists to discussion ethical dilemmas regarding patient treatment. Open, non-hierarchical discussions where every participant can reflect and is able to give his/her opinion without any judgment may contribute to reduce burnout (Haan et al., 2018).

Efforts to reduce workload in pandemic situations is a necessity. The high workload during the COVID-19 pandemic (Lucchini et al., 2020) combined with working with nurses untrained in critical care, increased feelings of reduced safety and quality of care (Heesakkers et al., 2021, Kok et al., 2021). Hospitals, and particularly ICUs, should create a flexible shell of healthcare professionals who are trained in critical care and can temporarily work in pandemic situations. Also, downscaling nursing care, such as less frequently washing patients and checking the indication of lines and physical therapy (mobilisation activities), is required to handle a surge of patients in crisis situations with, consequently, a higher risk for complications. Downscaling the quality of care goes against nursing values. Good communication and leadership are important to underline that down-scaling care is not an individual failure, but a management decision taken in extreme situations.

Structural system changes are needed. Generally, and in view of the aging population, also in the ICU, more nurses are needed. We need to get rid of the idea that ICU care can only be given by ICU nurses, we need more levels of nurses in the ICU with different tasks and responsibilities, working with and under supervision of ICU nurses. Furthermore, organizations and specifically policy makers should give nurses a more important role in crisis situations. This is not only reserved for physicians and managers; this is a team effort where nurses play a pivotal role.

Nurses play a crucial role in healthcare, including in crisis situations. However, in many organisations, but also in the media, their role is underexposed. Nurses should raise their voice more often, empower themselves; to be heard, in healthcare organisations as well as in the media (Rasmussen et al., 2022). Healthcare organisations should embrace their nurses and facilitate them more in leadership positions, decision making committees, governance advisory groups etc, to recognise their important role. Although the media talks about the nurses, but most often not with the nurses; most radio and television interviews are with doctors and managers, but sparsely with nurses.

Recognition of the important role of nurses in word and in act, is crucial. With this, we can better prepare ourselves for future challenges. Retaining and recruitment of bedside nurses is important for a healthy workload, to keep the nursing job vital, to increase the job satisfaction, and guarantee healthcare quality and safety. Captivate, bind and retain nurses for this important and beautiful job and we are better prepared for future pandemics.