Commentary: Critical care nurse burnout, moral distress, and mental health during the COVID-19 pandemic: A United States Survey.

Frontline healthcare staff have borne the brunt of the workload providing care for high volumes of ill persons diagnosed with COVID-19 ever since the World Health Organization declared a global pandemic on March 11, 2020. Nurses providing care in the intensive care unit (ICU) have experienced unprecedented, sustained high volumes of severely ill patients requiring invasive life-sustaining support including mechanical ventilation and extracorporeal membrane oxygenation. The unrelenting strain of caring for these critically ill patients has taken a toll on ICU nurses. In this issue of Heart & Lung, Guttormson and colleagues provide additional evidence of the detrimental impact of the pandemic on ICU nurses’ health and well-being.

The investigators aimed to describe moral distress, burnout, anxiety, depression, and post-traumatic stress disorder (PTSD) symptoms as well as the relationships among these variables by work setting and personal characteristics among a nationwide, cross-sectional survey of ICU nurses in the United States (U.S.). A battery of instruments was selected to measure the variables of interest while minimizing response burden for busy ICU nurses. Respondents were provided a toll-free Disaster Distress Helpline for those experiencing emotional distress.

A majority of the survey respondents were recruited through social media from October 2020 to January 2021. It is vitally important to keep this timeline in mind when interpreting the survey findings. This timeframe was within the first year of the pandemic during a period of frequently changing policies and procedures for providing care for severely ill ICU patients prior to wide availability of COVID-19 vaccinations. Survey respondents (n = 488) were predominantly bachelor's degree prepared, female Midwestern staff nurses 20–40 years old working in community hospitals with a median of 5 years ICU experience. The findings from these U.S. ICU nurses provides a snapshot of the early pandemic and the associated strains of concern regarding adequate supplies of personal protective equipment (PPE). A strength of this survey study is the investigators’ chose to measure variables of salience to ICU nurses beyond burnout. Among respondents, almost all nurses worked on designated COVID-19 units, experienced shortages of PPE, and only felt partially or not at all supported by hospital administration. Nurse-respondents reported moderate moral distress and burnout. A third of nurses reported moderate to severe anxiety as well as moderate to severe depression. Nurse-respondents were at risk for developing PTSD symptoms and felt their health was at risk when caring for COVID-19 patients.

The results of this survey are, unfortunately, not surprising. However, the most significant findings from this study are that nurses under 30 years of age with 5 or fewer years of ICU experience reported higher burnout, particularly in the presence of PPE shortages and little to no support from administration. Equipment shortages, including ventilators, and lack of administration support significantly influenced moral distress, personal trauma, depression, and anxiety. While individual characteristics may have contributed to mental and emotional health in these nurse-respondents, these findings illuminate the important contribution of administrative support to the health and well-being of the U.S. nursing workforce.

Limitations of this cross-sectional survey include a small number of respondents predominantly representative of the Midwestern U.S. It is not known if these findings are unique to the first year of the COVID-19 pandemic or if these results are relatively enduring. Lastly, it is unknown if the pandemic has exacerbated existing health challenges among the survey respondents. What is apparent is that the health and well-being of our nation's frontline ICU nursing workforce is seriously at risk. The authors provide recommendations for further research specifically investigating the inter-relatedness among moral distress, burnout, and mental health as well as the increased risk for PTSD-like symptoms. Likewise, interventions to promote the health and well-being of our nation's nursing workforce must be multimodal and at multiple levels from individual to systems.

Linda L. Chlan, PhD, RN, ATSF, FAAN

Disclaimer: The comments herein are solely the opinion of the author.

Declaration of competing interest

The author reports no conflicts of interest.