Burnout syndrome in intensive care unit nurses during the COVID 19 pandemic.

The aim of this study was to review the scientific literature on burnout syndrome among intensive care unit nurses during the COVID-19 pandemic. This narrative review considered publications on the current pandemic, as well as studies on worker health and burnout, focusing on intensive care unit nurses. The literature was organized into two thematic categories: (1) emotional distress in the daily work of intensive care unit nurses; (2) preventing burnout in these professionals during the COVID-19 pandemic. Although the literature on burnout is expressive, there is a need to transmit data produced during the pandemic and follow these professionals longitudinally, which could lead to the development of specific prevention and health promotion strategies. Changes in the emotional and working conditions of these professionals must become a permanent part of worker health research and practice, rather than a temporary measure during the pandemic.

Introduction

Intensive care unit (ICU) nursing staff must provide care in a work environment marked by extreme physical and emotional stress due to the high level of skill and attention required in emergency situations.[1,2] Nursing is essential in this environment, involving constant reflection about care strategies and the development of specific ICU protocols. Nursing has also contributed to the production of practice-related knowledge in the ICU environment with respect to technical procedures, management, and life support, as well as reflections on care.[3]

This context involves a number of specific characteristics, including high work and psychological demands, which can trigger disease processes. Burnout syndrome stands out in this environment, which is characterized by a set of physical and psychological signs and symptoms that result from poor occupational adaptation to an intense emotional load, including frustration with oneself and one’s job.[4] Stress is one determinant of burnout syndrome, especially “unmediated stress”, ie, when there is no possibility of a solution due to physical, psychological, behavioral and defensive factors. It should be pointed out that symptom onset can be due to aspects ranging from individual characteristics (including genetic factors), which that undergo a development stage, to work environment conditions. Burnout symptoms can have negative consequences on personal, organizational, and social levels.[5]

Burnout is among the greatest psychosocial problems of our time, having drawn the attention of the international scientific community, government institutions, corporations, and labor unions due to its impact on individual health status and, consequently, on performance at an organizational level, resulting in economic and social repercussions.[5]

In the ICU context, worker health outcomes are of concern, especially the effects of burnout. These symptoms can have negative effects on health, triggering negative feelings towards work and resulting in professional exhaustion due to wasted energy and resources.[6,7]

The ICU has been increasingly referred to as essential in the context of the coronavirus 2019 (COVID 19) pandemic. The effects of the pandemic, many of which are still unknown, are being researched in terms of collective health, as well as economics, education, and national security.[8,9]

One of the main characteristics of COVID 19 is the involvement of the respiratory system, which is why the demand for ICU care is so intense, since it involves procedures such as mechanical ventilation. Health professionals must combine the technical knowledge required to provide qualified care and the socio-emotional skills necessary to perform this complex service in an unfamiliar scenario that involves high demand, long work hours, and an emotional dimension that exceeds the parameters of their previous experience. Thus, although these professionals are highly qualified for this role, which involves specific skills, technical-scientific knowledge, the use of advanced technology, humanization, individualized care, and assistance provided with quality and effectiveness,[6] the context of the pandemic can result in overload and frustration.[10]

Due to the need for knowledge to better cope with this scenario, especially regarding health professionals directly involved in combating the pandemic, this study was guided by the role of ICU nurses, like other current studies that have aimed to understand how they have positioned themselves in this complex debate.[11] Of note, female nurses have been found to be more susceptible to mental illness during the COVID 19 pandemic than male nurses, although male nurses can also be affected by anxiety, depressive symptoms, stress, and sleep problems.[11] Apparently, sex has a significant influence; it has been shown that women have suffered higher levels of psychological distress during the pandemic.[12]

Based on this overview and with a view to contributing to this important debate about worker health, the objective of this study was to review the scientific literature on burnout syndrome in ICU nurses during the COVID 19 pandemic. It is expected that the knowledge gained during the pandemic can dialogue with the previous literature, producing robust evidence that can lead to the development of health care and health promotion protocols for these professionals.

Methods

This study was constructed from a narrative review of the scientific literature on COVID 19 in 2020 and of occupational health studies focusing on ICU nurses and the repercussions of burnout syndrome. Narrative studies are important because they provide both evidence and critical reflection about a given phenomenon.[13] The decision to conduct a narrative review was based on previous research that indicated the initial character of evidence about the health of nurses in the pandemic context. Although current studies highlight the urgent need to include nurses in occupational health investigations, burnout must still be considered in dialogue with evidence from before the pandemic, allowing the development of studies on and interventions for this target audience.

A narrative review of this type should be based on the available evidence, as well as current debate with the involved researchers and health professionals, striving to produce useful knowledge to address the current challenges. To achieve these objectives, literature searches were performed, especially for studies published since January 2020 with the pandemic as a point of reference. In addition, we searched for studies on the role of ICU nurses and their health problems as a result of burnout published before the pandemic. These searches were carried out in the LILACS, SciELO, PePSIC and MEDLINE databases/libraries, which index evidence from Brazilian and international studies. In this search, priority was given to studies published since January 2020 that reflect the pandemic context.

It should be pointed out that the data summarized here are under construction, since it is impossible to accurately estimate how long the pandemic will continue. Thus, this study is an attempt to coherently systematize a dynamic phenomenon about which new evidence is published every day, which complicates a more detailed analysis. The narrative character of this study is important, not because it promotes systematization, which could result in disconsidering important evidence for new health practices, but because it fosters debate, which must accompany any new evidence for a practice that is not only correct but critical, and is situated in a field that allows for perennial debate. Thus, it is expected that the reflections contained in this review will contribute to future empirical studies on ICU nurses, who should be followed longitudinally to encompass the evolving nature of the pandemic and the availability of new resources and treatments in the coming months.

Results and discussion

After intense exploration of the databases using the above described methodological path, two thematic categories emerged for discussion, which together contribute to the central objective of the review: (1) emotional exhaustion in the daily work of ICU nurses; (2) prevention of burnout in these professionals during the COVID 19 pandemic.

Emotional wear in the daily work of ICU nurses

Working in the ICU involves a high workload because the patients are subject to hemodynamic changes and imminent risk of death, thus requiring complex care, uninterrupted attention, and quick decision-making. The cognitive demands that arise from working with highly complex technology are expressive and can cause mental overload.[7]

Regarding the nurses’ occupational environment, some aspects are recognized as stressors, including: understaffing; unclear role distinction between nurses, nursing technicians, and nursing assistants; and a lack of social recognition, ie, depersonalization in relation to the profession. Overwork can lead to emotional, creative, and physical exhaustion, curtailing the professional’s energy level, efficiency, health, and well-being.[7]

The COVID 19 pandemic has reduced human resources in ICUs, due to the fact that professionals in risk groups have had to be dismissed and/or replaced by more resilient workers in better health[14]. Due to the daily overload experienced in the ICU, nurses may feel physically and emotionally exhausted, discouraged, and, over time, lose their motivation to work due to dissatisfaction and disillusionment[15]. Burnout syndrome is generally associated with the following factors: personality type, external locus of control, overinvolvement, pessimism, perfectionism, professional expectations and idealism, educational level and marital status, work overload, low level of control over activities, feelings of injustice in labor relations, shift work or night work, poor organizational support, conflicts with co-workers, occupation type, and role conflicts.[16,17]

Although the literature does not yet indicate which of these conditions are more significantly associated with burnout during the pandemic, it has been suggested that a social context of instability, associated with intense demands in this sector, can make nurses more susceptible to burnout during the pandemic. This can vary according to the level of disease control in each context, as well as external factors, such as expectations regarding the production of vaccines and medicines, for example. Such hypotheses must be tested in empirical studies during the pandemic, including the different epidemiological stages and their consequences for professionals who work directly on the front lines, represented in this study by ICU nurses.

Intensive care involves urgent and complex situations that demand specialized nurses, resulting in a cycle of rigidity, high demands, and uninterrupted control. These characteristics can have physical, cognitive, and affective costs that produce suffering and illness in workers, leading to burnout.[16]

The literature reports that occupational stress and physical and mental overload are recurrent in physicians[16] and ICU nurses due to the high psychological and emotional demand of providing care to critically ill patients. As a result of the previously described specificity of the work in this sector, ICU workers are vulnerable to burnout syndrome. Thus, there is a clear need for research that translates into preventive measures and intervention models in this context[18]. Although this need was understood prior to the pandemic, it is now reemerging due to the numerous challenges of the current health context.

Although ICU nurses suffer occupational stress and burnout, there is no consensus on which mechanisms trigger them and how they are expressed. It has been pointed out that emotional exhaustion, depersonalization, and a lack of personal fulfillment at work have been associated with moderate burnout scores[19]. Other studies have reported continued professional dissatisfaction among health professionals, which is related to stressors and symptom scores suggestive of burnout, characterized as an increase in the degree of dissatisfaction that influences health and quality of life.[18,19]

Because the technical and practical training of nurses tends to neglect the real needs of patients at risk of death, they are considered ill-equipped to function in a context of terminal illness/death. When caring for terminal patients, they provide the best care they can, but providing support and comfort for the patient and family is barely addressed in undergraduate courses. In other words, nurses are prepared to save lives, but not for situations in which life can’t be saved. Thus, working in this sector can cause emotional distress, contributing to burnout syndrome.[20]

The need to deal with the imminence of death in terminal patients and their families can lead to greater burnout susceptibility among nurses. Difficulties in this area can be associated with other stressful factors in the ICU, such as frequent emergency situations, lack of human and material resources, constant noise from medical equipment, rapidly evolving technology, family suffering, conflicts with coworkers, etc.[20-22]

Thus, ICU nurses must deal with the pain, suffering, and anguish of others, which can be a significant emotional burden, greater than that experienced in other hospital sectors. They are also more exposed to problems with interpersonal relationships, double shifts, and pressure from superiors.[22] Such conditions are important sources of stress and can lead to occupational diseases and burnout syndrome.[20,21]

This scenario, which has been widely researched, was given new meaning during the COVID 19 pandemic due to the burden placed on of front-line workers. The ICU has been considered an essential service during the pandemic, which has led to greater emotional instability among nurses due, first of all, to the challenges of this threat to global collective health, as well as to concerns about family members and socioeconomic needs.[23]

Since it is a fundamental part of the organizational structure in all formal health institutions, further professional development in nursing should be a concern, especially the acquisition of new skills and knowledge that allow a sufficient response to the COVID 19 pandemic. Thus, health managers must reflect on the importance of the ICU and its range of activities, which include a diverse and complex range of possibilities[7] that has been broadened in the current scenario of instability. Given the importance of these questions, this study will now turn to burnout prevention in the current work context.

Preventing burnout in ICU nurses during the COVID 19 pandemic

While researchers are looking for pharmacological measures and vaccines to fight COVID 19, the only precautions recognized worldwide to control transmission are isolation and social distancing. Isolation can generate negative feelings, such as loneliness, sadness, helplessness, and boredom, as well as behavioral reactions, such as sleep and appetite changes and interpersonal conflicts.[24] Such effects should also be investigated among ICU staff, since they continue to work with critically ill COVID 19 patients, often risking their lives due to the lack of adequate protective and safety equipment,[25] which can be a predictor of burnout syndrome.

Nursing involves a number of occupational stressors, which can be classified into five groups: work organization; professional interaction; a routine involving chemical, biological (eg, exposure to COVID 19), physical, mechanical, and psychosocial agents; personal life; and professional activity.[26] This profession usually entails a high rate of depression due to the work hours, staff dimensioning, shifting activities, emotional involvement with patients, absenteeism, a lack of coworkers, conflicts, and ambiguity of roles, as well as inadequate training and professional development.[27]

The ICU is characterized by variability, meaning that care not only depends on techniques, but the ability to deal with unexpected events, such as system breakdowns, lack of material, understaffing, patient instabilities that require the replanning of treatment, etc. Such variability shapes the state of the profession, and nursing professionals must master it to successfully provide care. In addition, the ICU is a closed sector, with poor local acoustics due to the involved equipment, making staff more sensitive to noise, as well as to physical and psychological damage. Such factors can contribute to the development of burnout syndrome.[21]

One study discussed stress and emotional suffering in hospital personnel,[28] reporting that mental health problems mainly affect nurses, given that they are on the front line of COVID 19 treatment and must deal not only with the risk of infection, but the lack of material and human resources to meet the demands of infected patients.[29] In addition to the high risk of infection and the possibility of death, these workers must also cope with the high chance of infecting friends and family members, as well as with the anguish and exhaustion of constant contact with death on a much greater scale than before of the pandemic. Nurses must also deal with the frustration of not being able to save lives, the threats and insults of people who are unaware of their situation, and social distancing from their support network of friends and family.[30]

Nurses play an extremely important role in the ICU. However, to perform their work with excellence, they need specific training that develops their functioning, skills, and manual dexterity, in addition to the ability to deal with highly emotional family members. They require technical-scientific knowledge, technological mastery, and the ability to provide qualified, humanized, individualized care.[21] Many nurses feel discouraged from maintaining social bonds, which leads increased feelings of isolation and changes in care protocols.[31] They must also operate according to strict biosafety protocols,[32] which can also be a significant stressor in this scenario of uncertainty and intense work.

Burnout is the final stage of a continuous process of perceived inadequacy, lack of resources, heavy demand, a reduced ability to solve problems, insufficient time, etc. In nurses, burnout syndrome has been characterized as the exhaustion of one’s emotional resources, a negative and distant attitude towards patients, and a negative assessment of one’s professional performance.[17,33]

A Canadian study conducted during the COVID 19 outbreak identified symptoms of stress and emotional distress among health professionals due to work environments that involve a high risk of infection, resulting in depressed mood and affecting their professional life[34]. Thus, psychological support should be provided for nurses, since they are currently more vulnerable to mental suffering and emotional exhaustion.

It should be pointed out that professionals are not always aware of burnout symptoms, which complicates diagnosis and treatment. This delay in recognizing symptoms and seeking professional help may be associated with psychological problems and greater dissatisfaction with work.[35-37]

Thus, to prevent health problems due to occupational diseases, it is essential to continuously improve the quality of life of ICU workers by developing protocols to reduce their stress.[38] Further studies on burnout syndrome in ICU nurses during the pandemic are needed to develop prevention and protection interventions, reducing its impact on this sector of the workforce.

Strategies to prevent burnout, especially during the pandemic, include: worker control of the nursing practice environment, organizational support,[39] changing the workplace routine, and approaching the nurse as a holistic being who belongs to a greater work environment, in addition to providing the necessary physical resources.[40] Although policies to improve the quality of life of nurses are necessary,[41] interventions must be developed on an institutional level so that nurses can cope with the stressors inherent to their profession,[42] especially ICU nurses during the pandemic.

For the most part, studies on the health of nurses have been limited to occupational risks, without considering other determinants of morbidity in the work process or the transformations imposed on the workplace during the pandemic. Nurses become vulnerable to occupational stress due to the working hours, lack of social and financial recognition, and a work environment that is often tense, closed, and cold, where they face sadness, illness, and death on a daily basis.

The current pandemic can intensify the physical and emotional exhaustion of these professionals, which must be mitigated through evidence-based methods developed during this epidemiological context. In addition to the hypotheses derived from searching the relevant literature, the role of these professionals and the social image of ICU nurses should be revised in light of the pandemic. Due to their importance in fighting the virus, this may be an opportune time to take a more careful look at the work and health conditions of nurses, promoting health in an effort to positively impact their health outcomes. These points must be followed up over the long term, seeking dialog between theories developed before, during, and after the pandemic, reaffirming the global character of the context and the unpredictability of its repercussions.

Final considerations

This study has reflected on how the COVID 19 pandemic has led to burnout syndrome in ICU nurses. It should be pointed out that the daily life of ICU workers is extremely controlled, requiring skill, preparation, and effective management. However, numerous problems can affect their daily lives, such as a lack of resources and support, work overload and, during the pandemic, the still unknown effects of COVID 19, which significantly contribute to their risk of burnout.

Of course, the literature on burnout published prior to the pandemic is still useful. What is important at this point to conduct studies during the pandemic so that the most up-to-date knowledge can dialog with classic propositions about this syndrome. Based on the available evidence and the topics addressed in this study, it can be stated that the pandemic predisposes nurses to burnout, especially those working on the front lines. Thus, mental health care specifically aimed at these professionals and their work conditions must be prioritized, developing protocols for more favorable responses, so that they can remain engaged and receive adequate physical, mental, and work conditions to continue providing intensive care for the duration of the pandemic.

It is essential to keep reflecting on prevention and health promotion among ICU nurses so they can continue to play their fundamental role in fighting the pandemic with quality and safety, without themselves becoming infected. Besides conducting further studies on this topic, greater attention should be paid to these professionals during this unstable and complex period. Finally, changes made to the work conditions of nurses should not be merely circumstantial, ie, resulting from the pandemic, but permanent improvements that supersede isolated health phenomena.