key: cord-0682275-5vz83dcz authors: Sumner, Sarah title: Impact of the COVID‐19 pandemic on the work environment and mental health of intensive care unit nurses: Reflections from the United States date: 2022-02-17 journal: Nurs Crit Care DOI: 10.1111/nicc.12759 sha: b6c2061278f312bcafa65c343cefab7873a4a0c1 doc_id: 682275 cord_uid: 5vz83dcz nan The coronavirus disease 2019 (COVID- 19) pandemic has been the most disruptive force to the intensive care unit (ICU) work environment this century. That disruption has been profoundly evident over the last 2 years as ICU teams around the world were overwhelmed with surges of critically ill patients in need of respiratory support and other advanced interventions. The first major COVID-19 surge in the United States hit New York City, New York in March 2020. As hospitals became overwhelmed, the New York state governor put out a desperate plea to health care providers across the nation to help New York. As the surge continued, the work environment suffered and ICU nurses began to experience burnout, emotional exhaustion, compassion fatigue, moral distress, turnover and showed intent to leave. [1] [2] [3] Since then, hospitals in the United States have been competing to secure temporary ICU nursesoutbidding each other with skyrocketing weekly rates meant to incentivize nurses to work under the demanding and uncertain conditions. 4 As ICU nurses cared for patients with the new, life-threatening severe acute respiratory syndrome coronavirus 2 (SARS-CoV 2) virusoften without adequate personal protective equipment (PPE)many self-quarantined to prevent exposing their loved ones to the virus. 1,3 While at work, those same nurses witnessed the fear and suffering of their patients who were similarly separated from their families. When possible, ICU nurses used tablets to facilitate video calls between patients and their families, but even that mode of communication was challenging as nurses shifts were poorly staffed, and nurses were trying to keep up with near-daily changes to PPE protocols and treatment regimens. 3 Conditions were so chaotic during the first New York surge that some families of the deceased were not notified of their passing for hours to days, and hospitals had to place the dead in refrigerated trucks because mortuaries could not keep up with rate of death. 5 The COVID-19 pandemic exacted unprecedented physical, psychological and moral injuries on ICU nurses who were pressured to continue working despite experiencing fatigue, burnout and symptoms of the virus themselves. 3 6 found that being a nurse, working in the ICU and lacking appropriate PPE were strongly associated with depressive symptoms. Conversely, health care workers who had received mental health support were less likely to report hopelessness or depressive symptoms (Khajuria) . The relationship between the work environment and nurse outcomes has been studied in nurses for decades. 7 8, 9 The HWEAT can be used to correlate changes in the work environment with ICU nurse outcomes. 9 Adverse mental health outcomes including burnout, anxiety, depression, moral injury and risk for suicide have been reported in nurses during the COVID-19. 1,10-13 Female nurses were already more than twice as likely as women in the general population to commit suicide. 14 Even a single nurse suicide is likely to have profound negative consequences on the unit and institution where that nurse worked. 15 Dr. Breen was reluctant to seek help as she was more concerned about the stigma of seeking psychological care than she was about her own well-being. After her death, her family lobbied the United States Congress to fund research on the impact of the COVID-19 pandemic on the mental health of healt hcare professionals. Beginning in 2022, grants totalling $140 million will be distributed to health systems and health training programs to identify strategies to prevent suicide, burnout and mental health conditions while promoting job satisfaction and the well-being of health care professionals. The funds will also raise awareness about the importance of mental health and fund research on the impact of COVID-19 on the mental health of health care professionals. 23 As tragic as the death of Dr. Breen was, her suicide brought the need to acknowledge the strains of the work environment on the mental health of health care professionals into focus. The promise of her legacy is the integration of mental health as a measure of a healthy work environment. The risk for suicide is particularly prescient to the ICU nursing community as female nurses were already twice as likely women in the general population to commit suicide before the pandemic. 14 Two major risk factors for suicide are work-related stress and mental health problems, which ICU nurses seem to be experiencing disproportionately during COVID-19. 14,24 Creative and deliberate interventions must be implemented at the hospital and unit level to improve the work environment to support the mental health of ICU nurses. Consider these three exemplars of programs in the United States to promote the mental health and well-being of health care professionals. The first two exemplars were in place before the pandemic, while the third one emerged during the pandemic. Although the cumulative effect of the COVID-19 pandemic on ICU nurses is unknown, it has clearly had a profound impact on the mental health of the ICU nursing workforce. The American Nurses Association (ANA) Code of Ethics requires nurses to adopt selfcare as a duty to self. 29 It is possible that ICU nurses in the United States are leaving their positions over mental health concerns experienced during the pandemic. If so, administrators and clinical nurses must collaborate to address threats to mental health in the work environment to retain and sustain the ICU nursing workforce. 24 Even before the pandemic, the relationship between the work environment and nurse outcomes including burnout, emotional exhaustion, compassion fatigue, moral distress, turnover and intent to leave had been well established. 30 Three innovative programs in the United States have been described that could be replicated across the country and around the world to assess, monitor and support nurse mental health and wellbeing. Further research is needed to understand the relationship between mental health-targeted programs and nurse perceptions of the work environment. When implemented according the AACN model, a healthy work environment can improve nurse satisfaction and retention. 31 The AACN has validated an instrument, the Healthy Work Environment Assessment Tool (HWEAT) that can be used for that kind of research. 8, 32 Addressing the work environment and its effect on the mental health of ICU nurses will be crucial to attract and retain a skilled workforce. The importance of these efforts cannot be overstatednurse mental health and well-being are the foundation for the strength and resiliency of the nursing profession. Severe burnout and poor mental health among healthcare workers 6 months after covid-19 pandemic declaration Addressing caregiver moral distress during the covid-19 pandemic Invisible moral wounds of the covid-19 pandemic: are we experiencing moral injury? Need a COVID-19 nurse? 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