key: cord-0683304-u9imv2re
authors: Troglio da Silva, Flaviane Cristine; Barbosa, Caio Parente
title: THE IMPACT OF THE COVID-19 PANDEMIC IN AN INTENSIVE CARE UNIT (ICU): PSYCHIATRIC SYMPTOMS IN HEALTHCARE PROFESSIONALS – A SYSTEMATIC REVIEW
date: 2021-03-25
journal: J Psychiatr Res
DOI: 10.1016/j.jpsychires.2021.03.044
sha: a897040ab7fd1b4e2544830ad1f551375cf3ded1
doc_id: 683304
cord_uid: u9imv2re

INTRODUCTION: During the COVID-19 pandemic period, the structure of the Intensive Care Unit (ICU) activities changed fast. It was observed that the mental and physical health of the frontline workers reached levels of extreme clinical and psychological concern. OBJECTIVE: Understand the impact that COVID-19 is having on the front-line clinical team in the ICU environment, as well as reveal what proposals are being made to mitigate the clinical and psychological impacts that this group experiences. METHOD: A systematic review was made following the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). We included any type of study on health workers during the COVID-19 pandemic, with results about their mental health. We were, therefore, interested in quantitative studies examining the prevalence of problems and effects of interventions, as well as qualitative studies examining experiences. We had no restrictions related to study design, methodological quality or language. RESULTS: Twenty-one studies reported on the urgent need for interventions to prevent or reduce mental health problems caused by COVID-19 among health professionals in ICU. Eleven studies demonstrated possibilities for interventions involving organizational adjustments in the ICU, particularly linked to emotional conflicts in the fight against COVID-19. CONCLUSION: The disproportion between the need for technological supplies of intensive care medicine and their scarcity promotes, among many factors, high rates of psychological distress. Anxiety, irritability, insomnia, fear and anguish were observed during the pandemic, probably related to extremely high workloads and the lack of personal protective equipment.

Coronavirus disease , in which the etiologic agent is the SARS-CoV-2 virus, belonging to the b-coronavirus family, has been classified as a pandemic since March 11, 2020, by the World Health Organization (WHO). This new pathology causes severe respiratory problems, leading the infected person, often, to need support in the Intensive Care Unit (ICU). [Dost et al., 2020; Due to the high virulence and infectivity, the disease in question soon made victims in figures so high that the number of ICU beds was depleting and causing chaos both in the scientific team and in the public [Zaka et al., 2020] . On the other hand, one of the measures found to try to alleviate this situation was the creation of field hospitals, as well as the relocation of ICUs specialized in certain pathologies for the care of individuals with COVID-19 complications. Same examples are the Cardiology Unit of Bergamo, in which 60% of its beds were occupied by COVID-19 positive patients [Senni, 2020] , and the reuse of the 14 beds of the pediatric ICU of the General Children's Hospital in Massachusetts for adults [Yager et al., 2020] .

Still, the level of stress is increasing in the front-line team, which includes doctors, nurses, and physiotherapists from the ICU. We are living in a period of war, in which suffering and death shine, both for those who live and for those who die, resulting from the disproportion between the needs of the sick ones and the available resources [Romanò, 2020] . From this point of view, stress is defined as the organic, psychological, and social response to harmful developers that the individual experiences [Wu et al., 2020] .

In this circumstance, it is noted that the health team is guided by physical and emotional resistance to face life and death situations, even if their integrity is at risk [Santarone et al., 2020] . Such commitment, especially from doctors, is remoted from the Hammurabi Code and the Hippocratic Oath. Nowadays, the main relationship of this group with society is based on the social contract, putting in question the expectations of the people for care, competence, altruism, integrity, responsibility, and the generation J o u r n a l P r e -p r o o f of the common good by the doctor. Given that, the doctor expects trust, autonomy, social recognition, self-regulation, and financial support of an own health system for the full exercise of his activity. However, the COVID-19 pandemic puts the contract at the extreme by asking us: do the risks experienced by these professionals do not have a limit? [Ferreira et al., 2020] .

In this context, it is necessary to remember that the history of humanity is marked by big outbreaks and epidemics as deadly as the current with devastating results on the psychic-organic health of the workers involved. For example, in 2003, in China and Canada, SARS-CoV-1 generated, in at least 10% of front-line professionals, an increase in the level of stress, with mental problems lasting up to 3 years after the trauma, with a focus on the sum of symptoms (dizziness, headache, breathing difficulties), burnout, anxiety, Posttraumatic Stress Disorder (PTSD), fear of future, outbreak, and, especially, depression [El-Hage et al., 2020; Zaka et al., 2020; Wu et al., 2020; Hou et al., 2020; Blake et al., 2020] .

Another relevant infectious and contagious disease was the Influenza A (H1N1) epidemic, in 2009. Such illness had psychiatric consequences in the health team, as, for example, the increase in anxiety, feelings of anguish, and addictions (nicotine and alcohol) [Blake et al., 2020; El-Hage et al., 2020] . Recently, in 2013 -2016 Sierra Leone, and Liberia experienced an outbreak of the Ebola virus, causing significant psychological symptoms for health professionals, such as depression, paranoid ideation, fear of death or having another similar experience, and PTSD. Such consequences had a relevant impact on the quality of life and work of these individuals Zaka et al., 2020; Maben and Bridges, 2020] .

Thus, it is clear that the mental and physical health of front-line workers has been already pushed to the limit in past situations. Given the normal time of society, it is known that at least 50% of the doctors fight against burnout or emotional exhaustion due to the stress experienced at work [Santarone et al., 2020] . Consequently, it is observed that the professionals from health team in the ICU environment brings with them scars and marks of personal battles that they fight daily with each other, and the accomplishment of their craft in the fight against COVID-19. [Blake et al., 2020] .

Therefore, the objective of this work is to understand the impact that is having on the front-line clinical team in the ICU environment, as well as to reveal which proposals are being made to mitigate the clinical and psychological impacts that this group experiences. Based on this assumption, the following research question was mapped: What are the impacts that Covid-19 is providing to frontline teams in an ICU environment? It takes into account the proposals that are being elaborated to face the clinical and psychological impacts of these professionals.

A systematic revision was made, following the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-Analysis), in the period from January 2020 to January 2021.

We included any type of study on health care workers in ICU during the COVID-19 pandemic, with results related to their mental health. We were, therefore, interested in quantitative studies examining problems and effects of interventions, as well as qualitative studies examining experiences. We had no restrictions related to study design, methodological quality, or language. The language problem was solved through a reasonable degree of comparability, which allowed us to systematically analyze the selected evidence, its critical evaluation process, and its success in including relevant studies in other languages.

We classify assessments according to their level of inclusion of studies in other languages. Reviews that excluded non-English studies with an explicit justification in the research question or research objectives were categorized as justified by R1 (that is, justified in English), while those that excluded non-English studies without justification were categorized as restricted to RR1 (that is, languages that are not restricted to English). Reviews that did not explicitly exclude studies that were not in English were J o u r n a l P r e -p r o o f categorized as RR1-open, unless they successively included studies that were not in English, in which case they were RR1-inclusive. Finally, revisions that did not declare language criteria were considered to be RR1-open.

To search for studies, the following databases were used: Pubmed, Scopus, ScienceDirect, Web of Science and Embase. We identified categorized references for the population "Intensive Care Units", and for the topic "Health Personnel" and Health Care Workers" and "Mental Health" and "Mental Disorders" and "Psychiatry" and "

Coranavirus" and " Coronavirus Infecction". Besides, we identified references by searching (title/abstract) in the database, using the keywords: psych *, stress *, ans *, depr *, mental *, sleep, worry, and somatic symptoms. We selected all references identified specifically for the inclusion criteria for this systematic review.

We have developed a data extraction form to collect data on participants and exposure to COVID-19, intervention, if relevant, and results related to mental health.

We extracted data on mental health problems, as well as related ones (that is, risk/resilience factors); strategies implemented or accessed by health professionals with the objective to treat their own mental health; perceived need and preferences related to interventions designed to prevent or reduce negative mental health consequences; and experience and understanding of the healthy mindset and related interventions.

One researcher (FCTS) extracted data and another verified the extraction. Two researchers (CPB and FCTS) independently assessed the methodological quality of systematic reviews using the AMSTAR tool (Shea et al., 2017) and qualitative studies using the CASP checklist (Critical Appraisal Skills Programme -CASP, 2020). A researcher (FT) assessed the quality of cross-sectional studies using the JBI Prevalence or the JBI Cross-sectional analytical checklist and longitudinal studies using the JBI Cohort checklist (Johanna Briggs Institute 2020).

J o u r n a l P r e -p r o o f

We summarized the results narratively. We described interventions and outcomes based on the information provided in the studies. When studies showed mental health results in numbers without numbers, we extracted them using an online software (https://apps.automeris.io/wpd/). We decided not to perform a quantitative analysis of summaries of the associations between the various correlates and health factors, due to a combination of heterogeneity in the measures and lack of control groups, and an embraced lack of descriptions necessary to confirm sufficient homogeneity. We rated the certainty of the evidence using the GRADE approach -(Grading of Recommendations Assessment, Development and Evaluations (Guyatt et al., 2011) .

Altogether, 573 evidences were found. With the subsequent application of the inclusion and exclusion criteria, 31 studies were included for qualitative foundations. Table 1 summarize the main methodological characteristics for inclusion or exclusion of the studies.

The most common methodological weaknesses in all the studies arose from insufficient reporting: samples, scenarios, and recruitment procedures were often not fully described.

Twenty-one studies reported the urgent need to implement interventions in order to prevent or reduce mental health problems caused by COVID-19 among health professionals in ICU. Eleven studies demonstrate the need for interventions to organizational adjustments in the ICU, especially related to the emotional conflicts involved in fighting COVID-19.

J o u r n a l P r e -p r o o f

None of the studies that implemented mental health interventions reported the effects of interventions on health professionals in the ICU due to the rapid entry and exit of patients versus death. The only data available to connect the impact of the pandemic on the mental health of health workers in the ICU came from two longitudinal research studies, that report changes over time, both of low-quality methodological value.

The summary of the results table below shows the studies that contribute to each mental health result. We evaluate that the certainty of the reported results of levels of anxiety, depression, distress, and sleep problems in health care professionals in the ICU during the COVID-19 pandemic, using the GRADE approach, is moderate. 3.7.

Twenty studies reported that health professionals in the ICU did not use other resources or had individual strategies to deal with their own mental health except the formal interventions. Professional and informal help were strategies reported by eight studies each. A minority (03 studies) of professionals demonstrated that seeking help from a psychologist was important (Figure 1 ).

The impacts of COVID-19 today encompass the social, political, economic, and, above all, the health of the whole society. Concerning the health aspect, it is known that the pandemic is restructuring the cognitive system of individuals, in which its function concerns the self-referenced control of information and responses to the interaction of external social afferents and the person's physiological systems. Consequently, the way the current reality is faced in which the indecision of tomorrow, the fear of death, the mourning of loss, the lack of freedom, and internal anguish are experienced uniquely by each person, who, automatically, responds to the stimulus with changes in both physical and mental health [Wu et al., 2020] .

In the face of this emotional pain, the feeling of guilt is humanly understandable.

The fact of witnessing unacceptable situations leads the individual to react by blaming himself, either for the choices made or for the inability to perform some actions, such as J o u r n a l P r e -p r o o f looking for non-existent answers when blaming the activities of others, for example, government actions or new medical guidelines [El-Hage et al., 2020] . In this perspective, it is seen that the paradox of negative and positive emotions coexists, and the psychic-organic integrity is determined by how each one feeds these emotions. In this sense, not everyone submitted to the same stressor factor will respond negatively.

However, everyone involved is vulnerable, especially those who are on the front lines in the fight against COVID-19 [Greenberg et al, 2020] .

For army doctors, maintaining sanity is the result, among many aspects, of the number of battles experienced. In this way, the most relevant characteristics of the group in question are promoting the patient's psychophysical protection, exercising the most humanized care, selecting the severity of each situation in the light of current scientific knowledge, and acting with the greatest efficiency in the help of as many as possible people [Piccinni et al., 2020] . However, we are experiencing a global health crisis that most closely resembles a war in which the best-prepared fighters are less susceptible to mental damage, while those facing their first battle suffer such ills early, particularly nurses [Maben and Bridges, 2020] .

Because of this, ever since the COVID-19 pandemic appeared, the imbalance between need and availability of resources marks all areas of medicine, especially in intensive care. ICU workers are playing the role of heroes and victims. As they fight for their patients' lives, the change in routine has harmed their health [Piccinni et al., 2020] .

The increase in the workload of doctors and nurses [Shen et al., 2020; Maben and Bridges, 2020; Shah et al., 2020] , associated with the exorbitant function of breaking bad news [Greenberg et al, 2020; El-Hage et al., 2020] , are changing the sleep-wake cycle, with reports of insomnia [Wu et al., 2020; Shah et al., 2020] . This situation has as impact the bad development of work activities, marked by physical and psychological exhaustion [Shen et al., 2020; Rana et al., 2020; Blake et al., 2020; El-Hage et al., 2020] .

In a connected way, the lack of personal protective equipment (PPE) is a coefficient of anxiety and fear experienced by the front-line team [Shen et al., 2020; Maben and Bridges, 2020; Rana et al., 2020; Blake et al., 2020] . In this circumstance, restrictive measures for the release of PPE and screening tests created by the United Kingdom were interpreted by second-line nurses as a discriminatory act [Maben and Bridges, 2020] . Given this, there is a close exposure of workers to the virus, which puts their lives at risk by maintaining the health of others. It is known that, in stressful pre-J o u r n a l P r e -p r o o f pandemic situations, it was common to seek support and comfort within the family.

However, currently, for fear of exposing their family members to COVID-19, the ICU team is performing self-isolation, intensifying the social support reduction and harming themselves [Shen et al., 2020; Maben and Bridges, 2020; Rana et al., 2020; Santarone et al., 2020; Pappa et al., 2020; Shah et al., 2020; El-Hage et al., 2020; Zerbo et al., 2020; Zaka et al., 2020] .

At the same time, the increase in the number of deaths [El-Hage et al., 2020] , reinforced by the news of the positive diagnosis of co-workers or their death, is commented on in the current literature as accessory causes of the psychic condition of the ICU team [Santarone et al., 2020; Blake et al., 2020; Zerbo et al., 2020] . Despite this situation, this group of professionals, especially the nurses, has been victims of social stigmas in which they are rated as carriers or vectors of the coronavirus [Maben and Bridges, 2020; Blake et al., 2020; El-Hage et al., 2020] .

While the use of PPE is essential in preventing the disease, doctors and nurses report difficulties in communicating with patients using these tools [Walton et al., 2020; Shah et al., 2020] . Despite this, moments of conflict are extended beyond the doctorpatient binomial. Because of the high infectivity, the hospital team follows new guidelines that make it impossible to maintain the practice of family visits to hospitalized patients and the presentation of the deceased to relatives is abolished.

Given this, disagreements arise between the patient's family, motivated by premature grief, and the ICU team [Shen et al., 2020; Mukhtar, 2020; El-Hage et al., 2020] .

Thus, the professionals of the ICU are seen by patients as the only human and affective bond in the impossibility of contact with their loved ones. This fact is relevant for both sides, whereas patients create insecure patterns of affable support in care professionals, and the last develop sentimental connections to the first. Consequently, when there is evidence of a cure for someone hospitalized in the ICU, this is a cause for celebration and joy for everyone who has followed this process with care. However, the ineffectiveness of the therapies performed and the patient's clinical decline promotes pain, grief, and anguish in everyone at the ICU, who no longer look at that individual as a mere patient, but as a member of the new family cycle created in the melancholy reality of COVID -19 [Maben and Bridges, 2020; El-Hage et al., 2020; Zerbo et al., 2020] .

In addition, most nurses report difficulties in adapting to the new protocols of the ICU services, which have become more rigid in the face of the current situation J o u r n a l P r e -p r o o f [Maben and Bridges, 2020; Blake et al., 2020; El-Hage et al., 2020] . This condition is connected to the multiple tasks that these professionals perform and to the unbalanced distribution of patients under the supervision of a professional [Wu et al., 2020; Shah et al., 2020] . Under usual ICU conditions, the proportion is one nurse to two or even four patients, and another backup nurse for every four beds, with the function of providing support in the face of excessive workload or for possible changes, if any professional becomes ill [Walton et al., 2020; Greenberg et al, 2020] .

In the meantime, a criticism mentioned by the Spanish Society of Intensive Nursing and Coronary Units concerns the lack of recognition of this group's specialty in intensive care and the negligence on the part of the services in hiring a sufficient number of physiotherapists. It has, generally, one physiotherapist per unit, who also suffers from work overload .

However, in a conflict situation, effective leadership is imperative. Thus, another relevant complaint from the ICU team is the negative lead of managers in certain sectors and, even with an increased workload and amount of work, the financial reward is considered insufficient [Shah et al., 2020] .

At the same time, the fear of lack of technical skills and knowledge about the SARS-CoV-2 virus are significant coefficients in the mental well-being of health care professionals [Shah et al., 2020; El-Hage et al., 2020] . To portray these aspects, a study in Turkey involving 346 people, including anesthesiologists and residents of the area, stated that the residents called to act in the ICU against COVID-19 were more indecisive, with a tendency to make wrong decisions, because of the small professional experience. [Dost et al., 2020] . A similar situation occurred with the pediatric ICU team of a hospital in Massachusetts, which started to accommodate adult patients with COVID-19 positive. As if the scarcity of information related to the disease in question was not enough, these professionals were challenged in the management of patients with biotype and clinical-laboratory parameters totally different from the usual [Yager et al., 2020] .

On the other hand, the reorganization of the physical spaces of the ICUs directly influences the team's dynamics. It happens because many professionals were relocated to other ICUs, having to work with people who were not their professional colleagues and because of new ones hired to enhance the teams. Such factors made the old team feel uncomfortable with the new member, with whom they did not maintain a cohesive bond in the coexistence relationship, having reports of the feeling that it did not have an J o u r n a l P r e -p r o o f open space to talk about their own emotions, a shame to question, and a fear of making any mistake and being judged by this. [Maben and Bridges, 2020; El-Hage et al., 2020; Zerbo et al., 2020] .

However, one of the main factors in the mental integrity of front-line health care professionals is the new ethical dilemmas that the pandemic has brought with it.

Doctors, mainly, have their cognitive abilities and memory required repeatedly, quickly, and under circumstances of high psychological tension. This situation results in the common selflessness of these workers about their own health [Blake et al., 2020; El-Hage et al., 2020] .

In this circumstance, allocation and screening of resources for the management of the patient in the ICU create uncertainties and self-questions from the doctors about the principles that govern their activity. Thus, acting with justice is not only giving the sick person access to available therapies but also rationalizing resources. Therefore, some ethical criteria, such as beneficence, non-maleficence, autonomy to make patient decisions, and shared justice, assists in the selection of beneficiaries for use of the ICU.

However, the pandemic means that these parameters can no longer be reconciled, causing stress to the doctor. Many professionals revealed that the uncertainty in the level of management is proportional to the clinical complexity that patients have.

Consequently, for them, it is considered as an attitude of high negative psychological impact the suspension of ventilatory support therapy in ICU, in comparison to the nonactivational of it and the aggregation of the patient in this environment [Rubio et al., 2020; Romanò, 2020] .

Ratifying this reality, several institutions are selecting health professionals intending to assess the psychic impacts of the pandemic. Thus, a cross-sectional survey using the Connor-Davidson resilience scale (CD-RISC) and the Social Support Rating Scale (SSRS), applied to 1521 professionals, obtained a prevalence of 14.1% of psychological imbalances . Similarly, a Chinese hospital, using the Zung Self-Assessment Depression Scale (SDS) and the Zung Self-Assessment Anxiety Scale (SAS) in a group of 23 doctors and 36 nurses, revealed that doctors under the age of 30 years had high scores for depression compared to older people [Lian et al., 2020] .

Therefore, it is clear that the consequences of COVID-19 in the ICU team are diverse. Among the reported outcomes are found: stress, anxiety, depression, anguish, anger, fear, guilt, insomnia and abuse of substances Kang et al., 2020; Rana et al., 2020; Blake et al., 2020; González-Castro et al., 2020; Senni, 2020] , J o u r n a l P r e -p r o o f as well as a deficit in labor productivity [Greenberg et al, 2020] and manifestations of compulsive-obsessive attitudes, such as excessive hand washing . In this sense, a study evaluating the mental integrity of 85 nurses at the ICU had as a quotient that 59% had reduced eating habits, 55% had fatigue, 45% sleep-related problems, 28% irritability, 26% constant crying and 2% suicidal ideations [Shen et al., 2020] .

The high predisposition for suicide among doctors is recognized. In the United States, the percentage of doctors showing typical Burnout symptoms reaches 54.4% [Shah et al., 2020] . In this sense, the fear of discrimination and of being labeled associated with the feeling of shame and denial, lead doctors to avoid talking about their feelings and stressors, as well as not seeking psychological and psychiatric support.

Therefore, these attitudes are decisive in the poor outcomes found for this group [Rana et al., 2020; Greenberg et al, 2020] .

Even so, the feeling of guilt is not restricted to the team that actively works in the ICU. That means the risks are beyond the walls of this environment. The professionals of this place, who have underlying diseases or are in a pregnant situation and were released from their work practice, report guilt for not being present during this pandemic moment. In addition, the risk of developing PTSD in the ICU team is above 10% of the range considered normal [Walton et al., 2020] . Besides, front-line female health professionals, young and exercising the position of nurses, when compared to doctors, showed symptoms of anxiety, depression and PTSD more frequently. The second-line professionals, on the other hand, show conditions similar to Munchausen syndrome by proxy [El-Hage et al., 2020] .

Given this situation, a systematic review with a meta-analysis of 13 crosssectional surveys with 33062 participants was carried out to assess the prevalence of anxiety, depression and insomnia in health professionals. It was found that while the Chinese population, during the same study period, had fluctuating rates of 22.6% -36.3% for anxiety and 16.5% -48.3% for depression, health professionals had similar numbers for anxiety (23.2%) and depression (22.8%), and also an average of 38.9% of insomnia after the emergence of the pandemic. In addition, it clarifies the high prevalence of psychological problems in nurses because the majority of the members of this profession are women, but, also because they have a more intimate contact with the patient and the routine provision of invasive services, such as sputum collection [Pappa et al., 2020] .

Despite these alarming numbers, not everyone who makes up the ICU team will develop such conditions. It means that, while it is relevant to analyze and evaluate the current psychological situation of front-line professionals, the individual's physiological responses, such as fear and anxiety, should not be conceptualized as a disease when the person is exposed to a stressful situation. Therefore, even if everyone experiences a challenging moment, both in their activity and in their personal integrity, most professionals exhibit resilience and, consequently, the chance of developing or maintain psychic-organic changes in the long term is small [Maben and Bridges, 2020; Walton et al., 2020] .

Thus, resilience is defined as the human capacity to face and recover from significant tribulations. Therefore, the characteristics expressed by resilient people are resistance, perseverance and hope. This demonstrates that psychological resilience is a protective factor, acting as a mean of primary prevention against mental pathologies and that results in aggrandizing the person that faces the adversities .

In this sense, when studying psychological stress in 2110 medical teams and 2158 students called to act against COVID-19 in Wuhan, it was noticed that the first group showed a feeling of confidence superior to the second one [Wu et al., 2020] . This analysis validates the hypothesis that the relationship between resilience and mental health is attenuated as the person gets older. In other words, middle-aged professionals are less dependent on this aspect, given that they have more technical experience, longer employment, and had experienced outbreaks and previous epidemics that have conditioned them to a mental state less susceptible to stress and fear. On the other hand, younger people show more anxiety-depression disorders. They, however, also show more willingness to seek help from mental services actively. In this way, young professionals are more likely to be conditioned to increase their resilience through techniques for managing stress and meditation, being, therefore, a priority group in the actions developed to improve the psychic-organic health of the ICU team .

At the same time, another factor related to resilience is social support. In this logic, social support denotes the experience that the individual has of belonging to a group of people who reciprocally help each other. Therefore, the maintenance of the integrity of the ICU team is a reason that helps to raise the levels of individual resilience, as the friendship with more experienced colleagues makes the professional J o u r n a l P r e -p r o o f believe in the possibility of obtaining the necessary help to face what makes them feel stressed, increasing, consequently, the belief that they can face the adversities by themselves. Therefore, the cohesion between colleagues and their respective managers is decisive in the way in which the coronavirus will act in the resilience and the health of these people [Maben and Bridges, 2020; Hou et al., 2020; Cai et al., 2020; Rubio et al., 2020; Yager et al., 2020] .

Based on what was exposed above, health systems take actions daily intending to prevent psychological damage to their members. One of the main actions is to encourage social support, whether by family members of health professionals or by their bosses. The way to shorten social distance and avoid viral load is through online methods, such as video calls [Shen et al., 2020; Walton et al., 2020; Blake et al., 2020; Wu et al., 2020] . At the same time, good leadership should be encouraged, based on an active communication between boss and workers. A fair leader is considered to be the one who shares his knowledge, anxieties and doubts honestly and shows empathy to others, as well as one that motivates the encouragement of its workers to maintain selfcare, and shows humanity and humility in his attitudes [Walton et al., 2020; Blake et al., 2020; Wu et al., 2020; Shah et al., 2020] . Therefore, the effectiveness in trying to maintain the current team is undeniable [Shen et al., 2020; Maben and Bridges, 2020; Zaka et al., 2020; Yager et al., 2020] . In case this is not possible, it is necessary to hire new members, associated with actions that make them familiar with the team and service dynamics [Shah et al., 2020] . Thus, it is clear that an extensive apparatus is not necessary to improve positively the performance of the front-line team. Chinese works report that nurses' felt gratitude from the general public that donated moisturizing hand creams [Maben and Bridges, 2020; El-Hage et al., 2020] .

In addition to these changes, other alternatives are suggested by health workers.

It is asked to hospitals, in a general way, to provide adequate environments so the teams can rest, especially because they are trying to maintain family isolation and do not have other places to rest Walton et al., 2020; Rana et al., 2020; Pappa et al., 2020; Zaka et al., 2020] . Besides this, it is suggested to redefine the equivalence between patients and nurses, seeking proportions such as 1: 1 or 1: 2, respectively, as well as the stimulus for hiring physiotherapists, specialized in intensive care .

Given this, several ICUs readjusted their shift dynamics. Thus, it was adopted a shift rotation model, in which, after 4-6 hours of continuous work, the health care team J o u r n a l P r e -p r o o f must rest [Shen et al., 2020; Kang et al., 2020; Walton et al., 2020; Rana et al., 2020; Pappa et al., 2020; Blake et al., 2020; El-Hage et al., 2020] . At the same time, the reduction in daily working hours to less than 16 hours per day revealed a drop of 18% in the rate of medical errors [Santarone et al., 2020] . Among the suggested mechanisms to reduce stress, it was well accepted practices as drawing, talking, singing, exercising, breathing deeply, and looking out the window [Shen et al., 2020; Chen et al., 2020; Neto et al., 2020; Wu et al., 2020] .

At the same time, to remedy the insecurity of technical and scientific knowledge, refresher courses are executed. In this way, as indicated by workers, hospitals provide courses for equipment management, biosafety Pappa et al., 2020; Shah et al., 2020] , and training for physiotherapists about the best parameters in the approach to mechanical ventilation in hospitalized patients [Pinto and Carvalho, 2020] .

As for the group of physicians residing in anesthesiology, it focuses on offering simulations directed to the techniques of orotracheal intubation and other duties specific to the specialty [Dost et al., 2020] . If it is not enough, many hospitals also develop education courses in palliative care, helping teams to have a more humanized and appropriate management of the emotional state of patients [Santarone et al., 2020; Zaka et al., 2020; Romanò, 2020] .

Despite this, it is necessary to have specialized support for the mental care of the ICU team. In this context, a psychologist, a psychiatrist, and professionals' family members constitute the mental health team. Some measures are recommended to achieve therapeutic success, such as starting the therapy process in comfortable spaces that reminiscent of good feelings -to obtain confidence in the tasks to be performed -, and encouraging teams to perform functions in pairs, with the exchange of emotional experiences or doubts about the job with those who they have a friendly relationship Kang et al., 2020; Walton et al., 2020; Rana et al., 2020; Santarone et al., 2020] . It is also essential that each team has its psychologist, either for individualized approaches or for group actions [Shen et al., 2020] .

However, management through virtual platforms is more indicated for health care teams that won by the trust of their therapists or in situations focused on discussing common team challenges [Kang et al., 2020; Greenberg et al, 2020; Neto et al., 2020; Zaka et al., 2020] . It is relevant to emphasize that not all members of health care teams immediately accept psychological help due to the prejudices and fears brought with them. Thus, there may be obstacles in the implementation of this approach. They need J o u r n a l P r e -p r o o f to be analyzed and changed according to the people's particularities .

In addition, it is necessary to demystify and offer to everyone, through telemedicine, consultations with psychiatrists, and the use of psychotropics, if it is necessary [Neto et al., 2020] .

In order to preserve mental integrity, several psychological approaches are reported in the literature. The coping model based on anticipating, planning, and dissuading [El-Hage et al., 2020] serves the same purpose as the health belief model applied to ICU teams in Pakistan. This psychotherapeutic instrument offers to the individual the possibility of identifying situations of susceptibility, assessing its severity, perceiving which factors are threatening, looking for what barriers exist and the benefits arising from overcoming them, and, finally, stratifying the ways in which the individual will use them. Therefore, the primary focus of psychological therapies means acting as a way of primary prevention from the impacts generated by COVID-19 on mental health, promoting in health care teams the maintenance of resilience [Mukhtar, 2020] .

Despite this, the impact generated by the coronavirus on medical ethics is substantial. In an attempt to improve the moral damage to the ICU doctors, several hospitals create guidelines to conduct decisions. It is also relevant that the leaders of the institutions reinforce that the medical decision is not an individual attitude, but the result of the ideals of a team [Rubio et al., 2020; Walton et al., 2020; Blake et al., 2020; Shah et al., 2020] . Because of this, one of the documents used as a reference is the one from the Italian Society for Anesthesia Analgesia and Intensive Care (SIAARTI). This document, published in an update on March 03, 2020, draws up guidelines for the hospitalization of patients in ICU. It also talks about the discontinuation of therapies in the face of the imbalance between their availability and their insufficiency [Romanò, 2020] . Through these paths, it is possible to relieve doctors of their responsibilities, which today has a high emotional cost, and create explicit tactics for allocating instruments at a time of unavailability [Piccinni et al., 2020] .

Finally, it is relevant that these actions must not be more harmful to the health of the ICU team. Given this, all the measures that the services carry out need to be adapted to the reality and the immediate need of the professionals. In this sense, taking into account psychological stress, the performance of psychological interrogations reveals a poor prognosis when compared to the benefits brought by the institution of deadening and mental reprocessing practices [Maben and Bridges, 2020; Greenberg et al, 2020] .

Thus, it was seen in the literature that the health care team stated that they dislike selfquestioners because they prefer the passive reception of information made available for longer periods for personal use when required, rather than being tested [Blake et al., 2020] . Therefore, it is imperative to monitor the ICU team. In this circumstance, nowadays, it is necessary to identify the most affected or susceptible individuals to work on primary methods of prevention of mental damage [Greenberg et al, 2020; Shah et al., 2020; El-Hage et al., 2020] . At the same time, this monitoring should be extended to post-pandemic periods, to hierarchically screen professionals, giving priority to the front-line team. Thus, after this moment, it is possible to use questionnaires aimed at identifying characteristic manifestations of anxiety, depression, exhaustion, impact, and mental suffering. The psychic vulnerability resulting from calamities, such as the current one, is a provider for pathological grief and PTSD. Therefore, it must be done an extra investment to carry out psychological follow-up from 6 to 12 months postpandemic properly [Maben and Bridges, 2020; El-Hage et al., 2020] .

Among the limitations found doing this work, the small number of published studies with the application of standardized questionnaires for the assessment of the psychological consequences in the evaluated subjects stands out. Consequently, the results found were heterogeneous. Besides, some studies have their methodology based on the acquisition of self-reports and this can be a bias factor. So, their results should be analyzed with caution. In this sense, future research must be done to demonstrate the ways that the actions of protection of the medical team are having effects, such as a more detailed assessment of the physical, mental and social repercussions that the pandemic will promote in the lives of these individuals.

During the COVID-19 pandemic period, the structure of the ICU activities changed rapidly. The disproportion between the need for technological supplies in intensive care and their scarcity, promotes, among many factors, higher levels of psychological stress. Anxiety, irritability, insomnia, fear, and anguish were observed J o u r n a l P r e -p r o o f during the pandemic, probably related to extremely high workloads and the lack of personal protective equipment. In this sense, promoting actions to mitigate such psychic-organic impacts is essential. It is necessary to reflect on the quality of planning for the preparation of health professionals in the ICU for the most diverse clinical and psychological barriers linked to the pandemic. 

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The authors would like to thank the School of Medicine of ABC -FMABC and Brazilian National Council for Scientific and Technological Development (CNPq) -institution linked to the Brazilian Department of Science, Technology.