As of April 2020, more than 2 million people worldwide had tested positive for COVID‐19,
and more than 200,000 deaths are attributed to this virus. It is estimated that around
15% of patients diagnosed with COVID‐19 will develop severe health complications,
and around 5%–10% will require intensive level care due to the seriousness of the
symptoms and the high mortality risk (3%–5%) (Baud et al., 2020; Murthy, Gomersall,
& Fowler, 2020). At the time of writing, COVID‐19 has caused the need for hospitalisation
of thousands of people due to the serious pneumonia type symptoms that result in extreme
breathing difficulty. Critical care units in hospitals around the world are treating
people experiencing potentially life‐threatening COVID‐19 symptoms. In some of these
settings, the pressure on staff is compounded by a lack of adequate personal protection
equipment (PPE) and staff shortages, as well as shortages of beds and mechanical ventilators.
Despite the challenges, nurses who work in critical and intensive care units deliver
the care required and we have witnessed their courage in recent media reports, with
nursing and medical personnel describing the difficulties they face on a daily basis
in providing care to these very ill and infectious patients. The current situation
has generated a range of stressors that could negatively impact nurses and other health
workers (Jackson et al., 2020; Usher, Durkin, & Bhullar, 2020). Critical care nurses
may be particularly affected by severe emotional distress which has been associated
with the development of compassion fatigue (CF) and/or burnout (Alharbi, Jackson,
& Usher, 2020). Indeed, Li et al. (2020), caution against ignoring vicarious traumatisation
caused by the COVID‐19 pandemic.
There is a known emotional impact for nurses’ witnessing prolonged suffering of patients
in environments such as intensive and emergency care units (Alharbi, Jackson, & Usher, 2019).
This impact is particularly related to their perceived inability to alleviate the
suffering of those in their care. Research evidence shows that health professionals
can experience various psychological problems when working in high‐pressure and high‐risk
scenarios, such as in times of disaster and pandemic. Kang et al. (2015) found an
increased risk for the onset of post‐traumatic stress disorder symptoms among rescuers
following the 2010 Yushu earthquake in China. The contextual factors surrounding COVID‐19;
such as the ease of transmission, lack of immunity among global populations, delayed
testing, limited medical equipment, uncertainty of the pandemic trajectory and the
general level of anxiety within the community all combine to place increasing pressure
on health and welfare systems (Centers for Disease Control & Prevention, 2020).
CF and its related symptoms are a particular issue for critical care nurses in disaster
contexts because the expectation to confront and cope with the need for care can exceed
the ability to provide it, potentially (indirectly) leading to emotional distress
in staff (Mathieu, 2014). In addition to witnessing/experiencing patient suffering
and death more frequently; having the responsibility for decisions related to resource
rationing and utilisation means critical care nurses are at heightened risk of developing
CF and moral injury during pandemics (Doherty & Hauser, 2019). Moreover, nurses working
under COVID‐19 conditions (like so many other healthcare workers) are vulnerable to
exposure to risk of infection, and have the added concern of potentially contracting
the virus themselves or unknowingly exposing family members and friends to heightened
risk. The concern about being infectious can lead to a reluctance to seek out assistance
from family or friends and may reduce the capacity to be compassionate in the workplace
(Wallace, Wladkowski, Gibson, & White, 2020). Craigie et al. (2016) refer to the “cost
of caring” or the occupational hazard of working in critical care settings. The literature
has clearly established that burnout and CF are high among all health professionals
but especially so for those who work in environments where they are confronted daily
with large numbers of people for whom the outcome is dire; such as the case for those
diagnosed with COVID‐19 and requiring admission to emergency or intensive care units
(Wallace et al., 2020).
Burnout is not just a term for being overworked; rather, it is a measurable condition
that takes a heavy personal toll on health care providers, leads to lower quality
care and increased errors (Alharbi et al., 2020). Similar to burnout, CF carries a
heavy personal toll, including isolation from others, excessive drinking and over‐eating,
drug use and other detrimental coping measures. CF also increases absenteeism and
turnover, and lowers morale (Alharbi et al., 2020). Importantly, it is known to be
linked to situations where nurses believe their actions will not make a difference
(Portnoy, 2011). This is unfortunately potentially the case for many patients with
COVID‐19 as once they are admitted to critical care units, events have shown us that
many will not survive.
Evidence to gain empirical insights into the impact of COVID‐19 on nurses is only
just beginning to emerge, with some unexpected findings. Wu et al. (2020) recently
conducted a study of 220 health professionals (physicians and nurses) to compare the
frequency of burnout between those professionals working on the COVID‐19 front line
in Wuhan province (n = 110) and those working in their usual hospital wards in hospitals
(n = 110). Notably, the authors reported that burnout frequency was in fact lower
among health professionals working on the COVID‐19 front line compared to those working
their usual wards (13% versus 39%, respectively (Wu et al., 2020).
Although these results were somewhat unexpected, the conclusion drawn by the researchers
provides an interesting insight into the nature of burnout and CF. They theorise the
lower‐level of burnout among the front‐line workers may be the result of these health
professionals having to place all of their focus on achieving positive outcomes for
patients (Wu et al., 2020). This explanation, however, arguably implies that the nurses’
focus is not on their own emotional well‐being. Moreover, as discussed previously
a leading risk factor for the development of CF among intensive care nurses is their
tendency to put the care needs of the patient above their own needs. According to
Wu et al. (2020), the focus of front‐line carers on what they are trying to achieve
rather than the personal impact of what they are trying to achieve may explain the
more favourable outcomes for this group.
For the nurses working in critical care environments, such as intensive care units,
there is no escaping the daily parade of seriously ill patients with predicted poor
outcomes in times such as those we are currently witnessing. We have seen and read
of nurses describing situations where all patients have died on a unit during the
course of an evening. It is hard to imagine the effect this has on the nurses working
that shift. For many of the nurses in this situation, there may be little support.
Hendin et al. (2020) have developed a framework for the provision of end of life care
by nurses to patients faced with immediate death from COVID‐19 or similarly highly
transmissible acute respiratory infections. At the centre of the framework is naturally
a focus on minimising risks of transmission to nurse professionals. However, the authors
also recommend the framework be underpinned by the “imperative for workplace colleagues
to support each other and to perform frequent debriefs” (p. 3). This, they conclude,
is vital to reduce the risk of front‐line nurses developing psychological problems
including CF, burnout and vicarious trauma (Hendin et al., 2020). Furthermore, as
Horesh and Brown (2020) argue, the most concerning aspect of the health care sector
(as opposed to healthcare worker) response to COVID‐19 for critical care nurses is
the lack of a clear set of guidelines on how best to manage self‐care and well‐being.
Current recommendations to front‐line healthcare workers are to ensure work‐life balance,
practice deep breathing, facilitate mindfulness and support other when possible are
modes of therapy or coping that independently or in combination can provide a positive
effect (Van Zyl & Noonan, 2018). However, these fall short of a formal and set of
guidelines (supported with resources) that critical care nurses can refer to specifically
to direct their self‐care efforts to manage their well‐being (Horesh & Brown, 2020).
At the very least, improved self‐care, both in and out of the hospital environment,
is necessary to help critical care nurses to reduce the risk of developing CF.
In conclusion, large‐scale public health events such as the COVID‐19 pandemic require
a dedicated and highly demanding response from critical care nurses. To support these
nurses, the broader response to COVID‐19 must include multiple stakeholders including,
but not limited to, senior nursing staff, government policymakers, technology designers,
hospital administrations, as well as members of the broader community. The decision
and actions of stakeholders can play a central role in assisting nurses to manage
the competing care demands caused by increased acuity, increased patient numbers,
clinical uncertainty and limited access to necessary equipment. Hence, in addition
to critical care nurses doing all they can to protect their own and their colleagues’
well‐being, they need to work with other stakeholders to mobilise beneficial partnership
and collaborate on developing creative solutions. Only through a collaborative effort
can any risks associated with CF and burnout in the critical care nurse workforce
be identified and mitigated.