Introduction

COVID-19 is an infectious disease caused by the SARS-CoV-2, with a predominance of respiratory symptoms. The World Health Organization (WHO) declared it a pandemic in March 2020. Until December 2022, more than 651 million cases and 6 million deaths were recorded worldwide ¹.

It was a fact the general population presented negative reactions to the pandemic, which represented a complex and multifaceted issue ². People have different ways of dealing with stressful situations depending on their training, life story, individual characteristics, and the community where they live. During the pandemic, in addition to the fear of contracting the disease, there was a constant impression of insecurity towards the daily activities of living in society, with changes in interpersonal relationships ³.

In addition, some groups responded more intensely to the COVID-19 pandemic stress, namely: younger individuals, females or those with chronic diseases; patients affected by COVID-19; health professionals who worked in assistance to COVID-19, and individuals with mental disorders, including problems related to substance use, such as alcohol and other drugs ^2,4. A Brazilian study indicates an increase in psychological factors such as sadness or depression (40.4 %), anxiety or nervousness (52.6 %) and sleep problems (43.5 %), amid this social niche ⁵.

Several studies show that health workers working on the front line of care for people infected with the COVID-19 virus are at an increased risk of developing psychological disorders, especially Nursing professionals ^2,6,7. Intensive Care Units (ICUs [8]) stand out among the hospital environments for health care during these pandemic times.

In this environment, Nursing care during the critical pandemic period was based on excessive working hours, inadequate staffing, a high number of admitted patients, and lack of professional training; in addition to the need to deal with the grief, pain, and suffering of others ^9,10. Nursing professionals are among the most devalued groups in the health area, even when representing the pillar of health services around the world. Within an ICU, Nursing professionals are the main caregivers and those with the longest contact times with the patients ¹¹.

Thus, the mental illness process in Nursing professionals responsible for the immediate and continuous care of critically-ill patients affected by COVID-19 and with higher rates of infection and death due to the disease stands out ^12-14. Various studies evidence the need to prioritize protection measures for the sake of preserving the optimization of their capacities ^6,7. The mental health care of an ICU Nursing team cannot be interrupted or minimized in the post-pandemic period, as certain individuals may be slow to externalize the psychological distress signs and symptoms ¹⁵.

Given the above, a gap is verified in the knowledge about ICU Nursing professionals’ mental health in the care provided to patients affected by COVID-19. To establish targeted and effective health promotion and prevention actions, this study aims at identifying, in the scientific literature, the mental health conditions of ICU Nursing professionals during the COVID-19 pandemic.

Materials and Methods

This is an integrative literature review. This approach provides a synthesis of knowledge and grouping of relevant research results in the practice, generating a solid and accessible overview of complex concepts, theories or related health problems ¹⁶. To develop the guiding question, the “Population-Concept-Context” (PCC) strategy was applied, where “P” is the ICU Nursing team, “C” is Mental health and “C” is the COVID-19 pandemic. Likewise, the following question was formulated: What is the ICU Nursing team’s mental health like during the COVID-19 pandemic?

Data collection took place from January to April 2022, in the following data sources: Cumulative Index to Nursing and Allied Health Literature (CINAHL); Scopus Content Overview (Scopus), PubMed, Embase and Web of Science. The following descriptors available in the Medical Subject Headings (MeSH) were listed: “Intensive Care Units,” “COVID-19,” “Mental Health,” and “Nurse”. AND and OR Boolean operators were used. The following crossing was obtained: ((“Intensive Care Units”) AND (“nurse” OR “nurses” OR “nursing”) AND (“mental health” OR “mental illness” or “mental disorder” OR “psychiatric illness”) AND (“covid-19”)).

The studies included were those conducted since 2020 (the year when the COVID-19 pandemic was declared), available in full in Spanish, English and Portuguese, which answered the research question. The articles excluded were those duplicated across the databases, as well as editorials, letters to the author, theoretical essays, literature reviews, dissertations, theses, and protocols.

Search and selection of the articles were the responsibility of two duly trained researchers, who worked independently through peer discussion. The State of the Art Through Systematic Review software was used as a support, which allows methodically organizing the development of literature reviews. Another researcher was consulted in case of disagreement. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations were adapted for this review ¹⁷.

The data were extracted through a data collection instrument prepared by the researcher in charge, including the following variables: title, authors, year of publication, country, journal, impact factor, language, type of study, level of evidence, and the evidenced mental health conditions. The data were organized in a Microsoft Excel 2010 spreadsheet.

Regarding the analysis of the levels of evidence corresponding to the studies included in this research, the recommendations proposed by Oxford’s Centre for Evidence-Based Medicine ¹⁸ were followed. For the diagnostic, treatment, and intervention studies, the following classification was observed: Level I - Randomized clinical trials; Level II - Prospective cohort studies; Level III - Retrospective cohort studies and case-control studies; Level IV - Case series; and Level V - Opinions or consensus. Studies related to etiology and prognosis followed this classification: Level I - Synthesis of cohort or case-control studies; Level II - Prospective cohort studies; Level III - Retrospective cohort studies; Level IV - Case series; and Level V - Opinions or consensus. In addition, the results were presented descriptively and visually, with the elaboration of figures and tables The main findings were interpreted and discussed against the pertinent literature. For being an integrative literature review, this research waived submission to any Research Ethics Committee.

Results

A total of 45 manuscripts were identified. While selecting the materials, duplicate studies (n = 65) and those that did not meet the inclusion criteria (n = 289) were excluded. In the eligibility stage, 29 studies were read in full. After the thoughtful full-reading analysis, 16 articles were included in the current sample. Figure 1 presents the flowchart corresponding to the process to select the studies and comprise the sample.

Source: Prepared by the authors

Figure 1 Flowchart corresponding to the process to select the articles included in the research, according to the PRISMA 2020 adapted recommendations. Brazil, 2022 

The final study sample evidenced more publications in 2021 (80.5 %), from countries in Europe (43.75 %) and Asia (37.5 %), with methodological designs corresponding to retrospective (62.5 %) and prospective (25 %) cohort studies, written in English (93.75 %). Table 1 shows the characterization of the articles included in the study according to publication journal, impact factor, method, level of evidence, and country of origin. The main findings from each selected study can be seen in Table 2, along with their authors and years of publication.

Thus, it was possible to create a summary chart of the mental dysfunctions in the ICU Nursing teams during the COVID-19 pandemic. Anxiety, depression, stress, and fear stand out as the most prevalent conditions in the Nursing team. Table 3 shows the disorders and the studies in which they were found.

Additionally, this study evidenced causal factors associated with the presence of these disorders in the mental health of these professionals. Uncertainty regarding patient care due to the lack of evidence-based treatment, absence of human and physical resources, work overload, and insufficient work experience was included. In the ICU, there is the aggravation inherent to the structural physical scope, as it is an isolated environment permeated by poor health prognoses, with frequent deaths. Finally, the number of colleagues infected and the fear of infecting themselves and their family members due to the virus’ high transmissibility rate are also mentioned.

Discussion

The ICU Nursing work in the treatment of COVID-19 patients during the pandemic led to damages to these individuals’ mental health. These professionals presented high anxiety, depression, stress and fear levels. The pandemic exerted an immense effect on health professionals’ general and mental health, many of whom faced this challenge in dire conditions and without institutional support, with impacts not only at a professional level but also on their morale and overall determination ^35-37.

The anxiety of health professionals who worked on the front line against the pandemic was shown in this study as the most prevalent impairment, a fact that corroborates with studies showing the significant increase of this condition when compared to previous periods ³⁷. Nurses are the most affected due to factors such as being mainly female, pre-existing diseases, physical symptoms of COVID-19, prolonged exposure to patients with COVID-19, and the fact that they work in an ICU ³⁸.

The prevalence of depression in the studies analyzed denotes an extremely relevant factor. This phenomenon is associated with Nursing professionals’ mental overload caused by concern about increased COVID-19 infection rates among professionals and excessive work in inappropriate conditions. Thus, the professionals who experienced the pandemic were more prone to developing psychological disorders, such as depression ^36,39.

The feeling of fear was found in most of the studies selected for this research; the motivations were associated with the fear of becoming infected or infecting family members and, consequently, leading them to death. A previous research study pointed to fear as one of the main feelings stated by the Nursing team, involving the fear of contaminating themselves or others and losing family members ⁴⁰.

In addition, a significant increase in work-related fatigue and the presence of insomnia in ICU professionals were evidenced. A study observed that most of the professionals presented loss of sleep quality and constant tiredness, mainly due to the high work demand to which they were subjected. In addition, symptoms such as headache, nervousness and sadness were found, confirming the physical and psychological effects of the pandemic period ⁴¹.

Thus, health professionals that work directly with patients with COVID-19 in high-risk environments presented more psychological symptoms when compared to those from other sectors. Direct assistance to people infected with the virus led to increased concerns about infecting family members and to higher anxiety, stress, insomnia and depression levels due to increased fear. In addition, nurses have the highest workload and the longest contact time in care provision, which act as determining factors in the deterioration of their mental health ⁴².

In this regard, the increase in the number of professionals infected and away from work caused overload to the teams, contributing to psychological exhaustion and feelings of loneliness and increased stress in this population ^{(43, 44)}. A study developed with an ICU Nursing team showed that the prevalence of Burnout syndrome was 25.5 % throughout the COVID-19 pandemic, a consequence of the high-stress levels in this population segment, among other reasons. Within the main causal factors, there is emotional exhaustion and depersonalization, arising from overtime and rigid workloads ^37,43. These data corroborate those found in the current study.

Thus, it is indispensable to consider the relevance of ICU Nursing work, especially in emergencies, such as the COVID-19 pandemic situation. In addition to that, it is necessary to provide adequate working conditions and psychosocial support to preserve these professionals’ mental health to guarantee the quality of the care provided ⁴². Countless studies reveal the need to offer psychological monitoring to the professionals who worked directly in coping with the pandemic, both in the short- and long-term, due to the intrinsic and unique characteristics of a global public health emergency ^45-47.

Studies on the harms caused to ICU Nursing professionals’ mental health during the pandemic period contribute to implementing actions targeted at five-year prevention, which aims at providing biopsychosocial care to the professionals, given the importance of preserving their health to ensure patient safety ^48,49. The pandemic period evidenced the relevance of this fifth aspect as indispensable to maintaining quality in terms of care and the work environment, reflecting on the strengthening of the health system ⁵⁰.

Thus, investments in the area of caregivers’ health are necessary to ensure safe health care. Nursing professionals are important actors in the provision of humanized care, focused on welcoming, directed listening and comforting patients. However, when these professionals are emotionally shaken, the nature of care is weakened. Thus, it is encouraged to carry out new research studies with greater methodological depth, to point out the mental health indicators of this population group and the measures adopted for its mitigation during the viral infection by the new coronavirus.

The type of study and the number of databases listed stand out as a limitation, which precludes comparing the articles analyzed and monitoring the daily evolution of the findings. For being an emerging topic, new scientific findings are published every day.

Conclusions

The results allowed identifying the conditions that affected the mental health of ICU Nursing teams during the COVID-19 pandemic, focusing on depression, anxiety, stress, and fear. Such conditions were mainly caused by the lack of evidence-based health-disease treatment, the deficit in human and physical resources, the care environment that was isolated from the other sectors, and the constant increase in the number of viral infections among professionals and their family members.

Thus, it is emphasized that preventing mental illness in Nursing teams should be considered an indispensable element for care quality and safety. It is necessary to implement policies, strategies, and methods to improve the psychological conditions of these professionals and thus ensure better quality in the services provided.