Caring for COVID‐19 infected patients admitted to redesignated coronavirus ICUs: Impact on nurse stress and burnout

Abstract

Objectives

The coronavirus disease 2019 (COVID‐19) pandemic globally impacted healthcare due to surges in infected patients and respiratory failure. The pandemic escalated nursing burnout syndrome (NBS) across the workforce, especially in critical care environments, potentially leading to long‐term negative impact on nurse retention and patient care. To compare self‐reported burnout scores of frontline nurses caring for COVID‐19 infected patients with burnout scores captured before the pandemic and in non‐COVID‐19 units from two prior studies.

Methods

The descriptive study was conducted using frontline nurses working in eight critical care units based on exposure to COVID‐19 infected patients. Nurses were surveyed in 2019 and in 2020 using Maslach Burnout Inventory (MBI), Well Being Instrument, and Stress‐Arousal Adjective Checklist (SACL) instruments. Researchers explored relationships between survey scores and working in COVID‐19 units.

Results

Nurses working in COVID‐19 units experienced more emotional exhaustion (EE) and depersonalization (DP) than nurses working in non‐COVID units (p= .0001). Pre‐COVID nurse burnout scores across six critical care units (EE mean = 15.41; p= .59) were lower than burnout scores in the COVID‐19 intensive care units (EE mean = 10.29; p= .74). Clinical significance (p= .08) was noted by an EE subscale increase from low prepandemic to moderate during the pandemic.

Conclusion

Pinpointing associations between COVID‐19 infection and nurse burnout may lead to innovative strategies to mitigate burnout in those caring for the most critically ill individuals during future pandemics. Further research is required to establish causal relationships between sociodemographic and work‐related psychological predictors of NBS.

Key points

• The study compares the scores for acute stress and occupational burnout between 2019 and 2020 measurements to highlight the impact of the COVID‐19 pandemic on nurse mental health.

• Additionally, this study compares burnout scores of nurses working in COVID‐19 designated intensive care units to those working in non‐COVID‐19 units to measure differences in intensity of burnout experienced by nurses based on infected patient exposure.

• This study highlights the need for systemic changes and health policies to protect the mental health and well‐being of the nursing workforce.

1. INTRODUCTION

Critically ill patients represent some of the most vulnerable and fragile patients within acute care health delivery settings; thus, they deserve nurses caring for them who are present, knowledgeable, and mentally well. The coronavirus disease 2019 (COVID‐19) pandemic impacted intensive care unit (ICU) nurses due to surges in infected patients with respiratory failure filling newly designated COVID‐19 unit beds. Care delivery environments shifted hastily within ICUs. At the same time, uncertainty intensified due to resource challenges and heightened emotions leading to safety concerns. ¹ , ² , ³ , ⁴ , ⁵ , ⁶ , ⁷ , ⁸ Psychological challenges faced by ICU nurses led to emotional exhaustion (EE), decreased personal accomplishment (PA), and depersonalization (DP) due to increased exposure to dying patients and futile care situations. Strains from the pandemic led to fewer support structures being in place for nurses dealing with the fear of infection, increased workloads, and personal protective equipment shortages. ¹ , ² , ⁹ , ¹⁰ , ¹¹ , ¹² , ¹³

Identifying factors impacting the mental health of critical care nurses inform establishments of unit‐level structures and implementation of processes to mitigate, or at least minimize, nursing burnout syndrome (NBS) and other emotional distress states. Promoting the mental well‐being of ICU nurses may assist in relieving emotional distress and contributes to an empathically focused environment, thus facilitating high‐quality patient care. Nurses working in ICUs dedicated to caring for COVID‐19 infected individuals faced occupational factors potentially making them even more susceptible to mental health problems during the pandemic. COVID‐19 pandemic‐related NBS developed due to increased burdens associated with futile care delivery, sharp admissions increase, and record‐high mortality rates within overstretched healthcare system ICUs. ¹ , ² , ⁴ , ⁵ , ⁶ , ¹⁴ Identifying sociodemographic, work‐related, and psychological predictors of NBS may help organizations better understand the negative psychological impact on ICU nurses working during future pandemics.

1.1. Background

Critical care clinicians experienced high rates of burnout before the pandemic, with nearly 86% of ICU nurses experiencing at least one classic symptom associated with NBS ⁵ and up to one‐third manifested severe NBS. ⁵ , ¹⁵ ICU NBS has been reported to be associated with many factors intensified by the COVID‐19 pandemic including the provision of end‐of‐life care, witnessing dying patients, and removing life‐sustaining treatments. ¹⁵ Furthermore, occupational burnout in ICU clinicians has been magnified by increased workloads and emotional burdens associated with caring for COVID‐19 infected patients. In a longitudinal cohort study, ICU healthcare professionals demonstrated a change in self‐reported burnout symptoms from 23% before the COVID‐19 pandemic (October–December 2019) to 36.1% (May–June 2020) during the peak of the pandemic. ³ Burnout is not only damaging to clinicians, but studies also suggest burnout negatively impacts the delivery of care, patient outcomes, and nurse satisfaction. ⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ Consequently, it is imperative to understand and prevent occupational burnout in critical care settings to protect both critically ill patients and those entrusted with providing their care.

As Maslach et al. ¹⁶ reported, occupational burnout is a psychological syndrome characterized by three key components: EE, DP, and a reduced sense of PA. Maslach et al. ¹⁶ developed a tool to measure cumulative burnout in employees resulting from prolonged workplace stress using subscales specifically measuring EE, DP, and PA, which were established as three components associated with occupational burnout. EE was identified as being strongly associated with burnout across multiple studies. ² , ⁴ , ⁵ , ¹² , ²⁰ Emotional exhaustion (EE), personal accomplishment (PA), and depersonalization (DP) represent highly correlated components associated with ICU nurses who have NBS. ⁵

1.2. Significance

A plethora of research has been published on the impact the COVID‐19 pandemic has had on healthcare workers, including nurses working in critical care, as researchers attempt to better understand the relationship between COVID‐19 infected patient exposure and the associated phenomenon of nurse burnout. Of the 60 countries included in 1 study, occupational burnout during the pandemic was reported to be highest (62.8%) in healthcare providers working in the United States. ⁴ In 2016, the Critical Care Collaborative Societies published a call to action concerning ICU clinician burnout, urging clinicians, administrators, and healthcare systems to acknowledge, address, and work to prevent burnout. ⁵ Unprecedented psychosocial, emotional, and physical demands associated with caring for COVID‐19 patients led to compromised mental health in the reviewed literature. ¹ , ² , ³ , ⁴ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ , ¹¹ , ¹³ , ¹⁴ , ¹⁷ Pandemic‐related stressors faced by ICU nurses and NBS must be further explored to answer the Critical Care Collaborative Societies' call to action. Through literature review, no study was identified that explicitly looked at the impact of caring solely for COVID‐19 patients in ICUs on NBS. This study aimed to determine what impact taking care of COVID‐19 infected patients had on NBS in ICU nurses.

2. METHODS

2.1. Intervention description

Researchers' primary outcome of interest was nurse burnout. For the purpose of this study, exposure to the care of COVID‐19 infected patients was viewed as the intervention. Based on evidence found through systematically evaluating peer‐reviewed literature reporting on the impact of the COVID‐19 pandemic on burnout syndrome in healthcare workers, researchers hypothesized: (1) NBS amongst nurses working in neonatal (NICU) and pediatric (PICU) ICUs will be less than NBS for nurses working in cardiac (CICU) and medical (MICU) ICUs converted to designated COVID‐19 ICUs; (2) NBS measured in nurses working in six critical care units in 2019 will be less than NBS measured in 2020 in the CICU and MICU after conversion to COVID‐19 ICUs. Because nurse burnout and stress scores had been captured in another institutional study before the pandemic in the two adult ICUs later dedicated to the care of only COVID‐19 infected patients, ²¹ an opportunity presented itself to conduct a comparative analysis. Institutional review board approval was received for both studies in 2019 and 2020, respectively.

2.2. Design

Case‐controlled (non‐COVID‐19 compared to COVID‐19) and cross‐sectional (pre‐COVID‐19 to post‐COVID‐19) quantitative comparative survey designs were used for this study. Researchers compared burnout levels in ICU nurses providing direct care to COVID‐19 infected patients within dedicated COVID‐19 units to nurses caring for non‐COVID‐19 infected ICU patients.

2.3. Setting

Nurses in the two adult ICUs were surveyed in February–March 2019 as part of a prior study published elsewhere ²¹ and after designation as COVID‐19 units in November 2020. Nurses working in the two children's ICUs served as the comparison group due to minimal exposure to COVID‐19 patients at the time the 2020 study was conducted.

2.4. Sample

Researchers collected survey data from registered nurses working 36 h a week and considered full‐time. A convenience sample of nurses were recruited for participation. Registered nurses were included in the 2019 study who worked full‐time on the day shift, worked no overtime, and were female. ²¹ In 2020, both female and male registered nurses were recruited who worked both day and night shifts in four ICUs (comparison [NICU and PICU] and intervention [CICU and MICU]) regardless of if nurses worked extra shifts. Researchers recruited registered nurses to participate based on their unit of employment and positions delivering direct patient care. Participants were excluded if they were not full‐time, under an agency contract, or worked in the nurse resource pool.

Researchers compared data collected from registered nurses working three 12‐h shifts in six critical care units in 2019 before the COVID‐19 pandemic (N= 51) and in November 2020 during the COVID‐19 pandemic after conversion to units for the care of COVID‐19 patients (N = 52). Next, investigators examined data collected from nurses (N= 90) during the COVID‐19 pandemic by comparing data between nurses (n= 52) working in two COVID‐19 ICUs (CICU and MICU) and the two ICUs (NICU and PICU) not yet routinely caring for COVID‐19 infected patients (n = 38) in two hospitals (pediatric and adult) within the same healthcare system.

The pandemic's impact on the control units' (NICU and PICU) operations and nurses was minimal compared to the overwhelming impact the pandemic was having on nurses working in the general hospital's interventional adult ICUs (CICU and MICU) only admitting critically ill COVID‐19 infected patients. The children's hospital, at the time of sampling, only had two children admitted with COVID‐19 infection with noncritical illness. Infected children were cared for by PICU nurses in a vacated nursing unit to evade introduction of the virus into the PICU itself. Three neonates had been admitted to the NICU after being separated from COVID‐19 positive, asymptomatic mothers immediately after birth.

The sample of nurses was primarily female. Race representation of the sample mainly included White participants. The total years of nursing experience were less than 10 years in greater than half of the sample. Total years of practicing nursing ranged from 2 to greater than 30 years. Most nurses had baccalaureate degrees in nursing science (BSN) or were graduates from a local nursing diploma program. Notably, 70% of nurses who worked in COVID‐19 ICUs reported having worked extra shifts compared to 29% of nurses working in non‐COVID‐19 ICUs (see Table 1).

Table 1.

Demographics and workload variables for study participants across all three comparison groups

Data collection date	February–March 2019		November 2020		November 2020
Sample group	Critical care units		COVID‐19 ICUs		Non‐COVID‐19 ICUs
Demographics	N = 51	Mean (%)	N = 52	Mean (%)	N = 38	Mean (%)
Age
21–30	n = 22	43%	n = 24	46%	n = 18	47%
31–40	n = 14	27%	n = 14	27%	n = 9	24%
41–50	n = 6	12%	n = 6	12%	n = 3	8%
51–60	n = 8	16%	n = 8	15%	n = 6	16%
61–70	n = 1	2%	n = 0	0%	n = 2	5%
Gender
Female	n = 51	100%	n = 43	83%	n = 36	95%
Male	n = 0	0%	n = 9	17%	n = 2	5%
Race
Asian			n = 1	2%	n = 4	11%
Black/African			n = 5	10%	n = 1	3%
Hispanic			n = 9	17%	n = 6	16%
White			n = 31	60%	n = 24	63%
Other			n = 6	12%	n = 3	8%
Education level
ADN	n = 22	43%	n = 6	12%	n = 4	11%
BSN	n = 22	43%	n = 28	54%	n = 23	61%
Diploma	n = 3	6%	n = 16	31%	n = 9	24%
MSN	n = 4	8%	n = 2	4%	n = 2	5%
Years of nursing experience
<2	n = 0	0%	n = 14	27%	n = 5	13%
2−5	n = 2	13%	n = 17	33%	n = 11	29%
6−10	n = 5	31%	n = 6	12%	n = 9	24%
11−15	n = 1	6%	n = 3	6%	n = 4	11%
16−20	n = 1	6%	n = 4	8%	n = 0	0%
21−25	n = 7	44%	n = 5	10%	n = 1	3%
26−30	n = 0	0%	n = 1	2%	n = 1	3%
>30	n = 0	0%	n = 2	4%	n = 7	18%
Shift worked
Day	n = 51	100%	n = 28	54%	n = 23	61%
Night	n = 0	0%	n = 24	46%	n = 15	39%
Extra shifts worked bi‐weekly
0			n = 16	31%	n = 27	71%
1			n = 10	19%	n = 2	5%
2			n = 12	23%	n = 5	13%
3			n = 7	13%	n = 1	3%
4			n = 3	6%	n = 0	0%
N/A			n = 4	8%	n = 2	5%

2.5. Data collection

Data were collected using printed surveys comprised of instruments selected to measure study outcomes and capture personal data (see Table 2). During the first period, data measuring burnout subscales, organizational stress factors, acute stress, demographics, and perception of outside nature views were collected from nurses working in six critical care units. During the second phase, the survey was administered to a sample of nurses working in four units (CICU, MICU, NICU, and PICU) located in both the health system's children's hospital and adult acute care facility.

Table 2.

Study variables and measurement instruments

Outcome variables and subscales	Measurement instrument
Burnout	Maslach Burnout Inventory‐
Emotional exhaustion	Human Services Survey for Medical Personnel
Depersonalization	(MBI‐HSS‐MP)
Personal accomplishment
Stress	Stress‐arousal adjective checklist
Experience of stress
Arousal

Control variables and subscales	Measurement instrument
Workload	Nurse perception questionnaire
Clinical units	Nurse perception questionnaire
Pre‐COVID (CICU, MICU)
During COVID (NICU, PICU)
Nursing practice environment	Nursing work index‐revised
Nursing foundations for quality of care
Nurse participation in hospital affairs
Nurse manager ability
Leadership and support
Staffing and resource adequacy
Collegial nurse‐physician relations

Independent variables	Measurement instrument
Demographic data	Demographic questionnaire
Age
Gender
Educational level
Provider role
Years of experience
Overtime worked
Shift worked

Data were collected from nurses both in 2019 and 2020 via a paper‐based survey including the following validated instruments: Maslach Burnout Inventory—Human Services Survey for Medical Personnel (MBI‐HSS‐MP), Stress‐Arousal Adjective Checklist (SACL), and the Nursing Work Index‐Revised (NWI‐R). Participants' demographics, including age, gender, education level, years of experience, and shift worked (added in 2020 because the 2019 sample included day shift nurses only), were also collected during both phases of the study.

2.6. Measurements

This study had two primary outcome variables. The first primary outcome variable was nurse burnout measured by the MBI‐HSS‐MP. ²² Various iterations for use in specific populations of the MBI were widely used across reviewed studies to assess healthcare providers for occupational burnout. ² , ⁶ , ¹¹ , ¹² , ¹⁴ , ¹⁵ , ²¹ The MBI instrument has been validated with reliability established in previous studies. ²³ , ²⁴ The subscale for EE measures feeling emotionally overburdened and fatigued by one's work. The DP subscale captures feeling numb and detached or unfeeling toward work‐related tasks and people. Lastly, the PA subscale measures a nurse's perception of success and competence in their nursing career.

The SACL was used to measure the second primary outcome variable of stress‐arousal in participants. Stress and arousal are two unique states independent of one another which can affect job performance due to different psychological consequences. ²⁵ Elevated stress levels occur in states of fear. Elevated arousal situationally occurs during incidents of coping with a stressor or fear. ²⁶ Arousal serves as a protective mechanism during times of stress and has been linked to improved performance when initially rising, thus making it favorable. However, as arousal states rise, performance worsens and becomes unfavorable. This triad of stress, arousal, and performance led investigators to measure stress and arousal in this study. The tool has been validated in highly stressful work environments. ²⁵

2.7. Covariates

Control variables of workload and clinical units were measured with the "Nurse Perception Questionnaire" developed to capture the number of shifts worked and clinical unit worked from study participants. Another control variable was the nursing practice environment. The nursing practice environment assessment served to measure consistency of the work setting as perceived by participants to determine whether changes to the practice environment, if detected, may have led to changes in burnout and stress‐arousal versus exposure to COVID‐19 infected patients. A frequently used and validated instrument, the NWI‐R, was used to assess the nursing practice environment using subscales to measure constructs strongly associated with skillful and high‐quality patient care delivery by nurses. ²⁷ The NWI‐R is recognized to be strongly associated with nurse job satisfaction, turnover, and retention. Additionally, previous studies established relationships between NBS and the independent variables of age, sex, education level, provider role, and years of experience. ² , ⁴ , ⁶ , ⁷ , ¹¹ , ¹² , ¹⁴ , ¹⁵ Researchers collected this personal data for exploration from participants to investigate possible relationships.

2.8. Analysis

Scores for each participant's subscale were first calculated independently before summative evaluations were employed to determine levels of burnout. All three subscales determined burnout levels of participating nurses, and further data analysis measured burnout of study subgroups. Data were entered into SPSS version 27 for analysis. Descriptive, frequencies, and Q‐Q plots were run to explore data in both comparison groups. Assumptions of normality were met in EE and DP subscales. The PA subscale data was skewed in both comparison groups. Independent sample t‐tests compared differences in mean scores on EE and DP subscales between COVID‐19 and non‐COVID‐19 ICUs. Mann–Whitney U‐test compared differences in mean PA scores between independent groups.

3. RESULTS

3.1. Burnout and stress in COVID‐19 and non‐COVID‐19 ICUs

To test the hypothesis that burnout scores among nurses working in non‐COVID‐19 ICUs would be less than burnout scores for nurses working in designated COVID‐19 ICUs, a comparison of EE, DP, and PA scores was made (see Table 3). Scores were calculated from surveys completed by 90 nurses at a regional peak in COVID‐19 infected adult patient admissions but before having a significant impact on neonatal and pediatric ICUs. Independent Sample t‐test results supported a statistically significant difference in EE and DP scores between COVID‐19 and non‐COVID‐19 designated ICUs. The large effect size for both EE and DP scores supported important differences in the magnitude and strength of scores between groups. Nurses working on COVID‐19 designated units experienced more EE and DP than nurses working on non‐COVID‐19 units. The Mann–Whitney U‐test examined the difference between the non‐normally distributed mean PA scores in the COVID‐19 and non‐COVID‐19 ICUs. A nonstatistically significant difference between mean PA scores in the COVID‐19 ICUs compared to non‐COVID‐19 designated ICUs was noted (SEM = 122.29).

Table 3.

Burnout scores of nurses working in non‐COVID ICUs and designated COVID ICUs in November 2020

Maslach Burnout Inventory subscale scores	COVID‐19 designated RNs (n = 52)	Non‐COVID‐19 RNs (n = 38)	p Value
Emotional exhaustion	18.2 (moderate)	8.6 (low)	.0001
Depersonalization	12.8 (high)	5.0 (low)	.0001
Personal accomplishment	32.6 (high)	36.8 (moderate)	.08

Abbreviation: RN, registered nurse.

The practice environments were similar based on NWI‐R scores: COVID‐19 designated ICUs (M= 103, SD = 21.75) and non‐COVID‐19 designated ICUs (M= 101, SD = 21.39). Notably, nurses self‐reported working more extra shifts in the ICUs caring for COVID‐19 infected patients: COVID‐19 designated ICUs (M= 1.17, SD = 1.09) and non‐COVID‐19 designated ICUs (M= 0.28, SD = 0.65).

3.2. Burnout before and after COVID‐19 outbreak

To test the hypothesis that NBS measured in nurses working in six critical care units in 2019 will be less than NBS measured in 2020 in the CICU and MICU after conversion to COVID‐19 ICUs, investigators established significance between participant groups using Levene's Test for Equality of Variance homogeneity. The effect size for both EE and DP scores did not support differences in the magnitude and strength of scores between pre‐COVID‐19 and COVID‐19 designated units. Statistical significance was not noted pre and post‐pandemic in these two groups using an independent sample t‐test. However, clinical significance was noted by an EE subscale increase (indicating more burnout) from low (before caring for COVID‐19 infected patients) to moderate (during the pandemic) (see Table 4). Critical care nurses working in dedicated COVID‐19 units self‐reported an acute stress score was much higher in 2020 (1.22= ± 5.9) compared to both before (‐5 + 6.21) and after (‐5 + 7.45) their worked shift in 2019. The PA scores decreased from before the pandemic compared to those measured during the pandemic.

Table 4.

Nurse burnout scores of nurses working in six critical care units measured in 2019 (pre‐COVID‐19) compared to 2020 burnout scores of nurses working in the primary COVID‐19 ICUs

Maslach Burnout Inventory subscale scores	Pre‐COVID‐19 critical care RNs (N = 51)	COVID‐19 ICU RNs (N = 23)	p Value
Emotional exhaustion	15.41 (low)	18.2 (moderate)	.59
Depersonalization	10.29 (high)	12.8 (high)	.74

Abbreviation: RN, registered nurse.

4. DISCUSSION

In all, 141 critical care nurses across eight critical care units participated in this study conducted to determine what impact taking care of COVID‐19 infected patients in COVID‐19 designated ICUs had on NBS. This study follows seminal work that measured the Chinese nurses' mental health, including burnout, during the COVID‐19 outbreak using a multisite cross‐sectional design at the peak of the pandemic in China (February 2020). ² The authors reported an increase in fear, anxiety, and burnout in frontline nurses compared to previous studies. ² Notably, a pre‐COVID‐19 study conducted during the Middle East Respiratory Syndrome outbreak demonstrated nurses' burnout levels continued to increase over time in response to prolonged and incessant exposure to infected patients. ²⁰ In our study, 70% of nurses working COVID‐19 ICUs reported working extra shifts compared to only 29% of nurses working in non‐COVID‐19 ICUs. Increased levels of stress and burnout may be attributed to the increased workload associated with working extra shifts. Remarkably, a previous study before the pandemic reported one additionally assigned patient to a nurse's workload was associated with a 23% increased risk for occupational burnout. ¹⁶ Further exploration of contextual and causal relationships between workload (i.e., extra shifts worked, additionally assigned patient) and occupational burnout may lead to interventional studies and inform policies aimed to mitigate harm to nurse mental wellbeing.

While the paired intensive care units were not from the same hospital caring for similar patient populations, COVID‐19 infection exposure was minimal compared to burdensome based on facility and unit. Non‐COVID‐19 dedicated ICUs in the general hospital would send nurses to the dedicated COVID‐19 ICUs for staffing shortages, thus they were not appropriate control units. The sample consisted of only 2 male participants and only 15 nurses working the night shift, therefore limiting between group comparisons based on gender and shift worked. Further research is required to establish relationships between sociodemographic and work‐related psychological predictors of NBS. Understanding relationships between variables may guide the development of strategies to build nurse resilience and decrease NBS in ICU settings impacted during future pandemics.

The COVID‐19 pandemic has highlighted the importance of understanding the impact of nurse burnout in nurses working in ICUs dedicated to caring for COVID‐19 infected patients. Investigators compared burnout and stress scores between critical care nurses working in two urban tertiary care hospitals located in the southwest United States stratified based on nurse COVID‐19 infected patient exposure. Important differences in EE and DP scores between COVID‐19 and non‐COVID‐19 units were supported. Nurses working during a COVID‐19 regional surge had statistically significant higher EE and DP scores. However, PA scores decreased from high to moderate and were not statistically significant. The PA score findings were inconsistent with a 2016 report of critical care nurses demonstrating EE (73%) as the most common symptom of NBS followed by lack of PA (60%) and DP (48%). ⁵ Perhaps nurses caring for critically ill infected patients, when sampled early in the pandemic, who demonstrated a minimal decrease in their PA scores may be explained by feeling a sense of helplessness associated with being key members of the medical team during worldwide shutdowns, futile care delivery, and unprecedented deaths compared to prepandemic findings. ¹² Additionally, the nursing workforce has experienced a disproportionate amount of stress during the pandemic, possibly contributing to subsequent increased levels of NBS. ⁴ , ⁶ Critical care nurse stress levels were significantly higher postpandemic in 2020 than measured prepandemic in 2019.

Politicization of masks and vaccines, denial of the virus existence, and feelings of isolation due to lack of public support led workers to leave not only their workplace, but the nursing profession. Stress mitigation and reduction measures should be priorities for employers and legislators for protection of a critical element of healthcare—critical care nurses working with the most sick and vulnerable individuals. Hospital balance of time off to care for employees and adequate staffing to care for patients represents the new challenge facing inpatient healthcare settings. Strategies to reduce burnout may need to be multifaceted to meet the needs of all nurses working in critical care settings. Some risk factors such as gender, age, and experience may not be mitigated, while other factors associated with NBS may be addressed thoughtfully through multimodal approaches of evidence‐based interventions. Approaches to NBS reduction may include physical and emotional hygiene support systems within the work setting such as resting rooms for mid‐shift naps, serenity rooms, yoga stations, guided mindfulness exercises, and hydration/nutrition stations. ⁴ , ⁸ , ⁹ , ¹⁰ , ²⁸ Protection of nurse mental wellness through establishment of physical and emotional hygiene support mechanisms supported by policies to ensure use may mitigate psychological consequences of working in high stress environments such as intensive care units and during future pandemics or COVID‐19 surges. ¹¹ , ¹³ , ²⁸ High nurse burnout may lead to suicide and substance abuse making understanding and mitigating the phenomena better essential. ²⁹

5. LIMITATIONS

The study had the following limitations. The study was a cross‐sectional design limited to data from only two urban tertiary hospitals located in a single state; thus, the findings may not be generalizable. Stress and occupational burnout were measured simultaneously, making it impossible to draw causal relationships between them. The information from the first round of data collection in 2019 was deidentified and only collected from day shift female nurses due to the study's design, thus limiting the comparison to the 2020 sample of nurses. Infected nurses or nurses with infected family members living in their households were not identified; hence, occupational burnout and stress may have been impacted by exposure to COVID‐19 infection outside of the work setting. Selection bias could not be avoided. Covariates found associated with NBS in reviewed studies were not captured from participants during data collection for this study, including marital status, patient workloads, income, and so forth. Due to the limited number of male participants compared to female participants, relationships could not be explained based on gender.

6. CONCLUSION

Understanding the negative mental health impacts of stress and burnout in critical care nurses informs approaches for overcoming threats to nurse mental health at institutional, policy, and individual levels. Many reviewed studies validated the prevalence of NBS and the urgency for implementing preventative strategies; however, few studies reported independent risk factors for NBS to guide their development. Nurse burnout syndrome has been identified as a global problem facing ICU clinicians. Pinpointing associations between COVID‐19 infection and nurse burnout may lead to strategies to mitigate burnout in those caring for critically ill individuals during future pandemics or other health emergencies. Opportunities for healthcare leaders to offer training and resources to support the emotional healing of nurses working on the frontlines in intensive care units, especially in the context of the recent COVID‐19 pandemic, may be necessary. Nurse mental wellness should be recognized by organizations as important as patient healing. Whether individual strategies of self‐care or organizational measures to protect mental well‐being of the nursing workforce are employed, systemic changes and health policies are needed to support and empower healthcare leaders and organizations to protect the mental health and well‐being of the nursing workforce.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

Roney JK, Mihandoust S, Bazan GN, et al. Caring for COVID‐19 infected patients admitted to redesignated coronavirus ICUs: impact on nurse stress and burnout. Nurs Forum. 2022;57:1321‐1329. 10.1111/nuf.12810

DATA AVAILABILITY

Data available on request from the authors.