key: cord-0757290-l1brtb8d
authors: Crowe, Sarah; Fuchsia Howard, A.; Vanderspank, Brandi
title: The Mental Health Impact of the COVID-19 Pandemic on Canadian Critical Care Nurses
date: 2022-03-14
journal: Intensive Crit Care Nurs
DOI: 10.1016/j.iccn.2022.103241
sha: 64a9c7cbecf1ba99f0ecee820e98fce6c9e8c24f
doc_id: 757290
cord_uid: l1brtb8d

OBJECTIVE: Focusing on Canadian critical care nurses (CCNs), the study objectives were to examine the impact of the COVID-19 pandemic on: mental health, quality of work life, and intent to stay in their current positions. RESEARCH DESIGN: Mixed-methods study using an online cross-sectional survey and integration of closed- and open-ended survey data. SETTING: Canadian CCNs working in an intensive care unit, high acuity unit, or intensive care step-down unit during the COVID-19 pandemic between May 2021 to June 2021. MAIN OUTCOME MEASURES: The survey consisted of four instruments: (1) the impact of event scale – revised, (2) the depression, anxiety, and stress scale, (3) the professional quality of life scale, and (4) intent to turnover tool, as well as one optional open-ended question. RESULTS: From across Canada, 425 CCNs responded. The large majority reported symptoms of post traumatic stress disorder (74%), depression (70%), anxiety (57%), and stress (61%). All (100%) reported moderate to high burnout, 87% were suffering from signs of secondary traumatic stress, and 22% intended to quit their current employment. Qualitative analysis of written comments submitted by 147 (34.5%) of the respondents depicted an immense mental health toll on CCNs that stemmed from 1) failed leadership and 2) the traumatic nature of the work environment, that led to 3) a sense of disillusionment, defeat, and an intent to leave. CONCLUSION: The mental health toll of the pandemic has been significant for Canadian CCNs and highlights the urgent need for individual supports and systems level changes.

As the COVID-19 pandemic has evolved, so has public health responses and modes of treatment when patients become critically ill, with critical care nurses (CCNs) constantly at the bedside (Mahase, 2020; Wang et al., 2020) . Evidence from previous outbreaks and disasters illuminated the psychosocial impact on healthcare workers, with risk of infection to their own family, access to proven personal protective equipment, as well as team / institution preparedness found to influence stress (Brooks et al. 2018; Greenberg et al., 2020; Khalid et al., 2016; Lai et al., 2020; Lima et al., 2020; McMahon et al., 2016; Matsuishi et al., 2012; Ives et al., 2009) . Research started to emerge detailing the impact of the pandemic on the well-being of the healthcare staff who have been on the frontlines providing care for patients with SARS CoV-2. Evidence of the burden borne by healthcare providers, particularly nurses, at the outset of the pandemic documented a significant impact to mental health (AlAteeq et al., 2020; Alharbi, Jackson, Usher, 2020; Azoulay et al., 2020; Gomez et al., 2020; Greenberg et al., 2021; Havaei et al., 2021a; Havaei et al., 2021b , Shaukat, Ali, Razzak, 2020 Vizhen et al., 2020; Wahlster et al., 2021) .

During the initial months of COVID-19, our team documented high levels of stress, depression and symptoms of PTSD among CCNs at a single site in British Columbia, Canada (XXX). We found 55% of participants reported symptoms of stress, 58% symptoms of depression, and 50% symptoms of PTSD at the time of data collection (XXXX). Given these findings and the ongoing pandemic wherein nurses have continued to care for critically ill patients in tremendously demanding circumstances, we anticipated ongoing mental health challenges that were also influencing nurses' ability and desire to continue in their work. Thus, we designed a new study that focussed on CCNs across the country, as opposed to a single institution, and included additional instruments to assess CCNs quality of work life and their intent to stay in their position. The aim of this study was to examine the mental health and quality of work life of Canadian CCNs providing patient care during the COVID-19 pandemic. The specific research questions were: what is the impact of the pandemic on CCNs' (1) mental health, (2) quality of work life, and (3) intent to stay in their current position one year into the pandemic?

This was a mixed-methods study using an online cross-sectional survey and the integration of closed-and open-ended survey data. We surveyed CCNs from across Canada between May 2021 and June 2021; a time considered to be the third wave of the pandemic in Canada. This study was approval by the XXX Research Ethics Board (Ethics #XXX). The survey platform was approved by the Research Ethics Board and, prior to the start of the survey an explanation that completion of the questionnaires constituted implied consent was included. No identifying data was collected from participants.

The Canadian publicly funded healthcare system covers all critical care costs. CCNs working in intensive care unit, high acuity unit, or intensive care step-down units during the COVID-19 pandemic were invited to participate. We recruited participants using convenience sampling. An email invitation to participate was distributed three times by the Canadian Association of Critical Care Nurses (CACCN), a national association composed of approximately 1000 CCNs. The invitation to participate contained a link to the online survey. Social media recruitment through Facebook and Twitter was also used -again, shared initially by the CACCN and then shared broadly by users.

We collected data using four questionnaires: the Impact of Event Scale -Revised (IES -R), the Depression, Anxiety, Stress Scale (DASS -21), the Professional Quality of Life scale (ProQoL), and the Intent to Turnover scale (Creamer, Bell, Falilla, 2002; Lovibond, Lovibond, 1995; Stamm, 2012) . These scales have demonstrated strong reliability and validity when used in previous nursing studies, including with CCN participants (McMahon et al., 2016; Maunder et al., 2004; Jiang et al., 2021) . Previously used to assess the impact of a public health crisis, the IES -R measures the psychological impact of an event, providing a brief snapshot in time of staff response to crisis, and capturing symptoms of post-traumatic stress disorder (PTSD) McAlonan et al., 2007; Weiss, 2007) . This 22-item scale asks respondents to reflect on how difficult a statement was in the past seven days with response options ranging from not at all (0 points) to extremely (4 points) (Creamer et al., 2002) . All 22 items are summed; a score of under 24 indicates no clinical concern, 24 to 32 indicates the presence of some PTSD symptoms, 33 to 36 indicates a cut off for probably diagnosis of PTSD, and a score of more than 37 indicates significant symptoms (Creamer et al., 2002) .

Previously used in pandemic research, the DASS-21 measures symptoms of depression, anxiety and stress McAlonan et al., 2007) . The 21-item DASS-21 asks respondents to reflect on how a specific statement applied to them over the past week with response options ranging from did not apply to me (0 points) to applied most of the time (3 points) (Lovibond, Lovibon, 1995) . The three sub-scale scores are summed and interpreted for depression [normal (0 to 9), mild (10 to 13), moderate (14 to 20), severe (21 to 27), and extremely severe (over 28)], anxiety [normal (0 to7), mild (8 to 9), moderate (10 to 14), severe (15 to 19), and extremely severe (over 20)] and stress [normal (0 to 14), mild (15 to 18), moderate (19 to 25), severe (26 to 33), and extremely severe (over 34) ( Lovibond, Lovibon, 1995) .

The PROQoL measures was chosen as it includes the constructs of compassion satisfaction, burnout, and secondary traumatic stress (Stamm, 2012) . It is commonly used to measure the negative and positive effects of helping others who experience suffering and trauma (Stamm, 2012) . The 30-item PROQoL asks respondents to reflect on their experiences over the past 30 days with response options ranging from never (1 point) to very often (5 points) (Stamm, 2012) . The three subscales are each The 7-item intent to turnover scale asks respondents about their level of agreement [strongly disagree (1 point), to strongly agree (5 points)] with statements about different aspects of leaving a position (Mobley, Horner, Hollingsworth, 1978) . Participant responses on each of the four study questionnaires were analyzed using descriptive statistics.

Following the questionnaires, we included an optional open-ended question asking participants if there was anything else they wanted to share. The research team (XXXXXX )analyzed these written responses using an inductive thematic approach that involved open coding of the participant's comments, the creation of a coding frame that was then applied to all the comments, the grouping and regrouping of the codes into larger categories, and eventually the construction of themes to describe the experiences and perspectives shared by the participants. This process involved the comparing and contrasting of the participants' different comments and ideas and ongoing research team deliberations by all investigators wherein we arrived at consensus regarding analysis and our interpretations (Norwell et al., 2017) . Aligning with Morse (1997), we did not consider inter-rater reliability of coders appropriate, but rather, aimed for insightful interpretation of the unstructured free-text data with contributions from each of the team members.

In total, 425 CCNs participated (Table 1 ). All Canadian provinces were represented in the sample. Nurses ranged from 20 to 65 years of age, with years employed in healthcare ranging from 1 to 46 years and a mean of 8.3 years in their current position.

The IES -R responses demonstrated high levels of PTSD symptoms at the time of completion ( Figure 1) . Overall, 74.4% of nurses were above the cut off for clinical concern for PTSD symptoms at the time of survey. While this represents high symptom burden at the time of survey, it is not diagnostic of PTSD, but provides a snapshot in time as to the experiences of CCNs. On the DASS -21, the majority reported depression (69.6%), anxiety (56.9%), and stress (60.7%) symptoms at the time of survey ( Figure   2 ). Responses on the PROQoL indicated that 100% of nurses surveyed were suffering from moderate to high burnout, and 87.1% had signs of secondary traumatic stress at the time of the survey (Figure 3 ).

Despite the high levels of burnout, the majority of participants (96.5%) also reported moderate levels of compassion satisfaction. Responses on the intent to turnover questionnaire indicated that 44% of nurses surveyed were thinking of quitting, 38.1% would like to work for different organization, 49.4% would like to look for a new job in the future, 23.3% already actively searching for a new job and 22.4% indicated they intend to quit (Table 2 ). Statistical analysis was performed using SPSS, however no significant differences in the subgroup analysis examining the difference between provinces, age groups, and years of experience for each of the IES-R, DASS -21, PROQoL, and Intent to Turnover was found.

The variables were compared using pearson's coefficient for correlations and chi-squares. Due to the sample size further analysis was not possible.

Comments were submitted by 147 (34.5%) CCNs. These ranged from 1-2 sentences to long detailed paragraphs. The comments depicted an immense mental health toll on CCNs that stemmed from 1) failed leadership and 2) the traumatic nature of the work environment, that led to 3) a sense of disillusionment, defeat, and an intent to leave.

The CCNs described feeling taken for granted by leadership. They reported being unacknowledged, unsupported, and disrespected by all levels of leadership including the federal and provincial governments, their health authorities, and hospitals. One nurse shared, "more than the pandemic, it is the mismanagement by the "leaders" that left us nurses feel[ing] burn[t] out and devalued" (participant 317, Ontario). Being re-deployed to unfamiliar areas and forced to work different schedules with no choice, with the added expectation to work extensive overtime, left some unable to look after their children or ailing family members. One participant commented:

"Mandatory redeployment causes further pandemic burdens by indiscriminately moving female nurses throughout their health authority. Women are already disproportionately impacted by the pandemic and then have to worry about mandatory redeployment further increasing stress/burdens as caregivers-both personally and professionally" (participant 127, British Columbia).

The CCNs indicated they were constantly working short staffed with higher nurse-patient ratios than is normal or safe, leaving them struggling to provide the high-quality care they were proud to deliver prepandemic.

The CCNs described those in leadership as failing to respect their contributions and the specialized skills and expertise required to work not only in critical care, but in the untenable COVID-19 ICU context. At best, the nurses were "barely able to keep up," and at worst, they felt disposable, "trashed and abused" by various levels of leadership. The negative impact of this perceived failure of leaderships on the nurse's mental health was exemplified the comment: Recognizing the demands and mental health effects on bedside staff, some CCNs in management positions described being wholly unable to adequately support staff. Inadequate compensation was considered by many CCNs "as not valuing the entire profession" (participant 221, Ontario). Many reported their frustrations with government unwillingness to negotiate with them for fair, equitable pay, threats of wage cutbacks, and having to work alongside physicians who were being compensated at much higher rates for doing nursing work.

Numerous CCNs described traumatic experiences that were consequences of caring for critically ill individuals during the pandemic. This included caring for a never-ending onslaught of "patient after patient getting sicker and sicker" and the momentous task of balancing facts with hope, as described by one nurse:

"It's difficult to look a sick, lonely, scared person in the eye, discussing intubation when I know … that there is a high chance this will be the last time they are awake FaceTiming their loved ones (participant 233, Alberta).

Caring for dying COVID patients under restricted visitation policies, wherein CCNs helped families say their last goodbyes and watch their loved one pass away, was characterized as traumatic by several respondents, including one CCN who explained:

"When patients passed away in the COVID ICU, families were not allowed in … we had to set up a zoom meeting for families to watch their loved one die. This was VERY traumatic. Imagine being a mother having to watch your child die on zoom? Or a child watching your parent die on zoom? ... A lot of spirits were broken for nurses working in this pandemic" (participant 381, Manitoba).

In reflecting on death and dying, the perceived limited number of critically ill patients with SARS-CoV-2 who recovered and the futility of their care robbed the nurses of hope and left them feeling deflated and unable to care.

Despite their efforts to uphold patient-and family-centred care under less-than-ideal circumstances, the CCNs also reported profoundly destabilizing experiences as a result of negative interactions with patients and family members alike. One nurse stated: "I'm tired, patients [sic] and families take out their frustration at nurses, and we are yelled at, even though we are doing everything we can to protect them" (participant 154, Ontario) .

These traumatic experiences were exacerbated by feeling profound disappointment and disconnect from some members of the public who refused to follow public health guidelines.

Many of the CCNs expressed their angst over losing their love for the nursing profession. The mental health toll was beyond any they had previously experienced, with disillusionment and defeat evident in comments such as this:

"In all my years of work, I have never so viscerally understood the depths of despair and feelings of worthlessness can be. I have not contemplated suicide, BUT I now understand how someone can feel that way. This past year has shattered me in ways I never thought possible. I hope, someday I can be myself again" (participant 46, British Columbia).

The CCNs commonly described feeling "hopeless and overwhelmed" by being stuck in their current job and as a nurse, due to family obligations and their perception of no alternative career options. Others freely admitted to wishing but being unable to make a career change, as exemplified by one nurse's comments that, "because I have a mortgage and kids to take care of… I regret becoming a nurse and am now trapped in a job that is soul sucking in order to continue to provide for my family" (participant 307, British Columbia). Several CCNs nearing retirement expressed relief that they would no longer be working as a nurse. Others indicated that the mental health toll was simply too much and, feeling utterly defeated, they intended to leave their current job or nursing for good.

"I have loved being a critical nurse and was grateful to have a job which I enjoyed ... Now I am exhausted, mentally and physically drained. I don't know how much more I have in me to give." (participant 343, Manitoba) .

The demands of the COVID-19 pandemic have continued to take a toll on the mental wellbeing of healthcare providers (AlAteeq et al., 2020; Alharbi et al., 2020; Azoulay et al., 2020; Gomez et al., 2020; Greenberg et al., 2021; Havaei et al., 2021a; Havaei et al., 2021b; Shaukat et al., 2020; Vizhen et al., 2020; Wahlster et al., 2021) . Our study aligns with the growing evidence of the tremendous negative mental health impact of the pandemic on CCNs. We highlighted the acute distress that is being experienced by some CCNs in terms of symptoms of PTSD, depression, anxiety, stress and burnout.

Contributing to this negative symptomology, we described their perspectives and experiences of failed leadership and the traumatic nature of the work environment, which led further to a sense of disillusionment, defeat, and an intent to leave their employment and the nursing profession.

The survey findings of this study confirm the negative mental health impact the pandemic is having on many CCNs. Prior to the pandemic, reported nursing PTSD rates ranged from 9% to 20%.

Recent data from the COVID-19 pandemic reports nursing PTSD rates ranging from 49% to 73% (XXX; Carmassi et al., 2020) . Our study was consistent with these findings as well as research findings focused more broadly on healthcare providers. The results also mirrored the results of first study that reported symptoms of PTSD in 74% of participants from a single Canadian site (XXXX). Depression and anxiety rates among healthcare providers during the current crisis have been found to range from 23% to 71% (AlAteeq et al., 2020; XXX; Havaei et al., 2021a; Havaei et al., 2021b; Shaukat et al, 2020; Vizhen et al., 2020; Wahlster et al., 2021) . Our first study reported similar rates of depression, anxiety and stress symptoms (XXXX). Similar validation has been found in prior studies examining professional quality of life. Pre-pandemic researchers have found a moderate to high degree of burnout and stress that impacted healthcare providers and CCNs' ability to provide care (Sacco et al., 2020; Austin, Saylor, Finley, 2017; Mohammadi, Peyrovi, Mahmood, 2017; Monroe, Morse, Price, 2020) . While our study reports higher episodes of burnout and secondary trauma symptoms than some other recent studies, the results are not unexpected when considering the work of CCNs in caring for COVID-19 patients (Inocian et al., 2021; Jiang et al., 2021) . It is highly likely that the cumulative mental health toll influenced the CCNs intent to turnover. Prior to the pandemic, nursing turnover rates were approximately 8% and theses are expected to climb post-pandemic (Nashwan et al., 2021; Raso, Fitzpatrick, Masick, 2021; Sheppard et al., 2021) . Raso et al. (2021) estimated post-pandemic turnover rates to reach 10%, whereas Sheppard et al. (2021) estimated 13% or higher; 22 .4% of the CCNs in our study indicated their intent to turnover. Given the relatively small sample size and self-report nature of the study, there are limits to the generalizability of study findings.

Our qualitative findings provide insight into the profound impact the COVID-19 pandemic has had on CCNs individually, as member of a team, and on their lives outside of work. Other studies have reported the impact on different groups such as critical care leaders, individual experiences and healthcare providers in general (Cenzig et al., 2021; Gonzalez-Gil et al., 2021; Hayes, Cocchi, 2021; Thusini, 2020) . This study differs from most to date, in that it offers a glimpse into the struggles of Overall the findings of this study paint a bleak picture from the perspective of many Canadian

CCNs. Not only have they experienced high levels of burnout, depression, anxiety and stress which has a profound impact on their health and wellbeing, but more than 20% want to leave their positions. This has the potential to cripple the Canadian health system. It follows then, that a solutions oriented approach to future research and interventions be prioritized by Canadian CCN leadership and likely internationally, to address not only a current nursing shortage in Canada, but to mitigate the imminent risk of a CCN shortage worldwide.

Strengths of this study lie in the national representation of participants and, while it was anticipated to be a survey-based study, the abundance of participant comments that allowed a richer and deeper understanding of CCNs' experiences. Study limitations included the smaller size (425) compared to the approximately 21,000 CCNs Canada wide (Canadian Nurses Association, 2021). This sample size, however, is comparable to previous published surveys conducted through the CACCN (Edwards, Throndson, Girardin, 2012; Rose et al., 2012) .This was rather surprising considering that we were requesting CCNs to complete a survey at a time during the pandemic when they were experiencing tremendous strain. Further, CCNs self-selected to participate thus likely contributing to a selection bias.

It is possible that our participants represent individuals motivated to respond because they were experiencing mental health challenges and appreciated the opportunity to contribute their perspectives.

This was also evident in the high response rate to the open-ended question, which might further represent the intensity of the participants' thoughts and emotions related to the questionnaires as well as the importance participants attached to qualifying, contextualizing, and even expanding upon their questionnaire responses. This high number of in-depth free text responses perhaps further represents participant's frustrations and the importance they attached to this research as one avenue for communicating the struggles they had endured.

The findings from this study, supported by literature, suggests that that mental health toll of the pandemic has been significant for CCNs. 

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Objective: Focusing on Canadian critical care nurses (CCNs), the study objectives were to examine the impact of the COVID-19 pandemic on: mental health, quality of work life, and intent to stay in their current positions. Results: From across Canada, 425 CCNs responded. The large majority reported symptoms of post traumatic stress disorder (74%), depression (70%), anxiety (57%), and stress (61%). All (100%) reported moderate to high burnout, 87% were suffering from signs of secondary traumatic stress, and 22%

intended to quit their current employment. Qualitative analysis of written comments submitted by 147 (34.5%) of the respondents depicted an immense mental health toll on CCNs that stemmed from 1) failed leadership and 2) the traumatic nature of the work environment, that led to 3) a sense of disillusionment, defeat, and an intent to leave.

The mental health toll of the pandemic has been significant for Canadian CCNs and highlights the urgent need for individual supports and systems level changes.

 There are Canadian CCNs who are experiencing profound mental health challenges related to the pandemic. There is an urgent need for initiatives that address these mental health challenges. Failure to promote healing or protect mental wellbeing of CCNs may lead to high rates of turnover

☒The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.☐The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

This research study received approval from the Fraser Health Research Ethics Board prior to any data collection occurring. The approval number is: FHREB 2021-046.