Introduction

The COVID-19 pandemic, since its inception in December 2019, has been associated with infections and patient deaths, as well as other harmful collateral damage to patients and society. This has exacerbated stress levels among professionals working in Intensive Care Units (ICUs) who care for these patients [1].

The virus responsible for COVID-19 is called Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and has high transmissibility and lethality [2]. It has been recognized as a severe public health problem in Brazil and worldwide [3,4].

The numbers of COVID-19 cases and deaths have been significant since the start of its spread. As of December 29, 2021, there have been 281,808,270 confirmed cases and 5,411,759 deaths worldwide [5]. These numbers highlight the magnitude of the medical and social impact of the disease, affecting both public and private hospitals and having economic consequences, particularly in less developed regions [6,7].

Vaccination efforts are underway worldwide, but there have been challenges in terms of logistics and the number of vaccines administered. Disparities in vaccination rates have been observed, with poorer and remote regions facing difficulties in access and distribution [7].

The COVID-19 pandemic represents not only a health challenge but also a sociological phenomenon that potentially affects the performance and satisfaction of healthcare professionals caring for hospitalized patients, many of whom have severe morbidity. Various external factors can influence the course and prognosis of the epidemic, including competition for vaccine acquisition, distribution logistics, vaccine acceptance by populations, economic consequences, and societal responses to preventive measures [9,10].

It is important to recognize and address the stressors faced by ICU professionals during this pandemic to achieve a desired balance between their health and satisfaction in delivering competent and quality care. Understanding and managing negative stress levels will have a positive impact on the work environment and administrative management during the pandemic. This knowledge can also contribute to future healthcare situations of similar importance. The aim of this study is to evaluate stress levels and exhaustion among professionals working in ICUs during the COVID-19 pandemic.

Materials and Methods

This cross-sectional study was conducted from August through September 2020, during the COVID-19 pandemic, in five ICUs from public and private hospitals in the State of Bahia, Brazil. The procedures were approved by the Research Ethics Committee of the Professor Edgard Santos University Hospital (HUPES) and by the National Research Ethics Committee (CONEP), being registered on the Plataforma Brasil-CAAE (Certificate of Presentation for Ethics Appreciation) n^º 30447520.3.0000.5577. Hospital institutions with public and private profiles were randomly chosen, considering restrictions resulting from the pandemic.

The census sampling included 192 healthcare professionals. The questionnaire methodology was a census with the main focus on a population census in ICUs to take stock and produce a total population count without omission or duplication. Another key focus was the ability to provide accurate demographic and socioeconomic characteristics pertaining to each enumerated individual. All teams composed of physicians, nurses, and physiotherapists from the studied intensive care units were surveyed.

The instrument sought to verify the experiences and perceptions of physicians, nurses, and physiotherapists through 75 questions presented in a script of qualitative questions on the various aspects that could reveal the most striking stressor elements that can raise exhaustion levels in the ICU during the COVID-19 pandemic. In this study, a question that included work-related mental and physical fatigue defined exhaustion.

The instrument included various demographic and work-related questions such as name, gender, date of birth, profession, exhaustion, use of controlled medication, living arrangements, marital status, physical activity, alcohol consumption, chronic tobacco use, having children, monthly income, decision-making in services, ICU protection measures, professional relationships, conflicts at work, professional vacations, training time, experiences with deceased COVID patients, previous COVID infection, use of Personal Protective Equipment (PPE), after-service rest, empowerment for pandemic care, shift duration, feeling safe with the team, multiple jobs, patient load, work

hours, stress moments, professional discouragement, difficulty relaxing, tiredness, work overload, stress perception, satisfaction with the chosen profession, work irritation, fear of COVID, ICU pressure, concerns in the ICU, feeling isolated, overload of responsibilities, feeling like a professional hero, thoughts of death, fear of dying from COVID, and handling patient suffering.

In the bivariate analysis for exhaustion, sociodemographic and work-related variables with a p-value less than 0.20 were included in a binary logistic regression model. The parameters used to assess the quality of the logistic regression were the Hosmer & Lemeshow tests (goodness of fit) to determine the adequacy of the model (p-value > 0.5), the Omnibus Tests (p-value < 0.05) to assess the improvement of the data in the equation with the model, and NargleKerke's R². A network analysis was performed to evaluate the psychological aspects associated with exhaustion, using the InsigSampler estimator with bivariate regression analysis and Bootstrap 500 of the non-parametric type.

This research applied the discourse analysis method as a qualitative approach to describe the ergonomic aspects of the stressor elements commonly observed in the ICU, according to the literature. Therefore, the scientific concept of discourse analysis and the critical points of using the theoretical tendency are presented.

Results

In 2020, a total of 192 professionals from five ICUs were invited to answer an electronic questionnaire. Out of the 192 participants, 115 ICU workers (60%) participated. Of the study participants, 30.4% were male and 69.6% were female. In the population, 34.8% were physicians, 30.4% were nurses, and 34.8% were physiotherapists. In the present work, the results of the questions, all conducted in ICU environments, were extracted descriptively. The response rate described in the article was 60%. Generally, response rates for online surveys are less than 20%. Table 1 shows exhaustion according to sociodemographic characteristics of ICU workers. Among ICU workers, exhaustion was 68% higher (PR=1.68; p<0.001) in nurses, 48% higher in professionals using controlled medication (PR=1.48; p=0.042), and 75% higher in females (PR=1.75; p<0.001).

Table 1: Exhaustion according to sociodemographic variables of ICU workers, Bahia, Brazil, 2020.

Table 2 presents the analysis of exhaustion based on factors related to the work of ICU professionals. The use of ICU protection resulted in a 38% reduction in exhaustion (PR=0.62; p<0.001), while working shifts lasting more than 12 hours led to a 48% reduction in exhaustion (PR=0.52; p<0.001) among ICU workers. Additionally, feeling unsafe during work contributed to a 49% reduction in exhaustion (PR=0.51; p=0.033) among professionals. On the other hand, not resting after work and having more than one job increased exhaustion by 44% (PR=1.44; p=0.04) and 61% (PR=1.61; p=0.009), respectively.

Table 2: Exhaustion according to the aspects related to work in the ICU, Bahia, Brazil, 2020.

The collinearity evaluation parameters, Tolerance index (>0.2), and VIF (<10), showed that the data fulfill the prerequisites for regression with the absence of multicollinearity. In logistic regression (Table 3), "ICU protection" (OR: 7.8) and "Appropriate Duration of the Shift" (OR: 0.5) were directly and inversely associated with exhaustion. The Hosmer & Lemeshow test (the goodness of fit) suggested the adequacy of the model (p = 0.58). Omnibus Tests (Chi-square = 36.372, df = 8, p < 0.000) showed the improvement of the equation with the model, and Nagelkerke's R² suggests that the model explains 37% of the variance in exhaustion.

Table 3: Logistic regression equation coefficients having Exhaustion as dependent variable among 115 ICU workers, Bahia, Brazil, 2020.

Table 3 explains that exhaustion was the dependent variable, and according to the method, the variables with significant values in the bivariate analysis of Tables 1 and 2 were included in the analysis model, as described in the method below.

In the bivariate analysis for exhaustion, sociodemographic and work-related variables with p-values < 0.20 were included in a binary logistic regression model. The parameters used to assess the quality of the logistic regression included the Hosmer & Lemeshow tests (for goodness of fit) to determine the adequacy of the model (p > 0.5), Omnibus Tests (p < 0.05) to assess the improvement of the model's fit with the data, and Nagelkerke's R².

The network analysis revealed stronger and inversely proportional relationships with the phenomenon of exhaustion, including feeling suffocated with responsibilities (-27.87), difficulties relaxing (-24.52), and irritability with the service (-24). There was a positive association between exhaustion and job satisfaction (24.92) (Figure 1). Detailed associations are described in Table 4.

Figure 1: Network analyses.

Table 4: Network analysis / weight matrix.

As showed in Table 4 there is a positive association between exhaustion and job satisfaction with a weight matrix value of 24.92. It was hard for health care workers to relax during covid-19 pandemic. The analysis also indicates that even nursing with a lower shift load than physiotherapy, it is the most affected by the multitude of procedures performed in the ICU.

Exhaustion was remarkable not only in admission but also in intubation, and pronation procedures, which involved dealing with families and performing complex procedures requiring different team competencies. These variables may be better measured in the future, with a methodology for acquiring and validating competences, in reducing the teams' stress levels [23].

Discussion

COVID-19 is a disease that triggers a cytokine storm, leading to inflammation, fibrosis, and cell death [13,14]. These factors directly affect the morphology and functionality of various organs in the human body, including the brain, heart, and others [15-18]. In this context, ICU workers live in constant fear and insecurity, resulting in elevated levels of emotional stress, anxiety, and depression [19]. As shown in this study, occupational stress among medical workers in the post-COVID period it is a very common [20]. The impact of stress on healthcare practice has been emphasized in the description of Burnout syndrome [21] since its initial report by psychologist Freudenberg in 1974. It is characterized as a chronic and inadequate response to work, caused by stress factors, and affects professionals at various levels of healthcare service delivery. The Maslach Burnout Inventory (MBI) is the most widely used instrument to assess and systematize the approach to this syndrome in related research [22].

Surprisingly, we found in logistic regression, ICU protection (OR: 7.8) and shift duration (OR: 0.5) were found to be directly and inversely associated with exhaustion. There is a significant consensus regarding the perception of moderate stress among physicians, physiotherapists, and nurses who do not engage in regular physical activity [23]. The relationship between a lack of physical conditioning and increased exhaustion may be a key area for future research. Exhaustion, characterized by a combination of mental and physical fatigue, is an important risk factor and may be recognized as a concern in the ICU workplace [24]. It can have adverse effects on the overall well-being of ICU staff, and professionals often express concerns about their physical fitness and accumulated occupational stress, which has been observed in other studies [25].

The ergonomic aspects presented in Table 1 were identified based on the self-perception of fatigue among ICU workers. Furthermore, there is a clear correlation between an unhealthy lifestyle and a decrease in physical and mental capabilities for job tasks [25,36]. Lifestyle and healthy habits, including regular physical exercise, are crucial factors in reducing fatigue and enhancing occupational quality among ICUs workers [23].

Regarding the relationship between profession and mental overload in the ICU, nurses appear to experience the highest levels of mental strain, followed by physicians and physiotherapists ref. The findings from the network analysis (Table 4) and (Figure-1) indicate a positive association between exhaustion and job satisfaction. Additionally, the analysis suggests that despite nursing having fewer shift hours than physiotherapy, it is more affected by the multitude of procedures performed in the ICU.

Exhaustion is particularly noticeable not only during patient admission but also during intubation and pronation procedures, which involve interactions with families and the execution of complex procedures requiring various team competencies. These variables may benefit from better measurement methods in the future, along with the development of methodologies for assessing and validating competencies to reduce stress levels among healthcare teams [26].

We conducted measurements of exhaustion and identified stressor factors associated with ICU work. However, it's important to note that the scales and "cutoff points" for diagnosing burnout syndrome still lack robust scientific evidence. Their application is primarily based on clinical observations and exploratory studies [24]. The literature shows variations in results related to stressor measurements, mainly due to the heterogeneity of psychometric properties within different samples [27,28]. The adaptation of inventories or questionnaires for a more consistent description of burnout syndrome remains an ongoing area of specialized research and publication.

Conclusion

Among the professionals evaluated in ICU environments, nurses were the most heavily impacted during the Covid-19 pandemic. Future studies in this area should delve deeper into exploring the relationship between fatigue, exhaustion, and levels of physical fitness. Among the various psychological aspects linked to exhaustion in ICU workers, tiredness was over seven times more prevalent than in those without exhaustion. Logistic regression analysis revealed that having access to ICU protection and working fewer hours on duty were associated with lower levels of exhaustion. Interestingly, higher levels of exhaustion were correlated with increased job satisfaction. In conclusion, this study suggests a need for a more comprehensive analysis of the attributes identified in the healthcare context, with a focus on examining the strength of correlations among variables, especially in the context of professional practice during the evolution of a pandemic.

This work was supported by the Post-Graduate Program in Medicine and Health, Federal University of Bahia, Brazil

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