COVID-19 pandemic in the intensive care unit: Psychological implications and interventions, a systematic review

Table 1 Summary of eligible studies on coronavirus disease 2019 in intensive care units

Ref.	Type	Population	Design	Outcomes and assessments	Results	Conclusions and observations
Sayde et al[138], 2020	C-S survey	265 ICU patients recruited, 20 refused, 185 excluded, 35 included: 17: Intervention group, (16 female, 11 male); 18 patients control group (15 female,13 male)	Diary and questionnaire administered 1 (BL), 4, 12, and 24 wk after ICU discharge (September 2017 to September 2018) in New Orleans, Louisiana, United States	Psychological distress, (IES-R), Anxiety and Depression (PHQ-8; HADS; GAD-7)	Controls had a significantly greater decrease in PTSD, hyperarousal, and depression symptoms at week 4 compared to the intervention group. No significant differences in other measures, or at other follow-ups. Both study groups exhibited clinically significant PTSD symptoms at all timepoints after ICU discharge	Diary increased awareness of the psychological support available to ICU survivors and family members
Huang et al[139], 2020	C-S online survey	6523 people with contact history, completed the survey, 260 were excluded, 6261 included. 3585 female (57.3%), 2676 male (42.7%)	Online questionnaire sent to participants of Hubei province and outside Hubei province, China, from February 10 to 15, 2020	Tested depression (PHQ-9) and public perceptions in response to the COVID-19 outbreak	Most people endorsed preventive and avoidance behaviours. People from Hubei, with contact history, and people who were infected or whose family members were infected by COVID-19, had a much higher prevalence of depression and anxiety	Assessing public response, perception, and psychological burden during the outbreak may help improving public health recommendations and deliver timely psychological intervention
Leng et al[140], 2021	C-S survey	90 ICU nurses; 65 female (72.2%), 25 male (27.8%)	Tests administered to ICU Wuhan (China) nurses, from 11 to 18 March 2020	PTSD (PTSD Checklist-Civilian and PSS), related to demographic survey and 2 open questions	Nurses have elevated PTSD levels. Nurses’ stress and PTSD symptoms were positively correlated. Isolated environment, concerns about personal protective equipment shortage and usage, physical and emotional exhaustion, intensive workload, fear of being infected, and insufficient work experiences with COVID-19 were a major stress source	Even highly skilled and resilient nurses experienced some degree of mental distress, such as PTSD symptoms and perceived stress
Lasater et al[80], 2021	C-S analyses	ICU nurses and ICU patients: First sample 4298 medical-surgical nurses; second sample 2182 ICU nurses	Staffing data collected from registered nurses in New York and Illinois using HCAHPS and AHA, between 16-12-2019–24-2-2020	Information on patient satisfaction, hospital characteristics	Over half the nurses experienced high burnout. Half gave their hospitals unfavourable safety grades and two-thirds would not definitely recommend their hospitals. One-third of patients rated their hospitals less than excellent and would not definitely recommend it to others	Hospital nurses had burn-out and were working in understaffed conditions in the weeks prior to the first wave of COVID-19 cases, thus increasing public health risks
Jain et al[81], 2020	C-S online survey	512 Indian anaesthesiologists, 227 female (44.3%), 285 male (55.7%)	Online questionnaire sent to anaesthesiologists across India from 12-5-2020 to 22-5-2020	Anxiety (GAD-7) and Insomnia (ISI)	Elevated COVID-19-related anxiety and insomnia levels of anaesthesiologists. Age < 35 yr, female sex, being married, resident doctors, fear of infection to self or family, fear of salary deductions, increase in working hours, loneliness due to isolation, food and accommodation issues and posting in COVID-19 duty were risk factors for anxiety. < 35 yr, unmarried, those with stress due to COVID-19, fear of loneliness, issues of food and accommodation, increased working hours favour insomnia	Anaesthesiologists on COVID-19 duty suffer from anxiety and insomnia
Kirolos et al[82], 2021	LS	41 families with a baby at NICU	Multicentre service evaluation in five United Kingdom neonatal care units, between July and November 2019	Surveys contained quantitative (9-point Likert scale, or closed-ended yes/no responses) and qualitative items (open comment boxes)	In post-implementation surveys (n = 42), 88% perceived a benefit of the service on their neonatal experience. 71% (n = 55) felt the service had a positive impact on relationships with families	Asynchronous video supports models of family integrated care and can mitigate family separation
Lasalvia et al[83], 2020	C-S online survey	2195 ICU HCWs; female 539 (24.7 %), male 1647 (75.3)	All healthcare and administrative staff of Verona University Hospital (Veneto, Italy) from April to May 2020	Psychological distress (IES-R), Anxiety (SAS) and mental health (PHQ-9)	63.2% of participants reported COVID-related traumatic experiences at work; 53.8% showed symptoms of post-traumatic distress; 50.1% showed symptoms of clinically relevant anxiety; 26.6% symptoms of moderate depression	The psychological impact of the COVID-19 pandemic on healthcare staff working in a highly burdened north-east Italy is high and to some extent higher than that reported in China
Ou et al[84], 2021	C-S study	92 nurses in isolation ward, female 85 (92.4%); male 7 (7.6%)	Test was administered to nurses in isolation ward, the Guangdong Province of China, in February 2020	Resilience and psychopathological symptoms (CD-RISC2; SCL-90)	Total resilience score was 87.04 ± 22.78. SCL-90 score ranged 160-281 (202.5 ± 40.79). Only 8.70% of nurses (n = 8) scored > 160 on the SCL-90, suggesting positive symptoms. Most nurses had 0 to 90 positive self-assessment items (median 14); 19.57% (n = 18) had > 43 positive items to CD-RISC 2	High resilience promotes physical and mental health, and may be improved by training, psychological interventions, and full use of hospital resources
Vlake et al[69], 2020	Case report	One COVID-19 patient (male), age: 57 yr	Test for evaluating COVID-19 ICU-VR intervention in one Dutch man with COVID-19	Anxiety and depression (HADS) and psychological distress (IES-R)	One week after receiving ICU-VR, levels of PTSD, anxiety, and depression had normalised and stayed normal 6 mo after discharge	Virtual realty improved psychological rehabilitation outcomes, hence they should be considered by clinicians for the treatment of ICU-related psychological sequelae after COVID-19
Fernández-Castillo et al[85], 2021	C-S survey	17 nurses: 6 male, 11 male	17 nurses of a tertiary teaching hospital in Southern Spain, from 12-30 April 2020	Semi-structured videocall interviews	Four main themes emerged from the analysis and 13 subthemes: “providing nursing care”, “psychosocial aspects and emotional lability”, “resources management and safety” and “professional relationships and fellowship”	Nursing care has been influenced by fear and isolation, making it hard to maintain humanisation of health care
Writing Committee for the COMEBAC Study Group et al[86], 2021	C-S telephone survey	834 eligible COVID-19 survivors: 478 evaluated (201 male, 277 female)	Survivors of COVID-19 in France underwent telephone assessment 4 mo after discharge, between July and September 2020	Respiratory, cognitive, and functional symptoms (Q3PC cognitive screening questionnaire, symptom Checklist and 20-item Multidimensional Fatigue Inventory; SF-36; cognitive impairment (MoCA)	244 patients (51%) declared at least 1 symptom absent before COVID-19: Fatigue in 31%, cognitive symptoms in 21%, and new-onset dyspnoea in 16%. The median 20-item Multidimensional Fatigue Inventory score (n = 130) was 4.5 for reduced motivation and 3.7 for mental fatigue. The median SF-36 score (n = 145) was 25 for the subscale “role limited owing to physical problems”. Among 94 former ICU patients, anxiety, depression, and PTSD symptoms were observed in 23%, 18%, and 7%, respectively. The left ventricular ejection fraction was < 50% in 8 of 83 ICU patients (10%)	4 mo after hospitalisation for COVID-19, a cohort of patients frequently reported previously absent symptoms
Stocchetti et al[87], 2021	C-S online study	Of 271 medical staff working in this ICU, 136 included: 84 nurses (62%) and 52 physicians (38%)	Nurses and physicians working in this ICU participated to online survey in January 2021	Burnout (MBI), anxiety (HADS); resilience (RSA) and Insomnia (ISI)	60% of participants show high burnout level: Nurses reported significantly higher scores of anxiety and insomnia levels. 45 % reported symptoms of depression, and 82.4% of the staff showed moderate-to-high levels of resilience	The COVID-19 pandemic can have a significant impact on ICU staff. Effective interventions needed to maintain healthcare professionals’ mental health and relieve burnout
Kirk et al[12], 2021	C-S online study	430 of 458 paediatric HCWs, concluded the online survey	Online survey administered to paediatric HCWs in the emergency, ICU and infectious disease units from April 28 to May 5 2020	Depression and Anxiety symptoms (DASS-21)	168 (39.1%) of respondent showed depression, 205 (47.7%) anxiety and 106 (24.7%) symptoms of stress. Depression reported in the mild (47, 10.9%), moderate (76, 17.7%), severe (23, 5.3%) and extremely severe (22, 5.1%) categories. Anxiety (205, 47.7%) and stress (106, 24.7%) were reported in the mild category only	A high prevalence of depression, anxiety and stress was reported among frontline paediatric HCWs during the COVID-19 pandemic
Yang et al[88], 2021	C-S online study	Of 1075 contacted individuals, 1036 front-line HPCD completed the online survey: Female 755 (72.9%), male 288 (27.1). 874 (84.4%) nurses, 162 (15.6%) physicians	1036 front-line HPCDs exposed to COVID-19 were tested online from 5 to 9 March 2020 in Wuhan, China	Sleep, insomnia, emotional regulation (RESE)	543 (52.4 %) reported symptoms of sleep disorders. HPCD for patients with COVID-19 in China reported experiencing sleep disturbance burdens, especially those having exposure experience and working long shifts	RESE is an important resource for alleviating sleep disturbances and improving sleep quality
Moradi et al[89], 2021	C-S survey	17 nurses in ICUs: 5 males and 12 females	Semi-structured face-to-face interviews were administered to nurses in ICUs of Urmia, Iran	Semi-structured face-to-face interviews	Four challenges throughout the provision of care for COVID-19 patients: ‘organization’s inefficiency in supporting nurses’, ‘physical exhaustion’, ‘living with uncertainty’ and ‘psychological burden of the disease	A profound understanding of ICU nurses’ challenges while caring for COVID-19 patients is needed to increase healthcare quality
Bruyneel et al[90], 2021	C-S online survey	1135 ICU nurses: Female 892 (78%); male 243 (22%)	Nurses in the French-speaking part of Belgium completed a web-based survey, April 21-May 4, 2020	Burnout (MBI)	68% burnout level. 29% of ICU nurses were at risk of depersonalisation, 31% of reduced personal accomplishment, and 38% of emotional exhaustion	Burnout risk requires monitoring and implementation of interventions to prevent it and manage it
Shariati et al[91], 2021	LS online survey	67 family members of COVID-19 patients admitted to the ICU	Longitudinal pre-post intervention online survey of 67 family members of COVID-19 ICU patients in three hospitals in Iran; May to August 2020	Stress symptoms (PSS-14)	Mean PSS-14 post-intervention significantly lower in the intervention group than in the control group (P < 0.001)	Use of web-based communication between nurses and family members was effective in reducing perceived stress
Kok et al[92], 2021	LS survey	Open cohort of ICUs professional: BL survey 252 respondents, response rate: 53%, male 66 (26.2%), female 186 (73.8%); and follow-up 233 respondents, response rate: 50%, male 65 (27.9%), female 168 (72.1%)	BL survey collected in October-December 2019 and follow-up survey sent in May-June 2020 to a university medical centre and a large teaching hospital in the Netherlands	Semi-structured interview form	The prevalence of burnout symptoms was 23.0% before COVID-19 and 36.1% after, with higher rates in nurses (38.0%) than in physicians (28.6%). Post-COVID-19 incidence rate of new burnout cases among physicians was higher (26.7%) than among nurses (21.9%). Higher prevalence of burnout symptoms after the beginning of the pandemic	Overburdening of ICU healthcare personnel during an extended period leads to burnout symptoms
Kürtüncü et al[93], 2021	C-S survey	18 COVID-19 patients: 4 females and 14 males	Telephone-conducted semi-structured interview of 18 ICU patients in Turkey; March-September, 2020	Semi-structured interview form	Interventions in ICUs are able to promote communication with patients and are essential for achieving positive circumstances	Families of missing patients may benefit from interventions of nurses aimed at working-through the loss and providing family support and care during their critical illness
Martillo et al[94], 2021	C-S online survey	45 COVID-19 ICU patients: Male 33 (73.3%), female 10 (22.2%)	Single-centre descriptive cohort study of ICU patients at Mount Sinai Hospital, New York; April 21 to July 7, 2020	Insomnia (ISI), mental health (PHQ-9), QoL (EQ-5D-3L), PTSD (PCL-5), telephone cognitive assessment (MoCA)	22 patients (48%) reported psychiatric impairment, and four (8%) had cognitive impairment. 38% at least mild depression, and 18% moderate-to-severe depression. 8% PTSD. 9% had impaired cognition	Severe COVID-19-related symptoms associated with high risk of developing PICS. Planning needed for appropriate post-ICU care
Donkers et al[95], 2021	C-S online survey	355 nurses, 108 supporting staff and 41 ICU physicians from 84 ICUs: 124 males, 380 females	Online questionnaire sent by email to Dutch ICU nurses and supporting staff from 7 April to 11 June, 2020	MD for HCWs (MMD-HP), Ethical Decision-Making (EDMCQ)	MD levels higher for nurses than others; “Inadequate emotional support for patients and their families” was the highest-ranked cause of MD for all participants; all participants judged positively the ethical climate regarding the culture of mutual respect, ethical awareness, and support	Targeted interventions on MD are important for improving the mental health of critical care professionals and the quality of patient care
Fteropoulli et al[96], 2021	C-S online survey	1071 healthcare personnel: 73% females, and 27% males	Anonymous online survey administered. May 25 to October 27, 2020, in Cyprus	QoL (WHOQOL-Brief), anxiety (GAD-7), depression (PHQ-8), burnout (CBI), and coping (Brief COPE)	27.6% moderate and severe anxiety, 26.8% depression. Being female, nurse or doctor, working in frontline units, perceptions of inadequate workplace preparation to deal with the pandemic and using avoidance coping were risk factors	There are several risk factors for psychological distress during the pandemic, which may be individual, psychosocial, and organisational
Peñacoba et al[97], 2021	C-S online survey	308 intensive care nurses: Female 268 (87%) and male 40 (13%)	Online form used to collect data from surgical and general critical care units in a public Spain Hospital, March 2020 to June 2020	Stress subscale (depression, anxiety, and stress in Spanish DASS-21), physical and mental health-related QoL (SF-36), GSES, and resilience (RS-14)	Greater perception of self-efficacy related to lower perception of stress and greater resilience, while higher resilience was linked to greater physical and mental health	Stress is related to physical and mental health factors which are linked to QoL through self-efficacy and resilience
Wozniak et al[98], 2021	C-S online study	3461 HCWs of 352 ICU	Online data collected from May 28 to July 7, 2020, at HUG, Switzerland	Socio-demographic data, lifestyle changes, anxiety (GAD-7; PHQ-9), psychological distress (PDI; WHO-5)	145 (41%) reported poor well-being, 162 (46%) anxiety, 163 (46%) depression, 76 (22%) peritraumatic distress. Working in ICU more than other departments changes eating habits, sleeping patterns, and alcohol consumption (P < 0.01)	High prevalence of anxiety, depression, peritraumatic distress and poor well-being during the first COVID-19 wave among HCWs, especially in ICU
Li et al[99], 2021	C-S survey	78 ICUs nurses: Female 4 (17.95%), male 64 (82.05%)	Data from 78 ICU nurses in Beijing COVID-19 hospital during March 2020	Depression (SDS), stress (PPS)	44.9% (n = 35) reported depressive symptoms, stress perception; work experience in critical diseases, and education are risk factors for depression	Work experience in critical illness is linked to depression. Psychological intervention may reduce it
Manuela et al[100], 2021	C-S survey	34 females, mothers of premature infants born before 32 wk of gestational age; 20 pre-COVID-19 period vs 14 during COVID-19 pandemic	20 mothers of premature infants recruited at HUG, CH, January 2018 to February 2020 before COVID-19 vs 14 mothers from November 2020 to June 2021	Postnatal depression (EPDS); (PSS:NICU), attachment (MPAS)	No significant differences for depression, stress, and attachment between the two groups; “trend” towards increase of depression symptoms in mothers during the COVID-19 pandemic; depression correlated with attachment and stress scores	Protective family-based actions and appropriate interventions to support parents during the COVID-19 pandemic can reduce depression and stress of mothers of premature infants
Nijland et al[76], 2021	LS survey	Of 326 ICU nurses, 138 (42.33%) participated; 86 VRelax users, male 13 (15%), female 73 (85%) and 52 non-users, male 9 (17%), female 43 (83%)	VRelax intervention investigated in Dutch ICU nurses in May, 2020	Single-question VAS-stress scale	VR reduced stress by 36% (mean difference = 14.0 ± 13.3, P < 0.005). 62% of ICU nurses rated VRelax as helpful to reduce stress	VRelax is effective in reducing immediate perceived stress
Scheepers et al[101], 2021	LS survey	Of 203 ICU and internal medicine staff, 103 residents (50.1%) participated	ICU and Internal medicine staff of AMC, Amsterdam, The Netherlands tested during the first wave of COVID-19, March 15 to June 30, 2020	Explored residents’ perceptions of well-being (well-being survey), and their perceived support of the well-being program during the COVID-19 pandemic	Residents working in the ICU reported significantly lower levels of mental well-being than internal medicine residents	Well-being programmes for ICU staff need to address ICU-specific stressors, enhancing supervision and peer support
Liu et al[102], 2021	Study 1: LS survey; study 2: LS survey	Study 1: Of 268 ICU nurses and 26 head nurses, 258 completed the survey: Female 220 (85.27%), male 38 (14.73%). Study 2: 64 ICU medical professionals: Female 40 (65.57%), male 24 (34.43%)	Study 1: ICU nurses of major Chengdu hospital, China, recruited. Retested after 3 wk for work engagement and rated by head nurses for taking-charge behaviour after further 3 wk. Study 2: ICU medical staff of same Chinese hospital completed scales on early March, 2020 and 2 wk later	Studies 1-2: Perceived COVID-19 crisis strength and work meaningfulness assessed with 5-point Likert scales, and demographic data. Self-rating of work engagement and clinician rating of taking-charge behaviour	Study 1: Health worker’sperceived COVID-19 crisis strength exerted a more negative effect on his or her work engagement and taking charge at work. Study 2: The interventions significantly decreased perceived COVID-19 crisis strength and increased work meaningfulness for medical staff in an ICU	Study 1: Frontline health workers worldwide have regarded the COVID-19 crisis as an extraordinarily stressful event. Study 2: Interventions are important for reducing stress during COVID-19 pandemic
Carmassi et al[103], 2021	C-S survey	265 frontline HCWs: Male 84 (31.7%), female 181 (68.3%)	Data was recruited in a sample of frontline HCWs at a major university hospital in Pisa, Italy, April 1 to May 1, 2020	PTSS (IES-R), anxiety (GAD-7), depression (PHQ-9), assess work and social Functioning (WSAS)	Subjects with acute PTSS have higher levels of PTSS, depressive symptoms, and moderate-to-severe anxiety symptoms	More long-term studies are needed to evaluate the impact of psychopathology on the socio-occupational functioning of health professionals
Secosan et al[104], 2021	C-S survey	Of 200 frontline HCWs, 126, 63% (32 nurses and 94 physicians) participated; male 35.7%, female 64.3%; 42.8% single, 52.3% married, 4.7% divorced	Data collected from Romanian frontline HCWs, March to April 2020	Psychological capital (PsyCap) (PCQ) related to anxiety and depression (DASS-21), burnout (MBI)	High anxiety predicts lower emotional exhaustion and a low level of mental health complaints about healthcare professionals when PsyCap is high	PsyCap is may decrease the impact of anxiety and depression on psychological outcomes in frontline HCWs. Psychological interventions can help ICUs staff
Scarpina et al[105], 2021	C-S survey	60 patients who survived COVID-19 infection: Male 58.3%, female 41.7%	Participants had been recruited at the COVID-19 post-ICU, from May 2020 to January 2021, in Italy	Fearful facial expressions recognition, perceived psychological functioning, Empathy (4-point Likert scale questionnaire)	Altered detection and recognition of fearful expressions and altered processing of fearful expressions in individuals who survived COVID-19 infection	Altered emotional face recognition could represent psychological distress; psychological interventions in rehabilitative settings can be helpful
Kapetanos et al[106], 2021	C-S survey	381 HCWs: 72.7% nurses (202 males, 75 males) 12.9% physicians (28 males, 21 males), 14.4% other occupations (18 males; 7 males)	Data on mental health status of HCWs collected from healthcare professionals from all over Cyprus from May to June 2020	64-item, self-administered questionnaire, which included DASS21 and MBI	Prevalence of 28.6% anxiety, 8.11% stress, 15% depression, and 12.3% burnout. Environmental changes included increased working hours, isolation, and separation from family	Also the second wave of the pandemic impaired psychological health of HCWs
Manera et al[107], 2022	C-S survey	152 COVID-19 patients: 101 males, 51 females	Retrospective assessment of post-infectious SARS-CoV-2 patients at Maugeri Scientific Clinical Institutes, Northern Italy, May 2020 to May 2021	Cognitive measures (MMSE) as related to disease severity (at-risk vs not at-risk: Neuro+ vs Neuro-)	Mild-to-moderate patients (26.3%) showed impaired MMSE performances; ICU patients made less errors (P = 0.021) on the MMSE than non-ICU patients. Age negatively influenced MMSE performance. For Neuro-patients, steroidal treatment improved MMSE scores (P = 0.025)	Mild-to-moderate patients, with mechanical ventilation who however are not admitted to an ICU, are more likely to suffer from cognitive deficits, independently from their aetiology
Mollard et al[108], 2021	C-S survey	885 postpartum women, 82.3% married	English-speaking adult postpartum women who gave birth in US hospitals from 1 March to 9 July 2020 participated in survey between 22 May to 22 July 2020	Demographic and health variables measured with self-report questionnaires; stress (PSS-10), Mastery (PM), and resilience (CD-RISC2)	Post-pandemic participants showed higher stress and lower resilience, high levels of depression, anxiety, and stress compared to a pre-pandemic normative sample. Women with an infant admitted to a NICU had higher stress. High income, full-time employment, and partnered relationships lowered stress. Lower stress increased mastery and resilience. Non-white women showed higher stress and lower resilience	Postpartum women are susceptible to stress, depression, and anxiety
Pappa et al[109], 2021	C-S survey	464 HCWs: Female 68%, male 32%; 43% nurses, 49% married	Six COVID-19 reference hospitals in Greece, from May 2020 to June 2020	Levels and risk factors of anxiety (GAD-7), Depression (PHQ-9), traumatic stress (IES-R), burnout (MBI) and fear (NFRS)	30% moderate/severe depression, 25% anxiety, 33% traumatic stress. 65% of respondents scored moderate-severe on EE, 92% severe on DP, and 51% low-moderate on PA. Predictors: Fear, perceived stress, risk of infection, lack of protective equipment and low social support	Need for immediate organisational and individual interventions to enhance resilience and psychological support for HCWs
Meesters et al[110], 2022	C-S online survey	25 parents (16 mothers, 9 fathers) of infants at NICU	Data collected at Rotterdam NICU from April to June 2020	Sociodemographic questions related to stressor (PSS:NICU) and COVID questionnaire	Most important sources of stress were being separated from, not being able to always hold their infant, and other family members not allowed to visit	NICU staff can support psychologically parents during hospital isolation and reduce the effect of restrictive measures
Piscitello et al[111], 2022	LS survey	Of 78 eligible, 33 ICU nurses (42%) completed survey: Female 29 (50.9%), male 28 (49.1)	Data collected November to December 2020 at Rush University	Nurse MD (MMD-HP)	Results pre and post intervention were not statistically different	Further research required to identify interventions that could improve nurses’ MD
Sezgin et al[112], 2022	C-S online survey	10 ICU nurses: 2 males and 8 females	Data collected by online survey in 10 ICUs of 7 hospitals in İstanbul, Turkey, October to December 2020 using the snowball method to recruit	Followed the Consolidated Criteria for Reporting Qualitative Research; 32-item checklist to identify major themes	‘Death and fear of death’, ‘impact on family and social lives’, ‘nursing care of COVID-19 patients’, ‘changing perceptions of their own profession: empowerment and dissatisfaction’, and ‘experiences and perceptions of personal protective equipment and other control measures’ are the major themes identified	There is need to improve working conditions and develop nursing standards in ICU
Rodriguez-Ruiz et al[113], 2022	LS online survey	HCW in ICU: 1065 in first time and 1115 in second time	Spanish ICUs in October to December 2019 and September to November 2020	MD (MMD-HP-SPA)	During the pandemic, nurses reported higher MD levels compared to the prepandemic period. ICU physicians reported significantly higher MD levels than ICU nurses during the prepandemic period, but not during the pandemic period	In Spain, during the COVID-19 pandemic, there is an increase of MD among ICU HCPs
Vlake et al[114], 2022	LS survey	89 post COVID patients: Male 63 (70%) and female 26 (39%)	VR efficacy data from Dutch post-ICU patients, June 2020 to February 2021; participants followed-up for 6 consecutive months	Psychological distress (IES-R) and QoL related to anxiety and depression (HADS)	High psychological distress levels in all groups. ICU-VR group showed improved ICU satisfaction with respect to the control group. 81% of patients reported a higher ICU quality, which was linked to virtual reality	ICU-VR is an innovative strategy to enhance satisfaction with ICU and improves ICU ratings aftercare, adding to its perceived quality
Fumis et al[115], 2022	C-S survey	Of 62 ICU physicians, 51 participated: Male 60.8%, female 39.2%; 76% married	Burnout investigated in ICU physicians during the second COVID-19 wave in São Paulo, Brazil, from December 10 to December 23, 2020	Questionnaire with demographic and occupational variables, and information on the impact of the COVID-19 pandemic on daily life (insomnia, lack of appetite, irritability, decreased libido, fear of being infected, fear of infecting loved ones, overspending) and MBI	19 (37.2%) showed high burnout, i.e., 96.1% low PA, 51.0% high DP, and 51.0% high EE. Conflicts between the ICU physicians and other physicians were 50%	ICU staff have high burnout level
Levi and Moss[116], 2022	C-S survey	10 ICU nurses: 9 females and 1 male; 3 married and 7 single	ICU nurses completed psychological stress survey during the COVID-19 pandemic in south-eastern United States from August to September 2020	Psychological Stress and PTSD Symptoms (PTSD Checklist), job satisfaction (a Likert-type scale), demographic information	The survey revealed 6 recurring themes: Change in Practice, Emotion, Patient’s Family, Isolation, Job Satisfaction, and Public Reaction. 7 of 10 ICU nurses reported PTSD symptoms; 6 of 10 wanted to quit their jobs	Critical care nurses during the COVID-19 pandemic are highly subjected to PTSD; its early identification may prevent other related health deteriorating problems
Righi et al[117], 2022	C-S survey	465 long COVID patients: 54% male and 46% female; 51 % hospitalised	Patients > 18 yr with SARS-CoV-2 infection at Verona University Hospital during February 29 to May 2 2020, followed for 9 mo	Duration and predictors of symptom persistence (symptom questionnaire), physical health and psychological distress (K10)	37% of patients had at least 4 symptoms; 42% had symptom lasting more than 28 d. 19% showed psychological distress after 9 mo. Female and symptom persistence at day 28 were risk factors for psychological distress	Patients with advanced age, ICU stay, and multiple symptoms were more likely to suffer from long-term symptoms, with negative impact on both physical and mental wellbeing
Gilmartin et al[118], 2022	C-S survey	22 post COVID-19 patients: Male 15 (68%), female 7 (32%)	A prospective cohort study through establishing a PICS follow-up clinic at Tallaght University Hospital in October 2020 for patients who had been admitted to their ICU	PICS investigated by psychological assessment for ICU (IPAT), PTSD (PCL-5), cognitive impairment (MoCA)	IPAT score was 6.6 ± 4.6 with a PCL-5 score of 21.1 ± 17.5 and a MoCA score of 24 ± 8.4, suggestive of mild cognitive impairment	Patients have a high burden of physical and psychologic impairment 6 mo following ICU discharge for post-COVID-19 pneumonia
Guttormson et al[119], 2022	C-S online survey	485 ICU nurses: Female 430 (88.1%), male 56 (11.5%)	Participants recruited from national United States sample of ICU nurses, through AACCN newsletters and social media during the COVID-19 pandemic, October 2020 to January 2021	Measure of MD (MMD-HP), burnout (PROQOL-5), PTSD symptoms (TSQ), anxiety, and depression (PHQ-ADS)	Nurses reported moderate-high levels of MD and burnout; 44.6% reported depression symptoms and 31.1% had anxiety symptoms, while 47% of participants showed risk for PTSD	United States ICU nurses had high levels of anxiety and depression and higher risk for PTSD
Likhvantsev et al[120], 2022	C-S survey	Of 403 eligible COVID-19 patients in Russian ICUs (Moscow), 135 participated	Prospective cohort study investigated patients admitted in COVID-19 ICUs, March to June 2020	QoL (SF-36 questionnaire)	Heparin treatment in the ICU proved to be the only modifiable factor associated with an increase in the physical component of QoL	Heparin treatment enhanced QoL during COVID-19 patient recoveries at ICUs
Shirasaki et al[121], 2022	C-S survey	54 family members (68.5% female, 31.5% male) of 85 patients (16.7% female, 83.3% male) with COVID-19 admitted to ICU participated	PICS-F was investigated between March 23, 2020, and September 30, 2021, in Japan	PICS-F related to Psychological distress (IES-R), anxiety, and depression (HADS), and PTSD (FS-ICU)	Family members had 24% of anxiety, 26% depression and 4% PTSD	One-third of family members of COVID-19 patients admitted to the ICU had symptoms of PICS-F
Amiri Gooshki et al[122], 2022	C-S survey	152 patients with COVID-19: Male 55 (36.2%), female 97 (63.8%); 98 (64.47%) married	Psychological consequences of COVID-19 were investigated at hospitals in south-eastern Iran in 2020	Demographic and background information, Depression, Anxiety (DASS-21), psychological distress (IES-R)	73% of patients showed severe PTSD, 26.3% moderate depression and 26.3% severe anxiety	Higher psychological load is enhanced by ICU admission, divorce, illiteracy, and retirement
Omar et al[123], 2022	C-S survey	445 HCWs (physicians, nurses, and respiratory therapists): 171 ECMO-ICU, 274 non ECMO-ICU; male 239 (53.7%), female 206 (46.3%)	HCWs grouped by ECMO service (ECMO-ICU vs non-ECMO-ICU) and burnout status (burnout vs no burnout), in 8 tertiary-care hospital ICUs in Qatar, January 1 to June 30, 2021	General and demographic questions, burnout (MBI-HSS)	288 HCWs reported burnout and 158 did not. PA lower among ECMO-ICU personnel compared with those in a non-ECMO-ICU (42.7% vs 52.6%, P = 0.043)	High burnout in both ECMO-ICU and non-ECMO-ICU personnel
Arshadi Bostanabad et al[124], 2022	C-S online survey	207 ICU nurses: Male 60 (29%), female 147 (71%); 51.7% married	Psychological empowerment was investigated in Iran, from February 2021 through April 2021	Psychological empowerment questionnaire, demographic information	Positive relationship between clinical competencies and psychological empowerment (r = 0.55, P < 0.001) and between clinical competencies and work experiences (r = 0.17, P = 0.01)	Clinical competency is linked to nurse health and quality of care
Zhang et al[9], 2022	C-S online survey	Of 3055 eligible PICUs HCWs, 2109 HCWs completed the survey: Female 1793 (85.2%) and male 316 (14.98%); 35.04% doctors and 64.96% nurses; 1456 (69.04%) married	Online survey was administered to HCWs in the paediatric ICUs of 62 hospitals in China on March 26, 2020	General information, PTSD (IES-R), anxiety and depression (DASS-21)	970 HCWs (45.99%) reported PTSD symptoms; 39.69% had severe depression, 36.46% anxiety and 17.12% high level of stress. Married HCWs showed higher risk of PTSD than unmarried. PTSD was influenced by marital status, intermediate professional titles and exposure history; while professional titles and going to work during the epidemic were a risk factor for depression	During public health emergencies, HCWs need specialised support
Kılıç and Taşgıt[125], 2023	C-S survey	93 parents who were not allowed to see their NICU babies as a response to the COVID-19 pandemic: 52 mothers (55.91%) and 41 fathers (44.09%)	Data collected between March and October 2021, in the NICU of a public hospital in Ankara, Turkey	Descriptive questionnaire, anxiety, depression, and stress (DASS-42), and Coping Style (CSS)	Depression subscale was 13.69 ± 8.86, Anxiety subscale 12.11 ± 8.37, and stress subscale 19.09 ± 9.24. CSS “self-confident” scale was 2.71 ± 0.65, “optimistic” 2.57 ± 0.59, “helpless” 2.29 ± 0.62, “submissive coping” 2.25 ± 0.49, and “seeking of social support” 2.38 ± 0.52. Participants who received information about their babies’ condition by nurses had lower mean CSS “helpless” and “submissive” subscale scores than others	For parents of NICU patients need use psychological empowerment programs to help them adopt active coping strategies to deal with challenges in times of crisis
Pappa et al[126], 2022	C-S online survey	464 self-selected HCWs: 68% female, 32% male; nurses (43%), married (49%)	Online questionnaire sent to ICU HCWs in Greece, from May 2020, to June 2020	Depression (PHQ-9), anxiety (GAD-7) and traumatic stress (IES-R) related to burnout (MBI) and level of fear (NFRS)	Depression was 30%, anxiety 0 25% and traumatic stress 33%. Burnout was high: 65% of HCWs scored moderate-severe on EE, 92% severe on DP and 1% low-moderate on PA	Need for interventions to enhance resilience and support wellbeing in pandemic
Vranas et al[127], 2022	C-S survey	Of 36 eligible intensivists, 33 participated: Female 12 (36%), male 21 (64%)	Semi-structured interviews conducted on ICUs of six United states between August and November 2020	Four S (space, staff, stuff, and system) semi-structured interview, related to MD, Burnout and Fear of Becoming Infected	Restricted visitor policies and their perceived negative impacts on patients, families, and staff enhanced MD. Burnout symptoms in intensivists were enhanced by experiences with patient death, exhaustion, and perceived lack of support from colleagues and hospitals	COVID-19 pandemic reduced ICU workers’ well-being, increased burnout and MD
Voruz et al[128], 2022	C-S survey	102 COVID-19 patients: 26 anosognosic, and 76 nosognosic patients	Tests administered by clinical psychologists and questionnaires online to patients at HUG	Neuropsychological battery (TMT, Stroop task, verbal fluency and GREFEX, backward digit span43 and backward Corsi test, Test for Attentional Performance, Rey-Osterrieth Complex Figure test, BECLA battery, WAIS-IV, QPC, BRIEF-A), psychiatric (ERQ, BDI-II, STAI, API, PTSD Checklist, GMI, DES, PSS, ESS) olfactory (Sniffing Sticks test battery), dyspnoea (self-report questionnaire), and QoL (SF-36)	Patients with anosognosia for memory dysfunction scored significantly lower on objective cognitive and olfactory measures compared with nosognosic patients; but reported significantly more positive subjective assessments of their QoL, psychiatric status, and fatigue. The number of patients exhibiting a lack of consciousness of olfactory deficits was significantly higher in the anosognosic group. Significantly more patients with lack of consciousness of olfactory deficits were in the anosognosic group, as confirmed by connectivity analyses	Cognitive disorders like anosognosia are related to different COVID-19 symptoms
Green et al[129], 2023	LS survey	24 ICU HCWs: 67% female, 33% male; 79% nurses	At Cedars-Sinai Medical Center (CSMC) in Los Angeles, CA, United States, over a 6-wk period from June 2020 to July 2020	Administered tests were: SAQ, TC, resilience (BRS), burnout (BSI)	Positive feedback paradigm enhanced resiliency and improve attitudes toward a TC	Need to improve TC and resiliency. A messaging interface to exchange mutual positivity can be a simple, low-cost intervention to provide an effective peer-to-peer support system
Wozniak et al[130], 2022	C-S survey	3461 HCWs. 352 ICU HCWs: Female 23 (66.5%), male 118 (33.5); 242 (68.7%) married. 3109 no-ICU HCWs: Female 2327 (74.9%), male 779 (25.1%); 1973 (63.5%) married	Mental health outcomes and lifestyles change in ICU HCWs and non-ICU HCWs; the study was carried out at HUG and 8 public hospitals in Switzerland, between May to July 2020	Anxiety (GAD-7), depression (PHQ-9), distress (PDI) and Well-Being (WHO-5)	ICU HCW: 41% showed low well-being, 46% symptoms of anxiety, 46% depression and 22% peritraumatic distress. ICU HCWs scored higher than non-ICU HCWs on all tests (P < 0.01). Working in ICU rather than in other departments, being a woman, the fear of catching and transmitting COVID-19, anxiety of working with COVID-19 patients, work overload, eating and sleeping disorders can enhance worse mental health outcomes	High prevalence of anxiety, depression, peritraumatic distress and low well-being during the first COVID-19 wave among HCWs, especially ICU HCWs
Tariku et al[131], 2022	C-S survey	402 of 423 eligible participants, responded to survey: Male 233 (58.0%), female 169 (42.0%); 137 (34.1%) married	HCWs mental disease was investigate in Ethiopia, during the coronavirus disease 2019	Survey assessing the presence of common mental disorders (SRQ-20)	22.6% of mental disorders in HCWs. Being female, married, having had direct contact with COVID-19 patients, working in COVID-19 treatment centres and ICU, having any symptoms of COVID-19, and poor social support were a risk factor for mental disorders in HCWs	On-fourth to one-fifth of Ethiopian HCWs have a mental disorder during COVID-19 pandemic
Wang et al[132], 2021	C-S telephone survey	Of 267 eligible patients, 199 COVID-19 patients participated in the survey; male 93 (46.7%), and female 106 (53.3%); age 42.72 ± 17.53; 163 ± 81.9 married	PTSD symptoms in COVID-19 survivors investigated with telephone survey 6 mo after hospital discharge in 5 hospitals of 5 Chinese cities, August to September 2020	Somatic symptoms after discharge (PHQ-15), PTSD (PTSD-8)	7% of participants having PTSD; socio-demographic status, hospitalization experiences, post-hospitalization experiences, and psychological status enhanced PTSD symptom	Effects of COVID-19 on survivors can also involve psychological aspects and last for many months after recovery
Moll et al[133], 2022	LS survey	Pre-pandemic survey, 1233 HCWs, of which 572 responded (46.5%): Female 408 (71.3%), male 127 (24.9%). Pandemic survey: Of 1422 clinicians, 710 (49.9%) responded to survey; female 529 (74.5%), male 146 (20.5%)	Burnout data collected March to May 2017 and June to December 2020, during the pandemic at Emory University, Atlanta (Georgia)	Burnout (MBI)	46.5% (572 respondents) in 2017 and 49.9% (710 respondents) in 2020 shown higher burnout symptoms. Nurses’ burnout prevalence increased with pandemic from 59% to 69% (P < 0.001), with increased EE and DP, and decreased PA. Other HCWs showed no differences in burnout levels between 2017 and 2020	Nurses are more at risk for burnout after the beginning of the COVID-19 pandemic
Groenveld et al[134], 2022	LS survey	Of 48 post-COVID-19 patients, 40 completed the survey: Female 68%, male 32%; median age 54 yr	Feasibility of virtual reality exercises at home for post-COVID-19 condition was investigated, between July 2020 and February 2021, in the southeast of the Netherlands	VR platform to reduce stress and anxiety and promote cognitive functioning	70% of participant report an advertising event during VR, but only 25% recall these events. 75% reports VR as having a positive influence on their recovery	VR physical exercises at home is feasible and safe with good acceptance
Lovell et al[135], 2023	LS online Survey	240 nursing staff, 8 permanent ICU consultants, 32 rotational registrars, 10 allied health staff members, and a team of 10 administrative and 20 operational support staff members of ICUs	A before-and-after interventional online study was conducted over a 2-yr period, between 2019 and 2021, in a 30-bed level-3 ICU within an Australian metropolitan teaching hospital	PERMA-Profiler, questionnaire to assess overall well-being (1 item), negative emotions (3 items: Sadness, anger, and anxiety), loneliness (1 item), and physical health (3 items)	Well-being scores after the intervention were not statistically different from BL. There are three key categories: Boosting morale and fostering togetherness, supporting staff, and barriers to well-being	Study findings may inform strategies for improving ICU staff members' well-being
Sun et al[136], 2022	C-S online survey	524 ICU nurses provided 340 valid questionnaires (64.89% actual rate); 313 females, 27 males; 229 (67.35%) married	Online questionnaire sent to ICU nurses of 15 Chinese provinces, December 2020 to January 2021	Tested calling (BCS) and resilience (BRCS) as related to thriving at work (TWS) and ethical leadership (ELS)	All variables strongly and positively correlated with each other. The high resilience group was closely associated with calling after adjusting for age, gender, marital status, and other factors	Nurses’ resilience underlies their promptness to stick to their duty and calling
Chommeloux et al[137], 2023	LS survey	Of 80 eligible patients, 62 patients supported by ECMO for severe ARDS were included in the study	Psychological disorders of ICU patients assessed at 6 and 12 mo after ECMO onset, March to June 2020 in 7 French ICUs	Anxiety, depression, PTSD, and QoL	Mental health is one of the most impaired domains: 44% of patients had significant anxiety, 42% had symptoms of depression and another 42% were at risk of PTSD, one year after admission to an ICU	Despite partial physical recovery one year after COVID-19, psychological function remains impaired

Calling, commitment to one’s duties due to internal or external value system prompts (must serve society and others, because of a supreme entity recommends so or because of one’s own beliefs). AACCN: American Association of Critical Care Nurses; AMC: Academisch Medisch Centrum; API: Apathy Motivation Index; ARDS: Acute respiratory distress syndrome; BCS: Brief Calling scale; BECLA: Batterie d’évaluation Cognitive du Language; BDI-II: Beck Depression Inventory Inventory-Second Edition; BL: Baseline; BRCS: Brief Resilient Coping Scale; BRIEF-A: Behaviour rating inventory of executive function; Brief COPE: Brief Coping Orientation to Problems Experienced; BRS: Brief Resilience Scale; BSI: Burnout Scale inventory; CBCL: Child Behaviour Checklist; CBI: Copenhagen Burnout Inventory; CD-RISC2: Two-item Connor-Davidson resilience index; CI: Confidence interval; C-S: Cross-sectional; CSS: Coping Stress Scale; DASS-21: Depression, Anxiety, and Stress Scale; DES: Dissociative Experience Scale; DP: Depersonalisation scale of the Maslach Burnout Inventory; ECMO: ExtraCorporeal Membrane Oxygenation; EDMCQ: Ethical Decision-Making Climate Questionnaire; EE: Emotional exhaustion of the Maslach Burnout Inventory; ELS: Ethical leadership scale; EPDS: Edinburgh Postnatal Depression Scale; EQ-5D-3L: Euro quality of life; ERQ: Emotion Regulation Questionnaire; ESS: Epworth Sleepiness Scale; FS-ICU: Family satisfaction with the intensive care unit survey; GAD-7: General Anxiety Disorder-7 Item; GMI: Goldberg Mania Inventory; GREFEX: Groupe de Réflexion sur l’Évaluation des Fonctions Exécutives battery; GSES: General Self-Efficacy Scale; HADS: Hospital Anxiety and Depression Scale; HCAHPS: Hospital Consumer Assessment of Healthcare Providers e Systems; HCP(s): Healthcare professional(s); HCW(s): Healthcare worker(s); HPCD: Healthcare providers; HUG: Geneva University Hospitals; ICU: Inventory of Callous-Unemotional Traits; ICU(s): Intensive care unit(s); ICU-VR: Intensive care unit - virtual reality; IES-R: Impact of Event Scale-Revised; IPAT: Intensive Care Psychological Assessment Tool; ISI: Insomnia Severity Index; K10: Kessler Psychological Distress Scale; LS: Longitudinal survey; MBI: Maslach Burnout Inventory; MBI-HSS: Maslach Burnout Inventory Human Services Survey for Medical Personnel; MD: Moral distress; MMD-HP: Measure of Moral Distress for Healthcare Professionals; -SP: Spanish version; MoCA: Montreal Cognitive Assessment; MMSE: Mini-Mental State Examination; MPAS: Maternal Postnatal Attachment Scale; NICU: Neonatal intensive care unit; NFRS: Numerical fear rating scale; PA: Personal accomplishment of the Maslach Burnout Inventory; PCL-5: Post-Traumatic Stress Disorder Checklist for Diagnostic and Statistical Manual of Mental Disorders-5^th Edition; PCQ: Psychological Capital Questionnaire; PICS: Post-intensive care syndrome; PICS-F: Post-intensive care syndrome-Family; PICU: Paediatric intensive care units; PDI: Peritraumatic Distress Inventory; PHQ-9: Patient Health Questionnaire-9; PHQ-ADS: Patient Health Questionnaire Anxiety and Depression Scale; PM: Pearlin Mastery Scale; PROQOL-5: Professional Quality of Life Scale; PsyCap: Positive psychological state, psychological capital; PSS-10: Perceived Stress Scale-10; PSS:NICU: Parental Stressor Scale:Neonatal intensive care unit; PTSD: Post-traumatic stress disorder; PTSS: Post-traumatic stress symptoms; QPC: Cognitive Complaints Questionnaire; QoL: Quality of life; Q3PC: Cognitive Screening, European AIDS Clinical Society cognitive screening questions; RESE: Regulatory, Emotional Self Efficacy Scale; RS-14: 14-item Resilience Scale; RSA: Resilience Scale for Adults; SAQ: Safety Attitude Questionnaire; SAS: Self-rating Anxiety Scale; SCL-90: Symptom Checklist 90; SDS: Self-rating Depression Scale; SFSW: Finnish Strongest Families Smart Website; SF-36 Questionnaire: Short Form Health Survey-36 item questionnaire; SRQ-20: Self-Reporting Questionnaire; SRSS: Self-rating sleeping situation scaling; TC: Teamwork climate; TMT: Trial making test; TSQ: Trauma Screening Questionnaire; TWS: Thriving at work scale; VAS: Visual Analogue Scale; VR: Virtual reality; WHO-5: World Health Organization Well-Being Index; WAIS: Wechsler Adult Intelligence Scale-Fourth Edition; WSAS: Work and Social Adjustment Scale.