Vulnerabilities of nurses in an intensive care unit: an integrative review

an integrative review was held from 2006 to 2019, with searches on the platforms/databases LILACS, BDENF, SciELO, MEDLINE, Scopus, CINAHL, and Web of Science. The theoretical framework of ergology, by Schwartz, was used and the guiding question “What are the main vulnerabilities of nurses who work in an intensive care unit”?

Results:

eleven articles were included. Five topics of vulnerabilities emerged: physical, emotional, communication process, care process, and organizational. We observed that the organizational vulnerability was kept as a common and intersection factor in developing the other four.

Conclusions:

vulnerabilities found have a relationship to the physical, emotional, communication, care process, and institution organization elements. The organization aspect intersected with the others, configuring itself as the core in this context.

Descriptors:
Nurses; Review; Occupational Health; Work; Intensive Care Units

Acronym	Definition	Description
P	Problem/subject	Nurses who work in intensive care unit
I	Intervention	Vulnerabilities under ergology framework
C	Control or comparison	Vulnerabilities in all dimensions
O	Outcomes	Vulnerabilities in the work process of the nurse who work in an intensive care unit

Search strategy I
I (English)	(Intensive Care Units) AND (Vulnerability) AND (Team Nursing)
I (Portuguese)	(Unidades de Terapia Intensiva) AND (Vulnerabilidade em Saúde) AND (Equipe de Enfermagem)
Search strategy II
II (English)	(Vulnerability) AND (Intensive Care Units) AND (Nursing)
II (Portuguese)	(Vulnerabilidade) AND (Unidade de Terapia Intensiva) AND (Enfermagem)

Title ⁽*⁾	Year/ Country	Design/ number of patients	Results	STROBE^§ § STROBE - Strengthening the Reporting of Observational Studies in Epidemiology;	COREQ^# # COREQ - Consolidated Criteria for Reporting Qualitative Research.	Evidence
The body speaks: physical and psychologic aspects of the stress in nursing professionals⁽¹⁴14 Rodrigues CCFM, Santos VEP. The body speaks: physical and psychological aspects of stress in nursing professionals. Rev Pesqui: Cuid Fundam. 2015;7(4):3587-96. https://doi.org/10.9789/2175-5361.2016.v8i1.3587-3596 https://doi.org/10.9789/2175-5361.2016.v... ⁾	2016 BRAZIL	Qualitative n = 21	The body suffers the manifestations of stress. Among the symptoms most evident by the interviewees, physical and mental fatigue and muscle pain stand out.	-	30	VI
Psychosocial factors and mental workload: a reality perceived by nurses in intensive care unit⁽¹⁵15 Vásquez PC, González R, Fernaud H, Cabrera D, Klijn P, Moreno B. Psychosocial factors and mental work load: a reality perceived by nurses in intensive care units. Rev Latino-Am Enfermagem. 2015;23(2):315-22. https://doi.org/10.1590/0104-1169.0044.2557 https://doi.org/10.1590/0104-1169.0044.2... ⁾	2015 CHILE	Transversal n = 111	The participants pointed out a high level of exposure to psychosocial risks of psychological demand (64%) and double shift (57%). A medium to a high level of the mental load was also observed.	22	-	IV
Risk factors to nurse safety in the intensive care unit of a general hospital⁽¹⁶16 Albuquerque SGE, Castro RD, Ferreira GLS, Oliveira KL. Fatores de risco à segurança do enfermeiro na unidade de terapia intensiva de um hospital geral. Rev Bras Ciênc Saúde. 2015;19:135-42. https://doi.org/10.4034/RBCS.2015.19.02.08 https://doi.org/10.4034/RBCS.2015.19.02.... ⁾	2015 BRAZIL	Quantitative n = 15	Nurses reported an excessive workload; precarious working conditions; excessive noise in the work environment; feeling pain in the body and episodes of stress, triggered by living with pain, suffering and death.	21	-	VI
Quality of life in the work: repercussions for the health of intensive care nursing workers⁽¹⁷17 Ramos EL, Souza VDO, Gonçalves FGA, Pires AS, Santos DM. Quality of work life: repercussions for the health of nursing worker in intensive care. Rev Pesqui: Cuid Fundam. 2014;6(2):571-83. https://doi.org/10.9789/2175-5361.2014v6n2p571 https://doi.org/10.9789/2175-5361.2014v6... ⁾	2014 BRAZIL	Qualitative n = 15	The excessive workload causes physical and mental strain. This situation generates conflicts and repercussions in the worker's health in the form of stress and body pain.	-	27	VI
Medical malpractices and quality of life related to the health of nursing professionals in intensive care units⁽¹⁸18 Pelliciotti JSS, Kimura M. Medications errors and health-related quality of life of nursing professionals in intensive care units. Rev Latino-Am Enfermagem. 2010;18(6):1062-9. https://doi.org/10.1590/S0104-11692010000600004 https://doi.org/10.1590/S0104-1169201000... ⁾	2010 BRAZIL	Transversal n = 94	In this study, 19.1% of the health professionals reported having made medical malpractice in the month before the survey. The health professionals who reported the malpractice tended to have worsening health status.	21	-	VI
The stress of the nursing team in the intensive care unit: the nurse as a mediator⁽¹⁹19 Coronetti A, Nascimento ERP, Barra DCC, Martins JJ. The stress of the team of nursing in the intensive care unit: the nurse mediating. ACM Arq Catarin Med. 2006;35(4):36-43. Available from: https://www.acm.org.br/revista/pdf/artigos/394.pdf https://www.acm.org.br/revista/pdf/artig... ⁾	2006 BRAZIL	Qualitative n = 21	The main causes of stress reported were linked to the difficulty of interpersonal relationships, lack of human and material resources, work conditions, fair distribution of the activities, professional respect, and lack of psychological support service.	-	20	VI
The relationship between nurses clinical competence and Burnout in neonatal intensive care units⁽²⁰20 Soroush F, Boroujeni AZ. The relationship between nurses’ clinical competence and burnout in neonatal intensive care units. Iran J Nurs Midwifery Res. 2016;21(4):424-9. https://doi.org/10.4103/1735-9066.185596 https://doi.org/10.4103/1735-9066.185596... ⁾	2016 IRAN	Transversal n = 86	Regarding the nurses' strain, results shown emotional exhaustion, and an inverse association between burnout at work and clinical competence, so that greater clinical competence generates less burnout at work.	22	-	VI
Impact of noise on nurses in pediatric intensive care units⁽²¹21 Watson J, Kinstler A, Vidonish WP, Wagner M, Lin L, Davis KG, et al. Impact of noise on nurses in pediatric intensive care. Am J Crit Care. 2015; 24(5):377-84. https://doi.org/10.4037/ajcc2015260 https://doi.org/10.4037/ajcc2015260... ⁾	2015 USA	Transversal n = 15	The levels of noise in the intensive care units exceed the recommended limits. There was a statistically significant correlation of noise with the increase in heart rate of professionals.	22	-	VI
The need to nurse the nurse: emotional labor in neonatal intensive care⁽²²22 Cricco-lizza R. The need to nurse the nurse: emotional labor in neonatal intensive care. Qual Health Res. 2014;24(5):615-28. https://doi.org/10.1177/1049732314528810 https://doi.org/10.1177/1049732314528810... ⁾	2014 USA	Qualitative n = 114	Health professionals mainly reported the lack of recognition at work, in addition to the lack of emotional support.	-	30	V
Attitude of nurses in an intensive care unit in the face of a malpractice: an approach based on bioethical references⁽²³23 Coli RCP, Anjos MF, Pereira LL. The attitudes of nurses from an intensive care unit in the face of errors: an approach in light of bioethics. 2010;18(3):324-30. https://doi.org/10.1590/S0104-11692010000300005 https://doi.org/10.1590/S0104-1169201000... ⁾	2010 BRAZIL	Qualitative n = 14	The responsibility in the face of professional malpractice supposes the recognition of nurses' vulnerabilities.	-	23	VI
The nurses experience of barriers to safe practice in the neonatal intensive care unit in Thailand⁽²⁴24 Jirapaet V, Jirapaet K, Sopajaree C. The nurses' experience of barriers to safe practice in the neonatal intensive care unit in Thailand. J Obstet Gynecol Neonatal Nurs. 2006;35(6):746-54. https://doi.org/10.1111/j.1552-6909.2006.00100.x https://doi.org/10.1111/j.1552-6909.2006... ⁾	2006 THAILAND	Qualitative n = 27	Multiple limitations and vulnerabilities were widely associated with the lack of personnel, human susceptibility to malpractices, team miscommunication, and multiple designated tasks.	-	30	V

Themes	Author(s), year of publication
Physical fatigue and body aches due to excessive load and double working hours.	Rodrigues et al. (2016)⁽¹⁴14 Rodrigues CCFM, Santos VEP. The body speaks: physical and psychological aspects of stress in nursing professionals. Rev Pesqui: Cuid Fundam. 2015;7(4):3587-96. https://doi.org/10.9789/2175-5361.2016.v8i1.3587-3596 https://doi.org/10.9789/2175-5361.2016.v... ⁾ Coronetti et al. (2006)⁽¹⁹19 Coronetti A, Nascimento ERP, Barra DCC, Martins JJ. The stress of the team of nursing in the intensive care unit: the nurse mediating. ACM Arq Catarin Med. 2006;35(4):36-43. Available from: https://www.acm.org.br/revista/pdf/artigos/394.pdf https://www.acm.org.br/revista/pdf/artig... ⁾ Soroush et al. (2017)⁽²⁰20 Soroush F, Boroujeni AZ. The relationship between nurses’ clinical competence and burnout in neonatal intensive care units. Iran J Nurs Midwifery Res. 2016;21(4):424-9. https://doi.org/10.4103/1735-9066.185596 https://doi.org/10.4103/1735-9066.185596... ⁾ Jirapaet et al. (2006)⁽²⁴24 Jirapaet V, Jirapaet K, Sopajaree C. The nurses' experience of barriers to safe practice in the neonatal intensive care unit in Thailand. J Obstet Gynecol Neonatal Nurs. 2006;35(6):746-54. https://doi.org/10.1111/j.1552-6909.2006.00100.x https://doi.org/10.1111/j.1552-6909.2006... ⁾
Mental burden related to living with suffering and death.	Rodrigues et al. (2016)⁽¹⁴14 Rodrigues CCFM, Santos VEP. The body speaks: physical and psychological aspects of stress in nursing professionals. Rev Pesqui: Cuid Fundam. 2015;7(4):3587-96. https://doi.org/10.9789/2175-5361.2016.v8i1.3587-3596 https://doi.org/10.9789/2175-5361.2016.v... ⁾ Ceballos-Vásquez et al. (2015)⁽¹⁵15 Vásquez PC, González R, Fernaud H, Cabrera D, Klijn P, Moreno B. Psychosocial factors and mental work load: a reality perceived by nurses in intensive care units. Rev Latino-Am Enfermagem. 2015;23(2):315-22. https://doi.org/10.1590/0104-1169.0044.2557 https://doi.org/10.1590/0104-1169.0044.2... ⁾ Ramos et al. (2014)⁽¹⁷17 Ramos EL, Souza VDO, Gonçalves FGA, Pires AS, Santos DM. Quality of work life: repercussions for the health of nursing worker in intensive care. Rev Pesqui: Cuid Fundam. 2014;6(2):571-83. https://doi.org/10.9789/2175-5361.2014v6n2p571 https://doi.org/10.9789/2175-5361.2014v6... ⁾
Psychological demand of the health professionals and lack of support by the institution.	Ceballos-Vásquez et al. (2015)⁽¹⁵15 Vásquez PC, González R, Fernaud H, Cabrera D, Klijn P, Moreno B. Psychosocial factors and mental work load: a reality perceived by nurses in intensive care units. Rev Latino-Am Enfermagem. 2015;23(2):315-22. https://doi.org/10.1590/0104-1169.0044.2557 https://doi.org/10.1590/0104-1169.0044.2... ⁾ Coronetti et al. (2006)⁽¹⁹19 Coronetti A, Nascimento ERP, Barra DCC, Martins JJ. The stress of the team of nursing in the intensive care unit: the nurse mediating. ACM Arq Catarin Med. 2006;35(4):36-43. Available from: https://www.acm.org.br/revista/pdf/artigos/394.pdf https://www.acm.org.br/revista/pdf/artig... ⁾ Cricco-Lizza et al. (2014)⁽²³23 Coli RCP, Anjos MF, Pereira LL. The attitudes of nurses from an intensive care unit in the face of errors: an approach in light of bioethics. 2010;18(3):324-30. https://doi.org/10.1590/S0104-11692010000300005 https://doi.org/10.1590/S0104-1169201000... ⁾
Excessive load and poor work conditions, such as lack of human and material resources.	Albuquerque et al. (2015)⁽¹⁶16 Albuquerque SGE, Castro RD, Ferreira GLS, Oliveira KL. Fatores de risco à segurança do enfermeiro na unidade de terapia intensiva de um hospital geral. Rev Bras Ciênc Saúde. 2015;19:135-42. https://doi.org/10.4034/RBCS.2015.19.02.08 https://doi.org/10.4034/RBCS.2015.19.02.... ⁾ Coronetti et al. (2006)⁽¹⁹19 Coronetti A, Nascimento ERP, Barra DCC, Martins JJ. The stress of the team of nursing in the intensive care unit: the nurse mediating. ACM Arq Catarin Med. 2006;35(4):36-43. Available from: https://www.acm.org.br/revista/pdf/artigos/394.pdf https://www.acm.org.br/revista/pdf/artig... ⁾
Excessive noise in the work environment, which leads to constant stress.	Albuquerque et al. (2015)⁽¹⁷17 Ramos EL, Souza VDO, Gonçalves FGA, Pires AS, Santos DM. Quality of work life: repercussions for the health of nursing worker in intensive care. Rev Pesqui: Cuid Fundam. 2014;6(2):571-83. https://doi.org/10.9789/2175-5361.2014v6n2p571 https://doi.org/10.9789/2175-5361.2014v6... ⁾ Watson et al. (2015)⁽²²22 Cricco-lizza R. The need to nurse the nurse: emotional labor in neonatal intensive care. Qual Health Res. 2014;24(5):615-28. https://doi.org/10.1177/1049732314528810 https://doi.org/10.1177/1049732314528810... ⁾
Medical malpractices, especially in medication, presupposes a worse state of mental health for the professional.	Pelicciotti et al. (2010)⁽¹⁹19 Coronetti A, Nascimento ERP, Barra DCC, Martins JJ. The stress of the team of nursing in the intensive care unit: the nurse mediating. ACM Arq Catarin Med. 2006;35(4):36-43. Available from: https://www.acm.org.br/revista/pdf/artigos/394.pdf https://www.acm.org.br/revista/pdf/artig... ⁾ Coli et al. (2010)⁽²⁴24 Jirapaet V, Jirapaet K, Sopajaree C. The nurses' experience of barriers to safe practice in the neonatal intensive care unit in Thailand. J Obstet Gynecol Neonatal Nurs. 2006;35(6):746-54. https://doi.org/10.1111/j.1552-6909.2006.00100.x https://doi.org/10.1111/j.1552-6909.2006... ⁾ Jirapaet et al . (2006)⁽²⁵25 Ding Y, Yang Y, Yang X, Zhang T, Qiu X, He X, et al. The mediating role of coping style in the relationship between psychological capital and burnout among Chinese nurses. PLoS One [Internet]. 2015;10(4):1-14. https://doi.org/10.1371/journal.pone.0122128 https://doi.org/10.1371/journal.pone.012... ⁾

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[1] Corresponding author: Marcelli Cristine Vocci. E-mail: marcellivocci@hotmail.com