Australian Critical Care 33 (2020) 106e111

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Australian Critical Care

journal homepage: www.elsevier.com/locate/aucc

Review Paper

Intensive care nurses' well-being: A systematic review

Rebecca J. Jarden, RN, MN a, b, *
Margaret Sandham, BHSc (Nursing), DClinPsych b
Richard J. Siegert, PhD c
Jane Koziol-McLain, RN, PhD b
a
Department of Nursing, Melbourne School of Health Sciences, 161 Barry St, Carlton, Victoria 3053, Australia
b
School of Clinical Sciences, Auckland University of Technology (AUT), North Shore Campus, 90 Akoranga Drive, Northcote, Auckland 0627, New Zealand
c
School of Clinical Sciences and School of Public Health and Psychosocial Studies, Auckland University of Technology (AUT), North Shore Campus, 90
Akoranga Drive, Northcote, Auckland 0627, New Zealand

article information a b s t r a c t

Article history: Background and purpose: Unique work challenges of intensive care nurses can cause both stress and
Received 8 June 2018 distress to nurses, evident in prevailing literature regarding burnout, compassion fatigue, and moral
Received in revised form distress. Identifying factors contributing to intensive care nurses' well-being would complement this
18 November 2018
focus on nurse ill-being, supporting the development of workplace well-being initiatives. The review
Accepted 25 November 2018
seeks to balance the existing negatively skewed evidence base by investigating intensive care nurses'
well-being rather than ill-being.
Keywords:
Objectives: The objective of this review was to systematically identify, appraise, and synthesise primary
Critical appraisal
Critical care nurses
research reporting intensive care nurses' well-being.
Intensive care unit Methods: The electronic search strategy included (1) bibliographic databases for published work and (2)
Systematic review forward and backward citation searches. Key search terms included [critical OR intensive] AND [nurs*]
Well-being AND [well*]. Inclusion criteria were as follows: (1) population: critical or intensive care nurses working
with adult or mixed adult and paediatric patients, (2) study type: primary research studies, (3) outcome:
intensive care unit nurses' well-being, and (4) publication available in the English language. Studies were
excluded if the group of intensive care nurses was not independently reported. Included studies were
critically appraised, and results were synthesised and presented descriptively. Semantics of the included
studies were explored to identify frequently used terms.
Results: Four primary research studies met the inclusion criteria, focussing on spiritual well-being, team
commitment, emotional well-being, and the effects of a mindfulness programme. The studies were
heterogeneous in terms of study focus, definitions, and measures, with small sample sizes, and of var-
iable quality and generalisability.
Conclusions: The well-being of intensive care nurses is currently understudied. Conceptualising intensive
care nurses' well-being, understanding correlates of well-being, and testing workplace interventions to
improve well-being remain significant opportunities for future research.
© 2018 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

1. Background may experience a variety of potential psychological harms such as

The contemporary intensive care work environment requires
nurses to respond rapidly to complex situations, often with inde-
terminable patient outcomes. In this work environment, nurses
* Corresponding author: Tel.: þ61 3 9035 5511.
E-mail addresses: rebecca.jarden@unimelb.edu.au (R.J. Jarden), margaret.
sandham@aut.ac.nz (M. Sandham), richard.siegert@aut.ac.nz (R.J. Siegert), jane.
koziol-mclain@aut.ac.nz (J. Koziol-McLain).
burnout1,2 and moral distress.3 These harms have been the focus of
a large body of international research focussing on ill-being.4 More
recently, global leaders have called for a shift in our gaze from nurse
ill-being (or the ‘negative side’ of well-being) to nurse health and
well-being.5
The emerging field of positive psychology highlights the value in
balancing this focus on ill-being with equal focus on what makes
and enables a life worth living.6, pp. 1
2 Well-being research reso-
nates strongly with positive psychology, exploring “the balance

https://doi.org/10.1016/j.aucc.2018.11.068
1036-7314/© 2018 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.
 R.J. Jarden et al. / Australian Critical Care 33 (2020) 106e111
point between an individual's resource pool and the challenges
faced”.7, p. 230 Both locally8 and globally,5 the vision is to achieve a
health and disability system that focuses on well-being and pre-
vention. To realise this vision and capitalise on the new opportu-
nities arising from fields such as applied positive psychology, this
systematic review seeks to expose the existing intensive care unit
(ICU) nurses' well-being evidence base.
2. Objectives
The objectives were to 1) systematically identify and synthesise
primary research studies reporting intensive care nurses' well-be-
ing and 2) critically appraise the methodological quality of the
study properties using the relevant quality assessment checklist.
3. Methods
The systematic review followed the Preferred Reporting Items
for Systematic Review and Meta-Analysis.9 In addition, the review
explored the text of the studies using the qualitative data analysis
software NVivo™ (QRS International, Victoria AU) to identify
commonly used terms in the intensive care nurses' well-being
literature. No protocol was published.
3.1. Review inclusion criteria
There were four inclusion criteria for this review: (1) population:
critical or intensive care nurses working with adult or mixed adult
and paediatric patients, (2) study type: primary research studies, (3)
outcome: ICU nurses' well-being, and (4) publication available in
the English language. Studies were excluded if findings for the
group of intensive care nurses were not independently reported.
3.2. Search strategy
A two-staged electronic search strategy was used to identify
studies that met the inclusion criteria: (1) electronic bibliographic
databases for published work and (2) forward and backward citation
searches. The following electronic databases were searched: Ovid,
PsycINFO, EBSCO Health databases, Scopus; the US National Library
of Medicine (PubMed); and Web of Science Core Collection. The
search was conducted in July 2017. Neither date nor country limiters
were applied. Grey literature was not searched. The database key
search terms included [critical OR intensive] AND [nurs*] AND
[well*]. A sample of the search strategy is provided in Appendix 1.
3.3. Study screening
Study titles and abstracts were reviewed for potential inclusion
by the first author (R.J.), and duplicates were removed. Studies were
excluded at this point if they did not report ICU nurses' well-being
as an outcome. Then, two reviewers (R.J. & M.S.) independently
read and assessed the full-text manuscripts against the inclusion
criteria (Appendix 2). Ambiguity was resolved in consultation with
a third reviewer (J.K.M.).
3.4. Data extraction
A data extraction form (Appendix 3) included the following el-
ements: study location, research design, well-being definition/s,
well-being dimension/s measured, well-being measure/s, sample
size (n), participant characteristics, intervention (if appropriate),
analyses, and main outcomes. Full-text studies were imported to
NVivo™.
107
3.5. Quality assessment
The included studies were appraised using one of three relevant
critical appraisal tools. For surveys, the cross-sectional appraisal
tool of the Center for Evidence-Based Management (CEBMa)10 was
used; for grounded theory, the qualitative appraisal tool of Critical
Appraisals Skills Programme11 was used; and for quasi-experi-
mental, the quasi-experimental appraisal tool of Greenhalgh et al.12
was used.
3.6. Data analysis
Results are synthesised and presented descriptively owing to
the heterogeneity of the eligible studies. Semantics of the included
studies are explored using NVivo's™ word frequency search for the
1000 most frequent words with a minimum length of four letters.
Common ‘stopwords’ (terms such as ‘were’ and ‘this’) were
excluded from the word frequency search. The word frequencies
are presented as a word cloud.
4. Results
4.1. Identification of studies
Database searches identified 1652 documents, with three
additional records from citation searches. After removal of dupli-
cates and title and abstract screening for potential inclusion, four
full-text articles were assessed and met the inclusion criteria. The
primary reason for exclusion was studies not reporting ICU nurses'
well-being as an outcome. The search strategy results are shown in
Fig. 1.
The characteristics of the four studies that met inclusion
criteria13e16 are summarised in Table 1. The included studies were
all primary research studies that varied in their research focus.
Research areas included spiritual well-being,13 team commit-
ment,16 effects of a mindfulness programme,14 and emotional well-
being.15 Three of the research methodologies were quantita-
tive,13,14,16 and one was a qualitative study.15 Research extended
through Iran,13 Italy,16 Malaysia,14 and Australia.15 Publications
were predominantly in nursing journals and included Nursing in
Critical Care, Australian Journal of Advanced Nursing, Applied
Nursing Research, and Journal of Caring Science. The number of
participants ranged from 15 (grounded theory) to 222 (survey). In
total, 387 ICU nurses participated in the four studies.
4.2. Overview and synthesis of included studies
The findings of the four included studies are now summarised
individually and then synthesised in terms of well-being definitions,
word frequencies, and well-being measures. First, Azarsa et al.13
identified in their survey of 109 Iranian ICU nurses that the higher
the nurses' spiritual well-being and the more positive their attitude
was towards spiritual care, the more they could provide spiritual
care to patients. Second, Galletta et al.16 found in their survey of 222
Italian ICU nurses that the relationship between nursing work
characteristics and team commitment was mediated by both
perceived supervisor support and job satisfaction, which in turn
strengthen individualeorganisation relationships and well-being.
Third, Hee Kim et al.14 identified in their quasi-experimental study
of 41 Malaysian ICU nurses that a mindfulness-based cognitive
therapy intervention demonstrated significant improvements in the
level of perceived stress, stress, anxiety, depression, mindfulness,
and happiness, with a moderate to large effect size. Fourth,
Siffleet et al.15 found in their grounded theory study of 15 Australian
ICU nurses five key categories and described the maintenance of
108 R.J. Jarden et al. / Australian Critical Care 33 (2020) 106e111

Records idenƟfied through

database searching:
AddiƟonal records
EBSCOhost (n = 488) idenƟfied through
Ovid psycINFO (n = 385) citaƟon searches
IdenƟficaƟon
Pubmed (n = 207)
Scopus (n = 396) (n = 3)
Web of Science (n = 176)

Total (n = 1652)

Records aŌer
duplicates removed
Screening
(n = 1020)
Records excluded for
not reporƟng ICU
Title and abstract nurse well-being as an
screened outcome

(n = 1020) (n = 1016)

Eligibility
Full-text arƟcles Full-text arƟcles
assessed for eligibility excluded
(n = 4) (n = 0)

Studies included
Included
(n = 4)

Fig. 1. Flow chart of search strategy results. ICU, intensive care unit.

emotional well-being for ICU nurses: ‘achieving best care’, ‘caring for
the patient's family’, autonomy within the ICU environment’,
‘teamwork’, and ‘previous nursing and life experience’. Across the
four studies, ‘relationships’ was the only feature common to more
than one study, as presented in the studies of Galletta et al.16 (as
support) and Siffleet et al.15 (as teamwork).
The present review intended to extract and compare definitions
of well-being. However, none of the four studies specifically
defined well-being or their focal area of well-being (e.g., spiritual
well-being or emotional well-being). The authors do broadly
discuss well-being terms of their study focus. Azarsa et al.13
discuss well-being in terms of spirituality and spiritual well-be-
ing, stating that “spiritual well-being is one of the most important
factors in human health and healthy lifestyle” (p.309). They
describe spiritual well-being as a “coordinated and integrated
connection between the internal forces” (p.309). Galletta et al.16
discuss well-being in terms of quality of working life, suggesting
that “improving nursing QWL (quality of working life) is crucial for
the well-being and effectiveness of an organization” (p.146) and
highlighting the links between the characteristics of nursing
practice and employees' general well-being. Hee Kim et al.14 discuss
well-being in relation to a measure of mindfulness and subjective
happiness. Siffleet et al.15 discuss well-being in terms of emotional
well-being. When describing the results from their study, they
suggest that emotional well-being is characterised by the “feelings
of happiness, enjoyment and personal satisfaction … experienced
when nurses felt that they had done their best” (p.306).
The present review also intended to identify measures of well-
being used in ICU nursing research; however, despite drawing
conclusions specifically stating the term ‘well-being’, only one of the
four studies included specific well-being measures.13 This was a
specific 10-item measure of spiritual quality of life, originally
developed by Paloutzian and Ellison.17 The measure has two sub-
scales: (1) religious well-being and (2) existential well-being. Val-
idity and reliability of the measure were reported by study authors.13
Exploration of the words extracted from each of the four studies
highlighted that the most frequently documented words were
emotional (n ¼ 25), experience (n ¼ 20), families (n ¼ 18), family
(n ¼ 18), stress (n ¼ 18), spiritual (n ¼ 15), anxiety (n ¼ 14), satis-
faction (n ¼ 14), and support (n ¼ 13). The top 100-word frequency
report (NVivo™) is illustrated as a word cloud (Fig. 2). The terms
‘emotional’ and ‘stress’ were evident in all four studies. ‘Emotional’
was most commonly combined with terms such as ‘needs’ and
‘distress’13; socio-emotional needs of employees;16 well-being,
exhaustion, dissatisfaction, barriers, fallout, and the avoidance of
distress to maintain well-being15; and negative emotional states.14
‘Stress’ was most commonly associated with the challenges of
working in an ICU and was evident both as a word on its own or
 R.J. Jarden et al. / Australian Critical Care 33 (2020) 106e111 109

Table 1
Characteristics of included studies.

Author Location Study focus Intervention Research design Outcome measures Sample Findings
size (n)

Azarsa et al.13 Iranian ICU Spiritual N/A Survey SWS, SCRS, and SCCS 109 The higher the nurses' spiritual well-being and
well-being the more positive their attitude was towards
spiritual care, the more they could provide
spiritual care to patients.
Galletta et al.16 Italian ICU Team N/A Survey Adapted NWI-R, WDQ, 222 Nursing work characteristics are directly
commitment SPOS, QSO, and OCQ related to team commitment. The nursing work
characteristics and team commitment
relationship was mediated by both perceived
supervisor support and job satisfaction, which
in turn strengthen individualeorganization
relationships and well-being.
Hee Kim et al.14 Malaysian Mindfulness Mindfulness-based Quasi-experimental PSS, DASS, MAAS, 41 Significant improvements in the level of
ICU cognitive therapy and SHS perceived stress, stress, anxiety, depression,
mindfulness, and happiness, with a moderate to
large effect size. Well-being outcome measures
were reportedly the MAAS and SHS.
Siffleet et al.15 Australian Emotional N/A Grounded theory N/A 15 Five key categories described the maintenance
ICU well-being of emotional well-being for ICU nurses:
‘achieving best care’, ‘caring for the patient's
family’, autonomy within the ICU environment’,
‘teamwork’, and ‘previous nursing and life
experience’.

N/A, not applicable; PSS, Perceived Stress Scale; DASS, Depression Anxiety Stress Scale; MAAS, Mindfulness Attention and Awareness Scale; SHS, Subjective Happiness Scale;
SWS, Spiritual Well-Being Scale; SCRS, Spiritual Care Rating Scale; SCCS, Spiritual Care Competence Scale; NWI-R, Nursing Work Index-Revised; WDQ, Work Design Ques-
tionnaire; SPOS, Survey of Perceived Organizational Support; QSO, Questionnaire of Organizational Satisfaction; OCQ, Organizational Commitment Questionnaire; ICU,
intensive care unit.

extended to form terms such as ‘moral distress’, ‘stressors’, and
‘distress’. The second most frequently presented word was ‘expe-
rience’. ‘Experience’ was related to positive work experiences,
satisfaction with job experience and perceived support, lack of
experiences of teamwork, the experiences of identification and
commitment among ICU staff nurses16, and how different situa-
tions were managed, including the negative impact extensive
nursing experience could have, for example, resulting in exhaustion
due to these nurses being overexposed to complex patients.15 In
Fig. 2. Exploratory NVivo™ word frequency cloud for the four included full-text
documents. Note: Figure from NVivo's™ word frequency query illustrating the 1000
most frequent exact word matches with minimum length of four characters. Word font
size represents frequency, with larger font indicating more commonly used words.
sum, the overview and synthesis of the studies highlight four very
disparate studies in terms of study focus, definitions, and measures.
The one commonality was the use of the terms ‘emotional’ and
‘stress’. The studies are now quality appraised to determine their
individual empirical rigour.
4.3. Quality assessment
Both studies using surveys13,16 were quality appraised using the
cross-sectional appraisal tool of the CEBMa.10 Of the 12 appraisal
items, Azarsa et al.13 clearly met six. In the study by Galletta et al.,16
nine of the appraisal items were met, with the remaining three
unclear. Strengths were clearly focused research aims and having
response rates of 68%16 and 78%.13 However, neither study identi-
fied sample size considerations for statistical power, reducing the
potential for scientifically valid results.18 Authors reported measure
validity and reliability, and results included statistical significance
analysis with confidence intervals. However, the potential for
confounders was only briefly acknowledged and dismissed in one
study13 and not the other.16 Overall, generalisability of results was
minimal in both studies because of the unique participant de-
mographics of each study's convenience samples.
The quasi-experimental pretest/posttest study of a mindfulness-
based cognitive therapy intervention14 was appraised using the
quasi-experimental appraisal tool of Greenhalgh et al.12 Of the 11
items in the checklist, Hee Kim et al.14 clearly met six of the items.
Key limitations to the study included their design; either a rando-
mised or nonrandomised controlled study rather than their quasi-
experimental design could have strengthened their research.
Although their research was clearly defined, it was difficult to
ascertain whether the intervention was independent of other
changes over time. The intervention adapted the original eight-
week intervention to five weeks to reduce the nurses' workload;
however, 10% of participants did not complete the programme, and
just 60% attended the programme all five weeks. Given this level of
dropout and the lack of a measure of compliance with the associ-
ated activities, it is difficult to ascertain the feasibility of the
intervention from a resourcing and workload perspective. The two
110 R.J. Jarden et al. / Australian Critical Care 33 (2020) 106e111
time points of data collection, validity and reliability of the primary
outcome measures, and quantitative measures recorded before and
after the programme provided data to enable reliable statistical
inference. Longer follow-up with further time points for data
collection may have demonstrated sustainability.
The Critical Appraisals Skills Programme11 qualitative appraisal
tool was used to explore the grounded theory study of Siffleet
et al.15. Of the 10 items of this appraisal, nine were met and sug-
gested that the study was credible, relevant, and rigorous. For
example, Siffleet et al.15 used an appropriate qualitative method-
ology and research design to explore a clearly stated research aim.
The recruitment strategy appeared appropriate to the aim of the
research, as were the methods used to collect data. The one aspect
not addressed was related to reflexivity. Researchers did not
disclose any information pertaining to their relationship with par-
ticipants, so reflexivity was not analysed.
To summarise, the quality assessment of the four studies
demonstrated similar heterogeneity to the studies themselves.
There was variable quality with both strengths and limitations. The
key strengths in the study by Azarsa et al.13 were the clear research
aims and response rate of 78%, and a limitation was the lack of
documented sample size considerations. Similarly, for the study by
Galletta et al.,16 the strength was the clear research aims, and the
absent sample size considerations were a limitation. For the study
by Hee Kim et al.,14 a strength was their clearly stated research
question; however, the study was limited by the potential for
confounders. For the study by Siffleet et al.,15 the strength was
evident in their methods, with a limitation of the lack of docu-
mented reflexivity, although it was unclear whether this would
have been necessary. One important limitation extending across
the studies was the lack of generalisability of their findings, pri-
marily due to study design or sample size.
5. Discussion
Research exploring intensive care nurses' well-being was found
to be largely absent in the existing published primary studies. Even
within the four identified studies investigating well-being, features
of ill-being were evident, illustrated in the exploratory word cloud
where terms such as stress, anxiety, distress, and depression were
prevalent. High-quality research design was even less visible. These
findings reflect broader employee well-being research. A system-
atic review of longitudinal studies that investigated employee well-
being constructs found that a majority of the 40 identified studies
focussed on ill-being or the “negative side” of employee well-be-
ing.4 For example, more than half of the studies focused on burnout.
This paucity of well-being research reflects a similar gap in the
broader theoretical conceptions of both nurse and intensive care
nurses' well-being, with the overwhelming focus on stress, fatigue,
and burnout.2,3,19e27
The feature of ‘relationships’ in two of the included studies15,16
reflects the wider well-being literature on healthcare system per-
formance.28 The review of Ray-Sannerud et al.28 identified positive
and negative determinants associated with healthcare workers'
well-being and their potential risk and contribution to system
performance. Positive determinants such as empowerment, quality
sleep, and positive workplace relationships were associated with
high performance, patient satisfaction, and lower turnover in-
tentions. Negative determinants such as burnout, psychological
distress, and poor social capital were associated with suboptimal
patient care, unprofessional conduct, and medical leave. The
importance of relationships also underpins strengths-based lead-
ership, for example, magnet hospitals.29
Key components of strengths-based nursing leadership are
proposed by Gottlieb et al.30 and include (1) working with the
whole, appreciating the interrelationship among parts; (2) recog-
nising uniqueness of staff, nurse leaders, and the organisation; (3)
creating work environments that promote nurses' health and fa-
cilitates development; (4) understanding the significance of sub-
jective reality and created meaning; (5) valuing self-determination;
(6) recognising that person and environment are integral and that
nurses function best when there is a ‘goodness of fit’ that capitalises
on their strengths; (7) creating environments that promote
learning and recognise the importance of readiness and timing; and
(8) investing in collaborative partnerships. The potential stressors
of ICU nursing provide significant opportunities to draw from
psychological capital (such as personal psychological
strengths) and the strengthening evidence base of positive psy-
chology and positive psychological interventions.31e34 An example
of an initiative in which the “positive” has been added to an orga-
nisation includes the Brilliance Project.35 Also, using the positive
organisational scholarship lens and a foundation of the humanistic
work ideology, the Big Hospital study examined an organisation
driven by humanitarian principles.36
Of the four studies included in the review, mindfulness, spiri-
tuality, emotional well-being, and team commitment were the key
research areas.13e16 Both mindfulness and spirituality have recently
been identified by critical care nurses as strengtheners of their
work well-being,37 with mindfulness being linked to both
improved well-being and productivity.38 Spirituality is also asso-
ciated with enhanced well-being in relation to improved connect-
edness with nature,39 and for nurses, it has been linked with
reduced emotional exhaustion.40 The role of positive emotions in
promoting resilience and well-being has a strong evidence base
underpinned by Fredrickson's broaden-and-build theory of positive
emotions.41 Finally, team commitment predicts collaboration be-
tween the interprofessional team, for example, nurses and physi-
cians,42 and is increasingly linked with transforming organisations
and effectiveness.43
Research investigating what is going well in people's lives is
an evolving research area, propelled by researchers and theorists
such as Peterson44 who suggested “what is good about life is as
genuine as what is bad and therefore deserves equal attention”
(p. 4). Positive psychology is just one area where this is evident,
promoting the exploration of what makes life worth living.6 This
review reflects an opportunity to balance the traditional model
of healing and repair45 with a model of health promotion and
prevention, for example, balancing recovery models with those
driving strengths,46 thriving,47 flourishing,6,48 resilience,49 and
optimal functioning.50 One such model is that of Seligman6 who
proposes five elements: positive emotion, engagement, positive
relationships, meaning, and accomplishment. These measurable
elements are thought to contribute to well-being, but no one
element specifically defines (nor operationalises) well-being.
Thus, this review's focus on well-being supports the develop-
ment of research programmes, potentially drawing from these
proposed models such as positive emotion, engagement, positive
relationships, meaning, and accomplishment, in investigating
health promotion and the prevention of ill-being, such as
burnout.
The present review is limited by not publishing the protocol;
given this, the research has been guided by the Preferred Reporting
Items for Systematic Review and Meta-Analysis9 to support the
reporting and rigour of the study. A second limitation was the broad
search terms, e.g., [well*]. Although the intent was to ensure the
variations in the spelling of well-being were captured, the impact
was to obtain a much larger nonspecific data set than was likely
necessary. Grey literature was not searched, nor were field experts
approached; thus, there is a possibility of an associated publication
bias influencing this study's results.
 R.J. Jarden et al. / Australian Critical Care 33 (2020) 106e111
6. Conclusions
Intensive care nurses' well-being is both understudied and un-
defined. In all the four heterogeneous studies identified, sample
sizes were small, and generalisability was low. The complexity and
unavoidable pressure of critical care nursing provides a unique
opportunity to balance existing research focused largely on ill-be-
ing with an equivalent emphasis on well-being. The future research
agenda is to engage with the key stakeholders, intensive care
nurses, to explore their conceptions of well-being, improve un-
derstanding of the correlates of well-being, and to test workplace
interventions to improve well-being.
Funding and financial disclosure
This research has not received funding.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.aucc.2018.11.068.
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