Study-work experiences of UK critical care nurses during the COVID-19 'pandemic'

Important observations from those 'on the front-lines'

The Journal of Advanced Nursing (JAN) is a world-leading peer review nursing journal that contributes to the advancement of evidence-based nursing, midwifery and healthcare by disseminating research scholarship of contemporary relevance and with potential to advance knowledge for practice, education, management or policy.

Participants

Twenty-eight critical care nurses (CCN) working in ICU in the UK NHS during the COVID-19 pandemic took part in semi-structured interviews between May 2021 and May 2022. 21 participants from NHS Scotland, five from England and two from Wales. Twenty-three participants (82.1%) were female and five (17.9%) were male. Participants had a mean age of 39.

Job Demands

The job demand of role complexity was expressed as three types of demand, namely, patient acuity and complexity of care; the demands of having to work in PPE, and the demands associated with remote communication with relatives.

Early COVID-19 patients, typically with multiple and severe organ failure, who many described as “the sickest of the sick.’’ (CCN20)

Complexity was expressed in relation to the difficulties of treating patients with an unknown, unpredictable disease and the scarcity of treatment options, particularly during the first wave. As one CCN with 29 years of experience recalled, nursing COVID patients was “absolutely foreign.” (CCN22)

Others recounted undertaking complex care tasks for the first time, including: proning ventilated, unstable and often clinically obese patients, operating unfamiliar equipment, including anaesthetic ventilators typically used in theatres, or delivering care in satellite ICUs (e.g., in theatres or recovery rooms). As shown below, complexity was particularly acute for CCNs new to ICU:

Harms from working in PPE

Staff reported visual field disturbances, reduced tactile sensitivity and impaired spatial awareness, “we all hit our heads a lot on different pieces of equipment” (CCN 17). PPE also impacted verbal and non-verbal communication, by reducing visual cues and speech clarity, adding to the complexity of communicating with families, patients and staff:

A critical care nurse from the West of Scotland comments:

Role complexity: Remote communication

Several staff reflected on the overwhelming responsibility of being the only channel of communication between patients and relatives. While complex communication, particularly regarding end-of-life care was acknowledged to be a fundamental part of critical care nursing, delivering such sensitive information remotely, whilst also supporting relatives, was incredibly challenging:

Complexity was compounded by in person visits being prohibited; often families had a limited understanding of critical illness and most found it difficult to comprehend the gravity of their relatives' condition. Consequently, staff emphasized the need to consciously adapt and tailor their language in the recognition that “you couldn't show them the jargon” (CCN 15). Such complexity is perhaps best captured here:

Harms from PPE continued..

The physicality of working in COVID ICU was a salient demand. Almost all described “physical exhaustion” associated with the use of PPE, often with regards to overheating “I was sweating from my eye sockets, and a few times you were like, I'm going to faint” (CCN 13) from West of Scotland.

Moreover, due to infection control guidelines, staff were prohibited from bringing water onto the unit. This, combined with time demands from removing and putting on PPE when exiting and entering the unit resulted in most staff experiencing severe dehydration and headaches:

While physical effort represents a key job demand, staff also described considerable physical impairments or injury due to such heightened demands. This included, substantial weight loss or gain, back injuries, fainting, urine and kidney infections, hearing impairments and pressure sores: An East of Scotland CCN explains:

Job-demand: Emotional load

Within almost every interview, CCNs described the increased emotional burden of their work throughout the pandemic. The unknown nature of COVID-19 generated fear and anxiety among many staff, particularly during the first wave. This was heightened by harrowing reports from China and Italy and fears of transmission to themselves, colleagues and family: “COVID was a terrifying thing” (CCN 37).

Job Resources

For some staff, the absence of physical presence on the unit, particularly from senior nursing management was pronounced.

Health Impairments

Almost all staff described the relentless nature of working during the pandemic as physically and emotionally exhausting “my body has just been hammered.”

Post vaccinations? ‘The second wave broke me.’

Staffing

More than ever, CCN's described an “enormous” loss of staff from their units, using language such as “haemorrhaging” to capture the magnitude of this loss:

Conclusions

The NHS and healthcare providers globally are in the midst of a worsening staffing crisis, aggravated by the challenges of the pandemic (Health and Social Care Committee, 2022). The implementation of robust strategies to both promote recruitment and importantly, to support the well-being and retention of critical care staff are urgently required.

End

Links:

Full study- https://onlinelibrary.wiley.com/doi/10.1111/jan.15773