Staff experiences,perceptions of care,and communication in the intensive care unit during the COVID-19 pandemic in Australia

BackgroundIn 2020, during the first wave of the COVID-19 pandemic in Australia, hospital intensive care units (ICUs) revised patient care practices, curtailed visiting, and augmented the use of personal protective equipment to protect patients, staff, and the community from viral transmission.AimThe aim was to explore ICU staff experiences and perceptions of care and communication with patients during the COVID-19 pandemic to understand how alternative ways of working have influenced work processes, relationships, and staff morale.MethodsThis was a qualitative exploratory design study using audio-recorded and transcribed interviews with 20 ICU staff members. Data were analysed using thematic analysis.FindingsFour major themes were derived from the data: (i) Communication and connection, (ii) Psychological casualties, (iii) Caring for our patients, and (iv) Overcoming challenges. Patient care was affected by diminished numbers of critical care qualified staff, limited staff entry to isolation rooms, and needing to use alternative techniques for some practices. The importance of effective communication from the organisation and between clinicians, families, and staff members was emphasised. personal protective equipment hindered communication between patients and staff and inhibited nonverbal and verbal cues conveying empathy in therapeutic interactions. Communication with families by phone or videoconference was less satisfying than in-person encounters. Some staff members suffered psychological distress, especially those working with COVID-19 patients requiring extracorporeal membrane oxygenation. Moral injury occurred when staff members were required to deny family access to patients. Workload intensified with increased patient admissions, additional infection control requirements, and the need to communicate with families using alternative methods.ConclusionThe results of this study reflect the difficulties in communication during the early stages of the COVID-19 pandemic. Communication between staff members and families may be improved using a more structured approach. Staff reported experiencing psychological stress when separating families and patients or working in isolation rooms for prolonged periods. A flexible, compassionate response to family presence in the ICU is essential to maintain patient- and family-centred care.     

Conditions and strategies to meet the challenges imposed by the COVID-19-related visiting restrictions in the intensive care unit: A Scandinavian cross-sectional study

ObjectivesTo examine conditions and strategies to meet the challenges imposed by the coronavirus disease 2019 (COVID-19)-related visiting restrictions in Scandinavian intensive care units.Research methodology/designA cross-sectional survey.SettingAdult intensive care units in Denmark, Norway and Sweden.Main outcome measuresLikert scale responses and free-text comments within six areas: capacity and staffing, visiting policies and access to the unit, information and conferences with relatives, written information, children as relatives and follow-up initiatives.ResultsThe overall response rate was 53% (74/140 participating units). All intensive care units had planned for capacity extensions; the majority ranging between 11 and 30 extra beds. From March–June 2020, units had a mean maximum of 9.4 COVID-19 patients simultaneously. Allowing restricted visiting was more common in Denmark (52%) and Norway (61%) than in Sweden where visiting was mostly denied except for dying patients (68%), due to a particular increased number of COVID-19 patients. The restrictions forced nurses to compromise on their usual standards of family care. Numerous models for maintaining contact between relatives and patients were described.ConclusionVisitation restrictions compromised the quality of family care and entailed dilemmas for healthcare professionals but also spurred initiatives to developing new ways of providing family care.     

Family support in intensive care units during COVID-19 visit ban: A multinational Delphi Study during first COVID-19 wave

ObjectivesThis study assessed opinions and experiences of healthcare professionals, former patients and family members during the first wave of the COVID-19 pandemic and focuses on challenges in family-centred care for intensive care unit patients and affected families.Research methodology/DesignA two-round modified Delphi process assessed the opinions and experiences of experts such as healthcare professionals, former patients and their families (n = 151).SettingThis study was conducted across four countries in Europe.ResultsIn total, 121 participants (response rate 80.13%) answered the first Delphi round; the second was answered by 131 participants (response rate 86.75%). Participants perceived family support in the intensive care unit as highly important during the COVID-19 pandemic. Enabling contact amongst patients, families and clinicians is regarded as essential to build hope and confidence in the treatment and the recovery process. The extraordinary situation led to the implementation of new communication structures such as video calls and websites.ConclusionA consensus was reached between healthcare professionals that virtual contact is essential for patients with COVID-19 and their families during visit restrictions. This should be done to establish confidence in the treatment.     

The end of life of patients with COVID-19 in intensive care unit and the stress level on their family members: A cross-sectional study

Background

During the Coronavirus disease 2019 (COVID-19) pandemic, hospital visits were suspended and video calls were offered to connect patients with their family members, especially toward the end of life (EoL).

Aim

The primary aim was to describe EoL care for COVID-19 patients dying in an intensive care unit (ICU). The secondary aim was to explore whether making video calls and allowing visits was associated with lower death-related stress in family members.

Design

Single centre cross-sectional study. The setting was the ICU of a COVID-19 center in northern Italy, during the first year of the pandemic. Data on patients who died in the ICU were collected; death-related stress on their family members was measured using the Impact of Event Scale-Revised (IES-R). The statistical association was tested by means of logistic regression.

Results

The study sample included 70 patients and 56 family members. All patients died with mechanical ventilation, hydration, nutrition, analgesia and sedation ongoing. Resuscitation procedures were performed in 5/70 patients (7.1%). Only 6/56 (10.7%) of the family members interviewed had visited their loved ones in the ICU and 28/56 (50%) had made a video call. EoL video calls were judged useful by 53/56 family members (94.6%) but all (56/56, 100%) wished they could have visited the patient. High-stress levels were found in 38/56 family members (67.9%), regardless of whether they were allowed ICU access or made a video call. Compared with other degrees of kinship, patients' offspring were less likely to show a positive IES-R score (odds ratio [OR] 0.22, 95% confidence interval [CI] 0.05 to 0.89).

Conclusions

During the first year of the COVID-19 pandemic, patients died without their family members at the bedside while on life-sustaining treatment. Stress levels were high in most family members, especially in patients' spouses. Video calls or ICU visits were judged favourably by family members but insufficient to alleviate death-related stress.

Relevance for Clinical Practice

During a pandemic, ICU access by patients' family members should be considered, particularly as the time of death approaches. Although generally appreciated by family members, EoL video calls should be arranged together with other measures to alleviate death-related stress, especially for the patient's spouse.     

Thematic analysis of intensive care unit diaries kept by staff: insights for caring

ObjectiveTo explore recurrent themes in diaries kept by intensive care unit (ICU) staff during the coronavirus disease 2019 (COVID-19) pandemic.DesignQualitative study.SettingTwo ICUs in a tertiary level hospital (Milan, Italy) from January to December 2021.MethodsICU staff members wrote a digital diary while caring for adult patients hospitalized in the intensive care unit for >48 hours. A thematic analysis was performed.FindingsDiary entries described what happened and expressed emotions. Thematic analysis of 518 entries gleaned from 48 diaries identified four themes (plus ten subthemes): Presenting (Places and people; Diary project), Intensive Care Unit Stay (Clinical events; What the patient does; Patient support), Outside the Hospital (Family and topical events; The weather), Feelings and Thoughts (Encouragement and wishes; Farewell; Considerations).ConclusionThe themes were similar to published findings. They offer insight into care in an intensive care unit during a pandemic, with scarce resources and no family visitors permitted, reflecting on the patient as a person and on daily care. The staff wrote farewell entries to dying patients even though no one would read them.Implications for clinical practiceThe implementation of digital diaries kept by intensive care unit staff is feasible even during the COVID-19 pandemic. Diaries kept by staff can provide a tool to humanize critical care. Staff can improve their work by reflecting on diary records.     

A co-design of clinical virtual care pathways to engage and support families requiring neonatal intensive care in response to the COVID-19 pandemic (COVES study)

BackgroundIn response to the COVID-19 pandemic, family presence restrictions in neonatal intensive care units (NICU) were enacted to limit disease transmission. This has resulted in communication challenges, negatively impacting family integrated care.AimTo develop clinical care pathways to ensure optimal neonatal care to support families in response to parental presence restrictions imposed during the COVID-19 pandemic.MethodsAn agile, co-design process utilizing expert consensus of a large interdisciplinary team and focus groups and semi-structured interviews with families and HCPs were used to co-design clinical virtual care pathways.ResultsThree clinical virtual care pathways were co-designed: (1) building and maintaining relationships between family and healthcare providers; (2) awareness of resources; and (3) standardized COVID-19 messaging. Modifications were made to optimize uptake and utilization in the clinical areas.ConclusionClinical care virtual pathways were successfully co-designed to meet these needs to ensure more equitable family centered care.     

‘Who will do it if I don’t?’ Nurse anaesthetists’ experiences of working in the intensive care unit during the COVID-19 pandemic

BackgroundDuring the COVID-19 pandemic, the workload on the intensive care unit (ICU) increased nationally in Sweden as well as globally. Certified registered nurse anaesthetists (CRNAs) in Sweden were transferred at short notice to work with seriously ill patients with COVID-19 in the ICU, which is not part of the CRNAs' specialist area. However, limited research has shed light on healthcare professionals’ experiences of the pandemic.ObjectivesThis study illuminates CRNAs’ experiences of working in the ICU during the COVID-19 pandemic.MethodsThis study used a qualitative method with an inductive approach to interview nurse anaesthetists who worked in the ICU during the COVID-19 pandemic.FindingsThe participants experienced ambivalent feelings towards their work in the ICU. They also lacked information, which created feelings of uncertainty and resulted in expectations that did not correspond to the reality. They described that owing to an inadequate introduction, they could only provide “sufficient” care, which in many cases caused ethical stress. Not being able to get to know their new colleagues well enough to create effective cooperation created frustration. Even though the participants experienced the work in the ICU as demanding and challenging, overall, they enjoyed their time in the ICU and were treated well by their colleagues.ConclusionsAlthough CRNAs cannot replace intensive care nurses, they are a useful resource in the ICU in the care of patients with COVID-19. Healthcare workers who are allocated from their ordinary units to the ICU need adequate information and support from their work managers to be able to provide the best possible care and to stay healthy themselves.     

Experiences of nurses with an innovative digital diary intervention in the intensive care unit: A qualitative exploration

IntroductionDiaries have been used regularly in various intensive care units (ICUs) in international settings. Hard copy diaries written by relatives became impractical during the COVID-19 pandemic due to ICU visiting restrictions and infection control considerations. The implementation of a web based application, named the “Post-ICU” diary, offered relatives the ability to collaboratively write in a digital diary, to easily upload photos, video and audio clips and to feel engaged with the patient at a safe distance. In addition it allowed nurses to easily provide up-to-date information. The aim of this pilot study was to explore the experiences of ICU nurses with the implementation process and application of the Post-ICU diary.MethodsA multicentre qualitative design with focus group interviews was used with ICU nurses in November 2020. Interview data were audiotaped and transcribed verbatim, and then a thematic analysis was performed to categorize the data.ResultsParticipants from three hospitals (n = 14), 57% of whom were women, with a mean age of 40.6 years, described their experiences with the Post-ICU diary. The following themes emerged: implementation process, COVID-19, integration, and motivation. The results showed that ICU nurses perceived the Post-ICU diary to be applicable in daily care and endorsed the added value of the digital Post-ICU diary as a new opportunity to improve interhuman connectedness. However, the nurses also experienced barriers such as non-user-friendly access, lack of time and hesitance to write short messages.ConclusionICU nurses reported that the Post-ICU diary had added value for patients and their relatives. However, in the beginning they also experienced barriers such as lack of time, insufficient integration with their own work processes, and challenges regarding writing short messages themselves. For structural embedding of the intervention, tailored strategies are needed to support ICU nurses in using this innovative Post-ICU diary.     

Cardiovascular nurses' experiences of working in the COVID-19 intensive care unit: A qualitative study

BackgroundCardiovascular nurses’ skills and experiences of cardiac critical care, management of cardiovascular emergencies, and mechanical circulatory support have been considered vital in providing nursing care for COVID-19 patients in intensive care units during the COVID-19 pandemic. To our knowledge, there are no studies have focused on the contribution and experiences of cardiovascular nurses in the critical care of COVID-19 patients.ObjectivesTo explore the experiences of cardiovascular nurses working in a COVID-19 intensive care unit during the pandemic.MethodsThe study was conducted as a qualitative study with phenomenological approach in June-December 2020. Study data were gathered from ten cardiovascular nurses through semi-structured interviews.ResultsSix themes emerged from the interview data: the duties and responsibilities in a COVID-19 intensive care unit; the differences of COVID-19 intensive care unit practices from cardiovascular practices; the transferrable skills of cardiovascular nurses in a COVID-19 intensive care unit; the difficulties encountered working in a COVID-19 intensive care unit; the difficulty of working with personal protective equipment; and the psychosocial effects of working in a COVID-19 intensive care unit.ConclusionCardiovascular nurses made an important contribution to the management of nursing services with their experiences and skills in the COVID-19 pandemic.     

Effective communication is key to intensive care nurses’ willingness to provide nursing care amidst the COVID-19 pandemic

BackgroundThe COVID-19 pandemic posed and continues to pose challenges for health care systems globally, particularly to Intensive Care Units (ICU). At the forefront of the ICU are highly trained nurses with a professional obligation to care for patients with COVID-19 despite the potential to become infected. The aim of this study was to explore ICU nurses’ willingness to care during the COVID-19 pandemic.MethodsA prospective cross-sectional study to explore ICU nurses’ willingness to provide care during the COVID-19 pandemic was undertaken between 25 March and 3 April 2020 at a large principal and referral teaching hospital in Sydney, NSW Australia.ResultsA total of 83 ICU nurses completed the survey. Approximately 60% reported receiving sufficient information from managers regarding COVID-19 and about caring for a patient with COVID-19. Ninety percent of nurses were concerned about spreading COVID-19 to their family. Sixty one percent of the nurses indicated that they were willing to care for patients with COVID-19. Receiving timely communication from managers was the only predictor of willingness to care among ICU nurses.ConclusionsEffective communication is a vital component during a public health emergency in order to promote nurses’ willingness to care for patients in the ICU.     

Factors that contributed to burnout among intensive care nurses during the COVID-19 pandemic in Saudi Arabia: A constructivist grounded theory

BackgroundIntensive care unit (ICU) nurses experience high levels of burnout during the COVID-19 pandemic due to multiple stressors. It has long been known that burnout is negatively associated with patient and staff outcomes. Understanding the triggers for intensive care nurses’ burnout during the pandemic can help to develop appropriate mitigation measures.ObjectiveThe objective of this study was to examine intensive care nurses’ experiences during the COVID-19 pandemic in Saudi Arabia to develop insights into the factors that influenced burnout.MethodsThe study was informed by a constructivist grounded theory design. The study was conducted in an adult ICU in a tertiary hospital in the Makkah province in the Kingdom of Saudi Arabia. All participants were registered nurses with at least 6 months’ experience in intensive care and experienced caring for COVID-19 patients.FindingsThis paper reports on preliminary findings from interviews with 22 intensive care nurses. A core category ‘pandemic pervasiveness’ was identified from the interview data, which makes reference to the ever-present nature of the pandemic beyond the ICU context. Family, work, and the wider world context are the three groups of contextual factors that influenced nurses' experience and perception of burnout.ConclusionMany issues identified from the findings in this study can be attributed to shortages in the intensive care nursing workforce. Thus, we join others in calling for healthcare organisations and policymakers to be creative in finding new ways to meet nurses' needs, motivate, and empower them to maintain and sustain the nursing workforce in highly demanding areas, such as ICUs. Nursing managers can play a crucial role in mitigating nurses’ burnout by identifying and tackling sources of stress that exist among their staff, specifically team conflict, workplace harassment, and discrimination.     

Family functioning of families experiencing intensive care and the specific impact of the COVID-19 pandemic: A grounded theory study

ObjectivesIn order to provide a deeper understanding of family functioning, the aim of this study was to identify, describe and conceptualise the family functioning of families where a formerly critically ill family member had stayed at the intensive care unit, with the impact of a pandemic.Research methodology/designThe study has a grounded theory design including interviews with eight families.SettingFormer adult intensive care patients cared for Covid-19 infection and their family. Eight patients and twelve family members from three different intensive care units.Main outcome measuresThe results presented are grounded in data and identified in the core category “Existential issues” and the categories “Value considerateness; Anxiety and insecurity in life; Insight into the unpredictability of life.”FindingsThe core category could be found in all data and its relationship and impact on the categories and each other. The core is a theoretical construction, whereas the family functioning of families where a formerly critically ill family member had stayed at the intensive care unit was identified, described, and conceptualised. Being able to talk repeatedly about existential issues and the anxiety and insecurity in life, with people that have similar experiences helps the patient and their family to consider and gain insight into the unpredictability of life, and thereby better cope with changes in life.ConclusionThere is awareness about the love that exists within the family. A willing to supporting each other in the family even if the critical illness made the family anxious and afraid.Implications for clinical practiceEven if the pandemic Covid-19 led to restrictions inhibiting family focused nursing, it is important to confirm the family as a part of the caring of the ICU patient. The patients are not alone, their family are fighting together for the future.     

Physical,social, mental and spiritual functioning of COVID-19 intensive care unit-survivors and their family members one year after intensive care unit-discharge: A prospective cohort study

ObjectiveTo describe the long-term functioning of patients who survived a COVID-19-related admission to the intensive care unit and their family members, in the physical, social, mental and spiritual domain.DesignA single-centre, prospective cohort study with a mixed-methods design.SettingThe intensive care unit of the University Medical Center Groningen in the Netherlands.Main outcome measuresTo study functioning 12 months after intensive care discharge several measurements were used, including a standardised list of physical problems, the Clinical Frailty Scale, the Medical Outcomes Study Short-Form General Health Survey, the McMaster Family Assessment Device, the Hospital Anxiety and Depression Scale, and the Spiritual Needs Questionnaire, as well as open questions and interviews with survivors and their family members.ResultsA total of 56 survivors (77%) returned the 12-month questionnaire, whose median age was 62 (inter-quartile range [IQR]: 55.0–68.0). Moreover, 67 family members (66%) returned the 12-month questionnaire, whose median age was 58 (IQR: 43–66). At least one physical problem was reported by 93% of the survivors, with 22% reporting changes in their work-status. Both survivors (84%) and their family members (85%) reported at least one spiritual need. The need to feel connected with family was the strongest. The main theme was ‘returning to normal’ in the interviews with survivors and ‘if the patient is well, I am well’ in the interviews with family members.ConclusionsOne year after discharge, both COVID-19 intensive care survivors and their family members positively evaluate their health-status. Survivors experience physical impairments, and their family members’ well-being is strongly impacted by the health of the survivor.     

Spiritual needs during COVID 19 pandemic in the perceptions of Spanish emergency critical care health professionals

ObjectivesTo investigate the perceptions and attitudes of health professionals working in emergency services and critical care units in Spain about spiritual care provided during the COVID-19 pandemic.MethodsA qualitative investigation was carried out using in-depth interviews.SettingEmergency and emergency and ICU health professionals from different regions of Spain.FindingsThe sample consisted of 47 nursing and one nursing assistant. The qualitative analysis yielded four main themes that reflect the following categories: “the experience with spirituality in clinical practice”; “resources and barriers to provide spiritual care”; “the COVID pandemic and spiritual care” and “training in spiritual care”. In addition, two subdeliveries were also obtained: “ethical dilemma” and “rituals of death”.ConclusionsThe majority of emergency and critical care nurses believe spiritual care is important to their clinical practice, but there are still several barriers to address patients’ spiritual needs. During the COVID-19 pandemic in Spain, professionals felt that spiritual beliefs have emerged as important needs of patients and the restrictions imposed by the pandemic made health professionals more exposed to ethical dilemmas and end-of-life religious issues. The general impression of health professionals is that more training and resources are needed on this topic.Implications for clinical practiceHealth professionals in emergency intensive care must provide nursing care that meets the spiritual needs of their patients to improve care in crisis situations such as the one suffered by the COVID-19 pandemic. For this, emergency services professionals must work and participate in the development of measures to overcome certain barriers present in emergency services, such as lack of time, lack of training and misconceptions that make it difficult to approach emergency services these needs.