Registered nurses' experiences of working in the intensive care unit during the COVID‐19 pandemic

Abstract Background During the pandemic, increased numbers of patients requiring intensive care unit (ICU) admission required an increase in ICU capacity, including ICU staffing with competence to care for critically ill patients. Consequently, nurses from acute care areas were called in to staff the ICU along with experienced intensive care nurses. Aims and objectives To describe Swedish registered nurses' experiences of caring for patients with COVID‐19 in ICUs during the pandemic. Design Mixed method survey design. Methods An online questionnaire was distributed through social media to registered nurses who had been working in the ICU during the COVID‐19 outbreak. Data were collected for 1 week (May 2020) and analysed using content analysis and descriptive statistics. Results Of the 282 nurses who participated, the majority were ICU nurses (n = 151; 54%). Half of the nurses specialized in ICU reported that they were responsible for the ICU care of three or more patients during the pandemic (n = 75; 50%). Among non‐intensive care nurses, only 19% received introduction to the COVID‐19 ICU (n = 26). The analysis of data regarding nurses' experiences resulted in three categories: tumbling into chaos, diminished nursing care, and transition into pandemic ICU care. Participants described how patient safety and care quality were compromised, and that nursing care was severely deprioritized during the pandemic. The situation of not being able to provide nursing care resulted in ethical stress. Furthermore, an increased workload and worsened work environment affected nurses' health and well‐being. Conclusions The findings from the present study indicate that nurses perceived that patient safety and quality of care were compromised during the pandemic. This resulted in ethical stress among nurses, which may have affected their physical and psychosocial well‐being. Relevance to clinical practice The COVID‐19 pandemic had a severe impact on nurses' work environment, which could result in burnout and staff turnover.

Relevance to clinical practice: The COVID-19 pandemic had a severe impact on nurses' work environment, which could result in burnout and staff turnover. which on 11th March 2020 was characterized as a pandemic and started to spread throughout the world. 1 In Sweden, the pandemic peaked during March to May 2020, resulting in higher intensive care unit (ICU) needs. Before the pandemic, Sweden had a total of 526 ICU beds, but only 207 beds provided a full spectrum of monitoring and life support technologies (level III units). 2 From a European perspective, Sweden had the second lowest number of intensive care beds (5.8 beds per 100 000 inhabitants) in Europe (range 4.2-29.2 beds) even before COVID-19. 3 While increasing ICU capacity implies increasing hospital beds, equipment, and pharmaceuticals, it is a real challenge to increase ICU staffing with competence to care for seriously ill patients. National data from Swedish health care providers have shown a lack of both registered and specialized nurses throughout Sweden, especially in emergency care. 4 2 | BACKGROUND COVID-19 is associated with severe conditions that require intensive care in approximately 5% of cases 5 ; the most common reason for intensive care is acute respiratory distress syndrome and the need for mechanical ventilation. 6 According to Swedish intensive care registry data, there was an increase in ICU care days from 20 566 days in 2019 to 40 214 days in 2020 (April-May). 7 To meet the need for staffing, health care personnel from non-ICU areas were transferred to the ICU setting. The outcomes in patient care as well as future resilience for treating COVID-19 patients depend heavily on the competence, stamina, and well-being of nurses who treat patients during the pandemic. The average ICU stay increased to 5.25 days (April-May 2020) compared with 2.65 days (April-May 2019). During the same period, the overall ICU mortality, which includes patients with and without COVID-19, increased from 7.45% (2019) to 9.4% in 2020. 7 A recently published meta-analysis showed that the pooled prevalence of ICU mortality among confirmed COVID-19 patients was 39%. 8 However, because national data presented in this study included ICU patients with and without COVID-19, the mortality rates between Sweden and other countries are difficult to compare. Mental health outcomes among frontline health care workers during COVID- 19 have previously been described and include post-traumatic stress symptoms as well as other psychological distress symptoms. 9 However, little is known about how nurses experienced working in the ICU during the acute phase of the COVID-19 pandemic. This knowledge is vital to enhance quality of care, patient safety, and staffs' work environment during future pandemics.

| AIM
The present study aimed to describe Swedish registered nurses' experiences of caring for patients with COVID-19 in ICUs during the pandemic.

| METHODS
A mixed method survey was developed based on the checklist for reporting results of internet surveys. 10 This study was conducted and reported adhering to the consolidated criteria for reporting qualitative research guidelines. 11 What is known about this topic • Nurse staffing levels and competence are associated with favourable patient outcomes.
• Increasing the ICU capacity during a pandemic implies increased ICU staffing, yet there is a general lack of registered nurses with competence to care for seriously ill patients.
• Frontline health care workers during pandemics might experience post-traumatic stress and psychological distress.
What this paper adds • Nurses described that patient safety in the ICU was compromised during the initial phase of the pandemic.
• Nurses transferred to work in the ICU required training and proper introduction and often lacked support.
• Nursing care was severely deprioritized during the pandemic, which was attributed to lack of time, resources, and competence needed.
• The notion of being unable to provide crucial elements of nursing care resulted in ethical stress among nurses.

| Setting and sample
The study was conducted in Sweden with nurses who were working in the ICU during the COVID-19 outbreak. In Sweden, registered nurses specializing in intensive or anaesthetic care undertake additional specialist training, including a 1-year master's degree. In Swedish ICUs, the nurse-to-patient ratio is normally 1:1-2. The speciality is multidisciplinary, and the team caring for critically ill patients consists of specialist nurses, nurse assistants, specialist physicians, and physiotherapists. This study used a convenience sampling approach. 12 Potential participants were specialized in either ICU or anaesthesia.
Participants were invited through the Facebook page of the Swedish Association for Anaesthesia and Critical Care Nurses. The Facebook page is public and might therefore have followers from other specialities as well.

| Questionnaire
An online questionnaire was developed by an expert group consisting of intensive care and anaesthesia specialist nurses (n = 4). Before distribution, the questionnaire was reviewed by a reference group of intensive care and anaesthesia care nurses (n = 4) and minor revisions of items were made. As the primary purpose of the present questionnaire was to collect experience of nurses working in the frontline of the pandemic, no further reliability or validity testing was performed.

| Data analysis
Quantitative data were processed by Excel and presented using descriptive statistics (frequencies and percentages). Qualitative data were analysed using manifest content analysis, with an inductive approach. 13 Answers from the open-ended questions were read and assimilated into the data to achieve an overall perspective. Thereafter, data were condensed and coded into categories. Categories were then reviewed and revised, findings were summarized, and extracts selected. The first step of the analysis (i.e., coding and abstraction of

| Ethical considerations
The respondents received information concerning the study's aim, including that data and anonymized quotes would be published in both national and international literature. The questionnaire was anonymous, and by answering the questionnaire, respondents agreed to the terms for publishing. This procedure corresponds to the World Medical Association's ethical principles that no ethical approval was needed when the respondents agree to participate by answering the posted questions. 14 The study did not need to seek ethical approval, as the Swedish Ethical Review Act (2003:406) does not include studies that do not handle sensitive data and patient data.

| Tumbling into chaos
At the beginning of the COVID-19 pandemic, nurses described their work as "being in a warzone." Participating nurses reported finding themselves in situations that they described as "chaotic," "surrealistic," and "unreal." Caring for patients with COVID-19 in the ICU posed many challenges. Many of the nurses reported that patients were severely ill and unstable, and some described that they were the sickest patients they ever cared for. End-of-life care in the ICU is particularly challenging. Sometimes relatives were allowed to visit when the patient was dying, but several participants described situations when this was not possible. In those cases, the nurses had to act as a patient relative proxy to provide comfort when no one could visit. Many described how this felt unethical and how they had to use different strategies to cope with this challenging situation.
The fact that relatives were not present contributed to depersonalisation of the patients, all calls from relatives were handled by others such as a physician or a counsellor. This was good as it eased work burden, but all patients became just like one 'grey mass' and we, the staff, become neutralised in a scary way; you just shut down to manage the situation. (Participant 125) However, nurses described how they had to adapt to this new situation, stating that care during the pandemic just had to be "good enough," but the notion of not being able to provide the same standards of care was challenging. Furthermore, many nurses described how their professional duties changed during the pandemic, and some nurses described that they felt more like assistants.
We  Our results show that at the beginning of the pandemic, nurses described the situation as tumbling into chaos. As stated by the International Council of Nurses, "Nurses have always worked under intense psychological pressure, but the current pandemic is making extraordinary demands on them both physically and mentally," which correlates well with our results. 15 As described by Liu et al, 16 health care providers showed a tremendous sense of responsibility and con- shown both in Italy and China, 9,27 which also strengthens our findings from a Swedish setting.

| LIMITATIONS
Despite our intention to have as representative sample as possible, sampling through social media could mean that we reached only a small sample from our designated target group. Further, there is also a risk that our sample might be biased as those nurses who felt strongly about their experiences might have chosen to participate to a greater extent.
However, recruiting participants via social media made it possible to reach a national population with different experiences during the same period, which was the intention. The timing of the data collection could have had an impact on the results of our study because the COVID-19 pandemic spread differently throughout the nation. However, our results show that the experience of nurses throughout the nation is similar despite differences in the number of patients treated for COVID-19.
As this is a national sample, our results should be viewed from a Swedish perspective; hence, differences in ICU organizations, nurses' competencies, and nurse-patient ratios between countries should be considered. Nevertheless, the findings of the present study share many similarities with other studies, not least regarding mental impact and ethical stress, and we believe that our results are transferable.

| IMPLICATION AND RECOMMENDATIONS FOR PRACTICE
Our results show that a pandemic has a severe impact on nurses' work situations. For example, our results imply that the prerequisites for providing ICU care shifted with consequences such as an increased workload and diminished nursing care. This could affect long-term mental health, result in increased staff turnover, and contribute further to nurse shortages. Several organizational issues need to be considered in clinical practice and future research in order to optimize the quality of nursing care. First, ICU nursing competence must be prioritized in the critical care team, especially when human resources are lacking, such as during the acute phase of a pandemic. Second, it is pivotal to have an introduction programme for each person who will work in the ICU. Third, nurses should receive both short-and longterm support to identify and mitigate physical and psychological illness and burnout. Finally, nurses need to be represented among hospital managers and leaders in organizing and planning future pandemic ICU care to ensure that nursing care is prioritized.

| CONCLUSIONS
The findings from the present study indicate that registered nurses working in the ICU context perceive diminished patient safety and quality of care during the COVID-19 pandemic due to a sudden surge in capacity of ICU beds despite lack of competence. This could have a negative impact on nurses' physical and psychosocial well-being, especially with regards to ethical stress. As specialized registered nurses are the backbone within the ICU setting, it is pivotal to further investigate COVID-19's impact on the long-term outcome of frontline health care workers and its impact on nursing care and patient outcomes.