Intensive care nurses’ experiences of caring for isolated COVID-positive patients during first wave of COVID-19

Abstract

Background:

COVID-19 has fundamentally changed all fields of health care. Intensive care nurses have been at the forefront of the pandemic facing the massive impact of the disease, both professionally and personally. This study investigated nurses’ experiences of caring for isolated COVID-19 positive patients in the intensive care department during the first wave of the COVID-19 pandemic. The study investigated how isolation affected the nurses themselves, how they related with their patients, and how isolation affected patient care in general.

Methods:

The study was performed at a 20-bed university hospital intensive care department in Copenhagen, Denmark. COVID-19 positive patients were isolated or cohort isolated. A dedicated nurse cared for each isolated patient and wore full personal protective equipment. The study is based on in-depth phenomenological interviews with intensive care nurses conducted in summer 2020. The interviews were structured according to the principles of “Phenomenologically Grounded Qualitative Research.” The data included observations from within the isolated patient rooms.

Findings:

Six intensive care nurses participated in the study. The analysis documented following themes consistently reported by all nurses: (1) a general sense of uncanniness, (2) intense feelings of confinement and co-isolation, and (3) heightened senses of bodily objectification, including how nurses’ experienced their patients and also themselves.

Conclusion:

This is the first Scandinavian phenomenological study to focus on mapping the experiences of intensive care nurses during the extreme circumstances of the first wave of the COVID-19 pandemic. Further studies may explore long-term effects, such as psychiatric morbidity or psychological functioning in these individuals.

Introduction

The COVID-19 pandemic has been the primary healthcare challenge worldwide since January 2020. The pandemic has mandated major changes in all fields of health care. Hospitals have continuously adapted educational efforts, logistics, staffing, and treatment to face COVID-19. ¹ In addition to these changes, strict isolation precautions in a high number of hospitalized patients have challenged patient care. The latent infection risk, challenges relating to personal protective equipment (PPE), and individual perceptions of this “uncanny” situation may arguably have contributed, affecting both patients and healthcare personnel fundamentally. ²

In the intensive care department, the most extreme effects of COVID-19 have been revealed. Intensive care nurses have been at the forefront of this pandemic, facing COVID-19 both professionally and personally. As might be expected, studies on mental health in frontline personnel have demonstrated both burnout and increased psychiatric morbidity during the pandemic.^3,4 Correspondingly, a number of qualitative studies employing various methods have addressed the negative impact of COVID-19 on nurses themselves, patient-relations, and patient care in the intensive care department.^5–16 However, no studies have specifically targeted this matter from a phenomenological perspective in a Scandinavian context. Since previous studies in non-COVID-19 patients in the intensive care department underline that compassionate nursing care is pivotal to recovery, ¹⁷ a thorough investigation of this matter seems pertinent.

Aim

The aim of the study was to investigate nurses’ experiences of caring for isolated COVID-19 positive patients in the intensive care department during the first phase of the COVID-19 pandemic in Denmark. Specifically, the study investigated how isolation affected the nurses, their relations with the patients, and patient-care in general.

Methods

Qualitative approach and research paradigm

The study is based on a phenomenological framework. Phenomenology was originally founded as a philosophical approach to the study of subjectivity and its relation to the lived world. This philosophical tradition has inspired a variety of empirical qualitative research methods used across a range of fields, including psychology, nursing, sociology, and anthropology. In this study, we employ a methodological approach termed Phenomenologically Grounded Qualitative Research (PGQR).^18,19 To apply PGQR, the researchers explicitly incorporate phenomenological concepts in the design of the study, using them to formulate the overarching research focus, the interview questions, and focus observations. ²⁰ The concepts used in the study design are called “existentials.”^18,19 These are the basic structures of experience, such as temporality, affectivity, spatiality, and embodiment. When using this approach, the researchers select specific existentials to investigate in the study, establishing a pre-defined scope. This allows for highly focused and in-depth interviews, which the researchers use to investigate the “modes” of each selected existential, understood as the particular way that the existential manifests for the participant. PGQR is not the only phenomenological qualitative method to incorporate these kinds of concepts into the study. However, most other phenomenological approaches employ more open-ended or exploratory study design and interview processes, incorporating existentials only at the stage of data analysis.

The principal investigator (PI; AK) is trained in both philosophy and qualitative research with a background in studying abnormal experiences. The PI had no prior knowledge of the intensive care milieu or relation to the department. To ensure relevant background knowledge, the PI followed the staff during their daily activities for 1 month, and did extensive observations from inside the isolated patient rooms.

Setting

The study was performed at a university hospital in Copenhagen, Denmark. During this initial phase of the pandemic, the intensive care department was extended from 12 to 20 ICU beds. Intensive care treatment modalities included non-invasive/invasive respiratory support, vasopressor support, and continuous renal replacement therapy. COVID-19 positive patients were isolated or cohort isolated. A dedicated nurse cared for each isolated patient. All health care personnel wore personal protective equipment (PPE), including hair covering, eye protection, filtering respirator, gown, and gloves when caring for patients. Nurses worked 8- or 12-h shifts, and no standards concerning work breaks were defined during this phase of the pandemic. No visitors or relatives were allowed in the intensive care department during this period of the pandemic. If patients were considered moribund, only very close relatives were permitted to visit the patient.

Design

The study is based on in-depth phenomenological interviews conducted in early summer 2020. The data material also included observations from within the isolated patient rooms. The purpose of including observations was to strengthen the frontloading process. Interviews and observations were conducted by the PI. All interviews were recorded and transcribed verbatim. Observations were documented in notes. The nurses were selected by the department nurse. Criteria for selection specified that nurses were permanent employees and not temporary staff. The sample was based on standards of qualitative research stating that six participants is enough for data saturation.^21–23 The study is reported according to Standards for Reporting Qualitative Research (SRQR) guidelines. ²⁴

Data collection

Data was collected through in-depth phenomenological interviews with the participants. The interviews were conducted in-person in an appropriate room at the department. Each interview lasted approximately 1.5 h. They were audiorecorded and transcribed verbatim. The existentials selected to guide the interviews were embodiment, affectivity, spatiality, and relationality/intercorporeality. There was no need to modify or adjust this selection throughout the data collection process.

Data analysis

The data was analyzed using the general six-phase process of thematic analysis. ²⁵ The process involves an initial familiarization with the material, a generation of initial coding, and finally a process synthesizing the data into themes. These themes constitute specific discoveries within the experiential structure under investigation. ¹⁹ For example, while it was determined in advance that the interviews would focus on bodily experiences, this did not predetermine which bodily experiences the participants would report, or how they described these experiences. The interviews were first read by the PI, providing a preliminary coding that divided the material into several themes and subthemes. This preliminary analysis was represented in a matrix and presented to the co-authors who contributed with suggestions for further specification and modes of meaning condensation. Through this iterative process, several themes were identified, and out of these, the themes presented in this study were selected, based on prevalence and reported intensity. Hence, final results include themes that were consistently reported across all participants, and represent the most salient features of the experiences of intensive care nurses during the first wave of the COVID-19 pandemic. Numerical data are presented according to distribution as median (range).

Trustworthiness

The trustworthiness of a qualitative study is achieved through data confirmability, credibility, and dependability. ²⁶ In the present study, trustworthiness was ensured through several steps. First, the PI was external to the department and had no prior relation with the nurses. Second, the study followed a detailed design where a systematic interview-guide was developed to structure interviews. Third, the interviews with the nurses were enriched with data triangulated from both observations from inside the isolated rooms and patient interviews. Fourth, while the initial coding and meaning condensation of the data analysis was first processed by the PI, it was subsequently confirmed, corrected, and adjusted by all authors in turn for increasing the acceptability of the coded data and synthetized themes.

Ethics

Ethical approval was not needed according to Danish law. Participation was voluntary and participants provided written and verbal informed consent before inclusion. All interviews were anonymized.

Findings

Six intensive care nurses participated in the study. None declined to participate. Five were female and one was male. Age was 45 (39–59) years. Nurses had 20 (13–32) years of nursing experience including 18 (8–29) years of intensive care experience.

The data analysis documented following three themes consistently reported by all nurses: (1) a general sense of uncanniness, (2) intense feelings of confinement and co-isolation, and (3) heightened senses of bodily objectification, including how nurses’ experienced their patients and themselves.

Theme 1: The uncanny

A consistent theme was a pronounced sense of feeling “uncanny.” In psychological terms, the uncanny refers to an affective state characterized by a disruption of the fundamental sense of feeling safe and at home in the world—famously described by figures such as Freud and Heidegger. ²⁷ The term “uncanny” is a translation of the German term “unheimlich,” which literally means “not home-like.” It is a mood or attunement characterized by the loss of a sense of familiarity with one’s overall situation and an unease in the face of what awaits. Although uncanniness may arguably be considered a fundamental mood of the COVID-19 pandemic per se, ² it was particularly pronounced among nurses working in the intensive care department.

The nurses described the entire situation during the first wave of the COVID-19 pandemic as characterized by a strong sense of uncanniness. Stepping into the isolated patient room was like stepping into a new and unfamiliar world. Although the physical surroundings where familiar, the strict isolation precautions fundamentally altered the sense or meaning of these surroundings, making everything seem eerie. One nurse said, “it was as if somebody had rearranged the furniture in your apartment without you knowing it. It is the same place and the same things, but it just does not feel safe anymore.” This sense of uncanniness had several constituents. First, personnel were covered in PPE. The natural flow of embodied interaction was therefore replaced by what was experienced as a “masquerade.” This resulted in a lack of intimate relations with patients and between colleagues. Second, the intensive care department with individual isolated patient rooms seemed segregated – like small, secluded islands. Third, the COVID-19 disease seemed unpredictable. As a nurse reported, “we were used to certain types of patients and were good at treating them. Patients with COVID-19 disease reacted unpredictably. They would suddenly go into cardiac arrest. I would think they could die any moment, and we did not know what was happening.” Fourth, the participants reported that part of the uncanniness resulted from a feeling of being separated from the rest of society, including feeling distanced from their own families. People in the outside world were not aware of the ongoing horrors and maintained a normal life. The nurses felt alone with the situation, having difficulties accepting an outside world that largely neglected these problems and continued the flow of everyday life. As a nurse stated:

It was like living in two worlds. You had just walked the dog and sent the kids to school, and then you entered this bubble of weirdness. Ordinary people thought it was like a flu. But in here patients were dying. I could not stand how lightly they took it.

Theme 2: Confinement and co-isolation

Another distinct theme emphasized by the interviewed nurses was a pronounced feeling of being confined in the patient room, and a corresponding sense of being co-isolated with the patient. Both nurses and patients reported feeling confined (unpublished results, Køster et al.). One nurse compared entering the isolated patient room with entering a kind of vacuum – a transition that resembled submerging and ascending when scuba diving. Not only did they enter a silent and strange new world but once in the room, they were confined and relied completely on the PPE for their own safety. Then, to leave the room, they were required to go through several steps of decontamination, which clashed with the nurses’ occasional overwhelming urge to flee the room. As a nurse noted, “this reliance on equipment is especially stressful if you get anxious.” For most nurses, this feeling of confinement included a constant desire to escape, which they suppressed, although it remained latent. The feeling of being confined in the isolated patient room created a sense of being co-isolated with the patient. However, this shared destiny with the patients did not translate into a feeling of connection or comradery. Rather, patients were seen as the reason for confinement and, hence, there was not any relief in sharing the experience with the patients. As a nurse noted, “all I wanted to do was to flee the room, but I could not do that, as the patient depended on me.” Another nurse added:

the contact with the patients was not good. It was a bit like, I could not be bothered to care. But that is also not true. I did care, but I had the feeling that it could not be good anyway.

Overall, the condition of isolation created a situation that was experienced as profoundly lonely by the nurses. Not only were they confined in the patient rooms with the patients; they were also isolated from their colleagues. This created a sense of being left alone with an overwhelming responsibility for their patient and a feeling that, if the situation turned critical, help was out of reach.

Theme 3: Objectification

A particularly salient experience emphasized by the nurses was a pronounced sense of bodily objectification. Bodily objectification can be broadly defined as experiencing the body of another person, or even one’s own body, as an object. In everyday life, when in the midst of habitual activities, our bodies tend to fade into the background of awareness – we experience through our bodies rather than having an experience of our bodies. Even when interacting with others, we are typically more aware of the other’s subjective expressions – for example, their emotions, desires, intentions – than we are of their bodies as specific kinds of physical objects. However, there are plenty of cases where human bodies can be experienced primarily as objects, for example, as a biomedical object, a mere physical object, or a sexual object. ²⁸ Although some degree of objectification of patients is, arguably, a part of an intensive care admission due to the nature of the care and treatment, objectification was significantly intensified during the first wave of the pandemic.

Because of the diversity and complexity of experiences reported by the participants, we have divided the theme of bodily objectification into three subthemes: Contamination, Anonymity, and Self-Objectification through the PPE.

Theme 3a: Contamination

Many nurses described a near-constant concern of being infected or contaminated with COVID-19, which made them distance themselves from their patients. The concern was not described merely as a fear of getting infected, or of passing the infection on to friends, family, or colleagues. Rather, participants described a pervasive feeling that the virus resided on the surface of their body, including their skin, hair, or clothes. This resulted in a heightened state of body awareness, in which their body felt icky or dirty. The nurses also described various decontamination rituals they regularly used to cope with this feeling, such as sterilizing everything after each day of work, for example, glasses, keys, or clothes, or taking a shower immediately when arriving at home to clean every part of themselves that might carry the virus. The fear of contamination mediated the nurses’ relation to the entire hospital milieu, where both objects and patients were flagged as potential sources of contamination. Importantly, this fear led to heightened objectification of the COVID-19 positive patients. For instance, nurses reported avoiding close proximity to the patient’s face, with the sense of personal contact this carries. Consequently, the nurses reported that they would increasingly relate to the patients as “biological machines” that needed maintenance. This was experienced as profoundly challenging to the nurses’ sense of integrity and experience of professional meaningfulness. “This is not how it is supposed to be. If taking care of patients is like this, I would not want to be a nurse,” as a nurse described it.

Theme 3b: Anonymity

Many nurses also reported that their clinical interactions were characterized by a sense of anonymity. This anonymity applied to both the patients and the nurses themselves. With respect to the patients, the anonymity was not only due to the objectification resulting from the fear of contagion. Participants also explained that the patients’ anonymity was exacerbated by the isolation precautions, which excluded relatives from the ward. Normally, relatives would help healthcare personnel understand their patient as a person. This is especially important in the intensive care department, where patients are often unable to speak or otherwise convey their personality to the healthcare personnel. By interacting with relatives, healthcare personnel therefore gain a sense of the patient’s personal and social identity. Losing this physical day-to-day contact with relatives made it difficult for the nurses to obtain a sense of the patient as a person. Again, the patient became an anonymous body in need of treatment.

On the other hand, the nurses also experienced themselves as anonymous in the eyes of their patients. Because of the PPE, patients could not differentiate the nurses – they all looked the same. However, this was not only the patients’ concern. The nurses expressed distress about being “faceless” in front of their patients. It limited their ability to develop and maintain the kind of genuine relationship with their patients that they were used to – at least with patients who they cared for during extended periods of time.

Theme 3c: Self-objectification through PPE

Lastly, several nurses described how the PPE caused objectification of their own bodies through constant irritation. The glasses would fog, and the mask would itch the face and the ears. It was hard for the body to breathe under the gown, which would make the nurses sweat. These irritations caused hyper-awareness of their own bodies as obtrusive objects. Hence, rather than being a tacit medium through which they would expertly care for their patients, their own bodies became an object of obstruction. The focus of their attention would be drawn away from the patient and into a preoccupation with their sensation of discomfort. Hence, the self-objectification caused by PPE further increased the distance between the nurses and their patients.

Discussion

Several studies have documented increased psychological distress and psychiatric morbidity as a result of the COVID-19 pandemic.^29–31 A national cohort study estimated changes in population mental health before and during the lockdown period in the UK. ³¹ The study assessed non-specific mental distress, documenting an overall increase compared with previous years. In patients, studies demonstrated significant levels of depression, anxiety, and insomnia during and after hospitalization for COVID-19. ³² Correspondingly, evidence shows a considerable proportion of healthcare professionals experiencing significant mental distress during the pandemic. ³ A questionnaire study by Barello et al. ⁴ investigated the work-related psycho-physical impact of COVID-19 in healthcare professionals in Italy. The authors documented increased psychological pressure, emotional burnout, and concomitant somatic symptoms. An online questionnaire among Swedish nurses documented the experiences of caring for COVID-19 positive patients in intensive care departments during the pandemic. ³³ Nurses described how patient safety was compromised, and nursing care was deprioritized. The overall situation resulted in severe stress. Finally, the workload and work environment affected both mental health and well-being. In parallel, several qualitative studies, including studies with a phenomenological approach, mapped the experiential context that accounts for these psychological effects resulting from treating COVID-19 positive patients (and arguably COVID-19 in general). These studies highlighted similar themes of increased mental/physical distress, but also addressed themes of compromised patient care, limited resources, and altered/distorted professional and personal relationships.^5–16

Strengths

This is the first Scandinavian study to focus exclusively on clarifying the experiences of intensive care nurses during the unusual and extreme circumstances of the first wave of the COVID-19 pandemic. Since the intensive care department of the hospital received the majority of acute COVID-19 hospitalizations in inner city Copenhagen, the experiences reported here are representative of a sustained practice of treating a substantial and constant flow of COVID-19 positive patients. The interviews were conducted immediately after the first wave of the pandemic when nurses where no longer immersed in the stressful situation, but when their experiences were still lucid. Furthermore, the interviews were supported by observations from within the isolated patient rooms. This inclusion of on-site observations strengthens the interview material with a third-person perspective that helped contextualize the descriptions of the nurses. No other study has, to our knowledge, included observations during this intense and stressful time. The study is the first of its kind to employ a dedicated phenomenological focus on the pre-reflective tacit and embodied dimension of nurses’ experiences. This was done by employing the PGQR framework.^18,19 Arguably, this framework is ideal to uncover aspects of experiences that would not emerge in other phenomenological methods that do not employ this dedicated focus. Examples of how PGQR has contributed with novel insights into the embodied and tacit dimensions of a phenomenon is the field of bereavement research.^34,35

Limitations

Some limitations need to be addressed. This study included nurses from a single intensive care department in Copenhagen, Denmark during the first wave of the pandemic. Hence, our findings only directly reflect the nurses’ experiences of this particular context. Experiences may arguably differ in other cultural, geographical, logistical, socioeconomic, or temporal settings. Similar phenomenological studies, however, demonstrate comparable findings.^5–16 Also, our data is limited to the context of COVID-19. Yet, similar themes of experiences exist in the care of non-COVID-19 patient groups subjected to strict isolation precautions. ³⁶ Potential differences need to be addressed in further studies. Finally, the findings of this study only describe immediate experiences perceived during the pandemic. Though these experiences clearly affected the included participants deeply, potential short- or long-term effects, for example, on psychiatric morbidity or psychological functioning is not assessed in this study.

In terms of future practice, the results of this study clearly demonstrate how fragile person-centered care is, when the overall conditions and psychological work environment becomes precarious. Hence, it illustrates how person-centered care needs to be a continuous focus point in intensive care.

Conclusions

This study investigated nurses’ experiences of caring for isolated COVID-19 positive patients in the intensive care department during the first wave of the COVID-19 pandemic in Denmark. Through in-depth phenomenological analyses and on-site observations, salient themes were identified, including a general sense of uncanniness, intense feelings of confinement and co-isolation, and, finally, heightened senses of bodily objectification, including how nurses’ experienced their patients and also themselves. Further studies should explore the potential long-term effects of these experiences in these individuals.