Intensive care nurses’ experiences of Covid-19 care: A practical and ethical challenge – a qualitative descriptive design

Abstract

The Covid-19 pandemic has generated new experiences of intensive care. It has entailed new working methods, treatment strategies, and ethical dilemmas. The aim of this study was to describe intensive care nurses’ experiences of Covid-19 care and its ethical challenges. Data collection consisted of 11 individual semi-structured interviews and a qualitative content analysis was used. The COREQ checklist was followed. Three main themes emerged: to meet Covid-19 patients’ needs for specifically tailored intensive care; to have a changed approach to the excluded relatives is unethical, but defensible; and to strive to protect ethical values needs to be considered as good enough. In conclusion, ICU nurses shouldered a heavy burden in taking responsibility for the safety of these patients, continuously learning about new treatment strategies. Caring for Covid-19 patients was to strive to make the best of the situation.

Introduction

Global spread of the SARS-CoV-2 coronavirus, the cause of the disease Covid-19, has brought human suffering and death to every corner of the world. SARS-CoV-2 was declared a pandemic on 11 March 2020. ¹ The authorities in various countries have attempted to halt the spread of the virus by imposing measures such as social distancing, school closures, cancellation of public events, and encouraging people to work from home. ² Since the coronavirus became a worldwide threat, several vaccines have been developed and approved ³ and vaccination programmes have been initiated. ⁴ As of September 2021, there have been over 218 million cases of Covid-19 worldwide, with about 4.5 million deaths attributable to the disease. In Sweden there have been over one million confirmed cases with over 14 thousand deaths so far. ¹ As of summer 2021, a second and third wave of the coronavirus have struck the world and several mutations have been identified.

Covid-19 patients present a different disease profile from that commonly seen in the intensive care patients under treatment for acute respiratory distress syndrome (ARDS), and therefore novel nursing and treatment strategies are required. ⁵ Covid-19 involves severe pneumonia, thrombosis, and organ failure. ⁶ Critically ill Covid-19 patients with acute respiratory failure require intensive care for the inflammatory process that afflicts the lower airways. ⁷ Patients suffering from ARDS are intubated and given ventilator treatment using invasive mechanical ventilation if they fail to respond to standard oxygen administration. ⁸ Studies show that administration of oxygen and respiratory support are crucial for survival. ⁹ Treatment with nitrous oxide (NO) also improves oxygenation at an early stage. ¹⁰

Critically ill patients with Covid-19 on ventilator treatment are turned between the supine and lateral positions on a regular, every-other-hour schedule. This prone positioning strategy promotes the ventilation of areas of the lungs. ¹¹ Early use of the prone positioning strategy over 16–24 hours results in beneficial treatment effects, ¹² improves oxygenation, and increases survival in Covid-19 patients. ¹³ However, treatment in the prone position is resource intensive and entails risks. ¹⁴ Turning the patient is associated with the risk of unintentional extubation or pulling out central and peripheral vascular access lines. Various complications including pressure ulcers afflicting the skin or eyes, peripheral nerve injury, circulation problems, and risk of aspiration may occur. ¹⁵

Ethical dilemmas are ever-present in the intensive care setting and the choices that must be made have consequences for patients, family, and staff. Intensive care ethics have come under closer scrutiny since the onset of the Covid-19 pandemic, ¹⁶ posing both practical and ethical dilemmas. Ethical dilemmas are not only about triage and withdrawal of life support decisions, they also regard family visits and quality of end-of-life support. Other challenges have been an urgent need to quickly increase the number intensive care unit (ICU) beds/new units, to recruit healthcare personnel and get access to enough drugs and equipment (cf. Kentish-Barnes et al. and Cadge et al.).^17,18

Guidelines for ICU priority setting in exceptional circumstances sets intensive care priorities as required by the current pandemic. The pandemic has forced healthcare to shift to a more utilitarian framework with a greater focus on promoting the health of communities and populations. A utilitarian approach has the aim of achieving the greatest benefit for the largest possible number of patients. Priorities are based on severity of disease, patient benefit, and reasonable use of resources. ¹⁹ Evaluation of patients’ status is required in order to continuously prioritize and reprioritize. Where the line is drawn for which patients get access to intensive care depends on the healthcare systems, which may be forced to ration the resources to treat patients with Covid-19 (cf. National Board of Health and Welfare, and Echeverry-Raad and Navarro-Vargas).^16,20 Research shows that nurses experience a feeling of inadequacy when they are forced to set difficult priorities in their nursing work. Caregivers experience troubled consciences when they are incapable of delivering ‘optimal care’ and being the caregivers they want to be (cf. Ericsson-Lidman and Strandberg, and Moradi et al.)^21,22 Healthcare staff exposed to the coronavirus also experience psychological stress ²³ and are at increased risk of developing mental ill-health (cf. Arnetz et al. and Gordon et al.)^24,25 ICU nurses have described psychological distress related to caring for Covid-19 patients in new ways, while subjected to rapidly changing policies during the early phases of the pandemic. ²⁶

The Covid-19 pandemic has entailed new challenges for medical science and intensive care, and the strain on ICUs around the world is not over yet (cf. Our World in Data and Rao et al.)^27,28 Working during a pandemic requires new priorities where intensive care personnel are subjected to situations in which they may have to compromise on ethical guidelines and principles that normally apply. For this reason, it is important to highlight the situation ICU nurses face when working under current circumstances. The study results may provide valuable insights that benefit intensive care personnel, patients, and families over the long term.

The aim of this study was to explore intensive care nurses’ experiences of Covid-19 care and its ethical challenges.

Methods and design

We conducted an empirical study with a qualitative descriptive design. ²⁹

Study context

Data were gathered from an ICU in northern Sweden in which ICU nurses, together with intensive care doctors, nursing assistants, and temporary personnel, cared for Covid-19 patients. The observation unit was repurposed to care for patients with Covid-19, designated the Covid ICU. During this period, the hospital's surgery department was partially shut down and anaesthesia and surgical personnel were transferred to the Covid ICU, where they worked with ICU personnel to care for Covid-19 patients. Consolidated Criteria for reporting Qualitative Research (COREQ) guidelines were followed. ³⁰

Participants and recruitment

A convenience sampling was made of those fulfilling the inclusion criteria, i.e. having specialist training and at least two years of work experience in intensive care. Contact was made with the head of operations and the head of department with a request to conduct a study at their unit. They were informed both verbally and in writing about the study and then gave their permission to carry out the study. The ICU nurses attended an informational ward meeting in which the ward supervisor provided information and a written invitation to participate in the study. Eleven ICU nurses (nine of them women) agreed to participate in the study. The participants were aged 34–62 years (median, 49 years) and had 4–33 years (median, 13 years) of work experience in intensive care.

Data collection

After the participants received verbal and written information about the study they all gave their written consent. The 11 semi-structured interviews were conducted by the first author in June 2020, and the ICU nurses could ask questions if needed and suggest the time and place of the interview. All participants were asked the same questions from an interview guide and they were given the opportunity to give open-ended responses, i.e. freely talk about the issues. ²⁹ The interview questions elucidated experiences associated with Covid-19 care and its practical and ethical challenges. Supplementary questions were asked for clarification. Examples of questions include: Can you tell us about what it is like to work as an intensive care nurse during the Corona pandemic? Can you tell us about if any ethical dilemmas have aroused? The interviews were conducted in a secluded room in the ICU unit, they were recorded and lasted 30–45 minutes. The transcribed interviews comprised 46,000 words.

Data analysis

Qualitative content analysis requires that data be processed and sorted into different groups based on content. ³¹ Content analysis involves open coding of data, sorting data with similar content into groups and then searching for common sub-themes and themes. The text from the interviews was read several times to gain an overall understanding of the content. Meaning units (i.e. units of text with a common message) that met the purpose of the study were extracted. Without losing any content, the meaning units were condensed and coded, after which they were sorted into groups based on similar content. Thereafter the text with similar content was abstracted into sub-themes and labelled to reflect the content. The sub-themes were finally sorted into themes based on what was common. ³¹ Finally, three themes and ten sub-themes emerged.

Ethical considerations

This research was planned, conducted, and reported in accordance with the Declaration of Helsinki. ³² Since this study began as a student master’s project, it was not subject to the Swedish Ethical Review Act. The university department reviewed the research proposal and granted ethical approval. ³³ The participants received a letter that included information about the aim of the study, voluntary participation, the right to withdraw and participant confidentiality. ³⁴

Results

The themes and, in italics, the sub-themes are presented below. The findings are illustrated by selected quotations from the interviews; numbers in parentheses show from which interview the quotations were taken.

To meet Covid-19 patients’ needs for specifically tailored intensive care

The ICU nurses described that they were on their toes when new patients arrived, putting on their personal protective equipment. They prepared for monitoring, intubation, intravenous infusions, and for using non-invasive ventilation (NIV) masks and respirators:

We check all equipment, including intubation equipment, and make sure that various treatment aids are available, including drugs, ventilators, etc. … the big difference is that everything has to be done while wearing a mask, visor, gloves, and other protective clothing. (6)

Patients with Covid-19 were connected to monitoring devices in order to observe their vital signs and other parameters. Most patients arrived with severe cough, but were awake and conversant and the nurses could obtain the most basic information. Some patients were immediately intubated, but in most cases patients could be intubated under calmer circumstances, oxygen could be administered, and arterial needles and central venous lines could be placed before sedation.

Providing ventilator care in the prone position was described as effective but resource intensive. The ICU nurses stated that they had rarely used proning in the past, but that it had now become a natural part of Covid-19 care. The benefits of proning include a quick treatment effect:

Prone positioning is almost magical! It's just unbelievable – down to 45% O₂ on the same patient who had a PO₂ (i.e. partial pressure of oxygen in the blood) under 8 on 70% and now with 45%, greater than 9 – just incredible! (8)

Proning involves recurrently turning the patient, alternating between the prone and supine positions. Turning patients was resource intensive and required multiple people from the team. The patient's head had to be turned every three hours. During turning and when the patient lay face down against the mattress, there were risks:

The tube can slip out or shift into the wrong position, the patient may become severely ill or you may have to perform CPR, or the patient's circulation may be adversely affected. You can’t perform oral hygiene measures, at least not adequately, during the 16–19 h they’re in the prone position, so it's been a real challenge in my opinion. (6)

The ICU nurses said that although many risks were associated with prone positioning, including unintentional extubation, endotracheal tube or tracheal obstruction, pressure ulcers, oedema, and circulatory complications. Prone positioning was still prioritized since it is associated with a clear improvement in patient oxygenation and ventilation.

The ICU nurses explained that they learned to recognize the various signs and symptoms of this new patient group. The behaviour of ICU Covid-19 patients was similar, but they did have a very different course of disease than the usual ICU patients. Therefore it was difficult to anticipate what the next treatment step should be. They reported that Covid-19 patients developed pulmonary emboli early in the course of the disease, unlike typical ICU patients. At that point the doctors began to prescribe thromboprophylaxis:

They often have pulmonary emboli and we give them blood thinners, which is one of the factors that makes their care different. This doesn’t happen with your ordinary patient. (10)

The ICU nurses described learning a new type of ventilator care. Patients displayed a characteristic breathing pattern as breathing against the ventilator. Triggering the ventilator (i.e., breathing against the ventilator) in response to a Covid-19 cough increased pressure in the lungs and caused oxygenation to drop. For this reason, large bolus doses of sedatives and muscle relaxants were required to relax the patients and help them breathe with the ventilator, raising nursing concerns about the consequences. Despite the high doses of sedating medications, these patients were not as circulatory affected as typical ICU patients:

This is the thing about the large-dose sedative infusions to prevent triggering the ventilator, the doses are enormous … and despite the large doses, they may still continue to trigger, quickly dropping the O₂ saturation. Despite initial administration of such a large bolus dose, they were circulatory unaffected, compared to many others. (7)

The ICU nurses also described that it was difficult to oxygenate patients and that uncommonly used ventilator modes and settings were needed, including volume-controlled pressure regulation.

Providing peace and security when waking from sedation was of importance. The patients were often delirious when coming out of sedation and this needed to be taken into account before sending them to the regular ward. The ICU nurses emphasized the importance of good nursing care once the patients were taken off sedation. One ICU nurse described how this was the point at which the soul needed to be cared for in order to help the patients feel calm and secure. The goal was that the patients should be able to sleep with the aid of a sleeping tablet instead of intravenous drugs in the aftermath of respirator treatment.

The ICU nurses felt joy and satisfaction when patients survived. Positive care experiences included being able to extubate patients with Covid-19 and watch them improve due to the care provided, which created a sense of satisfaction of a job well done. The interviewees had a desire for better aftercare and identified the lack of an intermediate care department. Covid-19 patients were sent to a regular ward once they could breathe on their own and only had minimal O₂ requirements. However, these patients were weak after being on the ventilator for a long time and required lots of mobilization. The ICU nurses felt that the receiving ward should be prepared to provide more advanced aftercare.

To have a changed approach to the excluded relatives is unethical, but defensible

The ICU nurses described that they were being forced to accept the fact that relatives were not allowed to visit. They felt that the relatives were always important, obviously for the patient, but also because they could provide valuable information about the patient. Due to the risk of contagion, however, they were not allowed to visit their loved ones in the Covid ICU – a management decision that the ICU nurses could well understand:

We can’t subject relatives to that situation (decide whether to visit). I feel that regardless of how uncomfortable it is for us, it's our job to set that limit. (1)

However, the ICU nurses expressed great compassion for the relatives who could not visit their critically ill loved ones and have necessary physical contact. Instead, when possible, relatives communicated with their loved ones via FaceTime and mobile phone.

The ICU nurses also felt that if a patient was critically ill and may not survive, the relatives had the right to know about the care provided. It was also difficult to explain how ill a patient was over the telephone. Being able to visualize the situation was considered important in conveying the right impression. The choice of words was very important:

It has been difficult to accurately describe the situation by phone alone – the visual aspect says an awful lot when a family member can see the critically ill patient on a ventilator. (2)

The ICU nurses narrated that they were also acting as an extended arm between relatives and a patient who dies. Situations arose in which patients failed to respond to treatment and the ICU nurses were forced to discontinue intensive care efforts. They described how difficult it was for them when patients were not allowed to be with their relatives at the end of life. ICU nurses were simply not used to this kind of approach:

At the end, when relatives could not be present … they played music or they spoke with their loved ones by phone … it touched me deeply. (6)

The ICU nurses described the need to master one more role, that of being vicarious for relatives who could not be there. Clearly, this was a complicated endeavour:

We also become an extended arm for the relatives – it's like we are closest to the patients when they finally die. (7)

To strive to protect ethical values needs to be considered as good enough

The ICU nurses described that they were striving to protect the patient's privacy and dignity. One ethical challenge was to protect patient privacy in the large multi-occupancy room. Some patients were awake before they were sedated, which meant that extra care needed to be taken when drawing curtains to protect privacy. Some ICU nurses felt that it was undignified to care for patients in a large room with other patients:

When the patient is awake, you really have to be careful in closing off the space, but everything you say can be overheard through the partitions, and this definitely poses an ethical dilemma. (1)

Being forced to reprioritize could create a feeling of inadequacy and a troubled conscience. The ICU nurses narrated that ethically challenging situations arose that caused a troubled conscience. The nurses wanted to do a good job without neglecting important measures but under these demanding circumstances they felt inadequate at work:

Somehow your conscience makes itself known all the time … a bit like inner strife, ‘Have I really done my best, could I have done anything differently?’ (2)

The desire to do more for patients than time allowed generated a troubled conscience. For example, when they only could accomplish the essentials with patients, such as prioritizing ventilator care and medications over everything else. ICU nurses also described having a troubled conscience and a sense of inadequacy in situations such as placing an NIV mask on a patient who was experiencing discomfort and panic:

We need to avoid things like aerosol spread, we can’t just turn on the machine before the NIV mask is hooked up, since that would cause leakage into the environment – it's a safety measure for both us and the surrounding patients … The patient says beforehand, since they are of course awake, ‘Please turn it on before you put the mask on me’, because they feel panic and I can understand that … that's when you really feel like a failure. (1)

Deviation from several hygiene practices due to drug and equipment shortages, and being forced to use drugs longer than prescribed posed new dilemmas. The inability to use the best materials, which they usually have access to, and being unable to change infusion sets according to ordinary routines posed a quandary.

The interviews revealed that doing one's utmost under these challenging circumstances contributes to peace of conscience. When ICU nurses had followed the guidelines and rules established during the pandemic and felt that they could not have done things in a better way they experienced a clear conscience.

Discussion

The aim of the study was to describe intensive care nurses’ experiences of Covid-19 care and its ethical challenges. Our results indicate that the ICU nurses strove to meet Covid-19 patients’ needs for specifically tailored intensive care. They worked diligently to prepare for and receive patients on arrival. They wore personal protective equipment, which was not in line with ordinary routine procedure, to protect themselves and others from being exposed to the infection. Despite that, before and upon patient arrival at the Covid ICU, the ICU nurses strove to do everything they could to safeguard the patients, despite having little experience of how various interventions should be implemented given an unfamiliar course of disease and unproven methods. A systematic review with 13 studies describes the experiences of nurses working in acute hospital settings during a pandemic. The results show that nurses have a strong sense of duty toward patients. Despite nurses’ sense of fear and vulnerability, nurses’ duty to care for patients comes first. ³⁵

Findings in our study show that learning to recognize the different signs and symptoms of a new patient group was complicated, but became part of the daily routine to make survival possible. Providing ventilator care in the prone position was considered effective but resource intensive; its benefits include improved oxygenation, ventilation, and, ultimately, survival among Covid-19 patients. Once a patient is successfully placed in the prone position, the patient should remain in this position for 12–16 hours. Placing a patient in the prone position requires a coordinated team effort to safely position the patient. ³⁶ The associated risks, such as endotracheal tube or tracheal obstruction, pressure ulcers, oedema, or circulatory complications, however, were challenges to watch out for. Findings in our study show that the benefits outweighed the risks because the patients got so much better. Our study shows that working under these conditions was worrying for the ICU nurses despite the fact that they had 4–33 years of work experience in the profession. Research shows the importance of trained workers in an ICU unit to ensure Covid-19 patients’ safety. ¹⁴

Managing the patient's sedation to relieve anxiety and pain and facilitate mechanical ventilation is one of the important tasks of the intensive care nurse. ³⁷ During the Covid-19 pandemic ICU nurses were initially forced to carry out duties that were not evidence-based, which generated feelings of anxiety concerning the possible consequences for the patient. In line with other studies, the findings indicate that Covid-19 patients required high doses of sedatives in order to tolerate ventilator care. ³⁸ Heavy sedation of ventilator patients has also been shown to be associated with an increased risk of death. ³⁹ Nevertheless, heavy sedation of patients proved necessary for them to tolerate ventilator care, since light sedation resulted in fighting the ventilator. Research has shown that ICU nurses experienced psychological effects as anxiety/stress, fear, helplessness as a result of caring for Covid-19 patients, as they showed different signs and symptoms than the usual ICU patient. ²⁵

Our finding is in line with other studies showing that Covid-19 patients are at increased risk of venous thromboembolism, which is inconsistent with the clinical picture of the usual ICU patient. Placing patients on anticoagulation therapy to both prevent and treat thrombosis was suggested (cf. Al-Mufti et al. and Tacquard et al.),^40,41 and Swedish guidelines were developed recommending thromboprophylaxis for Covid-19 patients. ⁴² Our results show that new knowledge concerning ARDS, ventilator settings, and drug management accumulated over time at Covid ICUs, and new studies have continuously built relevant knowledge. For example, a recent study now shows that cortisone is effective in treating patients with Covid-19 and ARDS. ⁴³ One conclusion is how intensive care was initially shrouded in uncertainty concerning this new patient group, but knowledge and experience accumulated over time. It is encouraging to see how quickly the emergence of new medical and nursing knowledge was successfully communicated and implemented in care settings, for example in the form of guidelines to support care providers. It has been shown that during a pandemic it is of vital importance that knowledge about the best practice is delivered in an easy and consistent way, avoiding conflicting messages. ³⁵

The ICU nurses experienced joy and satisfaction when patients survived, but also expressed the desire to optimize these patients’ aftercare. One study described the uncertainty and anxiety that ICU nurses have experienced during the Covid-19 pandemic at not being able to offer adequate care. Despite the pitfalls, nurses expressed a willingness and commitment to take responsibility and participate in the intensive care effort during the pandemic. ⁴⁴ This is also in line with a review of nurses’ experiences of working in a pandemic, showing that the nurses felt a great sense of professional duty to work. ³⁵ Positive experiences – confidence, a feeling of job pride, and inner satisfaction – is also shown during the Covid-19 pandemic. ⁴⁵

Our results show that the ICU nurses had a changed approach to the excluded relatives. It was described as an ethical dilemma that relatives were not allowed to visit their loved ones. Even if it was seen as unethical it was justifiable to prevent the spread of infection, a utilitarian reflection intended to benefit a greater number of people. The ICU nurses experienced, however, great empathy for patients and relatives separated by dire circumstances. It was impossible to replace the physical presence of relatives. What remained was to use technology to communicate and become extended arms for both patients and relatives. When the end of life was near it posed a complex and difficult challenge for nurses. Studies have shown that feelings of guilt can arise in ICU nurses when they are required to keep relatives separated from their loved ones at the end of life (cf. Robert et al. and Fernández-Castillo et al.).^46,47 The pandemic changed the conditions for nurses to provide the good care they wanted as they continuously had to learn what worked, which in itself was ethically challenging.

Our results show that the ICU nurses strove to protect ethical values, and under these challenging circumstances it was considered as good enough. An ethical challenge was to protect patient privacy and dignity in large multi-occupancy rooms. They strove to protect privacy by drawing curtains but everything said could be overheard, posing an ethical dilemma. However, the advantages of caring for patients in large multi-occupancy rooms included ease of monitoring and access to patients. ⁴⁸ The benefit of this was considered to outweigh the invasion of privacy.

Ethical challenges included being forced to prioritize ventilator care and medications over everything else and circumventing, for example, hygiene procedures. The desire to do more for patients than time allowed generated a troubled conscience. Also, performing nursing interventions that subjected the patient to significant discomfort, deviation from several hygiene practices due to drug and equipment shortages, and being forced to use drugs longer than prescribed posed new dilemmas. The results show that ICU nurses strove to follow the existing guidelines established during the pandemic. When they felt that they could not have done things in a better way they experienced a clear conscience. These results are in line with a study showing that one way to cope with ethically challenging situations that breed a troubled conscience is to address the situation constructively, i.e. by doing the best one can under the circumstances. ⁴⁹

Methodological considerations

A qualitative descriptive design captures the research subject's lived experience of a phenomenon in its natural setting. Data were collected through semi-structured interviews for which the interview guide contained open questions. The interviews were adapted to the interviewees and promoted a free narrative, which can be viewed as a strength.

A total of 11 ICU nurses, nine women and two men, participated in the study, for which the selection process was based on convenience. About 35 nurses were working in the ICU unit during the first wave of the pandemic, and all nurses who showed an interest participated. A qualitative content analysis should achieve variation in the collected data. ³¹ The participants varied in age and length of professional experience. Although most participants were female, which may be viewed as a weakness, their number was representative of the composition and gender distribution of the group as a whole. Despite the variation in age, gender, and experience, similar content emerged from all the interviews.

The interview text was subjected to inductive analysis. The meaning units of the text were coded and sorted into sub-themes and themes based on similarities of content. For credibility purposes, it is important to clearly describe the study's selection process, participant characteristics, data collection, analytical process, and results. ³¹ The authors have consistently and meticulously tried to clarify the methodology, analysis process, and context to enhance trustworthiness.

Conclusions

The results illustrate how, during the first wave of the pandemic, ICU nurses continuously learned new treatment strategies, acquired skills in managing contacts with family, and coped with the new ethical dilemmas confronting them. One understanding emerging from the results is that ICU nurses held the lives of the most critically ill Covid-19 patients in their hands and shouldered a heavy burden in taking responsibility for the safety of these patients. One interpretation of our results is that the attitude of ICU nurses caring for Covid-19 patients was to strive to make the best of the situation. The pandemic is still underway, and it is important that follow-up studies be conducted throughout the pandemic to highlight intensive care work and the impact of Covid-19 care on patients, families, and personnel.