Healthcare | Free Full-Text | “Who Takes Care of Carers?”: Experiences of Intensive Care Unit Nurses in the Acute Phase of the COVID-19 Pandemic

A total of 21 ICU nurses were interviewed (Table 3). The mean age was 34.04 years, SD = 7.4. Regarding sex, 71.4% were female and 28.6% male. Regarding marital status, 33.3% were married, 4.7% divorced, and 62% single. In total, 62% of the nurses did not have children. The average length of the nurses’ professional experience was 9.4 years, with 4.2 average years of experience in ICUs. Three main themes and eighth sub-themes were extracted from inductive data analysis.

3.1. THEME 1: COVID-19 in ICUs: Nurses on the Frontline

This theme encompasses the feelings and concerns that surfaced in nurses with the onset of the pandemic. The acute phase of the COVID-19 epidemic was perceived as entering a “battlefield”. Nurses developed feelings of fear and ethical dilemmas; but they also felt the importance of humanising care, accompanying the patient and dignifying the end of life.

Nursing on the battlefield: in the trenches.

Participants shared the perception of being on a battlefield, fighting against a relentless and unknown opponent that was cornering them. The feeling of chaos, lack of control and unfamiliarity generated high levels of anxiety before going to work and throughout their shifts. As one nurse expresses:

“New patients never stopped coming in, it was out of control… You saw people coming in and shutting down, their bodies could not cope with the virus….you knew that many people were left waiting for a respirator, and that many others were dying waiting for it…”

[IDI7]

The lack of information about the virus raised concerns in nurses about how to protect themselves effectively, and about the possibility of infecting their family members.

“At the beginning it was not clear how to protect yourself against the disease. This generated insecurity and fear among professionals (…) Fear of the unknown, of contagion… more than fear of me getting infected, of my family getting infected.”

[IDI5]

When a family member is especially vulnerable to infection, the situation is exacerbated and ethical and moral dilemmas arise for ICU nurses. Some of them had very vulnerable family members and did not know what to do.

“My husband (a kidney transplant recipient) wanted me to resign for fear of infecting him (…) That night I didn’t go to work, and in the following days I had time to become aware that this was what I had to do, and I would have to get through it any way I could (…)”

[IDI6]

Questioning the quality of care.

Nurses noted that the quality of care for patients suffering from COVID-19 was compromised. Factors such as unfamiliarity with critical care generated frustration. The lack of more time to care for each patient (occupational overload), together with the deficit of experience and safety in the development of procedures, generated tension in many nurses.

“Lack of time, lack of resources, lack of privacy for patients, lack of autonomy (…) Yes, there were certainly deficits in care, without a doubt.”

[IDI3]

In contrast, other participants emphasise that the quality of care was maintained at all times, and increased as the disease became more widely known.

“There was no lack of material, no lack of means. There was only a lack of information about the virus and the disease. It couldn’t be any different because no one knew its effects, but as the months went by, care and treatment became more and more successful.”

[IDI15]

Humanising care and providing company: death in isolation.

The need for the humanisation of critical care was a major challenge during the pandemic. Nurses showed greater sensitivity, observing how patients suffered alone. The loneliness and isolation to which many patients were subjected to at the time of their death is perceived by nurses as a fundamental shortcoming. Participants alluded to the fact that no one should die alone and noted that being accompanied was part of having dignity at the end of life.

“Death in isolation for me was the worst, holding hands with patients as they stopped breathing and died. The treatment of the body of the deceased, towards their families, who waited without knowing …, sometimes there was a lack of attention to dignity.”

[IDI4]

Some participants had the opportunity to accompany a family member who had COVID. It was at that moment when the nurses truly became aware of the gravity of the situation.

“Unfortunately, I experienced the death of one of my own family members in the COVID area. Being a worker at the hospital, I was given the option to stay with her wearing my PPE. Thanks to that, I was able to accompany her in her last days and in her final moments, … at that point, I was fully aware of the loneliness in which the rest of the patients were dying (…) God only knows the people who died in this kind of painful isolation, the number of relatives who couldn’t say goodbye and accompany their loved ones, where is the dignity in these deaths?”

[IDI12]

3.2. THEME 2: United against Adversity: Teamwork

This topic addresses the nurses’ experiences caring for critically ill patients in the acute phase of the pandemic. Novice nurses had to learn against the clock, which added extra responsibility for the experienced nurses. The pressure of providing care to all and the lack of knowledge of the disease generated doubts about the safety of the professionals and led to conflicting feelings within the team.

Observing experienced nurses and learning by doing.

Some participants were relocated to the ICU due to an increased need for staff. The new nurses were forced to learn against the clock, which generated negative experiences linked to stress. More veteran nurses managed the situation because of their skills, competence and years of experience. Faced with the intense pressure of caregiving, they doubled their efforts as patient caregivers and mentors to the new nurses.

“Learning to work in the ICU with foggy glasses, 3 pairs of gloves and unbearable heat (clothing). A patient would come in and you had to do a central catheterization to administer medication urgently, an artery to check their respiratory status and blood pressure, an intubation because they came in with their mouth open, like a fish out of water. In those situations, you cannot stop to teach the newcomers, they just learn by watching the veteran nurses.”

[IDI10]

“The veteran nurses were overloaded with their patients and training the newcomers, they were burnt out from teaching so much. Sometimes it was hard to ask them for favours when we had to perform a technique that we did not know how to do, but they always helped us to do it so that we could learn, or they did it themselves, … we will be eternally grateful for that.”

[IDI13]

When safety starts to falter.

The participants highlighted weaknesses in professional safety. The lack of knowledge surrounding the use of PPE and the amount of time spent in the isolation rooms, led to physical and psychological fatigue. Some of the nurses saw colleagues’ sheer exhaustion after caring for a patient for hours wearing PPE in isolation rooms. Regarding patient safety, the priority was always to save their lives.

“In my opinion, it was never diminished (safety). We always knew what the priority was, and it was them [the patients]. In an emergency, there was hardly time to put on PPE, but if it was necessary to save their life, we went into the [isolation] room.”

[IDI11]

Coming together to withstand the pandemic.

The nurses experienced moments of extreme tension in the ICU. Stress, fear and tension brought about feelings of selfishness and strained relationships among team members. However, participants emphasised that these negative feelings were eventually resolved and did not overshadow their sense of teamwork. Feeling that they were all in the same situation strengthened bonds, and nurses felt united through adversity. These situations created deep bonds between the nurses who worked together in ICU in the acute phase of the COVID-19 pandemic. There were many different feelings, both positive and negative:

“We did not have many NBC masks, … they had been donated by farmers in the province. Some people kept them in their lockers at the end of their shift (they didn’t care if their colleagues needed them). I also gained a lot of good things out of the experience, but the best without any doubt is the people I worked with, great colleagues and professionals, and more than that, friends.”

[IDI19]

“The bond between nurses grew, there was much more trust. There was no more tension between us, but a lot of support, respect and understanding (…) If I talk about the new colleagues, it’s the same, because everything was new for everyone. I welcomed them with open arms and I still have a friendship with many of them; adversity brought us together.”

[IDI2]

3.3. THEME 3: New Optics of Critical Care and the Nursing Profession

This theme describes participants’ perceptions of the profession after the acute phase of the pandemic and how it has affected their motivation towards the profession. Although they have felt undervalued by healthcare institutions, for most participants, working in the ICU during the peak of COVID-19 increased their professional and personal motivation. Facing the pandemic has made the nurses become more aware of their profession and has made them reflect on the role of nursing in society, which they had not been confronted with before.

“It was motivating to see what we are capable of as a profession when the situation demands it, it has also helped boost my professional development. I have learned a lot and believe I have improved as a nurse.”

[IDI14]

Discovering a passion for critical care nursing.

All participants showed an increase in professional motivation and a sense of self-improvement. Some participants new to the ICU perceived the opportunity to work in this unit as a daily challenge, and since then, have reported feeling like better nurses and more motivated professionally.

“There are days when you wake up without any motivation, since working as a waitress you would live with less anxiety and less responsibility than as a nurse (…) You have to give yourself the motivation, knowing that, thanks to your work, you can save lives and that, with the resources you are offered, we can make miracles happen.”

[IDI1]

Despite the difficulties and stress experienced, the attachment to critical patient care has grown in these nurses. In the ICU, they realise how much they can contribute to the profession and therefore, they want to stay in it.

“I wanted to die when I started, and now I love it. Now I can’t imagine working in any other unit other than the ICU. This is the true essence of being a healthcare professional, saving lives and learning new things, day in and day out, from all the professionals around me.”

[DI21]

“My motivation is at its highest. It has always been clear to me that the only important thing in life is health … and I have seen that in the ICU during the pandemic.”

[IDI15]

Reflections on the nursing profession.

After living through the acute phase of the COVID-19 pandemic, the participants sense a general undervaluation of the profession by health institutions. They emphasise that nurses have played a crucial role throughout the process, but that the profession has been neglected in the process. They feel that their profession has been undervalued and underpaid, with little recognition of the responsibility and risk it involves.

“Nursing is associated with having a calling. Because you feel a calling, you become a volunteer to work overtime, to not enjoy your days off, to give up vacations, to work holidays and weekends… to give up your life for someone else.”

[IDI17]

“We health professionals weren’t cared for then, nor are we cared for now. We face the misery of society, pain, illness and suffering on a daily basis. We deserve better equipment, more staff, better pay and rest, for the work we do.”

[IDI5]