Research Question

What is the experience of nurses who were taking care of patients with suspected or confirmed COVID-19 at the beginning of the pandemic 2020?

Sample

This qualitative interview study was performed between March and April 2020 in Stockholm, Sweden. Interviews were conducted at three different sites at the onset of the COVID-19 epidemic. A convenience sample was used to approach registered nurses who could provide us with firsthand experiences of caring for patients with suspected or confirmed COVID-19 infection. Convenience sampling entails choosing informants based on their availability and willingness to participate in the interviews (Polit & Beck, 2017).

Registered nurses working in three different healthcare settings within an urban region in Sweden; two primary care centers whereof one in a high socio-economic area and the other in an area with low socioeconomic status, and one inpatient COVID-19 ward (former internal medicine ward) at a large regional hospital), were asked to participate in the interview study. In total 12 RNs were asked to participate in the study; seven of them accepted, two RNs declined, and three RNs did not respond. All informants provided informed consent and were informed that their participation was voluntary and could end participation at any time without reason.

Inclusion Criteria

Inclusion criteria for participating in this study were registered nurses, working with patients with suspected or confirmed COVID-19 infection, with at least 6 months of prior work experience either from inpatient- or outpatient nursing care.

Exclusion Criteria

Exclusion criteria were registered nurses who did not work with patients suspected or positive for COVID-19 and/or with less than 6 months of work experience.

Data Collection

Semi-structured interviews with open thematic questions were selected as the data collection method since interviews can generate rich narratives from informants (Polit & Beck, 2017). An interview guide was used and consisted of the following themes: working with patients with COVID-19 infection, guidelines for the use of protective equipment, feelings about the current situation, and priorities.

During the interview, additional probing questions were asked to explore the informant's experiences of caring for patients with COVID-19. The chosen interview technique means that the interviewer aims to obtain as much information as possible by allowing informants to explain and express themselves openly (Polit & Beck, 2017). Interviews were conducted on the online platform Zoom due to pandemic restrictions. A pilot interview was recorded and lasted 65 min. Both the interviewer and the informants had their video cameras on to be able to see each other and communicate as normally as possible. Furthermore, using a camera allowed the interviewer to follow the informant during the interview and observe how the informant reacted to various questions. There was one occasion where the camera did not work but since the sound worked well the interview could still be held. All informants sat in a quiet environment at home or at work during the interview. The interviews were conducted with one informant at a time and lasted between 20 and 70 min until saturation occurred. The interviews were recorded via a function in Zoom and on a mobile phone to facilitate the verbatim transcription of the interviews afterward. All interviews were transcribed verbatim immediately after each interview.

Data Analysis

Transcripts were compared to the recordings and read several times to ensure accuracy and that they captured the informant's experiences expressed in the interview situation. The informants were also given the opportunity to read through the transcription of their own interviews for validation or clarification (Polit & Beck, 2017).

The texts were then analyzed through qualitative content analysis with an inductive approach (Graneheim & Lundman, 2004). The coding process was first performed by the second author and then evaluated by the entire research group. The first step entailed reading and rereading to grasp a sense of the whole, that is, what was in the foreground and what was in the background. In the second step, meaning units were created, and the parts that contained information relevant to the study were marked, condensed, given a code, and then placed into subcategories. In the third step, the subcategories were re-analyzed and compiled into categories, with each category expressing something specific about the content. In the fourth and last step of the analysis, meaningful units, subcategories, and categories were analyzed to find the latent content and finally based on these findings, themes emerged. The analysis process is not a straightforward process but rather an iterative process that revisits the text, categories, and themes several times to ensure the conformability of findings (Graneheim & Lundman, 2004).

Research Question Results

The results of the study describe how registered nurses from different healthcare settings experienced the care of patients with COVID-19 at the onset of the pandemic. The themes of Challenges with new routines, Difficult nursing decision, and Need of reflection and support, highlight the changes in working conditions experienced by the nurses during the first wave of COVID-19 in Sweden, see Table 2.

Challenges With New Routines

The healthcare organization rapidly changed and focused on taking care of patients who could not manage their symptoms at home. Support for those who could manage at home with professional medical advice was available through telehealth. At the primary care center, patients with symptoms of respiratory infection were assessed and treated in an outdoor tent in order to prevent the spread of infection. Home health nurses continued providing care according to previous routines, but patients with suspected COVID-19 symptoms were usually sent to hospital.

It went very fast from one day to the next. Then we reorganized our routines and all infected patients with upper respiratory tract infection for example cough, fever and other infection symptoms were assessed out in a triage tent. Inside the health center we have no patients with symptoms related to COVID 19. (p. 6)

At the hospital COVID-wards routines quickly changed, resulting in the need to develop and implement brief educational courses while managing heavier workloads, and ever-increasing stress levels. The new routines sought to develop efficient processes including, that is, creating an observational ward, increasing the number of hospital beds, moving patients to other somatic- or geriatric wards, transferring patients to infection wards, or discharging them.

The interviews revealed a sense of positive collaboration within the medical team. This teamwork became the glue that kept not only different departments and clinics together, but also various hospitals and primary care centers. When the COVID ward needed to transfer patients to other wards due to new incoming patients, the transfer process was performed more effectively. To adapt to the new situation of an increasing need for hospital care for patients with COVID-19, some clinics were closed in order to provide the new COVID-wards with the nursing staff. Nurses were transferred to the COVID departments. Although the nursing staff collaborated and helped each other, they also felt abandoned and left to solve complex situations, as demonstrated below:

We were thrown into it; we were told that we would get staff who would take care of monitoring patients, that we would get backup from staff at higher levels of care, but they never came. (p. 4)

Difficult Nursing Decisions

New ways to work with patients were established. Assessments by telephone, and asking questions about potential COVID-19 symptoms became a part of ordinary patient care. Since the most common symptoms of COVID-19 were fever, chest- or muscle pain, fatigue, or loss of sense of taste and smell, the initial triage was conducted by telephone with the goal of correctly guiding to the appropriate level of care. Patients who were directed to self-management at home received a telephone follow-up call by an RN to assess whether the patient had become worse and needed hospital care. Priorities were also made by using the L-ABCDE assessment tool, where L stands for life-threatening situation, A-airway, B-breathing, C-circulation, D-disability, and E-exposure, which assisted the nurses in their decision-making.

We created a template for how we should assess patients by telephone as many people call the primary care center for medical advice. It guides us on how we should assess the patients by telephone; if they needed to come to us for an assessment, who we should give self-care symptom management and advise to stay at home, or who we should send directly to hospital. (p. 6)

However, certain patients were difficult to safely assess over the telephone because it could lead to providing incorrect medical advice. Physical assessments in these cases took place at the primary care center or in the home, using the instrument L-ABCDE. The assessments were made by nurses or physicians and consisted of various parameters. This assessment guided decisions about whether the patient could be managed at home or needed hospital care.

The most difficult thing is to assess a patient before you have seen the patient, if for example, the homecare service has called, I’ll have to prioritize and assess the patient based on their history or report. (p. 2)

COVID-19 infection progressed differently in many patients, and it became clear that deterioration could occur several days after symptom onsets. When patients worsened, they developed severe respiratory problems, and the majority needed hospital care. Patients with respiratory insufficiency also displayed confusion and anxiety. Vital signs were monitored regularly and frequently, including venous sampling and blood gas to assess the severity of the patient's respiratory failure. Monitoring of oxygen saturation was also used to assess unstable patients.

A respiratory failure is usually what makes them worse—that they can’t maintain an optimal oxygen level. (p. 7)

Furthermore, the results showed the importance of triage at the primary care centers to assess if a patient needed hospital care or could manage at home. This triage contributed to a decreased burden for the emergency departments, which would not have been the case if the primary care centers had not developed a triage for suspected COVID-19 patients. There were challenges in accessing updates and new information while the patient intake was constantly increasing. Nurses worried about the protective equipment; if it would provide adequate protection enough or if the department would run out of protective equipment. Despite the challenges in gathering and disseminating information and the stressful work environment, several nurses emphasized the importance of cooperation. The triage was highlighted as contributing to more effective assessments and patient management.

Organization and Responsibility

The pandemic put the entire health care system and all its functions through an enormous stress test. Every health care worker, at every level, became involved in the pandemic. Every routine was scrutinized. Everything that could be done faster was performed even more efficiently by removing other aspects of nursing care. The organizations’ routines changed rapidly from, that is, encountering patients in real life to assessing them by video online or by telephone. The results show how patients were instructed to self-manage their symptoms at home in a completely new way. As patients with mild symptoms were sent home with self-management instructions and information on when to return to care while those with severe symptoms were admitted to hospital. These routines were implemented, and research showed that early diagnosis, isolation, and symptom management could decrease the spread of the virus (Shahriarirad et al., 2020). However, patients with mild symptoms who worsened after a week came back for a new assessment and triage and those with severe symptoms were then referred to hospital. Sometimes nurses at homecare referred the patient directly to hospital, which also was the case in a study by White et al. (2021). This is something that can be used more in current health care routines. The results highlight the need of education to support quick changes to routines as well as ensuring that health care personnel are given information and are updated in order to support teamwork and decision making in the clinic. As nurses at the COVID-19 ward worked in accordance with new guidelines that rapidly and repeatedly changed over the initial course of the pandemic while also caring for patients in need of intensive care but due to the lack of beds in intensive care units, patients had to stay in intermediate care where sometimes enough NIV-ventilators were unavailable. It is an important finding that education and some training came with these changes, although the information given was scarce and the educational content shallow and brief due to the novelty of the virus and the emergent nature of the situation. It shows how evidence can be implemented in work routines in the clinic quite fast when there is an urgent need to develop new routines of treatment and care to secure patient survival. Some of these new routines and new evidence are important to evaluate further to enhance the quality of care. As the pandemic emerged people died and nurses witnessed their patients die, including patients who could have survived at a higher care level but died due to a lack of intensive care beds. Similar findings are presented in a study by Phua et al. (2020) which described the shortage of ventilator support, medication, intensive care wards, etc., as frustrating for the healthcare staff and forced them into ethical dilemmas. This finding highlights the importance of having routines in place to handle stressful situations including time for reflection and psychological support. This is not only related to pandemics, but stressful conditions and ethical dilemmas occur on most days as a nurse. It is a question of a sustainable working climate and being able to continue working for many years. Nurses and other health care staff will always be put in ethically difficult situations. If these challenges are not handled properly and space is not given to the staff to discuss, reflect and improve care, competent staff might eventually leave their workplaces due to burnout. The result of the present study showed a lack of ethical and practical guidelines for medical staff to follow in times of the clinical trials conducted during the pandemic, leaving the nurses in ethical distress and feeling completely exhausted. The results showed that nurses valued teamwork with colleagues highly and described the importance of trust and support from each other when they needed to talk and reflect. These findings are supported in a study by Haas et al. (2020), where nurses also emphasized the importance of a quiet place to rest.

Reduce the Spread of Infection

Research has shown that COVID-19 is very contagious and can be transmitted indirectly as well (Arabi et al., 2020; Duncan & Lyall, 2020). Therefore, it was extremely important to use protection equipment and follow rigorous hygiene recommendations for the nurses to protect themselves and other patients. However, there was a shortage of protective equipment which complicated the work situation, leading to worries about becoming infected and infecting others. The lack of protective equipment was evident globally (Phua et al., 2020) and was a reality at the very beginning of the pandemic. The nurses in our study narrated that they had to reuse face masks and breathing masks due to shortages. Something that put them at a great risk of becoming infected as the risk for self-contamination is high when reusing protective equipment (Phua et al., 2020). This fact was very challenging for the nurses in our study as well and they were afraid of spreading the infection to others. The nurses in our study reported that they were unsure of how this level of protection equipment should be used and would have needed information and practice before using PPE in patient care. They had received scarce information or training on how to use it, which contributed to the feeling of anxiety and uncertainty among the nurses. However, this study was performed at the very beginning of the pandemic which should be considered.

Strengths and Limitations

The study was performed at the beginning of the pandemic, and it was difficult to recruit participants, due to the extremely high influx of patients and workload. Healthcare staff were mandated to work extra hours to maintain patient safety which was stressful. Therefore, the number of participants in the study was limited. In addition, since the risk for transmission of COVID-19 was high, the interviews were performed online which could be a disadvantage. However, the interviewer was familiar with the online video program and could handle the interview situation well. The authors, therefore, suggest exploring this method further when interviews are used as data collection. The video interview also gives the researcher the possibility to watch the interview again, not only the sound. The validity of the study was assured as the participants were given the option to read through the transcribed interview before analysis, in accordance with Polit and Beck (2017). In order to further ensure the validity and the reliability of the study a semi-structured interview guide was used, and a pilot interview was performed to test the interview guide. We also used the COREQ checklist when planning and reporting the study (Tong et al., 2007). The transferability of the study was confirmed as we chose to include participants from both primary care and inpatient care. However, we did not have participants from intensive care which would have been beneficial when describing the experiences of nurses at different care levels.

The authors greatly acknowledge the study participants.