The value of getting to know your colleagues‘Who will do it if I don’t?’ Nurse anaesthetists’ experiences of working in the ICU during the COVID-19 pandemic


                  Background
                  During the COVID-19 pandemic, the workload on the intensive care unit (ICU) increased nationally in Sweden as well as globally. Certified registered nurse anaesthetics (CRNAs) in Sweden were transferred at short notice to work with seriously ill patients with COVID-19 in the ICU, which is not part of the CRNAs’ specialist area. However, limited research has shed light on healthcare professionals’ experiences of the pandemic.
               
                  Objectives
                  This study illuminates CRNAs’ experiences of working in the ICU during the COVID-19 pandemic.
               
                  Methods
                  This study used a qualitative method with an inductive approach to interview nurse anaesthetists’ who worked in the ICU during the COVID-19 pandemic.
               
                  Findings
                  The participants experienced ambivalent feelings towards their work in the ICU. They also lacked information, which created feelings of uncertainty and resulted in expectations that did not correspond to the reality. They described that due to an inadequate introduction, they could only provide “sufficient” care, which in many cases caused ethical stress. Not being able to get to know their new colleagues well enough to create effective cooperation created frustration. Even though the participants experienced the work in the ICU as demanding and challenging, overall, they enjoyed their time in the ICU and were treated well by their colleagues.
               
                  Conclusions
                  While CRNAs cannot replace intensive care nurses (ICNs), they are a useful resource in the ICU in the care of patients with COVID-19. Healthcare workers who are allocated from their ordinary units to the ICU need adequate information and support from their work managers to be able to provide the best possible care and to stay healthy themselves.
               


Introduction 25
As of June 2021, more than 176,300,000 coronavirus cases (SARS-CoV-2) and more than 26 3,800,000 deaths have been confirmed globally (1). In Sweden, more than 1,080,000 cases have 27 been confirmed and 14,500 inhabitants have died from the SARS-CoV-2 (2). In one region in 28 the south west of Sweden, 2400 persons have been cared for at the regional hospitals and, 29 among them, 185 have been cared for in the intensive care units (ICUs) (3). 30 Hence, the COVID-19 pandemic has caused a large number of patients suffering from a new 31 virus. Through the massive arrival of critically ill patients to the hospitals, the COVID-19 32 pandemic has radically changed professional practice in ICUs (4). For example, many patients 33 require advanced care interventions, such as oxygenation with low-flow and high-flow systems 34 and intubation, to be performed quickly. With their expertise, Certified Registered Nurse 35 Anaesthetists (CRNAs) usually play an important role in intubation management in anaesthesia 36 and resuscitation. When many COVID-19-patients require oxygenation and intubation at the 37 ICUs, reorganizations in CRNAs' job functions have been applied to use their expertise within 38 ICU-care. Thus, such reorganisations have made it possible for ICUs to receive an increased 39 number of patients and thus respond to the rapidly emerging global need for advanced care (5). 40 SARS-CoV-2 is a newly discovered virus that is under continuous research, which means that 41 knowledge about its pathology and treatment guidelines may change at short notice (6). In their 42 study, Rana, Mukhtar and Mukhtar claimed that healthcare workers who participate in the care 43 of COVID-19-patients have to deal with both the risk of being infected by the SARS-CoV-2 44 themselves, and the risk to suffer from mental health problems such as feeling scared or worried 45 (7). Research has found that 37.5% of 557 critical care and emergency nurses, representing 26 46 public hospitals in the region of Madrid, are working with the fear of becoming infected from 47 treating patients with COVID-19 (7,8). In another study, Cannavò et al. (9) claimed that nurses 48 should have adequate personal protective equipment (PPE; i.e. protective gowns or gloves) to 49 J o u r n a l P r e -p r o o f build their trust, motivation and self-confidence. Moreover, among the 557 critical care and 50 emergency nurses in the region of Madrid, 28.3% experience elevated workloads with 51 decreased opportunities to rest while taking on more responsibilities caring for patients with 52 . Mental health issues, such as depression, anxiety, stigma and panic, are more 53 frequently experienced among nurses than before the pandemic (7). COVID-19-related anxiety 54 is to a higher extent reported by healthcare professionals who use social networks regularly, 55 compared with healthcare professionals who use such networks to a smaller extent (9). 56 According to a Spanish study including 92 nurses representing two hospitals, the emotional 57 work and workload during the pandemic are a risk for nurses' psychosocial health, while the 58 resources, measures and information available are a protective factor for their psychosocial 59 health. In the same study, further research is proposed to broaden the knowledge about how to 60 protect and care for nurses during their work in a pandemic (10). 61 Under normal circumstances, ICU nurses (i.e. nurse with a one-year master's programme and 62 certification requirements for ICU) are responsible for the care of seriously ill patients in the 63 ICU in Sweden (11). During the COVID-19 pandemic, however, the workload in the ICU 64 increased nationally in Sweden, which meant that many CRNAs (i.e. nurse with a one-year 65 master's programme and specialist degree in anaesthetics and critical care) were transferred at 66 short notice to work with seriously ill patients with COVID-19 in the ICU, an area outside the 67 CRNAs' specialist focus. The ICU nurse and CRNA's role differs in several aspects, for 68 example; while the ICU nurse handles the care of the patient throughout the day and draws up 69 short-and long-term plans for the care to be provided with physicians and assistant nurses, 70 CRNAs have shorter patient meetings and are thus less accustomed to drawing up long-term 71 plans for nursing (12). CRNAs are also unaccustomed to working with and treating infectious 72 diseases on a daily basis (13). Like ICU nurses, however, CRNAs are responsible for informing 73 and supporting relatives (12). Since the beginning of 2020, the COVID-19 pandemic has placed 74 J o u r n a l P r e -p r o o f great demand on healthcare and its workers, and CRNAs may be seen as both an important and 75 The material was analysed through content analysis (14), performed in three main phases: 104 preparation, organising and reporting. Each transcribed interview was read by [XX, XX] several 105 times to understand the essential meaning. Text that responded to the study aim was marked, 106 divided into meaning units and further condensed and labelled with codes. Differences and 107 similarities among the codes were compared and further merged into subcategories and 108 categories describing the manifest content. Lastly, an interpretative and solid theme emerged 109 that captured the latent underlying meaning of the content. Trustworthiness of the study was 110 established by using the framework in accordance with Lincoln and Guba (15). To strengthen 111 credibility, the analysis was characterised by iterative movements in which there was 112 transparency throughout the analysis by reflexion on each meaning and returning to the 113 transcripts if necessary, until agreement emerged among all authors. The intention was to form 114 categories that covered the data and reflected the study aim (14). To illustrate the original data 115 and enhance the description of the categories, the results section shares some excerpts from the 116 interviews. To strengthen credibility, the analysis was characterised by iterative movements in 117 which there was transparency throughout the analysis by reflexion on each meaning and 118 returning to the transcripts if necessary, until agreement emerged among all authors. The study was designed, planned and performed according to Swedish law, stating that ethical 121 approval is not needed when healthcare professionals are asked to participate in research about 122 work-related questions (16). The study followed national ethical regulations and the 123 Declaration of Helsinki (17). All participants were informed orally and in writing about the 124 study aim and that participation was voluntary and could be withdrawn at any time without any 125 negative consequences. This study was compliant with the COREQ checklist (18). 126

Findings 127
Eight participants were interviewed, five women and three men, who varied in age (30-54 years) 128 and working experience (1-22 years). One latent theme, four main categories and ten 129 subcategories emerged from the analysis ( Table 2). 130 Insert Table 2 about here 131

An emotional process from unpredictability and uncertainty to comprehensibility 132
An emotional process from unpredictability and uncertainty to comprehensibility is the latent 133 theme that emerged and ran as a common thread throughout the result. Initially, the participants 134 experienced ambivalent feelings and uncertainty before working at the ICU. These feelings 135 changed over time. As the participants became acquainted with the environment at the ICU and 136 the work continued, valuable experiences were created and feelings of belonging in the 137 workplace were expressed. This could be likened to an emotional process, from feelings of 138 unpredictability and uncertainty to comprehensibility. 139

Being assigned to a new department during a pandemic 140
The participants described feeling ambivalent when they were informed of their relocation to 141 the ICU. They experienced feelings of excitement, nervousness and a lack of information, 142 which facilitated a feeling of powerlessness and being treated like an object. 143

Ambivalent feelings and lack of information 144
The participants were interested in participating in the care of patients with COVID- 19 The participants understood that they, as CRNAs, were asked to work in the ICU, as the unit 153 was expected to be heavily burdened. Some expressed uncertainty about what they could 154 contribute to the ICU. As many received their schedule with only a few days' notice, high 155 demands were placed on their ability to adjust and prepare mentally. 156

The feeling of being treated like an object 157
The participants described that high demands were placed on them both as professionals and as 158 private individuals to adapt their lives to their employer's needs, which evoked a feeling of 159 powerlessness. They also expressed a wish to become more involved in the planning and to 160 have access to information right from the start. From this, the participants described feeling as 161 though they were being treated like an object. 162 The participants had expectations of functioning as a helping hand for the ICU nurses as they 173 had been informed of by their managers, which did not correspond to reality, and stress related 174 to patient responsibility arose. 175

Helping the ICU nurse 176
The participants had heard stories and seen pictures via television and radio showing seriously 177 ill patients with COVID-19 and a heavily burdened care service, which created expectations 178 that they would work in conditions similar to those of a catastrophe but without sufficient 179 resources. Others expected a well-planned and structured organisation and thought they would 180 contribute by assisting the ICU nurse with delegated tasks, but routines on how the introduction 181 and transfer of CRNA´s to the ICU would work out were insufficient. 182 I had been told that we would be an extended hand to the ICU nurses, so maybe I 183 really did not worry so much about it. I thought I would go there, and do what I 184 could, work more as a nurse or something. 185 Shortly after receiving a schedule of working hours, they were introduced to ICU work, and 186 they realised that they would face much greater responsibility than expected, though they felt it 187 was unclear what role they would take in the care. After a short and sometimes unstructured 188 introduction, including a few individual sessions, they learned the most basic routines around 189 the care in which they would be involved. 190

Patient responsibility facilitated feelings of stress and inadequacy 191
The participants experienced a rapid increase in responsibility that most did not feel completely 192 ready for when they had to take patient responsibility for several seriously ill patients with 193  Before the COVID-19 pandemic, relatives were welcome in the ICU 24 hours a day. Due to 262 restrictions, most of the contact with relatives was by telephone, which was sometimes 263 challenging, as it was difficult to describe a patient's wellbeing over the telephone. 264 As the participants lacked experience and sufficient knowledge of the care provided in the ICU, 265 they sometimes found it difficult to provide up-to-date information about clinical responses to 266 treatment or patient progress to the relatives. 267 As CRNAs, the participants were an asset in the care of patients with COVID-19 in the ICU. 288 They described that several tasks were similar to those they performed in the surgical room. 289 When the lack of specific ICU knowledge arose, they relied on previous surgical room 290 experiences to support their ICU work, for example their habit of being responsible for, and 291 monitoring respiration and circulation. 292 293

CRNAs competence contributed to feeling an asset 294
The participants experienced that their competence as CRNAs contributed to the care of patients 295 with COVID-19 in the ICU. Being responsible for the patient's breathing and managing the 296 airway was something that was perceived as manageable and safe, as this is a basic competence 297 in their regular work. 298 To check the ventilation…. I felt safe with that. Then there were a few different 299 machines, but still you felt at intubation that it was just as familiar. 300 The conditions of many patients with COVID-19 required them to be placed in an abdominal 301 body position, which the participants felt safe with, as it is also a common body position during 302 surgery. The participants were also familiar with many of the medications used in the care of 303 patients with COVID-19, which made them feel secure even though the medical indications 304 and doses were different from those they were used to. They also felt that they could contribute 305 to assisting the anaesthesiologist when patients needed to be anaesthetised or intubated. 306 However, some felt that anaesthesia in the ICU was significantly different from that performed 307 during surgery and that the ICU nurse was a significantly better and safer assistant to the 308 anaesthesiologist in the ICU environment. 309

The time in the ICU created lessons learned and feelings of pride 311
When summing up their time in the ICU, the participants felt proud of what they had contributed 312 during the COVID-19 pandemic. Working and helping in a global crisis made them realise that 313 they were able to do more than they thought they could before. 314 Although the work in the ICU was at times perceived as stressful and energy-intensive, the 315 participants gained a lot of lessons learned and experiences for their future work. They felt more 316 secure as CRNAs and became accustomed to handling fragile patients with vascular access 317 devices, tracheostomy and respirators. 318 One thing I take with me is that, even though it was hard, I'm pretty proud that I 319 made it. That I have stood there and done an okay job and that my colleagues 320 there think they have done a good job. I will remind myself that I did a good job. 321 Then I take with me that in a new situation, this is probably possible. 322 The participants believed that their experiences would lead to better collaboration between the 323 ICU and surgery staff, as they now have a better understanding of each other's work. 324

Discussion 325
This study focuses on CRNAs' experiences of working in the ICU during the COVID-19 326 pandemic. The participants initially experienced feelings of ambivalence and uncertainty about 327 working in the ICU; high demands were placed on them as professionals to adapt to their 328 employer's needs. The participants described a lack of information from their managers and a 329 short and unstructured introduction to ICU work, which gave rise to feelings of powerlessness. 330 Before the introduction, they expected to assist the ICU nurses; however, in reality, they had to 331 assume patient responsibility for seriously ill patients with COVID-19. Previous research shows 332 that communication between frontline working nurses and their managers is key to ensuring 333 efficient care management in times of crisis (8). Furthermore, a structured internship 334 programme has been described as helpful for new graduate nurses when orienting to a critical 335 care area (19). When healthcare professionals are forced by their organisations to change 336 workplaces, research suggests that professional training of ICU staff with a focus on teamwork 337 may facilitate their ability to cope with particularly acute situations (4). The participants in this 338 study expressed a desire to work in permanent teams, get to know their colleagues and gain 339 continuity in the collaboration, but reported that teamwork was lacking. The participants had 340 different approaches related to their experiences of working with seriously ill patents. CRNAs 341 with less experience double-checked themselves and the patients repeatedly to avoid missing 342 anything. CRNAs with broader experience saw ICU nurses as resources and took help from 343 them when needed. These differences indicate that CRNAs need individualised introductions 344 when they are relocated to work in the ICU at short notice. The results show that the participants felt stressed about several aspects of working in the ICU; 358 the patients with COVID-19 were more fragile than patients they usually care for in their 359 ordinary workplace and they could deteriorate rapidly from small changes in body position. The 360 workload was high and left little time to give 'a little extra' to the patients. The PPE was found 361 to hinder the care, as patients could not see the CRNAs' facial expressions and CRNAs had to 362 shout to be heard. Another aspect was the difficulty of caring for relatives and describing a 363 patient's wellbeing over the telephone. Stress is the state in which individuals can end up when 364 their resources are insufficient to manage their surroundings (20). According to the WHO (21), 365 every patient should be offered the best possible care and treatment, even when resources need 366 to be redistributed and, in some places, rationed, as in a crisis such as the COVID-19 pandemic. 367 Situations such as these, when resources are perceived as scarce, can give rise to nurses 368 experiencing ethical stress (2, 22), a feeling of inadequacy that arises when healthcare 369 professionals feel unable to provide the best possible care to the patient (23). It seems as a risk 370 that optimal care cannot be given if caregivers are stressed in various ways. It could be 371 understood that if the participants in the current study experienced ethical stress, further 372 exploration is needed to broaden such knowledge. 373 A common thread throughout the responses was that CRNAs experienced an emotional process 374 working in the ICU during the COVID-19 pandemic. Initial feelings of unpredictability and 375 uncertainty changed to comprehensibility. In a previous study, many nurses reported stress from 376 their workplace in the pandemic (24), and a positive relationship has been shown between ICU 377 nurses' stress, anxiety, insomnia and depression (25). Women experience higher scores for 378 depression, stress and anxiety than men (26). While men and women participated in our study, 379 more research is needed to draw conclusions regarding such possible gender-related symptoms. 380 However, nurses who are resilient and perceive higher organisational support have lower 381 anxiety related to working with patients with COVID-19 (27). Therefore, healthcare 382 organisations should create opportunities for nurses to reflect on and discuss their experiences 383 of work during a pandemic, as doing so enables them to provide each other with support and 384 suggest workplace adaptations to a pandemic (24). According to El-Hage et al. (28), the 385 COVID-19 pandemic should be seen as a wake-up call for public health managers in their work 386 to improve society's preparedness for global health crisis situations. To protect the mental 387 health of nurses' and other healthcare professionals, education, including e-learning, might be 388 helpful to improve communication skills and ability to possess teamwork, when handling 389 psychological problems occurring from treating patients with COVID-19 (29). 390

Strengths and Limitations 391
As research about CRNAs' experiences in caring for patients with COVID-19 in the ICU is 392 lacking, the inductive approach was a strength of this study. While exploring the phenomenon 393 with descriptions from only eight ICU nurses can be seen as a limitation, the data material was 394 rich in nuances and details from their everyday work in the ICU. To achieve credibility, every 395 attempt was made to involve participants with a maximum level of diversity of experience to 396 obtain rich descriptions, which is important for the transferability of the results. To perform the 397 data collection via video link is a strength since the informant could choose where to connect; 398 it was also a way to conduct the data collection without the risk of spreading SARS-CoV-2, but 399 it can also be seen as a limitation, as eye contact is reduced (30). 400 • Nurses' competence and skills develop through work experience and specialist nurse 413 education. It is therefore not possible to replace one nurse directly with another without risking 414 possible consequences for the nurse's health, patient safety and quality of care. Therefore, 415

Implications
introductions should be based on the nurses' general and individual experiences and needs. 416 • During crisis situations, when specialist competence needs to be transferred from one 417 speciality unit to another to cover staffing needs, it is important to provide a well-structured 418 introduction to reduce the feelings of stress and inadequacy that can be experienced by nurses 419 working outside their specialist area. 420 421

Conclusions 422
During their work in the ICU, the participants experienced an emotional process; their feelings 423 changed from unpredictability and uncertainty to comprehensibility as they became acquainted 424 with the environment of the ICU. When the work continued, they obtained valuable 425 experiences, which strengthened their feelings of belonging in the workplace. 426 CRNAs are an important yet vulnerable population in healthcare organisations. When their 427 working environment rapidly changes from a secure place where they have specific knowledge 428 and well-known colleagues to an unknown place where they have to work with patients 429 suffering from a new virus, the lack of information and unfamiliar colleagues may affect the 430 nurses' health, patient safety and quality of care. 431 With their anaesthesia nursing competence, CRNAs can be helpful in the care of patients with 432 COVID-19 in the ICU, but they cannot replace ICU nurses in their work. 433 The results of this study contribute knowledge about CRNAs' experiences of the COVID-19 434 pandemic, which healthcare organisations and managers in charge of CRNAs could use in their 435 organisation of staff resources and support to CRNAs in situations of crisis. 436

Conflict of Interest 437
The authors declare that they have no competing interests. 438 Table 1. Semi-structured interview guide.