Objective: To use the job demands-resources model of occupational stress to quantify and explain the impact of working in critical care during the COVID-19 pandemic on nurses and their employing organisation.
Design: Two-phase mixed methods: a cross-sectional survey (January 2021-March 2022), with comparator baseline data from April to October 2018 (critical care nurses only), and semistructured interviews.
Participants: Critical care nurses (n = 461) and nurses redeployed to critical care (n = 200) who worked in the United Kingdom National Health Service (primarily Scotland) between January 2021 and March 2022. The 2018 survey was completed by 557 critical care nurses (Scotland only). Survey response rate in Scotland was 32% but could not be determined outside Scotland. Forty-four nurses were interviewed (critical care = 28, redeployed = 16).
Methods: A survey measured job demands, job resources, health impairment, work engagement and organisational outcomes. Data were compared to 2018 data. Regression analyses identified predictors of health impairment, work engagement and organisational outcomes. Semistructured interviews were conducted remotely, audio-recorded and transcribed. Data were analysed deductively using framework analysis.
Findings: Three-quarters of nurses reached threshold for psychological distress, approximately 50% reached threshold for burnout emotional exhaustion and a third clinically concerning post-traumatic stress symptoms. Compared to 2018, critical care nurses were at elevated risk of probable psychological distress, odds ratio 6.03 (95% CI 4.75 to 7.95); burnout emotional exhaustion, odds ratio 4.02 (3.07 to 5.26); burnout depersonalisation, odds ratio 3.18 (1.99 to 5.07); burnout accomplishment, odds ratio 1.53 (1.18 to 1.97). There were no differences between critical care and redeployed nurses on health impairment outcomes, suggesting elevated risk would apply to redeployed nurses. Job demands increased and resources decreased during the pandemic. Higher job demands predicted greater psychological distress. Job resources reduced the negative impact of job demands on psychological distress, but this moderating effect was not observed at higher levels of demand. All organisational outcomes worsened. Lack of resources predicted worse organisational outcomes. In interviews, staff described the pace and amount, complexity, physical and emotional effort of their work as the most difficult job demands. The sustained high-demand environment impacted physical and psychological well-being, with most interviewees experiencing emotional and physical exhaustion, burnout, and symptoms of post-traumatic stress disorder. Camaraderie and support from colleagues and supervisors were core job resources. The combination of sustained demands and their impact on staff well-being incurred negative organisational consequences, with increasing numbers considering leaving their specialty or nursing altogether. Dissemination events with a range of stakeholders, including study participants, identified staffing issues and lack of learning and development opportunities as problematic. Critical care nurses are concerned about the future delivery of high-quality critical care services. Positive aspects were identified, for example, reduced bureaucratic systems, increased local autonomy and decision-making, recognition of the critical care nurse skill set.
Conclusions: The National Health Service needs to recognise the impact of COVID-19 on this staff group, prioritise the welfare of critical care nurses, implement workplace change/planning, and support them to recover from the pandemic. The National Health Service is struggling to retain critical care nurses and, unless staff welfare is improved, quality of care and patient safety will likely decline.
Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research as award number NIHR132068.
Keywords: COVID-19; CRITICAL CARE; JD-R MODEL; MENTAL HEALTH; MIXED-METHODS STUDY; NURSES; OCCUPATIONAL STRESS; WORKFORCE.
This study used a model of occupational stress to explore the experiences of nurses who worked in intensive care during the pandemic and its impact on them and the NHS. The study used: (1) a survey to measure nurses’ mental health, characteristics of their job during the pandemic and outcomes important to the NHS and (2) interviews to explore their individual experiences. Survey results were compared to a similar pre-pandemic survey from 2018. The survey involved around a third of all critical care nurses in Scotland and additional nurses in England and Wales. Compared to 2018, nurses were at six times the risk of psychological distress; a third reported concerning symptoms of post-traumatic stress. Nurses perceived a reduction in care quality and patient safety during the pandemic. Over a quarter of nurses were planning to change jobs in the next year. More favourable organisational outcomes (such as higher job satisfaction and reduced desire to change jobs) were associated with improved learning opportunities, the belief that the organisation was focused on staff well-being and quality of patient care. Interviews with nurses provided illustrative examples of these experiences and support the survey findings. Dissemination events identified continuing staffing issues and lack of learning and development opportunities as problematic, with nurses concerned about the future delivery of high-quality critical care services. Positive aspects were identified, for example, reduced bureaucratic systems, increased local autonomy and decision-making, and recognition of critical care nurses’ skill set. There was a strong sense that NHS culture needs to change to become a more open and caring environment. The NHS and Government need to consider how to meaningfully improve the critical care workplace. There is a need to continue to monitor staff stress and mental health, offer support to staff to recover, engage nurses in decision-making in relation to their working environment, and promote work environments conducive to building upon individual and team resilience.