Finally, 18 frontline nurses completed the interviews. Each participant was interviewed for 30 to 45 minutes. The sociodemographic and job characteristics of the study subjects are shown in Table 1.
Table 1
Demographic And Work Characteristics Of The Participants (n = 18)
Variable | Category | n | % |
Gender | | | |
| Men | 6 | 33.3 |
| Women | 12 | 66.7 |
Age(years) | | | |
| 20ཞ25 | 4 | 22.2 |
| 26ཞ30 | 4 | 22.2 |
| 31ཞ35 | 5 | 27.8 |
| 35ཞ40 | 4 | 22.2 |
| 40ཞ | 1 | 5.6 |
Marital status | | | |
| Unmarried | 5 | 27.8 |
| Married | 13 | 72.2 |
Education | | | |
| Advanced diploma | 2 | 11.1 |
| Bachelor's degree | 12 | 66.7 |
| Master degree or above | 4 | 22.2 |
Work years | | | |
| 1 ~ 5 years | 4 | 22.2 |
| 5 ~ 10 years | 7 | 38.9 |
| > 10 years | 7 | 38.9 |
COVID-19 support experience | | | |
| No | 3 | 16.7 |
| Yes | 15 | 83.3 |
After in-depth analysis and investigation, three themes finally emerged from our research as follows: (1) No plan survives contact with the enemy, (2) Expectations vs. Reality (3) Difficult to cover all aspects.
Theme 1: No plan survives contact with the enemy
Since the Wuhan outbreak in early 2020, we have witnessed remarkable achievements regarding prevention and control measures, medical supplies as well as diagnostic and treatment ability for COVID-19. In response to this pandemic, medical teams have been set up across the country and targeted training has been carried out to swiftly respond to the public health emergency. However, in the case of the Omicron variant in Shanghai, we found that even the well-prepared caught off guard by emergencies.
1.1 Butterfly effects caused by SARS-CoV-2 viral mutations
At the end of February 2022, a major outbreak with Omicron variant as the dominant COVID-19 strain spread through Shanghai. It is shown that the Omicron variant can be transmitted wider and faster and more difficult to detect. It is because of these characteristics that butterfly effects were triggered.
"The number of elderly patients with severe COVID-19 infections increased substantially in a short period of time due to the enhanced transmissibility of Omicron, a large population base and a large aging population of Shanghai as well as the underlying diseases of the elderly. Moreover, we had to be in line with the policy of ensuring admission and available beds for all patients. Therefore, the increase in the number of patients and the overload of human resources also directly led to the heavy workload of nurses". (Nurse 4)
The considerable increase in the number of patients also resulted in delayed medical supply, which directly affected nursing efficiency in patient care.
"For the care of critically ill patients, many equipment and devices as well as various medical products were required. Although the government tried its best to provide medical supplies for us, we could easily run out of stock due to the large number of patients. In addition, unlike before, some products were more difficult to obtain, so we had to come up with alternatives to complete nursing procedures, which was also challenging." (Nurse 7)
1.2 Caught off guard
A majority of participants in our study previously worked as frontline nurses in the Wuhan outbreak and took part in prevention and control work of COVID-19 in other places. Therefore, they were more experienced in providing care for COVID-19 patients with better mental preparation. However, we found out in the interviews that they could also be caught off guard by various situations.
"I participated in the fight against the Wuhan outbreak, and I am very familiar with the daily nursing process. I thought I could adapt quickly and become proficient as before, but things did not turn out as expected. We were actually very concerned about our risk of infection, because of the enhanced transmissibility of Omicron and common procedures for the elderly patients with severe COVID-19, such as sputum suction and invasive procedures, so we needed more time to adapt." (Nurse 2)
In addition to the psychological impact, it was also challenging to master the knowledge and skills for the nursing of elderly patients with severe COVID-19.
"We actually had received some theoretical and practical training before we came here, but we were still nervous when we arrived. Because we had to be familiar with all the aspects of care for the elderly patients with severe COVID-19, including nutrition, prone position and key points of ventilator management, while the previous training focusing on the prevention and control of hospital infection could not meet the actual clinical requirements." (Nurse 8)
"We did receive training on nursing procedures, but it was conducted in our own hospital with familiar equipment and sufficient supplies. However, all COVID-19 patients were admitted to designated hospitals for isolation, leading to the issues of material supply and resource allocation. In addition, it took us a while to get familiar with CRRT devices, frequently used by the patients with severe COVID-19." (Nurse 11)
Theme 2 Expectations vs. Reality
After they started to work in the ICU, the interviewees also encountered many challenges. They found that despite their preparations and assumptions, they were confronted with all kinds of problems beyond expectation in their actual clinical practice.
2.1 Communication barrier
All participants agreed that communication was key to understanding patient needs and gaining their cooperation, but there was a huge gap in communication even with awake patients.
"These patients are very old. We have patients struggling with cognitive decline, while some with hearing impairment. Meanwhile, some patients only use dialects. We have difficulty in verbal communication, so we can only occasionally communicate with gestures." (Nurse 2)
"Many seniors cannot express themselves clearly and accurately due to sensory decline, which requires us to spend more time on careful observation. For example, we had a patient who had a fracture in the hospital, but we didn't catch it because of his reduced ability to feel pain." (Nurse 6)
2.2 Unexpected patient complexity
The interviewees in this study all had the experience of ICU nursing and were skilled in the routine care of ICU patients. However, in this Omicron wave, the complexity of the elderly patients they encountered was beyond their expectation.
"It is really shocking. Many patients are suffering from dementia and disability. I have never cared for an elderly person like this before." (Nurse 5)
"In my experience with COVID-19, I have never provided care for so many elderly patients with severe COVID-19. Even though I had some severe patients, the situation was not that complicated." (Nurse 13)
3. Difficult to cover all aspects
In designated hospitals for treating COVID-19, due to limitations of diagnosis and treatment environment, human resources and medical supplies, the overall focus is on the treatment of COVID-19, even though the nurses have the intention of delivering "non-emergency" care, such as functional rehabilitation training and humanistic care, it is hard to fulfil.
3.1 Difficult to carry out functional rehabilitation
The post functional rehabilitation is regarded as an important part of the treatment of ICU patients. However, such routine care cannot be easily achieved in elderly patients with severe COVID-19.
"There is a gap between what you want to do and what you deliver. In the past, breathing exercises and limb functional exercises were very common in the care of critically ill patients, but we find it difficult to implement these exercises in COVID-19 isolation wards due to shortages of rehabilitation therapists and necessary equipment." (Nurse 1)
"As we have a lot of patients and we need to improve our patient turnover rate, so a lot of patients are transferred out of the ICU when their nucleic acid result turns negative and their basic condition improves, so we don't have enough time to complete those rehabilitation exercises." (Nurse 16)
3.2 Difficult to deliver psychological care
The combination of the fear of COVID-19 and isolation from the outside world can lead to psychological shock and panic for the elderly patients with severe COVID-19, therefore, they tend to have a higher demand for psychological care. However, due to the heavy workload of nurses and communication barriers, it is difficult to deliver psychological care.
"As they feel strange and anxious in this new environment of ICU, one of the most frequently asked questions by awake patients during their stay is when to go back to the general ward or go home" (Nurse 8)
"We work four-hour shifts with endless nursing tasks, and we also need to respond to changes in patients' conditions at any time, so we have little time to assess whether patients have psychological problems or address their needs." (Nurse 18)
"A lot of patients are not able to communicate because they are intubated and sedated, while awake patients can also have trouble communicating. I know they are in need of encouragement and support, but this communication barrier prevents it from happening." (Nurse 4)