Introduction
COVID-19 intensive care in the greater Stockholm area
The first patient with confirmed COVID-19, caused by the SARS-CoV-2, admitted to a Swedish intensive care unit (ICU) was reported on 6 March 2020. The Stockholm and Sörmland areas were the most severely affected in Scandinavia.
During spring 2020, over 250 patients with COVID-19 were simultaneously treated in the ICUs in the greater Stockholm and Sörmland areas, which normally staff 100 ICU beds. During the first 2 years up to 31 December 2021, a total of 11 241 care occasions for COVID-19 were recorded in this area, according to the Swedish Intensive Care Registry.1 There were periods with shortage of all kinds of resources such as personal protective equipment (PPE), drugs, ventilators, beds and staff. The first pandemic wave was followed by a calmer period before the second wave hit this area in November 2020.
Staff situation in COVID-19 ICUs
The situation during the first COVID-19 wave was different from what most of the staff had ever experienced.2–4 To manage the situation, nursing assistants, registered nurses, physiotherapists and physicians from operating departments, anaesthesia and general wards, as well as healthcare students, private caregivers and even non-medical staff were recruited to help in the area, as in other European countries.5
Regular intensive care staff (physicians, registered nurses and nursing assistants) were scattered, caring for patients in hastily equipped facilities not designed for intensive care, assisted by non-ICU staff. The newcomers had a short introduction, usually 1–2 days. They worked either in their own profession if possible, or as a nursing assistant. Therefore, the regular ICU staff had responsibilities of both caring for several patients more than usual and supervising colleagues not used to intensive care.
Members of the heterogenous care teams changed frequently, and their communication was impaired due to the PPE. Shortage of staff led to more and longer shifts and rotation between night and day shifts was common. Efficient treatment of severely ill patients with COVID-19 was uncertain, so guidelines were updated weekly. Because no relatives were allowed to visit due to the risk of infection, new tasks were added, such as daily updates by phone.
Staff health
High levels of stress and fatigue among doctors and nurses have earlier been discussed by scholars.6–8 Stress and burnout among doctors have even been called an epidemic,9–13 conferring considerable costs on individual and societal levels.14 Females’ higher levels of burnout have been described as due to work–home conflicts.15 16
More severe conditions such as post-traumatic stress disorder (PTSD) have been described among employees in surgery, obstetrics and emergency care. This has been found to correlate to sick leave and staff leaving their jobs or even changing career.7 17 18
Higher levels of PTSD and psychological distress were found in a review including studies of staff working in previous viral epidemics such as SARS and Middle East respiratory syndrome.19 Similar results were found in a sample of US nurses comparing those working with patients with COVID-19 and nurses treating other patient groups.20 Working more than 40 hours/week was a further risk factor. High burnout scores among staff treating patients with COVID-19 have been found in several recent studies.2 21–24
Patient safety in the COVID-19 ICU
Prepandemic studies have established staff safety attitudes to reflect patient safety measures such as medical errors, morbidity and mortality.25–27 The complex relation between safety attitudes and staff well-being has been discussed.28 29 Some scholars have considered safety culture as an aspect of work environment for healthcare staff.30
Due to the pandemic, normal standards for intensive care could at times not be maintained. A large study from the USA concluded that in periods when hospitals received many patients with COVID-19 and the proportion of these patients was large, patient mortality increased.31 Further, such a situation when normal standards of care cannot be maintained can cause staff moral distress, burnout and poor safety culture.2 21–23 30
The main aim of this study was to explore how ICU staff, both regular and temporary, assessed fatigue and safety culture during the first part of the COVID-19 pandemic in five hospitals in the Stockholm and Sörmland areas. We also aimed to elucidate how background factors and exposure to work affected burnout and safety attitude scores. A further aim was to identify and understand prominent stressors in this situation.