Title: Work-related stress: the Impact of COVID-19 on Critical Care and Redeployed Nurses
Funder: Chief Scientist Office, Scotland

Abstract: COVID-19 placed great pressure on critical care units. Critical Care Nurses (CCNs) were working under very difficult conditions and experienced significant challenges. For example, they had to deliver care whilst using very cumbersome personal protective equipment, many of their patients died from COVID-19 and, because relatives were not allowed access to critical care units, staff were the only people available to be with patients at the end of their lives, staff also had to communicate and support worried and bereaved relatives at a distance, and their work posed well-publicised potential risks to their own and their family’s health. In addition, the pressure on critical care units meant nurses from other areas were redeployed to critical care. These nurses experienced the same stressors as CCNs but with the additional challenges posed by having to work in a very different and new environment and without specialist critical care skills and training. It is possible that the physical and psychological wellbeing of nurses working critical care during the pandemic has been affected and their intention to continue in critical care nursing reduced. It is important, therefore, to understand how nurses working in critical care have experienced and been affected by the pandemic. In this study we will use a model of occupational stress called the Job Demand Resources model (JD-R model) to better understand stress in nurses working in critical care during the pandemic. The JD-R model states that stress occurs when the demands of a situation outweigh the resources available to meet those demands. Two types of resources are described, the personal resources of the individual nurse and the resources provided by the job and workplace. For example, a nurse might be highly resilient and their job might give them lots of control over how they work; both of which are resources available to help the nurse meet the demands of the job. However, when demands outweigh resources negative outcomes occur; e.g., the individual nurse might experience physical and mental health strain that presents as ‘burnout’, which affects their ability to care for their patients, and they may decide to leave critical care. We will ask all CCNs in the 20 adult critical care units in Scotland and 3 units in England and all nurses deployed to those units on at least 2 occasions to complete a questionnaire designed to measure the JD-R model. To examine how the current pandemic has impacted staff we will compare the results to a similar study completed just before the onset of COVID-19. This questionnaire survey will identify sources of stress before and during the pandemic and the factors that reduce or increase the impact of that stress on the physical and mental health of staff and their intention to stay in post. In addition, we will interview staff in depth to understand better their experiences of working in critical care during the pandemic. We will also ask staff about the support services they were offered, the services they used and those they found helpful. We will combine the results of the survey and interviews to develop a full understanding of the sources of stress in critical care and how the impact of that stress can be mitigated by the personal, job and support resources available to staff. In this way we will be better prepared to support staff if a second or third wave of the pandemic occurs and will be better placed to retain staff within critical care.

Lay abstract: Background: Critical care nurses (CCNs) and nurses deployed to critical care areas experienced significant challenges during the pandemic. They were faced with a multitude of difficult and new demands, including the high acuity and associated mortality rate of COVID-19 patients, the need to deliver care using personal protective equipment, to communicate and support relatives at a distance, and the well-publicised potential risks to personal and family health. There is a need to understand the impact of these increased demands at the individual, unit and organisational levels in order to know how best to support staff now and through possible second and third waves of the pandemic. This 2-phase, mixed methods study will use a theoretical model of occupational stress, the Job Demand Resource (JD-R) model to understand the impact of the COVID-19 pandemic on CCNs and staff deployed to critical care areas. The JD-R model specifies individual factors (personal resources e.g. resilience), work environment and job characteristics (job demands (e.g. workload) and job resource (e.g. autonomy)) variables that may lead to either negative (health impairment, reduced job satisfaction, burnout) or positive (work engagement, commitment) outcomes for staff, and organisational outcomes (intention to remain and quality of care). Phase 1: Questionnaire study: All CCNs employed within NHS ICUs in 20 adult critical care units across Scotland and three units in England (around n=2000) and registered nurses who were redeployed to critical care areas on at least 2 occasions will be invited to complete a questionnaire designed to measure all components of the JD-R model of stress. We have a recently completed study that employed the JD-R model to assess stress in CNNs prior to COVID. This study will act as baseline data for the current study. Structural equation modelling analyses will be used to assess the ability of the JD-R model to account for the data. These analyses will identify the sources of stress that impact on individual wellbeing and organisational outcomes, such as intention to remain in post. It will also identify factors that mitigate the impact of stress on individual and organisational outcomes. Phase 2: Qualitative Interviews: in depth interviews with CNNs and redeployed nurses (up to 35 interviews with a stopping criterion) will explore the challenges and consequences of delivering critical care services during the pandemic and information about the support services they were offered, used and found useful will be recorded. Framework analyses will be applied to the data with the JD-R model providing the initial codes for charting. Interview text that remains after extraction of the JD-R coded text will be analysed using the usual framework method. The use of the same theoretical framework for the quantitative and qualitative components of the study will facilitate integration of results across phase 1 and 2 of the study. Information about the support services offered, used and found useful by staff will be compared to the sources of stress and the factors that mediate or moderate the effect of stress on health and wellbeing identified in phase 1. Understanding the match and/or mis-match between stressors and support services provided will identify services to be retained, services that are candidates for discontinuance and areas of unmet need.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE