A qualitative study of physician perceptions and experiences of caring for critically ill patients in the context of resource strain during the first wave of the COVID-19 pandemic

Concerns about the physical and psychological consequences for healthcare providers tasked with caring for patients with the novel-coronavirus SARS-CoV-2, the virus causing COVID-19, have been well documented [1‐5]. From early in the pandemic, reports from countries around the world have detailed experiences of increased emotional distress, symptoms of depression, anxiety, insomnia and overall mental health disturbances among frontline staff [6‐11]. Furthermore, retrospective studies following the severe acute respiratory syndrome (SARS) outbreak in 2003 have shown that some healthcare providers who worked in locations where contact with SARS patients was common continue to experience symptoms of posttraumatic stress disorder years later [12‐14]. This is especially true in instances where psychological supports were minimal at the time [15]. Reduced confidence in training, fear of the unknown, limited hospital capacity, and insufficient support of personal protective equipment, are just some of the factors that have been shown to heighten healthcare worker experiences of negative psychological symptoms during the COVID-19 pandemic [16‐20].

Prior to the start of the pandemic in 2020, national reports indicated that hospital visits via the emergency department [21], as well as staff burnout [22], were already on the rise in Canada [23] . In fact, Canadian ICUs were operating at close to full capacity in 2016, particularly in large urban academic centers, leaving little flexibility for surge coverage [24, 25]. Demand for ICU beds is expected to increase with an aging population [26, 27]. Notably, depleted human resources (e.g., nursing availability), affected both bed and ventilator use in the ICU at this time [28]. Existing levels of resource strain have been further exacerbated since the start of the COVID-19 pandemic. High patient volumes and overwhelmed supply chains have led to both national and global shortages of the resources required to care for critically ill patients (e.g. ICU beds, ventilators, staff, etc) [29‐31] and to protect critical care providers from contagion (e.g. medical masks, N95 respirators) [32]. In extreme cases, insufficient resources have resulted in triaging life saving interventions (e.g. mechanical ventilation) [33] and unduly exposing providers to the virus [34‐36]. Risk of viral transmission increases when performing aerosol generating medical procedures (AGMP) [37], particularly tracheal intubation, which is commonly performed by frontline critical care providers [38, 39]. Executed without adequate personal protective equipment (PPE)—gloves, gowns, eye protection, N95 respirators—may further compromise frontline provider safety [40]. It remains unclear how anticipated or actual resource shortages have affected critical care physicians and the delivery of patient care in ICUs in Canada during the pandemic. To address this gap in our knowledge, and to generate information that may be used to inform hospital and provider focused guidance, we sought physicians’ perceptions and experiences of caring for critically ill patients in the context of actual or anticipated resource strain across multiple institutions during the COVID-19 pandemic.

We contacted 44 potential participants of which we interviewed 15. Non-respondents were contacted once following the initial email invitation. We conducted all interviews between March 25 and June 25, 2020. Interviews lasted a median (IQR) of 21 (15.3, 26.1) minutes. Table 1 presents the participant characteristics. The participants worked across 14 different ICU’s. All but one participant reported that patients with a diagnosis of COVID-19 had been admitted to their ICU at the time of interview. One participant offered to participate in member checking of their transcript.

Analysis revealed three overarching themes and multiple associated subthemes. Overarching themes included: 1) Conditions contributing to resource strain (e.g., continuously evolving pandemic conditions), 2) Implications of resource strain on critical care physicians personally (e.g., safety concerns) and professionally (e.g., practice change), and 3) Enablers of resource sufficiency (e.g., adequate human resources) (Fig. 1).

Overarching themes represent ideas that were largely echoed and emphasized by all participants in the study, while subthemes illustrate unique ideas related to a primary theme and provide a window into the diversity of participants’ perceptions and experiences. Subthemes were also shaped by the variability in pandemic preparations and COVID-19 case burden across ICUs and geographic regions. Quotations that exemplify themes and sub-themes are included in Tables 2, 3 and 4.

Caring for critically ill patients with a known or suspected novel infectious disease during a global pandemic is a complex task that requires multi-level (e.g., organizational, departmental, personal) planning and preparedness [48] to protect patients and health care workers [49]. The availability of resources is clearly an important mediator in successfully managing the care of critically ill patients in pandemic conditions [50]. Research during previous infectious disease outbreaks has shown that ample supplies of PPE significantly facilitated effective clinical care [51, 52], while insufficient or rapidly depleting PPE contributed to healthcare worker anxiety [53]. We conducted semi-structured interviews with critical care physicians in Canada to better understand their perceptions and experiences of caring for critically ill patients in the context of actual or anticipated resource strain during the COVID-19 pandemic. We identified three primary and interrelated themes: conditions contributing to resource strain, implications of resource strain on critical care physicians personally and professionally, and enablers of resource sufficiency.

When considering the management of essential resources required to care for patients with COVID-19, academic and mainstream media sources have been particularly concerned about adequate supplies of equipment (i.e., ventilators) and possible PPE shortages [29, 54, 55]. Our participants reflected similar concerns. In particular, the most salient and worrisome conditions that participants noted involved circumstances outside of their control (e.g., patient surges, supply chain shortages, etc.). At the same time, key enablers to support resource sufficiency in our study consisted of comprehensive planning and communication as well as early preparation. The issue of resource strain is likely further exacerbated by a healthcare system that already faced a growing demand for acute care with an aging population demographic [56]. Some participants described that their units had developed and enacted detailed plans to prepare for surge scenarios, including a tiered response of staffing and capacity depending on the number of patients with COVID-19 admitted to hospital. Other participants felt that their units were less prepared in that they were already experiencing shortages of PPE and were being presented with measures and mandates by their institutions to ration and conserve remaining supplies.

In addition to echoing the importance of adequate material resources, several of our participants also stressed the need for units to ensure that adequate numbers of properly trained personnel were available to care for incoming critically ill patients with COVID-19. In this respect, of particular concern to our participants were occurrences of large outbreaks at long term care facilities and outbreaks in neighbouring cities that would require hospitalization in their unit. Participants carried reports of global surges (where ICU bed need exceeded capacity leading to resource shortages and triage scenarios) [29] at the back of their minds, and largely did not know how their ICU’s pandemic planning would hold up in a similar scenario.

Our findings shed light on the importance of establishing ethical and legal parameters for healthcare workers as part of pandemic planning and preparedness [57]. In Canada, when a physician agrees to treat a patient, they have a legal duty to provide a certain standard of care [58]. In a state of emergency, individual provincial legislation may permit the provincial government to mandate physicians to perform certain services [59]. Yet, Canadian labor boards have outlined criteria to justify refusal to work which may be applicable during a pandemic [60]. Our participants highlighted the legal uncertainty surrounding physicians’ rights and obligations to continue to practice during a pandemic [59]. Some participants had conversations within their unit while others reached out to their governing bodies for guidance regarding the expectations of working as a physician during a pandemic and potentially without adequate PPE. This variability in awareness of the legal and ethical parameters for working during a pandemic highlights national discrepancies and suggests there are inadequate guidelines in Canada for what is expected of physicians during an infectious disease outbreak [59].

It is clear that the impacts of working during an infectious disease outbreak—particularly under conditions of real or anticipated resource strain—extend beyond the workplace setting. A recent systematic review highlighted the burden of mental health symptoms including anxiety, acute stress, depression and burnout among frontline healthcare workers during and following a disease outbreak [61]. Participants in our study experienced varying degrees of anxiety, particularly with respect to concerns for their family [62]. A small number of participants responded similarly to frontline workers around the world by finding alternate living accommodations (e.g., living in a hotel) to minimize exposure and risk to their families [63]. Other qualitative work indicates frontline healthcare workers in the China and the United States also dealt with anxiety about becoming infected themselves or family members becoming sick with COVID-19 [64, 65]. Other participants were much less concerned for the safety of their families, particularly their young children, potentially due to early reports indicating that the virus may not impact children as severely as adults [66, 67]. A general sense of anxiety and uncertainty was prominent throughout the interviews in regard to the pandemic placing the participants and their organizations in uncharted territory. National and provincial predictive models indicated first wave peaks that would induce resources shortages across the country [68‐70]. These models may have positively impacted and motivated early pandemic preparations, yet they may have also contributed to the stress and anxiety of healthcare providers and the public alike. While Canadian ICUs have a similar number of beds to Western European countries [71] a comparison in terms of conditions contributing to and implications of resource strain in ICU during a pandemic warrant further exploration.

There are some limitations that should be considered when interpreting our findings. First, the perspectives shared by our participants may not be transferable across Canada, as the majority of our participants practiced at urban academic institutions. Smaller community, regional or rural centres may have had varying levels of preparation and numbers of patients with COVID-19 leading to differences in perceived or actual resource strain. Second, physicians who felt particularly well prepared or conversely, highly strained, in terms of resource shortages may have been more motivated to volunteer for an interview. We attempted to mitigate this by purposively sampling a diverse group of critical care physicians in provinces that had variable numbers of people affected with COVID-19. This was further supported by using telephone interviews which enabled participation outside of the researchers’ home locations. Historically, interviews have been conducted face-to-face as the frame of social interaction and cues (e.g., body language) fits better within this method [72]. However, there is a growing acceptability [73] to conduct telephone interviews and evidence suggests strengths over face-to-face interviews such as ability to concentrate on voice instead of face, the feeling of not being judged and easier rapport over the phone [74]. The use of multiple interviewers has the risk of generating different data due to different interactions and participant perceptions [75], to mitigate this each interviewer followed the same introductory script and wrote memos following each interview that informed analysis. We also kept the interviewers and analysts consistent between data collection and analysis. Non-probability purposive sampling is often critiqued for being ambiguous and subjective.