Impact on staff of providing non-invasive advanced respiratory support during the COVID-19 pandemic: a qualitative study in an acute hospital

Abstract

ObjectivesTo explore the experiences of healthcare workers providing non-invasive advanced respiratory support (NARS) to critically unwell patients with COVID-19.DesignA qualitative study drawing on a social constructionist perspective using thematic analysis of semistructured interviews.SettingA single acute UK National Health Service Trust across two hospital sites.ParticipantsMultidisciplinary team members in acute, respiratory and palliative medicine.Results21 nurses, doctors (juniors and consultants) and physiotherapists described the provision of NARS to critically unwell COVID-19 patients as extremely challenging. The main themes were of feeling ill prepared and unsupported, a need to balance complex moral actions and a sense of duty to patients and their families. The impact on staff was profound and findings are discussed via a lens of moral injury. Injurious events included staff feeling they had acted in a way that caused harm, failed to prevent harm or had been let down by seniors or the Trust. Participants identified factors that mitigated adverse impact.ConclusionsAlthough many of the issues described by participants are likely immutable components of healthcare in a pandemic, there were several important protective factors that emerged from the data. Experience, debriefing and breaks from COVID-19 wards were valuable to participants and successfully achieving a peaceful death for the patient was often viewed as compensation for a difficult journey. These protective factors may provide modelling for future education and support services to help prevent moral injury or aide in its recovery.Trial registration numberRegistered on the Open Science Framework, DOI 10.17605/OSF.IO/TB5QJ

Non-invasive advanced respiratory support in end-of-life care and symptom management: systematic review

“…NARS also represented a symbol of hope to many patients 7 18 20 21. An active treatment that may buy time and another chance of life 14 15.…”

“…While there were potential symptom benefits to NARS, these were counterbalanced by significant treatment burdens. NARS may represent an anchor which adds burden to the patient and which of these opposing pulls is stronger, the hope and relief of the buoy or the symptom burden of the anchor, is difficult to predict 15 16 19 21 22…”

“…NARS was noted at times to contribute the breathlessness it was intended to treat,7 17–21 23–25 although this may improve with adjustment of settings and perseverance beyond initiation 7 17 19…”

“…This may be driven by worsening breathlessness but is also contributed to by feelings of claustrophobia related to the interface15 17 18 20 22 23 and the noise of the machine 15 17 20 22 26. The noise of NARS and the mask created issues in communication which complicated all aspects of care 17 21…”

“…Patients in receipt of NARs had a significant risk of mortality with high symptom burdens 16. The nature of this work, combined with the uncertain beneficence15 16 19 21 and potential maleficence of NARS,7 15 19–22 26 negatively impacted staff 19 21 22 26 29 32. Some of this maleficence was attributed to the unnatural elongation of the dying process 26 33…”