Skip to main content

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

Abstract

Background

The COVID-19 pandemic has led to global shortages in the resources required to care for critically ill patients and to protect frontline healthcare providers. This study investigated physicians’ perceptions and experiences of caring for critically ill patients in the context of actual or anticipated resource strain during the COVID-19 pandemic, and explored implications for the healthcare workforce and the delivery of patient care.

Methods

We recruited a diverse sample of critical care physicians from 13 Canadian Universities with adult critical care training programs. We conducted semi-structured telephone interviews between March 25–June 25, 2020 and used qualitative thematic analysis to derive primary themes and subthemes.

Results

Fifteen participants (eight female, seven male; median age = 40) from 14 different intensive care units described three overarching themes related to physicians’ perceptions and experiences of caring for critically ill patients during the pandemic: 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).

Conclusions

The COVID-19 pandemic has required health systems and healthcare providers to continuously adapt to rapidly evolving circumstances. Participants’ uncertainty about whether their unit’s planning and resources would be sufficient to ensure the delivery of high quality patient care throughout the pandemic, coupled with fear and anxiety over personal and familial transmission, indicate the need for a unified systemic pandemic response plan for future infectious disease outbreaks.

Peer Review reports

Background

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 [1,2,3,4,5]. 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 [6,7,8,9,10,11]. 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 [12,13,14]. 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 [16,17,18,19,20].

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) [29,30,31] 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 [34,35,36]. 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.

Methods

Study design

We used a qualitative description study design [41] conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research. A qualitative research design is appropriate to explore topics where little information is previously known and to provide in depth information of participants’ own meanings and experiences. The use of qualitative inquiry offered the unique opportunity to develop rich insight into critical care physicians’ perceptions and experiences of resource strain in the ICU during the COVID-19 pandemic. The Research Ethics Boards at the University of Calgary (#REB20–0377) and Dalhousie University (# REB2020–5106) approved this study. Participants provided explicit oral consent in lieu of written consent.

Participants

We recruited critical care physicians using a recent and accessible sampling frame previously developed by our team [42] of all clinical and academic faculty from adult critical care training programs in 13 Canadian universities. We used non-probability purposive sampling [41] to invite a diverse sample of female and male physicians, currently employed, across years of practice, in provinces representing three (Atlantic, Central, Prairies) of Canada’s five [Atlantic, Central, Prairies, Pacific, Northern Territories] major regions to ensure variation in experiences. We aimed to recruit 5–8 (15–24 in total) participants per region. To this end, we consecutively emailed invitations until we achieved data saturation [43]. No additional eligibility criteria were applied.

Data collection

We iteratively developed a semi-structured interview guide and pilot tested it with two critical care physicians to ensure the core questions and probes adequately addressed targeted topics. In the pilot test of the guide, we removed one question that asked if the participants’ ICU had admitted any patients with a diagnosis of COVID-19. We also added a question as suggested by one pilot participant in the interview de-brief around the ethical and legal parameters of working under resource shortages in a pandemic. Interview questions asked physicians to reflect on three major topics: (1) current capacity of their primary ICU to meet the needs of critically ill patients with COVID-19, (2) existing or anticipated factors that would jeopardize physicians’ ability to manage the care of COVID-19 patients effectively, and (3) implications for the healthcare workforce and the delivery of patient care (Additional file 1). Interview questions were developed from topics of interest in the news media, clinical discussions and validated through discussion with ICU colleagues [44,45,46]. We included demographic questions at the end of the interview guide to capture participant age, sex, marital status, clinical base specialty, and ICU size.

Interviews and pilot tests were conducted in English via telephone in a private office by two senior research associates (LK, CdD), both female and with Masters degree training in qualitative and health services research. Participants provided informed verbal consent prior to participating. Interviews were collected between March 25 to June 25th, 2020. We digitally recorded the interviews and sent the audio files to a transcription company (www.rev.com/) to produce verbatim transcripts. The interviewers (LK, CdG) reviewed, cleaned, and de-identified the textual data prior to analysis. Participants were offered the opportunity to review their interview transcripts as a form of member checking to maximize validity.

Data management and analysis

Qualitative analysis was conducted between April 27 and July 25, 2020. We used NVivo 12 (https://www.qsrinternational.com/) to manage the data and facilitate thematic analysis. Two researchers (LK, CdG) first reviewed and coded a small sample of the transcripts (n = 3) independently and in duplicate using open coding [47]. Initial codes were compared and discussed with a senior qualitative researcher (JPL) to create a first draft of the codebook. The researchers then analyzed an additional three transcripts using both open and axial coding, iteratively refining the codebook until all relevant ideas were included. Deviant cases and exceptions within the data were sought and resulted in alterations to the codebook if the data were relevant to the research question, interview questions and emerging themes. The complete dataset (n = 15 transcripts) was then coded in duplicate with the finalized codebook. Fracturing of the data through axial coding was particularly useful in theme development as it enabled researchers to look across interviews for nuanced differences in participant perceptions. Both researchers used memos to document initial ideas during interviews as well as to document the relationships between codes during analysis. The researchers held weekly meetings during the 4-month period of analysis, wherein themes were developed, revised, and refined. Although our team was prepared to recruit further, saturation of overarching themes was achieved after the codebook was stabilized but prior to full analysis of the dataset (approximately halfway through the 4-month data analysis period).

Results

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.

Table 1 Interview participant characteristics

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).

Fig. 1
figure1

Visual representation of themes and subthemes describing critical care physicians’ perceptions and experiences of caring for patients in the context of resource strain during the COVID-19 pandemic

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.

Table 2 Subthemes theme 1, Conditions contributing to resource strain descriptions and quotes, Participant ID_SexAge_Region_InstitutionType
Table 3 Subthemes for theme 2, Implications of resource strain descriptions and quotes, Participant ID_SexAge_Region_InstitutionType
Table 4 Subthemes for theme 3, Enablers to resource sufficiency descriptions and quotes, Participant ID_SexAge_Region_InstitutionType

Conditions contributing to resource strain

Several participants described their ICU as experiencing resource strain (e.g., limited essential supplies) at the time of interviewing, while others felt that strain would occur imminently if the number of patients requiring ICU services continued to rapidly increase in their region. Participants described several factors contributing to strain in their ICU, including: 1) Continuously evolving pandemic conditions (e.g., varying resource supply and demand, unpredictable patient surges), 2) Limited equipment (e.g., rationing of PPE, inadequate physical space in the unit) and supplies (e.g., medication), and 3) Staffing shortages (e.g. physician illness, increased patient demand). Of note, a small group of participants were becoming increasingly concerned about the resource availability in their ICU as requests to accept transfer patients from ICUs that had already reached capacity began to increase (Table 3). Other participants were particularly concerned about the possibility of having to admit multiple patients simultaneously (i.e., in the case of a long-term care home outbreak) and the demand this would place on their ICU and existing pool of limited resources (Table 2). As demonstrated in these examples, participants often framed their discussions of resource strain in the context of uncertainty about whether their ICU would be able to meet rapidly increasing demands as the pandemic progressed. Overall, participants were fairly confident in the pandemic planning occurring in their ICU yet remained unsure as to whether this planning would lead to actual preparedness for what was to come (Table 2).

Implications of resource strain

All participants in our study described both the personal and professional implications of working in the context of resource strain during the COVID-19 pandemic. In particular, two main subthemes related to the personal toll of their work emerged from interviews: 1) Concerns for personal and familial safety (e.g., transmitting the virus to family members), and 2) Psychological impacts (e.g., increased anxiety). Most striking was the degree of concern for the safety of family members (Table 3). For example, some participants made the difficult decision to self-isolate away from their immediate family members by residing in a hotel to ensure that they would not bring the virus home, while others took great pains to limit their risk of being a contagion by segmenting their home into “hot and cold zones” (i.e., hot zones being the spaces and surfaces that the physician in the family would inhabit or touch, cold zones being those designated to family members). Although the level of concern regarding transmitting the virus to family members did vary across participants from mild to serious, all participants indicated that if they had to work without appropriate PPE they would be very concerned about familial transmission. The unpredictable trajectory of the pandemic had a psychological impact on participants. Feelings of uncertainty about how the pandemic would develop and whether their unit’s planning and supplies would be sufficient, created increased anxiety in many participants as they “waited for the disaster to happen”. – Participant 4.

In addition to the noted personal implications of caring for critically ill patients in the context of pandemic resource strain, we identified three subthemes reflecting perceived implications to the healthcare workforce and delivery of patient care (i.e., professional implications):: 1) Changes to physician practice (e.g., less direct patient contact, more clinical work than normal, innovative solutions to PPE shortages), 2) Deteriorating health of colleagues (e.g., decline in colleagues’ physical and/or mental health), and 3) Legal and ethical considerations of working within resource scarcity (e.g., moral dilemma of acting versus not acting). In particular, participants from all regions described changes to their normal clinical practice, specifically emphasizing less direct patient contact as hospitals shifted protocols to minimize the number of people entering the rooms of patients with known or suspected COVID-19 (Table 3).

Several participants also described spending more time than usual on clinical service, while others expressed worrying more about colleagues who they believed were at a high risk due to pre-existing conditions. When asked about legal and ethical considerations of working during a pandemic without adequate PPE, some participants mentioned that their unit had not had any conversations regarding the legal requirements, while others had discussed the matter, yet remained unsure of their legal responsibilities (Table 3). Some participants further investigated their legal obligations by contacting their professional governing body.

Enablers of resource sufficiency

All participants in this study identified factors that supported individual physicians and ICUs to effectively manage the care of critically ill patients with COVID-19. We clustered enablers into four interrelated subthemes: 1) Sufficient equipment and supplies (e.g., staff, ventilators, unit space, medication), 2) Comprehensive planning and communication (e.g., early pandemic preparation, clear and consistent PPE guidelines), 3) Adequate human resources (e.g., colleagues and personnel), and 4) Early pandemic preparation (e.g., surge planning) (Table 2).

Early pandemic preparation was a particularly salient factor to support resource sufficiency. Participants described several actions that their ICU leadership began executing early in the pandemic to plan for different surge and strain scenarios, such as, updated ICU plans (e.g., creating more ICU beds within and across hospitals), modified call schedules (e.g., creating backup call schedules), and redeployed staff from other units to the ICU to meet increased capacity demands. In addition, all participants mentioned that their units were considering solutions to mitigate and prepare for potential PPE shortages, including recycling, reusing and finding non-traditional PPE alternatives (e.g. painter’s masks, 3D printing face shields).

Similarly, participants across all regions indicated that the early implementation of clear and concise PPE guidelines was a crucial component of pandemic preparedness. Many also noted that while guidelines may need to shift in accordance with pandemic circumstances, keeping staff apprised of these changes in a clear and transparent manner (i.e., rapid knowledge mobilization and translation) was vital. At the same time, although there was consensus across our participant pool regarding the need for clear and concise COVID-19 guidelines, perspectives on what should be included in those guidelines to sustain high quality care and staff safety were more nuanced. Varied opinions were most noticeable in discussing what PPE should be used when entering the room of a patient with COVID-19. For example, participants generally agreed that full PPE (e.g., with N95 respirator) is needed in a closed-circuit intubated patient room because, as explained by Participant 11, “[there is] risk that at some point, the circuit becomes disconnected spontaneously, exposing everyone in the room [to the virus]”, but diverged on whether or not full PPE was necessary when entering the room of every patient confirmed to have COVID-19, regardless of medical procedure (Table 4).

Discussion

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 [68,69,70]. 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.

Conclusions

The COVID-19 pandemic has placed many of hospitals and healthcare providers in uncharted territory. This study investigated physicians’ perceptions and experiences of caring for critically ill patients in the context of resource strain, and identified contributing conditions, implications, and perceived enablers to resource sufficiency. Continuously evolving pandemic circumstances and a sense of uncertainty expressed by our participants highlight the importance of an organized national pandemic response plan for subsequent waves of COVID-19 and future pandemics.

Availability of data and materials

The datasets generated and analysed during the current study are not publicly available due to the critical care community being small in Canada and raw interview transcripts when considered as a whole may potentially be identifying. The dataset in the current study are available from the corresponding author on reasonable request.

Abbreviations

PPE:

Personal protective equipment

SARS:

Severe acute respiratory syndrome

ICU:

Intensive care unit

References

  1. 1.

    Firew T, Sano ED, Lee JW, Flores S, Lang K, Salman K, et al. Protecting the front line: a cross-sectional survey analysis of the occupational factors contributing to healthcare workers’ infection and psychological distress during the COVID-19 pandemic in the USA. BMJ Open. 2020;10(10):e042752. https://doi.org/10.1136/bmjopen-2020-042752.

    Article  PubMed  PubMed Central  Google Scholar 

  2. 2.

    Chew NWS, Lee GKH, Tan BYQ, Jing M, Goh Y, Ngiam NJH, et al. A multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during COVID-19 outbreak. Brain Behav Immun. 2020;88:559–65. https://doi.org/10.1016/j.bbi.2020.04.049.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  3. 3.

    Du J, Dong L, Wang T, Yuan C, Fu R, Zhang L, et al. Psychological symptoms among frontline healthcare workers during COVID-19 outbreak in Wuhan. Gen Hosp Psychiatry. 2020;67:144–5. https://doi.org/10.1016/j.genhosppsych.2020.03.011.

    Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Spoorthy MS, Pratapa SK, Mahant S. Mental health problems faced by healthcare workers due to the COVID-19 pandemic-a review. Asian J Psychiatr. 2020;51:102119. https://doi.org/10.1016/j.ajp.2020.102119.

    Article  PubMed  PubMed Central  Google Scholar 

  5. 5.

    Shaukat N, Ali DM, Razzak J. Physical and mental health impacts of COVID-19 on healthcare workers: a scoping review. Int J Emerg Med. 2020;13(1):40. https://doi.org/10.1186/s12245-020-00299-5.

    Article  PubMed  PubMed Central  Google Scholar 

  6. 6.

    Fiest KM, Parsons Leigh J, Krewulak KD, Plotnikoff KM, Kemp LG, Ng-Kamstra J, et al. Experiences and management of physician psychological symptoms during infectious disease outbreaks: a rapid review. BMC Psychiatry. 2021;21(1):91. https://doi.org/10.1186/s12888-021-03090-9.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  7. 7.

    Pappa S, Ntella V, Giannakas T, Giannakoulis VG, Papoutsi E, Katsaounou P. Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: a systematic review and meta-analysis. Brain Behav Immun. 2020;88:901–7. https://doi.org/10.1016/j.bbi.2020.05.026.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  8. 8.

    Vizheh M, Qorbani M, Arzaghi SM, Muhidin S, Javanmard Z, Esmaeili M. The mental health of healthcare workers in the COVID-19 pandemic: a systematic review. J Diabetes Metab Disord. 2020;19:1–12.

    Article  Google Scholar 

  9. 9.

    Salari N, Khazaie H, Hosseinian-Far A, Khaledi-Paveh B, Kazeminia M, Mohammadi M, et al. The prevalence of stress, anxiety and depression within front-line healthcare workers caring for COVID-19 patients: a systematic review and meta-regression. Hum Resour Health. 2020;18(1):100. https://doi.org/10.1186/s12960-020-00544-1.

    Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, et al. Psychological impact and coping strategies of frontline medical staff in Hunan between January and march 2020 during the outbreak of coronavirus disease 2019 (COVID19) in Hubei, China. Med Sci Monit. 2020;26:e924171.

    CAS  PubMed  PubMed Central  Google Scholar 

  11. 11.

    Lai CC, Shih TP, Ko WC, Tang HJ, Hsueh PR. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and coronavirus disease-2019 (COVID-19): the epidemic and the challenges. Int J Antimicrob Agents. 2020;55(3):105924. https://doi.org/10.1016/j.ijantimicag.2020.105924.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Wu P, Fang Y, Guan Z, Fan B, Kong J, Yao Z, et al. The psychological impact of the SARS epidemic on hospital employees in China_ exposure, risk perception, and altruistic acceptance of risk. Can J Psychiatry. 2009;54(5):302–11. https://doi.org/10.1177/070674370905400504.

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Sim K, Chua HC. The psychological impact of SARS: a matter of heart and mind. CMAJ. 2004;170(5):811–2. https://doi.org/10.1503/cmaj.1032003.

    Article  PubMed  PubMed Central  Google Scholar 

  14. 14.

    Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, Leszcz M, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003;168(10):1245–51.

    PubMed  PubMed Central  Google Scholar 

  15. 15.

    Buselli R, Corsi M, Veltri A, Baldanzi S, Chiumiento M, Lupo ED, et al. Mental health of health care workers (HCWs): a review of organizational interventions put in place by local institutions to cope with new psychosocial challenges resulting from COVID-19. Psychiatry Res. 2021;299:113847. https://doi.org/10.1016/j.psychres.2021.113847.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  16. 16.

    Tran DT, Thanh NX, Opgenorth D, Wang X, Zuege D, Zygun DA, et al. Association between strained ICU capacity and healthcare costs in Canada: a population-based cohort study. J Crit Care. 2019;51:175–83. https://doi.org/10.1016/j.jcrc.2019.02.025.

    Article  PubMed  Google Scholar 

  17. 17.

    Lee ES, Tan SY, Lee PSS, Koh HL, Soon SWW, Sim K, et al. Perceived stress and associated factors among healthcare workers in a primary healthcare setting: the Psychological Readiness and Occupational Training Enhancement during COVID-19 Time (PROTECT) study. Singapore Med J. 2020. https://doi.org/10.11622/smedj.2020163.

  18. 18.

    Shahid H, Haider MZ, Taqi M, Gulzar A, Zamani Z, Fatima T, et al. COVID-19 and its psychological impacts on healthcare staff - a multi-centric comparative cross-sectional study. Cureus. 2020;12(11):e11753. https://doi.org/10.7759/cureus.11753.

    Article  PubMed  PubMed Central  Google Scholar 

  19. 19.

    Cabarkapa S, Nadjidai SE, Murgier J, Ng CH. The psychological impact of COVID-19 and other viral epidemics on frontline healthcare workers and ways to address it: a rapid systematic review. Brain Behav Immun Health. 2020;8:100144. https://doi.org/10.1016/j.bbih.2020.100144.

    Article  PubMed  PubMed Central  Google Scholar 

  20. 20.

    Ripp J, Peccoralo L, Charney D. Attending to the emotional well-being of the health care workforce in a New York City health system during the COVID-19 pandemic. Acad Med. 2020;95(8):1136–9. https://doi.org/10.1097/ACM.0000000000003414.

    Article  PubMed  Google Scholar 

  21. 21.

    CIHI. Hospital spending - Focus on the emergency department. 2020. https://www.cihi.ca/en/hospital-spending. Accessed 23 Mar 2021.

    Google Scholar 

  22. 22.

    Lim R, Aarsen KV, Gray S, Rang L, Fitzpatrick J, Fischer L. Emergency medicine physician burnout and wellness in Canada before COVID19: a national survey. CJEM. 2020;22(5):603–7. https://doi.org/10.1017/cem.2020.431.

    CAS  Article  PubMed  Google Scholar 

  23. 23.

    Rubin B, Goldfarb R, Satele D, Graham L. Burnout and distress among physicians in a cardiovascular Centre of a quaternary hospital network: a cross-sectional survey. CMAJ Open. 2021;9(1):E10–E8. https://doi.org/10.9778/cmajo.20200057.

    Article  PubMed  PubMed Central  Google Scholar 

  24. 24.

    CIHI. Care in Canadian ICUs. 2016. https://secure.cihi.ca/free_products/ICU_Report_EN.pdf. Accessed 23 Mar 2021.

    Google Scholar 

  25. 25.

    Fowler RA, Abdelmalik P, Wood G, Foster D, Gibney N, Bandrauk N, et al. Critical care capacity in Canada: results of a national cross-sectional study. Crit Care. 2015;19(1):133. https://doi.org/10.1186/s13054-015-0852-6.

    Article  PubMed  PubMed Central  Google Scholar 

  26. 26.

    Gibbard R. Meeting the care needs of Canada’s aging population. 2018. https://www.cma.ca/sites/default/files/pdf/MediaReleases/Conference%20Board%20of%20Canada%20%20Meeting%20the%20Care%20Needs%20of%20Canada's%20Aging%20Population.PDF. .

    Google Scholar 

  27. 27.

    Rewa OG, Stelfox HT, Ingolfsson A, Zygun DA, Featherstone R, Opgenorth D, et al. Indicators of intensive care unit capacity strain: a systematic review. Crit Care. 2018;22(1):86. https://doi.org/10.1186/s13054-018-1975-3.

    Article  PubMed  PubMed Central  Google Scholar 

  28. 28.

    Rocker GM, Cook DJ, Martin DK, Singer PA. Seasonal bed closures in an intensive care unit: a qualitative study. J Crit Care. 2003;18(1):25–30.

    Article  Google Scholar 

  29. 29.

    Iyengar K, Bahl S, Raju V, Vaish A. Challenges and solutions in meeting up the urgent requirement of ventilators for COVID-19 patients. Diabetes Metab Syndr. 2020;14(4):499–501. https://doi.org/10.1016/j.dsx.2020.04.048.

    Article  PubMed  PubMed Central  Google Scholar 

  30. 30.

    McMahon DE, Peters GA, Ivers LC, Freeman EE. Global resource shortages during COVID-19: bad news for low-income countries. PLoS Negl Trop Dis. 2020;14(7):e0008412. https://doi.org/10.1371/journal.pntd.0008412.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  31. 31.

    Kanji S, Burry L, Williamson D, Pittman M, Dubinsky S, Patel D, et al. Therapeutic alternatives and strategies for drug conservation in the intensive care unit during times of drug shortage: a report of the Ontario COVID-19 ICU drug task force. Can J Anaesth. 2020;67(10):1405–16. https://doi.org/10.1007/s12630-020-01713-5.

    CAS  Article  PubMed  Google Scholar 

  32. 32.

    Padilla M. ‘It feels like a war zone’: doctors and nurses please for masks on social media. New York Times. 2020.

  33. 33.

    Truog RD. The toughest triage - allocating ventilators in a pandemic. N Engl J Med. 2020;382(21):1973–5. https://doi.org/10.1056/NEJMp2005689.

    CAS  Article  PubMed  Google Scholar 

  34. 34.

    Medecins Sans Frontieres. Help and solidarity needed in in Europe to protect medical staff from COVID-19 2020. 2020. https://www.msf.org/covid-19-urgent-help-needed-across-european-borders-protect-medical-staff. Accessed 23 Mar 2021.

    Google Scholar 

  35. 35.

    Fink S, Weise K, LaFraniere S. ‘At War With No Ammo’: Doctors Say Shortage of Protective Gear Is Dire. New York Times. 2020.

  36. 36.

    Zhou P, Huang Z, Xiao Y, Huang X, Fan XG. Protecting Chinese healthcare workers while combating the 2019 novel coronavirus. Infect Control Hosp Epidemiol. 2020;41(6):745–6. https://doi.org/10.1017/ice.2020.60.

    Article  PubMed  Google Scholar 

  37. 37.

    Judson SD, Munster VJ. Nosocomial transmission of emerging viruses via aerosol-generating medical procedures. Viruses. 2019;11(10):940. https://doi.org/10.3390/v11100940.

    Article  PubMed Central  Google Scholar 

  38. 38.

    Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS One. 2012;7(4):e35797. https://doi.org/10.1371/journal.pone.0035797.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  39. 39.

    Brurberg K, Frethiem A. Aerosol generating procedures in healthcare and COVID-19. Rapid review. Oslo: Norweigan Institute of Public Health; 2020.

    Google Scholar 

  40. 40.

    Ng-Kamstra J, Stelfox HT, Fiest KM, Conly J, Parsons LJ. Perspectives on personal protective equipment in acute-care facilities during the COVID-19 pandemic. CMAJ. 2020;192(28):E805–E9. https://doi.org/10.1503/cmaj.200575.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  41. 41.

    Bradshaw C, Atkinson S, Doody O. Employing a qualitative description approach in health care research. Glob Qual Nurs Res. 2017;4:1–8.

    Google Scholar 

  42. 42.

    Parsons Leigh J, de Grood C, Ahmed SB, Ulrich AC, Fiest KM, Straus SE, et al. Toward gender equity in critical care medicine: a qualitative study of perceived drivers, implications, and strategies. Crit Care Med. 2019;47(4):e286–e91. https://doi.org/10.1097/CCM.0000000000003625.

    Article  Google Scholar 

  43. 43.

    Guest G, Bunce A, Johnson L. How many interviews are enough? An experiment with data saturation and variability. Field Methods. 2006;18(1):59–82. https://doi.org/10.1177/1525822X05279903.

    Article  Google Scholar 

  44. 44.

    Breen K. Coronavirus pandemic puts Canada’s supply of ventilators in the spotlight internet: global News; 2020. https://globalnews.ca/news/6682780/coronavirus-pandemic-ventilators-canada/. Accessed 5 Nov 2020.

    Google Scholar 

  45. 45.

    Keller JSL. How prepared are our hospitals for the coronavirus outbreak? The Globe and Mail; 2020.

    Google Scholar 

  46. 46.

    University of Toronto UHN, Sunnybrook Hospital. COVID-19 Modeling Collaborative 2020. https://www.covid-19-mc.ca/. Accessed 23 Mar 2021.

    Google Scholar 

  47. 47.

    Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. https://doi.org/10.1191/1478088706qp063oa.

    Article  Google Scholar 

  48. 48.

    Grabowski DC, Joynt Maddox KE. Postacute care preparedness for COVID-19: thinking ahead. JAMA. 2020;323(20):2007–8. https://doi.org/10.1001/jama.2020.4686.

    CAS  Article  PubMed  Google Scholar 

  49. 49.

    Murthy S, Gomersall CD, Fowler RA. Care for Critically ill Patients with COVID-19. JAMA. 2020;323(15):1499–500. https://doi.org/10.1001/jama.2020.3633.

    Article  PubMed  Google Scholar 

  50. 50.

    Tabah A, Ramanan M, Laupland KB, Buetti N, Cortegiani A, Mellinghoff J. Personal protective equipment and intensive care unit healthcare worker safety in the COVID-19 era (PPE-SAFE): an international survey. J Crit Care. 2020;59:70–5. https://doi.org/10.1016/j.jcrc.2020.06.005.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  51. 51.

    Den Boon S, Vallenas C, Ferri M, Norris SL. Incorporating health workers’ perspectives into a WHO guideline on personal protective equipment developed during an Ebola virus disease outbreak. F1000Res. 2018;7:45.

    Article  Google Scholar 

  52. 52.

    Hersi M, Stevens A, Quach P, Hamel C, Thavorn K, Garritty C, et al. Effectiveness of personal protective equipment for healthcare workers caring for patients with Filovirus disease: a rapid review. PLoS One. 2015;10(10):e0140290. https://doi.org/10.1371/journal.pone.0140290.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  53. 53.

    Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA. 2020;323(21):2133–4. https://doi.org/10.1001/jama.2020.5893.

    CAS  Article  PubMed  Google Scholar 

  54. 54.

    Vogel L. Canada’s PPE crisis isn’t over yet, say doctors. CMAJ. 2020;192(20):E563. https://doi.org/10.1503/cmaj.1095868.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  55. 55.

    CBC News. Ontario hospital staff told to ration masks as COVID-19 spreads 2020. https://www.cbc.ca/news/canada/toronto/toronto-covid-mask-rationing-hospitals-1.5509731#:~:text=Toronto,Ontario%20hospital%20staff%20told%20to%20ration%20masks%20as%20COVID%2D19,memos%20obtained%20by%20CBC%20News. Accessed 23 Mar 2021.

    Google Scholar 

  56. 56.

    Garland A, Olafson K, Ramsey CD, Yogendran M, Fransoo R. Epidemiology of critically ill patients in intensive care units: a population-based observational study. Crit Care. 2013;17(5):R212. https://doi.org/10.1186/cc13026.

    Article  PubMed  PubMed Central  Google Scholar 

  57. 57.

    Institute of Medicine. Ethical and legal considerations in mitigating pandemic disease: workshop summary. 2020. https://www.ncbi.nlm.nih.gov/books/NBK54167/pdf/Bookshelf_NBK54167.pdf. Accessed 23 Mar 2021.

    Google Scholar 

  58. 58.

    Picard E, Robertson G. Legal liability of doctors and hospitals in Canada: Thomson Creswell; 2008.

    Google Scholar 

  59. 59.

    Davies CE, Shaul RZ. Physicians’ legal duty of care and legal right to refuse to work during a pandemic. CMAJ. 2010;182(2):167–70. https://doi.org/10.1503/cmaj.091628.

    Article  PubMed  PubMed Central  Google Scholar 

  60. 60.

    Re Steel Co. of Canada Ltd. and U.S. W., Loc. 1005. Ontario Labour Arbitration; 1973.

  61. 61.

    Serrano-Ripoll MJ, Meneses-Echavez JF, Ricci-Cabello I, Fraile-Navarro D, Fiol-deRoque MA, Pastor-Moreno G, et al. Impact of viral epidemic outbreaks on mental health of healthcare workers: a rapid systematic review and meta-analysis. J Affect Disord. 2020;277:347–57. https://doi.org/10.1016/j.jad.2020.08.034.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  62. 62.

    Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic. JAMA. 2020;323(15):1439–40. https://doi.org/10.1001/jama.2020.3972.

    CAS  Article  PubMed  Google Scholar 

  63. 63.

    Wang X, Zhou Q, He Y, Liu L, Ma X, Wei X, et al. Nosocomial outbreak of COVID-19 pneumonia in Wuhan, China. Eur Respir J. 2020;55(6):2000544.

    CAS  Article  Google Scholar 

  64. 64.

    Fang M, Xia B, Tian T, Hao Y, Wu Z. Drivers and mediators of healthcare workers’ anxiety in one of the most affected hospitals by COVID-19: a qualitative analysis. BMJ Open. 2021;11(3):e045048. https://doi.org/10.1136/bmjopen-2020-045048.

    Article  PubMed  PubMed Central  Google Scholar 

  65. 65.

    Norful AA, Rosenfeld A, Schroeder K, Travers JL, Aliyu S. Primary drivers and psychological manifestations of stress in frontline healthcare workforce during the initial COVID-19 outbreak in the United States. Gen Hosp Psychiatry. 2021;69:20–6. https://doi.org/10.1016/j.genhosppsych.2021.01.001.

    Article  PubMed  PubMed Central  Google Scholar 

  66. 66.

    Peek L. Children and disasters: understanding vulnerability, developing capacities, and promoting resilience — an introduction. Youth Environ. 2008;18:1–29.

    Google Scholar 

  67. 67.

    Bi Q, Wu Y, Mei S, Ye C, Zou X, Zhang Z, et al. Epidemiology and transmission of COVID-19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study. Lancet Infect Dis. 2020;20(8):911–9. https://doi.org/10.1016/S1473-3099(20)30287-5.

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  68. 68.

    Herring J. Nearly 250 Albertans could need ICU admission at COVID-19 peak outbreakin ‘probable’ scenario. The Calgary Herald: Local News. 2020.

    Google Scholar 

  69. 69.

    Ogden NH, Fazil A, Arino J, Berthiaume P, Fisman DN, Greer AL, et al. Modelling scenarios of the epidemic of COVID-19 in Canada. Can Commun Dis Rep. 2020;46(8):198–204. https://doi.org/10.14745/ccdr.v46i06a08.

    Article  PubMed  PubMed Central  Google Scholar 

  70. 70.

    Alberta Health Services. COVID-19 Info for Albertans. 2020. https://www.albertahealthservices.ca/topics/Page16944.asp. Accessed 23 Mar 2021.

    Google Scholar 

  71. 71.

    Wunsch H, Angus DC, Harrison DA, Collange O, Fowler R, Hoste EAJ, et al. Variation in critical care services across North America and Western Europe. Crit Care Med. 2008;36(10):2787–93. https://doi.org/10.1097/CCM.0b013e318186aec8.

    Article  Google Scholar 

  72. 72.

    Gubrium JF, Holstein JA. Handbook of interview research: SAGE publications, Inc; 2001. https://doi.org/10.4135/9781412973588.

  73. 73.

    King N, Horrocks C. Remote Interviewing. Los Angeles: Sage Publications; 2010.

    Google Scholar 

  74. 74.

    Ward K, Gott M, Hoare K. Participants’ views of telephone interviews within a grounded theory study. J Adv Nurs. 2015;71(12):2775–85. https://doi.org/10.1111/jan.12748.

    Article  PubMed  Google Scholar 

  75. 75.

    Matteson SM, Lincoln YS. Using multiple interviewers in qualitative research studies. Qual Inq. 2009;15(4):659–74. https://doi.org/10.1177/1077800408330233.

    Article  Google Scholar 

Download references

Acknowledgements

None.

Funding

This work was supported by the Canadian Institutes of Health Research Canadian 2019 Novel Coronavirus (COVID-2019) Rapid Research Funding Opportunity – Operating Grant (grant number RN420046–439965) to Jeanna Parsons Leigh.

Author information

Affiliations

Authors

Contributions

All authors, JPL, LK, CD, RBM, JNK, HTS, KMF contributed to the study conception and design. LGK and CD conducted the interviews. CD, LGK, RBM and JPL contributed to data analysis. The first draft of the manuscript was written by JPL, LGK, CD and RBM and all authors commented on previous versions of the manuscript. All authors, JPL, LK, CD, RBM, JNK, HTS, KMF read and approved the final manuscript. JPL had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Jeanna Parsons Leigh.

Ethics declarations

Ethics approval and consent to participate

The Research Ethics Boards at the University of Calgary (#REB20–0377) and Dalhousie University (# REB2020–5106) approved this study. Participants provided explicit oral consent in lieu of written consent. Participants were provided with written study information emailed ahead of the interviews and consent was given in the form of explicit oral consent at the beginning of the audio recording. This approach was approved by The Research Ethics Boards at the University of Calgary (#REB20–0377) and Dalhousie University (# REB2020–5106) due to the professional nature of the pool of target participants who were caring for critically patients during an active pandemic and therefore had very limited time to participate in research.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1.

Semi-structured interview guide.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Parsons Leigh, J., Kemp, L.G., de Grood, C. et al. 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. BMC Health Serv Res 21, 374 (2021). https://doi.org/10.1186/s12913-021-06393-5

Download citation

Keywords

  • Qualitative research
  • Resource strain
  • COVID-19
  • Critical care physicians