Table 4.

Participants’ quotes for theme 3 and subthemes: Sources of moral distress and fatigue

Distressing clinical practices	New guidelines: “Well, the protocols have stabilised. That clearly changes a lot less than it used to. The level of protection is clearer and clearer for all of the staff. That also helps. So, because the protocols aren’t changing anymore, that means that everyone knows their protection methods.” (Nurse)
	Resuscitation: “But as soon as it’s an emergency situation, there’s a cardiac arrest, everyone gets dressed. We can’t just walk into the room directly and start maneuvers anymore. So, of course it’s been difficult, as much for nurses as for patient care attendants. I’ve even had discussions with certain doctors who also feel powerless. (…) We get the impression that we haven’t always been able to give our 100% because of the COVID measures.” (Nurse)
	End of life care: “Palliative care is the complete opposite. What we’re seeing now is we’re accompanying them in death, so it’s a kind of paradigm shift that we’re not used to doing in the emergency room. We’re very proactive at trying to save lives, and I’m not saying we’re not doing that anymore, we’re still trying to do that as much as possible too. But when we’re at another level, it’s more important to accompany, and we’re maybe less experts at that. Anyway, I’m not saying it’s my expertise.” (Nurse)
	Difficult decisions: “You know, I’m ready to take the risk, to go in there and do chest compressions. But here, I had the patient care attendant, the nurse, next to me. (…) Everything goes into the algorithm. Does the patient have a chance? Do I put my staff at risk?” (Physician)
Challenging distance with patients & families	Less physical presence with patients: “There’s nothing like being with the patient to witness the unsaid, attitudes, and all the transcultural aspects too. We know patients from different origins, from different social backgrounds will express themselves, will be different, and that, you have to be with the patient to see that. So walls, intercoms, the this and the that, I find it’s harming us. And we probably missed a few things in doing that, I think.” (Physician)
	Family visiting restrictions: “Already in the emergency, everything goes fast, and we don’t always have the time to be close to our patients. But I realise that, actually, at least I was closer to my patients than now! It wasn’t that bad after all. I find there’s a break and I find it sad for patients and their families because no, their answer is no, we don’t authorise any visits. We don’t tolerate any visits. So, the patient is alone, and often anxious.” (Nurse)
	Trying to humanise care: “I think in the first weeks, the stress made us less good. I had the impression that, my goodness, it put a lot of distance in the physician–patient relationship, all that “cling-clang” when you came into the room, the gloves, the mask, the visor, the blouses… Now I think I’ve gotten used to it, and I can laugh about it with patients. I find I’ve begun to have the same level of relationship with patients as I did before the pandemic. But it took a few days, weeks.” (Physician)
Ongoing sources of potential burnout	Structural stressors: “We had renovations. We had construction. We had quick changes in protocols, almost twice a day. (…) But that all happened pretty quickly. In less than one month, they built negative pressure rooms like they’ve never built before. We had five and now we have fifteen in the emergency room.” (Nurse)
	Information overload: “We don’t stop receiving e-mails. It’s non-stop. It comes in, it comes in, it comes in… I’ve never received this many e-mails in my life.” (PCA)
	Increased workloads: “I think the ministerial decree affected a lot of people. Full-time for everyone really led to everyone being in worse shape, worse spirits, be it in their lives, or their professional lives, or at home.” (Nurse) “We worked more, and shifts were more tiresome. I spoke to a lot of people on the team who said: “We were glad there were less patients because it was extremely draining, and stressful.” (Physician)
	Change fatigue: “I’ve received this last guideline change with lassitude. Because I know that the teams I work with, nurses and all that, they’ve had an incredible overdose of instructions, and we’re asking a lot of them. They’ve taken away their vacations… And they’re asking for a lot, a lot of changes. And I think they won’t be able to introduce any more changes.” (Physician)
	Pressures of working during the pandemic: “It’s difficult, it’s exhausting, it’s taxing what we do. We are with people. We always give our best. You can’t say: “Ah, well, today, I will do it halfway” or “today, I will take more breaks.” We can’t do that, and we are always constantly drained because everything takes more time, and we think more, we think about protecting ourselves, we think about assembling our things, we think more than usually, and we finish our days… And I too, am much more tired than I usually am.” (Nurse) “Given the emotional energy required to do this job on a regular basis, having downtime is really, really important and given the fact that we’re homeschooling, we’re maintaining a household, we’re supporting our partners, we don’t get an opportunity to recharge. I think that is really, really difficult and I think that’s something that’s been experienced by a lot of our staff as well. And then you have other staff who might not necessarily have younger children but have elderly parents in retirement homes or even just in the community who are far more vulnerable. And so, worrying about them and helping them and supporting them also requires an incredible amount of energy. And so, there’s really just no rest, there’s no recharging that typically happens and so I think that accumulatively can lead to compassion fatigue, and just at the end you don’t have anything left.” (Social worker)
	Distance with the general population: “There are people for whom life is taking back a slightly more normal course and they’re more relaxed because of that. For us, at work, we have a constant reminder that no, it will never be like before.” (Physician)
	Fatigue and potential burnout: “Right now, we’re a little exhausted, fed up. Summer vacations cancelled throughout all this. I don’t think we have the motivation or courage to say “OK, we have to plan for the worse, for the fall, for the winter. What measures are we going to put in place?” I get the impression that we’re not preparing for the worst, that the second wave will be terrible, because we’re so tired and exhausted after what we’ve just experienced.” (Physician)
	Lack of recognition from leadership: “I think we’re at wits end. At first, we were living this as a team and it was something special. ‘We’ll give it our all, we’ll get through it.’ But now, we get the impression we’ve been through it, but we’re still being manipulated like pawns.” (Nurse)