Table 2.

Participant quotes.

Theme 1: Communication and connection
Organisational communication The medical director, and our clinical nurse manager give us an update on what's going on in the unit in terms of patient numbers, COVID patients… you can ask questions about anything. You just type it in, and they answer that for you… the forum's a really good place to get the right knowledge at the right time from the right people. (P11, Nurse).  The communication was there…but you had to look for it. And it was tiring because you knew it was going to change by the time you read it the next day. But I think it was the nature of COVID, it just added another level of something going on around us (P12 Nurse).
Keeping families informed  We did try and do daily calls to family and teleconferences with them… but unfortunately some nurses found it difficult to make the time to do it. So sometimes I would call patients' families and they would say ‘we haven't had a conference call for more than a week’ (P10, Nurse).  I guess for older family members it was tricky because technology isn't accessible to everyone but it's also not user-friendly (P11, Nurse)  I had one guy that was still intubated but he was tolerating the tube. He was on ECMO … he was able to thumbs up his family which was quite nice, and I would encourage them to just talk … in one instance I lightened the sedation just for the communication (P15, Nurse).  Telehealth has been the saving grace of it. They are able to see their family member regardless… it can go for as long as they want. Some people just want to sit there and talk to their family member even if they are sedated…and I'll go about the nursing care (P2, Nurse).  The natural way that families cope when someone's critically unwell includes contact with nursing staff and doctors fairly regularly…And without that visiting time… they get more stressed, and they get more demanding… Two to 3 h of my time every day was taken up in phone calls to family members… Sometimes that meant being in hospital until 7:30-8:00 at night when normally I would finish at 6. (P5, Doctor).  If they rang up and were upset about it, as a clerk I would try and calm them, diffuse it and say, “One moment, I'll get the ICU liaison nurse to have a chat to you” and the nurse would have a chat to them, and they would work something out (P4, Ward clerk).
Staff to staff  If there was an intercom into the room rather than trying to use the desk phones to call in …. I think the communication would be easier if we just had better versions of the technology… (P8 Doctor).  To access things, I can't just walk in and out the room like I normally would. We've had a set up where we've had a PPE monitor and other staff. We just write a little note on our window and then they'd go and grab all the things for us (P3, Nurse).  We can't sit with each other in the tea-room, you have to yell across the room to talk to someone, so then you can't really talk about anything serious or how you're feeling because there's no privacy anymore…the TV's always on…a lot of people turned to scrolling on their phones… informal debriefing with peers was missed a lot (P11, Nurse).  At work you cannot get to know your colleagues. And because I was new, it was harder because of all these restrictions. The tearoom was changed, and socially distancing… (P13, Nurse).
Family supporters  It means so much to a patient. It just really lifts their spirits, and I believe that it would have a lot of benefits in their care…I've had an older person say, well, I'm gonna die soon so why you doing this to me and why can't I see my family? That was really challenging (P3, Nurse).  Wearing masks, made it harder for families and patients to see you and understand that there was humanity behind all those things… to see you smile… (P12, Nurse).  She recovered down the track and said that it was really hard because as lovely as the nurses and doctors were, she just didn't have her family. She just felt she was sticking it out on her own…that physical contact really meant something to her (P17, Nurse).  It's hard enough to look after patients who don't have family or friends visiting in normal times, if they're socially isolated…the strain on families and the secondary strain imposed on staff was tangible (P7, Doctor).
Theme 2: Psychological casualties
Fear of COVID  We have a daughter at home who is doing home schooling… Early on when we didn't know what to expect. There was fear that you could get infected… and infect our daughter… (P9, Nurse).  I feel very safe. I know I've been in those rooms for months and I haven't got it nor have any of my colleagues… I honestly feel more at risk going to the supermarket than being in my job because I know all the steps to take in the precautions (P3, Nurse).
Effect on home life  Kids home schooling and my husband at home trying to run a business. I'd come home to them all quite stressed and they've all got their own concerns …it was hard to debrief because everyone was having a hard time during that period (P14, Nurse).  (There were) conspiracy theories and it was hard to ignore that. I took that very personally and would get very upset….insinuating that it was all a big hoax, negative talk about vaccines … it was really upsetting when we could see the suffering of people we were looking after (P14, Nurse).  We would go for our walks just get out of the house… That was probably one of the most frustrating parts. We went from isolation to lock down. There was no reprieve from it. You come home and weren't allowed to leave the house (P15, Nurse).
Threats to morale  It was emotional impact … dealing out sympathy and compassion minute by minute throughout the whole day to multiple family members that's a natural process. But having someone intensely on the phone for an hour who's distressed…their loved one being critically unwell, that's a rapid drain of emotions …. It was unrelenting. (P5, Doctor).  This guy had six kids and they had the phone on speaker so that they could say goodbye before we turned the machines off… [the nurse] had an hour and half of family messages over the speaker from six adult kids saying goodbye to their dad…I think that the next day they went a bit easier on her with patient allocation. As far as I know that's it (P2, Nurse).  People were just burnt out or feeling really tired and a bit over it … I felt it wasn't acknowledged as well as it could have been. There were certain staff that had done a lot of heavy lifting… the unit as a whole was acknowledged for their hard work, but it did feel as though a lot of the staff took most of it… and didn't feel as though they were appreciated… (P14, Nurse).  I was hating going in and seeing very strong senior colleagues who I didn't think I'd ever see anything phase them, talk about being absolutely shattered… Just watching them break down at work was really scary, ‘cause it was like if they're not coping then how the hell is anyone else gonna be coping? (P20, Nurse).  No one had helped and I'd been in the room all alone pretty much all shift because you're senior and you don't need help. I am very competent, and people see me as very confident, but then it pushes you over the edge where you just cry (P12, Nurse).  The riot shields, they are different to the face shields. They gave me a killer migraine it is so much pressure on your head… I was literally crying as I was doing things because my head hurt so much but no one was able to come in and relieve me so I could get a drink… I know I'm being dramatic, but its soul destroying… it's torture (P2, Nurse).
Stress and burnout  All my family's in regional Victoria. Same with my partner. So, it was just him and me for the whole of last year, which took its toll on both of us. I realised how burnt out I was at the start of this year (when) I took some annual leave. (P19, Nurse).  People were talking about burnout a lot. A lot of people talked openly about dropping their hours and not wanting to be there…. I dropped my hours…I felt after last year, very exhausted and burnt out …(P20, Nurse).
Support for staff  We've always had a well-being team but during COVID they're definitely more active. They've had a book club started on WhatsApp and there's also a Facebook page… And they have food delivered to the unit. (P10, Nurse).  If you need a confidential Telehealth chat (with manager), that was always very, very available (P16, Nurse).  I tried to solve it by calling people, by sending text separately, by contacting people before and after work to see how they were going… (P5, Doctor).  … you get the big group email but it's so generic, you go “whatever” (P15, Nurse)
Theme 2: Psychological casualties
Managing stress  I'm a big walker and exercise nut …I do ‘step’ in the garage instead of at the gym. And then walking…I think, as a busy mum you just sort of get on with it. (P12, Nurse).  Usually I would run, but I had a foot injury … I thought it was just very bad timing that I couldn't do that exercise by myself … I find that very helpful to clear my head… I wasn't getting that break away from my family which was difficult…. three kids and home schooling (P14, Nurse).  I can still do yoga, which is nice. I can still go for walks with my dog… not being able to go out for a dance that's been definitely missed (P3, Nurse).  I bought a sewing machine, did baking, that sort of thing just to keep my mind occupied so I didn't think about really anything else. (P19, Nurse)  I do a lot of crocheting which is kind of my mindfulness activity. So, I did a lot more of that during lockdown. (P8, Doctor).  Yeah, no motivation. It was depressing. I just stay at home and watch movies and Netflix (P13, Nurse)  Eat too much, read books and watch movies. (P6, Doctor)  I'd come home and he would have dinner waiting for me… I'd strip my clothes at the door and walk straight to the shower, put my clothes into the washing machine and… he would have dinner ready for me… and too much alcohol (P15, Nurse)
Caring for our patients  Being in the isolated COVID rooms is a little bit of a barrier to doctors or senior nursing staff to come in and have a look and assess them… … I think there has to be an element of patient care that was affected (P11, Nurse).  You need to have a fair level of experience to be able to look after these patients…we experienced a strain on our workforce to a point where we probably expedited individuals being exposed to these sorts of critical patients earlier than they otherwise would have (P1, Nurse).  I think the standard of care dropped considerably. Staff feel stretched out… the ratio between senior staff and junior and redeployed staff… It felt like they were a lot of near misses that had happened that could have been avoided. (P17, Nurse).
Working in COVID rooms  If I had a patient who wasn't in COVID precautions, I could call the (doctor) and say, “I want you to come in and view this patient” and they'd come in… they'd look at the patient and they might have a listen to their chest, feel their pulses …Whereas in COVID they'd come outside the room and look through the glass… They assessed by what I was saying, the vital signs and the data that's in the notes (P20, Nurse).  …essentially, we were discouraged from doing anything aerosol generating, mouth care, we couldn't listen to their chest, you couldn't use a stethoscope (P15, Nurse).  Sometimes in those cubicles if I go out, I am just going to be behind and I am just going to be stressed …So I just crack on and do it …But you know we can get to a point where we can go through a 12-h shift without weeing (P15, Nurse).  When I was in the COVID rooms, I actually spent more time in PPE because I only got one break. I didn't have time to step out and have a drink at all…I'm sitting in the room sweating but also unable to have a drink so it's a special kind of torture (P2, Nurse).  It's been stressful because a lot of our patients were on ECMO which limits the number of nurses that can look after those patients. I was in there for weeks. It was very much the same people over and over again because of the skill mix. (P2, Nurse)  …I knew what it was like to be on the inside with not a lot of extra help. I didn't let that stop me going in … There was a patient that was on 2 ECMO circuits and just doing your obs takes a full hour… they are on a gazillion drugs and infusions…sometimes you just need an extra pair of hands to help you get in front (P15, Nurse).  You have to have the PPE monitors, extra nursing staff as well as physios and (ward support)… and we were looking after the technical stuff, the tubing… also keeping an eye that the patient was hemodynamically stable enough and having to either give sedation boluses or manage their blood pressure…Making sure all the connections on the ventilator were safe so you didn't inadvertently break the connection and put everyone at risk (P16, Nurse).
Staying safe  …and the sweat. Those gowns were just awful…I got into the habit of putting Duoderm over my nose and chin… It was over my ears where I really felt the pain… and on my face I get really itchy. Like I would want to rip my skin off (P15, Nurse).  The PPE monitors did a great job, and they were really good at highlighting and picking up on little things that you could improve on … (P8, Doctor).  There were moments of frustration…“seriously, do I have to come out and doff and re-don just for that? It wasn't really a breach!” (P15, Nurse).  I think a lot of people were intimidated by having a PPE monitor watch them…I had a few people say to me ‘don't judge what I'm doing’ (P11, Nurse). Medical emergencies  One of the consultants would usually go in very quickly and you would have another senior doctor on the outside …And you would have a bunch of nurses outside chucking things into the airlock… getting you whatever you need. Making up infusions and throwing them in… (P15, Nurse).  I think there was just a level of acceptance that you can only do what you can do, and we are not going to risk you or anyone else to be in there faster. You are not going in there without your full PPE on and whilst you're in there, you can only do what you can do to help that patient until somebody else can come in… (P15, Nurse).  I couldn't watch people try and resuscitate someone from outside and tell them what I needed them to do. I had to be in the room to be able to do that (P5, Doctor).
End-of-life care  In a few instances people died without ever having family visit in person …the greater suffering for them was the relative's death but it was compounded by the lack of contact (P7, Doctor).  It was just “no you can't come in”…it felt really wrong…I don't think there's a single family member that wouldn't have said “I will wear every single piece of PPE you give to me and I will isolate for 14 days afterwards to spend that time with my love” and we said “Nah. Sorry, it too risky”. And I just find that bullshit to be perfectly honest (P15, Nurse).
Overcoming challenges Workload  The late-night doubles where you're working 18 hin a row overnight… There was a stage where that was regular. So, you're working from 1:00 PM through till 7:30 the next morning. (P20, Nurse).
Changing roles, changing rules A lot of our senior staff ended up taking on different roles, so we were short of senior staff…that was a big hit for the unit (P17, Nurse).  We're still having a massive skill mix issue…. There are so many staff that aren't critical care registered nurses, almost 100% of the time you get sick, sick patients… I worked in ICU for6months before I took care of a ventilated patient, and these guys were having ventilated patients in their first week (P20, Nurse).  Having re-deployed staff comes with challenges…it was a lot of hard work to introduce them to the unit…it's such a different environment…we need more ICU experienced staff (P17, Nurse).  We started getting people from Caulfield…Suddenly I had 5 people following me around who'd never worked in ICU who had no skills or training in that area… then they took them back out again and we never saw them again… (P9, Physio).  The team support nurses were allocated in each pod and their role was support, help cover breaks…help with turns and education… I think that was a huge help…Every pod was getting smashed (P16, Nurse).  People who had previously been on call were getting called in for mundane everyday things and people who would normally be at home were in later at night. People who are expected to do research and education were at the bedside (P5, Doctor).  We split into a couple of teams so the nurses and ward support would do half and we would do half…They often have really large cannulas in their groins and neck…it's very important that they are not kinked or dislodged… A lot of these patients were morbidly obese and so they were a lot more difficult to reposition (P9, Physio).  Normally I would have a registrar, a senior registrar, plus or minus a pharmacist…we had to split it… it was quite difficult because they would have to debrief later in the day to try and find out who was doing what and how they were doing it (P6, Doctor).
Satisfaction with work  We thought he was going to die every day for weeks but last week we got a thank you video. He is at home and doing well. That was worth the migraine! (Participant 2, Nurse)  I think the biggest thing for me was how much we banded together as a unit…the really tight-knit friendships and bonds that have come from that … there was that level of trust like you've never probably had in someone else… (P19, Nurse)