Critical incidents and post-traumatic stress symptoms among experienced registered nurses during the COVID-19 pandemic: A cross-sectional study.

Background: Registered nurses working on the frontline during the COVID-19 pandemic encountered significant challenges, including exposure to critical incidents. Critical incidents refer to sudden unexpected clinical events that surpass an individual's ability to cope, leading to considerable psychological distress, which could potentially result in the development of post-traumatic stress disorder symptoms. Research has shown a high prevalence of post-traumatic stress disorder symptoms among healthcare workers, particularly those in close contact with COVID-19 patients. Objective: To assess the levels of post-traumatic stress symptoms among registered nurses in relation to exposure to working conditions during the COVID-19 pandemic, such as how much their work was affected by the pandemic, re-deployment, working hours hindering sufficient recovery between shifts and critical incidents. Design: Cross sectional study. Settings: The registered nurses working in multiple health care services covering all 21 geographic regions in Sweden. Participants: A total of 1,923 registered nurses, who are part of a Swedish national cohort and have been followed since their nursing education, were invited to participate in a survey in late September 2021 (15 to 19 years post graduation). Methods: The data were analyzed using descriptive statistics, unpaired t-tests, and one-way analysis of variance. Cohen's d was employed to quantify differences in mean levels between subgroups. Results: The response rate were 56.5 %. Over 50 % of experienced registered nurses reported significant disruptions to their work environments. In total, 85 % of registered nurses were exposed to at least one critical incident in their work during the pandemic, with 60 % facing organisational changes and nearly 50 % experiencing emotionally distressing situations. The exposure to work situations involving critical incidents consistently demonstrated strong associations with higher levels of post-traumatic stress disorder symptoms compared to those not exposed, with effect sizes ranging from moderate to high. Conclusions: This study underscores the profound impact that working conditions, such as redeployment and exposure to critical incidents, have on the mental health of registered nurses. We offer valuable insights into registered nurses' pandemic-related challenges, highlighting the need for support and interventions to prevent and manage critical incidents, ultimately promoting their well-being. We also highlight the significance of thorough workforce readiness planning for future pandemics and other challenging health care scenarios, such as staff shortage.

Fear of making a mistake: a prominent cause of stress for COVID-19 ICU staff-a mixed-methods study.

INTRODUCTION: The COVID-19 pandemic has had a profound effect on many domains of healthcare. Even in high-income countries such as Sweden, the number of patients has vastly outnumbered the resources in affected areas, in particular during the first wave. Staff caring for patients with COVID-19 in intensive care units (ICUs) faced a very challenging situation that continued for months. This study aimed to describe burnout, safety climate and causes of stress among staff working in COVID-19 ICUs. METHOD: A survey was distributed to all staff working in ICUs treating patients with COVID-19 in five Swedish hospitals during 2020 and 2021. The numbers of respondents were 104 and 603, respectively. Prepandemic data including 172 respondents from 2018 served as baseline. RESULTS: Staff exhaustion increased during the pandemic, but disengagement decreased compared with prepandemic levels (p<0.001). Background factors such as profession and work experience had no significant impact, but women scored higher in exhaustion. Total workload and working during both the first and second waves correlated positively to exhaustion, as did being regular ICU staff compared with temporary staff. Teamwork and safety climate remained unchanged compared with prepandemic levels.Respondents reported 'making a mistake' as the most stressful of the predefined stressors. Qualitative analysis of open-ended questions identified 'lack of knowledge and large responsibility', 'workload and work environment', 'uncertainty', 'ethical stress' and 'organization and teamwork' as major causes of stress. CONCLUSION: Despite large workloads, disengagement at work was low in our sample, even compared with prepandemic levels. High levels of exhaustion were reported by the ICU staff who carried the largest workload. Multiple significant causes of stress were identified, with fear of making a mistake the most significant stressor.

A first remotely-delivered guided brief intervention to reduce intrusive memories of psychological trauma for healthcare staff working during the ongoing COVID-19 pandemic: Study protocol for a randomised controlled trial.

Addressing the mental health needs of healthcare staff exposed to psychologically traumatic events at work during the COVID-19 pandemic is a pressing global priority. We need to swiftly develop interventions to target the psychological consequences (e.g., persistent intrusive memories of trauma). Interventions for healthcare staff must be brief, flexible, fitted around the reality and demands of working life under the pandemic, and repeatable during ongoing/further trauma exposure. Intervention delivery during the pandemic should be remote to mitigate risk of infection; e.g., here using a blend of digitalized self-administered materials (e.g., video instructions) and guided (remote) support from a researcher. This parallel groups, two-arm, randomised controlled trial (RCT) with healthcare staff working during the COVID-19 pandemic is the first evaluation of whether a digitalized form of a brief cognitive task intervention, which is remotely-delivered (guided), reduces intrusive memories. Healthcare staff who experience intrusive memories of work-related traumatic event(s) during the COVID-19 pandemic (≥2 in the week before inclusion) will be randomly allocated (1:1) to receive either the cognitive task intervention or an active (attention placebo) control, and followed up at 1-week, 1-month, 3-months, and 6-months post-intervention. The primary outcome will be the number of intrusive memories reported during Week 5; secondary and other outcomes include the number of intrusive memories reported during Week 1, and other intrusive symptoms. Findings will inform further development and dissemination of a brief cognitive task intervention to target intrusive memories.

Digitalizing a Brief Intervention to Reduce Intrusive Memories of Psychological Trauma for Health Care Staff Working During COVID-19: Exploratory Pilot Study With Nurses.

BACKGROUND: The COVID-19 pandemic has accelerated the worldwide need for simple remotely delivered (digital) scalable interventions that can also be used preventatively to protect the mental health of health care staff exposed to psychologically traumatic events during their COVID-19-related work. We have developed a brief behavioral intervention that aims to reduce the number of intrusive memories of traumatic events but has only been delivered face-to-face so far. After digitalizing the intervention materials, the intervention was delivered digitally to target users (health care staff) for the first time. The adaption for staff's working context in a hospital setting used a co-design approach. OBJECTIVE: The aims of this mixed method exploratory pilot study with health care staff who experienced working in the pandemic were to pilot the intervention that we have digitalized (for remote delivery and with remote support) and adapted for this target population (health care staff working clinically during a pandemic) to explore its ability to reduce the number of intrusive memories of traumatic events and improve related symptoms (eg, posttraumatic stress) and participant's perception of their functioning, and to explore the feasibility and acceptability of both the digitalized intervention and digitalized data collection. METHODS: We worked closely with target users with lived experience of working clinically during the COVID-19 pandemic in a hospital context (registered nurses who experienced intrusive memories from traumatic events at work; N=3). We used a mixed method design and exploratory quantitative and qualitative analysis. RESULTS: After completing the digitalized intervention once with remote researcher support (approximately 25 minutes) and a brief follow-up check-in, participants learned to use the intervention independently. All 3 participants reported zero intrusive memories during week 5 (primary outcome: 100% digital data capture). Prior to study inclusion, two or more intrusions in the week were reported preintervention (assessed retrospectively). There was a general pattern of symptom reduction and improvement in perceived functioning (eg, concentration) at follow-up. The digitalized intervention and data collection were perceived as feasible and rated as acceptable (eg, all 3 participants would recommend it to a colleague). Participants were positive toward the digital intervention as a useful tool that could readily be incorporated into work life and repeated in the face of ongoing or repeated trauma exposure. CONCLUSIONS: The intervention when delivered remotely and adapted for this population during the pandemic was well received by participants. Since it could be tailored around work and daily life and used preventatively, the intervention may hold promise for health care staff pending future evaluations of efficacy. Limitations include the small sample size, lack of daily intrusion frequency data in the week before the intervention, and lack of a control condition. Following this co-design process in adapting and improving intervention delivery and evaluation, the next step is to investigate the efficacy of the digitalized intervention in a randomized controlled trial.

Older patients' attitudes towards, and perceptions of, preoperative physical activity and exercise prior to colorectal cancer surgery-a gap between awareness and action.

PURPOSE: Time for preoperative optimisation prior to colorectal cancer surgery is limited and older people tend to decline exercise interventions. This study sought to describe attitudes towards, and perceptions of, preoperative physical activity and exercise in older people prior to colorectal cancer surgery. METHODS: This is a qualitative interview study, analysed with inductive content analysis. Seventeen participants scheduled for colorectal surgery were recruited as a purposeful sample from two hospitals in Stockholm, Sweden. Individual semi-structured interviews were conducted, face-to-face (n = 8) or by telephone (n = 9). RESULTS: Nine participants were male, median age was 75 years (range 70-91). The theme, 'a gap between awareness and action', was identified based on two main categories: 'Attitudes towards preoperative physical exercise have a multifactorial base' and 'Preoperative physical exercise is possible with a push in the right direction'. The material described a gap between awareness of the benefits of physical activity and reports of performing physical activity. The reasons for the gap between thoughts and action in this respect seem to be multifactorial. Support from others emerged as an important possibility for overcoming the gap. CONCLUSIONS: A gap between the patients' awareness and action appeared in our material. Understanding this can guide healthcare professionals (HCPs) as to the support needed preoperatively. Advice on physical exercise before surgery should be specific, and individually tailored support for action should be offered. This support should also consider the individual's current physical activity and preoperative attitude towards physical exercise.

Nurse perceptions of person-centered handovers in the oncological inpatient setting: A qualitative study.

BACKGROUND: Deficient communication during shift change can cause negative patient outcomes and hinder person-centeredness in care. Person-centered handover is performed together with the patient at bedside, with the intention of providing a safe and efficient handover while promoting patient participation. The knowledge about nurse perspectives on handover models that involve patient participation is sparse. OBJECTIVE: To describe registered nurses' perceptions of person-centered handover in an oncological inpatient setting. DESIGN: A qualitative interview study. SETTING: The study was undertaken at two oncological inpatient wards at the Karolinska University Hospital, Stockholm, where person-centered handover was implemented in 2015. PARTICIPANTS: Registered nurses who had worked at the wards for at least six months. We aimed for a full sample investigation. All eligible nurses (n = 13) were approached, and 11 chose to participate. Participants' age ranged from 23 to 60 years, the mean work experience was 10 years, and 4 out of 11 nurses were oncology nurse specialists. METHODS: Semi-structured interviews were performed by an independent researcher. The data was analyzed using content analysis with an inductive approach. RESULTS: Three main themes with ten subsequent subthemes emerged from the data. The main themes were: clinical communication and assessment; opportunity for patient participation; consequences for nursing care. In general, the nurses were positive towards person-centered handover, but they expressed concerns regarding patients' integrity and insecurities regarding bedside communication. All nurses described how they aimed at enhancing patient participation and viewed person-centered handover as an opportunity, but still perceived it difficult to succeed due to drawbacks and factors hindering nursing care. Overall, the nurses were positive regarding the involvement of patients in the handover procedure. Information provision from nurse to patient, as opposed to information exchange, was predominant. CONCLUSIONS: The intentions of person-centered handovers differed from the way it was actually performed, especially in regards to the obtained levels of patient participation, as described by nurses. Professional insecurity in relation to bedside communication with patients and their visitors is a novel finding that should be considered when implementing person-centered handovers. Overall, the perceptions of person-centered handovers, as expressed by the nurses, enhance our understanding of what to consider when implementing the model and why compliance may vary.

Early assessment and identification of posttraumatic stress disorder, satisfaction with appearance and coping in patients with burns.

BACKGROUND: The first year after severe burn is a psychologically challenging period for the patient. Patients may still struggle with burn-related physical and psychological problems such as posttraumatic stress disorder (PTSD) and body image dissatisfaction (BID). AIM: This study investigates the presence of PTSD, BID and coping, at three, six and twelve months after discharge for early identification of patients in need of focused support during rehabilitation. METHODS: Fifty-two adult patients with different degrees of burns were followed at three, six and twelve months after discharge and 36 patients completed all assessment points. A standardized clinical protocol was used for systematic assessment of PTSD (IES-R), BID (SWAP-Swe) and Coping (CBQ). The follow-up included an intervention with a burn nurse as a complement to the existing program. RESULTS: Approximately half of the patients had a risk of developing PTSD three months after discharge from hospital, and body image dissatisfaction was found to potentially predict risk of PTSD during follow-up. CONCLUSIONS: The findings suggest that it is important to include patients with less extensive burns in follow-up as this group is at risk of development of PTSD. Using standardized questionnaires in early follow-up along with assessment of body image dissatisfaction may facilitate detection of psychological problems.

The cultural adaptation and validation of a Swedish version of the satisfaction with appearance scale (SWAP-Swe).

BACKGROUND: Body image dissatisfaction is a source of stress after burns and it is important to attempt to objectively measure this aspect. Unfortunately, there are no Swedish questionnaires to assess satisfaction of appearance after burns. AIM: The aim of this study was to translate, culturally adapt and validate the Satisfaction With Appearance Scale (SWAP) into Swedish from American English to be used in the context of burn care. METHOD: The SWAP was translated and cross-cultural adapted inspired by the guidelines by Guillemin. Pre-testing with 13 burn patients was conducted and 90 patients tested the questionnaire in order to determine its psychometric properties. RESULTS: Cronbach's alpha was 0.89 indicating a high level of internal consistency of Swedish SWAP. Test for construct validity showed that length of hospital stay, more severe burns and female gender generated significantly higher scores in SWAP-Swe. The principal-components analysis found similar subscales according to the original SWAP that together accounted for 68% of the total variance. CONCLUSIONS: SWAP-Swe is a reliable and valid instrument for use in a Swedish speaking population. The questionnaire was perceived to be relevant for usage in the context of burn care and is well understood by the patients.

Adapting to life after burn injury--reflections on care.

A burn injury is an unforeseen event that means physical and psychological trauma for the person afflicted. The trauma experienced by different individuals varies greatly, as do perceived problems during care, rehabilitation, and throughout the remainder of life. The purpose of this study was to explore burn patients' experiences of adapting to life after burn injury to acquire a deeper understanding of the most important issues for patients when providing care during and after a burn injury. A qualitative approach was applied, and interviews were conducted with 12 adult burn patients (8 men and 4 women) 6 to 12 months postburn. The interviews were analyzed using Kvales' method for structuring analysis and comprised a close reading and interpretation of the texts. Analysis focused on the personal experiences of burn patients living after burn injury and treatment. Struggling with the consequences of burn injury and how patients perceived life today after treatment are important issues for adapting to life after burn injury. New experiences of a fragile body, coping with daily life, and reflections of burn care were also prominent themes. Patients with burn injuries need adequate repeated information about the plan for their care, about the physiological changes, and more support to handle the trauma event. The patients would also like to be more involved in their care. A program of support and preparatory work to help the patient to cope with the new bodily sensations and new body image is necessary and should begin during hospital care. A multidisciplinary team approach for pain treatment needs to be prioritized. In addition, multidisciplinary follow-up after burns need to include patients with minor burns.