key: cord-0954061-g38tgpek
authors: Fagerdahl, Ann-Mari; Torbjörnsson, Eva; Gustavsson, Martina; Älgå, Andreas
title: Moral distress among operating room personnel during the COVID-19 pandemic: A qualitative study
date: 2021-12-22
journal: J Surg Res
DOI: 10.1016/j.jss.2021.12.011
sha: a872b9522b1bab893f909b0bf7fb8fc176c14bb5
doc_id: 954061
cord_uid: g38tgpek

BACKGROUND: The ongoing COVID-19 pandemic has necessitated the reallocation of healthcare resources, and a minimization of elective activities. Healthcare personnel involved in COVID-19 care have been found to be negatively affected by the associated excess stress. The existing COVID-19 research has focused on the experiences among healthcare personnel in general, and not particularly on the operating room members, who have often been relocated to overburdened workplaces. Therefore, we aimed at exploring the experiences in this particular group. METHODS: This study has a qualitative inductive design based on interviews with a strategic sample of 12 operating room members: surgeons, anesthesiologist, specialist nurses and nurse assistants. The interviews were analysed using content analysis. RESULTS: Three themes were identified; “Feeling safe in the familiar and anxiety in the unknown”, “To be the ones left behind”, and “The possibility for recuperation in a seemingly everlasting situation”. The participants described working hard, although it was experienced as not enough according to their moral ideals. We interpreted this as feelings and signs of moral distress, a commonly described concept in previous studies during the COVID-19 pandemic, and a risk for burn out. CONCLUSIONS: The operating room members emphasized the negative stress of being in the unknown, of performing work tasks in an unfamiliar place and situation, and of experiencing conflicting feelings of relief and guilt. Organizational strategies towards a functional leadership and support should be emphasized. Such strategies might reduce the risk of psychological consequences such as burn out.

The ongoing COVID-19 pandemic has necessitated the reallocation of healthcare resources, and a minimization of elective activities. Healthcare personnel involved in COVID-19 care have been found to be negatively affected by the associated excess stress. The existing COVID-19 research has focused on the experiences among healthcare personnel in general, and not particularly on the operating room members, who have often been relocated to overburdened workplaces. Therefore, we aimed at exploring the experiences in this particular group.

This study has a qualitative inductive design based on interviews with a strategic sample of 12 operating room members: surgeons, anesthesiologist, specialist nurses and nurse assistants. The interviews were analysed using content analysis.

Three themes were identified; "Feeling safe in the familiar and anxiety in the unknown", "To be the ones left behind", and "The possibility for recuperation in a seemingly everlasting situation". The participants described working hard, although it was experienced as not enough according to their moral ideals. We interpreted this as feelings and signs of moral distress, a commonly described concept in previous studies during the COVID-19 pandemic, and a risk for burn out.

On March 11, 2020 , the Word Health Organization classified the Coronavirus disease 2019 (COVID- 19 ) as a pandemic, i.e. an infectious disease spread worldwide over multiple continents, affecting a substantial number of individuals (1). Even during a pandemic, the population will need access to non-pandemic related hospital care, such as surgery. Globally, the preconditions for such care changed drastically during the first half of 2020. A high disease burden caused by the COVID-19 pandemic has necessitated relocation of healthcare resources and minimization of elective activities (2) . An increasing demand for hospital beds, in particular in the intensive care unit (ICU) has been difficult to address (3) . One way to handle this high demand has been to cancel or postpone elective and sub-acute surgery and to utilize operating room (OR) wards for intensive care (4) . As a result, the number of performed surgical interventions has decreased drastically (2, 4, 5) . A diminished workload at the OR enables the personnel to be relocated to overburdened workplaces, such as to the ICU.

Studies have found healthcare personnel in the frontline during the COVID-19 pandemic to be negatively affected by a work situation associated with excess stress (6, 7) . For example, in a study by Morgantini et al. (6) , over 50 percent of the healthcare personnel, in 60 different countries, reported burn out. The high demands for healthcare coupled with limited resources during the pandemic make healthcare personnel prone to morally challenging decision making, which, in turn, may lead to moral distress. Moral distress is a theoretical concept originally defined by Andrew Jameton, and "arises when one knows the right thing to do, but institutional constrains make it nearly impossible to pursue the right course of action" (8) . As the concept has developed, the feeling of not being in control of the situation has been described as central, together with external factors preventing actions considered as 'the right thing to do' (9). Gustavsson et al. (10) explored the concept within disaster settings and defined moral stress as a normal reaction in situations where moral values J o u r n a l P r e -p r o o f cannot be acted upon, whereas moral distress is developed depending on contextual risk-and support factors (10) .

Working in the OR is complex with specific associated challenges compared with working in other areas. This complexity entails that the personnel needs to be flexible and creative to manage the unpredictable events that may occur, i.e. an ability of resilience for patient safety (11) . To our knowledge, this resilience among the OR personnel has not been previously studied during the pandemic, even though this group often were relocated to care for COVID-19 patients. The available COVID-19 research has focused on the perceptions and experiences among healthcare personnel in general and not particularly on the OR personnel. Therefore, we aimed to explore the OR team members´ experiences during the COVID-19 pandemic.

This study has a qualitative inductive design (12, 13) . This design entails that data is openly analysed according to similarities and differences to create patterns and is not driven from a hypothesis or a theory (12).

The study was performed at the OR wards of two large emergency hospitals in the Stockholm Region, Sweden. These hospitals have similar organization, similar patient groups, and were equally affected by the pandemic. The included OR team members were surgeons, OR specialist nurses, anesthesiologists, anesthesiology specialist nurses, and nurse assistants. In a normal healthcare J o u r n a l P r e -p r o o f Revised 2021-09-21 situation, these OR team members only work intraoperatively, i.e. during surgery and not at the preor postoperative wards. However, during the COVID-19 pandemic, several of the OR team members were temporarily transferred to work at either the ICU with COVID-19 care, or to the postoperative ward. During the study period, elective surgery was canceled or postponed and only acute and imperative surgery (predominantly cancer surgery) was performed.

A strategic sample technique was used where profession, sex, age, and work experience were taken into consideration (14) . Eligible participants were identified through contact persons at the two hospitals. An email with information regarding the study and a request to participate was sent out to the suggested OR team members. In total, 20 OR team members were asked to participate in the study, 12 accepted: four men and eight women with a median age of 60 years (range 38-70). The participants were general surgeons (n=3), anesthesiologist (n=1), OR specialist nurses (n=4), anesthesiology specialist nurse (n=1), and nurse assistants (n=3). The median work experience was 20 years (range 2-40).

Semi-structured interviews were performed during August to December 2020, using an interview guide created by the research group (Appendix 1). The interviews were performed by an OR nurse (AMF), familiar with the context but who had not been working in the OR during the pandemic. The 

The interviews were analysed using content analysis inspired by Graneheim and Lundman (13) , focusing on the latent content. The entire transcribed interviews were first read to get an overview and a sense of the whole texts where each interview was considered a unit of analysis. As the next step, meaning units that correlated with the aim of the study were extracted. Each meaning unit was labelled with a code and analysed according to similarities and differences and sorted into subthemes. Based on the sub-themes, main themes were identified (Table 1 ). The result of the analysis was discussed within the research group until consensus on interpretation was reached. Initially, ten interviews were performed and analysed. After performing and analysing two additional interviews, no additional information was obtained, and the research group judged that saturation of the material was reached (14) . Chosen quotes were translated from Swedish to English. When participants made a pause, this is stated with "…" in the quotations.

All participants received written information about the study in an initial email. The participants were informed that they could withdraw from the study at any time. Furthermore, participants were informed that their identity would not be revealed and that no information in the results would be traceable to any individual. Written informed consent was obtained from all participants. Before the interviews, information on the study aim and the interview procedure was provided. The recordings and transcripts were stored at a secure computer server to which only the research team had access. The investigation conforms with the principles outlined in the Declaration of Helsinki (16) . The study was approved by the Swedish Ethical Review Authority (Dnr 2020-01572).

We identified three themes describing the OR team members´ work experiences during the COVID-19 pandemic: "Feeling safe in the familiar and anxiety in the unknown", "To be the ones left behind", and " The possibility for recuperation in a seemingly everlasting situation" (Table 1 ).

This theme involves descriptions regarding the sense of comfort and security of working in the familiar environment of the OR coupled with the fear and anxiety of having to leave this comfort zone. The theme also relates to the aspects of being constantly exposed to new information and facts and having to adapt to this new information and updated guidelines regarding the management of COVID-19.

The participants described the OR ward as their comfort zone. They explained this feeling as being safe in their own familiar environment, with their usual daily working routines. They described that they were used to quickly adapt to sudden changes in their working conditions. The participants did not express any major difficulties working with the protective gear and explained that this level of protection is something they are used to in their daily work. Therefore, this aspect was not considered unusual, even though the pandemic brought extra focus on the utilization of protective gear.

I do think that for our sake it was, yes it was a change, but at the same time we are extremely used to this, we always work with sterile clothing or with gloves. It is our everyday life and face masks are our everyday life, so that is nothing unusual. For them [i.e other healthcare personnel, authors comment], it is like everything is new, so of course there is a difference. Naturally, we are better prepared, and we have a completely different knowledge, even though it is introduced more on the general wards, but we are still the best at it.

Participants representing all professions of the OR team described thinking initially that COVID-19 was nothing that would affect them personally. It was not until the numbers of admitted infected patients began escalating that the participants began to worry. Furthermore, they described feeling safe with the usage of protective gear; however, this feeling was affected by a need to constantly adapt to the shortage of material. Moreover, a fear of not being updated around the latest guidelines caused a feeling of insecurity regarding how to handle the protective gear correctly.

The participants' major concern was not the risk of getting infected themselves. Instead, their fear related to how the disease might affect their immediate family members. Some participants described that they were worried about how to cater for their children if they as parents would fall ill. Others expressed concerns for a partner at home, particularly if this person had risk factors, such as age above 65, or co-morbidities.

No, rather for my partner actually. Because he is in the category that he is ten years older than me…well, if you now see it harshly and very narrowly, then he belonged to one of the categories that were at most at risk. Initially at the ICU, if you were there working, you saw who it was lying in the beds… eeh, so I was more afraid that I would bring something home with me.

Revised 2021-09-21

One of the most stressful situations described by the participants was when they were relocated from the safety in the OR to the ICU, or when they had to perform surgical interventions outside of the OR. This relocation was associated with feelings of stress and anxiety. The participants who had alternated between working in the ICU and in the OR all described a feeling of insecurity when not being informed until the very morning of the relocation. A consequence of this just-in-time information was an inability to mentally prepare for the workday, resulting in increased anxiety. During this period, surgical interventions outside of the OR commonly involved the OR team, such as for patients scheduled for tracheotomy at the ICU. The participants described that these situations are associated with increased workload and feelings of anxiety and stress, even during normal circumstances. The ongoing pandemic exacerbated these feelings. Several participants described the psychological impact of witnessing many severely ill and dying patients at the same time. This image was expressed as something unusual compared to the OR environment, where they were used to focusing on one patient at a time. Further, the participants reported that they were not at all prepared for this new reality and described how the consequences of this virus really hit them. 

At the OR, the participants were presented with and had to relate to new information, new facts and guidelines regarding the management of the COVID-19. Guidelines were often updated, sometimes daily.

we got a lot of information in the beginning. We received information every morning with changed guidelines. Eh… so that… we got information about how we should dress… and about cleaning and which room… which operating room we should use and how long it should be empty afterwards. Well… that was it. And it changed a bit from day to day. It went very fast there in the beginning. There were a lot of routines that I experienced that changed from day to day. So, it was pretty hard to stay up to date with the latest.

This rapid change of information was particularly stressful when dealing with information regarding the use of protective gear. The instructions often changed from day to day, at times leaving the staff confused and stressed. These changes contributed to feelings of doubt and mistrust towards the management. Some of the participants suspected that the changed guidelines were due to the limited supply of protective equipment, particularly in the very beginning of the pandemic. Others intentionally put them in jeopardy. Furthermore, the participants believed that the management had tried their best with the means available, both in terms of knowledge and equipment.

I think they had our best in mind, but I think they had to act based on what they had, what they received… they had no choice either… if there is no material available there is no material… what in the world are they going to do….

The participants described how they corrected each other when they perceived that something deviated from the current guidelines. At times, such corrections created tension between coworkers, particularly when an OR team member wanted to use more extensive protective gear than was stipulated in the guidelines. Such situations led to misunderstandings and feelings of frustration.

The participants described how feelings of unsafety during surgery generated an extra stress load, which in turn led to a fear of jeopardizing the patient safety.

(*a specific face mask with filtration of airborne particles, author´s comment).

This theme consists of experiences related to remaining at the OR ward to perform the usual everyday work while attention and focus from both the management, colleagues, and the public were on the ICU and on the OR personnel being relocated. Furthermore, the theme contains feelings regarding the importance and value of maintaining the work needed at the OR ward during the pandemic.

Both the participants that were relocated to the ICU and some of those remaining at the OR ward described feelings of being abandoned. During this early period of the pandemic, the relocated personnel were organized under the management of the new ward, and some of them expressed the need for being better linked to their regular management for support.

But the only thing, I haven't encountered it myself, but I have heard of it, is that they would have appreciated more if the manager had visited the ICU on a regular basis and supported the poor OR staff that were thrown into "Mordor"

The participants who were relocated to the ICU experienced considerable challenges regarding professional competencies and the demands on their work role. They experienced a general view that they would be able to, without any further introduction or training, get directly into the ICU work. This generated considerable stress among those who were transferred to work in the ICU.

Furthermore, feelings of being insufficient generated performance anxiety which led to increased psychological stress and, sometimes, conflicts between the different healthcare professions. At times, the OR team members experienced a lack of understanding from the management that had repositioned them to a new workplace with limited information and education regarding the environment, tasks, and patient care.

…which turned out to be a big mistake for the staffs sake, because we are not… .there are different specialties of care, different, we certainly know respirators and ventilation but it is so much, much more with an ICU patient that we absolutely cannot….

Many of the participants described conflicting feelings of being left behind at the OR ward. Some felt a sense of relief not having to be exposed to the distress of working outside the familiar OR environment. However, others expressed feelings of guilt and feelings of letting their co-workers down. As a result, some OR team members tried to compensate by working even harder.

The feeling of pulling one's weight Throughout the pandemic, all participants described their workload as being markedly increased. The participants described situations, especially at the beginning of the pandemic, in which they performed their work without hesitation, even though they worried about the risks related to the virus and the correct handling of the protective gear. Some of them expressed these actions in terms of collegiality and work ethics, but also in terms of empathy for the patients in their vulnerable situation.

The participants described a strong sense of collegiality where they stood up for each other and collaborated to get the work done. This collegiality was especially strong when the OR team performed their work despite being worried about it and when relieving co-workers with a risk factor causing increased vulnerability to the virus.

Some of the participants felt that their work was overshadowed by the work their co-workers did at the ICU and wanted to emphasize that they too pulled their weight during the pandemic.

And what we got was that we "had only been here [at the OR], so we were protected " and I think that is a bit wrong because we were not protected, even if we were to some extent, but still I would not say that we were. Many of us were on pre-operative wards and in other COVID wards and on the ICU, so we were still assigned elsewhere. Even though we were somewhat spared. That it, that they thought there was an injustice in that we were not so affected. We have worked hard in a different way. That is important to mention

The possibility of recuperation in a seemingly everlasting situation This theme deals with the physical and psychological strains the pandemic had on both the workload and on the participants´ well-being, coupled with the importance of recuperation as a key element for handling the crisis. In addition, the theme contains the participants´ concerns for the future, including recurrent waves of the pandemic.

The participants expressed that they could never have anticipated to which extent the pandemic would affect both their own lives and their work situation. The participants described how they just did what had to be done at the beginning of the pandemic, and how, the longer and more severely the pandemic progressed, they gradually developed feelings of resignation and of being in an everlasting challenge.

Somewhere it was like this, it is only these ten weeks, then we get back to our usual schedule, and yes it was like that, I endured these weeks, then it will probably resolve. That was the attitude we had. It was calmer after the summer came. So, it felt like, I'm doing this this short period, but, but, I would not have endured, if I had known it would continue

The fear of the pandemic striking hard again and that the participants would find themselves back in the same situation was constantly present and stressful. Furthermore, some of the participants said that the experiences and knowledge from the first wave of the pandemic had created some comfort and confidence in handling upcoming situations. They described feeling strengthened by their achievements and pointed out the power of team collaboration in dealing with difficult situations.

However, some of the participants, expressed that their experiences had made them even more anxious since the experiences had made them aware of what was coming.

No, I am very afraid that it will be as it was last spring… once you are in the middle of it you do the best you can, that's how I feel, you do your best. But, now… I just get anxious knowing that I would end up there again. I must admit that I think it feels like the experience I had this spring feels… .no, I think it's worse to know what's expected of me.

The need for support and rest to ensure well-being

The need for formal emotional support during this crisis was emphasised by the participants. Several of them had received information about the possibility of professional support by the occupational healthcare unit, as a general offer at the workplace. However, some described that their co-workers were the main source of support and debriefing during this period.

we are a close group and so, with each other, that we can talk to each other and it is a huge and important thing that you can talk to each other, you dare to talk to each other. So, I think we helped each other very well, when we needed to talk. That, I am proud of that in our working group, it has always been like that, I think. I cannot ever remember when we did not support each other as well, when it is hard.

Despite the valuable support of co-workers, the need of professional debriefing was mentioned by some of the participants. Participants stressed that the support should be offered during a longer timeframe, and not only as a one-time occasion.

The participants described how their work during the pandemic had affected their private lives and their close relations. Many of the OR team members had to alter their work schedule during this time, adding extra working hours. The planned summer vacation was cancelled for many of the participants, leaving no period of continuous free time to look forward to. This also contributed to the stress and an intensified feeling of need for recuperation.

You were just home and sleeping and back to work then… There was like no life … private. It was just like surviving

When exploring the experiences of OR team members who worked during the COVID-19 pandemic, the main findings included feelings of anxiety and stress related to the ever-changing working situation, the fear of a practically unknown virus, and the constantly updated guidelines and information on protective equipment. These findings are in line with previous research on the experiences of non-OR healthcare personnel involved in the COVID-19 care (17) . Working in protective gear has been described as challenging to other frontline healthcare personnel and as a contributor to increased work-related stress during the pandemic (18) . Interestingly, the experiences of OR team members in the present study did, however, differ somewhat. For instance, OR personnel are used to working in protective gear on a daily basis, and they have special training in aseptic techniques and hygiene. These specific competencies in the OR team were mentioned by all the participants in our study and may have served as 'protectors', contributing to feelings of being safe and secure while remaining at the OR ward, performing the everyday work tasks.

Participants described working hard, although it was experienced as not enough according to their moral ideals. We interpreted this as feelings of moral stress derived from ethical challenges.

However, for some participants it might be feelings of moral distress depending on available protective factors. Some participants also described conflicting feelings, on the one hand relief of not Norwegian survey of 1,606 hospital-based nurses and physicians demonstrating increased levels of moral distress among personnel with altered work responsibilities due to the COVID-19 (19) . The findings of our study emphasize the need of proper introduction to a new work environment and tasks even when there is an acute situation, such as a pandemic. In general, aspects of workplace changes might be described as either positive, e.g. increased learning opportunities, or negative, particularly due to emotional exhaustion when feeling insecure (20) . This complex situation emphasizes the need of support from managers, especially when personnel are being relocated to unfamiliar contexts. Managers should provide an introduction and clearly communicate the new work conditions and tasks to allow for some degree of involvement in the decision-making (20) .

Some of our participants felt forced to work outside the OR, and the insufficient adherence and support contributed to the negative experience of their relocation. Also, being in a situation without an overview or possibility to plan was expressed as stressful. Shorter work shifts and regular followup by the managers, together with a clear description of the work plan and work schedule for each employee might lead to an increased feeling of being involved and a stronger sense of having control over the situation. All these factors may play a role in the risk of moral distress (10) . However, the participants did mention positive outcomes, which could serve as protective factors against moral distress such as professional development with increased knowledge, functional team collaborations, and the experience of being able to manage despite extreme conditions (10) .

The participants in this study described feelings of insufficient interprofessional knowledge and competence. In extreme situations, such as a pandemic, these insufficiencies risk hindering vital interprofessional collaboration. To facilitate collaboration, clear guidelines and structures need to be in place. Furthermore, an increased interprofessional collaboration during non-crises will result in increased knowledge and respect for other professional competencies. Interprofessional education refers to when two or more different professions learn with, from, and about each other (21) . In the J o u r n a l P r e -p r o o f The participants' main support mechanism was the informal support provided by co-workers, which could be explained by the fact that more formal support mechanisms were inadequate or unavailable. When faced with extraordinary situations such as a pandemic, it is essential to early establish a plan for professional and organizational support. Such actions may strengthen both the internal and the external resources for the individual healthcare personnel and reduce moral distress to avoid burn out (10). The healthcare system was strained in many countries even before the onset of the COVID-19 pandemic, with patients awaiting surgical procedures and a global nursing shortage (23) . This preexisting strain should be considered when summarizing the challenges ahead for healthcare providers once the COVID-19 pandemic subsides. The growing need of surgical care will be left for the OR personnel to handle and will require availability of a full work force. An alarmingly high level of healthcare personnel are suffering from burn out due to the pandemic (6), and there is a need of organizational support strategies both during and after disasters such as the COVID-19 pandemic to ensure the wellbeing of healthcare personnel (24) .

In addition to the negative aspects, the participants of our study also described that they contributed, collaborated, and learned a lot by their experiences during the pandemic. All negative J o u r n a l P r e -p r o o f and positive aspects should be taken into consideration in future situations, aiming at strengthening healthcare workers' moral, and developing organizational efforts to support working conditions.

Some limitations should be considered. This study was performed during a time of varying workload related to the COVID-19 pandemic which may have influenced the different participants' experiences depending on workplace and where in the pandemic phase they were at the time of the interview.

However, we explicitly asked the participants to focus on the time period of spring 2020, i.e. the early pandemic phase. Although data collection was initiated in August, some of the interviews were performed in December 2020, risking introducing recall bias (25) . However, considering the severe and extraordinary circumstances of the ongoing pandemic we judge this risk to be small.

Half of the interviews were performed digitally using a video conferencing system, something that might be considered a limitation. However, online conferencing systems have been increasingly common during the pandemic and the participants who chose this medium for their interviews felt conformable with the technique, as did the researchers. In addition, we did not experience any differences in the quality of the data we received form the various ways of interacting with the participants.

The small sample size could be considered to limit generalizability. However, in qualitative research the goal is not to generalize the findings to a larger population, but rather to explain and understand the phenomenon of interest. Instead of generalizability, the concept transferability is used. This concept can be explained as to what extent the findings can be transferred to other settings and groups, which is always up to the reader to interpret. To facilitate this, we have aimed to give a clear 

Feeling safe in the familiar and anxiety in the unknown Relief in working as usual in an extraordinary situation Fear of leaving the familiar for the frightening unknown To relate to the ever-changing truth

To be the ones left behind Feelings of abandonment and of being left behind The feelings of pulling one's weight

The possibility of recuperation in a seemingly everlasting situation

The seemingly everlasting challenge The need for support and rest to ensure wellbeing

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