OBJECTIVE

The novel coronavirus disease 2019 (COVID-19) pandemic has dramatically changed health care delivery and impacted health care providers. However, little is known about the impact of the pandemic in PICUs. In this qualitative study, we aimed to assess pediatric critical care providers’ perspectives on the impact of the COVID-19 pandemic on the experiences of patients and families in the PICU and on their personal and professional lives.

METHODS

Nineteen pediatric critical care and complex care attending physicians and nurse practitioners from a PICU in a tertiary, freestanding children’s hospital in the Midwest completed a semistructured, qualitative interview. Transcripts were analyzed by using thematic analysis.

RESULTS

For both PICU providers and patients and families, participants described a negative overall impact of the pandemic, especially relating to increased stress and fear of contracting the disease. Disease precautions such as visitor restrictions and restricting movement were reported to be particularly stressful for families because they limited coping strategies (eg, in-person social support). Providers described changes to the work environment, patient care, and their personal lives.

CONCLUSIONS

Results elucidate the perceived impacts of COVID-19 and associated hospital precautions on the lives of PICU providers, patients, and families. Providers, patients, and families likely require additional psychosocial support during the pandemic. When possible, policies regarding disease management should maximize safety while minimizing additional stress. Further research is needed to explore patient and family perspectives regarding the impact of COVID-19 and to evaluate the continued impact of COVID-19 over time.

Coronavirus disease 2019 (COVID-19) is an infectious disease spread via a novel coronavirus, severe acute respiratory syndrome coronavirus 2, which created a pandemic in March 2020.1  The restrictions required to manage the pandemic have caused disruptions from health care to education.2  Many adults report significant emotional distress during the pandemic3  related to the severity and contagiousness of COVID-19, uncertainty, and changes to daily routines and finances.4  This impact is likely exacerbated among patients, families, and providers in PICUs, because of preexisting stressors and heightened safety procedures. However, the comprehensive impact of COVID-19 in PICUs has not been empirically evaluated.

Independent of COVID-19, PICU patients and families experience tremendous stress because of illness and injury severity and environmental intensity.5  They are at elevated risk for adverse psychological outcomes,6  likely exacerbated by the pandemic. Among community parents, greater COVID-19–related stressors correlate with higher overall stress.7  Primary caregivers of a dependent reported greater stress surrounding fear of themselves or a loved one becoming infected than noncaregivers.4  Accordingly, parents of children with preexisting medical conditions, representing 70% of PICU patients,8  may experience greater fear of infection because of higher risk of severe COVID-19 infection and death.9  Additionally, hospital procedures to limit the spread of COVID-19 (eg, physical isolation, visitor restrictions)10  have been speculated to adversely impact patients and families in the PICU.11 

Like patients and families, PICU providers experience substantial stress independent of COVID-19.12  Risk of infection and pandemic-related precautions may worsen baseline stress. Providers with direct patient contact are at higher risk of contracting COVID-19,13  and pediatric and adult ICU providers report stress because of fear of contracting COVID-19 and passing it to their families.14  Furthermore, adult ICU providers report high levels of burnout, anxiety, and depression during the pandemic.15  Although it is important to note the greater prevalence and severity of COVID-19 among adults,16  many of these pandemic-related fears and stressors are likely shared.

Although researchers in some studies have evaluated the impact of COVID-19 among the general adult population and adult ICU providers primarily using quantitative methods,14,17  little is known about how COVID-19 has impacted experiences in the PICU. Qualitative research provides rich data regarding individual’s lived experiences, which cannot be fully assessed with quantitative methods.18,19  Thus, in the current study, we used qualitative interviews to describe PICU providers’ perspectives of the impact of COVID-19 on patients, families, medical providers in the PICU.

Critical care (noncardiac) attending physicians and nurse practitioners (NPs) were recruited from a 72-bed PICU in a major metropolitan area in the Midwest region of the United States.

The procedure for recruitment and data collection was part of an ongoing quality improvement initiative to understand medical provider identification and response to family distress in the PICU. The hospital’s Human Research Protection Program determined this project did not constitute human subjects’ research. The questions regarding COVID-19 were added to the project in March 2020 on the basis of the anecdotal clinical experiences that COVID-19 was contributing to the stress of providers, patients, and families. Providers who participated after the addition of these items were included in this analysis.

Single-study sessions were completed via Microsoft Teams videoconferencing.20  Participants provided verbal informed consent, completed a demographic questionnaire via Qualtrics,21  and participated in an audio-recorded interview conducted by trained personnel. Interviews were transcribed and then analyzed by using NVivo Software.22 

Throughout data collection, hospital COVID-19 procedures varied. See Fig 1 for time line. Visitor restrictions allowed 1 legal guardian to visit at a time and 2 total visitors during hospitalization.

FIGURE 1

Timeline of data collection and hospital COVID-19 procedures.

FIGURE 1

Timeline of data collection and hospital COVID-19 procedures.

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Demographics

We collected demographic information (eg, sex, race).

Qualitative Interview

A panel of experts in critical care, pediatric psychology, and qualitative methods developed a semistructured, qualitative interview using the framework proposed by Kallio et al (2016).23  Accordingly, the questions were intended to be clearly worded, single faceted, open-ended, and nonleading and to consist of 2 tiers: (1) main themes to encourage free expression, and (2) follow-up questions directing toward specific domains. The interview was pilot tested iteratively by the expert panel using the internal testing approach.23  See Table 1 for interview guide.

TABLE 1

Semistructured Qualitative Interview Guide

ConstructRequired QuestionsFollow-up Questionsa
Perceived patient and family impact How do you think the current COVID-19 pandemic has impacted patients and families in the ICU? How do you think it has impacted family distress in the ICU? How do you think the additional visitor restrictions due to COVID-19 have impacted patients and families in the ICU? 
Provider impact How has the current COVID-19 pandemic impacted you? How has it impacted you in your role as an ICU provider? Personally? 
ConstructRequired QuestionsFollow-up Questionsa
Perceived patient and family impact How do you think the current COVID-19 pandemic has impacted patients and families in the ICU? How do you think it has impacted family distress in the ICU? How do you think the additional visitor restrictions due to COVID-19 have impacted patients and families in the ICU? 
Provider impact How has the current COVID-19 pandemic impacted you? How has it impacted you in your role as an ICU provider? Personally? 
a

Asked as needed if participants did not spontaneously address this content.

All transcripts were coded by using reflexive thematic analysis to provide a rich description of the data set.23  An inductive approach was used given the exploratory nature of the study. All transcripts were reviewed by 3 graduate students to independently generate initial codes. A final codebook was collaboratively created. Two graduate students then applied this codebook to all transcripts. Agreement was evaluated by a third independent graduate student who led a discussion until 100% agreement was achieved. Next, codes were collated and reviewed by the 2 graduate students to independently identify latent themes (ie, underlying ideas, assumptions, and conceptualizations). Themes were discussed with a third graduate student present to resolve disagreement. Documentation of team meetings and consensus on themes was used to ensure qualitative credibility, dependability, and confirmability.24  Evaluation of data saturation to determine sample size and quantification of themes are inconsistent with reflexive thematic analysis and therefore were not used. Recruitment was terminated once all eligible participants were approached.

Given differences in training and workflows between NPs and attending physicians, post hoc exploratory analyses evaluating differences in theme prevalence were conducted using Fisher’s exact test to account for small cell sizes (ie, <5).

Through explicitly examining our assumptions, worldviews, and positionality relative to the participants, we increased awareness of their potential impact on the research process. Qualitative interviews and analyses were conducted by 3 graduate students in clinical psychology with interests and experiences in pediatric psychology. Although our student status, discipline, and research interests were not formally disclosed to participants, the context of the broader study focusing on family distress in the PICU and our assumptions about medical settings (eg, PICU is stressful) may have biased interviews toward discussing stress. We may have been more likely to follow-up on comments related to stress or highlight those themes. To minimize bias, we explicitly examined and discussed our positionality, used multiple coders, and, during interviews, sought to directly reflect participant’s responses and only prompt for additional impacts or clarification.

Nineteen providers, including 8 critical care NPs, 9 critical care attending physicians, and 2 complex care attending physicians (ie, specialists in caring for children with medical complexity frequently seen in the PICU), participated. Participants identified as female (79%), male (21%), white (79%), Asian (10.5%), and African American/Black (10.5%). All participants had at least 2 years of PICU experience (mean = 10.3, SD = 7.8, range = 2–30).

Participants described several effects of COVID-19 on patients and families. Specific themes included general negative impact, heightened fear and anxiety, stress from COVID-19 precautions, and changes in patient/family–provider interactions. See Fig 2A for thematic map and Table 2 for illustrative quotes.

FIGURE 2

Thematic maps of perceived impacts of COVID-19 on patients and families in the PICU and impact of COVID-19 on PICU providers. A, Thematic map of perceived impacts of COVID-19 on patients and families in the PICU. B, Thematic map of impact of COVID-19 on PICU providers.

FIGURE 2

Thematic maps of perceived impacts of COVID-19 on patients and families in the PICU and impact of COVID-19 on PICU providers. A, Thematic map of perceived impacts of COVID-19 on patients and families in the PICU. B, Thematic map of impact of COVID-19 on PICU providers.

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TABLE 2

Perceived Impact of COVID-19 on Patients and Families in the PICU

Themes and SubthemesIllustrative Quotes
General negative impact “I think the stress level is so much higher.” 
Heightened fear and anxiety  
 Fear of contracting COVID-19 “They’re afraid of COVID-19. They’re afraid of them getting it, their patient—their child getting it.” 
 “The stress of just worries about either their complex child contracting the disease, families with immuno-suppressed kids, kids with cancer, organ transplant, especially are very worried about what it would mean for their kid if their child gets COVID.” 
 Fear of the hospital “They’re too scared to bring their kids in so the kids are presenting late and they’re presenting sicker.” 
 Children’s fear of PPE “I think for the kids, we wear those CAPRs [controlled air purifying respirators], it looks like a space suit. I think that’s scary. None of our faces are visible anymore which is really distressing…they want to see a smile, they want to be reassured, and you can do stuff with your eyes but it’s not the same.” 
COVID-19 precautions  
 Designated COVID-19 floor  
  Fear of contracting COVID-19 “Our families all talk to each other and they all know that [specific floor] is the COVID positive floor and so yeah no one wants to go.” 
  Changed locations “You have a child who’s on one side of the hospital, they’ve been there for weeks. OK well now we get whatever this fever or whatever you want to call it, well now we have to schlep over to another floor for 2 days to wait on this test and then schlep back. That’s extremely distressful,” 
  Restricted movement “They also feel now isolated and stuck in the room.” 
 “I think that’s got to be hard being in that room 24/7 and not being able to go to the cafeteria, go get coffee, like you just need a mental break and I don’t think they get that.” 
 Visitor restrictions “Only one parent can come in at a time, which has been like really, really stressful for families” 
 “I think that was one of the big things that caused a lot of distress for them.” 
  Reduced social support “I think that’s honestly the biggest thing is you’ve taken away a lot of their support system.” 
 “Their normal support system of who could be there to support them or the sick child is diminished, and they feel alone. They’re just there by themselves so I think that they feel lonely, more stressed out, they don’t have people to talk to.” 
 “They don’t get any visits from their siblings or friends and that decreases morale.” 
  Balancing home responsibilities “They’re worrying about their child but they're also torn between worrying about things at home.” 
  Communication challenges “I think that those additional demands on families…needing to be the information giver to other people.” 
  Difficulty achieving exceptions “The administrative hoops that those exceptions had to go through was just so much more burdensome than it usually is.” 
Changes in patient/family–provider interactions  
 Reduced interaction “I think the biggest thing affecting [them] was probably that they have less interpersonal interactions with us because we try to stay out of the room now as much as possible, which is not how it used to be.” 
 “Their distress is so much worse because they don’t get that one-on-one communication often. They don’t get time to answer the questions.” 
 “If people are wearing masks all the time now you can’t see as much smiles and how people are–kind of that more personal face to face interaction... so I’m sure there’s a lot of missed social cues and nonverbal communication.” 
 Off-site consultants “They may talk to consult on a video chat which I don’t think–it is not the same as talking to someone in person.” 
Themes and SubthemesIllustrative Quotes
General negative impact “I think the stress level is so much higher.” 
Heightened fear and anxiety  
 Fear of contracting COVID-19 “They’re afraid of COVID-19. They’re afraid of them getting it, their patient—their child getting it.” 
 “The stress of just worries about either their complex child contracting the disease, families with immuno-suppressed kids, kids with cancer, organ transplant, especially are very worried about what it would mean for their kid if their child gets COVID.” 
 Fear of the hospital “They’re too scared to bring their kids in so the kids are presenting late and they’re presenting sicker.” 
 Children’s fear of PPE “I think for the kids, we wear those CAPRs [controlled air purifying respirators], it looks like a space suit. I think that’s scary. None of our faces are visible anymore which is really distressing…they want to see a smile, they want to be reassured, and you can do stuff with your eyes but it’s not the same.” 
COVID-19 precautions  
 Designated COVID-19 floor  
  Fear of contracting COVID-19 “Our families all talk to each other and they all know that [specific floor] is the COVID positive floor and so yeah no one wants to go.” 
  Changed locations “You have a child who’s on one side of the hospital, they’ve been there for weeks. OK well now we get whatever this fever or whatever you want to call it, well now we have to schlep over to another floor for 2 days to wait on this test and then schlep back. That’s extremely distressful,” 
  Restricted movement “They also feel now isolated and stuck in the room.” 
 “I think that’s got to be hard being in that room 24/7 and not being able to go to the cafeteria, go get coffee, like you just need a mental break and I don’t think they get that.” 
 Visitor restrictions “Only one parent can come in at a time, which has been like really, really stressful for families” 
 “I think that was one of the big things that caused a lot of distress for them.” 
  Reduced social support “I think that’s honestly the biggest thing is you’ve taken away a lot of their support system.” 
 “Their normal support system of who could be there to support them or the sick child is diminished, and they feel alone. They’re just there by themselves so I think that they feel lonely, more stressed out, they don’t have people to talk to.” 
 “They don’t get any visits from their siblings or friends and that decreases morale.” 
  Balancing home responsibilities “They’re worrying about their child but they're also torn between worrying about things at home.” 
  Communication challenges “I think that those additional demands on families…needing to be the information giver to other people.” 
  Difficulty achieving exceptions “The administrative hoops that those exceptions had to go through was just so much more burdensome than it usually is.” 
Changes in patient/family–provider interactions  
 Reduced interaction “I think the biggest thing affecting [them] was probably that they have less interpersonal interactions with us because we try to stay out of the room now as much as possible, which is not how it used to be.” 
 “Their distress is so much worse because they don’t get that one-on-one communication often. They don’t get time to answer the questions.” 
 “If people are wearing masks all the time now you can’t see as much smiles and how people are–kind of that more personal face to face interaction... so I’m sure there’s a lot of missed social cues and nonverbal communication.” 
 Off-site consultants “They may talk to consult on a video chat which I don’t think–it is not the same as talking to someone in person.” 

General Negative Impact

Almost all participants perceived that, in general, COVID-19 added stress and increased distress for patients and families. For example, participants commented, “The stress level is so much higher,” “Just heightened distress overall,” and “It has added another layer of stress.”

Heighted Fear and Anxiety

Many participants perceived heightened levels of fear and anxiety in patients and families related to 3 subthemes: fear of contracting COVID-19, fear of the hospital, and children’s fear of providers wearing personal protective equipment (PPE). Participants described that parents worry that they or their child may contract COVID-19 in the hospital. One participant stated, “They’re afraid of COVID-19. They’re afraid of them getting it…their child getting it.” Some participants noted that this fear may be heightened among parents of immunocompromised children. Participants suggested that families may fear the hospital because of a fear of contracting COVID-19, with some participants perceiving avoidance of the hospital, which occasionally resulted in sicker children. Some participants described that additional PPE worn by providers may increase children’s fear.

COVID-19 Precautions

Many participants described that hospital COVID-19 precautions and testing procedures, such as visitor restrictions and a negative-pressure, designated COVID-19 floor in the PICU, adversely impacted patients and families.

Participants described the impact of the designated COVID-19 floor with 3 subthemes: increased fear of contracting COVID-19, changed locations, and restricted movement. Participants perceived increased fear of contracting COVID-19 given the proximity of confirmed patients with COVID-19: “They all know that [specific floor] is the COVID positive floor and so no one wants to go.” It changed locations for many families, including those who would otherwise not come to the PICU or were on another PICU floor. Participants described restricted movement of these patients and families throughout the floor and hospital.

Participants described perceived effects of the additional visitor restrictions with 3 subthemes: reduced social support, balancing home responsibilities, and communication challenges. Almost all participants commented that these restrictions reduced social support for patients and families, given that partners, siblings, and peers could not visit. One participant reported, “You’ve taken away a lot of their support system.” Some participants described challenges related to balancing home responsibilities given that other children cannot visit and impacts on child care. Some described communication challenges related to communicating virtually and/or caregivers needing to relay information to others. Although some commented that exceptions to visitor restrictions are possible in end-of-life scenarios, a few described administrative challenges to achieving these accommodations.

Changes in Patient/Family–Provider Interactions

Approximately half of participants described changes in patient and family interactions with PICU providers and off-site consultants because of COVID-19 precautions. One participant described, “They have less interpersonal interactions with us because we try to stay out of the room now as much as possible.” Specifically, many indicated reduced interaction, resulting in less information shared and fewer opportunities for questions. PPE was reported to impact the quality of communication because of reduced nonverbal cues. Some participants also noted challenges related to interactions with off-site consultants because of virtual communication.

Participants described a variety of impacts on themselves. Themes included awareness of reduced severity in children, changes to the work environment, fear of COVID-19, changes to patient care, and impacts on personal life. See Fig 2B for thematic map and Table 3 for illustrative quotes.

TABLE 3

Impact of COVID-19 on Providers in the PICU

Themes and SubthemesIllustrative Quotes
Awareness of reduced severity in children “In pediatrics, thankfully we’re lucky, in that our patients aren’t that sick, but it’s impacting all of us in the day-to-day and just the world in general.” 
Work environment  
 Constant changes “I feel like the rules are always changing at work and what we’re doing one day versus another day and just the stress of trying to keep up with that.” 
 Loss of collegial interactions “…We are a team and we're used to seeing each other and interacting as a team. …we do something that's really not normal and we take care of people that are really sick…I think it takes away a level of support that we're used to having when we do have those, like, distressing situations that bother us… you can go home and talk to whoever you want about it, but they aren't going to get it the way you get it as your co-workers are going to understand it.” 
Fear of COVID-19  
 Contracting COVID-19 “Your own nervousness about getting it, getting COVID yourself, because you’re getting potentially getting exposed to families and kids.” 
 Exposing others to COVID-19 “I’m constantly questioning what–how would I feel if I’m the reason that my family got sick because I got something at work.” 
Patient care “I think that we all see patients less than when we did prior, like we try to limit the amount of times we go into rooms, because: one, if we’re carrying COVID we don’t want to give it to our patients, or 2, if they are like under investigation for COVID we don’t want to expose ourselves to it. So I think that we’re having a lot less actual patient interaction.” 
 “The biggest stressor is not feeling like you can take care of patients the way that you are used to. And that you want to. And what we would have 4 weeks ago called the gold standard is not close to what we’re doing now, and that causes a lot of moral distress.” 
Personal life “The bigger stress of it is that we’re still working while the rest of the world is shut down. So, like I have kids, and I had to scramble to figure out what to do for childcare.” 
 “Elderly parents or my grandmother, you know, should I–when I can see her, should I really go see her? Because I work in a medical environment.” 
 “All of the medical staff has taken a salary cut, so there’s a financial impact.” 
Themes and SubthemesIllustrative Quotes
Awareness of reduced severity in children “In pediatrics, thankfully we’re lucky, in that our patients aren’t that sick, but it’s impacting all of us in the day-to-day and just the world in general.” 
Work environment  
 Constant changes “I feel like the rules are always changing at work and what we’re doing one day versus another day and just the stress of trying to keep up with that.” 
 Loss of collegial interactions “…We are a team and we're used to seeing each other and interacting as a team. …we do something that's really not normal and we take care of people that are really sick…I think it takes away a level of support that we're used to having when we do have those, like, distressing situations that bother us… you can go home and talk to whoever you want about it, but they aren't going to get it the way you get it as your co-workers are going to understand it.” 
Fear of COVID-19  
 Contracting COVID-19 “Your own nervousness about getting it, getting COVID yourself, because you’re getting potentially getting exposed to families and kids.” 
 Exposing others to COVID-19 “I’m constantly questioning what–how would I feel if I’m the reason that my family got sick because I got something at work.” 
Patient care “I think that we all see patients less than when we did prior, like we try to limit the amount of times we go into rooms, because: one, if we’re carrying COVID we don’t want to give it to our patients, or 2, if they are like under investigation for COVID we don’t want to expose ourselves to it. So I think that we’re having a lot less actual patient interaction.” 
 “The biggest stressor is not feeling like you can take care of patients the way that you are used to. And that you want to. And what we would have 4 weeks ago called the gold standard is not close to what we’re doing now, and that causes a lot of moral distress.” 
Personal life “The bigger stress of it is that we’re still working while the rest of the world is shut down. So, like I have kids, and I had to scramble to figure out what to do for childcare.” 
 “Elderly parents or my grandmother, you know, should I–when I can see her, should I really go see her? Because I work in a medical environment.” 
 “All of the medical staff has taken a salary cut, so there’s a financial impact.” 

Awareness of Reduced Severity in Children

Some participants noted that COVID-19 symptoms are typically less severe in children than adults. However, all participants still described multiple ways in which COVID-19 has impacted them both professionally and personally. One participant described, “In pediatrics, thankfully we’re lucky in that our patients aren’t that sick, but it’s impacting all of us in the day-to-day.”

Work Environment

Many participants described changes to their work environment and structure, with 2 subthemes: constant changes and loss of collegial interactions. They reported the need to adapt to constant changes in hospital protocols. One participant noted, “The rules are always changing at work…just the stress of trying to keep up with that.” They described working from home more frequently and therefore some noted loss of collegial interactions. These participants expressed that fewer interactions with their colleagues resulted in less collaboration and social support.

Fear of COVID-19

Participants expressed concerns about contracting COVID-19 themselves from patients or families. Furthermore, participants worried about exposing others to COVID-19, such as friends and family. For example, a participant described, “I’m constantly questioning—how would I feel if I’m the reason that my family got sick because I got something at work.”

Patient Care

Some participants described changes in how they typically care for patients and families: “We all see patients less than when we did prior. We try to limit the amount of times we go into rooms, because: one, if we’re carrying COVID we don’t want to give it to our patients, or two, if they are under investigation for COVID we don’t want to expose ourselves to it.” Many described reduced patient and family interaction, with some indicating that these changes were stressful.

Personal Life

Participants indicated that COVID-19 impacted their personal lives, including child care, finances, and their ability to see family. One participant commented, “We’re still working while the rest of the world is shut down. I have kids, and I had to scramble to figure out what to do for childcare.”

All themes were present in NP and attending physician samples. NPs reported overall fear of COVID-19 more frequently than attending physicians (100% vs 45%, P = .029). This overarching thematic difference is primarily driven by NPs (75%) more frequently reporting fear of exposing others to COVID-19 than attending physicians (18%, P = .024). There were no significant differences in fear of contracting COVID-19 (P = .170) or any other themes (P = 0.103–0.999).

PICU providers universally reported negative impacts of COVID-19 on patients, families, and themselves. It is crucial to understand these stressors to mitigate them when possible: both for the remainder of the current pandemic and in the event of a subsequent one. These findings may have implications for other pediatric settings because COVID-19 precautions, testing, and treatment protocols have been widespread in pediatric medicine.

The current study extends previous research indicating that COVID-19 has increased stress, changed daily routines, and promoted fear of contracting COVID-19 among community adults,3,4  caregivers,4  and adult ICU providers15  by revealing that these effects are robustly felt in the PICU. Furthermore, these results suggest additional effects not previously described, including stressors unique to pediatric patients and families such as fear of PPE and reduced social support because of visitor restrictions.

Providers perceived several impacts on patients and families that may exacerbate preexisting levels of distress.6  COVID-19 likely increased fear and anxiety because of a fear of contracting COVID-19 at the hospital and additional PPE. Because perceived likelihood of COVID-19 infection correlates with distress among adults,25  this fear may contribute to heightened distress among PICU families. Providers reported that COVID-19 precautions, such as a designated COVID-19 floor and visitor restrictions, have negatively impacted patients and families. These changes likely limit coping strategies (eg, social support26 ) and time at the bedside, which parents report to be stressful.27  Finally, providers reported that COVID-19 has changed patient/family–provider interactions, which likely increases stress because of reduced communication and decreased feelings of provider support.28 

Given the perceived impact of the pandemic on patients and families, it is vital that PICUs increase psychosocial support and improve patient/family–provider communication. Hospitals should increase use of social workers and psychologists in the PICU, via telehealth or in-person. Child-friendly PPE should be provided when possible, and using child life specialists to teach children about PPE using dolls or coloring books may reduce fear.29  Patients and families are encouraged to engage with their social support networks via video, phone calls, and texting facilitated by provision of free Internet and charging equipment by hospitals.30  Use of technology (eg, virtual reality31 ) and art interventions32  may facilitate social connection and counter the effects of restricted movement. Although safety and disease containment must be prioritized, hospital administrators might consider treating patients with COVID-19 on their respective floors when this can be done safely, given that providers observed stress from cohorting patients with suspected or confirmed COVID-19. Finally, techniques promoting facial expressions (eg, clear masks) and exaggerating eye expressions, using hand gestures, speaking loudly, and displaying a picture of oneself when wearing PPE might facilitate communication and connection.33,34  Hospitals should also provide materials for families to record their questions.30 

PICU providers reported several impacts of COVID-19 on their professional and personal lives, which may increase preexisting risk for stress.12  NPs and attending physicians largely shared impacts of COVID-19, suggesting precautions caused common, widespread disruption. However, future research with ad hoc hypotheses and a larger sample is necessary to better evaluate group differences. Providers reported fear of contracting COVID-19 themselves, and providers, especially NPs, expressed fear of exposing their friends and family to COVID-19, which may lead to additional precautions in their homes (eg, isolation, moving residences). This fear and these precautions correlate with increased distress and poorer work outcomes, including higher turnover intentions.25,35,36  Providers reported changes in their responsibilities and job demands, managing constant policy changes, adapting to working from home, and reduced contact with patients and families. These changes may result in less camaraderie and lower compassion satisfaction (ie, satisfaction with work by helping others), which correlates with higher secondary traumatic stress and burnout.37  Although cited literature often evaluated burnout, the impact of the pandemic on providers is likely best conceptualized as increasing risk for moral distress and ultimately moral injury, defined as simultaneously knowing what care patients need but being unable to provide it because of uncontrollable constraints (eg, pandemic restrictions).38,39 

Given this likely increase in provider distress and moral distress, increased psychosocial support for providers is critical. Institutions should increase access to stress management and psychological first aid programs40  and as well as psychotherapy promoting active emotional processing of traumatic events, facilitating problem-focused coping, and reducing emotion-focused coping.12  However, provider use of wellness resources during the pandemic is low despite awareness of resources.41  It is important to normalize, encourage, and provide services that are accessible, relevant, and confidential. Intensivists describe peer support, departmental debriefings, and alternating exposure to patients with COVID-19 to be helpful.14  Hospitals should facilitate peer support programs and promote work schedules that enable adequate sleep.42,43 

Although this study advances our understanding of the ongoing COVID-19 pandemic in the PICU, there are important limitations to acknowledge. First, only NP and attending physician perspectives were represented. Future research should directly assess patient, family, and other PICU providers’ experiences of COVID-19. Nurses interact with families more frequently44  and are more likely to contract COVID-19 than attending physicians,35  which may result in different experiences. Quantitative data evaluating mental health outcomes would be helpful to assess these perspectives. Only 1 PICU was represented, and results may not generalize to other PICUs. Data were collected throughout the pandemic, and precautions, incidence rates, and media coverage have varied (eg, children’s hospitals caring for adults,45  increasing COVID-19 rates among children46 ). It is important to continually evaluate the impact across time.

The COVID-19 pandemic has clear implications for patients, families, and providers in the PICU. Additional stressors due to COVID-19 likely increase already elevated risk for distress among PICU patients, families, and PICU providers. When possible, hospitals should increase psychosocial support for PICU patients, families, and providers, reduce precautions when safe to do so (eg, visitor restrictions, cohorting suspected/confirmed COVID-19 patients), and provide resources to facilitate patient/family–provider communication given the challenges of fewer interactions and reduced nonverbal cues.

The authors thank the medical providers for contributing their time and personal experiences to the current study with the goal of improving the well-being of providers, patients, and families in the PICU. Thank you to Elizabeth Kossow (AA, Medical College of Wisconsin) and Connor Lynch (University of Wisconsin-Milwaukee) for their contributions to the transcription process; neither have conflicts of interest nor funding sources to declare. Finally, thank you to Milwaukee Collaborative for Resilience and Emotional Wellness Science (Milwaukee CREWS) for support in developing, implementing and presenting this work.

FUNDING: No external funding.

Kathryn Balistreri and Paulina Lim conceptualized and designed the study, collected and analyzed data, drafted the initial manuscript, and approved the final manuscript as submitted; Julia Tager conceptualized and designed the study, collected and analyzed data, critically reviewed the manuscript, and approved the final manuscript as submitted; Drs Davies, Karst, Scanlon, and Rothschild conceptualized and designed the study, supervised data collection, assisted with data interpretation, critically reviewed the manuscript, and approved the final manuscript as submitted; and all authors approved the final manuscript as submitted.

1.
World Health Organization
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WHO Director-General’s opening remarks at the mission briefing on COVID-19
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2.
Nicola
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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.

FINANCIAL DISCLOSURES: The authors have indicated they have no financial relationships relevant to this article to disclose.