The Lived Experience of ICU Clinicians During

the Coronavirus Disease 2019 Outbreak:

A Qualitative Study
Nancy Kentish-Barnes, PhD1
OBJECTIVES: During the coronavirus disease 2019 pandemic, frontline
Lucas Morin, PhD2
healthcare professionals were asked to reorganize the provision of critical
Zoé Cohen-Solal, MS1
care in unprecedented ways. Our aim was to gain insight into the lived ex-
perience of clinicians who worked in ICUs during the surge. Alain Cariou, MD, PhD3
Alexandre Demoule, MD, PhD4
DESIGN: Qualitative study using semistructured, in-depth interviews.
Elie Azoulay, MD, PhD1
SETTING: Clinicians who worked in three ICUs in Paris (France) during
the peak of the pandemic (April and May 2020).
PARTICIPANTS: Twenty-seven ICU clinicians (12 physicians, 11 nurses,
three nursing assistants, and one respiratory therapist).
MEASUREMENTS AND MAIN RESULTS: Interviews were audio re-
corded and analyzed using thematic analysis. Six themes emerged: coping
with initial disorganization and creating new routines, the intensification of
professional relationships and the development of unexpected collabora-
tions, losing one’s reference points and recreating meaningful interactions
with patients, working under new constraints and developing novel interac-
tions with family members, compensating for the absence of family mem-
bers and rituals at the end of life, and the full engagement of ICU clinicians
during the coronavirus disease 2019 crisis.
CONCLUSIONS: Among ICU clinicians, there was a sense of total pro-
fessional engagement during the surge. Caring for critically ill corona-
virus disease 2019 patients was fraught with challenges and generated a
strong feeling of responsibility, as clinicians felt they had to compensate for
the absence of family members. Rethinking policies about family visits and
safeguarding positive relationships among colleagues are two important
priorities for future healthcare crises.
KEY WORDS: clinician experience; coronavirus disease 2019; intensive
care; qualitative study

D
uring the first weeks of the coronavirus disease 2019 (COVID-19) pan-
demic, the healthcare system in France was rapidly overwhelmed by the
dramatic increase in cases (Fig. 1), prompting a complete readaptation
of hospital policies. Emergency departments’ operating procedures, drug pro-
curement, provision of critical care, decision-making, and patient and family-
centered care were profoundly reorganized in a matter of weeks (1). Intensive Copyright © 2021 by the Society of
care capacities were extended, new wards were built, additional staff was recruited Critical Care Medicine and Wolters
from other hospital units, personal protective equipment were made mandatory, Kluwer Health, Inc. All Rights Reserved.
patients were physically isolated, and visits for relatives were drastically limited. DOI: 10.1097/CCM.0000000000004939

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Kentish-Barnes et al

stage, negative emotions

were dominant, and pos-
itive emotions appeared
gradually. Self-coping
styles and psychologic
growth played an impor-
tant role in maintaining
mental health of nurses.
Another study of home
healthcare workers caring
for older adults and patients
with chronic illnesses
Figure 1. Context of the coronavirus disease 2019 (COVID-19) pandemic in France and in
during the COVID-19
the Paris area.
pandemic in New York City
reported that participants
These changes affected not only the patients and their were at heightened risk for contracting and transmit-
families but also the clinicians working in ICUs. ting COVID-19 and felt inadequately supported dur-
Recent surveys have shown that frontline clinicians ing the crisis (8).
experienced high levels of psychologic burden during During the first weeks of the pandemic, alarming
the epidemic. In a study from China, symptoms of news was circulating regarding the risk of hospital
anxiety and depression were documented in half of disorganization, clinician burnout, and triage.
ICU staff members (2). In the “BURDENCOV” survey Early reports in medical journals suggested that
(Psychological burden in ICU survivors of COVID-19, ICU resources were already at capacity and that
their relatives and healthcare providers)—conducted healthcare systems should prepare for a massive
in 21 ICUs in France between March and April 2020 increase in the number of critically ill COVID-19
(3)—symptoms of anxiety, depression, and peritrau- patients in order to avoid the total collapse of ex-
matic dissociation were found in, respectively, 50%, isting ICUs (9). The purpose of this study was to
30%, and 32% of the respondents. The highest prev- understand how ICU care was affected by the first
alence rates were reported by nursing assistants and surge of the epidemic—including work organiza-
nurses. An American survey showed that ICU clini- tion, professional relationships and patient and
cians (91% nurses) anticipated a number of limited family-centered care—and to gain insight into the
resources that may impact ICU care and expressed lived experience of healthcare professionals who
concerns about exposing their own relatives to the worked in ICUs, both in their work environment
virus, resulting in potentially high levels of stress (4). and in their personal life.
Quantitative studies are interesting in that they
show the prevalence of psychologic symptoms and METHODS
help identify associated factors. However, it is also im-
Design and Setting
portant to advance our understanding of the clinicians’
experience, views, beliefs, and subjective responses to We conducted semistructured, in-depth interviews
the epidemic (5). Qualitative research is useful to shed with healthcare professionals who worked in ICUs
light on the subjective experience of healthcare profes- during the first peak of the COVID-19 pandemic.
sionals working in the ICU, to gain insight into organ- Participants were recruited in three ICUs in central
izational issues and care delivery, and to improve our Paris, France, which were exclusively dedicated to
understanding of social interactions and emotional treating patients with severe COVID-19 pneumonia.
reactions in a context of public health crisis (5, 6). These ICUs are located in three large teaching hospi-
To date, only very few qualitative studies have fo- tals (Table 1). A purposeful sampling strategy (10) was
cused on clinicians’ experience during the COVID-19 used to ensure maximal variation in occupation (phy-
crisis. A study from China (7) shows that in the early sicians, nurse supervisors, nurses, nursing assistants,

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 Online Clinical Investigations

TABLE 1.
ICUs and Study Participants’ Characteristics
ICU 01: “Located in a teaching hospital with a total capacity of 700 beds. The number of beds in the ICU was
increased from 12 to 30 during the first surge of the pandemic. A total of 128 critically ill COVID-19 patients
were admitted between March 1 and the May 31.”

Code Role Age Range In a Relationship Children

Medical staff
01P01 Senior physician (31–40) Yes Yes
01P02 Registrar/assistant (31–40) Yes Yes
01P03 Resident (21–30) No No
01P04 Senior physician (41–50) Yes Yes
01P05 Senior physician (31–40) Yes Yes
Nursing staff
01N01 Nurse (21–30) Yes Yes
01N02 Nurse (31–40) Yes Yes
01NA03 Nurse assistant (41–50) Yes Yes
01NS04 Nurse supervisor (31–40) Yes Yes
01N05 Nurse (41–50) Yes Yes
ICU 02: “Located in a teaching hospital with a total capacity of 1,300 beds. The number of beds in the ICU was
increased from 24 to 36 during the first surge of the pandemic. A total of 95 critically ill COVID-19 patients
were admitted between the first of March and the 31st of May.”

Code Role Age Range In a Relationship Children

Medical staff
02P01 Senior physician (41–50) Yes Yes
02P02 Registrar/assistant (31–40) Yes No
02P03 Resident (31–40) No No
02P04 Senior physician (41–50) Yes Yes
Nursing staff
02N01 Nurse (31–40) No No
02RT02 Respiratory therapist (21–30) Yes No
02NS03 Nurse supervisor (41–50) No No
02NA04 Nurse assistant (21–30) Yes No
02NS05 Nurse supervisor (51–60) No Yes
(Continued)

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Kentish-Barnes et al

TABLE 1. (Continued).
ICUs and Study Participants’ Characteristics
ICU 03: “Located in a teaching hospital with a total capacity of 1,600 beds. The number of beds in the ICU was
increased from 24 to 32 during the first surge of the pandemic. A total of 110 critically ill COVID-19 patients
were admitted between March 1 and May 31.”

Code Role Age Range In a Relationship Children

Medical staff
03P01 Senior physician (31–40) Yes Yes
03P02 Registrar/assistant (31–40) Yes Yes
03P03 Resident (21–30) No No
Nursing staff
03N02 Nurse (31–40) No No
03NA03 Nurse assistant (31–40) No No
03N04 Nurse (31–40) No No
03N05 Nurse (31–40) Yes Yes
03NS06 Nurse supervisor (41–50) Yes No
COVID-19 = coronavirus disease 2019.
Codes: P = physician, N = nurse, NA = nurse assistant, NS = nurse supervisor, RT = respiratory therapist.

and respiratory therapists), gender, level of seniority,
and number of years of clinical experience in the ICU.
Eligible participants (currently working in one of the
ICUs and French speaking) were recruited by local
investigators via e-mails, personal solicitations, and
participant referrals. Out of 28 eligible individuals
who were approached for participation in the study, 27
accepted, and one declined. The study was approved
by the research ethics board Sud Méditerranée (2020-
A00809-30; CNRIPH: 20.03.27.73019). All partici-
pants provided verbal informed consent, including
permission to record the interview, and received no
compensation.
Data Collection
This qualitative study sought to explore the ICU clini-
cians’ experiences and practices during the COVID-19
surge, in the heat of the moment, in order to avoid
recall bias and a posteriori reconstruction of their
experience. Interviews were conducted in French be-
tween April 16, 2020, and May 13, 2020, by researchers
trained in qualitative methods (N.K-.B., L.M., Z.C-.S.).
Because of travel restrictions and stringent physical
distancing rules during the study period, interviews
were conducted over the phone.
The interview guide developed a priori by the inves-
tigators (N.K-.B., L.M., Z.C-.S. as well as three critical
care physicians, one psychiatrist and one nurse with
15 years of ICU experience) was structured around six
broad topics: 1) working conditions and professional
relationships, 2) difficulties in caring for severely ill
COVID-19 patients, 3) interactions with patients and
families, 4) difficult decisions and end-of-life care, 5)
repercussions on personal life, and 6) perspectives
for the future (Supplemental Table 1, Supplemental
Digital Content 1, http://links.lww.com/CCM/G209).
Questions were open ended, and participants were
encouraged to explore issues “they” considered rel-
evant. Interviews were conducted in French, audio-
recorded and transcribed verbatim by professional
transcribers. Interview data were anonymized during
transcription. Self-reported demographic data in-
cluding sex, age, and employment history were also
collected. Recruitment of new participants was inter-
rupted when informational saturation was reached,
that is when no new relevant information emerged
from the interviews (11).

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Data Analysis
As a first step, three researchers (N.K-.B., L.M., Z.C-.S.)
independently reviewed three randomly selected tran-
scripts and identified key themes and concepts that
occurred throughout the interviews using thematic
content analysis (12). A tentative codebook was there-
after developed through an iterative process that started
with the systematic comparison of the investigators’
respective codes and ended when the three authors
achieved consensus (13). Discrepancies were resolved
by discussion during videoconference meetings and
via e-mails. The three initial transcripts were recoded
using this refined codebook, and after final consolida-
tion, the researchers proceeded with the 24 remaining
interviews. The final codebook contained a total of
24 codes grouped into six underlying themes. To en-
sure the rigor of the methodology, all transcripts were
coded independently by the two investigators who had
not conducted the interview. Quotes were selected to
illustrate each theme and were subsequently translated
from French into English. Once coding was finalized,
themes were generated that were then reviewed and
consolidated by returning to the interviews. We then
defined and named our themes and proceeded with
writing up analysis of the data (12).
RESULTS
In total, 27 clinicians working in three different ICUs
were interviewed, including 12 physicians, four nurse
supervisors, seven nurses, three nursing assistants,
and one respiratory therapist (Table 1). Ten were
men, and 17 were women. Median age of participants
was 34 years (26–52 yr), two thirds were living with
a partner, and a little over 50% had children. Clinical
experience in the ICU ranged from 6 months to over
20 years. Interviews lasted between 45 and 90 min-
utes. We derived six themes from qualitative anal-
ysis (Table 2). Representative quotes are provided in
Tables 3 and 4. Full and additional quotes are pro-
vided in Supplemental Table 2 (Supplemental Digital
Content 2, http://links.lww.com/CCM/G210). Quotes
are coded as follows: ICU number (1–3); profes-
sional status (P stands for Physician, N for Nurse, NA
for Nurse Assistant, NS for Nurse Supervisor, RT for
Respiratory Therapist); and interview number. Strong
agreement was found between participants in spite of
their different professional statuses.
Critical Care Medicine
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Online Clinical Investigations
Entering the COVID-19 Crisis: From Initial
Disorganization to Daily Routine
The participants reported that, initially, they wor-
ried ICUs would be unable to cope with the sudden
outpouring of severely ill COVID-19 patients while
maintaining usual operating procedures, causing
them to feel rapidly overwhelmed. Terms such as
“confusion,” “unknown,” “brutality,” “madness,” “sur-
prise,” “disconcerting,” “oppressive,” and “shock” were
often used by clinicians: “During the first few days, it
was just madness” (01P02). This feeling of being over-
whelmed lasted approximately 7 days. Once clinical
practice, recommendations and protocols had been
adapted to the public health situation and to the spe-
cific needs of COVID-19 patients, physicians and
nurses found their bearings again (Table 3, Q1). In
spite of the surge, clinicians did not feel that admis-
sion criteria had changed, and triage did not become
an issue (Table 3, Q2).
The Intensification of Professional Relationships
and the Development of Unexpected
Collaborations
The epidemic made clinicians aware of the quality of
their professional relationships (Table 3, Q3). However,
some participants also described how during the first
week of the outbreak, due to the context, tensions also
unfolded (Table 3, Q4).
As hospitals were being reorganized and many new
ICU beds were installed, clinicians started to collabo-
rate with colleagues from the hospital they had never
met before. The notions of solidarity and teamwork
were mentioned by all the participants and turned out
to be much stronger than they had ever imagined pos-
sible (Table 3, Q5 and Q6). Participants felt that this
sense of professional solidarity helped breaking down
institutional roles and made it possible to get to know
others from a different angle. In addition, the enroll-
ment of clinicians from other care units and other hos-
pitals created a strong sense of support and cohesion
(Table 3, Q7).
Discovering the Unique Features of COVID-19
Patients: From Losing One’s Reference Points
to Recreating Meaningful Interactions
The pandemic brought about an unprecedented situa-
tion: caring for patients who “all” had the same disease
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Kentish-Barnes et al

TABLE 2.
Themes Derived From Qualitative Analysis
S. No. Themes

1 Entering the COVID-19 crisis: from initial disorganization to daily routine.

2 The intensification of professional relationships and the development of unexpected collaborations.
Reorganization of the ICU: working hand and hand or increasing tensions?
Discovering new collaborations.
3 Discovering the unique features of COVID-19 patients: from losing one’s reference points to recreating
meaningful interactions.
Specificities of the COVID patient: sudden deterioration, uncertainties, and monotony.
Caring for the patient: rapid transfer from the ICU, dehumanization, and compensating for the absence
of the family.
4 Family members: working under new constraints and developing novel interactions.
Restricted visiting and its impact on clinicians.
Developing novel interactions.
5 End-of-life care: compensating for the absence of family members and rituals.
A strong feeling of responsibility: discussing end of life with family members, facing the loneliness of dying.
Being the last witness.
The absence of rituals.
Generating complicated grief.
6 The ICU clinician: full engagement in the face of the COVID crisis.
Fear of contamination.
Strong identification.
An extreme physical experience.
Full work engagement.
COVID-19 = coronavirus disease 2019.

and the same clinical features. Physicians reported
being confused by the sudden deterioration of the
patients (Table 3, Q8). Not being in control was an-
other challenging experience for ICU clinicians. The
absence of solid medical evidence was disconcerting,
both at the individual level and at the level of the care
team (Table 3, Q9). The high degree of clinical un-
certainty during the first few weeks of the pandemic
led physicians to question themselves as well as their
ability to treat these patients effectively.
During the interviews, nearly all participants
expressed a feeling of monotony. Every single ICU bed
was occupied by patients presenting the exact same
clinical profile and physical features (Table 3, Q10).
Compared with the typical ICU patients, the clinical
trajectory of COVID-19 patients spanned over a much
longer period (Table 3, Q11), and almost all patients
were sedated and intubated for the entire duration of
their stay in the ICU. Over time the repetitiveness be-
came tedious: “It’s not intellectually stimulating; we
feel like we just aren’t able to move on” (01P01).
During the peak of hospital admissions, the rapid
transfer of the patient from the ICU to other wards
of the hospital was experienced as upsetting (Table 3,

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 Online Clinical Investigations

TABLE 3.
Representative Quotes for Themes 1–3
S. No. Themes

1 Entering the COVID-19 crisis: from initial disorganization to daily routine.

Q1 “After a few days, we got used to the situation, we knew what to do, we had adapted our practices” (01N02).
Q2 “I went to see two patients in the emergency department who were around 80-84 yr old and I said to myself
that it probably wouldn’t be reasonable to put them in intensive care (...). But these are patients whose ad-
mission to the ICU would also have been discussed before the health crisis anyway” (02P01).
2 The intensification of professional relationships and the development of unexpected collaborations.
Q3 “I realized that we were a tightly knit team and that we listened to each other a lot” (01NA03).
Q4 “At first, everyone was really on edge, focused on what they had to do and less attentive to each other” (03N02).
Q5 “Everyone is participating in their own way and as best they can, and it’s quite amazing to see the collaboration
we have with colleagues we don’t see very often” (02P03).
Q6 “In the evening, we wait for each other and we talk about how we feel. We try to support each other. There’s
always one of us who’s feeling a little bit better than the others, so it’s pretty much okay. (...) We’re there for
each other and yes I think that it’s stronger than usual” (02N01).
Q7 “We really felt supported. We had new nurses coming in who were really willing, really committed, it was such a
help to have them” (01N01).
3 Discovering the unique features of COVID-19 patients: from losing one’s reference points to recre-
ating meaningful interactions.
Q8 “And seeing the patients texting their relatives, sort of ‘goodbye’ messages, and us knowing the severity of the
illness (…). That is to say the incredible dissociation between the severity of the illness and the clinical presen-
tation of the patient because 2 hours later, the patient would be in a critical situation. It was striking” (03P01).
Q9 “Well, after 3 days, you realize that you don’t know how to treat it, that it doesn’t look at all like what you’ve seen
before, that you don’t understand why (...) We were thinking ‘but we’re actually really bad!’. I try to think about
new strategies all the time, saying ‘maybe we need to change this or that’ (01P01).
Q10 “(…) We spend our time doing the same things, the tasks are very repetitive, with a risk of mixing-up the
patients” (01P02).
Q11 “(…) It’s very slow, you have to be patient. In the ICU, we want to act immediately with immediate results but
here we just had to learn to wait” (02P04).
Q12 “Those who got better left the ICU really fast, we didn’t see them anymore, and we didn’t really know what hap-
pened to them afterwards. (…) So that was a little complicated and frustrating” (02P03).
Q13 “(…) she was transferred to another unit, but then I found out that she was intubated the next day and I kind
of experienced it as a… as if I had abandoned the patient by putting her in the hands of nurses who weren’t
qualified as intensive care nurses” (02N01).
Q14 “It’s getting a little ‘robotic’. I find that we have lost the relationship with the patient; even our transmissions are
a less precise and we don’t discuss little details as much. I think that as it’s the same for all the patients, we
just spend much less time talking about them” (01N01).
Q15 “The patient’s personal history, his medical history, pfff… they came in one ear, they went out the other. (…) It’s
more of a mechanical approach than a really empathetic approach” (01P01).
Q16 “When patients arrive awake and we have to intubate them immediately, we try to create a quick relationship,
because they are alone, without their family and we are maybe the last ones who will see them conscious.
So, we have to make sure we’re reassuring, as we don’t want the patient to feel anxious, we’re responsible of
what might be the last image he will see” (01N02).

COVID-19 = coronavirus disease 2019.

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Kentish-Barnes et al

TABLE 4.
Representative Quotes for Themes 4–6
S. No. Themes

4 Family members: working under new constraints and developing novel interactions.
Q17 “We’ve gone from being closed for the first 10 days to now, where families can come for end-of-life situ-
ations, and in other situations they can all come for at least one hour a day. (…) So, I think that was a
very good decision, to reintroduce some humanity” (01P01).
Q18 “I think it’s a shame, because I still feel like I’ve lost... because we’re busy all the time, there’re people every-
where, there’s noise all the time, so I have less time to say to myself ‘OK, I’m going to sit down with the family,
we’re going to do a little tour of the room, I’ll explain…’ (…). There’s a lack of something human” (01P02).
Q19 “Maybe it’s a little harder for families to express their feelings and ask questions over the phone. But we
try to say the same things we would say to their face. But it’s true that necessarily the relationship is not
the same, there’s no eye contact, no pausing, no seeing how the person reacts, no adapting ourselves
accordingly, there’s less of a relationship” (02P03).
Q20 “We set up a system where we were the ones who called the family at preset schedules and we had to
stick to them, because it was important to us, and we knew how they needed to hear from us as well”
(02P01).
Q21 “We create a bond that’s maybe a little stronger than usual, since we always have the one same person
on the phone each time” (02P02).
Q22 “For some patients we organize video calls, even if the patient is intubated. But at least the family can see
the room and see what’s going on, because just explaining with words (…) is very difficult” (02NA04).
5 End-of-life care: compensating for the absence of family members and rituals.
Q23 “For me personally, I found it very difficult to deal with the decisions to withdraw treatment in patients whose
families I had not been able to see and discuss the situation with. And that was hard because, for example,
when we extubated patients, the first terminal extubations, I didn’t feel like I could tell the family.” (01P01).
Q24 “My colleagues and I, we couldn’t bear to see people die alone. So, we held their hands until the end”
(01NA03).
Q25 “There was one family, we made sure they could be in the room. It makes sense, (…) it’s a satisfaction
knowing the patient didn’t die alone, and that he was with his loved ones” (02NA04).
Q26 “The body is wrapped in a body bag, and we’re the last ones to see the body. (...) It’s been very difficult
for me (…) to realize that it’s over; it’s me and the patient, and then it’s over. I know that once the zip is
closed, once we get him to the morgue, no one will ever see him again, his family won’t see him. (…)
It’s the only thing that really deeply touched me” (03N02).
Q27 “There was an obligation to put the body in the coffin immediately, that is to close the coffin immediately,
within 24 hours, which prevented families from observing certain customs and religious rites—such as
the ritual of washing of the body in certain religions—and which also prevented the family from seeing
the deceased, since the coffin was closed” (01P02).
Q28 “I had the feeling that we were generating pathologic grief for dozens of people. It’s dreadful” (01P01).
Q29 “(…) For the family’s grieving process, it’s also very important for them to be able to see their loved-one
one last time (…). We feel reassured now, because we work with people, not just cases, so we mustn’t
forget that. It’s a critical situation and everything is reorganized, we’re completely confused, but there
are certain things that must not change, and that’s one of them” (03N02).
(Continued)

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 Online Clinical Investigations

TABLE 4. (Continued).
Representative Quotes for Themes 4–6
S. No. Themes

6 The ICU clinician: full engagement in the face of the coronavirus disease crisis.
Q30 “What scares me the most is not necessarily being infected by the coronavirus, but it’s the risk of passing
it on to someone else, someone close to me. (...) I’m not scared for myself; I’m scared for my family and
friends” (03NA03).
Q31 “One night I woke up, I was sweating and I thought I had a fever, and in fact I was really stressed out,
that’s when I realized that I was actually really afraid of being infected and so I panicked, I had a hard
time breathing and I thought ‘well, that’s it’, I’ve got a severe form, I’m going to have to be intubated’”
(02RT02).
Q32 “The people we’re resuscitating are my parents. They are people in their 60s and 70s, who don’t neces-
sarily have a long medical history and who, overnight, find themselves in an extremely serious situation,
from which they might not recover. So, there is a lot of personal projection in these situations, which is
difficult” (01P01).
Q33 “My priority is that the patients who are being cared for in our beds leave the ICU alive, that’s the priority.
The priority is a public health priority; it’s clearly to save these people. Everything else is secondary. In
other words, if my children lose their [school] year, it’s secondary; it’s secondary to the lives of these
patients, and that’s how I explained it to them” (02NS05).
Q34 “I wonder if I shouldn’t do something else. At least for a while, because I need to see something different,
to do something different” (01P01).
Q35 “I’m starting to think about how long it’s going to last, and how we’re going to deal with it afterwards,
because this idea of a second peak is really scary” (01N01).

Q12). For some clinicians, the feeling of guilt added to
the frustration (Table 3, Q13).
The working conditions (intensity, repetitiveness,
personal protective equipment) and the total or par-
tial restriction of family visits generated a sense of de-
humanization. Participants highlighted the challenge
of providing care in a context of anonymity (Table 3,
Q14). They also reported a decrease in empathy due to
the increased workload and monotony (Table 3, Q15).
At patient admission, due to restricted family visits,
clinicians felt they had to compensate for the absence
of a loved one at the bedside (Table 3, Q16).
Family Members: Working Under New
Constraints and Developing Novel Interactions
The initial ban on family visits was a negative experi-
ence for all participating clinicians. In the three ICUs,
rules were rapidly changed, and visits were allowed, al-
beit with some restrictions (Table 4, Q17).
However, fewer and shorter interactions with family
members were mentioned as a source of frustration and
disorientation (Table 4, Q18). Communicating solely
over the phone was sometimes experienced as unsat-
isfactory as it did not convey nonverbal cues (Table 4,
Q19). Nevertheless, these interactions over the phone
were important for clinicians, and specific policies
were soon established (Table 4, Q20). In spite of initial
apprehension, these regular phone calls could be ful-
filling (Table 4, Q21). Other means of communication
with family members, such as video calling, were also
developed, but only marginally (Table 4, Q22).
End-of-Life Care: Compensating for the
Absence of Family Members and Rituals
The impossibility of meeting families face-to-face to
discuss the patients’ prognosis made end-of-life dis-
cussions more difficult than usual. The quality of com-
munication was hindered, and some information was
omitted (Table 4, Q23).
All participating clinicians—without exception—
expressed distress with the loneliness of dying dur-
ing the initial surge: “It’s not death itself, it’s seeing the

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Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Kentish-Barnes et al
patient die alone, without any family; that’s what’s diffi-
cult” (01P02). Clinicians were uncomfortable with this
situation and felt they should not leave the patients
alone (Table 4, Q24). When possible, the presence of
family members brought meaning to the end of life
(Table 4, Q25). When family members could not be
present, clinicians (and more specifically, nurses) felt
a strong responsibility because they were not only the
last ones to see the patient alive but also the last ones to
see the deceased’s body (Table 4, Q26). Clinicians were
aware that the absence of rituals could be harmful, and
yet, they could not change the rules (Table 4, Q27).
Clinicians were concerned that these particu-
larly difficult circumstances would increase the risk
of complicated grief among relatives (Table 4, Q28).
However, once rules regarding family visits were soft-
ened, clinicians felt more at ease with end-of-life care
(Table 4, Q29).
The ICU Clinician: Full Engagement in the Face
of the COVID-19 Crisis
The fear of being contaminated and of contaminat-
ing their loved ones was strong among ICU clinicians
(Table 4, Q30). However, they were very attentive to
their own symptoms and reported being overwhelmed
with anxiety (Table 4, Q31). Several participants
described this anxiety as being extremely burdensome.
Identification with patients was often mentioned
during the interviews. The patients who were admitted
to the ICU sometimes reminded them of themselves,
but more often, they reminded them of their loved
ones (Table 4, Q32).
Caring for ICU patients during the first few days
and weeks of the pandemic was described as an intense
physical and emotional experience. Indeed, clinicians
felt physically and emotionally exhausted, and many
stated they suffered from insomnia or nightmares. “I
couldn’t cut myself off from the situation” (01N02),
“I feel nervous night and day” (02RT02). While in
the ICU, their physical experience was described
as extreme: “It’s an exhausting, suffocating experi-
ence” (01P04). In spite of all the difficulties, clinicians
described themselves as being fully engaged in their
work (Table 4, Q33). For most participants, this ex-
perience confirmed their strong attachment to inten-
sive care medicine. However, for others, the intensity
of the event called into question their motivation for
e594     www.ccmjournal.org
Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
the future (Table 4, Q34). During interviews, the clini-
cians’ principal fear remained the threat of a second
wave of the epidemic (Table 4, Q35).
DISCUSSION
This qualitative study carried out in the midst of the
COVID-19 pandemic shows that although the expe-
rience of ICU clinicians changed rapidly over a short
period of time it remained intense, both professionally
and emotionally. During the first tumultuous days of
the surge, clinicians working in the ICU lost all sense
of normality. ICU culture was disrupted, and the cli-
nicians’ sense of belonging and their professional
identity were shaken. Many clinicians spontaneously
described symptoms of acute stress: they felt like in a
daze, they were more alert to danger, and they experi-
enced troubled sleep and bad dreams (14). As in the
study by Sun et al (7), these negative emotions were
more pronounced in the first week of the pandemic,
suggesting that frontline clinicians may benefit from
early psychologic support.
The initial surge was complex not only because of the
repeated changes in clinical protocols or because of the
exponential number of patients with severe COVID-19
pneumonia but also because of the unparalleled de-
gree of uncertainty surrounding the disease trajectory.
The lack of control and the absence of proven effec-
tive treatment were unsettling for ICU clinicians (15).
Physicians’ experience first oscillated between feelings
of stimulation and powerlessness and over time turned
to a feeling of monotony, fueled by the homogeneity of
patients’ clinical profile and symptoms. Monotonous
work has been shown to have a negative impact on
wellbeing with a decrease of job satisfaction and an
increase of psychologic distress (16). However, the re-
petitiveness mentioned by the participants was partly
counterbalanced by the unexpected evolution of some
patients, characterized by a rapid deterioration at times
where hope of recovery was high, adding a supplemen-
tary feeling of ineffectiveness that was sometimes ex-
perienced as depressing (7, 17).
Contrary to what they anticipated and to what was
reported in publications (18), in the participating
ICUs, patient triage did not seem to be an issue dur-
ing the first peak of the pandemic. More difficult was
the inability to fully adhere to the standard practice of
patient and family-centered care (19). The absence or
June 2021 • Volume 49 • Number 6

rare presence of family members was one of the most
difficult experiences for clinicians. They felt deprived
of one of their important roles, that is, care and sup-
port of the family as well as quality communication,
suggesting that the ban and/or restricted visiting poli-
cies should be reevaluated, for the benefit both of the
family and the clinicians. Telephone communication
seemed only partially satisfactory, as it precluded non-
verbal communication and, thus, made it very difficult
to take the families’ needs and emotions into account
(20, 21).
Due to substantial restrictions to family visits, cli-
nicians also felt that they had to compensate for the
absence of relatives at two crucial time points: first, at
admission and before sedation to reassure the patient
and second, near the end of life, when important deci-
sions arise. Caring for these dying patients was fraught
with challenges and generated a strong feeling of re-
sponsibility. During the initial phase of the COVID-
19 pandemic, clinicians found themselves facing these
situations alone, which are not only loaded with med-
ical issues but also represent an anthropologically sa-
cred sequence (22): without families, clinicians were
left with little nonmedical input to feed the deci-
sion-making process; they often had sole responsibility
for the patient at the end of life and after death had
occurred. They were concerned that the context may
generate complicated grief in family members (23, 24).
Previous research has shown that epidemics bring dis-
ruption to social norms, rituals, and mourning prac-
tices (25), suggesting the need to provide a supportive
framework for families in end-of-life situations, in-
cluding open visiting and the possibility of performing
rituals that allow a sense of continuity.
Working in an ICU is complex and physically, cog-
nitively, and emotionally demanding (26). During the
first few days and weeks of the pandemic, this became
overwhelming. The high workload, coupled with an
especially heavy emotional burden, did not, how-
ever, affect the physicians’ and nurses’ level of profes-
sional engagement. Previous research has found that
work engagement is often positively associated with
personal wellbeing and performance at work (27).
Recognizing this engagement may help decrease stress
and risk of burnout (28). Our study also shows that
working within an atmosphere of good professional
relationships reinforced a sense of safety for clinicians.
In spite of all the changes and the occasional tensions,
Critical Care Medicine
Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Online Clinical Investigations
safeguarding positive relationships among colleagues
was a priority as they can bring support during times
of upheaval and protection from loss of meaning.
Investing in these relationships was a coping strategy,
suggesting that developing peer support and team re-
silience is a priority. Systematic approaches designed
to integrate teamwork into practice have shown to be
effective (29). As described in other studies and differ-
ent contexts, in a time of crisis team solidarity is often
reinforced (7, 30). Throughout the interviews, clini-
cians expressed a feeling of pride and satisfaction in
having been part of this mission and appreciated the
social recognition that accompanied it.
Our study presents several limitations. First, it was
conducted in three ICUs located in large teaching hos-
pitals in the center of Paris. These ICUs share a number
of common features that make them a homogeneous
setting for qualitative research, but they are most likely
not representative of all ICUs in the country. Likewise,
although our purposive sampling strategy was
designed to maximize the diversity of ICU clinicians
who participated in the study, it does not guarantee the
generalizability of our findings to all ICU clinicians.
Participation in qualitative interviews was voluntary,
creating a possible selection bias: clinicians with dif-
ficulties in (or reluctance to) expressing themselves or
their experiences during the epidemic may have been
omitted. It should also be noted that our study is solely
focused on healthcare professionals working in the set-
ting of ICUs, when many other hospital settings and
medical specialties were involved in caring for severely
ill COVID-19 patients. Finally, face-to-face interviews
were not possible due to strict social distancing meas-
ures, and we had to resort to conducting interviews by
telephone, which may have negatively impacted the
richness of the empirical data that we collected (31).
CONCLUSIONS
This qualitative study provides in-depth understanding
of the experience of ICU clinicians during the very first
weeks of the COVID-19 pandemic. Lessons learnt from
this study offer important insight to better anticipate
policies and measures in future pandemics. First, con-
cern about family members was strong and reveals that
family-centered care is a core aspect of ICU clinicians’
identity. Policies restricting family visits urgently need
to be reevaluated as the pandemic continues. Second,
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Kentish-Barnes et al
this reevaluation is particularly important in end-of-life
situations during which open visiting is fundamental
both for families and clinicians as well as opportunities
to organize rituals. Third, clinicians invested in their
team relationships, which helped them cope in this
context: team building and safeguarding positive rela-
tionships among colleagues is thus a priority. Finally,
although the professional engagement of clinicians was
strong during the surge, some participants expressed
a feeling of exhaustion that questions their capacity to
maintain this level of engagement if a new public health
crisis was to unfold again.
1 AP-HP, Saint Louis University Hospital, Medical Intensive
Care, Famiréa Research Group, Paris, France.
2 Inserm CIC 1431, CHU Besançon, 25000 Besançon,
France.
3 AP-HP, Cochin University Hospital AP-HP Centre, Medical
Intensive Care and Université de Paris, Paris, France.
4 AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne
Université, site Pitié-Salpêtrière, Service de Pneumologie,
Médecine Intensive et Réanimation (Département
R3S) and Sorbonne Université, INSERM, UMRS1158
Neurophysiologie Respiratoire Expérimentale et Clinique,
F-75005 Paris, France.
Supplemental digital content is available for this article. Direct
URL citations appear in the printed text and are provided in the
HTML and PDF versions of this article on the journal’s website
(http://journals.lww.com/ccmjournal).
Supported, in part, by the French Ministry of Health, Programme
Hospitalier de Recherche Clinique 2020, APHP200389.
Dr. Kentish-Barnes’ institution received funding from the French
Ministry of Health. Dr. Demoule received funding from Medtronic,
Philips, Baxter, Hamilton, Fisher & Paykel, French Ministry of
Health, Getinge, Respinor, and Lungpacer. Dr. Azoulay’s institu-
tion received funding from Fisher & Paykel, MSD, Pfizer, Baxter,
and Gilead, and he received funding from Gilead, Baxter, Alexion,
Ablynx, and Pfizer. The remaining authors have disclosed that
they do not have any potential conflicts of interest.
For information regarding this article, E-mail: nancy.kentish@aphp.fr
ClinicalTrials.gov Identifier: NCT04341519.
REFERENCES
1. Robert R, Kentish-Barnes N, Boyer A, et al: Ethical dilem-
mas due to the Covid-19 pandemic. Ann Intensive Care 2020;
10:84
2. Lai J, Ma S, Wang Y, et al: Factors associated with mental
health outcomes among health care workers exposed to coro-
navirus disease 2019. JAMA Netw Open 2020; 3:e203976
e596     www.ccmjournal.org
Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
3. Azoulay E, Cariou A, Bruneel F, et al: Symptoms of anxiety,
depression, and peritraumatic dissociation in critical care cli-
nicians managing patients with COVID-19. A cross-sectional
study. Am J Respir Crit Care Med 2020; 202:1388–1398
4. Kleinpell R, Ferraro DM, Maves RC, et al: Coronavirus disease
2019 pandemic measures: Reports from a national survey of
9,120 ICU clinicians. Crit Care Med 2020; 48:e846–e855
5. Rusinová K, Pochard F, Kentish-Barnes N, et al: Qualitative
research: Adding drive and dimension to clinical research. Crit
Care Med 2009; 37:S140–S146
6. Sinuff T, Cook DJ, Giacomini M: How qualitative research can
contribute to research in the intensive care unit. J Crit Care
2007; 22:104–111
7. Sun N, Wei L, Shi S, et al: A qualitative study on the psycho-
logical experience of caregivers of COVID-19 patients. Am J
Infect Control 2020; 48:592–598
8. Sterling MR, Tseng E, Poon A, et al: Experiences of home
health care workers in New York City during the coronavirus
disease 2019 pandemic: A qualitative analysis. JAMA Intern
Med 2020; 180:1453–1459
9. Grasselli G, Pesenti A, Cecconi M: Critical care utilization for
the COVID-19 outbreak in Lombardy, Italy: Early experience
and forecast during an emergency response. JAMA 2020;
323:1545–1546
10. Emmel N, Sampling and Choosing Cases in Qualitative
Research: A Realist Approach, London, United Kingdom, Sage,
2013
11. Saunders B, Sim J, Kingstone T, et al: Saturation in qualitative
research: Exploring its conceptualization and operationaliza-
tion. Qual Quant 2018; 52:1893–1907
12. Braun V, Clarke V: Using thematic analysis in psychology. Qual
Res Psychol 2006; 3:77–101
13. DeCuir-Gunby JT, Marshall PL, McCulloch AW: Developing
and using a codebook for the analysis of interview data: An
example from a professional development research project.
Field Methods 2011; 23:136–55
14. Bryant RA: The current evidence for acute stress disorder.
Curr Psychiatry Rep 2018; 20:111
15. Shapiro J, Astin J, Shapiro SL, et al: Coping with loss of
control in the practice of medicine. Fam Syst Health 2011;
29:15–28
16. Melamed S, Ben-Avi I, Luz J, et al: Objective and subjective
work monotony: Effects on job satisfaction, psychological dis-
tress, and absenteeism in blue-collar workers. J Appl Psychol
1995; 80:29–42
17. Shaw SCK: Hopelessness, helplessness and resilience: The
importance of safeguarding our trainees’ mental wellbeing
during the COVID-19 pandemic. Nurse Educ Pract 2020;
44:102780
18. Sprung CL, Joynt GM, Christian MD, et al: Adult ICU triage
during the coronavirus disease 2019 pandemic: Who will live
and who will die? Recommendations to improve survival. Crit
Care Med 2020; 48:1196–1202
June 2021 • Volume 49 • Number 6

19. Davidson JE, Aslakson RA, Long AC, et al: Guidelines for fam-
ily-centered care in the neonatal, pediatric, and adult ICU. Crit
Care Med 2017; 45:103–128
20. Mehrabian A: Nonverbal Communication. Second Edition. New
York, NY, Routledge, 2017
21. Benbenishty JS, Hannink JR: Non-verbal communication
to restore patient-provider trust. Intensive Care Med 2015;
41:1359–1360
22. Van Gennep A: The Rites of Passage. 1st Edition. Chicago, IL,
University of Chicago Press, 1961
23. Kentish-Barnes N, Chaize M, Seegers V, et al: Complicated
grief after death of a relative in the intensive care unit. Eur
Respir J 2015; 45:1341–1352
24. Gesi C, Carmassi C, Cerveri G, et al: Complicated grief: What
to expect after the coronavirus pandemic. Front Psychiatry
2020; 11:489
25. Mayland CR, Harding AJE, Preston N, et al: Supporting adults
bereaved through COVID-19: A rapid review of the impact
of previous pandemics on grief and bereavement. J Pain
Symptom Manage 2020; 60:e33–e39
Critical Care Medicine
Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
Online Clinical Investigations
26. See KC, Zhao MY, Nakataki E, et al; SABA Study Investigators
and the Asian Critical Care Clinical Trials Group: Professional
burnout among physicians and nurses in Asian intensive
care units: A multinational survey. Intensive Care Med 2018;
44:2079–2090
27. Bakker AB: An evidence-based model of work engagement.
Curr Dir Psychol Sci.Science 2011; 20:265–269
28. van Mol MMC, Nijkamp MD, Bakker J, et al: Counterbalancing
work-related stress? Work engagement among intensive care
professionals. Aust Crit Care 2018; 31:234–241
29. Lisbon D, Allin D, Cleek C, et al: Improved knowledge, atti-
tudes, and behaviors after implementation of TeamSTEPPS
training in an academic emergency department: A pilot report.
Am J Med Qual 2016; 31:86–90
30. Shih FJ, Liao YC, Chan SM, et al: The impact of the 9-21
earthquake experiences of Taiwanese nurses as rescuers. Soc
Sci Med 2002; 55:659–672
31. Novick G: Is there a bias against telephone interviews in qual-
itative research? Res Nurs Health 2008; 31:391–398
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