“Being a round square in an extremely challenging situation”—Healthcare professionals’ experiences of palliative care during the COVID-19 pandemic – A deductive and inductive qualitative study

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During the pandemic, professionals across all healthcare contexts confronted enormous pressure due to a lack of pandemic readiness, practical and emotional challenges, and an increased number of dying patients. To support equitable high-quality palliative care for all people in future pandemics, it is crucial to learn from the nurses on the front lines during the COVID-19 pandemic. Aim To explore nurses’ experiences of providing end-of-life care in general and specialized palliative care settings to patients during the COVID-19 pandemic. Methods This qualitative study is part of a larger Swedish–Norwegian multi-center project called Palliative Quality Care COVID-19 (PaQC-C19). Data were collected in autumn 2021 and spring 2022 using qualitative individual interviews with 20 registered nurses and assistant nurses in general and specialized palliative care. A stepwise deductive and inductive qualitative content analysis was utilized in the search for domains and subthemes following the method of Elo and Kyngäs (2008). Results Three domains, one overarching theme, and nine subthemes were developed. The domains described positive and negative aspects as well as strategies used when providing modified palliative care, the challenges concerning contamination, and how the nurses experienced guidance from managers during the pandemic. The overarching theme “being a round square in an extremely challenging situation” summarizes how the nurses safeguarded the patients’ dignity and provided support to the next of kin in extremely challenging situations during the COVID-19 pandemic. Conclusions The results of this study suggest that the prerequisites for nurses and the palliative care approach they use change during a pandemic; they felt inadequate and insecure and struggled very hard throughout the seemingly never-ending pandemic. These findings can be used as a basis for reflection in collaborative learning interventions within palliative care and as a guide for teachers in educational palliative care programs. COVID-19 Health Healthcare professionals Nursing Palliative care Pandemic Qualitative method Figures Figure 1 Background During the COVID-19 pandemic, palliative care (PC) played an important role in supporting patients who were severely ill or dying wherever they were cared for [ 1 ], and multiple symptoms, such as respiratory problems, were the most frequent [ 2 ]. The PC approach aims to improve the well-being of patients and next-of-kin facing problems related to severe illness [ 3 ], and it involves all dimensions of life, including communication; symptom management; social, existential, and psychological needs; and end-of-life care [ 4 ]. The pandemic highlighted the importance of healthcare systems that delivered high-quality PC [ 5 ]. Many professionals in all healthcare contexts faced immense pressure due to a lack of pandemic preparedness and practical and emotional challenges, along with an increase in the number of dying patients. A scoping review stated that the pandemic was stressful and had a tremendous impact on healthcare professionals’ mental and physical health and well-being [ 6 ]. The pandemic placed a burden on global health systems, and worldwide, over 2.1 million COVID-19 deaths occurred in 2021 [ 7 ]. An increasing number of deaths occurred in the long-term care sector; the lack of pandemic preparedness and human resource issues, and shortages of personal protective equipment and medicines limited care [ 6 ]. Visiting restrictions had negative consequences for the health and well-being of patients and next-of-kin, and they led to ethical dilemmas for healthcare professionals [ 8 ]. Nurses found it challenging to provide PC during the pandemic, especially care related to information and continuity [ 9 ], and they experienced a reduced quality of sleep [ 10 ]. In Spring 2020, several Western European countries, including Norway (but not Sweden), entered a total lockdown to prevent the spread of infection and protect vulnerable groups, including older adults [ 11 , 12 ]. The total lockdown in Norway led to fewer deaths than normal among older adults at home and in nursing homes. Thus, the lockdown affected thousands of next-of-kin of patients at the end-of-life [ 13 ]. While other countries closed, Sweden did not. To reduce the spread of COVID-19, the Public Health Agency in Sweden recommended that healthcare staff apply physical distancing as much as possible, wear face masks, keep rooms ventilated, and practice good hand and respiratory hygiene [ 14 ]. Globally, a heavy responsibility was placed on nurses who were crucial in ensuring that persons approaching the end-of-life were supported during the pandemic[ 3 ]. A shift of resources also occurred between units, especially in long-term care. Units with outbreaks were prioritized to have better staffing levels and more nurses, with closer collaboration among staff. The pandemic also contributed to important learning and increased knowledge, not least related to practicing good hygiene, infection control, and digital communication [ 15 , 16 , 17 ]. The COVID-19 pandemic emphasized the importance of a healthcare system that delivers high-quality PC across all healthcare contexts in a time of extreme challenges. During the pandemic, healthcare professionals confronted enormous pressure because of a lack of pandemic readiness. They encountered both practical and emotional challenges due to the increase in the number of dying patients as well as insufficient resources to provide PC. Hence, to support equitable high-quality PC to dying people in future crises, such as pandemics, it is important to learn from the nurses who were on the front lines during the pandemic. Aim To explore nurses’ experiences of performing end-of-life care in general and specialized PC settings to patients during the COVID-19 pandemic. Methods Design This was a qualitative study involving nursing staff within the multicenter Swedish–Norwegian Palliative Quality Care COVID-19 (PaQC-C19) project. Data were collected through individual interviews in general and specialist PC. A stepwise deductive and inductive approach was utilized, including the stages of preparation, organization, and reporting of results, as described by Elo and Kyngäs [18]. Participants Registered nurses (RNs, n = 15) and assistant nurses (ANs, n = 5) in general PC (hospital and nursing homes) and specialized PC (the advanced PC team) were purposively sampled. The participants lived in urban and rural areas in Sweden (n = 10) and Norway (n = 10). All were women (N = 20), most had a partner and worked full-time, and had permanent employment. The inclusion criteria were employment in health and community care, experience in PC, and employment during the COVID-19 pandemic. The nurses did not need to have experience in caring for patients with COVID-19 infection (Table). Please insert the table about here Table Demographic information of nurses in Sweden and Norway in palliative care during the COVID-pandemic Data collection In the preparation stage, data were collected across different care contexts through individual qualitative interviews via secure digital audio and video recording [18]. The interview questions were related to participants’ experiences of performing PC and the treatment of patients with and without COVID-19, along with the experiences of the health and well-being of the RNs and ANs. A semi-structured interview guide was developed for this study (see Supplementary Material), which asked the participants what they thought was important for person-centered PC at the end-of-life, what the care was like, and what it was like for the nurses to care for the severely ill and dying during the COVID-19 pandemic. The opening question was “What is your experience in performing PC during the COVID-19 pandemic?” Nurses who provided written informed consent to participate were contacted to arrange a time and place for the interview. In Sweden, the interviews were conducted in secure rooms in Zoom, and in Norway, they were conducted through an electronic application. The interviews were conducted by a researcher involved in the project and were audio-recorded. They lasted between 20 and 60 minutes and were transcribed by a professional writing agency. Data analysis In the organization step, both deductive and inductive approaches were used [18]. In this phase, data were analyzed inductively, and open coding was utilized by reading and reflecting on the content in the Swedish interviews. Reflections describing different areas were written down, for example, “creative thinking in relation to relatives and patients”, “doing all we can and fighting”, “modified nursing care”, “the good death and death comes quickly”, and “inconstant leadership”. These areas guided the interview analysis, supporting the organization of the text into three domains. The content of the domains was discussed and compared in discussions with the whole research group. The first and last authors were primarily responsible for this phase; they read the text related to the domains several times, one domain at a time. All authors discussed the relevance of the content in each domain and gave objective comments. Then, the domains from the Swedish data were used as a deductive lens for the Norwegian data to search for patterns, similarities, and differences. In the final step, reporting the results [18], the Swedish and Norwegian data were merged into one text, and an inductive approach was used on the material as a whole. The text was abstracted into nine subthemes and one overarching theme describing the content and relationship between themes, which were all interconnected, to describe the experiences, feelings, and actions of RNs and ANs to gain a broader understanding of the content. In the analysis we returned from the whole to the parts in the data, to check whether the interpretation was true to the data, and that the subthemes identified were validated by other interviews in the dataset. Pre-understanding To better understand the research and uncover new knowledge, the research group’s self-awareness was discussed and critically reflected upon throughout the research process. Most researchers were RNs and PhDs (one researcher was a psychologist) with different epistemological approaches. The majority had work experience in PC and were familiar with qualitative methods. An understanding of one’s self-awareness is essential to enable new perspectives on the phenomena studied. Ethical considerations Ethical considerations followed the Declaration of Helsinki [19], and the good research practices built into the research process of the Swedish Research Council [20]. In an interview, the researcher takes responsibility for the participant’s dignity by being sensitive and accepting of the participant’s feelings and reactions. This was considered when designing the interview guide by formulating the questions in such a way that they were not offensive. The participants could withdraw their participation at any time without consequences, and they could contact the project coordinator if they had questions about the study. Collected data were stored at one university and pseudo-anonymized following the European Union’s General Data Protection Regulation [21]. Results In the analysis, three domains described nurses’ positive and negative approaches to PC during the pandemic as well as the strategies they used. One overarching theme and nine subthemes were created from the domains (Figure). Each subtheme is illustrated with quotes from Swedish (S and nr) and Norwegian (N and nr) participants. Please insert the figure about here Overarching theme: Being a round square in an extremely challenging situation The overarching theme encompasses the nurse’s descriptions of their feelings of being a round square in an extremely challenging situation. Being a round square in the pandemic was a prerequisite for the character the PC provided, and it built on and interconnected with the three domains and nine subthemes. This approach gave the nurses a structure in daily PC when they experienced the pandemic as infinite, chaotic, and exhausting. Their inner attitude helped them to withstand difficulties, as they were determined to relieve the suffering of the patients and next-of-kin. The nurses struggled to be true to their profession and compliant with the patients’ wishes and needs. They constantly reflected on issues such as “How do we do this now?”, “How do we want it?”, and “Who should be there?”. It was a completely new emotional situation involving negative feelings, such as fear and involuntary distancing. The nurses needed to adapt in a very short time to the new situation, and the instructions and recommendations related to the pandemic could change very quickly. Domain 1 Providing modified PC Modified PC meant that the prerequisites and the PC approach changed in negative and positive ways during the pandemic. Nurses’ negative feelings when providing PC during the pandemic had a profound impact on them, and they had to process difficult emotions, such as sadness and fear. They mainly performed hands-on nursing interventions, such as caring for the patient’s body by relieving symptoms and adapting the care environment. Psychosocial and existential PC needs could not be prioritized. This meant that person-centered care had to take a backseat. The subthemes related to this domain are as follows: feelings of being inadequate or adequate, caring for a dying patient or a dead body, and supporting next-of-kin in saying goodbye from a distance. Subtheme: Feelings of being inadequate Nurses’ stress levels increased during the pandemic, and spontaneous nursing care was lost, along with presence. Routines were disrupted, and it became difficult for the nurses “to be their profession”; they felt insufficient when caring for many patients simultaneously who were equally seriously ill or dying. “Caring for patients at the end-of-life is the most important thing we do, an honor; there must be no mistakes” (S6). The nurses strived to provide the best possible person-centered nursing care, but their time was limited. Nursing care was medicalized and became instrumental. The nurses experienced an inability to provide human support and physical closeness, such as touch and hugs, because of the protective equipment. They wished they had time to talk more with the dying patients and to sit by their bed more often. “The patient’s overall care needs are more than you can cope with” (S1). “You’re there to help patients to live in a dignified manner, and when you feel that you haven't done that, it's…it's painful” (N20). The nurses sensed a pattern of not being able to provide care as usual as the virus spread rapidly. Subtheme: Caring for a dying or dead body When nurses were caring for severely ill and dying patients, the situation was sometimes chaotic because the pandemic and death occurred unusually fast. It was a race against the clock all the time. “ They were holding up really, really well, then they just crashed; then it was really bad ” (S3). It could take minutes or hours, and two to three patients died per shift, young and old. Sudden emergencies could occur; in these cases, the nurses reported that they quickly wrapped the patient in a special black body bag and cleaned the room, and then the next patients were placed in the room. Many patients died, and patients were constantly being cycled through the hospital, like an assembly line which was considered undignified. Patients with COVID-19 died in a much more unpleasant way than other patients. They typically had a lot of anxiety and pain, and it was more difficult to relieve symptoms. Patients commonly had respiratory problems that could deteriorate very quickly, and they needed a lot of oxygen, which did not always help. “ When the disease changes, you know that this is not going to work ” (S1). “It was a bit of a shock when we thought that now they’re getting a bit better, and then they suddenly [patients] got much worse again” (N10). The nurses could check on the patient in the morning and leave for 5 minutes, and when they returned, the patient could be dead. One nurse described that it was a relief when death came fast: “ It was nice, that it went quickly, that they didn’t have to lie there and suffer anymore ” (S3). At the beginning of the pandemic, many patients died completely alone; crowding was common, and the nurses constantly thought about where to place the patients. Many patients did not have their own room, and many were placed in other areas of the ward, such as the dining room. The nurses reflected on the idea that patients have the right to a peaceful and dignified death, but many patients suffered during the pandemic. “It was just patients who were really struggling at the end, with their breathing and everything, and we couldn’t do anything more; they were given morphine and midazolam and what they could get at the time, but…but it wasn’t a quiet death. And that was tough. I struggled a lot for a while afterwards” (N20). Situations like this were described as a huge failure, and they occurred several times a week during the pandemic. Subtheme: Supporting next-of-kin in saying goodbye at a distance Supporting next-of-kin during the pandemic was challenging, especially in the beginning when families could not visit the patient; they dealt with various barriers, such as visit restrictions and a lack of protective equipment throughout the pandemic. “ The restraining order was hard for a while ” (S1). To reduce physical contact, one main action was that next-of-kin had to communicate and say goodbye at a distance through digital equipment. If next-of-kin were unable to visit because of restrictions, digital equipment such as iPads, Zoom, or Facetime were used for communication between the patient and their family members. The nurses helped the patient hold the tablet or use other digital means. At the beginning of the pandemic, next-of-kin could not visit the patient at all, and later on, they had to call and book a visit in advance. Nurses described that this was emotionally difficult for the next-of-kin, and many were in shock and grief. One nurse reported that family members would attempt to visit their ill relatives even if they experienced difficulties: “Everything for their spouse who was inside. They called daily, maybe twice a day...yes...I didn’t expect this” (N1). Some next-of-kin had a different cultural background, and disagreements could arise regarding what constituted a dignified death. This could lead to conflicts between the family and the nurses as well as among nurses. Regardless, the relationship with next-of-kin was experienced as special and unique; it was important for the nurses to pay attention to them and thus reduce feelings of distance. “It may sound like a triviality, but I think it’s very important to show interest for the next-of-kin…that you can see those who are around the patient ” (N3). The nurses worked to support the next-of-kin and the patients in the last moment of life, and they strove to ensure that death was as dignified as possible. The nurses called the next-of-kin after working hours to update them about the patient’s condition. This was appreciated and meaningful and gave the next-of-kin a sense of control. When a patient’s condition worsened, the nurses brought the phone into the patient’s room so that the next-of-kin could talk with the patient if possible. The nurses described that it was important for the next-of-kin to talk to the ill person as often as possible. “Many next-of-kin want to be here as much as possible at the end, and then they forget their own needs a bit” (N3). Some next-of-kin could not or did not want to say goodbye in person when death was imminent, and some were afraid of becoming infected themselves. Some chose not to stand guard because it was too difficult. Another barrier that increased distance was protective equipment, which was an obstacle to communication. Many next-of-kin chose to wear protective equipment when the patient was dying or after they died. Despite this, the moment of death could be quite peaceful, as one nurse described: “ We had a woman who was a little older, around 70 perhaps, who became very ill, and then she died, and it felt so unnecessary and difficult, but her husband sat with her and held her hand when she died ” (S4). Domain 2 Challenges concerning contamination in daily work The nurses experienced fear of becoming infected during the pandemic, especially at the beginning of the pandemic, and they did not experience any positive aspects of the pandemic. They lived very isolated and private lives and were afraid of spreading the infection to the patients. They did not know much about COVID-19, and everyone was scared, living in uncertainty with a virus that changed all the time. The subthemes related to this domain are: protecting oneself while being afraid of infecting others, adapting procedures and constantly observing patients’ symptoms, and reflecting on nursing actions after work. Subtheme: Protecting oneself while being afraid of infecting others Nurses thought extensively about how long the pandemic would last and how it would develop. They continuously checked on the patients to ensure that they were not infected or spreading the virus to others, and the nurses were observant of various symptoms. If there was even the slightest suspicion of infection, the patient was isolated, and a few members of the staff cared for the ill person. Regardless, they cared for patients who they did not know were infected. “ There was one woman in particular; they took a test on Friday, and it turned out that she wasn’t infected. Then the staff cared for her over the weekend, and then she was positive [for COVID-19] on Monday, and everyone who had cared for her became very sick ” (S5). The nurses could not always protect themselves from being infected. Those who became infected worked despite symptoms such as taste and smell changes, and they also worked in different departments. This awoke feelings of guilt if they passed the infection to the patients. “We had a COVID-19 patient; I had connected the patient and showered her, then I became afraid that I had infected her, and this stayed with me for a very long time: ‘What if I have infected another patient?’” (S4). During the pandemic, the nurses faced a lot of hard work, but the most important thing was that patients and their relatives always felt safe and protected. “ All the time thinking ‘infection’; we do it all ” (S7). Subtheme: Adapting procedures and constantly observing patients’ symptoms New care routines were developed during the pandemic, and all patients were tested in the morning and evening to catch any infections. The nurses always had their eyes and ears open for the slightest sign of infection, such as a cold or a patient feeling tired; those with symptoms were isolated and not allowed to socialize with other patients. “ You're always…um...observant of a lot of things and thinking about routines in dining situations, sanitizing the tables, keeping distance, putting up notes, being clear, and those who became ill were isolated ” (S4). Using protective equipment provided a feeling of security, for the nurse’s own sake, for the patients, and their family. At the same time, the equipment prevented the nurses from being present and close to patients, even though they wanted to be. “ You couldn’t touch the patient, but I did anyway, you couldn’t go in to the patient as you wanted, and that the patients really needed ” (S5) “For me, it’s been very important to use closeness as part of the care. So, I think it’s been...I’ve had [a] bad conscience because I feel that I did a poorer job” (N3). Using protective equipment was also frustrating because it took extra time to get dressed, and at the same time, it was necessary to protect themselves and others. Subtheme: Reflecting on nursing actions after work The nurses tried to leave work at work and to disconnect and release themselves from thoughts on current events and difficulties during the day when they were at home. Despite this, the nurses reported that they reflected and thought about many things during their spare time to prevent infection and protect the patients from COVID-19 in the long run. Before the nurses left the unit and went home, some of them tried to reflect together and talk about the difficult situations that had occurred during the day. Nevertheless, many nurses could not disconnect themselves from work; they dreamed about it at night and continued to reflect on how the day had been. “ God, has everyone done the right thing, have we done what we should? ” (S2). They double-checked with themselves that nothing had been missed during the day and worried about the new care routines introduced. They also thought extensively about how the cooperation with other professionals had been during the day. Sometimes, the nurses felt that they did everyone’s job and that fundamental nursing care did not work. They would go to the patient’s room in the ward, and no one had changed any protection on the bed or helped the patient sit up better in bed. Some nurses did not want to visit patients who had a lot of anxiety, answer the phone, or respond to an alarm from these patients. “ I was nervous and stressed, I came out and they [other staff] were sitting on the sofa in the lunch room and chose not to answer the phone; I was very, very angry ” (S8). Registered nurses needed to perform check-ups or controls on patients by themselves. Some nurses reported that they supported each other, working as a team. “ We were a small, bonded group, not really having time to give it all; it was usually that care was very time-pressured ” (S8). Domain 3 Experiencing leadership during the pandemic The nurses experienced different types of leadership during the pandemic. They had to deal with the fact that rules and regulations changed frequently, sometimes daily. In the early phase of the pandemic, nurses reported that the leaders focused on rules and regulations rather than attentive leadership. How the leaders communicated the changes differed, and nurses described that the leadership changed over time. Some leaders were creative and understanding, and they co-operated with the nurses throughout the pandemic. The subthemes related to this domain were as follows: lacking solution-oriented and attentive leadership; awareness of lack of competence in PC; and being guided by caring, active, and creative leaders. Subtheme: Lack of solution-oriented and attentive leadership The pandemic caused major challenges for the organization in that the leaders were not prepared to deal with, for example, the daily testing of patients and staff. “We had to test staff and patients, so a lot of my working hours were spent on that...testing every day” (N18). The leaders and staff had to deal with new recommendations and instructions before each shift, and especially in the “first wave”, the nurses found that the leaders were stressed and did not have time to inform them about what was going on. The nurses wished that the leaders had communicated the situation to them; they explained that the leaders faced a chaotic situation in solving acute problems, and although they were absent from the ward, they were available for talks. ‘One nurse reported that leaders would make statements such as:’ “Now we need to withdraw a bit now because it’s too rocky at the hospital, but we’re here, come to us if there’s anything” (S1). The interpretation of routines and guidelines and arbitrary interpretations of recommendations from the leaders differed and caused tension among the nurses. “There were a lot of abrupt swings back and forth…‘Now we do this and now we do that’…new directives every time; the Public Health Agency of Sweden also fumbled” (S5). Leaders were busy organizing care by relocating and recruiting staff, and they did not understand that the working environment was negatively affected or that the nurses did not support the type of care they provided during the pandemic. Nurses are used to relieving patients’ suffering, providing support, and being present; during the pandemic, the focus was on other things, and the care was not dignified. The nurses did their best and put their rights aside, and they did everything to do a good job and make a difference. However, one nurse reported: “ The personal sacrifices happened often, such as not [having] the ability to eat one’s meals, get breaks and toilet visits; it did not feel okay” (S6). As the pandemic continued, new challenges arose. The nurses had to work double shifts and schedule changes at short notice, and information was provided through text messages and phone calls. The leaders could not protect the nurses’ free time, and the very tired nurses eventually made mistakes, not because they were incompetent but because the organization had major shortcomings. The nurses gave examples of illness among colleagues, like post-traumatic stress disorder (PTSD) symptoms, physical reactions, increased heart rate, and signs of panic in the eyes. The nurses expressed the need for professional support after the pandemic: “There are many staff members who need counseling after the pandemic! ” (S1). The nurses believed that a well-functioning organization and leadership would have caught the symptoms and offered debriefing. In addition, it would not have transferred a heavy responsibility to the employees, giving them a bad conscience and making them feel inadequate. The nurses expressed that the leaders should have cared more about them—more than just giving them sweets now and then. Subtheme: Awareness of lack of competence in PC Nurses from other units and different specialties worked together during the pandemic because of relocation; not everybody knew each other, and nurses without knowledge and important experience in PC had to care for patients at the end-of-life. All the benefits of working as a team, which characterize PC, disappeared. “ You did the most important thing, then the other things had to be because of shortage of staff” (N19) Active treatment and curative intent were given until the patient died, and palliative symptom control was not carried out even though the nurses described that they “ had to work right up to the end” (S6). None of the professionals asked: “ What can we do, what should we do? ” (S7) The nurses faced difficulty in deciding on the point at which curative care should change to PC. The nurses expressed their gratitude for excellence in different areas of medicine and asked for support in the field of PC. One nurse reflected: “ There are fantastic doctors; there are infection rounds, X-ray rounds; why can’t we have palliative care rounds?” (S8) The shortage of specialists in palliative medicine led to a situation in which nurses with specialization in PC had the highest level of competence, something the local management did not understand or take seriously. The nurses felt that the management did not listen to them; they became sad and stressed when they could not perform person-centered PC, such as carrying out prescribed ordinations, including taking blood samples, inserting needles, or giving antibiotics to dying patients. They tried to follow the doctors’ orders, but they quickly told the doctors that it was not possible, as the patients did not want to accept the treatments. At the beginning of the pandemic, the nurses did not know how to handle such situations, but this improved with time. Subtheme: Being guided by active, creative, and understanding leaders The nurses described that creative and understanding leaders of a unit listen to the nurses, showing care and support when needed. The nurses’ abilities, responsiveness, and cooperation with colleagues to inform and develop routines and guidelines made the team intertwined. They reported that relying on leaders was the only way to cope with the daily changes in roles and regulations. “I have to relate to what my leader is saying. Today it is true” (N1). The nurses appreciated when leaders acted and supported them immediately when needed, such as when the leaders took responsibility, added extra staff when the workload increased, and provided clear information to the staff. This made the nurses feel that it was an educational period in their working life. The nurses reported that a sense of security was important in a group of many nurses. Some leaders organized whiteboards for the staff to write questions about things that were important during the pandemic, such as “ what material we need, what we wanted to change, visors, face masks, aprons, gloves on trolleys outside the room” (S3). The nurses reported that the leaders took them seriously in that they kept them informed. Many nurses reported being kept informed by leaders, and they gave various examples of leaders’ activities, such as digital meetings in teams and the frequent use of e-mail and group meetings to plan and inform. They received constructive feedback from the leaders, and this provided a sense of security even when it only was a quick fix. Leaders and nurses who cooperated during the pandemic created better routines and were aware that not everything could be solved; they also wanted to retain some of the advantageous routines that the pandemic produced. “When it was stricter, everything was quieter in the ward. For us too, we had it... there wasn’t so much to do at once. It was actually quite good, we all thought so, our head of the ward wants us to continue with visiting hours after the pandemic so that we have fixed visiting hours for next-of-kin morning and evening, so we have them then, and we can answer all questions and such, instead of all day and night, because we were interrupted so much in the things we were doing. So, it’s something we really want to continue with” (N4). Active leaders acknowledged absent nurses. One of the nurses described that the leader saw her even when she became ill. The nurse said: “my leader called me at home and asked how I was doing” (S3). Another nurse said that her leader contacted her before she went back to work. Other leaders also facilitated contact with occupational health services or psychological support. Discussion This study aimed to explore the experiences of RNs and ANs in Sweden and Norway in performing PC for seriously ill and dying patients during the COVID-19 pandemic. The domains and subthemes and the overarching theme highlight how complex and challenging it was to provide PC during the pandemic and how it affected the nurses. The overarching theme of “being a round square in an extremely challenging situation” describes how the nurses struggled to provide supportive and compassionate care to maintain patients’ dignity in situations of immense suffering. The theme also describes how the nurses strove to give structure to daily PC, providing modified PC during a seemingly endless pandemic. This was surprising, but it also emphasizes the central role that PC played within their profession and the importance of maintaining palliative, person-centered nursing care during a health crisis. The pandemic was an extraordinary traumatic event and represented an unfamiliar situation. This can be compared to a natural disaster; in other words, it was a stressful, uncertain, and traumatic experience [ 22 ]. Our paper presents positive and negative aspects and strategies in the following domains: providing modified PC (domain 1), challenges concerning contamination in daily work (domain 2), and experiencing leadership during the pandemic (domain 3). The domains and subthemes are discussed below. In domain 1, we found that the pandemic had a large emotional impact on the nurses’ daily work and their private lives. The nurses had to modify PC to prioritize hands-on nursing interventions to relieve symptoms such as pain and breathlessness and to organize the care according to the 2021 recommendations of the Public Health Authority in Sweden and the Norwegian Institute of Public Health [ 23 , 24 ]. The holistic approach of PC addresses physical, psychological, social, and existential suffering and well-being. During the pandemic, patients; psychosocial and existential PC needs were not priorities, and therefore, person-centered care took a backseat. Not being able to provide adequate care led to moral and ethical stress and contributed to poor health and burnout among staff. According to Lovell et al., the knowledge of the symptom burden and the impact of treatment on the PC needs of patients with COVID-19 were scarce during the pandemic [ 25 ]. This could cause healthcare professionals to feel powerless. A more active approach to identifying, assessing, and managing patients’ symptoms and their illness progress could be more supportive [ 26 ]. Communication is vital in PC, and Mohan et al. [ 27 ] highlighted that communication is fundamental to human interaction. Compassionate communication with patients and next-of-kin is an important part of the assessment of their expectations, goals, and values [ 28 ]. Dewar and Cook [ 29 ] described compassion, including empathy, love, and kindness, as pivotal in nursing. The nurses in our study could not meet the patients’ needs to talk about emotional fears or existential concerns such as anxiety because of protective equipment, limited recourses, the high number of acutely ill and dying patients, and lack of time. It was a completely new situation, and the nurses’ typical toolbox for PC did not fit in during the pandemic, as described by Sandsdalen et al. [ 30 ]. According to Kang et al., most healthcare professionals do not feel comfortable if they are unable to identify, clarify, predict, and control illness [ 31 ]. According to the nurses in our study, the modified PC approach also focused on how the dead body was cared for. During the pandemic, the body was wrapped in a black body bag to reduce the risk of the leakage of body fluids from body cavities [ 23 , 24 ]. This may have endangered the dignity of patients and next-of-kin because maintaining the dignity of the dead body is of utmost importance to healthcare professionals when disposing of the deceased. Kinnear et al. [ 32 ] found that the meaning of dignified care is multifaceted and a foundation of care. The nurses in our study supported the next-of-kin in saying goodbye to ill and dying patients from a distance through technology, such as iPads or telephones. According to Wakam et al. [ 33 ], using digital support may be a solution for staff to substitute the physical presence of next-of-kin, even if it is not always considered acceptable. Healthcare professionals must consider that the family may be unable to prepare for unexpected death because of inadequate social support and the inability to follow traditional rituals related to death. Wallace et al. reported that next-of-kin are at risk for complicated grief and PTSD [ 34 ]. Supporting next-of-kin before and after the death of a patient can positively influence bereavement outcomes. According to Lovell et al. [ 25 ] and Xiong et al. [ 2 ], PC is an important part of the COVID-19 response and the management of symptoms. In domain 2, we found that the nurses did not describe any positive experiences of the pandemic. They lived in fear of spreading the virus to patients and their own families, and they strove to find new pathways of providing care as the COVID-19 virus escalated nationally and globally. They constantly struggled to relieve symptoms and alleviate patients’ suffering [ 35 ]. They became distressed not only because they were experiencing a pandemic but also because they could not be physically close to the patients. They could not be present or available to the patient, which made them sad or miserable. Some nurses touched the patients without gloves even if they were aware of the risks. In this way, they chose to engage with suffering patients and did not turn away, a type of existential nursing action described by Arman [ 36 ]. It is not unusual during a pandemic for professionals to experience high-stress situations followed by psychological responses. According to Young et al., depression and anxiety are common, along with feelings of impatience and frustration [ 37 ]. Hillestad et al. [ 38 ] reported that nurses in nursing homes felt that the nursing home became a prison during the pandemic. The doors had to be locked, and restrictions prevented older persons and their families from coming and going as they wished. Furthermore, RNs are nearly twice as likely to report high stress of conscience compared with other staff in long-term care [ 39 ]. In our study, the nurses aimed to give priority to patients, next-of-kin, and their colleagues, sometimes neglecting their own needs. This meant that their quality of life was threatened, as they were more exposed to developing psychological stress during the pandemic. The nurses were not prepared to care for patients in a health crisis such as the COVID-19 pandemic. They primarily prioritized the goal of patient care, but the pandemic also demanded other PC priorities from both practical and ethical perspectives. After work, the nurses reflected on and summarized the care provided during the day. This is an approach that demands awareness of one’s perceptions, ethics, and practice. This allowed the nurses to learn from experiences, integrating that knowledge into improving PC when caring for patients during the pandemic. This is a type of reflection on action, as described by Patel and Metersky [ 40 ]. In domain 3, we found that the nurses experienced both positive and negative leadership during the pandemic. They often lacked attention from the leaders, solution-oriented leadership, and guidance from active leaders. The lack of attention from leaders may have prevented the detection of severe symptoms, such as post-traumatic stress in healthcare professionals, according to Di Tella et al. [ 41 ]. The nurses in our study made personal sacrifices and were physically and mentally exhausted when caring for patients with COVID-19. The nurses requested attentive and creative leaders during the pandemic who prioritized PC, cared about nurses, and provided attention. The nurses were very strained, and work stress, care burdens, and time constraints may be barriers that prevent nurses from engaging in self-compassion and self-care [ 42 ]. Being guided by management that was uncertain of how to deliver necessary materials, such as visors and mouthguards, left the nurses with feelings of loneliness. Even though the nurses experienced varying leadership during the pandemic, managers, nurses, and physicians contributed to important learning and increased knowledge related to the pandemic, including knowledge related to the practice of good hygiene, infection control, and digital communication [ 15 , 16 ]. In future pandemics, every effort must be made to avoid more catastrophic outcomes by building supportive work environments for healthcare professionals’ empowerment in all healthcare contexts to limit many of the harmful secondary effects of the pandemic [ 6 ]. Methodological considerations In the present study, we considered Elo et al.’s [ 43 ] checklist of trustworthiness to improve quality and transparency during the three phases: the preparation phase, the organization phase, and the reporting phase. The research team also had regular check-ins to keep track of their pre-understanding during the different phases. A strength of this study was that the nurses were interviewed by experienced clinicians and researchers in the field of PC. The participants were also confident during the interview and could express their experiences, paving the way for rich data. In the organization phase and the analysis of data, the richness of data on the subject and the shift between deductive and inductive qualitative content analysis were strengths. In this phase, domains were predetermined, developed, and combined with the overarching theme and subthemes. In the reporting phase, quotations were used systematically and demonstrating the entire process from data collection to reporting the results. The overarching theme and subthemes described the meaning of the content, reflected the subject of the study, and covered the data consistently. This study also had several limitations. First, all authors translated the interviews, either from Norwegian to Swedish or vice versa, which means that some words could have been misunderstood, and this may have influenced the results. The data may have been organized and analyzed subjectively, influenced by the researchers’ interpretation and bias. To prevent and clarify any misunderstandings, the researchers discussed and reflected on these together. A strength is that the different phases were discussed in the research group, and the results and quotes were read from both a Swedish and Norwegian perspective. Conclusion and clinical implications This qualitative study is a part of a larger multicenter project, “Palliative Quality Care COVID-19 (PaQC-C19)”. The results of this study suggest that the prerequisites and PC approach among nurses change during a pandemic; they felt inadequate and insecure, and they struggled very hard in a seemingly never-ending pandemic. Spontaneous nursing care was lost, and they had to modify the PC approach and their presence. Death usually came fast, and next-of-kin had to say goodbye from a distance; furthermore, the care for dead bodies was undignified. We identified a potential challenge that requires attention: managers in different care organizations should work closely with healthcare professionals during a crisis such as the COVID-19 pandemic. The results of this study can be used as a basis for reflection in collaborative learning interventions within PC and as a guide for teachers in educational PC programs. Future research should explore how RNs and ANs cope with their experiences of “being a round square” that they bear in mind after COVID-19 to learn how to prepare RNs and ANs for a potential new crisis, such as a pandemic or war. Declarations Consent for publication Not applicable. Availability of data and materials The qualitative data generated and/or analyzed in the current study are available upon reasonable request from the corresponding author but are not publicly available because of privacy or ethical restrictions. Conflict of interest None. Funding Both the larger project—Palliative Quality Care COVID-19 (PaQC-C19)—and this study were supported by a generous grant from the AFA Försäkring (grant no. DNR 200393) and the Norwegian Regional Foundation (grant no. 32174). The funding body had no role in the design of the study, data collection, analysis, or interpretation. Open access funding and language review were provided by Mid Sweden University. Authors’ contributions All the authors (CMJ, CO, ML, MT, MDG, VAG, AKH, TS, CB, RH, and JÖ) made substantial contributions to the study in all steps of the research process (design and methods, data collection, and analysis) and were involved in critically revising the manuscript. All authors developed the interview guide together. CMJ and JÖ wrote the draft, and all authors provided important intellectual content, constructive comments, and revisions in the development of the manuscript and gave final approval of the version to submit. Ethical considerations This study was conducted in the two Nordic countries—Sweden and Norway—and approval was thus obtained by The Swedish Ethical Review Authority (DNR 356 2021/01623) and the Norwegian Centre for Research Data (NSD) (reference numbers: 838156 and 634351). The study was conducted according to the principles of ethical research in the Helsinki Declaration [19]. Collected data were stored at one university and anonymized in accordance with the European Union’s General Data Protection Regulation [21]. All participants gave their written informed consent before joining the study, and participants were given the option to withdraw their consent to participate at any time. 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Health Care Workers’ Mental Health and Quality of Life During COVID-19: Results From a Mid-Pandemic, National Survey. Psychiatr Serv, 2021; 172(2): 122–128. https://doi:10.1176/appi.ps.202000424 Hillestad AH, Rokstad AMM, Tretteteig S, Julnes SG, Lichtwarck B, Eriksen S. Nurses’ ethical challenges when providing care in nursing homes during the COVID-19 pandemic. Nurs Ethics, 2023; 30(1): 32–45. https://doi:10.1177/09697330221105631 Munkeby H, Bratberg G, Devik SA. Registered nurses’ exposure to high stress of conscience in long-term care. Nurse Ethics, 2023; 30(7–8): 1011–1024. https://doi:10.1177/09697330231167542 Patel KM, Metersky K. Reflective practice in nursing: A concept analysis. Int J Nurs Knowl, 2022; 33(3): 180–187. https://doi.org/10.1111/2047-3095.12350 Di Tella M, Romeo A, Benfante A, Castelli L. Mental health of healthcare workers during the COVID-19 pandemic in Italy. J Eval Clin Pract, 2020; 26(6): 1583–1587. https://doi:10.1111/jep.13444 Chadwick R, Lown B. What do we need to do to sustain compassionate medical care? Medicine, 2016; 44(10): 583–585. https://doi.org/10.1016/j.mpmed.2016.07.003 Elo S, Kääriäinen M, Kanste O, Pölkki T, Utriainen K, Kyngäs H. Qualitative content analysis: A focus on trustworthiness. SAGE Open, 2014; 4(1): 21. https://doi.org/10.1177/215824401452263 Additional Declarations No competing interests reported. Supplementary Files SupplemantarymaterialInterviewguide.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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qualitative study","fulltext":[{"header":"Background","content":"\u003cp\u003eDuring the COVID-19 pandemic, palliative care (PC) played an important role in supporting patients who were severely ill or dying wherever they were cared for [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], and multiple symptoms, such as respiratory problems, were the most frequent [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The PC approach aims to improve the well-being of patients and next-of-kin facing problems related to severe illness [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and it involves all dimensions of life, including communication; symptom management; social, existential, and psychological needs; and end-of-life care [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The pandemic highlighted the importance of healthcare systems that delivered high-quality PC [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Many professionals in all healthcare contexts faced immense pressure due to a lack of pandemic preparedness and practical and emotional challenges, along with an increase in the number of dying patients. A scoping review stated that the pandemic was stressful and had a tremendous impact on healthcare professionals\u0026rsquo; mental and physical health and well-being [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe pandemic placed a burden on global health systems, and worldwide, over 2.1\u0026nbsp;million COVID-19 deaths occurred in 2021 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. An increasing number of deaths occurred in the long-term care sector; the lack of pandemic preparedness and human resource issues, and shortages of personal protective equipment and medicines limited care [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Visiting restrictions had negative consequences for the health and well-being of patients and next-of-kin, and they led to ethical dilemmas for healthcare professionals [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Nurses found it challenging to provide PC during the pandemic, especially care related to information and continuity [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], and they experienced a reduced quality of sleep [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Spring 2020, several Western European countries, including Norway (but not Sweden), entered a total lockdown to prevent the spread of infection and protect vulnerable groups, including older adults [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The total lockdown in Norway led to fewer deaths than normal among older adults at home and in nursing homes. Thus, the lockdown affected thousands of next-of-kin of patients at the end-of-life [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. While other countries closed, Sweden did not. To reduce the spread of COVID-19, the Public Health Agency in Sweden recommended that healthcare staff apply physical distancing as much as possible, wear face masks, keep rooms ventilated, and practice good hand and respiratory hygiene [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Globally, a heavy responsibility was placed on nurses who were crucial in ensuring that persons approaching the end-of-life were supported during the pandemic[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. A shift of resources also occurred between units, especially in long-term care. Units with outbreaks were prioritized to have better staffing levels and more nurses, with closer collaboration among staff. The pandemic also contributed to important learning and increased knowledge, not least related to practicing good hygiene, infection control, and digital communication [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe COVID-19 pandemic emphasized the importance of a healthcare system that delivers high-quality PC across all healthcare contexts in a time of extreme challenges. During the pandemic, healthcare professionals confronted enormous pressure because of a lack of pandemic readiness. They encountered both practical and emotional challenges due to the increase in the number of dying patients as well as insufficient resources to provide PC. Hence, to support equitable high-quality PC to dying people in future crises, such as pandemics, it is important to learn from the nurses who were on the front lines during the pandemic.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eTo explore nurses\u0026rsquo; experiences of performing end-of-life care in general and specialized PC settings to patients during the COVID-19 pandemic.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec4\"\u003e\n \u003ch2\u003eDesign\u003c/h2\u003e\n \u003cp\u003eThis was a qualitative study involving nursing staff within the multicenter Swedish–Norwegian Palliative Quality Care COVID-19 (PaQC-C19) project. Data were collected through individual interviews in general and specialist PC. A stepwise deductive and inductive approach was utilized, including the stages of preparation, organization, and reporting of results, as described by Elo and Kyngäs [18].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\"\u003e\n \u003ch2\u003eParticipants\u003c/h2\u003e\n \u003cp\u003eRegistered nurses (RNs, n = 15) and assistant nurses (ANs, n = 5) in general PC (hospital and nursing homes) and specialized PC (the advanced PC team) were purposively sampled. The participants lived in urban and rural areas in Sweden (n = 10) and Norway (n = 10). All were women (N = 20), most had a partner and worked full-time, and had permanent employment. The inclusion criteria were employment in health and community care, experience in PC, and employment during the COVID-19 pandemic. The nurses did not need to have experience in caring for patients with COVID-19 infection (Table).\u003c/p\u003e\n \u003cp\u003ePlease insert the table about here\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable\u003c/strong\u003e Demographic information of nurses in Sweden and Norway in palliative care during the COVID-pandemic\u003c/p\u003e\n \u003cp\u003e\u003cimg 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\"\u003e\u003cbr\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\"\u003e\n \u003ch2\u003eData collection\u003c/h2\u003e\n \u003cp\u003eIn the preparation stage, data were collected across different care contexts through individual qualitative interviews via secure digital audio and video recording [18]. The interview questions were related to participants’ experiences of performing PC and the treatment of patients with and without COVID-19, along with the experiences of the health and well-being of the RNs and ANs. A semi-structured interview guide was developed for this study (see Supplementary Material), which asked the participants what they thought was important for person-centered PC at the end-of-life, what the care was like, and what it was like for the nurses to care for the severely ill and dying during the COVID-19 pandemic. The opening question was “What is your experience in performing PC during the COVID-19 pandemic?” Nurses who provided written informed consent to participate were contacted to arrange a time and place for the interview. In Sweden, the interviews were conducted in secure rooms in Zoom, and in Norway, they were conducted through an electronic application. The interviews were conducted by a researcher involved in the project and were audio-recorded. They lasted between 20 and 60 minutes and were transcribed by a professional writing agency.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\"\u003e\n \u003ch2\u003eData analysis\u003c/h2\u003e\n \u003cp\u003eIn the organization step, both deductive and inductive approaches were used [18]. In this phase, data were analyzed inductively, and open coding was utilized by reading and reflecting on the content in the Swedish interviews. Reflections describing different areas were written down, for example, “creative thinking in relation to relatives and patients”, “doing all we can and fighting”, “modified nursing care”, “the good death and death comes quickly”, and “inconstant leadership”. These areas guided the interview analysis, supporting the organization of the text into three domains. The content of the domains was discussed and compared in discussions with the whole research group. The first and last authors were primarily responsible for this phase; they read the text related to the domains several times, one domain at a time. All authors discussed the relevance of the content in each domain and gave objective comments. Then, the domains from the Swedish data were used as a deductive lens for the Norwegian data to search for patterns, similarities, and differences.\u003c/p\u003e\n \u003cp\u003eIn the final step, reporting the results [18], the Swedish and Norwegian data were merged into one text, and an inductive approach was used on the material as a whole. The text was abstracted into nine subthemes and one overarching theme describing the content and relationship between themes, which were all interconnected, to describe the experiences, feelings, and actions of RNs and ANs to gain a broader understanding of the content. In the analysis we returned from the whole to the parts in the data, to check whether the interpretation was true to the data, and that the subthemes identified were validated by other interviews in the dataset.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\"\u003e\n \u003ch2\u003ePre-understanding\u003c/h2\u003e\n \u003cp\u003eTo better understand the research and uncover new knowledge, the research group’s self-awareness was discussed and critically reflected upon throughout the research process. Most researchers were RNs and PhDs (one researcher was a psychologist) with different epistemological approaches. The majority had work experience in PC and were familiar with qualitative methods. An understanding of one’s self-awareness is essential to enable new perspectives on the phenomena studied.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\"\u003e\n \u003ch2\u003eEthical considerations\u003c/h2\u003e\n \u003cp\u003eEthical considerations followed the Declaration of Helsinki [19], and the good research practices built into the research process of the Swedish Research Council [20]. In an interview, the researcher takes responsibility for the participant’s dignity by being sensitive and accepting of the participant’s feelings and reactions. This was considered when designing the interview guide by formulating the questions in such a way that they were not offensive. The participants could withdraw their participation at any time without consequences, and they could contact the project coordinator if they had questions about the study. Collected data were stored at one university and pseudo-anonymized following the European Union’s General Data Protection Regulation [21].\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn the analysis, three domains described nurses\u0026rsquo; positive and negative approaches to PC during the pandemic as well as the strategies they used. One overarching theme and nine subthemes were created from the domains (Figure). Each subtheme is illustrated with quotes from Swedish (S and nr) and Norwegian (N and nr) participants.\u003c/p\u003e \u003cp\u003ePlease insert the figure about here\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eOverarching theme: Being a round square in an extremely challenging situation\u003c/h2\u003e \u003cp\u003eThe overarching theme encompasses the nurse\u0026rsquo;s descriptions of their feelings of being a round square in an extremely challenging situation. Being a round square in the pandemic was a prerequisite for the character the PC provided, and it built on and interconnected with the three domains and nine subthemes. This approach gave the nurses a structure in daily PC when they experienced the pandemic as infinite, chaotic, and exhausting. Their inner attitude helped them to withstand difficulties, as they were determined to relieve the suffering of the patients and next-of-kin. The nurses struggled to be true to their profession and compliant with the patients\u0026rsquo; wishes and needs. They constantly reflected on issues such as \u0026ldquo;How do we do this now?\u0026rdquo;, \u0026ldquo;How do we want it?\u0026rdquo;, and \u0026ldquo;Who should be there?\u0026rdquo;. It was a completely new emotional situation involving negative feelings, such as fear and involuntary distancing. The nurses needed to adapt in a very short time to the new situation, and the instructions and recommendations related to the pandemic could change very quickly.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eDomain 1\u003c/h2\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003eProviding modified PC\u003c/h2\u003e \u003cp\u003eModified PC meant that the prerequisites and the PC approach changed in negative and positive ways during the pandemic. Nurses\u0026rsquo; negative feelings when providing PC during the pandemic had a profound impact on them, and they had to process difficult emotions, such as sadness and fear. They mainly performed hands-on nursing interventions, such as caring for the patient\u0026rsquo;s body by relieving symptoms and adapting the care environment. Psychosocial and existential PC needs could not be prioritized. This meant that person-centered care had to take a backseat. The subthemes related to this domain are as follows: feelings of being inadequate or adequate, caring for a dying patient or a dead body, and supporting next-of-kin in saying goodbye from a distance.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme: Feelings of being inadequate\u003c/h2\u003e \u003cp\u003eNurses\u0026rsquo; stress levels increased during the pandemic, and spontaneous nursing care was lost, along with presence. Routines were disrupted, and it became difficult for the nurses \u0026ldquo;to be their profession\u0026rdquo;; they felt insufficient when caring for many patients simultaneously who were equally seriously ill or dying.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Caring for patients at the end-of-life is the most important thing we do, an honor; there must be no mistakes\u0026rdquo;\u003c/em\u003e (S6).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe nurses strived to provide the best possible person-centered nursing care, but their time was limited. Nursing care was medicalized and became instrumental. The nurses experienced an inability to provide human support and physical closeness, such as touch and hugs, because of the protective equipment. They wished they had time to talk more with the dying patients and to sit by their bed more often.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;The patient\u0026rsquo;s overall care needs are more than you can cope with\u0026rdquo;\u003c/em\u003e (S1).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;You\u0026rsquo;re there to help patients to live in a dignified manner, and when you feel that you haven't done that, it's\u0026hellip;it's painful\u0026rdquo;\u003c/em\u003e (N20).\u003c/p\u003e \u003cp\u003eThe nurses sensed a pattern of not being able to provide care as usual as the virus spread rapidly.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme: Caring for a dying or dead body\u003c/h2\u003e \u003cp\u003eWhen nurses were caring for severely ill and dying patients, the situation was sometimes chaotic because the pandemic and death occurred unusually fast. It was a race against the clock all the time.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThey were holding up really, really well, then they just crashed; then it was really bad\u003c/em\u003e\u0026rdquo; (S3).\u003c/p\u003e \u003cp\u003eIt could take minutes or hours, and two to three patients died per shift, young and old. Sudden emergencies could occur; in these cases, the nurses reported that they quickly wrapped the patient in a special black body bag and cleaned the room, and then the next patients were placed in the room. Many patients died, and patients were constantly being cycled through the hospital, like an assembly line which was considered undignified.\u003c/p\u003e \u003cp\u003ePatients with COVID-19 died in a much more unpleasant way than other patients. They typically had a lot of anxiety and pain, and it was more difficult to relieve symptoms. Patients commonly had respiratory problems that could deteriorate very quickly, and they needed a lot of oxygen, which did not always help.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWhen the disease changes, you know that this is not going to work\u003c/em\u003e\u0026rdquo; (S1).\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It was a bit of a shock when we thought that now they\u0026rsquo;re getting a bit better, and then they suddenly [patients] got much worse again\u0026rdquo;\u003c/em\u003e (N10).\u003c/p\u003e \u003cp\u003eThe nurses could check on the patient in the morning and leave for 5 minutes, and when they returned, the patient could be dead. One nurse described that it was a relief when death came fast:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eIt was nice, that it went quickly, that they didn\u0026rsquo;t have to lie there and suffer anymore\u003c/em\u003e\u0026rdquo; (S3).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAt the beginning of the pandemic, many patients died completely alone; crowding was common, and the nurses constantly thought about where to place the patients. Many patients did not have their own room, and many were placed in other areas of the ward, such as the dining room. The nurses reflected on the idea that patients have the right to a peaceful and dignified death, but many patients suffered during the pandemic.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It was just patients who were really struggling at the end, with their breathing and everything, and we couldn\u0026rsquo;t do anything more; they were given morphine and midazolam and what they could get at the time, but\u0026hellip;but it wasn\u0026rsquo;t a quiet death. And that was tough. I struggled a lot for a while afterwards\u0026rdquo;\u003c/em\u003e (N20).\u003c/p\u003e \u003cp\u003eSituations like this were described as a huge failure, and they occurred several times a week during the pandemic.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme: Supporting next-of-kin in saying goodbye at a distance\u003c/h2\u003e \u003cp\u003eSupporting next-of-kin during the pandemic was challenging, especially in the beginning when families could not visit the patient; they dealt with various barriers, such as visit restrictions and a lack of protective equipment throughout the pandemic.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThe restraining order was hard for a while\u003c/em\u003e\u0026rdquo; (S1).\u003c/p\u003e \u003cp\u003eTo reduce physical contact, one main action was that next-of-kin had to communicate and say goodbye at a distance through digital equipment. If next-of-kin were unable to visit because of restrictions, digital equipment such as iPads, Zoom, or Facetime were used for communication between the patient and their family members. The nurses helped the patient hold the tablet or use other digital means. At the beginning of the pandemic, next-of-kin could not visit the patient at all, and later on, they had to call and book a visit in advance. Nurses described that this was emotionally difficult for the next-of-kin, and many were in shock and grief. One nurse reported that family members would attempt to visit their ill relatives even if they experienced difficulties:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Everything for their spouse who was inside. They called daily, maybe twice a day...yes...I didn\u0026rsquo;t expect this\u0026rdquo;\u003c/em\u003e (N1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome next-of-kin had a different cultural background, and disagreements could arise regarding what constituted a dignified death. This could lead to conflicts between the family and the nurses as well as among nurses. Regardless, the relationship with next-of-kin was experienced as special and unique; it was important for the nurses to pay attention to them and thus reduce feelings of distance.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It may sound like a triviality, but I think it\u0026rsquo;s very important to show interest for the next-of-kin\u0026hellip;that you can see those who are around the patient\u003c/em\u003e\u0026rdquo; (N3).\u003c/p\u003e \u003cp\u003eThe nurses worked to support the next-of-kin and the patients in the last moment of life, and they strove to ensure that death was as dignified as possible. The nurses called the next-of-kin after working hours to update them about the patient\u0026rsquo;s condition. This was appreciated and meaningful and gave the next-of-kin a sense of control. When a patient\u0026rsquo;s condition worsened, the nurses brought the phone into the patient\u0026rsquo;s room so that the next-of-kin could talk with the patient if possible. The nurses described that it was important for the next-of-kin to talk to the ill person as often as possible.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;Many next-of-kin want to be here as much as possible at the end, and then they forget their own needs a bit\u0026rdquo;\u003c/em\u003e (N3).\u003c/p\u003e \u003cp\u003eSome next-of-kin could not or did not want to say goodbye in person when death was imminent, and some were afraid of becoming infected themselves. Some chose not to stand guard because it was too difficult. Another barrier that increased distance was protective equipment, which was an obstacle to communication. Many next-of-kin chose to wear protective equipment when the patient was dying or after they died. Despite this, the moment of death could be quite peaceful, as one nurse described:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWe had a woman who was a little older, around 70 perhaps, who became very ill, and then she died, and it felt so unnecessary and difficult, but her husband sat with her and held her hand when she died\u003c/em\u003e\u0026rdquo; (S4).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDomain 2\u003c/h2\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003eChallenges concerning contamination in daily work\u003c/h2\u003e \u003cp\u003eThe nurses experienced fear of becoming infected during the pandemic, especially at the beginning of the pandemic, and they did not experience any positive aspects of the pandemic. They lived very isolated and private lives and were afraid of spreading the infection to the patients. They did not know much about COVID-19, and everyone was scared, living in uncertainty with a virus that changed all the time. The subthemes related to this domain are: protecting oneself while being afraid of infecting others, adapting procedures and constantly observing patients\u0026rsquo; symptoms, and reflecting on nursing actions after work.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme: Protecting oneself while being afraid of infecting others\u003c/h2\u003e \u003cp\u003eNurses thought extensively about how long the pandemic would last and how it would develop. They continuously checked on the patients to ensure that they were not infected or spreading the virus to others, and the nurses were observant of various symptoms. If there was even the slightest suspicion of infection, the patient was isolated, and a few members of the staff cared for the ill person. Regardless, they cared for patients who they did not know were infected.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThere was one woman in particular; they took a test on Friday, and it turned out that she wasn\u0026rsquo;t infected. Then the staff cared for her over the weekend, and then she was positive [for COVID-19] on Monday, and everyone who had cared for her became very sick\u003c/em\u003e\u0026rdquo; (S5).\u003c/p\u003e \u003cp\u003eThe nurses could not always protect themselves from being infected. Those who became infected worked despite symptoms such as taste and smell changes, and they also worked in different departments. This awoke feelings of guilt if they passed the infection to the patients.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We had a COVID-19 patient; I had connected the patient and showered her, then I became afraid that I had infected her, and this stayed with me for a very long time: \u0026lsquo;What if I have infected another patient?\u0026rsquo;\u0026rdquo;\u003c/em\u003e (S4).\u003c/p\u003e \u003cp\u003eDuring the pandemic, the nurses faced a lot of hard work, but the most important thing was that patients and their relatives always felt safe and protected.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eAll the time thinking \u0026lsquo;infection\u0026rsquo;; we do it all\u003c/em\u003e\u0026rdquo; (S7).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme: Adapting procedures and constantly observing patients\u0026rsquo; symptoms\u003c/h2\u003e \u003cp\u003eNew care routines were developed during the pandemic, and all patients were tested in the morning and evening to catch any infections. The nurses always had their eyes and ears open for the slightest sign of infection, such as a cold or a patient feeling tired; those with symptoms were isolated and not allowed to socialize with other patients.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eYou're always\u0026hellip;um...observant of a lot of things and thinking about routines in dining situations, sanitizing the tables, keeping distance, putting up notes, being clear, and those who became ill were isolated\u003c/em\u003e\u0026rdquo; (S4).\u003c/p\u003e \u003cp\u003eUsing protective equipment provided a feeling of security, for the nurse\u0026rsquo;s own sake, for the patients, and their family. At the same time, the equipment prevented the nurses from being present and close to patients, even though they wanted to be.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eYou couldn\u0026rsquo;t touch the patient, but I did anyway, you couldn\u0026rsquo;t go in to the patient as you wanted, and that the patients really needed\u003c/em\u003e\u0026rdquo; (S5)\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For me, it\u0026rsquo;s been very important to use closeness as part of the care. So, I think it\u0026rsquo;s been...I\u0026rsquo;ve had [a] bad conscience because I feel that I did a poorer job\u0026rdquo;\u003c/em\u003e (N3).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUsing protective equipment was also frustrating because it took extra time to get dressed, and at the same time, it was necessary to protect themselves and others.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eSubtheme: Reflecting on nursing actions after work\u003c/h2\u003e \u003cp\u003eThe nurses tried to leave work at work and to disconnect and release themselves from thoughts on current events and difficulties during the day when they were at home. Despite this, the nurses reported that they reflected and thought about many things during their spare time to prevent infection and protect the patients from COVID-19 in the long run. Before the nurses left the unit and went home, some of them tried to reflect together and talk about the difficult situations that had occurred during the day. Nevertheless, many nurses could not disconnect themselves from work; they dreamed about it at night and continued to reflect on how the day had been.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eGod, has everyone done the right thing, have we done what we should?\u003c/em\u003e\u0026rdquo; (S2).\u003c/p\u003e \u003cp\u003eThey double-checked with themselves that nothing had been missed during the day and worried about the new care routines introduced. They also thought extensively about how the cooperation with other professionals had been during the day. Sometimes, the nurses felt that they did everyone\u0026rsquo;s job and that fundamental nursing care did not work. They would go to the patient\u0026rsquo;s room in the ward, and no one had changed any protection on the bed or helped the patient sit up better in bed. Some nurses did not want to visit patients who had a lot of anxiety, answer the phone, or respond to an alarm from these patients.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI was nervous and stressed, I came out and they [other staff] were sitting on the sofa in the lunch room and chose not to answer the phone; I was very, very angry\u003c/em\u003e\u0026rdquo; (S8).\u003c/p\u003e \u003cp\u003eRegistered nurses needed to perform check-ups or controls on patients by themselves. Some nurses reported that they supported each other, working as a team.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWe were a small, bonded group, not really having time to give it all; it was usually that care was very time-pressured\u003c/em\u003e\u0026rdquo; (S8).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eDomain 3\u003c/h2\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eExperiencing leadership during the pandemic\u003c/h2\u003e \u003cp\u003eThe nurses experienced different types of leadership during the pandemic. They had to deal with the fact that rules and regulations changed frequently, sometimes daily. In the early phase of the pandemic, nurses reported that the leaders focused on rules and regulations rather than attentive leadership. How the leaders communicated the changes differed, and nurses described that the leadership changed over time. Some leaders were creative and understanding, and they co-operated with the nurses throughout the pandemic. The subthemes related to this domain were as follows: lacking solution-oriented and attentive leadership; awareness of lack of competence in PC; and being guided by caring, active, and creative leaders.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec24\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eSubtheme: Lack of solution-oriented and attentive leadership\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eThe pandemic caused major challenges for the organization in that the leaders were not prepared to deal with, for example, the daily testing of patients and staff.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;We had to test staff and patients, so a lot of my working hours were spent on that...testing every day\u0026rdquo;\u003c/em\u003e (N18).\u003c/p\u003e \u003cp\u003eThe leaders and staff had to deal with new recommendations and instructions before each shift, and especially in the \u0026ldquo;first wave\u0026rdquo;, the nurses found that the leaders were stressed and did not have time to inform them about what was going on. The nurses wished that the leaders had communicated the situation to them; they explained that the leaders faced a chaotic situation in solving acute problems, and although they were absent from the ward, they were available for talks. \u0026lsquo;One nurse reported that leaders would make statements such as:\u0026rsquo;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Now we need to withdraw a bit now because it\u0026rsquo;s too rocky at the hospital, but we\u0026rsquo;re here, come to us if there\u0026rsquo;s anything\u0026rdquo;\u003c/em\u003e (S1).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e The interpretation of routines and guidelines and arbitrary interpretations of recommendations from the leaders differed and caused tension among the nurses.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There were a lot of abrupt swings back and forth\u0026hellip;\u0026lsquo;Now we do this and now we do that\u0026rsquo;\u0026hellip;new directives every time; the Public Health Agency of Sweden also fumbled\u0026rdquo;\u003c/em\u003e (S5).\u003c/p\u003e \u003cp\u003eLeaders were busy organizing care by relocating and recruiting staff, and they did not understand that the working environment was negatively affected or that the nurses did not support the type of care they provided during the pandemic. Nurses are used to relieving patients\u0026rsquo; suffering, providing support, and being present; during the pandemic, the focus was on other things, and the care was not dignified. The nurses did their best and put their rights aside, and they did everything to do a good job and make a difference. However, one nurse reported:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThe personal sacrifices happened often, such as not [having] the ability to eat one\u0026rsquo;s meals, get breaks and toilet visits; it did not feel okay\u0026rdquo;\u003c/em\u003e (S6).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAs the pandemic continued, new challenges arose. The nurses had to work double shifts and schedule changes at short notice, and information was provided through text messages and phone calls. The leaders could not protect the nurses\u0026rsquo; free time, and the very tired nurses eventually made mistakes, not because they were incompetent but because the organization had major shortcomings. The nurses gave examples of illness among colleagues, like post-traumatic stress disorder (PTSD) symptoms, physical reactions, increased heart rate, and signs of panic in the eyes.\u003c/p\u003e \u003cp\u003eThe nurses expressed the need for professional support after the pandemic:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;There are many staff members who need counseling after the pandemic!\u003c/em\u003e\u0026rdquo; (S1).\u003c/p\u003e \u003cp\u003eThe nurses believed that a well-functioning organization and leadership would have caught the symptoms and offered debriefing. In addition, it would not have transferred a heavy responsibility to the employees, giving them a bad conscience and making them feel inadequate. The nurses expressed that the leaders should have cared more about them\u0026mdash;more than just giving them sweets now and then.\u003c/p\u003e \u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003ch2\u003eSubtheme: Awareness of lack of competence in PC\u003c/h2\u003e \u003cp\u003eNurses from other units and different specialties worked together during the pandemic because of relocation; not everybody knew each other, and nurses without knowledge and important experience in PC had to care for patients at the end-of-life. All the benefits of working as a team, which characterize PC, disappeared.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eYou did the most important thing, then the other things had to be because of shortage of staff\u0026rdquo;\u003c/em\u003e (N19)\u003c/p\u003e \u003cp\u003eActive treatment and curative intent were given until the patient died, and palliative symptom control was not carried out even though the nurses described that they \u0026ldquo;\u003cem\u003ehad to work right up to the end\u0026rdquo;\u003c/em\u003e (S6). None of the professionals asked: \u0026ldquo;\u003cem\u003eWhat can we do, what should we do?\u003c/em\u003e\u0026rdquo; (S7)\u003c/p\u003e \u003cp\u003eThe nurses faced difficulty in deciding on the point at which curative care should change to PC. The nurses expressed their gratitude for excellence in different areas of medicine and asked for support in the field of PC. One nurse reflected:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eThere are fantastic doctors; there are infection rounds, X-ray rounds; why can\u0026rsquo;t we have palliative care rounds?\u0026rdquo;\u003c/em\u003e (S8)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe shortage of specialists in palliative medicine led to a situation in which nurses with specialization in PC had the highest level of competence, something the local management did not understand or take seriously. The nurses felt that the management did not listen to them; they became sad and stressed when they could not perform person-centered PC, such as carrying out prescribed ordinations, including taking blood samples, inserting needles, or giving antibiotics to dying patients. They tried to follow the doctors\u0026rsquo; orders, but they quickly told the doctors that it was not possible, as the patients did not want to accept the treatments. At the beginning of the pandemic, the nurses did not know how to handle such situations, but this improved with time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eSubtheme: Being guided by active, creative, and understanding leaders\u003c/h2\u003e \u003cp\u003eThe nurses described that creative and understanding leaders of a unit listen to the nurses, showing care and support when needed. The nurses\u0026rsquo; abilities, responsiveness, and cooperation with colleagues to inform and develop routines and guidelines made the team intertwined. They reported that relying on leaders was the only way to cope with the daily changes in roles and regulations.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;I have to relate to what my leader is saying. Today it is true\u0026rdquo;\u003c/em\u003e (N1).\u003c/p\u003e \u003cp\u003e The nurses appreciated when leaders acted and supported them immediately when needed, such as when the leaders took responsibility, added extra staff when the workload increased, and provided clear information to the staff. This made the nurses feel that it was an educational period in their working life. The nurses reported that a sense of security was important in a group of many nurses. Some leaders organized whiteboards for the staff to write questions about things that were important during the pandemic, such as \u0026ldquo;\u003cem\u003ewhat material we need, what we wanted to change, visors, face masks, aprons, gloves on trolleys outside the room\u0026rdquo;\u003c/em\u003e (S3).\u003c/p\u003e \u003cp\u003eThe nurses reported that the leaders took them seriously in that they kept them informed. Many nurses reported being kept informed by leaders, and they gave various examples of leaders\u0026rsquo; activities, such as digital meetings in teams and the frequent use of e-mail and group meetings to plan and inform. They received constructive feedback from the leaders, and this provided a sense of security even when it only was a quick fix. Leaders and nurses who cooperated during the pandemic created better routines and were aware that not everything could be solved; they also wanted to retain some of the advantageous routines that the pandemic produced.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;When it was stricter, everything was quieter in the ward. For us too, we had it... there wasn\u0026rsquo;t so much to do at once. It was actually quite good, we all thought so, our head of the ward wants us to continue with visiting hours after the pandemic so that we have fixed visiting hours for next-of-kin morning and evening, so we have them then, and we can answer all questions and such, instead of all day and night, because we were interrupted so much in the things we were doing. So, it\u0026rsquo;s something we really want to continue with\u0026rdquo;\u003c/em\u003e (N4).\u003c/p\u003e \u003cp\u003eActive leaders acknowledged absent nurses. One of the nurses described that the leader saw her even when she became ill. The nurse said: \u003cem\u003e\u0026ldquo;my leader called me at home and asked how I was doing\u0026rdquo;\u003c/em\u003e (S3). Another nurse said that her leader contacted her before she went back to work. Other leaders also facilitated contact with occupational health services or psychological support.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aimed to explore the experiences of RNs and ANs in Sweden and Norway in performing PC for seriously ill and dying patients during the COVID-19 pandemic. The domains and subthemes and the overarching theme highlight how complex and challenging it was to provide PC during the pandemic and how it affected the nurses. The overarching theme of “being a round square in an extremely challenging situation” describes how the nurses struggled to provide supportive and compassionate care to maintain patients’ dignity in situations of immense suffering. The theme also describes how the nurses strove to give structure to daily PC, providing modified PC during a seemingly endless pandemic. This was surprising, but it also emphasizes the central role that PC played within their profession and the importance of maintaining palliative, person-centered nursing care during a health crisis. The pandemic was an extraordinary traumatic event and represented an unfamiliar situation. This can be compared to a natural disaster; in other words, it was a stressful, uncertain, and traumatic experience [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Our paper presents positive and negative aspects and strategies in the following domains: providing modified PC (domain 1), challenges concerning contamination in daily work (domain 2), and experiencing leadership during the pandemic (domain 3). The domains and subthemes are discussed below.\u003c/p\u003e \u003cp\u003eIn domain 1, we found that the pandemic had a large emotional impact on the nurses’ daily work and their private lives. The nurses had to modify PC to prioritize hands-on nursing interventions to relieve symptoms such as pain and breathlessness and to organize the care according to the 2021 recommendations of the Public Health Authority in Sweden and the Norwegian Institute of Public Health [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The holistic approach of PC addresses physical, psychological, social, and existential suffering and well-being. During the pandemic, patients; psychosocial and existential PC needs were not priorities, and therefore, person-centered care took a backseat. Not being able to provide adequate care led to moral and ethical stress and contributed to poor health and burnout among staff. According to Lovell et al., the knowledge of the symptom burden and the impact of treatment on the PC needs of patients with COVID-19 were scarce during the pandemic [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. This could cause healthcare professionals to feel powerless. A more active approach to identifying, assessing, and managing patients’ symptoms and their illness progress could be more supportive [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCommunication is vital in PC, and Mohan et al. [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] highlighted that communication is fundamental to human interaction. Compassionate communication with patients and next-of-kin is an important part of the assessment of their expectations, goals, and values [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Dewar and Cook [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e] described compassion, including empathy, love, and kindness, as pivotal in nursing. The nurses in our study could not meet the patients’ needs to talk about emotional fears or existential concerns such as anxiety because of protective equipment, limited recourses, the high number of acutely ill and dying patients, and lack of time. It was a completely new situation, and the nurses’ typical toolbox for PC did not fit in during the pandemic, as described by Sandsdalen et al. [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. According to Kang et al., most healthcare professionals do not feel comfortable if they are unable to identify, clarify, predict, and control illness [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to the nurses in our study, the modified PC approach also focused on how the dead body was cared for. During the pandemic, the body was wrapped in a black body bag to reduce the risk of the leakage of body fluids from body cavities [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This may have endangered the dignity of patients and next-of-kin because maintaining the dignity of the dead body is of utmost importance to healthcare professionals when disposing of the deceased. Kinnear et al. [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] found that the meaning of dignified care is multifaceted and a foundation of care.\u003c/p\u003e \u003cp\u003eThe nurses in our study supported the next-of-kin in saying goodbye to ill and dying patients from a distance through technology, such as iPads or telephones. According to Wakam et al. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], using digital support may be a solution for staff to substitute the physical presence of next-of-kin, even if it is not always considered acceptable. Healthcare professionals must consider that the family may be unable to prepare for unexpected death because of inadequate social support and the inability to follow traditional rituals related to death. Wallace et al. reported that next-of-kin are at risk for complicated grief and PTSD [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Supporting next-of-kin before and after the death of a patient can positively influence bereavement outcomes. According to Lovell et al. [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and Xiong et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], PC is an important part of the COVID-19 response and the management of symptoms.\u003c/p\u003e \u003cp\u003eIn domain 2, we found that the nurses did not describe any positive experiences of the pandemic. They lived in fear of spreading the virus to patients and their own families, and they strove to find new pathways of providing care as the COVID-19 virus escalated nationally and globally. They constantly struggled to relieve symptoms and alleviate patients’ suffering [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. They became distressed not only because they were experiencing a pandemic but also because they could not be physically close to the patients. They could not be present or available to the patient, which made them sad or miserable. Some nurses touched the patients without gloves even if they were aware of the risks. In this way, they chose to engage with suffering patients and did not turn away, a type of existential nursing action described by Arman [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. It is not unusual during a pandemic for professionals to experience high-stress situations followed by psychological responses. According to Young et al., depression and anxiety are common, along with feelings of impatience and frustration [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Hillestad et al. [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] reported that nurses in nursing homes felt that the nursing home became a prison during the pandemic. The doors had to be locked, and restrictions prevented older persons and their families from coming and going as they wished. Furthermore, RNs are nearly twice as likely to report high stress of conscience compared with other staff in long-term care [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn our study, the nurses aimed to give priority to patients, next-of-kin, and their colleagues, sometimes neglecting their own needs. This meant that their quality of life was threatened, as they were more exposed to developing psychological stress during the pandemic. The nurses were not prepared to care for patients in a health crisis such as the COVID-19 pandemic. They primarily prioritized the goal of patient care, but the pandemic also demanded other PC priorities from both practical and ethical perspectives. After work, the nurses reflected on and summarized the care provided during the day. This is an approach that demands awareness of one’s perceptions, ethics, and practice. This allowed the nurses to learn from experiences, integrating that knowledge into improving PC when caring for patients during the pandemic. This is a type of reflection on action, as described by Patel and Metersky [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn domain 3, we found that the nurses experienced both positive and negative leadership during the pandemic. They often lacked attention from the leaders, solution-oriented leadership, and guidance from active leaders. The lack of attention from leaders may have prevented the detection of severe symptoms, such as post-traumatic stress in healthcare professionals, according to Di Tella et al. [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The nurses in our study made personal sacrifices and were physically and mentally exhausted when caring for patients with COVID-19. The nurses requested attentive and creative leaders during the pandemic who prioritized PC, cared about nurses, and provided attention. The nurses were very strained, and work stress, care burdens, and time constraints may be barriers that prevent nurses from engaging in self-compassion and self-care [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Being guided by management that was uncertain of how to deliver necessary materials, such as visors and mouthguards, left the nurses with feelings of loneliness. Even though the nurses experienced varying leadership during the pandemic, managers, nurses, and physicians contributed to important learning and increased knowledge related to the pandemic, including knowledge related to the practice of good hygiene, infection control, and digital communication [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In future pandemics, every effort must be made to avoid more catastrophic outcomes by building supportive work environments for healthcare professionals’ empowerment in all healthcare contexts to limit many of the harmful secondary effects of the pandemic [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eMethodological considerations\u003c/h2\u003e \u003cp\u003eIn the present study, we considered Elo et al.’s [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] checklist of trustworthiness to improve quality and transparency during the three phases: the preparation phase, the organization phase, and the reporting phase. The research team also had regular check-ins to keep track of their pre-understanding during the different phases. A strength of this study was that the nurses were interviewed by experienced clinicians and researchers in the field of PC. The participants were also confident during the interview and could express their experiences, paving the way for rich data. In the organization phase and the analysis of data, the richness of data on the subject and the shift between deductive and inductive qualitative content analysis were strengths. In this phase, domains were predetermined, developed, and combined with the overarching theme and subthemes. In the reporting phase, quotations were used systematically and demonstrating the entire process from data collection to reporting the results. The overarching theme and subthemes described the meaning of the content, reflected the subject of the study, and covered the data consistently.\u003c/p\u003e \u003cp\u003eThis study also had several limitations. First, all authors translated the interviews, either from Norwegian to Swedish or vice versa, which means that some words could have been misunderstood, and this may have influenced the results. The data may have been organized and analyzed subjectively, influenced by the researchers’ interpretation and bias. To prevent and clarify any misunderstandings, the researchers discussed and reflected on these together. A strength is that the different phases were discussed in the research group, and the results and quotes were read from both a Swedish and Norwegian perspective.\u003c/p\u003e \u003c/div\u003e "},{"header":"Conclusion and clinical implications","content":"\u003cp\u003eThis qualitative study is a part of a larger multicenter project, “Palliative Quality Care COVID-19 (PaQC-C19)”. The results of this study suggest that the prerequisites and PC approach among nurses change during a pandemic; they felt inadequate and insecure, and they struggled very hard in a seemingly never-ending pandemic. Spontaneous nursing care was lost, and they had to modify the PC approach and their presence. Death usually came fast, and next-of-kin had to say goodbye from a distance; furthermore, the care for dead bodies was undignified. We identified a potential challenge that requires attention: managers in different care organizations should work closely with healthcare professionals during a crisis such as the COVID-19 pandemic. The results of this study can be used as a basis for reflection in collaborative learning interventions within PC and as a guide for teachers in educational PC programs. Future research should explore how RNs and ANs cope with their experiences of “being a round square” that they bear in mind after COVID-19 to learn how to prepare RNs and ANs for a potential new crisis, such as a pandemic or war.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe qualitative data generated and/or analyzed in the current study are available upon reasonable request from the corresponding author but are not publicly available because of privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBoth the larger project\u0026mdash;Palliative Quality Care COVID-19 (PaQC-C19)\u0026mdash;and this study were supported by a generous grant from the AFA F\u0026ouml;rs\u0026auml;kring (grant no. DNR 200393) and the Norwegian Regional Foundation (grant no. 32174). The funding body had no role in the design of the study, data collection, analysis, or interpretation.\u0026nbsp;Open access funding and language review were provided by Mid Sweden University.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors (CMJ, CO, ML, MT, MDG, VAG, AKH, TS, CB, RH, and J\u0026Ouml;) made substantial contributions to the study in all steps of the research process (design and methods, data collection, and analysis) and were involved in critically revising the manuscript. All authors developed the interview guide together.\u0026nbsp;CMJ and J\u0026Ouml; wrote the draft, and all authors provided important intellectual content, constructive comments, and revisions in the development of the manuscript and gave final approval of the version to submit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in the two Nordic countries\u0026mdash;Sweden and Norway\u0026mdash;and approval was thus obtained by The Swedish Ethical Review Authority (DNR 356 2021/01623) and the Norwegian Centre for Research Data (NSD) (reference numbers: 838156 and 634351). The study was conducted according to the principles of ethical research in the Helsinki Declaration [19]. Collected data were stored at one university and anonymized in accordance with the European Union\u0026rsquo;s General Data Protection Regulation [21]. All participants gave their written informed consent before joining the study, and participants were given the option to withdraw their consent to participate at any time. The information was provided again by the interviewer before the start of each interview.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank all the RNs and ANs who participated and shared their experiences; you will be remembered. They also express their thanks to the managers and other professionals for their contribution in recruiting participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eErsek M, Smith D, Griffin H, Carpenter JG, Feder SL, Shreve ST, et al. End-Of-Life Care in the Time of COVID-19: Communication Matters More Than Ever. 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Resubmitted to BMC Palliative Care Spring 2024. \u003c/li\u003e\n\u003cli\u003eKang Y, Shin KR. COVID-19: Korean nurses\u0026rsquo; experiences and ongoing tasks for the pandemic\u0026apos;s second wave. Int Nurs Rev. 2020; 67(4): 445\u0026ndash;449. https://doi:10.1111/inr.12644\u003c/li\u003e\n\u003cli\u003eKinnear D, Williams V, Victor C. The meaning of dignified care: an exploration of health and social care professionals\u0026rsquo; perspectives working with older people. BMC Res Notes, 2014; 67(4): 445\u0026ndash;449.https://doi.org/10.1186/1756-0500-7-854 \u003c/li\u003e\n\u003cli\u003eWakam GK, Montgomery JR, Biesterveld BE, Brown CS. Not Dying Alone - Modern Compassionate Care in the Covid-19 Pandemic. N Engl J Med, 2020;382(24): e88. https://doi.org/10.1056/nejmp2007781\u003c/li\u003e\n\u003cli\u003eWallace CL, Wladkowski SP, Gibson A, White P. Grief During the COVID-19 Pandemic: Considerations for Palliative Care Providers. 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Nurses\u0026rsquo; ethical challenges when providing care in nursing homes during the COVID-19 pandemic. Nurs Ethics, 2023; 30(1): 32\u0026ndash;45. https://doi:10.1177/09697330221105631\u003c/li\u003e\n\u003cli\u003eMunkeby H, Bratberg G, Devik SA. Registered nurses\u0026rsquo; exposure to high stress of conscience in long-term care. Nurse Ethics, 2023; 30(7\u0026ndash;8): 1011\u0026ndash;1024. https://doi:10.1177/09697330231167542\u003c/li\u003e\n\u003cli\u003ePatel KM, Metersky K. Reflective practice in nursing: A concept analysis. Int J Nurs Knowl, 2022; 33(3): 180\u0026ndash;187. https://doi.org/10.1111/2047-3095.12350\u003c/li\u003e\n\u003cli\u003eDi Tella M, Romeo A, Benfante A, Castelli L. Mental health of healthcare workers during the COVID-19 pandemic in Italy. J Eval Clin Pract, 2020; 26(6): 1583\u0026ndash;1587. https://doi:10.1111/jep.13444\u003c/li\u003e\n\u003cli\u003eChadwick R, Lown B. What do we need to do to sustain compassionate medical care? Medicine, 2016; 44(10): 583\u0026ndash;585. https://doi.org/10.1016/j.mpmed.2016.07.003\u003c/li\u003e\n\u003cli\u003eElo S, K\u0026auml;\u0026auml;ri\u0026auml;inen M, Kanste O, P\u0026ouml;lkki T, Utriainen K, Kyng\u0026auml;s H. Qualitative content analysis: A focus on trustworthiness. SAGE Open, 2014; 4(1): 21. https://doi.org/10.1177/215824401452263\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, Health, Healthcare professionals, Nursing, Palliative care, Pandemic, Qualitative method","lastPublishedDoi":"10.21203/rs.3.rs-4687738/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4687738/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe COVID-19 pandemic has highlighted the importance of healthcare systems that can deliver high-quality palliative care during extreme challenges. During the pandemic, professionals across all healthcare contexts confronted enormous pressure due to a lack of pandemic readiness, practical and emotional challenges, and an increased number of dying patients. To support equitable high-quality palliative care for all people in future pandemics, it is crucial to learn from the nurses on the front lines during the COVID-19 pandemic.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eTo explore nurses\u0026rsquo; experiences of providing end-of-life care in general and specialized palliative care settings to patients during the COVID-19 pandemic.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis qualitative study is part of a larger Swedish\u0026ndash;Norwegian multi-center project called Palliative Quality Care COVID-19 (PaQC-C19). Data were collected in autumn 2021 and spring 2022 using qualitative individual interviews with 20 registered nurses and assistant nurses in general and specialized palliative care. A stepwise deductive and inductive qualitative content analysis was utilized in the search for domains and subthemes following the method of Elo and Kyng\u0026auml;s (2008).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThree domains, one overarching theme, and nine subthemes were developed. The domains described positive and negative aspects as well as strategies used when providing modified palliative care, the challenges concerning contamination, and how the nurses experienced guidance from managers during the pandemic. The overarching theme \u0026ldquo;being a round square in an extremely challenging situation\u0026rdquo; summarizes how the nurses safeguarded the patients\u0026rsquo; dignity and provided support to the next of kin in extremely challenging situations during the COVID-19 pandemic.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe results of this study suggest that the prerequisites for nurses and the palliative care approach they use change during a pandemic; they felt inadequate and insecure and struggled very hard throughout the seemingly never-ending pandemic. These findings can be used as a basis for reflection in collaborative learning interventions within palliative care and as a guide for teachers in educational palliative care programs.\u003c/p\u003e","manuscriptTitle":"“Being a round square in an extremely challenging situation”—Healthcare professionals’ experiences of palliative care during the COVID-19 pandemic – A deductive and inductive qualitative study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-09 14:45:25","doi":"10.21203/rs.3.rs-4687738/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3a18b1ec-5356-46ad-abc3-f681f2666235","owner":[],"postedDate":"August 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-09T14:45:27+00:00","versionOfRecord":[],"versionCreatedAt":"2024-08-09 14:45:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4687738","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4687738","identity":"rs-4687738","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}