Marga Hoogendoorn

107 I NTRODUCT I ON It is generally recognized that the COVID-19 pandemic had a huge impact on nursing workload and the planning of the nursing staff in the Intensive Care Unit (ICU). Also in the Netherlands the COVID-pandemic hit hard. The ICUs were confronted with an increase in patients admitted, in an already existing situation of shortage of ICU nurses. The ICU bed capacity expanded from around 1100 beds in the normal situation to up to 1700 beds in April 2020 with the associated need for nursing staff 1 . In the Netherlands the nursing workload on the ICU was also considered high by ICU nurses as indicated in a survey among 700 ICU nurses by the Dutch professional Association for ICU nurses 2 Firstly, because they were confronted with an increase in numbers of patients per nurse. The high number of unplanned ICU admissions due to the COVID-pandemic caused an extreme pressure on the bed capacity on the ICU and therefore on the nursing staff 1 . The ICU management was forced to alter normal nursing staff planning, and to bypass the Dutch Guidelines for Intensive Care which states that an ICU nurse in the Netherlands takes care for one or two patients per shift 3 . During the peak of the COVID-19 crisis ICU nurses frequently had to take care for more than two patients per nurse. A study from Arabi et al described different methods to expand the ICU staffing pool during the COVID- pandemic, e.g. optimizing ICÜ-nursing capacity by increasing the number of patients per nurse and the use of non-ICU staff to reinforce the ICU staff 4 . Also in the Netherlands the ICU nurses were supported by non-ICU nurses for basic care, but the ICU nurses were still responsible for the wellbeing of a higher number of patients during their shift. This is relevant as earlier research showed that the number of patients per nurse on an ICU is related to the patient outcome 5,6 . Secondly, in addition to an increased number of patients, the ICU nurses were also confronted with a new patient category with a complex care demand. The nursing workload of patients with COVID-19 pneumonia was perceived high compared to the average patient admitted to the ICU. Recent research showed that in Italy and Belgium the nursing workload as expressed with the Nursing Activities Score was higher in patients with COVID-19 compared to other ICU patients 7,8 . Moreover, due to the pressure on ICU beds there was no capacity left for planned surgical patients with a need for postoperative care on the ICU 1 . This resulted in a decrease of planned admissions of less complex postoperative ICU patients; the available beds were mainly used for emergency medicine and surgery admissions. The combination of the potentially high nursing workload of both the COVID-19 patients and the other ICU patients could result in a higher workload per patient, and consequently a higher workload per nurse. Especially because the nurses had to take care of more than the normal number of patients. Recent research of