Marga Hoogendoorn

120 standard hygienic procedures. Working a few hours on the cohort-unit without leaving the unit and without being able to take a break and wearing the personal protection equipment all the time however was still an aggravating factor in the nursing workload 25 . Due to the special procedures in the COVID-period there was also an increase in the time needed for the standard hygienic procedures in non-COVID patients. The workload of the respiratory care was higher, which is in line with the higher number of ventilated COVID-19 ICU patients. The increase of workload in the category ‘Performing mobilization procedures with three or more nurses with any frequency’ can be explained by the frequency of turning patients into prone- or supine position as this became standard in the treatment of COVID-19 ICU patients 8,26,27 . We also found a difference in workload in the support and care of the patient and his or her relatives. This might have been influenced by both the high ICU mortality in COVID-19 patients (28.9%) as well as by visiting limitations during the COVID-pandemic. As a result of those limitations nurses worked with video conferencing with the family 28 . This video conferencing required a subsequent need for extra nursing time. This aspect can also explain the increase in needed time for support and care of the patient and his or her relatives for the non- COVID-patients because they were confronted with the same visiting limitations. Comparing the workload of COVID-19 patients of this study with results of other studies we found a higher Nursing Activities Score for COVID-19 patients in the study in Belgium (mean 92.0). A possible explanation could be the length of the shift, which is 12 hours instead of the 8-hours shift in our study. Also in Italy the Nursing Activities Score for COVID-19 patients was slightly higher than in our study (mean 84.0), which represented the nursing activities in 24 hours 7 . However, in both studies the increase of the Nursing Activities Score of COVID-19 patients compared to other ICU patients was 28 – 33%, which is comparable with the 30% increase we found in our study. Due to the combination of a higher workload per patient, the increase of the proportion of those patients compared to the total ICU patient population due to the long ICU length of stay, there was an increasing demand for the need for nursing care per ICU patient. This can also explain changes in care for the non-COVID patients as e.g the mobilization procedures; we saw a significant increase in category a – performing procedures once per shift with a decrease in category b - Performing procedures more frequently than once/ shift or with two nurses, any frequency. The high demand of the care for COVID-patients may have put pressure on the available nursing time for the other non-COVID patients, visible in the decrease of frequency of mobilization procedures.