This descriptive, international cross‐sectional study is the first study to describe and compare stress related to troubled conscience among perianaesthesia nurses from three countries who have been working in a COVID-ICU during the Coronavirus pandemic as compared to their usual workplace and compared to nurses who usually work in an ICU. The main findings were that overall SCQ scores and item scores were rated significantly higher when nurses were assigned to work in a COVID-ICU versus working in their usual workplace. Interestingly, there was a significant difference between all three countries when working in a COVID-19 unit. However, when working in the usual workplace, Swedish SCQ scores were significantly higher than the Netherlands, but not Denmark.
Even though Denmark and Sweden handled national management of the COVID-19 pandemic differently, those nurses have had similar responses to stressors from the pandemic: the reallocation of resources, lack of clear clinical guidelines and, most interestingly in terms of a stressed conscience, worry about not being able to provide patients appropriate treatment . Lake et al  explored factors associated with nurses’ moral distress and found that pandemic patient care situations were the largest source of moral distress. In that study, ICU nurses had the highest rate of moral distress.
It is difficult to determine why the Swedish overall SCQ scores were higher than Denmark or the Netherlands when caring for COVID-19 patients or in the usual workplace. When looking at the 9-item SCQ, Sweden had the highest stress of conscience level on 8 of the singular items. We found that nurses who worked in a COVID-ICU for 21 weeks or more had significantly higher SCQ scores. The mean number of weeks working in the ICU in Sweden was 30 weeks compared to Denmark (21.6) and Netherlands (14.2). So, it is very possible that the length of work time in the COVID-ICU in Sweden contributed to an increased stress of conscience. Also, when looking at demographics, many of the nurses from Sweden and Denmark reported having worked mainly in the ICU, while the nurses from Netherlands were mainly working in anaesthesia, the postanaesthesia care unit (PACU), and Day Surgery units. We postulate that it is possible the Swedish critical care nurses are most aware of best practices in caring for ICU patients compared to the Netherlands who do not work in the ICU, causing more suffering from stress of conscience due to new circumstances encountered while working in a COVID-ICU. However, that does not explain why Denmark’s overall SCQ scores are significantly lower than Sweden, although higher than the Netherlands. Differences in the provision of supportive strategies for the nurses in the different counties may have been a factor. Clark et al  found that key supportive strategies include: ensuring that the staff receive time off to rest and recuperate; monitoring and support for the long-term mental health of staff; and ensuring that staff received recognition and gratitude for their service. Staff training needs are also of great importance . Perhaps the Netherlands deployed a more well developed training process and provided ongoing emotional support for its nurses.
Nurses with < 10 years of practice experience participated in lower numbers, which may indicate some demographic barrier existed for taking the survey. We also know that perioperative nurses have reported fear of leaving the familiar for the unknown . In this study we found that the most stressing aspect of conscience for nurses working in the COVID-ICU was related to the high job demands and the lack of energy to devote themselves to their family as they would have liked. However, work: family conflict is a well-known and crucial problem encountered in nursing due to demanding workplace conditions even before the pandemic. This balancing act between work and personal life can threaten nurses’ health, leading to emotional exhaustion . That this aspect of conscience was experienced as most stressful is not surprising, and can be an explanation to earlier studies reporting that working in a COVID-ICU has a high impact on the mental well-being of nurses [13,14,15,16,17,18,19]. Another aspect of sense of conscience “forced to provide care that felt wrong in the Covid-ICU” was highly rated and aligns with other research such as the Sugg et al.  study about missed care among “COVID-nurses.” They found that the “COVID-nurses” struggled to support patients’ emotional wellbeing and mental health, and felt that they were unable to provide usual levels of support, reassurance, and interaction with patients. They also felt a lack of maintaining dignity and respect for patients’ values and beliefs .
Sweden experienced more COVID-19 deaths per capita, which may have contributed to the higher SCQ scores [26, 27]. It has been reported that inadequate workforce, having to triage patients due to lack of beds and/or equipment, being responsible for other staff members, and being asked to work in an area that was not in the respondents' expertise are factors associated with higher levels of stress when working in critical care settings during the early stages of the Corona pandemic . Whether these factors differ between the countries is currently unknown. Yet, Bergman et al. found that the introduction to the COVID-19 ICU varied in both content and length and resulted in a feeling of unpreparedness among Swedish nurses . Further, prior to the COVID-19 pandemic, Sweden had the lowest number of ICU beds per capita among the Nordic countries and rapidly scaled up its surge ICU capacity, enabling care for more individuals .
It is interesting to note that the Netherlands had similar scores regarding the work in a COVID-ICU versus a usual workplace because none of the participants reported that their usual workplace was the ICU. Initially, we believed that the Netherlands might have a higher level of stress of conscience because when working with COVID-19 patients, they were not in their usual workplace. This aligns with studies having reported that working in an area that is not in the respondents' expertise or not trained in ICU care are associated with a higher degree of stress, depression and anxiety [15, 28]. However, it is possible that because the ICU was not the usual workplace for the Dutch nurses they were given tasks versus usual nursing care, or possibly assigned to assist other experienced ICU nurses. It is also possible that the Dutch nurses were more clinically prepared and experienced a more suitable workforce, or that their limited time in the COVID-ICU (m = 14.2) contributed to the lower scores. When looking at COVID-19 hospitalizations and persons treated in ICU during the times our survey was open, Sweden and the Netherlands had similar population infection numbers with Denmark having the lowest numbers (ourworldindata.org). So those numbers do not explain the difference between Sweden’s SCQ scores with Denmark and the Netherlands either.
Of interest, Jokwiro et al  conducted a scoping review on the extent and nature of stress of conscience among healthcare workers. All 24 of the studies in the scoping review were conducted prior to COVID-19 pandemic. Yet, the SCQ scores were much higher than the scores in this study. For example, the highest mean score reported (0–225) was 63.6 in Registered Nurses (RNs) and nurse assistants who cared for older patients, and the lowest score reported was 24 in a mix of healthcare workers who cared for older, dementia patients . The highest mean overall score in our study was 31.8 (0 – 350). We are not sure why the stress scores among the studies in the scoping review are higher than the scores in this study. It is possible that this finding is related to the differences in personnel and settings. For example, the persons having the most responsibility (the RNs) had higher stress levels than the nurse assistants. The important point is that healthcare workers experience stress of conscience, and we must find and implement consistent evidence-based strategies to mitigate stress and promote workforce wellness and resilience.
Implications for practice and research
It is clear that nurses are suffering from stress of conscience during the pandemic partially due to: lack of resources; exhaustion from delivering complex care to COVID-19 infected patients; lack of preparation; poor leadership; repeated episodes of moral distress; and anxiety over the possibility of infection spread to themselves or their families [29,30,31]. Nurses have reported working because of a “sense of duty” . More efforts to protect nurses physically, psychologically and socially are a health care system imperative . Policy suggestions for mitigation include: allocation of necessary funding to provide essential protective equipment to all nurses; financial investments that improve nurse staffing; provision of psychological, physical, financial, and social support to nurses; and, ensuring a safe and positive work environment through legislation .
Other suggestions to decrease nurses’ stress include stable working conditions and better salaries . Morensen et al  and Lake et al.  point out the importance of not only focusing on the mental health of frontline nurses, but that leaders at every level should provide clear and consistent communication to their teams. Effective communication from leaders can decrease moral distress [17, 33]. Nurses working during the pandemic have also pointed out that the hero narrative divests policymakers of any responsibility and instead places it on the individual nurse or facility. The media can play a role by covering the pandemic realistically and without using the hero narrative as the only lens . The other narrative of nurses having responsibility for their own resilience has become a superficial response. By focusing on individual human responses, less attention is given to adequate organizational support that is a key component in creating positive working conditions . Organizational resilience can be fostered by addressing the priorities listed above. Other important suggestions for the mitigation of nurses’ stress are consistent support to frontline nurses, recognition of exposure to COVID-19 as a work-related injury, and addressing the violence and stigmatization of healthcare workers that has occurred in some countries during the pandemic .
Further research on stress of conscience should be conducted. From the work of Jokwiro et al  we know that nurses were experiencing moral distress before the pandemic. The pandemic has further exacerbated that distress, resulting in nursing burnout and nurses leaving the profession. There are few interventional studies that have focused on stress of conscience and how to effectively decrease that stress. Randomized controlled trials and phenomenological investigation would add to the scientific knowledge around stress of conscience. Research could also address the predictors and causes of COVID-19 related workplace violence and stigmatization .
There are several limitations to this study. Our sample was a convenience sample of nurses from three countries who completed a self-survey. We do not know the differences between those who completed the surveys and those who did not, nor between those nurses in other countries who did not complete the surveys. We do not know the possible response rate because of the international aspect of this survey. There are variables we may not have collected that contributed to the stress of conscience. As the pandemic has continued to impact healthcare workers for an extended period, a more detailed survey in the future may provide further information on the impact to practicing nurses. However, a strength of the study is a compilation of data from three countries as nurses struggle with life in the pandemic era.