The Lived Experiences of Nurses Working During the COVID-19 Pandemic.

BACKGROUND: Previous research on nurses during pandemics has focused on nurses working in one facility or type of unit; this study focuses on nurses caring for COVID-19 patients in a variety of units in different sites across the United States.
OBJECTIVE: The aim of this study was to understand the experiences of registered nurses working with hospitalized COVID-19 patients.
METHODS: This study used a hermeneutic phenomenology design. Semistructured interviews via telephone were conducted and then transcribed verbatim. Colaizzi's method of analysis was used. Data saturation was achieved with 14 participants.
RESULTS: Three major themes were evident. They were "the human connection," "the nursing burden," and "coping." Subthemes were identified under each major theme. DISCUSSION: This study depicted nurses who are caring, empathetic, and resilient. They had many recommendations for fellow nurses, the public, and health care organizations.

In the opening lines of a poem about the influenza of 1890, Winston Churchill, at the age of 15, wrote about the devastation and losses of an unknown disease: “Oh, how shall I its deeds recount—Or measure the untold amount—Of ills that it has done?”[1] Although COVID-19 (coronavirus disease 2019) is a new pandemic identified in 2019, there have been other worldwide pandemics. Each one of these pandemics has left its mark on civilization. The history of these pandemics is important because history repeats itself, and with each pandemic, we have gained knowledge to improve health care. Therefore, it is imperative that research be implemented to determine evidence-based interventions not only for patients but also to assist nurses caring for patients with COVID-19. A pandemic is defined as a new virus with widespread emergence, people do not have immunity, and there is simultaneous transmission worldwide. Seasonal epidemics are not considered pandemics.[2,3]

The most recent pandemic, SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2, COVID-19, formerly called 2019-nCoV), is defined as an illness caused by a novel coronavirus. This illness originated in Wuhan City, Hubei Province, China. The disease was reported to the World Health Organization on December 31, 2019. On March 11, 2020, the World Health Organization declared COVID-19 a global pandemic, its first such designation since declaring H1N1 influenza a pandemic in 2009.[4] Symptoms of COVID-19 are wide ranging and can be asymptomatic or severe leading to death. The incubation period for this disease has been estimated to be from 2 to 14 days. Major symptoms include fever, cough, dyspnea, fatigue, muscle aches, headaches, new loss of taste/smell, congestion, diarrhea, or nausea.[5] COVID-19 can cause a viral pneumonia with additional manifestations and complications. A large proportion of patients have underlying cardiovascular disease and/or cardiac risk factors. Identified preexisting problems associated with mortality include male gender, advanced age, presence of hypertension, diabetes mellitus, cardiovascular diseases, and/or cerebrovascular diseases.[6]

Between January 21, 2020, and September 22, 2020, the Centers for Disease Control and Prevention reported 6 825 697 confirmed and probable cases of COVID-19 and 199 462 deaths in the United States. Eighty percent of these deaths have occurred in people 65 years or older, and more than 54% of those have been male.[7] Although it is difficult to obtain accurate numbers for the United States in terms of actual hospitalizations related to COVID-19, it is known that the surge of patients hospitalized for this illness has taxed the health care system. As the primary health care professionals in hospitals, nurses have cared for these patients during all stages of the illness and have spent the most time with these patients at the bedside. COVID-19 is a global pandemic that has taken its toll across the world and has certainly taken a toll on nurses at the bedside.

BACKGROUND AND SIGNIFICANCE

As the number of cases of COVID-19 has grown, and an alarming number of patients have been hospitalized, nurses on the frontlines of health care working in hospitals have been faced with scenarios imaginable only a few short months before. Much has been surmised about their experiences in dealing with a novel emerging disease, which has been compared with what nurses experienced in the United States in 1918 with the influenza outbreak. Therefore, it is imperative that research be undertaken to determine what nurses are experiencing physically and emotionally to help form a beginning framework to help nurses today and in the future. This study is different from previous research because it was undertaken in the United States with interviews with nurses from different states during the pandemic. This research covered nurses working in the hospital on the frontline in intensive care departments, medical-surgical units, and emergency departments. Previous research has focused on the experiences of nurses during pandemics in one facility[7-9] or in one type of unit such as the emergency department,[9,10] maternity care,[11] or nurses using rescue extracorporeal membrane oxygenation therapy.[12]

PURPOSE OF THE STUDY

The purpose of this study was to understand the experiences of registered nurses working with hospitalized COVID-19 patients during the pandemic.

METHODS

Design

This study used a hermeneutic phenomenology design in order to elicit the lived experiences of nurses during the pandemic. Phenomenology is a qualitative approach that attempts to understand the experiences of and perceptions of experiences by individuals. Hermeneutics relies on interpreting and understanding experiences as opposed to simply describing experiences.[13]

Institutional Review Board Approval and Procedure for Informed Consent

Approval for the study was obtained through a university institutional review board. Interested participants were emailed an informed consent form, which was signed and scanned back to the researchers. Interviews were audiotaped, and no names of participants or employers were used during the interview.

Participants and Eligibility

The investigators first contacted nurses known to them across the United States who could help identify nurses working in direct patient care with patients diagnosed with COVID-19. Qualifications included registered nurses working directly with COVID-19–positive patients in a hospital setting. Nurses contacted were asked if they met the qualifications and if not, if they knew nurses who did. This is known as snowball sampling.[13] The researchers decided not to limit the geographic area to get a broad variety of experiences during the height of the pandemic. All 14 participants completed the interview.

Data Collection

The researchers each conducted semistructured interviews via telephone with each of the 14 participants. The interviews were audiotaped and then transcribed verbatim by the first author. Nurses' names were not recorded or used in the interview, nor was the name of the nurses' employer used in the interview. Interviews took 20 to 45 minutes. See Table 1 for the Interview Guide.

TABLE 1

Interview Guide

Tell me about the first time you cared for a COVID-19 patient.

Do you feel prepared to care for these patients?

What are your greatest concerns right now?

What are you doing for yourself now?

Does this compare with anything else you have ever done?

What has been the worst thing about this?

What has been the best thing that has happened related to your working with these patients?

How do you think you personally could have prepared differently?

Has this impacted your relationships with others?

Do you think this experience has changed you?

What suggestions do you have in terms of public health preparation for a possible future pandemic?

Data Analysis

Colaizzi's[14] method of analysis was used. This type of analysis is robust and includes member checking to increase credibility and reliability of results. Both researchers read through the transcripts several times to get a general feel of the data. At that point, significant statements were highlighted, examined for meaning, and then categorized into themes. Subthemes were also identified. After this process was complete, some of the participants were contacted to ascertain whether the themes identified captured their experiences.

FINDINGS/RESULTS

Data saturation was achieved with a sample of 14 participants. All participants were female and worked as staff nurses with occasional charge nurse duties. The nurses worked in medical-surgical units, intensive care units, and emergency departments. Six nurses worked in Texas, 4 in Louisiana, 1 in New York, 1 in Maryland, 1 in Connecticut, and 1 in Iowa. Work settings included large inner-city hospitals and rural hospitals. See Table 2 for description of participants.

TABLE 2

Participant Demographics (n = 14)

Characteristic	n (%)	Mean (SD, Range)
Age, y		40.3 (10.4, 25-59)
Race
White	11 (79%)
African American	3 (21%)
Highest nursing degree
Associate degree	3 (21%)
Bachelor's degree	10 (72%)
Master's degree	1 (7%)
Years of experience		10.8 (9.4, 1-33
State of practice
Connecticut	1 (7%)
Iowa	1 (7%)
Louisiana	4 (29%)
Maryland	1 (7%)
New York	1 (7%)
Texas	6 (43%)
Department worked in
Emergency department	5 (36%)
Intensive care unit	4 (28%)
Medical-surgical unit	5 (36%)

Three major themes were evident. They were “the human connection,” “the nursing burden,” and “coping.” Subthemes were identified under each major theme (Table 3).

TABLE 3

Themes and Subthemes

Theme	Quote
I. The human connection a. Dying with strangers b. My coworkers c. Changing relationships d. Sharing with the public e. Relationships with employers f. My outlook on life	“Families who could not be with their family members. That always bubbled up into my heart when I would be talking to these families on the phone.” “The patients are dying and they will not let their family members come. They are dying alone. They are dying with strangers.” “We have all rallied together. One of my coworkers went out on maternity leave. She actually started crying saying ‘I feel like I've abandoned y'all.’ She felt so bad because she wasn't there fighting the fight with us.” “I started reaching out to my coworkers. I would call them and see how they were doing.” “Value all members of the interdisciplinary team. You're going to have to rely on these teams, so cultivate those relationships early and be with a team that you trust and want to work with.” “I see people, some of my friends, especially on social media saying they think this is not serious. I do not really want to talk to people who have negative things to say about the precautions we are taking. When somebody does not see the same things you see, it is hard to hear. I've kind of distanced myself from them.” “I realize what it means to walk into a gas station or a grocery store and look at someone in the eye and smile. I wear a mask since I'm exposed to the virus every day. I really do miss smiling at people. It really just makes you feel better. And now if you are smiling, no one can see it. And it's like no one smiles anymore. They avoid contact. It's awkward. I do not like it.” “We really need prayers. I would really like to know that people are praying for us. We need prayers for strength and endurance and protection. This is a spiritual awakening.” “Get the flu vaccine! If not, the flu season is going to kill us (health care providers). It is. It's going to be like COVID in the first 2 weeks, except we do not know if it's the flu or COVID which is going to be horrible.” “Wash your hands!” “Go to the hospital if you need to. At first, people were scared to go to the hospital. The chest pains disappeared from the emergency department. People were waiting and coming into the emergency department with CPR [cardiopulmonary resuscitation] in progress because they waited too long. It was upsetting.” “I wish that people would better research the things they choose to believe. The media can change things around and exaggerate things or underestimate things. I just wish people had a little bit more sympathy or to try to understand the things they do not know about.” “There's been a lot of unknowns and learning as we go. The inconsistent information is hard to deal with.” “Our boss is awesome; the hospital is awesome. I am so proud to be working here.” I've gone through some traumatic things in my life. We really are not in control. I realize the importance of life and how short life is, and we need to live every moment to the fullest.” “I do not think things will affect me as much in the future. You know, having this kind of thing under my belt will make me more prepared for the future.” “It has been a humbling experience. It has given me time to reflect, time to know my children better since we are not constantly on the go.” “I've never been so proud to be a nurse. I feel like this has been an accomplishment.” “These kinds of things really dig into the spirit of nursing.”
II. The nursing burden a. Burdens b. Personal protective equipment c. The burden of being a hero d. Comparisons to war	“It was more mentally taxing than anything. I would see those people die, and at first, I was having bad dreams.” “I wasn't really nervous about going in, but I had a few coworkers who were incredibly nervous to go in the rooms. To the point where a couple was calling out in the beginning because their nerves were getting the best of them. It takes a lot out of you.” “At the end of my first day being pulled to this unit, I had chest pain, I had a headache.” “This is heartbreaking. I was prepared to take care of critically ill patients on ventilators. I wasn't prepared for what I was seeing; to see them all lined up against the wall. I felt like I was on a mission trip in a third world country.” “We turned rooms into negative pressure rooms. It is really noisy, really loud in there. So not only is the patient scared because whoever walks in has the whole outfit on. They cannot hear. I cannot hear. It is nerve wracking.” “It's not that I felt we were not prepared. I mean, we knew what to do, but there was a transition time. And, in the beginning, PPE was scarce. We had some, but we were scared about how long it was going to last and if we were going to be able to get more. Every move is very calculated. You have to make every trip into that room count. We never ran out of PPE, but it got a little scary there for a minute. I feel like our hospital has done really good with that. I do not think we could have done any better.” “If you have what you need, then you obviously feel more protected, you feel more prepared, and you feel better about going into the room and caring for these people.” “Comfort is hard to give when the patient cannot see your face. They cannot hear what you are saying. Your face is covered. It's like you are allergic to them or something. It's hard to feel comforted when someone walks in your room, and you cannot see their face. Or not coming in as often as we normally do to minimize exposure. They're really, really sick, and they are scared. I cannot imagine how that is to feel like you are alone.” “The community was there for us. This is going to make me cry. Different restaurants, the police department, they treated us like heroes. I'm just doing my job.” “I told my brother-in-law who is a fireman that people were calling us heroes, and I do not feel like a hero. He told me that people need heroes right now and to be proud to be one.” “Our police and fire department came to salute us. I almost wanted to hide my face. I do not deserve this. I'm just doing what I've been doing for the past 10 years. Every day.” “You take an oath to take care of people, and then you are going to quit when you need to take care of people? That would be like a police officer wanting to fight crime, but then quitting the first time a crime was committed.” “This is the environment I work in; this is what I signed up for.” “In as much as we are called heroes, we are human and we are scared.” “I've gone to Iraq and worked in the field hospital there. And just seeing the evil and the helplessness that people have… I guess that kind of prepared me a little bit.” “The total feeling of wearing the PPE. You cannot hear anybody; you cannot talk to patients that are awake enough to even see you; they cannot see your smiles. That was much harder than Iraq because of those things.”
III. Coping	“I have my Bible class. I cycle. I swim. I run.” “I made a garden. We're doing projects around the house. That's actually helped my anxiety level. I like it when projects get done. It makes me happy. And sleep. And I've been walking my dog a lot more.” “I discovered that I really like gardening. It gets me outdoors in the fresh air. My dog loves being outside.” “My colleagues and I pray a lot together. God is in control, and we are His hands and feet right now. It has made me rely on God because He is in control.” “I am focusing on getting sleep and on my days off exercise. I go walk in the park.” “I have a dog and I try to get outside. My husband's been really good, just trying to talk about it even though he does not quite grasp everything that's going on, but he's been very good about talking everything through.”

Theme I: The Human Connection

This theme focused on changes in human connections between nurses and others as a result of working during the pandemic. Identified within the theme human connection were 6 subthemes: dying with strangers, my coworkers, changing relationships, sharing with the public, relationships with employers, and my outlook on life.

DYING WITH STRANGERS

Every nurse identified this as a major concern related to caring for patients diagnosed with COVID. One nurse commented that “the absolute worst part is watching these patients die and there is no one; their families do not get to come see them. The staff is dressed from head to toe, there's no skin to skin, there's nothing. These people are dying with no one to touch them, no one that loves them around.” Several nurses were in tears talking about patients dying without their loved ones by their side.

MY COWORKERS

Every nurse talked about the increased teamwork that occurred as a result of working together in the pandemic. Comments such as “without a doubt we have bonded. Honestly, with our patients and staff and with each other” and “we are a close-knit group. I really do not think I could have made it through this as well as I have without them. We've got each other; we'll get through this” indicate the importance of teamwork during this time. Additionally, the senior nurses felt it is their responsibility to mentor the younger nurses through this difficult time: “being a seasoned nurse, they (newer nurses) also kind of look at us, not that we have all the answers, nobody does, but I feel like we are kind of the calm in the storm.”

CHANGING RELATIONSHIPS

Nurses indicated that their relationships with friends and families changed during the pandemic. Much of this was related to the fear of transmitting the virus to them, and some were related to the stress the nurses were experiencing, both mental and physical. Some nurses wanted to talk about their feelings with friends and families, and others did not. One nurse commented, “I would come home and my husband would say ‘How was your day?’ and I'm like, please do not….”

SHARING WITH THE PUBLIC

These nurses had much that they wished to share with the public. In particular, these nurses were concerned with the mental health of the general public as well as their physical health. They encouraged people to educate themselves, wash their hands, and prepare for the upcoming flu season by getting the flu vaccine. Worries about mental health were frequently noted. One nurse stated, “I am worried about the mental health of everyone. People are reverting to habits that aren't the best for them just to try to cope.”

RELATIONSHIPS WITH EMPLOYERS

Unlike many reports in the media, the participants in this study did not have many negative things to say about their employers. Although concerned regarding the amount of personal protective equipment (PPE) available, these nurses felt that their employers did their best to provide appropriate equipment in order to protect the staff. The participants did wish that information would have been more consistent and clearer. For example, this was a typical concern voice by participants: “When it was all starting, things changed on a daily basis. Obviously, no one knew the full information in the first days, but things were literally changing day by day. It was the constant changing of information that was definitely very difficult for us.” Other nurses were concerned about their future employment as nurses were being furloughed intermittently: “My greatest concern right now is being able to get my hours at work.”

MY OUTLOOK ON LIFE

Nurses felt they developed a deeper connection to their inner selves and their responses to situations. These participants had an opportunity to reflect on how this experience had changed them and their outlook on life. One word used by several nurses was grateful. “I am so grateful for life and the little things. For a walk in the park, sitting down for a meal with my family, going into rooms without a mask,” and “It makes me a little more grateful for life. A little bit more grateful for the time I get with people and a little more grateful for touch.”

Theme II: The Nursing Burden

This theme focused on the heavy burden nurses felt as they worked through the pandemic. This theme had four subthemes that focused on personal mental and physical burdens.

BURDENS

Nurses described the mental and physical burdens of working during this time. One nurse stated that “we were in tears when we went home; we were so stressed out, and we were just overrun.” The stress was almost overwhelming for some. Another nurse commented that “The beginning is now a kind of blur. It was new to everybody, and everyone was anxious. Now the stress level is definitely down. It's weird looking back because in that time you were just going to work and in survival mode. You were just going, doing, and then leaving and suppressing all of this stuff all day, and then I would get in my car and just cry on the way home and try to process it all. That was the scary part, I mean, like we are pretty strong people, but there were people breaking down at work, you know, nurses would go the break room, they'd cry for a few minutes, and go back to work.”

PERSONAL PROTECTIVE EQUIPMENT

Nurses not only worried about the availability of PPE, but discussed the physical issues associated with PPE and the barriers it presented when caring for patients. While nurses care for patients in isolation, one nurse commented that “Nurses forget how to don and doff PPE. It is tiring and very time consuming.” Nurses were also concerned for their patients, particularly those who already had issues with confusion. One nurse stated that “We had patients from nursing homes that had dementia, and then we are coming in looking like space aliens, astronauts, or something. They're already confused, and I just cannot imagine what that is like for them.”

The Burden of Being a Hero

Nurses have been lauded as heroes for their work during the pandemic. These participants expressed humility and thought themselves undeserving of hero status. All expressed a sense of thankfulness to the community but found being called a hero an uncomfortable experience. As one nurse said, “It's weird to be called a hero and have people thank you and really inside, I'm just like, literally I'm just doing my job. This is what I went to school for; this is what I'm doing with my life. They say it's the year of the nurse; we just did not think it would be this kind of year.”

COMPARISONS TO WAR

Two participants talked about their experiences as nurses serving in wars, and one stated, “I've been to war. I feel like this is very comparative.”

Theme III: Coping

Nurses found ways to cope with their mental and physical stressors during this time. Many spent as much time outdoors as possible, and many described a deeper spiritual connection with God, themselves, and others. One nurse commented, “I will tell you that anyone who's working with these patients who says they are coping well is probably not being honest.” On days off, nurses did what they could to escape what was going on at work: “I do not watch the news; I probably should, but I do not. Because I feel like I'm living the news.”

DISCUSSION

These findings depict nurses who are caring, empathetic, and resilient. A primary concern related to disruptions in human connections, especially with dying patients. This seemed to be the biggest concern of nurses interviewed. Although previous research has demonstrated a great concern for patients, it has not shown the great stress related to patients dying alone. Perhaps previous pandemics did not restrict visitors as has been the practice during the COVID-19 pandemic. Improved teamwork and an enhanced sense of family with coworkers has been discussed in previous research and is seen as an important component of coping with the extra stress and workload associated with caring for patients during a pandemic.[8,9,11,15,16] As with previous research, nurses are concerned not only for their own health but also, more particularly, for the health of their friends and family.[8,10,12,15-18]

It is evident from this study and many previous studies that the ever-changing policies and processes common to the beginning of the pandemic were a large stressor for nurses and added to the confusion and burden of caring for these patients.[10,16-18]

Nurses appreciated the support from the community but felt undeserving of hero status. Research in previous pandemics demonstrates support from the public as well.[9,15] This is in sharp contrast to some studies that suggested that nurses felt ostracized by the public and not supported by their organizations.[9,18,19] The burden of wearing PPE as a significant physical phenomenon was noted in this study and has been a recurring theme in previous research.[8,9,12,20,21]

Nurses expressed concern for the public during this study and pointed out that visits to the hospital had decreased, which they believed had resulted in increased morbidity and mortality of patients in their communities. A recent Health Tracking Poll conducted by the Kaiser Family Foundation[22] indicated that during this pandemic almost half of adults stated that they or someone in their home had put off medical care because of fear of the virus. This same survey revealed that nearly 40% of adults stated that worry or stress regarding the virus has had a negative impact on their mental health, and more than 10% stated that it has had a major impact on their mental health. Nurses were also concerned regarding the loss of income as they see fellow nurses and family members being furloughed. The Kaiser Family Foundation Health Tracking Poll also showed that more than 30% of adults polled stated that had trouble paying bills because of the pandemic. These factors will no doubt have a long-term effect on future health and well-being.

Limitations

This population consisted of 14 nurses from 6 different states from three different types of units. Qualitative studies cannot be generalized to other populations. The interviews were conducted in May 2020. Nurses may have not had enough time to process their feelings regarding working with patients during the pandemic.

Relevance to Clinical Practice

With four influenza pandemics in the past 20 years, it seems inevitable that we will face more in the future. Despite changes in technology and medical advancements, experiences of nurses in this phenomenology study are similar to those of nurses in previous pandemics and in other countries. These nurses present many ideas for change and issues that must be addressed. We claim to be a patient- and family-centered system, but thousands of patients dying without family contradict this philosophy. Processes and policies must be developed that allow patients to have their loved ones with them during times of illness.

These nurses expressed concern related to what the public was seeing on social media and mainstream media. We have an obligation to present facts and educate the public. People who thought the virus was nonexistent were misinformed. People who were scared to the point that they stayed in their homes instead of seeking needed medical attention were not properly educated. It is unknown how many people died as a result of staying home when they needed medical care. Nurses did not want the public to be fearful, but did suggest that many practices implemented during this pandemic should be kept such as hand hygiene, staying home if ill, and receiving recommended vaccines, particularly the seasonal flu vaccine. Another significant concern surrounded the mental health of the public.

Although the nurses in this study felt supported by their institutions, it has been reported elsewhere that that is not always the case. Frontline nurses must be on hospital disaster management committees and should also participate in national, state, and regional disaster management plans. There must be continuous readiness for the next pandemic. As the nurses in this study reported, they felt much more comfortable when they were fully protected with PPE. Education is also imperative with clear and consistent direction provided to all staff working with ill patients in all settings.

Nurses interviewed demonstrated resilience and healthy coping mechanisms. However, nurses across the globe need to have support in order to cope with the difficulties of working through a pandemic. Physical health is needed if nurses are to care for the physical health of others. Organizations should consider shorter work days and fewer days in a row for nurses to be able to rest and recharge. Equally important is the mental health of nurses. Many nurses were fearful and experienced great stress related to caring for so many critically ill patients at one time. Rest, time off, and access to counseling should be provided for nurses.

Future research should further explore PPE, in terms of both quantity and quality. Having a sufficient quantity of PPE is obviously a priority. Equally important is the quality of PPE. Nurses complained of physical discomfort wearing current PPE including heat, fatigue, and headache. The time required to properly doff and don PPE is excessive. Additionally, nurses expressed concern for patients who felt further isolated when they could not see the faces of caregivers or hear them, which comprised communication between nurses and patients and nurses and other caregivers.

The nurses interviewed for this study demonstrated a resiliency and professionalism that represent the heart of nursing. As one participant stated, “this type of experience really gets to the spirit of nursing.” By focusing on what they have to say and making some positive changes in the workplace, this can truly be the “Year of the Nurse.”