Italian nurses' COVID-19 experiences from mass media interviews: a qualitative study.

Introduction: The COVID-19 pandemic is heavily hitting healthcare systems around the world, and nurses are battling in the front line. Previous studies have reported nurses' responses to catastrophic situations, but also interviews released by Italian nurses to the main mass media channels could bear important messages for policy makers and stakeholders. This study describes Italian front-line nurses' experiences during the COVID-19 pandemic through television interviews.
Methods: This is a descriptive qualitative study. Data were collected through purposive sampling from Italian front-line nurses' interviews during the COVID-19 pandemic. Publicly available interviews between 7th and 29th March 2020 were collected from the websites of national and regional television stations. Thematic content analysis was used to describe, summarize, and classify data into macro themes. The study is compliant with Standards for Reporting Qualitative Research.
Results: A total of 21 television interviews were collected from front-line clinical nurses, nursing managers, nursing trade union representatives and representatives of the Nursing Regulator. Thematic analysis yielded four macro-themes: psycho-social effects of the COVID-19 pandemic on health professionals; altered patient relationships; personal safety; recognition and promotion of the profession. Conclusions: The COVID-19 pandemic has exacerbated some problems already present, such as the shortage of nurses, but has also turned the spotlight on the nursing profession. Highly involved and affected by the pandemic, nurses have become better known by the public and often also protagonists of public discussions. It is important that nurses' value as allies of the public emerges stronger from this dramatic situation. ©2021 Pacini Editore SRL, Pisa, Italy.

Introduction

Nurses have been central to the health care response to the COVID-19 (CV-19) pandemic. After China, the most heavily affected country has been Italy. Overwhelming numbers of acutely ill patients have almost swamped hospitals. Health professionals have abandoned normal shift patterns and have been working under extreme pressure. Throughout this pandemic the press coverage has been the only window that the public have on the situation and how professionals are responding and affected by it. Many nurses have been interviewed on the Italian media – presenting a unique, real time’ perspective on the CV-19 situation. These broadcasts have also been essential in showing the public how the pandemic is affecting hospitals and staff – the messages from nurses on the TV screens are emotive and powerful reflections of the pandemic as it was unfolding – often by practitioners who had just left the care environment or were preparing to enter it. In that way these broadcasts add another, more immediate, dimension to our understanding of CV-19. The contents of these TV interviews are more ‘raw’ than planned research interviews, more human than surveys and deserve to be recorded as part of the CV-19 legacy for nursing. Sharing the experiences and messages of Italian nurses can also be helpful for all those who are or will be facing this emergency around the globe. In addition, considering that similar pandemics may occur again in the future, the information emerging from this experience may be useful for further studies and to set up strategies and interventions in the field of clinical practice, management and education of nurses and other health professional who may find themselves in a similar situation.

BACKGROUND

The new coronavirus (CV-19), an infection that affects the lower respiratory tract and manifests itself with pneumonia in humans, was recently declared by the WHO as a pandemic and represents one of the most complex situations ever experienced by modern healthcare. Despite the implementation of rigorous containment and quarantine measures, the incidence of CV-19 infections continued to steadily increase worldwide [1]. Italy was strongly hit by the CV-19 pandemic and was the second country to be affected after China, and for a long time was the one with the highest number of cases in the world [1]. Since the 21st February 2020, when the first case of CV-19 in Italy was confirmed, the Italian national health system has undergone increasing pressure with a total of 4,178,261 confirmed cases of Coronavirus and 124,810 deaths, as of the 21st May 2021 [2].

Nurses, along with physicians and other health professionals, have been the ones mostly involved in caring for patients with CV-19 and have faced unprecedented challenges from emotional, social, and professional perspectives. The pressure on the national health system led to the need to increase human and material resources to deal with the pandemic, therefore the Italian Government authorized the Regions to recruit 20,000 health professionals, by funding 660 million Euros [3, 4]. Given the prevalence of the pandemic in Italy the health professional response and their implementation of aspects related to clinical care and management related of the CV-19 cases are a salutary message to the rest of the world [3]. The TV cameras of the whole world were pointed on Italian hospitals and have broadcast the interviews of health professionals – including nurses – during the first wave of the pandemic. These interviews often included appeals to the population to encourage compliance with the rules of isolation – to help reinforce the movement known as #iorestoacasa (I stay at home), promoted by the Italian Ministry of Health [2].

This growing phenomenon of social and mass media communications by nurses and health professionals is a symptom of the growth of the media and the immediacy of reporting in times of public emergency [5]. Such media attention contributes to the development and evolution of the public image of the nursing profession [6].

It is therefore useful to know and understand, by analysing direct testimonials and interviews broadcast by the mass media, how Italian nurses – who have worked in the front lines (in the fields of clinical practice, management, education and research) during the emergency – have experienced this pandemic and how these interviews have been reported to the population by the mass media. This enables an analysis of the issues they present, identifying possible points of future action, and contributing to the research on how the media portrays nursing. This study presents an analysis of these media interviews to show an overview of the nature and content of these appearances and what they tell us about the key aspects of nursing from the CV-19 care situation. The study also provides a unique ‘snapshot’ of the immediate issues in the early epidemic – untampered by experience and reflections. It thereby also provides a basis for future research to make comparisons from later in the epidemic.

Methods

DESIGN

A descriptive qualitative study.

DATA COLLECTION

Data were collected through reasoned choice sampling. The most relevant and representative testimonies and interviews of Italian nurses involved in the front line against the CV-19 pandemic were included. Publicly available personal experiences by nurses in the CV-19 front-line were collected from the websites of RAI (Radio Televisione Italiana), the three channels Italian television broadcaster with national and regional programs from the 7th to 29th March 2020. Data collection was retrospective and proceeded until data saturation was reached. The inclusion criteria for the media interviews were that they had to be made by registered nurses from different Italian regions (at any level of responsibility, with no age limit, and any type of work experience) involved to some extent in caring for CV-19 patients in different settings; nursing leaders (e.g. a representatives of the Nursing Regulatory Body or the Nurses’ Trade Union) who talked about other nurses’ witnesses or problems/concerns related to them; representatives of public institutions who in their speeches to the public clearly referred to issues regarding the nursing profession or spoke on behalf of nurses.

The study was approved by the Liguria Regional Ethics Committee (Reg. N. 143/2020 - DB id 10456). The manuscript is compliant with Standards for Reporting Qualitative Research (SRQR) [7].

DATA ANALYSIS

Data synthesis and the thematic analysis was informed by Braun and Clark’s [8] six step model for thematic analysis which we adapted for visual media. The recorded TV clips were repeatedly viewed by members of the research team and key statements/important comments and accounts were identified and then transcribed.

Step 1: familiarizing with data

At this stage, the researchers involved in the analysis “immerse themselves” in the data. This happened through a careful watching and listening of the data to become familiar with what was reported – being careful not to omit any significant information. An initial list of ideas was generated about what is in the data and what is interesting about them.

Step 2: generating initial codes

This phase includes the initial production of the codes from the data, thus identifying some characteristics of the data that may be interesting to analyze.

Step 3: researching the themes

After generating all the codes, the researcher sorted the different codes into potential themes and also explored possible relationships between codes, themes, and sub-themes.

Step 4: reviewing the topics

Once the various possible themes have been identified, these issues are reviewed and redefined; some themes can be grouped together, separated, or eliminated.

Step 5: defining themes

In this phase, the themes for analysis are defined and refined by identifying the essence of each of them and determining which aspect of the data captures each theme.

Step 6: writing

A detailed report of the analysis process and the results was then created, specifying the analysis methodology conducted to demonstrate the methodological rigor followed.

The interviews were initially selected by title, then they were repeatedly listened to be fully understood, and finally summarized using a specifically designed summary matrix, which included the source, the speech date, participants’ details, a summary of the content and the topics covered. Subsequently, an analysis matrix was created to obtain a general overview of all the collected interviews, through which we identified the sub-themes (starting from the topics) and the themes, which in turn were grouped into macro themes. Each macro theme has been described narratively and supported by quotations taken from the interviews (Fig. 1).

Fig. 1.

Theme map.

Results

The interviews were collected from a total of 14 sources (TV or online programs taken from RAI website), of which 5 included group interviews. The sample therefore consists of 23 interviews, specifically: 14 nurses working in the front line caring for patients affected by CV-19; 5 nursing directors or charge nurses; 3 nursing trade union representatives; and 1 representative of the Nursing Regulatory Body. Four macro-themes were identified describing the different facets of this health emergency.

THE PSYCHO-SOCIAL EFFECTS OF THE CV-19 EMERGENCY ON PROFESSIONALS

All the nurses, but particularly those who were currently caring for patients affected by CV-19, declared that they were living in a state of constant fear and anxiety, due to their inability to “do more” to help their patients and colleagues. The emotional impact that nurses were experiencing was evident – especially from a psychological perspective. This was apparent even in ICU staff used to dealing with very sick patients: “This is a very heavy situation from a psychological point of view and absolutely disarming” (an ICU charge nurse).

Fear was a frequently described emotion; fear for patients, for getting infected themselves and infecting their families. Under their uniforms and protective equipment health professionals are also human, they have the same thoughts and concerns as the rest of the population. CV-19 and the threat it posed to their loved ones was a constant companion: “At home, you try to avoid hugging and also other things you would normally do with your dear ones… and in the meantime, you always think about it” (a clinical nurse).

Those who were able to, lived separately from their families, to avoid infecting them, but this long period of persistent anxiety increased the psychological burden borne by health professionals and led to numerous personal sacrifices being made and dilemmas caused by conflicting loyalties and emotions: “I have tried to limit as much as possible all my contacts with my parents, grandparents, and children… (…). We have had to let go of many things, but a father cannot avoid celebrating his son’s birthday” (an ICU nurse).

Various interviews highlighted the psychological strain that nurses were under. This also included nurse managers who – along with their own fears – were having to manage the stress of their staff colleagues: “You bring home all the suffering because they suffer, and you see it all; I also always bring home the support and the smiles of my colleagues, smiles that are always there under their masks” (a nurse).

“… it is a dramatic situation… the psychological strain is devastating… We do not have any structured psychological support, and we analyse ourselves at the end of the day, when we are tired and sit at a table with the cakes they bring us; and I collect their tensions and tears” (an ICU charge nurse).

“We get sick too. When you find out that someone is positive... you get seriously worried, and I have been doing this job for 25 years. I look at my nurses who yesterday asked for psychological support. We all have elderly parents or children at home, and even if we take all the possible precautions, a moment of distraction due to tiredness can always occur” (a charge nurse).

The emotional burden of CV-19 was very evident. The exhausting shifts, low nurse-to-patient ratios for intensive care settings, and reduced time off, were all aspects of this war against CV-19, and like in all ‘wars’ – as this situation has often been defined – all available resources are used: “What then weighs more, to me but above all to my nurses, as I have already told them directly, I will never stop thanking. At the end of this story which I hope will last as little as possible, I will take them somewhere. They are genuinely massacred (...) We don’t have structured psychological support; we analyse ourselves at the end of the day when just tired, we put ourselves in front of a table with cakes that bring us, and I gather their tensions, their tears often. It is a very, very demanding test. At the end of this story, which I hope will last as little as possible, my nurses will work anyway” (head nurse).

In addition, nursing managers, in hospitals, the community and nursing homes, were facing very stressful situations in their areas of responsibility – mainly as a result of staff sickness resulting in shortages and the additional infection control concerns created by CV-19: “One day, I ended up having 102 nurses on sick leave, equal to 30% less staff on duty and obliged to do much more than they would normally do (…). I had to stay at home with a high temperature, but after three days, I went back to work. I intentionally did not do the swab test because otherwise, I would have run the risk of staying at home for 15 days, and this was impossible. One day I said to myself, «But I… what can I do? (with a broken voice) I can’t stop this tsunami»” (nursing director of a nursing home).

ALTERED RELATIONSHIP WITH PATIENTS

CV-19 also impacted on the core of the nurse patient relationship – a climate of fear connected with the problems caused by protective equipment were very evident in the nurse interviews: “... because caring for and taking charge of a person passes through empathy and contact, but here there is no contact. Then you think of miming to show you are close to the patient and transmit a sense of safety and reassurance through non-verbal communication. When completely covered by protective clothing, non-verbal communication is useless because it is not noticed” (a nurse from the ambulance service).

“The hall is full of scared patients. Lots of people with acute respiratory distress. People of all ages. People who suddenly had difficulty breathing, their temperature rapidly rose. Do you know what struck us most? That they did not say anything. They just lied in bed in silence, but their eyes were full of fear, which on their own spoke for all of them” (a clinical nurse).

Nurses were often the only person a patient with CV-19 could see and relate to, despite the difficulties caused by the disease and the protective equipment. In addition, physicians and nurses were also the only point of contact and source of information for patients’ families. Therefore, a great amount of trust, hope and comfort was placed on health workers by patients and their families. Many nurses reported that they helped patients to video-call their loved ones, literally becoming the voices for those patients who were too weak to talk: “Whenever possible, we try to facilitate communication: we call the next of kin twice a day, and we give to those patients who are awake the messages of love and affection sent by their sons, fathers, and mothers…” (an ICU charge nurse).

“... we decided to stay next to her, so that as well as monitoring her we could accompany her, otherwise she would have been alone” (a nurse from the ambulance service).

“The only way we could communicate with patients was with our eyes… somehow, maybe touching a leg, trying to send a message to their children because they do not have other relatives, they don’t have anyone” (a clinical nurse).

PERSONAL SAFETY

The correct use of Personal Protective Equipment (PPE) is essential to guarantee safety for patients and health professionals. In CV-19 the droplet nature of the infection meant that correct PPE use was essential – however, partly driven by the large amounts of infected patients’ issues with PPE were very evident in the nurse interviews. The system of care often dictated that nurses organized themselves to work in pairs: one stays outside the protected zone, and the other stays inside – delivering direct care. This means that whoever is inside must deal with the issues of wearing PPE for an exceptionally long time – something not usually seen in normal times: “… because having a mask over your face for 3-4 hours does not allow you to breathe well, you don’t feel fresh air… this can cause a bit of a headache, and reduces the level of attention, the heat of the protective suits … It is like running for 6 hours, at a certain point you necessarily need a break if you don’t want to collapse” (an ICU nurse).

The lack of adequate PPE was a real concern for most health professionals. PPE is the only barrier between the virus and practitioners and having to care for infected patients without it many nurses became infected with CV-19. This is recognized as an accident at work, as declared by the president of the Italian National Institute for Insurance against Accidents at Work (INAIL), who described this as another “bad wound on the already tormented body of our National Health System”. Nurses remarked on this as lacking the ‘right armour’: “… we want the right armour to fight against this war, otherwise it is useless… PPE is lacking… we want to be safeguarded” (a clinical nurse).

Nurses were working in conditions where their colleagues were becoming ill and dying – an issue that created enormous emotional stress: “The number of deaths between doctors and colleagues is in front of everyone, the number of infected colleagues … we know. So yes, I’m afraid, but I also have a great desire to be able to help and try to help” (a clinical nurse).

Alongside colleagues becoming infected and ill the lack of adequate PPE exacerbated the fear that many nurses had about taking the infection home to their families: “Our biggest fear is not getting in touch with the virus, which is something we daily do. Our fear is that accidentally infecting ourselves and consequently bring the virus home and infect those who are the closest and dearest to us in the home” (a clinical nurse).

RECOGNITION AND PROMOTION OF THE PROFESSION

Within the interviews nurses often underlined how their response to this emergency was not merely the result of their heroic actions, but was one where they recognised, they had a pact of accountability with the public – this duty was at the core of their work. “Helping others is at the basis of every healthcare profession, this is why I decided to be one (healthcare profession)” (an ambulance nurse).

Despite their tiredness, fatigue and fear, nurses continued to honour the founding values of their profession – such as caring and staying close to people, emphasizing the ‘non-extraordinary nature’ of the job they were doing: “I am physically tired because the protective equipment hurts me... I am psychologically exhausted, and so are all my colleagues who have been working in the same conditions for weeks, but this will not prevent us from doing our job as we have always done. I will continue to take care of my patients because I am proud to be a nurse and love my job” (a clinical nurse).

Many nurses remarked on the expressions of gratitude by people and institutions for their work, but also noted the irony of these thanks when previously their concerns about violence in the workplace went unheeded – suggesting the fickle nature of public appreciation: “The manifestations of gratitude these days are exceptional, and we are happy that people are close to us; they are our support. Unfortunately, however, only one month ago in our hospital, we had to stick up some notices to contrast acts of violence against health workers because we also have this kind of problem, but we hope that this emergency has now taught a lot of things to many people” (an ICU charge nurse).

“… we were heroes also 4 months ago, because we are continuing our daily battle… and especially in the Emergency Departments, during the winter season, we were attacked, but nobody said that we are heroes” (an Emergency Department Charge Nurse).

Discussion

This study aimed to explore the experiences of the Italian nurses involved in the CV-19 emergency through interviews broadcast on national television. The intention was to collect important messages for the nursing profession immediately, when it was still immersed in the emergency – unstructured and natural comments that provide a ‘raw’ picture of the way nurses were experiencing the CV-19 pandemic. Analysing the interviews also played another role – exploring how nurses spoke to the population through the media. Appeals ranging from respect for rules, staying away from other people, washing your hands, to hashtags like #stayathome, and similar, have crowded the social and mass media channels during this pandemic. Many of these appeals are made by nurses, physicians, and health professionals in general who have seen and often personally experienced the consequences of this virus. The tone and the ways things were being communicated varied, but the key message is always the same: ‘stay at home and do not foil our work’. The vivid images that the nurses interview depicted also presented a realistic picture of the risks to life brought by the CV-19 pandemic to a public that – in some instances – did not appreciate the extent of the health threat. The interviews form a sort of appeal to the sense of civic duty, respect for the rules imposed to contain the contagion, and respect for the sacrifices of all those workers who are trying to keep the country going. They also serve to raise the profile of the nursing profession nationally.

The interviews often occurred within a military type discourse – sometimes adopted by the nurses themselves. Newspapers and television often talked about “heroes” and “soldiers at war” in their reporting of the CV-19 pandemic [9]. Perhaps this choice is due to the need to be understood by non-professionals, by those who do not know the everyday life in hospitals. Yet nurses, as well as doctors, have always replied that they are “only” professionals and that they are acting exactly as usual. Perhaps we must seize the opportunity and take advantage of this media attention to get the correct messages across, to make nursing skills known [10]. Among the expressions of gratitude there are also many promises about changing and revaluing the nursing profession in Italy, for which nurses have been waiting a long time. As in the case of the response of the former Italian Prime Minister Giuseppe Conte, during his speech to the Parliament on 25th March 2020, to a letter addressed to him, published on the Facebook profile by a nurse working in the front line caring for CV-19 patients. In her public letter, she commented on the proposal included in the Legislative Decree n. 18 of 17th March 2020 (also known as the “Cure Italy Decree”) to give a bonus of €100 to healthcare workers, where she requested genuine respect for the profession to be shown by organizing a meeting with the trade unions to amend the national collective labour agreement. During his speech, the Prime Minister, quoting the nurse’s exact words, said that such requests will be remembered to resolve some issues regarding nurses’ organization and wages.

During this pandemic, Italian nurses, as well as those from all over the world, are facing Constant physical and emotional stresses like never: they work in hard and non-ordinary conditions with a different relationship with patients and families due to prevention measures. Nurses had to manage and create new ways of developing relationships with patients and families – using remote technology and message boards for example –. The pandemic has diminished the very workforce required to stem its progress – pushing both staff and healthcare systems to their limits [3, 11]. This has also been exacerbated by staffing issues highlighted before the pandemic [12, 13]. This emergency has made the vulnerability of health professionals visible to all and has perhaps also made the population aware of the responsibility they have in the correct and effective management of the health system. It has also shown how important it is to guarantee nurses and other health professionals the appropriate professional protection, both physical and psychological, through various interventions: establishing specific protocols to reduce the risk of contagion among health workers; providing adequate training; and psychological support, the issue of personal safety came across substantially from the interviews – highlighting resilience and courage, but also the risks nurses were taking [14, 15]. This experience must be considered as a lesson for everyone, not only as regards the more clinical or organizational aspects of the profession [16], but also for the protection of professionals, who will remain marked by this experience and will need prolonged support.

LIMITATIONS

As with all studies, this study has its limitations. First, the analysis of interviews broadcast on TV, were conducted by journalists not researchers, pursuing a different intent from ours. Furthermore, the limited period during which we collected the interviews may have missed other discursive themes. In addition, we only collected data from Italian TV – this may not reflect the messages portrayed by nurses in other countries – however, we feel that this study will allow others to make that comparison and extend this kind of study.

Conclusions

This study explored the experience of nurses involved in the CV-19 pandemic through the lens of the mass media. Future studies that directly involve nurses, but also patients and relatives, will be necessary to have a more complete picture of the complexity of the health emergency we are experiencing. In the year dedicated to nursing around the world, no one would have imagined that these would be the terms in which the importance of nurses within the health systems would be discussed. There has been talk of “heroes”, but it is perhaps more correct to stop and talk about the professionals who gave everything, even sometimes their own lives in this pandemic, to ensure that their contribution is not wasted.

The pandemic has not ended, but there are many lessons that we have already learned from this moment of crisis. One thing that this study underlines is the need to create an open and sincere communication channel with citizens. In Italy, but still in many countries around the world, nurses still struggle to define their role. The CV-19 pandemic has put nurses into the spotlight like never before – they have been able to portray their contribution and professionalism to the public in an unprecedented manner – hopefully this will be a positive outcome from this tragic pandemic. The need to ensure that health care systems are more pandemic ready is also a lesson from the painful stories of inadequate PPE. A key message for management therefore is the need to be prepared in terms of stocks of PPE but also staff training in its use. The strengthening of workplace policies and strategies to both physically and emotionally protect their staff is also essential. Workplace environments need to evaluate and strengthen their systems for providing staff emotional support. This needs to include tong term monitoring of staff stress. The pandemic also required nurses to be resilient, to be able to find new answers to new problems, changing the procedures in which they were competent to ensure that patients obtained the most appropriate care. However, it is imperative that health care organisations review skill mix and staffing numbers to ensure organisational resilience for future pandemic readiness. We also need to investigate whether nurse education programmes contain enough training on disaster or pandemic management – and enhance content accordingly. However, the impact this pandemic has had on nurses and nursing is not yet fully understood but based on the voice of nurses it seems clear that many things can no longer go back to what they were before.

Acknowledgements

Funding sources: this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.