key: cord-0903623-x4n9o16l
authors: Gordon, Jacqueline M.; Magbee, Terry; Yoder, Linda H.
title: The experiences of critical care nurses caring for patients with COVID-19 during the 2020 pandemic: A qualitative study
date: 2021-03-11
journal: Appl Nurs Res
DOI: 10.1016/j.apnr.2021.151418
sha: 7e6d318b7ad203a2df47bb90aab317faa8043675
doc_id: 903623
cord_uid: x4n9o16l

Due to a lack of literature about US critical care nurses caring for patients with coronavirus disease 2019 (COVID-19), the aim of this study was to examine their experiences caring for these patients. COVID-19 placed nurses at the forefront of battling this pandemic in the intensive care unit (ICU). Emerging international evidence suggests nurses experience psychological and physical symptoms as a result of caring for these patients. A qualitative descriptive design was used. Using purposive sampling, 11 nurses from one ICU participated in semi-structured interviews. Interviews were recorded and coded; data were analyzed using content analysis. An audit trail was maintained and member checking was employed. The experiences among critical care nurses caring for patients diagnosed with COVID-19 were categorized into five themes and subthemes. Emotions experienced was subcategorized into anxiety/stress, fear, helplessness, worry, and empathy. Physical symptoms was subcategorized into sleep disturbances, headaches, discomfort, exhaustion, and breathlessness. Care environment challenges was subcategorized into nurse as surrogate, inability to provide human comforting connection, patients dying, personal protective equipment (PPE), isolation, care delay, changing practice guidelines, and language barrier. Social effects was subcategorized into stigma, divergent healthcare hero perception, additional responsibilities, strained interactions with others, and isolation/loneliness. Short term coping strategies was subcategorized into co-worker support, family support, distractions, mind/body wellness, and spiritualty/faith. ICU nurses are experiencing intense psychological and physical effects as a result of caring for patients diagnosed with COVID-19 in a challenging care environment. Outside of work, nurses faced pandemic-induced societal changes and divergent public perceptions of them.

In December 2019 a novel betacoronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), surfaced in Wuhan, China (Centers for Disease Control and Prevention [CDC], 2020a). The virus rapidly spread globally and was characterized by the World Health

Vaccines are now available for nurses; however, they continue to endure the brunt of the pandemic at patients' bedsides amidst vaccination hesitancy (Coustasse et al., 2021) .

The virus primarily spreads through respiratory tract droplets, respiratory secretions, and direct contact and causes a distinct acute respiratory disease named coronavirus disease 2019 (COVID-19) (Guo et al., 2020) . Infection symptomatology varies drastically from no symptoms to lifethreatening complications including acute respiratory distress syndrome, multisystem organ failure, and ultimately, death (Grein et al., 2020) . Care of patients with COVID-19 in the critical care environment may be necessary (Arabi et al., 2020) . Multiple challenges are facing ICU teams including the ability to surge staffing, appropriate infection prevention and control, and staff protection (Ranney et al., 2020) . The interventions necessary to care for patients are predominantly carried out by nurses. This presents occupational risks because nurses' exposures to patients with COVID-19 are extended. As the pandemic continues, adequate supply of personal protective equipment (PPE) may not be available if hospitals continue to reach crisis capacity (Ranney et al., 2020) . The rapid spread of the virus coupled with the inadequate PPE supply in the US led the Centers for Disease Control and Prevention to issue guidance to optimize the PPE supply, including conservation strategies and re-use of conventionally disposable PPE (CDC, 2020b).

There is a paucity of research describing US nurses' experiences during the pandemic (Schroeder the psychological and physical effects of the COVID-19 pandemic on US nurses (American Nurses Association [ANA], 2020; Beckman, 2020; Shechter et al., 2020) . Therefore, the purpose of this study was to explore the experiences of critical care nurses working in central Texas amidst the pandemic.

A qualitative, descriptive design was used; an a priori theoretical framework was not selected for this study because the researchers were attempting to obtain an unbiased perspective of the nurses' experiences. Institutional Review Board (IRB) approval was obtained from the hospital system where the nurses were employed. A semi-structured interview guide was developed for the interview process. Nurses were recruited from the ICU where COVID-19 care was provided.

The study was explained to all potential participants, a waiver of signed consent was obtained from the IRB to ensure participants' confidentiality. Purposive sampling was used to recruit 11 ICU nurses who had cared for COVID-19 patients. The nurses agreed to be interviewed and audiotaped; all audiotapes were transcribed and validated by two researchers. Interviews were conducted in person with both the interviewee and researcher masked, six feet apart; additional interviews were conducted using the encrypted Zoom platform. Saturation was achieved after the 10 th interview but one additional interview was conducted to ensure saturation. majority of the population at this moment." (RN5)

"With everything that we have in nursing and this is the whole brand new illness that we are trying to learn and figure out, everything that we've learned and prepared for wasn't helping them at all (crying)." (RN2) "In some ways it's a feeling of helplessness with these patients because you kind of sit there and watch them suffer and there's not a whole lot you can do about it." (RN6) "And at those moments, there's nothing to do…you have to stand there…be helpless (crying)." (RN4)

"I'm worried about getting the disease, I'm worried about spreading it." (RN7) "That would worry me the most, is not being able to stay healthy to continue to help and work and to take care of not just the people, you know, in the hospital, in the ICU. Helping the staff I work with and then my family." (RN2) "I'm worried that I'm going to take it home to the people that I care about… I'm just worried that they'll be exposed elsewhere and being that I have seen how it can go, I worry about that…I just worry about my family…" (RN11)

Empathy.

"I learned to empathize with my patient, being in their shoes…That's what happened here, knowing his situation, knowing that he has kids that love him, care for him, the same level that I would love my parents." (RN5) "If you put yourself in the patient's shoes I now see this guy coming in with a mask on, goggles on, all gowned up how dissociative does that make them feel and no matter how I try my best to J o u r n a l P r e -p r o o f communicate with them, they themselves feel like they are the oddball, the black sheep of society in a sense." (RN2)

Subthemes of sleep disturbances, headaches, discomfort, exhaustion, and breathlessness were reported by all participants. Sleep was altered in all participants. Nurses believed PPE contributed to discomfort, headaches, and exhaustion.

"Yeah, sleeping wasn't a thing. I didn't really sleep." (RN2) "I definitely don't sleep that well anymore. And even when I do sleep, it's just anxious sleep." (RN5) "I'd have a hard time falling asleep because…my thoughts would just be racing." (RN9)

Headaches.

"I will have a headache every single day. I mean without a doubt." (RN4) "Like your head hurts. I always get migraines after." (RN8) "Now that I've started taking care of these patients, I've had three migraines." (RN11) Discomfort.

"It's like you know maybe we eventually will be able to flip them back over and then they're on their back for weeks but then in the end they end up dying anyways. So, yea that's our outcomes are typically people are dying…" (RN11)

"COVID caused so many other problems like they couldn't recover from that so they ended up dying anyways. So, it's also like tug of war between oh yeah we fixed it, we like basically fought against the disease and you won but all this other stuff that happened you couldn't win, or you couldn't beat it." (RN8)

"That in itself is just terrifying, the fact that I'm supposed to be working in an industry that gives, that has all the equipment that I need to do my job…It's like saying to a firefighter now you go to fight a fire but you gotta use a garden hose... We were too ill prepared as a country in general."

"I was angry about it [PPE re-use] and upset about it, but now that we've been doing it for months on end, it's kind of just become the norm." (RN4) "Our hospital created the PPE czar where they could make sure they had the PPE more available to us." (RN 8)

"The sheer isolation of it all I think has been the most difficult…" (RN2) "You know it's isolating to them and to us…" (RN3) "At first we were intubating everybody and now we're holding off until they really need to be intubated." (RN10)

"Language line is hard to use…through a plastic bag with somebody that has bipap making all this noise, it's hard to hear for them to hear me through the translator and for the translator to hear them…it's almost impossible." (RN6) "The majority of the population do not speak English, enough to communicate to have a conversation, but not enough with the tools we have to understand that 'hey' you're very sick."

(RN5)

The pandemic brought unique challenges to critical care nurses outside of the hospital. Social effects experienced by nurses were categorized into stigma, divergent healthcare hero perception, additional responsibilities, strained interactions with others, and isolation/loneliness.

"… someone's gonna spray me with Lysol at the grocery store. I don't have that big of a fear about that… those are things that I have witnessed through the media…fear of being shunned when you're just trying to do your job." (RN1) "You almost feel like the bubonic plague just walking around… that if someone touches you that they're gonna die instantly." (RN10)

"Everybody calling us heroes all the time; I don't like it because I don't think any of us feel like a J o u r n a l P r e -p r o o f Journal Pre-proof hero right now." (RN6) "I definitely have felt like a hero." (RN1) "I know that everybody's trying to be nice by calling us a hero but it's just like I don't feel that way, I never have felt that way. It doesn't feel like that, heroes are supposed to save everybody, we're not doing that." (RN9)

"It [homeschooling] was getting frustrating for both of us and I didn't want my wife to have to do that by herself... Because it's challenging, we're not teachers, we don't know how to do that on a consistent basis." (RN2) "So not only was I a nurse…but I was also a teacher…there's no day off…so it's just something you have to power through" (RN10)

"My attitude towards that dish that was left in the sink or… really stupid stuff…I'd ask my wife, 'why am I the only person that sees this?'" (RN3) "Patience is a lot less…I'm going to say what I've got to say and then walk away. I don't have as much tolerance…" (RN4)

The nurses that participated in this study were fearful and felt powerless against COVID-19.

Across the nation, visitation policies changed how nurses cared for patients and families. Isolated patients died alone without family members and this deeply affected the nurses' psychological well-being. Physical demands and the use of PPE while caring for patients with COVID-19 caused exhaustion, breathlessness, and discomfort. The psychological and physical effects the nurses reported are consistent with findings of Sun and colleagues (2020) reporting that nurses in China experienced fear, anxiety, helplessness, fatigue, and discomfort. Emerging qualitative findings suggest that these experiences are shared internationally by nurses (Kackin et al., 2020; Schroeder et al., 2020; Sun et al., 2020) . As cases surged in the US between March and July 2020, the American Nurses Association (ANA) surveyed almost 10,000 nurses, of which half stated they were overwhelmed, nearly 30% were experiencing feelings of depression, and over 70% were suffering from sleep disturbances (ANA, 2020). The findings from this study support the ANA's findings. In an environment plagued with pre-pandemic burnout and compassion fatigue, ICU leaders must heed the call to action as the virus exacerbates nurses' strained psychological and physical well-being (Blake, 2020; Moss et al., 2020) .

Challenges faced by nurses in the care environment included the inability to provide human comforting connections, experiencing patient deaths, isolation, PPE concerns, care delays, changing clinical practice guidelines, and language barriers. In contrast to PPE challenges reported by the media, participants in this study felt supported by their hospital with implementation of the PPE czar role. Implementing such strategies to readily provide PPE and educate about its use can mitigate fear in future pandemics (Fernandez et al., 2020) . Requisite isolation further complicated the use of translation tools with non-English speaking patients and J o u r n a l P r e -p r o o f Journal Pre-proof family members. Equipment, isolation, and care delay challenges also were reported by Kackin and colleagues (2020). Their findings are supported by the results from this study; nurses reported a sense of inability to readily intervene during emergencies. Additionally, in this study nurses attributed untoward patient outcomes to the delay caused by the need to don PPE.

Outside of work, while mainstream media extolled nurses as heroes, some participants endured homeschooling challenges and stigmatizing attitudes by those viewing them as virus carriers. A global conversation has arisen from the public healthcare hero narrative, noting that equating nursing with heroism is damaging to the individuals and the profession (Stokes-Parish et al., 2020) . Many participants in this study denounced the hero rhetoric.

A variety of mechanisms were used by nurses to cope with their experiences. Employee Assistance Program resources were appreciated by nurses in this study; however, they did not use them. Nurses were comforted and processed their experiences by discussing them with coworkers and significant others. Strategies within teams sharing the same experience, such as seeking out opportunities to reframe negatives and boost each other's wellbeing, or ending a shift with a check-in on everyone's wellbeing, and creating opportunities for colleagues to meet where there is a high degree of psychological safety may be beneficial (Billings et al., 2020; Groves, 2020; Watson, 2020) .

Healthcare crises caused by new infectious diseases, such as the Middle East respiratory syndrome-coronavirus (MERS-CoV), severe acute respiratory syndrome (SARS), and influenza healthcare system crises are holistic and informed by nurses' experiences during this pandemic.

Inherent to the nature of qualitative research, the findings from this study cannot be generalized to other settings and healthcare professionals. Participants in this study were from a single community hospital located in one region of Texas during the early stages of the pandemic.

Methods including multiple study sites over a longer duration may lead to alternative findings.

The ICU nurse participants experienced a high degree of job stress that manifested as psychological and physical effects. They encountered care environment and social challenges, and developed short term coping strategies as a result of caring for patients with COVID-19. It is essential for healthcare organizations to recognize critical care nurses' experiences during and after the pandemic. Inherently, the ICU is a high stress environment without the overlay of a global pandemic. Caring for COVID-19 patients can cause acute stress among these nurses to become chronic stress manifesting as chronic anxiety and ongoing depression. Healthcare leaders must prioritize being visible to the nursing staff and engaging in communication to understand their concerns and experiences. Nurses must be provided with the physical and emotional resources in their practice environment to combat the short and long-term deleterious effects of caring for COVID-19 patients such as provision of a psychiatric clinical nurse specialist. Local, https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-themedia-briefing-on-covid-19---11-march-2020. 

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