Abstract
Background
The COVID-19 pandemic overwhelmed the New York City area upon its arrival in the United States. Hospitals were unprepared to handle the influx of patients.
Methods
This study explored nurse/nurse practitioner experiences when caring for COVID-19 patients in New York metropolitan hospitals, concentrating on physical well-being. Data collection involved in-depth interviews with eight participants.
Findings
(A) physical safety of self, family members, colleagues, and patients greatly concerned participants; (B) caring for COVID-19 patients led to participants’ physical exhaustion; and (C) most participants’ sleep was impacted when caring for COVID-19 patients.
Conclusions
This study identified issues involving U.S. health care workplace safety during the COVID-19 pandemic, namely availability of personal protective equipment, lack of centralized knowledge-sharing capabilities, sleep problems, anxiety regarding physical safety of self and others, and insufficient/undertrained staffing. It serves as a foundation for future research and calls for changes in U.S. hospital policies and procedures during crises.
Background
On March 1, 2020, New York City reported its first case of COVID-19; 3 weeks later, the area was considered an epicenter of COVID-19 in the United States (McKinley, 2020; Yang et al., 2021). By June 1, 2020, more than 203,000 COVID-19 diagnoses were reported, including 54,211 known hospitalizations (Thompson et al., 2020). New York City hospitals and their human resources were stretched beyond capacity. Before the health crisis, the city’s hospitals supported approximately 20,000 patient beds (Villarreal, 2020). By April 3, 2020, New York’s Governor Cuomo communicated that area hospitals were essentially intensive care unit (ICU) hospitals for COVID patients (Villarreal, 2020).
The purpose of this phenomenological study was to explore nurse and nurse practitioner (NP) experiences in caring for patients with COVID-19 within greater New York City metropolitan area hospitals during the early weeks of the pandemic, concentrating on perceptions of physical well-being.
Methods
This research addressed the following research question:
Utilizing phenomenological qualitative inquiry, the intent was to explore participants’ meaning-making of a shared lived experience, while concentrating on in-depth participant description and interpretation of the shared phenomenon (Smith et al., 2009/2013). The shared experience for the research encompassed attending to the health needs of COVID-19 patients in the greater New York metropolitan area’s hospitals during the early weeks of the pandemic. Interpretative phenomenological analysis (IPA) was the specific approach used as it allows the researcher to glean a thick, rich description of participants’ unique experiences by requesting them to detail the phenomenon of interest (Smith et al., 2009/2013).
Eight participants were selected for the study; sample size in IPA is intentionally small, emphasizing in-depth quality to “represent a perspective, rather than a population” (Smith et al., 2009/2013, p. 49). Thus, fewer participants permit more time, reflection, and discussion than a larger data set allows. The selection criteria used to recruit the purposive participant sample are as follows: (a) frontline hospital nursing personnel who self-identified as experiencing impacts to their well-being while caring for COVID-19 patients; (b) performing full-time nursing duties for COVID-19-positive patients in the greater New York City metropolitan area during the height of the pandemic in that region; and (c) being in close contact with COVID-19 patients within greater New York City area hospitals.
Eastern University granted institutional review board approval; afterward, participant recruitment began via the researcher’s LinkedIn professional social media requests. The sampling frame included 95 hospitals in the greater New York metropolitan area (66 in New York City and 29 in outlying areas; NYS Health Profiles, n.d.). A helpline number was provided in the event interviews catalyzed distress, along with recommendations to phone a preferred provider.
Semi-structured interviews took place between May and July of 2020 via phone or videoconference. In accordance with IPA, the interview questions were solely focused on investigating the participant’s experience. The researcher deliberately set aside, also known as “bracketed,” her knowledge and opinions of the pandemic (Smith et al., 2009/2013). No themes were established a priori, and the interview questions were intentionally exploratory and open ended. Examples of these general questions include asking participants to describe their experiences working with COVID-19 patients, inquiring about impacts to their well-being, and questioning their management of such impacts. During each interview, probing questions were also used to glean full understanding of the individual participant’s experience. Examples of probing questions include “Can you expound upon that?” and “What feelings did that evoke at that time?” Member checking was performed to ensure data trustworthiness. The member checking process involved participants reviewing their own transcripts to confirm accuracy. A research log recorded the progress of the study (e.g., recruitment requests/responses, interview dates/times) and helped create an audit trail. Reflective writing and note-taking occurred throughout the study. Transcripts were uploaded to Dedoose (2021), a qualitative and mixed methods web application, for analysis. Each transcript was analyzed and line-by-line coding led to reduction of the data. Initial codes were grouped into categories relating to participant experiences and impacts to physical health. These categories included health and safety, personal protective equipment (PPE), exhaustion, sleep, and preparedness.
Results
The eight participants, four registered nurses (RNs), and four NPs working at eight different hospitals were interviewed between May and July of 2020 via phone or videoconference. With the exception of one participant, there was one major interview and one follow-up interview conducted, resulting in a total of 15 interviews. Emergent themes were as follows: (a) safety was the greatest concern of participants, specifically fears of the physical well-being of self, family members, colleagues, and patients; (b) caring for COVID-19 patients led to participants’ physical exhaustion; and (c) most participants specifically mentioned sleep when questioned about physical impacts of caring for COVID-19 patients.
Theme 1: Physical Safety
All participants expressed concern for their physical safety while working with COVID-19 patients. This concern was new for them as they typically felt safe at work. The unknown factors and degree of contagion associated with COVID-19 changed their perceptions of their workplace from a haven providing healing to a potentially dangerous place negatively impacting their health and those with whom they lived. Exacerbating this apprehension was the lack of PPE. Early in the pandemic, the staff was not issued high-filtering N95 masks, even when caring for COVID-19 patients. Participant 5, an NP, explained that she advocated for frontline workers, inquiring about the safety issues of lack of PPE, “How are you asking our frontline staff—both nurses and providers that are actually seeing patients, some of them are positive COVID, and you are not giving them an N95?” Participant 4, an NP, and RNs, Participants 1 and 6, revealed that their managers admonished nursing personnel early in the pandemic for wearing a less-protective surgical mask, unless they had not received the flu vaccine, even if the participants personally provided it. In 2013, New York State mandated that all health care workers in contact with patients wear a mask if they have not received a flu shot to avoid potentially infecting patients (see Caplan, 2013). Because Participant 4 was medically unable to receive a flu vaccine due to a preexisting health condition, she believed that the fact that she was permitted to wear a mask when others could not was the “only thing” that prevented her from contracting COVID-19. Yet, her coworkers were not so lucky. Participant 4 went on to say that COVID testing should have taken place much earlier in her workplace. She approximated that “90 percent of the NPs” that she worked with contracted the disease and “got it bad.” Most others echoed this problem as well. Participant 1, an RN, proffered, “those people who were forced not to wear a mask got sick and started calling out of work.” Participant 5, an NP who contracted COVID, lamented, “so many of us [employees] got sick” and that “we didn’t have enough staff.” Molly reminisced that her coworkers “all got sick at the exact same time.” This left Molly, who had been “nursing for a little over a year” to be “the most experienced person on the floor.” She shared, “I went to work and it was me and two other nurses and maybe no techs. Our unit has 30 beds . . . [we were] just trying to do just whatever we could, basically.” Participant 7 recalled a night where “there were only three nurses on the floor for 60 patients.”
Decreased staffing led to concerns regarding patient safety. Participant 6, an RN, relayed, “it was a different time there because we would have GI doctors covering ICU.” She explained that physician specialists disassociated from ICU care (e.g., gynecology) were pulled to work in the COVID units. She felt, as a nurse, she was to be “responsible” for the patients throughout this time. Participant 6 added, “I felt that my job meant so much at that time because we were the advocates for the patients. We were fighting with the physicians” to try to provide the best care. Participant 7 revealed, “we had psychiatrists, who have not seen a patient [in that capacity] since medical school, rubbing patients down.” The physicians were not the only health care workers who were deployed to unfamiliar territory. Participant 3, while sharing that nearly her entire hospital got turned into a COVID unit, indicated, “all of our nurses in our hospital were redeployed doing things that they were not used to doing.” Participant 5 spoke of a pediatric nurse who was now “managing a 300-pound patient on a lift.” She feared for patient safety, as nurses were deployed with “no training, no nothing, just thrown in there.” Participant 1 concurred, relaying an exchange with a physician who gave orders she was not accustomed to receiving: The doctor said, “Here, hang this Levophed,” and I’m like, “Can this go in the peripheral line or does this have to go in a central line?” And they respond, “The nurses do it.” And I’m like, “I don’t know.” Or they would say, “Oh, nobody did this tie out for the central line.” And I was like, “I don’t know what I’m doing, guys. You tell me. I’m not an ICU nurse, you have to prompt me to do things.” So, that’s how you had to learn what to do. So, people would ask, “Where is your OT tube?” I’m like, “I don’t even know what that is. You tell me. Where is it normally? This isn’t an ICU floor.” They’d ask, “Can you get me Versed?” And I’m like, “It has to come from pharmacy, we don’t keep that here.” So, then I’m running down to pharmacy to try and get Versed. It’s just stuff like that, which I think would’ve been fine if we had more staffing.
Adding to participants’ personal and patient safety concerns was the possibility of infecting family members at home. Participant 6 chose to stay in a hospital-provided hotel to avoid any potential physical danger to her family. Participants 1, 2, 5, and 8 explained how they attempted to clean themselves after their work shifts through what Participant 5 called a “strip routine.” This tedious task involved removing one’s clothing immediately upon entering one’s house, or at the doorstep of the home, securing the soiled clothing in a container, and sanitizing other personal items. The routine ended with a direct walk to the shower, where they would completely scrub prior to interacting with others.
Theme 2: Physical Exhaustion
Inadequate staffing, coupled with the overwhelming number of COVID-19-positive patients, led to physical exhaustion. Participant 2, an NP, was “absolutely exhausted from the increase in the workload,” which also entailed “working more hours.” Prior to COVID, a typical shift would involve “one ICU admission maybe, a night.” Early in the pandemic, she experienced 10 to 12 admissions per shift. She also explained the need to help RNs: Nurses needed help moving patients. They do a lot of prone therapy in ICU, which is essentially just turning a patient on their stomach to improve their oxygenation. In the good old days, this didn’t happen in masses and we had these specialty beds that we put them in that did the work for us. We had to manually turn all of these patients over ourselves.
Other NPs shared similar scenarios of heavy patient admissions. Participant 8 recalled, “It was exhausting . . . no such thing as a break. There was hardly any time to go to the bathroom. Leadership was intently working on getting staff to alleviate the workload. It took about a week.” Participant 5 concurred, noting repeated 12-hour shifts of “no stopping, no time to sit.”
Both RNs and NPs recognized that RNs spent the most time in COVID-positive patient rooms. Participant 1 estimated that RNs went into patient rooms hourly compared with NPs who would enter the rooms approximately 1 hour per shift. This added to physical exhaustion because many nurses were absorbing duties typically covered by other employees. Participant 5, revealed that many hospital employees were not entering patient rooms, except for the nurses. She explicated, “Nutrition [service employees] would leave [patient food trays] outside”; the nurses brought the trays to patients. Then, when she started her morning shift, “the tray from last night is there.” Environmental service employees were not emptying trash inside patient rooms Participant 5 relayed, “if you wanted to get rid of the garbage, you had to put the garbage outside the room and bring it back inside.” All participants exhibited a yearning to provide quality patient care under these extreme circumstances. Participant 5 said, The nurses are running like chickens without their heads. You got this 200-, 400-pound patient. You’re putting them on a bedpan, turning them, and cleaning them . . . inches away from them. Now . . . go into the next room and do the same.
Most participants worked at a frenetic pace for 12-hour shifts during the height of the pandemic.
Theme 3: Sleep
Six participants mentioned sleep when questioned about physical impacts of caring for COVID-19 patients. Participant 2 stated that a day off following a workday was for sleeping, “simply physically trying to recover from what you just did.” Participant 5 shared, “I would just go to sleep. I didn’t have energy for anything.” Participant 4 also responded that her sleep “definitely” increased when questioned about any physical impact of her work with COVID-19 patients.
Participants 1 and 3 experienced both sleep extremes while caring for patients during the pandemic. Participant 3 explained, “I wasn’t sleeping when we first started, when [COVID-19 patients] first started coming in . . . I couldn’t sleep at night; I couldn’t sleep during the day. I was up for days.” While interviewed, she mentioned she now slept more often, “I’ve never slept so much in my life. My days off, I don’t want to get out of bed.” Participant 1 also experienced sleep extremes, finding it problematic to “sleep enough. My sleep decreased. It increased for one week because I think I just couldn’t get out of bed. And then it decreased the rest of the time because I just felt anxious.” Participant 7 was unable to sleep throughout the entire ordeal, sharing, “I haven’t slept a night since COVID.” Thus, while most experienced an increase in sleep at some point, three suffered insomnia, with one participant experiencing insomnia the entire time he worked with COVID-19 patients.
Discussion
The theme of physical safety emerged quite strongly from the data. The lack of PPE at the U.S. onset of the pandemic was problematic within U.S. hospitals. Cohen and Rodgers (2020) named four contributors to the PPE shortage in the United States: (a) a hospital budgeting model that dissuades adequate inventories to minimize costs, (b) significant demand coupled with panic marketplace behavior, (c) federal government’s failure to maintain and distribute domestic inventories, and (d) major disruptions to the PPE global supply chain, which resulted in reduced exports of PPE from countries that the United States had been heavily dependent upon. Participants from this study corroborate the PPE shortages. They complained of lack of protection as hospitals conserved even surgical masks (vs. more-protective N-95 masks). Participants lamented that supervisors scolded employees for attempting to keep themselves from becoming exposed by requesting masks or even when they supplied their own masks in the early stages of the pandemic. Available PPE was guarded and rationed during this time, in part perhaps because some participants revealed that outpatients had been seen walking out with boxes of masks from hospitals because highly sought-after masks were unavailable to purchase at that time during the pandemic. This COVID-19 pandemic serves as a call for action for U.S. hospitals and suppliers to adequately prepare for similar crises to protect employees and prioritize their health. This emergency preparedness may involve more domestically produced PPE. The U.S. dependence on imported specialized PPE is high, according to Dai et al. (2020). They estimated that 90% of N95 masks are imported. Dai et al. also suggested that countries with sufficient inventory of domestically supplied PPE, such as Singapore and South Korea, experienced far fewer cases of clinicians becoming infected with COVID-19 than ill-prepared United States. The equipment is only one link in the chain for a rapid, scalable disaster response in U.S. hospitals. Other elements of consideration are physical space, medical staffing, and the hospital system itself (Harris & Adalja, 2021). No single response will work for individual hospitals, but these key components must be addressed and revisited periodically by hospital administrators as they revise policies and procedures to increase emergency preparedness.
The influx of patients arriving in the Greater New York Metropolitan area hospitals forced hospital administrators to rapidly strategize the management of staff, bed space, and supplies, to provide optimal patient care. The hospitals quickly became overwhelmed, resulting in COVID-19 patients accounting for a significant allotment of patient beds, according to participants. Not only was there a need for trained personnel in large numbers due to the sheer number of incoming inpatients but replacements were also needed for those who fell sick or needed to quarantine. Participants also shared that the deployment of staff from areas unaccustomed to providing care to patients with intensive care needs initially occurred due to lack of appropriate staffing. In addition, the nurses and other health care workers worked extended shifts and attended to more patients than they were accustomed. This created the concern for patient safety for some participants though most acknowledged that hospital administrators did the best they could under the dynamic circumstances. This pandemic highlighted the necessity of advanced preparation, as well as a collaborative network that rapidly disseminates information across systems, such as the newly established National COVID Cohort Collaborative (N3C; Haendel et al., 2021), to be used during widespread health emergencies. The N3C allows the rapid collection and analysis of clinical, laboratory, and diagnostic data from hospitals. The approach is expected to serve as a model for addressing future public health emergencies. A centralized information network was missing early in the pandemic and may have mitigated some participant-experienced problems, such as staff risk uncertainty, PPE availability, and properly trained health care personnel. Instead, individual hospitals or even individual health care workers were left to their own devices as COVID-19 cases and inpatient volume rose considerably each day. Furthermore, hospital administrators must institute policies that ensure the safety of staff members. As this study illustrated, health care personnel safety was not always prioritized, thereby resulting in patient safety concerns due to reduced staffing. Thus, governmental leaders, hospital administrators, and other major stakeholders must collaborate to consider this episode while working toward improved response systems for the future.
Poor sleep quality has been noted in the limited number of studies to date on COVID-related impacts. According to Steier et al.’s (2020) study of 611 British respondents, approximately 75% have experienced sleep changes during the pandemic. More than half of the participants experienced disrupted sleep, more than 40% had difficulties falling or staying asleep, while approximately 25% felt excessively sleepy or developed nightmares. In this study, most (five of eight) complained of bouts of excessive sleepiness, with three mentioning lack of sleep as problematic.
Huang and Zhao’s (2020) survey of 7,236 Chinese adults investigated participants’ COVID-19-related sleep quality. Results showed that health care workers were at high risk for poor sleep, complaining more about sleep quality than those in other occupations. Huang and Zhao’s and Casagrande et al.’s (2020) study of 2,291 Italian residents both showed that younger people (defined as <35 and <30 years of age, respectively) displayed more anxiety-related symptoms, with sleep quality being one of them. Although generalization was not the intent of this study, the six participants who encountered sleep issues enveloped all age ranges. Furthermore, the Casagrande et al. (2020) study found that sleep disorders were more common among females than males. The sole male in the study seemed to suffer disrupted sleep more than most of the females in this study, but again, traditional generalizability is not the intent of qualitative studies. Nonetheless, further research on sleep quality of individuals working in an unprepared health care system during a pandemic is warranted.
Further studies are needed representing other regions of the United States that subsequently experienced overwhelming hospital admissions. In addition, this study involved two interviews of seven of the eight participants that took place up to 4 weeks apart, which was beneficial in identifying some extended impacts (e.g., decreased sleep quality) despite reduction in COVID-19 hospitalizations. A longitudinal study of a greater number of health care workers is justified to determine any long-term physical impacts of caring for COVID-19 patients during high-volume admission periods.
This study identified specific workplace safety issues for nurses and NPs in the hardest hit U.S. metropolitan region at the beginning of the COVID-10 pandemic. Specifically, participants identified PPE availability, lack of centralized knowledge-sharing capabilities, sleep problems, anxiety regarding physical safety of self and others, and insufficient/undertrained staffing. These findings serve as a call for future quantitative research on PPE availability and preparedness, exhaustion, anxiety, and knowledge-sharing mechanisms for all health care workers during the pandemic. The findings are also meant to guide future U.S. health care and hospital policies in increasing the physical safety of nursing personnel.
Applying Research to Occupational Health Practice
This phenomenological study of eight U.S. nurses and nurse practitioners identified a number of workplace safety issues that stemmed from working on the frontlines of a pandemic. The following themes arose from the data: (a) safety was the greatest concern of participants, with fears of the physical well-being of self, family members, colleagues, and patients; (b) caring for COVID-19 patients led to participants’ physical exhaustion; and (c) most participants specifically mentioned sleep when questioned about physical impacts of caring for COVID-19 patients.
Improved pandemic preparedness may have prevented or minimized the adverse impacts. It is advisable for governmental leaders, hospital administrators, and other major health care stakeholders to review these findings to increase nursing safety in the event of a future health care crisis. Furthermore, the study’s findings lay the groundwork for further research on the physical safety of nursing personnel during a pandemic.
