Sprinting in a Marathon: Nursing Staff and Nurse Leaders Make Meaning of Practicing in COVID-19 Devoted Units Pre-Vaccine

Abstract

Objective

To describe the lived experience of nursing staff and nurse leaders working in COVID-19 devoted units (intensive care or medical unit) prior to vaccine availability.

Research Design

Qualitative phenomenological design with a focus group approach.

Methods

The study team recruited a convenience sample of nursing staff (nurses, and nursing assistants/nurse technicians) and nurse leaders (managers, assistant nurse managers, clinical nurse specialists, and nurse educators) at an academic medical center in the midwestern United States. Focus groups and individual interviews were conducted to encourage participants to describe their (1) experiences as nursing professionals, (2) coping strategies, and (3) perspectives about supportive resources. Moral distress was measured with the moral distress thermometer and qualitative data were analyzed with Giorgi-style phenomenology.

Results

We conducted 10 in-person focus groups and five one-on-one interviews (n = 44). Seven themes emerged: (1) the reality of COVID-19: we are sprinting in a marathon; (2) acute/critical care nurse leaders experience unique burdens; (3) acute/critical care staff nurses experience unique burdens; (4) meaning of our lived experience; (5) what helped us during the pandemic; (6) what hurt us during the pandemic; and (7) we are not okay. Participants reported a moderate level of moral distress (M = 5.26 SD = 2.31). They emphasized that peer support was preferred over other types of support offered by the healthcare organization. Participants expressed positive feedback about the focus group experience and commented that group processing validated their experiences and helped them “feel heard.”

Conclusion

These findings affirm the need for trauma-informed care and grief support for nurses, interventions that increase meaning in work, and efforts to enhance primary palliative communication skills. Study findings can inform efforts to tailor existing interventions and develop new, more comprehensive resources to meet the psychosocial needs of nursing staff and nurse leaders practicing during a pandemic.

Keywords

COVID-19 adaptation psychological psychological distress grief intensive care units leadership nurses

Introduction/Background

Nurses have experienced psychological trauma while caring for patients who were deteriorating and dying from COVID-19 (Leng et al., 2020; Wang et al., 2020). One of the greatest challenges for nurses caring for COVID-19 patients early in the pandemic was witnessing their extreme hypoxemic respiratory failure which was unresponsive to typical interventions (Hajjar et al., 2021; Leng et al., 2020; Wang et al., 2020). In the first two years of the pandemic, the death rate on many clinical units was double or triple pre-pandemic rates. While nurses worked diligently to provide supportive care to COVID-19 patients, they were demoralized by the high mortality rate (Galehdar et al., 2020; Joo & Liu, 2021). Clinical nursing interventions often did not improve outcomes for seriously ill COVID-19 patients (Deliktas Demirci et al., 2021; Dohrn et al., 2022).

Nurses have been physically and emotionally taxed during COVID-19 (Hall, 2020; Lai et al., 2020; Leng et al., 2020), and have experienced post-traumatic stress symptoms (Dohrn et al., 2022; Greenberg et al., 2021; Guttormson et al., 2022; Leng et al., 2020). The consequences of the high intensity workload and short staffing include overwhelming fatigue, sleep disturbances, eating problems, anxiety, acute stress disorder, and loneliness (Leng et al., 2020; Shechter et al., 2020; Wang et al., 2020). In fact, a high proportion of healthcare professionals may be struggling with their mental health, some with clinically significant symptoms of depression and anxiety (Pappa et al., 2020). In addition to extreme psychological burden, nurses also experienced other psychosocial and even physical burdens, such as social stigma and discomfort from personal protective equipment (PPE) use. The pandemic is contributing to nurses’ moral distress and burnout (American Association of Critical-Care Nurses, 2020). The consequences of unresolved moral distress and burnout include frustration, fractured team cohesion, inadequate communication and collaboration, and disengagement and attrition, exacerbating the workforce shortage (Christianson et al., 2022; McAndrew et al., 2018). Nurses who withstand the unrelenting stress and remain in practice may experience fear and dread regarding the potential for additional surges and new pandemics.

Review of Literature

Nursing literature regarding the COVID-19 pandemic has focused on the experiences and outcomes of nurses (Chegini et al., 2021; Deliktas Demirci et al., 2021; Dohrn et al., 2022; Gunawan et al., 2021; Joo & Liu, 2021; Moradi et al., 2021; Muz & Erdoğan Yüce, 2021; Sun et al., 2020); few have examined the experiences of nurse leaders. At the time of this study there was a limited body of literature on nurses’ perspectives about supportive resources provided by their organization (Shechter et al., 2020). To address these gaps, the research team conducted focus groups and individual interviews to help nursing staff and nurse leaders reflect on their practice; acknowledge their emotions; consider their relationships with patients, families, and colleagues during the pandemic prior to the availability of vaccines; and make meaning of their lived experiences. The study team responded to the Advisory Board's (Advisory Board, 2020) recommendations to create forums in which healthcare professionals can discuss their experiences and identify preferred support that fits into their day-to-day practice.

Methods

Theoretical Framework

Phenomenology was selected as the method of inquiry. The study was guided by the theory meaning reconstruction, a bereavement framework (Gillies & Neimeyer, 2006). This is a novel application of meaning reconstruction to the experiences of nursing staff and nurse leaders who may be grieving the unprecedented loss of patients, as well as the loss of their professional role as they have known it.

During times of profound stress and loss, meaning-making is a way to make sense of the world (Gillies & Neimeyer, 2006; Park, 2010), relieve distress, and promote personal growth (Breitbart, 2016; Frankl, 1946). Sharing stories of one's lived experience can initiate a process of reconstructing meaning through the elements of sense-making, benefit finding, and identity change (Gillies & Neimeyer, 2006; Rolbiecki et al., 2019) (Figure 1). Sense-making helps one explore the reasons why events happened in a certain way and process the impact these events have on one's life (Gillies & Neimeyer, 2006). For nursing staff and nurse leaders, revisiting significant patient care stories and processing their emotions can help them make sense of patient and family suffering, as well as their own experiences of sorrow as a professional caregiver. Benefit finding is examining the potential positive outcomes in a difficult experience (Gillies & Neimeyer, 2006), such as deeper emotional connection or a new understanding of another person's perspective. As nurses process their experiences they may be able to recognize the importance and value of their unique contributions to patient and family care. Identity change is an outcome of reconstructing meaning and can stimulate personal growth (Gillies & Neimeyer, 2006). By sharing reflections on how they have changed, nursing staff and nursing leaders may come to appreciate new aspects of their professional identity.

Figure 1.

Conceptual framework.

Design

A qualitative phenomenological design with a focus-group approach was selected for this study. Quantitative data on nurses’ and nurse leaders’ self-reported levels of moral distress were also collected in order to describe aggregate levels of moral distress at the time of participation in the study. This information provided context for the qualitative data.

Research questions:

What was the lived experience of nursing staff (nurses, nursing assistants, and nurse leaders—managers, nurse educators, clinical nurse specialists) working in acute and critical care during the height of COVID-19 and what were their moral distress levels at the time of participation in the study?

What are specific interventions and resources that nursing staff and nurse leaders believe supported their well-being during the height of the pandemic or have the potential to support their well-being?

How do nurses perceive the meaning-making process used in this study (emotions, experiences, and perspectives are shared and explored in a group setting) and do they believe this process is feasible and acceptable for nurses and nurse leaders?

Setting/Sample

This study took place at a large academic medical center in midwestern United States. The study team recruited a convenience sample of nursing staff (nurses, nursing assistants, or nurse technicians), and nurse leaders (managers, assistant nurse managers, clinical nurse specialists, and nurse educators) who worked in dedicated COVID-19 units (ICU or medical unit). Data collection (January 9, 2021 to February 24, 2021) aligned with the downtrend of the hospital's first surge in COVID-19 patients.

Inclusion Criteria

Nursing staff and nurse leaders eligible to participate were: (1) at least 18 years old (2) English speakers, and (3) currently practicing in a COVID-19 devoted unit directly caring for patients or in leadership.

Ethics

This study was approved by the research site's Institutional Review Board (PRO00039329). All participants engaged in an informed consent process. Those who participated in-person signed a consent form; those who participated via phone or Zoom provided verbal consent which was audio recorded. After participation, nurses were given a handout of resources for supporting well-being offered by the organization.

Instruments

The research team collected demographic and work-related characteristics. Participants completed the moral distress thermometer (MDT) a validated instrument that has been used to measure moral distress among nurses (Wocial & Weaver, 2013). The MDT is a single-item 11-point (0 to 10) scale that describes moral distress (none to worst possible) within the past week (Wocial & Weaver, 2013). The study's conceptual model guided development of the interview guide (Figure 2). Nurses completed open-ended questions about the acceptability (satisfaction) and feasibility (how easy was it to participate) of the focus group via Qualtrics.

Figure 2.

Interview guide for focus groups.

Trustworthiness

To ensure trustworthiness in the data collection and analysis process (Lincoln & Guba, 1985), the following actions were taken to address credibility: member checking (nurses provided feedback on results); examining data for the negative case; and study team debriefings about reactions to and interpretations of the data. To address transferability the study analysis team provided rich descriptions of the findings and included participant quotations. For dependability of the research process, members of the team that were not involved in the analytic process provided an inquiry audit. Finally, to address confirmability, the study team created a detailed audit trail of the data collection process and analytic decisions. The study team also engaged in the process of reflexivity in which the background of each researcher was considered and how it may have influenced the research process. Study team members were nurses who had practiced in various specialties, including critical care. The principal investigator (PI) leading the analytic process had not practiced as an ICU nurse during the COVID-19 pandemic.

Procedures

Study advertisements included flyers and emails, as well as hospital newsletters. Focus groups, limited to seven participants, were held after shifts in a conference room. Nurses could attend without pre-registering. If only one participant arrived for a session we conducted an individual interview to allow the participant to share their story. Nurses unable to attend an in-person focus group could participate in a one-on-one interview via Zoom or phone. Leadership teams registered in advance to participate together in the same leadership focus group.

Focus groups help researchers create a milieu in which participants can freely discuss their opinions, experiences, and insights about a phenomenon of interest (Onwuegbuzie et al., 2009). Each focus group began with broad questions and used probes to further explore ideas shared by participants (Finch et al., 2014). Focus groups were led by the PI and an additional research team member served as a co-moderator, observing non-verbal behaviors and recording field notes.

At the conclusion of the focus group discussion participants were asked to share their thoughts about their focus group experience. Nurses were later emailed a brief survey via Qualtrics to further comment on the feasibility and acceptability of this focus group experience. Participants who provided permission for the research team to contact them were invited to review and validate study findings.

Analysis

Participants’ work characteristics were analyzed with frequencies and percentages and responses on the MDT with descriptive statistics (mean and standard deviation). Giorgi's phenomenological method guided the analysis of the qualitative data (Giorgi, 1997). First the study team identified natural meaning units (close to the language of participants). Then the team regrouped and redescribed statements into focal meaning units (moving participant language into researcher language). Exemplary narratives were selected to illustrate themes and subthemes (Giorgi, 1997). The analytic process was initiated by having three research team members read the transcripts of the focus groups and interviews while concurrently listening to the audio-recording. They discussed and logged their initial reactions to the data. Each of these researchers independently coded two focus groups and then collaboratively developed an NVivo codebook. Using this codebook, the researchers independently coded three focus groups and compared their coding to ensure consistency. The research team conducted member checks with three participants to validate the analysis.

Results

Sample Characteristics

A total of 44 nurses and nurse leaders participated in the study (Table 1). The sample consisted of staff nurses (59%), nurse technicians (5%), and nurse leaders (36%) working in the medical ICU, cardiovascular ICU, and acute care units. Clinical experience ranged from six months to 20 years. The majority of participants were prepared at the baccalaureate level (80%) and more than half were 31 years of age or older (56%). The research team held a total of 10 focus groups and five one-on-one interviews ranging from 37 to 96 min (Table 2). Moral distress was moderate across all focus groups (M = 5.26, SD = 2.31).

Table 1.

Participant Characteristics.

Characteristic		N (%)
Role	Staff RN	26 (59.1%)
	Nurse Technician	2 (4.5%)
	Nurse Leader	16 (36.3%)
Unit	MICU	17 (38.6%)
	CVICU	15 (34.1%)
	Acute Care	12 (27%)
Time working on unit	6 months to 2 years	17 (38.6%)
	3 to 5 years	15 (34%)
	6 to 20 years	12 (27.2%)
FTE	0.80 or less	8 (18%)
	0.90 to 1.0	35 (79.5%)
Degree	Not reported ^a	9 (20.4%)
	BSN	35 (79.5%)
Age	18 to 30 years	19 (43%)
	31 to 61 or older	25 (56%)

Some demographic data not reported as small numbers could potentially identify participants.

Table 2.

Focus Group/Interview Information and Moral Distress Levels per Moral Distress Thermometer (MDT).

Focus group information	N (%)	M(SD)
Focus group information	N (%)	Range
Total number of interviews or focus groups	N = 15
In-person focus groups	N = 10
In-person one-on-one interviews	N = 2
Virtual one-on-one interviews (phone or Zoom)	N = 3
Total number of focus group participants	N = 10 (67%)
Total number of one-on-one interviews	N = 5 (33%)
Average number of participants per focus group		3.89(1.62)
		2 to 7
Focus group/Interview length		64.67(15.63)
		37 to 96 min
Moral distress per MDT		5.26 (2.31)
		0 to 9^a

Per MDT, 0 = no distress and 9 = highest distress.

Qualitative Findings

Seven themes were uncovered from analysis of the focus group/interview data (Table 3). Themes 2 and 3 illustrate differences in nurse and nurse leader experiences. All other themes represent a shared nurse and nurse leader lived experience.

Table 3.

Themes and Subthemes.

Theme	Subthemes
Theme 1: The reality of Covid-19: We are sprinting in a marathon	Challenges of patient and family care Extreme impact on our mind, spirit, body, and soul Professional and personal losses Whirlwind of changes every minute
Theme 2: Nurse leaders in acute/critical care experience unique burdens	Feeling helpless as a leader Leading through uncharted territory
Theme 3: Staff nurses in acute/critical care experience unique burdens	I am doing it all alone Moral injury
Theme 4: Meaning of the lived experience	Layers of impact Deeper relationships and stronger teamwork Dedication to patients Family takes away the burden of death Importance of caring for myself and my family
Theme 5: What helped us during the pandemic	Coping strategies We stay for our team Resources
Theme 6: What hurt us during the pandemic	Social isolation Inadequate resources and support Inadequate palliative care
Theme 7: We are not okay	We are forever changed

Theme 1: The Reality of COVID-19—We are Sprinting in a Marathon

One participant described what it was like to be a nurse during the first surge of COVID-19: “I feel like we’re sprinting in a marathon and everyone else is going at a nice pace” (Focus group 5).

Challenges of patient and family care. Nurses described the unique presentation of COVID-19 patients. “Caring for a COVID patient is very different than caring for a non-COVID patient…We basically had to relearn how to nurse, which was a lot. Normal treatment plans and disease processes that you would expect, and can anticipate, and can treat, didn’t apply” (Focus Group 2). Nurses felt powerless as patient advocates. “I feel like a big part of our role as nurses is to be advocates for our patients and when you feel like that's not enough and no one's listening and you can’t get what you need…that wears you down” (Focus Group 11). A nurse reflected, “It's hard because they (family) don’t get to see how sick their family members are, and they’re the ones making decisions to continue full support while their family member's probably been intubated and prone for a week straight” (Focus Group 6). Nurses astutely realized they should help the patient reach out via phone to the family as it could be the last time their family would hear their voice. This was particularly disconcerting when the patient was a parent with young children. Reflecting on the impact of visitor restrictions on the family, a nurse explained, “We are not allowing them (families) to have closure. And what kind of nightmares are family members going to have from their loved one dying (without their presence)” (Focus Group 12).

Extreme impact on our mind, spirit, body, and soul. Nurses described difficult working conditions, including limited PPE and long shifts without breaks leading to emotional exhaustion, anger, and symptoms of post-traumatic stress. Over time, patient care challenges took an emotional toll on nurses. “I just feel a little more hardened….I’m a little more numb to it … which is a big, big change” (Focus Group 3). A nurse explained her relief when she learned that “feeling numb” is an expected symptom of post-traumatic stress. Another nurse shared, “I snap all the time. I have no patience anymore. Some of the things that we’ve seen here continue to affect me personally, because you think about it all the time and it's devastating” (Focus Group 7). One nurse talked about her sleeping difficulties, “The nightmares were really bad. Waking up with night sweats, not sleeping. I’d either wake up crying or I’d be screaming. And they (the nightmares) always revolved around death” (Focus Group 12).

Professional and personal losses. Nurses did not enjoy coming to work, with one nurse explaining, “There were a lot more bad days at work than there are good days” (Focus group 8). Another asked, “What is joy? There were days I would sit there and be like, “I find joy in nothing.” (Focus Group 2).

Whirlwind of changes every minute. Nurses and nurse leaders described the difficulty of trying to keep up with constant, sometimes hourly, pandemic-related practice changes.

Theme 2: Acute/Critical Care Nurse Leaders Experience Unique Burdens

Feeling helpless as a leader. Providing directives to nurses in which they had little input was disempowering for nurse leaders. Nurse leaders wanted to do everything in their power to help staff but often there was nothing they could do but listen. “Every day…was being sort of this receptacle for people's pain” (Focus Group 10). Another leader talked about how difficult it was to see nurses return to work after a few days off. “On their first day back they would sit down at the table (for report). They would look up at the board at all the Covid patients and their eyes would start filling up with tears” (Focus Group 4). Leaders also had to learn to discern whether staff were in crisis or experiencing the day-to-day distress that became the new normal with COVID-19. A focus group reflected:

Speaker 2: You can really tell when someone is not doing well because they just explode.

Speaker 1: You can tell they snapped. That their personality kind of shifts (Focus Group 10).

Leading through uncharted territory. All leaders expressed that the strength of their leadership was tested during the pandemic. A nurse leader talked about her intention to protect nurses. “We had to figure out how to get them on the right page and make sure that they felt supported and how they could do their job to the best of their ability with the information we had at that time” (Focus Group 15). Another leader shared, “They’re scared. They need people to make sure they have what they need. We knew nothing about Covid… and these nurses were going in and out of these rooms” (Focus Group 4). Another challenge for leaders was onboarding new staff. “We saw like 25 nurses quit….we've hired a bunch of people and we’re trying to keep them, but we’re exhausted … It's really hard to onboard people while we’re so exhausted” (Focus Group 6).

Theme 3: Staff Nurses in Acute/Critical Care Experience Unique Burdens

Doing it all alone. “I do everything. I do the cleaning. Half the time I’m the physician or the pharmacist, I just feel like I’ve got so much on my plate sometimes” (Focus Group 7). Nurses were one of few healthcare professionals designated to enter patient rooms during the height of the pandemic which made nurses feel “like a line item” and “dispensable” (Focus Group 2).

Nurses were advised to limit the frequency and duration of patient contact, and yet, they still had to complete necessary care and intervene when patients were in distress, thus increasing their exposure time. The required PPE was bulky and hot. “I think about…insane frustration with having to go in rooms wearing all that we wear, when a lot of these patients are very confused and pulling off their oxygen and ‘satting’ at like 60 percent. And you put it all back on again and gather yourself and put their oxygen back on and restrain them, put the mitts on, whatever you have to do. It starts all over again, and it's just exhausting” (Focus Group 6).

Nurses did not want to leave their coworkers without help, so they worked overtime even when they did not want to. Nurses wanted others to understand the difficulty of their jobs. “I just wish everyone could see a day in the life of a Covid ICU nurse and what it is like to have all these patients intubated and paralyzed and flipped up and down” (Focus Group 2).

Moral injury. Nurses described moral injury attributed to the challenges of helplessly watching patients suffer.

Speaker 4: If you look at them (patients) in the bed…breathing so heavy and hard that the whole bed is shaking. 50 or 60 a minute…

Speaker 2: Their faces are purple.

Speaker 1: They’re blue.

Speaker 2: It's honestly gruesome to watch.

Speaker 4: We don’t even make eye contact with the patients because that's when you mess up. (Focus Group 8)

There were times when there were so many deaths that the units ran out of body bags. “I literally can’t do anything to help these people and I just stand there and watch them for 12 h of suffering (Focus Group 8).

Theme 4: Meaning of the Lived Experience

Nurses and nurse leaders discussed the meaning of working in their professional roles during the pandemic, and reflected on how the pandemic changed them as a person.

Layers of impact. “The emotional impact on the patients themselves and their family members, the impact of the distress on my peers and my leadership team, as well as the staff–there are so many layers to it” (Focus Group 12). Others talked about broader societal impacts, such as job losses, suicides among young people, and the financial fallout on families when people die (Focus Group 12). As nurses became more in-tune with the distress of their colleagues, they worked hard to be emotionally present to support them (Focus Group 2). Nurses knew that it was important to talk with others about their experiences. “I do worry if people are trying to go through this alone without sharing because you can’t. It will just consume you” (Focus Group 2).

Deeper relationships and stronger teamwork. A nurse leader reflected on her observations of staff, “Because they became a family in all this … this has deepened their relationships” (Focus Group 15). Leaders also discussed the new and deepened bonds that they formed with other leaders. “So as a leadership team, we kind of bonded together in supporting staff and that made things a little bit easier.” (Focus Group 15).

Dedication to patients. While it was incredibly hard to care for the COVID-19 population, nurses became protective of these patients. “I don’t want someone else to take care of them because I feel like we know what we’re doing now finally after 11 months” (Focus Group 5). One nurse shared, “I am dedicated to this patient. And I did CPR on her for three hours after caring for her for the last month and a half” (Focus Group 7). The nurses described their efforts to preserve the patient's dignity and to ensure they would not die alone.

Speaker 1: A nurse came to me this morning because we had a patient that was expected to die. We (two nurses) both were like, “We have to go in and hold their hand quickly.” It's become a thing in the last couple of months, which I like. I went in to hold this patient's hand and another nurse came in to support me.

Speaker 4: I used to work in an end of life unit prior to coming here. I think it's always felt like an honor to be someone who can be at someone's side at their worst hour and be there supporting them and their family. But I think it's taken another meaning now with Covid (Focus Group 5).

Family takes away the burden of death. Nurses caring for COVID-19 patients faced new challenges when patients’ families were unable to be physically present at the bedside. A nurse reflected on her previous thinking regarding families in the ICU. “They (family) can sometimes put more stress on our job and it is hard to meet the patient's needs and the visitor's needs. And when that (family visitation) was taken away, I think we’ve misjudged how important they (families) actually are” (Focus Group 12). This participant explained that families are important to nurses “because they take the burden of death away from us” (Focus Group 12). A consequence of the pandemic was that nurses improved their palliative communication skills as they navigated a high volume of emotionally painful discussions with families by phone regarding goals of care and end-of-life.

Importance of caring for myself and my family. Nurses explained that the strain of the pandemic taught them the importance of setting boundaries (Focus Group 5). A nurse commented, “Extra money is nice but you got your mental health to look after!” (Focus Group 13). A nurse leader commented, “But instead of just pouring and pouring and pouring, I’ve learned I need to focus on caring for myself…And it's the hardest lesson for me to learn” (Focus Group 15). Nurses shared their need to address the needs of their own families, which was also challenging during a pandemic. One group clarified their personal values as they discussed how they wanted to die should they be in the same situation:

Speaker 4: We all said, do not put us on ECMO. So if I get Covid and they say I have to cannulate you, No, just withdraw (treatment).

Speaker 2: I think a lot of us have gotten POAs (Power of Attorneys) and paperwork together more urgently than we would of previously (Focus Group 7)

Theme 5: What Helped us During the Pandemic

Coping strategies. Some nurse leaders used humor to help them through (Focus Group 10), while others found distractions that could help them avoid the constant pain they witnessed in their practice (Focus Group 2). A nurse shared, “You light a candle…and you try and focus on the moments that you were honored to hold the patient's hand versus the sad turn of events” (Focus group 4).

We stay for our team. A nurse shared, “I love my coworkers. I love talking to them. I don’t want to do (my nursing practice) anywhere else” (Focus Group 3).

Resources. While many resources were available, participants shared that peer support was preferred. Across the focus groups, nurses discussed the value and importance of sharing their emotions and experiences with fellow nurses who understood what it is like to be a nurse during a pandemic. However, it was difficult for some nurses to be vulnerable and show their emotions. A nurse explained, “It was more like a sense of embarrassment to expose myself so much and break down and cry about things in front of coworkers, thinking, I am the only one getting this upset” (Focus Group 7). Another nurse shared, “I think the thing that impacted me the most, and my colleagues in talking to them, was peer support rounding. Someone there acknowledging the work that you are doing and being there…to listen” (Focus Group 1).

Despite efforts across the organization to provide support, nurses pointed out that there are still missing components. One nurse leader explained that nurses want to feel more appreciated (Focus Group 4). Another nurse reflected on the need for, “Better training for us as staff to actually notice when people hit their stress points, their limits” (Focus Group 1). Patients’ recovery stories helped nurses see the importance of their work and motivated them to continue to do their difficult job.

The thing that kept my mental health strongest was a patient who was one of our first Covid patients who we intubated and put on CVVH. He was up and down and doing better and worse. Then he started getting better and better. I cared for him through the entire course of his stay. I got to bring his wife in to visit him for the first time in three months. And that was beautiful and probably the only thing that kept my head above water for the first few months of dealing with this. I was very blessed to have him as a patient for so many times because that progression kept me going… (Focus Group 3)

Theme 6: What Hurt us During the Pandemic

Nurses and nurse leaders discussed many factors that made their already difficult jobs more challenging professionally and personally.

Social Isolation . Nurses and nurse leaders discussed how the initial overwhelming support from the public at the start of the pandemic shifted to a lack of support (Focus Group 3). Nurses recognized that for the general public, “If you don’t see it (the Covid surge in the hospital), you don’t believe it” (Focus Group 10). Some patients’ families who were Covid deniers made their jobs more difficult. Another focus group reflected on the idea that people have lost human connection during the pandemic and “We no longer empathize…We almost look for something that sets us apart…so we don't have to understand the pain they are going through” (Focus Group 7). Others had to take a break from people in their personal lives because of their choices to not follow pandemic guidelines (Focus Group 8). Nurses described feeling very isolated and alone and even experienced stigma early in the pandemic, “It hurts when somebody you know is trying to avoid you because of what you do” (Focus Group 11). A nurse leader explained the challenges of leadership during the pandemic, “There was so much animosity between staff and leaders. We would hear the frustration because the upper leaders were overwhelmed and the staff didn’t feel supported” (Focus Group 15).

Inadequate resources and support. Nurses expressed frustration that they could not “see” executive leadership early on in the pandemic. Nurse leaders acknowledged they were emotionally unprepared for what they and their staff would face in clinical practice during the pandemic (Focus Group 15). The reuse of PPE early in the pandemic was terrifying for nurses, “Having to reuse the N95s…I felt scared. I would use the same N95 for two months straight” (Focus Group 1). Nurse leaders were conflicted about telling staff to do things that were not evidence-based due to the shortage of supplies (Focus Group 10). There was a great sense of guilt among leaders because they could not fully protect staff nurses who had to go in and out of COVID-19 rooms.

Inadequate palliative care. One group compared end of life care before and during the pandemic, “I feel like the end of life stuff has been . . . a lot more aggressive with this (pandemic). Before COVID, I feel like people could have that dignified kind of death, just be at peace (Focus Group 11).

Theme 7: We are not Okay

We are forever changed . A nurse explained, “I don’t know that one can ever heal or recover from the level of trauma that we’ve experienced in the last 10 months” (Focus Group 2). Another nurse shared, “That's it. We’re not okay. I can’t even think of when the pandemic is going to be over. I can’t even fathom to think of when things will be back to “normal” (Focus Group 7). A sentiment shared across groups was best captured by the statement, “I think we’ll be forever changed, most of us, in some way” (Focus Group 10).

Focus Group Acceptability and Feasibility

Table 4 highlights comments from nurses who responded to open-ended questions (n = 18) about the feasibility and acceptability of the focus groups. Overall, the comments support the acceptability of group-based processing. While one nurse commented that the discussion “brought back unwanted feelings,” most nurses commented that talking to the group was helpful in working through shared trauma. Although it required a time commitment, nurses shared that participating in the study was useful and feasible.

Table 4.

Acceptability and Feasibility of Focus Group Processing (n = 18).

Acceptability/Feasibility	Nurse comments
Acceptability	“I was very comfortable talking about my experiences and it was therapeutic in a way to have an outside party listen to our stories”
Acceptability	“It felt refreshing to…(have) my voice heard.”
Acceptability	“Think about some things I hadn’t yet thought about.”
Acceptability	“People might not realize the ability to discuss their feelings will actually help them cope better.”
Acceptability	“Participating in the focus group has made me look over the last 10 months and see how much has changed.”
Acceptability	“I thought it was quite healing to reinforce that my fellow co-workers are going through the same thing as I am”
Acceptability	“A nice way to collectively share our experiences and struggles as a team.”
Feasibility	“I would recommend continuing this practice in the future for staff on a more regularly scheduled basis.”
Feasibility	Suggestion: “An online format would help ensure staff did not have to drive to work (to participate) outside of work hours.”

Discussion

This study described the lived experience of nursing staff and nurse leaders working in COVID-19 devoted units prior to vaccine availability. To our knowledge, this is the first exploratory study of nurses’ experiences caring for patients with COVID-19 that applied a bereavement framework. Coping with loss requires the construction of a new reality in which one's view of the self and the world are vastly different (Gillies & Neimeyer, 2006; O’Connor, 2003). Findings from this study suggest nurses were still in the process of meaning reconstruction during the timeframe of this study. During the focus group discussions, nurses were making sense of bearing witness to so much death. They expressed appreciation for the opportunity to process this with colleagues who understood the intense experience of nursing during a pandemic.

By including nurse leaders, this study makes a unique contribution to the literature on the impact of the COVID-19 pandemic on healthcare professionals. While nurse leaders and staff nurses shared many of the same burdens, nurse leaders faced the challenge of implementing top- down administrative directives while supporting their staff, which tested their leadership. Consistent with emerging literature (Arcadi et al., 2021; Gunawan et al., 2021), nurses participating in this study felt exhausted and overwhelmed by rapid changes to practice. Nurse leaders were protective of nursing staff and determined to ensure that nurses had a voice during continual changes to protocols. They listened and absorbed staff suffering, increasing their own trauma. They deepened their bonds with fellow leaders, as did nurses with their colleagues.

This study was conducted during the downtrend of the first COVID-19 surge. Given the timing, the finding of moderate moral distress levels for nurses and nurse leaders points to the possibility that the pandemic created moral residue (Epstein & Hamric, 2009). Of concern, nurses in this study described experiences of moral injury. Moral injury occurs when one violates their personal or professional ethics in a high stakes situation (Richardson et al., 2020). Nurses felt tremendous guilt about their inability to relieve the immense suffering of their patients. Nurses were traumatized by delivering bad news to families and facilitating tragic telehealth visits between unresponsive patients and their families. Nurses expressed feeling hardened and numb and felt demoralized by being unable to fully provide the palliative and end of life support they felt their patients deserved. Other qualitative studies report similar findings (Dohrn et al., 2022; Galehdar et al., 2020; Gordon et al., 2021). In a study of 595 healthcare professionals, nurses reported the highest incidence (38.1%) of clinically significant moral injury (Rushton et al., 2022). Described as a “soul-ceasing experience,” moral injury often leads to a sense of betrayal (Richardson et al., 2020). This aligns with our findings that while nurses felt supported by their nurse unit leaders, they felt abandoned by the interprofessional team, high level administration, their communities, and society as a whole.

ICU nurses reported higher PTSD symptoms compared to recent veterans or patients after traumatic injury (Guttormson et al., 2022). Although we did not quantitatively measure PTSD or moral injury, nurses in our study described experiencing symptoms of PTSD and moral injury. For these nurses, the continuous exposure to death and the dire situation of limited resources was seared into their memories. Nurses and nurse leaders described their awakening when they acknowledged their post-traumatic stress symptoms. They had not anticipated they would have to consider post-traumatic stress as a daily hazard of their job.

Two systems issues that greatly impacted nurses’ and nurse leaders’ experiences was the lack of preparation for the pandemic and the depletion of resources that were essential to safely caring for the COVID-19 patient population (Chegini et al., 2021; Dohrn et al., 2022; Gunawan et al., 2021; Muz & Erdoğan Yüce, 2021). Across these studies, and captured in our subtheme of “inadequate resources and support,” nurses describe their shock, fear, and anger about how they did not have the tools and resources to do their job adequately and safely. Lack of healthcare system readiness was the root cause of their sense of fear and helplessness. Through pandemic lessons learned, nurses and nurse leaders can provide the roadmap for organizations to ensure that they are fully prepared for such future pandemics and other public health emergencies.

A resounding message from nurses in our study was that talking to other nurses who understood their story was their preferred strategy for coping. Peer-to-peer support program for healthcare professionals is an emerging strategy for health care systems to support their staff. At the time of our study, our hospital system had just launched a new peer-to-peer support training program. In a pilot of a peer support program conducted pre-pandemic, nurses reported their colleagues as the most important source of support, and of the respondents who received the peer support intervention, 100% found it helpful and would recommend it to others (Graham et al., 2019). This aligns with our results suggesting that a peer support intervention would be preferred and valued by nurses who are living through a pandemic.

Our findings suggest that an intervention for nurses that targets emotional distress is warranted. For example, Rosa et al. (2022) are adapting meaning centered psychotherapy (MCP) for healthcare professionals (MCP-HCP) (Rosa et al., 2022). MCP targets spiritual/existential distress by helping participants connect and reconnect to meaning and purpose (Breitbart et al., 2018, 2012, 2010, 2015). Outcomes of MCP include decreased anxiety and depression and increased spiritual well-being and quality of life (Breitbart et al., 2018, 2012, 2010, 2015). To date, there are few interventions that target existential distress among nurses. MCP-HCP could be delivered in a group format, which is responsive to the desire of nurses in our study to process their experiences with fellow nurses. MCP-HCP could also lay the foundation for creating moral communities where nurses can feel like they matter and the work they do makes a difference (Epstein et al., 2020).

Strengths and Limitations

This was a single site study at an academic medical center. The nurse and nurse leader sample reflects a subset of the larger nursing population working with COVID-19 patients at our institution. Self-selection bias likely impacts our results. We made considerable efforts to obtain a representative sample of nurses by extending our recruitment activities until there was no further interest in participation. The study team offered both focus groups and one-on-one interviews to accommodate the burden and stress of the pandemic. Those who participated in one-on-one interviews did not have the opportunity to experience meaning reconstruction with their peers, an aim of the study.

Implications for Clinical Practice

A clear message from our study and the broader literature is the need for systems to create policies and an infrastructure that supports nurses. Nurses in our study suggested that organizations offer training so nurses could recognize mental health crises among their peers. Peer support programs for nurses require further evaluation and testing. When comparing the health of the work environment from 2018 to 2021, there were dramatic decreases across all domains and moral distress ratings doubled (Ulrich et al., 2022). Further, pandemic preparation is a critical priority to ensure that healthcare organizations can provide adequate support to keep their staff safe (e.g., appropriate PPE), as well as address their psychological well-being (trauma-informed care and grief support) (Arabi et al., 2021). As nurses reconstruct meaning in this time of tremendous loss there is opportunity to promote the health of the work environment. A promising strategy is building an ethics infrastructure that supports nurses (Schlak et al., 2022). For example, a moral distress consultation service (Hamric & Epstein, 2017) could help nurses work through the moral injury they have endured, critically reflect on their experiences, and use the lessons they have learned from their experiences to transform healthcare.

Conclusions

We captured the perspectives of both nurses and nurse leaders, and noted that each experienced unique burdens based on their professional role. Nurses had to absorb the suffering of patients and families, while nurse leaders absorbed the suffering of their staff. As nurses and nurse leaders reconstructed the meaning of their experiences, they recognized that their team was a critical source of support that allowed them to continue to do their work. Importantly, nurses and nurse leaders who participated in this study valued the opportunity to process the meaning of their experiences; thus, group-based meaning-making for nurses is an important area for intervention development and testing. Organizations need to partner with nurses and nurse leaders to determine how to meet their ongoing need for support as we recover from one of the most tumultuous times in healthcare.

Footnotes

Acknowledgments

We express our deep appreciation to the nursing professionals who shared their stories and the nurse leaders who supported the project.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Natalie S. McAndrew

Jacqueline Christianson

References

Advisory Board (2020). Three strategies to build baseline emotional support (pp. 3–11). Advisory Board. https://www.advisory.com/research/nursing-executive-center/resources/2020/three-strategies-to-build-baseline-emotional-support?WT.mc_id=Email|Q320|RESEARCH + DOM|NEC|Resource|3 + Emotional + Support + Strategies

American Association of Critical-Care Nurses (2020). Moral distress in times of crisis. https://www.aacn.org/nursing-excellence/healthy-work-environments/∼/media/aacn-website/policy-and-advocacy/stat-20_position-statement_moral-distress.pdf.

Arabi

Y. M.

Azoulay

Al-Dorzi

H. M.

Phua

Salluh

Binnie

Hodgson

Angus

D. C.

Cecconi

Fowler

Gomersall

C. D.

Horby

Juffermans

N. P.

Kesecioglu

Kleinpell

R. M.

Machado

F. R.

Martin

G. S.

Meyfroidt

Citerio

(2021). How the COVID-19 pandemic will change the future of critical care. Intensive Care Medicine, 47(3), 282–291. https://doi.org/10.1007/s00134-021-06352-y

Arcadi

Simonetti

Ambrosca

Cicolini

Simeone

Pucciarelli

Alvaro

Vellone

Durante

(2021). Nursing during the COVID-19 outbreak: A phenomenological study. Journal of Nursing Management, 29(5), 1111–1119. https://doi.org/10.1111/jonm.13249

Breitbart

(2016). Meaning-Centered Psychotherapy in the cancer setting: Finding meaning and hope in the face of suffering. In Meaning-Centered Psychotherapy in the Cancer Setting. Oxford University Press. https://oxfordmedicine.com/view/10.1093/med/9780199837229.001.0001/med-9780199837229

Breitbart

Pessin

Rosenfeld

Applebaum

A. J.

Lichtenthal

W. G.

Saracino

R. M.

Marziliano

A. M.

Masterson

Tobias

Fenn

(2018). Individual meaning-centered psychotherapy for the treatment of psychological and existential distress: A randomized controlled trial in patients with advanced cancer: Individual meaning-centered psychotherapy. Cancer, 124(15), 3231–3239. https://doi.org/10.1002/cncr.31539

Breitbart

Poppito

Rosenfeld

Vickers

A. J.

Abbey

Olden

Pessin

Lichtenthal

Sjoberg

Cassileth

B. R.

(2012). Pilot randomized controlled trial of individual meaning-centered psychotherapy for patients with advanced cancer. Journal of Clinical Oncology, 30(12), 1304–1309. https://doi.org/10.1200/JCO.2011.36.2517

Breitbart

Rosenfeld

Gibson

Pessin

Poppito

Nelson

Tomarken

Timm

A. K.

Berg

Jacobson

Sorger

Abbey

Olden

(2010). Meaning-centered group psychotherapy for patients with advanced cancer: A pilot randomized controlled trial. Psycho-Oncology, 19(1), 21–28. https://doi.org/10.1002/pon.1556

Breitbart

Rosenfeld

Pessin

Applebaum

A. J.

Kulikowski

Lichtenthal

W. G.

(2015). Meaning-Centered group psychotherapy: An effective intervention for improving psychological well-being in patients with advanced cancer. Journal of Clinical Oncology, 33(7), 749–754. https://doi.org/10.1200/JCO.2014.57.2198

10.

Chegini

Arab-Zozani

Rajabi

M. R.

Kakemam

(2021). Experiences of critical care nurses fighting against COVID-19: A qualitative phenomenological study. Nursing Forum, 56(3), 571–578. https://doi.org/10.1111/nuf.12583

11.

Christianson

Johnson

Nelson

Singh

(2022). Work-related burnout, compassion fatigue, and nurse intention to leave the profession during COVID-19. Nurse Leader, S154146122200146X. https://doi.org/10.1016/j.mnl.2022.06.007

12.

Deliktas Demirci

Oruc

Kabukcuoglu

(2021). It was difficult, but our struggle to touch lives gave us strength’: The experience of nurses working on COVID-19 wards. Journal of Clinical Nursing, 30(5–6), 732–741. https://doi.org/10.1111/jocn.15602

13.

Dohrn

Ferng

Shah

Diehl

Frazier

(2022). Addressing mental and emotional health concerns experienced by nurses during the COVID-19 pandemic. Nursing Outlook, 70(1), 81–88. https://doi.org/10.1016/j.outlook.2021.07.009

14.

Epstein

E. G.

Haizlip

Liaschenko

Zhao

Bennett

Marshall

M. F.

(2020). Moral distress, mattering, and secondary traumatic stress in provider burnout: A call for moral community. AACN Advanced Critical Care, 31(2), 146–157. https://doi.org/10.4037/aacnacc2020285

15.

Epstein

E. G.

Hamric

A. B.

(2009). Moral distress, moral residue, and the crescendo effect. The Journal of Clinical Ethics, 4(1), 15–18. https://doi.org/10.1258/ce.2008.008053

16.

Finch

Lewis

Turley

(2014). Focus groups. In Qualitative research practice (2nd ed), pp. 211–242. Sage.

17.

Frankl

(1946). Man’s search for meaning (4th ed.). Beacon Press.

18.

Galehdar

Kamran

Toulabi

Heydari

(2020). Exploring nurses’ experiences of psychological distress during care of patients with COVID-19: A qualitative study. BMC Psychiatry, 20(1), 489. https://doi.org/10.1186/s12888-020-02898-1

19.

Gillies

Neimeyer

R. A.

(2006). Loss, grief, and the search for significance: Toward a model of meaning reconstruction in bereavement. Journal of Constructivist Psychology, 19(1), 31–65. https://doi.org/10.1080/10720530500311182

20.

Giorgi

(1997). The theory, practice, and evaluation of the phenomenological method as a qualitative research procedure. Journal of Phenomenological Psychology, 28(2), 235–260. https://doi.org/10.1163/156916297X00103

21.

Gordon

J. M.

Magbee

Yoder

L. H.

(2021). The experiences of critical care nurses caring for patients with COVID-19 during the 2020 pandemic: A qualitative study. Applied Nursing Research, 59, 151418. https://doi.org/10.1016/j.apnr.2021.151418

22.

Graham

Zerbi

Norcross

Montross-Thomas

Lobbestael

Davidson

(2019). Testing of A caregiver support team. EXPLORE, 15(1), 19–26. https://doi.org/10.1016/j.explore.2018.07.004

23.

Greenberg

Weston

Hall

Caulfield

Williamson

Fong

(2021). Mental health of staff working in intensive care during Covid-19. Occupational Medicine, 71(2), 62–67. https://doi.org/10.1093/occmed/kqaa220

24.

Gunawan

Aungsuroch

Marzilli

Fisher

M. L.

Nazliansyah Sukarna

(2021). A phenomenological study of the lived experience of nurses in the battle of COVID-19. Nursing Outlook, 69(4), 652–659. https://doi.org/10.1016/j.outlook.2021.01.020

25.

Guttormson

J. L.

Calkins

McAndrew

Fitzgerald

Losurdo

Loonsfoot

(2022). Critical care nurses’ experiences during the COVID-19 pandemic: A US national survey. American Journal of Critical Care, 31(2), 96–103. https://doi.org/10.4037/ajcc2022312

26.

Hajjar

L. A.

Costa

I. B. S. S.

Rizk

S. I.

Biselli

Gomes

B. R.

Bittar

C. S.

de Oliveira

G. Q.

de Almeida

J. P.

de Oliveira Bello

M. V.

Garzillo

Leme

A. C.

Elena

Val

de Almeida Lopes

Lacerda

M. V. G.

Ramires

J. A. F.

Kalil Filho

Teboul

J.-L.

Landoni

(2021). Intensive care management of patients with COVID-19: A practical approach. Annals of Intensive Care, 11(1), 36. https://doi.org/10.1186/s13613-021-00820-w

27.

Hall

(2020). The effect of the COVID-19 pandemic on healthcare workers’ mental health. Journal of the American Academy of Physician Assistants, 33(7), 45–48. https://doi.org/10.1097/01.JAA.0000669772.78848.8c

28.

Hamric

A. B.

Epstein

E. G.

(2017). A health system-wide moral distress consultation service: Development and evaluation. HEC Forum, 29(2), 127–143. https://doi.org/10.1007/s10730-016-9315-y

29.

Joo

J. Y.

Liu

M. F.

(2021). Nurses’ barriers to caring for patients with COVID-19: A qualitative systematic review. International Nursing Review, 68(2), 202–213. https://doi.org/10.1111/inr.12648

30.

Lai

Wang

Cai

Wei

Chen

Tan

Kang

Yao

Huang

Wang

Liu

(2020). Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Network Open, 3(3), e203976. https://doi.org/10.1001/jamanetworkopen.2020.3976

31.

Leng

Wei

Shi

Cao

Wei

Zhang

Xing

Wei

(2020). Mental distress and influencing factors in nurses caring for patients with COVID-19. Nursing in Critical Care, 26(2), 94–101. https://doi.org/10.1111/nicc.12528

32.

Lincoln

Y. S.

Guba

E. G.

(1985). Naturalistic Inquiry. Sage Publications.

33.

McAndrew

Leske

Schroeter

(2018). Moral distress in critical care nursing: The state of the science. Nursing Ethics, 25(5), 552–570. https://doi.org/10.1177/0969733016664975

34.

Moradi

Baghaei

Hosseingholipour

Mollazadeh

(2021). Challenges experienced by ICU nurses throughout the provision of care for COVID-19 patients: A qualitative study. Journal of Nursing Management, 29(5), 1159–1168. https://doi.org/10.1111/jonm.13254

35.

Muz

Erdoğan Yüce

(2021). Experiences of nurses caring for patients with COVID-19 in Turkey: A phenomenological enquiry. Journal of Nursing Management, 29(5), 1026–1035. https://doi.org/10.1111/jonm.13240

36.

O’Connor

M.-F.

(2003). Making meaning of life events: Theory, evidence, and research directions for an alternative model. OMEGA - Journal of Death and Dying, 46(1), 51–75. https://doi.org/10.2190/0CKD-PVQ0-T260-NTXU

37.

Onwuegbuzie

A. J.

Dickinson

W. B.

Leech

N. L.

Zoran

A. G.

(2009). A qualitative framework for collecting and analyzing data in focus group research. International Journal of Qualitative Methods, 8(3), 1–21. https://doi.org/10.1177/160940690900800301

38.

Pappa

Ntella

Giannakas

Giannakoulis

V. G.

Papoutsi

Katsaounou

(2020). Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis. Brain, Behavior, and Immunity, 88, 901–907. https://doi.org/10.1016/j.bbi.2020.05.026

39.

Parse

R. R.

(2001). Qualitative inquiry: The path of sciencing. Jones and Bartlett.

40.

Park

C. L.

(2010). Making sense of the meaning literature: An integrative review of meaning making and its effects on adjustment to stressful life events. Psychological Bulletin, 136(2), 257–301. https://doi.org/10.1037/a0018301

41.

Richardson

N. M.

Lamson

A. L.

Smith

Eagan

S. M.

Zvonkovic

A. M.

Jensen

(2020). Defining moral injury among military populations: A systematic review. Journal of Traumatic Stress, 33(4), 575–586. https://doi.org/10.1002/jts.22553

42.

Rolbiecki

A. J.

Washington

K. T.

Bitsicas

(2019). Digital storytelling as an intervention for bereaved family members. OMEGA - Journal of Death and Dying, 82(4), 570–586. https://doi.org/10.1177/0030222819825513

43.

Rosa

W. E.

Roberts

K. E.

Schlak

A. E.

Applebaum

A. J.

Breitbart

W. S.

Kantoff

E. H.

Pessin

Lichtenthal

W. G.

(2022). The critical need for a meaning-centered team-level intervention to address healthcare provider distress now. International Journal of Environmental Research and Public Health, 19(13), 7801. https://doi.org/10.3390/ijerph19137801

44.

Rushton

C. H.

Thomas

T. A.

Antonsdottir

I. M.

Nelson

K. E.

Boyce

Vioral

Swavely

Ley

C. D.

Hanson

G. C.

(2022). Moral injury and moral resilience in health care workers during COVID-19 pandemic. Journal of Palliative Medicine, 25(5), 712–719. https://doi.org/10.1089/jpm.2021.0076

45.

Schlak

A. E.

Poghosyan

Liu

Kueakomoldej

Bilazarian

Rosa

W. E.

Martsolf

(2022). The association between health professional shortage area (HPSA) status, work environment, and nurse practitioner burnout and job dissatisfaction. Journal of Health Care for the Poor and Underserved, 33(2), 998–1016. https://doi.org/10.1353/hpu.2022.0077

46.

Shechter

Diaz

Moise

Anstey

D. E.

Agarwal

Birk

J. L.

Brodie

Cannone

D. E.

Chang

Claassen

Cornelius

Derby

Dong

Givens

R. C.

Hochman

Homma

Kronish

I. M.

Lee

S. A. J.

Abdalla

(2020). Psychological distress, coping behaviors, and preferences for support among New York healthcare workers during the COVID-19 pandemic. General Hospital Psychiatry, 66, 1–8. https://doi.org/10.1016/j.genhosppsych.2020.06.007

47.

Sun

Wei

Shi

Jiao

Song

Wang

You

Liu

Wang

(2020). A qualitative study on the psychological experience of caregivers of COVID-19 patients. American Journal of Infection Control, 48(6), 592–598. https://doi.org/10.1016/j.ajic.2020.03.018

48.

Ulrich

Cassidy

Barden

Varn-Davis

Delgado

S. A.

(2022). National nurse work environments - October 2021: A status report. Critical Care Nurse, 45(5), 58–70. https://doi.org/10.4037/ccn2022798

49.

Wang

Liu

Zhang

Huang

Yue

(2020). Healthcare workers’ stress when caring for COVID-19 patients: An altruistic perspective. Nursing Ethics, 27(7), 1490–1500. https://doi.org/10.1177/0969733020934146

50.

Wocial

L. D.

Weaver

M. T.

(2013). Development and psychometric testing of a new tool for detecting moral distress: The moral distress thermometer. Journal of Advanced Nursing, 69(1), 167–174. https://doi.org/10.1111/j.1365-2648.2012.06036.x