key: cord-0690984-lwnm6af9 authors: Melnikov, Semyon; Kagan, Ilya; Felizardo, Helena; Lynch, Marion; Jakab‐Hall, Charlotte; Langan, Lisa; Vermeir, Peter; Luiking‐Martin, Marie‐Louise title: Practices and experiences of European frontline nurses under the shadow of COVID‐19 date: 2022-04-29 journal: Nurs Health Sci DOI: 10.1111/nhs.12936 sha: e5a5fc324bacfbed50d95fe1a3328dadd407b48e doc_id: 690984 cord_uid: lwnm6af9 The COVID‐19 pandemic has caused health professionals to deal with new situations they have not encountered before. Nurses were forced to cope with increased workloads, seriously ill patients, numerous patient deaths, and unresolved ethical dilemmas. This study aimed to examine the lived experiences of nurses across Europe during the first wave of the COVID‐19 pandemic. This was a qualitative narrative research study. Eighteen nurses from eight European countries (four each from the UK and Israel, three from Portugal, two each from the Netherlands and Ireland, and one each from Belgium, Italy, and Sweden) submitted narratives about their professional experiences during May–June 2020. The narratives were analyzed using thematic analysis. Seven categories across the narratives were condensed and interpreted into three themes: opportunities and growth, care management, and emotional and ethical challenges. The COVID‐19 pandemic has affected nurses emotionally and provided an opportunity to actively develop systems and skills needed to minimize harm and maximize benefits to patients and nurses. reported more than 401 million cases and more than 5.76 million deaths worldwide due to n.d.) . Like the rest of the world, European countries were seriously affected with thousands dying (Johns Hopkins University & Medicine, n.d.) . COVID-19 led to an increase in the demand for nurses, with many countries expanding their nursing workforce (Jiang et al., 2020) . Consequently, nurses were forced to cope with increased workloads, seriously ill patients, numerous patient deaths, and unresolved ethical dilemmas. The COVID-19 pandemic provided challenges to nurses but also gave them the opportunity for greater visibility to present their knowledge, practice, research, and creativity (DeWees & Miller, 2020; Torres Contreras, 2020) . The pandemic has also brought greater visibility to community-based nurses (Bowers et al., 2021) . During the global pandemic, leadership in nursing has become increasingly recognized, particularly for its role in decision-making, solving novel challenges, and providing high-quality and safe care to patients and families, as well as to their own workforces (Aquilia et al., 2020) . The role of nurses during the COVID-19 pandemic expands beyond providing the care for patients; nurses serve as a secure anchor allowing integration of all interprofessional teams (Buheji & Buhaid, 2020) . The pandemic forced all healthcare professionals, including nurses, to refine the focus of their care. Critical nurses increased their engagement in palliative care of COVID-19 patients (Rosa et al., 2020) . Due to the imposed isolation measures and restricted physical contact in Dutch nursing home, nurses focused on relationship-centered care both for the residents and their families (Rutten et al., 2021) . During the COVID-19 pandemic nurses faced various ethical challenges. The ethical challenges cover three main areas: nurses' safety, professional role, and moral distress (Firouzkouhi et al., 2021) . In terms of safety, there was the ethical dilemma as to what was the extent of their duty given the scarce resources and lack of personal protective equipment. In their professional role, nurses were ethically challenged when preventing many end-of-life patients with COVID-19 communicating face-to-face with their families. Lastly, a significant number of nurses faced moral distress due to the continuous pressure on them to maintain a sufficient allocation of resources to provide safe, high-quality nursing care, despite the chronic shortage of staff and equipment (Firouzkouhi et al., 2021) . While there is a fast-growing body of knowledge on COVID-19, there is currently no comprehensive collection of nurses' experiences from across Europe or an analysis of how such experiences could influence nurses and nursing practice. Therefore, this study aimed to examine the practices and experiences of nurses across Europe during the first wave of the COVID-19 pandemic. A narrative approach was used to analyze descriptions written by frontline nurses treating COVID-19 patients in the healthcare services across Europe. A written invitation was sent by one of the authors, the European Regional Coordinator in Sigma Theta Tau International (STTI), to 11 European chapters. The invitation contained an explanation of the study purpose and contact details. The chapters' nurse members were asked to participate by sharing a 250-word description highlighting the impact on nursing during the COVID-19 pandemic. Guidelines on topics to include in these descriptions or narratives were provided, namely: (i) quality and compassionate nursing care; (ii) nursing staffing and workforce issues; (iii) new roles, training, and preparation of nurses treating COVID-19 patients; (iv) the professional image and visibility of nurses; (v) nurses' impact on patient care and advocacy; (vi) the impact of the COVID-19 pandemic on the future of nursing; and (vii) nurses' contributions to policy and political decision-making. The study participants did not have any relationship with the authors of the manuscript. The inclusion criteria comprised registered nurses who were taking care of patients with COVID-19, regardless of their clinical area, education, or work experience. The data were collected between May and June, 2020. An inductive thematic analysis was followed (Braun & Clarke, 2006) , which encourages researchers to use their knowledge to inductively analyze data, maintaining a deliberate stance of curiosity that allows for reflexivity and awareness of their preconceptions of the data. The data consisted of the nurses' individual experiences and the meanings they attached to them. The data were coded and categorized. Following the decontextualization phase, where the text was considered in isolation from its usual context, the narrative text was coded separately to create categories and generate themes. In the recontextualization phase, the texts were reexamined according to the code units that had been identified. Mind maps and highlighting of texts allowed for the comparison and collation of themes as well as for the presentation of the findings. Each of the themes was explored drawing on specific quotes that highlighted the aspects to be noted. In the first stage, two researchers independently used inductive coding of the themes with each participant's narrative to finally gather and cluster the codes into major categories. In the second stage, two other researchers reanalyzed the collected data and revised the themes. The revised version was discussed, and the final version approved, by all of the authors. Ethical permission was obtained from the Ethical Board of the Nursing School of Coimbra, Portugal (approval #706/09-2020). Study participation was voluntary and no financial incentives were given. Written informed consent was obtained from all participants. The thematic analysis revealed seven categories, which were condensed and interpreted into three themes: (i) opportunities and growth; (ii) care management; and (iii) emotional and ethical challenges (See Table 1 ). The theme identified as "opportunities and growth" consists of the three categories discussed below: (i) leadership and mentoring; (ii) visibility and recognition of nurses' value; and (iii) professional pride and self-esteem. When describing their work, the nurses' most important professional competencies encompassed leadership, role modeling, and mentoring. Leadership skills were about being able to handle unforeseen situations, to design and implement policies, and to work with advocacy: "Significantly, nurses can be the calming voice within the storm and demonstrate their leadership potential. …We are in a position to expand our role as healthcare leaders and ensure that the people we look after feel safe" (I15, UK). Nurses also said that they are using their experiences of dealing with the COVID-19 pandemic to teach students and new nurses: "My clinical experiences are very valuable for me as a university lecturer in preparing nurses for the work in current and future disasters" (I11, Sweden). New nurses were also said to have effectively worked as a team: "Thanks to all recent graduates who have ventured to start their first days of work in these conditions" (I10, Portugal). Novice nurses reported on the positive impact of being guided and supported by experienced nurses: "I was supported by senior nurses to step into uncharted territories. These situations made me both uncomfortable and proud of myself, and have shaped me" (I12, UK). The COVID-19 pandemic brought not only challenges for nurses but also opportunities. The nurses in this study described an increased visibility of the nursing profession, a raised awareness of nurses' unique contribution: "UK Nurses are proud to have our National Chief Nurse stand with politicians and state the actions we need to take, but some people need help to do this" (I13, UK). The pandemic also brought visibility in other nursing care contexts: "In the year of the nurse, the coronavirus promoted the visibility of nurses' work higher than expected" (I1, Belgium). The positive reactions from the public emphasized the recognition of the value of nursing in the community. During the pandemic, people termed professional healthcare providers "super-heroes." The nurses' descriptions even provided quotes from members of the public: "Wow, a real hero, you are working in the hospital," and "you're doing a great job" (I4, Israel). The same voices were echoed by nurses in Portugal, "People made us feel like we were superheroes" (I10), and in the UK and Belgium: "We have seen extreme kindness and support from the public who came out in their thousands once a week to applaud the hard work of nurses/carers and the National Health Service" (I12, UK), and "Society fully supported the challenge healthcare providers faced in and out every day" and "The biggest opportunity for the following months and years is to keep this appreciation and recognition" (I1, Belgium). Thanks were expressed in different ways, from patients who recovered -"You saved my life. I thank you so much" (I6, Israel)as well as from public outstanding initiatives: "In Portugal people with empty houses made them available to health professionals working at the frontline" (I9, Portugal). Public recognition encouraged and strengthened nurses' motivation: "The challenges faced felt more bearable knowing we were appreciated!" (I12, UK), and "COVID-19 gave 'caring for' a new unseen dimension. No greater solidarity was seen before, not only within the nurses' teams, but also by the fact that society fully supported the challenges healthcare providers faced day in and day out" (I1, Belgium). Nurses recognized their own value and contribution which in turn promoted their professional self-esteem. The theme identified as "care management" consists of the following three categories: (i) team working and the effective management of nursing practice; (ii) the refinement in the focus of nursing care; and (iii) creativity, resilience and flexibility. Team working and the effective management of nursing practice Nurses reported that as members of multi-professional teams, they incorporated ways of managing care, ensured effective relations and interactions between different parts of the medical care system, and promoted team working: We worked closely with the infectious disease, occupational health and microbiology teams. Management pathways were developed for all patient groups including those who were homeless and so couldn't isolate at home, and for those who had deteriorated and needed to return to hospital. (I2, Ireland) Similarly, a participant from Belgium (I1) wrote: "Doctors supported nurses, nurses supported doctors. It was nice to see the excellent cooperation between healthcare workers." Improvement of teamwork was also mentioned in the majority of the narratives: "The interdisciplinary team came together very rapidly" (I2, Ireland), and "The team united as never before and I felt nurtured and nurtured others" (I12, UK). Teams working together were said to have made every effort to fight the pandemic: "Thanks… to all the nurses who didn't let anyone in the team give up! We were strong, we were united, and we managed to do our best" (I10, Portugal). Receiving empathy and support from colleagues also gave them the strength and confidence to handle difficult situations. Once the chaos began to settle, never before had I seen a team of healthcare workers (nurses, carers, GPs) and other homecare staff (activity coordinators, housekeepers, chefs, administrators) rally together to enhance the well-being of the care home residents during a time when they needed to self-isolate. A policy was adapted and implemented regarding lactation consultants' activities including individual consultations, while maintaining safety rules and avoiding contact with the mother and baby as much as possible. … online system counseling strategies were developed and embedded (professional forums, phone support). (I3, Israel) The nurses emphasized the importance of their role as patient advocates in preserving their patients' rights. In parallel with clinical activities, they asserted that it is vital for these rights to be maintained even during disasters such as the current pandemic: "There is no substitute for continuous human contact. In my view, patients' rights, such as dignity and equality in healthcare, must be maintained also during hard times" (I5, Israel). When providing nursing care at the individual patient level, nurses developed and utilized strategies in order to reach out to the public. In health promotion and disease prevention nurses were active on social media reaching out to many people: Working as an intensive care nurse, I realized the The high numbers of COVID-19 patients who died increased the nurses' stress and emotional burden, as shown by comments like "Normally nurses are shocked when more than one patient dies, now this is considered 'normal'" (I7, the Netherlands), and "I can't deny the toll each death has taken on me, as we fight for every single life" (I12, UK). This study aimed to discover the common experiences of European nurses under the shadow of the COVID-19 pandemic. A thematic analysis of 18 narratives from frontline nurses working in eight European countries revealed three main themes: opportunities and growth, care management, and emotional and ethical challenges. European healthcare systems during the pandemic. Indeed, healthcare systems worldwide have had to face challenges and changes according to this new situation. The discussion will focus on each of these main themes. The unconventional situation of COVID-19 highlighted nurses' leadership qualities, mentoring, personal example, mutual support, and Leadership moderated the association between fear of COVID-19 and nurses' secondary trauma, psychological distress, and turnover intention. Namely, when nursing leadership was high, this association decreased (Khattak et al., 2021) . and recognition by society. Indeed, especially in the first wave of the pandemic, nurses and nursing care were positively represented in the media at all levels of the pandemic response (Nayna Schwerdtle et al., 2020) . Despite this immediate positive effect, questions have also arisen about the long-term implications of this "hero" enthusiasm. Caution has been advised against exaggeration and over-enthusiasm in describing nurses as heroes since this can overshadow acute problems within the profession that are not being adequately addressed. These include inadequate working conditions and a lack of nurses (McAllister et al., 2020) . In this study it was found that nurses' visibility improved. However, the literature shows differing reports. Namely, the findings of a number of studies emphasized the lack of nursing leadership in the context of nursing practice visibility. For example, nurses did not have a sufficiently strong voice to speak about their professional interests and concerns, which were therefore not addressed in the main (Daly et al., 2020) . Similarly, Rosser et al. (2020) found not being visible was one of the three key characteristics of nursing leadership during the COVID-19 pandemic (in addition to not being collaborative and not being advocative of the personhood of citizens). Nevertheless, in this study, it seems that the participants did feel a sense of leadership at the personal level. This difference may be due to the fact that most of the nurses in the study were staff nurses working at the bedside and not nurses holding managerial positions. In this study the nurses described their personal growth at The findings of this study emphasized the importance of multiprofessional team working and mutual support. This is supported by previous studies. For example, a multidisciplinary team that included a diabetic nurse practitioner, a diabetes physician, a dietitian, and a social worker was required to streamline communication and transfer information within the team and to their patients, which contributed to the mental support of team members (Waizinger et al., 2021) . Also, frontline nursing home staff described their pride in their teamwork to provide the best quality of care to nursing home residents, citing their teamwork as an important factor affecting their ability to work during the pandemic (White et al., 2021) . The nurses described how they were required to make adaptions or refinements to the foci of their nursing care. Refined professional competencies included being able to disseminate pertinent information about COVID-19 to their patients, nurses, and the general public, including on social media; to improve their leadership skills; to adapt more to teamwork; and to increase patient safety. Similarly, heads of medical units and nurses in Spain reported that they focused on shared leadership and the sharing of information, and had high levels of trust while overseeing individual leadership and social contacts. These all led to reduced levels of COVID-19 contagion (Salas-Vallina et al., 2020) . Another study found that refined management strategies in non-isolated areas of a general hospital led to effective COVID-19 prevention (Xu et al., 2020) . Healthcare workers learned to work in a redesigned format, were exposed to clinical challenges, acquired additional skills, and faced difficulties, all of which were accompanied by uncertainty, risk of infection, threat of morbidity, and unusual workloads (Schwarz & Bouckenooghe, 2021) . Indeed, nurse managers in mental health centers reported on the change from a familiar routine to a new reality with family members' and volunteers' visits forbidden, and working in capsules . Nurses in this study reported the need to be resilient, creative, and flexible. Similarly, in order to respond effectively and to strengthen organizational capacity, senior and middle level managers, as well as staff clinicians, were required to be agile and resilient (Zarzaur et al., 2020) . Among the personal competencies that helped the study participants to be able to work long shifts in a tough environment was their resilience. Personal resilience has been shown to negatively predict COVID-19 anxiety among nurses (Labrague & De Los Santos, 2020) . Moreover, among healthcare providers, resilience has been observed to be associated with lower stress, anxiety, and fatigue and sleep disturbances (Huffman et al., 2021) . Given the contribution of resilience to reducing negative psychological effects during a pandemic, healthcare systems should implement the enhancement of resilience among nurses. Descriptions of nurses' creativity during the pandemic appear in the literature. Nurses working in the ICU found innovative and creative ways of using technology to allow family members to see patients (Luttik et al., 2020) , and communicate with physicians and nurses (Negro et al., 2020) . Pain management nurses used creative ways to address pain felt by isolated patients, moving patient-controlled analgesia pumps outside rooms, and when required, administrating medicine from a distance (Sowicz et al., 2021) . In this study, nurses also described being flexible. This is supported by a recent study where the flexibility of nursing home staff has been demonstrated by their ability to fulfill many roles simultaneously, for example, being "caregivers, entertainers, spiritual companions, family members," according to a nursing home administrator (White et al., 2021) . (Robert et al., 2020) . Other emotional considerations are related to unique aspects of COVID-19 patients' care, such as dying alone in isolation, the loneliness of patients who were prevented from meeting with family members, and the demands of strict distancing and separation. As reported by an ICU nurse, among the things that greatly troubled her and the families of patients who died was whether the patient died alone. Nurses assured families that their family members were being cared for and not dying alone (Luttik et al., 2020) . The study has several limitations. First, it is not possible to indicate causality but rather only the associations between the COVID-19 pandemic and the subjective experiences of nurses on the frontline of patient care. Second, the sample size was limited and all the participants were self-selected nurses, so further larger studies would be warranted. Third, since we included nurses from different countries, there is a possibility that a social desirability or competitiveness to embellish the reality may have been at play. Finally, the ratio of female to male participants was 8 to 1, therefore the nurses' perceptions were skewed to the female point of view. The COVID-19 pandemic has changed much about nursing and has provided an opportunity to actively develop systems and skills needed to minimize harm and maximize benefits to patients and nurses. The themes identified in this study, including opportunities and growth, care management, and emotional and ethical challenges, present a new opportunity for a significant reorganization of nursing practice. The study's central findings address the need to adapt clinical practice to the complex reality of isolation and social distance. The issues of emotional burden and ethical dilemmas in decision-making highlight nurses' main challenges during the pandemic. On an individual level, nurse managers are required to identify nurses at risk for an emotional burnout and offer them support. The consequences of pandemics raise issues that are universally applicable across countries. Policymakers are required to formulate policies to support dealing emotionally with the consequences of the pandemic, provide ethical decision-making support, and leverage the strengthening of professional pride and nurses' visibility by the public for advancing the status of nursing at the professional and general public levels. The changes in the public image and influence of nurses can shape future discussions on the role and remit of nurses in policy development and practical care. This study received no specific grant from any funding agency. The authors declare they have no conflict of interest. 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