key: cord-0744039-6zej17fi authors: Kellogg, Marni B.; Schierberl Scherr, Anna E.; Ayotte, Brian J. title: “All of this was awful:” Exploring the experience of nurses caring for patients with COVID‐19 in the United States date: 2021-07-22 journal: Nurs Forum DOI: 10.1111/nuf.12633 sha: 939da0555ab976c3018447191d8d7f63f297376c doc_id: 744039 cord_uid: 6zej17fi INTRODUCTION: Little research documents the experience of nurses caring for patients with COVID‐19 in the United States. This article explores the experience of nurses providing direct care to COVID‐19 patients to understand the working conditions and emotional impact of working in this pandemic on nurses. METHODS: Data were gathered through an online survey distributed via snowball sampling in July 2020. The survey included an open‐ended question asking nurses to describe a personal experience providing care to a COVID‐19 patient. Researchers analyzed 118 responses using content analysis. RESULTS: The experience of nurses providing care to patients with COVID‐19 was summarized into six themes: (1) feeling overwhelmed with the quantity of work (33.1%), (2) patient death (30.5%), (3) helplessness (23.7%), (4) absence of patient family presence and need for additional support (22.9%), (5) personal protective equipment (PPE) concerns regarding safety and how PPE can impair the nursing role (20.3%), and (6) lack of preparedness for the pandemic (16.9%). CONCLUSIONS: These findings suggest working directly with COVID‐19 patients is a significant psychological strain on nurses. Adequate personal and institutional support for nurses is needed to prevent and treat mental distress from working under these conditions. The SARS-CoV-2 (COVID- 19) pandemic has placed unrelenting pressure on healthcare systems as nearly 160 million people worldwide have become infected with the virus. 1 caused an unprecedented number of hospitalizations and deaths in the United States, increasing nurses' physical and emotional workloads. Nurses juggle many responsibilities, including caring for patients with varying needs, working with interprofessional team members, and addressing families' requests to help patients achieve the best outcomes. While working during the pandemic, nurses and other healthcare providers are at risk of developing psychological distress. 2 Psychiatric professionals warn about the potential devastation of the COVID-19 pandemic on healthcare providers' mental health. 3 Accordingly, research examining the mental health sequelae of COVID-19 in China suggests that healthcare workers caring for patients with COVID-19 experienced elevated depression, anxiety, insomnia, and psychological distress, particularly among workers in hard-hit communities. 4 Due to the highly infectious nature of the COVID-19 virus, caring for patients with COVID-19 presents a potentially lifethreatening risk to nurses' health particularly before the distribution of vaccines. Nurses are at risk of transmitting the virus to others, including friends or family, and consistent access to adequate personal protective equipment (PPE) is elusive. 5 In the spring of 2020, nursing-related professions were the highest percentage of healthcare workers hospitalized with COVID-19 (36.3%). 6 Several studies have explored the impact of COVID-19 on nurses and other healthcare workers around the world. 4, [7] [8] [9] [10] [11] [12] [13] [14] Many nurses reported feeling unprepared for the demands of nursing during a pandemic. A study of nurses in Spain found that nurses caring for COVID-19 patients reported not having the skills needed to care for their assigned patients and heavy workloads. 11 The reporting of challenging patient assignments was echoed in a study by Bruyneel and colleagues, 9 which found patients with COVID-19 in an ICU setting required almost one-to-one nursing care. Likewise, nurses in China reported working more hours with a heavier workload due to the pandemic. 14 Globally, there are concerns about risky work conditions. Many nurses report a desire to help during these stressful times and are willing to care for patients with COVID-19, but most also report concern about transmitting the virus to their families. 12 Fear of virus transmission was also emphasized in other publications. 11, 14 Despite the United States having the highest number of reported cases and deaths globally from COVID-19, 15 few published studies were found describing nurses' experiences in the United States during the COVID-19 pandemic. The demands of this global health crisis have the potential to create a lasting effect on the nursing workforce, and there is mounting evidence that working in the COVID-19 pandemic affects nurses and other healthcare workers' mental health. Studies of healthcare workers in several countries report that providers, including nurses, experience symptoms of exhaustion, anxiety, stress, depression, and posttraumatic stress related to the pandemic. 4, 7, 8, 10, 10, 13, 16 In particular, nurses may be more likely to report higher levels of anxiety, stress, and depression during the pandemic than the general population. 13 Nurses providing direct care to patients with COVID-19 may be at particular risk for developing worsened mental health outcomes. 11 Add to this that women are more likely to report higher levels of mental health symptoms than men, and women make up 91% of the nursing workforce. 7, 17 Nurses' mental health should be a primary concern for nursing administrators and managers as the pandemic continues. 18 This paper aims to explore the experiences of nurses who reported caring for patients with COVID-19 in the United States. This research is part of a more extensive cross-sectional study that examined the nursing experience during the COVID-19 pandemic using mixed methods and convergent data collection. The qualitative descriptive data are the focus of this paper. Data were collected through an online survey of nurses, including demographics, screening measures of mental health outcomes, and open-ended questions. 19 After obtaining approval from the University IRB, the survey was distributed in July 2020 through snowball sampling using social media and posting a survey link to the American Association of Critical Care Nurses Participate in Research Studies webpage. The survey remained open for responses for 3 weeks. Completion of the survey implied consent. Participants elected to enter an email address for a raffle for one $100.00 gift card as an incentive for participation. Email addresses were not connected with survey responses, and responses were anonymous. In addition, links for mental health services and crisis support were provided at the end of the survey. For this paper, we analyzed qualitative responses gathered from an open-ended question. 19 The item that asked nurses to: "Please share a personal experience with a COVID patient, including the circumstances surrounding the event." The purpose of asking nurses to describe a patient encounter was to understand the nursing experience of caring for patients during the COVID-19 pandemic in the United States. Data were analyzed using content analysis, which can be used to examine themes in written material. 20 Two researchers, a nurse and a clinical psychologist, analyzed the data independently. First, researchers read the written statements several times to gain an overall understanding of the nursing experience of caring for patients with COVID-19. Next, the researchers highlighted significant statements describing the nursing experience. Then, researchers coded these meaningful statements into themes. Triangulation was used to enhance the study's validity; a third researcher reviewed the statements and coded themes. 19 The three authors discussed and agreed on the themes and statements that fit into each theme, capturing the nursing experience's essence during COVID-19. Rich descriptions by participants are provided to further enhance validity and allow for decisions on transferability to other settings. 21 The content analysis identified six themes: (1) feeling overwhelmed with the quantity of work, (2) patient death, (3) helplessness, (4) absence of patient family presence and need for additional support, Table 2 for the occurrence and the percentage of each theme identified. The most frequent theme noted in one-third (33%) of the written responses by nurses was the feeling of being overwhelmed with the quantity of work or workload during the beginning of the COVID-19 pandemic: "They were so sick; it took every ounce of energy to keep them alive." One nurse wrote: "Oftentimes, I'd have to stay late or come in early to shifts when we were understaffed, and then come back in the following night." Another stated: Working ten weeks in the ICU, caring for COVID -19 patients was an experience that I hope I will not have to repeat. There were many sleepless nights, worries about catching the virus or giving it to my husband. At times, you feel alone because you are so tired, mentally and physically. The patient that sticks out in my mind is someone who was on a hi-flow (oxygen) and borderline getting in-tubated… He was so scared during the time I had him. I tried to comfort him, but of course, it didn't help. I was in full PPE, and his family wasn't allowed to visit. Nurses also felt that time required for donning the necessary PPE decreased patient safety: Sometimes it was scary because a patient would try to get out of bed, and you did not want them to fall, but you wanted to protect yourself, so you had to put all of your proper PPE on, which takes several minutes. One nurse voiced the time it takes to put on the protective equipment could mean the difference between life and death for patients: Donning and doffing all the PPE is what I struggle with the most. Losing precious time when a patient needs CPR, and everyone has to gown up. I know that it's necessary, but when you see it day in and day out, it is disturbing. One nurse succinctly stated how PPE affects the nurse and potentially the patient while working during the pandemic, saying: "The stress is high, I'm terrified I'll make a mistake in PPE, and I'll get COVID, or I'll be too busy to notice the small changes in COVID patients, and they will tank." 8 | THEME 6. LACK OF PREPAREDNESS FOR THE PANDEMIC Twenty nurses (17%) voiced the notable lack of preparedness for the pandemic, which was labeled on several levels, including specific units, hospitals, and the country: We all worried (about) how extensive our shortcomings were with language barriers, inexperience, lack of resources, etc. The patient was just the unfortunate combination of hoping we were doing enough, knowing we could have done better in different situations. It is a horrifying feeling to live through for months at a time. Another nurse wrote: The nurse assigned to the patient was part of the float pool. The rest of the nurses in the room were Medical Emergency Team members. There was not a single nurse who actually worked on the floor in the room with us. The patient was pronounced, and we needed information on how to do COVID postmortem care. No one knew. The charge nurse had no direction. We thought to call the ICU, who was able to advise us. One nurse described helplessness when working as a volunteer in a homeless shelter for COVID positive individuals: This finding concerns the mental health of nurses as critical illness, resuscitation, and sudden or traumatic death are related to increased stress symptoms in nurses. 23 Patient death is often interpreted as a traumatic experience for nurses, contributing to stress and other psychiatric symptoms. 24 These traumatic situations could lead to acute stress disorder, posttraumatic stress disorder, or secondary traumatic stress symptoms in nurses. 25 The themes that emerged in this study illustrate nurses' experience and challenges caring for patients with COVID-19. These findings suggest that factors associated with these working conditions contribute to nurses' emotional distress and psychological sequelae. There is a need for adequate personal and institutional support for nurses to prevent and cope with distress from providing care during and after the pandemic. Particular attention must be paid to the mental health of nurses who have provided direct care to patients with COVID-19; addressing nurses' mental health is vital to the health of patients and the community. The data that support the findings of this study are available from the corresponding author upon reasonable request. World Health Organization. WHO Coronavirus Disease Dashboard. WHO Coronavirus Disease Dashboard Managing mental health during COVID-19. 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