key: cord-0846911-7nci4q1q
authors: Iheduru‐Anderson, Kechi
title: Reflections on the lived experience of working with limited personal protective equipment during the COVID‐19 crisis
date: 2020-10-03
journal: Nurs Inq
DOI: 10.1111/nin.12382
sha: d5af3d8f864d36683c7f4a078779f7261dfe899f
doc_id: 846911
cord_uid: 7nci4q1q

Coronavirus disease 2019 (COVID‐19) has placed significant strain on United States’ health care and health care providers. While most Americans were sheltering in place, nurses headed to work. Many lacked adequate personal protective equipment (PPE), increasing the risk of becoming infected or infecting others. Some health care organizations were not transparent with their nurses; many nurses were gagged from speaking up about the conditions in their workplaces. This study used a descriptive phenomenological design to describe the lived experience of acute care nurses working with limited access to PPE during the COVID‐19 pandemic. Unstructured interviews were conducted with 28 acute care nurses via telephone, WebEx, and Zoom. Data were analyzed using thematic analysis. The major theme, emotional roller coaster, describes the varied intense emotions the nurses experienced during the early weeks of the pandemic, encompassing eight subthemes: scared and afraid, sense of isolation, anger, betrayal, overwhelmed and exhausted, grief, helpless and at a loss, and denial. Other themes include: self‐care, ‘hoping for the best’, ‘nurses are not invincible’, and ‘I feel lucky’. The high levels of stress and mental assault resulting from the COVID‐19 crisis call for early stress assessment of nurses and provision of psychological intervention to mitigate lasting psychological trauma.

permitted hospitals to amend their policies, allowing health care workers to reuse PPEs and move from patient to patient without changing their gowns or facemasks (CDC, 2020) .

Although this move appears unprecedented, it is in line with the guidelines for changes in health care delivery during emergencies, when the focus is on saving as many lives as possible, and health care providers including nurses, may be expected to practice outside of the normal scope of their practice (Koenig, Lim, & Tsai, 2011; Powell, Christ, & Birkhead, 2008) . These changes in standards of care were instituted by the Agency for Healthcare Research and Quality and the Office of the Assistant Secretary following the 911 terrorist attack, 2001 anthrax letter attacks, and the fears of the avian influenza pandemic in 2004 (Agency for Healthcare Research & Quality, 2005 , 2007 . Powell et al. (2008) emphasized that during disasters and endemics, health care providers need to discuss any anticipated changes to the standards of care, particularly as it relates to limited resources, such as ventilators. Because the community and the public are expected to adjust to the scarcity of resources, Powell and colleagues stressed that 'even before a patient comes to the hospital, political leaders and health officials must emphasize publicly that standards of care are and must be different in a public health disaster' (Powell et al., 2008, p. 25) . Health care providers must do whatever they can with the available resources. In a scarce resource environment, the focus of care shifts from the individual patient to optimizing outcomes for populations of patients (Chang, Backer, Bey, & Koenig, 2008; Koenig et al., 2011; Powell et al., 2008) . Veenema and Toke (2007, p. 72C) underscored the protection of health care workers during crises, stating that 'giving providers and their families personal protective equipment and instituting other measures such as staff rotation and stress management programs' are essential to preventing burnout.

In the context of COVID-19, while some hospitals require their staff to wear face masks at all times while onsite (Fox, 2020) , others are preventing their workers from wearing face masks brought from home, with some hospital administrations even threatening their staff with disciplinary action, including termination (Ault, 2020) .

These conflicting policy changes and confusion have posed a different type of challenge for health care workers.

There have been several online reports of nurses and other health care providers being intimidated or reprimanded for speaking out about their working condition during the pandemic. This prompted the American Nurses Association (ANA) to respond, calling on Occupational Safety and Health Administration (OSHA) to remind employers that retaliation against health care workers for speaking out and raising concerns about their personal safety while caring for COVID-19 patients is illegal (ANA, 2020c) . The ANA reminded nurses experiencing retaliation from their employers of their right to file a whistleblower complaint online with OSHA.

As many hospitals continue to restrict the use of PPE to preserve their supply in anticipation of growing COVID-19 cases with the rapidly evolving outbreak, many health care providers on the frontline believe that the PPE restrictions are impeding their ability to safeguard their welfare (ANA, 2020d) . These policy changes presented by health care organizations are in line with the crisis capacity category described by the Institute of Medicine (2010) and the CDC (2020). 'Crisis capacity is defined as adapting spaces, staff, and resources so that … you're doing the best you can with what you have. Staff may be asked to practice outside of the scope of their usual expertise. Supplies may have to be reused and recycled. In some circumstances, resources may become completely exhausted. Family members may be asked to provide basic patient hygiene and other aspects of care that do not require medical expertise' (Institute of Medicine, 2010, p. 13) .

Little research has examined the experiences of nurses during global, regional, or national health care crises related to disease outbreaks or natural disasters. Existing studies have focused on hospital preparation, availability of resources, and the safety of patients (Barbisch & Koenig, 2006; Karabacak, Ozturk, & Bahcecik, 2011; Ruchlewska et al., 2014; Tzeng & Yin, 2008) , the education of hospital staff (Powers, 2007) , emergency room nurses' description and management during a crisis (Vasli and Dehghan-Nayeri, 2016) , and the psychological impact of disease outbreaks on hospital workers (Sun et al., 2020; Wu et al., 2009; Yin & Zeng, 2020) . However, in mass casualty events and disease outbreaks, nurses may experience anxiety and personal loss (Sun et al., 2020; Veenema & Toke, 2007; Yin & Zeng, 2020) .

Most studies of nurses' experiences during a disease outbreak were focused on Asian countries due to current and previous experiences related to COVID-19, Middle East respiratory syndrome-coronavirus (MERS-CoV), and human swine influenza outbreak (Khalid, Khalid, Qabajah, Barnard, & Qushmaq, 2016; Kim, 2018; Lam & Hung, 2013; Su et al., 2007; Sun et al., 2020; Yin & Zeng, 2020) .

A study conducted in Turkey to determine the crisis management activities and attitudes of hospital nurse managers during times of crisis, such as earthquakes and bomb explosions reported that over '71% percent of the nurse managers surveyed in these hospitals left resolution of crisis to the top hospital management, 64.7% noted they increased the number of the staff members, and 58.1% said they ignored crises' (Karabacak et al., 2011, p. 323) .

Crisis situations such as the one presented by COVID-19 are a major barrier in providing optimal care as they have a strong impact on patients, their families, communities, and health care providers.

During a crisis, nurses and other health care providers face various moral and ethical conflicts and dilemmas (Koenig et al., 2011; Tzeng & Yin, 2008) . Patient care is significantly affected by several factors, such as stress and fatigue, workload, lack of time, demand for expertise (Kim, 2018; Lam & Hung, 2013; Mahmoudi, Mohmmadi, & Ebadi, 2013) , influx of patients, experiences of health care providers, as well as level of managerial support (Hagbaghery, Salsali, & Ahmadi, 2004; Healy & Tyrrell, 2011; Kelley et al., 2004 ). An ANA survey of 32,174 nurses working on the frontline during the COVID-19 crisis indicated that 74% were concerned about the lack of PPE, 58% feared for their personal safety, and 64% were extremely concerned about the safety of their friends and family (ANA, 2020d).

Considering the sparseness of empirical data on the lived experiences of nurses during crises situations, especially in the United States, this study examined the experiences of frontline nurses during the COVID-19 crisis. Crisis is defined as an undesirable event or outcome, which includes the element of surprise or disruption of action, and is a threat to the resources and well-being of an individual within the organization. It can have negative consequences, such as increased risk of death, delay in treatment, ignoring medical advice, and putting nurses under pressure (Vasli and Dehghan-Nayeri, 2016) . In crisis situations, important lifesaving resources, such as 'ventilators and components, oxygen and oxygen delivery devices, intensive care unit beds (adequately staffed and equipped), health care providers, medications, etc.) are likely to be scarce' (Koenig et al., 2011, p. 3) . Similarly, during the COVID-19 outbreak, the entire nursing workforce is facing a significant demand, which is anticipated to increase at an alarming rate.

The purpose of this study was to describe the lived experience of acute care nurses working with limited access to PPE during the COVID-19 pandemic.

How do registered nurses describe the lived experience of working with limited PPE during the COVID-19 crisis?

This qualitative descriptive phenomenological study explored the lived experiences of acute care nurses working on the frontline during the COVID-19 disease outbreak.

Descriptive phenomenology was chosen as the design for the current study because it explored and described the participants' everyday experiences as they lived them while working with limited PPE on the frontline of the 2020 COVID-19 crisis. Phenomenology as a research method is dedicated to describing the structures of experience as perceived by individuals without recourse to assumptions, judgments, or presuppositions (van Manen, 2017a) . It is the search for structure and essence in experience, to form a deeper understanding of the nature and meaning of everyday experience (Munhall, 2012) .

The focus is on providing rich textured description of the individual experiences as described by those who experience it. The role of the researcher is to describe what people experience and how they experience it (Finlay, 1999) , and to understand these experiences as much as possible through the eyes of the research participants.

Purposive sampling augmented with snowball sampling was used to recruit participants who met the inclusion criteria. To qualify to partake in the study, the participant was required to be a registered nurse, working in an acute care setting, or in units with diagnosed COVID-19 patients or . Recruitment was done through direct email to nurses working on the frontlines known to the author, via Facebook and LinkedIn posts, posts to nursing support forums, and by wordof-mouth. Participants were encouraged to share recruitment flyers with their colleagues to increase the sample size.

The study was approved and monitored by the Central Michigan University Institutional Review Board (IRB) for the Protection of Human Subjects in Research. The IRB-approved informed consent form was emailed to the participants for their review before scheduling the telephone interviews. Prior to each interview, verbal consent to participate in the study was audio recorded and transcribed as part of the interview. To ensure confidentiality, each participant was assigned a pseudonym (Creswell, 2012) , which was used throughout the research and for data presentation. All raw data were stored in dated folders in a secured network location. 

Phenomenology is focused on lived experiences, aimed at describing, not explaining, how and why meanings arise, without researcher bias (Finlay, 1999) . 'Phenomenology does not look for 'truth' but for the participants' perceptions of 'their truth'-their own experiences as they perceive them' (Sloan & Bowe, 2014, p. 1,300) . Using thematic analysis as described by Burnard, Gill, Stewart, Treasure, and Chadwick (2008) , once the audio recording had been transcribed, the author familiarized herself with the data and verified its accuracy by simultaneously reading the transcript and listening to the audio recordings. During this process, any personal information, which may have been erroneously included in the interview, was deleted. All transcripts were line numbered. During the second reading of each transcript, open coding was performed by highlighting sections of the text and entering words and phrases that summarize what is being said in the text into an excel spread sheet created for this purpose.

Next, all the words and phrases from each individual interview spread sheet were compiled onto a single page. Duplicate words and phrases were deleted, and overlapping and similar categories were refined and merged to reduce the number of categories. All the interview data relevant to the research purpose were allocated to the appropriate categories, which formed the final themes and subthemes. The author consulted a colleague not involved in the study to verify the coding process, and solicit unbiased feedback (Elo et al., 2014) . Finally, a report was written from the information organized in this table of findings.

Trust in qualitative research findings may be addressed using at least two of eight key strategies developed from Lincoln and Guba's model of trustworthiness (Creswell, 2012) . Lincoln and Guba (1985) introduced the criteria of credibility, transferability, dependability, and confirmability for the assessment of rigor. For the reader to appraise transferability to other settings or populations, the author has provided justification for the research design, detailed description of the inclusion criteria, sample characteristics, and data collection and analysis methods (Hader, 2010; Maher, Hadfield, Hutchings, & de Eyto, 2018) .

Bracketing, which allows one to become less assuming about another's experience, to be open, nonjudgmental and compassionate, and to present data from the perspectives of the participant rather than the researcher (Chan, Fung, & Chien, 2013) was practiced.

Owing to the unprecedented nature of the COVID-19 pandemic and its persistent broadcast on mass media, keeping a reflexive journal was very important for the author. The author chose to explore the experiences of these nurses because as a nurse who no longer worked in acute care setting, I wondered what it must be like to go to work every day during this crisis. It was important to hear directly from the nurses as they reflected on their everyday lived experiences. At times during the study interviews and data analysis, I was sometimes overwhelmed by the experiences described by these nurses. Therefore, keeping a journal was very important for me to document and explore these feelings, in order to fully represent the participant experiences rather than mine. The author also engaged with other nurse colleagues to reflect on the overall effects of the pandemic and continued to maintain a reflexive journal to elucidate evolving perceptions throughout the research process (Tufford & Newman, 2012) .

Member-checking was ensured by returning to six participants to verify the transcribed audio recordings and clarify statements made during the interviews. A summary of the findings and themes was discussed with four participants in a telephone conference call.

They all confirmed that the themes accurately reflected their experiences. This respondent validation is used to ensure the dependability and credibility of qualitative studies (Elo et al., 2014; Hadi & José Closs, 2016) .

The sample comprised of 28 nurses, 21 women and 7 men, aged 28 to 65 years. Their level of education ranged from associate degree to master's degree in nursing. All participants worked in acute care hospital, with 22 working in hospital in the northeast, 2 in the southeast, and 4 in Midwestern United States (Table 1 ).

The lived experience of acute care nurses working with limited access to PPE during the COVID-19 pandemic has been summarized into four themes. The first main theme is emotional roller coaster, which describes the intensity of the varied emotions the nurses experienced during the early weeks and months of the pandemic, encompassing the following subthemes: scared and afraid, sense of isolation, anger, felt betrayed, overwhelmed and exhausted, grief, helpless and at a loss, denial. Other main themes include: self-care, 'hoping for the best', 'nurses are not invincible', and 'I feel lucky'. The themes, subthemes, and participants' exemplar quotes are displayed in Table 2 . Age range (in years) 28 to 65

Experience of nursing practice (in years) 3 to 42

Highest level of nursing education

Associate's degree in nursing (ASN) 5

Bachelor's degree in nursing (BSN) 17

Master's degree in Nursing (MSN) 6

Unit of acute care employment

Medical-surgical unit (Med/Surg) 11

Emergency department (ED) 6

Intensive care unit (ICU) 10 'I felt like my employers were too busy covering their butts, that they continued to lie. On television, they tell the public that their main concern is the safety of their employees, but their actions were contradictory'. (Nikki)

Overwhelmed and exhausted 'The barrage of information was too much. I was mentally and emotionally exhausted to take advantage of them. I am still mentally exhausted. I cried a lot. I lose my patience with minimal provocation'. (Alexie)

'I was tired all the time. It was very hard getting out of bed, but I pushed myself to get up and go to work. After a very long day of seeing nothing but suffering and death, I feel mentally drained'. (Priest)

Grief 'I used to think that nurses can overcome anything, but the death of that nurse, was devastating for me. I know people die, but…, it just hit home for me, the death of a nurse, someone you work with, and… my heart just aches'. 

The sense of isolation was profound for some of the nurses. Although they went to work and were able to see their coworkers, many were isolated from their loved ones, for fear of unknowingly infecting them with the virus even when they were negative or asymptomatic. Because some of these nurses felt like their close relative, who are not health care providers, would be unable to understand their grief, they kept their true feelings to themselves. Therefore, close relatives did not know how to offer support, and were sometimes not able to recognize when their actions were perceived as unsupportive. In these situations, the nurses felt isolated and were not able to share their experiences with those who are closest to them.

Anger intermingled with fear was pervasive throughout the study. 

Interestingly, very few participants (three) discussed being physically exhausted. All of them discussed being 'emotionally and men- Some participants discussed being physically overwhelmed by working long hours and several days without days off for rest because nurse coworkers got sick or quit their jobs for fear of contracting the virus. One of the participants discussed being 'overwhelmingly exhausted', but was afraid to call out sick without being COVID positive because she had not been on the job for a long time and her manager was very critical of nurses who called out, reminding the nurses that sick calls during the COVID crisis will be considered during the annual evaluation.

Many participants discussed being overwhelmed and 'stressed out' with the volume of information received from work, social media, and television. Some reported being short-tempered, cried with minimal provocation, or for 'no apparent reason', and 'not being able to hold it together'. Alexie discussed being aware of important stress management strategies but not being able to use them due to mental and physical exhaustion.

Several nurses talked about their grief. Jackie discussed her grief in the following statement:

The pain and sorrow you feel when you learn that one of your coworkers has succumbed to this deadly virus. 

The feelings of helplessness and loss were echoed by many of the Robert's concerns were echoed by Amber who questioned the information being provided by her employer.

Least among the nurses' roller coaster of emotions was denial. Other nurses were in denial because they were receiving mixed messages from their employers, managers, and the government, and because it was easier to deny the reality.

Self-care, and the lack thereof, was expressed by more than half of the participants. Some described self-care as maintaining connections to other people, family, and friends during the difficult time.

For others it meant keeping up with their routines prior to the crisis, like exercising, taking time to rest, and connecting with loved ones. Some discussed not being able to 'shut it off' even when away from work. Watching excessive television or following the news on social media affected their sleep and increased their anxiety. Jane talked about forgetting to care for herself while caring for others.

Some of the participants used some unhealthy practices, such as increased smoking, alcohol consumption, and overeating or eating 'comfort foods', which were not particularly healthy to deal with increased stress.

Hoping for the best described what most of the nurses did once they reconciled to not having control over the pandemic or the non-availability of PPE. All the nurses in this study did what they were trained to do and hoped for the best outcome for themselves, their families, and their patients. For instance, Kasey stated, Just have faith, do your best, and hope for the best.

If it is your destiny to die from this virus, whether you go to work or not, you will die from it. It's like a mantra for me. It kept me from screaming out loud and going crazy. I went to work, did what I trained to do, and hoped for the best outcome.

Flower who has only been employed at her current hospital for a little over four months felt that she did not have a choice but to go to work stating that she did what she needed to do and 'hoped for the best'. Kelly also expressed being hopeful stating,

We are nurses; we do what needs to be done. It is up to the employers and the government to provide us what we need to do the important work of taking care of patients and saving lives. In the situation we found ourselves with lack of adequate supply of PPE, and other things…sometimes limited IV supplies, we did our best and keep our fingers crossed.

While many of these nurses have taken care of patients with various communicable diseases and worked with limited resources before, they expressed never having worked in situations where they lacked appropriate PPE. Several of the participants' comments indicated that they felt that they were viewed as invincible, able to continue to operate without proper care. Some felt that their employers perceived their lives and well-being as less important than that of their patients.

Twelve nurses in this study had eventually tested positive for COVID-19; seven were symptomatic but did not require hospitalization. In describing their experiences, they compared it to being su- I wish they would treat nurses with more care.

Others were told by their employers that even if they tested positive, but remained asymptomatic, they had to continue working. Noah expressed surprise at this instruction from her unit manager, stating, 'Nurses are often viewed as machines, unbreakable. We can be expected to be superhumanly resourceful and resilient, but in this crisis, we needed a little more caring'.

Several of the nurses talked about the need to feel supported and appreciated for what they were doing during the crisis when many around the world were sheltering in place, but they had to go to work. This is evidenced by Sophia's statement:

I am very grateful that the hospital eventually recognized the important work we were doing, that we too needed caring for. When they started providing safe transportation and meals for us, I was grateful. It made me feel like someone cared. Under the circumstances we had to work, it made a difference.

The above statement is in contrast to Abby's statement about not feeling supported by her employers and managers, comparing herself to hospital equipment, especially during the earlier days of the pandemic. She stated,

In the first three weeks of this madness, I just wanted to feel supported, I wanted to feel that my leaders and employers cared about me; I did not feel that… I felt like I was easily dispensable and placed at the same level as the hospital equipment. I seriously considered quitting, but I couldn't do that to my colleagues.

Nurses just want to be valued as humans…

The participants talked about feeling lucky. Lucky that they were not sick, were able to work and provide for their families and their 

This study aimed to describe the lived experience of acute care nurses who had to work with limited access to PPE during the COVID-19 pandemic. Their experiences denote intense emotional turmoil described under five main themes. The fear, anger, sense of isolation, exhaustion, and helplessness are consistent with feelings described by nurses caring for COVID-19 patients in China (Sun et al., 2020) . While many Americans were following the shelter-inplace orders issued across the country to protect themselves from COVID-19, tens of thousands of nurses across the United States were heading to work every day to care for patients affected by COVID-19 and others requiring hospitalization for various ailments.

The critical shortage of PPE for nurses and other health care workers placed them at risk of contracting the virus, becoming sick, and even dying. The emotional roller coaster was more pronounced during the earlier weeks of the pandemic in the United States, as also reported by Sun et al. (2020) . The nurses' negative emotions were more pronounced when they first began taking care of COVID-19 patients.

O' Boyle et al. (2006) reported that nurses were overwhelmed with the workload and longer work hours because some colleagues refused to work during the crisis.

The nurses were concerned about exposing their families to the virus, which was also a concern for nurses taking care of patients during the 2003 outbreak of severe acute respiratory syndrome (SARS) in Taiwan (Lee et al., 2005) , and Middle East respiratory syndrome-coronavirus (MERS-CoV) in South Korea. The sense of isolation was worsened with the nurses changing their home routine to protect their loved ones as was also reported by nurses caring for Ebola virus patients (Smith, Smith, Kratochvil, & Schwedhelm, 2017) .

Physical and mental exhaustion, and the sense of betrayal expressed by the participants has been reported in other studies (Lam & Hung, 2013; Sun et al., 2020) . O'Boyle et al. (2006) reported that nurses feared they will be abandoned, have limited access to PPE, be at risk of infection, and have unmanageable numbers of patients to care for in cases of public health emergencies like COVID-19.

With the care standards and infection control protocols changing frequently during the COVID-19 pandemic, the nurses were confused by the conflicting information they received. These changes also created moral and ethical dilemma for the nurses. Evidence from public health literature indicates that appropriate communication of information is a major challenge during public health disasters (Powell et al., 2008; Vasli and Dehghan-Nayeri, 2016) , and poor communication and inaccurate information can weaken public trust in the government and result higher mortality rates (Choi, Kim, Moon, & Kim, 2015) . The nurses in this study struggled to balance their concerns with personal safety with their ethical and moral obligation to provide quality care for their patients. This is in line with the evidence from Jiang (2020) study on the psychological impact and coping strategies of frontline medical staff in Hunan China during the outbreak of COVID-19, as well as Kim and Choi (2016) These nurses reported that they received conflicting information from their leaders at different levels. This is in conflict with ANA warning issued in March 2020 that a lack of PPE will increase the risk of nurses becoming ill themselves, and more equipment was necessary to mitigate potential staff shortages caused by illness and quarantines (ANA, 2020c). As reported by some of the nurses in this study, many health care organizations were not transparent with their nurses, many nurses were gagged from speaking up about the conditions in their workplaces.

Several of the nurses discussed self-care activities, such as exercise, meditation, and listening to podcasts, used to cope with the stress of dealing with the crisis. Some mentioned avoiding watching the news. Previous studies of nurses working with patients during severe disease outbreaks have highlighted the importance of selfcare activities to improve psychological well-being (Sun et al., 2020; Yin & Zeng, 2020) . Appropriate and supportive care for nurses is critical to prevent adverse short-and long-term outcomes for them and their families. Studies indicate that perceived support is an important factor for mitigating prolonged and complicated grief (Hutti et al., 2017; Kim, 2018) .

In Taiwan The nurses in this study did not report experiencing any stigma from the community as disease carriers. Which is in conflict with report from other studies where nurses and other health care providers reported being perceived as disease carriers and a threat to the safety of others (Maben & Bridges, 2020; Sun et al., 2020) . Nurses in this study reported being angry for several reasons. Maben and Bridges (2020, p. 2,743) reported that a 'failure to protect nursing staff adequately is causing anger and frustration, making nurses feel unsafe at work, while they are risking their own health and fearful of transmission to their families'. Another source of anger rose from the focus of inadequate access to PPE in acute and intensive care settings, making it seem that the lives of nurses and care providers in non-acute care settings appear to matter less.

Overall, the high levels of stress and mental assault resulting from the COVID-19 crisis calls for early stress assessment of nurses and providing psychological intervention to mitigate lasting psychological trauma. The author engaged in continued telephone communications with the two nurses who expressed wanting to hurt themselves during the interview for several weeks until they were able to secure professional psychological help. Further, it is critical for nurse leaders and health care administrators to understand the impact of grief on the nurses. While most nurses will experience normal grief reactions in response to the COVID-19 crisis, others may have significant, sustained, extremely intense, complex grief responses, which may negatively affect their physical and psychological well-being. Those battered by stress may be the last to recognize it and stigma can be an obstacle to asking for help. As expressed by one of the participants, some of the nurses may not want to appear weak, put pressure on their peers, or they may fear of letting down their teams. Therefore, nurse leaders must monitor their nurses for signs of complicated grieving, such as anxiety, depressive symptoms, and signs of post-traumatic stress disorders.

The sense of betrayal expressed by these nurses should not be brushed off. It must be addressed. There is still time for employers and nurse leaders to redeem and repair lost trust of some of their nurses. Nurse leaders and employers must respond to the needs of their nurses by using scientific evidence. Ongoing honest communication of facts and compassionate responses for the nurse's experiences must be ensured. Instead of protecting the institution, leaders must be transparent and lead with heart. Policies related to the COVID-19 must consider the many facets of the complex issues facing the nurses instead of taking a one-size-fits-all approach.

The existing stigma of mental illness has not dissipated because of COVID-19; therefore employers must do whatever they can to ensure that nurses who need help get it.

There are several limitations to this study. First, the qualitative nature of the study limits the generalization of the findings. All the interviews were conducted from a distance through telephone or audio-visual means, and therefor, there was limited observation of body language beyond the tone of voice. Although the study examined the lived experience of working with limited PPE during the COVID-19 crisis, the crisis is still ongoing and many of the nurses were working in less than ideal conditions. Future studies must examine the experiences of the nurses several months and years after the crisis is under control. The experiences of others working in health care during this crisis should also be explored.

The COVID-19 crisis is unprecedented. The degree to which nurses were exposed to death and experienced grief is alarming. Although there were weeks of warning of impending pandemic, health care organizations and the U.S. government failed in their duty to provide for and protect their health care workers. While many Americans socially isolated in their homes to avoid contracting the COVID-19, nurses were heading to work, willingly exposing themselves and in some cases their families. The findings of this study indicate that many nurses across the United States now need their employers and the organizations to be present for them. Although not explicitly named in some cases, many are suffering from trauma, and sustained mental and emotional stress. They need support for their mental and emotional health. It should not be assumed that nurses would seek help if needed. Employers and leaders should preemptively offer support and in some cases should mandate that nurses speak to counselors or psychologists to promote mental and emotional well-being. This is an important opportunity to fully recognize that nurses are invaluable but finite assets, for generations they bear inherent emotional strain on behalf of society. To mitigate the loss of currently practicing nurses which will likely worsen the projected nursing shortage, the nursing profession and health care leaders must do all they can to support the welfare of nurses during this crisis and beyond.

The author wishes to acknowledge all the nurses who took part in this study and the Central Michigan University, especially the College of Health Professions for providing the time release for the completion of this study.

Kechi Iheduru-Anderson https://orcid. org/0000-0003-2353-0410

Coronavirus Disease 2019 (COVID-19)

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Guidance for planners of the psychological response to stress experienced by hospital staff associated with COVID: Early interventions. COVID Trauma Response Working Group rapid guidance

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Forum on medical and public health preparedness for catastrophic events

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Factors influencing emergency nurses' burnout during an outbreak of Middle East Respiratory Syndrome Coronavirus in Korea

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Perceptions of emergency nurses during the human swine influenza outbreak: A qualitative study

Facing SARS: Psychological impacts on SARS team nurses and psychiatric services in a Taiwan general hospital

Naturalistic inquiry

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Ensuring rigor in qualitative data analysis: A design research approach to coding combining NVivo with traditional material methods

Barriers to nursing care in emergency wards

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Nurses' beliefs about public health emergencies: Fear of abandonment

Allocation of ventilators in a public health disaster

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Phenomenology and hermeneutic phenomenology: The philosophy, the methodologies, and using hermeneutic phenomenology to investigate lecturers' experiences of curriculum design

The psychosocial challenges of caring for patients with Ebola virus disease

Prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured SARS caring unit during outbreak: A prospective and periodic assessment study in Taiwan

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Crisis management systems: Staff nurses demand more support from their supervisors

Phenomenology and meaning attribution

But is it phenomenology? Qualitative Health Research

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When standards of care change in mass-casualty events

The psychological impact of the SARS epidemic on hospital employees in China: Exposure, risk perception, and altruistic acceptance of risk

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