key: cord-0885364-5evzt8bc authors: Arcadi, Paola; Simonetti, Valentina; Ambrosca, Rossella; Cicolini, Giancarlo; Simeone, Silvio; Pucciarelli, Gianluca; Alvaro, Rosaria; Vellone, Ercole; Durante, Angela title: Nursing during the COVID‐19 outbreak: A phenomenological study date: 2021-01-31 journal: J Nurs Manag DOI: 10.1111/jonm.13249 sha: 2c72ed74f1bf28c83f0a2b74ffa8a576a232b241 doc_id: 885364 cord_uid: 5evzt8bc AIM: The aim of this study was to explore the experience of Italian nurses engaged in caring for patients with COVID‐19. BACKGROUND: COVID‐19 found the health care world unprepared to face an emergency of such magnitude. Italy was one of the most affected European countries, with more than 250,000 cases. Understanding the impact of events of this magnitude on nurses provides a framework of knowledge on which educational training could be based to face similar situations in the future to prevent further breakdown. METHODS: The hermeneutic approach by Cohen was used. Semi‐structured interviews were conducted using a voice‐over Internet protocol. Interviews were transcribed, read in depth and analysed. RESULTS: Twenty nurses were interviewed. Four themes were extracted: uncertainty and fear, alteration of perceptions of time and space, change in the meaning of ‘to care’ and changes in roles and relationships. CONCLUSIONS: Psychological support in association with emergency training prevents stress and helps tackle compassion fatigue. IMPLICATIONS FOR NURSING MANAGEMENT: Policies to improve nursing science should be developed to ensure better quality of care, a higher number of professionals and, consequently, an increase in the safety of patients. increase in contagion quickly followed in countries, with the main outbreaks located in the northern regions, leading to one of the most dramatic epidemic scenarios in Europe. Italy is among the European countries that reported the highest number of confirmed cases (N = 403.000) (Johns Hopkins University, 2020) , and the number of total confirmed deaths was 36,474, with a detectable peak of cases between March and April. Due to this unpredictable health care need, organisational models were modified to provide suitable routes for symptomatic patients, managing cases at home or (when necessary) in hospitals, depending on the clinical-care complexity. It was crucial to intensify the role of nurses to increase the number of intensive or subintensive care units and, in extreme situations, set up entirely new hospitals. Health care professionals worked beyond the real possibilities, sustaining pressing work rhythms, often without the minimum adequate personal protective equipment to protect themselves and others in a situation of continuous change and uncertainty (Bagnasco et al., 2020; Liu et al., 2020; Nacoti et al., 2020) . (Legido-Quigley et al., 2020; Liu et al., 2020; Smith et al., 2020) . Nurses in particular showed coping skills and a spirit of service that sometimes compromised their well-being and underestimated their needs (Fernandez et al., 2020; Kang et al., 2018; Sun et al., 2020) . Moreover, the virus has had an emotional impact on health care professionals' mental health problems, such as increasing anxiety, sleep disorders, stress and depression symptoms (Huang & Zhao, 2020; Jackson et al., 2020; Kang et al., 2020; Lai et al., 2020; Usher et al., 2020; Zhang et al., 2020) . Another issue was the fear of transmitting the infection from health care professionals to their families, especially those who cared for an elderly family member outside a clinical setting or had children, with the anxiety caused by the awareness that they could be carriers of infection to others (Bagnasco et al., 2020; Chiang et al., 2007; Nacoti et al., 2020) . Despite other illnesses with an epidemic impact, after the epidemic of Spanish influenza (1918) (1919) (1920) , Italy had not faced emergency situations of this magnitude, and studies aimed at investigating their experiences in this pandemic situation are lacking. Understanding the impact of this event could provide a framework of knowledge on which educational training could be based in order to face similar situations and prevent further breakdown. The purpose of this study was to explore the experience of Italian nurses engaged in caring for patients with COVID-19 during the outbreak period through a phenomenological approach. The study was driven by the phenomenological hermeneutic approach developed by Cohen, which combines features of Husserlian descriptive and Gadamerian interpretive phenomenology. This method is ideal for research in nursing, especially when the topic of research is new, because it focuses on questions of meaning and on the lived experience of the subjects (Cohen et al., 2000) . The phases in which the method is articulated (Vellone et al., 2011) are summarized in Figure 1 . Participants were recruited in converted COVID-19 hospitals, and those who expressed their will to participate and gave their contacts were phone called to have a full explanation of the project and an appointment for the interview. The day of the interview was selected by participants according to their shifts and availability. This study followed the consolidated criteria for reporting qualitative research standards for the reporting of qualitative research (Tong et al., 2007) . Purposive sampling was used. All participants were nurses involved in hospital care of COVID-19-positive patients along the Italian peninsula. They were included if involved in direct care between March and April 2020. The interviews continued until the data were saturated with 20 nurses enrolled. The interviews were conducted in the native language (Italian), using a video call voice-over Internet protocol (VoIP) platform chosen by each F I G U R E 1 Method phases The study aims were explained before starting. The following questions were asked: 1. Could you tell me about your lived experience in caring for patients affected by COVID-19? What does this experience mean to you? 2. Could you tell me about a positive and a negative experience that were particularly significant to you during this outbreak period? Interviews proceeded until data saturation was reached, which, Adler and Adler (Baker & Edwards, 2012) , advise in a range from 12 to 60 participants. In the methodological text used for this study, it is defined as 'the idea that researchers have obtained enough data to have a complete description of the experience being studied' (Cohen et al., 2000; Polit & Beck, 2013) . Thus, once the teams were redundant and corroborated in their contents, at a raw analysis, data collection was declared closed. By video call interview, field notes were collected replicating the characteristics of classic face-to-face interviews (Janghorban et al., 2014) . Researchers' attention was focused on nonverbal content such as hand wringing or lack of eye contact which enrich the phenomenon comprehension (Phillippi & Lauderdale, 2018) . Finally, a sociodemographic questionnaire, created for this project, was used to collect information about the participants' characteristics. The study complies with the Declaration of Helsinki. Ethical approval was obtained before the study began by the institutional review board of Policlinico of Rome 'Tor Vergata'. Each participant submitted the informed consent form, which was collected via the voice-over Internet protocol platform in a separate audio file from the interview, to ensure anonymity to all participants. Data were kept confidential, and freedom to withdraw from the study at any time was guaranteed. Once transcribed verbatim, the interviews were checked for their accuracy by spot-checking, taking a subset of the transcripts (4 of 20) (MacLean et al., 2004) , reading and rereading the transcripts, and the field notes were repeatedly analysed following the method described above. Phenomenological process, described in chapter 7 of Cohen's Book (Cohen et al., 2000) . The interviews, data analysis and results check were conducted in the native local language of the study participants (Italian). The interviews and field notes were read and re-read in depth by two researchers (PA and AD) independently to provide theme extraction. Once all the interviews were analysed for themes, the two researchers met to state their agreement about the findings and definitions of theme extraction to establish trustworthiness (Guba and Lincoln criteria were used) (Gunawan, 2015; Lincoln & Guba, 1986 ). To ensure dependability, an external expert researcher nurse, not involved in the analysis process assessed the adequacy of the data and the preliminary results obtained checking the accuracy of the findings. Transferability was performed declaring the common values of nursing and the specific opportunities, conditions and limits of the settings in which it is performed in Italy. To assess reflexivity, bracketing was performed before analysing each interview by any researcher to avoid any preconception. To ensure confirmability, research steps taken from the start of a research project to the development and reporting of the findings were transparently described. To ensure credibility, the final organisation of the themes and subsequent content justifications were agreed by all members of the research team. No discrepancies or discordance was detected during these procedures; thus, the member checking with participants was performed to validate the themes and triangulation between analysts was performed to converge the findings. After having prepared the scientific report, translation processes and back translation were performed according to the WHO methodology for the validation of instruments in different cultures and languages from the source language, and it was chosen due to its scope. The methodology focuses on conceptual content rather than literal equivalent. In this way, it was possible to ensure that the meaning behind the data obtained was respected (World Health Organization, 2020b). Hence, the whole meaning was preserved according to the original data. Twenty nurses were interviewed according to the inclusion criteria. Most of the participants were male (n = 13). The mean age was 32.8 (SD = 7.8) years old. The main sociodemographic results are reported in Table 1 . The length of the interviews ranged from a minimum of 27 min to a maximum of 90 min, and the mean length was about 50 min. Four themes were extracted: uncertainty and fear, alteration in perception of time and space, change in the meaning of 'to care' and changes in roles and relationships. This theme encompasses a group of feelings shared by all study participants as distinctive to the experience of the pandemic. Uncertainty and fear have been manifested by nurses almost to the point of disruption since the initial days of the contagion, in such a way that a disorientation never experienced before was accompanied by the fear of the unknown. The possibility of direct involvement in a pandemic had been perceived as 'something far away' that would not directly touch their reality; this thought underlines a lack of awareness of pandemic situations. A participant reported this experience during the interview: Watson defines caring as: 'the moral ideal of nursing whereby the end is protection, enhancement, and preservation of human dignity' (Watson, 1988) and this is the meaning we take in count while describing this theme. The pandemic has caused an upheaval in ordinary organisational and professional structures. All the participants said they perceived a change in both their role within the organisation, perceived as es- The perception of their roles was also experienced in terms of self-image and how they were described by the media and citizens. Nurses lived the spirit of service and a professional identity that distanced itself from the idea of a 'hero' with which they felt identified by society, maybe downplaying those competences that had always been embodied, even before the pandemic. SS01: I don't feel anything like a hero, because I simply did my job. In this study, we explored the lived experiences of nurses who cared for COVID-19 patients. The analysis of the interviews allowed the identification of our themes: uncertainty and fear, alteration in perception of time and space, change in the meaning of 'to care' and changes in roles and relationships. Fear and uncertainty pervaded all the experience of the nurses interviewed, especially at the beginning of the pandemic. Facing something unknown is described in the literature as the element of commonality between all experiences of contact with an unknown health emergency (Chiang et al., 2007; Nacoti et al., 2020) . The experience of professionals of the subversion of the usual patterns of action in a context of uncertainty, which increases the perception of danger for themselves and for others, inevitably weighs on their psychological well-being. This phenomenon was previously described in several studies that analysed the psycho-physical consequences (mainly anxiety and stress) reported by nurses engaged in epidemic situations (Huang & Zhao, 2020; Jackson et al., 2020; Kang et al., 2020; Lai et al., 2020; Usher et al., 2020; Zhang et al., 2020) . (Fernandez et al., 2020; Sun et al., 2020; Wong et al., 2012; Yin & Zeng, 2020) . Nurses' well-being has a strong clinical implication for the quality of the outcomes sensible to nursing. As underlined recently by Lee and colleagues, coping strategies and psychological well-being directly impacted safety attitudes, which mediated nurses' practice environments (Lee et al., 2019) . In this study, the attitude towards duty and responsibility becomes a value shared by the whole community of health care professionals. Italian nurses strongly highlight the meaningful cohesion developed with their peers and the support and mutual solidarity that crossed the borders between the different professions. Those mechanisms of compensation allowed them to face with resilience the consequences of the pandemic on the entire health care system and the carers, confirming what has been experienced by colleagues in similar contexts (Legido-Quigley et al., 2020; Liu et al., 2020; Smith et al., 2020; Sun et al., 2020; Yin & Zeng, 2020) . All these characteristics and aspects of nurses contributed to overcome the outbreak despite lacks the system. Mutual adaptation between health care professionals has emerged from this situation as the most important implication we can assume for nursing management. In this scenario, even the paradigms of care have changed, but the fundamental assumptions of nursing have remained intact. The meaning of 'to care' in the COVID-19 pandemic consists of closeness, gestures of care and protection, and action despite distance. In fact, the words of the interviewed nurses revealed pure attributes of advocacy, the core principle of nursing care. The concept of advocacy, described in the literature, contains multiple elements that we find in the meanings expressed by the participants to our study. Being an 'advocate' means putting in place behaviours to promote and protect the well-being of those cared for and is achieved by helping them obtain from the health system what they need most, by virtue of the role of interconnection between those cared for, family members and the health organisation (Bu & Jezewski, 2007; Choi et al., 2014) . The experience of accompanying to death, often experienced more than once per shift, creates an emotional contagion reported by all participants in different forms, such as compassion, 'suffering with' in its original meaning (cum patior in Latin). Alignment with the meaning of compassion described by Schantz (2007) was detected through our interviews, defined as the feeling that allows an individual to emotionally perceive the suffering and pain of others in order to alleviate it, which is almost associated with the ethical principle of altruism (Schmidt & McArthur, 2018) .The 'invisible care' emerged though nursing outcomes, during the outbreak, implicate the importance of the proper ethical aspect as core content of the discipline, which go beyond the technicisms of the gestures. This implication is important not only for the management, who should invest in ethical care programmes but also recognize the development of nursing as a discipline though the academic teaching. Finally, in our last theme, nurses were resentful about their experience of being 'abandoned' by the organisational sphere, maybe due to the lack of clear and unique guidelines and the lack of adequate individual protective equipment. This peculiar aspect of the theme is strongly influenced by the Italian context in which, during the outbreak, the lack of an updated pandemic plan had been underlined by media. Nurses perceived themselves as exposed and as unprotected by those who should guarantee the organisation of the care systems during the emergency. This was previously reported in the literature in similar conditions as additional cause of stress and fatigue for health professionals Nacoti et al., 2020; Usher et al., 2020) . This theme underlines how the communication is crucial, between all the professionals, at any level, in a health care organisation. It is plausible to hypothesize that a stronger and better communication between the organisational spheres and the 'first line' would have reduced, if not eliminated, the sense of being abandoned expressed by our participants. Despite all the important results emerged, this study has some limitations. Beginning with the need for further studies on long-term impacts to detect which outcomes, in terms of stress and fatigue symptoms, this emergency will leave behind. The choice of a voiceover Internet protocol system to conduct the interviews because of COVID-19 restrictions, which does not allow for proper nonverbal communication and empathic listening, is another limitation. These limitations of the study should be considered when using our findings, even if it is plausible that the feelings and meanings are the same among nurses, even in other contexts, due to the strength of nursing principles with regard to the care of others. The purpose of this study was to explore the experience of Italian nurses engaged in caring for patients with COVID-19, what this study provides are the basis for work on the renewal of nurses and nursing identity in pandemic emergencies. This experience surely highlights the value of nurses and nursing care for the health care system, so policies of improvement of nursing science should be developed to ensure better quality of care, a higher number of professionals and, consequently, an increase in the safety of those cared for. The sense of loss and inadequacy should induce deep reflection on nursing education and organisational instruments of management. As highlighted in the introduction, the novelty of this study is the possibility of using its findings to improve nurses' preparation to face extreme situations, such as COVID-19, and to help those who lived through it to explain the meaning they gave to it through the narration of their experience. The psychological impact of the pandemic disease generates a need for psychological support in association with emergency training (few study participants had received appropriate training) to prevent stress and help tackle compassion fatigue. The intent of this paper is to highlight the positive aspects of nursing such as advocacy, elevated responsibility of the role and humanity to the point of self-sacrifice (e.g. isolation from loved ones) for 'common sense and well-being'. These values should be preserved and enhanced not only for the 'heroes' of this emergency but for the health care service of tomorrow. Nothing to declare. Ethical approval was granted by the Institutional Review Board of the University of Rome Tor Vergata (Reference n. 157/2020). 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