key: cord-0906636-xg7dy5i7
authors: Ness, Michelle M.; Saylor, Jennifer; Di Fusco, Leigh Ann; Evans, Kristen
title: Healthcare providers' challenges during the coronavirus disease (COVID‐19) pandemic: A qualitative approach
date: 2021-03-17
journal: Nurs Health Sci
DOI: 10.1111/nhs.12820
sha: 3825b556384b41c5fad34968c16776fced00c6b0
doc_id: 906636
cord_uid: xg7dy5i7

The uncertain trajectory of COVID‐19 has led to significant psychosocial impacts on nurses and other healthcare providers. Given the critical role of these providers in pandemic response, this study sought to gain a better understanding of the challenges faced by healthcare providers caring for adult patients during the COVID‐19 pandemic. A descriptive, qualitative study was conducted via semi‐structured interviews. A purposeful sample of healthcare providers (n = 23) caring for patients during the COVID‐19 pandemic was recruited to participate in interviews via snowball sampling and an information systems‐supported recruiting process (e‐recruiting). Thematic analysis revealed four themes: (1) Managing isolation, fear, and increased anxiety; (2) adapting to changes in healthcare practice and policy; (3) addressing emotional and physical needs of patients and their families; and (4) navigating evolving workplace safety. New evidence was introduced about nurses practicing outside their usual role. Nurses and other healthcare providers consistently reported increased anxiety during the pandemic. Hospital administrations can proactively support healthcare providers during this and future pandemics by ensuring access to mental health programs, standardizing communication, and developing plans that address equipment and supply availability.

such as respiratory therapists, physicians, and patient care technicians, play in pandemics. Early research has demonstrated that nurses caring for patients with confirmed or suspected COVID-19 experienced both physical and emotional exhaustion related to a sense of helplessness, increased patient workload, and lack of personal protective equipment (PPE) (Sun et al., 2020) . HCPs involved in caring for patients also experienced fear of contracting the virus and spreading it to family and friends (Xiang et al., 2020) . Jeffrey (2020) found that the COVID-19 pandemic has raised key ethical concerns for HCPs, including the moral dilemmas of isolation, quarantine, and isolation; tension around the duty to care in the face of personal concerns; and the impact of limited resources on the provision of care. Previous research has shown that HCPs caring for patients during epidemics such as influenza A subtype H1N1 (H1N1), SARS-CoV, and Ebola virus experienced increased distress related to fear of contracting and transmitting the disease (Alraddadi et al., 2016; Corley et al., 2010; Khalid et al., 2016; Speroni et al., 2015) . Existing literature indicates that HCPs experience psychosocial distress related to lack of access or rationing of healthcare resources, such as PPE, and balancing personal and professional responsibilities (Al-Dorzi et al., 2016; Kang et al., 2018; Y. Kim, 2018; Smith et al., 2017; Stirling et al., 2017; Sun et al., 2020) . The added responsibility to reprioritize care toward highly contagious patients adds to the complexity of these ethical dilemmas and increases moral distress (MD) among HCPs (McGowan et al., 2020; Thompson et al., 2006) .

Unknowns persist related to the SARS-CoV-2 virus and COVID-19 infection, including the physical, psychological, and economic impact the pandemic will have for years to come for patients, families, and the world at large. Nurses and other HCPs will experience significant physical and psychological impacts as they care for patients and their families. Unresolved ethical dilemmas from previous pandemics and epidemics persist during the coronavirus pandemic, leading to increased distress among HCPs. Therefore, the purpose of this study was to gain a better understanding of the challenges faced by HCPs caring for adult patients during the COVID-19 pandemic.

This study is part of a larger study that aims to understand the influence of personal and professional experiences caring for patients during the COVID-19 pandemic on HCPs' quality of life (QoL) and MD. This manuscript is a descriptive, qualitative analysis focused on understanding the challenges that HCPs faced at the beginning of the COVID-19 pandemic. Qualitative description allows for a rich, textural description of HCPs' experiences in their own words (Kim et al., 2017; Sandelowski, 2000) . Approval to perform this study was granted by the University of Delaware Institutional Review Board on April 29, 2020 (Project #1601049-1). This project was conducted in accordance with the Declaration of Helsinki. Prior to signing the consent form, all participants were informed of the purpose and voluntary nature of participating in this study.

A sample of 23 HCPs (see Table 1 ) from the U.S.A. completed the electronic eligibility survey to ensure inclusion and exclusion criteria were met. HCPs who directly cared for patients at least 50% of their work hours during the COVID-19 pandemic were primarily registered nurses (n = 18, 9%), employed in the acute care setting (see Table 2 ).

Additionally, HCPs were required to speak and read English and have an electronic device with video chat capability.

Study enrollment and interviews took place between May 2020 and July 2020. Electronic recruitment materials were shared on Facebook, on Twitter, and with contacts at hospitals nationwide. After determining study eligibility, participants completed electronic informed consent, followed by demographic and COVID-19 practice surveys via Research Electronic Data Capture (REDCap) (Harris et al., 2009) . Once complete, participants were contacted to set up a mutually agreeable time for the interview. Semi-structured interviews were conducted by the first author (M.N.) using an interview guide with open-ended questions (see Table 3 ) to explore the challenges faced by HCPs as they cared for patients during the COVID-19 pandemic. Interviews were conducted in a private home office recorded via ZOOM video conferencing technology and lasted approximately 1 h and participants were able to speak freely beyond the interview questions. The interviewer used two or three probes per question when necessary to clarify any questions and foster a deeper exploration of the participant's experience. Data collection ceased after data saturation was achieved and no new themes emerged. Interviews were transcribed verbatim using an automatic transcription service then verified by the first author (M.N.). Participants were assured of the confidentiality and anonymity of the data. At the close of the study, participants were entered into a drawing for one of four Amazon electronic gift cards worth $25 each.

A thematic approach was used to identify emergent ideas prior to beginning the coding process (Creswell & Poth, 2018) . The researchers collected and analyzed data concurrently, allowing the processes to influence each other (Sandelowski, 2000; Vaismoradi et al., 2013) . Interviews were organized by the first author and independently reviewed by the first and second authors (M.N. and J.S.) to identify emergent ideas prior to beginning the coding process (Creswell & Poth, 2018) . Once the initial interpretation of the data was complete, an inductive coding system was applied to refine the development of themes that emerged in the data (Creswell & Poth, 2018) . A list of 25-30 tentative codes were applied across the interview transcripts to assist in the development of themes (Creswell & Poth, 2018 ). An initial interpretation of the data led to the identification of emergent concepts including fear, practice issues, patient concerns, and safety forming the basis of the themes (Creswell & Poth, 2018) . Intercoder agreement was established by using an iterative process of recoding, rereading, and reanalysis of transcripts, which yielded four final themes. Intercoder discrepancies were resolved with the third author (L.D.), who is a clinician. For the final phase of thematic analysis, the authors choose participant examples for each theme as it related to the purpose of this study.

The consolidated criteria for reporting research (COREQ) checklist was used to ensure quality reporting in the study (Tong et al., 2007) . Prolonged engagement with participants and triangulation of the data were applied by locating evidence of qualitative codes in the demographic and COVID-19 practice survey (Lincoln & Guba, 1985) . The maintenance of detailed research activities including data collection and analysis increased the dependability of our findings (Lincoln & Guba, 1985) . Multiple researchers evaluated the findings, interpretations, and recommendations, ensuring confirmability in the research (Lincoln & Guba, 1985) .

Nurses and other HCPs were primarily employed in small (0-100 beds) to medium-sized (101-500 beds) hospitals (52%; n = 12). The majority (61%; n = 14) had been practicing for less than 10 years.

More than half of HCPs in our sample were required to change their practice area during the COVID-19 pandemic. Ten HCPs (43%)

reported that access to new PPE was restricted in their practice setting and 13 HCPs (57%) reported that they reused disposable PPE.

A thematic analysis of the qualitative data resulted in four major themes. These themes highlighted the challenges experienced by nurses and other HCPs, including physicians, respiratory therapists, and patient care technicians, caring for patients during the COVID-19

pandemic. Themes were as follows: (1) managing isolation, fear, and increased anxiety;

(2) adapting to changes in healthcare practice and policy;

(3) addressing emotional and physical needs of patients and their families; and (4) navigating evolving workplace safety.

3.1 | Theme 1: Managing isolation, fear, and increased anxiety

As the first cases of COVID-19 were identified in the U.S., its novel nature led to a great deal of uncertainty and a heightened sense of fear among nurses and other HCPs. Fear of the unknown was their greatest concern. S.G., a nurse, said, "…we just didn't know what we were doing, we didn't know, we didn't know who we were dealing with. So it was just super scary." HCPs felt unprepared for the emo- for." Most HCPs indicated that their institutions did not offer any mental health support specific to concerns about managing fear and anxiety related to COVID-19 and instead were directed to existing employee assistance programs for support.

All HCPs expressed extreme concern about contracting COVID-19 and spreading it to family and friends. H.L., a physician, said, "I needed to wrap my head around how I could be the safest at work, not bring it home to my family." Unfortunately, due to the concern of unknown viral transmission, many HCPs separated from family mem- on. And at first, they were saying put it on, leave it on, but then people would come around and question why you were wearing it."

Nurses reported that procedures varied from unit to unit, and occasionally from HCP to HCP. F.P., a nurse, noted, "My main concern is just not having the proper PPE or the proper information. Like one day they'll say suctioning is aerosolized and you need N95 and then I was told that it's not."

This study sought to explore the challenges experienced by nurses and other HCPs as they cared for patients and families during the COVID-19 pandemic. Fear of the unknown and managing their own personal stressors were undercurrents for HCPs on the frontline, consistent with studies that reported extreme physical fatigue and discomfort among nurses caring for patients during the MERS-CoV and Ebola outbreaks (Kang et al., 2018; Smith et al., 2017; Sun et al., 2018) . Nurses and other HCPs reported concerns about contracting and spreading COVID-19 to family and friends. These concerns led many HCPs in our sample to voluntarily isolate from family members while they cared for COVID-19-positive patients in the workplace.

Concerns about contracting and spreading COVID-19 are supported by Sun's research team (2020), who found that caregivers with children and elderly family members experienced significant negative psychological impacts as they cared for patients during the COVID-19

pandemic. Isolation and limited opportunities to practice typical stress reduction activities due to government-induced closures led to self- Nurses perceived that restrictive visitation policies, designed to prevent the spread of COVID-19, resulted in fear and feelings of increased isolation for patients. While visitor restriction is a reliable technique to control the spread of infectious disease (Danial et al., 2016) , it may be more beneficial for hospitals to find other ways to support the emotional needs of patients that are not contingent on nursing care. Hospital-established guidelines must consider the ethical impact of isolation and the burden it may place on

HCPs (Jeffrey, 2020) . Nonetheless, nurses were predominately alone at their patients' bedside (many of whom were very ill and scared) and served as their only support person. This research study found that nurses were often the only HCP permitted or willing to enter patient rooms, which increased their risk for infection and left them emotionally vulnerable in their added role as sole supporter for their patient. Alraddadi et al. (2016) found that HCPs were at increased risk for infection when in close contact with patients diagnosed with MERS.

In some instances, nurses were asked to change roles or perform duties that were outside of their normal practice area because other HCPs either refused or were instructed not to enter a patient room.

To the authors' knowledge, this finding is new to the literature as no prior studies revealed that pandemics required nurses to practice outside of their usual role. Performing additional duties or practicing in unfamiliar areas greatly enhanced the risk of exposure for nurses and led to concerns about the possibility of decreased quality of care. In addition to concerns about providing safe, quality care, HCPs working outside their usual area of practice experience increased distress regarding professional liability (Jeffrey, 2020) . Information for HCPs that addresses how to reduce personal safety risks may be recommended, given that more than half of the HCPs in this sample were asked to change their area of practice as their units became COVID-19 units. These changes were often made with little to no notice, and without further education or opportunity for nurses to change to a non-COVID unit. Similarly, previous research indicated that nurses who were involved in care outside of their usual area of practice experienced higher levels of self-reported stress (Fernandez et al., 2020; Seale et al., 2009 

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Michelle M. Ness https://orcid.org/0000-0001-5435-6932

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