EXPERIENCES FROM THE FRONT LINE: Stories of Nurses during COVID-19 |
Michael Evans, William Doan, Kiernan Riley, Kalei Kowalchik and Logan DeSanto
Abstract
With nearly 80 million confirmed COVID-19 cases in the United States, the COVID-19 pandemic has had significant effects on the US, the healthcare system, and frontline nurses. Effects on nurses working the frontlines of COVID-19 can be physical as well as emotional. It is necessary to explore experiences of nurses working the COVID-19 pandemic. In order to explore these experiences, Story Circles were utilized as a methodology to allow these experiences to be shared with researchers and other nurses. Two overarching themes emerged from these stories: navigating uncharted waters and persisting through the storm. Each theme had multiple sub-themes to be explored. Story Circles were an effective method in exploring nurses’ experiences, and many participants reported they felt it was therapeutic.
Introduction
The world has been facing the global spread of COVID-19 since the end of December 2019. COVID-19, which is a novel pneumonia, was first reported in the Wuhan City of China (Wang et al. 470). In March 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic. While statistics continue to rise, the Centers for Disease Control and Prevention (CDC) estimates that there has been nearly 80 million confirmed cases of COVID-19 and 980,000 confirmed COVID-19 deaths as of April 1st , 2022 (“COVID Data Tracker”) in the United States. The effects of COVID-19 include both physical and psychological aspects, including fever, dry cough, weakness, as well as feelings of anxiousness and sadness (Sampaio et al.pp. 3-5; Wang et al. pp.471-72). The COVID-19 pandemic has affected many individuals worldwide; however, health care providers have been particularly impacted by the pandemic (Sampaio et al. 6). Frontline workers, including nurses, have been exposed to unique and challenging experiences while working throughout the COVID-19 pandemic.
Frontline workers were more likely to experience psychological symptoms during the COVID-19 pandemic (Sampaio et al. 6). Resource shortages within hospitals left healthcare workers to make difficult decisions regarding rationing of care. In addition, rules and regulations within and outside facilities, including social distancing, have increased psychosocial stress (Wong et al. 382). Throughout these times, nurses were more likely to screen positive for acute stress disorder, depression, and anxiety than other healthcare workers (Shechter et al. pp. 3-5).
The experiences of nurses working the frontlines during the COVID-19 pandemic are important to explore. The purpose of this study was to allow for nurses to connect with other frontline nurses to gain an understanding of their individual and collective experiences. Previous research suggests the human brain is hardwired for stories (McMurray, Callie).When presented with a story, both sides of the brain work to process the words, interpret the story, and store its meaning in memory. Essentially, stories make the brain behave as if we are experiencing the events firsthand. The combination of these brain responses makes us empathize and connect with stories and storytellers (“Your Brain on Story: Why Narratives Win our Hearts and Minds”). It has been shown that on functional brain scans, many areas of the brain light up while listening to a narrative (Renken).
Through storytelling, nurses can have their voices heard by others who are able to understand the experiences (Lee e1). These stories allow for researchers to learn more about the experiences of these nurses. It is critical for all medical providers and society to hear these stories so appropriate interventions can be put into place for nurses now and in the future, when the next major crisis occurs. Telling stories in a Story Circle is a structured yet adaptable tool that allows for emotional connections and a sense of community. This paper will explore the methodology of Story Circle and its application to nurses working the frontlines, themes and sub-themes from Story Circles will be presented, followed by a discussion of their implications and conclusion.
Methodology
To explore the experiences of frontline nurses, a qualitative, focus-group design, guided by Story Circle methodology was utilized. Our trained moderator uses a variation of a Story Circle Methodology developed by the Roadside Theatre Company that has a similar structure to that used by the United Nations Educational, Scientific, and Cultural Organization (UNESCO) and the U.S. Department of Arts and Culture (UNESCO). During the Story Circle, our trained Story Circle moderator encouraged the nurses to “tell a story” related to three prompts:
Tell a story about working during the COVID-19 pandemic.
Tell a story about how this experience impacted you professionally.
Tell a story about how this experience impacted you personally.
Each participant was given time to reflect and respond to the prompts. All Story Circle sessions were held via Zoom and were audio recorded and transcribed verbatim and stored in secure password protected database. Thematic analysis of transcripts was done by two trained researchers utilizing horizontal coding . Results were reviewed by the entire research team.
Accompanying the Story Circles were a pre- and post-survey sent to participants via email by the PI. The pre-Story Circle survey focused on demographic data, while the post-Story Circle- survey evaluated the efficacy of the Story Circle and its potential therapeutic benefits. Both surveys were developed by the researcher.
Nurses were recruited in 2021using purposive and snowball sampling methods. Following Institutional Review Board approval, flyers were posted on social media platforms, distributed to known hospital educators and administrators to share amongst their staff, and shared within nursing social circles. Participants who responded to the flyer were provided with further study information and Story Circle time slots. Attendance was required to participate in the study and implied consent to the study.
Four Story Circle groups were held with the number of participants ranging from two to six participants per session. Each Story Circle session lasted one hour. All participants were asked to reflect on the listed three prompts regarding caring for patients with COVID-19.
Each participant was given 3-5 minutes to share a story before the next participant was asked to do the same. Following the completion of the first prompt, participants were asked to take a minute to reflect upon an answer for the next two prompts, which followed the same format.
Results
Participants (n=14) completed the demographics survey that was sent to them via email by the P.I. after they voluntarily expressed interest in participating in the study. Of the 14 participants, 13 identified their gender as female and 1 as male. The majority of participants were Caucasian, earned a bachelor's degree in Nursing, and identified English as their native language. All participants cared for COVID-19 patients in the previous month in a variety of care settings including the intensive care unit (ICU), emergency department (ED), telemetry, medical-surgical, and other settings such as hospice, oncology, and long-term care. Nurses cared for patients in a variety of rural and urban settings.
Theme: Navigating Uncharted Waters
Participants described feelings of fear and mistrust of the healthcare system while caring for patients with COVID-19 in a variety of settings. While each participant’s COVID-19 care experience was unique, a common theme amongst the nurses was feeling unprepared to adequately care for patients due to how novel COVID-19 was to healthcare as well as the frequently changing guidelines for patients with COVID-19. This theme includes seven subthemes: healthcare mistrust, fear of COVID-19, stress and loss of control, exhaustion/ burnout, advocacy, community frustration, and social isolation.
Subtheme: Healthcare Mistrust
As participants were working to care for COVID-19 patients over the course of the pandemic, while guidelines for caring for COVID-19 patients were frequently changing. Many nurses learned how to provide care for COVID-19 patients while actively caring for the patient. Some participants felt that these sudden guideline changes created mistrust for the healthcare system, their management, and current medical practice.
“Everything was changing minute by minute-- the policies. I remember, I actually tried to type up a list of policies to give to people on the upcoming shift because none of us knew what to do, or when to do it.” (P2)
Participants felt that despite the care they were providing throughout such uncertainty, they did not have support from leaders within the healthcare system. Participants were making sacrifices throughout their daily duties with no support from administrative personnel.
“We had nobody to fight for us and say absolutely we deserve a raise and so that was just like another punch to the gut that here we are really truly putting our lives at risk. You know, I think I just saw a statistic that there were 3600 healthcare workers who died during COVID--exposed at the job, exposed on the job. But yeah, that was just that's just kind of came to me, but that made me angry.” (P1)
Subtheme: Fear of COVID-19
As participants described their experiences of caring for COVID-19 patients, many nurses had initial feelings of fear during the beginning of the pandemic of bringing home COVID-19 to themselves and their loved ones. Many of the nurses endured the arduous battle of caring for patients and understood their acuity of the illness and feared for their own life as well. As nurses described the various changes in practice and policies during the pandemic, they also questioned the compromise of their safety and wellbeing while caring for others.
“I was completely exhausted, and I felt like crying and screaming and... terrified that I was going to get it (COVID-19), terrified that I was going to take it home to my kids and my husband. So, initially it went from just exhaustion and fear to then realizing I was in this for the long haul.” (P1)
“ I came home and cried and I was terrified. My anxiety went through the roof. I was anxious to leave the house, I was so scared of getting COVID. I am asthmatic, I have some cardiac issues, and I was just so, so paranoid. After seeing these horrible effects of watching people struggle for weeks to breathe, finally intubating them, feeling some relief that they're not struggling, but then the fear of are they going to wake up.” (P10)
Subtheme: Stress and Loss of Control
During their storytelling, nurses described trials of physical and emotional stress that they have endured while caring for patients with COVID-19 at the frontlines. Often, nurses felt like they had no control of their environment while caring for their patients.
“And just feeling like I was so hot, like I couldn't breathe and just this sense of claustrophobia. And eventually, I was like I’m not done, but I have to get out of this room. I thought I was going to pass out, and so I did (get out of the room) and I remember feeling that sense of claustrophobia and that just super, extreme heat for a couple weeks.” (P2)
Participants were asked to increase their patient assignments thus increasing their workload throughout the day. The increases in workload lead to additional stress and loss of control when considering the conditions of their assigned patients.
“I was the only nurse for 25 plus covid positive patients and of those I'm going to say probably 15 or more were critically ill that I'm doing hourly rounds on and then just knowing that we had been on isolation, with no visitors, since the end of February (choked up, crying).” (P8)
Subtheme: Exhaustion/Burnout
Another subtheme that was evident within the nurses’ stories was the feeling of exhaustion due to increased acuity of patient condition, lack of administrative communication and assistance, lack of staff and staffing support, and lack of hospital resources.
“I have to put my foot down and I have to say, no I'm not available to work that shift. No, I can't come in early. No, I can't take that many patients. You know, it's too much…I recognize that I'm just, I'm burned out, you know…how do I not be burned out when I'm still doing the same stuff?” (P8)
Feelings and reports of burnout were discussed, some of which highlighted their personal experiences in recognizing and coping with such feelings regarding their practice.
“I'm definitely more numb towards nursing than I have been before, and that has translated into my personal life as well. I’ve had to start therapy again because I have to learn how to feel again because I was so overwhelmed by everything that I stopped letting myself feel things. I actually purchased a burnout survey for myself to see where I was at, and I scored very high on the burnout survey. I pass[ed] it around [to] my coworkers; they all scored very high on the burnout survey. And listening to all your stories I know you'd also probably score very high on the burnout survey so know that you guys aren't alone.” (P11)
Subtheme: Advocacy
Many of the nurses became advocates during their time caring for COVID-19 patients. Discussions included advocating for adequate resources, including personal protective equipment (PPE), guidelines to provide consistent and quality care, and for patients and their families to communicate via electronic devices during hospitalization.
“A lot of times, I’ll hold the phone up to their ear and hear on the other end what the family members are saying to them, which is heartbreaking most of the time. But this wife asked me if I can hold the phone up to her husband because her granddaughter was with her, and her granddaughter and the grandfather were two peas in a pod, and it would mean so much to him to hear her voice. And that just really struck a chord with me because I personally am very close with my grandfather who's 88. And a lot of times when I'm at work, I see patients, just like him who just deteriorate so quickly and I oftentimes think about if that were to be him or if I were that family member.”(P9)
Some of the participating nurses reported advocacy for patients despite the rules and regulations regarding patient care set by administration.
“I’ve been a nurse for three/four years, and I was like I’m not letting somebody die by themselves. I couldn't do it. I pissed off the manager of the unit, because I went against what they said. But I said ‘screw you, no one’s dying alone’. And basically, the guy (participant shows emotion here, chokes up), he woke up, looked at me, kind of breathe[d] a sigh of relief and passed away. It was immediate. But that being said, it's been sitting with me, since, because for patients are literally alone in the ICU. And, unfortunately with this virus we're still have issues with COVID. I mean I've been doing this for two years now, we still have people who are dying alone.”(P6)
Subtheme: Community Frustration
Many of the participating nurses described feelings of frustration as they saw expressions of ignorance from the public in the community and through social media. Participants provided details of the trials they experienced as many of their close friends and family would share false information through social media platforms. Additionally, some nurse participants had feelings of anger related to seeing community members not following appropriate precautions or guidelines in public.
“Just going to the grocery store makes me so mad because you just see people that don't care. Going on social media makes me so mad because you just see people that don't care and they haven't seen what we've seen. And it's just so frustrating, because if everybody did the right thing we wouldn't be here” (P12)
Some participating nurses reported experiences of communicating with members of the general public even within the hospital systems. There were instances where participants found frustration when speaking with, as well as reading what members of the community shared regarding COVID-19.
“I think it was cancer. Maybe something completely not COVID related right. But we had allowed the family to come in and they were they were with her [the patient] in the last moments. And one of the sisters was in the room and the patient had just passed away and the sister confronted my coworker, the other RN, and she said, “I want to see this death certificate and so help me if it says COVID on this death certificate I’m going to sue you. I’m going to sue [the] doctor. I’m going to sue this whole hospital.” And it's just unbelievable to me. Like, your sister had just died, that wasn't COVID related. COVID was not going to be on the death certificate and at the time of her death, this is what the sister was feeling was anger over this conspiracy theory about COVID deaths. And it was just crazy to me. Anyway, but I guess personally it has been a very frustrating year in general with the public not understanding why this is important and not putting others before themselves and recognizing that my mask protects you and it's just plain consideration to wear a mask. And that's been frustrating for me.” (P2)
Subtheme: Social Isolation
While nurses spent time at the frontlines of the pandemic caring for their patients and their communities, they often experienced social isolation from their close families and friends. Many of the nurses describe the loneliness they experienced as family and friends would avoid them due to their part in actively caring for COVID-19 patients.
“When I first got my wedding dress I wanted to go and show my parents, and my dad wouldn't let me come over (pause for crying) to even show my parents my wedding dress.” (P11)
“So, I skipped a lot of birthday parties for my nieces and nephews last year, so I missed a lot of memories last summer and even to now with school and we don't have any active covid patients, right now, thank God, but I’m still very cautious about going out and spending time with people.” (P8)
Many of the participating nurses felt they were alone in their personal experience in caring for patients with COVID-19. They reported their desire to keep others around them safe by keeping themselves isolated.
“For Thanksgiving they [family] invited us over and I was expecting, okay we’re all going to go, we’re gonna wear masks or say hi, [and] we're gonna leave. And I walked in there was six different households sitting together at the table eating—grandparents, grandkids—and no masks. They're all eating together at the same table. I was like, how could you do this? How could you put each other at risk and make me watch? I was stuck between feeling like I was radioactive and feeling like nobody cared about what I’d seen or done.” (P11)
Theme: Persisting Through the COVID-19 Storm
While participants certainly identified struggles, both professionally and personally, they also shared stories of how working during the pandemic fostered their resolve for the nursing profession and helping others. Participants shared experiences of how their perspectives changed. They spoke of gaining confidence in their skills and having a greater appreciation of their own self-worth and valuing the use of technology to foster communication between patients and their loved ones. This theme includes four subthemes: change in perspective, confidence in skill, understanding self-worth, and innovation
Subtheme: Change in Perspective
As the pandemic wore on, participants shared that their perspective began changing from fear and a loss of control to one of gratitude and resilience. Participants stated:
“… just knowing that I’m strong, and knowing that I am flexible and knowing that I’m resilient. And I’m, you know, more educated….” (P2)
One participant changed positions from a full-time staff ICU nurse to a travel nurse, as they wanted more control over their career choices.
“I started a new job. I started to actually travel nursing and the reasoning for that was for my personal gain…whereas before [at the previous facility] I only would worry about what [are] my coworkers worried about, [are] my coworkers okay, am I, is my facility okay, or are my patients OK?” (P6)
Other participants discussed the importance of “family” and their perspective of life.
“… just the appreciation of my family, you know driving home at night thinking my troubles are so minute compared to what people are going to through.” (P10)
“ I have gained a lot of faith in my fellow nurses. We were extremely tight knit before the pandemic and during the pandemic. They were even more so our family….” (P12)
“…but we've had to really hunker down and support each other and try and just make sure everyone's mentally okay.” (P14)
Another participant talked about how taking care of their patients outweighed the risk of not following their hospital’s policies and protocols.
“In a way it didn't bother me and if I was breaking a rule at that point, we really didn’t care, because if I gave that family member peace of mind, then, at the end of the day, that's all that mattered to me.” (P13)
Subtheme: Confidence in Skill
Several of the participants discussed how working during the pandemic helped them grow as a nurse. Example quotes of their stories include the following:
“… I feel proud of myself. Proud that I was thrown into a situation like this and have handled it as well as I have and [that I] was able to adapt.”(P10)
Some participants gained a sense of independence in their practice as a nurse.
“I think it forced me to be more independent.”(P10)
Participants even reported feeling like leaders in their profession, despite the number of years in which they have been practicing as a nurse.
“…it kind of helped me take a leadership role in terms of nursing, because being freshly new they would sometimes put me as charge nurse up there after the manager would leave….” (P13)
Subtheme: Understanding Self-Worth
Participants also discussed how working during the pandemic has helped them to realize their own self-worth as a nurse. Sample quotes include the following:
“So, this impacted me professionally because it is—and this is going to sound so cliche but it's so true—it really taught me about the value of life.” (P7)
In addition, participants described the value of caring for themselves.
“I don't pick up any more overtime at work. I’ve made a point of making sure I do my hours, I come home, my husband [and] I also have a business, so I work at that too, so I’ve definitely learn[ed] to take better care of myself.” (P10)
Subtheme: Innovation
Nurse have also described stories of various ways they used innovation to care for patients during the pandemic, many of which can help better nursing practice for years to come.
“There's four-ish nurses and almost all of the patients were intubated, so they're all on blood pressure medicines, sedation medicines, all kinds of drips and all that stuff. And we ran our medicines outside the room so the IV pump was actually out in the hallway and we had long extension tubing that would go under the door to the patient. That way we could change our drips and stuff without having to go in and get gowned up every time [an] IV pump beeped (sniffles, no camera on)..” (P11)
Nurses described utilizing their own personal technology as a means of communication.
“And I do remember another patient, the family was on the phone with me. They lived in Delaware, [and] we were in New Jersey—and she [the patient] was dying. I was like if, if you want, I will give you my phone number, and you can Facetime me so you can at least see her and talk to her. And at the end of that they were like, thank you very much, because they are like, I don't know if we'll be able to get to see her. And so, I was able to let them see her probably for one of the last times.” (P13)
Post-Story Circle Survey Results
All 14 participants completed a post-Story Circle survey that was sent to them via email by the PI. The questions were formatted using a Likert scale ranging from 1-10. The majority of participants found Story Circles to be beneficial in sharing their story (M=8.73, SD=1.73). Participants also found Story Circles helpful in validating their feelings of caring for COVID-19 patients (M= 9.33, SD=0.87). Additionally, participants were asked to rate how impactful Story Circles were to their mental well-being. Participants found the Story Circles to be helpful to their mental well-being (M=8.27, SD=2.86). The post-Story Circle survey concluded with two open ended questions where participants were able to describe additional information regarding their COVID-19 experiences as well as describe their thoughts on participating in the Story Circle. After listening and participating in Story Circles, some nurses added some anonymous, positive comments about their work experience while caring for patients with COVID-19.
“I'm in awe of the unbelievable strength and perseverance of my fellow nurses. I hate that we all feel so beat up by this pandemic, but I could not be more proud of my peers!”
“I am proud to be a nurse, and I'm so proud that I was able to help so many during this pandemic. Yes, I am very tired, but I will continue to care for my patients without too much complaining. I just want a long vacation away from people!”
Many of the nurses who participated in Story Circles felt gratitude towards participating.
“I do think this was very beneficial. Not only to share my stories and my perspective, but to also hear others’ stories and perspectives as well.”
“Thank you. Thank you a million times. Honestly, hearing the one nurse talk about feeling numb and getting help pushed me to reach out to my doctor and also get help!”
“I appreciate the chance to have my voice heard. I know nurses all over are crying out, but we never fully get to tell our stories. Thank you for giving me a voice, even if it is a small one in this large, messed up world.”
Discussion
The two overarching themes which emerged were largely representative of what nurses identified as polar parts of working throughout the COVID-19 pandemic: there were positive and negative outcomes of this process. The first, Navigating Uncharted Waters, described the negative outcomes of working through the pandemic. The second, Persisting Through the COVID-19 Storm, highlighted the positives of nurses working tirelessly throughout the COVID-19 pandemic .
Navigating Uncharted Waters
Participants described within their stories feelings of fear and mistrust of the healthcare system while caring for patients with COVID-19 in a variety of settings. While each participant’s COVID-19 care experience was unique, a common theme was feeling unprepared to adequately care for patients due to how novel COVID-19 was to healthcare as well as the frequently changing guidelines of evidence-based practice of caring for patients with COVID-19. Related to this theme was healthcare mistrust. These damaging outcomes of COVID-19 on nurses are noted frequently in emerging literature. Fernandez et al. identified the importance of acknowledging the stress and anxiety of nurses working the frontlines in order to better support these nurses experiencing the outcomes of the pandemic.
Persisting Through the COVID-19 Storm
While participants certainly identified struggles, both professionally and personally working during the COVID-19 pandemic, they also shared stories of how working during the pandemic fostered their resolve for the nursing profession and helping others. As the pandemic wore on, participants shared that their perspective began changing from fear and a loss of control to one of gratitude and resilience. The changes in perspective reflected in the Gratitude/Change in Perspective subtheme were also reflected in several other subthemes, such as Confidence in Skill, Understanding Self-Worth, and Technology Innovation. These changes can help with better nursing practice going forward.
Positive outcomes in nurses associated with the pandemic are also discussed in the literature and are important to acknowledge in helping the nursing profession move forward in the post-pandemic world. For example, LoGiudice et al. (2021) described a major qualitative theme in their mixed-methods study as “Proud to be a nurse”, while Catania et al. (2020) described moments of resilience, team bonding, and enhanced spirit among nurses.
Implications
There are significant clinical and policy implications from the findings of this study. Clinically, even prior to the COVID-19 pandemic, there has been a significant nursing shortage (Marc, et al., 2019). Since the pandemic, this shortage is reaching critical levels (Barton et al., 2021). It is imperative to understand the nursing experience and how to better serve nurses to address contributors to stress and burnout and capitalize on positive aspects of nursing careers. For example, using results of this study, it would appear important to nurses to be informed of the research and evidence behind new policy changes as they occur throughout the changing pandemic.
Limitations
This study has several noted limitations. The reflections shared in a Story Circle are immediate and public with those present generating insights and stimulating additional stories as they are shared. Story Circles differ from focus groups as they employ a democratic structure giving everyone equal time, and they center on the story as a narrative form, rather soliciting answers to a series of questions. Conducting Story Circles over Zoom is not ideal, as the immediate and embodied experience of the participants is limited and mediated by the small “box” in which they appear. The open-ended responses generated in a Story Circle capture the messiness and diversity, as well as the common aspects of participant experiences, however, does not allow for follow-up questions, probing, or in-depth discussion following the story, leaving potential for missed information or data.
Conclusion
The COVID-19 pandemic has had a significant impact on nurses and nursing practice since its emergence in 2019. It is necessary to explore the experiences of nurses working the frontlines of the COVID-19 pandemic to better understand and support this healthcare profession. Story Circles are an effective methodology in exploration of these experiences. Through the utilization of Story Circles, nurses were able to express their feelings regarding their experiences as a therapeutic technique. The findings of this study have shown the need to create clinical and policy implications to better support nurses, as well as the resilience of nurses through the COVID-19 pandemic.
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Michael Evans, PhD., RN, is the Assistant Dean for Undergraduate Nursing Education and a Teaching Professor in Nursing at Penn State University.
William Doan, PhD is a Professor of Theatre in the College of Arts and Architecture, and Director of the Arts and Design Research Incubator at Penn State University.
Kiernan Riley, PhD., RN, is a home hospice nurse in Worcester, Massachusetts.
Kalei Kowalchik is a second-year PhD student at Penn State University.
Logan DeSanto is a fourth-year honor's nursing student at Penn State University.