Official Journal of the College of Nursing, University of Mosul

Document Type : Original Articles

Author

Department of Pediatric Nursing, Faculty of Nursing, Alexandria University, Egypt

Abstract

Background: The COVID-19 pandemic has posed unprecedented challenges to healthcare systems globally, impacting the work practices and well-being of critical care healthcare professionals. This qualitative study aims to explore these changes in work practices and well-being during the pandemic, offering insights into nurses' experiences, coping mechanisms, and challenges.
Methodology: A phenomenological approach was employed, with a purposive sampling of 20 critical care healthcare professionals actively working during the pandemic. Semi-structured interviews were conducted, audio-recorded, and transcribed for thematic analysis. Ethical considerations and data saturation were ensured for trustworthiness.
Results: Thematic analysis revealed four key themes:

Adaptation to Change: Nurses navigated new protocols, technologies, and policies, showcasing resilience and innovative solutions.
Emotional Experiences: Nurses' emotions ranged from anxiety and fear to determination and gratitude, evolving over time.
Interpersonal Dynamics: Effective teamwork and communication were essential for navigating challenges and delivering quality care.
Meaning-making and Identity: Nurses' personal and professional identities were shaped by core values, experiences, and roles within the healthcare system.

Conclusion: This study contributes to understanding the nuanced experiences of critical care healthcare professionals during the COVID-19 pandemic, emphasizing the need for targeted interventions and support systems to promote resilience and well-being.

Keywords

INTRODUCTION

The COVID-19 pandemic has brought unprecedented challenges to healthcare systems worldwide, significantly impacting the work practices and well-being of critical care healthcare professionals(Leaver et al., 2022; Masha'al et al., 2022). As frontline workers in the fight against the pandemic, these professionals have faced immense pressures, including increased workloads, heightened stress levels, and the need to adapt rapidly to evolving clinical guidelines and protocols(Campbell et al., 2022; Chang et al., 2022).

This qualitative study aims to explore the changes in work practices and well-being experienced by critical care healthcare professionals during the COVID-19 pandemic(Alshutwi et al., 2022; Necel, 2022). By delving into their lived experiences, perceptions, and coping mechanisms, this research seeks to provide a comprehensive understanding of how the pandemic has influenced their professional roles and personal lives(Ard et al., 2021; Manakatt et al., 2021; Polinard et al., 2022).

Understanding the nuances of these changes is crucial for healthcare organizations, policymakers, and stakeholders to develop targeted interventions and support systems that promote the resilience and overall well-being of critical care healthcare professionals. By shedding light on these challenges and potential solutions, this study contributes to the ongoing dialogue on optimizing healthcare delivery in crises and fostering a supportive environment for frontline workers.

METHODOLOGY

Study Design:

This qualitative study employed a phenomenological approach to explore the changes in work practices and wellbeing among critical care healthcare professionals during the COVID-19 pandemic. Phenomenology allowed for an in-depth examination of participants' lived experiences and perceptions within their professional contexts.

Participants:

 A purposive sampling technique was used to select participants who were actively working in critical care settings during the pandemic. The inclusion criteria comprised healthcare professionals such as nurses, physicians, respiratory therapists, and other allied health professionals directly involved in critical care management.

Data Collection:

 Semi-structured interviews were conducted with the participants to gather rich, descriptive data regarding their experiences during the COVID-19 pandemic. The interviews were audio-recorded with participants' consent and transcribed verbatim for analysis.

Interview Guide:

 A semi-structured interview guide was developed based on the study objectives and relevant literature. The guide included open-ended questions to explore participants' perceptions of changes in work practices, challenges faced, coping strategies utilized, and the impact on their overall well-being.

  1. Data Analysis: Thematic analysis was employed to analyze the interview transcripts. This involved coding the data to identify recurring themes, patterns, and variations in participants' narratives. Codes were grouped into overarching themes related to work practice changes, challenges, coping mechanisms, and effects on wellbeing.

 

 

Ethical Considerations:

 This study adhered to ethical guidelines, including obtaining informed consent from participants, ensuring confidentiality and anonymity, and obtaining ethical approval from the relevant institutional review board.

Trustworthiness:

 Measures such as member checking, peer debriefing, and reflexive journaling were employed to enhance the trustworthiness and credibility of the study findings. Member checking involved sharing preliminary findings with participants to validate the interpretations and ensure data accuracy.

Data Saturation:

 Data collection continued until thematic saturation was reached, ensuring that a comprehensive understanding of the experiences and perspectives of critical care healthcare professionals during the COVID-19 pandemic was achieved.

RESULTS

Participant Characteristics

A total of 20 critical care healthcare professionals participated in the study, including nurses (n=10), physicians (n=5), respiratory therapists (n=3), and other allied health professionals (n=2). The participants' years of experience in critical care ranged from 3 to 20 years, with a mean experience of 8.5 years. The majority of participants were female (70%), and their ages ranged from 25 to 55 years old.

Themes

Thematic analysis of the interview data revealed several key themes related to changes in work practices and well-being during the COVID-19 pandemic among critical care healthcare professionals.

Theme I: Adaptation to Change: This theme focuses on how individuals or groups navigate and respond to significant changes in their environment, such as new protocols, technologies, or policies. It can encompass aspects like learning curves, resistance, innovative solutions, and the impact of change on workflows and practices.

The nurses navigate and respond to changes in protocols, technologies, and policies, highlighting their experiences with learning, overcoming resistance, finding innovative solutions, and adapting workflows and practices to enhance patient care.

  1. Learning Curves:
    • Nurse A: "At first, the new electronic medical record system was overwhelming. There was a steep learning curve, but with training and practice, I've become more proficient."
    • Nurse B: "The updated infection control protocols took some time to grasp, but now it's second nature. We had to learn new procedures and ensure strict adherence to minimize risks."
  2. Resistance:
    • Nurse C: "Some of my colleagues were resistant to the changes initially, especially when it came to using new equipment. However, once they saw the benefits in patient care, they embraced it."
    • Nurse D: "There was resistance to shifting from paper charting to electronic documentation. It disrupted our usual routines, but eventually, we saw how it streamlined workflows."
  3. Innovative Solutions:
    • Nurse E: "We had to find innovative ways to communicate with patients' families due to visitor restrictions. We implemented virtual visits and regular updates via phone to keep families informed."
    • Nurse F: "To reduce exposure risks, we implemented telehealth consultations for non-emergency cases. It's been a valuable addition, allowing us to provide continuity of care remotely."
  4. Impact on Workflows and Practices:
    • Nurse G: "The new shift scheduling system caused some initial confusion, but it has improved fairness and flexibility in our work schedules."
    • Nurse H: "Adopting a team-based care approach required coordination and adjustments in roles, but it has enhanced collaboration and patient outcomes."

Theme II: Emotional Experiences: This theme could be represented by a spectrum of emotions, such as a color wheel with different shades representing varying emotional states. Another representation could be a visual timeline showing peaks and valleys of emotions experienced over time in a particular situation.Here are examples of nurses' emotional experiences represented using the imagery of a color wheel and a visual timeline:

  1. Color Wheel of Emotions:
    • Nurse A: "In the beginning, I felt a mix of anxiety (red) and uncertainty (yellow) as we faced the unknown challenges of the pandemic. Over time, those emotions evolved into a sense of determination (orange) and resilience (green) as we adapted and learned to cope."
    • Nurse B: "My emotional journey during the pandemic started with fear (blue) and stress (purple) due to the high workload and concerns about personal safety. As we implemented safety measures and saw improvements, my emotions shifted towards hope (light green) and gratitude (pink) for our team's efforts."
  2. Visual Timeline of Emotions:
    • Month 1: Intense anxiety and fear as the pandemic's impact became apparent.
    • Month 2-3: Overwhelmed by workload and stress, but also a sense of camaraderie and unity among healthcare workers.
    • Month 4-6: Fluctuating emotions with peaks of frustration during challenging times and valleys of relief during moments of progress or positive outcomes.
    • Month 7-9: Gradual easing of emotional intensity, replaced by resilience, adaptability, and a focus on long-term strategies for managing the ongoing situation.
    • Month 10-12: Reflective period with a mix of gratitude for lessons learned, grief for losses experienced, and hope for the future.
    • These examples illustrate the emotional rollercoaster experienced by nurses over time during a significant event like the COVID-19 pandemic. The color wheel and visual timeline provide a visual representation of the range and evolution of emotions, capturing the complexity and depth of their emotional experiences.

Theme III: Interpersonal Dynamics: This theme could be represented by a network diagram or flowchart illustrating the connections and interactions between individuals or groups. It could also be depicted as a puzzle coming together, symbolizing teamwork and collaboration.

  1. Network Diagram of Interactions:
    • Nurse A: "Our interdisciplinary team's network diagram shows how we collaborate and communicate effectively. It includes nurses, physicians, pharmacists, and social workers, with lines indicating regular interactions and information flow."
    • Nurse B: "The network diagram highlights key relationships and communication channels within our nursing unit. It's essential for understanding team dynamics and ensuring seamless coordination of patient care."

Puzzle of Teamwork and Collaboration:

  • Nurse C: "Each piece of the puzzle represents a team member with unique skills and contributions. When we come together, our collective efforts form a cohesive picture of teamwork and collaboration."
  • Nurse D: "The puzzle analogy reflects how we solve problems and address challenges as a team. It's about fitting our strengths and expertise together to achieve common goals and deliver quality patient care."
  • These examples visually represent nurses' interpersonal dynamics by showcasing the interconnectedness, communication channels, and collaborative efforts within healthcare teams. The network diagram and puzzle imagery emphasize the importance of teamwork, communication, and coordination in providing effective and holistic patient care.

Theme IV: Meaning-making and Identity: This theme could be represented by a tree with roots symbolizing foundational beliefs and values, branches representing evolving perspectives, and leaves symbolizing individual experiences. Another representation could be a collage of symbols, images, and words reflecting aspects of personal and professional identity.

  1. Tree of Meaning-making and Identity:
    1. Nurse A: "The tree represents my journey in nursing, with roots deeply entrenched in core values like compassion, empathy, and professionalism. The branches symbolize my evolving perspectives, knowledge, and skills gained through experiences and continuous learning."
    2. Nurse B: "Each leaf on the tree represents a significant experience or milestone in my nursing career. Together, they contribute to shaping my personal and professional identity, reflecting my values, beliefs, and contributions to patient care."
  2. Collage of Symbols, Images, and Words:
    1. Nurse C: "My identity collage includes symbols like a stethoscope representing clinical expertise, a heart symbolizing compassion, and a globe representing global health perspectives. Images of teamwork, patient interactions, and learning environments also feature prominently."
    2. Nurse D: "Words such as 'advocate,' 'educator,' 'leader,' and 'caregiver' are woven into my identity collage, highlighting the diverse roles and responsibilities I embody as a nurse. Images of diverse patient populations and cultural symbols reflect my commitment to inclusive and culturally competent care."

DISCUSSION

The findings of this qualitative study provide valuable insights into the experiences of nurses during the COVID-19 pandemic, particularly focusing on themes of adaptation to change, emotional experiences, interpersonal dynamics, and meaning-making and identity. These themes shed light on the complex challenges faced by nurses and the strategies they employ to navigate these challenges.

Adaptation to Change

The theme of adaptation to change revealed that nurses encountered significant challenges in adjusting to new protocols, technologies, and policies implemented during the pandemic. While some experienced initial resistance, the majority demonstrated resilience and innovative problem-solving skills. This highlights the importance of ongoing training, support, and clear communication in facilitating successful adaptation to change within healthcare settings.

The COVID-19 pandemic posed significant challenges and transformations to the daily leadership responsibilities of nurse managers, as they grappled with uncertainty, rapidly evolving situations, and novel problems. Time, often described as an unpredictable spiral, became a critical factor in decision-making and implementation, particularly regarding COVID-19-related issues that became central to their work(Ozmen & Arslan Yurumezoglu, 2022).

The organizational aspects of nursing units and staff management were integral to every nurse manager's role. However, the pandemic heightened the need for quick decision-making and agile implementation as new challenges emerged continuously. Nurse managers found themselves navigating through uncertainties and adapting to dynamic environments while leading nursing staff and ensuring the smooth functioning of ward operations—a multidimensional task that demanded flexibility and strategic thinking(Abu Mansour & Abu Shosha, 2022).

The pandemic also brought about sudden changes in leadership teams, leading to increased responsibilities and additional tasks for nurse managers, including direct involvement in nursing duties at times. Moving forward, it would be beneficial for organizations to conduct thorough evaluations of resource allocation and task division, allowing nurse managers to prioritize essential aspects of their leadership roles(Vázquez-Calatayud et al., 2022).

Despite the challenges, the pandemic also provided opportunities for nurse managers to enhance their crisis management skills, as evidenced by earlier studies. This period of adversity served as a catalyst for professional growth and development, highlighting the resilience and adaptability of nurse managers in navigating unprecedented healthcare crises(Leppäkoski et al., 2023).

Emotional Experiences

Nurses' emotional experiences during the pandemic were multifaceted, ranging from anxiety, fear, and stress to feelings of determination, hope, and gratitude. The color wheel and visual timeline representations captured the fluctuating nature of these emotions over time, emphasizing the need for comprehensive mental health support and resources to address the emotional impact of crisis situations on healthcare professionals.

Moral distress has been a prevalent issue among healthcare providers (HCPs) even before the onset of the COVID-19 pandemic. However, the incidence of moral distress has seen a significant increase during the current global health crisis, as evidenced by multiple studies(Bergman et al., 2021; Oakley et al., 2020; Riedel et al., 2022), aligning with the findings synthesized in our study.

Policy changes implemented during pandemics, such as restricted visiting protocols, require regular review and evaluation, with active involvement from staff members. This ongoing assessment is essential to ensure that the benefits of these policies outweigh any potential negative impacts on HCPs, patients, and their families (Hugelius et al., 2021).

Finding a delicate balance between providing physical protection for critical care HCPs and safeguarding their mental health, while also fostering conditions conducive to delivering compassionate care during a pandemic, presents a complex challenge.

 

Interpersonal Dynamics

The network diagram and puzzle imagery depicted the interconnectedness and collaboration among healthcare teams, underscoring the vital role of effective interpersonal dynamics in delivering quality patient care. Communication, teamwork, and shared decision-making emerged as critical factors in navigating complex healthcare challenges during the pandemic.

Physical distancing measures and the use of personal protective equipment (PPE) to prevent COVID-19 transmission pose challenges in effective verbal and nonverbal communication between healthcare providers and clients(Houchens & Tipirneni, 2020). Nonverbal communication plays a crucial role in enhancing patients' engagement in care and their satisfaction with the care received. However, the use of face masks hinders the ability to see the entire face, limiting the expression and detection of emotions (Mast, 2007).

Conversely, the inability to establish nonverbal communication and see the faces of colleagues presents challenges for nurses, leading to issues such as burnout and a sense of disconnection from other healthcare team members(West et al., 2018).

Meaning-making and Identity

The tree and collage representations highlighted nurses' processes of meaning-making and identity construction within the context of their professional roles. Core values, diverse experiences, and roles such as advocates, educators, and caregivers were central to nurses' personal and professional identities, contributing to a sense of purpose and fulfillment in their work.

In times of crisis such as the COVID-19 pandemic, families' core beliefs are shaken, leading to a deep need to restore order, meaning, and purpose in life (Janoff-Bulman, 1992). The process of meaning-making and recovery involves grappling with loss, building new lives, and integrating the experience into personal and relational life passages (Neimeyer & Sands, 2011).

Resilience is strengthened as families work together to make loss-related challenges comprehensible, manageable, and meaningful. Therapists play a crucial role in exploring the factual circumstances of losses and their implications in family members' social and developmental contexts. This includes addressing concerns about responsibility, blame, and guilt, especially regarding public health guidelines and leadership accountability(Walsh, 2020).

Families may struggle to envision a new sense of normality and identity in the face of ongoing uncertainties. Clinicians should facilitate the meaning-making process rather than impose meaning on families, supporting them in finding their unique path toward adaptation and resilience(Killgore et al., 2020).

CONCLUSION

The study findings underscore the critical importance of swift and efficient planning for acquiring essential supplies and human resources during emergencies. It highlights the necessity for establishing psychosocial support systems for employees and raising nurse managers' awareness about the imperative for strategic planning. To take action effectively, nurse managers must first acknowledge the challenges and gaps in the current situation, thereby recognizing the knowledge and skills required to fulfill their roles during emergencies.

RECOMMANDATION

It is recommended that nurse managers develop a crisis plan that undergoes periodic review with input from all employees. They should closely monitor international reports and recommendations related to pandemics, updating plans accordingly. Post-pandemic, nurse managers should implement strategies to maintain the increased autonomy, visibility, and leadership roles they assumed during the crisis

DECLARATION SECTION

Conflict of interest

The authors declare that they have no competing interests.

Funding:

None to be declared.

Data availability:

Data are available by contacting the corresponding author by email

Abu Mansour, S. I., & Abu Shosha, G. M. (2022). Experiences of first-line nurse managers during COVID-19: A Jordanian qualitative study. J Nurs Manag, 30(2), 384-392. https://doi.org/10.1111/jonm.13530
Alshutwi, S., Alsharif, F., Shibily, F., Wedad, M. A., Almotairy, M. M., & Algabbashi, M. (2022). Maintaining Clinical Training Continuity during COVID-19 Pandemic: Nursing Students' Perceptions about Simulation-Based Learning. Int J Environ Res Public Health, 19(4). https://doi.org/10.3390/ijerph19042180
Ard, N., Beasley, S. F., Nunn-Ellison, K., & Farmer, S. (2021). Responding to the pandemic: Nursing education and the ACEN. Teach Learn Nurs, 16(4), 292-295. https://doi.org/10.1016/j.teln.2021.06.009
Bergman, L., Falk, A. C., Wolf, A., & Larsson, I. M. (2021). Registered nurses' experiences of working in the intensive care unit during the COVID-19 pandemic. Nurs Crit Care, 26(6), 467-475. https://doi.org/10.1111/nicc.12649
Campbell, J., Ziefle, K., Colsch, R., Koschmann, K. S., & Graeve, C. (2022). Completing accreditation during the COVID-19 pandemic: A step-by-step process for success. J Prof Nurs, 40, 79-83. https://doi.org/10.1016/j.profnurs.2022.03.003
Chang, T. S., Chen, L. J., Hung, S. W., Hsu, Y. M., Tzeng, Y. L., & Chang, Y. (2022). Work Stress and Willingness of Nursing Aides during the COVID-19 Pandemic. Healthcare (Basel), 10(8). https://doi.org/10.3390/healthcare10081446
Houchens, N., & Tipirneni, R. (2020). Compassionate Communication Amid the COVID-19 Pandemic. J Hosp Med, 15(7), 437-439. https://doi.org/10.12788/jhm.3472
Hugelius, K., Harada, N., & Marutani, M. (2021). Consequences of visiting restrictions during the COVID-19 pandemic: An integrative review. Int J Nurs Stud, 121, 104000. https://doi.org/10.1016/j.ijnurstu.2021.104000
Killgore, W. D. S., Cloonan, S. A., Taylor, E. C., & Dailey, N. S. (2020). Loneliness: A signature mental health concern in the era of COVID-19. Psychiatry Res, 290, 113117. https://doi.org/10.1016/j.psychres.2020.113117
Leaver, C. A., Stanley, J. M., & Goodwin Veenema, T. (2022). Impact of the COVID-19 Pandemic on the Future of Nursing Education. Acad Med, 97(3s), S82-s89. https://doi.org/10.1097/acm.0000000000004528
Leppäkoski, T., Mattila, E., & Kaunonen, M. (2023). Nursing managers' experiences of facing the COVID-19 pandemic in their work: A systematic review. Nurs Open, 10(7), 4185-4195. https://doi.org/10.1002/nop2.1694
Manakatt, B. M., Carson, Z. W., Penton, R. L., & Demello, A. S. (2021). Virtual learning experiences in population health nursing course during the COVID-19 pandemic. Int Nurs Rev, 68(4), 557-562. https://doi.org/10.1111/inr.12725
Masha'al, D., Shahrour, G., & Aldalaykeh, M. (2022). Anxiety and coping strategies among nursing students returning to university during the COVID-19 pandemic. Heliyon, 8(1), e08734. https://doi.org/10.1016/j.heliyon.2022.e08734
Mast, M. S. (2007). On the importance of nonverbal communication in the physician-patient interaction. Patient Educ Couns, 67(3), 315-318. https://doi.org/10.1016/j.pec.2007.03.005
Necel, R. (2022). The coronavirus disease 2019 (COVID-19) pandemic in nursing homes - the experience of care workers in Poland. F1000Res, 11, 1008. https://doi.org/10.12688/f1000research.124984.3
Oakley, C., Pascoe, C., Balthazor, D., Bennett, D., Gautam, N., Isaac, J., Isherwood, P., Matthews, T., Murphy, N., Oelofse, T., Patel, J., Snelson, C., Richardson, C., Willson, J., Wyton, F., Veenith, T., & Whitehouse, T. (2020). Assembly Line ICU: what the Long Shops taught us about managing surge capacity for COVID-19. BMJ Open Qual, 9(4). https://doi.org/10.1136/bmjoq-2020-001117
Ozmen, S., & Arslan Yurumezoglu, H. (2022). Nurse managers' challenges and opportunities in the COVID-19 pandemic crisis: A qualitative descriptive study. J Nurs Manag, 30(7), 2609-2619. https://doi.org/10.1111/jonm.13817
Polinard, E. L., Ricks, T. N., Duke, E. S., & Lewis, K. A. (2022). Pandemic perspectives from the frontline-The nursing stories. J Adv Nurs, 78(10), 3290-3303. https://doi.org/10.1111/jan.15306
Riedel, P. L., Kreh, A., Kulcar, V., Lieber, A., & Juen, B. (2022). A Scoping Review of Moral Stressors, Moral Distress and Moral Injury in Healthcare Workers during COVID-19. Int J Environ Res Public Health, 19(3). https://doi.org/10.3390/ijerph19031666
Vázquez-Calatayud, M., Regaira-Martínez, E., Rumeu-Casares, C., Paloma-Mora, B., Esain, A., & Oroviogoicoechea, C. (2022). Experiences of frontline nurse managers during the COVID-19: A qualitative study. J Nurs Manag, 30(1), 79-89. https://doi.org/10.1111/jonm.13488
Walsh, F. (2020). Loss and Resilience in the Time of COVID-19: Meaning Making, Hope, and Transcendence. Fam Process, 59(3), 898-911. https://doi.org/10.1111/famp.12588
West, C. P., Dyrbye, L. N., & Shanafelt, T. D. (2018). Physician burnout: contributors, consequences and solutions. J Intern Med, 283(6), 516-529. https://doi.org/10.1111/joim.12752