Distress and Rewards of Nurses with Experience in COVID-19 Wards: A Qualitative Study

Research design

A qualitative descriptive study design using semi-structured interviews was adopted for this study. This study was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007).

Participants

The study participants were nursing professionals who have experience of working in a COVID-19 ward. The participants were employed at a large university hospital in the Kanto region of Japan. The hospital restructured general wards to accommodate infectious disease treatment in response to the COVID-19 outbreak. This ward, previously designed for treating infectious diseases, began operating as a COVID-19 ward after the hospital’s decision to admit COVID-19 patients. Pre-pandemic, nurses working in the general wards were requested to serve voluntarily for about two months in this infectious disease ward. Subsequently, after its conversion to a COVID-19 ward, the hospital implemented a three-month rotation system for nursing staff, based on a roster of volunteers who had served in the infectious disease ward before the pandemic. Participant recruitment was conducted by explaining the purpose and methods of the study to facility administrators, both verbally and in writing, and obtaining their consent. Following this, invitations to participate were extended to potential participants using posters and other methods.

Data collection

The study was conducted from January 2022 to March 2023, with interviews carried out from March 2022 to January 2023. Participants provided demographic information on an interview sheet including gender, years of experience, position, educational background, and weekly working hours before and after the onset of the COVID-19 pandemic. The interviews, conducted semi-structurally, focused on encouraging the nurses to reflect on their experiences working in COVID-19 wards. Interviews were conducted by a trained psychiatrist and occupational physician who are co-researchers in this study.

The content of the interview guide was as follows:

Data analysis

The transcription and analysis of the interview data were initially undertaken by the first author, and then conducted in collaboration with two other research team members who are nursing professionals. This was followed by a verification process involving the principal investigator and five additional members holding doctoral degrees. The interview data were analyzed utilizing methods of qualitative content analysis, specifically summary content analysis and exploratory content analysis (Flick, 2011). Summarizing content analysis involved rephrasing the data, eliminating insignificant or repetitive statements, and bundling similar expressions. Explanatory content analysis clarified ambiguous or contradictory statements by considering the context of their articulation. Transcripts were carefully summarized and analyzed, ensuring contextual integrity, and then abstracted to higher levels of generalization. Similar meanings were grouped into categories and subcategories. The results were repeatedly reviewed by co-researchers to ensure reliability and validity until consensus was reached.

Ethical considerations

Interviews were conducted in private rooms to ensure privacy, and data were analyzed with personal information excluded. This study was approved by the University of Tsukuba Medical Ethics Committee (Approval No.: 1690; Approval date: December 24, 2021). The study’s purpose and methods were explained both verbally and in writing to the facility administrators, and their consent was obtained before inviting participants. Participants were informed about the voluntary nature of participation, the possibility of withdrawing consent without disadvantage, anonymity, data security, and the publication of results. Consent was documented in writing before conducting the interviews.

Overview of study participants

Twelve nurses, 8 women and 4 men, participated in the study (Table 1). The average interview duration was 20.5 minutes. Age distribution included one in their 20s, four in their 30s, five in their 40s, one in their 50s, and one in their 60s. Years of experience ranged from four to over 20 years. The group comprised six staff nurses, three deputy head nurses, and three head nurses. The average weekly working hours were 44.2 before COVID-19 and 43.3 after.

Distress experienced by nurses working in COVID-19 wards

Analysis of interview content yielded 192 codes, 6 categories and 18 subcategories. Table 2 shows the four categories and 14 subcategories that were identified to describe the distress experienced by nurses working in COVID-19 wards. The four categories were: Risk of infection-related conflicts, Challenges in fulfilling job roles, Organizational conflicts, and Interpersonal conflicts.

With regards to the first category, Risk of infection-related conflicts, participants expressed fears related to COVID-19, with statements such as, “I was scared because I didn’t know where I might get infected,” “Before the vaccine rollout, there was a lot of fear,” and “During outbreaks, I didn’t want to work in the COVID-19 ward.” These statements reflect their fear of contracting the virus. Amidst these fears, one participant mentioned concealing their assignment to the COVID-19 ward due to concern about others’ perceptions, and was shocked upon overhearing conversations filled with prejudice against COVID-19. This led to stress about not being able to disclose their work in the COVID-19 ward openly.

Additionally, working in the COVID-19 ward triggered fears of becoming infected or a carrier, leading to self-critical thoughts like, “Even as a nurse, I worry about getting infected.” One mentioned how hearing of a nurse contracting the virus at a social gathering, despite hospital advisories against such gatherings, sparked negative feelings. There were also concerns for colleagues who became infected or were close contacts, reflecting a deep empathy for fellow staff members.

Working in a COVID-19 ward also brought anxiety about potentially infecting family members, compounded by societal prejudices. This resulted in worries about family and social relationships, with instances of biased neighbors or relatives making hurtful comments. The burden this placed on family members was another source of concern for the participant.

Regarding the second category, Challenges in fulfilling job roles, nurses expressed frustration related to their roles, with sentiments like, “I don’t want to stress the younger staff,” and “We need to understand it’s part of our ward duties.” Despite these feelings, they faced situations where temporary transfers became permanent, and expressed reluctance, saying, “I’m not doing this because I want to,” “If I could avoid it, that would be best,” and “Being single and living alone, it seems inevitable I’ll be sent.” These statements revealed a sense of obligation and questioning of why they must shoulder these responsibilities. There was also a sense of resignation, with thoughts like, “I can do this [my duties] because it won’t last forever,” and “Time will solve this,” indicating hope that time might ease the struggle with unfamiliar tasks. However, they still experienced stress due to these new duties. Amidst this vague anxiety, nurses wondered, “Where will I be in a few weeks?” and felt uneasy about being transferred to unknown wards without knowing what lies ahead, thinking, “Will I keep moving between wards forever?” and “There was never a moment of reassurance,” reflecting their anxiety about the uncertain future.

Despite these various stresses and anxieties, nurses noted differences in cooperation between wards and faced criticism from other departments, with remarks like, “You must be having an easy time now that the number of infections has decreased.” Those in managerial positions felt they were doing their best but often found themselves uncertain about what to do, feeling blamed and without the capacity to respond, leading to a sense of inadequacy in fulfilling their roles as nursing managers.

The category of Organizational conflicts highlighted the frustrations nurses experienced due to operational inefficiencies in the COVID-19 ward, such as “feeling helpless because preparations were inadequate” and “a negative atmosphere due to many uncertainties.” These issues contributed to a sense of difficulty in performing their duties. Nurses expressed a desire to share these challenges with the organization, feeling that “the extent of the difficulties wasn’t fully understood by everyone” and “there was a lack of effective communication with the higher-ups.” This led to a growing sentiment of wanting more support and understanding from the upper management. Furthermore, the experience led to a negative perception of the organization, with nurses realizing that “it’s an organization that oppresses and utilizes a top-down approach.” There was a collective sense of anger towards the upper management, indicating a deepening mistrust and dissatisfaction among the staff.

Regarding the final category, the necessity of building new relationships arose for those transferred to the COVID-19 ward. There was a sense of a weakened team spirit, as described by phrases like, “It felt like there was little camaraderie.” Nurses and doctors reported feeling unable to seek advice, leading to situations where “supervisors felt isolated.” This highlighted a scenario where establishing relationships with colleagues and the organization proved challenging. Amidst these struggles, a manager mentioned, “While it was good to hear everyone’s stories, it was also difficult.” This statement reflects the complexity of fostering relationships within the team. The hindrance in these efforts was attributed to poor relationships, as expressed in the comment, “The bad relationships became a constraint.”

Job rewards gained from working in COVID-19 wards

Two categories, Job rewards and Forming new human connections, were identified as more positive experiences gained from working in the COVID-19 wards (Table 3).

In the first category, Job rewards, the nurses described feeling a sense of mission and responsibility, gaining rewards from treating patients, and finding social significance in accepting them. Some viewed their experience positively as an opportunity for personal growth, gaining new insights and confidence through their work.

The second positive aspect was the category of Formation of new human connections in which participants describe how they found value in forming connections with staff from other departments and experienced a sense of unity within the ward, leading to cohesive teamwork.

Limitations and future prospects of this study

This study is limited by its focus on nursing professionals from a single facility, rendering the results non-generalizable. To construct a comprehensive theory, further data collection and analysis involving other institutions and a larger sample size are necessary. Additionally, capturing temporal changes was challenging, necessitating ongoing monitoring of the situation.

Based on the insights gained from this research, it’s essential to conduct quantitative studies to explore the content of nurses’ conflicts, especially during times of societal emergencies. This will contribute to the development of effective strategies and interventions to support nurses during such times. Moreover, a more detailed examination of the types of psychological support that can be offered to nurses is required to effectively address their specific needs and challenges. Nurses, as professionals, faced the necessity to respond to COVID-19, an unknown infectious disease, which brought with it severe feelings of anxiety and distress. Amidst these challenges, the nurses in our study also experienced personal growth and an expansion of connections with others, triggered by COVID-19. This has revealed how they, as professionals, are grappling with the dilemma of experiencing both distress and fulfillment, and their perspectives on how to perceive and manage this dilemma moving forward. Further investigations into both the negative and positive aspects brought by the pandemic can help us to understand how to support nurses in their vital caregiving work.