The Dilemmas, Distresses, and Rewards Experienced by Nurses Working in COVID-19 Wards: A Qualitative Study

Research design

This study employed a qualitative descriptive study design utilizing semi-structured interviews to deeply explore the experiences of nurses in COVID-19 wards. To enhance the rigor of qualitative reporting, the study adhered to the Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong et al., 2007).

Participants

The study participants were nursing professionals who had 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 had restructured general wards to accommodate infectious disease treatment in response to the COVID-19 outbreak. This ward, previously designed for treating infectious diseases, had begun 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.

Sampling technique

To recruit participants, a purposive sampling strategy was employed, specifically a criterion-based convenience sampling approach. Given that the study population was narrowly defined to nurses with experience in COVID-19 wards at a single university hospital in the Kanto region of Japan, purposive sampling was deemed optimal to ensure participants possessed the necessary experience relevant to our research questions.

The inclusion criteria were: (1) being a registered nurse; (2) having direct work experience in the COVID-19 ward at the participating university hospital during the study period (January 2022 to March 2023); and (3) being willingness to participate in a semi-structured interview.

Recruitment was conducted in several stages. First, the purpose and methods of the study were explained both verbally and in writing to facility administrators, and their consent was obtained. Seconds, as the hospital’s three-month rotation system for nurses volunteering to work in COVID-19 wards was used to identify potential participants who had served or were serving in COVID-19 wards. Third, posters were displayed in nurses’ lounges and other relevant areas within the hospital to disseminate study information and invite participation. Potential participants were also informed about the study by facility administrators. Fourth, prior to participation, all nurses who expressed interest were provided with detailed information about the study, including its purpose, procedures, voluntary nature of participation, and assurance of confidentiality. Written informed consent was obtained from all participants before the commencement of interviews.

A sample size of 12 participants was determined to be appropriate for this qualitative descriptive study, which aimed to explore experiences and perspectives in depth.

Questionnaire development

A semi-structured interview guide was developed to ensure focused and comprehensive data collection. The interview guide questions were developed through a multi-stage process. First the study’s aims were reconfirmed, focusing on distress, rewards, and dilemmas experienced by nurses in COVID-19 wards. Subsequently, a review of relevant literature was conducted, including qualitative studies on nurses’ experiences during times of health crises. This review helped identify key themes and areas to explore in the interviews. Next, based on the literature review and research aims, the research team drafted an initial set of open-ended questions. The team, comprising nursing professionals, qualitative research experts, and a psychiatrist, engaged in iterative discussions to refine these questions. These discussions focused on ensuring the questions’ relevance, comprehensiveness, clarity, and appropriateness for eliciting useful data from participants. The questions were primarily open-ended to encourage participants to freely share their experiences and perspectives, aiming to capture a wide range of experiences related to distress and rewards. The final interview guide was structured around four main categories designed to comprehensively explore the nurses’ experiences:

The preliminary interview guide was pilot-tested with two nurses with COVID-19 ward experience (but not included in the main study). Feedback from these pilot interviews led to revisions in question wording, flow, and overall appropriateness. These pilot interviews helped improve the clarity and flow of the questions, ensuring they were easily understood and effectively elicited the intended information. The research team confirmed the appropriateness and sensitivity of the interview guide based on the pilot testing.

Data collection

The study was conducted from January 2022 to March 2023. Participant recruitment and interview guide development began following ethical approval for the study in January 2022. The interviews, conducted semi-structurally, were conducted by a trained psychiatrist and occupational physician who were co-researchers in this study. Participants also provided demographic information on their interview sheet including gender, years of experience, position, educational background, and weekly working hours before and after the onset of the COVID-19 pandemic.

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 were 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. Data saturation was considered to have been reached when no new themes or subcategories emerged from the interview data, and existing categories were well-elaborated and richly described (Saunders et al., 2018). To ensure data saturation, we employed an iterative process of data collection and analysis. After each interview, the transcripts were analyzed, and subsequent interviews were conducted with attention to emerging themes. Data saturation was determined through ongoing discussions among the research team members, including nursing professionals and experienced qualitative researchers, after reviewing the transcripts and codes up to the 10th interview. While we continued to conduct two more interviews (total 12) to confirm saturation, no new significant themes or subcategories were identified, reinforcing our conclusion that data saturation had been achieved by the 10th interview.

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

The study involved 12 participants (8 women and 4 men) with a wide range of experience, from four to 21 years ( Table 1). The participants included six staff nurses, three deputy head nurses, and three head nurses. Weekly working hours remained largely consistent before and after the onset of the COVID-19 pandemic. Qualitative analysis of the interviews identified two overarching categories describing the nurses’ experiences in COVID-19 wards: (1) Distress Experienced by Nurses Working in COVID-19 Wards and (2) Job Rewards Gained from Working in COVID-19 Wards.

Distress experienced by nurses working in COVID-19 wards

This overarching category comprised four main themes: (1) Risk of Infection-Related Conflicts, (2) Challenges in Fulfilling Job Roles, (3) Organizational Conflicts, and (4) Interpersonal Conflicts. These four main themes were further divided into fourteen subcategories, which are summarized in Table 2, together with example statements from the interview transcripts to illustrate each subcategory. These themes represent the diverse sources of distress experienced by nurses during the COVID-19 pandemic.

The first theme, Risk of Infection-Related Conflicts: encompassed anxieties and conflicts stemming directly from the risk of infection. A significant subcategory was “Fear of contracting COVID-19,” with nurses expressing statements like, “I was afraid because I didn’t know where I might get infected,” revealing a pervasive fear of personal infection. This fear was often compounded by “Anxiety about family infection,” and “Struggles with family and societal relations.” Nine participants reported difficulties in this area. One nurse described encountering societal prejudice, stating “We experienced prejudice from those around us in society.” They concealed their COVID-19 ward assignment due to concern about negative perceptions, demonstrating the social burden nurses carried. Additionally, “Stress from not discussing ward duties” reflected in comments like “There was a stark disconnect between the world inside the hospital and the world outside,” and “Concern for infected or exposed staff” illustrated by thoughts such as “People questioned what I, as a nurse, was doing to prevent infection,” contributed to this theme, indicating anxieties about managing infection risks for themselves and their colleagues.

Challenges in Fulfilling Job Roles, the second theme, described the distress arising from the difficulties in performing their professional duties within the demanding COVID-19 ward environment. “Stress from unfamiliar tasks” was a major subcategory, with 20 participants reporting anxiety related to new responsibilities. Nurses expressed feeling unprepared and overwhelmed by tasks outside their usual scope of practice, sometimes feeling “We were rushed to meet deadlines, so we just did it.” This was linked to “Frustration in role fulfillment,” as nurses struggled to meet expectations and maintain their professional standards in the face of these new challenges. Sentiments such as, “I didn’t want to put extra stress on the younger staff,” and the reflection “I had to come to terms with my responsibilities as part of the Infection Control Unit.” “We were rushed to meet deadlines, so we just did it,” revealed a sense of obligation mixed with reluctance regarding their constantly changing roles. The “Thought of why I have to do it” and “Anxiety about not knowing what the future holds” illustrated by concerns like “I was anxious about being sent to a ward where I didn’t know anyone or what to expect,” and “Will I just keep getting moved from ward to ward forever?”, further illustrated their uncertainty and emotional burden. Moreover, “Criticism from other departments” added to their distress, as nurses felt misunderstood and undervalued by colleagues outside the COVID-19 wards, with comments like, “People assumed things must be easier now that case numbers are down.” Finally, “Inadequacy in managerial roles” was reported by managerial staff who felt uncertain and blamed, leading to feelings of inadequacy in their leadership capacity.

Organizational Conflicts, captured the distress stemming from systemic and organizational issues. “Frustration over inadequacies of the work system” was a central subcategory, indicating nurses’ feelings of helplessness due to inefficient systems and inadequate resources. One nurse’s statement about “There was so much uncertainty, and the atmosphere was tense” exemplifies this. The negative atmosphere caused by the many uncertainties within the organization also contributed to their distress. A strong “Desire for better responsiveness from upper management” emerged, with nurses feeling a lack of support and understanding from leadership. They expressed a need for more effective communication and recognition of the challenges they were facing, feeling that “Everyone shared a sense of anger toward upper management.” and “We all felt that our struggles weren’t being understood at all.” This lack of support created a sense of mistrust and dissatisfaction, leading to a perception of the organization as one “I was reminded again how this organization relies on top-down control.”

Interpersonal Conflicts, the final theme to emerge, describes the distress associated with difficulties in forming and maintaining relationships in the rapidly changing COVID ward environment. The subcategory, “Difficulty in establishing new relationships,” in indicated the challenges of building cohesive teams quickly with constantly changing staff. The feeling of weakened team spirit, described as “It felt like there was little camaraderie,” through statements like “I didn’t feel like I was part of a team,” and the sense that “My supervisor ended up completely isolated” illustrate the interpersonal struggles nurses faced in forming supportive professional connections. One manager’s comment, “Hearing everyone’s experiences was comforting, but also painful.” reflects the complexity of sustaining relationships amidst the high-stress environment. One comment, “Our poor relationships held us back” hindered effective teamwork and mutual support.

Job rewards gained from working in COVID-19 wards

Counterbalancing the distress, nurses also described positive aspects and rewards derived from their experiences, categorized into two main themes (1) Job Satisfaction and (2) Formation of New Human Connections – and four subcategories, as shown in Table 3 including example statements from the interview transcripts to illustrate each subcategory.

The first theme, Job Rewards, encompassed the intrinsic and extrinsic rewards experienced through their work. A core subcategory was “Sense of mission and responsibility,” with nurses expressing a heightened feeling of purpose and contribution during the pandemic, reflected in statements like “Even though patients were struggling, my role as a nurse didn’t change.” This sense of mission provided a strong motivator and source of fulfillment. Furthermore, the subcategory “Insights gained from experience,” emerged as a significant reward, with nurses recognizing the substantial professional growth they experienced. They viewed their experiences as an opportunity for personal growth, gaining new insights and confidence through their work, as one nurse stated, “It gave me a chance to build confidence.” and another reflected, “Being assigned to the COVID-19 ward changed the way staff felt empowered” demonstrating the positive personal and professional development stemming from these challenging times. Some simply found “It turned out to be an incredible experience.”

The second theme, Formation of New Human Connections, captured the unexpected positive outcomes related to new relationships formed during the pandemic. “Collaboration among staff” was a key subcategory, with nurses reporting a strengthened sense of teamwork and mutual support. Working with colleagues from different departments helped them to form new bonds and a shared sense of purpose in facing the common challenge, nothing “I was able to connect with colleagues from other departments” and “I heard many different perspectives from staff across various wards.” This collaboration extended to “Unity as an organization,” as some nurses perceived a greater sense of organizational cohesion amidst the crisis, feeling that “The wards became more unified” and “We truly came together as one team.” This unity, forged through shared adversity where “Discussions about how to manage the wards brought people together”, provided a crucial source of resilience and support, demonstrating the unexpected positive social outcomes of navigating the pandemic together.

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 is essential to conduct quantitative studies to further deepen our understanding of the various conflicts challenges that nurses face, especially when confronted with a large-scale medical emergency. This understanding would contribute to the development of effective strategies and interventions to support nurses during difficult 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 participating nurses in the current 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 conflicting experiences of both distress and fulfillment, and their perspectives on how to perceive and manage this tension 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.