Lived experiences of Overseas Filipino Worker (OFW) nurses working in COVID-19 intensive care units

Abstract

Background

Limited studies focus on the effects of the pandemic on the nurses' overall risks and wellbeing. At present, no single study has been published on Filipino nurses’ experiences outside the country during the COVID-19 pandemic.

Objective

This descriptive phenomenological study explored the Overseas Filipino Worker (OFW) nurses’ experiences working in COVID-19 intensive care units.

Methods

The study was conducted in Dubai, United Arab Emirates, where there is a high number of COVID-19 cases. This study utilized a qualitative Husserlian phenomenological approach to describe and explore the lived experiences of the OFW nurses’ caring for COVID-19 critically ill patients. The research key interview informants were eight ICU nurses who cared for COVID-19 patients in Dubai hospitals. Data saturation was reached. Data collection was done in 2020, and Collaizi’s method of data analysis was utilized.

Results

A total of 135 significant statements were extracted from the interview transcripts. There were 36 formulated meanings generated, and four themes emerged from this study. The first theme is Challenges During the Pandemic with the following subthemes: Away from Home, Caring for the COVID-19 Patients, and Fear of the Unknown. The second theme is Patient Care during COVID-19 with the following subthemes: COVID-19 ICU Patient Care and The Nursing Profession. Third, Adapting to Change with the subthemes: Living the New Normal and Protecting One’s Self from COVID-19. Lastly, Resilience Amidst the Pandemic with the following subthemes: Being with Others and Seeing Oneself.

Conclusion

Despite the existing challenges like cultural differences and homesickness faced by these OFW nurses and the new challenges they are faced with the pandemic today, they were still able to continue living and do what is expected of them. From the hassle of wearing the PPEs, shortage of PPE, and being transferred from one unit in the hospital to another, the OFW nurses were able to adapt to these changes. The nurses already got used to the routine, but the fear of getting infected by the virus is still there.

According to the World Health Organization (WHO, 2020a), COVID-19 is a highly transmissible disease caused by a SARS-CoV 2 strain. Literature has shown that nurses need to sacrifice their own needs to prioritize the crisis management strategies and a need to make selfless and significant contributions out of moral and professional responsibility (Aliakbari et al., 2014). There are limited studies focusing on the effects of the pandemic on the nurses' overall risks and wellbeing. At present, no single study has been published on Filipino nurses’ experiences outside the country during the COVID-19 pandemic. Thus, this descriptive phenomenological study will describe and explore Overseas Filipino Workers (OFW) nurses working in COVID-19 Intensive Care Units.

COVID-19 infection has quickly spread globally, and due to the sudden outbreak, nurses are faced with a lot of pressure and new challenges like being transferred to new units or wards and adjusting to what is presently called the new normal (Sun et al., 2020). Some studies have shown that when nurses are caring for patients with highly transmissible diseases such as SARS (Chung et al., 2005) and MERS-Cov (Kim, 2018), nurses tend to suffer from psychological issues such as loneliness, anxiety, fear, fatigue, sleep disorders, and other physical and mental health problems. A study found the prevalence rate of psychological effects among nurses involved in the treatment of infectious disease (such as SARS patients), namely: depression at 38.5%, insomnia at 37%, and post-traumatic stress at 33% (Sun et al., 2020). Furthermore, among the psychological status of Ebola patients’ caregivers, 29% of respondents felt lonely, and 45% received psychological counseling. On the contrary, the positive experience and growth brought by the collective anti-epidemic efforts were also demonstrated (Sun et al., 2020).

Presently, many studies are published on how the COVID-19 pandemic has strained the world’s healthcare systems that include nurses. As cited by Mo et al. (2020), among the healthcare workers, nurses are found to be the most anxious and stressed in caring and treating patients infected with the COVID-19. Nurses who provided direct patient care seemed to be more stressed, overworked, and psychologically disturbed and less fulfilled in their job compared to nurses in other areas of assignment (Zerbini et al., 2020). Hospital women nurses who performed diagnosis, care, treatment, and management of patients with COVID-19, have shown psychological disturbances such as anxiety, lack of sleep, and depression (Lai et al., 2020).

For many years, Filipino nurses have been migrating abroad to meet the very high demand in other countries. The Philippine Overseas Employment Administration estimates more than 13,000 health care professionals leave the country every year. Many Filipino families view the nursing profession as their ticket to a better life earning 15 times more than their salary while working in our local hospitals (Lorenzo et al., 2007). As other countries have a shortage of nurses, they began hiring Filipino nurses because it is more cost-effective than training their own nurses (Lorenzo et al., 2007). With Filipinos being fluent in English, innately caring for the elderly and the sick, being adept in adjusting to new cultures and learning new languages, and not minding working longer hours, they perfectly fit the bill for nursing.

The ongoing COVID-19 pandemic poses great pressure, most especially in the critical care areas due to the large number of patients requiring critical care (Shang et al., 2020). As observed, Filipino nurses assigned in these areas face a lot of struggles in managing these critical patients in terms of implementing new practices, frequent changes in the medical and nursing management, and the virus is not readily studied yet. On top of the mentioned challenges, these nurses also are worried about their families in the Philippines, adjusting to the environment, interacting with people with different cultures, and so much more.

Overseas Filipino Workers (OFW) nurses are already faced with challenges every day, especially because they are working away from their country. They worry about their safety while working and at the same time worry about their families back at home. A lot of changes have been implemented in the hospital to address staffing problems. Some of the nurses are being pulled out to other units, and leaves were canceled. In this time of the pandemic, they are forced to find means to adapt to the present situation. As nurses are placed in demanding situations, fulfilling their roles on the frontline while at higher risk just to save others, this study will explore and describe the lived experiences of the OFW nurses working in COVID-19 Intensive Care Units. This study can help hospital administrators and government agencies understand the situation of OFW nurses and serve as a basis for them to develop new or revised policies that are beneficial to the welfare of the nurses and the patients.

Methods

Study Design

This study utilized the qualitative Husserlian phenomenological approach to describe and explore the meaning of OFW nurses’ lived experiences caring for critically-ill patients with COVID-19. Descriptive phenomenology was used for it has laid the foundation for theoretical knowledge and methodological clarity and rigor in qualitative nursing research Abalos et al. (2016) and Norlyk and Harder (2010). Husserlian phenomenology allows the researchers to explore and describe the structures of consciousness as experienced from the first-person point of view.

Key Informants

The key informants are OFW nurses assigned in the COVID-19 intensive care units and interviewed at their houses and hospitals. The researcher used purposive sampling in choosing the participants or key informants of this study. Purposive sampling is a strategy selected that will give information necessary for the needs of the study (Polit & Beck, 2017). In this study, the research participants were eight ICU nurses who cared for COVID-19 patients in Dubai hospitals. Exclusion criteria of the study included the unwillingness to participate in the study and nurses with a COVID-19 diagnosis.

Data Collection

The main instrument of this study is the researchers, as cited by Polit and Beck (2017). This highlighted the role of the researcher during interviews and observations. An English and vernacular semi-structured interview guide made by the researcher was utilized and expert-validated. The language used was based on informants’ preference. This interview guide comprises three parts: warm-up questions, main questions, and follow-up or probing questions. Sample grand tour question is “Can you describe to me your experiences as a Filipino nurse caring for patients with COIVD-19 in ICU in another country?”. Probing was done to encourage the respondents to give more information. Probes were neutral to avoid bias. Open-ended questions were used to provide the respondents with ample opportunity to express their feelings.

Prior to starting the interview, bracketing was done. This is important to mitigate the preconceptions or biases that may taint the research process. During the interview, the standard COVID-19 safety protocols were followed. Important aspects of the research were explained and discussed with the key informants, such as the use of a tape recorder, the interview venue, and the time that can be devoted to the interview. Then informed consent was obtained from the key informants. The researcher remained neutral throughout the interview process. The researcher started the interview with the list of semi-structured interview questions the researcher has prepared through one-on-one, face-to-face interviews. The average interview duration was one hour and 30 minutes and was duly recorded. The interview was conducted by JMP, spending one day per informants. Translation and back-translation with the help of a language expert were done to ensure the accuracy of the translation.

Data Analysis

Colaizzi’s method of data analysis is deemed most fitting and was utilized. This method uses components of Husserlian phenomenology, putting a premium on the description of the lived experience (Morrow et al., 2015). Colaizzi’s method of data analysis consists of seven steps. The first is to read and re-read all the participants’ verbatim transcripts of the phenomena to acquire a feeling. Second, significant statements or phrases are extracted from participants’ transcripts pertaining directly to the research phenomena. Then, formulated meanings are constructed from the significant statements. Fourth, formulated meanings are arranged into cluster themes which evolve into emergent themes. Then the results were incorporated into a rich and exhaustive description of the lived experience. Sixth, the thorough description from the participants involved in the research was validated. Lastly, new or pertinent data obtained from participants’ validation was incorporated and adapted to attain congruence with the lived experience of the participants studied. This study is rooted in the phenomenological framework to explore the OFW ICU nurses’ experiences in caring for the COVID-19 patients to develop a composite description of the essence of the experience for all the participants. Data was collected and analyzed using the steps from Colaizzi’s descriptive phenomenological method. Significant themes and meanings were interpreted through rigorous analysis of data to formulate the composite findings for this research study.

Rigor of the Study

Multiple semi-structured interviews per informant were done in different time-points to facilitate qualitative research rigor. To enhance the trustworthiness of this study, the following steps were done. First, person triangulation was done where auxiliary informants confirmed the statements made by the key informants or participants. Other colleagues not included in the key informants were also interviewed for confirmation of the key informants’ statements. The second is time triangulation, where the same questions were asked at different time points during the interview. Lastly, method triangulation wherein aside from multiple individual interviews, observation was done by the researcher to confirm statements and the researcher’s reflection. Observations were done by looking at the congruency of the verbalizations and the facial expressions and non-verbal cues.

Ethical Consideration

The researcher assures that the study adhered to the basic ethical considerations. The COVID-19 safety protocols were implemented throughout the research process. The data gathering was done after the participants were informed of the purpose of the study and have provided informed consent. It was made clear to the OFW COVID-19 ICU nurses that their participation is voluntary and that they can choose not to complete the interview without any consequence. Further, the participants were informed of their anonymity and that the data provided will be kept confidential. This study was reviewed and approved by Cebu Normal University – Ethics Review Committee with an approval code of 606/2020-11.

Results

Characteristics of Key Informants

Table 1 shows the profile of the informants of the study, including the code name, age, sex, civil status, and length of time they were working in the COVID-19 ICU. It shows that the informants are between 28 and 32 years old, and most are married. The shortest length of time they spent in the COVID-19 ICU is six months, and the longest is 11 months. They are all registered nurses. Some are master’s degree holders.

Table 1.

Profile of the Informants

Code Name	Age	Sex	Civil Status	Length of time Working in COVID-19 ICU
SN01	29	Female	Married	Eight months
SN02	29	Female	Married	Six months
SN03	29	Male	Single	Ten months
SN04	30	Female	Married	Six months
SN05	32	Female	Married	Six months
SN06	32	Female	Married	11 months
SN07	31	Male	Single	Seven months
SN08	28	Male	Married	11 months

Thematic Analysis

A total of 135 significant statements were extracted from the interview transcripts from the eight informants. There were 36 formulated meanings generated from these significant statements, and four themes emerged from this study. The first theme is Challenges During the Pandemic with the following subthemes: (a) Away from Home, (b) Caring for the COVID-19 Patients, and (c) Fear of the Unknown. The second theme is Patient Care during COVID-19 with the following subthemes: (a) COVID-19 ICU Patient Care and (b) The Nursing Profession. Third, Adapting to Change with the subthemes: (a) Living the New Normal, and ( b) Protecting One’s Self from COVID-19. Lastly, Resilience Amidst the Pandemic with the following subthemes, (a) Being with Others and (b) Seeing One self. These themes will be discussed further in the following.

Theme 1. Challenges During the Pandemic

This discusses the problems faced by the key informants assigned in COVID-19 ICUs during the pandemic. According to Sadang (2020), the COVID-19 health crisis caused an unforeseen paradigm shift in nurses’ life in healthcare systems, resulting in stressful and overwhelming challenges in their daily battle against this illness.

Subtheme 1. Away from Home

This is about the challenges faced by the key informants working abroad. It includes the feeling of homesickness, being away from the family, the cultural differences that they have observed, and the cancellation of plans due to the pandemic.

SN01 stated that SS2 “Aside from that, being a nurse overseas means being away from your family and loved ones, so you miss out on special occasions and holidays.” She added that “Uhmm, actually church wedding namin dapat ng husband ko but because of this travel ban, di natuloy.” (Because of this travel ban, my church wedding was postponed).

SN04 also mentioned that SS39 “Di naman nawawala yung pagiging homesick” (Homesickness is always there) and added, “Miss ko na anak ko” (I miss my child).

SN07 mentioned that SS95 “Pero di gihapon mawa ang kamingaw uy samot nag close jud kaayo mos imong family.” (But the feeling of missing your family is always there, especially if you have a close relationship with them).

Lastly, SN08 said SS19 “Kanang homesickness ug cultural differences given naman.” (Homesickness and cultural differences are given).

The issue of homesickness has not been addressed by international human resource management for a long time. Despite the recognition in the literature that expatriates go through the critical issue of adjustment (Haslberger et al., 2014) triggers the feelings of disconnection and missing home and has been a not-easy-to-achieve situation (Ward et al., 2001).

Subtheme 2. Caring for the COVID-19 Patients

This discusses the concerns faced by ICU nurses assigned to care for COVID-19 patients. This includes the hassle of wearing personal protective equipment (PPE), feeling of anxiety of possibly getting infected, not meeting the standards of care, and thinking about their families back home worrying about their safety.

According to SN01, SS4 “At first, I was very anxious to handle COVID-19 positive patients because I was worried that I might also contract the disease.” SN03 also stated that “Mas kapoy lang sad ang sa COVID-19 kay mag PPE kag taas na time.” (It’s more tiring in COVID-19 units because you have to wear PPE for a longer period).

SN05 said, SS60 “Naa baya koy newborn sa balay nya simbako matakdan ko ig duty.” (I have a newborn at home, and I’m scared to get infected). She also added that “Kapoy pud kay the usual na daghan na layers na PPE, init kaayo maski aircon pa. Then if naay procedures sa bedside, lisod pud kay di kaayo ka kaklaro tungod sa face shield.” (It’s tiring because of the PPE. It feels really hot wearing them even with the air conditioner. If there are bedside procedures, it is difficult because you can’t see properly because of the face shield).

Lastly, SN07 verbalized that SS100 “Hadlok ko uy sa akong safety.” (I was scared for my safety).

Front-line nurses experience an enormous amount of work, long-term exhaustion, infection risk, and frustration with the death of patients they care for. They also face anxiety or even disagreement among patients and their family members (Shen et al., 2020).

Subtheme 3. Fear of the Unknown

This tackles the fears of the informants regarding the disease, the unpreparedness for this pandemic, and the uncertainty of the future.

SN01 stated that SS5 “Also, it is a new illness so little is known about the virus, its transmission and effects on different types of people.”

SN02 verbalized that, SS20 “Kuyaw pud kay mas higher imong chance ma infect unya handtud karon, wala pay mga certain treatment jud na makaingon kag effective jud plus if ever, simbako, matakdan ka, layo pa jus imong family.” (It is risky to get infected because until now there is no certain effective treatment, and if ever you get infected, you are very far from your family).

According to SN03, SS34 “In some aspects siguro kay diri sa UAE naa man jud silay disaster plan and kani na pandemic considered man na disaster but for sure di jud emotionally prepare ang tanan.” (In some aspects, because here in the UAE, they really have a good disaster plan and this pandemic is considered to be a disaster but one thing is for sure, we are not all emotionally prepared).

SN04 said, SS42 “Mahirap kasi wala naman talagang nakapagprepare for this pandemic.” (It’s hard because nobody was really prepared for this pandemic).

The current COVID-19 pandemic presents a considerable occupational vulnerability for the health care team, causing fear or anxiety. These can be brought about by knowing or having more information and fear of the unknown related to the virus (Coelho et al., 2020). Fear of the unknown appears to be a fundamental fear and is a core component of anxiety (Carleton, 2016; Gallagher et al., 2014).

Theme 2. Patient Care During COVID-19

Averting a nosocomial outbreak of COVID-19 through transmission from patients to healthcare workers is essential. New and improved policies have been implemented to protect the healthcare worker and the patient. This section discusses about the changes in the care provided to the COVID-19 patients and the roles and responsibilities of nurses.

Subtheme 1. COVID ICU Patient Care

This tackles about the care provided to the COVID-19 ICU patients in comparison to non-COVID-19 ICU patients. This also includes the support given by the nurses to the patients.

According to SN01, SS6 “Sa COVID-19 positive patients, mas clustered yung care na binibigay sa kanila.” (In COVID-19 patients, we provide clustered care). She also added that SS7 ”Dapat as much as much as possible, ilessen yung time sa loob ng patient’s room, to lessen also your exposure.” (As much as possible, we spend less time inside the patient’s room to lessen our exposure).

SN02 mentioned, SS24 “Ipafeel nako nila na makarely sila nako sa scariest time sa ilang life.” (I will let them feel that I am there at the scariest part of their life).

SN05 verbalized, SS71 “Ang ako lang is ikeep nako in mind na atimanon lang jud sila ug tarong. Mo empathize lang jud ta nila.” (I keep in mind to properly take care of them. We should empathize with them).

SN07 said, SS102 “And kailangan sad jud tas mga patients especially karon.” (And the patients need us especially nowadays).

Although nursing care of patients with COVID-19 is largely supportive, it should include a strong emphasis on alleviating the spread of contamination to staff, other patients, and the community (Deitrick et al., 2020). The first priority of any nurse should be to protect themselves with the appropriate PPE. Nursing care should focus on limiting the exposure and spread of the virus. The whole experience of COVID-19 infection, in the form of staying in isolation wards, could be very traumatic, even for patients who are minimally symptomatic or asymptomatic (Sahoo et al., 2020). It is important to provide support to these patients, especially during this time.

Subtheme 2. The Nursing Profession

Nurses are very valuable in the healthcare systems and are crucial to health promotion, disease prevention, and treatment (Robertson-Malt, 2020). The World Health Organization (WHO, 2020b) considers nurses and midwives as the cornerstone in helping countries meet their commitments to Universal health coverage.

SN03 stated that SS38 “It also made me realize how noble the nursing profession is, and I am proud that I have pursued it.”

SN04 mentioned SS58 “Also, dapat din natin alagaan sarili natin para mafulfill natin ang ating duty.” (We need to take care of ourselves to fulfill our duties).

SN05 verbalized, SS61 “Worried kaayo ko all the time pero unsaon ta man, part man nis atong trabaho.” (I am worried all the time but this is part of our job).

SN07 said, SS117 “And kita nurses di ta dapat moundang ug educate sa mga taw and should lead by example.” (And we nurses should not stop educating the others and should lead by example).

Nurses are usually in the front line of care. They make a difference in individual patients’ lives and the community as a whole. Due to their sheer numbers and the locations where they often work, nurses are key players in improving public health outcomes around the world (Robertson-Malt, 2020).

Theme 3. Adapting to Change

Change is inevitable, but a drastic one has happened during this pandemic. The way we live nowadays is different, and people around the world are starting to adapt to these changes. But until a safe and effective coronavirus vaccine is available, there will always be a risk of infection, especially now that people are starting to go back to work. Businesses are re-opening, and classes at some schools were resumed. This part discusses about the present situation, adjustments made, and self-protection.

Subtheme 1. Living the New Normal

This talks about the experiences of the key informants with our present situation in this time of the pandemic.

SN03 stated, SS33 “Sauna mogreet with a smile jud kas imong patients, tabi sa mga kauban, party2x, but karon? Di ka kastorya sa uban without a mask and social distancing.” (Before, we used to greet the patients with a smile, talk with our colleagues and attend parties. But now, we can’t even talk with others without a mask and social distancing).

SN04 said, SS51 “Wala na din kasi masyadong gala sa labas.” (We don’t go out that much anymore).

SN05 verbalized, SS77 “Then mask jud bisag asa kay aside sa protection sa imong self, makabayad tag fine.” (We wear the mask all the time not only to protect ourselves but also to avoid paying the fine).

SN06 mentioned about always wearing a mask, SS85 “Wearing a mask is part of my outfit every day since it is now mandatory.”

Ever since the WHO declared this pandemic, we were forced to change the way we live. According to the Centers for Disease Control and Prevention (2021), we have to practice physical distancing, wearing masks all the time, and doing hand hygiene all the time to help prevent the spread of infection. These practices were followed by the key informants.

The present pandemic pushed the key informants to look for ways to connect with their families in the Philippines even if they are far from them and discover new activities while staying at home most of the time.

SN02 said, SS25 “Ngita jud ug paagi na connected gihapon mi despite sa distance.” (We find ways to stay connected despite the distance).

SN03 stated, SS36 “Physical activities and constant communication lang jud with the family.” (Physical activities and constant communication with the family).

SN04 verbalized about adjusting to the present situation, SS45 “Ngayon, nakapag adjust naman na.” (I have adjusted now). She also added that she got more attached to her family, SS48 “Mas attached ako sa kanila ngayon. Sila kasi yung source of inspiration ko at strength.” (I’m more attached to them now because they are my source of inspiration ang strength).

SN05 mentioned about constant communication, SS65 “Video call video call lang kada adlaw.” (We just call each other through video call every day). She also mentioned, “Kailangan sad jud mo adapt.” (We need to adapt).

SN07 stated, SS94 “Pero naanad ra sad kadugayan.” (But I got used to it eventually).

Due to the present situation, the key informants looked for alternative ways to connect with their families in the Philippines using different platforms for this will give them strength while working abroad. They also did more enjoyable activities with their friends in their respective residences or accommodation to pass the time and verbalized that they have already adjusted to the present situation.

Subtheme 2. Protecting One’s Self from COVID-19

The following statements made by the key informants are indicative of ways on how to protect themselves from being infected with COVID-19.

SN01 stated, SS17 “Aside from religiously drinking vitamins and minerals, during this pandemic, I sanitize everything that I brought outside including bags, cards, and cell phone.” She also added, SS18 “Every after duty, I make sure to take a bath and disinfect properly the uniform I used in the hospital as well as clothes worn outside of the accommodation.”

SN04 mentioned, SS54 “As much as possible, healthy diet na din to boost my immunity.” (As much as possible, I make sure to have a healthy diet to boost my immunity).

SN07 said, SS116 “Di nato itake for granted ang policies to prevent infection.” (We should not take for granted the policies to prevent infection).

Lastly, SN08 stated about the value for health and having a healthy lifestyle, SS131 “Mas givalue nako akong health ron. SS132 Di na ko magsmoke. SS133 Maningkamot ko ug tug jud at least 8 hours a day, and magstart nag kaon ug vegetables.” (I value my health more. I don’t smoke anymore. I try to sleep at least 8 hours a day and started eating vegetables).

According to WHO (2020b), good nutrition and hydration are very important. People who eat a well-balanced diet be likely to be healthier with stronger immune systems and reduced risk of chronic illnesses and infectious diseases. As mentioned by the key informants, they are doing steps to protect themselves from the virus by observing health protocols and boost their immune systems.

Theme 4. Resilience Amidst the Pandemic

Resilience is an extensive concept that encompasses individual and social resources to thrive from challenging circumstances (Callueng et al., 2020). Because Filipinos often experience different calamities and disasters, they remain resilient and seemingly immune to such circumstances (Ang & Diaz, 2018). The current pandemic arises numerous psychological stressors due to health-related, social, economic, and individual consequences and may cause psychological distress (Petzold et al., 2020). Strategies such as keeping a healthy lifestyle and social contacts, recognizing anxiety and negative emotions, and nurturing self-efficacy may help with these stressors (Petzold et al., 2020). Having a good support system and being more positive and appreciative is helpful for OFWs to be more resilient in this time of the pandemic.

Subtheme 1. Being with Others

This section discusses the key informants’ support system, including their relationship with their colleagues during the pandemic and how this helped maintain their positive attitude despite being away from home.

SN01 stated about the bond with her colleagues, SS12 “Uhmm mas nagkabonding kami ng workmates ko actually kasi same same kami ng sentiments regarding this pandemic.” (We bonded more with my colleagues because we share the same sentiments).

SN02 mentioned about teamwork, SS26 “Mas givalue namo ang teamwork and mas gaan ang trabaho if magtinabangay.” (We value teamwork more because it makes out work easier). She also added, SS27 “Mas mofocus ta sa positive kaysa negative.” (We focus more on the positive than the negative).

SN04 stated about doing activities together with the colleagues who live with her, SS50 “Sa flat naman, mas nagkaroon kami ng time magbonding kasi most of the time nasa flat lang talaga kami kapag walang duty.” (In our flat, we bonded more because we spend more time together during our days off). SN07 also shared the same sentiments about doing activities with his flatmates,

SS12 “Aw duwa mig video games sa flat.” (We play video games in the flat).

SN 05 said, SS75 “Kita ra sad juy magsinabtanay ug magtinabangay.” (We understand and help each other).

The ICU is a stressful work environment. Nurses are experiencing exposure to workplace stress, verbal and physical hostility, burn-out, moral distress, circadian rhythm disruption, and depression (Shaw, 2015). The stressful work environment leads to low-quality nursing care. Teamwork and collaboration prevent errors and promote healthy work environments (Shaw, 2015), which was also experienced by the key informants.

Subtheme 2. Seeing Oneself

This section discusses the realizations of the key informants, including being more appreciative and giving importance to life.

SN02 stated that, SS29 “I learned to be more appreciative of what I have and what really matters.”

SN04 verbalized, SS57 “Narealize ko na life is short, dapat itreasure natin ito.” (I realized that life is short and we should treasure it).

SN05 shared the same opinion, SS78 “One, life is short.”

SN08 mentioned about appreciation, SS134 “Ug nalearn sad diay nakog appreciate ang little things.” (I learned to appreciate the little things).

According to a survey conducted by the National Research Group, roughly 90% of the respondents say that the COVID-19 pandemic “is a good time to reflect on what’s important to them” (Olin, 2020). The experiences of the OFW nurses made them realize the value of life that they have to cherish and appreciate.

Discussions

OFW nurses face a lot of challenges every day, even before this pandemic started. ICU nurses have to take care of critically ill patients and are required to be mentally, emotionally, and psychologically prepared every time they go to work. When the pandemic started, these OFW ICU nurses were being pulled out from their respective units and transferred to the COVID-19 ICU. New protocols were implemented, adjustments were made, relationships with the colleagues were stronger, and slowly, resilience was built with each other’s support. For the key informants, these situations are very difficult for them.

Challenges during the pandemic discuss the problems faced by the OFWs nurses being far from their homes, the issues they encountered when they were transferred to the COVID-19 ICU, and the fear of the unknown. Even before the pandemic started, these nurses were already faced with the problems of adjusting to a different culture, language barrier, and homesickness. At present, they are faced with additional problems like being unable to go home because their leaves were canceled. One informant also mentioned about her wedding ceremony being postponed because of this. Aside from these personal modifications, there are also changes in the workplace settings.

The key informants were then transferred to the COVID-19 ICU because the number of COVID-19 patients needing their care increased. They expressed their feeling of anxiety about being in the new unit and anxiety about contracting the disease. They also expressed the hassle of wearing many layers of PPE for long periods. Aside from this, they also mentioned about having a shortage of PPE. The major issues facing nurses in this situation are the critical scarcity of nurses, beds, and medical supplies, including personal protective equipment, as reviews indicate, psychological fluctuations and fears of infection among nursing staff (Al Thobaity & Alshammari, 2020). According to the key informants, the quality of care given to the COVID-19 ICU patients was not meeting the standards because they are spending less time inside the patient’s room to limit their exposure. As one informant has mentioned, they are not turning the patients to sides to release back pressure as often as the patients in the non-COVID-19 ICU.

Furthermore, another challenge the COVID-19 ICU nurses were facing is the fear of the unknown. During the time of the interview, there is little information on the management of the disease. They also expressed the feeling of uncertainty about the future. An American Nurses Survey of more than 30,000 nurses reported that 87% of nurses are very or somewhat afraid to go to work, 58% are highly concerned about their personal safety, and 55% about caring for a COVID-19 patient or person suspected of having the virus (American Nurses Association, 2020).

In addition, the difference in the care of patients in the COVID-19 ICU was also stated. Clustering of care is done to limit exposure. The nurses also verbalized to provide support to their patients, especially during these times. The importance of nursing as a profession was also realized by the nurses. They were reminded of their roles and responsibilities as a nurse and how noble the nursing profession is. Some expressed that they are just doing what they have to do because it is part of their job.

With all of these, being adaptive to change helped these nurses to cope with the present situation. The new normal when going out includes the wearing of a mask every day and observing physical distancing. On their days off, they mostly stay at home. Adjustments have been made for the current situation. They expressed about staying connected with the family, and time spent communicating with them through video calls has increased. After how many months of being assigned in the COVID-19 ICU, they have already made necessary changes to adjust to the present situation.

With the ongoing pandemic, it is important to protect one’s self. Measures to protect one’s health were done like taking a bath more than usual, having long hours of sleep and rest, and having a healthier lifestyle. The nurses also verbalized that they value health now more than ever. That this also helps building resiliency among them.

Building resilience is possible with the presence of a support system. The presence of the nurse’s friends as their second family helped them a lot. Closer bonds with their colleagues and workmates were formed through teamwork and doing activities together at home. Having a more positive outlook also helped them during this pandemic. Furthermore, the nurses realized the value of life and how it should not be taken for granted. They also learned to be more appreciative of the little things they have.

Lastly, the government and policymakers can possibly look into the situation of Filipino nurses in their country. They are currently anxious because they cannot take their leave or spend their vacation in the Philippines, even during their end of the contract periods. This factor adds up to their uncertainty abroad while they are practicing nursing in ICU amidst pandemics. According to Garcia et al. (2018), the Filipino culture is one of the main factors on why they have qualms in working away from their home. However, living here also means challenges in terms of compensation. Despite this, true-blooded Filipinos are willing to sacrifice for the family.

The limitation of the study includes focusing only on ICU Filipino nurses. Future studies could explore other target populations. Furthermore, the protection of these nurses is highly important to be explored by policymakers, and Philippine Nurses Association, and other relevant agencies. Providing them with enough PPE could help lessen the stress they feel being assigned in the COVID-19 ICU. Although the nurses were able to adapt to the present changes, it is highly suggested to provide an avenue for them to voice their concerns and make them feel that support is there from the management. There was no mention from the interviews about any compensation or support done by the management.

Conclusion

Despite the existing challenges like cultural differences and homesickness faced by these OFW nurses and the new challenges they are faced with the pandemic today, they were still able to continue living and do what is expected of them. From the hassle of wearing the PPEs, shortage of PPE, and being transferred from one unit in the hospital to another, the OFW nurses were able to adapt to these changes.

Up until now, the travel ban and cancellation of vacation leaves are still implemented. These nurses found ways to be connected with their families through frequent video calls through the internet. The nurses already got used to the routine, but the fear of getting infected by the virus is still there.

Support from peers and a positive outlook were also helpful to build resilience. They also learned to value life more and be more appreciative. All of these imply that OFW ICU nurses are resilient as they did their duties professionally and that comprehensive support be provided to safeguard their wellbeing as they continue making their significant contributions out of moral and professional responsibility in taking care of the COVID-19 patients.

Declaration of Conflicting Interest

No Conflict of Interest.

Funding

None.

Authors’ Contribution

JMP is the lead author from the conceptualization, formulation, and finalization of the research paper. JCC contributed significantly to the conceptualization, formulation, critiquing, and completion of the research paper. All authors agreed with the final version of the article.

Authors’ Biographies

Jane Marnel Pogoy, RN is a Graduate Study Researcher of Cebu Normal University, Philippines.

Jezyl C. Cutamora, PhD is a Director of Research Institute for Ageing and Health, a Vice Chair of Ethics Review Committee, and a Department Chair at the College of Nursing of Cebu Normal University, Philippines.

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.