Nurses’ Experience After First Wave of COVID-19: Implications for a Trauma-Informed Workforce

Abstract

Background

The COVID-19 pandemic impacted nurses worldwide, increasing their risk of burnout and compassion fatigue. Although the literature on nurse deployment has been limited, this study describes nurses’ experience and assesses their professional quality of life after the first phase of the pandemic and redeployment efforts.

Methods

In 2020, nurses returning from their deployment to COVID-19 treatment units were invited to complete the Professional Quality of Life Survey and gather for debrief sessions, referred to as campfires, in which semistructured questions about their experiences were administered among clinical nurses and nurse leaders. Employing a mixed methods design, the authors conducted descriptive statistics for survey responses and inductive thematic analysis to identify emergent themes from open-ended questions.

Results

A total of 19 campfires were held with 278 nurse participants. Of the 278 participants, 220 completed surveys. Of these, 194 (88%) represented 30 nurse leaders and 164 staff nurses. The majority of surveyed nurses in both groups reported compassion satisfaction despite reporting moderate levels of burnout and secondary traumatic stress. Qualitative themes from campfires with clinical nurses and nurse leaders revealed similarities, such as concern for safety and lack of choices and transparency, although each group faced unique challenges.

Conclusions

Findings related to post deployment and adverse psychological health suggest that a trauma-informed approach (ie, staff autonomy, physical and psychological safety, transparency, offering choices, leveraging voices, and collaboration) by leaders could enhance a culture of wellness, build resilience, and mitigate empathic burnout and also proactively and strategically thinking about preventive measures for future catastrophic events.

Introduction

The World Health Organization (WHO) designated 2020 the International Year of the Nurse and the Midwife, recognizing the critical role they provide in the delivery of health care.¹ On March 11, 2020, the WHO declared the novel coronavirus (COVID-19) a global pandemic. According to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network data, almost half of hospitals in the US (2199 of 4587) operated at more than 85% capacity at some point during the height of the pandemic, between August 2020 and April 2021.^2,3

This pandemic would be likened to the influenza virus of 1918 in severity. According to the CDC, some 500 million people worldwide aquired the influenza virus caused by the H1N1 strain, resulting in 50 million deaths, with some 675,000 taking place in the USUnited States.⁴ To date (May 2023), the WHO Coronavirus Dashboard reports that 6,938,3533 COVID-10–related deaths worldwide have been reported to them,⁵ and the U.S. reports 1,129,838 deaths.⁵ The redeployment of staff from pandemic-related closure of units, such as procedural, ambulatory, and perioperative spaces, to care for patients with COVID-19 created a unique set of concerns and considerations for nurses and nurse leaders.

Although nurses were essential in both pandemics, the psychological impact on nurses and other health care workers may have been worse during COVID-19 due to the unknown characteristics of the disease and the prolonged nature of the event.⁶ Keeling wrote a synopsis of nursing in the United States during the 1918 pandemic in Public Health Reports⁷ that highlighted the unique challenges of that time: the lack of a nursing work force, antivirals, and antibiotics, as well as an evolving scientific community. In 2020, the COVID-19 pandemic and related redeployment substantially impacted the psychological well-being of nurses.

The American Nurses Association (2020) surveyed 12,881 nurses between December 4 and 30, 2020, with the intention of examining the ongoing impact of the pandemic on their well-being. The results indicated that 72% of nurses felt exhausted, 64% were overwhelmed, 57% felt anxious or unable to relax, and 57% reported feeling irritable.⁸ Although the literature on nurse deployment has been limited, several articles have recently emerged. Robinson and Stinson used a hermeneutic phenomenology design in a sample of nurses working with patients with COVID-19.⁹ They identified 3 themes: 1) human connection, 2) nursing burden, and 3) coping.⁹ In one study, nurses who were redeployed reported higher levels of stress and anxiety and felt unsupported and abandoned during their deployment. Further, they identified communication that was structured, uniform, and employee-centered as key to assuring that redeployed nursing staff and management interacted early and proactively in planning for deployments.¹⁰ Additionally, Al Sabei et al found that nurse managers (ie, leaders) who were proactive in providing support, resources, and staffing directly impacted a reduction in the level of burnout.¹¹

Purpose

The literature is sparse on how to best lead in a health care organization during pandemics and specifically, on how to proactively and strategically integrate structural processes that mitigate the negative impact on health care workers. Initially, the purpose of this study was to describe the experience of clinical nurses and to assess their professional quality of life (eg, burnout, compassion fatigue, and secondary traumatic stress) after the first phase of the pandemic. However, after the authors initiated the present study, nurse leaders requested to be included, and additional clinical nurses who were deployed requested debrief sessions. Further, the authors wanted to share a set of recommendations based on their findings to inform organizational practice and policies in the future. Understanding the challenges that both clinical nurses and nurse leaders faced during this pandemic has the potential to illuminate and inform approaches and opportunities for health care organizations in the future.

Methods

During the summer of 2020, the impact of COVID-19 on the health care system, and in particular on nurses across the US and the world, was in the forefront of the news. The magnitude of the impact of COVID-19 would not be fully realized until the following year. However, the study described here and conducted with clinical nurses and nurse leaders provides some context to inform and help to better understand the critical concerns that arose as the pandemic persisted.

In late 2020, clinical nurses returning from deployment to COVID-19 treatment units were invited to complete a survey and gather for debrief sessions (referred to herein as campfires). Initially these campfires were offered to clinical nurses, but subsequently, nurse leaders from the units that clinical nurses were deployed from requested a similar debrief type session. The Mass General Brigham institutional review board made a nonhuman subjects research determination regarding this study.

Participants

Participants were recruited from a convenience sample of clinical nurses and nurse leaders from a large urban academic–teaching hospital. The clinical nurses were deployed from their home units to varied COVID-care units within the hospital. The nurse leaders were from the units of deployment. Initially, clinical nurses were invited to participate in one of 3 campfire sessions. As more nurses returned to their primary unit, additional requests for these sessions were made.

Study design

At first these sessions were intended as an opportunity for deployed clinical nurses to debrief their experiences. The authors had expected to conduct 3 sessions, referred to as campfires, denoting an informal gathering to dialog together. This project was not initially intended for research purposes given the timeliness of these debriefs and the demands on the authors’ system. However, due to numerous requests for these sessions, the authors pivoted to a mixed methods design that consisted of qualitative responses in a semi-structured group format and a cross-sectional quantitative survey. The authors adhered to the Consolidated Criteria for Reporting Qualitative Research¹² checklist following the third campfire, which improved the rigor and quality of reporting for the qualitative data and informed the study design for the remaining 16 sessions. Participants in each session ranged from 6 to 28 for clinical nurses across 15 campfires and from 3 to 8 nurse leaders across 4 campfires, totaling 19 campfires.

Study procedures

Survey and semi-structured campfires were conducted between May and August 2022. Participants provided verbal consent. Participants were physically spaced and masked according to CDC guidelines. Upon arrival to the campfire, participants were invited to anonymously complete the Professional of Quality Life (ProQOL) self-report 30-item questionnaire and place them face down. Once the surveys were completed, the authors reviewed the terms of engagement (Table 1) and began the campfire session.

Table 1:

Terms of engagement

WELCOME to CAMPFIRE DISCUSSION Finding our strength
This will be a space for sharing, listening, and healing, not debate, judgment, or criticism. We will:
Respect confidentiality. Honor the stories of others and be conscious not to share without permission. Share time equitably to ensure the participation of all. Assume good intent. Encourage people to use “I” statements and speak about their own experience and feelings, not that of others. Be intentional about suspending judgment, be curious, and come together in the spirit of solidarity. Be aware of our own unconscious bias. Be comfortable with moments of silence and reflection. Silence our phones. When speaking, ask ourselves: WAIT, WANT, WAIST: WAIT: Why am I talking? WANT: Why am I not talking? WAIST: Why am I still talking? When through speaking, state: “I’m done” or “I’m finished.”

Data collection

ProQOL Version 5

The ProQOL Version 5 (2009) is a validated tool that measures the impact of both positive and negative aspects of a person’s work as a “helper” on their perceived quality of life. The ProQOL was developed in 1995 by Figley¹³ and further developed by Stamm,¹⁴ with subsequent shorter versions being developed and validated.^15–17 There are 3 subscales—compassion satisfaction, burnout, and secondary traumatic stress—which include scoring for each subscale. The survey questions explore the positive aspects of helping (ie, compassion satisfaction), with high scores indicating professional satisfaction. The subscales of burnout and secondary traumatic stress measure the negative aspects of helping. Burnout is one of the elements of compassion fatigue, which is associated with hopelessness, and can affect one’s ability to do their job well. Secondary traumatic stress relates to work-related secondary exposure to stressful events. A 5-point Likert scale included the following response options: 1) never, 2) rarely, 3) sometimes, 4) often, and 5) very often. The burnout scale was reverse-scored (ie, “1” was reverse-coded as a “5”). The scale of scoring was calculated as low, moderate, or high. A sum score of 22 or less signified a low score; whereas a moderate score was 23–41, and < 42 approximated a high score. High scores on burnout and secondary traumatic stress subscales indicated concern for one’s well-being.¹⁸ To build trust and assure anonymity, the authors did not collect demographic data from the participants.

Campfire sessions

There were 3 flip charts in front of the semi-circle of participants, displaying each of the following 3 open-ended questions:

1. Can you share what you found challenging over the past few months?

2. Can you share some suggestions and recommendations for consideration going forward?

3. What was a strength or something positive that occurred for you over the past few months?

Responses from participants to the open-ended questions during the campfire were recorded on the flip charts in front of the participants and were clarified with them for accuracy. The duration of each session was 75–90 minutes.

Data analysis

The ProQOL survey results were entered into a secure, password-coded REDCap database, and each response was given a unique number. Each subscale item was entered into REDCap, scored according to their ratings, and summed per the ProQOL scoring scale.¹⁸ Frequencies and distributions were respectively calculated for each rating (low, moderate, and high) per subscale (compassion satisfaction, burnout, and secondary traumatic stress) for clinical nurses and nurse leaders. Additionally, the total average mean scores and standard deviations were calculated for each of the 3 subscales. Descriptive statistics were also calculated for the combined data from clinical nurses and nurse leaders.

The qualitative responses were entered into a secure, password-protected Excel database. Each response was considered one unit of analysis. To mitigate bias, two independent members of the study team became familiar with the data and coded the data using an inductive approach.¹⁹ These inductive codes were developed into preliminary themes, which through team discussions and resolution of discrepancies resulted in final themes.

Results

Of the 278 participants, 220 surveys were submitted, and 194 (88%) of the submitted, completed surveys were used in the analysis, representing 30 nurse leaders and 164 staff nurses. Approximately 50 participants arrived late and therefore did not have time to complete the survey.

The nurse leader sessions (n = 4) were conducted separately from the clinical nurses and comprised 3–8 participants per session. Staff nurse sessions (n = 15) were comprised of 6–28 participants per session. Most participants were clinical nurses (n = 248) who were deployed to care for patients with COVID-19. Thirty nurse leader participants were associated with the units where staff nurses were deployed. Nurses (n = 8) who were not deployed from these respective practice areas also attended and are represented in the total number of clinical nurse participants.

Quantitative data: ProQOL

As demonstrated in Table 2, the aggregated results of the ProQOL Survey for clinical nurses and nurse leaders were included in the total scores for each subscale. The mean (standard deviation) total average scores and range for all participants were reported for the 3 subscales: compassion satisfaction [36.98 (59.31); range: 22–49]; burnout [21.75 (50.63); range: 10–38]; and secondary traumatic stress [25.68 (51.46); range: 12–44], with a wide distribution of data evidenced by a high standard deviation. Of note, the standard deviation of scores for the nursing leaders was more closely clustered around the mean score as compared to the clinical nurses, demonstrating more reliable data reported for the nurse leaders and notable variability among the clinical nurses.

Table 2:

Professional Quality of Life scale

	Clinical Nurses		Nurse Leaders		Aggregate
	n	%	n	%	N	%
Total	164	—	30	—	194	—
Compassion satisfaction scale
Low ( < 22)	1	0.6	0	0	1	0.5
Moderate (23–41)	124	76.1	24	80	148	76.3
High ( < 42)	39	23.9	6	20	45	23.2
Average score [mean (SD)]	37.18 (49.72)		35.62 (9.51)		36.98 (59.31)
Burnout scale
Low ( < 22)	93	57.1	17	56.7	110	56.7
Moderate (23–41)	71	43.6	13	43.3	84	43.3
High ( < 42)	0	0	0	0	0	0
Average score [mean (SD)]	21.7 (42.78)		21.9 (7.72)		21.75 (50.63)
Secondary traumatic stress scale
Low ( < 22)	47	28.7	13	43.3	60	30.9
Moderate (23–41)a	114	69.5	17	56.7	131	67.5
High ( < 42)	3	1.8	0	0	3	1.5
Average score [mean (SD)]	26.09 (46.21)		23.28 (7.72)		25.68 (51.46)

^aAggregate data include the combined results of clinical nurses and nurse leaders.

SD, standard deviation.

Despite the unequal distribution in sample size between clinical nurses and nurse leaders, respective results shown for clinical nurse and nurse leaders (Table 2) revealed similar scores for the compassion satisfaction and burnout scales. In both groups, approximately 76% to 80% reported moderate compassion and 40% reported moderate burnout, yet 57% of leadership and 70% of clinical nurses reported moderate secondary traumatic stress. When comparing moderate scale scores for secondary traumatic stress between clinical nurses and nurse leaders, clinical nurses scores were 12.8% greater than those of nurse leaders, but the percentage of burnout scores between clinical nurses and nurse leaders was comparable.

Qualitative data: campfire sessions

During the campfire sessions, themes emerged from 3 open-ended questions. Qualitative themes from campfires revealed some similarities, as well as unique challenges, experienced by clinical nurses and nurse leaders based on their respective roles. The major themes are summarized below for each question among clinical nurses and nurse leaders, respectively, and shown with the corresponding participant responses in Table 3.

Table 3:

Campfire themes identified among clinical nurses and nurse leaders

Questions	Nurse staff domains	Nurse staff themes	Nurse staff responses	Nurse leader themes	Nurse leader responses
1. Can you share what you found challenging over the past few months?	COVID-19 redeployment process	Transparency	“Lack of transparency.”	Overwhelm and feelings of inadequacy	“I worried about my staff; everything was moving so fast.” “While I know I did my best; it didn’t seem like enough.” “It was hard to keep up with communication and often I felt I was not heard [as] we were just overwhelmed daily for months and still are.” “I think while we were trying to be transparent, the message was constantly changing and that was seen as dishonest by the staff.”
		Communication	“We were the most impacted, yet we had no voice, no say”; “told to do” (not asked). “Done to us, not with us.”
		Staff autonomy and agency	Anger: “No voice,” “not heard”; “no choices”; “I will not do this again”; “I may leave nursing.” Constant stress, fear, and anxiety: “Still feel anxious and on edge.”
	Lack of understanding	Work schedule	Rigidity with schedule, not allowed to swap; general confusion about place of work; different unit every day. Given duties and responsibilities for patient care: “Not prepared”; “did not have the knowledge I needed.” Emails went unanswered. Undue stress over last-minute changes. Overnight scheduling: ”Hadn’t work[ed] nights in years,” which caused major sleep and concentrations issues.	Difficulty meeting staff needs	“It was so hard trying to meet the needs of staff while also thinking about the patients and endless changes; there are many things we could have done better.”
		Physical and psychological safety	Worry for colleagues (some still deployed, others who have gotten ill): “Felt worried all the time”; grateful, yet guilty I was not deployed”; “guilty I was on the hotline while my peers were in COVID unit.” Feeling unsafe, both for self and for patients.
		Family challenges	“My community [people of color] were hit hard and many of my relatives were impacted—no acknowledgment for what my community or I what I was experiencing”; “family member died”; “family member on respirator”; “family members with COVID.” “Lack of concern for my family, my home issues, childcare, elderly parents, partner also a nurse was redeployed.” “Didn’t see my extended family for months”; “had no family support for my children due to isolation”; “I was even isolated in my home trying to protect my family and kids.”
	Lack of efficiency in matching of staff skills in redeployment placements	Hopeless / anxious / shame	“Asked to do skills I had no experience with”; “led to helplessness feelings.” “Much anxiety because every day I went to a new and different unit—I still have anxiety and am seeing my doctor for help.” “I had shame and guilt as I was not deployed—nothing changed for me.”	Limitations and situational constraints	“Having to tell staff what to do and giving them no choices was distressful to them and to me.” “I hope going forward we can match the skills set of nurses with needs and be more collaborative with staff.” “I had to follow the process even when I didn’t agree.” “Was hard to be limited by the choices we could offer, that just felt awful.”
		Underutilized	“Skills not valued or not used.” OR nurse: “We are experts in donning and doffing”; “we know how to prone patients”; “no one asked us.” “Some days just sat around, not utilized”; “wished I could have helped more—I feel very guilty.”
		Disempowered	“Often felt more like a burden than a help.” Nurse deployed to ICU: “Felt like a burden, not helpful”; “felt bad that the ICU nurse had a different extender every day”; “was hard to build any meaningful relationship being all over the place.”
2. Can you share some suggestions and recommendations for consideration going forward?		Clear communication	Clear messaging, transparency, regular schedule for messages (so we know to look for it) and communication around deployment process. Develop and execute a communication plan that includes the voices of staff nurses, and support staff. Speakers for computers—”was unable to hear education modules provided.”	Trauma-informed care	“Just as we are being invited to embrace our patients with trauma-informed care... we also need to embrace our staff with the same.” “We should and will continue to elevate the voices of staff nurses and continue to enhance our shared-governance efforts.”
		Transparent processes	Huddles, ND presence, visibility of leadership.
		Input from staff	Anonymous suggestion box—post answers.
		Equitable distribution of the workload	Promote equity in all we do. Take volunteers first. Ask for staff preferences. Encourage fairness and equity in covering shifts. Identify all available nurses for deployment so no one group carries the burden (equity). Know the skills of staff and match accordingly—create the list now in case needed in future.
		Peer support	Have a peer support program that is informed by staff nurses. Have a response team to care for the deceased and debrief/process with staff. Develop a buddy system—two nurses from the same unit go to the same unit together.
		Inclusion and representation of staff and leaders	Include representatives from nurses in charge and staff nurses in process.
3. What was a strength or something positive that occurred for you over the past few months?		Gratitude	Advantaged, fortunate than most. Blessed, grateful, gratitude. Grateful for early access to vaccine, me nor any of my family contracted COVID.	General support	“I found I could be supportive to our nurses and support staff of color” [recognizing that their communities were greatly impacted].
		Peer support	Peer support: “a game changer.” Met new colleagues in other practice areas.	Peer support	“I wish we had peer support built in for staff and for us.”
		Appreciation	Witnessed amazing courage. COVID Floor Nurse directors were ”amazing.” Talented, highly skilled, and hardworking nurses.	Appreciation	“Hard to find words—the staff deserve all the credit.”

ICU, Intensive Care Unit; ND, Nurse Director; OR, operating room.

Question 1. Can you share what you found challenging over the past few months?

Clinical Nurses

Clinical nurses shared a number of challenges. The process for nursing deployment was not always transparent, lacked clear communication that was dynamic, included sometimes erratic and unpredictable communication, and constrained staff’s autonomy and agency. There was serious distress surrounding staff feeling a lack of understanding around their work schedule, their physical and psychological safety, and family challenges.

One nurse stated, “I didn’t see my family in months, as I didn’t want them to get COVID—so I stayed by myself.” Most stated that not having a voice in decisions or having choices produced much anxiety, “done to us, not with us”; “we were the most impacted, yet we had no voice.” Some felt they feared speaking up would result in retaliation—“so I chose to suffer in silence.”

Several non-white nurses observed racist comments and reported that a lack of awareness of how COVID had disproportionally impacted their community and often times felt as though they were not receiving any compassion from colleagues. “My community [people of color] were hit hard and many of my relatives were impacted—no acknowledgment for what my community or I was experiencing.” “I had a family member die and there was no celebration of their life, no funeral, no way to grieve.” Some shared they had a family member on a respirator and could not visit them. Every non-white nurse shared that they witnessed or heard racist comments on a regular basis. For example, one shared, “Well [these people] pack so many into small living spaces, what do they expect?”

Another shared that staff seemed annoyed with patients who did not speak English, “it takes so much more time to care for [them].” Another nurse stated she was often mistaken for a member of the environmental services even when she wrote “RN” on her cap.

Finally, both clinical nurses and nurse leaders felt there was a lack of efficiency in matching staff’s skills to deployment placement. “Just because I worked in the ICU [Intensive Care Unit] more than 15 years ago, they felt I should be deployed there.” Nurses stated that not all nurses are alike, and “It would be like taking a nurse leader and telling them they need to work in med-surg because they worked there 10 years ago.” Nurse leaders agreed that a better process for matching staff skills with their deployment was needed.

Nurse Leaders

There were several similarities that nurse leaders and clinical nurses reported, including regarding the schedule and deployment, which caused much discourse for staff and leaders alike, in addition to some unique challenges specific to nurse leaders, such as the difficulties of staffing. Everyone found that communication efforts were noble, yet many felt overwhelmed with a tsunami of emails and notices. Nurse leaders shared that as soon as information was released, new information would come forth. Nurse leaders felt angst over trying to meet the needs of their staff and bringing resources to the bedside to care for patients with COVID and for patients hospitalized for other medical conditions during the pandemic. Fears around physical and psychological safety were ever-present for both leaders and clinical nurses, but clinical nurses reported fatigue with donning and doffing personal protective equipment.

Question 2. Can you share some suggestions and recommendations for consideration going forward?

Clinical Nurses

Suggestions from clinical nurses focused on clear communication, transparent processes, solicitation of input from staff, equitable distribution of the workload, peer support, and inclusion and representation of staff. Clinical nurses felt that although many modes of communication were utilized, a mainstream format would decrease the burden and repetitiveness of messages. Many shared that seeing messages in multiple languages was notable for the staff who spoke English as a second language, noting also that this was long overdue.

Nurse Leaders

Most nurse leaders shared that the unprecedented nature of the pandemic provided much insight into systems operations, issues of equity, staff wellness, and an understanding of how to share information effectively without overburdening the messaging. Many shared that mainstreaming messaging and having alerts for new important information would be helpful. Leaders recognized that messaging that goes out to staff caring for patients can be burdensome and overwhelming, as well as that staff should be included in developing a communication strategy for clinical staff. Leaders felt that trauma-informed care is something that should be applied to patient care services, as well as with all staff.

Question 3. What was a strength or something positive that occurred for you over the past few months?

Clinical Nurses

There was a general sense of gratitude, pride, and hope about the support and sense of camaraderie participants received from their nursing teams and peers, especially for their nurse colleagues working in acute care. Some clinical nurses shared that they discovered an interest in acute care, met colleagues from outside their areas, experienced deep admiration and respect for the nurses working in the acute care units, and enjoyed the interdisciplinary teamwork.

Nurse Leaders

Every nurse leader spoke of the pride that they had for their staff. One stated: “they [their staff] deserve all the credit.” Most felt the experience of leading during a pandemic highlighted their strengths and opportunities and will enhance their leadership skills in the future. Nurse leaders felt that they needed built-in peer support while also acknowledging support from their colleagues and superiors.

Discussion

The purpose of this study was to understand the experiences of clinical nurses and nurse leaders supporting those deployed during the COVID-19 pandemic and to inform leadership strategies in the future. In addition to sharing their experiences, the mixed methodology design allowed for a quantitative measurement of the real-time effects on nurses. The ProQOL results demonstrated the majority of nurses in both groups reported compassion satisfaction despite reporting moderate levels of burnout and secondary traumatic stress, whereas clinical nurses experienced greater secondary traumatic stress likely due to their direct care of very ill patients. Findings related to post-deployment and adverse psychological health suggest that clinical nurses and nurse leaders endorsed enhancing a culture of wellness by leveraging trauma-informed approaches. The themes shown in Table 4 are aligned with the Substance Abuse and Mental Health Services Administration’s six guiding principles of trauma-informed care,²⁰ thus, offering practical guidance for addressing the predominant needs reported by clinical nurses and nurse leaders.

Table 4:

Applying SAMHSA’s trauma-informed care principles to clinical nurses’ identified needs

Trauma-informed principles of care	Clinical nurse response	Applied principle
Safety	Nurses shared feelings of being both physically and psychologically unsafe at times.	Addressing both staff and patient safety throughout the organization in tandem is the major tenant of this principle.
Trustworthiness and transparency	Staff voiced concerns about feeling the deployment process was not always transparent.	This guiding principle assures that decisions are made with transparency and with the goal of building and maintaining trust with and among staff and with patients.
Peer support	Staff reported feeling isolated and alone when deployed, often not knowing anyone on the unit they were deployed with.	Staff welcomed the ideas of a buddy system when deployed and support from leadership as ways to enhance staff wellness. Leaders also felt a peer support model for leaders would be advantageous.
Collaboration and mutuality	Staff felt they would like to be included in procedures that are going to have a direct impact on them. Importance was placed on partnering and leveling of power differences between patients and staff and leadership and all staff throughout the organization while promoting shared decision-making and a high degree of mutuality of respect for each other’s expertise is key to this guiding principle.	The organization recognizes that everyone has a role to play in trauma-informed approaches and inclusivity is vital to assuring collaboration.
Empowerment, voice, and choice	Staff reported having no voice, not being heard, having no choices and feeling disempowered. This guiding principle asserts that patients and staff strengths are recognized, built upon, and validated.	The organization fosters belief in resilience, and in the ability of individuals and communities to heal and promote recovery from trauma. Organizational operation and workforce development and services are organized to foster empowerment for staff and patient alike. Organizations understand the importance of power differentials and ways in which patients and staff have historically been diminished in voice and choice and have been recipients of coercive treatment. Cultivating a culture of self-advocacy that is inclusive and promotes healthy encounters while being heard and seen are key to empowerment, voice and choice.
Cultural, historical, and gender issues	Staff of color felt they were not seen nor heard despite the impact of COVID-19 in their communities. Some had family members hospitalized or experienced the loss of a relative. Some staff of color shared they heard “racist” comments and felt excluded on units to which they were deployed.	This principle encourages the organization to proactively address stigma, explicit and implicit bias, and structural racism organizations leverage the healing value of traditional cultural connection while recognizing and addressing cultural and historical trauma. Organizations incorporate policies, procedures, and processes that are responsive and equitable in addressing the racial, ethnic, and cultural needs of individual patients and staff.

SAMHSA, Substance Abuse and Mental Health Services Administration.

The qualitative findings from the campfire discussions revealed that clinical nurses want to be more integrated into decisions that directly impact them, such as the deployment process. The process was not always perceived to be transparent and well communicated. Some clinical nurses also described a feeling of losing autonomy and agency, especially around their work schedule, physical and psychological safety, and unique family challenges. This was aligned with findings from several other studies using semi-structured interview methodology that also found there was a lack of structured, uniform, employee-centered communication around redeployment.^10,21,22 Similarly, from a review of articles (n = 22) published during this same study time period, authors concluded health care personnel redeployment was a predictor for negative impact to mental health, similar to the findings from the present study.²³

Furthermore, the authors also sought to learn and understand levels of fatigue and burnout after the first redeployment during the pandemic. Both burnout and secondary traumatic stress ranged from low to moderate, with the mean calculating to a low level of burnout and a moderate level of secondary traumatic stress. Compassion satisfaction scores also ranged widely but averaged within the moderate level. Nursing staff and leadership had comparable scores in compassion satisfaction and burnout, yet differed in secondary traumatic stress, with clinical nurses reporting higher levels of secondary traumatic stress, likely due to their direct clinical service to patients. The results of the present study vary slightly from the results of a systematic review of articles (n = 76) publishing data on burnout, compassion fatigue, and compassion satisfaction during the first year of the pandemic.⁶ Overall, the results in the reviewed articles found an increase in the rate of burnout, dimensions of emotional exhaustion, depersonalization, and compassion fatigue; a reduction in personal accomplishment; but levels of compassion satisfaction like those before the pandemic. The moderate rate of compassion satisfaction reported by the present study’s participants was a surprise. Although they clearly expressed frustration, they were still able to support each other and felt proud of their accomplishments caring for this patient population, despite the redeployment disruption.

Suggestions from interviews focused on wanting clear communication, transparent processes, soliciting input from staff, equitable distribution of the workload, peer support, and inclusion and representation of staff in the process This feedback also aligned with the six principles of a trauma-informed approach to care: safety; trustworthiness and transparency; peer support; collaboration and mutuality; empowered voice and choice; and cultural, historical, and gender issues.²⁰ COVID-19 was an event that extended beyond most nurses’ ability to cope and to maintain resilience, especially due to the sustained insult of the prolonged pandemic. Some article authors suggest using a trauma-informed approach, particularly when leading staff through traumatic events.²⁴ A trauma-informed leadership approach would provide a practical framework to support leading clinical nursing practice. For example, leaders could counter the loss of agency and control reported by nurses by employing shared decision-making models that incorporate choice and transparency, using an open-forum concept meeting that is regularly scheduled and consists of direct care practitioners. The meeting would allow for real-time feedback and sharing of mutual experiences, as well as connection and trust-building with leaders. Furthermore, organizations and leaders could implement peer support programs to provide support for and prevention from burnout and exhaustion/stress.

Although the conversion from conceptual knowledge of a trauma-informed leadership approach to active and practical implementation by leaders will require dedicated resources and a commitment to ongoing training, coaching,²⁵ and supervision, it has the potential to immensely contribute to countering the consequences of and preparing for future pandemics and other catastrophic events. Integration of the guiding principles discussed here into leadership skills will help to inform leaders on the intersection of trauma and wellness and respond in ways to help promote healing and mitigate retraumatization, as well as prevent burnout and promote staff retention and workplace satisfaction.

There were a number of limitations to this study, such as the small sample size and the single institution analysis, that limit generalizability. Participants self-selected to be in the study and did not represent all nurses who were deployed. The nurse leader group was smaller than the clinical nurses group and, thus, did not allow for an in-depth comparative analysis. The study relied on participants’ self-report, which is subject to social desirability and selective sharing. Although the results presented here may be found in other hospital settings, they might also differ. Moreover, given that this study was conducted during the COVID-19 pandemic, its results may have been influenced by the myriad of challenges that nurses encountered during this time.

Conclusion

The results of this study describe the experience and professional quality of life of a sample of clinical nurses and nurse leaders shortly after the first wave of the COVID-19 pandemic and nurse deployment. For some, deployment brought a general sense of gratitude, pride, and hope along with a lack of concern for compassion fatigue, but for others it caused a high level of burnout and secondary traumatic stress. Nurses expressed frustration regarding changing information, communication gaps, and transparency of processes, as well as a perceived lack of caring for their individual circumstances surrounding deployment. Participants offered substantive and practical suggestions for future consideration, not only for implementing deployments, but also for informing organizational leadership on integrating trauma-informed principles into leadership, policies, and procedures.