“Watching Over and Helping Each Other”: a constructivist grounded theory of collective support processes among Chinese clinical nurses during emerging infectious disease outbreaks

Abstract

Background

Emerging Infectious Diseases (EIDs) such as COVID-19 pose significant global health challenges. Nurses, as key responders in pandemics, endure substantial impacts on their physical and mental health. Thus, developing a comprehensive framework to enhance nurses’ psychological coping and resilience during public health crises is crucial.

Objective

This study aims to understand the experiences of Chinese nurses during the COVID-19 pandemic and to establish a theoretical foundation for disaster nursing.

Design

This qualitative study employs a constructivist grounded theory approach rooted in symbolic interactionism.

Settings and participants

The research includes 53 frontline nurses from 11 provincial capitals in China, recruited between May 2020 and June 2022.

Methods

Utilizing semi-structured interviews guided by existing research, the study conducted in-depth interviews. The theoretical saturation determined the sample size. Data were analysed using the constructivist grounded theory method.

Results

We propose a dynamic three-phase process—involvement, adjustment, and integration and growth—in which nurses progress from rapid engagement under high demands, and eventually rebalancing as resources increase, to resilient practice supported by mutual helping and renewed purpose.

Conclusions

The developed conceptual model emphasizes the importance of resources, support systems, and coping strategies in addressing stressors faced by nurses. It provides a conceptual model to enhance nursing education and support systems, advocating for policies that promote resilience and well-being. The study also stresses the need to challenge persistent social stereotypes by fostering a professional, gender-neutral image.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-025-04046-0.

Background

Globalization accelerates interpersonal communication and ecological interaction, significantly increasing emerging infectious diseases (EIDs) and raising the risk of its transmission. Corresponding uncertainty has become a significant global health threat in the 21st century [1]. In late 2019, COVID-19 emerged as an unknown virus, with transmission pathways and disease course yet to be fully understood [2]. Healthcare workers, especially nurses, were among the first to confront this emerging threat. Their initial experiences with the virus played a crucial role in shaping their coping strategies throughout this crisis.

COVID-19 has constituted the most severe global pandemic in almost a century, with over 600 million confirmed cases, more than 6.61 million deaths, and significant strain on the healthcare system, leading to substantial societal impact [3]. Effective response is crucial in emergency management of public health crises, and nurses are at the core of such response. Their essential contribution to fighting the COVID-19 pandemic has been acknowledged worldwide.

Yet, throughout the pandemic, frontline nurses confronted heightened infection risks and shortages of personal protective equipment (PPE), exacerbated by increased healthcare demand and panic buying [4, 5]. The influx of severe cases strained medical resources, including lack of critical equipment such as appropriately equipped intensive care unit (ICU) beds [6], leaving the overburdened nurse workforce with unprecedented challenges [7, 8]. Moreover, the early stages of COVID-19, marked by its severity and infectiousness, underscored the urgent need for nurses proficient in hospital infection control and ICU practices [9].

While early research on humanitarian emergencies primarily focused on the adverse psychosocial consequences, subsequent studies gradually began to explore positive facets of coping and adaptation [10, 11], noting that, in general, disasters including health emergencies do not inevitably cause psychological or social collapse; instead, they may stimulate diverse developmental trajectories, some of which are fundamentally positive [12].

Such adaptation and coping mechanisms are essential for nurses as they navigate the challenges posed by EIDs. Among the most influential frameworks in coping research is the transactional model of stress and coping developed by Lazarus and Folkman [13, 14]. Their theory conceptualizes coping as a dynamic process involving primary appraisal (evaluation of threat, harm/loss, or challenge), secondary appraisal (assessment of available resources), and reappraisal phases. Coping responses are broadly categorized as problem-focused or emotion-focused, shaping how individuals manage stressful demands. This model has been widely used to understand the psychosocial adaptation of nurses during crises, including pandemics [15].

However, while existing literature highlights the positive and negative outcomes of coping and underscores the role of social support and personal adaptability during crises, there remain significant theoretical gaps. Notably, many studies employing Lazarus and Folkman’s framework are cross-sectional, offering only snapshots of stress and coping strategies at isolated time points [16, 17]. In contrast, the rapidly evolving and prolonged nature of EID outbreaks presents unique longitudinal challenges that are insufficiently captured by classic models [18, 19]. For example, evolving psychosocial stressors over acute and chronic pandemic phases, ethical dilemmas encountered, and the dynamic interactions between individual, team, and organizational factors require a more nuanced theoretical lens. Moreover, the unique context of the Chinese healthcare system, characterized by specific sociocultural, ethical, and institutional configurations, and the temporal trajectory from acute to post-acute pandemic phases, remains underexplored. Our meta-synthesis of 64 qualitative studies further revealed the complexity and multiplicity of coping pathways, many of which involved nonlinear, iterative processes not fully articulated in existing models [20].

Recent post-pandemic studies mirror these theoretical gaps. A qualitative meta-aggregation of nurses’ post-COVID-19 experiences identified heavier workloads, fractured communication and diminishing support networks as enduring stressors, and showed that coping resources wax and wane in nonlinear trajectories over time [21]. The Johns Hopkins School of Nursing’s 2024 healthcare predictions report underscored the COVID pandemic’s sustained impact on nurses, including workforce shortages, mental health issues, and the need for systemic change to support nurses’ well-being and resilience [22]. Furthermore, a comprehensive 2024 analysis of nurse resilience revealed that despite nurses demonstrating strong resilience and work engagement, they encountered difficulties in de-stressing from work-life, highlighting the necessity for organizations to invest in strategies that help nurses decompress and maintain well-being [23]. These findings emphasize the continuing relevance and urgency of understanding nurses’ coping mechanisms in the aftermath of a global health crisis, particularly in contexts such as China, where healthcare systems and cultural factors may uniquely influence resilience and adaptation.

The present study seeks to address these gaps and develop a contextually conceptual model of nurse coping process during EID outbreaks in China. It aims to complement and extend the transactional model by elucidating the temporal, sociocultural, and organizational mechanisms underpinning nurses’ coping and adaptation, and by providing an empirically based theoretical framework tailored to disaster nursing in the context of EIDs.

Methods

Study design

This qualitative study is based on in-depth interviews and other narratives from Chinese nurses who responded to the COVID-19 pandemic. It utilizes constructivist grounded theory (CGT) based on symbolic interactionism, a qualitative research method that adopts a proactive, detailed, and reflective approach and offering greater flexibility compared to other grounded theory branches [24]. It is a participatory approach involving co-constructing theory through the interaction of researchers and participants [25]. The response of Chinese nurses to the COVID-19 pandemic is herein viewed as a social and psychological process, with subjective meanings constructed and shaped through interaction with the environment. This methodological approach aligns with the study’s purpose and enables exploring nurses’ pandemic response and development-related theories. This study follows the Guideline for Reporting and Evaluating Grounded Theory Research Studies (GUREGT) to ensure comprehensive and transparent reporting [26].

Sample and setting

With the first interview, this study commenced in May 2020 and was concluded with the final interview taking place in June 2022. The study was conducted in mainland China. During the study period, Chinese pandemic policies were adapted several times. From January 2020 to December 2022, despite stringent screening and isolation measures and strict official accountability systems, sporadic outbreaks occurred in various regions of China. Public health policies were implemented using big data for travel health codes, a zero-case policy, mass nucleic acid testing, and mass vaccination [27]. In December 2022, China lifted the strict public health strategies and downgraded COVID-19 to a Category B infectious disease [28]. Therefore, this study’s interview and analysis phases were conducted primarily within the context of China’s strict control measures.

Inclusion criteria for participants include frontline nurses holding a Chinese nursing practice license, actively engaged in clinical nursing since the COVID-19 outbreak, with a minimum of 3 months’ clinical experience, good communication skills, and voluntary participation. Stakeholders (Nursing Directors) are included if they have been in management positions for at least 3 months post-outbreak. Exclusion criteria apply to administrative nursing staff other than Nursing Directors, trainee nurses, and participants requesting data withdrawal within 48 hours post-interview.

The initial stage of the recruitment involved purposive and snowball sampling to ensure a diverse representation of participants. Social media were also used as a recruitment tool. Following preliminary data analysis, an iterative process of theoretical sampling was adapted, continuously supplementing the sample to explore developing concepts and fill theoretical gaps as suggested by grounded theory methodology. For example, initial analysis indicated that coping strategies might vary with clinical experience, prompting us to recruit nurses with extensive tenure in high-acuity settings such as emergency and ICU departments. Furthermore, the emerging concept of resignation in response to pandemic stressors led us to deliberately seek out nurses who had left their positions during or after COVID-19, in order to capture negative cases and enrich our understanding of coping boundaries. Additionally, to ensure multi-level perspectives, we purposefully included nursing department directors to explore how institutional support and management factors influenced frontline adaptation. Purposive sampling established a baseline of diverse participants, while theoretical sampling was employed throughout data collection to deepen key concepts and categories emerging from ongoing analysis.

The sample size was determined through an iterative, constant-comparison process of theoretical saturation. Data collection and analysis were conducted concurrently; after each round of interviews, we compared emerging codes with the existing codebook to identify any new categories or sub-categories. Saturation was deemed to have occurred when two consecutive interviews generated no novel codes. For example, interviews with nurses from diverse settings consistently revealed common coping styles, stressors, and support mechanisms, validating existing concepts. The cumulative interview numbers at which saturation was reached for every sub-category are presented in Supplementary File 1. This process ensured core categories like emotional resilience and adherence to protocols formed a comprehensive model addressing nurses’ coping with EID from psychological and social perspectives. Researchers from various disciplines (nursing, public health) and cultural backgrounds (Chinese, German) reviewed and confirmed the applicability of these findings within broader social contexts.

Data collection

This study used semi-structured, in-depth interviews to explore participants’ experiences and perspectives. Due to considerations of pandemic prevention policies, the micro-level settings for interviews performed predominantly involved a combination of online platforms (such as WeChat video calls, Tencent meetings, WeChat voice messages, and telephone conversations) and flexible offline arrangements.

Data collection and analysis were conducted concurrently, adhering to frameworks outlined by Kallio [29] and Bearman [30]. Pre-interview revisions incorporated existing literature and theories to draft an initial outline of the interview guide, which underwent iterative adjustments throughout the data analysis. The interview guide was developed for this study by the authors (see Supplementary file 2).

Demographic data collected included gender, age, ethnic group, education, work experience, job title, department, hospital level, work location, pandemic exposure history, and support experience. Interview methods and tools were adaptable, contingent upon pandemic prevention protocols, technological capabilities, and interviewee preferences. Options included face-to-face, video conferencing, telephone, WeChat, and QQ interviews, recorded via an iFLYTEK recording pen or computer software (see Supplementary File 3).

Initially, interviewers introduced themselves, reviewed materials, and secured consent. The semi-structured interview commenced with open-ended queries, leading to a detailed exploration of experiences and emotions. A concluding summary question was posed as well. Interviews typically last 30 to 90 minutes. Within 24 hours, the interviewer drafted a reflective memorandum and refined the interview outline.

Data analysis

This study employed Charmaz’s grounded theory approach, which encompasses initial, focused, and theoretical coding, along with constant comparison and memo writing [24]. This method allowed for the distillation of representative concepts from the data, streamlining the analysis process and enabling a deep understanding of participants’ experiences. This study used NVivo 12 software for qualitative data analysis.

Data analysis began with initial coding, where in each transcribed interview was examined line by line. This close engagement with the data aimed to identify significant statements and phrases that captured the essence of participants’ experiences. Codes were generated directly from the data, adhering closely to participants’ own words to preserve the authenticity of their narratives. For instance, statements such as “I felt overwhelmed by the workload,” “Communication with colleagues was strained,” and “The hospital environment was chaotic” were initially coded as “overwhelming workload,” “strained colleague communication,” and “chaotic hospital environment,” respectively.

During the focused coding phase, these initial codes were compared and analysed to identify patterns and relationships across the data. Significant and frequently occurring codes were synthesized into broader subcategories based on shared meanings and underlying concepts. For example, codes related to personal challenges and pressures were grouped under “Individual Stressors,” those concerning interactions with others under “Interpersonal Stressors,” and those related to the broader context under “Environmental Stressors.”

Theoretical coding involved integrating the subcategories and exploring the relationships between them to construct a coherent theoretical framework. Through constant comparative analysis, the subcategories were further refined and elaborated, culminating in the overarching category of “Stressors.”

To ensure a more comprehensive understanding, we analysed data from nurse directors and frontline nurses both separately and comparatively. Directors’ perspectives were used to triangulate and contextualize the findings from frontline nurses, especially regarding organizational support and resource allocation. This comparative approach enabled us to identify points of alignment and contrast between the two groups.

Throughout the analysis, memo writing was integral to documenting analytical insights, theoretical ideas, and reflections on the data. Memos facilitated critical engagement with the emerging categories and supported the ongoing refinement of the theoretical framework. Constant comparative analysis was employed at each stage, comparing data to data, code to code, and category to category. This iterative process ensured that the subcategories and categories developed were grounded in the data and that the analysis captured the complexity of participants’ experiences.

We used a forward–back translation procedure for Chinese interview quotations to ensure semantic equivalence. The initial forward translation (Chinese to English) was conducted independently by a bilingual researcher with clinical nursing and qualitative methods training (YL); a second bilingual researcher performed the back translation (English to Chinese) (DW, YZ). Discrepancies between the source and back-translated versions were identified via line-by-line comparison, discussed to consensus, and, when necessary, adjudicated by a senior bilingual team member (XF, JR). An audit trail documented translation decisions. Both the original Chinese and final English excerpts are available in the supplementary materials (see Supplementary File 4).

Researchers systematically employed strategies to enhance theoretical sensitivity, including closely tracking data clues, conducting comparative analyses of codes and cases, regularly reviewing the literature, constructing theoretical categories, and writing reflective memos. Throughout the research process, the researcher (YL), who served in the role of clinical nurse, navigated between being an insider and an outsider.

The primary researcher, a clinical nurse, navigated between insider and outsider roles throughout the research process. As an insider with participants from the same hospital or personal connections, the researcher shared common experiences shaped by similar policies and pandemic responses. This familiarity facilitated rapport but also necessitated reflexivity to mitigate potential biases. Reflective journaling helped the researcher recognize and address preconceptions, ensuring interpretations remained grounded in participants’ perspectives.

As an outsider with participants from different hospitals or regions, the researcher approached the data with openness to new insights and differences arising from varied local policies and cultural contexts. The complementary perspectives and collaborative coding from multiple researchers contributed to the development of a comprehensive theoretical perspective (see Supplementary File 5).

Rigour and trustworthiness

The principal author collaborated with others to analyse the data and ensure credibility, originality, relevance, and usefulness, following Charmaz’s guidelines [24]. Researchers maintained rigor by thoroughly engaging with the data [31] and used theoretical sampling, participant feedback, and detailed data descriptions to strengthen the credibility and relevance of their interpretations. Additionally, the researcher enhanced credibility and relevance through audit trails, reflective memos, and diagrams.

Ethical considerations

This study was approved by the Biomedical Ethics Committee. All interviews were conducted in secluded spaces to ensure privacy. Identifiers were replaced with codes, and the code key was stored separately on an drive with restricted access. Anonymized transcripts were analyzed in NVivo 12; all audio files, transcripts, memos, and the NVivo project were stored on access-controlled devices and accessible only to authorized team members. Audio recordings and consent forms were stored separately from de-identified datasets to minimize re-identification risk. All participants provided written informed consent according to respective forms and were assured of their right to withdraw at any time, and emotional reactions during interviews were handled with sensitivity.

Results

In this study, 53 participants from 11 regions in China participated (Table 1). Most participants were from Sichuan Province (45.3%), Guangdong Province (18.9%), and Shanghai (9.4%). The average age was 33.13 years, and the majority were women (83.0%) working primarily in tertiary A hospitals (95.6%) across various departments. Job positions were as follows: 2 Nursing Directors (3.8%), 13 Head Nurses (24.5%), 36 Registered Nurses (67.9%), and 2 Nurse Trainees (3.8%). Most had contact with infected individuals and over half had ICU experience. Additionally, most participants were married (60.4%) and had children (52.8%), with the majority not being the only child in their family (62.3%). Detailed job positions and departmental affiliations are available from Supplementary File 3.

Table 1.

Participants’ characteristics (n = 53)

Demographic information		n(%)
Age (mean (SD))		33.13 (7.45)
Years of Experience (mean (SD))		11.47 (8.34)
Gender	Female	44 (83.0)
	Male	9 (17.0)
Ethnicity	Han	48 (90.6)
	Other	5 (9.4)
Job Position	Nursing Director	2(3.8)
	Head Nurse	13(24.5)
	Registered Nurse	36(67.9)
	Nurse Trainee	2(3.8)
Highest Education	Junior College	3 (5.7)
	Graduate	11 (20.7)
	Undergraduate	38 (71.7)
	Unknown	1 (1.9)
Hospital Location	Sichuan Province	24(45.3)
	Guangdong Province	10(18.9)
	Shanghai	5(9.4)
	Other	13(24.5)
	Unknown	1（1.9）
Experience of Caring for Infected Patients	No	15 (28.3)
	Yes	38 (71.7)
Previous Experience in EIDs	No	45 (84.9)
	Yes	8 (15.1)
Previous Disaster Relief Experience	No	47 (88.7)
	Yes	6 (11.3)
ICU Work Experience	No	24 (45.3)
	Yes	29 (54.7)
Marital Status	Married	32 (60.4)
	Single	20 (37.7)
	Widowed	1 (1.9)
Do you have children?	No	25 (47.2)
	Yes	28 (52.8)
Are you an only child？	No	33 (62.3)
	Yes	20 (37.7)
Interview Approach (%)	Face-to-Face	24 (45.3)
	Online	29 (54.7)
Number of times you were interviewed	1	47 (88.7)
	2	6 (11.3)

Four participants were recruited through social media. Interviews were conducted both online (n = 29) and face-to-face (n = 24). Their experiences included working in hospitals, cabins, community emergency management, first aid care, and nucleic acid sampling. One participant requested that information about his highest academic qualifications and work location be withheld.

Outline of the conceptual model:“Watching Over and Helping Each Other”

Based on our data, we developed the “Watching Over and Helping Each Other” conceptual model, with the overarching core category being “Watching Over and Helping Each Other”, to explain how clinical nurses manage social and psychological stress during EID outbreaks, represented by the COVID-19 pandemic. Figure 1 presents the core product of our constructivist grounded theory analysis—the conceptual model “Watching Over and Helping Each Other,” including its phases and linkages.

Fig. 1.

Conceptual model from constructivist grounded theory: “Watching Over and Helping Each Other”

The name of this conceptual model was inspired by the traditional Chinese idiom “SHOU WANG XIANG ZHU,” which signifies the solidarity and mutual aid of neighbouring communities banding together to overcome invaders or unexpected disasters. This idiom encapsulates the collective resilience and cooperative spirit demonstrated by nurses during the pandemic. The idiom comprises three key components that form the categories of our overarching core category. The character “SHOU” (Commitment) reflects the dedication and responsibility of nurses at multiple levels. Nurses are a crucial force supporting the healthcare system at the social level. At the organizational level, they undertake diverse tasks to meet the demands of the pandemic response. At the individual level, they are devoted to protecting their health and that of others. The character “WANG” (expectation) embodies the hopes and aspirations of nurses. They expect to fulfill their professional roles effectively and seek recognition and respect from society for their contributions during the crisis. The character “XIANG ZHU” (mutual help) highlights the importance of mutual support and collaboration. Nurses engage in peer support and self-adjustment to cope with stress, integrating internal and external resources to promote personal and team growth.

Integration with existing frameworks

To enhance the conceptual clarity and transferability of the “Watching Over and Helping Each Other” conceptual model, we linked its categories to the Job Demands-Resources (JD-R) model and cultural constructs such as collectivism and tightness [32]. The JD-R model is a well-established framework in occupational stress research that categorizes job characteristics into demands and resources, which influence employee well-being and performance [33]. The JD-R model, a cornerstone of occupational stress research, posits that workplace characteristics are bifurcated into demands and resources, which respectively influence employees’ stress responses and motivational states [34]. Within this integrated framework, “SHOU” (commitment) aligns with the JD-R model’s concept of job demands, encapsulating the persistent physical and emotional burdens nurses endure during pandemics, such as high workloads and psychological strain. Conversely, “WANG” (expectation) corresponds to job resources, particularly social support and professional recognition, which serve as motivational buffers mitigating the adverse effects of demands. Similarly, “XIANG ZHU” (mutual help) resonates with job resources, notably peer support and teamwork, providing emotional and practical sustenance that alleviates stress and promotes growth.

Cultural constructs further refine this integration. Tightness, characterized by stringent social norms and low tolerance for deviation, reinforces “SHOU” (commitment) by heightening nurses’ sense of duty, thereby shaping their responses to job demands [35]. Collectivism, which prioritizes group cohesion and interdependence, amplifies the efficacy of “XIANG ZHU” (helping) in stress amelioration and growth facilitation, reflecting the communal orientation inherent in nurses’ mutual support systems [36]. These cultural moderators are incorporated into a revised conceptual model Fig. 2., which provides an explanatory mapping that situates this construct within the JD–R framework and summarizes stressor-related relationships; it complements, but does not replace, the core CGT model in Fig. 2. This figure maps the subcategories onto the JD-R framework while integrating collectivism and tightness as moderating influences, elucidating the dynamic interplay between job demands, resources, and cultural factors.

Fig. 2.

Explanatory mapping to the JD–R framework and stressor relationships

The overarching core category “Watching Over and Helping Each Other” therefore comprises three interconnected categories—SHOU (commitment), WANG (expectation), and XIANG ZHU (mutual help)—whose relative salience shifts across time. During an initial phase, that is Being in a Pandemic, the “SHOU” component is most important, as nurses must confront the realities of the pandemic and re-commit to their roles while facing a challenging and sometimes chaotic situation. At this stage, elevated job demands outweigh available resources, explaining the high stress levels identified in our data. In a subsequent phase, Moving Forward in Adversity, the “WANG” category is emphasized as nurses navigate challenges while renegotiating social expectations and adapting professional aspirations. Here, additional job resources (e.g., better PPE supply, public praise) gradually offset demands, producing a buffering effect predicted by the JD-R model. The final phase, Integration and Growth, relates to “XIANG ZHU” and implies a focus on nurses supporting one another based on previous experiences and integrating these experiences to foster growth. Personal resources dominate this stage, enabling trajectories from coping toward post-adversity growth, consistent with JD-R propositions on resource gain spirals. To reflect this complexity, we note that the functions of “WANG” and “SHOU” are context‑dependent: recognition can tip into moral pressure, and commitment can lead to internalized strain and corresponding inter-, intra-, or person-role conflict. We therefore treat demands and resources as dynamically appraised rather than fixed attributes within the three‑phase process.

Involvement phase

Although we present the phases sequentially, they often overlap and can be revisited as conditions change. What follows reflects a typical trajectory rather than a rigid sequence. The “involvement phase” reflects the initial stage in which nurses confront an EID outbreak, requiring rapid mobilization of internal and external resources to cope with unprecedented challenges. During this period, nurses activated their professional competence, resilience, and moral commitment while simultaneously relying on organizational and familial support systems. This fusion of inner strength and external backing formed the basis for their cognitive appraisal of a complex and shifting environment.

The COVID-19 pandemic emerged as a multifaceted stressor (see Fig. 3). Nurses were confronted by overlapping sources of stress, including exhausting workloads, strained interpersonal dynamics, and persistent concerns over inadequate protective equipment.

Fig. 3.

Relationship between subcategory and its concepts of stressor

As one participant recounted,

I am currently reflecting on this, and it is quite distressing. When I was at the fever clinic, it was extremely cramped and overcrowded. Following the outbreak, there was a significant surge in outpatient consultations, estimated to be around 500 to 600 per day. (N9, male, 33 years old)

Responsibilities to family, organization, and society often reinforced nurses’ professional dedication, but these same factors also generated emotional tension when collective expectations clashed with individual fears. As N32 explained:

As I told my nurse, I let myself feel fear, but I will not back down. They are mothers too … … They are afraid, but we cannot abandon our duties. So, I must keep going. I am there daily, ensuring they follow safety protocols to prevent problems. (N32, female, 44 years old)

This constant negotiation between professional duty and self-preservation contributed to a heightened sense of psychological strain, manifesting as fear, anxiety, and at times, pride and fulfilment.

I think many people are still experiencing significant psychological pressure, leading them to rely on sleeping pills to get rest. (N4, female, 37 years old)

In response to these pressures, nurses leveraged both internal qualities—such as perseverance and adaptability—and external resources, including peer support and institutional guidance.

When we first arrived in Wuhan, we had no experience with protective gear. Local infection control experts trained us in isolation protocols and correct procedures for protective clothing. I practiced diligently and feel less anxious about this during my second assignment. (N39, female, 27 years old)

A recurring concept throughout the data was the impact of collective effort.

It is all about teamwork; no one can do it alone. With everyone involved, there is nothing to fear. The team’s strength is my greatest support. (N11, female, 41 years old)

Cognitive appraisal determined how nurses interpreted their predicament. Some perceived the circumstances as threatening, others normalized the adversity, while a few perceived it as a unique opportunity for growth. This psychological transition underpinned their evolving coping responses.

Initially, in January, it was quite terrifying. Going to work felt like exchanging one’s life for another. During that period, not going to work was not an option, leading many to perceive the job as dark and dangerous. (N3, female, 30 years old)

I just feel that wherever you go, it is all work; it is the same, just different environments. (N17, female, 35 years old)

In your life experiences, encounters like this are rare, few and far between. It could be unfortunate, but having participated and triumphed over it, I consider it a fortunate event in my life. (N15, female, 30 years old)

Involvement is dominated by SHOU (commitment) under high demands, with initial resources too thin to offset strain. As acute demands stabilized and resources (e.g., PPE, peer guidance) accumulated, nurses shifted from rapid mobilization to iterative recalibration, marking the onset of what we call adjustment phase.

Adjustment phase

As conditions stabilized and learning spread through teams, nurses entered an adjustment phase characterized by flexible, iterative coping. In the adjustment phase, nurses engaged in an ongoing process of “moving forward in adversity,” constantly re-evaluating coping strategies as the pandemic situation evolved. Rather than adhering to a single coping style, participants described fluidly alternating between problem-focused and emotion-focused approaches as they sought to restore and maintain their physical and psychological equilibrium.

Problem-focused coping predominated when tangible solutions were possible, such as adapting clinical protocols to minimize risk exposure and improve workflow.

At the last cabin, we changed our setup to position staff at the upper air vent and patients at the lower air vent, which helped circulate the air. This made us feel the virus content was lower, reducing psychological pressure. (N52, female, 38 years old)

Simultaneously, emotion-focused strategies [37], such as self-regulation and leaning on personal networks, enabled nurses to process fear and uncertainty.

Now you only have two choices: either be a deserter and flee, or bravely face it head-on, with no other options. I tackled this matter with a smile and would still confront it even if tears were shed. I have few choices, so I would rather face it with a smile. (N20, female, 31 years old)

For stressors that could not be directly resolved, nurses often reinterpreted their experiences through meaning-focused coping, reframing fatigue or emotional hardship as evidence of meaningful contribution [38].

I believe that feeling tired is also valuable. For instance, residents often appreciated our hard work and dedication during nucleic acid sampling and vaccine administration. Despite the long hours, we did not feel fatigued because we found our work meaningful. (N10, female, 29 years old)

Although imbalances—physical or psychological—were common, most nurses reported that these episodes were temporary and could be ameliorated through mobilization of resources and adaptation.

Our first support mission in Wuhan took us nearly a week to adjust. However, by the second mission, we were operating smoothly by the next day, and by the third day, it felt easy with no challenges. Apart from the initial chaos on the first day, we quickly got back on track” (N31, male, 32 years old, second interview)

Ultimately, adjustment reweights toward WANG (expectation) and XIANG ZHU (mutual help) as resources buffer demands and coping becomes flexible. As coping repertoires became routinized and peer bonds deepened, adaptation increasingly consolidated into shared practice and identity, opening the path to integration and growth.

Integration and growth phase

Building on accumulated learning and solidarity, nurses entered a phase of integration and growth that consolidated practice, identity, and mutual support. The final stage, “Integration and Growth,” signified not only recovery from acute stress but also a transformative re-evaluation of professional purpose and personal meaning. During this phase, nurses reconstructed their roles and values, considering both the hardships and the affirming experiences of the pandemic.

While the public “hero” narrative elevated societal recognition, many nurses questioned the cost of such idealization, expressing discomfort with being labelled as superhuman or self-sacrificing.

Society has many misunderstandings about medical workers. I think the expectations are too high, almost idealizing us. Medical workers are just ordinary people. For example, I see myself as an ordinary person. (N44, female, 35 years old)

For others, positive feedback and visible patient recovery served as crucial affirmations of professional value, facilitating renewed commitment to nursing despite persistent challenges.

Sometimes I hope the management personnel can better recognize our nursing work, and if we truly make it a profession, it will garner the greatest recognition. (N19, female, 37 years old)

The pandemic also prompted some nurses to reflect deeply on life priorities, shifting their focus toward psychological well-being and valuing stability and connection with loved ones.

Many people used to spend a lot of energy on career development and other pursuits, but when you are suddenly isolated from the world, you seem to pay more attention to your psychological growth. (N29, female, 31 years old)

Participants emphasized the importance of cherishing the present and finding meaning in day-to-day existence.

After returning, we often talked about how we should not overthink things. Just do well at the moment, which brought more reflection for me. (N42, female, 36 years old)

Experiences with collaboration, patient care, and social acknowledgment contributed to a maturing professional identity for many.

I increasingly like this job because you can see patients improve day by day through our efforts, and that gives me a sense of accomplishment. (N5, female, 38 years old)

Male nurses encounter societal stereotypes related to gender roles in nursing, which can create challenges in openly discussing their identities. One nurse (N31) indicated this shift in confidence, stating: ‘At first, my parents were not very supportive of this profession. When people asked if I was studying medicine, they assumed I would be a doctor. Now, I tell people I am a nurse in the ICU, and many are surprised, asking, “Are there male nurses?” “Yes, there are many.”’ This illustrates a growing ability among male nurses to face their professional roles and challenge public perceptions.

The cumulative effect of adversity and teamwork significantly enhanced nurses’ cohesion and sense of belonging, a legacy they expected would endure beyond the pandemic.

I think our team’s cohesion is excellent because we went through hardships together, which strengthened our unity. (N32, female, 44 years old)

Overall, most nurses described tangible gains in professional knowledge, emotional adjustment, and confidence in managing future emergencies. For some, persistent stress or lack of recognition led them to leave the field, demonstrating that integration can entail both growth and withdrawal.

During that process, we learned as we went, exchanging experiences and studying literature, guidelines, and consensus documents. I gained significant knowledge in pandemic prevention, emergency response, and infectious diseases. (N43, female, 44 years old)

I felt a lot of pressure from it, so I made the decision to resign … I had mentioned to my family about a month or two before leaving that I wanted to quit, that I wasn’t happy staying there, and that I didn’t want to do it anymore. I felt a lot of pressure and couldn’t keep doing it. (N36, male, 23 years old)

Integration and growth foreground XIANG ZHU and personal resources, consolidating gains while recognizing that for some, sustained strain prompts exit.

Discussion

This study explores various aspects of nurses’ experiences in responding to EID outbreaks, including stressors, individual resources, support systems, cognitive evaluations, coping styles, and phases of integration and growth. Through a constructivist grounded theory approach, our findings reveal that coping with pandemic stress extends beyond individual strategies to encompass communal coping processes, reflecting the collectivist cultural context in which Chinese nurses operate. Additionally, it compares these findings with previous research to highlight both consistencies and unique insights.

Involvement phase

In the involvement phase, this study categorizes stressors into three levels based on their relationships: individual, interpersonal, and environmental. This category aligns with findings from a qualitative systematic review conducted at the end of 2020, which summarized that frontline nurses experienced psychological, social, and emotional distress while managing work demands, social relationships, and personal lives [39]. However, from a culturally specific perspective, given the longer duration of this study and the shift in the global response to COVID-19 towards a more prolonged presence, along with the differences in public health policies and vaccine distribution speeds between Eastern and Western countries [40], this study identifies additional stressors beyond those previously mentioned.

Influenced by China’s traditional collectivist culture, which is characterized by strong social norms and a low tolerance for deviance [41], as well as Confucian ethics, particularly the concept of “filial piety” [42], nurses faced conflicts between collective interests and family caregiving responsibilities when required to perform extensive emergency pandemic-related duties. This conflict often led to heightened self-imposed expectations and demands regarding “commitment and responsibility” and “lack of family care,” increasing their perceived stress. These culturally specific stressors shaped not only individual experiences but also the communal responses that emerged during the adjustment phase.

The perspectives of nurse directors provided important context for interpreting frontline nurses’ experiences. Both groups highlighted critical shortages of resources and increased workloads during the pandemic, indicating broad alignment regarding organizational support challenges. However, directors tended to focus more on system-level planning and resource distribution, while frontline nurses emphasized immediate daily needs. These complementary viewpoints allowed us to triangulate key findings and offered a more holistic view of organizational challenges and supports.

Adjustment phase

Our findings reveal that while nurses employ individual coping strategies (problem-focused, emotion-focused, and meaning-focused), the adjustment process is fundamentally shaped by collective coping mechanisms rooted in collectivist values [43]. This aligns with recent literature on communal coping, which emphasizes shared appraisal and collective action in response to stressors [44]. In the Chinese context, mutual support among colleagues, collaborative problem-solving, and collective resilience emerged as central to nurses’ adjustment processes, extending traditional coping frameworks to incorporate culturally specific communal dimensions.

Problem-focused coping is typically used for environmental stressors, while emotion-focused coping is more common for individual-level stressors. Meaning-focused coping styles are employed when nurses face stressors related to the environment or interpersonal relationships that are beyond their control. Understanding these coping styles can inform interventions aimed at supporting nurses in their adjustment processes. However, these individual strategies are embedded within and supported by communal processes, as nurses consistently described relying on team cohesion and collective support systems.

A qualitative study in the Sultanate of Oman also found that healthcare workers mainly employed problem-focused and emotion-focused coping styles [45]. Another systematic review of literature from Western countries noted that the most common coping styles were refocusing and revaluation [46], which are akin to meaning-focused coping as defined in this study. The preference for different coping styles may be attributed to cultural and religious differences between East and West.

Chinese cultural values emphasize collectivism, which ensures family safety through collective efforts, often involving sacrificing individual interests to maintain family or group stability. Thus, under the influence of a collectivist culture, Chinese nurses may prefer problem-focused coping or emotion management strategies [47]. More significantly, our data suggest that Chinese nurses engage in communal coping through shared emotional regulation, collective meaning-making, and coordinated action processes that reflect the interdependent nature of stress appraisal and response in collectivist cultures [48].

Integration and growth phase

Most nurses reported an enhanced sense of professional identity, value, and societal recognition. The integration phase represents a dialectical process where individual growth is intertwined with collective transformation of the nursing profession’s social standing. Some nurses summarized their growth and gains, proposing directions for improvement and future expectations, while others ultimately chose to leave the nursing profession.

Previous research on this phase has predominantly focused on concepts related to professional identity, professional image, and nurses’ retention intentions [49, 50]. Studies on professional identity reveal variations based on nurses’ different specialties, experiences, or stages of the pandemic. For instance, a survey conducted among Chinese nurses showed that their professional identity was at a moderate level, with 68.9% and 83.9% of respondents reporting positive changes in their professional identity after witnessing or participating in frontline work against COVID-19 [49]. In contrast, another study conducted in China indicated that the overall support experience negatively impacted nurses’ professional identity [50]. These findings highlight the importance of both context and timing in understanding nurses’ professional identity during the pandemic.

The “hero narrative” emerged as a contested discourse that both elevated and constrained nurses’ professional identity. While media portrayals initially celebrated nurses as heroes, this narrative paradoxically undermined their professional expertise by emphasizing sacrifice over skill and compliance over clinical judgment [51–53]. Our participants rejected this simplistic framing, seeking instead recognition of their professional competence, clinical decision-making abilities, and leadership contributions. This tension between public imagery and professional reality reflects deeper structural issues in how nursing is valued within healthcare systems and society.

Nurses’ retention intentions are also critical for nursing human resource management post-pandemic. This study found that a few nurses might choose to leave the nursing profession due to ineffective mobilization of internal and external resources, poor cognitive evaluations, and an inability to cope with stress. Within the collectivist context, decisions to leave the profession were often negotiated through family and peer consultations, reflecting the communal nature of career transitions in Chinese culture.

Significant regional and temporal differences exist in nurses’ intentions to leave their jobs. A survey conducted from March to April 2020 at a tertiary hospital in Wuhan, China, revealed that 60.2% of nurses reported a high tendency to leave, with 13.0% having a very high tendency to leave [54]. In contrast, a cross-sectional study conducted in Canada from July to November 2020 showed that nurses caring for COVID-19 patients had higher levels of chronic fatigue, poorer quality of care, lower job satisfaction, and higher turnover intentions (22.3%) [55]. An integrative review indicated that post-pandemic research has increasingly focused on predicting nurses’ turnover intentions through the negative impact of the pandemic on nurses’ mental health, with a significant increase in turnover intentions post-pandemic [56]. The global shortage of nursing personnel, already evident before the pandemic, may be exacerbated by the pandemic’s psychological and other negative impacts, leading to further workforce attrition [8].

Although our data collection was completed prior to China’s December 2022 policy shift from zero-COVID to Category B management, our findings highlight enduring needs for flexible healthcare deployment and scalable mental health support—demands likely to persist or intensify during major policy transitions. The dynamic nature of public health policies can significantly affect both psychosocial responses and resource demands among healthcare workers. These findings underscore the importance of adaptive preparedness strategies that remain responsive to ongoing policy changes and evolving psychosocial needs in future health crises.

Nuancing the JD–R mapping: dual roles and cultural mechanisms

We note that “WANG” (expectation) and “SHOU” (commitment) can be dual‑edged. Recognition and public praise (WANG) motivate, yet when idealized as a “hero” narrative they become performance or moral demands (e.g., N44). Likewise, commitment (SHOU) enables a sense of duty but respective internalized pressure may also contradict safety requirements or family roles, creating role conflict and overcommitment (e.g., N32). In general, resources and demands shift with appraisal and adaptation phase.

Culturally, tightness improves coordination and compliance but may dampen individual voices, heightening pressure with regard to SHOU. Collectivism strengthens “XIANG ZHU” (mutual help) via: (1) information sharing through dense ties; (2) emotional co‑regulation via shared identity; and (3) norm reinforcement (reciprocity, reduced help‑seeking stigma). These mechanisms specify how cultural conditions trigger–resource dynamics and support trajectories toward growth.

Limitations

This grounded theory study included 53 nurses from 11 provinces and municipalities across China. The participants were diverse in age, gender, ethnicity, region, education level, professional title, position, hospital grade, department, experience caring for infected patients, disaster rescue experience, and job retention decisions, making the sample broadly representative. Additionally, the data were collected over a two-year period, allowing for a more comprehensive understanding of the issues faced by nurses during the pandemic. This extended data collection time likely contributed to data saturation, further strengthening the validity of our results. However, there are some limitations to this study.

First, the lack of standardized scales to objectively assess participants’ stressors and stress levels represents a limitation of this study.

Second, our theoretical sampling included frontline nurses and two nursing directors to provide organizational context for frontline coping. The inclusion of nursing directors aimed to enrich theoretical completeness through managerial perspectives and cross-validate findings. However, we acknowledge that their experiences differ from frontline nurses, defining this as the study’s boundary regarding hierarchical representation within nursing.

Third, the study intentionally focused on nursing perspectives (including directors as part of the nursing hierarchy) without incorporating other stakeholder groups such as physicians, patients, or volunteers. This deliberate boundary allowed for in-depth analysis of nursing experiences during the pandemic, though future research could explore interprofessional dynamics.

Fourth, our data were collected during China’s zero-COVID policy, when nurse infections were rare and highly stigmatized as signs of infection-control failure. Institutional rules and fear of reputational harm deterred infected nurses from joining the study; for example, participant N53 noted that colleagues who had tested positive would only speak under strict anonymity. Consequently, the emerging conceptual model is bound to nurses without disclosed infections, a context-driven constraint rather than a methodological flaw.

With the decreasing virulence of the virus, widespread vaccination, development of antiviral drugs, and adjustments in pandemic prevention policies, it is worth exploring whether the fear and stigma associated with COVID-19 infection will change. However, this issue must be thoroughly analysed due to the study’s funding constraints. In future research, conditions permitting, we will focus on this topic to better understand clinical nurses’ social and psychological responses in the dynamic evolution.

Conclusion

This study developed the “Watching Over and Helping Each Other” conceptual model to analyse the psychosocial processes of clinical nurses coping with EIDs from a local cultural perspective. Situated within collectivist cultural norms, the conceptual model advances coping research by depicting adaptation as a fluid oscillation between vigilant involvement and reciprocal support, thereby extending predominantly individual-level models to an integrated socio-cultural framework. The resulting perspective clarifies how personal, relational, and organizational forces interact to foster growth, balance, and sustained professional commitment under epidemic pressures. These insights suggest that multilevel interventionssuch as peer-mentoring networks, formal recognition of nursing contributions, and institution-wide mental-health resources can transform collective strength into enduring well-being and high-quality care. Future work should empirically test this framework across diverse settings and employ longitudinal designs to trace its developmental trajectories, providing a stronger evidence base for disaster-preparedness policy and workforce planning.

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Abbreviations

EID

Emerging Infectious Disease

PPE

Personal protective equipment

ICU

Intensive care unit

CGT

Constructivist grounded theory

Author contributions

Yunting Luo: Conceptualization, Investigation, Data Curation, Formal analysis, Writing Original Draft, Funding acquisition. Xianqiong Feng:Methodology, Supervision, Writing Reviewing and Editing. Dandan Wang: Investigation, Formal analysis. Yafang Zheng: Writing Original draft preparation, Writing Reviewing and Editing. Xu Qiao: Investigation. Shiqi Jia: Investigation. Xujia Xiao: Investigation. Jan D. Reinhardt: Conceptualization, Supervision, Writing Reviewing and Editing, Funding acquisition.

Funding

This study was supported by the West China Nursing Discipline Development Special Fund Project of Sichuan University (HXHL20008).

Data availability

The data analysed in this study are partially available within the manuscript.

Declarations

Ethics approval and consent to participate

This project was approved by the Biomedical Research Ethics Committee, West China Hospital of Sichuan University (2020–1233). All procedures followed the ethical guidelines set by the Helsinki Declaration. The study complied with ethical standards, guaranteeing voluntary participation, anonymity, and confidentiality. Written informed consent was obtained from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.