Table 2.

Key Themes and Illustrative Quotes.

Theme		Illustrative quotes
1. Moral Distress		“I’ll be a nurse thirty-one years at the end of the month and I have never seen the amount of death I have seen in the last three months. And it is beyond emotional and physical. And, you know, it's just you feel so bad for the patient, the family, the staff, because we’re not allowed visitors. So, these patients, a lot of times, are dying without their family present. So, we’re, of course, we’re stepping in and we’ve never let anyone die alone.” “And to know that there was just one gown that I wore for the entire shift, we would come out and like spray each other down with bleach and then hang the gown up. And we wore one mask the entire time. It was frightening because we know that's not what's supposed to be done. N95 s were not created for you to wear for eight to 12 h shift… never changing it in between patients [and] just not being able to take it off at all.” “I chose to be a nurse practitioner because I love the patient interaction, especially touch…I love the fact that I could touch you and hold your shoulder and say, hey, you’ll be OK, or I would pull this stool in the room, listen to your concerns and address them because that's what I wanted to do. That's what I love to do. Now we’re finding that, not only as nurses are we going through compassion fatigue, but the volume is so tremendous that you’re not able to do that. And then I come back with feelings of guilt. It's not about quality time with the patient anymore, because not only is my cup empty, but there's so many more people to take care of.” “[COVID-19 has been] the most emotionally taxing experience of my career as a nurse just because, like me personally, any time I lose a patient, any time something is wrong with a patient, I feel for them… I’m praying for my patients. I cry when they pass. So…to see the overflow of death was traumatizing…That's exhausting to even think about when we get into [nursing it's] because we do care and we want to, you know, make the difference.” “It's a new paradigm for nursing to choose between nursing and taking care of yourself.” “Yeah. It felt so horrible. It felt like so here I am putting myself at risk, coming to work, taking care of patients and I may contract something… and what's going to happen to me. Who's going to take care of my family? … I think the institutions didn't… really think about the health care workers and their safety. It's scary because it's a lot that's unknown…The anxiety level of knowing that a patient is [COVID] positive is definitely tremendous. There's so much that's unknown. You don't know. You absolutely don't know.” “I think we’re going to have massive burnout across this country with…nurses who have been working with COVID patients. And if they don't have a good support network, they’re not going to do well. So, I think that needs to be things in place to have some kind of a tracking system or something to see how people are doing, especially in the midst of a crisis.”
	1.1. Fear	“Well, mentally. I mean, I feel like the mental, the psychological part is just the number one for us in the health care field. And we just don't know. It's the fear of the unknown.” “This virus made a lot of older nurses and nurses with preexisting conditions retire. It did instill a lot of fear to the point of the nurses quit[ting] their jobs… It just shook everything.” “Nursing [is a] hazardous occupation…It can be quite dangerous, you know…even when we had patients with hepatitis and TB… But when you’re dealing with HIV, you can get…prophylaxis. With COVID, it's the waiting game…So it's kind of scary to me, it's kind of dangerous.” “I think a lot of people get scared of the idea of taking care of someone who is so infectious, but…nurses are used to dealing with adapting situations… I think the fear was very real and it's gonna stick with people for a long time.”
	1.2. Frustration	“It does make me frustrated that there's no medical people in management. So, it's like people are making decisions, aren't necessarily aware of how it works. Right? Which is always the frustration. But it's really apparent in this situation?… Why are we not having more power and more say in things?… I’m seeing a lot of gaps that need to be addressed.” “I love my job. I love doing patient care…[but] I was not being the provider that I like to be in that first week or two when people were coming in for things that were not urgent, for things that they did not need immediate care for, for things they could have done over the phone or waited, you know, months in some cases, or didn't even need health care for, period. And so, when those patients came in, it was very difficult to ‘mask,’ to use an appropriate term. It was very difficult to mask my frustration with them.” “When I first learned of COVID-19, it was kind of downplayed. I guess there were a lot of unsure because it is a fairly new disease. And so…in early March, I remember receiving a letter from our organization, the AANA, which recommended that all health care providers, nurse anesthetists wear N95 masks when participating in intubations and, you know, anything that having kind of respiratory, you know, a risk of respiratory secretions being excreted. And there was a lot of backlash when I went to work saying that we need N95 s. We were told that they had locked the N95 s up and that we did not need N95 masks to provide care and that… we just need a regular surgical mask. And to my dismay… after reading what our organization had told us about the recommendations, a lot of nurses and nurse anesthetists were agreeing with the hospital for fear of backlash, for fear of being fired, for fear of not having work.” “People didn't have a lot of knowledge about [COVID-19]. And I felt like… there were a lot of changes and protocols that [were] being made and changes to our hours and operations in general without a lot of consent from employees, which was just really frustrating for a lot of people…So yeah, it was really stressful, lots of adjustment, but lots of changes are happening really fast.” “I think [frustration] has been the experience of a lot of nurses. Right? To go through a lot, make a lot of sacrifices, and it's often overlooked.”
	1.3. Powerlessness	“Even when I was there prior to COVID, we were not really involved in…decision making. And it's really unfortunate because the people who govern…nurses are not people who have health backgrounds. So if we make a suggestion, it sort of falls on deaf ears because they’re not health professionals. So how do they know what's important, especially if they’re not listening to us?” “I was just very nervous… with a lot of the administrators. I felt like I was powerless because they had these masks and they were locking them up. And, you know, it was almost like, this is all we have.” “[I was told by a manager] ‘You know, if you’re going to complain about it, you can find another job’… I really felt very demoralized.” “I mean, you didn't have a choice, when this was all happening… you lose your job if you don't come to work. So just knowing that if something like this happens again, you don't have a choice. You have to come to work… unless you want to lose your job, obviously.” “So unfortunately, it's the nurse mentality. I feel we kind of just suck it up and we move on. But I know that it's been hard.”
	1.4. Guilt Around Letting Others Down	“I feel bad if I leave because I love the people I work with and so I have a little bit of guilt about abandoning them. But mentally and physically, I don't know how I can keep this up.” “There were situations where they were not proning [patients]. So, you would see a patient who would be on high flow nasal cannula and or optiflow and then find them not proning… then you would see them decompensate. You’d be thinking, ‘if they were proned would they get better. Are we like making them worse by not giving them this treatment that we know that could help them?’ So, we would…have these discussions with doctors about that [during] panels [and] debriefs afterwards. We talked about how we did feel like…things were unethical. We did talk to the doctors about it, you know, trying to advocate for patients. But it kind of didn't necessarily feel like we went anywhere with it. We felt like people…wouldn't help…the same thing would happen. Like the patients get intubated and they would eventually pass. And so, they said we could have put an ethics consult in for that. But at that time, it's like so frustrating, you know, that I don't know if we could … have helped.” “It's an interesting time… to be a health care provider because usually you don't think there's just this level of fear. I think that didn't exist before… between patient and provider like especially with our pregnant patients, I think they were like, ‘oh my God, I’m going to [go into the] clinic. And if I don't have COVID, I’m going to get it from [the healthcare team].’ And we…felt the same way, like our patients were going to give us COVID. All of a sudden, this person who's coming in for her care could potentially give you an illness that might do nothing to you or it might kill you…it injected this uncertainty into patient provider relationship.” “The hardest part…for me, was the separation of the families [from] the patient and the suffering that [it] caused… My patients… many of them were elderly and… their spouses would be sobbing on the phone saying, ‘is there any way you can get me into that room?… I’ve been at his side for 65 years…. Now at this important time, I can't be with him.’ And it broke my heart. It was very hard. So that, for me, was the hardest thing.”

AANA = American Association of Nurse Anesthesiology.