Health Experiences of Nurses during the COVID-19 Pandemic: A Mixed Methods Study

Abstract

This study characterizes the impact of the COVID-19 pandemic on the mental and physical health of nurses. Qualitative data (collected using semi-structured interviews) were integrated with quantitative data (collected concurrently using the SF-12 Health Survey). Nurses (N = 30) compared their health prior to and during the first pandemic wave (March–May 2020). Interviews were analyzed thematically; descriptive statistics and t-tests compared pre-pandemic to current SF-12 scores. Qualitative findings demonstrated an impact on nurses’ mental health expressed as isolation, loss, intense emotions, and feelings of being expendable. Impact on nurses’ physical health included exhaustion, personal protective equipment skin breakdown, limited breaks from work, and virus exposure. Quantitative results show nurses’ experienced declines in overall mental health (p < .001), and multiple physical health domains: role limitations due to physical problems (p < .0001), bodily pain (p < .0001), and general health (p < .0001). Promotion of nurses’ well-being and safety, as well as education in emergency preparedness, must be given precedence to protect nurses’ health.

The COVID-19 pandemic surprised the world leaving no country or person unaffected. The public health crisis illuminated deficiencies in all industries, most notably in health care. The lack of preparedness, resources, support, and communication strategies overwhelmed, burdened, and even sacrificed frontline health care workers (De Kock et al., 2021; Greenberg et al., 2021). Nurses who often were the sole frontline caregivers for hospitalized patients developed physical symptoms and psychological distress negatively impacting their health and well-being (Pollock et al., 2020).

Multiple studies have described the impact of caring for COVID-19 patients on nurses’ emotional and mental health. A range of psychological responses to caring for these patients have been reported including significant levels of anxiety, depression, posttraumatic stress disorder (PTSD), insomnia, burnout, and stigma (Chew et al., 2020; Chutiyami et al., 2021; Galanis et al., 2021b; Shaukat et al., 2020; Stimpfel et al., 2022). A meta-analysis of the psychological burden on frontline health care workers during pandemics (SARS, H1N1, MERS, Ebola, COVID) demonstrated the most significant and prevalent concerns were about transmission of COVID to their family (60.4%), stress (56.8%), one’s own health (46%), sleeping difficulties (39.9%), burnout (31.8%), depression (25.7%), anxiety (25.4%), and symptoms of PTSD (24.5%) (Busch et al., 2021). Less attention has been given to the impact on nurses’ general health (beyond contracting COVID and the subsequent sequalae) but the following have been reported: fatigue/exhaustion, skin breakdown from personal protective equipment (PPE) use, dehydration, headaches, and muscle tension (Chew et al., 2020; Chutiyami et al., 2021; Galanis et al., 2021a; Häussl et al., 2021; Manookian et al., 2022).

Few studies conducted in the United States have described the impact on both physical and mental health using mixed methods of semi-structured interviews and standardized general health assessment questionnaires (Allobaney et al., 2020). For example, Gray et al. (2021) conducted a cross-sectional survey of nurses’ experiences that focused on psychological responses. The questionnaire included open-ended questions that were analyzed qualitatively. LoGiudice and Bartos (2021) had nurses complete the Brief Resiliency Coping Scale followed by a request for nurses to write about their experiences caring for their patients and themselves; 22 of 43 nurses gave responses so brief that the narratives could not be used in the qualitative analysis. Stimpfel et al. (2022) used semi-structured interviews and questionnaires to address psychosocial health of nurses but did not address impact on nurses’ physical health.

Therefore, we conducted a mixed-methods study to assess the impact of caring for hospitalized COVID-19 patients on nurses’ physical and mental health. The integration of qualitative and quantitative data provides a deeper understanding of the overall health of acute care nurses during the first wave of the pandemic. This understanding is vital to ensure that we support and amplify the voices of frontline nurses to promote safe, quality health care and generate knowledge for future pandemics (Fernandez et al., 2020).

Purpose

The purpose of this study was to characterize the impact on nurses’ mental and physical health of caring for COVID-19 patients during the first wave of the pandemic. Specific aims were to

1. Describe nurses’ perceptions of their mental and physical health in caring for hospitalized adults with COVID-19 during the first wave of the pandemic (March through May 2020)

2. Compare mental and physical health scores of nurses providing direct patient care prior to and during the first wave of the COVID-19 pandemic.

Methods

Study Design and Sample

A convergent mixed-methods design was used with quantitative and qualitative data being collected concurrently (Creswell & Clark, 2017). Data were analyzed independently and then integrated to provide a holistic view of the pandemic’s impact on the mental and physical health of frontline nurses. Quantitative data were collected using electronic surveys, while qualitative data were collected through virtual semi-structured interviews. The University of Michigan Health Sciences and Behavioral Sciences Institutional Review Board deemed this study exempt (HUM00183253).

We purposively sampled registered nurses (RNs) from across the United States via social media campaigns (Facebook and Instagram) to elicit a representative sample from different regions of the country. Inclusion criteria are as follows: (a) RNs practicing in the hospital, (b) provided direct care on an adult medical, surgical, obstetrics, COVID, critical care unit or emergency department, and (c) had a minimum of 3 years of RN experience. Three years of experience was selected in an attempt to isolate the impact of the pandemic on nurses’ health, as opposed to the impact of being a novice nurse (Benner, 1984). Participants were recruited until thematic saturation was reached, which was determined through ongoing discussion among the analytic team.

Qualitative and Quantitative Instrumentation

Semi-structured interview guide

A semi-structured interview guide was designed to elicit an in-depth description of the participant’s personal and professional experiences and what individual, contextual, and social factors influenced their experiences during the first wave of the pandemic. Demographic questions were included at the end of the guide. The guide was piloted with a frontline psychiatric nurse who was practicing during the first wave of the pandemic to gain feedback regarding the content, flow, and cohesion of the guide.

Optum ® SF-12 v2 ® Health Survey

The Optum ® SF-12 v2 ® Health Survey was used to assess the mental and physical health of nurses (Ware et al., 1996). Two versions of the survey were used, one that questioned nurses’ health pre-pandemic, and the other that questioned their current health (within the last 4 weeks) during the pandemic. The SF-12 is a self-report of health that has high internal consistency (Cronbach’s alpha = 0.87), established validity (Al Omari et al., 2019), and high reliability in retrospective scoring compared to contemporary reports (intraclass correlational coefficient ranges: 0.83–0.91) (Kwong & Black, 2017). We elected to use the SF-12 given its brevity and multidimensional conceptualization of health, its high sensitivity to change, and more consistent retrospective scoring compared to other self-reported health surveys (Jenkinson et al., 1997; Johnson & Coons, 1998).

The SF-12 consists of 12 items and includes a Mental Health Component (MC) and Physical Health Component (PC). The MC encompasses four domains (i.e., vitality, social functioning, role limitations due to emotional problems, role limitations due to mental health), as does the PC (i.e., physical functioning, role limitations due to physical problems, role limitations due to bodily pain, general health). Standardized scoring results in MC and PC Summary Scores and scores for each of the eight domains that range from 0 to 100, with higher scores reflecting better self-reported health (Ware et al., 1996).

Data Collection Procedures

Qualitative data collection

In total, 60-minute interviews (one interview per participant) were conducted from July 2020 through November 2020. Two authors (M.H. & A.M.) trained in qualitative research conducted the interviews via Zoom video conferencing. All interviews were audio recorded, transcribed verbatim, redacted for identifying information and stored on a password-protected server.

Quantitative data collection

Upon enrollment, participants received an email survey with two versions of the Optum ® SF-12 v2 ® Health Survey (pre-pandemic and current health). A secure web application, Research Electronic Data Capture (REDCap) was used to send and manage the data. Participants completed both versions of the SF-12 v2 surveys prior to their scheduled interview.

Data Analysis

Qualitative data analysis

Qualitative data were analyzed using Braun and Clark’s process for reflexive thematic analysis (Braun & Clarke, 2006): (a) data familiarization from reading the transcripts several times to get an overall feeling of the content and patterns, (b) generation of initial codes, (c) collating codes into overarching themes, (d) identifying the supporting data for the themes, (e) defining and labeling themes, and (f) final analysis of codes and themes.

Transcripts were analyzed by a three-member coding team (M.H., A.M., and M.T.) with experience in qualitative analysis. The three analysts reviewed all transcripts to familiarize themselves with the data. Two analysts (M.H. and A.M.) then independently coded the first five transcripts to develop an initial codebook, which was reviewed by the third analyst (M.T.) who acted as an auditor. One analyst (A.M.) then coded the remaining transcripts and iteratively modified the codebook throughout the process. Regular team meetings were held to debrief and reflect throughout the coding process. The three analysts independently grouped the final codes into overarching themes, which were discussed among the team to reach a consensus on naming of the final themes. All analysts participated in identifying supporting data for themes, defining and labeling themes, and finalizing the analysis. Multiple strategies were used to uphold rigor in the analysis to promote credibility, dependability, confirmability, and transferability of the findings (Table 1) (Morse et al., 2002; Thomas & Magilvy, 2011). ATLAS.ti was used to manage the qualitative data (Scientific Software Development, 1997).

Table 1.

Strategies Used to Maintain Rigor in Qualitative Analysis.

Component of Rigor	Definition	Strategies Used
Credibility	Confidence that can be placed in the truth of the research findings	• Frequent debriefing sessions • Frequent reflexive discussions among analysts • Use of a three-member analytic team with training and experience in qualitative analysis • Compared findings with prior research
Dependability	Likelihood of replicability of findings	• Use of a three-member coding team • Maintained an audit trail • Open dialogue within research team
Confirmability	Representativeness of findings in relation to participants’ experience	• Maintained an audit trail • Frequent reflexive discussions among analysts • Use of multiple quotation exemplars to illustrate the experiences of the majority of participants
Transferability	Extent to which findings can be applied in other situations	• National recruitment strategy • Thick description of findings with relevant quotes to support themes

Quantitative data analysis

Descriptive statistics (frequencies, percentiles, means, and standard deviations [SDs]) were used to analyze demographic data. Both versions of the Optum ® SF-12 v2 Health Survey (pre-pandemic and current health) were scored using Quality Metric Health Outcomes™ Scoring Software 2.0 to ensure accurate, standardized scoring (Saris-Baglama et al., 2007). Means (SDs) were calculated for each of the eight health domains, as well as for the Mental and Physical Health Component Summary scores. Tests of distribution (skewness, kurtosis, Jarque-Bera test [Jarque & Bera, 1980]) were performed for scores at both timepoints. Given that there were no missing data, minimal skewness, and no significant outliers, two-tailed, paired sample t-tests were used to compare the pre-pandemic and current scores.

Results

The study sample included 30 RNs, mostly female (90%), between the ages of 25 and 62 years (mean = 40; SD = 10.6); the majority were white (n = 26; Hispanic = 1; Native American = 1; Asian = 1; African American = 1). All participants were direct care RNs, had a bachelor’s degree or higher, and practiced between 3 and 33 years (mean = 13; SD = 9.3). Most participants were from large urban or academic medical centers (85%) with the remaining from community or critical access hospitals (15%). Nurses worked in Michigan, New York, Florida, New Jersey, Illinois, Ohio, South Carolina, Indiana, and Georgia. All states except Georgia and Florida had shelter in place orders at the time of data collection.

Integrated Results

The mental and physical health impact on nurses is demonstrated in the narrative below through description of the qualitative themes with exemplar quotations and presentation of the quantitative SF-12 results. Additional quotes are included in Online Supplementary Table 1 to further support qualitative themes. Table 2 illustrates integration of the mixed methods data by linking quantitative SF-12 Mental and Physical Component Summary scores and each of the health domain scores with relevant themes and exemplary quotes from the qualitative data.

Table 2.

Integrated Results Pertaining to the Mental and Physical Health of Nurses during the Pandemic (N = 30).

Mental Health
SF-12 Health Survey Components	Pre-Pandemic Mean (SD)	Current Mean (SD)	p-Value	Relevant Qualitative Themes	Exemplar Quotations
Mental Component Summary Score	52.5 (5.6)	41.7 (9.4)	<.0001
Vitality	56.6 (5.0)	50.7 (9.7)	.001	Loss Intense emotions Expendable	“I mean if it’s breaking these nurses. They’re the toughest people on the planet. They’ve been doing this for 25 years. Nothing shakes them. Nothing breaks them. And to see them dissolve into a pile is like oh, no, this is real.” (P15)
Social functioning	50.4 (6.1)	43.0 (10.4)	<.0001	Isolation Loss Intense emotions	“Well, it’s tough because normally we would have a little party or all go camping together, do something fun but we can’t get together, you know. We can’t come together as a family basically, which we’ve done in the past. . .To me, that’s what works.” (P02)
Role limitations due to emotional problems	53.9 (4.5)	45.2 (9.0)	<.0001	Isolation Loss Intense emotions Expendable	“Not only were we giving them Hospice, but we were holding their hands and sitting there on the phone with their loved ones as they are passing away. And that is emotionally more draining than physically draining.” (P18)
Role limitations due to mental health	51.4 (5.6)	41.0 (10.2)	<.0001	Intense emotions Expendable	“I realize now and I was realizing before why they said nurses are going to experience PTSD from this because me holding that patient and that family member’s hand like as they passed multiple times throughout the week, I’m not really able to let that affect me while I’m working because I have other patients who I need to care for. I need to just put that to the back of my mind so that I can process it at another time in a safe place not where I have to have my mind clear for all of my other patients.” (P03)
Physical Health
SF-12 Health Survey Components	Pre-pandemic mean (SD)	Current mean (SD)	p-value	Qualitative themes	Exemplar quotations
Physical Component Summary Score	54. 0 (6.1)	53.3 (8.5)	.5
Physical functioning	51.8 (8.1)	50.8 (8.9)	.5	Expendable Exhaustion Breaks	“Physically, I would say I definitely gained a lot more gray hairs with it. During the time we were out there, we were almost like physically and mentally exhausted; definitely both. But whenever we were off we didn’t even feel like doing anything because we were just worn out because there were days you’d go home and you were just exhausted from everything you did. And you just felt run down. It’s almost like you felt sick leaving with how awful you felt whenever you were finally done with your shifts.” (P28)
Role limitations due to physical problems	56.3 (2.9)	52.4 (7.2)	.0004	Exhaustion Exposure Use of PPE Skin Breakdown	“Everything is harder. Everything is harder. We could have used a break. We could have used support. We could have used. . . I don’t know but we definitely needed and still do need a break. We need to step away from it all because it’s like the treadmill never stopped running. We never got to turn it down. We never got to step off and get a glass of water. We just kept running just from the pandemic into this new normal where our patient’s acuity is tripled and we have less resources to take care of them” (P26)
Role limitations due to bodily pain	52.0 (7.3)	46.0 (10.9)	.0003	Loss Exhaustion Exposure	“I have had a lot of pain issues since March, a lot of sleep issues, a lot of like nerve kind of issues, headache kind of issues and. . . my doctor recently diagnosed me with fibromyalgia. She thinks it was triggered back when all of this started. So, who knows what the stress triggered.” (P23)
General health	55.0 (5.0)	51.5 (10.5)	.0008	Exhaustion Use of PPE Exposure	“And we got our first rule out COVID patients and because they weren’t ruled in yet and it would take a little while to get the test back we weren’t allowed to waste an N95 going in and out of the room so they gave us regular surgical masks and we just limited the number of people that went in there. They would not give us an N95 mask. Those nurses all caught COVID.” (P30)

Broadly, nurses spoke openly about how caring for COVID patients impacted their mental and physical health, which was substantiated by declines in several mental and physical health domains on the SF-12. One nurse shared:

Well, it affected me emotionally because I was made to believe that I was going to die, either from the virus, giving it to my family and/or my friends. Socially, I was also outcasted from everybody because they thought that I carried the virus because I worked in a hospital. It’s also affected me physically because I contracted COVID from the hospital and then gave it to my family. I was sick for five days, couldn’t breathe, it was horrible. (P22)

Mental Health Impact

Themes (in italics) that emerged from the qualitative data regarding the mental health impact focused on isolation and loss and intense emotions including fear, frustration, anger, guilt, and being faced with moral and ethical dilemmas. Experiences and associated emotions in caring for COVID patients were traumatizing, demoralizing, and dehumanizing leading to feelings of being undervalued and ultimately expendable.

Qualitative findings relating to the mental health impacts on nurses are corroborated by quantitative results as the mean Mental Health Component Summary score (MCS) decreased significantly from 52.5 (SD = 5.6) to 41.7 (SD = 9.4) from pre-pandemic to the initial wave (p <.0001). All mental health domains of vitality, social function, role limitations due to emotional problems, and mental health also declined significantly (p ≤ .001; Table 2).

Isolation and loss

Participants shared how isolation and loss affected them on a personal and professional level. Personally, they suffered isolation from the social stigma cast by family, friends, and society and their own fear of potentially exposing others to the virus. One participant stated, “At first, I was isolated to the basement for a month and that was very difficult to be away from my husband and our kids. So that part was emotionally draining” (P22).

Professional isolation was associated with wearing PPE that inhibited participants’ ability to communicate with other health care workers and patients. Many nurses described feeling isolated from the health care team as they were often the only team member going into patients’ rooms which resulted in nurses absorbing additional responsibilities.

Other disciplines weren’t coming to help us either like the physical therapy, occupational therapy, speech therapy, and they were telling us that there’s not enough PPE to go into the room to care for these patients. So, it was solely just nurses and more times than not even physicians wouldn’t go into the room. . . .just all these responsibilities that were thrown onto the nursing discipline to pretty much do absolutely everything for this patient. It just felt like the whole weight of the world was on our shoulders and we were the patient’s lifeline. (P03)

Nurses experienced loss on a professional level as coworkers died, retired, resigned, and were redeployed all compounded by the absence of ancillary staff (e.g., physical therapy), leaders, and patients’ families. They lost more patients in a short timeframe than they had lost before, which intensified their fear and uncertainty. One stated, “In the beginning people were upset that they might catch COVID and then our institution lost five employees to COVID-19 and a couple of coworkers took it home to family members and lost their family members” (P16). Another participant explained,

And so, April was just hard because I did not feel like we were saving anybody. Every person we put on a ventilator it felt like a death sentence, and here I was taking care of these COVID patients, and I didn’t have a single CCVH [Continuous Veno-Venous Hemofiltration] patient live that had COVID. So, I had the highest kill record on the floor. (P21)

The loss of support from families of patients due to visitor restrictions resulted in nurses becoming their patients’ surrogate family. It was a heavy burden to bear.

I do not have the emotional bandwidth to be everything for a human. Like I don’t have the emotional bandwidth to be their nurse, their therapist, their sister, their mother, their everything. I don’t have that. I don’t have the time. I don’t have the resources and I don’t have enough. Just, I don’t. . .it was draining for us. We did it. We did it happily, but it drained us. So stressful. (P26)

There was a loss in their beliefs and respect for health care leaders, society, professional health care organizations, and the federal government. Lack of appreciation and respect perceived by nurses amplified their feelings of loss:

Even though a lot of ICU nurses like to say we’re hard asses and we can separate everything, we can’t. It shows you that you do have like some sort of positive, maybe altruistic thoughts and beliefs when it comes to your job. And then you realize that to your job. . .you are a number and so is the person that you’re taking care of. You’re nothing but money. Then when you hear from some of your peers outside of it like “You know, it’s a hoax. It’s not true. It’s, you know, political to prevent the President from whatever.” It’s damaging, it’s not healthy. (P08)

Another participant summarized: “It was a nightmare. It was horrible. I’ve never felt so let down by people that are supposed to be in charge in my life” (P11).

There was a loss of coping strategies such as peer and family support, the ability to exercise in their local gym, respite care for family members, and leisure time from working long hours. One participant related, “I miss being able to feel well enough and being able to go out and walk at the beach or walk in the woods. I miss that connection to nature. That part feels like a loss” (P23).

Intense emotions

Nurses’ stories were filled with intense emotions of fear, anxiety, frustration, anger, guilt, and being faced with moral and ethical dilemmas. The constantly changing expectations and directives nurses received from leadership and the minimal leadership presence on the unit contributed to these emotions:

I think the fear of getting sick was also a really difficult aspect. The fear of you getting sick, getting your family members sick, all that weighs on your mind every time you’re walking into work. . .. And honestly for me it also weighs on my conscience heavily. (P21)

It just felt like we hit road blocks on every single platform. That was really frustrating and it caused a lot of anxiety because you didn’t know what you should be doing, what the safest thing to be doing was for you for your own health, for your family’s health, for your patient’s health, and for me that caused a lot of anxiety and frustration. (P21)

And the other thing is that with all of this going on you are not seeing any of the higher level managers coming through—the directors, the CNO, you know, the chief medical officer—you’re not seeing any of those folks coming to those units to just get a pulse for how those employees feel on those units. I have not seen one of those people come to our floor since COVID started. And they won’t even meet us in the hallway and I think that makes us feel more of a number than a person. (P18)

Expendable

As loss, isolation, and emotions of nurses became more intense, the burden became harder to bear. Their safety and the safety of their loved ones were more at risk with each shift. The experience was traumatizing, demoralizing, and dehumanizing, ultimately leading to feeling as if they were expendable. One participant stated, “I just feel that the PPE situation was a big deal and how we were treated having to reuse it. We were treated like sacrificial lambs” (P08). Another said, “We were literally the frontline soldiers. I felt like I was going to war every day” (P03). Yet another participant related their feeling that

We were very expendable. I mean right down to our pulse. They just wanted bodies in there and if we got sick, we got sick. If we died, we died. No big deal. And I know because one of my close friends died, it was no big deal. (P30)

Physical health impact

Five themes (in italics) emerged about the physical health impact on RNs. Nurses talked extensively about the wear and tear on their physical health from (1) the use of the PPE; (2) inability to take breaks; and (3) skin breakdowns from PPE and frequent handwashing. They also talked about (4) exhaustion and (5) exposure to and/or contracting COVID.

Quantitative results showed a nonsignificant decrease in the overall Physical Component Summary score (p = .5); however, three domains of physical health did decline significantly (p < .001): role limitations due to physical problems, role limitations due to bodily pain, and general health (Table 2). Nurses described how exhaustion, exposure, and contracting COVID-19 affected their physical function, and described how inadequate PPE, exhaustion, exposure, and contracting COVID-19 influenced their general health, which corresponded with significant declines in general health domain scores (p < .001; Table 2)

Exhaustion

Descriptions of exhaustion were ubiquitous across nurses’ stories and seemed to link strongly to physical as well as mental health. One participant stated,

We are gowned and respiratored and face shielded and double gloved and hooded the whole entire time, and I had gotten dehydrated. The next day I woke up and I had a sore throat. I was exhausted. . .I was kind of short of breath because I was so fatigued. (P03)

Another nurse explained, “I’m tired. It’s just kind of programmed in my head. . .I go to work. I get the job done. I take it sometimes to heart too much and one of these days I’m going to fall apart” (P02).

Use of PPE

Most nurses described how the use of PPE impacted their physical health, including experiences with heat exhaustion and dehydration from prolonged PPE use:

We were washing our gloves and we were hand sanitizing our gloves and it was just so hot and me being a 24-year-old relatively very healthy nurse got dehydrated and needed to go to urgent care the next day because I was so ill from it. We were sweating. Like we sweat in our masks all day as it is but like, oh my gosh, it was just unbearable.” (P03)

Skin breakdown

Skin breakdown from handwashing and PPE use was also common, as one of the nurses explained, “So, it made me just wash my hands more and handwashing in the hospital can be really frustrating because then you end up with a bunch of tiny little paper cuts because your skin integrity is diminished” (P19). Another participant recalled,

For instance, I had too tight of a different style of N95 and I ended up with MRSA on my nose, so I had to take ten days off, and I wasn’t even paid for that time and that was from working in the COVID ICU and having to have that mask on for 12 hours.” (P08)

Breaks

Nurses described how the lack of breaks, including meal breaks, bathroom breaks, and time away from work affected their physical health, as well as their ability to physically sustain high-quality patient care. “There were days when it was almost impossible to go to lunch because I was the only nurse over there that that was trained to run the filter” (P11).

Exposure to and/or contracting COVID

Nurses shared their own experiences with frequent, repeated exposure to the COVID-19 virus. Many of those who contracted COVID-19 described experiencing prolonged symptoms that continued to affect their physical health weeks and months later:

You know, and even now, we don’t even have proper PPE. I contracted COVID because I didn’t have it and I nearly died and I’m 36 years old. And then I gave it to my whole family. I don’t remember five days of my life. I mean I’m recovered now. My family is recovered now. I have a raspy voice as I think it damaged my vocal cords. . .I do notice that my voice is deeper, and it gets raspy, and it was never like that before.” (P25)

Another participant stated, “Now we we’re going into six different rooms for breakfast, lunch and dinner. We felt like we were exposing ourselves a lot more than any other discipline” (P07).

In summary, nurses’ stories and their SF-12 scores reflect the cumulative impact of individual, professional, and societal stressors experienced in caring for hospitalized COVID-19 patients during the first wave of the pandemic. The negative impact on their physical and mental health was significant.

Discussion

This mixed-methods study addressed the impact of caring for hospitalized COVID-19 patients on both the physical and mental health of nurses, whereas the majority of prior studies focused only on nurses’ mental health (Chutiyami et al., 2021; Feingold et al., 2021; Giorgi et al., 2020; Gordon et al., 2021; Grailey et al., 2021; Joo & Liu, 2021; Ness et al., 2021; Peccoralo et al., 2022; Preti et al., 2020; Shah et al., 2021). Furthermore, studies that examined the impact on physical health focused on specific symptoms (e.g., headaches, fever, cough, insomnia) or adverse events secondary to PPE use (e.g., skin breakdown) rather than general health using a standardized health assessment tool such as the SF-12 (Chew et al., 2020; Chutiyami et al., 2021; Galanis et al., 2021a; Häussl et al., 2021; Manookian et al., 2022; Namikawa et al., 2021; Shaukat et al., 2020). Furthermore, this study revealed significant declines in general health and role performance from physical and mental health problems heretofore not addressed in previous research.

With the emergence of the COVID-19 pandemic, nurses faced unrealistic workloads; insufficient resources and PPE; risk of infection; stigma; and mental, emotional, and moral burdens of caring for patients with a new and unpredictable disease (Grailey et al., 2021; Halms et al., 2021). Nurses’ roles and responsibilities shifted rapidly to accommodate the complex needs of patients (Hossain & Clatty, 2021; Joo & Liu, 2021). These changes took a toll on nurses physically and mentally as demonstrated in the qualitative findings and supported by findings from the SF-12 in which there were significant declines in the mental health summary score, four mental health domains (vitality, social functioning, role limitations due to emotional problems, and role limitations due to mental health) and three physical health domains (role limitations due to physical problems, role limitations due to bodily pain, and general health). These findings are congruent with others that show nurses experienced physical, psychological, and moral distress during the pandemic and that the mental health burden was profound (Gordon et al., 2021; Preti et al., 2020; Shah et al., 2021; Sriharan et al., 2021; Watson, 2022). Nonsignificant changes in the SF-12 physical health scores (summary score and physical function) may reflect the focus of these items on the ability to do specified activities (e.g., moving a table, stair climbing) in contrast to the focus on role limitations from physical problems or bodily pain that comprised the other items of the physical health domains

The emotional impact was exacerbated by feelings of frustration about limited leadership visibility and perceived insensitivity to exposing self or loved ones to the virus while they juggled competing demands for patient care, staff safety, and being the surrogate family member. Nurses felt expendable. The constantly changing protocols coming from leadership on use of PPE and care of COVID patients contributed to uncertainty and lack of confidence in actions to protect themselves, their patients, and their family and friends. Nurses were continually exposed to COVID with little voice in determining their desire to work with these patients or being deployed to provide care for patients in which they had little expertise. They described feeling like soldiers in a war without the necessary equipment and resources to win the war or to keep themselves safe. They felt defeated from the virus overtaking their patients and were terrified about contracting the virus and spreading it to their families. These qualitative findings are supported by SF-12 findings of significant declines in mental health scores. Nurses reported having less vitality, role limitations due to emotional and mental health problems, a decline in social functioning, and a more than 10-point decline in overall mental health. These findings are corroborated by other studies (Joo & Liu, 2021; Ness et al., 2021; Norman et al., 2021; Preti et al., 2020). Studies have not reported, however, changes in role performance due to emotional and mental health problems.

Nurses shared that caring for patients affected their physical health and function. Exhaustion was prevalent and supported by a significant decline in the vitality scores of the SF-12. Nurses reported skin breakdown, dehydration, and skin infections from PPE use. Adverse effects on physical health secondary to PPE use reported by others include pressure injuries, dermatitis, dehydration, and headaches (Galanis et al., 2021a; Manookian et al., 2022).

Exposure to and contracting COVID was prominent. Nurses were continually exposed to COVID; they became the “super-exposed” group of health care professionals with little compensation for hazardous work. Several nurses talked about experiences of having COVID, the impact on their physical health, and limitations in carrying out various roles, supported by significant declines in role limitations due to physical problems or bodily pain on the SF-12. As noted by others (LeClaire et al., 2022; Sriharan et al., 2021), nurses diverged from the profession’s ethical constructs regarding patient care due to a lack of resources, and leadership support creating moral distress, a chronic sense of betrayal, and loss of trust. These cumulative effects limited nurses’ ability to carry out their personal and professional roles, and ultimately led to declines in overall health supported by significant declines in General Health scores of the SF-12. The impacts on physical health found in this study are also reported by others and include fatigue, exhaustion, insomnia, and headache (Chew et al., 2020; Chutiyami et al., 2021; Häussl et al., 2021; Namikawa et al., 2021; Shaukat et al., 2020). No studies evaluated the physical health impact using a standardized, general health assessment scale.

Implications

COVID-19 has imposed new challenges for the well-being of nurses, and nurses are leaving health care or seeking non-direct care positions that will accentuate the shortage of nurses (American Nurses Foundation, 2022; Costa & Friese, 2022; Kurtzman et al., 2022; LeClaire et al., 2022). Findings from this study and supported by others suggest the following three broad recommendations: (1) promoting the well-being of nurses and the nursing workforce; (2) providing safe and supportive work environments; and (3) preparing the nursing workforce for pandemic response (Busch et al., 2021; Costa & Friese, 2022; Grailey et al., 2021; Halms et al., 2021; Hossain & Clatty, 2021; Joo & Liu, 2021; Lekagul et al., 2022; Ness et al., 2021; Norman et al., 2021; Preti et al., 2020; Shah et al., 2021; Sriharan et al., 2021).

Promoting well-being

The well-being of nurses impacts the delivery of high-quality, safe patient care, the functioning of health systems, and the financial viability of health care organizations (Veenema et al., 2022). Multifaceted and multilevel approaches at the individual, organizational, and policy level are necessary to promote nurses’ well-being (Costa & Friese, 2022; Hossain & Clatty, 2021). Given our findings, organizations must make improving nurse well-being a priority by creating work environments, cultures, and policies that address adequate resources such as staffing, scheduling, PPE, workload, and decision-making, as well as systems of care delivery that facilitate collaboration, communication, and professionalism (Busch et al., 2021; Buselli et al., 2021; DePierro et al., 2020; Lekagul et al., 2022; Rauch et al., 2020). Frontline nurses must have a voice; that is, to be proactively engaged in designing resources they perceive as valuable to foster their well-being rather than having the resources imposed on them (Tebes et al., 2022). Nurse leaders have a large responsibility for improving nurses’ well-being through their leadership style and by creating safe and supportive work environments (Bleich & Bowles, 2021; Morganstein & Flynn, 2021; Sriharan et al., 2021; Stimpfel et al., 2022).

Safe and supportive work environment

A safe and supportive work environment for nurses to provide quality care encompasses strong and supportive leadership, adequate human and material resources, and fostering a positive practice culture. Nurses in this study relayed that they felt isolated, felt a sense of loss, and rarely saw their nurse leaders. They reported via the SF-12 worsened social functioning and declines in role performance secondary to physical, emotional, and mental health issues. Leaders must be sensitive to the multiple potential responses of staff and deploy targeted strategies to address each (Bleich & Bowles, 2021; Grailey et al., 2021; Stimpfel et al., 2022). Several actions by nurse leaders are recommended: (1) being visible on patient care areas and interacting with staff to check in about their physical and mental well-being; (2) transparent, bidirectional, and open-ended communication with staff; (3) active listening; (4) provision of education and training not only about safety measures but also the disease (COVID-19); and (5) proactive, real-time mental health support and psychological interventions (Bleich & Bowles, 2021; Catton & Iro, 2021; Grailey et al., 2021; Halms et al., 2021; Joo & Liu, 2021; Ness et al., 2021; Ralph et al., 2021; Schwartz et al., 2020; Shuman & Costa, 2020; Sriharan et al., 2021; Stimpfel et al., 2022; Watson, 2022).

Nurses shared with us that resources to provide care to COVID-19 patients were in scarce supply, including PPE and staffing. Some recommendations to address resource shortages include (1) use of nontraditional staffing models to maximize efficiency of nurses and assistive personnel; (2) scheduling more time between shifts for physical and emotional recovery; (3) frequent short breaks from clinical duties; (4) adjustment of shift duration to account for high demands of infection control practices; (5) promoting voluntary redeployment of staff whenever possible; (6) instituting hazard pay; and (7) providing resources to help with family responsibilities such as child or elder care, and lodging for staff away from family (Bambi et al., 2020; Galanis et al., 2021a; Halms et al., 2021; Manookian et al., 2022; Norman et al., 2021; Schwartz et al., 2020; Shuman & Costa, 2020; Sriharan et al., 2021). It is imperative, going forward, that organizations and administrators have plans in place to accommodate rapid surges in the need for PPE and human resources.

In this study, practice cultures were characterized as chaotic, uncertain, and constantly changing. Plans to improve communication that are designed to acknowledge the evolving information about COVID and recognize the unusual circumstances faced by nurses are needed (Joo & Liu, 2021; Ness et al., 2021; Norman et al., 2021; Ralph et al., 2021; Schwartz et al., 2020; Shuman & Costa, 2020). Verbal, non-verbal, and written communication must address the emotional, mental health, and physical challenges experienced by staff, thereby creating a culture where seeking help is not stigmatized (Busch et al., 2021; Norman et al., 2021; Shah et al., 2021; Stimpfel et al., 2022; Veenema et al., 2022).

Preparedness for pandemic response

Multiple calls to address nurse readiness for the pandemic response have been issued (Catton, 2022; Preti et al., 2020; Shuman & Costa, 2020). Findings from this study demonstrate that nurses were not prepared to respond to the COVID-19 pandemic. Lessons learned during prior pandemics and infectious disease outbreaks (e.g., H1N1 influenza pandemic; SARS; Ebola) were not applied to emergency preparedness for the COVID-19 pandemic (Catton, 2022). General knowledge about health system emergency preparedness is lacking among nurses and health system leaders who play key roles in public health emergencies. There is a notable absence in schools of nursing regarding emergency and pandemic response and training of students to achieve competency in this area. Lack of competency in crisis leadership contributes to mistrust among hospital leaders, nursing leaders, and frontline staff. The nation’s nurses are not currently prepared for disasters, including pandemics and other public health emergencies (Leaver et al., 2022; National Academies of Sciences, Engineering, and Medicine [NASEM], 2021)

Actions to advance the national nurse readiness for pandemic response requires bold and expansive efforts to prepare for public health emergency responses (Leaver et al., 2022; NASEM, 2021; Veenema et al., 2022). A national strategic plan, informed by nurse experts in disaster preparedness and public health emergency response, is essential to identify gaps in knowledge and skills of the nursing workforce and action steps to address them. More urgently, education of pre-licensure and practicing nurses regarding pandemic preparedness is needed and should encompass lessons learned during the COVID-19 pandemic (Leaver et al., 2022). For example, we found significant declines in nurses’ role performance and general health heretofore not demonstrated. Thus, it is imperative that emergency preparedness and response plans address both declines in role performance and general health to support nurses and assure a viable workforce. Professional nursing organizations must unite to prepare nurses for future pandemic-related challenges (NASEM, 2021). Health system leaders must ensure that pandemic response plans have policies to ensure safe working environments, adequate pay for nurses during a public health crisis, and adequate human and material resources to meet the demand. These plans must address training, communication, and protection of the nursing workforce (Costa & Friese, 2022; Leaver et al., 2022; Stimpfel et al., 2022; Veenema et al., 2022).

Conclusion

This mixed-methods study demonstrates the cumulative mental and physical health effects of the first wave of the COVID-19 pandemic on frontline nurses. Clearly, we as a health care society were unprepared for this COVID-19 global emergency. This resulted in unintentional consequences for nurses who are the backbone of quality and safety in health care. We must respond to the calls for action to correct the significant shortcomings and to be prepared for future disasters and emergencies.