A mixed methods study: The grief experience of registered nurses working on the frontlines during the COVID‐19 pandemic

Abstract

Aim and Objective

The purpose of this study was to generate a conceptual definition and theory of grief for nurses working on the frontlines during the COVID‐19 pandemic using grounded theory methodology.

Background

The COVID‐19 pandemic has had a negative impact on nurses working on the frontlines. The increasing flow of diagnosed COVID‐19 cases, diverse unknowns and demands in the treatment of patients with COVID‐19, and depression related to countless deaths can trigger grief experiences.

Design

A mixed methods approach, including the qualitative method of grounded theory and a quantitative 30‐question survey, was used in this study.

Methods

Eight focus group sessions were conducted with registered nurses working on the frontlines during the pandemic. Sessions were audio recorded and analysed using constant comparative data analysis. Following the interviews, a survey including demographics and self‐report inventories was completed by participants. The COREQ checklist was used to assess study quality.

Results

Major concepts that emerged include ‘facing a new reality’, ‘frustrations’, ‘stress’ and ‘coping’. Core concepts were combined into a conceptual definition of grief and a grounded theory of the experience of nurses working on the frontlines during the pandemic. Cross comparisons of qualitative and quantitative findings were made and compared with the literature.

Conclusions

This study provides a better understanding of the grief experience of nurses working on the frontlines during the COVID‐19 pandemic. It is necessary to recognise professional grief and develop intervention strategies that lead to grief reconciliation.

Relevance to Clinical Practice

Findings provide useful insights for healthcare administrators to provide support and develop interventions to reduce frustrations and stress of frontline registered nurses.

Patient or Public Contribution

This study design involved registered nurses participating in focus group sessions. Participants detailed their experience working on the frontlines of the COVID‐19 pandemic with patients, family and hospital administration.

What does this paper contribute to the wider global clinical community?

• This study explored the grief experience of Registered Nurses, including their frustrations, stress and coping strategies as they faced the new reality of working on the frontlines during the COVID‐19 pandemic.

• Findings provide useful insights for healthcare administrators globally to develop processes and interventions to reduce the frustrations and stress of frontline registered nurses and to support them during their grief process.

1. INTRODUCTION

The qualitative method of grounded theory was used to answer the primary research question: ‘How do nurses working on the frontlines during the COVID‐19 pandemic describe their grief experience?’ A quantitative self‐report inventory, Track One of the Two‐Track Bereavement Questionnaire (Modified), was also used to capture data and explore its utility in measuring nurses' grief experience. Qualitative and quantitative results were collected and compared. The purpose of this study was to facilitate the discovery and description of nurses' grief as it is experienced working on the frontlines in the United States during the coronavirus 2019 (COVID‐19) pandemic.

2. BACKGROUND

The COVID‐19 pandemic has focused both national and global attention on the crucial role of nurses who are working on the frontlines to care for patients. While most people actively avoid anything that could expose them to the coronavirus, nurses have willingly remained on the frontlines to provide care to all patients, regardless of the risks. Thousands of healthcare workers have contracted the coronavirus, with many of them unfortunately dying due to exposure. However, nurses have remained committed to providing quality patient care despite these risks, demonstrating a core ethical commitment to nursing as defined in the American Nurses Association's (2015) Code of Ethics that endorses nursing endeavours to deliver dignified, humane care, regardless of the challenges and social context associated with health care.

COVID‐19's human‐to‐human transmission capability, as well as its association with high morbidity and potential fatality, can intensify an individual's perception of personal danger. In fighting COVID‐19, not only might nurses become infected and put their and their families' lives at risk; they may also face stress, hopelessness, helplessness, burnout and post‐traumatic stress disorder (PTSD). These negative outcomes may occur due to an increasing flow of suspected and/or diagnosed COVID‐19 cases; long work shifts with diverse unknowns and demands in the treatment of patients with COVID‐19; shortages of supplies and staffing; depression in the face of the coexistence of countless deaths and ethical dilemmas (Al‐Mandhari et al., 2020; Neto et al., 2020; Rabow et al., 2021). Moreover, the COVID‐19 pandemic may have placed the mental well‐being of nurses at risk (Rabow et al., 2021; Shaw, 2020). Exposure to intense suffering during a pandemic has been associated with increased depression, anxiety, insomnia, and distress. These psychological symptoms may lead to high rates of suicide, workplace violence, increasing burnout levels, high turnover and poor quality of care (Chirico & Leiter, 2022; Chirico, Afolabi, et al., 2021; Chirico, Sacco, & Ferrari, 2021; Magnavita, Chirico, Garbarino, et al., 2021; Magnavita, Chirico, & Sacco, 2021). Furthermore, there remains a risk that the outbreak will create a ‘second pandemic’ of mental health crises in health systems and communities (Choi et al., 2020, p. 340).

Wallace et al. (2020) described the relationship of the COVID‐19 pandemic to anticipatory, disenfranchised and complicated grief for providers. Policies and practices related to social distancing and visitor restrictions in healthcare facilities that have been implemented to mitigate the impact of COVID‐19, along with the direct impact of the spread of COVID‐19, further exacerbate issues of grief that are relevant to health providers. As nurses build both professional–client relationships and personal bonds with their patients, patient deaths can trigger grief experiences (Chen, Chow, & Xu, 2021).

Many frontline nurses have stepped up to serve as the ‘proxy family’ for their patients. For instance, holding the smartphone or tablet up for the dying patient to communicate with their family has placed nurses more directly in the role of surrogate comforter or communicator during times of anticipatory grief. This exposure to intense suffering and loss represents a new and stressful role for the bedside nurse (Rabow et al., 2021). Grief and bereavement experiences of healthcare workers have both short‐term and long‐lasting effects (Chen, Liu, et al., 2021). Nurse leaders must anticipate the effects on nurses working on the frontlines during the pandemic and develop strategies to promote mental wellness and resilience (Choi et al., 2020). Few studies have focused on the grief of nurses working on the frontlines during the COVID‐19 pandemic. Despite this, Chen, Chow, and Xu (2021) found that the bereavement experiences of nurses and physicians in mainland China were influenced by workplace violence against caregivers, traditional Chinese medical ethics, the strong death taboo and inadequacies of the healthcare system. Similarly, there has been a scarcity of research on the mental well‐being and grief of health providers that documents the mental stress, anxiety and moral distress these providers encounter as they work during a pandemic. However, emerging concepts and new learning modes regarding the grief experience have begun to take shape (Chew et al., 2020; Choi et al., 2020; Nagesh & Chakraborty, 2020; Neto et al., 2020; Shaw, 2020). The results of this study will expand our knowledge of the grief experience of nurses working on the frontlines during the COVID‐19 pandemic and have implications for the development of effective support programs for health providers.

For the purpose of this research, grief is defined as a normal, dynamic, unique and multidimensional response to perceived losses. Other key concepts/study variables will be defined herein as well.

3. METHODS

3.1. Design

A mixed methods approach, including the qualitative method of grounded theory and a quantitative 30‐question survey, was used in this study. The purpose of this study was to generate a conceptual definition and theory of grief for nurses working on the frontlines during the COVID‐19 pandemic using grounded theory methodology. The research design consisted primarily of qualitative data collection with a quantitative component. The study was conducted virtually via Zoom focus group sessions. The qualitative method of grounded theory was used to analyse eight recorded virtual focus group interview sessions. The interviews lasted 60–90 min and elicited descriptions of nurses' experiences caring for patients on the frontlines during the COVID‐19 pandemic. The transcribed interviews were examined, and units of meaning were identified in each transcription. Phrases with common meanings were grouped together, in keeping with grounded theory analysis. Immediately following the focus group interviews, the RN Demographic Form and a quantitative self‐report inventory, Track One of the Two‐Track Bereavement Questionnaire (Modified), were completed by the RNs. Descriptive statistics were used to analyse data from the RN Demographic Form. Quantitative examination of data included scoring and evaluation of Track One of the Two‐Track Bereavement Questionnaire (Modified). Those scores were then compared with qualitative findings. Researchers used the Consolidated Criteria for Reporting Qualitative Research checklist to report this study (Appendix S1).

3.2. Ethical aspects

The study was approved by the institutional review board of the university in which registered nurses were enrolled. All registered nurses participated voluntarily and were informed about the study aims and procedures. They provided informed consent and were assured anonymity. Participants were informed of their right to participate and withdraw from the study at any time.

3.3. Data collection

3.3.1. Sample/participants

A sample size of 24 was obtained when saturation occurred during data analysis. Of the participants, 87.5% were female, and 75% were 40 or less years of age. All had a BSN or higher degree. The sample was 79.2% Caucasian. Five of the participants were involved in indirect care of 80 or more deceased patients, and 1 participant administered direct care to over 50 deceased patients. Table 1 provides further details on the demographic characteristics of participants.

TABLE 1.

Demographic characteristics of RN participant

	Total	Percentage
Gender
Female	21	87.5
Male	3	12.5
Average age	34.5
Age range
21–30	11	45.8
31–40	7	29.2
41–50	4	16.7
>50	2	8.3
Education level
BSN	17	70.8
Graduate/professional degree	7	29.2
Race
Asian	1	4.2
Black (African American)	4	16.7
White (Caucasian)	19	79.2
Ethnicity
Not Hispanic/Latino	24	100
Direct care – deceased patients (Avg #)	22
1–20	17	70.8
21–40	2	8.33
41–50	3	12.5
>50	1	4.17
No data available	1	4.17
Indirect care – deceased patients (Avg #)	51
0–20	11	45.8
21–40	3	12.5
41–60	4	16.7
81–100	3	12.5
101–200	1	4.2
201–300	1	4.2
No data available	1	4.2

The protocol for this project was approved by a university for scientific merit and protection of human subjects. Next, purposive sampling was used to select RNs who worked during the COVID‐19 pandemic from a cohort of nurses meeting the following inclusion criteria: worked on the frontlines in acute care with patients diagnosed with COVID‐19 between March and September 2020; worked a minimum of 24 h per week for a minimum of 3 weeks during March 2020 to September 2020; and experienced the death of at least one patient.

Nurses were originally contacted through email by their nurse managers or their Doctor of Nursing Practice program director. Recruitment also occurred through email invitations, social media posts and advertisements on the websites of professional nursing organisations. Emails included an invitation to participate in the study and contact information for the principal investigators. Nurses contacted one of the principal investigators who determined their eligibility and obtained verbal informed consent. Registered nurses were assigned to one of eight potential virtual Zoom focus group sessions.

3.3.2. Focus groups

Approval was obtained from the university Institutional Review Board, and verbal informed consent was received from all participants. Eight virtual Zoom focus group sessions were conducted between October 2020 and February 2021. Each focus group was video‐ and audio‐recorded and lasted 60–90 min. The focus groups were conducted by two nurse scientists (LW, SJ) experienced in qualitative research methods and familiar with direct and indirect nursing care. One of the nurse scientists facilitated the group sessions while the other captured field notes, summarised the sessions and asked the nurse participants at the end of each session to validate the summary. The initial statement, ‘Tell us about your experience caring for patients on the frontlines during the COVID‐19 pandemic’, was used to elicit the nurses' experiences. Probing questions included the following: (1) Can you all speak to your emotional state while going through all of this? (2) Has it been hard to compartmentalise and put work aside? (3) Have you accessed counselling at work or sought support outside of work? (4) What impact have the patient deaths had on you? (5) What effect has your experience had on your relationships? (6) Can you tell us about forums that have provided the opportunity for you to be heard? and (7) Have any of you considered quitting?

3.3.3. Questionnaires

Immediately following the focus group interviews, a 30‐question survey that included the RN Demographic Form and a quantitative self‐report inventory, Track One of the Two‐Track Bereavement Questionnaire (Modified), was emailed to participants who were asked to complete and return it the same day. Upon receipt of the completed survey, participants were sent a $25.00 Target e‐gift card.

RN demographic form

This 10‐item, self‐report survey included a mix of open‐ and closed‐ended questions regarding the participant's age, gender, highest education level, race and ethnicity, country of origin and number of years in the United States. Also, questions on this form inquired about the number of deceased patients for whom direct and indirect care were provided, approximate dates of death experiences, age range of deceased patients and circumstances of the patients' deaths.

Track One of the Two‐Track Bereavement Questionnaire (Modified)

This questionnaire contains 20 self‐report items related to biopsychosocial functioning and traumatic perception of loss rated on 5‐point Likert scales. Nineteen of 20 questions on this instrument included response set choices of: 1. True, 2. Mostly true, 3. Neutral, 4. Mostly false, 5. False and 6. Not applicable. One question used a different response set of choices (i.e. 1. Several times a day, 2. Almost daily, 3. Almost every week, 4. Almost every month, 5. Almost never and 6. Not applicable). The wording on this instrument was minimally modified to adapt questions to address nurses who had experienced loss of their patient(s).

3.4. Data analysis

3.4.1. Qualitative

Data analysis consisted of transcribing the virtual focus group sessions verbatim within 24–48 h after each session, underlining and categorising key phrases or statements, inferring meaning from the categorised data, developing a comprehensive definition of grief and conceptualising a grounded theory of the grief experience of RNs working on the frontlines during the COVID‐19 pandemic. The constant comparative method as described by Glaser and Strauss (1967) and Corbin and Strauss (2015) was used to analyse the data.

A transcription service was used to transcribe the audio‐recorded interviews, which were then uploaded into QDA Miner, a text‐oriented database management computer program that facilitated the creation, storage, analysis and retrieval of data. The transcribed interviews were read thoroughly several times, and conceptual units of meaning were identified and underlined. Common conceptual meanings were grouped to form categories. Categories were defined, and the characteristics of the categories were combined into core concepts that were connected to form a conceptual definition of the grief process.

Sequencing of behaviours was noted between and across participants. Cross comparisons of findings from the focus groups were made and then compared with the literature. After the theoretical sorting, the relationship of the concepts was determined, and the collective relationship of the concepts to the grief process was identified in the framework of the theory. Through constant counteraction with the data, the theory emerged, complete with properties, conditions and strategies.

3.4.2. Quantitative

On Track One of the Two‐Track Bereavement Questionnaire (Modified), a combined overall Grief Score was defined as the average of the 20 questions. The demographic and grief data were described using frequency and percentage or median and interquartile range as appropriate. The associations between grief measurements and age were measured using Spearman's correlation. Wilcoxon rank sum test was used to compare median grief measurements between levels in gender, education and race. The level of significance was set at 0.05. All analyses were performed in R‐4.0.3.

3.4.3. Validity and reliability/rigour

Methodological triangulation, achieved through both qualitative and quantitative methods, was the primary strategy to produce rigour. The research team collected and analysed both qualitative and quantitative data, which allowed for more complete and corroborated results. The data analysis and interpretation used a convergent design that is displayed in Table 2 (Creswell & Plano Clark, 2018). Major core concepts that emerged from the qualitative data analysis were compared with the findings of multiple quantitative self‐report items analysed regarding the frequency, median and interquartile ranges of findings.

TABLE 2.

Comparison of qualitative and quantitative findings

Themes of questions in Track 1 TTBQ (modified)	Core concepts	Median (IQR)
Sense of difficult life (4) Meaning of life has changed (5) Life has changed for the worse (6) Self‐perception (10, 11)	Facing a new reality	2.9 (2.4–3.2)
Confusing feeling and thoughts (7) Self‐perception (10, 11)	Frustrations	2.67 (2–3.42)
Depressed mood (2) Anxious (3) Confusing feeling and thoughts (7) Difficulty functioning (12)	Stress	3 (2.44–3.5)
Health status (1) Adaptive functioning (8, 9) Maladaptive functioning (12) Difficult social interaction (12) Supportive relationships (family) (13) Supportive relationships (others) (15) Spousal support (16) Parental role (17) Values and beliefs (18) Personal coping (19) Need of help (20)	Coping	1.65 (1.54–2.34)

Abbreviations: IQR, median interquartile range; TTBQ, Two‐Track Bereavement Questionnaire.

Trustworthiness was determined by researcher triangulation with two principal qualitative investigators (LW, SJ) who had prolonged engagement with the data and persistent observation through data analyses and interpretation. Participants were assured confidentiality and anonymity. Referential adequacy entailed checking preliminary findings and interpretations against archived ‘raw data’. Finally, member checking was conducted with participants who validated the findings, which facilitated a thick description of the data to be provided. The Consolidated Criteria for Reporting Qualitative Studies (COREQ) checklist was followed for reporting this qualitative research (Appendix S1).

Dependability was determined by having a nurse expert in grounded theory examine the process of the inquiry and determine its acceptability. Data, findings, interpretations and recommendations were examined, and an expert attested that the findings were supported by data and the study was internally coherent.

Confirmability was established by the audit trail as described by Corbin and Strauss (2015). This method was conducted with records such as raw data, data reduction, analysis products, data reconstruction and synthesis products and process notes.

Rubin's Two Track Bereavement Questionnaire was selected to assess registered nurses' grief. The Two‐Track Model of Bereavement Questionnaire (TTBQ) was designed to assess response to loss over time. Track I focuses on the bereaved party's biopsychosocial functioning, while Track II concerns the bereaved party's ongoing relationship with the range of memories, images, thoughts, and feeling states associated with the deceased. This instrument is clinically relevant, provides a methodologically sound approach to grief assessment and demonstrates construct, convergent and concurrent validity and reliability in samples of bereaved individuals who have experienced the personal loss of a family member or significant other (Rubin et al., 2009). With permission from the author, questions in Track 1 were modified to address the bereavement of RNs in relation to patient loss rather than personal loss. In this study, we explored the performance and clinical utility of the modified instrument for assessing the grief difficulties of registered nurses related to the loss of patients. Quantitative data were examined to determine the relationship to the concepts that emerged from qualitative analyses. Accuracy of quantitative findings was independently verified by multiple members of the research team (AF, EM, TM, JD). Although Cronbach's alpha on this adaptation of Track I of the revised Two‐Track Bereavement Questionnaire was low 0.481, previous scientific studies have used .45 as the lower threshold for acceptable or sufficient internal reliability (Taber, 2018).

4. RESULTS

4.1. Qualitative findings

The following four major core concepts emerged from the data: ‘facing a new reality’, ‘frustrations’, ‘stress’ and ‘coping’ (Table 3).

TABLE 3.

Findings of concepts emerging from data and categories

Grief categories	Core concepts
Countless patient deaths Expected patient deaths Unexpected patient deaths Continuous patient deaths (ongoing) Consecutive patient deaths (same shift) Senseless deaths Changing policies Futile care Diverse unknowns Fear of infection	Facing a new reality
Hospital administration ○ Frequent changes Policies Protocols Units ○ Lack of staff ○ Long work shifts ○ Shortage of supplies ○ Lack of respect Diverse unknowns Demands of patient care Futile care Uncertainty about care	Frustrations
Physical ○ No time for bio breaks ○ Fertility issues Emotional ○ Ethical dilemmas Spiritual Social ○ Personal obligations	Stress
Adaptive ○ Meditation ○ Hiking ○ Music ○ Exercise ○ Pen pal ○ Pet adoption ○ Return to school ○ Compartmentalisation ○ Support ○ Counselling Maladaptive ○ Drinking alcohol ○ Overeating ○ Sleeping all the time ○ Online shopping ○ Compartmentalisation ○ Lack of support	Coping

4.2. Facing a new reality

Facing a new reality is defined as becoming aware, confronting, and adjusting to the new reality of the work environment, which in this case included an increased number of continuous and consecutive patient deaths, diverse unknowns regarding effective nursing care and treatment, changing policies and protocols, lack of administrative support and fear of being infected with and exposing others to COVID‐19.

To relieve the frustration and stress caused by this new reality, RNs sought and received support and engaged in coping strategies. The effectiveness of the support received, and coping strategies employed were directly related to the RNs' adjustment to the losses and the new reality. Data validate that in the first few months of the pandemic, many RNs were extremely frustrated and stressed by the new reality, but as the months progressed, they adopted adaptive and maladaptive coping mechanisms, such as compartmentalising their work life and personal life, and they began to adapt to the new reality.

4.3. Frustrations

Frustration is defined as the feeling of being upset or annoyed, especially because of an inability to change or achieve something. Certain factors such as frequent changes in policies, protocols or units; lack of staff; long work shifts; shortage of supplies; and lack of respect triggered frustration with hospital administration. RNs expressed frustration with the demands of patient care and feeling uncertain that the care they were providing was effective, which therefore caused their care to seem futile since no specific treatment protocol was identified as being effective. Participants reported their frustrations in the following comments:

The policies kept changing, what PPE we needed versus what we didn't need. Everything each day was ‘You don't know what you're coming into….’ It's like administration just change things at will. Whatever seems might benefit them, that's what's going to go for the day, and that's frustrating because we live by policy in this profession and with regulations, but it goes out the door when it's not beneficial to them, so that's hard, dealing with that all year long.

So, it's been very frustrating, because at the beginning, they put up all the signs in all the hospital yards, ‘heroes work here’, and people would bring us food and goodie bags and all this stuff, and that was a few months. And then as it kept going, people thought that it was just over, and so I'm like if you really respected us, then you would stay home, you'd wear a mask and follow the guidelines. You wouldn't just be out doing whatever you want.

…deciding which unit is going to be COVID and sticking with it. We've flopped our units probably three, four times.

What makes it harder is a lot of the administration and people like that just … They don't get it. They're still on top of us about taking out Foleys and things like that, and I totally get it, but I'm like we barely have the staff to prone these people twice per shift, you know? Much less turn them and clean them up if they soil the bed and things like that. It's … It's very frustrating.

You have to empty your own trash because housekeepers won't even go in. I'm feeling like it is bad when you have to do your job and 30 other people's job. And it's no point of complaining or asking because you know they're not going to do it. So, when you get through in your room at the end of the day, you know you got to pull your trash, you got to pull everything for the nurses coming on for you, make sure the tray is out the room. Because dietary haven't been in there, housekeeping haven't been in there. The floor is sticky. It's a mess. The needle boxes running over. It's crazy.

You would have to wear an N95 all day. You would only get one gown for the whole shift if the whole hospital was COVID.

It's like, ‘We're not going to come in there. We're going to work from home for the past eight months and make all these big decisions that don't really affect us. It just affects you.’ Then, like I said, you just don't feel like your voice is heard.

You don't know what you're walking into on a day‐to‐day basis. That could be really, super challenging.

4.4. Stress

Stress is defined as the physical, emotional, spiritual, and social turmoil experienced due to numerous frustrations related to a new reality. Physical and emotional stress comprised the largest categories. Data examples of physical stress included the following:

I can't use the restroom at work, literally like two minutes, I cannot go to the bathroom and not have them saying, ‘Hey, there's a phone call coming in for you.’ ‘Hey, your patient wants this.’ ‘Hey, your drip's running dry.’ It's exhausting some days. I'm like, I should just put a Foley in myself so I don't have to take these breaks into the bathroom. And then I can just be out here because they're going to bug me regardless.

The only thing that keeps me going sometimes is drinking my water during my shift, and you're telling me I have to go to the break room to drink water for a couple minutes. When do I have a couple minutes to just drink water? I have to do that throughout the day, and that really, really, really upset me. That I'm not getting dehydrated or sick or headaches because I can't have water.

One of the physical stressors described by a participant included fertility issues. The following data describes her personal experience:

So, we've been trying to have a baby for like two years, and the first year I was like, ‘Okay, sometimes it can take a year,’ but then the second year there's COVID, and now I don't know if the stress of working in the hospital all the time is causing issues with my fertility or if I really have issues.

4.5. Coping

Coping is defined as cognitive, behavioural or psychological strategies that are used by RNs to alleviate stress. Adaptive coping was a category that included activities such as meditation; hiking; listening to music; exercise; pet adoption; returning to school; adopting a pen pal; compartmentalising; and both seeking and providing support to colleagues, family and friends. The RNs sought and received counselling, which they found helpful:

Do you know Katy Perry's song, “Eye of the Tiger”? That's what I listen to every day going to work with my coffee. I'm so sleepy, and so that's how I make it through the day.

I take that in with me each time I come to work, and I always listen to this gospel song. It's by John P. Kee, and it's titled “You Blessed Me,” and inside the song, it say [sic] you blessed me over and over again, and it's true…

The counselling, honestly, I think I was really lucky to find a counsellor that seems to deal with medical professionals a lot. And so she was really helpful about trying to find healthy coping mechanisms, both at home and at work.

…diet and exercise to just keep up healthy coping habits and taking good care of myself as much as I can. And so that's helped me process these emotions and still be able to show up for work in a good mental place, I guess, to be able to hold that space for these people when they come.

So, I just got into something called post crossing where they pair you up with people all over the world and you write and send postcards, and just having that outlet and then actually making pen pals from some of those people that you've sent those cards to. So, I've been writing to people in a bunch of different countries. One pen pal, she's a doctor [from] Germany, and so just talking about their experiences versus our experiences and the differences and similarities has been really a release.

I got a puppy. I adopted him – that really helped me.

I also got back in school for my FNP, so I feel like that's been something new to concentrate on, take my priorities off of just thinking about only my job.

Participants also engaged in maladaptive coping strategies to alleviate stress, including drinking alcohol, overeating, sleeping all the time, and online shopping. Participants recognised compartmentalisation as being both adaptive and maladaptive:

I definitely feel like I drank a lot more. I was almost worried that I might be becoming an alcoholic and because we take care of so many alcoholic patients, you are like, look at the things they're doing and experiencing, and you're like, if I quit drinking, am I going to withdraw? So, I actually just did dry January just to check on myself and see if I wouldn't have withdrawal symptoms, and fortunately I didn't, but that's like, it's not something we should have to worry about, and we shouldn't have those unhealthy coping mechanisms, but we do. I sleep, I pig out, I online shop, and I just try to shut that part of the world out, and then I work my days blocked, so I get four days off, and on the day before I have to go back, I'm just super down, depressed because I know I have to go back to work the next day.

Core concepts were combined into a conceptual definition of grief and a grounded theory of the experience of nurses working on the frontlines during the COVID‐19 pandemic. Facing the new reality led to many frustrations, which in turn led to stress (physical, mental, spiritual, social), causing the participants to mitigate this stress by using coping (adaptive and maladaptive) that influenced the their ability to face their new reality on an ongoing basis. The reality changed over time and became less intense, and many participants became numb to this change, which enabled them to continue in the new reality. The new reality became the ‘new normal’ as they learned to function in a different work environment (Figure 1).

FIGURE 1.

GRIEF model depicting RNs' grief experience during a pandemic.

4.6. Quantitative findings

Demographic characteristics of participants are summarised in Table 1. The majority (87%) of the 24 participants were female, Caucasian (79%), had a bachelor's degree in nursing (100%), and had resided in the United States for a median of 29 years (interquartile range: 26–36 years). There was a significant difference in support according to gender (p = .0129), with females (median 1.33) reporting greater support than that described by men (median 2.33). No significant differences were found in responses based on education, race or years living in the United States.

Findings revealed a median of 2.21, with an interquartile range of 1.87–2.8 for overall grief. The overall grief score was not significantly associated with age, gender, race, education, or years resided in the United States (p > .05). Eleven nurses voiced a need for help following death experiences (question 20). Two participants (8.33%) answered this question as mostly true, and nine participants (37.5%) acknowledged that this was somewhat true. Nineteen of the 24 RNs agreed that the world around them had changed, and 13 RNs reported that their self‐perception had changed.

4.7. Comparison of findings

Comparisons were made between the concepts and categories that emerged from the qualitative data with quantitative self‐report items. Multiple self‐report items reflecting major concepts were analysed regarding the frequency, median and interquartile ranges of findings. The themes of questions were aligned with the four major qualitative concepts (Table 3). The median score for the TTBQ Track I items associated with ‘Facing a New Reality’ was 2.9 on a 1–5 Likert‐type scale, indicating inconsistency with the qualitative findings that showed RNs experienced tremendous difficulty adjusting to the new reality of multiple, consecutive deaths; diverse unknowns related to treatment of patients with COVID‐19; changing policies and protocols; lack of administrative support; and fear of being infected with and exposing others to COVID‐19. Participants described their experiences in the following ways:

We weren't able to treat appropriately. Then just the massive loss of life. You know, I worked for eight plus months and only saw two people actually make it, so that was really hard. We get all these emails from our CEO saying, “Everything's getting better. Everything's calming down,” and then that week, our unit had 10 deaths in one week. Our whole unit cleared out.

I guess a good word would be overwhelming and confusing because, as healthcare providers, we're supposed to know how to fix things and treat things. You're presented something that's very new that, at the beginning, we didn't even know how to treat it correctly. We were doing the protocols and procedures that we thought were correct to treat that, and nobody's getting better. Then, we were getting the medicine that we thought was going to help, and they would get worse. I felt kind of helpless during all of it, I guess, because we didn't have proper protocol.

And we noticed that things were changing very rapidly. The rules within the hospital, the policy was evolving. It was constantly something was being added or changed. So, I agree with that feeling of uncertainty, of not knowing what are we doing? Are we doing the right thing today? Or were we doing something better yesterday, and why something we did earlier all of a sudden makes no sense.

I know this might seem very dramatic, but I felt very betrayed by upper‐level management….I felt like I had to really fight tooth and nail to get an N95 to go into these patients' rooms when it first started. There was so much in the air of appropriate PPE, and you're fine with a simple face mask?! …it was just really traumatic because there was so much unknown.

I was anxious. I was worried about bringing it home to my children. So, I took myself elsewhere to sleep, many occasions separated from my family. That was, that is not what I wanted to be a nurse about. I want to be a nurse to take care of people. I don't want it to adversely affect how I take care of my children.

The TTBQ Track I items associated with ‘Frustrations’ had a median score of 2.67. This finding was also inconsistent with qualitative findings, as participants expressed overwhelming frustration with multiple care‐related aspects including lack of public understanding, changing treatment protocols, changing hospital policies and communication with families. Participants detailed their experiences in multiple instances:

Then, the patients don't really even understand. I discharged a patient on Tuesday who was still COVID positive, and she already had a list of places. She was going to go to Walmart. She was going to go to all these stores and stuff. I was like, ‘But, you're supposed to be quarantining.’ She was like, ‘I don't have time for that.’ She knows what she's supposed to do and won't do it. It's really frustrating.

I've also been really frustrated because people don't really understand, who don't work on the frontlines, what you're doing when you're at work, and how bad your patients are, and how sick, and how fast they can change. They want to have a family get‐together, and you're like, what? No. I'm not doing that. I'm the crazy person for saying no and for putting those boundaries up.

It was frustrating for everybody because, like I said, the doctors are coming in not confident because, first, you're intubating everybody you see cough. Then, it's like, no, we're going [to] shift that perspective. We're not going to do that anymore. We're just going to have everyone on a high‐flow nasal cannula and then wait to the very last second to intubate.

Yeah. I think that was frustrating, is like, things were constantly changing, and this medicine works, this medicine doesn't work. Then, it's like, wait, just kidding, this one doesn't work anymore.

I agree. It's very frustrating with all the policy changes because there's not any kind of memo or anything that says, ‘Hey, we changed this policy.’ It's just when you do something, you're like, ‘No, you shouldn't have done that. We do it this way now.’

I've had families call in with a list that they got off Google, like, ‘Why are you not doing this drug? Why are you not doing this drug?’ Like, you got that off Google.

‘Stress’ was the only major concept with findings that were somewhat consistent with the quantitative results, as indicated by the median score of 3.16 (2.33–3.67) for the TTBQ Track I items associated with this concept. Most participants described feeling highly increased amounts of stress, with one participant describing it this way:

Also, no visitation and having to constantly update family members on the phone. They're not able to see their loved ones and even connect how sick they are. They just kind of have to take your word for it, so that part is just kind of an added stress of ‘Okay. I'm trying to take care of these people,’ and they're continuously dying, and we don't know what to do to fix it or how to help them. Then, the added stress of I have to tell their family members like, ‘Okay. We just lost them.’ They haven't … They walked into the hospital just really short of breath, and they were fine, and they were lucid. That was a really hard struggle for me.

A second participant stated,

So I feel extra stressed. Like I know that, I mean, our numbers are already going up. We had five codes in the COVID unit on Tuesday, and it was just bam, bam, bam, bam. It's just, these people are just so sick….

Another participant described her stress this way:

For me, it's been really stressful because I'm taking care of super sick people who can't see their family. Then, I'm very worried about taking it home to my family. It just like puts the stress on 100.

Participants' quantitative ‘coping’ score had a lower median of 1.67 for the associated TTBQ Track I items, reflecting an overall positive report of coping methods, which was incongruent with the qualitative findings. While some participants reported having adaptive coping mechanisms, most participants reported maladaptive coping techniques including increased use of alcohol, excessive sleeping, and weight gain:

What I've seen is that when we do go to breakfast after work, there's a large amount of alcohol that tends to be involved, and I think that's become a real issue with a lot of nursing staff. I've been using more alcohol than I did in the past since COVID started as well. You didn't have time for meditation or exercise or all the good things that would have helped you. You had time to pour a glass of wine on your way to the couch where you fell asleep. My husband would have to take it out of my hand before I dropped it. It was … there was no time to have good healthy habits.

That's all I did. I'd wake up. I'd fall asleep back on the couch. I'd eat dinner, I'd fall asleep back on the couch. I was just asleep constantly.

I've probably gained 15 pounds over the course of the past year. And I feel like I'm also trying to handle all of this by eating more too, it works. It's like, okay, I'm gonna go eat a snack before I go do this. It's very odd, but that's how I feel like I'm coping with the day‐to‐day craziness of work.

5. DISCUSSION

The present study explored the grief experience of nurses working on the frontlines during the COVID‐19 pandemic. Our findings suggest that RNs are facing similar experiences as they navigate the challenges of working on the frontlines in this worldwide crisis. McCallum et al. (2021) stated that nurses may experience long‐term complicated grief once the pandemic has ended. At the time of this study, nurses are and have been witnessing death in unprecedented numbers as well as facing multiple physical, social, emotional and mental challenges. Thus, results of this research suggest that RNs are currently experiencing complicated grief.

Based on our qualitative data, we identified four major concepts encompassing the grief experience: facing a new reality, frustrations, stress and coping. Facing a new reality is defined as becoming aware, confronting and adjusting to the new reality of the work environment. Consistent with other research, we found that the pandemic has brought about numerous challenges related to patient deaths, treatment unknowns, everchanging policies and protocols, lack of support from administration and fear of viral infection (Ali et al., 2020; Al‐Mandhari et al., 2020; Neto et al., 2020; Rabow et al., 2021). While nurses often experience death in their professional settings, the increased rate at which patients are dying and the excessive number of deaths associated with the pandemic pose an unusual level of psychological trauma for these RNs. Studies indicate that nurses are not only coping with anticipated deaths, but they are also coping with unanticipated deaths of much younger patient populations. Consistent with the literature, we also found that they are coping with the deaths of colleagues, which presents additional emotional ramifications including fear of succumbing themselves and exposing their loved ones to the virus (McCallum et al., 2021; Wallace et al., 2020).

Nurses are accustomed to providing effective treatment to patients and being a part of their journey to recovery. Playing an integral role in this healing process is an essential part of being an RN. However, treatment of patients hospitalised with the COVID‐19 virus has been fortuitous at best, leaving nurses feeling that their care is futile. The frustration and stress experienced because of continuously changing treatment protocols, which rarely result in healing outcomes, has caused feelings of dejection. Moreover, the unexpected and continuously changing policies and feelings of abandonment by hospital administration further contribute to their grief experiences.

The concepts of frustrations and stress were pervasive throughout each of the focus group sessions. We define frustration as the feeling of being upset or annoyed, especially because of the inability to change or achieve something. Stress is defined as the physical, emotional, spiritual and social turmoil experienced due to the numerous frustrations related to the new reality. To mitigate the emotional and psychological effects of the frustrations and stress related to their new reality, RNs developed various coping mechanisms that were both adaptive and maladaptive. Individual personality characteristics and life circumstances influence the impact of negative experiences and the deleterious effects of stress. Resilience and optimism are characteristics that influence perspective and affect psychological well‐being (Conversano et al., 2010; Ervasti et al., 2019). Thus, despite the difficulties associated with being a frontline worker in a pandemic, some nurses use positive coping strategies including adopting a pet, exercising, and becoming a pen pal to international colleagues undergoing similar challenges. Alternatively, some participants indicated that they use maladaptive coping techniques such as increased alcohol use, excessive sleep and increased spending.

6. CONCLUSION

Nursing educators must provide education related to self‐care, resilience and grief management strategies. Similarly, nursing curricula need to include comprehensive information related to work‐related grief. Healthcare systems also must develop interventions to help nurses prepare for loss and support them in their grief over the deaths of patients and co‐workers from COVID‐19. Healthcare systems should provide opportunities for RNs on the frontlines to take a brief and simple pause after hearing about or witnessing a patient's death to mourn the loss. Regular debriefing sessions for RNs to reflect on their experiences caring for individuals diagnosed with COVID‐19 and their death experiences may assist the RNs in processing their grief. Strategies to support RNs through their grief include recognising losses and expressing grief privately and publicly. Remote memorial services and support groups may also be helpful. Journaling, meditation, relaxation techniques, accessing podcasts and watching short videos focused on reducing stress may all be helpful in mitigating stress. Study results highlighted the need for open communication between administrators and RNs working on the frontlines so that RNs have opportunities to voice their needs and let leaders know about the issues that cause distress in the practice setting. Healthcare systems need to accept the responsibility of investing in grief support resources and offer protected time for RNs to access convenient psychological support and counselling.

Development of instruments that measure nurses' responses to traumatic events and professional bereavement is needed. Investigating the grief experiences of nurses working in other healthcare and community settings such as palliative and hospice care, and long‐term care is important for a more comprehensive understanding of the grief experience of RNs. Further research is also needed regarding the availability and effectiveness of resources provided by healthcare systems for RNs experiencing grief. Studies should be designed to examine cultural and systemic factors of the grief experience. Comparisons of the grief experience of RNs and other healthcare workers in different countries may enhance understanding of the professional grief experience.

RELEVANCE TO CLINICAL PRACTICE

The results of this study expanded our knowledge of the grief process of nurses working on the frontlines during the COVID‐19 pandemic and have implications for the development of effective support and grief intervention strategies. With the scope and unpredictability of the COVID‐19 pandemic, we must acknowledge that the frustrations, stress and grief of RNs may lead to a mental health crisis. While no one can definitively predict what it takes for RNs to effectively mourn the loss of countless patients, it is vital to try to prevent or mitigate the psychological distress and trauma associated with deaths caused by the pandemic. Through recognising the risks of unresolved grief, healthcare systems have an opportunity to promote resiliency and resources to address the individual and professional grief of RNs working on the frontlines during the COVID‐19 pandemic.

Implementation of occupational safety precautions is critical in preventing long‐term disability of workers affected by COVID‐19. Policymakers and occupational health stakeholders should promote occupational health surveillance and risk assessment to address challenges in the workplace. Health promotion and prevention programs that include resilience training, self‐care and social support are critical for early diagnosis and prevention of burnout and PTSD. Public health officials should ensure the continuity of spiritual and religious activities as well as social support for patients and their families during the pandemic and provide training for registered nurses on this topic (Chirico, 2021; Chirico, Afolabi, et al., 2021; Chirico & Sacco, 2022; Chirico, Sacco, & Ferrari, 2021).

FUNDING INFORMATION

This study was financially supported by a university research fellowship award.

CONFLICT OF INTEREST

The authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Supporting information

Appendix S1.

Williams, L. A. , Accardo, D. , Dolgoff, J. , Farrell, A. , McClinton, T. , Murray, E. , & Jacob, S. R. (2022). A mixed methods study: The grief experience of registered nurses working on the frontlines during the COVID‐19 pandemic. Journal of Clinical Nursing, 00, 1–13. 10.1111/jocn.16579

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available upon request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions, and allowances on public data sharing were not included in the informed consent procedures for our participants.