The experiences of pediatric nurses deployed to adult COVID-19 wards

Abstract

Background

The coronavirus pandemic created an unprecedented deployment of health professionals. The objective of this study was to describe the experiences of pediatric nurses transferred to adult COVID-19 wards during the first wave of the pandemic.

Methods

We performed a qualitative study using a phenomenological approach. Nurses were recruited on a voluntary basis. All participants moved from a pediatric ward and were redeployed to an adult COVID-19 ward in another hospital. Interviews were carried out face to face in line with social-distancing guidelines. We used a script of open-end questions. The interviews were recorded and transcribed in full and qualitative data were analyzed using NVivo software.

Results and Conclusions

In total, 23 nurses were interviewed. Our analysis revealed positive and negative experiences given the different types of support the nurses received, individual attitudes that promoted resilience in a crisis situation, ethical conflicts linked to end-of-life care, and their perspectives on the next wave of the pandemic. The main difficulties encountered by the transferred nurses were related to their working conditions and safety, communication about working practices, and end-of-life patient care. In most cases, the individual resilience strategies put in place and the different forms of social support enabled them to cope with stress and maintain their commitment. However, some interviewees would have benefited from improved managerial support. For all participants, their perception of this support and the benefits of their experience influenced their willingness to be transferred to an adult ward again during a future wave of the pandemic.

1. Introduction

The coronavirus pandemic in 2020 created numerous healthcare challenges and required an unprecedented deployment of health professionals. Healthcare organizations and staff had to restructure and search for new ways of working on an almost daily basis in order to deal with the rapidly increasing number of patients with complex care needs against the background of shortages in both staff and equipment [1]. In France, non-urgent hospital care was suspended from March 12, 2020, which considerably decreased hospital activity and meant that intensive care capacity could be doubled [2]. To avoid having some wards staffed entirely by specialists and other wards staffed entirely by non-specialists, it was necessary to quickly train healthcare professionals and construct teams that included professionals both from intensive care units and from non-specialized wards [3].

Acute geriatric units were also severely affected and were required to restructure and call on professionals from other specialties for support. Pediatric hospitals wanting to participate in the collective effort and support the wards most affected by the influx of adult patients with COVID-19 had two different approaches: Some hospitals admitted adult COVID patients to pediatric wards, while others redeployed pediatric staff to adult COVID-19 wards [4,5].

Our research concerned a pediatric hospital that took the second approach. Many pediatric nurses were able to play a key role in the treatment of adults with COVID-19 by volunteering to work in critical care units and geriatric wards. Organizational changes during crises have been shown to have a significant impact on workers' personal lives and physical and psychological well-being, with studies reporting an increase in the prevalence and severity of depression, anxiety, and insomnia in health professionals experiencing this kind of disruption [6,7]. A recent study of nurses involved in treating patients with COVID-19 revealed that negative emotions such as fear, anxiety, and concern were present from an early stage [8]. The characteristics of this pandemic (such as the rapid spreading, lack of information about the virus, severity of the disease, and death of healthcare professionals) and the procedural changes that dominated its management both also contributed to the general atmosphere of anxiety.

Resilience, flexibility, and creativity became the watchwords for frontline health workers [9], whose ability to adapt was a major factor in ensuring the safety of the protocols put in place and the continuity of patient care. However, the rapid onset of the pandemic meant that these professionals were not always provided with adequate support when faced with organizational changes. For pediatric nurses, this was aggravated by the fact that their training was not immediately applicable to the adult or geriatric COVID-19 wards.

Recently published qualitative studies are now allowing us to understand the psychological impact of the pandemic [10], particularly in terms of stress and resilience and in relation to the paradoxical situations that frontline nurses were confronted with during this period [11,12]. The experiences of a pediatric hospital that created an intensive care unit (ICU) for adults with COVID-19 in a pediatric postsurgical ward during the COVID crisis demonstrate that the healthcare professionals' knowledge and experience outweighed their lack of familiarity with the medical specificities of caring for adults. However, no French research has yet been published regarding the effect of this kind of mobilization on the experience of pediatric nurses. In our study, pediatric nurses were often reassigned to new teams in unfamiliar hospital settings, including extremely technical wards such as high-dependency units and ICUs. They were often required to care for adults or older people, who sometimes also had cognitive dysfunction. The nurses were also confronted with situations they were ill-prepared for, such as high fatality rates and ethical questions related to decision-making. Additionally, alongside a heavy workload, difficult practical conditions, and traumatic situations, they also had to overcome the fear of contracting the disease or infecting their loved ones [13].

We used Hurssel's descriptive phenomenological method [14] to gain insight into the professionals’ individual experiences of this situation. This approach assesses the person's “phenomenal field,” in other words their overall experience and subjective reality [15], which could allow us to better prepare for future epidemics and pandemics, particularly in terms of their human and organizational impact. The aim of this study was to describe the lived experience of pediatric nurses during their deployment to adult wards during the COVID-19 crisis, in order to identify the cognitive and adaptive mechanisms that were mobilized and the organizational factors that influenced these mechanisms.

2. Materials and methods

2.1. Cohort and recruitment

We performed a qualitative study using a phenomenological approach. The COREQ guidelines checklist was used to report this study. We recruited pediatric nurses who were transferred to the adult ward of another hospital during the first wave of the COVID-19 pandemic in France between April and June 2020.

The participants were selected based on the following criteria related to their location and profession: nurses qualified for more than 1 year, practicing in pediatrics, assigned to adults on acute geriatric wards, high-dependency units, or ICUs, for a minimum duration of 1 month during the COVID-19 pandemic, regardless of the working hours.

These criteria allowed us to recruit a sufficiently homogeneous population while maintaining a variety of experiences and personalities, making it possible to identify the common threads arising from the participants’ diverse experiences.

All individuals who were eligible for the study and willing to participate received an email with written information and an informed consent form for the study, which they completed in advance of the interview. Participants could withdraw their consent at any point. In the event that a participant was overcome with emotion during the interview, we proposed a suitable psychological intervention to prevent secondary psychological damage (Table 1 ).

Table 1.

Study characteristics (N = 23).

Profession	Pediatric nurse (N = 15)
	Pediatric nurse practitioner*(N = 8)
Age (years)	22–51 (mean: 30)
Sex	23 women
Ward assigned to	ICU, HDU (N = 12)
	Acute geriatrics (N = 11)

^⁎Pediatric nurse practitioner is an approximate equivalent for the French puéricultrice, which is an advanced specialism of nursing focused on children and families.

ICU: intensive care unit; HDU: high-dependency Unit.

2.2. Data collection

Data were collected by three researchers who were healthcare managers practicing in the same pediatric hospital but who had not been involved in managing the study participants. Data concerning the participants’ experiences were collected upon their return to their original ward. The main data coding was carried out by a researcher who did not participate in the data collection; however, a systematic verification of the coding was carried out collectively by all the researchers.

All interviews were conducted using the same script, made up of open-end questions. Data collection was performed between May and September 2020, soon after the first wave of the COVID-19 pandemic in France. The face-to-face individual interviews took place in a private room at the professionals’ workplace. With the participants’ agreement, all interviews were recorded and then transcribed in full and anonymized. The interviews lasted an average of 43 min (1008 mins/23 interviews). Interviewers were careful to maintain a neutral position that was empathetic and respectful of the participants’ subjectivity. We used the communication techniques described by Carl Rogers, such as unconditional acceptance, active listening, and reformulation, to promote authentic communication. The recordings and transcripts of the interviews allowed all researchers to access the entirety of the data and collaborate effectively throughout the analysis, while remaining faithful to the participants’ accounts.

2.3. Thematic content analysis

We transcribed the interviews and collated the data into a corpus, which was then condensed. We classified the data into themes and sub-themes, and then coded them using the NVivo software. During the interviews, reformulation was constantly used by the researchers to ensure that the lived experience expressed by the participants was well understood. Special care was given to the lived experience that affected the participants by thoroughly analyzing the applied thematic content.

3. Results

In total, 43 health professionals were initially approached and 11 refused to participate in the study. Of the 32 people interviewed, 9 were excluded because they did not match the inclusion criteria. There were no interviewees who refused to participate and/or withdrew their consent during the study period. Our cohort was, therefore, made up of 15 nurses and eight nurse practitioners and were all recruited at a pediatric hospital in Paris. It may be worth noting that reaching data saturation allowed us to stop the interviews with the 23rd participant. The interviews lasted 30–75 min (mean: 43 mins). The interviews were conducted by three of the authors, who were all female. Their professional activity at the time of the survey was as follows: (a) FD, senior health executive; (ii) VJL, midwife, and (c) HA, senior health manager. FD and VJL both already had trained experience in conducting interviews and published research. FD had previously worked as a design engineer in a nursing research department at the Ecole des Hautes Etudes de Santé Publique (EHESP) and VJL is a professor of public health for midwifery students at the Faculty of Medicine. All authors were accompanied by a research professional, DD, who has experience of more than 20 years in Montreal, Canada. He provided expertise in the processing and analysis of qualitative/mixed data and had past experience in collaborating with a large number of academic, public, and governmental bodies in the French-speaking world.

3.1. Themes

We identified four main themes: perceptions and expectations of support, resilience to stress, ethical conflicts, and feelings about future waves of the pandemic (Fig. 1 ).

Fig. 1.

The four main themes that pediatric nurses experienced during their deployment to adult COVID-19 wards.

3.2. Perceptions and expectations of support

3.2.1. Managerial support

Our analysis showed that the nurses were particularly sensitive to demonstrations of support from their professional and social circles, and, to a lesser extent, from their loved ones. From the professional side, the attitude of the management toward the participants provoked positive or negative emotions depending on whether or not they felt supported. Regular phone calls from their line manager during their redeployment, the communication of information about workplace organization, and explicit thanks were all seen as particularly supportive in this context.

• -“Our line managers were very present throughout, very, very present throughout. They phoned us at the beginning of our shift in the evening and sent us texts, so we felt supported.”
• -“She [the line manager] showed us the procedures, she showed us the websites on the computer, she was really available and stayed late in the evening. She stayed for the night shift nurses too. So that was a really positive thing. She was really supportive…”

However, not all participants felt they had been adequately supported: The lack of information about shift scheduling, the length of their deployment, and where they were being transferred to contributed to their feeling of losing their bearings. For some of the participants, the lack of a manager when they arrived in the ward meant that they felt unwelcome and unsupported.

• -“I didn't feel this support, which was a negative for me.”
• -“In the end, what was really difficult was the lack of information, because we'd been sent somewhere without ever knowing why we'd been sent there, for how long or when we'd be back.”

The participants also felt that when management did not remember their names or give them positive feedback, it showed a lack of interest. In some cases, this feeling led the participants to doubt the usefulness of their work.

• -“After a month, [management] didn't know who we were or where we were from…”
• -“They never said anything! It would have been good to know whether what we did was any good. If they were pleased with our work…”

“So, we were, like, ‘What are we doing here?’ ‘Why did they tell us to come here?’”

The nurses experienced very different working conditions depending on where they were deployed, which sometimes led them to question the effectiveness of management. Some of the nurses sent to ICUs that were particularly well staffed felt that there was a disconnect between the chaos that they had anticipated and the reality of their experience. In acute geriatrics, the lack of equipment and personnel was sometimes experienced as putting staff in danger, and provoked feelings of discontentment toward management. It also led some participants to question their commitment or their willingness to maintain their commitment. Within the ICU, the following was stated:

• -“We never really lacked protective equipment, there were lots of staff: sometimes there were 15 nurses for seven or eight patients.”
• -“I set off expecting it to be like a war zone…but it wasn't at all. So yeah, sometimes I wondered whether I really needed to be there.”

In acute geriatrics, the following statements were made:

• -“We also didn't have enough equipment! That was really what put us in danger as healthcare workers…”

“We didn't even have any gloves left, we only had one pair of gloves to use for all the patients’ personal care in the morning. We didn't have any scrubs — we had to fight to have scrubs for the day, it was the same thing with our masks, we had nothing!”

3.2.2. Peer support: a community based on common experience

The majority of the study participants felt that their integration into their new team was helped by collectively experiencing something new. The shared experience created bonding within the teams and meant that the nurses felt reassured and supported by their peers, which allowed them to have a better experience. In some cases, the pandemic had a leveling effect in terms of the hierarchy, which enabled greater openness, and made it easier to discuss changes in working practices.

• -“The fact that we were living through the same thing, that created bonds with people I wouldn't have got to know otherwise…”
• -“It was good for them [interns], and us too, because we felt like we were on the same level as them, and we could talk to them and explain, ‘Well we do things like this…so when you give us instructions like this it makes our job more difficult’… and I think that made us all rethink the way we do things, which is good.”

Peer support was often found through informal shared experiences. However, the majority of participants also expected formal support from their hierarchy: to be able to share their feelings and experiences in a group setting and to feel heard as an individual:

• -“But it's true that other than discussions in the corridors, we never had an official time all together to talk about how we were finding it, or even just how we were feeling.”
• -“It's also good to be heard by people higher up in the hierarchy, who had a different experience because they had a different job. We felt like we were considered as individuals.”

3.2.3. Support from patients and the general public

Thanks, respect, and attention from patients and their families, as well as from the general public, were cited as being key factors in nurses feeling recognized during this period. This recognition helped to maintain the participants’ motivation and gave them a sense of purpose, even though the working conditions were sometimes considered as being more important.

• -“Yes, because it made me think maybe I'm not just doing this for no reason. Even though we're trained for this job and we love it, I think that having that recognition is motivating because it can be a difficult job.”
• -“But we don't work to get a ‘thank you.’ We just want to have the right equipment and to be able to do our jobs properly.”

3.3. Reactions to stress

3.3.1. Facing the unknown

All participants felt stress and anxiety in the days leading up to their transfer. For the majority, this was dominated by fear of the unknown or doubting their own abilities in terms of treating adults with COVID-19.

• -“I wondered if I would be able to manage a ward like that on my own without knowing how it worked.”
• -“It was really stressful because you just arrive with what you know how to do… it really makes you lose your bearings.”

Although the majority of the nurses adapted to their new working environment, some found that they felt recurrent stress when faced with the unknown, or that their fatigue persisted even when they had returned to their original role.

• -“In our job, we have to be flexible. So, after a while we understood the working environment better, as well as the patient care and monitoring. So yeah, we were less stressed towards the end!”
• -“During the day, I couldn't get to sleep. My mind was racing, I couldn't stop thinking about patient care, treatments, or even whether the patient would still be there the next day.”

3.3.2. Having a positive attitude

For some of the participants, accepting the situation, enjoying the work, and forcing themselves to stay positive allowed them to reduce the stress related to the pandemic.

• -“I tried to stay positive and focus on all the positives I could take from it.”
• -“When you're faced with COVID and the whole situation, at a certain point you have to stop stressing, step back a bit and accept it.”

3.3.3. Knowledge sharing

Some nurses transferred to geriatric wards found it difficult to adapt to the rhythm of care, and felt that patient management sometimes bordered on malpractice. They struggled to provide the same quality of care that they were used to in pediatrics, especially in terms of the human and relational aspects.

• -“It wasn't easy to go from pediatrics to geriatrics because geriatric care in France is not ideal. Some things felt like a production line, and that really bothered me.”
• -“I really didn't like the way patients were treated, I felt like it was bordering on abuse.”

The nurses sometimes tried to work in the same way as they had in pediatrics.

• -“I tried to adapt, but we also tried to do things our way a bit, which is maybe a bit ‘pediatric,’ but it's also very human.”

3.3.4. The reassurance of routine

Getting used to the way things worked and implementing routines allowed the majority of nurses to deal with this stress and to adapt to the organizational changes after a few days of settling in.

• -“They explained things to me and I just followed little by little. I found my bearings and my way of doing things, I got to know how the ward worked and I adapted to it and to the patients, who are just different to my usual patients.”
• -“I knew what I was going to do in my day, I didn't know what state my patients would be in, but I knew how to care for them, I knew the treatments and the side effects, I knew how to use the technology, I knew my colleagues… it wasn't as stressful.”

3.4. Benefits experienced

For the majority of the professionals we interviewed, their transfer to a COVID ward was a formative experience that showed them what they were capable of, strengthened their ability to adapt, and improved their self-confidence or sense of competence. Some nurses were proud of having participated in the collective effort.

• -“It really helped me to be more flexible.”
• -“I think that's where you realize you can take care of any patient, no matter how old or what condition they have… that was a good experience.”
• -“I can say that I was one of the people who helped during the crisis. And I'm quite proud of myself professionally.”

However, some participants felt an ongoing disconnect, which made things complicated in terms of their relationship with their loved ones, and when they returned to their original role.

• -“I really felt like I was living in a completely different reality to other people, to my family.”
• -“It was hard to go back because there was a distance between us and our colleagues. On one hand, they wanted to know how it had gone, but we felt, like, ‘If you haven't experienced it, you can't understand it’.”

3.5. Ethical conflicts and the values of nursing

The participants we interviewed stated that they had experienced some emotionally difficult situations, with ethical questions for which they were ill prepared. These situations included the lack of alternative treatments due to age, decisions about withholding or withdrawing life-sustaining treatment (WWLST), informing patients of these decisions, the isolation of dying patients, and dealing with the bodies of the deceased patients.

3.5.1. Lack of alternative treatments

Some nurses who were transferred to geriatric wards were shocked by the lack of pain relief or alternative treatments to offer to some of the older patients with COVID-19, and they felt that it should have been possible to be flexible with the age criteria.

• -“We very quickly understood that we were doing nothing. That was really brutal. I realized that I was participating in… I'm going to try not to cry… that I was participating in a genocide, in the sense that I didn't have what I needed to treat people, no morphine, not enough oxygen.”
• -“What really made me angry was that they said there was nothing we could do for these people! It's like we were letting them die. I thought to myself, ‘No, this isn't right!’ Even if these people are elderly, in my opinion [the doctors] could have treated them anyway.”

They also thought that death was not inevitable and took hope from older patients who improved spontaneously.

• -“I had a 101-year-old grandmother who came out of hospital and survived COVID, and that made me think, ‘It's ok, they're actually not all going to die.”

3.5.2. WWLST decisions

The majority of the nurses we interviewed had not been involved in making WWLST decisions. Because of this, they sometimes struggled to understand why certain decisions had been made.

• -“The doctors came to those decisions between themselves… I was never asked to participate in making that kind of decision.”
• -“Some patients’ treatment was stopped earlier than other patients. We didn't know why.”

In some cases, continuing patient care was also difficult to understand and led to participants losing a sense of meaning.

• -“I just know that we continued treatment, which didn't make sense to me. I couldn't see a way she could recover!”

  “In the end, we maybe could have let her go peacefully, with dignity, and that annoyed me because I didn't see the point of carrying on her treatment instead of doing things properly and supporting her towards the end of her life.”

However, when WWLST decisions were made collectively, they were easier for the professionals to accept and implement. The involvement of the team in these decisions allowed the nurses to feel heard and led to a consensus decision. Their participation meant that some protocols became less important, and new criteria such as comfort and quality of life were considered.

• -“We were able to say our bit, and because there were regular meetings we could say what we thought, and they listened to us.”
• -“We generally wanted to move away from the protocol about respiratory rate and focus more on the patient's comfort. We talked to the geriatricians, who agreed with us in the end about the fact that we shouldn't focus so much on this protocol and that we should think about the wider context.”

3.5.3. Informing patients about WWLST

Nurses who were involved in informing patients of WWLST decisions were marked by how these conversations took place in some wards. Overcrowding meant that there was a lack of privacy and confidentiality, and this, combined with the lack of time to discuss the decision with the patient, complicated the treatment and led to the staff feeling powerless. It also increased the anxiety of patients in the same room who were able to hear the conversations.

• -“Sometimes the conversations about withdrawing treatment happened just behind a screen, and all the other patients could hear! It was a really difficult situation, especially in terms of patient privacy.”
• -“It was in the ward, between two screens. So, the patient in the next bed was crying because he thought the same thing would happen to him. They were the same age!”

3.5.4. Loneliness in the face of death

The participants had some difficulties with end-of-life care, mainly related to their lack of experience and the patients’ isolation. The nurses felt frustrated that they were unable to care for patients in a way they considered acceptable. Some participants reported that they provided a high level of emotional support for patients in an attempt to make the end of their life more bearable.

• -“I left at 11 p.m. on that day, it was a long day, but the patient knew that she was going to die alone because she didn't have any family. They didn't really need a nurse to transfer her, but I went anyway because it didn't feel right to leave her alone.”
• -“It was frustrating because her family couldn't visit her, and we just cleaned her face and her privates and put her in a body bag… that was really hard, especially when it's the first time, and they told me she couldn't see her family and she'd been put in a body bag and taken to the morgue, and we put a new patient in her bed the next day…”

3.5.5. Dealing with the bodies of deceased patients

Some of the participants who witnessed the high mortality rate were uncomfortable with how the bodies of dead patients were dealt with. Wrapping the corpses in plastic body bags, their rapid transfer to the mortuary, rushed organ retrieval, and the lack of space in the morgue were all raised as contributing to a lack of dignity at the end of the patient's life.

• -“We had at least one death every day of that month. It was really hard for the team. It was the assistant nurses who took the bodies down to the mortuary. I remember one assistant nurse who didn't want to go down there anymore because the bodies were piling up and she came back up to the ward crying.”
• -“She hadn't even been dead for an hour and they came to retrieve her organs, put her in a bag, and she was gone. I felt like that was pretty inhumane, and I wasn't the only one who felt like that. In general, none of the paramedical staff were ok with what was going on.”

3.6. Looking toward another wave

3.6.1. Conditional commitment

The study participants spontaneously raised the subject of their transfer in the case of a second wave. They held a variety of positions on the subject. Of those who were prepared to be transferred again, some cited the prioritization of their professional commitment over their own wishes; others cited the value of the experience.

• -“It was a valuable professional experience despite the stress and the fear. Personally, I'd be willing to do it again if there was a second wave, I hope there isn't, but I'm ready to take it on!”
• -“In this job, there's always the risk of being in emergency measures! I said to myself, in any case, if I have to do it, I have to do it.”

Some nurses felt that the experience they acquired during the first wave meant that it would make sense for them to be transferred again if there were to be a second wave. However, they also expressed some reservations.

• -“I worked with the COVID protocol, whereas other wards never even saw the protocols. So, I have that experience at least, and it would be a shame not to use it in the future if it's needed.”
• -“I would like to go back but…it would have to be different.”

Other participants had stronger opinions one way or the other. The feeling of having given a lot without receiving the same in return, or not feeling sufficiently protected, meant that some nurses had reservations about returning to the COVID wards, without completely ruling out the possibility in the event of a second wave. Similarly, these nurses laid out certain conditions.

• -“I would definitely go back, because we have to do what we can to help, and I think we do this job to think about others before ourselves [laughs]. But I think I would try to take a bit of a step back.”
• -“Maybe we'd be less gullible… we gave a piece of ourselves to go and work in conditions that were, let's be honest, close to zero in terms of safety.”

Of those who refused categorically, some explained their position by a persistent fear of doing the wrong thing and being confronted with the death of patients again. Other nurses cited the problems related to their payment.

• -“We're always afraid of doing the wrong thing, of making mistakes. I didn't feel like I was ready to deal with deaths. If they asked me to go back today I would say so because I just couldn't.”
• -“I lost the equivalent of 55 h of work, even though I was working through the crisis, and I lived through things that people here didn't. That was actually the biggest trauma of my transfer.”

4. Discussion

This phenomenological study explored the unique experience of pediatric nurses who were deployed to the frontline in adult wards during the first wave of the COVID-19 pandemic. Four main themes emerged: (1) perceptions and expectations in terms of support, (2) resilience to stress, (3) ethical conflicts related to end-of-life care, and (4) feelings about a future wave of the pandemic.

Being transferred to the frontline exposed the professionals to a significant amount of stress and required a high level of resilience. In this context, the nurses we interviewed had high expectations of managerial support in terms of emotional support, institutional support, and information. Their accounts revealed that those who felt supported had a more positive experience, and that when support was felt to be insufficient or nonexistent, this had a negative impact. In both cases, the perceived support affected the professionals’ commitment and/or motivation, including their willingness to be transferred again for a second wave. This observation supports Blau's social exchange theory (2007), which emphasizes that, “workers willingly participate in mutual behaviors towards (and to the benefit of) their employer, when they feel that the latter contributes in a significant way to the quality of their working environment, but, equally, when the employer recognizes the efforts workers” [16].

Nurses also highlighted the importance of support from their peers in helping them adapt to their new environment and work safely. This kind of support seems to have created good conditions for mutual learning and reconsideration of professional practices. The solidarity built between professionals from different backgrounds also allowed the nurses who were transferred to feel a sense of belonging despite their lack of knowledge of the particular working environment. Additionally, recognition from patients and society as a whole seems to have reinforced the participants’ sense of purpose.

These observations lead us to consider multiple dimensions of support as being integral to protection against stress, but also to engaging and teaching professionals in crisis periods. They also shed light on the role of management and managerial practices in supporting professionals. Although stress may seem like a natural and inevitable response in a crisis situation, the deployment of pediatric nurses to adult wards does not seem to have been a particular difficulty for our study participants, nor does the fact of treating patients with COVID-19. The nurses’ foundational professional training seems to have allowed them to build up enough experience with adults to deal with this situation. The complementary training that was offered also helped to ensure safe practices. It also seems that implementing routines, learning the working practices specific to the ward, and adopting a positive outlook were important factors in adapting to organizational changes and achieving emotional security.

However, being faced with death and ethical questions related to end-of-life care was particularly difficult for the participants in our study. Not understanding certain decisions, poor end-of-life conditions for some patients, and the way the bodies of deceased patients were treated challenged their professional values and raised ethical questions for which they were ill prepared. The ethical conflicts generated by these situations require a higher level of support, particularly because it has been shown that a positive ethical climate and the degree of ethical stress have an effect on nurses’ satisfaction at work and on their intention to leave their job [17].

Our study also showed that involving nurses in WWLST decisions was essential for their commitment to the patient treatment plan and to better consider the patients’ comfort and quality of end of life. Our findings are in line with the recommendations of the French National Ethics Committee, which advises the implementation of a collective and interdisciplinary decision-making process based on explicit and justified criteria, but also the provision of support to teams who are confronted with ethical dilemmas, such as decisions about which patients to prioritize [18].

A sense of professional responsibility and solidarity was one of the key motivating factors in professionals putting themselves forward for transfer and overcoming the fear of being put in challenging situations. It was also a determining factor in their willingness to participate in future crisis situations. The principle of “professional dedication” was highlighted by the media, but it was not the full picture, with one study [19] reporting that some institutional factors provide a better explanation for the mutual help we observed than the “dedication” the media focused on. This is also in line with the more hesitant approach of some of the participants in our study. As such, improvement of initial integration, emotional and organizational support, better equipment, financial recognition, and greater involvement of professionals in decision-making seem necessary for the willing participation of the greatest possible number of people in crisis situations.

This study highlights the importance of the role of managers and organizations in supporting professionals in this context. Protecting workers’ health, supporting staff, organizing the workload, and preparing the handover seem to be the key tasks of the line manager in crisis situations, which also means that line managers must be supported by their managers [20]. Additionally, our study highlights the importance of considering professionals’ experiences in order to improve their well-being, organizational tools, and provision of care.

This study also had limitations. First, we reached data saturation at the 23rd participant, which may not have provided the representation intended to be analyzed. Second, the limited variability of the participants may not have been adequate to explore the experiences fundamentally even though this study was specific to health professionals within the pediatric nursing department. Lastly, the full transcripts of the interviews were not sent back to the participants because many of them had to change or be transferred to another hospital and they could no longer be reached. This may have posed a limitation to the study because the participants also did not provide feedback on the data.

5. Conclusion

To our knowledge, this is the first French study of the experience of pediatric nurses who were transferred to adult wards during the first wave of the COVID-19 pandemic. Our findings shed light on how to better support health professionals such as nurses in crisis situations. We found that the role of management was critical for this support to be met. The quality of integrating nurses into a new care environment, follow-up from the transfer, anticipation of how the work is organized, fairness in how the nurses are treated, and efficiency concerning payment of their extra hours were all elements that were absent in management during the first wave of the COVID-19 pandemic.

These findings can be transferrable and applicable in other crisis situations that require the mobilization of health professionals. Solutions that can enable better management in the future include: (a) integrating nurses into the decision-making process, particularly in the event of limited treatment availability; (b) providing psychological support to the nurses, in particular by setting up active and ongoing real-time therapy sessions throughout a ward rather than setting up appointments in a room; (c) not neglecting material support to health professionals (such as protective equipment); (d) organizational support; (e) providing post-crisis psychological and management support; and (f) encouraging team feedback and comments.

Moreover, it would be interesting to conduct future studies with a multicenter approach both with professionals working in pediatrics or other units and with those working in other centers so that the variables, similarities, and differences can be further explored. It could also be interesting to study the experiences of professionals who are not mobilized during a crisis situation.

Declaration of Competing Interest

None.