United States nurses' experiences during the COVID-19 pandemic: A grounded theory

Abstract

Objective: The objective of this study was to explore nurses' experiences and perceptions at selected United States (U.S.) healthcare sites during the COVID-19 pandemic.

Background: The COVID-19 pandemic brought rapid changes to the healthcare community. While a few studies have examined the early pandemic experiences of nurses in China and Europe, nurses' experiences across the United States have remained relatively underexplored.

Design: A qualitative study design was used.

Methods: Using a constructivist grounded theory methodology and methods, we conducted eight focus groups across four hospital sites in the eastern, midwestern and western United States. Registered nurses with a minimum of six months' experience working in all clinical specialties were eligible. Forty-three nurses participated. Data were analysed iteratively using the constant comparative method. The COREQ guidelines supported the work and reporting of this study.

Results: The nurses experiencing a pandemic (NEXPIC) grounded theory emerged positing associations between four interrelated themes: Challenges, Feelings, Coping and Ethics. Nurses reported Challenges associated with changes in the work environment, community and themselves. They expressed more negative than positive feelings. Nurses coped using self-care techniques, and teamwork within the healthcare organisation. Moral dilemmas, moral uncertainty, moral distress, moral injury and moral outrage were ethical issues associated with nurses' Challenges during the pandemic. Moral courage was associated with positive Coping.

Conclusions: Awareness of frontline nurses' complex and interrelated needs may help healthcare organisations protect their human resources. This new theory provides preliminary theoretical support for future research and interventions to address the needs of frontline nurses.

Relevance to clinical practice: Nurses face added distress as frontline at-risk caregivers. Interventions to promote nurses' ability to cope with personal and professional challenges from the pandemic and address ethical issues are needed to protect the nursing workforce. This study offers a new substantive theory that may be used to underpin future interventions.

Keywords: COVID-19; anxiety; burnout; delivery of care; emotions; ethics; focus groups; grounded theory; pandemic; qualitative research; stress.