The psychological experience of Chinese nurses in support of COVlD‑19 frontline: A qualitative study

Ju‑Hong PEI, Hai‑Xia CHEN, Xing‑Lei WANG,2,Rui‑Ling NAN,3, Xin‑Man DOU,4, Xian PENG

1School of Nursing, Lanzhou University, Lanzhou, Gansu,China; 2Department of Liver Diseases Branch; 3Department of EICU; 4Department of Nursing, Lanzhou University Second Hospital, Lanzhou, Gansu, China; 5Institute of Medical Psychology, Basic Medical College, Lanzhou University,Lanzhou, Gansu, China

ABSTRACT

Objective: The objective of the study is to explore the real psychological experience of the frontline support nurses in fight against COVID‑19,so as to provide a reference basis for targeted intervention and ensure the mental health of the frontline support nurses.

Methods: The objective sampling method was used to conduct semi‑structured interviews with 9 frontline support nurses fighting COVID‑19,and the interview contents were analyzed using Colaizzi’s 7‑step method.

Results: The psychological experience of frontline support nurses in fight against COVID‑19 can be summarized into four themes: The coexistence of negative psychological experience and positive psychological experience (tension, anxiety, fear, and depression); psychological pressure; many factors that affect the negative psychological experience (the stimulation of the external environment, the care of family members,the guidance of network public opinion); and solid support system (good family support and rich social support).

Conclusion: Although frontline support nurses have negative emotions and bear great psychological pressure, they all have a high sense of professional responsibility. Therefore, managers should pay attention to their psychological experience and provide targeted assistance to them.

Keywords: COVID‑19, frontline nurse, psychological experience, qualitative research

INTRODUCTION

COVID-19 has caused a large global outbreak and become a global public health emergency.[1,2]COVID-19 is mainly clinically manifested as fever, fatigue and dry cough, mainly transmitted by droplets and close contact. Severe cases rapidly develop into acute respiratory distress syndrome and septic shock on the basis of pneumonia, which are life-threatening. As of March 30, 2020, data from the World Health Organization showed that there were more than 640,000 confirmed cases in 200 countries/regions.[3]As the main place to receive and treat patients,[4]hospitals are the main battlefield to fight against the epidemic of COVID-19. Since the epidemic outbreak, hospitals across the country have responded to the call of the state by rapidly dispatching medical staff to participate in the rescue at the first time and become the core force to win the battle of epidemic prevention and control. However,due to the insufficient understanding of COVID-19 in the medical community, most medical workers have no coping experience and adequate preparation and meanwhile are faced with stress such as long working hours and heavy workload, which lead to psychological problems such as anxiety, terror, and interpersonal sensitivity.[5-8]Therefore,we conducted qualitative interviews with frontline support nurses in fight against COVID-19 to further understand the true feelings of frontline support nurses and its influencing factors, provide the reference basis for scientific, effective,targeted intervention to them and the formation of nursing personnel of public health emergencies, and provide a basis to establish a long-term mechanism to responding to public health emergencies.

METHODS

Participants

The objective sampling method was used to select the frontline support nurses who participated in the fight against COVID-19 in a Gansu public hospital in China from January to February 2020 as the research objects. The inclusion criteria for this study were as follows: (1) nurses with strong language competence to fully express their inner feelings and (2) nurses volunteered to participate in this study. The number of participants was determined according to the criterion that no new topics appear.[9]In this study, a total of 9 frontline support nurses were selected. The descriptive characteristics of the participants are summarized in Table 1.

Procedure

This qualitative study used a descriptive interpretative methodology.[9]Individual semi-structured in-depth interviews with open-ended questions[10]were conducted.The interviews allowed participants to describe their experiences in their own words and to provide their perspective[11]about psychological experience during the fight against COVID-19. According to the research purpose, by consulting the literature, a clinical nurse expert with working years of more than 20 years who has ever participated in disaster psychological relief such as the “Wenchuan Earthquake” and “Yushu Earthquake in Qinghai province” and who is a professor of nursing and one who has been engaged in psychological consultation for 17 years and is also a registered psychological counselor and an associate professor, selected two front-line support nurses in fight against COVID-19 to conduct a preinterview to determine the outline of the interview. The questions asked in the interviews are described as follows: (1) Can you talk about your main psychological feelings during the fight against COVID-19? (2) Can you talk about what affect your mood and feelings during the fight against COVID-19?and (3) Can you talk about whether your families or friends gave you enough support to participate during the fight against COVID-19?

The interviewer is one of the principal researchers who is experienced in psychological working. Before the interview,she communicated with participants to determine the interview time and place. The interview time was selected after participants were off work, and the interview place was a quiet office in the hospital. The interview time lasted 20–30 min. During the interview, the researcher used the interview techniques such as questioning, examining minutely, repetition, summary, and response in a “neutral”manner in a guided way to dig into the real feelings of participants. No comment was made on the interview content. The changes in tone, body movements, and facial expressions of participants were carefully listened to and observed through the combination of recording and notes.

Within 24 h after the end of the interview, the principal researcher and another researcher read the transcripts independently, grouped data into categories, and recorded the changes of emotion and expression of the interviewees in the corresponding positions, so as to better analyze, their real feelings. From their initial categories, the researchers then compared and contrasted their findings and developed subthemes, and then the key themes that captured the meaning of the data. In this study, Colaizzi’s 7-step method was used to comprehensively analyze the acquired data.[10]Transcripts were read and coded independently toward the end of the data collection period by the third researcher to further verify the themes developed and that data saturation had been achieved.

Table 1: Descriptive characteristics of the participants

Ethic consideration

Before the interview, the purpose and significance of this interview were introduced to participants, the necessity of recording and notes was explained, and the interview information was promised to be kept confidential. After obtaining the consent of the nurses interviewed, the informed consent forms were signed.

RESULTS

Theme 1: Negative psychological experience coexists with positive psychological experience

Negative psychological experience

Stress and anxiety

Similar to the results of relevant studies,[5]nurses showed stress and anxiety in the face of unfamiliar working environment, lack of understanding of diseases, lack of experience in dealing with such events, and worried about family members and family members worrying about themselves. Interviewee 1 said, “I was nervous to see all the paramedics in protective clothing, seeing this for the first time.” Interviewee 2 said, “When I first came to work here, I was not familiar with the working environment, I didn’t know where the instruments and equipment were placed, I didn’t know the working habits of doctors, and I was afraid that I couldn’t cooperate with doctors well. I would be cautious and anxious when I worked.” Interviewee 3 said, “Although the baby’s father is good, I still missed my child, worried about my child crying and looking for me.” Interviewee 4 said, “I’m always a little nervous when I first go to work in a strange working environment.” Interviewee 7 said, “I was very nervous when I was going into the ward. When I was eating, I received a call to COVID-19 frontline. Our family didn’t eat too much, and I cried in the bathroom secretly.”Interviewee 9 said, “When I first got here, I couldn’t sleep during the workday. I was a little anxious.”

Fear

As a newly discovered coronavirus, COVID-19 spreads quickly and is highly infectious. At the early stage of support, some nurses were afraid to go to work for fear of being infected.In addition, nurses were not sure whether they would participate in such public health emergencies next time.Interviewee 2 said, “Every time I went to work, I was afraid of what I might do if I was infected.” Interviewee 7 said, “I thought, in case of getting infected, I would not to tell the family, in the hospital isolation treatment. If I went, I would tell my sister what happened. a lot of planning, anyway.”Interviewee 8 said, “It’s still very hard and dangerous when I go to work. Supplies are short now, and were plentiful at first.” Interviewee 9 said, “I never thought I would do this for the rest of my life. I don’t know if I will do it again.”

Depression

Depressive feeling refers to the psychological experience that the individual’s freedom or desire is restricted, which is directly manifested as depression, slow reaction and heavy psychological pressure.[11]Some nurses have different degrees of oppression when they face a large number of infected patients in a short period of time every day and closed management environment. Interviewee 4 said, “I’m isolated in the hospital for this period, sometimes I feel really depressed.” Interviewee 9 said, “Sometimes after my shift,it can be a little stressful, but after a video call with family,I feel better.”

Positive psychological experience–professional responsibility

The participants showed a high degree of professional responsibility and a sense of satisfaction in achieving self-worth as patient care improved. Interviewee 3 said,“When I really got into my work, I forgot that their disease was contagious and I just wanted the patients to get better.” Interviewee 6 said, “Once the protective clothing is taken off, it will be wasted. However, there are not enough supplies, and it’s a waste of time to take off a protective suit.” Interviewee 7 said, “On the day I went there, a patient was in a coma. Another day, she woke up after emergency treatment and cried. At that moment, I was both happy and sad.” Interviewee 5 said, “Although I was very tired, I’ve never felt any regret. It is our professional, and I think it is a kind of exercise for myself.”

Theme 2: Psychological stress

In the process of fighting COVID-19, some nurses felt great psychological pressure when they were initially in the stage of getting familiar with work in the face of unfamiliar environment and lack of understanding of the disease. In addition to the stress of the patient’s condition, short periods of overwork and intense attention from all sides can further increase the pressure on nurses. Interviewee 1 said, “I also don’t know when the epidemic will end. After the epidemic is over, I can go back to my work unit. There is a lot of pressure to work here.” Interviewee 2 said, “Under pressure,I will be more nervous than usual at work and worry about my performance.” Interviewee 6 said, “Every shift lasts 6 h,protective clothing cannot be taken off during work, so in order to avoid going to the toilet, drink less water, many people recommend using diapers.” Interviewee 9 said, “The epidemic is serious, the media and people all over the country are watching, so I am particularly afraid of making mistakes,especially wearing goggles and gloves, the needle is much more difficult than usual, sometimes only by touching the puncture.”

Theme 3: Many factors affect negative psychological experience

External environmental stimulus

External environmental factors and a small number of infected medical staff are external triggers that aggravate the negative psychological experience of frontline support nurses. Interviewee 1 said, “The situation here is quite serious. The whole hospital is in a tense state.” Interviewee 8 said, “When you see a health care worker infected on the Internet, you will worry about yourself.”

Concern for family

Some nurses, especially those with children of their own,have more negative psychological experience because they are worried about the health of their family members and their worries about them. Interviewee 3 said, “When I talked to my child on video after work, he asked me when I was going back home. I felt very uncomfortable and couldn’t help crying.” Interviewee 6 said, “My parents are older, and my husband is a policeman, who is also in the front line, so I entrust my children to relatives.” Interviewee 7 said, “My sister says my mother cries at home every day.”

Online public opinion orientation

Different from the outbreak of severe acute respiratory syndromes in 2003, this outbreak has a wide coverage and fast information transmission. While helping to prevent and control the epidemic, the authenticity of a lot of internet information is still not guaranteed, and even professionals may be troubled by the complex information. Interviewee 2 said, “At the end of every day you watch the situation,you see the number of confirmed cases going up, you get worried.” Interviewee 5 said, “Seeing the news of Dr. Lee’s death, we all experienced a certain degree of psychological fluctuations.” Interviewee 8 said, “Since participating in the frontline rescue, I have paid special attention to all kinds of information about the pandemic on the Internet.”

Theme 4: Solid support system

Good family support

Family support refers to emotional support and material help from family members,[12]mainly from spouses and parents.Respect, understanding and support from family members provide strong spiritual support for nurses to fight against the epidemic. Interviewee 3 said, “My husband takes care of the child at home, he supports me very much.” Interviewee 5 said, “Two teachers of us have children at home who need more concern. Fortunately, all of their families are very supportive.” Interviewee 6 said, “It was under my husband’s encouragement that I signed up for this mission.”

Abundant social support

Good social support can maintain good individual’s emotional experience and individual’s protection action in the stress state, thus reduce job burnout feeling.[13]Effective professional support, adequate logistical support,and recognition from patients can provide adequate social support to frontline support nurses. Interviewee 1 said, “I will arrange to practice wearing protective clothing and train various professional knowledge for the first few days.”Interviewee 3: “The patients are also very appreciative of our work. You can see their heartfelt thanks, which has strengthened our confidence in fighting the epidemic.”Interviewee 4 said, “Despite being quarantined, they are well fed and housed without any problems.” Interviewee 5 said,“Several of us would take a walk at the door in the morning or before dinner to talk.” Interviewee 6: “The head nurse, the director and colleagues in the department sent me messages,asking me about my situation here and caring about me. I was very moved. When my friends heard I was here, they all called me and I was lucky to have so much attention.

DISCUSSION

Focus on the anti‑epidemic frontline support nurses'negative psychological experience

Public health emergencies of infectious disease are often manifested as the emergence of a large number of patients,treatment difficulty and great social impact, resulting in hospital overload. When a large number of patients are admitted, the demand for nurses is far greater than that of other medical personnel, and nurses who are in close contact with patients are still under great psychological pressure even after strict precautions.[14-16]This study was found that most of the frontline support nurses fighting COVID-19 had different degrees of stress, anxiety, and fear of getting infected. During the fight against COVID-19, the hospital adopted closed management, and nurses became the subject of isolation while caring for patients, their daily life was restricted, and faced with overload work, they would experience varying degrees of depression.[17,18]Therefore,hospital managers should accurately grasp the psychological status of frontline nurses fighting COVID-19, implement diversified psychological intervention strategies, timely and effectively assess nurses’ psychological problems, relieve their psychological symptoms, promote their psychological recovery, and thus ensure the smooth progress of rescue work. In addition, nurses should also strengthen their own psychological attention, timely and correct emotional catharsis, share their feelings and experience with other nurses, affirm their own work, and seek professional help when necessary.

Attach importance to the cultivation of positive psychological experience

The nurses’ psychological experience produced during the fight against COVID-19 was not all negative, but also positive.Through this study, we have found that nurses have strong sense of responsibility, professional ethics, and self-value realization. When patient’s treatment progresses or the nursing work is approved by the patient and society nurses showed a strong professional identity, manager should not be confined to the nurse’s negative psychological assessment and intervention, but need more attention to the cultivation of positive psychological experience. Therefore, in clinical practice, managers should not only pay attention to nurses’negative emotions, but also actively guide nurses to enhance their professional ethics and sense of self-realization. Besides,nurses also need to understand their professional role, work with patients to confront the threat of illness, and enhance their sense of professional purpose.

Strengthening humanistic care

There are many factors influencing the psychological experience of front-line nurses fighting COVID-19. In this study, we found that unfamiliar working environment,heavy workload, fear of being infected and worried about family members are some of the reasons for nurses’ negative psychological experience. Therefore, the management should be in close contact with nurses, to provide multi-dimensional care and help, in addition to the spiritual care, when necessary to provide some specific measures,such as vacation incentives or financial incentives.[19]In addition, nurses should be as free of worries as possible,ensure adequate logistical support, and keep in touch with family and the outside world.

Keep abreast of the latest information

The COVID-19 has a particularly rich source of information from various official media and we-media, and a lot of information has been widely spread without confirmation.In such a context, people tend to have feelings of suspicion,fear and so on, thus causing fear.[20]Therefore, after entering the quarantine area, nurses should further learn the latest news related to COVID-19, understand the relevant cutting-edge consultation, master the actual situation of the frontline medical staff fighting against COVID-19, and understand the development of the epidemic objectively and rationally.

CONCLUSION

In this study, through in-depth interviews with nine frontline support nurses in fight against COVID-19, it was found that the psychological experience of COVID-19 frontline support nurses during the fight against the epidemic mainly includes four themes: Negative psychological experience coexists with positive psychological experience; psychological stress; many factors affect negative psychological experience; and solid support system. Managers should fully recognize the negative psychological experience and great psychological pressure of frontline nurses, attach importance to the cultivation of positive psychological experience, strengthen humanistic care, timely provide the latest news related to COVID-19 and professional psychological help when necessary, in order to ensure the mental health of frontline medical staff.

Financial support and sponsorship

This work was supported the Lanzhou city science and technology development program project: Psychological intervention study of mind-fulminant behavior delivery on COVID-19 isolated protective medical workers.

Conflicts of interest

There are no conflicts of interest.