Education, Faculty of
Educational and Counselling Psychology, and Special Education (ECPS), Department of
DSpace
UBCV
Yan, Brian
Master of Arts - MA
University of British Columbia
With the advent of the COVID-19 pandemic, a global event resulted in a shutdown occurring on a scale never seen before. Across the world, healthcare systems were pushed past maximum operating capacities and began to buckle, leaving frontline healthcare workers to bear the brunt of its severity. There is a scarcity of Canadian empirical knowledge regarding how nurses experienced working throughout the COVID-19 pandemic. The present study utilized in-depth narrative interviews with four nursing practitioners who had worked in hospitals during the pandemic, providing care to COVID-19 positive patients. Thematic content analysis was conducted on participant interviews to examine their stories of how they navigated their work and the challenges they faced. Five key themes emerged from the analysis the participant’s narrative interviews: Concerns about Personal Safety, Struggles with Workload, Administrative Presence, Perceptions of Nursing Culture, and Personal Mental Health. These themes are presented and discussed in terms of their implications for future practice, research and policy.
HOW DO CANADIAN NURSES UNDERSTAND THEIR WORK EXPERIENCE DURING THE COVID-19 PANDEMIC? by BRIAN JASON IAN YAN B.A., Simon Fraser University, 2019 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE AND POSTDOCTORAL STUDIES (Counselling Psychology) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) April 2024 © Brian Jason Ian Yan, 2024 ii The following individuals certify that they have read, and recommend to the Faculty of Graduate and Postdoctoral Studies for acceptance, the thesis entitled: HOW DO CANADIAN NURSES UNDERSTAND THEIR WORK EXPERIENCE DURING THE COVID-19 PANDEMIC? submitted by Brian Yan in partial fulfillment of the requirements for the degree of Master of Arts In Counselling Psychology Examining Committee: Dr. Marla Buchanan, Professor, Counselling Psychology, UBC Supervisor Dr. Bill Borgen, Professor, Counselling Psychology, UBC Supervisory Committee Member Dr. Marvin Westwood, Professor Emeritus, Counselling Psychology, UBC Supervisory Committee Member iii Abstract With the advent of the COVID-19 pandemic, a global event resulted in a shutdown occurring on a scale never seen before. Across the world, healthcare systems were pushed past maximum operating capacities and began to buckle, leaving frontline healthcare workers to bear the brunt of its severity. There is a scarcity of Canadian empirical knowledge regarding how nurses experienced working throughout the COVID-19 pandemic. The present study utilized in-depth narrative interviews with four nursing practitioners who had worked in hospitals during the pandemic, providing care to COVID-19 positive patients. Thematic content analysis was conducted on participant interviews to examine their stories of how they navigated their work and the challenges they faced. Five key themes emerged from the analysis the participant’s narrative interviews: Concerns about Personal Safety, Struggles with Workload, Administrative Presence, Perceptions of Nursing Culture, and Personal Mental Health. These themes are presented and discussed in terms of their implications for future practice, research and policy. iv Lay Summary With the advent of the COVID-19 pandemic, a global shutdown resulted in healthcare systems being overwhelmed with patients while fighting insufficient staffing and resources leaving frontline healthcare workers to bear the brunt of the blow. Despite the importance of the effect on the healthcare system, there is limited Canadian research knowledge regarding how nurses experienced working throughout the pandemic. The present study examined the stories of four nursing practitioners who had worked in hospitals during the pandemic, providing care to COVID-19 positive patients. Participant interviews were analyzed for key findings and commonalities across their stories of adapting to new challenges in the workplace and implemented coping strategies. The findings are discussed in terms of key themes that emerged and their implications for future practice, research and policy. v Preface This thesis is an original, unpublished, independent work by the author, B. Yan. This research was covered by UBC Ethics Certificate number H23-02860. vi Table of Contents Abstract ......................................................................................................................................... iii Lay Summary ............................................................................................................................... iv Preface .............................................................................................................................................v Table of Contents ......................................................................................................................... vi Acknowledgements ........................................................................................................................x Chapter One Introduction ............................................................................................................1 Statement of the Problem ............................................................................................................ 1 Rationale for the Study ............................................................................................................... 3 Purpose of the Study ................................................................................................................... 5 Significance of the Study ............................................................................................................ 5 Chapter Two Literature Review ..................................................................................................7 Theoretical Underpinnings.......................................................................................................... 7 Burnout ................................................................................................................................... 7 Secondary Traumatic Stress/Compassion Fatigue ............................................................... 10 Vicarious Trauma ................................................................................................................. 13 Coping Theory ...................................................................................................................... 15 Research Findings ..................................................................................................................... 18 Middle East ........................................................................................................................... 18 Asia ....................................................................................................................................... 21 Europe ................................................................................................................................... 24 North America ....................................................................................................................... 26 Summary of Findings & Research Question ............................................................................ 29 vii Chapter 3: Methods ....................................................................................................................32 Social Constructionism and Narrative Theory .......................................................................... 32 Narrative Inquiry ....................................................................................................................... 33 Historical Underpinnings ..................................................................................................... 33 Basic tenets of narrative inquiry ........................................................................................... 34 Rationale for Narrative Inquiry ............................................................................................ 35 Description of Sample ........................................................................................................... 36 Procedures ................................................................................................................................. 37 Screening Process ................................................................................................................. 37 Pilot Interviews ..................................................................................................................... 38 The Research Interview......................................................................................................... 38 Data Analysis ........................................................................................................................ 39 Phase 1: Transcription and Data Familiarization .............................................................. 40 Phase 2: Generating Initial Codes ..................................................................................... 41 Phase 3: Categorizing Codes into Possible Themes ......................................................... 41 Phase 4: Reviewing Themes. ............................................................................................ 41 Phase 5: Defining and Naming Major Themes ................................................................. 42 Phase 6: Producing the Report .......................................................................................... 42 Criteria for Evaluating Trustworthiness .................................................................................... 43 Member Checking ................................................................................................................. 43 Researcher Subjectivity and Reflexivity ............................................................................... 44 Ethical and Diversity Considerations.................................................................................... 44 Significance of Study ................................................................................................................ 45 viii Chapter 4: Results.......................................................................................................................46 Introduction to the Themes ....................................................................................................... 46 Theme 1: Concerns about Personal Safety ............................................................................... 46 Personal Protective Equipment (PPE) ................................................................................. 47 Physical Violence .................................................................................................................. 48 Verbal Harassment ............................................................................................................... 49 Theme 2: Struggles with Workload .......................................................................................... 50 Patient Load .......................................................................................................................... 50 Sanitation .............................................................................................................................. 51 Time Management ................................................................................................................. 53 Theme 3: Administrative Presence ........................................................................................... 55 Policies and Communication ................................................................................................ 55 Staffing and Staff Placement ................................................................................................. 56 Support for Nursing Staff ...................................................................................................... 59 Theme 4: Perceptions of Nursing Culture ................................................................................ 60 Supportive Colleagues .......................................................................................................... 61 Bullying ................................................................................................................................. 62 Self-Sacrifice ......................................................................................................................... 63 Theme 5: Personal Mental Health............................................................................................. 64 Moral Distress ...................................................................................................................... 65 Anxiety and Stress ................................................................................................................. 66 Coping Mechanisms .............................................................................................................. 67 Public Opinion ...................................................................................................................... 69 ix Summary of Results .................................................................................................................. 70 Chapter 5 Discussion and Conclusions .....................................................................................72 Discussion of the Findings Relative to Nursing Literature ....................................................... 72 The Findings and Theories behind Nurse’s Mental Health Stresses. ................................... 73 The findings relative to current literature of nurse’s work experience during COVID-19. . 77 Practical Implications and Contributions of the Findings......................................................... 80 Implications for Nurses ......................................................................................................... 81 Implications for Healthcare Administrators and Institutions ............................................... 83 Implications for Community Professionals ........................................................................... 85 Strengths and Limitations of the Study ..................................................................................... 86 Implications for Future Research .............................................................................................. 87 Conclusion ................................................................................................................................ 89 References .....................................................................................................................................90 x Acknowledgements I would like to make a special acknowledge for the four nurses who participated in this study. Without their willingness to share their stories and experience in the field, I would not have the narratives to compile and share with others. Thank you for the work you do and I hope change comes your way so that you find your profession more supportive. Thank you to the faculty and staff of the UBC Counselling Psychology Program, whom have all supported me and impacted my future practice in the counselling field. To my thesis committee Dr. Marla Buchanan, Dr. William Borgen, and Dr. Marvin Westwood, I offer my sincerest gratitude for their time, advocacy, and engagement throughout the entire process. Marvin, thank you for taking such an interest in this work, providing impactful feedback and its potential relation to group work. Working with you in the CGCT helped inspire my desire to enter the counselling field. Bill, thank you for your engaging contributions and having been such a supportive practicum supervisor. You were always ready to openly share your expertise, both the highs and the lows. Marla, I don’t think I have enough space to highlight your contributions. Without your mentorship, kind and constant support, I would not have been able to find the level of growth in the program that I have achieved. If there needs to be somebody who embodies the aspects of Person Centered Therapy, Marla, you are it. I am forever grateful for the level of care you have shown me at every stage of my program and research. Significant thanks are also owed to my parents, family and friends for their unending support. This work is also dedicated to those who saw the beginning of my graduate journey and are not here to witness its completion. 1 Chapter One Introduction Statement of the Problem When reading about the health care field today it is almost impossible to not see the terms stress, fatigue or burnout. With the advent of the COVID-19 pandemic, the healthcare system was suddenly put to the test, and healthcare workers had no choice but to adapt on the fly to their new working reality. Over 86% of Canadian healthcare workers felt more stress during the pandemic and 95% reported their jobs being impacted (Statistics Canada, 2022b). Almost one in four nurses reported planning on changing their job or leaving their job in the next three years. In British Columbia, Canada, there are over 4,000 nursing vacancies (Statistics Canada, 2022a), creating a nursing shortage and resulting in emergency rooms shutting down or having reduced hours. Nurses have been reporting high levels of mental and physical strain due to shift extensions, getting called in on their off days and burn out (CBC, 2022). Experienced nurses are experiencing levels of grief, trauma and loss on a daily basis to the point where they cannot properly cope and are unable to work several days in a row, resulting in being too unwell to properly care for their patients. With experienced veteran nurses struggling in the current health care environment, nurses newer to the profession are left to suffer the full weight of the strain within the healthcare system. Levels of absence in healthcare settings have doubled during COVID-19 when compared to pre-COVID levels (CBC, 2022). It is imperative we understand the mental health cost to health providers on more than just a quantitative level as scales fail to provide the context of one’s lived experience and descriptions of the cost to healthcare providers beyond a statistical number or percentage. When 2 immersed in such challenging environments, nurses begin to absorb the trauma they work with (Crowe et al., 2021). Nurses are constantly exposed to patients helplessness and vulnerability which can prompt concerns about their own sense of power or efficacy (Foli et al., 2021). Nurses may find themselves identifying with their patients loss of control over their own lives due to stringent safety rules and quarantining procedures. The extended separation from their loved ones or families comes with a cost and can take the form of vicarious traumatization. Susceptibility to burnout is increasingly higher due to the frustration, powerlessness and inability to achieve perceived goals in relation to the pandemic (Maslach & Leiter, 2016). These goals are typically related to balancing patient care and treatment with personal safety or frustration with new protocols that are not communicated efficiently (Foli et al., 2021). When asking healthcare workers why they were planning on leaving their job or retire early, 63.2% of those surveyed reported reasons related to burnout as the primary cause (Statistics Canada, 2022b). All of these types of traumas can be linked to nurses’ ability to cope with stressors, which when perceived as beyond their ability to deal with and endangering their own well-being results in an increased risk of suffering from mental health crises (Lazarus & Folkman, 1984). A method to develop more effective and proactive coping skills can centre on developing strategies that align with the nature of the stressor and cultural context the individual is in (Wong & Wong, 2006). In the context of nursing, interventions that may have the greatest success in bolstering their ability to cope may lie within lived experiences of their unique circumstances and using it as a guide for development of coping strategies. Nurses in COVID-19 treatment wards have been found to experience increased levels of anxiety, depression and sleep disturbances compared to non-COVID-19 wards (Tamrakar et al., 2021). A Jordanian study found up to 64% of nurses have experienced symptoms of acute stress 3 disorder (ASD) during their work in the pandemic and are at high risk for PTSD predisposition (Shahrour & Dardas, 2020). Disaster healthcare workers report rates of ASD between 14.6-40.5%, and healthcare workers in combat zones have ranged between 5.3-8.5%. If that does not draw a strikingly bleak comparison then what will? In Canada, as many as 73.5% of nurses have developed PTSD symptomology compared to the 8.5-20.3% pre-COVID-19 (Crowe et al., 2021). Rates of anxiety and depression in nurses around the world have skyrocketed and are at significant risk to develop more serious mental health issues. Psychiatric caseness was found in 90% of the 96 nurses in Nepal (Tamrakar et al., 2021), 40% of 194 nurses in Istanbul reported suffering from moderate to severe insomnia (Kandemir et al., 2021), and 57% of Canadian nurses reported mild to severe depression (Crowe et al., 2021). There is no doubt that nurses are facing extremely challenging mental health situations. Rationale for the Study With the evidence at hand, there is no doubt nurses are facing a serious risk of developing mental health disorders. The quantitative findings across the globe all echo the same sentiment; nurses need help. Even so, through a review of the literature, there are many gaps that need to be addressed. There is plenty of quantitative information regarding how nurses are being under immense amounts of stress resulting in anxiety and depression but it fails to capture the lived experiences and personal cost of each individual. There are qualitative studies available regarding the nursing experience during the COVID-19 pandemic; however a vast majority takes place outside of North America, where different economic and cultural values may play a role. In Turkey, nurses were prohibited from quitting and were legislated to continue working in hospitals as there was a shortage of qualified staff (Yıldırım et al., 2021). This could ultimately have contributed to the desire of many participants indicating their desire to leave the profession, 4 due to the lack of autonomy in their own profession. However, these findings differ with reports in China that despite the adverse working conditions, nurses were finding a renewed sense of commitment and passion for nursing and a dedication higher than before (Chen et al., 2020). Of the few North American studies available, a vast majority also take place in the United States. One American study also noted the severe lack of North American empiricism when it came to understanding the nurses experience of the pandemic noting it as part of the reason they conducted a study (Foli et al., 2021). None of the studies surveyed utilized a narrative methodology, as the available qualitative research predominantly used content analysis or a phenomenological approach. There are generalized themes and sentiments from nurses that have been drawn but no personal stories of their struggle working in healthcare settings. In order to give context to the readily available numbers, nurses must be presented an opportunity to give power to their stories and share their learned experiences. The clear lack of Canadian research in this area is as large an indicator as can be, that research is indeed required. What kind of perceptions do Canadian nurses have of their profession? What kind of help seeking behaviour did Canadian nurses engage in during the pandemic? The one Canadian study situated in British Columbia was primarily a quantitative study with brief interviews (Crowe et al., 2021). These are just a few questions that need answering, and that can only happen through conducting more research in which nurses can express and describe their personal experiences. How our healthcare workers face and progress through challenging environments is of paramount importance, and researching those narrative experiences will allow us to hear from the voices of nurses themselves. By performing a narrative study, information will be gathered from stories that explain and give testimony to the lived effects of participants and how they 5 were affected. Narrative research will give insight into what has to change in order for nurses to thrive instead of suffer. By generating more data about this phenomenon, it will facilitate greater knowledge transfer and dissemination of information for organizations who don’t know how to help their workers. Policy and practice can become better informed to help prevent future challenges when facing a public health emergency. If we don’t act, we will fail our healthcare workers because they did not receive the support they need and deserve. Purpose of the Study With such widespread negative experiences and challenges, nurses are opting to leave the profession in an attempt to maintain their own mental wellbeing. How can interventions be properly developed when there is a lack of understanding in how nurses cope? Counselling psychology has a role to play in helping understand the mental cost to healthcare providers. The purpose of this study is to collect narratives from nurses working during COVID-19 to get their perspective on the challenges, struggles and coping mechanisms they have experienced. By utilizing in-depth interviews, their personal stories led with their voice and language will help us understand their resilience and consequences to working on the frontlines of healthcare. With the information gathered through this study, recommendations may be generated to help address this topic in future circumstances. This study will employ a narrative research design to answer the following research question: How do Canadian nurses understand their work experience throughout the COVID-19 pandemic? Significance of the Study The COVID-19 pandemic is still here and it does not seem to be stopping anytime soon. Over 4,000,000 cases of COVID-19 have been confirmed and 50,000 deaths to date in Canada (Government of Canada, 2023). Hundreds of people are dying a week and thousands of new 6 cases emerge weekly. Our health care system is under attack and we need to do all we can to help ease the burden of the workers supporting the infirmed. 7 Chapter Two Literature Review This chapter summarizes the available research surrounding nurses’ experience working during the COVID-19 pandemic that informs the current investigation. The chapter begins with an overview of theories associated with nurse’s mental health stresses followed by research findings situated by geographic context. Here is where the prevailing struggles of nurses are explored in detail, supported by empirical data. The chapter will then conclude with a summary of the findings and highlight gaps in the literature, leading to the presentation of the current study. Theoretical Underpinnings Burnout Burnout as a concept has its origins with service based helping professions. Virtually unheard of prior to the late 1970s, burnout became a concept of widespread interest and popularity appearing in articles, books, and in popular media (Maslach & Jackson, 1984). There were arguments at the time stating that it was not a new phenomenon but rather a new name for an already known state, including depression, job dissatisfaction, anomie or job stress (Maslach & Leiter, 2016). Primarily characterized by emotional exhaustion, depersonalization and reduced personal accomplishment, burnout has been found to more commonly occur among individuals who work with people in some human service capacity such as nursing, teaching and social services. The characterizations may surface as being emotionally overextended or drained by their work with others, being unfeeling and callous towards colleagues or those in their care, and feelings of declining competence and success in their work. The common assumption about burnout is that it is an issue with the worker, that they are trying too much or are too exhausted 8 and incompetent, resulting in burnout. However, research thus far has not supported the argument that burnout is directly and singularly related to the individual (Maslach, 2003). Use of a multidimensional model contrasts the one-dimensional concept of stress as it expands beyond the individual stress experience to include responses to the job and to the self. Instead of the traditional singular focus on the individual stress experience, this model aims to view the experience within the individual’s social context. Each of the three burnout characterizations tends to relate to the workplace environment differently. The basic stress response manifests itself as exhaustion which is a necessary but not sufficient criterion for burnout. However, the exhaustion is what leads individuals to disengage themselves from their work emotionally and cognitively as a way to cope with work demands. It is generally found that exhaustion and depersonalization emerges as a result of work overload and social conflict, while the reduced sense of personal accomplishment arises from a lack of resources to better accomplish tasks (Maslach, 2003). The lack of resources can stem from lack of necessary tools, information, training or time. In the case of a pandemic, supplies may be delayed or insufficient, along with having to develop new protocols and practices on the fly can become a heavy strain on any worker. A different emphasis on each burnout characteristic results in different patterns of work experience and burnout risk. A newer development in the conceptualization of burnout has been to focus on the opposite of the three characteristics, namely the positive factors. Job engagement has been defined by researchers to be the antithetical side of the burnout dimensions: energy, involvement and sense of efficacy (Maslach, 2003). The implications of engagement research have been that interventions may prove to be more efficacious when focusing on building engagement instead of attempting to reduce burnout dimensions. However, most burnout interventions tend to focus 9 on individual centered approaches which is paradoxical considering that research has supported situational and organizational factors playing a more significant role in contributing to burnout than individual factors. Individual interventions and strategies may help alleviate the exhaustion variable but often do not make any meaningful change on the other dimensions. The most common recommendations on the individual level have included changing work patterns, developing coping skills, obtaining social support and promoting good health and fitness (Maslach & Leiter, 2016). Compounding this is that in the workplace, individuals generally have a much lower ability to exert control over their stressors compared to their home or personal lives. As burnout became a more clearly identifiable problem, assessment measures were required in order to properly identify burnout. Initial measurement tools only focused on the exhaustion dimension until the Maslach Burnout Inventory (MBI) which was the first measurement to assess the three dimensions of burnout (Maslach & Leiter, 2016). After decades of burnout research, six key domains have been identified as the largest organizational risk factors across occupations: workload, control, reward, community, fairness and values. Too high a workload depletes the capacity of individuals to meet the demands of their job, providing little opportunity to recover and balance their lifestyle, becoming unsustainable. Clear linkages between lack of control and burnout have been established when employees perceive their influence to have little effect on their autonomy and access to resources necessary to do their job. The reward domain concerns lack of recognition or reward as a risk factor to increase vulnerability to burnout because it devalues the work and worker. Community is the ongoing relationships employees have with their colleagues and can be defined by the amount, or lack of social support they have with one another. Fairness ties similarly with lack of control in that the 10 perception of the worker in seeing decisions involving their work as fair or equitable, including their treatment during the process, which defines how they feel in the workplace. Lastly, values are the motivating connection between the worker and the workplace which when confronted with a gap between organization and individual, leads to feeling split between work they want to do versus work they have to do. Secondary Traumatic Stress/Compassion Fatigue The concept of secondary traumatic stress (STS) originates from the desire to help or helping of a traumatized individual (Figley, 2002). It is a condition where an individual experiences the symptomology of post-traumatic stress disorder (PTSD), but exposure to the trauma is from the knowledge about it from another individual [the client] to whom the symptoms are directly linked. Practitioners who are exposed to patients’ fear, pain and suffering on a regular basis may begin to experience similar fear, pain and suffering due to their empathy and compassion for their client (Figley, 1995). All healthcare workers or front-line first responders are at risk of experiencing STS (Beaton & Murphy, 1995). This population views trauma as part of their everyday life and accept the exposure as part of the job. However, the concern lies in that the trauma exposure is repetitive which leads to a cumulative effect. Studies of occupational stress of emergency medical service workers have found high levels of burnout, stress, strain and lower coping skills compared to other occupational groups (McCammon & Allison, 1995). Re-conceptualized as compassion fatigue by Charles Figley (1995), practitioners having worked with patients of a specific type may begin to mirror patient anxieties or fears. To be specific, compassion fatigue is defined as, a state of tension and preoccupation with the traumatized patient through persistent arousal (Figley, 2002). Individuals that have higher 11 capacity to feel and express empathy are theorized to be at increased risk for compassion fatigue. Unlike burnout or countertransference, compassion fatigue is characterized by a sense of helplessness and confusion confounded by isolation from supporters (Figley, 2002). Compassion fatigue can emerge suddenly with little warning in contrast to burnout which emerges gradually as a result of emotional exhaustion. As part of Figley’s theory, unlike burnout which may require occupational or career changes, compassion fatigue is treatable if identified and treated accordingly. Following Figley’s compassion stress and fatigue eleven variable model (2002), the steps leading to an individual succumbing to compassion fatigue is laid out. It starts with the practitioner’s empathic ability to notice the pain of the client, affected by the amount of exposure and empathic concern they feel. Without motivation to respond to people in need, the practitioner’s empathic response will be insufficient and will fail to deliver high quality service. Empathic response is the result of the exposure and concern of the practitioner, resulting in the acceptance of emotions experienced by the patient such as fear, hurt, and anger which comes at an emotional cost. Residual compassion stress is the remaining emotional energy from the practitioner’s empathic response to the client which in high enough levels can negatively affect quality of life, and is maintained by the following two sets of coping actions: the level of disengagement with the patient can lower or prevent compassion fatigue which allows the practitioner to practice self-care, and the level of satisfaction the practitioner feels in their efforts to help their client. Prolonged exposure to the patient without periodic breaks may prove to be detrimental as the level of traumatic recollections the practitioner carries within themselves from regular interaction can result in life disruptions that in a high enough degree, affect the practitioner’s routines or life responsibilities. 12 These factors separately normally cause a tolerable level of distress but when combined together, significantly increase the chance of developing compassion fatigue. Not everyone reacts the same to what may be described as a traumatic event. Many variables including physical and psychological development, age, and circumstance dictate how an individual will respond (Cerney, 1995) There are five implications to Figley’s (2002) model that can help prevent compassion fatigue. First, is to provide an overview of compassion fatigue, as education about the condition is seen as vital. Second, is to desensitize the practitioner to the traumatic stressors so they can increase their resilience levels to acknowledge and work through future scenarios that may cause traumatic stress reactions. Exposure dosage is the third implication, intertwined with the second implication as it is essential to the success of effective desensitization in order to facilitate recovery. Fourth, is to increase the practitioner’s social support system and fifth, is to address toxic relationships that are a source of strain and stress. To help prevent compassion fatigue, what appears to be most helpful is to acknowledge that not all patients will benefit from treatment and that they must not isolate themselves. To maintain opportunities to express their feelings of turmoil, guilt, responsibility, they must have access to support and clinical supervision to gain assistance in rebuilding their clinical practice and well-being (Cerney, 1995). However, with the COVID-19 pandemic and various quarantine protocols in place, traditional means of support seeking may have been inhibited, as person to person talks or being with a group was no longer practiced to which most healthcare providers have acclimated. It is important to understand how these supporters have been affected as a result of their exposure to traumatized patients, because only by understanding the process can there be work to 13 prevent additional, subsequent traumatic stress among supporters while also increasing the quality of care for the patients in their care (Figley, 1995). Vicarious Trauma Professions working firsthand with traumatized individuals are not without risk of traumatizing themselves. It is possible for people to display signs and symptoms of the aftermath of serious trauma without having experienced it directly. Despite having education and training, including supervision of interacting with the treatment of clients, no one is immune to the exposure of the client’s trauma (McCann & Pearlman, 1990). Nightmares, fearful thoughts, intrusive images and suspicion of others are common symptoms amongst traumatized individuals. These reactions can occur as a result of short or long term reactions to working with particular clients, thought to be a type of countertransference. Alterations in the individuals’ cognitive schemas, personal beliefs, expectations or assumptions about the self and others can be due this countertransference exposure. This process has since been termed “vicarious traumatization” (McCann & Pearlman, 1990). To put it simply, vicarious traumatization is an accumulation of memories of clients traumatic material that affects and is affected by the practitioner’s perspective of the world (Figley, 1995). It has also been explained by contagion theory (Figley, 1995). This mostly commonly affects health professionals such as nurses and doctors as well as mental health professionals who may be in close proximity with a traumatized individual over a short or long period of time. A key aspect to understanding vicarious trauma lies in the countertransference phenomenon. Traditionally referred to as the activation of a therapist’s unresolved or unconscious conflicts and concerns, within the trauma context it encompasses the painful 14 feelings, images and thoughts that accompany work with traumatized individuals (McCann & Pearlman, 1990). Working with traumatized clients may promote moral or judgmental feelings about the self after exposure to the clients’ trauma. This can manifest as feelings of aggression, rage, grief, horror, loss of control and a sense of vulnerability. As per McCann and Pearlman’s theory (1990), it is their belief that working with trauma survivors will leave lasting alterations to one’s cognitive schemas, and have a significant impact on the workers’ feelings, relationships and life. Another foundational aspect of vicarious trauma is the theory of personality coined Constructivist Self-development Theory (Pearlman & Saakvitne, 1995). The underlying premise is that humans construct their own realities through development of cognitive structures, also referred to as schemas, which are then used to interpret events (McCann & Pearlman, 1990). These schemas involve beliefs, assumptions and expectations which allows individuals to make sense of their experiences. The main hypothesis of the constructivist self-development theory is that trauma disrupts the client’s schemas and the nurses or therapists helping the client experience disruptions in the very same schemas. According to McCann & Pearlman (1990), individuals who have experienced deceit, betrayal or a violation of trust may pass that on resulting in cynicism or distrust. Descriptions of loss of safety such as threats or harm incurred can disrupt a helper’s own sense of security. Victimized persons may expose the helper to feelings of helplessness or vulnerability leading to concerns over their own sense of power over life events. In extreme cases, feelings of helplessness, depression or despair about uncontrollable events can be experienced by the helper due to this schema disruption. With this in mind, it is even more essential that helping professions understand the risks of working with traumatized 15 populations but also know how important it is to acknowledge, express and work through these experiences in order to maintain their own well-being. Coping Theory Stress is seen as an unavoidable aspect of human experience, but the ability to cope has been posited to make a significant difference in adaptive outcome. Stress is defined as a relationship between a person and the environment, viewed as taxing or beyond their ability to deal with and endangering their own well-being (Lazarus & Folkman, 1984). When faced with certain environmental demands and pressures, individuals and groups differ in their sensitivity, providing varying interpretations and reactions. The reflection of the importance of coping can be seen within cognitive behaviour therapy, which is a focus examines how a person construes events and uses interventions to develop change in thought, feeling and action. In Lazarus and Folkman’s Transactional Theory of Stress and Coping (1984), they determined that there were three main processes when it came to stress: the two cognitive appraisal processes—primary and secondary appraisal, and coping. Three kinds of primary appraisal were categorized: irrelevant, benign-positive, and stressful (Lazarus & Folkman, 1984). When the interaction with the environment poses no threat to the person’s well-being, it is categorized as irrelevant. Benign-positive appraisals occur when the interaction is perceived as positive or promises to be so. These appraisals are characterized by emotions such as happiness, serenity, and elation. Stress appraisals are when there is the threat of harm, loss or challenge. The adaptational significance of a threat permits an individual to begin anticipatory coping to the extent where it can be planned and worked on in advance. An example can be preparing for a new working environment due to a pandemic. The challenging aspect of the stress appraisal is in the anticipation of preparing coping mechanisms characterized 16 by excitement and exhilaration, whereas threat appraisal is typically characterized by fear or anxiety. It is important to note that threat and challenge are not mutually exclusive as there are situations where both appraisals can be made simultaneously. Secondary appraisal is the evaluative process that considers available coping options, the likelihood of success, and the ability to employ the coping strategy effectively or not (Lazarus & Folkman, 1984). This appraisal is an essential part of any stress encounter due to the fact it dictates the upcoming behaviour or action. There is also the chance of a reappraisal which may change the primary appraisal due to new information from the environment which can either relieve or increase the pressure being experienced. Lazarus and Folkman (1984) also generated their own definition of coping as a process orientated, constantly changing, cognitive and behavioral effort to manage internal and external demands that threaten to exceed the capability of the individual. According to Lazarus and Folkman (1984), the process orientated approach to coping begins with an assessment of what the person actually does instead of what they should do. Second, the specific context of the individual’s thoughts or actions are examined. Third, is the change in coping thoughts and behaviours as the stress incident occurs. By breaking down coping into three steps, it provides a shifting process that requires reliance on different strategies for different situations and separates itself from the traditional definition of coping as a trait-oriented response. Although the process is linear in explanation, it does not occur in such an orderly fashion as the outcome of one of the three processes may change a preceding one (Carver et al., 1989). To start, a nurse might feel they are well equipped to handle the new work related stress until they are in that environment and reappraise the situation, finding their coping is less effective than expected. Then a secondary reappraisal may begin to determine what coping response might work best. 17 To measure how people respond differently to stress, a multidimensional coping inventory (COPE, Carver et al., 1989), was created in which three different dimensions are measured (Carver et al., 1989). The first is problem-focused coping which aims at problem solving or actions aimed at amelioration of stress, also referred to as active coping. Five scales are used in this first dimension examining acts of active coping, planning, suppression of activities, or seeking out support. Second is emotion-focused coping which focuses on reducing or management of the emotional distress. This is also measured using five scales which look at instances of seeking emotional support, acceptance or denial of the stressor, or positive reinterpretation. Third is the measurement of coping responses that are potentially less efficacious. This dimension only has three scales and measures items such as disengagement in order to deal with the stressor. Engaging in behavioural disengagement is thought to be as dysfunctional as it is commonly identified with the helplessness phenomenon. Another perspective on coping is the Resource-congruence Model which posits sufficient resources and appropriate utilization of resources lead to effective coping (Wong & Wong, 2006). Inversely, if an individual does not have sufficient resources or deviates too far from congruence, it will make the individual more susceptible to stress. In this model, the efficacy of the coping depends if the coping response is congruent with the type of stress and the cultural context it is situated within. A key feature of Wong and Wong’s model is creative coping which involves the idea that by developing many resources, the likelihood of stressful encounters will be diminished. This can also include the reduction or removal of stress by transforming or further developing existing resources available. As soon as a stressor is identified by primary appraisal, reactive coping begins. At this point, two types of congruence are required for effective coping: accurate appraisal of the demand and available resources, and selection of strategies congruent 18 with the nature of the stressor and the cultural context it is in. If these two requirements are met, then it will lead to amelioration of stress. The resource-congruence model emphasizes a proactive approach compared to traditional reactive measures to stress with the concept of preventing stress instead of treating stress. It views cultivating coping resources as the most effective coping method and also the most neglected (Wong & Wong, 2006). By requiring cultural and stress response congruence, it has gained multicultural applicability in developing interventions by emphatic inclusion of the individual’s personal cultural values and practices. Another aspect of the model is the focus on the individual as unique, who may not find the coping strategies someone else may use in an identical situation effective. The resilience of the individual is not only predicated by the number of coping skills available but also by their personality attributes. Someone who is determined, optimistic and flexible may find greater success in employing coping strategies as opposed to someone who gives up easily and rigidly follows certain methods. I now turn to a description of the research findings on this topic. Research Findings Middle East Nurses are essential front line healthcare workers that help control the pandemic through triaging patients and engaging in primary care. However, they do so while facing significant challenges such as risk of infection, work overload, and psychological risk (Yıldırım et al., 2021). In a multi-site survey study of 194 intensive care unit nurses in Istanbul, findings supported the hypothesis that healthcare workers involved in the direct care and treatment of COVID-19 patients were more susceptible to poorer mental health symptomology (Kandemir et al., 2021). Results showed that 65.5% of participants were suffering from moderate to severe 19 depression, 58.3% were suffering from anxiety and 72.3% experiencing moderate to severe levels of stress. Moderate to severe insomnia was also reported in 39.7% of the sample, leading the researchers to draw a positive relationship between the four symptoms. With a majority of nurses suffering from mental health issues, the recommendation of implementing preventative measures was highlighted in order to reduce risk of suicide, leaving the profession, and other negative life outcomes. In Jordan, a cross-sectional study of 448 nurses was examined to quantify how vulnerable nurses were to developing acute stress disorder (ASD) and other forms of psychological distress (Shahrour & Dardas, 2020). Over 60% of the sample met the criteria for acute stress disorder and were also showing high risk for a post-traumatic stress disorder predisposition. Of the remaining sample, 41% were found to be suffering from significant psychological distress symptoms. In this study, researchers found evidence to suggest that younger nurses were more prone to experience psychological distress compared to older, more veteran nurses. To quantify the results into a greater context, the prevalence of ASD among disaster workers are reported to range between 14.6-40.5%, and healthcare workers in combat zones are reported to range from 5.3-8.5% (Shahrour & Dardas, 2020). The aggressive initial spread of COVID-19 paired with the high infection rates were thought to be part of the reason why the nurses in the sample showed such high levels of acute stress disorder, as well as the lack of preparation by hospitals in allocation or resources and support staff. Turkish nursing associations have reported how nurses had no choice but to work in COVID-19 units without appropriate training and lack of access to personal protective equipment (PPE); therefore, increasing the fear of getting sick and spreading the virus to family members or society (Yıldırım et al., 2021). A phenomenological study of 33 nurses working in 20 COVID-19 units for at least one month found four key themes; nurses feeling their needs were unmet through lack of support from management, anger at the unrealistic expectations placed onto them, questioning their commitment to the nursing profession, and making a decision about whether to continue in the nursing profession. A reoccurring subtheme described how nurses were not getting enough sleep or rest due to the shortage of staff, requiring them to have fewer breaks and a shorter gap between shifts. Researchers hypothesized that these themes may have been exacerbated by the fact hospitals in Turkey removed annual leave rights and suspended leaving the profession during the COVID-19 pandemic (Yıldırım et al., 2021). With nurses being given low levels of autonomy within their work and the ever increasing expectation of the profession as saviours, reports of feeling undervalued and ignored with low compensation highlight a fragile environment. Another Turkish study was performed with 19 nurses and utilized qualitative semi-structured interviews over an online messaging service to explore what barriers they were facing (Akkuş et al., 2022). Psychosocial adaptation was a focal point amongst nurses, citing experiences of stigmatization, exhaustion, burn-out and compassion fatigue due the constant flow of patients and disruption of their personal lives. Issues of acquiring PPE was also noted; however, there was more of a discourse relating the difficulty nurses faced in providing direct care and treatment while wearing PPE. Nurses voiced how difficult it was to hear voices from colleagues or patients with masks on, or how the goggles would fog up or collect sweat. Bombarded with constantly changing information regarding best practices and policies, the nurses reported working in adverse conditions they were not sufficiently prepared for. In Iran, a qualitative phenomenological study was performed involving 15 nurses to understand their experiences of providing care for COVID-19 patients (Chegini et al., 2021). 21 Psychological stress was an apparent theme, with many nurses reporting high levels of fear, stress, anxiety and desolation in the face of the pandemic. Organizational issues in the hospitals centering on improper planning by management, lack of staffing, lack of PPE and challenges to meeting protocol and guidelines was another theme commonly cited. Social factors primarily played a negative role for all the nurses in the study: the social panic, rumors and false news surrounding treatment and the cause of COVID-19, as well as the blatant failure to comply with health protocols exacerbated the psychological stresses they were already feeling. Some nurses did find the encouragement and support from friends and family enough to be reaffirming to the nursing profession. Lastly, nurses reported professional issues such as inadequate training of staff in new protocols and unreasonable work shift durations which could be up to 72 hours without a break (Chegini et al., 2021). There was a mix of positive and negative responses to all the themes except for organizational challenges which were all overwhelmingly negative. Asia With the pandemic causing a rise in fear and anxiety in most of the population, a study was performed in Asia to compare the levels of anxiety and depression in intensive care nurses treating COVID-19 patients and other intensive care nurses treating non-COVID-19 patients. In a quantitative comparative cross-sectional study of 96 nurses in Nepal, researchers found no statistical significant difference between COVD-19 and non-COVID-19 intensive care nurses in regards to depression and anxiety (Tamrakar et al., 2021). Psychiatric caseness was present in 85.4% of the sample, with depressive symptoms in 21.2% of the COVID-19 nurses and 9.1% in the non-COVID-19 caring nurses. Anxiety was reported in 36.5% of the COVID-19 nurses and 27.3% among the other nurses. The only statistical difference found between the nursing groups was in relation to sleep disturbances and confidence in caring for their patients, both of which the 22 COVID-19 nurses reported more problems with. Across the entire sample, 64% reported dissatisfaction with their work and 32 of the nurses intending to change departments. This study’s conclusion was that anxiety and depression were both commonly reported ailments with the intensive care nurses. Although the nurses working with COVID-19 patients had higher levels, it was not statistically significant (Tamrakar et al., 2021). In Wuhan, China, researchers sought to explore the work experience of front line nurses treating patients infected with COVID-19. Using a phenomenological method, 30 nurses from a designated COVID-19 hospital were recruited to participate in semi-structured interviews (Tan et al., 2020). Two main themes were generated: negative experiences during clinical work and positive impacts of clinical work. A recurrent subtheme of negative psychological experiences during clinical work was shared amongst all participants, citing fear and anxiety due to the unfamiliar disease and work environment, paired with the helplessness and frustration at only being able to provide empathy and compassion. The negative experiences were primarily centered on the work environment, with nurses pointing at the shortage of health care workers, lack of PPE and inadequate knowledge and training to deal with the disease. Participants in the study also emphasized the need for counselling support to help maintain healthcare workers mental well-being in times of great stress. Nurses noted they were not given access to psychological interventions in a timely manner, which promoted deterioration of their mental health. Positive impacts of working during COVID-19 were reported as a sense of improved professional responsibility and promotion of professional identity as front line healthcare workers providing essential treatment to those in need (Tan et al., 2020). To understand experiences of front line nurses, a study of public online diaries on a popular Chinese website, Sina Microblog, was performed in Jinan, China. Using inductive 23 content analysis, twelve nursing blogs from nurses, encapsulating 205 separate entries were examined (Chen et al., 2020). Two main themes were identified: construction of a better self and constructing a strong support network. The blogs mentioned the positive emotions associated with taking care of patients and the pride and sense of achievement they felt when patients recovered. Social support from significant others and colleagues was listed as vital to maintain a positive outlook, as well as finding self-support from narrating their personal experiences through these blog entries. Findings suggested that nurses were able to discharge negative emotions through focusing on the positive interactions with patients, colleagues, friends, significant others, and especially though reflecting upon them in their blogs. Similar to the study mentioned prior, there was also an improved sense of professionalism due to the importance of their occupation, but also found that their passion for nursing had actually increased (Chen et al., 2020). A study in Singapore also sought to better understand nurses’ experience of working in hospitals during the pandemic and engaged in semi-structured online interviews with 17 registered nurses across the country (Goh et al., 2021). Reports of physical and psychological challenges related to the working conditions of the hospitals, linked to lack of sufficient PPE and poor communications with management and staff over protocol, information distribution and giving feedback. Nurses voiced having to dispel their worries and embrace their professional roles to demonstrate commitment to their jobs and the reliance they subsequently needed from family and friends in order to overcome mental and physical challenges. The participants in the study also cited the need for accessible psychosocial support for healthcare staff in order to persevere and maintain their health (Goh et al., 2021). 24 Another Wuhan based study looked to assess posttraumatic growth levels and its influencing factors among frontline nurses during the COVID-19 pandemic. With a sample of 116 nurses working in COVID-19 isolation wards, a quantitative cross-sectional study was performed using the 20-item Chinese version of the Posttraumatic Growth Inventory (PTGI) (Peng et al., 2021). Study participants with children reported significantly higher posttraumatic growth scores than those without, with researchers believing the difference may be a result of receiving communicative support from family members. Nurses were confined to their rooms after work, at designated hotels and commonly reported insomnia, hair loss, weight loss, and loss of appetite during their stay. No significant differences in posttraumatic growth scores were attributed to gender, age, education level or work experience (Peng et al., 2021). Europe In Seville, Spain, an inductive content analysis study was implemented to investigate intensive care unit nurses experiences in caring for critically ill patients (Fernández-Castillo et al., 2021). At this care facility, the mortality rate was at 42.4%, and 17 nurses working at the ward participated in semi-structured online interviews. While providing nursing care, nurses mentioned the isolating environment they were working in, trying to minimize contact with the patient and subsequently not being able to develop the rapport they were used to having with patients. The sudden increase in workload and use of PPE were noted to de-humanize patient care, struggling to provide the same level of quality care to every patient and being unidentifiable with PPE on. Psychosocial liability was another theme, with fear being the most reported emotion by participants, not only because of how the nurses were reacting to the pandemic but how it would also affected patient care. Frustration with resource management and misinformation from the media reportedly added to the pre-existing fear nurses were developing. 25 Nurses did however find a strengthening of professional relationships due to the reliance they developed with their respective health teams to share and cope with the physical and psychological burdens they faced (Fernández-Castillo et al., 2021). Comparable findings were identified in an Italian study in Genoa, where researchers examined issues facing front line nurses through a descriptive qualitative study (Catania et al., 2021). With 23 study participants, they shared how the lack of PPE exacerbated the already high risks they were facing in dealing with COVID-19 positive patients. The massive organizational and logistical changes they faced as a professional also added to the physical and psychological challenges they were facing. Nurses had to make the choice and live away from their family to avoid spreading any infection and had to learn to lean on their colleagues for support instead. The importance of resilience and effective management were suddenly thrust into the spotlight and gaps in management’s sensitivity with their workers were highlighted. Participants complained about the lack of protocols established for patient care while wearing PPE and available methods to communicate with their families. The overall sentiment was that the leadership group were insufficiently prepared for the impact of a pandemic on their staff and subsequently contributed to the psychological stress nurses were facing (Catania et al., 2021). A British study looked to quantify the levels of resilience, anxiety and depression working in respiratory units during the pandemic and used an electronic survey to reach 255 nurses (Roberts et al., 2021). Measures in the study included a resilience scale, GAD-7, PHQ-9 and relevant demographic data such as age and gender. Results showed that 21% were experiencing moderate to severe anxiety, 17.2% experiencing moderate to severe depressive symptoms, and 18.9% having low or very low resilience level scores. Using a regression analysis authors showed correlations between depression and anxiety variables, as well as age and years 26 of qualification as a nurse. The most significant implication of the findings is that younger nurses with less experience exhibited higher levels of anxiety, depression and lower resilience and that individuals between the ages of 35-50 were less likely to score above the threshold for anxiety and depression. It was noted that since 79% of the population were over the age of 35 and had significant nursing experience, which may explain the lower percentage of the sample having notable anxious and depressive symptomology (Roberts et al., 2021). North America In an effort to understand American nurses working experience, a country wide study was performed with eight focus groups spread across four hospitals sites in the West, Mid-West and Eastern United States (Kelley et al., 2021). Guided with constructivist grounded theory methodology, researchers analyzed the information gathered from their 43 participants using the constant comparative method. From their data, they established four prominent, interrelated themes; challenges, feelings, coping and ethics, all of which were expressed negatively more so than positively. The challenges nurses reported included the moral uncertainty of treating patients while trying to maintain personal safety, sudden change in work policy, increased workload, lack of transparency from management and partnered organizations, and the perceived unfair treatment and disrespect nursing as a profession received during the pandemic. Nurses cited feeling many overwhelming emotions such as guilt and terror due to working in difficult conditions paired with possible exposure to a potentially lethal virus. Upon reflection, many participants indicated they were traumatized from their working experience but never had time to process their emotions and had no choice but to suppress and bury them in order to continue working. Participants admitted to turning towards substance use and abuse due to the failure of their coping strategies and skills. Only a few nurses admitted to seeking medication and therapy 27 in recognition of their waning coping ability. Lastly, the moral ethics of balancing harm to themselves or family were cited to be at odds with how to care for their patients due to the uncertainty with treatment procedures. Instances of moral distress, dilemma, injury and outrage were well represented in participant accounts (Kelley et al., 2021). In Massachusetts, a study using semi-structured interviews of 16 ICU nurses looked to explore how nurses experienced caring for COVID-19 positive patients (Cadge et al., 2021). Four major themes were identified and commonly shared amongst participants. Challenges of working with new co-workers and teams due to staffing shortages meant nurses had to constantly adjust to new team dynamics and establish new communication patterns. Adding to this was the challenge of maintain existing working relationships, as some nurses were deployed to other care units while some remained with their home unit. Nurses who were deployed to new units reported feeling disconnected and a loss of comfort compared to the support they felt they had in their home unit. The importance of nursing leadership quickly became a focus as the pandemic continued. New procedures and protocols would be disseminated, and nurses found those in leadership positions a source of support, as strong leaders would instill confidence and hope. The last theme surrounds the dissatisfaction with hospital leadership in acknowledging the difficulty of their work. Some nurses perceived the lack of medical supplies as poor support, but primarily centered on the absence of material supports such as wage increases and retirement benefits (Cadge et al., 2021). Another country wide, American study looked to explore how frontline nurses worked through the COVID-19 pandemic. Upon the premise that nurses were facing many workplace stressors such as patient acuities and budget cuts, it was reasonable to hypothesize that nurses were at higher risk of psychological trauma. A qualitative study using two open response items 28 was performed via online survey asking about the traumas experienced, and substance use or other mental health issues experienced or witnesses in other nurses (Foli et al., 2021). Of the 102 participants who responded, there were 70 responses to the first item and 65 responses to the second. Five themes were established from the first item including the experiencing of psychological distress in multiple forms, the tsunami of death induced by so many patients passing away, feeling torn between personal safety and professional duties, job disillusionment combined with intent to leave the profession, and the post traumatic growth experienced in themselves and others. From the second question, three themes were highlighted. An overwhelming sense of exhaustion due to the length of the pandemic was labeled as there being a mental health crisis now. Nurses were also candid in admitting to using various substances to cope, with alcohol being the most prevalent along with tobacco, also listing use of recreational drugs and changing food consumption patterns. The third and last theme surrounded the weakening coping mechanisms of nurses and increased maladaptive coping. Isolation from their friends and family severed a foundational source of support and due to other nurses suffering from mental health issues, their ability to provide support to their peers decreased significantly. Researchers concluded that nurses were experiencing high levels of secondary trauma through daily grief and loss, workplace violence that could take the form of angry families of patients who have passed and the systemic trauma due to lack of staff, medical errors, insufficient PPE and the perception that nurses are to be used as tools (Foli et al., 2021). In a Canada wide study, researchers looked to establish if critical care nurses would suffer from psychological trauma during an infectious outbreak. A mixed methods approach was utilized, primarily composed of questionnaires including depression, anxiety and stress scales then conducting qualitative interviews with a portion of the participants (Crowe et al., 2021). The 29 study sample size was 109 nurses, 15 of which were asked to participate in semi-structured interviews. Findings from the questionnaires showed that 38% of the sample showed significant risk of developing PTSD, 23% as a concern to possible development, and 13% to probably develop PTSD. Other present symptoms included 57% reporting mild to severe depression, 67% reporting anxiety and 54% reporting high levels of stress. From the 15 participant interviews, five themes were generated using inductive thematic analysis. Rapidly changing policy and information was strongly linked with the feeling of overwhelming and unclear communications between nurses and administrators. Nurses cited having to develop new methods to meet patient needs while keeping themselves safe; this was connected with the lack of PPE or use of alternative PPE they were not familiar with and causing physical discomfort. One nurse reported not going to drink water although being thirsty because there was not enough time to remove PPE and put it back on. Another theme was the struggle to manage home and personal commitments to themselves or family. Due to treating COVID-19 patients, some nurses lived away from their family or would not see them for extended periods of time due to scheduling. The last theme involved the constant changing of clinical teams and how nurses felt they would lose their team identity and be unsure of newcomer abilities, paired with the additional effort to integrate new members into their workflow resulting in more stress (Crowe et al., 2021). Summary of Findings & Research Question In this chapter, current research surrounding nurses experiences in working with COVID-19 patients have been thoroughly explored. At this point in time, it is well-established that nurses suffer from anxious and depressive symptoms and are at high risk for developing more serious mental health issues (Crowe et al., 2021; Kandemir et al., 2021; Peng et al., 2021; Roberts et al., 2021; Tamrakar et al., 2021). Of a 440 participant sample, 64% met the criteria for acute stress 30 disorder and were categorized as high risk for developing PTSD (Shahrour & Dardas, 2020). In Canada, COVID-19 PTSD symptom presence amongst nurses have more than tripled (Crowe et al., 2021). Nurses are working in extremely challenging environments and being traumatized with no time to unpack their experience or better understand how to adaptively cope (Kelley et al., 2021). Faced with overwhelming organizational issues such as shortages in staffing and lack of communication from management in the face of the pandemic have only served to add to distress being felt (Catania et al., 2021; Chegini et al., 2021; Crowe et al., 2021; Foli et al., 2021; Tan et al., 2020; Yıldırım et al., 2021). Inadequate access to PPE has also created barriers to patient care and treatment for fear of their own personal, family and public safety (Akkuş et al., 2022; Catania et al., 2021; Chegini et al., 2021; Foli et al., 2021; Goh et al., 2021; Tan et al., 2020). Quantitative research has been very clear about the mental health obstacles the nursing profession is facing. The available qualitative studies that have been conducted have shown issues in management, levels of fear, and professional reflection (Akkuş et al., 2022; Cadge et al., 2021; Chegini et al., 2021; Chen et al., 2020; Fernández-Castillo et al., 2021; Goh et al., 2021; Yıldırım et al., 2021). Interestingly enough, only the North American studies have mentioned maladaptive coping methods such as substance abuse in nurses to deal with their mental state (Cadge et al., 2021; Foli et al., 2021). However, the qualitative studies that have been investigated primarily utilized phenomenological or content analysis approaches, using relatively large sample sizes or mixed methods studies using several open ended items at the end of a questionnaire. None of the research has utilized narrative inquiry as a method to explore nursing experiences. Without narrative accounts from the nurses in the field, their voices and stories will not be heard and be reduced to numbers and general themes. There has also an abundance of various forms of 31 research in many parts of the world, but much fewer in North America and very few in Canada. From the data, we can generate general themes from other countries and nurses but their experiences are tied with their environmental settings and may not be as transferrable to a Canadian context. In Turkey, nurses were prevented from quitting and had no choice but to continue working in healthcare during the pandemic by government legislation, which may have contributed to the desire to leave the profession (Yıldırım et al., 2021). In China, a similar scenario was in place where nurses were relocated to work at frontline hospitals and as a matter of public service, had to continue working with COVID-19 patients (Chen et al., 2020; Peng et al., 2021; Tan et al., 2020). However, in their research findings in China, there were results that showed an actual increase in passion and commitment to the nursing profession. This is to say that there are differences in nursing populations that could be tied to their citizenship and as a country comprised of many cultures, it would be of interest to see how Canadian nurses experienced COVID-19. With all the evidence at hand, there is clearly a lack of deep, qualitative exploration and a gap in understanding Canadian nurses and their working experience throughout the pandemic. Quantitative research has set the stage that the nursing profession is at high risk for developing mental disorders and is currently suffering, but what can be learned from their personal stories? In order to generate more data that can support future research, policy and interventions, more research is required. Therefore, I will conduct a narrative study to better understand the voices and personal narratives of Canadian nurses who have not had a chance to tell their story. The research question is: How do Canadian nurses understand their work experiences throughout the COVID-19 pandemic? 32 Chapter 3: Methods The purpose of this chapter is to describe the research procedures for this qualitative study which will explore how Canadian nurses understand their working experiences during the COVID-19 pandemic. Narrative inquiry will be the method used to guide this investigation, an approach grounded in social constructionism which involves challenging common-sense knowledge of ourselves and our world (Burr, 1995). Key tenets of social constructionism will be presented followed by a brief history of narrative inquiry to ground the epistemological and methodological approach of my study. After, I will outline why a narrative study is suitable to answer my research question. Next I will describe the study procedures, outlining the recruitment process, the selection criteria, the data collection procedures and data analysis steps. Lastly, will be a presentation of the criteria used to establish trustworthiness in the study and its findings, followed by a brief discussion of ethical and diversity considerations. Social Constructionism and Narrative Theory Social constructionism is a post-modern approach that examines the ways individuals develop their knowledge and form their understandings of the world. Differing from traditional psychology, social constructionism follows an anti-essentialist and anti-realist stance that holds that there are no strictly objective facts or correct interpretations of reality (Burr, 1995). Concepts including personality are examined with a critical lens and seen as fluid within its context unlike the traditional assumption that is it constant throughout life. Views that are taken for granted as fact are challenged when using a social constructionist lens to invite understanding that all things are constantly changing and varied in meaning—a keystone of social constructionist theory (Bruner, 1991; Burr, 1995; Clandinin, 2016; Gergen, 1999; Polkinghorne, 33 1988; Riessman, 2008). Being suspicious of our assumptions of the world and how it appears is encouraged to oppose the positivism and empiricism espoused in traditional science. Ways of understanding is also rooted in historical and cultural specificity. Knowledge of the time is not only from that period in history but also from social and economic arrangements present in the culture (Burr, 1995). By challenging the preconception that knowledge of the world is not derived from the objective world, social constructionism posits that social processes lie at the root of how our truths are generated (Burr, 1995). Truth is not a reflection of objective observations but rather the sum of social processes and interactions between people. Lastly, is the concept of knowledge and social action being inter-connected. While there may be many different understandings spanning a variety of different forms, each different construction of reality invites a different kind of action from humans (Burr, 1995). What may be seen as irresponsible behaviour and should receive punishment may change when the behaviour is examined from a different lens. Social constructions also posits that language is a unique human communication that allows people to give expression to existing things in the world (Burr, 1995). Seen as a necessary precondition for thought and as a form of social action, it serves as the bedrock of socially constructing knowledge through dialogue and social interaction. Narrative Inquiry Historical Underpinnings Narrative inquiry is an approach used to study human lives in a way to honor the lived experience as a source of important knowledge and understanding (Clandinin, 2016). The term “narrative” has not a set meaning but is often associated with “story” (Riessman, 2008). Historical influences can be linked back to Greek tragedies which represent a collection of 34 events, experiences and emotions. The narrative is supported by a plot which has an order of events which serves to awaken emotions and mirror an interpretation of the world. Narrative theory has shifted with prevailing movements over time, including French structuralism, Russian formalism, post-structuralism, cultural analysis and postmodernism (Riessman, 2008). In the late 1960’s, narrative research traditions began to emerge in response to several contemporary movements in an effort to turn away from positivist modes of inquiry (Riessman, 2005). The “memoir boom” in literature and popular culture, combined with the identity politics in the US, European, and other transitions such the emancipation of people from marginalised populations promoted the exploration of personal life. Narrative inquiry can also find its roots in contributions from many different definitions of personal narrative, depending on the discipline from which it originated. History, anthropology, sociolinguistics, psychology and sociology have all referred to the concept of a life story, created from interviews, observation and text (Riessman, 2005). If the 1960’s were the budding of the field of narrative inquiry, then the 1980’s was when it blossomed. Landmark works in women’s studies with participation from named scholars brought more attention to the field, eventually creating space for the writings of women of color (Riessman, 2008). Narrative inquiry continued to flower over the next several decades to now, where it can be found in virtually every field and social science discipline. Basic tenets of narrative inquiry Narrative inquiry is the methodological approach involving critical inspection of personal narratives, examining the structure, content, and context of stories in relation to its social context (Riessman, 2008). Human experience is organized by the memory of events in the form of narratives which have an built-in story explained over a specific period of time (Bruner, 1991). The goal is not to find objective truths but to understand the story tellers’ unique lens that shapes 35 their narrative. Narratives can refer to the process of making a story, the cognitive scheme of a story or the result of these processes such as stories, histories or myths (Polkinghorne, 1988). By focusing on the primary experiences and examining each event in context to the before, during, and after, narrative meaning is created (Polkinghorne, 1988). As a narrative explains the experience of a person, it also provides a glimpse into their beliefs, desires, theories, and values (Bruner, 1991). It is a relational activity that gathers others to listen and empathize, so an active participant can listen and question (Riessman, 2012). Rationale for Narrative Inquiry Just as participants’ accounts of their lives are relative to a specific period in time and cultural context, our interpretations are equally situated in a perspective and history that may have shifted over time (Riessman, 2012). By utilizing a narrative inquiry methodology, the participant’s descriptions of their life events and understanding can be excavated and reassessed to clarify and give order to what may have been fragmented, chaotic, unbearable or invisible (Riessman, 2008). Because the stories are told as they were understood at the time by the participant, it provides the present individual an opportunity to untangle and make sense of the past. Therefore, this research study will seek to better understand how nurses have constructed their own understanding of their experiences and furthermore, gain insight into the decision making and choices they had to make during the COVID-19 pandemic. The social constructionist foundations of narrative inquiry offers participants the opportunity to tell the story as it “really” happened and make sense of that unique perspective (Riessman, 2008). Narrative inquiry invites the audience to enter the perspective of the narrator telling their story and pulls them into the world, where the audience can be moved emotionally through imaginative identification. Essentially, the narrative approach assists in revealing truths 36 about nurse’s experience working during COVID-19. By establishing a narrative from a nursing perspective, their story can speak to audiences who may have interpreted it differently from the outside and give voice to those who have felt silenced and suppressed. Narrative inquiry will also generate data through in-depth accounts of several different nurses’ experiences during COVID-19, providing an opportunity to discover nuanced perspectives and meaning in their stories which have otherwise not been addressed in current COVID-19 literature. Description of Sample To be eligible for participation in this study, participants had be above the age of 19, be a currently practicing nurse and be a licensed member of the British Columbia College of Nurses & Midwives. At minimum, participants must have indicated having at least 6 months’ experience working with COVID-19 patients during the pandemic. Potential participants with a longer duration of experience were preferred as they provided an opportunity for a more in-depth recounting. The rationale behind the minimum of 6 months of experience was due to many of the reviewed studies using 1 month as their criteria, and wanting to explore the experiences of those who have spent longer periods of time working in the environment (Chegini et al., 2021; Fernández-Castillo et al., 2021; Kandemir et al., 2021; Tamrakar et al., 2021; Yıldırım et al., 2021). A majority of the remaining literature surveyed did not have experience requirements with COVID-19 patients, assuming that working critical care nurses would have treated them in some sort of capacity. Participants were required to have conversational fluency in English in order to be able to share their experience in an interview setting. There was no specific age range due to the interest in hearing different perspectives of nurses with varying amounts of experience, as it has been suggested more veteran nurses have a higher resilience and resistance to anxious and depressive symptomology (Roberts et al., 2021). 37 The aim of this narrative inquiry was to produce thick, rich, description about the lived experiences of nurses through the stories they shared. With that in mind, this study sought to recruit a purposeful sample of four to five nurses. This sample size is typical in narrative inquiry (M. Buchanan, personal communication, April 15, 2022). In order to recruit these participants, I placed posters at various hospitals in the Greater Vancouver area: Vancouver General Hospital, St. Paul’s Hospital, Richmond Hospital, UBC Hospital, Mount Saint Joseph Hospital, and Burnaby Hospital (See Appendix A). The same recruitment posters were also shared digitally over social media (i.e. Facebook, Instagram, and Twitter). A sample size of four practicing nurses participated in the present study. The participants represented various wards from different hospitals from the Lower Mainland of British Columbia. All participants were licensed nurses and had at least provided care for COVID-19 positive patients for 6 months. Participant reports of their years of experience as a practicing nurse varied between two to nine years. Procedures Screening Process Potential participants who responded to the posters were be sent a consent form through email and asked to review the consent process prior to scheduling a phone screening interview (See Appendix B and C). During the screening interviews, the purpose of the study, ethical considerations (eg. confidentiality, voluntary participation and the right to withdraw), and the expected time commitment was outlined, including that there may be follow-up questions at a later date. Participants were reminded that by participating in this study, they may experience distress when recalling moments or situations they have experienced. Participants were provided a list of available counselling resources (See Appendix E) prior to the start of the interview, in 38 the event they experienced significant distress and sought support services. The screening interview also served as a primer for participants to begin considering what important moments and learnings they would like to share about their COVID-19 experience. A suggestion to write down a list of experiences they may want to discuss was made, and if possible, to establish a timeline. Any additional important learning experiences they gained was also be encouraged to be noted down. Pilot Interviews I conducted one pilot interview to practice interviewing and to learn about the research questions and interview procedures. The purpose of the pilot interview was to better familiarize myself with the process and have an opportunity to discover how to explore their stories and to answer questions or concerns that may be raised. Recording procedures and equipment was also tested at this time. Pilot interview data assisted in the further development and revision of questions and procedures. The Research Interview Interviews were conducted over teleconferencing (i.e., Zoom) using a secured UBC licensed account. To start each interview, I invited the participant to share their story with the following guiding question: “How do you understand your working experience throughout the COVID-19 pandemic, starting from the onset until now?” Then the participant was given time to recount their experiences in full. A formalized interview structure was not be imposed onto the participants as per the narrative approach; however, an interview protocol was be utilized to serve as a guide for exploring participant stories and perspectives (See Appendix D). Follow-up and clarifying questions were used during the interview to probe deeper and allow the participants to lead their storytelling, identifying salient aspects of their experience (Murray, 39 2003). Due to the distressing nature of the topic, empathetic and supportive statements were used in order to facilitate a safe environment for participants to tell their story without apprehension or stress. Interviews were between an hour and a half to two and a half hours in length, depending on the topics and amount shared by participants. Digressions from the topic at hand were also explored as they provided contextual and associative cues in relation to the story (Riessman, 2012). Interviews were be recorded using a password protected device and stored internally in an encrypted folder. Participants were offered to select a pseudonym of their choice for narratives, data storage and analysis in order to maintain their confidentiality. However, no participant provided a pseudonym so a random name generator was utilized and checked with the participant for compatibility. A separate, password protected master list connecting pseudonym and participant identities were stored in a separate encrypted folder to maintain security. Data Analysis This study utilized a combination of narrative analytic methods proposed by Riessman (2008), in parsing participant stories of their COVID-19 experience and thematic analysis (Braun & Clarke, 2006), to examine the data gathered. Narrative analysis is the broader categorization of a group of methods used to interpret texts that share a common storied form (Riessman, 2008). Attention was paid specifically to the sequence of action as a distinguishing feature, particularly on the actors and places involved in context to the time it happened. How the speaker assembled and sequenced their story and their use of language, all communicated a level of meaning. Instead of separating the participant account into thematic categories, the account as a whole was preserved and treated as a unit. During analysis, the researcher investigated how and why the incidents were storied in a particular way, to whom the story is for, for what purpose, why was it told in that particular sequence and if there were any cultural cues it drew from (Riessman, 40 2008). The analysis also involved a deep exploration into the contexts described in the narratives that may have influenced how the story was constructed. Thematic analysis was chosen due to study size and intention to give voice to each participant. The interest laid in the content of participant’s story, and to interpret what was said by focusing on the meaning: the “what” instead of the “how”, and “told” versus the “telling” (Riessman, 2005, p. 2). By collecting the stories shared, conceptual groupings from the data were to be created inductively by organizing the narratives into themes. Braun and Clarke’s (2006) six-step approach to thematic analysis was used as a guideline for transcribing and coding the interviews. The process entailed: (1) transcription and data familiarization, (2) generating initial codes, (3) categorizing codes into possible themes, (4) reviewing themes, (5) defining and naming major themes, and (6) producing a report. It is important to recognize that these analytical guidelines were not a fixed framework and exhibited flexibility in order to best fit the research question and data. Braun and Clarke’s (2006) method is described below: Phase 1: Transcription and Data Familiarization. Prior to transcription, it was vital to be familiar with the data so that the depth and breadth of content is well understood. When transcribing the data, there was no set guideline, however was at minimum, a verbatim account of all verbal and nonverbal (eg. coughs) utterances. The key importance here was to retain the essence of what was given from the verbal account to remain true to its original nature (eg. punctuation of data that can alter meaning). It is because of this that transcription can be seen as an interpretive act where meanings are being created, influenced by the analyst’s subjectivity (Lapadat & Lindsay, 1999). Therefore, it was necessary to present the co-constructed knowledge and interactive aspects of the interview, as well as my own assumptions and ideas during the process that impacted by transcription process. I transcribed each interview verbatim and made 41 note of any paraverbal and nonverbal utterances to try and represent the participant’s story as true to nature as possible. I reviewed the interview and transcription several times to ensure no elements were missed and to increase the level of familiarization with the data. This review process was one form of immersion where I was actively looking for meaning and patterns that began to take shape. It was at this point where making notations for possible codes and themes were made to assist future steps (Braun & Clarke, 2006). Phase 2: Generating Initial Codes. Having familiarized themselves with the data, the process began of producing initial codes that appeared to be interesting, identifying segments of raw data (Braun & Clarke, 2006). An excel spreadsheet was utilized to display the transcript and code the data and to make notes to identify segments of interest. During this phase, I coded for as many potential themes as possible, including as much of the surrounding data to prevent loss of context and meaning to the text (Braun & Clarke, 2006). Even contradictory or inconsistent themes were included to avoid narrative smoothing. Phase 3: Categorizing Codes into Possible Themes. With all data having been initially coded and sequenced, it was now time to focus on analysis at a broader level. Codes were gathered and sorted into potential different themes and sub-themes. Relationships between codes, themes and different levels of themes were being examined for relevance. Analysis began of the coded data to inductively draw upon latent themes within the text and sort them into main and sub themes. Data that did not fit into any theme was sorted into a miscellaneous category for future reference and eventual discardment. By the end of this phase, a sense of the significant individual themes emerged. Phase 4: Reviewing Themes. This phase involved the refining the possible themes generated in Phase 3 in two levels. During this first level, some candidate themes were collapsed 42 into a single theme due to lack of supporting data, or broken down into separate themes due to data heterogeneity(Braun & Clarke, 2006). Regardless of the breakdown, the data within themes was meaningfully correlated to retain clear distinction from one another. In the event that a theme did not fit or was problematic, was reworked into a new theme, separating the data into other existing themes, or discarded from analysis. The second level considered the individual themes relative to the entire data set as well as how the thematic map generated in level one reflected meaning to the data set as a whole (Braun & Clarke, 2006). There was a need to re-code additional data for themes that was missed in the earlier coding stages. Possible new themes of interest were identified as well, requiring another re-coding of data. It is important to note that this analysis was a recursive process, moving back and forth as required until satisfied with the thematic map. Phase 5: Defining and Naming Major Themes. The fifth phase of data analysis involved further defining and refining the themes presented for analysis and then analysis the data within each theme. This process was to identify the nature of each theme and what aspect of the data it captured (Braun & Clarke, 2006). Simple paraphrasing of the data content was not sufficient, requiring identification of what is interesting about the themes and why. By the end of this phase, I was able to clearly define what my themes were and what they were not, as well as providing an appropriate name for each theme. Phase 6: Producing the Report. This final phase involved the final analysis and write-up of the report supplemented by the set of fully worked-out themes. This write-up sought to provide a concise and coherent account of the story generated from the data, convincing the reader the merit of the analysis. Inclusion of transcript examples was utilized to demonstrate sufficient evidence of the themes within the data set while providing vivid examples, capturing 43 the essence of the story being told (Braun & Clarke, 2006). While the extracts were used to illustrate a compelling story, the analytic narrative it served went beyond simple description of the data and established an argument supporting the analysis in relation to the research question. This report represents the Findings Chapter of this thesis. Criteria for Evaluating Trustworthiness Member Checking To instill a sense of trustworthiness in the findings, member checks were held with each of the participants to ensure credibility of the narratives presented by the researcher. These follow-up meetings were guided by Riessman’s (2008) four concepts of resonance, comprehensiveness, coherence, and pragmatic value. Participants were be emailed a summary of narrative themes generated from the data along with interview excerpts to read over and think about feedback to provide in the included member checking sheet. Resonance was assessed by asking the participants if the presented themes resonated with their experience of the interview and the narrative as told. Comprehensiveness was evaluated by asking participants if any important themes or aspects of the interview were left out or not represented to their satisfaction. Were there any major gaps or inconsistencies? Coherence was determined by asking if the participants found the themes understandable. Was there clarity in the findings? Pragmatic value was assessed by asking if the overall findings have any value for the counselling profession and health care professionals. Any additional feedback or recommendations shared by participants was taken into consideration when writing the discussion chapter regarding its implications for future research and practices. The protocol for member checking procedures is described in Appendix F. 44 Researcher Subjectivity and Reflexivity As the researcher, I must remain cognizant of the influence that my personal perspectives and experiences may play in the process of shaping the participants’ narratives and subsequent themes (Murray, 2003). By interacting with multiple participants throughout the interview process, my own perspectives and interpretations of shared stories may have been impacted from one to the next. It is also important to recognize that I was the one who organized and picked the participants who are in the present study and assumed the role of an interviewer when conducting narrative reviews and member checks. There was the possibility the interviews given by the participants were impacted due to this role divide. I am aware that I am not a nurse but a graduate student conducting research, and may have been considered an outsider asking questions about a potentially sensitive topic and difficult experience. My own experience and knowledge of COVID-19 may have potentially influenced how I navigated the interview and the type of questions I chose to ask. I remain aware that my predispositions may have led me to interpret their stories in self-confirmatory manner. All of these factors had the potential to influence many aspects of the research process and I endeavored to remain transparent in all facets, interacting with the participants, during the data analysis and writing of the final report. To assist in my reflexivity, I kept a research journal where I could interrogate my opinions and thoughts about the findings and research process. Ethical and Diversity Considerations This study was approved by the Behavioural Research Ethics Board of the University of British Columbia prior to commencing the research. Due to the potentially sensitive nature of the topic, a safe space was created for the participants to share their stories as well as building a rapport to allow them to be as comfortable as possible. To ensure the psychological and 45 emotional safety of the participants, each were informed prior to, and during the interview process that they may withdraw from the study at any time, and that they were under no obligation to participate. To ensure confidentiality, all data was secured inside an encrypted folder inside a password protected device, as well as having pseudonyms attached to their respective data files. Participants were made aware of available counselling resources and services through the resource sheet provided prior to the interview, and no participants requested any debriefing or support at the end of the interview (See Appendix E). Significance of Study By exploring the stories that nurses constructed of their working experience during COVID-19, this narrative study gave voice to the nursing population that has suffered so much and been underrepresented in current research. By giving clarity to the struggles nurses faced, their stories may give information to shape future practice and policy, contributing a more sustainable and healthier future for essential workers. This also provided further content for anyone who wishes to become better informed about nurses working experience during COVID-19, whether it is other health professionals, friends, or family. 46 Chapter 4: Results In the narrative interviews utilized in the present study, participants were invited to share their stories of their work experience as nurses during the COVID-19 pandemic. These stories were composed of various aspects of their lived experience during the pandemic, ranging from the struggles they faced due to the influx of patients and constantly changing procedures to finding their inner resilience to continue working along with the support of colleagues. The findings are constructed with an approach intended to represent the participants’ point of view and understandings. Five key themes are presented with supporting narrative segments taken directly from participants’ interviews describing their work experiences. Introduction to the Themes Each of the four participants in the present study had unique perspectives and experiences to tell regarding their work experience during the COVID-19 pandemic. However, there were overlapping commonalities across the participants’ accounts culminating in the emergence of codes during the thematic content analysis of the narrative stories. Five key themes were formed that represent various common experiences shared and not shared between the four participants. The five main narrative themes are: a) concerns about personal safety, b) struggles with workload, c) administrative presence, d) perceptions of nursing culture, and e) personal mental health. Theme 1: Concerns about Personal Safety Definitions of personal safety included participants’ explicit and implicit recounting of their work environment being hazardous and dangerous. Participants described not only a concern for their wellbeing due to dwindling personal protective supplies (PPE), but also an 47 unprecedented increase in negative to hostile interactions with patients to where it became a regular occurrence instead of a rarity. Through the participant narratives, three subthemes emerged: a) personal protective equipment, b) physical violence, c) verbal harassment. Personal Protective Equipment (PPE) A commonly shared sentiment across the participants was that the shortage of PPE at the onset of the COVID-19 pandemic caused a certain level of stress. Guidelines surrounding usage of PPE were constantly changing in response to the shortage and nursing practices that had been ingrained into practitioners were now being shifted in a way that caused some concern for personal safety. Prior to the pandemic, best practices were described as changing masks every time a nurse would enter and leave a patient’s room or after a treatment as it would be considered contaminated. Due to the shortages, nurses were being instructed to reuse N95 masks, which are the masks of preference due to its higher filtering capability and they were surrounded by uncertainty if COVID-19 was capable of airborne transmission. One nurse mentioned how they were told to place their mask in a paper bag when not in use, in an effort to keep it cleaner. Another nurse described how her unit would wear a surgical mask on top of the N95 mask in an attempt to mitigate degradation while being unsure if it did anything at all. As Samantha recalled: But at the time, there was a whole shortage of N95s. So I think the proper standard is that you're only really supposed to wear the N95 for about 20 minutes before the seal isn't as effective as it should be, but we would be asked to wear the same N95 for the whole day, or like reuse it. And I'm just like, “How does that work?” Because once you take it off, you've broken that seal and….you know, so I think it's just a lot of, like, skepticism too towards what we were being told. 48 There was a consensus that with the PPE shortage it was a constantly struggle of trying to figure out what they should be doing at the time with the limited resources they had available. The skepticism Samantha described was the prevailing sentiment across the participants where they were to treat infected patients with masks that may no longer be effective in protecting them. Participants described their frustrations with the entire situation and collectively questioned if they wanted to keep working with these conditions in place. Physical Violence Due to the rapid spread of COVID-19, an influx of patients were entering the healthcare system and what used to be rare instances of physical violence at the workplace seemed to became more common. One nurse recounted how many of the COVID-19 patients she treated were from displaced populations that generally did not have access to housing or housing in which they could be isolated. Some of these patients had substance usage or mental health issues that would prove to be a very challenging time for them during their hospital stay resulting in acts of violence. Another nurse described how despite the hospital having posters stating to have a no tolerance policy on violence against staff, they felt it was meaningless due to there being no actual consequences. Sara described how nurses are often left to fend for themselves as help would often be far away: There was an instance where a patient was actively trying to use a weapon to where it’s like, staff… towards like healthcare workers like the nurses, physiotherapists and also towards security as well. We’re on the 10th floor and whenever we call security it takes around like 10-15 minutes for them to come up and that’s a long time. And a lot can happen within that time. So usually we try to just protect ourselves and try to deescalate 49 whenever the patient is escalating, but there’s honestly not much more that we could do…and at that point we had to call the police. Nurses have an obligation to provide care to their patients and if violent acts occur, they would call for security or restrain the individual if possible, and then were expected to continue providing treatment as if nothing happened. A nurse vented their frustration asking “the way people like physically treat us, and just…like in what other situation would this be okay?” All participants agreed that they were no strangers to physical violence in the workplace, but now the frequency it was occurring was something they had never experienced before. Verbal Harassment In tandem with the rise of physical violence, verbal harassment was found to be rising just as fast, if not even faster. Nurses described how patients would need to be isolated when found to be COVID-19 positive and would become frustrated that they were not being released or argue with staff about the treatment procedures. A prevailing commonality across all participants was also how visitors would frequently violate visitor guidelines (i.e., Not wear a mask or too many visitors at once), leaving the nurses to try and explain why they need to follow the rules and were met with anger and outrage. One nurse described how much of a challenge this would prove to be as they would not be inclined to physically remove someone if they were found violating the rules; therefore, they were “constantly trying to be polite about it,” but would receive “push back” devolving into an argument. Silas recalled how he would handle patients that would “talk back” or disagree with following the rules: There’s like at first, there’s like a ton of patients who didn’t believe it or like, you know, didn’t…didn’t feel that, like, didn’t feel that it was real. And honestly, that for us at least, I…I didn’t actually find that too much of a problem because we were just like, if you 50 don’t wear a mask, you’re not getting surgery and then or just like, if you don’t get a mask, like, we’re not like you’re not, you’re not going to get care. They’ll hate it, but they’ll do it, yeah. The nurses expected to be providing care and discussing treatment options but found themselves relegated to becoming a verbal “punching bag” for many disgruntled patients. Part of this would be attributed to the anti-COVID-19 sentiment that some patients carried, which will be explored further in a later theme. Theme 2: Struggles with Workload The nurses unanimously agreed that their workload significantly increased during the COVID19 pandemic. Participants described their workload as duties related to the number of patients they care for, tasks associated with caring for them, and the amount of time required completing those tasks. Three subthemes emerged and are discussed below: a) patient load, b) sanitation, c) time management. Patient Load Patient loads were defined as the number of patients assigned to each nurse, with participants reporting the “average load” as four patients per nurse, possibly five if the patients’ presentations were deemed less challenging and intensive. During the pandemic, this load shifted drastically to accommodate the sheer number of patients requiring treatment and one nurse described the situation by stating that: “We don’t have enough beds for patients. There are patients who are sitting in the ER for like a day or two because we don’t have any inpatient beds for them.” The staggering number of patients was literally exceeding the physical limitations of the unit spaces nurses were working in. Silas disclosed his workload situation at his unit as: 51 And we're a very small ward with not a lot of nurses and not, we're only staffed for like 4 to 6 patients a day. But you know, I think for about, for about a year, a year and a half, uh, we’re up to like, almost double or more uh patients on the ward at all times. Silas’s experience was not unique, as the other participants echoed very similar sentiments about their patient loads increasing substantially and being placed under greater strain trying to care for them all. One nurse mentioned in passing that “it’s like it’s always been the same situation, we’re understaffed, but it was more like, like you just knew you were understaffed like every single day.” Nurses described the weight they felt due simply to the added number of patients they were expected to attend to, not even factoring in their various requirements of care. Sara voiced her concerns as: We only have 4 nurses on the unit looking after like 25 people, that’s not appropriate like safety wise, it’s not safe for the patient or the nurses. We…it would be great if we can look and have eyes on everyone, but we can’t do that. Limitations of their ability to provide care to larger patient loads were an emphasized concern shared by all participants. Another dimension adding more to their workload was the possibility of having to train new hires on the job while providing care. A nurse stated how “it feels more stressful as the one orientating them because on top of that, we have our own patients.” Not every participant was involved in a training capacity due to the type of units they belonged to but this sentiment was shared by more than one participant. Sanitation With the fear of the infection spreading, sanitation procedures and policies were rapidly changing to try and minimize the risk of transmission at hospitals. Nurses described changing their own sanitation habits simply due to “muscle memory” of having to do it so often at work 52 that it carried over into their own personal life. All participants described their shift from commuting to work and home in scrubs changing to always having a change of clothes and trying to shower and change their shoes when leaving the workplace in an attempt to prevent bringing any bacteria home. The main focal point that emerged from the interviews was that in the workplace, new policies or lack thereof added to their workload. One nurse recalled how his unit did not have any clear policy about cleaning their equipment and workspaces but did so anyways, “to make sure and just kind of help protect everybody.” This seemed to vary participant to participant relative to their units, but Samantha’s unit had a clarified policy which required them to clean multiple times a day, with her expressing: But then, yeah, we…we were getting tasked to clean our own workspaces like the, the medicine cart is one of our big workspaces that we have because they’re kind of specific to the room. And now we were being told that we had to…make sure that we’re cleaning it all the time and everything, but we’re already busy with an increased workload of everything else and now they’re like, but make sure you clean all of your workspaces and like wipe everything down and just constantly be wiping everything down. But you know, I’m like, why can housekeeping not do that? Why are we doing more stuff on top of the increased workload that we already have because of COVID? This frustrated sentiment was shared by all participants and was not limited to cleaning their workspaces and equipment. Whenever patients were discharged, their rooms would have to be sanitized for an incoming patient and one nurse described how they would normally utilize a machine dispersing ultraviolet light operated by a technician to clean the rooms. The issue the nurse raised was that technicians were only staffed until 5 pm so if any patients were to be received after that time, nurses would have to physically wipe down the room twice in an attempt 53 to sanitize the space while being unsure if it is even thorough enough compared to the machine. Nurses were being tasked with filling in the gaps while being on the frontlines of patient care and it has only served to adversely affect their workloads. Time Management Time management in this instance seemed to circle around two topics by the participants: a) the amount of time required providing care for patients increasing and b) the amount of time they had for themselves while at work, such as breaks. As evidenced by the previous two subthemes, with increased patient loads and increased duties to complete, nurses were short on time with a long list of tasks. A common challenge nurses were facing was how they would have to put on and off their PPE after treating patients, especially if they were in an isolation room due to patients being COVID-19 positive. A nurse described the process as taking up to 10-15 minutes just to get all their gear on and prepare all the supplies required to treat the patient. This was called “cluster care” by the nurses, where they would try to do all they could for the patient in one visit so they would not have to visit several times with the added time expenditure of “donning and doffing” their PPE. In order to perform their tasks safely and minimize their risk of exposure, the time required to treat patients had also become a delaying factor for doing their charting or transitioning to another patient. A significant impact of this was stated by Silas who purported that in order to do their jobs given the time limitations; they would have to skip some steps in order to provide care. Like I mean the, the thing about that is like in, in my opinion like it’s, it’s…it’s not new. Like, with all the guidelines and protocols and how to do things properly from admin and you know all the books and instructions and whatnot, like you can’t do your job. Like there’s…there’s no way. Like I…I…I can guarantee you that every nurse right now in the 54 hospital is not following the rulebook, like word for word, like that, you can’t do your job. Silas would go on to clarify that nurses would not be skipping steps in patient care but rather personal care in terms of not donning all the required PPE such as wearing a face mask and properly securing it in order to save some time and provide treatment in a more timely manner. For some other nurses, they reported instead of skipping steps to ensure timely patient care that they would add a step instead. This would take the form of coming in to work early and reading patient charts and discussing with the previous shift nurse any complications or information they would need to know. A nurse mentioned how although its unpaid time, it was something she found necessary to do so for the safety of her patients and her own, given the confines of their working hours. Due to the more restrictive schedules associated with wearing PPE and giving care to patients, nurses reported having less time for personal care. Sara stated: And until we feel like we can actually take the PPE off, we're not doing anything for ourselves like we’re, we're not going to the washroom, we’re not going to pee, we’re not going to eat like, just make sure you get your stuff done and then once you know that you can take down your PPE. It's like OK. The pressure to try and complete as many tasks as they could in their allotted time per patient would prove to be challenging to their own wellbeing. Silas also spoke about the nature of sacrificing their own personal time in order to get things done. Yeah, like I had to, like…I had a shift where my first break was at 6:00 pm. Yeah, I started at 6:30 am. So like, I would just like after that I would just be like OK, like if my breaks at like 4:00 PM, …that’s OK. 55 Theme 3: Administrative Presence From participant accounts, this theme is the overarching managerial portion of their work experience that involved a) policies and communication, b) staffing and staff placement, and c) support for nursing staff. Administrative presence would prove to be a strong emergent theme in every participant’s story as it would dictate whether their work environment was more bearable or not. Participants shared both positive and negative sentiments that coloured their perspective on their work environment. Policies and Communication The ever changing policies and communications from the health authorities and hospital administration staff was a universally shared experience by all participants. During the initial onset of the pandemic, due to the lack of information about the disease, it was not uncommon to have new information being disseminated daily by various different sources with different interpretations. Nurses were directly dealing with infected patients and a shared frustration about feeling that they were behind the curve of that information, or ill-equipped with what procedures to follow. Samantha described: It felt like, information was changing by the day and even within the day, it would be, told that like for example that it’s spread by droplet and there’s a certain way that you have to protect yourself for that. And then like the next day, they’re saying it’s airborne and then they’re kind of saying again that its droplet. And then so I think all of those things were constantly changing. So it was just a big, like, fear of the unknown type of thing or, like, fear of how do we even protect ourselves from this? 56 The inconsistent communications by administration regarding best practices and protocols only fueled indecision and confusion over how to best do their jobs. As a newer nurse at the time, Sebastian shared: So it’s constantly changing everywhere you go cause, they have to like figure out, you know, between staff and between patients and all the areas in between. So it was just a lot of changes at once and trying to keep up with it was a little daunting, especially for myself. One nurse described having raised her concerns to management with suggestions on how to better streamline workflow and sanitation processes to alleviate some pressure on the nurses and never received any response. Another nurse shared the same sentiment but added how they would get reprimanded for raising their concerns to management, almost to discourage the voicing of suggestions. The nurse added how their manager was “just not really good, just not receptive in any way to any kind of feedback and not supportive.” Most of the participants shared that the communications from administration were usually in the form of long emails that were sent the night before their shifts, providing little to no time to read up on changes and having to wade through a mass of information to find policy changes relevant to their unit and practice. One nurse mentioned how in order to try and keep everyone on the same page, their unit team would have a quick “team huddle” at the start of their shift to briefly discuss any changes and concerns, independent of administration. Staffing and Staff Placement All of the participants spoke of their observations that pre-pandemic staffing was barely sufficient, and then becoming noticeably insufficient as the pandemic began. However, what emerged from the stories showed a juxtaposition of both positive and negative staffing 57 experiences shared by the participants. One nurse shared how they would experience frustration due to the lack of available staff to help with a patient, and how they would be left “awkwardly standing there for someone to come by” on a regular basis. With the increased workload and limited allotted time, nurses voiced how during the pandemic the lack of personnel slowed down their ability to provide efficient care to their patients. Samantha stated: When I first started working, I started working in 2019, so before I had a taste of pre- pandemic healthcare and now it just it’s…it’s just so much worse than it used to be in terms of like sheer volume of people, acuity of people coming in. And then for us, it’s…we haven’t had it really any increase in resources. We haven’t had any change in our staffing model to kind of accommodate that. And even when we did have like a lot of COVID patients around and like on my floor too, it didn't feel like we were really supported in any way. Another nurse commented how they had accepted that they were in a profession that was chronically understaffed and supported and to just have to “suck it up,” and that it was a commonly accepted mentality in their line of work. The participants who voiced having less of a staffing issue attributed it to better management and allocation from their unit coordinators. A nurse explained that due to being part of a larger unit, they would receive more attention and staffing from management. They would have a large pool of nurses to call into work and did not require any specialty training, enabling even greater access to more nurses if the situation necessitated it. This nurse noted how “there’s only been a few instances where we’ve been short staffed, but it gets fixed pretty quickly.” Another nurse mentioned how their manager was working on staffing up their unit and added a float nurse, a nurse without designated patients, to provide an extra hand in monitoring or 58 administering care. Silas described how his unit coordinators played a significant role in keeping patient flow moving and ensuring adequate staffing: It was a lot of, uh, a lot to do with the coordinator, just like pushing people out of our ward just because we can't accommodate and whatnot…I do think it was just like really good coordination with like the patient care coordinator as well as the nurses…Yeah, a lot of like, like a lot of hard working people there that you know, would pick up, like a lot of shifts. Like over like, you know, months like, days on end and yeah for some reason like…we just had enough people to kind of cover the patients. Silas would go on to explain how he had experienced both “good and bad” coordinators but that the two that he had during the pandemic were “amazing.” His management would also consider staffing a senior nurse on every team when possible to provide support and leadership to the more junior nurses in his unit which improved the patient flow in his opinion. Staff placement is in relation to what unit the nurses were assigned to. According to their experiences with staffing, both positive and negative experiences were shared by participants. One nurse described how they would be “protected” by their leaders and prevented from being assigned to another ward or unit citing their specific training being required or being familiar with the patients in their care already. This positive experience would seem to be in the minority as the other participants generally shared quite negative opinions about how they were moved to different wards in need of more staffing with little warning. A nurse stated how they were “dropped into another ward without any type of training orientation or anything, but you’re expected to just jump in there and work as if you work there.” Participants shared how nurses may share a general basic knowledge and training, but that other wards have different protocols, 59 medications dispensed and administered, unfamiliar colleagues to coordinate and work with, and different procedures they were not familiar with at all. Sara disclosed: I felt like if I go in, I’m just, you know, I’m trying to be the best nurse I could be and try to do the best for my patient and support my team. And that was the mindset that I like, go in with. But now like when I go in and it’s like, oh, like, who am I working with today? Like who are the people I’m working with today? Who’s…who’s on, like the management on…on… who’s…who’s the, the team of doctors I’m gonna be working with? Those are some things that I’m, I feel like I’m paying attention more to now because before it’s just like we’re all on the same team. It doesn’t matter who’s working with who, but now it does matter because….It’s like, who can I rely on? Who can I like? Who can I trust to like, support me? Like, truly, truly support me? This type of self-questioning was a common trend among several of the participants, sharing how they would feel “totally incompetent” because they would be “trying to play catch up the whole day, trying to learn as you go.” These nurses felt that the patients expected a certain level of competency and deservedly so, but that they felt it was unacceptable to be placing nurses without the requisite experience or training into a unit they had never worked in before. A nurse disappointedly shared how they did not feel their leadership had tried to remedy this issue in anyway and had just been using what should have been a pandemic stopgap measure as a longer term solution. Support for Nursing Staff Nurses shared varying experiences with administrators supporting the nursing staff in relation to training, avenues of mental health supports, or listening to the nursing staff for desired changes. One nurse shared how their manager was not a nurse and had never worked in patient 60 care before, and would fail to appreciate the concerns shared by nursing staff. This nurse described it as “like a negative amount of support for us…it’s made me want to quit quite a few times…that unit anyways.” Another nurse shared how they felt their administrators tried to advocate for the unit but was constantly overwhelmed with trying to run a larger unit and would not be able to address many concerns due to their own workload. Nurses said they understood that the administration was under a certain level of stress as well but that did not excuse them for leaving the nurses to suffer because of administration’s lack of planning or preparation. Samantha bleakly stated: I really don’t think that they know what we’re doing. They I think they’re so far removed that there’s no understanding of what our work entails and it feels like they’re very out of touch from their employees. One participant shared how many new precedents were being set due to COVID-19 and that nurses were left alone to “figure it out with a manager and see what would come of it.” This nurse expressed how nurses would have to push for their voices to be heard and advocate for themselves since the administrators were not seemingly receptive. The overall sentiment shared by participants were that nurses were left to fend for themselves and that they felt the administrators were closer to hostile rather than the supportive leadership they were hoping for or expecting during a never before seen time of healthcare pressure due to the pandemic. Theme 4: Perceptions of Nursing Culture Participants broadly described the culture of their respective units as working together as a team, communicating to one another, and developing friendships. Nurses collectively agreed that they relied heavily on their colleagues to get through their workday as well as seek emotional support when needed. A common sentiment was how a nursing unit’s culture was 61 proactive in trying to address issues staff were facing and evenly distribute the workload. This culture, however, is not without its darker side as while participants noted many positive aspects of nursing culture, they all voiced how bullying between staff was a common occurrence due to established hierarchies within the units. As participants shared various unique experiences in their units, several overlapping key components of nursing culture emerged: a) supportive colleagues, b) bullying, and c) self-sacrifice. Supportive Colleagues Every participant shared similar experiences of having supportive colleagues in their unit, especially during the pandemic. Nurses described how fellow staff were willing to help each other complete tasks and promote difficulties as “learning experiences” to grow as a healthcare worker. Regardless of tenure and experience, participants reported how their unit nurses embraced learning new policies, use of equipment and new cases to promote a positive team environment. One particular point every participant focused on was how their colleagues stepped in and helped out with a patient even when facing a heavy patient load on their own end as well as to “have each other’s backs.” How participants viewed their work experience throughout the pandemic relied significantly on the amount of support they felt they were getting from their team, as fellow nurses trying to face the onslaught of patients together. Sebastian elaborated on how his unit culture was a strong support for him: So we want to make sure we’re supporting each other throughout the day, so that’s one big thing, our unit does pretty well. Everyone’s quite supportive. We’re constantly asking each other, . . . If you need any help with anything and you know just being there for each other and you know bouncing ideas off, so we’re not just kind of nursing alone, we’re there as one kind of big team. We’re kind of just always looking out for each other on the 62 unit and…and that’s kind of how we got through, I think the ordeal there, yeah, just kind of constantly reminding each other and looking out for each other in that sense. Part of that supportive culture was also tied into coming to work early and staying late to provide handover between shifts. Nurses described how to help the next nurse get caught up on their patients by spending extra, unpaid time to debrief them on any updates and current treatment plans. One nurse reported how they would check in with other members, asking if they were feeling okay or hydrating enough. Samantha described how her team would take on extra work to help a colleague have a break: Thankfully, where I work, our breaks are sacred and we do our best to not cut them short. I know that’s not the case in a lot of other workplaces. But I think, the way our ward runs, we try really hard to help each other and cover each other so that we can take our breaks. Another nurse described how in their unit, everyone would pick up extra shifts or overtime so the administration would not activate a mandatory overtime protocol. This way, everyone worked a bit harder as opposed to one shift taking the brunt of the work. The collective message given by participants was that teamwork and camaraderie was a necessity in order to do their jobs well as it is not feasible to do it alone. Bullying A universally shared experience as a nurse by the participants included how workplace bullying was quite common. Participants specified how it was generally not due to personality differences but rather experience gaps. With the advent of the COVID-19 pandemic, due to being short staffed, nurses recalled how administration would be hiring more workers to enter the unit and the experience gap would cause “lots of conflicts.” One nurse described how they were always told during nursing school about horizontal bullying and how “nurses eat their young,” 63 only to realize that it was very prevalent and true in the workplace. One nurse attributed the bullying to “an old culture that’s just been passed along,” almost like a hazing ritual. Samantha reported: You would think it’s full of a lot of really caring people, and it is. But I would say nursing culture itself can be kind of toxic. I see it on my unit. I’m lucky that I get along with my coworkers and I work in general with a good team, but I, I can’t say that it’s always good like you do see…a lot of bullying between colleagues. Especially like from more senior colleagues to the more junior ones. That definitely exists. A nurse described how they might have skipped being bullied due to having worked in the same ward during their preceptorship and having developed a relationship with the staff, avoiding becoming a target as a less experienced nurse. This nurse could not be sure if that was the case or not but noted that other newer nurses who had no prior experience with the ward received more negative attention from tenured staff. Another nurse shared how they learned there were certain people they should “be on the good side of,” as the more senior staff or management would have a lot of input in determining where you would be assigned. Self-Sacrifice This theme emerged as an overall sentiment shared by all participants regarding entering the nursing profession. Nurses shared how they generally understood they would be facing adversity on the frontlines of healthcare as part of their job. However, during the pandemic, the adversity they were facing rose to such a level that it made some question their commitment to the profession. One nurse said “I don’t expect patients to like, you know, actively thank me and things like that, but at least be respectful, like I’m still a human too…” Nurses described how they would be going to work with COVID19 positive patients to provide treatment and care, 64 knowing they were risking their own safety because it was in their nature to do so. That’s why they chose the nursing profession, to help others, and this is to the point where they were doing so at a possible cost of their own wellbeing. This sacrificial nature of nurses has been an underlying theme with spending extra time to debrief other nurses, taking extra shifts to support the team, not taking breaks so that the patient can receive more care time. Even when faced with possible traumatic incidents, nurses described their mentality to just “accept it” and continue working. Silas recalled: Like you know, if you know, you get your first like code blue or you get your first time where like someone dies in front of you like…it’s just I, I feel like it’s just something in the beginning, yes, it’s like a shock and you know, like some people can’t cope with it as well, and, you know, they need, like other support or whatnot. After the first few times, honestly, like most nurses and at least from what I know, they just, they just accept it for what it is....I think people just kind of at some point, just accept that this is the job and this is what and like. This is what we got ourselves into. It is a black and white sentiment where nurses are admitting to feeling exhausted and not wanting to come into work but do it anyways because that is “what we’re supposed to do.” A nurse explained how they would be so busy and how an emergency would interrupt their break and that going on break four hours later or not drinking water for ten hours would become the norm. Theme 5: Personal Mental Health The final theme captures the participants’ various mental states from their stories of experiencing the pandemic. Participants spoke about how they would find strength and support in their friends and colleagues, or how they would face challenges in the workplace. Four key 65 findings emerged from participants stories including: a) moral distress, b) stress and anxiety, c) coping mechanisms, and d) the impact of public opinion. Moral Distress Moral distress was described by participants as being constrained by institutional policies to perform tasks or provide service in a way that they did not think was appropriate or “right.” Nurses recognized that in the face of being short staffed and overwhelmed with patients that they would have to make difficult choices, but they felt that hospital policies were one of the greatest challenges they had to personally overcome when dealing with patients. Due to the lack of beds and space in hospital wards, patients were in much closer proximity to one another and placed wherever there was room. One nurse described how in their ward there was only one enclosed room, so the remaining patient’s beds were essentially “beside each other,” with only a curtain separating them. The nurse described the unit’s surprise when policies were shifted to amend stating that curtains were sufficient barriers, unable to hide their disbelief. Samantha recalled her reaction to the new orders: Now the direction is “Oh it’s the airborne procedure, but they can go in a four bedroom, but you just have to close the curtain.” So there’s just a lot of, like, what the f***? Like this doesn’t make it like, pardon my French, but it’s just like it. Just a lot of it. Just. Didn’t really make sense from our standpoint and I don’t know, I guess it was just a constant change of information that we were getting. How are you supposed to properly protect other patients? And how are you supposed to properly isolate people when they’re literally in the same room, separated by curtains? Nurses were implementing policies that stood against what they were taught and trained for, lending to increasing moral distress. This also applied to the PPE shortage when providing 66 care to isolated COVID-19 positive patients with a well-worn N95 mask and being told by management that it was sufficient protection, despite having been educated about how much less effective they become after being used even once. Nurses reported being placed in a situation where they had no choice but to go along with whatever policy was enacted despite disagreeing internally. Anxiety and Stress Nurses reported increased levels of anxiety and stress during the pandemic, largely attributed to the inundation of patients and fear of contracting COVID-19. Due to the high infection rates, nurses reported feeling “on edge” at the workplace and being “on guard.” Participants expressed higher levels of anxiety associated with possibly bringing bacteria home to their families, particularly older parents or grandparents who were more susceptible to contracting the disease. A nurse stated how that anxiety was constantly on their mind, unaware of how it could possible affect their loved ones. Working with higher patient loads and more chronic, long term clients who presented as much more severe cases also added to participants’ anxiety. One nurse’s personal observation of the situation was that “people were like, so much sicker, like, during that period” and would need more attention and care. There was so much fear of the unknown as Silas described: You’ll hear a lot of people like talk about like pre shift anxiety where like they can'’ sleep before like starting their set. Like I’ve had a time where I’ve slept like one hour before my shift, and then I just sucked it up and I just went. And because like, I couldn’t do anything else. And then even personally, like . . . I think I’ve had it twice when I was starting out, that I, I had like 2 panic attacks at night before starting a shift as well. 67 Difficulties with quality or lack of sleep due to stressors were shared by other participants as well. Nurses who were not as protected in their unit by staffing placement experienced what could be described as their biggest trigger, being placed in a different unit. One nurse described how their unit would ask for volunteers instead of assigning staff to different units due to individual’s comfort levels with working in COVID-19 wards. This nurse’s unit would respect the wishes of a nurse who voiced their concerns and would be adamant in not being assigned in those wards. However, not all the participants’ experiences were so fortunate. Samantha detailed her experience with the unit assignment lottery: So like that on its own, like moving to an unfamiliar workplace, it was already a huge stressor. Like I know some people ended up having panic attacks and would have to leave work when they were told that they would be pulled. You know, like I wouldn’t be able to sleep at night because I would be worried that I was gonna be pulled. Coping Mechanisms During the pandemic, self-quarantine measures were enacted in British Columbia and that led to a severance of being able to physically meet up with friends and family for a long period of time. All the participants shared memories of having virtual hangouts in place of going out to dinner or doing activities together as a replacement. For one nurse, this proved to be difficult as they stated how their friend group was their primary support group and that despite being able to see them through a screen, there was a significant difference compared to physically being around them. Physical activity was found to be a productive coping strategy as one nurse commented how they noticed becoming “stagnant” due to staying home all the time and only moving around at work. Because transmission of COVID-19 was supposed to be less 68 likely in the outdoors with adequate distance between people, outdoor activities became a go-to strategy. Sara recounted how it made a significant impact on her wellbeing: I like to go for runs outside, that, I think the running outside, like doing, uh, physical activity and just being outdoors has been a game changer for me because I’m always cooped up, either if it’s not inside the hospital, inside a patient’s room, it is staying inside my room so that I don’t affect the rest of my family. Two participants raised a point in how that despite the stressors of being a nurse, there was also a benefit in being able to still see their colleagues and physically meet people compared to individuals not in healthcare. This reportedly assisted in lessening feelings of isolation and promoted in-person socialization due to the nature of their work. These were among the more adaptive coping mechanisms mentioned by participants but there were also times when they could not implement strategies such as going outside for a walk during their shift. Outdoor activities could be done before or after work, but during their shift, nurses shared how it was still a struggle to deal with all the sickness and workload. Silas stated: I’ve had some like terrible shifts and like, honestly, like, when you're seeing like the lowest of the low like, you kind of just, if it’s not that, then you’re pretty satisfied. That’s the job. And then if you can’t cope with it, then you figure out some way to cope with it or you don’t. Then you just continue working. This mentality was embraced by all participants, echoing how they would just “suck it up” and have to accept “this is the job.” There was no clarification about if it buoyed their spirits but by supressing their feelings, they could continue to do their job. 69 Public Opinion At the onset of the pandemic when quarantine measures were in place, nurses described a large scale outpour of public support for healthcare workers and the term “essential workers” became quite popular. One nurse mentioned how they appreciated all the praise and support from the public but preferred to be “backstage in doing what I have to do,” and saying how they know their job is helping others which fueled the internal support system to continue working. This proved to be a common general sentiment amongst the nurses as they all expressed appreciation for the public support. Nurses shared how they rarely heard words of appreciation and that it was nice to hear open support, noting that “it was a really nice change.” Sara described: So I think that was during the peak of COVID, I feel like that’s when nurses really felt like heard and like respected and….seen? All those years before COVID-19 like I just kind of felt like from what I spoke with my colleagues that have been nurses for like decades, that kind of felt like they were seen for the first time, that what they do is actually important. Nurses conveyed how they were saddened that it took a global pandemic for the public to take notice of their work and its importance but appreciated it, hoping that the recognition would last. Unfortunately, the court of public opinion also swung the other way as the pandemic progressed and anti COVID-19 sentiments began to rise and adversely affect nurses. Nurses recalled how there were large scale protests at the hospitals, decrying the vaccine mandates and social distancing orders by the government. One nurse described how due to the protests, a family that was informed of their loved one being close to passing away was unable to make it to the hospital in time due to the crowds in front protesting, and the subsequent whirlwind of upset they faced in the aftermath. Samantha reported: 70 We did deal with people who were very like, COVID non-believers or like anti-vax. You know, that type of mindset or that mentality. And we did deal with people like that in the hospital though, and I found that really challenging. I think that was a hard part. I think I…I almost even quit my job. What was once overwhelming public support was quickly being overshadowed by fatigued populations, tired of the pandemic rules and desiring a return to pre-pandemic lifestyle. However, not all participants received the anti-COVID-19 sentiments as personally, citing how even prior to the pandemic that there would be opinionated individuals who did not believe in the treatments being provided or the type of care response. One nurse stated “there’s going to be people that don’t like what you’re doing or don’t believe that they need what they need.” Another nurse who shared that same feeling added that while it was challenging, that it was not unique to the pandemic and it has always been a balancing act of maintaining professionalism while explaining to patients or visitors that nurses don’t make the decisions and are “aiming in the wrong direction.” Summary of Results Through the narrative interviews, participants in the present study shared many aspects of their work experience as nurses during the COVID-19 pandemic. Aspects of personal safety issues on the job were illuminated and the types of treatment nurses were facing from non-cooperative patients. Nurses experienced a significant increase in their workload causing a dilution of allotted time for patients and ensuing difficulty with completing all their assigned tasks in the confines of their shift, with low regard for their own personal breaks. An emphasis on administrative difficulties with communicating new policies or supporting nurses with appropriate training was highlighted as nurses were left feeling unsupported. Participants also 71 described how the unit nursing culture could be both a protective and aggravating factor in the workplace, stemming from the support received from colleagues to the bullying an inexperienced nurse could face. Finally, stories of the mental health struggles the nurses faced were shared, encompassing the difficulties in dealing with stress and anxiety, as well as coping methods utilized in order to combat the loneliness and isolation. These findings offer meaningful contributions to the existing literature surrounding nurses experiences during the pandemic and may serve to inform further research or policy in this area. These contributions are discussed in the next chapter. 72 Chapter 5 Discussion and Conclusions The present study explored the narratives of four practicing nurses who worked in hospitals during the COVID-19 pandemic. This is one of the first Canadian research studies to utilize a narrative research method to investigate the impacts of working during the pandemic from the direct perspectives of healthcare workers. This study presents unique research findings which offer important contributions with respect to complimenting and addressing gaps in the available current literature as well as having implication for future research, policies and practices involving nurses. The findings of this study will be discussed relative to the context of the existing literature concerning nursing traumas and their pandemic practice. Then, findings will be discussed in terms of its ability to contribute to research investigations of nursing work experiences during the pandemic and potential directions for future research. Practical implications of the findings for the nursing profession will be discussed, including recommendations for improving support and access for healthcare workers. Finally, the strengths and limitations of the present research will be presented. Discussion of the Findings Relative to Nursing Literature The five key themes of this study—Concerns about Personal Safety, Struggles with Workload, Administrative Presence, Perceptions of Nursing Culture, and Personal Mental Health present both consistent and inconsistent findings from the present theory and research literature regarding nurse’s working experiences during the COVID-19 pandemic. These themes are discussed in relation to the literature regarding theories associated with mental health stresses in healthcare fields, and then how they are represented in the research findings from various geographical areas. 73 The Findings and Theories behind Nurse’s Mental Health Stresses. In the literature, burnout is characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment found to commonly occur among individuals who work in a service based industry, including nursing (Maslach & Leiter, 2016). These aspects of burnout may present as being emotionally drained, experiencing depersonalization, and having doubts about their own competence and successes in the workplace. Consistent with this literature, the participants in the study identified experiencing many of those symptoms characteristic of burnout. In the findings many participants described how they were experiencing the fatigue of increased patient loads and responsibilities, and feeling exhausted as well as having levels of disengagement in order to cope with the demands placed upon them. The lack of resources in the form of PPE, training, or adequate staffing further contributed to the work overload, fueling participant’s admissions of feeling incompetent and inadequate in their roles as nurses. Participants reported how they would be constantly adapting to changing policies and guidelines and how they were left feeling ungrounded in their practice. A common finding amongst all participants was how there was a tendency from management to focus on individually centered approaches to supporting their staff which is paradoxical considering that research has shown individual factors play a much lesser role compared to organizational factors. Participants engaged in one-on-one support from management colleagues or social supports, which may have helped alleviate their levels of exhaustion but would otherwise not make any meaningful change in any other of the burnout dimensions. The consistent increased workload continued to deplete the capacity of the participants to meet the demands of their job and provided little to no opportunities to recover. Several participants expressed how they would question their commitment to their profession 74 and why they continued to work in spite of the adverse conditions they were facing. Clear linkages between lack of control and burnout have been established in the theory when employees perceived to have low levels of autonomy paired with inadequate resources. Lastly, the aspect of moral distress shared by participants disrupted the value domain of burnout, serving to reduce motivation between them and their workplace due to feeling split between the work they wanted to do versus the work they had to do. Another theory applicable to the plight of nurses revolves around the concept of secondary traumatic stress (STS), which is a condition where an individual experiences the symptomology of PTSD but the exposure is indirect as it originates from a patient (Figley, 1995). In the time of a global pandemic, where an unknown disease was being spread across the population, patients entering care would exhibit fear and elements of suffering due to comorbidities or just the severity of the infection. Although nurses view trauma as part of their everyday life and accept that exposure as part of the job, the cumulative effect is the focal point of concern as the exposure is repetitive. In this study, participants shared low levels of STS symptomology as their anxieties and fears were rarely connected directly to the patients under their care, rather to the entire work environment. However, participants did report levels of helplessness in the face of administrative policy and guidelines, compounded with a level of isolation from supports (i.e., direct contact with close friends). These factors could contribute towards the reconceptualization of STS to the construct known as compassion fatigue (Figley, 2002). With waning personal capacity to handle work stresses, compassion fatigue could emerge suddenly like a breaking point as opposed to burnout which is the result of gradual emotional exhaustion. 75 A key factor in compassion fatigue is the decoupling of motivation and the practitioner’s level of empathy for the client or patient. In this study, the participants were all able to consistently find sufficient motivation to provide quality care, drawing from personal reserves and colleagues’ support. No participant shared having felt enough empathic stress from caring for patients to the point where it culminated in notable disruptions in their typical routines or responsibilities outside of the workplace. However, participants did express the acceptance of their limitations of care due to institutional factors inversely provided a level of disengagement from the clients, allowing them to preserve a level of internal satisfaction in the care they could provide. This was shared through the commentary of participants saying how “that’s the job” and “you do what you can,” and knowing that they were working to the best of their ability given the confines of whatever restrictions they were facing. With that said, the participants may have shown susceptibility to compassion fatigue during the COVID-19 pandemic, but there were no expressed occurrences where participants felt they had succumbed to an overly empathic response to those in their care. This could be explained due to multiple factors including the personal coping abilities of the participants or desensitization to the traumatic stressors over time and developing a resilience level sufficient to work through the pandemic. Another theoretical element underlying nursing mental health problems can be found in vicarious trauma. This is thought to be a type of countertransference from working with short or longer term individuals who have suffered trauma, and posited to be unavoidable (McCann & Pearlman, 1990). When working with traumatized clients, the helper may manifest moral or judgemental feelings about themselves, paired with feelings of loss of control, grief, rage, and a sense of vulnerability. Again, there no explicit descriptions from participants describing how their own sense of safety was disrupted due to interactions with a patient. Rather, participant 76 recollections of loss of safety centered on direct exposure to a threat such as unruly patient or the fact that they were working in infection positive wards and were risking transmission themselves. This may be partially attributable to the fact that some of the participants were working in specific wards where the patients were unable to speak or communicate clearly that it could have mitigated the patient’s ability to verbally share their traumas and expose the nurses to it. Feelings of helplessness were shared by participants but none of them attributed that to interactions with patients, rather stating is was the limitations of the workplace. Coping theory may provide a reason why the participants in the study seemed to not suffer from more serious mental health outcomes. Stress can be defined as a relationship between a person and their environment, and the ability to interpret and react to the demands and pressures faced (Lazarus & Folkman, 1984). The participants understood the pressures of the healthcare system they were facing during the pandemic and could begin anticipatory coping of problems they faced, such as staffing issues and lack of supplies. When faced with the actual stressor, with sufficient preparation, the nurses were able to sufficiently address and overcome the challenges and thus did not suffer as deeply. Many times the capacity of some participants were challenged, especially when being assigned to different wards; but despite being vocal about how they felt unprepared or unsupported, it did not deter them from doing their job to the best of their ability. Universally across the participants, they sought support from family, friends and colleagues and engaged in stress relieving activities such as exercise or games to keep their mind off work. No participant expressed the perception that they had insufficient resources to cope with the stressors they faced; however they all mentioned desiring more resources. Following Wong and Wong’s Resource-Congruence Model of Coping (2006), cultivating more coping resources would the best and most efficacious method but is often the most neglected. 77 Despite participants stating how they would be open to more resources, they also universally shared that they were unsure of how and where to find them. The findings relative to current literature of nurse’s work experience during COVID-19. Similar to the research literature, there seems to be elements of universality in the nursing profession spanning across the globe. Several studies have found nurses describing that the rapidly changing policies and unclear communications between nurses and administrators were causing feelings of overwhelm (Akkuş et al., 2022; Crowe et al., 2021; Kelley et al., 2021), which were echoed by the present study participants. There is a general consensus that nurses were being forced to adapt at a pace they were ill supported for, while balancing the lack of PPE required to do their jobs. Much of the research literature has presented how nurses struggled mentally and physically with insufficient supplies of PPE to keep themselves safe while treating COVID-19 positive patients but also how there was a lack of familiarity with using it while providing care as well (Akkuş et al., 2022; Catania et al., 2021; Chegini et al., 2021; Crowe et al., 2021; Goh et al., 2021; Kelley et al., 2021; Tan et al., 2020). This is consistent with the findings, where participants expressed how they had to develop new methods to meet patient needs and keep themselves safe at the same time. One participant recalled how they developed a pseudo-sign language in order to communicate because the patient had a weak voice due to infection and with the mask and face shield on, was unable to hear him. In instances such as these, participants were unable to develop the level of rapport they had previously established with other patients, leading to a weaker relationship between nurse and patient mentioned in one of the surveyed studies (Fernández-Castillo et al., 2021). There is a clear element of frustration from nurses in both the literature and present study in how they were suffering from their institutional confines in policy and practice to meet patient 78 needs. Participants described how they would forego wearing some PPE to speed up the delivery of care for a patient in need, potentially risking their own safety. This would lead to a cumulative effect due to their own anxieties about possibly being a carrier of COVID-19 and bringing it home to family or friends. Participants spoke of their struggles with administration in regards to staffing and staff placement in different units or wards. Participants highlighted the importance of working as a team to provide care to patients and losing that team identity and familiarity when relocated elsewhere in the hospital. When moved to a new unit, the nurse would be unsure of the new team’s abilities and workflow, while simultaneously being cut off from the support and comfort provided by their home unit (Cadge et al., 2021; Crowe et al., 2021). Participants recounted how their levels of anxiety would greatly increase when being chosen to move units due to the uncertainty and foreknowledge that they would have to work even harder to get up to speed. A slight deviation from the literature was the focus of being displaced, when studies found nurses worried about the new unit’s abilities, whereas the present study participants recalled questioning themselves due to being unprepared. Administrative complaints also branched into management not being receptive of concerns or suggestions made by frontline staff (Catania et al., 2021; Chegini et al., 2021; Tan et al., 2020; Yıldırım et al., 2021). A few participants indicated that their experience was similar to the literature, findings that their suggestions were ignored and that by voicing them could put them at risk of management ire. A participant clearly stated how there was well known administrators they did not want to irritate in order to have a better work experience. One point of concern from the literature was that nurses wanted greater access to psychosocial supports due to the amount of support they required to overcome mental and 79 physical challenges at the workplace (Goh et al., 2021; Tan et al., 2020). Reflecting those studies, participants reported a greater reliance on family and friends as emotional supports, citing a lack of formal support in the workplace paired with uncertainty of how to proceed in accessing available resources. Several participants described experiencing panic attacks and sleep disturbances due to the fear or anxiety of working in COVID-19 wards. These themes were also present in the literature, expanding into clinical insomnia whereas the participants in the present study did not (Kandemir et al., 2021; Peng et al., 2021; Tamrakar et al., 2021). Another finding from the literature was the conclusion that nurses experience high levels of secondary trauma due to the workplace violence and grief they are exposed to on a regular basis (Kelley et al., 2021). From the participant stories, this is a finding that rings true where participants noticed an increase in violence during the pandemic. This was hypothesized to be due to just the sheer number of patients flowing into the healthcare system, not necessarily a greater percentage of patients being violent. Participants did note that verbal harassment greatly increased as a result of changing hospital policies that involved visitor guidelines. Several participants shared similar sentiments where they felt like they had to shift into an enforcement role instead of a care role due to these types of incidents. One of the clearest deviations from a majority viewpoint in the literature is the fact that the present study took place in Canada. Of the surveyed literature, little empiricism was available regarding nurse’s work experience during COVID-19 in North America and even fewer still in Canada. Unlike some studies in other parts of the world, there was no legislation enacted to prevent healthcare workers from quitting their jobs (Yıldırım et al., 2021), and no mandated relocation of staff to other hospitals and clinics to different parts of the country without their consent (Chen et al., 2020; Peng et al., 2021; Tan et al., 2020). Participants willingly stayed in 80 their profession and continued to provide care for patients despite the adverse conditions they faced. Participants discussed how they considered quitting or changing professions but that was a choice available to them unlike some other nurses in other geographic locations. Another geographic and possible culturally affected result was how in China, studies found their nurses experiencing an increase in passion for their job and commitment to the profession (Goh et al., 2021; Peng et al., 2021; Tan et al., 2020). This was not the case in the present study where most of the participants were left speculating about their future in nursing and the possibility of shifting roles to better fit their lifestyle. Participants also described how despite the negative consequences of being a frontline healthcare worker was present; it provided them very unique opportunities to have a lessened degree of disruption in their lifestyle during the pandemic. While quarantine procedures and social distancing measures were enacted in British Columbia, nurses continued to go to work and socialize with their colleagues in physical proximity. While the environment of the workplace changed, the core nature of their job stayed the same—providing care for patients. An interesting deviation found in North American literature was the introduction of maladaptive coping mechanisms. In two American studies, they found nurses reporting an increase in substance use such as alcohol or tobacco in order to combat the increased stress they were experiencing (Foli et al., 2021; Kelley et al., 2021). None of the participants in the present study indicated that they utilized any substances as a coping mechanism, denying the use of any recreational drugs as well. Practical Implications and Contributions of the Findings The present study is intended to provide insight into how Canadian nurses understand their work experience during the COVID-19 pandemic and what is needed for future 81 development and implementation of supports and resources. This study offers an understanding of in-depth, lived experiences of nurses who were working at the frontlines of healthcare during the pandemic. These findings have multiple potential applications to the general field of counselling psychology and specifically to nursing-based practices. Following the design of the research study, many of the recommendations have been co-constructed by the research participants and researcher through discussions that emerged during the interviews and member-checking procedures to review the study findings. One of the primary intended contributions of this research is to share the knowledge generated in the present study with healthcare institutions and other nursing professionals to support and inform development of future policy, practice, and guidelines. Several participants discussed the need for more Canadian nursing literature surrounding their work experiences, including the present study, to be made accessible by administrators and related healthcare staff for review. One participant had mentioned that with the lack of available empiricism regarding their difficulties encountered in the workplace, they felt that nurse’s struggles were being diminished and that the results of the research should be promoted to the general public via online sources and social media. The implications of the findings for different groups will be detailed next, including other nurses, healthcare administration and institutions, and the counselling psychology profession. Implications for Nurses The results of the present study indicate that nurses are being taxed mentally and physically in their jobs without any recourse. One avenue to use the knowledge generated by this study could be to promote nursing education of different mental health stresses such as burnout, so that nurses can better understand these potential negative health outcomes and be more aware 82 of symptoms and signs. Several of the participants mentioned how they were unsure if what they were experiencing was something clinically significant or transient, due to not having much knowledge surrounding those topics. By publicizing more information regarding difficulties nurses face, it may help reduce stigma about help seeking behaviours in that they are not alone in facing stressors. This would also bring attention to the almost “self-sacrificing nature” that many of the participants described, almost viewing themselves as expendable workers due to the lack of support they received, where they just “accept that this is the job.” Unavoidable health consequences should not be a defining feature of the profession when it is in fact, avoidable to an extent. The most notable strategy utilized by participants was seeking support from colleagues due to the inherent similar understanding, working in the same unit or at the very least, same profession, facing the same demands. If nurses can increase their understanding of potential risks, they can better recognize it in themselves and others, and encourage seeking help and support. Nurses can share coping strategies they have found useful and utilize their colleagues for group support. Internal promotion within the profession to learn coping strategies may be of great benefit in reducing the levels of stress they encounter. An interesting implication from the study is also how nurses in more acute units with increased levels of training may have developed more robust support systems internally within their ward. One of the participants described how their ward was several floors and had a much higher number of staff, making stronger connections with everyone more difficult. Another participant described a completely contrary experience where because they were a small unit, they would frequently have overlapping shifts and would get to know each other better, finding more support and trust in each other’s abilities. Another unintended consequence of being in a 83 specialty ward is that during the pandemic, a participant described how they were better protected from being moved to other units or wards due to their specific training. Due to a necessary skillset, it became a protective factor against being uprooted and placed elsewhere, cutting their access to their home unit and support system. It is essential to maintain the well-being of nurses who are the front line providers of care so that they have long, purposeful careers. By bolstering their coping abilities and reinforcing practices that promote strength and solidarity, nurses may find greater support within their profession leading to an increase in personal capacity. Implications for Healthcare Administrators and Institutions The study findings have generated many suggestions and areas where nurses believe they can be better supported. The first of which would be to provide more training opportunities or regular workshops that can be integrated into orientations for newer staff. These trainings could involve psycho-education surrounding mental health topics and create an opportunity for nurses to interact with other health professionals and inform them of self-regulatory practices. Participants stressed the importance of proactive training opportunities on the side of administration so that they are supporting the nurses in providing necessary education to prepare them for their work. This would also potentially bridge some of the gaps that participants felt about administration where there is a disconnect in understanding what nurses face on a regular basis. By engaging in the workshops/trainings, administrators can better build a shared understanding of what their staff face and facilitate opportunities to have collaborative conversations regarding best practices. Another important implication for the findings could inform the creation of policies and best-practices guidelines that could be utilized across healthcare institutions. Several participants 84 described at length how they would be moved from their home unit into a foreign ward with little to no preparation, resulting in high levels of self-doubt and anxiety. Administrators should take note of the predicament they are placing their nurses in and should look for less disruptive methods to integrate other nurses into different units where they can feel supported and adequately prepared for their new environment. Being moved at a whim due to lack of staffing prevents nurses from feeling grounded in their environment and prevents the building of stronger working relationships within their units. Further policies that can be examined including implementing more universal visitor rules across wards to prevent confusion when working in different units. Participants described facing challenges in explaining to visitor’s time limitations and number of visitors allowed due to the discrepancy in other wards. By unifying certain policies, it can support nurses in their person-centred service aspect of the job. Another potential implementation may also include a dedicated changeover time between nursing shifts to provide oncoming staff an opportunity to review patient charting and share important information. Participants reported how they would try to squeeze this practice into their work but having to do so while off the clock by coming early or staying late, just to support other nurses was very stressful. Adjusting the distribution of responsibilities placed on the nurses could also be of great benefit. A point of contention amongst participants encircled the sanitation procedures and tasks being placed on the nurses with very restrictive guidelines in terms of desired frequency. Nurses were already suffering from increased patient loads and decreased staffing, by adding more responsibilities to their load only further serves to exacerbate their exhaustion. Potential solutions could involve increasing the frequency of sanitation staff throughout the ward and increasing the staff to supplement it. Participants indicated they would felt less stressed if they 85 did not have to worry about cleaning their workspace every time they used it while simultaneously needing to attend to patient needs. Lastly, the greatest implication gathered from participants was for administration to promote easier access to supportive resources. Participants stated how they were unaware of how to access mental health supports or what resources were even available. One participant described how even just being informed about employee assistance programs on a semi-regular basis would be of great benefit to remind nurses what is available and who to contact. The barrier to access support was perceived to be quite daunting by participants which served to discourage seeking help and administrators can help bridge that gap by being proactive about disseminating information. These implications are emphasized by the potential of future epidemics and being able to apply learnings from the current study. Healthcare administration and agencies can utilize the findings to assist in laying the foundations of a more robust healthcare infrastructure, in order to minimize the impact to staff while maintaining operational capacity. Implications for Community Professionals The study findings pertaining to mental health symptomology and lack of understanding by nurses have important implications for counselling and mental health professionals who work within the healthcare system. The research clearly shows that nurses are suffering from negative mental health outcomes as a result of their profession, exacerbated by the pandemic. Despite this, participants were unsure if they should seek out counselling services due to the uncertainty of how to access these supports, if their presentation was severe enough to warrant support, and that they may view counselling as reactive instead of proactive. As participants mentioned finding value in workshops and trainings, this could be an opportunity for mental health professionals to 86 facilitate some of these trainings and build collaborations with healthcare workers in regards to training of nurses, implementing effective interventions, and other supportive efforts. Both community agencies and private practice practitioners have a valuable opportunity to extend services to this population and support greater knowledge transference to administration and staff. The study findings also provide an alternate lens into understanding the lived experiences of nurses who have worked during the COVID-19 pandemic and can promote insight into how nurses perceived themselves and the role they play in the healthcare system. Participants have acknowledged feeling objectified by the public, dehumanized by uncooperative patients and visitors, and desensitized to their work in order to maintain a level of operational capacity. Strengths and Limitations of the Study The design and findings of the research have both strengths and limitations. A considerable strength of this study was the narrative approach to the investigation, offering an in-depth, exploratory means of examining nurse’s unique stories of their experiences working during the COVID-19 pandemic. Based on the comprehensiveness of the data obtained in each participant interview, the sample size was deliberately kept small (n=4). The sample was also limited geographically to urban centres in the Lower Mainland of British Columbia. By recruiting nurses from one geographic location provides the opportunity to gain a more extensive understanding of nurses who work in the Lower Mainland. However, this also prevents generalization of the findings across British Columbia, or Canada as the sample cannot be considered adequately representative. Narrative research methods do not purport generalizability due to its typical small sample sizes and its theoretical stance in a post-modern paradigm. The narrative methodology utilized in the present research did not seek to obtain objective, quantifiable evidence regarding how nurses suffered from poorer mental health 87 outcomes compared to pre-pandemic levels. This approach to the research instead recognizes that the participants experiences are highly influenced by the context and culture of their workplace, own personal capacities and coping skills. The goal of the research was not to produce generalizable results across all nursing professional, but rather to provide a comprehensive examination of participant stories and their narratives to generate their unique lived experiences. Despite some specific differences amongst the information gathered from the study participants, many commonalities were found. Participant experiences were reflective of the institutions they were employed at, what type of unit they practiced in, and the amount of experience they had available to them. In this study, all participants practiced in a hospital setting as none were from community health practices or from leadership positions. While the researcher paid close and detailed attention to the analysis and coding of each participant interview, there may be limitations in capturing the full narrative due to the depth of each individual’s story and goal of establishing shared themes. Implications for Future Research The present study has implications for several directions of future research. First, given that the data was obtained from a small sample of local nurses, an expansion of the study may be warranted to include a greater number of participants across a larger geographic area. As the sample of nurses all practice in the Lower Mainland, it would be beneficial to include healthcare workers from across British Columbia, including more rural areas of the province, to obtain greater representation of nurses from outside major metropolitan areas. This would allow for a more robust perspective of nurse’s work experience during the COVID-19 pandemic across the province and may have greater implications for informing policy and practice. More rural areas with fewer resources may have struggled even greater than those in major cities and faced an 88 even greater strain on their healthcare system and staff. Ultimately, the goal would be to expand the research across Canada, which would allow for comparison of data across the different provinces and territories. Most of the present research regarding nurse’s work experience during the pandemic is focused on investigating the empirical and quantitative outcomes, such as levels of stress and anxiety. There is limited attention directed towards understanding how the nursing professionals experienced working in healthcare during the pandemic within the context of their geographic location and related stakeholders. The present study thoroughly investigated the experiences of one group of key stakeholders, the nurses. Another potential expansion of the present research would be involve investigating how other healthcare workers experienced working during the pandemic to compliment the present study or provide an alternative perspective. These other healthcare workers could involve administrative staff who have been implicated by nurses as a focal point of concern in the healthcare system, custodial staff regarding sanitation practices, nursing students who are looking to enter the field after having experienced how crippling a pandemic can be, patients who had received care during the pandemic, and any other involved stakeholders. This could provide a more comprehensive and systemic view of the experiences of individuals involved in creating nurse’s work experiences during the COVID-19 pandemic, as well as supporting future planning for the care of staff. The participants in the present study came from two hospitals across the Lower Mainland of British Columbia and from different units. According to the stories from the participants, there was a lack of a clarified universal standard of practice and policy across units, wards or hospitals. Different wards had different rules on visitation and different units had expanded patient loads differently and changed their staffing levels. This indicates that further investigation is warranted 89 to determine whether British Columbian hospitals could benefit from inter-unit and inter-institutional practice models and implementation guidelines. Studies that can focus on developing an integrated, generalized approach that can be adopted by British Columbian health facilities could support establishing best-practices for practicing nurses, schools and nursing students impacted by the pandemic. By doing so would also support a more commonly accepted approach potentially across the country. Conclusion The present study offers an in-depth exploration of the experiences of four nurses who provided care to patients during the COVID-19 pandemic. This is one of the first Canadian studies to explore the lived experiences and various dimensions of the nursing profession through a narrative approach. Important perspectives of nurses who are lauded as the frontline workers of healthcare have been established and the severity of their situation expanded upon. The findings of this research have potential value to stakeholders across the healthcare system and outside of it; hospitals, healthcare administers, educators, nursing schools, mental health professionals, and the public community at large. All of whom have a responsibility to better understand how nurses view their work and play a role in better supporting them as essential workers providing vital services. Research into healthcare workers COVID-19 work experiences are still developing in Canada as well as implementing new practices to better support healthcare workers. As a researcher and future counselling professional, my hope is that this research will contribute to and inform policy/practice development and expansion of support for nurses in our healthcare system. 90 References Akkuş, Y., Karacan, Y., Güney, R., & Kurt, B. (2022). Experiences of nurses working with COVID-19 patients: A qualitative study. Journal of Clinical Nursing, 31(9–10), 1243–1257. https://doi.org/10.1111/jocn.15979 Beaton, R., & Murphy, S. (1995). Working with People in Crisis: Research Implications. In C. R. Figley (Ed.), Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder In Those Who Treat The Traumatized (pp. 51–81). Routledge. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa Bruner, J. (1991). The Narrative Construction of Reality. Critical Inquiry, 18(1), 1–21. https://doi.org/10.1086/448619 Burr, V. (1995). An Introduction to Social Constructionism. Taylor & Francis. https://doi.org/10.4324/9780203299968 Cadge, W., Lewis, M., Bandini, J., Shostak, S., Donahue, V., Trachtenberg, S., Grone, K., Kacmarek, R., Lux, L., Matthews, C., McAuley, M. E., Romain, F., Snydeman, C., Tehan, T., & Robinson, E. (2021). Intensive care unit nurses living through COVID-19: A qualitative study. Journal of Nursing Management, 29(7), 1965–1973. https://doi.org/10.1111/jonm.13353 Carver, C. S., Weintraub, J. K., & Scheier, M. F. (1989). Assessing Coping Strategies: A Theoretically Based Approach. 56(2), 267–283. https://doi.org/10.1037//0022-3514.56.2.267 Catania, G., Zanini, M., Hayter, M., Timmins, F., Dasso, N., Ottonello, G., Aleo, G., Sasso, L., & Bagnasco, A. (2021). Lessons from Italian front‐line nurses’ experiences during the 91 COVID‐19 pandemic: A qualitative descriptive study. Journal of Nursing Management, 29(3), 404–411. https://doi.org/10.1111/jonm.13194 CBC. (2022, May 10). “Burnt out” B.C. nurses rally at legislature over staffing shortages | CBC News. CBC. https://www.cbc.ca/news/canada/british-columbia/burnt-out-b-c-nurses-rally-1.6448774 Cerney, M. (1995). Treating the “Heoric Treaters.” In C. R. Figley (Ed.), Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder In Those Who Treat The Traumatized (pp. 131–149). Routledge. Chegini, Z., Arab‐Zozani, M., Rajabi, M. R., & Kakemam, E. (2021). Experiences of critical care nurses fighting against COVID‐19: A qualitative phenomenological study. Nursing Forum. http://dx.doi.org/10.1111/nuf.12583 Chen, H., Sun, L., Du, Z., Zhao, L., & Wang, L. (2020). A cross‐sectional study of mental health status and self‐ psychological adjustment in nurses who supported Wuhan for fighting against the COVID‐19. Journal of Clinical Nursing. http://dx.doi.org/10.1111/jocn.15444 Clandinin, D. J. (2016). Engaging in Narrative Inquiry (0 ed.). Routledge. https://doi.org/10.4324/9781315429618 Crowe, S., Howard, A. F., Vanderspank-Wright, B., Gillis, P., McLeod, F., Penner, C., & Haljan, G. (2021). The effect of COVID-19 pandemic on the mental health of Canadian critical care nurses providing patient care during the early phase pandemic: A mixed method study. Intensive and Critical Care Nursing, 63, 102999. https://doi.org/10.1016/j.iccn.2020.102999 Fernández-Castillo, R.-J., González-Caro, M.-D., Fernández-García, E., Porcel-Gálvez, A.-M., & Garnacho-Montero, J. (2021). Intensive care nurses’ experiences during the COVID-19 92 pandemic: A qualitative study. Nursing in Critical Care, 26(5), 397–406. https://doi.org/10.1111/nicc.12589 Figley, C. R. (1995). Compassion Fatigue as Secondary Traumatic Stress Disorder: An Overview. In Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder In Those Who Treat The Traumatized (pp. 1–20). Routledge. Figley, C. R. (2002). Compassion fatigue: Psychotherapists’ chronic lack of self care. Journal of Clinical Psychology, 58(11), 1433–1441. https://doi.org/10.1002/jclp.10090 Foli, K. J., Forster, A., Chang, C., Zhang, L., & Yu-Chin, C. (2021). Voices from the COVID-19 frontline: Nurses’ trauma and coping. Journal of Advanced Nursing. http://dx.doi.org/10.1111/jan.14988 Goh, Y.-S., Ow Yong, Q. Y. J., Chen, T. H.-M., Ho, S. H. C., Chee, Y. I. C., & Chee, T. T. (2021). The Impact of COVID-19 on nurses working in a University Health System in Singapore: A qualitative descriptive study. International Journal of Mental Health Nursing, 30(3), 643–652. https://doi.org/10.1111/inm.12826 Government of Canada. (2023, January 23). Coronavirus disease (COVID-19). https://www.canada.ca/en/public-health/services/diseases/coronavirus-disease-covid-19.html Kandemir, D., Temiz, Z., Ozhanli, Y., Erdogan, H., & Kanbay, Y. (2021). Analysis of mental health symptoms and insomnia levels of intensive care nurses during the COVID-19 pandemic with a structural equation model. Journal of Clinical Nursing. http://dx.doi.org/10.1111/jocn.15918 Kelley, M. M., Zadvinskis, I. M., Miller, P. S., Monturo, C., Norful, A. A., O’Mathúna, D., Roberts, H., Smith, J., Tucker, S., Zellefrow, C., & Chipps, E. (2021). United States 93 nurses’ experiences during the COVID-19 pandemic: A grounded theory. Journal of Clinical Nursing, n/a(n/a), 1–14. https://doi.org/10.1111/jocn.16032 Lapadat, J. C., & Lindsay, A. C. (1999). Transcription in Research and Practice: From Standardization of Technique to Interpretive Positionings. Qualitative Inquiry, 5(1), 64–86. https://doi.org/10.1177/107780049900500104 Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping (11. [print.]). Springer. Maslach, C. (2003). Job Burnout: New Directions in Research and Intervention. Current Directions in Psychological Science, 12(5), 189–192. Maslach, C., & Jackson, S. E. (1984). Burnout in organizational settings. Applied Social Psychology Annual, 5, 133–153. Maslach, C., & Leiter, M. P. (2016). Understanding the burnout experience: Recent research and its implications for psychiatry. World Psychiatry, 15(2), 103–111. https://doi.org/10.1002/wps.20311 McCammon, S., & Allison, J. (1995). Debriefing and Treating Emergency Workers. In C. R. Figley (Ed.), Compassion Fatigue: Coping with Secondary Traumatic Stress Disorder In Those Who Treat The Traumatized (pp. 115–130). Routledge. McCann, I. L., & Pearlman, L. A. (1990). Vicarious traumatization: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3(1), 131–149. https://doi.org/10.1007/BF00975140 Murray, M. (2003). Narrative psychology and narrative analysis. In P. M. Camic, J. E. Rhodes, & L. Yardley (Eds.), Qualitative research in psychology: Expanding perspectives in methodology and design. (pp. 95–112). American Psychological Association. https://doi.org/10.1037/10595-006 94 Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors (1st ed). Norton. Peng, X., Yang, Y., Gao, P., Ren, Y., Hu, D., & He, Q. (2021). Negative and positive psychological experience of frontline nurses in combatting COVID-19: A qualitative study. Journal of Nursing Management, 1(9). https://doi.org/10.1111/jonm.13481 Polkinghorne, D. (1988). Narrative knowing and the human sciences. State University of New York Press. Riessman, C. K. (2005). Narrative Analysis. In Narrative, Memory & Everyday Life (pp. 1–7). University of Huddersfield. Riessman, C. K. (2008). Narrative methods for the human sciences. Sage Publications. Riessman, C. K. (2012). Analysis of Personal Narratives. In J. F. Gubrium & J. A. Holstein, The SAGE handbook of interview research: The complexity of the craft (2nd ed., pp. 367–380). SAGE Publications, Incorporated. Roberts, N. J., McAloney-Kocaman, K., Lippiett, K., Ray, E., Welch, L., & Kelly, C. (2021). Levels of resilience, anxiety and depression in nurses working in respiratory clinical areas during the COVID pandemic. Respiratory Medicine, 176, 106219. https://doi.org/10.1016/j.rmed.2020.106219 Shahrour, G., & Dardas, L. A. (2020). Acute stress disorder, coping self-efficacy and subsequent psychological distress among nurses amid COVID-19. Journal of Nursing Management, 28(7), 1686–1695. https://doi.org/10.1111/jonm.13124 Statistics Canada. (2022a). Add/Remove data—Job vacancies and average offered hourly wage by occupation (broad occupational category), quarterly, unadjusted for seasonality. https://www150.statcan.gc.ca/t1/tbl1/en/cv.action?pid=1410035601 95 Statistics Canada. (2022b, June 3). The Daily—Experiences of health care workers during the COVID-19 pandemic, September to November 2021. https://www150.statcan.gc.ca/n1/daily-quotidien/220603/dq220603a-eng.htm Tamrakar, P., Pant, S. B., & Acharya, S. P. (2021). Anxiety and depression among nurses in intensive care units. Nursing in Critical Care, nicc.12685. https://doi.org/10.1111/nicc.12685 Tan, R., Yu, T., Luo, K., Teng, F., Liu, Y., Luo, J., & Hu, D. (2020). Experiences of clinical first-line nurses treating patients with COVID-19: A qualitative study. Journal of Nursing Management, 28(6), 1381–1390. https://doi.org/10.1111/jonm.13095 Wong, P. T. P., & Wong, L. C. J. (Eds.). (2006). Handbook of Multicultural Perspectives on Stress and Coping. Springer US. https://doi.org/10.1007/b137168 Yıldırım, N., Aydoğan, A., & Bulut, M. (2021). A qualitative study on the experiences of the first nurses assigned to COVID-19 units in Turkey. Journal of Nursing Management, 29(6), 1366–1374. https://doi.org/10.1111/jonm.13291 96 Appendix A: Recruitment Poster 97 Appendix B: Consent Form Consent Form Study Title: How do Canadian nurses understand their work experience during the COVID-19 pandemic? Principal Investigator: Dr. Marla Buchanan, Department of Education and Counselling Psychology, UBC. Co-investigator: Brian Yan, Department of Education and Counselling Psychology, UBC. This research is being conducted as part of the thesis requirement for a Master’s degree in Counselling Psychology. Upon completion, the thesis will be a public document that can be viewed through the UBC library. Purpose: This study aims to explore the stories Canadian nurses construct of their working experience throughout the COVID-19 pandemic to better understand how it has affected their lives. By conducting this study, nurses’ stories and experiences will be given voice that would be otherwise unheard. These stories will have the ability to challenge other narratives and provide greater personal context from the perspective of the working nurses for other healthcare professionals and any others who wish to become better informed. Study Procedures: As a result of the phone screening interview that you completed, this consent form confirms your eligibility to be included in the study described above. If you choose not to participate in the study, the screening interview information will be securely destroyed. If you choose to continue to participate, you will be asked to take part in a 1-2 hour interview where you will be asked to speak about your work experience throughout COVID-19. If the interview is to occur in-person, participants will be asked to complete the COVID-19 Self-Assessment tool prior to meeting (https://covidcheck.gov.bc.ca/). In the case of a positive COVID-19 test, the interview will be postponed and rescheduled at a later date when the participant no longer tests positive on a rapid antigen test The interview will be carried out by the co-investigator, Brian Yan, at the Psychological Services and Counselling Training Centre at UBC, participant home, privately booked room, or Zoom, and will be audio recorded. Once your interview has been transcribed and developed into themes which tell the story of your experience, a copy will be sent to you as a password protected document via email for your feedback to ensure the breakdown of your experience is accurate. You will be asked to return the document via email with any comments or edits that you wish to make, within two weeks of receiving it. A follow-up meeting may be requested if the investigator needs to ask more questions or clarify some edits. The time commitment in total will be approximately 3 hours. 98 Potential Risks: Some of the questions asked may require you retell experiences that are associated with strong emotions, both positive and negative. You do not have to answer any questions if you do not want to. Also please know that you are also free to stop your participation in the interview, or withdraw from participating in the study, at any time. You will be provided with a resource list of local supports and services at the beginning of the interview for reference. Potential Benefits: You may find that participation in the study and sharing of your experiences of your work during COVID-19 as rewarding and beneficial. New insights or understandings may be formed through this interview process and sharing your story, or through the data review towards the end of the study. Your participation will contribute valuable information to our understanding of nurses work experience during COVID-19 and may serve to develop and improve counselling and mental health support services. Confidentiality: The data gathered from the screening interview, the study interview, and follow-up contact is confidential, and steps will be taken to protect your identity. Only the two principle investigators will review interview data, transcripts, and audio recordings. To protect your identity, pseudonyms will be used when storing the data and reporting findings. All audio recordings, transcripts, and summaries will be coded and devoid of any identifying information. Audio recordings and data files will be stored within an encrypted folder in a password protected device that only the principle investigators will have access to. After the study is complete and all data has been transcribed from the audio recordings, the data will be held for five years before being destroyed. Research findings may be distributed to peers and published publically on available databases, websites, presented at a conference, or shared with other research participants. If a journal article was to be published using the findings from this study, there is a possibility that the gathered data may be made available in order to publish which in turn increases the potential of participants being identified. If this is to ever happen, participants will be contacted and informed of this prior to publication. Once the data is made available, participants will not be able to withdraw their data. Remuneration: You will receive compensation for your participation in this study in the form of Amazon gift cards potentially totalling $35. You will receive one gift card of $25 at the beginning of your involvement in the interview section of the study, and a further gift card worth $10 when sent the member checking sheet which can be returned with comments or amendments. You may retain any gift cards received even if you opt to withdraw from the study. Contact: If you want further information or have questions concerning this study, please do not hesitate to contact Brian Yan. You may also contact Dr. Marla Buchanan. If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598. 99 Consent: Your participation in this research study is entirely voluntary. You may decline to participate in this study or withdraw your participation at any time without negative consequences. Your signature indicates that you have read, understood, and agree to this information and consent to participate in this study. Your signature also indicates that you consent to the audio recording of the interview. You will be given a copy of this consent form to keep for your own record. Ethics ID: H23-02860 Signature: _________________________ Date: ________________________ 100 Appendix C: Phone Screening Protocol Hi there! Thank you so much for taking an interest in our study. This phone call is an opportunity for me to quickly explain a little bit about the study, the requirements to participate in the study, what the study may involve, and also provide an opportunity for you to ask any questions. Are you okay if I proceed? The purpose of this study is to explore the stories that nurses can tell about their working experience during COVID-19. The goal is to better understand the lived experience and how nurses were navigating their constantly evolving environment. This is a narrative study so this will be a co-operative effort between us to establish a story that fits your experience. If you choose to participate, I will need you to be able to attend an in-person or online interview that would take anywhere between 1-2 hours. If we conduct the interview in-person, you will be required to complete the COVID-19 self-assessment tool prior to meeting (https://covidcheck.gov.bc.ca/). It is important to note that this is not a form of counselling, but an opportunity for you to share your story. At the completion of the interview you will receive an Amazon gift card for 25$. After the interview has been transcribed and analyzed, I will ask you to read over the themes we have generated and ask you to provide feedback on them via a member checking sheet you will be sent with the data. Upon receiving the completed sheet you will receive a $10 Amazon gift card as a token of appreciation for continuing to work with our study. Barring any clarifications on the feedback, that will be all the participation required. If some feedback requires clarification, we may contact you via email or if so desired, a video conference call, to ensure that we understand the feedback and incorporate it justly. All data gathered from this screening interview, the study interview and follow-up will be kept confidential. Only my supervisor and I will have access to the data and pseudonyms will be used when reporting the findings in any publications that result from the study. Do you have any questions so far? So I have a few quick questions just to confirm your eligibility for this study. 1. Are you a nurse who has spent at least 6 months working with COVID-19 patients in the past 3 years? 2. Where did you work as a nurse during that time period? 3. Are you confident in your ability to read, write and speak English? 4. Would you be able to attend an interview in person? a. If not, would Zoom be preferable? 101 Appendix D: Interview Protocol Study Site Orientation: Inform participant where the bathrooms, water fountain, and interview room is (if applicable). Share the Informed Consent Form and do not proceed further until it is signed. Interview Process Orientation: Are you comfortable? Just remember, if there is anything you feel uncomfortable about sharing, you can choose not to respond to my question or ask to stop the interview at any time or ask for a break. Ultimately it will be your choice about what you want to share during this interview. Before we begin, do you have any questions? Orientating Statement: The principal question I have for you is: “Can you tell me the story of your work experience as a nurse, during the COVID-19 pandemic, from the beginning until now?” Prompts to expand on participant accounts:  What was working in that environment like for you?  Could you tell me more about your experience working with COVID-19 patients? o Could you tell me more about that? o What does that mean?  What did you learn from working during the COVID-19 pandemic?  What did you notice about yourself during that time? o What does that mean to you? o Can you give me an example? o Can you name any consequences that come from it?  Can you tell me what stuck out the most for you about working during the COVID-19 pandemic?  What are your thoughts on staffing during the COVID-19 pandemic?  How was your personal life affected? o How did you make it work?  What is your understanding/opinion of “nursing culture”? o How did public perception of the nursing profession affect you?  Has your perspective on the nursing profession changed over time?  Where/how did you seek support?  What kind of support do you think would be most helpful? 102 Appendix E: Resource Sheet Care to Speak: Peer Support for BC Healthcare Workers Access online chat support at www.careforcaregivers.ca/caretospeak/ or call 1-866-802-7337 (PEER) for peer support Monday-Friday, 5pm-9pm, or Monday, Tuesday and Wednesday from 10am-2pm. Centre for Practitioner Renewal Find support focused on sustaining health care providers in the work place by addressing features of resilience, communication and health relationships. Call 1-604-767-2770 or email info@thecprteam.com. BC COVID-19 Mental Health Network Access free, phone based, short-term support with a counsellor. Email bccovidtherapists@gmail.com to receive an appointment time. Wellness Together Canada Access free counselling and support as well as self-guided courses, apps and other resources at: www.wellnesstogether.ca UBC Psychological Services and Counselling Training Centre Receive free counselling from Counselling Psychology Masters and Doctoral students in training. Call 604-822-1364 for more information. Reduced-Cost Counselling Options in Vancouver: https://willowtreecounselling.ca/wp-content/themes/willowtree/reduced-cost-counselling.pdf Below are confidential support services for individuals experiencing significant distress: Crisis Centre Distress Line: Greater Vancouver 604-872-3311 or BC-wide 1-800-SUICIDE (1-800-784-2433) Online Distress Services www.crisiscentrechat.ca BC Mental Health Support Line: 310-6789 (no area code needed). Provides support available 24 hours a day. 211 - Call this 3-digit number for information and referral to a range of community, social, and government services If you have an immediate emergency, call 911 or the crisis line at 604-872-3311 103 Appendix F: Member Checking Study Title: Narrative accounts from Canadian nurses of their COVID-19 experience. Research Question: How do Canadian nurses understand their working experience throughout the COVID-19 pandemic? Participant Name: 1. Resonance: Do these themes resonate with the interview we had together? 2. Comprehensiveness: Are these themes comprehensive? Is there anything missing that you feel should be included? Is there anything that needs revision? 3. Coherence: Do these themes make sense to you? Do you have any questions on how the themes were generated? 4. Pragmatic Value: Do you think the findings are useful?
Thesis/Dissertation
eng
Counselling Psychology
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Buchanan, Marla
How do Canadian nurses understand their work experience during the COVID-19 pandemic?
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