Beyond Burnout: Nurses’ Perspectives on Chronic Suffering During and After the COVID-19 Pandemic

Design

This study utilized a qualitative descriptive design and inductive approach to ensure rich and in-depth data were captured from participants regarding the phenomenon of interest (Sandelowski, 2000, 2010). The epistemological underpinnings guiding this qualitative descriptive approach included using an inductive process to develop knowledge regarding the phenomenon of interest and subjectivism that highlights the participants’ individual perspectives and experiences as well as the researchers’ perspectives conducting the analysis (Bradshaw et al., 2017).

Sample and Setting

Participants were eligible if they were registered nurses (RNs) and provided care to patients during the COVID-19 pandemic between March 2020 and September 2022. This timeframe is the estimated time when U.S. restrictions for the COVID-19 pandemic were implemented. Participants were eligible if they worked at one of two community hospitals part of an academic health system and level one trauma center in the southeastern United States. This study focused on RNs to understand the perspectives of nurses in direct care roles at the patients’ bedside (American Association of Colleges of Nurses [AACN], 2023), thus advanced practice registered nurses were not eligible for the study.

Recruitment

A purposive sample of nurses were recruited for participation via a flyer in a digital nursing newsletter with the assistance of the fourth author (DA). All study recruitment materials and procedures were reviewed by the Duke Health Institutional Review Board (IRB, Pro00111167) and the study was determined to be exempt from ongoing IRB review.

Data Collection

Due to the COVID-19 pandemic and scheduling challenges, three small group interviews (n = 2) and two individual interviews were conducted. Group interviews were selected to encourage participants’ ability to discuss with one another and build upon each other’s comments to elicit rich details about the problem or phenomenon (Marshall & Rossman, 2014). Interviews lasted approximately 60 to 90 min, were video and audio recorded, transcribed verbatim, and occurred virtually via a secure Zoom meeting. Participants provided verbal consent at the beginning of the interview after reviewing the consent form via email sent prior to the interview. Participants received a $40 Amazon gift card for remuneration.

The first author (MP) conducted the interviews and began with a brief description of the study’s purpose, allowing time for questions, participant introductions, and guidelines for the interview. An interview guide (Appendix A) was created, reviewed, and revised by the first (MP) and last (AW) author before finalizing. The interview guide aimed to elicit a discussion of four psychological and emotional concepts of interest: compassion fatigue, second victimhood, burnout, and moral injury. These four, common and overlapping concepts, were chosen due to their prominent use in healthcare and current scholarly literature; the third author (SS) is an expert in second victimhood and especially helpful in defining that concept.

Participants were provided with a definition of each concept during the interview. The definitions are shown in Table 1 in the order they were presented to the participants. These definitions were chosen based on their comprehensiveness and detailed descriptions for participants to refer to share their perspectives. It is pertinent to highlight that the second victim definition presented to the participants was formulated by an individual renowned for their expertise in second victimhood research. This previous version was recently updated in 2023 to “individuals working within an environment offering/providing care and are professionally/personally traumatized by exposure to a challenging clinical case/event.” (S. D. Scott, 2023, p. 272). Open-ended questions on participant experiences were asked regarding each concept to understand the impact of working with patients during the COVID-19 pandemic; all participants were asked the same questions. The first author (MP) asked follow-up questions and probing questions to follow participants’ direction during the interview to elicit detailed information based on responses to questions. Field notes were captured during interviews to assist in contextualizing any verbal and non-verbal observations and were analyzed with the transcripts to enrich the study findings.

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Table 1.

Concept Definitions.

Compassion fatigue	“the overall experience of emotional and physical fatigue that social service professionals experience due to the chronic use of empathy when treating patients who are suffering” (Newell & MacNeil, 2010, p. 61)
Second victimhood	“individuals working within an environment who are offering/providing care and are personally or professionally traumatized by exposure to a complex acute or chronic clinical case/event” ( S. Scott, 2022 )
Burnout	“a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed and characterized by three dimensions: feelings of energy depletion or exhaustion, increased mental distance from one’s job or feelings of negativism/cynicism related to one’s job, and reduced professional efficacy” (WHO, 2019, para. 4)
Moral Injury	“[moral injury] refers to a type of moral suffering characterized by exposure to circumstances that violate one’s moral values and beliefs in ways that erode integrity, moral capability, perception of basic goodness, and create distress on a psychological, behavioral, social, or spiritual level” (Rushton et al., 2022, p. 713)

Data Analysis

Conventional content analysis was used to analyze the data (Hsieh & Shannon, 2005). The three phases of content analysis were conducted: (1) data preparation; (2) data organization; and (3) data reporting (Elo & Kyngäs, 2008; Hsieh & Shannon, 2005). In the first phase, the data were prepared by the first author (MP) (Elo & Kyngäs, 2008). The transcripts and field notes were reviewed and edited against the recording and read multiple times, line-by-line, to ensure coding captured all pertinent manifest content from interview findings (Elo & Kyngäs, 2008; Miles et al., 2020, p. 86). In the second phase, the data were organized by the first author (MP) to group data that was related to concepts of interest in the study (Elo & Kyngäs, 2008). An inductive coding approach was used, which led to the creation of descriptive codes that were connected to the participants’ language and rich description (Hsieh & Shannon, 2005). Meaning units were words and sentences from the transcripts that were contextualized to create codes using the participants’ own words and then codes were aggregated according to similarities to develop themes (Graneheim & Lundman, 2004). A codebook with code names, definitions, and quotation exemplars was created; the codebook was revised iteratively throughout analysis (Glesne, 2016, p. 198; Turner, 2014). NVivo 14 was used for coding the data and creating and managing the codebook (Lumivero, 2023). In addition to the first author (MP) reviewing all transcripts, 20% of each transcript were reviewed by two authors independently, each author reviewing 10% of each transcript. The two authors were the second (TO) and last (AW) author, with the second author (TO) having expertise in qualitative methods and data analysis and the last author (AW) having qualitative experience while working in a supervisory role throughout the study process. Data were organized into themes associated with each concept with an additional theme identified for concept connections. Preliminary findings were reviewed and final themes were agreed upon with consensus from all three authors reviewing authors (MP, TO, and AW, respectively). An audit trail was kept during the analysis process to track all analytical decisions made. In the third phase, data were reported in finalized and agreed upon themes to present the study’s results (Elo & Kyngäs, 2008).

Trustworthiness

The authors acknowledged their personal and interpersonal reflexivity during the research process through conscious awareness, reflection, and appraisal of possible subjective influence when evaluating and analyzing data (Olmos-Vega et al., 2023). The authors have between several years to decades of qualitative, clinical, and nursing research experiences from various specialties; the authors all identify as female and ages range from 30s to 60s. None had personal relationships with any of the participants. These potential author characteristics have been acknowledged during the data analysis process. Credibility, transferability, dependability, and confirmability were utilized to enhance rigor and trustworthiness during the conduct of the study. Credibility involves prioritizing internal validity while including thick description and member reflections (Tracy, 2010). To enhance credibility, multiple researchers provided peer examination on data analysis, findings, and conclusions to ensure member reflections were detailed and concrete. Transferability relates to how study findings can be applied to other situations or scenarios (Lincoln & Guba, 1985). To prioritize transferability, thorough descriptions and detail were offered regarding study methods for potential of application to other clinical settings and the nursing profession. Dependability prioritizes consistency of findings, examining both the process of conducting the research and product to ensure findings are supported by the data (Hoepfl, 1997). To enhance dependability, details of the research methods were carefully recorded and presented in this manuscript. Lastly, confirmability prioritizes the direct viewpoints of participants to ensure their voices directly shape the study findings (Lincoln & Guba, 1985). To prioritize confirmability, an audit trail was maintained to record the data analysis process and decision-making among the research team.

Waves of Compassion Fatigue

In the theme, waves of compassion fatigue, several nurses related to the definition of compassion fatigue presented to them in Table 1, specifically the chronic need for empathy while caring for patients that can lead to emotional fatigue and physical fatigue. Nurses were familiar with the concept of compassion fatigue and thought the definition of compassion fatigue was sensible and self-explanatory. Nurses highlighted that their experiences with compassion fatigue fluctuated throughout the COVID-19 pandemic, which was perceived to correlate with waves of COVID-19 infections. For example, one nurse stated that “compassion fatigue comes in waves” and another explained it “can be like a spectrum.” Nurses expressed being extremely emotionally fatigued from caring for patients without replenishment, so much so that they began feeling numb as they set their emotions aside and choose not to deal with them as a coping mechanism. The emotional burden of caring for COVID-19 patients led to weight loss and poor nutrition in one nurse. Compassion fatigue was an experience that nurses felt compiled or snowballed, particularly when experiencing grief and other emotions during end of life care throughout the COVID-19 pandemic. Nurses were exposed to increased rates of death and dying during the COVID-19 pandemic. One nurse explained that compassion fatigue became specifically challenging when witnessing patients struggle:

With this compassion fatigue I have suffered with it a lot. Especially with the COVID patients seeing them struggling for their lives, difficulty breathing, especially with family members in the room it makes the situation a little bit worse – RN 02

A nurse discussed that although physically exhausted, compassion for patients increased during the COVID-19 pandemic after watching patients endure the unknown while navigating illness from COVID-19 infection. Another nurse felt that the “compassion fatigue” concept implied a negative connotation, as if the nurse did not have any compassion left for patients. In contrast, another nurse believed compassion was sustained for patients during the COVID-19 pandemic. From these various perspectives, there was no consensus among nurses regarding how nurses related to the definition of compassion fatigue.

Traumatization Within Second Victimhood

In the theme, traumatization within second victimhood, some nurses were familiar with the second victimhood concept definition after experiencing traumatization from acute and chronic clinical events. They discussed feelings of fear, guilt, and worry related to the unknown and how these emotional responses were an indication of being personally traumatized as a second victim. The word “traumatized” stood out most to nurses due to the extent and magnitude of the COVID-19 pandemic on the entire nursing profession. The second victimhood concept was new to several nurses. It required explanation, such as historical context regarding second victims who either were part of a medical error or traumatic patient event (Wu, 2000). However, two nurses did not see themselves as victims, with one not understanding how the patient is a victim when nurses are doing their best to provide care. Despite the description and lack of personal connection to the concept, one nurse described understanding for other nurses who may relate to second victimhood:

Victimhood is complex. . . I don't think I've ever really thought of myself or I thought [of] nurses as a victim. I never kinda pull those layers. . . I’m sure there are some folks because there is some really interesting cases out there, but I don’t think I can relate to the victimhood. – RN 05

Of the nurses that did relate to second victimhood, they also discussed its possible relationship to Post-Traumatic Stress Disorder (PTSD), with one nurse disclosing having been diagnosed with and currently being treated for PTSD. This nurse (RN 03) in particular, related to second victimhood the most of all concepts and stated, “I still get a little bit of anxiety when I hear the word ‘COVID’ on the news or just out in public” and “If someone says the word vaccine I get, I immediately get tense.” Furthermore, a second nurse described feeling like a second victim from interacting with a nurse after having coded her husband in the ICU:

I still have to see the nurse that I know that I coded her husband. . . For the longest time after, like he passed, when she would see me, she would just like literally go the other direction. And I'm going to go the other direction. So I think that's a hard thing, because he was young. We're all basically the same age. – RN 08

In addition to nurses as second victims, several nurses thought that second victimhood could be extended to their family and friends during and after the COVID-19 pandemic. For example, family members were impacted by watching the nurse be increasingly more exhausted and fragile, while taking additional precautions to avoid infection risk. Lastly, nurses felt troubled by feeling obligated to endure the stress of caring for patients during the COVID-19 pandemic, leading to distress and career changes:

Do I still feel like a second victim sometimes? Yes, because COVID has caused our nursing career to completely change. I chose to be a nurse. I chose the field I wanted. I didn't choose what has happened since COVID. So um that to me still gives me the idea that I am a victim and my career has completely changed because of COVID. - RN 01

Never the Same After Chronic Burnout

In the theme, never the same after chronic burnout, most of the nurses in this sample were familiar with the concept of burnout, as well as the following indicators from the burnout definition: the chronic workplace stress, energy depletion or exhaustion, increased mental distance from one’s job, cynicism, and negativism. Burnout was the most well-known concept among all nurses, and many nurses felt that burnout is just “part of nursing” and that it will be experienced by all nurses at some point in their career. Of all four concepts, burnout is the only concept that all nurses resonate with to some extent. The reduced professional efficacy component of burnout was understood the least by nurses, as nurses related this component to “professionalism,” which nurses believed they maintained despite the stress of the COVID-19 pandemic that led to challenges with completing nursing tasks with confidence.

Emotional stories shared by nurses related to burnout were mostly connected to physical and mental exhaustion. Many nurses described reaching a “breaking point” where they either decided, in an effort to reduce their burnout, they must work fewer hours, spend less time in patient rooms, mentally or emotionally check out, or switch nursing roles. Specifically, two nurses did switch roles during the COVID-19 pandemic. Nurses recognized that challenges with staffing, including short staffing and high nurse-patient ratios contributed to nurses’ burnout and led to patient safety risks that changed the quality of care provided to patients.

Several nurses felt strongly that burnout must be prevented before it occurs and that nurses may never be the same after experiencing burnout. One nurse said this simply, “burnout is the end result” after enduring hardships at work. Nurses described burnout as something that is chronic and “increases over time.” Even though nurses were interviewed from late 2022 to early 2023, burnout still resonated the most out of all the concepts with nurses interviewed, which aligns with the chronic nature of burnout described by nurses. Nurses expressed that large-scale change across the profession is necessary to effectively mitigate burnout, as it has continued to increase throughout the COVID-19 pandemic and beyond. Although burnout was frequently reported and quickly related to by nurses, their responses were often direct and confident in connection to the concept.

Moral Injury: Nurses Couldn’t Do Their Best

In the theme, moral injury: nurses couldn’t do their best, several nurses related to the moral injury definition presented to, suggesting their experiences included events that violated their moral and ethical values in ways that led to distress and diminished their capacity to provide care to patients. However, this concept was new to other nurses, required additional explanation, and was not easily grasped. For example, one nurse initially felt this definition meant that a nurse had pushed their religious or moral beliefs onto a patient when they should not have. Limited discussion regarding integrity and social and spiritual levels were discussed with the concept. However, one nurse was unaware of moral injury before participating in this study but resonated with this concept the most after talking through the definition; this nurse described several former experiences with moral injury, having been given language to describe prior violations of her moral and ethical values.

Nurses felt they could not provide the care they desired based on their values and beliefs due to workload and time limitations. For example, nurses were consumed by donning and doffing additional PPE during the COVID-19 pandemic leading to less time providing care to their patients. Additionally, one nurse reflected on patients’ wishes not always being followed thoroughly. The initial wave of the COVID-19 pandemic led to an increased need for ICU treatment for cases of severe infection, but patient and family preferences for specific lifesaving treatments were not always prioritized when there was a sense of urgency to initiate intensive care, leading to moral injury for the nurse. Concerns regarding COVID-19 infection prevention, constantly evolving organizational policies and practices, and public health were also tied closely with nurses’ moral injury. Prior to the COVID-19 pandemic, nurses were used to strict policies and procedures related to infection prevention and PPE use, however, this changed during the pandemic and led to moral injury:

Well, the first thing I think about is when we had to reuse like N95s, and like PPE. And I remember. . . they're saying, you know, we have to reuse this for like a week, and you know, when you're working as a nurse for so many years, and you are taught sterile technique. . . you would never reuse like a dirty anything. And then here we are reusing an N95 for 5 days and then we get a new one. So when I think of moral injury, that's what comes to my mind. – RN 05

Concept Connections

Nurses discussed each concept individually but concepts were often discussed together as nurses described their experiences and how the nursing profession has been impacted during and after the COVID-19 pandemic. The most well-known and commonly experienced concepts were burnout and compassion fatigue. Mental and physical exhaustion were at the forefront of nurses’ experiences and related to increased workloads and staffing challenges. Although compassion fatigue was the first concept discussed, burnout was quickly integrated into the nurses’ language when describing their emotional and physical fatigue experienced from burnout:

The emotional part just gets pushed to the back, and it becomes just more physically, just like just trying to get the work done and get everything going. So, then you get fatigued, and then kind of burnt out. – RN 03

While discussing burnout, a few nurses discussed that their burnout led to reduced compassion for patients but that both concepts went hand-in-hand. This revelation was related to nurses’ exhaustion and staffing challenges, and presents the chronic nature of experiencing both burnout and compassion fatigue overtime:

. . . we've been very short staffed and the hospital has put out all kinds of incentives for people to work extra shifts. . . and I found myself working more and more because it was great to make the money. But then again, you just get tired and frustrated and you go into work, and you realize that you're not happy to be there, and you're exhausted, and you don't feel very much compassion. You’re just doing your job, and you're not being the best nurse that you could be. . . At some point, I just stopped signing up for extra shifts. RN - 07

Furthermore, second victimhood was discussed prior to burnout, but the connection between the two co-occurring concepts was evident, as a nurse (RN 02) shared: “the second victimhood is really real. It’s not only [from] the COVID patients. We have people with different diagnoses. So, taking care of all the patients has been stressful and the burnout is real.” Considering moral injury (also known as moral distress) another nurse (RN 06) found that “moral distress was causing me to have compassion fatigue and burnout,” highlighting the chronic nature of both burnout and compassion fatigue after experiencing morally distressing events.

As nurses reflected on all four concepts, several nurses expressed that these concepts may occasionally be discussed in the clinical setting, most commonly burnout, but the concepts are often used differently and may not be fully understood by nurses. Nurses stated that these concepts should be discussed more, as several nurses were unaware of one or more of the concepts, with two nurses identifying most with a previously unaware concept. This realization was unsettling to one nurse (RN 03) who stated, “You know I don’t think that’s a coincidence, because if we knew about it, we would have done what we can to take care of it.” With nurses asserting that burnout is chronic and challenging to recover from, most nurses agreed that drastic change is needed to improve working conditions and provide more support resources to promote the well-being of nurses.