The ICON interview study: Stigma and Support during Covid-19

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At the outset of the pandemic, the Florence Nightingale Foundation and Burdett Trust for Nursing generously pledged funding for a piece of work to examine the effects of the Covid-19 pandemic on frontline nursing staff’s psychological health as a way to aid their long-term recovery.

What we did

Twenty-seven nurses were involved in semi-structured qualitative interviews after the first wave of Covid-19 in July 2020 and 25 of these nurses were interviewed again at the beginning of the second wave 1 in December 2020 (n=25). Interviewees included 26 nurses and one midwife (hereafter called nurses collectively) from England, Scotland and Wales who worked in a range of settings. All interviews were conducted remotely via Zoom or Teams. In the interviews we used open questions to elicit stories and undertook interviews with the same people on two occasions making it a longitudinal study. This method helped us to assess the impact of working during Covid-19 on these nurses’ practice over time as the stressors of working during the pandemic changed. To gain a broad range of nurses we interviewed people of differing ages and experience, from differing grades, specialities settings and parts of the UK. For example, we spoke to mental health and learning disability nurses, community nurses, nurses who worked in social care and redeployed nurses. From the 18 nurses who we had spoken to who had been redeployed during the pandemic, 7 were redeployed to ICU.

What we found

Our data revealed the anxiety, frustration, guilt and inner turmoil that nurses’ had experienced and continue to do as the trajectory of the pandemic progresses. The majority of our participants experienced distress due to the challenges of the work in the first and second waves of Covid-19 which included compromised care delivery. Their daily involvement in caring for patients whose treatment options were limited together with the extremely high death rates increased their distress. For example, Amie and Ellie below expressed perspectives that we frequently heard:

Within one week we’d had nine deaths, and it was just so traumatic. Not only did we have nine deaths but the deaths happened in a way that we’d never planned. Amie, care home manager, int1

The things that you see and everybody is really sick (…) a lot of people are young. Everybody has the same disease, and it’s just, there’s just so much death, and I think staff are going to feel very blue for a very long time. Ellie, redeployed to ICU, int2

Moral distress was experienced by nurses not having the time or sufficient resources to provide their normal high standards of care which was deeply traumatising for some of our interviewees. Nurses spoke about the distress generated through external constraints preventing them from caring for their usual patients. The distress nurses felt was profound and they felt this had lasting effects. For example, Gaby below reflected on the distress that stayed with her:

I think that I was definitely having signs of trauma in a sense of, when I think about it, because I would go home and I really couldn’t… you know there’s still people now, and I think about their names every day, even now, and I think about them, and it just makes me so sad, about how you’re part of that treatment (…) I think everybody there, we want to just look after people, and you feel that you’ve not looked after them. Gaby, redeployed to rehabilitation centre, int1

Although distressed, many of our interviewees did not wish to accept the psychological support offered by their Trusts. Nurses seemed to delay accessing support until they deemed it absolutely necessary and at this point many chose to access it via sources outside of their organisations such as charities or Unions. There was hesitancy to disclose problems to managers due to stigma or worries about being judged by colleagues suggesting in some settings it remains psychologically unsafe for staff to disclose mental health challenges, and some worried about the perceived impact on their career. For example, interviewees talked about not accessing resources at their Trust’s wellbeing centre because they did not want to be seen as ‘weak’:

A lot of us think if we go for support maybe we’re looked upon as a bit weak, that’s another thing. And like I said, more time, we don’t have time to go to these meetings and do yoga and have wellbeing sessions. Camila, ICU, int1

The value of social support from colleagues to protect nurses from the negative impact of emotional demands was evident and we highlight how essential our nurses found this form of support during the pandemic. For most of the nurses we spoke to, the main positive of their experience was the camaraderie they experienced with colleagues, either whilst working with groups of nurses or virtually via WhatsApp or other social media groups.

Support wise, I think we’ve just got to be there for each other (…) I think we can keep that team cohesiveness together. You know, they keep making these Tik Toks. We don’t post them but they’re on one of the WhatsApp groups. They’ve just had people in tears of laughter so that’s been a really good outlet. Jo, redeployed to ICU, int2

I set up a little WhatsApp group, a redeployment support group. So when I knew that people were being deployed (…) I was able to kind of give some advice. Gaby, redeployed to rehabilitation centre, int1

In their own social media support networks, nurses felt empowered to share their experiences with colleagues who had ‘been through the same thing’. For nurses who may have experienced difficulties accessing social support at work or in online groups other methods of social support do exist. For example, Schwartz rounds are multidisciplinary forums where staff convene to discuss the social, emotional, and ethical aspects of work experiences, have successfully moved online (Team Time) due to the pandemic, and offer a possible alternative for those who experience less social support Understanding Schwartz Rounds – YouTube. Additionally, the Florence Nightingale Foundation provided online peer group coaching sessions for nurses and midwives managing the leadership challenges, professional conflicts, and ethical struggles during the pandemic. The feedback on this service reflects the desire to access support externally from the employing organisation, as a result of the anonymity and safety this offers. Our data has highlighted the need for future research into participatory interventions, focusing on cohorts of nurses who can use their ‘inside’ knowledge to act as ‘experts by experience’.

Authors on behalf of the ICON interview study team:

Dr Anna Conolly, Research Fellow

Professor Jill Maben, Professor of Health Services Research and Nursing