https://orcid.org/0000-0002-6730-4725
Abstract
: Nurses experience varied forms of work-related stress with Covid 19 being one of the major causes of stress among frontline nurses. This study aims to explore the challenges faced by frontline nurses when caring for covid-19 patients at the Ga East Hospital which is one of the main Covid referral centers in the country. A qualitative exploratory research design was employed to explore the lived experiences of nurses at the frontline using a semi-structured interview guide with probes to conduct in-depth face-face interviews. Data was tape-recorded and transcribed verbatim and analyzed using content analysis. The sample size was 38. Two (2) themes and nine (9) sub-themes were generated from the analysis of this study. Participants in this study brought to bear their responsibilities as frontline nurses and the difficulties faced whilst discharging their duties. It is also interesting to know that the frontline nurses did not experience any shortage of logistics however, some challenges identified included Difficulty using personal protective clothing, fear of getting infected, and challenges with transportation Frontline nurses had varied roles when caring for Covid 19 patients, however, several challenges are experienced whilst ensuring this, hence measures should be put in place to overcome these challenges to facilitate the smooth discharging of duties as frontline nurses.
1. Introduction
Nurses constitute the majority of the healthcare workforce globally. They are the group of health workers that are most of the time with patients, most vulnerable to hazards and making moral decisions. Hence, they experience varied forms of work-related stress (Schwerdtle et al., Citation2020). The COVID-19 pandemic has been found to increase nurses’ stress in their workplaces. This has been found to influence the quality of care provided by nurses (Kim et al., Citation2021; Schwerdtle et al., Citation2020).
A study in Wuhan, China, revealed that 29.8% of nurses and other healthcare workers experienced signs of stress (Zhu et al., Citation2020). Many nurses in China experience immense physical and psychological stress (Xiong et al., Citation2020). A significant number of nurses in China identified long hours of work during the covid-19 pandemic as a major source of their stress (X. Mo et al., Citation2020). Coupled with the aforementioned, also revealed that nurses in China are experiencing an unprecedented higher-than-usual patient-nurse ratio owing to the ravages of covid-19 (Maben & Bridges, Citation2020).
Similarly, nurses caring for covid-19 patients in India experience banishment and rejection from society, outright eviction from their places of residence by landlords, discrimination, and fierce attacks in public places and public transport (Chatterjee & Chakraborty, Citation2021). In addition, a study in South Asian countries discovered that front liners in India were discriminated against and stigmatized (Banerjee, Citation2020). They also had poor sleep due to the increased workload and were anxious because of the unavailability of adequate personal protective equipment. In Australia, a study identified social distancing during the lockdown as another source of stress. This has made unavailable to nurses, their needed source of social support (Halcomb et al., Citation2020).
It has been observed that Ghana has a restrained healthcare system due to the insufficient number of nurses compared to patients. For example, Ghana has a population of about 30 million and an estimated 27 nurses and midwives per every 10,000 people (Afulani et al., Citation2021). Seven (7) out of every 10 healthcare workers including nurses experienced high levels of stress with the increasing number of patients with COVID-19 becoming a major source of concern for them. The healthcare workers were scared of COVID-19 infection because, there was inadequate testing, personal protective equipment, and isolation wards. Psychologically, the healthcare workers were stressed due to their colleagues’ infection and death rates. Evidence suggests that increased levels of stress tend to impair employees’ performance and adversely affect their attitudes and behaviors (Chawla & Kelloway, Citation2004))
2. Methods
Research design is described as a statement that explains the characteristics of particular research (Lim, Citation2006). The researcher added that a study design usually gives detailed information on the type of research and also gives suggestions about the type of data that will be of importance to the researcher. An exploratory qualitative research design was used. This design permitted the researchers to explore the experiences of frontline nurses during the provision of care to patients who were diagnosed with Covid 19
3. Target population
The target population for this study will be nurses working at the frontline in the fight against covid-19 at the Ga-East Municipal hospital, Kwabenya.
4. Sample size and sampling technique
In this study, the purposive sampling technique, also known as “judgmental sampling” will be employed to select participants. With the purposive sampling technique, participants were deliberately selected from the population. This permitted researchers to collect rich data for the robustness of the study. The sample size is explained as qualitative research is determined at the point of saturation, where no new information is obtained from the participants (Afulani et al., Citation2021). Therefore, the researcher will interview till there is no new information to be retrieved. The sample size was therefore 38.
5. Data collection procedure
First of all, ethical clearance was obtained from the Dodowa Health Research Centre Institutional Review Board (DHRCIRB) with protocol number DHRCIRB/096/09/21. An introductory letter and ethical clearance certificate were submitted to the administration of Ga-East Municipal Hospital, Kwabenya to seek permission. The researchers paid a visit to the administration of the hospital where the In-service Coordinator, the Deputy Director of Nursing Services (DDNS), and the researchers met and discussed the study. The researchers introduced themselves and expounded on the purpose of the research and the sample to be recruited for the study. The purpose and procedure of the research were explained to the nurses who met the inclusion criteria. This was done to make them understand that they have the free will to decide whether they should participate in the study or not. They were allowed to sign a consent form after
Face-to-face in-depth interviews were undertaken at the facility and in their houses on a date and time suitable for the participants with the covid-19 protocols in mind. The interviews were recorded using a voice recorder after seeking the consent of the participants. In all, thirty-eight participants were interviewed with the help of the semi-structured interview guide. In the course of the interviews, the researcher listened closely and reduced all forms of distractions that might disrupt the conversation on the issue of experiences of nurses in the management of patients with covid-19. The researcher wrote down issues of interest in her notebook during the interview as the need may arise for further clarification on them. The interviews lasted between thirty to sixty minutes. The researchers expressed their gratitude to the participants for their time at the end of each interview. The entire data collection lasted for 2 months.
6. Data analysis
The reliability of a search instrument concerns the extent to which the instrument yields the same results on repeated trials (Graue, Citation2015). The study made use of content analysis. Audiotapes from the interview sections were played over and over again to discover patterns and themes as most qualitative materials were obtained from interviewees’ verbal responses. The recorded data obtained from the interview session was transcribed verbatim into a word document. The researchers then familiarize themselves with the data by reading the transcripts severally. The data was condensed by allocating a few words to the content whilst maintaining the meaning of the respondents. Following the condensation, the words with similar meanings were put together. Finally, two main themes and 11 sub-themes were generated from the study analysis.
6.1. Methodological rigour
Methodological rigor ensures that qualitative researchers are more concerned about giving out studies that are very high in quality, reflecting reality and truth (Mathy et al., Citation2003). A qualitative study’s trustworthiness means methodological soundness and adequacy, which comprises four criteria: credibility, transferability, dependability, and confirmability (Pereira, Citation2012).
7. Results
7.1. Socio-demographic characteristics of participants
The target population for the study was made up of male and female nurses within the age range of 23 to 48 years working at the Ga-East Municipal Hospital. The sample included a mix of 38 participants who were all interviewed. A total of 25 (66%) of the 38 participants were between 23 and 30 years of age and the remaining thirteen had ages ranging between 31 and 48 years. The majority 25 had a 1st degree in nursing, and more than half of them, twenty belong to the Akan tribe. Also, the majority of the participants thirty were Christians. The other information is demonstrated in Table
Table 1. Socio-demographic data of the participants
7.2. Organization of themes
Two (2) main themes were identified from the study analysis. Under these main themes, nine sub-themes were also generated. The main themes and sub-themes are represented in Table :
Table 2. Organization of Themes Two (2) main themes were identified from the study analysis. Under these main themes, nine sub-themes were also generated. The main themes and sub-themes are represented
7.3. Roles of frontline nurses in the management of Covid-19 cases
Frontline nurses narrated several experiences during the covid-19 pandemic. The data gathered during the interview sessions revealed the various roles nurses played in the treatment and management of patients hospitalized for covid-19 as follows
7.4. Sub-theme one (1): Testing and training all staff for Covid-19 management
Medically, testing helps in detecting, diagnosing, and monitoring a particular disease or determining a course of treatment. Among the various roles, the frontline nurses played in the management of Covid-19, is testing. This role was part of the duties of the various covid-19 isolation ward charge nurses, the nurses who were the coordinators and assistants. They periodically test their staff and make themselves available to be tested. This was depicted in the narrations below:
“As the coordinator, I made sure that samples were taken frequently from every staff and myself for testing so that if one person is infected, we can quickly isolate and start treatment for the person. We then swap that whole team and bring another team on board till the other team on 14 days quarantine is over”. (R24)
Even though some of the nurses were not given the direct role of taking samples from their colleagues for testing, they assisted in the procedure.
“I was assigned the duty of taking staff personal details before they go for their samples to be taken, I made sure that the required number of staff to be tested per day, undergo the testing procedure, to make sure that everyone gets tested in order to detect infections early and to prevent the transfer of infection among the staff”. (R5)
“I was made in charge of counseling the staff before they go for testing, so they come to me and we talk to allay their fears and anxiety relating to the covid-19 test. After that, they go and take the samples. Initially, they were anxious about taking the test but as time passed, they were ok”. (R12)
Training of staff for Covid 19 management was done to increase the skill and knowledge of the nurses selected to care for patients in the various covid centers. For the purpose of providing quality care to patients with covid-19 during the pandemic, a series of training programs were organized for staff during the pandemic. The following statements affirmed this fact:
“So, in the management of covid-19 per the department I find myselffirst of all, training staff in infection prevention and control and the safety practices on how to manage infectious diseases. And because covid-19 is something new in the country, I organize the training sessions for the staff before they are posted to the various covid-19 isolation wards”. (R24)
“With my technical know-how combined with the years of experience working as a nurse, I was among the nurses sent for the initial covid-19 training. After that, I had the opportunity to train the nurses placed under my supervision as well. So, I normally with the assistance of the coordinators, provide training for other staff who are not so good at certain areas, especially with the covid-19 care”. (R1)
7.5. Protecting other staff and patients
Another crucial role that was seen to be taken up by nurses was making sure that in as much as the patients are being protected from cross-infection, their colleagues were also kept safe, as infection of one could lead to infection of all. Below are some remarks from the participants:
“As nurses we made sure that we protected ourselves as well as our patients by always wearing our face masks, and washing our hands frequently among other covid-19 protocols. We were monitoring ourselves for any signs and symptoms of covid-19 like cough, sore throat, fever, and loss of smell or taste. Also, we made sure that, our PPEs were worn the right way before we go into the wards to perform nursing procedures on the patients.”. (R16)
“Every day when we get to work, we clean the nurses’ station and the various wards. Every time we are about to go to the patients, we assist each other in donning our PPEs. Just as we don PPEs the right way, when we are done performing tasks for the patients and we come out, we doff the right way also, to prevent contamination. As you know if one person gets infected, the probability that all of us will get it is very high”. (R13)
7.6. Provision of care to Covid-19 patients
Frontline nurses provide various forms of care to covid-19 patients daily. The result of the study revealed that nurses were the key players in providing care for the patients since the majority of them were admitted due to the critical state in which they were. The care rendered included assistance in maintaining personal hygiene, feeding, monitoring vital signs, administration of oxygen, and other health-related care. This was evident from the responses of participants as stated below:
“One of the roles I would say I played as a front-line nurse was providing forms of emergency care for the patients when they arrive on the ward. Most of them were brought in a critical state, like when they start experiencing shortness of breath. So, we provide emergency care like administration of oxygen, strict monitoring of vital signs with emphasis on low saturation levels and respiratory rate”. (R16)
“I was performing usual nursing roles example, checking the vital signs of patients, feeding them, and also giving bed baths. Because I was at the highly dependent section where virtually everything is done for the patient, I changed diapers, I administered medication, performed non-invasive ventilation that is using the mask, on patients with moderate cases”. (R7)
“Most of the patients that were being admitted here were with comorbidities, such as asthma, diabetes, and all that, so we had to manage them for both Covid-19 and their pre-existing conditions. So, most of the time we had a lot to do. For instance, with patients that came with diabetes, we had to be doing constant blood glucose monitoring and giving insulin alongside Covid-19 management”. (R5)
A number of the frontline nurses were not concerned about the nursing procedures only, but inculcated education into their daily care to the covid-19 patients:
“I was also focused on providing education to most of the patients I take care of, including their family members. I always strongly advise them on the stated preventive measures like hand washing, use of mask, social distancing as well as on compliance to the intake of vitamin c and zinc”. (R10)
7.7. Making logistics available for work
Making logistics available for work was one of the sub-themes identified by some of the participants. The logistics included PPEs, bed linens, hand sanitizers, soap, and paper towels. Per the positions most of the nurses find themselves in, as charge nurses, they made sure that logistics were made available for the smooth running of the ward. Below are some remarks from the participants:
“As a supervisor, I make sure that our working environment is clean by supervising the dusting to ensure that it is done well. We also do requisition for consumables and other items for use on the ward and then ensure that they have been brought from the stores”. (R11)
“I go to the stores to make sure that all logistics are available for staff to work with and are of a good standard, and making sure that there is enough for future use”. (R24)
Few participants commented that their facility only experienced a shortage of logistics on a few occasions:
“Our ward in charge was always concerned about the PPEs and other working materials, like the gloves, nasal prongs or masks for oxygen administration and sanitizers. He always made sure that there were no shortages. He made sure that all the things we needed for the day were always available. Apart from the days, we had more patients than usual. When it happens like that, we even go to other wards to take some from them”. (R20)
7.8. Roles of older nurses and those with co-morbidities
Age was a factor when frontline nurses were recruited for the care and management of covid-19 patients. The result of the study reflected that older nurses and nurses with co-morbidities, such as Asthma, Diabetes, and Hypertension were basically not allowed to be involved in the direct care of covid-19 patients, as they are at high risk due to the status
“In my ward nurses with comorbidities were not allowed to enter where the patients were kept, talk of performing any procedure on the patients. They were at the nurse’s station to help with documentation and also communicate with patients’ relatives”. (R16)
“Nurses with comorbidities were not allowed to enter the covid-19 isolation ward but were mainly at the Out Patient department made to do administrative work. The same with some of the older nurses we came to meet”. (R18)
“The duty of the elderly nurses and those with comorbidities who come to work was to supervise and do all the paperwork, like recording medications and nurses’ notes. They also assisted the younger nurses to do administrative work and writing reports”. (R20)
7.9. Stresses experienced by frontline nurses
Another issue the front-line nurses raised was the stressful situations they experienced during the pandemic. The majority of these front-line nurses noted that they encountered diverse forms of stress due to different factors which ranged from work overload resulting from a shortage of nursing staff to the fear of getting infected with covid-19, amongst others. The following were the stressors that emerged from the analysis of the result:
8. Difficulty using PPES
PPEs are worn to protect the user from exposure to health risks or hazards. Examples include gloves, goggles, high-visibility clothing, and safety footwear among others. From the result of the study, it was evident that one of the major difficulties the nurses faced was the discomfort experienced when fully clad in the PPEs for long hours of work, even though it was meant for their protection. The following responses supported this fact:
“My main challenge was feeling uneasy wearing the PPEs, this was my first time wearing a face mask throughout the shift, that is, for 12 hours. It was very uncomfortable for me because I had to intermittently go to the restroom to take it off to breathe. One of my colleagues nearly fainted some time ago. Wearing the PPEs for long hours was just very uncomfortable”. (R2)
“As for the PPEs, they were very uncomfortable. Wearing it for long hours was the most stressful aspect. The heat in the gown was unbearable, it made a few of our colleagues collapse inside the ward when they were attending to patients. Working fully clad in the PPEs for long hours really gave me discomfort and stressed me up. I pray I don’t see myself in this situation again”. (R24)
“It was really tiring; the very uncomfortable nature of the PPE emanates from the plastic material used to make it. Also, you have to be assisted to don it. Not only that, you have to work dressed in it for at least 4 hours at a time before you can take it off. It even makes you more tired than the nursing procedures. You get so drenched in sweat that, when you come out of the ward, one may think you poured water on yourself”. (R13)
9. Fear of getting infected
All over the world, covid-19 has raised the level of fear that is associated with communicable nature. People are more mindful of their surroundings nowadays than they used to be, owing to the highly contagious nature of covid-19. Covid-19 protocols are being adhered to strictly, because of the fear of getting infected or transferring the infection. Below are some remarks from the participants:
“Unlike the normal times on the ward, during the covid-19 pandemic, we were always in a hurry to leave the patient’s bedside. This is because we were scared that we will get infected. So right after performing your nursing procedures, you leave. We couldn’t even go close to the patients as often and freely as we do in normal times. It was really a stressful situation, knowing very well that patients need communication as much as nursing care”. (R19)
“The thought of a possible infection with covid-19 was not a joke, it was very stressful. At one instance my face mask came off while I was attending to a critically ill covid-19 patient. You can just imagine the fear and anxiety. I had to rush through my procedure and go out and doff. That day I was the most miserable nurse. The worst of all, the patient I was working on died a few hours later. I was very sad and thought I was going to test positive”. (R14)
Because of fear and anxiety related to the large number of deaths recorded with covid-19, many volunteer nurses went back to their original hospitals in order to protect themselves.
“Because of the high risk involved, some of the nurses who voluntarily came to assist started leaving when some of our colleagues got infected. Our numbers went down as they left due to the fear of getting infected too. This increased our stress level since we had to work for longer hours to cover up for the reduced staff strength”. (R20)
Another stress frontline nurses experienced in relation to the fear of getting infected was the fact that, they were stigmatized. Below is one of those narrations:
“Sometimes I face the challenge of getting close to people who know me. Because, when they see me coming, they immediately reach for their face masks, out of the fear that I may infect them. The worse feeling is when commercial drivers don’t want to pick you up to work, just because you are coming to Ga-East Municipal hospital (the covid-19 centre). Some of the drivers even tell us that we are all infected just like the patients. These kinds of statements and behaviors were really stressful”. (R9)
10. Transportation from home and work
Frontline nurses made use of different forms of transportation to work daily. They reported that, because of the lock down and the distance from the main road to the hospital, they face a lot of challenges transporting themselves to work and back. They utilized taxis, motorbikes, uber or bolt and some even walked all the way to work. They stated that transportation had been one of their major stressors. The following are the comments made by the participants:
“For me, transportation was one of my problems. During the lockdown, I didn’t get car from where I was staying. So, I walked from my house to the main road, to join the government bus provided to transport essential workers. By the time I get to work, I am already tired”. (R13)
“Because of the far distance from my house to de workplace, and only a few public transport systems were available, I had to request uber or bolt. It was so expensive, but I had no other option. I spent so much on transportation that, by the middle of the month, my salary is finished. It really had a strain on my finances and that stressed me a lot “. (R16)
“At a point, we had to wait for each other when we close at night. So that we can walk as a group to the main roadside to get taxis home. Because the distance from the hospital to the township is far and lonely at night. Personally, I was stressed with that arrangement and made my zeal for the work go down”. (R5)
11. Separation from family and friends
Another form of stress experienced by frontline nurses during the pandemic was separation from family and friends. It had diverse impacts on the relationships between frontline nurses and their families and friends. The majority of them could not stay in their own homes due to stigma or the fear of infecting family members. Some of them relocated their families elsewhere so that they can be safe. Below are some of the frontline nurses’ comments:
“Yes, I experienced stress. My husband was very scared I would bring the infection to them at home. I tried so much to convince him but to no avail. I told him that I volunteered to be at the frontline, so he should understand my passion to save lives. He then agreed partially, but on the condition that we send the kids to their grandparents in our village, because there were no cases of covid-19 recorded there. I reluctantly agreed to that option but within me, I wasn’t ok”. (R24)
“I got detached from my family due to the work. At one point, I didn’t have any form of social life at all. I didn’t have the time to get in touch with my family and friends. Because after work, I get so tired and unable to call them or even return their calls. That really stressed me a lot”. I also have to send my children to my mother because my working hours became longer and I wasn’t having enough time for them. I was also afraid that I will infect them with covid-19”. (R16)
“They were very scared, contrary to my excitement. My hypertensive mum said I shouldn’t come home. She was angry that I said I was going to nurse covid-19 patients. She was really scared I was going to get her infected with covid-19, because of her comorbidity. She kept saying I shouldn’t do it and it strained my relationship with her”. (R3)
12. Shortage of staff
Pertaining to the stresses frontline nurses experienced, the shortage of staff was one major one. It was more evident at the peak of the pandemic when patients’ numbers doubled. Frontline nurses re-counted that; the nurse-patient ratio was very poor thereby increasing the workload on the few that were available. The following responses of the participants revealed this finding;
“As the workload increased, we couldn’t get the corresponding number of workers and this really placed a lot of stress on us. The nurse-patient ratio was not encouraging at all, it made us really exhausted. But it got better when the patients’ numbers dropped”. (R3)
“Actually, the staff strength was not good, so we ended up working overtime. The staff strength compared to the workload I will say, was in-proportionate so, it really caused a lot of stress for us. We had to go into the wards more frequently. It actually increased our fears in relation to possible infection. However, it got better when other nurses were called to join”. (R18)
“I wish we had a retained better nurse-patient ratio. Earlier, before the peak of the pandemic, we had enough staff. But later getting to the peak, we didn’t have enough staff. We were unable to give each and every patient holistic care. Sometimes patients needed example food, affection, and attention, but due to the inadequate nurse-patient ratio, they had to wait till it’s their turn for the 4 hourly routine visit to their ward”. (R10)
“During the second wave, the stress was so much for most of us. The work was so demanding that even those on annual leave were called back to work. Nurses from other facilities around too were also called to come and help”. (R22)
13. Discussions
The current study found that most of the nurses who were the charge nurses and coordinators per their positions performed the duties of organizing the other staff periodically for testing. They also gave treatment to those infected and isolate the staff who got exposed in their line of duty. This is consistent with a study that stated that in China nurses were found to be involved in self-monitoring for signs and symptoms, self-isolation, and reporting any signs of infection to their immediate charge nurses or coordinators for further necessary action and help (Huang et al., Citation2020). In as much as the coordinators were getting the others tested, they did not forget to test themselves as well. This similarity may be a result of the highly infectious nature of the disease. The importance of this practice is directed toward early identification, isolation, and treatment to prevent the spread of the infection to help retain the Staff’s numerical strength. Taking into consideration the high level of demand for nursing staff, this role was not taken for granted by the frontline staff. This vital practice by the frontline nurses helped to reduce the number of staff being infected with covid-19.
Due to the unexpected nature of the Covid-19 pandemic, the nurse coordinators and senior critical care nurses engaged in providing training on covid-19 and how to manage infectious diseases to meet the high demand for critical care nurses in the fight against Covid-19. This was a good initiative taken by the coordinators, as it helped to impart knowledge on covid-19 diagnosis and management, swiftly to the newly recruited nurses. It equipped the nurses with adequate technical know-how in dealing with covid-19. This initiative taken by the nurse coordinators and critical care nurses in this study is comparable to the observation made that, charge nurses and nurses who are advanced in the care of patients have a major role in training and supervising new and upcoming nurses (Schwerdtle et al., Citation2020). Also, expert critical care nurses who are conversant with present-day practice and machinery should direct the new nurses in Intensive Care Units because a lot of them will be nervous about the additional duties and the application of unaccustomed practices example, taking care of patients in ventilator support lying prone and those who are also highly infectious.
Another vital role that was taken up by the frontline nurses was the responsibility of protecting themselves from covid-19 infection, and also protecting patients in their care from cross-infection. The participants in this study, followed the covid-19 protocols of the WHO strictly to avoid contracting the virus. They always wore their face masks, don their PPEs, and wash their hands under running water frequently, among others. Frontline nurses were monitoring each other for signs and symptoms of covid-19 like cough, sore throat, fever, and loss of smell or taste. This role implies that nurses cared about the welfare of each other, having in mind that, an infection for one is an infection for all. This keeps them from being negligent when it comes to safety precautions.
This was also practiced in Beijing China and increased constant monitoring of infection control measures and safety precautions became a major role of nurses at hospitals (Cao et al., Citation2020). Similarly, some researchers reported that during pandemics such as Covid-19, nurses play a major role in regard to self-monitoring for signs and symptoms (Huang et al., Citation2020).
Frontline nurses in this study were found to have provided various forms of care to covid-19 patients daily since the majority of patients were admitted in their critical state. Nurses rendered emergency care for stabilizing patients with difficulty in breathing, which involved close monitoring of vital signs with emphasis on the respiratory rate and oxygen saturation, oxygen administration, and other health-related care. Due to the critical nature of some patients’ conditions, nurses also fed them and bath them in bed. The nurses can early detect deviations in the patient’s breathing patterns and vital signs when they closely monitor them. The oxygen saturation is also monitored to ascertain improvement or depreciation for prompt intervention. Medication administration has not been left out. This supports the findings of a study in China, where it was observed that nurses play a myriad of roles in their efforts to treat covid-19 patients, which included but are not limited to the triaging of patients and detecting suspected cases; delivering vital treatments during emergencies and handling suspected Covid-19 patients with caution (Xie et al., Citation2020).
Another role identified by the participants in this study is the duty of making logistics available for work. Per their positions as charge nurses, most of the participants made sure that, working materials were available for the smooth running of the ward. They procured logistics such as PPEs, hand sanitizers, liquid soap, paper towels, and bleach among others. They always made sure they had the requisite items for work delivered from the stores every day, to avoid shortages on the ward. In addition to making sure the items for work were available, nurses ensured that the materials are also in good condition; in the sense that, the materials are intact and had not expired. A striking similitude was found between the findings in this study that, nurses made logistics available for work during the covid-19 pandemic, and nurses ensure the active supply and usage of hygiene materials and PPEs. Since materials are used by the nurses to work, it is just so that, they made sure they have them in stock for use at all times when the need arises (Jackson et al., Citation2020)
Age was a factor when frontline nurses were recruited for the care and management of covid-19 patients. The result of the study reflected that older nurses and nurses with comorbidities such as Asthma, diabetes, and hypertension, among others, were not allowed to be involved in the direct care of covid-19 patients, as they were at high risk due to the state of their immune system. As such, they either were allowed to go on leave or given assignments that did not directly involve physical contact with the patients. Some participants in the current study reaffirmed that, on their wards, older nurses who did not go on leave were positioned at the nurses’ station to help with administrative work, documentation of patients’ vital signs and treatment; and also give information taken from the patients to their relatives. This helped to drastically reduce their exposure to the virus because they were vulnerable to the disease due to their fragile immunity. Similarly, a researcher described nurses as the gatekeepers of the health system (Adib-Adib-Hajbaghery, Citation2013). They emphasized that nurses coordinated activities between other hospital staff, visitors, and the community.
PPEs were worn by frontline nurses to fully protect them from covid-19. The current study found that some of the frontline nurses’ challenges were the discomfort they experienced when fully clad in the PPEs for long hours of work, even though it was meant for their protection. Some participants had a challenge with the face mask. Some of the participants experienced difficulty in breathing, which made them visit the restroom intermittently to remove it temporarily to enable them to breathe. This is a bad practice because the removal and re-wearing can be a source of infection for the nurses. In light of the foregoing, a lesser number of hours at work during pandemics could be observed to reduce the stress from long hours of working in the face masks.
The findings in the current study, are similar to a study that revealed that nurses identified prolonged hours of work and wearing Personal Protective Equipment for very long hours as a source of stress (X. Mo et al., Citation2020).
Frontline nurses in this study narrated that, the fear of getting infected with covid-19 was another stressful situation for them because they were in close contact with the patients. Nurses in this study averred that, unlike the normal times before the advent of covid-19, they were always in a hurry to leave the patient’s bedside during the covid-19 pandemic all the time due to the fear of getting themselves infected. This caused them psychological stress in the sense that they were not able to meet the patients’ need for communication. This implied that the stress associated with the fear of getting infected had an adverse spillover effect on the quality of nursing care during the pandemic. It is therefore essential that hospital authorities provide a platform for nurses to express their fears and stresses, where corresponding appropriate education or stress relievers can be offered. In agreement with the current study, a study mentioned that studies of similar pandemics in the past were indicative of the fact that, nurses who were in direct contact with potentially fatal viruses, exhibited fear of endangering their personal and family health (Cai et al., Citation2020).
Frontline nurses faced diverse challenges regarding transport from home to work and vice-versa. These challenges were a result of the fear associated with the disease, the lockdown, and the distance from their home to the hospital facility where they work as frontline nurses. During the pandemic, some of the frontline nurses could not get access to transportation from where they stayed due to the lockdown that was imposed by the government. Some of the participants walked long distances to work as a result of the absence of means of transportation. These developments, make them get to work late, already exhausted and stressed. Some of the frontline nurses narrated that commercial transport drivers refused to get them on board owing to the fear of being infected by frontline nurses. Some nurses with the wherewithal reported that they resorted to uber, bolt, and other expensive transport companies which made them spend so much on transportation that by the middle of the month, the bulk of their salaries was spent on transportation.
Most participants who were interviewed in this study stated that they experienced stress because at a point during the pandemic, they had to separate from family and friends. Some of them could not stay in their homes due to the fear of infecting family members, resulting in some relocating their children elsewhere so that they can be safe. This was a major challenge to some participants since their children were not under their close observation. They were involved with the work so much that, they either got too tired to call their family members or return their calls. They also were not able to spend quality time with their children and felt so detached from them. This was a result of long hours of work. A study in Italy observed that nurses were compelled to live alone and away from their families owing to the constant fear of infecting loved ones with covid-19 which placed a strain on their relationship with their families and significant others, a finding that correlates with that of the current study (Catania et al., Citation2021).
Another main factor that contributed to the stress experienced by frontline nurses was the poor nurse-to-patient ratio. This was highlighted from the response made by participants in this study, indicating that, the numerical strength of nurses on duty daily was inadequate and this was more evident at the peak of the pandemic when patients doubled. Nurses in the current study re-countered that, the nurse-patient ratio was very poor thereby increasing the workload on the few that were available. A lot of nurses chose not to participate because of the fear caused by the international news about the disease and the havoc it had caused. Some also left for their original hospitals due to the stress they encountered at the covid-19 isolation center. A few also resigned out of fear. These developments made nurses at post exhausted, which in turn reduced the quality of care given to the covid-19 patients. Similarly, earlier scholarly works by some researchers revealed that nurses in China experienced an unprecedentedly higher-than-usual patient-nurse ratio owing to the ravages of covid-19. Shortage of staff can lead to stress and burnout and vice versa, and therefore calls for attention by authorities (Maben & Bridges, Citation2020). More nurses may have to be employed and trained on infection prevention practices in readiness for any eventualities.
14. Conclusion
Frontline nurses had varied roles when caring for Covid 19 patients which aim at protecting other staff and patients, however, several challenges are experienced whilst ensuring this, hence measures should be put in place to overcome these challenges to facilitate smooth discharging of duties as frontline nurses. In addition, most studies on Covid 19 focus on patients and the general public, hence it is imperative for more studies to be done to address the stress nurse caregivers of Covid 19 patients encounter during care delivery to Covid 19 patients.
Authors contribution
A.P.N: Conception of the idea, Data collection, and analysis, drafting of the manuscript and final approval of the version to be submitted.
EOA: Conception of the idea, Data collection, drafting of the manuscript and final approval of the version to be submitted, corresponding author
E.E.K Conception of the idea, Data collection, drafting of the manuscript and final approval of the version to be submitted.
E.O.B: Conception of the idea, Data collection, drafting of the manuscript and final approval of the version to be submitted
J.A: Data collection, drafting of the manuscript and final approval of the version to be submitted.
Z.A: Data collection, drafting of the manuscript and final approval of the version to be submitted
J.K: Revision of the manuscript for publication, data analysis, editing, and literature review
Abbreviations
Deputy Director of Nursing Services-DDNS, Dodowa Health Center Institutional Review Board- DHRCIRB, Intensive Care Unit- ICU, Personal Protective Equipment- PPEs, World Health Organization- WHO.
Availability of data and materials
The study data and materials are available as an attachment file.
Ethics approval and consent to participate
Dodowa Health Center Institutional Review Board granted an ethical clearance certificate for this study with protocol ID No. DHRCIRB/096/09/21. Participants were given a written consent form to sign before the interview guide was administered. Their verbal consent was also sought individually before engaging them in the study.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
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