Second victim syndrome among nursing professionals as a result of COVID-19: qualitative research
verfasst von:
Inmaculada Corral-Liria, Marta Losa-Iglesias, Ricardo Becerro-De-Bengoa-Vallejo, Elena Herraiz-Soria, César Calvo-Lobo, Marta San-Antolín-Gil, Sara González-Martín, Raquel Jimenez-Fernández
The infection caused by the COVID-19 virus, with its high capacity for spread and transmission, reached the level of an international pandemic, affecting many people and resulting in a large number of deaths.
Aim
To analyse the experiences of nursing professionals caring for patients with COVID-19 during the early stages of the pandemic and the skills or coping strategies that they employed.
Methods
A qualitative study was carried out with an interpretative phenological design. Semistructured interviews were conducted with 20 nursing professionals working in emergency and critical care units, which were adapted to care for patients with symptoms of the disease, in public hospitals in Madrid, Spain. The data were analysed following, the Interpretive Phenomenological Analysis (IPA) of Smith et al.
Findings
Five themes were identified: “emotional brain training (EBT) to cope with great emotional stress”, “material and sequential difficulties”; “an experience similar to a war that can cause burnout”; “Second Victim Syndrome (SVS), the emotional impact of witnessing trauma”; and “Surviving COVID-19 with overloads of energy and positivity”.
Conclusion
Nursing professionals who cared for patients with Covid-19 during the first wave of the pandemic lived an experience in which they experienced a brain training of feelings, including sadness, impotence, fear, anger, pain and much worry. They also experienced a great feeling of suffering and guilt as in Second Victim Syndrome, in a situation similar to a war, due to the number of deaths caused by the virus, with all this resulting in a great overload of work. It is essential that these situations do not affect the mental health of these professionals in the dimensions that they did, and it is necessary to regain enthusiasm and motivation to provide comprehensive care for patients with COVID-19. Nursing professionals are not alone and need to be taken care of to respond to the chaos that can cause a pandemic, without ignoring the risks that it entails. They require specific training, which is necessary to provide them with proper security, and it is necessary to develop health and welfare policies, which will not be possible without first understanding their experiences.
Hinweise
Publisher’s Note
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Abkürzungen
IPA
Interpretive phenomenological analysis
EBT
Emotional brain training
SVS
Second victim syndrome
PPE
Personal protective equipment
ANA
American Nurse Association
Introduction
COVID-19 infection is caused by the SARS-CoV-2 virus, which belongs to the coronavirus family. It has such a high capacity for spread and transmission that it reached the level of an international pandemic. This virus can cause a respiratory disease that varies in severity, ranging from mild symptoms similar to a cold to pneumonia or Acute Respiratory Distress Syndrome, thus increasing its severity and requiring specialized care and ventilatory support. In these cases, it could lead to death, especially in the early stages of its emergence, when its symptoms, progression, treatment, and complications were unknown [1, 2].
In Spain, by the end of 2020, there had been more than 7 million infections and more than 90,000 deaths, with a decrease in life expectancy of 1.5 years and a greater effect on older people and those with a series of comorbidities and mental health conditions [3].
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In the early stages of the pandemic, nursing staff had to intensify their work because of the disproportionate increase in the number of severely ill patients and the need to provide more specific care. They lacked personal protective equipment (PPE), critical care devices, and hospital space [4]. Furthermore, the treatment to cure them was not known, generating greater uncertainty and the need to continuously change both interventions and safety and protection measures. At times, owing to the great instability in the care provided, they received contradictory recommendations, leading to the inappropriate use of devices and materials. The number of affected individuals increased, leading to a significant shortage of healthcare personnel, including nursing staff, who also became infected. They experienced anxiety, depression, insomnia, fear of contracting the virus, and fear of transmitting it, especially to their families, as most nurses lived with them. This also led to a rejection of their own work. Additionally, feelings of anger, frustration, and indignation arose, generating increasing stress and physical as well as emotional exhaustion, pain, and confusion. They began to feel overwhelmed by the lack of support and increasingly frustrated [5‐10]. Nevertheless, nurses showed tremendous responsibility and effort to alleviate the suffering of patients, their families, and themselves [11, 12]. This effort was not enough given the chaotic situation that they were experiencing, leading to many mental health problems, consequently, their workload increased, reaching very high levels [9, 10].
Additionally, feelings of having been able to do more arose when caring for severely ill patients with COVID-19 infection, in an environment of adversity, chaos, crisis, and a continuous increase in deaths. Nurses questioned whether their intervention had been sufficient. All of this generated great suffering, especially emotional suffering, as they felt responsible for the harm done to patients. These experiences are very similar to those caused by the Second Victim Syndrome (SVS), where healthcare professionals experience significant emotional stress, which can lead to trauma following an adverse event with patients, medical errors, or injuries related to safety incidents [13, 14]. The American Nurse Association (ANA) [15] recognizes this syndrome, acknowledging the impact of providing care under such conditions, which affects many people, families, and healthcare professionals themselves, who become second victims. Nurses were unable to do enough for the millions of people who died in isolation, away from their families and loved ones, with some receiving inappropriate and incomplete treatments. Approximately 76% of healthcare professionals could be affected, with manifestations that, if untreated, could seriously harm their emotional and physical well-being, and even compromise patient safety [16‐21].
Just as feelings and emotions were studied as part of the experience during this pandemic, coping strategies also needed to be specified because they were very significant. Various quantitative studies focused on these skills, addressing and relating them to stress. There was a need to specify them to serve as a guide in future pandemics, especially those related to strict protective measures for all patients. Strategies such as social support played a key role in managing stress [22‐24], although the perception of threats and the use of negative coping strategies were sometimes associated with increased social dysfunction, depression, anxiety, and the appearance of somatic symptoms [22, 25]. As various studies have show, these professionals experienced an extreme situation, with a series of proposals and actions to face a pandemic, involving a range of clinical functions and an enormous workload [26‐28].
This study aims to understand the lived reality of providing care to COVID-19 patients during the first wave of the pandemic and on the front lines, as well as the coping strategies employed. Both issues are highly relevant and are explored using a qualitative methodology to reveal the participants’ realities through an interpretative phenomenological design. With the pandemic, healthcare systems had to redefine their patient care approaches for COVID-19 and change their own self-care practices. Therefore, the frontline exposure of nurses, their experiences and skills, providing care in different public hospitals in the Community of Madrid, the capital of Spain and the region with the highest number of deaths at that time, were crucial [29].
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Aim
To analyse the experiences of nursing professionals caring for COVID-19 patients early in the pandemic and their coping skills and strategies.
Methodology
Design and Sample
This study was conducted with a hermeneutic phenomenological design to understand and explain the lived experiences of nursing staff in the first stages of the pandemic while coping with an unknown virus [30, 31]; how that reality was experienced in a hospital setting; the effect that it had on nursing professionals on the front lines; their experiences, meanings, and interpretations of events that occurred during patient care [30, 32, 33]; and the overall feelings, thoughts, performances, assumptions, cognitions, perceptions, internalized facts, emotions, realized responses, and acquired behaviours of their lived experience [34]. This design was used to address the characteristics of events as they happened, the behaviour of those affected, their understanding and their importance for health management, education, health resources and research, in the face of a pandemic with a great global impact [35‐37]. The epistemological foundations of Heidegger’s interpretative phenomenology focus on Being-in-the-World (Dasein), given the importance of human existence and its relationship with the environment. This approach examines how individuals perceive and make sense of their experience (intentionality), which is fundamental for nurses to interpret or manage their experiences while caring for COVID-19 patients. Interpretation is emphasized as a fundamental process for understanding this experience (hermeneutics), and it is both temporal and authentic, allowing for a deep and nuanced understanding of the experiences of nursing professionals [38‐41].
The inclusion criterion was that nurses had worked during the first acute phase of the pandemic with patients diagnosed with COVID-19, who were treated in medical hospitalization units, emergency services and intensive care units of public hospitals in Madrid, Spain. The vast majority of these units were created exclusively to provide COVID-19 care given the serious situation of all affected people. Professionals working in other fields who worked voluntarily, given the circumstances in which the health system was located, and who did not treat patients diagnosed with COVID-19 were excluded (such as nurses in other patient care, management, pharmacy, rehabilitation, blood bank, operating room, or haemodialysis).
The participants were captured through purposive sampling, deliberately, considering the inclusion criterion of the study [42] and snowball sampling, through the recommendation of the initial participants who provided the researchers’ contact information [43] on Facebook, Instagram and Twitter social networks, where an explanation of the objective and purpose of the research was published, creating a specific account. Prospective participants were asked for their email addresses so that they could be interviewed and share their experiences. As this was a very emotional subject, data collection took several months to complete.
Data saturation was reached when 17 interviews were analysed, given that no new ideas or new themes appeared, reaching a sufficient breadth of significance in relation to the experience of the participants. Three more interviews were subsequently conducted to data saturation. As no new or relevant data were obtained, the sample for this study was reduced to 20 informants [44].
Data collection
Data were collected in October, November, and December 2020. A total of 20 semistructured interviews were conducted with a flexible script of open-ended questions (Table 1) to obtain the meanings of the lived experiences of the events that occurred [45, 46]. Given that social distancing was established as a preventive measure to avoid new infections, all the interviews were conducted by video calls through Meet or Teams. The interview questions developed from the validated Connor-Davidson Risk Resilience Scale (CD-RISC), which measures resilience to stressors, and the AAQ-II (YUC) Acceptance and Action Questionnaire-II (AAQ-II). This questionnaire assesses the extent to which people, faced with events associated with psychological distress, manage to accept them and keep their goals and values in mind, orienting their actions towards them. A question about the lived experience in the whole of the previous lived situation was added to the guide. These interviews were subsequently transcribed, and the participants were guaranteed data protection.
Table 1
Questionnaire guide
Semistructured interview questionnaire guide
What skills and/or resources have you used to cope with this situation generated by the COVID-19 pandemic?
What are the feelings you have had during this pandemic?
How have you adapted to the situation generated by the pandemic?
What difficulties have you faced during the period you have been with COVID-19 patients? What has been your greatest memory?
How have you felt while working with COVID-19 patients? What have you been most concerned about during your workday?
What do you consider your level of work stress to have been like?
Data analysis
The approach of Smith et al. [47] was used to analyse the data. This approach consists of six steps: (1) Step 1: Reading and re-reading: This step involves “immersion”, as researchers, in the original data by collecting the most significant experiences that are shown or by noting down some important issues referred to by the informants themselves, while maintaining an order. Re-reading facilitates the development of the structure of the analysis and its ability to connect sections of other interviews. (2) Step 2: Initial noting. This step constitutes the most detailed level of analysis and examines the meaning of the content. (3) Step 3: Developing emergent themes. The annotations and units of meaning support their meaning, and the first emerging themes emerge. At this moment the analysis becomes more complex, the details of the participants’ experiences are taken into account, and the complexity of the interrelationships, connections and patterns of analysis increases. (4) Step 4: Searching for connections across emergent themes. This step consists of establishing connections between the set of themes developed. (5) Step 5: Moving to the next case. The process of analysis is repeated, although its complexity and level of meaning increase. (6) Step 6: Looking for patterns across cases. Some kind of connection is sought, such as the relevance of the themes in terms of units of meaning, being able to re-configure or re-label them, taking the most important of the issues that have been extracted from the informants themselves, the most profound, to reach higher levels of interpretation, arriving at a more holistic view.
Ethical considerations
This research conformed to the tenets of the Declaration of Helsinki [48]. The participants were informed of the objectives and purpose of this study, and informed consent was obtained from each individual via mail. All of these procedures were carried out following the guidelines of the Ethics Committee of the Universidad Rey Juan Carlos.
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Criteria of rigour
This research met the criteria of rigour according to [49]. The credibility of the transcripts of the experiences, and the transferability and replicability of the contents to other contexts with characteristics similar to those of this study were established. There was consistency in the systematic recording of the participants, performing appropriate sampling with different participants, interpreting the data, and reporting at all times their positions as researchers, maintaining their neutrality in the analysis of the data. The COREQ guidelines for qualitative research were followed [50].
Reflexivity in this case refers to the connection with the study situation with the researcher. Here, the main researcher was a teacher of nursing students in the critical care units of different hospitals in the city of Madrid, and who lived in this area during the COVID-19 pandemic [51, 52].
A triangulation of the results of the participant data analysis was carried out in a synchronous online session with 10 participants, who attended voluntarily when invited to show their experiences to confirm researchers’ data analysis showed their lived reality. This procedure was carried out to reinforce the validity of the study, and its reliability and to gain a deeper understanding of the experience [53, 54].
The reliability or consistency and stability of the results obtained were verified through a review of the data analysis by three researchers from this working group. Additionally, an online session with four qualitative research experts was held to show them how the codifications and interpretations were carried out [55].
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Findings
The participants in this study had a mean age of 32.85 years; 30% were men, 70% were women, 75% had had COVID-19, 25% were asymptomatic, and the rest had symptoms but no sequelae at the time of the study.
The sociodemographic characteristics of the participants are shown in Table 2
Table 2
Sociodemographic characteristics of the participants
Participants
Time at work or exposure to the COVID-19 virus
Service in which you worked during the first wave of the pandemic
Service in which you worked before the pandemic
Info 1
3 months
COVID-19 unit adapted to The situation
Psychiatric Unit in another Hospital
Info 2
3 months
Critical Care Unit adapted to COVID-19
Critical Care Unit
Info 3
3 months
Critical Care Unit
Surgical Unit
Info 4
3 months
COVID-19 unit adapted to the situation
Diagnostic test unit
Info 5
2 months
Emergency Unit adapted to COVID-19
Emergency Hospital Unit
Info 6
1 month
COVID-19 unit adapted to the situation
O.R.
Info 7
3 months
Respiratory Care Unit adapted to COVID-19
Critical Care Unit
Info 8
3 months
COVID-19 unit adapted to the situation
Emergency Hospital Unit
Info 9
3 months
Critical Care Unit adapted to COVID-19
Critical Care Unit
Info 10
3 months
Critical Care Unit adapted to COVID-19
Maternity Unit
Info 11
2 months
Critical Care Unit adapted to COVID-19
Critical Care Unit
Info 12
3 months
Emergency Hospital
Obstetrics & Gynaecology Unit
Info 13
2 months
COVID-19 unit adapted to the situation
Surgery Unit
Info 14
2 months
COVID-19 unit adapted to the situation
Surgery Unit
Info 15
3 months
COVID-19 unit adapted to the situation
Surgery Unit
Info 16
2 months
Critical Care Unit adapted to COVID-19
Critical Care Unit
Info 17
1 month
Critical Care Unit adapted to COVID-19
Palliative Care Unit
Info 18
3 months
Critical Care Unit adapted to COVID-19
Surgery Unit
Info 19
3 months
Critical Care Unit adapted to COVID-19
Gynaecology Unit
Info 20
3 months
Emergency Room
Emergency Hospital Unit
The results are summarized in the following diagram (Diagram 1).
Diagram 1
Different themes and the most important issues of the themes
×
Upon analysing the interviews conducted with nursing professionals, five themes emerged.
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Brain training of feelings: Overwhelming emotional stress generated and accompanied by a great diversity of feelings
The informants referred to a series of feelings, such as sadness that made it difficult to go to work, grief at the number of victims whom the virus was generating, compassion for the suffering of patients and families, and a great deal of pain.
Feelings of course of fear, of sadness, of seeing how a patient came through the door and suddenly five minutes later he was very bad (very bad, very bad), and we lost him. (Info 4)
It was like a continuous sadness. (Info 5)
The participants expressed personal fear of working with such an unknown infection; lacking experience, training, and skills; fear of infecting their family; and fear of everything happening. However, as time passed, they began to respect the virus.
What I was afraid of was to catch it and bring it to my house … . afraid that people you don’t want to catch it will have a bad case of it. (Info 2)
I was very afraid because we were facing a totally different situation, a totally unknown evolution of the virus. Patients with pneumonia did not do well as such. (Info 1)
The participants reported concerns about what was happening and about the fact that nothing would be forgotten, accompanied by great work pressure due to a lack of resources, a lack of treatment and knowledge, a lack of protective materials (such as PPE and approved masks, having to reuse them and having to wear the same ones for weeks) and inadequate staff numbers. These factors produced great anxiety and bewilderment.
The participants also mentioned loneliness because of isolating themselves from their families and friends and having to refrain from giving kisses and hugs or any other gestures of affection.
There was guilt at the feeling or thought of infecting someone by not carrying out existing safety measures and thinking that they could be asymptomatic and have the disease without having any tests performed.
There was great uncertainty about not knowing what would happen and insecurity about not knowing the evolution of the patients.
The participants reported feeling helpless because they could not keep their families together in those moments of pain and suffering.
There was a great overload of stress both at home and at work. As a result, there was no time to provide optimal care, nor was it possible to support patients’ families since it was necessary to maintain distance, which caused great fatigue and extreme exhaustion.
I was concerned that everything I explained to them, I didn’t do it in the right way, so that they would understand. (Info 4)
The fear that you were getting from not having taken these precautionary measures. (Info 8)
The biggest memory I have in the ER is how suddenly patients were coming in and dying. (Info 10)
We had a lot of overload and had a very bad time. (Info 14)
I felt a lot of uncertainty about what was going to happen and, I think that, as I said before, we were working like machines, in a totally automated way. (Info 10)
I did not understand why the hospital, when it received the material (PPE), did not care whether we kept them for a week or two days and didn’t check whether the masks were useful or not. (Info 15)
A series of material and sequential difficulties
There was a shortage of protective equipment, such as PPE, goggles, and FPP2 masks, which they did not have, alternatively, when the participants had such equipment, they had to be reused for several days or even a week. In addition, the participants in this study presented a series of difficulties in communication because they always wore masks, given that, depending on the age of the patient, this problem could be aggravated because the patient had become disoriented or did not hear well. The participants also commented that they experienced a lack of dexterity when changing habits and protocols continuously.
The nurses also mentioned great limitations when facing an unfamiliar situation, working in a new service without knowing where the materials were located, and sometimes not knowing what care to provide or how to provide it. They had a self-taught learning process whenever and however they could, and they had no time to adapt to the pandemic, with all of the physical, emotional, and social consequences that this entailed.
Difficulties in terms of the material, difficulties in terms of communication, being dressed in a suit, wearing a mask, dealing with very old people who sometimes do not listen properly and present dementia. (Info 6)
It’s been a totally self-directed learning experience. We have acted in an automaton-like way, like machines. So, I learned as the days went by. (Info 7)
Tragic moments: an experience similar to a war, resulting in great professional attrition
The participants reported that they attended to relatively serious patients, both young and old, who were admitted to the emergency unit, and within a few hours of being in the hospital, were dying. The worst aspect was that nothing could be done to prevent them from suffering and feeling suffocated owing to the need for oxygen. The bodies accumulated in the mortuaries, and the number was so high that other places had to be set up for this purpose. Various medications were administered to patients to avoid this tragic situation, but they had no effect. The patients’ health did not improve, and seeing them in those conditions was very hard, desperate, and painful.
All of this was considered an experience similar to a war where these professionals were soldiers with no skills, no experience, and no previous specific knowledge. It was a matter of survival, and of trying to save lives. In the ICU, everything was chaotic, and death was very close at hand. The nurses did not know what to do or how to take care of themselves.
Everything that they experienced and suffered caused great professional wear due to the overload of work they maintained, the lack of resources and the results. There were days when they worked much more than twice as much; the workload was extremely high, and the fatigue and despair were continuous.
There came a time when, although it was very hard to be there, it was like war. Patients died shortly after coming to the ICU. They died and died, and we did not know what to do or how to act. Deaths and more deaths. They were suffocating. (Info 7)
Second victim syndrome: high emotional impact
Some nursing professionals experienced feelings similar to SVS because of the guilt caused by being unable to attend to and offer appropriate care and because of feelings of helplessness since they could not do anything else. It was as if they were wrong with the procedures (guilt was continually in their thoughts). They saw how so many people were dying alone in their beds, having been deprived of oxygen, especially elderly individuals, who needed closer and continuous care, given the circumstances, it was impossible to provide such care. In addition to the number of deaths in a short period, there were the deaths of people who had been admitted to the hospital for other conditions and whose health situation was complicated by the fact that they had acquired COVID-19 in the hospital.
Anger, guilt, and helplessness were the main feelings of the participants when they did not know how patients with COVID-19 were going to evolve and when their colleagues were newly admitted because they were infected at work and died.
The continuous changes in the protocols established in the units could be different 12 or 24 h later, while nurses witnessed multiple deaths and sometimes felt very responsible for them.
That feeling … seeing death so close and not being able to accept that it is the normal evolution of what is perhaps a patient who starts to get worse. However, well, you try to do something about it. You knew there was nothing you could do. That was, to tell the truth, the hardest thing for me. (Info 20)
Look, it’s a horrible situation. There are no resources, but they are getting everything they need. (Info 16)
Surviving COVID-19 with energy and positivity
In the face of all of these difficulties, nurses’ developed coping strategies or skills, including empathy, assertiveness, active listening, and communication. It was important for the participants to be dynamic to move forwards and not remain paralyzed, to rapidly change habits, to convey hope without falsehoods, to generate continuous learning, to talk frequently among colleagues, and to support each other and, sometimes family and friends, although always maintaining a safe distance or making phone and video calls. Thoughts often focused on “not throwing in the towel” and “never giving up on anything at any time.” The participants were also proud of the applause that they received in the evening, which made them feel very good, even if it was only for a short period of time.
Likewise, these skills were conditioned on their adaptation process and the series of phases that they identified during the pandemic. (1) The first phase was identified as being full of surprises and uncertainty, with little capacity to react and denial of what was happening. (2) The second phase was characterized by a brief tranquillity, where everything seemed to be somewhat simpler or less complex. (3) The third phase was identified by analysing and knowing what was happening.
You couldn’t help them, and the feeling was that you were leaving them a little defenceless. And, man, the helplessness, and also the responsibility you had to have to control the shift a little bit. (Info 16)
So many people kept dying that sometimes we didn’t have time to take them to another place. Everything was horrible, and the feeling of guilt and error was very great. (Info 20)
The companionship, for me, was very important. To know that the patient was in bad shape but that you could lean on your colleagues to make you stronger, to keep fighting. (Info 17)
Discussion
The experiences of nursing professionals who cared for COVID-19 patients in various studies highlight management and leadership roles, which were very complex during times of pressure, uncertainty, and catastrophe with many infected cases. Nurses worked beyond their limits, implementing more effective and personalized services, and discovering new ways of care amidst so much uncertainty. They performed new tasks and acquired new skills [56‐58]. In this sense, these studies differ from ours because our participants did not comment on the performance of management.
Additionally, a change in care was observed, with activities being limited to isolation, minimizing contact with the patient, and a lack of closeness as determining factors [59]. The difficulties in acquiring PPE prevented the provision of humanized care, exacerbating the lack of control and thus increasing insecurity. The lack of material and human resources generated a lack of safety, which led not only to another change in care, but also to dehumanization and a deterioration in personal well-being and self-demand [60]. In our study, the participants did not mention failure, but they mentioned a very heavy workload, which triggered great stress and even professional burnout. In another study, the focus was on inhumane care, highlighting the importance of therapeutic communication, which was negative and made even more difficult by protective measures. COVID-19 patients were immersed in great loneliness despite attempts to connect with their families through video calls and phone calls [61]. In our study, the participants reported that it was inevitable for professionals to sense the patients’ loneliness; they did not feel it themselves but sometimes isolated themselves to avoid infection. In the family context, studies have highlighted the suffering of nursing professionals due to being away from their families, leading to exhausting lives with great responsibilities. There was talk of a break in intrafamilial continuity, as working so many hours and being so deficient made them ineffective in their primary role, requiring separation to face the situation [61, 62]. In our study, the family always showed solidarity and cooperation with the nursing staff, while maintaining a prudent distance to avoid possible infections.
In relation to the feelings experienced, various studies highlight numerous negative emotions, such as fear, depression, fatigue, discomfort, helplessness, suffering due to the high number of cases, sadness, pessimism, exhaustion, self-demand, a heavy emotional burden, significant psychological harm, a sense of failure, shyness, bad mood, insomnia, anxiety [60, 61, 63], discomfort, guilt, pessimism, emotional fluctuations due to panic, lack of motivation, lack of meaning, hopelessness, worthlessness, and compassion fatigue, in addition to being stigmatized and causing more health problems [64‐68]. Many of these feelings are observed in our study, but stigmatization is not mentioned. Instead, the participants referred to isolation and loneliness, as well as being perceived as an infection risk, as already mentioned, but at no point did they mention feeling stigmatized.
The number of people dying increased, which decreased their motivation because they did not feel rewarded for so much effort and so many negative outcomes. Additionally, at that time, there was no camaraderie; there was a self-demand that led them to failure [60]. In our study, failure as such was not mentioned, although they highlighted a heavy workload, triggering great stress and even significant professional burnout.
Some studies have referred to coping and self-care, improving diet by consuming vitamin-rich and more protein-rich foods, and increasing water intake to boost the immune system, whenever circumstances and the heavy workload allowed [65]. Nurses activated psychological defence mechanisms, such as speculation, as mentioned, as well as isolation, distraction, and insomnia [63]. Other professionals highlighted obtaining information on the internet, practising relaxation techniques, meditating, and listening to music to relieve stress [64]. In our study, the nursing professionals went with the flow of circumstances and preferred not to think about what was happening. Unlike what was mentioned above, they disconnected from social media and the internet. Additionally, they did not mention that their sleep was affected at any time.
Additionally, anxiety can be highlighted due to the circumstances experienced and being in the face of death, as noted by Galendar [69], which in turn causes great agony and increases stress, especially when seeing so many young people die with such a high mortality rate and being unable to help them due to the unknown dimensions of the disease’s severity. In this study, the participants emphasized the inability to hold funerals and burials and the fear of infecting their families and themselves. The feeling was very unpleasant, with restrictions on mobility, food, and drink, which affected their mood, body image, and self-esteem, presenting a duality between the fear of self-care and protection (work environment), and increasing their anxiety. In several studies [67, 70‐74], authors specified feelings of anxiety, depression, and possibly post-traumatic stress in the moments following the experience of the situation. These results were similar to those obtained in our study. In the study by Maideen et al. [75], the data analysis conducted on the discourse of different discussion groups identified themes such as a roller coaster, a destructive disease, a work situation full of ups and downs, an attempt to adapt as best as possible by managing optimal self-care with great social support, and a struggle in the mind and heart, manifesting as great anguish, stress due to uncertainty, and a role reversal. In our work, we did not observe any role changes, but we observed changes in the functions and activities of the nursing professionals. For example, they were in surgery and were transferred to the ICU without any training. The participants also mentioned a lack of knowledge, a lack of training to care for COVID-19 patients, the use of PPE, and how to isolate patients and protect them from infection, especially at the beginning.
All of this has been studied based on a series of phases: the first phase involves the accumulation of negative emotions; the second phase involves psychological and vital adaptation and psychological support; and the third phase involves responsibility, self-reflection, and positive emotions [58]. In our study, the phases are also similar.
Similarly, in our study, the nursing professionals expressed their helplessness at seeing so many people die without receiving treatment that could save them; they still did not know the optimal therapeutic strategies. They experienced a situation similar to a war, with many people with the virus in hospital units that were adapted to offer them the most appropriate care, although it was very insufficient. Second Victim Syndrome (SVS), as noted by various authors [76‐78], is defined as the person providing patient care being traumatized by the extraordinary situation exacerbated by the COVID-19 pandemic, which imposed an additional burden on healthcare systems. A dual strategy was necessary; it was essential to quickly support second victims and strengthen the resilience of all those who were immersed in this situation and felt that they had failed to ensure safety and quality care during adverse events that caused harm to patients [79]. They focused on support programmes for professionals who had experienced this difficult situation, promoting coping strategies and overcoming situations such as those caused by the pandemic. Additionally, Kazuaki et al. [80] conducted a systematic review specifying studies related to this syndrome experienced by ICU professionals due to the significant psychological burden, facing feelings of guilt, anxiety, and anger at oneself, and decreased self-confidence. This study demonstrates that SVS is a common problem affecting healthcare professionals, especially in these units, particularly owing to the feelings that are revealed and considered very important, coinciding with our work.
In relation to coping strategies, the main strategies highlighted are psychosocial methods, Maideen [75], spiritual coping, emotion-focused and problem-focused coping, active and useful methods such as exercise, improved nutrition, rest, self-control, support systems such as social support Sehularo [81], effective communication with family and friends, and a positive attitude towards a challenging situation Iddrisu [82]. In our study, the coping strategies were similar, emphasizing empathy, assertiveness, and active listening.
Limitations
During the pandemic, accessing nursing professionals to participate in this study was very difficult. The main reasons for this difficulty were the inability to meet in person to conduct the interviews due to health restrictions, the intense workloads that made nurses exhausted and unwilling to do anything, the great emotional impact of this situation and the presence of an unknown researcher (recall that it was a very painful subject to remember).
The interviews were conducted by video. To maintain a safe distance, they could not be conducted face to face.
The professionals who participated in this study did not have any post-COVID-19 sequelae at that time; some had been infected with greater or lesser symptoms, but nothing that could have had an impact on their quality of life or on the performance of their work.
Implications for the profession and/or patient care
This study makes three key contributions: (1) Different studies have identified great uncertainty in the face of protocol changes in the care of patients with COVID-19, challenges with changes in the work environment and the relationships between professionals; emphasizing the workload burden and the evolution of protocols (2) new initiatives, comparing situations and finding favourable information; (3) in the field of care, a wide range of highly technical care is offered that, given the characteristics of the pandemic, could not be provided, such as the evolution of protocols (4) to specify and show a series of skills for dealing with situations of tragic impact (5) to make visible the great work that the nursing professionals have performed, their feelings and the consequences that these have had for themselves. It is very important to know how nurses feel in order to know how to care for them, knowing that they are not alone and can be cared for (6) to improve care for professionals and care in the health system, as well as at the educational level, and to provide another approach to research. (7) The use of personal protective equipment (PPE) is essential, considering all the care required for its continuous use. (8) Patient-centered care should be as humanized and personalized as possible, according to patients’ needs despite difficulties. (9) For those who have suffered from secondary victim syndrome, there must be emotional support, resilience training, and the promotion of a supportive culture.
Conclusions
Nursing professionals who cared for patients with COVID-19 in the first wave of the pandemic lived an experience in which they experienced brain training of feelings, including sadness, impotence, fear, anger, pain and much worry. They also experienced a great feeling of suffering and guilt as in Second Victim’s Syndrome, in a situation similar to a war, due to the number of deaths caused by the virus, with all of this resulting in a great overload of work. It is essential that these situations do not affect the mental health of these professionals in the dimensions that they did, and it is necessary to regain enthusiasm and motivation to provide comprehensive care for patients with COVID-19. Nursing professionals are not alone and need to be taken care of to respond to the chaos that can cause a pandemic, without ignoring the risks that it entails. They requires specific training, which is necessary to provide them with proper security, and it is necessary develop health and welfare policies, which will not be possible without first understanding their experiences.
Acknowledgements
We thank all the nursing professionals who participated in this study.
Declaration
Ethical approval
This study was evaluated by the Research and Ethics Committee of King Juan Carlos University under registration number: 0906202014120
Consent to participate
All participants in this study provided their consent to participate by signing the document created for this purpose.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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Second victim syndrome among nursing professionals as a result of COVID-19: qualitative research
verfasst von
Inmaculada Corral-Liria Marta Losa-Iglesias Ricardo Becerro-De-Bengoa-Vallejo Elena Herraiz-Soria César Calvo-Lobo Marta San-Antolín-Gil Sara González-Martín Raquel Jimenez-Fernández
