LIVED EXPERIENCE OF NURSES CARING FOR COVID-19 PATIENTS

An Undergraduate Thesis
Presented to the Faculty of the
COLLEGE OF NURSING
MSU – Iligan Institute of Technology
Tibanga, Iligan City

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

First Name Middle Initial Last Name

First Name Middle Initial Last Name
First Name Middle Initial Last Name

July 2021
 CHAPTER 1

INTRODUCTION

Background of the study

Coronavirus disease 2019 (COVID-19) is caused by a new coronavirus first

identified in Wuhan, China, in December 2019 (CDC, 2020). Coronaviruses are a

large family of viruses with four genera: alpha, beta, gamma, and delta. The most

pathological diseases caused by human coronaviruses are SARS, MERS, and

COVID-19. The International Committee on Taxonomy of Viruses named it the

severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), and the

respiratory illness caused by the virus was named coronavirus disease 2019

(COVID‐19) by the World Health Organization (Gorbalenya et al., 2020). The virus

causes disease in humans and animals, following infection with the coronavirus that

causes COVID-19, patients can develop respiratory failure, which can lead to death

(Karimi et al., 2020). According to the World Health organization, As of January

2021, 92,506,811 people have been infected worldwide, of which 2,001,773 have

died from COVID-19. In the Philippines, according to the latest global report,

496,646 people have been infected and 9,876 have died. The Department of Health

identified 2,736 health care workers who were found out to be infected of the

disease, of which 1,006 were nurses (Department of Health, 2020).

As a result of the rapid initial growth in the number of infected patients in

the Philippines, there was insufficient local medical staff and facilities to meet the

demand which caused the cases to continuously increase. Lack of medical facilities

and staff, confusion within the treatment system, the unpredictable nature of the
disease, social isolation, and the widespread transmission of the virus have had

intense consequences for the healthcare system. The emergence of COVID‐19

exerted unprecedented pressure on the country's health care system and presented

various challenges to its nursing workforce, potentially affecting nurses’ work

performance and mental health and even putting their lives at risk (Lv et al., 2020;

Maben & Bridges, 2020; Mo et al., 2020).

Due to these circumstances, it imposes greater challenges to the healthcare

workers, specifically to the nurses who are in the line of taking care for the patients

who are infected with the virus. Overburdened critical care units have had to

struggle with a shortage of beds, specialised personnel, and medical resources due

to a substantial increase in the number of newly diagnosed cases and the quick

advancement of the disease into a critically sick state have made the care more

complex (Peng et al., 2020). Even before the COVID-19 pandemic, nurses have

already been experiencing shift fatigue. The current outbreak has magnified it

further.

Since the onset of the coronavirus, only a few studies have been conducted

and published navigating the effects of the disease outbreak on the health among

nurses. The majority of the research that has been conducted and published has been

quantitative research. The results of this study will provide input for policymakers

and nursing administrators on how to effectively support frontline nurses during

this pandemic. This study will serve as a medium for nurses to show us their

personal experiences as medical frontlines. This can help us become aware of what

they have been through during one of the biggest health crises the world has ever
encountered. We will discover their daily challenges in caring for COVID-19

patients, how this pandemic affected their overall health status, and learn some

important lessons they acquired throughout. With this we will have a deeper

understanding of what it’s like to become a nurse in the Philippines during this

pandemic. Therefore, this study aims to explore and understand the experience of

nurses taking care of COVID-19 patients.

Statement of the Problem

This study aims to explore the lived experience of nurses caring for patients

with COVID-19. It tries to describe the challenges they experienced and how it

affects their daily lives as a whole

Significance of the Study

This study hopes to establish a deeper understanding of nurses’ personal

experiences during the pandemic while fulfilling their duties as medical frontliners.

It aims to develop an immense appreciation for their hardships and sacrifices to

serve patients in need. Furthermore, this study could be of importance to the

following:

Nurses. Analysis of the data gathered will provide actual and practical

understanding of nursing practice and to create certain strategies for better nursing

care management for COVID-19 patients.

Nursing Students. The information presented in this study will enable them

to have a better knowledge about the lived experiences of nurses caring for COVID-
19 patients. Hopefully, this study will serve as their inspiration to strive hard and

become a globally competent nurse.

Clinical Instructors. The data provided will direct clinical instructors to

devise instructional plans for nursing students intended for the sets of basic

standards and effective procedures to be conducted as anticipated in the clinical

setting while treating or caring for patients with COVID-19

Nursing Schools. Academic administrators, college curriculum writers, and

nursing program developers will benefit from the circumstances depicted in the

study by including additional learning material on nursing management for

COVID-19 patients in the curriculum to better prepare students for the future.

Philippine Nurses Association. The information obtained and provided can

be utilized as a guide to help address diverse concerns from their workplace or

pressing matters in order to support the overall well-being of nurses caring with

COVID-19 patients, as well as their professional development toward the highest

standards of nursing and to mold them to become globally competitive nurses.

Department of Health. The final results and the data gathered by the

researchers can be utilized as reference to create health policies and regulations for

the benefit of both healthcare providers and patients. This will ensure that the public

has access to quality health care service while protecting our frontliners.

Future Researchers. The ideas and data presented can be used as reference

in conducting new research or in testing the validity of other related findings. This

study will also serve as their cross-reference that will give them a background or an
overview of the lived experiences of nurses who are taking care of COVID-19

patients.
 CHAPTER 2

REVIEW OF RELATED LITERATURE

This chapter presents the related literature and the research paradigm. It

includes related literature from various sources such as online journals, books,

publications, and existing related studies that are considered to be useful and helpful

in the overall composition of the study. It also includes the research paradigm which

shows a comprehensive understanding of the variables discussed in this study.

Primacy of Caring Theory

This study is anchored on Patricia Benner and Judith Wrubel’s the Primacy

of Caring Theory. This theory emphasized that nursing practice allows for creating

coping possibilities, opportunities for connecting with and caring about people, and

the ability to provide and receive help (Benner, P. A., & Wrubel, J. (1989). Nurses’

experiences while caring for COVID-19 patients is greatly influenced by the

uniqueness of each nurse and what they determine and constitute as vital in

providing quality care. With the challenges and changes posed by the global

pandemic, there is an increase in the complexity of the care provided and according

to new research, a risk that threatens the substance of care delivered subsequently

exists (Karlsson, 2020). Furthermore, this study aims to illuminate the context of

caring as a phenomenon in nursing practice that affects the nurses’ general

experience.
 In the Theory developed by Patricia Benner, she came up with the term

"From Novice to Expert" to describe her concept (From Novice to Expert - Patricia

E. Benner, 2020). The theory identifies five levels of nursing experience:

1. A novice is a beginner who has no prior experience, is taught general rules

to help perform tasks, rules are: context-free, independent of specific cases, and

applied universally and Rule-governed behavior is limited and inflexible.

2. The advanced beginner shows acceptable performance, has gained prior

experience in actual situations to recognize recurring meaningful components,

and the Principles are based on experiences, beginning to be formulated to guide

actions.

3. A competent nurse generally has two- or three years’ experience on the job

in the same field. More aware of long-term goals Gains perspective from

planning own actions based on conscious, abstract, and analytical thinking and

helps to achieve greater efficiency and organization.

4. A proficient nurse Perceives and understands situations as whole parts, more

holistic understanding improves decision-making and learns from experiences

what to expect in certain situations and how to modify plans.

5. Expert nurses no longer rely on principles, rules, or guidelines to connect

situations and determine actions, have much more background of experience,

have an intuitive grasp of clinical situations and their performance is now fluid,

flexible, and highly proficient.

 Expertise influences nurses' clinical judgment and quality of care and

develops when a nurse tests and refines both theoretical and practical knowledge in

actual clinical situations (Benner, 1984). According to Benner and her colleagues,

nurses develop skills of engagement as a result of their involvement in diverse

circumstances and learning from them. This means that they know how close or far

to be with patients and families during vital periods of threat and recovery (Benner,

2001; Benner et al., 2009). Nurses need these abilities to deal with the stress that

comes with their jobs. When confronted with an emotionally difficult patient, an

overprotective parent, or a relative who disagrees with a loved one's end-of-life

decision, nurses must know how to approach the situation so that they may meet

the person's needs without losing themselves in the process.

Emergence of the COVID-19 Pandemic

Corona viruses had been known to cause pandemics. SARS-CoV and

MERS-CoV were the first coronavirus outbreak which has resulted in

socioeconomic and psychological losses in the past (MA, 2020). The latest threat

to global health is the ongoing outbreak of the respiratory disease that was recently

given the name Coronavirus Disease 2019 (Covid-19). Covid-19 was recognized in

December 2019 (Fauci et al., 2020) and on 30. January 2020, the WHO Emergency

Committee declared a global health emergency based on growing case notification

rates at Chinese and international locations.

According to the World Health Organization, the virus can spread from an

infected individual's mouth or nose in little fluid particles when they cough, sniffle,

talk, sing or inhale vigorously. Others can get COVID-19 when the infection gets
into their mouth, nose or eyes, which is bound to happen when individuals are in

immediate or close contact (under 1 meter distance) with a contaminated individual.

Current evidence recommends that the primary way the infection spreads is by

respiratory drops among individuals who are in close contact with one another. Any

circumstance wherein individuals are in closeness to each other for extensive

periods of time expands the danger of transmission. Indoor areas, particularly

settings where there is poor or no ventilation, are riskier than outside areas.

Regardless of whether they have symptoms, contaminated individuals can be

contagious and the infection can spread from them to others. Lab information

proposes that contaminated individuals are most infectious just before they develop

symptoms, to be specific 2 days before they manifest symptoms. As mentioned in

the article by the Harvard Health Publishing, some people who had acquired the

virus are asymptomatic. At the point when the infection causes manifestations,

common symptoms include body ache, dry cough, fatigue, chills, headache, sore

throat, loss of appetite, and loss of smell. In certain individuals, COVID-19 causes

more serious manifestations like high fever, severe cough, and shortness of breath,

which frequently demonstrates pneumonia.

The first suspected case in the Philippines was investigated on January

22,2020. Both patients were said to be Chinese nationals that were on a vacation in

the Philippines during January 2020. Patient 1 was a 39-year-old female who

experienced cough and sore throat. Patient 2 was a 44-year-old male who

experienced fever, cough and chills. On January 31, SARS-CoV-2 viral RNA was

reported to be detected by PCR on the initial swabs, and he was identified as the

2nd confirmed COVID-19 infection in the Philippines. COVID-19 cases in the

Philippines continue to increase despite having the strictest and longest lockdown

in the country.

Knowledge of Caring

As a practice, nursing highlights the importance of caring. In a study by

Eriksson (1997), there are three perspectives of caring in nursing including: “caring

nursing”, “nursing care” and “nursing nursing”. Specifically, “caring in nursing” is

characterized by an emphasis on compassion that observes the patient objectively

without prejudice and stresses her or his suffering and needs. Especially amid the

challenge of a global pandemic, the healthcare scenario has changed and nurses

have adapted in every aspect including caring. An understanding of the current

circumstances of nurses in the context of caring, specifically from the point of view

of those who had been in the front lines, is vital in providing evidence-based

suggestions for nurses in similar dispositions during future health crises (Sandang,

2020).

Health Condition of Nurses

Various reports have been published to generate information on the holistic

health of nurses while caring for COVID-19 patients. Research undertaken in Iran

demonstrates that mental and emotional distress is encountered by nurses working

in wards and treatment centers designated for COVID-19 patients and working in

insufficient professional conditions. Caring for patients with COVID-19 requires

high mental demands thus causing anxiety and stress to the nurses (Karimi et al.,

2020). The participants in the study conducted by Jonaid Sadang encountered,

during this difficult situation, the extensive demands, the physical and mental
challenges in and out of their workplace, the lack of sufficient human resources,

and the inadequate administrative strategies and government support given

exhausted them and caused them confusion, anxiety, and panic. The position of the

job and the attendance of training related to COVID-19 predicted fear of COVID-

19. Reduced job satisfaction, increased psychological distress and improved

organizational and technical turnover intentions were correlated with an increased

level of fear of COVID-19. Of the 325 nurses in the study, 123 were found to have

dysfunctional levels of anxiety (Labrague & Santos, 2020). While confronting fear

and anxiety, Nurses respond to "the call of duty." Aside from this, they also

experience strain, stress, insomnia, denial, frustration, and fear (Biana & Joaquin,

2020). Generally speaking, most studies suggest that Nurses face considerable

physical, mental, emotional and even spiritual conditions.

Work Experience of Nurses Caring for COVID-19 Patients

Many recurring themes are prevalent in many nursing cares studies

especially in the care of the new COVID-19 patients. Nurses are also humans

therefore also having to know fear in their line of work. A qualitative study on 21

nurses show they quickly adapted to pandemic-related care delivery thus having felt

a “sense of duty” to care for such patients despite an increase in patient exposure

all the while increasing the risk of infection (Schroeder et al., 2020). This shows

that nurses are able to evolve since their work is highly dynamic. The study

concluded that public health emergencies such as COVID-19 affects nursing

practice and can be used as an opportunity to optimize and develop healthcare

structures, nursing processes and better patient outcomes. We still cannot ignore the
fact that this pandemic produced a more negative outcome towards our frontliners.

Mentioned in a study by Bai, et. al. (2004), mental problems arose from a health

crisis such as the SARS outbreak in 2004. The health crisis resulted in a disturbance

in the daily lives of nurses that lead to overwhelming and stressful work conditions.

Nursing Workload

There have been many reflections and studies that are concerned with

increased workload, a lack of essential items and the well-being of our nurses.

Workload pertaining to an increase in COVID-19 patients that rendered workforce

and essential items to be inadequate. Moreover, in this (unexpected) COVID-19 era,

new factors can tremendously influence nursing workload. COVID-19 patients

require prophylactic measures to prevent or contain the spread of the virus to other

patients: donning protective garments, specific decontamination procedures,

isolated dedicated areas where specific supplies are stored. A study conducted by

Karimi Z et. al. in Iran revealed insufficient basic medical facilities and the wards

are not similar to isolated wards. The substandard care conditions and lack of

facilities were thought to be the pressing concerns identified in the nurses’

statements. All these measures increase nursing workload (Giuliani et al., 2018).

The sudden lack of ICU beds and mechanical ventilators has led to an increasing

number of conversions of recovery and operating rooms into new COVID-19 areas

(Bambi et al., 2020, Lucchini et al., 2020). Therefore, the COVID-19 era is driving

the need to enhance nursing workload scores with new issues, including the time

for donning and doffing personal protective equipment (PPE), the additional time

taken to provide care wearing PPE, the need for distanced communication between
patient and relatives, and the need to manage the increasing incidence and severity

of agitation and delirium due to the isolated environment (Kotfis et al., 2020). This

concern leads Australia and the United Kingdom to consider fast-tracking the return

of nurses who may be recently retired and allowing limited registration to people

who may be suitable like international qualified nurses (Jackson et al., 2020).

Another study states that treatment of coronavirus patients should not only be the

focus in nursing care as it is highly supportive but also a strong focus in mitigating

the spread of infection to staff, other patients, and the community (Deitrick et al.,

2020).

Nursing Workforce

The pandemic has put a strain on the health-care system, particularly nurses,

who are facing the most difficult problems as a result of the enormous coronavirus

spread around the world (Buheji, 2020). Nurses face new professional, social, and

psychological concerns as a result of COVID-19. According to studies, the most

major limiting factors in managing the spread of infectious diseases are increased

workload and a labor shortage. In the COVID-19 crisis, a shortage of nurses and a

rise in the number of patients have considerably increased each nurse's workload,

and these conditions can be harmful to nurses' physical and emotional health (Lam

et. al., 2019). In the initial response to the pandemic, the ICN report highlights three

major concerns: maintaining safe staffing levels; staff and patient safety when

nurses are called to work in unfamiliar environments, such as providing critical care

with hardly any training; and insufficient personal protective equipment (PPE).

Moreover, based on the findings of a study conducted in the United States, the
chance of burnout and job dissatisfaction increases by 23 and 15 percent,

respectively, with the addition of each patient and the increase in the workload of

nurses (Aiken et. al, 2002). As a result, to prepare health-care systems to address

these problems, a coordinated global response is required (Remuzi, 2020).

According to the World Bank (2017), global pandemic preparedness is necessary

for global security and should be included as part of a program to enhance health-

care systems. The WHO (2014) suggests that, in order to prepare hospitals to deal

with epidemics, staff shortages should be expected related to absenteeism and

increased demand for services, and a plan should be put in place to manage this

deficit, which may include the employment of additional workers. Low nursing staff

numbers, particularly nurse-to-patient ratios, are linked to disease spread in health

care settings and the probability of an epidemic (Ferrer et. al, 2014). One of the

most important responsibilities of hospitals is effective staffing and planning.

Sufficient human resources can boost nurse productivity and clinical outcomes,

which is the primary goal of the health-care system (Nazari et. al, 2006).

Conditions of medical care equipment

Nurses on the frontlines who respond to COVID-19 face medical concerns

such as injury, disease, and depression, which may be related to nurses' fear of

infection and worry over the workload associated with COVID-19 patients. Another

factor that may put frontline nurses at risk of depression is their concern for their

families and children (Martin, 2011). Therefore, providing nurses with updated

COVID-19 data and assuring the supply of PPE are important and may assist to

alleviate their fears and concerns (Tzeng et. al, 2006). Unfortunately, the US
Department of Health and Human Services reported a widespread PPE shortage.

Hospitals claimed that heavier than usual use of personal protective equipment

(PPE) was contributing to the shortfall, and that a weak supply chain was delaying

or prohibiting them from refilling PPE essential to protect personnel. Hospitals

indicated that the increased number of beds hampered their ability to care for

patients due to a shortage of vital supplies, equipment, and logistic assistance. Items

such as intravenous treatment (IV) poles, medical gas, linens, toilet paper, and food

were noted as being in short supply in hospitals. Others stated that no-touch infrared

thermometers, antiseptics, and cleaning materials were in short supply. Isolated and

smaller hospitals also faced serious challenges in keeping the resources they

required and fast refilling when they ran out. The lack of personal protective

equipment (PPE) and medical supplies raises the infection rate among nurses, as

evidenced by the fact that many nurses became infected. In Italy, for example, many

nurses and physicians became infected, resulting in death (Shanafelt et. al, 2020).

To put it another way, a lack of PPE can lead to infection, and illness can have a

negative impact on healthcare personnel' mental health and lives. Fear of infection,

which leads to psychological alterations and can lead to burnout, is another effect

of a shortage of PPE and medical supplies (Fernandez et. al, 2020).

It is crucial to provide a suitable environment for nurses and other healthcare

providers to work. Nurses should be provided with vital equipment such as PPE,

such as face masks, gloves, and a motorized air-purifying respirator as needed, and

other essential medical materials to help them operate optimally and competently

(Al Thobaity et. al, 2017). To guarantee that medical resources are not in short

supply, responsible leaders must recognize needs and provide these resources,
taking into account the number of healthcare professionals and patients who may

require medical or nursing care.

Patient Compliance

The term "compliance" refers to the process of a patient adhering to the

prescriber's and dispenser's instructions. It is defined as "the degree to which a

person's behavior (in terms of taking prescribed medication, adhering to diets, or

implementing lifestyle changes) corresponds with medical or health advice

(Florida, 2012). Medical non-compliance is already viewed as a major public health

issue that places a significant financial strain on today's health-care systems.

(Vermeire et al., 2001). Noncompliance is predicted to cost the US economy

between $100 and $300 billion per year, including expenditures associated with

needless hospitalizations, nursing facility admissions, and early deaths (Improving

Prescription medicine adherence is key to better healthcare, 2011).

Patients who are compliant ‘submit' to their doctors' prescriptions and take

their medicine or follow their instructions. Non-compliance, sometimes known as

disobedience, is the failure or reluctance to comply. (Vermeire et al., 2001). Several

factors were discussed with regards to noncompliance. Psychiatric problems (the

more symptoms reported, the lower the compliance) and treatment parameters such

as the length of therapy, the number of medications recommended, the cost, and the

frequency of dose are all linked to low compliance (Griffith, n.d.). In general, the

higher these criteria are, the lower the compliance. Non-compliance is frequently

attributed to the regimen's complexity and miscommunication, particularly in senior

patients with memory impairments who are unable to follow complex sets of

instructions.

The predicted beneficial benefits of even the most thoroughly and

scientifically-based treatment regimen will not be achieved if the patients do not

adopt or comply with the treatment plan faithfully. As a result, this may place an

additional load on healthcare personnel, particularly on nurses who are in direct

contact caring for the patients.

Patients Self-care ability

Self-care is frequently regarded as a key part of resiliency: persons who are

able to meet their needs sufficiently are generally able to deal better (Self Care in

Therapy, 2009).The ability of a patient to perform self-care can be assessed by a

registered nurse through direct observation as the patient performs self-care

activities,, and a standardized tool or test that measures the patient's abilities in

terms of their basic and activities of daily living (RegisteredNursing.org Staff

Writers, 2016). The patient's motivation, social support, physical and psychological

condition, neurological status, musculoskeletal abilities and deficiencies, cognitive

capacities, and level of development can all have an influence on the client's ability

to undertake self-care and activities of daily living. Nurses also assist and support

patients with their personal hygiene and personal care needs as needed. Setting the

patient up and helping them as needed, as well as giving the patient with assistive

gadgets and equipment such as a long shoe horn and adapted toothbrushes, can all

help the patient achieve the highest level of independence possible.

(RegisteredNursing.org Staff Writers, 2016). The nurse organizes care in order to

enhance the patient's independence and to ensure that the patient's living

environment is safe and supportive of his or her specific requirements (Self-Care

Deficit – Nursing Diagnosis & Care Plan, 2016).

While self-care can aid in the prevention of future health issues, it is not a

cure or therapy for sickness or illness in and of itself. Self-care abilities are one tool

that helps patients regain their health (Wanchai, 2018). This may aid individuals

with chronic diseases like COVID-19 in managing symptoms, reinforcing other

parts of health, and increasing emotional well-being. (Lawler, 2021). In patients

with chronic illnesses, self-care has an impact on both clinical and person-centered

outcomes. Those who practice self-care more efficiently have a higher quality of

life, fewer hospitalizations, and lower mortality rates as those who practice poor

self-care (Riegel et al., 2019). Thus, an increase in self-care ability leads to an

increase in the success rate of treatment. Patients who are able to perform self care

activities and Activities of Daily Living have a greater probability of success with

their treatment plan than those who are unable. Patients who have been intubated or

in ventilators are an example. With that said, it demands nurses exert greater effort

in their care.

Patients Condition

Patients infected with COVID-19 can experience a range of clinical

manifestations, from no symptoms to critical illness. The National Institution of

Health grouped patients infected with covid-19 into the following severity of illness

categories: Asymptomatic or presymptomatic infection, mild illness, moderate

illness, severe illness, critical illness. Individuals with asymptomatic or pre

symptomatic infection are those who test positive for COVID-19 on a virologic test

(e.g., a nucleic acid amplification test [NAAT] or an antigen test) who do not have

COVID-19-related symptoms. Those patients with mild illness experience any of

the COVID-19 symptoms (fever, cough, sore throat, malaise, headache, muscle

pain, nausea, vomiting, diarrhea, loss of taste and smell) but no shortness of breath,

dyspnea, or abnormal chest imaging. Patients with moderate illness are individuals

who have an oxygen saturation (SpO2) of less than 94 percent on room air at sea

level and exhibit indications of lower respiratory illness during clinical examination

or imaging. Individuals with an arterial partial pressure of oxygen to fraction of

inspired oxygen (PaO2/FiO2) ratio of less than 300 mm Hg, respiratory frequency

greater than 30 breaths/min, or lung infiltrates greater than 50% on room air at sea

level are under severe illness category. Individuals who have respiratory failure,

septic shock, and/or multiple organ dysfunction are under the critical illness

category.

According to the Centers for Disease and Control Prevention, some people

are more prone to become severely ill than others. A person with COVID-19 who

is severely unwell may require hospitalization, intensive care, a ventilator to assist

them breathe, or possibly death. People who are at a higher risk, as well as those

who live or visit with them, should take extra precautions to avoid contracting

COVID-19. This includes older adults, people with medical conditions, pregnant,

and recently pregnant people. Health care providers should monitor such patients

closely until clinical recovery is achieved. Before a substantial number of infected

individuals require hospitalization, active preparedness measures must be put in

place (Murthy et al., 2020). As the condition of patients increases in severity, this

also imposes a greater risk to the nurses.

After careful review of available literature, the following assumptions have been

identified:

1. Nurses have varying work experience, knowledge of caring, and health

status.

2. The care given by nurses to COVID-19 patients may be influenced by

patients' own compliance, self-care capacity, and condition.

3. Nurses' experience in caring for COVID-19 patients are significantly

affected by nursing workforce, nursing workload, and the medical care

equipment condition.

Research Paradigm

This study aims to recognize the experiences of nurses caring for COVID-

19 patients. The experience of nurses are analyzed using various factors that may

contribute to their overall disposition. Figure 1 illustrates the classification of these

factors into three categories, including individual factors, patient factors, and

organizational and equipment factors.

 Fig 1. Research Paradigm

The nurses’ individual factors pertain to the participants’ distinct profiles as

members of the healthcare team. The participants may have varying work

experience, knowledge of caring, and health status. With the challenges of a global

pandemic, nurses may optimize their past experiences and existing qualities in

providing care for their patients. Each nurse may have their own individualized

approach and outlook in caring that may affect their experience. The patient factors

refer to the patients’ disposition while being cared for in COVID-19 facilities as

encountered by the nurse. Patient compliance, patient self-care capacity, and the

patient’s condition may influence the care delivered by nurses. Different patient

scenarios may elicit distinct interventions performed by nurses. Lastly,

organizational and equipment factors encompass the condition of the COVID-19

facilities the nurses work in. The challenges brought about by the global pandemic
caused significant changes in hospitals and other healthcare facilities. Various new

demands emerged that significantly affected the nursing workforce, nursing

workload, and the medical care equipment condition. These factors are perceived

to influence quality of care they will be able to provide over their whole experience

in the COVID-19 facility. All of the aforementioned factors are potential causes that

could impact the overall experience of nurses caring for COVID-19 patients.
 CHAPTER 3

RESEARCH DESIGN AND METHODOLOGY

This chapter provides information on the research method of the study. This

chapter includes how the researchers will make the study possible, how they will

gather information, and the location where they will conduct the study. The parts

included in this chapter are the research design, locale, respondents, sampling

technique, research instruments, data gathering procedure, ethical considerations

and data analysis.

Research Design

This qualitative study will utilize a phenomenological research design. To

understand how individuals experience the world, qualitative research is used.

While qualitative research has many approaches, they tend to be flexible and

concentrate on retaining rich meaning when interpreting data (Bhandari, 2020). The

approach's main purpose is to arrive at a description of the nature of the

phenomenon in question (Creswell, 2013). Interviews will be conducted with a

group of people who have firsthand knowledge of a topic, event, or experience. In

this case, the researchers will try to discover and interpret the meaning of nurses’

lived experiences in caring for COVID-19 patients. The data gathered will be read

and reread and culled for phrases like themes that will be grouped to form clusters

of meaning (Creswell, 2013). The researchers would use this method to determine

the event's, situation's, or experiences' universal meaning and gain a deeper

understanding of the phenomenon.

Locale

There are limitations in the conduct of our research due to the ongoing

pandemic occurring worldwide. Online data collection and interviews are carried

out through video calls or private messaging. In this way, by following safety

procedures and not putting both respondents’ and researchers’ health at risk, we can

successfully reach our respondents. The target population for this study is nurses

looking after COVID-19 patients residing in the premises of Region 12

(SOCSKSARGEN), Mindanao, Philippines.

Source:https://www.google.com/url?sa=i&url=https%3A%2F%2Fkapuluanngpilipinas.wordpress.
com%2F2016%2F05%2F16%2Fregion-xii-
soccsksargen%2F&psig=AOvVaw0xP1QKnvQV2G2jmZ4wUrFj&ust=1627476073073000&sour
ce=images&cd=vfe&ved=0CAsQjRxqFwoTCKj3yYGjg_ICFQAAAAAdAAAAABAD)

Fig 2. Map of Region 12

Participants of the Study

In this study, there will be 15 participants, regardless of their gender and

age, working directly as front liners in hospitals catering to COVID-19 patients in

Region 12 who will be recruited utilizing snowball sampling. Hospitals such as

COVID Treatment Facilities in M’lang District Hospital and Dr. Jorge P. Royeca

are just some of the many hospitals wherein symptomatic patients are kept for

treatment.

Sampling Technique

A referral technique using snowball sampling will be utilized by the

researchers due to local restrictions imposed by this pandemic. In order to spend

less time screening suitable target participants as well as easier time developing a

trusting relationship with the participants. The “snowball” sampling is a research

technique through survey and data registration which is typically used in sociology,

psychology, or management studies, and are recommended when: the population

cannot be strictly delimited or detailed; the characteristics of the sample are rare; a

good research method when the study is on behaviors, perceptions, customs, for the

description of “typical” cases which cannot be generalized for an entire populations

(Naderifar et al, 2017). Snowball sampling consists of two steps as discussed by

Glen (2014). First, the researchers will identify the potential subjects in the

population. Oftentimes, only one or two subjects can be found initially. Finding

nurses who are willing to participate is a great challenge since it is expected that

they have a tight schedule and personal businesses to attend to in their free time.
Second, the researchers will ask the subjects to recruit other people (and ask those

people to recruit). These steps are repeated until the necessary sample size is

obtained.

The inclusion criteria will be: (a) employed and working as a registered

nurse in any hospitals within region 12 which treat symptomatic COVID-19

patients, (b) serving directly in the hospital following the COVID-19 public health

crisis declaration in the Philippines, (c ) gender and age are irrelevant, and (d)

willing to participate in the research study without expecting any monetary

compensation

Research Instrumentation

A semi-structured interview will be conducted initially through video

conferences and phone calls due to local pandemic restrictions. This aims to pursue

the meanings of the central themes the interviewee tries to convey (McNamara,

2009). Open-ended questions will be asked during the sessions in order to obtain

impartial information and to give the participants more options for responding. The

research instrument consists of two (2) parts. Part one of the interview guide

consists of the socio-demographic data or profile of the participants such as their

name, age, gender, address, the name of the hospital they currently work at, and the

number of their years in service. Part two of the interview guide consists of seven

questions which support the main question “What are your experiences while caring

for COVID-19 patient?” These seven questions also contain supporting questions

to enable the participants to elaborate on their answers. The interview guide is

systematically designed to get and produce open responses from the participants.
Preference for the use of an interview guide is based on the fact that it is the least

expensive means of gathering data, it helps avoid personal bias, it enables in-depth

discussion on specific topics and it encourages open responses to sensitive issues at

hand. In addition, the instrument will be validated by the adviser before using it in

the actual interview.

Data gathering procedure

At this point, the researchers have completed and identified the appropriate

participants of the study using snowball technique. Before formally starting the

interview, the researchers will first obtain the signed informed consent from the

respondents indicating their voluntary participation in the study. After that we will

individually contact the study's fifteen participants via video chat or private

message and plan a schedule for the interview based on their availability. The mode

of communication will also be based on their preference or accessibility but video

calls and phone calls are opt for. When all of that is settled, the interview will finally

begin. The one-on-one interview with the participants will be conducted using the

interview guide/questionnaire. In part one of the interview guide, the researchers

will first gather the socio-demographic data of the participants such as their name,

age, gender, address, the name of the hospital they currently work at, and the

number of their years in service. Part two of the interview guide has seven questions

prepared by the researchers which aims to answer the main question 'What are your

experiences while caring for COVID-19 patients?’ Part two of the interview will

begin with a question pertaining to the process of how the participant accepted the

job and responsibility as a COVID-19 nurse despite the great risk that comes along
with it. The participants will identify the factors that they considered, what

prompted them to accept the responsibility, and their major concerns before they

started working. Next, the participants will describe their experiences on the first

day of their work and enumerate their preparations, explain the differences between

COVID ward and a medicine ward in terms of its working condition, and describe

their work environment, colleagues, and availability of equipment. The researchers

are also interested to know the common challenges nurses encounter daily upon

caring for COVID-19 patients and how they overcome these challenges. After that,

a more personal question such as “Have you experienced a loss of a COVID-19

patient?” will be asked to the participants. The researchers aim to know what the

participants felt in this situation and how this personal experience affected them.

Fifth question aims to know the lessons learned by the participants from their

experiences that they ought to be important and worthy to share. These lessons

would be helpful for aspiring nursing students who may work in a COVID-19 ward

to know what certain adjustments they should make, expectations, and to prepare

themselves for a high risk job. The following question intends to explore the impact

of the pandemic to a COVID-19 nurse’s overall health (physical, mental, and

emotional). Finally, the interview will end asking about the participants’

recommendations or advice to improve the quality of nursing care towards patients

with COVID-19. They will identify the main problem that they noticed upon caring

for COVID-19 patients and what specific measures they took to address the

problem. The enumerated problems can be solved if addressed to the proper

organizations and departments which can be possible through this study.

 The interview will be quite lengthy and may last for 30-60 minutes each,

depending on the participant’s response. The participant may answer in English,

Tagalog, or vernacular. As part of the ethical protocol, permission to audio-record

the interviews will be obtained. Standards for documenting qualitative analysis will

be closely followed in the data collection process. Following the collection of the

recorded data, the researchers will then transcribe it in a verbatim manner and

translate it to English so it may be well understood in the study. Finally, the

researchers will analyze and interpret the data.

Data Analysis

After the semi-structured online interviews will be conducted using a

prepared interview guide wherein the fifteen participants are encouraged to talk

freely and express their ideas using their own words, the researchers will finally

proceed to data analysis. The descriptive Colaizzi method will be used to analyze

the obtained data. The following steps represent the Colaizzi process for

phenomenological data analysis (cited in Sanders, 2003; Speziale & Carpenter,

2007).

1. After translating in English, each transcript should be read and re-

read in order to obtain a general sense about the whole content.

2. For each transcript, significant statements that pertain to the

phenomenon under study should be extracted. These statements

must be recorded on a separate sheet noting their pages and lines

numbers.

3. Meanings should be formulated from these significant statements.

 4. The formulated meanings should be sorted into categories, clusters

of themes, and themes.

5. The findings of the study should be integrated into an exhaustive

description of the phenomenon under study.

6. The fundamental structure of the phenomenon should be described.

7. Finally, validation of the findings should be sought from the research

participants to compare the researcher's descriptive results with their

experiences.

Figure 3. The process of descriptive phenomenological data analysis created by Colaizzi (1978).
Demonstrating Trustworthiness of the Study Findings

A qualitative research design needs to display trustworthiness in

providing rigor and strength to the study validity and reliability in all the stages

including the gathering of data, data analysis, and description. The rigor of this

study will be based on Lincoln and Guba four criteria: credibility, confirmability,

dependability and transferability. Researchers' credibility will be established by

extended interaction with the data, findings, discovery of different findings, and

member verification. Fifteen nurses with valuable expertise caring for COVID-19

patients will be recruited to provide a large and extensive data set for confirmability.

The researchers will also look into and explain every aspect of the study, from

sampling to data collection and processing, and compare the results. A qualitative

research expert will double-check the descriptions and coding. The researchers will

utilize questions to analyze the phenomena in order to substantiate the findings. To

boost dependability, coding methods will be applied during the analytical process.

Ethical considerations

The qualitative research study entitled “Lived Experience of Nurses Caring

for Patients with COVID-19” aims to recognize the challenges and personal

experiences of nurses who took care of COVID-19 patients and how these

experiences impact their lives. Through this we can formulate recommendations to

improve the working conditions as well as the nursing care given to COVID-19

patients. This research will involve the participants’ cooperation in an online

interview that will take about 30-60 minutes. The study may require an audio-visual
recording to assist with the accuracy of the responses; however, the participants also

have the right to refuse the audio-visual video recording. Rest assured, the

cooperation of the participants is completely voluntary. They have the right to

discontinue participation and any information that has already been collected will

be discarded. There will be no penalty given to the participants for choosing not to

participate. Moreover, the participants’ identities will be kept confidential to the

extent provided by the law. Their names will not be used in any report or

publication. Instead of their actual name, numbers will be used during transcription

of the answers. All information/data gathered will be kept in a secured locker and

when the study is completed and the data is analyzed, all data will be destroyed.

There is no direct risk for the participants in this study but their participation

will definitely help the researchers find the answers to their research problem. The

information gathered will be evaluated in order to find ways to enhance the working

circumstances of healthcare workers in partnership with the respective healthcare

organizations and government agencies. Incentives or compensation will not be

given to the participants however the researchers will extend their immense

gratitude verbally. Furthermore, the information provided by the participants will

be exclusively shared within the research team only and their identity will not be

revealed. The results of the study will be published and shared to the community

but confidentiality will still prevail. Lastly, health security measures as established

by the Inter-Agency Task Force on Emerging Infectious Diseases (IATF-EID) will

be strictly followed during the conduct of this study for the protection of both

participants and researchers.

References

Stanisławski, K. (2019). The Coping Circumplex Model: An Integrative Model of

the Structure of Coping With Stress. Frontiers.
https://www.frontiersin.org/articles/10.3389/fpsyg.2019.00694/full

Suzuki, T., Hayakawa, K., Ainai, A., Iwata-Yoshikawa, N., Sano, K., Nagata, N.,
Ishikane, M. (2021). Effectiveness of personal protective equipment in
preventing severe acute respiratory syndrome coronavirus 2 infection among
healthcare workers. Journal of Infection and Chemotherapy, 27(1), 120–122.
https://doi.org/10.1016/j.jiac.2020.09.006
 Republic of the Philippines
MSU-Iligan Institute of Technology
COLLEGE OF NURSING
AACCUP Level II Accredited
Andres Bonifacio Avenue, 9200 Iligan City Philippines
Tel No.: (063) 63 2210744 / (063) 63 2214050 Local 4266

RESEARCH PARTICIPATION INFORMED CONSENT

LIVED EXPERIENCE OF NURSES CARING FOR COVID-19 PATIENTS

Before you decide to participate in this study, please read this consent form
carefully.
Purpose of the study
The purpose of this present study is to explore the lived experience of nurses
caring for patients with COVID-19. It tries to describe the challenges they
experienced and how it affects their daily lives as a whole.
Type of Research Intervention
This research will involve your participation in an interview that will take about
one and a half hours.
The study requires audio-visual recording to assist with the accuracy of the
responses. You have the right to refuse the audio-visual video recording.
I consent to video recording: Yes _______ No_______
I consent to audio recording: Yes _______ No_______
I consent to photographs: Yes _______ No_______
Time Frame

The interview will last for one hour and thirty minutes..

Voluntary participation
Your participation in this study is completely voluntary. Should you want to
discontinue participation, any information already collected will be discarded.
There is no penalty or loss of benefit for choosing not to participate.
Confidentiality
Your identity will be kept confidential to the extent provided by law. Your
name will not be used in any report or publication. Your information will be
assigned a code number. All information/data gathered will be kept in a secured
locker. When the study is completed and the data have been analyzed, the list will
be destroyed.
 Risks and Benefits

We are asking you to share with us some very personal and confidential
information. If you may feel uncomfortable talking about some of the topics, you
do not have to answer any question or take part in the discussion/interview if you
don't wish to do so, and that is also fine. You do not have to give us any reason for
not responding to any question, or for refusing to take part in the interview.
Additionally, there is no direct benefit for the participants in this study but your
participation will definitely help the researchers find out the lived experience of
nurses caring for COVID-19 patients.

Incentive or Compensation
You will not be paid or given incentives for your participation; therefore, you will
not be adversely affected in any way if you choose not to participate.
Sharing the Results

The information that you will provide will be shared within the members of the
research team however, your identity will remain confidential. The result of the
study will be shared to the community, conferences and might be published so that
other interested individuals or groups may learn from the study.

Right to withdraw from the study

You have the right to withdraw from the study at any time without consequence or
penalty.

Whom to contact if you have questions about the study

If you have questions regarding the study, you may contact the researchers
through 09950018045 and their adviser

This proposal has been reviewed and approved by The College Research
Committee, which is a committee whose task it is to make sure that research
participants are protected from harm.

I have read all the information, or it has been read to me. I have had the opportunity
to ask questions about it and any questions I have been asked have been answered
to my satisfaction. I consent voluntarily to be a participant in this study.
Print Name of Participant__________________
Signature of Participant ___________________
Date ___________________________
I confirm that the participant was given an opportunity to ask questions about the
study, and all the questions asked by the participant have been answered correctly
and to the best of my ability. I confirm that the individual has not been coerced into
giving consent, and the consent has been given freely and voluntarily.
A copy of this ICF has been provided to the participant.
Print Name of Researcher/person taking the
consent________________________
Signature of Researcher /person taking the
consent__________________________
Date ___________________________
 Questionnaire

Socio-demographic Data:

1. What is your name?

2. Age?

3. Gender?

4. Where are you from?

5. What's the name of the hospital where you currently work?

6. How many years in service?

Main question: “What are your experiences while caring for COVID-19

patients?”

1. How did you start working in the COVID-19 ward? Tell us more about

the process.

a. What were the factors that you considered?

b. What prompted you to accept the responsibility?

c. What were your major concerns before you started working?

2. How was your experience in caring for patients with covid-19 for the first

time?

a. What preparations did you do before going to work?

b. How was your work environment? Colleagues? Equipment?

c. What are the differences between a COVID ward and a medicine

ward in terms of working conditions?
3. What are the common challenges you encounter daily?

a. What was the most challenging case that you encountered upon
caring for COVID-19 patients?
b. How did you overcome these challenges?

4. Have you experienced a loss of a COVID-19 patient?

a. How did you feel?

b. How would you describe this experience?

c. How did this experience affect you?

5. What lessons did you learn from your experience?

6. What do you think is the impact of the pandemic on your overall health?

a. Physically

b. Emotionally

c. Mentally

7. What are your recommendations or advice to improve the quality of

nursing care towards patients with COVID-19?

a. What is the main problem you noticed upon caring for patients

with COVID-19?

b. What measures did you take to address the problem?