UC Irvine

Background: There are over 2.9 million Registered Nurses (hereafter nurses) in the United States, making nurses the largest group of healthcare workers. Of these, nearly 1.7 million nurses work in the acute care hospital settings. The recent novel coronavirus pandemic caused significant disruptions in the nurses’ ability to do their work safely and effectively due to shortages in equipment, staffing, information as well as conflicting priorities between nurses and their organizations. These experiences have highlighted the importance of interactions between nurses and the organizations within which they work and who set policies regarding their practices.Purpose: The specific aims of the study are 1) describe nurses’ experiences working during the pandemic; 2) examine nurses’ goals and priorities regarding their work during the pandemic; 3) describe how these experiences have shaped their relationships towards their leaders and organizations; and 4) develop a conceptual framework to explain how nurses navigate mechanisms of clinical governance (policies, regulations, official recommendations, best practice statements and others) and which helps identify potential strategies for improving nurses’ ability to do their work safely and effectively. Methods: A qualitative study based on focus group data and a grounded-theory methodological approach was conducted via video teleconferencing with nurses from the United States. The participants also completed an online demographic questionnaire. Convenience sampling of participants was conducted, and participants recruited via social media. A series of semi-structured focus groups were conducted, recorded and transcripts produced. The data from these focus groups were analyzed with qualitative data analysis software and pertinent codes were generated. These codes’ relations were mapped via the same software and conceptual overlap identified. Results: From the above analysis, three critical challenges emerged from the participants’ responses: 1) widespread leadership failures; 2) overwhelming uncertainty and ambiguity; and 3) unprecedented physical and psychosocial vulnerability. Given the centrality of these challenges in nurses’ experiences, a novel approach to nursing leadership was developed. This approach, based upon the tenets of Trauma Informed Care, are proposed as a means of leading while supporting and caring for a team of nurses. Finally, the focus-group data inspired a theoretical exploration of the roles of vulnerability, interdependence and agency in nursing practice through the lens of Actor-Network Theory. Conclusion: The study found that nurses, vulnerable to the physical and psychosocial effects of their work even at the best of times, experienced extreme vulnerability during the pandemic. This was exacerbated by the failure of leadership that many nurses reported. Nurses expected their organization, and those with the institutional power within them, to support and protect them as they faced the pandemic and its many challenges. Instead, they too often felt abandoned and sacrificed. But nurses pushed back strategically to pursue their goals. Nurses are indeed vulnerable, but are also agentive, professional actors who leverage relations with others to shape their work and workplaces in ways which align with their own values. Relations between actors shape and define the experiences of all involved, for better or worse. Perhaps there is a role for a trauma informed leadership in nursing to shape these relations into networks of mutual support and care for a more effective, genuine and humane nursing practice.