Understanding nurses experience of stress during the COVID-19 pandemic in an acute Irish hospital: Single embedded case study

Background: Stress has been classified as the health epidemic of the 21st century. Nursing is a high-stress occupation, with stress among nurses linked to poorer health and increased absenteeism. Over 80% of nurses in Ireland reported feeling stressed and nearly 70% of nurses considered leaving the profession due to stress. More recently, the COVID-19 pandemic has increased nurses' stress globally. Epidemiologic, clinical, and experimental studies have found that acute or chronic stress significantly impacts individuals’ physical and emotional well-being. There are reported links between stress and physical disorders, including inflammation, metabolic, reproductive, autoimmune, and malignancy. This suggests that all the biological systems of the human body are affected by stress. This highlights the need to identify the specific causes and impact of stress on nurses in the acute hospital in Ireland. Additionally, it is crucial to explore existing coping strategies and propose recommendations for future interventions aimed at reducing stress among nurses. Aim: The aim of this study was to examine nurses' stress working in an acute hospital during the COVID-19 pandemic. Method: Set within an interpretivist framework, the research employed a robust single case study conducted in an acute hospital in the Republic of Ireland. A theoretical framework was developed to guide the research. Using case study research, a blend of semi-structured interviews, surveys, and documentary evidence were employed to provide an in-depth, holistic perspective on the complex sources and impacts of stress on frontline nurses. Thirty-four nurses across four directorates namely medical, surgical, oncology and unscheduled care and from various skill set that included Staff Nurses (SN), Senior Staff Nurses (SSN) and Clinical Nurse Manager (CNM) took part in semi structured interviews. In addition to this the Nurse Occupational Stress Scale (NOSS) and the COVID-19 Questionnaire adapted from the MERS-CoV Perceived Stressors Questionnaire were used to collect quantitative data from 232 nurses across the hospital. Finally, documentary evidence was gathered using the safe staffing framework, staff shortage records and staff sickness records. Results: Through a rigorous qualitative analysis, the study identified three central themes: Causes of Nurses' Stress – The study revealed that the pandemic, heavy workloads, communication breakdowns, and organisational challenges significantly heightened stress levels. Impact of Nurses' Stress – Findings highlighted the severe physical and psychological impact on nurses, as well as its negative effects on patient care and overall workflow. Nurses' Stress Coping Strategies – The study explored the personal and professional methods nurses employed to manage stress effectively. These themes were further supported by quantitative data. The NOSS identified the main sources of stress among nurses were feelings of powerlessness (75%) and high work demands (72%), followed by interpersonal relationships (63%) and work–family conflict (55%). Less frequently reported causes included unmet basic needs (51%), workplace violence (38%), and organisational issues (21%).. Meanwhile, the COVID-19 Questionnaire adapted from the MERS COV Perceived Stressors Questionnaire Nurses reported high stress levels due to fear of transmitting COVID-19 (80%) and witnessing patient deterioration (80%), along with uncertainty about the pandemic, caring for sick colleagues, and challenging work conditions (all at 73%). Other stressors included PPE-related issues, infection risk, and emotional strain from constant exposure and safety conflicts. Part-time staff and nurses in Unscheduled Care and Surgical units reported higher stress in specific domains. However, COVID-19-related stress was consistently experienced across all groups, indicating a uniform impact of the pandemic. Documentary evidence linked to the safe staffing framework revealed that among the four directorates studied, only one aspect of the framework was consistently met—clinical nurse managers were encouraged to assess ward quality measures and align them with nurse staffing (via Quality Care Metrics and Hospital In-Patient Enquiry (HIPE) data. Furthermore, staff shortages and increased sickness levels were prevalent across the study site during the research period. The study’s innovative use of the Pillar Integration Process (PIP) visually mapped these findings, offering a clear, evidence-based depiction of stress in healthcare. Additionally, survey data pinpointed key stress drivers, while documentary evidence provided crucial context regarding staffing and sickness trends. Conclusions: Rooted in stress and coping theory, this research established a theoretical framework that guided the literature review, analysis, and discussion. By offering in-depth qualitative and quantitative insights, the study provided a comprehensive understanding of the multifaceted nature of nurses' stress during the COVID-19 pandemic. It highlighted the interplay between external stressors, such as heavy workloads and staff shortages, and their psychological and physical impact on nurses. It also identified stress coping strategies that may mitigate against stress. The study concluded with evidence-based recommendations for mitigating stress in acute hospital settings, emphasising organisational interventions, enhanced support systems, and resilience-building strategies. Additionally, it offered valuable directions for future research, encouraging further exploration of long-term stress management solutions in healthcare. The findings are transferable to other acute care settings, contributing to a broader understanding of occupational stress and its implications for both nurses and patient care.

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University of Galway

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Attribution-NonCommercial-NoDerivatives 4.0 International

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University of Galway Theses (PhD Theses)