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Received: 20 November 2020    Revised: 9 December 2020    Accepted: 15 January 2021

DOI: 10.1111/jonm.13253

ORIGINAL ARTICLE

Nurses’ experiences of being recruited and transferred to a

new sub-­intensive care unit devoted to COVID-­19 patients

Matteo Danielis RN, MNS, PhD, Nurse Educator1,2  |

Luca Peressoni RN, MNS, Head Nurse2 | Tommaso Piani RN, MNS, Head Nurse2 |
Tiziana Colaetta RN, Head Nurse2 | Maura Mesaglio RN, MNS Director2 |
Elisa Mattiussi RN, MNS, Nurse Educator1,2 | Alvisa Palese RN, MNS, PhD, Associate Professor1

1
School of Nursing, Udine University, Udine,
Italy Abstract
2
Udine University Hospital, Azienda Aim: To describe the experiences of Italian nurses who have been urgently and com-
Sanitaria Universitaria Friuli Centrale, Udine,
pulsorily allocated to a newly established COVID-­19 sub-­intensive care unit.
Italy
Background: In the context of the COVID-­19 pandemic, no studies have documented
Correspondence
the experience of nurses urgently reallocated to a newly created unit.
Matteo Danielis, Department of Medical
Sciences, University of Udine, Italy, Viale Method: A qualitative descriptive study. Twenty-­
four nurses working in a sub-­
Ungheria 20 –­33010 Udine, Italy.
intensive care unit created for COVID-­19 patients participated in four focus groups.
Funding information Audio-­recorded interviews were verbatim-­transcribed; then, a thematic analysis was
This research received no specific grant from
performed.
any funding agency in the public, commercial
or not-­for-­profit sectors. Results: The experience of nurses was summarized along three lines: (a) ‘becoming a
frontline nurse’, (b) ‘living a double-­faced professional experience’ and (c) ‘advancing
in nursing practice’.
Conclusions: Nurses who experienced being mandatorily recruited and urgently re-
allocated to a COVID-­19 unit lived through a mix of negative feelings in the early
stages, a double-­faced situation during the episode and, at the end, the perception of
global growth as a person, as a team and as a professional.
Implication for nursing management: Nurse managers could play a key role in iden-
tifying and preparing nurses in advance to mitigate their concerns and their sense of
unpreparedness. The value attributed to nursing care should be promoted both dur-
ing and after the current COVID-­19 pandemic.

KEYWORDS

COVID-­19, coronavirus outbreak, pandemics, nurses’ experiences, recruitment, qualitative

research

1 |  I NTRO D U C TI O N COVID-­19 as a viral respiratory disease with extensive and rapid in-
fectiousness (The Lancet Infectious Disease, 2020). As the disease
The SARS-­CoV-­2 virus, responsible for the consequent infection was confirmed to have human-­to-­human transmission (Liu & Liu,
named COVID-­
19, has caused 66,422,058 cases and 1,532,418 2020), with a clinical presentation ranging from a mild upper respira-
deaths in over 250 countries as of 07 December 2020 (WHO, 2020). tory tract infection to severe respiratory failure, a rapid increase in
As early as January 2020, the World Health Organization defined hospital capacity in terms of beds and units (e.g. a structural division

J Nurs Manag. 2021;00:1–10. wileyonlinelibrary.com/journal/jonm© 2021 John Wiley & Sons Ltd     1 |
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2       DANIELIS et al.

in COVID-­19 and COVID-­19-­free areas) was immediately undertaken psychological safety) (Holroyd & McNaught, 2008; Shiao, Koh, Lo,
in the many affected countries, including Italy (Baggiani et al., 2020). Lim, & Guo, 2007). Furthermore, nurses deployed from a clinical area
The COVID-­19 pandemic in its first and second wave in Europe, have reported a deterioration of the quality of care due to the moral
causing nearly 105,000 deaths by November 2020 (WHO, 2020), distress from their perceived lack of competence in providing care
has forced Italian hospitals to act according to three different strat- (Corley, Hammond, & Fraser, 2010) and the perceived disruption of
egies: caring for infected patients, protecting other hospitalized pa- services caused by pandemics (Halcomb et al., 2020). In addition,
tients from being infected and preventing the spread of the disease nurses have reported the perception of increased workloads (Liu,
among health care professionals. To prevent the health care system Luo et al., 2020; Liu, Wang et al., 2020) also due to additional tasks
from collapsing and to urgently respond to the increasing numbers (e.g. writing policies, educating staff, performing receptionist duties)
of COVID-­
19 patients, several reorganisation interventions have incorporated in the nursing role (Halcomb et al., 2020; Shiao et al.,
been implemented in a short time: the number of intensive care unit 2007).
beds has been increased, elective surgical procedures have been Each respiratory pandemic has been reported as having a sig-
cancelled, and new units have been established, while other units nificant impact on the employment status, as it leads to a profound
have been converted for COVID-­19 patients (Danielis & Mattiussi, change in the nursing role, practice and caseloads (Halcomb et al.,
2020; Lipsitch, Swerdlow, & Finelli, 2020; Mari, Crippa, Casciaro, 2020). Nowadays, recruiting resources and identifying new spaces
& Maggioni, 2020; Rosenbaum, 2020). As a consequence, entire to take care of COVID-­19 patients are the main strategy to cope
nurse groups have inevitably been relocated to new units (Bagnasco, with the health care crisis. Accordingly, understanding the perceived
Zanini, Hayter, Catania, & Sasso, 2020). meaning and challenges of nurses caring for COVID-­
19 patients
Nurse reallocation, named mandatory mobility, has been poorly in this context is crucial. However, to our best knowledge, expe-
studied and mainly in its antecedents (e.g. nurse shortage in some riences of nurses urgently and compulsorily reallocated in a new
sectors) and impact on dissatisfaction, especially when the process unit in times of substantial reorganisation of an acute care hospital
is irregular, short and organised the day before or the day of the have never been documented. Expanding knowledge regarding the
change itself (van Schingen, Dariel, Lefebvre, Challier, & Rothan-­ nurses’ mandatory mobility might help nurse managers to be proac-
Tondeur, 2017). According to these negative implications, the im- tive in identifying strategies to accompany this process successfully.
portance of implementing a planned inter-­unit mobility has been
underlined (van Schingen et al., 2017). However, during a pandemic,
unplanned mobility in new units has been documented as occurring 2 | A I M
often (Danielis & Mattiussi, 2020), but implications on staff have
been poorly documented. As a consequence, evidence informing The aim of this study was to describe the experiences of Italian
nurse managers in their delicate role is still limited. nurses who have been urgently and mandatorily transferred in a
The most recent systematic review on nurses’ experience of newly established sub-­intensive care unit for COVID-­19 patients.
working during the challenging times of a respiratory pandemic was
conducted in 2020 (Fernandez et al., 2020), covering the period from
2005 (Chung, Wong, Suen, & Chung, 2005) to 2020 (Lam, Kwong, 3 | M E TH O D
Hung, & Chien, 2020). Authors have examined studies highlighting
the experiences of 348 nurses working in acute care hospitals during 3.1 | Study Design
a viral respiratory pandemic, namely the severe acute respiratory
syndrome (SARS), the Middle East respiratory syndrome (MERS), A qualitative descriptive study based on focus group methodology
Avian influenza (H5N1) and the swine flu (H1N1). Of the 13 stud- (Vaismoradi, Jordan, Turunen, & Bondas, 2014) was undertaken in
ies included in the final analysis, almost all were phenomenological May 2020 and reported here according to the COnsolidated crite-
in design and mainly performed in the South-­East Asia (e.g. South ria for Reporting Qualitative research principles (Tong, Sainsbury, &
Korea [Kim, 2018]). According to the findings, most research was Craig, 2007). The study design was selected as its focus is on de-
focused on acute care nurses’ shortages during the pandemics, and scription, rather than examining relationships or associations (Kumar,
understaffing was one of the major issues affecting nurses who had 2018), and its capacity to explore new insights on a nursing-­related
been called to cope with a demanding work experience (Fernandez phenomenon, by collecting perceptions from health care profession-
et al., 2020). als directly involved (Kumar, 2018).
In other primary studies, nurses have been reported to experi-
ence stress when being reallocated and involved in settings such as
infectious disease units outside their usual field of practice (Seale, 3.2 | Setting and Sample
Leask, Po, & MacIntyre, 2009). Moreover, rapidly changing the clin-
ical practice setting without appropriate preparation has been re- A 1,000-­bed academic hospital located in north-­east Italy was ap-
ported as contributing to an increased sense of inadequacy, leading proached. Specifically, a newly created sub-­intensive care unit with a
to vulnerability (e.g. workplace stress, concerns for physical and total of 19 beds was selected as the study setting. This unit provided
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care for COVID-­19 patients discharged from the intensive care unit 3.4 | Data analysis
between 21 March (opening day) and 24 April (unit closure) 2020.
The staff included registered nurses (RNs), medical doctors (MDs), First, the audio-­recorded focus groups were all verbatim-­transcribed.
nurse assistants (NAs), physical therapists (PTs) and respiratory Consecutively, three researchers (MD, EM and LP) carefully and in-
therapists (RTs). The nurse-­to-­patient ratio was 1:3, with three NAs dependently read the narratives to acquire a global view of the expe-
per shift. riences. Then, the data were thematically categorized by induction
A maximum variation purposeful sample method (Patton, 2015) (Tie, Birks, & Francis, 2019).
was adopted. Specifically, RNs who were (a) transferred urgently The first step was to highlight the meaning of each participant’s
and mandatorily to the newly established sub-­intensive care unit, narrative by attempting to recognize the actual sense that RNs as-
(b) at any level of professional nursing experience and (c) willing to cribed to his/her personal experience. Particular attention was given
participate in the study were eligible. Thus, all 28 RNs were invited to words used by them. Then, a preliminary coding of the data was
to participate in the study by the nurse managers (LP, TC). Nurse performed independently by three researchers (MD, EM and LP)
managers were entrusted with the recruitment strategy of the par- following an inductive approach (Hsieh & Shannon, 2005), with dis-
ticipants due to their (a) professional role, (b) knowledge of the re- agreements solved by involving a fourth researcher (TP). In this step,
search project and (c) on-­the-­job experience. However, each eligible researchers also identified and labelled the representative quotes
participant was left free to participate or not in the study. A total of from RNs’ words. To ensure anonymity, quotes were indexed as
four RNs refused to participate mainly due to time constraints due being from one of the four focus groups (e.g. FG1), and each RN was
to family responsibilities. numbered consecutively (e.g. RN1).
Then, codes as defined by researchers were merged in catego-
ries and subsequently aggregated in themes (Tie et al., 2019). Three
3.3 | Data collection procedure researchers (MD, EM and LP) performed the analysis separately.
Thereafter, they discussed the findings that emerged and labelled
Four focus groups were conducted by two researchers (MD and categories and themes through a constructive dialogue. The coding
EM) who were nurse educators working at the university level and stage created a total of 20 initial codes where each quote extracted
urgently recruited in the sub-­intensive care for COVID-­19 patients’ was categorized. In the second stage, codes with similar meanings
unit during the first outbreak. They possessed advanced education and concepts were grouped into six categories. Then, the last pro-
in the nursing field and were trained to conduct interviews. Given cess of data synthesis resulted in the generation of three themes.
their clinical role, they were in contact at the time of interviews with The final list of codes, categories and themes was mutually agreed
participants (e.g. work colleagues). The focus groups were carried on.
out at the end of the first Italian wave, shortly after the sub-­intensive
unit closure.
Six nurses were, on average, involved for each focus group; 3.5 | Rigour
the focus groups were ended when data saturation was reached
(Vasileiou, Barnett, Thorpe, & Young, 2018), as judged by two re- Methodological rigour (Maher, Hadfield, Hutchings, & de Eyto,
searchers independently (MD and EM). Researchers (MD and EM) 2018) was ensured by following different strategies: (a) credibility
acted as moderator and interviewer, respectively. The main question was pursued by involving nearly all RNs working in the unit and by
asked was—­‘can you please describe your experience of being urgently engaging researchers with adequate knowledge and research skills
and mandatorily transferred to this newly created sub-­intensive care unit (see authors); (b) dependability was ensured by homogeneous ques-
caring for patients with COVID-­19?’—­by encouraging answers and in- tions, prompts and stimuli across all focus groups; (c) confirmability
teractions among participants. In addition, probing questions were was achieved by reporting quotes and a detailed description of their
asked during meetings (e.g. ‘What do you mean?’ and ‘Can you explain source (a path of the entire process is available from the authors
this a little further?’) to clarify the experiences or turn the attention upon request); and (d) transferability was ensured by using a maxi-
back to the main topic. The interview questions were not provided mum variation purposeful sample until data saturation.
in advance to the participants.
All focus groups were conducted in a ventilated, quiet and pri-
vate room in the hospital to ensure confidentiality and facilitate 3.6 | Ethical considerations
the comfort of participants. In addition, all participants adhered to
physical distancing and wearing of face masks throughout the focus The research protocol was approved by the nurse director of the
group discussion to avoid aerosol transmission of COVID-­19. At the hospital and by the chief nurses. According to the Italian regulations
beginning of the discussions, researchers presented the study aims and to the nature of the study, namely qualitative data collection
and collected demographic and professional data (e.g. age, educa- without patients’ involvement, no authorization from the Ethical
tion). Each focus group lasted approximately 60 minutes (range: 50–­ Committee was required. RNs were approached and asked to par-
75 minutes). ticipate in the study on a voluntary basis; moreover, at the beginning
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4       DANIELIS et al.

of each focus group, participants’ written consent to study participa- TA B L E 1   Participants’ characteristics
tion was collected. In addition, RNs were also free to withdraw from
Registered nurses
the study at any time and they did not receive any reward. Privacy, N = 24
rights and confidentiality of participants were ensured throughout
Gender, n (%)
each phase of the study by anonymizing the focus group narra-
Female 17 (70.8)
tive. This study was conducted according to the criteria set by the
Age, years, mean (SD) 34.1 (6.7)
Declaration of Helsinki.
Education, n (%)
Nursing diploma 2 (8.3)

4 |   R E S U LT S Bachelor's degree 3 (12.5)

Advanced educationa  19 (79.2)

The study included 24 RNs, mostly females (70.8%; n = 17), with Working hours/week, n (%)
an average age of 34.1 years. As reported in Table 1, the majority >30 22 (91.7)
were educated at the university level (79.2%; n = 19), and over 90% Working experience, years, mean (SD) 9.3 (6.8)
were working full-­time. Participants reported on average 9.3 years Working unit before the current experience, n (%)
of work experience as a nurse; the majority of them were working Medical 10 (41.7)
in medical (41.7%; n = 10) and acute care settings (33.3%; n = 8)
Acute 8 (33.3)
just before starting the experience in the sub-­intensive care unit for
Surgical 3 (12.5)
COVID-­19 patients.
Chronic 3 (12.5)
The experience of being urgently and mandatorily transferred to
a newly established unit is expressed by three themes: (a) ‘becoming SD, standard deviation.
a
For example. master's degree
a frontline nurse’, (b) ‘living a double-­faced professional experience’
and (c) ‘advancing in nursing practice’ (Table 2).
the treatment protocols…there were things we had to learn by ourselves’
(RN6). However, given that all nurses were newcomers and unpre-
4.1 | Becoming a frontline nurse pared and no experts were available, the occasions for supervision
were limited.
Nurses transferred urgently to the new unit felt themselves as called
to the frontline. Due to the great challenge that they had in front of
them and the urgency of the call not giving them the time required 4.2 | Living a double-­faced professional experience
to be prepared both personally and professionally, nurses felt mixed
emotions and a sense of unpreparedness. In overcoming the first impact of being urgently transferred, nurses
Specifically, the mixed emotions were reported as emerging in began to live a double-­faced experience, where on the one side they
the early stage of the urgent recruitment. While some participants experienced an ever-­desired nursing care, and on the other, they suf-
reported being frightened by the unknown—­‘Fear lies in not know- fered breakdowns in the care processes never experienced before.
ing the danger’ (RN2)—­others experienced a lack of information and Nurses rapidly changed their patterns of care according to the
preparedness—­‘I was called in one afternoon for a night shift in the in- optimal conditions created by nurse managers where the amount
fectious disease unit, and after one hour I was told to come here [the of staff and the skill mix were appropriate: ‘Having less patients to
sub-­intensive care unit] for the following day’ (RN4). This experience care for, thus, a fair nurse-­to-­patient ratio, guarantees a relationship
triggered a widespread sense of inadequacy: ‘I immediately felt inade- with the patient’ (RN21). Paradoxically, they reported implementing
quate and even unqualified due to my previous professional experiences’ a primary nursing model of care for the first time ‘being able to en-
(RN20). sure a 360° of care, broaden social skills and timing (RN20)’, because in
As a consequence, most of the nurses perceived unpreparedness daily care, this was prevented by the unfavourable nurse-­to-­patient
to practically respond to the call. As described in Table 2, a partic- ratio. According to their experience, nurses focused their priorities
ipant complained that (s)he was not ready in time to be on duty, as on (a) spending time in therapeutic relationships by helping patients
there was just not enough information: ‘I was called in at 7 p.m. to to cope and stay relaxed: ‘the shared stories, staying together to listen
come at 9 with no information whatsoever’ (RN11). In addition, as the to them, to keep them calm’ (RN12); (b) implementing new strategies
health care professionals caring for COVID-­19 patients had to pro- of communication by using mobile phones, tablets and computers,
tect themselves and other patients from contagion, nurses tried to thus preventing a sense of loneliness in patients—­‘the video call with
do their best to gain clearly defined pathways: ‘We tried to create the a tablet…knowing that you can communicate with a family member’
dirty/clean pathways with tape, but we didn’t know if we were doing it (RN13)—­given the perceived need for support; and (c) improving pa-
correctly’ (RN12). Some nurses recognized their own skill limitations tients’ physical residual abilities, as in the case of eating and drinking:
and the need for supervision: ‘As newcomers, we didn’t know the drugs, ‘I encouraged them to recover their independence’ (RN5).
DANIELIS et al.       5|
TA B L E 2   Data synthesis by extracting and abstracting findings in common categories and themes

Abstraction: Codes as defined by Example of quotes extracted from focus Focus groups/
Abstraction: Themes Categories researchers groups registered nurses

Becoming a frontline Feeling mixed Being frightened ‘…fear lies in not knowing the danger’. FG1RN2, FG1RN4,
nurse emotions (FG1RN2) FG2RN10, FG2RN12,
FG3RN13, FG3RN15,
FG 4RN19, FG 4RN21,
FG 4RN22
Living in uncertainty ‘…first, one week at home without knowing FG1RN2, FG1RN4,
where I would go, you don’t know what to FG2RN9, FG2RN12,
expect,…then, I was called in one afternoon FG3RN18, FG 4RN20
for a night shift in infectious diseases and
after one hour I was told to come here the
day after…’ (FG1RN4)
Feeling inadequate ‘…from a professional point of view, I FG1RN1, FG1RN4,
immediately felt inadequate and even FG2RN8, FG3RN16,
unqualified due to previous professional FG3RN17, FG 4RN20
experiences’. (FG 4RN20)
Perceiving Being unready ‘I was called in at 7 p.m. to come at 9 with no FG1RN2, FG1RN6,
unpreparedness information whatsoever’. (FG2RN11) FG2RN7, FG2RN10,
FG2RN11, FG3RN16,
FG 4RN23, FG 4RN24
Trying to do our best ‘We tried to create the dirty/clean pathways FG1RN3, FG1RN5,
with tape, but we didn’t know if we were FG2RN9, FG2RN12,
doing it right’. (FG2RN12) FG3RN19
Being in need of ‘What was also missing was the brainstorming FG1RN1, FG1RN2,
supervision with the other departments involved in this FG1RN6, FG2RN8,
emergency; as newcomers, we didn’t know FG2RN9, FG2RN11,
the medications the treatment protocols… FG2RN12, FG3RN13,
there were things we had to learn by FG3RN15, FG3RN18,
ourselves. In other words, positive feedback FG 4RN19, FG 4RN20,
and constant updates were lacking’. (FG1RN6) FG 4RN22, FG 4RN23
Living a double-­faced Experiencing ever-­ Caring for the right ‘Having fewer patients to care for, thus, a fair FG1RN5, FG2RN9,
of professional desired nursing number of patients nurse-­to-­patient ratio’. (FG 4RN21) FG2RN11, FG3RN18,
experience care FG 4RN21
Experiencing a primary ‘Being able to guarantee a 360° assistance, FG1RN1, FG1RN3,
nursing model of care broaden social skills and timing…trying to FG1RN5, FG2RN7,
redirect a confused patient, being close FG2RN9, FG2RN11,
to a patient with their legs out of bed, FG3RN15, FG3RN16,
shampooing … these were strong points’. FG3RN18, FG 4RN20,
(FG 4RN20) FG 4RN21, FG 4RN23
Perceiving the need for ‘I would have liked more involvement from FG1RN1, FG1RN3,
psychological support a psychological point of view, in this health FG1RN6, FG3RN13,
to patients emergency, against an invisible virus that FG 4RN24
nobody knew and on which there were so
many uncertainties, a greater psychological
involvement for the patients, of course’.
(FG4RN24)
Having time to spend ‘The time we dedicated to them, the shared FG1RN3, FG2RN7,
with patients stories, staying together to listen to them, to FG2RN12, FG3RN17,
keep them calm, things that you cannot do FG 4RN20
elsewhere’. (FG2RN12)
Implementing ‘Another strong point was also the video call FG1RN2, FG1RN6,
innovative with a tablet because some patients are FG2RN7, FG3RN13,
communication disoriented and, while you see people wearing FG3RN16, FG 4RN23,
strategies heavy protections all around you, knowing FG 4RN24
that you can communicate with a family
member, that even the nurse can talk with
them, is extremely useful, something which
should be studied and explored for semi-­
intensive and intensive care units’. (FG3RN13)

(Continues)
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6       DANIELIS et al.

TA B L E 2   (Continued)

Abstraction: Codes as defined by Example of quotes extracted from focus Focus groups/
Abstraction: Themes Categories researchers groups registered nurses

Improving patients’ ‘In some instances, I encouraged the patients FG1RN5, FG2RN9,
physical residual to do things by themselves…it comes natural FG2RN11, FG3RN18,
ability to me…and I encouraged them to recover FG 4RN21
their independence’. (FG1RN5)
Suffering Coping with the new ‘The use of nursing documentation is FG1RN4, FG2RN7,
breakdowns in documentation fundamental and arriving in a ward where no FG2RN11, FG 4RN19,
care processes system one had ever seen that documentation was a FG 4RN21
weak point…’ (FG2RN7)
Dealing with some ‘Perhaps the collaboration between nurses and FG1RN2, FG1RN5,
critical issues in doctors and between nurse assistants and FG2RN10, FG3RN16,
collaboration with nurses was challenging; it would have been FG 4RN19, FG 4RN20
other HCPs better to work on it a bit more’. (FG2RN10)
Mixing different habits ‘…the struggle to introduce evidence-­based FG2RN8, FG3RN15,
regarding nursing nursing in a ward, sometimes even if a FG3RN18
practices practice, such as calculating the water
balance, is easily resolvable if an operational
definition for fluid balance is introduced.
There is still a great resistance stemming from
mere habit…’ (FG3RN15)
Advancing in nursing Coping with the Compensating for lack ‘Risks create tension in seeking information… FG1RN1, FG1RN3,
practice challenging of knowledge we are eager to look online…online courses, FG2RN10, FG3RN13,
working scientific articles’. (FG1RN3) FG3RN17, FG 4RN22
environment Experiencing mutual ‘I never felt alone, and there was always FG1RN2, FG1RN4,
support within the someone who, before I asked, asked me if I FG2RN7, FG2RN9,
team needed help. This was the strong point of this FG2RN11, FG3RN14,
group’. (FG2RN9) FG3RN17, FG 4RN20,
FG 4RN21, FG 4RN23,
FG 4RN24
Expanding Having gained new ‘It is easier to say what I have learned, such FG1RN1, FG1RN2,
professional competencies as non-­invasive ventilation devices like FG1RN3, FG1RN5,
nursing role helmets, masks, and high-­flow nasal cannula, FG2RN8, FG2RN10,
on which I was helped by a colleague from FG2RN11, FG2RN12,
Pulmonology… it is easier to learn on the FG3RN13, FG3RN15,
field than at home from books; I have used FG3RN17, FG3RN18,
everything that I have lived and experienced FG 4RN21, FG 4RN23,
over the years. You don’t learn to see the FG 4RN24
emptiness in the patient’s eyes at university
but here’. (FG2RN17)
Expanding decision-­ ‘…another positive thing is that we made FG1RN4, FG1RN6,
making abilities decisions on our own. Here we decided FG2RN8, FG2RN9,
whether to remove PIVCs, NGTs, CVCs, FG2RN10, FG2RN12,
and the doctors trusted us. This constant FG3RN17, FG 4RN19,
exchange should be the future of this FG 4RN20, FG 4RN23
profession; it should be a reality because it is
a growth…’ (FG 4RN23)
Strengthening the ‘Also writing ‘nurse’ and putting the name FG1RN3, FG2RN7,
professional role on the front of the overalls was important. FG2RN9, FG2RN11,
identity Paradoxically, I felt a stronger identity when FG2RN12, FG3RN14,
in disguise than when I was not’. (FG3RN16) FG3RN16, FG 4RN19,
FG 4RN21

HCPs, health care professionals; PIVC, peripheral intravenous catheter; NGT, nasogastric tube; CVC, central venous catheter; FG1RN1, focus group
n.1 registered nurse n.1.

By contrast, nurses suffered from breakdowns in the care pro- as ‘no one had ever seen that documentation’ (RN7). The relationship
cesses never experienced before due to different factors. First of with other health care professionals was also reported as a challenge
all, documenting nursing activities in the new forms was challenging, because of the lack of reciprocal knowledge, trust, confidence and
DANIELIS et al. |
      7

experience as a team: ‘It would have been better to work on it a bit our nurses seem to live this experience alone, as also the well-­known
more’ (RN10). Moreover, some nurses faced variability in the clini- process of socialization (Hunter & Cook, 2018) is not possible: in
cal approaches, requiring efforts in the attempt to establish shared fact, each nurse was a newcomer in the unit, and no formal and/
standards of care: ‘For example, calculating the fluid balance is easily or informal rules, norms or social processes had been established.
resolvable if an operational definition for fluid balance is introduced’ Nurse managers are called to create a team, promote group rules and
(RN15). norms and create a concerted response to the challenge.
Throughout this experience, nurses’ concerns about caring for
COVID-­19 patients were mainly due to the fear of the unknown in-
4.3 | Advancing in nursing practice fectious disease and the sense of unpreparedness. The first issue
was also raised in 2003 with the severe acute respiratory syn-
The complexity of the experience was reported as a great opportu- drome outbreak and in 2006 with the Avian flu (Tzeng & Yin, 2006).
nity to improve nursing practice. First, in the attempt to cope with Furthermore, many nurses expressed inadequacy in caring for pa-
the challenging environment by filling in the gaps in the knowledge, tients affected by an emerging infectious disease, as previously
nurses reported to increase their efforts in self-­directed learning by documented (Ambrosi et al., 2020; Holroyd & McNaught, 2008;
accessing ‘online courses, scientific articles’ (RN3) and by establishing Lam et al., 2020), thus suggesting that these feelings are common
partnerships with their new colleagues with the purpose of help- in times of an outbreak. Concurrently, nurses’ unpreparedness for
ing each other: ‘I never felt alone, and there was always someone who, a viral respiratory pandemic was reported as an existing problem, in
before I asked, asked me if I needed help’ (RN9). As a consequence, line with previous studies on the emerging infectious disease out-
nurses reported to experience the expansion of the professional breaks (Holroyd & McNaught, 2008; Lam et al., 2020). In addition,
nursing role by (a) gaining new competencies, ‘such as non-­invasive due to the unexpected nature of the pandemic, nurses were sud-
ventilation devices like helmets, masks, and high-­flow nasal cannula’ denly introduced to the COVID-­19 unit without appropriate training
(RN17) mainly on an individual basis, given that only distance edu- (Ambrosi et al., 2020). As a consequence, unpreparedness further in-
cational practices were allowed; (b) increasing their decision-­making creased concerns and uncertainties among nurses in the early phase
abilities—­‘We made decisions on our own; here we decided whether to of recruitment.
remove devices’ (RN23)—­thus increasing their professional independ- After this first stage of experience, where emotional issues
ence; and (c) strengthening the professional role identity—­‘I felt a prevailed, participants reported to have had the great opportunity
stronger identity when in disguise than when I was not’ (RN16)—­thus to function as ‘full nurses’, because they were immersed in such
advancing the status of nursing. a context where a proper number of resources in terms of nurse-­
to-­patient ratio allowed them to implement the desired care. This
finding constitutes a novelty as compared to the available literature.
5 | D I S CU S S I O N First, once the appropriate nurse-­to-­patient ratio was provided, par-
ticipants implemented the primary nursing care model. Then, owing
Every pandemic was reported to have a significant impact on em- to the severity of the illness and the complexity of the clinical, psy-
ployment status (Halcomb et al., 2020); however, no evidence on the chological and social needs due to forced isolation (Lucchini et al.,
experience of nurses who had been urgently recruited to a newly es- 2020), nurses also engaged in providing human care by considering
tablished unit has been documented to date. Having evidence on this all fundamental needs. In order to overcome patients’ sense of iso-
phenomenon could provide the means to develop recommendations lation in the absence of family caregivers, nurses reported their en-
for nurse managers who are in charge of human resources manage- gagement in spending time in therapeutic relationships with patients
ment. In this context, we involved a group of experienced nurses and in performing effective video-­calling with family members, as
with diverse clinical background acquired in different units. All of recommended by Negro et al. (2020). Along this line, nurses seem
them were newcomers to the settings, the unknown patients’ clinical to have experienced a unique condition whereby it could be possi-
issues, and also the nurse manager and staff. They lived a totally new ble to prevent missed nursing care (Longhini et al., 2020), typically
personal and professional experience characterized by three main regarding emotional support and basic care needs required by both
themes: ‘becoming a frontline nurse’, ‘living a double-­faced profes- patients and families.
sional experience’ and ‘advancing in nursing practice’. In contrast, the newly created team in the new unit caused some
Practising on the frontline means that nurses perceived an enemy breakdowns in the care processes: in using the new documenta-
that they are called to fight. In describing the pandemic, words re- tion which triggered difficulties, in meeting the need to build the
lated to ‘war’ as concept and practice have been extensively used team by overcoming communication issues and in establishing ap-
(e.g. Liu et al., 2020) but also recently questioned (Varma, 2020) be- propriate care standards while dealing with the variability in clinical
cause the pandemic–­war analogy has been considered both danger- approaches. All these aspects could be explained by the fact that
ous and wrong. While pandemics require collective, concerted and the new unit was created in a short time and that all members of
coordinated responses, wars divide people. From their point of view, staff were new and had different backgrounds. Therefore, it seems
 |
8       DANIELIS et al.

that nurses experienced issues in those aspects that are usually well 6 | CO N C LU S I O N S
established in the units, such as the documentation processes, the
communication among team members and the standard of care. In Considering the current and ongoing situation of the COVID-­19
other words, they experienced an in-­depth break in routine rules and pandemic and the reality of mandatory redeployment of nurses to
actions (Rytterstrom, Unosson, & Arman, 2011). Within this frame- areas providing acute care to this group of patients, having data
work, nurse managers can have a great responsibility to establish, on their lived experience might support nurse managers in their
develop and support meaningful routines (Rytterstrom et al., 2011). decision-­
making processes. Nurses who lived the experience of
Moreover, establishing a technical support team and preparing train- being mandatorily recruited and urgently reallocated to a COVID-­19
ing plans to meet all requirements could be helpful strategies when unit reported a mix of negative feelings in the early stages. Then,
setting up new COVID-­19 units in order to maintain a high standard they experienced a double-­faced situation as they merged positive
of care (Wu et al., 2020). and negative experiences which were triggered by the opportunity
In the face of various challenges, at the end of the experience, to implement the primary care model, mainly due to the appropriate
participants reported a global growth at (a) individual level, where nurse-­to-­patient ratio, while the absence of routines and rules in
they experienced the full responsibility of being a self-­
directed the unit capable of ensuring a sense of security, all increase the dif-
learner; (b) team level, where reciprocal solidarity and support in- ficulty. At the end of the experience, nurses reached a point where
creased the overall capacity of the group; and (c) professional level, they experienced global growth as a person, as a team and as a
where the nursing role was expanded. In spite of coming from differ- professional.
ent clinical backgrounds, nurses worked in multidisciplinary teams
centred on collaborative care, which is considered a crucial approach
to enhance patient outcomes, especially in pandemics (Fernandez 7 | I M PLI C ATI O N S FO R N U R S I N G
et al., 2020). Moreover, the bedside nurses caring for COVID-­19 pa- M A N AG E M E NT
tients felt boosted in their professional role and identity, in line with
a previous study that reported Chinese nurses' narratives of caring Nurse managers have a key role in actively supporting nurses before,
for severe acute respiratory syndrome patients (Liu & Liehr, 2009). during and after the pandemic outbreak. In particular, proper com-
Similarly, as reported in our study, nurses’ beliefs about professional munication, training and adequate resources seem to be mandatory
growth were consistent with the study by Corley et al. (2010), par- to prevent nurses’ concerns and fears in the initial stages. Moreover,
ticularly in terms of acquired skills (e.g. airway management). All of in preparing for the second wave, or in future outbreaks, identifying
these growth processes reflect the great ability to adapt to a new and preparing expert nurses on a voluntary basis in advance, by of-
situation and to cope with resilience. In other words, nurses’ shift fering them simulation sessions, can prevent concerns as well as the
from negative feelings to positive outcomes leads to the idea that sense of unpreparedness that might affect self-­confidence, increas-
they experienced post-­traumatic growth, as recently documented ing moral distress and frustration.
(Cui et al., 2020). The adequate amount of staff provided in the newly established
unit allowed nurses to rediscover some elements of fundamental
care and to implement the primary care model. Caring for COVID-­19
5.1 | Study limitations patients turned out to also be an opportunity for improving team
working and collaboration. Creating opportunities where nurses can
Some limitations of this study need to be acknowledged. First, we share these experiences might help them to give meaning and to in-
involved nurses caring for COVID-­19 patients in a sub-­intensive crease confidence in nurses not involved in the first wave, as, for
care context, which was only a part of the entire hospital undergo- example, students. However, the value attributed to the nursing care
ing a full restructuring. Therefore, in the future, it is advisable to and to the appropriate amount of nursing resources at the bedside
involve different settings of care. Moreover, we involved only ex- during the pandemic should be promoted and continued by nurse
pert nurses (with > 9 years of experience) suggesting that it should leaders also over the outbreak while returning to normality.
be important to study the experiences of novice nurses as well as Finally, it is imperative to continue to collect precious insights
those of other health care professionals’ mandatory recruited in from nurses’ experiences in order to support innovative actions for
the care of COVID-­19 patients (e.g. medical doctors and physio- future pandemic outbreaks. In addition, this extraordinary situation
therapists). Additionally, the data were collected at the end of May may stimulate new ideas for a systems approach to health care deliv-
2020, during lockdown and when the sub-­intensive care unit was ery, such as enforcing technological innovation, decentralizing ser-
near to its close. Therefore, the narratives might be influenced by vices in a range of settings (e.g. community health programmes) or
the short duration of the experience and by its imminent ending. considering to make available temporary wards with dedicated staff
Collecting longitudinal data in different time points from these that can be easily recruited in the case of a health emergency.
nurses—­and from others involved in the second wave of COVID-­19
with longer working involvement—­could help in understanding the AC K N OW L E D G E M E N T
entire experience. The researchers are grateful to all the participating nurses.
DANIELIS et al. |
      9

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