Since the onset of the COVID-19 pandemic, perinatal nurses have faced unprecedented challenges caring for childbearing families. Nurses experienced multiple obstacles to providing patient-centered care due to poor understanding of COVID-19 and precautions designed to reduce viral transmission, particularly at the beginning of the pandemic. In some cases, hospital policies led to traumatic experiences for childbearing people and their families. For example, some hospitals prohibited visitors from entering the hospital as a measure to prevent transmission of COVID-19 (Arora et al., 2020; Van Syckle & Caron, 2020). These restrictions prevented family members, doulas, and others from providing support to childbearing people in perinatal units, at times leaving them alone except for clinicians employed by the hospital where they were giving birth (Mayopoulos et al., 2021). Further trauma was experienced by many childbearing people who were separated from their infant after birth due to concerns about transmission of COVID-19 (Bartick, 2020). As late as November 2020, guidance from health care organizations on whether to separate mothers with suspected or confirmed COVID-19 from their newborns was conflicting (Centers for Disease Control and Prevention, 2020; Perrine et al., 2020).
Visitor restrictions and separation of mothers from their infants are contrary to evidence-based care provided by perinatal nurses, whose practice is based on patient-centered guidelines promoting skin-to-skin bonding, early and exclusive breastfeeding, and labor and postpartum support by family members, friends, and doulas (Association of Women's Health, Obstetric, and Neonatal Nurses [AWHONN], 2016, 2018, 2021). Evidence suggests that inability to provide high-quality, patient-centered care during the COVID-19 pandemic has generated ethical challenges and moral distress (Brown et al., 2022) as well as burnout and intention to leave the nursing profession (George et al., 2021).
Researchers have found self-care such as self-compassion, mindfulness (Delaney, 2018), and stress management (Adimando, 2018) can address burnout and the stress of caring for patients experiencing traumatic events. Compassion satisfaction, which is the positive effect of caring for other people, is another countermeasure to stress and burnout (Sacco & Copel, 2018). Before the COVID-19 pandemic, perinatal nurses were found to have moderate-to-high levels of compassion satisfaction (Mashego et al., 2016); however, the effect of the COVID-19 pandemic on nurses' satisfaction and ability to cope with stress is unknown. Understanding how nurses have coped with the challenges of providing care to childbearing families during the pandemic is critical to informing policy and research that can support the retention of this essential workforce. Therefore, our objective was to explore perinatal nurses' perceived challenges, job satisfiers, and self-care as part of a larger study on professional quality of life among U.S. perinatal nurses providing direct care during the COVID-19 pandemic.
Study Design and Methods
Data for this content analysis were derived from a survey disseminated in May of 2021 to perinatal nurses providing direct patient care in U.S. hospitals. Eligible participants were licensed as a registered nurse in the United States, 18 years or older, able to read and write in English, and provided direct patient care on a perinatal unit (i.e., antepartum, labor and delivery, postpartum, neonatal intensive care). Respondents were eligible to complete the survey if they responded to a screening question stating they had provided direct patient care at any time since the onset of the COVID-19 pandemic in March of 2020. The survey was created in Qualtrics and included an informed consent, and the opportunity to be entered into a raffle to receive a $50 Amazon gift card as an incentive for participation. Respondents were recruited by email to a list of 5,384 AWHONN members filtered to select only nurses whose majority of time was spent providing direct patient care in a U.S. hospital perinatal unit. Respondents were also recruited via an electronic newsletter and online member forum of the National Association of Neonatal Nurses (NANN). The study was determined to be exempt by the Towson University institutional review board. The survey included questions about respondent demographics and characteristics of the unit and hospital where respondents were employed. We asked three open-ended questions to explore nurses' perceived challenges, job satisfiers, and self-care.
Demographic data were analyzed descriptively using Stata/IC 17. Qualitative data were analyzed in Excel using an iterative process of content analysis using a content-analytical summary table (Miles et al., 2018). All qualitative responses were downloaded into an Excel spreadsheet. Using an inductive process, a research assistant read each entry line by line and identified initial codes. Two nurse scientists independently reviewed all entries line by line, consolidated the codes, and tracked their agreement with the coding. Codes were discussed with the team until consensus was achieved. Responses could be assigned more than one code because some respondents wrote several sentences that included multiple topics. Descriptive statistics were used to calculate the frequency of codes.
Results
Of the emails sent to 5,384 AWHONN members, 3,819 (70.9%) opened the email and 388 (7.2%) participants began the survey. Responses from 80 participants were excluded either because consent had not been completed or 60% or more of the survey was incomplete. Of 308 respondents to the larger survey study on professional quality of life, 297 (96.4%) responded to one or more open-ended questions (Table 1). Mean age of respondents was 44 years (SD 11.58). Most identified as female (n = 291, 97.98%), White (n = 238, 80.13%), had a Bachelor's degree or higher education (n = 274, 92.2%), and had 16 or more years of nursing experience (n = 144, 48.48%). The majority worked as staff nurses (n = 171, 57.58%) on antepartum, labor and delivery, or LDRP units (n = 214, 72.05%). Over half of respondents (n = 171, 57.58%) reported working overtime. Ninety percent (n = 268) of respondents were AWHONN members and nearly 8% were NANN members (n = 23). Table 2 presents codes identified from responses to open-ended question about challenges, job satisfiers, and self-care. Table 3 provides additional descriptions of codes.
Challenges
We identified seven codes from 295 respondents who answered the question about the most challenging aspects of caring for patients during the COVID-19 pandemic. The codes in descending order of frequency were: changing guidelines, policies, and protocols; personal protective equipment (PPE) as a barrier to communication; visitor restrictions; fear of infecting self or family; lack of resources; administrative decisions and lack of support; and poor compliance with COVID-19 policies.
Changing Guidelines, Policies, and Protocols. One-third (n = 101, 34%) of respondents described frequently changing guidelines, policies, and protocols, particularly when COVID-19 was poorly understood at the beginning of the pandemic. Frequently changing policies were those addressing visitor restrictions, PPE requirements, documentation, COVID testing, and how to handle newborns of mothers with confirmed COVID-19. Some respondents reported changes occurred on a daily basis and others described weekly changes. One respondent stated, The evidence was not there or changed constantly. Trying to keep up with that (part of my job) was exhausting. Another participant described a reduction in the frequency of changes since the beginning of the pandemic, I could not keep up with all the changes in the beginning! It is better now.
Personal Protective Equipment as a Barrier to Communication. One-quarter (n = 73, 24.6%) of respondents reported continuous use of PPE, particularly masks, as a barrier to connecting and communicating with patients. One respondent described the emotional barrier as a feeling of disconnection. The mask 'separates' you from your patient, making it harder to develop a connection. Another respondent reported, Masks make it impossible to simply smile at your patient. A respondent described difficulty communicating, Due to the mask communication is sometimes misinterpreted between providers and nurse and patients.
Visitor Restrictions. Over one-fifth (n = 64, 21.5%) of respondents described visitor restrictions as a challenge. Nurses were concerned about the effect of visitor restrictions on their patients' mental health. One respondent described, watching new mothers go through the life changing experience of delivering a child without their desired support system by their side...I worry for the mental health of my patients. Some respondents described the difficulty of taking on more responsibility for labor support. One respondent described meeting increased need for continuous bedside labor support that is usually provided by a patient's designated support person. Another respondent was concerned about the ability of the chosen visitor to provide support, Sometimes their spouse or partner is not the best emotional support and they would benefit greatly from a doula or someone like their mom also being there.
Fear of Infecting Self or Family. Eighteen percent of respondents (n = 54) feared infecting themselves or their family members with COVID-19. Many nurses noted this as a concern particularly at the beginning of the pandemic. One respondent reported, I didn't feel safe toward the beginning of the pandemic. My outlook has improved greatly since I was vaccinated.
Lack of Resources. Fourteen percent (n = 43) of respondents reported lack of resources such as PPE and staffing. One respondent stated, In the beginning, not having access to PPE and not being able to feel protected against COVID patients. Another respondent described how poor work conditions resulted in lower quality care, The expectation of doing more with less has been very overwhelming. It has been difficult to work very short-staffed and to be expected to care for 6-8 patients at a time, including in the COVID units. Patients are not getting the appropriate care they need and deserve.
Administrative Decisions and Lack of Support. Nearly 12% (n = 35) of respondents reported distrust in decisions about COVID-19 protocols and felt a lack of support from administrators. Some respondents reported administrative decisions were inconsistent and jeopardized nurse safety. One respondent reported, We were initially threatened with unpaid leave if we wore face masks at work. Days later, we were threatened with being fired if we didn't wear masks. Later, the institution attempted to compel us to wear recycled masks (many with stains on them). A commonly reported challenge was floating to other units. A respondent stated, the most challenging and distressing part of my job is floating to other units to help when they are short. Not being familiar with other floors and their nursing practice.
Poor Compliance with COVID-19 Policies. Eight percent (n = 25) of respondents reported noncompliance with policies by patients, visitors, and sometimes coworkers. One respondent described this frustration, People who just blatantly refuse to acknowledge that we're in a pandemic - refuse to wear masks, take a test, and complain about everything.
Job Satisfiers
We identified five codes from the 289 responses about the most satisfying aspects of caring for patients during the COVID-19 pandemic. The codes in order of descending frequency were providing high-quality care, visitor restrictions, business as usual, teamwork, and appreciation of health care workers. Of note, nearly 3% (n = 8) of respondents reported having no job satisfiers.
Providing High-Quality Care. Nearly half (n = 137, 46.1%) of respondents reported being satisfied by providing exceptional care that resulted in positive outcomes. One respondent reported, I am happy to still bring a positive experience to them when they arrive anticipating it will be a stressful situation because of all the restrictions and masks, etc. When I am still able to make it a great labor and delivery for them, I'm fulfilled in my job. Respondents valued their role as advocates for vaccination, described by one respondent as educating patients regarding the latest on COVID-19 itself, the latest available treatments and the vaccine information. Often patients get their information off of social media and it is very satisfying to talk to them regarding scientific research and data from valid medical journals when they are receptive to learning.
Visitor Restrictions. Over one-quarter (n = 77, 25.9%) of respondents were satisfied with pandemic-related visitor restrictions because they felt they were able to establish a stronger rapport with patients and had greater ability to provide patient education because of fewer interruptions. One respondent reported, I feel like I have more time with my patients, time to go over education, and I feel the new families I care for have more time to rest and retain information. Another respondent described improved parent bonding with the newborn and increased breastfeeding rates due to a lack of interruptions from visitors. Respondents noted that patients had more opportunity to rest and were able to avoid challenging family dynamics. Increased patient autonomy was also observed, described by one respondent as patients being better able to openly communicate with limited visitors. Patients (were) able to speak up more.
Business as Usual. Nine percent (n = 27) of respondents were satisfied with continuing to provide nursing care during the pandemic. One respondent shared, I feel like it is a privilege to continue to work and care for people during the pandemic. People think of us as superheroes when we are only doing what we love to do. Some respondents described feeling unaffected by the pandemic due to the low number of patients infected with COVID-19 on their unit.
Teamwork. Five percent (n = 16) of respondents described strong nursing teamwork, explained by one respondent as More caring for each other because we are going through an unknown situation together. I have learned how to appreciate different specialties. Collaboration with nurses from other specialties was also noted as a satisfier. One respondent reported, Team work with med-surg, and critical care nurses made a great difference...I can't thank my fellow med surg educators (enough) for supporting me so I could support my nurses.
Appreciation of Health Care Workers. Nearly 5% (n = 14) of respondents described feeling highly valued as a health care worker by members of their community. One respondent shared, Individual patients seem more appreciative towards nursing and health care staff in the hospital.
Self-Care
We identified five codes from 289 responses about self-care. The codes in order of descending frequency were mental health, physical health, no self-care, religion and spirituality, and self-indulgence.
Mental Care. About half of respondents (n = 152, 51.2%) reported focusing on mental health. Strategies included therapy or psychiatric medication, self-help groups, employee assistance, meditating, hobbies, and limiting exposure to news and social media. Many respondents reduced their work hours, avoided overtime, and took mental health days. One respondent reported, Not overworking to fill the gap in my unit, taking more time to rest at home, learning to have boundaries between work and family life. Another respondent described using a resource offered by her hospital, The hospital has set up areas for relaxation that are nice, but I rarely have time to use them.
Physical Care. About half of respondents (n = 145, 48.8%) reported self-care focused on physical health. This included resting and sleeping more during days off from work, exercising, eating nutritious food, taking supplements, enjoying the outdoors, and alternative therapy such as yoga or acupuncture. One respondent reported, I have incorporated a healthier diet and also added in more exercise because I need all the energy I can get to be 100% for my patients.
No Self-Care. Nearly 13% (n = 38) of respondents stated they were not using any self-care strategies. One respondent reported a feeling of hopelessness, There has been almost zero self-care. Work demands more and more. Being denied PTO due to mass numbers of nurses quitting. Had to call a therapist today because I cry every day that I have to work.
Religion and Spirituality. Approximately 9% (n = 26) of respondents reported engaging in religious and spiritual practices. One respondent reported having increased faith that God will either protect me or use it to teach me to depend more on Him and another described reading self-help books about spirituality and manifestation.
Self-Indulgence. Ten percent (n = 30) of respondents described consuming alcohol or food, over sleeping, shopping, taking long baths, and getting manicures and pedicures. One respondent described drinking more wine (sad face emoji) and another reported sleeping all the time, spending money I don't have.
Clinical Implications
Challenges identified in this study, such as frequently changing guidelines and lack of available PPE, were unique to the COVID-19 pandemic. Other challenges, such as inadequate nurse staffing and poor practice environments, were well-documented issues prior to the COVID-19 pandemic (American Nurses Association, 2015). Our findings also provide insights about job satisfiers and self-care, which are protective against secondary traumatic stress and burnout (Sacco & Copel, 2018).
One clinical implication of our findings was that communication of consistent, evidence-based guidelines is essential to providing high-quality care. Our findings that frequent changes in policies, guidelines, and protocols led to feelings of psychological distress among labor and delivery nurses are consistent with George et al. (2021). In a study about maternal care professionals' perspectives on challenges during the COVID-19 pandemic, Brown et al. (2022) found that moral distress resulted from inability to provide high-quality care, which is supported by our results. Encouragingly, our respondents reported a decrease in frequency of practice changes over time as understanding of viral transmission and the effects of COVID-19 in pregnancy are better understood.
Personal protective equipment and adequate unit staffing are critical to protecting perinatal nurses and ensuring safe patient care. Lack of available PPE during the pandemic has been identified as a specific stressor for labor and delivery nurses (Brown et al., 2022; George et al., 2021) and obstetricians and gynecologists (Riggan et al., 2021). Our respondents reported that PPE was more available later in the pandemic; however, they did not describe a concurrent improvement in nurse staffing. Before the pandemic, research examining nurses' perceptions of adherence to AWHONN staffing guidelines suggested most labor and delivery units were compliant with guidelines (Simpson et al., 2019). Future research is needed to investigate adherence to recently published nurse staffing standards (AWHONN, 2022) to determine the effect of the COVID-19 pandemic and the national nursing shortage on nurse staffing in perinatal units.
Despite the challenges of providing care within the context of the COVID-19 pandemic, nearly all respondents identified one or more job satisfiers. This finding is encouraging because feeling satisfied by caring for others, also referred to as compassion satisfaction, protects nurses against burnout and the stress of caring for patients experiencing traumatic events (Sacco & Copel, 2018). The most frequently reported job satisfier was the ability to provide high-quality care. Respondents described appreciating the ability to spend extra time and effort to ensure minimal disruption to the birth experience. Although some evidence suggests compensation is the leading factor in retaining nurses (Senior, 2021), our results indicate that nurses are primarily focused on achieving optimal patient outcomes.
The vast majority of respondents identified one or more strategies for self-care; however, most strategies were implemented outside of the work setting. Although many respondents reported taking time off from work and avoiding overtime in open-ended responses, more than half of the respondents reported working overtime when specifically asked about this practice. Future research is needed to identify self-care perinatal nurses can implement at work, such as respite rooms; yet, the challenge remains of providing adequate space and time (Gregory, 2021).
Our finding that visitor restrictions were reported as both a leading challenge and a leading satisfier suggests perinatal nurses have mixed feelings about visitor restrictions. In a survey of childbearing women and labor and delivery nurses, Elling et al. (2022) also found that respondents reported mixed feelings about visitor restrictions. Positive reports were consistent with our findings that visitor restrictions were associated with higher quality care, better patient education, increased rest, and decreased family strain. The only negative outcome reported by Elling et al. was that visitor restrictions resulted in lack of support from family members. Respondents in our study described expending additional effort to support patients when there were limited visitors. Future research could identify strategies to engage visitors as support people.
Limitations
One limitation of our study is that respondents were asked open-ended questions with no opportunity for researchers to follow-up on responses. Response bias is a potential limitation that could have led respondents to respond more favorably to questions, particularly about job satisfiers and self-care. Our sample lacked racial and ethnic diversity which may have led to the omission of perspectives from different racial groups. Respondents were members of their professional nursing specialty associations and likely represented a group that is more engaged professionally.
Conclusion
Our study highlights challenges that were unique to providing patient care within the context of the COVID-19 pandemic, including frequently changing guidelines and lack of PPE. Despite the challenges of caring for childbearing people during the pandemic, perinatal nurses remained satisfied with some aspects of their work. Most respondents reported engaging in one or more types of self-care outside of the work setting. Future research is needed to examine strategies for self-care while at work in the hospital setting.
Acknowledgment
This study was supported by the Towson University College of Health Professions' dean's office and Summer Undergraduate Research Institute. The authors would like to thank Carrie Price, Research Impact and Health Professions Librarian at Towson University, for assisting with searching the literature.
CLINICAL IMPLICATIONS
* Communication of clear, consistent, evidence-based guidelines is essential to providing high-quality patient care.
* Provision of resources such as PPE and adequate nurse staffing is crucial to protecting perinatal nurses and ensuring safe patient care.
* Supporting perinatal nurses' ability to provide high-quality care is a potential strategy to increase job satisfaction.
* Future research is needed to identify self-care practices that perinatal nurses can implement while at work.
* Future research is needed to identify strategies to include visitors as supportive members of the labor and postpartum teams.
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References