Theme 1. Participants expressed experiences of factors related to physical exhaustion.
During the interviews, some professional nurses narrated experiences related to physical exhaustion at the hospital in the Northwest Province. This broad theme culminated in increased workload as a sub-theme. The sub-sub themes emerged are clarified in the following section:
Sub-theme 1.1: Increased workload
Increased workload emerged as a sub-theme with the following sub-sub themes identified:
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Reduced numbers of professional nurses on any shift
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Nurses had to forfeit days-off thus working long hours and many days.
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Lack of rest led to compromised physical health.
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Orientation and supervision of inexperienced relief nurses was negatively affected.
Sub-sub theme 1.1.1: Reduced numbers of professional nurses at any shift
Through probing, professional nurses reported reduced numbers of professional nurses during any shift. This was reported by different nurses as follows:
“Those that could come for overtime maybe you know, they could! But you would start a day with a shortages of normal staff, 3 short from the shift and then you just have to take it because you will call people to come for overtime but people feared coming to work on your normal shift so imagine now calling them for overtime and they have now more fear of just no I will be exposed to that thing and, and, and … No! I’m not coming! So, we tried to call other professional nurses for overtime to come and help but it was difficult” (Participant H).
“They have now opened a new ward and there is no staff. Antenatal was not there before Covid so it’s a new ward, so we were using ward 6 (Labour ward) neh combined with gyene. So, now they have taken Ante Natal Care (ANC) aside (Participant L).
“People (Professional nurses) were resigning, they couldn’t handle the stress, and they couldn’t handle the workload in the hospital. It was really tough!” (Participant B).
“During that time of Covid-19 we had the contract employees so now they are terminated we [are] still struggling as we are speaking now, I have come for overtime to backup one of my colleagues which is having 27 patients so if maybe I didn’t come to back her up which means she was supposed to have been working alone looking after those 27 patients.” (Participant L)
Professional nurses in this study regaled that although people were hired during Covid-19, they still experienced reduced numbers of professional nurses on any shift. This was a result of nurses resigning and going on pension due to fear of Covid-19 infection, hence the shortage. Similar research findings demonstrated that most nurses in the Northwest Province of South Africa resigned due to increased workload in the advent of Covid-19 [11]. This contributed to reduced numbers of professional nurses on any shift. The South African health care system was also faced with a high number of patients admitted in hospitals generally, overwhelming health institutions in all the provinces [2]. In addition, one USA study also reported an increase in nursing workload due to the high number of patients in their study [5]. Therefore, nurses who remained on duty after resignations, deaths, retirement and quarantine literally experienced unbearable workload during Covid-19 [11].
Sub-subtheme 1.1.2: Nurses had to forfeit days-off thus working long hours and many days.
During the discussion, professional nurses reported that they had to forfeit days-off thus working long hours and many days:
“Our hours of rest were limited because we had to help, so we were working more hours than expected and then really it was tiring for us” (Participant C).
“But it was like hard for us because we were not getting enough rest but were …. Because we were trying to cover up. There was nothing we could do” (Participant A).
“We (professional nurses) had to really really stretch because absenteeism was high” (Participant B)
“We were always on overtime because there was a shortage especially for our unit” (Participant C)
This study confirmed that professional nurses had to forfeit days-off thus working long hours and many days due to high absenteeism. This was because professional nurses were trying to manage the crisis as there was nothing else, they could do. This led to nurses always being on overtime and tired. Similar to a study conducted in America, this study confirmed many nurses struggled with long hours and inadequate staffing [14]. In addition, one Zambian study also found that nurses and midwives had a heavier workload and worked longer hours than usual. As a result, they had higher chances of direct contact with Covid-19 patients [9].
Sub-subtheme 1.1.3: Lack of rest led to physical health being compromised.
During the interview, professional nurses reported that a lack of rest led to compromised physical health:
“Oh my god! That one eh! Even our legs are painful eh! Like yeah!” (Participant A).
“I think the abseentism! People end up exhausted and they absent themselves from work and they request leave; others take sick leave because they say they are afraid of Covid, neh” (Participant G).
“So, we have to stretch ourselves, where you found yourself being a professional nurse working 7 days 12 hours a day, neh, not even going on rest because other people were isolated because they contracted, and they were diagnosed with Covid” (Participant F).
“If you are sick or not feeling well you had to do it on your own time and then on top of it if you are sick; being lethargic from overworking or having signs of being affected by something” (Participant E)
Professional nurses in this study expressed physical exhaustion and painful legs due to lack of rest, attributed to excessive absenteeism, unplanned leave and sick leave. These findings are corroborated in a study conducted in the USA which established that nurse reported exhaustion when providing care and performing invasive interventions9.
Sub-subtheme 1.1.4: Orientation and supervision of inexperienced relief nurses
During the interview, professional nurses reported severe constraints in the orientation and supervision of inexperienced relief nurses. This was reported as follows:
“Remember I said some when you come for overtime the group that is on duty, neh, then it was the contractors, so it was you have to stretch, neh! You stretch yourself for the patients’ sake and you must teach the contractors. It was not the same!” (Participant F)
“So, in our shift we probably had like 12 staff workers with 5 professional nurses and the rest would be junior nurses and not everyone is actually trained to care for that number of patients because not everyone has the experience and knowledge for that” (Participant J)
“… And it was difficult, neh, some of them were not experienced. They were qualified but they were not working. After qualifying as nurses, they were not employed in any facility, so they were straight from home, neh, and some saying it’s been 5 years, it’s been 2 years that I was at home without being employed. And so, people were sick by then, so it was you having to teach all those nurses. The contract nurses and the patient also here when they needed your attention. So, it was both, the new nurses and the patients who needed your attention” (Participant F)
“Noooo! The extra staff that we had was only [a] few nurses and they were juniors, and they were expected to work under supervision which they didn’t get due to shortage, so they just had to flow” (Participant B).
In this study, it was identified that relief nurses did not have experience and knowledge of working in a specialized unit such as ICU during Covid-19. On the other hand, some nurses lacked training in operating equipment such as ventilator for Covid-19 patients. As a result, nurses had to take on an extra workload in supervising inexperienced relief nurses during Covid-19. This finding confirms the results of a study conducted in America on the experiences of nurses providing care for patients with Covid-19. In the aforesaid study, it emerged that some nurses did not know how to operate mechanical ventilators due to the limited skill in Intensive Care Unit [5]. These findings suggest that support for nurses providing care to patients during the outbreak of Covid 19 should be strengthened [5].
Theme 2: Participants reported experiences of factors related to emotional pain.
During the interview professional nurses reported experiences of factors related to emotional pain and the loss of loved ones through death as a sub-theme.
Sub-theme 2.1: Loss of loved ones through death
Loss of loved ones through death emerged from the above theme, then gave birth to the following four sub-sub themes:
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Pain of losing colleagues, family members and friends
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Shortage and loss were emotionally traumatising.
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Unable to cope and anticipation of the worst to happen.
Sub-sub theme 2.1.1: Pain of losing colleagues, family members and friends.
Professional nurses reported that it was painful to lose colleagues, family members and friends during the interview as follows:
“…. But ey! It was really painful because I even lost one of my friends. The one I was working with night duty.” (Participant A).
“Oh my God! (Taking a deep sigh). Yoh! But it was not easy (sad). You know it was not easy for us, you know losing a colleague it’s like losing one of your family members because we are very close, we are working together that interpersonal relationship we used to have you know it was not easy to be honest.it was not easy.” (Participant A).
“Also, we lost some of our staff members, it was so painful to be honest (Participant A)
“We were not only affected by the number of patients, but we also lost staff members as well and we were losing family members” (Participant H)
In this study, nurses expressed emotional pain due to loss of colleagues. As a consequence of the close working relationship, some nurses described the painful loss of colleagues as similar to losing a family member or a friend. The study conducted on the nurses as the frontline against Covid-19, reported that nurses experienced emotional trauma when nursing Covid-19 patients [7, 15]. In addition, most nurses in the Northwest Province of South Africa resigned due to fear of infection and trauma from Covid-19-related loss of life in the advent of Covid-19 [11]. Furthermore, South Africa reported an increased rate of Covid-19 infection, which resulted in high mortality rate and many health professionals including nurses succumbed to the virus, creating more shortage of nurses [2].
In addition, the study identified that nurses also experienced loss of family members and friends due to Covid-19, resulting also in severe emotional trauma. These findings corroborate those of a survey conducted in Italy regarding the Covid-19 pandemic where 54.4% of professional nurses complained of emotional stress due to the loss of life attributed to the Covid-19 pandemic [4]. Furthermore, out of the 54.4% nurses who lost their lives, some were Covid-19 contacts to patients and colleagues, hence the emotional trauma [4].
Sub-sub themes 2.1.2: Shortage and loss were emotionally traumatizing.
In addition to the professional nurses having experienced shortage and loss, they also reported that they were emotionally traumatized as follows:
“You have to continue doing it (the work) whether there is… a shortage, being short staffed …you know even being emotionally drained even if you have personal problems” (Participant E).
“Everything wasn’t in place to be honest, we were tired, and emotionally we were drained. That’s how I can explain it.” (Participant B)
“We were losing family members and still must come to work you can’t take the day off because every week someone at home has passed away. I must come to work; I have to go to funerals. We were losing a lot of people at the time” (Participant H).
“With all the shortage you have to leave your babies in the room allocated… go look for oxygen cylinder then bring it to the room and then connect it yourself, so it was like [an] extra mile that was not even supported” (Participant E)
The study further verified that shortage was attributed to the loss of life of colleagues due to the Covid-19 pandemic, resulting in nurses experiencing emotional trauma. This ratifies the study conducted in the Limpopo Province of the Republic of South Africa, where the main cause of shortage was attributed to absenteeism of professional nurses due to sick and family responsibility leave days [16]. The hospital database of the Bojanala district in the Northwest Province indicates that with the arrival of the Covid-19 pandemic more nurses resigned due to loss of life directly linked to the epidemic [11]. In addition, the arrival of the Covid-19 pandemic in 2020 from March to August, South Africa recorded the highest cumulative deaths in the African region accounting to 90% [10]. In all, there was massive loss of lives and severe shortage of professional nurses, heightening the emotional trauma.
Sub-sub theme 2.1.3: Unable to cope and anticipation of the worst to happen.
Professional nurses were unable to cope, anticipating the worst to happen, as reported here:
“We were not able to cope, like when you knock off to go home, you do not know sure where you stand and some of us, we used to spend like 4 to 5 days self-isolating from your family and not being able to see your family. It was not conducive to us at all” (Participant E)
“People got sick, people got admitted and by that time others were afraid even when you [were] off you would say” Noooo, I’m gonna stay home now, I’m off! This overtime staff ah! Ah! I can’t do this.” You see trying to protect yourself from the pandemic itself. So… Aah! It was a lot” (Participant I).
“We were not coping, that is why I was saying we were edgy we were angry even when you get home the treatment that you get from when you come from work” (Participant C)
In this study, professional nurses stated that the treatment they received at home when they knocked off during Covid-19 was the same as they received at work. Professional nurses reported that they had to self-isolate for days without seeing their family members due to fear of infecting them. They (The professional nurses) did not know where they stood with Covid-19 infection when they got home, and this resulted in nurses failing to cope as they anticipated the worst to happen to them and their families. In addition, one study verified that nursing forces as front liners in the advent of Covid 19 were not trained and experienced to cope and handle the pandemic crisis [7]. The study further established that professional nurses lost loved ones through death during the Covid-19 pandemic, adding more to staff shortages. In addition, some professional nurses had to deal with loss of family members and friends due to the Covid-19 pandemic, resulting in emotional trauma and pain. As a result, nurses were unable to cope during the pandemic as they ultimately anticipated the worst.
Furthermore, South Africa reported an increased rate of Covid-19 infection, which resulted in high mortality rate and many health professionals succumbed to the virus, creating more shortage of nurses [2]. In addition, most professional nurses in the Northwest Province of South Africa resigned due to fear of infection and trauma from Covid related loss of life [11].
Theme 3: Participants expressed experiences of factors related to mental health challenges due to Covid-19
During the interview discussion, professional nurses shared their experiences related to mental health challenges due to Covid-19 as a theme. Depression and mental stress emerged as a sub-theme discussed as follows:
Sub-theme 3.1: Depression and mental stress
Depression and mental stress were sub-themes that emerged from the theme of mental health challenges experienced by nurses due to Covid-19. That led to the following sub-sub themes:
Sub-sub theme 3.1.1: Hospitalizations in the mental health institution due to Covid-19
“Other nurses were admitted in [the] mental institution. I don’t know whether they couldn’t handle the exhaustion or what?” (Participant B).
“That is why I’m saying we were so depressed. We were so stressed, we were so emotional, every time we were snapping” (Participant C)
The study verified that nurses were hospitalized in mental health institutions because they were unable to handle the Covid- 19 pandemic exhaustion caused by shortage.
The study identified that mental health conditions experienced by nurses during the Covid-19 pandemic were depression and mental stress. This is evidenced by nurses who stated that they were always emotional and snapping. Furthermore, one study conducted in Asia found that nurses experienced mental health problems such as depression, anxiety, insomnia attributed to a lack of support from management during the pandemic [6].
The study discovered that nurses experienced mental health challenges such as depression and mental stress due to the Covid-19 pandemic. As a result, some nurses were admitted in mental health institutions, whereas other nurses resigned due to inability to cope during the pandemic. This confirms the results of a study conducted in Asia in the advent of Covid-19 where nurses experienced mental health problems such as depression, anxiety, insomnia attributed to a lack of support from management [6].
Sub-sub theme 3.1.2: Resignations due to stress and inability to cope.
“They are trying to hire more nurses, neh, but people when they get here, because of the workload as I have said. They don’t cope so they don’t feel free to work here anymore, some of them they are resigning. You know we had I think 6 nurses, they resigned 24-hour notice. Just imagine, it shows that people they can’t cope with the workload. I’m telling you!” (Participant A).
“As far as I know a lot of people tried to move from the big city to the villages. One of the causes actually is the professional nurses moving from our ward going back home maybe because they thought Covid is not that severe back at home like in the city, so it caused shortage on itself because we were already short staffed” (Participant H)
“Yes, they did, neh. They hired nurses but due to this workload of course, some nurses they did resign. They couldn’t cope with the workload, they resigned” (Participant A)
This study shows that some nurses opted to resign and relocate from big cities to the villages during the Covid-19 pandemic. This is because nurses could not cope with the pandemic, whereas others believed that Covid-19 was more severe in cities than in villages. Whereas the British study on global nurse’s shortage found that in countries like Zambia, nurses left organizations for skill interests, remuneration, and relocation amongst other things [17]. On the other hand, health institutions that were severely affected by the Covid-19 pandemic contributed to a shortage of nurses by offering higher salaries and hazard allowances to nurses from other institutions. As a result, most nurses relocated to those institutions [18]. Furthermore, another study confirmed that nursing forces as front liners in the advent of Covid-19 were not trained and experienced to cope and handle pandemic crisis [7].
Theme 4: Participants reported experiences of factors related to the negative impact on the healthcare system due to Covid-19
The interview discussions confirmed professional nurses had negative experiences related to the healthcare system due to Covid-19 as a theme, verifying the evidence that shortages severely crippled the system as a sub-theme.
Sub-theme 4.1: Shortage crippled the system during Covid-19
The sub-theme on shortages emerged from the experiences related to the negative impact on the healthcare system due to Covid-19. The following sub-sub themes were then inferred from the above sub-theme as discussed below:
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high attrition rate
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Covid-19 exacerbated shortage.
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No plan in place for Covid-19
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Quality patient care was compromised.
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Shortage of material resources
Sub-sub theme 4.1.1: High attrition rate during Covid-19
During the conversation, some professional nurses singled out high attrition rate during Covid-19 as follows:
“It got better with the Covid-19 contract workers and then it got bad again now because the contracts ended. (Participant H)
“So, people are being hired, people are going on pension and some are resigning” (Participant L)
“They resigned. Even now we are still experiencing shortage to be honest in this facility” (Participant A)
“Yoh! It was tough! And the other thing Uhmm… people were resigning, they couldn’t handle the stress, and they couldn’t handle the workload in the hospital. It was tough!” (Participant B)
Nurses in this study stated that although attempts were made to lessen shortage of nurses through contract, some resigned while the others went on pension without replacement. Therefore, the situation worsened when contracts ended, and it did not make any difference. This is supported by the inferences reporting that nurses left the profession due to remuneration issues while others were forced to leave due to nurse-to-nurse bullying and unhealthy work environment [19].
Sub-subtheme 4.1.2: Covid 19 exacerbated shortage
During the discussion professional nurses experienced exacerbated shortages due to Covid-19, reported differently as follows:
“Then it got better with the Covid-19 contract workers and then it got bad again now because the contracts ended. So that seemed like a temporary solution and now is not as bad as Covid-19 but it still there” (Participant H)
“We worked with contracts, and they will extend and extend and as soon as it’s better they leave then we go back to square 1 of that shortage” (Participant K)
“Shortage was there, yah, in our hospital we have been with this shortage for a long time but with the Covid it was worse” (Participant K)
The study identified that shortage existed before Covid-19 for a long time in the hospital of the Northwest province and it worsened during the pandemic. Nurses voiced the concern that contract workers seemed like a temporary solution because when it ended after countless extensions, shortages went back to pre-Covid states. A study conducted in Italy regarding the Covid19 pandemic found that nurses were quarantined, and this only worsened the dire staff shortages [20]. The hospital database of the Bojanala district in the Northwest Province indicates that, with the arrival of the Covid-19 pandemic, more nurses resigned [11]. These findings consolidate the point that South African professional nurses were isolated and quarantined, adding more to the already strained shortage [16].
Sub-sub theme 4.1.3: No plan in place for Covid-19
The discussion established that some nurses expressed that there was no plan in place for Covid − 19, reported as follows:
“There was no such! There was no plan. Every day it was like this is supposed to be done like… we were changing like headless chickens here. Today they will tell you gore noooo this is not a postnatal ward anymore, you guys are gonna admit this and that like they were changing drastically every day. There was something new every day.” (Participant I).
“My experiences during that time, it was eh, we were having a lot of shortage. So, the backup that we got during that time, it was like we got a contract employee but there not so much to cover that shortage because according to the shortage of this hospital since I was employed here. The shortage was there even now the shortage is still existing” (Participant L).
“Shortage was there, yeah, in our hospital we have been with this shortage for a long time but with the Covid it was worse because at one stage we had to nurse the intensive care unit patient in a normal unit of which we didn’t even know how to operate the ventilator. To me the shortage was terrible and demanding to us” (Participant K)
“And then again with regard to shortage of resources I believe if we had all the resources we needed and then infrastructure built specifically for that period at the time, I believe some of the things would have been better.” (Participant I).
“Uhmm our hospital, I’m not sure how many beds our hospital has, but I think by that time we could have gotten, would have been like to use other facilities in near areas like maybe our level 1s hospitals and staff like that. Maybe down referrals: referring the more stable patients to accommodate the ones that were in critical conditions” (Participant J).
In addition, the study established that the hospital did not have a Covid-19 plan, therefore daily routine and units were changing drastically. Professional nurses expressed that they were changing plans like headless chickens, changing something every day. This ratifies the results of one study conducted in South Africa, which found that health facilities in all four South African provinces had Covid-19 contingency plans for the general population, except for health care workers [21].
This study found that Covid-19 exacerbated shortage of human and material resources because there was no plan in place for Covid. Patient care was compromised due to low staff patient ratio and high attrition rate. This impacted negatively on the health care system due to the Covid-19 pandemic. A study conducted in the four Provinces of South Africa focused on organizational factors associated with health worker protection during Covid-19 [16]. The study found that health facilities in all four provinces had Covid-19 contingency plans for the general population except for health care workers. The South African health care system was also faced with a high number of patients.
Sub-sub theme 4.1.4: Quality patient care was compromised due to Covid-19
Through the interview questions some professional nurses expressed that Quality patient care was compromised, reported as follows.
“No, we go for a quarantine but the others that were remaining, they had to work like that. 3 professional nurses and then with a maybe 5 department, when I say 5 department I say: admission there must be at least 3 professional nurses in the admission department, the one fetching the baby, the other 2 working in admission but we must be forced to work alone. Fetching ceasers and admission at the same time, delivery [and] working alone in delivery room” (Participant G).
“There was no quality of nursing obviously! (Clapping her hands)” (Participant B)
“No, you will be overworked to such a point, neh, where sometimes you get angry at patients for needing your assistance. Let’s say maybe they will call you, they will call you in room 1 and when you attend to room 1, when you are on your way to room 1 somebody in room 2 will call you. You go from room 1 to room 2 somebody else will call you at the end of the day you see you end up being stressed and having too much on your shoulders” (Participant F).
The nurses indicated clearly that patients were neglected during the Covid-19 pandemic because they had to leave their ward patients to go nurse some of their patients admitted in other wards. As a result, quality of patient care was compromised. In addition, two studies conducted in the European region identified that lack of resources such as beds for Covid-19 patients and shortage of staff compromised provision of standard nursing care to the patients [7]. Furthermore, another study suggests there were cases of poor nursing quality care due to low nurse patient ratio and lack of managerial support for nurses in the advent of Covid-19 [19].
Sub-sub theme 4.1.5: Shortage of material resources due to Covid-19
During the discussion, professional nurses expressed shortage of material resources as follows:
“As I’m talking to you, there is no paper towel to wipe our hands. We just wash and wipe with a pillowcase so even in Covid-19 there were no paper towels at some point” (Participant C).
“The masks are those things that were scarce” (Participant D).
You know we ended up like being given some of the PPEs by other institutions. (Participant A)
“Even the resources like the instruments that we are supposed to use, lack of instruments” (Participant A).
During the Covid-19 pandemic professional nurses experienced shortage of material resources such as P masks. Consequently, they had to ask from other institutions. Furthermore, lack of instruments and paper towels was an issue at a hospital in the Northwest Province. This remains a problem that must be resolved. In addition, nurses expressed that they had to use pillowcases to wipe their hands. These results are like those of a study conducted in the Netherlands where a shortage of personal protective equipment (PPE) during Covid-19 exposed nurses to the risk of contracting the virus [3]. As a result of shortage of PPE, most nurses contracted the Covid-19 virus and had to absent themselves from work to go on quarantine [4].
Theme 5: The participants expressed experiences of factors related to organizational support during Covid 19
Some professional nurses experienced a serious lack of organizational support during Covid-19, emerged as a theme. The subtheme that came out from the fifth theme is reported as follows:
Sub-theme 5.1: Some participants felt supported by the management and colleagues during Covid-19
Some nurses felt supported by the management and colleagues during Covid-19 and the participants had this to say:
“Somehow the management was there with us because we would always call and they would sometimes come up with solutions but some of the things were above us and above them. Such cases needed other people from other levels” (Participant I).
“Uhmm, I believe that the support that we received at that time was quite effective you know like management also trying to intervene were they could” (Participant J)
“But doctors from different departments were able to assist in the relevant departments which made it easier for the other doctors as well. There was some sort of support like” (Participant J).
“We had a memorial service by the staff members” (Participant A).
“With the colleagues there was support, everyday there was support including when one was sick, we the colleagues had to see to it: phone and check on our colleagues” (Participant E).
Staff that were working at OHS, they used to call us, comfort us, and counsel us telephonically” (Participant F)
This study reveals that some nurses experienced organizational support from management and colleagues during the Covid-19 era, whereas the study findings on nursing shortage suggests lack of retention of nurses’ due lack of managerial support for nurses in the advent of Covid-19 [19]. In addition, the study conducted on mental health problems faced by healthcare workers due to Covid-19 found that in the advent of Covid-19 nurses experienced mental health problems attributed to a lack of support from management [6]. In this study, nurses expressed that the management provided sufficient and effective support to the staff during Covid-19 era, because some of the things that the nurses needed were above the management i.e. budget. However, in one study on Asian experiences, the findings confirm that in the advent of Covid-19 nurses experienced mental health problems attributed to a lack of support from management [6]. This is further supported by an American study whose findings suggest that there was lack of retention of nurses, poor work environment, poor nursing quality care due to nurse patient ratio and lack of managerial support for nurses in the advent of Covid-19 [19]. In contrast, in the Asian study findings, nurses did not receive any support from the management [6].
Theme 6: Participants expressed factors related to support required by professional nurses regarding shortage in the advent of Covid-19
Factors related to support required by professional nurses regarding shortage in the advent of Covid-19 support emerged as the main theme during data analysis. This is supported by the following three sub-themes:
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A need for mental, emotional and physical support
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Adequate human and material resources is required.
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A need for monetary support and proper planning
Sub-theme 6.1: A need for mental, emotional and physical support during
Covid 19
During the discussions professional nurses said they needed counselling to mitigate the mental, emotional and physical trauma:
“We needed to have some sort of counselling, we were not only affected by the number of patients, we were losing staff members as well and we were losing family members” (Participant H)
“We need something like counselling” (Participant C)
“I think by counselling, they didn’t provide that by that time. After we are from quarantine, we filled up the forms with OHS (Occupational health and safety)” (Participant G)
“We didn’t get any support and I wish we had d they could just eh! Give us counselling of some sort. We didn’t get any support! We didn’t get any support!” (Participant B)
“I felt we needed counselling first because at that time our mental state was a mess: we were in a situation we have never been in before.
The study discovered that nurses needed mental health support in the form of counselling to mitigate mental health conditions brought by the Covid-19 pandemic. In addition, a similar study conducted in Asia found that in the advent of Covid-19 nurses experienced mental health problems such as depression, anxiety, insomnia attributed to the lack of support from management [6].
The study findings verified that nurses needed counselling to mitigate mental, emotional and physical trauma due to loss of lives during the Covid-19 pandemic. This is supported by another study conducted in Asia countries which found that professional nurses identified emotional stress due lack of access to psychologists and psychiatrist [4]. Furthermore, professional nurses in Italy singled out emotional stress due to lack of access to psychologists and psychiatrists [4]. This indicates that there was no support in the form of counselling. Furthermore, a study conducted in Asia found that in the advent of the Covid-19 pandemic nurses experienced mental health problems such as depression, anxiety, insomnia attributed by lack of support from management [6]. Additionally, 54.4% of professional nurses in Italy expressed emotional stress due lack of access to psychologists and psychiatrists [4].
Management did not care to do so. Furthermore, nurses expressed that when one nurse was sick during the Covid-19 era and there was no one for overtime, managers should leave their managerial work and work in the unit. However, the study findings suggest that during Covid-19, nurse managers were only running the facilities whereas nurses were at the frontiers of the Covid-19 pandemic. As a result, nurses experienced no support at all from the management [6]. In addition, the discussion verified that professional nurses needed emotional support even for the bereaved families and colleagues’ families. Furthermore, the Asian nurses expressed poor working conditions due to lack of support from the management, hence the rationale for the mass resignations [6].
Sub-theme 6.2: Adequate human and material resources are required in the advent of Covid-19
In the discussion, professional nurses needed adequate human and material resources in the advent of Covid-19. Reported as follows:
“We needed our managers to be there and our doctors to be there for us. So, our doctors wanted all our patients to be nursed accordingly whereas you are all alone” (Participant C)
“They (managers) are always there in their offices; they didn’t come down and say what your problems are? How can we help you? What do you need?” (Participant C).
“In this hospital, in the managerial side towards the nurses, there was no support at all even the nursing manager sometimes was aware that we are struggling in the sense of shortage. We didn’t get support; everyone is for himself and then yeah” (Participant E)
“I feel like our government must or should have at least built a new hospital, hired more nurses and then akere (is that so) there was a budget for that period. Remember there was a certain budget that was specifically for Covid-19” (Participant I)
The study established that some nurses needed support from the management because they did not care about shortage of staff. This is because the nurses reported that management was aware of shortage but then they did not mitigate these. Some nurses expressed that contract workers were hired for other hospital units except theirs. Other nurses reported that the management expected them to meet their monthly targets even with the exacerbated shortage due to Covid-19. In addition, literature shows that nurse manager’s roles during Covid-19 pandemic were to run the facilities, thereby neglecting the severe challenges experienced by nurses [22].
This study also verified that nurses needed resources related to instruments during the Covid-19 pandemic, including paper towels. One study conducted in the European region also identified that the lack of resources such as instruments, medication, intensive care unit (ICU) beds for Covid-19 patients [7, 15]. Professional nurses in this study identified the shortage of PPE such as masks during the Covid-19 pandemic to protect themselves from getting infection. As a result, they had to ask from other institutions. In addition, a study conducted in the Netherlands identified shortage of personal protective equipment (PPE) during the Covid-19 pandemic [3]. The study identified that nurses needed material resources such as paper towels instead of using pillowcases. The European country studies also reported lack of instruments and resources in the advent of the Covid-19 pandemic [7], making fundamental connections to the findings established in the current one.
This study also reveals that shortage existed before Covid-19 and nurses have been experiencing it for a long time. Although contract workers were hired, some nurses felt it was a temporary solution because when contracts ended, shortages went back to square one. Nurses expressed that they needed recruitment of more nurses or relief nurses because Covid-19 exacerbated shortage, and or hire contract workers. This is because nurses expressed that management do not care about shortage of staff, hence there is no staff augmentation.
Sub-theme 6.3: Need for monetary support and proper planning is required in the advent of Covid-19
The above-mentioned sub-theme emerged from the above-mentioned theme and was reported as follows:
“They worked 2 days because the salary that gets in its less compared to when you work 2 days because the tax becomes more so that 3rd day it means that you were sacrificing because it doesn’t count a lot (Participant C).
“It would be money because some days would be difficult to get someone, it won’t count because if you say I should come work not on my shift, and you give me a day off, if I’m taking that day off I’m creating another space and another shortage so that is why I say as nurses we need more money” (Participant H).
“ So I think even in the future they should allow us to work overtime in order to give good patient care” (Participant C)
“They said they would pay us because we had Covid in the ward but until now nothing, compensation nothing until now (clapped both hands once)” (Participant G).
“They must also increase our salary, bathong! We worked very hard during Covid-19 and then there was no increment you see, yah! Since Covid there is no increment. They must just see to it to improve our salaries” (Participant K).
“When they (managers) were planning they could have included us to say Covid-19 does not mean only for adults” (Participant C)
The study established those nurses needed remuneration for the risk of contracting Covid-19 infection because they worked hard. In addition to that, it was found that nurses were the most undervalued professionals, hence they were underpaid whereas they risked their lives performing dangerous duties during Covid-19 [23]. As a result of low wages some elderly nurses retired, adding more to shortage [18].
In this study, nurses expressed the need for their remuneration and to be processed quicker because some nurses reported the outstanding compensation since Covid-19 started. In addition, another study conducted found that nurses argued that they were not rewarded, nor praised nor given incentives for the extra work done during Covid-19 [14]. The study also revealed that nurses needed unlimited overtime and to be remunerated fairly during Covid-19. This is because some nurses reported that they were only allowed to work 2 days to be remunerated, when they worked more tax affects their remuneration. Furthermore, nurses expressed that they needed monetary overtime as a solution to shortage because it encourages nurses to come for overtime. Other nurses expressed that they needed unlimited overtime during Covid-19 to be remunerated to give good patient care. In addition, nurses reported that, the management expected nurses to perform duties that were outside their scope of practice during Covid-19 without remuneration [14].
In this study, professional nurses needed the management to plan better for the pandemic, i.e., have inclusive plans that accommodates all types of patients in place for pandemic management and to involve them in planning processes. This is supported by one study conducted in the Limpopo province of South Africa, which found that health facilities in four provinces had Covid-19 contingency plans for the general population except for health care workers [16]. The study identified that nurses needed remuneration as a form of support during the Covid-19 pandemic for the risk of contracting Covid-19, to be processed quicker and unlimited remunerated overtime in an attempt to solve shortage9. Another study reported that, the management expected nurses to perform duties that were outside their scope of practice during Covid-19 [5]. On the other hand, nurses argued that they were not rewarded, nor praised or given incentives for the extra work done during Covid-19. In addition to that, another study found that nurses were the most undervalued professionals, hence they were underpaid whereas they risked their lives performing dangerous duties during Covid-19. As a result of low wages some elderly nurses retired, adding more to shortage. This shows that nurses required support from the management as well as remuneration in the era of Covid-19, also low wages contributed to shortage of nurses.