https://orcid.org/0000-0003-0991-8232
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Abstract
The COVID-19 pandemic severely disrupted healthcare systems, placing immense physical, emotional, and organizational strain on front line nursing staff, including registered nurses and nursing assistants. These professionals faced heightened stress due to increased virus exposure, global personal protective equipment (PPE) shortages, and rapidly changing protocols. This study sought to explore the experiences of registered nurses and nursing assistants working in inpatient care during the COVID-19 pandemic, focusing on workplace stressors and available or recommended resources to mitigate these challenges. Despite extensive documentation of elevated stress and burnout among nurses during COVID-19, little is known about how registered nurses and nursing assistants appraised specific workplace stressors and evaluated the adequacy of available organizational resources during the pandemic. Using a qualitative descriptive design, semi-structured interviews were conducted with 14 registered nurses and six nursing assistants from COVID-19 and non COVID units at a large academic medical center. Guided by Lazarus and Folkman’s Stress and Coping Model, the analysis identified a range of personal, interpersonal, organizational, and societal stressors. Personal stressors included long work hours, loss of loved ones to COVID-19, and feelings of isolation. Interpersonal stressors involved exposure risk, emotional strain from coworkers’ stress, and shifts in bedside roles. Organizational stressors encompassed staffing shortages, changes in protocols, and being called off shifts. Societal stressors included inconsistent public health messaging and concerns about protecting vulnerable family members. Participants emphasized the importance of authentic leadership and nursing-centered delivery of resources in addressing these stressors. Six key resource categories emerged: emotional support, staffing, safety, compensation, communication, and stress management. Findings highlight the critical role of nurse managers, effective communication, and staffing policies in mitigating workplace challenges. While rooted in a U.S. context, these insights may inform strategies to support nursing staff globally in future crises, reinforcing the need for tailored, sustainable approaches to front line caregiver well-being.
Citation: Adynski GI, Dictus C, Adynski H, Killela MK, Myer EA, Morgan L, et al. (2026) Experiences of registered nurses and nursing assistants during COVID-19: Work stress, stress appraisal, and workplace resources; A qualitative descriptive study. PLoS One 21(3): e0345525. https://doi.org/10.1371/journal.pone.0345525
Editor: Rogis Baker, Universiti Pertahanan Nasional Malaysia, MALAYSIA
Received: October 20, 2025; Accepted: March 7, 2026; Published: March 27, 2026
Copyright: © 2026 Adynski et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data cannot be shared publicly due to ethical restrictions related to the protection of participant confidentiality and the terms of Institutional Review Board (IRB) approval. The minimal data set underlying the results presented in this study contains potentially identifiable participant information and is therefore subject to access restrictions. Data are available from the University of North Carolina at Chapel Hill Institutional Review Board (UNC-CH IRB) for researchers who meet the criteria for access to confidential data and obtain appropriate ethical approval. Requests for data access may be directed to the UNC-CH IRB at irb_questions@unc.edu, which serves as the non-author institutional point of contact and will coordinate review of data access requests in accordance with institutional policies.
Funding: We received funding from the Rita and Alex Hillman Foundation to support this work through their Hillman Scholars Program in Nursing Innovation Advancing Early Research Opportunities grant mechanism. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: Author EA is employed by RTI Health Solutions, Research Triangle Park. This author did not receive compensation from RTI Health Solutions for this work. No patents, products in development, or marketed products are associated with this study. The remaining authors declare no competing interests. This does not alter our adherence to PLOS ONE policies on sharing data and materials.
Introduction
The COVID-19 pandemic created unprecedented challenges for healthcare systems, particularly for registered nurses (RNs) and nursing assistants (NAs) on the frontlines. Coronavirus disease 2019 (COVID-19) is a highly infectious respiratory illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which led to a global pandemic beginning in late 2019. These professionals faced significant changes to patient populations and treatments, work environments, and daily workflows, which can contribute to heightened stress levels [1]. RNs and NAs were at high risk of experiencing stress due to their critical role in patient care during the pandemic and the rapid changes to their daily work likely increased work-related stress, regardless of caring for COVID-19 positive patients [1]. Significant global Personal protective equipment (PPE), including items such as masks, gowns, gloves, and face shields, shortages across high- and low-income countries left healthcare workers lacking standard PPE and reusing single-use items, leading to adverse effects like heat, thirst, pressure sores, headaches, bathroom access issues, and extreme exhaustion [2]. Nursing staff were at increased risk for COVID-19 due to their direct exposure to airborne and droplet transmission, as they spent more time in patient rooms than other healthcare professionals even before the increased demands of the pandemic [3]. This prolonged exposure translated into higher infection and mortality rates among RNs than physicians during the pandemic [4]. In addition to infection and mortality disparities, descriptive studies have shown an increased level of anxiety, depression, and insomnia for healthcare workers during COVID-19 [5–7]. A study from the end of 2020 showed almost 70% of RNs reporting anxiety symptoms with almost 40% being in the moderate and severe range [8].
Stress and anxiety in the healthcare workplace can have profound consequences, including impacts on patient and organizational outcomes. Workplace stressors include increasing demands and decreased resources are directly linked to burnout [9–11]. Burnout, defined as emotional exhaustion, depersonalization and lack of personal achievement at work, [12] has detrimental effects on both individuals and healthcare systems. RN burnout leads to lower patient satisfaction and lower quality of care [13]. High burnout levels and low resilience lead to increasing turnover of the nursing workforce [14–17], resulting in significant financial costs for organizations and the loss of valuable institutional knowledge held by departing staff [18]. In the United States (U.S.) turnover can cost range between $22,000 to over $88,000 per RN [19].
Although a substantial body of literature has examined RN stress during the COVID-19 pandemic, nursing assistants’ experiences remain underrepresented, particularly within studies examining how inpatient nursing staff appraised workplace specific stressors and available resources [20]. NAs are often left out of the literature even though their responsibilities to provide personal patient care place them in close proximity to the stressors of caring for patients during COVID-19, just like their nurse counterparts. Addressing these gaps is critical for guiding healthcare leaders, researchers, and policymakers as they prioritize efforts to promote resilience and reduce burnout among the current nursing workforce, who are still experiencing residual stress of COVID-19. Understanding the experiences of inpatient RNs and NAs during the pandemic, in their own words, allows for the identification of actionable strategies to address stress and burnout both during future crises and in routine practice. These insights may be applied to other non-inpatient settings, [21,22] as the challenges faced by nursing staff are reflected across diverse healthcare contexts globally.
This qualitative descriptive study, guided by Lazarus and Folkman’s Stress and Coping Model, [23,24] aimed to explore the experiences of RNs and NAs in the southeastern U.S. providing inpatient care during the COVID-19 pandemic. The present study focuses on exploring how nursing staff experience work-related stressors, appraisal of that stress, and the workplace resources that were available or recommended to manage these stressors. Although Lazarus and Folkman’s framework encompasses both individual coping processes and environmental factors, this study deliberately focuses on organizational stressors and structural resources, and does not examine individual-level coping strategies such as self-care or professional resilience. This work addresses critical gaps in our understanding of how RNs and NAs perceive similar events as stressful or not, and the workplace resources they identify to cope with work-related stress, particularly during heightened periods such as the COVID-19 pandemic. Although centered within U.S. context, these findings and recommendations can be relevant internationally, especially in inpatient care settings where nursing staff faced similar challenges during the pandemic. These findings can also be applied to other crisis situations, offering valuable insights for supporting healthcare workers in times of extreme stress.
Materials and methods
Design
This study employed a qualitative descriptive design to explore the experiences of inpatient nursing staff during the COVID-19 pandemic. Data were collected through semi-structured, individual interviews with registered nurses (RNs) and nursing assistants (NAs) who were providing direct inpatient nursing care during the pandemic. This approach allowed for consistency across interviews while maintaining flexibility to probe individual experiences related to workplace stressors, and available resources. A key strength that supports rich, practice-relevant descriptions grounded in participants’ own words. A limitation of this design is that findings reflect experiences within a specific institutional context; however, detailed reporting of the setting and analytic process supports the trustworthiness and applicability of the findings to similar care settings. The study adhered to the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines to ensure standardized and transparent reporting of qualitative research methods and findings [25] (see S1 Appendix file).
Theoretical framework
The study was guided by Lazarus and Folkman’s Stress and Coping Model, [23,24] which conceptualizes stress as a process involving primary appraisal (evaluating whether a stressor is perceived as a threat or not, with positive appraisals indicating no threat and negative appraisals indicating a threat) and secondary appraisal (assessing the availability of internal and external coping resources, with positive appraisals indicating resources are available and negative appraisals indicating they are not). Utilizing this framework, directed content analysis was applied to inform the development of the interview guide and shape the qualitative analysis. Qualitative, semi-structured interviews examined how the COVID-19 pandemic affected the work experiences of RNs and NAs, their perceptions of job-related stress, the availability of workplace resources, and recommendations for future resources to address healthcare system crises. The interviews also explored how RNs and NAs appraised and managed stressors during the pandemic, with particular attention to the effectiveness or absence of workplace resources (See S2 Appendix for Interview Guide). The interview guide was piloted with a nurse, RN not employed at the medical center, to ensure clarity, relevance, and alignment with the study objectives.
Study setting, sample, and recruitment
This project was conducted at a large academic medical center in the southeastern U.S. A purposeful stratified sampling method was used to gather representation of both COVID and non-COVID inpatient nursing staff to have a comprehensive view of the experience of working during a time of crisis. Target sample sizes were set at 6 participants across RN-COVID, RN-Non-COVID, NA-COVID, and NA-Non-COVID to achieve balanced representation across these groups. Participants were recruited through informational flyers posted throughout the hospital, hospital-wide employee listservs, and in-person recruitment at individual unit staff meetings.
Recruitment continued until predetermined recruitment goals were met. Despite repeated recruitment efforts, we were unable to meet the target enrollment goals within the NA-COVID subgroup. We did not assess saturation within subgroups because the analysis was not designed to compare experiences across subgroups; rather, purposeful subsampling was used to ensure a range of experiences, including those of underrepresented nursing assistants, were reflected in the data. A final sample of 20 participants is consistent with qualitative research standards for data sufficiency [26]. During analysis, code saturation was assessed, defined as the point at which no new codes were identified in successive transcripts [26]. No new codes emerged in the final transcripts, supporting that the sample size was sufficient to address the study aims.
Inclusion and exclusion criteria
Inclusion criteria included full-time RNs or NAs who spent >80% of their clinical time delivering direct patient care at the bedside and had worked on their current unit for at least three months before the start of the pandemic. COVID units were defined as floors that primarily take care of patients with COVID-19 (e.g., COVID-19 intensive care units, COVID-19 acute care units, Emergency Department (ED)). Non-COVID units included all other inpatient units within the medical center (Medical Surgical, Step Down, Women’s, Pediatrics, Psychiatry). Stratification across hospital roles and unit type was used to ensure diversity of experience, capturing perspectives from nursing staff working in both COVID-designated and non-COVID units, as well as different clinical settings and patient populations.
Data collection
Participants completed initial consent as a part of an initial eligibility screening survey via Qualtrics where they learned about the goals for the proposed research. During recruitment participants were informed they would be compensated for their participation in the qualitative interview. A total of 71 participants expressed interest in completing an interview, including 58 registered nurses (9 RN-COVID, 49 RN-Not COVID) and 13 nursing assistants (0 CNA-COVID, 13 CNA-Not COVID). Participants were then enrolled on a first come, first serve basis. If capacity was reached for a certain sampling stratification, each subsequent participant was placed on a waitlist to be contacted if attrition occurred. If a participant was unable to be contacted after three failed attempts, the next eligible individual on the waitlist was contacted. Eligible individuals received a confirmation email to schedule a 45–60 minute Zoom Interview. Within the scheduling email, additional mental health resources were provided, including a copy of the informed consent document. At the beginning of the interview, the study team reviewed the consent information with participants and obtained verbal consent before proceeding with the interview. Participants completed the Zoom interviews in private settings, such as their homes or private offices, to ensure confidentiality and minimize potential interruptions. Participants were allowed to stop the interview at any time for any reason; however, no participants chose to withdraw from the study or discontinue the interview or required a repeat interview. Interviews were conducted by trained study team members (MK, EM, CD, HH). All interviews were audio-recorded and professionally transcribed verbatim. Research team members checked all transcripts for accuracy against the audio-recordings and de-identified the transcripts to protect participant confidentiality. After the interview, the participants received a $50 gift card by email as compensation for their time. Trained interviewers also completed a brief memo to document their impressions of the interview and to engage in reflective practice. Interviews were conducted between April 2021 and September 2021.
Data analysis
All interviews were analyzed using directed content analysis with deductive coding and theming, guided by the Stress and Coping Model, while also allowing for emergent themes to arise [27,28]. Dedoose (Los Angeles, CA) qualitative software was utilized to code all de-identified interviews. Initially, the codebook was generated based on the Stress and Coping Theory. The initial codebook was piloted on a subset of interviews and definitions were refined and additional codes were added.
Three teams of two coders independently coded each interview (CD, HA, MK, EM, LM, HH), reviewed the interview notes, and subsequently convened to reach a consensus. Two coders worked independently to code the interviews and then met to reconcile codes and review memos [29]. To ensure dependability, an audit trail documenting all work, including raw data, data synthesis, and process notes, was maintained throughout the process [30]. We developed a hierarchical coding tree grounded in the Stress and Coping framework, comprising major domains of stressful events, primary appraisal, secondary appraisal, adaptive outcomes, and resources (including resources offered or available to participants and recommended resources), with each domain subdivided into conceptually related child codes. These teams then met with the larger group of coders to further debrief and refine the codebook as new themes and subthemes emerged through an iterative process. This procedure was conducted for 14 interviews. Once the codebook reached stability, the remaining 6 interviews were coded independently until data saturation was reached [31].
Ethical considerations
Ethical approval to conduct this study was obtained by the institutional review board at the University of North Carolina at Chapel Hill (#20–2323) as well as approval from the hospital governance nursing research council within the medical center.
Rigor and reflexivity
To enhance the rigor of the study, credibility was ensured through investigator triangulation, where multiple coders analyzed the data to validate findings. Additionally, an audit trail was maintained, including reflective memos and documentation of analytic decisions, to promote transparency and dependability.
Reflexivity was integral to the research process, as all members of the research team including coders, study designers, and authors shared professional nursing backgrounds, with many actively working in inpatient settings during the COVID-19 pandemic. The research team includes six PhD-prepared RN (PhD-RNs) and one bachelor’s-prepared RN who is currently a Doctor of Nursing Practice student. The research team comprised five female members, two male members, and one gender-expansive member, reflecting diverse gender representation. At the time of data collection among the PhD-RNs, four were PhD students, four were employed as registered nurses within the healthcare system where the data was collected, one was a faculty member at a university, one a post-doctoral fellow, and one was a BSN nursing student. Importantly, none of the team members had established personal or professional relationships with the participants, nor did they hold supervisory or hierarchical roles over them, reducing the potential for bias. Participants were informed that the interviewers were registered nurses. The research team’s identities as nurses and firsthand experiences allowed them to bring valuable insights into the nuances of nursing practice and challenges faced during the pandemic, while also shaping the framing of the research questions and interpretation of data. The research team brought extensive experience and training in nursing practice, healthcare systems, qualitative and quantitative research methods, and public health. Their expertise included clinical practice as registered nurses, advanced academic preparation in doctoral programs, faculty roles in higher education, and specialized knowledge in areas such as mental health, community health, and healthcare policy. Recognizing the potential for these shared experiences to introduce bias, the team engaged in deliberate reflexive practices, such as regular discussions about positionality, reviewing reflective memos to document assumptions and insights, and holding team meetings to critically examine the coding process. These strategies ensured that the findings were firmly grounded in the data and authentically represented participants’ voices, rather than being overly influenced by the researchers’ personal experiences.
Results
Characteristics of participants
The final sample included 20 participants, 14 of which were RNs and 6 of which were NAs. Of the RNs, 1 had a nursing diploma, 4 had associate’s degrees, 8 had bachelor’s degrees, and one had a master’s degree. At the hospital from which the sample was collected, 13 participants worked on units that accepted and treated patients who were known to be COVID + , and 7 participants worked on units that did not accept known COVID+ patients. All participants were recruited from the same large academic medical center in the southeastern United States. Table 1 offers a demographic overview of all participants.
Main findings
This paper aimed to define nursing workplace stressors and resources along with the various positive and negative ways RNs and NAs appraised these stressors and resources. The main findings of this paper will be divided into two sections of stressor and resources. RN and NA stressors, definitions, and primary appraisals, and quotes are illustrated in Table 2. Resources, definitions, secondary appraisals, and quotes are illustrated in Table 3.
Stressors
The major types of stressors that RNs and NAs experienced can be categorized as 1) personal stressors, 2) interpersonal stressors- coworkers, 3) interpersonal stressors- patients and patients’ families, 4) organizational stressors, and 5) societal stressors. The next section will go over the definitions of these stressors and examples of RNs’ negative and positive appraisals of them. Table 2 outlines the stressors identified by RNs and NAs, including definitions, primary appraisals, and illustrative quotes.
Personal stressors.
Participants described several stressful events that occurred outside of work, that impacted their work lives, such as financial stress, changing childcare needs, feelings of isolation, and loss of loved ones to COVID-19 or other ailments. While some RNs were expected to work extra hours due to COVID-19, many were asked to reduce their hours because their units canceled scheduled shifts due to low census. (e.g., canceled elective procedures in the early stages of the pandemic). This reduction in work hours led to some nurses to experience increased financial distress from working fewer hours.
Many RNs endorsed general distress from their personal stressors including feelings of helplessness, fear, exhaustion, anger, anxiety, overwhelmed feelings, and feeling of being on an “emotional roller-coaster”.
Few participants perceived the COVID-19 pandemic as non-stressful or reported feeling indifferent to changes in their personal stress levels. When participants described positive or neutral stress appraisals, they described additional context as to why they felt this way. Some noted that other personal stressors such as the death of a family member unrelated to COVID-19 overshadowed the challenges of care delivery during the pandemic. Some staff members described caring for COVID-19-positive patients as less stressful than other patient care. Once policies and treatment protocols were established, the care became more standardized, which made it more familiar compared to patients with more unknown and complex care needs. Many described the familiarity of working with COVID positive patients as ‘the new normal’. Similarly, others shared that previous clinical experience with infectious disease care helped them feel more confident and comfortable providing care during this time.
Interpersonal stressors- coworkers.
These were challenges that arose from heightened difficulty in achieving harmony between and among coworkers. This included communication breakdowns, bullying, or vaccine hesitancy among staff. Specific stressors involved the transition to becoming a COVID unit, bullying from peers, reluctance among staff to care for COVID-19 patients, and the need for stronger teamwork and communication. Additional factors included difficulties in obtaining consults, experiencing or witnessing racism at work, and the emotional toll of watching coworkers undergo significant stress.
Negative appraisal of interpersonal stress involved viewing stressors related to interactions with colleagues and support systems as harmful, worsening feelings of isolation, burnout, and lack of support. Participants expressed feeling abandoned when coworkers avoid COVID-19 rooms, increasing their workload and intensifying isolation and resentment. The burnout of colleagues further strained the remaining staff, heightening stress and frustration. Participants discussed frequent absenteeism exacerbated staffing shortages, overwhelming those present. Furthermore, participants stated insufficient management support can make RNs feel undervalued and unsupported. Lastly, non-compliance with safety protocols was perceived to increase risk and mistrust among staff.
Participants also reported feeling frustrated about their role at the bedside and the assumptions surrounding their work hours. During the COVID-19 pandemic, they were required to have direct patient contact and spend long hours in COVID-19 rooms, while some of their colleagues avoided entering patient rooms and opted for telemedicine care. This often meant that nursing staff had to enter the room an additional time just to deliver telemedicine equipment, adding to their workload and exposing them to risk to accommodate a colleague.
Positive appraisal of interpersonal stress involved viewing stressors related to interactions with colleagues as opportunities for growth, solidarity, and pride in the profession. Some participants described their peers as heroes, which instilled a sense of pride and reinforced their commitment to nursing. Reliance on coworkers for support with PPE and patient care strengthened teamwork, making stressful situations more manageable. Additionally, even when peers masked their true feelings, positive attitudes helped uplift individual spirits and foster a supportive environment. For example, one participant described how she knew her colleague was “faking it,” but the positive outlook helped her regardless.
Interpersonal stressors- patients and families.
Participants stated being under immense stress due to their interactions with patients and their families, especially during the early stages of the COVID-19 pandemic. The risk of exposure to the virus, dealing with argumentative or combative patients, caring for higher-than-normal acuity or different patients, and coping with patient deaths all contributed to the described heightened stress levels.
Participants’ emotional reactions to the stressors of COVID-19 patients were diverse. Participants expressed fear and stress surrounding conflicts with patients and their families, often stemming from restricted visiting hours for patients’ families. Participants expressed stress related to the increased acuity of patients causing higher and more challenging workloads. Finally, participants expressed immense feelings of grief and sadness related to the increased death and dying of patients.
Participants had some strong positive appraisals of caring for patients as well, and these positive appraisals largely stemmed from feeling as though they were making a difference in the lives of their patients and their families, leading to a rewarding feeling. Others reported that COVID-19 patients’ care was not inherently more complicated than their pre-pandemic usual patients and did not feel significantly different in that regard.
Organizational stressors.
Organizational stressors were defined as increased responsibilities and/or challenging processes that alter the work environment. They arose from expectations and pressures from leadership, changes in work protocols, uncertainty surrounding PPE usage, and shifts in staffing, such as team members leaving, the integration of traveling staff, or the dynamics of interdisciplinary teams. Additional stressors included assuming charge RN responsibilities, fluctuations in workload, caring for unfamiliar patients, and shortages of essential supplies like medications. Other factors contributing to stress included lack of access to food and coffee during off-hours, being called off from scheduled shifts, and navigating a changed work environment despite no formal changes to job requirements.
Participants expressed feelings of loss of control and frustration with power dynamics, where power struggles and breakdowns in communication led to feelings of not being listened to or valued. RNs and NAs described feeling less confident in their skills and feeling used, dehumanized, or expendable. RNs also described how increased workloads, time spent in patient rooms, and assuming the risk of COVID-19 exposure were expected of nursing staff more than other healthcare workers. For example, one RN described needing to enter a patient’s room additional times to set up a video conference call with a physician so that the physician team would not need to enter the room.
Alternatively, some participants expressed feelings of being valued and grateful for their jobs. They successfully adapted to new workflows and found confidence in their abilities, which made the situation more manageable, along with proper PPE. Improvements in the work environment, including staffing changes, contributed to reduced stress. While many recognized both the organizational challenges and benefits, some participants reported a growing sense of progress, with stress levels decreasing and the acceptance of the “new normal” becoming routine. A clearer understanding of expectations provided reassurance.
Societal stressors.
Participants felt stress at the societal level stemming from the universal experience of COVID-19 as a stressor at a local, state, national, and international level. Participants expressed concern regarding a lack of available information at a societal level on COVID-19, varied community responses (or lack thereof) to COVID-19, and a concern about protecting the immunocompromised in society at large. Participants were concerned about relaxing distancing guidelines too early that could cause surges in cases at hospitals. Lastly, participants discussed fearing for their family members and themselves being exposed to COVID-19 in public.
Participants described societal stress from fear of acquiring COVID-19 due to a lack of clear national safety guidelines, as well as fear of premature relaxation of distancing guidelines and rising COVID-19 infection rates. Participants described specific fears about immunosuppressed loved ones suffering from government public health mandates that could put vulnerable populations at risk. Participants expressed that the beginning of the pandemic was a time of heightened fear and uncertainty, yet these feelings decreased over time.
While few participants stated truly positive appraisals of the societal level stressor of COVID-19, many expressed a quick adjustment and acceptance of COVID-19 as the new normal. They adapted to testing for infection before attending events and helping their families navigate this space. Others expressed how they could handle the stressor of the pandemic as long as they had the proper PPE.
Resources
Two overarching themes related to authenticity and nurse-centeredness in the delivery of resources were identified, along with six types of resources: emotional support, staffing, safety, compensation, communication, and stress management. Both positive and negative appraisals were observed across all resource types. Table 3 presents these resources, along with their definitions and the positive and negative evaluations from RNs and NAs for each resource.
Authenticity and nurse-centeredness in the delivery of resources.
Two cross-cutting themes emerged regarding the delivery of resources. Across many different types of resources, participants emphasized the importance of how resources were delivered. They described key themes such as authenticity, individualization, and integration of supports into their workflow. For example, participants noted that the same small gesture could evoke drastically different reactions depending on the context of its delivery. A large ice cream party from hospital administrators was perceived as “a slap in the face” or dismissive and impersonal, whereas a chaplain offering a cookie during a one-on-one visit was perceived as genuine and supportive. Participants thought it was important that there were a variety of resources offered, recognizing that what works for one person might not be the same as what helps someone else. Participants also discussed barriers to accessing and utilizing certain resources, which often felt like “lip service” or superficial efforts rather than meaningful support. They expressed frustration that if management genuinely valued their mental health, they would prioritize structural changes, such as providing protected time for lunch breaks.
Emotional support from managers, chaplains, and coworkers.
Participants noted the importance of emotional support from managers and coworkers as a crucial resource for RNs and NAs navigating the challenges posed by the pandemic. Requests for emotional support encompassed various forms of support, including managers proactively checking in on nursing staff through individual or group meetings, chaplains offering avenues for RNs to decompress and seek solace amidst the distressing experiences encountered at work, and peers extending emotional support to one another, both within the workplace and in their personal lives. Many participants viewed this support positively, highlighting that their managers did what they could within the constraints of the crisis situation, and chaplain services were especially appreciated, with some recommending expanded access to chaplain support. Peers were also recognized as a vital source of strength due to their shared experiences and mutual understanding. However, not all participants experienced this support. Some described a lack of emotional support from both peers and management, especially among those working in float pool positions who were not assigned to a consistent unit. These participants often felt isolated and overlooked, emphasizing the uneven distribution of support and its impact on staff well-being. This contrast underscores the critical role that consistent emotional support plays in bolstering resilience and sustaining the healthcare workforce during crises.
Staffing and personnel.
Participants endorsed good staff-to-patient ratios, with travel RNs to meet gaps and experienced staff to better manage the stress of providing care during COVID-19. Retention efforts such as hazard pay or bonuses for staying rather than paying travel RNs high/signing bonuses was a highly requested intervention.
Staffing was typically the first area mentioned by participants when asked about recommended supports. Participants noted challenges around short staffing and the way staffing was handled. Participants described being floated to unfamiliar units to meet staffing demands, which was particularly challenging especially if being floated to a different nursing specialty. Alternatively, some reported a reduction in work hours due to changes in providing elective procedures and a decrease in patient volume census. Participants recommended a greater emphasis on retention (bonuses for staying rather than or in addition to hiring bonuses), noting the importance of maintaining experienced staff given many left the institution for example to retire early or seek better paying travel nurse contracts. They also mentioned challenges because of shortages in other roles of the health care team and the importance of the larger collaborative team, as many tasks fell to RNs to do. For example, due to limited hospital visitors and reductions in support staff had to take on responsibilities that would typically be handled by others, such as transporting patients, a task usually done by support staff, or providing additional emotional support, which would often be shared with family members.
Participants expressed a complex mix of understanding and resentment regarding RNs leaving to work as travelers for better pay. However, they also acknowledged travel RNs as a valuable resource for addressing staffing issues and wished that their units had brought them on sooner. Additionally, strong RN-to-patient ratios were seen as a positive, and access to experienced staff was deemed critical.
Personal protective equipment and safety.
Safety refers to the presence and availability of resources, processes, or systems that protect RNs from physical, emotional, or occupational harm while performing their duties. This includes, but is not limited to, the provision of adequate PPE, adherence to infection control policies (e.g., vaccination mandates, symptom checks), and access to security personnel. PPE and vaccines were the most spoken of issues around safety.
Some healthcare workers felt unsafe due to inconsistent safety protocols, particularly before all patients were swabbed for COVID-19. They preferred working in COVID-19 units where full PPE was standard because on other acute units, there was uncertainty about whether patients had the virus and subsequently less PPE. The initial lack of clear separation between COVID-19 and non-COVID-19 units heightened anxiety. Although safety improved after units were assigned, frustration persisted with coworkers who did not believe in vaccines and patients who frequently removed their masks, contributing to a sense of inevitability about getting COVID.
Many healthcare workers expressed confidence and a sense of safety in their workplace due to the availability of proper PPE. While masks were mandated in the hospital, but not always outside, staff felt safer in the COVID-19 unit because of the full protective gear required there. This reassurance of safety allowed them to focus on their duties and manage the stress of the pandemic more effectively, knowing they were well-protected.
Benefits, compensation, and gifts.
Participants expressed appreciation for certain benefits and suggested additional financial incentives and support to make working more appealing or manageable. These included hazard pay, tuition reimbursement, parking, accessible childcare, and benefits such as paid time off (PTO), Family Medical Leave Act (FMLA) leave, and disability support. Additionally, they appreciated small tokens, cards, food, and parties from the community, managers, hospital, and others to show appreciation and recognition, including ice cream or pizza parties.
Participants expressed dissatisfaction with the access to childcare assistance and raised concerns about the fairness and transparency of available benefits and compensation. Additionally, some participants felt frustrated with the generic nature of gifts from hospital leadership, feeling that small gifts like ice cream or a pizza party would not solve their problems.
Participants expressed their gratitude for the available benefits and compensation. In one instance, a colleague donated PTO to support a team member during a family emergency, which was deeply appreciated. The act of receiving gifts made participants feel valued and acknowledged, particularly when the gesture came from an individual.
Communication and knowledge.
During COVID-19, participants noted that the protocols and knowledge they needed were rapidly changing due to the new and emerging disease. Some participants felt they lacked access to essential information, highlighting the necessity for improved communication channels. Participants expressed the need for greater communication and transparency regarding rapidly changing protocols and knowledge during the COVID-19 pandemic to ensure they could stay up to date on best practices. Staff recommended improving communication channels by suggesting a variety of accessible and consistent methods to help RNs and NAs obtain the information they need. Participants noted that communication channels such as town hall meetings, Webex staff meetings, training sessions, journal clubs, and the intranet were valuable tools for obtaining essential information. Transparent communication and routine check-ins, including access to a resource RN, were highlighted as crucial for ensuring all staff were well-informed.
Health, wellbeing and stress management.
Participants discussed how hospitals provided health, well-being, and stress management resources such as on-site cafeterias and coffee, opening conference rooms for lunch, providing break/quiet rooms, offering pet therapy, having TVs available, hosting support groups, offering Employee Assistance Programs (EAP), utilizing wellbeing indexes, providing online resources for wellness and meditations, and encouraging physical activity. These resources can help take care of basic needs, manage stress, cope with mental health challenges, and cope with workplace stressors.
Participants highlighted the need for more time and support to attend to their basic needs, such as having proper lunch breaks and staying hydrated. While the hospital promoted online mental health and stress management services, very few participants interviewed actually described utilizing these resources. It is important to note how the availability of these virtual resources did not necessarily translate to the RNs feeling like they had the time to access them, especially if they were not even able to take regular lunch breaks.
Several participants talked about using therapy offered through EAP and found it helpful. One participant mentioned that they would not have sought therapy if they had not known about EAP. The resource helped them cope with the grief and loss they were experiencing outside of work, enabling them to continue performing well in their job despite the personal challenges they were facing.
Discussion
At present, the start of the COVID-19 pandemic was nearly six years ago. While this research was framed as highlighting gaps in the ability to respond to a pandemic, it also illuminates broader systemic weaknesses in healthcare’s ability to manage crises and maintain quality care in routine practice. The findings provide insight into the experiences of RNs and NAs, identifying stressors, available resources, and gaps in support systems. Addressing these gaps is critical for improving workforce well-being and strengthening crisis preparedness. In light of these findings, this discussion will outline the major themes, strengths and limitations of the study and offer recommendations for future research. Additionally, it will provide actionable suggestions for RN managers and health system leaders to translate these insights into meaningful policy and practice improvements.
One key theme emerging from this study is the disproportionate exposure of RNs to COVID-19, leading to significant stress and burnout. RNs spend the majority of patient contact time, accounting for 86.1% to 88.2% of total time in intensive care unit patient rooms, compared to physicians’ 9.9% to 13.1% [3]. This prolonged exposure translated into higher mortality rates among RNs than physicians [4]. Given their increased mortality rates, low-paid health workers, such as RNs and nursing home staff, were referred to as the “sacrificial lambs” of the pandemic in some reports, [32] reinforcing the essential role of nursing in crisis response and the necessity of ensuring their protection and support. Data from the National Nurses United revealed significant racial disparities in COVID-related RN deaths, with Black and Filipino nurses disproportionately affected, underscoring critical equity issues that require further exploration to address systemic inequities and ensure protection for all nurses [33]. Past research has extensively linked workplace stressors to burnout and its negative consequences for patient care and RN retention [9,12,34]. However, while studies have quantified the financial and organizational impacts of turnover, [35,36] there remains a gap in understanding the specific stressors faced by RNs and NAs during the COVID-19 pandemic and how they perceived available resources [23,24].
Another critical finding was the importance of authentic and RN-centered resource delivery. Participants perceived similar resources differently based on whether they felt the support was genuine or superficial. Unit managers were identified as crucial sources of support, as their presence was seen as personal and meaningful, contrasting with impersonal gestures from hospital leadership. Research supports the role of authentic leadership in fostering trust, job satisfaction, and retention [37,38]. In addition to nurse managers, chaplains were seen as a significant source of support for nursing staff, particularly because the chaplains proactively came to them making this support more accessible. Research on chaplain care for healthcare staff continues to expand, underscoring the vital role chaplains play in addressing workplace challenges like work-life stress, moral distress, and ethical concerns. Interventions among pediatric ICU nurses demonstrate improved coping, enhanced work-life balance, and greater optimism and problem-solving abilities [39]. Our findings are in alignment with other recent studies which highlight their significant contributions during the heightened stress of the COVID-19 pandemic, where chaplains provided essential support to staff [40–42]. This study contributes to the growing evidence that chaplains may be especially suited for supporting nursing staff because they can deliver support in an authentic and nurse-centered way. Furthermore, embedding support into nursing workflows, including compensated educational time, unit managers collaborating with night and weekend teams, and guaranteeing resource accessibility, was deemed vital for effectiveness.
Participants also reported that rapidly changing policies and procedures were major stressors and that nurse managers helped communicate these changes. Nurse managers serve as intermediaries between administration and front line staff, and their ability to effectively communicate and implement policy changes is crucial [43]. However, during the pandemic, nurse managers faced extreme workloads, ethical dilemmas, and high stress, requiring both individual and structural interventions to support their role [44–46]. Research indicates that leadership styles such as transformational, authentic, ethical, and servant leadership positively influence RN well-being [38]. Thus, strengthening RN manager competence and job satisfaction through targeted interventions could yield downstream benefits, including improved care quality and reduced turnover [47–51].
Staffing shortages exacerbated stress and burnout, leading to increased turnover and loss of institutional knowledge as experienced staff retired early. Participants expressed frustration over being reassigned to unfamiliar units without adequate support or cross-training, which added to their stress. Workplace relationships were related to higher stress levels, with participants reporting that coworker support, or lack thereof, affected their ability to cope. Bullying, racism, and ineffective communication further compounded stress, underscoring that adequate staffing alone does not resolve workplace challenges. State-mandated RN staffing ratios have been shown to improve patient outcomes, reduce burnout, and increase job satisfaction [52]. Additionally, while travel RNs do not negatively impact patient outcomes, they are often viewed unfavorably by permanent staff, complicating team dynamics [53]. Increased wages do not directly reduce burnout but do improve job satisfaction and retention [54]. These findings highlight the need for holistic staffing strategies that go beyond hiring additional personnel to address underlying workplace culture and support structures.
Strengths and limitations of the work
The study has some limitations. The reliance on retrospective interviews, conducted in 2021 after COVID-19 vaccines became available, introduces the potential for recall bias, as participants may not accurately remember or may reinterpret past experiences. Additionally, given the extended data collection period, it is challenging to distinguish between appraisal and existing coping or adaptation, particularly as participants expressing positive (non-threat) appraisals may reflect post-coping adaptations rather than initial appraisals of COVID-related stressors. A limitation of the study was that transcripts were not returned to participants for review, and member checking was not conducted; however, the results were disseminated back to participants to disseminate findings. The findings may also have limited transferability, as data were collected from a single hospital, restricting applicability to other healthcare settings.
Nursing assistants, particularly those working on COVID floors, were harder to recruit than registered nurses, leading to their disproportionate representation in the study and potentially limiting insights into assistive personnel’s experiences during the pandemic. Further research could include comparative designs between RN and NA workplace stressors to further isolate and understand the experiences of NAs. Furthermore, the present analysis does not examine individual coping dimensions, which are a critical component of Lazarus and Folkman’s model as part of secondary appraisal. Future research may include individual coping to understand how nursing staff navigate stressors in addition to workplace resources. Additionally, despite reflexivity efforts, researcher bias remains a concern, as all study team members had backgrounds in nursing, which could have influenced data interpretation. To address these limitations, future studies could include multiple institutions, collect data closer to real-time to reduce recall bias, integrate individual coping experiences, and incorporate external researchers to enhance objectivity in qualitative analysis.
Despite these limitations, this study demonstrates several strengths, including its use of Lazarus and Folkman’s Stress and Coping Model, which provides a well-defined theoretical framework for understanding how RNs and NAs managed stress during the COVID-19 pandemic. This study’s strengths lie in its in-depth exploration of the multifaceted stressors faced by both RNs and NAs, categorizing them into personal, interpersonal, organizational, and societal domains. By including both positive and negative appraisals, the study provides a nuanced understanding of nursing staff’s RNs’ experiences during a crisis. The rigorous qualitative methodology, including directed content analysis, investigator triangulation, and an audit trail, enhances the credibility and dependability of the findings. Additionally, the purposeful stratified sampling ensured diverse representation of both COVID and non-COVID inpatient nursing staff, allowing for a more comprehensive exploration of their experiences.
Recommendations for further research
Building on the findings of this study, several directions for future research are recommended. The findings underscore the urgent need for health systems to implement evidence-based strategies that enhance crisis preparedness and address long-standing workforce challenges. This study reveals a critical cross-cutting theme centered on the authentic and nursing-focused delivery of resources. Specifically, it identifies six key types of resources necessary for supporting healthcare workers: emotional support, staffing, safety, compensation, communication, and stress management. These insights should guide future research to prioritize the testing and development of targeted interventions aimed at boosting the resilience and well-being of healthcare workers, such as chaplain-led interventions. Future research should also incorporate individual coping dimensions to provide a more comprehensive understanding of how both personal and organizational factors influence stress and coping mechanisms. The COVID-19 pandemic has highlighted significant gaps in the ability of health systems to respond effectively to both crises and routine care needs. Addressing these deficiencies requires developing and evaluating RN-centered interventions that offer robust support mechanisms for RNs and NAs, focusing on stress management, resource availability, and overall workplace well-being. Additionally, future research could explore other operational outcomes such as staff burnout and staff intention to leave or turnover. Collaboration with NAs, RNs, nurse managers, health system leaders, and governmental entities will be crucial in designing interventions that are practical, scalable, and sustainable. By investing in comprehensive intervention development and testing, future research can play a pivotal role in preparing the nursing workforce for future crises and enhancing quality of care and organizational outcomes.
Implications for policy and practice
Based on the current findings, several actionable strategies and recommendations can be implemented at the unit, organizational, and policy levels to enhance supportive workplace environments and address workplace stress during crises. At the unit level, recommendations include providing more resources and authentic leadership training for RN managers and ensuring management is physically present across all shifts to support staff [55–57]. Organizational-level recommendations focus on maintaining access to essential services during crises, offering mental health and wellness programs, enhancing communication systems, providing structured training, increasing compensation and benefits, sustaining a supportive workforce, and focusing on staff retention [18,55–65]. Societal and policy recommendations call for establishing state-mandated adequate RN-patient ratios and enforcing vaccine mandates to ensure workplace safety [66–69]. For a detailed summary of participant-driven recommendations and the supporting evidence base, refer to Table 4. By adopting these strategies, health systems can better support their workforce and improve overall care delivery in both routine and crisis situations.
Conclusion
This qualitative descriptive study explored the experiences of RNs and NAs providing inpatient care during the COVID-19 pandemic, focusing on their work-related stress, how they appraised that stress, and the workplace resources available or needed to manage these challenges. The findings highlight critical gaps in crisis preparedness, leadership support, and staffing strategies. Addressing these issues is essential to improving RNs’ and NAs’ well-being and ensuring high-quality patient care. By investing in sustainable workforce solutions, fostering authentic leadership, and implementing meaningful systemic changes, health systems can create a healthcare environment that better supports and values its nursing workforce.
Supporting information
S2 Appendix. COREQ (Consolidated criteria for reporting qualitative research).
https://doi.org/10.1371/journal.pone.0345525.s002
(DOCX)
Acknowledgments
Research reported in this publication was supported by the Dick and Timmy Burton Post-Doctoral Fellowship at the University of Utah College of Nursing. The content is solely the responsibility of the authors and does not necessarily represent the official views of the University of Utah.
We are grateful to the staff nurses and nursing assistants who participated in our study and shared their experiences, strengths, and challenges in delivering care during the pandemic. We also thank the members of the Nursing Research Council for their support and assistance in facilitating this hospital-wide study. Finally, we thank the Dr. Cheryl Jones for her support of this work.
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