Nurses’ health and work experiences during the COVID-19 pandemic in Swedish prehospital and hospital care: A deductive content analysis through the lens of the swAge model

Nurses’ health and work experiences during the COVID-19 pandemic in Swedish prehospital and hospital care: A deductive content analysis through the lens of the swAge model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Nurses’ health and work experiences during the COVID-19 pandemic in Swedish prehospital and hospital care: A deductive content analysis through the lens of the swAge model CICILIA NAGEL, Petra Nilsson Lindstrom, Albert Westergren, Sophie Schon Persson, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5069662/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Jan, 2025 Read the published version in BMC Public Health → Version 1 posted 4 You are reading this latest preprint version Abstract Nurses represent a high percentage of employees in health care; however, there is a shortage. Working as a nurse includes both advantages, such as job security, and disadvantages, such as a greater risk of developing mental ill health. Aim: To explore which salutogenic and pathogenic factors influence nurses’ health and work situation. Methodology: In-depth interviews with nurses who worked during the COVID-19 pandemic. Snowball sampling and deductive content analysis were performed. Findings: When conditions were lacking in providing good care, there was a feeling of betrayal and anger toward the organizations. Moreover, collegial support was crucial for mental health, and some nurses experienced flourishing. Conclusion: Healthcare professionals in Sweden face several challenges, including undersized organizations and the need for primary care expansion to reduce hospital burdens. A better balance of resources (equipment, funding, staff) is essential for nurses to perform effectively. Strong colleague support enhances interprofessional collaboration, but organizational prerequisites are crucial. Improved working conditions and organizational support help retain nurses. Identifying factors for a sustainable working life involves understanding nine key areas and their interactions. Healthcare organizations and managers should consider these areas to promote sustainability. To ensure a competent supply, we must rethink the resources we have by using new working methods, digitization, the transfer of tasks to primary care, etc. Nurses must advocate for equitable systems, fair compensation, and safe environments. Nurses salutogenic pathogenic work situation health deductive analysis 1. Background Nurses constitute the largest workforce in healthcare services [1]. High turnover among nurses has long been acknowledged as a worldwide problem [2]. Owing to existing nursing shortages, the aging of the nursing workforce and the long-term effects of COVID-19, ICN estimates that up to 13 million nurses will be needed globally to fill the nurse shortage gap in the future [3]. To secure a well-functioning healthcare service, it is important to have a sufficient number of nurses. However, demographic changes imply that a lack of labor supply in the healthcare sector is a past, current and future concern in most European countries as well as in the U.S. [4–5]. Nursing is a profession with unique potential for exposure to environmental and occupational hazards in the work setting [6], especially since much of the work involves direct contact with patients [7]. Despite all the negative work experiences that nurses describe, there are many positive aspects to the profession, such as job security, colleagues, developing communication skills and having great opportunity for advancing in their career, according to further studies. Such salutogenic factors and processes promote work-related health and contribute to and maintain the health and well-functioning of the individual, in an organization or in a society [8], whereas the pathogenic perspective focuses on understanding the origins of health risks and treating disease [9]. Previous research [10–11] has shown that a sense of coherence can maintain or improve an individual’s health when faced with adversity. In nursing, having a sense of coherence has been shown to be a strengthening resource for work-related well-being when facing challenging work situations [12]. Nurse well-being at work is defined as a nurse’s positive evaluation of oneself and one’s contributions to the work of nursing [13]. Nurses’ well-being is conditioned by both the work and personal resources available. Work resources refer to the physical, psychological, organizational, or social aspects of the work that must be performed to provide quality care [14]. Personal resources refer to a person’s characteristics, including those related to a sense of control and resilience in trying to control their surrounding environment [14]. On the other hand, nurses’ health problems can be caused by poor working conditions [15]. A physically strenuous working environment can lead to poor health [16]. The heavy lifting and strenuous work postures that are common in nursing have been shown to contribute specifically to neck, shoulder, and knee conditions, as well as to lower back pain, which in turn can be associated with leaving nursing care [17]. Job stress can jeopardize the physical and mental health of nurses, reduce their energy and work capacity, result in inadequate care, and, in turn, negatively impact patient outcomes [18]. Studies have shown that nurses have a greater risk of developing mental health problems due to continuous exposure to workplace risk factors such as shiftwork [19], human suffering, inadequate staffing and heavy workloads [20]. Studies have also shown that healthcare workers have higher rates of suicide [19; 21]. Thus, nurses are considered to be at high risk of stress-related disorders [22], and their work situation may be associated with adverse effects, such as stress and burnout [23–24]. The COVID-19 pandemic has increased work stress among already strained nurses, putting their mental health and well-being at risk [25]. According to an American study, nurses use personal protective factors to build personal resilience to cope with challenges and difficult situations while increasing their ability to face future situations and achieve a greater level of well-being [13]. Unlike most countries that imposed strict lockdowns and widespread closures, Sweden opted for a more lenient approach where the focus was on social distancing measures. Nurses and other healthcare professionals must perform patient care in full personal protective equipment [26]. The COVID-19 pandemic has become an extreme situation; thus, nurses’ voices need to be heard, which is why this study, where we look at most parts of nurses' lives and work situations, is important. 2. Aim The aim was to identify the salutogenic and pathogenic factors that influence nurses’ health and work situation related to the COVID-19 pandemic in Sweden. 3. Method 3.1 Setting and sample The informants in this study worked as nurses in either the southern or middle part of Sweden during the COVID-19 pandemic. The participants’ sociodemographic characteristics are described in Table 1 . Snowball sampling was used to reach nurses from different settings and achieve a wide range of experience. The first author sent out a request for informants in a social media group for anesthetic nurses in the Region of Skane in southern Sweden, where the initial informant replied and was given more information about the aim of the study. Other informants were found through the first author presenting the study at staff meetings at different wards and through the first author’s contact net. The inclusion criteria were as follows: registered nurses who encountered COVID-19-positive patients at their workplace (such as ambulances, emergency departments, intensive care units, specialized COVID-19 units and infection control wards) and who had a good understanding of Swedish or English. After twelve interviews, the data started to become saturated, but two more interviews were conducted; in total, 14 nurses from southern Sweden and the middle of Sweden were interviewed. Table 1 The participants’ sociodemographic characteristics. n = 14 Age, mean (range) 40 (29–64) Gender (female) (%) 9 (64.3) Postgraduate Diploma in Specialist Nursing, n (%) 7 (50.0) Civil status n (%) Live-in partner 4 (28.6) Married 8 (57.1) Single 2 (14.3) Years in the profession n (%) 30 3 (21.4) Workplace for the participants n (%) Ambulance 3 (21.4) Emergency care 4 (28.6) Infection unit 3 (21.4) Specialized COVID unit (non-ICU) 1 (7.2) Intensive care unit (ICU) 3 (21.4) 3.2 Design A qualitative study with individual semistructured interviews was conducted since qualitative research focuses on understanding individuals' experiences, perspectives and behaviors in their natural environment, in this case, nurses. In-depth questions such as “Can you describe in your own words what happened when the pandemic came?” were asked, and depending on their answers, further probing questions were asked. Individual interviews were chosen as a data collection method to ensure that the nurses’ unique circumstances and needs were the focal point of the interviews [27]. Individual interviews are preferable when there are sensitive questions since they give the informant a better opportunity to open up and share their experiences [27]. 3.3 Data collection The interviews took place in May/June 2023 and October/November 2023. All interviews were performed by the first author. The semistructured interview guide that functioned as a checklist for the interviewer was based on the results from the SwAge model [28–30], which consists of nine determinant spheres of a sustainable working life for all ages, salutogenic theories [8–9] and results from previous studies from this research group [31–32]. The interview guide was processed by the authors and agreed upon. After three pilot interviews were conducted, the authors made small adjustments to the interview guide. The interview locations were chosen by the informants; five of the interviews were conducted in conference rooms adjoining their workplace, four in a room at a nearby library, three in the informants’ offices and two at local coffeeshops. The interviews lasted between 64 and 119 minutes; informed consent was obtained from each participant. Each interview was recorded and transcribed verbatim. 3.4 Data analysis All the interviews were transcribed verbatim and pseudonymized by the first author. Each interview was given a number between 1 and 14. Content analysis was used to obtain a condensed and broad description of the phenomenon. The data from all the interviews were organized in NVivo software (version 14) and analyzed by researchers C.N. and K.N. through deductive content analysis [33–35] on the basis of the theory of a sustainable working life for all ages (SwAge model) [28–30]. A deductive content analysis was chosen to distill the relevant portions of the gathered data. Deductive content analysis is an appropriate method when the text is interpreted from predetermined (theoretical) codes. Deduction involves drawing conclusions from general principles to specific instances. In deductive content analysis, existing theories and prior research inform the refinement and potential extension of a theoretical framework [36]. Our study followed several steps: constructing a thematic matrix based on theories and the determinant spheres in the SwAge model [28–30]; reading all interviews together to gain a holistic understanding (done twice); marking specific interesting parts in the text; color coding; and finally grouping codes on the basis of their meanings, similarities, and differences into themes. All the authors contributed to the final content analysis. The presentation of deductive findings in our results section is organized around the four predetermined themes derived from the determinant spheres of the theoretical SwAge model [28–30]. Some experiences address issues across multiple themes, leading to their inclusion in more than one of the four main themes : health effects of the work environment : 1. the diagnoses, self-rated health and functional diversity; 2. the physical work environment; 3. the mental work environment; 4. the working hours, work pace and time for recuperation; the financial situation; 5. personal finances; social inclusion, support and sense of community; 6. the personal social environment; 7. the social work environment; the execution of work tasks and activities; 8. work satisfaction, motivation, stimulation and the core of work; and 9. knowledge, competence and ability. 3.5 Ethical considerations The study was performed in accordance with the Declaration of Helsinki [37] and with the Swedish law of research ethics [38]. The benefits of the study were deemed to outweigh the potential harm to the informants. The rules for data management and data storage were followed in accordance with the University Policy as well as the GDPR [39]. Participation in the study was voluntary, and informed consent was obtained from all the informants. The study was approved by the Swedish Ethical Review Authority (2016/867 and 2020 − 01897). 4. Findings The analysis focused on in-depth investigations and identification of both salutogenic and pathogenic factors in nurses’ complex work situations before, during and after the COVID-19 pandemic. Below, the deductive findings are reported on the basis of previous research on nine areas of importance for sustainable working life, i.e., the SwAge model [28]. 4.1 Nurses’ health Some nurses described that their health and well-being continued to be good before, during and after the pandemic. They did not get COVID-19 and did not feel stressed. They felt that since they could not control what happened, they just went with the flow. Not being afraid of infecting others with the virus. In contrast, there were those who had concerns but felt like they could not think about it constantly. “…I didn’t care too much about the risk of infection because it was not something that you could go around brooding over and at the same time do the work that was expected of us…” (Informant 1) On the other hand, there were many things that they still carried with them and that they had trouble sleeping at night because they thought about what they had witnessed, things that they could have done differently and many ‘what ifs’, informants described that they could still not fall asleep unless listening to podcasts or the radio to switch off their thoughts. They described having to work during the pandemic while not feeling well, how their workload affected their mental health and how that, in turn, manifested in physical symptoms such as heart palpitations, pain, anxiety, headache, and exhaustion. Some of the informants stated that they had been on extended sick leave during and/or after the pandemic. There were also physical injuries due to wearing personal protective equipment (PPE), such as hair being pulled off, allergic reactions, eczema, and wounds on the face. They also described that they were worried about the long-term effect of having to wear facemasks of low quality for extended periods, leading to the material disintegrating and causing them to breathe in particles. With public gyms closed, the nurses had inferior circumstances to maintain their physique to stay healthy and avoid injuries. 4.2 Physical work environment. The informants described not having relatives accompanying the patients as both positive and negative. The positive side was that there was more space in the wards since most patients usually had one or two relatives with them. The negative aspect was that many, especially older patients, were left by themselves, thus making it more difficult for nurses and other healthcare staff to notice declines in patients’ health since they were unable to constantly monitor patients. Improving organizational skills, developing new ways to work and, in some instances, refining procedures that require fewer staff members were positive effects of the pandemic. In contrast, the nurses described that there was a shortage of PPE, hand sanitizer and medicine during the pandemic. In some cases, nurses had to work without proper safety equipment. Some nurses stated that safety equipment, such as visors and military-grade breathing masks, was available but that they were not allowed to use it since it lacked proper CE-marking. Some nurses decided to go against this and wear military-grade breathing masks. Many noted how the guidelines regarding which PPE were to be used changed depending on what material was available in their department: "...because as I saw it, it was quite obvious that they started to reduce the safety requirements in relation to the staff in regard to what kind of material they had available and that is a betrayal" (Informant 4) Several nurses described how they were asked to reuse protective equipment and, in some cases, save their breathing masks in a special container if, by some chance, the technological advances were to find a method to sanitize them. They described how, in some cases, they worked in rooms with more than one patient and how doctors would sanitize their gloves before walking to the next patient. The nurses described how they were told to wear long sleeve robes, gloves, breathing masks and visors while going between patients in the intensive care unit (ICU) and that when they questioned this, they were told that it was a standard procedure. Some nurses stated that they in their workplace had a seasoned nurse assistant that had secret stashes of gloves and other material, which they were very thankful for since that meant that they still had material unlike other wards. All the informants agreed that working in the PPE was exhausting and hot and that they found it difficult to communicate while wearing it. The physical work environment itself was described by most nurses as not being the best even before the pandemic with overcrowding, a lack of beds, etc. During the pandemic, many wards had to reconfigure their spaces by building temporary walls and using whatever space was available, such as ambulance bays and outpatient clinics. This led to several negative events “It turned out to be a bit of a fake build, so it happened that there was a pensioner who came in and was not truly very sick; she leaned on a railing that was not screwed down properly and fell, then she got a subdural hematoma instead.” (Informant 1) Some drawbacks to the changed work environment were that ambulances had to offload their patients outside regardless of weather conditions, thus exposing patients, some very critically ill, both to the elements but also to a lack of privacy. Cramped patient spaces filled with medication pumps and ventilator hoses, some wards were not equipped for the high level of care needed, poor ventilation, and having to spend time searching for equipment or materials caused frustration among the staff. Nurses had to work in tents or sheds outside without proper heating to triage patients coming into the emergency wards. The increased need for high-level care has led hospitals to open intermediate care departments and specialized COVID-19 units. With the increased need for patients on respiratory care, ICUs had to use dated respiratory machines and borrow anesthetic machines from operating wards. One redeeming factor that facilitated work was that nurses who worked in the emergency wards claimed that the flow of patients to the wards improved during the pandemic because most patients ended up in infection clinics. 4.3 Mental work environment. Some nurses stated that they did not believe that the pandemic would reach Sweden or that it would be like a regular influenza. When the pandemic hit, they felt caught off guard regarding how ill some of the patients were, and nurses described the pandemic as being slapped in the face. Several nurses stated that they were not prepared mentally for a second or third wave of the pandemic. Stress was a major denominator, whether it was ethical stress from not feeling that your best was good enough and that you were always one step behind or if it was because they were reallocated to other wards (voluntarily/involuntarily) or lacked time to perform work duties or stress from not being able to find material and/or equipment in their usual location during the pandemic. Some nurses felt that it was stressful not to be in control of the situation and expressed how high some of the demands were, both from the organization, from the patients and ultimately from themselves, for them to cope with all the changes. One thing that alleviated some of the stress was when the doctors started calling the patients’ relatives and updating them on their situation, which led to fewer calls into the wards, which in turn freed up time for the nurses to tend to their patients. With respect to threat and violence, the nurses stated that there was always an element of that but that it usually stemmed from anxiety and frustration. Some nurses stated that it increased during the pandemic when relatives were not allowed into the hospital and when patients were turned away from the hospital and asked to seek help/treatment in primary care; hence, nurses (and other hospital staff) faced both patients and their relatives’ frustrations. Many nurses described that their mental health was affected by their work situation, whether it was having seen and/or experienced tragic patient losses, feeling anxious due to fear of making an error or feeling frustrated that they were unable to perform well at work since the conditions were lacking and that things had to be good enough. Many nurses described unethical situations. "...when you had to stand with these old people who had to die in your hand without relatives/.../and I have stood there with a gas mask on, it was not dignified, it is not okay…" (Informant 10) Some nurses described the mental work situation as being emotionally draining owing to rapidly changing routines, feeling a sense of prepping, or going into survival mode, or feeling that their work identity was taken away from them by being forced to work in other wards/other shifts or not being able to offer support to colleagues owing to restrictions and themselves feeling emotionally drained. There was also frustration, especially from paramedic nurses, about having to be exposed to the virus when dealing with patients who did not truly need help. 4.4 Working hours, work rate and recovery. Some of the nurses who worked in emergency departments stated that their workload decreased, especially at the beginning of the pandemic, when they experienced a lower influx of patients because people feared coming to hospitals and later in the pandemic due to a better outbound patient flow. On the other hand, the increased work pace during the pandemic as well as increased sick leave resulted in some nurses not being able to take breaks on their workday, whereas in some wards, they were able to go on their lunchbreaks. The increased sick leave resulted in nurses having to work extra shifts, double shifts and frequent shift changes with short notice, all of which affected the possibility of recuperation. Nurses described how they had difficulty sleeping and how they walked around in a blur on their days off; some nurses lacked the energy to exercise and that it was somewhat draining waiting for that call to come, asking them to do extra shifts. They described not being able to mentally recover from the pandemic because it was all around them, regardless of whether they were in a store or at home, listening to the news and feeling tired and anxious about having to return to work. "...it was terrible not to like your job, to sort of feel Sunday night that now it is Monday again/…/to dread going to work..." (Informant 6) Nurses were thankful to those who had been reallocated to their ward/unit, but some stated that it did, in fact, cause extra strain on the experienced staff from having to monitor both their own patients but also felt that they had to monitor the other staff. A positive effect of the pandemic that the ICU nurses described was that some experienced nurses were allocated as team leaders in rooms where there were several patients and that these team leaders were allocated only one patient so that they could support the other staff allocated to that room. Whereas many nurses stated that they did not receive compensation for their overtime, a few nurses stated that when they did overtime, they were given so-called “COVID-time” that they could claim when they felt they needed rest, and the managers tried to accommodate this when they had the opportunity to do so. 4.5 Personal finances As mentioned previously, several nurses faced long-term sick leave during and/or after the pandemic, which affected their personal finances. Most of the nurses stated that they were not given any compensation other than from the extra work hours they performed; most of the nurses stated that they had hoped for. On the other hand, with society in more or less lockdown, they did not spend much money. "I have worked a lot of extra shifts/.../I have accumulated a lot of money and that is good, but it is not an active choice…" (Informant 4) Before and during the pandemic, some nurses stated that they had considered leaving their workplace and even the profession but that it was probably not the right time at the moment; after the pandemic, many nurses left their workplace and even the profession. Among the informants, five out of fourteen nurses changed their workplace after the pandemic. One thing that most nurses described was that they were glad that their work was not affected by the pandemic in an economic sense and that that was something certain they could hold on to in a situation when most things were uncertain. The supply of personnel from other departments and county councils meant a certain amount of work relief. 4.6 Private social environment. Having support and understanding from their families and friends was important, and most nurses experienced this to some extent. Some nurses reported that their worklife has been balanced due to the pandemic; they stated that they mentally brought their work home with them and that they were too tired and/or afraid of spreading the virus to meet up with others. Some nurses stated that their friends or family had difficulties understanding what they had to face at work and that their schedule could change with little or no notice. On the other hand, some nurses described that they had family and friends who worked or had worked in healthcare that could offer support and understanding. Something many nurses described as stressful was that they could receive calls from work during their time off. "... one's privacy is not respected and that in turn also affects people close to one , i.e., your partner or friends..." (Informant 7) Owing to many relatives working from home, some nurses stated that their recovery time was negatively affected. There was, however, little silver lining in that the fear of missing out was less prominent because most of society was shut down from time to time. On the other hand, many nurses felt frustrated toward those in society that did not adhere to restrictions and guidelines. Having to cope with going from one reality where they were caring for critically ill patients due to the pandemic to seeing people out and about without protective masks played havoc with their minds. 4.7 Work social environment. Support from work colleagues was unanimously described as good, as they felt seen and heard and that there was good teamwork—even with other professionals such as doctors and caring services. There was a sense of reliability and comfort among the staff, which is important for managing patient safety. With respect to support from managers, half of the informants felt that they had good support from their closest managers, whereas the rest felt that the managers were unsupportive and invisible. "...it was not the captain who stood at the frontline, but it was the captain who hid in the basement..." (Informant 2) Some of the informants said that their managers did not care for their employees; it was taken for granted that you should show up and work and that managers were not proactive, which created frustration. Trust in managers and the organization dwindled. Many nurses expressed resentment toward the organization, regional boards and the government for how they handled things during the pandemic and that Sweden's regions have failed in their task—that primary care must do its job. Most agree that it has not worked well at the organizational level but that it has been resolved at the individual/team level. "...I know that I once thought that now it is almost a social experiment that you are part of, you see it from the inside, what happens to an organization if it turns out like this?" (Informant 3) Many felt lied to, that the management should have been honest regarding the guidelines for which protective equipment they should use. Moreover, disappointingly, the managers convinced some to accept stimulus money instead of calling it over time, that it was dishonorable to buy yourself free from overtime to improve your statistics. Most informants felt that healthcare has not received the confirmation it deserves, that it is as if the pandemic never happened and that the rest of the world wants to put it behind them whereas many who lived it still must deal with the consequences from the pandemic. 4.8 Satisfaction, meaningfulness and motivation with work tasks. There was a lack of balance regarding work effort and reward. The informants stated that it was frustrating that nothing became of appreciation from the public during the pandemic. Some nurses stated that they felt unvalued as experienced staff and that it was hard to become motivated enough to go to work, especially when they were aware of what they would face during the pandemic. Both the high workload and the feeling that one sometimes over-treated patients affected their work motivation. Some felt frustrated that they were not doing what they were trained to, that they were stuck on administrative duties or that they were caring for persons who did not need their level of expertise. "...job satisfaction decreases when we care for patients we are not supposed to care for..." (Informant 13) Many nurses felt that even though it was hard work, it was satisfactory to feel needed and to be able to roll up your sleeves and feel that what you do makes a difference. Some stated that it felt like they grew with what they had to face, whereas others felt satisfied in watching other colleagues flourish. "...it was hard when it was going on in a way, but yes, it was very useful to have been part of it, very educational after all" (Informant 13) 4.9 Knowledge, competence and ability. The nurses described the importance of providing clear information on “the right level” to everyone involved, especially to those who perhaps lacked medical knowledge. Most nurses felt that they had been given information to perform their work duties but that it was difficult to keep up to date with the information since most information was given through work emails, which they did not have time to read. Some wards/units relied on whiteboards to convey the most recent information. A few nurses expressed that they wished the organizations had been proactive and contacted other clinics nationally and internationally and inquired about their experiences to be better prepared when the pandemic reached Sweden. Some nurses felt that there was a lack of competence either among themselves or from staff around them and that they were forced to work with patients above their skill level. "... it could be shifts when I was working as the most experienced nurse, well it was like I was expected to take care of patients who I hadn't even been trained on..." (Informant 7) While some nurses felt that there was a lot of learning by doing, they were also able to learn from what was less successful, which enabled them to obtain different perspectives and that their competence grew since this was not something they could learn by reading about in a book. Despite these challenges, some positive changes emerged from Sweden’s experience with PPE during the pandemic: healthcare personnel (HCPs) had to find creative solutions due to PPE shortages. They developed alternative cleaning methods and improved protective gear, showing resilience and adaptability. There was also increased awareness. The pandemic highlighted the importance of PPE for HCPs and the general public. This raised awareness about infection prevention and the need for adequate supplies. 5. Discussion We wanted to identify which salutogenic and pathogenic factors in the work situation influenced nurses before and during the COVID-19 pandemic, as well as after the restrictions were lifted. It was clear that the nurses were more or less prepared to sacrifice their health and, to some extent, their lives for patients' well-being, and some were still suffering the consequences of this. Some of the things we found were that many of the informants felt disappointment and even anger toward the healthcare organizations, that they were not given the prerequisites to perform the job that they wanted to do, and that they generally feared fighting an invisible enemy, i.e., the COVID-19 pandemic. Nursing operates within a social contract—a mutual understanding between healthcare organizations and the public they serve. This contract implies certain expectations and responsibilities. During the pandemic, many nurses felt that the healthcare system broke this social contract by not taking care of those who needed it the most—i.e., older persons. Nurses require certain prerequisites to perform effectively: adequate staffing to manage patient loads, a safe work environment, fair compensation regarding working hours, equitable pay and recognition. Some nurses felt that they were lied to and manipulated by the organizations. Instances of deception, manipulation, or broken promises erode trust. When nurses experience dishonesty or betrayal, their professional well-being and commitment are undermined. During the pandemic, nurses relied on their colleagues for support to alleviate stress and compensate for deficiencies. Self-rated health, diagnosis, injuries Research has shown that health and work environment health effects are crucial for a sustainable working life [28–30]. While some nurses in the present study stated that their health was not affected by the pandemic, some experienced poor self-rated health, such as problems sleeping and anxiety. Research [40] has shown that individuals who have an innate ability to withstand adversity or are able to maintain good interpersonal relationships are more likely to maintain good mental health and well-being during the COVID-19-related lockdown. The American Nurses Foundation [41] reported that nearly fifty percent of nurses reported stressful or traumatic experiences due to COVID-19. Many nurses were also found to have experienced anxiety or depression due to COVID-19 [42–43]. Many of the participants in the present study stated that they had been on extended sick leave due to exhaustion or burnout. As reported in previous studies [31–32], burnout and emotional exhaustion were common among nurses who worked during the pandemic. The conditions faced by nurses during the pandemic threatened their health and well-being as well as their ability to do their work [44]. Many nurses in the present study mentioned feeling stressed at work and from work. Work-related stress is a prevalent issue among healthcare personnel globally [45]. Research indicates that it increases the likelihood of cognitive failure, which, in turn, impacts patient safety [46]. With respect to physical health in this study, we have the whole array between physical well-being and physical ill-health. Most of the nurses in the present study reported that they were infected by the COVID-19 virus at work; hence, they suffered from work-related illness. Some of the nurses in the present study stated that they had experienced physical symptoms such as headache and muscle pain. A previous study [47] reported that when an individual experiences extreme stress and an overwhelming work situation, it can cause both psychological and physical symptoms. Healthcare organizations must look for nurses’ health and well-being. The American Nurses Association states that policymakers, healthcare leaders and institutions should recognize and address nurses’ unique mental health needs and implement strategies to ensure that these needs are met under all conditions [48]. As one study mentioned, healthcare organizations rely on healthcare professionals’ health and well-being to be able to provide efficient healthcare services [49]. This is important to consider for the future since we already face a global nursing shortage, with many more nurses nearing retirement age or leaving their work due to working conditions. Physical work environment Many healthcare systems were caught off guard and scrambling to provide beds and material during the COVID-19 pandemic, as described in an international literature review [44]. The physical work environment is an important area for a sustainable working life [28–30]. One concern in the present study was the suboptimal care environment, as well as patients being cared for at the wrong care level, which could lead to a lack of staff and patient safety. Temporary or remodeled departments meant that there were risks of work accidents, overloading of muscles and joints, and incorrect lifting techniques. According to the Swedish Work Environment Act [50], work needs to be planned so that it can be performed in a safe and healthy environment (2 §), and the workplace needs to be appropriate from a work environment point of view (3 §). Work hygienic conditions regarding air, sound, etc., need to be satisfactory (4 §). If we look at the results from the present study, these conditions were not met since nurses stated that they worked in temporary workstations outdoors without proper heating and on wards without proper ventilation. The lack of protective equipment or not being allowed to use available protective equipment since it does not have proper labeling could influence nurses’ health. One study [1] reported that the lack of protective equipment was a cause of unnecessary stress for nurses during the pandemic. The nurses in the present study also reported that working with protective equipment was exhausting, which was supported by other studies [1]. As previously mentioned, many nurses were infected with the COVID-19 virus while at work. As many described, both limited access to and improper use of said PPE increase the risk of becoming infected by the virus and/or spreading the pathogen to others. Having adequate personal protective equipment is a key factor in keeping healthcare workers safe [43]. From the positive aspects found in the present study, one can hope that the improved patient flow and intrahospital collaboration could continue to prevent patients from having to stay in emergency wards due to a lack of beds. Mental work environment Some nurses in the present study reported that they did not feel that the pandemic would affect them, as was also reported in other studies [1]. Many felt caught off guard and not prepared for how the situation would evolve. Different aspects and factors in the mental work environment were found to cause stress. The nurses in this study expressed ethical stress and conscience stress. While both ethical stress and conscience stress are related to ethical concerns, ethical stress is a more general term that encompasses a broader range of ethical dilemmas and conflicts, whereas conscience stress is a specific type of ethical stress that arises from a sense of guilt or shame. A study from Sweden [47] showed that when nurses were unable to attend to patients’ needs, it caused them stress and made them feel unprofessional. Another cause of stress was the inability to offer both instrumental and social support to their colleagues due to restrictions and themselves feeling emotionally drained or being too busy with their work duties. A lack of control was expressed by some nurses, which was also supported in previous studies [31–32], where nurses described not feeling in control of their schedule or being forced to reallocate to other wards during the pandemic or forced to work nightshifts. The fact that employees are allowed to participate and be included as far as possible in decisions and processes is important for their health and is an important aspect of work motivation and a sustainable health-promoting work situation [28, 51]. Some nurses in the present study expressed high personal demands on how they perform their work and did not have the prerequisites to perform their work well. A study from Belgium [14] stated that performance expectations are associated with physical and psychological costs. Another study further reported that high job demands, such as a high workload, can lead to exhaustion and further health problems [52]. The findings from the present study showed that nurses were unhappy with their working conditions. This is supported by a literature review [53] that showed that this is a common concern among nurses. What is a little baffling is that it is a preventable problem; if organizations take proper action to improve nurses’ work environment, they can improve their health and well-being. In the long run, it can also lead to nurses wanting to remain at their workplace [54]. Worktime, workpace, and recuperation The findings of the present study showed that many nurses experienced high workloads and increased workpaces. The work schedule, work pace and possibility to recuperate are important areas for a sustainable working life [28–30]. Most nurses in our study stated that they had to work overtime and take extra shifts. This was also reported in our previous research [31–32]. Another study [1] revealed that exhaustion and work overload were what nurses struggled most with during the pandemic. In terms of recuperation, some of the nurses in our study had opportunities to take breaks at work, whereas some were unable to do so owing to their workload. The body and mind need to rest to function properly, and not having time to relax can cause errors at work [31]. Some nurses expressed that they had problems falling asleep because they were stressed and overworked. This finding was also corroborated in a study from Sweden [47], where nurses described feeling physically tired but unable to relax. Nurses in the present cohort also stated that it was difficult to think about work when they had time off since they were constantly reminded of the pandemic. For nurses to have a decent workplace, it is vital that their workload is manageable and that they have opportunities for recuperation at work and between work shifts. The economy All the nurses in the present study stated that they did not feel affected by the COVID-19 pandemic from an economic point of view, as many felt comforting when everything else was in turmoil. A study from the U.K. reported that due to the COVID-19 pandemic, staff were unlikely to lose their jobs [55]. If anything, their personal finances were better because they were working overtime, and they did not have the opportunity to spend much money since much of society was shut down due to restrictions. Some nurses did feel that the extra money they earned was insufficient in relation to their work effort, almost mockery. Research findings indicate that economic and other factors, whether directly or indirectly linked to COVID-19, had a substantial impact on people’s quality of life during the pandemic [56]. Research has shown that personal economic factors are important for a sustainable working life [28–30]. Private social environment Employees have a life outside work. While some nurses in the present study felt that they had a good balance between work and their private life, a majority felt that there was an imbalance toward work. Previous studies [57–59] have shown that an imbalanced work-life can be associated with health problems. Nurses who deal with severely ill COVID-19 patients face two realities: their hospital reality and their social reality when they see the general public sitting outside cafes and restaurants. For some, it was difficult to combine these two realities. Having social support from friends and family was important. One study [60] revealed an association between long-term sick leave due to mental health issues and a lack of social support. The nurses in the present study recognized the support they felt from the general public, which has also been described in other studies [1]. To ensure nurses’ well-being and job satisfaction as well as to be able to combat nursing shortages, it is vital to prioritize social support and work‒life balance within organizations. By doing so, we can retain skilled professionals and uphold high-quality patient care. Work social environment Support, especially in difficult times, is important for everyone, especially when having to endure over two years of all that the COVID-19 pandemic has led. The work social environment, with relationships and social support from managers, colleagues and other people who employees face, is an important area for a sustainable working life [28–30]. The nurses in the present study experienced good support, feeling safe in their workgroup and having improved teamwork with nurse assistants and doctors. This finding was also expressed in other studies [1]. However, with respect to managers, there were more diverse experiences with some nurses experiencing good support, whereas others felt that managers were unsupportive and absent. A previous study [47] also reported that managers were absent and that they lacked interest in the employee’s situation as well as patient safety. Support from leaders is important for reducing the risk of nurses experiencing anxiety, depression, and burnout [61]; reducing sickness absence [62]; and improving nurses’ job satisfaction [63–64]. Many expressed that they were unsatisfied with and experienced anger toward the healthcare organization, which was also expressed in other studies [65]. Some of the nurses felt deceived and betrayed by the employer, by them changing protocols for what PPE the nurses should wear depending on what material they had in stock. Instead of being honest and admitting that – yes, it was not guaranteed that the protective equipment was the best alternative but that it was what they had to work with – thus putting nurses’ health at risk. Ensuring the well-being of nurses is a shared responsibility involving not only the nurses themselves but also the systems and organizations that provide support [66]. Feeling a sense of duty toward patients but also their colleagues was something that many of the nurses stated was what made them come to work even though they felt tired or stressed. Nurses have a duty to care for patients, but at the same time, there must be a balance between caring for patients and trying to keep nurses and other healthcare professionals safe. It is important to address nurses’ ethical concerns and well-being to maintain resilient healthcare staff [67]. Satisfaction, motivation, meaningfulness, stimulance with work tasks and activities at work The nurses in the present study stated that it was hard to keep themselves motivated not only partly because they knew what they were going to face but also because they were caring for patients whom they were not supposed to care for. Some nurses felt that the level of care was subpar, that they were unable to perform as well as that they would like, which affected their motivation. As stated previously, the nurses in the present study stated that there were issues with their working environment, such as a lack of space and a lack of proper ventilation. As reported in a previous study [47], the working environment is an important aspect of maintaining patient safety and nurse job satisfaction. On the other hand, there were nurses in the present study who stated that they felt that the work they do is meaningful and that it gave them a chance to roll up their sleeves and show their ability. The meaningfulness of one’s work was also found to be important for nurses’ mental health in another article [1]. Knowledge, skills and competence development To perform one’s work tasks and activities, employees need knowledge, skills and competence, which is also important for a sustainable working life [28–30]. Good communication, between colleagues and, in some instances, between managers and staff, was described by the nurses in the present study. Good communication and good relationships are valuable tools for a health-promoting organizational and mental work environment [28]. Nurses in the present study stated that there was a lack of introduction when they worked in other wards during the pandemic, and some nurses stated that they cared for patients beyond their level of expertise. A lack of proper training or introduction can lead to deficiencies in patient safety. Some nurses stated that they worked according to learning-by doing since the pandemic was unknown to everybody and that they had to learn what worked best, but that also caused some nurses to feel that they were novices in the profession again. The latter was also reported in a previous study [47] in which nurses described feeling new in the profession. It is important to take what we have learned from this pandemic and make adjustments in healthcare organizations so that we are better prepared for when the next pandemic or major event takes place. 6. Strengths and limitations Since our data were drawn from semistructured interviews that took place a few years after the COVID-19 pandemic began in 2020, there is a risk of recall bias. The informants’ memories may not be accurate or reliable, but since the nurses’ experiences we are interested in and time could have given them time to think back and reflect on their situation, we believe that the data are reliable. By acknowledging the potential for recall bias and taking steps to mitigate it, researchers can increase the accuracy and reliability of their findings. The interviews allow for detailed and in-depth data collection, providing rich insights into participants’ perspectives. Using deductive content analysis can be seen as both a strength and a limitation. Using an existing framework provides a more efficient process and structured approach to data analysis. The use of an existing framework facilitates the comparison of findings across different studies or contexts. Some may argue that the reliance on existing theories can limit the discovery of new insights or unexpected findings. Hence, we used a semistructured interview guide, which gave the interviewer the opportunity to delve deeper into the different areas. Some researchers may state that predefined categories may introduce bias, as researchers might overlook data that do not fit the existing framework. To ensure that no data were overlooked, several researchers completed the coding. 7. Conclusions Some of the challenges faced by healthcare professionals in Sweden are that healthcare organizations are undersized and that there need to be better opportunities for primary care to expand to ease the burden on hospitals. There needs to be a better balance between resources (e.g., equipment, funding, and staff) for nurses and other healthcare providers to be able to carry out their work. Nurses are generally unhappy with their working conditions, a common concern that is preventable with proper organizational actions. As far as competence provision is concerned, we must rethink the resources we have by using new ways of working, digitalizing, using and increasing the competence of existing staff, moving tasks to primary care, etc. We have to take care of the existing staff so that they can continue and thrive. Improving the work environment can enhance nurses’ health and well-being, potentially leading to better retention of staff. For a sustainable working life, it is crucial that nurses have a manageable workload and opportunities for recuperation both at work and between shifts. Ensuring the well-being of nurses is a shared responsibility between nurses and the organizations that support them. Work-related stress is a prevalent issue among healthcare personnel globally, increasing the likelihood of cognitive failure and impacting patient safety. Healthcare organizations must prioritize nurses’ health and well-being. Policymakers and healthcare leaders should implement strategies to address nurses’ mental health needs, especially given the global nursing shortage and challenging working conditions. Nurses struggle with motivation because of challenging conditions and care for patients outside their usual scope. Despite these challenges, some nurses find their work meaningful, which positively impacts their mental health and motivation. Nurses had limited time to stay updated on the latest guidelines, relying on colleagues and managers for information. It is important to learn from the pandemic and make necessary adjustments to healthcare organizations to be better prepared for future pandemics or major events. Conversely, to identify salutogenic and pathogenic factors, one must highlight all nine areas of importance in the SwAge model and understand how these nine areas interact in the complex work situation of nurses. Therefore, health care organizations and managers should consider all these areas when developing measures to promote a sustainable working life for nurses. Nurses must advocate for equitable healthcare systems, fair compensation, and safe working environments. Declarations Ethics approval and consent to participate The study has approval from the Swedish Ethical Review Authority (2016/867 and 2020-01897). All participants gave informed consent to partake in the study. Consent for publication All the authors read and approved the final version of the manuscript. Availability of data and materials N/A Competing interests The authors declare that they have no competing interests Funding This research was funded by Interreg (European Regional Development Fund, EU), grant number NYPS20303383; FORTE FORMAS, grant number 2020-02746; and the Research Platform for Collaboration for Health, Kristianstad University, Sweden. Funding number 9/2021. Acknowledgments The authors wish to acknowledge the nurses who took time out of their lives to partake in the study. Author contributions C. N was responsible for data collection and writing the initial draft of the manuscript. C.N. and K.N. performed the initial deductive content analysis. All the authors contributed to the conception and design of the study and the final content analysis and to the writing and critical revision of the manuscript. References Shivairová, O; Bártlová, S; Hellerová, V; Chloubová, I. Nurse’s mental health during Covid-19 pandemic. Cent Eur J Nurs Midw, 2023, 14(1):795-804. Hayes, L.J; O’Brien-Pallas, L; Duffield, C; Shamian, J; Buchan, J; Hughes, F; Spence Laschinger, H.K; North, N. Nurse turnover: A literature review – An update. Int J Nurs Stud, 2012, 49:887-905. International council of Nurses Policy Brief. The Global Nursing shortage and Nurse Retention. 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Cite Share Download PDF Status: Published Journal Publication published 24 Jan, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 13 Sep, 2024 Editor assigned by journal 12 Sep, 2024 Submission checks completed at journal 12 Sep, 2024 First submitted to journal 11 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5069662","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":353425725,"identity":"4b387637-f39b-4d45-a256-8a43ab747a4c","order_by":0,"name":"CICILIA NAGEL","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5ElEQVRIiWNgGAWjYDACZgaGAw8MoJwHFQcM8KqGa0mAqUs4Q4wWsEoYI7GNCC387cwPDyQU2DGYsx+/+CBx3h1j8wb2hw/waZE4zGYAdFgyg2VPTrFB4rZnZjIHeIzxWmXAzAPyCzODwYGcNInEbYdtJBh42CSI0FLPYHD+TfqPxDkgLezPfxCh5TCDwY30YwyJDYfNgDaY4dMB88txHoMbb5glEo4dNpZg5jHG6zD+/sOPP3z4Uy1ncD794YcPNYcNZ7C3P/yA1xoo4AEiaDgxE6MeAtgfEK92FIyCUTAKRhQAAIpSSXJBBdaMAAAAAElFTkSuQmCC","orcid":"","institution":"Kristianstad University","correspondingAuthor":true,"prefix":"","firstName":"CICILIA","middleName":"","lastName":"NAGEL","suffix":""},{"id":353425726,"identity":"f64304f2-b8b4-4061-8b97-afc4dc2ca94e","order_by":1,"name":"Petra Nilsson Lindstrom","email":"","orcid":"","institution":"Kristianstad University","correspondingAuthor":false,"prefix":"","firstName":"Petra","middleName":"Nilsson","lastName":"Lindstrom","suffix":""},{"id":353425727,"identity":"c44100c1-8127-4861-97eb-6796d45987c8","order_by":2,"name":"Albert Westergren","email":"","orcid":"","institution":"Kristianstad University","correspondingAuthor":false,"prefix":"","firstName":"Albert","middleName":"","lastName":"Westergren","suffix":""},{"id":353425728,"identity":"9bb60621-f761-48e4-891a-be73fbc94ea9","order_by":3,"name":"Sophie Schon Persson","email":"","orcid":"","institution":"Kristianstad University","correspondingAuthor":false,"prefix":"","firstName":"Sophie","middleName":"Schon","lastName":"Persson","suffix":""},{"id":353425729,"identity":"dfcd0546-b272-4361-888e-a0875e726fad","order_by":4,"name":"Kerstin Nilsson","email":"","orcid":"","institution":"Kristianstad University","correspondingAuthor":false,"prefix":"","firstName":"Kerstin","middleName":"","lastName":"Nilsson","suffix":""}],"badges":[],"createdAt":"2024-09-11 09:00:34","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5069662/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5069662/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12889-024-21152-x","type":"published","date":"2025-01-24T15:57:19+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":74859292,"identity":"2caf9d2e-0e4f-49cc-a336-1c0bac5f1d7b","added_by":"auto","created_at":"2025-01-27 16:14:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":731385,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5069662/v1/d6041bbe-a257-4458-900c-75b049f84ce5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Nurses’ health and work experiences during the COVID-19 pandemic in Swedish prehospital and hospital care: A deductive content analysis through the lens of the swAge model","fulltext":[{"header":"1. Background","content":"\u003cp\u003eNurses constitute the largest workforce in healthcare services [1]. High turnover among nurses has long been acknowledged as a worldwide problem [2]. Owing to existing nursing shortages, the aging of the nursing workforce and the long-term effects of COVID-19, ICN estimates that up to 13\u0026nbsp;million nurses will be needed globally to fill the nurse shortage gap in the future [3]. To secure a well-functioning healthcare service, it is important to have a sufficient number of nurses. However, demographic changes imply that a lack of labor supply in the healthcare sector is a past, current and future concern in most European countries as well as in the U.S. [4\u0026ndash;5]. Nursing is a profession with unique potential for exposure to environmental and occupational hazards in the work setting [6], especially since much of the work involves direct contact with patients [7].\u003c/p\u003e \u003cp\u003eDespite all the negative work experiences that nurses describe, there are many positive aspects to the profession, such as job security, colleagues, developing communication skills and having great opportunity for advancing in their career, according to further studies. Such salutogenic factors and processes promote work-related health and contribute to and maintain the health and well-functioning of the individual, in an organization or in a society [8], whereas the pathogenic perspective focuses on understanding the origins of health risks and treating disease [9]. Previous research [10\u0026ndash;11] has shown that a sense of coherence can maintain or improve an individual\u0026rsquo;s health when faced with adversity. In nursing, having a sense of coherence has been shown to be a strengthening resource for work-related well-being when facing challenging work situations [12]. Nurse well-being at work is defined as a nurse\u0026rsquo;s positive evaluation of oneself and one\u0026rsquo;s contributions to the work of nursing [13]. Nurses\u0026rsquo; well-being is conditioned by both the work and personal resources available. Work resources refer to the physical, psychological, organizational, or social aspects of the work that must be performed to provide quality care [14]. Personal resources refer to a person\u0026rsquo;s characteristics, including those related to a sense of control and resilience in trying to control their surrounding environment [14].\u003c/p\u003e \u003cp\u003eOn the other hand, nurses\u0026rsquo; health problems can be caused by poor working conditions [15]. A physically strenuous working environment can lead to poor health [16]. The heavy lifting and strenuous work postures that are common in nursing have been shown to contribute specifically to neck, shoulder, and knee conditions, as well as to lower back pain, which in turn can be associated with leaving nursing care [17]. Job stress can jeopardize the physical and mental health of nurses, reduce their energy and work capacity, result in inadequate care, and, in turn, negatively impact patient outcomes [18]. Studies have shown that nurses have a greater risk of developing mental health problems due to continuous exposure to workplace risk factors such as shiftwork [19], human suffering, inadequate staffing and heavy workloads [20]. Studies have also shown that healthcare workers have higher rates of suicide [19; 21]. Thus, nurses are considered to be at high risk of stress-related disorders [22], and their work situation may be associated with adverse effects, such as stress and burnout [23\u0026ndash;24]. The COVID-19 pandemic has increased work stress among already strained nurses, putting their mental health and well-being at risk [25].\u003c/p\u003e \u003cp\u003eAccording to an American study, nurses use personal protective factors to build personal resilience to cope with challenges and difficult situations while increasing their ability to face future situations and achieve a greater level of well-being [13]. Unlike most countries that imposed strict lockdowns and widespread closures, Sweden opted for a more lenient approach where the focus was on social distancing measures. Nurses and other healthcare professionals must perform patient care in full personal protective equipment [26]. The COVID-19 pandemic has become an extreme situation; thus, nurses\u0026rsquo; voices need to be heard, which is why this study, where we look at most parts of nurses' lives and work situations, is important.\u003c/p\u003e"},{"header":"2. Aim","content":"\u003cp\u003eThe aim was to identify the salutogenic and pathogenic factors that influence nurses\u0026rsquo; health and work situation related to the COVID-19 pandemic in Sweden.\u003c/p\u003e"},{"header":"3. Method","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Setting and sample\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe informants in this study worked as nurses in either the southern or middle part of Sweden during the COVID-19 pandemic. The participants\u0026rsquo; sociodemographic characteristics are described in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Snowball sampling was used to reach nurses from different settings and achieve a wide range of experience. The first author sent out a request for informants in a social media group for anesthetic nurses in the Region of Skane in southern Sweden, where the initial informant replied and was given more information about the aim of the study. Other informants were found through the first author presenting the study at staff meetings at different wards and through the first author\u0026rsquo;s contact net. The inclusion criteria were as follows: registered nurses who encountered COVID-19-positive patients at their workplace (such as ambulances, emergency departments, intensive care units, specialized COVID-19 units and infection control wards) and who had a good understanding of Swedish or English. After twelve interviews, the data started to become saturated, but two more interviews were conducted; in total, 14 nurses from southern Sweden and the middle of Sweden were interviewed.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe participants\u0026rsquo; sociodemographic characteristics.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;14\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean (range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (29\u0026ndash;64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (female) (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (64.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostgraduate Diploma in Specialist Nursing, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCivil status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLive-in partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (28.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (57.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears in the profession\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (28.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorkplace for the participants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmbulance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (28.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfection unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecialized COVID unit (non-ICU)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (7.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntensive care unit (ICU)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (21.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Design\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eA qualitative study with individual semistructured interviews was conducted since qualitative research focuses on understanding individuals' experiences, perspectives and behaviors in their natural environment, in this case, nurses. In-depth questions such as \u0026ldquo;Can you describe in your own words what happened when the pandemic came?\u0026rdquo; were asked, and depending on their answers, further probing questions were asked. Individual interviews were chosen as a data collection method to ensure that the nurses\u0026rsquo; unique circumstances and needs were the focal point of the interviews [27]. Individual interviews are preferable when there are sensitive questions since they give the informant a better opportunity to open up and share their experiences [27].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Data collection\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe interviews took place in May/June 2023 and October/November 2023. All interviews were performed by the first author. The semistructured interview guide that functioned as a checklist for the interviewer was based on the results from the SwAge model [28\u0026ndash;30], which consists of nine determinant spheres of a sustainable working life for all ages, salutogenic theories [8\u0026ndash;9] and results from previous studies from this research group [31\u0026ndash;32]. The interview guide was processed by the authors and agreed upon. After three pilot interviews were conducted, the authors made small adjustments to the interview guide. The interview locations were chosen by the informants; five of the interviews were conducted in conference rooms adjoining their workplace, four in a room at a nearby library, three in the informants\u0026rsquo; offices and two at local coffeeshops. The interviews lasted between 64 and 119 minutes; informed consent was obtained from each participant. Each interview was recorded and transcribed verbatim.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Data analysis\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAll the interviews were transcribed verbatim and pseudonymized by the first author. Each interview was given a number between 1 and 14. Content analysis was used to obtain a condensed and broad description of the phenomenon. The data from all the interviews were organized in NVivo software (version 14) and analyzed by researchers C.N. and K.N. through deductive content analysis [33\u0026ndash;35] on the basis of the theory of a sustainable working life for all ages (SwAge model) [28\u0026ndash;30]. A deductive content analysis was chosen to distill the relevant portions of the gathered data. Deductive content analysis is an appropriate method when the text is interpreted from predetermined (theoretical) codes. Deduction involves drawing conclusions from general principles to specific instances. In deductive content analysis, existing theories and prior research inform the refinement and potential extension of a theoretical framework [36]. Our study followed several steps: constructing a thematic matrix based on theories and the determinant spheres in the SwAge model [28\u0026ndash;30]; reading all interviews together to gain a holistic understanding (done twice); marking specific interesting parts in the text; color coding; and finally grouping codes on the basis of their meanings, similarities, and differences into themes. All the authors contributed to the final content analysis. The presentation of deductive findings in our results section is organized around the four predetermined themes derived from the determinant spheres of the theoretical SwAge model [28\u0026ndash;30]. Some experiences address issues across multiple themes, leading to their inclusion in more than one of the four main \u003cem\u003ethemes\u003c/em\u003e: \u003cem\u003ehealth effects of the work environment\u003c/em\u003e: 1. the diagnoses, self-rated health and functional diversity; 2. the physical work environment; 3. the mental work environment; 4. the working hours, work pace and time for recuperation; the financial situation; 5. personal finances; social inclusion, support and sense of community; 6. the personal social environment; 7. the social work environment; the execution of work tasks and activities; 8. work satisfaction, motivation, stimulation and the core of work; and 9. knowledge, competence and ability.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.5 Ethical considerations\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e The study was performed in accordance with the Declaration of Helsinki [37] and with the Swedish law of research ethics [38]. The benefits of the study were deemed to outweigh the potential harm to the informants. The rules for data management and data storage were followed in accordance with the University Policy as well as the GDPR [39]. Participation in the study was voluntary, and informed consent was obtained from all the informants. The study was approved by the Swedish Ethical Review Authority (2016/867 and 2020\u0026thinsp;\u0026minus;\u0026thinsp;01897).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"4. Findings","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe analysis focused on in-depth investigations and identification of both salutogenic and pathogenic factors in nurses\u0026rsquo; complex work situations before, during and after the COVID-19 pandemic. Below, the deductive findings are reported on the basis of previous research on nine areas of importance for sustainable working life, i.e., the SwAge model [28].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Nurses\u0026rsquo; health\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSome nurses described that their health and well-being continued to be good before, during and after the pandemic. They did not get COVID-19 and did not feel stressed. They felt that since they could not control what happened, they just went with the flow. Not being afraid of infecting others with the virus. In contrast, there were those who had concerns but felt like they could not think about it constantly.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;\u0026hellip;I didn\u0026rsquo;t care too much about the risk of infection because it was not something that you could go around brooding over and at the same time do the work that was expected of us\u0026hellip;\u0026rdquo;\u003c/em\u003e (Informant 1)\u003c/p\u003e \u003cp\u003eOn the other hand, there were many things that they still carried with them and that they had trouble sleeping at night because they thought about what they had witnessed, things that they could have done differently and many \u0026lsquo;what ifs\u0026rsquo;, informants described that they could still not fall asleep unless listening to podcasts or the radio to switch off their thoughts. They described having to work during the pandemic while not feeling well, how their workload affected their mental health and how that, in turn, manifested in physical symptoms such as heart palpitations, pain, anxiety, headache, and exhaustion. Some of the informants stated that they had been on extended sick leave during and/or after the pandemic. There were also physical injuries due to wearing personal protective equipment (PPE), such as hair being pulled off, allergic reactions, eczema, and wounds on the face. They also described that they were worried about the long-term effect of having to wear facemasks of low quality for extended periods, leading to the material disintegrating and causing them to breathe in particles. With public gyms closed, the nurses had inferior circumstances to maintain their physique to stay healthy and avoid injuries.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Physical work environment.\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe informants described not having relatives accompanying the patients as both positive and negative. The positive side was that there was more space in the wards since most patients usually had one or two relatives with them. The negative aspect was that many, especially older patients, were left by themselves, thus making it more difficult for nurses and other healthcare staff to notice declines in patients\u0026rsquo; health since they were unable to constantly monitor patients.\u003c/p\u003e\u003cp\u003eImproving organizational skills, developing new ways to work and, in some instances, refining procedures that require fewer staff members were positive effects of the pandemic. In contrast, the nurses described that there was a shortage of PPE, hand sanitizer and medicine during the pandemic. In some cases, nurses had to work without proper safety equipment. Some nurses stated that safety equipment, such as visors and military-grade breathing masks, was available but that they were not allowed to use it since it lacked proper CE-marking. Some nurses decided to go against this and wear military-grade breathing masks. Many noted how the guidelines regarding which PPE were to be used changed depending on what material was available in their department:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"...because as I saw it, it was quite obvious that they started to reduce the safety requirements in relation to the staff in regard to what kind of material they had available and that is a betrayal\"\u003c/em\u003e (Informant 4)\u003c/p\u003e\u003cp\u003eSeveral nurses described how they were asked to reuse protective equipment and, in some cases, save their breathing masks in a special container if, by some chance, the technological advances were to find a method to sanitize them. They described how, in some cases, they worked in rooms with more than one patient and how doctors would sanitize their gloves before walking to the next patient. The nurses described how they were told to wear long sleeve robes, gloves, breathing masks and visors while going between patients in the intensive care unit (ICU) and that when they questioned this, they were told that it was a standard procedure. Some nurses stated that they in their workplace had a seasoned nurse assistant that had secret stashes of gloves and other material, which they were very thankful for since that meant that they still had material unlike other wards. All the informants agreed that working in the PPE was exhausting and hot and that they found it difficult to communicate while wearing it.\u003c/p\u003e\u003cp\u003eThe physical work environment itself was described by most nurses as not being the best even before the pandemic with overcrowding, a lack of beds, etc. During the pandemic, many wards had to reconfigure their spaces by building temporary walls and using whatever space was available, such as ambulance bays and outpatient clinics. This led to several negative events\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It turned out to be a bit of a fake build, so it happened that there was a pensioner who came in and was not truly very sick; she leaned on a railing that was not screwed down properly and fell, then she got a subdural hematoma instead.\u0026rdquo;\u003c/em\u003e (Informant 1)\u003c/p\u003e\u003cp\u003eSome drawbacks to the changed work environment were that ambulances had to offload their patients outside regardless of weather conditions, thus exposing patients, some very critically ill, both to the elements but also to a lack of privacy. Cramped patient spaces filled with medication pumps and ventilator hoses, some wards were not equipped for the high level of care needed, poor ventilation, and having to spend time searching for equipment or materials caused frustration among the staff. Nurses had to work in tents or sheds outside without proper heating to triage patients coming into the emergency wards. The increased need for high-level care has led hospitals to open intermediate care departments and specialized COVID-19 units. With the increased need for patients on respiratory care, ICUs had to use dated respiratory machines and borrow anesthetic machines from operating wards. One redeeming factor that facilitated work was that nurses who worked in the emergency wards claimed that the flow of patients to the wards improved during the pandemic because most patients ended up in infection clinics.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Mental work environment.\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSome nurses stated that they did not believe that the pandemic would reach Sweden or that it would be like a regular influenza. When the pandemic hit, they felt caught off guard regarding how ill some of the patients were, and nurses described the pandemic as being slapped in the face. Several nurses stated that they were not prepared mentally for a second or third wave of the pandemic. Stress was a major denominator, whether it was ethical stress from not feeling that your best was good enough and that you were always one step behind or if it was because they were reallocated to other wards (voluntarily/involuntarily) or lacked time to perform work duties or stress from not being able to find material and/or equipment in their usual location during the pandemic. Some nurses felt that it was stressful not to be in control of the situation and expressed how high some of the demands were, both from the organization, from the patients and ultimately from themselves, for them to cope with all the changes.\u003c/p\u003e\u003cp\u003eOne thing that alleviated some of the stress was when the doctors started calling the patients\u0026rsquo; relatives and updating them on their situation, which led to fewer calls into the wards, which in turn freed up time for the nurses to tend to their patients. With respect to threat and violence, the nurses stated that there was always an element of that but that it usually stemmed from anxiety and frustration. Some nurses stated that it increased during the pandemic when relatives were not allowed into the hospital and when patients were turned away from the hospital and asked to seek help/treatment in primary care; hence, nurses (and other hospital staff) faced both patients and their relatives\u0026rsquo; frustrations.\u003c/p\u003e\u003cp\u003eMany nurses described that their mental health was affected by their work situation, whether it was having seen and/or experienced tragic patient losses, feeling anxious due to fear of making an error or feeling frustrated that they were unable to perform well at work since the conditions were lacking and that things had to be good enough. Many nurses described unethical situations.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"...when you had to stand with these old people who had to die in your hand without relatives/.../and I have stood there with a gas mask on, it was not dignified, it is not okay\u0026hellip;\"\u003c/em\u003e (Informant 10)\u003c/p\u003e\u003cp\u003eSome nurses described the mental work situation as being emotionally draining owing to rapidly changing routines, feeling a sense of prepping, or going into survival mode, or feeling that their work identity was taken away from them by being forced to work in other wards/other shifts or not being able to offer support to colleagues owing to restrictions and themselves feeling emotionally drained. There was also frustration, especially from paramedic nurses, about having to be exposed to the virus when dealing with patients who did not truly need help.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Working hours, work rate and recovery.\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSome of the nurses who worked in emergency departments stated that their workload decreased, especially at the beginning of the pandemic, when they experienced a lower influx of patients because people feared coming to hospitals and later in the pandemic due to a better outbound patient flow. On the other hand, the increased work pace during the pandemic as well as increased sick leave resulted in some nurses not being able to take breaks on their workday, whereas in some wards, they were able to go on their lunchbreaks. The increased sick leave resulted in nurses having to work extra shifts, double shifts and frequent shift changes with short notice, all of which affected the possibility of recuperation. Nurses described how they had difficulty sleeping and how they walked around in a blur on their days off; some nurses lacked the energy to exercise and that it was somewhat draining waiting for that call to come, asking them to do extra shifts. They described not being able to mentally recover from the pandemic because it was all around them, regardless of whether they were in a store or at home, listening to the news and feeling tired and anxious about having to return to work.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"...it was terrible not to like your job, to sort of feel Sunday night that now it is Monday again/\u0026hellip;/to dread going to work...\"\u003c/em\u003e (Informant 6)\u003c/p\u003e \u003cp\u003eNurses were thankful to those who had been reallocated to their ward/unit, but some stated that it did, in fact, cause extra strain on the experienced staff from having to monitor both their own patients but also felt that they had to monitor the other staff. A positive effect of the pandemic that the ICU nurses described was that some experienced nurses were allocated as team leaders in rooms where there were several patients and that these team leaders were allocated only one patient so that they could support the other staff allocated to that room. Whereas many nurses stated that they did not receive compensation for their overtime, a few nurses stated that when they did overtime, they were given so-called \u0026ldquo;COVID-time\u0026rdquo; that they could claim when they felt they needed rest, and the managers tried to accommodate this when they had the opportunity to do so.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.5 Personal finances\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eAs mentioned previously, several nurses faced long-term sick leave during and/or after the pandemic, which affected their personal finances. Most of the nurses stated that they were not given any compensation other than from the extra work hours they performed; most of the nurses stated that they had hoped for. On the other hand, with society in more or less lockdown, they did not spend much money.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"I have worked a lot of extra shifts/.../I have accumulated a lot of money and that is good, but it is not an active choice\u0026hellip;\"\u003c/em\u003e (Informant 4)\u003c/p\u003e \u003cp\u003eBefore and during the pandemic, some nurses stated that they had considered leaving their workplace and even the profession but that it was probably not the right time at the moment; after the pandemic, many nurses left their workplace and even the profession. Among the informants, five out of fourteen nurses changed their workplace after the pandemic. One thing that most nurses described was that they were glad that their work was not affected by the pandemic in an economic sense and that that was something certain they could hold on to in a situation when most things were uncertain. The supply of personnel from other departments and county councils meant a certain amount of work relief.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.6 Private social environment.\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHaving support and understanding from their families and friends was important, and most nurses experienced this to some extent. Some nurses reported that their worklife has been balanced due to the pandemic; they stated that they mentally brought their work home with them and that they were too tired and/or afraid of spreading the virus to meet up with others. Some nurses stated that their friends or family had difficulties understanding what they had to face at work and that their schedule could change with little or no notice. On the other hand, some nurses described that they had family and friends who worked or had worked in healthcare that could offer support and understanding. Something many nurses described as stressful was that they could receive calls from work during their time off.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"... one's privacy is not respected and that in turn also affects people close to one\u003c/em\u003e, i.e., \u003cem\u003eyour partner or friends...\"\u003c/em\u003e (Informant 7)\u003c/p\u003e\u003cp\u003eOwing to many relatives working from home, some nurses stated that their recovery time was negatively affected. There was, however, little silver lining in that the fear of missing out was less prominent because most of society was shut down from time to time. On the other hand, many nurses felt frustrated toward those in society that did not adhere to restrictions and guidelines. Having to cope with going from one reality where they were caring for critically ill patients due to the pandemic to seeing people out and about without protective masks played havoc with their minds.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.7 Work social environment.\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSupport from work colleagues was unanimously described as good, as they felt seen and heard and that there was good teamwork\u0026mdash;even with other professionals such as doctors and caring services. There was a sense of reliability and comfort among the staff, which is important for managing patient safety. With respect to support from managers, half of the informants felt that they had good support from their closest managers, whereas the rest felt that the managers were unsupportive and invisible.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"...it was not the captain who stood at the frontline, but it was the captain who hid in the basement...\"\u003c/em\u003e (Informant 2)\u003c/p\u003e\u003cp\u003eSome of the informants said that their managers did not care for their employees; it was taken for granted that you should show up and work and that managers were not proactive, which created frustration. Trust in managers and the organization dwindled. Many nurses expressed resentment toward the organization, regional boards and the government for how they handled things during the pandemic and that Sweden's regions have failed in their task\u0026mdash;that primary care must do its job. Most agree that it has not worked well at the organizational level but that it has been resolved at the individual/team level.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"...I know that I once thought that now it is almost a social experiment that you are part of, you see it from the inside, what happens to an organization if it turns out like this?\"\u003c/em\u003e (Informant 3)\u003c/p\u003e\u003cp\u003eMany felt lied to, that the management should have been honest regarding the guidelines for which protective equipment they should use. Moreover, disappointingly, the managers convinced some to accept stimulus money instead of calling it over time, that it was dishonorable to buy yourself free from overtime to improve your statistics. Most informants felt that healthcare has not received the confirmation it deserves, that it is as if the pandemic never happened and that the rest of the world wants to put it behind them whereas many who lived it still must deal with the consequences from the pandemic.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.8 Satisfaction, meaningfulness and motivation with work tasks.\u003c/h2\u003e \u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThere was a lack of balance regarding work effort and reward. The informants stated that it was frustrating that nothing became of appreciation from the public during the pandemic. Some nurses stated that they felt unvalued as experienced staff and that it was hard to become motivated enough to go to work, especially when they were aware of what they would face during the pandemic. Both the high workload and the feeling that one sometimes over-treated patients affected their work motivation. Some felt frustrated that they were not doing what they were trained to, that they were stuck on administrative duties or that they were caring for persons who did not need their level of expertise.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"...job satisfaction decreases when we care for patients we are not supposed to care for...\"\u003c/em\u003e (Informant 13)\u003c/p\u003e\u003cp\u003eMany nurses felt that even though it was hard work, it was satisfactory to feel needed and to be able to roll up your sleeves and feel that what you do makes a difference. Some stated that it felt like they grew with what they had to face, whereas others felt satisfied in watching other colleagues flourish.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"...it was hard when it was going on in a way, but yes, it was very useful to have been part of it, very educational after all\"\u003c/em\u003e (Informant 13)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003e4.9 Knowledge, competence and ability.\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe nurses described the importance of providing clear information on \u0026ldquo;the right level\u0026rdquo; to everyone involved, especially to those who perhaps lacked medical knowledge. Most nurses felt that they had been given information to perform their work duties but that it was difficult to keep up to date with the information since most information was given through work emails, which they did not have time to read. Some wards/units relied on whiteboards to convey the most recent information. A few nurses expressed that they wished the organizations had been proactive and contacted other clinics nationally and internationally and inquired about their experiences to be better prepared when the pandemic reached Sweden. Some nurses felt that there was a lack of competence either among themselves or from staff around them and that they were forced to work with patients above their skill level.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\"... it could be shifts when I was working as the most experienced nurse, well it was like I was expected to take care of patients who I hadn't even been trained on...\"\u003c/em\u003e (Informant 7)\u003c/p\u003e \u003cp\u003eWhile some nurses felt that there was a lot of learning by doing, they were also able to learn from what was less successful, which enabled them to obtain different perspectives and that their competence grew since this was not something they could learn by reading about in a book.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eDespite these challenges, some positive changes emerged from Sweden\u0026rsquo;s experience with PPE during the pandemic: healthcare personnel (HCPs) had to find creative solutions due to PPE shortages. They developed alternative cleaning methods and improved protective gear, showing resilience and adaptability. There was also increased awareness. The pandemic highlighted the importance of PPE for HCPs and the general public. This raised awareness about infection prevention and the need for adequate supplies.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eWe wanted to identify which salutogenic and pathogenic factors in the work situation influenced nurses before and during the COVID-19 pandemic, as well as after the restrictions were lifted. It was clear that the nurses were more or less prepared to sacrifice their health and, to some extent, their lives for patients' well-being, and some were still suffering the consequences of this. Some of the things we found were that many of the informants felt disappointment and even anger toward the healthcare organizations, that they were not given the prerequisites to perform the job that they wanted to do, and that they generally feared fighting an invisible enemy, i.e., the COVID-19 pandemic. Nursing operates within a social contract\u0026mdash;a mutual understanding between healthcare organizations and the public they serve. This contract implies certain expectations and responsibilities. During the pandemic, many nurses felt that the healthcare system broke this social contract by not taking care of those who needed it the most\u0026mdash;i.e., older persons. Nurses require certain prerequisites to perform effectively: adequate staffing to manage patient loads, a safe work environment, fair compensation regarding working hours, equitable pay and recognition. Some nurses felt that they were lied to and manipulated by the organizations. Instances of deception, manipulation, or broken promises erode trust. When nurses experience dishonesty or betrayal, their professional well-being and commitment are undermined. During the pandemic, nurses relied on their colleagues for support to alleviate stress and compensate for deficiencies.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSelf-rated health, diagnosis, injuries\u003c/em\u003e \u003c/p\u003e \u003cp\u003eResearch has shown that health and work environment health effects are crucial for a sustainable working life [28\u0026ndash;30]. While some nurses in the present study stated that their health was not affected by the pandemic, some experienced poor self-rated health, such as problems sleeping and anxiety. Research [40] has shown that individuals who have an innate ability to withstand adversity or are able to maintain good interpersonal relationships are more likely to maintain good mental health and well-being during the COVID-19-related lockdown. The American Nurses Foundation [41] reported that nearly fifty percent of nurses reported stressful or traumatic experiences due to COVID-19. Many nurses were also found to have experienced anxiety or depression due to COVID-19 [42\u0026ndash;43]. Many of the participants in the present study stated that they had been on extended sick leave due to exhaustion or burnout. As reported in previous studies [31\u0026ndash;32], burnout and emotional exhaustion were common among nurses who worked during the pandemic. The conditions faced by nurses during the pandemic threatened their health and well-being as well as their ability to do their work [44]. Many nurses in the present study mentioned feeling stressed at work and from work. Work-related stress is a prevalent issue among healthcare personnel globally [45]. Research indicates that it increases the likelihood of cognitive failure, which, in turn, impacts patient safety [46].\u003c/p\u003e \u003cp\u003eWith respect to physical health in this study, we have the whole array between physical well-being and physical ill-health. Most of the nurses in the present study reported that they were infected by the COVID-19 virus at work; hence, they suffered from work-related illness. Some of the nurses in the present study stated that they had experienced physical symptoms such as headache and muscle pain. A previous study [47] reported that when an individual experiences extreme stress and an overwhelming work situation, it can cause both psychological and physical symptoms.\u003c/p\u003e \u003cp\u003eHealthcare organizations must look for nurses\u0026rsquo; health and well-being. The American Nurses Association states that policymakers, healthcare leaders and institutions should recognize and address nurses\u0026rsquo; unique mental health needs and implement strategies to ensure that these needs are met under all conditions [48]. As one study mentioned, healthcare organizations rely on healthcare professionals\u0026rsquo; health and well-being to be able to provide efficient healthcare services [49]. This is important to consider for the future since we already face a global nursing shortage, with many more nurses nearing retirement age or leaving their work due to working conditions.\u003c/p\u003e \u003cp\u003e \u003cem\u003ePhysical work environment\u003c/em\u003e \u003c/p\u003e \u003cp\u003eMany healthcare systems were caught off guard and scrambling to provide beds and material during the COVID-19 pandemic, as described in an international literature review [44]. The physical work environment is an important area for a sustainable working life [28\u0026ndash;30]. One concern in the present study was the suboptimal care environment, as well as patients being cared for at the wrong care level, which could lead to a lack of staff and patient safety. Temporary or remodeled departments meant that there were risks of work accidents, overloading of muscles and joints, and incorrect lifting techniques. According to the Swedish Work Environment Act [50], work needs to be planned so that it can be performed in a safe and healthy environment (2 \u0026sect;), and the workplace needs to be appropriate from a work environment point of view (3 \u0026sect;). Work hygienic conditions regarding air, sound, etc., need to be satisfactory (4 \u0026sect;). If we look at the results from the present study, these conditions were not met since nurses stated that they worked in temporary workstations outdoors without proper heating and on wards without proper ventilation. The lack of protective equipment or not being allowed to use available protective equipment since it does not have proper labeling could influence nurses\u0026rsquo; health. One study [1] reported that the lack of protective equipment was a cause of unnecessary stress for nurses during the pandemic. The nurses in the present study also reported that working with protective equipment was exhausting, which was supported by other studies [1]. As previously mentioned, many nurses were infected with the COVID-19 virus while at work. As many described, both limited access to and improper use of said PPE increase the risk of becoming infected by the virus and/or spreading the pathogen to others. Having adequate personal protective equipment is a key factor in keeping healthcare workers safe [43]. From the positive aspects found in the present study, one can hope that the improved patient flow and intrahospital collaboration could continue to prevent patients from having to stay in emergency wards due to a lack of beds.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003eMental work environment\u003c/em\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSome nurses in the present study reported that they did not feel that the pandemic would affect them, as was also reported in other studies [1]. Many felt caught off guard and not prepared for how the situation would evolve. Different aspects and factors in the mental work environment were found to cause stress. The nurses in this study expressed ethical stress and conscience stress. While both ethical stress and conscience stress are related to ethical concerns, ethical stress is a more general term that encompasses a broader range of ethical dilemmas and conflicts, whereas conscience stress is a specific type of ethical stress that arises from a sense of guilt or shame. A study from Sweden [47] showed that when nurses were unable to attend to patients\u0026rsquo; needs, it caused them stress and made them feel unprofessional. Another cause of stress was the inability to offer both instrumental and social support to their colleagues due to restrictions and themselves feeling emotionally drained or being too busy with their work duties.\u003c/p\u003e \u003cp\u003eA lack of control was expressed by some nurses, which was also supported in previous studies [31\u0026ndash;32], where nurses described not feeling in control of their schedule or being forced to reallocate to other wards during the pandemic or forced to work nightshifts. The fact that employees are allowed to participate and be included as far as possible in decisions and processes is important for their health and is an important aspect of work motivation and a sustainable health-promoting work situation [28, 51]. Some nurses in the present study expressed high personal demands on how they perform their work and did not have the prerequisites to perform their work well. A study from Belgium [14] stated that performance expectations are associated with physical and psychological costs. Another study further reported that high job demands, such as a high workload, can lead to exhaustion and further health problems [52]. The findings from the present study showed that nurses were unhappy with their working conditions. This is supported by a literature review [53] that showed that this is a common concern among nurses. What is a little baffling is that it is a preventable problem; if organizations take proper action to improve nurses\u0026rsquo; work environment, they can improve their health and well-being. In the long run, it can also lead to nurses wanting to remain at their workplace [54].\u003c/p\u003e \u003cp\u003e \u003cem\u003eWorktime, workpace, and recuperation\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe findings of the present study showed that many nurses experienced high workloads and increased workpaces. The work schedule, work pace and possibility to recuperate are important areas for a sustainable working life [28\u0026ndash;30]. Most nurses in our study stated that they had to work overtime and take extra shifts. This was also reported in our previous research [31\u0026ndash;32]. Another study [1] revealed that exhaustion and work overload were what nurses struggled most with during the pandemic. In terms of recuperation, some of the nurses in our study had opportunities to take breaks at work, whereas some were unable to do so owing to their workload. The body and mind need to rest to function properly, and not having time to relax can cause errors at work [31]. Some nurses expressed that they had problems falling asleep because they were stressed and overworked. This finding was also corroborated in a study from Sweden [47], where nurses described feeling physically tired but unable to relax. Nurses in the present cohort also stated that it was difficult to think about work when they had time off since they were constantly reminded of the pandemic. For nurses to have a decent workplace, it is vital that their workload is manageable and that they have opportunities for recuperation at work and between work shifts.\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe economy\u003c/em\u003e \u003c/p\u003e \u003cp\u003eAll the nurses in the present study stated that they did not feel affected by the COVID-19 pandemic from an economic point of view, as many felt comforting when everything else was in turmoil. A study from the U.K. reported that due to the COVID-19 pandemic, staff were unlikely to lose their jobs [55]. If anything, their personal finances were better because they were working overtime, and they did not have the opportunity to spend much money since much of society was shut down due to restrictions. Some nurses did feel that the extra money they earned was insufficient in relation to their work effort, almost mockery. Research findings indicate that economic and other factors, whether directly or indirectly linked to COVID-19, had a substantial impact on people\u0026rsquo;s quality of life during the pandemic [56]. Research has shown that personal economic factors are important for a sustainable working life [28\u0026ndash;30].\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003ePrivate social environment\u003c/em\u003e \u003c/p\u003e \u003cp\u003eEmployees have a life outside work. While some nurses in the present study felt that they had a good balance between work and their private life, a majority felt that there was an imbalance toward work. Previous studies [57\u0026ndash;59] have shown that an imbalanced work-life can be associated with health problems. Nurses who deal with severely ill COVID-19 patients face two realities: their hospital reality and their social reality when they see the general public sitting outside cafes and restaurants. For some, it was difficult to combine these two realities. Having social support from friends and family was important. One study [60] revealed an association between long-term sick leave due to mental health issues and a lack of social support. The nurses in the present study recognized the support they felt from the general public, which has also been described in other studies [1]. To ensure nurses\u0026rsquo; well-being and job satisfaction as well as to be able to combat nursing shortages, it is vital to prioritize social support and work‒life balance within organizations. By doing so, we can retain skilled professionals and uphold high-quality patient care.\u003c/p\u003e \u003cp\u003e \u003cem\u003eWork social environment\u003c/em\u003e \u003c/p\u003e \u003cp\u003eSupport, especially in difficult times, is important for everyone, especially when having to endure over two years of all that the COVID-19 pandemic has led. The work social environment, with relationships and social support from managers, colleagues and other people who employees face, is an important area for a sustainable working life [28\u0026ndash;30]. The nurses in the present study experienced good support, feeling safe in their workgroup and having improved teamwork with nurse assistants and doctors. This finding was also expressed in other studies [1]. However, with respect to managers, there were more diverse experiences with some nurses experiencing good support, whereas others felt that managers were unsupportive and absent. A previous study [47] also reported that managers were absent and that they lacked interest in the employee\u0026rsquo;s situation as well as patient safety. Support from leaders is important for reducing the risk of nurses experiencing anxiety, depression, and burnout [61]; reducing sickness absence [62]; and improving nurses\u0026rsquo; job satisfaction [63\u0026ndash;64].\u003c/p\u003e \u003cp\u003eMany expressed that they were unsatisfied with and experienced anger toward the healthcare organization, which was also expressed in other studies [65]. Some of the nurses felt deceived and betrayed by the employer, by them changing protocols for what PPE the nurses should wear depending on what material they had in stock. Instead of being honest and admitting that \u0026ndash; yes, it was not guaranteed that the protective equipment was the best alternative but that it was what they had to work with \u0026ndash; thus putting nurses\u0026rsquo; health at risk. Ensuring the well-being of nurses is a shared responsibility involving not only the nurses themselves but also the systems and organizations that provide support [66].\u003c/p\u003e \u003cp\u003eFeeling a sense of duty toward patients but also their colleagues was something that many of the nurses stated was what made them come to work even though they felt tired or stressed. Nurses have a duty to care for patients, but at the same time, there must be a balance between caring for patients and trying to keep nurses and other healthcare professionals safe. It is important to address nurses\u0026rsquo; ethical concerns and well-being to maintain resilient healthcare staff [67].\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSatisfaction, motivation, meaningfulness, stimulance with work tasks and activities at work\u003c/em\u003e \u003c/p\u003e\u003cp\u003eThe nurses in the present study stated that it was hard to keep themselves motivated not only partly because they knew what they were going to face but also because they were caring for patients whom they were not supposed to care for. Some nurses felt that the level of care was subpar, that they were unable to perform as well as that they would like, which affected their motivation. As stated previously, the nurses in the present study stated that there were issues with their working environment, such as a lack of space and a lack of proper ventilation. As reported in a previous study [47], the working environment is an important aspect of maintaining patient safety and nurse job satisfaction. On the other hand, there were nurses in the present study who stated that they felt that the work they do is meaningful and that it gave them a chance to roll up their sleeves and show their ability. The meaningfulness of one\u0026rsquo;s work was also found to be important for nurses\u0026rsquo; mental health in another article [1].\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eKnowledge, skills and competence development\u003c/em\u003e \u003c/p\u003e \u003cp\u003eTo perform one\u0026rsquo;s work tasks and activities, employees need knowledge, skills and competence, which is also important for a sustainable working life [28\u0026ndash;30]. Good communication, between colleagues and, in some instances, between managers and staff, was described by the nurses in the present study. Good communication and good relationships are valuable tools for a health-promoting organizational and mental work environment [28].\u003c/p\u003e \u003cp\u003eNurses in the present study stated that there was a lack of introduction when they worked in other wards during the pandemic, and some nurses stated that they cared for patients beyond their level of expertise. A lack of proper training or introduction can lead to deficiencies in patient safety. Some nurses stated that they worked according to learning-by doing since the pandemic was unknown to everybody and that they had to learn what worked best, but that also caused some nurses to feel that they were novices in the profession again. The latter was also reported in a previous study [47] in which nurses described feeling new in the profession. It is important to take what we have learned from this pandemic and make adjustments in healthcare organizations so that we are better prepared for when the next pandemic or major event takes place.\u003c/p\u003e"},{"header":"6. Strengths and limitations","content":"\u003cp\u003eSince our data were drawn from semistructured interviews that took place a few years after the COVID-19 pandemic began in 2020, there is a risk of recall bias. The informants\u0026rsquo; memories may not be accurate or reliable, but since the nurses\u0026rsquo; experiences we are interested in and time could have given them time to think back and reflect on their situation, we believe that the data are reliable. By acknowledging the potential for recall bias and taking steps to mitigate it, researchers can increase the accuracy and reliability of their findings. The interviews allow for detailed and in-depth data collection, providing rich insights into participants\u0026rsquo; perspectives. Using deductive content analysis can be seen as both a strength and a limitation. Using an existing framework provides a more efficient process and structured approach to data analysis. The use of an existing framework facilitates the comparison of findings across different studies or contexts. Some may argue that the reliance on existing theories can limit the discovery of new insights or unexpected findings. Hence, we used a semistructured interview guide, which gave the interviewer the opportunity to delve deeper into the different areas. Some researchers may state that predefined categories may introduce bias, as researchers might overlook data that do not fit the existing framework. To ensure that no data were overlooked, several researchers completed the coding.\u003c/p\u003e"},{"header":"7. Conclusions","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSome of the challenges faced by healthcare professionals in Sweden are that healthcare organizations are undersized and that there need to be better opportunities for primary care to expand to ease the burden on hospitals. There needs to be a better balance between resources (e.g., equipment, funding, and staff) for nurses and other healthcare providers to be able to carry out their work. Nurses are generally unhappy with their working conditions, a common concern that is preventable with proper organizational actions. As far as competence provision is concerned, we must rethink the resources we have by using new ways of working, digitalizing, using and increasing the competence of existing staff, moving tasks to primary care, etc. We have to take care of the existing staff so that they can continue and thrive. Improving the work environment can enhance nurses\u0026rsquo; health and well-being, potentially leading to better retention of staff. For a sustainable working life, it is crucial that nurses have a manageable workload and opportunities for recuperation both at work and between shifts. Ensuring the well-being of nurses is a shared responsibility between nurses and the organizations that support them.\u003c/p\u003e\u003cp\u003eWork-related stress is a prevalent issue among healthcare personnel globally, increasing the likelihood of cognitive failure and impacting patient safety. Healthcare organizations must prioritize nurses\u0026rsquo; health and well-being. Policymakers and healthcare leaders should implement strategies to address nurses\u0026rsquo; mental health needs, especially given the global nursing shortage and challenging working conditions. Nurses struggle with motivation because of challenging conditions and care for patients outside their usual scope. Despite these challenges, some nurses find their work meaningful, which positively impacts their mental health and motivation. Nurses had limited time to stay updated on the latest guidelines, relying on colleagues and managers for information. It is important to learn from the pandemic and make necessary adjustments to healthcare organizations to be better prepared for future pandemics or major events.\u003c/p\u003e\u003cp\u003eConversely, to identify salutogenic and pathogenic factors, one must highlight all nine areas of importance in the SwAge model and understand how these nine areas interact in the complex work situation of nurses. Therefore, health care organizations and managers should consider all these areas when developing measures to promote a sustainable working life for nurses. Nurses must advocate for equitable healthcare systems, fair compensation, and safe working environments.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study has approval from the Swedish Ethical Review Authority \u0026nbsp;(2016/867 and 2020-01897). All participants gave informed consent to partake in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by Interreg (European Regional Development Fund, EU), grant number NYPS20303383; FORTE FORMAS, grant number 2020-02746; and the Research Platform for Collaboration for Health, Kristianstad University, Sweden. Funding number 9/2021.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to acknowledge the nurses who took time out of their lives to partake in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eC. N was responsible for data collection and writing the initial draft of the manuscript. C.N. and K.N. performed the initial deductive content analysis. All the authors contributed to the conception and design of the study and the final content analysis and to the writing and critical revision of the manuscript.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col start=\"1\" type=\"1\"\u003e\n\u003cli\u003eShivairov\u0026aacute;, O; B\u0026aacute;rtlov\u0026aacute;, S; Hellerov\u0026aacute;, V; Chloubov\u0026aacute;, I. Nurse\u0026rsquo;s mental health during Covid-19 pandemic. 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The National Academies Press. https://doi.org/10.17226/25982\u003c/li\u003e\n\u003cli\u003eMu\u0026ntilde;oz-Rubilar, C.A; Pezoa Carrillos, C; Mundal, I.P; De las Cuevas, C; Lara-Cabrera, M.L. The duty to care and nurses\u0026rsquo; well-being during a pandemic. Nursing Ethics, 2022, 29(3):527-539.\u003c/li\u003e\n\u003c/ol\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Nurses, salutogenic, pathogenic, work situation, health, deductive analysis","lastPublishedDoi":"10.21203/rs.3.rs-5069662/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5069662/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eNurses represent a high percentage of employees in health care; however, there is a shortage. Working as a nurse includes both advantages, such as job security, and disadvantages, such as a greater risk of developing mental ill health. Aim: To explore which salutogenic and pathogenic factors influence nurses’ health and work situation. Methodology: In-depth interviews with nurses who worked during the COVID-19 pandemic. Snowball sampling and deductive content analysis were performed. Findings: When conditions were lacking in providing good care, there was a feeling of betrayal and anger toward the organizations. Moreover, collegial support was crucial for mental health, and some nurses experienced flourishing. Conclusion: Healthcare professionals in Sweden face several challenges, including undersized organizations and the need for primary care expansion to reduce hospital burdens. A better balance of resources (equipment, funding, staff) is essential for nurses to perform effectively. Strong colleague support enhances interprofessional collaboration, but organizational prerequisites are crucial. Improved working conditions and organizational support help retain nurses. Identifying factors for a sustainable working life involves understanding nine key areas and their interactions. Healthcare organizations and managers should consider these areas to promote sustainability. To ensure a competent supply, we must rethink the resources we have by using new working methods, digitization, the transfer of tasks to primary care, etc. Nurses must advocate for equitable systems, fair compensation, and safe environments.\u003c/p\u003e","manuscriptTitle":"Nurses’ health and work experiences during the COVID-19 pandemic in Swedish prehospital and hospital care: A deductive content analysis through the lens of the swAge model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-12 03:36:21","doi":"10.21203/rs.3.rs-5069662/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-13T05:48:58+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-13T03:16:27+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-13T02:44:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2024-09-11T08:57:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"95f6ebae-6f50-49b6-8c16-bca6674da4bf","owner":[],"postedDate":"December 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-27T16:11:37+00:00","versionOfRecord":{"articleIdentity":"rs-5069662","link":"https://doi.org/10.1186/s12889-024-21152-x","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-01-24 15:57:19","publishedOnDateReadable":"January 24th, 2025"},"versionCreatedAt":"2024-12-12 03:36:21","video":"","vorDoi":"10.1186/s12889-024-21152-x","vorDoiUrl":"https://doi.org/10.1186/s12889-024-21152-x","workflowStages":[]},"version":"v1","identity":"rs-5069662","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5069662","identity":"rs-5069662","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}