Exploring Frontline Nurses' Experiences During the COVID-19 Pandemic: A Qualitative Multiple-Case Study

Exploring Frontline Nurses' Experiences During the COVID-19 Pandemic: A Qualitative Multiple-Case Study | 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 Exploring Frontline Nurses' Experiences During the COVID-19 Pandemic: A Qualitative Multiple-Case Study Jaqueline Witter, Elsa-Sofia Morote, Marsha Reynolds-Henry This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7953532/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: The COVID-19 pandemic created unprecedented challenges for frontline nurses, who faced increased workloads, emotional strain, patient mortality, and shifting policies. This study explores nurses’ resilience, self-efficacy, coping strategies, and support systems after returning to work following COVID-19 infection. Methods: A qualitative multiple-case study was conducted at an Inner-City Safety Net Hospital in New York State. Ninety registered nurses completed a pre-survey, and 39 volunteered for one-on-one interviews. Nine nurses were randomly selected for interviews. Data were analyzed using inductive thematic analysis. Results: Three major themes emerged: Resilience & Self-Efficacy, Coping & Mental Health, and Work Support. Nurses demonstrated adaptability, emotional and physical strain, reliance on faith and peer support, and a strong commitment to patient care. Teamwork, organizational communication, and evolving hospital policies served as significant support factors. Conclusions: Despite profound challenges, nurses showed exceptional resilience and dedication. Organizational support systems, teamwork, and mental health resources are essential to sustaining nurses’ well-being in future crises. Trial registration: Not applicable. COVID-19 Nursing Resilience Self-Efficacy Mental Health Qualitative Research Frontline Nurses Teamwork Healthcare Workforce Background The COVID-19 pandemic, which emerged in December 2019, ushered in a global health crisis that had far-reaching consequences for individuals worldwide. Alongside its devastating health impacts, the pandemic engendered a profound set of mental health challenges, including anxiety, stress, and depression, largely attributed to the dearth of adequate information for managing the novel coronavirus. At the forefront of the response were frontline nurses, who exhibited remarkable courage and dedication in caring for patients and their loved ones. These nurses confronted a myriad of formidable challenges, stemming from the relative novelty of the virus, as well as factors such as increased workloads, staffing shortages, patient mortality, insufficient personal protective equipment (PPE), and the rapid implementation of fluctuating health policies and regulations. This qualitative, multiple-case study has delved into the experiences of frontline nurses during the COVID-19 pandemic, seeking to illuminate the factors that motivated them to return to work despite the perilous conditions. To support this study, a pre-survey was answered by 90 registered nurses from an Inner-City Safety Net Hospital, all of which had contracted COVID-19 and subsequently returned to work. Thirty-nine nurses who participated in the survey also volunteered to participate in a one-on-one interview. A random sample of nine registered nurses was invited to be interviewed in regard to their experience of contracting COVID-19 and returning to work. Data collection for this research employed a two-pronged approach, combining a pre-survey with semi-structured, one-on-one interviews. The objective was to gain insights into the primary motivations driving registered nurses to rejoin the workforce, their strategies for managing the daily pressures of work upon their return, the support, or lack thereof, extended by their employers and peers, and how the pandemic transformed their quality of life and influenced their future professional trajectories. This study contributes to a deeper understanding of the resilience and commitment of frontline nurses during unprecedented global health crises, shedding light on the pivotal role they played in mitigating the adverse effects of the COVID-19 pandemic. The purpose of this study is to examine the sense of resilience and self-efficacy among nurses upon returning to work after COVID-19 infection, as well as to identify any themes that emerge from their insights on coping strategies and the support they received from employers and peers during this period. Theoretical Framework In examining the resilience of nurses during the COVID-19 pandemic, Afshari et al. (2021) found that stress, job satisfaction, burnout, and age were significant predictors of nurses' resilience. This study highlights the significance of individual factors in influencing nurses' ability to adapt and endure in challenging circumstances. In contrast, Scherr-Schierberi et al. (2020) focused on the mental health challenges faced by nurses providing direct care to COVID-19 patients. They highlighted the increased levels of distracted practice among these nurses, suggesting that resilience and social support may play a crucial role in mitigating the psychological impact of their work. Regarding personal factors and resilience, Afshari et al. (2021) emphasized the influence of personal characteristics. LoGiudice and Bartos (2021) shed light on the significance of clear protocols in enhancing resilience. LoGiudice and Bartos discussed the negative effects that constantly changing hospital protocols had on nurses' emotional well-being. This finding suggests that organizational support and consistency in protocol are essential factors for bolstering nurses' resilience. The experiences of nurses caring for COVID-19 patients and the identified workload burden, fear, depression, anxiety, unmet needs, as well as physical and psychological burdens, were significant challenges (Ahmadidarrehsima et al., 2022). Ahmadidarrehsima et al. (2022) highlight the difficulties that nurses faced during the pandemic. However, Sierakowska et al. (2022) found that nurses' levels of stress were not attributed to their age, work experience, nursing role, or designated work areas. Instead, they found that nurses working in inpatient areas exhibited higher self-efficacy, emphasizing the importance of supporting nurses' mental health, regardless of their demographic characteristics. Similarly, Duncan et al. (2021) identified various factors, including social distancing, conservation of personal protective equipment, and telehealth, that hindered efficient care practices during the pandemic. Their study highlights the importance of addressing system-wide challenges to ensure the well-being of healthcare workers. Meanwhile, Rathnayake et al. (2021) emphasized the need for policies, training, resources, shift improvements, and incentives to support nurses, suggesting that a multifaceted approach is necessary to alleviate the negative impact on their mental health. Fournier et al. (2022) has already considered the mental health of nurses, discussing the impact of COVID-19 on the mental health of healthcare professionals in France. They identified anxiety, insomnia, burnout, depression, and psychological stress as prevalent issues. In contrast, Kalyan et al. (2022) focused on the mental health impact of quarantine on healthcare workers. They emphasized the need for support to prevent adverse psychological reactions, particularly in regard to healthcare workers being isolated due to quarantine. Kaur et al. (2022) analyzed how frontline nurses mentally and physically prepared themselves to manage COVID-19 patients, highlighting the pivotal role of training and support in fostering nurses' resilience. In a similar study, Liu et al. (2022) examined the impact of the delta variant on healthcare workers in China, advocating for interventions to mitigate anxiety among healthcare staff, particularly in the face of emerging new variants. A study by Kyle J. Rehder et al. (2023) examined the impact of the COVID-19 pandemic, with a particular focus on teamwork within U.S. hospitals. It revealed a decline in collaborative efforts and emphasized the need for proactive team training to enhance both patient safety and workforce well-being. Conversely, Zwhwei, Wang, et al. (2023) explored team resilience and performance networks among Chinese nurses, proposing interventions to fortify nurses' ability to withstand stress and enhance the quality of services through improved teamwork (Rezaee et al., 2023). In the same vein, Zeynep, Osman and Ahmet (2022) highlighted the positive relationship between job motivation and teamwork attitudes among intensive care nurses in Turkey, indicating that a motivated team can foster more effective teamwork. On the other hand, Nasrin, et al. (2022) discussed the barriers to teamwork experienced by nurses in Iran, emphasizing the need for organizational support and effective planning to facilitate teamwork during the pandemic, especially in the face of challenges like inadequate education and poor communication. Study Aim and Design The purpose of this qualitative, multiple-case study was to explore the experiences of nurses during the pandemic. The researchers determined that a qualitative, multiple-case study would be the best methodology based on Yin ’ s (2018) determination that such an approach would be most relevant for providing an understanding of the topic. Data was collected from two sources 1) a pre-survey 2) semi-structured one-on-one interviews. A total of 9 people were interviewed. The following research questions guided this multiple case study: RQ1. How do nurses describe their sense of resilience and self-efficacy when returning to work after having COVID? RQ2 What themes emerged from the crucial insights of nurses regarding their coping strategies and support provided by employers and peers after having COVID? A case-study approach permitted an in-depth investigation with multiple sources of evidence (questionnaires and interviews). This investigation allowed the researchers to understand the cases in a multifaceted way (Yin, 2018). Yin (2018) suggested that single case studies are appropriate if the research objective is to explore a previously researched subject. He recommended multiple-case design when the intent of the research is a description, theory building, or theory testing. Farquhar et al. (2020) posited that the case-study format is appropriate for answering three basic questions: when, how, or why. The subject under investigation centered on capturing or explaining a new phenomenon. To explore the lived experiences of nurses who contracted COVID-19 and continued to work during the pandemic, the researchers conducted a qualitative data analysis. This move enabled research questions to naturally form while providing meaningful context thanks to exploring a relatively new phenomenon within an environment where the event was occurring (Farquhar et al., 2020; Yin, 2018). The use of qualitative analysis pre-surveys, and semi-structured interviews, served as data sources to answer the research questions. The researchers gathered data for this qualitative case study through various methods. Interviews with the nurses provided in-depth background on crucial insights of their lived experiences. The interview questions were carefully constructed with elements of formal research on similar topics being used as the basis of the semi-structured interviews. This qualitative, multi-case study is a research approach that facilitates the exploration of a phenomenon within its context using a variety of data sources (Baxter & Jack, 2008). Data Analysis The analysis followed a structured, multi-step qualitative process. Researchers first immersed themselves in the data by reading each transcript multiple times to gain a grounded understanding of participant experiences, noting early impressions, recurring ideas, and emerging patterns. Through open coding, transcripts were examined line by line, and meaningful segments of text were labeled to capture emotions, stressors, coping behaviors, workplace challenges, and reflections in participants’ own words. Axial coding then allowed researchers to compare codes across all transcripts, grouping related concepts into broader categories such as resilience, teamwork, emotional strain, coping strategies, and perceptions of organizational support. Using iterative comparison and guided by Yin’s pattern-matching approach, these categories were refined and reorganized until three overarching themes emerged: Resilience and Self-Efficacy, Coping and Mental Health, and Work Support: Teamwork and Policies. Methodological rigor was strengthened through a comprehensive triangulation process. Multiple researchers independently coded the transcripts, compared interpretations, and met regularly to review discrepancies. Differences in coding were discussed in depth, categorized, and resolved through consensus, ensuring that themes reflected collective judgment rather than individual bias. Triangulation extended beyond coding to include cross-checking themes with analytic memos, an audit trail of coding decisions, and pre-survey data. This multi-layered verification enhanced credibility, dependability, and confirmability throughout the study. Pre-survey data were used to contextualize interview findings, verify participant demographics, and support themes related to emotional impact and workplace challenges. The final synthesis integrated all findings into a cohesive narrative capturing the complexity of nurses’ experiences returning to work after COVID-19 infection while managing the pressures of a demanding clinical environment. Sample and Population This study included a pre-survey answered by 90 registered nurses from an Inner-City Safety Net Hospital from New York State, all of which had contracted COVID-19 and subsequently returned to work. Thirty-nine of the nurses who answered also volunteered to participate in a one-on-one interview. A random sample of nine registered nurses were invited to be interviewed regarding their experience of contracting COVID-19 and returning to work. The inclusion criteria for nurses who were interviewed were as follows: Being a licensed registered nurse at the study site Providing direct patient care during the pandemic Having contracted COVID-19 and returned to work Willingness to complete a pre-survey and/or participate in an interview There is no single ideal number of participants to be interviewed in qualitative research, as it depends on what the researcher believes will be suitable for answering the relevant research questions. For instance, Creswell and Creswell (2017) suggested between five to 25. Glaser and Strauss (1967) saw saturation to be the point of diminishing return. Meanwhile, Guest, Bunce, and Johnson (2006) noted that data saturation might be attained by as little as six interviews, depending on the population ’ s sample size. In this case, the researcher randomly selected 10 registered nurses to participate (of the 39 who volunteered) in an in-depth one-on-one interview. One participant revealed that he wasn ’ t sure that he had COVID-19, therefore the interview was dropped. The interview data was analyzed from 9 Registered Nurses. IRB approval was obtained from an Inner-City Safety Hospital where all of the registered nurses are employed, and all participants completed a consent form. Materials and Instruments Strauss and Corbin (1999) acknowledged that a literature review should be carried out before fieldwork commences and that the researcher should enter the research area with some knowledge of the phenomenon being studied. Strauss and Corbin (1999) considered that the literature could be used to help derive questions that the researcher would like to use in their fieldwork (Strauss & Corbin, 1999). Furthermore, Yin (2018) referred to the literature review to develop the case study protocol, which includes the research objectives and case study questions (Yin, 2018). The instruments and materials were created for each phase of data collection using selected literature. Pre-survey. The goal of this survey was to identify nurses that had COVID-19 or a COVID Variant while working, and learn how they were exposed to the virus, what year it was, the severity of the symptom, time out of work, if they have residual symptoms, what challenges they encountered after returning to work from the virus and what they found helpful upon their return. Demographic questions were also collected (do they work full time, are of work, gender identity, race/ethnicity). Only nurses who had COVID were allowed to complete the survey. The first question asked if the person had COVID, if not, the survey would thank them for taking part. One-on-one interviews. After the 90 Registered Nurses completed the survey, they were asked if they were willing to volunteer to take part in a one-on-one interviews. A total of 39 people volunteered, 10 of which were randomly selected. Nine people were interviewed in the end as person number 10 did not test herself to learn if she had COVID or not. The one-on-one interviews were based on six questions. We wanted to learn what their primary motivation was to return to work, how they managed the everyday pressures of work after they returned, the support (or lack of) they received from the employer or peers, how the pandemic changed their quality of live and the future regarding their profession. The interviews lasted for a total of 30-45 minutes for each participant and they were taped and transcribed by the researchers. Ethical Considerations The study received approval from the Institutional Review Board of a Safety Net Hospital in New York. All procedures were conducted in accordance with the Declaration of Helsinki and the ethical principles outlined in the Belmont Report. Participation was voluntary, written informed consent was obtained from all participants, and confidentiality was strictly maintained throughout data collection, handling, and reporting. Results Pre-survey In total, 90 participants completed the pre-survey (comprising 49% females, 9% Hispanics, 30% African Americans, 18% Asian-Pacific, and 5% White). Among the respondents, 54 individuals confirmed that they had contracted COVID-19. Among those who contracted the virus, 53.3% were employed on a full-time basis. Additionally, 39% of these individuals believed that they had contracted COVID-19 at their workplace, while 13% were uncertain about the source of their infection. A total of 20% reported contracting the virus between 2019 and 2020, with the remaining cases occurring between 2021 and 2022. Furthermore, the manifestation of symptoms varied among these COVID-19 cases, with 10% being asymptomatic, 31% experiencing mild symptoms, 16% presenting with moderate symptoms, and 4.4% enduring severe illness. In terms of the duration of absence from work due to illness, 10% were absent for less than a week, 33% were absent for a duration ranging from 1 to 2 weeks, while the remaining participants were absent for over three weeks. 38% of respondents made the decision to return to work following their illness independently, while 18% followed employer directives based on CDC guidelines. As for the presence of long-haul syndrome, 35% of participants reported no such symptoms, 8% indicated that they had experienced these symptoms for a prolonged period, 7% reported occasional occurrences, and 11.1% stated that they were still affected by long-haul symptoms. Upon returning to work, nurses encountered various challenges, categorized as follows: Sickness-related challenges, such as tachycardia, fatigue, cough, brain fog, and muscle pain, were reported by 47% of participants. Issues related to masks and personal protective equipment (PPE) were noted by 5% of respondents. Psychological challenges, including anxiety and depression, were experienced by 16% of participants. A subset of respondents (30%) reported feeling a return to normalcy without significant challenges. In terms of the support received: Approximately 40% of participants reported receiving support from colleagues and supervisors. A quarter of respondents (25%) indicated that they did not receive any form of support. Eighteen percent of participants reported receiving support, including a transfer to another work area without human resources (HR) barriers, additional days off, and extra payment. Fourteen percent of participants expressed that they did not require any additional support. The reasons for the non-participation of those participants who declined one-on-one interviews were investigated. It was found that 50% of non-participants cited concerns that such interviews would evoke "bad memories" and potentially exacerbate feelings of depression. Comments such as "the experience was horrific, but for some reason I survived" were indicative of this sentiment. The remaining 50% of non-participants cited time constraints as their primary reason for declining the interviews. Interviews Both research questions were addressed through the presentation of three major themes: Resilience & Self-Efficacy, Copying & Mental Health, and Work Support: Teamwork & Policies. RQ1. How do nurses describe their sense of resilience and self-efficacy when returning to work after having COVID? Resilience & Self-Efficacy Within the context of the crisis, this thematic exploration examines the responses and experiences of nurses as they actively engaged with and confronted the multifaceted challenges that arose. At its core, this theme illuminates the remarkable qualities of resilience, teamwork, adaptability, and self-efficacy that nurses demonstrated in the face of adversity. Concurrently, it acknowledges the profound emotional toll exacted upon their own well-being. As articulated by one nurse, a vivid representation of the collective determination of nurses emerges: "Recognizing the imperative of enduring together, we forged a tight-knit bond and adopted a genuinely 'hands-on' approach to our duties amidst the crisis." Another nurse, further contributing to the narrative, underscored the rapidity with which nurses adapted to the evolving crisis: "Upon my return to work, I dedicated myself wholeheartedly to the nurturing of my patients, facilitating their journey back to good health. This encapsulates the essence of nursing—bestowing joy through aiding others." In a similar vein, an interviewee accentuates the inevitability of adaptation by remarking: "The new normal presented us with no alternative but to adapt, persistently providing care at the zenith of our abilities." Conversely, it was imperative to acknowledge the influence of the crisis on nurses' self-efficacy and emotional well-being. A nurse, who had previously contracted COVID-19, candidly expressed her apprehension upon returning to work: "Re-entering the workplace was accompanied by a degree of trepidation. It necessitated meticulous consideration of how proceedings would unfold, particularly in a state of vulnerability where the provision of care becomes an onerous endeavor." In summary, this theme not only underscores the multifaceted nature of nurses' experiences during the crisis, highlighting their resilience and unwavering commitment, but also underscores the emotional and psychological toll, particularly among those who had contracted the virus. Furthermore, it unveils an aspect of their resilience centered around the strengthening of career and personal aspirations, as elucidated by one nurse's perspective: "This experience has compelled me to reevaluate the significance of my life. I've cultivated a deeper commitment to self-care, including adequate rest, to safeguard against illness. Furthermore, it has rekindled my ambitions, such as pursuing further education with the aim of becoming a Diabetic Educator. The crisis has catalyzed a collective desire among nurses to embark on educational pursuits in various domains." RQ2 What themes emerged from the crucial insights of nurses regarding their coping strategies and support provided by employers and peers after having COVID? Coping and Mental Health Within the context of interviews with nurses, this thematic exploration delved into the multifaceted dimensions of their mental health and the strategies they employed to navigate the challenges inherent in their profession during the pandemic. This theme aims to shed light on the intricate interplay between coping mechanisms, faith, support systems, and evolving perspectives, as experienced by nurses. Through the interviews, nurses were able to candidly discuss their encounters with the specter of depression. It transpires that some choose to seek solace through therapy as a means of managing their mental well-being. Additionally, the "serenity prayer" emerged as a poignant guiding principle for certain nurses, providing solace in the midst of adversity. Faith also played a pivotal role in the lives of the nurses interviewed. Prayers became a recurring motif during interviews, with their significance as sources of strength and resilience being emphasized. Interestingly, some nurses openly shared their fears of mortality, grappling with the stark reality of the crisis and even coming to terms with the possibility of their own demise. A cornerstone of the nurses' coping strategies was the unwavering support received from families and peers, which played an instrumental role in nurturing resilience among them. Furthermore, the eventual control established by the hospital over the crisis, coupled with the advent of vaccinations, ushered in a palpable sense of relief and calmness. One participant articulated this: "The situation has significantly improved, and the work environment has stabilized. Our floor is no longer designated for COVID patients, and we now have specialized units to manage such cases." Moreover, nurses collectively experienced a period marked by trauma that manifested in the form of challenges within the hospital, as well as the personal toll it exacted on their lives and the lives of their family and friends. The scarcity of staff and shortages of personal protective equipment (PPE), including the reusing of masks, weighed heavily on their experiences. Concurrently, nurses reported experiencing physical manifestations of distress, including migraines and episodes of "brain fog," further reflecting the significant strain they endured. Seeking support emerged as a pivotal coping mechanism, with nurses turning to therapists, virtual medical consultations, and other resources to address their mental health needs. Additionally, nurses grappled with the heart-wrenching loss of family members and friends, amplifying the personal tragedies they had to contend with. The responsibility of safeguarding both their loved ones and workplace compelled nurses to adopt stringent measures, including self-isolation. In summary, the "Coping and Mental Health" theme provided a comprehensive understanding of the profound psychological and emotional complexities experienced by nurses during the pandemic. It underscores the diverse array of coping strategies they employed, the significance of faith and support systems, as well as the dynamic nature of their perceptions as the pandemic unfolded. Work Support: Teamwork & Work Policies Within the framework of nurses' interviews, the theme of "Work Support" emerged as a central element that underscores the vital role of teamwork and organizational policies in facilitating their ability to cope with the challenges posed by the pandemic. This theme highlights the significance of mutual support among nurses and the role of healthcare facilities in implementing policies to create a conducive work environment. One nurse aptly stated, "Teamwork is dreamwork," succinctly encapsulating the paramount importance of collaboration and unity among healthcare professionals. Nurses consistently expressed the profound support they provided to one another, with daily communication and shared prayers serving as a testament to the camaraderie that developed among them. This sense of unity transcended the workplace, with nurses describing their colleagues as becoming akin to family members, providing assistance and reassurance during difficult times. One nurse eloquently expressed this sentiment, stating: "It's like family. They came to me, asking if I was okay, offering help with anything. You can always count on them." Furthermore, nurses acknowledged the transformative effect of the pandemic on staff dynamics, fostering a closer-knit team and altering the way they approached their work. On an organizational level, hospitals played a pivotal role in offering support through the implementation of policies aimed at enhancing the working environment. Nurses recognized the concerted efforts to facilitate vaccination programs and applauded the constant communication of new policies and guidelines. "So many things have been put in place in terms of vaccinations," one nurse said when reflecting on the proactive stance taken by the hospital in regard to safeguarding the well-being of its staff. Moreover, nurses appreciated the regular dissemination of information related to personal protective equipment (PPE), which contributed to a heightened sense of safety. In summary, the "Work Support" theme is enriched by nurses' own words, emphasizing the vital role of teamwork and mutual support during the pandemic. It also underscores the impact of senior leadership availability, as well as the proactive measures taken by healthcare facilities to create a supportive and secure work environment for nurses during these challenging times. Discussion In this multi-case study, the researchers sought to gain insights into how nurses describe their sense of resilience and self-efficacy, as well as their coping strategies and the support they received from employers and peers upon returning to work after contracting COVID-19. This study further underscored the interconnectedness of self-efficacy and resilience among nurses, as both attributes played a pivotal role in their ability to navigate the complexities of the COVID-19 pandemic. The importance of spiritual connection, familial and peer support was also significant as these support systems played a crucial role in helping nurses cope with mental health issues. Teamwork in the nursing profession also proved to be crucial in mitigating the high levels of stress and challenges faced during the pandemic. Registered nurses recognized the efforts made by the hospital to improve their policies on safety measures for proper protective equipment. It is recommended that nursing professionals undergo comprehensive training in effective teamwork strategies and be encouraged to establish and actively participate in support networks within the healthcare setting. These networks can serve as platforms for mutual assistance and emotional support, bolstering the resilience of nurses and their ability to navigate challenging situations collectively. Despite these formidable obstacles, nurses exhibited an extraordinary resilience as they provided essential support to patients, families, and friends. They rapidly adapted to the exigencies of life-and-death situations, while enduring physical, emotional, and psychological strains. Throughout this period, nurses remained unwavering in their commitment to the nursing profession, fostering invaluable human connections and demonstrating a profound sense of resilience. This study has identified three major themes that encapsulate the experiences of nurses: Resilience and Self-Efficacy: The nurses we interviewed exhibited remarkable resilience and a strong sense of self-efficacy, emphasizing their belief in themselves and their future career aspirations. Their unwavering commitment to patient care, even in the face of personal challenges, was evident, aligning with the findings of Ashari et al. (2021) who linked job satisfaction with resilience. Additionally, the nurses emphasized the critical role of social support from their colleagues, reinforcing their level of resilience, as previously discussed by Sherr-Schierberi et al. (2020). The study further underscores the interconnectedness of self-efficacy and resilience among nurses, as both attributes played a pivotal role in their ability to navigate the unique complexities of the COVID-19 pandemic. Coping and Mental Health: Our findings revealed that nurses faced and coped with depression, anxiety, and mental health challenges during the COVID-19 crisis. This was a struggle that persisted even after they had contracted COVID-19 themselves. Moreover, the study shed light on the coping strategies employed by nurses to manage their mental health during and after the pandemic. Spirituality emerged as a predominant coping mechanism, followed by finding solace as a means of emotional relief. The importance of familial and peer support was underscored, as these support systems played a crucial role in helping nurses cope with the mental health issues faced. The significance of faith and support systems in enabling nurses to weather the mental health crisis during the peak of the pandemic and beyond aligns with prior research, as highlighted by Kaur et al. (2022), who emphasized the need for training and support to address such concerns. Work Support: Team and Policies: Our study reaffirmed the pivotal role of teamwork in the nursing profession, with nurses emphasizing the importance of their colleagues as akin to family. This sense of unity and mutual support among team members was crucial in mitigating the stress and challenges faced during the pandemic. While the nurses expressed a perception of distance from hospital administration during the pandemic, they still highlighted the support they provided to each other. Additionally, nurses recognized the efforts made by hospitals to improve their policies, particularly in the realm of safety. These findings align with prior research by Rehder et al. (2023), which stressed the significance of teamwork in alleviating the stress level of nurses. In summary, our study underscores the multifaceted nature of nurses' experiences during the COVID-19 pandemic, shedding light on their resilience, coping mechanisms, and the critical importance of teamwork and policy improvements in supporting their efforts on the front line of healthcare. Implications for Practice This study highlights several key implications for nursing practice and organizational leadership: Enhance Teamwork Training and Foster Supportive Networks for Nurses. It is recommended that nursing professionals undergo comprehensive training in effective teamwork strategies and be encouraged to establish and actively participate in support networks within the healthcare setting. These networks can serve as platforms for mutual assistance and emotional support, bolstering nurses' resilience and their ability to navigate challenging situations collectively. Provide Training in Support Mechanisms, Including Mediation and Spirituality. Nurses should receive training that encompasses a range of support mechanisms, including conflict mediation and the integration of spirituality in their coping strategies. This training can equip nurses with valuable skills for managing conflicts constructively while nurturing their mental well-being. Doing so will ultimately enhance their capacity to provide high-quality care. Periodic Review of Hospital Policies to Ensure Adequate Support for Nurses. Hospitals are encouraged to conduct periodic reviews of their policies and procedures, with a specific focus on addressing the needs and concerns of nursing staff. Ensuring that nurses have access to the necessary resources and support systems should be a priority. Policy adjustments should be made to optimize nurses' working conditions and facilitate their ability to provide safe and effective patient care. Implement Knowledge Training Opportunities (e.g., Micro Credentials, Certifications) On-Site. To enhance the efficacy of nursing staff and foster their professional development, healthcare institutions should consider implementing on-site knowledge training programs. These programs can include micro credentials and certifications tailored to nurses' specific roles and responsibilities. Such initiatives not only augment the competence of nurses but also contribute to their resilience by instilling a sense of achievement and mastery in their profession. Strengthening resilience-building interventions: Programs that enhance coping, self-efficacy, and stress management may support nurses in crisis settings. Investing in mental health resources: Accessible psychological support, debriefing sessions, and trauma-informed care are essential. Improving communication systems: Clear, timely, and consistent policies reduce confusion and enhance nurses’ sense of safety. Reinforcing teamwork and collaboration: Peer support networks and team cohesion can mitigate emotional burden and improve morale. Limitations This study has several limitations. The sample was limited to 90 nurses from a single Safety Net Hospital in New York, which may affect the transferability of findings to other settings. Additionally, the qualitative interviews were conducted with a small, randomly selected subset of volunteers, which may not fully capture the diversity of all nurses who contracted COVID-19. Despite these limitations, the rich narratives provide valuable insight into the lived experiences of frontline nurses returning to work post-infection. Summary Overall, the study underscores the extraordinary resilience of frontline nurses and the critical role of organizational support, communication, and mental health resources. Understanding these experiences is essential to preparing healthcare systems for future public health crises and supporting the long-term well-being of the nursing workforce. Conclusion This qualitative multiple-case study explored the experiences of frontline nurses who contracted COVID-19 and returned to work during the height of the pandemic. The findings highlight three interrelated themes— Resilience and Self-Efficacy , Coping and Mental Health , and Work Support: Teamwork and Policies — that collectively shaped nurses’ ability to navigate intense clinical and emotional demands. Despite physical strain, emotional burden, and uncertainty, nurses demonstrated remarkable resilience, a strong sense of purpose, and sustained commitment to patient care. Their coping strategies, reliance on peer support, and personal beliefs contributed significantly to their ability to adapt and persevere. At the organizational level, teamwork, communication, and evolving hospital policies emerged as essential sources of support, although inconsistencies early in the pandemic heightened stress and confusion. These findings underscore the critical importance of strengthening mental health support, enhancing communication systems, and investing in organizational structures that promote resilience and teamwork. By understanding the lived experiences of nurses’ post-infection, healthcare systems can better prepare for future public health crises while promoting the long-term well-being and retention of the nursing workforce. Abbreviations CDC – Centers for Disease Control and Prevention PPE – Personal Protective Equipment IRB – Institutional Review Board RN – Registered Nurse Declarations Ethics approval and consent to participate This study received ethical approval from the Institutional Review Board of a Safety Net Hospital in New York. All study procedures involving human participants were conducted in accordance with the Declaration of Helsinki and the ethical principles outlined in the Belmont Report, as well as institutional guidelines for research with human subjects. Prior to data collection, all registered nurses were informed of the study’s purpose, procedures, confidentiality protections, and their right to withdraw at any time. Written informed consent was obtained from every participant before completing the pre-survey and before participating in one-on-one interviews. Consent for publication All participants provided consent for the publication of anonymized data. Availability of data and materials The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding This study received no external funding. Authors’ contributions JW contributed to IRB submission, study design, data collection, and manuscript development. ESM led the study design, data analysis, and writing of the manuscript. MRH contributed clinical expertise, analysis validation, and manuscript review. All authors read and approved the final manuscript. Acknowledgements The authors extend gratitude to the CEO and Senior leader of Safety Net Hospital, as well as the nurses and staff in NY, for their participation and dedication. References Ahmadidarrehsima, S., Salari, N., Dastyar, N., & Rafati, F. (2022). Exploring the experiences of nurses caring for patients with COVID-19: A qualitative study in Iran. BMC Nursing, 21(16), 1–7. https://doi.org/10.1186/s12912-022-00805-5 Baxter, P., & Jack, S. (2008). Qualitative Case Study Methodology: Study Design and Implementation for Novice Researchers. The Qualitative Report, 13(4), 544-559.https://doi.org/10.46743/2160-3715/2008.1573 Creswell. J.W. and Creswell, J.D. (2017) Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 4th Edition, Sage, Newbury Park. Duncan, R., Szabo, B., Jackson, Q. L., et al. (2021). Care and coping during COVID-19. Clinical Journal of Oncology Nursing, 25(1), 48–55. https://doi.org/10.1188/21.cjon.48-55 Fournier, A., Laurent, A., Lheureux, F., et al. (2022). Impact of the COVID-19 pandemic on the mental health of professionals in 77 hospitals in France. PLoS One, 17(2), 1–19. https://doi.org/10.1371/journal.pone.0263666 Glaser, B., & Strauss, A. (1967). The Discovery of Grounded Theory: Strategies for Qualitative Research. Mill Valley, CA: Sociology Press. Guest, G., Bunce, A., & Johnson, L. (2006). How Many Interviews Are Enough?: An Experiment with Data Saturation and Variability. Field Methods, 18(1), 59-82. https://doi.org/10.1177/1525822X05279903 Farquhar, J., Michels, N., & Robson, J. (2020). Triangulation in industrial qualitative case study research: Widening the scope. Industrial Marketing Management . Kalyan, G., Sharma, N., Kaur, S., et al. (2022). Lived experiences of nurses during quarantine:qualitative study from North India. Nursing and Midwifery Research Journal, 1–13. Kaur, J., Dhandapani, M., Kaur, S., et al. (2022). Acceptance and preparedness to be COVID warriors: Self narratives of frontline nurses of a tertiary care center. Florence Nightingale of Nursing, 30(1), 25–32. Liu, Y., Hou, T., Gu, H., et al. (2022). Resilience and anxiety among healthcare workers during the spread of the SARS-CoV-2 delta variant: A moderated mediation model. Frontiers in Psychology, 13, 1–10. https://doi.org/10.3389/fpsyt.2022.804538 LoGiudice, J. A., & Bartos, S. (2021). Experiences of nurses during the COVID-19 pandemic: A mixed-methods study. AACN Advanced Critical Care, 32(1), 14–25. Rathnayake, S., Dasanayake, D., Maithreepala, S. D., Ekanayake, R., & Basnayake, P. L. (2021). Nurses ’ perspectives of taking care of patients with coronavirus disease 2019: A phenomenological study. PLoS One, 16(9), 1–17. https://doi.org/10.1371/journal.pone.0257064 Rehder, K., Adair, C., Eckert, E., Lang, R., Frankel, A, Proulx, J., Sexton, J.B. (2023). Teamwork Before and During COVID-19: The Good, The Same and the Ugly… Journal of Patient Safety, 19 (1), 36-41 Rezaee, N., Mardan-Hamoolen, M., Hamidi, H (2023). Barriers to Teamwork in Caring for Patients with COVID-19: A Qualitative Analysis of Nurses ’ Perceptions in a Secondary Care Setting in Iran. International Journal of Healthcare Management, 16.(1) 86-92 Strauss, A., & Corbin, J. (1999). Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed.). Sage Publications, Inc. Wang, Z., Liang, Q., Yan, Z., Liu, J., Liu, M., Wang, X., Wang, J., Huang, J., Luan, X. (2023). The Association Between Team Resilience and Team Performance in Nurses During the COVID-19 Pandemic: A Network Analysis. BMC Nursing; 22-54 Yin, R. K. (2018). Qualitative research from start to finish. The Guilford Press. Zeynep, T; Osman, Y; Ahmet, K. (2022). Teamwork Attitudes and Job Motivations of Intensive Care Nurses During the COVID-19 Pandemic: A Descriptive, Cross-Sectional Study. Türkiye Klinikleri Journal of Nursing Sciences, 14 ( 4) 983-92 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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-7953532","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":549283775,"identity":"103e412d-3852-4fad-a9ce-cd8b273ba7d3","order_by":0,"name":"Jaqueline Witter","email":"","orcid":"","institution":"SBH Health System","correspondingAuthor":false,"prefix":"","firstName":"Jaqueline","middleName":"","lastName":"Witter","suffix":""},{"id":549283776,"identity":"3dad1fc0-e8f4-4a76-9dbd-09ef5ca5ce48","order_by":1,"name":"Elsa-Sofia Morote","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6klEQVRIiWNgGAWjYBADOcaGAwieBGENCQzGpGtJbEDm49XCL3b42IePP2zSmxsPP5NgqDmcZ3CA+eBtHjxaJGenJc+ckZCW29hwzEyC4djhYoMDbMnW+LQY3M4xZuZJOAzUcsBMgrHhcOKGAzxm0vi02EO0/E9nbDj+DaqF/xteLQbSYC0HEhgbzsBtYcOrReJ2WjLjjLRkw8aGM8UWCcfSE2ceZjO2nINHC//s5MMMH2zs5A1nHN9440ONdWLf8eaHN97g0QIHhjMOsEgkABkKh4lRDgLy/A3MH8CMBmK1jIJRMApGwUgBAKPNUSGVccTCAAAAAElFTkSuQmCC","orcid":"","institution":"City University of New York (CUNY)","correspondingAuthor":true,"prefix":"","firstName":"Elsa-Sofia","middleName":"","lastName":"Morote","suffix":""},{"id":549283777,"identity":"bf00badf-47e0-4dae-8f01-9ad1fe1212b9","order_by":2,"name":"Marsha Reynolds-Henry","email":"","orcid":"","institution":"healthcare pace","correspondingAuthor":false,"prefix":"","firstName":"Marsha","middleName":"","lastName":"Reynolds-Henry","suffix":""}],"badges":[],"createdAt":"2025-10-27 11:31:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7953532/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7953532/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":96628002,"identity":"465bb6c4-f335-4117-bfd3-9da0f6004788","added_by":"auto","created_at":"2025-11-24 12:12:30","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":47353,"visible":true,"origin":"","legend":"","description":"","filename":"SBHStudycorrectedNov5.docx","url":"https://assets-eu.researchsquare.com/files/rs-7953532/v1/fb8897b6f46df5e0f2ca901e.docx"},{"id":96628003,"identity":"b11ca665-e745-44b8-b9d8-520473c2c9f2","added_by":"auto","created_at":"2025-11-24 12:12:30","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5130,"visible":true,"origin":"","legend":"","description":"","filename":"e2a1933061ff40d0999eebf16920848e.json","url":"https://assets-eu.researchsquare.com/files/rs-7953532/v1/51438d2ecdeff6f6e13f3aa9.json"},{"id":109168183,"identity":"f40f84d2-5d50-4594-8a1f-55558e1c5e1d","added_by":"auto","created_at":"2026-05-13 08:32:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":218575,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7953532/v1/a423b9cb-98b5-4683-972a-9d0701cea483.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring Frontline Nurses' Experiences During the COVID-19 Pandemic: A Qualitative Multiple-Case Study","fulltext":[{"header":"Background","content":"\u003cp\u003eThe COVID-19 pandemic, which emerged in December 2019, ushered in a global health crisis that had far-reaching consequences for individuals worldwide. Alongside its devastating health impacts, the pandemic engendered a profound set of mental health challenges, including anxiety, stress, and depression, largely attributed to the dearth of adequate information for managing the novel coronavirus. At the forefront of the response were frontline nurses, who exhibited remarkable courage and dedication in caring for patients and their loved ones. These nurses confronted a myriad of formidable challenges, stemming from the relative novelty of the virus, as well as factors such as increased workloads, staffing shortages, patient mortality, insufficient personal protective equipment (PPE), and the rapid implementation of fluctuating health policies and regulations.\u003c/p\u003e\n\u003cp\u003eThis qualitative, multiple-case study has delved into the experiences of frontline nurses during the COVID-19 pandemic, seeking to illuminate the factors that motivated them to return to work despite the perilous conditions. To support this study, a pre-survey was answered by 90 registered nurses from an Inner-City Safety Net Hospital, all of which had contracted COVID-19 and subsequently returned to work. Thirty-nine nurses who participated in the survey also volunteered to participate in a one-on-one interview. A random sample of nine registered nurses was invited to be interviewed in regard to their experience of contracting COVID-19 and returning to work.\u003c/p\u003e\n\u003cp\u003eData collection for this research employed a two-pronged approach, combining a pre-survey with semi-structured, one-on-one interviews. The objective was to gain insights into the primary motivations driving registered nurses to rejoin the workforce, their strategies for managing the daily pressures of work upon their return, the support, or lack thereof, extended by their employers and peers, and how the pandemic transformed their quality of life and influenced their future professional trajectories. This study contributes to a deeper understanding of the resilience and commitment of frontline nurses during unprecedented global health crises, shedding light on the pivotal role they played in mitigating the adverse effects of the COVID-19 pandemic.\u003c/p\u003e\n\u003cp\u003eThe purpose of this study is to examine the sense of resilience and self-efficacy among nurses upon returning to work after COVID-19 infection, as well as to identify any themes that emerge from their insights on coping strategies and the support they received from employers and peers during this period.\u003c/p\u003e"},{"header":"Theoretical Framework","content":"\u003cp\u003eIn examining the resilience of nurses during the COVID-19 pandemic, Afshari et al. (2021) found that stress, job satisfaction, burnout, and age were significant predictors of nurses\u0026apos; resilience. This study highlights the significance of individual factors in influencing nurses\u0026apos; ability to adapt and endure in challenging circumstances. In contrast, Scherr-Schierberi et al. (2020) focused on the mental health challenges faced by nurses providing direct care to COVID-19 patients. They highlighted the increased levels of distracted practice among these nurses, suggesting that resilience and social support may play a crucial role in mitigating the psychological impact of their work.\u003c/p\u003e\n\u003cp\u003eRegarding personal factors and resilience, Afshari et al. (2021) emphasized the influence of personal characteristics. LoGiudice and Bartos (2021) shed light on the significance of clear protocols in enhancing resilience. LoGiudice and Bartos discussed the negative effects that constantly changing hospital protocols had on nurses\u0026apos; emotional well-being. This finding suggests that organizational support and consistency in protocol are essential factors for bolstering nurses\u0026apos; resilience.\u003c/p\u003e\n\u003cp\u003eThe experiences of nurses caring for COVID-19 patients and the identified workload burden, fear, depression, anxiety, unmet needs, as well as physical and psychological burdens, were significant challenges (Ahmadidarrehsima et al., 2022). \u0026nbsp; Ahmadidarrehsima et al. (2022) highlight the difficulties that nurses faced during the pandemic. However, Sierakowska et al. (2022) found that nurses\u0026apos; levels of stress were not attributed to their age, work experience, nursing role, or designated work areas. Instead, they found that nurses working in inpatient areas exhibited higher self-efficacy, emphasizing the importance of supporting nurses\u0026apos; mental health, regardless of their demographic characteristics.\u003c/p\u003e\n\u003cp\u003eSimilarly, Duncan et al. (2021) identified various factors, including social distancing, conservation of personal protective equipment, and telehealth, that hindered efficient care practices during the pandemic. Their study highlights the importance of addressing system-wide challenges to ensure the well-being of healthcare workers. Meanwhile, Rathnayake et al. (2021) emphasized the need for policies, training, resources, shift improvements, and incentives to support nurses, suggesting that a multifaceted approach is necessary to alleviate the negative impact on their mental health.\u003c/p\u003e\n\u003cp\u003eFournier et al. (2022) has already considered the mental health of nurses, discussing the impact of COVID-19 on the mental health of healthcare professionals in France. They identified anxiety, insomnia, burnout, depression, and psychological stress as prevalent issues. In contrast, Kalyan et al. (2022) focused on the mental health impact of quarantine on healthcare workers. They emphasized the need for support to prevent adverse psychological reactions, particularly in regard to healthcare workers being isolated due to quarantine.\u003c/p\u003e\n\u003cp\u003eKaur et al. (2022) \u0026nbsp;analyzed how frontline nurses mentally and physically prepared themselves to manage COVID-19 patients, highlighting the pivotal role of training and support in fostering nurses\u0026apos; resilience. In a similar study, Liu et al. (2022) examined the impact of the delta variant on healthcare workers in China, advocating for interventions to mitigate anxiety among healthcare staff, particularly in the face of emerging new variants.\u003c/p\u003e\n\u003cp\u003eA study by Kyle J. Rehder et al. (2023) examined the impact of the COVID-19 pandemic, with a particular focus on teamwork within U.S. hospitals. It revealed a decline in collaborative efforts and emphasized the need for proactive team training to enhance both patient safety and workforce well-being. Conversely, Zwhwei, Wang, et al. (2023) explored team resilience and performance networks among Chinese nurses, proposing interventions to fortify nurses\u0026apos; ability to withstand stress and enhance the quality of services through improved teamwork (Rezaee et al., 2023).\u003c/p\u003e\n\u003cp\u003eIn the same vein, Zeynep, Osman and Ahmet (2022) highlighted the positive relationship between job motivation and teamwork attitudes among intensive care nurses in Turkey, indicating that a motivated team can foster more effective teamwork. On the other hand, Nasrin, et al. (2022) discussed the barriers to teamwork experienced by nurses in Iran, emphasizing the need for organizational support and effective planning to facilitate teamwork during the pandemic, especially in the face of challenges like inadequate education and poor communication.\u003c/p\u003e\n\u003ch2 id=\"_Toc212966692\"\u003eStudy Aim and Design\u003c/h2\u003e\n\u003cp\u003eThe purpose of this qualitative, multiple-case study was to explore the experiences of nurses during the pandemic. The researchers determined that a qualitative, multiple-case study would be the best methodology based on Yin\u003cspan dir=\"RTL\"\u003e\u0026rsquo;\u003c/span\u003es (2018) determination that such an approach would be most relevant for providing an understanding of the topic.\u003c/p\u003e\n\u003cp\u003eData was collected from two sources 1) a pre-survey 2) semi-structured one-on-one interviews. A total of 9 people were interviewed.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe following research questions guided this multiple case study:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eRQ1. How do nurses describe their sense of resilience and self-efficacy when returning to work after having COVID?\u003c/li\u003e\n \u003cli\u003eRQ2 What themes emerged from the crucial insights of nurses regarding their coping strategies and support provided by employers and peers after having COVID?\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eA case-study approach permitted an in-depth investigation with multiple sources of evidence (questionnaires and interviews). This investigation allowed the researchers to understand the cases in a multifaceted way (Yin, 2018). Yin (2018) suggested that single case studies are appropriate if the research objective is to explore a previously researched subject. He recommended multiple-case design when the intent of the research is a description, theory building, or theory testing.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFarquhar et al. (2020) posited that the case-study format is appropriate for answering three basic questions: when, how, or why. The subject under investigation centered on capturing or explaining a new phenomenon. To explore the lived experiences of nurses who contracted COVID-19 and continued to work during the pandemic, the researchers conducted a qualitative data analysis. This move enabled research questions to naturally form while providing meaningful context thanks to exploring a relatively new phenomenon within an environment where the event was occurring (Farquhar et al., 2020; Yin, 2018). The use of qualitative analysis pre-surveys, and semi-structured interviews, served as data sources to answer the research questions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe researchers gathered data for this qualitative case study through various methods. Interviews with the nurses provided in-depth background on crucial insights of their lived experiences. The interview questions were carefully constructed with elements of formal research on similar topics being used as the basis of the semi-structured interviews. This qualitative, multi-case study is a research approach that facilitates the exploration of a phenomenon within its context using a variety of data sources (Baxter \u0026amp; Jack, 2008).\u0026nbsp;\u003c/p\u003e\n\u003ch3 id=\"_Toc212966693\"\u003eData Analysis\u003c/h3\u003e\n\u003cp\u003eThe analysis followed a structured, multi-step qualitative process. Researchers first immersed themselves in the data by reading each transcript multiple times to gain a grounded understanding of participant experiences, noting early impressions, recurring ideas, and emerging patterns. Through open coding, transcripts were examined line by line, and meaningful segments of text were labeled to capture emotions, stressors, coping behaviors, workplace challenges, and reflections in participants\u0026rsquo; own words. Axial coding then allowed researchers to compare codes across all transcripts, grouping related concepts into broader categories such as resilience, teamwork, emotional strain, coping strategies, and perceptions of organizational support. Using iterative comparison and guided by Yin\u0026rsquo;s pattern-matching approach, these categories were refined and reorganized until three overarching themes emerged: Resilience and Self-Efficacy, Coping and Mental Health, and Work Support: Teamwork and Policies.\u003c/p\u003e\n\u003cp\u003eMethodological rigor was strengthened through a comprehensive triangulation process. Multiple researchers independently coded the transcripts, compared interpretations, and met regularly to review discrepancies. Differences in coding were discussed in depth, categorized, and resolved through consensus, ensuring that themes reflected collective judgment rather than individual bias. Triangulation extended beyond coding to include cross-checking themes with analytic memos, an audit trail of coding decisions, and pre-survey data. This multi-layered verification enhanced credibility, dependability, and confirmability throughout the study. Pre-survey data were used to contextualize interview findings, verify participant demographics, and support themes related to emotional impact and workplace challenges. The final synthesis integrated all findings into a cohesive narrative capturing the complexity of nurses\u0026rsquo; experiences returning to work after COVID-19 infection while managing the pressures of a demanding clinical environment.\u003c/p\u003e\n\u003ch3\u003eSample and Population\u003c/h3\u003e\n\u003cp\u003eThis study included a pre-survey answered by 90 registered nurses from an Inner-City Safety Net Hospital from New York State, all of which had contracted COVID-19 and subsequently returned to work. Thirty-nine of the nurses who answered also volunteered to participate in a one-on-one interview. \u0026nbsp;A random sample of nine registered nurses were invited to be interviewed regarding their experience of contracting COVID-19 and returning to work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe inclusion criteria for nurses who were interviewed were as follows:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBeing a licensed registered nurse at the study site\u003c/p\u003e\n\u003cp\u003eProviding direct patient care during the pandemic\u003c/p\u003e\n\u003cp\u003eHaving contracted COVID-19 and returned to work\u003c/p\u003e\n\u003cp\u003eWillingness to complete a pre-survey and/or participate in an interview\u003c/p\u003e\n\u003cp\u003eThere is no single ideal number of participants to be interviewed in qualitative research, as it depends on what the researcher believes will be suitable for answering the relevant research questions. For instance, Creswell and Creswell (2017) suggested between five to 25. Glaser and Strauss (1967) saw saturation to be the point of diminishing return. Meanwhile, Guest, Bunce, and Johnson (2006) noted that data saturation might be attained by as little as six interviews, depending on the population\u003cspan dir=\"RTL\"\u003e\u0026rsquo;\u003c/span\u003es sample size. In this case, the researcher randomly selected 10 registered nurses to participate (of the 39 who volunteered) in an in-depth one-on-one interview. One participant revealed that he wasn\u003cspan dir=\"RTL\"\u003e\u0026rsquo;\u003c/span\u003et sure that he had COVID-19, therefore the interview was dropped. The interview data was analyzed from 9 Registered Nurses.\u003c/p\u003e\n\u003cp\u003eIRB approval was obtained from an Inner-City Safety Hospital where all of the registered nurses are employed, and all participants completed a consent form.\u003c/p\u003e\n\u003ch3\u003eMaterials and Instruments\u003c/h3\u003e\n\u003cp\u003eStrauss and Corbin (1999) acknowledged that a literature review should be carried out before fieldwork commences and that the researcher should enter the research area with some knowledge of the phenomenon being studied. Strauss and Corbin (1999) considered that the literature could be used to help derive questions that the researcher would like to use in their fieldwork (Strauss \u0026amp; Corbin, 1999). Furthermore, Yin (2018) referred to the literature review to develop the case study protocol, which includes the research objectives and case study questions (Yin, 2018).\u003c/p\u003e\n\u003cp\u003eThe instruments and materials were created for each phase of data collection using selected literature.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePre-survey. The goal of this survey was to identify nurses that had COVID-19 or a COVID Variant while working, and learn how they were exposed to the virus, what year it was, the severity of the symptom, time out of work, if they have residual symptoms, what challenges they encountered after returning to work from the virus and what they found helpful upon their return. Demographic questions were also collected (do they work full time, are of work, gender identity, race/ethnicity). Only nurses who had COVID were allowed to complete the survey. The first question asked if the person had COVID, if not, the survey would thank them for taking part.\u003c/p\u003e\n\u003cp\u003eOne-on-one interviews. After the 90 Registered Nurses completed the survey, they were asked if they were willing to volunteer to take part in a one-on-one interviews. \u0026nbsp;A total of 39 people volunteered, 10 of which were randomly selected.\u003c/p\u003e\n\u003cp\u003eNine people were interviewed in the end as person number 10 did not test herself to learn if she had COVID or not. The one-on-one interviews were based on six questions. We wanted to learn what their primary motivation was to return to work, how they managed the everyday pressures of work after they returned, the support (or lack of) they received from the employer or peers, how the pandemic changed their quality of live and the future regarding their profession. The interviews lasted for a total of 30-45 minutes for each participant and they were taped and transcribed by the researchers.\u003c/p\u003e\n\u003ch3 id=\"_Toc212966696\"\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003eThe study received approval from the Institutional Review Board of a Safety Net Hospital in New York. All procedures were conducted in accordance with the Declaration of Helsinki and the ethical principles outlined in the Belmont Report. Participation was voluntary, written informed consent was obtained from all participants, and confidentiality was strictly maintained throughout data collection, handling, and reporting.\u003c/p\u003e"},{"header":"Results","content":"\u003ch3\u003ePre-survey\u003c/h3\u003e\n\u003cp\u003eIn total, 90 participants completed the pre-survey (comprising 49% females, 9% Hispanics, 30% African Americans, 18% Asian-Pacific, and 5% White). Among the respondents, 54 individuals confirmed that they had contracted COVID-19. Among those who contracted the virus, 53.3% were employed on a full-time basis. Additionally, 39% of these individuals believed that they had contracted COVID-19 at their workplace, while 13% were uncertain about the source of their infection. A total of 20% reported contracting the virus between 2019 and 2020, with the remaining cases occurring between 2021 and 2022.\u003c/p\u003e\n\u003cp\u003eFurthermore, the manifestation of symptoms varied among these COVID-19 cases, with 10% being asymptomatic, 31% experiencing mild symptoms, 16% presenting with moderate symptoms, and 4.4% enduring severe illness. In terms of the duration of absence from work due to illness, 10% were absent for less than a week, 33% were absent for a duration ranging from 1 to 2 weeks, while the remaining participants were absent for over three weeks.\u003c/p\u003e\n\u003cp\u003e38% of respondents made the decision to return to work following their illness independently, while 18% followed employer directives based on CDC guidelines. As for the presence of long-haul syndrome, 35% of participants reported no such symptoms, 8% indicated that they had experienced these symptoms for a prolonged period, 7% reported occasional occurrences, and 11.1% stated that they were still affected by long-haul symptoms.\u003c/p\u003e\n\u003cp\u003eUpon returning to work, nurses encountered various challenges, categorized as follows:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eSickness-related challenges, such as tachycardia, fatigue, cough, brain fog, and muscle pain, were reported by 47% of participants.\u003c/li\u003e\n \u003cli\u003eIssues related to masks and personal protective equipment (PPE) were noted by 5% of respondents.\u003c/li\u003e\n \u003cli\u003ePsychological challenges, including anxiety and depression, were experienced by 16% of participants.\u003c/li\u003e\n \u003cli\u003eA subset of respondents (30%) reported feeling a return to normalcy without significant challenges.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eIn terms of the support received:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eApproximately 40% of participants reported receiving support from colleagues and supervisors.\u003c/li\u003e\n \u003cli\u003eA quarter of respondents (25%) indicated that they did not receive any form of support.\u003c/li\u003e\n \u003cli\u003eEighteen percent of participants reported receiving support, including a transfer to another work area without human resources (HR) barriers, additional days off, and extra payment.\u003c/li\u003e\n \u003cli\u003eFourteen percent of participants expressed that they did not require any additional support.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe reasons for the non-participation of those participants who declined one-on-one interviews were investigated. It was found that 50% of non-participants cited concerns that such interviews would evoke \u0026quot;bad memories\u0026quot; and potentially exacerbate feelings of depression. Comments such as \u0026quot;the experience was horrific, but for some reason I survived\u0026quot; were indicative of this sentiment. The remaining 50% of non-participants cited time constraints as their primary reason for declining the interviews.\u003c/p\u003e\n\u003ch3 id=\"_Toc212966699\"\u003eInterviews\u003c/h3\u003e\n\u003cp\u003eBoth research questions were addressed through the presentation of three major themes: Resilience \u0026amp; Self-Efficacy, Copying \u0026amp; Mental Health, and Work Support: Teamwork \u0026amp; Policies.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eRQ1. How do nurses describe their sense of resilience and self-efficacy when returning to work after having COVID?\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003eResilience \u0026amp; Self-Efficacy\u003c/h4\u003e\n\u003cp\u003eWithin the context of the crisis, this thematic exploration examines the responses and experiences of nurses as they actively engaged with and confronted the multifaceted challenges that arose. At its core, this theme illuminates the remarkable qualities of resilience, teamwork, adaptability, and self-efficacy that nurses demonstrated in the face of adversity. Concurrently, it acknowledges the profound emotional toll exacted upon their own well-being.\u003c/p\u003e\n\u003cp\u003eAs articulated by one nurse, a vivid representation of the collective determination of nurses emerges: \u0026quot;Recognizing the imperative of enduring together, we forged a tight-knit bond and adopted a genuinely \u0026apos;hands-on\u0026apos; approach to our duties amidst the crisis.\u0026quot;\u003c/p\u003e\n\u003cp\u003eAnother nurse, further contributing to the narrative, underscored the rapidity with which nurses adapted to the evolving crisis: \u0026quot;Upon my return to work, I dedicated myself wholeheartedly to the nurturing of my patients, facilitating their journey back to good health. This encapsulates the essence of nursing\u0026mdash;bestowing joy through aiding others.\u0026quot;\u003c/p\u003e\n\u003cp\u003eIn a similar vein, an interviewee accentuates the inevitability of adaptation by remarking: \u0026quot;The new normal presented us with no alternative but to adapt, persistently providing care at the zenith of our abilities.\u0026quot;\u003c/p\u003e\n\u003cp\u003eConversely, it was imperative to acknowledge the influence of the crisis on nurses\u0026apos; self-efficacy and emotional well-being. A nurse, who had previously contracted COVID-19, candidly expressed her apprehension upon returning to work: \u0026quot;Re-entering the workplace was accompanied by a degree of trepidation. It necessitated meticulous consideration of how proceedings would unfold, particularly in a state of vulnerability where the provision of care becomes an onerous endeavor.\u0026quot;\u003c/p\u003e\n\u003cp\u003eIn summary, this theme not only underscores the multifaceted nature of nurses\u0026apos; experiences during the crisis, highlighting their resilience and unwavering commitment, but also underscores the emotional and psychological toll, particularly among those who had contracted the virus. Furthermore, it unveils an aspect of their resilience centered around the strengthening of career and personal aspirations, as elucidated by one nurse\u0026apos;s perspective: \u0026quot;This experience has compelled me to reevaluate the significance of my life. I\u0026apos;ve cultivated a deeper commitment to self-care, including adequate rest, to safeguard against illness. Furthermore, it has rekindled my ambitions, such as pursuing further education with the aim of becoming a Diabetic Educator. The crisis has catalyzed a collective desire among nurses to embark on educational pursuits in various domains.\u0026quot;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eRQ2 What themes emerged from the crucial insights of nurses regarding their coping strategies and support provided by employers and peers after having COVID?\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch4\u003eCoping and Mental Health\u003c/h4\u003e\n\u003cp\u003eWithin the context of interviews with nurses, this thematic exploration delved into the multifaceted dimensions of their mental health and the strategies they employed to navigate the challenges inherent in their profession during the pandemic. This theme aims to shed light on the intricate interplay between coping mechanisms, faith, support systems, and evolving perspectives, as experienced by nurses.\u003c/p\u003e\n\u003cp\u003eThrough the interviews, nurses were able to candidly discuss their encounters with the specter of depression. It transpires that some choose to seek solace through therapy as a means of managing their mental well-being. Additionally, the \u0026quot;serenity prayer\u0026quot; emerged as a poignant guiding principle for certain nurses, providing solace in the midst of adversity. Faith also played a pivotal role in the lives of the nurses interviewed. Prayers became a recurring motif during interviews, with their significance as sources of strength and resilience being emphasized. Interestingly, some nurses openly shared their fears of mortality, grappling with the stark reality of the crisis and even coming to terms with the possibility of their own demise.\u003c/p\u003e\n\u003cp\u003eA cornerstone of the nurses\u0026apos; coping strategies was the unwavering support received from families and peers, which played an instrumental role in nurturing resilience among them. Furthermore, the eventual control established by the hospital over the crisis, coupled with the advent of vaccinations, ushered in a palpable sense of relief and calmness. One participant articulated this: \u0026quot;The situation has significantly improved, and the work environment has stabilized. Our floor is no longer designated for COVID patients, and we now have specialized units to manage such cases.\u0026quot;\u003c/p\u003e\n\u003cp\u003eMoreover, nurses collectively experienced a period marked by trauma that manifested in the form of challenges within the hospital, as well as the personal toll it exacted on their lives and the lives of their family and friends. The scarcity of staff and shortages of personal protective equipment (PPE), including the reusing of masks, weighed heavily on their experiences. Concurrently, nurses reported experiencing physical manifestations of distress, including migraines and episodes of \u0026quot;brain fog,\u0026quot; further reflecting the significant strain they endured.\u003c/p\u003e\n\u003cp\u003eSeeking support emerged as a pivotal coping mechanism, with nurses turning to therapists, virtual medical consultations, and other resources to address their mental health needs. Additionally, nurses grappled with the heart-wrenching loss of family members and friends, amplifying the personal tragedies they had to contend with. The responsibility of safeguarding both their loved ones and workplace compelled nurses to adopt stringent measures, including self-isolation.\u003c/p\u003e\n\u003cp\u003eIn summary, the \u0026quot;Coping and Mental Health\u0026quot; theme provided a comprehensive understanding of the profound psychological and emotional complexities experienced by nurses during the pandemic. It underscores the diverse array of coping strategies they employed, the significance of faith and support systems, as well as the dynamic nature of their perceptions as the pandemic unfolded.\u003c/p\u003e\n\u003ch4\u003eWork Support: Teamwork \u0026amp; Work Policies\u003c/h4\u003e\n\u003cp\u003eWithin the framework of nurses\u0026apos; interviews, the theme of \u0026quot;Work Support\u0026quot; emerged as a central element that underscores the vital role of teamwork and organizational policies in facilitating their ability to cope with the challenges posed by the pandemic. This theme highlights the significance of mutual support among nurses and the role of healthcare facilities in implementing policies to create a conducive work environment.\u003c/p\u003e\n\u003cp\u003eOne nurse aptly stated, \u0026quot;Teamwork is dreamwork,\u0026quot; succinctly encapsulating the paramount importance of collaboration and unity among healthcare professionals. Nurses consistently expressed the profound support they provided to one another, with daily communication and shared prayers serving as a testament to the camaraderie that developed among them. This sense of unity transcended the workplace, with nurses describing their colleagues as becoming akin to family members, providing assistance and reassurance during difficult times. One nurse eloquently expressed this sentiment, stating: \u0026quot;It\u0026apos;s like family. They came to me, asking if I was okay, offering help with anything. You can always count on them.\u0026quot; Furthermore, nurses acknowledged the transformative effect of the pandemic on staff dynamics, fostering a closer-knit team and altering the way they approached their work.\u003c/p\u003e\n\u003cp\u003eOn an organizational level, hospitals played a pivotal role in offering support through the implementation of policies aimed at enhancing the working environment. Nurses recognized the concerted efforts to facilitate vaccination programs and applauded the constant communication of new policies and guidelines. \u0026quot;So many things have been put in place in terms of vaccinations,\u0026quot; one nurse said when reflecting on the proactive stance taken by the hospital in regard to safeguarding the well-being of its staff. Moreover, nurses appreciated the regular dissemination of information related to personal protective equipment (PPE), which contributed to a heightened sense of safety.\u003c/p\u003e\n\u003cp\u003eIn summary, the \u0026quot;Work Support\u0026quot; theme is enriched by nurses\u0026apos; own words, emphasizing the vital role of teamwork and mutual support during the pandemic. It also underscores the impact of senior leadership availability, as well as the proactive measures taken by healthcare facilities to create a supportive and secure work environment for nurses during these challenging times.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this multi-case study, the researchers sought to gain insights into how nurses describe their sense of resilience and self-efficacy, as well as their coping strategies and the support they received from employers and peers upon returning to work after contracting COVID-19.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study further underscored the interconnectedness of self-efficacy and resilience among nurses, as both attributes played a pivotal role in their ability to navigate the complexities of the COVID-19 pandemic. The importance of spiritual connection, familial and peer support was also significant as these support systems played a crucial role in helping nurses cope with mental health issues. Teamwork in the nursing profession also proved to be crucial in mitigating the high levels of stress and challenges faced during the pandemic. Registered nurses recognized the efforts made by the hospital to improve their policies on safety measures for proper protective equipment.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is recommended that nursing professionals undergo comprehensive training in effective teamwork strategies and be encouraged to establish and actively participate in support networks within the healthcare setting. These networks can serve as platforms for mutual assistance and emotional support, bolstering the resilience of nurses and their ability to navigate challenging situations collectively.\u003c/p\u003e\n\u003cp\u003eDespite these formidable obstacles, nurses exhibited an extraordinary resilience as they provided essential support to patients, families, and friends. They rapidly adapted to the exigencies of life-and-death situations, while enduring physical, emotional, and psychological strains. Throughout this period, nurses remained unwavering in their commitment to the nursing profession, fostering invaluable human connections and demonstrating a profound sense of resilience.\u003c/p\u003e\n\u003cp\u003eThis study has identified three major themes that encapsulate the experiences of nurses:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResilience and Self-Efficacy: The nurses we interviewed exhibited remarkable resilience and a strong sense of self-efficacy, emphasizing their belief in themselves and their future career aspirations. Their unwavering commitment to patient care, even in the face of personal challenges, was evident, aligning with the findings of Ashari et al. (2021) who linked job satisfaction with resilience. Additionally, the nurses emphasized the critical role of social support from their colleagues, reinforcing their level of resilience, as previously discussed by Sherr-Schierberi et al. (2020). The study further underscores the interconnectedness of self-efficacy and resilience among nurses, as both attributes played a pivotal role in their ability to navigate the unique complexities of the COVID-19 pandemic.\u003c/p\u003e\n\u003cp\u003eCoping and Mental Health: Our findings revealed that nurses faced and coped with depression, anxiety, and mental health challenges during the COVID-19 crisis. This was a struggle that persisted even after they had contracted COVID-19 themselves. Moreover, the study shed light on the coping strategies employed by nurses to manage their mental health during and after the pandemic. Spirituality emerged as a predominant coping mechanism, followed by finding solace as a means of emotional relief. The importance of familial and peer support was underscored, as these support systems played a crucial role in helping nurses cope with the mental health issues faced. The significance of faith and support systems in enabling nurses to weather the mental health crisis during the peak of the pandemic and beyond aligns with prior research, as highlighted by Kaur et al. (2022), who emphasized the need for training and support to address such concerns.\u003c/p\u003e\n\u003cp\u003eWork Support: Team and Policies: Our study reaffirmed the pivotal role of teamwork in the nursing profession, with nurses emphasizing the importance of their colleagues as akin to family. This sense of unity and mutual support among team members was crucial in mitigating the stress and challenges faced during the pandemic. While the nurses expressed a perception of distance from hospital administration during the pandemic, they still highlighted the support they provided to each other. Additionally, nurses recognized the efforts made by hospitals to improve their policies, particularly in the realm of safety. These findings align with prior research by Rehder et al. (2023), which stressed the significance of teamwork in alleviating the stress level of nurses. In summary, our study underscores the multifaceted nature of nurses\u0026apos; experiences during the COVID-19 pandemic, shedding light on their resilience, coping mechanisms, and the critical importance of teamwork and policy improvements in supporting their efforts on the front line of healthcare.\u003c/p\u003e\n\u003ch2 id=\"_Toc212966701\"\u003e\u003cstrong\u003eImplications for Practice\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis study highlights several key implications for nursing practice and organizational leadership:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eEnhance Teamwork Training and Foster Supportive Networks for Nurses. It is recommended that nursing professionals undergo comprehensive training in effective teamwork strategies and be encouraged to establish and actively participate in support networks within the healthcare setting. These networks can serve as platforms for mutual assistance and emotional support, bolstering nurses\u0026apos; resilience and their ability to navigate challenging situations collectively.\u003c/li\u003e\n \u003cli\u003eProvide Training in Support Mechanisms, Including Mediation and Spirituality. Nurses should receive training that encompasses a range of support mechanisms, including conflict mediation and the integration of spirituality in their coping strategies. This training can equip nurses with valuable skills for managing conflicts constructively while nurturing their mental well-being. Doing so will ultimately enhance their capacity to provide high-quality care.\u003c/li\u003e\n \u003cli\u003ePeriodic Review of Hospital Policies to Ensure Adequate Support for Nurses. Hospitals are encouraged to conduct periodic reviews of their policies and procedures, with a specific focus on addressing the needs and concerns of nursing staff. Ensuring that nurses have access to the necessary resources and support systems should be a priority. Policy adjustments should be made to optimize nurses\u0026apos; working conditions and facilitate their ability to provide safe and effective patient care.\u003c/li\u003e\n \u003cli\u003eImplement Knowledge Training Opportunities (e.g., Micro Credentials, Certifications) On-Site. To enhance the efficacy of nursing staff and foster their professional development, healthcare institutions should consider implementing on-site knowledge training programs. These programs can include micro credentials and certifications tailored to nurses\u0026apos; specific roles and responsibilities. Such initiatives not only augment the competence of nurses but also contribute to their resilience by instilling a sense of achievement and mastery in their profession.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eStrengthening resilience-building interventions:\u003c/strong\u003e Programs that enhance coping, self-efficacy, and stress management may support nurses in crisis settings.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eInvesting in mental health resources:\u003c/strong\u003e Accessible psychological support, debriefing sessions, and trauma-informed care are essential.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eImproving communication systems:\u003c/strong\u003e Clear, timely, and consistent policies reduce confusion and enhance nurses\u0026rsquo; sense of safety.\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eReinforcing teamwork and collaboration:\u003c/strong\u003e Peer support networks and team cohesion can mitigate emotional burden and improve morale.\u003c/li\u003e\n\u003c/ul\u003e\n\u003ch2 id=\"_Toc212966702\"\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThis study has several limitations. The sample was limited to 90 nurses from a single Safety Net Hospital in New York, which may affect the transferability of findings to other settings. Additionally, the qualitative interviews were conducted with a small, randomly selected subset of volunteers, which may not fully capture the diversity of all nurses who contracted COVID-19. Despite these limitations, the rich narratives provide valuable insight into the lived experiences of frontline nurses returning to work post-infection.\u003c/p\u003e\u003ch2\u003e\u003cstrong\u003eSummary\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eOverall, the study underscores the extraordinary resilience of frontline nurses and the critical role of organizational support, communication, and mental health resources. Understanding these experiences is essential to preparing healthcare systems for future public health crises and supporting the long-term well-being of the nursing workforce.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis qualitative multiple-case study explored the experiences of frontline nurses who contracted COVID-19 and returned to work during the height of the pandemic. The findings highlight three interrelated themes\u0026mdash;\u003cstrong\u003eResilience and Self-Efficacy\u003c/strong\u003e\u003cstrong\u003e, \u003cstrong\u003eCoping and Mental Health\u003c/strong\u003e,\u003c/strong\u003e and \u003cstrong\u003eWork Support: Teamwork and Policies\u003c/strong\u003e\u003cstrong\u003e\u0026mdash;\u003c/strong\u003ethat collectively shaped nurses\u0026rsquo; ability to navigate intense clinical and emotional demands.\u003c/p\u003e\n\u003cp\u003eDespite physical strain, emotional burden, and uncertainty, nurses demonstrated remarkable resilience, a strong sense of purpose, and sustained commitment to patient care. Their coping strategies, reliance on peer support, and personal beliefs contributed significantly to their ability to adapt and persevere. At the organizational level, teamwork, communication, and evolving hospital policies emerged as essential sources of support, although inconsistencies early in the pandemic heightened stress and confusion.\u003c/p\u003e\n\u003cp\u003eThese findings underscore the critical importance of strengthening mental health support, enhancing communication systems, and investing in organizational structures that promote resilience and teamwork. By understanding the lived experiences of nurses\u0026rsquo; post-infection, healthcare systems can better prepare for future public health crises while promoting the long-term well-being and retention of the nursing workforce.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCDC \u0026ndash; Centers for Disease Control and Prevention\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;PPE \u0026ndash; Personal Protective Equipment\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;IRB \u0026ndash; Institutional Review Board\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;RN \u0026ndash; Registered Nurse\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThis study received ethical approval from the Institutional Review Board of a Safety Net Hospital in New York. All study procedures involving human participants were conducted in accordance with the Declaration of Helsinki and the ethical principles outlined in the Belmont Report, as well as institutional guidelines for research with human subjects. Prior to data collection, all registered nurses were informed of the study\u0026rsquo;s purpose, procedures, confidentiality protections, and their right to withdraw at any time. Written informed consent was obtained from every participant before completing the pre-survey and before participating in one-on-one interviews.\u0026nbsp;\u003c/p\u003e\n\u003ch3 id=\"_Toc212966708\"\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eAll participants provided consent for the publication of anonymized data.\u0026nbsp;\u003c/p\u003e\n\u003ch3 id=\"_Toc212966709\"\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003ch3 id=\"_Toc212966710\"\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003ch3 id=\"_Toc212966711\"\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThis study received no external funding.\u0026nbsp;\u003c/p\u003e\n\u003ch3 id=\"_Toc212966712\"\u003eAuthors\u0026rsquo; contributions\u003c/h3\u003e\n\u003cp\u003eJW contributed to IRB submission, study design, data collection, and manuscript development.\u003cbr\u003e\u0026nbsp;ESM led the study design, data analysis, and writing of the manuscript.\u003c/p\u003e\n\u003cp\u003eMRH contributed clinical expertise, analysis validation, and manuscript review.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003ch3 id=\"_Toc212966713\"\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eThe authors extend gratitude to the CEO and Senior leader of Safety Net Hospital, as well as the nurses and staff in NY, for their participation and dedication.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAhmadidarrehsima, S., Salari, N., Dastyar, N., \u0026amp; Rafati, F. (2022). Exploring the experiences of nurses caring for patients with COVID-19: A qualitative study in Iran. BMC Nursing, 21(16), 1\u0026ndash;7. https://doi.org/10.1186/s12912-022-00805-5\u003c/li\u003e\n \u003cli\u003eBaxter, P., \u0026amp; Jack, S. (2008). Qualitative Case Study Methodology: Study Design and Implementation for Novice Researchers. The Qualitative Report, 13(4), 544-559.https://doi.org/10.46743/2160-3715/2008.1573\u003c/li\u003e\n \u003cli\u003eCreswell. J.W. and Creswell, J.D. (2017) Research Design: Qualitative, Quantitative, and Mixed Methods Approaches. 4th Edition, Sage, Newbury Park.\u003c/li\u003e\n \u003cli\u003eDuncan, R., Szabo, B., Jackson, Q. L., et al. (2021). Care and coping during COVID-19. Clinical Journal of Oncology Nursing, 25(1), 48\u0026ndash;55. https://doi.org/10.1188/21.cjon.48-55\u003c/li\u003e\n \u003cli\u003eFournier, A., Laurent, A., Lheureux, F., et al. (2022). Impact of the COVID-19 pandemic on the mental health of professionals in 77 hospitals in France. PLoS One, 17(2), 1\u0026ndash;19. https://doi.org/10.1371/journal.pone.0263666\u003c/li\u003e\n \u003cli\u003eGlaser, B., \u0026amp; Strauss, A. (1967). The Discovery of Grounded Theory: Strategies for Qualitative Research. Mill Valley, CA: Sociology Press.\u003c/li\u003e\n \u003cli\u003eGuest, G., Bunce, A., \u0026amp; Johnson, L. (2006). How Many Interviews Are Enough?: An Experiment with Data Saturation and Variability. Field Methods, 18(1), 59-82. https://doi.org/10.1177/1525822X05279903\u003c/li\u003e\n \u003cli\u003eFarquhar, J., Michels, N., \u0026amp; Robson, J. (2020). Triangulation in industrial qualitative case study research: Widening the scope. \u003cem\u003eIndustrial Marketing Management\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eKalyan, G., Sharma, N., Kaur, S., et al. (2022). Lived experiences of nurses during quarantine:qualitative study from North India. Nursing and Midwifery Research Journal, 1\u0026ndash;13.\u003c/li\u003e\n \u003cli\u003eKaur, J., Dhandapani, M., Kaur, S., et al. (2022). Acceptance and preparedness to be COVID warriors: Self narratives of frontline nurses of a tertiary care center. Florence Nightingale of Nursing, 30(1), 25\u0026ndash;32.\u003c/li\u003e\n \u003cli\u003eLiu, Y., Hou, T., Gu, H., et al. (2022). Resilience and anxiety among healthcare workers during the spread of the SARS-CoV-2 delta variant: A moderated mediation model. Frontiers in Psychology, 13, 1\u0026ndash;10. https://doi.org/10.3389/fpsyt.2022.804538\u003c/li\u003e\n \u003cli\u003eLoGiudice, J. A., \u0026amp; Bartos, S. (2021). Experiences of nurses during the COVID-19 pandemic: A mixed-methods study. AACN Advanced Critical Care, 32(1), 14\u0026ndash;25.\u003c/li\u003e\n \u003cli\u003eRathnayake, S., Dasanayake, D., Maithreepala, S. D., Ekanayake, R., \u0026amp; Basnayake, P. L. (2021). Nurses\u003cspan dir=\"RTL\"\u003e\u0026rsquo;\u0026nbsp;\u003c/span\u003eperspectives of taking care of patients with coronavirus disease 2019: A phenomenological study. PLoS One, 16(9), 1\u0026ndash;17. https://doi.org/10.1371/journal.pone.0257064\u003c/li\u003e\n \u003cli\u003eRehder, K., Adair, C., Eckert, E., Lang, R., Frankel, A, Proulx, J., Sexton, J.B. (2023). Teamwork Before and During COVID-19: The Good, The Same and the Ugly\u0026hellip; Journal of Patient Safety, 19 (1), 36-41\u003c/li\u003e\n \u003cli\u003eRezaee, N., Mardan-Hamoolen, M., Hamidi, H (2023). Barriers to Teamwork in Caring for Patients with COVID-19: A Qualitative Analysis of Nurses\u003cspan dir=\"RTL\"\u003e\u0026rsquo;\u0026nbsp;\u003c/span\u003ePerceptions in a Secondary Care Setting in Iran. International Journal of Healthcare Management, 16.(1) 86-92\u003c/li\u003e\n \u003cli\u003eStrauss, A., \u0026amp; Corbin, J. (1999). Basics of qualitative research: Techniques and procedures for developing grounded theory (2nd ed.). Sage Publications, Inc.\u003c/li\u003e\n \u003cli\u003eWang, Z., Liang, Q., Yan, Z., Liu, J., Liu, M., Wang, X., Wang, J., Huang, J., Luan, X. (2023). The Association Between Team Resilience and Team Performance in Nurses During the COVID-19 Pandemic: A Network Analysis. BMC Nursing; 22-54\u003c/li\u003e\n \u003cli\u003eYin, R. K. (2018). Qualitative research from start to finish. The Guilford Press.\u003c/li\u003e\n \u003cli\u003eZeynep, T; Osman, Y; Ahmet, K. (2022). Teamwork Attitudes and Job Motivations of Intensive\u003c/li\u003e\n \u003cli\u003eCare Nurses During the COVID-19 Pandemic: A Descriptive, Cross-Sectional Study. T\u0026uuml;rkiye Klinikleri Journal of Nursing Sciences, 14 ( 4) 983-92\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"COVID-19, Nursing Resilience, Self-Efficacy, Mental Health, Qualitative Research, Frontline Nurses, Teamwork, Healthcare Workforce","lastPublishedDoi":"10.21203/rs.3.rs-7953532/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7953532/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: The COVID-19 pandemic created unprecedented challenges for frontline nurses, who faced increased workloads, emotional strain, patient mortality, and shifting policies. This study explores nurses’ resilience, self-efficacy, coping strategies, and support systems after returning to work following COVID-19 infection.\u003cbr\u003e\nMethods: A qualitative multiple-case study was conducted at an Inner-City Safety Net Hospital in New York State. Ninety registered nurses completed a pre-survey, and 39 volunteered for one-on-one interviews. Nine nurses were randomly selected for interviews. Data were analyzed using inductive thematic analysis.\u003cbr\u003e\nResults: Three major themes emerged: Resilience \u0026amp; Self-Efficacy, Coping \u0026amp; Mental Health, and Work Support. Nurses demonstrated adaptability, emotional and physical strain, reliance on faith and peer support, and a strong commitment to patient care. Teamwork, organizational communication, and evolving hospital policies served as significant support factors.\u003cbr\u003e\nConclusions: Despite profound challenges, nurses showed exceptional resilience and dedication. Organizational support systems, teamwork, and mental health resources are essential to sustaining nurses’ well-being in future crises.\u003cbr\u003e\nTrial registration: Not applicable.\u003c/p\u003e","manuscriptTitle":"Exploring Frontline Nurses' Experiences During the COVID-19 Pandemic: A Qualitative Multiple-Case Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-24 12:12:25","doi":"10.21203/rs.3.rs-7953532/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1fc4bfc1-f0ba-4ca0-94ae-bf49ba6b6855","owner":[],"postedDate":"November 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T08:28:49+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-24 12:12:25","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7953532","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7953532","identity":"rs-7953532","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}