Received: 21 February 2021 | Revised: 17 April 2021 | Accepted: 30 April 2021 DOI: 10.1111/jonm.13362 ORIGINAL ARTICLE Front-­line nurses' responses to organisational changes during the COVID-­19 in Spain: A qualitative rapid appraisal Glòria Tort-­Nasarre PhD, Senior Lecturer1,2 | Bruna Alvarez PhD, Assistant Professor3 | Paola Galbany-­Estragués PhD, Senior Lecturer3,4 | Martí Subías-­Miquel MSc, RMHN, 3,5 Assistant Professor | Eva Vázquez-­Segura RNM, MA, Assistant Professor3,6 | 3 Diana Marre PhD, Associate Professor | Maria Romeu-­Labayen PhD, Assistant Professor3,7 1 Health Education Research Group (GREpS), Faculty of Nursing and Physiotherapy, Abstract University of Lleida, Lleida, Spain Aims: To identify the organisational changes faced by front-­line nurses working with 2 Calaf Primary Care Center, SAP Anoia-­ COVID-­19 patients during the first wave and describe how they responded to these Gerència Territorial Catalunya Central, Institut Català de la Salut, Calaf, Spain changes. Background: The COVID-­19 pandemic has altered the provision of care and the man- 3 AFIN Research Group and Outreach Centre, Autonomous University of Barcelona, Cerdanyola del Vallès, Spain agement of health care around the world. Evolving information about SARS-­CoV-­2 4 Research Group on Methodology, Methods, meant that health care facilities had to be reorganised continually, causing stress and Models and Outcomes of Health and Social anxiety for nurses. Sciences (M3O), Faculty of Health Science and Welfare, Centre for Health and Social Methods: Qualitative study based on Rapid Research Evaluation and Appraisal Care Research (CESS), University of Vic-­ (RREAL). The research took place in hospital and community health settings of the Central University of Catalonia (UVIC-­UCC), Vic, Spain Spanish national health system with a purposive sampling of 23 front-­line nurses. 5 Parc Sanitari Sant Joan de Déu, Sant Boi de Semi-­structured interviews were conducted between May and June 2020. The dura- Llobregat, Spain 6 tion was 30–­45 min per interview. We used the Dedoose® data analysis software to Department of Public Health, Mental Health and Mother-­Infant Nursing, Faculty perform a thematic analysis. of Medicine and Health Sciences, University Results: Nurses responded to organisational changes using the following strategies: of Barcelona, Barcelona, Spain 7 improvisation, adaptation and learning. Department of Public Health, Mental Health and Mother-­Infant Nursing, Faculty Conclusion: Our rapid approach allowed us to record how nurses responded to chang- of Medicine and Health Sciences, University ing organisation, information that is easily lost in a disaster such as the COVID-­19. of Barcelona, L'Hospitalet de Llobregat, Spain Implications for nursing management: Knowing about their strategies can help plan- ning for future health disasters, including subsequent waves of the COVID-­19. Correspondence Paola Galbany-­Estragués, PhD, Profesora Titular, Research Group on Methodology, KEYWORDS Methods, Models and Outcomes of Health COVID-­19 (coronavirus disease 2019), health care facilities, nursing, organisation and and Social Sciences (M3O), Faculty of Health administration, qualitative research Science and Welfare, Centre for Health and Social Care Research (CESS), University of Vic-­Central University of Catalonia (UVIC-­ UCC), Sagrada Familia 7, 08500 Vic, Spain. Email: paola.galbany@uvic.cat This is an open access article under the terms of the Creative Commons Attribution-­NonCommercial-­NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-­commercial and no modifications or adaptations are made. © 2021 The Authors. Journal of Nursing Management published by John Wiley & Sons Ltd. J Nurs Manag. 2021;00:1–9. wileyonlinelibrary.com/journal/jonm© 2021 John Wiley & Sons Ltd | 1 2 | TORT-­NASARRE et al. 1 | I NTRO D U C TI O N What is already known about the topic? In the face of COVID-­19 pandemic, all aspects of the provision • The increased demand for health care and prioritization and management of health care were affected. Spain implemented of COVID-­19 patients resulted in a work overload for measures to prevent the spread of COVID-­19: quarantine, isolation, health care professionals. Effective leadership among social distancing and a stay-­at-­home order, which were insufficient. nursing managers helps institutions meet organisational Spain was among the countries to suffer the highest mortality in the challenges. However, this support was often lacking at first wave in Europe and around the world (Sánchez-­Villena & de La the beginning of the pandemic, as health systems were Fuente-­Fig uerola, 2020). overwhelmed by the flow of patients. Health systems should have well-­defined plans to maintain con- trol of the situation and to ensure the ability to provide care. If the What this paper adds? health system cannot guarantee this, nurses feel abandoned and un- safe (O'Boyle et al., 2006). Health managers should consider these • Understanding the organisational changes that took concerns because they can affect pandemic response (McMullan place during the COVID-­19 pandemia and how nurses et al., 2016). During the first wave of the pandemic, health systems responded to them can inform planning for future health were disorganised and often lacked organisational support to help disasters. nurses cope with the situation. • Front-­line nurses reported developing self-­management strategies to find solutions to the organisational changes they faced during the first wave: problem-­solving, adap- 2 | BAC KG RO U N D tation and learning. The increased demand for health care and prioritization of COVID-­19 patients resulted in a work overload for health care professionals. The complexity of care due to the lack of knowledge about the virus and its circumstances, both in health disasters in general and in the case of transmission pathways, the scarcity of personal protection equipment COVID-­19 in particular. (PPE) and the lack of specific treatments for COVID-­19 resulted in a Given this scarcity, we investigated nurses' ability to develop and marked increase in stress among health care workers (Mo et al., 2020). respond to changes in their work environment and the provision of The need to adapt the provision of services as information on SARS-­ care during the first wave of the pandemic. Our findings can be use- CoV-­2 emerged required rapid changes in care procedures and pro- ful in planning for future pandemics or other health disasters, espe- tocols, which increased nurses' stress and anxiety (Lázaro-­Pérez cially because our rapid approach allowed us to collect data while the et al., 2020). Nurses had difficulty maintaining a work environment crisis was still underway. Understanding the organisational changes that was ethical and safe—­both physically and psychologically—­and that took place and how nurses responded to them can inform plan- facing the challenges of the pandemic (Ulrich et al., 2020). ning for future health disasters. The aim of this study was to identify In previous pandemics, nurses have shown professional re- the organisational changes faced by front-­line nurses working with sponsibility and ensured patient care despite limited resources COVID-­19 patients during the first wave and describe how they re- (McMullan et al., 2016). Nurses acted in these health disasters de- sponded to these changes. spite suffering alarming psychological symptoms, sacrificed their own needs and acted selflessly (Aliakbari et al., 2015). Despite feel- ing unprepared to respond to a given health disaster, nurses devel- 3 | M E TH O DS oped higher-­than-­expected emergency response skills and a high sense of ethical and professional commitment (Jeong & Lee, 2020). 3.1 | Design Personal resilience and social and institutional support are pro- tective factors against adversity and stress during health disasters A qualitative study was carried out using Rapid Research Evaluation (Labrague et al., 2018). In the COVID-­19 pandemic, personal resil- and Appraisal (RREAL) (Vindrola-­Padros et al., 2020). The RREAL ience and social support have helped nurses handle stress and have model is particularly suited to studying health emergencies because been key to nurses' mental health (Cooper et al., 2020). High levels it makes possible to obtain qualitative results in a short period of of institutional support are protective against the stress and anxi- time (Green & Thorogood, 2013). ety caused by health disasters such as emerging infectious diseases. Effective leadership among nursing managers helps institutions meet organisational challenges (Labrague et al., 2020). However, 3.2 | Participants and data collection this support was often lacking at the beginning of the pandemic, as health systems were overwhelmed by the flow of patients. There is Participants were selected based on purposive sampling (Morse & little information about how front-­line nurses respond to changing Field, 1995). We used the snowball technique (Naderifar et al., 2017) TORT-­NASARRE et al. | 3 to recruit nurses from hospital and community health settings who systematically to meet our research objectives, following the steps provided care during the first wave of the pandemic in Spain, which proposed by Braun and Clarke as detailed in Table 2 (Colorafi & took place from March to May 2020. The inclusion criterion was Evans, 2016) (see Table 2). being a registered nurse caring for COVID-­19 patients during the first wave in Spain. The exclusion criterion was being on leave from work during this period. 3.4 | Rigour We sent email messages to nurses known to the research team explaining the study objectives, inviting them to contact us by email This study meets the criteria of credibility, transferability, dependa- if they were interested in participating and asking them to forward bility and confirmability, which ensure trustworthiness in qualitative the message to other nurses. We sent further information and the research (Polit & Beck, 2017). We took a reflexive stance, consider- informed consent document to the potential participants who re- ing that three of the researchers (1, 4 and 5) are nurses involved in sponded. After they returned the signed consent document, we providing care during the COVID-­19 pandemic. (However, they had scheduled an interview via Skype or Zoom. We conducted continu- had no prior contact with the participants). The interviewers took ous analysis of the data until reaching saturation at 23 participants. notes on their own impressions and reactions when they interacted At this point, we considered data collection to be complete. The with participants in order to take their own positionality into account socio-­demographic characteristics of participating nurses are sum- during analysis. COREQ was used as reporting guidelines in line with marized in Table 1. EQUATOR (Tong et al., 2007). Three team researchers (1, 2 and 3) conducted semi-­structured interviews with 23 nurses from different health care sectors from May to June 2020. We asked participants the following questions: 3.5 | Ethical considerations –­ In your opinion, how has the organisation of the health system The study was approved by the institutional review board of the changed since the start of the pandemic? host university (IRB) (File 5184) and followed the principles of the –­ In your experience, how have these organisational changes af- Helsinki Declaration. The participants received oral and written in- fected your tasks and roles and how nursing care is delivered? formation explaining that their participation was voluntary and that they could withdraw from the project at any time. We anonymized The duration of the interviews was 30–­45 min, and all interviews the interviews by substituting names with an alphanumeric code. were recorded. 4 | R E S U LT S 3.3 | Data analysis We identified three themes in participants' reports of their re- We used Braun and Clarke's (2014) thematic analysis to identify sponses to organisational changes and the provision of care during the most frequent topics from the interviews that were relevant the first wave of the pandemic: problem-­solving, adaptation and to the study objectives. Using the Dedoose® software package, learning. Each theme contains two or three subthemes (see Table 3). we identified meaning units and grouped them into subthemes and themes. We identified patterns in the data and organised the themes 4.1 | Improvisation TA B L E 1 Socio-­demographic characteristics of participants Nurses had to find innovative solutions to solve problems aris- Distribution by sex ing from the care needs of people infected or potentially infected Male 5 22% with COVID-­19. The abrupt start of the pandemic required nurses Female 18 78% to improvise in order to protect themselves from contagion and Total 23 100% to work in new spaces that had been devised for caring for COVID-­19 Distribution by age patients. 23–­29 years 8 35% 30–­49 years 10 43% 50–­62 years 5 22% 4.1.1 | Improvisation in the use of protective material Distribution by type of health centre The participants reported using improvisation to protect themselves, Hospital 15 65% given the lack of certified protective gear. This included both mak- Primary care 6 26% ing do with whatever certified equipment was available and making Intermediate care 2 9% their own equipment out of uncertified materials. 4 | TORT-­NASARRE et al. TA B L E 2 Phases of thematic analysis, following Braun and Clarke (2014) Phases Description Collaborators 1 Become familiar with the data by listening to recordings, transcribing them and reading and GTN, BA, PGE, MSM, EVS rereading the transcripts 2 Identified meaning units within transcripts and generate codes. Identify relationships among GTN, BA, PGE, MSM, EVS codes 3 Identified relationships between subthemes GTN, BA, PGE 4 Created groups of codes into seven subthemes. Define each subtheme GTN, BA, PGE, MRL 5 Identify three themes comprised of seven subthemes. Name the themes. Devise a glossary GTN, BA, PGE, DM, MRL of themes 6 Wrote the final report GTN, BA, PGE, DM, MRL TA B L E 3 Themes and subthemes Themes Subthemes 1. Improvisation a. Improvisation in the use of protective equipment b. Improvisation of spaces to care for people with COVID-­19 2. Adaptation a. Workplace mobility b. Minimizing risk while caring for people with COVID-­19 c. COVID-­19 care protocols 3. Learning a. Seeking knowledge b. Sharing knowledge We handled organization on the fly, with the material In the ICU they had covered the door with plastic we had at the time. So we were really improvising a sheeting and set up a table with the necessary mate- bit, to tell you the truth. rial, although for PPEs you had to go to the supervisor (P5 nurse) and ask her for them. (P16 nurse) We went to buy plastic to make masks because we didn't know if we were going to have any; the surgical Nursing care was improvised in various facilities, some of them ones didn't work. We didn't know at first how things new, reorganised according to the characteristics of the virus and the were going to go. paths of contagion. These organisational changes caused a sense of (P1 nurse) chaos and disorganisation. Well, how can there not be gowns available? I need We've had to learn where everything was, the layout it to be waterproof, because I have to be next to him. of the space. We were lost because it wasn't only a And the gentleman has no mask, and I have to wash new facility that we didn't know but also the facility and feed him. That's when we started with garbage was upside down, since the space had to be organized bags, like in many places. We made our own… we felt differently to treat the virus. It was really hard for me protected. to find equipment and things, and that made the work (P25 nurse) more difficult and caused frustration. (P27 nurse) 4.1.2 | Improvisation of spaces to care for people As these examples show, participants used improvisation to ad- with COVID-­19 dress the organisational challenges presented by the pandemic. Some participants reported that they improvised the internal or- ganisation of care services to face the problem of a lack of directives 4.2 | Adaptation from management. Because this health emergency created unprecedented pressure on We organized the floor ourselves without help, since health services, participants had to adapt their work practices in un- they didn't give us any guidelines on how to act, etc. expected ways. Participants reported having to adapt quickly to new (P12 nurse) departments, risks and care protocols. TORT-­NASARRE et al. | 5 4.2.1 | Workplace mobility family member, you have to give them a gown, a suit that they have to put on, masks. Numerous nurses around Spain were forced to move between hos- (P5 nurse) pital departments, between primary care centres and between reg- ular hospitals and field hospitals. This mobility caused uncertainty among participants, because the changes were unpredictable. 4.2.3 | COVID-­19 care protocols Every day at 7 pm they told us what work we'd do the New information continually emerged about the transmission and next day. We didn't know if we'd being doing respi- treatment of SARS-­CoV-­2. Participants reported difficulty in adapt- ratory care, wound care, house calls… Each day was ing so frequently to new protocols. different. We've been like this for 3 months. (P29 nurse) We've had about 12 protocol changes, and I understand it, since we have to adapt. But of course before we could The constant movement of nurses to different facilities and to de- adapt to one, it was already changed to another one. partments that served COVID-­19 patients exclusively meant that they (P16 nurse) had to adapt quickly. The existence of different protocols at different facilities caused a We have been adapting very quickly to a way of doing complex adaptation process as a consequence of the confusion, inse- things and to equipment that weren't our standard curity and lack of trust related to their reliability and applicability. ones. I think we're doing a good job. (P19 nurse) Sometimes the indications are even contradictory: there are areas where it's very defined, and others not at all… That creates confusion, since in the end you don't know 4.2.2 | Minimizing risk while caring for people sick what you have to do. For example, the versions of my with or potentially sick with COVID-­19 home facility and the facility where I've been working until now are contradictory. I think we need a little more The characteristics of COVID-­19 conditioned planning care to mini- organization to come to an agreement among all of us. mize the risk of contagion. Nurses had to adapt to the shortage of (P29 nurse) PPEs. Contact with patients who were infected or potentially in- fected with COVID-­19 had to be minimized to reduce the risk of in- As seen in the above examples, changing circumstances meant that fection. They had to adapt the frequency with which they conducted nurses had to be ready to adapt their ways of working. interventions and organised themselves so as to carry out as many as possible in a single visit to the patient. 4.3 | Learning Maybe you had to be there [with the patient] for two hours because if it was a new admission maybe it took Faced with a lack of knowledge about clinical practice, diagnostic you two hours. And then later, only on a few occa- procedures, care pathways, the use of PPE and measures to reduce sions, when we had to bathe the patient, we made the risk of contagion, participants reported that they acted proac- it coincide, for example, with the medication or the tively to find answers to their questions. They acquired this pro- change of position or with everything we had to do fessional knowledge outside of conventional training, which was with that patient. But of course if there's an emer- generally not available due to the crisis. gency, of course you have to go back in. You have to get dressed again and go in. (P1 nurse) 4.3.1 | Seeking knowledge Another of the adaptive changes explained by nurses refers to the Although some health centres attempted to train professionals, sev- support provided to relatives of people sick with COVID-­19. eral participants reported that they had to learn on their own. Above all, we weren't able to provide support to fam- When they take me out of my department overnight ily members until after a month or so. From when and tell me, ‘Starting tomorrow your department is the pandemic started, a month and a half almost or closed; you're going to the COVID floor,” they don't something like that. Because there wasn't protection tell me what will happen, what won't happen, how I equipment. Each person that you took in to see a should work, how I should protect myself. I start on 6 | TORT-­NASARRE et al. my own to look at how it's transmitted, where I have the capacity of front-­line nurses to develop professionally during to be more careful. Whether it's by medium-­sized health crises (Xue et al., 2020) and especially during the first wave of droplets, by contact… But [I did this] on my own. COVID-­19, with implications for nursing management. (P3 nurse) Participants agreed that the lack of time for formal, institutional 5.1 | Improvisation training led them quickly to seek knowledge on their own, an activity that had not been typical. During the first wave of COVID-­19, one of the main problems nurses faced was the lack of PPEs. Participants had to maximize the avail- I think training is difficult because it's something that able equipment and, as a result, had to limit their contact with pa- no one knows. COVID is very new. At the beginning of tients, resulting in the feeling that they were offering poorer quality February it was a normal flu that all of us had to get. care, as also seen in Rushton and Grady (2020). Other studies have And in the end, it turns out that it's much stronger. So, shown that working without the proper protection causes nurses to I think that everyone is lacking training and we have feel fear (Liu et al., 2020), stress (Mo et al., 2020) and a lack of safety to learn on the fly and learn from our mistakes. (Yin & Zeng, 2020). To compensate for the lack of PPEs, participants (P24 nurse) used improvised equipment to protect themselves. In the face of risk, participants found solutions on their own—­without institutional support—­so that they could keep working. 4.3.2 | Sharing knowledge The urgent need for new spaces to care for people sick with COVID-­19, the lack of clear guidelines from management and the Participants shared new knowledge about COVID-­19 with their col- lack of ICU and critical care beds meant that participants had to leagues through professional groups. solve organisational problems through innovative strategies and improvisation. Labrague and De los Santos (2020) have shown that I downloaded a lot of things, and the articles I read when these changes are accompanied by good institutional support, them as they were published. I would go on the inter- they cause less anxiety in nurses. Other researchers have shown net, contact some anesthetists and say, “All the docu- that effective communication can prevent conflicts caused by dis- mentation you have, send it to me… so that I can read crepant protocols (Karam et al., 2018). Our analysis indicates that and know a little about the course of the disease,” in the absence of clear guidelines and institutional support, nurses because it's also a pathology that you do not know solved problems quickly to provide care for people infected with or about. potentially infected with COVID-­19, making do with the resources (P3 nurse) that were available. They often shared this knowledge through social media. 5.2 | Adaptation At first in a group we sent each other protocols that we found, actions that must be taken when the case Emergency care nurses in China at the onset of the pandemic re- becomes complicated. Even the basic things that ported that attitudes such as motivation and enthusiasm helped no one explained: how to put a patient in prone po- them adapt to being moved across departments, facilities and even sition, instead of the venti-­ a basic mask, wearing a regions to care for people with COVID-­19 (Hou, Zhang, et al., 2020; Monaghan [type of PPE] because it reduces the risk Hou, Zhou, et al., 2020; Lam et al., 2019). Our participants reported that you will infect others. being able to adapt quickly to new work environments, overcoming (P10 nurse) the uncertainty caused by being in a different department or facility or with different colleagues or on a different schedule. As we have shown, learning was a key way that participants re- The scarcity of PPEs at the beginning of the pandemic was sponded to organisational changes during the pandemic. generalized around the world and health facilities established pri- orities according to the risk of exposure (Hou, Zhang, et al., 2020; Hou, Zhou, et al., 2020). This lack of PPEs and its effect on patient 5 | D I S CU S S I O N care has been identified in previous epidemics (Lam et al., 2019). Our participants had to adapt to new protocols for using PPEs. We identified three themes in participants' descriptions of how Scarcity caused them to plan their interventions with patients ac- they responded to organisational changes during the first wave of cording to the availability of PPEs. This had an impact on nursing the COVID-­19 pandemic in Spain: (a) improvisation, (b) adaptation interventions, because contact with patients who were infected or and (c) learning. Our analysis contributes to our understanding of potentially infected with COVID-­19 had to be minimized to reduce TORT-­NASARRE et al. | 7 the risk of infection. Participants reported that this necessity gave Spain had similar experiences. We should also note that the stress them the sense that the quality of care was lower. Previous re- and trauma experienced by some participants could have influenced search shows the high degree of commitment and responsibility their responses. of nurses during natural disasters (Aliakbari et al., 2015) and in epidemics such as influenza (Lam & Hung, 2013) and Ebola (Pincha Baduge et al., 2017). Participants' ability to adapt to organisational 7 | CO N C LU S I O N S changes, despite risk to their own health and lack of adequate in- stitutional support, points to their commitment to providing pa- Our rapid approach made it possible to capture fleeting information tient care. about how facilities were organised and how nurses worked during In previous epidemics, emergency room nurses positively evalu- the first wave of the COVID-­19 pandemic. Understanding nurses' ated the protocols and clinical guidelines that were updated as infor- ability to respond to organisational changes during the first wave of mation about the pathogen became available. The confusion caused the COVID-­19 pandemic can be useful for redesigning work sites and by the lack of knowledge about the pathogen was also identified as organisations and implementing the changes needed to ultimately an adverse factor at the beginning of a pandemic (Lam et al., 2019). improve staff health and patient outcomes. Participants reported According to Xue et al. (2020) in natural disasters, the lack of clear developing self-­management strategies to find solutions to the protocols and clinical guidelines for the everyday work of profes- organisational changes they faced during the first wave: problem-­ sionals affects their capacity to make decisions and prioritize care. solving, adaptation and learning. These results fill a gap in the litera- Our results show that this finding also applies to the COVID-­19 ture about how nurses deal in their daily practice with organisational pandemic. changes during a health disaster. 5.3 | Learning 8 | I M PLI C ATI O N S FO R N U R S I N G M A N AG E M E NT When health centres could not provide training to nurses, partici- pants learned about the virus on their own. Reinforcing strategies Nursing supervisors and administrators can use these findings to im- for individual learning is key, but systemic training could be more prove organisational management policies in health disasters, includ- useful in these situations (Kackin et al., 2020; Yin & Zeng, 2020). ing subsequent waves of the COVID-­19 pandemic. Understanding Research shows that in previous epidemics such as Ebola, emer- nurses' ability to respond to organisational changes during the first gency service professionals reported that they had sufficient prepa- wave of the COVID-­19 pandemic can be useful for motivating and ration to offer care to infected people (Pincha Baduge et al., 2017). encouraging nursing teams. Obviously, the most important thing In Spain, during the first wave of COVID-­19, there were insufficient health centres can do is plan adequately based on the experience data about SARS-­CoV-­2 and its transmission pathways. The pace of of nurses during this health disaster to ensure that protective gear, formal training could not keep up with changing information about spaces, communication and training are adequate. the virus. As a result, our participants shared with other profession- als the information they acquired. This support and cooperation AC K N OW L E D G E M E N T S among co-­workers have also emerged in other studies of COVID-­19 We thank the participants who collaborated in this project. We also (Hou, Zhang, et al., 2020; Hou, Zhou, et al., 2020; Sun et al., 2020). thank Dr. Susan Frekko for her feedback and for translating the man- Our results reveal the capacity of nursing teams to learn on their uscript into English from the original Spanish and Catalan. own, given the unavailability of formal training. We have shown that social networking is an additional way that nurses share information C O N FL I C T O F I N T E R E S T with colleagues both within and outside of nursing and locally and We have no conflict of interest. internationally. Our analysis reveals nurses' ability to develop pro- fessionally during health disasters. AU T H O R C O N T R I B U T I O N S All the authors have participated in the conception and design of the work. GTN, BA, PGE, MSM, EVS, DM and MRL have made substan- 6 | LI M ITATI O N S A N D FU T U R E tial contributions to conception and design, or acquisition of data, or D I R EC TI O N S analysis and interpretation of data; given final approval of the version to be published. Each author should have participated sufficiently in Our qualitative design means that our results cannot be generalized the work to take public responsibility for appropriate portions of the beyond the study population. To achieve generalizable results, a content; and agreed to be accountable for all aspects of the work in next step would be to design a mixed-­method study that would allow ensuring that questions related to the accuracy or integrity of any us to examine the statistical significance of our findings. A compara- part of the work are appropriately investigated and resolved. GTN, tive angle is also necessary to determine whether nurses outside BA, PGE and MRL been involved in drafting the manuscript. GTN, 8 | TORT-­NASARRE et al. BA, PGE, MSM, EVS, DM and MRL revising it critically for important Labrague, L. J., & De los Santos, J. A. A. (2020). COVID-­19 anxiety among front-­line nurses: Predictive role of organisational support, personal intellectual content. resilience and social support. Journal of Nursing Management, 28(7), 1653–­1661. https://doi.org/10.1111/jonm.13121 E T H I C A L A P P R OVA L Labrague, L. J., Hammad, K., Gloe, D. S., McEnroe-­Petitte, D. M., Fronda, The study was approved by the Institutional Review Board of the D. C., Obeidat, A. A., Leocadio, M. C., Cayaban, A. R., & Mirafuentes, E. C. (2018). Disaster preparedness among nurses: A systematic re- Universitat Autónoma de Barcelona (File 5184). view of literature. International Nursing Review, 65(1), 41–­53. https:// doi.org/10.1111/inr.12369 DATA AVA I L A B I L I T Y S TAT E M E N T Labrague, L. J., Lorica, J., Nwafor, C. E., & Cummings, G. G. (2020). Author elects to not share data. Predictors of toxic leadership behaviour among nurse managers: A cross-­sectional study. Journal of Nursing Management, 2021(29), 165–­ 176. https://doi.org/10.1111/jonm.13130 ORCID Lam, K. K., & Hung, S. Y. (2013). Perceptions of Emergency Nurses Glòria Tort-­Nasarre https://orcid.org/0000-0001-5270-821X during the Human Swine Influenza Outbreak: A Qualitative Bruna Alvarez https://orcid.org/0000-0002-9069-4573 Study. International Emergency Nursing, 21, 240–­246. https://doi. Paola Galbany-­Estragués https://orcid. org/10.1016/j.ienj.2012.08.008 Lam, S. K. K., Kwong, E. W. Y., Hung, M. S. Y., Pang, S. M. C., & Chien, W. org/0000-0003-3775-1695 T. (2019). A qualitative descriptive study of the contextual factors in- Martí Subías-­Miquel https://orcid.org/0000-0001-8853-0468 fluencing the practice of emergency nurses in managing emerging in- Eva Vázquez-­Segura https://orcid.org/0000-0002-7832-4721 fectious diseases. International Journal of Qualitative Studies on Health Diana Marre https://orcid.org/0000-0003-2852-3762 and Well-­Being, 14(1), 1626179. https://doi.org/10.1080/17482​ 631.2019.1626179 Maria Romeu-­Labayen https://orcid.org/0000-0001-9482-9474 Lázaro-­Pérez, C., Martínez-­López, J. Á., Gómez-­Galán, J., & López-­ Meneses, E. (2020). Anxiety about the risk of death of their patients REFERENCES in health professionals in Spain: Analysis at the peak of the COVID-­19 Aliakbari, F., Hammad, K., Bahrami, M., & Aein, F. (2015). Ethical and legal pandemic. International Journal of Environmental Research and Public challenges associated with disaster nursing. Nursing Ethics, 22(4), Health, 17(16), 1–­16. https://doi.org/10.3390/ijerp​h1716​5938 493–­503. https://doi.org/10.1177/09697​33014​534877 Liu, Q., Luo, D., Haase, J. E., Guo, Q., Wang, X. Q., Liu, S., Xia, L., Liu, Braun, V., & Clarke, V. (2014). What can “thematic analysis” offer health Z., Yang, J., & Yang, B. X. (2020). The experiences of health-­c are and wellbeing researchers? International Journal of Qualitative providers during the COVID-­19 crisis in China: A qualitative study. Studies on Health and Well-­being, 9(March 2017), 20–­22. https://doi. The Lancet Global Health, 8(6), e790–­e798. https://doi.org/10.1016/ org/10.3402/qhw.v9.26152 S2214​-­109X(20)30204​-­7 Colorafi, K. J., & Evans, B. (2016). Qualitative descriptive methods in McMullan, C., Brown, G. D., & O'Sullivan, D. (2016). Preparing to respond: health science research. Health Environments Research and Design Irish nurses' perceptions of preparedness for an influenza pandemic. Journal, 9(4), 16–­25. https://doi.org/10.1177/19375​86715​614171 International Emergency Nursing, 26, 3–­7. https://doi.org/10.1016/j. Cooper, A. L., Brown, J. A., Rees, C. S., & Leslie, G. D. (2020). Nurse re- ienj.2015.10.004 silience: A concept analysis. International Journal of Mental Health Mo, Y., Deng, L., Zhang, L., Lang, Q., Liao, C., Wang, N., Qin, M., & Huang, Nursing, 29(4), 553–­575. https://doi.org/10.1111/inm.12721 H. (2020). Work stress among Chinese nurses to support Wuhan Green, J., & Thorogood, N. (2013). Qualitative methods for health research. for fighting against the COVID-­19 epidemic. Journal of Nursing SAGE. Management, 28, 1002–­1009. https://doi.org/10.1111/jonm.13014 Hou, T., Zhang, T., Cai, W., Song, X., Chen, A., Deng, G., & Ni, C. (2020). Morse, J., & Field, P. (1995). Qualitative research methods for health profes- Social support and mental health among health care workers sionals (2nd ed.). Sage Publications. during Coronavirus Disease 2019 outbreak: A moderated media- Naderifar, M., Goli, H., & Ghaljaie, F. (2017). Snowball sampling: A tion model. PLoS One, 15(5), 1–­14. https://doi.org/10.1371/journ​ purposeful method of sampling in qualitative research. Strides al.pone.0233831 in Development of Medical Education, 14(3), 67670. https://doi. Hou, Y., Zhou, Q., Li, D., Guo, Y., Fan, J., & Wang, Y. (2020). Preparedness org/10.5812/sdme.67670 of our emergency department during the coronavirus disease out- O'Boyle, C., Robertson, C., & Secor-­Turner, M. (2006). Nurses' beliefs break from the nurses' perspectives: A qualitative research study. about public health emergencies: Fear of abandonment. American Journal of Emergency Nursing, 46(6), 848–­861.e1. https://doi. Journal of Infection Control, 34(6), 351–­357. https://doi.org/10.1016/j. org/10.1016/j.jen.2020.07.008 ajic.2006.01.012 Jeong, S., & Lee, O. (2020). Correlations between emergency code Pincha Baduge, M. S., Moss, C., & Morphet, J. (2017). Emergency awareness and disaster nursing competencies among clinical nurses: nurses' perceptions of emergency department preparedness for A cross-­sectional study. Journal of Nursing Management, 28(6), 1326–­ an Ebola outbreak: A qualitative descriptive study. Australasian 1334. https://doi.org/10.1111/jonm.13086 Emergency Nursing Journal, 20(2), 69–­74. https://doi.org/10.1016/j. Kackin, O., Ciydem, E., Aci, O. S., & Kutlu, F. Y. (2020). Experiences aenj.2017.02.003 and psychosocial problems of nurses caring for patients diagnosed Polit, N., & Beck, C. (2017). Nursing research: Generating and assessing ev- with COVID-­19 in Turkey: A qualitative study. International Journal idence for nursing practice (10th ed.). Lippincott, Williams & Wilkins. of Social Psychiatry, 1–­10. https://doi.org/10.1177/00207​6 4020​ Sánchez-­V illena, A. R., & de La Fuente-­Figuerola, V. (2020). COVID-­19: 942788 Quarantine, isolation, social distancing and lockdown: Are they the Karam, M., Brault, I., Van Durme, T., & Macq, J. (2018). Comparing in- same? Anales de Pediatria, 93(1), 73–­74. https://doi.org/10.1016/j. terprofessional and interorganizational collaboration in health- anpedi.2020.05.001 care: A systematic review of the qualitative research. International Sun, N., Wei, L., Shi, S., Jiao, D., Song, R., Ma, L., Wang, H., Wang, C., Journal of Nursing Studies, 79(November 2017), 70–­83. https://doi. Wang, Z., You, Y., Liu, S., & Wang, H. (2020). A qualitative study on org/10.1016/j.ijnur​stu.2017.11.002 the psychological experience of caregivers of COVID-­19 patients. TORT-­NASARRE et al. | 9 American Journal of Infection Control, 48(6), 592–­598. https://doi. literature. Journal of Clinical Nursing, 29(23–­24), 4514–­4531. https:// org/10.1016/j.ajic.2020.03.018 doi.org/10.1111/jocn.15476 Tong, A., Sainsbury, P., & Craig, J. (2007). Consolidated criteria for re- Yin, X., & Zeng, L. (2020). A study on the psychological needs of nurses porting qualitative research (COREQ): A 32-­item checklist for in- caring for patients with coronavirus disease 2019 from the perspec- terviews and focus groups. International Journal for Quality in Health tive of the existence, relatedness, and growth theory. International Care, 19(6), 349–­357. https://doi.org/10.1093/intqh​c/mzm042 Journal of Nursing Sciences, 7(2), 157–­160. https://doi.org/10.1016/j. Ulrich, C. M., Rushton, C. H., & Grady, C. (2020). Nurses confront- ijnss.2020.04.002 ing the coronavirus: Challenges met and lessons learned to date. Nursing Outlook, 68(6), 838–­8 44. https://doi.org/10.1016/j.outlo​ ok.2020.08.018 How to cite this article: Tort-­Nasarre G, Alvarez B, Vindrola-­Padros, C., Chisnall, G., Cooper, S., Dowrick, A., Djellouli, N., Galbany-­Estragués P, et al. Front-­line nurses' responses to Symmons, S. M., Martin, S., Singleton, G., Vanderslott, S., Vera, N., & Johnson, G. A. (2020). Carrying out rapid qualitative research during organisational changes during the COVID-­19 in Spain: A a pandemic: Emerging lessons from COVID-­19. Qualitative Health qualitative rapid appraisal. J Nurs Manag. 2021;00:1–­9. Research, 30(14), 2192–­2204. https://doi.org/10.1177/10497​32320​ https://doi.org/10.1111/jonm.13362 951526 Xue, C. L., Shu, Y. S., Hayter, M., & Lee, A. (2020). Experiences of nurses involved in natural disaster relief: A meta-­synthesis of qualitative