Overcoming the challenge of COVID‐19: A grounded theory approach to rural nurses' experiences

Abstract Introduction This study inquires into nurses' changing perceptions with regard to the efforts in preparation for working in a COVID‐19 ward in the rural Japanese context. Methods Data were collected using ethnographic methods and semi‐structured interviews among 16 nurses working in the COVID‐19 ward of a rural community hospital in Japan. A grounded theory approach was used for the qualitative analysis. Results In total, 70 hours' observation and participation were completed, and 27 pages of field notes were taken and used for the analysis. In addition, 32 interviews were conducted with 16 participants. Four themes emerged from the data: pre–COVID‐work perceptions, overcoming fear, shadow cast by working in the COVID‐19 ward, and an integrated approach to the fear of COVID‐19. The nurses initially felt unpredictable fear. However, the establishment of standard approaches and practices for COVID‐19 gave them confidence in their safety and helped them regain sympathy for patients. Nevertheless, working on COVID‐19 cases negatively affected their activities outside of the ward, and some of them developed an identity crisis as they feared for the future. Conclusion Better teamwork, comprehensive understanding of COVID‐19, and continuous provision of proper knowledge in rural hospitals should be driven by appropriate understanding and sympathy for nurses and patients in COVID‐19 wards. The results of this study can be applied to mitigate nurses' fear, improve teamwork, and ensure understanding of COVID‐19 by all medical staff in rural hospitals.


| Participants
Participants were 16 nurses who worked in a COVID-19 ward. They had previously worked in general departments in the hospital or in wards specializing in infections. After one ward was converted to a COVID-19 ward, they were voluntarily assigned to it after being provided with general information about COVID-19 and the necessity of wearing N95 masks and PPE (personal protective equipment) by a nurse specializing in infectious diseases. Next, they prepared the ward for COVID-19 by dividing it into safe, semi-infectious, and infectious zones. After they had practiced managing COVID-19 by simulation, the ward started accepting patients. Working in the ward, the nurses discussed and revised their care management practices collaboratively and discussed them with infectious disease nurses.
COVID-19-dedicated nurses were bunked in a hospital dormitory and provided free meals by the hospital. Their movement was not restricted, and they used the same rooms as other medical staff to change clothes for work.

| Ethical considerations
Before providing written consent, participants were informed that the data would only be used for research purposes. They were also informed about the research aims, data disclosure procedures, and steps taken to protect personal information. This study was approved by the Unnan City Hospital Clinical Ethics Committee (approval number: 20200005).

| Measurement
Ethnography and semi-structured interviews with participants were conducted by the first author, a specialist in family medicine, medical education, and public health, charged with treatment of COVID-19 patients. This author participated in the nurses' activities, such as cleaning the ward and delivering food to patients, observing nurses' work and approaches to patients with COVID-19 for 3 days, participating in discussions of care management, and taking field notes.
Next, the researcher interviewed the participants regarding their work in the COVID-19 ward. Three main questions were asked: How did you feel about working in this ward before being assigned here? How do you feel about your present working conditions? And do you feel that there have been any difficulties or that any changes should be made regarding working here? Each interview lasted about 30 minutes and was recorded, transcribed verbatim, and reviewed and confirmed by the interviewee. Participants also wrote down the challenges they faced and their suggestions for better processes and shared them with the researcher.

| Data analysis
Grounded theory was used to identify changes in nurses' perceptions of preparation for COVID-19 and working in the COVID-19 ward. The first and second authors carefully read the field notes, transcriptions, and participants' difficulties and suggestions. The first author then coded the content and developed codebooks based on repeated reading (initial coding). 17 The study used process and concept coding. 18 The second author also coded the materials and discussed the coding and codebooks with the first author; on this basis, the authors inducted, merged, deleted, and refined concepts and themes by oscillating between research materials and initial coding in the subsequent axial coding. 17 Discussion of data and coding continued until mutual agreement was reached and no new codes or concepts appeared. For member checking, the analysis was provided to all participants, whose feedback was included in the final revision of the themes and concepts. Eventually, no new themes emerged during member checking, indicating saturation. Finally, the theory was discussed and agreed upon by all the authors.

| RE SULTS
Overall, 70 hours of observation and participation was performed, 27 pages of field notes were written and analyzed, and 32 interviews were conducted with 16 participants (each interviewed twice).
Through grounded theory, four themes emerged: pre-COVID-work perceptions, overcoming fear, shadow cast by working in the COVID-19 ward, and integrated approach to the fear of COVID-19. Figure 1 presents a conceptual model of this study's results.

| Fear of being infected
Prior to working in the COVID-19 ward, the participants experienced fear of COVID-19 as a result of vague evidence about this unprecedented health event and felt anxious owing to the possibility of infection in the ward. As they were exposed to varied information through television, the Internet, and their families and friends, their anxiety and concern about working in the ward grew. I was exposed to too much information regarding this infection. The contents were hectic and fearful for me. I was motivated to work at this ward, but the information from friends and family could have also prevented me from going to this ward because of their fear of COVID-19. These complicated situations confused me, leading to more fear of working here.

| Unsatisfactory preparation
As COVID-19 spread quickly in Japan, local governments acted rapidly, setting up special beds and wards. Participants felt preparations had been so quick that they had not prepared themselves adequately for COVID-19 before being expected to treat it. Stress interfered with their efficient absorption of required infection control knowledge.

| Fear for and interest in the future
Participants experienced anxiety about the future and felt it hard to return to their previous jobs owing to lost experience with regular nursing care. Some participants wished to continue working in the COVID-19 ward; although they felt fear, they were motivated to help fight this new disease.
We thought that we were not prepared to deal with the patients of COVID-19 because of the lack of time

| Confidence in controlling the infection
After starting work in the ward, participants realized that most patients with COVID-19 did not have severe symptoms and did not need frequent intervention. Thus, firsthand experience made them confident that they would not be infected too easily. In addition, their anxiety regarding unsatisfactory preparations was dispelled by the frequent experience of wearing PPE and N95 masks and moving around the ward within the zoning setup.

| Identity crisis as nurses
As participants built good relationships with patients, they tried to work with patients more closely-a core part of nursing work and identity. However, risk of infection meant they also needed to maintain distance from patients, which led to identity crisis as nurses.
They realized that touching and listening to patients, aside from building better relationships, was vital to their professional identity, which they hoped to regain.
We can usually make good relationships with patients by touching and listening to them at short distances.
However, now we do not act like that. Although we understand the present situation, we are unintentionally approaching patients. We have to restrain our identity as nurses.

| Continuous improvement of teamwork
To moderate participants' stress and anxiety, collaboration in the ward was essential. While working, participants shared ideas and experiences and encouraged each other. Mutual understanding mitigated their stress and anxiety, stimulated teamwork, and potentially prevented them from experiencing depression.

| Comprehensive understanding of COVID-19
Negative feelings about the nurses among other medical staff were elicited by the latter's poor understanding of COVID-19. The COVID-19 ward was established so quickly that most medical staff were not appropriately informed about COVID-19 and the required ward structure. Participants indicated that comprehensive understanding of COVID-19 among stakeholders might mitigate negative feelings toward the ward.
We established effective teamwork in this ward.
Here, we can share various ideas and motivate each other to work. This teamwork should be driven to maintain a good mental condition of the nurses.
Besides, a larger number of hospital staff should be aware of the condition of this ward. Their misunderstanding can cause misconduct towards this ward's nurses. Although nurses of this ward cannot work as hard as they used to previously, we hope to be treated more naturally, because we do not experience severe working conditions. Pandemic situations expand the volume of health information, which can cause confusion and misunderstanding. 19,20 The situation might be exacerbated by a large proportion of older people in rural settings, which may cause high mortality rate if infected. 1 As this study's participants stated, in their situation, where rural people could not acquire proper information, caring for patients with COVID-19 exacerbated fear of infection. 21 At the same time, pandemics are shown to stimulate rural nurses to work 8,22 ; professionalism can drive motivation to protect their hospital and decide to work in the infection ward-especially here, as most of the nurses were indigenous to the city.
Rural nurses in COVID-19 wards adjusted their working conditions through effective collaboration. As the participants stated, by applying required guidelines and subscribing to the advice of infection control nurses and epidemiologists, they understood the situation better and reduced their fear of the unexplainable, 23 repeating, and routinizing actions for infection control. 24 In addition, revision of infection control methods based on nurses' experiences and guidelines enabled development of infection control processes more suitable for the ward's conditions. 25 As participants also stated, their hospital is relatively small, and most nurses have worked together and know each other. This situation can facilitate their preparation for working and revision of working conditions. Furthermore, results showed that by controlling their fear, nurses could consider patients' anxiety and difficulties One of this study's limitations is that the interviewer was a physician in the same hospital as the nurses. This might have led nurses to be less critical of physicians in their responses. Also, the interviewer might not have fully understood the nurses' tasks, which could have led to irrelevant interview questions being asked. 37 To overcome this limitation, the interviewer observed the participants and participated in their work in the COVID-19 ward for 3 days to understand their daily tasks. Another limitation relates to differences in the COVID-19 pandemic situation worldwide; the impact in Japan is mild as compared to other countries. The results of this study can be applied to mitigate nurses' fear, improve teamwork, foster understanding of COVID-19 by all hospital staff, and ensure continuous provision of proper knowledge. These actions can drive comprehensive approaches to COVID-19 in rural hospitals and generate appropriate understanding and sympathy for nurses and patients in COVID-19 wards.

| CON CLUS ION
This study has clarified changes in the perceptions of nurses in the COVID-19 ward of a rural hospital in Japan and explained their views on potential responses. Grounded theory revealed four themes: pre-COVID-work perceptions, overcoming fear, shadow cast working in the COVID-19 ward, and integrated approach to fear of COVID-19.
Nurses working in COVID-19 wards previously felt unpredictable fear and negative perceptions regarding COVID-19; after working in the ward, they established and improved methods for approaching COVID-19, acquired confidence in their safety, and regained sympathy for patients. However, working in the COVID-19 ward also negatively affected their activities outside of the ward, inducing identity crisis and anxiety about the future.

ACK N OWLED G EM ENTS
We would like to thank all the participants who took part in this research.

CO N FLI C T O F I NTE R E S T
The authors have stated explicitly that there are no conflicts of interest in connection with this article.