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

Abstract

Working as a nurse offers job security but also poses risks for mental health issues. This study aims to explore factors and processes that affected health and work experiences among nurses in Sweden during the COVID-19 pandemic. Semi-structured interviews were conducted with 14 nurses from high COVID-19 patient load areas (ambulance, emergency departments, ICU, infection wards, and specialized COVID-19 wards). A deductive content analysis using the SwAge model’s nine determinant areas, was performed. The COREQ-checklist was adhered to. Nurses were prepared to sacrifice their health for the well-being of their patients, with many still facing the repercussions. They voiced their disappointment with healthcare organizations for providing insufficient support. The pandemic disrupted the social contract between healthcare organizations and the public, particularly in elder care. To perform effectively, nurses need adequate staffing, a safe work environment, fair compensation, manageable workloads, and recognition. Instances of deception and broken promises have undermined trust and professional well-being. During the pandemic, nurses leaned on their colleagues for support to manage stress and compensate for shortcomings. Nonetheless, nurses also reported experiencing resilience, adaptability, and flourishing. Nurses in Sweden face challenges such as undersized organizations and the need for primary care expansion to reduce hospital burdens. A better balance of resources is essential for effective performance. Improved working conditions and organizational support are crucial for retaining nurses. Identifying factors for a sustainable working life involves understanding key areas and their interactions. Healthcare organizations and managers should consider these areas to promote sustainability.

Background

Nurses constitute the largest workforce in healthcare services [1]. High turnover among nurses has long been acknowledged as a worldwide problem [2]. Owing to existing nursing shortages, the aging of the nursing workforce and the long-term effects of COVID-19, ICN estimates that up to 13 million nurses will be needed globally to fill the nurse shortage gap in the future [3]. To secure a well-functioning healthcare service, it is important to have a sufficient number of nurses. However, demographic changes imply that a lack of labor supply in the healthcare sector is a past, current and future concern in most European countries as well as in the U.S. [4, 5]. Nursing is a profession with unique potential for exposure to environmental and occupational hazards in the work setting [6], especially since much of the work involves direct contact with patients [7].

Despite all the negative work experiences that nurses describe, there are many positive aspects to the profession, such as job security, colleagues, developing communication skills and having great opportunities for advancing in their career. Salutogenic factors and processes promote work-related health and contribute to and maintain the health and well-functioning of the individual, in an organization or in a society [8], whereas the pathogenic perspective focuses on understanding the origins of health risks and treating disease [9]. Previous research [10, 11] has shown that a sense of coherence can maintain or improve an individual’s health when faced with adversity. In nursing, having a sense of coherence has been shown to be a strengthening resource for work-related well-being when facing challenging work situations [12]. Nurse well-being at work is defined as a nurse’s positive evaluation of oneself and one’s contributions to the work of nursing [13]. Nurses’ well-being is conditioned by both the work and personal resources available. Work resources refer to the physical, psychological, organizational, or social aspects of the work that must be performed to provide quality care [14]. Personal resources refer to a person’s characteristics, including those related to a sense of control and resilience in trying to control their surrounding environment [14].

On the other hand, nurses’ health problems can be caused by poor working conditions [15]. A physically strenuous working environment can lead to poor health [16]. The heavy lifting and strenuous work postures that are common in nursing have been shown to contribute specifically to neck, shoulder, and knee conditions, as well as to lower back pain, which in turn can be associated with leaving nursing care [17]. Job stress can jeopardize the physical and mental health of nurses, reduce their energy and work capacity, result in inadequate care, and, in turn, negatively impact patient outcomes [18]. Studies have shown that nurses have a greater risk of developing mental health problems due to continuous exposure to workplace risk factors such as shiftwork [19], human suffering, inadequate staffing and heavy workloads [20]. Studies have also shown that healthcare workers have higher rates of suicide [19; 21]. Nurses are at high risk for stress-related disorders [22], with their work conditions often leading to stress and burnout [23, 24]. Previous research on the COVID-19 pandemic indicates that demographic characteristics, social factors, and work organization have significantly burdened frontline nurses, resulting in high stress and burnout levels [25], thereby jeopardizing their mental health and well-being [26]. The pandemic has posed numerous challenges to healthcare workers, influenced by various contextual factors impacting their experiences and needs [27].

According to an American study, nurses use personal protective factors to build personal resilience to cope with challenges and difficult situations while increasing their ability to face future situations and achieve a greater level of well-being [13]. Unlike most countries that imposed strict lockdowns and widespread closures, Sweden opted for a more lenient approach where the focus was on social distancing measures. Nurses and other healthcare professionals had to perform patient care in full personal protective equipment [28]. The COVID-19 pandemic has created an unprecedented and extreme situation, highlighting the critical need to listen to nurses’ experiences. This study is essential as it comprehensively examines various aspects of nurses’ lives and work conditions, ensuring their voices are heard and their challenges are understood. By doing so, we aim to shed light on the factors affecting their well-being and work environment during this crisis.

Aim

The aim was to explore factors and processes that affected health and work experiences among nurses in Sweden during the COVID-19 pandemic.

Method

Setting and sample

The informants in this study worked as nurses in either the southern or middle part of Sweden during the COVID-19 pandemic. The informants’ sociodemographic characteristics are described in Table 1. Snowball sampling was used to reach nurses from different settings and achieve a wide range of experience. The first author sent out a request for informants in a social media group for anesthetic nurses in the Region of Skane in southern Sweden, where the initial informant replied and was given more information about the aim of the study. Other informants were found through the first author presenting the study at staff meetings at different wards and through the first author’s contact net. The reason for using snowball sampling was to identify the right population for our purpose of the study i.e. ensure that our study included those with the most relevant experiences to provide richer and more comprehensive insights into the factors affecting nurses’ health and work conditions during the pandemic. The inclusion criteria were as follows: registered nurses who encountered COVID-19-positive patients at their workplace (such as ambulances, emergency departments, intensive care units, specialized COVID-19 units and infection control wards) and who had a good understanding of Swedish or English. After twelve interviews, the data started to become saturated, but two more interviews were conducted; in total, 14 nurses from southern Sweden and the middle of Sweden were interviewed.

Table 1 The informants’ sociodemographic characteristics

Design

A qualitative study with individual semistructured interviews was conducted since qualitative research focuses on understanding individuals’ experiences, perspectives and behaviors in their natural environment, in this case, nurses. In-depth questions such as “Can you describe in your own words what happened when the pandemic came?” were asked, and depending on their answers, further probing questions were asked. Individual interviews were chosen as a data collection method to ensure that the nurses’ unique circumstances and needs were the focal point of the interviews [29]. Individual interviews are preferable when there are sensitive questions since they give the informant a better opportunity to open up and share their experiences [29].

Data collection

The interviews took place in May/June 2023 and October/November 2023. All interviews were performed by the first author. The semi structured interview guide that functioned as a checklist for the interviewer was based on the results from the SwAge model [30,31,32], which consists of nine determinant areas of a sustainable working life for all ages, salutogenic theories [8, 9] and results from previous studies from this research group [33, 34]. The interview guide was processed by the authors and agreed upon. After three pilot interviews were conducted, the authors made small adjustments to the interview guide such as including an open question at the beginning of each interview: “What were your initial thoughts when hearing about the COVID-19 virus?”. The pilot interviews were deemed to have rich content and were therefore included in the study. The interview locations were chosen by the informants; five of the interviews were conducted in conference rooms adjoining their workplace, four in a room at a nearby library, three in the informants’ offices and two at local coffee shops. The interviews lasted between 64 and 119 min; informed consent was obtained from each informant. Each interview was recorded and transcribed verbatim.

Data analysis

All the interviews were transcribed verbatim and pseudonymized by the first author. Each interview was given a number between 1 and 14. Content analysis was used to obtain a condensed and broad description of the phenomenon. The data from all the interviews were organized in NVivo software (version 14) and analyzed by researchers C.N. and K.N. through deductive content analysis [35,36,37] based on the theory of a sustainable working life for all ages (SwAge model) [30,31,32]. A deductive content analysis was chosen to distill the relevant portions of the gathered data. Deductive content analysis is an appropriate method when the text is interpreted from predetermined (theoretical) codes. Deduction involves drawing conclusions from general principles to specific instances. In deductive content analysis, existing theories and prior research inform the refinement and potential extension of a theoretical framework [38]. Our study followed several steps: constructing a thematic matrix based on theories and the determinant spheres in the SwAge model [30,31,32]; reading all interviews together to gain a holistic understanding (done twice); marking specific interesting parts in the text; color coding; and finally grouping codes on the basis of their meanings, similarities, and differences into themes. All the authors contributed to the final content analysis. The presentation of deductive findings in our results section is organized around the four predetermined themes (Health effects of the work environment; The financial situation; Social inclusion, support and sense of community; and The execution of work tasks and activities) derived from the determinant spheres of the theoretical SwAge model [30,31,32]. Some experiences address issues across multiple themes, leading to their inclusion in more than one of the four main themes: Health effects of the work environment: (1) the diagnoses, self-rated health and functional diversity; (2) the physical work environment; (3) the mental work environment; (4) the working hours, work pace and time for recuperation; The financial situation; (5) personal finances; Social inclusion, support and sense of community; (6) the personal social environment; (7) the social work environment; The execution of work tasks and activities; (8) work satisfaction, motivation, stimulation and the core of work; and (9) knowledge, competence and ability.

Ethical considerations

The study was performed in accordance with the Declaration of Helsinki [39] and with the Swedish law of research ethics [40]. The benefits of the study were deemed to outweigh the potential harm to the informants. The rules for data management and data storage were followed in accordance with the University Policy as well as the GDPR [41]. Participation in the study was voluntary, and informed consent was obtained from all the informants. The study was approved by the Swedish Ethical Review Authority (2016/867 and 2020 − 01897).

Findings

The analysis focused on in-depth investigations and identification of both salutogenic and pathogenic factors in nurses’ complex work situations before, during and after the COVID-19 pandemic. Below, the deductive findings are reported on the basis of previous research on nine areas of importance for sustainable working life, i.e., the SwAge model [30].

Nurses’ health

Some informants reported maintaining good health and well-being throughout the pandemic, feeling unstressed and unaffected by COVID-19. They adopted a “go with the flow” attitude and were not afraid of infecting others. In contrast, there were those who had concerns but felt like they could not think about it constantly.

“…I didn’t care too much about the risk of infection because it was not something that you could go around brooding over and at the same time do the work that was expected of us…” (Informant 1).

Conversely, others experienced significant stress, trouble sleeping, and persistent thoughts about their experiences and actions during the pandemic. They reported mental health issues manifesting as physical symptoms like heart palpitations, pain, anxiety, headaches, and exhaustion, with some taking extended sick leave. Physical injuries from PPE, such as hair loss, allergic reactions, eczema, and facial wounds, were also common. Concerns about the long-term effects of low-quality facemasks and the inability to maintain physical fitness due to gym closures further impacted their well-being.

Physical work environment

Informants noted both positive and negative aspects of not having relatives accompany patients. Positively, it created more space in the wards. Negatively, it left many, especially older patients, alone, making it harder for healthcare staff to monitor their health since the informants had to check on them more frequently and thus more walking.

The pandemic led to improved organizational skills, new work methods, and refined procedures requiring fewer staff. However, there were significant shortages of PPE, hand sanitizer, and medicine. Some informants had to work without proper safety equipment, and although some PPE was available, it was not always CE-marked and thus not permitted for use. Despite this, some informants chose to use military-grade breathing masks. Guidelines for PPE usage often changed based on available materials in each department.

“…because as I saw it, it was quite obvious that they started to reduce the safety requirements in relation to the staff in regard to what kind of material they had available and that is a betrayal” (Informant 4).

Several informants reported being asked to reuse protective equipment and save used breathing masks for potential future sanitization. They worked in rooms with multiple patients, with doctors sanitizing gloves between patients. Informants stated that they were instructed to wear full protective gear in the ICU, which was exhausting and hindered communication. Some informants relied on secret stashes of supplies from seasoned nurse assistants.

The physical work environment was already challenging before the pandemic, with overcrowding and a lack of beds. During the pandemic, wards had to reconfigure spaces, using areas like ambulance bays and outpatient clinics, leading to several negative events.

“It turned out to be a bit of a fake build, so it happened that there was a pensioner who came in and was not truly very sick; she leaned on a railing that was not screwed down properly and fell, then she got a subdural hematoma instead.” (Informant 1).

Drawbacks of the changed work environment included ambulances offloading patients outside, exposing them to the elements and compromising privacy. Cramped spaces, inadequate equipment, poor ventilation, and the need to search for materials frustrated staff. Informants had to triage patients in unheated tents or sheds. The increased demand for high-level care led to the creation of intermediate care departments and specialized COVID-19 units. ICUs used outdated respiratory machines and borrowed anaesthetic machines. However, the flow of patients to emergency wards improved as most were directed to infection clinics.

Mental work environment

Some informants initially underestimated the pandemic, thinking it would be like regular influenza. When it hit, they were caught off guard by the severity of patients’ illnesses and felt unprepared for subsequent waves. Stress was a major issue, stemming from ethical concerns, reallocation to different wards, time constraints, and difficulty finding materials. The lack of control and high demands from the organization, patients, and themselves added to their stress.

Some informants described how doctors calling patients’ relatives to provide updates helped reduce stress by freeing up nurses’ time. However, threats and violence increased due to relatives’ frustration over hospital restrictions and patients being redirected to primary care. The informants’ mental health suffered from witnessing tragic losses, fear of making errors, and frustration over inadequate working conditions. Many described facing unethical situations.

“…when you had to stand with these old people who had to die in your hand without relatives/…/and I have stood there with a gas mask on, it was not dignified, it is not okay…” (Informant 10).

Some informants found the mental work situation emotionally draining due to rapidly changing routines, a survival mode mentality, and feeling like their work identity was compromised by being reassigned to different wards or shifts. Restrictions prevented them from supporting colleagues, adding to their emotional exhaustion. The informants that worked as paramedic nurses were particularly frustrated by exposure to the virus when treating patients who didn’t truly need help.

Working hours, work pace and recuperation

The informants that worked in the emergency department reported a decreased workload early in the pandemic due to fewer patients making hospital visits and improved patient flow later on. However, the increased work pace and high sick leave rates during the high points in the pandemic led to some informants being faced with missed breaks, extra shifts, and frequent shift changes, hindering recuperation. Some informants struggled with sleep, felt constantly tired, and lacked energy for exercise. The omnipresence of the pandemic, even outside work, prevented mental recovery, leaving them anxious and exhausted.

“…it was terrible not to like your job, to sort of feel Sunday night that now it is Monday again/…/to dread going to work…” (Informant 6).

The informants appreciated the help from reallocated staff but felt it added strain on experienced staff who had to monitor both patients and new staff. A positive outcome was the assignment of experienced nurses as team leaders in ICU rooms, allowing them to support other staff. While many informants did not receive overtime compensation, some were given “COVID-time” to rest, which managers tried to accommodate when possible.

Personal finances

As previously mentioned, several informants experienced long-term sick leave during and after the pandemic, impacting their personal finances. Most informants reported receiving no additional compensation beyond payment for extra work hours, which fell short of their expectations. However, due to the lockdown, their expenses were relatively low.

“I have worked a lot of extra shifts/…/I have accumulated a lot of money and that is good, but it is not an active choice…” (Informant 4).

Before and during the pandemic, some informants considered leaving their workplace or even the profession but felt it wasn’t the right time. Among the informants, five out of fourteen nurses changed their workplace after the pandemic. Many informants expressed relief that their jobs were economically stable during the pandemic, providing a sense of certainty amidst widespread uncertainty. The additional personnel from other departments and county councils also provided some work relief.

Private social environment

Support from family and friends was important for most informants, though some struggled with balancing work and personal life due to fatigue and fear of spreading the virus. While some informants’ families and friends had difficulty understanding their challenges and unpredictable schedules, others received support from those with healthcare experience. Many informants found it stressful to receive work calls during their time off.

“… one’s privacy is not respected and that in turn also affects people close to one, i.e., your partner or friends…” (Informant 7).

Many informants reported that having relatives working from home negatively impacted their recovery time. However, a small silver lining was that the fear of missing out was reduced since much of society was periodically shut down. Conversely, some informants felt frustrated with those who ignored restrictions and guidelines. Transitioning from caring for critically ill patients to seeing people without protective masks in public was mentally challenging for them.

Work social environment

Support from work colleagues was universally praised, with informants feeling seen, heard, and experiencing strong teamwork, even with doctors and other care professionals. This sense of reliability and comfort among staff was crucial for patient safety. Regarding managerial support, half of the informants felt well-supported by their immediate managers, while the other half found their managers to be unsupportive and absent.

“…it was not the captain who stood at the frontline, but it was the captain who hid in the basement…” (Informant 2).

Some informants felt that their managers did not care about their employees, taking their presence for granted and lacking proactivity, which led to frustration. Trust in managers and the organization diminished. Many informants expressed resentment towards the organization, regional boards, and the government for their handling of the pandemic, believing that Sweden’s regions failed in ensuring primary care fulfilled its role. While most agreed that the organizational response was inadequate, they noted that issues were resolved at the individual and team levels.

“…I know that I once thought that now it is almost a social experiment that you are part of, you see it from the inside, what happens to an organization if it turns out like this?” (Informant 3).

Many informants felt deceived by management’s lack of honesty about protective equipment guidelines. Additionally, they were disappointed that managers persuaded some to accept stimulus money instead of overtime pay, viewing it as dishonorable to manipulate statistics. Most informants believed that healthcare has not received the recognition it deserves, feeling as though the pandemic is being forgotten by the world, while those who experienced it firsthand continue to deal with its lasting consequences.

Satisfaction, meaningfulness and motivation with work tasks

There was an imbalance between work effort and reward, leading to frustration among some of the informants who felt unappreciated by the public. Many informants felt undervalued and struggled with motivation, especially given the high workload and over-treatment of patients. Some were frustrated by being assigned administrative tasks or caring for patients who didn’t require their expertise.

“…job satisfaction decreases when we care for patients we are not supposed to care for…” (Informant 13).

Many informants found satisfaction in the hard work, feeling needed and knowing their efforts made a difference. Some felt they grew from the challenges they faced, while others took pride in seeing their colleagues thrive.

“…it was hard when it was going on in a way, but yes, it was very useful to have been part of it, very educational after all” (Informant 13).

Knowledge, competence and ability

The informants emphasized the need for clear, accessible information, especially for those without medical knowledge. While they received necessary information, keeping up was challenging due to reliance on work emails. Some wards used whiteboards for updates. A few informants wished for proactive outreach to other clinics for better preparation. Some felt there was a lack of competence among staff, and that they were forced to work with patients beyond their skill level.

“… it could be shifts when I was working as the most experienced nurse, well it was like I was expected to take care of patients who I hadn’t even been trained on…” (Informant 7).

Some informants felt they learned by doing and grew in competence through practical experience. Despite challenges, positive changes emerged from Sweden’s PPE experience during the pandemic. The informants described how their workplace came up with creative solutions, alternative cleaning methods, and improved protective gear, demonstrating resilience and adaptability. The pandemic also raised awareness about the importance of PPE and infection prevention for both healthcare workers and the public.

Discussion

We aimed to identify factors affecting nurses’ work situations before, during, and after the COVID-19 pandemic. The participants were willing to sacrifice their health for the well-being of their patients, and many continue to suffer the consequences. They expressed disappointment towards healthcare organizations for failing to provide the necessary support and relied on their colleagues for support to manage stress. To perform effectively, nurses require adequate staffing, a safe work environment, fair compensation, manageable workloads, and recognition. Instances of deception and broken promises eroded trust and undermined their professional well-being. The motivation for many came from the satisfaction of feeling needed and knowing that their hard work made a difference.

Nurses’ health

Research highlights the importance of health and work environment for a sustainable working life [30,31,32]. While some informants reported unaffected health during the pandemic, others experienced poor self-rated health, including sleep problems and anxiety. Previous research [42] has shown that resilience and good interpersonal relationships were linked to better mental health during lockdowns. Nearly 50% of nurses reported stress or trauma due to COVID-19 [43], with many experiencing anxiety or depression [44, 45]. Extended sick leave due to exhaustion or burnout was common among the informants, this was also reported in previous studies [33, 34]. Many informants mentioned feeling stressed at work and from work. Work-related stress is a prevalent issue among healthcare personnel globally [46]. Research indicates that it increases the likelihood of cognitive failure, which, in turn, impacts patient safety [47]. Physically, the informants reported a range of health issues, with many contracting COVID-19 at work and experiencing symptoms like headaches and muscle pain. A previous study [48] has shown that extreme stress and overwhelming work conditions can cause both psychological and physical symptoms. Healthcare organizations rely on healthcare professionals’ health and well-being to be able to provide efficient healthcare services [49]. Healthcare organizations must prioritize nurses’ health and well-being. Policymakers and leaders should address nurses’ mental health needs and implement supportive strategies [50]. This is crucial given the global nursing shortage and the number of nurses nearing retirement or leaving due to working conditions.

Physical work environment

This study highlighted concerns about suboptimal care environments and patients being treated at inappropriate care levels, risking staff and patient safety. Many healthcare systems were unprepared for the COVID-19 pandemic, struggling to provide beds and materials [51]. The physical work environment is crucial for a sustainable working life [30,31,32]. Temporary or remodeled departments increased the risk of work accidents and improper lifting techniques. According to the Swedish Work Environment Act [52], work should be safe and healthy, with satisfactory hygienic conditions. However, the informants reported working in temporary outdoor stations without proper heating and in wards with poor ventilation. The lack of protective equipment or not being allowed to use available protective equipment since it did not have proper labeling caused unnecessary stress and increased infection risk. The informants also reported that working with protective equipment was exhausting, which was supported by other studies [1]. Adequate PPE is essential for healthcare worker safety [45]. Despite challenges, improved patient flow and intrahospital collaboration during the pandemic could help prevent overcrowding in emergency wards.

Mental work environment

Some informants initially felt the pandemic wouldn’t affect them, but many were unprepared for its impact, this was also reported in other studies [1]. The informants stated that various factors in the mental work environment caused stress, including ethical and conscience stress. Ethical stress involves broad ethical dilemmas, while conscience stress stems from guilt or shame. A Swedish study [48] found that not meeting patients’ needs caused stress and feelings of unprofessionalism. Additionally, the informants struggled to support colleagues due to restrictions and their own emotional exhaustion.

The informants reported a lack of control over their schedules and being forced to work in different wards or night shifts during the pandemic, this was also found in previous studies [33, 34]. Participation in decision-making is crucial for their health and motivation [30, 53]. The informants stated that high personal demands and inadequate resources led to stress. Studies show that high job demands cause exhaustion and health issues [14, 54]. The informants were unhappy with their working conditions, and previous research has shown that this is a common problem [55]. However, this is a preventable problem; if organizations take proper action to improve the work environment it can enhance nurses’ health and retention.

Working hours, workpace, and recuperation

The informants faced high workloads and increased work pace, often working overtime and extra shifts. Exhaustion and work overload were major issues, this was also found in previous studies [1, 33, 34]. Some informants had opportunities to take breaks, but others couldn’t due to their workload, leading to stress and sleep problems. A Swedish study [48] showed that nurses felt physically tired during the pandemic but were unable to relax. The body and mind need to rest to function properly, and not having time to relax can cause errors at work [33]. It is crucial for nurses to have manageable workloads and opportunities for rest to maintain a sustainable working life.

Personal finances

The informants reported that the COVID-19 pandemic did not affect them economically. Many found comfort in their financial stability amidst the chaos. A U.K. study [56] indicated that job security was high during the pandemic. The informants stated that they had better personal finances due to overtime work and reduced spending opportunities. However, some felt the extra pay did not adequately reflect their efforts. Research shows that economic factors significantly impacted quality of life during the pandemic [57] and are crucial for a sustainable working life [30,31,32].

Private social environment

While some informants felt they had a good work-life balance, most experienced an imbalance favoring work. Previous studies [58,59,60] have linked poor work-life balance to health issues. Nurses treating severely ill COVID-19 patients faced two contrasting realities: their intense hospital environment and the public enjoying leisure activities. This contrast was challenging for some. Social support from friends and family was crucial. One study [61] found a link between long-term sick leave due to mental health issues and a lack of social support. The informants appreciated the support from the general public, as noted in previous research [1]. To ensure nurses’ well-being and job satisfaction and address nursing shortages, it’s essential to prioritize social support and work-life balance within organizations. This approach helps retain skilled professionals and maintain high-quality patient care.

Work social environment

Support is crucial, especially during challenging times like the COVID-19 pandemic. A positive work social environment, with support from managers and colleagues, is vital for a sustainable working life [30,31,32]. The informants felt safe and experienced improved teamwork with nurse assistants and doctors, this was also supported by previous research [1]. However, experiences with managers varied; some informants felt supported, while others found managers unsupportive and absent. Effective leadership support is essential for reducing anxiety, depression, and burnout [62], decreasing sickness absence [63], and improving job satisfaction [64, 65].

Many informants expressed dissatisfaction and anger toward the healthcare organization, a sentiment echoed in other studies [66]. Some informants felt deceived and betrayed by their employer, who changed PPE protocols based on available stock rather than admitting the lack of protective equipment. This approach puts nurses’ health at risk. Ensuring nurses’ well-being is a shared responsibility that involves both the nurses and the supporting systems and organizations [67].

Many informants expressed that their sense of duty to both patients and colleagues motivated them to work despite feeling tired or stressed. While nurses are committed to patient care, it’s crucial to balance this with ensuring the safety of nurses and other healthcare professionals. Addressing nurses’ ethical concerns and well-being is essential for maintaining a resilient healthcare workforce [68].

Satisfaction, meaningfulness and motivation with work tasks

Informants in this study found it challenging to stay motivated, partly because they anticipated difficult situations and cared for patients outside their usual scope. Some felt the care they provided was subpar, impacting on their motivation. They also reported issues with their working environment, such as limited space and poor ventilation. As reported in a previous study [48], the working environment is crucial for patient safety and job satisfaction. However, some informants felt their work was meaningful, giving them a chance to demonstrate their abilities. The meaningfulness of work is also important for nurses’ mental health, as noted in another study [1].

Knowledge, competence and ability

To perform one’s work tasks and activities, employees need knowledge, skills and competence, which is also important for a sustainable working life [30,31,32]. Good communication between colleagues and, in some instances, between managers and staff, was described by the informants. Good communication and good relationships are valuable tools for a health-promoting organizational and mental work environment [30].

The informants stated that they received little to no introduction when assigned to different wards during the pandemic, and some had to care for patients beyond their expertise. This lack of proper training or orientation can compromise patient safety. Some informants adopted a learning-by-doing approach due to the unprecedented nature of the pandemic, which made them feel like novices again. This sentiment was also noted in previous research [48]. It’s crucial to apply the lessons learned from this pandemic to improve healthcare organizations’ preparedness for future pandemics or major events.

Strengths and limitations

Given that our data were collected from semi structured interviews conducted a few years after the COVID-19 pandemic began in 2020, there is a potential risk of recall bias. The accuracy of the informants’ memories may be questionable. However, since we are focused on the nurses’ experiences, and the passage of time may have allowed them to reflect on their situations, we believe the data are reliable. By recognizing the possibility of recall bias and taking measures to mitigate it, researchers can enhance the accuracy and credibility of their findings. The interviews provide detailed and in-depth data, offering rich insights into the informants’ perspectives, which supports the dependability of the study. Employing deductive content analysis has both advantages and disadvantages. An existing framework offers a more efficient and structured approach to data analysis, enabling easier comparison of findings across various studies or contexts. However, relying on established theories might restrict the discovery of new insights or unexpected findings. To address this, we used a semi structured interview guide, allowing the interviewer to explore different areas in depth. Some researchers argue that predefined categories can introduce bias, potentially causing researchers to overlook data that doesn’t fit the existing framework. To prevent this, multiple researchers were involved in the coding process. We provided a detailed description of the research process, reflected on the interviewers’ preunderstandings, and used direct quotes to enhance the paper’s credibility. Conducting a member check would have further ensured the accuracy of the results. The researchers have made efforts to describe the research settings and participants in detail to enhance transferability.

Conclusions

Nurses were generally unhappy with their working conditions - an issue that could be prevented with proper organizational actions. Enhancing the work environment can improve nurses’ health, well-being, and retention. A manageable workload and opportunities for recuperation are essential for a sustainable working life. Ensuring nurses’ well-being is a shared responsibility between nurses and organizations. Work-related stress is prevalent among nurses and can negatively impact patient safety. Therefore, healthcare organizations must prioritize nurses’ health and well-being. Policymakers should address nurses’ mental health needs, especially in light of the global nursing shortage. Despite challenging conditions, many nurses find their work meaningful, positively impacting their mental health and motivation. During the pandemic, nurses relied on colleagues and managers for updates on guidelines. Learning from the pandemic is essential for improving future preparedness. Healthcare organizations should address all areas of the SwAge model to promote a sustainable working life for nurses. Additionally, nurses must advocate for equitable healthcare systems, fair compensation, and safe working environments.