What Healthcare Workers Told Us about Working through the COVID-19 Pandemic: A Qualitative Analysis of Digital Audio Stories

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Introduction
Te experiences during the COVID-19 pandemic, over the past two years, have resulted in an incomprehensible impact on everyday life. Everyone has personal COVID-19 experiences and memories, and none are more vivid than those of healthcare workers. As the time passes, memories may fade, yet stories will remain. It would be wise to examine the stories shared by healthcare workers as a reminder of what happened and what we can learn from those experiences.
Storytelling has demonstrated benefts as an efective tool to educate, build self-efcacy, strengthen coping strategies, and process adverse life events [1]. Telling stories is one of the most powerful means we have as a culture to document, share, learn, and promote connections. Te use of digital audio storytelling is becoming more common as a tool to use in health promotion and wellness [1][2][3].
Everyone has a story. Yet, the literature is lacking in how the stories from healthcare workers during the pandemic afected the individual healthcare worker at that time or how these stories are embedded in patient care and healthcare systems. Te purpose of this article is to explore the results from a qualitative analysis of audio stories captured during the second wave of the COVID-19 pandemic and second to compare these results to a prior analysis of audio stories captured during the frst wave of the COVID-19 pandemic. Tese digital stories are one facet of a larger study conducted during the frst year of the pandemic. Examining this data collected over time will add to the identifcation and support needed to change within the healthcare system.

Design, Setting, and Study Population.
A descriptive qualitative study was conducted within a large healthcare system in Southeast Michigan. Data collection began in April 2020 through January 2021. Audio diaries were collected during the frst and second waves of the pandemic in Michigan, as measured by the number of patients hospitalized with COVID-19 across the study healthcare system (see Figure 1). Te second wave analysis focused on stories collected from November 11, 2020, to January 21, 2021 (see Figure 1). Recruitment targeted all healthcare workers, not just those on the frontline or involved in direct patient care. Invitations to participate were periodically included in daily COVID-19 update emails sent out by the health system's communication department to all employees and contracted providers.

Data Collection.
Te recruitment announcements directed interested participants to a study website, where they could consent to participate in the study, provide basic demographic information, and submit an audio recording. Te consent form included the following statement: you can talk about whatever you would like to share. Tis might include stories about your own experience, stress, or emotional response; observations regarding the health system or individual preparedness, responsiveness, or adaptation regarding the pandemic; or anything regarding individual or collective ability to care for our patients and ourselves. Tere were no specifc prompts once they completed demographic data collection and proceeded to the recording webpage. A list of support resources was provided in case participants were in distress. Participants were asked to not include any personal or patient identifers in their recordings. Te audio recording was limited to 5 minutes. Participants had the option to return to the website and record as often as they desired.

Data Analysis.
Each story was recorded using Camera Tag® which included both the audio recording and corresponding written transcription. A grounded theory approach was used to analyze the audio diary content, and both audio recordings and written transcripts were analyzed concurrently. Two reviewers, using an open-coding method, created a line-by-line analysis. After their independent review, a comparative iterative process was used to synthesize results and refne the themes. A third reviewer examined the results for further refnement, clarity, and reduction of bias [4]. In addition, in order to minimize investigator biases, researchers coding the second wave of audio stories were unaware of the results of the analysis of the frst wave of stories. Once the second wave analysis was carried out, results were reviewed by both teams, and similarities and diferences in outcomes using a constant comparative process were identifed.

Ethics
Approval. Study participation was anonymous and voluntary. Ethical approval was obtained by the institutional review board.

Demographics.
Tere were twenty-one audio stories submitted between November 11, 2020, and January 21, 2021. Te demographic and participant characteristics captured were age, gender, and role in patient care (see Table 1). Te participants ranged in age from 18 to 74 years old, with approximately one-half (54.2%) under 44 years old. Interestingly, there was 23.8% of respondents in the 55-64year age range and 9.5% in the 65-74-year age range. Tese groups from 55 years and over are approaching retirement age yet were working during this time. More women (61.9%) participated than men (38.1%).
Also, lastly, 71.3% of participants stated they were involved in some area of direct patient care: 19% a medical provider, 19% nursing, and 33.3% in the other healthcare provider category. Tis also included 19% in administrative roles. Many of the audio diaries included the roles participants were engaged in during their recordings.

Audio Stories.
Te qualitative analysis revealed four themes. Tey were as follows: negative emotional response/ impact, leadership/administrative failures, imposed or changing role expectations, and concerned feelings/statements of optimism and hope. Findings are summarized in Table 2. Teir stories revealed a rich tapestry of experiences, feelings, interpretations, and actions needed to be taken and how they adapted to the COVID-19 pandemic. Te following paragraphs display the range of statements found in each theme.

Negative Emotional
Response/Impact. Statements describing the intense emotions related to living and working in health care during the pandemic were found in this theme. Fifteen of the twenty-one diaries (71.4%) included words, phrases, and audible emotions. Statements from participants such as "it was a total nightmare" (diary #1), "most difcult time of my life" (diary #14), "it is stressful, every day is still stressful" (diary #10), and "lots of anxiety" (diaries #2, 5, 10, 12, and 16) were present. Audible emotions, such as deep sighing, pausing, and even being obviously choked up, were heard. Te following direct statements are included: "I don't think anyone who has not actually worked for 12  Also, another comment is as follows: "in the ICU it was very traumatic period. . .many times I was the last face people saw and I held their hand and talked to them before they were intubated. . .many of them did not survive" (diary#15).
Tese are examples of the feelings from healthcare workers, from their own lens, as they lived and worked during the COVID-19 crisis all the while trying to do their best.

Leadership/Administrative Failures and Concerns.
Te leadership theme captures the words and phrases regarding leadership responses 8-11 months after the onset of the pandemic. Seven diaries (33.3%) contained words or phrases expressing their thoughts on how leadership responded. Participants used phrases such as "mixed messages" (diary #5), "leadership response was a disgrace" (diary #9), "felt dissociated from administration" (diary #15), "seemed to be in the bunker" (diary #15), and "healthcare hero did not include all staf" (diary #10) as well as "felt hospital did the best they could" (diary #5).
Te deeper stories told a tale of negative perceptions towards healthcare leadership and administration. One participant shared: "the response of the hospital has been a disgrace. Tey have done nothing to keep the staf, the patient's, the doctors or providers safe. Tey've made this terrible pandemic worse in every way and fashion. We have to beg for the ability to get protective equipment. Tey've provided no universal testing, no clear guidance on how to deal with colleagues that are positive, and limited support, I'm completely disappointed" (diary #9).

Also, another stated:
"I felt very disassociated from administration because they seem to be in a bunker and put out information that oftentimes was false and misleading. Unfortunately, the anesthesia contract was canceled during COVID which made for really poor morale. Because of the administration's actions the environment has become more and more toxic period. It's an unfortunate period and believe I will have PTSD as a result of this experience" (diary #15).
Also, "Tere were mixed messages from the administration about when we were supposed to work and when we were to stay home. . .. I do not hate my hospital but the fallout always ended on the nurses" (diary #5).
While another stated:  Figure 1: Timeline of data collection correlated with COVID-19 cases in the health system.  Negative emotional response/impact related to living through and with the pandemic. Tese were found in the following words, phrases, and audible emotions Overall summary is that those closest to bedside care described (experienced) far more emotional, scary, fearful comments. Te audible emotions were apparent in tone, words, and language (i) "It was a total nightmare" (ii) Audible sighing and deep breathing as they told their stories (iii) "Most difcult time of my life" (iv) Used words such as "anxious," "PTSD," "depression," "increased stress, anxiety,  Tese are the stories of how participants perceived leadership's failure to communicate efectively and support all healthcare workers. Healthcare workers felt that they bore the brunt of care and that there was an expectation of something more from their leadership.

Imposed or Changing Role Expectations.
Tese statements uncover the awareness of the participants on how their own roles changed due to the pandemic. Some were deployed from their home area to other areas in the hospital, and others were asked to do other roles beyond their usual assignments. More were in usual roles with new or added responsibilities, and lastly, some were working remotely. Tere was an overall awareness of how their day-to-day lives, regardless of whether they worked in direct care or indirect care even including home life, changed. Seven of the diaries (33.3%) included statements that refected an awareness of how their roles changed. Te following displays the actual stories shared: Also, "I volunteered for a COVID unit and it defnitely brought us together as a work family. I volunteered on a unit I hadn't worked before and it didn't take long for them to make me, include me like family on the team. . .they were happy to have me" (diary #14).
Also, other role changes resulted from roles outside of the hospital. One story included

"I worked in the trades is very stressful because we did cut at this facility and it was hard and I had to do a lot of extra work at home to support my wife" (diary #21).
Tese statements all share how healthcare workers were aware of the signifcant changes in work roles, work assignments, and balancing home life needs.

Feelings/Statements of Optimism and Hope.
Tese were statements related to how their experiences had some measure of goodness. Teir stories revealed descriptions of what they learned, pride in how they coped, and positive personal outcomes. Acknowledging the magnitude of these moments, there were statements of hope for the future and optimism for positive outcomes. Nine of the diaries (42.8%) included statements related to hope and optimism. Words of hope related to vaccine development and maintaining positive personal outlook were found. Specifc statements are as follows: "there is more hope right now since the vaccine is available" (diary #13).
During these remarkable times, maintaining hope and optimism remains. Tese stories told us while many recognized the horror of caring for people during the COVID-19 pandemic, they were still able to look forward seeking a better tomorrow.

Discussion
Tese stories revealed the complex, multifaceted, and emotional response of healthcare workers in a wide variety of roles. Each audio diary contained at least one to three of the above mentioned identifed four themes.
Comparing the frst and second audio diary analyses from the larger study ofered the following insights [5]: First, there was a continuation of stories relating to both fear and hope. Te frst analysis labeled the themes as paradoxical. Paradoxical Teme 1: harsh work environment resulted in psychological distress, contrasting with personally rewarding experiences which aligned with negative emotional response/impact and feelings/statements of optimism and hope. It is unclear at this point what conclusions can be drawn from these results. One might suggest that each day brought a new challenge with no clear endpoint. Yet, it certainly demonstrates the deep impact of their perceptions, interpretations, and memories of living through a pandemic. Giving voice to one's experiences, fnding meaningful purpose, and maintaining hope during critical times in one's life are an essential coping strategy [6][7][8].
While the frst two themes appeared in the previous analysis during the frst wave of the pandemic [5], the themes of leadership failures and changing roles emerged during the second surge of the pandemic. Tough many studies also reported similar fndings related to the frst two themes, relatively few studies have highlighted leadership issues and changing role expectations during the pandemic [9,10]. It might be purported that it was so early in during the crisis that the priorities of care left little time for leadership to fully understand the role needed to lead and support the staf. As COVID-19 unfolded, the information and directions changed constantly as infections spread and death rates climbed. Te immediate focus was on PPE, stafng, isolation, or standards of care, and that was the leadership focus. Te staf's need for direction and support followed the awareness of changing roles as care needed to be adapted, stafng issues became more apparent, and resources were changed.
Leadership failures/concerns were not an expected result. Comments ranging from no clear guidance or mixed messages are overshadowed with more severe comments of "disgrace" to "toxic workplace." During times of crisis, people look to their leaders for direction, meaning making, and/or empathy [11,12]. Tese results revealed there was a perceived lack of direction, meaning making, and empathy displayed by their healthcare leader. For healthcare workers, these stories acknowledge the intense uncertainty that persisted, and yet, they still expected leadership to safely guide them.
Te literature refers to these unprecedented situations as "wicked problems" [13]. Wicked problems are defned as those problems with a social or cultural context that is difcult or impossible to solve for as many as four reasons: incomplete or contradictory knowledge, the number of people and opinions involved, the large economic burden, and the interconnected nature of these problems with other problems [14]. Clearly, healthcare workers perceived that their leadership failed in supporting their work as they were presented with many "wicked problems" from supply shortages, stafng, and a huge loss of life. It is not surprising that workers were confused by the day-to-day changes made in protocols, stafng, and processes or the challenges of keeping up with communication in a large system. Nonetheless, leadership must acknowledge these perceptions and address them up front to renew faith with their workers.

Te Benefts of Capturing Stories.
Te fallout from working during these times has resulted in poor morale, changes in quality standards, severe stafng shortages, and morale distress [10]. It is not about what is right or wrong but what comes next. Now is the time for leadership to take a breath and lean into addressing the concerns of staf so that the system can recalibrate towards a postpandemic world [15].
Tese audio diaries may have provided some therapeutic benefts for the staf responding by being able to put their thoughts into words and "get it out." Using the stories directly from healthcare workers opens an intimate lens to their experience "through their own eyes." From the researcher's perspective, hearing the audio recordings while reading the transcripts also ofered the ability to witness the participant's emotional prosody, the nonverbal tone of the speech, which includes loudness, speech rate, and pauses. Hearing the vast array of emotions added depth and clarity. Stories are powerful. Using stories, Bennett el al. [9] explored the impact of the pandemic on healthcare workers with similar results. Teir study was conducted within the frst wave of the pandemic and also identifed the disconnection between leadership and frontline staf. Other studies using stories during this time reported comparable themes related to emotional response, hopelessness, and hopefulness but no leadership concerns [9]. Furthermore, there is a belief that being able to articulate their own experiences with limited structure or judgement may be therapeutic to the storyteller [1].
Understanding healthcare workers stories today will allow leaders to address the concerns of healthcare workers for the future. Te frst step starts with the awareness of the issues. While these audio dairies captured a moment in difcult times, the awareness of the leadership failures correlates with the awareness of role change from frontline workers. Teir stories told us that the staf did not feel their leaders were present, gave clear messages, or displayed empathy. Protocols were changed rapidly, and social isolation contributed to the fragmented communication. Simply stated, healthcare workers' stories reveal not only a failure of leadership but also of an acute need for efective leadership. It is essential for leaders to use all tools available to address these issues as avoiding it will only increase the anguish of the lived experience from the pandemic [16]. Clearly, now would be a time for leaders to refect on what worked and what needs improvement.

Limitations.
Te study's limitations include a relatively small convenience sample from a single large healthcare system in the Midwest United States. Te sample size represented a wide range of healthcare positions, from intensive care staf to administrative roles. It is unclear how various roles difered in their experiences during the pandemic. It may only represent people who had a particularly distressing or rewarding experience. Respondents represented those who were comfortable and able to use the audio recording, and recording could be carried out in any location with an Internet connection. It is also unclear where and when the respondents chose to record their stories and how this may have infuenced their responses. Participants were able to sign in to recording their stories as many times as they wished; yet, no one signed in more than once or used the entire fve minutes for their story. Generalizability is limited.

Implications for Nurse
Leaders. Te audio diary study represents a small snapshot into the daily lives of healthcare workers captured through their own stories during the second surge of the pandemic. As the pandemic unfolded, understanding the changes in lived experiences allows for Journal of Nursing Management a better response in preparation should another healthcare crisis, however unlikely, occur. Te use of storytelling is a valuable tool to capture real-time thoughts, perceptions, and practices [17]. It allows for connection through discussions of shared experiences and adds to the growing body of knowledge, documenting the fear and emotional toll for healthcare workers, identifed avenues for hope, and fnally clearly revealed acute care leadership shortcomings [3]. Further research is needed as healthcare continues to address the multitude of the COVID-19 issues challenging healthcare systems.
While no one could have predicted a pandemic, not addressing the resultant fallout would be reckless. Te outcomes of the COVID-19 pandemic are complex and complicated. Addressing the impact from COVID-19 goes beyond developing new protocols or treatments. Te postpandemic healthcare world has created a cultural shift. One example is the severe nurse stafng shortage. Nurses remained at the frontline of caring for the very ill and were considered heroes by the public. Yet, the vaccine mandates forced nurses to resign, adding to the many other reason's nurses left the bedside [6]. New technology flled the gap as healthcare workers were limiting their exposure to infected patients, allowing for the telemedicine practice to emerge [18]. In regard to leadership, the current healthcare research and commentary is flled with suggestions on how leaders can motivate workers, how to recognize intent to leave, and negative perceptions about work place culture [19]. Carruci and Hogan [19] state that having meaningful conversations and focusing on priorities not on productivities are strategies that leaders can use to rebuild their teams. How does this relate to the audio diary study? Sharing stories can create connection. Looking forward to solutions for today's problems, storytelling, and shared experiences can create the opportunity for meaningful conversations, identifying priorities, and rebuilding teams.

Conclusion
While this is a small study, the results of this study are consistent with those of other studies that were conducted during this time [9,17,20,21]. As the COVID-19 pandemic moves into an endemic phrase, healthcare systems, leaders, and staf will begin to take a breath and begin the process of recovery, from a system perspective and a human perspective. Tese stories will serve as a powerful reminder as memories may fade and open up a new viewpoint for rebuilding. It is our hope that storytelling will become a valuable tool to increase understanding, process improvement, and hopefully healing.

Data Availability
Te audio diary data used to support the fndings of this study are available from the corresponding author upon request.

Conflicts of Interest
Te authors declare that there are no conficts of interest.