Author ORCID Identifier


Defense Date


Document Type


Degree Name

Doctor of Philosophy



First Advisor

Patricia Kinser


Aim: To explore the lived experience of intensive care unit (ICU) nurses and physicians - health care providers (HCPs) - during the first year of the COVID-19 pandemic and to use their experiences to begin to elucidate vulnerabilities, social patterns, norms, policies, and practices in need of systems-level reform within the U.S. healthcare system context.

Background: The novel coronavirus, SARS-CoV-2, and its associated respiratory disease, COVID-19, emerged in late 2019, spreading rapidly throughout the world as a global pandemic and becoming one of the most serious and deadly emerging infectious respiratory diseases of the modern era. COVID-19 is one of only a handful of emerging infectious respiratory disease pandemics to impact the United States in the past century. COVID-19 quickly overwhelmed critical care capacity, supply chains, and the health care workforce.

Design: A qualitative phenomenological approach was used to explore frontline ICU HCP experiences working in a medical respiratory intensive care unit (MRICU) and providing care for patients with COVID-19 at a large, urban, academic medical center during the first year of the COVID-19 pandemic.

Methods: ICU HCP lived experience was explored using a phenomenological approach within a socioecological framework. In-depth qualitative interviews (n=11) were conducted with ICU nurses (n=9) and physicians (n=2) from September 12 to November 12, 2020. A modified Stevick-Colaizzi-Keen method was used for inductive thematic analysis and identification of common themes.

Results: Results show two overarching experiences of ICU HCPs during the COVID-19 pandemic: First, participants experienced on-going, chronically distressing events while working in an intensive care unit during the first year of the COVID-19 pandemic. These experiences are highlighted through five themes, which are analogous to morally injurious events: (1) betrayal by individuals and systems; (2) patient harm and death within crisis standards of care; (3) overwhelm in the face of disproportionate harm and death related to COVID-19 itself; (4) concerns about erosions to family-centered care; and (5) nurses feel expendable. These morally injurious events occurred at multiple socioecological levels, predominantly from systems-level factors. Second, participants described an additional overarching experience centered on the concept of being “in the room” of patients with COVID-19. Themes were identified within three major socioecological levels: (1) within inter- and intra-personal contexts of (a) feeling trapped in another world, (b) nurses doing all jobs on the frontline, (c) nurses behind the glass doors; (2) within the healthcare system context of (a) power dynamics and (b) nurses/ patients being invisible in the room; and, (3) within a societal context of perceiving COVID-19 and patients as invisible. HCP participant experiences during the COVID-19 pandemic illuminate underlying patterns of gendered relationships and organization.

Conclusions: This study demonstrates that participants experienced chronically distressing events and related sequelae while working on an ICU during the first year of the COVID-19 pandemic. These experiences were interpreted within two frameworks: moral injury and gendered occupation. ICU HCPs experienced morally injurious events during the COVID-19 pandemic that are analogous to those previously documented in military populations. Participant experiences also revealed that hierarchical and gendered organizational structures within the healthcare system had a negative impact on HCPs during the COVID-19 pandemic, particularly on nurses. Systems-level norms, policies, and practices in need of reform were identified from HCP experiences and recommendations are given to improve systems-level responses to future public health crises. Consideration of HCP lived experience is imperative to ethical responses that address system vulnerabilities and injustices. The ICU HCP experience provides crucial information as we plan for the future of healthcare in the U.S., particularly in the context of new SARS-Co-V-2 variants, additional COVID-19 surges, and the inevitability of new emerging infectious diseases.


© Heather M. Fudala

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VCU University Archives

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VCU Theses and Dissertations

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Available for download on Thursday, April 29, 2027