Enforcing the rules versus 'doing what’s right':
Lived experiences of labour and delivery nurses in the context of COVID-19
Michelle Grafton | University of the Fraser Valley

Introduction

Results

o Since the advent of the COVID-19 pandemic in March of 2020, healthcare workers all over the
globe have seen their work change drastically.

PPE & Protocol

Increased Labour

Nurse/Patient Relationship

Psychological Tolls

o Among this group are labour and delivery (L&D) nurses, responsible for the care of pregnant
women and newborns during pregnancy, labour, and immediately after childbirth.

Changes in protocol
o Visiting rule restrictions – only
one person, who cannot be
switched out
o All patients screened for COVID
o Anyone with a temperature
treated as COVID-positive until
proven otherwise
o Babies may be separated from
mothers whose COVID results
are pending
o No pre-shift meetings

Emotional labour
o Emotional labour refers to emotion required in
the course of an occupation9
o Support person restrictions result in nurses
providing more emotional and mental support
for patients whose partners are unwilling or
unable to provide that support

Importance of the nurse/patient connection
o The most enjoyable and fulfilling part of the
work
o The relationship as inherently emotional,
supportive, and physical during labour

Moral injury
o Moral injury occurs when people are forced to act or behave in ways that
conflict with their moral beliefs, causing inner conflict10

o Although L&D nurses make up only a small portion of healthcare workers, they play a unique
and vital role caring for some of the most vulnerable members of our society.
o The pandemic and its accompanying restrictions are particularly posed to affect the work of
these nurses, whose relationships with patients typically involve close personal contact as
well as mental, emotional, and physical support – especially vital during the labour and
birthing process.1
Objective: This qualitative pilot study aims to understand how the everyday lived experiences of
labour and delivery nurses has changed in the context of the COVID-19 pandemic.

“We used to always – you get on shift,
and everyone sits in the room to do
report together. Whereas with COVID,
because they don't want so many people
in a room, there's no report, so you just
go and find your chart and do your thing.
But then there's no… You don't feel like
you're starting as a team..” –Claire

Background
o The pandemic has had significant psychological effects on healthcare workers, as well as
considerably altered the policies, procedures, and responsibilities involved in their work. 2,3,4
o Previous pandemics and epidemics have taken a heavy psychological and emotional toll on L&D
nurses and other healthcare workers.5
o Even outside of the pandemic, L&D nursing in particular involves a significant amount
of emotional labour, intense nurse-patient relationships, and ethical dilemmas.1
o L&D nurses have rarely been the topic of qualitative study in Canada prior to the pandemic,6 and
no qualitative research has yet been conducted in Canada since the advent of COVID-19. This
study aims to initiate the process of filling this gap in knowledge.

o An in-depth understanding of how the everyday work of L&D nurses has been transformed by
COVID-19 allows for the identification of ways to better support these nurses in their vital work.

Methods & Methodology

o Minimal risk study
according to TCPS2
guidelines8
o Informed, voluntary,
ongoing participant
consent

Participants
Recruited

Method:
Interviews

o Three L&D nurses
o Data collected
recruited through
through in-depth,
personal contacts
semi-structured
o Pseudonyms used to
interviews of
protect participant
approximately one
anonymity
hour

“Patients can feel a little bit lost without their mom, or
they feel like they're missing that… yeah, that motherly
presence. And so then you have to be not just doing
your job, but also kind of like the replacement de facto
mom for the day.” –Kelsey

Thematic
Analysis

o Thematic analysis
to analyze data
o Data coded and
sorted into broad
themes and subthemes

"I feel like I come across a lot less encouraging, when
they can't really see my face, they can't see my
expressions as much. It just, it makes the whole thing
so much more… hospitalized." –Taylor

o Nurses play 'motherly role' for those patients
missing their mothers during labour
o Nurses are constantly reassuring patients who
are fearful or frustrated with COVID or
accompanying protocols
Responsibilities
o Following all COVID protocols is an added
responsibility
o Taking on the additional role of ‘rule enforcers’,
ensuring patients also follow COVID protocols
o Increase in menial tasks, such as retrieving food
and water for patients, due to COVID protocols

Time
o Takes longer to get ready for shift because of
increased precautions/changes in protocol
o Protocols increase the amount of time and
energy it takes to do tasks in general

Discussion & Implications

Phenomenology is a qualitative methodology that seeks insight as to the subjective, lived
experiences of individuals, focusing on understanding how they interpret their reality in terms
of the meanings they attach to the world around them. 7

Ethics
Approval

PPE Precautions
o Nurses must wear masks in the
hospital at all times
o Nurses must wear masks,
goggles, gowns, and gloves
whenever interacting with a
patient
o All patients and support people
must wear masks at all times,
except for patients when they
are in labour

Masks as relational barriers
o Increased PPE precautions as barriers to
connection with patients
o Masks in particular seen as a significant barrier
because they cover the face and hide facial and
emotional expressions, including smiles

o This study illustrates the extent of the changes and challenges
experienced by L&D nurses in the context of the COVID-19 pandemic.
o Nurses are working under exhausting and time-consuming precautions
and protocols. The emotional labour, physical labour, and responsibility
required of them at work has increased. PPE protocols have put up a
relational barrier between nurses and their patients.
o The increased psychological toll on L&D nurses has concerning
implications for mental health:
o Exhaustion is a strong predictor of burnout at work, which is also
associated with mental health conditions such as depression and
changes in work such as decreased productivity. 11
o Lack of fulfilment at work is associated with depression, decreased
work satisfaction, and other negative mental health outcomes. 12
o Moral injury is strongly associated with negative health outcomes in
the realms of PTSD, depression, and anxiety. 13
o Conflictual communication as demonstrated by hospital administration
is associated with both increased stress in nurses and decreased
desire to stay at nursing jobs long-term. 14

o Masks as not just physical, but emotional and
relational barriers loosening the connection
between nurse and patient
o There are less births where nurses feel ‘let in’
by the patient

Maintaining connection and intimacy
o Despite barriers, the intimate and personal
nature of labour is maintained to some degree
o Still feel able to make a significant emotional
connection with patients in some cases

“There are certain rules that we’re supposed to keep, but there's also certain times
where you feel like those rules should be… bent is the wrong word. But you feel like
there should be an understanding for the fact that maybe this isn't the time to say
that her husband can't be in the room for this really stressful time. So that part, I
mean, is just an example of us having to kind of be the mitigators of the
rules versus balancing out what's right.” –Kelsey

o Forced to decide between following official protocols and bending rules
to provide the best care for the patient – following rules versus
'doing what’s right'
o Separating mothers and newborn babies when mother’s COVID results
are pending
o Denying labouring women their requests for their mothers to be present
o Enforcing rules prohibiting the switch-out of the support person
o Treating patients as COVID-positive when they know they likely aren't
Burnout and exhaustion
o Exhausting to constantly ensure patients and self are following protocols
Feelings of loss
o Loss of teamwork - work has become more solitary
o Loss of intimate emotional connection with labouring mothers or new
parents in some cases
o Loss of enjoyment and fulfillment in work
o Loss of gratitude and appreciation in day-to-day work
Uncertainty and frustration
o Uncertainty and frustration regarding lack of communication and everchanging protocols on the part of administration
o Frustration over a lack of a proper mental health day

Proposed Interventions
Schwartz Rounds

Improved communication

The individual counselling currently
offered by hospitals is not specific
to COVID-19, and nurses would
rather debrief with other nurses.
Schwartz Rounds are guided forums
that would allow nurses to reflect
on shared experiences and support
each other. 15

Communication between
administration and nurses needs
to be improved.
This could be accomplished by
informing nurses in advance of
any policy and protocol changes,
and possibly asking for nurse
input before policy finalization.

Mental health days

Additional research

Implementing a proper mental
health day would serve both to
improve nurse well-being16 and
as a way for administration to
identify and provide additional
help to nurses who are struggling
with mental health.

Additional research must be
conducted on L&D nurses to
further understand how their
working lives have been affected
by the pandemic so that
appropriate interventions can be
identified and implemented.

References
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