Since late 2019, the novel coronavirus disease 2019 (COVID-19) has remained a global threat, with a continuous surge in the number of new infections, fatalities, and the emergence of new variants. As of July 2023, approximately 767.6 million individuals worldwide have contracted COVID-19, with 6.9 million deaths reported, and these figures continue to increase [1]. Similar to other countries, South Korea (hereafter referred to as Korea) has suffered substantial human loss and socioeconomic burdens from the pandemic, with 35,000 deaths attributed to COVID-19 [2]. Moreover, since 2019, COVID-19 has posed a formidable challenge to the healthcare workforce in Korea, as they have been working diligently to prevent the spread of the virus and to care for patients with confirmed or suspected infections. Korean healthcare professionals (HCPs) have been appreciated for their professional efforts and dedication in combatting the infection, with the public referring to them as heroes and angels through the “Thank You Challenge” [3]. Despite this recognition, Korean HCPs still faced diverse hardships that cannot be easily alleviated by expressing gratitude and encouragement from the public.

Among the various HCPs, nurses have been at the frontline in providing direct care to patients during the pandemic. Consequently, they have suffered from physical and psychological symptoms, including posttraumatic stress disorder, depression, physical fatigue, and skin problems [4, 5, 6], resulting from constant and close contact with infected patients. Moreover, nurses encountered various difficulties, including increased workloads due to caring for high-acuity patients, job-related stress resulting from inadequate education and staffing for patient care, and insufficient provision of personal protective equipment (PPE) by institutions [4, 5, 7]. These issues can lead to decreased coping abilities and job satisfaction and increased turnover rates among nurses [8]. Consequently, this scenario presents a significant concern for the nursing workforce and public health.

Globally, an increasing number of studies have examined the impact of the COVID-19 pandemic on the nursing workforce. During the initial phase of the pandemic, most studies focused primarily on the physical and psychological health of nurses, their workload, infection risks, and control measures [9, 10, 11, 12]. Subsequently, researchers explored how the pandemic affected nurses’ roles, their interactions with other healthcare professionals, and operations and support within healthcare organizations [13, 14, 15]. However, most studies have been conducted within a single country, and evidence comparing nurses’ experiences and the corresponding changes in organizational operations and professional roles across different countries is limited. Given Korea’s renowned reputation for well-established preparedness and management protocols [16, 17], exploring the perspectives of Korean nurses regarding work during the pandemic is particularly relevant.

Korea has a universal health coverage system and is a high-income country [18]. Compared with other Organisation for Economic Co-operation and Development countries, Korea has exhibited a significantly lower number of COVID-19-related deaths without stringent lockdown policies [17]. Previous qualitative studies have described the perspectives of Korean nurses working during the pandemic, encompassing various clinical settings including hospitals temporarily closed due to the pandemic [19], screening clinics [20, 21], emergency rooms [22], and long-term care hospital [23]. However, most of these studies were conducted in a single hospital or a few hospitals, which limits the generalizability of the findings. Moreover, the sample sizes in previous studies were small, ranging from 8 to 21 participants [4, 21]. In addition, limited aspects of nurses’ work experiences have been identified. For instance, while prior studies have mentioned the discomfort of wearing PPE and the excessive workload [6, 24, 25], little attention has been paid to nurses’ interactions with other professionals and operational and structural changes within their organizations during the pandemic. Thus, there is a need for scientific evidence of how organizations have adapted their operations and how nurses’ roles have evolved in response to these changes within Korea’s universal healthcare system.

This study was designed to capture the perspectives of nurses working at hospitals in Korea during the pandemic. This study was part of an international study that sought to capture nurses’ perspectives on their workplace and clinical practices across the world. The international comparative research to which this study belongs was initiated by the New York University (NYU) College of Nursing [26]. Researchers worldwide joined this research consortium, and this is the only study that represents a Korean sample. A comprehensive exploration of nurses’ perspectives on various aspects, from a personal to the organizational level, will help us assess the changes implemented and identify persisting problems. Such an understanding will aid in better preparedness for future pandemics. Lessons learned from the perspectives of Korean nurses during the pandemic may also prove to be beneficial for other countries.

A total of 145 responses were collected. However, 19 incomplete responses (only the screening questions were completed) and three duplicate responses were noted. The final sample size for the analysis comprised 126 participants. More than 80% of the participants (n = 104) were aged 20~39 years. Most participants were female (n = 111) and had a bachelor’s degree (n = 102). Forty-one participants had nursing experience of 0~3 years (32.5%). Most nurses provided direct care to adult patients in specialized units, including intensive care units, emergency departments, and operating rooms. Table 1 summarizes the participants’ characteristics.

Table 1
Characteristics of Participants (N = 126)

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Six themes related to nurses’ perspectives on work during the pandemic were identified and organized at the personal, task, and organizational levels (Figure 1). In this study, the personal level involved the personal lives of nurses, including their relationships with family, friends, and others. Meanwhile, the task level was related to their work, and the organizational level involved where they worked, including their organization’s structures and operational procedures.

Figure 1
Perspectives of frontline nurses working during the COVID-19 pandemic.
PPE = Personal protective equipment; COVID-19 = Novel coronavirus disease 2019.

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This study explored the perspectives of Korean frontline nurses during the pandemic using a combination of machine-based network analysis and summative content analysis. A comprehensive understanding of the nurses’ perspectives was obtained by exploring their personal lives, roles, responsibilities, organizational structures, and workplace operations. This information can be used to develop a more supportive work environment for nurses during future pandemics.

The personal-level theme was consistent with previous literature, indicating that the pandemic posed a risk to nurses’ personal lives as it restricted their daily activities and heightened their concerns about infecting their families [21, 22, 42, 43]. The impact of the pandemic on their personal lives has led some nurses to experience anxiety and depression [19, 21, 42]. Despite numerous domestic and global reports on the personal challenges faced by nurses, there is a paucity of research examining their coping mechanisms and how the pandemic has affected their families. Therefore, further exploration of these topics in future research is warranted.

Our findings indicate that at the task level, nurses encountered challenges due to the inadequate quality of PPE provided by their organizations and the overwhelming number of responsibilities they were expected to fulfill. Despite the crucial role of PPE in protecting nurses and patients, our findings revealed that the quality of PPE provided to frontline workers was inadequate. Similar findings have been reported in other studies [22, 44], indicating that concerns about PPE extend beyond its mere provision to include its quality; it is crucial to improve the quality of PPE to ensure a safer working environment. Nurses reported an increase in their roles and responsibilities during the pandemic, which aligns with previous studies [5, 6]. Our findings indicate that nurses were tasked with new responsibilities such as medical waste management, formal caregiving, nurse aiding, and supply management, which are not traditionally considered professional nursing roles [5, 6]. Moreover, hospitals worldwide implemented restrictions on visitors [45], leading to additional responsibilities for nurses such as providing meal assistance, making continuous calls to family members, educating families, and providing emotional support to patients. Although these restrictions effectively prevented transmission and infection, they heavily burdened the nurses [5, 6, 19, 45]. Thus, organizational support is necessary to enable nurses to care for patients while minimizing the risk of infection. In addition, nurses dispatched to COVID-19 units had to acquire new knowledge and skills to effectively care for patients with varying conditions, irrespective of their previous work experience. The expanded and challenging roles observed among Korean nurses were consistent with reports from other countries, including China, Singapore, and the US [26, 46, 47]. Our study suggests that COVID-19 units should consider the nature of nurses’ roles when assigning duties and provide adequate training and support to help nurses adapt to their new responsibilities.

In this study, changes in the structures and operations of organizations in response to the pandemic were identified within the organizational-level themes. One interesting, the theme of interprofessional collaboration yielded inconsistent statements among the participants. While some reported positive experiences of constructive communication and effective teamwork with other professionals, others encountered conflicts, primarily due to concerns about infection. This inconsistency in nurses’ statements regarding interprofessional collaboration aligns with the findings of other studies conducted in Korea and the US [21, 26, 42, 14]. Given the critical importance of interdisciplinary collaboration in the functioning of healthcare facilities, further investigation into organizational changes related to interprofessional collaboration is warranted.

This study highlights the importance of effective workforce management in response to the pandemic. The theme of workforce management has revealed systemic issues in the current healthcare system in Korea, including a shortage of nurses trained to care for COVID-19 patients, sudden deployment of nurses, and frequent shift changes with short notice periods. These factors can contribute to stress and a sense of helplessness among nurses, ultimately leading to lower quality of care due to inadequate preparation time [26]. While it may be challenging to anticipate every situation during a pandemic [48], it is crucial to recognize that nurses’ unpreparedness can significantly impact patient outcomes. Therefore, it is essential to develop flexible and situational strategies for workforce management, including the recruitment, arrangement, and retention of workers, while allowing sufficient preparation time.

As reported by our study participants, hospitals implemented new facilities exclusively for COVID-19 patients and established dedicated COVID-19 isolation units. However, the sudden or rapid redirection of health services and resources to control and manage COVID-19 has presented challenges for nurses, as they had to adapt to these changes quickly. Abrupt diversions, without timely and appropriate notice, can impose significant burdens on nurses as they strive to adjust while providing patient care [49]. Additionally, units unrelated to COVID-19 may encounter difficulties in supplies and staffing provisions due to the establishment of new facilities [49]. Therefore, it is crucial to strike a balance between establishing new healthcare facilities and maintaining the existing ones. Further investigations are warranted to develop flexible and situational strategies to promote this balance. Furthermore, the themes related to organizational change emphasize that structural and operational improvements should be developed to prepare for future public health emergencies [6, 19, 48].

As previously mentioned, multiple countries participated in this international comparative study and conducted their own studies using the same research tools as this study [26]. Currently, only data from the US have been published [26], enabling a comparison with data obtained from Korea. Discussing perspectives on the changes in nursing roles, redeployment, and interprofessional collaboration in these two countries is relevant. In both countries, staff nurses were required to perform a wide range of work tasks, including cleaning, waste management, laboratory work, and assuming the roles of nursing assistants and clerical staff. This was observed in general wards and intensive care units. One difference between the two countries was the role of advanced practice nurses. In the US, advanced practice nurses were able to work more efficiently because of the lifting of restrictions on their scope of practice during the pandemic, driven by workforce shortages [26]. However, as Korea does not have an officially legalized advanced practice nurse system, changes in the role of advanced practice nurses could not be identified.

Furthermore, nurses in both countries expressed concerns about redeployment. Many nurses were reassigned to units with higher acuity, different patient populations, or different practice areas compared with their previous units, often working alongside dispatched nurses. They consistently reported that they were assigned without sufficient training or support. However, US nurses associated this issue with increased risks at work stemming from a lack of experience and compromised patient safety [26], while Korean nurses were more concerned about frequent changes in work shifts and a lack of day offs. This disparity may be attributed to the fact that the largest group (31.0%) of participants in the US study [26] consisted of highly experienced nurses with 11+ years of experience, whereas that in the Korean study consisted of nurses with less than three years of experience (32.5%). Moreover, the mean age of all Korean participants was 32.4 ± 7.6 years, representing a generation that values work-life balance. Further investigation is required to understand the divergent perceptions of redeployment. Moreover, nurses in both countries mentioned the positive and negative aspects of interprofessional collaboration. Positive aspects included increased respect, bonding, and improved patient care. Negative aspects included conflicts with physicians who were concerned about the risk of COVID-19 infection and were reluctant to visit patients in their rooms [26]. As physicians conducted assessments and provided care from outside the room, nurses in both countries were obligated to remain inside the room to provide the necessary direct care to patients, thereby making them more vulnerable to COVID-19 infection [26].

In this study, the combination of machine-based text network analysis and traditional content analysis provided several distinct advantages from a methodological standpoint, extending beyond the mere presentation of qualitative research in a more scientific manner. First, text network analysis allowed us to identify key concepts, themes, and their interconnections within nurses’ descriptions, providing a visual representation of the complex network of perspectives expressed by the participants [35, 36]. This approach helps uncover potential clusters or key concepts that may have been overlooked using traditional qualitative analysis alone. Traditional content analysis complements this analysis by including depth and granularity. This involves systematically categorizing and summarizing textual content in a context [37]. By organizing and condensing the data into meaningful categories, summary content analysis facilitates a more comprehensive understanding of the nurses’ perspectives, ensuring that vital information is not overlooked.

Moreover, combining these two methods presents a powerful approach to data analysis in an international comparative research context. It enables cross-country comparisons and an in-depth exploration of each country’s data. Text network analysis contributed to the identification of similarities and differences in emerging themes across countries, facilitating a broader understanding of the experiences of the global nursing workforce during the pandemic. Summative content analysis provides a comprehensive contextual understanding of the distinct aspects and variations within the data from each country. Additionally, it considers the cultural, societal, and contextual factors that may influence nurses’ perspectives. Ultimately, this integrated methodological approach enhanced our understanding of the complex and multifaceted nature of nurses’ experiences during the pandemic in an international comparative context.

This study has several limitations. First, the generalizability of this study’s findings may be limited to nurses working in hospitals and may not extend to other healthcare settings, such as outpatient medical offices, community health centers, and residential treatment centers. Second, the cross-sectional data collection method used indicates that the timing of data collection may have influenced the findings. Finally, the use of network analysis and summative content analysis in this study may have overlooked less frequently mentioned opinions and may have been subject to the researchers’ subjective judgment throughout the analysis process.

Nevertheless, this study provided valuable insights into the perspectives of frontline nurses regarding their work during the pandemic at the personal, task, and organizational levels. These findings can inform the development of comprehensive strategies to provide better working conditions for nurses. Methodologically, this study combined traditional and machine-based analyses, which are validated through an iterative process. Additionally, the study used an online survey for data collection and demonstrated the potential of this method for qualitative studies, despite the preference for face-to-face data collection.

Frontline nurses play a critical role in providing comprehensive care to isolated patients with COVID-19. This online qualitative study was conducted to explore the perspectives of frontline nurses working during the COVID-19 pandemic using a pragmatic approach that combined traditional and machine-based analyses. As a result, six themes emerged at the personal, task, and organizational levels: Nurses’ personal lives have been negatively impacted, and they frequently face heavy workloads and stress primarily due to insufficient support. This study highlights the necessity of enhancing personal, professional, and institutional areas to effectively respond to the pandemic and guide improvements in resources, systems, and policies to prepare for future pandemic situations.