Into Action

Even before the US declared COVID-19 a national emergency on March 13, 2020, Villanova Nursing professors and students had begun hearing firsthand accounts from preceptors and clinical instructors, who urged students not to come to the hospital for their clinical practica.

Soon, the already overburdened health care workforce was beset with a catastrophe that even the most experienced among them had never before seen. In those early days, caseloads in health care facilities increased rapidly, adverse outcomes and patient deaths soared due to the absence of effective treatments, inadequate staffing led to extended work hours, and a shortage of PPE increased the risk of infection and transmission for essential workers.

Seeing a critical opportunity for Villanova to lead a study on the impact of the pandemic on front-line workers, Dr. Kaufmann, who conducted large-scale studies at the National Institutes of Health for more than 25 years, approached Dean Havens with the idea for CHAMPS. The dean, a passionate advocate and scholar who has conducted decades of research on the nursing workforce, nursing practice environments and quality care, wholeheartedly agreed. And together they set out to make it happen.

“We got involved in this study very early in COVID, and we knew how vital it was that we learn from this experience and contribute knowledge to inform future policy and public health strategies,” Dean Havens says. “In the midst of all that was going on at that time, we were able to engage so many outstanding researchers in the College of Nursing because they knew it was such important work.”

The initial steering committee helping to shape the study had 12 members with a wide range of backgrounds, including psychology, psychiatric mental health, qualitative and quantitative research, statistics, family health, and public health.

“It was a collective think tank,” says Linda Copel, PhD, RN, PMHCNS, BC, CNE, ANEF, NCC, CGP, FAPA, professor of Nursing. “People came at this from a variety of different perspectives.”

CHAMPS launched in May 2020, with financial support from Maureen ’84 FCN and John Lloyd; Travere Therapeutics Inc.; Molly and Stanton ’92 CLAS McComb and the McKesson Foundation; 1842 Day donors; and internal funding from the Fitzpatrick College of Nursing. The research design consisted of three components:

• A cross-sectional study of respondents who consented to participate in a single assessment of health
• A longitudinal study of participants who agreed to repeated waves of data collection so the researchers could look at how their responses and health changed over time
• A registry of participants who enrolled in the longitudinal study and agreed to be contacted for future ancillary observational studies and randomized clinical trials

“It’s no small feat that this all came together in a collaborative way with a sizable team that had lots of different ideas,” says Margaret Brace, PhD, ’04 CLAS, research assistant professor of Nursing, who is a statistician with a background in public health. She joined Dean Havens as a co-principal investigator on the study in 2022. “It’s amazing that this study was mobilized so quickly—that allowed us to capture some really vivid and important data from early on in the pandemic experience so that we could get that longitudinal view.”

Innovating and Educating

Over the course of 13 months, health care workers and first responders were recruited nationwide through many channels, including professional and trade groups, alumni societies, social media, news media articles and facilities that treated or interacted with patients with COVID-19.

CHAMPS investigators stopped recruitment in June 2021 after they had enrolled 2,762 participants, 1,534 of whom agreed to participate in the longitudinal study and the registry. They gathered four rounds of data—baseline data and three follow-up rounds.

“We decided to gather that data through a web-based survey that people could complete in less than 20 minutes so it wouldn’t interfere with their day-to-day work obligations, which were massive and ongoing,” Dr. Copel explains.

For the first year, the steering committee met weekly—initially, to organize the study structure and design and map out the methods they would use to collect the data, and later, to analyze the data and begin planning publications to share their findings. And at every step along the way, they took advantage of opportunities for learning.

“This study enabled us to capture a historic event in health care and in the work of health care professionals, and also to teach people within the college who had not been involved in research before what it meant to be involved with a large national research study,” Dean Havens says.

Jennifer Dean Durning, MSN, CPNP-PC, ’24 PhD, was one of those researchers. Coming into Villanova’s PhD in Nursing program in 2019, she had 19 years of clinical experience as a pediatric nurse practitioner—but she had never conducted research before.

She joined the team as a research assistant for CHAMPS just a few weeks after the study had launched. In addition to attending the weekly steering committee meetings, Dr. Durning assisted with carrying out literature reviews, developing survey questions, and ensuring the data was accurate and properly formatted for analysis, and she eventually helped with research and writing for journal submissions. Dr. Durning now has coauthored seven scholarly publications—four of which came from CHAMPS itself.

“It was definitely an excellent learning experience,” says Dr. Durning, an instructor of Nursing at Massachusetts General Hospital Institute of Health Professions in Boston. “In addition to the hands-on research work, it was so pivotal for me to be in a room with such accomplished researchers, to see how decisions were made.”

Telling the Whole Story

Initially, CHAMPS was envisioned as a quantitative study, but a few of the steering committee members thought it would be an ideal opportunity to capture other aspects of the front-line workers’ experiences through qualitative research. Quantitative studies rely on numerical or measurable data, whereas qualitative research is descriptive and typically involves personal accounts or observations.

“Qualitative research is really a love of mine because there’s a richness to the stories and experiences of people that gives life to the quantitative data,” says Dr. Copel. “It also gave front-line workers an opportunity to be heard.”

They added two qualitative elements to the survey:

• A single, open-ended item: “If you wish, please describe your experiences during the COVID-19 pandemic in as many words as you need.”
• A question toward the end that asked, “Would you be willing to participate in a qualitative interview?”

The data they gathered from these two items informed three different journal publications: a thematic analysis of the qualitative interviews in the International Journal of Qualitative Studies on Health and Well-being; a thematic analysis of the free-text responses in PLOS One; and a thematic analysis of free-text responses that looked specifically at the experiences of new nurses in the International Nursing Review.

A total of 1,079 participants—nearly 40%—answered the open-ended item; the vast majority were nurses, and about 75% of them worked in hospital settings.

The length of the typed responses ranged from one or two words to 1,407 words. “We had one participant type out eight pages in response to that one open-ended question, and that was very, very moving,” Dr. Copel says. “The fact that these workers took the time to respond amid everything that was going on is important.”

The COVID-19 pandemic substantially exacerbated already high levels of burnout and negative psychological consequences among health care workers, and the studies revealed major psychological and physical stress among essential workers.

A thematic analysis of the open-ended responses identified four major themes: facing hopelessness, yet looking for hope; witnessing frequent death; experiencing disillusion and disruption within the health care system; and suffering from escalating emotional and physical health problems.

“The qualitative stories really impacted most of us,” Dean Havens says. “What stuck with me was a quote in one of the papers from a health care worker who explained how they felt like they had gone from being heroes to zeroes within a matter of months. At first, everybody cheered when they left work and congratulated them, and then, as the months wore on, they felt forgotten.”

In addition to that qualitative data, CHAMPS study participants provided self-reported information about their demographics and work environment, physical and mental health, and psychosocial factors. Follow-up questionnaires were administered at six-month intervals to ascertain changes in health, well-being and lifestyle based on measures of anxiety, depression, traumatic distress, insomnia and burnout.

That information helped to quantify the extreme physical and psychological toll health care workers were experiencing during that time. For instance, hospital-based registered nurses in the US exhibited over twice the rates of trauma and nearly double the rates of depressive symptoms than hospital workers globally reported during the acute phase of the pandemic, according to cross-sectional study results that the CHAMPS investigators published in Applied Nursing Research.

“I did not expect the level of depression, post-traumatic stress disorder, eating issues—just the devastation that many, many health care workers experienced during the crisis,” Dean Havens says. “We collected data for two years, and even at that point, some of the participants were still exhibiting high levels of trauma and depression, and considering leaving the profession entirely.”

The Work Continues

The CHAMPS data—quantitative and qualitative—adds to a growing body of research that is just beginning to look at the pandemic’s long-term implications on the future of the health care workforce, particularly for nurses. A 2021 nationwide survey conducted by the American Association of Critical-Care Nurses found that 92% of nurses stated the pandemic would cut their careers short. A 2023 study from the National Council of State Boards of Nursing helped to quantify that, reporting that approximately 100,000 nurses in the US left the workforce due to stress, burnout and retirements in the first two years of the pandemic, and more than 610,000 nurses reported an intent to leave the workforce by 2027.

“Without nurses, who’s going to take care of us?” says Rachel Baskin, RN, CPN, '19 MSN, a doctoral student in Villanova’s PhD in Nursing program. “We’re already in a nursing shortage, and we can’t afford to lose any more nurses, so it’s critical to identify the effects of working during the pandemic on the nursing workforce. We want to be able to address these issues and identify proactive measures health care institutions can put in place.”

Baskin will be using the CHAMPS data to explore those effects in her dissertation. Some of the questions in the study touched upon whether participants had exposure to previous traumatic experiences before COVID-19, and whether they felt they had adequate staffing, equipment and support during the pandemic.

As part of her statistical analyses of data, Baskin will look into whether any of those factors contributed to worse mental health outcomes. “We can absolutely prevent some of those things,” Baskin says. “We need to be asking, how can we address any lingering effects of working during COVID that caused issues with our health care workers? And what can we learn from our mistakes during COVID to provide them with better support in the future?”

She’s currently in the process of analyzing the CHAMPS data and putting together her dissertation for a final defense in the fall.

“The longitudinal registry component sets this study apart from others,” Baskin says. “We have this really unique data set available to us to give us this information of how certain behaviors and indicators of mental health changed across time as the pandemic fluctuated.”■

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Questions may be directed to Margaret Brace, PhD, research assistant professor in the M. Louise Fitzpatrick College of Nursing, who now serves as the CHAMPS study’s principal investigator, at margaret.brace@villanova.edu.