The COVID-19 pandemic is responsible for a variety of emotions, including fear, anxiety, anger, sadness, despair, and grief. But as a member of a nurse educator team for three pop-up “surge” ICUs, I feel those six emotions don’t even begin to explain what we have seen our team experience every day.

The fear, anxiety, and anger are always first. These three ICUs were created by taking nurses from the post-anesthesia care unit, endoscopy, interventional radiology, cardiac cath lab, same day surgery, Mass Eye and Ear Institute, North Shore Medical Center, and anesthesia. The last time most of these nurses worked in an ICU or ED was anywhere from 3 months to 22 years ago. Some have never worked as an ICU or ED nurse or did it briefly before becoming a certified registered nurse anesthetist (CRNA). Now they’re being asked to take care of patients with a diagnosis they have no experience with. To make it just a bit more unsettling, they have to learn to document on the fly in the inpatient electronic health record (EHR) platform, which differs from that used in their “normal” nursing worlds. So yes, I see lots of fear, anxiety, and anger in their eyes, words, and actions in the beginning…and it’s understandable.

The sadness, despair, and grief all come later. These emotions are expected when we are caring for critically-ill patients, some of whom will not recover. The problem isn’t that the team experiences these emotions, it’s that they come in between so many other positive ones, causing a rollercoaster of highs and lows. After just a few shifts, you see the confidence building. The nurses are manipulating the equipment more adeptly, they no longer ask where supplies are located, and the volume of chatter in the unit goes down significantly. They listen intently during rounds to learn more about coronavirus pathophysiology and signs and symptoms to worry about. They start to bond with their team members. Each day they’re paired with a different general care nurse, who also is new to the unit and the role they have been put in. Yet, the pair takes some comfort from knowing that they’re in this together. You can see in the nurses’ faces and interactions that they are feeling more confident and competent, but then the patient takes a turn for the worse, and the emotions come crashing down again.

Once these nurses get “comfortable,” having done three or four shifts in the same ICU, they may be placed in a different ICU to take care of neuro or surgical ICU patients, as well as COVID-19 patients. The learning process starts all over again. The rollercoaster wave of anxiety returns as they get paired with different nurses each day and learn a new area and patient population.

The first 4 weeks of these units were chaotic, with new staff coming from all over to be oriented each week. The nurses are learning so much each day and so their focus is hypervigilant on what is in front of them. Rarely are they able to look up and see what others are experiencing. As a nurse educator, I was privy to a different focus and more of a global view. Looking around, I see…

Snapshot: A nurse is trying to chart in the EHR and is complaining to all who can hear about using the new platform. I see one of our e-Care specialists make her way over to assist. She stays calm and offers guidance while still letting the nurse vent her frustrations. She is patient in her interactions and I feel relieved to have so many e-Care specialists here for support.

Snapshot: A nurse in one unit is taking holy water from the chaplain and learning how to bless her patient who is now comfort measures only. She and her nurse partner for the day are prepping the patient so that his family can be with him while they withdraw the medications that are stabilizing his blood pressure. He passes peacefully while his wife sobs and his daughter, quietly and stoically, rubs her mom’s shoulders. After the family leaves, I offer to help the nurses with post-mortem care, but they decline and quietly do it with each other. They have no idea that just around the corner…

Snapshot: Two nurses are cheering as their patient gets extubated and smiles. They air high-five each other and I give them colorful dry erase markers to celebrate the occasion by drawing balloons and gold stars on the patient’s glass doors. They have no idea that around the corner a wife and daughter just said goodbye to their loved one or that two of their colleagues are internalizing their grief while they do post-mortem care. When they find out later in the shift, they feel guilty that they had such a positive day in the ICU, while their colleagues did not.

Fast forward 1 week and we are past the “surge” in Massachusetts. Our ICU numbers have declined and we officially close one of these three ICUs. Everyone has fallen into a routine in their new roles. Patients are improving every day and we are seeing more successful extubations, tracheostomies, and transfers to the step-down units and floors. The nurses are laughing with their neighbors who are caring for the patient on the other side of the hall. The bonding of all these different teams is evident everywhere you turn. And then it happens…

Snapshot: A surgical ICU patient keeps dropping his pressure and becomes coagulopathic. His two nurses never leave the room all day as they hang one blood product after another, increase the dose of norepinephrine bitartrate, and wait to hear if he will return to the operating room. Meanwhile, two doors down…

Snapshot: The family and chaplain are here as a patient gets extubated. Everyone is uncertain if the extubation will be successful and have agreed to let nature take its course. Surprisingly, an hour later, he is doing great! Across the hall…

Snapshot: Four nurses suddenly hear that this is their last week in these ICUs because the off-site surgical center they work at is reopening. They cheer and smile and pose for pictures, then suddenly start to tear up. They realize they will be leaving all these people they have bonded with, many of whom are now considered friends. This shared experience, though difficult, has touched them deeply and they struggle with straddling between excitement and sadness. Finally, down the hall…

Snapshot: Other ICU nurses look at the four nurses longingly with envy. They wonder how much longer before they will return to their home base. How many more night shifts? How many more weekends? What will their normal job even be like when they return, since so many patients have been waiting for their procedures for months? An alarm goes off, so they push their feelings and questions aside as they don their PPE and head back into the patient’s room.

Another week goes by and the nurse educators’ roles become less about teaching and learning and more about debriefing and listening. The nurses are now quite comfortable caring for ICU patients, but that allows them more down time to start processing some of the suppressed emotions of the last 4 weeks. Some work through their heart-breaking experiences with death, while others let their anger bubble to the surface.

Snapshot: When I walk into one ICU at 6:30 AM and ask a nurse how she is doing, I hear, “How much longer will I be here? What’s the plan for this ICU? We’ve done all they have asked from us, so it’s time to shut this unit down.” We spend 45 minutes working through her questions and feelings.

Snapshot: When I round a corner, I see the nurse whose patient passed away 10 days ago. I ask her how she is doing, and she smiles as we talk for 30 minutes about how meaningful that experience was for her. We discuss her emotions over the last week and how she experienced an emotional letdown a few days earlier. She retreated for a day or two and even took a little time away from family, as she needed space to process her emotions. I’m happy talking with her, as I can see she is past the grief and is forever positively changed after that heart-wrenching experience.

Snapshot: I see a nurse come away from a patient’s bed, her eyes glistening. Her patient was finally more alert and awake, so was able to FaceTime with his family. This was the nurse’s third day in a row with the patient, so she knows him and his family well now. They cried. She cried. This nurse was deployed late in the surge to staff an ICU that only opened for 3 days. Since it closed, she had not had a patient assignment to start the day and just floated around this unit where needed to help until an admission arrives. Now she has a primary patient and this experience gives her new purpose and meaning in her deployed nursing role.

Snapshot: A group of nurses are across the hall from each other and are discussing whether we will see a resurgence of COVID-19 in the fall. They analyze what could be done to prevent it, but in the end resign themselves to the fact that it can happen again at any time. One nurse says to the group, “At least we know where we all will be assigned; we will be back here again. Welcome to Ground Hog Day.” No one laughs. They are all processing that realization quietly on their own.

Snapshot: I get a text from one of my deployed ICU nurses confirming that occupational health just told her she tested positive for COVID-19. I’m heart broken. She has a special needs child at home. She had all the right PPE, so how could this happen? I know she could have contracted it anywhere, but is there something we could have done to better protect her? I can’t help wondering…

It’s a privilege to be a part of something so global, yet so personal in each of our little healthcare microcosms. The emotional rollercoaster is something healthcare workers experience every day in every unit, so it’s nothing new. What makes the COVID-19 experience different is, well…everything. We created ICUs out of nowhere, we put teams together from all specialties and pushed them well beyond their comfort zone, and we did it with short notice.

Our experience isn’t different from that of many other cities experiencing this pandemic, but it’s our experience and that makes it unique. The emotional cost of COVID is yet to be determined. It will take time to really process and decompress from the rollercoaster ride, but hopefully one day soon, we will all experience the most important emotion—inner peace.

Melissa Mullen is a nursing practice specialist at Massachusetts General Hospital in Boston.