A total of 30 nurses participated in this study, whose demographic information is shown in Table 2. After analyzing the data, 120 primary codes, 16 subcategories, and 2 main categories were extracted (Table 3), which are mentioned along with quotations and explanations.
1- Experiences and challenges
With the outbreak of COVID-19 in Iran and the hospitalization of its patients in hospitals, the personal and work life of nurses who are the most important medical personnel in fighting against COVID-19 undergo changes such as lack of protective equipment, high work pressure, marginalized physical health, problems related to the use of protective equipment, getting excluded ion, lack of supportive work environment, problems related to patients, psychological problems, fear, marginalized personal and family life and the challenge of communication with patients' families.
Lack of protective equipment. One of the most important problems that nurses had in facing with COVID-19 disease from the very beginning of the disease was the lack of protective equipment such as gloves, high quality masks, face shields, disinfectant solution, and isolation clothes. This was a concern for many nurses and endangered their health.
"From the very first days we did not have isolation clothes. Many times we had to have contact with patients who were suspected of having COVID-19 without isolation clothes. Now the situation has improved, but sometimes we have to economize a lot." (P 4)
"Two pairs of gloves a day was too little for us." (p. 6)
"In the beginning, when we had a shortage, they gave us a simple mask which was of very low quality." (p. 11)
"In the early days, we had little hygienic products, we had to save a lot, and our lives were in danger." (p. 3)
High work pressure. With the increase of prevalence of COVID-19, the number of hospitalized patients increased day by day, and many hospitals faced a shortage of nurses, which led to longer hours of work for nurses. Also, since COVID-19 patients did not have any companions, most of their work was done by nurses, and due to their physical condition, nurses had to check them more than other patients. These issues put nurses under a lot of work pressure.
"We have been so busy. The number of patients is increasing and we have to work harder." (p. 23)
"The COVID-19 patient has a lot more work to do. We have to pay attention to and check them all the time because they don’t have any companions." (p 2)
"Because the number of our staff has decreased and the number of patients has increased, we have to work much harder than before." (p. 17)
"We have a lot of work, we do not have a rest, I am getting tired, I am getting less" (p 4)
Marginalized physical health. With the increase of work pressure and psychological problems that occurred to nurses in some cases, their health was affected and they faced problems such as fatigue, headache, muscle fatigue, weakness and lethargy. Also, due to high work pressure and work stress, their sleep quality was low and in terms of nutrition, they faced digestive problems, disrupted eating hours, and eating habits. Most female nurses also reported that they had many problems during menstruation because they did not get enough rest.
"Sometimes I get so tired that I’m to fall asleep standing up." (p. 19)
"I do not have enough rest and sleep so I have a headache; I have pain in whole body." (p 27)
"Sometimes we get so busy we can't even eat lunch and dinner, recently my stomach has a problem." (p. 16)
"I had menstruation last week; I went to the brink of death. I got very annoyed; I have never gotten bothered like this in my life by menstruation." (p. 5)
Problems related to the use of protective equipment. Most of the nurses stated that it was difficult for them to use protective equipment and it caused them many problems such as facial ulcers, shortness of breath, heat, sweating, body burns, itching and leg wounds. Due to the transmission COVID-19, nurses were forced to pay more attention to health issues and work for hours with protective equipment to avoid getting the disease. This made their work even harder.
"When I wear isolation clothes, I get very hot so I sweat a lot and my skin burns." (p. 12)
"Since I have been wearing these clothes, my skin has become sensitive and it itches all the time. I am very bothered." (p. 14)
"I get short of breath when I use shields, masks, etc. I often feel suffocated" (p. 21)
Getting excluded. Most nurses reported being neglected outside the hospital by friends, neighbors, and even family, and many people cut contact with them. Because COVID-19 is transmitted in a variety of ways, nurses who have contact with patients are more at risk of getting the disease. This makes people afraid of nurses. Also, since it is possible to carry the disease displaying no symptoms, people are more afraid of nurses and this leads to their getting excluded in society and even in the family.
"Most of our relatives don’t greet me warmly anymore. They fear I go to their house. I met them several times outside, but they did not even say hello." (p. 26)
"Our neighbor's wife told my mother “Tell your daughter not to come home and stay in the hospital, otherwise we, the residents of the building, will have to evict you from the building.”" (p. 4)
"My brother-in-law no longer lets my sister and her children come to our house for fear that I might take COVID-19. I am very upset with their behavior" (p. 8)
"People behave badly with us outside when they find out that we are nurses. I once took a taxi and said I wanted to go to the hospital. When he found out that I was a nurse and I work in the COVID-19 ward, he refused to take me to the destination and made me get out of the car. His behavior bothered me for a couple of days. "(p. 29)
"My husband always insists that I don't go to work anymore, he says “you will take COVID-19, we will be miserable”, but I can't, my conscience doesn’t let me do such a thing." (p. 14)
"One of the biggest problems for us, nurses working in the COVID-19 ward, is that many of our families do not support us when we really need them in this situation. A friend of mine said his father told her “I’ll give you twice the money the hospital gives you if you don’t go to work”."(p 20)
Lack of supportive work environment. Most nurses were dissatisfied with the quality of services provided by the hospital, stating that they had problems in the workplace such as not having a suitable place to rest, crowded break rooms, lack of motivational stimuli such as material rewards, worries about dismissal, lack of psychological counseling to cope with the stress related to COVID-19 and lack of adequate training in how to deal with COVID-19 patients.
"We all have to stay in the hospital, but we do not have a good place to rest at all. Sometimes it gets too crowded and it is not possible to take a rest." (p. 9)
"The officials praise us all the time but do nothing to make us happier and more hopeful. They did not provide us with any material rewards." (p. 3)
"We nurses have had the most stress and anxiety since COVID-19 came. Our days and nights have been messed up, but they have not provided us any counseling to calm down." (p. 12)
"During the early spread of COVID-19, I was very confused. I did not know exactly how to treat patients. I was afraid of them because we weren’t trained for such a situation." (p. 28)
Problems related to patients. A number of nurses stated that they had been abused and bullied by COVID-19 patients. They were also upset to see COVID-19 patients in poor condition. In addition, because COVID-19 patients were unaccompanied, they felt lonely and homesick in the hospital, which made it difficult for them to cope with the hospital conditions and caused them to have tension with the nurses in some situations.
"Patients who had been hospitalized for a few days became very homesick and impatient, and we had to calm them all down." (p. 19)
"Some patients talked to us badly and insulted us." (p. 7)
"Some COVID-19 patients were tired of staying in the hospital. They were less tolerant and sometimes they fought with our colleagues." (p. 6).
Psychological problems. Most nurses stated that they were depressed due to the complex and difficult conditions that had arisen. Also, some of them had self-morbidities and constantly thought they had COVID-19. The grief of losing colleagues was another psychological problem of nurses. Some of them were upset and worried that they would see their co-worker died or had to stay home.
"I was much stronger early on, but now I’m losing my patience and tolerance and I think about negative things all the time. I feel I got depressed, I’m very impatient." (p. 18)
"For a short time, I have been thinking I got infected? I tested twice, which was negative. I even told my family what to do if something happened to me." (p. 1)
"I always think I'm sick. I was very careful, but I still think I'm sick. I check myself all the time. When I have a cough I get worried." (P. 23)
"A few days ago, one of our colleagues passed away. We were very upset. My mind is very busy with it." (p. 6)
"I am very upset to see that some of my colleagues are infected and being bothered." (p. 17)
Fear. Most participants stated that worry and fear sometimes disrupt their lives. Most of them had fears of being infected, carrying, and transmitting to their families, the continuation of the disease and the unknownness of the COVID-19 virus.
"All my worries and fears are that I will pass the disease on to my family, because my father has a kidney transplant and he lives with us." (p. 11)
"I am very afraid of catching COVID-19. When I see the condition of patients, I am more afraid, but I don’t show it. Sometimes I tell my patients not to be afraid of COVID-19 while I myself really fear of it." (p 27)
"I am worried that this disease will continue. Life in these conditions has really become very difficult for us nurses. I feel that if it continues, we won’t be able to tolerate." (p. 16)
"That they discover something new about this disease every day makes me even more frightened because I get sure that scientists know very little about this disease and that is why they cannot find a cure for it." (p. 2)
Marginalized personal and family life. As the number of COVID-19 patients in Iran increased, as well as the medical staff becoming ill and in need of rest, hospitals became understaffed and the remained nurses had to spend more time in the hospital. This made them no longer available to the family. On the other hand, because of the possibility of being a virus carrier, many nurses preferred to stay in the hospital even when they were off-duty and did not return home, which further alienated them from their families. Some other nurses, who had to stay in the hospital full time, fell behind on many personal life plans such as marriage and their children’s birthday.
"Sometimes it takes more than a week for me to see my family." (p. 8)
"I haven’t seen my 6-month-old son; I really missed him." (p. 15)
"I could not attend my son's birthday. I was very upset. I was away from them when my family needed me more than ever. I feel I am not a good father for them." (p. 18)
"My husband and I were supposed to get married in April, but I was at work all the time and we couldn’t have a celebration." (p. 30)
The challenge of communicating with patients' families. Because the families of COVID-19 patients could not be with them, they were constantly in contact with the nurses to know about their patients, and the nurses were sometimes forced to report bad news to the families, such as the death or deterioration of the patient’s status. This had become a concern for most nurses, who stated that they had many problems with patients' families. Also, because the families were far away from their patient and could not see his condition closely, when they heard the news of their patient's death, they sometimes accused the nurses of not treating their patient properly. This also caused tensions between families and nurses.
"Sometimes when I had to tell the patient's family that the test was positive, I got very annoyed. I did not know how to tell them; people were very afraid of this disease." (p. 3)
"I have reported the death of the patient to the families 3 times so far. It’s a very hard work, we feel ashamed that we could not do anything for them." (p. 10)
"When we report the death of a patient to the families, some of them accuse us of being shirkers, sometimes they even insult us." (p. 25)
"Some families found our phone number and called us. Sometimes they called so many times that we felt impatient and frustrated; they wanted to know about their patient's condition all the time." (p. 11).
"Some people who called us or whom we called were bothering us; they expected us to explain the whole treatment process to them, asking a lot of questions. Sometimes we had no way but to turn off our phones." (p. 22)
2- Strategies for adapting to working conditions
In the face of the existing situation, nurses took some actions to increase the tolerance threshold or adapt better to new conditions, such as performing religious-spiritual activities, creating an empathetic atmosphere in the workplace, spiritualizing their work , trying to convince the family and gain their support, strengthening sense of self-worth and responsibility.
Performing religious-spiritual activities. Some nurses stated that they resorted to religious and spiritual activities such as praying, saying their daily prayers, and listening to the Qur'an in order to strengthen their spirits and calm themselves. In fact, through approaching God, they tried to find more peace.
"When I am very tired, I try to say my prayers at a suitable time; I get rid of tiredness." (p. 28)
"When I am under a lot of stress, I get a chance and listen to the Quran. Then I feel very calm; it makes me feel good." (p. 9)
"When I talk to God, I feel that He hears my words, I calm down. I ask him to save us from this disease." (p 12)
Creating an empathetic atmosphere in the workplace. Most nurses reported that during the outbreak of COVID-19 their work and emotional relationships at work changed for the better, and they liked and helped each other more than before. In fact, nurses could make the workplace more conducive by creating an empathetic atmosphere by creating emotional relationships with patients, strengthening relationships with other colleagues, forgiveness and devotion, helping colleagues, giving positive feedback to colleagues, talking more with colleagues, and providing an atmosphere for jokes and laughter.
"I try to talk more with patients. Honestly, both they and I calm down. Sometimes I listen to their heartache; they talk about their past and their memories." (p. 14)
"Since the COVID-19 patients were admitted to our ward, the colleagues have helped each other more because they know we are all in a difficult situation." (p. 9)
"I feel good to see my colleagues help me. I have recently started my work. When they encourage me I feel good." (P. 16)
"When we are less busy, we sit and talk with our colleagues. We are all like each other and understand each other well, so we feel very calm when we talk to each other." (p. 24)
"Sometimes I joke with patients, I take the rise out of them, they like it too. When I'm not there, they ask my colleagues about me. Sometimes I joke with my colleagues; this makes me less bothered." (p. 17)
"Sometimes when there is a lot of pressure on me, I talk to my colleagues and change our shifts. They used to not accept it so easily, but now everyone understands each other; a very good atmosphere has been created in the hospital. I wish it always stays the same, even when the disease is controlled." (p 5)
Spiritualizing their work. In order to cope with the new conditions, some nurses tried to give their work a spiritual aspect by considering their work as jihad in the way of God, equating death due to COVID-19 with martyrdom, receiving rewards in the hereafter. Some nurses considered themselves Mujahideen for the sake of God and believed that if they were infected with COVID-19 and died in this way, they would go to heaven because they were martyred in the way of God. They also believed that if they died, they would have a great reward with God in the hereafter.
"I now really think I'm on the battlefield. I'm not afraid of death. I used to be very scared, but not now because I'm sure if I die I'll go to heaven" (p. 11)
"Our work is almost something like jihad in the way of God. Few people accept to work in these conditions, even if they are given a very high salary." (p. 8)
"When I think that I am fighting for God and if I die I am a martyr, my courage increases and I want to work more." (p 26)
"Despite the fact that I work many hours, I do not feel tired at all because I know that God sees everything and sees my troubles, and I am sure that one day he will reward me for this effort, whether it is in this world or the hereafter." (p. 14)
Trying to convince the family and gain their support. Some nurses stated that they had tried to gain the support of the family so that they could get help from them as a strong emotional resource. To convince the family and gain their support, they took measures such as explaining the necessity of being in the hospital, explaining the importance of nurses' work, observing health principles and comforting the family, showing working conditions to family members, and making phone and video calls to the family.
"It was very important to me that my family be behind me, so I talked to them from the beginning and told them that if we nurses were not, the situation would get worse and everyone might get infected." (p. 13)
"I promised my family that I would take care of myself as much as possible so that I would not get infected. In order to ease their mind, I sometimes make a video call with the clothes I wear to see that I respect them and make them feel better." (p. 3)
"I talked to my wife and explained the working conditions to her. Thank God my wife is reasonable. She accepted the conditions and supported me a lot during this period, unlike my other colleagues who often had problems with their families." (p. 18)
"I try to call my mom or dad at least once a day and talk to them, so they can relax when they are less afraid and support more" (p. 21)
Strengthening sense of self-worth and responsibility. The attention and support of the people and the media to the medical staff, especially nurses, in cyberspace, made nurses feel happy and satisfied, so that it strengthened their sense of self-worth and responsibility.
"I feel good when I see that everyone thanks us and thinks of us." (p. 1)
"When I see that everyone is supporting us nurses, I feel that my work is very valuable; I like my work more than before." (P. 27)
"I did not like my job very much before. Last year, I took the entrance exam to go to study medicine, but now I understand what an important job I have." (p. 15)
"I used to make excuses and liked not to go to work. When I came, I was very bored and only thought about when my work would end, but this is not the case now. My sense of responsibility for my work has increased." (p. 13)
"I try to think more about the positive aspects of my work and how valuable it is; this way I feel better about it and it gets easier for me to work." (p. 6)