The participants included 13 nurses (4 men and 9 women). Eleven of whom had bachelor's degree and two had Master of Science in nursing. Median ages of participants were 27-42. Minimum and maximum of work experience for nurses were 2 and 15, respectively. Mean of work experience was 10 years. At first, 350 codes were derived and then after reducing, deleting and merging the codes in analysis phases, all codes decreased to 180. Finally, 13 sub subcategories, 5 categories and 2 themes were achieved. The labels of themes included "self-care strategies" and "social support strategies ". Self-care strategies including 2 main category of problem-based strategies and escape/ avoidance strategies. Social support strategies including 3 main categories of family support, organizational support and community support.
Self-care strategies
Majority of participants stated that CF among nurses is inevitable due to caring nature of nursing profession and considered self- care strategies as a one of the most important of the preventive strategies of CF. Self-care strategies are activities that control and repel the source of stress, distract the person from the stressful environment and keep them away from the stressful situation.
Problem-based strategies
Based on of participants’ statements, this category can be classified into 4 subcategories including acceptance, adaptation, alteration and energy recovery.
Acceptance: There are some topics in this subcategory that nurses mentioned such as accepting existing conditions, accepting inability to change, accepting the behaviors of others, accepting one's own and others' mistakes, learning how to forget them, being responsible, and having a positive attitude.
Adaptation: This subcategory consisted of rebuilding issues and problems, gaining a sense of self-control, time management, prioritizing affairs, creating a work-life balance, separating personal and professional life, setting reasonable standards, and suppressing idealism. Nurses considered idealism annoying. If a nurse is an idealistic person and wants to provide high quality care, it will damage him/her. What is more, the participants emphasize that the ability to balance work-life activities is an important adaptive skill. One participant said:"We have to learn to separate work and life issues to get less hurt" (a nurse with 15 years of experience).
Change: This subcategory includes changing positions, changing perspectives, changing patterns and communicational behaviors (expressing emotions, talking about existing problems, dealing with issues). Some nurses even considered that facing with major challenges are opportunities for personal growth. "After 14 years working, I've learned that I shouldn't run away from problems, I must face with them. Sometimes exposures to painful and suffering circumstances of the patients get me closer to God, and it makes me grow spiritually. ”
The participants mentioned some activities such as regular exercise, healthy recreation, adequate time for work and rest, and traveling as measures for restoring energy and enhancing the strength of nurses. One participant added: "I think, nurses cannot take care of themselves, they don't exercise regularly, they don't have eat healthy food, and they do not have any planned entertainment. Many of them don't have enough rest; they just go to hospital and come back home"(A nurse with 10 years of experience).
The participants showed defensive strategies are one of the most significant strategies in the prevention of CF. This main category consisted of distracting and escape/ avoidance. Distracting included distancing oneself from others, preferring to be alone, being unwilling to crowded situation. Furthermore, nurses are also using escape/ avoidance strategies as effective way to protect themselves. The escape / avoidance strategy included being absent in the workplace, staying away from colleagues, ignoring patients, considering the patients as object, too many delays, a desire to quit their jobs. One participant stated: "Some days, I'm so tired emotionally that I can't work. I don't want to go to the hospital and care patients. I don't want to listen to my patients. I don't have the usual compassion and empathy. I’ve become apathetic and indifferent. I think I want to escape from my situation". (A nurse with eight years of experience)
Social support strategies
Social support strategies are the most noticeable preventive ways that have been repeatedly stated by the participants. This category includes three subcategories: family support, organizational support, and community support.
Family support includes support of parents, spouse, children, and friends. The family is a fundamental principle in supporting nurses in family and professional life. An Iranian societies, like many Asian countries, are family-oriented and they have traditional views and values about working of women, especially in the nursing profession and especially in the evening and night shifts, and this is while clinical nurses have to work in all shifts(morning, afternoon and evening). Based on Iranian culture in some areas, it is not desirable for a family, especially for the man of the family, therefore the lack of family support was emphasized in the statements of some participants. One of the nurses with 13 years of experience stated in this regard: "family support is very important, my husband does not like my job because of night shifts and working with male colleague and male patients and I do not receive support from my husband at all. If he supports me, I will be less mentally tired. In fact, I go home exhausted and come back to work more tired without any recovery".
Organizational support
Based on the experiences of the participants, organizational support was another strategy of social support. This category is rather large and includes three sub-categories of the financial and human resources management, educational support and creating a supportive environment.
The financial and human resources management: lack of funding, lack of nursing staff, lack of resources and lack of adequate financial resources for nurses were considerable issues that were stated by almost all nurses. In this respect, one of the nurses in the intensive care unit said: "Our work pressure is very high. The number of nurses is very low. "If the number of staff is so large that we do not have to work overtime, both our mental and physical fatigue will be reduced." with 10 years of experience in nursing.
Educational support: the participants mentioned training as one of the most significant approaches to prevent and manage CF. Awareness of this phenomenon, causes, risk factors and effective interventions is essential because many nurses and nursing managers are not aware of the nature of this phenomenon and even they equate it with burnout. Many participants acknowledged the need to integrate adaptive skills training programs, stress management, crisis management, and communication skills in the nursing curriculum, and even constant education. A participant with 7 years of experience said: "Since working with patients creates a very stressful situation, I have to be trained all kinds of methods of adaptation, stress management, crisis management to be able to use them in sensitive situations.
Creation of supportive environment: The participants considered that the creation of a supportive environment can be another approach for prevention and management of CF. They added, to achieve this goal, the managers’ support, the peers’ support (colleagues), the doctors’ support and inter-professional cooperation are very effective. A participant with 8 years of experience stated: "We have a lot of shifts and limited resources in transplant department, but the personnel have created a friendly environment. We all work together with cooperation. Both the head nurse and the doctors support us. "It relieves a lot of our stress." Another nurse added, "We talk to our colleagues about the pain and suffering of patients and even mourn and cry together. These conversations make us mentally calm".
The government and the nation’s support
The nurses also mentioned the key role of the government and the nation in preventing of CF. Governmental support included adequate funding, the development of policies for supporting nurses, the creation of an appropriate culture to enhance nurses' dignity, and the promotion of social positions. One participant added: "The nurse should be supported by the government, when the policies of government are supportive and nurses feel supported, they are less likely to suffer from mental and emotional fatigue."
Table 1: the data analysis process
Sub sub-category
|
Sub- category
|
category
|
Acceptance
|
Problem-solving strategy
|
Self-care strategies
|
Adaptation
|
change
|
energy restoration
|
escape/avoidance
|
Avoidance strategy
|
Distancing
|
family support
|
Family support
|
Social support strategies
|
significant others support
|
The financial and human resources management
|
Organizational support
|
Create of educational support
|
Government support
|
The government and
the nation’s support
|
Nation support
|