Nurses Lived Experiences, Burdens and Coping Strategies During COVID-19 Pandemic

This is a qualitative phenomenological study that was designed to navigate through nurses’ lived experiences, burdens, and coping strategies while working with COVID-19 patients. The sample included 20 nurses who had worked with COVID-19 patients for more than or equal to 6 months. The interviews were conducted between October 1, 2021, and April 15, 2022. At that time, the third COVID wave had elapsed, and we were peaking on a fourth pandemic wave, so included participants had lived through a minimum of 2 to 3 peaks. Six themes emerged, which were: nurses coping with COVID-19 crisis, professional relationship burden, personal burden, environmental burden, physical symptom burden, and emotional burden of the crisis. Nurses’ lived experiences during the pandemic were deep, intense, and moderately to highly affecting their ways of thinking, feeling, and behaving. That experience opened nurses’ eyes on countless number of challenges that require special attention, care, and preparation on many levels. The minimal preparatory levels are personal, departmental, organizational, and strategic.


INTRODUCTION
The COVID-19 pandemic had hit the health care systems all around the world. 1 The health care systems were steeply challenged, and the man power behind the wheel was in a severe struggle.Nurses were working around the clock to meet the escalating health care demands. 2 It had been a marathon under strict conditions of fear of being infected or communicating the infection to the loved ones, emotional We would like to thank the participating nurses for their time.Appreciation is offered for The University of Jordan, Ministry of Health in Jordan and the Private hospital sector for their facilitation, help and support.
Data supportive for the findings of this study are available upon request from the corresponding author.The data are not publicly available due to confidentiality and ethical restrictions.

This work is totally funded by the Deanship of Scientific and Academic Research in The University of Jordan.
We as authors declare that we meet the authorship criteria according to the latest guidelines of the International Committee of Medical Journal Editors.
Our contribution to the paper building was almost equally significant and we are in agreement with the manuscript in its submitted version.R.A.J. wrote the main manuscript.K.D. and M.N. reviewed the manuscript and contributed significantly in the data collection and analysis processes.
The are no conflict of interest to declare.

Supplemental digital content is available for this article.
Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.cnqjournal.com).
fatigue, and discomfort when wearing the personal protective equipment (PPE). 3urveying nurses' lived experiences during pandemics yields super attention because it is the nurses who fight the battle against death and degraded quality of life.Nurses are the war front liners; if they manage to survive through the times of adversity, then the whole war is inevitably won. 4,5any researchers had described nurses' experiences during COVID-19.Sun et al reported that nurses in China went through negative emotions of fatigue, discomfort, and helplessness. 6Khatatbeh et al reported the lived experiences of nurses caring for COVID-19 patients in Jordan.Nurses' emotional reactions, how they dealt with the crisis at personal and organizational levels, sources of support, stigma, and extreme workload were all described.Those findings reinforced the conclusion that COVID-19 came with burdens. 7Among those burdens are the ones reported by McGlinchey et al in Ireland/the United Kingdom.Some nurses felt frustrated because they were unable to ease patients' discomfort, and they were hesitant to engage in the best way in the patient's care due to the fear of getting the infection. 8amanzadeh et al revealed that nurses in Iran said that they were distracted from care due to the growing sense that the disease could intimidate nurses and nurses' families' health.The intimidators had become worse because of a lack of scientific information, a sense of ambiguity, increased workloads, and changes in lifestyle, eg, nurses' self-quarantine and social isolation. 9railey et al described some effects of COVID-19 on the United Kingdom's nurses, eg, psychological distress, fear, isolation, and moral injury.Besides, there were changes in team dynamics; some of them were positive such as improved teamwork and cohesiveness, while others were negative, especially when talking about redeployed nurses who lacked the "necessary knowledge and experience" to manage COVID-19 needs and workload complexities.At the end of the first wave, nurses' coping strategies were effectively activated. 10hularo et al summarized the coping strategies used by nurses during COVID-19.They included the use of COVID-19 protective measures, avoidance strategy, social support, faith-based practices, psychological support, and management support. 11hile Puto et al compared the coping strategies used by nurses who worked with patients infected with COVID-19 during the pandemic with those used by nurses who managed regular cases.They concluded that nurses managing active cases were more stressed and used coping strategies focused on the problem and the related emotions. 12n Jordan, nurses lived unprecedented stress during the pandemic.The cost of caring was so high but not well rewarded or adequately documented.Being under tremendous pressure had drawn ominous states of mind to protect self, beloved ones, and the community.It had been a day-today struggle of will, power, system, policy, and belief. 13,14Hereby came the importance of purposefully conducting those in-depth interviews and intentionally avoiding, at this critical juncture of health history, to relay on quantitative scales.This study aimed to navigate through the lived experiences of nurses who managed COVID-19 clients, investigate the burdens, and understand the coping styles activated to keep nurses resilient, at the time of unexpected adversity.We know little about how nurses managed their care and life burdens within a very confining and challenging context, thereby we hoped to fill that gap.

Design
A qualitative interpretative phenomenological methodology was applied as it seemed one of the most useful approaches in exploring nurses' lived experiences, burdens, and coping styles during the COVID-19 emerging scenario.It had offered the chance to "use nurses word of mouth" rather than to offer scales that may not touch, approximate, or capture the essence of the true meaning of their experiences. 15Interpretative phenomenological analysis (IPA) is a qualitative approach that aims to provide detailed examinations of personal lived experiences.It is explicitly idiographic in its commitment to examining the detailed experience of each case in turn, prior to the move to more general claims.IPA is a particularly useful methodology for examining topics that are complex, ambiguous, and emotionally laden; in such sense, it fitted our purpose of describing nurses' experiences during COVID-19. 16

Study participants and sampling strategy
Purposeful sampling was carried out, guided by specific inclusion criteria.The first criterion was to include nurses who hold fieldwork.The second criterion was to choose nurses who had worked at least 6 months with active COVID-19 cases on a regular basis, especially during the first 2 pandemic waves in Jordan, which had peaked on November 18, 2020, and March 17, 2021, respectively.The third pandemic wave had approximately peaked on November 21, 2021, and the fourth wave had peaked on February 18, 2022. 17he picked clinical sittings were composed of a major academic hospital, a major semigovernmental hospital, a large private hospital, a central governmental hospital, and nurses from COVID-19 field hospitals.The principles of data saturation were employed where the data were considered sufficient, as indicated by the in-depth redundancy on interview number 18, though 2 more interviews were conducted to confirm saturation. 18

Data collection
The data were collected between October 1, 2021, and April 15, 2022.The research team (researchers K.D. and M.N. who have satisfactory qualitative research experience) headed toward the selected clinical settings and held meetings with nursing managers to facilitate the data collection process.Then, the research idea was explained to nominated nurses; informed consent was read, and the interview guide (See Supplemental digital content, Appendix 1, available at:) was delivered as a printed version.All inquiries were answered, especially those related to anonymity, privacy, and confidentiality before heading to a private spot, in the work setting to sign the informed consent and perform a structured interview.The interview time ranged from 45 to 75 minutes.
The final sample size was 20 nurses after 5 participants dropped.The reasons for dropping were: unsuccessful arrangement of suitable meeting conditions because of the nurses' busy schedules, frequent extremely tiring night shifts, and sudden cardiopulmonary arrests of clients at the time of the interview.No repeated interviews were carried out and field notes were documented promptly.Transcripts weren't returned to participants for corrections or comments.It is necessary to report that there were no previous relationships or acquaintances between the researchers and the participants, which would have affected the quality of the data or brought any subjective bias.
Participants refused to use audiotape devices for recording because of the sensitivity of the topic and a vague sense that a legal implication could be pursued.With respect to that, the researchers distributed roles; one of them led the questions while the other handled the immediate verbatim transcription in the interview guide.The interview guide was based on relevant literature and revised by 3 specialists.It was prepared to give insights into the studied phenomenon. 19

Data analysis
Thematic analysis was carried out by the 3 main researchers (R.A.J., K.D., and M.N.) who executed regular weekly sessions to analyze the interview guides, one by one.Open coding was initially done to identify words with similar meanings.Focus coding was conducted to group codes that sounded similar, a process that ended up with the Burdens and Coping Strategies During COVID-19 Pandemic formulation of the preliminary themes.A constant comparative method of data analysis was adopted to make sure that all data are checked, coded, categorized, and compared thoroughly. 20Disagreements on themes and subthemes were discussed constantly and reached consensus.Ultimately, a revision process was run twice to ensure the credibility and trustworthiness of analytical decisions.Those decisions were enhanced through a reflexivity process that included writing reflective journals, memos, and appropriate referrals to supportive literature. 21In addition, other researchers were invited to cross-check the themes to reduce subjective bias and confirm the findings, conclusions, and recommendations. 22 illustrative example of how we moved from open coding to themes is provided in Table 1.

FINDINGS
Table 2 shows the sociodemographic characteristics of the participants who were assigned numbers to ensure anonymity and non-traceability.The ranks, workplaces, and units were not reported to further minimize the chances of identifiability.
There were 6 themes, namely, nurses coping with COVID-19, professional relationship burden, personal burden, environmental burden, physical symptom burden, and emotional burden (Figure 1).During COVID-19, it was understandable that nurses were living and working under stressful conditions.A successful use of effective coping strategies can help nurses manage stress resiliently and pass through critical moments with intact morals and less traumatized souls.There were 2 subthemes.

Subtheme 1: Adaptive coping strategies
There were 3 main reported adaptive coping strategies.First, many nurses described talking to significant others (social support) as a major technique to help ease edgy emotions and stressful thoughts.
C4 said: "Talking with family and friends helped me during the crisis."Second, physical rest and sleeping helped.
C2 said: "Having rest at home after a full day of pressured work helped me."Third, many participants turned to "faith-based beliefs and practices" to guide them.For example, believers thought that a higher power has dominance over their lives, things are predestined, death is a final destination for every living creature, and it cannot be avoided, so it may be a wiser decision to accept death or God's will rather than to repel against or turn faith.
C6 said: "Reading from the holy Quran, belief in the certainty of death and the belief in God's control over everything in our life helped me through the crisis." While C23 reported: "Nothing deserves, there is no escape from death even with the availability of supplies and the highest price medicines.I reached a conclusion that age is predetermined even with the artificial lung!Spiritual beliefs helped me during the crisis, I am so astonished from people who don't believe in death and after life.My

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Copyright © 2024 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.psychological distress made me unable to argue with them.Money became useless; it doesn't take death away."

Subtheme 2: Maladaptive coping strategies
At the times of adversity and hardship, some nurses turned to less resilient coping strategies to help them escape reality and avoid overthinking.Substance use is one mechanism of maladaptive coping.The interviewed nurses reported over drinking coffee, increased smoking, turning to use electronic cigars, taking acetaminophen or nonsteroidal anti-inflammatory drugs for stress-induced headaches, smoking shisha, Panadol night alone or combined with serdalod to ease falling into sleep, power drinks to keep awake, and deanxit to reduce anxiety.
C2 said: "I used to drink 400 ml coffee before COVID-19 and smoked 15 cigarettes.After the crisis I started to drink 800 ml coffee daily and smoked a packet and half.I started taking denexate to ease my anxiety.Then I quitted regular smoking and turned to electronic cigarettes; I started to smoke everywhere at home, at work and in the car." C25 reported: "After COVID-19 I had trouble in falling asleep, I can't sleep except if I take two tablets of Panadol night and serdalod 3 mg, 2 tablets."He added: "I watched TV movies for 9 continuous hours to escape reality."The last quote described another maladaptive coping which is "TV addiction."

Theme 2: Professional relationship burden
Four subthemes emerged, which were nurse-nurse relationship, nurse-patient's family relationship, nurse-patient relationship, and nurse-manager relationship.

Subtheme 1: Nurse-nurse relationship
It was evident that nurses were soldiers in the frontlines; they were back to back.It was almost unanimous that the relationship between nurses was supportive during the first pandemic waves.It was instinctual for them to understand that they only had each other.
C2 said: "My relationship with my senior colleague was good during the crisis.Colleagues supported each other by lending a hand."C20 said: "The colleagues were supportive; the in charge nurse wore the PPE and entered the patients' rooms with us."

Subtheme 2: Nurse-patient's family relationship
Nurse-patient's family was a dichotomous relationship.Some nurses felt relieved because there were no visitors to bother them with redundant inquiries, multiple complains, and extra tasks to perform.The other aspect was expressive for the need of the family to be there, at the bed side, in order to participate in the care and in the direct supervision of their sick family member.Many nurses attributed that to the need to be lent a hand while providing patient's self-care, to have someone attend all the time to monitor the patient, report deviations from normal, escort patient to the bathroom, feed, return oxygen devices, and call for help in case of emergencies.
C3 reported: "The absence of patients' families helped me focus during the crisis.With the quarantine my worries faded and the load became less because I only communicated with the clients not with 100 visitors."C20 said: "I won't forget a patient who was on CPAP.She frequently removed the oxygen mask, I was not able to be available for her 24 hours a day.Sometimes patients were about to die, but you don't know, they could die in the bath room.It takes time to prepare ourselves and wear the PPE to be able to offer help.The family was not there!So the patient could aspirate and there is no one to tap his back or call for help."

Subtheme 3: Nurse-patient relationship
Because of the isolation of infected COVID clients, social interaction chances were mitigated.Special end-of-life emotional needs

Burdens and Coping Strategies During COVID-19 Pandemic
and a kind of nurses' emotional involvement with patients challenging experiences took place.As a result, some nurses shifted their formal communication paradigms and adopted a more active role.
C3 said: "Before COVID, I didn't socially communicate with the clients or their families; I preferred to stay formal.I didn't want to be affected emotionally by them.During COVID crisis, things became different.I started to communicate with the isolated COVID clients more than other patients."

Subtheme 4: Nurse-manager relationship
Relationship of nurses with their managers and direct supervisors during the pandemic fluctuated between positive, negative, and neutral.
C1said: "My manager was neutral.He didn't support me.He didn't thank me.We didn't see the managers.We didn't take raises on the salary.They didn't cover the lack of staff." C23 said: "my manager had a very negative role.There was no empathy, no encouragement, nor appreciation!Those who did mistakes were exposed in public!He refused to let me leave early one day and I committed a medication error."C4 said: "My supervisor was cooperative and understood the psychological and physical burdens of COVID.He arranged the schedule well.Verbal recognition was given constantly.He used good manners in dealing with the staff but financial reward was lacking."

Theme 3: Personal burden of the crisis
Nurses revealed 2 challenges at the personal level, which were the social distancing effect on family dynamics and cost of social status.

Subtheme 1: Social distancing effect on family dynamics
Social distancing measures were imposed to decrease contagiousness of the disease but caused suffering to nurses and their families.Some nurses were relying on their families to care for their children or as a resort for social life, but due to the lock down and geographical distance, they were unable to reach each other, and a relative state of loneliness and isolation resulted.Sadly, nurses were reluctant to hug and kiss their children or socially interact with their fathers, mothers, and beloved ones.Some nurses forbade themselves from seeing their parents for extended durations.
C8 said: "They were nasty days.It was difficult for me to manage my life.My family and my husband's family were so distant."C20 reported: "At the beginning, I wanted to hug my daughters but I couldn't.I was afraid.I cried more than once because I was the care provider for them; my husband works outside the country."

Subtheme 2: Cost of social status
During COVID-19, nurses with family responsibilities and family members to care for were the most challenged.For example, some nurses were married with children, and some children were so young and required attention.Other nurses were divorced with children, and they faced the single mothering high demands aligned with the lock down responsibilities of buying the groceries, emotional nourishing, caring, and remote teaching.Some single nurses who lived with their parents were pushed negatively and stigmatized in a certain way by their families because they dealt with COVID patients and simultaneously carried the risk of disease transmission.Notably, younger male and female nurses especially singles were experiencing higher stress levels during the pandemic, and they were managing their days with extreme difficulty.C10, a new mother of a 70-day baby, said: "married female nurses were in severe struggle during the pandemic.They can't handle things in equilibrium inside and outside home!I can't perform less than expected at work so the defect was at home.I communicated less with my husband.I didn't show affection to my eldest son due to lack of time."

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CRITICAL CARE NURSING QUARTERLY/JULY-SEPTEMBER 2024 C12 said: "I am a divorced mum.I had to provide all my children's needs during the pandemic.I had the challenge of keeping my family safe.I had to teach my children after doing two round shifts because the learning during the lock down was online."

Theme 4: Environmental burden of the crisis
This theme is composed of 7 subthemes as follows: ambiguity, PPE strain and isolation precautions, low morale of some nurses, lack of financial reward, unpreparedness to deal with COVID-19 crisis (a dual challenge made of the rapid and unexpected deterioration of COVID patients combined with high mortality rates, and a fake sense of readiness to manage the escalating COVID rhythms), workload and care demands, and lack of supplies, equipment, and experience.

Subtheme 1: Ambiguity
Nurses revealed that ambiguity of the virus behavior created a state of ambivalence in the treatment and pharmacological management approaches.The protocols were frequently changing and conclusive evidences were critically lacking.
C9 reported: "It was a totally new experience!Every time we were trying a new COVID management protocol.The doctors tried it then stopped it.I felt that whatever we do with COVID patients who were on CPAP, BiPAP or ventilators; their condition will never improve.I felt so disappointed and I thought that this virus is manufactured!Every client was affected in a different way.No case scenario was similar to the other.Things were so confusing!"

Subtheme 2: PPE strain and isolation precautions
It was unanimously stated by interviewed nurses that wearing the PPE was a torture especially when worn for long times and when the nurses involved in the care were smokers.They added that it was annoying to be in it, and they couldn't see well.C20 said: "Wearing the PPE was a burden.It takes time to wear the PPE.Sometimes the patient suffocates, dies, arrests, collapses, falls in the bathroom and we can't timely help him because we need to wear the PPE first." C2 said: "I am a smoker and I drink coffee; the PPE made that difficult.After 2 hours in the PPE, continuing to provide nursing care becomes almost impossible." C3 added: "I was psychologically upset from wearing the PPE and the eye goggles.It was annoying to me and I couldn't properly see.I reduced the time I spend with the client and the number of times I enter the client's room due to the PPE and fear of getting the infection."

Subtheme 3: Low morale of some nurses
Some participants reported that a few nurses, especially those who were redeployed from other hospitals to COVID-19 care centers, had low morals, were not professional, and did not meet the minimum standards of nursing care.
C23 said: "Some nurses had no conscience!They took temperature once per shift.They worked two hours and rested for the rest of time, especially redeployed nurses; they were not cooperative.Some patients may have died of negligence; due to aspiration, for instance."

Subtheme 4: Lack of financial reward
All interviewed nurses felt injustice and dissatisfaction during COVID-19 because they were not sufficiently financially rewarded, or did not take extra paid vacations, and work burden was doubled when senior nurses were infected or when help nurses were replacing the sick.
C3 said: "There were a lot of injustices secondary to COVID.Nurses who reside far away and said I couldn't come to work, were excused.Nurses incentives decreased because the financial returns were less and the number of patients was less too."

Burdens and Coping Strategies During COVID-19 Pandemic
C21 added: "We felt severe injustice as a medical care team.We didn't take our right as the other managerial employees, who took two weeks paid vacation.There was a shortage in nurses in the first two peaks because they got COVID.Once four seniors were infected and the floor was left with junior majority who lacked any nursing experience!"

Subtheme 5: Unpreparedness to deal with COVID-19
Unpreparedness to deal with COVID-19 was a dual challenge that included: the rapid and unexpected deterioration of COVID patients combined with high mortality rate, as well as a sense of fake readiness to manage the escalating COVID rhythms.

The rapid and unexpected deterioration of COVID patients combined with high mortality rate
Nurses said that they were not used to the rapid deterioration and sudden collapse scenarios, especially for younger people who were previously healthy.Besides, high mortality rate of patients secondary to COVID-19 complications, such as pneumonia, respiratory failure, and renal failure, was one aspect that nurses were not prepared to endure or accept.
C22 said: "During the second peak there were a lot of mortality." C5 reported: "The experience was shocking!I am so used to the ICU work but the rapid change in the condition of a stable patient; all of sudden his lungs collapse and fail!It was something difficult to comprehend.COVID nature was not foreseeable.Deterioration and death can ensue within minutes or seconds!" C20 commented: "a patient was 36 years old and he had a chest tube.He was calling repeatedly.We thought that he was nagging but got shocked!He was fighting death and those calls were his last in life.We found him dead in his room minutes later.We weren't used to that rapid rhythm of deterioration and sudden death especially of young people!"

Fake sense of readiness to manage the escalating COVID rhythms
Despite the national efforts to combat the virus and the huge budgets that the Ministry of Health had allocated for prevention, vaccination, and treatment of COVID-19, there were shortages, gaps, weaknesses, and lack of proper training, especially on the new imported machines.It worth telling that a percentage of relocated nurses to COVID care units had not any ICU experience and did not know how to manage ventilators.It seemed that the nursing bodies were managing at the microcirculatory level rather than at the higher managerial or strategic levels.
C21 said: "My direct supervisor helped as much as he can but the higher management was pretending that the situation is stable!And when the things went wrong, they told us to manage the situation alone.They didn't increase the staff number.There were new devices which were left in the storehouse and weren't used because we didn't know how to operate them!"

Subtheme 6: Workload and care demands
Work load was significant during the first 2 peaks but became less later, secondary to certain action measures such as a decrease in the number of admissions, closing outpatient clinics, over-the-phone consultations, renewal of medicines by delivery service, and providing volunteer nursing and medical services at home level.
C10 said: "Number of patients was huge; more than 50 patients.They needed a lot of care."C25 commented: "Number of work hours was exhausting during the pandemic." C21 explained: "The elderly clients had higher physical needs.They were weak and lost their muscle tone.They weren't able to stand.They needed help in their basic needs.They had bad nutritional status and they refused to eat."

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CRITICAL CARE NURSING QUARTERLY/JULY-SEPTEMBER 2024 C3 stated: "People were talking and complementing our work as we were the white army.But on the ground, we were the only ones who were tortured.For us, the work load was increasing in the time when the rest of people took paid vacations." C22 said: "The hospital stopped allowing escorts and this doubled the load on nurses.The management forced us to stay intensively with the patient in his room, and this thing was severely annoying due to the PPE and the increased infection risk."

Subtheme 7: lack of supplies, equipment and experience
It was reported that there were sometimes lack of supplies, protective equipment, oxygen, bilevel positive airway pressure (BiPAP)/continuous positive airway pressure (CPAP), and some medications, as well as a clear defect in the supportive infrastructure.
C6 said: "I had told the hospital director about the disadvantages of the COVID department.I told him about the absence of proper ventilation system.Having one bathroom.No place for nurses to eat.No sink.No negative pressure and no proper staffing." C22 said: "Most of the clients were on CPAP and ventilators.Not all nurses had adequate experience of how to deal with those ventilation support equipment.We were originally a CCU team!Suddenly we became ICU team.The ventilation system was ineffective and there was no negative pressure." C12 reported: "oxygen, medications and escorts, were not available for some patients."C20 commented: "It was a COVID floor not an ICU, so I can't be with the patient for 24 hours.The hospital provided CPAP only for those whose oxygen level was less than 80%.Ventilators were only used for those whose saturation level is less than 70%.If the PPE was insufficient we didn't work with clients!" Theme 5: Physical symptom burden Majority of nurses suffered from physical symptoms secondary to their work during the pandemic such as headaches, lack of sleep, nightmares, pain in the knees, joints, muscles, bones, legs and back, lack of concentration, and loss of appetite.
C21 mentioned: "My concentration dropped significantly during the pandemic due to high stress.Nursing work during the crisis had brought muscle and bone pain and headaches.We were officially running on pain killers!" C13 said: "Till the moment (January 2, 2022) there has been no continuous sleep.I have nightmares.I see the patients strangulating me especially those patients who were arrested and resuscitated!The maximum sleeping time was three hours."C10 added: "I didn't take care of my self during the pandemic, so I didn't take my vitamins.I experienced knee, back, joint and bone pains and headaches."

Theme 6: Emotional burden
There were 6 subthemes that represented the most dominant emotions.

Subtheme1: Anxiety, fear, and anger
Anxiety and fear were significantly dominant in the analog with the interviewed nurses.Fear for themselves, their families, patients, other people, risk of infection, complications, death, and stigmatization.
C4 said: "I was afraid to infect my family or anybody.I didn't see my Mum for five months.I never went back to Ajlune during the peaks."C3 stated: "I was afraid that anything bad could happen to me because I had seen a lot of young people who were medically free and gone to ICU.I had seen others who developed lung fibrosis and went home on oxygen therapy!" C12 commented: "people died from COVID.I was always afraid even after me and my family got the infection!I used to shower immediately and washed my clothes.I didn't blend with people to avoid contaminating them."C9 added: "I was so afraid from the situation.I was afraid for myself and my family.
My brother was afraid from me despite me taking all the necessary precautions.He left home for two days!At first I resented this.I felt Forsaken!"C13 explained: "I was lonely and afraid for my family.There was a constant feeling of dereliction because all of patients died.In March, April and May, no body reverted post CPR.The patients died suffocated or chocking." In a much related sense, nervousness, anger, and loss of temper were characteristic moods of some nurses because of the high stress.
C13 said: "I was always wondering whether the PPE could 100% protect me from infection.I didn't allow my family members to enter my room, and they understood that.I became so nervous, ill-tempered and so hasty in decision making.It was easier for me to misinterpret any person's talk and be angry with him!I didn't want to talk most of the time!"

Subtheme 2: Empathy and sympathy
Remarkably, empathy with patients and their stories was reported by nurses.It reflected the very sensitive, humanistic, and professional aspects of nurses' personality.
C4 said: "The patients who were on BiPAP were frequently asking for water.It was difficult for them to drink because of the device.But, I used to wet their lips.The deaths and the clients yawning, all affected me when I went home.The son wanted desperately to see his parents.Those events had pushed me to think what would happen if I were in their situation?"C21 narrated: "We started to care more for our clients physically and psychologically.We joked and laughed with them.We called the families whose relatives were intubated to see them.I remember the first pregnant female client who was 28 years old.We had tried everything with her.She had been given all the medications including Actemra.There was an argument whether to deliver her or not.The mother wanted the baby to see life but the family preferred the mother over the baby.Eventually a cesarean section was done.Her saturation level was 82-84% and she was put on BiPAP, then she improved and was put on simple face mask.We were so happy with the improvement.She was mobilized but unfortunately she developed fever and pulmonary embolism a couple of days after and given an intravenous thrombolytic.But nothing worked.She passed away.Everyone empathized at every single moment with her and we were all touched by her departure." Unfortunately, some nurses exceeded the safe borders of empathy to the dangerous edges of sympathy.They went through tough suffering and a wide range of intolerable feelings.
C5 reported: "a 36 years lady was on cortisone though she died very quickly.I was sad for her husband and children.I imagined myself in their place and that feeling was tough." C4 illustrated: "the suffering and the moaning of the dying clients accompanied me home!" C13 said: "Nothing could express the shock that I was in.Suddenly, the face of the client turns to a face of a beloved one.I was afraid that today I am working with this client but tomorrow, I could work with my mother!That feeling was unbearable."

Subtheme 3: Compassion fatigue and depression
Many nurses reported deep feelings of shock and intense psychological trauma due to the rapid unexpected losses and the preceding clients' suffering.Nurses who were managing COVID-19 patients were experiencing high risk of depression and compassion fatigue.
C21 said: "A lot of clients were on mechanical ventilators.Numerous codes and deaths.All contributed to my depression and compassion fatigue." C13 added: "At the beginning of the crisis we thought that everything was okay.We had misestimated the whole situation and we were emotionally shocked.If you close your eyes for seconds a client could die!It was so difficult to separate life from work."

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Subtheme 4: Sadness
The feelings of sadness were frequently reported because of patients stories.
For example, C4 said: "I felt severe sadness for the mother who had lost two sons in a car accident.Then, she lost her remaining Asthmatic 23 years old son with COVID."C22 told us that: "There was a prisoner whose hands were cuffed to the bed and a cup was watching him.His lungs were collapsing.He was in terror.I can't forget his eyes.I was touched.I told the cup to un-cuff him and told the client not to worry anymore!He passed away!" Subtheme 5: Burnout Some nurses threatened every day to quit.They were totally burntout.
C25 said: "I planned to quit.I could work as a driver instead!" C23 said: "I was so depressed to an extent that I was ready to quit nursing!"

Subtheme 6: Hopelessness and helplessness
Nurses felt so desperate when it came to the ultimate outcomes of COVID-19.Negative feelings of losing hope and being unable to offer help to postpone or hinder death were overwhelming and prevalent.
C25 said: "I felt detached from reality during the COVID-19 CPRs.I felt so helpless when the patient dies.I felt so lost"(Facials were full with emotions mixed with terrible silence).
C22 illustrated: "Burial and shrouding of COVID-19 clients was a complete horror.Their pictures are not leaving my mind.The moments of death and the horror in their eyes because their families were not around!You knew as a nurse that the patient is totally heading towards his grave but you couldn't tell; and the patient himself didn't know that he is dying!"C23 elaborated: "I felt so helpless during COVID times.Even with expensive drugs available like ECMO and IV immunoglobulin.All seemed so irrelevant and useless.
Thousands are spent but no difference is brought!Depression is escalating with don't resuscitate cases (DNR).It was a mixture of losing hope!" C5 closed: "Sometimes a thought keeps crossing your mind that this client is definitely going to die.I don't give him life and I was unable to win him extra time.In such context, it was so difficult to deal with the clients."

DISCUSSION
During COVID-19, nurses were immersed in ominous moments through which they were testing their stamina, patience, tolerance, adaptability, and faith.Nurses used both adaptive and maladaptive coping strategies to manage their stress and emotional pain.On the adaptive coping side, Jordanian nurses utilized social support, sleep and rest, and faith-based beliefs such as God's control of our lives, inevitability of death, certainty of predestiny, and belief-based practices, eg, praying, reading the Holy Quran, asking for forgiveness, and prayers.Sehularo et al reported similar findings. 11On the maladaptive coping side, some nurses turned to less resilient coping strategies, which included some forms of substance use such as increasing their coffee and cigarette consumption, taking analgesics to ease their headaches and physical pain, and ingesting pills to facilitate falling into sleep. 23Suhalaro's review revealed the avoidance strategy to be frequently used by nurses to manage their caring associated stress. 11To compare against, a study from Poland reported use of active coping and planning frequently but the least used strategies were behavioral disengagement and substance use. 24he second part of our qualitative study covered the burdens encountered by nurses during the crisis.On behalf of the professional relationship burden, nurses described their supportive relationship to be facilitative to their caring role. 25On the contrary, nurse and patient's family relationship was ambiguous, troublesome, complicated, and ambivalent.It seemed that eliminating the

Burdens and Coping Strategies During COVID-19 Pandemic
visitations and/or limiting them had created a bipolar outcome.Thus, some nurses felt relieved because there were no body to bother them.Others felt severely stressed because there were no body in the patient's room to watch for him, help in the care, and ask for help in cases of suffocation, desaturation, falling down, or collapse.In fact, scarce literature discussed this very specific aspect during the pandemic.But Guttormson et al documented that nurses complained from lack of family presence in the ICU. 26In a different sense, Keen et al discussed the viewpoint of nurses about the importance of their role as a family-patient liaison during the pandemic, which helped in minimizing nurses' moral distress. 27he third aspect of the professional relationship burden showed a shift in paradigm of some nurses to a more active role in communicating with COVID clients in spite of the standing fear of being infected.Shin and Yoo emphasized that South Korean nurses proactively provided care for COVID-19 clients and accepted their roles in protecting lives and implementing effective communication strategies even in deviated health situations. 28he fourth dimension of the relationship burden focused on the nurse-manager relationship.Some nurses believed that it was supportive, and others said it was definitely unsupportive and the rest viewed it as neutral.Roe et al documented that communication with management varied within levels of leadership.They stated that communication with leaders was frequent but confusing.The first-level leadership was supportive, but other levels were non-appreciative. 29heme 3 discussed 2 major personal burdens of the pandemic, which included the social distancing effect on family dynamics and cost of social status.First, social distancing helped in cutting the risks of infection but gave birth to negative social consequences such as isolation, loneliness, lack of social interaction, difficulty in finding day/ night care for children, and a distorted way in saying goodbye for the dying beloved ones. 30Häussl et al matched our findings. 31cond, the cost of social status during the pandemic such stigmatization by family members, increase life demands especially for nurses who had children, lived with or cared for elderly, divorced with children, single mothers and younger single nurses (less than 26 years); were all reinforced by various studies. 32hereas theme 4 proved that COVID-19 pandemic came with multi-arm environmental burden.First, ambiguity in COVID-19 changing policies, protocols, and managements was confusing, and it did not help nurses do their job and increased their stress when thinking of their safety and patients' ultimate clinical outcomes.Durodié confirmed that perceiving ambiguity in health information, ie, uncertainty elicited from believing information that lacks credibility, reliability, or adequacy, is typically associated with pessimistic appraisals (eg, high perceived disease risk). 33This was transcribed by nurses decreasing their entries to patients' rooms, minimizing therapeutic interaction time, limiting the medication frequencies, and a dramatic feeling of doubt that none of COVID trial managements would help or cure. 34econd, PPE and isolation precautions created burdens.Jose et al twinned our findings and emphasized adverse health effects of PPE.For example, headache, extreme sweating, difficulty in breathing, nasal bridge scarring, and pain on the back of the ears. 35esides, the combination of workload and the impermeable nature of the PPE increased the heat strain.The National Healthcare Communication Program stated that when clinicians wear the PPE, they appear intimidating to the patients, mask non-verbal communication, and make hearing difficult. 36Our findings focused more on the time required to wear the PPE, the drop in number of patient room entries due to the need to wear it, suffering of smoker nurses, and a tiring system of 2 hours in/2 hours out.Besides, some nurses reported that if the PPE was unavailable, they would not enter the room.The PPE mandated badly affected salvaging clients in life-threatening conditions and was negative

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CRITICAL CARE NURSING QUARTERLY/JULY-SEPTEMBER 2024 on the risk of falling down due to the time required to wear it.Third, low morale of some nurses was exposed during the crisis, mostly in the form of low quality and low quantity of provided care.Some participants reported criticisms especially of redeployed nurses who were assigned to COVID-19 care centers.This finding was supported by Drake, who rationalized low team morale during pandemics by saying "stress, distraction and fear can bring low morale."She suggested that stress decreases morale by causing fatigue that lowers productivity, and it can lead to division replacing unity and criticism over caring. 37Disappointment could be tackled by more days off, but if not feasible, ways should be found to let staff members exit work environment during their shift, eg, outdoor break times.
Fourth, there was a lack of financial reward for being on duty while others were paid and at home; in addition, there was at kind of inequity in risk of exposure to patients with COVID-19 when compared to resident doctors or specialists who kept their exposure to a minimum (may be because they were afraid for their lives).We quote from Guttormson et al "physicians were unwilling to go into the patient's rooms.That staff created a sense of injustice and dissatisfaction among nurses." 26Specht et al reported that nurses took responsibility and were ready to contribute to whatever necessary during the pandemic, but they expressed the importance of financial reward. 38ifth, unpreparedness to deal with COVID-19 crisis imposed a dual challenge: (a) the rapid and unexpected deterioration of COVID-19 patients combined with high mortality rates and (b) a fake sense of readiness to manage COVID rhythms.A panel created by WHO concluded that the world was unprepared for the COVID-19 pandemic and remains vulnerable to the next major health crisis.They reported that political focus to prepare for more waves is flagging, and at the current pace, transformative change will take years to complete.They stated: "each death is a personal loss and has reverberating health, social and economic impacts on families, communities and countries.These losses were preventable but not prevented."Finally, the panel's extensive investigation revealed failures and gaps in governments' national and international responses, which sadly failed to protect the public. 1lthough Jordan was among the first countries to implement highly strict preventive and control measures, the Jordanian preparedness and response strategy can benefit from the ongoing global experiences and scenarios regarding COVID-19 pandemic. 39Thus, countries, including Jordan, must take serious steps to strengthen their health care system capacity in order to be well-prepared for similar crises in the future. 40Such steps must contain having a sufficient reservoir of medical devices and PPE as well as a backup of highly trained health care staff of critical units, generous emergency response fund, high and consistent individual compliance with the preventive measures, collaborative efforts in providing critical decisions during crisis times, adopting and implementing very precise technical WHO guidelines in emergency health situations, maintaining high levels of awareness within the society, strengthening and operational translation of the government-society partnerships, having a well-formulated national preparedness and response strategy with effective leadership, and implementing internationally standardized guidelines in crises management. 41he final 2 subthemes in the environmental burden were workload and care demands and a lack of supplies, equipment, and experience.In this regard, our respondents reported a fluctuated workload between high and acceptable levels, which differed significantly between variable units, floors, health settings, pandemic waves, and redeployment to other work places.Nevertheless, those nurses who reported high workloads and severe fatigue assured that they did not neglect their patients and gave them full care, on the

Burdens and Coping Strategies During COVID-19 Pandemic
expense of their self-care, own comfort, family, and home duties.
Besides, nurses who cared for critically ill COVID-19 patients, elderly, weak, people with dementia, those on ventilators, and oxygen delivery systems complained of high around the clock care demands even in the very basic needs, which was exhausting physically and emotionally.Challenges extended to involve a lack of supplies such as PPEs (sometimes), some medications, equipment such as BiPAPs, CPAPs, and ventilators, and sometimes being unable to operate some imported technologies like intravenous pumps.Along with the juniors lacking any experience, there were also challenges such as reallocated nurses lacking ICU experience and not knowing how to manage clients on ventilators, and everybody not quite sure about the accurate COVID-19 effective case management or sound protection precautions.
Those findings were supported in literature.Bruyneel confirmed that there was a significant increase in nursing workload during the COVID pandemic.Given the impact of the high workload on both the risk of burnout of ICU nurses and the quality of care, he emphasized a need to reassess ICU nursing staff requirements to adequately manage new waves of COVID-19 and recommended further research to explore possibilities for deployment of non-ICU nurses on the ICU. 42urthermore, Hoogendoorn et al results showed both a significant higher number of patients per nurse and a significant higher Nursing Activities Score per Intensive Care nurse (76.5 vs 50.0,P < .001) in the COVID-19 period compared to the non-COVID period.The Nursing Activities Score was significantly higher in COVID-19 patients compared to both the pneumonia patients and the non-COVID patients, mainly due to more intense hygienic procedures, mobilization and positioning, support and care for relatives, and respiratory care. 43Besides, PPE shortages were many times reported around the globe and in the United States, especially during the first 2 waves and tracked by health care organizations. 4 Theme 5 conveyed nurses suffering from physical symptoms secondary to their work during the pandemic such as headaches, lack of sleep, nightmares, pain in the knees, joints, muscles, bones, legs and back, lack of concentration, and a loss of appetite.Similar findings were reported by Barello et al, where 45% of their sample experienced with high frequency at least one physical symptom in the previous 4 weeks.In particular, increased irritability, change in food habits, difficulty falling asleep, and muscle tension and moral distress. 44he final discussed theme was the nurses' emotional burden.The most reported emotions were anxiety, fear, anger, empathy, sympathy, compassion fatigue, depression, sadness, burnout, hopelessness, and helplessness.Many studies around the globe had emphasized similar emotional outcomes of the pandemic.For example, Kishi et al analyzed 895 questionnaires of nurses' Accumulated Fatigue and Japanese Burnout Scale and found significant relationship between engaging in COVID-19 care and psychosocial/physical burden particularly in the form of distress, emotional fatigue, emotional exhaustion, and burnout risks. 45Whereas Molina-Mula et al survey of 892 Spanish nurses confirmed the presence of emotional fatigue, anxiety, moderate posttraumatic stress evident in general nurses, and severe posttraumatic stress evident in ICU nurses. 46esides, Pisanu et al ascertained psychological distress among nurses during the first COVID-19 outbreak in Italy.Female and younger respondents experienced more frequently negative emotional states such as irritability, anxiety, loneliness, and insecurity. 47n behalf of our study participants, anxiety and fear were provoked mainly by the risk of getting or transmitting the infection to family, other people, and the beloved ones, fear of death, fear of unknown, and sometimes due to lack of experience, especially younger nurses.While the provokers of sadness were the patients tragic stories and their families losses, especially when young people die, leaving their mothers or children behind.The triggers of anger and loss of

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CRITICAL CARE NURSING QUARTERLY/JULY-SEPTEMBER 2024 temper were basically work burden related, especially with COVID-19 protocols, stress, grief, moral distress, and infection precautions.Helplessness and hopelessness were stemmed from the fact that nurses were seeing people dying along with the associated high rates of failed cardiac and pulmonary resuscitations despite of all the high price of medications, advanced management, and efforts to preserve lives and improve clinical outcomes.
Compassion fatigue, depression, and burnout are interrelated emotional phenomena. 48ajority of our respondents reported those negative feelings, which were attributed mainly to the high unprecedented mortality rates, poor clinical outcomes, and being occupied with and hyper-vigilant to excessive patients' suffering and families' emotional reactions.In brief, nurses were emotionally shocked by reality and could not separate work from life.Nurses' emotional responses to patients' stories fluctuated between empathy and sympathy 49 .][52] This "emotional surge" sadly had the likelihood to exhaust the medical care system for as long as the public health crisis lasts.

Strengths and limitations
This study included different ranks of nurses of variable demographic and social characteristics, which made the sample heterogeneous.The picked clinical settings and units included a wide range, which made some participants' experiences deeper, richer, and more intense than those of others.In spite of that, most of the participants ended up recalling similar stories with consistent impacts.It could be concluded that, at the interview time, our participants were at the beginning of the emotional recovery state, but the memories were fresh and touching as some of them burst into tears or tried to hold tears, their facial expressions betrayed them, their body language was exposing the moved inner state of mind, and there were severe moments of meaningful silence.

CONCLUSIONS
This study is unique because of the indepth filming of the nurses' experiences during the COVID times in Jordan; it gave us the impression that nurses' experiences unite in hardship.The need for care to be given to the caregivers must be emphasized constantly at this point of recent history.Nurses cannot keep giving endlessly without being looked after, listened to, nourished, and properly and continuously supported and rewarded.Policymakers and nursing administrators are recommended to actively ensure nurses stay resilient during pandemic challenging times.Moreover, increasing awareness about compassion fatigue, depression, empathy, sympathy, substance use, spiritual power, resilience, and effective coping strategies with life and work stressors should be introduced and enhanced during preparatory nursing profession education.Further qualitative research may shed more light on the psychological distress "after effects" on nurses' life and work viewpoints and decision-making approaches.Another research focus could be lent to an in-depth investigation of nurses' substance use, coping, resilience, and spiritual power when implied in crisis situations.Finally, the nurse-patient's family relationship in stable and crisis situations requires to be analyzed and understood more profoundly.

Relevance for clinical practice
Nurses' physical, mental, emotional, and spiritual health and coping strategies during the COVID-19 pandemic affected their way of comprehending and dealing with their selfcare, family dynamics, patient's care, communication styles, work environment, and professional future expectations, potentials, and

Ethics approval and consent to participate
Ethics approval was obtained from the ethical and scientific committee in the School of Nursing, University of Jordan.Then, a second approval was collected from the Deanship of Academic Research, University of Jordan.Afterward, the University of Jordan institutional ethics review board's approval was granted.Finally, ethics approval was obtained from the Ministry of Health in Jordan and the ethical review boards of the included hospitals.Hereby, we declare that the informed consent was explained, handled, and signed prior to data collection, with the rights to refuse to participate and to withdraw at any point after acceptance of participation emphasized to nominated participants along with no harm principle in accordance with the Declaration of Helsinki. 53
Burdens and Coping Strategies During COVID-19 Pandemic prospects.Nurses must be supported psychologically by reinforcing positive coping strategies, offering ventilation systems, open dialogues, support groups, and professional mental health help at regular basis, not only in crisis times.Standardized operational and clinical guidelines should be grounded to facilitate nurses' preparedness for the recurrence of COVID-19 waves and any future pandemics.

Table 1 .
Example of Theme Development: Emotional Burden a

Table 2 .
Demographic Characteristics of the Participants Abbreviations: m, male; f, female.a Withdrawn.b He was a clinical instructor.