Design
A qualitative interpretative phenomenological methodology was applied as it seemed to be one of the most useful research approaches in exploring nurses lived experiences, burdens and coping styles during the COVID-19 emerging context. It had offered the chance to “ use nurses word of mouth” rather than to offer them scales and prepared set of optional answers that may or may not touch, approximate or capture the essence of the true meaning of their experiences (Tuffour,2017).
Study Participants And Sampling Strategy
Purposeful sampling method was carried out, guided by pre-specified inclusion criteria. The first criterion was to include nurses who hold field work not administrative roles. The second criterion was to choose nurses who had worked at least six months with active COVID-19 cases on a regular basis especially during the first two pandemic waves in Jordan which had peaked on (18, November,2020 and 17, March,2021) respectively ( Ministry of Health, 2021). It worth mentioning that the third pandemic wave had approximately peaked in Jordan on 21, November, 2021 (Arabic CNN, 2022) and the fourth wave had peaked on 18, February,2022 (AlmamlakaTV,2022).
The picked clinical sittings composed from a major academic hospital, major semi-governmental hospital, large private hospital, central governmental hospital and nurses from COVID-19 field hospitals. The principles of data saturation were rigorously employed where the data were considered sufficient, indicated by in-depth redundant data on interview number 18, though two more interviews were conducted to confirm saturation (Saunders, 2018).
Data Collection
Data were collected between 1, October, 2021 and 15, April,2022. The research team headed towards the selected clinical settings and held prescheduled meetings with nursing managers and supervisors to facilitate data collection processes. Then, the research idea was explained to nominated nurses, consent forms were read and interview guide was delivered as a printed version. All inquiries were answered especially those related to anonymity, privacy and confidentiality before heading to a private spot to sign the consent and perform the interview. The interview time ranged from 45 minutes to 75 minutes.
Participants refused to use audiotape device for recording because of the sensitivity of the discussed topic and a vague sense that a legal implication could pursue; in respect to that two research assistants participated in each interview, one of them led the questions while the other handled the immediate verbatim transcription in the interview manual which was designed with appropriate spaces to contain the provided answers. The paper-based research manual was based on a highly relevant literature review and revised by three specialists in the field. It was specially prepared to give deep-enough comprehensive insights into the studied phenomenon (Busetto et al, 2020) .
Data Analysis And Rigor
Thematic content analysis was carried out by three researchers who executed regular weekly sessions to analyze the research manuals one by one. Open coding was initially done to identify words with similar meanings (Lorelli et al, 2017). Focus coding was conducted to group codes that sounded similar, a process which ended up with formulation of the preliminary themes. Constant comparative method of data analysis was adopted to make sure that all data are checked, coded, categorized and compared thoroughly (Cypress, 2017). Disagreements on themes and subthemes were discussed constantly and reached consensus. Ultimately, a revision process was run twice to ensure credibility and trustworthiness of analytical decisions. Those decisions were enhanced through reflexivity process that included writing reflective journals, memos and appropriate referral to supportive literature (Forero et al, 2018). In addition, other researchers were invited to cross-check the themes to reduce subjective bias and confirm the findings, conclusions and recommendations (Johnson et al, 2020).
Findings
Table 1 shows the socio-demographic characteristics of the participant nurses who were assigned numbers to ensure anonymity and non-traceability. The ranks ,work places and units are not reported to further minimize the chance of identifiability. The sample included a total of 20 nurses, 10 staff nurses with Baccalaureate level, 3 nurses with diploma level, 1 PhD holder, 6 nurses with master degree. The average age of participants was 34.15, the youngest participant was 24, while the oldest was 48 years old. The average nursing experience was 10.9 years with a minimum reported experience of 1 year and a maximum experience of 25 years. 9 nurses were married, 2 divorced and 6 single. Male nurses were 9 and females were 11.
Table 1
demographic characteristics of the participants
Code | Age | gender | status | experience | Education |
C1 | 38 | F | divorced | 17 | Bsc |
C2 | 37 | m | married | 14 | Bsc |
C3 | 36 | m | married | 11 | Bsc |
C4 | 37 | m | single | 12 | Bsc |
C5 | 36 | m | married | 11 | Bsc |
C6 | 48 | F | married | 25 | Bsc |
C7 | 36 | m | married | 16 | Master |
C8 | 31 | F | married | 10 | Master |
C9 | 35 | F | Single | 14 | Bsc |
C10 | 26 | F | married | 5 | Bsc |
C11 | 30 | F | married | 8 | Diploma |
C12 | 33 | F | divorced | 10 | Diploma |
C13 | 26 | m | single | 6 | Diploma |
C14-C18* | | | | | |
C19 | 32 | F | single | 7 | master |
C20 | 35 | F | married | 13 | master |
C21 | 35 | m | married | 13 | master |
C22 | 34 | F | single | 10 | Phd |
C23 | 24 | F | single | 1 | Bsc |
C24 | 34 | m | married | 13 | Bsc |
C25 | 40 | m | married | 2** | master |
m: male, F: Female *withdrawn ** he was a clinical instructor outside Jordan |
Table 2
Theme/subtheme | 1 | 2 | 3 | 4 | 5 | 6 | 7 |
Nurses coping with COVID-19 crisis | Positive coping strategies | Negative coping strategies | |
Professional relationship burden | Nurse – Nurse | Nurse- Patient’s family | Nurse- Patient | Nurse- Manager | |
personal burden | Social distancing effect on family dynamics | Cost of social status | |
environmental burden | Ambiguity | PPE strain and isolation precaution | Low morale of some nurses | Lack of financial reward | Unprepared-ness to deal with COVID19 crisis | Work load and care demand | lack of supplies, equipment and experience |
Physical symptom burden | |
Emotional burden | anxiety and fear | Prodromal of emotional distress | Nervous-ness and anger | Hopelessness and helplessness | Empathy | |
Six themes had 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. As shown in Table 2 along with the relevant subthemes.
Theme 1: Nurses Coping With Covid-19 Crisis
During the COVID-19 pandemic, it was understandable that nurses were fighting 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, minds and bodies. There were two subthemes here.
Subtheme 1: Positive Coping Strategies
There were three main reported positive coping strategies. First, many nurses described talking to significant others (social support) such as a mother, a grandmother, a wife, a friend, a colleague or a relative as a major technique to help ease turbulent emotions and stressful thoughts. C4 said: “ talking with family and friends helped me during the crisis”. Second, after along tiring day, physical rest and sleeping helped. C2 said: “ having rest at home after a full day of pressured work helped me through the crisis”.
Third, many participants turned to “faith based beliefs and practices” which helped them float during tough intolerable times especially for believers who think that a higher power has dominance over their lives, things are predestined and death is a final destination for every living creature; it can’t be avoided no matter what, 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 highest price medicines. I reached a conclusion that age is predetermined even with the artificial lung! Spiritual beliefs are so important and they helped me so much during the crisis, I am so astonished from people who don’t believe in death and after life, my psychological distress made me unable to argue with them. Money doesn’t mean anything and it doesn’t take you away from death.”
Subtheme 2: Negative Coping Strategies
At the times of adversity and hardship, some nurses turned to less resilient coping strategies that could help them escape reality and avoid thinking or overthinking. Substance use is one mechanism of negative coping. The interviewed nurses reported over drinking coffee, increased smoking, turning to use electronic cigars because they could be used easily anywhere, taking panadol/Panda or non-steroidal anti-inflammatory drugs (NSAIDs) as Brufen for stress induced headaches, smoking shisha, Panadol night alone or combined with serdalod to ease falling into sleep, power drinks to keep awake, deanxit to reduce anxiety.
C2 said : “I used to drink 400 ml coffee before the 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 level. Then I quit regular smoking and turned to electronic cigarettes; I started to smoke everywhere at home, at work and in the car”. Besides, 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 3mg, 2 tablets”. He added: “ I watched TV movies for 9 continuous hours to escape reality”. The last quote describes another negative coping and reality escape mechanism which is “TV addiction”.
Theme 2: Professional Relationship Burden:
Four subthemes emerged which were nurse-nurse relationship, nurse-patient’s family turbulent relationship, nurse-patient relationship and nurse-manager relationship.
Subtheme 1: Nurse-nurse Relationship
It was evident that nurses were like soldiers on the fire frontlines; they were back to back. It was almost unanimous that the relationship between nurses was supportive during the first pandemic waves. It was almost instinctual for them to simply understand that at the end of the day we 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 Turbulent Relationship
Nurse-patient’s family situation was a dichotomous relationship which was most approximate to the word “ weird”. Some nurses felt relieved and less stressed because there were no visitors to bother them with redundant inquiries, multiple complains and extra tasks to perform. On the contrary, the other aspect was expressive for the need of the family to be there, at the bed side, and to participate in the care as well as in the direct supervision of their sick family member. Many nurses attributed that to a desire to minimize portion of the care burden, to be lent a hand during providing patient’s self- care, to have someone attending all the time to monitor the patient, report deviations from normal and escort patient to the bathroom, feed, return oxygen devices and call for help in case of need or emergency. C3 reported: “the absence of patients’ families “visitors” helped me focus during the COVID crisis and time was more available… with the quarantine my worries faded and the load became less because I only communicated with the clients not with 100 clients’ families”. While 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
Nurses are usually overloaded and the time for communication with clients is kept to a minimum. Because of the COVID-19 special nature, isolation of infected clients which mitigates their social interaction chances, special end of life emotional needs, and a kind of nurses emotional involvement with patients challenging experiences; some nurses shifted their formal communication paradigms and took a more active role. For example 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, but I was anxious from staying too long in the room due to the fear of infection transmission”.
Subtheme 4: Nurse-manager Relationship
Relationship of nurses with their managers and direct supervisors during the pandemic was variable in nature. It 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”. On the other hand, C23 said : “ my manager had a very negative role. There is no empathy, no encouragement, nor appreciation! Those who did mistakes were exposed in public and that was totally wrong! He refused to let me leave early one day and I committed a medication error ”. Finally, C4 said: “ My supervisor was cooperative and understood the psychological and physical burdens of the COVID times. He arranged the schedule well. Verbal recognition was given constantly. The break time was good. He used good manners in dealing with the staff nurses but financial reward was lacking”.
Theme 3: Personal Burden Of The Crisis
Nurses revealed two challenges at the personal level during the pandemic 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 in more than one way to nurses and their families. Some nurses were relying on their families to care for their children or as a resort for time out and social life but due to the lock down and geographical distance, they were unable to reach such destinations and a relative state of loneliness and a sense of isolation resulted.
Besides, mourning for the beloved ones took a totally different mode where you couldn’t hug your diseased or say good bye to him nor funeral houses were allowed to let neighbors and friends play consolation role. Finally, nurses were reluctant to hug and kiss their children or socially interact with their fathers, mothers and beloved ones, some nurses even forbade themselves voluntarily 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.” Whereas C21 said: “ My grandmother passed away in the COVID time, when it was forbidden to see and say good bye to those who die due to the unfamiliarity with the contagiousness of the disease. I can’t talk right now about my feelings towards her. And he fell in tears.” 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 (marital status of the nurse, caring for children and elderly)
During COVID-19 difficult times nurses with family responsibilities and family members to care for were the most challenged. For example, some nurses were married with children, some children were so young and require more 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 deal with COVID patients and simultaneously carry 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 who is a new mother of a 70 days baby and a boy who is one year old said : “ married female nurses were in severe struggle during the pandemic and before that as well. 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, with my husband, my children and caring for the cleanliness of the home. I communicated less with my husband and he complained because of that. I didn’t show affection to my eldest son due to lack of time.” While 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 and children safe and away from the COVID risk. I had to teach my children after doing two rounds shifts because the learning during the lock down was totally online. The father was totally absent!”
Theme 4: Environmental Burden Of The Crisis
This theme is composed of seven subthemes which are: ambiguity, PPE strain and isolation precautions, Low morale of some nurses, Lack of financial reward and nurses feeling of injustice and dissatisfaction, 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 of the disease. The protocols were frequently changing and conclusive evidences were critically lacking.
C9 reported: “ It was a totally new experience! Everyone is learning. Every time we are trying a new COVID management protocol. The doctors try it then stop it. I felt that whatever we do with the COVID patients who are on CPAP, BiPAP or ventilators; their condition will never improve. I felt so disappointed and I thought that this virus is manufactured! Every client is affected in a different way. No case scenario is similar to the other. At the beginning, things were so confusing!”
Subtheme 2:ppe Strain And Isolation Precautions
It was unanimously stated by interviewed nurses that wearing the PPE to provide care for the COVID patients was a real torture especially when worn for long times and when the nurses involved in the care were smokers. They added that it was lengthy to wear the PPE, 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. There was no family member to help or to call for help!”. Whereas 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 in front of me. 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 specially those who were redeployed from other hospitals to the COVID-19 care centers, had low morals, weren’t professional and didn’t meet the minimum standards of nursing care during their duty days. For example, C23 said: “ Some nurses had no conscience! They took temperature once per shift. They worked two hours and rested for the rest of the 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 And Nurses Feeling Of Injustice And Dissatisfaction
All interviewed nurses almost felt certain injustice during the COVID-19 duty days because they were not sufficiently financially rewarded, or didn’t 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.” 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 paid week 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 Crisis (A Dual Challenge)
Unpreparedness to deal with the emerging COVID-19 was a dual challenge which included: the rapid and unexpected deterioration of COVID patients combined with high mortality rate, and a sense of fake readiness to manage the escalating COVID rhythms.
A-the Rapid And Unexpected Deterioration Of Covid Patients Combined With High Mortality Rate:
Nurses expressed that they weren’t used to rapid deterioration and sudden collapse scenarios especially for younger populations or for 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, by any means, prepared to deal with, endure or accept.
C22 said: “ During the second peak there were a lot of mortality in hospital and in the family”. 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 who was ready to be transferred to the floor, then all of sudden his lungs collapse and fail! It was something difficult to absorb. COVID nature is not foreseeable. Deterioration and death can ensue within minutes or even seconds!” Whereas C20 commented: “…a patient who was 36 years old and he had a chest tube. He was calling us repeatedly. We thought that he was nagging and a bad tempered client…we got shocked! He was fighting death and those calls were his last ones in life. We found him dead in his room minutes later. We were sorry for him. We weren’t used to that rapid rhythm of deterioration and sudden death especially for young people!”
B-fake Sense Of Readiness To Manage The Escalating Covid Rhythms
Despite the national efforts to combat the virus and the huge budgets which the ministry of health had located for prevention, vaccination and treatment of COVID-19, there were shortages, gaps, weaknesses and lack of proper training specially on the new imported machines. It worth telling that a percentage of relocated nurses to COVID care units hadn’t any ICU experience and didn’t know how to manage ventilators. It seemed that the nursing bodies were managing at the microcirculation level, rather than on the higher managerial or strategic levels.
C21 said: “ My direct supervisor helped as much as he can; but the 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 two peaks but may became less later on secondary to certain action measures such as decrease number of admissions, closing outpatient clinics, over-phone consultations, renewal of medicines by delivery, and providing volunteer nursing and medical services at home level.
C10 said: “ Number of patients was huge. More than 50 patients and only assigned nurses will take care of them. 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. We asked the doctors to insert nasogastric tubes for them…” C3 highlighted: “ People are 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.” Finally, 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, BiPAP/CPAP, some medications as well as a clear defect in the infrastructure that supports a unit to receive COVID-19 patients.
For example, C6 said: “ I had told the hospital director about the disadvantages of the COVID department. I told him about the absence of a proper ventilation system. Having one bathroom. No place for nurses to eat. No sink. No negative pressure. And no proper staffing because the nurses were afraid.” While C22 said: “Most of the clients were on CPAP and ventilators. Not all the nurses had adequate experience how to deal with those 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: “There were a lot of patients whom the oxygen and medications as well as escorts were not available. They needed a lot of help.” At the end, 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 saturation level is less than 80%. And ventilators only 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 Of The Crisis
Majority of nurses suffered from one type or more of 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.
C21 mentioned: “My concentration had 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 (2, January, 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 had experienced knee, back, joint and bone pains beside headaches.”
Theme 6: Emotional Burden Of The Crisis
Subtheme1: anxiety and fear
Anxiety and fear were significantly dominant in the analogue with the interviewed nurses. Fear for themselves, their families, patients, other people, risk of infection, complications, death, stigmatization among many others.
C4 said: “I was afraid that I could infect my family or anybody. I live alone in Amman. I didn’t see my Mum for five months. I never went back to Ajlune during the peaks.” While C3 said: “I was afraid that anything bad could happen to me at any time 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!” Besides, 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 wash 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!” Finally, 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.”
Subtheme 2: Sympathy
Some nurses exceeded the safe borders of empathy to the dangerous edges of sympathy with their COVID-19 patients. They went through tough suffering induced experiences of wide range of intolerable feelings.
C5 reported: “ .. a 36 years lady who was on cortisone though she died very quickly. I was so sad for her husband and children. I imagined myself in their place and that feeling was tough.” Where 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 a kind of intense psychological trauma due to the rapid unexpected losses and clients’ suffering that was happening directly in front of their eyes, day to day and every day. 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.” Where C13 added: “ At the beginning of the crisis we thought that everything was okay…we had misestimated the whole situation, so we were emotionally shocked. If you close your eyes for seconds a client could die! It was so difficult to separate life from work.”
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 son who had asthma and was 23 years old with COVID”. And 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 severely touched.. I told the cup to un-cuff him and told the client not to worry anymore! Then, he passed away!”
Subtheme 5: Burn Out
Some nurses went so far in their stress levels until they reached a level that they were threatening almost every day that they will quit and look for another job. They were totally burnt out.
C25 said: “ I planned to quit.. Leave work.. I could work as a driver instead!” And C23 said: “ I was so depressed to an extent that I was ready to quit nursing!”
Subtheme 6: Nervousness And Anger (Loss Of Temper)
Nervousness, anger and loss of temper was characteristic of the mood status of some nurses both at work and at home because of the high unprecedented stress they faced during the pandemic.
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 those times to misinterpret any person’s talk and be angry with him! I didn’t want to talk most of the time!
Subtheme 7: 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). While 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!”
Finally 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 as well. In such context, it was so difficult to deal with the clients.”
Subtheme 8: Empathy
On the positive emotional scheme empathy with patients and their stories and conditions was reported by nurses who provided care to COVID-19 patients. Empathy reflected the very sensitive, humanistic and professional aspect of nurses personality.
C4 said: “The patients who were on BiPAP were frequently asking for water even a little. 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 reflected on me when I went home. The son wanted desperately to see his father or his mother. Those events had pushed me to think what would happen if I were in their very same situation?”
C21 added: “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 caesarian 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 a thrombolytic intravenous. But nothing worked out. She passed away. Everyone empathized at every single moment with her and we were all touched by her departure.”