The participants of the study were 18 people, 10 women and 8 men. The participants ranged in age from 24 to 42 years, including 6 physicians and 12 nurses, of whom 13 were married, and 5 were single. In the present study, participants fall into three general categories that contributed to the psychological distress of health care personnel. The first category included demands at 4 sub-categories: nature of illness, media coverage, and social and leadership demands. The second category was job resources and the third category was individual resources. The main categories each with subcategories described in Table 1. The data from interviews showed 236 open codes in 10 sub-categories and 3 categories were obtained in this context. Categories and subcategories have been shown in Table 3.
Table 3. Coding of participants’ experiences
Nature of illness
Shortage of supportive equipment
Shortage of manpower
Shortage of special equipment
Non-payment of arrears
Lack of vehicles
First category: Demands
Nature of the disease
The staff noted that the causes of the psychological distress, caused by the nature of the disease, included work overload, wearing protective clothing, ambiguity about the disease, quarantine, fear of infection, fear of being at work, sleep problems, fear of more outbreaks, and fear of more mortality.
Regarding workload, some interviewees cited high work pressure, hard work, difficult and stressful working conditions, and lack of vacations. For example, participant No. 1 said: “If I want to talk about the working conditions of nurses before corona, the working conditions were very difficult; now corona has been added to it, and the burden of stress and extra and new work has made the situation much worse”.
Difficulties of wearing protective clothing are another concept that most employees declared in sub-category named “the nature of the disease”. For example, participant No. 15 said: “Wearing a mask and gloves and also using a face shield for several hours are very difficult because it cannot be tolerated for an hour, but you have to endure it in six hours and you cannot even meet your basic needs”. The next factor is lack of awareness about the disease.
Another concept that causes discomfort is the lack of definitive treatment for the disease. Participant No. 15 said: “It causes us to have a lot of mortality here. The patient comes with a lung infection and we cannot do anything here. Those whose lungs are completely involved. We do not have the right treatment for them. The treatments are supportive to see how long the body lasts. On the other hand, Participant No. 8 said: “Every day they gave me a new protocol, every day they said to do this, tomorrow they said this is wrong, do that.” These issues were confusing.
Another concept of this section was the fear of attendance at work. Participant No. 9 said: “In the first days, there was a great fear among doctors and nurses which we all wanted to avoid accepting patients in hospital.” Alternatively, the participant No. 2 said: “the night we wanted to back work, we wished and asked God never back to the hospital.”
“Fear of infection” is another concept of “the nature of the disease”. In this regard, Participant No. 11 said: “I have been most concerned about my family since this period began. Anyway, every time I come here, the environment is polluted and there is a possibility that I will be the carrier of this disease. ” Also, participant No. 9 said: “The fear of getting sick was both for myself and for those around me and my family, I have the same fear right now, and this has made me nervous.”
Another concept in the nature of the disease was “quarantine”. For example, participant No. 8 said: “We cannot visit our families and public places like shopping centers, leisure venues, etc. Well, sometimes walking down the shopping gives people peace of mind that we are deprived." Or participant No. 2 said, “We cannot see our family. We have been in quarantine for about a month and a half now; we cannot even kiss our family members and friends. ”
The next concept in the nature of the disease is “repetitive work”. As participant, No. 8 said: “The repetition of days and things have really made the situation difficult. The monotonous repetition of daily work had a negative effect on our mind. ”
Worry of further outbreaks is another concept related to the nature of disease. Participant No. 1 said, “I am really worried about more outbreak.”
The next concept is the “death of patients and colleagues”. In this regard, participant No. 16 said: “The death of patients and colleagues, especially medical colleagues in different cities, had a very bad effect on us.”
“Sleep problem” are another concept of the nature of the disease. As participant No. 9 said, “I woke up frequently at night and I was stressed and dreaming of the dead.”
In the demands of the nature of the disease at the social level, the people's lack of attention to health and quarantine orders is one of the things that the participants called distress. For example, participant No. 11 said: “In this situation, I am afraid of people's negligence; some people are very careless. We see some who have no symptoms but come to the hospital to get a simple medicine, or some have symptoms but we see that they have no mask.”
Regarding “fear of stigma" on the class of demands of the community, the participant No. 9 said: “Once an ambulance driver did not allow us to sit in the front seat, because he did not want to get sick.” Or participant No. 2 said: “I am worried that the society will not accept us anymore. We even wanted to extend the rent of the house last month but they said that we are nurses and they did not accept us. ”
The Media coverage was listed in the nature of the disease to note that Media tend to overemphasize negative news. As participant number 4, said: “we all receive negative news, ambiguities and rumors about this disease”; also, participant No. 5 said: “Rumors and exaggeration of virtual networks and news bother me a lot.”
“Injustice” is one of the leadership and organizational demands, as the participant No. 8, said: “I think they are abusing us, indirectly said that this is your job and you have to do it”. Additionally, there is mistrust. In this regard, participant No.3 said: “Our most concern is that after the crisis, nurses would be forgotten again.” At this level, “the provision of compulsory services” was another issue that some employees pointed out, for example, the participant No. 10 said: “The fact that we had to work under duress and pressure bothered me and I was annoyed why I had to be forced.”
“Economic problems” were another distress at this level. For example, participant No. 8 said: “economic difficulties caused by sanctions in our country was one of my concern because the health system cannot meet the people needs well and this disease get out of control.”
Another concept at this level was “lack of transparency of managers”. As participant No. 6 said: “Lack of transparency of decisions taken.”
Another concept at this level was “manager’s anxiety”. The same participant said: “One of the main problems that bothered many staff was manager’s behaviors. At first, managers should be able to control their stress and should not suffer anyone, but unfortunately our boss and managers were in crisis themselves and could not lead the crisis.”
Another concept at this level was “lack of efficient management”. In this regard, participant No. 8 said: “Another thing that bothered me was mismanagement at different levels”. Another issue at this level was “misconduct of managers” as the participant No. 6 said: “very aggressive behavior of one of my managers made me very upset that all the staff had felt these behaviors and regretted the behavior of the senior managers”.
Second category: Job resources
In this category, participants discussed deficiencies in equipment and manpower that caused distress. For example, participant No. 9 said: “We saw how much stress our colleagues endured to get the protective equipment of masks and gloves in the first days of corona virus outbreak.” In addition, participant No. 5 said: “There has been a lack of personal protective equipment, including masks, clothes, gloves, etc., that nearly all hospitals face with this problem.”
Regarding deficiency and fatigue of human resources, participant No. 4 said: “There was not enough infectious and internal specialists and nurses in the center.” There were a lack of special equipment, as participant No. 6 said, “COVID-19 test was not taken from all of the personnel; it was taken if they had symptoms.” Improper nutrition was another issue raised in this category. Participant No. 15 said: “Another problem is that the children complained of poor nutrition. Some days the quality of food (dinner or lunch) they gave the staff here was not good.”
Another concept at this level was a lack of timely payment of arrears: “It is very annoying that our arrears that should have been paid years and months ago have not been paid. The lack of vehicles was also raised as a distressing issue. As participant No. 2 said: “We had a problem in transferring patients to our hospital; there is no car, or anything here."
Third category: Individual resources
In this category, participants talked about effective individual resources for reducing their distress during corona virus outbreak. These codes were included 5 categories: problem-oriented coping, compassion satisfaction, spirituality, personality traits and social support.
In the problem-oriented concept, concepts such as following the instructions, doing favorite things, gain valid information, lack of attention to news, and maintaining morale were obtained. For example, regarding the concept of following protocols, participant No. 4 said: “We provided the safety equipment for ourselves. We suggest what we should do. We emphasize hand washing, keep repeating the use of medical equipment and also keep our distance from the patient. We try to do more in this process.”
Participants No.3, regarding gaining a valid information concept, said: “We were searching, reading up-to-date articles, reading WHO site, and I was doing some research myself on the COVID-19. Now, I'm sending this article to Lancet Magazine, which I hope will be accepted. We tried to send each other up-to-date content, and this made it possible for us to reduce some of our stress and nervous problems. ”
“Doing favorite things” was another individual resources, which participant No.4 noted: “These days, I try to read more books in my spare time. I want to watch comedy movies and listen to my favorite songs.”
Based on the participants’ accounts of their experiences, compassion satisfaction with concepts such as empathy with the patient, the joy of improving patients' health, interest in people, and commitment to the patient may act as one of the effective individual resources for reducing stress.
Some participants mentioned empathy with the patient. As participant No. 12 said: “Mostly, patients' anxiety and worries bothered me, and made me very sad.”
Some participants mentioned that they feel satisfied with the patient's recovery. As participant No. 5 said: “If a patient is discharged and his family take him to leave the hospital, I will be fine.” Also, participant No. 12 said: “I felt good for helping, and I did not have any worries or fears. I enjoyed it more when I saw someone happy because I helped him/her. I felt satisfied.”
Spirituality was another category, including strong faith, and hope to God's grace and pray. Some participants, such as the participant No. 4, regarding spirituality, said: “I work in a place where, in return for the health of that patient, a smile comes to their lips makes me happy. I do this to please God and I hope this feeling will never go away.”
Another category included personality traits, including high self-confidence, challenging interest, realism, sense of humor, high adaptability, hope, courage, strong thinking, adherence to ethics, relax, and flexibility.
Participant No.14 noted about interest in the challenge as a personality trait and said: “What makes my situation more bearable for me is that I really like the challenge and I hate working behind the desk and doing a routine job.” Participant No. 11 noted a high compliance capability with these statements: “I adapt myself very quickly to each situation. Of course, sometimes I was grumbling, but it did not make me very upset, or I did not care about others' bad behavior. ” In this regard, for ‘humor’, participant No. 3 said: “at work, we try to do fun to make the space happy.”
Finally, in the social support category, we found concepts such as teamwork, talking with friends, appreciation of nurses, and video call with family. Participant No. 13 noted: “When I saw people thanking me or saying we would like to take photo with you, and when I saw people's good reactions and awareness about our work's difficulties, it made me very happy.”