23 members of the medical personnel (6 doctors, 10 nurses, and 7 Pre-hospital emergency personnel) were interviewed in the present study. Table 1 shows the demographics of the participants. 3 main themes—psychological tension, inefficient management, and contextual factors—and 11 categories emerged from the collected data. The themes and categories are shown in Table 2.
1. Invasion of psychological tension
The participants declared that the following inflicted considerable psychological tension on them: the sudden immergence of the disease, the fast increase in the number of the infected, deaths of young colleagues without a major illness in their medical history, extended work shifts, terror of contracting the disease or transferring the disease to one's family, and longs hours away from one's family. All these sources of psychological tension can influence the quality of care provided by the caregivers. The theme of invasion of psychological tension is divided into three categories: stress at work, terror and anxiety, and depression.
A. Stress at work
The medical personnel participating in the present study stated that the sudden emergence of the novel coronavirus in Iran and the subsequent increase in the number of suspected and confirmed cases of infection in clinical centers, the rise in their workload and extension of work shifts, their having to wear protective equipment continuously, and the critical (red alert) conditions in the hospitals inflict considerable occupational-psychological tension on the personnel. This tension, in turn, threatens the quality of care.
"I was in the central infection ward where the coronavirus patients were, in my protective clothing and shields, gloves, and goggles which I had been wearing for 6 hours on my shift. I was soaked with sweat and the spots where my face shield and glasses were pressing on my face and ears were killing me. There were more and more patients and their conditions were getting worse and worse. I'd been in the hospital since yesterday and the sudden increase in our workload was a huge shock to me. I'd never been exposed to this much tension at work. But I have to work and give care in this distressing situation. Well, such a shock and workload is a challenge to my caregiving" (Participant 5).
B. Terror and anxiety
The participants stated that the emergence of the novel coronavirus and its high speed of transmission have caused a lot of fear in ordinary people and even the medical personnel who are in close contact with the infected patients. These personnel are worried about their own contracting the disease or transferring it to their colleagues and families. Moreover, the deaths of a few members of the medical personnel who were responsible for coronavirus patients have struck fear into the hearts of the medical personnel.
"Well, everyone is worried about getting sick. We are in direct contact with these patients, always taking their sputum samples, or suctioning the very sick patients. We are afraid that we might get the disease or give it to a colleague or to our families. Some of our colleagues have gotten sick and two of them who were young too passed away. Well, we are all naturally filled with a deep sense of fear and anxiety" (Participant 16).
C. Depression
The participating personnel also mentioned that their constant presence in the hospitals designated for coronavirus patients, minimum contact and communication with their colleagues, and being away from their families over this period have caused them to experience signs of depression. Despite their efforts to keep their spirits, as well as the spirits of their colleagues and patients up, they still cannot avoid the psychological tension.
"During our shifts, we try to avoid all unnecessary contact and conversation with our colleagues and patients. Everyone is very careful. But all these intensive work shifts, our having to be overly cautious, and our distance from our families have made us kind of depressed. Everyone looks anxious and sad. Of course, we sometimes play music and dance to it to keep our spirits and the patients' spirits up and get away from this sense of depression. This kind of behavior is not acceptable to the system, but even the administrators and authorities understand our situation now" (Participant 3).
2. Inefficient management
From the perspective of the medical personnel participating in the present study, efficient management is a key factor in successfully handling crises, including the coronavirus crisis in Iran, and minimizing clinical challenges. Although the healthcare system in Iran has developed significantly over the past decades, there are certain deficiencies and defects in these systems which hinder effective handling of crises. This theme consists of five categories: lack of a preset action plan, lack of preparation drills, and inadequate supply of high-quality services, inadequate supply of equipment and facilities, and poor provision of information to the public.
A. Lack of a preset action plan
The medical personnel mentioned that planning and preparing for infection crises, including coronavirus will minimize anxiety and fear in the public and the medical personnel, reduce social chaos, and improve organization in hospitals.
"A preset action plan that determines which hospitals in every province are the primary medical centers for treating patients in case of infectious or biological diseases does not exist, or if it does, the medical personnel are not aware of it. This disease suddenly became an epidemic and they decided which hospitals should be infection care centers on an ad hoc basis. Out of nowhere, we were informed that our hospital is a coronavirus center. Well, in such conditions, everyone gets nervous and the medical staff faces challenges in providing care. The existence of a preset action plan for such situations, like predetermining the hospitals and units which should be in charge in case of an infectious disease and even pre-training the nurses, can help control these clinical challenges" (Participant 9).
B. Lack of preparation drills
One of the important extracted categories in the present study is lack of preparation drills. The medical personnel declared that they had not had any drills related to infectious and biological epidemics to be at least slightly prepared for such crises. Only the medical staff of military hospitals is given drills and training to be ready for health-related crises.
"There were never any drills for the medical personnel of organizations managed by the Ministry of Health to prepare them for infection crises. There are only occasional mock drills for dealing with a crisis for the nurses and doctors at military hospitals. Well, we hadn't been trained and this affects our handling of this crisis and ability to provide effective care" (Participant 18).
C. Inadequate supply of high-quality services
The participants stated that though they were making their best efforts to provide care to the coronavirus patients, the large number of the patients who were admitted to the designated hospitals and lack of staff and test kits made it impossible for them to provide timely and high-quality of care.
"There are too many patients in the clinics and emergency departments of the hospitals selected for coronavirus patients, we have shortage of medical staff and test kits, and the patients sometimes have to wait for some time to be tested or admitted, which makes them annoyed and aggressive and providing care becomes a challenge" (Participant 7).
D. Inadequate supply of equipment and facilities
In the present study, the medical personnel mentioned that in order to provide high-quality care, caregivers must have access to the necessary equipment and facilities in abundance so that they can provide care with peace of mind.
"When you enter the ward, all you get is an apron, a pair of gloves, and a mask, and throughout the shifts, they keep saying that we are short of equipment. I agree that in these conditions we need to conserve, but lack or unavailability of equipment makes caring for coronavirus patients a challenge" (Participant 21).
E. Poor provision of information to the public
The participants stated that the awareness campaigns and self-care and prevention educational programs for coronavirus all started when the disease had already emerged and was becoming an epidemic. This posed a major challenge to controlling the spread of the infection and providing high-quality care.
"It was when the coronavirus appeared and was becoming widespread that the television and social media began to educate the public. Before that, people and the medical personnel didn't receive any information to learn about the coronavirus and how to deal with infected patients. It is true that later people were educated to some extent especially through the television, but in the first few days of the emergence of the infection, we were faced with an influx of patients who didn't know what to do" (Participant. 1).
3. Contextual factors
Another extracted theme in the present study is contextual factors. According to the participants, the principles and manners of providing care are influenced by certain cultural and environmental factors, including: the severity of an infectious disease, how it is transmitted, the public's hygiene beliefs in every culture, and some people's selfish attempts to capitalize on the conditions in a crisis, like coronavirus. This theme is divided into three categories: the severity and rate of transmission of the infection, incorrect hygiene beliefs, and opportunism.
A. The severity, type, and rate of transmission of the infection
The medical personnel declared that the little-known nature of this emerging infection (COVID-19), lack of a definite cure for it, its long incubation period, and, most importantly, it’s very high rate of transmission, have increased the number of people who carry the virus and the patients who visit medical centers, a major challenge to the healthcare system.
"Unlike other infections, like H1N1, this infection is easily transmitted from person to person and the virus survives on surfaces for long periods, thus the need for systematic and quick disinfection. Well, with the sudden emergence of the infection, many healthy and infected people came to medical centers. This overcrowding of people resulted in a lot of close contact between them and the transmission of the disease. All in all, the high rate of transmission of this infection increases the number of patients and makes caregiving difficult" (Participant 6).
B. Incorrect hygiene beliefs
Another important category of the theme of contextual factors is incorrect hygiene beliefs. The participants stated that in every culture, including Iran, people have their own beliefs about hygiene, but occasionally these beliefs, as in the case of coronavirus, are not based in fact and lead to additional health problems, whereby the rate of visits made to medical centers is increased, which adversely affects the quality of care.
"It is a custom for people in Iran to shake hands and kiss. On the other hand, many people don't observe hygiene behaviors, such as washing their hands properly after a handshake or toughing surfaces. Such behaviors put them at greater risk of catching the infection. Also, many Iranians believe in the healing powers of herbs—it is true that consumption of such herbs as cinnamon, ginger, and garlic helps with preventing colds and relieving coughs and sore throats, but overuse of them can trigger allergic reactions, especially in the elderly with a history of cardiovascular disease or diabetes. This increases the number of people who have the symptoms of a coronavirus infection in medical centers, which challenges caring for real patients" (Participant 14).
C. Opportunism
Another danger to public health and healthcare which the participants referred to was the opportunism of some businesspeople who hoard or increase the cost of personal protective equipment, including gloves and masks, and certain foods.
"The prices of gloves and masks suddenly tripled. In a short time, drugstores ran out of masks and gloves. The prices of food products that contain vitamin C went up, too. Even in these conditions, some people remain opportunistic and seek to make large profits. The opportunists hoarded millions of masks and gloves. Such inhuman behaviors pose a greater threat to public health in the coronavirus crisis" (Participant 10).