Since the purpose of this study was to identify nursing challenges in caring for COVID-19 patients after a transitional shock period, the current qualitative research was carried out using a conventional content analysis approach. Content analysis is a qualitative research method in which data is described in a conceptual form in order to develop knowledge, gain new insight, and develop the practical guidance (15).
Participants and Setting
Using purposive sampling method, this study was conducted on 20 nurses caring for COVID-19 patients admitted to public hospitals affiliated to Tabriz University of Medical Sciences, Iran. Collecting data continued until the data was saturated and no new data was obtained (interview 17). Three more interviews were conducted to confirm the data saturation. In the last three interviews, the data analysis led to the emergence of repetitive codes and no new code was obtained. The decision on data saturation was made through reviewing the codes by the research team and two other experts.
Due to the fact that face-to-face interviews were risky during the pandemic for the researcher and nurses, data were gathered using semi-structured, in-depth telephone interviews with 20 eligible nurses. Analysis was conducted iteratively and in parallel with interviews such that as themes emerged, they were incorporated into interview schedules to gather more comprehensive information. Thus, as the study progressed, interviews became semi-structured and an interview guide was used to ensure that all topics were addressed. The interviews lasted for 45-60 minutes (mean=52 minutes). Recruitment of the participants was performed through professional communications by holding a meeting with gatekeepers, as well as sending invitations and emails in which the objectives of the study had been described. Before starting the interview, the researcher explained the interview process including arrangements for audio-recording and transcription and obtained written informed consent from all participants. At the beginning of each interview, after a few warm-up questions, the participants' demographic information was collected, and then the interview began with a general question.
There were two main questions as follows:
- What concerns did you have while working with a confirmed or suspected COVID‐19 patient?
- What problems did you have in the ward or the hospital?
Also, during the interview, some probing statements were made to encourage participants to provide more information and clarify their responses. Examples include: "Could you please explain it in more detail?", "What does [x] mean?", and "Could you give an example?" Towards the end of each interview, further questions were asked such as: "Do you think there's anything untouched?" Recruitment and interviews continued until the data was saturated (i.e., no new themes emerged from the analysis). All interviews were recorded using a voice recorder. In one case, the participant was reluctant to allow audio-recording; thus, written notes were taken. Data collection lasted for approximately seven months, and the entire study was conducted from April to October 2020.
Taking a conventional content analysis approach, the data was analyzed using the steps proposed by Zhang & Wildemuth (16). First, the transcript of each interview was read several times by the researcher to gain familiarity with the data and to develop a preliminary understanding of the related concepts. Then, the data was coded into the semantic units (at words, sentence, and paragraph levels). The semantic units were compressed and amalgamated while their content was maintained. Finally, using continuous comparison, evaluation, feedback, and interpretation, the codes were compiled to form the categories and subcategories. MAXQDA10.0R250412 software was used to manage the data.
In this study, to assure the trustworthiness of the data, criteria including credibility, dependability, transferability, and confirmability, as proposed by Lincoln and Guba, were used (17). To ensure the credibility of the data, the researcher had a long-term relationship with the participants, which aided trust and openness. During the study, the interview transcripts, the semantic units, and the extracted codes were presented to the participants to control their consistency with their experiences. All reasonable attempts were made to ensure that the participants, as a group, had maximum diversity in terms of their experience, length of service, age, and gender. Dependability was determined through review of data and coding by a co-worker. Two external examiners with a PhD degree in nursing, who had experience in qualitative research, were asked to review the interview transcripts, the initial coding, and the categories. Any disagreements were discussed in a meeting, and a consensus was achieved among the research team about the correct coding. Regarding transferability, the characteristics of the research population and the research process were described clearly and accurately so as to make it possible to follow the research path and the key decisions be made in the analysis. The confirmability of the data was established by the researchers actively putting aside their own thoughts and assumptions about the topic, accurate recording of the research procedure and documentation, refraining from deep review of texts. This was all assisted by input from the rest of the research team.
In this study, 20 nurses (age range: 25-49 years) were interviewed in-depth. Findings related to the individual and professional characteristics of the participants are presented in Table 1. Data analysis revealed four themes and eight categories. The themes were: ‘duality in the form of care’, ‘bewilderment and ambiguity in care planning’, ‘workload’, and ‘positive image with social isolation’ (Table 2(
Duality in the Form of Care
Nursing care for patients with COVID-19 had two spectrums of marginal care and empathy and cooperation. On the one hand, several factors such as the unknown nature of the disease for patients, fear of getting infected, etc. changed the focus of nurses to the marginal factors. On the other hand, factors such as the voluntary presence of treatment staff and nursing students, people's appreciation of the treatment staff, etc. caused empathy and cooperation among the medical staff, especially nurses.
Analysis of the findings of this study showed that with the prevalence of COVID-19 in Iran and hospitalization of patients in wards, many factors caused more attention of treatment staff to be directed towards cases outside the care and treatment of patients. During the beginning days of the outbreak, the treatment staff were not notified of hospitalized patients with COVID-19 due to political issues as well as controlling the peace of the society.
After the hospitalization of COVID-19 patients, due to fear of the disease, a number of staff refused to provide care and treatment to these patients in the wards.
“… mostcolleagues had the fear and anxiety of going to bedside with coronavirus patients…” (Participant No. 2).
Empathy and Cooperation
Participants in the study stated that nurses from other wards, and even other hospitals, volunteered to attend the wards where patients with COVID-19 were admitted to care for them.
“Nurses in other wards called me saying that they would like to work in our ward to care for COVID-19 patients, or students even wanted to work in the COVID-19 ward ...” (Participant No. 3).
The nurses compassionately performed caring activities for the patients with COVID-19 despite being aware of the poor facilities and lack of equipment (masks, gauntlets, and gloves).
“It is true that our masks and protective clothing are non-standard, but this is not a reason to leave patients. I myself go to the patients and feed them, give them their medicines on time, and I am not worried about getting infected ...” (Participant No. 6).
Bewilderment and Ambiguity in Care Planning
The COVID-19 pandemic has killed many people around the world with multiple mutations and despite the availability of several COVID-19 vaccines, controlling the transmission chain is very difficult. This category had two subcategories including ‘the leakage of incorrect information’ and ‘lack of scientific information’.
Leakage of Incorrect Information
The results of data analysis showed that due to the limited scientific information on COVID-19, a lot of false information was shared on social media about the treatment and care of patients with COVID-19. Some fraudulent people took advantage of this opportunity by commercializing their equipment and commodities in the form of traditional medicine, or so called ‘Islamic Medicine’.
“Once, one of my friends called me and said that it is true that soda is effective in treating COVID-19. I was really shocked and upset ...” (Participant No. 14).
Lack of Scientific Information
The results of data analysis showed that due to the unknown nature of the disease, different treatment and care procedures were performed, some of which resulted in serious side effects.
“Early in the disease, there were many problems because doctors were somewhat incapable of treating the disease, which made it difficult for us nurses to care…” (Participant No. 5).
Normally, the workload of nurses in Iran is assumed to be very high. After the outbreak of COVID-19 in Iran, this workload increased due to the increased psychological burden in the living and working environment of nurses, as well as the high care load in COVID-19 patients. This category had two subcategories including ‘change in lifestyle’ and ‘perceived care pressure’.
Chang in Lifestyle
The results of data analysis showed that the nurses preferred to self-quarantine themselves in a different environment (not their own homes) to prevent the transmission of the disease to their family members and the community. Being away from the family led to stress in family members, a drop in the education of children, and fear of continuing the situation in the future.
“My son's teacher complained about his incomplete homework...” (Participant No. 4).
“The family also suffered from stress and anxiety and prayed a lot for us…” (Participant No. 15).
Perceived Care Pressure
The data showed that nurses were dissatisfied with wearing personal protective equipment due to their non-standard and inconvenient design.
“The hospital provided poor quality equipment to work with patients …” (Participant No. 3).
The lack of a separate and distinct room outside the COVID-19 ward for rest and nutrition, excessive sweating in the personal protective equipment kit and dehydration were among the nurses' major complaints.
“Wearing clothes and masks was so hard for us; we felt as if we were dead...” (Participant No. 7).
Anorexia in patients with COVID-19, excessive thirst for water and oxygen, diarrhea, and death of young patients without a history of the disease were other issues that increased the pressure and workload of nurses.
“I was very upset when I saw that a conscious patient had problem with ventilation and that he still had problem with giving too much oxygen ...” (Participant No. 19).
Positive Image with Social Isolation
Nurses were supported by the community and praised in the media; they were called ‘health defenders’ at the beginning of the COVID-19 outbreak. However, when they appeared in the community, people distanced themselves from the treatment staff. The two subcategories in this category were ‘society supporting’ and ‘general avoidance’.
The results of data analysis showed that nurses were encouraged and supported by family, friends, and the community.
“Since the start of COVID-19 crisis, the family continues to support me. This may be due to the sanctity of the field and the difficulty of our work, because I felt it myself.” (Participant No. 9).
Messages of thanks were sent to nurses in the form of letters, telephone messages, or on social media in different parts of the country. Nationwide, the community members and officials erected billboards thanking nurses as health defenders.
“I was really proud of all these thanks messages ...” (Participant No. 1).
Our results showed that nurses faced different reactions from people.
“They only chant slogans, but it is not practiced in the society! Suppose that we are going somewhere while maintaining social distance by wearing mask and gloves; but when people find out that we are nurses, they behave as if we are an infected individual.” (Participant No. 11).
Participants also reported that some of their relatives and friends cut off communication and telephone calls with them due to being in contact with COVID-19 patients.
“Unfortunately, some relatives and friends stopped travel with me. They think as if it is only the healthcare staff that are infected with the virus! Maybe the virus cannot be transmitted in taxis and public places! As soon as they realize that I am a nurse, they stay away from me…” (Participant No. 6).
Some of the participants expressed that they had to provide a false residence address in the patient registration system of the Ministry of Health when they were infected with the virus due to people's improper behaviors.
“When I got infected with the virus, I did not provide my correct home address because they came from the health center to disinfect the building, stairs, and other places. I was afraid that our neighbors would react badly to me...” (Participant No. 16).