The participants’ ages ranged from 28 to 47 years, with the mean being 34.1 years. The majority of the participants were female (Table 1). Analyses of the data resulted in 510 initial codes, 14 subcategories and four main categories, namely: providing care with uncertainty and anxiety, facing psychological and mental tension, creating a context for support, and experiencing personal-professional growth (Table 2).
Providing care with uncertainty and anxiety and facing psychological and mental tension were the challenges which the nurses in the present study experienced when they faced and cared for patients with COVID-19.
1. Providing care with uncertainty and anxiety
One of the findings of the present study was providing care with uncertainty and anxiety. This category consisted of the subcategories of providing care as a professional duty, concern over transmitting the infection to one’s family, fear of the unknown aspects of the disease, and concern over making wrong decisions.
1.1. Providing care as a professional duty
According to the participants’ experiences, despite a lack of facilities and personal protective equipment, there was a dominant sense of commitment among nurses to perform their professional duties in the COVID-19 pandemic. From the nurses’ point of view, working in difficult and dangerous conditions is part of a nurse’s job which must be maintained during the pandemic of an emerging disease.
“… anyway, it’s my job to give care in all circumstances and I had to do it at that time …” (P1).
1.2. Concern over transmitting the infection to one’s family
Despite their commitment to perform their professional duties, the nurses in the present study were worried about transmitting the infection to their families and their concern acted as a barrier to their stress management. The participants also mentioned that when their colleagues were infected, the fear of contracting the disease in the near future was a barrier to their stress management.
“… I was really worried that I could be the source of infection to my 60-year-old parents …” (P6).
1.3. Fear of the unknown aspects of the disease
One of the major barriers to stress management in the face of COVID-19 was lack of knowledge about the nature of the infection. Fear of the personnel arising from the unknown aspects of the disease was a main source of stress.
“… We didn’t know anything about it. The disease was completely unknown to us …” (P 3).
1.4. Concern over making wrong decisions
Some of the nurses were working in COVID-19 units voluntarily; however, they admitted that they had felt doubtful about their decision to provide voluntary care to COVID-19 patients in the first few days.
“... I kept wondering if my decision was right or not …” (P 4).
Another nurse stated that:
“Maybe the decision I made was a step to fulfill my personal commitment …” (P 2).
2. Facing psychological and mental tension
Many of the nurses who were working in COVID-19 units declared that they had experienced a variety of psychological issues during their practice in these units which prevented them from managing their stress. This category consisted of the sub-categories of families’ insistence on quitting one’s job, working in difficult conditions, lack of personal protective equipment, and feeling rejected.
2.1. Families’ insistence on quitting one’s job
One of the sources of psychological tension for the nurses was the insistence of some of their family members that they should quit their profession as nurses during the pandemic.
“My dad was strongly against me staying in this profession at those critical times …” (P 3).
2.2. Working in difficult conditions
Many of the participants described working in personal protective gear as very difficult. They also referred to work fatigue and physical exhaustion due to work overload as barriers to stress management.
“When your shift is over, you can barely breathe; with a high PaCO2, it’s hard to breathe … it’s hard to eat in this coverall, you can’t drink any water through your shift … the fatigue …. Working in such conditions won’t let you manage stress” (P 12).
2.3. Lack of personal protective equipment
The participants stated that one of the major barriers to stress management was lack of personal protective equipment and coveralls, especially in the first few days of the pandemic. According to one of the nurses:
“When the epidemic started, we didn’t have access to special gear for COVID-19 protection and had to care for the infected with minimum equipment, in regular masks and uniforms ...” (P 5).
2.4. Feeling rejected
Another barrier to stress management in COVID-19 units was being treated inappropriately and rejected by the personnel in non-COVID-19 units. One of the participating nurses stated that:
“When I got on the hospital shuttle, I felt so nervous. All the other staff that didn’t work in COVID-19 units would protest and tell the driver that he shouldn’t let me get on board … I should get off ….” (P 7).
Some of the participants had experienced rejection by their family members and relatives, which made it more difficult for them to manage stress.
“Once, when one of my relatives saw me, she took her son’s hand and walked away from me …” (P 3).
3. Creating a context of support
In the present study, the participants believed that creating a context of support is an important stress management strategy in facing and caring for COVID-19 patients. This category consists of the subcategories of proper intradepartmental management, support of the authorities, and effective communication skills.
3.1. Proper intradepartmental management
The participants’ experiences showed that proper intradepartmental management, e.g. planning according to the personnel’s conditions, replacing COVID-19 personnel with volunteers, avoiding discrimination, playing soft music in the units, and using effective interpersonal communication skills, including empathy, humor and spreading positive thinking, can contribute to the personnel’s stress management. During the COVID-19 crisis, the unit managers tried to make plans according to the personnel’s conditions in order to reduce the personnel’s stress.
“The husband of one of my staff here could spend two weeks a month with his wife …. I arranged her shifts so she didn’t have to work or worked less when her husband was with her so she wouldn’t be so worried about infecting her husband …” (P 1).
To reduce nurses’ direct contact with COVID-19 patients, the unit managers put the overstressed nurses in charge of recording patients’ history in their files in order to reduce stress in them.
“One of my staff was stressed out …. I made her the shift supervisor so she would be busy with the patients’ files and have less direct contact with the patients …” (P 8).
3.2. Support of the authorities
In order to support the nurses by helping them manage their stress, the unit and hospital authorities arranged certain hours for the nurses to meet with the hospital counselor or for the counselor to see the nurses.
“Whenever the personnel felt they were suffering from psychological tension and needed counseling, they could visit the hospital counselors ….” (P 11).
Another strategy used by the authorities to help the nurses manage their stress was setting up workshops to inform the nurses about the pathophysiology of COVID-19, how the infection is transmitted, the correct use of personal protective equipment, and regimens that boost the immune system. This information proved very influential in reducing stress in the nurses.
“We didn’t have any preparation from before; education is really important; once we learned more about the disease, we could protect ourselves better …. We were less stressed …” (P 12).
According to the participants, continuing education was integral to enabling them to manage the stress caused by being in contact with COVID-19 patients. Even though the presence of the supervisors and the other members of the treatment team in the environment could communicate a sense of support and hope to the nurses, some of the supervisors refused to be present in the places where the patients were being cared for.
“Our supervisor won’t even enter the unit to see for herself what kind of issues we are dealing with here …” (P 9).
3.3. Effective communication skills
The head nurses’ use of effective communication skills in their interactions with the staff was found to be a successful approach to stress management in those critical times. In addition, through empathy, the unit personnel tried to connect to their colleagues’ inner worlds and have a mutual understanding of their emotions and concerns, thereby coping with the stress caused by the COVID-19 crisis. The participants stated that in an empathetic relationship, they could experience a sense of support.
Showing appreciation and giving rewards were found to be effective stress management strategies which could raise the personnel’s spirits and improve interpersonal relationships. According to one of the participants:
“One of the main issues for the nurses who are doing a good job in these units is not receiving any appreciation or rewards. There is a limit to any person’s tolerance. Some turn to spirituality for strength, but not everyone is spiritual. In short, there is a lack of appreciation …” (P 5).
Other behaviors which contributed to the nurses’ stress management were exchanging friendly banters with each other, spreading positive thinking, and remaining optimistic about the future.
4. Experiencing personal-professional growth
The participants referred to experiencing personal-professional growth as one of the outcomes of working in the very difficult conditions created by the spread of COVID-19. Caring for COVID-19 patients was a constructive experience which could prove instrumental in coping with problems in the future. Making an effort to use various stress management skills in the face of COVID-19 improved nurses’ empowerment and gave them a chance for personal growth. Compared to the time before the emergence of COVID-19, nurses can focus on their problems better and manage stress and stressors more effectively. This category consists of the subcategories of improved learning, perception of positive feelings at the end of a crisis, and self-transformation.
4.1. Improved learning
The participants believed that, despite all the difficulties, working during the pandemic had resulted in their gaining useful knowledge. Their experiences showed that providing care during the COVID-19 pandemic had helped them develop time management skills, learn to make optimal use of the available equipment and deal with deficiencies, improve their medication knowledge, increase their knowledge of emerging diseases, and learn to make effective use of infection control strategies.
“I had read a few things about emerging diseases, but working in this pandemic has given me the chance to gain hands-on experience of caring for these patients …” (P 7).
4.2. Perception of positive feelings at the end of a crisis
While providing care to COVID-19 patients, the participants had experienced such positive feelings and emotions as elevated self-confidence, personal satisfaction, the opportunity to prove their competence, and the good feeling of overcoming the difficulties and challenges of caring for COVID-19 patients.
“Working in these conditions created a positive sense of being useful to others in me ... which made me feel happy and lively and physical fatigue could not take away my happiness …” (P 6).
Many of the participants mentioned feeling good about solving problems and happiness about serving one’s fellowmen to be among other outcomes of working in the COVID-19 crisis.
“Having been put on the path to serve my fellowmen was the positive feeling that I experienced …” (P 4).
Another participant stated:
“I feel happy now that I could live through the problems I had at the time …” (P 12).
The results of the study showed that the experience of caring for COVID-19 patients in difficult conditions had strengthened relationships between colleagues and between friends at work. Many of the participants had come to have higher regard for the meaning and value of their lives and what they had. The participants compared working in the COVID-19 crisis to fighting in a war which had transformed them by making them braver in the face of critical conditions and more empowered in managing difficult times.
“Working during the current pandemic has helped me discover my abilities …. Now I know how to act in war conditions …” (P 7).