key: cord-0833538-d29yh8hg
authors: Villar, Ralph C.; Nashwan, Abdulqadir J.; Mathew, Rejo G.; Mohamed, Ahmed S.; Munirathinam, Sathish; Abujaber, Ahmad A.; Al‐Jabry, Mahmood M.; Shraim, Mujahed
title: The lived experiences of frontline nurses during the coronavirus disease 2019 (COVID‐19) pandemic in Qatar: A qualitative study
date: 2021-05-05
journal: Nurs Open
DOI: 10.1002/nop2.901
sha: 3c2dab7adfd0fdbf46e2520a11aec6d8b7c1781f
doc_id: 833538
cord_uid: d29yh8hg

AIM: This study aims to explore the lived experiences of frontline nurses providing nursing care for COVID‐19 patients in Qatar. DESIGN: Qualitative, Phenomenological. METHODS: Nurses were recruited from a designated COVID‐19 facility using purposive and snowball sampling. The participants were interviewed face‐to‐face using semi‐structured interview questions from 6 September–10 October 2020. The interviews were transcribed and analyzed using Colaizzi's phenomenological method. RESULT: A total of 30 nurses were interviewed; (76.7%) were deployed for >6 months. Three major themes were drawn from the analysis: (a) Challenges of working in a COVID‐19 facility (subthemes: working in a new context and new working environment, worn out by the workload, the struggle of wearing protective gear, fear of COVID‐19, witnessing suffering); (b) Surviving COVID‐19 (subthemes: keeping it safe with extra measures, change in eating habits, teamwork and camaraderie, social support); and (c) Resilience of Nurses (subthemes: a true calling, a sense of purpose).

have deployed some nurses working in governmental hospitals to COVID-19 designated facilities and the recruitment of nurses (who are currently in the country with valid nursing license and willing to work in a COVID-19 facility) was accelerated. Orientation and training were fast tracked to hasten the deployment of nurses to different COVID-19 facilities in Qatar. For instance, existing government employee nurses who worked in post anaesthesia care units were given at least 10 days to train under a preceptor to work in critical care units.

Because of the change in the working environment, healthcare providers had to work in areas that did not meet infection control standards. They were confused about the difference in protocols like prescribing and carrying out doctor's orders (Liu, Luo, et al., 2020) . In addition, different studies have shown that health-care professionals who were treating COVID-19 patients have higher risks of physical and mental health problems due to insomnia, stress, anxiety and depression (Liu, Luo, et al., 2020; Lu et al., 2020; Xiao et al., 2020) .

According to the International Council of Nurses (ICN) report, around 2,262 deaths in nurses has been listed and more than 1.6 million got infected. In addition to ICN's report there is an alarming number of burnout and exhaustion among nurses leading them to quit their jobs (ICN, 2021) . The safety and health of the frontline nurses are critical to ensure safe and quality nursing care to patients and is vital in the quest to overcome the COVID-19 crisis or future pandemics. Different studies had shown that nursing is a profession that accumulates tons of stress that has an alarming effect on the physical, mental and social well-being especially during outbreaks (Janda & Jandová, 2015; Lee et al., 2018; Liu, Luo, et al., 2020; Lu et al., 2020; Marjanovic et al., 2007; Torales et al., 2020) . Nurses in Qatar are working tirelessly since the beginning of the pandemic.

However, little is known about the experiences and effect of the COVID-19 pandemic on frontline nurses in Qatar. Therefore, the aim of this study was to assess the experience of frontline nurses providing nursing care for COVID-19 patients in Qatar.

To uncover the meaning of the frontline nurses' experience during the COVID-19 pandemic, a qualitative, phenomenological research design was used. Phenomenology explores how individuals make sense of the world in terms of meanings they create (Pope & Mays, 2020) . The purpose of phenomenological research is to focus on the lived experiences of the participants. It emphasizes the importance of personal perspective and interpretation.

A semi-structured interview guide question was used in this study to collect data. Probing questions were formulated to get an in-depth understanding of the participants' experiences guided by the participants' initial responses. The participants were selected through purposive and snowball sampling. Interviews were conducted face to face while observing infection control precautions in a private room within the study site (RCV, RGM, ASM and SM conducted the interviews). Four open-ended questions were first asked: (a) Can you describe to me your experience of taking care of patients with COVID-19? (b) What were the differences in working in a COVID-19 facility from your previous working environment?

(c) What were your feelings, thought processes or emotions when you were providing nurse care for COVID-19 patients? and (d) How did you cope up with the COVID-19 crisis? Probing and follow-up questions were then formulated to get an in-depth understanding of the participants' experiences guided by the participants' initial responses, examples were: "Can you specify the difficulties you mentioned in providing care to patients with COVID-19"; "Based on your experience during this pandemic, what are your nursing career plans 1-3 years from now"; "What else could you have done more"; "How did you feel?"; "Can you tell me more or can you expand on this please", and so on. With the participant's permission, interviews were audio-recorded to aid in the accurate transcription and analyzed using Colaizzi's phenomenological method. All participants provided written informed consent.

The study was conducted in Hazm Mebaireek General Hospital (HMGH), a designated COVID-19 facility in Qatar, which extended its capacity to 560 beds to provide quality care to most patients with moderate to severe symptoms of COVID-19.

The participants were enrolled in the study using purposive and snowball sampling. The first 10 participants were recruited from their departments as identified by the researchers to be eligible, considering that they were: (a) registered nurses who took care of patients with COVID-19 in Qatar; (b) registered nurses who were assigned to HMGH for at least one month during the COVID-19 pandemic; and (c) were willing to participate in the study. The other participants were recruited through snowball sampling.

Interviews were done face to face while observing infection control protocols and the conversations were audio-recorded to facilitate transcriptions of the responses which was done 24 hr from the interview and was reviewed by two researchers of this study. Identifiers were removed from the transcripts and codes were used to label participants (e.g., N1, N2, N3, etc.).

Interviews were done from 6 September-10 October 2020. The participant's characteristics were obtained before the interview.

The participants were informed that they have the right to withdraw from the study at any time should they decide not to participate in further sessions. The schedule of the interview was based on the participant's availability and convenience. The data, including the audio-recorded files, was stored in the protected computer by Hamad Medical Corporation (HMC) in accordance with the corporate policies and guidelines.

In this study, Collaizzi's seven-step procedure analysis for the phenomenological method was followed [58] . The data and themes were developed by RCV and RGM and discussed by all authors. Colaizzi's seven-step method of analysis is seen in Figure 1 . 

Our sample consisted of 30 nurses as seen in Table 1 . The mean age of the participants was 31 years (standard deviation (SD) 2.8 years), with a mean work experience of 9.1 years (SD 2.7 years) and with a mean work experience in Qatar of 2.5 years (SD 0.9 years). 66.7% of participants were married. Four participants (13.3%) were women.

The participants were from different specialties, with a total of nine participants from Emergency Care, six from Medical-Surgical units, six from the Critical Care Unit, five from Ambulatory Care Unit, and four from the Perioperative Department. Eleven participants (30%) were deployed to units different from the units that they worked in before the COVID-19 crisis. Among them, five nurses were deployed from outpatients to inpatient wards and emergency rooms, four perioperative nurses were deployed to critical care units and emergency rooms, one critical care nurse was deployed to an inpatient ward, and one school nurse (with neonatal, medical-surgical background) was deployed to an inpatient ward. The remaining 19 participants were assigned to the same units where they worked previously. None of the participants experienced working in a largescale pandemic like the current COVID-19 pandemic. Amongst the participants, 76.7% were deployed for 6 months or more, 10% were deployed for 4-5 months, and the remaining were deployed for a month.

Three major themes were drawn from the analysis as seen in 

Nurses in a COVID-19 facility encountered numerous challenges that impacted their physical, psychological and emotional wellbeing. This theme consisted of five sub-themes relating to the stress from working in a new context and environment workload, wearing PPE's, fear and witnessing patient suffering. The first three weeks I was assigned to test patients for COVID-19. When the cases increased, I was deployed to the emergency room to care for acute patients.

After some time, I was transferred to the inpatient ward. When you are a new staff you will be trained F I G U R E 1 Collaizi's method of data analysis 

In the initial stages of the pandemic, the frontline nurses in this study were exhausted due to the surge of patients. Nurses had to take care of more patients than they used to and adjust to demanding shift schedules to support staffing needs. They had more tasks to accomplish and they had to work for extended hours caring for critically ill patients. Most of the nurses felt tired because of the workload:

There was an influx of patients. 

Front line nurses during the pandemic faced numerous challenges, physically, psychologically and emotionally brought by COVID-19.

This theme describes the different coping mechanisms or adaption that the nurses in this study used to overcome the challenges of working in a designated COVID-19 facility.

Nurses feared acquiring COVID-19 and consequently spreading it 

According to the participants in this study, nurses in a COVID-19 facility in Qatar were able to get the job done because they worked together as a team. According to the participants of the study a good relationship was developed during the most difficult hours even if they had only worked with the other nurses for less than six months.

The support was good; no complaints at all. Every now and then, we talked to each other. We were a family here. You can openly speak or voice out to other charge nurses. I am lucky, I became friends with most of the charge nurses. We were a team. We developed a good relationship. We always looked forward to working together. We developed a camaraderie even though we only met during the COVID-19 crisis.

(N26)

Nurses in this study sought social support during their battle with COVID-19. In a new world where social meetings were prohibited, nurses in a COVID-19 facility found support from their families and people they worked with.

Talking to someone was the best stress reliever. There was no option to visit your friends or relatives due to this pandemic. Even though it's hard to sit alone in your room after the duty, it was the right thing to do.

As much as possible, I will call my wife who's in India to talk about the stress at work. Although sometimes you cannot share everything as it might do more harm than good. So, I call some of my colleagues to whom I am really close to and share my troubles.

(N22)

Nurses in the study showed resilience to work in the pandemic despite the risks involved. Nurses perceived their role as of utmost importance during this pandemic. They found value and purpose in a time of need and they considered it as a part of their job. Frontline nurses in this study did not find COVID-19 as a reason to quit but as a driving force to pursue it.

Most of the participants in the study described nursing as a vocation. Caring for patients in the time of crisis allowed them to save lives and bring comfort to those in need.

I believe as a nurse it is our job to take care of them.

I never thought of quitting. Being a nurse is great because it gives you the capability to help people, regardless of who they are and where they come from.

(N27) Adversities that the nurses encountered most especially during the initial and peak phase of the pandemic were very common.

Nurses working in a pandemic like COVID-19 were more likely to report stress compared to those who were not dealing with patients infected by the virus (Alshekaili et al., 2020; Mo et al., 2020) .

Our findings are comparable with Liu, Luo, et al., (2020) ) and Shoja et al. (2020) . Nurses in our COVID-19 facility were stressed out because they had to face a virus that was not completely understood, they had to adjust to new pathways and policies, master new nursing skills and report to a new unit with less or zero time for training and orientation. During the initial stages of the pandemic, there was insufficient and contrasting information on the treatment, mode of transmission and measures to contain the virus. In the study by Park et al. (2020) , reading or hearing about the severity and high contagiousness of COVID-19 was identified as the most common stressor.

None of the nurses in our study have worked in a pandemic with the kind of magnitude of COVID-19 pandemic. Without proper channel or dissemination of facts, nurses may be exposed to misleading information which can cause higher levels of stress and confusion (Park et al., 2020; Tasnim et al., 2020) . to prepare nurses during the pandemic, continuous education and training should be provided to assure that nurses are confident to take care of patients during a pandemic (Liu, Luo, et al., 2020) .

Nurses have a high probability of experiencing low professional quality of life because of stress and burnout even prior to COVID-19 (Kim et al., 2014) . Without a doubt, nurses who were caring for COVID-19 patients have experienced high stress levels and increased risk of mental health conditions (Liu, Luo, et al., 2020; Shahrour & Dardas, 2020; Xiao et al., 2020) . In comparison with previous studies of nurses working in emergency rooms and critical care units pre-COVID-19

pandemic, workload and witnessing patient's suffering have been sources of stress among nurses (Brandford et al., 2016; Janda et al., 2015; Al-Abdallah et al., 2019) . In addition, wearing PPEs for long hours caused a lot of physical discomfort among nurses. Some nurses also questioned the quality of the PPEs provided by the hospital. Managing COVID-19 patients and adhering to infection control procedures is associated with increased workload for nurses, including donning and doffing procedures of PPEs and intensive care workload needed by critically ill COVID-19, such as intubation, central line and arterial line insertions, changing positions, and so on. (Giuliani et al., 2018) . In the study of Lucchini et al. (2020) , the nursing workload among those who worked with COVID-19 patients in ICU increased by 33%, while Bruyneel et al. (2020) showed that the workload increased by 20%, showing more load during the night shift (27% night shift vs. 21% morning shift) (Bruyneel et al., 2020) .

Furthermore, nurses must wear complete PPEs (headcover, N95 mask, face shield or goggles, gown and shoe cover) for long hours to keep them safe especially during aerosol-generating procedures.

In the current study, nurses found wearing PPEs for long hours uncomfortable and was associated with reports of sweating, headache, suffocation and injuries to the face. These findings were consistent with the findings of recent research highlighting challenges associated with wearing PPEs faced by health-care workers managing COVID-19 patients. For example, wearing protective masks and clothing cases was identified as a main stressor by frontline medical staff (Xiao et al., 2020) . Several reports also showed that wearing PPEs was associated with physical discomfort, facial pressure injuries, chest pain, anoxia, headache, visual disturbances and dermatitis (Atay & Cura, 2020; Bruyneel et al., 2020; Liu, Luo, et al., 2020; Ong et al., 2020; Shoja et al., 2020; Singh et al., 2020) .

Fear is a negative emotion that foster behaviours that can impact the physical and psychological well-being of nurses (Espinola et al., 2016; Harper et al., 2020; Yıldırım et al., 2020) . Because of the fear of COVID-19, frontline nurses were motivated to develop defensive behaviours (Espinola et al., 2016) . Fear of COVID-19 prompts nurses to foster behaviours to protect themselves and their families.

In Hubei, China more than 3,000 medical staff were infected by the COVID-19 during its early stages which cause fear among healthcare providers (Liu, Luo, et al., 2020) . Infection among nurses during outbreaks has always been a problem; health-care workers reported persistent fear because of the highly contagious nature of the virus and during the SARS crisis in Canada trust in equipment/infection control initiatives was negatively related to emotional exhaustion and state anger (Liu, Luo, et al., 2020; Marjanovic et al., 2007) . Lack of appropriate knowledge and skills in emergency disaster rescue and training related to covid-19 were also associated with increased fear (Labrague & de Los Santos, 2020; Liu, Zhai, et al., 2020) . This can compromise patient care and debilitate the workforce. It is necessary to further investigate the fear of COVID-19 among nurses in Qatar to establish measures or policies to improve their working conditions to safeguard their physical and mental health.

Nurses play the most crucial role in managing COVID-19 patients, and therefore, stressors experienced by nurses can negatively impact the quality of patient care (Karimi et al., 2020) . Nurses care for patients 24/7 thereby placing them at high risk of being infected. In addition, the therapeutic relationship and the specialized type of care evolved an emotional impact for nurses' caring of prolonged suffering patients in intensive and emergency care units (Alharbi et al., 2019) which most participants of this study clearly stated. One of the unique aspects of the COVID-19 pandemic is that majority of nurses' witness patients dying alone. Because of hospital policy, family visits were prohibited to prevent further spread of the infection. This led nurses to use their smartphones to connect patients to their loved ones causing ethical dilemmas on privacy and hospital rules (Wakam et al., 2020) . A creative approach should be evaluated to allow physical and virtual visits and thereby improving patient's satisfaction and outcomes and nurses' morale (Ganeshan et al., 2021; Rose et al., 2021) .

The capacity of nurses to recover from adversities during COVID-19 was evident in our study. Nurses in Qatar demonstrated self-care and protective behaviours which can be both beneficial and harmful. Some of the participants in our study made conscious effort to stay fit through exercise and eating right while others reported eating more in response to stress. There was a common knowledge among some of the participants that eating a lot would increase their immunity. Consuming high energy-dense foods is a typical response to stress; some studies show that stress has a significant correlation with weight gain (Niu et al., 2017; Tsai et al., 2019) . During the COVID-19 pandemic change in eating habits was a common coping mechanism for nurses working in Saudi Arabia (Alhusseini & Alqahtani, 2020) . Stress and the change of shifts can influence how and what nurses eat and may contribute to weight gain and obesity (Almajwal, 2016; Karakaş, 2020) . (Jassar et al., 2020) . It is important to note that majority of nurses in Qatar are expatriates.

Therefore, it is vital for nursing leaders to recognize and continue fostering this sense of belongingness and team spirit among nurses (Liu, Luo, et al., 2020) .

Frontline nurses in a COVID-19 facility in Qatar showed resilience and willingness to work amidst the risks of getting infected. This was supported by the study of Nashwan, Abujaber, et al., (2020) where nurses in Qatar were willing to take care of patients infected with COVID-19 . Consistent with other studies, majority of nurses were passionate and were willing to be at the frontlines in the battle against a formidable virus because they find it as a calling and a part of their jobs (Lee & Lee, 2020; Liu, Luo, et al., 2020; Liu, Zhai, et al., 2020; LoGiudice & Bartos, 2021) .

The health and safety of frontline nurses should be emphasized during a time of the pandemic. Nurses should feel safe and comfortable when treating patients during a viral pandemic like COVID-19. There should be an avenue for nurses to safely raise their concerns in the workplace. Maximum working hours and shift arrangements must be favourable to allow more rest periods to prevent and minimize the workload. In addition, mental health support should be easily accessible and assessment be provided for all frontline nurses; and there should be a consistency in the quality and provision of PPEs among nurses (Liu, Luo, et al., 2020; Shoja et al., 2020) . Furthermore, there must be a worldwide commitment to improving the comfortability of wearing PPEs. Self-care must be promoted among nurses and authorities should make every effort to provide a safe venue for recreation. It is at utmost importance that government and health-care leaders and the population, in general, provide comprehensive support to frontline nurses during the current COVID-19 pandemic as well as potential future communicable disease outbreaks and pandemics.

Frontline nurses during the COVID-19 pandemic in Qatar faced many challenges that compromised their physical, emotional and psychological well-being. However, despite all the adversities, nurses in

Qatar were willing to work and take care of patients infected with COVID-19. Government and health-care leaders should lead an example in providing comprehensive support to nurses to protect their well-being. Policies and protocols should be established to mitigate and anticipate stressors brought about by the catastrophic crisis in a pandemic.

This phenomenological study explored and described the lived experiences of frontline nurses during COVID-19 in Qatar. The study was limited in scope since we only interviewed 30 participants in a single COVID-19 facility. Another limitation was the possibility of selection bias and uneven distribution of nurses basing on gender and expertise. Lastly, the interview was done months after the peak of COVID-19 cases in Qatar and responses might have been different if it was conducted during the initial and peak cases of COVID-19.

The publication of this article was funded by the Qatar National

Library. The authors would like to acknowledge the nurses who participated in the study.

None. 

All data generated during this study is included in this published article.

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