key: cord-1049881-x8ujfjhl
authors: Moradi, Yaser; Baghaei, Rahim; Hosseingholipour, Keyvan; Mollazadeh, Farzin
title: Challenges experienced by ICU nurses throughout the provision of care for COVID‐19 patients: A qualitative study
date: 2021-02-02
journal: J Nurs Manag
DOI: 10.1111/jonm.13254
sha: eb83f10d817c71844f11aacc2c48c1cc7c477c02
doc_id: 1049881
cord_uid: x8ujfjhl

AIM: To explore the challenges experienced by ICU nurses throughout the provision of care for COVID‐19 patients. BACKGROUND: The intensive care unit nurses, who are at the frontline of fighting against COVID‐19 and defusing this crisis, are faced with various challenges throughout the provision of care for COVID‐19 patients. METHODS: In this qualitative descriptive study, a total of 17 nurses working in intensive care units were selected using purposive sampling. Data were collected using semi‐structured face‐to‐face interviews. After recording and transcribing interviews, the concepts were extracted using the content analysis method. FINDINGS: The nurses reported the four following challenges throughout the provision of care for COVID‐19 patients: ‘organization's inefficiency in supporting nurses’, ‘physical exhaustion’, ‘living with uncertainty’ and ‘psychological burden of the disease’. CONCLUSION: The present study portrayed a clear understanding of the challenges faced by nurses working in intensive care units during the crisis of the COVID‐19 pandemic based on their lived experiences. IMPLICATIONS FOR NURSING MANAGEMENT: A profound understanding of these challenges in the current critical situation can help health care authorities adopt appropriate measures to resolve these challenges, provide health care facilities, support the health workforce, give accurate and evidence‐based information and perform psychological interventions on how to handle the current crisis.

of intensive care units (ICUs), which led to increased working hours of intensive care providers and the use of different rotating-shift patterns (ICN, 2020) . In addition, in similar crises such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), health care providers, especially nurses, were exposed to severe and debilitating stresses, whose sources included fear of infection, stigma, lack of human workforce and lack of trust Maunder et al., 2003) . By investigating health care providers who had working experience during the MERS epidemic in 2015, Lee et al. found that these individuals exhibited post-traumatic stress disorder during the epidemic and even over time . Similarly, this problem was also observed in the SARS epidemic in 2003, as health care providers were badly stressed by the unknown nature of the disease, its high contagiousness and their heavy workload (Maunder et al., 2003) .

ICU nurses at the centre and frontline of defusing the crisis of the COVID-19 pandemic (Chen, Liang, et al., 2020) have a major role in the affected countries. The health status of health care workers can affect the provision of continuous and comprehensive patient care and have a significant effect on how to deal with public health crises and pandemics (Chang et al., 2020) .

A variety of challenges impose severe psychological and physical strains on nurses throughout the provision of care for patients with COVID-19 in ICU (Park & Park, 2020; See et al., 2018) .

In Italy, nurses experienced a particular and yet irritating situation because of their inability to save patients and the likelihood of transmitting the disease to their family members, which could have affected patient care (Kaniadakis, 2020) . Furthermore, nurses are at a greater risk of developing psychological problems such as anxiety, depression, insomnia and stress . They may also face a variety of challenges due to being in a stressful situation that they have never experienced before (Liu et al., 2019) .

In a study by Sun et al., nurses caring for COVID-19 patients reported different psychological problems, including fatigue, discomfort and helplessness due to the heavy workload during the shifts (Sun et al., 2020) . Despite the lack of studies examining the challenges faced by ICU nurses throughout the provision of care for COVID-19 patients based on their experiences, Shen et al. revealed that ICU nurses have to face several difficulties including working in an unfamiliar environment, lack of experience in caring for infectious patients, anxiety about being infected, heavy workload, extreme exhaustion and depression due to failure to treat critically ill patients (Shen et al., 2020) . In a systematic review, Fernandez et al. reviewed the results of 13 qualitative studies on nurses' experiences during the COVID-19 pandemic and concluded that health care systems should respond appropriately to the challenges and perceived issues of the caregivers of COVID-19 patients. Otherwise, nurses are likely to experience significant physical and psychological problems, which can lead to burnout and shortage of the nursing workforce (Fernandez et al., 2020) .

Therefore, efforts to meet these challenges appear necessary.

However, before that, further studies are required to provide insight into these challenges and thus facilitate changes in the existing situation to improve nurses' working conditions, provide safe and quality care for patients and ultimately ensure patient safety. Given that little information is available regarding the challenges faced by ICU nurses throughout the provision of care for COVID-19 patients, it is therefore important to conduct a study to understand the existing challenges based on the nurses' lived experiences. A profound understanding of these challenges in the current critical situation can help health care authorities adopt appropriate measures to overcome the limitations, meet the challenges faced by nurses and provide quality and safe patient care, so that essential actions can be taken to reduce both the length of hospital stay for critically ill patients and the mortality rate caused by COVID-19. Accordingly, the present qualitative study was conducted to explore and describe the challenges experienced by ICU nurses throughout the provision of care for COVID-19 patients.

In the present study, a qualitative descriptive approach was used to explore the challenges experienced by ICU nurses throughout the provision of care for COVID-19 patients.

This approach was selected because it provides first-hand facts associated with a phenomenon such as understanding knowledge and insight of health care professionals regarding a less understood event or phenomenon (Turale, 2020) . Sandelowski considers this approach as the preferred choice for researchers who wish to provide a direct description of a phenomenon or an event (Sandelowski, 2010) .

A total of 17 rotating-shift nurses working in medical ICUs of a coronavirus (COVID-19) centre, Urmia, Iran, were recruited using purposive sampling. The centre has three ICUs with 27 beds and equal occupancy rates, in which a number of 50 nurses were working.

Since the coronavirus outbreak, all of the centre's beds have been dedicated to COVID-19 patients.

The inclusion criteria consisted of the following: ICU nurses with at least one year of critical care experience, having experience of caring for COVID-19 patients, having no history of COVID-19 and willingness to participate in the study and share their experiences.

Data were collected using semi-structured face-to-face interviews by a researcher and faculty member of the School of Nursing and Midwifery (YM). Participants were asked to describe their experiences concerning the main question of the study: 'What were the challenges you experienced as an ICU nurse in caring for Then, the interviewer continued the interview to examine their deeper experiences by asking more exploratory questions such as:

'What do you mean?', 'Please explain', 'Could you be more explicit?', 'Why?' and 'How?' All interviews were conducted by observing the principles of personal protection and coordination with participants in classrooms available in clinical fields. The researcher tried to protect participants' privacy and give participants utmost comfort. With the participants' consent, the researcher recorded all conversations during the interviews. Each interview lasted for 30-45 min, and each participant was interviewed once. Interviews persisted until saturation of data.

It is noteworthy that data saturation occurred with 15 nurses, and two other interviews were conducted to guarantee the saturation.

Prior to the beginning of the study and after obtaining approval of the Research Ethics Committee of Urmia University of Medical Sciences (Ethics No. IR.UMSU.REC.1399.021), the researcher introduced himself to the participants, explained the study objectives and methodology, obtained their written informed consent and assured them that the personal data would be regarded as strictly confidential.

Data were analysed using content analysis based on Granheim & Lundman method (Graneheim & Lundman 2004) . After each session, the recorded contents of interviews were carefully listened to several times, transcribed verbatim on paper and then typed in Microsoft Word®. Three of the authors classified and analysed data using MAX.Q DA-10 R250412. The semantic units were identified and encoded after careful review of the transcripts. At this stage, the initial codes were generated as explicit and implicit codes.

Then, codes were merged and categorized according to similarities.

Attempts were made to make the most homogeneity within categories and the most heterogeneity between categories.

The trustworthiness of the qualitative results was assessed using credibility, confirmability, dependability and transferability (Speziale et al., 2011) .

Credibility was achieved through ongoing engagement with the study subjects and data, prolonged engagement through frequent review of the interviews, corrective views of experts on the process of interviews, their data analysis, extraction of data, views expressed by some participants and those involved in a qualitative study on the interview texts and extracted codes and subcategories, and diversity of subjects by recruiting ICU nurses (as participants) from health centres providing care to COVID-19 patients.

Moreover, to ensure credibility and rigour of translated quotations, two bilingual researchers separately translated the Persian text into English. A native English translator, who had a PhD, was consulted to ensure proper translation of English terminologies into Persian.

Regarding the confirmability, all activities were accurately recorded including study stages and how data were collected. The study stages including data collection, data analysis and formation of themes were fully explained to enable scrutiny by readers. The study process was also made available to a number of study collaborators to confirm its rigour.

To assess dependability, another external auditing was used to assess similarities and differences between external auditors' understanding of the issues and the researcher's understanding.

For transferability, the researcher tried to fully explain the context in which the study was conducted by an accurate description of the participants, sampling method, and time and place of data collection so that the reader could have a positive view of data transferability.

A total of 17 ICU nurses participated in this study, whose demographic characteristics are presented in Table 1 . Data analysis led to the extraction of four themes of 'Organization's inefficiency in supporting nurses', 'Physical exhaustion', 'Living with uncertainty' and 'Psychological burden of the disease' as challenges experienced by ICU nurses throughout the provision of care for COVID-19 patients (Table 2 ).

One of the concepts extracted according to the nurses' experiences was the organisation's inefficiency in supporting nurses. This theme included four subthemes of 'Poor organizational support', 'Excessive workload', 'Shortage of personal protective gear' and 'Discrimination in providing protective gear'.

According to data analysis, insufficient support, failure to rewarding the personnel and no financial support of the hospital indicated poor organisational support for the ICU nurses.

We expect officials to come and visit us, moti- They don't stick to the shifts and we are working as before. Our shifts are tight and we are short of the workforce. They have promised to solve the shortage of workforce but to no avail as yet. We work every damn day.

(P5, female nurse)

The shifts we work are really killing, not tiresome, but killing. We have not been given leave, and we have been told that we must be in the hospital during this crisis. They don't give us proper off time, Doctors are dominant here. Doctors are given the best gear, but it isn't like that for nurses. A nurse is condemned to work with any equipment they are given.

(P17, female nurse)

Since the nursing office is afraid of doctors, they give them any kind of clothes, shields or protective gear they want, yet nurses who are more in contact with the patients are not given such gears.

(P7, male nurse)

Physical exhaustion was another challenge emphasized by nurses.

This theme consisted of two subthemes of 'Exhausting protective covers' and 'Physical complications'.

Nurses expressed the following as exhaustive challenges: reduced ability and focus when working with personal protective gear, unbearable heaviness of personal protective gear, difficulty eating/ drinking and inability to use the bathroom due to protective gear.

The heaviness of protective covers and gears reduces our abilities. It is very hard to focus on work with these clothes.

(P4, male nurse)

The clothes we wear make us very tired during the shift. Besides, with these on, we cannot eat or use the bathroom, especially during night shifts. Pardon me, many women have UTI, and some suffer from constipation because they have sluggish bowel.

(P12, female nurse)

Based on the nurses' experiences, prolonged care of COVID-19 patients had led to some complications, including physical tiredness, spots, skin damage and hormonal disorders.

We are truly tired. In this ward, all female nurses are covered in spots because of stress, and some have hormonal disorders. Our skin is badly damaged under the mask and medical caps.

(P5, female nurse)

Living with uncertainty was another concept extracted from data analysis. This theme consisted of three subthemes of 'Unclear nature of the disease', 'Fearing oneself and family being infected', and 'Desire to quit the job'.

Based on the nurses' experiences, the unknown nature of the disease due to the lack of knowledge on the prognosis, lack of specific medications, unknown transmission route, unclear clinical presentation and lack of a specific vaccine was one of the causes of a vague and uncertain situation.

The biggest concern is the lack of knowledge about this disease, since there is no treatment for it and you We are worried about our loved ones, and fear that we might be accidentally infected and carry this unknown disease home and pass on the disease to the spouse, children, father, and mother.

(P1, male nurse)

Low desire to attend the shift, regretting for being a nurse and thinking about quitting suggested the nurses' desire for quitting their jobs.

The situation is such that many colleagues don't want to come to their shifts.

(P11, male nurse)

what is going to happen. We were all unhappy about being a nurse, and wish we had another job that would take us away from this setting.

(P8, female nurse)

Another challenge extracted from the nurses' experiences was the psychological burden of the disease. This theme consisted of two subthemes of 'Domestic distress' and 'Psychological turmoil'.

The Our lives have gone off-track, and we have no peace.

Before the current pandemic, when we got home after the shift, we could at least cuddle our children.

My wife and I would at least talk together, but not now! We cannot cuddle our children. Contacts are limited. We suspect and doubt anything and everything in our own home, which is the safest place in terms of Corona.

(P16, male nurse)

Our family are afraid that we might take the virus home and they could be infected. Their mentality is that we are all infected and could infect them all. It seems they fear us.

(P3, female nurse)

According to the nurses' experiences, the stress caused by COVID-19

was associated with the incidence of psychological turmoils such as fear, worry, restlessness, depression, confusion, anxiety, nervous moods and aggression.

The stress caused by this disease has made me a little more aggressive, as I sometimes even become hostile toward my family, especially my brother.

(P15, female nurse)

Our colleague has been infected and hospitalized. I know him, he had no immune system disorder. Now that he gets sick in bed, I see that someone with a good immune system has been infected and hospitalized, and this stresses me.

(P1, male nurse)

The present study examined the challenges experienced by ICU nurses throughout the provision of care for COVID-19 patients using a qualitative descriptive approach. Four themes were extracted as challenges faced by ICU nurses, including 'Organization's inefficiency in supporting nurses', 'Physical exhaustion', 'Living with uncertainty' and 'psychological burden of the disease'.

The onset of this pandemic in many countries exposes nurses to various challenges such as inadequate resources, insufficient PPE, increased number of patients, lack of human workforce, health system's lack of preparedness (to cope with the pandemic) and a vicious cycle. These challenges cause nurses physical and mental strains and complex ethical issues Maben & Bridges, 2020; Turale et al., 2020) .

ing them as one of the important challenges during the novel coronavirus outbreak. The individuals' perceived organisational support and general feelings and beliefs are such that the organisation values the cooperation of its members and is concerned about their prosperity and future. However, the nurses' experiences suggested that the organisation did not make much effort to fulfil nurses' expectations of caring for COVID-19 patients. Poor organisational support, excessive workload, shortage of personal protective gear and discrimination in providing protective gear were the issues that confirm the above challenge. ICU nurses complained about the lack of personal protective gear such as medical masks, N95 respirators, protective gowns and shields, latex and disposable gloves, protective goggles and special protective gear.

Nurses heroically attempted to provide care and save human lives in fighting against COVID-19. Many of them worked long shifts for weeks with no days off. Most of them did not have proper PPE and were exposed to the risk of infection with COVID-19, and unfortunately, some died from the disease (Catton, 2020) .

The shortage of personal protective gear has been experienced in other similar epidemics due to increased demand, poor management, distribution of resources and the lack of crisis-oriented vision (Musau et al., 2015; Sun et al., 2020) .

Nursing is highly important for community health and well-being everywhere and helps the economic prosperity of countries, since health and wealth are two sides of a coin, of which people are already aware. Politicians who praised nurses for their commitment and bravery during this pandemic should allocate sufficient financial resources to support them, ensure access to proper and sufficient PPE and meet their financial needs (Catton, 2020) .

In addition, discriminatory and unfair behaviours towards nurses compared with doctors in receiving protective gear were described as a highly unpleasant experience when caring for COVID-19 patients. This is rooted in doctor-dominant policies in Iran. Baraz-Pordanjani et al. (2014) argues that the distribution of authority in Iran's health care system is disproportional and biased towards doctors (Baraz-Pordanjani et al., 2014) . This inequality in the distribution of authority can suitably explain the presence of discrimination. Therefore, it is highly important to create an efficient supportive system for providing proper protective gear and suitably allocating human workforce to facilitate the nurses' adaptation to the existing situation and optimize their performance of anti-pandemic tasks.

Physical exhaustion was described as another challenge faced by ICU nurses. The unbearable heaviness of personal protective gear on the one hand and the shortage of personal protective equipment on the other hand made nurses refrain from eating, drinking and using the bathroom due to the inability to change the gear during their shifts.

In a vicious cycle, this had caused further physical exhaustion due to complications such as dehydration, urinary tract infection and constipation. Furthermore, prolonged care for COVID-19 patients was associated with the incidence of complications such as physical tiredness, spots, skin damage, especially on facial skin due to constant use of respirators, and hormonal disorders. In a study by Kim, nurses described heavy perspiration due to unbearable body heat caused by personal protective gear and fog on protective goggles caused by respirators as the main causes of physical tiredness (Kim, 2018) . In a study by San et al., nurses, providing care for COVID-19 patients, felt severe physical tiredness and discomfort due to the spread of the disease (Sun et al., 2020) . The provision of quality personal protective gear can be effective in reducing physical harm and tiredness during long shifts (Im et al., 2018; Lam & Hung, 2013 ).

An another challenge faced by ICU nurses was living with uncertainty, which confused them. The stress caused by the unknown nature of the disease, fear of being infected and the possibility of infecting others made nurses refrain from providing basic care and even thought to think about leaving their jobs. This finding agrees with that found by San et al. and Liu et al. (Liu et al., 2019; Sun et al., 2020) . Knowing the risks of this highly contagious disease and caring for infected colleagues are the things that none of the personnel who experienced SARS-CoV could ever forget (Siyu et al., 2020; Wu et al., 2009 (Park & Park, 2020; See et al., 2018) .

The incidence of behavioural problems such as irritability, anger and other maladaptive behaviours in nurses and their family's anxiety and concern, and generally reduced quality of interpersonal relationships in the family can lead to domestic distress.

Nurses caring for patients with contagious diseases are worried about their health status and concerned about infecting their families and friends, which doubles their worry (Lam & Hung, 2013) .

Nurses with old people in their families receiving immunosuppressive medications and those with children were most worried (Koh et al., 2012; Lam & Hung, 2013) . Therefore, some nurses changed their place of residence, and some isolated themselves (Lam & Hung, 2013) . Meanwhile, some nurses were psychologically supported by their family and people around and improved their emotional state by writing letters and diaries Sun et al., 2020) .

Hence, it is currently essential to carry out psychological interventions to increase mindfulness and resilience of nurses and their families (Dai et al., 2020; Wong et al., 2020) .

The 

The present study explored only the experiences of Iranian ICU nurses. However, qualitative studies are not concerned with the generalizability of the results, it is recommended that similar studies in other contexts be conducted to make the results more generalizable. In addition, this was a short-term study, and prolonged engagement with the subjects can provide a valuable way to identify the present and future challenges.

Knowledge on the challenges faced by nurses in pandemics such as the current COVID-19 pandemic raises awareness in the health care systems regarding how to manage and cope with the current and similar future crises, and leads to the support and protection of the most valuable asset of the health care system, namely nurses through the development of evidence-based systems. Moreover, supporting nurses directly improves patient care and safety.

To provide safe and quality care during the pandemics, governments and health care systems must minimize physical and psychological burden on nurses by providing adequate personal protective equipment among members of the health care team, ensuring adequate workforce, modifying nurses' working hours, rewarding the personnel and paying attention to their concerns, providing accurate and evidence-based information and conducting psychological interventions on how to cope with the current crisis. This is because supporting nurses directly improves patient care and safety. Finally, using the results of the present study leads to the support and protection of nurses, improved patient safety and preparedness of health care systems for dealing with pandemics.

The researchers would like to thank all participants in this study.

No conflict of interest has been declared by the authors.

YM, RB, FM and KH contributed to study conception and design. YM and FM collected data. YM, RB, FM and KH analysed and interpreted the data. YM, RB and FM drafted the article. YM, RB, FM and KH critically revised the article.

The Ethics Committee of Urmia University of Medical Sciences approved this study (Ethics No. IR.UMSU.REC.1399.021).

Author elects to not share data.

https://orcid.org/0000-0001-9331-7573

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