Nurses' lived experiences of caring for patients with COVID-19: a phenomenological study.

Background: COVID-19 is an infectious disease caused by a novel Coronavirus which transmits from person to person throughout the world. This study aimed to explore the lived experiences of nurses' caring for patients with COVID-2019 in the context of the healthcare system of Iran.
Methods: This is a phenomenological study with 13 participant nurses (6 men and 7 women) who were caring for COVID-19 patients in one of the university hospitals in Southeast of Iran. Qualitative data were analysed by the seven steps of Colaizzi's method.
Results: Participants reported around a five-month history of caring for COVID-19 patients. After analysis, 597 codes, 16 categories, four sub-themes, and one theme were extracted. "Caring from self-sacrifice to avoidance" was the main theme of the study with sub-themes of "Anxiety Chain", "Manifestation of Humanitarian Caring", "Ethical Challenges", and "Challenges of Overcoming Crisis". Conclusions: Nurses explained their caring experiences with patients on a continuum from humanitarian caring and self-sacrifice to caring avoidance. Because of the multi-sources of psychological stress and ethical challenges together with this infection, healthcare managers should plan for holistic regular psychological support services, prevention of job inequalities, and do strategic planning for access to enough resources in the healthcare system.

Introduction

Coronavirus disease-2019 (COVID-19) is a serious infectious threat to public health throughout the world (Eghbali et al., 2020). It is caused by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) (Astuti and Ysrafil, 2020). There is a novel Coronavirus (2019-nCoV), which transmits from one person to another and also across generations (WHO, 2020; WHO, 2020a). The first cases of the novel disease were reported in Wuhan, Hubei province of China, on 31st December 2019 (WHO, 2020b). It was rapidly spread in other parts of China and subsequently an ongoing pandemic was developed worldwide within a three month period (Perez and Abadi, 2020). The World Health Organization (WHO) identified it as a pandemic on 11 March 2020 (Astuti and Ysrafil, 2020). In Iran, the first confirmed case was reported on 19th of February 2020 in Qom Province, South of Tehran (Arab-Mazar et al., 2020; Nourizadeh et al., 2020). Based on the WHO report up to the 8th of August 2020, the number of total confirmed cases and deaths were 322,567 and 18,132, respectively, in Iran. Community transmission was reported as a major transmission classification in this society (WHO, 2020c). With vaccination of the people, new hopes for the disease control were created. But, there are still different challenges, including non-complete, low coverage of vaccination, insufficient immunity in the communities (Maserat et al., 2021; Moradi et al., 2021), and emerging and spreading new variants in the world, such as Delta (Alexandar et al., 2021).

COVID-19 needs a worldwide plan of action to battle the disease because of the vastness of the disease spread, the main role of the public in the prevention (Qian et al., 2020), and various aspects of the pathogenesis of the virus as well as the complex spectrum of its clinical outcomes (Perez and Abadi, 2020). COVID-19 is a major threat to the public in the community and also for healthcare providers in hospitals and clinics (Huang et al., 2020). The high risk of the disease transmission, disease stigmatisation, a shortage of healthcare providers, and limitations to provide the personal protective equipment and necessary facilities have made the current situation worse (Liu et al., 2020; Perez and Abadi, 2020).

Evidence shows that “caring” is a context specific and interpersonal process. It is the core of nursing practice (Andersson et al., 2015; Karlsson and Pennbrant, 2020). Human existence is associated with caring (Pereira, 2020). The results of a study show that caring for COVID-19 patients has been accompanied by an insufficiently comprehensive approach, and it has threatened professional values (Pazokian et al., 2021). For providing nursing care, communication with patients is very essential, and this is happening through considering the patients, understanding them, and accepting professional responsibilities as a nurse (Karlsson and Pennbrant, 2020). A review of the literature shows that the number of qualitative studies in the area of nurses’ experiences with COVID-19 is scarce. The results of a study in Hong Kong indicated that caring for new COVID patients caused anxiety in nurses (Tiwari et al., 2003). In a qualitative study in South Korea, nurses experienced fear during caring for patients with Middle East Respiratory Syndrome-Coronavirus (MERS-CoV), but concurrently they felt a kind of moral compulsion (Kim, 2018). In a study based on Parse’s Human Becoming Theory for framing the stories of eight nurses during the MERS outbreak, Korean nurses explained the disease as a global health challenge that posed a considerable threat to the people (Im et al., 2018). Also, a qualitative study in the COVID crisis showed that Chinese nurses and physicians expressed their patients’ well-being as their main responsibility (Liu et al., 2020). Evidence shows that ethical issues can emerge in the workplace and healthcare providers following the crisis of the disease (Patel et al., 2020). Mood swings and even suicide have been reported by nurses during the COVID-19 crisis (Rachubinska, 2022). Anxiety, depression, sleep disorders, and stress have also been reported as psychological problems in the healthcare providers of COVID-19 patients (Liu et al., 2020). Moreover, decreased self-efficacy and performance can be the result of stress and anxiety in nurses with COVID-19 patients (Pragholapati, 2020).

Since no study was found about nurses’ experiences in this area, a qualitative study with a phenomenological approach was conducted. The aim of this study was to explore the lived experiences of nurses in caring with COVID-19 patients in the context of the healthcare system of Iran.

Methods

Design

This is a qualitative study with a descriptive phenomenological approach which was approved by the research ethics committee of the university (ethical code: IR.IRSHUMS.REC.1399.003). The focus of the phenomenological study is to extract the essence of a phenomenon in a way that has been perceived by a person (Neubauer et al., 2019).

Participants and data collection

Participants were 13 nurses who did caring for COVID-19 patients in triage-emergency, infectious wards, and Intensive Care Units (ICUs). They were registered by purposive sampling from one of the university hospitals in Southeast of Iran. This general hospital is a referral centre for COVID-19 patients. The first suspected patient with COVID-19 was admitted on 21st of February 2020 in this hospital, and the first positive case of the disease was confirmed here on 27th of February 2020. The inclusion criteria were: being a staff nurse at the hospital with at least two months caring for COVID-19 patients and having one year or more nursing experience at the hospital. The aim and procedure of the study were explained in detail for all participants. Also, they received necessary information regarding voluntary participation, confidentiality of the data, and they could withdraw from the study at any time. Prior to the study, an informed consent form was taken from all participants. Data were collected by two authors (NH and ZSH) through semi-structured interviews with all participants to get their lived experiences with “patient care” in the context of the study. All interviews were audio recorded and subsequently were written verbatim. Several sample interview questions were: “Please explain one day of your caring experience with COVID-19 patients”, “How can you compare this experience with your previous experiences of patient care?” and “Please explain about the impact of caring on relationships with your family and community”. Based on the participants’ responses, the process of interviewing proceeded and more probing questions were asked. The place of interviews was a private room in the wards of the hospital. Participants were interviewed before or after the working shift at the hospital, according to their preferences. A total of 13 interviews were done with a mean of 51.15±8.86 minutes (range: 39–67 minutes). Data saturation was reached with 11 participants and interviews continued with two more participants.

Data analysis

Colaizzi’s method was used to analyse the qualitative data. This qualitative method has seven steps (Morrow et al., 2015). Data were analysed following the end of each interview, on the same day or the next. It was started by reading and re-reading the transcript. In the second step, significant statements that were related to the phenomenon were extracted. Then, formulating meaning was achieved by deep consideration of the main relevant statements and phrases. Next, formulated meanings were aggregated into the themes and theme clusters. Later, an exhaustive description of the phenomenon’s structure was developed. Subsequently, fundamental structure of the phenomenon was described. The final step was validation of the findings by participants’ feedback on the analyses (Wirihana et al., 2018).

Rigor of the study

Guided by the Lincoln and Guba criteria (Anney, 2014), rigor was achieved using several procedures. To ensure credibility, data were gathered from nurses representing different wards, both genders, single and married nurses as well as nurses with and without children. Member checking was achieved by having study participants read and confirm the extracted codes and categories. All participants confirmed the final structure statements. Adjustments in codes and categories were made based on participants’ comments and those of two external reviewers. Transferability of findings was facilitated by content description, participant selection, and explanation of analytic content. Research team meetings were held to reach a common agreement on extracting codes, labels, categories, sub-themes, and overall theme. Dependability was established by providing a detailed description of the data collection phases and using an audit trail reviewed by two university faculty members with doctoral degrees in nursing.

Results

Descriptive results

A total of 13 nurses, 6 men and 7 women, with a mean age of 27.69± 3.83 years and a mean work experience of 5.46 ±3.25 years, participated in the study. Sixty-nine percent of them were married and 46% had children. Totally, 13 interviews were conducted with participants. All nurses reported around a five-month history of caring for COVID-19 patients.

Qualitative Results

After analysis, 894 primary codes were extracted. Following integrating similar codes, 597 codes, 16 categories, four sub-themes, and one main theme emerged (Table 1). The main theme of the study was “Caring from self-sacrifice to avoidance”. Four sub-themes were extracted from the main theme of the study, including “Anxiety chain”, “manifestation of humanitarian caring,” “ethical challenges”, and “challenges of overcoming a crisis.”

Table 1.

Nurses’ lived experiences of caring for COVID-19 patients at a general hospital in Southeast of Iran, 2020.

Theme	Sub-themes	Categories	Quotations
Caring from self-sacrifice to avoidance	Anxiety chain	Immersion in the whirlpool of stress	“Daily news on television and radio, report the number of morbidity and mortality cases of Corona all over the world. Also, the news of the death of doctors and nurses makes me and my family really anxious.”(Pn.3)
		Holistic psychological support-A missed component of caring	“We all need psychological support but none of us received it….even my patients and their families…. If I had talked to a psychologist before entering the Corona ward, I might have found it easier to work with my patients who are also anxious…” (Pn.5)
		Hallucination of sickness	“I should say that working with protective cloth is not easy, it becomes very hot inside of the cloth… many times I was confused between getting the disease and a normal situation and only feeling hot in the body…. Anyway, after taking care of the Corona patient, the hallucination of getting the disease bother you…”(Pn.1)
	Manifestation of humanitarian caring	Love the essence of caring	“During the whole time of patients' care, you are careful not to become infected and not to transmit the infection to your beloved ones at home. We all have stress and we don’t want anyone to get it. I am so careful because I love my patients, my family and myself. In this situation, your soul must be very generous, so that you can endanger yourself to save others' lives.” (Pn.6)
		Caring in distress environment	“The experience of workload and wearing a gown together with a protective shield during caring for Corona patients is really unpleasant. When you are wearing those clothes and shield, it’s like being in a steam Sauna… while sweat enters your eyes and burns them and your breathing becomes difficult, also.” (Pn.12)
		Fighting with an unknown enemy in two fronts	“All nurses in the frontlines of the Corona struggle, are fighting with the disease by providing special care with hope for their patients …the hope of victory against the disease, and not to transfer the virus to others” (Pn.2)
		Turning the crisis into the opportunities	“One of the important things during the Corona pandemic is the unity and empathy between the staff at hospital, the stronger communication between the staff and the managers. For better outcomes, there were some changes, they were planned and two hospital wards integrated … they caused management of the workforce, identifying and assigning separate wards for Corona patients, providing the necessary facilities and equipment, such as Intensive Care Units beds and so on.”(Pn.7)
		Growing up together with the crisis	“Corona led me and all my colleagues towards a better understanding of the concept of “patient care in a life-threatening situation”… It also helped us to have a better understanding of the patients' needs. It caused nurses to have a better communication with these patients and ultimately caused improvement in the nursing performance.” (Pn.11)
		Spiritual connection	“My interesting experience with Corona patients is connection to the spirituality. When a patient who is suffering from acute respiratory distress, dies ….. at that time, I can feel God is very close to me…I feel him inside of myself and feel that he is supporting me to overcome the disease and do my responsibilities to the best of my ability.”(Pn.13)
	Ethical challenges	Patients' rights	“Some nurses are very afraid of the disease and try to stay far from the patients. They just stay in patients’ rooms for a short time, provide some small care or even sometimes ignore it, in order to keep themselves safe…Um this is contrary to the patients’ rights.” (Pn.4)
		Corona stigma	“Actually behaviors of the people around those who are caring for Corona patients are not good. They escape from you. And that’s very difficult for me.” (Pn.9)
		Caring avoidance	“When the clinical supervisor told me that I should go to the Corona ward, I requested to cancel my work commitment in the governmental hospital (after nursing education, there is a compulsory work commitment in the governmental healthcare centers around 19–24 months period), but it was not accepted. I was very anxious and absent from my work for a few days. I was looking for a legal reason not to go to the Corona ward…” (Pn.9)
		Inequalities in the job	“The most important of my concerns is “why should I have to work in the Corona ward, but not the rest of the nurses at this hospital?” (Pn.6)
	Challenges of overcoming the crisis	Worldwide pain experience	“When you hear that the Corona virus has spread in most countries of the world and there is high mortality and streets are devoid of people, and there are quarantine rules in different countries, you feel how much close you are to the end of the world. How is it possible that with all of the advancements in science and technology in the 21st century, world’s scientists are unable to treat, prevent and stop this disease?” (Pn.8)
		Denial and resistance	“I had four old patients who did not believe in Corona at all, and said that the disease is related to our destiny. If your destiny is death, this disease can be an excuse and you cannot stop it.”(Pn.2)
		Shortage of facilities	“Shortages of facilities and the lack of good quality of them, is one of the challenges of caring for Corona patients. When you don’t trust your mask on your face and you feel your patient’s exhaled air come inside of your mask, it makes you crazy.” (Pn.10)

Pn: Participant number.

Theme: Caring from self-sacrifice to avoidance

It reflects the efforts of nurses to care for COVID-19 patients across a continuum from humanitarian care and self-sacrifice in a rapid and progressive crisis to avoiding care. Nurses felt a conflict between their duties as a nurse and their self-protection from the disease and the protection of their families at home due to fear of this unknown disease and its rapid transmission. Nurses who were involved in caring for COVID-19 patients were volunteer nurses or nurses who were forced to care based on the hospital rules and decisions. The sense of duty and commitment to human health led nurses to endure hardships under very harsh conditions, like the soldiers on the front lines. But, some nurses tended to avoid care of these patients or even leave their job. Fear of the unknown disease, death anxiety and to keep safe their family members as well as job inequality, led some nurses to escape from patient care. Anyway, this is not negligible that nurses provided caring in an exhausting situation due to workload, shortage of workforce, insufficient medical protective equipment, and the use of personal protective equipment for long hours.

Sub-theme 1: Anxiety chain

It refers to the diffuse and multi-sources stress in the hospital and in the society. With the official announcement of the arrival of the Coronavirus in Iran, many sources of concern appeared. The anxiety about a new infectious disease was increased by the news and rumours among people in the society and it was spread to the individuals in an obscure context. Nurses experienced anxiety due to different reasons; the highly infectious nature of the disease, the lack of certain treatment, limitation in access to the personal protective equipment (PPE), incidence and mortality rate news, death anxiety, and the integration of the wards and opening of a new ward for COVID-19 patients at hospital. Furthermore, not enough compliance with prevention principles of the disease by lay people, the hospitalisation of COVID-19 patients in only one general hospital of the city where patients were admitted for other diseases, and the lack of enough psychological support, exacerbated the crisis situation for nurses and the rest of the healthcare team members.

There are three categories in this sub-theme, including “immersion in the whirlpool of stress”, “holistic psychological support—a missed component of caring”, and “hallucination of sickness”.

Category 1: Immersion in the whirlpool of stress

The stress of dealing with infected patients, caring-induced anxiety, the physical tension of protective equipment, and the stress of mortality among patients and colleagues, as well as the stress of family members’ protection against the virus, overwhelmed the nurses. In addition to workplace stress, uncertainty about the quality of medical protective equipment, caring for family members with chronic diseases, and excessive costs increased the stress of nurses.

Category 2: Holistic psychological support - A missed component of caring

Since the onset of the Coronavirus was a stressful, exhausting, and challenging experience, psychological support for patients and their families, nurses, and the rest of healthcare providers is essential. However, there was not a holistic support program at the hospital.

Category 3: Hallucination of sickness

A common feeling amongst nurses was a hallucination of illness. The slightest sore throat, cough, or any other sign or symptom made them anxious, wondering if they also had COVID-19. This sentiment was expressed by participants.

Sub-theme 2: Manifestation of humanitarian caring

It represents the efforts of nurses under difficult psychological and physical conditions to save the lives of their patients and protect other people. Overcoming fears, professional conscience, nursing duties, and commitments in addition to faith and self-sacrifice for saving others’ lives led to the stream of humanitarian care towards the patients.

There are six categories in this sub-theme, including “love ‐ the essence of caring”, “caring in distress environment”, “fighting with an unknown enemy in two fronts”, “turning the crisis into opportunities”, “growing up together with the crisis”, and “spiritual connection”.

Category 1 Love ‐ the essence of caring

Nurses provided caring by their love for the patients while they felt uncomfortable and very warm inside the protective clothing and delivered care in a distressing situation in the hospital. They were satisfied with caring of their patients. Love for caring and love for taking care of oneself and beloved ones were experienced during this difficult period of life. Self-protection against the Coronavirus from head to toe at every shift was difficult but necessary in order to protect oneself and others in the hospital, at home, and in the community. Some nurses preferred to stay far from their children, spouses, parents, and friends to protect them from the disease, it seems a romantic separation. Some nurses could not go to their home for a month or more, and some nurses from other departments and even outside the hospital became a volunteer to provide caring for COVID-19 patients.

Category 2: Caring in a distress environment

There was a difficult circumstance in the workplace. Responsibility in a troubling situation and weariness, because of more patients being conceded and nursing obligations, made caring more unpredictable. Moreover, warm climate, continuous utilisation of protective clothing (shield, and mask on the face, wearing protective garments), timely access to the toilet, eating, and drinking while wearing protective coverings, and whole body perspiration during caring as well as the absence of sufficient cooling in the ward environment made caring very hard for nurses.

Category 3: Fighting with an unknown enemy in two fronts

Nurses were concerned about the health of their patients, themselves, and their families. They were fighting at both sides, in the hospital and their homes. It was an endless battle against the disease. The struggle with an unknown enemy with a highly contagious nature and unspecified treatment makes the role of nurses more expansive and revered.

Category 4: Turning crisis into the opportunities

While the Coronavirus caused worries among nurses, it also had some positive aspects. Several changes took place at various levels of the hospital to increase resources, including access to more medical equipment, facilities, and modification of work scheduling for healthcare providers, and improving the quality of care. Empathy among the hospital’s multidisciplinary professionals was considerable. Integration of the hospital wards, patients triage in an open space, and increasing the number of beds in the intensive care unit (ICU) were done to prevent the spread of the Coronavirus inside the hospital units, and from the hospital to the community.

Category 5: Growing up together with the crisis

Caring for COVID-19 patients was accompanied by nurses’ growth in the individual and professional levels. This situation was initially experienced with stress and anxiety by nurses, but later, there was an improvement in nurses with regard to sense of strength and professional empowerment. Nurses’ awareness and performance increased regarding the patient needs and having better communication with highly infectious patients. Nurses learned to strengthen themselves at different times, be able to help others, and become a source of hope and support for their patients in the crisis situations.

Category 6: Spiritual connection

The Coronavirus pandemic was associated with consciousness, interconnection, and the transcendence experience in nurses. Nurses described closeness to God, confidence in God’s support, selflessness, valuing selflessness to save others, and becoming a volunteer to save the people’s lives. More prayer was one of the experiences of the spiritual growth in our participants.

Sub-theme 3: Ethical challenges

The tension associated with the highly contagious nature of the Coronavirus, the fear of death, particularly at the onset of the disease, had compromised patients' rights. Conflicting data on treatment, lack of successful treatment, and vaccines at the onset of the disease, complications of infection and other reasons resulted in some nurses avoiding caring for these patients. They tried to have minimal contact with these patients and keep some distance to reduce the risk of infection.

From this sub-theme four categories have been extracted, including “patients’ rights”, “Corona stigma”, “caring avoidance”, and “inequalities in the job”.

Category 1: Patients’ rights

The fear of Coronavirus among nurses and the prioritisation of their patients’ safety led to some nurses being unable to provide adequate care and to not have enough communication with their patients. In addition, shortage of medical equipment and ventilators also led to disregard for the rights of the elderly patients at hospital. Therapeutic relationships between nurses and their patients were affected by the COVID-19 pandemic. The families were even deprived of a deserving farewell ceremony with the dead patients’ body, which is the right of patients and their families.

Category 2: Corona stigma

Working at the hospital in the COVID-19 ward caused stigma challenges for nurses in both places, in the workplace and in the place where they lived. Stigmatisation was started by nurses who were working in other wards of the hospital. In addition, family members, relatives, and neighbours showed avoidance behaviour to the nurses who were working in the COVID-19 ward.

Category 3: Caring avoidance

Anxiety over the rapid spread and the fatal nature of COVID-19 impacted the work of a few nurses. It caused a feeling of death anxiety and an unwillingness to care for these patients. Some nurses avoided caring for COVID-19 patients, and in some cases, they were absent or left their work.

Category 4: Inequalities in the job

The crisis of the disease caused a significant burden on certain hospital healthcare services, such as healthcare services in infectious ward and intensive care units. The workload for COVID-19 care, the expectations of the healthcare system to improve the quality of patient care, and the limited facilities created job inequities and tensions for nurses.

Sub-theme 4: Challenges of overcoming crisis

The crisis of rapid distribution of the disease made it an ongoing challenge to overcome the disease. The sub-theme of “challenges of overcoming crisis” has three categories, including “worldwide pain experience”, “denial and resistance”, and “shortage of facilities".

Category 1: Worldwide pain experience

The Coronavirus spread rapidly throughout the world, infecting and killing numerous people in different countries. Regardless of sex, religion, and culture, many people were infected with the Coronavirus and experienced the grief of losing loved ones and the complications of morbidity.

Category 2: Denial and resistance

One barrier to disease control was the thoughts and special beliefs of some people. They did not know about the disease, did not believe it, and did not believe how dangerous it might be. There are those who believe their health, sickness, and death are their fate and they cannot change it. As a result, they resisted to accept the new disease. This group tried to escape from the reality of the illness.

Category 3: Shortage of facilities

More facilities were necessary for patients and nurses safety like protective clothing, oxygen, and ventilators. Shortages of them created restrictions on controlling the COVID-19 crisis. The number of hospital beds was not in proportion to the number of admitted patients at the peak of the disease. In addition, sometimes there was medical equipment but not of good quality (such as face shields, masks, gloves, and protective clothes).

Discussion

In this phenomenological study in our context, the wide experiences of nurses about caring for their patients with COVID-19 were explored during the pandemic crisis. At the beginning of the crisis, our participants experienced psychological tensions. They explained it by immersion in the whirlpool of stress. Vibrations of the wave of COVID-19-induced stress, anxiety, fear, and concern were transferred from person to person, media to the person, and the physical environment to the person. The sub-theme of the “anxiety chain” in the study is consistent with the theme of “infectious anxiety disorder” in Cassel et al.’s study. The authors explained a contagious form of anxiety with a high speed spreading worldwide unhappiness (Cassels et al., 2014). Our participants experienced anxiety from multiple sources in line with previous studies (Cui et al., 2020; Kim, 2018; Wind et al., 2020). Evidence shows that stress and anxiety in the medical staff are prevalent difficulties following the COVID-19 crisis (Ghaffari et al., 2020). Nurses experienced depression, anxiety, sleep disorder, and distress during the COVID-19 outbreak (Santarone et al., 2020). The results of a study showed that the first week of caring for COVID-19 patients was accompanied with a highly negative emotional burden for nurses, but they gradually adapted to the situation (Sun et al., 2020). Findings of a study showed that 34% of Chinese nurses suffered from mild anxiety, also 3.5% and 0.4% of them, respectively, reported moderate and severe anxiety due to the highly infectious nature of COVID-19, high risk of disease transfer to healthcare providers and their families as well as the death of their colleagues in the healthcare team (Cui et al., 2020). Hallucination of sickness and fear of contamination with the disease can increase the anxiety (Wind et al., 2020). Delayed psychological supports can lead to the psychological problems in persons involved in the crisis (Javadi et al., 2020). Nurses and the rest of healthcare providers, who are involved with the patients, need psychological support. It is even necessary for their families; especially if they have small children at home (Cui et al., 2020). It is emphasised that some important parts of the worldwide fight against COVID-19 also depended on the psychological atmosphere of the environment. The frontline healthcare providers should have more resilience and maintain their mental health (Santarone et al., 2020).

The stream of positive and negative lived experiences of our nurses following their caring efforts in difficult psychological and physical conditions appeared with the sub-theme of the “manifestation of humanitarian caring”. A sense of dutifulness and commitment to human’s health caused nurses to endure many hardships in very distressing conditions, like soldiers on the frontline. Chinese nurses explained their responsibility for saving patients' lives during the COVID-19 time. They described it as a combat with an unknown enemy in the battlefield. They needed to strengthen themselves continuously by increasing their knowledge (Liu et al., 2020). Our nurses provided caring for their patients while they were in a distressing atmosphere at hospital. They explained it as a humanitarian caring, while their caring was implemented in an exhausting situation due to the workload, equipment shortage, wearing personal protective equipment for long hours, and hesitation about their safety. This uncertainty has been previously reported by nurses during caring for MERS-CoV patients (Kim, 2018). Wearing personal protective equipment has been described as a major physical and professional challenge by the healthcare providers. Chest pain, breathing hard, deficiency of oxygen, sweating, difficulty in moving, and doing the procedures has been explained by the Chinese nurses (Liu et al., 2020). Fatigue, exhaustion, and discomfort were also reported by the nurses (Sun et al., 2020). Although these problems could reduce the physical strength of the nurses (Kim, 2018), our participants continued with their caring. They integrated their love with caring for their COVID-19 patients. This result is similar to an earlier study. This study showed that many nurses and healthcare providers delivered their healthcare services to patients with limited protective equipment. They sacrificed their lives to protect their patients in a humanitarian crisis (Smith et al., 2020).

In our study, the sub-theme of the “fighting with an unknown enemy in two fronts” showed nurses’ efforts for both their patients and their own family. In a study, nurses described caring as an inevitable part of their job responsibility for MERS-CoV patients, but it is very important to keep safe their own family against the disease also (Kim, 2018). One of the interesting experiences of nurses in our study was turning the crisis into the opportunities. They experienced tough working condition with COVID-19 accompanied by good team working, management of the crisis, and turning threats into the opportunities at the hospital. This result was not in line with a study which reported challenges between various healthcare specialties in team working in different provinces of China (Liu et al., 2020). This difference can be pertained to the different contexts of these studies in two countries. But evidence shows that team working and support decrease the fear of the communicable disease, create a feeling of becoming stronger, and being proud of oneself as a nurse (Kim, 2018).

Moreover, growing up together with the COVID-19 crisis and spiritual connection were other positive experiences which were explained by nurses in our study. Nurses reported a type of special growth that started simultaneously with the crisis, or in other words, growth in line with stress. Positive growth under pressure was explained in an earlier study. More support, greater value of the nursing profession and family appeared under a pressure situation (Sun et al., 2020). In our study, the initial anxiety of nurses changed into the positive growth, as the Coronavirus spread. But, post traumatic growth occurs after the event (Tamiolaki and Kalaitzaki, 2020). Furthermore, our participants experienced spiritual connection in line with a similar study (Tamiolaki and Kalaitzaki, 2020). They explained it as an appreciation and re-valuation of their life and more communication with their family. Findings of a study with COVID-19 patients showed that healthcare providers found a meaning in their life and described it with cherishing life, courage, overcoming difficulties, and improvement in self-protection and communicative skills (Liu et al., 2020).

Ethical challenges were another experience of our participants in this study. Our nurses experienced stigma of the disease. They became conspicuous at the hospital and even at their living place in the community; and people tried to avoid them. This result is consistent with earlier studies (Kim, 2018; Santarone et al., 2020). In Kim’s study, authors reported that not only nurses but also their family members experienced discriminatory behaviours (Kim, 2018). Stigmatisation is always present in the rapid epidemic of the disease (Qian et al., 2020). Our results showed that under this atmosphere, some of the nurses tried not to care for COVID-19 patients, especially at the beginning of outbreak. Avoidance behaviour was attributed to some extent to the very infectious and rapid spread of the disease, which makes it difficult to control. It seems that a tangible sense of danger is created when the frontline healthcare providers try to handle life and death situations; however, at the same time, their own lives are at a great risk (Santarone et al., 2020). Withdrawal of patient care in nurses can also be an expected response behaviour to the harmful aspects of their job and may help them to be far from the stress for a while (Shapira-Lishchinsky and Even-Zohar, 2011). Of course, shortage of facilities and inequalities in the healthcare organisation can make the situation worse. Our participants complained of workload, shortage of protective clothes, and inequalities in the hospital. In our study, workload for caring of patients together with high expectations of the quality of care brought about more tension for nurses. Facilities shortage such as gloves, mask, hospital beds, and ventilators has been mentioned in previous studies (Perez and Abadi, 2020). It is a barrier in overcoming crisis (Qian et al., 2020). Mismatch between members' effort, performance, and participation is called the distributive injustice (Pérez-Rodríguez et al., 2019). Evidence shows that organisational inequalities can damage both persons and organisations, and lead to psychological distress and burnout (Pérez-Rodríguez et al., 2019).

Limitations

This study was done in only one university hospital and this can make a bias. But, it was the only place in the city for treatment of the COVID-19 patients. This study was conducted five months after the spread of the disease in the country. Nurses’ experiences at this stage support future interventions that may lead to better quality of care and greater protection of patients and nurses.

Conclusions

“Caring from self-sacrifice to avoidance” emerged as the main theme of the study for the wide experiences of nurses with their COVID-19 patients. Nurses as soldiers fighting in the frontline of COVID-19 experienced the multi-sources of psychological stress and ethical challenges. Understanding these experiences helps to plan for development of quality of care. Thus, psychological support for nurses should not be ignored. More attention should be paid to establish job equalities and adequate resources at hospitals to prevent the burden of caring in nurses.

Key points for policy, practice, and/or research

• Understanding nurses’ experiences of caring for COVID-19 patients helps to plan for the development of quality of care.

• Fear of COVID-19 and its rapid transmission caused avoiding care which was in conflict with nurses’ responsibility for caring.

• Nurses experienced not only psychological distress when caring for COVID-19 patients but also a type of special growth; this occurred simultaneously.

• It is important to keep safe nurses from stigmatisation.

• Healthcare managers should focus on providing holistic regular psychological support services, preventing job inequalities, and accessing adequate resources in hospitals.