The present study was conducted to identify the challenges, strategies and outcomes of stress management for nurses who come into contact with and provide care to COVID-19 patients. Analyses of the collected data showed that the nurses’ experiences could be classified into four categories: providing care with uncertainty and anxiety, facing psychological and mental tension, creating a context for support, and experiencing personal-professional growth.
One of the findings of the present study was nurses’ feelings of uncertainty and anxiety in providing care. The nurses were worried about transmitting the infection to their family members, were not adequately aware of the nature of the disease, and were in fear of making wrong decisions about caring for COVID-19 patients; yet, they deemed it their professional duty to provide care to those patients. In another study, the nurses were worried about facing patients with COVID-19, contracting the infection and transmitting it to their loved ones. The nurses were also concerned about the unknown aspects of the disease and its potentially dangerous nature, uncertainty about the end of the pandemic, and the impact of the pandemic on their job security and other working conditions [26]. Another study reported that the healthcare personnel suffered psychosocial issues, e.g. depression, anxiety, and stress, as a result of having inadequate knowledge about COVID-19, continuously caring for the infected, work overload, frequent exposure to distressful events, such as death, and fear of infecting their families [27]. In yet another study, the nurses suffered from stress due to caring for the infected and work overload, which resulted in their experiencing burnout, emotional fatigue, and despair [28]. De Kock et al. found that, the COVID-19 crisis had an impact on the nurses’ mental health and increased their anxiety, stress, and sleep difficulties. The occupational, psychosocial, and environmental risk factors associated with adverse mental health outcomes during the COVID-19 pandemic identified through their study [29]. The frontline healthcare workers commonly reported increased workloads, which impacted on their psychosocial health. The healthcare workers reported increased hours and weekend shifts, additional time taken to manage PPE and staff shortages as frequent sources of stress. However, because of staff shortages, some nurses described feeling guilty for taking time off to rest [30].
Several studies suggest long-distance psychological interventions, including video conferencing, online programs, applications, and even telephone calls, to help care providers cope with their anxiety [31, 32]. In China, Internet-based programs are used to screen and identify individuals who are prone to psychological disorders and to provide self-learning protocols and guidelines to the healthcare personnel and the general public in the form of videos and pamphlets [33]. During a pandemic, digital interventions should be used to address anxiety, depression, self-torture, and suicide, as well as to gather information, perform triage and introduce medical interventions via online applications or phone calls and text messaging for those with limited access to digital sources [34, 35]. Measures, such as workshops and counseling with a psychologist, should be taken to decrease stress and anxiety in nurses who are directly involved in caring for COVID-19 patients as prolonged anxiety can lead to psychological distress, depression and other psychological issues.
Another finding of the present study was nurses’ exposure to mental and psychological tension which originated from the insistence of their families that they should quit their jobs, feeling rejected, witnessing the death of their colleagues and friends, fear of infecting their families, lack of medical equipment, and fatigue. According to one study, the major contributory factors in the psychological pain of nurses, doctors, therapists and other healthcare professionals were the emotional efforts and physical fatigue that they experienced in caring for COVID-19 patients whose conditions were deteriorating quickly. Seeing and caring for colleagues who were severely infected or lost their lives to COVID-19, lack of ventilators and other medical equipment needed to care for patients in critical conditions, and anxiety due to new clinical roles and work overload were other causes of psychological distress [36].
As a result of social stigmatization, the nurses suffered from social dejection and loneliness. They preferred to be isolated because they were afraid that they might transmit the infection to others [37]. Another study reported that frequent changes in the hospital policies, routines, and guidelines which were updated confused the nurses [38]. In another study, the participants reported work overload as a result of lack of medical protective equipment: the nurse managers had to reduce the number of care providers to ensure that all the personnel had access to protective equipment by conserving it. Moreover, to avoid going to break rooms during working hours, the healthcare professionals did not eat anything, and they experienced severe emotional distress and grief if their patients passed away [39]. During the COVID-19 pandemic, nurses were exposed to so many psychological issues that they sometimes had to resign [40].
According to Maslow's hierarchy of needs, physiological and safety needs are two of the basic and essential needs of mankind. If these needs are satisfied in them, nurses can experience self-esteem, love and self-actualization and, consequently, meet other individuals’ needs without feelings of exhaustion or burnout. Thus, authorities and governments should decrease the physical and mental pressure caused by the COVID-19 pandemic by creating an appropriate work environment, supplying adequate PPE, managing work shifts effectively, and considering the physical and mental health of nurses [12]. Support interventions, including informing the public about the pandemic and self-quarantine, providing enough resources to meet the basic needs of nurses in quarantine, and giving nurses easy access to social media so that they can be in touch with their friends and families can encourage nurses to stay in their jobs [37]. Also, counseling the personnel and preparing them for the challenges in their profession and giving a clear picture of what they are going to face can prove helpful [41].
Research findings show that mental health interventions for the time of the pandemic, including crisis management, education in resilience, improvement in quality of life and life satisfaction, confrontational strategies, education via guidelines and protocols, screening programs and long-distance Internet-based interventions, are effective methods to manage the psychological consequences of the pandemic for nurses [42, 43]. Strategic support and planning across the country and arranging for psychological first aid during crises which are potentially offered by telemedicine are among the interventions which must be employed. In addition, comprehensive plans should be developed to reduce mental pressure on nurses through prevention and intervention, e.g. screening and purposeful visits, to avoid further mental health issues in this population [44, 45]. Educational programs about death anxiety can result in better nursing care in critical situations. Educational workshops are effective in reducing death anxiety [14]. Giving nurses active guidance and motivating them to achieve psychological growth during the pandemic can contribute to their psychological adaptation [46].
Another finding of the present study was the role of creating a context of support. The participants’ experiences showed that intradepartmental management, support of the authorities, and effective communication skills are effective ways to support nurses in the stressful conditions caused by the pandemic. A context of support will reduce nurses’ anxiety and help them continue to provide quality healthcare services in the crisis. According to one study, personal resilience protects nurses from anxiety by enabling them to adapt to irritating, stressful conditions. In addition, public support for nurses plays a significant role in their achieving positive emotional states in stressful times, such as the outbreak of a disease [47]. In another study, the nurses practiced self-isolation as a protection strategy [38]. The nurses believed that one of the greatest challenges in their workplace during the pandemic was lack of a crisis management plan on the management and ministry of healthcare levels [48]. In Billings et al. study working with coworkers during the pandemic was considered to provide an important source of mutual support and opportunities to learn from each other. The employees reported feeling supported by their organizations when there was a clear alliance and shared decision making between senior managers and frontline healthcare workers [30].
The experiences of the nurses and doctors in another study showed that one way to prevent the physical and emotional exhaustion caused by working in special care units is using educational interventions to develop resilience in the personnel. Also, regular and systematic educational programs designed to improve the healthcare personnel’s preparation and efficacy in crisis management seemed essential [49]. Healthcare professionals were also found to rely on self-management mechanisms. They preferred to focus on their work rather than listen to rumors about COVID-19. Some of the other personnel engaged in relaxation activities, including seeing movies, taking showers, and reading. They also stressed the significance of good nutrition and adequate rest and sleep [39].
Moreover, stress management approaches, including relaxation, biofeedback, cognitive strategies, interventions focused on eliminating or decreasing stressful working conditions, such as job redefinition and clear job description, formation of joint personnel committees, and increasing the personnel’s participation in organizational decisions are essential to controlling stressful conditions [50]. One support strategy for the personnel in the frontline of caring for patients with COVID-19 is providing them with online psychological support services which enable the personnel to express their needs. Access to mental health care is possible through telemedicine managed by mental health experts, mobile phone applications, online sources, and virtual peer support. Online psychological care networks are useful in dealing with the stress and concerns of healthcare professionals and their families and relatives and other individuals [51]. One study classifies nurse managers’ experiences of management of the nursing workforce during the COVID-19 crisis into management of workforce recruitment (volunteers and non-volunteers) and management of workforce (via motivational measures and psychological support). Successful crisis management depends on using flexible and situation-based principles of management toward recruiting adequate workforce and retaining the current workforce [52]. By creating a pleasant work environment, encouraging colleague support, and raising trust in the personnel, nurse managers can improve nurses’ stress management skills. Nurse managers play a key role in the promotion of inter-professional relationships in clinical environments, which can contribute to nurses’ mental health [11]. Providing a supportive environment through crisis management training, providing adequate equipment and manpower, and developing resilience skills in staff helps nurses manage stress.
Another finding of the present study was the nurses’ experiencing personal and professional growth. This theme consisted of the subcategories of improved learning, perception of positive feelings at the end of a crisis, and self-transformation. According to a study, one of the psychological experiences of the nurses who cared for COVID-19 patients was perception of growth under pressure and appreciation of life. The nurses declared that, in the pandemic, the picture of the nursing profession had improved, nurses had realized their potential, and nurses’ ability to cope with difficulties in life had elevated [46]. Another study reported an increase in nurses’ self- esteem and sense of responsibility during the pandemic [39]. One of the significant experiences of new nurses was learning during the pandemic. The nurses stated that caring for COVID-19 patients gave them a chance to develop their clinical skills, gain hands-on clinical experience, and learn how to adapt to critical conditions. They also learned methods of protecting themselves, using the equipment needed in caring for COVID-19 patients, time management, and providing care in the shortest possible time to minimize contact with the infected [53]. Another study reported an increase in nurses’ awareness about the value of the nursing profession and their sense of achievement and pride. Moreover, the nurses had a better perception of their professional and social identity and established stronger relationships with their colleagues. Many of the nurses had a greater appreciation of life and everything which they had. The pandemic had given them a chance to realize their full potential, which, in turn, increased their self-confidence. In addition, by self-reflection, the nurses discovered their weaknesses and tried to develop their knowledge and skills. They appreciated the support of their friends, colleagues and the society and developed a more positive perspective on the significance of life and family health [54].
Appreciating life and experiencing increased self-power are the characteristics of post-traumatic growth which may emerge in individuals following a stressful experience. As a result of cognitive reconstruction after trauma, individuals experience personal vulnerability and come to believe that they are not capable of predicting and controlling certain events in life. In response to the unstable nature of life, individuals reconsider the little things in life which used to be important or unimportant to them, which in turn, results in their changing their priorities in life and having a deeper apperception of life [55]. The results of studies show that projecting a positive image of the nursing profession in the society helps nurses find their potential, improves nurses’ professional knowledge and skills in the epidemic of emerging diseases, and increases nurses’ awareness of their personal and professional growth and professional identity by extension.
As the main strength of this study, we conducted one of the qualitative studies that explored strategies and outcomes of stress management based on experiences of the nurses who provide directly care to COVID-19 patients. One of the limitations of the present study was the fact that, because of the COVID-19 pandemic, the interviews were not conducted on a face-to-face basis. However, the researchers tried to have a better interaction with the participants by making video calls to them. Another limitation of the study was that the interviews were conducted individually. Focus group interviews allow for the collection of richer information.
