Abstract
Background:
Nurses, as health advocates and front-line fighters in the coronavirus disease 2019 (COVID-19) pandemic, experience severe professional stress and psychological crises.Objectives:
The present study was conducted to explain the nurses’ perception of expected organizational and professional support during the COVID-19 pandemic.Methods:
In this qualitative study, data collection was performed through semi-structured, individual, and in-depth interviews. A total of 20 nurses participated in the study through purposive sampling. The data were collected within June-October 2021. The collected data were analyzed based on Granheim and Lundman’s method.Results:
The findings of the study were presented in the form of 4 main themes and 10 subthemes, including lack of physical support (i.e., lack of tools and equipment and problems concerning using personal protective equipment to care for COVID-19 patients), lack of psychological support (i.e., paying attention to nurses’ job stress and mutual understanding of managers and nurses), lack of welfare support (i.e., high workload, financial support, providing facilities for nurses for employment, and providing facilities to support staff in childcare), and weakness in efficient crisis management (i.e., insufficient attention of managers to the principles of crisis management and the lack of a standard infectious disease hospital for COVID-19 patients).Conclusions:
Health system policymakers should provide comprehensive physical, psychological, and welfare support for nurses, effective professional and organizational context, and efficient crisis management to improve the quality of care.Keywords
COVID-19 Hospital Administration Nurse Psychological Support Financial Support Qualitative Research
1. Background
As a pandemic, coronavirus disease 2019 (COVID-19) has shocked the healthcare system intensely in most countries of the world, and one of the main problems in dealing effectively with this disease is the lack of specialized medical and care staff, which leads to long forced working hours and cancellation of many personal and recreational programs (1).
Nursing is a difficult and risky profession. The working conditions of nurses impose a high level of physical and mental pressure on them (2) because they face some issues, such as high workload, conflicts with doctors and patients, death of patients (3), and variable working hours (4). On the other hand, working conditions are changing rapidly, and nurses have to continuously develop their occupational skills and adapt to the progress of their profession (5).
The results of numerous studies show that exposure to COVID-19 has increased the level of occupational stress and brought about uneven mental-psychological conditions (6-8) and job burnout in nurses (9, 10).
Nurses, as the front-line fighters against the disease, are involved in some issues, such as diagnosis, treatment, and care of patients with this disease. Excessive work pressure and exposure to the dangers of contracting the disease have also added to the psychological burden on them and their families. Other issues, namely the lack of personal protective equipment (PPE) in many care centers, lack of specific drugs or vaccines for definitive control and prevention of the disease, which was more obvious at the beginning of the disease, media pressure, and psychological atmosphere, were all among the issues that could affect nurses and overshadow their accuracy and skill in providing effective care services (11).
The above-mentioned challenges make it necessary to look for ways to reduce them. Support is known as an important resource for dealing with distress and improves the health of a person (12). Nurses support patients routinely; however, due to the nature of their work, they need support. If the organization is supportive and encouraging, staff innovation and creativity will increase, individuals’ commitments to the organization will develop, and motivation will increase (13). In healthcare organizations, lack of organizational support is associated with high-stress levels, burnout, job dissatisfaction, and poor patient care outcomes (14).
The existence of such support in the work environment, especially from the nursing management, increases the ability of the individual to deal with stress, the efficiency of the individual in the environment, and the job satisfaction of nurses (15). According to the results of Feng et al.’s study, perceived support is the second effective protective factor in nurses’ psychological distress (4). Additionally, Gholi Roshan et al. observed a negative and significant relationship between perceived support and the psychological distress of nurses (16). Riahi et al. stated that support has a significant negative relationship with nurses’ mental health (17).
Organizational and professional support is defined as the means to encourage, assist, provide information, and reassure employees through guidance and supervision to improve accountability, quality practices, and service delivery. If the staff feel supported, they feel they have been treated fairly and provided with resources and tools to perform effectively (18). A review of the literature shows that few studies have qualitatively explained the perceptions of nurses concerning organizational support in the COVID-19 crisis. A deep understanding of these ideas is largely possible through a qualitative method because qualitative research has a special efficiency in answering questions that contain human interpretations and mindsets and provides the best way to describe life experiences (19).
Qualitative research allows the researcher to enter the inner world of the participants to determine the meanings formed in a culture and discover the variables (20). This issue shows that awareness of the experiences and understanding of healthcare personnel of organizational support in a qualitative manner can lead to valuable results in planning, removing obstacles, and promoting organizational support.
2. Objectives
This study aimed to investigate the perceptions and experiences of nurses regarding the expected support during the COVID-19 pandemic in a qualitative study.
3. Methods
3.1. Study Design and Aims
The present study used a descriptive qualitative design. The reporting of the study was based on the consolidated criteria for reporting qualitative research (COREQ) checklist (21).
3.2. Participants
This study was conducted in southern Iran within June-October 2021. In this study, 20 nurses were selected through purposive sampling. Participants who met inclusion criteria were willing to be interviewed, and could provide key information were chosen for this study. Selecting participants from various settings (i.e., Motahari Hospital and Pymanie Hospital) and maximum variation sampling (e.g., age, gender, and working experience) helped the authors gain a wide range of perspectives and experiences. The inclusion criteria were a bachelor’s degree or higher in nursing and at least one year of clinical work experience in the COVID-19 pandemic.
3.3. Data Collection
Data collection in this study was performed through semi-structured, individual interviews. All semi-structured interviews were conducted face-to-face by the first author of the article. The time and place of the interview were chosen by the participants. The location of the interviews was determined to be a quiet and comfortable place offering privacy. The participants declared their approval to participate by signing a written consent form. The semi-structured interview started with open-ended questions followed by probing questions. The interview questions were as follows:
Have you been supported by your organization and workplace managers in the conditions of the COVID-19 pandemic?
Based on your experience, what is nurses expected organizational and professional support in the COVID-19 pandemic?
What was the response of the managers you asked for support?
As participants talked, follow-up questions, such as “What do you mean by...?” and “Can you give an example?”, were used. Each interview lasted between 30 and 60 minutes.
3.4. Data Analysis
The contractual content analysis method with Granheim and Lundman approach was used to analyze the data (22). The interviews were transcribed verbatim. Moreover, the interviews were read several times to get a clear meaning of the whole transcript. The transcripts were divided into meaningful units and made more concentrated for lucidity and conciseness. The more concise meaning units were abstracted and labeled with codes. The codes were categorized into subcategories and categories according to constant comparative analysis to investigate similarities and differences. Primary categories were extracted as the expression of the latent content of the text. Guba and Lincoln’s criteria were used to rigor the accuracy of the collected data (23). The researchers had prolonged engagement with the data (8 months). Member checking and peer debriefing were used to validate the data analysis. All the research details, including demographic characteristics, selection of participants, and data collection, were clearly explained, and appropriate quotations were used. Three authors of this article (two assistant professors and an associate professor), who were faculty members of the School of Nursing, Jahrom University of Medical Sciences, Jahrom, Iran, with more than 15 years of experience in nursing and management, conducted this qualitative research.
3.5. Ethical Approval and Consent to Participate
Written informed consent for participation was obtained from the study subjects. This study followed the principles of the revised declaration of Helsinki, a statement of ethical principles directing physicians and other study subjects in medical research involving humans. The subjects’ data anonymity and confidentiality were maintained. Moreover, the study was approved by the Institutional Research Ethics Committee of Jahrom University of Medical Sciences (ethical code: IR.JUMS.REC.1400.015).
4. Results
Totally, 20 nurses participated in the study, including 8 and 12 male and female subjects, respectively. The participants’ mean values of age and work experience were 34.25 ± 6.22 and 10.81 ± 5.98 years, respectively (Table 1). Expected support from nurses during the COVID-19 pandemic led to the extraction of 4 themes and 10 subthemes. The four main themes included the lack of physical support, lack of psychological support, lack of welfare support, and weakness in efficient crisis management (Box 1).
Descriptive Characteristics of the Participants
| Participant | Age (y) | Gender | Education Level | Specialty | Working Experience (y) |
|---|---|---|---|---|---|
| P1 | 40 | Female | Bachelor’s degree in nursing | Head nurse | 18 |
| P2 | 30 | Female | Bachelor’s degree in nursing | Nurse | 8 |
| P3 | 38 | Female | Bachelor’s degree in nursing | Head nurse | 16 |
| P4 | 40 | Female | Bachelor’s degree in nursing | Nurse | 15 |
| P5 | 30 | Male | Master’s degree in nursing | Nurse | 6 |
| P6 | 24 | Female | Bachelor’s degree in nursing | Nurse | 2 |
| P7 | 37 | Female | Master’s degree in nursing | Nurse | 14 |
| P8 | 27 | Male | Bachelor’s degree in nursing | Nurse | 3 |
| P9 | 38 | Female | Master of Science | Head nurse | 14 |
| P10 | 36 | Male | Bachelor’s degree in nursing | Nurse | 10 |
| P11 | 29 | Male | Master of Science | Nurse | 3 |
| P12 | 32 | Female | Bachelor’s degree in nursing | Nurse | 11 |
| P13 | 45 | Female | Bachelor’s degree in nursing | Head nurse | 17 |
| P14 | 36 | Male | Master’s degree in nursing | Head nurse | 13 |
| P15 | 25 | Male | Bachelor’s degree in nursing | Nurse | 3 |
| P16 | 41 | Female | Master’s degree in nursing | Nurse | 20 |
| P17 | 39 | Male | Master’s degree in nursing | Head nurse | 10 |
| P18 | 40 | Female | Bachelor’s degree in nursing | Nurse | 15 |
| P19 | 31 | Male | Bachelor’s degree in nursing | Nurse | 6 |
| P20 | 44 | Female | Master’s degree in nursing | Head nurse | 16 |
Themes and Subthemes Extracted from Content Analysis
| Themes |
|---|
| Physical support |
| Lack of tools and PPE |
| High staff workload |
| Physical problems due to long-term use of PPE |
| Psychological support |
| Paying attention to nurses’ job stress |
| Mutual understanding of managers and nurses |
| Welfare support |
| Financial support |
| Providing facilities for nurses for employment |
| Providing facilities to support nurses in childcare |
| Weakness in efficient crisis management |
| Insufficient attention of managers to the principles of crisis management |
| Lack of a standard infectious disease hospital for COVID-19 patients |
4.1. Lack of Physical Support
The first theme was the lack of physical support, including the lack of tools and equipment and problems concerning using PPE to care for COVID-19 patients.
4.1.1. Lack of Consumable Tools and Personal Protective Equipment
The lack of equipment and PPE had made performing duties a major challenge for nurses. On the other hand, these shortages aggravated the fear and stress of nurses. One of the participants said:
“Early on, especially in the first and second COVID-19 picks, the hospital stock of masks, especially N95 masks, gloves, shields, and guns was very low. It was not dealt with as quickly as it should have been.” (P4).
4.1.2. Physical Problems due to Long-term Use of PPE
Long-term use of PPE has caused some problems, such as headaches, nausea, kidney pain, and severe allergic skin reactions. As in the design of many of these devices, consideration of long-term use has not been taken into account. One of the participants said:
“Our working conditions and clothing are such that we cannot even drink water, and we all had kidney pain and kidney stones; our facial skin was bruised, and the skin of our hands had eczema.” (P2).
4.2. Lack of Psychological Support
The second main theme in this study was psychological support, including paying attention to staff job stress and mutual understanding between managers and nurses.
4.2.1. Paying Attention to Nurses’ Job Stress
Nursing is a stressful job, and employees of this profession usually face high levels of physical and mental workload, especially during the COVID-19 pandemic, when due to special conditions, work pressure became very intense. At the beginning of the epidemic and increasing hospitalization of patients, there was an unforeseeable situation where patients were admitted to hospitals without specific symptoms, and health personnel was exposed. On the other hand, health personnel was informed about the sick nurses and their hospitalizations and deaths. One of the participants said:
“The job of the nurses itself is stressful, especially now that we are dealing with an infectious disease and critically ill patients; we are witnessing the deaths of nurses, and every day there is new news that the virus has mutated.” (P10).
4.2.2. Mutual Understanding Between Managers and Nurses
Another important challenge was the insufficient understanding and lack of attention of the managers to the problems of the personnel and not paying attention to them, which caused dissatisfaction. One of the participants said:
“Some managers were sometimes really very indifferent to the problems of the staff. For example, if you told them we had a shortage of PPE, they would tell us that it was not available right now. You are in a critical situation.” (P15).
4.3. Lack of Welfare Support
The third major theme in this study was welfare support, including high workload, financial support, providing facilities for COVID-19 ward staff for employment, and providing facilities to support staff in childcare.
4.3.1. High Staff Workload
As the epidemic continued, the number of patients admitted to the wards increased, and the need for patient care increased accordingly, resulting in an increase in nurses’ physical and mental workload. On the other hand, instead of increasing the department’s staff, the nurses’ infection with COVID-19 and the reduction of the active workforce increased the workload and worsened the situation. One of the participants said:
“The big problem was the insufficient number of nurses in each ward. Sometimes, two or even three nurses got involved, which made it difficult to set the ward together.” (P1).
4.3.2. Financial Support
Considering the important role of nurses during the COVID-19 pandemic, their statements indicate the necessity of financial encouragement and increasing the income of nurses during the pandemic. One of the participants said:
“During the COVID-19 pandemic, there was not much change in nurses’ salaries. However, we buy better and safer masks to use at work at our own expense, and these are additional costs that have been imposed on us.” (P7).
4.3.3. Providing Facilities for Nurses for Employment
Another expected support for nurses was changing their employment status and providing job security. One of the participants said:
“I am a contract nurse working in the COVID-19 ward since the first day. We were told that the COVID-19 ward nurse is accepted to take an employment exam; however, there was not much change in the results of the exam.” (P8).
4.3.4. Providing Facilities to Support Nurses in Childcare
Nurses are expected to be supported by managers and organizations to take care of their children during the COVID-19 pandemic because, due to the contagiousness and the 14-day incubation period of this disease, nurses cannot be sure that they and others are healthy or carriers. Leaving the care of children to individuals and care centers was an important challenge. One of the participants said:
“We could not send the children to kindergarten as they can be disease vectors. We could not get help from our families. We could not even have a babysitter at home. The responsibility for the children was on my wife and me. What did they do for us in this challenge?” (P16).
4.4. Weakness in Efficient Crisis Management
The fourth major theme was the weakness in efficient crisis management in the organization, including managers’ lack of attention to the principles of crisis management and the lack of a standard infectious hospital for COVID-19 patients.
4.4.1. Insufficient Attention of Managers to the Principles of Crisis Management
From the participants’ point of view, managers’ insufficient attention to the principles of crisis management, such as weak planning, non-operationalization of plans, examination of the weak points and strengths of previous crises, and compliance with standards, was among the challenges of COVID-19 nursing management. One of the participants said:
“Previously, crisis management conferences were held, and solutions to some problems were predicted and presented; however, unfortunately, in time of the COVID-19 crisis, we have the same challenges, and we are dealing with them.” (P13).
4.4.2. Lack of a Standard Infectious Disease Hospital for COVID-19 Patients
From the point of view of nurses, the most important expected solution for infection control is the existence of a standard hospital for COVID-19 patients with appropriate and sufficient equipment to isolate patients. Accordingly, this solution helps all hospitals not face the challenge of COVID-19 patients. One of the participants said:
“We still have a location crisis. If we also have an infectious disease hospital with suitable facilities for hospitalizing infected patients, many of our problems will be solved.” (P20).
5. Discussion
The findings of this study showed that during the COVID-19 pandemic, nurses faced some challenges, such as the lack of physical support, lack of psychological support, lack of welfare support, and weakness in efficient crisis management that needed support. Based on the participants’ experiences, lack of PPE and long-term use of PPE were among the most important challenges of nurses, which overshadowed their physical health. This issue has been stated and emphasized in other Iranian studies (24).
In a study conducted by Martin-Delgado et al. in three Latin American countries, approximately 70% of attending physicians, nurses, and health professionals lacked adequate PPE, most of which were related to guns, N95 masks, and face shields. These conditions have negatively affected health services during the COVID-19 crisis (25). Therefore, to ensure the adequacy of medical equipment, health system managers should identify needs and provide adequate resources for staff considering the number of healthcare providers and expected patients in need of medical care and nursing. In this regard, Jahangiry et al. stated that Iran is one of the 10 countries in the world that has been widely affected by COVID-19. Nurses working in COVID-19 wards in Iran have experienced five severe waves of COVID-19 (26). Complex, stressful conditions and the provision of nursing care in COVID-19 conditions with clothing and equipment for personal protection in intensive work shifts have overshadowed resilience and, consequently, nursing performance. Therefore, it is necessary for health policymakers and senior nursing managers to provide comprehensive organizational support, including financial and economic support, psychological support, and medical facilities and equipment needed by nurses in these difficult and complex COVID-19 conditions (27).
Based on the results of the present study, paying attention to psychological support is an issue that should be considered by nursing managers. In this regard, the results of a study by Mohammadi et al. showed that significant increase in patients, death of young colleagues without a history of the disease, increased work shifts, fear of getting sick and even transmitting the disease to relatives, and being away from family put much stress on medical staff (28). In this regard, OdomForren stated that nurses in the COVID-19 crisis experience high psychological and professional stress, compared to other health team staff, which can adversely affect the quality of care, patient care, patient safety, and nurses’ quality of life. Therefore, it is necessary for health system policymakers to take the necessary measures and strategies to increase the resilience, psychological skills, mental health, and psychological support of nurses (29).
Nursing managers should always try to maintain the morale of their employees. Organizational support helps nurses to make ethical decisions and increase their commitments, all of which reduce their job stress (30). According to the results of various studies, the shortage of nurses was one of the main challenges in effectively dealing with the COVID-19 crisis, which has led to long mandatory working hours and the cancellation of many personal and recreational programs for nurses (1, 31). With the increase in staff working hours and long shifts in the hospital and the closure of infant and childcare centers, the staff faced the problem of taking care of their children and other family members (32).
One of the expectations of nurses was financial incentives for personnel. It is necessary to consider financial incentives for the treatment staff and other involved personnel. Experience has shown that financial incentives for nurses have been very effective in increasing their cooperation. Support systems and incentives were important resources for managing the conflict between the family and professional roles of nurses (33, 34).
Weaknesses in efficient crisis management in the organization, including managers’ lack of attention to the principles of crisis management and the lack of a standard infectious disease hospital for COVID-19 patients, was another theme extracted in the present study. In this regard, the results of a study by Bijani et al. showed that unfamiliarity with the principles of crisis management, lack of management knowledge during the COVID-19 crisis, and lack of equipment and specialized hospitals were the most important challenges in COVID-19 crisis management (35).
In addition, in a study conducted through interviews with experts in the field of crisis and disaster management in Nepal, the weakness in leadership and guidance of organizations in crisis conditions was raised as a serious problem (36). The results of studies by Mohammadpour et al. and Sharifi and Khavarian-Garmsir also showed that comprehensive and efficient crisis management is the key to success in the COVID-19 crisis, which overshadows other factors (37, 38).
In this study, only individual interviews were used to collect the data; therefore, it is recommended to use other methods in future studies, including focus group interviews. In addition, in this study, only the experiences of nurses have been reviewed; therefore, it is recommended that the future experiences of other members of the health team be reviewed.
The strength of the present study is the limitation of the studies conducted on the subject of support for nurses. Moreover, conducting qualitative research and providing clear examples of the support expected by nurses are other strengths of this study.
5.1. Conclusions
Nurses have experienced severe psychological stress and crises during the COVID-19 pandemic. Therefore, managers and health system policymakers should provide comprehensive physical, psychological, and welfare support to nurses and provide effective professional and organizational context and efficient crisis management to improve the quality of care. With correct and accurate planning, scientific and powerful management and unity of command can significantly prevent the impact of challenges on the disaster crisis management process in hospitals and provide nurses’ expected support.
Acknowledgements
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