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Exploring Nurses' Experiences of Psychological Distress During Care Galehdar et al. BMC Psychiatry (2020) 20:489 https://doi.org/10.1186/s12888-020-02898-1 RESEARCH ARTICLE Open Access Exploring nurses’ experiences of psychological distress during care of patients with COVID-19: a qualitative study Nasrin Galehdar1, Aziz Kamran2, Tahereh Toulabi3 and Heshmatolah Heydari4,5* Abstract Background: COVID-19 infection is a new disease that infects a large number of people, killing a ratio of whom every day in the world. Healthcare staff, especially nurses, experience a great deal of psychological distress during care of COVID-19 patients. Detecting factors that disturb nurses’ mental health during care of these patients can help to reduce their psychological distress. Therefore, this study aimed to explore nurses’ experiences of psychological distress during care of patients with COVID-19. Methods: The present qualitative research was performed using the conventional content analysis method in Iran from March to May 2020. Participants in this study included the nurses caring for patients with COVID-19, and they were selected based on the purposeful sampling method. The data was collected through 20 phone call interviews and analyzed based on the method proposed by Lundman and Graneheim. Results: Qualitative data analysis revealed 11 categories including death anxiety, anxiety due to the nature of the disease, anxiety caused by corpse burial, fear of infecting the family, distress about time wasting, emotional distress of delivering bad news, fear of being contaminated, the emergence of obsessive thoughts, the bad feeling of wearing personal protective equipment, conflict between fear and conscience, and the public ignorance of preventive measures. Conclusion: The data showed that the nurses experienced a variety of psychological distress during care of patients with COVID-19. Through proper planning by authorities, it is possible to manage the risk factors of mental health distress in nurses and improve their mental health status. Keywords: COVID-19, Nurses, Mental distresses, Qualitative study * Correspondence: [email protected] 4Social Determinates of health center, Lorestan University of Medical Sciences, Kilomer 4 Khorramabad-Broujerd road Kamalvand, Khorramabad 6813856967, Iran 5Department of Home-based palliative care, ALA Cancer Prevention and Control Center (MACSA), Tehran, Iran Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Galehdar et al. BMC Psychiatry (2020) 20:489 Page 2 of 9 Background province with 350 active beds, was considered as the central COVID-19 is a newly emerged infectious disease which site for managing COVID-19 patients. Other counties also was first identified in Wuhan, China on December 31, allocated parts of their capacities for taking care of patients 2019 [1]. The World Health Organization (WHO) with COVID-19. According to formal statistics, 1981 nurses declared the disease as a pandemic on March 11, 2020 areatthefrontlineofprovidingcaretoCOVID-19patients due to its rapid spread throughout most countries across in this province [16]. Therefore, based on the nature of the globe [2]. Until May 31, 2020, the worldwide num- qualitative research which aims to find root problems, and bers of affected and deceased patients with COVID-19 the fact that the researchers are experts on qualitative re- were 6,162,399 and 371,035, respectively. In Iran, until search methodology, we decided to conduct a qualitative May 30, 2020, the number of people contracting the study to explore nurses’ experiences of psychological dis- virus was 148,950 with the death toll standing on 7734 tress during care of patients with COVID-19. Recognizing [3]. Around 20% of COVID-19 patients may experience the factors affecting nurses’ mental health can help to severe symptoms necessitating oxygen therapy or other create a safer workplace for them. inpatient interventions, and only 5% of them require admission to the intensive care unit (ICU) [4]. Methods COVID-19, as an emerging disease, is related to the This qualitative study was carried out with a conven- SARS-COV [5] and has many unknown clinical dimen- tional content analysis approach. sions. Health care workers can play an important role in supporting and helping the patients to rehabilitate [6]. Participants In particular, COVID-19 disease has great effects on The nurses working in the public hospitals affiliated with healthcare workers and leads to some challenges for this Lorestan University of Medical Sciences comprised the vital part of the society. These problems include an in- study population. The participants were selected by pur- creasing need for medical staff; increasing costs for poseful sampling. Inclusion criteria were at least 2 weeks personal protective equipment (PPE), diagnostic tests, working experience in taking care of patients with beds and ventilators, as well as rising mortality [7, 8]. COVID-19 and willingness to participate in the study. Nevertheless, many health care workers are at the risk of contracting the virus and even death, and it is largely Collecting data impossible to reduce this threat to zero [9]. Due to its As there was an immediate need to improve the care for unique properties such as high spreading rate, being COVID-19 patients, and the fact that face-to-face inter- unknown, and jeopardizing the lives of health care staff, views were risky for both the researchers and nurses, we COVID-19 has caused so much confusion and many managed to gather the data through semi-structured in- challenges among health care workers. depth telephone interviews. The calls were made in Psychological distress including depression and anxiety March and April, 2020. Initially, the characteristics of has been reported in the health staff working at the front- the nurses working in COVID-19 wards were gathered line of fighting COVID-19 amid the outbreak [10–13]. by looking at their profiles available at the hospitals’ Among health staff, nurses are among the most involved in nursing offices. Afterwards, we contacted the partici- fighting against the COVID-19. Actually, they regularly are pants during their off-times. After explaining the study in direct contact with patients from the time of admission objectives and acquiring verbal consent from the to the discharge. Therefore, nurses are highly exposed to selected nurses by the first author, a proper time to carry psychological distress compared to other health workers out the interview was agreed with the participant. The during the pandemic [14]. The nurses providing intensive duration of the interview was decided based on the and ongoing health services during previous epidemics had nurses’ convenience, tolerance, and working experience. been reported to experience the highest level of job stress An electronic device was used to record all the inter- and mental distress compared to other treatment staff [15]. views. The participants were asked some key questions Lorestan, as one of the overcrowded provinces of Iran, is as “Please describe a day of taking care of hospitalized located in the western region ofthecountry.Likeother patients with COVID-19”, and “Please talk about your parts of the world, the prevalence of the COVID-19 in this unpleasant experiences”. The interview continued province has been increasing since its emergence. Lorestan according to the answers provided by the participant, province has 11 cities with a population of 1,760,000, and and based on these answers, more in-depth questions its capital is Khorramabad. Eighteen hospitals affiliated to such as “what do you mean?”, and “please explain more Lorestan University of Medical Sciences are responsible for about this” were asked. delivering healthcare to the patients across the province. By choosing probing questions, the researcher directed During the COVID-19 outbreak, Shohaday-e-Ashayer the interview to achieve the goals of the study. The Hospital, as one of the most important hospitals of the interviews lasted for 25 to 40 min. Sampling and data Galehdar et al. BMC Psychiatry (2020) 20:489 Page 3 of 9 collection continued until reaching data saturation and Lorestan University of Medical Sciences approved the obtaining no new data from the interviews [17]. study protocol (Code: IR.LUMS.REC.1399.006). Data analysis Results Data collection and data analysis were conducted simul- A total of 20 nurses including 15 (75%) women and 5 taneously. The data was analyzed using Graneheim and (25%) men with the mean work experience of 7.25 ± 5.9 Lundman’s content analysis approach [18]. Initially, the years and the average age of 31.95 ± 6.64 years partici- interviews were transcribed verbatim. We listened to the pated in the study (Table 1). Qualitative data analysis interviews and read their transcripts for multiple times revealed 11 categories and 5 sub-categories (Table 2). to arrive at a general perception of their content. A unit of analysis consisted of a transcript interview whose se- Death anxiety mantic units included words, sentences, and paragraphs.
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