Iran Journal of Nursing

Background & Aims: Epidemics and their consequences have widespread effects on health care workers. Since hospital work environments are under high workload, complexity, and chaos, and are constantly changing due to different medical and care developments. During epidemic and pandemic crises, this situation is exacerbated by an increase in the number of patients and lack of resources, resulting in an increased likelihood of physical and mental vulnerability of staff. In this regard, the Covid-19 pandemic has caused physical and psychological challenges for hospital staff more than the previous epidemic, especially since the high prevalence and mortality rate of the virus is the most important challenge in this field. The other common unprecedented consequence of these conditions can be depression, anxiety, insomnia, and burnout of staff especially among the elderly and experienced staff. These secondary consequences have negative impacts on the quality of the services provided by the staff and act as major barriers to effective health care delivery. However, despite the many barriers, some facilitators can facilitate and improve the delivery of different services. For example, protective actions, social distancing, and widespread detective strategies, and detection of patients can play an important role in controlling the disease and thus reducing the workload of health staff.  Therefore, identifying barriers and facilitators in health care delivery for patients can be helpful in the management of this pandemic and we can rely on them to provide the basis for further studies and thus better planning. Therefore, this study aimed to explore the barriers and facilitators of caring for Covid-19 patients.
Materials & Methods: This qualitative study was conducted in 2020 employing Conventional content analysis Approach. In this study, semi-structured interviews were conducted with 11 physicians and 14 nurses who were working in the Covid-19 units of hospitals affiliated to Tehran University of Medical Sciences and were willing to participate in the study. In order to follow the social distancing, all interviews were conducted virtually via Skype, WhatsApp, and by phone at intervals of 45 to 60 minutes by an experienced interviewer. Some interviews were conducted visually and some orally at the request of the interviewee. Interviews were continued until the data saturation and not reaching the new code in the last three interviews. Data analysis was performed according to the proposed steps of Granheim and Landman. Finally, the interviews were transcribed, typed, and read several times to extract the original codes. The codes were then merged and classified based on the similarities, and finally the hidden concepts were extracted from the data.
Results: A total of five themes and 14 subthemes were extracted from 340 initial codes in this study. The themes of this study were double-edged sword culture, individual factors, changes in care approach, organizational factors, and ethical challenges. In the theme of double-edged sword culture, two sub-themes of ‘collectivistic culture’ and ‘facilitator culture’ emerged. The cultural diversity of the community has created problems for the management of this disease and even the care of patients. Ignoring social distancing despite the warnings of Ministry of Health officials due to adherence to customs such as visiting and handshaking, had led to the spread of the disease and made its control difficult. Especially in the dominant Iranian culture, shaking hands is a custom and wearing gloves and masks is not a routine. On the other hand, in the culture of collectivism, they also help and cooperate with others, as they produced protective equipment and disinfectants through teamwork. Others encouraged inpatients by providing virtual communication through virtual networks which helped the treatment team and facilitated the caring process. Due to the rapid spread of the disease, the treatment team, in addition to being afraid of being a carrier, also had emotional problems due to quarantine. But having the idea that the nurses should not put stress on others, enduring psychological and physical stress as a result of the situation became more difficult. In this regard, in the theme of individual factors, three sub-themes of ‘fear’, ‘emotional emptiness’, and ‘ambassador of peace’ emerged. The nature of the disease, the use of protective equipment by the personnel, social distancing, changes in patient communication, changes in professional interactions, and feelings of powerlessness in virus management have all been challenges for the treatment team in caring for these patients. This condition has also affected nurse-nurse or physician-nurse interactions. But the pandemic made another change in the treatment team, and that was teamwork. Medical and nursing staff stated that they had not cooperated closely before for various reasons and refused to work as a team, but lack of equipment, insufficient knowledge about the disease had instinctively brought the treatment team closer to each other and all tried to do their best to eliminate the disease. Thus, ‘care metamorphosis’, ‘communication’, ‘missing links in care and treatment’, and ‘integration’ were the three sub-themes emerging in the theme of change in the approach to care. The themes of organizational factors included lack of necessary infrastructure, lack of equipment, manpower and lack of adequate space for patient care, but they were encouraged and continued to work with the support of hospital managers, the Deputy Minister of Health and the support of the Minister of Health. The four sub-themes of ‘structural problems’, ‘lack of manpower’, ‘insufficient equipment’, and ‘lack of organizational support’ were the most important obstacles for the treatment team in providing the best therapeutic performance. Another theme that emerged in this study was moral distress with two sub-themes of ‘guilt’ and ‘moral helplessness’ in which the individual raised issues such as lack of privacy, and not being at the bedside of a dying patient as his main concerns. Lack of privacy, reliance on writing the last name on the clothes and not introducing themselves to the patient at the beginning of the patient admission due to high workload and lack of time, elimination of the principle of respect for autonomy, lack of regular patient visits in the final stages of life except moral distress are discussed and classified.
Conclusion: According to the results, culture, individual, and organizational factors can be considered as both barriers and facilitators. But ethical challenges, as an important obstacle, can cause burnout in the medical staff. It is suggested that the authorities provide more psychological support to the treatment team, or give them a recovery period by employing new staff and reducing the workload of the treatment team. Also, getting help from a psychologist and psychiatrist, encouraging people to exercise, meditation and music can help strengthen the workforce in hospitals. Therefore, authorities should plan to increase the resilience of the medical staff in emerging and man- made phenomena such as the Covid-19 pandemic.