The categories of this stage included (1) Shock; and (2) The dilemma of staying or leaving. Shock had the following subcategories: (a) Denial; (b) Terror and (c) Anxiety. The dilemma of staying or leaving had the following subcategories: (a) Family's priority. (b) Professional duties.
This stage consisted of the real experiences of every human in facing and dealing with crises, and included the following subcategories: (1) Denial; (2) Terror, and (3) Anxiety in this category, the nurses did not take the illness seriously and did not believe it was a dire issue when dealing with patients with COVID-19.
One of the nurses said: "I didn't believe it at all at first and didn't think it would come to this country until I saw a patient myself". This issue was also evident in physicians’ diagnosis and the hospital managers’ treatments. The nurses stated that, at first, they did not believe their patients had COVID-19, and the officials had not initially provided them with sufficient equipment and facilities either because they also did not believe that patients with COVID-19 would be hospitalized in their wards. One nurse stated: "It's tough these days. At first, there were very few equipment, which made it much harder. And when we asked for getting equipment, they didn't believe that COVID-19 was really here and so they gave us equipment in insufficient numbers and hardly".
Nurse “I had to take care of this kid for one shift, and I had contacted them and asked for extra nursing and protective equipment, and I was told that they would give me the equipment if I had written ‘definite positive’ on the patient's record and that the only thing they would provide us with was a gown. This was very funny to me. What did they mean? This patient who needs suction, should I not have the equipment?!! No goggles?”
So, in the first encounter with the disease, nurses and even the hospital management did not believe we might get patients with COVID-19 in our wards.
Exposure to the disease with inadequate equipment and uncertain information about care and treatment pushed the nurses into the second subcategory, which was terror. In this subcategory, nurses experienced an incredible amount of terror in providing care, and although its level was not the same in all the nurses, they all acknowledged the uniqueness of this experience of terror. One of the nurses stated: "When an infant came in coughing, well, I myself froze for a moment [after hearing the name of the disease], because it was the first time I was faced with this situation, and I had only heard about it before".
Nurse 3: "I was frightened and in terror and realized that the disease was very dangerous. I was very scared at first, but then found out that not everybody dies and my fear got diminished as I gained more information".
Nurse "My first experience with a COVID-19 patient was with someone whom everybody feared and ran away from. As a nurse, I felt bad being around him too. I was afraid".
In this subcategory, the continuance of previous uncertainties about providing care to these patients provoked new uncertainties and the management's inaccurate understanding of the emerged problem and the community's reactions to news of the disease steered nurses toward the anxiety. In this subcategory, the formerly severe reactions became more balanced and nurses carried on with their professional duties despite their fear and concerns.
Nurse 2 argued: “Caring for an infant with apnea was very hard, and caused us a lot of stress when something happened to them. You are so stressed when you start at first”.
Another nurse stated: “Many of my colleagues were very stressed and even took sedatives”.
Nurse 7 said: “No one was very keen to provide care to these patients at first, but gradually, we got more used to it. Both ourselves and the patient's company were anxious and stressed. Despite the anxiety about providing care to these patients, they were less afraid and were able to provide better patient care”.
Nurse "We are no longer so scared, and now I even feel for the patients. I feel for patients with COVID-19 a lot more".
Nurse "Our fear gradually abated, and we learned how to use the equipment and take care of the tasks".
Nonetheless, the lack of knowledge about the disease treatment and care and nurses' poor professional knowledge and experience in dealing with this disease still made them frightened and anxious about providing care to these patients.
Nurse "I have studied so much, but I'm really sad that I can't help my patients the way I wish to".
Nurse "At first, the physicians and nurses were confused, and we didn't really know what to do. It was a horrible feeling”.
b. The Dilemma of Staying or Leaving
The dilemma of staying or leaving included the following subcategories:
Family's priority: This had four subsets, including the family's concerns, the family's encouragement, maintaining the family's health, and missing the family. Nurse said: "At that moment, I wished for the sake of my family that I would not have to provide care to these patients".
Nurse 8: "They joked around with me in the early days when I returned home and felt that I was a COVID-19 carrier. But we got used to it after a few days and I no longer had any fear nor did my family ".
Nurse "I had to live away from my family at that time. I had to do that".
In this subcategory, the first and foremost priority was the family. All the nurses stated that they were badly concerned about being a carrier and infecting their families. The fear of losing a loved one to this disease and the heavy conscience it caused were intolerable for the nurses. Some of the nurses even had this feeling about the public and expressed their concern about endangering the community's health.
Nurse "For the sake of my parents, and if there is a 1% chance that I get infected, my entire family may be infected, and losing a loved one, the thought of it was very frightening. It may have crossed my mind for a moment to quit nursing, but then I thought that my colleagues are providing care and I can't leave them alone".
Another nurse said: "I was thinking about my family on the way home and about how to enter so as not to transfer the virus and not infect anyone in the taxi right now".
Moreover, the family was heavily concerned about their nurse family member, and different experiences were formed in this respect. Some families encouraged their nurse member to quit out of the fear of getting infected and dying. Others encouraged their nurse family member to continue her professional duties despite their severe concerns. Some nurses had not told their family about their taking care of patients with COVID-19 at all and had concealed the issue.
Nurse "I had so much stress and didn't want to say anything to my spouse to worsen his stress".
Nurse "I didn't tell my mother the truth about our hospital, because I knew it would worsen their stress and concerns".
Nurse "My mother kept telling me to leave and that I didn't need to work".
Nurse "My family always encouraged me and my mother said that I should fulfill my duty".
Missing the family was another subcategory. The nurses had somewhat quarantined themselves while providing care to these patients and did not mingle with their family members a lot and always kept their distance from their family. Missing the kiss of their children as well as the supportive touch of their family was very hard and painful for the nurses.
One nurse stated: "I wish I could cuddle and kiss my child, but I keep away from him right now for his own sake".
Nurse "I keep away from my family and am mostly in my room doing my own chores. I worry that they catch the disease and I be to blame".
Professional duties: These meant performing professional duties despite the unsafe work environment, both psychologically and equipment-wise, and having a sense of responsibility and conscientious obligation.
One nurse stated: "Because of my conscience, whatever I do, I ask myself and make sure if I have done the right thing or not. Have I handed over the patient properly at shift change or not? Many of the guys didn't show up and backed out, which made the job harder for us, as we had to provide care to more patients".
Nurse said: "One of the patients coughed a lot, so I went to their bedside and trained them and did my nursing duties, which proved very good for him and I knew it would be effective. I never saw the patients who recovered and were discharged, but saw mostly the patients who were intubated and this increased my sense of responsibility”. Nurse "I am on the medical team and have responsibilities and I'm not meant to quit my job. I believe a sense of responsibility is very important. I have to accept the responsibilities that come with this job".
Nurse "I definitely would not choose this if it was in the early days, but not now. I'm now on this path and must carry on".
Another nurse said: "I'm a nurse, after all, and have responsibilities and should do my job. When you are dealing with patients, you realize that, poor things, it was not their fault; they have been infected and you should do whatever you can for them".
In the early stages of this experience, the health teams’ and especially the managers' lack of knowledge about treatment, care, and the importance of Personal Protective Equipment (PPE) had put the nurses under extra mental, emotional, and even physical pressure, and had faced them with the dilemma of staying or quitting their job. The importance of family and the nurses' love for their family, and fear of facing the patients when they did not have sufficient knowledge, experience, and equipment, had faced the nurses with a real mental and emotional dilemma: The dilemma of staying or leaving.
In general, in stage one, the nurses suffered severe emotional crises when providing care to these patients, such that, on the one hand, they shouldered the responsibility of maintaining their family's health, and on the other, they had to fulfill their professional responsibilities as well. In such circumstances, the lack of care facilities, knowledge, and experience made the situation and choosing harder for nurses. This situation creates an ongoing and difficult mental and emotional struggle for nurses.
Nevertheless, by the end of this stage, nurses had reached a relative mental stability and could control their emotions; they had accumulated greater work experience and could better take care of themselves, their family and the patients in the special circumstances of this disease.
The difficult work conditions and fear of the disease initially made the conditions difficult for nurses, but they gradually came to terms with it and became able to provide care with greater power. One nurse said: "Nobody wished to provide care to the patients at first, but we gradually got used to it. Both ourselves and the patients’ company had a lot of stress and anxiety at the beginning".