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Inquiry Article

Nurses' perspectives of taking care of patients with Coronavirus disease 2019: A phenomenological written report

• Sarath Rathnayake,
• Damayanthi Dasanayake,
• Sujeewa Dilhani Maithreepala,
• Ramya Ekanayake,
• Pradeepa Lakmali Basnayake

10

• Published: September iii, 2021
• https://doi.org/10.1371/journal.pone.0257064

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Abstract

The pandemic of Coronavirus affliction 2019 (COVID-19) has brought significant pressure on nurses globally as they are the frontline of care. This report aimed to explore the experiences and challenges of nurses who worked with hospitalised patients with COVID-19. In this qualitative written report, a purposive sample of 14 nurses participated in in-depth telephone interviews. Information were analysed using Colaizzi's phenomenological method. Five key themes emerged: (1) physical and psychological distress of nurses, (two) willingness to work, (iii) the essential role of support mechanisms, (4) educational and informational needs of nurses and (5) the function of modern technology in COVID-19 intendance. Although the provision of care led to physical and psychological distress among nurses, with their commitment and professional obligation, it is a new experience that leads to personal satisfaction. Guilty feeling related to inefficiency of intendance, witnessing the suffering of patients, discomfort associated with wearing personal protective equipment (PPE), work-related issues (e.one thousand., long hour shifts), negative impact to the family and rejection by others are the leading distress factors. Religious beliefs, including keeping trust in practiced and bad claim, have become a strong coping mechanism. Addressing distress amid nurses is essential. The reported learning needs of nurses included skills related to donning and doffing PPE, skills in performing nursing procedures and breaking bad news. Nurse managers need to pay special attention to expanding training opportunities as well as support mechanisms, for example, welfare, appreciations and counselling services for nurses. Mod engineering, particularly robots and telecommunication, tin can perform an essential role in COVID-19 care. The institution of timely policies and strategies to protect health workers during a national disaster like COVID-19 is needed.

Commendation: Rathnayake Due south, Dasanayake D, Maithreepala SD, Ekanayake R, Basnayake PL (2021) Nurses' perspectives of taking care of patients with Coronavirus illness 2019: A phenomenological study. PLoS ONE 16(9): e0257064. https://doi.org/10.1371/journal.pone.0257064

Editor: Harald Gündel, University Infirmary Of Ulm, Federal republic of germany

Received: November xvi, 2020; Accepted: August 21, 2021; Published: September 3, 2021

Copyright: © 2021 Rathnayake et al. This is an open admission article distributed nether the terms of the Artistic Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Information Availability: All files are bachelor from the OSF database (DOI ten.17605/OSF.IO/PHX43).

Funding: The authors received no specific funding for this work.

Competing interests: The authors have alleged that no competing interests exist.

Introduction

Coronavirus illness 2019 (COVID-xix) is a respiratory infectious disease acquired past a newly identified coronavirus named SARS‐CoV‐ii [1, 2]. Health workers, specially nurses, take to play a pregnant role in combating this wellness problem on both preventive and curative sides. A recent systematic review identified that nurses accept a pivotal role in healthcare when responding to infectious disease pandemics and epidemics [3]. Koh et al. [4] report that facing emerging respiratory diseases is an unavoidable wellness hazard for nurses who are in the frontline of intendance as nurses accept to live, experience and accept this risk. Caring for patients with COVID-19 demands more than knowledge and training [5]; however, the literature supports that nurses provide this intendance without acceptable expertise [6]. Moreover, several studies have explored that nurses experience extra pressure level, burden and psychological problems during global respiratory outbreaks (e.k. Severe Acute Respiratory Syndrome [SARS], H1N1 influenza, Homo Swine Influenza and Center East Respiratory Syndrome [MERS]) [7–xiii]. Therefore, nurses demand continuous support and preparation to improve their preparedness and efficacy of crisis direction too as to cope with psychological problems and safeguard their well-being [3, six].

However, there is limited evidence related to nurses' experiences concerning caring for patients with COVID-19 globally. The available studies take mainly focused on exploring concrete and psychological distress [v, vi, fourteen]. Liu et al. [6] have reported that health workers, including nurses dedicated to combating this pandemic while they experienced physical and emotional stress. In that location is a written report that examined the overall perception of nurses towards COVID-19 intendance, and it identified challenges faced by nurses, for example, feeling of inefficiency, stress, fatigue, dilemma concerning intendance delivery and problems associated with using personal protective equipment (PPE) [xv]. In a crisis like COVID-19, it is difficult to codify a well-established evaluation plan; therefore, post hoc reflection of wellness workers helps to manage hereafter crises effectively [9]. Therefore, further exploration of experiences, particularly the overall experiences of nurses who cared for patients with COVID-19, is essential. This written report aimed to explore the experiences of nurses who cared for patients diagnosed with COVID-xix during the initial catamenia of the crisis in Sri Lanka.

Materials and methods

Study blueprint

This qualitative study employed Colaizzi's phenomenological approach [16].

Participants and recruitment.

Participants were nurses who took care of patients with COVID-xix in public hospitals for COVID-19 patients in Sri Lanka. A purposive sample of nurses was initially recruited through social media (i.e. Facebook). And so, the snowballing sampling method was applied to recruit potential participants. Data saturation was considered to determine the sample size [17]. Nurses who cared for at least one patient diagnosed with COVID-19 in public sector hospitals, who could speak in Sinhala, volunteers who were willing to participate in this study, and who were able to articulate their experiences were included. Nurses who worked in the individual sector were excluded.

Information collection process.

In-depth telephone interviews were conducted past the first researcher during June 2020, using an interview guide developed past the enquiry team based on the literature and aim of this study (Table 1). The phone method helped to collect data during the curfew catamenia with travel restriction. After identifying the potential participants, we distributed written information sheets and consent forms via electronic media (i.e., email and WhatsApp). Possible time for both parties was set. Interviews were digitally recorded with prior permission from the participants. The duration of the interviews was ranged from 50 minutes to 75 minutes.

Ethical considerations.

We obtained upstanding approval for this study from the Ethical Review Commission, Faculty of Allied Health Sciences, University of Peradeniya, Sri Lanka. Verbal informed consent was sorted earlier data collection and recorded as a part of the telephone interviews.

Data analysis.

Three members of the research squad transcribed digital audio files. All personal identifiers were removed from the transcripts. Participants received the transcripts to check their accurateness and resonance with their experiences [eighteen]. Based on Colaizzi's phenomenological approach [xvi], relevant themes were identified. When writing the detailed description, relevant quotes were translated into English language from the Sinhala language by two researchers and the consensus was accomplished. In the reporting of this study, we followed the consolidated criteria for reporting qualitative enquiry (COREQ) checklist (S1 Appendix) [19].

The trustworthiness of the study.

The iv-dimensional criteria were applied to ensure the trustworthiness of this study [xx, 21]. To attain Credibility, participants received a re-create of the transcription for member checking. Persistent observation of data was ensured by identifying themes and sub-themes, including reading and re-reading data and identifying statements and meanings relevant to nurses' experiences. Additionally, participants received a summary written report based on findings to check whether the analysis captures their experiences. For example, P13 said that results are a representation of the experiences and challenges they experienced during providing COVID-19 care. Transferability was assured by providing acceptable contextual information (setting, sample, sample size, sample strategy, socio-demographics, inclusion and exclusion criteria and interview procedure). Dependability was achieved by using accepted standards i.due east., Colaizzi phenomenological approach [16] in data assay. To assure conformability, the showtime researcher identified the potential statements and meanings for the starting time transcription, and these meanings were discussed with other researchers for consensus. A continuous discussion was endured for new meanings. The first and 2d researchers categorised meanings and identified themes and sub-themes. A consensus was achieved for the concluding themes among squad members.

Results

Demographic characteristics

Table two shows the demographic characteristics of the participants. The sample consisted of one male and xiii female nurses.

Findings

Five fundamental themes and their attended sub-themes were identified (Table 3). Nurses were de-identified in reporting (e.k., P1).

Theme one: Physical and psychological distress among nurses

This theme discusses the physical and psychological distress experienced by nurses.

Fear towards COVID-19.

Participants identified COVID-nineteen as a frightening disease. They stated that they were at increased run a risk of getting the infection; this hazard was unavoidable, which led to increased fearfulness of exposure to the virus. "Really, information technology is a risk. No affair how many safety precautions we take. If there is a slight mistake, nosotros demand to be afraid." (P13). I nurse said that she heard several deaths due to COVID-19 amid wellness workers around the world, and information technology worsened her feeling of scared. Some participants said that they were panicked when they heard the showtime diagnosed patient was coming to the unit and showed farthermost fear when admitting the get-go patient. One participant said that she had a hallucination similar feeling after the provision of care. "… Sometimes it's like hallucination while on duty in the ward…sore throat. When I become habitation, I merely feel like that… hurts a lot" (P2). Participants stated that they followed precautionary measures to maintain their wellness and to prevent from COVID-19. The reported measures were regular hand washing, regular temperature checking, drinking hot water, using traditional remedies like coriander and ginger mixed water, taking cod-liver oil, taking a high dose of Vitamin C, taking anti-histamine, having hot water baths and steam inhalation.

The negative affect on the family unit.

The majority of participants showed a feeling of fear related to being a potential carrier for family members. "I was a little scared that it would happen to me, but I scared, I would give this terrible affliction to my husband, then to his family unit, the mother is likewise old…" (P6). They said that their family members were besides scared, and dealing with those suffering was intolerable. Returning abode and living with family members in the aforementioned house, living in hospital accommodations and looking after kids were another issues reported. Participants reported that separation from family members, especially from their kids, was intolerable. "At that time, I came home, and my 2 babies were next door with my sister. I'one thousand over hither. I stand in the yard looking at my two children. How they are in that thou. Information technology'south really hard to think" (P14).

Social stigma and discriminations.

Participants said that they were rejected by peers, co-workers, family members, neighbours and lodge, making them frustrated. 1 participant said that when she worked in the COVID-nineteen unit, others looked at her like a patient with COVID-xix positive. "At that time, others looked at me; it was just like corona to me…" (P14). Another participant said that not only the general public, wellness staff too rejected them. "..Oh. Really sad. So when the health staff does the same. You don't need to talk almost ordinary people" (P13). Moreover, few participants said that they and their families were rejected past the neighbours, shops, and taxi drivers. "Afterward this infirmary was named as a corona hospital, there were rejections from the shops effectually" (P11). The bulk stated that they did not tell others that they were working in COVID-19 units, and this condition led to limited social interactions and self-isolation. Some participants noted that rejection might exist attributed to social stigma and the frightening nature of COVID-19.

Work-related physical and psychological discomfort.

Piece of work-related factors, including lack of staff, working long hour shifts, increased workload, and inadequate residual time, were other main factors that led to physical tiredness and psychological burden. "In some shifts, the workload is too much for a unmarried nurse; so, at that place was no fourth dimension, we didn't even take h2o or cup of tea" (P13). "At that place were only two nurses for xv patients in this ward, but we had to piece of work for about 50 patients. Information technology was very difficult for us and tired. When we finished our duty, we were exhausted" (P2). Therefore, they highlighted that they require adequate rest time to improve their immunity.

Additionally, wearing PPE is i of the main factors that led to the physical and psychological burden. Reported physiological discomfort included difficulty breathing, excessive sweating, headache, back pain, skin harm and pressure level on the nasal bridge due to strips of goggles, airsickness, fainting and visual disturbances. "…that goggle.., put on a cap.., it's as well much to bear, the day earlier I had a headache for a day and a half or ii… and back pain, we walked in boots …, It's hard.., there is a big discomfort in the torso…" (P3). Participants further reported mist due to facemask and googles made difficulties in cannulation and drawing claret. In terms of psychological burden, i participant stated that wearing a PPE start time was a frightening experience. "I was so scared. I mean, it was hard to breathe when I put on an N95 mask. I felt very restless for a while. Then, I idea for a while, and that feeling went away a chip. So, I went to collect blood…" (P12). They further said that they had an dubiousness related to protection received from PPE. They said that they had to have boosted measures earlier donning PPE, for example, eating and drinking adequate water and going to washrooms, adding emotional discomfort. Moreover, all participants identified removing PPE as a very relaxing experience. 1 participant said that it might be due to physical relaxation or releasing from the hazard of contact with patients. Another participant stated this experience as 'similar attaining Nirvana', (i.e., a Sinhalese saying related to a feeling of sheer relaxation). "…after removing the PPE…, like going to Nirvana. Um… .it's like going to Nirvana…" (P2).

Witnessing patients experiences.

Participants said that they witnessed the suffering of patients, including their fear of death. "…the fear in the heart of the patient when he was admitted. This is a fatal affliction. All those patients told the story; we will die or what will happen to us…" (P12). They further stated that patients were very anxious, and some patients reported depressive symptoms, especially when they received positive PCR results. "…those guys… . yeah, psychologically really upset. Let'southward assume that when a patient is discharged, from the same set, if one patient cannot get dwelling house, that ways he is the just positive, they mourned… like in a funeral…" (P8). They further said that older people and people with chronic diseases were terrified, and older people were helpless in the wards equally nurses could not attain them all the time. Several participants stated that informing negative results to patients was the happiest feel for the patients and nurses. "He is 27 years old boy…I said, blood brother, your study is negative, at present you can go, I really said 'brother'… that boy was so worried. He cried when I told him that his PCR was negative, that's happiness…" (P14). "I told the patient that your study is negative and you tin go home in the evening. This is the best, happiest last moments out there…" (P2).

Guilty feeling related to inefficiency of care.

Although they were empathetic towards patients, participants stated that they had to limit care due to strict guidelines imposed. This situation caused a reduction in straight care time that led to the inefficiency of intendance. For example, i participant stated, "... I did just any works need to practice. We tin can't go inside ever without PPE…" (P11). Many participants said that wearing PPE limited the establishment of a good nurse-patient relationship. "…poor people. I meant they don't see us. Really, they don't know who we are. They know we're nurses because nosotros say we're nurses." (P2). They further stated that the provision of intendance with these limitations led to a guilty feeling every bit they were unable to provide adequate care compared to usual care. "Those people are terrified. We are less likely to get likewise close to a patient, even to reassure, when that happened, I felt distressing when I couldn't do that" (P11).

Coping mechanisms.

Many nurses highlighted that they believed their faith and followed religious activities before and after their duty shifts. "I am a Buddhist, of whatsoever religion, everyone is bound to give nursing care by their religion. I think my organized religion has taught me a lot virtually this. If we do something good, our parents and we will get something proficient. I actually believe this" (P11). Some nurses believed that everything happened according to 'proficient' and 'bad' merits, and if they did a fair job, they would re-paid it as a prevention from COVID-19. "No matter what we practise, you become it as skillful or bad merit whether you are a Catholic, a Muslim, a Buddhist or whatever. Although the style of saying 'good and bad merit' in each religion has inverse, the fashion of receiving is the same"(P2). As reported by nurses, the main group who shared their suffering were nursing peers and friends. "We all talk together… we can't get dwelling. Sometimes in the quarters, talking to two or three people, (laughing)… and sharing our grief" (P3). Other reported methods were crying, trying to hiding uncomfortable thoughts (i.e., repression) and rationalisation. "…at the aforementioned fourth dimension… No, it will non happen. He was also wearing a mask; I was likewise wearing a mask. This did non happen…" (P1).

Theme 2: Willingness to work

This theme highlights nurses' willingness to provide care, including their sense of professional obligation.

Sense of professional person obligation.

Nurses highlighted a sense of obligation for piece of work. Some participants reported that they should provide this care because they were nurses. "Information technology is not right to leave this time due to personal matters… . I am a nurse. I go paid" (P1). They showed their dedication and professional commitment to providing care. I participant said that her fellow nurse ran to a patient without completing PPE donning when the patient self-remove her endotracheal tube. "The patient self-removed the tube. The saturation of the monitor is dropping. Monitors are alarming. Now, she was half-dressed…, this nurse suddenly ran without goggles and boots" (P 14). Participants stated that this was an opportunity to serve the community and mother country that everyone cannot exercise. "I think I was able to do something meliorate than others. Nosotros were able to practise a lot for patients' happiness… (P9). "…I had a feeling that I also participated in that national mission…" (P6).

Provision of intendance is a new experience.

As COVID-19 care is a newly emerged area, some participants stated virtually their motivation to provide intendance. They were curious and had a desire to work with patients. "Really, I had to see how she (patient) was…, how we could deal with her…?" (P3). "It was a unlike experience … that's why… at that time, information technology felt like to practice something… that ways I felt to become to COVID intendance unit" (P 7). Participants farther viewed that information technology was a new experience for their professional life and an opportunity to learn and examination new care strategies and protocols. "Everything is a new procedure and a new experience" (P12). "As a staff fellow member, I tried my best to reduce patients' stress. It feels like weird nursing intendance, not normal nursing. Did it in a new style. We had to adapt to the problems that arose" (P11). Ane participant noted that information technology was the best feel she had in her nursing life.

Personal satisfaction of nurses.

Although the provision of care was a terrible experience for them, many participants stated that they were delighted with the given care at the end of their placements. They used the words "happy", "pleasure", or "proud" to explicate their satisfaction. "It's nice to be involved with something similar this. It's a pleasure. Anybody is scared. We, as nurses, are directly involved. Proud of it. Glad to be able to do something as a nurse that not anybody can do…" (P6). I participant said that she felt like a 'hero' when she first cared for a patient. Moreover, they stated that they were happy equally mass media promoted and highlighted their contribution to the COVID-19 crisis.

Theme 3: Educational and information needs of nurses

This theme encapsulates the educational and informational needs of nurses who cared for patients with COVID-19.

Need for prior training and instruction.

All participants highlighted the demand for prior preparation and education to provide care for patients with COVID-19. Few participants said that previous experiences related to providing intendance for H1N1 influenza and MERS were beneficial to provide successful intendance. "…When H1N1 was in that location, I was on duty in that ward. With that experience, I was non scared. I accept fifty-fifty taken claret samples from H1N1 positive patients" (P2). Although some nurses had participated in related training programmes, some reported on inadequate or no prior training opportunities, and it increased their fear of patients and care. "We placed in that location; we had to exercise everything. But I didn't have any training. I always felt I would contaminate considering I didn't know how to do" (P14). "It was a petty training. To wear PPE and how to do the cleaning. Simply, when I went to the ward, I thought, it was not enough" (P10). I nurse stated that simply demonstration was not adequate for wearing PPE, and nurses should have fifty-fifty i opportunity to wearable a PPE kit earlier the bodily practice. They highlighted that the basic nursing curriculum needs to accost these aspects, and a sufficient number of nurses should be trained to confront hereafter challenges in a crunch like COVID-19.

Learning needs of nurses.

How to maintain safety during COVID-nineteen care, including donning and doffing of PPE, and performing nursing procedures, including collecting samples for PCR and disinfection, were the main care-related learning needs. "I did non fifty-fifty know how to wearable the kit. N95 masks were not fifty-fifty in the ward (i.e. usual workplace). So, I was embarrassed considering I did non know how to do" (P14). The other prioritised learning need was breaking bad news. Participants highlighted the challenges faced during informing positive PCR results to patients. "If we did fourteen PCRs, nosotros say how many negatives and how many positives to patients. Only a few of these people were negative. Others were positive. We had people from different countries equally well as from the Navy. It may vary from country to country" (P11). One participant said that they informed results to all patients as a grouping, while another stated that some patients wanted total confidentiality on positive PCR reports.

Learning strategies of nurses.

Participants farther explored various learning strategies that they used during this period. Some nurses have participated in the planned preparation programmes conducted at the National Institute of Infectious Disease (NIID), Angoda, and they said that it was beneficial in providing intendance. Some hospitals accept arranged institutional-based in-service programmes earlier opening new units. The majority noted that peers, especially experienced and trained nurses, helped them to learn wearing PPE and other intendance. "There were nurses who were trained. I asked them and did the aforementioned" (P7). According to participants, self-directed learning was a robust method, and the internet and the media helped improve their knowledge of COVID-19 care. Additionally, participants highly valued the availability of care guidelines and protocols and receiving timely information enabled them to go new noesis and provide safe intendance.

Theme 4: Essential function in support mechanisms

This theme highlights the importance of support mechanisms, including workplace back up and personal back up networks for nurses.

Need for adequate resource

Participants emphasised that a comfortable piece of work environment was paramount in providing adequate care, and they highly valued the availability of sufficient man resources, other facilities and equipment. They highlighted that a pre-plan is essential when establishing units for people affected with COVID-19. Ane participant stressed that they had a sufficient number of supportive staff, and information technology was very helpful. "While at that place were positive patients, in that location was a larger grouping of minor staff than the states. They gave skilful support in our works" (P13). Participants said that the availability of facilities, particularly adequate protective measures, cleaning facilities and bathing facilities, are essential to ensure their condom and occupational preparedness. "…to get the maximum care from u.s., we need to have acceptable protection. If nosotros do non receive those things, nosotros are besides afraid, and it is difficult to give proficient care" (P11). However, some nurses reported inadequacy of facilities and equipment; for example, inadequate PPE, poorly arranged patient and staff areas, lack of restrooms, lack of facilities for cleaning and bath, and inadequate facilities to communicate with patients.

Demand for welfare during frightening health crises.

The majority of the participants highlighted the need for welfare facilities, especially foods, transport and accommodation during a crisis. "We could have provided more facilities, food, transport, accommodation. Nosotros returned home daily. It'southward difficult. No trouble, because none of us was COVID positive. If nosotros came dwelling house while we were COVID positive…what will happen?" (P12). As reported past nurses, imposing curfew, travel brake, lack of public transport, and limited shopping opportunities accept limited their mean solar day-to-twenty-four hours life. Many emphasised that endmost schools have created an additional burden to them equally they had to wait after their children while dedicating themselves to provide continuous intendance during this crisis. Some participants reported that managers of some hospitals paid attending to nurses' welfare simply expanding was essential.

Demand for appreciation and incentives.

Nurses highlighted a lack of appreciation for their tireless efforts in caring for patients from managers and administrators. However, they identified patients as the main appreciators. I nurse said that patients' feedback and appreciations were stuck on the door and window glasses equally poems. "When patients leave, they stuck poems on the glasses. They take written, they were very scared when they came. But they were treated well. Felt like they were at home, and they had everything they needed" (P10). Although few hospital directors and nurse managers appreciated them, the bulk highlighted a lack of appreciations from authorities. "They said, they will ship a letter, just, still I did not receive" (P12). The lack of incentives (e.g. additional allowances and risk allowances) was another of import betoken highlighted by nurses. Moreover, some participants said they had economic issues and did non receive payment for their overtime duties. "Nosotros were labelled as wellness heroes. Nosotros know nosotros worked. Although labelled, we did not receive our overtime and public holiday payment even" (P2). They said that this situation demotivated them.

Need for professional counselling services.

Although some nurse managers supported to relieve the psychological stresses of nurses, many participants stated a lack of professional counselling services for both patients and staff who were in need during this situation. One participant said that she was depressed due to changing her workplace and placing her in a COVID-19 unit of measurement, but she did not receive any support to cope with her psychological concerns. Another nurse said that the establishment of counselling needs to be initiated at the very start. "I recollect information technology would be squeamish to accept counselling for nurses at the very beginning. We had nurses who did not come up for the duty" (P8).

The support network of nurses.

Participants identified the support received from peers, co-workers, family unit, friends and neighbours equally the primary branches of their support network. Many inferior nurses said that their senior nurses helped them in conclusion making. They appreciated the help received from the intendance assistants and junior staff who worked in the same units. However, participants said that staff who worked exterior the COVID-19 care units had expressed farthermost fearfulness of COVID-19, and it has led to difficulties in getting their service washed. The majority of nurses highly valued the support received from the family in terms of psychological and other supports. Some nurses said that family unit members encouraged them to go to work. "My married man ever said y'all have gone to practice good to people where many people are reluctant to go. You lot go. You lot exercise not go to practise any wrong. Practice non be agape" (P14). Many participants said that family members and relatives looked after their kids during this challenging period. However, one participant reported a negative experience. "I live in my husband's business firm. My husband's mother left the house when I said I am working in COVID hospital" (P7). Some participants said that their friends and neighbours helped them bring food and other stuff to their houses, manage household works, and provide transport.

Office of nurse managers and administrators.

Participants highlighted that infirmary assistants and nurse managers accept a central role in COVID-19 intendance, especially ensuring support for nurses. Nurses highly valued nurse managers' positive leadership roles. Some participants identified nurse managers as experts because they used their prior experiences related to crisis management in organising COVID-xix care. The activities led by nurse managers, for case, doing bones take chances assessment amidst nurses earlier placing to COVID-nineteen units, the system of training programmes, granting leaves, arranging progress meetings, and arranging welfare, were highly appreciated. "Really, they are good. They helped us. They looked afterward patients too as us. They asked what the issues are and what the shortcomings are. They arranged meetings to talk" (P9). However, some participants highlighted poor support received from and weak leadership qualities of nurse managers. They expected stiff leadership qualities from nurse managers. I nurse said that when more patients come, nurse managers fabricated decisions that benefited the establishment than the staff. "Some of their answers, sometimes, to the advantage of the establishment. Yes. Sometimes, they practise not think near usa at all. If not, they give the timely answers" (P2). Other primary issues reported related to nurse managers' function were placing nurses to COVID-19 units without asking their willingness or informing them, selecting simply junior nurses, changing duty roster without informing, placing both husband and wife to COVID-19 care units, inadequate supervision, understaffing, and poor advice and coordination. I participant said that training was given to other nurses, merely she had to work in the COVID-19 care unit without training. "At that fourth dimension, I was really angry with the direction. Others took the training, but we had to work" (P14). Many participants reported that they did not receive an opportunity to check PCR or did not receive a quarantine period, and they directly placed to the previous workplaces just after completion of duty at COVID-19 units.

Need for timely policies.

Participants further highlighted the need for timely policies in managing the COVID-19 crunch. These policy concerns included government, institutional and unit of measurement-level policies, including pre-planning before opening hospital and units, recruitment and duty delegation, resource resource allotment, policies related to infection command, testing PCR and providing facilities and welfare. One participant said that there was a plan for quarantine for nurses where necessary. Another one said that in that location was an excellent belch policy in the hospital. "We did not discharge a patient until three consecutive PCRs are 'negative'. Only after three were negative, the patient was discharged" (P8). However, many participants reported that there was no expert plan to place the nurses in COVID-19 units, and one participant said that immediate calling is not a successful method.

Theme 5: Office of modern technology in COVID-xix care

This theme highlights the uses of modern technology in COVID-xix care.

Robots in direct patient care.

Participants stated that they used robots to deliver foods, medicines and other stuff to patients. Participants said that using robots in direct patient care reduced contact time with patients, which was a big help for nurses. "That means we practice non always collide with the patients. Nosotros had a robot. He is the one who sends all the foods to the patient. Nosotros only collide directly with the patient when we take blood. That'due south why we accept to become very rarely" (P7). "Nosotros did not take much contact. We went to the patient when nosotros wanted to collect blood and PCR. All the foods and medicines were sent to patients through the robot. And then, having a robot was a big aid" (P12). However, i participant said that there was a guilty feeling when introducing robots to COVID-19 care equally it express the nurse-patients interactions. To escape this guilty feeling, this nurse further noted that she maintained communication at an optimal level when she went to collect blood from the patient. "In that location, we only had an upset. That means nosotros tin't go to the patient. Then, when nosotros went to collect blood, nosotros definitely talked to the patient. That means nosotros were talking to the patient rather than over the phone or robot at that time. The relationship was well maintained" (P12).

Telecommunication in patient intendance.

Participants stated that modern communication methods, such as mobile phones, intercom system, and video camera systems, were used to amend nurse-patient communication, which helped to minimise exposure time to patients. "Most of the time, the patient and nosotros communicated over the phone. And so, we were not exposed. Also, there was a video cam. We can talk to the patient even when robot went to the patient" (P2). One nurse highlighted the need for modern technology to amend communication with patients. "If in that location is a style to keep communication, a camera organisation, in that location is a style to talk about their problems and know their needs" (P4). One nurse stated that video records that included health instruction used to educate patients virtually COVID-19 and prevention. Additionally, nurses said that smart technologies, mainly smartphones, were promoted to patients as a way of communicating with their loved ones via video telephone call.

Modern technology in data seeking.

Participants stated that the internet was i of the main sources of information seeking. They said that websites and YouTube were used to learn not only cognition but besides in learning the necessary skills required. One nurse who did non receive prior training stated that she used videos bachelor on YouTube to know how to provide care for patients with COVID-nineteen. "With the support of others, I found out by watching the videos on YouTube." (P7). NIID has adult a video related to COVID-nineteen care, and many nurses have used it to learn the required skills. "I watched the video by IDH (i.e., a short name for NIID). How this should be treated. How to wear PPE…How to remove PPE" (P1). Additionally, social media has been used to share and receive information. One nurse said that when she was appointed to the newly established care unit, she contacted a nurse who worked in NIID through Facebook and got the necessary information and knowledge related to caring for patients with COVID-19. "A nurse at IDH, which means, I'thou not her friend. I made her my friend on my Facebook. (Laughing). I asked details from her, how is the patient cared for?" (P2).

Give-and-take

This study explored the experiences of nurses who cared for patients with COVID-419 in Sri Lanka, particularly in the initial period of the crunch. To the authors' knowledge, this study is one of the outset studies to examine the overall experiences of nurses every bit the recent studies related to caring for patients with COVID-19 have focused mainly on physical and psychological distress [5, 6, 14, 22].

In line with recent studies related to COVID-19 care, this study reported a higher level of physical and psychological distress among nurses [5, 6, 14, xv, 22]. Fright towards COVID-nineteen has become one of the top reasons for their psychological distress. Contempo studies report an farthermost fright of COVID-19 among the general public [23] and wellness workers [6, 15]. Consequent with our findings, Kim [10] reported fear amid nurses towards contagious respiratory diseases is inevitable. The highly infectious nature, the loftier morbidity and mortality rates, the nature of the novelty of illness [24], and the not-availability of drug or vaccine [14] take increased this fear. Similar to our study, fear of contact and transmission of the disease is a significant result confronted by nurses during respiratory affliction outbreak [6, eight]. In our study, nurses have paid special attention to maintain their wellness, and they have followed dissimilar measures to prevent the infection. This result is consequent with a recent study [fourteen]. Extreme fear towards affliction affects not but the psychological health of nurses but also patient care. To minimise the fear of COVID-19 among nurses, expanding education and training opportunities to improve cognition and skills related to COVID-xix intendance is essential. Managers demand to ensure a prophylactic work environs for nurses in COVID-19 care units.

Similar to the findings of a contempo study [15], this study reports fright of illness amongst nurses has been aggravated by existence a carrier for the family members. Due to this situation, family members have shown extreme fear as they work in COVID-xix care units. Government need to ensure adequate precautions for nurses when they render to families. Additionally, the about reported causes for psychological stresses were separation from family members for an extended period and the inability to physically present to the family unit during this hard fourth dimension. Like findings can be found in other studies [5, 22]. Improving resiliency among nurses is essential. Back up networks for families of health workers who are in the frontline of COVID-19 care need to exist expanded.

Consistent with the findings of a previous written report [25], facing social stigma and discrimination, mainly rejection past others related to COVID-xix care constitute in this study, are common issues for nurses worldwide [26]. Stigma has led to label nurses as 'disease carriers' [24] and limited social interaction and isolation among nurses. The stigma associated with COVID-nineteen is a predictor of compassion satisfaction, burnout, and compassion fatigue among health workers [25]. The present study reported non only the behaviour of the general public but also the behaviour of staff who did not work in the COVID-19 frontline contributed to stigmatisation and discrimination. To minimise the possible stigma and discrimination, improving public awareness needs to be expanded.

Moreover, this study reports sadness, worries and feeling of guilt related to care provision among nurses. Sadness and worries are mainly attributed to witnessing patients' suffering, and recent studies on COVID-nineteen intendance also reported a similar phenomenon [6, xv, 22]). COVID-19 signifies with rapid progression of symptoms with loftier bloodshed and ofttimes leads to death [27]. Evidence indicates that witnessing patients' sufferings, especially the painful end of a patient, is one of the main sources of psychological pressure amongst nurses [22]. Moreover, this state of affairs has increased past the guilty feeling of nurses considering they have to provide limited intendance compared to usual intendance due to strict care guidelines imposed; for example, wearing PPE earlier contact with patients. Like to the present written report, the feeling of the inefficiency of care has been explored in a recent study [fifteen]. These negative consequences are associated with exhaustion, compassion fatigue and reduced well-being of nurses [28]. Improving psychological resilience is essential to cope with these issues [24, 29], and psychological counselling for nurses are recommended [15].

Consistent with recent studies, this study farther reported that understaffing, long working hours, shift work, and increased workload were associated with physical and psychological distress amongst nurses [5, 6]. World Health System (WHO) [30] highlights that piece of work-related factors are positively related to the development of fatigue, staff burnout, increased psychological distress and reduced mental health among nurses who cared for patients with COVID-19. Paying attention to improving work conditions for nurses is essential. Moreover, discomfort related to PPE was found to exist one of the significant sources of physical and psychological stress of nurses in this study, coinciding with the contempo findings concerning COVID-nineteen care [6, 14]. Difficulty in animate, excessive sweating, headache, back pain, pressure on the nasal bridge due to strips of goggles, feeling of vomiting and fainting, and visual disturbances were the main bug identified. This written report further identified that discomfort is increasing due to prolong usage of PPE, and a recent scoping review reported that prolonged use of PPE led to severe physiological discomfort; for case, skin breakdown among nurses [31]. To minimise the negative consequences of wearing PPE, nurse managers need to plant strategies for ensuring the safety of staff members by minimising the fourth dimension required to wearable PPE.

This study further explored the coping mechanisms used past nurses during this menstruum. Interestingly, religious behavior and practices and keeping trust in good and bad claim accept go a powerful coping strategy among nurses. These beliefs assistance people to manage their stresses effectively compared to those who exercise not accept religious practices [32]. Other reported coping strategies were sharing with peers, crying, repression and rationalisation. Among nurses on the front lines of COVID-19, strategies for coping with stress must be strengthened.

Although COVID-19 is a very frightening disease that led to physiological and psychological burden among nurses, similar to previous findings, this written report reports the professional obligation, motivation and dedication of nurses who provide care for patients with COVID-xix [5, 15]. The delivery of nurses has been reported in previous respiratory outbreaks, for case, SARS [9] and swine influenza [11]. Sunday et al. [five] highlight that negative emotions are dominant in the early on stage of the crisis, only positive emotions appear gradually in the later phase. Similar to this phenomenon, this study says that nurses view COVID-19 care as a new feel and leads to personal satisfaction at the terminate of their duty placements. Provision of treat patients with COVID-19 is a neat opportunity for the professional growth of nurses that include honour and respect [five]. The present study reports that mass media portrays nursing positively, and nurses' contribution has been highly valued globally. Consequently, authorities need to appreciate and promote nurses' invaluable contribution; so, nurses can continue this care efficiently.

Like to contempo studies [5, 14], this study reports the importance of prior education and preparation for nurses during pandemics. Lack of noesis is 1 of the main reasons for insecurity, and providing education on prevention and control of COVID-xix can reduce the psychological burden and insecurity amongst nurses [fourteen]. This study reports inadequate or no prior training opportunities for nurses, and this situation leads to increasing fright and psychological distress related to providing COVID-xix care. Donning and doffing PPE, performing nursing procedures and breaking bad news were identified as prioritised educational needs of nurses. Especially, breaking bad news has been identified as a core component of communication concerning COVID-nineteen care, and demand for resources and support for effective bad news conversations is highlighted [33]. Didactics and preparation opportunities are needed to be expanded for nurses apropos the above learning needs in the Sri Lankan Context. This study further highlights the need for calculation this content into bones curricula; therefore, nurse educators need to modify basic nursing curricula in Sri Lanka.

In addition to the availability of formal training programmes, peer learning, availability of care guidelines and protocols, cocky-directed learning, including the use of the internet and videos, such equally a video adult by NIID, are the main learning strategies used by nurses. Promoting peer learning and ensuring timely care guidelines and protocols are essential. Cocky-directive cognition has a promising role in health profession pedagogy [34], particularly in emerging pandemic like COVID-xix. Ensuring the availability of self-directive learning materials and providing facilities, for case, the internet and computers can promote nurses' motivation for learning during health crises.

This report further highlights the support mechanisms bachelor for nurses in the workplace and their personal life. Available support mechanisms of the workplace include the availability of adequate resources that ensure a safe work surround, welfare facilities, appreciations and incentives, and counselling facilities. WHO [30] also highlights the need for a salubrious, prophylactic and decent working surroundings for all health workers who provide care during the COVID-19 pandemic. Similar to previous studies, this study highlights the need for acceptable resources, such as human resources, concrete facilities, equipment, and PPE, to ensure a comfortable work environment [5]. This study further highlighted the office of the administrators and the need for timely policies in addressing the above aspects. Nurse leaders have an essential role in ensuring the safety of nurses [35]; therefore, the strong leadership qualities of nurse managers are crucial. Clinical leaders can be introduced to current practice settings in Sri Lanka.

In line with previous studies [5, 6, 14], this report identified the importance of support networks, including back up from managers, peers, co-workers, family unit, friends and neighbours. The absence of sufficient support during infectious pandemics brings brusk-term and long term impact on nurses' mental health [36]. Hence, regime and media need to pay special attention to highlight the need for support for health workers during this crisis and strengthening the available back up networks. Additionally, weaknesses in support strategies, especially welfare facilities for nurses, including accommodations, transport and meal facilities, were reported. Society has been limited due to curfew and lockdown, travel restrictions, closing shopping and limited transport. Therefore, expanding welfare for nurses should exist prioritised. Moreover, our study reported a lack of appreciations, including incentives for nurses. In comprehensive workforce planning and evolution, appreciations and incentives are crucial to concenter, retain and motivate health workers [37]. Establishing policies and strategies is essential to appreciate nurses' hard piece of work in the Sri Lankan context.

This report further explores the use of modern engineering in COVID-19 care. One of the uses is telepresence robots. To the authors' knowledge, this is the first experience of using robots to provide direct nursing intendance by nurses in the Sri Lankan context. Robotic systems tin can significantly reduce the transmission risks of infectious diseases for frontline workers because robots tin provide care from a safe distance [38]. Nurses reported that robots were primarily used in serving foods and medicine. But, robots tin be effectively used in other areas, for example, disinfection, measuring vital signs and assisting border controls in COVID-19 care [39]. Although nurses viewed that the use of robots in care helped to reduce direct contact time with patients, information technology led to a guilty feeling. With possible advantages, irresolute nurses' perception towards robotic interventions in delivering care for frightening diseases like COVID-nineteen may be benign. More studies are recommended to examine user acceptance towards telepresence robots in direct nursing intendance in low-income countries similar Sri Lanka.

Additionally, modern ICT, including internet, mobile technology, telephone, video engineering with conferencing, net-based instruction and videos, and social media, has been used in direct nursing intendance, informal pedagogy and information seeking. This report highlights the importance of those technologies in maintaining patient care while minimising possible contact. The literature emphasises the importance of modernistic technology in patient advice, workplace-based learning and increasing public awareness apropos COVID-19 care [40]. Therefore, nurses must be provided with the necessary support and facilities to utilise virtual technologies effectively. Skills grooming, including assessing patient'due south not-verbal cues, emotional states and their understandings through virtual technologies, is essential [40].

Limitations

We conducted phone interviews. The absenteeism of visual cues, the potential for the distraction of interviewees by environmental disturbances and technological issues related to telephones are some limitations in telephone interviews [41].

Determination

This phenomenological study provides an insight into the experiences of a sample of nurses who took care of patients with COVID-19 in Sri Lanka. Although COVID-19 is a frightening disease with many negative impacts on nurses and their families, with their delivery and professional obligation, taking care of patients with COVID-19 is a new experience that leads to personal satisfaction amid nurses. Physical and psychological distress among nurses is a common phenomenon due to worries related to witnessing the suffering of patients, guilty feeling related to limitations of care, work-related factors, discomfort associated with wearing PPE, negative bear upon to family and stigma and bigotry. Addressing psychological distress among nurses is a priority demand. Infirmary administrators and nurse managers have a significant role in making a comfortable work surround for nurses, including creating timely policies, providing adequate resources, training opportunities, comfy shift methods, welfare, appreciation methods and incentives for nurses. Main support networks include the support received from direction, peers, co-workers, family, friends, and neighbours. Strengthening these support mechanisms is essential. Previous instruction and training, equally well as proper guidelines, are necessary to provide adequate treat patients with COVID-19. The main learning needs of nurses include donning and doffing of PPE, breaking bad news and performing nursing procedures. Expanding learning opportunities and revision of basic curricula have emerged. Moreover, modern technology, peculiarly robotic interventions and mod ICT can be integrated into patient care and nurses' educational activity. To face up future challenges, the establishment of new intendance models, training programmes, nursing specialities and favourable policies related to COVID-19 care is crucial in the Sri Lankan context.

Supporting information

Acknowledgments

The authors would similar to thank all nurses who participated in this study.

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