Research Homework
The title: Exploring the Psychological distress among frontline' Nurses during COVID-19
Setting: King Khalid University Hospital in Riyadh-Saudi Arabia
Qualitative Study.
1- Introduction: talk in general about the psychological distress, frontline nurses, Covid-19. World health organization’ opinion about psychological distress, supporting that with previous national & international studies. also, including the aim of the study.
2- Theoretical framework: how is it suitable for the study, make an argument about it. Mention previous studies use this framework. Show how do you apply the theory with the variables. Show it in a figure model.
3- Significant of the study: mention previous studies talked about this study title, why it is important, is going to make differences? How will it be published?
4- Material and Methods: don’t mention the hospital name just, write (Saudi Government Hospital.
– study design: talk about their emotion and experience, talk about the design type like (phenomenon or ground … etc.). and mention some previous talk about the design type.
– participants and setting: talk about them generally, like their type, numbers, age, work, ward…etc.
– Data collection: how did you collect the data, what did use for that.
– Saturation: how did you judge that you feel saturated for the sample?
– Rigors: how you will apply validity & reliability. Using supported study (has 5-6 steps in qualitative study, read about it and use them).
5- Finding:
– data collection
– data analysis
– tabulation data
– Methodological rigors
6- Discussion: first, you mention the aim of the study then, mention all themes separately with its interpretation and mention a pervious supported study with all sub themes separately.
7- Limitation
8- Conclusion: in summary, including the recommendations
9- Implication:
– For research
– For education
10- References: revising them and add the new references.
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Title: Exploring the Psychological Distress among Frontline’ Nurses during COVID-19 Pandemic.
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Student name: Ahmed Hassan Shujaa
Student ID: 443106295
1. Introduction
The covid-19 epidemic has been very damaging, forcing many nations to combine their healthcare services to develop a common vaccine for the disease. It brought about an increase in psychological distress among many frontline workers. It caused panic, stress, anxiety, burnout, and fear among many healthcare workers since they were at the frontline to ensure those diagnosed with the disease were well treated. The pandemic negatively affected the frontline workers, either mentally or their well-being. However, most of them were infected with the disease, while others lost their lives due to the virus.
It caused more panic to the nurses and doctors since they were at a higher risk of being infected with the disease since they were handling the patients themselves. Healthcare workers, especially nurses, were employed to effectively fight against the virus that had killed so many people. In many areas, the psychological status of all the healthcare workers was a major concern since they were the ones handling the Covid 19 patients and taking care of them. It was very obvious that they would be highly affected mentally and psychologically. Both non-frontline and frontline workers had to work in very challenging conditions with limited resources hence had to experience negative psychological impacts from the Covid 19 virus.
However, the frontline line workers had more contact with Covid patients than the non-frontline workers. Despite the virus being highly transmittable and deadly than any other heard of virus, these workers had to work tirelessly to ensure the patients were handled and treated effectively. The frontline workers in areas with limited resources were more susceptible to the virus since they were not effectively dressed for the virus. Furthermore, Covid 19 came unexpectedly; hence hospitals had not enough equipment to handle the disease effectively. Most hospitals were overpopulated with insufficient testing equipment, medication, and personal protective attire. Moreover, the staff to handle the patients was not enough.
At first, many public hospitals had declined to treat Covid 19 patients, which caused more pressure on the frontline workers working in public hospitals. It took a toll on the frontline workers, for they also feared contracting the disease. In addition, the health workers were facing stigma as many people believed they were carriers of the virus since they were dealing with the Covid 19 patients. People did not want to associate themselves with them, increasing depression and anxiety. People feared many people with flu-like symptoms since the public believed it was the virus.
Many infected people tried avoiding the hospitals. Later on, there was a need to set up platforms for the healthcare workers' mental health to express all they felt and their feelings about the virus and how it affected their health and psychology. The frontline workers had to work very hard to ensure they treated the Covid 19 patients effectively and with a lot of care, and it was also advisable to take care of their mental health. Poor health of the workers may cause poor treatment of patients, and it may lead to more spread of the virus since the healthcare workers themselves are not healthy. However, there was limited concern about the frontline workers.
The pandemic caught everybody by surprise, especially the healthcare workers who had never experienced such a thing before. They experienced psychological effects such as feelings of sadness, sorrow, depression, anxiety, etc. However, they needed to find ways of suppressing these psychological effects and treat patients as if everything was normal. First of all, they were also afraid of losing their life; therefore, it affected the relationship between patients and nurses because the patients were viewed as a threat instead of victims.
However, there is a way all animals, including human beings, adapt during a difficult time. The nurses later adapted after enough research and training had been done on Covid-19. The patient outcome started improving especially after the vaccine was released and people started getting vaccinated. The eight participants who were interviewed had different views on the pandemic. Their responses and the main themes of the research have been discussed below.
Aim of the study
The study aims to explore participants’ recent work experiences during the COVID-19 pandemic and to understand the psychological distress among the nurses. It aimed at breaking down each aspect of the main theme and understanding the reasons behind their feelings. Some of the studied feelings include Sorrow, fear, anger, frustration, etc. The study also aims at analysing some of the social aspects that supported the nurses during the tough period of the pandemic. Some of the social aspects that the study has focused on include internal support, social support, and external support. Additionally, the study aims at analysing their work experience. Aspects such as burnout during work and the preparedness or readiness towards the pandemic have been analysed. The study also aimed at analysing the emotions and feelings of these workers, their motivations, and their preparedness for the occurrence of a similar experience. The research aims at studying how the relationships of these workers were affected. Some of the additional aims of this study include:
1. How the nurses adapted to the pandemic situation.
2. To understand the new policies, guidelines, or protocols that were applied to deal with the pandemic.
3. The challenges the nurses experienced.
4. How the pandemic affected the trust between patients and caregivers.
5. Some of the difficulties the nurses dealt with.
6. Why the nurses have suicidal thoughts during the pandemic period.
Methods Design and procedure
A qualitative research method was assigned by a phenomenological approach to explore participants’ recent work experiences during the COVID-19 pandemic and to understand the psychological distress among the nurses. I used audio diaries(interview) face to face. Data were collected at one time from April to May 2022. Frontline workers from King Khalid University Hospital in the Saudi Arabia, Riyadh Regin. 8 nurses were recruited for participation in this study. Inclusion criteria were met if the participant was a nurse and worked on intensive care unit that provided care for COVID-19 patients. From April to May, participants were recruited via E-mail on the ward by the manager and the author. If they were willing to participate, they contacted the ward’ manager. All participants received an information letter about the study. An informed consent form preceded the audio dairies, in which participants indicated whether they would participate in the audio diaries. The Ethical Review Board of the King Saud University Medical City gave approval for this study.
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1. Qualitative data collection & sample.
1. The qualitative data (audio diaries) were collected during the first time. The participants were instructed to record 1 audio diaries through interview (face to face and online ‘zoom platform”). eight participants (nurses) shared 8 audio diaries, 2 of them were male and other were female.
1. Qualitative measures. Audio diaries. To explore participants’ recent work experiences during the COVID-19 pandemic, and to understand the psychological distress among the nurses. I asked participants to record experiences that had a significant impact on them, either positive or negative). All shared entries were in English, with a duration of 20 to 30 minutes, and were transcribed verbatim before analysis.
6. Statement of Problem
1. Psychological distress was common among frontline nurses during the Covid-19 pandemic. The nurses were at a higher risk of contracting this disease than other healthcare professionals. Psychological distress became a huge problem because, by that time, research had not been properly done on the pandemic. Most of the concepts considered as fact when the pandemic attacked are not considered true nowadays. Apart from being a danger to them, these nurses were also a danger to their family members and close friends.
Theoretical Framework
Figure 1. Neuman’s Systems Model Core Concepts Neuman & Fawcett, 2011, p. 20. This study focused on multilevel factors of stressors from the internal and external environment. Neuman and Fawcett (2011) define the internal environment as occurrences or interactions within the internal boundaries of the client, which are associated with the intrapersonal stressors. The external environment is defined as occurrences or interactions outside of the external boundaries of the client, which are associated with intrapersonal stressors as well as extra-personal stressors. Within the varying states of wellness and illness, all stressors can be associated with internal and external stressors that affect the client organization (Neuman & Fawcett, 2011). Frontline’ Nurses can experience multilevel factors of stressors within all environments. Neuman and Fawcett (2011) define stressors as system instabilities caused by tension-producing provocations. Internal and external stressors may lead to negative or positive outcomes, which depends on the perceptions and negotiation abilities of the clients on internal and external stressors. Neuman and Fawcett (2011) explain that internal and external stressors are characteristically passive and neutral, and depending on the client’s view of the stressors, the interaction can be considered harmful or beneficial. During stress, people respond and react, which is followed by a method of modification and adjustment in efforts to return the person to a normal state or well-being, but when the flexible lines of defence are penetrated and can no longer provide protection, intervention is needed. (Olowokere & Okanlawon, 2015). Frontline’ Nurses’ abilities to respond and cope with stressors can affect their risk of psychological distress. Olowokere and Okanlawon (2015) highlight the importance of prevention as part of the goal in maintaining a state of relative wellness or normality by preventing the reoccurrence of a stressor response. Olowokere and Okanlawon (2015) highlighted different levels of prevention that included primary prevention, secondary prevention, and tertiary prevention. Primary prevention was defined as prevention established once a stressor is identified or suspected. When symptoms of stress have occurred and interventions have been implemented, secondary prevention is involved. Tertiary prevention follows secondary prevention and is aimed to gain client stability by adjustment and modification. The NSM theory was used to present psychological distress as a concept that is experienced by frontline’ nurses during the COVID-19 pandemic and identify associated factors that breakthrough or penetrate the normal line of defence within frontline’ nurses. The systems model theory supports understanding of psychological distress and associated stressors among frontline’ nurses and the nurses’ responses to those stressors. The theoretical framework can aid in gaining an understanding of future interventions that can positively affect psychological distress in frontline’ nursing.
Figure 1. Neuman’s Systems Model.
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MAIN THEME “With interpretation” |
Sub-theme “With interpretation” |
Quotation “With interpretation” |
Supported studies for each sub-theme |
Recommendation |
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Psychological aspects Interpretation: concerned with a nurse’s mind and thoughts (mental or emotional rather than physical. One of the factors can affect nurse’s situation |
Shocking Interpretation: Impact on nurses’ stability. may contribute to disturb nurses to provide quality care. |
Participate (1): in the beginning of pandemic, we all were shocked. Interpretation: They were shocked because Covid-19 was a new disease. They had never handled it before, thus, did not know how to deal with it. |
COVID-19 confessions: a qualitative exploration of healthcare workers experiences of working with COVID-19 Authors: Bennet et al. (2020) |
. Physical therapy is one of the best ways of dealing with psychological issues Secondly, attending therapy sessions would have helped with stress and depression. Thirdly, getting a hobby to do in free time so that an individual is not stressed. |
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Mental Effective Interpretation: It affects nurses think, feel, and act. It also helps determine how nurses handle stress, relate to others, and make choices. Paly role to affect nurse’s situation mentally. |
Participate (1): in the beginning I got mentally effected even outside of the work. Participate (2): I was really mentally exhausted more than physically from the pandemic. Participate (3): the pandemic mainly affected me mentally, physically and personally. Participate (4): one of our staff got infected and that affected us. Participate (5): the patient was talking in front of me then he died. Participate (7): there was a pregnant patient, she died while we were doing CPR procedure and that affected us all mentally. Interpretation: The responses indicate that the pandemic affected the mental health of the participants more that the physical health |
COVID-19 pandemic and mental health consequences: Systematic review of the current evidenceAuthors: Nina Vindegard and Michael Eriksen Benros (2020)
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Stress: Interpretation: the feeling of being overwhelmed or unable to cope with mental or emotional pressure. It disturbs nurses for being focus on their duty |
Participate (6): due to as a new pandemic, we were so stressed to get infected and affect our family. Interpretation: The pandemic affected the closeness that they initially had because of the fear of contracting the disease |
Traumatic Stress in Healthcare Workers During COVID-19 Pandemic:A Review of the Immediate ImpactAuthors :Benfante et al. (2020) |
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Depression Interpretation: a mood disorder that involves a persistent feeling of sadness and loss of interest. One of the sequences of pandemic cases. |
Participate (1): we got depressed due to losing our staff friend. She dead suddenly. We could not help her. Participate (2): we were known that she will not stay a life. It is hard. Participate (3): in the beginning I felt depressed from the pandemic situation. Three months later, I started feel motivated and hopeful. Participate (6): there was a beloved patient who dead later because the Pandemic and I really got depressed I am not motivated to go back again to the work. Interpretation: The death of close friends, colleagues, or close people lead to depression among the people who remained behind |
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Frustration Interpretation: the feeling of irritability or anger because of the inability to achieve something. Many nurses got tired mentally for they provide and get bad outcome. |
Participate (1): how to say! Friend of mine dead in front us and we could not help her. She was in bad situation. She was saying please, do not let me die. Participate (2): she was not just friend. She was like my mother. It is so frustrated to die, Participate (4): one of our medical staff dead. he sacrificed to relief patients and later he got infected with corona and dead. this situation frustrated me heavily. Participate (5): there was a patient who was in good situation and was for charger suddenly he got worse in breathing we could not mange his situation. Participate (7): we were known that is a new pandemic and clear vaccination and people die in front of you. this is frustrated. Interpretation: To sum it up, the death of loved ones leads to frustration among these workers. It is because the loved ones who died depend on them to save them |
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Sorrow Interpretation: deep distress, sadness, or regret especially for the loss of someone or something love. Losing someone who be loved to is so difficult |
Participate (4): you cannot imagine that your staff friend will be die one day. It is so upset. Participate (7): there were many sad situations during pandemic when you see your friend dying and you do everything then die later on. It is sad emotional. Interpretation: The pandemic brought a sorrowful mode among the healthcare workers since they saw people they were close to die |
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Fear Interpretation: an unpleasant often strong emotion caused by anticipation or awareness of danger. Getting infected from catch a virus and translate it to other |
Participate (1): I really was afraid to get infected and transfer the virus to my beloved people. Participate (3): to be honest I am afraid to get infected on now. Participate (4): at this time, I am afraid to be infected of the virus and transfer it to my family and they die because of me. Interpretation: Most of these workers developed a fear because such pandemic has never been experienced before. They were afraid of contracting or transmitting the disease to their loved ones |
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Isolation Interpretation: the state of being in a place or situation that is separate from others. To be alone and a way from friends and family around you |
Participate (3): I was isolated in the beginning of pandemic even at work. I was share anything with any one even my family. Participate (4): even at home I was alone at home and go out for necessary. Do nothing for my family. It was hard to be isolated. Interpretation: Most of the participants such stated they felt isolated because they spent most of their time alone since people were avoiding them |
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Overload Interpretation: give too much of duties to (someone or something). Extra duty under pressure and get a little days-off |
Participate (1): I just sleep 5-6 hours then I go back again to work. We were work for 12 hours per day and no more days-off. Participate (3): they pulled me out to the ICU Ward and that was overload for me. Participate (4): we were under overload. Participate (5): We were work for 18 shifts per month and that is too much. Interpretation: There was influx of patients and therefore it meant they work overload was too much due to a high patient to nurse ratio. Most of these healthcare workers had not days of, thus burnout |
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Crying Interpretation: to express vain regrets for what cannot be recovered or undone. Due to what you see in front of you as bad news. |
Participate (2): I was crying hysterically; friend of mine was dying then dead. I took sick leave for two days. Participate (3): to be honest I am emotional person I was crying all the time. Participate (6): emotionally, I was crying for one week, the patient who died was friendly. Interpretation: Human beings are emotional creatures and therefore whenever they lost a friend or felt bad about the situation, crying was the only way out of letting go of the emotions |
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Anxiety Interpretation: a feeling of fear, dread, and uneasiness. It might cause nurse to sweat, feel restless and tense, and have a rapid heartbeat. uncomfortable circumstances around nurses. |
Participate (4): in the beginning the situation was scary at all. Interpretation: When the pandemic started the participant went through anxiety because it is a new situation that has never been dealt with before |
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Unexpected situation Interpretation: an infected behavior is unexpected, it surprises nurse because nurse did not think that it was likely to happen. When you think that the case is going to be well but in an opposite way is not |
Participate (7): we were unawareness about the Pandemic. There were complications every day. Interpretation: The more the complicated the situation became, the more surprised the nurses were because they have never dealt with the situation before |
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Trustless Interpretation: not having or given to confidence in Nursing Supervisor, Director or manager. Get unbelieve promises during the work. |
Participate (3): nursing administration gave us unbelieve promises about financial support. Interpretation: The pandemic economically affected all nations in a negative way. The nurses were being overworked with no financial support. It made them loose hope in the management |
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Suicide thoughts Interpretation: Nurse has thoughts, ideas, or ruminations about the possibility of ending your own life Because what you have got due to your psychological effects |
Participate (3): I thought of committing suicide. Interpretation: It is so hard to see close friends and colleagues die day by day. It is so traumatizing and that is why most of these workers had suicidal thoughts |
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Work-experience Interpretation: A period of work in a workplace, May help nurses to be more confidentiality to face the infected cases. |
Burnout Interpretation: Exhaustion caused by constantly feeling swamped. It's a result of excessive and prolonged emotional, physical, and mental stress Extra duty over what nurses assigned to. |
Participate (1): I was observed for 4 patients at the same time in ICU Ward. Participate (3): I felt that I got burnout. I could not function then I stopped. Participate (6): work hours and days got increased we could not stay with our family. We were not comfortable. Participate (4): we were under pressure being covering other wards at the same time. Interpretation: Unlike machines, humans get exhausted when they are overworked. Lack of days off and more patients lead to burnout |
The Work Experience of Newly Recruited Male Nurses during COVID-19: A Qualitative StudyAuthors Zhou et al. (2021) |
Employing more staff into the organization. Secondly, the nurses should have days off to relax from the tiresome routine. Thirdly, The organization should put in breaks for performing interesting activities. |
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Shortage Interpretation: a situation in which there is less of nurses’ staff or equipment in the ward. |
Participate (1): We had shortage in Nursing staff. Also, in experience. Participate (2): there were shortage in nursing staff and no more days-off at work. Participate (4): there were a shortage in the medical equipment. Participate (5): staff shortage and experiences’ staff were nothing. Interpretation: The world was not prepared to handle the Pandemic. The shortage of medical equipment and nurses compared to the number of patients made it too difficult |
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Readiness Interpretation: the condition of nurses being read. ready movement; promptness; quickness. ready action; ease; facility. Getting ready in regarding to knowledge and skill. |
Participate (1): we got learnt from the pandemic, we can deal with nowadays. Participate (2): now I can deal with covid-19 cases because I faced a lot of cases. Participate (3): I feel that I am ready to deal with covid-19 patients but, I don’t want to work in ICU ward. Participate (4): I cannot say that I am not expert enough. I got a lot of benefits from covid-19 cases so, I am ready to face it. Participate (5): what I learnt that I give all the patients the same care and that helped me a lot to be ready. Participate (7): we were ready enough. Participate (8): in the beginning was hard to handle it but with time we are being expert to provide a good quality of care. Interpretation: The more challenges an individual faces when performing tasks, the better they get at solving i . The nurses are now ready to deal with any cases of Covid-19. |
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Difficulty Interpretation: the quality or state of being hard to do, deal with, or understand and handle or control Covid-19 'cases during pandemic. |
Participate (1): we knew that is a pandemic so, everything was out of hand. Participate (2): we cannot manage more. What we had to do is to continue regardless the effort. Participate (2): I saw the patient through sleeping I could not get rid of the patient case which has died due to the pandemic Participate (3): it was real difficult days, we were survived. Participate (4): the pandemic situation was so difficult; it was difficult to go to the work to get infected. Participate (5): there was no clear reasons for patients' death, a lot of patients dead. Patients were not response to the medications were giving. It is difficult. Participate (6): the more difficult was how to stay wearing 95 mask all the time and get out from the ICU ward. Participate (8): was difficult to change patients position to enhance breathing exactly with obese. Interpretation: All the agreed that indeed Covid-19 was one of the most difficult times they had to go through their entire years of practice. |
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New guidelines, protocol, medication, policy Interpretation: May contribute to improve the quality of care. |
Participate (1): protocols policy and medications were changing with time. Participate (5): guidelines were updating everyday based on patient’s situation. Especially covid-19 cases. Interpretation: Adjustments had to be made within the working environments in order improve patient outcome. |
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Struggling Interpretation: to make strenuous or violent efforts in the face of difficulties or opposition struggling with the problem. Do what you can to do and stand out regardless the hard-pandemic cases. |
Participate (1): I was struggling when pandemic started but l got strong later on. Interpretation: The participant admits that even with difficulties, one usually adapts to it with time. |
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Lectures Interpretation: a talk or an online lesson given on a particular subject or a scolding given after someone did something wrong or bad or know nothing. Online seminar could enhance providing care. |
Participate (1): we had a lecture to how to deal with covid-19 cases every day before the endorsement. Participate (2): every morning and evening shift was a lecture about pandemic symptoms and protection to get ready. Participate (4): there was an online course about covid-19 every day. Interpretation: Training is an important aspect in the medical field. The nurses needed to train on how to effectively deal with Covid-19. |
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Self-study Interpretation: The study of something by oneself, as through books, records, etc., without direct supervision or attendance in a class: May help to know more about Covid-19 cases and how to control. |
Participate (1): I was self-learner. I updated my knowledge and skills every day. Participate (2): they tell us anything new information about Pandemic. If do not know you have to ask them (nursing administration).do not do anything you do not know about. Interpretation: An individual must take time and carry out individual research . Most of these nurses saw the need to do more research on handling the pandemic |
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Adaptation Interpretation: the act or process of changing to better suit a situation. To face and cope up with with new situations and handle them well. |
Participate (2): you will learn new knowledge and skills while you adapt with the situations and how make a discussion and work as a one team. The experience is so important. Participate (3): I have no problem to adapt with new environment and pandemic everywhere. Participate (5): I was new graduated. Some staff were forced to work in ICU, but I was volunteered to participate with the medical team in the ICU so, I can adapt with. Interpretation: The nurses needed to adapt on how to work on new and challenging environments to fight the pandemic. |
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Unexpected death Interpretation: People suddenly die with no clear reasons. |
Participate (5): based on the patient situation I directly know he/she will be in good case or get worse and dead later. Interpretation: It is so hard to believe that people who you normally interact with die unexpectedly. The unexpected death is what lead to stress in these workers in the first place |
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Social aspects Interpretation: The social aspect focuses on variables within the society Could help or affect nurses’ personality to focus more and get stronger. |
Internal support Interpretation: A way to encourage nurses to provide good quality May help nurses to encourage them to provide a good quality care |
Participate (1): Y es, we got moral support from head nurse, supervisor and we support each other. Participate (2): we got moral support every day from nursing director and staff as well. Participate (3): there was no support at all. Participate (4): our head nurse was supporting us every day. We thank him a lot. Participate (5): no one support me. I entirely supported myself. Participate (7): unlimited suppor . Emotional, personal, equipment's support. We always thank God. Participate (8): completely no support, we just support each other as a staff. Interpretation: Support from other healthcare professionals and the organizations authority helped keep the nurses on track. |
Nurses' burnout and associated risk factors during the COVID-19 Pandemic: A systematic review and meta-analysis Authors: Galanis et al. (2020) |
1)The internal support should be encouraged in order to motivate them and create an effective working environment. 2) Allow the nurses to visit or talk to their loved ones when its necessary or they are stressed to work. 3) Rotating them to work in different organizations for specified duration in order to learn new ways or advanced ways of handling the pandemic to improve patient outcome. |
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External support Interpretation: A way to encourage nurses’ staff to provide good quality May help nurses to encourage them to provide a good quality care. |
Participate (1): we are working in ICU Ward no one could enter so, no one can support us from outside. Participate (2): no support from outside the hospital. Participate (6): there was financial and moral support from Ministry of Health and government. Participate (7): to be honest, there was supporting us nationally. Even from Ministry of Health. Interpretation: Interacting with other people from other organizations was also a way of motivating them and ensure they learn new skills applied in other organizations. |
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Family support Interpretation: A way to encourage nurses to protect him/herself and be strong. |
Participate (3): only indirectly family support. Interpretation: Family is the closest thing an individual can depend on during tough time. Families played a huge role in reducing stress. |
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Qualitative Data Collection
It is evident that the method of collecting qualitative data was through interviews. The interview model was the structured kind that was carried out in an orderly manner. Every respondent was asked similar questions in order to understand how they felt towards the pandemic and how their attitude changed towards work; The Qualitative data collection was aimed at understanding psychological distress in a less statistical manner. It aimed at understanding the impact of the pandemic on the respondents rather than focusing on the statistical aspects of the respondents. The interviews were done separately to ensure every respondent had an independent answer. Furthermore, these respondents had different views on what to answer when it came to the pandemic experience.
The psychological experiences of the frontline nurses in Saudi Arabia can be summarized in three themes: Firstly, Psychological aspects, four themes; Firstly, concern for the health of families and friends, negative emotions due to shocking, mental effective, stress, frustration fear, Isolation, fatigue from the overwhelming work, crying and suicide thoughts. The second theme was Work-experience to be more confidentiality to face the infected cases. The third theme is social aspects to affect nurses’ personality to focus more and get stronger. During the early stages of the pandemic, negative emotions were dormant compared to positive emotions. The Work experience that the frontline nurses embraced played a crucial role in maintaining the mental health of these nurses.
Apart from this study, most of the earlier studies also indicated the number of negative emotions in the first week. As the number of patients increased in King Khalid Hospital in Saudi Arabia, the workload increased more. The overwhelming work is what leads to negative emotions. Additionally, the nurses required protective clothing to avoid contracting the infection. The shortage in supply for these clothing increased the risks of contracting COVID-19, thus, more negative emotions. The failure to meet both physical and psychological needs to handle the pandemic led to helplessness.
At first, all the participants expressed stress, fear and depression of contracting the pandemic. However, the level of anxiety declined with time. Additionally, most of these nurses expressed their concern about the impacts of this disease. For example, they feared their relationships with other family members and close friends.
It is only natural for human beings to to be more confidentiality to face the infected cases. All the nurses activate the psychological defence mechanism to adapt with the changes in their working environment. These mechanisms included Burnout, shortage, readiness, difficulty, struggling, adaptation, etc.
Growth Under Pressure
Even though the pandemic affected the significant sectors, the public still requires the health sector to perform. All the nurses were reminded of their oath to protect their patients. Most nurses were grateful for family members, friends, colleagues, etc. The pandemic also made them realize how family and friends are important in one's life. More than 65% of the respondents were being pushed and promoted by their professional responsibility to participate in their mission to contain the Covid-19 pandemic (Sun et al., 2020). Most of these nurses found ways of adapting to the pressure they were facing in their line of work and started to focus on the courage to face life and reality.
The negative emotions were only experienced at the early stages of the pandemic. As fear took over at the early stages, some nurses and healthcare professionals were already evaluating control progress epidemic prevention and felt confident in the capability of their government to handle the epidemic. Instead of being controlled by fear, the frontline nurses decided to embrace training and practice to deal with the negative emotions. Most of these nurses accepted and volunteered on tasks while showing great calmness when handling these tasks. The negative feelings started to subside after the environmental adaptation and pre-job training had occurred (Sun et al., 2020). Additionally, some nurses felt calm and relaxed when they entered the negative pressure ward to take care of patients.
Additionally, family and team support helped these nurses eliminate negative emotions and embrace happiness and other positive emotions. To sum it up, any form of appreciation from the public or the government brought happiness to the nurses and other healthcare professionals and encouraged those to work hard towards containing the pandemic (Sun et al., 2020).
Data Collection Analysis
Audio dairies
From the interview responses, three things are evident. First, there was fear, stress, and depression at the beginning of the pandemic. Second. The stressed individuals decided to find ways of dealing with the stress, and finally, everything started getting back to normal because they had adapted to the changes. When the pandemic began, people were stressed, shocked, frustrated, depressed, etc. It was because they had never encountered such a pandemic before. The fact that most governments failed to manage this pandemic led to shock, fear, stress and depression. For example, Participant (1) responded that when pandemic started, we all were shocked. Participate (4) responded that meanwhile, I am afraid to be infected of the virus and transfer it to my family and they die because of me. Participate (6) responded that because it is a new pandemic situation, we got stress to be infected and trans the disease to other. Participant (6) responded that there was a beloved patient who dead later due to the Pandemic and I really got depressed, I am not motivated to go back again to the work.
. Additionally, persistent feelings of stress due to the bad events led to depression. Participant (1) admits that losing a close friend because of the pandemic sent her into depression. Additionally, the work experience also leads to depression and suicidal thoughts among these healthcare workers. Shortage of workers led to more burnout which increased the level of stress among these workers. For example, participant (2) admitted that there was a shortage of nurses and no working days off.
Secondly, the workers decided to find ways of, getting new knowledge through lectures, self-study and adapting to the pandemic situation. They did this to ensure they maintain a healthy mental state that is suitable for maintaining a good working environment. For example, Participant (2) responded that every morning and evening shift was a lecture about pandemic symptoms and protection to get ready. Participant (1) responded that she was self-learner. I updated my knowledge and skills every day. Participant (5) responded that she was new graduated. Some staff were forced to work in ICU, but I was volunteered to participate with the medical team in the ICU so, I can adapt with. Etc.
Similarly, most male workers decided to embrace physical therapy to adapt to the situation and deal with stress.
Finally, the third phase was supporting to return things to normal. The fear and tension ended because of, family, internal and external support for these workers. For example, Participant (3) explained that her family was supporting me every day in directly way. Participant (1) stated Yes, our manager and supervisor support us morally, and we support each other. Participant (2) reflected that every morning nursing administrator support them well. Participant (6) responded that they got mental and financial support from ministry of health and government as well. Participant (7) told that, obviously, ministry of Health supported us enough. The fear and tension ended because of external, family, and internal support for these workers.
Summary of Qualitative Results
The Qualitative results aimed at understanding the psychological distress in depth by not only depending on the statistical data. It answered questions of What, Who, and Why. For example, it explains Can you reflect on a work experience or situation (positive or negative) that made a big impact on you today? Please discuss this experience in as much detail as possible, including: In what context did this experience occur? (Situation). Who were involved? Do not record names but name your relationship to these persons and the roles they fulfil. (Who). Why did you choose to share this experience? What insights has this experience brought you? Can you also explain in more detail in which way this situation affects you emotionally? What did you find difficult about this situation and what did you find easy? To what extent did you or did not feel competent to deal with this situation? To what extent did you feel or not feel sufficiently prepared to deal with this situation? To what extent did you feel supported by those involved? How did you experience the collaboration with those involved? Etc. These results enabled us to identify factors that lead to the high prevalence of psychological such as high expectations. It has also helped identify the impacts of psychological distress on the nurses, families, friends, and the overall nation.
1. Discussion
Among all the psychological distress, fear turned out to be the most common psychological reaction across the frontline nurses who provided healthcare during the Covid-19 pandemic in Saudi Arabia. After fear, it was followed by burnout, anxiety, depression, and then stress. There are many reasons why fear was the most common psychological distress among these individuals. First, they feared failing to provide adequate healthcare services to their patients due to the high nurse-patient ratio. They also lacked protective clothing to protect them from contacting Covid-19. Another possible explanation for the high prevalence of fear is the fear of get infected and carrying the virus to their families and friends. During the early stages, the frontline nurses and most healthcare professionals experienced a shortage of Personal Protection Equipment (PPV). It also contributed to a high level of fear among these individuals.
On the other hand, the possible explanation for burnout is the high workload demand and irregular long working hours that these nurses were not initially used to. They needed to adjust to these changes by putting on PPE before working and showering before they went home. These activities also contributed to the burnout psychological distress in these workers. Additionally, the burnout and fear among these health workers led to stress, anxiety, or depression. According to Ching et al. (2021), China had the highest number of health workers suffering from depression during the Covid-19 pandemic.
Research carried out by Kock et al. (2021) suggested that female nurses who had close contact with Covid-19 patients had more to gain from the efforts aimed at psychological well-being. However, they were also the most stressed or depressed about family, fear of infection, and many more. Kock et al. (2021) also suggest that among all the healthcare professionals, nurses were the ones who were at a higher risk of adverse mental health outcomes during the Covid-19 pandemic.
When psychological distress attacked these nurses, they needed to develop coping or adapt to these changes. Sehularo et al. (2021) conducted a study to explore the healthcare workers' coping strategies during the pandemic. The research revealed that the nurses adopted faith-based practices, avoidance strategies, protective measures, psychological support, social support, and management support as ways of coping with the pandemic. Sehularo et al. (2021) concluded that these strategies helped the nurses reduce stress and burnout during the pandemic.
1. Limitations and Delimitations
It is almost impossible for research to be carried out without experiencing problems or difficulties. For this research, the first limitation to be encountered was that most depressed frontline nurses did not want o to participate in this research. Some of the participants refused to answer some questions, thus affecting the accuracy of the research. Another limitation was that minimal resources had researched the same topic. It meant that there were minimal resources to compare my results with. Additionally, insufficient sample size also acted as a limitation to the study. On the other hand, delimitations make my projects project more realistic and minimize the amount of work done during the study. Some of the delimitations that were upheld in this research study include The study is limited to psychological distress in frontline nurses during Covid-19, The research must study the future of research on the same topic, The study does not cover the medical signs and symptoms of Covid-19, and The study is limited to Saudi Arabia's healthcare organizations, particularly the King Khalid University Hospital in Riyadh-Saudi Arabia.
1. Recommendations for Practice
There is a need to protect our frontline nurses from physical and mental dangers to deliver quality services to their patients. They are usually stressed because of the long hours they work. The first step is to lay out the stressed nurses to not make mistakes while on duty. Some of the symptoms the organization should be on the lookout for includes sadness, burnout, loss of appetite, irritation, anger, sleeplessness, and many more.
The nurses should be encouraged to exercise regularly, manage their diet, share their feelings, limit their exposure to social media, etc. The organizations should come up with resources that help manage nurses' stress. It may include a small facility for counselling and guidance, resources for entertainment, and many more. Additionally, the organization should consider using more technological resources to reduce burnout. Technologies such as Artificial Intelligence to reduce administrative burden, Machine learning for predictions, Data analytics tools for the analysis process, and electronic health records to improve the productivity of nurses when it comes to data retrieval.
1. Recommendations for Future Research
For this research, some of the limitations will be solved. For example, increasing the sample size should be considered to make the research more accurate. The study area should also be expanded from Saudi Arabia to other nations. Different institutions in different countries have different resources and experience different problems. The best area to expand this research in Wuhan in China, where the virus started. It is also important to revisit the participants who had depression and look at their progress. Finally, it would be reasonable to explore the new policies and strategies that King Khalid University Hospital in Saudi Arabia to hire employers to ensure these healthcare professionals do not repeat such occurrences.
Conclusion:
In summary, the nurses went through a lot of challenges during the Covid-19 pandemic. It is because they were not prepared and had not been trained on how to deal with such difficulty. Additionally, they became stressed because the pandemic had a negative impact on how they were treated in society. They were initially viewed by society and heroes who could save them from medical difficulties. During the pandemic, they suffered from stigmatization due to the fact they were the only individuals who were at a greater risk of getting Covid-19. They also became stressed because of how their relationships with their families and close friends had been affected because of the fear of spreading the disease to their loved ones.
Organizations decided to develop strategies for handling the pandemic. They pulled out more staff and adjusted the hospital policies to improve patient outcomes. It was through internal support from their seniors, external support from other nurses from other organizations, and improving their mental state through therapy.
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