key: cord-0841329-fai79kxl
authors: Radfar, Moloud; Hemmati Maslak Pak, Masumeh; Mohammadi, Farshad
title: The organisational and managerial challenges experienced by nurses recovered from COVID‐19: A phenomenological study
date: 2021-07-09
journal: J Nurs Manag
DOI: 10.1111/jonm.13394
sha: 84d6a3294e140a9e8ad7acc82956689ecbd7df95
doc_id: 841329
cord_uid: fai79kxl

AIM: This study was conducted to discover the organisational and managerial challenges of nurses recovered from COVID‐19. BACKGROUND: Nurses, who are at the front line of fighting against COVID‐19, face numerous organisational and managerial challenges that impose a burden on their already heavy burden of infection. Working in challenging situations can affect the quality of nursing care. METHODS: This qualitative study was conducted through an interpretive phenomenological approach. To collect the data, 18 semistructured interviews were held with 15 recovered nurses, which were then analysed using van Manen's method. RESULTS: The data analysis led to the extraction of four themes: nurses as victims of organisational prejudice, a profession surrounded by problems, insufficient sources for dealing with COVID‐19 and post‐COVID‐19 development. CONCLUSION: This study showed the organisational and managerial challenges of recovered nurses from COVID‐19. Although these nurses had positive experiences, they needed eliminating organisational prejudice, minimizing concerns and sufficient resources to deal with the crisis. IMPLICATIONS FOR NURSING MANAGEMENT: It is believed that these results can be used as a guide to nurse managers to improve the experience of recovered nurses from COVID‐19 by treating all employees with equal kindness, considering to their problems and minimizing burden by actively providing resources.

From late 2019, a novel disease emerged in the world that was declared a pandemic in March 2020 by the World Health Organization (WHO) and is ongoing. This pandemic is not only a health crisis but also a social and human crisis. This disease has led to injustice, prejudice and unemployment on a global scale (Bertello et al., 2021) .

To date, approximately 110 million people have been infected with this disease around the globe, with 2,300,000 mortalities among them (WHO, 2020) . COVID-19 has affected many dimensions of all communities and organisations. Health and medical organisations are some of the key organisations in today's societies, and human resources constitute one of their major elements (Zamanzadeh et al., 2020) .

As a major part of the human resources in these organisations, nurses are the main force in the fight against COVID-19 who provide care services to the patients in high-risk and challenging situations and are affected more than anyone else (Muz & Erdo gan Yüce, 2021) .

Nurses provide their daily nursing care in addition to caring for infected or suspected cases of COVID-19 (Peng et al., 2020) . In these circumstances, they are both in the front line of caring for infected patients and fighting against the disease and thus incurring the risk of infection and are also faced with many problems and challenges (Al Ghafri et al., 2020) . Based on literature, nurses may experience moral distress, long work hours and fatigue in addition to psychological problems. Meanwhile, there are also organisational challenges that are not under the control of nurses but that impact them. These include a shortage of nursing force, heavy workloads and shortage of personal protective equipment (Al Ghafri et al., 2020; Chen et al., 2021; Rezaee et al., 2020) .

Although these challenges impact nurses' personal safety and efficiency and increase occupational hazards , they still continue their role in taking care of patients and controlling the infection and contribute massively to the continuation of health care (Muz & Erdo gan Yüce, 2021) . Still, the quality of care provided is affected, and the provision of high-quality care in these circumstances is a controversial topic (Karimi et al., 2020) . Furthermore, nurses' poor workforce conditions can lead to occupational burnout, job dissatisfaction and an increased turnover tendency.

These problems exacerbate the shortage of workforce as a global challenge, reduce the quality of care by imposing additional costs on health-related organisations and eventually reduce patient satisfaction (Zamanzadeh et al., 2020) . Therefore, discovering and sharing nurses' experiences during the pandemic can clarify the magnitude of impact of these challenges on the patients, nurses and health care organisations (Lee et al., 2020) . Moreover, paying attention to nurses' needs can guarantee the quality of services provided during the COVID-19 pandemic (Fern andez-Castillo et al., 2021) . Efforts to deal with these challenges are therefore crucial, which, in turn, require further studies on the topic to gain an insight into the challenges faced by nurses and then facilitate the provision of high-quality care to patients by improving the nurses' work conditions (Y. Moradi et al., 2021) .

Some of the challenges experienced by nurses during the COVID-19 pandemic have been illustrated in different studies; still, conducting a qualitative study to discover the experiences and identify the challenges from the viewpoint of nurses who have themselves been infected seems to be a major step toward strengthening the evidence in this domain. The present study is part of a larger study aiming to discover the experiences of patients recovered from COVID-19. The data extracted by that study from the experiences of nurses who had been infected and then recovered directed the research team toward the organisational and managerial challenges faced by nurses. Therefore, the present study was conducted to discover the organisational and managerial challenges experienced by nurses recovered from COVID-19 during this pandemic.

This study adopted van Manen's six-stage phenomenological qualitative approach, which is a systematic approach for studying and interpreting phenomena (van Manen, 2016).

The participants were nurses who had recovered from COVID-19 and were selected via purposive and snowball sampling. The first person was a nurse who had recovered from the disease with experience in taking care of COVID-19 patients that had been selected in our main study. Based on the data resulting from the interview with this nurse, the next participants were selected from the list of nurses who had contracted the disease in hospitals in Urmia (Iran). The participants belonged to all levels of nursing and were selected from different hospitals of Urmia to achieve maximum variance. The inclusion criteria were (a) receiving a definitive diagnosis of COVID-19 by a specialist, (b) working in health care centres during the COVID-19 epidemic, (c) willingness to discuss the subject and the ability to express one's experiences and (d) no hearing or vision problems affecting the interview process. The interviews continued until data saturation was reached, and there was no predetermined sample size. Saturation was taken as the emergence of repetitive concepts and expressions in the interviews and the nonemergence of new codes in the last two interviews.

The participants included 15 nurses who had recovered from COVID-19 and worked in hospitals in Urmia. Eleven nurses had a bachelor of nursing, three had master's degrees and one had a doctorate in nursing and all worked in the clinical setting. Five nurses worked in the dedicated COVID-19 ward whereas 10 worked in other wards and levels. Their mean age was 39.2 years. Eleven nurses were female, and the rest were male. A total of 80% were married, and the rest were single. The mean work experience of the participants was 16 years. Table 1 presents the characteristics of the participants.

The data were collected via semistructured in-depth interviews, which started from late September 2020 and continued until mid-February or 'Is there anything you would like to add?' A total of 12 interviews were held at the hospital in which the participants worked, three were held online and three in a location other than the hospital, as chosen by the participants. The mean duration of the interviews was 48 min.

Although the traditional philosophical hermeneutic phenomenology rejects the existence of method, the pragmatics of research requires a recognizable and structured approach (Morley et al., 2020) . Therefore, in order to use a structured method for data analysis, the van Manen's method was selected. Although he believes that text analysis is an art, he recognizes the need for a set of steps for developing an accurate and replicable study. He proposes a dynamic six-step interaction for interpretive phenomenology (van Manen, 2016) that guides data analysis process, and the actions performed in each step are presented in Table 2 . In this study, data analysis began after the first interview and simultaneously with the process of data collection. Each interview was transcribed verbatim, the text was read multiple times and a general understanding of it was written in several paragraphs. The sentences and phrases describing the phenomenon were selected, T A B L E 2 The stages of data analysis using the van Manen's method

Turning to the nature of lived experience

Conducting interviews and taking field notes, reflecting on the interviews and getting immersed in the data.

Reflecting on the interviews and getting immersed in the data and accessing different dimensions of the phenomenon by collecting experiences via interviews.

Reflecting on essential themes that characterize the phenomenon Writing down the researcher's previous knowledge, thoughts, and preliminary reflections, specifying their level and then putting them aside and focusing on the data.

Writing a narrative of the experiences of each participant to obtain the main elements of the experiences.

Maintaining a strong and oriented relation to the phenomenon Transcribing, coding and analysing the interviews; long-term engagement with the data; attention to the meanings in the context of the experiences; several rounds of reading and separating the key concepts.

Recursive examination of the narratives, identifying the similarities with a hybrid view, emergence of subcategories, emergence of themes and achieving the whole. and themes were extracted. In the analysis process, the research team returned to the transcripts many times to clarify the relationship between the themes and resolve the contradictions. The themes and subthemes were separated, ultimately leading to the emergence of four themes.

To ensure the trustworthiness of the data, criteria including credibility, dependability, confirmability and transferability were used (Speziale et al., 2011) . Credibility was ensured by establishing 

The analysis of the data from the narratives of nurses who had recovered from COVID-19 yielded four themes and 16 subthemes (Table 3) .

This theme included four subthemes: permanent financial problems, intraprofessional prejudice, extraprofessional prejudice and inequality in regulations.

Although preoccupying one's mind with financial problems will never lead to inner satisfaction, the continuous financial problems of nurses are an impenetrable impasse that has to be overcome. 

The data analysis revealed that nurses were dissatisfied with the insufficient resources at their disposal for dealing with COVID-19.

This theme had four subthemes: fighting with bare hands, unsuitable facilities and amenities, a shortage of workforce and an excessive increase in workload.

The recovered nurses described dealing with COVID-19 as fighting in the front line and did not believe that they deserved to fight with bare hands without protective equipment. One of them said: 

The recovered nurses had realized the importance of personal protective equipment more than the other nurses and knew that the unavailability of such equipment exposed them to serious risk. One of the participants said:

We had very little equipment. They gave us a simple face mask for each shift. We could not protect ourselves with it for seven hours in the hospital environment … There're hand sanitizers, some gloves, but in limited amounts; they are not enough to protect us in a standard way. (P9, female, 51 years)

Another chronic problem in the nursing profession is the shortage of workforce and the low nurse-to-patient ratio, which is a global challenge. This problem became even more prominent with the emergence of the COVID-19 pandemic when infected nurses exited the service system and there were no substitutes for them. According to one nurse:

When our colleagues are on sick leave, I and my other colleagues should cover for them in the ward. I used to work with three patients in the CCU in the past, but now, I work with five patients, because there aren't enough nurses or substitutes. (P9, female, 51 years)

An excessive increase in the workload of the recovered nurses after returning to work was a problem that bothered them due to the complications of COVID-19, such as fatigue. One of the participants discussed this problem and said:

With the emergence of COVID-19, our workload has increased. Some of our colleagues are on a leave, and there are more patients. There are also more critically-ill patients and a heavier workload. (P4, female, 35 years)

Although COVID-19 caused many problems for nurses, the recovered nurses also had positive experiences of the disease, which they classi- 

Despite all the problems, the recovered nurses adhered to moral care and kept this adherence alive within them. One of the participants revealed:

The authorities did not support me and my colleagues, 

According to the recovered nurses, social distancing had made them realize the value of one another and their families more than before, and they planned to spend more time with them in the future. Chegini et al. (2021) , one of the challenging topics was the organisational prejudice to which nurses fall prey. The evidence obtained in this study indicates that prejudice is still growing in the nursing profession. Organisational prejudice puts a burden on nurses, and nurses react to these unjust behaviours in different ways. These reactions can harm an organisation and have consequences. In fact, organisational prejudice is the same as injustice. Employees who observe injustice in the workplace may show different degrees of negative reactions, which can adversely impact their commitment to the organisation and profession as well as their performance (Shohani, 2019) . According to Rice et al. (2008) , when nurses feel subjected to prejudice, their performance drops to a level below the optimal level, and they experience moral and psychological challenges as well. Prejudice in the nursing profession prevents the organisation from achieving its mains goals, that is, providing essential and effective care to patients, and also affects the nurses' cooperation (Shohani, 2019) . In the present study, the recovered nurses compared themselves when they were infected with other professionals and the employees of other organisations and noticed the inequalities more than ever before. The recovered nurses mentioned the physician dominance over the system as an extraprofessional prejudice by which nurses fail to gain their proper status. Because overcoming prejudice improves intraprofessional and interprofessional cooperation for nurses (Shohani, 2019) , health care organisations should take serious measures for resolving the existing prejudice.

The recovered nurses expressed having a profession surrounded by problems as one of their major challenges. This subject can be interpreted as nurses being surrounded by one thought, and that thought reflects the problems in the nursing profession. They knew the difficulties of this profession since the day they started it, but these difficulties became more apparent to them with the emergence of COVID-19. They realized the difficulties of their profession even more when they compared themselves with the employees of other organisations. They viewed COVID-19 contraction as their first crisis, but other crises were in store for them too. Being transferred to the COVID-19 ward because of their presumed immunity, the affairs and difficulties associated with getting sick leave, the difficulty of the job due to increased workload and the authorities' lack of attention to the persistent physical complications of COVID-19, such as fatigue, were factors that inflicted an additional pain on them besides the pain of the disease itself. In a similar study, He et al. (2021) examined nurses' experiences and reported that they were faced with many problems during this pandemic. It should be noted that despite the challenges and problems, nurses do their best to provide high-quality care to patients, and the problems they have expressed are mostly organisational and managerial and cannot be resolved by nurses themselves. In the same vein, Tjoflåt et al. (2018) state that nurses are sometimes accused of deficiencies that are out of their responsibility, and because their care quality is affected by these deficiencies, that cause nurses to suffer from moral distress.

According to the data analysis, insufficient resources were another challenge facing the majority of the recovered nurses. They likened fighting COVID-19 to a battlefield in which they found themselves barehanded first-line soldiers. The nurses also mentioned insufficient facilities and personal protective equipment, the shortage of substitutes for nurses who got COVID-19 to be able to use sick leave just like the employees of other organisations and their excessively increased workload after returning to work. They highlighted the fact that, due to the shortage of protective equipment, they had to ration the available equipment and purchase protective equipment from their own pocket. Similarly, many studies during the pandemic have mentioned insufficient resources such as personal protective equipment including face masks, latex and disposable gloves, face shields, gowns and hand sanitizers and noted that insufficient resources may affect the spirits and health of nurses, as taking care of patients in this situation can threaten their own and their families' life due to the contagious nature of the disease (Cousins et al., 2021; Emanuel et al., 2020; Karimi et al., 2020; Mo et al., 2020; Ranney et al., 2020) . Sasso et al. (2019) evaluated the use of sufficient personal protective equipment as important for controlling contagious diseases. Other studies on COVID-19 have similarly reported challenges such as shortage of workforce, heavy workloads and shortage of personal protective equipment as the problems of nurses during this pandemic (Havaei et al., 2021; Mo et al., 2020; Shahrour & Dardas, 2020) . However, in one study in the United States, nurse managers did not mention a shortage of, or problems with, facilities and personal protective equipment (White, 2021) . In the recent decade, the shortage of nurses in Iran has been a challenge for health care managers. Based on the results reported by Ebadi and Khalili (2014) , the main reason for this shortage in Iran is that nurses quit their jobs due to organisational factors and poor management models.

In the process of contracting the disease and returning to work, all the recovered nurses experienced various types and degrees of challenges, but they also experienced positive aspects, mostly includ- 

The present study reveals the important aspects of organisational and managerial challenges experienced by Iranian nurses recovered from COVID-19. The findings demonstrate that bedside nurses felt that they were treated without care and kindness while ill as physicians or nurse managers were. They also perceived being uncared for because they were asked to provide care without proper protection. The nurses were doing their best to perform good nursing care but found this difficult due to problems such as transferring to the COVID-19 wards after return to the work, sick leave follow-up without any understanding of their situation and getting to infection by taking care of COVID-19 patients. They perceived these problems added to the previous problems which were doubled with the onset of the pandemic. Also, the results revealed that nurses were dissatisfied with the insufficient resources at their disposal for dealing with COVID-19 including shortage of workforce, workload increasing and unsuitable facilities and amenities. According to the results although COVID-19 caused many problems for nurses, the recovered nurses also had positive experiences of the disease that gave them a better understanding of life and its values and professional point of view for instance, development of care culture, promotion of nursing social dignity and humanistic and moral behaviours.

A limitation of this study was that some female nurses did not consent to having a face-to-face interview with the male interviewer due to the special cultural context of Iran, and the interviews were held with this group on WhatsApp. This limitation may have affected the richness and depth of the interviews. Another limitation was the restrictions on intracity transportation during the pandemic, which made it difficult to go to hospitals and conduct the interviews.

Nurse managers can improve the experience of nurses who contract COVID-19 by treating all employees with equal kindness and concern when ill, regardless of rank. When working wards of recovered nurses after return to the work are decided upon, their roles and responsibilities in their daily lives and their problems such as fatigue, working hours, night shifts and financial problems should be considered to help reduce the negative impact of crisis in nurses. Nurse managers also can minimize burden on nurses by actively providing sufficient personal protective equipment, ensuring adequate workforce by proper distribution of them, modifying nurses' workload and paying attention to their concerns. Finally, using the results of the present study nurse managers can turn the pandemic threat into a good opportunity to develop profession and a culture of care, promote the position of the nursing profession in the society and promote moral and humanistic behaviours.

We wish to express our gratitude to the Deputy for Research and Technology of the Urmia University of Medical Science, the Student's Research Committee of Nursing and Midwifery Faculty, and all the participants. The authors disclosed receipt of the following financial support for the research, authorship and/or publication of this article:

This research has been funded by the Urmia University of Medical Science.

No conflict of interest has been declared by the authors.

Ethical approval (IR.UMSU.REC.1399.318) was obtained from the Ethics Committee of Urmia University of Medical Sciences in West Azarbaijan, Iran, prior to beginning the study. The participants were briefed on the study and then gave consent for taking part in the interviews and having their voices recorded. They were also ensured that their data would remain confidential.

Author elects to not share data. 

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