{'fraction_non_alphanumeric': 0.03050431761279444, 'fraction_numerical': 0.013540442491441419, 'mean_word_length': 5.183886255924171, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Experiences of critical care nurses fighting against COVID‐19: A qualitative phenomenological study

Abstract Aim This study sought to describe the experiences of critical care nurses caring for patients infected by coronavirus disease 2019 (COVID‐19). Design A qualitative phenomenological design was used. Methods We enrolled 15 nurses who provided care for patients infected by COVID‐19 purposively and through snowballing, using a phenomenological approach in critical care units of Iran's public hospitals between May and June 2020. The semi‐structured interviews were carried out either via face‐to‐face or telephone and were analyzed using the 7‐step method of Colaizzi. Results The experiences of nurses caring for patients infected with COVID‐19 were categorized into four challenges, including psychological (eight subthemes), organizational (six subthemes), social (six subthemes), and professional (five subthemes). In general, based on the current classification, there seems to be a mixture of positive and negative effects on the psychological, social, and professional challenges and the negative effect only on the organizational challenges. Conclusions Positive and negative emotions and experiences have coexisted for the critical care nurses since the COVID‐19 outbreak. Emotional support and psychological counseling play an important role in maintaining nurses' optimal mental health during the COVID‐19 crisis. Adequate protective equipment, financial and nonfinancial supports, effective communication, training and hiring of staff, and appropriate work shifts are also required to reduce nurses' negative experiences when providing care for the affected individuals.

On the 19th of February, in the city of Qom, 150 km south of Tehran's capital city, Iran announced two cases of death attributed to  This was the first officially diagnosed death report in the Middle East, West Asia, and North Africa for COVID-19. 8 Despite the disease's detection in a few weeks, there were inadequate efforts to control the pandemic. In Iran, the spreading of the virus was fast, and all 31 provinces were affected by March 5, 2020.
The combination of the COVID-19 outbreak and its consequences in Iran with the greatest new sanctions put on Iran by the United States has created a range of hurdles to the country's health sector. 9 This has contributed to a rise in the disease burden and the fatality rate. 9 According to statistics released by the Ministry of Health and Medical Education in Iran, the definite sum total cases in Iran had hit 526,490 by October 18, 2020, 10 while globally, there have been 39,442,444 cases were confirmed of COVID-19, including 1,106,181 deaths reported to WHO. 11 Encountered with this difficult situation, healthcare professionals actively involved in the diagnosis and care of  patients are at risk of experiencing psychological challenges and other signs of mental health issues. The ever-increasing number of confirmed and suspected cases, the immense workload, the shortage of personal protective devices, the broad media coverage, the lack of appropriate medications, and the sense of insufficient assistance could all add to the psychological pain of healthcare professionals. [12][13][14] The shortage of critical care nurses with qualifications and expertise is more critical than everything else in this crisis. 15 Critical care patients undergo mechanical ventilation. Many of them will require specialized life support, like extracorporeal membrane oxygenation, constant renal replacement therapy, and prone ventilation. 16 Critical nurses face a great deal of workload, long-term exhaustion, the threat of infection, and concern with the mortality of the patients they care for. They also have to deal with anxiety and even misunderstanding among patients and their families. Complications are far more prevalent in the critical care units than in conventional care units due to the vital and urgent nature of the support for organs needed. 17 Disorders in physical and mental health affect the performance of nurses in providing services. Numerous studies have shown that the prevalence of psychological disorders such as stress, depression, and anxiety in these employees is high, In many cases, performance issues are associated with risk factors in the workplace such as pain, suffering, and death of patients, the conflict between co-workers, hard work, sensitive working conditions, and other factors related to the physical environment such as working with devices and materials. [18][19][20] Nurses seem to be at risk of contracting illnesses that patients have, as nurses are charged with the treatment of the patients. Sometimes, diseases, such as COVID-19, can be contracted by even the healthiest of nurses.
By strengthening themselves with correct nutrition, staying up to date with vaccines, and remaining physically healthy, it is essential for nurses to take care of them. 21 Overall, 64% of Iranian critical care nurses were thinking of leaving their job in the latest Iranian study; 81% stated the quality of working life was poor, and 82% of nurses reported their job to be extremely stressful. 22 Other studies have also shown that burnout and turnover in nurses have a significant relationship with factors such as stroke and stress. 23,24 The result of these events can be a reduction in the quality of service and patient dissatisfaction. Therefore, nurses must study this issue and provide continuous training when in intense crisis situations.
The literature indicated that nurses suffered from some of the most harmful psychological disorders, such as anxiety, fear, and labeling stress at the time of the spread of SARS and Ebola. 25 These, in turn, seriously affected the quality of their activities and services. 26  Recent studies have highlighted the diagnosis, clinical characteristics and treatment, 3 and the disease prevalence. 27 Other studies have discussed the seriousness of psychological issues on medical personnel 28,29 and the importance of providing psychological help for them. 30

| Participants and recruitment
Participants were recruited for the study through the purposive and snowball sampling procedure. The inclusion criteria were (1) nurses who provided direct care for patients infected with COVID-19 at critical care units and (2) working for at least 1 month at the critical care units during the pandemic. The sample size was determined by data saturation, that is, at the point where no new topics from interviewees' experiences were generated. After 15 interviews, saturation was achieved, and data saturation was confirmed.
The selection process was developed through maximum variation sampling in terms of characteristics such as age, gender, work experience, educational status, and city. Finally, we interviewed 15 nurses from seven cities of Iran. Eight individuals already known to the interviewers and others were approached via snowball sampling.

| Ethical considerations
The Ethics Committee of Qazvin University of Medical Sciences reviewed, approved, appraised, and sanctioned the study protocol (ethics code: IR.QUMS.REC.1399.205) based on the fact that all interviews were to be recorded and transcribed on tape and that participants were allowed without discrimination to withdraw at any time. The interviewer (ZCH) clarified the study aims and noncompulsory nature of the study to the participants in advance and went through the informed consent form with the participants after they read it and asked if they had any questions. They were asked to sign the consent document and then given a copy once they were satisfied that all of their questions had been addressed. The consent form was signed electronically by phone interviewees. The authors ensured that all participants' information was handled with utmost anonymity and confidentiality through applying numbers as an alternative to names (i.e., P1, P2, etc.).

| Data collection
Data were collected via semi-structured, in-depth telephone and face-to-face interviews between May and June 2020. Seven participants preferred the face-to-face interview, while eight of them preferred the telephone interview. The face-to-face interviews were organized and handled in an isolated, quiet room without interruptions. The interviews were conducted in Persian by one of the authors. With participants' permission, the interviews were taperecorded. The length of interviews ranged between 30 and 90 min, with an average of 50 min. The interview guide was designed based on relevant literature and experts' opinions. 32,33 Also, the authors obtained information about participants' age, marital status, work experience, and type of units at the outset of the interview.

| Instrumentation
Data were gathered with open-ended questions. The researchers designed the interview guide in line with the existing literature. [32][33][34] The interview guide included the main question stating that: "Please, tell me about your experiences while taking care of patients infected with COVID-19". In addition to this, we asked the following openended follow-up questions to obtain further detailed experiences: (1)"How do you distinguish providing care concerning the epidemic and your regular job in the original department?"; (2)"How did you feel on the first day?"; (3)"What challenges did you encounter?"; (4) "How did you respond?"; (5) "What external support have you received so far?," and (6) and "What other types of supports do you think are necessary?". Probing questions like "Please tell me all about that," was used to deepen the discussion. Pilot interviews with two people were conducted before the start of the study interviews. The interview procedure and questions were updated in accordance with these pilot interviews.
Data gathering was carried out concurrently with the analysis of data. The audio recordings achieved from the interviews were immediately transcribed verbatim by one of the authors and reviewed by the other author for accuracy. The interviews, initial transcripts, and interpretation of the results were in Persian. The third author translated all quotes into English, and the first author backtranslated to ensure context was preserved. The results were approved by all authors, and the highlighted quotations were selected.

| Data analysis
Data analysis was performed simultaneously with the interviews. The audio recordings achieved from the interviews were immediately transcribed verbatim by one of the authors and reviewed by the other author for accuracy. The interviews, initial transcripts, and interpretation of the results were in Persian. Third author translated all quotes into English, and the first author back-translated to ensure context was preserved.
The results were approved by all authors, and the highlighted quotations were selected. Data were analyzed through Colaizzi's phenomenological analysis method including familiarization, identifying significant statements, formulating meanings, clustering themes, developing an exhaustive description, producing the fundamental structure, and seeking verification of the fundamental structure. 35 The analysis and coding of the data were achieved using MAXQDA 10 data qualitative analysis software.
In this study, strategies such as trustworthiness, credibility, transferability, dependability, and conformability of data were duly considered. 36 Credibility was achieved via in-depth interviews followed by checking and approving of the extracted codes. All authors independently analyzed the transcripts. The findings were then contrasted and CHEGINI ET AL.
| 573 conversed until consensus on themes, subthemes, and codes were achieved. Transferability was accomplished by considering differences in the interviewees' characteristics and adequate quotes acquired through in-depth interviews. Dependability and conformability of the results were also ensured through reporting and recording of the study steps and processes.

| RESULTS
Nine male and six female nurses in ages 28-50 years with an average age of 39.53 ± 6.89 enrolled in this study. The work experience ranged from 2 to 35 years with an average of 17.69 ± 8.8. More information about the characteristics of the participants is specified in Table 1.    Negative quotes: -"At the time of the outbreak and while caring for our patients, our greatest concern was the stress of getting infected by the virus." -P1 -"In the early days, we were really obsessed with using detergents and disinfecting surfaces." -P9 -"My concern was to spread the infection to the children and where to stay if I got infected. Where should the children stay and who should take care of them?" -P12 Positive quotes: -"My brother posted a photo of me on his Instagram page, and this sense of pride encouraged me." -P8 -"I was inspired by the fact that my family was proud of me." -P6

| Theme 2: Organizational challenges
Many participants reported challenges regarding their organization, especially those affecting the hospitals. Improper planning, staff shortage, challenges in relation to protocols and guidelines, lack of transparency in data and statistics about the disease, poor communication, and lack of personal protective equipment were also mentioned as organizational challenges by participants.
-"There was no mask in the early days of the disease. We saw that disinfectant solutions were not in the ward and could not be found. The supply of gloves was reduced. Equipment was scarce." -P2 -"The existing protocols were not well observed, and on the other hand, new protocols were issued every day, which sometimes contradicted the previous ones and made us doubt." -P10 -"In the early days, we tackled the shortage of manpower in many wards of hospitals providing services to COVID-19 patients. Some employees were scared, and they disappeared. Staff shifts were longer than before, and the workload was very high." -P15

| Theme 3: Social challenges
Challenges concerning the social domain were varied and ranged in positive and negative points. Participants also commented that these views include positive experiences such as increasing social solidarity and altruism, attention, appreciation, and observance of hygiene principles, and negative experiences such as increasing social panic; growing rumors and false news; and failing to comply with health protocols.
Positive quotes: -"People in the community thanked us, and their good prayers were encouraging and inspiring." -P3 -"Shortly after the onset of the disease, people's solidarity and public assistance increased. Feelings of altruism had increased among members of the community." -P6 -"Over time, healthcare professionals were highly praised. In the first days, we were under a lot of pressure, but little by little, we were supported by the people and the government, and the healthcare professionals were introduced as heroes in the society, and this motivated us." -P11 Negative quotes: -"Early in the onset of the disease, there were many rumors, and one of our most important tasks when serving was to counter these rumors and provide appropriate evidence for patients." -P15 -"Fear was evident on the faces of the patients and their families.
There were rumors that any patient who was hospitalized would definitely die." -P7

| Theme 4: Professional challenges
Participants reported advanced issues regarding their professional conditions. Despite all the supports, in some cases, discrimination against personnel was reported by the participants, such as inadequate salaries and benefits, leave, and type of contracts. Some participants felt that the training was not enough. Many other participants were worried about the future of their job. They also stated that their work shifts were inappropriate.
-"The working shift program is not suitable at all… I work for more than 72 hours and cannot sleep for 2 hours yet." -P11 Facing the worst highly unpredictable risky situations, one was possibly able to provide different excuses for absenteeism. However, participants felt that their commitment to the profession has improved since the COVID-19 outbreak.
-"I never intended to leave my job; instead I tried harder." -P11 -"I never thought about taking a leave of absence from work." -P6 -"The letter of cancellation of the leave came, and the state of readiness was announced. We did not cancel the contract in the public hospitals, and many contracts were even extended. However, this happened in private hospitals, and I heard that many intensive care unit personnel canceled contracts." -P5 -"There was no financial, equipment, or psychological support, and they even gave us a few extra shifts. For some staff, the corona fee (the fee paid to employees/staff working in the corona wards) has not yet been paid, and the payment figures have varied." -P14 anxiety and depression symptom, 40 sleep difficulties or insomnia, 39 and work stress 41   Physical and mental rewards given by nurses and caregivers are also among significant factors concerning support issues. 44 It has been indicated that positive emotions make a major contribution to improving and adjusting psychological traumas. 45 A cross-sectional study in China found that the front-line nurses' burnout, anxiety, depression, and fear were negatively correlated with social support. 4 A systematic review study has been revealed insufficient social support was one of the risk factors for developing negative psychological consequences among healthcare professionals, and providers in all sorts of disasters. 46 Therefore, social support for nurses is vital during epidemics. 28 Taking psychological intervention for nurses and other healthcare professionals in an epidemic, such as strengthening multidimensional social support, guiding positive coping styles, and stimulating positive emotions, is required to promote the psychological health of providers.

| Limitations
This study reviews the experiences of critical care nurses as care providers to patients with COVID-19 in Iran. Using a diverse sample from all over the country was the strength of the study; however, a few limitations must be highlighted. First, in a qualitative study with a limited sample size, only nurses' experiences were examined, so the experiences of other hospital staff and managers need to be further explored. It seems that reviewing the long-term experiences of the subjects may provide valuable findings.

| CONCLUSIONS
The present study sought to explore thoroughly and extensively, using a phenomenological approach, the experiences of critical care nurses during the COVID-19 epidemic. Findings of the present study show that during the COVID-19 epidemic, positive, and negative emotions were experienced due to psychological, organizational, social, and professional challenges. Hospital managers should institute strategies and interventions to reduce the psychological problems of critical care nurses.
Healthcare personnel needs emotional and psychological support and professional psychological counseling, but they should also be continuously monitored. Adequate protective equipment, financial and nonfinancial supports, effective communication, training and hiring of more staff, and appropriate work shifts are also essential to reduce staff's negative experiences providing care to COVID-19 infected patients.

ACKNOWLEDGMENT
We would like to thank all those who participated in this study. This study was funded by the Qazvin University of Medical Sciences (Grant No.: 14004339).