Frontline nurses experiences about human caring during pandemic of COVID‐19: A directed content analysis study

Abstract

Aim

This study aims to investigate experiences of frontline nurses about human caring during COVID‐19 pandemic based on the Ten Caritas Processes® of Watson's Human Caring Theory.

Design

A directed content analysis was performed.

Methods

A total of 15 frontline nurses were recruited by purposive sampling from Razi hospital (north of Iran), in 2020 and semi‐structured interviews were conducted.

Results

Extracted categories based on Ten Caritas Processes® included feeling satisfied in providing care to patients, effective presence with patients, moving towards self‐actualization (moving towards transcendence), care with trust and compassion, experience positive and negative emotions, creativity in providing care, self‐directing learning experience in the field of care, unfavourable environment for providing care, feeling acceptance and worth, uncertainty (facing the unknown). This study showed that communication skills, self‐sensitivity, patient dignity, teaching‐learning and problem‐solving skills, holistic attention to the patient, and the provision of a healing environment are necessary for patient care.

1. INTRODUCTION

COVID‐19 has affected the health and lives of more than one million people worldwide (Al Thobaity & Alshammari, 2020). Iran is the second country to report two deaths from COVID‐19, 50 days after China on February 18, 2020, and was prevalent in Iran for long period (Rassouli et al., 2020). With the outbreak of COVID‐19, nurses were the first groups providing health care services to the infected people (Loprinzi et al., 2020). Numerous studies have shown that nurses caring for patients with COVID‐19 face a lots of challenges, including fear of infection for themselves and their families, anxiety, physical and mental burnout, and psycho‐emotional problems and workplace issues, including lack of equipment and workforce, lack of support from authorities, ethical issues and leaving work (Greenberg et al., 2020; Turale et al., 2020). In addition, one of the main challenges was the constant change of care management guidelines and treatment protocols, which result in providing care in uncertainty conditions (Catania et al., 2021). All of nurses were morally obligated to provide services for patients infected with COVID‐19, but they faced a lots of callenges including high pressure due to high workload, lack of workforce and sufficient resources that could affect patient's outcomes (Mo et al., 2020).

In this situation, nursing theories that can guide the practice of nursing discipline can be useful (Wei & Watson, 2019). By using nursing theories in patient care, patient care standards and quality of life will be improve, and nursing care costs will decrease (Fawcett & Desanto‐Madeya, 2012). Undoubtedly, the importance of promotion of humanism in nursing during COVID‐19 pandemic requires the knowledge of nurses in this field. One of the leading theories in the field of humanism is Watson's Human Caring Theory, which was proposed by Jean Watson in 1975 (Watson, 2018). This theory has a holistic perspective on caring and considers the goal of nursing as helping people to increase balance and harmony between soul, body and mind (Watson, 2013). So, considering that COVID‐19 affects different aspects of physical, psychological and emotional in infected patients (Pedrosa et al., 2020), using this theory that focuses on all dimensions of health will be helpful.

Studies have shown that if Watson's Human Caring Theory is integrated in the practice, we will see positive consequences for both nurses and patients (Durant et al., 2015; Wei et al., 2019). Considering that COVID‐19 pandemic in Iran has been a difficult experience and identifying them will provide us a deeper understanding, the present study aimed to investigate experiences of frontline nurses about human caring during COVID‐19 pandemic based on the Ten Caritas Processes® of Watson's Human Caring Theory.

2. BACKGROUND

Watson's Human Caring Theory states that human existence should not be treated and cared for as an object and nurses should pay attention to client's mind, body and soul. In this theory, the environment is defined as a calming, beautiful and comfortable place and care has a spiritual aspect that is associated with the involvement of mind, soul and body and their effectiveness together (Watson, 2013). Watson's Human Caring Theory aims to ensure harmony between one's health and illness experiences and emphasizes a holistic approach to human care (Watson, 2018). According to Watson's Human Caring Theory, caring is considered as a process including Ten Carative factors (Watson, 1979), which evolve to Ten Caritas Processes®. Ten Caritas Processes® include forming humanistic‐altruistic value systems, instilling faith‐hope, cultivating a sensitivity to self and others, developing a helping‐trust relationship, promoting an expression of feelings, using problem‐solving for decision‐making, promoting teaching‐learning, promoting a supportive environment, assisting with the gratification of human needs and allowing for existential‐phenomenological forces (Watson, 2007). As the philosophy and core values of the theory progress, the challenge is to find ways to transform and implement the Caring Science in everyday clinical practice.

3. METHODS

This study is a directed content analysis research based on Watson's Human Caring Theory that aims to explore the experience of nurses about human caring for patients with COVID‐19 in Iran, 2020. In Watson's Human Caring Theory, one of the research methods that have been proposed is the qualitative approaches (Watson, 2013). In this regard, directed content analysis is one of the qualitative research approaches that determine a phenomenon under the guidance of a theory (Assarroudi et al., 2018; Hsieh & Shannon, 2005). The theoretical framework of this study is based on Watson's Human Caring Theory (Watson, 2018). Using this research approach, the researchers were able to use Ten Caritas Processes® of Watson's Human Caring Theory as a guide to review and describe nurses' experiences of caring for patients with COVID‐19.

3.1. Setting and sample

In this study 15 nurses working at Rasht Razi hospital (north of Iran) included by purposeful sampling. Inclusion criteria were nurses who have at least six‐month experience in caring for patients infected with COVID‐19. The exclusion criteria were the presence of auditory problems and lack of willingness to participate in the study. The participants were key informants and they had in‐depth information and experiences about the intended phenomena.

3.2. Data collection

Data collection was performed between March and July 2020. In order to assure maximum variation, nurses with different gender, educational level, roles in the department and from different ward of hospital were included. Average time of the interviews were 45 min. Data collection was continued until data saturation when the new data did not modify or develop the theory or provide some suggestions for a new category.

The tools used included demographic information form (including: age, gender, job, marital status, work experience, history of caring for patients during crisis), semi‐structured interview guide and field notes. The main framework of interview guide was based on Ten Caritas Processes® of Watson's Human Caring Theory. All interviews were conducted by one of the authors of this article (SP), who is a PhD candidate in nursing, has several years of research experience and has a rich understanding of Watson's theory of caring based on studying of a lot of articles and books. After the first interview, the transcripts were presented to two faculty members in this project, and after their approval, the rest of the interviews were conducted. At the beginning of each interview, informal interviews with nurses were conducted, explaining the objectives of the study and assuring them that all information obtained from them would be kept confidential and they can withdraw from continue interview whenever desired.

For interview, we used an interview guide. All of the questions were asked based on Ten Caritas Processes® of Watson's Human Caring Theory (Table 1). In the first session, questions such as “Tell us about human care in the COVD‐19 crisis” and “What experiences did you have with caring for patients with COVD‐19 infection?” were asked. Then, based on the answers, the questions were directed. Probing questions such as “can you tell more…?” or “can you provide an example” were asked for further investigations.

TABLE 1.

Interview guide.

Questions	Ten Caritas Processes® of Watson's human caring theory
What factors made you continue to provide care despite all the deficiencies?	Forming humanistic‐altruistic value systems
How did you give hope to patients during the COVD‐19 pandemic?	Instilling faith‐hope
What factors caused you to be present in the hospital and not leave your job?	Cultivating a sensitivity to self and others
What factors caused you to have compassion with patients and your colleagues?	Developing a helping‐trust relationship
What positive and negative feelings do you have about caring for patients during the COVD‐19 pandemic?	Promoting an expression of feelings
Do you have trouble providing patient care? How did you solve it?	Using problem‐solving for decision‐making
Considering that the COVD‐19 disease had recently spread in Iran and no new information was available, how did you manage the situation or provide care of the patients?	Promoting teaching‐learning
What were the deficiencies in providing care for these patients? How was the condition of care facilities and workforce?	Promoting a supportive environment
What made you hope to continue working and caring for patients in this crisis?	Assisting with the gratification of human needs
Considering the fact that COVD‐19 was unknown in Iran during early time of pandemic, how did you take care of these patients? What experiences do you have in this field?	Allowing for existential‐phenomenological forces

Rigour in this study has been assured by Lincoln & Guba's criteria including authenticity, credibility, conformability, dependability and transferability (Elo et al., 2014; Lincoln & Guba, 1985). To assure authenticity, researchers try to portray nurses' experiences for readers, so that the readers will be able to understand these experiences. Recruiting of participants were done until data saturation that it enhanced dependability. Researchers' prolonged engagement with the data, member checks and data triangulation with maximum variation in sampling were ensured credibility. To ensure confirmability, two researchers, who were nursing faculty member and had rich experience in the field of qualitative research, supervised the research process. To ensure transferability, thick description was used, which means a clear description about study context, recruiting and characteristics of the participants, data collection and analysis process, so that readers and researchers will be able to do similar research in another another context.

3.3. Data analysis

Each interview was transcribed verbatim after recording. Then, transcripts were read several times to create immersion in the data. Data management was done by MAXQDA 20 software®. Data analysis was performed based on directed content analysis introduced by Hsieh and Shannon (Assarroudi et al., 2018; Hsieh & Shannon, 2005). According to this method, the principal researcher (SP) did initial open coding based on Ten Caritas Processes® of Watson's Human Caring Theory (Watson, 2018). The codes were then reviewed with another researcher (ZT), and in case of any disagreement, the original text of the interviews was reviewed to resolve the issue. The most important steps in content analysis guided in this study were performed as follows: reading the typed interviews as a whole so that the participants' sense of existence is understood; Using Ten Caritas Processes® of Watson's Human Caring Theory to encode and determine categories; Selecting participants' quotes that supported each of the codes; Thinking and rethinking the central idea of participants' conversations and translating participants' perceptions of human care into writing.

3.4. Ethical considerations

This study has been approved by Ethics Committee of Guilan University of Medical Sciences (IRB Approval No: IR.GUMS.REC.1399.009). Participation in this study was optional, and nurses were assured that all information obtained from them would be kept confidential.

4. RESULTS

4.1. Participants

Participants were 15 frontline nurses providing care for infected patients with COVID‐19. Their average work experience was 9.7 ± 1.2 years. The age range of nurses were between 25 and 45 years and the mean were 34.8 ± 1.2 years. Other demographic information is provided in Table 2.

TABLE 2.

Demographic characteristics of participants (N = 15).

No.	Gender	Education	Age	Marital status	Working ward	Work experience	Position
1	Female	Bachelor	25	Single	Emergency	3	Nurse
2	Female	Bachelor	26	Single	Emergency	1	Nurse
3	Female	Bachelor	25	Married	Emergency	2	Nurse
4	Female	Bachelor	26	Single	Emergency	3	Nurse
5	Male	Master	37	Single	Emergency	12	Staff nurse
6	Female	Bachelor	42	Married	ICU	16	Nurse
7	Male	Master	40	Single	ICU	17	Nurse
8	Female	Bachelor	36	Married	ICU	9	Nurse
9	Male	Bachelor	33	Single	ICU	8	Nurse
10	Female	Bachelor	36	Single	ICU	12	Staff nurse
11	Female	Bachelor	28	Single	Internal	9	Nurse
12	Female	Bachelor	39	Single	Emergency	19	Supervisor nurse
13	Female	Bachelor	41	Married	Internal	13	Nurse
14	Female	Master	45	Single	Internal	19	Head nurse
15	Female	Bachelor	43	Married	Internal	17	Nurse
Mean ± SD			34.8 ± 1.2			9.7 ± 1.2

4.2. Participants experiences about caring from patients with COVID‐19

The results of the interviews were categorized based on Ten Caritas Process® of Watson's Human Caring Theory (Table 3).

TABLE 3.

Categories extracted based on Ten Caritas Process® of Watson's Human Caring Theory.

Caritas process	Extracted categories	Quotes
Forming humanistic‐altruistic value systems	Feeling satisfied in providing care to patients	“…when we saw the patients getting well and going home, it was enough for me and I felt satisfied…”
Instilling faith‐hope	Effective presence with patients	“…all our nurses and I went to the near patients' beds even more than before. We educate patients to have hope and always request them to remember God and be calm in these moments…”
Cultivating a sensitivity to self and others	Moving towards self‐actualization (moving towards transcendence)	“…I had a few days off when This pandemic first arrived, but when I saw that people were in severe need of a nurse, I went on a voluntary shift…”
Developing a helping‐trust relationship	Care with trust and compassion	“… Although the workload was high, but I tried to provide compassionate care for my patients and sympathize with them…”
Promoting an expression of feelings	Experience positive and negative emotions	“…Because of weak protections, sometimes I was really scared to go to work and my family told me do not go at work…”
Using problem‐solving for decision‐making	Creativity in providing care	“…During this pandemic, I feel I have certain abilities now that I did not have before, such as how I manage to care for a sick patient. It has improved a lot and I try to provide the best care with the least facilities…”
Promoting teaching‐learning	Self‐directing learning experience in the field of care	“… I had no experience of caring for such patients before …and because the lack of protocol and guideline for treatment and care, in many situation nurses should act according to their previous learning and experiences … ”
Promoting a supportive environment	Unfavourable environment for providing care	“…We had to wear personal protective clothing until the end of the shift, and we could not eat or rest at all during the shifts…”
Assisting with the gratification of human needs	Feeling acceptance and worth	“…Although we were working in difficult conditions, but as soon as I thought that if I died of COVID‐19, I would be considered a martyr, I had a very good inner feeling and it calmed me…”
Allowing for existential‐phenomenological forces	Uncertainty (facing the unknown)	“… It was really one of the hardest times of my career since this pandemic came, I had a lot of bitter experiences, especially when young patients came and at first, they were apparently very good, but then, they had cardiac arrest and quickly expired… really this situation and the fact that we could not do anything was painful for us … ”

4.2.1. Feeling satisfied in providing care to patients

Caring for patients with COVID‐19 had led to the satisfaction of needs such as altruism and love for others in nurses, and it ultimately led to the formation a sense of satisfaction in providing care.

In this regard, one of the male nurses with 8 years of experience in the ICU stated:

… It is true that there were many shortcomings and difficulties, but as soon as we saw the patients getting well and going home and praying for us with all their being, it was enough for me and I felt satisfied … (P9)

4.2.2. Effective presence with patients

The nurses' statements show that they cultivated a sense of hope and trust in God by communicating effectively with the patients under their care and by valuing their patients' beliefs. A staff nurse, who has worked in the ICU for 12 years, says:

… When this COVID‐19 disease spreaded early, many of our medical staff were afraid to go near the patients so that they would not get infected, but as far as I can remember, all our nurses and I went to the near patients' beds even more than before. We gave them and their families hope, I always asked them to remember God and be calm in these moments, I really felt sorry for this patient and I think one of the best care interventions for this patient was their need to not be alone … (P10)

4.2.3. Moving towards self‐actualization (moving towards transcendence)

Patients' hard physical conditions and the urgent need for care, resulted in that nurses did not leave their job and were present in the hospital. Also, when their colleagues fell ill, they attended their shifts voluntarily and sacrificed themselves.

One of the female nurses working at the emergency department says in this regard:

… I had a few days off when this pandemic first spreaded in Iran, but when I saw that people were in emergency caring by nurses, I went on a voluntary shift … (P4)

4.2.4. Care with trust and compassion

In the crisis of COVID‐19, high work pressure caused nurses to have a better understanding of their colleagues' feelings during shifts and patient care, despite enduring many hardships, and there was an atmosphere of friendship, cooperation and sympathy between them.

One of the head nurses of the internal department with 19 years of experience in this field says:

… Although I was a head nurse, but because the high workload and my heart was really burning for my nursing staffs, I wanted to do everything I could for them workforces, so I took care of the patient like a bedside nurse… (P14)

4.2.5. Experience positive and negative emotions

Nurses' statements show that in providing care to patients with COVID‐19, experiences such as respect for patients and their families, professional growth, burnout, social stigma, acceptance of the nursing profession in the community were examples of negative and positive experiences. The head nurse with 19 years of experience and master's degree in nursing in this field says:

… During early prevalence of COVID‐19 in Iran, we did not know anything about prevention and management of it. Althouth, we did not have a clinical guideline …. because of these challenging situation sometimes I was really scared to go to work and my family would stop me and tell me not to go to work, but I thought to myself, if I am scared and leave my job, then what will happen to the sick people and I just wanted this situation to end soon … (P7)

4.2.6. Creativity in providing care

Nurse's experiences shows that their exposure to caring from critically ill patients, especially in night shifts, lack of access to experienced staff in crowded shifts and lack of access to medical team support lead to the formation of creative solution capacities in them.

One of the nurses who worked in the emergency department says:

… It's really true that since COVID‐19 came, we've been through a very, very difficult situation and we're still involved, but I feel I have certain abilities now that I did not have before, such as managing and caring for a very critically ill patient infected with COVID‐19. In fact, my ability has improved a lot and I try to provide the best care with the least facilities … (P3)

4.2.7. Self‐directing learning experience in the field of care

Giving care to patients infected with COVID‐19 was the first experience of nurses participating in this study. Guilan was the second province in the Iran that involved, so nurses present at the frontline of providing care faced new situations that neither were in their curriculum nor in the clinical setting.

Dealing with stressful situations of caring for patients with severe respiratory distress, taking actions that were not previously described in their duties and dealing with critical situations result in enabling nurses to give care to patients based on their knowledge and help them for gaining knowledge based on the patient's care context.

One of the nurses says:

… It was the first time in my career as a nurse that I saw such a crisis and I had no previous experience of caring for such patients before … Unfortunately, even during my university years, we did not trained any training in this field and nor we did not have a specific protocol and guideline for treatment and care … (P3)

The use of novice nurses along with experienced nurses led to the transfer of knowledge between the two groups in complex care situations.

Numerous encounters with critically ill patients, and the search for solutions by nurses led to the formation of self‐directed learning mechanisms in nurses.

One of the nurses says in this regard:

… We were severely encountered with physician shortage and in many cases, when patients with COVID‐19 came, we should provide them basic medical treatment, for example: we would administer basic medicines to them without physician's order and this was not legally our duty … Also, when there was no physician, we even had to intubate our patients … (P9)

4.2.8. Unfavourable environment for providing care

High workload, nurse shortage, lack of equipment, changing the hospital as the main centre of admission of patients with COVID‐19, the sudden outbreak of the COVID‐19, the high rate of COVID‐19 transmission and the long stay of critically ill patients in hospitals had led to inappropriate environment for caring. One of the nurses working in the ICU says:

… When we wore these clothes, a few minutes later our bodies were completely drenched in sweat and it was really difficult for us to breathe, and this made it impossible for us to provide good nursing care … (P7)

Due to the lack of equipment in the hospital, when nurses wore personal protective equipments during a night shift, they had to keep them until the end of shift. One of the nurses says:

… We had to wear personal protective clothing until the end of the shift, and we could not eat or rest at all during the shifts… (P2)

4.2.9. Feeling acceptance and worth

Providing care by nurses and the portrayal of their activities by the national and international media led to the appreciation of their sacrifices and forgiveness. Even this issue was so important that in the first days of the outbreak of the disease, the Iranian leader in a televised speech called the nurses who died because of COVID‐19 infection were considered as martyrs, and this issue conveyed a very good feeling to the nursing society.

One of the nurses who worked in the emergency department says in this regard:

… Although we were working in difficult conditions, but as soon as I thought that if I died from COVID‐19, I would be considered a martyr, I had a very good inner feeling and it calmed me … (P5)

4.2.10. Uncertainty (facing the unknown)

In the COVID‐19 pandemic, nurses faced unpredictable situations, and the only work that they could do was create empathy and cooperation with each other as a whole so that they could successfully overcome them.

One of the nurses says in this regard:

… It was really one of the hardest times of my career since this pandemic came, I had a lot of bitter experiences, especially when young patients came and at first, they were apparently very good, but then, they had cardiac arrest and quickly expired… really this situation and the fact that we could not do anything was painful for us … (P8)

5. DISCUSSION

In this study, the experiences of frontline nurses regarding the human caring of patients with COVID‐19 in Guilan based on Ten Caritas Processes® of Watson's Human Caring Theory have been investigated and 10 categories were extracted.

One of the extracted categories was the “feeling satisfied in providing care to patients”, which is related to the first Ten Caritas Processes®, that is, forming humanistic‐altruistic value systems. According to Watson's Human Caring Theory, existence of loving kindness causes effective communication between oneself and others (Wei & Watson, 2019). In this study, nurses acknowledged that caring for patients with COVID‐19 had led to the satisfaction of needs such as altruism and love for others in nurses and ultimately led to the formation of a sense of satisfaction in providing care. In fact, the existence of this effective relationship between the patient and the nurse led to the provision of effective care, better treatment outcomes and ultimately led to the formation of a sense of satisfaction in providing care. These findings are consistent with the results of the study of Rezapour et al. (2021). Also, effective relationship can result in the “effective presence at the patients' bedside” and is related to the instilling faith and hope (Watson, 2013). In the COVID‐19 pandemic, nurses stated that they provided loving care to patients and gave patients and their families heartfelt hope and faith. These findings are consistent with the study of Thrysoee et al. (2021).

“Moving towards self‐actualization” or “moving towards transcendence” was another category in this study. The nurses' statements show that despite the risk of transmitting the disease to themselves and their families, they did not leave work. These results are consistent with the findings of Lee and Lee (2020). This finding is related to the cultivation of sensitivity to oneself and others of Watson's Human Caring Theory (Watson, 2013) because in the COVID‐19 pandemic, one of the main reasons why nurses were always present in the field of care and willing to sacrifice in this crisis was friendship with themselves and others, their altruism and compassion. The “care with trust and compassion”, is associated with developing a helping‐trust relationship. According to this Ten Caritas Processes®, developing a helping‐trust relationship means heart‐centred‐caring relationship with others. Shin and Yoo (2022) showed that during COVID‐19 pandemic, there was a close relationship between patients and nurses (Shin & Yoo, 2022). According to a study by Ghanbari‐Afra et al. (2021), in Iran, showed that during COVID‐19 pandemic, high workload caused nurses to have a better understanding about patient care, despite enduring many hardships, and there was an atmosphere of friendship, cooperation and sympathy with patients and also colleagues(Ghanbari‐Afra et al., 2021).

Another finding was the “acceptance of positive and negative emotions”. This category is associated with promoting an expression of feelings of Ten Caritas Processes®, and it means acknowledging and processing positive and negative feelings of one's own and others non‐judgmentally (Watson, 2013). During the COVID‐19 pandemic, nurses learned to cope with many problems and manage critically ill patients from culturally different backgrounds and give them hope and peace. In fact, the art of nursing care obliged them to treat patients without any judgement. The findings of the present study are consistent with studies of Lee and Lee (2020) and Thrysoee et al. (2021).

The “creativity in care delivery” was another finding which is related to using problem‐solving for decision‐making. Creativity requires nurses to use all means of acquiring knowledge and combining medical science with the art of care. Improving the caring‐healing process requires a combination of art, ethics, knowledge and personal experience to improve care outcomes (Watson, 2013). Nurses in this study acknowledged that in the crisis of COVID‐19, they used all methods to save patients' lives, and effective care of patients required to combine knowledge with art, ethics and caring heart (Pashaeypoor et al., 2019). On the other hand, ignoring the creativity of nurses in general is one of the important obstacles in implementing Watson's theory in Iran. Creativity in providing care leads to improving nurses' ability to make clinical decisions (Pashaeypoor et al., 2019).

Another extracted category was the “self‐directed learning experience”. In fact, considering that Guilan was the second province in Iran to be involved in providing care to such patients, nurses had little information and knowledge in the field of caring for these patients, and self‐directed learning helped to improve their knowledge and practice. This is related to promoting teaching‐learning Caritas Processes® (Watson, 2013). In fact, nurses and health care team in the COVID‐19 crisis were constantly gaining new knowledge and information in this area, but gaining knowledge alone was not enough, and establishing heart‐to‐heart communication with the support and empathy from authorities had very important influence. The present findings are consistent with the study of Lee and Lee (2020) and Kalateh Sadati et al. (2021).

The “unfavorable environment for providing care” was another category that is associated with promoting a supportive environment (Watson, 2013). According to the participants, high workload, lack of equipment, changing studied hospital as the main centre of admission of patients with COVID‐19, lack of nurses and physicians, and fatigue and physical and psychological exhaustion of nurses led to inappropriate care environment for patients. In this situation, nurses were not able to play their roles such as counselling, educating, coordination, caregiving and supporting very well. In this regard, the study of Farzianpour et al. (2017) is consistent with the present results, and it has been suggested that in order to provide care based on Watson's Human Caring Theory, managers should pay attention to the shortage of nurses and physicians and prepare appropriate equipment (Farzianpour et al., 2017).

“Feeling acceptance and worth” was another finding. Nurses were happy that the authorities valued them and provided them with financial and spiritual support. In fact, authorities respected to nurse's dignity and this resulted an inner positive feeling for them.This finding is related to the assistance gratification of human needs of Ten Caritas Processes®, which believes that respect for human dignity by nurses with colleagues and with patients can leads to a healing environment (Watson, 2013). These findings are consistent with the studies of Rezapour et al. (2021) and Thrysoee et al. (2021).

The last category was “uncertainty”, which is related to allowing for existential‐phenomenological forces. This Caritas Processes® contains the opportunity for human beings to embrace the unknown and be able to solve miracles (Watson, 2018). Although there have been many advances in care, it is still fraught with ambiguities and complexities, especially in the COVID‐19 pandemic where nurses have encountered many unknowns and different ways to deal with them that are consistent with our study (Arnetz et al., 2020; Lee & Lee, 2020). It seems that during COVID‐19 pandemic, nurses experienced challenging situation and for manging it, they did not have enough training. This lack of training show us the need to revising nursing curricula and integreate similar content in bachelor deggree of nursing (Jackson et al., 2020).

Given that patients with COVID‐19 were isolated due to the risk of spreading the disease, the use of Watson's Human Caring Theory, which is based on individual interactions, can lead to a better understanding of the needs of these patients and help nurses provide quality care.

5.1. Limitations

One of our limitations was that some nurses were reluctant to participate in the study due to the high workloads. Also, we included nurses who have at least six‐month experiences in caring for infected patients with COVID‐19, but we should notice that the work experience can make difference in providing care for patients. For example, there are huge differences between a nurse who have 6 months experience and a nurse with 12‐months experiences or more. [Correction added on 5 May 2023 after first online publication: The Limitations section has been modified.]

6. CONCLUSION

Providing care for patients with COVID‐19 is challenging and to ensure their safety and providing high quality of care, nurses should pay attention to all physical, psychological and spiritual dimensions of care. To achieve this goal, nurses need more skills including interpersonal communication skills, self‐sensitivity and patient dignity, teaching‐learning and problem‐solving skill, holistic attention to the patient, and providing a healing environment, all of which can derivate from Ten Caritas Processes® of Watson's Human Caring Theory.

AUTHOR CONTRIBUTIONS

Zahra Taheri‐Ezbarami: study conception, analysis, data collection, literature review, drafting, editing and finalization. Atefeh Ghanbari: study conception, data collection, literature review, drafting, editing and finalization. Latif Panahi: study conception, data collection, literature review, drafting, editing and finalization. Somaye Pouy: Correspondence, study conception, analysis, literature review, drafting, editing and finalization.

FUNDING INFORMATION

This study was supported by Deputy of Research and Technology of Guilan University of Medical Sciences.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

Taheri‐Ezbarami, Z. , Ghanbari, A. , Panahi, L. , & Pouy, S. (2023). Frontline nurses experiences about human caring during pandemic of COVID‐19: A directed content analysis study. Nursing Open, 10, 5089–5097. 10.1002/nop2.1744

DATA AVAILABILITY STATEMENT

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.