From pervasive chaos to evolutionary transition: The experience of healthcare providers during the COVID‐19 pandemic

Abstract

Aim

The outbreak of the COVID‐19 pandemic confronted healthcare providers, especially physicians and nurses, with many unprecedented changes and physical and psychological pressures. This study aimed to explore the healthcare providers' experiences providing healthcare services for patients during the COVID‐19 pandemic in “Golestan, Northeast Iran”.

Design

Qualitative, conventional content analysis.

Methods

A total of 13 eligible participants were recruited through the purposeful sampling method. Data were gathered using semi‐structured in‐depth individual interviews. Transcripts were analysed using an inductive content analysis based on the Elo and Kyngas model. The COREQ checklist was used to prepare the manuscript.

Results

The analysis of the data in this study led to the development of 16 subthemes and 5 themes emerged as follows pervasive chaos, imposed difficulties, paradoxical perceptions, committed efforts, and constructive transition.

Conclusion

The experience of HCPs during the COVID pandemic in “Iran” showed that despite the physical, mental, emotional, and social consequences, a kind of constructive evolution and transition has also taken place in personal, professional, and organizational dimensions. It is suggested that managers while strengthening and protecting the capabilities and skills that have emerged, to reduce the tensions of HCPs, have developed programs for comprehensive support from them in physical, psychological, social, and financial dimensions.

Relevance to Clinical Practice

It is necessary to improve inter‐professional cooperation, empathy, teamwork, professional commitment, and continuous learning in crises.

1. INTRODUCTION

In late December 2019, a highly contagious and novel species of Coronavirus (COVID‐19) emerged in Wuhan, China, and spread rapidly across the world (Chen et al., 2020). In March 2020, the World Health Organization (WHO) called it a pandemic disease and declared it a significant threat to public health (Saffari et al., 2020). The first cases of COVID‐19 were identified on February 19, 2019, in “Iran”; since then, the number of new cases and deaths has exponentially increased (National Committee on Covid‐19 Epidemiology, Ministry of Health and Medical Education, IR Iran, 2020).

Evidence during and after the outbreak of severe acute respiratory syndrome (SARS) has shown that an emerging infectious disease causes extreme stress in healthcare providers due to the fear of being infected by the disease, family‐related health concerns, job stress, interpersonal isolation, and quarantine (Maunder et al., 2004, 2010; Wong et al., 2005) and affects their ability in doing their duty (Aiello et al., 2011). COVID‐19 has been the first respiratory pandemic since the 1918 flu that had extensively affected the world (Eftekhar Ardebili et al., 2021). Healthcare providers, particularly nurses and physicians, have been more susceptible to COVID‐19‐oriented physical and psychological risks because of their responsibility in treating and caring the patients. As the frontline group, they are severely affected by the high mortality rate, high disease transmission capacity, deficiencies of health systems (Ji et al., 2020), being exposed to new unprecedented situations (Lee et al., 2021), and long and frequent peaks of COVID‐19.

In “Iran”, with the confirmation of the first infected case, all public centers, such as educational centers and gyms, were closed and their activities were suspended. The disease spread rapidly and the number of infected cases increased sharply. The health system and healthcare providers had no experience with such a widespread disease in the country. The lack of health equipment and facilities was identified as the biggest problem ahead. In each city, certain medical centers were defined and designated to provide care to affected patients. In addition, because of the lack of adequate staff, many doctors and nurses volunteered to work in the COVID centers. Charities and community‐based organizations participated widely to provide the resources needed. To provide consistent approaches for disease prevention, detection, and treatment as well as nursing care, the Ministry of Health and Medical Education formed special committees to develop practical guidelines and protocols for application in medical centers. Therefore, medical center managers and staff faced with a huge number of diverse submitted instructions and changes in daily practice. They had to work in such a disturbed and full of crisis setting with strange and unknown experiences.

A comprehensive understanding of the healthcare providers' experiences with a multi‐professional approach during the COVID‐19 epidemic paves the way for developing supportive and educational programs and optimal responsiveness to similar events in the future, along with better management of health systems.

2. AIM

This study aimed to explore the healthcare providers' experiences providing healthcare services for patients during the COVID‐19 pandemic in “Golestan, Northeast Iran”.

3. METHODOLOGY

3.1. Study design

This qualitative descriptive study with conventional content analysis design was done on healthcare providers in the referral hospital of COVID‐19, “Sayyad Medical and Educational center”, during the COVID‐19 pandemic. This approach helps one understand one's experience when encountering less‐known phenomena and creates new knowledge and insights (Polit & Beck, 2018). The Consolidated criteria for reporting qualitative studies (COREQ) (Tong et al., 2007) was used when developing and reporting methods and findings (Appendix S1).

The first author is a female faculty member (Ph.D. in Nursing), a lecturer, and a researcher in Nursing management and education. She has many years of experience working in adult and children's hospitals. The second author is a female faculty member (MSc in Psychiatric Nursing, Ph.D. in Nursing), a lecturer, and a researcher in Nursing management and education. She has many years of experience working in the ICUs and mental units. The third author is a male nurse (BScN, MSc in clinical psychology), a researcher in mental health, and still employed at the “Sayyad Medical and Educational center”. The last author (Ph.D. in nursing) is a female nurse. She has many years of experience working in adult and children's hospitals but was at the time of the study employed by the University. The researchers have conducted this study to understand the situation and needs of healthcare providers during the pandemic, to provide a basis for enhancing the physical and mental health of personnel, improving the quality of patient care, and optimal management of health organizations in these conditions.

3.2. Setting

Interviews were conducted in a well‐equipped hospital for admitting patients with COVID‐19, “Sayyad Medical and Educational center”, in the “Golestan” province. This hospital is the largest Medical‐Educational subspecialty center in the province with 400 active beds. It was a referral hospital during the COVID‐19 pandemic.

3.3. Participants

The healthcare providers; as key participants, were recruited face‐to‐face between May 2020 and April 2021. Two researchers referred to different wards of the “Sayyad Medical and Educational center” and invited the healthcare providers to participate in this research. In this call, the title, aim, method of conducting the study and data gathering, and contact with the researchers were described. 14 eligible healthcare providers agreed to participate and signed informed consent. A purposeful sampling method was used to recruit study participants. The inclusion criteria were having experience caring for patients with COVID‐19 for at least three months. Moreover, the researchers considered the maximum variation in age, gender, work experience, education level, and position in selecting participants. One of the healthcare providers later withdrew due to her unwillingness to recount her experiences. Finally, after 13 interviews and a lack of new codes' emergence, data saturation was confirmed based on the opinion of the research team.

3.4. Data collection

The data were collected through semi‐structured individual interviews. Face‐to‐face interviews were performed by the principal investigator. She was trained in qualitative interviewing as a part of her academic education. The interview started with a warm‐up question to establish a relationship and trust. Then, the participants were asked to describe a one‐day experience providing healthcare to a patient with COVID‐19. The researchers asked probing and follow‐up questions based on the participants' answers and descriptions. Each interview lasted between 50 and 80 min, and the time and place of the interview were determined based on the participants' preferences in a private hospital room. All the interviews were audio‐recorded with participants' consent using Digital Voice Recorder and transcribed using Microsoft Word software 2010. Two transcribed interviews were reviewed and checked in a meeting with participants and modified based on their comments. The researcher's observations during the data‐gathering phase were recorded as field notes and used for better interpretation in the data‐analysis phase. Pilot or repeated interviews were not performed.

3.5. Data analysis

The researchers then performed data analysis based on the Elo and Kyngas model, including preparation, organizing, and reporting (Elo & Kyngas, 2008). Therefore, transcribed interviews were read repeatedly several times to gain a general understanding and determine the semantic units by the researchers (R.T. and R.M.). They coded the sentences and paragraphs that reflected the participants' experiences using MAXQDA software V.10. Then, R.T., H.K., and M.M. compiled the codes reflecting a concept by constantly comparing their similarities and differences. Subsequently, they formed the sub‐themes and main themes. Finally, the research team reviewed all the sub‐themes and main themes. After reaching to consensus, the study findings were confirmed by the research team.

3.6. Data trustworthiness

Researchers used Goba and Lincoln's criteria to achieve data trustworthiness (Polit & Beck, 2018). In addition to allocating sufficient time to collect data analysis, the researcher tried to obtain more in‐depth data by creating a friendly atmosphere and prolonged contact with the participants to enhance the credibility of the data. They got the credibility of the data by constantly reviewing them and some of the extracted code. Also, the extracted themes were reviewed by four participants. They stated the themes accurately reflected their experiences.

The findings' dependability was done by transcribing the interviews as soon as possible, peer review, and continuous review of the data. To ensure the study's confirmability, the researchers discussed all stages of the research, interviews, transcriptions, codes, categories, and the degree of agreement of the research team. In addition, the transferability of findings was enhanced by selecting participants with maximum variation and thick descriptions of the research location, interactions, and processes observed during the research. To maintain reflexivity during the stages of data collection, analysis, and reporting, the research team held meetings to learn about their beliefs and experiences and discussed them. They also tried to analyse and interpret the data according to the context and experiences of the participants.

3.7. Ethics considerations

This study was performed in accordance with the Declaration of Helsinki (‘World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects,’ World Medical Association, 2013) and was approved by the Research Committee of “Golestan” University of Medical Sciences on March 10, 2019, with the ethics code. Before starting the interviews, the researcher informed participants about the purpose of the study, the right to voluntarily participate in the study or withdraw, and the confidentiality of the information and then obtained informed consent to record the interviews.

4. FINDINGS

The study participants were 13 healthcare providers aged 26–50 years with work experience of 1.5–22 years; 54% were males, and 61% were single (Table 1). The researchers conducted the interviews from May 2020 to April 2021 (the second to the fourth peak). The content analysis of the interviews resulted in 1973 codes, 33 categories, 16 sub‐themes, and five themes. The themes explaining the experience of healthcare providers in providing services to patients with COVID‐19 encompass “pervasive chaos”, “imposed difficulties”, “paradoxical perceptions”, “committed efforts”, and “constructive transition” (Table 2).

TABLE 1.

The demographic characteristics of the participants.

Number	Age (year)	Sex	Marital status	Education	Position	Work experience (year)
HCP1	39	Male	Married	Bachelor in Nursing	Nurse in COVID ward	13
HCP2	34	Female	Married	Bachelor in Nursing	Emergency nurse	9
HCP3	33	Female	Single	Bachelor in Nursing	Head nurse of COVID ward	13
HCP4	37	Female	Single	Masters in Nursing	ICU nurse	12
HCP5	26	Female	Single	Bachelor in Nursing	ICU nurse	1.5
HCP6	26	Female	Single	Bachelor in Nursing	Emergency nurse	4
HCP7	34	Male	Married	Bachelor in Nursing	Emergency nurse	9
HCP8	50	Male	Married	MD	Emergency physician	22
HCP9	40	Male	Single	MD	Internist	16
HCP10	40	Female	Single	PhD in Health services management	Clinical supervisor	15
HCP11	26	Male	Single	Bachelor in Laboratory Sciences	Laboratory personnel	3
HCP12	29	Male	Single	MD	Emergency physician	3
HCP13	41	Male	Married	Masters in nursing	Clinical supervisor	19

TABLE 2.

Themes, subthemes and categories extracted from the content analysis of the data.

Theme	Sub‐theme	Category
1. Pervasive chaos	Dysfunction in human resources efficiency	Professional performance Physical‐mental capacity
	Organizational dysfunction	Structural level Functional level
	Tense atmosphere	Therapeutic environment Family/social atmosphere
2. Imposed difficulties	Physical‐psychological pressures	Physical symptoms Psychological symptoms
	Role‐related tensions	Ethical dimension Professional dimension
	Changing communication processes	Family relationship Social interactions
	Organizational challenges	Funds Human resources and equipment
3. Paradoxical perceptions	Receiving opposite feeling	Individual‐oriented Social‐oriented
	Facing dual action	Professional responsibility dimension Social feedback
4. Committed efforts	Resilience and adaptation	Mood and calmness maintenance Supporting colleagues
	Providing comprehensive care	Effective communication Performing professional duties Understanding the patient and providing mental–emotional support Satisfying the companions
	Family protection	Prevent disease transmission Psycho‐emotional support
	Eliminating barriers and shortcomings	Crisis management Providing human force and equipment
5. Evolutionary transition	Individual expansion	Gaining experience Development of individual skills
	Professional development	Promotion of professional status Expansion of professional roles and participation
	Organizational adaptation	Patterning and order

4.1. Pervasive chaos

With the sudden onset of the outbreak of COVID‐19 and its rapid spread, healthcare providers experienced widespread confusion and some pervasive chaos. Data analysis revealed that this chaos originated from the disruption in the efficiency of human resources, organizational dysfunction, and a tense atmosphere.

4.1.1. Disruption in the efficiency of human resources

The confrontation of HCPs with a large number of patients and their various symptoms and multiple treatment/care needs, changes in routine care plans, the unknown nature of the COVID‐19 disease, multiple and sometimes conflicting roles, excessive fatigue, increased work volume, shortage of staff, stress and anxiety caused by the disease and transferring it to others gradually reduced their physical and mental capacity and ultimately their efficiency.

… You know, a large amount of care and follow‐up of the patient's condition, which did not exist before, was suddenly added to our work, and the disease suddenly changed the form of work …. We would take a four‐page patient history, systematically recorded it, and followed up accordingly. Furthermore, we went on the patients' visit; the patients deteriorated; we were doing CPR … The patients didn't have a companion, so in addition to medical work with the workload and shortage of staff, we had to help the patient with eating, urination and defecation, and care in case of falls. If I could not, I would feel guilty and consider myself responsible. Doing all these was difficult and overwhelming. (HCP3)

4.1.2. Organizational dysfunction

The extent and speed of the spread of COVID, especially at the beginning, affected the structure and functions of healthcare organizations. Based on the experience of the HCPs, sudden changes in the current processes of admission and management of patients, disturbance in the management of facilities and human resources, shortage of supplies and equipment needed for the treatment of patients, high volume of referrals of critical ill patients, lack of defined protocols for triage and treatment of patients, inconsistency, lack of transparency, and changes in task descriptions led to disorder and the inability of the organization to provide services and respond to patients' needs. Therefore, they experienced the hospital as a battlefield and saw themselves in the position of frontline soldiers who are unable to defend themselves and others against enemy attacks.

We have not seen the war, but based on what we had seen in the movies and what had been explained to us, or the scenes and documentaries we saw, it was exactly like a war. Patients were admitted without the regulations and procedures of the ward, there was no bed and equipment, and there were a lot of critically ill patients. Everything was messed up. (HCP 4)

4.1.3. Tense atmosphere

The conditions of the treatment and care environment, especially the departments such as emergency and ICU, have changed in such a way that they have led to the experience of a tense and uneasy atmosphere for nurses and doctors. Continuous alarms of monitors and ventilators; patients' restlessness and extreme anxiety, the high number of clients and their companions, lack of equipment and facilities, the anger and irritability of the staff due to their inability to patient management were the most important factors that caused this experience for the HCPs.

Lack of human force, the large number of patients, and work pressure on the staff had made the atmosphere tense. This psychological atmosphere affected the physicians and the residents, too. I mean, they were all defying in some way. Therefore, we were more afraid of what annoying actions and reactions from the colleagues we would experience in the hospital than getting sick; it was annoying. (HCP10)

In addition to the tensions in the clinical environment, the presence of a high level of fear and anxiety among the family members and the community level, contradictory news in the media, and the publication of rumours and warnings by international health organizations deepened the understanding of this tense atmosphere for HCPs because they faced these conditions not only in the work environment but also in the family environment, media, and society.

The information about the disease and what was happening was widespread, the news, the television… Every day we heard something happened to a nurse or a doctor; it made me more nervous; however, I tried not to think about it and move forward with hope …. (HCP2)

4.2. Imposed difficulties

The theme of the imposed difficulties is formed based on 4 sub‐themes of physical‐psychological pressures, role‐related tensions, changing communication processes, and organizational challenges. This theme represents a wide range of tension and pressure in different dimensions that HCPs faced while caring for these patients.

4.2.1. Physical‐psychological pressures

According to the participant's statements, they suffered various physical and psychological‐emotional symptoms due to exposure to a critical and unprecedented situation. Physical symptoms included muscle pains, excessive sweating, headache, heatstroke, weakness and lethargy, confusion, and impaired ability to meet the necessary needs such as nutrition and excretion caused by working with special protective clothing. The exposure of HCPs to an unknown disease and fear of contracting it, high mortality of patients, high workload, and self‐isolation lead to psychological/emotional symptoms such as stress, anxiety, insomnia, irritability, sensitivity, anger, obsession, aggression, feelings of loneliness, feelings of emptiness, and lack of motivation in them.

We sweat a lot wearing these clothes. When I come home, I have muscle pains, headaches, weakness, and symptoms of electrolyte disturbance, and I am confused until night. Then, I start thinking about the previous shift, what it was like, and how the next shift will be. These make you sensitive; you lack the previous capacity and get nervous sooner at home. (HCP1)

4.2.2. Role‐related tensions

In this sub‐theme, it was found that HCPs, due to their sensitive and decisive role in providing services to patients, close contact with them, and making decisions about their care and treatment, experienced tensions in their professional and moral dimension. Among the issues that they have faced in the professional dimension; can mention the family's opposition to continuing to work in the health system, the worry caused by the transmission of the disease to the family members, the death of colleagues, repeated infections with COVID, observing the struggle and suffering of patients, sudden death of patients and inform their family.

In that situation, we were very concerned about the condition of the patients and their follow‐up. On the other hand, we were worried about transmitting the disease to our family members. We experienced a lot of stress. (HCP 3)

The patients were suffering and struggling and we could not do anything. They had a sudden cardiac arrest and died. We were reporting so many deaths; I have given a lot of bad news to the companions. It was too much for our capacity. (HCP5)

Furthermore, they were morally exposed to tensions such as feeling guilty due to ineffective treatment and care interventions, the transmission of the disease to family members, ethical dilemmas in deciding about the patient's clinical condition, or the fair distribution of facilities and equipment.

It is an unpleasant feeling. You know the patient is not well, but you have to prioritize; I mean, I have to decide which patient should go to the ICU. It is hard. It is very hard. The COVID‐19 ICU is full right now, and I have at least two patients who need to be there. I do not know which one should be taken to the ICU. This situation puts a lot of stress on you. (HCP 9)

4.2.3. Changing communication processes

The other phenomenon that healthcare workers experienced was a change in the communication processes at the family level and social interactions. According to the participant's statements, close contact with patients, the feeling of being a carrier, and the fear of transmitting COVID to family members led to a deliberate reduction of emotional and physical relationships with family members, and voluntary avoidance of friends and acquaintances by HCPs. On the other hand, at the community level, their communication was challenged due to the role of being the HCP and the resulting stigma. These changes aggravated the feeling of loneliness and social isolation among HCPs.

Stigmatization is very annoying. My own experience was that when I wanted to take the elevator, I was told if I could use the stairs. They thought we would make them sick. My friends had similar experiences, too. (HCP 1)

4.2.4. Organizational challenges

The sudden and progressive outbreak of COVID‐19 posed several organizational challenges to the healthcare system, including the supply and distribution of human resources (especially physicians and nurses) and medical equipment and facilities (the number of beds, medication, oxygen, and personal protective equipment). Also, the lack of planned and need‐based distribution hindered HCPs' timely access to resources.

… It was a difficult situation. We did not have any empty beds left. Patients had trouble getting oxygen; sometimes, we connected one oxygen capsule to two people. We lacked equipment and adequate protective clothing for our job. It affected our work and our spirit. (HCP 7)

On the other hand, the financial tensions imposed on the health system at the macro level led to making decisions on the payment system. The disproportionate situation between the healthcare team payment and the provided services led to a sense of discrimination, lack of value, and reduced motivation among the staff, especially the physicians and nurses.

What we were doing was not because of making money, but for spiritual reasons; not just because of the Hippocratic Oath, but due to the conscience, commitment, and responsibility to the people. But this kind of payment is discouraging and so little compared to what we were doing; it discouraged us and reduced our motivation. (HCP 9)

4.3. Paradoxical perceptions

Another theme was paradoxical perceptions, including two sub‐themes of receiving opposite feelings and facing dual action.

4.3.1. Receiving the opposite feeling

This sub‐theme refers to the formation of opposite feelings, some of which were caused by the nature of the COVID disease and its impact on the interventions of HCPs, and others were caused by society's reactions to their presence and efforts to fulfil their professional roles.

Facing the high mortality of patients of all ages and the lack of an effective treatment method, especially at the beginning of the outbreak, led to a sense of hopelessness and despair, sadness, and grief among HCPs. Knowing more aspects of this emerging disease and providing effective drugs and treatment protocols; brought them a sense of hope, joy, and happiness due to the recovery of terminally ill patients.

At first, it was horrible. The patient who came on his own was severely affected by shortness of breath within a few hours and needed an ICU hospitalization. You couldn't do anything; whatever you did was not effective. We knew what would happen to the patient. We were disappointed. However, this is not the case now; with the treatment protocols, the staff manages the patient, and most of them get better. (HCP 2)

From the social aspect, public fear caused by COVID‐19 led to the formation of an atmosphere in the media and society that praised and encouraged HCPs and introduced them as heroes, and symbols of sacrifice. This social support to some extent caused encouragement, a sense of value, and reduced stress of HCPs to provide services to patients with COVID. But following the occurrence of subsequent peaks and the continued death of patients; society also lost its motivation to provide psychological support to HCPs. Therefore, providing optimal services by them in this situation was considered more as a duty and their fatigue and problems were not taken into consideration. The result of these reactions was the feeling of being ignored and left alone.

There was no manager. Six or seven nurses and I had to handle the shift. If there was a shortage, it was my problem. If there was no oxygen or a ventilator, it was my problem. I had to handle them all alone … (HCP 7)

4.3.2. Facing dual action

The experience of the participants showed that they faced dual actions from colleagues and society. In such a way that at the height of the disease outbreak, some employees performed their professional roles with generosity and sacrificed even during their illness or despite heavy work shifts to provide human resources for medical centers. They worked long hours besides their work shift or volunteered to care for patients. But at the same time, some others caused more pressure on other staff due to the fear of getting sick by taking actions such as non‐responsiveness, frequent absences, unjustified sick days, and turnover. Facing this contradiction in playing a professional role brought about the experience of empathy, self‐sacrifice, commitment, and professionalism, on the one hand, and lack of motivation, extreme physical and mental fatigue, feelings of discrimination and injustice, and reduced cooperation with colleagues, on the other hand.

I was at the hospital in the morning; I went to my private practice in the afternoon until 9 pm. When I arrived home, I had a rest for one hour, and then I would answer people's questions on the phone until 2 a.m. I would see test results and CT scans and advise people. But some colleagues did not answer their phones and closed their private practices for a long time, especially in the early days. (HCP 9)

With the repetition of COVID peaks and their prolongation, the role of different sections of society to cooperate with HCPs has changed. Therefore, the staff witnessed the non‐cooperation of people in compliance with health protocols, the reduction of the participation of donors and non‐governmental organizations in providing resources, and the occurrence of disrespectful and violent behaviours among patients' companions. These factors played an important role in aggravating the fatigue and burnout of the personnel.

I was trying to control myself; it was hard, especially when many companions insulted and disrespected …. We were exposed to these behaviors whenever there was a shortage of bed and equipment, while we were not to blame at all; enduring these conditions put a lot of pressure on us. (HCP10)

4.4. Committed efforts

This theme consisted of 4 sub‐theme: resilience and adaptation, eliminating barriers and shortcomings, providing comprehensive care, and family protection, indicating the continuous and extensive efforts of HCPs to play their individual, social, and professional roles despite being in critical situations.

4.4.1. Resilience and adaptation

Being in a stressful and erosive situation of providing services to COVID patients made it necessary for HCPs to acquire adaptability and strengthen resilience not only in the individual dimension but also in the group dimension. Therefore, in the individual dimension, they used their ability and capacity to control fear, and stress management, maintain calmness, and distract thoughts towards workplace events. In the interpersonal dimension, they also tried to play an effective role in the adaptation and relaxation of their colleagues by strengthening the morale of their colleagues, helping them to perform assigned tasks, providing reassurance, empathy, and cooperation, and reducing environmental tensions and stress.

I tried hard not to show my fear to my colleagues… I relied on God and prayed. I was a supervisor and had to manage the situation. My colleagues relied on me, so I had to stay strong. I reassured them and stayed by them. I did my best to eliminate the shortcomings and consider the complaints of the companions. Sometimes I helped them with their clinical work, too. (HCP13)

4.4.2. Eliminating barriers and shortcomings

The HCPs with any position and managerial level attempted to eradicate the barriers and compensate for the shortcomings caused by the critical condition. They managed and controlled the situation, helped address the staff/colleagues' concerns, established a calm atmosphere in the workplace, provided workforce and protective equipment, performed frequent triage and managed beds, and facilitated patients' admission and treatment processes (i.e., home visits).

I tried to be present in the wards all the time, especially in the emergency room, which was very crowded …; I thanked my colleagues and apologized for the shortcomings to encourage them a bit. I tried to calm them down by talking to them and following up on the problems by corresponding with the senior officials. (HCP 5)

4.4.3. Providing comprehensive care

The goal of the mentioned efforts was to provide comprehensive health services to patients and their families. The staff knew that the quality and comprehensiveness of services were affected by the unpredicted circumstances and sometimes were uncontrollable. Taking actions such as trying to understand the patients' conditions, reassuring and emotionally supporting them, communicating effectively, and listening actively, they attempted to satisfy the companions and provide care based on the patient's requests. Besides, they tried to pay attention to the spiritual and psycho‐emotional needs of the patients and families as much as possible.

Patients needed a lot of support because they feared … We tried to talk to them more and empathize with them. Even if we did not have time, we tried to patiently answer the patients' and their companions' questions. We noticed that they needed to find information to reduce their fear; we even did it on the phone. (HCP 2)

4.4.4. Family protection

The participants declared that hardworking and committed staff were more prone to excessive stress and fatigue. Part of the experience was related to the ongoing effort to protect the family and beloved ones. They said that long and tedious shifts, close and lengthy treatment of patients, frequent COVID‐19 infection, and the possibility of transmitting the disease to family and relatives always meant that they had to devote part of their energy and capacity to protect them. To reassure and reduce the anxiety of family members, they self‐quarantined, stayed at work instead of being with family, changed residence, refused to talk about the work environment, pretended that working condition was alright, frequently self‐screened, and concealed their disease.

My parents, especially my mother, were under a lot of pressure. I did not tell them about the hospital events. Instead, I would say that everything we need exists at the hospital: we have clothes and gloves. I did not say anything about the people dying out of COVID‐19. I tried to stay calm, although I was tense. My mother was comforted when she saw my calmness. (HCP 10)

4.5. Evolutionary transition

This theme is formed based on 3 sub‐theme of individual expansion, professional development, and organizational adaptation, and shows that the COVID‐19 pandemic, despite creating physical, psychological‐emotional, and social tensions in the HCPs; has also brought them the experience of type of gradual and constructive evolution.

4.5.1. Individual expansion

Over time, the health workers experienced a type of personal growth as a result of gaining more clinical experience in managing patients and increasing their knowledge about COVID. For example, doubtful, stressful, despairing, and inefficient caring at the onset of the pandemic gradually gave way to safer and more consistent care with a sense of control over the situation and empowerment. Also, providing services in these critical conditions improved skills such as crisis management, problem‐solving and clinical decision‐making skills, creativity, stress management, collaboration, empathy, and mutual understanding among HCPs.

Now the situation has changed, and if a patient comes, I can better manage him. I notice and follow the protocols. The passage of time has reduced my fear, so I have a better reaction to the patient and behave better …. I have gained experience and can manage patients. If the same situation occurs, I can work better. (HCP 1)

4.5.2. Professional development

Providing services to COVID patients in an unstable, stressful and erosive situation led to the strengthening of cooperation, improvement of inter‐professional relations and teamwork, improvement of interpersonal relations, and more effective management of patients. Based on the experience of the HCPs, these factors were introduced as an effective solution to overcome the critical situation and deficiencies. Also, the extensive need of patients and families to receive services at three levels of prevention made nurses move away from their stereotypical and repetitive duties and be able to play other roles such as counsellor, supporter, educator, and coordinator.

…. Our team relationship with the physicians had improved. We talked a lot with the doctors about the treatment process, the disease process, and the new patients. We gave them feedback on the effectiveness of the drugs so that they could make decisions. Patients called from home informed us about their symptoms and asked for help. We gave them the necessary advice. We also instructed those discharged from the hospital on how to take drugs. The patients needed help, support, and hope; we would help them as much as possible. (HCP 2)

More than any other era, the COVID pandemic demonstrated the importance, effectiveness, and commitment of HCPs, especially doctors and nurses, to the public. In such a way the improvement of the image and social position was sought, especially for nurses. This has changed the beliefs and attitudes of nurses towards the dignity and position of this profession as influential members of the healthcare team; it has become an incentive for them to play a more responsible and professional role.

Well, I was not interested in nursing that much, but I became interested in it during the COVID‐19 pandemic because I noticed that I could do something for the patients, save them, or even be comforting to the patient in that situation. I realized that a nurse is valuable, and so is nursing …. (HCP 6)

4.5.3. Organizational adaptation

According to the experience participants, the organization at the beginning of the crisis faced a kind of confusion and disorder due to the lack of specific and defined procedures for the diagnosis, admission, and treatment of patients, the lack of human resources and equipment, and the disruption in their distribution and was not able to provide the desired services; over time, it became consistent and orderly. Because the experience of numerous and long peaks caused managers to be able to maintain the efficiency and effectiveness of the organization through increasing coordination and inter‐departmental cooperation, improving the diagnostic‐therapeutic processes by developing protocols, providing human resources, therapeutic‐care, and protective equipment, and distributing them. This reduced the stress and work pressure of the HCPs to some extent.

The treatment protocols were gradually communicated to us; Processes were defined for the management of patients from admission to discharge. We performed the treatments according to the protocol. This improved the situation in the wards better to some extent, the work progressed, and cooperation took place. (HPC 3)

5. DISCUSSION

The present study explored the experiences of HCPs in providing services to patients with COVID in “Golestan, Northeast Iran”. In general, the experience of the study participants indicated entering into initial chaos, facing pressures in physical, psycho‐emotional, social, and economic dimensions, trying to overcome them, and finally achieving some kind of evolution and control.

The pervasive chaos theme reveals that the sudden, progressive, and widespread occurrence of COVID‐19 created a sense of immersion in a multifaceted and unexpected confusion among HCPs, which was a source of great stress for them. This condition was created due to facing a considerable number of critically ill patients, high mortality, lack of human sources and equipment, increased workload, loss of control, rapid changes in routine diagnosis and treatment processes, contradictory information, ambiguity in the role, the emergence of new roles, uncertainty and lack of treatment protocols, and fear. Other researchers have reported similar experiences with healthcare staff in their studies (Eftekhar Ardebili et al., 2021; Lee et al., 2021; McGlinchey et al., 2021; Monjazebi et al., 2021; Pazokian et al., 2021). Villar et al. found that adapting the nurses of the COVID facilities to new policies and pathways, sudden changes in roles and responsibilities, and insufficient recognition of the virus was a challenge and brought a lot of stress to them (Villar et al., 2021). Park et al. also identified reading and hearing about the severity or high contagiousness of COVID‐19 as the most common cause of stress (Park et al., 2020). The lack of proper channels or accurate dissemination of facts causes health workers to be exposed to misleading information and experience higher levels of stress, conflict, and confusion (Park et al., 2020; Rücker et al., 2021).

In confirmation of the results of the present study, other studies also reported the lack of organizational preparedness (Chemali et al., 2022; Rücker et al., 2021) and poor organization of care by the majority of HCPs (Chemali et al., 2022). The changes that occurred in organization of care, especially at the beginning of the pandemic, were chaotic (Chemali et al., 2022; Rücker et al., 2021) and the changes in roles and responsibilities and their allocation were perceived as unfair and unsatisfactory (Chemali et al., 2022). Only in one study, changes were perceived positively in work organization and nurses expressed satisfaction with an improved nurse–patient ratio resulting from organizational changes (Fernandez‐Castillo et al., 2021). The physical presence of first‐line managers has been emphasized by HCWs due to their ability to create order in chaotic conditions, provide information, pay attention to concerns and problems, and generally provide supportive leadership in critical situations (Rücker et al., 2021). Not being prepared to deal with critical situations and not having enough time to deal with the rapid increase in the number of patients has had many physical and psychological consequences for healthcare staff (Koontalay et al., 2021). Therefore, it seems that the creation of up‐to‐date educational and information platforms, timely development of treatment protocols, stress management training, coherent planning to manage critical situations, and the physical presence of first‐line managers should be on the managers' agenda.

The theme of imposed difficulties revealed that the use of protective equipment while providing services to COVID‐19 patients is an important challenge for HCPs and causes many physical symptoms such as headache, dehydration, excessive sweating, muscle pains, weakness and lethargy, and difficulty meeting the essential needs in them. In line with these findings, other studies have shown that healthcare staff has experienced fatigue, skin damage, muscle pain, dehydration, nasal and facial ulcers, shortness of breath, and respiratory problems (Khatatbeh et al., 2021; Lee et al., 2021; Saffari et al., 2020). Xiao et al. found that the use of personal protective equipment such as masks and gowns is an important stressor for frontline medical workers (Xiao et al., 2020). Using it for long hours is uncomfortable (Villar et al., 2021) and leads to an increase in the workload of nurses, especially in departments such as the ICU (Giuliani et al., 2018). Therefore, it is necessary to design clothes of more appropriate quality, make arrangements for rest, eat food in a safe environment, and adjust working hours to maintain the health and efficiency of staff.

In addition to the physical symptoms, the study participants reported the occurrence of psychological symptoms such as fear, stress, anxiety, worry, insomnia, irritability, sensitivity, anger, obsession, aggression, and loneliness during the process of providing services to COVID‐19 patients. In other recent studies, problems such as fear of being infected by COVID‐19, and fear of transmitting the disease to their family (Eftekhar Ardebili et al., 2021; Khatatbeh et al., 2021; Lee et al., 2021; McGlinchey et al., 2021; Monjazebi et al., 2021; Rezapour et al., 2021), anger, sleep disorders and insomnia, anxiety, loneliness, and irritability (Liu et al., 2020) were found among the healthcare staff. Nevertheless, in the study of Nashwan et al., the quality of life of nurses working in COVID‐19 facilities was evaluated favourably, and their stress, anxiety, depression, sleep quality, and eating habits were not significantly different from nurses in non‐ COVID‐19 facilities. Because the managers provided sufficient support to them and provided personal protective equipment and in this way provided their mental and physical health in the face of critical conditions (Nashwan, Villar, Al‐Qudimat, et al., 2021). Based on this evidence, the necessity of comprehensive support, provision of appropriate equipment, and interventions to reduce the stress of employees in times of crisis is determined.

The staff reported significant levels of moral distress and burnout because of caring for critically ill patients and their high mortality and feeling of guilt due to ineffective treatment, along with deciding how to distribute the resources or provide health services to patients. In confirmation of these findings, Rucker et al.'s study also showed that the lack of knowledge about the treatment and how the disease progresses, especially at the beginning of the pandemic, caused moral stress among HCPs (Rücker et al., 2021). Other studies have reported factors such as making difficult life‐related decisions alone, judgement beyond their expertise, uncertainties about the accuracy of choices, being in moral dilemmas, inequality, and decision‐making on how to distribute resources such as beds and drugs as the biggest stressors (Billings et al., 2021; Lee et al., 2021).

Isolation oneself and living away from family due to fear of transmitting the disease to the family and exposure to being stigmatized in social interactions were other experiences that staff had during the COVID‐19 pandemic. Many studies have shown that healthcare providers, especially in the early COVID‐19 pandemic, experienced many changes in their family and social processes; they were forced to stay in a hospital or hotel to protect their families. They also perceived rejection, discrimination, and others' avoidance in their social interactions (Billings et al., 2021; Eftekhar Ardebili et al., 2021; Fawaz & Samaha, 2020; Khatatbeh et al., 2021; Lee et al., 2021). Rurker et al. found that HCPs feel stigmatized due to working with COVID‐19 patients, and its result is social isolation, which has consequences for their psychological well‐being (Rücker et al., 2021). In a study conducted by Nashwan et al., which examined the prevalence of stigmatization during the COVID‐19 pandemic among HCPs in seven different countries, it was found that HCPs perceive high levels of stigmatization towards themselves (Nashwan et al., 2022). These findings, in addition to specifying the extent and importance of this phenomenon, specify the necessity of developing educational programs based on valid content and public awareness to manage it during pandemics because this can have a significant effect on maintaining the mental well‐being of HCPs (Nashwan et al., 2022; Singh & Subedi, 2020).

Lack of human resources, lack of personal protective equipment and disruption in their distribution, inadequate resources, and therapeutic space were also organizational challenges faced by HCPs. Many other studies have reported these challenges in medical centers that provided services to COVID‐19 patients (Billings et al., 2021; Eftekhar Ardebili et al., 2021; McGlinchey et al., 2021; Pazokian et al., 2021). These challenges are a source of imposing stress and anxiety, increased workload, and threat to staff health, which can lead to burnout, job dissatisfaction, turnover, and reduced quality of care. Meanwhile, studies show that providing organizational support and allocating human resources and equipment can reduce HCPs anxiety and stress (Alnazly et al., 2021; Labrague & De Los Santos, 2020).

Decreased motivation and a sense of discrimination were other experiences reported by the participants due to unfair and disproportionate financial payments compared to the provided services. Lee et al. (2021) concluded that healthcare providers approved they often experienced unfair behaviours or received insufficient emotional and financial support despite their sacrifices and efforts as frontline staff (Lee et al., 2021). Lack of rewards can increase the risk of psychological factors in the workplace (Siegrist, 2008) while appreciating and rewarding the efforts of healthcare providers reduce their fatigue (McClelland et al., 2018) and motivate them to provide better quality care to patients (McAlearney et al., 2015).

According to the theme of the paradoxical perception, the participants declared that they frequently experienced emotions of frustration and grief due to patients' lack of recovery, ineffective treatment interventions, and patient death, especially in the early COVID‐19 peaks. Then, the recognition of more aspects of COVID and the formulation of more effective treatment protocols and patient recovery brought a sense of hope, happiness, satisfaction, and usefulness among the HCPs. In line with these results, in the study by Villar et al., nurses also reported discomfort, sadness, and a feeling of helplessness from observing the suffering of patients and their death, in contrast to the feeling of pleasure and purposefulness of care due to their recovery (Villar et al., 2021).

Other studies have also reported the presence of positive and negative emotions and their fluctuations in HCPs (Monjazebi et al., 2021; Munawar & Choudhry, 2021; Sun et al., 2020).

The participants expressed that the occurrence of subsequent peaks and the continued death of patients caused them to receive contradictory feedback from society and the media. Such way that at the beginning of the pandemic, they were considered heroes and symbols of sacrifice, and after a while, they were neglected and felt lonely and helpless. This feedback caused psychological tensions in them. In this regard, the results of the study of McGillis et al. showed that the media compared nurses to Florence Nightingale in the early stages of the Ebola outbreak and focused on the image of nurses as heroes who take care of Ebola patients. But following the spread of Ebola outside the African continent, and the failure of medical and nursing practices to control it, media narratives began to cast a guilty image of nursing and describe the role of nurses, their knowledge, and expertise in solving public health crises was neglected (McGillis Hall & Kashin, 2016). Recognizing the difficult and incredibly valuable work of HCPs during the pandemic is an important part of the community's response. However, efforts should be made to do this without citing the language of heroism that emphasizes the ideas of self‐sacrifice (Cox, 2020), to create fewer psychological consequences for HCPs. Therefore, making the community aware of the professional duties of HCPs, especially doctors and nurses in critical situations, not comparing a pandemic to war and describing the HCPs as heroes, directing the media to raise people's awareness of the disease and attract their participation in its control is very important.

The other experience of participants showed that they faced the turnover and absence of some of their colleagues due to the fear of getting the disease, especially during the peak of the Corona epidemic and the need for more manpower. Despite this fear, many of them were still trying to provide services to patients by increasing the volume and shifts of their work. In confirmation of these results, the study of Ariapooran et al., in “Iran” also showed an increase in the intention to turnover nurses compared to the pre‐COVID era (Ariapooran et al., 2021). Previous pandemics (eg, H1N1) have also reported higher absenteeism rates among nurses during outbreaks than under normal conditions (Considine et al., 2011; Ip et al., 2015).

Labrague and De Los Santos found that the fear of being infected with the coronavirus is an effective factor in nurses' intention to leave the profession and the organization (Labrague & De Los Santos, 2020). Another study also introduced job stress and resilience as predictive components of nurses' willingness to turn over during the COVID‐19 pandemic (Haji et al., 2021). In a study conducted by Nashwan in Qatar, it was found that staff has a high tendency to turnover due to the psychological response to the fear of COVID‐19 and this tendency is higher in nurses over 30 years old, working in the ICUs, work experience more than 5–10 years and attendance more than 3 months in COVID‐19 wards (Nashwan, Abujaber, Villar, et al., 2021). This is despite the evidence showing that having more knowledge and facing less risk in the work environment improves nurses' willingness to care for COVID‐19 patients (Nashwan, Abujaber, Mohamed, et al., 2021). This finding clarifies the importance of developing programs to reduce the job stress of employees, their access to reliable and up‐to‐date knowledge, and the promotion of safety in their work environment, especially during pandemics.

The theme of committed efforts also showed that during the COVID‐19 pandemic, in addition to providing services to patients, HCPs were forced to use part of their capacity and ability to increase resilience and psychological adaptation, protect the family, and take more comprehensive care of patients, and eliminate the deficiencies.

Therefore, they used measures such as listening to music, praying, and reading books for their resilience and adaptability. Several studies have also shown that nurses have used coping strategies such as music, telephone communication, watching movies, and praying to maintain their morale and self‐confidence during the pandemic (Monjazebi et al., 2021).

Because HCPs felt that were the agent of disease transmission and stress to their families, they took on the responsibility of protecting them. Therefore, they tried to prevent the transmission of the disease to their family members by isolating themselves, performing multiple screenings, and strictly following disease prevention protocols. In line with these results, the lived experience of nurses in Qatar also showed that due to the feeling of insecurity and the fear of transmitting the disease to their relatives, they take extra measures such as using extra accessories on protective equipment, taking frequent showers, cleaning equipment, using masks at home and self‐ isolation to protect the family (Villar et al., 2021).

HCPs in conditions of uncertainty in the diagnosis, treatment, and prognosis of COVID‐19; they were involved in complex and multifaceted care of COVID patients. Their experience showed that COVID patients in addition to physical care, need much psychological and emotional support due to loneliness, fear, despair, and inability to meet their essential needs. Therefore, the care was mainly based on the patient' preferences and paying attention to the spiritual and psycho‐emotional needs. These conditions led to an increase in the workload of HCPs, especially nurses. In line with these results, in the study by Rücker et al., determined that the workload of nurses increased during the COVID pandemic, and this caused symptoms of stress and burnout in them.

Prohibiting the presence of relatives and companions for these patients is mentioned as an important and time‐consuming part of the care process for the nursing staff. However, the experience of the HCPs showed that the patient‐centered aspect of care during the COVID pandemic has become more prominent and has brought a sense of meaningfulness and pride to them (Rücker et al., 2021).

Facing all kinds of shortages, especially personal protective equipment, at the beginning of the pandemic caused them to take action to provide the equipment themselves. HCPs in other study also expressed such an experience and introduced it as barrier to patient care (Rücker et al., 2021). Meanwhile, studies have shown that providing adequate personal protective equipment for personnel and meeting their needs has an effective role in reducing stress and increasing their resilience (Billings et al., 2021; Khatatbeh et al., 2021). Therefore, the attention of managers of healthcare organizations to these dimensions and creating the necessary platform to provide them can largely preserve the capacity and ability of HCPs to provide optimal care to patients.

The constructive transition theme in the present study showed that the HCPs experienced fear, uncertainty, helplessness, and desperation in their care of patients at the beginning of the COVID outbreak.

With the passage of time and in pursuit of gaining knowledge about the various dimensions of the disease, access to high‐quality protective equipment, successful clinical experience in the management of COVID patients, and access to standard and effective protocols, the care process was accompanied by feelings such as competence, efficiency, value and safety in HCPs. In confirmation of these results, Rücker et al. also found that health workers caring for COVID patients experienced both feelings of helpless, as well as meaningfulness, and pride They reported feeling helpless due to not being able to provide adequate assistance and comfort to patients and a sense of meaningfulness due to focusing on patient‐centered care (Rücker et al., 2021). The findings of a scoping review also revealed that the COVID pandemic has had a positive and negative impact on the personal and professional identity of HCPs. In such a way that negative emotions were more dominant at the beginning of the epidemic, and then positive emotions such as increased motivation, purposefulness, pride, resilience, and a problem‐solving attitude were gradually formed (Chemali et al., 2022). Many studies have shown that passing through the conditions of the diseases such as SARS and COVID‐19 and their challenges has been associated with personal and professional development such as gaining experience and skills (Eftekhar Ardebili et al., 2021), new knowledge and the ability to work in similar conditions, personal growth, increasing resilience (Chiang et al., 2007), the feeling of trust, professional competence (Sun et al., 2020), effective communication and adaptation, teamwork, and being supportive (Khatatbeh et al., 2021; Rücker et al., 2021; Villar et al., 2021) and improving the professional status and public image, especially in nursing (Fontanini et al., 2021; Zhang et al., 2021). Improving interpersonal relationships, cooperation, and empathy among the HCPs are the most important sources of support, learning, and resilience (Billings et al., 2021). The COVID‐19 pandemic required quick and effective responses that were only possible through inter‐professional collaboration. A review of the scientific documents related to inter‐professional collaboration during the first year of the COVID‐19 pandemic confirms the importance of this approach in providing more comprehensive and secure services (Fernandes et al., 2021).

Based on the results of this study, designing psychological support programs and the presence of mental health team in the hospital, modifying work shifts, providing quality and appropriate personal protective equipment, planning standard and defined treatment/care programs for patients, providing the possibility of delegating part of patient care (providing essential needs and emotional‐psychological support) to the patient's family members, optimal management of human resources and equipment, and appropriate rewards and incentives can prevent the loss of their mental and physical energy for the mentioned activities and provide them a safe and peaceful environment so that they can perform their professional roles.

5.1. Limitations and strengths

This qualitative study was conducted to explain the experiences of healthcare providers during the COVID 19 pandemic based on the cultural context and structure of the “Iran” health system. Therefore, the results cannot be generalized to healthcare providers in other countries. These results, along with other similar studies, can provide a more comprehensive view of critical situations such as COVID‐19 and be the basis for effective interventions and correct decision‐making to maintain the physical and mental health of healthcare providers. This study's strengths is that it has been carried out during three consecutive and long COVID‐19 pandemics, with the participation of healthcare providers at different levels and positions. This feature has led to more comprehensive and deep perception and exploring, changes in the long time.

6. CONCLUSION

The experience of HCPs during the COVID pandemic in “Iran” showed that despite the physical, mental, emotional, and social consequences, a kind of constructive evolution and transition has also taken place in personal, professional, and organizational dimensions. This caused the HCPs and the organization to test themselves in the real field and acquire skills and capabilities that are valuable and a source of survival. HCPs unexpectedly entered a complex, lengthy, and corrosive process. Similar to SARS and MERS, COVID‐19 mitigated the physical and mental health of healthcare staff; however, the difference is that in the latter, these problems are much more profound due to the prolongation of the pandemic and the constant change in the disease following new mutations. Therefore, it is suggested that managers, while strengthening and protecting the capabilities and skills that have emerged, to reduce the tensions of HCPs, have developed programs for the proper management of human resources, providing protective equipment and treatment facilities, psychological support and encouragement, enhancing inter‐professional interactions and teamwork, providing up‐to‐date training and standard treatment protocols in critical situations.

7. RELEVANCE TO CLINICAL PRACTICE

During the COVID‐19 pandemic, expanding inter‐professional collaboration, empathy, commitment, self‐sacrifice, and improving individual competencies such as creativity, increasing up‐to‐date knowledge, and stress management helped healthcare providers to play their professional role and overcome the pressures of multiple peaks. Therefore, improving and strengthening inter‐professional cooperation, teamwork, professional commitment, continuous learning in healthcare providers along with their psychological, social and economic support can play an effective role in reducing the consequences of widespread and long pandemics such as COVID‐19.

AUTHOR CONTRIBUTIONS

Homeira Khoddam have made contributions to study design, analysis, interpreting of data, drafting and revising the manuscript. Mahnaz Modanloo have made contributions to study design, analysis, interpreting of data, drafting and revising the manuscript. Reza Mohammadi have made contributions to acquisition, analysis and interpreting of data, drafting and revising the manuscript. Razieh Talebi have made contributions to study design, acquisition of data, analysis and interpreting of data, drafting and revising the manuscript. All authors read and approved the final manuscript.

8. FUNDING INFORMATION

This work was supported by the Golestan University of Medical Sciences, School of Nursing and Midwifery.

CONFLICT OF INTEREST STATEMENT

The authors of this article declare that they have no conflict of interest.

RESEARCH ETHICS COMMITTEE APPROVAL

This study is a research project approved by the Research Committee of Golestan University of Medical Sciences on March 10, 2019, with the ethics code IR.GUMS.REC.1398.387.

Supporting information

Appendix S1

Khoddam, H. , Modanloo, M. , Mohammadi, R. , & Talebi, R. (2024). From pervasive chaos to evolutionary transition: The experience of healthcare providers during the COVID‐19 pandemic. Nursing Open, 11, e2035. 10.1002/nop2.2035

DATA AVAILABILITY STATEMENT

Data consist of the transcribes of interviews with participants who were conducted in Persian. Some of the items are translated and mentioned in the text of the article as quotations. The findings of this study are available on request from the corresponding author.