Nurses' recovery experiences during the COVID‐19 pandemic in Isfahan, Iran: A qualitative study

Abstract

Aim

The aim of this study is to explore and describe the recovery experiences of nurses working in COVID‐19 wards.

Background

The global outbreak of coronavirus in 2020 has extracted job stress for nurses. Job stress has impacts on physical and mental health and performance, so recovery is essential to restore the lost energy resources.

Method

Semi‐structured interviews were conducted with 12 nurses in Isfahan city of Iran.

Results

The research results were extracted as 5 main themes, 14 subthemes and 54 items. The main themes are detachment from work, relaxation, non‐work activities, affiliation and meaning. The combination of these themes led to the clear statement that using recovery experiences is a major step toward relieving the nurses' COVID‐19‐related stress and their physical and mental resuscitation.

Conclusion

The use of recovery experiences, including detachment from work, relaxation, non‐work activities, affiliation and meaning by nurses, helps them cope with job stressors and regain their resources.

Implications for Nursing Management

It is the responsibility of health system policy makers, hospital managers and nurse managers to design and implement training programmes for nurses to use recovery experiences as stress management techniques in their profession.

1. INTRODUCTION

Coronavirus disease 2019 (COVID‐19) was first reported in December 2019 in Wuhan, China (Munster et al., 2020). With the quick spread of COVID‐19 worldwide, it was stated a pandemic by the World Health Organization (World Health Organization, 2022). Despite creating depression, anxiety and stress by the COVID‐19 pandemic for almost everyone (Gloster et al., 2020), it has been more challenging for health care personnel (Lasalvia et al., 2021). Nursing is a stressful profession, and those working in this job generally experience high levels of work stress that was intensified by the impact of the COVID‐19 pandemic, which had a negative effect on nurses (Shah et al., 2021). Long working hours, excessive work stress, fear of infecting loved ones (Costantini et al., 2020), a high risk of infection, being away from family members, insufficient personal protective equipment, limited contact with family and friends (Jackson et al., 2020; Qi et al., 2020), the difficulty of working with personal protective equipment (Fernandez et al., 2020), feeling incapable of helping patients, difficulty in making a balance between family life and work life (Greenberg et al., 2020) and coping with the death of patients have put much stress on nurses. As a result of these factors, general physical health concerns have been created, leading to some psychological problems, such as fear, anxiety, depression (Cabarkapa et al., 2020; Cortés‐Álvarez & Vuelvas‐Olmos, 2020), avoidant behaviours, labelling, post‐traumatic stress disorder and sleep disturbance (Liu, Luo, et al., 2020; Zhang et al., 2020), burnout, frustration and boredom. These cause hopelessness and helplessness, lower work speed and reduced productivity (Frawley et al., 2021; Liu, Yang, et al., 2020).

1.1. Background

When the Middle East Respiratory Syndrome (MERS) got spread, it was found that nurses used some sort of personal coping strategies, such as relaxation activities, pursuing strict personal protective measures, involving in prayer, exercise and sports and chatting with family and friends for coping with the MERS‐COV outbreak with a positive attitude. They also attempted to make themselves busy with home activities and avoided media news concerning MERS‐COV so that their minds were distracted away from MERS‐COV (Khalid et al., 2016). According to the results of a qualitative research on nurses, psychological defence mechanisms were activated in all nurses, which included isolation, speculation, self‐consciousness, rationalization, distraction and humour. Besides, nurses used new and existing knowledge of psychological decompression transferred by the internet or colleagues for adjusting themselves. They used psychological approaches in an active or passive manner, like writing letters and diaries, mindfulness, breathing relaxation, emotional expression and music meditation when coping with work stress (Sun et al., 2020). Another qualitative research carried out in Jordan on nurses indicated that there were many supportive sources for those working with patients with COVID‐19, including friends, family, community and organizational support (Khatatbeh et al., 2021). Furthermore, another study showed that nurses utilized various adaptive coping strategies, including instrumental support, emotional support, venting, planning and acceptance for restoring their resources (Singh et al., 2021). Also, a phenomenological study conducted on Turkish nurses showed that nurses used short‐term coping strategies, like listening to music, sports and expressing their thoughts and emotions about the pandemic by writing diaries and letters for combating the negative impacts of the COVID‐19 pandemic. Moreover, they took psychosocial support from their families and the social environment during the COVID‐19 pandemic (Kackin et al., 2021). Recently, a Chinese study reported that nurses took positive measures, such as talking with friends and family members; confining watching COVID‐19 news; expressing their emotions by screaming, crying or throwing items; seeking psychological support from colleagues and expressing their needs and concerns to supervisors for coping with stress (Zhang et al., 2020). Using an empirical phenomenological approach, a qualitative study demonstrated the use of self‐management strategies by nurses for keeping a good mood. Some of them did relaxing activities, for example, reading book, watching films and taking a shower, and some preferred to pay less attention to news on COVID‐19 (Liu, Luo, et al., 2020).

An advanced search in the available studies indicates that there are some qualitative studies conducted to explore the experiences of nurses caring for COVID‐19 patients. However, the number of studies that explored the recovery experiences of nurses is few. The aim of this qualitative study is to investigate the recovery experiences of nurses caring for patients in the COVID‐19 ward to provide the basis for the development and implementation of management, care and protection programmes of the nurses in a more informed and accurate way.

1.2. Conceptual framework

Recovery from job stress is a process that allows employees to restore their energy resources (Lundberg, 2005). In this process, an individual's functional systems used during a stressful situation return to their pre‐stress level. The recovery process can be regarded as an opposite process of the stress process that leads to the repair of damaged mood and is often reflected in reducing physiological stress indices (Meijman & Mulder, 1998). In addition, recovery can be elicited by certain subjective experiences, leisure‐time activities and physiological processes occurring during sleep (Sonnentag, 2018). To evaluate the main psychological processes that can help a person recover from job stress, Sonnentag and Fritz (2007) suggested a framework of four major recovery experiences: psychological detachment from work, relaxation, mastery and control, based on the Conservation of Resources theory (Hobfoll, 1998) and the Effort‐Recovery Model (Meijman & Mulder, 1998). The first experience, detachment means mental disengagement from thoughts related to work. The second experience, relaxation hints at low levels of physical or mental activity and little intellectual or physical effort. The third experience, control points to be able to make decisions on one's leisure activities, and the last one, mastery encompasses learning opportunities and challenges, resulting in feelings of achievement and competence. Subsequently, Newman et al. (2014) conducted a meta‐analysis of 363 articles within psychology and leisure sciences and added affiliation and meaning experiences to the framework of recovery experiences in their DRAMMA Model, which aimed to explain how leisure activities relate to subjective well‐being. They also replaced control with autonomy. Autonomy is one of the fundamental psychological needs proposed in Self‐Determination Theory (Ryan & Deci, 2000), which is highly similar to control but is broader since it generally emphasizes feelings of volition rather than just having control over one's leisure schedule. Through meaningful leisure activities, people obtain something appreciated in their life (Iwasaki, 2008). Furthermore, proactively engaging in activities that add meaning to one's life is likely to improve well‐being (DRKS00013650, 2018). The last recovery experience in the DRAMMA Model is affiliation. Affiliation refers to feelings of belongingness with other people and the fulfilment of people's innate need for relatedness (Ryan & Deci, 2000), which can foster social support (Coleman & Iso‐Ahola, 1993; Freysinger & Flannery, 1992) and produce higher levels of happiness as supporters help regulate affect and thoughts through shared activities (Lakey & Orehek, 2011).

2. METHODOLOGY

2.1. Design

A phenomenological approach was adopted in this qualitative study for a comprehensive investigation and description of the recovery experiences of nurses who cared for patients with COVID‐19 in Isfahan, Iran. We observed the consolidated criteria for reporting qualitative research standards (Tong et al., 2007).

2.2. Setting and time

The research setting included four public hospitals. The reason for choosing them was that given the Ministry of Health instructions in Iran, these four hospitals were in charge of controlling the COVID‐19 disease and delivering health care services in Isfahan city. The data were collected from 7 April to 30 October 2021.

2.3. Sample

The sample included nurses in caring for patients with COVID‐19 in the four public hospitals of Isfahan city in Iran. The purposive sampling method was used to select participants. The research inclusion criterion included being experienced in caring for patients with COVID‐19 for at least 3 months, having at least 1 year of work experience as a clinical nurse, and willingness to share experiences with the researchers. The research was continued until reaching data saturation, and the number of participants reached 12 nurses. It was attempted to choose participants from all four hospitals so that deep experiences of nurses are obtained in various situations for achieving the essence of the study phenomenon as much as possible.

2.4. Data collection

The data were collected via an individual, in‐depth interview technique using a semi‐structured questionnaire. After a literature review, the researchers developed a semi‐structured questionnaire under the supervision of supervisors and advisors. There are three main open‐ended questions:

• Please explain how you recover yourself from stress at work environment during Covid‐19 outbreak.

• Please explain how you recover yourself from stress at off‐times during Covid‐19 outbreak.

• Have done others anything to help your recovery from stress?

When a specific matter was mentioned by the participants regarding their experience and perception, the interviewer asked for further explanations and examples. At the beginning of the interview, the interviewer asked about participants' marital status, age, years of work experience and months of work experience at COVID_19 wards. The interview was ended by asking the participant whether he/she wanted to add anything more. The duration of the interviews was 45 to 60 min (except one lasting for 30 min). After arranging the place and time of the interview, the interviews were done considering the comfort of interviewees in a coffee shop (four cases), hospitals (four cases) and call interviews (four cases). Nonverbal and verbal expressions were recorded using a voice recorder and written notes. Interviews were done by the female researcher, who was a PhD candidate in organizational behaviour management.

2.5. Data analysis

After transcribing the voice recordings of the interviews into writing, the researchers checked the consistency between the transcripts and recordings. Then, data coding was performed. After coding the first four transcripts independently, the researchers gathered for making a joint decision concerning the codes. In the next step, themes were extracted from the data. Phenomenological analysis steps proposed by Colaizzi (1978) were applied for data analysis. The following steps were implemented in this process:

1. Reading transcripts and taking short notes for understanding the meanings assigned to a phenomenon and the experienced emotions.

2. Selecting significant expressions directly associated with a phenomenon.

3. Examining these expressions and formulating expressions with shared meanings.

4. Grouping the formulated meanings into categories, subthemes, and themes.

5. Combining the gained results with comprehensive, rich life experiences.

6. Defining the basic conceptual structure of the respective phenomenon.

7. Confirming the results through a second meeting with the participants and comparing their experiences with the obtained results.

2.6. Trustworthiness

The following four criteria were used to realize the study's trustworthiness: credibility, transferability, dependability and confirmability (Lincoln & Guba, 1986). Credibility was acknowledged by triangulation and obtaining participant approval. Participants were asked to confirm the data obtained during the data collection phases by interviewing them. It was conducted with participants from different situations to obtain multi‐perspective information. Additionally, researcher meetings were conducted at short intervals for discussing the research process and usefully implementing the intertextual qualifications and experiences of the researchers. In term of transferability, the characteristics of the research population and the research process were described clearly and accurately to make it possible to follow the research path and make key decisions in the analysis. To evaluate the reliability of the data, they were extracted and coded by two researchers separately. The researchers arranged and categorized the texts based on the interview questions. The text of each interview was read several times and then analysed. The two researchers then extracted the statements and compared the codes to reach an agreement. The researchers actively put aside their thoughts and assumptions about the topic, recorded and documented the research procedure accurately and refrained from deep review of texts to ensure the confirmability of the data. This was reinforced by input from the rest of the research team.

2.7. Ethical considerations

Ethical approval was obtained before the study began by the Research Ethics Committee of Islamic Azad University, Tehran North Branch with the code IR.IAU.TNB.REC.1400.058. The participants completed the written consent form. The ethical considerations were adhered to by informing the research objectives and methods and taking informed consent for participation before the interview. Furthermore, participants could leave the research at any time they wished. Moreover, participant anonymity, honesty in data analysis and presentation of results were other ethical principles considered in this work.

3. RESULTS

A total of 12 nurses caring for COVID‐19 patients participated in the study. Their age range was between 26 and 54 years, their total work experience was between 2 and 18 years and their work experience in the COVID‐19 ward was between 5–18 months. They consisted of three male and nine female nurses, five of whom were single and seven were married. Three of them had master's degrees in psychiatric nursing, and nine had a bachelor's degree in nursing (Table 1).

TABLE 1.

Characteristics of participants (n = 12)

Participants	Gender	Marital status	Age	Education degree	Work experiences as a clinical nurse (year)	Work experiences in COVID‐19 ward (month)
N1	Female	Single	35	Bachelor	13	18
N2	Female	Single	28	Bachelor	3	5
N3	Male	Married	36	Master	11	15
N4	Female	Married	54	Bachelor	18	12
N5	Female	Married	42	Master	13	10
N6	Male	Single	26	Bachelor	2	5
N7	Female	Married	41	Master	15	18
N8	Female	Single	26	Bachelor	3	12
N9	Female	Married	35	Bachelor	5	5
N10	Female	Single	32	Bachelor	6	13
N11	Female	Married	29	Bachelor	7	10
N12	Male	Married	30	Bachelor	5	13

Data analysis revealed 5 themes, 14 subthemes and 53 items. The themes were ‘detachment from work’, ‘relaxation’, ‘non‐work activities’, ‘affiliation’ and ‘meaning’ (Table 2).

TABLE 2.

Recovery experiences

	Themes	Subthemes	Items
1	Detachment from work	1. Physical detachment from work	✓Post‐work break shifts ✓Sick leave
		2. Psychological detachment from work	✓Not talking about work, COVID‐19, and patients during non‐work time ✓Not pursuing the COVID‐19‐related news during non‐work time ✓Sleep
2	Relaxation	1. Relaxation experiences in the hospital's restroom	✓Rest and relaxation in the resting room, ✓Drinking tea, coffee, etc. in the hospital's resting room
		2. Relaxation experiences outside the hospital	✓Listening to music ✓Taking a shower ✓Being in nature ✓One‐day trips ✓Using soothing herbal teas ✓Referring to a consulting psychologist to get tips for peace of mind
		3. Relaxation experiences coming from protocol compliance	✓Peace of mind because of not getting sick after starting strict protective measures ✓Sense of relief coming from the feeling of being safe by following protective measures
3	Non‐work activities	1. Mastery experiences	✓Learning to play an instrument ✓Participation in training courses (a foreign language and calligraphy) ✓Studying at university ✓Studying for the university entrance exam ✓Cycling, mountaineering, etc.
		2. Fun activities	✓Watching favourite movies and reading books ✓Spending time in cyberspace (using pages and channels of poetry and literature, using motivational channels and pages in Telegram and Instagram) ✓Taking care of household chores (cleaning the house, shopping for the house, taking care of the garden and flowers, cooking)
4	Affiliation	1. Affiliation to the organization and colleagues	✓Social interactions with colleagues in the resting room ✓Hanging out with colleagues ✓Helping each other ✓Head nurse's empathy and cooperation with staff to arrange nurses' work and off shifts, giving gifts to nurses, and head nurses' voice contact with staff not present in the ward to greet them and give them reassurance ✓Educational supervisor's support and empathy including training the protocols, continuous visits to the ward for empathy with nurses, and monitoring protocol compliance for nurses' health ✓The Ministry of Health's support of nurses by paying COVID‐19 fees to them ✓The hospital manager's providing personal protective equipment and items needed by the COVID‐19 ward ✓Appreciation of nurses by holding various celebrations and ceremonies, especially the nurses' day
		2. Affiliation to family	✓ Spending leisure time with the family ✓ Talking with family members, especially the mother ✓ Playing with kids ✓ Walking in or around the city with one's spouse ✓ Creation of a happy mental atmosphere at home by the mother ✓ Reducing the nurse's responsibility at home ✓ The family's preparing the nurse's favourite food for him/her
		3. Affiliation to friends	✓ Being with friends ✓ Audio or video communication with friends and acquaintances during non‐work time
		4. Affiliation to patients	✓ Establishing an emotional relationship with patients and listening to them ✓ Patients' and their companions' appreciation of nurses in different ways
		5. Affiliation to the community	✓ Regarding community members as one's family ✓ Support and sympathy of various public organizations such as the governor's office, municipality, police, and private organizations ✓ Support by people in various ways ✓ Support by the Islamic Republic of Iran broadcasting
5	Meaning	1. Meaningfulness of the job	✓ The nurse's perception of being at the frontlines in the fight against the COVID‐19 pandemic and having a sense of pride for that ✓ Voluntary attendance in the COVID‐19 ward to help fellow human beings ✓ Nurses' perception of self‐sacrifice and devotion for their fellow human beings ✓ Nurses' sense of success and happiness when a patient is discharged
		2. Connection with GOD	✓ Playing religious songs in the ward ✓ Saying prayers ✓ Relying on and trusting in God ✓ Parents' prayers for the nurse

3.1. Detachment from work

Under this theme, a total of two subthemes are determined.

3.1.1. Physical detachment from work

According to in‐depth interviews with nurses, being away from stressful situations of hospitals helped them to relieve strains. This subtheme includes two items:

• Post‐work rest shifts: Nurses experienced relieving in the setting rather than the hospital environment.

I choose my work shifts with the large distance between them with a relative recovery, some successive working shifts followed by some successive resting shifts. (N1)

Taking intensive shifts and then resting for a few days and being away from the hospital for rejuvenation. (N2)

• Sick leave: most of the nurses have had COVID‐19. Although the illness was destructive, a 2‐week sick leave helped them to rejuvenate.

I was very tired. Then, by the positive result of corona test, I took two weeks of sick leave and left the environment, which helped me a lot for recovery. (N3)

3.1.2. Psychological detachment from work

The majority of the nurses stated that not thinking about job‐related problems was an effective strategy in reducing stress. This subtheme includes the following three items:

• Not talking about work, coronavirus and patients during non‐work time: Nurses reported that they tried not to talk about coronavirus and patients during their rest time and keep themselves busy to refrain from thinking about the epidemic.

I try to forget about work when I go home. The mistake I made earlier was to tell them about COVID‐19 patients in the hospital, which made my mother cry. But now, when I go home and my mother asks me what's up, even in the worst conditions, I say everything is OK, and I avoid talking about my workplace at home. I try to shut down the work issue at home. (N1)

• Not pursuing COVID‐19‐related news during non‐work time: Nurses noted that they limited watching or listening to news related to COVID‐19 in order to detach mentally from work.

I never follow the news of COVID‐19. I rarely watch TV. I remind myself not to listen to the news of COVID‐19, and I have recommended this to my family and friends as well. COVID‐19 is a universal reality, but knowing where a certain number of people have died doesn't solve our problems. (N4)

• Sleep: Nurses unanimously emphasized that getting enough sleep was a way to relieve physical exhaustion and psychological detachment from work.

I try to get 8 hours of sleep under any circumstances, or I can't keep on working. I did as little housework as possible and went to bed. I try to regain my energy through sleep. (N5)

3.2. Relaxation

There are three subthemes under this theme.

3.2.1. Relaxation experience in the hospital's resting room

From the nurses' point of view, despite their large amounts of work, the short opportunities that were provided to rest and drink tea or eat in the resting room had a great effect on relieving mental exhaustion. This subtheme consists of two items:

• Resting and relaxation in the resting room:

At first, we had too much work and stress to eat anything, even during the break. We had relaxation in the resting room for a few moments and it was useful. (N4)

• Drinking tea, coffee, etc. in the hospital's resting room:

We use the resting room as long as we can just drink tea or take a ten‐minute break to relieve exhaustion. (N5)

3.2.2. Relaxation experience outside the hospital

Participants stated that after one or more work shifts with a high volume of work, performing various relaxing activities during their leisure time helped them experience a sense of relief. Moreover, some of them visited a consulting psychologist to get tips for peace of mind. This subtheme consists of five items:

• Listening to music:

I listen to music in my leisure time; it calms me down. (N1)

• Taking a shower:

I take a shower when I go home. It gives me energy. (N6)

• Being in nature:

I have chosen nature to recover myself. I try to spend 12 hours in nature at least once a week. I don't mean a park. I mean out‐of‐town nature. (N2)

• One‐day trips:

Short trips of ten or twelve hours recover me. For example, I recently had a one‐day trip to Kashan. It was very effective. (N6)

• Using soothing herbal teas:

I use complementary medicine such as music therapy and soothing herbal teas to recover. (N7)

• Referring to a consulting psychologist to get tips for peace of mind:

I had too much stress at first. I went to a counselor for about two months to get rid of it. (N8)

3.2.3. Relaxation experience coming from protocol compliance

Although long‐term use of personal protective clothing and masks increased the nurses' job strain due to extreme heat, difficulty in moving and lack of oxygen, nurses experienced relaxation because of not getting sick by complying with the health protocols. They also experienced relief coming from the feeling of being safe by observing the protocols. This subtheme consists of two items:

• Peace of mind because of not getting sick after starting strict protective measures:

Many colleagues who did not observe the protocols completely were infected, but I've had no problem yet. I wear scrubs and a mask at work, and when I get home, I immediately take a shower and change my clothes completely. (N9)

• Sense of relief coming from the feeling of being safe by following protective measures:

I follow the protocols, but I've not had much stress. I know I will not get infected if I observe the protocols. (N5)

3.3. Non‐work activities

Non‐work activities refer to activities done during leisure time and not related to work duties. This theme consists of two subthemes.

3.3.1. Mastery experiences

The participants stated that they spent a part of their leisure time on challenging and educational activities and learning new skills unrelated to work. This subtheme consists of five items:

• Learning to play an instrument (music):

I sometimes play the guitar. It helps me a lot in these conditions. (N10)

I play the guitar and train my child how to do it. (N9)

• Participation in training courses (a foreign language and calligraphy):

I do calligraphy. I go to language classes. Of course, I did so before the outbreak of COVID‐19, but doing them in these conditions will really help me. (N10)

• Studying for higher educational levels:

I study at home in my leisure time. I intend to pursue my studies. Reading books calms me down and gives me a sense of ability. (N9)

• Studying in the master's programme:

Upon the outbreak of COVID‐19, I was admitted to continue my studies at the master's level of psychiatric nursing. I spend a part of my leisure time studying. (N4)

• Cycling and mountaineering:

We have formed a mountaineering team with our nurse colleagues since the beginning of the COVID‐19 outbreak, and we go mountaineering on Saturdays and Wednesdays. It is very effective, and we would be completely destroyed without it. I sometimes go biking as well. (N3)

3.3.2. Fun activities

It was revealed that doing fun activities kept the nurses' minds off work and calmed them down. This subtheme consists of four items:

• Watching favourite movies or reading favourite books

I also have entertainment programs, things like shopping, reading my favorite books and articles, and watching interesting and comedy movies. (N1)

• Using favourite pages and channels in cyberspace such as poetry, literature and motivational channels and pages, etc.

I also spend some time in cyberspace like Instagram. It entertains me and takes my mind off work. (N6)

• Taking care of household chores (cleaning the house, shopping for the house, taking care of the garden and flowers, cooking):

Sometimes you want to distract from time and place for a few minutes so that your mind is calm and you do not think about anything. I take care of the garden and the flowers and plants. I water the flowers. Also, I take care of the household chores to keep my mind off work. (N4)

3.4. Affiliation

Establishing social relationships to relieve stress and obtain support was one of the strategies reported by nurses. This theme comprises five subthemes:

3.4.1. Affiliation to the organization and colleagues

Social interactions with colleagues and receiving their support experienced by nurses more than ever. This subtheme manifested itself in various concepts (eight items):

• Social interactions with colleagues in the hospital's resting room:

We tell jokes in the resting room. We laugh. We talk about non‐work issues. We narrate our memories about family, children, or patients who have recovered. We try to forget work at the moment. (N1)

We talked and laughed. We all ordered food and ate in the restroom. We held birthday celebrations for each other. We told jokes. We did funny things to change the atmosphere. (N8)

• Hanging out with colleagues:

We hang out with friends and the nursing team. We drove around. For example, when I was on a long shift, we would hang out after work with colleagues. I would have dinner and then go home. (N8)

• Receiving help from colleagues:

In the ICU, we have to cover patients in turn. Most of the time, our male colleagues do this because they know about ladies' sensitivity. It is really difficult to wear scrubs and a mask. (N8)

• Head nurse's empathy and cooperation with staff to arrange work and off shifts:

Our head nurse cooperates with the staff in taking intensive work shifts and then taking time off. This head nurse values us, making me so focused on my work. The staff will face challenging conditions if they are not cooperated within taking shifts. A good head nurse is a blessing in these conditions. (N2)

In the beginning, no one visited the COVID‐19 ward. But we had a supervisor who came to the ward. She told jokes to us and cheered us up to work harder. The head nurse also phoned to greet us and ask about patients' conditions. (N10)

• Educational supervisor's support and empathy (i.e., training the protocols, continuous visits to the ward to empathize with nurses and monitor compliance with protocols for nurses' health)

I am an educational supervisor. We had to train the treatment staff and visit the wards regularly. I went to the ward for an hour every day to remind them that they were not alone and we were all together. We are a team. (N4)

• Paying COVID‐19 fee to nurses:

They considered COVID‐19 fee for us. After 4 months, they paid us 6 million Tomans. They paid some nurses 4 million Tomans due to their shorter shifts. When I got COVID‐19, they brought me a fruit dish (laughing). (N8)

They paid us the COVID‐19 fee. They paid us 3,900 million Tomans for six months. They made us a little happy. In this bad economic situation, it is only money that can make us happy. (N11)

• The hospital's providing personal protective equipment and items needed by the COVID‐19 ward:

The air conditioners of the ward were out of service and didn't meet the needs. All the windows had been closed so that the air would not leak this ward. The hospital manager regularly inspected the ward and saw the conditions. The air conditioners were repaired or replaced, and we were regularly provided with masks and other equipment. (N5)

• Empathy with nurses by holding various celebrations and ceremonies, especially Nurse's Day:

Once a show was held on the grounds of the hospital during Nowruz. I found it very interesting and felt very good. For a moment, it completely took my mind off the hospital. It was very effective. (N2)

They held a ceremony on Nurse's Day and gave us a certificate of appreciation. They gave a gift card on another Nurse's Day. (N6)

3.4.2. Affiliation to family

All nurses stated that they spent most of their leisure time with their family members. There are seven items under this subtheme:

• Having dinner with the family:

Being in the family atmosphere and eating with my family members recover me. I often go to work cheerfully in the morning. It means the recovery is made. (N6)

• Talking with family members, especially mothers:

I talk to my mother when I'm under much pressure, and it calms me down a lot. (N5)

• Playing with kids:

I play with kids. Seeing them relieves my exhaustion. (N3)

• Walking in or around the city with one's spouse:

We sometimes went to restaurants with our family. Sometimes we went to the park or around the city. We also went to my parents' and parents‐in‐law's houses once every two or three months. (N12)

• Creation of a happy mental atmosphere at home by the mother:

Earlier, I became very nervous at home. My mother dealt with it and said nothing, trying to understand my situation. Little by little, they created happy and joyful conditions at home. For example, they offered to go shopping together to keep my mind off work and COVID‐19. (N1)

• Reduce the nurse's responsibility at home:

I used to buy everything, including bread, but my parents have been doing that since the outbreak of COVID‐19. They do not expect me to do these things anymore, and they understand me. (N6)

• The family's preparing the nurse's favourite food for him/her:

Because I love food (laughing), my mother cooks my favorite foods when I'm home. (N2)

3.4.3. Affiliation to friends

According to the participants, communicating with friends, even in cyberspace, made them strong. This subtheme consists of two items:

• Being with friends:

We sometimes hang out with college peer friends or with high school friends. Being with them gives me energy. (N6)

• Audio or video communication with friends and acquaintances:

I am very sociable and regularly have visual communication with them, which really gives me energy. (N7)

3.4.4. Affiliation to patients

This subtheme included nurses' expressions about the emotional connection between them and patients in the COVID‐19 ward. There are two items under this subtheme:

• Establishing an emotional relationship with patients and listening to them:

Each patient is usually hospitalized in the COVID‐19 ward for 12‐14 days and should be taken care of by each nurse during 6‐7 shifts. Therefore, an emotional relationship is established between them. (N6)

• Patients' and patient companions' appreciation of nurses in different ways:

After discharge, many patients bring sweets to thank us. Some others write a poem on paper to give us. It is very effective. We become very happy when young patients are discharged. Some patients posted stories with images and names of nurses after their discharge. All this made us happy. The most important thing for us is the patient's recovery, and then these things. (N5)

3.4.5. Affiliation to the community

In stressful work conditions, nurses always considered themselves to belong to the community, which resulted in receiving social support and empathy from different community groups that brings them a sense of psychological security. This subtheme consists of four items:

• Regarding community members as one's family:

I told the taxi driver that I observe the health protocol because I am concerned about others' health as much as I am about my family's health. (N8)

• Support and sympathy of various public organizations such as the governor's office, municipality, police and private organizations:

The municipality gave the staff a ticket worth 800,000 Tomans to use in the City of Dreams and a Gondola Lift. A confectionery also gave us sweets packages for Nowruz. (N8)

Some banks have considered facilities and loans for treatment staff. (N3)

• Support by people in various ways:

Some people and benefactors brought us flowers, sweets, and fruits. This benevolent act gave us spiritual energy because our efforts were seen. In general, people have become more familiar with the nurses' job than ever before, and their views have changed. (N3)

• Support by the Islamic Republic of Iran Broadcasting by training the health protocols and making movies and documentaries of the efforts of the medical staff:

When COVID‐19 had just spread, the IRIB came to our hospital, interviewed the colleagues, and made a video, which was broadcast later. (N10)

Since the IRIB started training the health protocols to the people, we have had less work to do. (N4)

3.5. Meaning: This theme consists of 2 subthemes

3.5.1. Meaningfulness of the job

Despite facing this unknown disease and unpredictable risks and fearing infection, nurses showed a high sense of responsibility and chose to stay with patients. There are four items under this subtheme:

• The nurse's perception of being at the frontlines in the fight against the COVID‐19 pandemic and having a sense of pride for that:

I had a colleague whose husband was a military. He sometimes had a mission to go to the border for whom she was always worried. I tried to comfort and calm her down. I said this was part of his job and he had to deal with it. I couldn't imagine that one day I would be at the forefront of a fight. I sometimes feel proud if I can do something for the patient. (N10)

• Voluntary attendance in the COVID‐19 ward to help fellow human beings:

In addition to being the referral center of COVID‐19 in the second and third peaks, I was proud to voluntarily serve in Isabn‐e‐Maryam and Khorshid hospitals when COVID‐19 had just spread in March 2020, two referral centers of COVID‐19. (N1)

• Nurses' perception of self‐sacrifice and devotion for their fellow human beings:

In our country, a nurse is a myth, a symbol who must manage various crises including financial and human resource crises, sympathize and serve patients, and play various roles of mothers, wives, children, etc. in the family. They care more about THEY ARE and YOU ARE than about I AM. (N4)

• Nurses' sense of success and happiness when a patient is discharged:

I was motivated when I noticed a patient feeling better at the beginning of the shift. I talked to the patient and laughed, and I transferred this good mood and motivation to other patients as well. (N8)

News about a patient's death has a very bad impact on our mood, while a patient's discharge makes us happy. (N6)

3.5.2. Establishing connection with God

From the participants' point of view, connection with God, as the supreme, might was an eternal source of relaxation. This subtheme consists of four items:

• Playing religious songs in the ward:

I sometimes played religious songs in the ward to calm the patients down. In those difficult conditions, sometimes you thought that God was gone. By doing this, I became calmer. It was as if we were told that God has not forgotten us. (N10)

• Saying prayers:

In the workplace, praying for 20 minutes kept my mind off the workplace. Prayer is solitude that a person has with himself. This act changes one's mood. It has an effect. It has a greater effect in the workplace than at home. It seems to be sincerer, more useful. (N3)

• Relying on and trusting in God:

I try to live in such a way that God helps me when I have a problem. Trusting God makes me feel good and supported by God. (N5)

• Parents' prayer for the nurse:

God has always helped me thanks to the prayers of my parents, who are very pleased with me, as well as the prayers of patients because I have a good relationship with them. (N5)

I get energy when I give an unaccompanied patient a glass of water, and he/she prays for me. (N10)

4. DISCUSSION

This study was performed to investigate the recovery experiences of nurses caring for patients with COVID‐19. The analysis of the interviews allowed the identification of our themes: detachment from work, relaxation, non‐work activities, affiliation and meaning. To facilitate comparing our findings with other literature, we present our discussion in a structured manner per main themes.

• Detachment from work

This study found that nurses attempted to take intensive shifts and then rest for a few days, being away from the hospital for rejuvenation. Despite the importance of the physical distance from the workplace for recovery, it could not be adequate (Hartig et al., 2003). Also, the nurses in the present study adopted various types of distraction strategies during their leisure time, for example, not pursuing COVID‐19‐related news, not talking about work problems and getting enough sleep to stop thinking about work. Psychological detachment from work goes beyond the pure physical absence from the workplace during off‐job time and abstaining from job‐related tasks (Sonnentag & Bayer, 2005). According to the Effort‐Recovery Model, recovery occurs when no further demands are made on the functional systems called upon during work (Meijman & Mulder, 1998) and when people have psychological detachment from work during their off‐job time, the chances for reduction of demands on the functional systems taxed during work and recovery are increased (Sonnentag et al., 2010). The Conservation of Resources Theory assumed that individuals struggle to obtain, retain and protect their resources (Hobfoll, 1998). The resources are threatened by stress, and consequently, well‐being and health could be harmed. To recover from stress, individuals have to gain new resources and restore threatened or lost resources that can result from detaching from work. As indicated by similar studies, nurses adopted various distraction approaches, including limiting the use of media, making themselves busy for avoiding thinking about the pandemic and escaping negative comments regarding COVID‐19 (Kackin et al., 2021; Khalid et al., 2016; Zhang et al., 2020). Moreover, previous studies indicated that from the point of view of nurses, getting enough rest and sleep could be an effective way for relieving stress (Bozdağ & Ergün, 2021; Qi et al., 2020; Sun et al., 2020). Similarly, a study observed that sleep was significantly and positively related to mental health (Scott et al., 2021).

• Relaxation

Despite the high workload, the nurses in this study reported using short opportunities provided to them for resting, drinking or eating in the hospital resting room. Additionally, they used different strategies, like taking a shower, listening to music, taking one‐day trips and spending time in nature during their leisure time for stress relief since they believed that they had to be strong and focus on their duties for saving more lives. Likewise, according to previous reports, nurses adopted such strategies as drinking and eating, breathing exercises (Sun et al., 2020), listening to music and sports (Kackin et al., 2021; Khalid et al., 2016), meditation, yoga, safari (Zhang et al., 2020) and taking a shower and resting (Qi et al., 2020) for coping with stressful situations. Also, our findings indicated that nurses visited a consulting psychologist for getting tips for peace of mind and decreasing their stress. As reported by similar research during a MERS‐COV Epidemic, nurses received help from family physicians or other doctors as one of the strategies used for reducing stress (Khalid et al., 2016). During an outbreak, positive emotions can be strengthened by the activities that are deliberately sleeted with the aim to relax the mind and body, including resting, meditation and so forth, or doing other activities like listening to music, walking in a beautiful natural environment and so forth. The potential for relaxation experiences to increase positive affect and decrease activation are essential for recovery in two respects. First, stressful work leads to prolonged activation and the processes that reduce this prolonged activation are crucial in order to restore an organism's pre stressor state (Brosschot et al., 2005). Second, positive emotions can undo the effects of negative emotions and positive affect resulting from relaxation experiences will be helpful in reducing negative affect resulting from job stress (Fredrickson, 2000). Additionally, nurses in this study experienced not getting sick after starting strict protective measures (handwashing, wearing a face mask, etc.), and they observed that by following protective measures themselves and their colleagues would be safe, as a result, following protective measures gave them a sense of peace. Moreover, this feeling that following protective measures would make them safe helped their peace of mind. In other word, the atmosphere formed base on this fact that not getting sick after starting strict protective measures caused following measures that gave them a sense of relaxation. Moreover, it should be mentioned that according to the Job‐Resource Demand Theory (Demerouti et al., 2001) and Demand‐Control Model (Karasek, 1979), when people comply with health protocols, they take a sense of control over the conditions that is helpful in generating the resources (McDowell et al., 2019). As demonstrated by similar studies, nurses observed strict personal protective measures (such as washing, mask and gown) as a coping strategy for alleviating stress. After realizing the fact that they did not get sick following initiating strict protective measures, their stress decreased and their resilience increased (Khalid et al., 2016; Khatatbeh et al., 2021; Rahman et al., 2020). Another similar study showed that in the case of an outbreak, confidence in the safety and positive attitudes in the workplace were factors promoted the willingness of medical staff for active participation in anti‐epidemic work (Aoyagi et al., 2015).

• Non‐work activities

In this study, the nurses reported performing educational and challenging activities irrelevant to work during their leisure time, for example, learning a foreign language, learning to play an instrument, studying scientific books and doing professional sports, like mountaineering, for making themselves busy and not thinking about work and attaining new skills. These kinds of activities known as mastery in The DRAMMA Model (Newman et al., 2014) can be useful for distracting attention from job‐related issues since they provide learning opportunities and challenging experiences in other domains. Although these experiences can be additionally demanding for the individuals, it is expected that they help achieve recovery as these activities are helpful in building up new internal resources, including competencies, self‐efficacy and skills, and create positive affect (Hobfoll, 1998). The findings of this part of the study are new and inconsistent with other studies on the experiences of nurses caring for patients with COVID‐19. Nevertheless, recovery studies provide some examples in this regard. Taking a language course, learning a new hobby or climbing a mountain are typical examples of mastery activities (Sonnentag & Fritz, 2006). Also, this study indicated that conducting fun activities, like reading books, watching favourite movies, spending time in cyberspace and taking care of household chores, was helpful for the nurses in stress relief. In contrast to the mastery experiences, fun activities do not result in skill learning but are helpful in balancing negative and positive emotions through reinforcing positive emotions. Thus, these activities can improve mental well‐being (Linley et al., 2009). The findings of this part are consistent with the results of several similar studies on nurses' experiences during COVID‐19 that reported different kinds of activities, such as watching movies and series, cooking, cleaning the house, painting, reading books and feeding animals experienced by nurses to increase positive affect (Kackin et al., 2021; Liu, Luo, et al., 2020; Sun et al., 2020).

• Affiliation

In the current study, it was found that nurses made social relationships with their friends, colleagues, family and patients for alleviating stress and attaining support. Maslow (1954) proposed the third step of his hierarchy of needs, known as belongingness and love, a crucial need of human beings after meeting physiological and safety needs. Social relationships encourage positive emotions and ultimately improve quality of life (Brajša‐Žganec et al., 2011). Moreover, social relationships can foster social support (Coleman & Iso‐Ahola, 1993). Social support can lead to the generation of higher levels of happiness since supporters are helpful in regulating thoughts and emotions through shared activities (Lakey & Orehek, 2011). As reported by nurses in this research, providing personal protective equipment by the hospitals and support from the head nurses were significant measures. Besides, the factors that motivated nurses in this period included payment of the COVID‐19 fee by the hospitals, colleague encouragement, sharing jokes or humour among colleagues, empathy with nurses by holding ceremonies and celebrations, suitable shift scheduling and support from the educational supervisors. As a result of these supportive sources, nurses felt a sense of safety and not being alone. Previous studies have identified various supportive sources for nurses who work in highly stressful environments, such as support from colleagues and organization (Khatatbeh et al., 2021; Liu, Luo, et al., 2020), adequate material supply, support from team leaders, allowance provided by the government, training and educational programmes in the hospitals, sharing experience by senior staff, suitable shift scheduling, colleagues encouragements (Zhang et al., 2020), satisfying material needs, arrangement of working hours, meeting the equipment needs (Kackin et al., 2021), acknowledgment of their efforts (Alsubaie et al., 2019; Munnangi et al., 2018), the mutual solidarity and support and a meaningful cohesion created by colleagues (Arcadi et al., 2021). Additionally, a similar study reported that nurses experienced receiving support and flexibility from their direct managers particularly related to scheduling during the pandemic as a supportive source (Cho et al., 2021; Ripp et al., 2020). Also, in a study on Brazilian nurses, it was observed that nurses needed financial appreciation within and after the pandemic (Bolina et al., 2020). Another finding of our study demonstrated that most of the leisure time of nurses was spent with their family members (kids, mother and spouse) and they received support and encouragement from their families in various ways, including making a peaceful mental atmosphere at home, diminishing responsibilities of the nurse and preparation of their favourite food. Additionally, according to the nurses in this study, they received positive energy from their social relationships with friends. Also, as shown by the findings, there was a good relationship between the nurses and patients, and patients were highly respectful toward nurses which gave the nurses good feelings. There is consistency between these findings and other studies that reported frequent communication with friends and family in different ways, like calling them or talking with them (Khalid et al., 2016; Khatatbeh et al., 2021; Munnangi et al., 2018; Zamanzadeh et al., 2021; Zhang et al., 2020) and receiving gifts and respect from patients (Sun et al., 2020) as efficient sources to get positive emotions.

Community support was the other source of support reported by nurses in this study. Companies and people supported nurses in different ways, including bringing flowers, giving gifts, donating money, bringing food and sweets for the nurses in the hospitals and calling them ‘health defenders’. According to the nurses, people became more familiar with their job than ever and community views about nurses were changed positively. Consistent with our findings, previous studies found that nurses received community support in the form of calling nurses as the hero in media (Arcadi et al., 2021), donating supplies and financial aid by some companies and paying for their anti‐epidemic health insurance by the government (Sun et al., 2020; Zamanzadeh et al., 2021).

Several similar studies reported that different types of social support made the health care providers feel they were not alone (Liu, Luo, et al., 2020). In addition, it is essential to provide social support for nurses in the combat against pandemics (Kang et al., 2020). Furthermore, social support is crucial both for mental health improvement and motivation (Yin et al., 2021). A systematic review concluded that both personal and organizational support are accompanied by less mental distress (Sirois & Owens, 2021). As emphasized by Naushad et al. (2019), an absence of psychosocial support is a critical risk factor for negative psychological consequences in all kinds of disasters.

• Meaning

Our study indicated that nurses might have different reasons for leaving their job, like facing highly unpredictable situations with the highest infection risks and the risk of disease transmission to their family members. Although they could quit their work with the excuse of worry for their family members or any other excuses, they all were highly committed to their job. There were a large number of volunteer nurses to take care of COVID‐19 patients. Nurses stated saving others' life as one of their goals, which made their life meaningful. As argued by Steger and Kashdan (2013), meaning denotes the individual's experience of having a feeling of importance and purpose in their life and is regarded as a crucial element of well‐being. Several similar studies indicated that in coping with this unprecedented and serious health crisis, many nurses worldwide sympathetically worked in the frontline and cared for patients (Kalateh Sadati et al., 2021; Khalid et al., 2016; Maben & Bridges, 2020; Naushad et al., 2019; Zamanzadeh et al., 2021). Similarly, another research indicated that the whole community of health care professionals perceived attitude toward responsibility and duty as a shared value (Arcadi et al., 2021). Additionally, as shown by a systematic review, the belief in duty was the factor that affected the individual's willingness for working during an influenza public health emergency (Devnani, 2012). According to a study on Iranian nurses, it seemed that the actions of nurses went beyond professional commitment, and the nurses perceived it as an obligation based on the social system values, and they had a conscious or unconscious commitment to them. These social values are primarily rooted in Iranian religious values, which establish a creative link between human and religious concepts and are emphasized during social crises (Kalateh Sadati et al., 2021). Moreover, the present study indicated that connection with GOD was a spiritual source to relieve stress. Nurses reported that they played religious songs in the COVID‐19 ward, said prayers and relied on and trusted in God, which provided them a sense of not being alone, calmness, hope and positive mood. There is an agreement between our findings and the findings of a study that reported the robust coping mechanisms in nurses, including a belief in a higher power or a greater good, for example, surrendering to God with the belief that death or life is in God's hands. Surrender does not mean one is weak, but rather, it means there is a combination of effort and prayer (Gunawan et al., 2021).

4.1. Limitation

The study had several limitations. First, this study adopted a qualitative method and a phenomenological approach. Since it is impossible to generalize the results in a qualitative method, caution should be taken in generalizing the results to other groups and organizations. Second, since the purposive sampling method was used to select participants (the COVID‐19 pandemic conditions made us use this method), the generalizability of our findings is limited. Third, the fact that the scope of the study was limited to hospitals in Isfahan city that has cultural‐regional values different from other regions was another limitation of the study. Different results may be obtained by conducting the study in other regions with different cultural characteristics.

5. CONCLUSION

Although people recover themselves in different ways, the main psychological experiences (such as psychological detachment from work and relaxation) are almost the same for everyone (Sonnentag & Fritz, 2007). Findings from this study were extracted as five main themes: detachment from work, relaxation, non‐work activities, affiliation and meaning. The use of recovery experiences plays an essential role in coping with job stress among the employees of various organizations, especially health care workers, emphasizing nurses caring for Covid‐19 patients. Using these experiences is effective in achieving relaxation and restoration of the lost energy resources during working hours. Since nurses are considered the main assets and competitive advantage of health care organizations, it is essential to consider their physical health, mental health and well‐being. The findings of this study provided new insight into the lived experiences of Iranian nurses in the battle of COVID‐19. However, the results do not include the experiences of all nurses in this country. Hence, it is suggested that future research validate the findings of this study in the hospitals of other cities of this country.

6. IMPLICATIONS FOR NURSING MANAGEMENT

According to the participants in this study, they had not received any training on recovery strategies. It is the responsibility of health system policy makers, hospital managers and nurse managers to design training programmes on recovery and its implementation for health care workers, especially nurses. In this way, they can train stress management techniques and job recovery strategies, thereby ensuring the physical and psychological health as well as the optimal performance of nurses in future major crises.

The higher nursing education authorities are also recommended to include in the health and medical textbooks appropriate content on how to cope with stress and recover from stress and foster students' mental health as future nurses. Moreover, according to the participants, one of the sources of recovery for them was receiving material and psychosocial support. Therefore, the relevant authorities suggest designing and implementing financial support policies for nurses and paying special attention to supportive policies to reduce nurses' burnout. After going through this challenging phase, such supportive approaches in emergencies will serve as a basis for coping with difficult future situations.

CONFLICT OF INTEREST

None of the authors had conflict of interest.

ETHICS STATEMENT

The studies involving human participants were reviewed and approved by the Research Ethics Committee of Islamic Azad University, Tehran North Branch, with the code IR.IAU.TNB.REC.1400.058. We received written consent form from all participants in prior to the interview sessions. In addition, all participants were allowed to exit from the study at any stage voluntarily, and all verbatim transcriptions were saved anonymously.

AUTHOR CONTRIBUTIONS

Azam Hosseinzadeh contributed to the data collection, data analysis, and manuscript drafting. Akbar Etebariankhorasgani participated in the study design and the interpretation results. Alborz Gheitani contributed to the study design, data collection data analysis, and interpretation and developed the study's semi‐structured questionnaire. Reza Ebrahimzadeh contributed to the study design and the interpretation results and developed the study's semi‐structured questionnaire. Roya Torkashvand participated in the study design and interpretation results.

Hosseinzadeh, A. , Khorasgani, A. E. , Gheitani, A. , Ebrahimzadeh, R. , & Torkashvand, R. (2022). Nurses' recovery experiences during the COVID‐19 pandemic in Isfahan, Iran: A qualitative study. Journal of Nursing Management, 30(8), 4090–4106. 10.1111/jonm.13863

DATA AVAILABILITY STATEMENT

The dataset generated and analysed in the qualitative interviews is not publicly available due to the potential for individual and organizational privacy to be compromised. Reasonable requests for parts of the qualitative data will be considered by the corresponding author.