Nurses participating in this study talked about the unpredictability surrounding COVID-19. They expressed the uncertainty that became evident in their formerly routine environment. For some, it was difficult to understand what to do. They wondered how to assuage patient fears and make them feel safe and secure as they were dying. Questions engulfed their minds, taking them to an unsettled place of disquietude. Some nurses wondered whether they would contract the virus from their patients or transmit it to family members. All of these feelings of uncertainty led to being obsessed over what was to come next. Below is an excerpt from the focus group participants.

The nurses were fearful as they set about their daily tasks.

Initially, when this started in our mind, we should know if we are infected, we should not transfer this to our colleagues.

We were afraid of taking the infection home. We heard that infected people will die immediately…we were disinfecting everything.

...We were very worried because one staff was sneezing, and his eyes were red he told us that this is because of his chronic allergy. But we insisted on sending him home and he had to be tested as per their colleagues' request.”

Sometimes patients get transferred to the unit, but you don't know if they are infected.

However, nurses noted that after the initial panic had subsided, they increased their diligence with regard to measures necessary to prevent contamination and cross contamination. They began to arm themselves with information that would protect themselves, their patients, and their family members. In the following, nurses describe the support in the form of awareness they received from the various departments at the NCCCR.

The nurses were hopeful when information could be readily accessed.

Hamad Corporation gave us information each minute. They were updating and supporting us.

We had daily huddles to discuss any updates related to COVID-19, and infection control personnel would come around to provide information and support daily.

Participants mentioned how it was important for them to maintain a sense of calm for their patients. Perhaps it was a way of ameliorating how they felt within themselves. Once the initial panic had subsided, it was time to acclimate to the new normal.

The nurses realized they must acclimate to the milieu of the context of the situation.

In the beginning we were scared; now we feel confident and competent.

Now there are fewer restrictions, especially in the palliative care unit, as all rooms are private. We communicated with the nursing leaders and multidisciplinary team…we allowed the family to stay—especially for dying patients.

Slowly, slowly we understood the situation and we tried to accept the situation and to act in accordance with the situation. Now the situation has changed, and we are more relaxed and less stressed.

Things are returning to normal, and we are relaxed. I feel free now.

Nursing through a pandemic is fraught with all kinds of unknowns, and COVID-19 has been associated with so many deaths. Being a nurse requires striking an equitable balance between accountability to patients and family. COVID-19 left everyone with a sense of the unknown. For healthcare workers, there was the added complexity of ethical dilemmas related to their role as a caregiver and to their uncertainty regarding whether they could safely enter their own home environment.

Palliative care includes providing comfort measures and allowing family members to visit at will. During a pandemic, this was a difficult task that required the nurses to grapple with new policies that excluded family and children from visiting loved ones. The nurses wrestled with the thought of not being able to address the last wishes or provide sufficient comfort to patients, which was normally provided by family members. This situation was particularly difficult for those patients with small children, which created a kind of angst in nurses that many had never previously felt.

Working in palliative care means requires attending to patients.

So that was really a challenging situation for us. Some had small kids. Small kids were not allowed into the hospital.

One lady died in our unit, and we could not fulfill her wishes. Her last wish was to see her son. She died without seeing her child.

Some patients were unable to travel back to their home countries because of travel restrictions. We tried to overcome this issue by arranging video calls with their families. This gave a little comfort to our patients. That was our goal.

Nurses had mentioned that, at times, patients requested traditional food. However, that was difficult because items from the outside could not be brought into the facility for fear of contamination. However, some family members responded aggressively out of a fear that their loved ones would die alone without the comforts of home.

Terminally ill patients requested their home food…which was not allowed…. With our program coordinator, we made a decision to allow home-cooked food.

One of the relatives was aggressive, and he wanted to see the patient. He asked me if it was my mother or father in this situation and I could not visit, how would I feel? Staying with the patient for 10 to 15 minutes is not enough. There are a lot of restrictions.

The nurses were poised to deliver as many last wishes to the patient and family as they possibly could. In the face of death, family members were so engrossed in ensuring their loved ones were as comfortable as possible and had all the comforts of home that they momentarily forgot the veracity of the situation. It left the nurses with a sense of helplessness. There were little they could do except comply as best they could and keep a demeanor that exuded warmth and comfort as they worked to fulfill the wishes of their dying patients.

Patients traditionally depend on verbal and nonverbal communications with nurses. However, with the new restrictions in place because of COVID-19, such communication was not possible. When a nurse walked into a room with their face covered by a mask and personal protective equipment (PPE), that sense of warmth is absent, which changes the first impression of patients.

We enter a room with a smile, but they can’t see that through our masks. So, we try other ways to show caring.

We approach the patient with a smile on our face, but the mask is covering our face, which hinders the communication between us and the patient…. Through our smile, we want to show them that we are open and that we are there to help them. But the mask…covers that up. Then, we changed the situation by conveying all this through our voice.

Providing quality of care is a core responsibility of nurses. There should be no limits placed on the type of care that is given. Nurses spend time providing therapeutic touch to patients so they may feel valued and have a sense of belonging. However, being required to physically distance and to limit time spent with patients made it particularly difficult to provide appropriate care to patients near death.

Our patients need more time; our patients are bedridden, and some are in the dying stage. We cannot give care in just 5 minutes and then leave the room. For some patients a bed bath will take one and half-hours. For some patients it takes even more time.

Some patients, they want to hug and touch us. Through touching, we can provide psychological support to the relatives and even to the patients…. Physical distancing limits our expression and activities.

How to face this difficult situation, especially for end-of-life care, we cannot…distance ourselves from our patients. We cannot limit exposure.

During the grieving process when a patient is dying, we cannot provide the power of touch and the power of healing to the grieving family.

She was crying loudly and hugged me after her son's death. Even though we did not want it, they came and hugged us. We were concerned about our families and children in this situation. It was difficult to maintain physical distancing.

Nurses are ubiquitous and patients have come to expect that nurses will be there to provide warmth and caring. On the other hand, nurses deal with death, dying, and grief in palliative care every day. However, this can be onerous at best during a pandemic in which multiple restrictions exist. In this new world where everything is turned upside down, nurses must support each other to wrestle with this new way of being as they provide care within their respective healthcare units.

During COVID-19, there were increased case numbers in every department. This led to the redeployment of many nurses from one unit to another, including palliative care. Nurses expressed apprehension at arriving in a new unit and having to follow the lead of the other more-experienced nurses in that unit. Many who went to other units felt out of place as they cared for patients who were dying. This led to the need for collaboration between nurses to survive in a new environment.

The nurses felt supported when working in the comfort of their home environment.

I was moved to another unit for one month. So, during that time I felt I was left alone because I could not see my colleagues. Then, my colleagues came to the unit and visited me and they asked how I was feeling…if I was okay.

…I felt cared for by everybody as a redeployed nurse. We have very good leaders. The supervisors prepared us well to work in the COVID facility. We were 100 staffs from different facilities. The environment was safe, and they taught us the donning and doffing procedures. They observed us and, if we made mistakes, they corrected us in a good manner. Really, after 45 days, I did not want to come back to my unit. I felt I'm a valuable staff.

One of the issues that many of the nurses mentioned was a fear of contracting COVID-19 and worries regarding how others would perceive them if they did. They wondered if others would think they had been negligent in their duties. They also feared avoidance by fellow colleagues in the event they contracted the virus.

When they became ill, the nurses perceived support from their colleagues.

I was panicked and sad when I was informed, because I was worried about myself and my family at that time.

I thought they would avoid me, but they did not.

We received support from our colleagues through frequent calls. On a daily basis they asked how we were feeling.

When we got COVID and when we came back everyone was really supportive, and we did not feel anything. No one was pointing at us or anything.

We did not feel isolated.

Some of the participants mentioned the aphorism that most nurses “eat their young.” However, in these unprecedented times, the opposite was true. Nurses dealt with upheaval daily and made their way through by banding together until they eventually settled into a new normal.

This interpretive descriptive study elucidated key themes experienced by nurses working during the pandemic. These themes consisted of transitioning to the new normal, ethical dilemmas, and collaboration and support for fellow colleagues.