Coping strategies adopted by frontline nurses in dealing with COVID‐19 patients in a developing country during the pandemic: A qualitative study

Abstract Aim This study aimed to explore the coping strategies adopted by frontline nurses in dealing with COVID‐19 patients during the pandemic in Bangladesh. Design A qualitative descriptive study. Methods Purposive sampling was used to recruit seventeen frontline nurses from three COVID‐19‐specific hospitals in Dhaka City. In‐depth online interviews and semi‐structured questionnaires were used to collect data through the Google Meet platform. Interview sessions audio–video were recorded, interpreted, analysed, verbatim transcribed and quotes of the participants were verified by member checking. Thematic analysis was used in this research. The study's reporting guidelines were based on the consolidated criteria for reporting qualitative research. Results Seven themes were identified after careful data analysis: (i) A positive attitude in dealing with challenging situation, (ii) Intimate partner's influence, (iii) Self‐emotional regulation, (iv) The tendency to avoid negativity, (v) Motivated by professional obligations, (vi) Religious influence, (vii) Recreational activities. No patient or public contribution This study explored various coping strategies employed by frontline nurses in caring for COVID‐19 patients. No patient or public contribution was investigated.

| 3647 RONY et al. 80,000 and 180,000 health workers are estimated to have died (World Health Organization, 2021).
Coping strategies are behavioural and cognitive techniques used to manage stressful situations and factors related to the quality of service provided while rendering clinical responsibilities (Usman & Fahy, 2021). Frontline nurses employed team cohesion, emotional confidence, behavioural control and psychological empowerment as coping mechanisms at work (Bayuo & Agbenorku, 2018). Effective coping strategies significantly influence an individual's improved physical and mental health outcomes (Budimir et al., 2021).
However, nurses used various coping strategies in dealing with COVID-19 patients, including nurses' self-strategies (self-emotional regulation, empathy for patients, self-protection and recreational activities; Huang et al., 2020), nursing strategies at the ethical level (application of nursing knowledge, attitudes and values, following an evidence-based practice.), employers' techniques (problem-focused coping, such as effective planning and sufficient instrumental support, and skill mix: the combination of experienced and new nurses), and nursing leaders' strategies (fostering strong teamwork among nurses; Catania et al., 2021).
During this pandemic, healthcare workers were emotionally and physically harmed due to working in inadequately prepared clinical environments. Denning et al. (2021) revealed that a statistically significant portion of the UK's healthcare workforce was emotionally exhausted from combating COVID-19 patients. Ayar et al. (2022) also highlighted that healthcare professionals had struggled with work-life balance, depression and mental health issues.
Moreover, throughout this pandemic, workplace violence against healthcare workers increased (Zhu et al., 2022). In the USA, 31% of healthcare workers were subjected to abusive behaviour by patients (Akther, 2021). According to a study from Canada, 75% of healthcare personnel were victims of workplace violence during this pandemic (Cregan & Kelloway, 2021). These problems worsened in low-and middle-income countries (LMIC) because they did not have enough healthcare facilities, staffing, planning and clinical equipment (e.g., personal protective equipment, ventilator support; Rony et al., 2021).
Since Bangladesh is an LMIC with a very high population density, the COVID-19 situation deteriorated here due to the scarcity of healthcare personnel and the small number of healthcare facilities already struggling to cope with increased demand for services (Hossain et al., 2021). Siddiqui (2020) mentioned that the country faced a 0.3 million-strong healthcare personnel deficit. However, nurses played a vital role in managing patients in the healthcare system because they worked closely with patients and spent most of their time at the patient's bedside. Previous studies investigated a limited number of variables on coping strategies that influenced frontline nurses to care for COVID-19 patients (Canestrari et al., 2021;Munawar & Choudhry, 2021;Özçevik Subaşi et al., 2021;Zhang, Jiang, et al., 2021;Zhang, Niu, et al., 2021). According

| Study design
A descriptive qualitative approach was used to explore the coping strategies that motivated frontline nurses in caring for COVID-19 patients. This approach was employed because it represents a realistic view of healthcare workers in a healthcare setting (Mulhall, 2003).
This study was initiated in three dedicated COVID-19 hospitals in Dhaka, Bangladesh. The findings of this study were presented using the Consolidated Criteria for Reporting Qualitative Research Checklist (Tong et al., 2007).

| Participants
Participants were recruited by purposive sampling from multiple COVID-19-specific hospitals in Dhaka City. The following criteria were used to choose participants: (i) have at least 1 year of experience working with COVID-19 patients. (ii) have worked in a healthcare facility with a capacity of 200 or more patients. (iii) be at least 23 years old.
One co-author was a frontline nurse who participated in the study because he met the inclusion criteria. As a result, to avoid bias, the co-author was not involved in the data collection process. Before data collection, investigators provided detailed information about the data collection procedure, potential risks and participant rights.
The participants' availability determined the interview schedule.
In this study, the sample size was estimated using the data saturation process. It indicates the most effective coping mechanisms revealed by frontline warriors exposed to COVID-19 in challenging medical settings. Data saturation was reached until new coping techniques were identified from the participants (Chew et al., 2021;Coyne & Cowley, 2006). Two more participants were interviewed to verify data saturation. The characteristics of participants are represented in Table 1.

| Questionaries development
The validity and reliability of the questionnaire were determined in two phases. In phase-I, questions were sent to two public health research experts for review and then were amended based on their feedback. In phase-II, pilot research was conducted to clarify respondents' understanding and eliminate any ambiguity. Finally, three open-ended questions were used to investigate data about how nurses coped in managing COVID-19 patients in a healthcare setting, including.
• What has your experience been with COVID-infected patients?
• How have you been inspired to deal with COVID-19 patients?
• How did you cope with the challenging COVID-19 situation?

| Data collection
Data were collected from three COVID-19-specific hospitals in Dhaka between December 2021 and March 2022. One co-author abstained from data collection to avoid bias because he was a frontline worker and participant in this study. Other authors gathered email addresses from hospital administration and then sent an invitation email to frontline nurses who met the inclusion criteria. If they accepted, respondents were invited to participate in an in-depth online interview session with semi-structured questionnaires via the Google Meet platform for 50-60 min. All interview sessions were conducted entirely in Bengali. Audio and video recording of the interviews were done for data interpretation and analysis. The interview session was scheduled at the convenience of the participants.

| Data analysis
Three authors separately listened to recorded interviews multiple times and then transcribed the participant quotes. The authors then mailed each respondent's quotes back to the same respondent to verify data accuracy and internal validity. Participants' acknowledgment and confirmation of the quotes were kept. Irrelevant quotes that did not match the study's objectives were removed. Only data related to the study purpose were kept for the final analysis and translated from Bangla to English. After that, an expert translator reviewed the data set for originality. Secondly, the authors extracted codes from primary data individually. Thirdly, the authors eliminated duplicate codes and then similar codes were separated to form subthemes ( Figure 1). Following that, emerging themes were developed.
Thematic analysis is a method academics use to find deep insights into a phenomenon and discover the connections between variables (Alhojailan, 2012).

| Ethical considerations
The International Nursing College, Bangladesh, review committee approved this study (HRM/INC/319/1/11/2021). Before the interview began, participants were informed about the right to withdraw from the research and that their voluntary nature of participation. In addition, participants' scanned signatures were obtained through email prior to conducting the online interviews.
Participants were assured that their information would be kept confidential.

| Rigour
The trustworthiness of this study was determined based on the following four criteria: credibility, transferability, dependability and confirmability: (i) member checking was used to verify that the primary data collection was credible; (ii) an audit trail was maintained by retaining the original data set's evidence (audio recording and handwritten datasheet); the audit trail demonstrates that the investigation has derived evidence-based findings; (iii) each author examined the data independently to confirm the study's dependability; (iv) triangulation was used to determine the confirmability of this study's findings; (v) data saturation was achieved to assure transferability.

| Characteristics of the participants
Seventeen respondents participated in this study with the majority (n = 13; 76.47%) being female. Their ages ranged from 25 to 41 years (mean = 31.5 years; SD = 3.54). Participants' working experience ranged between 2 and 17 years (mean = 1.77 years; SD = 7.25).
Twelve nurses were married and four were unmarried while one was divorced. In term of religious belief, 13 nurses were Muslim, three were Hindu, and one was Christian.

| Thematic analysis
Seven themes were identified from the data analysis that described how frontline nurses coped with the COVID-19 pandemic while caring for the coronavirus-infected patients.

| Motivated by professional obligations
In a nutshell, a nurse's professional obligations describe the most fundamental things related to nursing practice and the objectives of nursing. It helps shape one's career as a nurse and points one toward the areas of expertise. In this study, nurses were committed to their belief that, as nurses, they should always be able to care for patients, which encouraged them to give comprehensive care during the pandemic circumstances.

| Recreational activities
Participating in recreational activities has been related to improved mental health, higher self-confidence and independence, a more fertile imagination and a more satisfying sense of accomplishment. We explored that nurses used various recreational activities to reduce stress because their leave was limited, and going out was restricted due to lockdown.

| DISCUSS ION
Due to the unprecedented number of coronavirus infection cases during the pandemic, medical facilities worldwide had a difficult time treating infected individuals. This study investigated how frontline nurses dealt with COVID-19-infected patients during that challenging clinical situation using various coping strategies. We revealed that nurses were able to tackle the pandemic issue from their positive enthusiasm in dealing with the challenging situation created.

Nursing intervention is efficiently accomplished when nurses have
a positive interest about their workplace (Dobrowolska et al., 2021;Jiang et al., 2021). Positive interest at work results in higher levels of service quality (Othman & Nasurdin, 2019). According to Kim-Soon et al. (2022), there is a strong link between nurses' positive interest in nursing care and patient satisfaction. Because a positive attitude assists nurses in adjusting to difficult situations by eliminating factors associated with an adverse working environment (Kim et al., 2018), Badu et al. (2020) also discussed that nurses' positive interest in performing clinical responsibilities is one of the most critical tactics in dealing with workload situations that encourage nurses to engage in hands-on care. Moreover, the positive patient outcomes in healthcare organizations largely depend on nurses' positive attitudes toward patient management (Nashwan et al., 2021). Several studies have demonstrated that a nurse's negative attitude significantly affects providing appropriate nursing care (Rayner et al., 2019;Weare et al., 2019). However, developing coping strategies enhances the nurses' interest in handling critically ill patients .
During this pandemic, the influence of intimate partners of nurses contributes as a source of coping strategies to adjust to the stressful hospital environment. Intimate partners' support helps healthcare workers feel more confident mentally, which allows them to avoid emotional distress (Sundborg et al., 2018). Supportive intimate partners considerably contribute to constructing a healthy work-life balance (Jack et al., 2019), positive feelings about one's job (Alvarez et al., 2018), higher-quality service (Ogbe et al., 2020) and psychological well-being (De Kock et al., 2021), all of which boost nurses to manage a stressful working condition (McLindon et al., 2018).
Employees who receive adequate support from an intimate partner are more likely to engage in high-quality work (Keynejad et al., 2020).
Additionally, the positive influence of an intimate partner might be beneficial in maintaining one's determination, managing work-family conflict and engaging efficiently at work (Bermele et al., 2018). In contrast, the negative impact of an intimate partner creates poor attention at work (Anderson et al., 2018), job burnout and dissatisfaction, which lessens job interest and makes it more challenging to continue the job (Deen et al., 2022).
The current study revealed that nurses could maintain selfcontrol while caring for COVID-19 patients amid the terrible pandemic. Emotional self-control enables nurses to handle their job workloads better and develop self-confidence and self-resilience (Hatami et al., 2022;Rony et al., 2022). It can help resolve workrelated conflicts by developing work engagement, empathy for patients and passion for nursing tasks in the clinical setting (Cuartero & Tur, 2021). This coping technique also develops nurses' ability to make proper decisions in the healthcare setting and sustains nurses' emotional adjustment by recognizing unpleasant feelings associated with working circumstances (Cooper, 2018 avoid negative things such as annoyance, hostility and anxiety (Lee & Jang, 2019).
During the COVID-19 situation, nurses ignored negativity related to COVID-19 news that dramatically impacted their ability to become mentally strong. Nurses avoided negative news about COVID-19 to avoid suffering from psychological distress. This coping mechanism helps nurses handle the stresses of caring for critically suffering patients (Besirli, 2020). Cho and Steege (2021) investigated that avoiding negative things impacts nursing performance and can improve nurses' emotional well-being and professional commitment. Furthermore, avoiding negativity increases job happiness, job retention and productivity, with positive patient outcomes (Rasool et al., 2021). In contrast, if healthcare employees receive unfavourable information related to the workplace, this can depress their minds, leading to feelings of patient burden during patient care (Richards et al., 2022). Additionally, experiencing negative factors about working conditions impacts the reduction of mental strength (Zhang, Jiang, et al., 2021;Zhang, Niu, et al., 2021).
The current study explored nurses' professional obligations when dealing with COVID-19 patients during the pandemic. Nursing professional obligations embody nurses' ethics, values and motivations to give excellence in care for the patients (Ghazanfari et al., 2022;Suandika et al., 2021). It aids nurses in understanding professional objectives and nursing principles (McNett et al., 2021). Pajakoski et al. (2021) remarked that nursing professional obligations help nurses manage a less-than-ideal working environment and deliver better patient health outcomes. This coping strategy improves the problem-solving ability of nurses, influencing them to give higher-quality nursing care (Bayram et al., 2022). Furthermore, nursing professional obligations strengthen nurses' commitment to caring for critical patients (Adam et al., 2021). On the other hand, nurses' insufficient professional obligations suppressed their enthusiasm for patient bedside practice (Sapri et al., 2022).

| Implications of this study
This study's findings will aid nurses in adjusting to the workload, fostering positive psychological outcomes and enhance emotional self-

| Limitations and recommendations
In this study, an online interview was conducted with frontline nurses due to the COVID-19 protection limits and the convenience of frontline nurses. A few participants were private job holders. So, it is essential to conduct other studies on a large scale to find out the coping strategies adopted by frontline nurses working in the private job sector. In addition, to find more effective coping mechanisms, a qualitative study should be conducted with nurse managers and leaders who led frontline nurses throughout the COVID-19 pandemic. This would contribute to exploring different inspirational and survival strategies for nurses. It is recommended other studies be conducted to develop a coping scale instrument to assess the level of coping skills adopted by frontline nurses, which would aid in examining the relationship between the quality of nursing care and the use of coping mechanisms.

| CON CLUS IONS
Coping strategies help nurses have emotional self-control and give effective nursing care. The quality of patient care is highly dependent on how well a nurse can adopt their coping techniques to adapt to working environments. Coping strategies enable nurses deal with difficult situations and develop greater resilience in their workplace, particularly in resource-poor settings. Coping skills also assist nurses in maintaining psychological well-being and dealing with stressful working conditions. Moreover, coping mechanisms strongly influence nurses' ability to maintain a relatively healthy work-life balance. to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

ACK N O WLE D G E M ENTS
The authors are very pleased to-Professor Anisur Rahman Forazy

FU N D I N G I N FO R M ATI O N
There was no external fund taken for this current research.

CO N FLI C T O F I NTE R E S T S TATE M E NT
The authors' have no competing interest at all.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data sets used and analysed during the current study are available on reasonable request.

E TH I C A L A PPROVA L
The International Nursing College, Bangladesh, review committee approved this study (HRM/INC/319/1/11/2021). Before the interview began, participants were informed about the right to withdraw from the research and that their voluntary nature of participation.
In addition, participants' scanned signatures were obtained through email prior to conducting the online interviews. Participants were assured that their information would be kept confidential.