The concept analysis of helplessness in nurses during the COVID‐19 pandemic: A hybrid model

Abstract Aim ‘Helplessness’ is one of the psychological concepts that exploring nurses' helplessness during the COVID‐19 pandemic can lead to timely intervention and empowerment of nurses. Design Concept development. Methods It was carried out using Schwartz‐Barcott and Kim's hybrid model. Results In the literature review, helplessness is characterized by anxiety symptoms (muscle tension, headache, anorexia and insomnia) and, to some extent, depression (loneliness, guilt, apathy and insensitivity). In the fieldwork, five categories were obtained, including antecedents of helplessness (the nature of the disease, professional responsibility, personal lifestyle disruption and social behaviours), attributes of helplessness (inability to do more for the patient, inability to control the situation, feeling of uselessness, frustration, giving up and uncertainty to continue), consequences of helplessness (increase clinical error, physical manifestations and psychological manifestations), strategies to reduce feelings of helplessness and the difference among helplessness, powerlessness and hopelessness. Conclusion Nurses' helplessness occurs when the nurse has no control over the situation and cannot change it.

situation (Tarzian, 2000) or a feeling of inadequacy for the patient (Farrell, 1989). The feeling of inability to help further relieve the physical stress of dying children and the psychological stress of their families are perceived by nurses as a feeling of 'helplessness' (Olofsson et al., 2003). Physicians feel helpless in response to increasing patient dependence and the physician's need for more time, especially when the patient requests that the physician cannot fulfil (Meier et al., 2001).
In psychology, 'helplessness' is confirmed by a person's verbal report, indicating discouragement, dissatisfaction, pessimism about the future, crying, boredom and guilt (Renan Alves et al., 2017).
In the past, the concept of 'helplessness' in psychology has been defined by two theories 'learned helplessness' and 'helplessnesshopelessness'. In the theory of learned helplessness, Seligman et al. said 'helplessness' is experienced when a person realizes that his or her response has no effect on the outcome, and as a result of this cognitive error, the motivation to respond is weakened. In the theory of 'helplessness-hopelessness', anxiety and depression with the feeling of 'helplessness' are described as expecting negative consequences in the future that are uncontrollable (Seligman, 1975).
Nurses' experiences of helplessness differ from explaining this concept in the form of theories (Drew, 1990), and to date, a clear definition and its characteristics have not been provided in nursing.
In addition, there is a conceptual overlap of helplessness in scientific texts with other psychological concepts such as powerlessness and hopelessness (Pan & Chiou, 2004). While each concept of powerlessness and hopelessness is related to a particular state of mind and describes different sensations, 'helplessness' occurs when a person believes that necessary action has been taken, resulting in a feeling of inability to work harder and maintain energy. According to the latest NANDA nursing diagnoses, definitions and classification, hopelessness is defined as 'the feeling that one will not experience positive emotions or an improvement in one's condition', and powerlessness is 'a state of actual or perceived loss of control or influence over factors or events that affect one's wellbeing, personal life, or the society'. (Herdman et al., 2021).
During the COVID-19 pandemic, healthcare providers' workloads have increased. In the meantime, nurses ignoring their needs have accepted their moral and professional responsibility in caring for patients. Wearing personal protective equipment during long working hours can lead to physical stress (Ornell et al., 2020;Sun et al., 2020;Tan et al., 2020;White, 2021). In addition, the feeling of insecurity against infection and transmission to family members, observing the suffering of patients in the absence of the family and the family's suffering away from the patient's bedside have caused severe psychological stress for nurses (Allahverdipour, 2020;Hacimusalar et al., 2020). Studies have shown that when nurses have close contact with patients with emerging infectious diseases, they experience loneliness, anxiety, fear, fatigue, sleep disorders and other physical and mental health problems (Nelson & Lee-Winn, 2020;Sun et al., 2020).
In caring for COVID-19 patients, feelings of helplessness have been described as the inability to help patients and families, thinking about continuing the disease indefinitely and frustration with wearing personal protective equipment (Allahverdipour, 2020). All in all, the nurses faced a situation that was painfully unknown to them.
Most of them had enthusiastically and selflessly started caring for the patients, hoping that their efforts would pay off and they would soon return to society in good health, but they faced a situation that was indescribable and exhausting for them and in their evaluations.
They did not meet the desired results and had not reached according to the provision of their services. The health services providers did not have a precise definition of this phenomenon and did not know its dimensions and cause scientifically and clearly, and they needed to know this new situation well. The community providing health services needed to receive sufficient support and be empowered in this situation, and this was not possible without identifying all aspects of the helplessness phenomenon created in the care of patients with COVID-19. Helplessness can threaten the nurse's physical and mental health and affect the quality of care and his/her physical and mental health. The new experience of nurses' helplessness in dealing with the COVID-19 pandemic needs a more in-depth study and a more appropriate definition. Accurate and timely diagnosis of helplessness as an abstract psychological response to acute conditions in nurses during the COVID-19 pandemic can lead to timely intervention and empowerment of nurses who demonstrate the characteristics of this concept. Therefore, we conducted this study to define helplessness and clarify it in nurses during the COVID-19 pandemic.

| PR AC TI C A L G OA L S
By clarifying the nurses' understanding of helplessness, a clear and precise definition of this concept can be provided in the nursing of COVID-19 patients. This definition makes it easier to understand the situations that nurses refer to as helplessness, avoids using other psychological concepts and introduces appropriate design tools to measure it. On the other hand, the need to prevent this phenomenon becomes apparent in the healthcare team, and the way to design prevention and support programmes for nurses becomes clear.

| THEORE TIC AL PHA S E
We conducted a literature review focusing on the conceptual definition and measurements of helplessness in nursing. The overall flow chart of the literature review is shown in Figure 1.

| FIELDWORK PHA S E
The fieldwork phase aims to confirm and purify a concept by developing and integrating the analysis started in phase 1 with ongoing empirical observations done in this phase. This phase includes four steps: selecting a research environment, entering into negotiations, selecting participants and collecting and analysing information (Schwartz-Barcott, 2000).
We selected the participants with a purposeful sampling method from a referral hospital for COVID-19. Bachelor's degree-level nurses with at least 3 of work experience in the COVID-19 pandemic who are willing to participate in the study and able to provide informed consent entered to the study.
Due to following physical distance rules during the pandemic, we conducted in-depth interviews using video calls (WhatsApp) and phone calls. Observational information on the clinical settings, which could not be collected through phone calls, was gathered through questions. Ten nurses participated based on their experience providing care to COVID-19 patients and observing the maximum variation in gender, age and work experience. All nurses had a history of being infected with COVID-19 (Table 2).
Data were collected using in-depth semi-structured individual interviews. At the beginning of this phase, an initial interview guide was prepared, which helped the researcher to ask more questions to explore the area. Lincoln and Goba's criteria (credibility, transferability, dependability and confirmability) ensured data quality (Lincoln & Guba, 1985).
In this regard, the researchers tried to increase the credibility of the findings by establishing appropriate interaction and in-depth interviews with the participants, immersion in data, interviewing the maximum variety of participants, writing field notes, peer checking the analyses and coding. A review by participants was also used. All research documents were carefully presented and recorded, including operational notes (basic information from the recording, field notes and memos) and theoretical notes (guidance questions, interview form and informed consent) to increase conformability.

| FINAL ANALY TIC PHA S E
The theoretical phase findings, experimental observations and qualitative data are integrated. Their results were compared, analysed and integrated (Bousso et al., 2009). In this phase, we paid attention to the practical situation of helplessness to make a useful definition that fits COVID-19. All categories in the previous phases were compared and analysed in relevance to yield themes that seemed supported through literature and fieldwork data (Ide-Okochi & Tadaka, 2016). The analytical approach of this phase helps to redefine the concept. We scanned the definition dragged from the theoretical phase approved in the fieldwork phase, what characteristics were in the theoretical phase but could not be verified in the fieldwork phase and what characteristics were not in the theoretical phase but verified in the fieldwork phase. Through this process, we found similarities and differences between the two phases and analysed them; then, we defined the concept with emphasis on the COVID-19 situation.

| E THIC AL CONS IDER ATIONS
The Research Ethics Committee has approved this study of the The meanings of helplessness and helpless in the Merriam-Webster dictionary are lacking protection or support, marked by an inability to act or react and being unable to be controlled or restrained (Merriam-Webster). In medical terminology, helplessness is defined as a 'state of incapacity, vulnerability, or powerlessness associated with the perception that one cannot do much to improve a negative situation that has arisen' (Merriam-Webster, 2021).

| Helplessness and related concepts in nursing
The oldest definition of helplessness in nursing is related to 'hopelessness and helplessness', published in 1964 (Shea & Hurley, 1964).
Two nurses named Shea and Harley defined hopelessness as 'the feeling that any attempt to positively change a patient's condition is doomed to failure before it is made' and helplessness as 'The belief that everything that can be done has been done, which leads to an inability to conserve energy and make an effort'. (Shea & Hurley, 1964).
Carlson and Blackwell defined helplessness in 1970 as 'a complex syndrome of emotions, thoughts, and behaviors that occurs when events are out of control'. In other words, everything that can be done has been done, and no action significantly affects the result.
Helplessness is the feeling of drowning due to losing control over the surrounding world (Carlson & Blackwell, 1978). In 1985, Clifford defined the concept of helplessness in nursing care as 'the feeling of being broken by losing control of the surrounding environment' (Clifford, 1985).
In 1990, Drew explored the concepts of helplessness, hopelessness and powerlessness based on Erickson's theory and explained their differences. He proposed hope versus hopelessness, purpose and skill versus powerlessness and willpower and selfcontrol versus helplessness (Drew, 1990;Pan & Chiou, 2004).
Studies showed that helplessness would have different somatic, emotional and cognitive manifestations depending on the individual's perspective and previous experiences, but participants in all studies have experienced helplessness as feeling useless due to a lack of control over the situation (Back et al., 2015;Meier et al., 2001;Tarzian, 2000).
Helplessness is an inevitable experience for nurses and physicians who work with severe illnesses (Back et al., 2015). There are two models of 'less involvement' in physicians and 'excessive involvement' in nurses in the helplessness experience. While the physician withdraws and behaves passively and insensitively, nurses feel pressured, anxious and even frustrated because the professional structure puts them in a position of 'unauthorized responsibility', which means nurses feel responsible for alleviating the suffering caused by the patient's medical decision while not being allowed to change or challenge the decision (Back et al., 2015).
The findings of the review of studies of helplessness in other populations related to nursing, including patients and their families, are summarized in Table 1.

| Helplessness scales
The search for a tool to measure helplessness in different populations and nurses had no results. Existing tools measure the phenomenon of learned helplessness in the patients or caregivers. (Lovibond & Lovibond, 1995;Omachi et al., 2010;Quinless & Nelson, 1988).

| Nurses' helplessness in the COVID-19 pandemic
The significant increase in the hospitalization of patients during the COVID-19 pandemic had a significant impact on nurses. Nurses experienced anxiety, depression, post-traumatic stress disorder and unresolved grief (White, 2021). Nurses caring for patients with COVID-19 frequently reported feeling a sense of helplessness (Kellogg et al., 2021). Qualitative studies of nurses' experiences during the COVID-19 pandemic revealed that nurses were more likely to report feelings of helplessness; when nurses felt that their efforts for the patients were not enough (while they wanted to help the patients more, it was not possible), and when the nurses were unable to meet their physical and mental needs. In addition, increased workload, lack of information about the disease, the need to wear personal protective equipment (PPE), fear of disease transmission to family and friends and social isolation have caused loneliness and helplessness in nurses (Gordon et al., 2021;Ornell et al., 2020).
In a phenomenological study, Sun et al. showed that nurses report fear of making mistakes or not doing enough for patients as a precondition for negative emotions such as anxiety and helplessness; failing to meet their physical and psychological needs brought a sense of helplessness (Sun et al., 2020). In the study on front-line nurses' experiences treating COVID-19 patients, nurses stated that the feeling of uselessness in nursing care has contributed to helplessness and powerlessness (Tan et al., 2020). In another study, nurses experienced a deep sense of helplessness when they felt that their learning and experiences in the nursing profession could not help the patients. They inevitably observed the patient's suffering and could not do anything (Gordon et al., 2021). Nurses expressed wanting to do more to help their patients and described how it was often beyond their control to TA B L E 1 Characteristics of the concept of helplessness in reviewed studies published before COVID-19.
Author and year Study population Concept properties Clements & Cummings, 1991 Nurses caring for patients with pain The inability to provide comfort to clients with pain caused nurses to feel helpless with frustration characteristics, leading to the avoidance of patients and apathy Farrell, 1989 Nurses and families of dying patients Not being helpful to the loved one in the final time led to a sense of helplessness, resulting in guilt in nurses and families Olofsson et al., 2003 Paediatric nurses The lack of time for optimal care of patients makes nurses experience emotions of frustration, powerlessness, hopelessness and inadequacy because they feel unable to influence the situation Tarzian, 2000 Patients with respiratory distress Nurses responded to the patient's loss of control and their own sense of helplessness by avoiding patients suffering from air hunger Meier et al., 2001 Physicians of seriously ill patients Physicians developed a sense of helplessness related to patients increasing dependency and demands on the physician's time, and against the impossible request and began to avoid patients Milberg et al., 2004 Relatives of patients in palliative care Helplessness concerned the next of kin's perception of the patient's suffering and the next of kin's own feelings of insufficiency and resulted in both physical and psychological symptoms, such as muscle tension, headache, loss of appetite, anxiety and depression. Helplessness is related to feelings of guilt, anger and loneliness. Samuelsson et al., 2002 Fathers experienced stillbirth Fathers felt inadequate to protect their partners and experienced helplessness. Farrell, 2002 Families of patients with ovarian cancer Family members experienced helplessness due to not being helpful to the loved one in the final time. Lindholm et al., 2002 Significant others of patients with breast cancer Significant others' experienced helplessness when they could not influence the situation during the patient's suffering. Mehta & Ezer, 2003 Spouses of patients with pain Spouses described helplessness when witnessing their loved one in pain, which is tied to a sense of loss of control, uselessness and the inability to influence the situation change their conditions (Kellogg et al., 2021). In White's study, nurses described having to give up the 'meticulous care' they usually provided and only being able to do the 'basics' for patients causing them to feel helpless (White, 2021). Medical students at the forefront of COVID-19 treatment have expressed frustration and helplessness with phrases such as 'I want to cry' and 'I think about leaving the field every day'. The researcher states in this article that if they ignore the problem of helplessness and ways to reduce it in these students, they will suffer from 'learned helplessness' in the next phase and emphasizes that efforts should be made to prevent it as much as possible (Shaw, 2020

| Fieldwork phase
The findings of the fieldwork phase were classified into five main categories: antecedents of helplessness, attributes of helplessness, consequences of helplessness, strategies to reduce feelings of helplessness and the difference among helplessness, powerlessness and hopelessness. Characteristics derived from the concept of helplessness in the theoretical phase and fieldwork phase are shown in Table 3.

Antecedents of helplessness:
The antecedents of helplessness were categorized into four subcategories: the nature of the disease, professional responsibility, personal lifestyle disruption and social behaviours. A female nurse defined the strange and unknown nature of the disease in this way: We did not know what would happen to the patient in 2 min, and this was very strange … the distance between life and death was very short … while the patient was fully awake, talking, and drinking fluids, he/she was not in bed tomorrow … and it bothered me mentally, especially if he/she was young.
Another nurse mentioned her sense of professional responsibility in the COVID-19 pandemic and said: We had no choice but to adapt to the situation … because there was no more workforce and co-workers who wanted to support us and cover our shifts so that we could have a short rest … There was no other way.
The COVID-19 pandemic has disrupted the lifestyle of nurses, as one of the participants described the situations that made her feel helpless: Helpless means that my husband and I are sick, and I have a 4-year-old child at home, for whom I had to prepare different food and put it in a separate room. My son wanted us to hug him … I had to go on shifts, too.
The increase in the number of patients due to non-observance of health protocols made nurses helpless: We were helpless. We were tired because we saw that some people did not follow the health protocols, the number of patients was increasing day by day, our wards were all full, and our colleagues were getting infected one by one.

| Attributes of helplessness
The fieldwork results showed that nurses' attributes of helplessness during the COVID-19 epidemic included the inability to do more for the patient, inability to control the situation, feeling of uselessness, frustration, giving up and uncertainty to continue. One of the critical care nurses experienced helplessness in this situation: In the face of this disease, when I could not help the patient, I felt helpless … One was dying in front of my eyes, and I could not do anything.
The patient's non-response to nursing care made the nurse feel helpless and inadequate: The patient who had come was breathing, talking, and what happened was that suddenly his condition got worse in an hour or two! … We felt uselessness, we felt empty.
We saw that the patient was getting worse day by day. You do whatever you must do, but it does not affect the patient's recovery, causing a feeling useless.

TA B L E 2
Demographic and occupational information of the participants.

Variables Participant information
Age ( TA B L E 3 Characteristics derived from the concept of helplessness in the theoretical phase and fieldwork phase.

Theoretical phase Fieldwork Analytical phase
Antecedences Inability to provide comfort to clients with pain (Clements & Cummings, 1991) Not to be helpful to the loved one in the final time (Farrell, 1989) Perception of patient's suffering (Gordon et al., 2021;Lindholm et al., 2002;Mehta & Ezer, 2003;Milberg et al., 2004;Tarzian, 2000) Patients' increasing dependency and demands on the physician's time, and against the impossible requests (Meier et al., 2001) Fears of disease recurrence (Ferrell et al., 2002) COVID-19 knowledge and intervention deficit, the need to wear personal protective equipment (PPE) and fear of disease transmission to family and friends (Gordon et al., 2021;Ornell et al., 2020;Sun et al., 2020;Tan et al., 2020) The nature of the disease The problems and challenges in nursing care related to nature of disease Lack of time for 'meticulous care' for patients (Olofsson et al., 2003;Sun et al., 2020; White, 2021) Heavy workload (Kellogg et al., 2021;Ornell et al., 2020;Sun et al., 2020;Tan et al., 2020) Professional Responsibility Insufficient professional responsibility When the nurses were unable to meet their physical and mental needs (Gordon et al., 2021;Ornell et al., 2020;Sun et al., 2020;Tan et al., 2020) Social isolation (Gordon et al., 2021;Ornell et al., 2020;Sun et al., 2020;Tan et al., 2020) Personal lifestyle disruption Social and family isolation Lifestyle disruption

Attributes
Inability to act or react. Not able to be controlled or restrained and incapacity (American Psychological Association, 2021;

Frustration
Thinking about leaving the field (Shaw, 2020) Uncertainty to continue Indetermination

Consequences
Avoidance of patients (Clements & Cummings, 1991;Meier et al., 2001;Tarzian, 2000) Absence of response (Olofsson et al., 2003) Affect the quality of care (Tan et al., 2020) Threaten safety Safety threats Stress, irritability, physical and mental fatigue and despair (Ornell et al., 2020) Muscle tension, headache, loss of appetite, sleeplessness, anxiety/worry, depression, feeling of loneliness and anger (Milberg et al., 2004;Sun et al., 2020) Anxiety, dependence, withdrawal and demoralization (American Psychological Association, 2021) Apathy (Clements & Cummings, 1991) Guilt (Farrell, 1989;Milberg et al., 2004) Self-blame (Tan et al., 2020) Crying (Shaw, 2020)  We felt helpless…, we said let it be whatever it wanted; we really could not stand these clothes anymore. It is not easy to work in these conditions. When my body gets tired of doing a heavy activity, I experience powerlessness that goes away with one to two hours of rest, but when I feel helpless, I am mentally and emotionally tired, and it may bother me for 2-3 weeks to get out of my mind.

Participants experienced differences between helplessness and hopelessness:
When you feel helpless, when you see that everything you do is not working for her, hope may be very dim, but you still have hope.

| Findings from the final analysis
According to the literature review, helplessness is a mental concept and a negative psychological feeling that nurses experience when they cannot comfort patients while perceiving their suf- likelihood of feeling helpless has increased because they could not meet their physical and mental needs and lived in social isolation for a long time.
In helplessness, the person feels unable to help themselves or anyone else. When the nurses feel unable to influence the situation and have no control over it, care is not helpful to the patient and feeling of uselessness, insufficiency, inadequacy, ineffectiveness and frustration, they feel helpless and think about leaving the field repeatedly.
Helplessness causes numerous physical and psychological symptoms. A helpless nurse experienced anxiety symptoms (muscle tension, headache, loss of appetite and sleeplessness) and, to some extent, depression (loneliness, guilt, crying, self-blame, apathy and irritability). These physical and psychological changes cause avoidance of patients, absence of response and affect the quality of care.
Helplessness differs from powerlessness and hopelessness, which in some cases have overlapped with these concepts.
In the second phase of the study, the results of the fieldwork showed that the antecedents of helplessness emergence during the COVID-19 pandemic include the nature of the disease, professional responsibility, personal lifestyle disruption and social behaviours.
These findings are along with the results of the first phase in aspects of patient care, professional responsibility and personal lifestyle disruption affecting the occurrence of helplessness in nurses. The social behaviours that lead to nurses' helplessness were not found in the literature.

Attributes of nurses' helplessness in the COVID-19 epidemic
include the inability to do more for the patient, inability to control the situation, feeling of uselessness, frustration, giving up and uncertainty to continue. These findings confirm the results of the first phase.
There was no difference between the consequences of the helplessness found in the first and second phases. A helpless nurse experiences anxiety and depression symptoms. During the COVID-19 pandemic, nurses who experienced helplessness stated that their and their patients' safety had been threatened.
Most nurses try to control feelings of helplessness by maintaining hope, supporting colleagues, caring for themselves and taking refuge in spiritual beliefs. Some nurses also try to eliminate this feeling by taking extended sick leave or requesting resignation. In the first phase, no results were found to compare with the findings of the second phase of this study, which shows the strategies of nurses to manage helplessness during the COVID-19 pandemic. In phase 2 of this study, nurses repeatedly used powerlessness and helplessness and compared the two concepts. According to their experience, helplessness is much more enduring than powerlessness, does not decrease with rest and there is no relationship between workload and the intensity of feeling helpless. They believed that powerlessness was more tolerable than helplessness. Also, nurses referred to maintaining hope while being helpless. In helplessness, nurses are discouraged from improving the condition, but they are not hopeless. With hope, they believe that they will feel better in the future.
Thus, they actively sought new information about how to care for and treat COVID-19 disease. The differences and overlapping of these three concepts were also found in the first phase of this study.

| DISCUSS ION
Regarding the antecedents of helplessness, nurses felt helpless by observing non-compliance with health protocols that increased the number of patients. According to this finding, Brazilian and Italian nurses, tired and helpless from caring for the large number of patients with COVID-19, have appealed to all citizens through social media, asking them to 'stay home' and follow public health recommendations (Fontanini et al., 2021;Forte & Pires, 2020 (Sun et al., 2020). In the COVID-19 pandemic, in addition to increased workload, lack of information on how to transmit, manage and treat the disease, the need to wear personal protective equipment (PPE), fear of transmitting the disease to family and friends and subsequent social isolation of nurse's caused loneliness and helplessness in nurses (O'Boyle et al., 2006;Ornell et al., 2020;Sun et al., 2020) -observing the sufferings of patients and families who had been far apart have also caused severe psychological stress, including a sense of helplessness for nurses (Nelson & Lee-Winn, 2020;Sun et al., 2020). An antecedent of helplessness that was presented in the articles but did not appear in the results of the fieldwork phase is that nurses feel trapped in the decisions of physicians, patients and families and feel responsible for alleviating the suffering caused by the patient's medical decision, while not being allowed to change or challenge the decision (Back et al., 2015).
To the findings of the second category of attributes of helplessness, nurses' uncertainty to continue nursing or to resign in situations where they and their families were at risk was identified. Feelings of doubt and hesitation have been identified as an essential component of anxiety (Back et al., 2015) and as one of the underlying factors of feelings of helplessness (Sand et al., 2008). Regarding the subcategory of feelings of powerlessness, Tarzian (2000) showed that nurses of dying patients experienced 'helplessness' due to the impossibility of administering more narcotics at the patient's request to reduce pain and attributed it to the inability to control the condition (Tarzian, 2000).
Nurses of dying children perceive helplessness as the inability to help further relieve children's physical stress (Olofsson et al., 2003).
Helplessness has also been experienced due to the inability to provide patient care in telenursing care models (Arneson et al., 2020). About the subcategory of feeling uselessness, nurses have reported 'helplessness' in caring for dying patients in the form of feelings of inadequacy. Also, based on the experiences of front-line nurses in treating COVID-19 patients, the feeling of uselessness in patient care has been the antecedent of a sense of inability and frustration (Tan et al., 2020).
The feelings of fraction and diminution expressed by the nurses' speeches are standard terms in the Persian language, equivalent to helplessness and inability. The English equivalent of these two terms is to give up. Seligman often refers to the term give up as an example of helplessness (Seligman, 1975 (Back et al., 2015).
About distinguishing helplessness from the powerlessness and hopelessness category, other studies pointed out that these concepts overlap, as in the study of Milberg et al. (2004) and Clements and Cummings (1991) that the concepts of powerlessness and helplessness were used synonymously (Clements & Cummings, 1991;Milberg et al., 2004). In 1990, Drew examined the concepts of helplessness, hopelessness and powerlessness separately based on Erikson's theory and explained their differences. Considering their conceptual proximity, he proposed their opposite concepts: hope versus despair, purpose and skill versus disability and willpower and self-control versus helplessness (Drew, 1990). Some features of helplessness extracted from the results of the fieldwork reflect the definition of powerlessness in NANDA nursing diagnoses, definitions and classification. NANDA defines powerlessness as 'a state of actual or perceived loss of control or influences over factors or events …' (Herdman et al., 2021). In this study, uncertainty in roleplay, depression, insufficient participation in care, lack of control and guilt are common features of helplessness and powerlessness.
There is also a fine line between the characteristics of helplessness and hopelessness. In NANDA's nursing diagnoses, definitions and classification, the attributes of hopelessness include a change in sleep patterns, loss of appetite, expression of words indicating discouragement and insufficient involvement in care (Herdman et al., 2021) which are consistent with the attributes of helplessness found in this study.
Generally, nurses experience helplessness during the COVID-19 pandemic, similar to before, especially in attributes and consequences. Most of the differences are in the antecedents of helplessness. In non-pandemic conditions, the nature of the disease (e.g. being chronic and incurable) had the most significant impact on the incidence of nurses' helplessness (Clements & Cummings, 1991;Farrell, 1989;Olofsson et al., 2003). While during pandemics, the significant effects of the disease on nurses' personal lives, their confrontation with professional and moral conflicts and even people's social behaviours were important antecedents of helplessness in nurses. The results of the fieldwork show that the consequences of nurses' helplessness correspond to the characteristics of anxious and somewhat depressed moods. Nurses used self-control and willpower techniques as positive defence mechanisms against feelings of helplessness and expressed hope during this phenomenon.

| CON CLUS ION
Nurses' helplessness is a mental concept and is a negative psychological feeling that has the characteristics of anxiety and depression. It occurs when the nurse feels he/she has no control over the situation and cannot change it, her knowledge and care are not helpful for the patients and she/he cannot help the patient further. Helplessness is a feeling that many nurses experience during the COVID-19 pandemic. Challenges in nursing care related to the nature of the disease and heavy workload caused a sense of insufficient professional responsibility in nurses. Also, nurses experienced social and family isolation and lifestyle disruption during COVID-19. With such conditions, they feel helpless in the forms of feeling unable to be effective for the patient, incapacity, loss of control, uselessness, frustration and indetermination. Changes occur in the nurse's physical and psychological state, along with the feeling of helplessness, which threatens the safety of herself/himself and her/his patients.
Therefore, diagnosing the clinical manifestations of helplessness makes it possible to treat the diagnosed cases, manage human resources and reduce harm to staff. Moreover, on the other hand, with timely intervention, its adverse effects on patients can be prevented. Given the importance of the issue and the fact that this type of helplessness may occur in other medical groups that interact directly with the patient, similar research is recommended.

| LI M ITATI O N S
This study was conducted during the COVID-19 pandemic, which limited face-to-face interviews due to health protocols. The interviews were conducted by telephone or online (WhatsApp), so collecting observational data from clinical settings was impossible.

ACK N O WLE D G E M ENTS
The

FU N D I N G I N FO R M ATI O N
This study was not funded by any institute and was supported by the Tehran University of Medical Sciences (TUMS) with grant no: 99-2-101-49387.

CO N FLI C T O F I NTE R E S T S TATE M E NT
None.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing is not applicable to this article as no datasets were generated or analysed during the current study.