Nurses' experience of work stress related to COVID‐19 regular prevention and control in China: A qualitative study

Abstract Aim To explore the experiences of nurses' work stress related to COVID‐19 regular epidemic prevention and control in China. Background The global COVID‐19 epidemic is still severe, and China's ongoing regular epidemic prevention and control still cannot be relaxed, which places demands on nurses. Methods Thirty nurses and eight nurse managers were interviewed using semistructured in‐depth interviews, and the data were analysed by the Colaizzi seven‐step analysis method. Results Four themes were extracted as follows: environmental factors, organizational factors, personal factors and positive factors in coping with stress. Conclusions Nursing managers should pay attention to construction of the first‐line departments of regular epidemic prevention and control. The shortage of nurses' human resources and the increase of nurse–patient conflicts are problems that need to be solved urgently. In addition, this research also emphasizes the importance of promoting nurses' stress‐related growth and thinking about the possibility of reform. Implications for Nursing Management The construction of the hospital environment and increasing the resilience of nursing teams require attention. We should attach importance to the training of nurses' communication skills and provide sufficient organizational support and economic guarantees for nurses. Finally, perhaps we should also consider whether it is necessary to reform the relevant hospital systems and how to reform them.

to be solved urgently. In addition, this research also emphasizes the importance of promoting nurses' stress-related growth and thinking about the possibility of reform.
Implications for Nursing Management: The construction of the hospital environment and increasing the resilience of nursing teams require attention. We should attach importance to the training of nurses' communication skills and provide sufficient organizational support and economic guarantees for nurses. Finally, perhaps we should also consider whether it is necessary to reform the relevant hospital systems and how to reform them.

K E Y W O R D S
COVID-19, nurse, qualitative research, regular epidemic prevention and control, work stress 1 | BACKGROUND According to the information provided by the WHO, as of 13 October 2021, there were 238,521,855 confirmed cases of COVID-19 worldwide, 4,863,818 deaths and more than 300,000 newly confirmed cases per day (WHO, 2021). The prevention and control of the epidemic is far from over, and we still need to attach great importance to it. Since the outbreak of the COVID-19 epidemic, hospitals have remained on the front line of prevention and control, and all medical staff have been under great pressure. As the largest group among medical staff and the closest contact with patients, nurses deserve our attention. Murat et al. (2021) found that nurses suffered high levels of stress and burnout and moderate depression during the outbreak of the epidemic in Turkey. Shahrour and Dardas (2020) found that 64% of nurses experienced acute stress disorder, and 41% of nurses had psychological distress during the outbreak of the epidemic in Jordan. A meta-analysis of the literature on the mental health status of front-line medical staff published between December 2019 and June 2020 showed that the incidence of depression among front-line nurses who participated in caring for COVID-19 patients during the outbreak of COVID-19 was 28%, and the incidence of anxiety was 22.8% (Salari et al., 2020). Since April 2020, the epidemic in China has been well controlled, and China has entered the stage of regular prevention and control . There have been many studies investigating the work stress and mental health of nurses during the outbreak period Tu et al., 2020;Zhan et al., 2020;Zhang, Miao, et al., 2020), but there were few studies on the work stress of nurses during the regular prevention and control period. Judging from previous experience, nurses' work stress during the regular prevention and control period must be much less than that during the outbreak period. However, Wu et al. (2020) investigated the incidence of burnout of front-line nurses and nurses in general wards during the outbreak period and found that nurses in general wards were more prone to burnout. This shows, on the one hand, that we may underestimate the level of work stress that nurses bear during the regular prevention and control period. Therefore, we designed this study to explore the work stress of Chinese nurses during the regular epidemic prevention and control period. Considering that Chinese hospitals have taken a series of measures to address regular epidemic prevention and control and that the working environment of nurses has changed greatly, the previous scale for measuring work stress may not be applicable to this study. Therefore, this study adopted the phenomenological approach in qualitative research to explore the work stress experience of nurses related to regular epidemic prevention and control. The global COVID-19 epidemic is still severe, and the findings of this study may provide some references for other countries to respond to the epidemic in the future.

| METHODS
This study is qualitative. A phenomenological approach was used to explore the theme of nurses' work stress experience during COVID-19 epidemic regular prevention and control. And this study was conducted in January 2021.

| Theoretical framework
Robbins' occupational stress model (Fradreck, 2018;Humayon, 2018) was used as the theoretical framework of this study. The stress model identified three potential stressors: environment, organization and individual. Based on this, a semistructured interview outline of nurses' work stress experiences during regular epidemic prevention and control was compiled.

| Participants
The subjects of the study were mainly nurses and head nurses who worked in the clinic during the regular prevention and control period in two hospitals in East China and North China. The sampling methods were convenience sampling and snowball sampling. The inclusion criteria were as follows: (a) having a nurse qualification certificate, (b) participating in clinical work for ≥3 months during the regular epidemic prevention and control period and (c) being willing to participate in this study. Nurses and head nurses from various hospitals and multiple departments in the same hospital were selected to ensure the adequacy of the samples. The sample size was ultimately determined by information saturation.

| Data collection
The interview methods were face-to-face interviews and WeChat voice interviews. Face-to-face interviews were conducted in the nurses' free time or after work and in quiet lounges or offices.
WeChat voice interviews were scheduled with the interviewees in advance and were conducted when the interviewees were resting at home or in other quiet places. Before the interview, the researcher informed the interviewees of the purpose, significance, anonymity and confidentiality of the study. The consent of the interviewee was sought for the recording, and the dissenters only took notes. The duration of each interview was approximately 20-60 min. During the interview, more in-depth questions or new related topics could be discussed according to the actual situation.

| Interview outline
Based on Robbins' occupational stress model (Fradreck, 2018;Humayon, 2018), an interview outline was developed under the guidance of experts with qualitative research experience. After the outline was initially formed, two nurses who participated in clinical work during regular epidemic prevention and control were selected for preinterviews, and the interviewees were asked to point out unreasonable problems in the interview outline. The interview outline was modified according to the pre interview results, and the final outline was completed after being reviewed and approved by experts. The outline of the nurse (head nurse) interview is as follows: ① What stress has the regular epidemic prevention and control put on you

| Data analysis
The recordings were listened to repeatedly, and the recording data were transcribed verbatim. Members of the research team jointly verified the transcribed content. The transcribed text was imported into the qualitative research software NVivo 12.0 plus, and the data were encoded and refined according to Colaizzi's seven-step analysis method (Colaizzi, 1978).

| RESULTS
A total of 30 nurses and 8 head nurses were interviewed. The basic information of the interviewees is shown in Table 1. Five nurses were nonrecorded, represented by N1-N5, and the rest were represented by NA-NY. Ns1-Ns8 was used to represent the head nurses.
Four themes were extracted as follows: environmental factors, organizational factors, personal factors and positive factors in coping with stress. The first three themes were described under the framework of Robbins' stress model, which not only described the stressors of regular epidemic prevention and control but also described the stress experience of nurses. The last theme described the positive psychological experience of nurses in coping with the stress brought by regular epidemic prevention and control.

| Technical factors
The detection of novel coronavirus involves nucleic acid detection technology, which takes a long time from throat swab collection to nucleic acid test results. In the process of waiting for the results of nucleic acid detection, patients may conflict with medical staff due to lack of desired treatment and resistance to isolation measures. The nucleic acid test takes too long, and the patient loses

T A B L E 1 Basic information of interviewees
Due to the long time required for nucleic acid testing, nurses were also in a state of tension while accompanying patients waiting for results.
All patients are unknown. We do not know why he has a fever.
We still have some fear. After all, the epidemic is still serious. (NC) The results of the nucleic acid will not be known until tonight, but with this patient under our supervision all day, there must be pressure on your mind. (NI)

| Hospital environmental factors
As fever clinics and infection departments have undertaken the task of isolation, the resettlement site was far from the core hospital area of the hospital, and channel management was relatively strict during regular epidemic prevention and control. It often took substantial time for fever patients to find the ward. Some patients were dissatisfied with this and vented their emotions on the medical staff.
The location of the fever clinic is reasonable; that is, it is an infected building that is far away from the entire hospital area. It is unreasonable that it is too far away for patients to find. (NC) The patient took a long time to get here from the clinic…he is not angry over there, he is just angry right here, because he is facing you The hospital implemented a 'semiclosed' management mode for patients and their families. All channels of the hospital were strictly managed, and most channels in the ward were managed by the ward itself. Some wards had no access control, and the channel management depended on nurses, which increased the workload of nurses and depleted the human resources of nurses.
The management of each floor depends entirely on our medical staff. We have many other things to do; how can we take care of so many…(Ns3) From six o'clock in the morning to nine thirty in the evening, the gate is guarded, which is equivalent to assigning three nurses to guard every day. (Ns4) We hope it has a system or access control so that there is no need to artificially block the patient's family members, resulting in unnecessary disputes…because the labour cost of nurses is actually quite large.(Ns5)

| Workload increase
Regular epidemic prevention and control has added much work to nurses, and some changes have taken place in the daily work processes of nurses. This additional work includes the treatment process of fever patients and patients from high-risk areas, admission of new patients, increasing the daily work of nurses in the ward. The work content has increased, but there is no more nursing human resources, which makes nurses busier and more stressed.
For some patients who return from medium-and high-risk areas or have fever of unknown cause, the treatment procedure is much more complicated than before.

| Increased role stress of nurses
Regular epidemic prevention and control has increased the workload and difficulty of work, which increases the stress of nurses' work tasks. At the same time, hospitals have also put forward higher requirements for nurses, which has also increased the stress associated with nurses' role tasks.
First, training, inspection and assessment related to regular epidemic prevention and control have increased.
There are a lot of things to learn, such as the meetings…(NJ) More inspections…such as the inspection of hospital sense con- Nurses are the main force in regular prevention and control. (Ns4).

| Decrease in revenue
Due to the impact of the epidemic environment and strict prevention and control of hospitals, some patients choose not to see a doctor temporarily or not to see a doctor in hospitals with strict prevention and control. The number of patients in the hospital has decreased, the income of the hospital has been reduced and nurses have also been affected.

| Positive factors for coping with stress
During the interview, we found some positive psychological feelings of nurses outside the framework of Robbins' stress model, which are described here as an extension.

| Hope
Although the outbreak of the epidemic and the current regular epidemic prevention and control have brought tremendous pressure to nurses, nurses still firmly believe that the disaster will be overcome, face reality optimistically and are full of hope in their hearts.

| Patience
During the normalization of epidemic prevention and control, nurses

| A sense of security
Although the measures taken by the hospital in response to normalized prevention and control have created some pressure, it also made nurses feel safe and secure and made nurses believe that the epidemic is preventable and controllable; thus, their hearts are more stable.
In fact, we are not as nervous at work as when the epidemic first broke out because we think it can be controlled. (NB) Hospital infection control is stricter. I think it's good to be stricter. in the short term. The nurse-patient conflicts caused by patients waiting for nucleic acid test results can be solved only from the perspective of management. Our interviews found that such conflicts between nurses and patients mostly occur in fever clinics, and most of them are caused by a lack of desired treatment and the emotional excitement of patients. To solve such problems, fever clinics should be able to meet some needs of patients and take appropriate measures for patients' diseases. If it is impossible to deal with them, it should be carefully explained to patients and their families to make them feel at ease. As the first-line of defence of hospital departments, fever clinics play a vital role during the outbreak of the COVID-19 epidemic in China (Wang et al., 2021). Managers should also pay attention to the construction of fever clinics during regular epidemic prevention and control.
Experience during the outbreak period tells us that a reasonable hospital layout and complete hospital facilities can improve work efficiency and prevention and control effects Lai et al., 2020). The problem of ward distance cannot be solved from the perspective of architecture, but patients can be guided to find the ward quickly with clear route instructions by setting up road signs and hospital layout maps. Our interviews found that many nurses held the hope that the epidemic could end soon and that the hospital could restore the previous order as soon as possible. Although nurses complained about the 'temporary' measures that required nurses to guard the ward gate due to the lack of access control of the hospital, they could understand and cooperate. What managers should consider is that perhaps we should not restore the previous order but take this opportunity to establish a new order. The prevention and control of COVID-19 has consumed a lot of our energy, which is a challenge for us, but at the same time, it is also an opportunity for us to establish a new medical management system order and comprehensively improve hospitals' abilities to respond to public health emergencies. Should these 'temporary' measures of regular epidemic prevention and control, such as the management of patients and their families and the control of hospital infections, be upgraded to 'permanent' measures?
Should the hospital-related management system reform? This is a question worth pondering.
The increase in workload has made nurses' human resources more strained. Recruiting more nursing staff is the most direct solution; however, even before the outbreak, the human resources of nurses were in short supply worldwide. No more nurses could be recruited (Shaffer et al., 2020). Some scholars (Duncan, 2020) believe that means of improving the resilience of nursing teams and make limited nurse human resources play a greater role is an issue that we should seriously consider in the current epidemic. As early as the beginning of this century, nursing managers of some hospitals in China advocated a method to increase the resilience of the nursing team, that is, establishing 'mobile nurse banks', and formulated detailed methods for training and managing mobile nurses (Wang et al., 2005). According to the reports of hospitals (Han et al., 2020;Wang et al., 2005;Wu, 2021;Ye et al., 2011) (Carmassi et al., 2020;Cooper et al., 2020;Foster et al., 2020). Income level is positively correlated with job satisfaction and negatively correlated with burnout and turnover (Ran et al., 2020;Wubetie et al., 2020;Zhang, Wei, et al., 2020). During the regular epidemic prevention and control period, while hospitals and managers put forward high standards and strict requirements for nurses, they should also pay attention to providing nurses with sufficient organizational support and economic security and pay attention to nurses' mental health.
Positive factors of nurses in coping with stress related to prevention and control that include 'hope', 'unity', 'patience' and 'sense of security' are forms of stress-related growth and are protective factors against the adverse effects of stress (Yıldırım & Arslan, 2021). Research shows that (Antebi-Gruszka et al., 2021) positive reappraisal, social support and emotional expression are all related to greater stress-related growth. Therefore, managers can promote nurses' stress-related growth by praising and encouraging nurses, giving nurses enough support and listening to nurses' emotional expressions to better deal with epidemic prevention and control.
In addition, this study found that during regular epidemic prevention and control in China, the management stress of head nurses seems to be greater than that of ordinary nurses. However, since the purpose of this study is to explore the work stress experience of ordinary nurses, there was no more in-depth exploration of the stress of head nurses, and follow-up research should pay more attention to the stress of nursing managers.

| CONCLUSIONS
Construction of the first-line departments such as fever clinics should be valued by hospitals and nursing managers, and sufficient financial and organizational support should be given to nurses participating in the prevention and control work. The shortage of nurses' human resources and the increase of nurse-patient conflicts are problems that need to be solved urgently. In addition, this study also emphasizes the importance of protecting and promoting nurses' stress-related growth. Finally, a question worth pondering is whether it is necessary to take this opportunity to reform the hospital-related management system and how to reform it.

| IMPLICATIONS FOR NURSING MANAGEMENT
Our study describes the work stress experience of nurses related to COVID-19 regular epidemic prevention and control in China, highlighting some problems in nursing management. First, the prevention and control of the epidemic should pay attention to the construction of the hospital environment, especially for first-line departments such as fever clinics. The equipment and facilities should be fully equipped, and the work process should be optimized to improve patient satisfaction and reduce the occurrence of nurse-patient con-