https://doi.org/10.15218/ejnm.2022.05 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article Nurses’ experiences during the COVID-19 pandemic in Duhok City ABSTRACT INTRODUCTION The Covid-19 outbreak was reported for the first time in Wuhan, China, in Decem- ber 2019[1]. It quickly became an inter- national health crisis impacting physical, psychological, social, and economical status of people around the world [2, 3]. The virus is transmitted from person to person through respiratory droplets, un- sanitary and highly crowded places, and enclosed environments[1]. The rapid Background and Objectives: Covid-19 is one of the health issues that has had a major im- pact on health services all around the world. It was declared a pandemic on March 11, 2021. The nurses were on the frontline of the fight against the Covid-19, which had physi- cal, psychological, social, and economic effects on health and health outcomes. It is crucial that nurses’ experiences during the pandemic are identified. This study aimed to explore nurses’ experiences, knowledge, and practices regarding the pandemic. Methods: A cross-sectional study was conducted among nurses in the Duhok City in the Kurdistan Region of Iraq. The online survey was distributed to nurses using a structured questionnaire. The number of nurses who participated in the study was 110. The data col- lection was conducted from 10th May to 10th August 2021. Data analysis was conducted using SPSS statistical software (version 23.0). Descriptive statistical analysis was conducted using frequency, percentage, mean, and standard deviation. Results: The study revealed that the mean age of nurses was 30 years with a standard de- viation of 7 years. The highest percentage of the nurses (44.5) were a Bachelor’s degree holders. The nurses had concerns regarding their employment status, workload, and threatened to leave their job. Having sufficient personal protective devices and work pro- tocols to help decrease the risk of infection and stress and anxiety were important issues. Nurses need more training and support systems from leaders and employers to go for- ward and work safely and comfortably. Conclusions: The study highlighted essential points regarding the nurses’ experiences dur- ing the pandemic such as the impact of workload, shortage in staffing, threatened termi- nation of employment, and having to do non-nursing activities or tasks. It was clear that the nurse managers have a significant role in providing efficient support to nurses. Cre- ating a safe work environment and essential guidelines is crucial for promoting a better quality of care during the pandemic. Keywords: Covid-19; Nursing Care; Pandemic Ronak Hassan Barwari; Department of Nursing, College of Nursing, Duhok University, Duhok, Iraq. (Correspondence: ronak.muhammad@uod.ac) Sarah Jawad Kadhim; Department of Nursing, College of Nursing, Duhok University, Duhok, Iraq. Khalid Ibrahim Mohammed; Department of Nursing, College of Nursing, Duhok University, Duhok, Iraq. 43 Erbil Journal of Nursing & Midwifery Received: 08/12/2021 Accepted: 13/02/2022 Published: 30/05/2022 mailto:ronak.muhammad@uod.ac https://doi.org/10.15218/ejnm.2022.05 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article spread of Covid-19 resulted in a major risk to public health and economic systems globally. It changed the daily life of people significantly [4], becoming a public health emergency with a high rate of deaths, hos- pitalizations, and socio-economic disrup- tion. The lack of hospital capacity, insuffi- cient numbers of personal protective equipment, and insufficient ventilators were significant issues among the affected countries [5]. The pandemic impacted all health care providers, but especially nurses [6]. Nurses are a crucial part of the health care system in responding to health crises, pandemics, and epidemics. The nurses were in the frontline to fight the Covid-19 pandemic [7]. Nurses provide direct patient care and play a key role to reduce the risk of exposure to infectious disease[8]. How- ever, they are vulnerable to being infected because of their direct contact with the infected patients and their family members [9]. Nurses’ knowledge of disease influ- ences their attitudes and practices as any incorrect attitudes or practices increase the risk of disease transmission [6]. As a result of the pandemic, the health care workers get exhausted, impacted financially, and psychologically, often suffering from uncer- tainty, fear, anxiety, and dread, which have been reported globally [10]. Furthermore, the health care system increases the de- mand for manpower and resources for pre- vention and treatment requirements [1]. Nurses are the main members of a health care system who must control, treat, and prevent the spread of infectious diseases. Moreover, they are responsible for provid- ing care, and a variety of procedures in re- sponding to patient needs that enhance the health of individuals as a result of the Covid-19 virus [1]. Despite the professional obligation of nurses toward their patients and the community during the pandemic, their concerns regarding their work and the risk of being infected or transmitting the disease to family members and friends increased significantly [8]. Therefore, this study was conducted to identify nurses’ experience of the pandemic and to under- stand and identify the implications of the pandemic on their knowledge, access to personal protective equipment, nursing care and employment status. The purpose of this study was to explore nurses’ experi- ences during the pandemic and identify its impact on themselves and patient out- comes. The cross-sectional study design was con- ducted among nurses at teaching hospitals in Duhok City. A total of 300 nurses were invited to participate in this study. The sur- vey was distributed through an online link. The inclusion criteria encompassed all male and female nurses with different de- grees in a nursing specialty, have one year and more of experience, and worked in different units of hospitals. The nurses who had less than one year of experience and worked at out-patient clinics were exclud- ed from the study. The study was under- taken between May and August 2021 at the teaching hospitals in Duhok City in the Kurdistan Region of Iraq. After obtaining approval from the Scientific Committee of the College of Nursing of University of Duhok, the survey link was sent through emails and Viber groups to the nurses. The informed consent was obtained from the nurses. Nurses who agreed to participate in the study were asked to click on the sur- vey link and respond to the survey. A total of 110 nurses participated in the study. The sample size was estimated based on Slovin's Formula which is a random sam- pling technique formula to measure sam- pling size. The formula is: n = N / (1+Ne2). n = no. of samples N = total population 44 Erbil Journal of Nursing & Midwifery METHODS https://doi.org/10.15218/ejnm.2022.05 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article years with an SD of 6. Results of Table 1 show the mean score of weekly working hours that was 38 hours before the pan- demic decreasing to 30 hours during the pandemic. e = error margin / margin of error (0.05) In our study, the total number of nurses at three public hospitals is 556. 556 / (1 + 556 * 0.5²) = 233 nurses. The re- sponse rate in this study was estimated at 233/556*100= 20%. The questionnaire was adapted and modified for the study purpose[3]. The modified survey consisted of two parts: Part I was related to the par- ticipants’ demographics and Part II in- volved the survey items. Part II contained three subscales: the nurses’ professional experiences subscale included seven items, the nurses’ knowledge of Covid-19 pan- demic contained six items, and the nurses’ clinical practice subscale included six items. The response to all items was done by ei- ther yes or no. Data analysis was conduct- ed using SPSS version 23. Descriptive statis- tics were applied to analyse the de- mographics, nurses’ experience, knowledge, and practices such as the fre- quency, percentage, mean, and standard deviation. The mean age of nurses was 30 years with ± 7 SD. The percentage of female nurses was 41.8%, while the percentage of male nurses was 58.2%. Regarding the level of education of the participants, less than 10% of nurses had post-graduate degrees, almost half of the nurses had Bachelors’ degrees (44.5%). The percentage of nurses who have graduated from the nursing insti- tute was 42.7%, and only five nurses were graduated from nursing high school. Re- sults of the present study show that more than half of the nurses were married 51.8%, and 47.3% were single. Regarding the unit of work 42.7 % of the nurses work in the intensive care unit, the number of participants who worked in the medical wards was 30%, and only three nurses were working in the emergency room. The calculated mean of experience years was 7 45 Erbil Journal of Nursing & Midwifery RESULTS Table 1: Nurses Demographics Demographics F (%) AgeMean ±SD = 30±7 110 (100) Gender Male 64 (58.2) Female 46 (41.8) Level of Education Post- Grad- uate 9 (8.20) Bachelor- Degree 49 (44.5) Nursing Institute 47 (42.7) School of Nursing 5 (4.5) Marital Status Married 57 (51.8) Single 52 (47.3) Divorced 1 (0.9) Area of Work (Unit) Critical care units (ICU, CCU, HDU) 47 (42.7) Surgical Units 21 (19.1) Medical Units 33 (30) Maternal and Pediat- ric Units 6 (5.5) Emergency Room 3 (2.7) Total 110 (100) Mean ±SD Years of Experience 7±6 Weekly working hours before covid pandemic 38±28 Weekly working hours during covid pandemic 30±25 https://doi.org/10.15218/ejnm.2022.05 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article 42.7%, and 53.6 % of the nurses experi- enced an increase in their employment hours during the pandemic. A high per- centage of the nurses (59.1%) threatened to terminate their job and 47.3% were thinking about leaving their job. In addi- tion, 70.9% of the nurses stated that they did non-nursing duties. Covid-19 on health care workers including nurses. Furthermore, 84.5% of the nurses knew that they were working in a high-risk environment. More than half of the partici- pants (60.9%) stated that they got support from their employers. 46 Table 2 shows that majority of nurses re- sponded with yes for the experience items. The highest percent of the nurses (77.3%) declared the issue with the workload, un- derstaffing, and lack of resources. The per- centage of nurses who never had experi- ence with chronic infectious diseases was Table 3 shows nurses’ knowledge regarding Covid-19. Most of the nurses (91.8%) were knowledgeable regarding protecting them- selves and their patients from the infec- tion. The study results demonstrate that 90.9% of the nurses understand the risk of Erbil Journal of Nursing & Midwifery Table 2: Nurses’ Experiences after the Covid-19 pandemic Nurses’ Experiences Yes No F (%) F (%) 1. Experience with Infectious illnesses (e.g., Hepatitis virus) 63 (57.3) 47 (42.7) 2. Increased hours of employment per week because of the pandemic 59 (53.6) 51 (46.4) 3. Threatened termination of employment because of the pandemic 65 (59.1) 45 (40.9) 4. Did you face workload, Understaffing and lack of resources 85 (77.3) 25 (22.7) 5. Reductions in nursing role (fewer tasks to do). 60 (54.5) 50 (45.5) 6. Additional tasks within nursing role doing non-nursing duties. 78 (70.9) 32 (29.1) 7. Did you think about leaving your job because of the pandemic? 52 (47.3) 58 (52.7) Table 3: Nurses’ Knowledge Regarding Covid-19 pandemic Nurses’ Knowledge Yes No F (%) F (%) 1. At present, I have sufficient knowledge of Covid-19 77 (70) 33 (30) 2. Understand the risks of Covid-19 on patients and healthcare workers 100 (90.9) 10 (9.1) 3. I understand how to protect myself during the pandemic 101 (91.8) 9 (8.2) 4. I understand how to protect my patients during the pandemic 101 (91.8) 9 (8.2) 5. I feel that my work put my health at risk during the pandemic. 93 (84.5) 17 (15.5) 6. I feel well supported in my clinical role by my employer. 67 (60.9) 43 (39.1) https://doi.org/10.15218/ejnm.2022.05 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article personal protective equipment. Moreover, the percentage of nurses who never got trained to work for Covid-19 patients was 50.9%. The results show that 77.3 of nurs- es followed infection protection measures. fear of getting infected. Also, nurses were concerned about doing additional tasks that were not related to their profession. This had a negative impact on their work and made them think about leaving their job. Being threatened to lose or actual loss of employment during the pandemic was identified [3].It was clear that the nurses experienced a more stressful working envi- ronment because of increase in workload, lack of resources, nursing shortages, no- nursing tasks, and burnout. The virus ad- versely affected health care providers’ job commitment and made them more anx- ious [14]. Also, the anxiety and stress of the pandemic resulted in work dropout [14, 15]. It impacted nurses’ work and their thoughts to quit their job because of the pandemic. While, in another study, nurses did not intend to leave their job because of the pandemic[16]. Protecting nurses who are in high-risk areas requires local, nation- al, and international strategies to provide sufficient protective devices [11, 13]. Moreover, having information and suffi- cient understanding related to the pan- demic risk and using protective measures 47 Erbil Journal of Nursing & Midwifery Table 4 reveals that 88.2% of the nurses knew the importance of wearing personal protective equipment during work. Also, 70% of the nurses understood the im- portance of social distancing and wearing The Covid-19 pandemic affected the Kurdi- stan Region of Iraq with a large number of suspected and confirmed cases and the transmission of the virus to the health care providers [11]. Providing health care ser- vices during the pandemic had significant impact on nurses [12]. They were aware of the danger of working in an environment that endangers their lives, family mem- bers, friends, and colleagues. Based on our results, nurses’ working hours increased during the pandemic. It might be related to the shortages in nurses at Duhok hospitals and the admission of a high numbers of Covid-19 patients to the hospitals for treatment. In addition, there was an in- crease in nurses’ time off work because of the home quarantine when they were in- fected or had direct contact with infected people [13]. In comparison, a study that was conducted in Australia showed that the working hours of nurses decreased during the pandemic[3]. This shortage was connected to the threatened termination of employment, and it was identified by the nurses in this study. It might be there- sult of the stress of the pandemic and Table 4: Nurses’ Practice Regarding Covid-19 pandemic Nurses’ Practices Yes No F (%) F (%) 1. Have you been trained to work for Covid-19 patients? 54 (49.1 56 (50.9) 2. Have you followed social distancing? 77 (70) 33 (30) 3. Have you been wearing a mask and gloves during the hospital practice? 97 (88.2) 13 (11.8) 4. Do you regularly follow infection protection measures? 85 (77.3) 25 (22.7) 5. I have sufficient personal protective equipment in my workplace 69 (62.7) 41 (37.3) 6. Do you have guidelines about the use of personal protective equipment? 65 (59.1) 45 (40.9) DISCUSSION https://doi.org/10.15218/ejnm.2022.05 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article is required to protect them and mitigate psychological distress [16, 17]. Nurses sac- rificed their lives during the pandemic to care for patients [5]. However, in our study, some nurses were not satisfied with their employer’s support despite their hard work in high-risk environment. To alleviate the challenges related to working in high- risk settings, nurses need adequate support from hospital leaders and managers to con- tinue their work and reduce that burden [18]. Support systems and healthy work environments enhance the quality of care and commitment to work during critical times[19]. To ensure that the nurses are protected and able to provide nursing care, nurses must receive mental health support [3]. An unsafe environment during the pan- demic increases turnover and retention issues [20]. The support system is im- portant to be considered by the nursing leaders through the pandemic outbreak, especially for younger or less experienced nurses [12, 21, 22]. To help those nurses who provided direct care for suspected or confirmed cases of Covid-19, it is suggested to give them formal leave days [21]. Hav- ing guidelines regarding the safety measures is helpful for the nurses to feel more comfortable and supported in their work. The nurse leaders should ensure that the nurses’ work is based on a guidelines and consistent with protocols to provide health care efficiently. Nurses require gov- ernments, policymakers, and nursing groups to engage in supporting nurses dur- ing the pandemic [8]. Because increased risk of nurses being infected, it is important to develop specific protocols to reduce the risk of infection and interactions with Covid -19 patients [9].Concerning nurses’ health, the use of strict measures such as the prac- tice of good personal hygiene, social dis- tancing, using personal protective equip- ment appropriately involved wearing suits, masks, gloves, eye, and foot protective barriers, and following infection control measures were factors considered by the nurses through their practices. The short- age of protective equipment and resources impacts negatively on the quality of care [18]. Moreover, nurses’ education and training through the pandemic regarding protective measures are helpful to de- crease infection transmission [9]. As it shows, the lack of nurses’ experience about the pandemic increases the risk of infection [14].Helping nurses to follow reli- able sources for the care of a Covid-19 pa- tients, for example, assessment of their condition, and possibilities to deliver them special nursing care are important. Fur- thermore, nurses need to participate in educational programs, and attend lessons that can greatly contribute to the develop- ment of their information and skills [7]. Working together as a team in protecting each other during the pandemic and ap- preciating their colleagues and sharing their experiences is valuable [8]. The study concluded that the nurses gained valuable experience during the pan- demic. They followed the infection control and social distancing measures to protect themselves from infection. To assist nurses and help them bear the difficulties they face while working, it is crucial to consider their protection through providing suffi- cient protective equipment. Nurses need leadership support to go forward and over- come the complexity of putting their health at risk during the pandemic. The majority of nurses were happy with their leaders’ support. The authors would like to thank the nurses who participated in the study. Also, special thanks to everyone who helped and sup- ported us to conduct this study. 48 Erbil Journal of Nursing & Midwifery CONCLUSION ACKNOWLEDGMENT https://doi.org/10.15218/ejnm.2022.05 Erbil j. nurs. midwifery, Vol. 5, No. (1), May 2022 Original Article [9] Huang L, Lin G, Tang L, Yu L, Zhou Z. Special attention to nurses’ protection during the COVID-19 epidemic. Springer; 2020. [10] Chew C, Eysenbach G. Pandemics in the age of Twitter: content analysis of Tweets during the 2009 H1N1 outbreak. PloS One. 2010;5 (11):e14118. [11] AL‐Abrrow H, Al‐Maatoq M, Alharbi RK, Al- noor A, Abdullah HO, Abbas S, et al. Under- standing employees’ responses to the COVID ‐19 pandemic: The attractiveness of healthcare jobs. 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