Introduction

The covid-19 disease is spreading rapidly in the world [1, 2]. In May 2022 there were more than, 620 million people in the world infected with Covid-19 disease, of which 6.55 people had died, and in Iran, out of 7.55 million infected, 144 thousand had died by this date [3]. The widespread pandemic of Covid-19 and its consequences have affected all aspects of health services globally, including home care [2].

Home care nursing is not a new field in the healthcare system in Iran; however, recent years have seen a significant increase in the number of home care agencies. There are currently 850 home care agencies operating in the health sector and a further 1400 are awaiting the official permit [4]. At the First stage, at the discretion of the treatment team and with the consent of the families, the patient is transferred home for the care to continue [4]. After the Covid-19 pandemic in Iran, home care was divided into two general categories: caring for Covid-19 patients and caring for patients with other diseases [5]. Most people in the second group are vulnerable patients cared for at home due to some chronic diseases or complications caused by aging [6]. Home care nurses in Iran have a bachelor’s degree or higher and take courses to take care of patients at home. These nurses work under the supervision of home care agencies licensed by the Ministry of Health [7].

The Covid-19 pandemic poses many potential challenges to home care nursing due to the risk of virus transmission [8]. However, according to the literature, home care nurses have received less attention than hospital nurses during the pandemic, and a limited number of studies have been conducted on the problems and challenges faced by these people [9]. Since some studies have mentioned the high workload and vulnerability of the nursing staff in home care [10, 11], it seems that the new conditions have increased the vulnerability of these people. On the other hand, according to reports, some nurses working in hospitals have experienced safety concerns, anxiety, stress, fatigue [12, 13], and fear and anxiety caused by family members being infected with this disease [14]. Studies also show that nurses at the forefront of the fight against Covid-19 disease have suffered a great deal physically and emotionally [15, 16]. Home care nurses, like hospital nurses, seem to face many challenges. Because the home environment is designed to be lived in rather than being a place for care, these individuals face different and unique challenges [17].

A study conducted in New York indicated a variety of challenges faced by home care nurses during the COVID-19 pandemic; the challenges mentioned in this study include being ignored by other members of the community, a high chance of contracting COVID-19, a lack of training courses during the pandemic, and a shortage of protective equipment and facilities [18]. However, there are few studies conducted to inspect the challenges faced by home care nurses in Iran specifically during the COVID-19 pandemic; therefore, there is demand for further studies in this sector of Iran’s healthcare system [10]. On the other hand, home care nursing challenges during the Covid-19 pandemic in Iranian society was influenced by cultural and social factors [19]. The home care nurse usually has a close relationship with family members and the patient, so it seems that he/she has a close relationship with the social structure and family customs and has his/her own problems [20, 21]. In fact, nurses’ perceptions of the crisis are shaped by the complexities of laws, patients, families, and home care agencies [22].

A careful inspection of the faced challenges can present a clear picture of the nurses’ conditions during the COVID-19 pandemic, which will in turn result in effective measures to improve home care conditions. Therefore, the present study explains the nurses’ perception of the challenges of home care during the Covid-19 pandemic.

Materials and methods

Study design

The present study was performed using a qualitative method and a conventional content analysis approach based on the steps proposed by Granheim and Lundman. The conventional content analysis approach is a flexible method for analyzing textual data. It is used when there is not enough knowledge about a phenomenon and, with an inductive approach, emphasizes the creation and development of categories and the interpretation of written or spoken content. In this approach, categories and their names emerge from the data [23]. This article is based on the COREQ (consolidated criteria for qualitative research) checklist (Supplementary File 2) [24]. This study was performed in three home care nursing agencies affiliated with the Iran University of Medical Sciences, Tehran, Iran.

Participants

Participants included 16 home care nurses who were selected through purposive sampling, and the sampling was continued until data saturation (categories saturation table is attached to the article). Inclusion criteria included more than 1 year of work experience in home care, a bachelor’s degree or higher in nursing, the experience of home care during the Covid-19 pandemic, and a willingness to participate in the study. Exclusion criteria included reluctance to participate in the study and restrictions of cooperation. None of the nurses were excluded from the study. The first person in this study was an experienced one who, after being briefed on the objectives of the study and how to participate, entered the study willingly.

Data collection

This study began in November 2020 after receiving the code of ethics and ended in September 2021. A semi-structured interview method was used to collect data. The interview guide was prepared and approved based on three pilot interviews. Interview times ranged from 30 to 60 minutes. The Place for the face-to-face interview was chosen according to the participant’s preference: in one of the rooms of the home care agencies. Examples of questions used in the interviews were: “How would you describe home care for people with Covid-19?”, “In your experience, what are the challenges and problems in caring for a patient at home during the Covid-19 pandemic?” All the interviews ended with this question: “Is there a question that came to your mind but I did not ask?” Or “Is there anything else you want to add?” Due to the outbreak of Covid-19,causing less contact with the participants, some of the interviews were conducted through WhatsApp or Skype. The interviewer was experienced in conducting interviews for qualitative research. With the participants’ permission, all interviews were recorded by a recorder and then typed word by word by the interviewer. MAXQDA 10 series software was used to manage the data while maintaining the confidentiality of the information. Further interviews were performed with the participants 1–2–4-7-10 to increase the trustworthiness and eliminate some ambiguities or questions. No new data were collected in these interviews and all the concepts seemed to be well defined and explained (Supplementary File 1). Then, to ensure saturation, two additional interviews were conducted beyond saturation, and the data of these people were placed in categories.

Data analysis

Data analysis was performed simultaneously with data collection through Graneheim and Lundman (2004) steps (Table 1) [23]. The interviews were immediately recorded and transcribed. The transcripts of the interviews were read several times to immerse the researcher in the data. The words, sentences, and paragraphs relevant to the purpose of the study in each interview were considered meaning units. These meaning units were coded using participant words or appropriate tags extracted from the data. The codes were constantly reviewed and compared. Similar items were placed in common categories and then the main categories were created.

Table 1 Steps of data analysis by Graneheim and Lundman (2004) method
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Trustworthiness

The trustworthiness of the data in this study was evaluated based on the steps proposed by Lincoln and Guba [25]. The member checking method was used to ensure credibility, during which, home care nurses were asked to confirm the conformity between the categories produced and their experiences. Two experts also used peer checking in the field of qualitative studies for the trustworthiness of data coding and classification. Scrutiny of the data and the related documents was conducted by two external observers and the preservation of documents related to the different stages of the research added to the dependability of the study. To ensure transferability, the researcher gave detailed explanations, such as a detailed description of the participants, the sampling method, and the time and place of data collection, so that the reader could comment on the transferability of the findings. Recording all the procedures of the study and reporting the research process enhanced the confirmability.

Findings

A total of 16 nurses were interviewed. The mean age of the participants was 31.25 ± 3.60. Demographic characteristics of the participants are reported in Table 2. The main findings of this study included 7 categories and 22 sub-categories (Table 3). Main Categories included the onset of a new chapter: from avoidance to relapse, burnout, the vortex of moral distress, social stigma, difficulty in breaking the transmission chain, care inhibitors related to patient and family, and deficiency of support: the crisis of home care nursing agencies during the crisis. It should be noted that due to the number of times problems were expressed by nurses, study participants understood all the challenges equally and gave equal importance to all the challenges.

Table 2 Demographic characteristics of the participants
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Table 3 Categories, sub-categories, and some quotes of the participants
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The onset of a new chapter: from avoidance to relapse

From the interviewees’ point of view, one of the challenges of home care in the Covid-19 pandemic was the onset of a new chapter: from avoidance to relapse, which included three sub- categories: dealing with emerging developments, vacating the field of care, and a gradual re-orientation to care. Participants noted that before the outbreak of Covid-19, they experienced normal conditions in home care and normally lived with the patient’s family and took care of the patient. The emerging changes occurred suddenly and they encountered an emerging and unknown disease. The nurses pointed out that at the beginning of the outbreak, they did not tend to take care of the patients at home personally, and some of them even refused to take care of patients at home and withdrew from care. The nurses also noted that they gradually returned to care over time.

“Everything suddenly changed, the sudden arrival of Covid-19 changed all our routines and plans. I was not the only one who refused to go home to take care of the patient. Many of my colleagues left home care and resigned. But as time passed, we started taking care of the patients again ”(P10).

Burnout

From the nurses ‘perspective, the second challenge of home care during the Covid-19 pandemic was burnout, which consisted of the mental pressure due to vulnerability, physical injury, and the stress caused by injury. According to the participants, burnout was one of the most critical and influential consequences of the pandemic, which affected the care and the lives of nurses working in the home care sector. Mental pressure due to vulnerability in nurses during the Covid-19 period took on wide dimensions such as anxiety, fear, worry, depression, and a sense of insecurity. Many of them experienced a constant feeling of uncertainty about the environmental pollution or the possibility of the patient and the patient’s family getting Covid-19. Participants stated that due to the lack of nurses in home care and the family’s request to reduce commuting to the home, nurses were subjected to long shifts and experienced high degrees of physical fatigue, leading to Covid-19 disease and severe symptoms and complications. Many nurses expressed great fear and concern for others and their families (major concerns).

“It is fear and anxiety on one hand and its physical fatigue on the other. We believe it is part of our job but we also have a family. We usually say that if it happened to me, it is because of what I accepted to do, but what about my family? I don’t want anything to happen to my family”(P14).

Vortex of moral distress

From the participants’ point of view, another critical challenge in home care was the vortex of moral distress. The moral distress further led to helplessness and feelings of futility. According to the participants, spiritual torture and the resulting helplessness were the essential components of the vortex of moral distress. The nurses stated that they felt ashamed and had the pang of conscience, guilt, helplessness, disability, and futility in the face of the disease.

The nurses even likened the Corona virus and its mutations to a vortex they had been sucked into and which they could not escape.

“Hearing people die and suffer made me feel guilty because I saw that people were still getting sick despite the vaccine. I was embarrassed that no medicine was efficient and that the patient was getting sick and we were sending him to the hospital. I was feeling helpless and completely paralyzed because of Covid-19 and its endless mutations. I felt that my nursing skills no longer worked ”(P16).

Social stigma

From the participants’ perspective, social stigma was one of the challenges of home care during the Covid-19 pandemic. One of the challenges that nurses experienced during this period was the suspicion of those around them about being a vector. The nurses also stated that they were being ignored compared to the hospital nurses so even the vaccination of these people was delayed compared to the hospital nurses.

They were even isolated due to the suspicion that they had contracted the disease and that they were acting as vectors. This isolation caused them to hide their nursing profession in the community.

“If anyone in the family knew you were a home care nurse of a Covid-19 patient, they ran away. They always thought you were a Covid-19 vector. In the society, if someone knew that you were the home care nurse of covid-19 patients, they would not take you in a taxi. I was lonely and so I walked away. We were one of the last groups to be vaccinated; but we also work with the Covid-19 patients, so what was the difference between the hospital nurses and us? ”(P3).

Difficulty in breaking the transmission chain

Nurses took steps to prevent members involved in care from transmitting the Covid-19 virus and tried to break the transmission chain. The difficulty in breaking the transmission chain was one of the challenges of home care during the Covid-19 period for participants. One of the challenges the nurses faced in breaking the transmission chain was physical separation. To do this, nurses had to develop strategies in the confines of the home to isolate their presence, the patient, and the equipment. On the other hand, the implementation of the personal protection strategies had many difficulties (lack of equipment, difficulty of observance, and exhaustion) in the long shifts. Despite the many efforts of nurses in implementing these strategies, over time, nurses saw a gradual decline in following health protocols and the problems associated with them.

“We had to isolate ourselves from the rest of the members in the house. You know, the situation in the house changes completely due to its limitations. You know wearing those clothes in the house where we used to have comfortable clothes was a separate issue, but these were for earlier times. Now, it’s not like that anymore. Both we and the family only wear masks and can no longer dress like before” (P11).

Care inhibitors related to patient and family

Care inhibitors related to patient and family included family-related care barriers and patient-related care barriers. The nurses stated that some families were unable to provide adequate equipment for their patients in some cases due to shortages or high prices.

Furthermore, some other families who believed in traditional medicine insisted on carrying out some traditional customs such as visiting the patient in groups or giving him/her medicinal plants. Also, some families trusted whatever medical advice they read on the internet and insisted on carrying it out on the patient.

Nurses facing the challenge of patient-related care barriers pointed to non-adherence to treatment due to cognitive deficits, high fear of Covid-19 infection and death, as well as the occurrence of various problems and complications.

“The families behaved very emotionally. They did not think they were getting the Covid-9 themselves now; they kept coming to see the patient and did not keep their distance. The patient was restless, and we weren’t allowed to take care of him/her. When they met the family, they looked worse, and the family wanted to test everything they heard from here and there on the patient ; Things such as herbal medicine and other things ”(P5).

Lack of support: crisis of home care nursing agencies during the crisis

‘Lack of support; the crisis of home care nursing agencies during the crisis was another challenge related to home care in the Covid-19 pandemic. One of the challenges for nurses in home care was the crisis mismanagement of the agencies. Instead of crisis management, the agencies fueled the problems and the challenges of this period with mismanagement and lack of planning and anticipation. On the other hand, according to the nurses, the supervisors, who had an important role in controlling and managing the crisis as an observer, were not sufficiently qualified in this field. Nurses announced they faced a lack of training despite the need for up-to-date training. In addition to all these challenges, nurses pointed to the lack of financial and legal support (untimely and inadequate payment, not exercising the labor law, not being given a sick leave, and not exercising the insurance law). Lack of logistical support (drug and equipment shortages) was another challenge for home care nurses, who, in some cases, rationed personal protective equipment. In addition to the lack of equipment, nurses in the Covid-19 crisis faced the challenge of lacking efficient human resources (doctors, nurses, and medical teams).

“Our agencies were so badly managed that it looked like there was no crisis. The equipment was rationed for us. We did not have gloves or a syringe. They were constantly increasing our shift hours. “Whatever we said to the supervisor, she could not manage, she was only the victim of his seniors” (P12).

Discussion

This study was the first of its kind studying the challenges faced by home care nurses during the COVID-19 pandemic in Iran. The findings of this study indicate that these nurses experienced a new season in their job during this period. Being afraid of contracting the disease at the beginning of the period, home care nurses refrained from fulfilling their duties at the beginning of this period. However, they gradually returned to their jobs. The two major reasons that made home care nurses return to their jobs was first, their financial needs, and second, the support people and the government started to give them midway through the pandemic. This support showed itself in titles such as “health care heroes” and “health care warriors” which were given to the health care staff. Unlike home care nurses in Iran, their counterparts in other countries [26] and in hospitals in Iran [27] didn’t discontinue their jobs at the beginning and continued looking after patients into the pandemic. This study indicates that these nurses lacked adequate training and preparation to face a crisis; therefore, they stepped away from fulfilling their duties due to the fear of contracting the disease. The participants in this study stated that home environment was not infection-free compared to that of a hospital. They also believed that home care shifts were twice as long as hospital shifts and this increased chances of contracting the disease. The nurses in this study also stated that they were not able to disinfect the home environment in a proper way and therefore refused to do their jobs at the beginning of the pandemic. Proper training is a contributing factor in nurses’ crisis management ability and infection control [20] and numerous studies have indicated a lack of regular training for home care nurses [20]; therefore, creating and implementing a scheme that prepares home care nurses for new diseases, trains them on how to face new crises, and instructs them in infection control is highly recommended.

In the present study, the burnout and fatigue that the nurses experienced showed themselves in the form of physical and psychological distress. The psychological distress showed itself in the form of stress and fear of contracting the disease as well as worrying about transmitting the disease to the other members of their families. Other studies have also pointed out the fear nurses had of transmitting the disease to the family members [18, 28]. Similar to the findings of other studies, the participants in the present study also experienced different levels of fear, stress, obsession, and depression during the pandemic [29, 30]. This study also confirms the results of other studies [27] indicating that fatigue results from physical and psychological burnout. Fatigue also caused negligence in safety measures to control infection, which significantly reduced patient care [31] and even threatened the patients’ as well as nurses’ health causing them to eventually contract the disease [27]. This finding also confirmed other studies’ results [26, 27]. Based on these results, it seems that the physical and psychological distress inflicted on home care nurses during a pandemic must be regularly checked in order to prevent the consequences [32].

The participants in this study also underwent some spiritual suffering and experienced feelings of helplessness. There was a unique sense of moral confusion among the participants in the present study. Some factors making home care nurses undergo moral and spiritual distress were the increasing numbers of patients along with their worsening health conditions, high death rates, the long period of the pandemic, and inability in infection control. The participants described such circumstances as a “swallowing whirlpool which left them no way to escape”. Although studies conducted in China and some Middle Eastern countries [33, 34] indicated a similar feeling of guilt and shame among nurses, such feelings appeared to be more intense among Iranian nurses [35].

Home care nurses also experienced social stigma, discrimination, and isolation during this period. Social stigma and isolation came from the circle of people close to these nurses who suspected that they had contracted the disease and therefore acting as vectors. Home care nurses also felt discriminated against as opposed to hospital nurses, who received more media attention and were more appreciated by the public during the pandemic. There are other studies confirming this finding as well [18, 28]. The social stigma attached to home care nursing could also affect these nurses’ full-hearted commitment to their social service [36]. As people highly likely to be transmitting the disease, hospital nurses also felt the social stigma attached to their jobs [37]. Home care nursing acted as support for the health care system during the pandemic and removed the pressure on the system during the periods when the number of patients increased dramatically [5]. This fact, nevertheless, didn’t change the social negligence that these nurses experienced compared to hospital nurses whose jobs received more attention during the pandemic [18].

Despite their numerous problems, these nurses did their best to adhere to protective measures; however, this protection decreased dramatically over time. The reason for this decrease was the nurses’ and the families’ decreasing sensitivity to COVID-19 over time. Similar to other studies [15, 24], this study also showed that home care nurses had a shortage of equipment. The reason for this shortage was the less attention that the society paid to these nurses compared to other nurses [18]. The study also found out that in some occasions, these nurses used their personal budget to buy the equipment. Since infection control is less possible in the home environment compared to a hospital, protective measures must be taken more seriously at home [4]; therefore, it is recommended that the supervising organizations inspect and evaluate home care agencies more carefully and promptly provide them with sufficient protective equipment.

A unique challenge indicated in this study was the role of protection inhibitors. The Iranian culture highly values family bonds, which makes Iranian people more willing to take care of their family members at home [25]. However, families are not educated properly on home care and its requirements [26]. Another observation made by this study was the families’ undue interventions, their insistence on conducting some unscientific or traditional protective measures, which caused trouble for home care nurses. Not being properly educated by professionals, families believed the information on social media and insisted on practicing them at home and on their patients. As several studies have indicated, insisting on conducting unscientific protective measures stems from the family members’ compassion towards their other family members [27].

Resisting treatment and an extreme fear of COVID-19 and its unknown consequences were among the inhibitors in this study. As a person involved in the process of treatment, the patient’s cooperation with the nurse can enhance the quality of the protection [38]. Therefore, in order to prevent such challenges, it is highly recommended that home care agencies hold training courses for both nurses and families prior to the home care process [38].

Another challenge that the nurses faced was the agencies’ mismanagement and their inability to manage the crisis. One of the reasons for this mismanagement was that home care agencies experienced a level of shock when faced by the pandemic. The agencies’ unpreparedness for the pandemic created several challenges for home care nurses. Another challenge putting these nurses under great pressure was the shortage of health care staff during the various surges in Corona cases. The agencies also failed to provide them with sufficient equipment, which in turn increased the pressure on home care nurses. Other studies also have indicated the shortage of protective equipment available to the health care staff [4, 22]. This study, along with other studies [18], indicated that home care agencies lacked reserve equipment to face the crisis, which in turn created another crisis during the pandemic. The results also showed that in numerous cases, nurses could not use their medical leave of absence because they had to return to their jobs due to a shortage of medical staff and this increased the nurses’ vulnerability to the disease [26]. These results also indicated that the agencies’ inability to manage the situation even intensified the crisis. Since crisis management is vital in controlling critical situations [28], there must be some schemes implemented prior to the crisis in order to control it at the right time [29].

It must be noted that home care is completely a new sector in Iran, and despite its remarkable improvements, there is still room for planning and improvement [39].

One of the limitations of this study was the difficulty in finding samples due to the Covid-19 pandemic. This limitation was solved by making the necessary arrangements with several different home care services agencies. Also, due to the possibility of infection and also because of the face masks, it was not possible to see the full face of the participants. Therefore, the level of respondents’ trust in the interviewer could not be determined.

Conclusion

The findings of this study showed that nurses have experienced several challenges during the Covid-19 pandemic since 1398 (2019), which has greatly impacted the nurses’ health and how their services at home. This study captured the nurses ‘perception of the challenges of home care during the Covid-19 pandemic, a period of unprecedented change and difficulty. Based on the findings of this study, it is recommended that subsequent applied and in-depth research be conducted in order to develop comprehensive guidelines for monitoring home care nursing in the country under conditions such as the Covid-19 pandemic. Based on the findings of this study, it can be stated that identifying the challenges of home care and seeking effective and efficient solutions can help policy-making and decision-making of officials by improving the quality of information and reducing stress and anxiety, which will result in high-quality performance in critical situations.