1 INTRODUCTION

The COVID-19 pandemic is a global public health emergency. It was first detected in the Wuhan region of China in November 2019 from where it spread throughout the world, creating multi-faceted health and social challenges (Zhou et al., 2020). On February 21, 2020, the first case of COVID-19 was diagnosed in Israel, and healthcare workers (HCWs) found themselves on the front line (Savitsky et al., 2021). Consequently, Israeli hospitals needed to rapidly arrange clinical spaces and reorganize clinical teams to deal with suspected and confirmed patients with COVID-19. The sudden onset of the life-threatening disease led to extraordinary pressure on nursing staff (Pappa et al., 2020) and compromised their resilience (Vinkers et al., 2020). Specifically, many HCWs were placed in areas outside their usual clinical speciality and expertise. They experienced physical exhaustion by working the longer hours needed to meet both their own usual professional responsibilities and their organizations' new requirements. Furthermore, the HCWs were at risk due to inadequate personal equipment and their vulnerability to becoming infected, thereby potentially spreading the virus among colleagues and family members (Pappa et al., 2020).

The COVID-19 outbreak affected HCWs' well-being, with them reporting symptoms of depression and anxiety (Bohlken et al., 2020). Similarly, Shechter et al. (2020) indicated that among New York City HCWs employed during the COVID-19 pandemic, 57% reported acute stress, 48% depressive symptoms, and 33% anxiety symptoms. Moreover, in a survey that included healthcare providers from the United States and Israel, higher resilience scores were associated with a lower likelihood of anxiety or depression and less COVID-19-related worries such as getting infected, dying from COVID-19, currently having COVID-19, family members getting COVID-19, unknowingly infecting others, and experiencing significant financial burdens following COVID-19 (Barzilay et al., 2020). The conclusion was that the encounter with stressful COVID-19-related events led to stimulated coping strategies and resilience.

According to Cooper and Quick (2017), psychological stress occurs when environmental demands go beyond the perception of a subject's ability to cope with them. A stressful transaction may elicit coping strategies that refer to cognitive and behavioral efforts to manage (i.e., reduce, minimize, master, tolerate) both internal and external demands (Lazarus & Folkman, 1984). Coping essentially has two functions: to manage or solve the problem by removing or circumventing the stressor (problem-focused function), and to regulate, reduce, or eliminate the emotional surge associated with the stressful situation (emotion-focused function) (Lazarus & Folkman, 1984). Carver et al. (1989) suggested that problem-focused coping strategies can potentially involve a variety of responses such as planning, taking action, seeking assistance, and screening out other activities. As for emotion-focused coping strategies, they can potentially involve responses such as the venting of emotions, denial, positive reinterpretation, and seeking social support for emotional reasons.

A pre-COVID study showed that the most common coping strategy used by HCWs to reduce staff stress was the acceptance of the critical situation and the adoption of a positive attitude in the workplace (Khalid et al., 2016). Similarly, recent Italian research among HCWs (i.e., nurses, physicians, technical health professionals, social health operators, and other healthcare professions such as physiotherapists, dentists, and midwives), revealed that a positive attitude toward the stressful situation (the COVID-19 pandemic) was the main protective factor, while seeking social support and avoidance strategies were risk factors for distress levels related to the COVID-19 pandemic (Babore et al., 2020). Consistent results were found among Israeli social workers who worked in various organizations (including general hospitals) during the first wave of the pandemic (in April 2020), namely, certain coping strategies—especially emotion-focused coping—were associated with higher psychological distress, and with job demands that tended to evoke stress (Ben-Ezra & Hamama-Raz, 2021).

Coping behaviors and psychological resilience have been identified as important strategies to enhance nurses’ abilities to adapt to stressful situations, traumatic events, and adversity to maintain optimal mental and psychological health (Hart et al., 2014). Resilience has been described as the ability to “bounce back” from negative emotional experiences and to adopt flexible solutions to the changing demands of stressful experiences (Cooper & Quick, 2017; Tugade & Fredrickson, 2004). Resilience was found to involve rapidly returning to pre-stress levels of functioning and maintaining a stable equilibrium (Smith et al., 2008). In the context of a pandemic, Foster et al. (2020) demonstrated that resilient HCWs were more likely to rebound effectively and endure the pandemic-associated psychological burden, than non-resilient HCWs. Additionally, Labrague's systematic review (2021) based on 31 quantitative studies, revealed that resilience of HCWs during the COVID-19 pandemic was strongly linked to reduced burnout, compassion fatigue, anxiety, depression, and psychological distress.

In Israel, both society and government perceived the spread of COVID-19 as a national security event (Marciano, 2021), and the adoption of military metaphorical language seemed to provide a method for understanding threatening and unexpected situations, in addition to guiding behavior related to the pandemic (Sabucedo et al., 2020). The use of military language intensified during the pandemic and stood out in the discourse of the HCWs (Tanous, 2020).

Given all the above, the current study aimed to explore in-depth, subjective professional and personal experiences of Israeli nurses who directly treat COVID-19 patients. An examination of their positive and negative emotions can help clarify their particular resilience and coping strategies in dealing with national health crises, thereby enabling health administrators to establish relevant interventions to promote nurses' coping strategies and subjective well-being. The conclusions can improve the quality of medical care provided to COVID patients now and in future epidemics.

Our exploration was guided by the following research questions: (1) How do the nurses describe their experiences during the COVID-19 pandemic in relation to their work with patients who were affected by COVID-19? (2) What were the nurses' strategies for coping with the challenges they faced during the COVID-19 pandemic?

2 METHODOLOGY

This study was conducted at a medical center in Israel's north that provides care for the population of northern Israel and also serves as a military hospital. This paper is based on a qualitative study that utilized a qualitative paradigm aimed at holistically understanding phenomena by examining worldviews, experiences, and subjective meanings that are influenced by environmental contexts and the participants’ subjective interpretations (Denzin, 2017). It sees the world as complex and dynamic, containing numerous layers of meanings and views acted upon by the environmental context (Braun & Clarke, 2006).

2.1 Participants

Eighteen nurses were interviewed (ten females and eight males). All the nurses worked in one medical center that provides care for the population of northern Israel. The age range was from 31 to 53 years, and their seniority in the center ranged from 4 to 30 years. They were selected through a convenience sampling and snowball technique (Patton, 2015).

2.2 Data collection instruments and procedures

Our data were gathered via in-depth, semi-structured interviews. Twelve participants were interviewed individually through face-to-face interviews by the first or the fourth authors, and six interviews were conducted online using the Zoom application.

The interview guide was developed by the authors and included questions regarding the nurses' personal and professional experiences. Questions included, for example: Tell me about your experience during the COVID-19 pandemic (personally and professionally); What issues bothered you during this period (personally and professionally)? and What helped you to handle these issues?

2.3 Data analysis

The data were based on qualitative thematic content analysis—basically, a descriptive presentation of qualitative data—describing what the participants said, while staying close to their actual words (Patton, 2015). In the first stage, as part of the qualitative analysis, the researchers audiotaped and transcribed all the verbal and nonverbal responses given during the interviews, and the texts were read and reread multiple times. The second stage included identifying and open coding those units in the text that were relevant to the research topic. Those units were then coded according to recurrent themes, with the themes mapped according to methodically identified interconnections (Denzin, 2017). This allowed for a systematic thematic analysis of the data, and the establishment of information units that consisted of groups of words or phrases, and groups of categories identifying emerging patterns and themes (Glaser & Laudel, 2013).

In qualitative research, the terms "rigor" and "trustworthiness" replace the terms "validity" and "reliability" (Denzin & Lincoln, 2011). To ensure the study's rigor, the first and fourth authors performed the data collection. Three authors conducted the data analysis of all the material separately and then reviewed the themes and patterns together. In cases of disagreement, they discussed the data until they reached consensus with the help of a fourth researcher involved in the study. “Member checking” of the findings, conducted with a group of five nurses, promoted rigor of the analysis during the final stage (Koelsch, 2013), by confirming agreement on the themes identified in the interviews.

2.4 Ethical considerations

The study protocol was approved by the medical center's Institutional Review Board and Ethics Committee (No. 0075-20-BNZ). After approval, the authors approached the potential interviewees, and explained the study's context and aims. The interviewees then signed informed consent forms stating their willingness to participate in the research study, having been assured of total confidentiality and anonymity. Participants’ names were changed to pseudonyms to protect their privacy (Allen & Wiles, 2016).

3 FINDINGS

Three central themes emerged from the qualitative analysis: maneuvering between professional demands and personal-family life; nurses’ coping strategies and resilience factors; and nurses' use of metaphorical language.

3.1 Maneuvering between professional demands and personal-family life

Analysis of the narratives revealed the conflict created as the nurses attempted to fulfill their various roles, as professionals who are responsible for patients during difficult times, and at the personal-family level as people who have social-family responsibilities.

3.1.1 Experiences at the professional level

“We did not know how the disease spread and progressed.” Most of the study participants talked about the feeling of surprise, the fear of the unknown, the confusion, and the lack of medical equipment, which burdened them at the beginning of the pandemic. Omar said, “I did not choose to be in the COVID department; it was the management's decision. At first, there was uncertainty and a lot of concern, but it was our duty to do the right thing.” Remarks similar to Omar's highlighted the fears that prevailed at the start of the pandemic. Sarah shared, “At first, I had fears that someone would arrive with COVID, and we were not protected well enough, because there was a time when there were not enough masks or disinfectants.” She added, “In the first days, there was confusion and chaos, until we got all the instructions. There was a fear of the unknown.”

With the onset of the pandemic, according to the Israeli Ministry of Health guidelines, the working day was divided into two shifts instead of three. The difficulty was particularly emphasized in the COVID department where there was intensive work with no opportunity to feel refreshed. Rona reported difficulty coping: “Due to fatigue in a shift of long, continuous hours, I was afraid to fall asleep at the wheel on my way home after work.”

Faten referred to the shortage of nursing staff that increased the load and fatigue, saying:

There are a lot of patients, there is not enough staff, and I alone dispense medication to them. I check every patient 20 times and am constantly afraid to miss something. Towards the end of the shift, I feel exhausted and tired, counting the minutes until I leave.

Some nurses noted that beyond their normal work, they were compelled to perform new roles. Lemar clarified this point: “I had to do the work of a social worker, a physiotherapist, and a dietician, because they only gave telephone counseling, and were not physically available.”

In many cases, the nurses witnessed the patients' mental distress and their need for warm human contact. In the absence of staff who could provide emotional support in the COVID department, and despite the fear of infection, Marina described a case where she took a risk, saying, “I took off a glove and touched a patient, because I saw that he really needed human warmth. Afterwards I washed my hands several times with disinfectant, yet still had the feeling I was infected with the virus.”

However, most of the study participants said that after the onset of the pandemic, time passed, and the fear and apprehension faded. This was an inclusive approach taken by many of the participants who considered the panic at the beginning of the pandemic to be a result of COVID-19-related national and international media reports. Rena said, “Already in the first month, we saw people not collapsing in the streets as the media presented, and I felt quite safe to go up and talk to a patient, with standard protection.”

Concurrent with the negative feelings of uncertainty and distress, the nurses reported positive feelings associated with receiving protective equipment and the desire to look after the staff. As Ameer explained, “It was a priority to keep the staff safe. You take care of yourself first, protecting yourself, and then you approach a patient and save lives.” Another factor that contributed to the positive emotions was the professional development of some of the nursing staff despite the situation. Sami described, “I have professionally developed in the direction of intensive care, and I started teaching remotely as a clinical instructor. It was a new and quite exciting experience.” Other nurses noted the positive emotions resulting from feeling particularly essential during this period. Rami said, “Throughout the period, I worked, I felt great, I felt that I was vital and that my work was needed.”

3.1.2 Experiences at the personal level

“I was afraid to get infected and to infect my family.” Concern for the family was of paramount importance. Most of the nurses described a sense of stress and fear for the health of family members, especially elderly parents. In Omar's words, “I was afraid to visit my parents, and to unknowingly infect them with the virus.” Some noted the feeling of injustice, especially as it related to the elderly. Roni explained, “The pandemic caused a breach of the natural balance. It was impossible to ignore the injustice and the neglect of the elderly, who felt terrible loneliness.” Ibraham referred to the forced distance from his extended family, saying, “I was preoccupied with the disconnect from my family. For a month and a half my children saw only me and my wife.”

In addition to noting family-related stress factors, a large proportion of nurses referred to their mental well-being and described their longing for days off and recreation with friends and family. Sami elaborated on this, saying, “There are no holidays, no weekends, [I] cannot go out with friends and visit family. My life was spent most of the time either at home or at work.” Others described the feeling of loneliness because of social distancing. Miriam framed this, saying, “I had a terrible feeling of loneliness because of the ban on meeting people.”

At the same time, nurses noted personal factors that contributed to positive emotions. The findings indicated that the new division of work hours (12 h on, 24 h off) made it possible to spend more time with the family, so much so that they talked about “family discovery.” Yakob said, “Today, I have more time with family and am financially unaffected. Our work is vital.” Like most nurses, Jannet referred to the resource of time, and her words emphasized the exciting experience of being at home, “This good feeling that you are home and have time!” Lian expressed a sense of calm regarding her children, “I feel calm that the children are at home, and there is no need to worry about them.” Despite the atmosphere of uncertainty and stress that accompanied most of the nurses, some tried to see the positive side of the situation and expressed general optimism. Yosef explained, “On a personal level, I have a feeling this will be a period we will yearn for later.” Sami commented on the support of colleagues, and said, “The fact that everyone continues to smile and support each other gives a very positive feeling of optimism and hope.”

Most nurses seemed to indicate that as a result of changes to work hours, and the resultant free time compared to before the pandemic, they invested time in themselves and their families and, thus, a positive emotion emerged.

3.2 Nurses’ coping strategies and resilience factors

Despite the feelings of distress, uncertainty, and apprehension they experienced as a result of the pandemic, the nurses presented factors that helped them cope well with the new situation, despite their intensive exposure to COVID patients.

All nurses discussed the individual and group resilience factors and noted that they chose to deal with the situation on their own, electing not to follow the hospital management's offer to seek psychological treatment to improve their coping. They noted the strengthening foci, and attached importance to the human environment, to social and family support, to respect and appreciation from those around them, to the search for knowledge and information, to routine maintenance through time organization, to quick decision-making, good protection, and optimism. These factors often enabled the participants to manage the stress.

3.2.1 Social and family support

“I discovered how much people helped during difficult times.” The analysis of the data showed that the social and family support component was a dominant coping and resilience factor. The nurses pointed to positive interpersonal relationships between peers, mutual help, cohesion, closeness, and family support. Lian's remarks reflect the views of many nurses, “To my surprise, the relationships have improved miraculously. People have kept morale high, helped, and supported each other.” Others cited optimism and mutual help as a significant resilience factor, “The optimism, help, and support for each other helped my mental resilience and that of others.” Importantly, some nurses commended the support and consideration of management and the support and appreciation of the people around them, inside and outside the hospital, as significant positive factors that helped them effectively cope. Rami recounted, “There was a sense of satisfaction and appreciation that we were in the COVID department. We felt support inside and outside the hospital.”

In addition to getting satisfaction and appreciation from the hospital staff, other nurses emphasized family support as a significant factor that helped them during the pandemic. Like other nurses, Yakob began by describing the support of his nuclear family as a resilience factor, and said, “My wife and kids were proud of my work; they supported and cheered, even though they had a hard time with the distancing.” Daniela said, “When schools were closed due to the pandemic, I have no idea how I would have managed if my parents could not help. They spent time with the children and prepared meals for the whole family.” It was evident that the nurses emphasized the importance of social and family support in dealing with the challenging situation of the pandemic; the support component appeared to be integral to their resilience and served as a significant protective factor.

3.2.2 Respect and appreciation from those around

“I was happy to see the gratitude shown by the armed forces.” Many nurses referred to the appreciation that the medical-therapeutic staff received from the general population. In Sarah's view, the appreciation helped her continue working despite her concerns. “At first, when all the people went out on the balconies and applauded the professional staff, it really helped, because you felt that people did appreciate your work.” Lemar added, “The feeling of being appreciated for your work warms the heart.” Yosef also referred to verbal and material giving as a factor that helped them cope, saying, “We heard many words of encouragement and thanks from people, also gifts, meals from families and large companies and chains, and that really helped and encouraged us.”

3.2.3 Search for information

“Knowledge is power.” Nurses talked about the thirst for knowledge and information related to the pandemic, and the means of defending against it. Since the virus was new, the staff sought knowledge from every possible source, and learned about the virus while providing treatment. Miri's voice reflects the voices of most other nurses, “I went online and became interested in artificial respiration methods and reviewed what I had learned a long time ago,” “I read a lot of articles about the virus, especially in the first days, and I felt that a lot of things were exaggerated.” Ameer described the feeling of relief that resulted from the renewal of knowledge, “There was relief, and much renewal and reading of material related to the pandemic.”

These examples highlight the importance of knowledge as a factor that could help staff understand the virus and conduct themselves accordingly.

3.3 Nurses' use of metaphorical language

The study findings showed that most nurses used their own personal and professional experiences to sharpen and reinforce their coping abilities. To do so, they employed metaphors from the field of military fighting. Specifically, they conceptualized the pandemic through metaphors such as war, war heroes, the front, enemy, victory, and crisis. The war terminology pointed to the body of a COVID-19 patient as a region of invasion by the deadly virus, and thus, the therapy quest was given heroic significance, particularly in cases where the war ended in victory.

3.3.1 The pandemic as war

“I felt we were at war.” Most nurses refined the message of the pandemic as war, repeating words that emphasized the need for victory. It was evident that the use of war metaphors reflected their management of the pandemic threat and helped them frame their work as fighting against a subversive, unknown, and nearly invincible enemy. Rami described the situation, “There was a feeling that we were preparing well for what would happen. It was like someone preparing well for war and waiting for it to start to fight.” Describing the working conditions during the pandemic, Omar said, “We encountered many logistical difficulties, and the work required much maneuvering. It was a war waged in every sense of the word.” The use of the warfare metaphors reflected a situation that had evoked feelings of concern and threat among nurses, and there was a strong need to recognize the virus as the “enemy” and confront it to win. Phrases like “We have declared war on the invisible enemy” were expressed.

The nurses were caught in a dilemma between their professional identity as people who were expected to help others, and their personal-family duties. Omar highlighted the issue, and said, “In this war as in real war, my job is to care for patients, but also to protect the staff and my family from getting infected.” Lian recounted her personal conflict as a mother, and a nurse who was required to work:

I have a child with a compromised immune system, and the conflict was whether to stay at home with him or take part in the war. I involved the management, they showed consideration, and we found a solution where I could contribute without harming the child.

These examples are evidence of the metaphors of war running like a common thread through the texts, thus amplifying the image conveyed by the nurses.

3.3.2 The virus as an enemy and a silent killer “I wanted to know the enemy.” The metaphor of war was linked to identifying the enemy (the virus) and protecting others (patients and families) from it. Miriam described a sense of professional responsibility, “We have a moral duty to take care of the sick, and we will do everything so that the enemy does not win.” The findings indicated that the staff confronted the virus, as highlighted in Yosef's words, “We are facing an invisible enemy, and we need to defeat it.” Ameer added,

We were faced with an awkward situation in terms of an exceptions committee, instructions that changed on a daily basis, and not always in an understandable manner. We had to stand firm and heroically defeat the enemy without breaking down.

The findings showed that nurses perceived the virus as a mute killer attacking the population. Yakob said, “It [the virus] is a silent and unpredictable killer, it is impossible to know when it attacks and whom it attacks. It is a battle between two unequal sides.” The lack of familiarity and difficulty in dealing with the virus led to a state of confusion. Phrases like “When you do not know your enemy, it leads to a state of uncertainty” were heard among many nurses. The interviews also showed that protective equipment such as masks and respirators became the only “weapons and ammunition” available to deal with the virus, being the mysterious enemy. Lian explained, “I was a personal example of putting on a mask and gloves and defending well to defeat the enemy.”

Despite the fear of contracting the virus, most of the nurses expressed pride in taking part in the fight. Lian said, “In the COVID department, my job was to guide the team that protected the caregivers of the COVID patients. I am proud to take part in this fight.”

In the cases described, the metaphors helped to turn the unfamiliar pandemic into something as familiar as a war and an enemy. The use of such metaphors helped the nurses understand reality and the “invisible” virus with which they were dealing.

3.3.3 The health workers as heroes “For everyone, we were the heroes at the front.” During the pandemic, health workers inspired the general population, who treated them as heroes struggling to save patients. Citizens stood on the porches of houses, saluting and applauding, as a sign of appreciation and respect for the staff. This situation gave the nurses much satisfaction, but also generated pressure that they could not meet expectations, as described by Jannet:

My job in the COVID department gave me a lot of satisfaction. The support from the whole community gave me strength. They treated us like heroes, but in truth it was stressful, because inside I felt afraid to get infected and to infect the family.

The nurses’ awareness of the community's expectations and the people's use of the heroism metaphor did not always match their feelings. For example, Sarah emphasized that she did not see herself as a hero or that fulfilling her role was an act of heroism, “People treated us as heroes, but I did not think I was doing anything heroic.” This situation was difficult for the staff because of the feeling of impotence and inefficiency of the medical treatments. Throughout the interviews, it was apparent that in the early stages of the pandemic, the nurses did not have adequate protection, and were in a state of fear and apprehension of the pandemic, and of infecting significant people in their lives, which did not match the hero characterization of which the citizens conceived.

4 DISCUSSION

This qualitative study aimed to examine the subjective experiences (positive and negative emotions), coping strategies, and resilience of Israeli nurses who directly treat COVID-19 patients. The data analysis yielded three main themes, which emphasize complex or ambivalent emotions on both the professional and personal levels and provide a better understanding of coping with stress.

4.1 Existing between the professional and personal experiences

Most nurses reported feelings of stress and panic, especially in the first weeks of the pandemic's outbreak, following reports in the news and social media in Israel and around the world. These reports, some of which turned out to be incorrect, exacerbated the stress and concern for the safety and well-being of the nurses. These findings are consistent with the findings of various studies that have described the negative impact of the media and the use of online social networks on mental health, such as increasing depression, anxiety, and mental distress among adults (Zhao & Zhou, 2020).

However, in comparison with the other studies (e.g., Barzilay et al., 2020; Bohlken et al., 2020; Shechter et al., 2020), our findings were surprising, showing that nurses reported rapid adaptation to the new situation, and a decrease in anxiety and stress levels shortly after the onset of the pandemic. The reasons are various: rooted in the nurses receiving significant and plentiful information from the hospital management and conducting extensive independent searches online, while other reasons are related to their own preparation and experience in negotiating stressful events. These efforts improved their knowledge and skills, which, in turn, help alleviate fear, and enable them to better cope with the pandemic.

The findings show that the threat of the pandemic placed the nurses in situations in which they had to make difficult decisions that reflected and exacerbated their role-related conflicts. It is evident that they tried to balance the conflicts related to their “professional duty” to care for patients (Kirsch, 2020) with their “personal duty” to protect their personal and family health and safety (Chen et al., 2020; Lipworth, 2020).

Concern for the safety and well-being of the family, the fear of infection, and the concern of interpersonal isolation resulted in emotional distress among health workers during the stressful health situation of the SARS pandemic (e.g., Maunder et al., 2008). Similarly to those studies, at the onset of the pandemic, nurses in this study risked their health to care for patients, despite the lack of masks and protective gear. Many worked to the point of exhaustion, and some even isolated themselves to protect their families from being infected with the virus. It seems that their professional commitment serves as a strong motivation to continue working, despite the great concerns. These findings are consistent with the findings of a study by Hewlett and Hewlett (2005), which examined the experiences of HCWs in Central Africa during Ebola-like pandemics. However, in Israel, in addition to the threat and fear of infection, the pandemic disrupted the daily lives of the staff on personal and professional levels. Similar to other studies, some experienced altered social activities and vacations, and disruptions to internships and/or educational experiences as a result of the uncertainty about the pandemic's progression (Cipolletta & Ortu, 2021). This, too, shows the mixed personal and professional impact of the pandemic upon the nurses.

4.2 Nurses' resilience and coping strategies

According to the psychological stress and coping theory (Lazarus & Folkman, 1984), the pandemic can be perceived either as a threat or as a challenging and controllable object. Evaluation of the event can affect coping styles: “problem-focused” versus “emotion-focused” coping. Following the COVID-19 pandemic, and despite the feelings of stress, apprehension, anxiety, and uncertainty, most nurses reported the use of coping strategies that helped them manage the situation and reduce stress.

The study findings are consistent with previous studies (e.g., Khalid et al., 2016; Munawar & Choudhry, 2021) conducted among medical teams, indicating a diverse resource pool of coping strategies that may help HCWs face difficulties during their work. Particularly striking is that most of the nurses’ coping was “problem-focused” (Lazarus & Folkman, 1984), including taking direct action, searching for information to give meaning to a topic that seemed beyond their comprehension—known in the research literature as “infodemic” (Gao et al., 2020)—and employing an active problem-solving approach. Only a few nurses used “emotion-focused” strategies such as perception of life as valuable, maintaining a positive attitude, and optimism. In fact, the use of an emotion-focused coping method stems from the fact that the study participants could not change the course of the existing situation.

Just as the range of HCWs’ stress-inducing factors is wide and varied, so is their range of factors that can increase resilience. This can be explained by Ungar's (2008) definition that resilience concerns both the individual's ability to mobilize resources to deal with stress and risk, and the ability of the family, community, and society to provide the individuals with significant opportunities and experiences for their well-being.

Accordingly, the study findings show that nurses had their own ideas on how to deal with the stress created as a result of the pandemic. Most of them learned to live with the reality and to cope with the difficult situation by using diverse resilience and coping factors; mainly the support of both the nuclear family and the wider social surroundings (Walsh, 2003).

Social support is defined as the existence or availability of people who care about the individual and make him/her feel valued and loved, by transferring resources, instrumental and/or emotional, from one social system to another (Hobfoll & Stephens, 1990). Accordingly, as this study showed, social support plays an important and influential role on the subjective perception of HCWs. Social and community support is expressed through “appreciation and respect from those around,” solidarity, empathy, and practical help (Pruitt & Zoellner, 2008). This finding is consistent with the findings of Marey-Sarwan (2020), which indicated that the social support component positively affects coping with stress and trauma, and that community cohesion gives rise to personal confidence and enables one to cope in the face of severe crises.

4.3 Nurses' use of metaphorical language

Study participants used metaphors (pictorial expressions) to associatively describe their inner world. In so doing, they provide valuable information on how they perceive and deal with reality. Metaphors are one possible way to give meaning to events and are an effective tool for describing and understanding complex situations, which helps enrich expression (Brown, 2008). In the present study, conceptual metaphors including abstract and tangible components, represent a thought pattern, and allow words to be mapped into contexts that include time components and control (e.g., Kövecses, 2010).

The findings suggest that metaphors constitute experiential patterns constructed from the perceptions and memories that the research participants had accumulated. Using metaphors helped the nurses see and understand the significance of the pandemic in the more familiar terms of their human experience. Thus, the metaphors served as a source of resilience and coping. During the interviews, there was much use of military terminology such as war, enemy, hero, and victory. The metaphors illuminate and sketch meaning; they link the known to what one seeks to know (Walsh, 2020). It seems that the parallels the nurses drew between the pandemic and the military reality helped organize their behavior and thinking, including cognitive processes of perception and memory.

Study participants described the epidemic as war and the virus as an elusive enemy that must be fought in every way possible. The specific formulations they use reflect the language of the battlefield in Hebrew. The militaristic discourse reflected a rationale of "no choice" to legitimize the use of any means appropriate to thwart violent threats. The use of these metaphors may be affected by the militaristic ethos and security circumstances that have existed since the establishment of the State, in 1948 (Ben-Eliezer, 1995, 2019).

In the Israeli context, where reality is saturated with wars, surveillance, and armed conflicts (Ben-Eliezer, 2019; Zureik, 2011), metaphors of warfare take on special significance. The metaphors that were interwoven into most of the interviews highlight the nurse's attempts to deal with the virus as the threatening enemy. At the same time, the nurses refrained from representing themselves as heroes, which would oblige them to intervene and deal with the pandemic when they were unable to do so. Similarly to other studies, participants in this study stressed that they did their duty as professionals regardless of COVID (Cipolletta & Ortu, 2021; Kirsch, 2020; Lipworth, 2020). It was also evident that the use of concepts of heroism, which emphasize ideas of self-sacrifice and steadfastness in the face of the threatening enemy, did not take into account the personal health risks to which the nurses were exposed. As such, its use may have negative psychological consequences for the workers themselves (Cox, 2020).

The violence of the pandemic, as apparent in the language used to define and frame it, was not only affected by the sudden appearance of the pandemic, its political economy (Bailey & Moon, 2020; Boettke & Powell, 2021), or the militarized political context (Gibson-Fall, 2021); it was a combination of the affective politico-economic context that carried global and local ramifications and economies. Framing the shocking effect of the pandemic, militarizing pain and physical illness further revealed the affective apparatus facing health workers.

While metaphors may serve a positive role for the understanding of unexpected and threatening events and for guiding behavior, that conclusion is not uniform. For example, Silva (2020) argues that the use of metaphors from the world of warfare may have undesirable consequences for both crisis management and the more general sociopolitical dynamic. This is because the metaphors emphasize issues such as confrontation with the enemy instead of using images related to treatment, empathy, and solidarity during medical emergencies.

The affective apparatus, embedded in a what we might call a political-health economy of shock, was packed with a sense of horror and heroism that included fear of uncertainty, a state of unending unexpectedness, a sense of loss of control, and actual loss of lives. Complex dynamics and ever-changing assemblages of the machineries of power at play during COVID-19, whether between the social, personal, medical, economic, and professional, or between the formal regulative or informal sociocultural, created a major state of affective confusion. Combining the militarized framings with nurses’ experiences that ranged between heroism and horrorism, attest to what Tanous (2020) revealed in his study on the healthcare system as a foundational pillar of governance, and what critical scholars suggested—that medical language is deeply militarized (Fuks, 2010). The intensified use of militarized language during the COVID-19 pandemic (Kanji, 2020), calls for further engagement with questions of affects, economic and cultural contexts, nature of pandemic, sociopolitical reforms and policies, and more.

4.4 Study limitations

This study has limitations that need to be acknowledged and addressed. The first is that the effect of the pandemic is still unclear. Hence, nurses’ reactions, their hesitations, lack of clarity, their terminology, and modes of framing their own observations are all affected by the nature of the global pandemic. Second, the qualitative approach used in this study represents the specific participants, their voices, and their insights. Qualitative studies reveal deep analyses but cannot be generalized in relation to other health workers. Research involving a larger number of participants would add another layer to understanding participants’ subjective interpretation of their experiences. Third, the interviews were conducted face-to-face and via Zoom, which can present potential bias. Fourth, the presence of the interviewers and the way the questions are presented to the participants can also introduce a bias. However, the researchers have extensive experience conducting interviews while being sensitive to the study participants. The first author is an expert in qualitative research and teaches courses in this field, and the fourth author has undergone training workshops in conducting interviews.

4.5 Practical recommendations

Given the availability of technological means and the limitations imposed by social distancing, hospital administrators can offer interventions by innovative means. This includes instructional videos, online team seminars, and online workshops aimed to build and promote effective resilience and coping strategies in connection with future health challenges. To reduce nurses' stress, hospital administrators can offer online cognitive behavioral therapy (CBT), which has proven effective in treating stress among non-healthcare populations (Weiner et al., 2020). Other possibilities include mindfulness-based stress reduction (MBSR) intervention, which is known to promote relaxation and cultivate nonjudgemental awareness of sensations, thoughts, and feelings in HCWs (Rakesh et al., 2017), and foster psychological resilience in nurses (Huffman et al., 2021).

In addition, the findings demonstrate the importance of peer support and family support, which provide a positive sense of belonging and security, reduce nurses' stress and anxieties, and enable them to function more effectively. Thus, it is suggested that hospital management initiate and organize support groups to encourage nurses to share personal concerns and professional experiences and also offer counseling and workshops that may help them balance work and home. It is also important to publish up-to-date guidelines that provide nurses with psychological support services based on stress management coping strategies. Furthermore, the nurses stressed that searching for information about COVID-19 helped them deal with the state of uncertainty. Hence, the hospitals can disseminate and make reliable, research-based information, such as that synthesized by the Cochrane Collaboration (2021) and the Joanna Briggs Institute (2021), easily accessible.

ACKNOWLEDGEMENTS

The authors gratefully acknowledge the nurses for volunteering their valuable time and participating in the study.

CONFLICT OF INTERESTS

The authors declare that there are no conflict of interests.

AUTHOR CONTRIBUTIONS

Conception and design: Marey-Sarwan Ibtisam, Hamama-Raz Yaira, Hamama Liat, and Asadi Ahmad. Acquisition of data: Marey-Sarwan Ibtisam and Nakad Bothaina. Analysis and interpretation of data: Marey-Sarwan Ibtisam, Hamama-Raz Yaira, and Hamama Liat. Writing, original draft preparation: Marey-Sarwan Ibtisam, Hamama Liat, Hamama-Raz Yaira. Writing, revising the article critically for important intellectual content: Marey-Sarwan Ibtisam, Hamama-Raz Yaira, Asadi Ahmad, Nakad Bothaina, and Hamama Liat. Final approval of the version to be published: Marey-Sarwan Ibtisam, Hamama-Raz Yaira, Asadi Ahmad, Nakad Bothaina, and Hamama Liat.