The coronavirus disease (COVID-19) is now a worldwide public health emergency. As essential and central parts of the COVID-19 patient care team, nurses and nurse assistants are facing all kinds of challenges caused by the disease and the pandemic. Understanding these challenges and the way nurses and nurse assistants handle and cope with them provides important knowledge on how to improve management of future pandemics and endemic situations. Thus, the present study explored the challenges faced by nurses and nurse asssitants who cared for COVID-19 patients in hospitals and long term care facilities in Italy, Austria and Germany.n = 30), nurse coordinators (n = 6) and nurse assistants (n = 5) from hospitals (n = 32) and long-term care facilities (n = 9) in Austria, Germany, and Italy. Data were collected between August and December 2020 through semi-structured interviews. The collected data were analyzed using qualitative content analysis.The study employed a qualitative design. Purposive sampling was used to select the participants consisting on nurses  Knowledge, skills, and training ; (ii) resources and risk ; (iii) coping strategies .Nurses and nurse assistants who participated in this study faced many personal and professional challenges, and used different coping strategies to manage the situation. Some of these strategies can be applied to reduce these challenges and create better working conditions for nurses and nurse assistants in similar events. Further research, training of staff, and adaptation of institutional policies may help develop new strategies to face future pandemics successfully. Coronavirus disease COVID-19) is a respiratory infectious disease caused by a newly identified coronavirus named SARS-CoV-2. It emerged in China in December 2019 and has spread worldwide 9 is a re. The disPandemics negatively impact health systems and health professionals, who are the most important and leading force in the fight against pandemics . MoreoveHealth professionals, particularly nurses, met an unknown infectious disease, a daily changing situation due to new novel variants such as Delta and Omicron. Modifying treatment guidelines for this very contagious illness and caring for COVID-19 patients without knowing about the virus, treatment, and adequate care faced nurses and nurse assistants with different challenges , 7 SeverThe COVID-19 pandemic is a new challenge to worldwide healthcare systems and will not be the last one. Therefore, further exploration of healthcare professionals' experiences, particularly the general difficulties, feelings, and applied coping strategies of nurses and nurse assistants who have cared for COVID-19 patients in hospitals and long-term care facilities, will help to manage future crises better. Accordingly, this study aimed to examine the challenges faced by nurses and nurse assistants who cared for COVID-19 patients in hospitals and long-term care facilities during the first wave in Italy, Austria, and Germany.A qualitative exploratory design using semi-structured interviews and qualitative content analysis was applied , 20. ThiThe study was conducted following the Declaration of Helsinki  and the via email, which was signed and sent back to the researchers who arranged Zoom meetings as suitable for the participants. Seventy participants expressed interest in participating voluntarily in this study, and ten withdrew due to personal issues. The recruitment and interviewing process happened simultaneously in all included countries. The sample size was determined based on data saturation, which refers to “the repetition of discovered information and confirmation of previously collected data”  were conducted to test the set guide. The interview procedure and questions were adapted per the pilot interviews. Data were collected through semi-structured in-depth interviews conducted online in the native language of the respective participant by a native-speaking author between August and December 2020. The final interview guide covered various aspects of the COVID-19 pandemic. Questions of the interview guide related to the data presented in this paper are shown in via Zoom were preferred. Each participant received a private email with an invitation to the interview and information about the aim and content of the study. Furthermore, they got information about the research team before arranging the interview. The date and time scheduled for the interview were agreed upon by both the participants and the interviewer. After receiving participant's written and oral permission, all interviews were conducted and audio and video-recorded. During the interviews, it was ensured that both the participant and the interviewer were alone and in a quiet environment. All interviews were immediately transcribed verbatim using F4 software , and reading and rereading the transcripts and the field notes . AfterwaThe directed content analysis combined deductive and inductive strategies , 22. Furvia in-depth interviews followed by adding, checking, and approving the extracted codes. Consistent with guidance from Elo et al.  knowledge, skills, and training, (ii) resources and risks, and (iii) coping strategies .At the beginning of the COVID-19 outbreak in Europe, there was limited knowledge about the virus, the disease, infection, protection, and control. Most participants from Italy said they felt uncertain and unprepared for such a pandemic. They compared the COVID-19 pandemic to a tsunami because the situation worsened quickly. Healthcare professionals and corporate bodies were unprepared to take the necessary measures and acquire the knowledge needed to deal with such a situation:It was an unforeseeable thing, in the sense that even... especially at the beginning, no one was prepared for this virus, no one knew about it, and therefore treating any patient was difficult at the beginning.” (I-P4)“In this period, when this “new job” arrived for us, it was like a tsunami because we had to reorganize ourselves mentally and personally in managing a new situation to which we were not accustomed.” (I-P5)“Some participants from Austria and Germany, where the first pandemic wave came later, reported specific preparation measures such as reorganizing wards to improve intensive care capacities, purchasing orders for protective equipment, or implementing internal hygiene guidelines and protocols. However, several participants, mainly from nursing homes, felt unprepared and did not experience preparative measures in their facilities.We had a training session exactly 1 day before the ward (.) was converted to a COVID ward (.). A lady came from (...) I don't remember which department, but she did the training with us. Yes, how to properly enter and exit. The handling, how to do. The communication with the patients...” (A-P32)“Okay, so in the first wave, which started at the end of March, I work in an intensive care unit with ten beds. Since February, we have had four beds constantly blocked, and to prepare for the wave.” (G-P35)“You could have used the time to prepare better. I think things didn't go so well at my ward. My ward manager didn't take it that seriously. And the staff were all very concerned. I mean, it was new for everyone, but in the hospital, it was just again different. And um, there was no training, no briefing, but “so please do it now.”” (G-P38)“Almost all interviewees reported a lack of practical skills in treating COVID-19 patients. Patients overloaded hospital capacities by far, and many died in a short time after being admitted to the hospital, providing no time for any treatment. In addition, some Italian interviewees indicated that they lacked time to learn about COVID-19 and new practical skills during the first wave of the pandemic. Furthermore, some interviewees talked about organizational problems related to the lack of information and skills:Unfortunately, there was no time to get information because there was no information available, so we launched into this “fight” with our eyes closed, without knowing exactly where we were going.” (I-P7)“We didn't have a standard working technique because everyone came from different departments. I usually work in general medicine, but I worked with people from psychiatry or a pneumology ward, so there was a bit of organizational difficulty from the team's point of view.” (I-P12)“At the time of the interviews (around the second wave of the pandemic and still before vaccination was available), participants complained about a lack of clear evidence-based protocols and safe treatment.What kind of treatment could we provide for COVID-19 cases when we are living with his situation for 9 months, and we still don't know what/a safe cure or vaccine is not yet known (.), and we're still as in the first day even though 8–9 months have passed?” (G-P40)“While some interviewees talked about the unexpected situation they faced, they pointed out that they had undergone brief training on preparedness very soon after the pandemic started. Such training mainly focused on using protective equipment, hygiene, and infection prevention, mainly consisting of online (video) lessons.The only course I did was one online course on protective equipment, so let's say regarding what had to be done legally precisely and what had to be done because it was a rule. Regarding courses on managing the COVID patient, they were not done. Probably, there wasn't even the time, but the courses weren't done. I learned everything on the field.” (I-P11)“Some training courses were done, but they were more about staff protection, hygiene protection, and transmission protection. These were the training that was mainly offered.” (G-P40)“In the first phase of the pandemic, effective practical training for protective materials was frequently impossible due to material shortages. Only a few participants received training and instructions on-site at their facility. Some participants wished for more advanced training on treatment options, such as training prone positioning.What I found burdensome, really burdensome, was that I thought: There are so many recommendations from the professional associations (...), and this is not being implemented. Or it takes so long. Or, of course, we don't train the prone position. (...) We don't train how to put on and take off protective clothing. Because there is not enough.” (A-P25)“Some participants indicated that they learned many new techniques during the COVID-19 pandemic. They described their experience during the COVID-19 pandemic as unique because they learned to use protective equipment and all the necessary devices for an emergency of this nature and how to manage patients in such critical situations. One of the Italian participants said that they learned everything by doing.Everything we learned in the field, in the COVID phase. Just 1 day before we opened the department, our managers gave us a course on dressing and undressing and talked to us in a little more detail about COVID and the studies that had just emerged, but it was all speedy. What we learned, we learned in the field, mainly.” (I-P9)“Participants also helped by sharing their knowledge and teaching other colleagues the techniques they knew. The formation of new teams by successfully integrating colleagues from other wards or agency workers facilitated learning from each other.So, we looked for videos, we asked for information (...), we structured ourselves in a little way / We gave ourselves tasks so that everyone looked for indications on how to dress (...), that is, we watched the videos, and we did rehearsals. I did many trials on how to dress and undress; I did a lot of them. And then I showed it to the others.” (I-P23)“Yes, the teamwork and the solidarity in the team was excellent (.) and (.) because we also had so many temporary workers, (.) so they are incredibly well trained, and I learned a lot from them in practice, as far as ventilation is concerned and (.) all kinds of things.” (A-P33)“On the other hand, some wards reported a lack of communication and information within the team.The chief physicians have constantly communicated with us in the intensive care unit and have exchanged ideas. Unfortunately, not so intensively with the nursing team, but only the heads, yes, and the communication has fallen by the wayside a bit, which I found very unfortunate.” (G-P35)“Participants reported that constant learning during the pandemic and successful adaptation of treatment protocols positively affected professional self-confidence and job satisfaction.Um (....) it's a constant learn (...), you go into work already self-confident. Therefore, with specific experience values, you go into the situation in (...) relatively more relaxed. If a patient comes from the shock room, you go into the matter completely different because you have the experience.” (A-P24)“Well, it gives me joy. I also enjoy my job more. I'm learning; that gives me pleasure and this incredible good teamwork.” (G-P38)“Participants generally perceived a lack of resources regarding personal protection in the workplace. There was an initial lack of equipment and other resources, which posed a greater danger to health care workers and the patients they were in contact with. The most common complaints included the lack of masks, gloves, hand gels , demand for proper use, and the establishment of collective protection measures:Another problem did not have the protective material. You can't arrive on Monday to count the masks to wear to be able to enter an intensive care unit with COVID and say, “Until Thursday, we have some; after that, we don't know if they'll arrive.” When you experience them first hand, these are things that you say, “Jesus, how have we ended up?” These things are worrying (...), because none of us was willing to go in without protection because it was like going to the slaughterhouse; I mean, what do you do? Do all go in like this, without protection? That doesn't exist, that is/ Afterwards, the problem of not having enough protective material existed probably all over the world because it was also seen in America and other places. Still, in my opinion (...) it had to make people think and act accordingly to what the situation was, that is.” (I-P19)“We didn't have enough masks, for example. FFP2 masks and FFP3 masks, we always had to save. Um, and we were also controlled. Of course, that also destroys the trust relationship a bit (...). And then everyone looks a little bit, well ok, but now I have to protect myself. And not to show any consideration for the others.” (G-P38)“While many participants reported a lack of resources and protective equipment, sufficient protective material was initially available in some facilities, particularly in Germany and Austria. However, lack of knowledge, training, and insecurities are sometimes misused.I can say that the equipment was misused a lot due to the lack of knowledge (..) of the virus, or how can I call it? The difficulty or the severity of the virus; then, the equipment was highly misused. Though, over time it was realized that resources were running out.” (G-P40)“Some participants talked about the difficulties they faced while working with the protective equipment due to physical problems such as exhaustion caused by heat and breathing problems or because they could not touch the patients, couldn't speak to them, or keep eye contact.We were not used to working with (..) let's say, FFP2 masks, which gave an intense headache. At the end of my shift, I had a headache related to using the visor.” (I-P12)“The mask's loops are as unbearable as they cause ear irritation and “decubitus,” sometimes they become red. We are under time pressure and stressed, which is even more problematic (touching the ears). The air is limited (.) in some way.” (G-P41)“Participants frequently mentioned the additional workload and burden caused by dressing and changing protective equipment.We should wear (.) shoe covers over the shoes before entering the room; we enter, and/we should change the clothes every time we enter and get out of a room. So, entering a room, getting out, and entering another room. It's not that/we cannot enter a room with the same clothes. We should change clothes, and wear new ones. So, it's the same thing throughout the day.” (G-P41)“Several participants also perceived patients or residents as distressed when nurses were suddenly dressed in complete protective equipment.I would say that the patients' reaction when they resulted positive (.) was bad, and they were uncomfortable when the personnel got dressed up like that.” (G-P40)“That was also the problem because the (.) older, demented patients thought we were aliens. (…) I don't know what they thought, but they panicked, and we had to sedate one of them because (.) she went crazy. And I understood that” (A-P29)“Because nurses and nurse assistants faced a previously unfamiliar emergency, most of them initially did not know how to protect themselves and others with absolute certainty. As they saw the situation worsen and colleagues getting ill or dying, they started to self-isolate, fearing infecting themselves or spreading the virus to family members.When I saw some colleagues falling ill, both doctors and nurses, I decided to move away. I went to live in a flat alone, quite close to my family so that I could see them from the terrace, but I lived in a flat alone because I was afraid of infecting them.” (I-P18)“While deaths increased daily, healthcare professionals did not know how to treat patients and their sickened colleagues and felt at higher risk. With tears in their eyes, some interviewees stated that they felt frightened and in danger of their lives, their family's, and their colleagues' lives.Watching my colleague die (cries) and choosing whether to intubate him or not. That was the most painful thing. I hope I'll never have to live it again, never again! I hope I will never feel that again. I don't want to see a colleague of mine suffocate, to hear a colleague of mine telling his wife, “This is the last time I'm going to say goodbye to you because I have to be intubated if I want to live, but unfortunately I know I'm never going back.” (I-P8)“I also had a relatively young colleague, 26, and she was very sick. So, she came to work after 3 weeks and was extremely dyspnoeic. You couldn't talk to her normally, so she was breathing calmly, which got me. Before that, I was like, “yeah, okay, Corona is already bad,” so I also felt it was bad, but I thought like, “well, if you get it, you're young, it'll be okay somehow” and then when I saw that, it already scared me. You don't know what the consequences will be. You don't know how it will happen.” (G-P36)“Carelessness and negligence were frequently associated with infection among healthcare professionals. In some cases, interviewees working in nursing homes stated that some of their colleagues did not wear masks or did not follow the appropriate rules and were infected by patients. In other cases, they were the ones who infected patients without knowing they were COVID-19 positive. Some participants stated that most nursing home residents were infected and, therefore, all staff was infected. In other cases, although some colleagues tested COVID-19 positive, they continued to work.Because (.) yes, so you don't feel well and (..) yes. I've also seen colleagues who didn't take hygiene very seriously, sitting in bed with patients in a protective gown, and I thought, that's impossible, that he wouldn't get infected.” (A-P33)“We had a colleague, who saw it very (.) um (.) chillingly, so very relaxed, then came out with the mask, with which she was in the patient room, and afterward she came in the nursing office and hung the mask down over the table. then a colleague asked me during the check-in (.) “Is this the mask that she was wearing with the patient?” “Yes, and?.” So we didn't perceive the seriousness of the situation at all at the beginning.” (G-P35)“Several organizational problems arose due to many infections among healthcare professionals. The condition of healthcare professionals led to a personnel shortage, resulting in the nurses having to deal with various difficulties.There are personnel shortages, especially in the wards where there are mainly COVID patients because a part of them have resulted positive, unfortunately; some others are not present because of being sick or other reasons. So, (..) it's difficult, at the moment. There are shortages.” (G-P39)“Some Italian participants reported that the situation became even more complicated when the head nurses became sick.We were alone without the head nurse because she also fell ill immediately due to COVID-19. We did not need management, but we had already needed a guideline. Then, one of our colleagues died, and we saw his death until the end. So, practically speaking, we lacked organization and the possibility of working well with available management. Then, organizational, yes, because (...) people got sick; we remained very few at work and were always the same staff.” (I-P8)“Other interviewees stated a shortage of tampons and treatment for their infected colleagues. It led to a chaotic situation and changed the work rhythm of the healthcare professionals. Since most of the healthcare staff was ill, the nurses and their assistants who were still healthy had to work extended shifts every day and cancel their yearly vacations.Yes, as far as shifts are concerned, I had a much more irregular rotation in the previous period, from March 1stto March 17th, where many colleagues fell ill. Therefore, we were all asked to skip the rest periods, return, and extend, and it was crazy with the shifts, but we followed a regular rotation. (...) It happened once that a colleague had tested/ when they started to do the serological tests, she tested positive for the serological test, so clearly, she did the swab, and while waiting for the swab report, she couldn't come to work. Therefore I had to skip a rest to come back, but not/ other times not, the shifts were regular.” (I-P11)“Several participants experienced feelings of stress, anxiety, and fear facing COVID-19. They did not know how to protect themselves and feared contracting their families the virus.Well, we even had to wear; I once had to wear glasses, diving goggles. Because at that time, we didn't know how it would be transmitted, and somehow I took everything that was available in terms of protective equipment, even though I now think to myself, how is this supposed to get through my glasses into my eye? (...) But of course, I was still in a situation where I was even more afraid than I am now.” (A-P29)“A world pandemic which caused stress for the medical and nursing staff. Every time we entered that room, we had to be isolated with masks and PPE, and it was a huge emotional load.” (G-P40)“The nurse mothers were terrified of bringing the virus home to their children, but it was the same for me, for my mother who is an elderly, as it was unknown.” (I-P2)“I have never been afraid that I would infect myself. I've only always been afraid that I'd carry it into the home. Because that would be fatal, of course.” (A-P27)“Although healthcare professionals had already begun implementing protective measures for safety and hygiene (based on previous experience with pandemics), participants stated they began to isolate themselves to protect their families.When I saw some colleagues falling ill, both doctors and nurses, I decided to move away. I went to live in a flat alone, quite close to my family so that I could see them from the terrace, but I lived in an apartment alone because I was afraid of infecting them.” (I-P18)“When participants in this study were asked how they coped with the situation, they indicated that they applied various strategies to cope with the actual situation. Some of the individual methods nurses and nursing assistants used are explained below.Many participants used humor in their professional teams or families as a strategy to cope with stress, fear, panic, and drama caused by the pandemic. They showed that even in such a tragedy, there could be many humorous situations from which one learns how to deal with difficult situations in life, give and receive more love, and add the color of positivism to this unique experience.Well (..), maybe when we were joking together or/ (..) Inside, all locked up, we were joking together, almost as if it was nothing. So, it was nice, because it means that we love each other, because (laughs) if in times of difficulty.” (I-P22)“Giving a smile or creating humorous situations has proven helpful for healthcare professionals and patients.So even in the ward, maybe we tried to “laugh” with the patient who maybe couldn't hear us because he had the ventilator, so, maybe we made some gestures; anyway, in this tragedy, we always tried to make the persons smile.” (I-P4)“Several participants reported a grim sense of humor between colleagues due to stressful work.Yes, that is a bit of gallows humor. Meanwhile, it is like this, if someone coughs at our ward, we don't say “Bless you!” anymore but “COVID!” so (laughs) we have developed peculiar and unusual humor, but I think that in a special area, it is an outlet. As long as it's not offensive or you still know what it's about, I think it's within reason.” (A-P24)“Our study participants indicated that they learned to live with and adapt to the actual situation during the pandemic. At the pandemic's beginning, specific knowledge was limited, but as the days passed, they studied and acquired expertise about COVID-19 and learned how to behave and act.Then, well, the fear of contracting a disease that no one knew about; therefore, we didn't know how to deal with it. So we studied the disease daily, checked the internet, and updated ourselves; it was a unique update to face this crisis safely.” (I-P23)“Actually, all established concepts. These guiding principles, everything we did was somehow all (...) so void because it came differently every day. In addition, you can't stop it anymore, so we said it doesn't matter how we do it. The main thing is that they are cared for well, and we are fine.” (A-P26)“Nurses and nurse assistants had to adapt to the situation, using protective equipment, isolation, insults, or a lack of equipment and medication. Some participants said their team missed this time because they learned to work under these conditions and difficulties, which also had a positive aspect.So, it wasn't easy. However, we adapted, we understood that we had to change our habits. Anyway, we keep on doing it, and I hope that we have the strength to continue.” (I-P5)“Several participants shared their opinion that COVID-19 will continue being a health care issue and that everyday life has permanently changed, at least for the next couple of years. They got used to protective measures such as masks and routine testing for infection at work and in everyday life. This adaption to the pandemic led to reduced perceived risk. Some participants stated that they are no longer afraid of being infected, while others even reported careless use of protective measures.Some colleagues still have such panic (.) yes, and there are employees who are more relaxed now. So I have to say, I am now/. I would no longer be afraid of getting infected, and then I just wear protective equipment.” (A-P31)“Yes, and I think they were also more aware of their material, so they dealt with it more consciously. Such things like ““oh, come on, it ‘'s okay”” or ““I”ll just have a quick look here,”” or ““I don't need any protective equipment for that,”” or something like that. That was not the case in the first wave.” (G-P38)“Different ways of coping with the COVID-19 pandemic were of great interest to the participants in this study. Conversations, hugs, despair, and support among friends and colleagues were successful coping strategies.Well (...), actually talking with colleagues, because by experiencing the same situation, we got (..) strong. Let's say that living the same situation we also (laughs)/ We said, “Wow, but what are we living?” (laughs). But we got strong together.” (I-P17)“So I think it would be more difficult if I didn't talk about it with my friends. I have many friends who work in the health care system so that I could talk about it very well with them and quasi so yourself (.) experience a bit (.) of pseudo-psychological care, and then it goes already.” (G-P34)“The team support helped many of the participants to handle the demanding situations.Two colleagues were about to collapse and maybe even cried during their shifts for several days. We tried to make a team effort and said: “Come on, if you can't do it, stay at home, but if you stay here, move on, because if you cry, then I cry, we cry in two, it becomes a disaster.” Then, they managed to do it.” (I-P4)“Another participant stated that he managed to cope with the situation by using organizational strategies for himself and the team in which he worked, taking on the role of teacher for some young colleagues, and avoiding anxiety and panic situations.At the beginning, it was more a handing over of tasks among colleagues, among more experienced colleagues or those who had already (...) done shifts in those departments and explained to the others how to dress and undress.” (I-P18)“Several participants indicated that it was crucial to protect themselves physically and mentally; otherwise, they would have gone crazy. They showed that they tried to follow all hygiene rules, not shake hands or hug each other, support each other emotionally, and work as a team. They joined and tried to eat well and strengthen their immune systems.Also, do something for myself and (...) for the physical I did a detox treatment with an energy specialist. So much for the spiritual topic, Yes, I believe in something like that. So I went to the energy specialist, and this body's detoxification was good for me.” (A-P26)“Self-protection and protection of the other (.), also protection for my family of course.” (G-P35)“And then, I would advise them [young colleagues] to try to detach their mind when they leave the hospital and (...) not to take home too many, let's say, psychological burdens from there, to try to keep the working life separated from everyday life.” (I-P16)Most of the participants said that they managed to cope, work and succeed in the pandemic situation only thanks to the support and love of their families.And then, they practically facilitated me in everything at home, and I didn't do anything. I practically went to work, arrived home, and maybe slept in the afternoon. I only washed my clothes, and that's all. I made my bed; I did my things, I found the food already ready, they left me in peace, and let's say that I was lucky at this point. I mean, I received support from my family, and that's why I didn't want to leave because they had also offered some houses, some places for us nurses to stay during this period; I didn't want to go because I needed my family, I needed (...) to arrive home and find all these things.” (I-P23)“My partner's smile, my partner's smile, yes. He understood what my job was, a lot. He was close to me and everything.” (I-P8)“Talking about the stressful and burdensome situations at the workplace with family members or close friends was a frequently applied strategy to cope with psychologically demanding circumstances.It was interesting to hear what some of the participants, who are mothers, reported about the obstacles they faced during the COVID-19 pandemic, not only at work but also in the family, since they did not have time to take care of the children, who in many cases stayed at home alone. One of them pointed out.How do I manage with the children? When the schools closed, my husband also had to work. That was a big challenge. Um, I wrote a diary myself as a coping strategy, which has proven quite good. Then I tried. At some point, I stopped watching the news (...) because it drove me crazy.” (A-P25)“This study describes the challenges of nurses and nursing assistants with the novel disease while caring for COVID-19 patients during the first wave of the pandemic in Austria, Germany, and Italy. The main findings of our qualitative analysis demonstrated that participants expressed their experiences on three themes: Knowledge, skills, and training; resources and risks for health care workers; and coping strategies.The unknown course and treatment of the virus put pressure, fear, and uncertainty on the nurses and nursing assistants interviewed, especially at the beginning of the pandemic, which they perceived as a “tsunami” situation. Accordingly, Arcadi et al.  found thIt has been demonstrated that there is high individual-level heterogeneity in willingness to comply with COVID-19 preventive behaviors such as mask-wearing and hand hygiene among the general population as well as among healthcare workers , 35. UncThe speed of the spread of COVID-19 made it extremely important for healthcare professionals worldwide to use PPE. Countries generally unprepared and most affected by the pandemic experienced problems accessing PPE. This study found that participants from Italy did not have enough PPE supplies, particularly at the beginning, while in Germany and Austria, it was reported to have been misused. In addition, the requirement to use PPE for extended periods led to deviations from the proper use of PPE recommended in the guidelines and various other problems . AccordiAlthough others in the community had to stay home and avoid social contact, healthcare professionals, especially nurses and nursing assistants, continued to be exposed to the virus while providing care , 10, 40.While the present analyses mainly focused on nurses and nursing experiences during the first phase of the pandemic, it does not emphasize the mental issues caused by the long-lasting overload. The Chen et al.  meta-anaThe three main themes (and their subcategories) identified in our study (i) knowledge, skills, and training; (ii) resources and risks for the healthcare professionals; and (iii) coping strategies are related to the healthcare workers' organizational support, and the failure of support and coping can lead to mental health issues among healthcare professionals as demonstrated previously. Organizational support, in particular work support  and personal support , has been shown to predict different levels of anxiety and levels of life (dis)satisfaction during the COVID-19 pandemic . Access Interestingly, the chance of having distress and depression symptoms varied significantly by the number of working days among younger healthcare workers and were negatively associated with job satisfaction and life satisfaction but positively associated with job turnover intention. In contrast, office days were positively associated with job and life satisfaction among older colleagues, suggesting that younger healthcare staff who did not work many days and senior healthcare staff who worked more days are the most mentally vulnerable groups , 46. As The results of the present study, similar to Zhang et al.  findingsSimilarly, participants in the Lee et al. study thought that positive thinking and a friendly work environment reduced stress when caring for COVID-19 patients . In addiFurthermore, several participants of this study developed new strategies and rituals for taking care of themselves , 42. AllDuring the pandemic, the experience and skills of nurses and nursing assistants improved, and they had the chance to strengthen their skills by participating in a multidisciplinary team . SimilarFinally, this project showed that a positive attitude and conversations with family, friends, and the team leader were the most important coping strategies among nurses and nursing assistants. As Slama et al.  noted inDuring the interviews, the participants addressed various other aspects of the pandemic, including ethical and legal issues, organizational influences,  teamwork, impact on the social environment, long-term impacts of the pandemic, and mental and emotional reactions. These aspects will be addressed in subsequent publications, where mental health will be discussed in-depth.This study examined the difficulties nurses and nursing assistants experienced in caring for COVID-19 patients in hospitals and nursing homes in Austria, Germany, and Italy. They presented many challenges, including lack of knowledge about an unknown disease, organizational problems such as lack of staff and PPE, training problems, difficulties in using PPE, risk and infection, isolation, and different feelings. To overcome these challenges, participants in this study used different coping strategies, such as humor and laughing with each other and with patients, adapting to the new situation and learning to cope with reality, creating warm teamwork, receiving and providing support, taking care of themselves, and especially communicating and being supported by family and friends. Therefore, some of these strategies can be applied to reduce these challenges and create better working conditions for nurses and nursing assistants in similar events. These include providing the proper and sufficient PPE, a good work environment, financial and social support, managing pandemic situations effectively, developing new ways of communication between staff, patients, and families, and paying more attention to healthcare professionals. Further research, training of staff, and adaptation of institutional policies may help develop new strategies to combat future pandemics successfully.The results of our research may influence the improvement of nursing care and management during pandemics. It is a contributing factor to the literature on healthcare during a pandemic. This study provides information on the challenges nurses, and nursing assistants lived during the COVID-19 pandemic in different settings  in three European countries. Most of our sample are nurses, as they are the healthcare professionals with the most contact with patients in the studied settings. Our findings are limited to nurses and nursing assistants who worked during the COVID-19 pandemic in Austria, Germany, and Italy.via Zoom, which might be considered a limitation. Future research should examine health professionals' difficulties during COVID-19 in different countries, including non-EU countries.Furthermore, the travel restriction made it impossible to conduct the interviews face-to-face. Still, they had to be completed online Data are not publicly deposited but are available  upon request to the authors.The studies involving human participants were reviewed and approved by RCSEQ. The patients/participants provided their written informed consent to participate in this study.NP, SP, and CZ contributed to conception and design of the study. Data extraction: NP, CR, and BB. Analysis: NP, CR, and CZ. NP led and wrote the first draft of the manuscript, with the contribution of CZ. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The potential devastation that a nuclear accident can cause to public health and the surrounding environment demands robust emergency preparedness. This includes gaining a greater knowledge of citizens’ needs in situations involving radiation risk. The present study examines citizens’ attitudes to a remediation scenario and their information and communication needs, using focus group data (n = 39) and survey data (n = 2291) from Sweden. The focus groups uniquely showed that adults of all ages express health concerns regarding young children, and many also do so regarding domestic animals. Said protective sentiments stem from a worry that even low-dose radiation is a transboundary, lingering health risk. It leads to doubts about living in a decontaminated area, and high demands on fast, continuous communication that in key phases of decontamination affords dialogue. Additionally, the survey results show that less favorable attitudes to the remediation scenario—worry over risk, doubt about decontamination effectiveness, and preferences to move away from a remediation area—are associated with the need for in-person meetings and dialogue. Risk managers should thus prepare for the need for both in-person meetings and frequent information provision tasks, but also that in-person, citizen meetings are likely to feature an over-representation of critical voices, forming very challenging communication tasks. Major nuclear power plant (NPP) accidents are some of the most challenging disaster scenarios, affecting public health, the environment, and wildlife . They prHowever, NPP accidents have revealed the challenges in communicating information to worried and distrustful citizens ,8,9. In Previous research has shown that when citizens are permitted to again live in a decontaminated area, younger adults, women, and parents report particularly high levels of worry and, sometimes, the desire to avoid risk altogether by starting over in an unaffected area ,10,15,162, is 5.4% for newborn girls, which is higher than that for 30-year-old women by a factor of 4.5  to get today’s values, becquerel or radium, or whatever it is—to see the situation” (R8:3). The interviews thus demonstrated the possibility of drawing on some of the more recent communication technologies in conveying information about the remediation.The focus groups also show that respondents wanted to know such things as what the remediation plan looks like, possible deviations in the work, and how long the clean-up will take. Opportunities to ask questions about the remediation process and its risks, as well as to meet those responsible for the remediation, were requested above all in the initial stage of the remediation process. In the groups containing younger women, it was believed that such ongoing “listening” and “transparent” communication work during the decontamination process could lead to less worry and increased trust. Simultaneously, there was a general concern and doubt expressed about the ability of the responsible actors to even manage to conduct such transparent and dialogical communication activities . One of the elderly men stated the following: “But the question is whether they can handle it when they are cleaning up. Do you have that organizing ability then? Not in the beginning, you definitely don’t. But of course, it [decontamination] spans a year, by then they must have built something up.” (R2:1). The respondents expressed concerns that authorities could not cope with the clean-up situation and all communication issues simultaneously.For a few respondents in several groups—regardless of age and gender—the worry and uncertainty surrounding such a scenario were so strong that they believed their attitudes could turn into “outrage” and agitation related to receiving government information. The scenario aroused such strong feelings of uneasiness and levels of worry that some older female respondents believed that life in the area would be a thing of the past in such a scenario: “I do not know if I need it [information], because it’s over. I think so”, stated one woman, with the agreement of the others in her group (R5:4). They saw it as a possibility that they would have little need for information at all and that they would not be influenced or persuaded by frequent monological information or dialogical communication from the authorities.Although the answers varied among respondents, a recurring interpretation was that, despite reassuring messages from the authorities, one would feel worried. “Even if they say it is safe, it will probably stay in one’s head somehow”, said a woman in her 20s (R3:5), referring to her worry over radiation risk. Another group of women emphasized that they “do indeed trust the authorities” (R10:1) but that their worry was rather rooted in the invisibility and severity of the risk.The analysis of the survey data shows that there is an overall positive relationship between the level of worry over risk and the preference for modes of communication that enable some level of dialogue, such as asking questions or making suggestions. However, we found no similar, clear association between the level of concern about ionizing radiation and the preference regarding written information cf. . Thus, tp < 0.05); “once per month” and all other values (p < 0.05); “every other month” + “every six months” and all other values (p < 0.05); and “not at all” + “every six months” and all other values (p < 0.05).As shown in Another important area of discussion in the focus groups was the challenges associated with remediation, as summarized in Moreover, in their assessment of the effectiveness of decontamination, respondents drew on their understanding of radiation as posing a transboundary risk, as summarized in In addition to statements that expressed doubt about decontamination because the risk was perceived as being difficult to contain, respondents applied more holistic interpretations of what constitutes a successful recovery. As can be seen in p < 0.05); “once per month” and all other values except for “every other month” (p < 0.05); and “not at all” + “once every six months” and all other values except for “every other month” (p < 0.05).In addition to worry being associated with preferences for more frequent communication activities with the possibility of dialogue, we found that lacking belief in the effectiveness of the remediation is associated with similar communication preferences. As shown in Furthermore, the more respondents doubted the effectiveness of remediation, the more common it was for them to express the need for in-person meetings with the authorities responsible for decontamination. We did not see the same effect on preferences regarding written information by letter or email. Those results show, if graphed, a high point in the middle and no statistically significant results cf. .When it comes to perceived dread risk, citizens prefer measures that remove the risk or separate people from it . This waThe same sentiments were applied to pets, whose movements can hardly be controlled if behavioral restrictions apply. Another element that makes it less attractive to stay is that a decontaminated area encompasses regulations regarding mobility, potentially indefinitely. A man in his 30s captured several of these aspects in the following statement: “I would not like to think about where I go, what I do, all the time. Even though I might feel safe in the house perhaps, a lot is going on all around. So, there is a lot to think about—family, children, dogs, animals. It’s probably easier to just move and forget about it.” (R8:1).As shown in Finally, the discussions related to settlement featured many practical issues, mentioned in the points at the end of p < 0.05); “once per month” and all other values except for “every other month” and “once every six months” (p < 0.05); and “not at all” and all other values except for “once every six months” and “every other month” (p < 0.05).Another measurement of risk attitude—whether respondents found it probable that they would stay after decontamination—also showed a clear relationship with preferences regarding communication. As shown in Preferences regarding the frequency of written information, however, peak in the middle if graphed in a bar chart, and in fact the most risk avoidant alternative corresponds with the least need for written information cf. .The extent of damage that NPP accidents can cause to public health and the environment continue to cause concern, necessitating further understanding of not only reactor safety but also citizens’ attitudes and behaviors that would affect safety measures in communities in the event of an accident . ApplyinThe focus group results showed the breadth of lay approaches to risk and risk communication, and the importance of a holistic perspective on remediation. Particularly uniquely, the results indicate that individuals’ concerns about children’s health are as multifaceted as are their relationships with children; they thus involve not only people’s concern for their own children but also for siblings and nieces (as per younger respondents), grandchildren (as per senior respondents), and more. Although other studies have shown parents’ concerns about children’s health in remediation situations, particularly mothers , all focAnother novel finding is that pets—which naturally want to sniff around during walks in green areas—were included in some respondents’ circles of concern in a remediated area with elevated radiation levels, adding incentive to move permanently. This is very likely also an issue that is more pronounced in our findings in a Western cultural setting, than would be the case in a region where it is unusual for a dog to be part of a household and for it to live indoors and be taken out for walks. In addition, the analysis of focus groups showed that citizens’ attitudes to radiation risk and the effectiveness of decontamination are rooted in the notion that the risk itself is difficult to control both temporally  and spatially . Although this does not in any way imply new knowledge about radioactive material, it shows that laypeople assess the effectiveness of decontamination not only on the basis that radiation levels are below a limit value, but on perceptions of the challenging nature of the risk, and also on how life as a whole will be affected in the area in the long run. Regarding communication, all focus groups expressed the need for both swift information, and ahead of critical phases more reflective dialogue with those responsible. A stand-out result regarding communication was how strongly younger respondents preferred involvement through modern technology, both in terms of information on demand 24/7 and radiation measurement for residents staying in the decontaminated area.Specifying certain results regarding communication, the analysis of survey data (n = 2291) and three indicators of risk attitude  showed that the more negative an individual’s attitude is toward the remediation scenario, the more opportunities they want to be involved in communication that allows for dialogue. Thus, while research on the risk information seeking and processing (RISP) model has shown that more frequent one-way information is needed when citizens harbor negative risk attitudes , the preIn connection to this, intentions to tolerate risk and return after evacuation appeared to relate to things other than the quality of the information and communication provided. The decision to stay is mainly determined by risk perception, general stigmatization of the residential area, belief in the effectiveness of decontamination, relatives choosing to stay, and/or school or job opportunities in the affected area. The importance of social ties, for example, was very important to the respondents, as has been confirmed by other studies . HoweverMoreover, according to the focus group data, citizens associate a recovery scenario necessitating evacuation with serious accidents such as those in Chernobyl and Fukushima, triggering associations with their own mediated experiences and stories of dread risk. Commonly, citizens imagine that future accidents and recovery attempts will generate strong risk aversion, the propensity to flee, conflicting values, victims facing injustice, and jeopardized trust in the institutions responsible for the whole process. The life situation in a partially polluted area  is also considered by groups of citizens to create life-threatening and difficult-to-handle dilemmas. It is obvious, then, that the conditions for information and communication work between authorities and victims will become very complex and difficult. The results therefore also suggest that the great confidence shown both in previous studies  and in gThe lessons to be drawn for policy and practice from the study include that citizens have very high demands on a decontaminated area—with everything from very low radiation dose levels, to job opportunities, and permission for various outdoor activities—if the alternative of moving should not seem more reasonable. This is a challenging issue to resolve, as extensive remediation is difficult and expensive to implement. Furthermore, responsible agencies should prepare for both rapid information provision, but also in-person meetings with residents that allow for the exchange of thoughts and ideas. At such meetings, however, our results indicate that responsible actors should expect an over-representation of critically minded stakeholders who do not share the authorities’ overall goal that citizens will move back after evacuation. Still, to openly engage in such conversations, listening and answering questions, can be reassuring and build important trust. In addition, the prospects for successful communication for all involved would be better if policies allowed a higher degree of freedom of action for those affected—for instance, through financial compensation and not just a plan to relocate everyone. Otherwise, the responsible state agencies will likely face an uphill battle as they attempt to convince large groups of citizens that they should tolerate a possible risk that they will not, in reality, tolerate. Previous major accidents also show that planned restoration and actual results differ greatly, as has been the case in several areas of the Fukushima prefecture ,18.Finally, it should be pointed out that our study is subject to certain limitations. Even though we have combined qualitative  and quantitative  data in a mixed methods approach, all our results specifically concern the Swedish context. Based on cultural and policy similarities, the results are relevant for other countries as well; however, more countries need to be studied in a similar way to increase our knowledge of the effects of different national circumstances in the event of a nuclear accident involving evacuation, decontamination, and relocation. Furthermore, the present study examined attitudes to a hypothetical scenario, and respondents’ behavioral intentions indicate preferences rather than actual actions constrained by life circumstances. Without, for example, financial compensation, more people than indicated by our study may choose to stay in a decontaminated area, for reasons such as having mortgages while the value of their properties plummet. Future studies can highlight any potential hypothetical bias by more systematically comparing scenario-based studies and research on accident-affected areas.


While the evacuation from Kabul was a very public and highly reported event, often with celebratory tones in the international media as Western governments sought to “rescue” Afghan allies, those Afghans who travel to the UK via illegal routes are often stigmatized; demonized in press and political discourses. Building on the emerging body of literature that uses “journey as a narrative device” and drawing upon our novel dataset, we analyze how diverse migrants tell their stories and present agency, within contexts of extreme hazards, to achieve their imagined future. Moreover, applying a spatio-temporal lens we advance understanding of the intersection of place and time in how Afghans traveling to the UK, including recent evacuees, are framed differently with resultant consequences for how border crossings are negotiated and narrated. In so doing, we complicate simplistic categories of deserving vs. undeserving, genuine vs. fraudulent, evacuees vs. irregularised migrants.Through the “hostile environment” migration policy, the UK government has expressed its commitment to do whatever possible to deter and expel unwanted migrants. Faced with the loss of power in the context of globalization, the Conservative administration, elected in 2010, presented itself as a guarantor of citizens' security. The political discourse of “taking back control” of the nation's borders has resulted in increasingly restrictive immigration and asylum policies. In this paper, we present narratives of Afghans who arrived in the UK at different times and through different routes. As well as those evacuated from Kabul airport in 2021, we also interviewed participants who traveled  The announcement by US President Joe Biden, in April 2021, of withdrawing US troops from Afghanistan triggered a race against time for Western governments to leave ahead of 31st August. The Taliban's rapid advance throughout the country and their national power takeover on 15th August turned Kabul Hamid Karzai International Airport into the epicenter of a precarious international operation that aimed to evacuate those who worked with the government, their families and other vulnerable people on humanitarian flights UNOCHA, .Thousands of civilians packed into the area around the airport, waiting for days in appalling conditions, enduring high temperatures without water or food Latifi, . During The British Army evacuated around 15,000 Afghans. In the UK, the government received these evacuees as part of Operation Warm Welcome, which aimed to save the lives of those who worked with and for the British forces in Afghanistan. By ensuring their safe departure, the government intended to fulfill a moral debt to them and “ensure Afghans arriving in the UK receive the vital support they need to rebuild their lives, find work, pursue education and integrate into their local communities” Gov.UK, .via irregular routes, e.g. in small boats or the backs of lorries. In 2021, more than 25,700 people crossed the English Channel in small boats—more than triple the 2020 total. Afghans constituted 24%  of the 4,540 people who arrived on English shores in small boats between January and March 2022, followed by Iranians  and Iraqis  ,,via irrevia irregular routes in 2021, and others who made hazardous journeys in the 1990s, before the advent of mobile technologies, and in 2015, during the so-called “migration crisis”. This novel dataset allows us to explore the range and diversity of migrant journeys via “irregular routes” including slow, dangerous and protracted experiences over many years, as well as the rapid movement of people through a “regular route” during the highly publicized evacuation process in August 2021. As explained in the next section, we analyse our data using “journey” as a narrative device, to gain insights into how these diverse migrants describe, present and make sense of their experiences of leaving Afghanistan and moving to the UK at different times and through different routes.As explained in our Methods section, a unique aspect of our project is the diversity of participants. As well as Afghans who were safely evacuated from Kabul airport, we also interviewed some who arrived The notion that millions of migrants are “on the move” and heading for European countries has become a vociferous political discourse which simplifies and misrepresents diverse migration flows . Using “journey” in this way allows researchers to analyse how migrants “construct meaning, subjectively and collectively”  identified as female, and 43.3% (N = 13) identified as male. Route and year of arrival in the UK varied greatly among participants, with just over half  having arrived between 2020 and 2021. All participants have been pseudonymised, with culturally appropriate names, to protect their identities.As a relatively small qualitative study, we make no claims to representativeness, nonetheless, consideration was given to the diversity of the sample in terms of gender, age, family situation and time of arrival. Just over half of our participants , their Dutch citizenship ensured their EU mobility rights so they crossed the border to the UK without any restrictions.Rabiya's expectations for her children in the UK show the significant role of imagination in migrants' decision-making on their journey  and quickly moved Abubakar's inside the processing center. Rank and connections can facilitate the processes of crossing borders. After a very short time, he was on the plane and on his way to the UK. The evacuation, although chaotic and highly dangerous, as mentioned at the start of the paper, was also relatively quick. In contrast to the long, protracted journey of people like Sher Shah who traveled for months via Turkey and Greece to France and finally to the UK, evacuees found themselves traveling from Kabul to London within 24 hours.Abubakar described the scene as he approached the processing center: “a lot of rush and scrabbling of people'. Despite his former rank and authority, he now needed to join the queue alongside thousands of other Afghans. Waiting in the queue for eight hours, Abubakar recounted that a man organizing the queue asked with surprise: “‘What are you doing here?”' I said: “What is everybody doing here? We all want to leave Afghanistan”. “Do you have any approval, like an email?” I said: “Yes, I have my email”. “Please come to the gate”.“ This encounter seems to imply that the official was surprised to find a high-ranking government official in the queue  and her two sisters (25 and 26) arrived in the UK as part of the evacuation in August 2021. Malala told us how her father passed away when she was seven years old, and, several years later her mother had left Afghanistan to join a brother in another country. Thus, Malala and her sisters were living in Kabul “without a male guardian”. When the Taliban took control of Kabul in August 2021, Malala was a university student, studying journalism and computing, with dreams of setting up an all-female IT company: “I studied Computer Science and saw how women struggle to find a job because in Afghanistan the belief is that women are not good at IT. I wanted to set up a company and hire female employee and challenge the status quo”. However, her imagined future was destroyed when the Taliban took control of Kabul.Malala's narrative powerfully evoked her shock when the government suddenly collapsed on 15th August 2021. Her sister had worked in a government department, moreover without a male guardian the three siblings felt vulnerable: “Everyone was scared. We hide our ID cards because I was a University student and a journalist, which were both very dangerous”.In an effort to escape from Kabul, Malala told us how she quickly mobilized her social capital by enlisting the help of a journalist from a well-known European newspaper. Malala had gotten to know this journalist by assisting her on some stories in Afghanistan. “We were in touch all night and day. We were hopeless that it might work because the situation was bad at the airport”.The British Embassy responded on the last day of the evacuation, 26th August, and the three sisters headed to the airport. They tried to convince the authorities that their emails were authentic while standing for hours in a filthy canal: “The men didn't trust us… They just looked at our documents and handed them back to us”. Malala told us that many people were using faked IDs or claiming people as their relatives in order to secure their evacuation, while “so many other people who deserved to be evacuated were left behind”. In the chaos at the airport, Malala asserted the seeming randomness of who was evacuated and who was left behind: “I was so shocked, because there were a lot of people…and they were not at risk at all, and they were allowed to go through”. She told us about an Afghan policewoman who was in danger from the Taliban but, without influential connections to support her claims, was unable to navigate the evacuation process and was left behind. Thus, in contrast to Abubakar who positioned himself as a deserving refugee unlike those arriving “illegally”, Malala presents a more nuanced picture that suggests the apparent unfairness of who achieved evacuee status.Malala vividly described the dangerous scene at the airport. After waiting for hours she finally caught the attention of two British female soldiers: “They found me in the water; I handed the emails to them, and then they checked my sisters' names, and they allowed us all to get in”. The British Army checked the sisters' IDs and interviewed them because they did not have British passports. They then checked their identities by phoning their influential contact, the well-known journalist, and the British Embassy, and finally gave the sisters permission to leave Kabul.Malala and her sisters traveled on a military plane from Kabul to Doha, where they stayed for one night, and then were put on a commercial flight to London. Malala recounted her mixed feelings:“It was kind of joy that I was safe, and it was sad that I was leaving my country behind and lots of friends behind… I was worried about everyone”.After their plane landed at Heathrow, they were hosted in a quarantine hotel for 10 days and then moved to a bridging hotel in Central London, where they remained for over 1 year. Having suddenly found herself in London without any prior plan to leave Afghanistan, Malala, like many other evacuees, is having to rebuild her life, re-define her dreams and re-imagine her future in the UK. Unlike those who embark on long journeys where much time is devoted to imagining a new life in the destination society  over time. Imagination is a key ingredient in the narrative of migrant journey not just as a story of the past but as a device for making sense of their present and expected future. By contrast, for those who recently arrived, especially those who experienced rapid evacuation and who suddenly found themselves in London, almost overnight, imagined futures are still being constructed as they adjust to new and unfamiliar environments. Moreover, those who had recently arrived The UK policy of closing down routes of legal entry and making the asylum process more difficult, has resulted in rising numbers of people trying to enter the country through irregular routes.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.The studies involving human participants were reviewed and approved by London Metropolitan University. The participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.