We employed a cross-sectional study and recruited a convenience sample of patients with COVID-19 from five hospitals (including two designated hospital, one newly built hospital, and two makeshift hospitals) in Wuhan, Hubei Province from 10 to 15 April, 2020.

Firstly, we obtained the ethics approval from the Institutional Review Board and the survey approval from nursing managers of the local hospital. Then, the recruitment notice for this study was circulated by two local nurses who worked as research assistants, through a WeChat group (a widely used social-media platform in China), and contact with potential participants was established. The inclusion criteria involved: (a) patients confirmed with coronavirus pneumonia according to the “Novel Coronavirus Pneumonia Diagnosis and Treatment Plan (Eighth Edition)” (National Health Commission of the People’s Republic of China, 2021), referring to having relevant clinical manifestations, such as fever, dry cough, fatigue, sore throat, loss of smell (taste), diarrhea, and other self-perceived or clinically recognizable symptoms and signs; have a history of exposure to patients with new coronavirus infection and asymptomatic infections within 14 days of onset; the coronavirus nucleic acid tested positive; (b) those who participated in the study voluntarily, with informed consent; and (c) those able to express their thoughts with clarity and consciousness. Correspondingly, the exclusion criteria involved: (a) people with previous severe mental or cognitive impairments, comprehension, memory, orientation, and other audio-visual impairments; and (b) those who participated in other related researches at the same time.

According to the Kendal’s sample size calculation principle that the sample size is 5–10 times the number of independent variables (Lewis, 2002). There were 15 variables in this study, including six socio-demographic factors, five disease related factors, two intrapersonal factors, and two interpersonal factors. Thus, the sample size was 90–180 with a 20% invalid response rate. Finally, a total of 120–130 patients with COVID-19 participated in the study (response rate: 92.3%).

Data were inputted and analyzed by using IBM SPSS 20.0 (SPSS Inc., Chicago, IL, United States). The count data was represented by relative number, χ² test or Fisher’s exact probability method was used for intergroup comparison; the measurement data was expressed in terms of mean (X¯) and standard deviation (SD), and t-test was used for intergroup comparison. We used hierarchical multiple regression analysis to analyse the influencing factors. A two–tailed p value < 0.05 was considered statistically significant.

We designed a descriptive phenomenological study, aimed at describing and exploring the meanings of respondents’ lived experiences. The participants were HCWs involved in medical aid missions in Hubei Province, China, where the initial outbreak of COVID-19 occurred. The participants were selected through convenience and purposive sampling.

The main researchers (XB, LL, and XC), female, nurses, joined the medical aid mission team and made the study known to HCWs by issuing electronic invitations post via the WeChat platform. Then, potential participants who agree to join the study can contact the research team by scanning the QR code displayed in the invitation. Totally, we contacted both integrated and mixed aid mission teams from five hospitals, and ended the e-invitation when data saturation. Furthermore, before the study began, the researchers and the participants did not know each other. After we further introduced the content of the study to participants, a total of five HCWs declined further interviews, mainly due to lack of interest or lack of time. After the 25th participant completed the interview, the data reached saturation and no new information was generated.

Since face-to-face interviews pose a risk of infection to both interviewers and interviewees, we managed to collect data through semi-structured in-depth video interviews conducted from 10 to 30 April, 2020. Besides, we recorded all interviews electronically, and also collected the participants’ gender, age, education level, professional qualification, working tenure, original working department, specialist qualification, duration of aid, position in aid team, mission site, and team form (see Table 1). Researcher ensure confidentiality by using numbers instead of names (for example, nurses N1, N2, etc. and physician P1, P2, etc.) and deleting identifying information from the record. And a semi-structured format with open-ended questions was used, developed by the research team based on relevant literature and own understanding. Illustrative questions were: “please describe the experience of providing psychological care to patients with COVID-19”; “what was the difference between providing psychological care and working in the original department due to the epidemic”; “what problems did you experiencing in providing psychological ca 247 re to patients”; “what help have you received”; “what other help did you need”; “how did you feel overall.” Probing questions, such as “please elaborate on that,” were used to elicit more information.

The interviews were conducted in Chinese by two researchers (XB and AW), with XB being the primary interviewer to ask questions and AW acting as an assistant to supplement questions and take notes. Both researchers are competent for qualitative research. In addition, XB, as a nurse, has worked in the hospital for nearly 10 years and has good communication skills with HCWs. Moreover, we conducted separate video interviews at a time convenient for participants, because the HCWs were quarantined after a shift at their designated dormitory room. Each interview was audio-recorded and lasted for 30–45 min.

In order to ensure the accuracy and reliability of the study, before the interview began, we sent the interview outline to other experts with extensive experience in qualitative research for review before the interview began. Additionally, after transcribing and forming the primary code, the researchers sent the text and code to participants in a WeChat message and asked them to determine whether the extracted code was consistent with the views they expressed. Moreover, we tried to purposefully increase the diversity of participants, such as gender, age, professional qualification, working tenure, duration of aid, etc.

Data collection and data analysis are carried out at the same time. These recordings were transcribed verbatim within 24 h of the interview, and the accuracy was reviewed by the interviewer. The interviews, original transcripts, and data analysis were all written in Chinese. Researchers use Nvivo 10 software to use Colaizzi’s phenomenological method for data analysis and topic induction. Two researchers (AW and JL) double-coded the interview data to check consistency and accuracy. Then we discussed the coding differences until all researchers reached a consensus. After that, we reorganized and classified codes to generate different themes/sub-themes, and on this basis, we explored deeper issues in subsequent interviews. We stop data collection when the subject reaches saturation. AW was responsible for translating all citations into English, and JL was responsible for back translation to ensure that the meaning was preserved.

In total, 120 participants were recruited for the study (response rate: 92.3%). As shown in Table 2, among all the patients, the mean age was 51.16 years (SD 15.39, range from 20 to 85), 57.5% of the patients are male, and the majority of patients lived in city (90.0%). Most patients were diagnosed for more than 21 days (83.3%), and 76.7% of the patients were hospitalized for more than 15 days. In terms of severity of disease, the patients with mild and common types accounted for the most, accounting for 73.4%, but only 26.6% of patients were severe and critical types.

The study shown that 25.7% of patients reported higher level of psychological distress (n = 31, scoring ≥4). In regression analysis, after controlling the sociodemographic variables, only severity of COVID-19 (β = 0.282, P = 2860.025) and uncertainty in illness (β = 0.345, P = 0.007) shown significant effect on psychological distress in the regression model (F = 8.937, R² = 0.294, P = 0.07; see Table 3).

The first theme cluster identified was “particularly needed psychological care.” All participants agreed that the main differences between the work of caring for COVID-19 and previous work were that apart from caring for patients with infectious diseases in the isolation ward, another obvious problem was the psychological distress of the patients.

“The patients are quarantined and see the increasing number of infections every day. They are very worried and distressed and very dependent on you.” (N1)

When many HCWs just entered the setting, they did not pay much attention to it at the beginning. After going into the setting, they especially felt the emotional status of patients. Sometimes HCWs could clearly feel the anxiety of patients through some simple conversations during ward rounds and operations. “Patients are very eager to go to ask about their condition when they see physicians and nurses.” (N5)

From the experience of HCWs, the main reason for the patient’s significant psychological distress is that COVID-19 was a new disease, “because the disease was uncertain, the deterioration of disease condition would become very bad, and the patients could not expect the future.” (N16) Secondly, due to the treatment of the disease, the patient required to be isolated from family and friends. Especially if the treatment last for a long time, patients did not understand the policy, and when they saw people around them discharged from hospital, they would have doubts about their own situation. Finally, patients would also worry about recurrence and infection after cured. “Some people say that they are still reluctant to go out even though they have recovered after being discharged from the hospital. They are afraid that going out will increase the burden on everyone and their families. Therefore, everyone’s psychological condition may be different.” (N2) At the same time, negative emotions will accumulate, “if he or she does not find a good way, it will also increase his or her emotional burden.” (N18)

“They will ask us, what should I do if my disease cannot be cured? Will I be locked in this place forever and not allowed to go out? so the patient is still very anxious.” (P3)

According to the working experience of HCWs, “when we observe the patients with a good state of mind, their overall treatment effect and overall recovery will be much better than some anxious patients, including the improvement of mental state and many clinical symptoms, they are much better, much faster.” (P1)

Therefore, patients need particularly psychological attention. “Sometimes patients are not necessarily afraid of pneumonia or virus, after solving the psychological problems, their mood will be relaxed.” (P1)

Psychological distress must be paid attention to, and how to recognize these manifestations of patients is very critical. “Illness can be treated in accordance with COVID-19 guidelines, but there are no guidelines for psychological problems.” (N2). The patients present different manifestations, including implicit, reverse, explicit, and physiological.

Some patients shown implicit manifestations, such as denying the disease, refusing to communicate with disease-related matters, being silent and alone, passively cooperating with treatment, and feeling guilt, etc.

“Some patients are unwilling to get out of bed. There is a young man in his 20s who is actually not very sick. He would rather play on his mobile phone in bed than communicate with people in the same room.” (N11)

“Some patients said that they could not go out, otherwise they would infect and harm others, and they felt that they were black sheep and criminals. We can understand from his language, in fact, he feels guilty in his heart.” (N15)

Some patients shown a reverse performance. “Although they looked positive, they actually had a lot of thoughts in their hearts, ask about the results of the examination every day and when they can do nucleic acid again. I can feel that he does actually really mind the COVID-19.” (N1)

Although some people will be particularly depressed, reluctant to say, but there were still a number of people mood swings, the performance of overt behavior, such as complaining, crying, distrust of the treatment plan, but also take some inappropriate ways to vent to the doctors and nurses.

“There was a patient called the health institution at night, he felt the hospital had cheated him and locked him up deliberately.” (N15)

“Some patients search a lot of information on the Internet, and will match their own situation with the information they find. In many cases, they cannot understand the current treatment measures, so they show impatience and distrust for HCWs.” (P3)

“Some patients shown physiological manifestations. For example, some patients usually suffer from sleep disorders. They would complain about the harsh conditions of our room and think that the alarm from its equipment disturbed his sleep in a very bad emotional state.” (N3)

Despite the psychological distress, HCWs said that most of the patients were in a relatively good mental health. Under this kind of physical and mental pressure, the patient can still show some positive adaptations. The 362 most obvious of these is that the patient will self-adjust and show an attitude of hope, acceptance, and trust, “I believe the doctor will cure it and overcome this disease,” (N2) “Patients feel they have to be optimistic and accept that in order to overcome the virus.” (P2)

Patients will also make cognitive adjustments, look at the positive side, and learn to be grateful. “Now thanks to the medical policy and good living conditions, they will have the opportunity to receive free concentrated treatment in the isolation ward. If it was in the hard times before, they may be very sick or even dead and have infected many people.” (N10)

“The patients even gained growth and insight. One patient we cared for who was discharged reported that his entire outlook on life had changed and that he was hopeful for the future.” (N1)

In addition to psychological adaptation, some patients also show behavioral adaptation, especially active cooperation with treatment, active exercise, and even take the initiative to help HCWs do some work within their capacity.

“Every day we enter ward, whether we teach patients how to play fitness Qigong, do breathing exercises, or ask about their condition of disease, eating, and sleeping, they are very willing to answer questions one by one.” (N1)

“Sometimes, when we are doing disinfection and sterilization, many patients will take the initiative to help.” (N10)

Healthcare workers attach great importance to psychological care, and perform routine psychological state observation and referral to professional psychological services. Specifically, during ward rounds, doctors in each shift should report the screening work of psychological problems so as to timely conduct psychological intervention, and if not, they will be referred to a professional psychologist. Most patients, as long as they can operate smart phone, they can communicate directly with a counselor through WeChat.

Healthcare workers all stated that the most important thing to deal with patients’ psychological distress is to let patients feel the care, patience and respect from HCWs, so as to build patients’ confidence and trust to HCWs. Most patients’ psychological distress can be alleviated and controlled. “In the past work, most of the missions were about professional knowledge. Here, we communicate with patients more carefully and treat them like their loved ones.” (N4)

It is also crucial to communicate the patients’ disease condition timely and objectively. “HCWs allows patients to know the truth of their disease while inspiring them with examples of curing patients.” (N5) “Let him build confidence, fully understand their treatment plan, fully understand his disease condition, and let him know that we have not given up on him, no one has given up on him, and we are all concerned about him.” (N8)

Secondly, it is also important to meet the patient’s life needs as much as possible, because the patient is in an isolation ward. “As long as he puts forward some reasonable requirements, we will try our best to help him solve the problem and meet his needs. Let him know that when he comes here, we will help him treat the disease thoroughly, so as to gain his trust.” (N5)

Other strategies for alleviating psychological distress include: promoting the emotional connection between patients and HCWs, patients and their families, and patients. “They can also bring their own mobile phones and communicate with their families independently” (N2); as well as listening patiently, they need someone to listen to their thoughts so that they can gradually adjust their mentality.

“We originally planned to buy a cake for a patient for his birthday, but because the epidemic was serious and we couldn’t buy a cake, we brought him a big apple. He was very moved and cried in the ward at that time. He was very grateful to us.” (N13)

“We have a WeChat group, most of the patients will send some positive messages to the group.” (P7)

And some verbal and non-verbal communication skills are also effective, which be used more and more since working in isolation wards. “Even through glass, we will greet patients, communicate through gestures, or provide some household items. I think the more this form of communication, the better for promoting mutual relationship.” (N1)

For verbal communication, we observed and inquired about patients’ physical conditions, or used indirect written expressions.

“……If the patients are embarrassed to say it, I have encouraged them to write on the sticky notes. For example: we are confident to defeat the epidemic with you here, etc.” (N3)

It is also helpful for patients to adjust their emotions and relieve psychological distress by providing them with some ways to divert attention, such as watching TV, doing exercise, listening to music, etc.

Although caring for COVID-19 patients can be a challenge, HCWs feel needed and validated after devoting their efforts. “Even if the patient does not say thank you, HCWs will feel very gratified and realized the value of work.” (N1) “Some patients would apologize to me after calming down, explaining that they were out of control and should not have yell at me. I was quite moved.” (N13)

HCWs witnessed a scene of mutual support between patients, which has a great impact on their own values. “Both father and son are sick, father cares about his son especially, father and son depend on each other, support and encourage each other, the scene is still very moving.” (N13)

Patients express their gratitude every day, which empowers and motivates the HCWs, many of whom come from other provinces to support the frontline.

“No matter positive or negative patients, they are very, very grateful to our frontline medical team. Up to now, people in the WeChat group still ask whether we have gone home, thank us and miss the days with us very much.” (N1)

After completing the hard work and successfully evacuating the ward, many HCWs felt the recognition from patients and ordinary residents, which sublimated their sense of professional honor and responsibility, and helped them to be more committed to their career.

“When we left, we 437 saw some residents had written their thanks on old bed sheets and many sanitation workers and police officers waved to us. I was really touched and thought if the epidemic happens again, I would not hesitate to join in the fight.” (N13)