Aim: In this study, it is aimed to examine the subjective experiences of nurses who worked voluntarily in COVID-19 services at the beginning of the pandemic. It is known the most psychologically affected group among healthcare professionals working with COVID-19 patients is nurses.

Materials and Methods: The research was carried out using the narrative technique, the descriptive qualitative research methods. The data were collected with the "Nurse Introductory Information Form" and "Semi-structured Questionnaire for the Story of Being a Nurse in Fighting the Pandemic". Data were analyzed using the Story Evaluation Scale.

Results: Seven nurses between the ages of 23-36, working in 3 different hospitals, participated in the study. Nurses stated they voluntarily care for patients between 2 weeks-17 months with the ethical values of benefit, respect for the individual, equality-justice, feelings of love, compassion, mercy. Emotional expressions in nurses' stories were determined as 'sadness (n=3), remorse, gratitude, pride (n=2), fear (n=4), anxiety (n=2), panic, worry, uneasiness, satisfaction, inadequacy’. Nurses used the metaphors of 'Motherhood, Heroism, Life Risk, Bomb Squad, Being a Trench on the Front, Warrior, Going to Fire' for their fight against COVID-19. Nurses reported that they experienced problems such as sweating, shortness of breath, limitation of communication, difficulty in care, decreased water intake while working with protective equipment. It has been reported family and peer support, team solidarity, belief in fulfilling sacred duty, suggestion, patience facilitate coping.

Conclusions: It is necessary to increase the psychological resilience of nurses and to defend their rights in the political arena.

In March 2020, the World Health Organization declared the viral Coronavirus disease as a pandemic and the first case was seen in Turkey [1,2]. The pandemic process reveals the deficiencies in public health systems in Turkey as well as all over the world and causes negative effects in terms of social, economic, physical and psychological health [3-5]. This process creates a physical and psychological burden on nurses, who are at a key point in the diagnosis, treatment and care of COVID-19 patients from hospitalization to discharge [1,6-9]. Zerbini et al. [4]  report that the healthcare personnel working with COVID-19 patients at the Ausburg University Hospital are not equally affected by the pandemic, and that the most psychologically affected group is the nurses working in the COVID-19 services with a higher perception of stress. Unprepared involvement in the process, the ever-increasing number of confirmed/suspicious cases, the discomfort of wearing personal protective equipment for long hours and insufficient equipment, fatigue due to excessive workload, fear of getting infected and infecting family members, media news, insufficient sense of support threatens health, well-being and ability to do business of nurses [4,7,9,10]. The use of programs aimed at increasing the physiological and psychological resilience of nurses involved in the pandemic process and improving working conditions gains importance in this process [5,11].

There are a limited number of qualitative and quantitative studies in the literature examining the fears, anxieties, stress-causing factors and how the process affects nurses' physical and psychological health during the COVID-19 process in the world and in Turkey [1,7,9,12,13]. However, factors such as the differences in the health systems of the countries and the difference in the selection of nurses to care for COVID-19 patients (voluntary or compulsory) prevent the generalization of the literature results [14]. In this study, the subjective experiences, physical and psychological difficulties, and the emotions and thoughts they experienced of a group of nurses who volunteered to provide care to COVID-19 patients at the beginning of the pandemic were examined using the narrative technique, one of the descriptive qualitative research methods. It is believed that this research will also contribute to the related literature in a methodological sense.

Qualitative Approach and Research Paradigm

Qualitative research is a type of research that explores real-world problems and provides deeper insights into them [15]. Narrative Research, a type of qualitative research, helps to understand an event from the perspective of the people directly involved [15,16]. In this study, the stories of nurses who worked voluntarily in COVID-19 clinics when COVID-19 cases started to be seen in Turkey were discussed. The researchers carried out this research with the constructivist paradigm approach, which is a subcategory of post positivism. Therefore, researchers have the understanding that 'The nurses included in the study decided to work voluntarily in the COVID-19 clinic with their own worldviews and built this experience from their own perspective of reality.' [15,17]. This research was written with the Standards for Reporting Qualitative Research in mind. [18].

Researcher Characteristics and Reflexibity

With this research, the experiences of the participants will be transformed into knowledge through content analysis and reflections [17]. Researchers have not previously worked on the COVID-19 service and are not closely associated with participants. While the researcher was doing clinical practice at the hospital, she was impressed by the head nurse's words about the sacrifice of the nurses who voluntarily fought in the COVID-19 clinic. Researchers believed that the subjective experiences of these nurses should be brought to the literature. Researchers accepted the nurses' own experiences and perspectives of reality as they were.

Sampling Strategy

In this study, sample selection was not made within the framework of the constructivist paradigm. Therefore, no generalizations were made regarding the research results. A purposeful working group has been determined to experience the phenomenon of 'voluntarily working in the COVID-19 clinic' [16,17]. The study group was reached by the snowball method. The researchers reached the nurses who experienced the phenomenon through the head nurse of the hospital where they performed clinical practice. The research was carried out with 7 nurses working in 3 different hospitals of the same university. The data collection process was terminated when there were no nurses recommended to be reached by the participants. This research expresses the subjective experiences of 7 nurses concerned.

Ethical: Data Security

The study was approved by Lokman Hekim University Non-Invasive Clinical Research Ethics Committee (2021/ 081). Participation in the research was on a voluntary basis. The data were kept in a locked cabinet and computer by the researchers. The personal information of the nurses participating in the study was kept confidential and data such as name and surname were not included in the data collection forms. Research and publication ethics were complied with in the article.

Data Collection Instruments

Research data were collected using the "Nurse Introductory Information Form" and the "Semi-structured Questionnaire for the Story of Being a Nurse in Fighting the Pandemic"

Nurse Introductory Information Form: 

The form prepared by the researchers; it consists of 9 questions about the participant's age, gender, marital status, whether they have children, their education level, their years in the profession, how many years they have worked in the institution they are working in, the clinic they work in and in which position they work in the institution, apart from the COVID-19 clinic.

Semi-Structured Questionnaire For The Story Of Being A Nurse In Fighting The Pandemic: 

This form was created by researchers to help nurses narrate their experiences in the Covid-19 service. The form consists of 11 open-ended questions regarding the items listed below.

• The process of deciding to voluntarily work in the COVID-19 clinic in the fight against the pandemic,
• Professional ethical principles that inspire volunteering
• -Working time in the COVID-19 clinic, unforgettable moments and emotions experienced during this time
• Metaphor phrase about being a nurse in the fight against the pandemic
• Factors that make it difficult to cope with the pandemic and create an emotional burden
• Coping methods used by nurses throughout the process
• Suggestions for solutions to improve the process

Data Collection Methods

The researchers reached the nurses in the study group via telephone and explained the purpose of the study. The researchers informed the participants about the data collection forms and answered the nurses' questions. An appointment was requested from the nurses who agreed to participate in the study, and data collection forms were hand-delivered. The data of the nurses who wanted to receive the data forms by e-mail were collected online. The researchers gave the nurses one week to fill out the forms. Filled forms were received by hand and via e-mail.

Units Of Study

The age range of the nurses (n=7) in the study group is between 23-36. Six of the nurses are women and five are single. Only the male participant reported that he had a child. Four of the nurses are undergraduate, one is associate degree and two are high school graduates. The professional experience years of the participants are 2, 4, 5 (n=2), 6, 8 and 10, respectively. Apart from the COVID-19 clinic, the participants work in the intensive care unit (n=2), general surgery clinic (n=3), gynecology clinic and pediatric clinic. The male participant is the responsible nurse of the intensive care unit, and a female participant is the responsible nurse of the general surgery clinic.

Data Processing

The data were transferred to the Word file as it was by a researcher. The researchers read the data and gathered together and discussed whether there were any incomprehensible expressions. Researchers have reached a consensus that there is integrity in the data.

Data Analysis

According to the constructivist paradigm, in qualitative research, the methodology should be built on "making meaning from the data expressed about the phenomenon in the mind" [16,17]. In this study, the data were analyzed using the Story Evaluation Scale developed by Sönmez and a holistic meaning was extracted from the data. The items of the Story Evaluation Scale are 'What is the subject of the story?', 'Where, when and between whom does the story take place?', 'How does the story begin, develop and end?', ‘What are the emotional, logical, illogical expressions, metaphors in the story?" and 'What is the message the story wants to convey?' [16]. The researchers placed the relevant sections in the data in the blank opposite each question on this scale and checked for consensus. Consistency was determined in the independent analyzes of the researchers. The places in the data that are not suitable for the scale questions were not included in the analysis. The metaphors used by nurses could not be categorized due to the small number of them.

Techniques To Enhance Trustworthiness 

After the data were analyzed, the opinions of the participants were taken to ensure internal validity and reliability, and the opinions of 2 experts to ensure external validity and reliability. Experts are required to have at least one article on qualitative research within the scope of SCI. One of the experts is Veysel Sönmez, who developed the Story Evaluation Scale.

This section has been created under 3 headings. The first title includes the findings on the questions of "What is the subject of the story?", "Where, when and between whom does the story take place?", "How does the story begin, develop and end?". The second title includes the findings for the question "What are the emotional, logical, illogical expressions, metaphors in the story?" In the third title, it will be given the findings related to the situations that make the struggle difficult and solution suggestions in the stories of the nurses for the question "What is the message that the story wants to give?".

Findings Regarding The Place, Time, Development and Subject Of The Stories

The stories of the nurses take place at the beginning of the pandemic in Turkey and in the COVID-19 clinic. Nurses stated that they voluntarily care for COVID-19 patients between 2 weeks and 17 months with the ethical values of benefit, respect for the individual, equality-justice, and feelings of love, compassion and mercy. It was found that nurses volunteered with different motivation sources. These are being experienced in the profession, living alone, awareness of national struggle, awareness of duty, wanting to be hope, empathy skills and wanting to support the team. The subjects of nurse stories are loss of patients, solidarity within the team, panic and fear among patients/relatives-nurses, patients being isolated (alone) for days, uncertainty about the prognosis of the pandemic, awareness about contagion, and the helplessness of nurses and patients against COVID-19. The subject of the unforgettable experiences that the nurses stated in their stories is given below in their own words.

Participant I: ‘One of my patients died while I was on a single watch. I will never forget that moment.'

Participant II: ‘We were going to greet our first patient in the isolation room, after putting on her/ his personal protective equipment, I saw my colleague's hands shaking and felt frightened. I said, 'You take off your clothes and I will meet the patient'. She/ he said to me, 'You have just had a child, I'll wear it bro.'

‘One of our patients, a 71-year-old male patient, formed a strong trust between us on the first day of his hospitalization. I tried to support her psychologically by saying that he would get over this disease aimed moral motivation and that the days would come when he would visit me here. The event go too far that he only drank food, water from my hand. There were times when I waited for his to sleep, even though my shift was over most of the time. Every sentence of our conversation for few minutes before he was intubated are on my mind. I can not forget.'

Participant III: I witnessed the moments of fear and panic that COVID-19 created in our patients. I can never forget the communication of patients and their relatives, the concerns of our patients. It is impossible for me to forget my first patient and her/ his emotional change. I can never forget the emotional bond our teammates during the process of entering my patient's room and the fear I experienced inside myself after entering the room.

Participant IV: ‘It was when the epidemic had just begun. Those first periods when even doctors don't know what to do. I had only one patient, 30 years old, much younger. I was impressed by my patient's inability to leave the room for days, leaving her/his family behind, and waiting for days with uncertainty in that ward where we go at certain hours of the day and narrow.’

Participant V: ‘In fact, my entire mission process was an unforgettable experience for me. In this process, we had to work by learning against a disease heard for the first time.'

Participant VI: ‘Among the experiences I had during the COVID-19 process, we became conscious that the patient who received Cpap increased the risk of transmission and that we should approach the patient with more attention.’

Participant VII: ‘I was impressed by the fact that I restricted my movements when I put on the protective equipment, having to work with them despite the very hot weather, seeing every material and everywhere infected and seeing the patients helpless in their rooms.’

Findings Regarding Emotional, Logical, Illogical Expressions and Metaphors In Stories

Emotional expressions in nurses' stories were 'sadness (n=3), remorse, gratitude, pride (n=2), fear (n=4), anxiety (n=2), panic, worry, uneasiness, satisfaction, inadequacy’. Some statements regarding these findings are as follows. 

Participant II: ‘Being able to touch a life is an invaluable happiness. We are still at the beginning of our duty with pride. I am grateful to my mother and my father for raising me like this.’

Participant V: ‘It was a difficult period when I felt that I had reached a sense of professional satisfaction as well.’

Participant VI: ‘While I was doing our best emotionally for the patient, I felt inadequate when the patient was faced with a lack of oxygen.’

Participant VII: ‘First of all, I felt uneasy. I had fear and anxiety. I didn't know what will happen. First of all, I had to protect myself and it made me sad to approach patients in this way.’

‘Especially our elderly patients were in such a difficult situation that they could not take their medicines. We were trying not to stay in the rooms for a long time, especially in order to protect ourselves. When one of my patients was like this, I felt a burden, conscientiously and ethically and I stayed with my patient in her/ his room until she/ he met her/ his needs.’

Nurses especially managed the volunteering process in a logical way. There were no illogical expressions in the stories of the nurses. The logical expressions determined in the stories of the nurses are given below.

Participant I: ‘Since I live alone, my risk of being a carrier was low. That's why I volunteered.’

Participant II: ‘My 10 years of intensive care experience pushed me forward in volunteering in this process.’

 ‘I saw this epidemic as a health war. Just as we gave thousands of martyrs for our country. It was a war and we were the nurses in the military too. We considered the all result. We have tried to do our duty in the best way, without making any discrimination based on language, religion or race.

Participant IV: When I heard that a Covid service will open in our hospital when the epidemic occurs I stayed in a house with my friends in order not to bring a possible illness to my family.

Nurses used the metaphors of "Motherhood, Heroism, Life Risk, Bomb Disposal Team, Being a Trench on the Front, Warrior, Going to Fire" for their fight against COVID-19.Due to the small number of these metaphors, they could not be categorized and are listed in Table 1. 

 *Tablo 1 The table format is arranged according to Döş 2010 and Küçük 2020.

Table 1. Metaphors Stated by Nurses Regarding the Case of 'Combating COVID-19'

Findings Regarding The Main Idea Of The Stories

In the stories of nurses; situations that complicate their fight against the pandemic and cause complaints, the methods they use in coping and solution proposals that will facilitate their fight against the pandemic have been identified. These expressions of the nurses were evaluated as the main message of the stories in terms of contributing to the fight against COVID-19. Nurses reported that they experienced problems such as sweating, shortness of breath, limitation of communication, difficulty in providing care and decreased water intake while working with protective equipment. It has been determined that the fear of being a carrier, restrictions, the society's non-compliance with the rules, the lack of equipment, the longing for family and children and the work-oriented management approach have a corrosive effect through the process. Insomnia, loss of appetite and desire to cry are the reported complaints. Some statements regarding these findings are given below. 

Participant I:‘Air temperature. The overalls we're wearing. The masks we wear. In short, all protective equipment made our maintenance and struggle difficult.’

Participant II: ‘Think about it, you work in Covid intensive care 6 days a week. There is a curfew on the weekend. Living like this for about 1 year has worn us out a lot.’

Participant III: ‘The fact that we have patients who died in the fight against the epidemic and that this number tends to increase has caused the 

level of fear in me to increase.’

‘Although the protective equipment we used was beneficial for us, it was also tiring to work with them just as much.’

Participant IV: ‘There have been many times when we emotionally said enough is enough. Because human wanting to return to their normal life, to walk around freely, to work. Apart from that, working with protective equipment was also physically difficult, of course.'

Participant V: ‘It was difficult for people to act so inconsiderately and to complicate things, not to obey the rules, while we were fighting so hard for people -disregarding our own lives-. We are still fighting for it.’

Participant VI: ‘When we were inadequate in the fight against the epidemic, my appetite decreased and I lost weight.’

Participant VII: ‘While working at the COVID-19 Clinic, I stayed in a separate room from my family and kept my interaction to a minimum. I was not in the same environment with them, I was in the same house away from them and alone. That period was very tiring for me and I wanted to cry.’

Nurses reported that family and peer support, team solidarity, belief in fulfilling a sacred duty, suggestion and patience facilitate coping (See Figure 1).

It has been determined that nurses offer solutions to facilitate the fight against the pandemic, such as educating the society, encouraging the implementation of the rules, providing psychological support and accommodation to health personnel, practices that will increase motivation and in-service trainings (isolation and COVID-19, psychological coping skills). Some statements regarding these findings are given below.

Participant II: ‘To be conscious as a society. To be trained. To learn, to teach and to apply. If we had succeeded, as a society. Our struggle will be more effective and successful.’

Participant III: ‘Psychological support can be provided to working personnel. In addition, support can be provided with motivating factors (accommodation, promotion, certificate, financial reward, etc.).’

Xi Zhang et al. reported in their study that the social and behavioral difficulties experienced and tragic scenes related to death come to life in their minds by nurses caring for COVID-19 patients long after the end of their duties [21]. Arnetz et al. on the other hand, reported that nurses to witness their patients' illness experiences and deaths cause stress [10]. In our study, it is remarkable that nurses reported negative experiences about unforgettable moments (such as; the moment the patient lost while keeping watch alone and the moment when a patient with a love bond is intubated). 

In the researches, health personnel who took part in the COVID-19 pandemic have reported that working with protective equipment and masks increased their workload, made communication difficult and caused some physical complaints [6,22,23]. In our study, nurses have reported physical complaints such as shortness of breath and sweating, limited communication, decreased water intake and difficult caregiving while working with protective equipment.

Kackin et al. reported that the fear and anxiety of nurses working in the COVID-19 pandemic increased and they showed obsessive and depressive symptoms [24]. Ethical challenges are common in clinical nursing practice, and an infectious environment could put nurses under ethical challenges more easily, which may cause nurses to submit to negative emotions and psychological pressure, damaging their mental health [25]. In our study, nurses reported that they give care for COVID-19 patients with feelings of fear, anxiety, panic and uneasiness. It was thought the fact that the nurses included in the study were in the first teams formed at the beginning of the pandemic, the uncertainty and lack of information about the pandemic, the loss of patients, the risk of being infected or carrier, caused these negative feelings.

In a cross-sectional study evaluating the burnout of frontline healthcare workers in the COVID-19 pandemic in Spain, healthcare professionals defined the situation as "medical warfare" due to the increasing number of cases and lack of protective equipment [26]. Another study reported that the institution's failure to meet the safety, convenient working hours and training needs of nurses regarding the care of COVID-19 patients causes stress for nurses [10]. In our study, a nurse reported that the institution's failure to provide adequate protective equipment and to follow a work-oriented policy rather than an individual-oriented one made it difficult to combat the pandemic and patient care. In particular, it was thought the fact that nurses were assigned to COVID-19 clinics without receiving orientation training would have increased their stress. In addition, nurses who care for COVID-19 patients in our study have described the fight against COVID-19 using metaphors such as "Heroism" and "Warrior". However, Gordon et al. in a qualitative study investigating nurses' care experiences with COVID-19 patients, participants do not find it appropriate to be described as heroes [27]. In a study conducted in Turkey, it was reported that the pandemic not only caused high levels of uncertainty and anxiety, but also caused professional erosion and remorse of nurses for their profession [28]. In this study, nurses stated that they are proud to take part in this struggle and that the nursing profession is sacred. The fact that the nurses included in the study voluntarily took part in the fight against the pandemic may explain this result.

In two different qualitative studies in which nurses who care for COVID-19 patients shared their experiences in the USA and Hong Kong, nurses stated that they have coped with their negative emotions thanks to the effective team collaboration, friend and family support, the sense of pride, the sense of duty and responsibility of the profession during the process [27,29]. Khatatbeth et al. healthcare workers reported that they see their institutions as an important source of support due to the provision of protective equipment, as well as their family, friends and colleague’s [30]. In our study, nurses reported that family and friend support, team solidarity and belief in fulfilling a sacred duty facilitate coping. 

Karimi et al. reported that the isolation and quarantine experiences of nurses who care for COVID-19 patients felt restricted and negatively affected their work and family life in this process [31]. In our study, a participant mentioned that being exposed to quarantine on days off after giving care to COVID-19 patients in a closed area, such as an intensive care unit, is wearing out. In our study, the suggestions of nurses to educate the society and to encourage the implementation of the rules to facilitate their fight against the pandemic are in line with the statements of Chau et al. which emphasizing the importance of the contributions of the educated and knowledgeable society in the control of the pandemic [29]. In a study investigating the psychological burden of COVID-19 on healthcare workers, it has been reported that the stress levels of nurses in the workplace during the pandemic process increase due to sudden assignments to COVID-19 clinics, increased workload and conflicts within the team [14]. In our study, it was stated by the participants that increasing the solidarity and communication within the team was effective in coping with the psychological burden of the pandemic.

Nurses who are new to the profession want to voluntarily care for COVID-19 patients with different motivation sources (such as; awareness of the need for many nurses, an important professional experience opportunity, living alone and apart from the family) [37]. In a study, it was reported that nurses working in the COVID-19 clinic changed their living spaces to protect their families [33]. Similarly, in our study, it is striking that the nurses who care for COVID-19 patients mainly consist of nurses who are new to the profession, single and do not live with their families. However, in our study, it was thought that the volunteering of the nurse, who is married and has children, with the awareness that he is experienced in the profession, is important in terms of providing quality nursing care to COVID-19 patients.

As a result, nurses play a key role in the fight against the COVID-19 pandemic. While performing this task, nurses face many physical and psychological problems. In this sense, it is necessary to carry out concrete studies to increase their physical and psychological resilience [1,7-9]. In particular, nurses working in COVID-19 clinics without receiving orientation training (such as isolation, COVID-19 transmission routes and prevention) can pose a threat to their own health and the health of their patients. The problems experienced by nurses working at an intense pace in the fight against the pandemic to protect their physical and mental health and their demands for the solution of these problems can be conveyed to the relevant authorities by politicians, national and international nursing associations and health institutions. The need for support systems for nurses during and after the pandemic, by closely monitoring and developing, can reduce the negative mental and physical effects. Despite the increase in vaccination rates, due to the high number of new cases and deaths in Turkey and all over the world, it is recommended to take concrete steps such as defending the rights of nurses in the political arena, ensuring that they receive psychological support in their institutions and improving their working conditions.

As a result, nurses play a key role in the fight against the COVID-19 pandemic. While performing this task, nurses face many physical and psychological problems. In this sense, it is necessary to carry out concrete studies to increase their physical and psychological resilience [1,7-9]. In particular, nurses working in COVID-19 clinics without receiving orientation training (such as isolation, COVID-19 transmission routes and prevention) can pose a threat to their own health and the health of their patients. The problems experienced by nurses working at an intense pace in the fight against the pandemic to protect their physical and mental health and their demands for the solution of these problems can be conveyed to the relevant authorities by politicians, national and international nursing associations and health institutions. The need for support systems for nurses during and after the pandemic, by closely monitoring and developing, can reduce the negative mental and physical effects. Despite the increase in vaccination rates, due to the high number of new cases and deaths in Turkey and all over the world, it is recommended to take concrete steps such as defending the rights of nurses in the political arena, ensuring that they receive psychological support in their institutions and improving their working conditions.

The study was approved by Lokman, Participation in the research was on a voluntary basis. Lokman Hekim University Non-Invasive Clinical Research Ethics Committee (2021/ 081). The personal information of the nurses participating in the study was kept confidential and data such as name and surname were not included in the data collection forms. Research and publication ethics were complied with in the article.

We thank the Prof. Dr. Veysel Sönmez and the nurses in the study group.