key: cord-0783142-thh7j76n
authors: Yıldırım, Nazmiye; Aydoğan, Arzu; Bulut, Melisa
title: A qualitative study on the experiences of the first nurses assigned to COVID‐19 units in Turkey
date: 2021-03-13
journal: J Nurs Manag
DOI: 10.1111/jonm.13291
sha: 58316168aa397ae6b96a5f80b9d78f5c9139d7bf
doc_id: 783142
cord_uid: thh7j76n

AIM: To explore the experiences of the first nurses assigned to work in COVID‐19 units with the onset of the outbreak in Turkey. BACKGROUND: Even though the risks faced by nurses while performing a dangerous task during the epidemic are similar, their experiences may differ. METHOD: This qualitative study was carried out with 17 nurses. The interviews were carried out individually and online. The data were analysed using Colaizzi's phenomenological method. RESULTS: From the analyses of the data, four key themes have emerged as follows: ‘needs’, ‘anger’, ‘questioning’ and ‘decision’. Needs include visibility, support, adaptation and sleep/rest. Nurses were angry because of their unmet expectations, feelings of injustice, and selfish and insensitive behaviours they faced. They questioned their profession and decided to either alienate from the profession or continue with the gains they had made. CONCLUSION: This study found that nurses perceived an imbalance between their efforts and their achievements. IMPLICATIONS FOR NURSING MANAGEMENT: This study provides evidence for nursing managers to anticipate problems that may arise both during and after the outbreak. Nurses should be made to feel that they are valued members of the health care institution, and effective strategies should be implemented to improve their perceptions of organisational justice.

crises, it is important to identify the needs and concerns of nurses (Peiro et al., 2020) . In quantitative studies (Lai et al., 2020) and reviews (Preti et al., 2020) in the literature on this subject, it has been shown that sleeping and mood disorders involving depression, posttraumatic stress symptoms, anxiety and distress were high among nurses. In the qualitative studies, it has been demonstrated that Chinese nurses need survival, relationship, growth and development (Yin & Zeng, 2020) , but they experienced work pressure, difficulties and different psychological stages (He et al., 2020) . In one of the studies conducted with Iranian nurses, it was reported that the main experience included care erosion, the needs of nurses and the development of the profession (Galehdar et al., 2020) . As can be seen, qualitative studies provide a broad perspective on the experiences of nurses. However, studies have usually been generally conducted with Chinese and Iranian nurses. Finding themselves abruptly in a chaotic environment, nurses began to work in their new units with sudden changes. The Turkish Nurses Association (TNA) explained the problems nurses experienced during this process and emphasized that nurses had to work in these units without having adequate time and training opportunities. TNA stated that nurses experienced problems such as access to personal protective equipment, fear of getting sick and infecting their relatives and society, lack of personnel and intense and difficult working conditions (Şenol Çelik et al., 2020) . Corley et al. (2010) reported that these problems were also experienced by Australian nurses during the H1N1 influenza epidemic. Exposure to social stigma was another problem frequently reported during MERS (Choi & Kim, 2018; Kim, 2017; Park et al., 2018) , SARS (Maunder, 2004) and the COVID-19 outbreaks (Xiang et al., 2020) . In addition to these issues, TNA stated that the problems faced by nurses in Turkey were related to fulfilment of basic needs, pricing and their professional and personal rights (Şenol Çelik et al., 2020) . However, it is necessary to reveal the experiences of nurses caring for coronavirus suspected or infected individuals through scientific studies. Determining the experiences of nurses with the COVID-19 pandemic and how they were affected by this challenging process will be a guide for them to develop solutions.

It is the duty of nursing managers to manage nursing manpower in health care organisations, to provide appropriate recruitment, employment and relocation. This task can be more challenging in crisis such as epidemics. As a matter of fact, one study revealed that the management of the COVID-19 crisis was perceived differently from other crises by nursing managers (Poortaghi et al., 2021) . Grasping the experiences of nurses from the moment that they are selected to work with suspected coronavirus or diagnosed patients can provide nursing managers useful information to manage nursing staff more appropriately in this period of epidemic and in possible new outbreaks in the future. In this context, the research aimed to explore the experiences of the nurses who were first assigned to work in COVID-19 units in Turkey from the very beginning of the process.

A qualitative study of phenomenological research design has been adopted to explore the experiences of front-line nurses caring for coronavirus-infected patients. This design was chosen because it offers a high degree of freedom in defining a new phenomenon (event or experience) from the perspective of the participants, providing rich data and detailing their experiences (Yıldırım & Şimşek, 2016) . In particular with the establishment of various COVID-19 units in the hospitals where they work, a descriptive phenomenological approach was followed to understand the lived experiences of the nurses who were first selected to work there. This approach is concerned with revealing the essence of the researched phenomenon and capturing the experience 'precisely as it presents itself, neither adding nor subtracting from it' (Morrow et al., 2015; Willing, 2013) . Although the phenomenon has been tried to be seen from the participant's perspective, we should state that the researcher is a tool in data collection and analysis, lives in the same sociocultural environment with the participants and has nursing experience; therefore the epistemological paradigm guiding this study is a constructivism (Merriam, 2018) .

Participants in this study were selected via the purposeful and snowball sampling method. The study involved registered nurses who were first assigned to work in COVID-19 units and who were in their positions for more than a month and agreed to voluntarily participate in the study. The criteria for inclusion in the study were a registered nurse who was the first to be assigned to work in COVID-19 units and held this position for more than a month and agreed to voluntarily participate in the study. The exclusion criteria were nurses who were not working in the COVID-19 unit during the research period and who were COVID-19-positive. Moreover, among nurses working in the hospitals and COVID-19 units (emergency department, inpatient service, intensive care unit, filiation) from the different regions (Marmara, Aegean, Central Anatolia and South-eastern Anatolia Regions) of Turkey, 21 nurses were invited to the interview. Among them, one did not have time and three did not choose online meetings, so they were unable to attend the study.

The sample size (Yıldırım & Şimşek, 2016) was determined by the data saturation, and 17 participants were interviewed in total. The demographic and professional features of the nurses participating in the study are presented in Table 1 . 

The data were collected by the researchers between 27 May and 25

August 2020. Semi-structured interviews were carried out individually via Skype. The aim and process of the study were explained by contacting each potential participant over the phone. An appointment was made with the participant who accepted to participate in the study. Seven potential participants were already known to one of the researchers (NY or AA). The researcher ( At the beginning of the interview, information was obtained about the age, sex/gender, marital status, level of education, nursing experience, the region and the type of institution they were currently working in, their main departments, the COVID-19 unit they were assigned to and the number of days they worked in that unit. Then, with the open-ended question 'Could you please tell us about your working process with patients who are suspected or diagnosed with coronavirus?' they were asked to describe their experience from the beginning of the process. To obtain detailed accounts, questions such as 'How were the first nurses to work in the COVID-19 units selected?', 'How was your assignment communicated to you' and 'What was your first reaction when you learned this?' were asked. In the following, the questions 'How do you feel about the next process and now' and 'How do you think your experiences affect your personal and professional life?' were also asked.

There was only one interview per day between data collection

dates. Interviews took about 45-60 min. All interviews were recorded with the permission of the participant, and online recordings were transcribed within 24 hr by the interviewer on the evening of the interview. Since the interview recordings included images and sounds, the non-verbal indications of the participant could be more clearly noticed.

In the analysis of the qualitative data obtained from the interviews, the 7-step analysis method developed by Colaizzi (1978) for the phenomenological studies was used (Morrow et al., 2015) . In this context, the interview texts were first read by three researchers independently and repeatedly. Thus, the data were made familiar and it was tried to be understood what was being explained.

The important statements in the interview texts were selected, and restated and expressed in general terms. Then, the implicit data within the statements were identified and analysed. The researchers formulated the meanings by discussing them until they reached a consensus and validated them. In the following, they identified and organised the themes into clusters and categories.

The themes and subthemes of the research were developed with clear statement expression. The findings of the research were presented to the participants, and the accuracy of the themes and content was strengthened. In addition, the comments of the participants were referred to so that the reader could verify the interpretation and analysis of the data. (Tong et al., 2007) .

In this study, a total of 17 nurses, two male and 15 females, were Table 1 .

Four main themes and nine subthemes were attained with the interviews (Figure 1 ).

As a result of the interviews with the nurses, four subthemes were attained under the main theme of needs. As a result of the questioning, it was understood that some of the participants decided that they no longer wanted to continue in this profession, and some of them considered that they developed personally and professionally.

that during this period, they became alienated from their profession, that they wanted to retire as soon as possible or that they would leave when possible.

4.2. Continue with the gains: Some of the participants stated that they were proud of being a nurse, they realized the importance of their profession and their achievements, the peace they felt after helping the patient could not be compared with financial gains and they felt more satisfaction. Some also noticed that their empathy skills improved and that they were able to understand patients much better in this process and learn to be patient and approach them with compassion. Some stated that they saw their inner strength during the pandemic process and became much more mature. 

This study focused on the experiences of nurses who were first assigned to conduct their professions among the suspected individuals or diagnosed patients with coronavirus following the onset of the COVID-19 pandemic in Turkey from the very beginning of the process. Revealing both their primary needs and sources of anger, this study showed that nurses had a perception that they were not treated as they deserved, despite the risks they faced, the responsibilities they took on and their efforts. It was revealed that their experiences in the pandemic process led them to question nursing and brought them to a crossroads.

In other qualitative studies conducted with nurses caring for patients with COVID-19, their health, safety, information, humanistic concern, interpersonal and family needs (Yin & Zeng, 2020) , and the need for comprehensive, financial and moral support from the authorities (Galehdar et al., 2020) were reported. In this study, the need for support and information emerged, and it was determined that nurses' need to be visible, be respected and be valued stands out. Studies conducted before the pandemic show that nursing is perceived by society (Kaynar Şimşek & Ecevit Alpar, 2019), patients and physicians as an auxiliary profession that fulfils the wishes of doctors (Yılmaz et al., 2019) , and that nurses have a negative perception on their profession. In Turkish films, it has been determined that nurses are sometimes like saviours but often cannot make their own decisions professionally and cannot use their professional autonomy, and their independent roles are ignored and are reflected on the screen with a sexist perspective (Gören & Şahiṅoğlu, 2018) . In parallel with the similar studies conducted in different countries (Karimi et al., 2020; Tan et al., 2020) , it was determined in our study that nurses experienced intense fear and anxiety at first, but these emotions sooner were replaced by anger. In addition to their verbal expressions, the severity of their anger was clearly observed from their tone of voice and facial expressions. Maunder (2004) also reported that during the SARS epidemic, the nurses were outraged by their reluctant selection and not being allowed to refuse their appointments. The ICN stated that nurses are angry and that the main reason for their anger was lack of support and unpreparedness (ICN, 2020). For these reasons, in our study, nurses mostly emphasized unfair treatment as the source of their anger. The nurses thought that they were subjected to injustice by comparing what they achieved through their efforts, both with their expectations and with other employees. In a study conducted with nurses involved in the COVID-19 rescue mission, feelings of unfairness were reported as one of the identified themes (Sheng et al., 2020) . Kim (2018) revealed that in the MERS epidemic, nurses were disappointed that they were not rewarded for their efforts in such a risky situation.

Organisational justice must be provided for the welfare of employees in institutions. It can become even more important in times of health crises, such as epidemics. Conducting our study during the pandemic period and with the first assigned nurses may have made the feelings of unfairness more pronounced.

Organisational justice is considered to have three components:

distributive, procedural and interactional justice (Colquitt, 2001) .

In our study, results were obtained, including all three dimensions of organisational justice. When the COVID-19 epidemic started in our country, the nurses who started to work with individuals with suspected coronavirus or patients diagnosed with it first evaluated whether the distribution of tasks, the distribution of protective equipment and then the distribution of additional payments were fair. This assessment corresponds to the distributive justice component. In previous quantitative studies conducted with nurses in our country, this dimension of organisational justice was reported to be lower than other components (Seyrek & Ekici, 2017) . In terms of procedural justice regarding the issue of how the distribution was carried out, nurses questioned how decisions were made-such as which hospital would be a pandemic hospital and which nurses would work in COVID-19 units-and stated that the managers of the institutions they work with should be transparent. They also clearly stated that they were uncomfortable with the way the decisions were communicated. This disturbance also shows that in terms of the interactional justice component, they think that the relationship between the decision-makers and the executive of the procedures and the employee is unfair. It is one of the stated experiences that they suddenly learned that they were assigned to a different service while getting used to a new service just through a message sent to the phone. This situation also led to increased uncertainty, vigilance, feeling anxious and uneasy, and inability to rest. In the months when COVID-19 cases were intense, the removal of their annual leave rights, even the suspension of their rights such as leaving the profession and resignation, may cause an increase in anger of physically exhausted nurses due to their restricted rights. As a matter of fact, when the findings of this study were presented to the participants, some of them stated that they experienced these feelings much more intensely in the last months.

Numerous studies on organisational justice have shown that the perception of justice has many emotional, attitudinal and behavioural consequences (Aboul-Ela, 2014) . In other studies, it was found that organisational justice in nurses was associated with work engagement, turnover intention (Cao et al., 2020) , workplace deviance (Hashish, 2019) , threatening and negative behaviours (Seyrek & Ekici, 2017) . These results seem similar to our study, the nurses questioned their profession and stated that they no longer wanted to continue their nursing duties and would leave when they had the opportunity. Taking these into consideration, it suggests that nurses' sense of injustice may have serious consequences today and after the epidemic is brought under control. During the 2003 SARS epidemic, it was reported that their willingness to work decreased and they were considering resigning (Bai et al., 2004) . Crises are turning points. They can create opportunities for development and growth, and challenges and problems. Similar to the results of the various qualitative studies conducted in this process (Galehdar et al., 2020; Liu et al., 2020; Sheng et al., 2020; Tan et al., 2020) , some of the nurses have also stated that they learned new things from their experiences and this profession. 

Nurses are undoubtedly the primary professional group that shoulders the heavy burden of this pandemic, but it was concluded that they thought that they were not appreciated, either materially or morally in return for their sacrifices. 

COVID-19 outbreak reminded us that we live in an unpredictable world. The management of health care institutions faced challenges. Nursing managers can benefit from this study to determine the problems that may arise during this period when the epidemic continues to spread rapidly and after it is brought under control.

Given that nurses' experiences in the MERS outbreak were associated with their intention to provide care to patients with a newly emerging infectious disease (Oh et al., 2017) , it is hoped that the results of our study will also be useful for future outbreaks.

Hospital managers can use this study as a guide to re-organise institutional policies to meet the needs and expectations of nurses. 

Human Research Ethics Committee (institution numbered 2020/05).

The authors would like to thank participants for their cooperation.

No conflict of interest was declared by the authors.

NY contributed substantially to the conception of the study and design, analysis and interpretation of data, and writing the major portion of the paper. AA contributed substantially to the interpretation of the results, data collection and writing the paper. MB contributed substantially to the design, data collection and analysis of data. 

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