key: cord-0902111-d107i02b
authors: Cengiz, Zeliha; Isik, Kevser; Gurdap, Züleyha; Yayan, Emriye Hilal
title: Behaviours and experiences of nurses during the COVID‐19 pandemic in Turkey: A mixed methods study
date: 2021-08-31
journal: J Nurs Manag
DOI: 10.1111/jonm.13449
sha: aeb4c4cdc406fbd4c755379b0b489d82020917a4
doc_id: 902111
cord_uid: d107i02b

AIM: The aim of this work is to present behaviours and experiences of nurses in Turkey during the current coronavirus pandemic. BACKGROUND: The coronavirus pandemic leads to difficulties for most health care workers, especially for nurses who mostly accompany patients and are on the front line. METHODS: In the study, a parallel mixed pattern converging quantitative and qualitative research methods was used. RESULTS: The model revealed that 41 years old or older, diabetic, female, single professionals, working in the pandemic department took more personal measures. Five main themes appeared regarding the experiences of the nurses during the pandemic period: (1) psychological and mental strain; (2) personal protective equipment; (3) organizational, physical, and social strains; (4) change in professional values; (5) turning the crisis into an opportunity. CONCLUSIONS: Personal measures are associated with the risk status. There is a need to protect nurses with significant measures by providing psychosocial support, meeting their basic needs, and preventing all complications likely to occur due to increasing workload. IMPLICATIONS FOR NURSING MANAGEMENT: More efforts should be made to ensure good work, fair treatment, no tolerance for discrimination, and equal compensation conditions.

The treatment of COVID-19 patients is a serious matter that requires training, the right personal protective equipment, the availability of modern intensive care units, and the availability of experienced health care professionals (Misra, 2020) . Even if the potential inadequacy of ventilators and intensive care beds is remedied properly to treat the patients, the abundance of materials and beds would not be useful unless there is sufficient workforce (Chen et al., 2013; Lai et al., 2020) .

COVID-19 creates several negative effects on health professionals via various factors including increased patient load and risk of infection (Adams & Walls, 2020) . More than 120,000 health care professionals (reported on 9 December 2020) in Turkey have been infected with coronavirus (Ministry of Health, 2020) . The data show that health care professionals are among the risk groups affected most by the outbreak in the country. Nurses are undoubtedly the health-related work force mostly needed in this global crisis. During this crisis, nurses play a key role in dealing with complex cases that require hospitalization. In this period, the abundance in the number of nurses may not be sufficient alone to provide adequate nursing services. Along with a quantitatively sufficient workforce, it is also necessary to maximize the ability of each nurse in providing care to patients with high performance. Considering that fluctuations in the number of critical patients may sustain for weeks to months, it is important to enable nurses to work with full potential for a long time (Shanafelt et al., 2020) .

The need for providing care for the people affected by has put intense pressure on nurses (González-Gil et al., 2021) . Nurses providing care for the infected patients needed to isolate themselves to avoid transmitting this virus to their loved ones, and therefore, they stayed away from various support systems. During the epidemic period, nurses and other health professionals experienced burnout and compassion fatigue as a result of intense and continuous workload (Schwerdtle et al., 2020) . Studies have shown that nurses experienced symptoms such as burnout, depression, anxiety, insomnia, and posttraumatic stress disorder during the epidemic process (Hacimusalar et al., 2020; Lai et al., 2020; Schwerdtle et al., 2020) . In a study, it was found that nurses experienced more despair than doctors and other health professionals (Crowe et al., 2021) .

It is important to provide the detailed analysis of the current and future needs of nurses to support the nursing workforce. There is a need for studies pointing out what nurses experienced during the COVID-19 pandemic in Turkey and across the world. This study sought to investigate behaviours and experiences of nurses working in Turkey during the COVID-19 pandemic. The study focused specifically on understanding the nurses' perception of their risk for transmission, personal precautions they took for COVID-19, changes in working conditions, and physical, psychological, and social changes they experienced.

The present study used a convergent parallel mixed methods design, a methodological design consisting of two distinct phases. In the quantitative dimension of the study, the relationship between nurses' risk status and their personal precautionary status was examined through a structural equation model. The qualitative dimension, on the other hand, was carried out based on a descriptive phenomenological pattern, one of the qualitative research methods, to examine the personal experiences guiding nurses' behaviour during the pandemic process and the meanings they attributed to the process (Braun & Clarke, 2006) . The main purpose of the phenomenological pattern is to understand the essence of an object by reducing individual experiences of a phenomenon to a universal explanation (Creswell, 2014) .

Although face-to-face interviews are preferred more in descriptive phenomenology, it has been reported that other methods such as written narratives, blogs, research diaries, and online interviews may also be used for data collection (Morrow et al., 2015) . In addition, it has been suggested that open-ended structured interviewing via questionnaires can be used to explore topics ranging from participants' perceptions, cultural differences, and interpretations (Marshall & Rossman, 2014) . Therefore, in this study, we predicted that nurses' experiences could be investigated by a self-administered

(online) open-ended structured survey (Ataro, 2020) . In this study, we combined the data obtained via quantitative research with the phenomenological research pattern's feature of "the inclusion of individual experiences." Thus, we integrated the data regarding nurses' behaviours during the pandemic period and their experiences that could guide these behaviours into the interpretation of the general results to provide a comprehensive view of the effects of the current pandemic on nurses (Creswell, 2015; Crowe et al., 2021) . Research questions in this context are as follows:

1. How do nurses assess their own risk situations? 2. What is the status of nurses regarding taking personal precautions against COVID-19 and complying with social distance rules?

3. How did COVID-19 affect nurses' work environments, social lives, and physical and psychological conditions?

The research was carried out between 10 April and 15 June 2020 in nurses with internet access from seven geographical regions of Turkey. At the time of study, there were about 205,000 registered nurses in Turkey. Based on the sample size calculation performed via power analysis, a minimum of 1070 responses were targeted . Nurses participated in the research were reached through the snowball sampling method. Information about the study and an electronic link for the questionnaire were distributed on the social media through a professional organization, the Turkish Nurses Association. The survey was conducted at the peak of the pandemic in Turkey. This short time frame was chosen to capture a snapshot of the condition and also to gain insight into emerging policies and practices. Nurses working actively during the data collection period were included in the study. Nurses who were on leave or quit their profession at the time of the study were excluded from the study. As a result, a total of 1306 questionnaires were filled out by the nurses.

For the research, a self-report structured questionnaire was developed by the researchers. After a comprehensive literature review on the subject, 5-point Likert-type questions were prepared regarding the nurses' personal measures, risk status, and compliance with social distance rules with regard to COVID-19. A pilot study was performed by taking the opinions of 11 nurses regarding the questions prepared.

Validity and reliability analyses were performed for the Likert part of the questionnaire. Also, open-ended questions were included in the questionnaire. The questionnaire consisting of 41 questions were divided into four sections:

1. The sociodemographic characteristics section consists of questions regarding age, gender, marital status, tenure in the profession, and the work unit. 

Due to curfew restrictions, risky hospital environments, restrictions of entry into hospitals, and because the distribution of questionnaires personally may pose a risk of contamination, face-to-face interviews were avoided. Therefore, the surveys were delivered during the peak of COVID-19 to the participants online by nurses with a doctorate or a master's degree. The questionnaire was presented as a Google form.

The participants were invited through personal e-mail messages. The data were collected between 5 May and 1 June 2020. Duplicate entries were prevented by allowing one submission for each participant's Google account.

In the study, reliability analysis and multicollinearity analysis were performed with the SPSS 25 statistical program. Afterwards, a structural equation model was established with the AMOS 24 software to assess the effects of the measures taken by the nurses against the risk of COVID-19 in relation with the variables, and a multiple group analysis was conducted. The significance level was accepted as p < .05.

In the reliability analysis of the questionnaire used in the study, we calculated two values: composite reliability (CR) and average variance extracted (AVE). The CR value analysis shows the extent to which a hidden variable is represented by the observed variables that constitute itself. The obtained CR values are generally parallel with the calculated Cronbach α values. CR results must be .70 or above.

The AVE value should be greater than the unexplained variance and also over .50. Any Cronbach alpha (α) value of .90-1.00 expresses perfect reliability. The Cronbach alpha (α) value of the questionnaire we used was calculated as .969, the AVE value as .984, and the CR value as .953, so it is seen that the questionnaire was reliable.

Multicollinearity was checked in the data to make sure that there was no relationship between the independent variables, and the calculated variance inflation factor value was not over 10 (2.225) (Albayrak, 2005) . themes. In the model, saturation appears to be confined to the level of analysis, and its implication for data collection is at best implicit. As a result, the thematic analysis process, based on a descriptive phenomenological approach, extended to identifying meanings using the original data, organizing them into patterns, and writing the resulting themes related to the aim of the study and the real context. When the findings were reported, they were explained in reverse (i.e., starting with the themes and the descriptive text, illustrated with quotes).

Thus, the meanings obtained from the experiences of the participants were explained in a meaningful text organized in themes (Sundler et al., 2019) .

Before the initiation of the research, approval was obtained from the local ethics committee and the Ministry of Health. Before the implementation of the survey, information about the study was shared with each participant in written. The online data collection system was configured in a way that the participants were allowed to respond to the questionnaire after they were informed about the study.

For the quantitative phase, a total of 1270 questionnaires were analysed after 34 questionnaires were removed because they were incomplete (25 questionnaires) or filled out by nurses who did not meet the inclusion criteria (nine questionnaires). Participants were mostly female (n = 988; 78.6%), young people aged 30 years and under (n = 897; 40.1%), single (n = 777; 61.1%), working in intensive care units (n = 305; 24.0%), and with a tenure of less than 5 years (n = 781; 61.5%). The demographics analysed in the first part of the questionnaire are presented in Table 2 . For the qualitative phase, 1306 questionnaires were reviewed and 52 of them were transferred from the Excel program to NVivo. Fifteen male and 37 female participants were included in the qualitative analysis. More than half of the sample (n = 30) stated that they were working in pandemic services (services where patients with COVID-19 were treated) for a long or short term. Again, the same participants (n = 30) reported that they were still staying in a dormitory or hotel away from their home. With these characteristics, the participants who completed the questionnaires represented demographic variability and a wide range of experiences.

The participants' effort level to comply with the rules of personal protective equipment (PPE) was very high (over 84.0% "agree/ shows that more personal precautions are taken in case of risk (Table 3) .

As a result of the thematic analysis, five main themes were identified, and each had its own subthemes. While the first four themes stressed the negative aspects of the nurses' experiences during the pandemic period, the last theme interestingly showed the positive aspects of their experiences.

Stress, anxiety, and fear

It was observed that simultaneous exposure to many factors such as uncertainty, workload, insomnia, equipment-related problems, change in the work environment, and the risk of infecting the beloved ones led to intensive stress. One participant responded, "In every watch duty, I was stressed and I experienced extreme stress and insomnia. The pandemic has made our stressful work environment more stressful. It used to affect only us, but now, we are worried about our families and environment" (P 18). The mentioned stress was more intense especially for the nurses who stated that they worked at pandemic departments. One of the participants working in a pandemic department responded, "This is not something to say in words. Only those who share this environment can actually understand it. We are extremely busy and work under stress. The risk is high, working conditions are difficult and unsafe" (P 27).

Anxiety and fear were reflected in feelings such as concern about the future, fear of death, fear of losing someone loved or rules. If I don't obey the rules, I feel like I will get sick and die at any time" (P 17). Another participant responded, "I feel weak, I'm afraid I won't be able to protect my family. Every patient is a suspect!" (P 18).

Excessive workloads, work environments that are substantially different from the familiar ones, and environmental pressure caused depressive emotions and obsessive behaviours in many nurses. One participant responded, "The intensive care area, which is already depressing, has become more and more depressing. I feel like a robot that is worried about its own life, runs for other lives and has forgotten itself" (P 28). Another participant responded, "My obsessions have increased and this affects me more and more every day. I started to feel like this virus is everywhere" (P 30).

The nurses frequently mentioned that the need to provide care to many patients simultaneously and changing conditions exhausted them mentally during the pandemic period. It is noteworthy that the intense feeling of uncertainty makes this fatigue permanent. One participant responded, "Being restricted and distant, behaving more carefully, obeying hygiene rules-warning those who don't, changing the current habits, working more! I'm tired, I need to listen to myself. This obscurity feels like it will always be like this" (P 1). 

Low comfort due to continuous use Participants, especially those working in critical areas like intensive care units, emphasized that they had difficulty in using PPE. Many participants reported particularly complaints of sweating, sore throat and headache, difficulty in breathing, and allergies related to the longterm use of PPE. A participant responded, "The equipment I use makes me sweat a lot. I get more tired. We need the equipment to be produced in compliance with long-term work" (P 1). Another participant responded, "The use of masks has led to nasal discharge and sore throat. I have a headache due to wearing a mask all the time, my hands are constantly chapped. I think the worst of all is not getting air" P (8).

The care required in putting on and taking off PPE often cause physical fatigue. One participant responded, "It is an unbelievable work load to visit the patient's room with equipment. This means standing for hours. Your effort while trying to protect yourself is very tiring" (P 21).

Some participants stated that they could not find sufficient materials in the early periods of the pandemic. One participant responded, "At the beginning, we had a shortage of materials for a long time. It is really such a risky action to enter the patient room with lack of equipment that we experience inexplicable fears" (P 17). Some nurses complained about the quality of the materials. One participant responded, "We had difficulty in finding suitable equipment in the hospital; we had to use unsuitable masks" (P 9).

Changes in working environment, order, and hours COVID-19 changed the working ecology of all the hospitals.

Participants reported that they experienced this change sometimes when they were assigned to other units, and often by working very long hours. One participant responded, "My unit, team, and working hours have completely changed. Sometimes, we had two 24-hour shifts a week" (P 32). Another participant responded, "I am at a different department in every watch duty or every month. My work pattern has been out of order. I had to work where I had never worked and adapt to the unit in a short time, this is very difficult" (P 25).

Several participants stated that they were not sufficiently compensated for the work they did. A participant responded, "I don't think our efforts are valued. Of course, we will do our best, but we must be compensated (accordingly)" (P 3). Another participant responded, "I should be provided with satisfactory financial support. The gaps between the payments of the nurses and doctors should be eliminated. All we want is arrangement in salaries and additional payments, because we exist altogether" (P 19).

Some participants had difficulties in arriving at workplaces during this period. Nurses working in remote areas, such as district hospitals, mentioned about their transportation problems. To express this problem, one participant responded, "We are having difficulties in matters such as transportation due to the restrictions. I wait for a bus for one hour to go to work" (P 7). Social life has become nothing more than the telephone and the Internet" (P 11).

The nurses mentioned that they felt lonely and excluded, sometimes only because they were health professionals, and sometimes because they stayed at dormitory alone. One participant responded, "People stay away from me because I am a health professional. This affects me negatively and I feel unhappy" (P 4 

Nurses are at the centre of the health system. They expect this fact to be known that their services should be visible, and the difficulties they experience on daily basis should be noticed. One participant responded, "What we mostly need is that our people should value our effort and be careful. All I need is to be thanked. But not with clapping. I want everyone to know that I am also in the sector and I am right in the middle of it" (P 3). Another participant responded, "I want to see support, tolerance and understanding. I want our administrators, our environment and the society to realize the seriousness of the work we do. I need our dedication to be noticed" (P 7).

The pandemic caused difficulty in nurses' performance and motivation. One participant responded, "I am very exhausted.

Although it is the nurses who mostly deal with patients, this value is not appreciated, which has decreased my motivation and job satisfac- 

Some participants stated that their belief in their own power and the power of their profession increased while struggling against COVID-19. In addition, nurses emphasized teamwork and stated that their belief in their team increased. One participant responded, "I feel that I am professionally satisfied, I have gained great experience and my self-confidence has increased. Definitely, the pandemic has made our work lives difficult, but it has made contributions to us as well" (P 6). Another participant responded, "We are making history.

Being a part of it is sublime. It has been a very tiring process, but I would never think about sitting in my house under any circumstances. It is awesome to be able to serve people and to take on responsibility in such a period" (P 12). Another participant replied:

"COVID-19 made me very tired, but it also improved me a lot. Especially seeing that the cooperation within our team has increased and everyone is making an effort to take responsibility increases my belief in my profession." (P26).

Behind the positive experiences expressed by many participants were the feeling of spirituality. Many participants expressed that they learned to be patient, understood the value of their freedom and their possessions, and got more mature. One participant responded, "Although the restrictions were initially unsettling, they taught me a lot. I have learned how to be patient, how to content myself, how valuable every breath and every step I take is, and how precious living freely is" (P 26). Another participant responded, "I think this period will be an investment in my future life, I'm now mature" (P 6). Another 

The quantitative part of the research revealed that the rate of taking personal measures against COVID-19 was high in nurses (min: 61.1%, max: 89.3%). It was also stated that health professionals reported a high rate (88.7%) of good practice during the COVID-19

period (Saqlain et al., 2020) . The structural equation model revealed that 41 years old or older, female, and single participants, those who were diabetic, and those working at pandemic departments were more likely to take personal measures against the risk of COVID-19. Saqlain et al. reported that experienced nurses (>5 years)

were more likely to demonstrate good practice (Saqlain et al., 2020) . These results indicated that nurses were able to take personal measures to protect the public health and themselves during public health emergencies. These results suggest that nurses whose strengths are recognized may play key roles in future public health emergencies.

The current pandemic had a compelling effect on nurses. In this study, excessive behaviours seen in high-risk participants reflect the overarching theme of "psychological distress." This overarching theme is woven along the subthemes of "stress, anxiety and fear"

and "depressive emotions, obsessive behaviors, and psychological fatigue." The psychological strains indicated had characteristics that could prevent the nurses from working with full potential and may affect their future experiences. These findings were consistent with the results reported in previous studies (Bohlken et al., 2020; Brooks et al., 2018; Khalid et al., 2016; Liu et al., 2020; Nemcová et al., 2017; Ran et al., 2020; Wu et al., 2020) . These findings suggest that the psychological distress experienced by nurses is important. Considering the frequency of the mental symptoms in nurses, it is necessary for them to take part in interventions in order to be able to cope with their mental issues (Bohlken et al., 2020; LoGiudice & Bartos, 2021) . The research during past pandemics has shown that health care workers are more likely to develop postpandemic stress disorder (Lee et al., 2018; Tam et al., 2004) . Increasing the number of staff, arranging the shift system, providing psychological counselling and guidance in the form of support services on online platforms or by phone, especially to relieve front-line nurses can alleviate the permanent effects of psychological difficulties (Çınar et al., 2021; Kang et al., 2020) .

A high level of efforts to comply with PPE rules (over 84%) were thought to result in low comfort. In the subtheme of low comfort due to continuous use of PPE, various problems such as sweating, difficulty in breathing, allergy, and sore throat were highlighted, which showed the difficulty in working in PPE for a long time. Studies touching upon the comfort level in relation with PPE have shown that nurses spend a lot of time to change their clothes, fog-drips appear on the glasses deteriorating the sight of the nurses, headache, sore throat, dehydration, and sweating occur during the use, and temporary deformation is observed on some nurses' skin and faces as they wear N95 masks for a long time (Den Boon et al., 2018; Ong et al., 2020; Zhang et al., 2020) . It is believed that arrangement of shift hours and durations by administrators according to workloads and duties among the nurses who use and do not use PPE, and collaboration and increasing the number of professionals will be useful (Chirico et al., 2020; Jiang et al., 2020; Zhang et al., 2020) . In addition, the findings highlight the importance of providing adequate ergonomic and validated protective equipment.

The subthemes of "change in the working environment, order, and hours" and "financial difficulty and transportation problems" indicated that the pandemic changed the entire nature of the hospitals.

Unusually long working hours and organizational disorders in newly opened pandemic departments and newly formed teams were the most common administrative problems. Previous research showed that actual working hours were longer than the ideal working hours preferred by nurses . It was also reported that long working hours could contribute to a series of negative effects on nurses, patients, and the health system (Bae & Fabry, 2014; Kunaviktikul et al., 2015) . Working with low salaries under these challenging conditions and differences in payments were mentioned by the nurses in a rebellious way. Hospital administrators should be sensitive to the needs and demands of the nurses in order to increase their compliance with the changing working conditions and to realize the problems they experienced (Adams & Walls, 2020; Jiang et al., 2020) .

The fact that 61.1% of the participants stated that they could get sufficient and regular sleep pointed to the problems related to basic needs. We associated these problems with the subtheme of "fatigue due to increased workload and insomnia." In a research study conducted in China, physical strains were mentioned repeatedly . Physiological needs of the nurses who participated in the study mainly included adequate rest, eating, and going to the toilet. Yao et al. (2020) concluded that seven front-line nurses who provided care to COVID-19 patients had heavy workloads. Work intensity affects the efficiency and strength of the nurses. For this reason, it is important to continuously optimize the number of nurses and to arrange the shift systems in a way that provides adequate rest and nutrition in order to ensure the continuity of the workforce (Çınar et al., 2021; He et al., 2021; Kang et al., 2020; Wang et al., 2020) .

The efforts of the nurses to comply with the quarantine conditions and social distance rules in the working environment and food halls are remarkable. Our findings that high rates of adherence to quarantine rules (85.0%) and social distance rules while working (75.7%) or eating (81.7%) provided information about the social lives of the nurses. Among the qualitative results, the subtheme "An ongoing process between home and hospital: being trapped and loneliness" supports these findings. For nurses, the need to comply with strict quarantine conditions has brought their social life into inexistence. Social life, which was described by nurses as an ongoing process between loneliness and home/hospital, was over for the nurses. Many nurses felt trapped and excluded. On the contrary, nurses wanted to be visible and right in the middle of the health system. How working and living conditions of the nurses will be managed and how their social needs will be ensured are important problems that need to be addressed by health administrators (Shanafelt et al., 2020; Zhang et al., 2020) . Although the hospitals where the nurses work provide adequate support for sheltering due to the risk of contamination, it has been observed that the nurses are insufficient in supporting personal family dynamics. The lack of arrangements made it impossible for nurses to overcome the psychological burden of being separated from their relatives. These situations forced them to cope with their anxiety and fears on their own (Muz & Erdo gan Yüce, 2021) .

The study included many nurses with chronic diseases such as lung disease, diabetes, and heart disease (lung diseases = 46; heart diseases = 46, diabetes = 7 and other chronic disease = 63), and they are in the vulnerable group for COVID-19. It was found that 46.7% of the nurses thought that they were COVID-19 carriers. In addition, some of them reported that they were more likely to be sick (38.9%). It was assumed that this situation led to the development of negative thoughts about the profession in many nurses who thought that they were vulnerable. Throughout the theme of change in professional values, the desire to be noticed and visible, the feelings of low performance and motivation were repeated. In this context, our study showed that in the pandemic period, conditions such as exhaustion, burnout, alienation from the profession, feeling unworthy, injustice, administrative deficiencies, and role confusion led to performance and motivation difficulties. In previous studies, organizational justice belief in nurses has been found to be associated with work commitment, intention to leave (Cao et al., 2020) , and negative behaviours (Seyrek & Ekici, 2017) . As in past epidemics, nurses stated that they did not want to continue their profession in this epidemic (Bai et al., 2004) . Our findings are consistent with the results from past epidemic periods. In this respect, these thoughts of the nurses may indicate that there may be serious consequences creating obstacles to the delivery of quality care in the future. In fact, crises are turning points (Yıldırım et al., 2021) . Sometimes there are achievements in all challenges.

So, there were also nurses who reported positive experiences in this crisis. The theme of our results about "transforming crisis into an opportunity" indicated that there were positive changes in the professional and spiritual feelings of some nurses. These nurses stated that gaining experiences, and cooperating and succeeding in the pandemic process increased their professional satisfaction. Participants in a past study also stated that although it was difficult to take care of COVID-19 patients, it strengthened their willpower, helped them discover their potential (Sun et al., 2020) , and that society's appreciation of them and understanding the meaning and value of nursing strengthened their motivation (Muz & Erdo gan Yüce, 2021).

The main limitation of this study was the fact that the experiences of the nurses were obtained via their self-evaluations, which was far from objectivity by definition. Because some nurses had limited online experiences and some were unable to access the questionnaire due to technical issues, response rate may have been negatively affected. Third, in the analysis of online messages, misinterpretations may have occurred because online messages cannot transmit nonverbal signs. However, we analysed all the messages within the context by attentively reading them.

The present research presents scientific data for nurses, authorities that develop health care policies during pandemic periods, and health care administrators. This study showed that personal measures are related to the risk status. The themes obtained as a result of the experiences of the nurses revealed that there is a need to protect the nurses with important measures such as the use of strong psychosocial and psychological help, meeting their basic needs, providing social support, fair distribution of the duties, and the determination of ideal working hours for preventing the damages which may arise due to increased workload.

Our study highlights some of the important issues related to COVID-19 for nursing managers. First, we could be prepared to protect sensitive groups of nurses who strive to take personal precautions, especially according to the model described vulnerable groups as those who work in pandemic services and those with chronic diseases. Good mental health support could be essential in times of crisis. Planning longer term psychological support could be vital, especially for nurses who are in the high-risk group and need more personal measures. PPE-related discomfort was strikingly pronounced. Nurse managers have the opportunity to ensure that the right type of equipment is available, and take action against PPE-related problems by organizing working hours for frontline nurses. Finally, our study highlights the need for greater national cooperation between governments, health systems, and managements to ensure optimal response, timelines, and correct communication in future health emergencies. In this context, more efforts could ensure good work, fair treatment, no tolerance for discrimination, and equal payment conditions and environments together with the political reform (Black et al., 2020) .

Ethics Committee of Inonu University Institute of Health Sciences (decision number: 2020/669).

We would like to thank the deceased all nurses who participated in our study for their contribution to the studies.

No potential conflict of interest was reported by the authors.

This work has no financial supporter. 

The data that support the findings of this study are available from the corresponding author upon reasonable request.

ORCID Zeliha Cengiz https://orcid.org/0000-0002-3819-1717

Kevser Isik https://orcid.org/0000-0001-9081-7660

Züleyha Gurdap https://orcid.org/0000-0002-2231-8218

Emriye Hilal Yayan https://orcid.org/0000-0003-0075-4171

Supporting the health care workforce during the COVID-19 global epidemic

Çoklu Do grusal Ba glantı Halinde En küçük Kareler Tekni ginin Alternatifi Yanlı Tahmin Teknikleri ve Bir Uygulama

Methods, methodological challenges and lesson learned from phenomenological study about OSCE experience: Overview of paradigm-driven qualitative approach in medical education

Assessing the relationships between nurse work hours/overtime and nurse and patient outcomes: Systematic literature review

Survey of stress reactions among health care workers involved with the SARS outbreak

COVID-19: The case for health-care worker screening to prevent hospital transmission

COVID-19 pandemic: Stress experience of healthcare workers-a short current review

Using thematic analysis in psychology

A systematic, thematic review of social and occupational factors associated with psychological outcomes in healthcare employees during an infectious disease outbreak

Effects of organisational justice, work engagement and nurses' perception of care quality on turnover intention among newly licensed registered nurses: A structural equation modelling approach

Burnout, job satisfaction, and medical malpractice among physicians

COVID-19: Protecting healthcare workers is a priority

Perceived stress and affecting factors related to COVID-19 pandemic of emergency nurses in Turkey

A concise introduction to mixed methods research

Revisiting mixed methods and advancing scientific practices

The effect of COVID-19 pandemic on the mental health of Canadian critical care nurses providing patient care during the early phase pandemic: A mixed method study

Nurses' perceptions and demands regarding COVID-19 care delivery in critical care units and hospital emergency services. Intensive & Critical Care Nursing

AMOS ile Yapısal Es¸itlik Modellemesi Seçkin Yayıncılık

Anxiety and hopelessness levels in COVID-19 pandemic: A comparative study of healthcare professionals and other community sample in Turkey

The experiences of nurses infected with COVID-19 in Wuhan, China: A qualitative study

The performance and professionalism of nurses in the fight against the new outbreak of COVID-19 epidemic is laudable

The mental health of medical workers in Wuhan

Healthcare workers emotions, perceived stressors and coping strategies during a MERS-CoV outbreak

Nurses' extended work hours: Patient, nurse and organizational outcomes

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019

Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients

Mental health status of doctors and nurses during COVID-19 epidemic in China

Experiences of nurses during the COVID-19 pandemic: A mixed-methods study

Designing qualitative research

Doctors and healthcare workers at frontline of COVID 19 epidemic: Admiration, a pat on the back, and need for extreme caution

Colaizzi's descriptive phenomenological method

Experiences of nurses caring for patients with COVID-19 in Turkey: A phenomenological enquiry

Quality of life in patients with diabetic foot ulcer in Visegrad countries

Headaches associated with personal protective equipment-A cross-sectional study among frontline healthcare workers during COVID-19

Risk factors of healthcare workers with corona virus disease 2019: A retrospective cohort study in a designated hospital of Wuhan in China

Knowledge, attitude, practice and perceived barriers among healthcare professionals regarding COVID-19: A Cross-sectional survey from Pakistan

Nurse expertise: A critical resource in the COVID-19 pandemic response

Nurses' perception of Organisational justice and its effect on bullying behaviour in the hospitals of Turkey. Hospital Practices and Research

Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic

A qualitative study on the psychological experience of caregivers of COVID-19 patients

Qualitative thematic analysis based on descriptive phenomenology

Severe acute respiratory syndrome (SARS) in Hong Kong in 2003: Stress and psychological impact among frontline healthcare workers

Contingency management strategies of the nursing department in centralized rescue of patients with coronavirus disease 2019

A comparison of burnout frequency among oncology physicians and nurses working on the front lines and usual wards during the COVID-19 epidemic in Wuhan

Qualitative study on work stress of first-line nursing staff in children's hospital against new coronavirus pneumonia

A qualitative study on the experiences of the first nurses assigned to COVID-19 units in Turkey

Nurses reports of actual work hours and preferred work hours per shift among frontline nurses during coronavirus disease 2019 (COVID-19) epidemic: A cross-sectional survey

Behaviours and experiences of nurses during the COVID-19 pandemic in Turkey: A mixed methods study