key: cord-0987378-qvbkynot authors: Köse, Selmin; Gezginci, Elif; Göktaş, Sonay; Murat, Merve title: The Effectiveness of Motivational Messages to ICU Nurses during the COVID-19 Pandemic date: 2021-11-01 journal: Intensive Crit Care Nurs DOI: 10.1016/j.iccn.2021.103161 sha: 0f68a7c3c1d7b01d9879d57a6cbeb0fa5ac31788 doc_id: 987378 cord_uid: qvbkynot OBJECTIVES: To examine the effect of motivational messages on optimism, hopelessness, and life satisfaction of intensive care nurses during the COVID-19 pandemic. Study Design This is a multicenter, randomized controlled, open-label study. Research Methodology/Design The study was conducted with a total of 87 nurses working in the COVID-19 intensive care units of three hospitals in Istanbul. Motivational messages were sent via SMS to the participants in the motivational group (n=41) for 21 days. The data were obtained using a Personal Information Form, the Life Orientation Test, Beck Hopelessness Scale, and the Satisfaction with Life Scale. RESULTS: The nurses’ mean age in the motivational and control groups was 28.4±7.6 and 26.9±3.7 years, respectively. Before the messages, no statistically significant difference was found between the two groups in terms of life orientation (p=0.059), hopelessness (p=0.214), and satisfaction with life (p=0.898) scores. After the messages, life orientation (p=0.042) and life satisfaction (p=0.040) scores were significantly higher in the motivational group compared with the control group, and the hopelessness score was significantly lower (p=0.005). CONCLUSION: According to our study, motivational messages sent to intensive care nurses during the pandemic increased their level of optimism and life satisfaction and decreased their level of hopelessness. Trial registration: blinded for review The coronavirus disease (2019) COVID-19 pandemic has affected health systems globally and required healthcare professionals to perform at a high level. In this process, the mental health and well-being of intensive care nurses, who bear the greatest burden in health systems, is negatively affected. When factors that affected nurses were examined, they were the long working hours and high patient care burden, dealing with uncertainties due to and worrying about themselves and their families (Shen et al., 2020; Azoulay et al., 2020) . In countries where the number of cases is high and increasing, intensive care nurses have been affected primarily from a professional standpoint, but also mentally, emotionally, and socially (Hong et al., 2021; Pappa et al., 2020) . Nurses have to deal with many challenging situations throughout the day. These difficult situations may be caused by patients or relatives, colleagues, or organization-related (e.g. payment related, housing, staff shortages). In everyday life, they cause high stress among nurses, which can create burnout (Guo et al., 2018) . In a systematic review (2019), stress and burnout syndrome in critical care nurses was examined and it was emphasized that burnout syndrome was a serious problem for the healthcare system (Friganović et al., 2019) . High stress can turn into serious psychological problems such as post-traumatic stress disorder, depression, and anxiety disorder in the long term (Hong et al., 2021; Pappa et al., 2020) . When the literature is reviewed, pessimistic thinking, feelings of hopelessness, and anhedonia, which are considered among depressive symptoms, can be observed in intensive care nurses. The results of the study conducted by Shen et al., (2020) with 85 intensive care nurses showed that nurses had fatigue, decreased appetite, sleep problems, aggression, and suicidal thoughts, albeit at low rates (Shen et al., 2020) . In another study in the United States of America (USA), it was found that 80.1% of nurses experienced moderate/high stress, 43% had anxiety, and 26% had depression (Kim et al., 2021) . In the study conducted by Murat et al., (2020) in Turkey during the COVID-19 pandemic, it was found that the level of stress and burnout was high and the level of depressive symptoms was moderate among nurses (Murat et al., 2021) . As the COVID-19 pandemic continues, these symptoms are predicted to be higher in nurses who have not previously provided critical patient care due to the intensive care unit (ICU) patient volume (Shen et al., 2020; Pappa et al., 2020; Cheng et al., 2020) . Motivation affects the daily life of individuals, helps them to be ready and changes their behaviours. With this, motivation got affected from external factors such as life satisfaction, life orientation, and feeling hope (Rathore et al., 2015) . Change can be affected by using tools that increase motivation in individuals positively. Motivational messages are one of the tools that are effective, cheap, and easy-to-use, and help to increase the motivation of the individual. The literature shows that COVID-19 affects nurses' psychological well-being negatively. Besides, interventions to prevent mental health problems or promote mental health should be planned in accordance with the restrictions taken to prevent the spread of COVID-19. From the beginning of the pandemic, internet use has increased in many sectors such as health, economy, and education, and mobile phones are very effective in this increase (De' et al., 2020) . In the literature, mobile phone technology was used for individuals to help gain healthy behaviours and to improve disease management (Newton et al., 2018; De Vries et al., 2017; Xu et al., 2019; Hawkins et al., 2018) . Interventions other than motivational messages have been performed to increase the well-being of nurses via mobile phones. In China, call centres (30-minute interviews) provide healthcare professionals with support for their mental state and well-being. It was reported that interventions could help nurses with the problems experienced during the pandemic by supporting self-efficacy without the need for advanced intervention (Chen et al., 2020) . During the COVID-19 pandemic, using mobile phones can be the best option to support nurses, regardless of the location and time. Although several studies are mobile-message based (De Vries et al., 2017; Hawkins et al., 2018) , there is a paucity of data regarding the effectiveness of text message programs as a motivational tool. Therefore, we aimed to provide support to ICU nurses' mental health with motivational messages sent over the phone because increasing the mental health and well-being of nurses is as important as fighting the pandemic. Hence, the study's purpose was to examine the effect of motivational messages on optimism, hopelessness, and life satisfaction of intensive care nurses during the COVID-19 pandemic, and it was hypothesized that motivational messages would increase the nurses' life orientation and life satisfaction while decreasing hopelessness. RQ1. How did motivational messages affect ICU nurses' optimism during the COVID-19 pandemic? RQ2. How did motivational messages affect ICU nurses' hopelessness during the COVID-19 pandemic? RQ3. How did motivational messages affect ICU nurses' life satisfaction during the COVID-19 pandemic? This research was a multi-centre, open-label, randomized-controlled clinical trial. The study was conducted in accordance with the Consolidated Standards of Reporting Trials (CONSORT) and prospectively registered on clinicaltrials.gov.tr (No: blinded for review). This research was performed with nurses working in the COVID-19 ICUs of three training research hospitals and a university hospital, which were designated as pandemic hospitals and affiliated to the Ministry of Health in Istanbul between February 1 st , and March 1 st , 2021. The population of the study consisted of nurses working in the COVID-19 ICUs of these hospitals (n=120). The criteria for inclusion in the study were being a nurse, working only during the day shift on weekdays in the COVID-19 ICU, using a mobile phone, and accepting to participate in the study. In the institutions where the study was conducted, nurses work one month of night shifts and one month of day shifts according to the monthly working schedule. Nurses, who worked between February and March 2021 were included in the study. The exclusion criterion for the study was not fully completing the data collection forms. Randomization was performed using computer-based random sequence numbers (www.random.org). The random allocation sequence and the assignment of the participants to the groups were conducted by the researchers. Participants were numbered according to the order of inclusion in the study and assigned to the motivational group or control group according to random order numbers on the randomization list. Due to the research design, the principal investigator and patients were not blinded to allocation; however, the evaluator was blinded to the group allocation. Motivational group: Before starting the study, the opinions of the nurses working in the COVID-19 ICU about the content of motivational messages that would positively affect their level of optimism, hope, and life satisfaction were obtained. Motivational messages prepared by the researchers in line with the feedback received from the nurses were presented for expert opinions. Necessary arrangements were made with the recommendations of an expert team consisting of three nurse academics and two psychologists. The experts' evaluation was performed by considering the Davis technique (Davis, 1992) . Experts scored each statement on a scale of 1-4 (1=not suitable, 2=item needs to be tailored, 3=suitable, but needs minor change 4=very convenient). As a result of content validity, the messages consisted of 44 statements and the Content Validity Index of the content was found as 94%. Nurses were allowed to take a short break (5-10 minutes) by the head nurse and access messages after they heard the message tone at the time of notification. Motivational messages were sent to the mobile phones of the nurses in the motivational group at 09:00 AM, 12:00 PM, 05:00 PM, and 07:00 PM for 21 days (Table 1) . Different motivational messages were sent to the participants every day by the researchers. One-day sample motivational messages are shown in Table 1 . Table 1 Control group: Motivational messages were not sent to nurses in the control group, and they continued their routine work in the ICU. Nurses in the control group took breaks in accordance with their unit. Data in the study were collected online using a Personal Information Form, the Life Orientation Test (LOT), the Beck Hopelessness Scale (BHS), and the Satisfaction with Life Scale (SWLS). Due to the COVID-19 pandemic, the first meeting with the participants was held using an online platform, the participants were given the necessary information about the study and their consent was received. The Personal Information Form, LOT, BHS, and SWLS were administered to the participants before the interventions began (at the first day of the study) as a pre-test. At the end of the interventions (at the end of the 21st day of the study), the LOT, BHS, and SWLS were readministered to the participants as a post-test. The primary outcome of this study was the difference in life orientation scores between the two groups as measured using the LOT. The secondary outcomes were the difference in hopelessness scores and life satisfaction levels between the two groups as measured using the BHS and the SWLS. The 19-question personal information form, created by the researchers in line with the literature, included questions that would contribute to determining the sociodemographic characteristics of the individuals and their professional lives during the COVID-19 pandemic (Topuz, 2018; Polat et al., 2016; Atasoy and Turan, 2019; Yesilcinar et al., 2020) . A revision of LOT was developed by Scheier et al., in 1994 . The Turkish validity and reliability study of the revised version of the test was conducted by Kahleoğulları in 2017. The test aims to reveal the differences between individuals in terms of optimism and pessimism. The test is evaluated as a 5-point Likert type (1: I do not agree at all, 5: I strongly agree). Items 3, 7 and 9 are scored in reverse. The lowest score that can be taken from the test is 6 and the highest is 30; low scores indicate pessimism and high scores indicate optimism. The Cronbach's alpha coefficient was 0.78 in the original study of the scale, and 0.75 in the study of Kahleogullari (Scheier et al., 1994; Kahleogullari, 2017) . In the present study, Cronbach's alpha coefficient was found as 0.71. The BHS was developed by Beck et al., in 1974. Its Turkish validity and reliability study was conducted by Durak and Palabıyıkoğlu in 1994 . The purpose of this scale, which was developed taking into account Beck's cognitive theory, was to determine the hopelessness level of individuals. The scale consists of 20 items and three sub-dimensions: emotions and expectations about the future, loss of motivation, and hope. The lowest possible score on the scale is 0 and the highest is 20, and the higher the score, the higher the hopelessness level of the individual. In the original study of the scale, the reliability coefficient of Kuder-Richardson-20 was 0.93. In Durak and Palabiyikoglu's study, the Cronbach alpha coefficient was found as 0.78 for emotions and expectations about the future, 0.72 for loss of motivation, and 0.72 for hope (Beck et al., 1974; Durak & Palabiyikoglu, 1994) . In the present study, Cronbach's alpha coefficient was found as 0.85. The scale was developed by Diener et al., in 1985 and adapted into Turkish by Dağlı and Baysal in 2016 . The scale, built on the concept of life satisfaction, which is one of the components of subjective well-being, aims to evaluate general life satisfaction. The scale consists of a single dimension and five items. In the Turkish version, it is a 5-point Likert-type scale and is scored between 1 and 5 (1: strongly disagree, 5: totally agree). The lowest score that can be obtained from the scale is 5 and the highest score is 25, and the higher the total score, the higher the life satisfaction level. In the original study, the Cronbach alpha coefficient was 0.87, and in the study of Dagli and Baysal it was 0.88 (Diener et al., 1985; Dagli and Baysal, 2016 ). In the present study, Cronbach's alpha coefficient was found as 0.76. The size of the study sample was calculated using the G*Power (v. 3.1.9.6.) program. A similar study using the Beck Hopelessness Scale was used for sample calculation (Topuz, 2018) . As a result of the power analysis (80% representation ability, α=0.05, and effect size=0.6), it was calculated that a total of 78 nurses would be required as a sample of 39 interventions and 39 as the control group. However, taking into account possible losses during the study, the number of participants was increased by 10% and 93 nurses were included, 44 in the motivational group and 49 in the control group. The study was completed with a total of 87 nurses (41 interventions and 46 controls) because three nurses from the motivational group and three from the control group did not respond to the final test ( Figure 1 ). The data obtained from the research were evaluated using the Statistical Package for the Social Sciences software package (SPSS-IBM Corporation v.24 Armonk, NY). Number, percentage, mean, standard deviation, median, minimum, and maximum values were used for the descriptive statistics of the study. The compatibility of the variables to normal distribution was evaluated using the Shapiro-Wilk test. Categorical data comparisons between independent groups of the study were analysed using the Chi-square test and Fisher's exact test. It was determined that the LOT and SWLS data showed normal distribution, whereas the BHS data were not normally distributed. In comparing the mean scores between the two groups, Student's t-test was used for variables with normal distribution, and the Mann-Whitney U test was used for variables that did not show normal distribution. Comparison of the pre-test and post-test mean scores of the groups were evaluated using the paired-sample ttest for data with normal distribution, and Wilcoxon's rank-sum test for data that did not show normal distribution. Variables were considered significant at the 95% confidence level and with p-values less than 0.05. For authorization of the research, an application was made to the COVID-19 Scientific Research Platform under the Republic of Turkey Ministry of Health, General Directorate of Health Services on January 8 th , 2021, and the necessary approval was obtained (Number: 2021-01-05T13_54_08). In addition, the research was found ethically appropriate by the Ethics Committee on January 29 th , 2021 (Decision Number: 2021/47-31). The study was conducted in compliance with the principles of the Helsinki Declaration. Before asking the research questions, an informed consent form explaining the purpose of the research and the use of personal data for scientific research was included in the online system. Participants were asked to answer the questions after first reading and approving this prepared statement. For data security, only individuals with the link were allowed to access the research questions; the participants' data was encrypted and only researchers were allowed access. The mean age of the motivational group and control group was 28.4±7.6 and 26.9±3.7 years, respectively. Women constituted 80.5% of the nurses in the motivational group and 73.9% of the control group. Considering their educational status, it was found that most of the nurses in both groups were undergraduates. It was determined that there was no statistically significant difference between the motivational group and control group in terms of sociodemographic characteristics (p>0.05) ( Table 2) . Table 2 3.2. The nurses' characteristics regarding their profession during the COVID-19 pandemic The years of experience as a nurse was 6.0±8.1 for the motivational group and 4.4±3.2 years for the control group, and the years of experience in the ICU was 4.4±6.0 and 3.6±3.1 years, respectively. Most (90.2%) of the nurses in the motivational group and 87.0% of the nurses in the control group worked in adult ICUs. The job satisfaction level of the nurses was determined as 31.7% in the motivational group and 54.3% in the control group, which was statistically significantly different (p=0.034). Except for job satisfaction, no difference was found between the groups in terms of the characteristics of the nurses during the COVID-19 pandemic (p>0.05). During the COVID-19 pandemic, almost all nurses stayed in their own homes (motivational group: 97.6%, control group 97.8%). It was determined that 36.6% of the motivational group and 52.2% of the control group considered the isolation measures in their units to be sufficient and they similarly had no difficulty in finding personal protective equipment (PPE) (motivational group: 68.3%, control: 67.4%). The rate of diagnosing COVID-19 among colleagues was similar in both groups (motivational group: 97.6%, control group: 100%), and the rate of losing colleagues due to COVID-19 was 4.9% in the motivational group and 15.2% in the control group. Considering the volunteer working status of the nurses during the pandemic, 48.8% of the motivational group and 41.3% of the control group stated that they were willing to work voluntarily (Table 3) . Table 3 3 There was no statistically significant difference in the mean LOT scores between the groups before the motivational messages (p=0.050), but a statistically significant difference was found after the motivational messages (p=0.043). In the motivational group, the increase in LOT scores after motivational messages (22.2±3.5) compared with before (18.5±3.1) was statistically significant (p<0.001). In the control group, LOT scores of post-test (20.5±4.3) compared with pre-test (20.0±3.8) were found to be similar (p=0.536). There was no statistically significant difference between the motivational and control groups in the mean BHS scores before the motivational messages (p=0.214), but a statistically significant difference was found after the motivational messages (p=0.005). In the motivational group, the decrease in BHS scores after motivational messages (3.7±3.2) compared with the messages (6.6±2.8) was statistically significant (p<0.001). Although BHS scores decreased in the post-test (5.9±4.2) compared with pre-test (6.4±4.4) in the control group, the difference was not statistically significant (p=0.983). Although there was no statistically significant difference in mean SWLS scores before motivational messages between the groups (p=0.853), a statistically significant difference was found after the motivational messages (p=0.040). In the motivational group, the increase in SWLS scores after the motivational messages (17.4±2.0) compared with before the messages (14.2±2.3) was statistically significant (p<0.001). SWLS scores increased in the post-test (16.0±3.7) compared with pre-test (14.1±4.1) in the control group, and the difference was statistically significant (p=0.028) ( Table 4) . The COVID-19 pandemic has affected the whole world and adversely affected health systems. This has caused significant psychological pressure on nurses involved in the care of critically ill patients with COVID-19 (Shen et al., 2020; Muller et al., 2020) . In a comprehensive systematic review that examined studies to improve the well-being and mental health of healthcare professionals during the COVID-19 pandemic, it was reported that studies involving interventions to reduce mental health problems of healthcare professionals were limited and the effects of these interventions were not reported (Muller et al., 2020) . In Hong et al.'s study, (2020) , the stress levels of nurses who underwent comprehensive psychological intervention in the COVID-19 pandemic were found at an acceptable moderate level. In the same study, stress levels were associated with the health status of nurses and their families, the spread of the virus, and the concerns they experienced due to changes in their jobs (Hong et al., 2020) . In a study of the psychological problems experienced by nurses during the COVID-19 pandemic, it was stated that the stress and burnout levels of nurses were high and their depression levels were moderate. 8 Similarly, in other studies, it has been reported that a significant portion of healthcare professionals working at the forefront of the pandemic, especially nurses, experience high rates of anxiety, depression, insomnia, and distress (Pappa et al., 2020; Murat et al., 2021; Muller et al., 2020) . In the present study, it was determined that motivational messages significantly increased optimism levels in intensive care nurses during the COVID-19 pandemic compared with nurses who did not receive them, even though it was a single-site study. Although the COVID-19 pandemic causes various psychological problems for nurses, motivational support may have positive effects on nurses' life orientation. In the study of Yesilcinar et al., it was stated that intensive care nurses had a moderate level of hopelessness, and their job motivation levels were high (Yesilcinar et al., 2020) . In the present study, it was found that motivational messages sent to intensive care nurses had a significantly positive impact on hopelessness levels. It is thought that the nurses working in COVID-19 ICUs need motivational support and that the motivational support provided by professional members is effective in increasing the hope levels of nurses. Although intensive care nurses are satisfied with providing compassionate care to patients and their families, they are also at risk in terms of fatigue. The quality of professional life depends on the balance between compassion satisfaction and work fatigue (Jakimowicz et al., 2018) . In a study conducted with healthcare professionals during the COVID-19 pandemic, it was found that nurses had less compassion fatigue and burnout, and compassion satisfaction was higher than in physicians (Ruiz-Fernández et al., 2020) . In another study, it was found that intensive care nurses providing care to patients with COVID-19 had a high burnout level and a moderate level of life satisfaction. As the burnout levels of intensive care nurses increase, their life satisfaction levels decrease (Cin & Hosgor, 2020) . In the present study, the postintervention life satisfaction levels were found to be significantly higher in the nurses who received motivation messages than in those who did not. As a result of these studies, it is seen that intensive care nurses are at risk in terms of compassion fatigue during the COVID-19 pandemic, but motivational messages have an effect on their life satisfaction. The COVID-19 pandemic has had a significant impact on people's mental health and emotions and has also led to changes in coping strategies. The national measures and decisions taken in the COVID-19 pandemic are similar to those in the severe acute respiratory syndrome (SARS) epidemic process that emerged in Hong Kong in 2003. It is known that the mental state of nurses and the community is similarly affected (Liu et al., 2012) . In a study that examined healthcare workers in high-risk areas in Beijing for 3 years, post-traumatic stress symptoms associated with SARS were observed in 10% of the participants, mostly nurses (Wu et al., 2009 ). Owing to the experience gained from the SARS epidemic, Hong Kong has been managed the impact of COVID-19 on the mental health of nurses with effective the preventative measures. (Cheung et al., 2021) . In Spoorthy et al.'s study, the effect of the COVID-19 pandemic on the mental health of healthcare professionals and the interventions used for mental health were examined. The authors stated that healthcare professionals are less interested in professional help, pay more attention to social support and communication, and have fewer mental health problems with social support (Spoorthy et al., 2020) . Life satisfaction, hope, and optimism are the positive keys that enhance the psychological well-being of individuals. All three keys define a multidimensional approach such as professional life, family life, social life, and should be considered with a holistic approach (Rathore et al., 2015) . In Spoorthy et al.'s (2020) study, positive motivational factors such as supportive environment, positive role models, appreciation by peers/patients helped to increase the motivation of healthcare professionals (Spoorthy et al., 2020) . In the present study, it was determined that motivational messages sent to intensive care nurses in the COVID-19 pandemic had positive effects on nurses' mental health and well-being, increasing optimism and life satisfaction, and decreasing hopelessness. In line with the literature, it is seen that social support, communication, and motivation given to intensive care nurses working in the frontline during the pandemic are of great importance. There are some limitations that should be addressed with future research. First, the results obtained from this small single-site study are limited to the research participants, they cannot be generalized to all nurses working in COVID-19 ICUs. Besides, the study was conducted in a short time and the researchers cannot be sure that nurses continued with the intervention after the study. In addition, the intervention has short-term effects. There is a need for longitudinal research to determine the long-term effectiveness of motivational messages. Second, all data were based on nurses' self-reports. Moreover, before the research, the mental health status of nurses was not examined. Third, the researchers cannot be sure about the amount of participation in the intervention group such as applying the interventions written in the text, or cross-over effects from colleagues. Also, the participants could not be blinded due to the research design and demoralization and performance threats could be a limitation for validity. Obtained results distinguished that our hypothesis were confirmed and motivational messages sent to intensive care nurses during the COVID-19 pandemic increased their levels of optimism and life satisfaction, while decreasing levels of hopelessness. Motivational techniques applied to intensive care nurses during the pandemic have great importance for the nurses' mental health. It is recommended to increase professional and social support systems to improve the motivation and mental health of nurses working in pandemic wards. More evidence-based studies are needed to increase the motivation of intensive care nurses during the pandemic.  Intensive care nurses working at the forefront during the COVID-19 pandemic are negatively affected mentally.  Evidence-based studies are needed to increase the motivation of intensive care nurses during the pandemic. The data were collected before intervention. (n=0) Assessed for eligibility (n=120) This is a multicenter, randomized controlled, open-label study. The study was conducted with a total of 87 nurses working in the COVID-19 intensive care units of three hospitals in Istanbul. Motivational messages were sent via SMS to the participants in the motivational group (n=41) for 21 days. The data were obtained using a Personal Information Form, the Life Orientation Test, Beck Hopelessness Scale, and the Satisfaction with Life Scale. The nurses' mean age in the motivational and control groups was 28.4±7.6 and 26.9±3.7 years, respectively. Before the messages, no statistically significant difference was found between the two groups in terms of life orientation (p=0.059), hopelessness (p=0.214), and satisfaction with life (p=0.898) scores. After the messages, life orientation (p=0.042) and life satisfaction (p=0.040) scores were significantly higher in the motivational group compared with the control group, and the hopelessness score was significantly lower (p=0.005). According to our study, motivational messages sent to intensive care nurses during the pandemic increased their level of optimism and life satisfaction and decreased their level of hopelessness. The coronavirus disease (2019) COVID-19 pandemic has affected health systems globally and required healthcare professionals to perform at a high level. In this process, the mental health and well-being of intensive care nurses, who bear the greatest burden in health systems, is negatively affected. When factors that affected nurses were examined, they were the long working hours and high patient care burden, dealing with uncertainties due to COVID-19, and worrying about themselves and their families (Shen et al., 2020; Azoulay et al., 2020) . In countries where the number of cases is high and increasing, intensive care nurses have been affected primarily from a professional standpoint, but also mentally, emotionally, and socially (Hong et al., 2021; Pappa et al., 2020) . Nurses have to deal with many challenging situations throughout the day. These difficult situations may be caused by patients or relatives, colleagues, or organization-related (e.g. payment related, housing, staff shortages). In everyday life, they cause high stress among nurses, which can create burnout (Guo et al., 2018) . In a systematic review (2019), stress and burnout syndrome in critical care nurses was examined and it was emphasized that burnout syndrome was a serious problem for the healthcare system (Friganović et al., 2019) . High stress can turn into serious psychological problems such as post-traumatic stress disorder, depression, and anxiety disorder in the long term (Hong et al., 2021; Pappa et al., 2020) . When the literature is reviewed, pessimistic thinking, feelings of hopelessness, and anhedonia, which are considered among depressive symptoms, can be observed in intensive care nurses. The results of the study conducted by Shen et al., (2020) with 85 intensive care nurses showed that nurses had fatigue, decreased appetite, sleep problems, aggression, and suicidal thoughts, albeit at low rates (Shen et al., 2020) . In another study in the United States of America (USA), it was found that 80.1% of nurses experienced moderate/high stress, 43% had anxiety, and 26% had depression (Kim et al., 2021) . In the study conducted by Murat et al., (2020) in Turkey during the COVID-19 pandemic, it was found that the level of stress and burnout was high and the level of depressive symptoms was moderate among nurses (Murat et al., 2021) . As the COVID-19 pandemic continues, these symptoms are predicted to be higher in nurses who have not previously provided critical patient care due to the intensive care unit (ICU) patient volume (Shen et al., 2020; Pappa et al., 2020; Cheng et al., 2020) . Motivation affects the daily life of individuals, helps them to be ready and changes their behaviours. With this, motivation got affected from external factors such as life satisfaction, life orientation, and feeling hope (Rathore et al., 2015) . Change can be affected by using tools that increase motivation in individuals positively. Motivational messages are one of the tools that are effective, cheap, and easy-to-use, and help to increase the motivation of the individual. The literature shows that COVID-19 affects nurses' psychological well-being negatively. Besides, interventions to prevent mental health problems or promote mental health should be planned in accordance with the restrictions taken to prevent the spread of COVID-19. From the beginning of the pandemic, internet use has increased in many sectors such as health, economy, and education, and mobile phones are very effective in this increase (De' et al., 2020) . In the literature, mobile phone technology was used for individuals to help gain healthy behaviours and to improve disease management (Newton et al., 2018; De Vries et al., 2017; Xu et al., 2019; Hawkins et al., 2018) . Interventions other than motivational messages have been performed to increase the well-being of nurses via mobile phones. In China, call centres (30-minute interviews) provide healthcare professionals with support for their mental state and well-being. It was reported that interventions could help nurses with the problems experienced during the pandemic by supporting self-efficacy without the need for advanced intervention (Chen et al., 2020) . During the COVID-19 pandemic, using mobile phones can be the best option to support nurses, regardless of the location and time. Although several studies are mobile-message based (De Vries et al., 2017; Hawkins et al., 2018) , there is a paucity of data regarding the effectiveness of text message programs as a motivational tool. Therefore, we aimed to provide support to ICU nurses' mental health with motivational messages sent over the phone because increasing the mental health and well-being of nurses is as important as fighting the pandemic. Hence, the study's purpose was to examine the effect of motivational messages on optimism, hopelessness, and life satisfaction of intensive care nurses during the COVID-19 pandemic, and it was hypothesized that motivational messages would increase the nurses' life orientation and life satisfaction while decreasing hopelessness. RQ1. How did motivational messages affect ICU nurses' optimism during the COVID-19 pandemic? RQ2. How did motivational messages affect ICU nurses' hopelessness during the COVID-19 pandemic? RQ3. How did motivational messages affect ICU nurses' life satisfaction during the COVID-19 pandemic? This research was a multi-centre, open-label, randomized-controlled clinical trial. The study was conducted in accordance with the Consolidated Standards of Reporting Trials (CONSORT) and prospectively registered on clinicaltrials.gov.tr (No: blinded for review). This research was performed with nurses working in the COVID-19 ICUs of three training research hospitals and a university hospital, which were designated as pandemic hospitals and affiliated to the Ministry of Health in Istanbul between February 1 st , and March 1 st , 2021. The population of the study consisted of nurses working in the COVID-19 ICUs of these hospitals (n=120). The criteria for inclusion in the study were being a nurse, working only during the day shift on weekdays in the COVID-19 ICU, using a mobile phone, and accepting to participate in the study. In the institutions where the study was conducted, nurses work one month of night shifts and one month of day shifts according to the monthly working schedule. Nurses, who worked between February and March 2021 were included in the study. The exclusion criterion for the study was not fully completing the data collection forms. Randomization was performed using computer-based random sequence numbers (www.random.org). The random allocation sequence and the assignment of the participants to the groups were conducted by the researchers. Participants were numbered according to the order of inclusion in the study and assigned to the motivational group or control group according to random order numbers on the randomization list. Due to the research design, the principal investigator and patients were not blinded to allocation; however, the evaluator was blinded to the group allocation. Motivational group: Before starting the study, the opinions of the nurses working in the COVID-19 ICU about the content of motivational messages that would positively affect their level of optimism, hope, and life satisfaction were obtained. Motivational messages prepared by the researchers in line with the feedback received from the nurses were presented for expert opinions. Necessary arrangements were made with the recommendations of an expert team consisting of three nurse academics and two psychologists. The experts' evaluation was performed by considering the Davis technique (Davis, 1992) . Experts scored each statement on a scale of 1-4 (1=not suitable, 2=item needs to be tailored, 3=suitable, but needs minor change 4=very convenient). As a result of content validity, the messages consisted of 44 statements and the Content Validity Index of the content was found as 94%. Nurses were allowed to take a short break (5-10 minutes) by the head nurse and access messages after they heard the message tone at the time of notification. Motivational messages were sent to the mobile phones of the nurses in the motivational group at 09:00 AM, 12:00 PM, 05:00 PM, and 07:00 PM for 21 days (Table 1) . Different motivational messages were sent to the participants every day by the researchers. One-day sample motivational messages are shown in Table 1 . Table 1 Control group: Motivational messages were not sent to nurses in the control group, and they continued their routine work in the ICU. Nurses in the control group took breaks in accordance with their unit. Data in the study were collected online using a Personal Information Form, the Life Orientation Test (LOT), the Beck Hopelessness Scale (BHS), and the Satisfaction with Life Scale (SWLS). Due to the COVID-19 pandemic, the first meeting with the participants was held using an online platform, the participants were given the necessary information about the study and their consent was received. The Personal Information Form, LOT, BHS, and SWLS were administered to the participants before the interventions began (at the first day of the study) as a pre-test. At the end of the interventions (at the end of the 21st day of the study), the LOT, BHS, and SWLS were readministered to the participants as a post-test. The primary outcome of this study was the difference in life orientation scores between the two groups as measured using the LOT. The secondary outcomes were the difference in hopelessness scores and life satisfaction levels between the two groups as measured using the BHS and the SWLS. The 19-question personal information form, created by the researchers in line with the literature, included questions that would contribute to determining the sociodemographic characteristics of the individuals and their professional lives during the COVID-19 pandemic (Topuz, 2018; Polat et al., 2016; Atasoy and Turan, 2019; Yesilcinar et al., 2020) . Scheier et al., in 1994 . The Turkish validity and reliability study of the revised version of the test was conducted by Kahleoğulları in 2017. The test aims to reveal the differences between individuals in terms of optimism and pessimism. The test is evaluated as a 5-point Likert type (1: I do not agree at all, 5: I strongly agree). Items 3, 7 and 9 are scored in reverse. The lowest score that can be taken from the test is 6 and the highest is 30; low scores indicate pessimism and high scores indicate optimism. The Cronbach's alpha coefficient was 0.78 in the original study of the scale, and 0.75 in the study of Kahleogullari (Scheier et al., 1994; Kahleogullari, 2017) . In the present study, Cronbach's alpha coefficient was found as 0.71. The BHS was developed by Beck et al., in 1974. Its Turkish validity and reliability study was conducted by Durak and Palabıyıkoğlu in 1994 . The purpose of this scale, which was developed taking into account Beck's cognitive theory, was to determine the hopelessness level of individuals. The scale consists of 20 items and three sub-dimensions: emotions and expectations about the future, loss of motivation, and hope. The lowest possible score on the scale is 0 and the highest is 20, and the higher the score, the higher the hopelessness level of the individual. In the original study of the scale, the reliability coefficient of Kuder-Richardson-20 was 0.93. In Durak and Palabiyikoglu's study, the Cronbach alpha coefficient was found as 0.78 for emotions and expectations about the future, 0.72 for loss of motivation, and 0.72 for hope (Beck et al., 1974; Durak & Palabiyikoglu, 1994) . In the present study, Cronbach's alpha coefficient was found as 0.85. five items. In the Turkish version, it is a 5-point Likert-type scale and is scored between 1 and 5 (1: strongly disagree, 5: totally agree). The lowest score that can be obtained from the scale is 5 and the highest score is 25, and the higher the total score, the higher the life satisfaction level. In the original study, the Cronbach alpha coefficient was 0.87, and in the study of Dagli and Baysal it was 0.88 (Diener et al., 1985; Dagli and Baysal, 2016 ). In the present study, Cronbach's alpha coefficient was found as 0.76. The size of the study sample was calculated using the G*Power (v. 3.1.9.6.) program. A similar study using the Beck Hopelessness Scale was used for sample calculation (Topuz, 2018) . As a result of the power analysis (80% representation ability, α=0.05, and effect size=0.6), it was calculated that a total of 78 nurses would be required as a sample of 39 interventions and 39 as the control group. However, taking into account possible losses during the study, the number of participants was increased by 10% and 93 nurses were included, 44 in the motivational group and 49 in the control group. The study was completed with a total of 87 nurses (41 interventions and 46 controls) because three nurses from the motivational group and three from the control group did not respond to the final test ( Figure 1 ). The data obtained from the research were evaluated using the Statistical Package for the Social Sciences software package (SPSS-IBM Corporation v.24 Armonk, NY). Number, percentage, mean, standard deviation, median, minimum, and maximum values were used for the descriptive statistics of the study. The compatibility of the variables to normal distribution was evaluated using the Shapiro-Wilk test. Categorical data comparisons between independent groups of the study were analysed using the Chi-square test and Fisher's exact test. It was determined that the LOT and SWLS data showed normal distribution, whereas the BHS data were not normally distributed. In comparing the mean scores between the two groups, Student's t-test was used for variables with normal distribution, and the Mann-Whitney U test was used for variables that did not show normal distribution. Comparison of the pre-test and post-test mean scores of the groups were evaluated using the paired-sample ttest for data with normal distribution, and Wilcoxon's rank-sum test for data that did not show normal distribution. Variables were considered significant at the 95% confidence level and with p-values less than 0.05. were asked to answer the questions after first reading and approving this prepared statement. For data security, only individuals with the link were allowed to access the research questions; the participants' data was encrypted and only researchers were allowed access. The mean age of the motivational group and control group was 28.4±7.6 and 26.9±3.7 years, respectively. Women constituted 80.5% of the nurses in the motivational group and 73.9% of the control group. Considering their educational status, it was found that most of the nurses in both groups were undergraduates. It was determined that there was no statistically significant difference between the motivational group and control group in terms of sociodemographic characteristics (p>0.05) ( Table 2) . Table 2 11.2. The nurses' characteristics regarding their profession during the COVID-19 pandemic The years of experience as a nurse was 6.0±8.1 for the motivational group and 4.4±3.2 years for the control group, and the years of experience in the ICU was 4.4±6.0 and 3.6±3.1 years, respectively. Most (90.2%) of the nurses in the motivational group and 87.0% of the nurses in the control group worked in adult ICUs. The job satisfaction level of the nurses was determined as 31.7% in the motivational group and 54.3% in the control group, which was statistically significantly different (p=0.034). Except for job satisfaction, no difference was found between the groups in terms of the characteristics of the nurses during the COVID-19 pandemic (p>0.05). During the COVID-19 pandemic, almost all nurses stayed in their own homes (motivational group: 97.6%, control group 97.8%). It was determined that 36.6% of the motivational group and 52.2% of the control group considered the isolation measures in their units to be sufficient and they similarly had no difficulty in finding personal protective equipment (PPE) (motivational group: 68.3%, control: 67.4%). The rate of diagnosing COVID-19 among colleagues was similar in both groups (motivational group: 97.6%, control group: 100%), and the rate of losing colleagues due to COVID-19 was 4.9% in the motivational group and 15.2% in the control group. Considering the volunteer working status of the nurses during the pandemic, 48.8% of the motivational group and 41.3% of the control group stated that they were willing to work voluntarily (Table 3) . Table 3 There was no statistically significant difference in the mean LOT scores between the groups before the motivational messages (p=0.050), but a statistically significant difference was found after the motivational messages (p=0.043). In the motivational group, the increase in LOT scores after motivational messages (22.2±3.5) compared with before (18.5±3.1) was statistically significant (p<0.001). In the control group, LOT scores of post-test (20.5±4.3) compared with pre-test (20.0±3.8) were found to be similar (p=0.536). There was no statistically significant difference between the motivational and control groups in the mean BHS scores before the motivational messages (p=0.214), but a statistically significant difference was found after the motivational messages (p=0.005). In the motivational group, the decrease in BHS scores after motivational messages (3.7±3.2) compared with the messages (6.6±2.8) was statistically significant (p<0.001). Although BHS scores decreased in the post-test (5.9±4.2) compared with pre-test (6.4±4.4) in the control group, the difference was not statistically significant (p=0.983). Although there was no statistically significant difference in mean SWLS scores before motivational messages between the groups (p=0.853), a statistically significant difference was found after the motivational messages (p=0.040). In the motivational group, the increase in SWLS scores after the motivational messages (17.4±2.0) compared with before the messages (14.2±2.3) was statistically significant (p<0.001). SWLS scores increased in the post-test (16.0±3.7) compared with pre-test (14.1±4.1) in the control group, and the difference was statistically significant (p=0.028) ( Table 4) . Table 4 12. The COVID-19 pandemic has affected the whole world and adversely affected health systems. This has caused significant psychological pressure on nurses involved in the care of critically ill patients with COVID-19 (Shen et al., 2020; Muller et al., 2020) . In a comprehensive systematic review that examined studies to improve the well-being and mental health of healthcare professionals during the COVID-19 pandemic, it was reported that studies involving interventions to reduce mental health problems of healthcare professionals were limited and the effects of these interventions were not reported (Muller et al., 2020) . In Hong et al.'s study, (2020) , the stress levels of nurses who underwent comprehensive psychological intervention in the COVID-19 pandemic were found at an acceptable moderate level. In the same study, stress levels were associated with the health status of nurses and their families, the spread of the virus, and the concerns they experienced due to changes in their jobs (Hong et al., 2020) . In a study of the psychological problems experienced by nurses during the COVID-19 pandemic, it was stated that the stress and burnout levels of nurses were high and their depression levels were moderate. 8 Similarly, in other studies, it has been reported that a significant portion of healthcare professionals working at the forefront of the pandemic, especially nurses, experience high rates of anxiety, depression, insomnia, and distress (Pappa et al., 2020; Murat et al., 2021; Muller et al., 2020) . In the present study, it was determined that motivational messages significantly increased optimism levels in intensive care nurses during the COVID-19 pandemic compared with nurses who did not receive them, even though it was a single-site study. Although the COVID-19 pandemic causes various psychological problems for nurses, motivational support may have positive effects on nurses' life orientation. In the study of Yesilcinar et al., it was stated that intensive care nurses had a moderate level of hopelessness, and their job motivation levels were high (Yesilcinar et al., 2020) . In the present study, it was found that motivational messages sent to intensive care nurses had a significantly positive impact on hopelessness levels. It is thought that the nurses working in ICUs need motivational support and that the motivational support provided by professional members is effective in increasing the hope levels of nurses. Although intensive care nurses are satisfied with providing compassionate care to patients and their families, they are also at risk in terms of fatigue. The quality of professional life depends on the balance between compassion satisfaction and work fatigue (Jakimowicz et al., 2018) . In a study conducted with healthcare professionals during the COVID-19 pandemic, it was found that nurses had less compassion fatigue and burnout, and compassion satisfaction was higher than in physicians (Ruiz-Fernández et al., 2020) . In another study, it was found that intensive care nurses providing care to patients with COVID-19 had a high burnout level and a moderate level of life satisfaction. As the burnout levels of intensive care nurses increase, their life satisfaction levels decrease (Cin & Hosgor, 2020) . In the present study, the postintervention life satisfaction levels were found to be significantly higher in the nurses who received motivation messages than in those who did not. As a result of these studies, it is seen that intensive care nurses are at risk in terms of compassion fatigue during the COVID-19 pandemic, but motivational messages have an effect on their life satisfaction. The COVID-19 pandemic has had a significant impact on people's mental health and emotions and has also led to changes in coping strategies. The national measures and decisions taken in the COVID-19 pandemic are similar to those in the severe acute respiratory syndrome (SARS) epidemic process that emerged in Hong Kong in 2003. It is known that the mental state of nurses and the community is similarly affected (Liu et al., 2012) . In a study that examined healthcare workers in high-risk areas in Beijing for 3 years, post-traumatic stress symptoms associated with SARS were observed in 10% of the participants, mostly nurses (Wu et al., 2009 ). Owing to the experience gained from the SARS epidemic, Hong Kong has been managed the impact of COVID-19 on the mental health of nurses with effective the preventative measures. (Cheung et al., 2021) . In Spoorthy et al.'s study, the effect of the COVID-19 pandemic on the mental health of healthcare professionals and the interventions used for mental health were examined. The authors stated that healthcare professionals are less interested in professional help, pay more attention to social support and communication, and have fewer mental health problems with social support (Spoorthy et al., 2020) . Life satisfaction, hope, and optimism are the positive keys that enhance the psychological well-being of individuals. All three keys define a multidimensional approach such as professional life, family life, social life, and should be considered with a holistic approach (Rathore et al., 2015) . In Spoorthy et al.'s (2020) study, positive motivational factors such as supportive environment, positive role models, appreciation by peers/patients helped to increase the motivation of healthcare professionals (Spoorthy et al., 2020) . In the present study, it was determined that motivational messages sent to intensive care nurses in the COVID-19 pandemic had positive effects on nurses' mental health and well-being, increasing optimism and life satisfaction, and decreasing hopelessness. In line with the literature, it is seen that social support, communication, and motivation given to intensive care nurses working in the frontline during the pandemic are of great importance. There are some limitations that should be addressed with future research. First, the results obtained from this small single-site study are limited to the research participants, they cannot be generalized to all nurses working in COVID-19 ICUs. Besides, the study was conducted in a short time and the researchers cannot be sure that nurses continued with the intervention after the study. In addition, the intervention has short-term effects. There is a need for longitudinal research to determine the long-term effectiveness of motivational messages. Second, all data were based on nurses' self-reports. Moreover, before the research, the mental health status of nurses was not examined. Third, the researchers cannot be sure about the amount of participation in the intervention group such as applying the interventions written in the text, or cross-over effects from colleagues. Also, the participants could not be blinded due to the research design and demoralization and performance threats could be a limitation for validity. Obtained results distinguished that our hypothesis were confirmed and motivational messages sent to intensive care nurses during the COVID-19 pandemic increased their levels of optimism and life satisfaction, while decreasing levels of hopelessness. Motivational techniques applied to intensive care nurses during the pandemic have great importance for the nurses' mental health. It is recommended to increase professional and social support systems to improve the motivation and mental health of nurses working in pandemic wards. More evidence-based studies are needed to increase the motivation of intensive care nurses during the pandemic.  Intensive care nurses working at the forefront during the COVID-19 pandemic are negatively affected mentally.  Evidence-based studies are needed to increase the motivation of intensive care nurses during the pandemic.  Motivational messages sent to intensive care nurses during the COVID-19 pandemic have positive effects on nurses' optimism, hopelessness, and life satisfaction. The data were collected before intervention. Investigation of the relationship between midwives' and nurses' emotional labor and life satisfaction Symptoms of anxiety, depression, and peritraumatic dissociation in critical care clinicians managing patients with COVID-19. A cross-sectional study The measurement of pessimism: The hopelessness scale COVID-19 under the SARS Cloud: Mental Health Nursing during the Pandemic in Hong Kong Mental health care for medical staff in China during the COVID-19 outbreak COVID-19 tanılı hastalara bakım veren yoğun bakım hemşirelerinin yaşam doyumu ve tükenmişlik düzeyleri Adaptation of the satisfaction with life scale into Turkish: the study of validity and reliability Instrument review: Getting the most from a panel of experts Impact of digital surge during Covid-19 pandemic: A viewpoint on research and practice Experts get me started, peers keep me going: comparing crowd-versus expert-designed motivational text messages for exercise behavior change The satisfaction with life scale Beck umutsuzluk ölçeği geçerlilik çalışması Stress and burnout syndrome and their associations with coping and job satisfaction in critical care nurses: a literature review Burnout and its association with resilience in nurses: A cross-sectional study Web app-and text message-based patient education in mohs micrographic surgery-a randomized controlled trial Stress and psychological impact of the COVID-19 outbreak on the healthcare staff at the fever clinic of a tertiary general hospital in Beijing: a cross-sectional study Compassion satisfaction and fatigue: A crosssectional survey of Australian intensive care nurses Validity, Reliability and Factor Structure of the Turkish Versions of Purpose in Life Scale, Meaning in Life and Life Orientation Test-Revision Predictors of poor mental health among nurses during COVID-19 pandemic Depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic The mental health impact of the covid-19 pandemic on healthcare workers, and interventions to help them: A rapid systematic review Determination of stress, depression and burnout levels of front-line nurses during the COVID-19 pandemic A Church-Based Weight Loss Intervention in African American Adults using Text Messages (LEAN Study): Cluster Randomized Controlled Trial Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis The impact of the recruitment procedures, organizational commitment and hopelessness levels on their intention to leave the institution and nursing care Life satisfaction and life orientation as predictors of psychological well-being Compassion fatigue, burnout, compassion satisfaction and perceived stress in healthcare professionals during the COVID-19 health crisis in Spain Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): A reevaluation of the Life Orientation Test Psychological stress of ICU nurses in the time of COVID-19 Mental health problems faced by healthcare workers due to the COVID-19 pandemic-A review Hemşirelerin yaşam doyumu ve umutsuzluk düzeyleri arasındaki ilişki: Sabuncuoğlu şerefeddin eğitim ve araştırma hastanesi örneği Lecture presented at: 3.International 21. National Public Health Congress Lay health supporters aided by mobile text messaging to improve adherence, symptoms, and functioning among people with schizophrenia in a resource-poor community in rural China (LEAN): A randomized controlled trial Determination of relationship between moral sensitivity, job motivation and hopelessness in intensive care nurses The psychological impact of the SARS epidemic on hospital employees in China: exposure, risk perception, and altruistic acceptance of risk