Nurses as the leading fighters during the COVID-19 pandemic: Self-transcendence

Abstract

Background

The Covid 19 pandemic has led to and continues to pose challenges for healthcare systems globally, especially in intensive care units. This research was conducted to examine the self-transcendence of the leading fighters, intensive care nurses, during the Covid 19 pandemic.

Methods

The descriptive phenomenological research method was used in the study. The research was carried out between June and December 2020 with the nurses who care for Covid 19 patients in the Covid 19 intensive care service in different provinces of Turkey. The research was completed with 25 participants. A semi-structured interview form prepared based on the Theory of Self-Transcendence (vulnerability, self-transcendence, and well-being) and based on the literature was used to collect data.

Ethical considerations

Ethical requirements were respected in every phase of the research process. Results: The nurses in the study were found to experience vulnerability due to “administrative loneliness,” “inability to give care,” “fear of being a source of infection,” and “loneliness of patients.”

Conclusions

It has been found that “improvement in nursing roles and skills,” “being proud for oneself and the team,” “understanding the value of life,” and “feeling like a superhero due to the responsibilities shouldered during the pandemic” support nurses’ self-transcendence, which contributes to physical and mental well-being.

Introduction

Nurses, who are indispensable members of the intensive care unit team, have a professional, legal, and ethical obligation to work in constant and close contact with patients. Fulfilling these obligations in the best way possible has become even more important due to the inability of family members to be involved in the care of patients who need treatment due to Covid-19, the obligation of nurses to work long hours under pandemic conditions, and the risk for themselves and their relatives due to the nature of their work.¹ Lord et al. (2021)² state that the willingness of nurses to provide care during the pandemic may be affected by their perceptions of the risk of exposure to Covid-19 and their concerns about the health of family members. The fact that nurses witness the suffering and death of Covid-19 patients can further increase their fear and anxiety.³ Although low levels of anxiety are helpful for motivation in various life situations, persistent anxiety negatively affects both physiological and psychological health.⁴ Unmanaged anxiety can have long-term negative effects on the job performance and job satisfaction of nurses, leading to reluctance to work, an increase in the use of leaves or reports, and ultimately their cease of employment.⁵ People find meaning in the difficulties of life despite their negative effects. Again, in these difficult times, people expand their boundaries, grow spiritually, and connect with the others around.

The Covid 19 pandemic has led to and continues to pose challenges for healthcare systems globally, especially in intensive care units. Many studies have been conducted to address the vulnerabilities of nurses during the Covid 19 epidemic.^3,11-13 However, the number of studies examining nurses’ self-transcendence is limited. In the study of Liu et al., (2020)¹⁴ with health workers and in the study of Sun et al. with nurses (2020),¹⁵ the difficulties of taking part in the Covid 19 epidemic and the coping methods used by the participants in the face of these difficulties were discussed; however, the effect of self-transcendence on their well-being was not been adequately addressed. This research was conducted to examine the self-transcendence of the leading fighters, intensive care nurses, during the Covid 19 pandemic.

Theoretical framework

With the Theory of Self-Transcendence, Reed (2011)⁶ aims to provide a framework for research and practice on enhancing well-being particularly in difficult life situations, where individuals and families face a loss or a life-limiting illness. The theory has three basic concepts: self-transcendence, well-being, and vulnerability. Self-transcendence is an individual’s capacity to expand one’s own boundaries into a more mature, broader perspective of life. According to the theory, self-transcendence is possible when one expands his or her boundaries through internal (by acquiring greater awareness of one’s philosophy, values and dreams), interpersonal (by relating to others and the environment), temporal (combining the past and future in making sense of the present), and transpersonal (capacity to reach higher goals or spiritual dimensions) means. The self-transcendence state of the individual is expressed through various behaviors and perspectives such as sharing wisdom with others, accepting death as a part of life, helping others, learning about the world, and finding spiritual meaning in life.⁷ Well-being is defined as the feeling of feeling whole and healthy in line with one’s own integrity and health criteria. Life satisfaction, positive self-concept, hopefulness, happiness, and sense of meaning in life are expressed as well-being indicators. The self-transcendence state of individuals contributes to well-being.⁸

Vulnerability, another basic concept of the theory, includes individuals’ awareness of death or the experience of difficult life events. It is thought that life events that increase the inadequacy and vulnerability of individuals may initiate progress toward a renewed sense of identity and expanded self-boundaries. Self-transcendence mediates the effects of vulnerability (illness, lack of hope or strength, uncertainty, and death anxiety) on well-being. This explains how well-being is possible in life-threatening situations that people endure. According to the theory, in addition to these three basic concepts, personal and contextual factors also affect well-being and can increase or decrease the relationship between the three basic concepts. Examples of these factors are age, gender, cognitive ability, health status, significant past life events, personal beliefs, family support, and sociopolitical environment.⁷

Self-transcendence, which has been indicated to accompany serious life experiences that intensify one’s sense of vulnerability or death, is a concept related to the nursing discipline.⁷ In another study by Hunnibell et al. (2008)⁹ on nurses’ burnout syndromes and self-transcendence, it was revealed that self-transcendence is a resource for nurses and can protect them against burnout. Palmer et al. (2010)¹⁰ revealed a significant positive relationship between acute care nurses’ work engagement and their self-transcendence. It has been determined that nurses increase their self-awareness and internal consistency through their self-transcendence and make sense of difficult working situations.

Methods

Research design

The descriptive phenomenological research method was used in the study.¹⁶ In the reporting of the research, the Consolidated Criteria for Reporting Qualitative Research-COREQ was used as a guide.¹⁷

Participants and sample

The research was carried out between June and December 2020 with the nurses who care for Covid 19 patients in the Covid 19 intensive care service in different provinces of Turkey. The participants were determined using the snowball sampling method. Being willing to express oneself and being reflective were used as the criteria for selecting the nurses to be interviewed. The snowball sample selection was initiated with a nurse known to the research team, who works in the Covid 19 intensive care unit of the university hospital in the province where the researchers live. Information about a nurse working in another intensive care unit (not limited to the hospitals of the province where the research was conducted) and meeting the criteria was requested from each interviewed nurse. In this way, a total of 25 nurses working in the Covid 19 intensive care unit were reached.

In qualitative research, the sample size varies according to the participants’ ability to provide sufficient information.¹⁸ For this reason, the number of participants to be included in the study cannot be determined before the research, and data collection is terminated when the data start to repeat itself and new data do not emerge.¹⁹ In this study, data collection was terminated shortly after the data started to recur. The research was completed with 25 participants. The mean age of the intensive care unit nurses participating in the study was 29.9 ± 5.5 (min:23, max:42) and seven of them were male. The mean total years of experience was 7.9 ± 4.8 (min: 0.3, max: 18). 2.9 years (min: 0.6, max: 10) of this period has been in the intensive care unit, and the mean duration of working in the Covid 19 intensive care unit is 3.9 months (min: 2, max: 9). Of the participants, 11 of whom are married, seven work in mega cities and the others work in four different cities.

Data collection tools

A semi-structured interview form prepared based on the Theory of Self-Transcendence (vulnerability, self-transcendence, and well-being) and based on the literature was used to collect data. At the beginning of the semi-structured interview form, some preliminary questions such as age, marital status, total years of experience in the profession, duration of working in the intensive care service, duration of working in the Covid 19 intensive care unit were asked. Then, 15 questions (Do you remember the first time you were told that you would work in the Covid 19 unit? What worried you the most about caring for a patient diagnosed with Covid 19 in the first days of the pandemic? Did you think you were competent enough to care for a patient diagnosed with Covid 19 in the first days of the pandemic? How did you manage to stay good/healthy during the Covid 19 pandemic? What changes have occurred in the meaning and purposes of your life during the Covid 19 pandemic? How did these changes in the meaning and purposes of your life during the Covid 19 pandemic affect your nursing care? What kind of developments do you think there are in your life? What is the general experience of being a nurse in the Covid 19 pandemic? etc.).^14,20,21 In addition to these questions, a series of questions (Can you elaborate on this more? How did you feel about this?) was included in the interview, which encouraged the participants to answer or provide clarification.

Data collection

The data were collected through telephone interviews with intensive care nurses due to the risk of transmission of New Covid 19. A voice recorder was used in the interviews with the permission of the participants. The interviews lasted an average of 35 min (min.30, Max:56), a total of 875 min. The recorded data were then transcribed. The transcription of the interviews was 138 pages. In the transcription of the data, behavioral data of the participants (laughing, distress expressions, crying or silence/pauses, etc.) were also recorded in order to increase data quality.

Data analysis

A combination of inductive and deductive analysis was used to analyze the data. First of all, irrespective of the Self-transcendence Theory (inductive), the data were analyzed using Colaizzi’s data analysis method of descriptive phenomenological studies.²² Based on this method, first, the data were read independently by the researchers to get familiar with their experiences of self-transcendence. In the second step, the researchers identified the expressions directly related to the nurses’ self-transcendence experiences. In the third step, important expressions were carefully examined and the resulting meanings were determined. Each important quotation selected from the texts was coded one by one and the meaning integrity was tried to be ensured. In the fourth step, the researchers created themes and sub-themes from experiences with common meanings. In step six, the comprehensive explanations that were created were turned into short, condensed statements that capture only those aspects considered essential to the structure of the phenomenon. Finally, in the seventh step, interview transcripts, codes, and themes were sent to three random participants to receive feedback on the relevance of the findings. The themes and sub-themes formed at this stage are as follows:

Three themes and eight sub-themes that we obtained using Colaizzi’s steps are shown in Figure 1. Under the theme of maturation through difficult experiences are the sub-themes of (1) different experiences, (2) cooperation, and (3) interpretation. Under the theme of adaptation are the sub-themes of (1) physical and (2) psychological adjustment. Under the theme of difficulties encountered are the sub-themes of (1) professional challenges, (2) familial challenges, and (3) vulnerability. In the second stage of data analysis, the inductively obtained themes were associated deductively with the components of the self-transcendence theory (Figure 1).

Figure 1.

Themes, and sub-themes of the qualitative analysis.

Ethical considerations

Prior to the research, approval was obtained from the Social and Human Sciences Ethics Committee of Ondokuz Mayıs University (2020/385). In addition, necessary legal permissions were obtained from the Ministry of Health in order to carry out the study. The purpose of the study was explained to the participants, and the volunteers were included in the study. The participants from different hospitals and provinces included in the study were given codes to ensure data confidentiality. In addition, the researchers who analyzed the data do not have information about the identity of the participants.

Validity and reliability of data

In qualitative research, validity and reliability are related to the accuracy, replicability, reliability, transferability, and confirmability of scientific information.²³ For this reason, the draft interview form created using open-ended questions was presented to the experts on qualitative research before the application. The purposive sampling method was used, and once the interviews with the participants were completed, the audio recordings were written down word for word. In the content analysis, the relationship between the themes and the sub-themes that make up these themes was checked and integrity was ensured. Two researchers analyzed the data independently to check the reliability of the findings, and during the coding process, opinions were exchanged about the suitability of codes obtained from the data repeated more than once.

Results

Data analysis revealed three themes and sub-themes and categories grouped under these themes. Findings are discussed under the headings of self-transcendence, well-being, and vulnerability. (Figure 2)

Figure 2.

Themes, sub-themes, and self-transcendence as a result of the qualitative analysis.

Self-transcendence

Under the heading of self-transcendence experiences of nurses working in the intensive care unit in the pandemic, the following sub-themes were revealed: “improvement in nursing roles and skills” under the sub-heading of self-transcendence through the internal path; “being proud of oneself and the team” under the sub-heading of self-transcendence through the interpersonal path; “understanding the value of life” under the sub-heading of self-transcendence through the temporal path; and “feeling like a superhero” under the sub-heading of transcendental self-transcendence.

Inner path

Participants’ statements describing self-transcendence through the internal path were analyzed under the heading of “improvement in nursing roles and skills.”

Improvement in nursing roles and skills

Nurses’ statements describing self-transcendence through the internal path were analyzed under the heading of “improvement in nursing roles and skills”. 12 nurses working in the intensive care unit stated that there has been an improvement in nursing roles and skills during the Covid 19 epidemic. The statements of a nurse emphasizing the improvement in her decision-making skills and managerial role are as follows:

“…I think my decision-making ability has improved a little bit more. Nurses have a managerial role… I think my role in preparing the patient for intubation, preparing the environment, and communicating with the team has improved…” (P3).

Some nurses stated that they gained experience in the fight against the pandemic and learned how to stay strong psychologically.

“…You are racing against time. The maximum time you can endure with the protective equipment next to the patient is threehours, and you have to do everything you can do in this time at the speed of light. So you become so practical. We are now great in planning (P9).

“…I now know very well how I should intervene in critical moments and how I should stay strong psychologically…“(P11).

Participant 25 expressed this improvement as follows:

“…Our experience in nursing has increased. We gained experience in the fight against pandemics…”

The statements of a nurse who turned to her inner self and questioned the conscientious dimension of her professional efforts in her experience of being a nurse in the pandemic are as follows:

“…We work with empathy. Therefore, we did not say ‘Let’s not do this not to catch the virus’, so I have peace of mind at the end of the day. We did everything we could. We took that risk. Since our profession is a profession that requires dedication, I do this job with love. Doing it with love contributes to success…” (P23)

12 nurses reported that they learned more about the disease after they started caring for Covid 19 patients, and they understood how they should approach the disease and patients. They stated that the uncertainty in their minds about the care process disappeared and it was replaced by experience. They stated that they got used to this situation and fulfilled the requirements of professionalism:

“…We didn’t have Covid-positive patients for a month, but now they started to come again. In the beginning, I did not want to go to the hospital at all, but now I am comfortable. Since I know how I can deal with the patient and make my plans, I am not afraid anymore. I can say that I no longer hesitate to care for a positive patient…” (P3).

“…The pandemic was a total uncertainty for me at first because we watched what was happening in other countries, we saw people who fell and died while sitting on the bench. Then when we started dealing with patients, that uncertainty gradually disappeared. Experience took its place over time. Now, sometimes they say this patient has Covid, but as soon as we see the patient, we say, ‘There is nothing wrong with this patient. You see he has normal respiration…” (K19).

P9 expressed her experiences regarding the illness and the uncertainty and overcoming of the uncertainty regarding the nursing care when the pandemic first started:

“…I was on guard duty at the beginning of the pandemic and I felt so bad. I had a stomachache like a child starting elementary school. But now I am doing my best. I’m just not in this situation. Many people are in this situation. Frankly, I’m going a little more comfortably because I’m doing my best. I got a little more used to it. I also learned to integrate this into my life…“.

A nurse stated that she got used to giving care to Covid-19 patients over time, and she was happy about the positive consequences of the effort she exerts:

“…As the process progresses, you get used to how the disease affects patients and how you can respond when you provide care. In other words, you get used to the disease. You do your best to do the right thing, and when you get the reward, you feel so happy… (P16).

Interpersonal path

Participants’ statements describing self-transcendence through the interpersonal path were analyzed under the heading of “being proud of oneself and the team.”

Being proud of oneself and the team

17 of the participants stated that nursing is a profession that requires self-sacrifice; when they see patients recover with the treatment and care they provide, they become happy; and the improvements in the patients as a result of the interventions motivate them and give them hope;

“…Nursing is a rewarding profession. It’s a very tiring job. We have a difficult job, but we did our job well. It was a time when I said ‘How lucky I am! I have this profession’. You learn that you do not go to work just to kill time. You do this job to “add life”. Let’s not just think about deaths and bad results, because we have had very positive feedback thanks to the nursing care we have provided. It makes me happy to see that the patients who were in very serious conditions are recovering…” (P16)

They stated that they did their best with their teammates in their challenging duties during the Covid 19 pandemic, and therefore they were proud of themselves and their team.

“…To tell the truth, I am happy to take part in this war. I am with my friends, I struggled with them. That’s why I’m proud of myself and my friends…” (P5).

“…When there were things that I did not understand, my teammates were supportive. Great wars were fought in intensive care units, and they are still being fought. This is a great teamwork…” (P21).

Temporal path

The statements of the nurses working in the intensive care unit describing their self-transcendence through the temporal path were gathered under the heading of “understanding the value of life.”

Understanding the value of life

Almost half of the participants who worked in the intensive care unit during the Covid 19 epidemic stated that they understood how important it is to be together and breathe in this process. They stated that health is more important than anything else and that death can come all at once. They reported that they understood the importance of living in the moment during the pandemic. The words of a nurse who stated that she understood that breathing is a great blessing are as follows:

“…We really missed our family. I haven’t seen their faces in two months. I just talk to them on the phone. I understood how important they are for me. I realized how valuable it is to sit face to face and talk and do something together. After seeing the condition of the patients, we understood that we live on thin ice. We saw how difficult it became to breathe just because of a tiny virus. It is very nice to breathe; it is a great blessing…” (P1).

P3 defined the importance of living in the moment through the past and present experiences of patients who suffered respiratory distress due to Covid-19:

“…Health has become the most important possession. The experiences those people have had here… It’s a difficult process when the person who you thought was perfectly healthy three days ago, who, you thought, could walk around with his friends, suffocates in front of you. You automatically say that health is an important blessing. You understand its value…”

Transpersonal

The statements of the participants describing their transpersonal self-transcendence were gathered under the heading of “feeling like a superhero.”

Feeling like a superhero

Seven nurses working in the intensive care unit stated that they knew the patients treated in the intensive care unit had no other choice but themselves.

“…that was my duty. Just as when a war breaks out, sorry I get so emotional about this (crying)… and we knew that we should not leave the field, just as the police or soldiers do not leave the field. I was also aware that these patients had no other choice but us…” (P3).

The nurses stated that they felt like superheroes from time to time during this difficult process of caring for Covid 19 patients:

“…Sometimes we felt like superheroes. The patient has no contact with any of his relatives. The patient depends on you, and you have to meet all his needs…” (P1).

Well-being

In the study, physical and mental well-being themes emerged under the theme of well-being.

Physical well-being

Ten nurses stated that they paid attention to regular nutrition in order to increase their resistance and continue to work in difficult conditions during the Covid period, and they took supplements to increase their immunity. The statements of the nurses on this aspect of well-being are given below.

“…I took care of my diet. I tried to regulate my sleep because we heard that sleep and rest are very important to improve immunity. We took supplements. We took vitamin C, immune booster daily pills. All of us received vitamin C in intensive care…” (P2).

Mental well-being

15 nurses stated that they played games and took part in some entertaining and leisure activities at home during the Covid 19 pandemic to maintain their mental well-being. Most of the nurses have acquired new hobbies such as painting, riding a bicycle, and learning to use an instrument. One participant stated that she did not want to wear herself out more by constantly thinking about Covid 19:

“…We took up hobbies that we can do at home. We found activities that we can do alone. I tried painting. I tried to learn how to make handicraft. After constantly thinking about Covid and going through that process, you get worn out. When we engage in different leisure time activities, we relax a little. We also tried to communicate with our close friends and relatives by phone…” (P1).

Some nurses, on the other hand, stated that they motivated themselves by believing that this difficult process would end, like everything else, and they reduced their anxiety by learning about some religious practices and the disease. In this way, they were motivated and were able to cope with the process:

“…We will eventually overcome this pandemic. Hope is the most important thing. We hoped. Hopefully, we will continue fighting without losing our hope…” (P25).

Vulnerability

Three themes were identified under the title of vulnerability, which are professional, familial, and patient vulnerability. Professional vulnerability includes the sub-themes of “administrative loneliness” and “inability to care”. The theme of familial vulnerability includes the sub-theme of “fear of being a source of infection.”

Professional vulnerability

The professional vulnerabilities of nurses working in intensive care units are grouped under the headings of “administrative loneliness” and “inability to provide care.”

Administrative loneliness

Eight nurses stated that they could not receive the support they expected from the hospital administrators during the time they worked in the Covid 19 intensive care unit. It is understood from the statements that nurses’ expectations of support are mostly psychological support, and the fact that nurse administrators stayed away from the clinic has affected other nurses negatively. The statements of P7 on this subject are as follows:

“…Nobody talked to us. Our intensive care unit was directly turned into Covid intensive care unit. You know, they have never said “Dear friends, you can overcome this”. They want us to do everything. I don’t know, but the head nurse could have come and checked on us. After all, she is also a nurse and I’m working in one of the most important intensive care units in this process. They came once as far as I remember, but they wore a lot of masks, they seemed very nervous, which was not expected of a head nurse…”.

The nurses stated that the responsibility was mostly on their shoulders during the pandemic and they could not see the support and value they expected. P23 explained his sensitivity on this issue with the following words:

“…I knew that we have a very important profession, and I understood it better. We were officially at war. Nursing is very, very different. Our value should have increased. The expected value was not given. We need more motivation and support, be it psychologically or socially…“.

Pointing out that care requires being with the patient for a longer period of time, P24 stated that the necessary importance was not given to this with the following statements:

“…Nurses have the heaviest burden among all the healthcare staff because the doctor makes his 5 minute visit and leaves. As a nurse, you have to take care of the patient, you have to feed the patient, you have to change the diaper. If the patient has a pain, you have to relieve it. You give blood, and you have to wait to see if there is risk of allergy. I think 95% of the responsibility was on the shoulders of nurses. Nobody mentions this…”.

Eight nurses stated that they were concerned about whether the protective equipment was sufficiently protective at the beginning of the pandemic and the continuity of the supply of protective equipment:

“…I felt fear, just fear because I wondered if they would be protective enough. I was thinking whether we were taking adequate precautions and whether we would be given enough protective equipment. I thought we were not protected enough…” (P12)

Inability to care

Eight participants stated that they felt inadequate because Covid 19 is a new condition and there is no known treatment and care. Some of the expressions of inadequacy experienced by nurses are given below.

“… (at the beginning of the pandemic) I don’t think I was capable because I was afraid too. This is the first time we have encountered such a thing. As the world, we have faced such an epidemic. We were all worried. I don’t think we were capable at that point…” (P5).

Feelings of not being adequate for patients were also shared by P12:

“…We were trying our best to relieve our conscience, of course, but there is always a feeling of inadequacy because you can’t reduce the patient’s complaints anyway. You do your best, but you think that you cannot support the patient…”

P16, on the other hand, stated that the continuation of the patient’s complaints despite all the efforts supports the feeling of inadequacy and makes him mentally tired:

“…From the patient’s perspective, I did know which position I should give. I didn’t know which position would be better. …I didn’t know if the treatment would work. …. I didn’t do anything very confidently. But we are here, we are trying to do our job in the best way. I work in tertiary intensive care. I faced many traumatic events, deaths. None of my patients would come and say ‘how are you’ and suddenly die within 24 hours. …Similar things were happening, but very rarely. But while most of these patients were people we could come and communicate with by talking, we were tired because they were getting worse and dying in a very short time. In every sense…” (P16).

P20 stated that patients’ fears worsened the situation and their increased expectation for help caused them emotional strain as follows:

“…I had a very hard time emotionally. They come with fear. I’m sure most of them are worsened by fear anyway… so I’m witnessing that too. In this case, I feel inadequate. No matter how much we talk and no matter how much we empathize, they always expect more from us and not being able to meet these expectations affects people badly. …”.

P22, on the other hand, stated that she questioned himself by asking herself “What else could be done?”:

“…I wondered if it was something that was caused by us when there were patients who could not recover. “Can anything better be done? Can’t we do better things?” one thinks, but we try to do the best in line with what our conditions require. Frankly, I had clear conscience when I was leaving the intensive care unit…”.

Familial vulnerability

Familial vulnerabilities of the participants were grouped under the heading of “fear of being a source of infection.”

Fear of being a source of infection

Ten nurses stated that due to their duties during the Covid 19 pandemic, they were worried that they would infect their families and society with the virus, that they paid attention to this, but were afraid.

P16 said, “…My biggest concern was to be infected with the virus and carry it to the people I love. Not only we but also people around us were at risk because we could carry the virus...”

P15, who is married, said, “…I am married. My wife is pregnant. She was on leave at that time. My only anxiety was to take the virus home…”.

Patient vulnerability

Nearly half of the nurses stated that they were psychologically affected by the fact that patients could not see their relatives due to the risk of infection and they walked to death alone, which caused them to feel helpless. In this regard, P2 said:

“…Patients were dying alone. This wore us out the most. Even now you have goose bumps. They came with no one. We didn’t know who they were. We were just writing “Covid-19” in their files. They are alone and there is only you; you have to cope with whatever problems they have, and their loneliness affects you more psychologically. You feel as if they are lonely, as if they are dying in such a dark place…” (P2).

P7 stated that the limited number of visits to the patients at the beginning of the pandemic may have made the patient feel lonely and fearful with the following words:

“…I thought the patients were very lonely. Normally we go right in when something happens. There were also some conscious patients. We used to visit the patients twice at first. In the morning and in the evening only. They were all alone. I’m sure they were afraid. I felt sorry for them about that…“.

Personal and contextual factors

The study revealed that the personal and contextual factors that come to the fore in nurses’ self-transcendence experiences during the pandemic are experience and living with the family.

Experience

Two nurses stated that they were new graduates and five nurses did not have intensive care experience, which affected them negatively.

“…I started intensive care in mid-April. In May, I was transferred to the Covid 19 intensive care unit. I constantly consulted the nurses working with me. I know they were fed up with me sometimes, but there was nothing I could do because I am new, I have not enough experience and we are going through a pandemic. I’m a new graduate; it’s been like 10 months. And I have no previous experience…” (P6).

P24 stated that feelings of inadequacy due to not being experienced were a challenging experience for them:

“…I was very upset when I saw the patients. An indescribable feeling. On the one hand sadness, and on the other hand the desire to help. The feeling of not knowing something because I have no intensive care experience. We helped patients with these feelings. Intubation, respiratory problems, arrests…all these were really bad…“.

In this process, family support increased their strength of endurance: “…Our family offered great support during this period. We kept going strong thanks to their emotional support…”(P21).

Living with the family

11 nurses stated that living with their families affected them negatively due to the fear of infection, and the other people also had an effect on this.

“…The people around me were telling me things like ‘Don't come home, stay away from your husband because he may catch the illness because of you’. Such stataments wore me out psychologically in that process…“(P3).

P5 stated that having a chronic disease in the family contributed to the fear of infection:

“…I have to come home. There are people with chronic diseases in my family, so I was afraid that something would happen to them…”.

Nurses with children stated that they were adversely affected by this process for fear of transmitting the disease to their children.

“…I was nervous, and I was about to cry even if I didn’t show it at first. My children are small and I have not been able to push them away from me. I experienced such distress, fear, anxiety…”(P8).

However, nurses living alone described this situation as luck in this process:

"…I live alone. That’s why I always felt luckier and more comfortable because I didn’t have to worry about infecting someone else…“(P18).

Discussion

The first theme of the study is self-transcendence, which consists of four sub-themes. Self-transcendence is a fundamental human trait associated with self-actualization and living a meaningful life. It is known that individuals with a high level of self-transcendence experience less depression.¹⁰ The nurses participating in the research stated that they experienced a pandemic for the first time and that there was an improvement in nursing roles and skills in this process. The nurses particularly stated that their critical decision-making skills have improved, they are more practical and planned, and they have gained experience in the fight against pandemic. They interpreted the motivating factors in the development of these roles and skills as “staying psychologically strong” and “not having the luxury of losing time when the situation is urgent” as well as “meeting the demands of the process.” The inner path of self-transcendence has been observed in the nurses every day with the search for conscience “from not wanting to go to work to going to work without any worries” and “not to do something while trying not to be infected with the virus.” In the studies conducted with nurses during the Covid-19 pandemic, it has been revealed that there is significant growth in the skills of developing professional responsibility and self-reflection²⁴ and that healthcare workers gain knowledge, skills, and experience.²⁵ In their study with nurses, Sun et al.¹⁵ stated that nurses were more self-sacrificing and more in solidarity with their teammates during the pandemic. Another study²⁶ which investigated the care experiences for Middle East respiratory syndrome-corona virus (MERS-CoV) patients determined that nurses were proud of providing high-quality care and fulfilling their responsibilities, and demonstrated a good teamwork. In addition, it was stated that the professional solidarity among the nurses who took part in the pandemic is higher than ever.

The repeated exposure of nurses working in intensive care to human deaths during the Covid 19 pandemic leads to an increased awareness of their own mortality (vulnerability). In this study, the nurses working in the intensive care unit stated that they realized the importance of health during the Covid 19 pandemic, comprehended the importance of breathing and living in the moment, and were proud of themselves for taking part in this difficult struggle as an individual and as a team. Their belief in recovery and healing, which is inherent in nursing, has increased. Such awareness and growth is in line with nurses’ definition of self-transcendence through the temporal path, which Reed describes as “the process by which past experiences are linked to the future so that they can give meaning to the present.” The participants stated that after they started to care for individuals diagnosed with Covid 19, they had more knowledge about caring for Covid-19 patients, uncertainty was replaced by experience over time, and they learned to cope with the process, which describes the process of how the relationship between “vulnerability, self-transcendence, and well-being” is modified and facilitated by the environment they are in. The nurses stated that the state of transcending oneself, expanding beyond the self to something higher (a spiritual state of being) made them feel like a “superhero.” The superhero metaphor is accompanied by feelings of elevation, such as awe, enthusiasm, and feeling elevated/high, which are the characteristics of self-transcendence. Thus, the nurses work not with an extrinsic motivation, reward, or demand, but with intrinsic motivation guided by the awareness that the COVID-19 patients have no other choice but them, and they focus more intensely on doing the right thing. This finding is similar to the findings of Monjazebi et al.²⁷ stating that “nurses approach patients more sympathetically and provide better care to meet all their needs because patients are lonely and do not know how to fight infection.” Similar to our study, Abuhammad et al.²⁸ also state that nurses have been seen as heroes by many people due to their responsibilities during the pandemic, and at the same time, nurses defined themselves as heroes. The study of Mohammed et al.²⁹ examined the effects of heroic discourse on nurses struggling with the COVID-19 crisis, and found that this discourse is not a neutral expression of appreciation and sentimentality, but a tool used to achieve multiple purposes such as the normalization of nurses’ exposure to risk, the practice of model citizenship, and the protection of existing power relationships that limit ability. However, few studies have problematized the hero discourse in nursing and examined the effects of this discourse on the professional, social, and political identities of nurses.^30,31 In another study, the investigation of the role of the media’s portrayal of nurses as heroes in times of crisis in the superhero perception of nurses will be a guide for the in-depth understanding of the subject.

The nurses stated that they paid attention to regular sleep and nutrition during the pandemic to ensure their physical well-being, and that they took supplements to support their immunity. It is seen that similar practices were also done by the nurses working during the Covid 19 pandemic.^14,15 Reed claims that with self-transcendence, a greater awareness of the spiritual and existential realms is displayed.³²

The nurses reported that in order to ensure and maintain their mental well-being, they have turned to personal and professional activities that will ensure positivity instead of focusing on the destructiveness of Covid-19. Watching comedy movies,^14,15,27 singing, dancing,²⁷ listening to music,¹⁵ praying, meditation,^15,27 often thinking that they are treating people or that the pandemic will be gone oneday, watching news about Covid 19 less¹⁵ reading books and keeping a diary^14,15 are some of these activities. The nurses used coping strategies that they deem appropriate for them in the difficult process they were in.

“Vulnerability” Reed²⁰ which is characterized by the awareness that life is deadly when people’s needs for others are not met in situations where the risk of deterioration of health or even the end of life is high or in other vital crises, can be reinforced in both patients and healthcare professionals. The nurses in this study stated that they did not receive the support they expected from the administrators during the pandemic and that they had difficulty in finding themselves valuable as workers. The administrative attitude stated in this study is also closely related to the interpersonal dimension of self-transcendence Reed³³ and appears to form the basis of “professional vulnerability” in nurses. Nursing management seems to have contributed to the perception of “professional vulnerability,” consciously or unconsciously.

It is stated that nurses who have been in the forefront during the Covid 19 pandemic are concerned about infecting their families with the virus.^{14,15,25,27,34} In this study, although the participants acted cautiously, they stated that they were worried about being a source of infection for their families due to their responsibilities during the pandemic. In this case, living with the family has emerged as a contextual variable that has increased anxiety in nurses and caused psychological challenges. This situation was considered as the familial vulnerabilities of nurses.

In the study of LoGiudice and Bartos,³⁴ it was found that Covid 19 patients are alone in the hospital, the nurses are their family, the loneliness of the patients negatively affects the nurses, and the nurses not only meet the medical needs of the patients but also provide emotional support to them. In the study of Abuhammad et al.,²⁸ the nurses stated that their patients were worried, and they felt responsible for them and defended their rights. Similar results were revealed in this study as well.

Limitations and strength

This study has four important limitations. The first is that the results of the study cannot be generalized to all the nurses due to the small sample size resulting from the nature of the research method and the use of purposive sampling. The second is that only intensive care nurses who care for patients diagnosed with COVID 19 were included in the study, and nurses who care for individuals diagnosed with COVID 19 in other clinics were not included in the study. The third limitation is that the gestures and facial expressions of the participants could not be detected and integrated with the findings, except for those that could be understood during the speaking process, such as crying, laughing, and pausing, since individual interviews were conducted on the phone. Finally, the study did not include focus group discussions that could contribute to the emergence of new data that may arise from the interaction of the participants with each other. However, the results of this study provide important data on the self-transcendence experiences of nurses working in the intensive care unit during the COVID 19 pandemic.

Conclusion

This study investigated the self-transcendence of nurses working in the intensive care unit during the Covid 19 pandemic. The nurses in the study were found to experience vulnerability due to “administrative loneliness,” “inability to give care,” “fear of being a source of infection,” and “loneliness of patients.” It has been found that “improvement in nursing roles and skills,” “being proud for oneself and the team,” “understanding the value of life,” and “feeling like a superhero due to the responsibilities shouldered during the pandemic” support nurses’ self-transcendence, which contributes to physical and mental well-being. It is recommended that nurses and administrators positively support the self-transcendence experiences of nurses in this challenging process by providing training, doing practices to increase psychological resilience, and employing mentoring systems that support inexperienced nurses. In addition, the development of institutional culture in a way that strengthens nurses in the working environment may be effective in solving the problems.

ORCID iD

Mesiya Aydin https://orcid.org/0000-0002-4632-6562