The earthquakes with the epicenter in Kahramanmaraş caused severe destruction and many casualties in 11 provinces of Türkiye.1 It was further reported that 2.3 million individuals residing in the provinces affected by the earthquake have directly experienced sheltering problems.2 Many tent cities and container cities were built to temporarily solve the shelter problem. Besides residential units, many health care institutions were also damaged.2 Primary health care services particularly have the potential to provide psychosocial support, protect public health, and accelerate the post-disaster recovery process in cities established for temporary accommodation.Reference Koçer, Akpek and Vural3, Reference Lamberti-Castronuovo, Valente and Barone-Adesi4 Turkish Nurses Association (THD) organized a service campaign to provide voluntary public health nursing services in the Altınşehir K1 container city in Adıyaman province. This voluntary service, which was launched approximately 1 month after the earthquake, was upheld for a total of 15 months.5
Nurses belong to the professional organization with the highest number of members who assume roles on the front lines when a disaster occurs, providing first aid, nursing care, coordinating services, and providing health trainings, as well as taking part in the provision of health care services.6 Nurses are known to undertake significant roles such as preventing infectious diseases, providing psychological support to the injured, managing shelters, providing rehabilitation, and assessing the disaster response in the field in the post-earthquake period.Reference Firouzkouhi, Kako and Abdollahimohammad7 Nurses can further engage in volunteering activities in situations where the number of health professionals is insufficient and access to health services is restricted. Nurses in Türkiye thus traveled to the earthquake-affected zone upon assignment or voluntarily after the earthquake and worked in many different areas.Reference Harmanci Seren and Dikeç8
It is, therefore, extremely important to discover the experiences of nurses who provided health services in such a devastating disaster. There are studies in the literature addressing the experiences of nurses who voluntarily visited the earthquake region immediately after the Kahramanmaraş earthquakes.Reference Emirza, Uzun and Şenses9, Reference Mercan Annak, Erdoğan and Yıldız Emre10 However, no study has been found that specifically reveals the experiences of nurses who provided voluntary public health services in container cities. This study aims to contribute to the literature by revealing the experiences of nurses who volunteered to provide public health services in container cities constructed after the earthquake. It is thought that the results of the study will contribute to the strengthening of disaster nursing by exploring the experiences of nurses working voluntarily in public health services in container cities.
Methods
Research Design and Theoretical Framework
This study was conducted with a phenomenological design to reveal the experiences of nurses who volunteered to provide care services in container cities established after the earthquake.Reference Creswell11 All authors conducting the study are female and are PhD students. One of the authors completed a course on qualitative research and had experience with qualitative study, while the other had previously experienced qualitative study. COREQ checklist was referred for reporting the study.Reference Özden, Tekindal and Gedik12
Sample and setting
Nurses who volunteered to serve in the primary health care services organized by THD in Adıyaman Altınşehir K1 container city following the earthquakes were included in the study. Forty-five nurses were invited to the study via the messaging application used to communicate with each other. Nurses who volunteered for at least 1 week at different times in the first 6 months following the earthquake were selected using the purposive sampling method. The sample size was determined based on data saturation. The researchers observed recurring data starting from the seventh interview. The absence of new information in the subsequent 2 interviews indicated that data saturation had been achieved, and the study was completed with a total of 9 participants.Reference Hennink and Kaiser13
Data Collection Tools
Study data were collected using a “Personal Information Form” and “Semi-Structured Questionnaire.”
Personal Information Form
The Personal Information Form, developed by the authors to define the sociodemographic and professional characteristics and volunteering processes of the nurses, includes 11 questions.
Semi-Structured Questionnaire
The Semi-Structured Questionnaire, developed by the authors, featured 15 open-ended questions. The opinions of 2 experts were sought for the Questionnaire. Pilot interviews were conducted with 2 nurses assigned in the region. Pilot interviews were excluded from the study and the final form was created after revisions.
Data Collection
Participants were invited to the study via a Google Forms link. Personal characteristics of the nurses who provided consent to participate in the study were collected with this form and an interview was scheduled accordingly. Participants were reminded to be alone in a calm environment where they could express themselves comfortably during the interview. In-depth individual interviews were conducted by 2 authors via a video conferencing program in a single session. Interviews were conducted by 2 researchers between January 11-29, 2024. The interviews, which took an average of 45 minutes, were audio-recorded. The third author was separated from the data collection process to eliminate bias.
Data analysis and synthesis
Data analysis was initiated after the first interview, and the data collection and analysis were conducted simultaneously. Each author transcribed the audio recordings of their interviews. Transcribed data were then transferred to the MAXQDA software and analyzed separately by 2 authors to ensure triangulation in research. The 6-step thematic analysis method was used to analyze the data. In this process, the researchers first gained familiarity with the data through repeated readings. Then, meaningful statements were coded. Similar codes were grouped together to form themes, which were reviewed for consistency with the data. Any discrepancies that emerged were discussed and resolved by mutual agreement among the researchers. In the final stage, the themes were defined, named, and reported with supporting participant quotations.Reference Braun and Clarke14 Data collection was finalized when the data obtained did not make a significant contribution to the existing themes, demonstrating that data saturation had been reached.Reference Rahimi and khatooni15
Setting and rigor
This study met the 4 criteria recommended for validity, reliability, and rigor, namely transferability, credibility, confirmability, and dependability.Reference Ahmed16 The authors used the bracketing method to control their own experiences and opinions.Reference Creswell11 Intercoder reliability in the study was ensured by using an 8-item guideline.Reference Cofie, Braund and Dalgarno17
Ethical Considerations
Approval was received from the Scientific Research Ethics Committee of Lokman Hekim University on November 30, 2023 (No: 2023196). Permission to correspond with the participants was further received from THD. Participants’ written informed consent was received via the online platform and participants’ credentials were anonymized. The research was conducted in accordance with the Declaration of Helsinki.
Results
Nine nurses, between 27-60 years of age, who provided volunteering service in the region for an average of 7.89±1.20 days, participated in the study. Descriptive characteristics of the participants are presented in Table 1. Five themes were derived in the study examining the experiences of nurses from volunteer services provided in the container city. Themes related to participants’ experiences are illustrated in Figure 1.
Demographic information of participants
Thematic structure of volunteer nursing experiences in the container city.
Theme 1: Factors Affecting Participation in Volunteer Activities
Nurses’ decisions to volunteer in the disaster area were grounded in a process involving individual motivation, professional belonging, psychological readiness, and social interaction. Volunteering was perceived not as a personal choice, but as a reflection of a sense of belonging to the nursing profession and ethical responsibility.
“.. I can say that this profession gives me strength. I have a purpose, I am a nurse, and I can do this. There is a certain role assigned to my profession and I want to undertake it…” P4
“I have to go, I need to be there, I need to do something. What I do here is not enough for me.” P9
The decision to volunteer was neither sudden nor easy for the nurses. They reported experiencing stress responses, such as difficulty concentrating and distraction in the aftermath of the earthquake, and stated that they were only able to decide to volunteer once they felt psychologically ready.
“At first, I couldn’t really think of participating in the volunteering activities, either. I felt helpless here, I didn’t know what to do, I was experiencing psychological symptoms such as confusion and inability to focus. But the time I visited the region, some time had passed since the earthquake and I was feeling a bit more comfortable psychologically.” P3
“First, I needed to prepare myself, especially psychologically. Because we are human too, and the scenes we encounter affect us as well. I went there when I felt most ready.” P8
On the other hand, social relationships were also found to play a role in the decision to volunteer. Participants stated that having someone to act together with gave them courage, and knowing they were not alone made them feel safe.
“… When I learnt that a friend of mine was going alone, I wanted to go with her.” P1
“… an academician from the association supported me (She is talking about someone who had prior experience there). These recommendations encouraged me. So, I have definitely decided to go.” P8
In addition, the sharing of experiences by volunteers who had previously worked in the disaster area helped facilitate the decision-making processes of nurses planning to volunteer.
“I asked my colleagues who were already there about the situation. That gave me a bit of courage.” P2
“I talked to friends who had been there before. After speaking with them, my decision became clear.” P8
Theme 2: Scope of Volunteer Services
Volunteer nurses provided a wide range of primary health care services in the container city following the earthquake. These included first aid interventions, field assessments, chronic disease management, wound care, health education, infectious disease control, opportunistic screening, antenatal follow-up, home visits, and referrals.
“We came up with every case that a health professional can encounter, such as birth, breastfeeding the newborn, baby care, hygiene, bathing, trauma and academic problems of primary and secondary school children, adolescent problems, sexual problems of newlyweds arising from marriage, problems of the elderly, geriatrics, wound care of individuals who were or were not trapped under the rubble, wound dressing. Of course, Of course, I put health education at the top.” P6
“They lack materials such as pads, condoms and diapers, and we distributed them to those we could reach. We were procuring and giving through the association.” P1
During their volunteer work, nurses collaborated with other health care professionals, including physicians, midwives, psychologists, and social workers.
“We collaborated with the midwife assigned to the container city and accompanied women to cancer screenings. We referred pregnant women who missed their check-ups to family health centers for follow-up." P1
“We worked together with psychologists to provide abuse prevention education for children." P5
“We connected individuals in need of psychological support with psychologists and referred them to social services when necessary.” P3
During emergencies such as earthquakes, voluntary activities were carried out with flexible time management and strong teamwork, going beyond routine service delivery.
“Being in the region, having the opportunity to manage the process, being able to organize and constitute a team as if I had been working with individuals. I had never met for years were really valuable experience for me.” P2
“Frankly speaking, ours was a flexible task completely outside the concept of working hours… we were working from 7 or 8 o’clock in the morning until 10 or 11 in the evening.” P5
Theme 3: Challenges Experienced in Volunteer Activities
During their volunteering process, nurses experienced challenges related to the physical conditions they were working in.
“Rain would leak through the containers. We experienced that a few times. We were worried about the materials inside getting wet, and also about fire risks due to the electrical wiring.” P9
“The heat was unbearable, and since we were out in the field, we were affected even more. Each container had an air conditioner, but it wasn’t enough.” P5
Nurses working in the disaster area had to cope not only with physical challenges but also with intense emotional burdens. They stated that witnessing traumatic events left a deep impact on them and that they experienced emotional difficulties while trying to fulfill their professional roles.
“I really had a hard time when the individuals who came to the interview cried by my side. There were times when I couldn’t hold back my tears, I cried with them. When I came back, I couldn’t recover for about a week…” P7
“Listening to people’s stories, their losses, and the fact that the debris was still everywhere—it was hard… Seeing people living in tents among the rubble, thinking about it, knowing it—was difficult.” P4
“It was emotionally difficult, truly. I often found myself on the edge between empathy and sympathy. Despite all my years of experience, even I struggled.” P6
Nurses faced difficulties in engaging individuals in the activities during their volunteer services. Community participation was limited, as women were often occupied with household chores, childcare, and elder care, while men were mostly away at work.
“Women are still women in catastrophes, wars and disasters… Women’s roles can be diminished, restricted however they still prevail; therefore, women were in a very difficult situation. It could sometimes be difficult to engage them in the activities.” P6
“In fact we could not see adult men around during the day, they were at work. We could not reach the men.” P3
On the other hand, rapidly emerging needs in the disaster area required flexibility in time and case management, which directly impacted the sustainability of plans and the organization of care services.
“There was always someone knocking on your door with a different need, so things didn’t always go as planned.” P4
“It was not possible to identify the problem, to make plans for it and carry out these plans in a week. We also had some trouble with time management and case management.” P6
Volunteer nurses experienced difficulties due to the lack of clarity regarding their duties, authority, and responsibilities.
“I will intervene, but is it right for me to do it? Because there are existing staff there but I am a volunteer.” P5
“I am a volunteer nurse, and there are things that go beyond my authority.” P6
Theme 4: Achievements of Volunteer Activities
Despite the many challenges caused by the earthquake, nurses described their volunteer experience as both a personal and professional gain. This experience not only enhanced their professional satisfaction but also reinforced their knowledge of emergency management and strengthened their roles in disaster settings.
“It was sad but I also felt very satisfied, I was once again very proud of my profession. We are members of a very special and beautiful profession… I always say that “I am glad to be a nurse.” P6
“Until now, we had no experience in disaster nursing apart from the pandemic. I saw there how I could work as a nurse in a natural disaster environment and how I could manage the crisis. I am much more knowledgeable and much more organized now.” P2
At the same time, the voluntary activities provided in the container city enhanced professional visibility and strengthened the image of nursing.
“I think our presence there, that is, the services provided under the umbrella of the Turkish Nurses Association, has a huge impact. People got to know the nursing profession, they have known the association, I think it had a huge impact in terms of professional visibility.” P4
“Our activities were very effective in showing the community that nurses play an active role in society. Letting them feel that we were there for them strengthened the trust between us.” P8
Theme 5: Suggestions for Improving Volunteering Services
Nurses suggested that nursing services should be delivered in accordance with their areas of specialization to improve the quality of the activities provided. They also emphasized that the number of nurses should be determined based on population size to enhance both the quality and quantity of services.
“Particularly psychiatry nurses are needed to provide psychological support. There were already individuals with mental illnesses and we further encountered individuals who were prone to mental problems and were likely to be triggered after a trauma.” P8
“There were 5 or 6 of us in the volunteer team; we didn’t have the capacity to screen all the elderly people in the container city or to observe who needed what. In that sense, the number of people available to provide services was insufficient.” P3
Nurses advocated for longer durations of volunteer assignments to ensure effective information flow and maintain coordination. They also noted that flexible time management throughout the day could enhance both the capacity and effectiveness of interventions directed at individuals.
“Individuals could not come to the health care center before 16:00 as the weather was very hot. Because it was really hot enough to overtake the sun. Service hours needed to be extended a little more in order to reach more people.” P2
“Each week, a new team would arrive and want to start things over with a different approach, which made things more difficult. I wish we could have worked longer with people we already knew.” P9
Nurses emphasized that strengthening communication between teams and coordination with other institutions and organizations in the region could facilitate service delivery.
“I think each team should pass on information to the next one—for example, they could say, ‘We identified these issues here, so you can come prepared for that.’ That way, communication and collaboration would improve.” P7
“We were identifying patients and individuals in need in the container city and planning interventions, but we were able to offer solutions more easily when we collaborated. If there is good planning and cooperation with other institutions present, things actually run more smoothly.” P9
Nurses emphasized that the creation of disaster action plans that clearly include the distribution of tasks is important for the effective delivery of health services.
“There was a problem in ensuring the continuity of the people who would come to the region and provide volunteer service. In case of a possible earthquake disaster, it would have been useful to identify the people who would undertake volunteer work in advance.” P3
“If what needs to be done in disaster situations and the authorities of each team are planned in advance—before a disaster happens—and if we, as nurses, know our roles and responsibilities before going into the field, then we can truly do a good job.” P9
It was emphasized that enriching the educational curriculum and giving more emphasis to disaster nursing practices are necessary for disaster preparedness.
“While taking our vocational courses, we also take courses on natural disasters, but it is not possible to practice them. Course contents can be expanded in this regard. Topics related to disasters should be added in in-service trainings in hospitals.” P2
“In the face of such a societal crisis, I realized that while we are taught theoretical knowledge in our courses, practical training is also very important.” P3
Nurses advised their colleagues to prepare themselves psychologically and to keep their knowledge about nursing practices up to date.
“It is important to be aware of the fact that a vulnerable group will be encountered and to be psychologically prepared after an earthquake or disaster. Therefore, we also need to be really strong to empower and help these individuals.” P8
“In a societal crisis, what are the existing problems and what can I do… It might be helpful for them to review the literature and refresh their knowledge on this.” P2
Discussion
Factors Affecting Participation in Volunteer Activities
For volunteering nurses to be able to effectively take part in the post-disaster period, the factors affecting their participation in volunteering services need to be understood. Volunteering nurses emphasized that communicating with people who had previously provided services in the region will positively affect their participation in activities in the container city. Knowing the conditions will make it easier for the nurses who will be assigned in the region to be prepared for the risks they may encounter.Reference Tunç18 The advice of the team who has already experienced volunteer nursing in the region can guide future volunteers.
The significance of social support in protecting and maintaining physical and mental health is already well-known.Reference Xue, Shu and Hayter19 Nurses argued that social support would be effective in participating in volunteering activities. It is reported that an environment with uncertainty and vital risks, such as an earthquake, provides more support and unity among team members.Reference Tunç18 Volunteering nurses who have not been to a disaster area before may want to have this experience with someone they know in order to feel safe.
In this study, it was concluded that professional affiliation and a strong sense of responsibility played a positive role in nurses’ participation in volunteer activities. It was reported that nurses working in the Kahramanmaraş earthquake zones had a strong motivation, desire, and responsibility to touch people’s lives.Reference Segev, Suliman and Gorodetzer20
Scope of Volunteer Services
The disaster environment may affect team communication and cooperation, as it bears uncertainty, chaos, and vital risks.Reference Farokhzadian, Mangolian Shahrbabaki and Farahmandnia21 The nurses who volunteered to participate in this study concluded that they demonstrated a good example of teamwork and organizational skills despite having just met each other. Nurses who took part in similar organizations reported that they cooperated well in the field despite the lack of coordination and that each team coming from different cities quickly adapted to the order.Reference Tunç18 It is argued that strong cooperation and solidarity in carrying out post-earthquake nursing activities can improve service quality. In addition, nurses stated that they continue their duties regardless of working hours in this environment of cooperation and solidarity. In this way, nurses aimed to reach more individuals. Nurses have provided selfless nursing care services despite limited resources and risks in the crisis environment caused by disasters.Reference Farokhzadian, Mangolian Shahrbabaki and Farahmandnia21
Volunteer nurses have carried out health activities such as first aid intervention, wound care, chronic disease management, referral, field screening, epidemic prevention initiatives, pregnancy follow-up, opportunistic screenings, home visits, and health trainings, as well as distribution of materials for basic needs and social services in cooperation with different institutions and organizations. Similarly, it is known that nurses working in crisis situations such as earthquakes carry out various nursing activities.Reference Li, Li and Chen22, Reference Okur, Özaydın and Şen23 In addition, nurses ensured coordination with other professionals by assuming case manager and leadership roles. During disasters such as earthquakes, nurses play multifaceted roles that encompass not only direct clinical care but also organizational leadership, team coordination, ethical decision-making, and the provision of psychological support.Reference Pierre, Ramos and Shimizu24 The presence of nurses in container cities may contribute to social recovery by strengthening the provision of health services.
Challenges Experienced in Volunteer Activities
Nurses stated that they had difficulty reaching women in the container city because of their roles, such as housework and childcare, and men because they were at work during the day. It is reported that women continue to fulfil their social roles such as child and family care after the earthquake,Reference Ural, Yalçın and İlkin Aydın25 while men may neglect themselves by taking more responsibility during earthquakes.Reference Usta, Gunduz and Atalay26 In this case, it is thought that gender roles may limit individuals’ access to health services and social support activities after the earthquake.
Volunteering nurses reported that they experienced indecisiveness in some cases due to unclear roles and responsibilities. It is known that uncertainty regarding the scope of care that nurses will provide in disaster situations may cause confusion and anxiety.Reference Farokhzadian, Mangolian Shahrbabaki and Farahmandnia21 Studies emphasize that this uncertainty constitutes a significant obstacle to disaster management.Reference Al Harthi, Al Thobaity and Al Ahmari27 It is thought that a clear definition of duties, authorities, and responsibilities for disaster nursing will ensure that the service is carried out effectively.
It was observed that nurses experienced psychological difficulties, such as disappointment, ambivalence, and difficulty in coping individually, throughout their volunteering services. Nurses were noted to have felt fear, guilt, and helplessness while trying to provide volunteering services to disaster victims and trying to cope with their own emotional reactions.Reference Yanik and Ediz28 It is a known fact that nurses are at higher risk of psychosocial difficulties in the event of a disaster and more often experience post-traumatic stress disorder compared to other professions.Reference Uyar, Salman and Aydar29, Reference Sato, Techasrivichien and Omori30 In this context, it can be said that nurses working in the region need psychosocial support during disaster processes.
Achievements of Volunteer Activities
Volunteer nurses stated that the services they provided in the container city allowed them to attain disaster nursing experience. It was argued that nurses assigned in earthquakes gained professional experience in disaster nursing under difficult conditions.Reference Okur, Özaydın and Şen23, Reference Akbari, Yari and Ostadtaghizadeh31 Nurses had the opportunity to practice the theoretical knowledge they acquired during their academic education in the field activities. The nurses participating in the study mentioned that the experience they gained in disaster nursing improved their professional satisfaction. Accordingly, it was concluded that nurses assigned in disaster areas experienced professional satisfaction despite long and flexible working hours;Reference Yanik and Ediz28 they had the opportunity to increase their professional satisfaction due to helping earthquake victimsReference Sançar, Cüceler and Özcanarslan32 and they felt peaceful throughout their assignment.Reference Akbari, Yari and Ostadtaghizadeh31 Nurses further emphasized that the disaster nursing experience they gained through this volunteering activity improved their crisis management skills. It is emphasized that being able to uphold professional services despite limited equipment and resources contributes to the development of crisis management skills.Reference Akbari, Yari and Ostadtaghizadeh31, Reference Sani Mert and Koksal33
Volunteer nurses further counted the development of their empathy among their individual gains. An improvement in the empathic skills of nurses providing services to individuals in earthquake zones was reported in the literature.Reference Okur, Özaydın and Şen23, Reference Sançar, Cüceler and Özcanarslan32 However, it was further emphasized that the term of assignment after the earthquake may have a negative effect on empathic skills by causing emotional and mental fatigue.Reference Sani Mert and Koksal33 The reason why the nurses participating in this study did not express negative opinions may be attributed to the fact that they participated in a volunteering service for a relatively shorter time. The fact that all nurses participating in this study are female is consistent with the findings indicating that female nurses have higher empathy levels.Reference Yanik and Ediz28
The nurses stated that the realization of voluntary activities in the container city through the professional association strengthened the image of professional nursing. Similarly, the active involvement of nurses in the COVID-19 pandemic, another disaster, has increased the prestige of the nursing profession.Reference Kiyat, Karaman and İşcan Ataşen34 It was emphasized that volunteering in the activities of professional organizations supports professional development via positive emotions such as trust, belonging, and motivation, and improves the visibility of the profession.Reference Karabey, Gülsoy and Yıldırım35
Suggestions for Improving Volunteering Services
Volunteers suggested keeping working hours flexible, strengthening the coordination with other institutions in the region, improving communication means between volunteering teams, and engaging senior nurses in the team. It may be useful for nurses to take part in the planning of public health services in disaster management processes.
Volunteering nurses further suggested that disaster nursing should be included in detail in undergraduate nursing education and post-graduate in-service trainings. It is important for nurses to have basic knowledge and skills to be able to work effectively in disaster situations. It is also recommended to plan theoretical and practical trainings aiming to improve nurses’ disaster competencies.Reference Okur, Özaydın and Şen23 Detailed coverage of disaster nursing in undergraduate and graduate programs and in-service trainings will strengthen the ability of nurses to cope with such situations.
Conclusion
Volunteering nurses assumed a key role in the implementation of public health services in the container city after the earthquake. Throughout this voluntary service, nurses experienced various difficulties besides attaining personal and professional gains. The difficulties experienced revealed solution suggestions for improving volunteering activities. The results may provide guidance for strengthening further disaster nursing practices.
Limitations
The results obtained with the qualitative approach are inherently context-specific and cannot be generalized. Conducting the study in Turkish language may be a limitation in the transfer of cultural context in the translation process. All participants were female, and the experiences of male nurses could not be reached. Participants may have idealized their experiences as they assumed a valuable role as volunteer nurses; this may have caused a social desirability bias.
Author contribution
Study design: NO, SK, KK; Data collection: NO, SK; Data analysis: NO, SK, KK; Study supervision: NO, SK, KK; Manuscript writing: NO, SK, KK; Critical revisions for important intellectual content: NO, SK, KK.
Acknowledgements
The article was presented as an oral presentation at the 8th International 19th National Nursing Congress (September 25-28) in Ankara, Türkiye.
The authors would like to express their sincere gratitude to the Turkish Nurses Association for granting permission and providing support for this study, as well as to the volunteer nurses who shared their valuable experiences.
Funding statement
This research has not received any specific grants from funding organizations in the public, commercial,or non-profit sectors.
Competing interests
The authors declare no conflicts of interest.
Ethical standard
Ethical approval for this study was granted by the Lokman Hekim University Scientific Research and Publication Ethics Committee, with the Ethics Approval Number 2023196, dated November 30, 2023. Necessary permissions were obtained from the Turkish Nurses Association. The study was conducted in full compliance with all applicable ethical rules and regulations, ensuring the protection of participant confidentiality and rights. Informed consent was obtained from all participants. Participants completed the questionnaire after agreeing to complete the survey through the link provided.
