Altruistic Experiences of Nurses Affected by the Earthquake: A Phenomenological Study

Introduction

In this era of globalization and individualism, expectations of nurses are increasing day by day in crisis situations caused by all natural and man-made disasters. ¹ Nurses have always played a critical role at the forefront in every crisis where human life is at risk and health must be protected. ² The COVID-19 pandemic, which affected the entire world, highlighted the immense dedication of nurses who worked overtime and provided exceptionally altruistic care. ³ On the other hand, during crises such as pandemics, disasters, and earthquakes, nurses were both victims and caregivers. This situation was a potential ground for them to experience value conflicts, and they were emotionally and physically challenged.^4–7 In this context, the question arose as to whether nurses would fulfill their healthcare obligations in tense situations where their personal safety was threatened. ⁸ As victims, did nurses want to show altruistic behavior by sacrificing their own well-being?

Altruism is the moral practice of caring for the well-being of others and has historically been part of the nursing profession, described as the heart of nursing. ⁹ Altruism is one of the professional values that reflects the standard of nursing care, embodying concern for the well-being of others and a willingness to make sacrifices for their needs and prioritize them. ¹⁰ It was found that before the COVID-19 pandemic, nurses were not fully willing to respond altruistically to patients’ ethical demands, ⁸ but contrary to fears, nurses’ commitment and willingness increased in the early stages of the pandemic. ¹¹ Indeed, this revealed that altruism is not an outdated value, but rather the foundation of the nursing care philosophy. ¹² Supporting this, both the American Nurses Association (ANA) and the International Council of Nurses (ICN) emphasize that altruism is not only an individual trait but also a professional expectation.^13,14 This emphasis shapes how nurses provide care, advocate for patients, and contribute to public health. Whether in daily clinical practice or during crises such as natural disasters, altruism remains at the heart of nursing ethics and professionalism. ¹⁰ Furthermore, the Science of Nursing has been based on the universal values of humanism and altruism as a sacred calling since Nightingale. The nursing profession exists to provide compassionate care and health services to everyone. ⁹ Similarly, Watson’s Human Care Theory is based on altruistic nursing care as a healing process. The first characteristic of the theory’s ten-point healing process points to altruism as “maintaining human values by showing kindness and compassion towards oneself and others and acting selflessly.” ¹⁵

Nurses’ altruistic behaviors driven by empathy or compassion are mostly represented by voluntary activities. ⁴ Altruism is particularly prominent in the care process for vulnerable and sensitive groups. ¹⁰ However, while altruism generally requires the intention and capacity to act for the benefit of others at personal cost, ¹⁶ this capacity for costly behavior may diminish when personal resources are strained or depleted. ¹⁷ The descriptive portrayal of nurses’ altruistic behaviors for all natural or man-made disaster scenarios where all resources are disrupted is not yet clear. ¹⁸ Nurses’ willingness to provide healthcare during crises created by disasters is necessary to ensure an acceptable standard of care, so understanding these spontaneous altruistic actions is essential.

Background

Over the past decade, natural disasters such as earthquakes, tsunamis, and floods have affected more than 2.6 billion people worldwide, strained medical resources, and caused numerous casualties. ¹⁹ Turkey, a country at high risk for earthquakes, experienced a catastrophe on 6 February 2023, with two major earthquakes measuring 7.7 and 7.6 magnitude centered in Kahramanmaraş. ²⁰ These earthquakes resulted in 50,783 deaths and 115,353 injuries across 11 provinces. Approximately 14 million people were affected and 37,984 buildings collapsed; this went down in history as the disaster of the century in Turkey. ²⁰

After natural disasters, the struggle for survival and rescue efforts of people trapped under rubble lead to an increase in demand for health and treatment services. ⁵ As an important part of the universal healthcare system, the critical role of nursing professionals in disaster management has been emphasized. ⁶ However, the psychological impact on nurses during and after an earthquake can significantly affect their mental health and their capacity to fulfill their professional responsibilities. ²¹ This is because nurses’ responsibilities extend beyond clinical care and involve managing the care provided to survivors rescued from the rubble and their families, which encompasses complex spiritual, cultural, mental, and ethical dimensions. ¹⁹ When nurses are survivors of such disasters, their experiences are multifaceted and highly complex. The consequences of this can result in an inability to manage nursing care and difficulties in providing altruistic nursing care.^5,7 Understanding how nurses cope with these challenges is essential to improving support systems and ensuring effective and sustainable care management during such crises. ⁷

In Turkey, following earthquakes, nurses have faced multiple challenges in healthcare delivery, including protecting patient rights and privacy, prioritizing the treatment of certain injured individuals over others, and dealing with psychological, managerial, and organizational problems.^6,21 Burnout syndrome, working under intense and adverse conditions, and addressing ethical issues have also emerged as major challenges faced by nurses during natural disasters.^5,8,21–24 However, previous studies have shown that altruism in nursing is equivalent to personal or work values, ⁸ equivalent to professional skills and a reflection of expertise, perceived responsibility, and self-esteem awareness due to the value of the profession they have embraced,^8,18 motivation to guide care and the basis of job satisfaction, ²³ and has been addressed as an ethical issue in disaster situations. ⁵ Although studies have been conducted following earthquakes, no research has been found in the literature on how altruistic behaviors are shaped in an extraordinarily destructive crisis environment among nurses affected by earthquake. However, there is a novelty gap in deeply understanding nurses’ values in stressful environments such as earthquakes and evaluating them from a philosophical perspective. Addressing this literature gap, how nurses affected by the earthquake manage altruistic care in the crisis environment created by an extraordinarily destructive earthquake is a phenomenon that needs to be understood in more detail. Therefore, examining the acute, medium, and long-term effects of altruistic care provided to earthquake victims under challenging working conditions and sanctions is considered worthy of special research. Given the uniqueness and unknown nature of this experience, the phenomenological method was chosen as the best way to explore it. Considering that scientific studies show that nurses’ experiences in different situations are influenced by their values, cultures, religions, and social and historical interactions, clarifying these experiences in the cultures of different countries will help the international nursing community better define the situation and perform more efficiently under specific conditions. ²⁴

Method

Data collection

Nurse Information Form: It consists of a total of nine questions covering the nurses’ age, gender, marital status, whether they have children, educational status, years of professional experience, the unit they worked in after the earthquake, whether the clinic or hospital they worked in was damaged by the earthquake. The data collected through this form were used to identify the participants’ socio-demographic and occupational characteristics and to support the contextual interpretation of the qualitative findings. These data were not used for any comparative or stratified analysis.

Semi-Structured Interview Form: This consists of a total of eight questions that assess the processes related to the altruism experiences that nurses experienced after the earthquake. The first question of the form focuses on the effects of the earthquake on nurses affected by the earthquake. Subsequently, it addresses how victim nurses managed the care processes, the feelings that providing care as an earthquake-affected nurse created in them, and their experiences and feelings related to this period. In addition, questions questioning their altruism experiences in personal, family, and professional terms are also included in the form (Table 1). The semi-structured interview form was developed by the researchers in accordance with the relevant literature^5,6,8,18 and based on the study’s objectives. Three expert opinions were sought in the finalization of the semi-structured interview form to evaluate the form’s scope and content appropriateness. The experts were academician nurses who lived in the earthquake zone, experienced in teaching nursing ethics in a nursing program, had studies on nursing values, and held a doctorate in nursing. Based on the experts’ feedback, the clarity, scope, and comprehensibility of the questions were revised, and the final version of the form was finalized. Following this, pilot interviews were conducted with two nurses to assess the scope and content suitability of the semi-structured interview form, as well as the clarity of the questions. The pilot interviews concluded that no changes to the form were necessary, and the data obtained from the pilot application were not included in the final analysis of the study.

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Table 1.

The questions of the semi-structured interview form.

No	Questions
1	What were the personal effects of the earthquake on you? (What did you personally experience? Please explain.)
2	What happened in the early period after the earthquake regarding patient care processes? (How did you manage patient care after the earthquake? How did you cope? What difficulties did you experience—such as role changes, changes in the care environment, or risks encountered? What changed? What was different? How was the situation regarding shortages of resources such as electricity, water, or medical supplies?)
3	How did it feel to provide care as a nurse who was also an earthquake victim?
4	How do you assess your efforts during this period? Were there situations where you felt inadequate, lacking, or unable to keep up? Do you think you could have done more?
5	Were there times when you thought you could no longer continue providing nursing care? (Did you ever want to stop managing care?)
6	What do you think about the concept of sacrifice in your profession during the earthquake?
7	Were there situations in which you had to sacrifice your personal life because of your professional responsibilities during the earthquake?
8	Were there times when you struggled with the expectations of sacrifice from your institution or society during the earthquake? (For example: low salary but caring for more patients, providing the best care with insufficient staff, or maintaining quality care despite limited resources and poor conditions.)

The data for this study were collected through semi-structured face-to-face interviews conducted by a researcher with nurses between November 2023 and October 2024. Data collection was carried out approximately 1 year after the earthquake, allowing for a comprehensive assessment of nurses’ experiences across different periods (acute, medium, and long-term processes). The interviews were conducted in a quiet room with only the researcher and the nurse present, at a time chosen by the nurses themselves when they were available.

Prior to the interviews, participants were provided with detailed information about the study’s purpose, content, and the scope of the data collection process. Participants were informed about the general content of the questions in the demographic form and the semi-structured interview questions. Additionally, it was clearly stated to all participants that participation in the study was entirely voluntary, and that they had the right to refuse to answer any question or to stop the interview at any stage. Given that the participants had experienced a traumatic disaster, the interviews were conducted using a trauma-sensitive approach by researcher. Emotional reactions were carefully monitored during the interviews by researcher, and the interviews were paused when five participants showed clear signs of distress. The interviews resumed after the participants indicated that they felt emotionally ready and well. Additionally, participants were provided with information about available psychological support resources if needed. Each interview with the nurses lasted approximately 40–45 min and recorded. The interviews were recorded by the researcher conducting the interview using a voice recorder, with the participants’ consent. The researcher who interviewed the participants is a nurse working in the province where the study was conducted, holds a master’s degree in nursing, and is an earthquake survivor who actively served as a nurse in both administrative and care processes in the field during the post-earthquake period. After each interview, the researcher took specific notes about the relevant nurse and recorded all interviews. Through these notes, the researcher engaged in ongoing critical reflexivity regarding her feelings, thoughts, and potential biases, thereby enhancing the trustworthiness of the analysis by making researcher positionality explicit. In addition, the researcher analyzed the participants’ demographic information to support a contextual interpretation of their experiences. This process was addressed within the scope of reflexivity, which is an important methodological element in qualitative research.

Results

This study, completed with participation of 17 earthquake nurses affected by the earthquake, determined that the majority of participants (70.58%) were female, 52.94% were single, had an average age of 30.24, 35.29% had children, and 70.58% had a bachelor’s degree. In addition, the average years of experience in the profession was 7.82, 29.41% worked in the emergency department (Table 2).

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Table 2.

Socio-demographic characteristics of study participants (n = 17).

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Characteristics	​
Gender	n (%)
Female	12 (%70.59)
Male	5 (%29.41)
Marital status	n (%)
Married	9 (%52.94)
Single	7 (%47.06)
Age	​
Range	24–45
Mean	30.24
Having children	n (%)
Yes	6 (%35.29)
No	11 (%64.71)
Educational degree	n (%)
College	1 (%5.88)
Associate’s degree	1 (%5.88)
Bachelor’s degree	3 (%17.65)
Postgraduate	12 (%70.59)
Years of occupation
Range	2–25
Mean	7.82
Unit	n (%)
Emergency department	5 (%29.41)
İntensive care<	2 (%11.76)
Operating room	2 (%11.76)
Oncology	1 (%5.88)
Endoscopy	1 (%5.88)
Pediatrics service	1 (%5.88)
Pediatric allergy and ımmunology	1 (%5.88)
Internal medicine	1 (%5.88)
Mixed internal medicine	2 (%11.76)
Mixed	1 (%5.88)
Whether the hospital where nurses works was damaged by the earthquake	n (%)
Yes	16 (%94.12)
No	1 (%5.88)

After analyzing the interviews with the participants using Colaizzi’s phenomenological analysis method, four main themes reflecting the participants’ altruism experiences emerged: (i) The lifesaving mission; (ii) The light of altruistic care; (iii) The weight of altruistic care; and, (iv) Balancing acts: the challenge of professional and personal life (Table 3). 20 different sub-themes were identified related to these four main themes. These identified themes comprehensively present the altruistic experiences of nurses at the personal, social, and professional levels during the care process they provided after the earthquake.

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Table 3.

Themes and sub-themes derived from the data analysis.

Main themes	Sub-themes	Statements of nurses
The lifesaving mission	• The first, the others• Safety first, for all• Having risk to rescue• Acting with caretaker’s reflex• Holding the line of physical and physiological safety• Protecting own family and own patients• Working driven by purpose	P1: “After it stopped (referring to the earthquake), I went straight into the clinic. Everything in the clinic had been knocked over. The patients were inside, and I couldn’t leave them behind. While I was dealing with the patients, I forgot about my family. I couldn’t reach my family anymore. But I couldn’t leave the hospital and go. I kept going. Because they needed me there too. I couldn’t leave and go.” (Participant is crying).P11: “I was working at the hospital when the earthquake struck. The electricity went out with the earthquake at night. Everything was scattered. The hospital was shaking. When the shaking subsided, I tried to get the patients out in a panic using my phone flashlight. One patient’s room was locked, I tried to open it, I kicked the door, I hit it. I tried to get all the patients out using my phone flashlight.”P3: “We risked our lives, entered the ruined hospitals, went upstairs, got the patients, and came down.”P4: “Education was suspended, everything was suspended, but unfortunately we cannot suspend healthcare. We are aware of this, but it is a huge burden for us. I have my family, my children, and people I care about. On the day of the earthquake, some of our colleagues did not leave the hospital even though their loved ones were trapped under the rubble. That is why I think nurses are the most self-sacrificing group.”
The light of altruistic care	• Feeling the silent worth of care• Living the value of being there• Rebirth through giving• Resilience forged in altruism	P16: “As someone who survived the rubble, my first goal was to heal the patients. What I did brought me both happiness and pride; being able to contribute as someone who experienced the earthquake was very meaningful to me.”P9: “I was very happy; I felt good about myself for coming as a volunteer. Feeling that I was helping people in some small way gave me great happiness. The patients often said, ‘We’re so glad you’re here, we’re so glad you’re here.’ I really experienced professional fulfillment there. We were working in difficult conditions; there was no proper place to sit or rest. Despite this, I felt much more satisfaction and happiness than I do in my current routine work.”P13: “At that moment, we didn’t feel anything… But 2 weeks later, when I returned home, I felt my conscience very sharply. Being on the ground during this process, being able to touch people, was very valuable.”P16: “After getting my family to a safe place, I tried to go to the hospital. I think I did more than I could, but as I started working actively here, I felt that I was helping people more. That’s why I’m just now starting to feel like myself again.”P12: “We climbed onto that building even though it was in danger of collapsing. I left my own living space and came to work. I also stayed in a tent for 3 months during this process. Actually, I stayed in a greenhouse; I slept and woke up among the cucumbers. I left there and returned to work. But in that sense, I feel good; I say, ‘I’m glad I did it.’”P17: “Because when they arrived (the nurses who came from outside to help), they had nowhere to sleep. They were constantly caring for patients and had no safe environment; moreover, it was very cold. Despite this, they continued to provide care. There were nurses who slept in body bags to protect themselves from the cold. I think this requires great sacrifice.”P1: “Being there made me feel good to some extent. Caring for patients made me feel that I was really useful to them.”
The weight of altruistic care	• Keeping others alive while losing oneself• The silent weight of responsibility• Invisible labor• Silent helplessness• Living the nursing oath	P8: “I was on shift that day. I went without food for a very long time. I found some fruit in the back of my friend’s car, peeled it, and we ate it. Because I hadn’t eaten anything all day. However, I was able to eat at the hospital in the evening. By then, more than 24 h had passed.”P8: “Working was really hard. Not only were our conditions terrible, but we were also in an area affected by the earthquake, so we weren’t in a good psychological state. We were working in tents; sometimes they would flood, and we had to work with our feet raised. Despite this, we continued to do our job.”P1: “Everyone who could stay did stay. Even those with children left their children somewhere and came to work. They would stay for two or 3 days, go see their children, and then come back. So, a lot was expected of us. We had done more than we could, but even more was demanded of us.”P13: “The healthcare sector is a sector that operates entirely based on the conscience of its workers. The family aspect is something we often forget within ourselves. Because we usually neglect the people next to us but try to benefit people far away whom we cannot reach.”P5: “Those who come already expect special attention from you. There were times with patients when they treated us as if we were outsiders from another city. During that period, I often wondered, ‘Why am I working right now?’ The patients and their families had very different expectations of us. This situation bothered me a lot. I felt like my personal life had been stolen; it was as if only the hospital existed… We worked non-stop for 15 days during that period, and I felt like I was living in the hospital day and night.”P17: “After the earthquake, people were more tense and intolerant. We weren’t working with a team we were used to; we were trying to get used to a new team and different patient profiles. Things that wouldn’t normally be a problem became problems because of the stress of the earthquake. They would get angry about things they shouldn’t have gotten angry about and could react unpredictably. We had done more than our share, but they had also been affected by the earthquake; both sides had valid points.”P9: “I can say that my efforts went unrewarded. The reason our efforts went unrewarded was that after calling us and bringing us in, the volunteers weren’t given enough support or encouragement. Our social lives were over, but nothing was done. I came as a volunteer; I wasn’t obligated to. But I wasn’t sent where I wanted to go. At the very least, while working as a volunteer, I should have been able to do my job where I wanted to. That’s why my efforts went unrewarded.”P10: “I think I did my best. I believe the most important aspect of the nursing profession is being conscientious. This profession begins with conscience; if you don’t have a conscience, you can’t be a nurse. Because my conscience kicked in, I tried to do my best; I wanted to be helpful to people.”
Balancing acts: The challenge of profession and personal life	• Conflicts among individuals, professional and social values• Fighting for care management• Tension psychological• Bound by law, not by will	P2: “This was a very different situation. It would have been unconscionable to leave people who were completely dependent on you at that moment. I acted this way because it truly required a great sacrifice.”P10: “I came voluntarily, but everything was quite inadequate. There was a shortage of supplies; since there was no hospital, the space was very limited, with only tents. People were in a state of utter helplessness. There were children without coats or socks. Psychologically, I felt terrible. Normally, I always approached patients with compassion and kindness, but there I was overcome by a different feeling; I wanted to hug strangers, to cry together.”P15: At first, our intention was to help people, to save someone. But when I looked back a month later, I had lost about 10-15 relatives around me. I was working in the field without mourning them. At that moment, I realized that I was also exhausted. I needed to stop and spend a little more time with my child. It was difficult.”P6: “I went through the same thing (referring to the earthquake); it wasn’t too bad for me personally, my house wasn’t destroyed, but in March there were still people sleeping in the park, their homes destroyed. In that cold, their clothes in tatters, their children without shoes… I felt so sorry for them. I know I cried, I felt terrible. We tried to help as much as we could, but psychologically, you’re already in a bad place, and the person in front of you is in an even worse situation. What I felt in that situation was unbearable.”P9: “The institution I worked for expected too much from us; that was the hard part. We were expected to do something with the limited resources we had, but we were expected to act like highly competent, flawless hospital staff. It was as if they hadn’t experienced the earthquake, as if the hospital and the city hadn’t been destroyed, and we were expected to do everything perfectly. They acted as if we were there by force. In the early days, only healthcare workers were working; other professions weren’t involved. Teachers and other public employees didn’t go out into the field, but we were told, ‘This is your job; no matter what the circumstances, you will provide perfect care.’ We encountered these expectations both at the hospital and in the community.”P10: “I felt I needed to be more compassionate. Because people were already in a bad psychological state and needed us. I felt I had to treat them with care, provide better service, and perform my nursing duties to the best of my ability. This could be exhausting for me under difficult conditions.”P15: “I felt strong, I felt empowered. But emotionally, it was very difficult. I was leaving my child behind; my mind was always on him, worrying whether he was safe or not. My family was elsewhere, but I took my place in the field with both my nursing skills and my sense of social responsibility. I did things with this motivation, but I struggled emotionally; not physically.”P16: “To be honest, there were times when I felt very tired and even needed treatment myself. I participated in some workshops with the psychosocial support teams that came here because we also needed psychological support. There were times when I felt weak and needed to share with someone, but we tried to resolve these issues collectively. Sometimes we couldn’t resolve them completely, but we managed to lighten the load.”P6: “I especially remember one woman: She had two ambu bags in her hands, her child on one side and her husband on the other. Both were dead, but the woman was crying and trying to use the ambu bag, perhaps hoping they would come back. That image is still in front of my eyes; it affected me deeply.”P5: “During the earthquake, nurses were assigned to work in every area; we acted as a buffer everywhere. Sometimes we carried supplies, sometimes we cleaned. Sometimes we trained newcomers, sometimes we went into surgery… We made all kinds of sacrifices.”P3: “During the earthquake, we stayed in three-story containers, and they were very dirty. Despite this, we stayed there and made sacrifices.”
		P10: “Most of the time, the necessary materials for treatment were not available. When a patient in poor condition arrived in tent conditions, you couldn’t intervene because there were no materials. Even if you needed to intubate them, it was impossible. We were working in very primitive conditions. There was no second hospital to go to, no other intervention point. We were performing first-line interventions: opening veins, reducing fever, and then transferring them. People seriously injured in the earthquake were distributed to surrounding provinces, so we could only provide initial intervention.”P15: “We took on a huge responsibility. As a clinical nurse, we used to treat a certain number of patients with specific treatments and care; but during the earthquake, everything changed. We were involved in everything from cleaning to participating in the diagnosis process with the doctors. We took on greater responsibilities, and I think we handled it well. The hierarchy had disappeared; everyone was doing everything. We worked more collectively, but our responsibilities increased accordingly. Hygiene issues were significant; there were no toilets, bathrooms, or clean water. This situation was a serious challenge for both the public and us healthcare workers. Finding food was also a separate problem. In fact, the first vaccination centers could only be set up 5 days after the earthquake. Until that day, people suffered greatly.”P7: “We were still in shock from the event. Even in the green area of the tent where we would examine and treat patients, there was no proper coordination; it was unclear who would do what, and tasks were not clearly defined. There was a severe shortage of supplies and equipment. Patients couldn’t express themselves and had multiple problems; we couldn’t even decide which intervention to perform first. Patient monitoring and accommodation were major problems. Weather conditions were another issue; tents were damaged by wind and rain, water leaked inside, and heating and air conditioning didn’t work properly. Everything was difficult, but we tried to do the best we could.”P9: “The difference between the hospital and the tent was huge. We worked in the cold and couldn’t warm up. Our meals were irregular. As nurses, we could work 24 h, but there was no place to rest; inevitably, we needed time for ourselves. When it rained, we got wet, and the tent was freezing cold. On days when we weren’t working, we moved to containers; the containers were either very cold or extremely hot in the summer. There were a lot of flies, and the working environment was almost non-existent; 15-20 people were working in one room.”P10: “Seeing the helplessness of the patients in the hospital and their wait to be rescued was very hard on my psyche. We had to give injections through clothing; the place was full of human corpses. We tried to stop the bleeding and ease the pain by using the sheets we found as tourniquets. The children were in the emergency room, and we were treating every patient who came in with a lack of supplies and information. People with bruised feet, injured arms or heads… I felt terrible.”P6: “On the first day of the earthquake, my wife and I went to the hospital; there were bodies everywhere. Traffic was gridlocked, roads had collapsed, no one could reach anyone. There was a second earthquake inside the hospital, and no supplies could be retrieved. There was no IV fluid, no ambu bag, and there were patients who needed to be intubated. There was insufficient staff; there were people transporting their spouses in ambulances, lucky if they could find an ambu bag.”P7: “The most difficult issue for us was the medications used. Most of them came from foreign countries and were in languages we couldn’t understand, like Chinese and Russian… We weren’t given any information about what they were or how to use them. Some doctors tried to explain because they knew foreign languages, but we didn’t know the medications used in the emergency room and had great difficulty knowing which medication was indicated and which was the equivalent. The lack of medical supplies was also a problem; dressing materials, bandages, and even vaccines were insufficient.”
		P1: “We received a letter stating, ‘If you or your immediate family are not trapped in the rubble, you must return to work within 2 weeks.’ When we received this letter, we were forced to return to work. However, we had nowhere to stay and no resources. We had no choice but to return and continue working.”P15: “So much should not have been expected of nurses who were earthquake victims; I was also affected by the earthquake, as were my colleagues working with me. We were mostly the ones who remained in the field. In June, 4 months after the earthquake, the assignments of personnel brought in from outside were canceled. So we were left on our own. Think about it: within 4 months, you have to move your family and yourself to a safe area, solve the problems of shelter, food, hygiene, and water, and then start working. The healthcare personnel working here couldn’t do that; they didn’t. The assignments were canceled, the flexible work schedule ended, and we continued like this.”P16: “I don’t think any individual should feel such sacrifice on themselves. First, you have to protect yourself, especially during a disaster. But the administrators pushed us into this role: ‘You’re a nurse, you’re a doctor, you’ll make sacrifices for society. You can work in a container without air conditioning in 45-degree heat in the summer; there is no bathroom or toilet, but you will work.’ I did not feel such a sacrifice within myself. As both a nurse and a human being, I was on the ground to help those affected by the earthquake, to strengthen myself alongside them, and to rebuild Antakya together. I don’t see this as sacrifice; it was solidarity.”

The lifesaving mission

This theme addresses the experiences of nurses affected by the earthquake in ensuring the survival of their patients, their loved ones, and themselves during and after an earthquake. A total of seven sub-themes have been formed under this main theme: (1) The first, the others; (2) Safety first, for all; (3) Having risk to rescue; (4) Acting with caretaker’s reflex; (5) Holding the line of physical and psychological safety; (6) Protecting own family and own patients; and (7) Working driven by purpose (Table 3).

Nurses affected by the earthquake first tried to save the lives of others during the earthquake (The First, the Others), prioritized ensuring safety for all (Safety First, for All), took risks to rescue others (Having Risk to Rescue), acted with life-saving reflexes (Acting with Caretaker’s Reflex), tried to maintain the line of physical and psychological safety (holding the line of physical and psychological safety), and protected their families and patients (Protecting own family and own patients).

P11: “I was working at the hospital when the earthquake struck. The electricity went out with the earthquake at night. Everything was scattered. The hospital was shaking. When the shaking subsided, I tried to get the patients out in a panic using my phone flashlight. One patient's room was locked, I tried to open it, I kicked the door, I hit it. I tried to get all the patients out using my phone flashlight.”

This main theme represents how nurses worked with a life-saving mission (working driven by purpose) after the earthquake, despite the earthquake and the risk of losing their own lives, in line with the purpose of their profession. The “life-saving mission” redefined their professional identity while also providing a framework of meaning that helped them stay psychologically resilient.

P3: “We risked our lives, entered the ruined hospitals, went upstairs, got the patients, and came down.”

The light of altruistic care

This theme focuses on the positive experiences nurses affected by the earthquake had when they put themselves second in the care they provided after the earthquake, thereby providing truly altruistic care. Furthermore, based on participant statements, this theme emphasizes that Nurses’ altruistic attitudes have a healing aspect not only for others but also for themselves. A total of four sub-themes have been identified under this theme: (1) Feeling the silent worth of care; (2) Living the value of being there; (3) Rebirth through giving; and (4) Resilience forged in altruism (Table 3).

Nurses, especially some nurses who experienced personal loss, expressed that they felt the care they provided was valuable (Feeling The Silent Worth of Care) because they achieved professional satisfaction from the idea that the care they provided achieved its purpose and because they felt peace of mind from helping others.

P16: “As someone who survived the rubble, my first goal was to heal the patients. What I did brought me both happiness and pride; being able to contribute as someone who experienced the earthquake was very meaningful to me.”

Some participants stated that even if they couldn’t do anything, just being there for the earthquake victims made them feel valuable and that the care they provided was valuable (Living The Value of Being There), believing that it gave the patients confidence and hope. This theme also represents how nurses, without expecting anything in return, not only as a professional responsibility but also as a moral duty, ensured the sustainability of care, which in turn helped them, as individuals affected by the earthquake, to rebuild their lives (Rebirth Through Giving). Furthermore, the participants’ statements show that the resilience demonstrated by nurses in the post-earthquake process is actually an inner strength forged in altruism (Resilience Forged in Altruism).

P1: “Being there made me feel good to some extent. Caring for patients made me feel that I was really useful to them.”

The weight of altruistic care

This main theme, nurses affected by the earthquake, represents the burdens created by altruistic attitudes in the post-earthquake care process through five sub-themes: (i) Keeping others alive while losing oneself; (ii) The silent weight of responsibility; (iii) Invisible labor; (iv) Silent helplessness; and, (v) Living the nursing oath (focusing on prioritizing professional responsibilities) (Table 3). Some nurses stated that while acting with professional ethics and moral responsibility in caring for their patients, they put themselves in the background physically, psychologically, and socially (keeping others alive while losing oneself). Therefore, they report that this altruistic care creates burdens such as emotional strain, excessive responsibility, and feelings of guilt when leaving the hospital (the silent weight of responsibility). Nurses have postponed their own wounds while trying to alleviate the pain of others; this situation has created the invisible burden of nursing roles. Several nurses stated that they worked long hours without receiving compensation for the altruistic care they provided after the earthquake, that they received low salaries, and that they were invisible to society (invisible labor). This situation appears to have shifted nurses providing altruistic care from a position of helping others to a position of silently seeking help (silent helplessness).

P8: “Working was really hard. Not only were our conditions terrible, but we were also in an area affected by the earthquake, so we weren't in a good psychological state. We were working in tents; sometimes they would flood, and we had to work with our feet raised. Despite this, we continued to do our job.”

Lastly, under this theme, it has been revealed that the majority of nurses perform altruistic care not as an intrinsic goal but as a professional responsibility (living the nursing oath).

P10: “I think I did my best. I believe the most important aspect of the nursing profession is being conscientious. This profession begins with conscience; if you don't have a conscience, you can't be a nurse. Because my conscience kicked in, I tried to do my best; I wanted to be helpful to people.”

Balancing acts: The challenge of profession and personal life

This final main theme is classified into four sub-themes that address the struggles nurses face between their professional and personal lives: (i) Conflicts among individuals, professional and social values; (ii) Tension psychological capital; (iii) Fighting for care management; and (iv) Bound by law, not by will (Table 3).

While trying to maintain altruistic care, nurses have also taken on responsibilities such as coping with personal losses, controlling individual emotions, and ensuring the safety and support of their families. These responsibilities have caused nurses to experience conflicts between their individual, professional, and social values.

Participant statements reveal that the psychological capacities of nurses affected by the earthquake, such as self-efficacy, optimism, and hope, also experience tension (Tension psychological capital) as they strive to maintain a balance between their individual, personal, and professional roles while performing their duties in extraordinary circumstances.

P15: “At first, our intention was to help people, to save someone. But when I looked back a month later, I had lost about 10-15 relatives around me. I was working in the field without mourning them. At that moment, I realized that I was also exhausted. I needed to stop and spend a little more time with my child. It was difficult.”

P6: “I especially remember one woman: She had two ambu bags in her hands, her child on one side and her husband on the other. Both were dead, but the woman was crying and trying to use the ambu bag, perhaps hoping they would come back. That image is still in front of my eyes; it affected me deeply.”

In the aftermath of the earthquake, nurses faced difficulties in providing care in an unfamiliar environment due to issues such as lack of resources, insufficient staff, working in different units, taking on tasks outside their area of expertise, working with different teams, and lack of coordination within teams. This situation demonstrates that nurses are fighting to maintain altruistic care.

P10: “Most of the time, the necessary materials for treatment were not available. When a patient in poor condition arrived in tent conditions, you couldn't intervene because there were no materials. Even if you needed to intubate them, it was impossible. We were working in very primitive conditions. There was no second hospital to go to, no other intervention point. We were performing first-line interventions: opening veins, reducing fever, and then transferring them. People seriously injured in the earthquake were distributed to surrounding provinces, so we could only provide initial intervention.”

Finally, the fact that several nurses practiced their profession after the earthquake not voluntarily, but due to financial hardship or legal obligation (bound by law, not by will) led to a conflict between their professional and personal values.

P1: “We received a letter stating, ‘If you or your immediate family are not trapped in the rubble, you must return to work within two weeks.’ When we received this letter, we were forced to return to work. However, we had nowhere to stay and no resources. We had no choice but to return and continue working.”

Discussion

Altruistic care, characterized by selfless concern for the welfare of others, is concentrated in disaster scenarios where nurses are compelled to act despite limited resources, challenging working conditions, and personal trauma. ¹⁹ This study qualitatively examined the experiences of nurses who provided care despite being victims themselves in the earthquake recorded as the disaster of the century in Turkey.

This study identified four main themes: nurses who experienced the earthquake and continued to provide care undertook the life-saving mission while simultaneously experiencing difficulties in maintaining a balance between professional and personal life, which characterized altruistic care. However, it was determined that sustaining altruistic care has both natural burdens and benefits/advantages for nurses. Understanding these phenomena requires an in-depth examination of the emotional, psychological, and physical effects of such sacrifice under difficult conditions. Although altruism has not been directly researched for earthquakes in the literature, Slettmyr et al. (2022) addressed the altruistic care experiences of nurses providing care during the COVID-19 pandemic, one of the greatest crises of the recent past. ¹¹ The results were quite similar to the main and sub-themes of this study. Although not officially defined as a disaster, there are parallels between the COVID-19 pandemic and a disaster. This situation emphasizes that nurses can repeat their altruistic care behaviors under any conditions during times of crisis.

Altruistic care, which reflects the essence of nursing, is known as a form of self-sacrifice that compels nurses to prioritize patient well-being at the expense of their own psychological well-being in life-threatening situations such as earthquakes. ³¹ The first theme of the study revealed that nurses affected by the earthquake primarily tried to save the lives of others and prioritized ensuring everyone’s safety during the earthquake. In doing so, it was found that they took risks to save others and acted with life-saving reflexes. Results from a hermeneutic literature review examining altruism as a nursing value showed that altruism emerged strongly in situations where care was provided to vulnerable and defenseless groups, motivating nurses to protect patient dignity and provide safe care. ¹⁰ At the same time, this theme revealed that nurses who take on a life-saving mission struggle to maintain the line between protecting their families and patients on the one hand and their own physical and psychological health on the other. In this study, some nurses stated that while acting with professional ethics and moral responsibility in the care of their patients, they put themselves in the background physically, psychologically, and socially. Previous research has supported that practitioners and decision-makers face ethical dilemmas that place an emotional burden on them during disasters.^5,19,32,33

Furthermore, the results of this study show that nurses often respond instinctively in crisis situations with a deep sense of duty. However, being unable to balance this with personal safety while practicing their profession may further exacerbate the psychological burden nurses face during and after disaster events. ³⁴ Other studies have shown that nurses experience high levels of depression, anxiety, and stress while caring for earthquake victims, ³⁵ that this situation reduced their work performance and that they were exposed to professional difficulties and post-traumatic stress disorder ²¹ and ethical dilemmas.^5,34 For nurses to provide holistic care, including altruism, in emergencies, it is vital to comprehensively understand disaster nursing competencies ³¹ and specific clinical, personal, and ethical competencies to successfully manage all challenges. ¹⁹

In the second theme of this study, nurses stated that they were able to provide care conscientiously, without expecting anything in return, rather than out of professional responsibility. The striking finding was that nurses described this situation as reconnecting them to life. It was observed that the altruistic care provided by nurses who had lost loved ones gave them professional satisfaction, and that simply being there for the earthquake victims made them feel valued and that the care they provided was valuable. The conclusion: the resilience shown by nurses was a spiritual strength shaped by altruism. In one study, nurses living in different provinces affected by the same earthquake defined the nursing profession as “selflessness, obligation, tiredness, and satisfaction,” which was consistent with our findings. ³⁶ Another study found that nurses in this earthquake fulfilled their professional roles and demonstrated commitment to their profession despite experiencing loss of life and property and feeling lonely, exhausted, and helpless. ³⁷ A study conducted revealed that altruism also strongly influenced job satisfaction in the United States. ³⁸ Other studies in the literature show that even nurses who volunteered to provide care in earthquake zones despite not being from those areas ³⁹ or nurses who had the opportunity to care for earthquake victims at their hospital thanks to the transfer of victims, ⁴⁰ experienced peace of mind, satisfaction, and professional fulfillment. All these results highlight the power and resilience of the altruistic care provided by nurses. The feeling of making a difference for others through altruistic care ⁸ may have contributed to a sense of doing meaningful work. This therapeutic aspect of altruism may help alleviate feelings of helplessness and hopelessness, but it should not replace meeting nurses’ own psychological needs. If nurses continue to neglect their own health and well-being while finding meaning in their work, this could potentially lead to long-term negative health outcomes. ³⁵ In this sense, nurses can be empowered primarily through training programs focused on providing holistic care in disaster situations. Furthermore, it is important to develop strategies to increase nurses’ psychological resilience in order to ensure the sustainability of care in crisis environments.

However, this study revealed that the third theme was that nurses experienced conflict within themselves due to emotional burdens such as feeling an excessive sense of responsibility while providing altruistic care and feeling guilty when leaving the hospital. Witnessing patients’ pain may have triggered feelings of compassion in them, which may have motivated them to make sacrifices for others. Issues such as trauma, grief, and compassion fatigue can make it difficult for nurses to think about their own well-being. ⁴¹ At this point, the most striking finding of this study was that nurses postponed their own wounds while trying to ease the pain of others. In other words, it revealed that nurses had even postponed their personal health due to their commitment to altruistic patient care. These claims highlight a deep dynamic in the nursing profession: personal trauma being overshadowed by the weight of professional responsibility. This describes the invisible burden of nursing roles.

Furthermore, in this study, some nurses felt that despite working long hours for low pay without receiving compensation for the altruistic care they provided in the aftermath of the earthquake, their efforts were not recognized by society. We can say that this situation removed nurses from their position of helping others and silently placed them in a position of seeking help in many contexts. The tendency of nurses to take on both the caregiver and selfless healer roles in crisis situations such as natural disasters, often neglecting their own physical and emotional needs, was a finding consistent with the literatüre. ¹⁰ Moreover, this study revealed that the majority of nurses performed altruistic care primarily out of professional responsibility rather than as an intrinsic goal. However, the literature suggests that working under stress, pressure to maintain high standards of care, making difficult prioritizations, failing to fully uphold ethical and professional principles despite all efforts, and being unable to alleviate pain and anxiety can lead to unique and varied difficulties, and feelings of inadequacy. ³⁵ All these findings can lead to the development of moral stress, which increases the risk of burnout ⁴² making this finding quite concerning in terms of the sustainability of interventions in disaster/crisis settings.

Furthermore, the effects of this dynamic can extend beyond individual nursing practice to impact the quality and outcomes of patient care, potentially initiating a highly complex cycle. When nurses have a support system, they can be more resilient and provide higher-quality, more effective care, which is critical not only for their own well-being but also for the overall effectiveness of the healthcare system.^43,44 In the context of preserving altruistic value, it is clear that systematic efforts are needed to recognize the importance of nurses’ mental health and to ensure that supportive mechanisms addressing their emotional needs can be swiftly integrated into the system during crises. Indeed, these findings may point to the need for systemic change that emphasizes the visibility and acceptance of nurses’ struggles and contributions to the healthcare system (internal sources of motivation) and provides financial motivation (external sources of motivation).

The complexities associated with altruistic care in the nursing profession are increasingly becoming worthy of research, particularly as nurses strive to balance their professional commitments with the individual challenges they face. Studies have shown that high levels of altruism correlate positively with job satisfaction and professional identity in nursing.^10,18

However, in the final theme of this study, nurses’ experiences of conflicts among individuals (such as coping with personal losses), professional (such as controlling individual emotions), and social values (such as ensuring the safety and support of their families) while performing their duties under extraordinary conditions highlight the profound impact of altruism on their psychological well-being. Tunç (2023) highlights that such conflicts are particularly evident in environments where natural disasters increase the demand for medical care and push nurses to their biopsychosocial limits. ⁴⁵ Findings on this theme for disaster or crisis settings are again consistent with other studies.^5,8,39 Furthermore, this study shows that nurses’ attempts to balance these three roles lead to Tension psychological capital such as self-efficacy, optimism, and hope. Facing the suffering of patients, families, and colleagues in crisis situations, along with the conflict between the obligation to provide high-quality care and the ability to fulfill this commitment, has also been reported in previous research. ¹¹ Addressing nurses’ feelings of inadequacy and recognizing the internal conflicts between their altruistic attitudes and the realities of their professional identity can help reduce the psychological pressure on them. ³⁹ This type of tension can affect nurses’ individual health and indirectly affect the quality of patient care. In this case, it becomes important to develop strategies that create an environment that supports nurses’ well-being and values altruism. Another issue identified in this study is that nurses experienced difficulties in providing care due to problems such as lack of resources, insufficient staff, working in different units, working in unfamiliar areas, working with different teams, and lack of coordination within the team after the earthquake. These results are similar to those of previous studies.^32,40,41 This situation revealed that nurses were fighting to maintain altruistic care.

It was a striking finding that several nurses described practicing their profession bound by law, not by will in the post-earthquake period. This finding raises the question: In disaster/crisis environments where service is expected without the necessary institutional support, remuneration, or recognition, could there be a risk of potential abuse of the altruistic nature of nursing? Again, in environments with limited resources, the possible consequences of nurses compromising their altruistic values must be investigated. It is essential to establish physical support structures that strengthen nurses’ psychological and emotional well-being and working conditions so that they can continue to focus on altruism without negatively affecting their own health and patient outcomes. ¹⁸ Finally, with the support of policymakers, promoting an organizational culture that encourages altruistic care and providing competitive financial resources are valuable for preserving altruistic care. ¹⁰

Finally, the study findings indicate that nurses’ experiences of altruistic care in disaster settings are shaped not only by individual motivations but also by inhibiting and facilitating structural and psychosocial factors. The sustainability of altruistic care is challenged by inhibiting factors such as high workload, psychological stress, role conflicts, and invisible labor, while a sense of professional purpose, motivation to provide care, team collaboration, and meaning-making processes emerge as key facilitators supporting this behavior. These findings highlight that enhancing the sustainability of nursing care during crises requires not only individual resilience but also the strengthening of organizational support mechanisms. In this context, increasing psychological resilience training in disaster preparedness programs, strengthening internal support systems, and improving working conditions can be considered important strategies for preserving nurses’ capacity for altruistic care.

Strengths and limitations

This study is unique in that it is the only study among the limited studies conducted after such a large-scale earthquake that specifically examines the altruistic care behaviors of nurses affected by the earthquake. It is also the first study to highlight the altruistic care provided by nurses who personally experienced the earthquake during and after the earthquake, in other words, in the acute, medium, and long-term processes.

There are a few limitations in this study. Since the questions used in the data collection process and the statements obtained from participants are retrospective, inaccuracies in the process of recalling the past may cause information bias. As this study was conducted in one province of a country, cultural differences between provinces may also have affected the interpretation of the data. Finally, since this study was conducted using purposive sampling, the use of a small sample size may also be considered a limitation.

Conclusion

This study highlighted the efforts of nurses affected by the earthquake to continue providing altruistic care by undertaking the life-saving mission despite unique challenges that test their resilience at every level and conflicts between their professional and personal lives. It also revealed the positive professional and ethical contributions of the altruistic care they provide. In this context, it was observed that the emotional, ethical, professional, and practical dimensions of altruistic nursing care interact in a complex manner. This research provided reasons to understand and support nurses’ experiences of altruistic care and their unique needs in crisis conditions where all resources are limited. It is recommended that altruism be addressed in personal, professional, and environmental contexts in disaster situations in order to transform these experiences into human and professional lessons and to take the necessary measures.

Implications in practice

This study may shed light on strategies to be planned for future nursing educators, nurse managers, disaster nursing researchers, and health policy makers in disaster preparedness and response. The need for continuous development to foster and maintain altruistic values is evident. Prioritizing both nurses’ biopsychosocial health and altruism capacity can create an environment in healthcare systems where professional excellence and personal well-being develop together. Ultimately, this can contribute to improving the quality of care provided to patients. Identifying a series of strategies necessary for preserving nursing values and strengthening altruistic care management is of vital importance for the effective management of nursing services in potential future disaster scenarios. It is important to establish management systems necessary for developing nurses’ personal skills in preparing for potential disasters and increasing their resilience in post-disaster trauma management. Investment should be made in disaster preparedness and mental health resources to improve the well-being of nurses and, consequently, the overall strength of the healthcare system. Furthermore, it is recommended that safe working environments and biopsychosocial support programs be planned so that nurses’ psychological and physiological well-being is not neglected. Disasters can damage the psychological capital of health systems and cause the disruption of nursing dynamics; disaster nursing development programs can be effective in preventing this. Regular, simulation-based disaster preparedness programs can be organized to ensure physical safety and psychological resilience. Finally, with the support of policymakers, it is necessary to emphasize the importance of comprehensive care in disasters in accordance with international standards and to redefine nursing values and roles within this framework. For all these contexts, further studies with larger and more diverse samples, different disaster settings, and longitudinal approaches are needed to better understand the long-term impact and contextual determinants of nurses’ altruistic experiences during disasters.

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