Introduction: The COVID-19 pandemic had significant repercussions for the everyday life and public health of society. Healthcare professionals were particularly vulnerable. Here, we interviewed medical residents about their lived experiences during the pandemic to offer a phenomenological analysis. To this end, we discuss their pandemic experiences considering Jaspers’ “limit situation” concept – that is, a radical shift from their everyday experiences, to one causing them to question the basis of their very existence. Methods: We interviewed 33 medical residents from psychiatry and other specialties from the Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP) who either (a) worked directly with COVID-19 patients or (b) provided psychiatric care to other healthcare professionals. Semi-structured interviews were developed using the Inductive Process to Analyze the Structure of lived Experience (IPSE). Results: The descriptions of the lived experiences of medical residents during the pandemic were organized into four content themes: (a) existential defense, (b) limit situations during the COVID-19 pandemic, (c) changes in lived experience, and (d) new world meanings through lived experience. Conclusion: During the COVID-19 pandemic, medical residents experienced what can be thought of as a “limit situation,” as they encountered the healthcare delivery challenges coupled with the social isolation imposed by the COVID-19 pandemic. These challenges included fear of infection and potential death, uncertainty about the future, and the emotional overload caused by the sharp increase in patient deaths. That said, after facing such a limit situation, residents reported feeling strengthened by this experience. This is consistent with the notion that when confronted with limit situations, we draw on our resources to overcome adversity and, in turn, reap existential gains. Health care providers might use these experiences to energize their own professional approach.

The word “plague” had just been spoken for the first time. (...) Pestilence is in fact very common, but we find it hard to believe in a pestilence when it descends upon us. There have been as many plagues in the world as there have been wars, yet plagues and wars always find people equally unprepared. (...) They continued with business, with making arrangements for travel and holding opinions. Why should they have thought about the plague, which negates the future, negates journeys and debate?

The Plague, Albert Camus

The COVID-19 pandemic saw the world face a sadly recurrent experience in human history. The repercussions of the “seismic shift” [1] caused by the pandemic reverberated through the public health system, as well as the everyday life of individuals and societies – as both faced the uncertain future posed by this “new plague.”

In this context, physicians and other healthcare professionals deserve special consideration. Like the rest of the world, they experienced the effects of this change in their day-to-day lives, and they also had to deal with the unique challenges the pandemic inflicted on their profession. These challenges included work overload in care delivery, insufficient technical-scientific knowledge of COVID-19, and the pain and loss associated with the unavoidable death of countless patients. Unsurprisingly, quantitative surveys document the psychological impact of the pandemic on healthcare workers, who sought mental healthcare at alarming rates [2‒8].

In Brazil, the pandemic overwhelmed the healthcare system to the point that medical residents had to work as frontline staff in care delivery. The Hospital of Clinics of the USP School of Medicine (HCFMUSP), Latin America’s largest public hospital complex, was designated as a dedicated COVID-19 referral care unit for the state of São Paulo. This challenge involved reconfiguring 500 beds across wards previously assigned for specialized inpatient care to cater to COVID-19 patients [9].

So challenging was this new professional reality that healthcare workers were compared to “warriors in a battle” [10]. This made it crucial to offer these workers psychological support [3, 4]. For this purpose, an extensive outpatient infrastructure was set up to provide mental healthcare to professionals who requested it [11, 12].

The pandemic experience can be conceptualized as a “limit situation,” a term coined by the German psychiatrist and philosopher Karl Jaspers. A limit situation is a disruptive event in someone’s existence – one in which they come face to face with the possibility of a rupture – what Jaspers referred to as the “basic situation.” The basic situation denotes the limits common for all persons because it represents situations in which human existence experiences an instability of integrity and unity. As described by Fuchs, these situations notably include the following: having to die, having to suffer, having to fight, being at the mercy of chance, and facing the inevitability of guilt [13]. In these limit situations, technical knowledge and life experience will not be sufficient to cope with the suffering imposed by the circumstances experienced.

In such situations, individuals invoke existential defense strategies to provide protection. Defense strategies or “housing” (Gehouse) are attitudes or thoughts that offer protection against existential questioning. Though necessary in the short term, such housing could also provide a “false feeling of stability, safety, or self-esteem” as it “hides the antinomies1 of Dasein by constructing conceptions of the world that harmonize” (pp. 336–54) [14]. In this way, the limit situation is one in which an existential defense is ultimately insufficient. This causes the individual to become aware of their existence and, consequently, their finitude [13].

Heidegger offers a helpful term to help us consider limit situations, Dasein. Dasein is a German word composed of the verb “to be” (sein) and the adverb “there” (da). This is because the object of study of Heideggerian phenomenological analysis is different from man, as he is generally considered. Dasein refers to human existence. To elaborate, a human is a mode of being that will inevitably face situations where they will ask themselves about the meaning of existence, the meaning of being [15]. Indeed, inquiring about the conditions of a particular human experience addresses the ontological characteristics of man.

One human response to facing a limit situation is anxiety. Anxiety, on the one hand, causes suffering and discomfort. According to Heidegger [15], this occurs because there is a tension in human experience, between being oneself and estranging oneself in the face of an inevitable situation of choices and responsibilities. Consequently, the affective disposition, in such a situation, is anxiety, and for the same reason, it is the affect that is tied to the meaning of existence. That said, though the limit situation destabilizes the integrity and unity of Dasein, it is from anxiety that a person can grow as they experience an authentic relationship between themselves and the world [13]. In light of these ideas, the present study aimed to create a qualitative study that would address the existential experience of doctors during the COVID-19 pandemic, considering the pandemic as an example of a limit situation.

We devised a methodology centered on the first-person narrative perspective of the experiences recounted by the interviewed residents. To this end, we administered semi-structured interviews to residents in psychiatry and other medical specialties who worked directly with COVID-19 patients and to psychiatry residents who provided psychiatric care to HCFMUSP professionals. We then conducted a phenomenological analysis of these experiences, invoking the relevance of the philosophies of Karl Jaspers and Martin Heidegger, in the context of ontological considerations.

IIa. Data Collection

We utilized the Inductive Process to Analyze the Structure of lived Experience (IPSE) for this qualitative study. The five stages of the IPSE method are (1) setting up a research group; (2) ensuring the originality of the study; (3) recruiting and sampling, aiming for exemplarity; (4) data collection, accessing experience; and (5) data analysis. The IPSE approach is an appropriate qualitative research method given its clear definitions and rigorous method for lived experience analysis [16].

Two members of our research team, experienced in qualitative research [17‒20], suggested this method. They also suggested training a group of interviewers to cover a larger sample. We then devised a semi-structured interview script that would reveal the COVID-19 pandemic in the physicians own words (see online supplementary material; for all online suppl. material, see https://doi.org/10.1159/000536135). The interviewers received interview training from the chief interviewer. After completing the first round of training, the research team convened to answer the following questions: (a) what they did well as an interviewer; (b) what they did not do well as an interviewer; (c) which questions worked best; (d) which questions were less successful; (e) at which points in the interview could there have been more follow-up questions or probing; (f) which interviewing techniques and strategies they used effectively; (g) what the interviewer might do differently in subsequent interviews; and (h) questions or concerns about the interviewing process and suggestions for revisions to the protocol. Subsequently, in the third part of the training, the researchers interviewed the chief interviewer for a final quality check. Following this training procedure, the interviews were conducted by the chief interviewer and trained interviewers [21].

Purposive sampling was used to ensure a broad sample of medical residents who worked on the COVID-19 front line [22]. The only exclusion criterion was the refusal to participate. Potential participants were contacted using a “snowball” strategy where each interviewee indicated another potential interviewee [23]. This strategy netted 41 participants. Twenty-one residents were recruited from a total of 80 residents in the psychiatry program, and 20 residents were recruited from other specialties (from a pool of over 300 residents). Of the 41 participants, eight residents did not accept (no interest) or could not participate due to personal reasons. Thematic saturation was reached with the remaining 33 interviews [24‒26].

Of the 33 remaining participants (20 males; 13 females), 23 worked directly with COVID-19 patients, and 10 provided psychiatric support to other healthcare professionals. Specialties of the interviewed residents were as follows: psychiatry (N = 18), general practice (N = 7), pediatrics (N = 3), surgery (N = 2), ophthalmology (N = 1), infectious disease (N = 1), and hematology (N = 1). We note that eight psychiatry residents had to work as general practitioners during the pandemic due to work overload. The interviews ranged from 45 to 70 min; no interview was canceled or invalidated. All participants agreed to participate and signed a free informed consent form. The research was conducted from July 2020 to January 2021. In Brazil, this period comprised the end of the first wave of the pandemic and the beginning of the second [27].

The interviews were conducted online using Google Meet video calls and stored in a Google Drive private account. Video transcription was performed by a third-party company with expertise in transcriptions and an established reputation for avoiding improper disclosure of the information obtained. The interviews were conducted in Portuguese and translated by an experienced language professional. We assigned pseudonyms to participants and did not quote any interview passage to prevent identifying personal traits.

IIb. Data Analysis

The analysis of the interviews followed the IPSE method. Passages related to the participants’ subjective experiences were manually selected through a coding procedure – no software was used. To elaborate, we adopted internal coded language related to the four identified themes; we then used these identified terms to utilize in a detailed search within each of the interviews. Later, the research group held an in-person meeting to determine which content themes were common across analyses. Four main content themes were identified across all interviews, which are presented in the Results section. The validity of this study was ensured through investigator triangulation, reflection of the researchers on judgments and prior theoretical knowledge, attention to negative cases that were not related to the structure of the experience in question, and the transferability of results to other contexts [16].

Four distinct content themes were identified based on the descriptions of the lived experience of participants: Existential Defense (IIIa); Distressing Experiences (IIIb); Changes in Lived Experience (IIIc); and New World Meanings through Lived Experience (IIId).

IIIa. Existential Defense: Participant Descriptions of Defense in the Face of the Limit Situation

This content theme has been divided into two subthemes: (1) examples of housing – elucidating attitudes or thoughts offering protection against existential questioning, and (2) explaining the function of these defense strategies (see online suppl. Table 1).

IIIa. 1. Examples of Housing

Three examples of housing can be identified in the interviews:

IIIa. 1.1. False Impression. Gregório uses a defense strategy when he connects being unafraid to die with the idea that, because he was young, he would develop a milder case of the disease, even though he knew his reasoning was based on a “false impression.”

Gregório: “I was even a bit reckless because I wasn’t afraid to catch it. I was taking the necessary precautions for me and the others, but I had the impression, maybe a false impression, that ‘it is going to be a mild case; I’m young, after all.’ And there was also the factor of wanting to catch it early to take it out of the way, you know? So, during the pandemic, I was far more afraid that people I love might fall ill than I would catch something. Dying wasn’t a fear that paralyzed me, nor even affected me strongly.”

IIIa. 1.2. Invulnerability of the Self. The possibility of dying or suffering may be related to the individuals themselves but may also be linked to the other. Despite knowing age was not a determining factor for case severity, Eliana was more afraid to harm others than herself. This type of housing can be considered a thought that considers a supposed invulnerability of the self, while the other is vulnerable. She explains how she deals with the feeling of existential vulnerability of the other even knowing rationally that she is also in danger.

Eliana: “I’m scared to transmit it to people I love, but I’m not afraid to catch it myself. What I do fear is to be assigned as a general practitioner, for example, and not know what to do, you know, and cause harm to another person. But I don’t fear much for myself, at least consciously. (...) Even though you never know who’s going or not to develop a severe case.”

IIIa. 1.3. Everlasting Afterlife. Religious thoughts are typical cultural thoughts that provide boundaries and security in relation to existential questioning. Religions address the difficulty that humans have in perceiving life as finite. In this sense, thoughts about infinite life after death can bring some comfort to existence. However, even though they provide comfort, they are not sufficient to fully appease the feeling of existential anguish in the face of death.

Helena: “I believe in the afterlife. I don’t know exactly what it will be like, but I believe there’ll be a future. Heaven, not the heavens, the physical sky, but everlasting heaven with God. I think this comforts me, but at the same time it doesn’t take away this feeling of loss and absurdity, anxiety and strangeness of when people around me go.”

IIIa. 2. Function of the Defense Strategies

Some functions of defense strategies can be identified in the interviewees’ statements.

IIIa. 2.1. Protection against Feelings Unsettling to the Self. Existential questioning can be regarded as distressing because it can be frightening to contemplate the possibility of death. Thus, according to Fabiana, one function of these defense strategies is to block feelings that are too unsettling to the self.

Fabiana: “There was the case of a resident in our hospital who became severely ill. So, when you visit the ICU, you don’t see just senior patients or risk groups; there are relatively young patients, and some really young. This showed me that anyone can catch it and develop a severe case, even though the incidence is much lower. (...) I guess it’s not something I give much thought to; it scares me, you know. I’m afraid of dying. I don’t know, there’s a kind of mental block, I guess. I don’t think it’s natural at my age, but I’m talking for myself. I don’t think I ever gave it much thought because just imagining that everything could come to an end scares me stiff.”

IIIa. 2.2. Protection against Vulnerability. Along the same lines, Hilton shows how this defense operates: even when we find ourselves vulnerable, there is an idea that keeps the conscience well protected against this vulnerability.

Hilton: “Of course, we know this is a possibility, rationally I mean, but we somehow put up a defense mechanism and I don’t think this kind of stuff applies to us. (...) I kind of felt distant from this; I didn’t believe it would happen to me, you know. I had this sensation. (...) I feel like, as long as our parents are alive, we can’t die. It’s almost like they are a generational barrier against death. So, first, your grandparents have to die, then your parents, and only then can you think about your own death. I know this doesn’t make any rational sense. (...) Covid and the experience I just told you about have brought me closer to my patients. For instance, I saw once a Covid patient for a psychiatric consultation; he was just a little older than me, but even so he got severely sick, had to be intubated and was on the verge of death. Now that I recall, at the time I was like: ‘Damn! I’m vulnerable some way too’.”

IIIa. 2.3. Protection against Finitude. Similarly, Marília describes a situation in which she confronts the anguish of questioning her existence. Marília tells us that her familiarity with death relates to her difficulty projecting herself into the future. For Marília, projecting into the future presents a challenge because this future may not exist (due to the possibility of death). She then compares her familiarity with death to a kind of weakness.

Marília: “When I was a little younger, I felt imminent finitude, as if my life was going to end very soon, like I didn’t have a long life expectancy. This was something I thought about a lot. And maybe this is what gives this sense of familiarity with finitude, with these weaknesses. Maybe this sensation of death, of imminent end, was much because I had a hard time planning things, projecting myself into the future, imagining what and how I would live in the future.”

IIIb. Distressing Situations: Participant Descriptions of Their Anxiety in Response to the Limit Situation

The second conceptual theme pertains to the descriptions where participants are aware of the anxiety provoked by their experiences during the pandemic. In these situations, existential defense is ineffective in shielding them from being aware of their existence and finitude, and it triggers anxiety. This might have occurred because these situations represent instances in which the residents experienced instability in their lives (summary: online suppl. Table 2).

IIIb. 1. Having to Fight

Having just become a doctor, Fabiana had to face the COVID-19 pandemic with little experience when there were still many questions about the disease. This experience, according to her, became even more stressful because there were high expectations from the population regarding the fight against the disease. Emotional overload caused by patient deaths and uncertainties about the future are other experiences described in this report.

Fabiana: “Oh, I went through different phases during the pandemic. At first, I was terrified, I didn’t think it was actually happening. I’ve just graduated and had never worked before starting my residency. Watching TV, I was like ‘Wow, it’s going to peak here in Brazil, hospitals will get overwhelmed, and whatnot.’ I was dead scared, you know. Everyone was telling me to stay at home, my friends were working remotely, but I had to go out to work. It was a strange feeling, as if I wasn’t ready enough for what they were expecting from the doctors. (...) And now, towards the end, it was like “When is life getting back to normal? Will the vaccine work? Is there going to be a second wave? As far as the patients go, my sensation was one of helplessness at times.”

IIIb. 2. Possibility of Dying

Within this medical context, Francisco reveals a distressing experience, his fear of being in contact with patients with such a contagious disease. The anxiety related to his experience arises from being constantly close to these patients, which keeps him constantly worried about the possibility of contracting the disease.

Francisco: “Yes, I’m still afraid of... I haven’t had this disease yet, Covid. Although just slightly, I am afraid of catching it, of course, and developing a severe case. Fear is not always on my mind, but at times I do feel scared of getting infected at work, because it has happened to some of our workmates, though only a few. But it often crosses my mind, and you’re always wondering if you’ve had it or not. Even though the tests come back negative, we are so exposed that I find it hard to not have been in contact, and I may have had a false negative. And I keep thinking whether I’m still exposed to it or not. (...).”

IIIb. 3. Being at the Mercy of Change

Medical residents experienced the pandemic under varying circumstances due to their specific roles as doctors. However, just like all citizens, they also faced changes in their daily lives. These alterations in daily life appear to have been experienced by the participants as a significant source of anxiety, boredom, insecurity, fatigue, stress, and sadness, in addition to the fear of infection, as expressed by Francisco, Eliana, and Hilton.

Francisco: “I guess there have been different moments during the pandemic, of course, fluctuations of feelings, of well-being. To me, these fluctuations have been much more frequent during this time than in normal life, because the context is more stressful. The fact that life has changed so much made my mood take a turn for the worst at moments.”

Eliana: “I think at the beginning I was feeling more nervous because of all the changes in plans, in daily routine. I guess my life was very much anchored in the tasks I had planned. So, when things started falling apart, it was a moment of great anxiety for me, of trying to get my life back on track in different ways. Something like this.”

Hilton: “What I felt most upset about was that my routine was totally broken. (...) This affected me, and I started to feel kind of... I started to feel really annoyed about many things, and bored all the time. After some time, I managed to settle into some routine, (...) schedule my day as if I had things to do, even though I didn’t, things like waking up, taking a shower, getting dressed... This started to make a difference and lift my spirits. That’s how I got adapted. I took up reading and enjoyed other forms of entertainment. This way, I managed to create a sensation of comfort.”

IIIc. Changes in Lived Experience: Participant Descriptions of Life Changes Imposed by the Limit Situation, Highlighting Any Resulting Disproportions in Consciousness and Their Associated Anxiety

If limit situations bring us face to face with our existential fragility, they manifest in the experience of anxiety [13]. From a phenomenological perspective, anxiety is rooted in a structural disturbance of phenomenology’s foundations, namely, temporality, spatiality, intersubjectivity, and corporeality [28]. The third conceptual theme relates to “Changes in Lived Experience” which can be subdivided into Structural Disturbance of Phenomenology’s Foundations (IIIc.1) and Intersubjectivity as a Stabilizer of the Psychic Structure (IIIc.2) (summary: online suppl. Table 3).

IIIc. 1. Structural Disturbance of Phenomenology’s Foundations

The structure of consciousness can be accessed through temporality, corporeality, spatiality, and intersubjectivity.

IIIc. 1.1. Temporality without a Future. In Clovis’ description, there is an experience of anxiety that “is a pain in the neck.” This discomfort arises from uncertainties related to the future of the pandemic, which prevents him from meeting with his parents or having any stability in his profession. It has been reported that, from a phenomenological viewpoint, anxiety is anchored in a structural disturbance of phenomenology’s foundations. Disproportions related to these foundations are what trigger the emergence of anxiety.

Clovis: “No, they were different, it’s getting worse now, especially because it’s coming... not coming to an end, but it’s easing off. Still, there’s something that kind of drags on, kind of comes and goes, comes and goes... So, I think this phase has gotten worse, now in August, it did get worse. My parents, for example, I thought... I’d already bought a ticket, and my parents thought all this was going to end in August, but, man, it didn’t. It’s going to drag on through October, November, December... So, it’s a pain in the neck. (...) About our residency, everything we had planned is slowing to a crawl, getting done in dribs and drabs. It’s gotten worse; these dribs and drabs situation made it all worse, because we really thought it would be over by August and everything would go back to normal, but it didn’t happen.”

IIIc. 1.2. Uncertain Future. In his way, Gregório reveals how uncertainty related to the future leads to spatial narrowing. This spatial narrowing is felt as being connected to both uncertainty about the future and interpersonal distancing. The impossibility of predicting the future causes anxiety because there is an indefinite wondering about what might happen. Linked to this experience, the loss of everydayness disrupts the experience of the continuous flow of time and, at the same time, “messed up” his psychic life. Psychic life becomes disordered precisely because it is no longer limited by the vital spaces and encounters that used to define it.

Gregório: “Part of it, I think, is the narrowing, like, the future gets more uncertain, ‘what’s the future going to be like?’ It gets harder to predict, and this causes some anxiety, I mean, not knowing how it will be in one or two months, or maybe 15 years, from now. (...) What’s going to happen to our social bonds? Even cultural and social activities, where’s this all heading? The chance that they wouldn’t be resumed so soon made me anxious. I think the loss of contact, not seeing people face-to-face and hanging out with them, also generated a lot of anxiety. Not knowing when I’d have the opportunity to see my parents again, for instance, because my father even lives in another city. (...) And there’s this idea that physical spaces greatly delimit our psychic life. When I’m at work, I get into work mode; when I’m at home, I get into home mode. There’s this sensation that you wake up, leave home, and when you get back home at the end of the day, it’s over, now it’s my time for leisure, or study, anyway. And not having all this in physical form messed up with my psyche.”

IIIc. 1.3. Constricted Spatiality. Social distancing was another emblematic experience of the pandemic, especially during quarantine periods. There is a natural balance between distance and proximity in relation to intersubjective relationships. This balance was compromised during the pandemic, leading Eliana to feel suffocated and spatially constrained. She feels suffocated precisely because she cannot meet with family or friends.

Eliana: “At the most critical moment, the impression was one of suffocation, a certain limitation of possibilities, not being allowed to see people, family. This was significant, I think. Not being allowed to get to know and hang out with the colleagues I had started residency with, this I think was significant. There’s also the question of feeling spatially constrained.”

IIIc. 1.4. Bodily Awareness. Anxiety also manifests as a hallmark of corporeality. The self-perception of being hyper-alert to possible symptoms of the disease is described by Helena. In this case, there is an imbalance between the bodily sensation that operates as the background of existence, also referred to as lived body (Leib) and the bodily sensation characteristic of the object body (Körper), which appear in experience through symptoms [29].

Helena: “‘I caught it, that’s it, I caught it, it’s over. It’s going to be next year, if I’m not away from my activities next year.’ I started to pay attention to the symptoms: ‘Can I smell? Yes, I can. Can I still taste? Yes, I still can.’ Then I started having some mild respiratory symptoms, and my test came back positive. So, I don’t know if I got infected at that time or before; what I do know is that I became hyper-alert when I noticed my fault. I wasn’t so scared, but as soon as realized my mistake, I kept an eye on the symptoms. I was alert, worried, waiting for my time to come, assuming I had exposed myself to a real risk. But now I’m scared of catching it again. I’m not afraid to die; I’m afraid of having to go through it all again.”

IIIc. 2. Intersubjectivity as a Stabilizer of the Psychic Structure

On the one hand, from the subjective reports of the participants, it can be observed that anxiety presents itself during moments when the fundamental structures of consciousness are shaken. On the other hand, the reports show that it is possible to achieve stabilization by re-proportioning one of these structures. In the account presented here, the participants spoke about intersubjective experiences that alleviated anxiety and brought moments of satisfaction and balance.

IIIc. 2.1. Friends as Support. In Fabiana’s account, she demonstrates how intersubjective support mitigates her anxiety. She relied on friends as her support system and realized the importance of living with two friends during this period. At the same time, she sought to stay close to other work friends by “checking in on each other.”

Fabiana: “I’m very lucky to live with two friends. I have friends who live totally alone, and only now things are getting a bit more flexible. But in the beginning, I used to imagine how hard it must be to live alone. The people I knew from the hospital, who were somehow exposed, we tried to keep contact, even if it was just to order food together; we tried to support each other, check in on each other.”

IIIc. 2.2. Feeling Loved. Liliana, on the other hand, describes feeling loved by her friends and family, and she has never felt closer to them than during the pandemic. Therefore, Liliana describes how the experience of feeling loved creates a spatial closeness (even though “physically distant”), reducing the distance between her, her family, and her friends. Previously in this report, it was observed how the disproportion between proximity and distance is anxiety-inducing (Results IIIc 1.3). Here, we have an example of rebalancing this disproportion despite the physical distance.

Liliana: “I’ve never been closer to friends and family than during this period. We kept in touch through video calls and messaging. Though physically distant, I talked to them every day. There was kind of a waiting line for video calls with them. So, I truly felt very loved, very cherished.”

IIIc. 2.3. Creating Moments and Knowing People. Úrsula points out that the helpless feeling she has is linked to her feeling alone and knowing that no one will show up to assist her. This thought corresponds to its opposite, namely, realizing that meeting people and having enjoyable moments with them make all the difference. Úrsula’s perception reveals how important everyday encounters with others are. Once again, there is need to rebalance the disparities between proximity and distance.

Ursula: “Sometimes I felt helpless, when I realized I was alone and nobody would show up for the next shift; it was really up to us. But I think that the day-to-day, getting to know people, creating moments of fun even in the middle of work, this made all the difference.”

IIId. New World Meanings through Lived Experience: Participant Descriptions of Their Experiences during the Period following the Pandemic

Jaspers points out that it is possible to go through a limit situation and come out of the experience feeling strengthened [13], and this is reported by our participants (summary: online suppl. Table 4).

IIId. 1. Vulnerability as Opportunity

Liliana could not have put Jaspers’ argument into words any better. She starts by describing how the feeling of vulnerability turned her into a person who takes more risks. This was only possible because this same feeling of vulnerability allowed her to reflect on her existence.

Liliana: “Now that I’m thinking about it, during that period of the year, my predominant attitude was maybe one of ‘I’ll go all in, I’ll take action, I’ll jump at this chance, I’ll make the most of it.’ It never occurred to me consciously that ‘Oh, anything can happen, I may catch the virus and die tomorrow.’ I didn’t think about that consciously, but the sensation of vulnerability in the face of the pandemic turned me into a person who takes more risks, who seizes on every opportunity. (...) And I think this was the result of this feeling of vulnerability.”

IIId. 2. Experience of Growth Regarding the Power of a Farewell

Roberta begins to value farewells more after witnessing the experiences of people who could not say goodbye to their loved ones. This reevaluation of values was only possible, according to her, because she empathetically experienced the suffering of her patient’s daughter. From a phenomenological perspective, it becomes clear that existential growth occurs through interpersonal relationships with their characteristic exchanges of meanings and emotions.

Roberta: “I think I’ve learned to value more the power of farewells, because I’ve seen many people who couldn’t say goodbye, and I reflected on how I would feel. (...) So, it gives it all a new meaning. On one occasion, a patient was dying, and his daughter asked me, ‘Please, put us on a video call so I can see him for the last time,’ but in reality, I don’t know if I can say this, the patient was already dead. So, it was really sad, he was very, very ill. His daughter was a practical nurse, and she wanted to see him for the last time, you know, by video call. So, everybody kind of left the room, leaving there just me, another resident, and her, who was saying goodbye to her father. I thought, ‘Gee, this is the last time she’s going to see her father, she won’t see him ever again, not even in his coffin, she won’t have even this right.’ I think sometimes I undervalued these moments, but then you realize that it made a huge difference for her, and maybe she made a difference in how her father passed away. (...) Again, I don’t think we are prepared to deal with death, but it was an experience of growth regarding the power of a farewell, the power of a religious ritual, anyway. (...) I don’t know if I can quantify how much this represents, how much this makes you rethink. (...) So, all my patients, like in this particular case, have meant a lot in my life, I think.”

IIId. 3. Uncertainty as Reassuring

Marília’s observes that life, as it has presented itself to her, is unpredictable. This unpredictability leads her to understand that it is not always possible to execute what was planned. This provides her with some serenity.

Marília: “I don’t think the content of my concerns may have changed so eminently, but I think temporality, the experience of temporality of my biographical life has changed. I felt like I had problems; I needed to solve them in the short run. And I had this idea of getting ahead in life, also in the short run, in the sense of lifetime. I needed to have things early. This was kind of my mindset. And some of the things I had planned can no longer be accomplished now, and it’s beyond me to solve this. So, I think I’ve become more serene, and now I let things flow without that constant sense of emergency.”

IIId. 4. Existential Questioning as Contact with Yourself

Gregório realizes that interpersonal distancing (its “virtualization”) caused by the pandemic “forced introspection for spending a lot of time alone that has somehow changed how we look at life and loneliness.” It is precisely this painful introspection that allowed him to modify his beliefs.

Gregório: “There’s a kind of virtualization of the world and a forced introspection for spending a lot of time alone, without any contact, that I think has somehow changed how we look at life and loneliness. I think that having to deal with this in a more straightforward way has changed some beliefs, maybe not religious ones, but about life and death, and how to deal with that. I think that at this more spiritual moment some changes may have occurred, like living a bit more at peace with ourselves, restructuring our relationships... I don’t know if we can call these changes spiritual; I think we can.”

IIId. 5. An Example of Existence as Inspiration

Seeing a dear acquaintance depart, this life can be an enriching experience, especially when it concerns someone like Helena, who admired them for leading a meaningful life. Helena realizes that she admires this person for their faith as well. This led her to feel more faith and dedicate herself to helping others.

Helena: “I saw an acquaintance of mine pass away. She had a meaningful life, full of faith. Her life was largely dedicated to helping others. So, seeing this old lady I knew die at the age of 96, give or take, during the pandemic, reinforced my faith and made me wish to leave a legacy like hers, devote myself to others, and live surrounded by people.”

IIId. 6. Closeness to Death as a Rebirth

Tania reports that despite the terrible feeling of closeness to death, several patients and their families she came into contact with recounted that, after being discharged, they felt a sense of rebirth. It is not hard to infer that the patients also experienced existential growth from the limit situation of confronting the end of existence face to face.

Tania: “There’s something a patient’s daughter once said that I think left quite an impression on me. I was responsible for telling her that her mother had died, and she told me, ‘I’ve been living my mother’s wake since she came into hospital because, as I haven’t seen her since, it looks to me like she was already dead.’ So, this would be the negative side, but there’s the other side. The patients who lived through the disease – who were not few; they were many – looked like they had been reborn, like they were a different person. Some families called me to thank for the care delivered to their loved ones, and many said it felt like a rebirth. This was frequent in my conversations with the families that reached out.”

IVa. Existential Defense

Existential defense provides “housing” that protects the individual from situations that are potentially threatening. The threatening nature of these situations lies in the revelation of the antinomies inherent in existence, the fragility of that existence in the face of death, and the meaning of existence for Dasein. The present study offers examples of thoughts that function as “housing” that are observed throughout the interviews (see Results IIIa). For example, Hilton describes believing he is too young to die (Results IIIa 2.2). Other participants also provided numerous examples utilizing housing (Results IIIb). In these instances, the individual is confronting their own existence; that is, they are recognizing and finding a way to cope with their finitude. In the words of Jaspers, “to exist is becoming aware of one’s existenz” (see [13]). Recognizing their own existence, in the face of COVID-19, is the source of much of the anxiety reported by participants in the present study. It is the “fear that paralyzed” that invoked the "housing" (Results IIIa 1.1). This feeling was eloquently described by Fabiana (Results IIIa 2.1): “there’s a kind of mental block, I guess (...), because just imagining that everything could come to an end scares me stiff.”

IVb. The COVID-19 Pandemic as a Limit Situation

Basic situations are preconditions of limit situations. Basic situations become limit situations when they cease to be simple generalities and become distressing experiences for the individual. The descriptions of the distress experienced by the medical resident participants during the pandemic can be thought of as limit situations, because they constitute basic situations that were experienced as distressing. Three of these limit situations are especially noteworthy: Having to Fight (Results IIIb. 1.) – either because they worked on the front line, often during a shortage of technical equipment (i.e., protective clothing, ventilators, etc.) needed to match the virus; Possibility of Dying (Results IIIb. 2.) – due to the prospect of contracting the disease; and Being at the Mercy of Change (Results IIIb. 3.) – many were transferred from working in their specialties to the COVID-19 front line. This led to dealing with their insecurities about the adequacy of their training. Unfortunatley for these individuals, it is the antinomic nature of existence that underlies the semantic link between having to fight, the possibility of dying, and being at the mercy of change.

It is notable that in many participant descriptions of their experiences, the main challenge faced was the shift in everydayness (Results IIIb 3) [30, 31]. From an ontic perspective, everyday experience translates to the daily tasks carried out during a certain period, given that the human being is often thrown into a determined sphere of the world [32]. However, the manifestation of anxiety is observed in response to a shift in everydayness, which may be better understood in light of the ontological foundations of existence. In everyday dealings, Dasein finds itself in a context of socially shared practices and understandings related to an impersonal mode of living. In this way, Dasein is under a sort of “tutelage” by others, that is, any others capable of representing that impersonal mode of living [32]. In Heidegger’s words, “What is decisive is just that inconspicuous domination by Others which has already been taken unawares from Dasein as Being-with” (p. 164) [33].

In Heideggerian terms, it can be said that Dasein, in its impersonal everyday mode, is in a situation of serenity because things happen as they are supposed to happen. Events such as the COVID-19 pandemic abruptly altered this connection with the impersonal [34], causing participants to have “days of sadness, boredom, and frustration” more frequently than “in normal life.” In other words, “anxiety breaks everyday impersonal identifications – what was familiar becomes uncanny. Uncanniness, to Heidegger, means not feeling at home” [32]. The return to an impersonal routine, such as that described by Hilton (Results IIIb 3), places him once more in a comfortable situation.

IVc. Changes in Lived Experience and Its Relation to New World Meanings through Lived Experience

The experience of these limit situations has a revealing and dialectical nature: revealing in both the (a) disruption of everydayness, which eventually makes plain the phenomenal constitution of the housing that is employed and destabilized, and (b) conscious experience of this situation, in which individuals become aware of, and reflect upon, their own existence. This experience is also dialectical in so far as it enables, based on existential suffering, a “leap to freedom” in structures competent to deal with the limit situation [13, 35]. Indeed, it is precisely because human existence is essentially dialectical that it can mature and transform across its biographical trajectory [36]. The very nature of human existence as it continuously interacts in opposition, tension, and ambiguity – which is what characterizes the dialectical movement – is what enables this transformation (p. 4) [37]. This process also assigns a specific meaning to each experience, based on its relationship with the meaningful totality of existence. This totality is ontologically rooted in all the relations associated with human existence, both intersubjective and those with the world. What the phenomenological comprehension reveals, therefore, are the a priori (transcendental) foundations that underpin existence and can thus be considered a condition for existential possibility. This condition may be defined as a zone of determinations and restrictions within which experiences can emerge, and a personal biography can develop and express itself (p. 3) [37].

The experience of a limit situation, despite destabilizing the housing and its phenomenal constituents, engenders a new configuration and signification of life. In this respect, the participants have overcome adversity and found support in alternative existential possibilities available under those circumstances, such as interpersonal relations (see examples in Fabiana’s, Eliana’s, and Ursula’s accounts [Results IIIc 2]). Therefore, against possible destabilizations of consciousness, an important tool is intersubjectivity, which acts as a stabilizer of the psychic structure [35].

Across the particpant interviews presented here (see Results IIIc), the evidence of structural destabilization has to do with temporality, spatiality, corporeality, and intersubjectivity [38]. In addition, these accounts make it clear that these disproportions can occur simultaneously. For example, a temporal or intersubjective disproportion can also be felt as a spatial disproportion. To elaborate, the spatial limitations of living everyday life cause mental confusion, similar to interpersonal changes in proximity and distance.

Another example of disproportion can be observed in the account of Clovis (Results IIIc 1.1). Specifically, the characteristics of this experience related to the temporal proportions of activity and waiting [39] are present. Activity is an experience oriented toward the future. Waiting, on the contrary, suspends activity and detains the individual in relation to their future acts. Thus, though the individual does not move toward the future, their impression is the opposite; it is the future that appears to move toward the individual. This type of experience “contains within itself a factor of brutal detention and makes the individual anxious” (pp. 83–7) [39].

In emotional terms, participant accounts (IIIc 1) show that the experience of destabilization can be understood as an experience of anxiety. Although the participants were troubled by anxiety, they showed a noticeable capacity to respond to the pandemic (Results IIId), often resulting in existential gains. Fuchs states that, even though the continuity of one’s planned life is interrupted by a limit situation, this interruption creates an opportunity for freedom, especially the freedom to enter a limit situation, deal with it, and simultaneously find support for an existential “upswing” or Aufschwung [13].

As Heidegger understands anxiety as a basic mood, in which Dasein can stand before itself more authentically, it is possible to provide a phenomenological interpretation of the accounts presented here. The participants’ experience of anxiety awoke them out of their impersonal everyday affairs that existed before the pandemic. Though uncomfortable, the experience of anxiety exposed the uncanniness of the world, which enabled them to establish a more authentic relationship with themselves (see Results IIId). As Heidegger says,

“Anxiety makes manifest in Dasein its Being towards its own most potentiality-for-Being – that is, its Being-free for the freedom of choosing itself and taking hold of itself. Anxiety brings Dasein face to face with its Being-free for (propensio in...) the authenticity of its Being, and for this authenticity as a possibility which it always is. But at the same time, this is the Being to which Dasein as Being-in-the-world has been delivered over” (p. 232–3) [33].

To summarize, the act of entering a limit situation brings to light the housing that is meant to protect individuals from collapse, as they experience alterations in lived experience. The participants who provided their accounts here have come out of a tragic set of circumstances strengthened, having gained self-knowledge and become more authentic. When confronted with limit situations, they found that they could draw on their own resources and, depending on the circumstances, find support not only to overcome adversity but also reap existential gains. These accounts allowed us to understand the lived experiences of medical professionals during the COVID-19 pandemic in terms of the costs and benefits associated with a limit situation.

IVd. Scientific Implications

A qualitative study of phenomenological interpretation should avoid the universalization of results. The methodology applied here assumed that the sample space was circumscribed by a specific context (i.e., medical care delivery during a pandemic). It is the relationship between the participants and the context in which they found themselves that allowed for a meaningful interpretation of their experience [40].

Hence, in addition to exemplifying a theory based on concrete life experiences – which necessarily strengthens it – this study also encourages the reader to reflect on the applicability of the results to their own lives and to seek within themselves possibilities for coping with a similar situation [41, 42]. Indeed, the present study allows readers to transfer conceptual findings to other contexts in their lives [43]. For example, our results point to two practical strategies for coping with a pandemic and its associated social isolation: the first is the need for in-person gatherings and the strengthening of relationships to cope with adversity, a strategy also recommended by other qualitative studies [44‒47]. The second is the need to maintain a routine, however exiguous it may seem (see also [48]). These two strategies predict effective relief of the distress experienced during a pandemic [49‒53].

The present study also calls on physicians to reflect upon their own profession. To elaborate, in order to think or speak about a particular experience, it is necessary to use language. The way in which language is used will shape how physicians assign meaning and existentially perceive their profession. For example, a metaphorical comparison between a physician and a soldier in battle will unnecessarily create a military narrative. This narrative not only implies that a particular situation is highly serious, but also that the situation demands a mortal sacrifice from physicians. Further, the calling of these healthcare professionals as “heroes,” has become a trend during the pandemic – this is counterproductive in a circumstance in which healthcare professionals feel powerless in the face of the virus [48, 54‒57]. Though intended as a tribute, this comparison serves only to heighten fear and anxiety within the healthcare system [10].

Conversely, comparing health care workers’ experiences to limit situations is much more appropriate. More than a metaphor, this is a phenomenological description of an experience that was particularly human and experienced together with peers. In addition, the limit situation comparison is accurate and easily applied. This comparison conveys the idea that facing a pandemic will inevitably cause sadness and sorrow, thereby enabling healthcare professionals to approach this existential mission more openly. After ensuring that certain precautions are taken, there remains the possibility that these professionals will find a free and authentic life within themselves. As attested to by the participants who discovered this existential possibility for themselves, this understanding led to “less fear and more willingness to care.”

Qualitative studies have shown that several groups of individuals who experienced distress during the pandemic emerged from this experience feeling more liberated [47, 58‒68]. These participant groups varied greatly in terms of demographics and contexts. For example, these studies examined everything from the experiences of COVID-infected patients who had recovered, healthcare professionals who dealt with the pandemic, the general adult population in quarantine, and even medical students. Despite these differences, there was a shared experience observed across these differing groups and contexts. Given this diversity, a philosophical theory that can account for this shared experience remains essential for organizing and understanding this phenomenon; the present study uses deep and clear subjective accounts to theoretically underpin this experience. The clarity of the accounts is dialectically supported by and sustains the theory.

The present study also offers an additional practical implication – theoretical knowledge of this type of experience can enable physicians to recognize similar situations more easily. As we have suggested, a deeper perception of human existence will more directly impact medical professional practice, changing the way professionals approach their daily work and deal with the challenges imposed by a pandemic. This will enable physicians to not only better deal with these challenges, but also allow physicians to be more empathic, as they have shared the experiences lived by their patients.

IVe. Scientific Limitations

The purposive sampling implemented here allowed for the identification of individuals who were willing to recount their subjective experiences [69]. That said, our “snowballing” recruitment strategy may have biased our sample to be like-minded, as subsequent participants were known to other participants. In addition, because both the researchers and the participants worked at the same hospital, preconceived notions about the potential findings of the investigation could have influenced the results [70]. To mitigate this possibility, senior researchers, who were hierarchically above the residents, did not take part in the interviews. It is impossible, however, to be certain that these biases were completely absent. Finally, the present study participants constituted a special sample in that they were medical residents at the country’s top medicine residency. Thus, it is not known how these results would generalize to a sample of individuals with fewer linguistic resources [69].

Regarding the limitations of qualitative research, this study was conducted with the methodological rigor proposed by Williams, including transferability, credibility, reflexivity, and transparency to provide the research with greater quality [43]. Despite this methodological rigor, the phenomenological analysis is interpretative. For this reason, we present quotes from participants in the Results section separate from our phenomenological interpretation presented in the Discussion section.

The experience lived by the medical residents in the face of the COVID-19 pandemic can be usefully understood as a limit situation; the residents faced a distressing experience that caused a shift in their everydayness. This shift manifested in social isolation and in the challenges associated with providing clinical care to their patients. These challenges also included the fear of infection, uncertainty about the future, fear of dying, and the emotional overload caused by patient deaths. It is hoped that sharing these qualitative data about this existential experience will promote better coping on the part of physicians by offering a more accurate linguistic description of what happened. This will better prepare them for future similar situations, allowing for a more empathic approach and better care.

An ethics approval (reference number: 4.122.449) was approved by the National Research Ethics Commission (CONEP), from the Brazilian Ministry of Health, and a written informed consent to participate was obtained from all participants in this study.

The authors declare that they have no competing interests.

We have no sources to report.

Flávio Guimarães-Fernandes conducted interviews, discussed the material with the colleagues, and wrote most of the article. Laelia Benoit reviewed the entire text, making necessary modifications in relation to the English language, and helped to reorganize the results. Luiza Magalhães de Oliveira conducted interviews, discussed the material with the colleagues, and wrote the methods part. Paulo Chenaud Neto and Débora Chou Feniman conducted interviews, discussed the material with the colleagues, and wrote the introduction part. Aline Villalobo Correia, Nathaly de Oliveira Bosoni, and Daniela Medina Macaya conducted interviews and discussed the material with the colleagues. Euripedes Constantino Miguel led the main research that enabled the approval of this study by the Ethics Committee and also assisted in rewriting the article, pointing out the necessary modifications to be made. Daniela Ceron-Litvoc and Gustavo Bonini Castellana led the group and organized the discussions as well as raised the main aspects that appeared in the interviews. The authors read and reviewed the article critically and approved the final manuscript.

1

Antinomy refers to the inherent contradictions of life that cannot be overcome and must simply be accepted (e.g., the existence of good and evil, life and death, justice and injustice) [13].

All data generated or analyzed during this study are included in this report. Further inquiries can be directed to the corresponding author.

1.
Carel
H
,
Ratcliffe
M
,
Froese
T
.
Reflecting on experiences of social distancing
.
Lancet
.
2020
;
396
(
10244
):
87
8
. .
2.
Karasu
F
,
Öztürk Çopur
E
,
Ayar
D
.
The impact of COVID-19 on healthcare workers’ anxiety levels
.
Z Gesundh Wiss
.
2022
;
30
(
6
):
1399
409
. .
3.
Vizheh
M
,
Qorbani
M
,
Arzaghi
SM
,
Muhidin
S
,
Javanmard
Z
,
Esmaeili
M
.
The mental health of healthcare workers in the COVID-19 pandemic: a systematic review
.
J Diabetes Metab Disord
.
2020
;
19
(
2
):
1967
78
. .
4.
Greenberg
N
,
Docherty
M
,
Gnanapragasam
S
,
Wessely
S
.
Managing mental health challenges faced by healthcare workers during covid-19 pandemic
.
BMJ
.
2020
;
368
:
m1211
. .
5.
Hummel
S
,
Oetjen
N
,
Du
J
,
Posenato
E
,
Resende de Almeida
RM
,
Losada
R
, et al
.
Mental health among medical professionals during the COVID-19 pandemic in eight European countries: cross-sectional survey study
.
J Med Internet Res
.
2021
;
23
(
1
):
e24983
. .
6.
Brillon
P
,
Philippe
FL
,
Paradis
A
,
Geoffroy
M-C
,
Orri
M
,
Ouellet-Morin
I
.
Psychological distress of mental health workers during the COVID-19 pandemic: a comparison with the general population in high- and low-incidence regions
.
J Clin Psychol
.
2022
;
78
(
4
):
602
21
. .
7.
Hennein
R
,
Mew
EJ
,
Lowe
SR
.
Socio-ecological predictors of mental health outcomes among healthcare workers during the COVID-19 pandemic in the United States
.
PLoS One
.
2021
;
16
(
2
):
e0246602
. .
8.
Carvalho-Alves
MO
,
Petrilli-Mazon
VA
,
Brunoni
AR
,
Malbergier
A
,
Fukuti
P
,
Polanczyk
GV
, et al
.
Dimensions of emotional distress among Brazilian workers in a COVID-19 reference hospital: a factor analytical study
.
J Psychiatry
.
2022
;
12
(
6
):
843
59
. .
9.
Miethke-Morais
A
,
Perondi
B
,
Harima
L
,
Montal
AC
,
Baldassare
RM
,
Moraes
DP
, et al
.
Overcoming barriers to providing comprehensive inpatient care during the COVID-19 pandemic
.
Clinics
.
2020
;
75
:
e2100
. .
10.
Brencio
F
.
Mind your words. Language and war metaphors in the COVID-19 pandemic
.
rpfc
.
2020
;
9
(
2
):
58
73
. .
11.
Fukuti
P
,
Uchôa
CLM
,
Mazzoco
MF
,
Cruz
ID
,
Echegaray
MV
,
Humes
EC
, et al
.
COMVC-19: a Program to protect healthcare workers’ mental health during the COVID-19 Pandemic. What we have learned
.
Clinics
.
2021
;
76
:
e2631
. .
12.
Scarduelli
FCV
,
Fukuti
P
,
Corchs
F
,
Miguel
EC
,
Humes
EC
.
COMVC-19, a program to protect healthcare workers’ mental health during the COVID-19 pandemic, and the second wave of the pandemic: a new moment and the impact of previous experiences
.
Clinics
.
2021
;
76
:
e3574
. .
13.
Fuchs
T
.
Existential vulnerability: toward a psychopathology of limit situations
.
Psychopathology
.
2013
;
46
(
5
):
301
8
. .
14.
Jaspers
K
.
Psicología de las concepciones del mundo [Psychologie der Weltanschauungen]
.
Madrid
:
Gredos
;
1967
.
15.
Giacoia
O
Jr.
.
Heidegger urgente: introdução a um novo pensar
.
São Paulo
:
Três Estrelas
;
2013
.
16.
Sibeoni
J
,
Verneuil
L
,
Manolios
E
,
Révah-Levy
A
.
A specific method for qualitative medical research: the IPSE (inductive process to analyze the structure of lived experience) approach
.
BMC Med Res Methodol
.
2020
;
20
(
1
):
216
. .
17.
Castellana
GB
,
Barros
DM
,
Serafim
AP
,
Busatto Filho
G
.
Psychopathic traits in young offenders vs. non-offenders in similar socioeconomic condition
.
Braz J Psychiatry
.
2014
;
36
(
3
):
241
4
. .
18.
Castellana
GB
,
Schraiber
LB
,
de Oliveira
TR
,
de Barros
DM
.
“I would prefer not to”: assessing competence to consent in a case of refusal of cancer treatment
.
Clin Ethics
.
2019
;
14
(
1
):
42
5
. .
19.
Ceron-Litvoc
D
,
Messas
GP
.
Análise Fenômeno-estrutural da Temporalidade no Primeiro ano de Vida
.
Rev Subj
.
2019
;
19
(
1
):
1
12
. .
20.
Ceron‐Litvoc
D
,
Soares
BG
,
Geddes
J
,
Litvoc
J
,
de Lima
MS
.
Comparison of carbamazepine and lithium in treatment of bipolar disorder: a systematic review of randomized controlled trials
.
Hum Psychopharmacol
.
2009
;
24
(
1
):
19
28
. .
21.
Sattin-Bajaj
C
.
On the same page: a formal process for training multiple interviewers
.
Qual Rep
.
2018
;
23
(
7
):
1688
701
. .
22.
Palinkas
LA
,
Horwitz
SM
,
Green
CA
,
Wisdom
JP
,
Duan
N
,
Hoagwood
K
.
Purposeful sampling for qualitative data collection and analysis in mixed method implementation research
.
Adm Policy Ment Health
.
2015
;
42
(
5
):
533
44
. .
23.
Parker
C
,
Scott
S
,
Geddes
A
. In:
Atkinson
P
,
Delamont
S
,
Cernat
A
,
Sakshaug
JW
,
Williams
RA
, editors.
Snowball sampling
.
SAGE Research Methods Foundations
;
2023
. .
24.
Fusch
P
,
Ness
LR
.
Are we there yet? Data saturation in qualitative research
.
Qual Rep
.
2015
;
20
:
1408
16
. .
25.
Hennink
MM
,
Kaiser
BN
,
Marconi
VC
.
Code saturation versus meaning saturation: how many interviews are enough
.
Qual Health Res
.
2017
;
27
(
4
):
591
608
. .
26.
Fontanella
BJB
,
Luchesi
BM
,
Saidel
MGB
,
Ricas
J
,
Turato
ER
,
Melo
DG
.
Amostragem em pesquisas qualitativas: proposta de procedimentos para constatar saturação teórica
.
Cad Saude Publica
.
2011
;
27
(
2
):
388
94
. .
27.
Barcellos
C
,
Xavier
DR
.
As diferentes fases, os seus impactos e os desafios da pandemia de covid-19 no Brasil
.
Rev Eletron Comun Inf Inov Saude
.
2022
;
16
(
2
). .
28.
Messas
G
,
Tamelini
M
.
The pragmatic value of notions of dialectics and essence in phenomenological psychiatry and psychopathology
.
Thaumàzein
.
2018
;
6
:
93
115
.
29.
Fuchs
T
.
Körper haben oder Leib sein
.
Gesprächspsychotherapie und Personzentrierte Beratung
.
2015
;
3
:
144
50
.
30.
Okoloba
M
,
Ogueji
I
,
Darroch
S
,
Ogueji
A
.
A multinational pilot study on the lived experiences and mental health impacts from the COVID-19 pandemic
.
Glob Psychiatry
.
2020
;
0
(
0
). .
31.
Prezotti
JA
,
Henriques
JVT
,
Favorito
LA
,
Canalini
AF
,
Machado
MG
,
Brandão
TB
, et al
.
Impact of COVID-19 on education, health and lifestyle behaviour of Brazilian urology residents
.
Int Braz J Urol
.
2021
;
47
(
4
):
753
76
. .
32.
Vial Roehe
M
,
Dutra
E
.
Dasein, o entendimento de Heidegger sobre o modo de ser humano
.
Av Psicol Latinoam
.
2014
;
32
(
1
):
105
13
. .
33.
Heidegger
M
.
Being and time
.
Translated by J. Macquarrie, E. Robinson
. 17th ed.
Oxford
:
Blackwell
;
2001
.
34.
Wei
Y
,
Tang
J
,
Zhao
J
,
Liang
J
,
Li
Z
,
Bai
S
.
Association of loneliness and social isolation with mental disorders among medical residents during the COVID-19 pandemic: a multi-center cross-sectional study
.
Psychiatry Res
.
2023
;
327
:
115233
. .
35.
Isao Miyamoto
W
,
Guimarães-Fernandes
F
,
Ceron-Litvoc
D
.
The quarantine experience set off by the COVID-19 pandemic, seen from a phenomenological perspective
.
rpfc
.
2020
;
9
(
2
):
24
57
. .
36.
Messas
G
,
Fukuda
LO
.
O diagnóstico psicopatológico fenomenológico da perspectiva dialético-essencialista
.
Rev Pesq Qual
.
2018
;
6
(
11
):
160
91
. .
37.
Messas
G
.
The existential structure of substance misuse: a psychopathological study
.
Cham
:
Springer
;
2021
.
38.
Velasco
PF
,
Perroy
B
,
Gurchani
U
,
Casati
R
.
Lost in pandemic time: a phenomenological analysis of temporal disorientation during the Covid-19 crisis
.
Phenomenol Cogn Sci
.
2022
;
22
(
5
):
1121
44
. .
39.
Minkowski
E
.
El tiempo vivido. Mexico D.F
.
Fondo de Cultura Económica
;
1973
.
40.
Feldon
DF
,
Tofel-Grehl
C
.
Phenomenography as a foundation for mixed models research
.
Am Behav Sci
.
2018
;
62
(
7
):
887
99
. .
41.
Wagstaff
C
,
Jeong
H
,
Nolan
M
,
Wilson
T
,
Tweedlie
J
,
Phillips
E
, et al
.
The accordion and the deep bowl of spaghetti: eight researchers’ experiences of using IPA as a methodology
.
Qual Rep
.
2014
;
19
(
24
):
1
15
. .
42.
Neubauer
BE
,
Witkop
CT
,
Varpio
L
.
How phenomenology can help us learn from the experiences of others
.
Perspect Med Educ
.
2019
;
8
(
2
):
90
7
. .
43.
Williams
V
,
Boylan
A-M
,
Nunan
D
.
Critical appraisal of qualitative research: necessity, partialities and the issue of bias
.
BMJ Evid Based Med
.
2020
;
25
(
1
):
9
11
. .
44.
Fernández-Basanta
S
,
Espremáns-Cidón
C
,
Movilla-Fernández
M-J
.
Novice nurses’ transition to the clinical setting in the COVID‐19 pandemic: a phenomenological hermeneutic study
.
Collegian
.
2022
;
29
(
5
):
654
62
. .
45.
Hurly
J
.
Along Came a Virus: leisure in a Dangerous Time Hermeneutic phenomenological explorations of the lifeworld experiences and meanings of leisure of African immigrant mothers and daughters, during the COVID-19 pandemic [dissertation]
.
Edmonton, AB
:
University of Alberta
;
2022
.
46.
Son
H-M
,
Choi
W-H
,
Hwang
Y-H
,
Yang
H-R
.
The lived experiences of COVID-19 patients in South Korea: a qualitative study
.
Int J Environ Res Public Health
.
2021
;
18
(
14
):
7419
. .
47.
Liu
Q
,
Luo
D
,
Haase
JE
,
Guo
Q
,
Wang
XQ
,
Liu
S
, et al
.
The experiences of health-care providers during the COVID-19 crisis in China: a qualitative study
.
Lancet Glob Health
.
2020
;
8
(
6
):
e790
8
. .
48.
Zubek
J
,
Ziembowicz
K
,
Pokropski
M
,
Gwiaździński
P
,
Denkiewicz
M
,
Boros
A
.
Rhythms of the day: how electronic media and daily routines influence mood during COVID‐19 pandemic
.
Appl Psychol Health Well Being
.
2022
;
14
(
2
):
519
36
. .
49.
Holmes
EA
,
O'Connor
RC
,
Perry
VH
,
Tracey
I
,
Wessely
S
,
Arseneault
L
, et al
.
Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science
.
Lancet Psychiatr
.
2020
;
7
(
6
):
547
60
. .
50.
Labrague
LJ
.
Psychological resilience, coping behaviours and social support among health care workers during the COVID‐19 pandemic: a systematic review of quantitative studies
.
J Nurs Manag
.
2021
;
29
(
7
):
1893
905
. .
51.
Gayatri
M
,
Irawaty
DK
.
Family resilience during COVID-19 pandemic: a literature review
.
Fam J Alex Va
.
2022
;
30
(
2
):
132
8
. .
52.
Fuller
HR
,
Huseth-Zosel
A
.
Lessons in resilience: initial coping among older adults during the COVID-19 pandemic
.
Gerontologist
.
2021
;
61
(
1
):
114
25
. .
53.
Fu
X-W
,
Wu
L-N
,
Shan
L
.
Review of possible psychological impacts of COVID-19 on frontline medical staff and reduction strategies
.
World J Clin Cases
.
2020
;
8
(
15
):
3188
96
. .
54.
Nelson
H
,
Hubbard Murdoch
N
,
Norman
K
.
The role of uncertainty in the experiences of nurses during the Covid-19 pandemic: a phenomenological study
.
Can J Nurs Res
.
2021
;
53
(
2
):
124
33
. .
55.
Khatatbeh
M
,
Alhalaiqa
F
,
Khasawneh
A
,
Al-Tammemi
AB
,
Khatatbeh
H
,
Alhassoun
S
, et al
.
The experiences of nurses and physicians caring for COVID-19 patients: findings from an exploratory phenomenological study in a high case-load country
.
Int J Environ Res Public Health
.
2021
;
18
(
17
):
9002
. .
56.
Phillips
J
,
Alipio
JK
,
Hoskins
JL
,
Cohen
MZ
.
The experience of frontline nurses during the COVID-19 pandemic: a phenomenological study
.
West J Nurs Res
.
2023
;
45
(
4
):
327
34
. .
57.
Brockopp
D
,
Monroe
M
,
Davies
CC
,
Cawood
M
,
Cantrell
D
.
COVID-19: the lived experience of critical care nurses
.
J Nurs Adm
.
2021
;
51
(
7–8
):
374
8
. .
58.
Wang
Y
,
Pan
X
,
Bai
Y
.
The experience of patients with COVID-19 in China: an interpretative phenomenological analysis
.
Psychol Res Behav Manag
.
2021
;
14
:
877
87
. .
59.
Oorsouw
R
,
Oerlemans
A
,
Klooster
E
,
Berg
M
,
Kalf
J
,
Vermeulen
H
, et al
.
A sense of being needed: an interpretative phenomenological analysis of hospital-based allied health professionals’ experiences during the COVID-19 pandemic
.
Phys Ther
.
2022
;
102
(
6
):
pzac052
. https://doi.org/10.1093/ptj/pzac052.
60.
Yip
Y-C
,
Yip
K-H
,
Tsui
W-K
.
Psychological experiences of patients with coronavirus disease 2019 (COVID-19) during and after hospitalization: a descriptive phenomenological study
.
Int J Environ Res Public Health
.
2022
;
19
(
14
):
8742
. .
61.
Ardakani
MF
,
Farajkhoda
T
,
Mehrabbeik
A
.
Lived experiences of recovered COVID-19 patients after hospitalization: a phenomenological research
.
Iran J Nurs Midwifery Res
.
2022
;
27
(
4
):
308
16
. .
62.
Sun
N
,
Wei
L
,
Wang
H
,
Wang
X
,
Gao
M
,
Hu
X
, et al
.
Qualitative study of the psychological experience of COVID-19 patients during hospitalization
.
J Affect Disord
.
2021
;
278
:
15
22
. .
63.
Aldiabat
K
,
Alsrayheen
E
,
Valsaraj
BP
,
Abu Baker
R
,
Al-Harthi
I
,
Qutishat
M
, et al
.
The lived experiences of COVID-19 quarantined Omani adults: a phenomenological study
.
Am J Qual Res
.
2022
;
6
(
3
):
229
50
. .
64.
Finstad
GL
,
Giorgi
G
,
Lulli
LG
,
Pandolfi
C
,
Foti
G
,
León-Perez
JM
, et al
.
Resilience, coping strategies and posttraumatic growth in the workplace following COVID-19: a narrative review on the positive aspects of trauma
.
Int J Environ Res Public Health
.
2021
;
18
(
18
):
9453
. .
65.
Asiones
N
.
COVID-19 and the mental health crisis faced by students from a private university in the Philippines: a phenomenological study
.
Fam J Alex Va
.
2023
:
106648072311570
. .
66.
Firouzkouhi
M
,
Kako
M
,
Abdollahimohammad
A
,
Nouraei
M
,
Azizi
N
,
Mohammadi
M
.
Lived experiences of the patients with COVID-19: a hermeneutic phenomenology
.
J Caring Sci
.
2023
;
12
(
1
):
57
63
. .
67.
Luong
V
,
Burm
S
,
Bogie
BJ
,
Cowley
L
,
Klasen
JM
,
MacLeod
A
, et al
.
A phenomenological exploration of the impact of COVID‐19 on the medical education community
.
Med Educ
.
2022
;
56
(
8
):
815
22
. .
68.
Alzayani
S
,
Al-Roomi
K
,
Ahmed
J
.
The lived experience of medical students during COVID-19 pandemic: the impact on lifestyle and mental wellbeing
.
Arab Gulf J Sci Res
.
2022
;
40
(
4
):
415
23
. .
69.
Sass
L
,
Pienkos
E
.
Varieties of self-experience: a comparative phenomenology of melancholia, mania, and schizophrenia, Part I
.
J Conscious Stud
.
2013
;
20
(
7–8
):
103
30
.
70.
Laverty
SM
.
Hermeneutic phenomenology and phenomenology: a comparison of historical and methodological considerations
.
Int J Qual Methods
.
2003
;
2
(
3
):
21
35
. .