https://doi.org/10.1177/0020764020942788 International Journal of Social Psychiatry 1 –10
© The Author(s) 2020 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/0020764020942788 journals.sagepub.com/home/isp E CAMDEN SCHIZOPH
Introduction
The outbreak of coronavirus disease 2019 (COVID-19), which began in Wuhan, China, continues to spread rapidly around the world (Liu et al., 2020). In Turkey, the first COVID-19 cases were reported on 10 March 2020. The data are updated daily, and, as of June 2020, there are more than 191,600 diagnosed cases, with over 5,000 deaths and over 164,200 recoveries (Republic of Turkey Ministry of Health, 2020a).
The extant literature on this subject states that the con-tinuously increasing numbers of COVID-19 patients, the increased workload, the limited availability of personal protective equipment, positive cases and death news in the media get around rapidly, the lack of specific treatment medications and the lack of support may increase the men-tal health burdens of healthcare workers (Lai et al., 2020). Studies conducted on previous outbreaks have stated that mental problems may emerge as a result of the acute effect
of an outbreak (Bai et al., 2004; A. M. Lee et al., 2007; Maunder et al., 2003).
Nurses, as a major population of healthcare profession-als serving in the COVID-19 pandemic, continue to serve in diagnosing, treating and caring for patients for weeks with limited resources (Newby et al., 2020). The literature states that nurses, who are faced with this critical condi-tion and who are at risk of infeccondi-tion, are exposed to sig-nificant stress, and this intensely experienced stress brings
Experiences and psychosocial problems of
nurses caring for patients diagnosed with
COVID-19 in Turkey: A qualitative study
Ozlem Kackin, Emre Ciydem , Ozgur Sema Aci
and Fatma Yasemin Kutlu
Abstract
Background: Nurses, who are playing an important role during the coronavirus disease 2019 (COVID-19) outbreak, are exposed to a range of psychosocial stressors due to unforeseen risks.
Objectives: The objective of this study is to determine the experiences and psychosocial problems of nurses caring for patients diagnosed with COVID-19 in Turkey.
Settings: The data were collected between 9 May and 12 May 2020, in Istanbul, Turkey.
Participants: The study sample consisted of 10 nurses, who cared for patients diagnosed with COVID-19.
Methods: The research employed the descriptive phenomenological approach. The interviews were conducted face-to-face via the internet and were analysed with Colaizzi’s seven-step method.
Results: The experiences and psychosocial problems among nurses caring for patients diagnosed with COVID-19 were categorised under three themes, which were further divided into subcategories. The theme of the effects of the outbreak was divided into working conditions, psychological effects and social effects; the theme of short-term coping strategies was divided into normalisation, refusal to dwell on experiences, avoidance, expression of emotions and distraction; and the theme of necessities was divided into psychosocial support and resource management.
Conclusion: The nurses caring for patients diagnosed with COVID-19 in Turkey were adversely affected, both psychologically and socially, by the pandemic; they used short-term coping strategies, and they needed psychosocial support and resource management. They also faced stigmatising attitudes and experiencing burnout and were at risk for secondary traumas due to witnessing disease and death.
Keywords
Coronavirus disease 2019 (COVID-19), nurse, psychosocial, coping, qualitative study
Department of Mental Health and Psychiatric Nursing, Florence Nightingale Nursing Faculty, Istanbul University – Cerrahpaşa, Istanbul, Turkey
Corresponding author:
Emre Ciydem, Department of Mental Health and Psychiatric Nursing, Florence Nightingale Nursing Faculty, Istanbul University – Cerrahpaşa, Abide-i Hürriyet Cd, Şişli, 34381 Istanbul, Turkey.
Email: emreciydem@hotmail.com
psychosocial problems along with it (Huang et al., 2020; Lai et al., 2020).
The COVID-19 outbreak affected various countries in a short time, but at different intervals. The outbreak arriving in Turkey later than in other countries presented the oppor-tunity to make some preparations, but pandemic periods contain unforeseen risks. Nurses are exposed to a range of psychosocial stressors because of these risks, and it may also be said that nurses diagnosing, treating and caring for COVID-19 patients in Turkey will experience similar risks, problems and concerns. The present research, which is among the first studies on the subject conducted in Turkey, aims to expand the scope of the available informa-tion on the topic at hand by contributing results from a different geography and culture. The nurse perspectives revealed by the research outcomes may guide organisa-tions towards taking the necessary precauorganisa-tions to ensure employee health and safety. The results may also guide non-governmental organisations and the state in establish-ing necessary policies via psychosocial support studies to increase the mental well-being of nurses caring for COVID-19 patients in Turkey. Although healthcare teams serve together in the care process, task distributions and levels of experience among the team members may vary. Thus, the experiences of nurses can expand the scope of information in the current literature.
The purpose of this study was, therefore, to determine the experiences and psychosocial problems among nurses caring for COVID-19 patients in Turkey.
Methods
Throughout this study, the authors followed the Standards for Reporting Qualitative Research (Tong et al., 2007).
Design
This study employed a descriptive phenomenological research pattern, which is a qualitative research method. Descriptive phenomenology describes individuals’ daily life experiences, as well as the meanings of these experi-ences as interpreted by those who live them (Husserl, 1960). This approach was chosen in the current research to reveal the experiences and psychosocial problems of nurses caring for patients diagnosed with COVID-19 in Turkey and to understand the nurses’ feelings, thoughts and perspectives.
Research team and reflexivity
The researchers have been working as research assistants (PhD students) and faculty members (Professor) on a nurs-ing faculty in the department of mental health and psychi-atric nursing. They have worked as nurses/supervisors in hospitals in the past. Two of the researchers are 28, one is
34, and another is 58 years old. Two have completed psy-choanalytic psychotherapy training, and one is continuing to receive this training along with psychodrama training. The researchers are three females and one male, all of whom are trained in qualitative research. The researchers were also acquainted with six of the participants.
Setting and time
The data were collected between 9 May and 12 May 2020, in Istanbul.
Sample
The study sample consisted of nurses who cared for patients diagnosed with COVID-19. The most important determinant in the phenomenological pattern of selecting study groups is that the chosen participants must have experienced the examined phenomenon in all its aspects (Creswell, 2020). Thus, to be included in this study, nurses were required to be over the age of 18 years and to have cared for patients diagnosed with COVID-19. The study sample was chosen via the snowball technique, which is a purposive sampling method. To determine the number of nurses for the sample, data saturation in qualitative research was considered, and data saturation was found to be achievable with 10 nurses (N = 10).
Data collection tools
Data were collected with a Questionnaire Form and a Semi-Structured Interview Form. The researchers created the Questionnaire Form in line with the extant literature. The form consisted of 18 questions asking for information about individual and professional characteristics, about how the participants had cared for COVID-19 patients and about the related results (Lai et al., 2020). The researchers also created the Semi-Structured Interview Form in line with the extant literature, and it consisted of the following three open-ended questions (Huang et al., 2020; Lai et al., 2020; A. M. Lee et al., 2007):
1. What experiences did you have while caring for a patient diagnosed with COVID-19?
2. What psychosocial problems have you experienced when caring for a patient diagnosed with COVID-19?
3. Could you please explain your views on your cop-ing strategies when carcop-ing for a patient diagnosed with COVID-19?
Data collection process
The data were collected via an individual, in-depth inter-view technique. Before beginning the research interinter-views,
pilot interviews were held with two participants other than the main participants. The interview process and questions were modified in line with these pilot interviews.
Due to the safety measures taken within the scope of COVID-19, individual, in-depth interviews were con-ducted by three of the researchers (O.K., E.C. or O.S.A.) in a one-on-one, face-to-face format via the Internet. First, the individuals chosen by the snowball sampling method were called on the phone; the research purpose and method were explained to those participants who met the inclusion criteria; and times for the online interviews were arranged. The interviews were held in quiet, convenient home envi-ronments for a properly executed conversation. During each interview, the interviewer and participant were alone. Written and verbal consents were obtained from the par-ticipants at the beginning of each online interview. The interviews lasted between approximately 45 and 90 min-utes. Written notes and a voice recorder were used to record both verbal and nonverbal expressions. Interview transcripts were sent to the participants for approval, fur-ther comments and/or corrections.
Strengths and limitations
This research presents several overarching strengths. In scanning the literature, the researchers determined that the qualitative studies related to the COVID-19 outbreak were limited and that there was no study regarding nurses com-bating the pandemic in Turkey. As the authors could not go to hospitals, due to the safety measures implemented within the scope of outbreak, the interviews were conducted online. However, the participants were interviewed face-to-face via a video call. This method allowed for both verbal and nonverbal data to be acquired. The interviewers were trained in interviewing skills, and experts and peers were informed about the interview process after each interview. The Semi-Structured Interview Form and the interview process were revised via pilot interviews. The researches also believed that obtaining the data from different institu-tions, and using a sample consisting solely of nurses, could better explain the common experiences on the subject.
However, the study also had several limitations. For instance, precise and generalisable results could not be attained because the research implemented a qualitative design and because the sample size was restricted. The study was also conducted in the short-term, and the long-term experiences of the research subjects would be a valu-able avenue for future exploration.
Ethical issues
Ethical approval was obtained from the Istanbul University – Cerrahpaşa Social and Humanities Ethics Committee (08.05.2020-60247). Permission was also
granted by the Council for Scientific Research Studies of the Directorate General of Health Services affiliated to the Ministry of Health, Republic of Turkey. At the begin-ning of the online meetings, the participants were informed of the provisions of the 1995 Declaration of Helsinki (as revised in Brazil, 2013), and their written and verbal consents were obtained. When the partici-pants’ information was being collected and stored, the researchers paid close attention to the principle of confi-dentiality. To this end, all identifying information was anonymised by assigning nicknames during transcrip-tion. The transcriptions were shared with all participants for their approval. Voice recordings, transcripts and interview notes were stored on a password-protected computer, and all obtained data will be destroyed 5 years after the completion of the research and publication procedures.
Data analysis
The voice recordings obtained from the interviews were converted into writing by E.C. Afterwards, the consistency between the recordings and the transcripts was checked by F.Y.K. Data were coded by all four researchers (O.K., E.C., O.S.A. and F.Y.K.). After the researchers coded the first four transcripts independently, they came together to make a joint decision regarding the codes. Themes were then obtained from the data. The MAXQDA 20.0 statistics software package and Colaizzi’s (1978) phenomenological analysis steps were used for data analysis (Colaizzi, 1978). The following steps were implemented in this process:
1. Transcripts were read several times, and short notes were taken to understand the meanings attrib-uted to a phenomenon and the emotions experienced.
2. Important expressions directly related to a phe-nomenon were selected.
3. These important expressions were examined, and expressions with common meanings were formulated.
4. The formulated meanings were grouped into cate-gories, themes and subthemes.
5. The obtained results were combined with rich, comprehensive life experiences.
6. The basic conceptual structure of the phenomenon in question was defined.
7. The results were confirmed through another meet-ing with the participants in which their experiences were compared with the results obtained.
The acquired themes and codes were examined by an expert, experienced academician apart from the main researchers, and the results were determined to overlap.
Trustworthiness
The trustworthiness of this study was realised based on the following four criteria: credibility, transferability, depend-ability and confirmdepend-ability (Lincoln & Guba, 1985). Credibility was achieved by obtaining participant approval, describing the studied phenomenon in detail, using the MAXQDA 20.0 software package to analyse the data, comparing the results with the findings of previous research, conducting researcher meetings at short intervals to discuss the research process and advantageously imple-menting the intertextual qualifications and experiences of the researchers. To ensure transferability, the research sample, environment and process were presented clearly. Intertextual participant statements were quoted directly, and detailed definitions were developed between the stud-ied context and the study itself. Dependability was achieved through inter-coder consistency and by sending all data collection tools, the raw data, the encodings made during the analysis phase and the drawn inferences to a specialist not involved in the research. Confirmability was ensured by using more than one data collection method, considering each researcher’s reflective comments and having each researcher code the data individually.
Results
The findings are presented in two sections. The first por-tion provides findings related to the individual and profes-sional characteristics of nurses, and the second portion presents the themes drawn from the results:
1. Findings related to individual and professional characteristics of the nurses.
The individual and professional characteristics of the nurses caring for COVID-19 patients are given in Table 1.
2. Themes.
Based on the data analysis, the experiences of the nurses caring for COVID-19 patients, as well as the nurses’ opin-ions about the psychosocial problems they experienced, were gathered into three themes: ‘effects of the outbreak’, ‘short-term coping strategies’ and ‘needs’. The categories, codes and sample quotations identified for each theme are presented in Table 2.
Discussion
During the interviews, this study observed that the sam-pled nurses were both sad and stressed due to the morbid-ity, mortality and unpredictable risks of the pandemic. It was also determined that they were tired because of wors-ening working conditions, rather than because of changing working hours, but they were still willing to combat the pandemic.
Effects of the outbreak
Nurses reported that the quality of patient care was nega-tively affected, and ethical dilemmas emerged due to wors-ening working conditions and changing routines during the outbreak. Similarly, Sun et al. (2020) report that nurses’ normal working hours and workloads have increased by approximately 1.5–2 times due to the COVID-19 outbreak (Sun et al., 2020). During the pandemic in Turkey, nurses’ workplaces have been changed, and new nurses have been recruited to be able to fill out the health workforce. All nurses have been trained in the pandemic, with priority given to nurses who were recently beginning in the profes-sion. Hospital managers have made the necessary arrange-ments to protect pregnant nurses or nurses with chronic disorders (Republic of Turkey Ministry of Health, 2020b). However, these new arrangements may have caused the working conditions to worsen and the routines to change.
Liu et al. (2020) report that healthcare professionals should be informed about preventing and controlling infection and that hospitals should provide safe working environments (Liu et al., 2020). It has also been reported that the following points could contribute to bettering per-sonal and team performance: the authorities providing information about personal protective equipment, setting maximum working hours and reasonable shift times to protect nurses from excessive workload, providing infor-mation on ethical dilemmas that may occur in connection with the outbreak and using supportive statements and effective communication techniques (Adams & Walls, 2020; Vincent & Creteur, 2020). In addition, effective communication, clear descriptions of individual and team roles, the establishment of standardised procedures and the development of a sense of belonging can help prevent con-flicts caused by differences in procedures and communica-tion while working with staff from various specialties and clinics (Karam et al., 2018).
This study has found that the nurses felt fear and anxi-ety; their obsessions increased, and they showed depressive symptoms. These findings are supported by other studies reporting that healthcare professionals have felt negative emotions, such as anxiety and fear, in the early stages of the pandemic (S. H. Lee et al., 2005; Maunder et al., 2006). These psychological reactions are normal reactions to cri-ses. However, the rapid spread of COVID-19, its treatment being unclear and healthcare workers becoming infected and dying in many countries (including Turkey) may have triggered these reactions. Also, in this process, some par-ticipants living with their families (i.e. worrying they might infect their loved ones), being stigmatised by society or being in the process of social isolation or quarantine, may have increased their anxiety and fear.
Nurses caring for COVID-19 patients have been reported to be at risk for various mental problems later in the pandemic (World Health Organization, 2020; Xiang et al., 2020). Thus, monitoring nurses’ mental problems and implementing early intervention methods, such as
Table 1.
Individual and professional characteristics of nurses caring for patients diagnosed with COVID-19.
Nurse No. Nurse 1 Nurse 2 Nurse 3 Nurse 4 Nurse 5 Nurse 6 Nurse 7 Nurse 8 Nurse 9 Nurse 10 Nurse’s age 40 27 24 29 33 30 29 25 27 33 Nurse’s gender Male Female Female Female Female Male Female Female Female Female
Nurse’s education status
Bachelor Bachelor Master degree Bachelor Master degree Bachelor Bachelor Bachelor Master degree Bachelor Marital status Single Single Single Married Single Married Single Single Single Single Number of children 2 0 0 0 0 2 0 0 0 0
Number of relatives living together
5 3 1 1 0 4 0 5 5 0 Original department Urology Urology
The Turkish Red Crescent Hemodialysis Centre Operating Room
Neonatal İntensive Care Unit
İnfectious Diseases İnternal Medicine
Cardiology
Neurology
Worked on COVID-19 ward department
Pulmonology
Pulmonology
The Turkish Red Crescent Hemodialysis Centre COVID-19 Clinic Infectious Diseases Infectious Diseases Intensive Care Unit Infectious Diseases Intensive Care Unit
Hours/week worked on COVID-19 ward before interview
40 hours 40 hours 40 hours 56 hours 56 hours 40 hours 56 hours 60 hours 40 hours 40 hours
Length of care to COVID-19 patient (day)
7 days 64 days 45 days 30 days 14 days 30 days 30 days 22 days 4 days 42 days
Hours/week worked on COVID-19 ward
26 hours 24 hours 40 hours 56 hours 56 hours 56 hours 48 hours 62 hours 48 hours 56 hours
Caring for patients with infectious diseases before COVID-19 ward
No Yes No Yes No No Yes Yes Yes No
Going home status
No Yes No Yes Yes No Yes Yes No No
COVID 19 diagnosis with relatives
No No Yes No No No Yes Yes No Yes
COVID-19 transmission to herself/ himself
No No No No No No No No No No Psychiatric disease No No Yes No No No No No No No
Table 2.
Themes, categories, codes and sample quotations identified in interviews with nurses.
Theme
Sub-theme
Codes
Quotations
Effects of the outbreak
(a)
Working conditions
Lack of equipment, unfairness in work distribution, change of the working unit, worsening working conditions, process management, being appreciated as healthcare personnel, difficulty in working with different team members, decreased quality of care, obligation to make ethical decisions, and the risk of infection due to frequent contact in nursing
Nurse 1: ‘We need to be a little better about the equipment .
.
.’.
Nurse 6: ‘.
.
. You cannot readily intervene when there is an emergency. After all, as you have to
think about yourself, it could be an issue .
.
.’.
Nurse 6: ‘While the assistant or the doctor enters the patient room o
nce a day, we enter the same
room 10 to 15 times. Therefore, it is more likely to infect us .
.
.’.
Nurse 7: ‘Nurses I have never known or seen. They were assigned to our service unit from another one. I don’t know their reactions .
.
. we had a dispute the other day with another Nurse .
.
. It
feels as if working in another hospital. Different patients, a different or
der’.
Nurse 8: ‘There is a patient lying there, you know that the patient nee
ds you, but wearing that
protective equipment, feeling his/her physical pain in your own body, you may have to work for an hour at most once you wear the helmet. It gives you a headache. You cannot enter the isolation rooms without those garments, and those garments are extremely smo
thering you. Sometimes,
leaving the room when we admit new patients can take 2.5-3 hours without exaggeration. When we leave, you find yourself in full of sweat .
.
.’.
Nurse 8: ‘I feel that the quality of patient care has dropped down due to the inadequate equipment, uncertain treatment, and the risk of transmission, so I feel sorry’.
(b)
Psychological effects
Stress, increased obsessions, feeling threatened, uncertainty about the future, increased anxiety, increased attention and concentration, introversion, aggression, increased hygiene measures, witnessing the process of deceased COVID-19 patients go through, feeling suspicious, feeling as if infected with COVID-19 with the slightest symptom, life becoming meaningless, depressive symptoms, fear
Nurse 2: ‘.
.
. Uncertainty, .
.
. really uncertainty about everything .
.
. what will happen to the
hospital, what will happen to us when we go home’. Nurse 2: ‘I left my family alone .
.
. My mother suffers from high blood pressure, what happens if she
becomes infected .
.
. there is the fear of losing her .
.
.’.
Nurse 5: ‘I did not tell my parents that I was working in the Corona ward because they would worry, I only told my brother and my sister. I told them I would only go to 4 watches’. Nurse 7: ‘.
.
. I was already a little obsessive .
.
. I constantly wash my hands and disinfect them. I
constantly wash my clothes, take a bath right away. Now my obsession
has increased even more’.
Nurse 9: ‘.
.
. I was shocked when I saw how the dead bodies were sealed. It is very different from
the application we do in our routine. Nobody wants to die or say goodby
e to life .
.
. You think that
when you see this situation, the same might happen to me or my family .
.
. you go crazy .
.
. So I
feel like we’re going to live through the judgement day .
.
.’.
(c)
Social effects
stigma, spending the most amount of time in hospital, risk of transmission, social isolation
Nurse 7: ‘I can’t leave home. Our life is just from home to work, from work to home .
.
. When I
can’t meet my friends, there is not much left to talk about on the phone
’.
Nurse 9: ‘My social relationships have decreased a lot, I cannot see my
friends, my best friend was
supposed come visit me after a month, but those in the unit, where my friend worked, said that he/ she
could
not visit Nurse
9. My friend came to me really demoralized . . . He/she
did not tell anyone
about his/her visit .
.
. When he/she returned, he/she acted as if he/she had not visited me .
.
. This
situation wears me down emotionally .
.
.’.
(Con
tinu
Theme
Sub-theme
Codes
Quotations
Short-term coping strategies
(a)
Normalisation
Thinking that it is temporary, accepting it as the necessity of the profession
Nurse 6: ‘Let’s say it is work ethics .
.
. I know this is the job I have to do .
.
. That’s what keeps me
going. After all, I have been trained for this .
.
. we are on the field in this process .
.
. who will take
care of the patients once we retreat .
.
.’.
(b)
Refusal to dwell on their experience
Not thinking about the incidents
Nurse 7: ‘I tried not to think at first. I think more in the hospital. When
I come home, I go to my
room and try not to have close contact with family members. I comfort
myself saying that these
days will pass, only some more days to go, as if it is a temporary perio
d. At first, I was thinking a lot,
so my fear, panic and anxiety were very high. Now they decreased, as I am not thinking about it’.
(c)
Avoidance
Limited use of media, avoiding negative comments about COVID-19
Nurse 5: ‘.
.
. I do not watch any news in the evening, I follow them on the Internet. I muted all of
the WhatsApp groups, I check them out for about 5
mins when I am available .
.
. to see if there is
anything involving me .
.
. I protect myself like this .
.
.’.
(d)
Expression of feelings
Crying, making online calls
Nurse 2: ‘.
.
. I am not someone who cries a lot but I am crying’
(e)
Distraction
Doing sports, being thankful, watching movies and series, cooking, cleaning the house, painting, listening to music, reading books, feeding animals, keeping positive notes
Nurse 3: ‘.
.
. I’ve been cooking more, making up new recipes’
Needs
(a)
Psychosocial support Meeting the need for psychosocial support
Nurse 9: ‘.
.
. We don’t know coping strategies .
.
. I feel like consulting an expert, so it would
be much much better if psychosocial support were to be provided by psychologists, therapists in related fields by making appointments .
.
. We really need some sort of support, because we are
under a lot of risk’.
(b)
Resource management
Meeting the physical needs, getting opinions about working places, aids being oriented towards needs, increasing the number of nurses, arrangement of working hours, meeting material needs, meeting the need for equipment Nurse 8: ‘There are still not enough nurses. Because lack of staff who knows intensive care is felt too much. New appointments have been made, but they are also very recent graduates. The number of nurses is low’.
COVID-19: Coronavirus disease 2019.
Table 2.
professional psychological counselling and strengthened crisis support systems, are recommended (Chevance et al., 2020; Liu et al., 2020). These interventions are especially important to prevent secondary traumas caused by wit-nessing disease and death. Therefore, the Mental Health Programme for Coronavirus (KORDEP) has been estab-lished to provide psychosocial (via phone or online sys-tems) counselling and mental support services to at risk individuals, who are negatively affected by COVID-19, primarily healthcare professionals. KORDEP is supported by many universities, non-governmental organisations and professional associations. Many professionals, including psychiatric nurses, psychiatrists, psychologists and social workers, operate within this cooperative programme, and it has been decided that KORDEP will continue, not only in the COVID-19 process, but also in any disaster and trauma scenarios Turkey may face in the future.
Almost every country worldwide has taken various measures to prevent the spread of COVID-19. Infection control interventions, full or partial quarantines, social dis-tancing regulations and restrictions on meetings are among these measures. However, while they have reduced the pandemic’s levels of mortality and morbidity, they have caused social isolation and stigma (Xiang et al., 2020). Fear, uncertainty and stigma are reportedly common in biological disasters, and they prevent interventions from being implemented to improve mental health (World Health Organization, 2020; Xiang et al., 2020). In this study, nurses reported that they moved away from social environments because of the risks of being stigmatised by society and of transmitting the disease; hence, they felt isolated and lonely. In the interview process, some partici-pants had difficulty talking, became upset and cried. It was determined that the nurses not only felt anxious about the deterioration of their own physical and mental integrity, but also feared infecting their families, friends and other individuals around them. Therefore, they preferred to be isolated. Responding to the call of Turkey’s Minister of Health, the public applauded healthcare workers through the windows of their homes for three designated minutes over 3 days to boost the healthcare workers’ morale. Many musicians have also composed songs in support of health-care workers. However, some of the sampled nurses had either been warned, or saw warning letters written by the residents of their apartments, to be careful of what they touched when they returned home from work. Thus, the nurses, who were lauded as heroes, were also stigmatised by some members of society considering their potential to carry the virus.
Studies conducted by Kim (2018) and Xiang et al. (2020) have found that such situations caused healthcare workers to prefer social isolation, to feel guilty and to pre-fer living in a dormitory that limits their contact with the outside world (Kim, 2018; Xiang et al., 2020). Similarly, health personnel and their families struggling during the
Middle East Respiratory Syndrome coronavirus (MERS-CoV) (2003) pandemic were stigmatised and excluded by society as potential carriers (Kim, 2018). It has also been reported that health personnel in the quarantine process have experienced burnout, have been unable to fulfil their professional and family roles, have experienced deteriorat-ing job performance and have felt a high desire to resign (Brooks et al., 2018).
Healthcare professionals and their families may feel stigmatised, angry, stressed, fearful, guilty, helpless, lonely, tense, sad and anxious under the influence of the pandemic process and quarantine. They may also exhibit avoidance behaviour. Therefore, supportive interventions may be helpful, such as keeping the quarantine process as short as possible, informing the individual and society about the pandemic process and quarantine, providing adequate material to meet the basic needs of the quarantine nurses and activating social networks through individuals can communicate with their family and friends (Adams & Walls, 2020; Liu et al., 2020).
Short-term coping strategies
This study has determined that the nurses used short-term coping strategies to combat the negative effects of the COVID-19 pandemic. Similar to the findings of this study, it was previously reported that personnel having cared for patients during the MERS-CoV pandemic considered combating the pandemic to be their professional responsi-bility and ethical duty (Khalid et al., 2016; Naushad et al., 2019). In the SARS pandemic process, nurses changed their attitudes and tried to remain positive instead of feel-ing nervous (S. H. Lee et al., 2005). In the process of COVID-19, nurses have defined the fight against the pan-demic as a phenomenon supporting positive experiences and growth (Sun et al., 2020).
This study has also found that the nurses used strategies to refuse to focus on their experiences, to avoid and to express their feelings. Similarly, it has been reported that nurses have received psychosocial support from the social environment and their families during the COVID-19 pro-cess and that they have expressed their emotions and thoughts regarding the outbreak by keeping diaries and writing letters (Kang et al., 2018; Sun et al., 2020). In a study conducted during the SARS outbreak, most partici-pants refrained from watching the news about SARS because this news put unnecessary pressure on them (S. H. Lee et al., 2005). The findings of this study are consistent with the aforementioned research.
The currently sampled nurses used strategies, such as sports and listening to music, to deal with the negative effects of the pandemic. Similarly, Sun et al. (2020) state that nurses used breathing exercises and listened to music (Sun et al., 2020). Unlike the results of this study, Maunder et al. (2006) has determined that healthcare workers mostly
used negative coping strategies, such as hostile confronta-tion and self-blame, during the SARS outbreak (Maunder et al., 2006).
Preferred coping methods may differ, depending on the interaction between the organisation levels of the person-ality and present external factors, such as the existence of support sources (e.g. family and socioeconomic level). The fact that the participants mostly used short-term cop-ing strategies, as seen in this study, may be due to the recent onset of the outbreak and the ongoing process. Determining nurses’ coping strategies, strengthening the effective ones, and applying appropriate intervention methods for the ineffective ones are important methods of preventing possible mental problems.
Needs
The results of this study have revealed that nurses strug-gling with the COVID-19 outbreak need psychosocial sup-port and resource management. These findings are similar to the needs healthcare workers experienced during the MERS-CoV pandemic process (Khalid et al., 2016). Sun et al. (2020) emphasise that properly allocated human resources and personal protective equipment should be provided to create a supportive and safe working environ-ment in pandemic manageenviron-ment (Sun et al., 2020). However, Naushad et al. (2019) emphasise that a lack of psychosocial support is an important risk factor for nega-tive psychological outcomes in all types of disasters (Naushad et al., 2019). Since a pandemic is a crisis that occurs abruptly and affects the majority of a population, increased psychosocial and resource needs are common effects (Chew et al., 2020). At the onset of the COVID-19 outbreak, healthcare professionals’ need for medical equipment increased in Turkey. To meet this need, medical equipment was produced with private sector–government cooperation. However, the preparations for crisis and dis-aster situations are insufficient. Risk management is important before disaster situations (such as pandemics) so that their negative effects can be minimised.
This study has found that nurses caring for COVID-19 patients in Turkey were negatively affected by the pan-demic, both in psychological and social terms. They also used short-term coping strategies and required psychoso-cial support and resource management. Although the health workers sampled in this study were mostly sup-ported by society, they sometimes encountered stigmatis-ing attitudes. Therefore, further studies may be conducted to determine the causes and levels of stigmatisation among healthcare professionals. Again, it is thought that burnout may occur due to the increased workload placed on nurses during the pandemic process. Therefore, future studies may consider the causes and levels of burnout in nurses, and interventions can be planned to reduce burnout and help nurses effectively cope with problems. The COVID-19 pandemic has also presented the risk of secondary
traumas, as nurses are subjected to watching disease and death occur. Therefore, the authors recommend that other research be conducted concerning the secondary traumas (e.g. witnessing death, exposure to media contents) that may emerge in nurses. Quantitative studies with larger sample groups would also reveal scientific evidence on this subject, and planning descriptive studies and organis-ing trainorganis-ing programmes for different healthcare profes-sionals will be important for maintaining an effective, quality service.
Acknowledgements
The authors thank the nurses who contributed to this study and all the healthcare professionals who served during the COVID-19 outbreak. The authors alone are responsible for the content of the article.
Author contributions
O.K., E.C., O.S.A. and F.Y.K. contributed to study design. O.K., E.C. and O.S.A. contributed to data collection. O.K., E.C., O.S.A. and F.Y.K. contributed to data analysis. O.K., E.C., O.S.A. and F.Y.K. contributed to manuscript writing.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs
Emre Ciydem https://orcid.org/0000-0002-2886-6848
Ozgur Sema Aci https://orcid.org/0000-0003-1321-0579
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