nurses caring Covid

942788
research-article2020
ISP0010.1177/0020764020942788International Journal of Social PsychiatryKackin et al.
E CAMDEN SCHIZOPH
Original Article
Experiences and psychosocial problems of
nurses caring for patients diagnosed with
COVID-19 in Turkey: A qualitative study
International Journal of
Social Psychiatry
2021, Vol. 67(2) 158­–167
© The Author(s) 2020
Article reuse guidelines:
sagepub.com/journals-permissions
https://doi.org/10.1177/0020764020942788
DOI: 10.1177/0020764020942788
journals.sagepub.com/home/isp
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-toface 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
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 continuously 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 mental 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 professionals 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 condition and who are at risk of infection, are exposed to significant stress, and this intensely experienced stress brings
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: [email protected]
Kackin et al.
159
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 opportunity 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 information on the topic at hand by contributing results from a
different geography and culture. The nurse perspectives
revealed by the research outcomes may guide organisations towards taking the necessary precautions to ensure
employee health and safety. The results may also guide
non-governmental organisations and the state in establishing 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.
34, and another is 58 years old. Two have completed psychoanalytic 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.
Methods
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):
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 experiences 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.
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
1.
2.
3.
Research team and reflexivity
The researchers have been working as research assistants
(PhD students) and faculty members (Professor) on a nursing faculty in the department of mental health and psychiatric nursing. They have worked as nurses/supervisors in
hospitals in the past. Two of the researchers are 28, one is
What experiences did you have while caring for a
patient diagnosed with COVID-19?
What psychosocial problems have you experienced
when caring for a patient diagnosed with
COVID-19?
Could you please explain your views on your coping strategies when caring for a patient diagnosed
with COVID-19?
Data collection process
The data were collected via an individual, in-depth interview technique. Before beginning the research interviews,
160
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 conducted 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 environments for a properly executed conversation. During
each interview, the interviewer and participant were alone.
Written and verbal consents were obtained from the participants at the beginning of each online interview. The
interviews lasted between approximately 45 and 90 minutes. Written notes and a voice recorder were used to
record both verbal and nonverbal expressions. Interview
transcripts were sent to the participants for approval, further 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 combating 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-toface 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 institutions, 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 longterm experiences of the research subjects would be a valuable 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
International Journal of Social Psychiatry 67(2)
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 beginning 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 participants’ information was being collected and stored, the
researchers paid close attention to the principle of confidentiality. To this end, all identifying information was
anonymised by assigning nicknames during transcription. 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.
2.
3.
4.
5.
6.
7.
Transcripts were read several times, and short
notes were taken to understand the meanings attributed to a phenomenon and the emotions
experienced.
Important expressions directly related to a phenomenon were selected.
These important expressions were examined, and
expressions with common meanings were
formulated.
The formulated meanings were grouped into categories, themes and subthemes.
The obtained results were combined with rich,
comprehensive life experiences.
The basic conceptual structure of the phenomenon
in question was defined.
The results were confirmed through another meeting 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.
Kackin et al.
161
Trustworthiness
Effects of the outbreak
The trustworthiness of this study was realised based on the
following four criteria: credibility, transferability, dependability and confirmability (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 implementing 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 studied 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.
Nurses reported that the quality of patient care was negatively affected, and ethical dilemmas emerged due to worsening 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 profession. Hospital managers have made the necessary arrangements 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 personal 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 information 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 conflicts caused by differences in procedures and communication while working with staff from various specialties and
clinics (Karam et al., 2018).
This study has found that the nurses felt fear and anxiety; 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 crises. 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 participants 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
Results
The findings are presented in two sections. The first portion provides findings related to the individual and professional 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’ opinions 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 sampled nurses were both sad and stressed due to the morbidity, mortality and unpredictable risks of the pandemic. It
was also determined that they were tired because of worsening working conditions, rather than because of changing
working hours, but they were still willing to combat the
pandemic.
45 days
Pulmonology Pulmonology
40 hours
64 days
24 hours
Yes
Yes
No
No
No
40 hours
7 days
26 hours
No
No
No
No
No
Worked on COVID-19 ward
department
Hours/week worked on COVID-19 ward
before interview
Length of care to COVID-19 patient
(day)
Hours/week worked on COVID-19 ward
Caring for patients with infectious
diseases before COVID-19 ward
Going home status
COVID 19 diagnosis with relatives
COVID-19 transmission to herself/
himself
Psychiatric disease
COVID-19: Coronavirus disease 2019.
The Turkish
Red Crescent
40 hours
Single
2
5
Urology
Single
0
3
Urology
Yes
No
Yes
No
40 hours
No
Single
0
1
The Turkish
Red Crescent
24
Female
Master degree
Marital status
Number of children
Number of relatives living together
Original department
27
Female
Bachelor
40
Male
Bachelor
Nurse 3
Nurse’s age
Nurse’s gender
Nurse’s education status
Nurse 2
Nurse 1
Nurse No.
Nurse 5
No
Yes
No
No
56 hours
Yes
30 days
No
Yes
No
No
56 hours
No
14 days
Hemodialysis COVID-19
Centre
Clinic
56 hours
56 hours
33
Female
Master
degree
Married
Single
0
0
1
0
Hemodialysis Operating
Centre
Room
29
Female
Bachelor
Nurse 4
Table 1. Individual and professional characteristics of nurses caring for patients diagnosed with COVID-19.
No
No
No
No
56 hours
No
30 days
Married
2
4
Neonatal
İntensive
Care Unit
Infectious
Diseases
40 hours
30
Male
Bachelor
Nurse 6
25
Female
Bachelor
Nurse 8
27
Female
Master
degree
Single
0
5
Cardiology
Nurse 9
No
Yes
Yes
No
48 hours
Yes
30 days
No
Yes
Yes
No
62 hours
Yes
22 days
No
No
No
No
48 hours
Yes
4 days
Infectious Intensive Infectious
Diseases Care Unit Diseases
56 hours 60 hours 40 hours
Single
Single
0
0
0
5
İnfectious İnternal
Diseases Medicine
29
Female
Bachelor
Nurse 7
No
No
Yes
No
56 hours
No
42 days
Intensive
Care Unit
40 hours
Single
0
0
Neurology
33
Female
Bachelor
Nurse 10
162
International Journal of Social Psychiatry 67(2)
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
stigma, spending the most amount of
time in hospital, risk of transmission,
social isolation
(b) Psychological
effects
(c) Social effects
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
(a) Working
conditions
Effects of the
outbreak
Codes
Sub-theme
Theme
(Continued)
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 once 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 order’.
Nurse 8: ‘There is a patient lying there, you know that the patient needs 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 smothering 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’.
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 goodbye 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 . . .’.
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 . . .’.
Quotations
Table 2. Themes, categories, codes and sample quotations identified in interviews with nurses.
Kackin et al.
163
Doing sports, being thankful, watching
movies and series, cooking, cleaning
the house, painting, listening to music,
reading books, feeding animals, keeping
positive notes
Meeting the need for psychosocial
support
COVID-19: Coronavirus disease 2019.
(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
Crying, making online calls
(d) Expression of
feelings
(e) Distraction
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’.
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’.
Limited use of media, avoiding negative
comments about COVID-19
(c) Avoidance
(a) Psychosocial
support
Nurse 3: ‘. . . I’ve been cooking more, making up new recipes’
Not thinking about the incidents
(b) Refusal to
dwell on their
experience
Needs
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 . . .’.
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 period. 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’.
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 . . .’.
Nurse 2: ‘. . . I am not someone who cries a lot but I am crying’
Thinking that it is temporary, accepting
it as the necessity of the profession
(a) Normalisation
Quotations
Short-term
coping
strategies
Codes
Sub-theme
Theme
Table 2. (Continued)
164
International Journal of Social Psychiatry 67(2)
Kackin et al.
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 witnessing disease and death. Therefore, the Mental Health
Programme for Coronavirus (KORDEP) has been established to provide psychosocial (via phone or online systems) 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 distancing 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 participants 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 healthcare 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 prefer 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
165
Middle East Respiratory Syndrome coronavirus (MERSCoV) (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 deteriorating 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 responsibility 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 feeling nervous (S. H. Lee et al., 2005). In the process of
COVID-19, nurses have defined the fight against the pandemic 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 process 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 participants 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
166
used negative coping strategies, such as hostile confrontation 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 personality 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 coping 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 struggling with the COVID-19 outbreak need psychosocial support 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 environment in pandemic management (Sun et al., 2020).
However, Naushad et al. (2019) emphasise that a lack of
psychosocial support is an important risk factor for negative 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 disaster 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 pandemic, both in psychological and social terms. They also
used short-term coping strategies and required psychosocial support and resource management. Although the
health workers sampled in this study were mostly supported by society, they sometimes encountered stigmatising 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 COVID19 pandemic has also presented the risk of secondary
International Journal of Social Psychiatry 67(2)
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 organising training programmes for different healthcare professionals 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
Ozgur Sema Aci
https://orcid.org/0000-0002-2886-6848
https://orcid.org/0000-0003-1321-0579
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