ABSTRACT

Introduction:

We aimed to self-evaluate the impact of front-line health workers’ perspective on their profession, family, social life and to determine how emotions and thoughts changed in the process.

Methods:

This is a questionnaire answered according to a 5-point Likert scale, which involved the demographic characteristics of the staff and the self-assessment of their views on their profession, family, and social life. Evaluations were made in the categories of occupational satisfaction, individual fear, professional ethics, meeting physical needs, trust in institution-infrastructure support, trust in the work team, and the effects on family life through categorized queries. Volunteer healthcare staff work actively in the units, where the patients with suspected or diagnosed infection were treated, included in the study. A year later, the questionnaire was administered again. The multiple logistic regression model was used to determine the factors.

Results:

Regarding the first year of the pandemic, no significant difference was determined in the individual fear of getting sick and professional ethics scores of healthcare professionals in Turkey. The scores of meeting physical needs, trust in the team, and institutional infrastructure support in the working environment were significantly decreased (p<0.05). While working conditions affected the family significantly (p<0.05), ethical behavior scores were above the average in both periods.

Conclusion:

The study reveals a profile of healthcare staff who maintain their professional ethical behaviors, are satisfied with their profession and can tolerate the impact of working conditions on family order, despite the drawbacks of the ongoing fear of getting sick.

Keywords: Healthcare workers, professional ethics, fear

Introduction

Serious cases of pneumonia of unknown cause, which broke out in China and spread rapidly all over the world. With the increasing workload amid all the unknowns, it is thought that the Coronavirus disease-2019 (COVID-19) pandemic, as in other previous outbreaks in the world, has multifaceted negative effects in addition to the increasing workload on healthcare professionals (HP).¹

Previous studies revealed that the risk of developing psychiatric problems in HPs was directly associated with being young, being a woman, being a nurse, having a child, insufficient social support, quarantine experience, lack of experience in the profession, long working hours, lack of education and equipment, as well as unknowns about the virus.^1-4

This study was designed to search for answers to questions of “How do HP view their profession in the shadow of the pandemic?” and “how do they consider their own life?”. As far as we know, this study is the first study in Turkey that involves the perspective of HP toward his/her profession under pandemic conditions. Moreover, it is forecasted that the study would provide basic data to support the moral-mental well-being and teamwork dynamics of HPs in extraordinary situations and epidemics and would guide the studies to be planned and the institutional structuring.

Materials and Methods

The first part of the study was carried out in May 2020, which can be considered the onset of the pandemic in Turkey, and the second part was carried out at the end of the first year of the pandemic by the Pediatric Emergency Department of Akdeniz University. Ethics Committee approval of Akdeniz University Faculty of Medicine (no: 2012-KAEK-20) and Ministry of Health Ethics Committee approval (no: 2020-05-12T11_46_12) were obtained.

This is a questionnaire study composed of two parts prepared in the electronic environment and consisting of 30 questions. The first part involves 14 open-ended/multiple-choice questions regarding the descriptive characteristics of HPs. The second part consists of 16 questions answered according to a 5-point Likert scale, which involves the self-assessment of HPs’ views on their profession, family, and social life during the COVID-19 pandemic. In the first 14 questions, the participants were asked about their age, sex, city of residence, occupation and professional experience, place of duty, working hours, institution, marital status, whether they lived with anyone over the age of 60, whether they had children, and whether they lived apart from the family while living with their families before the pandemic. Through the questions grouped in the questionnaire, assessments were made in the categories of occupational satisfaction, individual fear, professional ethics, meeting physical needs, trust in institution-infrastructure support, trust in the work team, and the effects of circumstances on family life. The questionnaire was delivered to the participants via the network. The inclusion criteria for the study were to be actively working in the units where patients with COVID-19 infection/suspect or diagnosis were cared for. Volunteer practitioners, research associates, specialist physicians, lecturers, sub-branch assistants/specialists, nurses, and paramedics were included in the study. In the second part of the study, nearly one year later, the same questionnaire was administered again with the same method. The data of the two periods were compared. Among the main subjects of professional satisfaction, individual fear, professional ethics, meeting physical needs, trust in institution-infrastructure support, trust in the work team, and the effect of conditions on family life, the factors that most affect the change in the process were determined.

Statistical Analysis

The software SPSS (Statistical Package for the Social Sciences) 23.0 was used for statistical analysis of the data. Categorical measurements were summarized as numbers and percentages, and continuous measurements as mean and standard deviation (median and minimum-maximum where appropriate). Shapiro-Wilk test was used to determine whether the parameters in the study showed a normal distribution. Mann-Whitney U test was used in the analyzes of non-normally distributed two groups, and Kruskal-Wallis tests were used in the comparison of groups of more than two. Tamhane’s T2 test, one of the post-hoc tests, was used to determine the source of the difference between groups in more than two groups. In the multiple logistic regression modeling, those with scale scores below the mean values were considered low, while those above it were considered high. The multiple logistic regression model was used to determine the factors impacting the patients’ individual fear, professional ethics, ability to meet physical needs, trust in the team in the working environment, trust in the institution-infrastructure support, occupational satisfaction, the impact of working conditions on family order, and the total score of the scale. The results were considered statistically significant at p<0.05.

Results

Demographic Characteristics

A total of 1.216 HPs, 809 (66.5%) of whom were female, and 1.078 (88.7%) of whom were living and working in 31 metropolitan cities where lockdown was mandated and the pandemic was relatively intense as of May 2020 were included.

At the end of the COVID pandemic, the same questionnaire was administered again based on a simple random sampling method to 300 HPs, 126 of whom also participated in the first phase of the study, 275 living and working same.

The socio-demographic characteristics of the healthcare personnel who participated in the study at the onset and at the end of the first year of the pandemic are presented in Table 1.

Table 1

Data on the Reliability and Validity of the Scale Used

Individual fear scale score range (SSR) and professional ethics, meeting physical needs, trust in the team in the working environment, trust in the institutional infrastructure support, and the effect of working conditions on family order SSR were between 2-10 points, while professional satisfaction SSR was 4-20, and total SSR was 16-80 points.

In the first phase of the study, the reliability Cronbach's alpha coefficient value of the scale, namely Cronbach's alpha internal consistency was found to be 0.788 (reliable) and 0.763 (reliable) in the second phase. Tables 2a and 2b show the reliability and validity tables of the questionnaire scales administered at the onset and the first year of the pandemic.

Table 2a

Table 2b

In the first phase of the study, the Kaiser-Mayer-Olkin value of the total scale size was 0.822, and 0.763 in the second phase. This value indicated that the sample size was “excellent” in the first phase and “moderate” in the second phase for factor analysis. Besides, when the results of the Barlett sphericity test were analyzed, it was noticed that the chi-square values were significant(X²=3767.269; p<0.05), (X²=1122.543; p<0.05), respectively.

The scale scores evaluating the participants’ view of their own life in 7 categories in both periods are tabulated in Table 3.

Table 3

Table 4 a and b show the distribution of the scale scores of the participants, at the onset (a) and at the end of the first year (b) of the pandemic, in terms of the socio-demographic characteristics.

Table 4a

Table 4b

The effects of the socio-demographic characteristics of the participants on the total score of the “social life and professional perspective of healthcare professionals” scale and the sub-domain scores during the pandemic were assessed via multiple logistic regression analysis on a sample of 1.516 people who responded to the questionnaire at the onset and at the end of the first year of the pandemic. In this evaluation, ranges for related characteristics were specified as follows; <31 years of age ≤31, 6 years < professional experience ≤6 years, institutions worked in -training/public hospitals and university hospitals-others, departments served: emergency services and others, 12< working hours ≤12, 5< weekly working days ≤5. The multiple logistic regression analysis results of the relationship between the scale total and sub-domain scores of HP and their socio-demographic characteristics are presented in Table 5.

Table 5

Discussion

As in the rest of the world, in Turkey the COVID pandemic has rapidly affected healthcare workers. They sought to adapt themselves to the rapid and compelling changes in family and social lives as well as to the changing working conditions.

Fear is an emotion arising from the unknown associated with the individual’s feeling of safety or the safety of others at risk.⁵ Albeit the fear of getting sick individually and transmitting the disease to their relatives decreased at the end of the first year compared to the beginning of the pandemic, the difference between the two periods was not significant. In publications discussing severe acute respiratory syndrome, Middle East respiratory syndrome, Ebola, HIV, and influenza outbreaks, it has been reported that 22-80% of front-line healthcare workers have high fears and anxieties of getting sick and transmitting the disease.^1,4,6-8 It has been emphasized that fear increases the level of anxiety and stress in healthy individuals.^6,7

In our study, the high fear of getting sick and transmitting the disease individually at the onset of the pandemic was found to be significantly correlated with the profession, place of duty, and working hours. The mean scores of the faculty members, those working in the outpatient clinics, and HPs who had shorter daily working hours were higher. This seemingly contradictory result might be due to the “uncertainty” factor that constitutes the essence of fear. Because at the onset of the pandemic, institutions channeled protective equipment and resources to emergency services and intensive care units, where patients were admitted first. The HPs working in these departments gained knowledge and experience more actively and rapidly, and they started to learn about the disease. At the end of the first year of the pandemic, fear was significantly higher in those who were over 45 years old and worked for more than 20 years, and was married. Over time, it has become clear that the risk of contracting COVID-19 disease and a severe course of the disease is higher among the older age group. Hence, as the pandemic progressed, older people were started to be employed in a flexible working schedule by institutions. This result might also explain the relationship between individual fear of getting sick and short working time.

At the onset of the pandemic, there were many unanswered questions regarding the clinical manifestations, transmission routes, lethality, treatment, and prevention of the disease. Under these circumstances, the fear score measured at baseline was moderate, slightly higher than that determined in the first year, but did not show any significant difference. This can be explained by the practical experience gained with patients and the increase in scientific elucidating data over time. The fact that the decrease in fear did not show a significant difference at the end of the first year might be due to the intensity and the fact that the threat of fatal disease has not yet disappeared.

In our study, the views of HPs regarding professional ethical behavior were similar at the end of the first year compared to the onset of the pandemic, the mean scores they obtained from this category were almost the same in both periods, and their mean ethical behavior scores were above the middle level according to the scale dimension. In the literature, it is suggested that in the display of ethical behavior in critical times, the adequacy of resources and the perception of combating a deadly disease, as well as the contamination concerns of HPs with their families, might be determining factors.^9,10 It has been underscored that ethical behavior anxiety of healthcare workers may increase, particularly in countries where the question of “who needs critical care more” has to come to the fore in this pandemic.^9,10 It is stated that at the onset of the pandemic, the videos of patients appearing on social media, begging for help, healthcare workers are being attacked by patients’ relatives, and being described as “heroes” just because they are doing their job, can contribute to this chaos, and that cultural differences might also play a role in the process.^9-11

In our study, based on the results of the first period, professional ethical behavior scores increased with advancing age and increasing professional experience. Ethical behavior scores were higher for those who were married, had children, and those working in COVID services. It can be explained by the contribution of the positive support created by professional experience and familial integrity.
Likewise, the professional ethical thoughts of the HPs, who continued to live with the family, were similar in the second period. In this study, which is based on the self-assessment of HPs, the fact that HP in Turkey uphold their professional principles in the extraordinary circumstances of the pandemic in both periods can also be explained by the intense feeling of empathy experienced during this challenging period. On the other hand, in both periods, long working hours, which reduced physical and psychological tolerance, adversely impacted professional ethical thinking.

In our study, the mean scores of HPs in meeting their physical needs at the end of the first year compared to the onset of the pandemic were significantly lower. Employees thought they were in more distress. Of the participants, the assistant physicians, who were generally at the forefront of the pandemic conditions, were younger, had less experience in the profession, had long working hours and worked at the university hospital, thought that they could not meet their physical needs adequately in both periods of the study. This can be explained by the fact that the number of patients in our study increased throughout the pandemic, as well as by the long working hours and working in more than one service associated with a higher rate of COVID. Similarly, it has been emphasized in the literature that the main concern of HPs is the lack of meeting their physical needs.^1,7

Patient care and treatment services are basically provided in institutional integrity. The systematic functioning of the process, staff, and material management should always be patient-oriented. In crises such as outbreaks, institutions are responsible for eliminating all disruptions, arranging team and equipment needs, optimal personnel management for patients and healthcare workers, and taking necessary precautions.⁹ At the end of the first year of the pandemic, the mean score of HPs in the categories of trusting the team in the working environment and the support of the institution they work for in terms of opportunities, working conditions, and infrastructure was significantly lower compared to the mean score obtained at the onset of the pandemic. This might be associated with the possible burnout due to the increased workload of HPs, whose positive thoughts on ethical behavior did not differ throughout the pandemic. Because the institutions were applying a flexible working schedule at the onset of the pandemic, they switched to working with less leave and for longer periods to meet the workload created by the increasing patient admissions during pandemic course. In support of this finding, in the second period of our study, participants were working in more than one ward with a higher percentage of working days and hours. Besides, due to the illness of an HP in a team, they had to stay in quarantine causing a decrease in the number of active personnel. Throughout the pandemic, the feeling of loneliness of HPs may have deepened with the contribution of weariness, restriction of life, increased frequency of encountering mortal situations, and changes and challenges in working conditions.

Nonetheless, despite all the drawbacks, HPs were significantly more satisfied with their jobs at the end of the first year than at the beginning of the pandemic. In both periods, those who were older and had a longer professional life (>20 years), had shorter working hours and were more satisfied with being a member of this occupational group. This situation can be explained by the feeling of trust that experience gives and the happiness of being able to touch lives despite all the risks.

Participants believed that working conditions during the pandemic had a more adverse impact on their family life at the end of the first year than at the beginning. As reported in the literature that the family life of HPs is adversely affected during outbreaks.^1,12-14 Although the rate of those living separately from their families and children during the pandemic course is fewer in our study, the necessity to work more frequently and with longer working hours due to the increasing workload throughout the pandemic may cause HPs to spend less time with their families and affect their familial social life.

When logistic regression analysis was conducted on all participants in our study, it was found that the total scores of the scale, which represents the self-evaluation of the HPs under pandemic conditions and their perspectives on their profession and social life, were significantly negatively correlated with being at the beginning of their profession during the period of the pandemic. This group, which admitted patients on the front line and intensively during the pandemic, also felt inexperienced in their profession and considered that their social lives were adversely impacted.

HPs who have children and live with the elderly at home were more afraid of getting sick and infecting them and their relatives. Likewise, it has been revealed in the literature that being a woman, being married, having children, and working as a nurse have a greater impact on the fear and anxiety of getting sick and being contagious.^{1,4,6,8,15,16}

The ethical behavior score in the profession was positively correlated and significantly higher among those working in public hospitals and emergency services, residents and general practitioners and females. This can be interpreted as a sign that the group, which has intense contact with patients in the continuation of medical service during the pandemic, continues to adhere to ethical principles.

Of the professional groups included in the study, assistants, general practitioners, paramedics, nurses, and those working in public institutions, those who met pandemic patients more frequently had significantly lower scores in meeting their physical needs. This outcome might be arising from the adverse impact of the increased burden of work.

Living in metropolitans, where admissions due to COVID-19 were high, and working in government institutions and emergency services were found to be significantly and negatively correlated with the scores of trusting institution infrastructure and work team. This can be explained by the potential increased workload and the inability to meet physical needs. On the other hand, living with his family and children was significantly positively correlated with the score of trust in the team in the work environment. This situation might be indicating the positive contribution of family support to the HPs.

The occupational satisfaction score was significantly negatively correlated with being a woman and having less experience in the profession. This might be due to the cumulative effect of increased workload as well as domestic responsibilities of women. It indicates that the health worker, who is at the beginning of her profession and has shouldered the heavy pandemic burden, might be questioning this situation and the professional alternatives. Similar to the category of occupational satisfaction, being a woman showed a negative correlation in the category of the effect of working conditions on family life.

Study Limititations

The main limitation of this study is that only 126 employees participated in both stages, since not all of the HP who participated in the study at the first stage could be reached.

Conclusion

Ethics

Ethics Committee Approval: The first part of the study was carried out in May 2020, which can be considered the onset of the pandemic in Turkey, and the second part was carried out at the end of the first year of the pandemic by the Pediatric Emergency Department of Akdeniz University. Ethics Committee approval of Akdeniz University Faculty of Medicine (no: 2012-KAEK-20) and Ministry of Health Ethics Committee approval (no: 2020-05-12T11_46_12) were obtained.

Informed Consent: In the electronic environment, the relevant consent was obtained from the participants at the beginning of the survey application.

Peer-review: Internally and externally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: Ö.T.K., N.E., R.G., Concept: Ö.T.K., N.E., R.G., Design: Ö.T.K., N.E., Data Collection or Processing: Ö.T.K., R.G., Analysis or Interpretation: Ö.T.K., N.E., Literature Search: Ö.T.K., Writing: Ö.T.K., N.E.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

References

Lai J, Ma S, Wang Y, Cai Z, Hu J, et al. Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease 2019. JAMA Netw Open. 2020;3:e203976.

Wong TY, Koh GCh, Cheong SK, Lee HY, Fong YT, et al. Concerns, perceived impact and preparedness in an avian influenza pandemic--a comparative study between healthcare workers in primary and tertiary care. Ann Acad Med Singap. 2008;37:96-102.

Chigwedere OC, Sadath A, Kabir Z, Arensman E. The Impact of Epidemics and Pandemics on the Mental Health of Healthcare Workers: A Systematic Review. Int J Environ Res Public Health. 2021;18:6695.

Lee SM, Kang WS, Cho AR, Kim T, Park JK. Psychological impact of the 2015 MERS outbreak on hospital workers and quarantined hemodialysis patients. Compr Psychiatry. 2018;87:123-7.

Garcia R. Neurobiology of fear and specific phobias. Learn Mem. 2017;24:462-71.

Ornell F, Schuch JB, Sordi AO, Kessler FHP. “Pandemic fear” and COVID-19: mental health burden and strategies. Braz J Psychiatry. 2020;42:232-5.

Shultz JM, Cooper JL, Baingana F, Oquendo MA, Espinel Z, et al. The Role of Fear-Related Behaviors in the 2013-2016 West Africa Ebola Virus Disease Outbreak. Curr Psychiatry Rep. 2016;18:104.

Maunder R, Hunter J, Vincent L, Bennett J, Peladeau N, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003;168:1245-51.

Morley G, Grady C, McCarthy J, Ulrich CM. Covid-19: Ethical Challenges for Nurses. Hastings Cent Rep. 2020;50:35-9.

Nelson SE. COVID-19 and ethics in the ICU. Crit Care. 2020;24:519.

Turale S, Meechamnan C, Kunaviktikul W. Challenging times: ethics, nursing and the COVID-19 pandemic. Int Nurs Rev. 2020;67:164-7.

Bai Y, Lin CC, Lin CY, Chen JY, Chue CM, et al. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv. 2004;55:1055-7.

Kisely S, Warren N, McMahon L, Dalais C, Henry I, et al. Occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and meta-analysis. BMJ. 2020;369:m1642.

Rodriguez RM, Medak AJ, Baumann BM, Lim S, Chinnock B, et al. Academic Emergency Medicine Physicians’ Anxiety Levels, Stressors, and Potential Stress Mitigation Measures During the Acceleration Phase of the COVID-19 Pandemic. Acad Emerg Med. 2020;27:700-7.

Tang L, Pan L, Yuan L, Zha L. Prevalence and related factors of post-traumatic stress disorder among medical staff members exposed to H7N9 patients. Int J Nurs Sci. 2016;4:63-7.

Lee AM, Wong JG, McAlonan GM, Cheung V, Cheung C, et al. Stress and psychological distress among SARS survivors 1 year after the outbreak. Can J Psychiatry. 2007;52:233-40.

Self-assessment of the Feelings and Thoughts of Healthcare Professionals Regarding Their Social Lives and View of the Profession at the Onset and at the End of the First Year of the COVID-19 Pandemic