INTRODUCTION

Pandemic refers to the occurrence of a specific disease worldwide or over a very wide area that crosses international boundaries, which usually affects a large number of people (1). Coronavirus disease-2019 (COVID-19) was first seen in China in December 2019, which quickly became a worldwide threat, and was declared a pandemic by the World Health Organization in March 2020. The first case in Turkey was reported on March 11, 2020, and as of April 30, 2021, the total number of reported cases was 4,820,591 with 40,131 deaths (2). It has been approximately 1.5 years since the pandemic started. Important progress has been achieved in its treatment during this period; however, the exact treatment is yet to be found.

Isolation is the most effective method in the primary treatment of infectious diseases (3). Therefore, together with face masks and hand hygiene, it has been the main measure that was used to prevent the spread of the disease during the COVID-19 pandemic (4). Since the disease has a very high transmission rate and many people showed to be asymptomatic carriers of the virus, the governments had to enforce strict social isolation rules that must be followed by all people, regardless of their health status. Similar to many countries, several precautions were taken for social isolation in Turkey since the pandemic began. The national and international transportations were restricted and even prohibited, and shopping malls and entertainment centers were closed and education was switched to online applications. The time for these restrictions and regulations to return to the past normal is still unknown. Pandemics can cause social changes, regulations, and restrictions, along with many uncertainties. Moreover, everyone is affected by these changes in their daily lives and work habits, and problems in food, shelter, and basic needs arise, aside from the direct effect of the disease during this pandemic. All these situations may lead to increased psychosocial distress in individuals.

Studies have demonstrated that public mental health is adversely affected during the COVID-19 pandemic (5,6). Healthcare professionals, occupying the frontline during pandemics, have increased risk for mental health besides the increased risk of contacting viral infection (7-9). Excessive workload, unpreparedness, and emotional distress are the reported reasons for increased psychological problems in the health professionals (e.g., fear of infection and family concerns) (4,8). Compared to previous ones, the COVID-19 pandemic is more challenging because of some specific features of the virus, such as high contagiousness, a rather low level of knowledge on its course and long-term consequences, and a lack of established treatments or vaccines (10). Moreover, this is an unprecedented scenario for most hospitals worldwide, which is accompanied by great challenges in various aspects of health care, such as hygiene concepts, sufficient protective measures and equipment, and competence and capacity of the intensive care unit (ICU). Furthermore, many healthcare professionals have been isolated, not only from their social environment but also from their families unlike other people because of their higher risk of contacting the virus and becoming a carrier and their exposure to the illness and loss of their counterparts.

Studies demonstrated that healthcare professionals have higher levels of anxiety and hopelessness compared to the community samples during the COVID-19 pandemic (4). Symptoms of anxiety, depression, stress, and burnout are more common in frontline healthcare professionals, who are involved in the diagnosis, treatment, and care of patients with COVID-19, compared to those who do not work on the frontline (11,12). Gender and occupation showed the importance for their psychological well-being; fear of COVID-19 is higher in females and nurses (13). Social support is associated with a positive COVID-19 attitude in health professionals (14). Social support was associated with burnout in nurses who are at the center of this pandemic (15). Many studies were conducted on healthcare professionals; however, they were carried out especially in the acute and shock phase of the pandemic and examined only certain symptoms by considering limited parameters.

Therefore, this study aimed to examine the psychological adjustment and its association with COVID-19 attitude and social support among the frontline healthcare professionals during the COVID-19 pandemic in Turkey. The study was conducted 8 weeks after the emergence of the pandemic to eliminate the acute stress effects. Out first hypothesis is that anxiety, depression, burnout, and hopelessness would be higher in healthcare professionals who had more contact with patients with COVID-19. The second is that higher social support and a positive attitude towards COVID-19 would be associated with better psychological adaptation.

METHODS

Study Design and Participants

This descriptive cross-sectional study was conducted from May 1, 2020, to June 30, 2020, in two state hospitals that were located on the European side of Istanbul. These two hospitals share the same staff and serve most of the COVID-19 cases on the European side of Istanbul since the beginning of the COVID-19 pandemic. The total number of hospital beds of these hospitals is 1,618 (1,008+610) and the total intensive care beds are 513 (408+105). Assuming a pooled standard deviation of 5 units, the study would require a sample size of 44 for each group (i.e., a total sample size of 88, assuming equal group sizes) to achieve a power of 80% and a significance level of 5% (two-sided) and detect a true difference in means between the test and the reference group of 3 units. Inclusion criteria of the study include healthcare professionals who are 18-65 years old, with voluntary participation in the study and are capable of filling up the forms. Healthcare professionals were asked about their medical and psychiatric history, and those with a psychiatric or chronic illness were excluded from the study. Participants were divided into 6 subgroups according to their occupations: specialist doctors, resident doctors, nurses, caregivers, medical secretaries, and security guards. All participants filled out the data form, hospital anxiety-depression scale (HADS), beck hopelessness scale (BHS), maslach burnout scale, fear of COVID-19 scale (FC-19S), and multidimensional scale of perceived social support (MSPSS).

Measurements Tools

Data form: This form was developed by the researchers to gather information related to sociodemographic information (e.g., sex, age, family, and occupation) and COVID-19 attitudes and knowledge of participants. Questions related to COVID-19 attitudes and knowledge were as follows: 1) Are you following new literature knowledge on COVID-19 disease? (answers were: 1. yes and 2. no); 2) Did you have laboratory, radiological, and COVID-19 polymerase chain reaction (PCR) tests until today? (answers were: 1. yes and 2. no); 3) Do you think the pandemic will end (answers were: 1. yes and 2. no); 4. Do you think your institution provides adequate protection methods for COVID-19? (answers were: 1. yes, 2. no, and 3. partially provided).

HADS: This is a 4-point scale consisting of two subscales, HADS-anxiety (rating the anxiety level) and HADS-depression (rating the depression level). Each subscale consists of seven items. Participants answer each item thinking of their emotions and/or behavior during the past week. Higher scores indicate higher levels of anxiety and depression (16). The Turkish validity and reliability study was done by Aydemir et al. (17).

BHS: This is a 20 item self-assessment instrument to measure hopelessness (18). The participant is asked to evaluate each of the 20 statements and decide whether the statement describes his/her attitude in the previous week. The scale has nine inverse items to prevent acquiescence. The total score range from 0 to 20, indicating the number of items endorsed in the hopeless direction. Its Turkish validity and reliability were done by Durak and Palabıyıkoğlu (19).

Maslach Burnout Inventory (MBI): The MBI is a 7-point Likert-type scale, consisting of a 22-item rating of the three dimensions of burnouts, namely emotional exhaustion, depersonalization, and personal accomplishment (20). Its Turkish validity and reliability study was done by Ergin (21).

FC-19S: It was developed by Ahorsu et al. (22) to measure the fear level related to COVID-19. The 5-point Likert type scale has a single factor structure and consists of seven items (1= strongly disagree; 5= strongly agree) (22). Its Turkish validity and reliability study was done by Ladikli et al. (23).

MSPSS: This Likert-type scale was developed by Zimet et al. (24) which evaluates the adequacy of social support received from three different sources: family (MDSPSS-Family), friends (MDSPSS-Friends), and significant others (MDSPSS-significant others). It has a total of 12 items. Its Turkish validity and reliability study was done by Eker et al. (25).

Ethical Approval

Written and verbal consent of each participant was obtained. This study was conducted according to the provisions of the Declaration of Helsinki in 1995. Approval was obtained from the ethics committee of the same hospital with the University of Health Sciences Turkey, Bakirköy Dr. Sadi Konuk Training and Research Hospital (protocol number: 2020-157).

Statistical Analysis

The Number Cruncher Statistical System program was used for statistical analysis. Descriptive statistical methods (mean, standard deviation, median, frequency, percentage, minimum, and maximum) were used to evaluate the study data. The suitability of quantitative data to normal distribution was tested by the Shapiro-Wilk test and graphical analysis. The Student’s t-test was used to compare normally distributed quantitative variables between two groups, and the Mann-Whitney U test was used to compare quantitative variables that did not show normal distribution between two groups. The One-Way analysis of variance and Bonferroni corrected binary evaluations were used to compare more than two groups of quantitative variables with normal distribution. The Kruskal-Wallis and Dunn-Bonferroni tests were used to compare more than two groups of quantitative variables that did not show normal distribution. The statistical significance was accepted as p<0.05. Relationships between numerical variables were examined with the Pearson Correlation Coefficient. Dunn’s test was performed to make pairwise comparisons. P-values of <0.05 were considered statistically significant.

RESULTS

Characteristics of the Sample

A total of 557 healthcare professionals, wherein 204 (36.6%) were male and 353 (63.4%) were female, participated in the study. Among the participants 26.9% (n=150) were specialist doctor, 13.6% (n=76) were resident doctor, 17.4% (n=97) were nurse, 16.5% (n=92) were medical secretary, 14.7% (n=82) were caregiver, and 10.8% (n=60) were security guard. Majority of them was working in outpatient (37.7%; n=210) and inpatients clinics (30.9%; n=172), whereas the rest was working in emergency (16.0%; n=89) and ICU (15.4%; n=86).

Attitudes and COVID-19-related Knowledge of Participants

Among the participants, 67.1% (n=374) had the COVID-19 test and 43.8% (n=244) had the thoracic computerized tomography examination at least once since the pandemic began. The test result was positive in 20.9% (n=78) of those who had the COVID-19 polymerase chain reaction (PCR) test. Sufficient protection for themselves against the COVID-19 infection was thought to be provided by their institutions in 39.9% of participants. The attitudes and COVID-19-related knowledge of Participants’ are presented in Table 1.

Gender Differences in Scale Scores

Evaluation of gender differences in scale scores revealed that females had higher levels of HADS-anxiety (p=0.001; p<0.01), FC-19S (p=0.001; p<0.01), MBI-emotional exhaustion (p=0.001; p<0.01), MSPSS-friend (p=0.018; p<0.05), and MSPSS-significant other subscale (p=0.017; p<0.05) than males (Figure 1).

Occupational Differences in Scale Scores

The Kruskal-Wallis test and One-Way ANOVA analysis were performed to differentiate the variables into occupational groups, and results were reported in Table 2. No gender difference was found in the FC-19S scores. The BHS scores were significantly higher in resident doctors (mdn=8) and caregivers (mdn=10) compared to other occupational groups [H (5)=45,583, p<0.001]. The HADS-anxiety scores were significantly higher in resident doctors [F (5,5511)=3,072, p=0.011]and the HADS-depression scores were higher in caregiver [F (5,551)=4,557, p<0.001] than the others. The MBI-emotional Exhaustion [F (5,551)=10.094, p<0.001] and MBI-Depersonalization [H (5)=29,190, p<0.001] scores were highest in the resident doctors than others. The MBI-personal accomplishment scores were statistically significantly higher in specialist doctors (mdn=21.5) and security guards (mdn=23) compared to others [F (5,551)=11.060, p<0.001]. The MSPSS-family scores were significantly higher in specialist doctors compared to nurses and resident doctors [H (5)=62,031, p<0.001].

Hospital Unit Differences in Scale Scores

The Kruskal-Wallis test and One-Way ANOVA analysis were performed to determine the hospital unit differences in scale scores, and results were presented in Table 3. Compared to those working in other hospital units, participants working at ICU had significantly higher scores of HADS-depression [F (3,553)=6,759, p=0.001], FC-19S [F (3,553)=8,961, p<0.001] and MBI-emotional exhaustion [F (3,553)=5,690, p<0.001]. Compared to those working in inpatient clinics, participants working in outpatient clinics had significantly higher scores of MBI-personal accomplishment [F (3,553)=5,881, p<0.001] and MSPSS-family [H (3)=15,729, p<0.001] and MSPSS-friends [F (3,553)=6,828, p<0.001]. No difference was found in the hospital unit in the BHS, HADS-anxiety, MBI-depersonalization, and MSPSS-significant other scores.

Relationship Between Scale Scores and COVID-19 PCR Testing Status Among Participants

Participants were examined in 2 groups, as those who had the COVID-19 PCR test and those who did not, and the scale scores of these two groups were compared. The Mann-Whitney and Student’s t-tests were applied in statistics and results are shown in Table 4. Those who had the COVID-19 PCR test (mdn=6) had a significantly higher BHS score (z=-3.123, p=0.002) than those who did not (mdn=5). Scores of HADS-anxiety (t=3.024, p=0.003), HADS-depression (t=3.382, p=0.001),and FC-19S (t=3.022, p=0.003) were higher among those who had COVID-19 PCR test than those who did not, and the MSPSS-friend average scores were low. The MSPSS-Significant score value was lower in those who had the COVID-19 PCR test (mdn=17.5) than those who did not (mdn=20) (z=-2.222, p=0.026).

Comparisons of Social Support Subscale (MSPSS) Scores With Other Scale Scores

The Pearson correlation analysis was applied to determine the relationship between the MSPSS scores and other scale scores, and the results are shown in Table 5. Negative correlations were found between the scores of BHS and each MSPSS subscales [Family (r=-0.397), Friend (r=-0.366) and Significant other (r=-0.369)] (for all p<0.01). In addition, the MSPSS (family, friend, and significant other) scores were negatively correlated with HADS-anxiety, HADS-depression, and MBI-emotional exhaustion (p<0.01). A statistically significant negative correlation was found between the MSPSS-friend and FC-19S scores (r=-0.167, p<0.01). Moreover, the MSPSS (family, friend, and significant other) scores positively correlated with MBI- depersonalization (r=0.228, r=0.207, and r=0.242, respectively) (for all, p<0.01).

DISCUSSION

Many people suffered a severe illness course or died due to COVID-19 infection. Many experienced severe illnesses or the death of loved ones. In addition, people were exposed to economical, daily life, educational, and occupational changes. Many governments applied rules for social isolation to both sick and healthy individuals to prevent the spread of the disease. The time to return to previous normals is unknown. All these may lead to increased distress in an individual’s life. Recent studies have demonstrated that the COVID-19 pandemic leads to distress and negative outcomes on the psychosocial well-being of the general population. Health workers are also part of society. Moreover, they have to work with patients with COVID-19 due to their professions, which makes it inevitable for them to be affected by the pandemic process. Healthcare professionals carry increased risk not only in physical but also mental health because they work in the frontline during the pandemic (4,7,9). Psychosocial adjustment to a specific stressor is related to the characteristics and social environment of the individual. Therefore, people are not equally influenced by stressor exposure during the pandemic. This study aimed to examine the psychosocial adjustment and its individual and environmental correlation in healthcare professionals who worked in pandemic hospitals from the beginning of the pandemic. That is, we examined the healthcare professionals who worked at the frontline during this pandemic and found that their psychological well-being was related to their gender, occupation, and the hospital unit where they worked during the pandemic. Moreover, social support, COVID-19 attitude, and psychosocial adjustment were interrelated with each other.

Studies have shown that during the COVID-19 pandemic, the psychosocial adjustment of the healthcare professionals is affected by gender, and females have higher anxiety, depression, and distress levels than males (11,12,26). In addition, a systematic review and meta-analysis study in this group have found that the pooled anxiety prevalence was 29.06% in females and 20.92% in males (27). This current study found higher levels of anxiety, COVID-19 fear, emotional exhaustion, and social support in female healthcare professionals compared to male counterparts. The female gender is well-known to be associated with an increased risk for anxiety disorders and is more vulnerable than males in the presence of stress (28). Our gender-related result supports the literature knowledge.

Examination of participants according to their occupational groups and hospital units showed that psychological health was most dramatically affected in assistant doctors, caregivers, and those working in the ICU. The highest levels of anxiety, hopelessness, emotional exhaustion and depersonalization were seen in assistant doctors, and the highest depression scores were seen in caregivers. Contrarily, the highest personal success scores were seen in specialist doctors and security guards. Working in the ICU was associated with increased depression, fear of COVID-19, and emotional exhaustion, whereas working in the outpatient clinic was associated with increased personal success scores. All these findings indicate that closer and frequent contact with patients with COVID-19 causes increased negative psychological outcomes in healthcare professionals. In pandemic hospitals, resident doctors and caregivers and healthcare professionals in ICU worked in close contact with longer durations. Moreover, the healthcare professionals in the ICU had to experience their colleagues’ serious illness course and death due to COVID-19. While all these are already difficult and troublesome, when the unknowns about the COVID-19 pandemic are considered, it may lead to an increased psychological burden on these healthcare professionals, especially those working in the ICU.

Frontline healthcare professionals could be more accustomed to potentially distressing experiences than non-frontline professionals, thus showing a lower negative response to challenging situations (12,14). However, studies have shown that nurses and those who work in the frontline with close contact with patients and those who work for long hours have more frequent negative psychological outcomes among the healthcare professionals during the COVID-19 pandemic (4). Moreover, these studies were conducted in the acute phase of the pandemic and included only specific occupational groups. Contrarily, this current study included all hospital staff working in COVID-19 pandemic hospitals serving patients with COVID-19 only. All participants were the frontline healthcare professionals since they worked in a pandemic hospital. Therefore, we think that our study predicts the relationship of psychosocial adjustment with the hospital unit and occupational groups in frontline healthcare professionals better than the previous studies.

The World Health Organization and the scientific world emphasize the importance of prevention methods for the disease spread in the general population and health care professionals from the beginning of the pandemic. Special equipment and working hours arrangements were recommended for healthcare professionals. However, particularly at the beginning of the pandemic, as in many other countries, adequate equipment was not provided in many health institutions in Turkey, and medical doctors in different specialties had to work in COVID-19 outpatient and inpatients clinics with long working hours. Thus, we thought that frequent and unexpected changes in workplaces might lead to anxiety, hopelessness, and burnout in healthcare professionals.

This study examined the COVID-19 knowledge and attitudes of healthcare professionals. A majority reported that they were following new literature on COVID-19 and believed that the pandemic would end. In addition, a majority reported the insufficient provision of protection for COVID-19 infection from their institution. An inverse relation was demonstrated between the COVID-19 attitude and psychological adjustment in the healthcare professionals. In healthcare professionals, insufficient protection from COVID-19 means increased risk not only for getting sick but also for carrying the disease to their families. These thoughts lead to further social isolation within the family. All these factors were thought to increase the psychological burden on healthcare professionals and result in negative psychological outcomes. Similar studies emphasize that healthcare professionals are concerned about the protection or safety of themselves and their families from the disease, which is also another important stress factor (29). Trumella et al. (14) also state that a negative COVID-19 attitude can affect healthcare professionals mentally and even negatively affect their work performance.

Social support is one of the most important resources to cope with the psychological burden following the pandemic (29). Social support given to medical staff reduced anxiety and stress levels and increased their self-efficacy. Keeping stable working teams, improving communication and recognition, and providing clear guidelines and social support are examples of how the working environment could be improved during the pandemic (4,30).

Our study findings showed a negative relationship between social support and anxiety, depression, emotional exhaustion, depersonalization, and fear of COVID-19. COVID-19 attitude was more negative in those with low social support. Social support differed in occupational groups. Caregivers, resident doctors, and nurses had lower social support than others. The highest social support was seen in specialist doctors and outpatient clinic staff.

Our study results pointed out that the psychological adjustment and COVID-19 attitude of healthcare professionals working at the frontline during the COVID-19 pandemic were negatively affected, especially in those with lower social support. In addition, higher social support was associated with personal achievement. These findings were consistent with the literature. Our most striking finding related to social support was that healthcare professionals who work closely and have frequent contact with patients with COVID-19 had lower social support. These healthcare professionals themselves may be avoiding social contact because of their higher disease-carrying risk. Moreover, they may be isolated by their social environment and even by their family member. Especially in the first months of the pandemic, when the news in media warned many people in the society to stay away from healthcare professionals and healthcare professionals are labeled as contagious.

Study Limitations

The major limitation of this study was its cross sectionality. Another limitation is the sample. The subgroups of the sample had different educational levels with probable different socio-cultural and economic levels. In addition, this study was carried out on only one side of Istanbul and did not include the health care professionals from rural areas of the same city or country. However, the risk of transmission and lack of resources remains a common problem in healthcare facilities all around the country and future research needs to examine the experiences of healthcare workers within the rural hospitals as well.

CONCLUSION

This study evaluated the psychosocial adaptation of the healthcare professionals in a multidimensional approach, considering many areas, including depression, general anxiety, phobic anxiety specifically towards the COVID-19 disease, and hopelessness. Consistent with the literature, results showed that healthcare professionals were negatively affected by the COVID-19 pandemic process in terms of psychosocial adjustment. In addition, study results indicate that gender, occupation, and hospital unit are important factors for psychosocial adjustment during the pandemic. Moreover, psychosocial adjustment showed to be related to social support and the COVID-19 attitude of the healthcare professionals. Today, the COVID-19 pandemic continues. In the long run, the life quality and functionality of healthcare professionals should be considered. Our study results indicated that healthcare professionals who have high contact with patients with COVID-19 have high anxiety for themselves and their families. Therefore, planning for psychosocial support programs and providing psychiatrist or psychologist assistance at regular intervals is thought to be important for healthcare workers. In addition, social support can be provided to health workers through institutions, associations, and professional organizations. Considering that the pandemic process will continue and new or different pandemic processes may emerge, providing adequate protective equipment against the specific infectious disease, providing adequate rest periods, and determining a regular job and place for health workers in the frontlines during the epidemics will have a more functional result in their psychosocial adjustment and professional lives. This study revealed the healthcare professionals that have increased risk for psychosocial adjustment problems, study results are valuable for both healthcare professionals and hospital managers, as well as the governments.

Acknowledgments

The authors would like to thank all the participants who kindly agreed to participate in the study.

ETHICS

Ethics Committee Approval: This study was conducted according to the provisions of the Declaration of Helsinki in 1995. Approval was obtained from the Ethics Committee of the same hospital with the University of Health Sciences Turkey, Bakirköy Dr. Sadi Konuk Training and Research Hospital (protocol number: 2020-157).

Informed Consent: Written and verbal consent of each participant was obtained.

Authorship Contributions

Surgical and Medical Practices: F.A.K., Concept: F.A.K., S.Y., Design: F.A.K., İ.K., Data Collection or Processing: F.A.K., S.Y., İ.K., Analysis or Interpretation: F.A.K., S.Y., İ.K., Literature Search: F.A.K., S.Y., Writing: F.A.K., S.Y.

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

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