A Qualitative Study: What Are the Psychosocial Experiences of the Turkish Doctors During the COVID-19 Pandemic?

The present qualitative and exploratory study aimed to determine the ideas, feelings, behaviors, and changes in the working and family lives of actively working Turkish doctors during the Covid-19 pandemic. The researchers tried to understand the social and work-related problems of the doctors. Therefore, this study may be considered as a starting point for future studies. The participants (61 doctors) filled out a questionnaire that consisted of demographic information and 17 open-ended questions. 49.3 % of them were actively working in specialized pandemics hospitals. In the present qualitative research, non-numerical data were collected to understand the psychosocial experiences of the doctors, and their most crucial quotations were categorized and reported, - as it is essential to report the quotations and the narratives in the descriptive analyses of the qualitative research. The researchers’ aim was to gather in-depth insights into their experiences and then generate new ideas for future quantitative research. The researchers used two of the nonprobability sampling types, i.e., snowball sampling and convenience sampling because of


INTRODUCTION
The first-line interventions for all pandemics are behavioral methods and vaccinations to reduce mortality and disease.Unfortunately, vaccinations cannot be easily available, just as in the case of COVID-19.On the other hand, behavioral methods are easy to practise, because they include hygiene (e.g., handwashing with soap, wearing face masks) and social distance (e.g., quarantine of infected persons, school closure, remaining at home).
The science of psychology gives us the essential tools to avoid emotional problems such as fear, stress, and anxiety, and behavioral problems such as not following the general rules.Psychological reactions to pandemics play a crucial role in the spread of the disease because emotional distress may cause social disorder in different ways.In fact, people react differently when they are threatened by infection.It is important to cope with the threat of pandemic influenza, e.g., the possibility of losing family members, having financial problems, losing jobs, and so on.Therefore, psychology has a crucial role for managing societal problems.Furthermore, psychology serves to manage maladaptive defensive reactions because when people are threatened with infection, there may be increases in xenophobia and stigmatization (Taylor, 2019).
Healthcare systems are particularly important to care for patients.The workers in these systems are crucial to struggle against the pandemic.They (doctors, nurses, etc.) are a part of the great system in a country and are the frontline workers in the struggle against pandemics.In this qualitative research, the researchers conducted a study with actively working Turkish doctors during the ongoing pandemic, COVID-19.
Social networks serve to spread beliefs and fears about infection through some specific channels.Firstly, information can be transmitted by mass media and/or rumors.Secondly, observational learning can be another channel, i.e., by observing other people giving different responses to stimuli.The third channel can be direct personal experiences, for example, traumatic experiences.
The spread of fear is a kind of emotional interaction.When we talk about observational learning, we should mention the social learning theory of Albert Bandura.Bandura Taylor, 2019) argued that emotions spread through observational learning.Therefore, fearful emotions and reactions can be acquired via communicating with people who express their fears about pandemics.According to Aronson (1994), who emphasized the importance of emotional appeals, "the impact of fear appeals is context-specific" (p.90).He gives some examples from the health literature.In summary, pandemic-related fear can be experienced because of both observational learning and information transmission.Rumors, true or false, and media reports are important determinants in the transmission of information.
The news media are criticized for exaggerating different situations by manipulating emotions, for example, by using emotional language or by making 'excessive' comparisons in order to appeal to the sensations of people (e.g., using dreadful metaphors in order to describe infection).
People share information through social media, as well.Social media users generally utilize dramatic and emotional tones of language to disseminate what they want to say.However, social media can disseminate not only information, but also misinformation, and thus there is the risk of an increase in excessive fear.
When people feel at risk, they cannot turn attitudes into action.In the case of an epidemic, "terror, blame, rumors and conspiracy theories, distrust of the authorities, and panic can all come together" (Quick and Fryer, 2018).Therefore, attitudes do not always turn into behavior (Kağıtçıbaşı, 2003).Even though the health authorities remind people to wash their hands, for example, Safiye Neslihan ERCAN -İlayda ULAŞ some of them may still not follow the basic hygiene rules.Was Freud (1961) right when he argued that "all living matter aspires to return to its inorganic state"?Is it about 'death instinct', i.e., do some people 'unconsciously' want to spread the virus?
Excessive fear or no fear at all? Balance is essential to cope with a problem, in this case, the COVID-19 pandemic.It should be the duty of all the members of society to protect each other and the 'soldiers' of this struggle, i.e., the doctors, by following the rules and regulations of society.That is the process of socialization: Socialization is the process during which the members of society learn to follow social norms and values in society (Bilton et al., 2008).We have responsibilities towards each other.
There is a branch of psychology called 'Health Psychology', which is mostly related to behavioral medicine, clinical psychology, and psychiatry.Health psychologists focus on various models to study health-related topics.The essential model is called the 'biopsychosocial model' because it emphasizes the connection among biological factors (e.g., viruses), psychological factors (e.g., behavior, stress), and social factors (e.g., education) (Albery and Munafò, 2008).Generally, concerning the models in health psychology, one social input in the models is always general health.So, health psychology can be seen as a branch of psychology that connects to medicine.

METHODOLOGY
This study was initiated after obtaining the ethics committee approval from Altınbaş University Scientific Research and Publication Ethics Committee with the decision dated 06.12.2021 and numbered 21054.
The present exploratory study aimed to determine the ideas, feelings, behaviors, and changes in working life and family life of actively working Turkish doctors during the COVID-19 pandemic.In this qualitative exploratory study, the narratives of the doctors were reported in quotations because in qualitative research narrative, public health is important "in offering audience critical tools for navigating and decoding pandemic storytelling" (Davis and Lohm, 2020).
The psychological health of the doctors affects public health because they are the frontline 'soldiers' in this war of humanity against the present virus.
They should learn to cope with stressful situations.COVID-19 will not be the last pandemic, so we should take precautions against future pandemics.Therefore, the coping mechanisms of the doctors should be bettered.
The researchers of the current study tried to understand the social and work-related problems of the doctors.Therefore, this study may be considered as a starting point for future studies, because it is essential to diagnose the problems before struggling against them.
The participants consisted of 61 doctors in the specialized branches of anesthesia and reanimation, gynecology, obstetrics, cardiovascular surgery, physiotherapy, furthermore family doctors, dentists, general practitioners, infectious diseases specialists, and others.Thirty-two (52.5 %) were male and 29 (47.5 %) were female.The age range was between 23 and 68 with a mean of 41.4.Thirty-six (59 %) were married, and 21 (34.42 %) were single, and 4 of them (6.58 %) stated another relationship status.Thirty-nine (63.9 %) had children with a mean age of 16.2 and 22 (36.1%) did not.

Procedure
Because of the intense working hours of the doctors-of whom 49.3 % were actively working in specialized pandemic hospitals during the COVID-19 pandemic, convenience sampling and snowball sampling were preferred to reach them.
The convenience and the snowball sampling are two of the nonprobability sampling types, and they are used when the accessibility to the sample is difficult.
The participants filled out a questionnaire that consisted of demographic in- formation and 17 open-ended questions.It was possible to fill out the questionnaire in approximately twenty minutes.The open-ended questions gave participants a chance to write down their answers in a narrative format, as well.
Demographic information consisted of questions on age, gender, marital status, specialization, number of children, and so on.
The questionnaire consisted of 17 open-ended questions, prepared after a pilot study between August and October 2021 with 15 participants, and scrutiny of some books about the psychology and history of pandemics (Davis and Lohm, 2020;Snowden, 2019;Taylor, 2019).Furthermore, some questions (e.g., questions about books and films) were asked to examine their connection to the general and social culture during the pandemic.The questionnaire was revised based on the results of the pilot study.
After getting the ethical committee's approval on December 6, 2021, the questionnaire was administered to the participants by the researchers via sending an electronic link.First, it was adapted into the format of a Google form (G-Forms).The participants were assured of the anonymity and confidentiality of their responses.Before starting to answer the questions, they marked a confirmation page.On the instruction page, the researchers gave an e-mail address (pandemiarastirma@gmail.com) to the participants in order to respond to them if they have any questions about the research and to give a debriefing after the completion of the research.The questionnaire was available online from December 7, 2021, until December 20, 2021, for after the "satisfaction level" of the qualitative research, it was no longer possible to get any new data through convenience sampling or snowball sampling.

RESULTS
The narratives and the quotations are crucial for qualitative research.In qualitative research, the data obtained at the end of the research are always observed, selected, reduced, and summarized in an organized manner.Qualitative data can be analyzed in some steps, and one of these steps is descriptive analysis, which is the one used in the present study.In future research, with larger sample size, the researchers plan to conduct a qualitative analysis by using a qualitative software program, such as NVivo, Atlas.ti,Maxqda, and HyperRESEARCH.Furthermore, a quantitative study may be conducted with a questionnaire based on the answers from the present qualitative study.The present study is an exploratory study, i.e., it aims at exploring issues which have not previously been asked.Exploratory studies are generally qualitative in nature, but if the sample size is a large one, it can also be quantitative.
The researchers asked: "During the pandemic, while performing your profession, if you want to express what you are experiencing with a single word, what would be that word?"Most of the participants gave the common answers of "anxiety", "difficulty", "stress" and "uneasiness".Some of them gave the answers of "tiredness", "fear", "patience", "precaution" and "sadness".
One of the most important social support mechanisms is family, which is a dynamic concept, and is affected by social changes.Family and home life create a social support environment.In addition, social support has a positive impact on health.It has a therapeutic role, and it decreases the probability of developing mental illness (Özbay et al., 2021).To understand how their lives had changed, the researchers asked the participants two different questions about how their lives had changed inside and outside the home.
Mostly, doctors who worked during the pandemic did not have the chance to stay at home and feel safe.The biggest fear was of bringing the virus into the home and infecting their family members.Four participants stated that they separated their rooms and toilets, and one participant was staying in different hotels, not at home.Doctors who had children stated that they wanted to hug their children, but they did not even after they disinfected themselves.Some doctors emphasized the importance of the home as a 'shelter'.However, they experienced social isolation and some related problems more than others.Almost all of them stated that they did not have a social life anymore."My home is my shelter and I do not want to leave it.At home, I can wander without a mask.""We lived distant with my children.We experienced compulsory separations." In addition, the researchers asked the participants whether they experienced any problems with their patients and the patients' relatives or not, with two different questions.Nine participants claimed that they did not experience any kind of problem.On the other hand, all the other doctors experienced problems with their patients.The most outstanding answer was about the patients who did not want to wear a face mask or who did not wear it properly.
One of the questions in the questionnaire was about the equipment the doctors were using while treating their patients.Almost all of them expressed the difficulties of working with protective equipment such as face masks and gloves.Some of them, especially the dentists, stated that they were accustomed to working with face masks.
The most difficult experience of working with a lot of equipment was breathing.Almost all the doctors argued that they could not breathe, and they had communication problems, as well.In fact, wearing face masks may have an unintended consequence because it may increase anxiety by reminding one of health-related threats (Taylor, 2019)."N95 face mask and face shield render the communication with the patient more difficult.Especially, while working with child patients, it becomes more difficult to communicate with them and to convince them."They experienced headaches, movement problems and dermatological problems, as well.
"I feel suffocated after a while.Among a lot of things to do, I was annoyed with continuously changing the equipment.My overalls, because of the hot weather, are transforming in such a manner that you cannot wear them again after only five minutes.The gloves make my hands crimson, with a lot of wounds." In addition, because they experienced problems with their motor skills under the equipment, the demands of the work caused an increase in their stress level."Hot, not moving at ease, breathing your own breath under the mask and therefore feeling a kind of hunger for oxygen, feeling always stress while working." "No oxygen, no movement, always sweating and therefore always and easily tired.Problematic, very problematic.That is what I experienced." The researchers determined that the participants had a very busy work life and worked seven days a week.Most of them had sleep problems.As Freud (1955) stated, "a dream is the fulfillment of a wish".In fact, a doctor with two children stated: "In my dream I saw the Minister of National Education.He told me that he would not open schools."Furthermore, Freud (1955) argued that "dreams showed a clear preference for the impressions of the preceding days" p. 187.In fact, some of the doctors had dreams about the events that they had recently experienced.
"I had a conflict with my manager because he was not fair.So, I had a dream about this." "I see people without face masks outside, and then I see people without face masks in my dreams, and I am so much worried…" "In my dream, I see my colleagues.Two or three days ago, in my dream, my assistant was promoted to manager and fired me." The participants, who watched films and read books, generally mentioned comedy in their answers.It can be concluded that they needed more pleasure at the end of their busy and stressful working hours.As argued by Freud (2016), "the laughter in humor is a sign of pleasure".
In this research, the doctors were asked about the environmental reactions because of their work.Most of them talked about the anxiety of their relatives, and the respect and pity of their neighbors.They talked about fear: their relatives and their neighbors were afraid of them because of their work.
"Because I am a healthcare worker, they are looking at me with a deep fear.""They treated me as if I had leprosy.""They escaped from us as if had the plague; however, they demanded information by telephone calls.""My neighbors treat me as if I am the virus itself.Yesterday, one of them ran towards the elevator." The researchers asked this question to the doctors: "When the pandemic ends, what will change in people's lives?"And the doctors made some predictions for the so-called 'new lives' and 'new world' after the COVID-19 pandemic.
The answers can be grouped into two categories.The first category is composed of the doctors who believe there will be no change after the end of the pandemic, because they think everything will be forgotten even though there will be some psychological problems.
"I expect no radical change…Only the process of psychological recovery.""They will forget… Memory loss…" "If the pandemic ends, everyone will forget everything.People will forget the importance of health.They will go back to consuming.They will forget the importance of nature and the value of doctors.After forgetting all these things, they will go back to their old lives.""Psychological problems will remain.For example, there will be a lot of depressed and anxious people." The second group is composed of doctors who believed that people would learn from what they experienced as social beings.They had a quasi-hopeful future perspective for humanity, even though they thought that there would be some psychological problems.They predicted an increase in individualism and social isolation, and a number of online platforms as well.
"No one will be like before!" "New world order… Maybe more social isolation…" "They will learn the importance of health.""People will learn hygiene, they will better control themselves, they will learn how to pass time alone, there will be more digital platforms, more individualism.""Psychological problems, but new rules in order to cope with unspoken new pandemics…"

DISCUSSION AND CONCLUSION
The World Health Organization (WHO) has the primary role of directing international health within the global system and leading countries in health responses, i.e., it has responsibility for international public health.The organization holds media briefings on the COVID-19 on a regular basis.Because of the high levels of circulation of the Omicron variant, on February 17 and then on March 2, 2022, it gave a briefing on quarantine rules and contact tracing policies because of the need for recent adjustments (World Health Organization, 2022).
The present qualitative study was conducted with 61 doctors during their struggle against the pandemic.A pilot study was carried out to test the functioning of the questionnaire, and the questionnaire was revised based on the results of the pilot study.It was difficult to conduct research with the doctors during the pandemic process because of their intense working hours, even if the questionnaire was an online one.Therefore, convenience sampling and snowball sampling were preferred to reach them.They filled out a questionnaire that consisted of demographic information and 17 open-ended questions.
Thanks to these open-ended questions, the researchers obtained important quotations and narratives from the participants.By definition, this kind of data is crucial for descriptive analyses in qualitative research, especially when it is an exploratory study.
The aim was to determine the ideas, feelings, behaviors, and changes in working life and family life of actively working Turkish doctors during the COVID-19 pandemic.The researchers tried to understand the social and work-related problems of the doctors.Therefore, this study may be considered a starting point for future studies, because it is essential to diagnose the problems before struggling against them.
The participants associated the COVID-19 pandemic with the concepts of "anxiety", "difficulty", "stress", "uneasiness", "tiredness", "fear", "patience", "precaution" and "sadness".The most difficult experience of working with a lot of equipment was breathing.Almost all the doctors mentioned that they could not breathe, and they had communication problems.They experienced headaches, movement problems and dermatological problems, as well.
In the literature on the COVID-19 pandemic, it is possible to see a lot of studies concerning the different aspects of pandemics.For instance, one piece of research focuses on the cyberloafing behaviors of students in health programmes of various universities in Turkey during distance education (Özdemir et al., 2021).There are other recent studies about the relationship between the vaccination process and stress (Akkuş et al.,2021) and, outpatient care and emergency services (Khalil, 2021).In addition, in line with the present study, there is a study focusing on the psychosocial problems of nurses during the COVID-19, due to their increased responsibilities (Yeşilyurt and Vaizoğlu, 2021).In conclusion, there is a great need for effective strategies to prevent psychosocial problems in healthcare workers.The present study may be further developed and may shed light on future research.
The last question was about the hopes after the COVID-19 pandemic.Some of the doctors believe there will be no change after the end of the pandemic, because they thought everything would be forgotten even though there will remain some psychological problems.Some others believed that people would learn from what they experienced, and they had a quasi-hopeful future perspective for humanity even though they thought that there would be some psychological problems.They predicted an increase in individualism and social isolation, and social isolation and a number of online platforms as well.Even though they had different kinds of explanations about the life after the pandemic, there was a very important common point: the emphasis they placed on the importance of the science of psychology.
Ethical Approval: This study was initiated after obtaining ethics committee approval from Altınbaş University Scientific Research and Publication Ethics Committee with a decision dated 06.12.2021 and numbered 21054.

Authors' Contributions:
The first author Safiye Neslihan Ercan coordinated the whole study, prepared the questionnaire, found the participants, summarized and categorized all the qualitative data by making descriptive