Social isolation emanated psychological exhaustion and disconnectedness among physicians during the COVID-19 pandemic: Results of a qualitative study in Pakistan

doi:10.21203/rs.3.rs-4191695/v1

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Social isolation emanated psychological exhaustion and disconnectedness among physicians during the COVID-19 pandemic: Results of a qualitative study in Pakistan

https://doi.org/10.21203/rs.3.rs-4191695/v1

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Background: During the COVID-19 pandemic, many healthcare providers remained on call in COVID-19 wards, isolation centres, and emergency departments, caring for both infected and non-infected patients. Physicians have faced various challenges during the pandemic, including the stress of working with limited resources, the physical burden of long work hours and fear of public abuse in terms of stigmatization. Therefore, this study focusses on social-psychological aspects of isolation period of physicians during the COVID-19 pandemic.

Methods: It is a qualitative study based on responses from 14 physicians working in two hospitals located in Islamabad, which is the capital city of Pakistan (Pakistan Institute of Medical Sciences [PIMS] and PolyclinicHospital). In-depth interviews were conducted with selected physicians by using an interview guide as a tool of data collection to explore the experiences of those physicians who suffered from COVID-19 and lived in isolation as their quarantine period. The data was analyzed by using thematic analysis technique.

Results: The study explored isolation experiences of physicians during the selected period of COVID-19 and significantly found that two major themes emerged, i.e. psychological exhaustion (depression, anxiety and loneliness were subthemes) and disconnectedness (relational detachment and lack of interaction were subthemes).

Conclusions: This pandemic crisis has significantly resulted in having adverse impact on the ability of physicians to approach both potential and existing patients. Particularly in times of such a crisis, adequate measures have to be taken to address mental health issues of the health workforce.

Isolation

Psychological exhaustion

Disconnectedness

Physician

Corona

SARS-CoV-2

In February 2020, the COVID-19 pandemic first appeared in Pakistan, forcing the country’s first state-wide lockdown in March 2020. Pakistan has entered its second wave of the COVID-19 peak, with semi-lockdown in hot spots across the nation in November 2020, with total cases approaching 0.4 million. The country, which has a population of 212 million people, is known for its resource limits and physician-to-patient ratio of 1:1,300 [1]. Many healthcare providers remained on call in COVID-19 wards, isolation centres, and emergency departments, caring for both infected and non-infected patients [2]. Physicians have faced a number of known health and well-being challenges since the COVID-19 outbreak, including the stress of working with limited resources, the physical burden of long work hours and fear of public abuse in terms of stigmatization [3]. The apprehensive situation was prevailed among masses due to the widespread and deadly nature of COVID-19 and the very challenging task was assigned to the physicians to fight this scuffle by saving lives of the patients [4]. During initial days, many of the physicians also died by COVID-19, they worked day and night and sacrificed their lives to save others [5]. This ultimately increased their vulnerability to face psychological distress [6] and emotional exhaustion [7] along with psychosocial maladjustment, especially during their isolation period of quarantine [8].

Sociological literature moves beyond the mere difference between subjective and objective nature of social isolation [9] and explains how societal norms, values, attitudes and cultural background shape people’s choices [10], how they make way to certain people and hinder involvement opportunities for others [11], and how these restrictions shape whole societies [12]. Social isolation is the lack of social contacts [13]. Social isolation also occurs when an individual fails to integrate into mainstream society [14, 15]. Whereas, mainstream society includes institutions, communities and families’ [16] with people unable to integrate in their social circle and participate in it during social isolation [17].

Social isolation could be defined as the lack of attachment [18]. A dearth of social connections leads to social isolation [19]. When people fail to connect in terms of their daily interactions it may lead to marginalization pushing certain groups more away from the mainstream line [20, 21]. Social isolation has bad effects on emotional and mental health of individuals which ultimately leads to low self-esteem [22, 23], followed by a lack of opportunities and limiting their social affiliation [24]. Feelings of an outsider or emotions related to being separate from others are the main causes of social isolation [25, 26]. The degree of how much an individual or a group is socially isolated could be determined by the frequency of their interactions in their daily life practices [27].

Social isolation is one of those social problems which directly disturb the society as a whole [28–30]. Being treated differently implants the feelings of ignorance and exclusion from main stream society and it ultimately creates alienation among isolators [31, 32]. Meanwhile by nature, human beings are social animals; they cannot thrive in isolation [33] which means they have to be in a healthy circle of networks of communication and social engagements [34]. Social isolation is a very common phenomenon of old age [35, 36], when people lose their economic roles [37], or have suffered loss of their closed ones [38] and are unable to do physical activities, their social circle turn into limited and resulting to concede social isolation [39].

The social relationships have been affected in each domain, i.e. social interaction [40], social support [41], and social networks [42]. Lack of social interaction and social isolation are found to be associated with the trajectories of negative mental health [43], helplessness [44], denial [45] and marginalization [46]. The voluntary reduction in social interaction because of Covid-19 also created issues of anxiety [47], depression [48] and psychological distress [49].

Many studies on COVID-19 evinced that social isolation is one of the major reasons in creating psychosocial issues of health [49–51]. It worsens the situation for those who are already susceptible to depression or loneliness [52, 53] and also make it worse by separating people from their support systems which are either their friends or family members [54–56]. Due to minimum interaction, social isolation has created a space for those who are already vulnerable to mental problems because of unemployment [57] and poor health conditions [58]. The practice of social isolation puts the entire humans at the edge of anxiety [59, 60], depression [50] and loneliness [61] by creating panic in the form of its perceived lamentable nature [62].

Therefore, this study focusses on social-psychological aspects of isolation in the group of physicians who got quarantined during the COVID-19 pandemic.

Study design

The study intended to explore the experiences of those physicians who were in isolation during COVID-19 by following the standard operating procedures (SOPs) as defined by the Government of Pakistan1 and World Health Organization (WHO)2. To best fulfil the purpose of this study, in-depth face to face interviews were conducted with those participants, who were back to their normal life to explore the responses of study participants. A qualitative study was carried out to gather the desired information by using an interview guide as a tool for data collection.

Participants

A purposive sample of 14 physicians (including seven men and women each) was chosen. Participation was voluntary and before data collection process, the participants were informed about the purpose of this study. Because of busy schedules or personal issues, we had to approach 30 physicians to reach the sample. The participants were selected for interview by keeping in mind their working schedule because being frontline worriers; they remained busy day and night to perform their duties and it could be an infuriating practice to arrange an interview session with them. The selection was based on defined inclusion criteria as a requirement of consecutive sampling technique [63]. According to the inclusion criteria, we included physicians i) who lived in isolation for at least 15 days after tested positive with COVID-19 during the first and second wave and/or completed their isolation period (not limited to numbers), ii) who were not running their private clinics and only working in the selected hospitals (to avoid replications), and iii) who were living in Pakistan at the time of initiation of the first wave of COVID-19 (to have an experience of a first impression and socio-psychological impact of the pandemic).

Interview guide

An interview guide was developed by the research team as a tool for data collection and the nature of research equations was open-ended by allowing the participants to discuss and reveal their information, experiences and feelings in existent quintessence. The following questions were asked:

When did you hear about COVID-19 and started working with positive cases? What were your feelings about it?

When did you came to know that you are COVID-19 positive? What were your feelings?

Please describe your overall experiences during the isolation period.

Please describe your emotional state during the isolation period.

Please discuss your psychological state and experiences during isolation period.

How did COVID-19 generally – and your isolation period particularly – affect your life (personal and professional)?

Which uncertainties prevailed significantly during your isolation period?

Data collection

Data was collected from two hospitals. One was Pakistan Institute of Medical Sciences (PIMS) and the second one was Polyclinic Hospital, both located in Islamabad, the capital city of Pakistan. The data collection was initiated in November 2020 and lasted till April 2021, almost covering the second and third wave of COVID-19 in Pakistan. The process of data collection remained very slow because of unavailability of participants for interview, particularly due to their health issues, their professional engagements and due to the strict lockdown imposed by the Government of Pakistan. Data were collected by the primary author of this study in English language.

Data analysis

We used thematic analysis according to Braun and Clarke [64]. We followed a six-phase approach that enables to discover and concentrate to the relevant components of a theme analysis and also facilitate the analysis. The six steps are structured in a logical order, but it needs to be ensured that the analysis is not a straightforward task. Rather, the analysis is iterative and cyclical, forcing the researcher to go back and forth between phases as needed [64].

Thematic analysis is a lengthy procedure that grows as the researcher progresses through the various stages. It can lead to new data interpretations, which may necessitate more repetitions of prior steps. As a result, it is critical to think of the six-phase method as a series of suggestions rather than rules that should be adapted to the data and research questions at hand (Braun and Clarke, 2014). The six phases of the thematic analysis are as follows:

Familiarization with the data

Generating initial codes

Generating themes

Reviewing potential themes

Defining and naming themes

Producing the report

All the phases were followed sequentially while analyzing the collected data.

[1] https://covid.gov.pk/guideline

[2] https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public

Psychological exhaustion

The respondents of the study were emotionally drained out during their period of isolation because the period of 15 days and many cases it lingered on, till 30 to 35 days due to physical weakness. The participants considered COVID-19 as a challenge and a negative event, which posed a severe emotional burden and psychological tiredness because of its chronic and fearful results. The results of this study also explored that the physicians were living in isolation and due to limited outdoor exposure, they were physically and psychological worn out.

Although participants had a sufficient family support, encouragement and sympathies to bear the pain of this lethal ailment, they often thought about the ultimate consequences of this disease such as death. As they were aware that death happened in many cases following COVID-19 infection, it ultimately puts them into the worst form of psychological strength.

Social isolation created many psychological problems including stress, anxiety, depression, posttraumatic stress disorder and overall fear. It also affected their social life, in terms of limited communication, lack of interaction, loneliness and detachment from their communal life. Social isolation also resulted in the feeling of helplessness among people who provided care to the patients. One physician also expressed his feeling in the following manner:

It was very painful for us to let they people die, because of this deadly disease, which was initially untreatable in the whole world because of the muddled health state in the world. (P3)

Depression and anxiety

It has been recorded that most participants reported a severe form of depression during their isolation period. As they were aware of the existing health conditions within Pakistan and their lofty demand in hospitals to serve the patients, they were also unable to join their duties as they were tested COVID-19 positive. The physicians reported depression, because of their inability to perform their duties and especially when they were exposed to at high risk of death.

I was in depression, because I was unable to perform my official duties, and neither could I join my family because of my isolation period. (P1)

At times, during my isolation period, I was depressed and fearful of dying alone. (P7)

The inability to treat their patients and perform their duties created depression and anxiety among study participants, because they were bound to be in isolation and had no physical contact with their patients and family members. The participants also experienced and revealed the fear of dying alone because of during their isolation period; they faced worse psychological and emotional problems.

Loneliness

As a preventive practice, the physicians lived in isolation for almost 15 days as an SOP, after performing their duties in COVID-19 wards. The 15 days isolation period was very important for physicians and for their families, because during their duty period they had frequent interaction with patients of COVID-19 and had a greater vulnerability to suffer from its consequences.

During the isolation period, the respondents of the study reported loneliness, because they were detached from their daily routines and, particularly, they had limited interaction with their patients, colleagues and family members.

I was lonely during isolation period, because I was no more involved in official duties or in household chores. (P9)

Even though, I am a physician, but I often thought, what would I do if I could not recover from this deadly disease, because I was alone and need emotional support of my parents and family. (P4)

Some of the cases (physicians) reported worst experiences of social isolation and they confronted loneliness. Although the participants received ample moral and emotional support from their family members and the community praised them as considering national heroes, to some extent they felt loneliness during their isolation period. One of the male participants stated:

Instated having lot of moral, social and emotional encouragement, I was alone. I was in a dire need of having someone physical present to me to enjoy the normal life. (P2)

Disconnectedness

Social connectedness is associated with social adjustment and healthy interaction among individuals. However, during the COVID-19 pandemic, following SOPs for the safety of oneself as well as for others, people were asked to follow social distancing, which created social disconnectedness among individuals.

Relational detachment

COVID-19 is cindered as a contact disease and it created a sense of detachment among the general population and particularly among those, who agonised this virus. Along with the circumstances caused by social distancing and self-isolation, the main concerns of the physicians are their incapability of serving patients due to patients’ lack of knowledge about internet and technology, or their lack of knowledge about the technological means used for the online health care services.

Most of the times, when my patients were advised to connect me through online social networking, it was difficult for them to use those platforms and I could not guide them properly because to their poor knowledge of technology and internet. (P11)

The rapid magnification of digital interaction during COVID-19 was not common for all and particularly not for those, who were elder, illiterate or new users. In many cases, the patients were advised to contact their physicians through online mode of communication, but it was very difficult for them to communicate with them, because of the patients’ lack of knowledge to use the internet and smartphones or computers/laptops.

Lack of interaction

The snare of social relations was badly disrupted during COVID-19, as it created hindrances and limited people not to contact physically with each other. One of the physicians said:

It was very difficult for us to limit our social interaction with others, because we have to mitigate the chronic situation of the pandemic by fighting as frontline workers. (P13)

Physicians have a prime responsibility to serve the masses. At the same time, they had to perform their errands as parents, siblings or as a spouse. With all such roles and responsibilities, the physicians had to mitigate the risk of putting their lives at a stern risk. A female doctor emphasized:

I was worried about my children and husband, because I was unable to spend time with them, as working all time in COVID-19 wards for the treatment of patients and then visiting my home where I cannot meet my family directly, because I have to be quarantine for a week. (P10)

Life in isolation created many psychological and emotional problems in addition to the socio-psychological maladjustment in their routine life, not only during pandemics like COVID-19. It has been explored that individuals require healthy interaction [65], strong social bonding [66, 67], sense of solidarity [68, 69], and sense of interconnectedness [70, 71] to ensure the existence of community life.

People abridged their social interaction with friends, family members and with community members, either voluntary or by following SOPs defined by WHO and the Government of Pakistan. Although quarantine has shown to be an effective method for combating infectious disease epidemics across the world in the past [72], restriction of movement and being separated from one’s friends corroborated unpleasant psychological impacts [73]. Isolation posed negative psychological impacts such as anger [74], hopelessness [49], anxiety [75], life dissatisfaction [76], and a lack of self-control [77] during the COVID-19 pandemic.

These results from the previous studies among the general population is also visible in our study sample of physicians. In addition, physicians and other health-care workers are most concerned about spreading the illness to their families. There is also concern that if they become ill, they may betray the health system and their patients by being unable to participate [78]. Physicians all over the world have been facing issues in communicating with their patients due to pandemic crisis [79]. This pandemic crisis has significantly resulted in having adverse impact on the ability of physicians to approach both potential and existing patients. During the first wave of COVID-19 in Pakistan, most of the physicians were tested positive and they spent days (15 days as an SOP and till they were retested negative) in isolation. During the isolation period, due to fear of uncertainty, poor management, massive deaths, unavailability of vaccines and curative measure of the pandemic, they faced severe psychological uneasiness and discomfort because of all these concerns.

This study is based on qualitative data from physicians of two hospitals in one city of Pakistan. For that reason, it does not claim to be representative, but it sheds some light on the experiences of physicians during quarantine or isolation. The study explored isolation experiences of physicians who experienced isolation during a selected period of COVID-19 and significantly found that two major themes emerged, i.e. psychological exhaustion (depression, anxiety and loneliness were subthemes) and disconnectedness (relational detachment and lack of interaction were subthemes).

By using an exploratory research design, the study aimed to explore the experiences of physicians during their isolation period. During their isolation, physicians faced psychological exhaustion in terms of depression and anxiety as well as social disconnectedness in terms of relational detachment and lack of social integration with their family members, colleagues and patients, particularly due to a lack of physical proximities. The participants expressed their experiences of loneliness, depression and anxiety and particularly their social detachments form their responsibilities (as healthcare frontline workers). They showed off a very serious concern in terms of psychological mania by being not able to pay attention to their patients.

COVID-19 Coronavirus disease 19

PIMS Pakistan Institute of Medical Sciences

SOP Standard operating procedure

WHO World Health Organization

Ethics approval and consent to participate

The study was conducted after ethical approval of the Shaheed Zulfikar Ali Bhutto Institute of Science and Technology. It followed the Declaration of Helsinki’s principles. Written informed consent was obtained from the participants after introducing them to the purpose of the study.

Consent for publication

Not applicable.

Availability of data and materials

The dataset generated and analysed during the current study is not publicly available due to the fact that the information is based on qualitative data. However, anonymized data is available from the corresponding author on reasonable request.

Competing interests

FF is Associate Editors at BMC Public Health. All the other authors declare no conflict of interest.

Funding

This research received no supporting funds from any funding agency in the public, commercial, or not-for-profit sectors.

Authors’ contributions

MAuHR and MMM conceptualizes the study. MAuHR was responsible for data collection. MAuHR and MMM performed data analysis, FF supervised this proves. MAuHR drafted the manuscript, MMM and FF revised it critically for important intellectual content. All authors approved the version to be published and agree to be accountable for all aspects of the work.

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Competing interest reported. FF is Associate Editors at BMC Public Health. All the other authors declare no conflict of interest.

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Social isolation emanated psychological exhaustion and disconnectedness among physicians during the COVID-19 pandemic: Results of a qualitative study in Pakistan

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Abstract

Background

Methods

Study design

Participants

Interview guide

Data collection

Data analysis

Results

Psychological exhaustion

Depression and anxiety

Loneliness

Disconnectedness

Relational detachment

Lack of interaction

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

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