1 INTRODUCTION

Coronavirus (COVID-19) emerged in Wuhan, China, in December 2019 (Vieira et al., 2020). It was declared as a pandemic by the World Health Organisation (WHO) on 11 March 2020, and it has had extensive effects on social life globally (Knorst et al., 2021). Measures taken to reduce contact and maintain physical distance have limited interpersonal relationships. Hard and partial lockdown and quarantine have caused a shift towards online education and remote work, changing people's behaviours and habits drastically (Özden & Parlar, 2021; Vasiliu et al., 2020). In this period, people's roles, routines, habits, and lifestyles have changed significantly (Balser et al., 2020; Gehman, 2021). These changes have prevented many people from participating in activities and occupations they value, making it difficult to establish an occupational balance within their roles and routines (Agbaria & Mokh, 2021; Gehman, 2021). Consequently, the COVID-19 pandemic has had great negative effects on individuals' occupational participation (Jensen et al., 2021).

Occupations cover the activities and tasks that involve meaning and value for individuals, connected with their life roles and fulfil their own inner needs. There are different performance areas such as self-care activities, work and productive activities, and play and leisure activities (Roley et al., 2008). In order for these activities to be conducted in harmony with each other, occupational balance must be established. Occupational balance is a multidimensional concept that emerges depending on the level of participation in occupations, the proportionality of the time allocated to these occupations, the compliance of the occupations with social norms, and the fulfilment of roles (Eklund et al., 2017; Eklund & Argentzell, 2016). Occupational balance is an important concept and is usually the centre of attention within occupational therapy interventions (Wagman et al., 2017; Yazdani et al., 2018). Occupational therapists hold the view that occupational balance is the foundation of health promotion and well-being. Occupational balance enables the person to develop their identity and roles through participation in various activities, which in turn provides socialisation and increases well-being (Håkansson et al., 2011; Wagman et al., 2012).

The rapid spread of COVID-19 has created difficulties in healthcare systems. By the late 2020s, 300,000 cases of COVID-19 had been reported in Turkey. Healthcare professionals had to cope with stressors such as lack of protective equipment, deaths associated with COVID-19, fear of transmitting the virus to family members and loss of colleagues in this period (Hall, 2020). Working and risk conditions varied among the healthcare professionals who were in direct contact with COVID-19 patients and those who worked in less risky situations. For example, healthcare professionals exposed to SARS-CoV-2 infected patients in the emergency rooms, infectious wards, and intensive care units had a much higher risk of anxiety, depression, and sleep disturbances than healthcare professionals working in other wards (Wang et al., 2021; Wańkowicz et al., 2020). Additionally, healthcare professionals, who had higher-than-normal mortality rates, had to cope with long-term separation from their families, adapt to changing work practices and procedures, and manage fatigue caused by protective equipment and higher-than-usual working tempo (Brooks et al., 2020; Lai et al., 2020).

Healthcare professionals put extra effort into performing their activities and roles at home, both at work and after work (Wagman et al., 2017). The perspectives of occupational therapists working in health institutions regarding the factors that increase stress levels were examined, and they stated that a high level of stress was caused by an imbalance between these activities (Clouston, 2014). Wagman et al. (2017) states that factors that cause occupational imbalance for healthcare professionals and the ways to reach occupational balance should be investigated. Healthcare professionals are one of the most affected groups during the pandemic. They are trying to adapt to the pandemic while simultaneously becoming a workforce that is more important and in demand than ever before (Hammell, 2020). It is important to develop an understanding of how healthcare professionals perform their dual roles during the pandemic. Today, it seems more important than ever before that healthcare professionals achieve a balance of occupation as they adapt to the pandemic and create strategies that will help this adaptation (Hammell, 2020; Ornell et al., 2020).

The importance of occupational balance is frequently mentioned in the related literature; however, evidence-based studies examining the occupational balance of healthcare professionals are limited. Although many people have managed to return to normal life or routine activities gradually, the same does not seem possible for healthcare professionals. It is not known how the occupational balance differs among healthcare professionals who take a more active role in the pandemic conditions compared with those working in areas where there is less contact with infected patients. This study aims to examine the occupational balance of healthcare professionals in the COVID-19 pandemic. Specifically, the study compares the occupational balance of those who actively work with COVID-19 patients and that of healthcare professionals who do not and explores changes in levels of occupational balance compared with the pre-pandemic period.

2 MATERIAL AND METHODS 2.1 Study design

The current study has a mixed method design, which includes collecting qualitative and quantitative data together (Almalki, 2016). The mixed method approach is well suited to answer the research questions guiding this research. In the quantitative stage of the study, the Turkish Occupational Balance Questionnaire (OBQ11-T) collected data specific to the healthcare professionals' level of occupational balance. Following this, semi-structured interviews collected qualitative data that explored the occupational balance and related issues in more depth and revealed the participants' unique experiences of working in this environment. The evaluations were conducted from September 2020 to December 2020, following the approval of the Ethics Committee.

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2.2 Study population

Invitations to participate in the study were shared via online channels (Facebook/Twitter) and through personal communication channels (e-mail, messages). This snowball sampling method supported recruitment of study participants representative of healthcare professionals from various vocational groups working in different state hospitals (different cities/locations). The sample size was not predetermined, and an iterative approach of simultaneous data collection and analysis was adopted until reaching data and time saturation. The working individuals included in the study were those in direct contact with the risk groups such as COVID-19 outpatient clinics, wards, and filiation teams, whereas the control group consisted of healthcare professionals working outside of the pandemic services (e.g. therapists and dieticians) After the invitation, out of 350 healthcare professionals interviewed, 230 agreed to participate in the study, and 24 of them subsequently met the exclusion criteria: part-time employees (n = 12), those who were on a special leave (e.g. maternity leave) (n = 4), those under the age of 18 (n = 3), remote professionals (n = 3) and those who did not complete the study (n = 2). A total of 206 individuals, 105 of whom were working and 101 were not working during the pandemic, were included in the study. Because the job structures, requirements, and characteristics of each occupational group could differ, the qualitative interviews aimed to include at least 20 individuals from each occupational group. Qualitative interviews with 171 participants were completed (September 2020 to December 2020).

2.3 Instruments: Socio-demographic Form

Participants who volunteered to participate in the study were screened for inclusion by online completion of the Socio-demographic Form. The Socio-demographic Form collected information from healthcare professionals such as age, gender, vocation, work time, work schedule, and shift cycle.

2.4 Instruments: Occupational balance questionnaire (OBQ11-T)

Participants completed the OBQ11-T occupational balance questionnaire as an online form. The purpose of the scale is to measure satisfaction according to the amount and diversity of the daily occupations of the individual and to define the occupational balance according to the results obtained (Wagman & Håkansson, 2014). For the latest 11-item version of the test, a Turkish validity and reliability study was conducted with 0.922 test and retest coefficient and 0.785 Cronbach alpha (Günal et al., 2020). Each item in the scale is scored on a 4-point Likert scale (0–3) that varies between “strongly disagree” and “strongly agree”. The total score ranges from 0 to 33 with the addition of each item, with higher scores indicating a higher occupational balance (Håkansson et al., 2020).

2.5 Semi-structured interviews

This study, which aimed to investigate in depth how healthcare professional's occupational balance has been affected during the pandemic period, required an intensive qualitative interview process. Consensual qualitative research (CQR) analysis, a qualitative methodology developed by Rhodes et al. (1994), was selected (Hill et al., 1996; Rhodes et al., 1994). CQR is a constructivist approach that allows participants to build their own facts and their own internal experiences, although researchers use a consensus process to analyse data (Hill et al., 2005). Following the specific guidelines for conducting CQR (Hill et al., 2005), semi-structured interviews conducted at a time mutually arranged to best suit the work schedules and conditions of the participants thus supporting a comfortable interview. The four authors (GG, KÖ, GZ, DA) completed the interviews using online videoconferencing (Zoom/Skype) technologies. Each meeting lasted for about 30–40 min. The participants were asked for permission to record the interviews, and the audio and video recordings of the interviews were obtained upon the participants' consent. Voice writing (dictation) feature of the Microsoft Word was used to transcribe the audio and video recordings of the interviews.

Semi-structured interview questions are presented in Appendix A.

2.6 Data analysis 2.6.1 Quantitative data

SPSS software Version 24 was used to carry out the statistical analyses. The variables were investigated using visual (histograms, probability plots) and analytical (Kolmogorov–Smirnov) methods to see whether they displayed a normal distribution. Descriptive analyses were conducted using medians and interquartile ranges (IQR) for the non-normally distributed and ordinal variables. Because the data such as occupational balance were not normally distributed, non-parametric tests were conducted to compare these parameters. Healthcare professionals working actively with COVID-19 patients were determined as the study group (SG), whereas those without direct contact with COVID-19 patients were determined as the control group (CG). Parameters between the groups (SG and CG) were compared via the Mann–Whitney U test.

2.6.2 Qualitative data

The interview recordings of the qualitative stage of the study were transferred to Microsoft Word files. The five authors of the current study used the consensual method to compare the data among cases in order to determine the domains and core ideas for each case and to generalise the findings within the sample. CQR analysis was used to evaluate the qualitative data: (a) trustworthiness of the method; (b) coherence of the results; (c) representativeness across samples; (d) testimonial validity; and (e) applicability of the results as recommended (Hill, Thompson, & Williams, 1997). A total of five researchers, including one professor, two lecturers and two occupational therapists working in a public hospital, conducted this analysis.

2.6.3 Consensus coding

Hill et al. (1996) suggest that researchers find key ideas within domains defined by CQR, which can be categorised into themes at the centre of the consensual qualitative analysis. They state that this methodology “reduces the potential bias inherent in the use of a single judge and produces a richer conceptualization of the phenomenon (p. 209).” The research team worked collectively to create an environment where each team member could openly share their ideas and perspectives. When differences emerged, they analysed the data once more to present evidences for their ideas, eventually reaching a consensus after discussing the themes and variables. Initially, the team independently used open coding techniques to assign each meaningful piece of data (adjoining text on the same topic) to predetermined domains (Spradley, 1979). After completing independent coding of data to create domains, the authors met to discuss how each unit should be coded. Then, each author independently read all the data for a given case within each domain and wrote down the “core ideas,” and then the whole team discussed to reach a consensus about each core idea. A consensus version was developed using agreed-on core ideas and exact quotes. Cross-analysis was performed. Based on the key ideas in the field for each question, the team looked for similarities in the key ideas. They then categorised similar basic ideas in each case (in every field) under themes. After identifying the themes, the team reviewed all interview data to make sure the key ideas were present and correct. Themes and sub-themes were determined for each interview question. Because the number of individuals interviewed was high, the qualitative data were presented in percentage expressions to make it easier to understand. The data including the themes, sub-themes and related participant expressions were summarised into tables by the authors. Details on the resulting themes are summarised in Appendix A.

2.7 Ethical consideration

Before the authors of the current study started to conduct the study, they obtained approval from Ethics Committee at Biruni University Non-Invasive Clinical Investigation Ethics Committee. It was also examined by the Ministry of Health, and the study conducted in the COVID-19 pandemic was found to comply with the regulation (file number: 12T13_57_30). The procedures used in this study adhere to the tenets of the Declaration of Helsinki. All respondents and their signed online informed consent forms for participation.

3 RESULTS 3.1 Participant profile

Participants were allocated to the SG including healthcare professionals working actively during the COVID-19 pandemic (n = 105) and the CG group, which included healthcare professionals not working actively (n = 101) in this period. As depicted in Table 1, the SG included 78 (74.3%) female and 27 (25.7%) male participants with a mean age of 30.7 (standard deviation [SD] = 5.8) years. The CG included 73 (72.3%) female and 28 (27.7%) male participants with a mean age of 31.8 (SD = 6.2) years. No significant differences were found between the groups regarding age, gender, marital status, and caregiver role (P > .05). The participants' demographic characteristics are presented in Table 1.

TABLE 1. Participants' socio-demographic qualities Study group (n = 105) Control group (n = 101) Range M (SD) Range M (SD) Z P-value Age (year) 23–50 30.7 (5.8) 24–53 31.8 (6.2) −1.814 .214 Frequency (%) Frequency (%) Gender Female 78 (74.3) 73 (72.3) Male 27 (25.7) 28 (27.7) Marital status Single 55 (52.4) 55 (54.5) Married 50 (47.6) 46 (45.5) Caregiver role Yes 48 (45.7) 38 (37.6) No 56 (53.3) 48 (47.5) Abbreviation: M (SD), mean and standard deviation. 3.2 Healthcare professionals' working conditions

As depicted in Table 2, healthcare professionals in the SG worked a mean 6.6 (SD = 2.9) months during the pandemic. Additional findings about healthcare professionals' work conditions are presented in Table 2.

TABLE 2. Participants' working conditions Study group (n = 105) Control group (n = 101) Range M (SD) Range M (SD) Working experience (year) 1–27 7.7 (6.9) 1–30 8.4 (8.4) Working time weekly (hour) 8–96 48.3 (14) 1–96 38.5(14.8) Working time pandemic (month) 1–10 6.6 (2.9) - - Frequency (%) Frequency (%) Enough break Yes 49 (46.7) 53 (52.5) No 56 (53.3) 48 (47.5) COVID-19 Infected 59 (56.1) 28 (43.9) Not infected 46 (43.8) 73 (56.2) Abbreviation: M (SD), mean and standard deviation.

Fifty-nine (56.1%) participants in the SG and 46 (43.8%) participants in the CG had been infected with COVID-19.

The analysis of the participants' professions revealed that nurses constituted the largest group in the SG, whereas other healthcare professionals constituted the largest group in the CG. Distribution of all professions within the SG and CG is given in Figure 1.

Participant vocations in both groups. CG, control group; SG, study group

3.3 Healthcare professionals' occupational balance

The mean score of total occupational balance in the SG was 9.2 (SD = 5.2), compared with 11.5 (SD = 5.8) in the CG. The occupational balance of the healthcare professionals in the SG was found to be significantly lower than that of healthcare professionals in the CG (P = .005) (Table 2).

When the occupational balance of healthcare professionals was examined based on the amount of breaks they had, it was identified that individuals who did not have enough breaks had a significantly lower level of occupational balance (P < 0.001) (Table 2).

The level of occupational balance of healthcare professionals infected with COVID-19 was found to be lower than that of healthcare professionals who had not been infected with COVID-19 (P = .006) (Table 2).

3.4 Qualitative findings on occupational balance The participants' descriptions of how they managed their daily life with work and other occupations were consistent with the predefined themes: self-care activities, productivity activities, recreational activities, personal factors, environmental factors.

CQR presents the results in terms of general and typical results. An overall result means that the theme is prominent in the responses of participants. This section presents general and typical findings by theme. Qualitative findings on occupational balance are presented in Appendix A.

3.4.1 Theme 1: Self-care activities

According to one of the sub-themes of this theme, healthcare professionals' self-care, functional mobility, and community management activities were affected negatively. Thirty-six percent of the participants stated that their personal activities changed during the pandemic period. The typical results included problems in self-care activities due to reasons such as sleep deprivation, depression, stress, and tiredness. Self-care activities included personal care (feeding, sleeping), functional mobility (transfers, indoor, outdoor), or community management (shopping). One participant said, “My daily routine is going to work and eating on the days when I work. When I don't work, I usually sleep. Sleeplessness becomes quite a problem during heavy work” (Participant 95). Another participant said, “I can't take care of myself sufficiently because of a bad mood due to the COVID infection transmitted from the hospital as well as sleep disorders and psychological problems” (Participant 18).

3.4.2 Theme 2: Productivity activities

According to one of the sub-themes of this theme, healthcare professionals' paid work, household management, and school activities were affected negatively. Roughly 40.7% of the participants stated that the reason for the deterioration in occupational balance was the “increase in workload.” One participant said, “I think it's broken. The workload is heavy. Because we have been working at the same place for a long time. I feel tired both physically and psychologically. This situation affects the participation in my activities, and therefore I participate in such activities less. I don't feel like doing anything” (Participant 36). Also, participants stated that they had difficulty in doing household chores (%25.24). Carrying out both chores and their children's educational activities was a trouble for the participants. On the contrary, the time spent in work-related activities increased (Table 3).

TABLE 3. Findings related to occupational balance Study group (n = 105) Control group (n = 101) Range M (SD) Range M (SD) Z P-value OBQ11-T total 1–23 9.2 (5.2) 1–24 11.5 (5.8) −2.781 .005* Enough break (yes) (n = 102) Enough break (no) (n = 104) Range M (SD) Range M (SD) OBQ11-T total 2–24 12.4 (6.2) 1–23 8.2 (4.8) −5.004 <.001** Infected COVID-19 (n = 87) Not infected COVID-19 (n = 119) Range M (SD) Range M (SD) OBQ11-T total 1–24 8.6 (5.1) 1–24 11.9 (5.9) −2.285 .006* Abbreviations: M (SD), mean and standard deviation; OBQ11-T, Occupational Balance Questionnaire. * P < .01. ** P < .001. 3.4.3 Theme 3: Recreational activities

According to one of the sub-themes of this theme, healthcare professionals' active and passive recreation activities were affected negatively. Fifty-four percent of the participants stated that they had difficulty in social activities. One participant said, “I can't see my family. My social activities are completely over” (Participant 38). It was stated that among the recreational activities, the most restricted areas were doing sports, spending time with friends or family, and going to the cinema, cafe, or theatre. Another participant said, “Before the pandemic, I used to exercise every day, now I almost never do it” (Participant 67).

3.4.4 Theme 4: Personal factors

Fifty-seven percent of the participants stated that their occupational participation and range of activities were negatively affected, as they feared the risk of carrying the disease to their family or beloved ones. A participant said, “The time we spend between hospital and home has increased even more due to COVID-19 for 8 months. Since I am a healthcare professional, I unwittingly avoided many activities in order not to be in crowded environments in society and not to infect others if I have the disease” (Participant 84).

3.4.5 Theme 5: Environmental factors

According to one of the sub-themes of this theme, healthcare professionals' physical environment and institutional environment negatively affected thier occupations. Participants stated that their activities were negatively affected by the risky business environment and the long hours they spent in the workplace. Also, the majority of the participants stated that their social activities were negatively affected because of the measures/restrictions taken by the state due to the pandemic. One participant said, “Working hard, working with a mask and special clothes is extremely tiring, your mind is full of fear. The enormous stress is already exhausting for your soul, heart and body. With these factors, even when taking a bath can be impossible, which occupations can be done in a balanced way?” (Participant 58).

4 DISCUSSION

The findings reveal that healthcare professionals who are actively working in the pandemic cannot come together with their families, their self-care activities are affected, the time they spend in the workplace has increased, leisure time activities are limited, and thus their occupational balance is negatively affected. During the pandemic, most healthcare professionals have faced problems such as heavy workload, stress, fatigue, perceived insomnia, and perceived depression. Factors such as exposure to risk, fear of infecting their beloved ones and families, lack of protective equipment (Lai et al., 2020), physical fatigue in long-term use of protective equipment, limited resources (Çankaya, 2020), and busy working hours (Nakata et al., 2012) are important factors that affect healthcare professionals' mental health and psychological well-being (da Silva & Neto, 2020). A study conducted by Çankaya (2020) reveals that healthcare professionals' well-being during the pandemic was worse than the time before the pandemic. Similarly, our findings show that the level of occupational balance of healthcare professionals who took an active role during the pandemic was lower than those who did not take an active role. These findings have emerged as a result of the analysis of both quantitative and qualitative data. Though the OBQ11-T questionnaire showed a significant difference between the groups, the participants of the qualitative stage mentioned that their occupational balance was affected badly. In addition, our results allow comparison between healthcare professionals. The group of healthcare professionals working most actively during the pandemic is composed of nurses. They took a more active role in the pandemic compared with other healthcare professionals, and their occupational balance was disturbed. Another important finding of the current study is that the level of the occupational balance of the individuals who took sufficient breaks during the work was found to be higher. This finding is valuable to occupational therapists as long working hours are important to the health, well-being, and performance of professionals (Shoja et al., 2020).

Zafran (2020) categorised the activities people most need and tend to do during the time when they adapt to the pandemic. These activities include engaging in activities (phone calls, online training, virtual chats), centre-oriented activities (yoga, meditation, long walks), creative activities (drawing, writing, painting, singing), thought-provoking activities (contemplation, prayer, yoga, journaling), and contributory activities (carrying out projects, reaching those in need). The participants in our study stated the activities they started to do frequently during the pandemic were housework (cleaning, cooking), passive recreation (watching television, reading books), domestic activities (handicraft, hobby), and productivity activities (work, study, online courses). Although healthcare professionals turned to new activities during the pandemic, their occupation and role balance was destroyed. In our study, most of the healthcare professionals stated that their self-care activities did not change during the pandemic. Those who had problems in self-care activities stated that they could not spare as much time as before for these activities due to reasons such as perceived insomnia, depression, stress, and fatigue. Among the self-care activities, the most affected area was especially sleeping. In the study by da Silva and Neto (2020), it was found out that one of the most common problems experienced by healthcare professionals is insomnia and that insomnia is a risk factor for anxiety and depression.

The study by Shoja et al. (2020) showed that the total workload of healthcare professionals who took an active role during the pandemic was significantly worse than other employees. However, the increase in the working hours of healthcare professionals is one of the important factors affecting their level of anxiety (Nakata et al., 2012). Similarly, healthcare professionals stated that their workload increased, the time spent on work activities increased, and they had to work at weekends and have night shifts, which resulted in increased responsibilities, professional burnout, occupational atrophy, and unprofessional duties. In particular, they stated that the change in job descriptions was the most influential factor on productivity activities.

According to a study conducted in Sweden, female healthcare professionals spend twice as much effort in housework than men, and their participation in leisure time activities is restricted (Wagman, 2017). When we look at family roles in Turkey, it is known that women take more responsibilities (Günay & Bener, 2011; Taylan, 2009). In our study, female healthcare professionals who actively worked during the pandemic time stated that they could not devote much time to housework and could not support the educational needs of their children due to the increasing burden in the workplace. This makes it more common among women to have a destroyed occupational balance. We think that organising family roles as well as sharing and improving women's working hours will contribute to their occupational balance.

Håkansson et al. (2020) emphasised that level of satisfaction and balance at work as well as productive and leisure activities affect people's life satisfaction, so occupational therapists should focus on issues such as occupational balance and meaning of occupations. Pandemic conditions have also affected the leisure activities of healthcare professionals. Socialisation in particular was one of the most affected areas. Individuals stated that they stayed away from their families, they could not see their beloved ones for a long time, and they mostly turned to online meetings. In addition, leisure time activities mostly focused on passive activities such as reading books and watching television. Leisure time activities were organised in China to help the staff working in the pandemic to reduce their stress (Lai et al., 2020). We think that such practices are important to ensure the occupational balance of healthcare professionals and should be implemented routinely. Healthcare professionals working actively in COVID-19 services stated that there was a work–family conflict, difficulties in how to manage due to changes in the workforce, and conflicts arising from not being able to fulfil their roles fully (Baki & Piyal, 2020). Similarly, our findings show that healthcare professionals have difficulty in maintaining occupation–role balance. Most of them have changed in their parental, family, social, and professional roles compared to the time before the pandemic. They spend less time with their family and relatives due to reasons such as the anxiety of infection, increased workload, and fatigue. Emotional reactions such as stress, sadness, restlessness, and anger are observed in employees with the change of occupation-role