https://doi.org/10.15218/ejnm.2021.04 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Lived Experiences of Patients with COVID-19 in the Kurdistan Region, Iraq: A Qualitative Study ABSTRACT INTRODUCTION COVID-19 emerged in 2019 and became an invisible assassin in 2020 which spread around the world. Since then, it has been threatening people’s health and lives. It has also led to substantial economic and financial difficulties around the world [1]. The statistics of July 21, 2020, released by the World Health Organization. (WHO), re- vealed that there were 14,883,578 positive cases of individuals with COVID-19, of which 8,937,163 recovered and 614,019 died. The same report showed that there were 94,693 positive cases of COVID-19 in Iraq by the same date, of which 62,836 recovered and 3,869 died. The report also showed 7,936 positive cases of COVID-19 in the Kurdistan region of Iraq, of which 3,233 recovered and 266 died [2].A very high rate of infection is one of the conse- quences of COVID-19, resulting in a high Background and objective: COVID-19 has adverse effects on physical and mental health and threatens the quality of life significantly; therefore, it is necessary to help COVID-19 patients with their lifestyle, which is tightly bound to the quality of their lives. The present study aims to develop plans to improve the quality of life among COVID-19 patients by an- alyzing their lived experiences. Methods and patients: The present qualitative study was conducted from August to Sep- tember 2020 on twelve COVID-19 patients hospitalized in Erbil’s Emirates Hospital, the Kurdistan Region of Iraq. In-depth semi-structured interviews (12) were utilized to collect data. Trustworthiness was ensured by making an excellent prolonged relationship with the patients, peer-checking, member-checking, and implementing experts’ suggestion at every stage. Four main themes were extracted from the interviews, which were transcribed ver- batim and analyzed using the six methodological activities proposed by Van Manen. Results: The present study results indicated that COVID-19 patients have a difficult time dealing with the disease and getting adapted to their new situation, leading to a remarka- ble decrease in the quality of their lives. Analyzing the transcribed interviews led to emer- gence of four main themes: “disbelief in being really ill,” “fear and stress,” “changes in lifestyle,” and “seriously adhering to health guidelines.” Conclusion: Our results showed that COVID-19 patients suffer from physical pain and un- dergo poor mental health due to fear and stress resulting in worsening quality of life. A deep understanding of COVID-19 patients’ states and situations is highly significant to help nurses and nursing managers plan effective strategies for caring for patients with COVID- 19. Keywords: COVID-19 pandemic, phenomenological study, COVID-19 patients’ lived experience Sarhang Qadir Ibrahim ;Department of Nursing, College of Nursing, Hawler Medical University, Erbil, Iraq. (Correspondence: sarhang.ibrahim@hmu.edu.krd) 32 Erbil Journal of Nursing & Midwifery Received: //20 Accepted: 18/2/2021 Published: 30/05/2021 https://doi.org/10.15218/ejnm.2021.04 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article level of fear and anxiety of getting infected As a result, this pandemic caused almost all countries’ lockdown and imposed strict re- strictions on people’s free movements [3]. It is necessary to focus and observe the emotions involved in a pandemic, such as anger and fear, to understand the psychiat- ric and psychological repercussions. As an adaptive animal defense mechanism and a key to survival, fear includes several biolog- ical processes that involve in readiness to respond to events that are potentially threatening. However, in case of dispropor- tionate or chronic fear, it will become a harmful element that causes various psy- chiatric disorders to develop [4]. In a pan- demic, stress and anxiety levels in healthy individuals rise due to fear, and pre- existing psychiatric symptoms intensify [5]. The level of infection risk should be consid- ered and protective steps need to be taken into account by individuals who are at higher risk of COVID-19 and those who live with them. In places where social distanc- ing is challenging to maintain, and protec- tive measures are impracticable, general rules need to be considered [6]. During epi- demics, the number of those whose mental health is negatively affected is more than those affected by the infection; therefore, quality of life decreases dramatically among all people. As revealed by past trag- edies, the mental health implications are more prevalent and can last longer than the epidemic itself. Moreover, the eco- nomic and psychosocial effects cannot be calculated if their resonance is considered in different contexts. In addition, mental disorders can lead to high economic costs. Appropriate strategies adopted to improve mental health may benefit the physical health and economic sectors [5].Since COVID-19 is a relatively new virus, there is limited understanding of the risk of being affected. In this regard, a study conducted in the Kurdistan region of Iraq revealed that protective behavior measures were adhered to the respondents reasonably. However, there was a relatively low fre- quency of undertaking some significant protective behaviors. It was also shown that protective behaviors were provoked by the risk perception of COVID-19 to a limited extent, such that it is a challenge to modify behaviors even for those who are well aware and well-educated [7].In addi- tion to death and fear, the COVID-19 pan- demic has negative impacts on families, schools, companies, public places, and work routines resulting in isolation and feelings of helplessness and abandonment. Moreover, its negative effects on the econ- omy can raise the level of insecurity in so- ciety [8]. Many laboratory and histopatho- logical tests have been performed to de- vise protocols to deal with the highly infec- tive virus of COVID-19. These tests have largely neglected real-life experiences of COVID-19 patients’ which are highly signifi- cant in developing strategies to improve patients’ quality of life. [9].The investiga- tion into the psychological issues and lived experiences of COVID-19 patients during their hospitalization has a high decisive impact on the process of recovery for these patients. Given the high prevalence of COVID-19 infection in the Kurdistan re- gion of Iraq, this study was conducted to evaluate the lived experiences of COVID-19 patients during their hospitalization period to devise techniques to improve the quali- ty of their lives. Study design: The present qualitative study was carried out by Van Manen’s (1990) hermeneutic phenomenological method [10].Patients and setting: The study sample consisted of 12 COVID-19 patients hospi- talized in Erbil’s Emirates Hospital, the Kur- distan Region of Iraq. The study was con- ducted over three months from August 33 Erbil Journal of Nursing & Midwifery METHODS AND PATIENTS https://doi.org/10.15218/ejnm.2021.04 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article down the interviews into words, phrases, and sentences to depict the patients’ lived experiences. Transcripts were reread and scrutinized several times to confirm under- standing of patients’ lived-experiences. Trustworthiness: Trustworthiness in quali- tative studies refers to the level of sound- ness or adequacy [10]. To ensure a qualita- tive study’s trustworthiness, it is essential to justify the results’ reliability and de- scribe the data analysis procedure [11]. In the current study, trustworthiness and the accuracy and rigor of the findings were en- sured through peer checking conducted by two professors who also revised the tran- scripts and the extracted codes. Addition- ally, a friendly relationship between the participants and the researcher ensured the rigor of this study. Following data anal- ysis, member checks, discussions of the study results between patients and the researcher, were conducted to obtain pa- tients’ feedback. Every stage of the study was monitored by two more expert profes- sors in the field, and their suggestions were taken into account. Data collection was conducted during a period of 3 months to ensure prolonged engagement. Ethical considerations: Approval from the Ethics Committee of College of Nursing, Hawler Medical University (No. 7 on 26-7- 2020) was obtained for this study. Patients were provided with sufficient information about the study’s objectives, data collec- tion methods, and confidentiality of the collected information. Patients were as- signed a unique code to keep the collected data anonymous and to protect their confi- dentiality. All files were stored in a safe and secure place. Patients were informed of the right to abandon the study whenev- er they wanted to. Informed written con- sent were obtained from patients prior to the start of the study. 2020 to September 2020. Patients were selected using a purposeful sampling meth- od. The inclusion criteria were being diag- nosed with COVID-19, age of over 18 years, willingness and consent to participate in the study, and having undergone treat- ment and hospitalization procedures. Ex- clusion criteria were lack of willingness or consent to participate in the study and ina- bility to describe their lived experiences. Data collection: In-depth semi-structured interviews were conducted with the pa- tients in order to collect the required data. For this purpose, a small relaxing room at Erbil’s Emirates Hospital was used. The in- terviewers established a friendly relation- ship with the patients to elicit as much in- formation as possible. Patients were in- formed and reassured about the confiden- tiality of their information. The duration of the interviews was flexible, ranging from 55 to 70 minutes, and enough time was given to the patients to answer the ques- tions with as many details. To ensure pa- tients’ comfortability, they were inter- viewed by interviewers of the same gen- der. Predetermined questions used to di- rect the interviews included general ques- tions such as “How is it like to suffer from COVID-19?”, “When did you notice you had coronavirus?”, “How did it feel in the be- ginning?”, and “What is it like to have COVID-19?” and were followed by more specific questions such as “How has COVID- 19 changed your life?” or “What have been the effects of COVID-19 on your daily life?”. With the patients’ permission, all inter- views were recorded and transcribed ver- batim and then translated for further anal- ysis. Data analysis: The transcripts of the interviews were analyzed through content a analysis approach. The accuracy of the translated transcripts was checked by com- paring them to the recorded interviews several times. Afterward, holistic, detailed, selective approaches were used to break 34 Erbil Journal of Nursing & Midwifery ) https://doi.org/10.15218/ejnm.2021.04 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article Table 1 describes the patients’ sociodemo- graphic characteristics. The majority of the patients were males (66.66%), over 36 years old (75%), Muslims (75.5%) and re- side in urban areas (83.33%). Of the pa- tients, 33.33% had university degrees, 25% had high school degrees, 16.66% had pri- mary degrees, and 25% were illiterate. Half of the patients had a good socioeconomic status (See Table 1). Content analysis of the scripts based on Van Manen’s (1990) hermeneutic phenom- enological method led to the emergence of four main themes: “disbelief in being really ill,” “fear and stress,” “changes in life- style,” and “seriously adhering to health guidelines.” These themes are presented in two major categories: before getting the disease and after getting the disease. Theme 1: Disbelief in being really ill Interviews with the COVID-19 patients re- vealed that some of them had not taken the disease seriously before they got it. Patients described their experiences in this regard as follows.“Before I got corona, I thought that this disease did not even ex- ist, and it was just a political game played by the governments to control people, cut their salaries or wages, and even kill senior citizens to cut their pension.” (Patient 3) “Before I developed the disease, I never wore a face mask or gloves because I did not take the disease seriously, and I be- lieved that it did not exist and it was a ru- mor spread by governments all over the world. I really regret my wrong belief which caused me to be hospitalized here for more than 10 days.” (Patient 7) “I didn’t trust the media and statistics of coronavirus until I myself got the disease. In the beginning, I couldn’t believe, so I vis- ited 2 different clinics, and finally came here. They all confirmed that I had corona disease.” (Patient 9) Theme 2: Fear and stress Patients’ accounts of their experiences re- vealed that COVID-19 caused immense fear and stress in their lives. Their fear and stress were related to the probability death and concerns of the disease spread- ing among their family members. Patients described their experiences in this regard as follows. “Once I was diagnosed with coronavirus, I was filled with fear and stress. I was really scared to die. I had a lot of stress to transfer the disease to my 35 Erbil Journal of Nursing & Midwifery RESULTS Table 1: The patients’ socio demographic data Socio-demographic and clinical variables n(%) Sex Female 4(33.33) Male 8(66.66) Age (years) 18-25 1(8.33) 26-35 2(16.66) 36-45 4(33.33) 46 ≤ 5(41.66) Place of residence Urban 10(83.33) Rural 2(16.66) Education level Illiterate 3(25.0) Primary 2(16.66) High school 3(25.0) University 4(33.33) Religion Muslim 9(75.5) Christian 3(25.0) Employment Employed 8(66.66) Unemployed 4(33.33) Socioeconomic status Poor 3(25.0) Good 6(50.0) Very good 3(25.0) https://doi.org/10.15218/ejnm.2021.04 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article water.” (Patient 5). “The treatment has been a long procedure. I remember on the first days of my hospitalization, I couldn’t breathe without the ventilator. It’s really hard not to be able to breathe in or out. I’m an active person, but I’ve been here on this bed for more than 8 days without any activities, which is really boring.” (Patient 8)Theme 4: Seriously adhering to health guidelines The final theme that emerged from the patients’ stories was their em- phasis on following the guidelines recom- mended by the Ministry of Health. Patients described their experiences in this regard as follows.“ I remember I always made jokes about those who followed the health guidelines and were wearing face masks and gloves until I myself got the disease and I came to know that this disease is quite serious and fatal, so I recommend all my friends and people to follow the health guidelines.” (Patient 4) “If I had followed the health guidelines rec- ommended by the Ministry of Health, I wouldn’t have got the disease. So, I recom- mend everybody that they take corona se- riously, it’s really debilitating, and its treat- ment is quite costly.” (Patient 5) “If you love your life, family, and friends, please adhere the health guidelines, wear face masks and gloves, wash your hands regularly, eat healthy food, drink a lot of water, and more importantly keep social distance. I wish I had adhered all the guidelines recommended by the Ministry of Health.” (Patient 11) The spread of COVID-19 is remarkably high, and it results in uncommon effects. The symptoms of COVID-19 include short- ness of breath, dry cough, aches, and fe- ver. It can also lead to respiratory failure and dysfunction of different organs [12]. Its adverse effects have been observed on all sectors of society, including education, 36 Erbil Journal of Nursing & Midwifery family members. It’s a really painful dis- ease, and during my treatment, I felt I was going to die many times.”(Patient 1). “It’s a really painful and stressful disease. Its pain is not just physical, it is also men- tal. The physical side is related to the pain it causes in your muscles, legs, chest, and eyes. Its mental pain is related to the fear and stress it causes because of your family members and the society which consider coronavirus as a shame and almost every- body gets away from you, even your dear- est ones.”(Patient 10). “Before I got the disease, I heard and read a lot about its pain, and when I was told that my corona- virus test was positive, I got quite shocked and felt fear and stress deep inside. I feared that I might transfer the disease to my family members. I was also filled with a feeling of shame because our society has really negative attitude toward this dis- ease.” (Patient 12)Theme 3: Changes in lifestylePatients stated that COVID-19 had changed their lives significantly, and they had to live in a quite different way. In their accounts, they talked about changes in their sleep, food, physical activities, and special treatment. Patients described their experiences in this regard as follows. “Being a corona patient means to live a quite new life. I used to sleep about 5 to 6 hours, but since I got COVID-19, I have to sleep about 10 hours, following my doc- tor’s order. I’m a quite sociable person, and I like to spend most of my time with my family members and friends, but because of my disease I haven’t seen anyone in per- son for more than two weeks. I only speak to them on the phone.”(Patient 2) “I didn’t use to do any exercise before I got corona, but these days I’m doing exercise for about half an hour every day. It’s a part of my treatment. I’ve also had to change my eating habits. Nowadays I’m eating a lot of watery food and fruits like watermel- on and cucumber. I also drink a lot of DISCUSSION https://doi.org/10.15218/ejnm.2021.04 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article economy, and food. Successful dealing with the COVID-19 pandemic and its im- pacts on society requires collective efforts and cooperation of organizations, govern- ments, and individuals [13]. Adverse effects of COVID-19 on physical and mental health continues to threaten quality of life [14]. Supporting COVID-19 patients with their lifestyle can improve the quality of their lives. In this study, nearly all patients stat- ed that prior to being infected with COVID- 19 they did not believe that COVID-19 ex- isted. Rather, they believed it was a politi- cal game by the government used to con- trol people. This finding aligns with Uscinski et al. (2020) which reported people’s belief in COVID-19 conspiracy theories. Uscinski et al. found that believing in such theories were rooted in psychological predisposi- tions resulting in distrust of information distributed by experts and other authori- ties as well as believing that major events like the COVID-19 pandemic are products of conspiracies, and ideological and parti- san motivations. Uscinski et al. further re- marked that such conspiracy beliefs have negative effects on devising and adhering to treatment as well as developing coping strategies to reduce the consequences of such events [15]. As the results of the pre- sent study indicated, considering COVID-19 as a political game or a conspiracy led to individuals being infected by the virus. Al- most all countries in the world are current- ly affected by the COVID-19 pandemic. The number of COVID-19 patients in the Kurdi- stan region of Iraq continues to increase. The second theme in the present study was fear and stress felt by both patients and heathy individuals. In this regard, it is stat- ed that since COVID-19 is highly infectious, people in affected countries are suffering from fear, stress, and anxiety which in turn threaten their mental health and wellbeing [14], and the negative attitude of the com- munity toward COVID-19 disease and patients worsen these critical situations [16]. To prevent infection of more people who might surge to hospitals, home treat- ment and quarantine are the best solu- tions for reliable and educable patients who have mild or no symptoms and ob- serve all due diligence. Quarantining in the home which is one of most effective con- trol measures for epidemic diseases can also reduce people’s stress and fear due to being with family members and being helped by them [17,18].It was also stated that the patients felt shameful to have COVID-19 disease. In this regard, it is stat- ed that quarantine and restricted interper- sonal relationships may result in senses of shame and loneliness which can be tackled by taking these measures for the purpose of recovery and family reunion. In addition, psychiatric nurses are recommended to develop programs in the form of psycho- logical support or comprehensive spiritual care packages and utilize multiple media channels to help patients overcome such feelings [19].The third theme was found to be changes in lifestyle of patients and peo- ple. This finding is also emphasized by oth- er studies which showed that the COVID- 19 pandemic has disrupted trades and movements all over the world and nega- tively impacts day-to-day businesses and life. Dramatic changes can happen in die- tary and sleep patterns as a result of ad- hering to quarantine rules and can cause additional stressful conditions or exacer- bate existing stressful conditions[20,21]. Such stress can be the result of people’s worry about their next paycheck, shortage of food on the grocery shelves, and staying at home all day long [22]. Additionally, both physical and mental health can nega- tively be influenced by poor quality sleep. The ability of the immune system to resist infections can also decrease. In this regard, it is recommended that electronic devices should be turned off, watching news needs 37 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2021.04 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article impossible to recruit more patients. Anoth- er limitation is related to the relatively short duration of engagement with the pa- tients and data collection, which can affect the reliability and validity of the findings because trust and good relationship which form over time and are vital for phenome- nological studies can highly be affected. COVID-19 patients have a poor quality of life which is even worsened as a result of fear and stress. A deep understanding of such patients’ situations is vital to help nurses and nursing managers plan effec- tive strategies to provide care to patients with COVID-19. This includes making changes in their lifestyle, encouraging them to adhere to health guidelines, and providing them with psychological support and appropriate treatment. The author declares no competing inter- ests. [1] Byrne L, Wykes T. A role for lived experience mental health leadership in the age of Covid- 19. Journal of mental health. 2020;29(3):243 –6.https:// doi.org/10.1080/09638237.2020.1766002 [2] Coronavirus Disease (COVID-19) Situation Reports [Internet]. Who.int. [cited 2020 Aug 25]. Available from: https://www.who.int/ emergencies/diseases/novel-coronavirus- 2019/situation-reports . [3] Cascella M, Rajnik M, Cuomo A, Dulebohn SC, Di Napoli R. Features, Evaluation, and Treatment of Coronavirus. 2020 Oct 4. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan–. PMID: 32150360. [4] Garcia R. Neurobiology of fear and specific phobias. Learning and memory. 2017;24 (9):462–71. [5] Shigemura J, Ursano RJ, Morganstein JC, Kurosawa M, Benedek DM. Public responses to the novel 2019 coronavirus (2019-nCoV) in Japan: mental health consequences and to be minimized, alcoholic and caffeine drinks should be avoided, and regular schedule for sleeping needs to be made [23]. The patients in the current study re- ferred to complete changes in their life- styles due to COVID-19 pandemic. In a similar study, it is mentioned that peo- ple’s day-to-day life around the world has changed due to destructive effects of COVID-19 pandemic. It is also stated that taking up a new lifestyle and being pro- vided with special treatment are keys to improvement in the quality of their lives. Moreover, adhering to health guidelines such as wearing masks and gloves, wash- ing hands regularly, eating and drinking healthy, and keeping social distance are key to preventing COVID-19 [24]. In addi- tion, remote conduction of business train- ing and assessments needs to be taken into account to avoid gatherings [25,26].It has been stated that social media can provide the public with disseminating in- formation, and many individuals will ex- perience isolation during hospitalization or quarantine at home [27,28]. However, social media needs to turn into an effec- tive source of information and means for keeping abreast of the broad amount of medical knowledge [29]. Countries with humanitarian-cooperative culture, low education levels, and pronounced social disparity are reported to have no parame- ters for estimating the effects of COVID- 19 on the population’s behavior or men- tal health .8 As a result, it is necessary to provide health guidelines aimed at im- proving individuals’ mental health in such countries [30].The present study had some limitations. The first limitation is related to the limited number of the pa- tients who participated in the present study, which limits the generalizability of the findings to other groups of people in other places. However, due to the situa- tion of COVID-19 patients, it was almost 38 Erbil Journal of Nursing & Midwifery CONCLUSION Competing interests REFERENCES https://doi.org/10.15218/ejnm.2021.04 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article [15] Uscinski JE, Enders AM, Klofstad CM, Seelig M, Funchion J, Everett C, et al. Why Do Peo- ple Believe COVID-19 Conspiracy Theories? The Harvard Kennedy School Misinformation Review [Internet]. 2020; Available from: http://dx.doi.org/10.37016/mr-2020-015. [16] Duan, L., Zhu, G. Psychological interventions for people affected by the COVID-19 epi- demic. The lancet psychiatry. 2020;7(4):300- 302. http://10.1016/S2215-0366(20)30073-0 [17] World Health Organization (WHO). Home care for patients with Middle East respirato- ry syndrome coronavirus (MERS-CoV) infec- tion presenting with mild symptoms and management of contacts: interim guidance. World Health Organization; 2018: 2.3.2020. [18] Li D. Challenges and responsibilities of family doctors in the new global coronavirus out- break. Family medicine community health. 2020;8(1):e000333. https://10.1136/fmch- 2020-000333. [19] Asgari P, Jackson AC, Bahramnezhad F. Resil- ient care of the patient with COVID-19 in Iran: A phenomenological Study [Internet]. Research square. 2020. Available from: http://dx.doi.org/10.21203/rs.3.rs-24733/ v1. [20] Jin YH, Cai L, Cheng ZS, Cheng H, Deng T, Fan YP, et al. A rapid advice guideline for the diagnosis and treatment of 2019 novel coro- navirus (2019-nCoV) infected pneumonia (standard version). Military medical re- search. 2020;7(1), 4. https:// doi.org/10.1186/s40779-020-0233-6. [21] Haleem, A., Javaid, M., Vaishy, R. and Vaishb, A. Effects of COVID-19 pandemic in the field of orthopaedics. Journal of clinical orthopaedics and trauma. 2020;11(3):498– 499. https://10.1016/j.jcot.2020.03.015. [22] Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. The psycho- logical impact of quarantine and how to re- duce it: rapid review of the evidence. Lancet. 2020;395(10227):912–20. https:// doi.org/10.1016/S0140-6736(20)30460-8. [23] Abdurahman AA, Bule M, Shab-Bidar S, Re- zaei S, Djafarian K. The association between sleep duration and risk of abnormal lipid profile: a systematic review and meta- analysis. Obesity medicine. 2020;18:100236. https://doi.org/10.1016/ j.obmed.2020.100236. [24] Haleem A, Javaid M. Effects of COVID-19 pandemic in daily life. Current medicine re- search and practice. 2020;10(2):78–9. target populations. Psychiatry and clinical neurosciences; 2020;74:281-2. [6] Sahoo S, Mehra A, Suri V, Malhotra P, Yad- danapudi LN, Dutt Puri G, et al. Lived expe- riences of the corona survivors (patients admitted in COVID wards): A narrative real -life documented summaries of internal- ized guilt, shame, stigma, anger. Asian journal of psychiatry. 2020;53 (102187):102187. [7] Shabu S, Amen KM, Mahmood KI, Shabila NP. Risk perception and behavioral re- sponse to COVID-19 in Iraqi Kurdistan Re- gion [Internet]. Research square. 2020. http://dx.doi.org/10.21203/rs.3.rs-22025/ v1 . [8] Ornell F, Schuch JB, Sordi AO, Kessler FHP. “Pandemic fear” and COVID-19: mental health burden and strategies. Brazilian journal of psychiatry. 2020;42(3):232–5. http://dx.doi.org/10.1590/1516-4446- 2020-0008. [9] Aziz PY, Hadi JM, Sha AM, Aziz SB, Rahman HS, Ahmed HA, et al. The strategy for con- trolling COVID-19 in Kurdistan Regional Government (KRG)/Iraq: Identification, epidemiology, transmission, treatment, and recovery. International journal of sur- gery open. 2020;25:41–6. [10] Holloway I, Wheeler S. Qualitative Re- search in Nursing and Healthcare. 2010. Oxford: Wiley-Blackwell. [11] Elo S, Kyngäs H. The qualitative content analysis process. Journal of advanced nurs- ing. 2008;62(1):107–15. http://10.1111/ j.1365-2648.2007.04569.x. [12] Weible CM, Nohrstedt D, Cairney P, Carter DP, Crow DA, Durnová AP, et al. COVID-19 and the policy sciences: initial reactions and perspectives. Policy sciences. 2020;53 (2):1–17. https://doi.org/10.1007/s11077- 020-09381-4. [13] Adolph C, Amano K, Bang-Jensen B, Full- man N, Wilkerson J. Pandemic politics: Timing state-level social distancing re- sponses to COVID-19. Journal of health politics, policy and law Internet]. 2020; Available from: http:// dx.doi.org/10.1215/03616878-8802162. [14] Liu, X., Kakade, M., Fuller, C.J., Fan, B., Fang, Y., Kong, J., et al. Depression after exposure to stressful events: lessons learned from the severe acute respiratory syndrome epidemic. Comprehensive psy- chiatry. 2012;53(1):15–23. 39 Erbil Journal of Nursing & Midwifery https://doi.org/10.15218/ejnm.2021.04 Erbil j. nurs. midwifery, Vol. 4, No. (1), May 2021 Original Article doi: https://10.1016/j.cmrp.2020.03.011. [25] Guidance for surgeons working during the COVID-19 pandemic [Internet]. Rcseng.ac.uk. [cited 2020 Aug 20]. Availa- ble from: https://www.rcseng.ac.uk/ coronavirus/joint-guidance-for-surgeons- v1. [26] OSHA Guidance on Preparing Workplaces for COVID-19. 2020. U.S. Department of Labor Occupational Safety and Health Ad- ministration, OSHA 3990-03 2020. [27] Ahmad AR, Murad HR. The Impact of So- cial Media on Panic During the COVID-19 Pandemic in Iraqi Kurdistan: Online Ques- tionnaire Study. Journal of medical inter- net research. 2020;22(5): e19556). https://10.2196/19556. [28] Pappot N, Taarnhøj GA, Pappot H. Tele- medicine and e-Health Solutions for COVID -19: Patients’ Perspective. Telemedicine journal and e-health. 2020;26(7):847–9. https://10.1089/tmj.2020.0099. [29] McGowan BS, Wasko M, Vartabedian BS, Miller, RS, Freiherr, DD, Abdolrasulnia, M. Understanding the factors that influence the adoption and meaningful use of social media by physicians to share medical in- formation. Journal of medical internet re- search. 2020;14(5):e117.doi: https://10.2196/jmir.2138. [30] Dieltjens, T., Moonens, I., Van Praet, K., De Buck, E. and Vandekerckhove, P. A system- atic literature searches on psychological first aid: lack of evidence to develop guide- lines. PloS one. 2014;9(12), e114714. https://doi.org/10.1371/ journal.pone.0114714. 40 Erbil Journal of Nursing & Midwifery