key: cord-0719728-gxcu4su7 authors: Pasay-an, Eddieson; Alshammari, Farhan; Mostoles Jr, Romeo; Gattud, Vincent; Cajigal, Jupiter; Buta, Joyce title: Estudio cualitativo sobre las experiencias de las enfermeras en cuanto a estigma social en el contexto de la COVID-19 date: 2022-05-13 journal: Enferm Clin (Engl Ed) DOI: 10.1016/j.enfcle.2021.05.002 sha: 0b753b82b9a3c2a0123533b80058c7db01636877 doc_id: 719728 cord_uid: gxcu4su7 AIM: This study aimed to examine the social stigma experienced by healthcare workers caring for people diagnosed with COVID-19. METHODS: This research employed a qualitative-phenomenological approach. It was conducted at the COVID centers of the Hail region, Kingdom of Saudi Arabia. Both purposive and snowball sampling were used, resulting in 15 participants. However, saturation was identified in the 11th participant. Interviews were conducted online through a Zoom platform, with at least 50 min per participant. Thematic analysis was used in analysing the data. RESULTS: The nurses recorded four themes and three subthemes based on one-on-one interviews. These themes included (1) Labeling nurses as “COVID Nurses,” with a subtheme of frustration, (2) “Fear of the unknown,” with a subtheme of “uncertainties,” (3) Nurses’ need for support, and (4) the Love for the profession, with a subtheme of “nurses’ worth.” CONCLUSION: Nurses who cared for patients diagnosed with COVID-19 experienced stigma. They were labeled “COVID Nurses.” They experienced fear of the unknown and uncertainties and felt they needed support. Despite these experiences, the nurses felt fulfilled as they have a high regard for their profession. The experiences of these nurses call for intervention to help them before, during, and after any health-related crisis. In this context, nurses will be prepared mentally and emotionally to face the challenges in their career. Healthcare workers who work with stigmatized individuals are predisposed to stigma, 1 which is a social process that labels, stereotypes, and estranges an individual, resulting in inequality and a loss of status, all of which arise in the sense of authority. 2 This stigma affects both the well-being and the psychological characteristics of the healthcare workers. Healthcare workers who have been caring directly for patients with infectious diseases are not excused from experiencing stigma from a social perspective. Previous study findings have demonstrated that healthcare workers can feel emotional discomfort based on their rejection of diseaserelated practices, which can lead to stigmatizing responses that hinder their capacity to be professional caregivers, thus weakening the quality of care. 3 This causes an individual to be perceptually classified by others in an undesirable, rejected stereotype, rather than in acceptable norms. Healthcare workers responding to the challenges brought by COVID-19 are at high risk of acquiring the infection. This is due both to the lack resources and to the nature of their work. 4 Indeed, the International Council for Nurses (ICN) believes that healthcare workers are highly susceptible to acquiring the disease. 5 This also held true in the case of severe acute respiratory syndrome (SARS) in 2002, where 22% of the SARS patients in Hong Kong were healthcare workers. 6 In March 6, 2020 in northern California of the United States, three healthcare workers were reported to have tested positive for the virus, and dozens have been in isolation. 7 In Spain, at least 14% of the healthcare workers were recorded on March 25, 2020 as having been infected. Due to a perceived connection with the disease, the latter scenarios have put healthcare workers at risk both of stereotyping and of facing discrimination. Healthcare professionals in India, for example, have been shunned by others because of a fear of being infected. 8 Healthcare workers in the Philippines have suffered abuse and stigma amid panic over COVID -19 infections. 9 Looking back to the scenario during the vancomycin-resistant enterococci (VRE) outbreak, nurses were both blamed for the outbreak and they were resentful of the increased workload. 10 From the aforementioned context, the medical professionals responding to the health demands due to COVID-19 are not just physically stressed; they also face considerable influence on their psychological health because of the related social stigma. 11 Although these expressions of stigma are widely recognized, the lack of understanding regarding their impact is sparse in the literature. According to Nyblade and colleagues, 12 while cases of stigma are emerging as a problem in the healthcare context, interventions for surmounting the challenge are lacking. Because it helps to recognize the presence of social stigma and how it affects the healthcare workers who are directly interacting with COVID-19 patients, this study is of significance to the present situation regarding the COVID-19 pandemic. Recognizing this problem at the early stage can help the healthcare workers to address such concerns, thus, it helps to reduce their stress and fears they may have in their work. This study aims to explore the social stigma experienced by the healthcare workers caring for those who are diagnosed with the COVID-19 infection. The findings of this study will help policy makers to customize interventions to help nurses cope with their experiences. This investigation employed a qualitative-phenomenological research approach. The study participants were nurses who were assigned as frontliners during the pandemic period of COVID-19. The researchers initially invited 15 frontline nurses to participate in the study. However, the point of saturation was regarded as on the 11th participant. This study took place in the COVID Center hospitals of the Hail region, Kingdom of Saudi Arabia. Both purposive and snowball sampling were employed in this study. For the purposive sampling, the researchers included nurses that had a direct interaction or rendered care to COVID-19 patients, volunteered to participate, and could speak and understand English. For the snowball sampling, the researchers used referrals to identify nurses who had experienced social stigma because they cared for patients diagnosed with COVID-19. Table 1 presents the demographic profile of the respondents. An invitation letter was initially sent to the participants so that they could make their decision about volunteering to participate. After that, a consent form was provided for them to sign before they participated. The date, time, and location of the interview were all dependent on the participants. Four researchers conducted the interviews represented by three males and one female. These interviewers are presently working in the academe and had a long experience in the conduct of interview. While most of the researchers had volunteered serving in the hospitals during the pandemic, they have no direct relationship with the participants and have no prior encounter before the actual interview. Before the actual interviews, the researchers asked the participants for permission to record them. Semistructured questions were used to guide the researchers. The following grand question is one example: ''Can you describe to me your experience about being stigmatized?'' Probing questions were used to clarify and explore the answers of the participants further (e.g., Can you explain further or clarify what you mean by that? Can you give an example?). Since this study was carried out during the lockdown period, interviews were conducted through online using the Zoom platform. The time duration for the interview per participant was at least 50 minutes to one hour. The interviews took more than a month to conclude with the consideration on the availability of the participants. Two researchers independently reviewed the interview materials, summarized and extracted meaningful statements, and formulated the themes that were present. The research team discussed and resolved conflicting opinions on the contents of the themes. The data was collected in June and July 2020. The researchers established protocols and procedures in conducting the study. The quantity of data collected by the researchers was confirmed, and then the participants checked it to establish the credibility of the results. This was to ensure that their descriptions of their individual situations were transcribed completely. As one of the interventions given by the researchers, a debriefing was performed to deal with the nurses' psychological distress. This study was conducted with the approval of the Institutional Review Board of the University of Hail (H-2020-0144). The purpose and importance of the research study and other considerations, such as the freedom to withdraw anytime during the interview session, were explained to the participants. Confidentiality, anonymity, and the rights of the participants were ensured at all times. The data collected in this study was analyzed using a thematic analysis, which is a method of analyzing qualitative data. This method is used to identify, analyze, and interpret the patterns and interior hidden themes of qualitative data. While the nurses differed based on their demographics, they characterized similar experiences toward social stigma. They charted four themes and three subthemes based on the one-on-one interviews. These include (1) ''Labeling Nurses as 'COVID Nurses,''' with a subtheme of ''Frustration,'' (2) ''Fear of the Unknown,'' with a subtheme of ''Uncertainties,'' (3) ''Nurses' Need for Support,'' and (4) the ''Love for the Profession,'' with a subtheme This study aimed to explore the experiences of the healthcare workers in caring for those diagnosed with COVID-19. While frontline nurses are responding to the pandemic, they encounter the same experiences that include stereotyping. For example, nurses were labeled as ''COVID Nurses'' when people saw them as carriers with the potential of spreading the virus in the community. This study finding, in which stereotyping is common with these nurses amid the pandemic, agrees with that of Lohiniva et al., 1 who state that healthcare workers are predisposed to stigma. Similar to the study findings of Maben and Bridges, 13 the nurses were perceived to be a carrier of a disease and that they compromised the safety of others. Indeed, labeling the nurses and seeing them as infectious could have the potential of impairing their abilities as competent providers, and this could result in undermining the quality of care. This study result revealed several components or drivers contributory in the formation of the stigma among nurses during COVID-19 epidemic. 14 Such a result implies that people still have a lack of understanding regarding COVID-19, which necessitates the government helping to educate people through mass media education, so that nurses are not discriminated against. Indeed, according to Lucas and Phelan, 15 the stigma is very much communicated in their interaction with the nurses. Conversely, the nurses felt frustrated with the circumstances that, despite sacrificing their lives and the safety of their families, they were stereotyped. This emerging perception of themselves very much reflect the internalization of their stigma experience. 16 Such frustration may result in exhaustion from their work and thereby compromise the quality of care that they deliver. According to Lai et al., 17 stigmatization increases an avoidable burden on the work and lives of the healthcare providers, and thus contributes to their burnout. This finding indicates that, for nurses to deliver the quality of care that is expected from them, support and understanding from the stakeholders, colleagues, friends, and family are important. For example, hospital management should reassure their nurses that they will get the care they need so that they do not feel helpless. In addition, the need to form a team to help these nurses in such situation is of paramount importance in order for them to feel supported. The experiences of the frontline nurses as they respond to the COVID-19 pandemic can shape their own individual response, maintenance of well-being, and capability to render their responsibilities. The label of ''COVID Nurses'' places emphasis on the virus rather than the health professionals combating the pandemic. The public stereotyping of nurses during the pandemic has been observed 1,15 to predispose them to stigma. Paradies, Bastos and Priest 16 described that interpersonal interactions reveal the social process component of stigma. Healthcare workers were perceived to be carriers of a disease and that they compromised the safety of others. 13, 18 The individual understanding and perceptions that come from both misinformed and informed sources regarding COVID-19 have become the defining characteristics that define these nurses. Earlier research discussed that healthcare workers can also feel emotional anxiety as a result of their personal rejection and this may lead to stigmatizing responses that hinder their ability to deliver appropriate treatment, hence lowering their efficiency. 3 Such result implies the health authorities need to have a mass education that correct this perception in order for the healthcare workers especially these nurses to be protected from being stigmatized. Mass education and correct information can refute misinformation and misconceptions that fuel discriminatory behaviors. Further, public attribution that nurses are infectious could have a negative impact on their well-being, impairing their competence and undermining the quality of care that they can render. 19 While being continually exposed to health risks, nurses feel simultaneous frustration with the unfair characterizations from others. Stigmatization brings another layer of challenge to both the professional and personal lives of the healthcare providers, leading to both deviations from work process compliance 20 and burnout. 17 It is important therefore that the nurse leaders should look into the ways that these nurses feeling be compensated. Nurse leaders, for example, will look into ways to change the working conditions of nurses. As echoed by the nurses in this study, the fear of the unknown implies that, despite being protected with equipment, they still felt vulnerable to acquiring the disease, The term ''COVID Nurses'' corresponds to a term that has been used to label nurses who have had a direct interaction with a patient diagnosed with COVID-19. According to the study participants, they were known as ''COVID Nurses'' by people who seemed to distance themselves because they believed that the nurses had already been infected with the virus. ''Frustration''----refers to the upset feeling of the nurses regarding the label being given to them----this may result in stress or exhaustion. 24 already identified, that nurses are more stressed when their family's health is concerned during the pandemic. In addition to the physical and mental demands and the risks of being in the frontlines during the pandemic, the experiences of stigmatization contribute to fears, taking an emotional toll and providing yet another requirement for the nurses to cope with. Nurses react individually to these experiences, according to their own coping mechanisms. Mertens et al. 21 observed that successfully using coping mechanisms provides a protective function limiting the nurses' fears, while those who deny or avoid recognizing and dealing with their fears further aggravate the negative emotions. The emotional responses ranging largely from fear to fatigue can progress to anxiety, burnout, and depression, not excluding other associated conditions. 22, 25 Since nurses remain at the frontlines of the pandemic, it is crucial to develop and maintain mechanisms providing mental health support accordingly, 24 to build their individual resilience, and to improve their mental resilience. 22 Despite the experiences of labeling and fear fueling their cry for support, many nurses remain steadfast in the performance of their duties and responsibilities, indicating their dedication to the nursing profession. It likewise reflects other nurses' motivation to continue working during the pandemic. 26 Other nurses who similarly faced the challenges of the pandemic also maintained positive attitudes and appropriate standard practices in the performance of their duties. 27 The communicated fidelity to their responsibilities in their chosen profession demonstrates understanding of the nature and science of assisting patients toward recovery, while expressing their need of support shows cognizance of the hazard risks for them to continue holding the frontlines effectively. It is in this context that hospital administrators should note that endurance after a stigmatizing encounter always necessitates careful observation and action. Despite their training, nurses' optimistic attitude will invariably lead to negative outcomes over time if stigmatization is continued. This implies therefore that hospital administrators should provide continuous training to nurses on how to address the problem. Further, acknowledging the big contribution of nurses to healthcare may even increase their level of performance at work. Overall, this study contributes to realizing the effect of stigma as experienced by the nurses. It adds to the understanding of the intrapersonal and interpersonal elements in the process of stigma formation and contextualizes how it specifically shape the nurses experiences during the pandemic. It also gives a better view of nurses' first-hand specific experiences where it affects their well-being and their work. Acknowledging stigma at the early stage can help the nurses to prevent its effect and thus, it helps to reduce their stress and fears they may have in their work. Exploring these experiences will inform the nurse leaders, and policymakers to tailor fit a strategy addressing the effect and prepare the healthcare workers to prevent stigma. It is worth noting that organizational policies should look into the manifested and practiced stigma before it bears impact to the health and social well-being of nurses. In turn, the nurses will be able to focus on their work delivering the quality of care the patients deserve. This research acknowledged some of the limitations. For instance, we did not include participants 12 through 15 in the interviews. Doing so might help to further explore additional perspectives of the data that was gathered. The nurses who were unable to speak and understand English were excluded, and including them may provide a different perspective that adds robustness to this study. In this study, nurses who cared for patients diagnosed with COVID-19 experienced stigma and they were labeled ''COVID Nurses.'' Because they are also vulnerable to the disease, they had uncertainties and fear of the unknown. The nurses need support as well. However, despite their experiences, they felt fulfilled since they have high regard for their profession. The experiences of these nurses call for a disaster plan to be in place for pandemics, to guide nurses before, during, and after any health-related crisis. In doing so, nurses will be prepared both mentally and emotionally. This research does not received fund from any agency. HIV stigma toward people living with HIV and health providers associated with their care: qualitative interviews with community members in Egypt Conceptualizing stigma Combating HIV stigma in health care settings: what works? 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