key: cord-0754783-bi7v6ryr
authors: Hsiao, Chun‐Ting; Sun, Jia‐Jing; Chiang, Yi‐Hsuan; Chen, Hsiu‐Lien; Liu, Tsui‐Yao
title: Experience of patients with COVID‐19 in hospital isolation in Taiwan
date: 2021-09-22
journal: Nurs Health Sci
DOI: 10.1111/nhs.12878
sha: 6688347677a6662aec49b81e0e92ccaeb4586bad
doc_id: 754783
cord_uid: bi7v6ryr

The COVID‐19 pandemic has significantly impacted everyone's lives, challenging us in ways that can be frustrating, daunting, and intensely emotive. This qualitative study explored the isolation experiences of patients with COVID‐19 in a hospital in northern Taiwan. We collected data from nine patients in June–July 2020, conducting semi‐structured, virtual face‐to‐face, in‐depth interviews to gather input on two topics: (1) the psychological effect of hospital isolation on patients, including the psychological burden, stress response, support, disease stigma, and fear of returning to society; and (2) the patients' cognition and behaviors, which included tracking epidemic information, monitoring disease progression, soliciting suggestions about hospital isolation, and gauging comprehension after recovery. The results confirmed that hospital isolation significantly impacts patients physically, psychologically, spiritually, and socially. Thus, the isolated patients faced the dual challenges of fighting, adapting to, and recovering from the disease itself and struggling in isolation to maintain positive beliefs, independently assess their condition, and gain strength from the knowledge of continuing social support.

At the end of 2019, an outbreak of pneumonia with an unknown cause was detected in Wuhan, Hubei, China (Ge et al., 2020) . The World Health Organization (WHO) soon announced that the cause was severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).

On 20 January 2020, the WHO declared the coronavirus disease 2019 (COVID-19) a Public Health Emergency of International Concern (PHEIC); on 11 March 2020, it was declared a pandemic (WHO, 2020a). As of 21 July 2021, there were 190 860 733 patients aged 60 and over and those with compromised immune systems and comorbidities such as cardiovascular disease, diabetes, respiratory system disease, malignant tumor, and cancer were more likely to become ill and have the highest mortality rate Huang et al., 2020; Wang et al., 2020) .

On 21 January 2020, Taiwan treated its first patient with a confirmed case of COVID-19, placing her in the negative pressure isolation ward of a hospital. Since then, the infectious power of the disease has rapidly increased. During this study's data collection phase (June-July 2020), the Taiwan Centers for Disease Control reported 693 confirmed patients with COVID-19, with 574 in hospital quarantine; seven perons had died (Taiwan Centers for Disease Control, 2020) . A comprehensive review of the pandemic examining the virus transmission characteristics, infection rates, and current border controls and other epidemic prevention measures showed that the incidence and mortality rates of COVID-19 were relatively low in Taiwan (P.-F. Rothan & Byrareddy, 2020) . Of the patients interviewed for this study, 68.3% had only mild symptoms (5.8% were asymptomatic), 23.3% had developed pneumonia, and 8.4% were critically ill (K.-L. .

While there has been significant research into the physical effects of COVID-19, there have been fewer investigations into the psychological impact of the pandemic, and fewer still have explicitly focused on the experiences of quarantined individuals during major infectious disease outbreaks (Jung & Jun, 2020; Panchal et al., 2021) . This qualitative study explored the isolation experiences of nine patients with COVID-19 in a hospital in northern Taiwan between June and July 2020.

During quarantine and hospital isolation, patients often experience feelings of panic, loneliness, anxiety, fear, depression, stress, guilt, helplessness, anger, separation from relatives, loss of freedom, and boredom (Bo et al., 2021; Guo et al., 2020; Panchal et al., 2021) .

Other social effects can include personal, professional, and educational uncertainty, financial insecurity, housing and healthcare challenges, social discrimination, disease stigma, and even increased domestic violence (Brugliera et al., 2020; Guo et al., 2020; United Nations, 2020) . When combined, these effects can lead to or exacerbate mental illness (Jung & Jun, 2020) . Brooks et al. (2020) found that negative psychological effects, including posttraumatic stress symptoms, confusion, and anger, were associated with longer quarantine durations, infection fears, frustration, boredom, inadequate supplies, inadequate or conflicting information, financial loss, and stigma. A systematic review also found that healthcare workers spend less time in isolation than patients. Moreover, patients do not understand their medical conditions, which may affect their dissatisfaction with hospital isolation (Abad et al., 2010) . Therefore, it is essential to provide patients with disease updates, medical staff support (Peng et al., 2004) , basic necessities, electronic products, and access to entertainment to alleviate boredom. These measures also help establish a two-way communication channel, reducing the adverse physical and psychological effects caused by prolonged isolation (Brooks et al., 2020) . Hospitals can improve isolation care by preparing the environment, providing patients with clear nursing guidance, and addressing the patients' need after moving into the isolation ward.

Infected patients in isolation can experience physical and mental stress. Feeling isolated and powerless in the face of personal health risks and the pressures created by public health emergencies can lead to stress, anxiety, depression, isolation, avoidance habits, frustration, and physical health risks, among other negative health and social outcomes (Barratt et al., 2011; Purssell et al., 2020) . Research conducted in the official isolation facility in New South Wales, Australia, on the interactions of patients with COVID-19 reported that the patients shared both positive and negative lived experiences of infection, loneliness, and disease (Shaban et al., 2020) .

Some countries have experienced so many cases and such high infection rates that people with mild cases have been encouraged to isolate at home. Since the initial outbreak of COVID-19 in Taiwan about a year ago, the number of confirmed cases and deaths in the country has remained lower than in many other countries (Taiwan Centers for Disease Control, 2020). Since Taiwan has sufficient medical capacity, after the patients' condition is diagnosed, patients are sent to the hospital for isolation and treatment. This study sought to understand the subjective experiences of patients with COVID-19 isolated and treated in a hospital in Taiwan to discover how their physical, psychological, and social conditions changed during hospital isolation.

As a qualitative research design, phenomenology is essentially the study of lived experience or the lifeworld-the world as we experience it in the here and now (van Manen, 1997) . According to Polkinghorne (1983) , it is trying to grasp or comprehend the meaning of human experience as it is experienced. This study followed Tong et al.'s (2007) consolidated criteria for reporting qualitative research (COREQ) to ensure rigor in the process used to subject the recordings of the interviews to content and inductive analyses to extract the underlying information.

Using purposive sampling, we recruited patients with COVID-19 who had been admitted to a regional hospital in northern Taiwan for isolation and treatment (Ranjbar et al., 2012) . The inclusion criteria were as follows: aged 18 or over; diagnosed with COVID-19; gave their informed consent to be interviewed; could speak and read Chinese; and had access in isolation to electronic equipment with a video chat function. The exclusion criteria were patients who were not stably conscious or had a history of mental illness. The participants' average length of hospitalization was at least 7 days.

We collected the data through semi-structured, virtual face-to-face, in-depth interviews conducted between June and July 2020. The first author arranged the interview times for both parties. We conducted and recorded the interviews using the Google Meet videoconferencing application in a private office. We devised our interview outline after consulting previous research and relevant experts. The main prompts were these: "please talk about your feelings or experiences of COVID-19"; "please talk about your feelings or experiences of hospital isolation"; and "please talk about what affected your feelings or experiences of combating COVID-19." The interviews were transcribed verbatim and coded by the first author to extract information and analyze the data. During and after the interviews, the researchers summarized and clarified the patients' answers if necessary. Each interview lasted about 60 min, depending on when saturation seemed to have occurred. Saturation in qualitative research means that further data collection or analysis is deemed redundant or unnecessary because no new codes or themes are being discovered. This can be termed inductive thematic saturation. To determine the saturation point, we followed Saunders et al.'s (2018) findings that saturation should be operationalized according to the research questions. We adopted data repetition and information saturation to determine the study sample size; that is, we terminated data collection when we found no new themes emerged when reviewing the accumulated interview data.

We conducted content analysis to examine the interviews, repeatedly reviewing the interview transcripts to clarify the meaning and connotation of each topic and identify the overall concept. We looked for thematic groups that stretched the data diversity as far as possible and recognized frequent repetition in the themes as empirical evidence that a category was saturated. We adopted the data analysis procedure proposed by Colaizzi (1978) . After we transcribed the interview records, we reviewed them multiple times to identify and clarify meaningful statements about the patients' experiences and feelings. Finally, we extracted, transcribed, coded, and classified them into themes in a semi-open manner to extract their meanings, then interpreted and validated their relevance and described the overall results (Morrow et al., 2015) .

We verified the reliability of the study by applying the concept of trustworthiness proposed by Lincoln and Guba (1985) , which we interpreted as including the following: (1) only patients whose COVID-19 infections were confirmed by different sources were recruited into the study; (2) the research participants could communicate clearly, and they verified the final verbatim transcripts to ensure the credibility of the information; (3) we recruited as many individuals as possible who met the eligibility criteria to ensure the diversity and transferability of the information; (4) we conducted peer reviews to confirm the consistency of the results and consulted qualitative nursing experts to ensure data reliability and dependability; and (5) we were personally involved in collecting the research data (interviewees' data, audio records, interview outline, and analysis files), recording the process objectively and specifically. In addition, these records were preserved for future reference to ensure that the confirmability of each individual's interview record could be tracked (Lincoln & Guba, 1985) .

This study was reviewed and approved by the Research Ethics Committee of Taipei City Hospital (TCHIRB:10905019-E). After receiving both verbal and written information about the study, the participants provided their written informed consent to participate. We did not collect any identifying information; participants were free to leave the study at any time without giving a reason; and all data were password-protected and encrypted. During the interviews, the researchers treated the participants with respect, listened intently, and answered their questions.

The average age of the patients with COVID-19 was 33 years, and the average length of hospitalization was 1 month. Three patients (33%) had a master's degree or higher, and four (44%) patients had a bachelor's degree. Most of the patients were unmarried (77%) and asymptomatic (66%). They had various occupational backgrounds, including service providers, military personnel, domestic and international students, researchers, and retirees. Four (44%) contracted the virus overseas, three (33%) contracted it from warship clusters, and two (23%) contracted it locally. Table 1 shows the study participants' basic information. Table 2 summarizes the two main themes we identified from our analysis of the interview content: (1) the psychological effects of hospital isolation on patients, and (2) the cognition and behavior of patients during hospital isolation.

One of the two recurring themes in the isolated patients' interviews was the negative psychological pressures related to the isolation and their worry about returning to society after recovery. The patients described the psychological journey from learning about the epidemic to being infected and finally treated and discharged from the hospital.

They shared their feelings about being hospitalized for a long time in the isolation room, expressing their negative attitudes and beliefs felt about the disease and their "self-response ability." This theme had four subthemes, described in the following sections.

When we asked the patients to describe their feelings during hospital isolation, they talked about the anxiety associated with knowing they could not leave the hospital, their guilt for causing trouble to others, and their feelings of being stranded in the isolation ward for an extended period. They described the psychological burdens in various ways, but many felt pushed to the verge of mental collapse.

You felt that you were trapped in a small space within a large space, and that you were constantly compressed in a small space, especially when the lights were off. Therefore, I felt that I was walking on an end- 

The longer the hospital isolation, the more helpless the patients felt.

The patients learned about their recovery status through hospital examinations and felt disappointed when the result remained positive, ruling out discharge from the hospital. However, this psychological burden was alleviated by different stress responses and support measures, such as communication with and care from medical staff, family and external support, recreational activities, spiritual sustenance, 

The second recurring theme was the patients' evolving understanding of COVID-19 before they became infected, while they were hospitalized and quarantined, and after discharge. They could understand their physical condition through self-observation, and this informed their understanding of the disease. Because they had been confined to the isolation ward for a long time, they also proposed additional equipment and policies that would better meet the needs of others in isolation. After recovery, one patient said, "I cherish my health even more, and act to change the behavior of disease stigmatization."

There were four subthemes.

Because COVID-19 is a highly contagious disease, the global media have been providing continuous updates on the epidemic, including the basics of COVID-19 infection control. The patients with COVID-19 in this study mentioned that they actively read the news or searched for independent information sources to stay updated during the epidemic. Initially, they knew little about the disease's symptoms or transmission mode. However, after they were hospitalized, they understood the progression of their disease more comprehensively as medical staff provided them with correct information. 

This study revealed that hospital isolation during the COVID-19 epidemic affected patients physically, psychologically, socially, and spiritually. The study's patients recollected their rich experiences of the negative emotions they had felt: fear (especially after the diagnosis), concern about transmitting the virus to relatives and friends, social Our results confirmed that despite the stressful effects of hospital isolation, the interviewees tried to remain optimistic, actively tracked information about the pandemic, and improved their understanding of the pandemic and the disease itself. This result is consistent with the findings of Hung et al. (2005) in Taiwan.

In addition to independently assessing their physical conditions and monitoring their physical and psychological changes after contracting the virus, this study's patients also began to adapt to their new lifestyles in the isolation ward. They committed themselves to staying positive, self-motivating, living a regular life, and exercising. . We found that patients were keen to track COVID-19

information and pandemic trends, as in K.-L. , confirming that timely reports on the health crises and updates on government policies positively support health self-efficacy. Access to accurate and reliable information improves patient confidence.

This study had several limitations. First, we only interviewed patients with COVID-19 from one isolation center in Taipei 

This study found that patients diagnosed with COVID-19 and placed in hospital isolation experience numerous negative emotions such as fears about their and others' health, dread of disease stigma, fear of reinfection and infecting relatives and friends, and the psychological burdens of enforced confinement in hospital isolation. However, we also found that the psychological stress could be alleviated by providing information enabling the patients to self-assess and evaluate the disease's progression. Helping the patients self-monitor their physical and psychological changes after infection gave them a sense of control over the disease that helped ease their psychological stress. Also invaluable was the social support provided by medical staff and the patients' families and friends. This study confirmed that patients isolated with COVID-19 infections gained insights from their unique experiences that positively affected their commitment not to take for granted the preciousness of life, with most resolving to eat better, exercise, and educate themselves about their health.

Our one-on-one in-depth interviews allowed the patients with COVID-19 to share their experiences during hospital isolation and after they returned to society. The interview process helped the patients express their emotions and provided an appropriate health consultation channel. They supported Taiwan's epidemic prevention measures and the hospitals' policies to protect patients in isolation wards, acknowledging the overall quality of the medical care and services while nevertheless calling for more focused support for patients in isolation.

This study's results could serve as a reference to improve the care of patients in isolation with COVID-19. Hospital management should provide appropriate resources and upgrade the mental-health-related capabilities of the medical staff to improve the quality of isolation inpatients' care.

We collected data from patients with COVID-19, gathering their psychological experiences over time through one-to-one interviews to gain a greater understanding and comprehensive and authentic data on hospital contact isolation. We observed positive emotions coexisting with negative emotions and affirmed others' findings on psychological tolerance and development under strain during epidemic stress. We preliminarily explored the effects of hospital isolation on the psychological health of patients with COVID-19. Practical-based learning should be considered to improve the nursing curriculum related to hospital contact isolation and psychological health to improve patient care during health crises.

We would like to thank nursing managers and frontline medical staff for their support and help, and the patients for their willingness to share their experiences and feelings during hospital isolation. Without their collective support, this study could not have been completed.

The authors declare that they have no conflicts of interests.

Study design: Chun-Ting Hsiao, Tsui-Yao Liu, Jia-Jing Sun.

Data collection: Chun-Ting Hsiao, Hsiu-Lien Chen, Jia-Jing Sun.

Data analysis: Chun-Ting Hsiao, Yi-Hsuan Chiang, Tsui-Yao Liu.

Manuscript writing: Chun-Ting Hsiao, Jia-Jing Sun, Yi-Hsuan Chiang.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethics restrictions.

Yi-Hsuan Chiang https://orcid.org/0000-0003-0881-6621

Tsui-Yao Liu https://orcid.org/0000-0002-0582-3204

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