COVID-19 associated social stigma as experienced by frontline nurses of Hail: A qualitative study

The coronavirus, otherwise known as COVID-19 or SARS-CoV2, is a family of first detected viruses in the latter part of the year 2019 in Wuhan, China. It has leaped into a pandemic disease in just a short time reaching almost all populated parts of the world plunging economies while causing millions of deaths and it is still emerging spreading with more infectious mutations as of the end of 2020. It overwhelmed Government and health care institutions with the large turnout of infected. The virus transmission effectively occurs in close distance person-to-person interactions and contacts. Among the vulnerable group worst hit are the health care workers receiving the most brunt and social stigma. Health care workers of Hail were not spared and had experienced social stigma too. Such demeaning experiences have led to this study to explore the sentiments of nurses stricken by COVID-19. This study utilized the descriptive-qualitative research methods that include NVivo plus in analyzing the transcribed statements of respondents. The thematic analysis employed yielded the classification of the participants' responses within three themes: Personal sentiment, pessimistic image, and unsupportive environment. The nurses diagnosed positively with COVID-19 felt stigmatized in their workstation and the community during and after complete recovery and undertaking the mandatory quarantine period. Since this study is limited to hospital nurses, parallel research is highly recommended to investigate other healthcare workers' sentiments and determine what allows stigmatization of the COVID-19 patients. © 2021 The Authors. Published by IASE. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).


Introduction
*At present, the world is experiencing a severe health crisis caused by the Coronavirus (COVID-19), a highly infectious disease that emanated from Wuhan City, the Capital of China's Hubei Province, in the middle of December 2019 (CDC, 2020a). This contagious disease is a newly identified pathogen that grew into an epidemic inflicting thousands of Wuhan residents and now a dreaded pandemic spreading swiftly across the globe in just two months through close unguarded interactions among individuals or infector and infectee via respiratory droplets and contacts with a contaminated surface where the coronavirus can withstand up to 72 hours (WHO, 2020a;2020b). In this worldwide health predicament, countless patients with COVID-19 are being taken to the hospitals for treatment and health workers are highly susceptible to acquire the disease (ICN, 2020). The statistics show that medical professionals who respond to the health demands from the patient with COVID-19 are not just physically stressed but a possible considerable influence on their psychological health-related to social stigma (CDC, 2020b;WHO, 2020a;2020b).
In 2003, during the outbreak of Severe Acute Respiratory Syndrome (SARS, a disease similar to , some health workers in a hospital in Toronto, Canada have acquired this disease. Those health workers who participated in the research study experienced psychological distress and social stigma (Maunder et al., 2003). In China, a crosssectional survey of health workers in hospitals was conducted and revealed that the front-liners directly engaged in offering treatment to patients with COVID-19 are at greater risk of developing mental health crises (Lai et al., 2020). The research studies mentioned here are related to the psychological impact of infectious disease outbreaks on front-liners; nonetheless, existing related literature on perceived social stigma by the frontline nurses on emerging infections associated with COVID-19.
Statistics from the World health organization on the cases of COVID-19 are being updated regularly. The number of cases keeps growing every day and the more the frontlines nurses and doctors are at risk of acquiring the virus (WHO, 2020a;2020b). Though these frontline nurses are considered heroes because of their commitment and dedication during this health emergency, their possible individual exposure to COVID-19 and the negative social stigma have some irreparable impact on their public life. This study's researchers have read and heard from social and mainstream media news articles; news broadcasts, and stories about social disgraces and discrimination experienced by frontline nurses from different countries worldwide during the COVID pandemic. To cite an example, in the Philippines Cebu City, a motorcycle-riding tandem splattered chlorine to a nurse who was on his way home from duty (Rubrico, 2020). Many nurses have also experienced disgrace from taxi drivers in Egypt who refused to transport them after rendering hospital duties. The taxi drivers fear that nurses might infect them with the dreaded virus. In another incident in the central city of Bhopal, doctors who just came from their hospital duty were stopped by police officers, and worst these police officers verbally accused the doctors of spreading coronavirus and not satisfied, and the policemen crushed the doctors with their baton (Altstedter et al., 2020).
Studying the present condition of frontline nurses, especially on their demeaning personal experiences in this health crisis, is relevant because understanding the psychological effect will encourage the community to be more considerate towards the health workers. It also helps in address issues concerning social stigma among medical professionals. This research study was then conceptualized to explore frontline nurses' stories regarding social stigma related to the occurring COVID-19 hysteria with the above as a premise.

Design
A descriptive qualitative study was utilized to explore frontline nurses' humiliating experiences on the COVID-19 associated social stigma.

Participant/setting
The participants were frontline nurses from various hospitals in the City of Hail. The inclusion criteria considered were: a) medically diagnosed with coronavirus disease 2019; b) willingly sign the consent to participate in the interview and freely share experiences and personal views associated with the COVID-19; c) had hospital duties three months before the interview; d) completed the 14-day quarantine period; and e) asymptomatic during the conduct of the interview. The exclusion criteria were: a) participant signed the consent but not willing to be interviewed; b) participant who has reported to duty after undertaking the quarantine but still with mild cough; and c) participant currently assigned in the isolation room COVID-19 patients.

Sampling
The sampling that was utilized in this study was purposive and snowball because participants were only nurses assigned in the various hospitals in Hail City who were diagnosed with coronavirus disease. After identifying the prospective interviewee, a nurse with a history of coronavirus disease, a snowball sampling technique was applied to ask the participant to refer other nurses who were also COVID-19 positive. This snowball technique was more comfortable for the researcher to find other possible subjects within their circle as people's perceptions of the patient with coronavirus are considered a disgrace in the community.

Data collection
The data gathering commenced upon approval by the ERB of the conceptualized research proposal numbered H-2020-089 and with the hospital authorities' permission. Invitation letters containing the extent of participation, benefits, and the rights to withdraw from the study together with consent forms were sent to potential participants. Moreover, the researchers gave the likely respondents ample time in deciding whether they participate or not. If they agreed to participate, venue and interviews were scheduled and according to the most available or convenient time for the participant. Interviews in this research study were conducted within a period of 8 weeks. Before the interview is conducted, a semi-structured question is prepared to lead the researcher to ask the participant questions: Will you describe how your experiences were when you found out you were positive COVID? Were there any chances you experienced disgrace from the people around you after you were contacted with COVID19? The interview guide prepared has a conversation flow leading to a different topic; however, it ensured that the research's significant purpose was addressed. Identifiers such as the full name of the participants were replaced with code names to ensure confidentiality. An audio recording was used throughout the interview and with permission from the participants.

Data analysis
Each participant's statements or narratives were transcribed and entered into the NVivo plus for identification of the most frequent word used by respondents. Then the frequent words were carefully digested and completely understood the whole sense of their predicaments and then themes were created and analyzed.

Results
From the interview data, the following themes were analyzed using the thematic analysis: Personal sentiment, pessimistic image, unsupportive environment. All of the 9 participants had COVID-19 and undergone a 14-day quarantine period. As per the gathered data analysis, most of the participants rarely experienced social disgrace during their quarantine period. The participants mostly encountered social stigma when they were asymptomatic and had social contact after their isolation and began their hospital work.
The participants' complete and original statements are arranged below as per theme for better comprehension of the exact thought and messages.

Personal sentiment
When COVID-19 spread and became pandemic, infirmaries became busy caring for patients stricken by it and thousands have recovered, yet many of them perished due to the newly discovered virus's complicated symptoms. Hospital health care workers (HCW) were not spared by the virus or respiratory disease, especially the frontline nurses and doctors, causing them several deaths. The COVID-19 has not only physically overwhelmed the frontline HCWs, but has also disturbed their weary emotional wellbeing.
In this study, the personal sentiment characterizes the emotional state of the participants who are presumed unwelcomed by the people around them. The participants expressed that they were discriminated against for hosting the infectious disease. For better appreciation and understanding, presented below are some of the participants' narratives that would explain more on this theme.
When the participants were asked questions regarding their perceptions on what other people think about them upon learning they got infected with COVID-19: Participant 1 (P1) "I was the first operating room staff nurse in my hospital that became positive COVID-19. I felt that my colleagues were all against me because no one from my colleague sent any text message or phone call when I was positive. During that time, I got depressed." Another participant shared similar sentiments or feelings toward her costaff in the ward, "I have six co-staffs in our ward. When I was COVID-19 positive and admitted in that same ward's isolation room, no one from my co-staff has ever visited me. I felt they dislike seeing me because I got infected by COVID-19, so I was stressed." P3 told her story, thinking of little vengeance after: "During my 14-day quarantine, my close friends never sent any text message for me, so I am angered and felt sad for them. I told myself that when I am done with the quarantine, I will not talk to them.
Five of the participants who were not residing with their families or whose families are in other countries told the researchers that they have not revealed or informed their respective families that they were tested positive for covid-19 because of fear that their family members will worry too much. But P7 told a different experience with her family, and she said she has a little child, "when my husband learned I was COVID-19 positive; he was tensed. He was worried that I might infect my child and the whole family. I am affected very badly." P4 shared her experience from a public place: "There was one time when I went to the supermarket to buy kitchen stuff. I was wearing my laboratory gown then. People in the supermarket stayed away from me. I felt embarrassed and felt as if I am a person with a contagious disease. My anxiety level during that time was high. The next time I went to the supermarket, I made sure I was not in my hospital uniform."

Pessimistic image
Fortunately, some participants received encouragement and moral support from some of their colleagues, but most of them experienced the negative impacts of COVID-19 upon learning they were positive for the disease. Even after recovering and undertaking the mandatory quarantine period, they still experienced disgraces at their workplaces.
As the second theme, this study's pessimistic image refers to the nurses who tested positive for COVID-19 and instantaneously looked upon as very infectious persons or undesirable like criminals considered as dangerous instead of praiseworthy health care providers. The following statements of experiences from the participants could very well fall under a pessimistic image. P4: "I have a friend who is also a nurse from another ward. We exchanged text messages before coronavirus. But after I recovered and back to my work, she no longer sends text messages." P4 had a different experience from that of her co-staff, "when I was admitted in the isolation room, no one from my co-staffs visited me. I just put in my mind that maybe, they were all busy that time so no one was able to see me." In another case, P5 expressed her disgust over her experience with the nursing administration office concerning her application for sick leave, "When our nursing admin officer learned that I was COVID-19 positive last two weeks ago, she shouted angrily asking why I entered the office despite having a history of COVID-19. She then instructed me to leave right away. Another male nurse who was present during that time and heard our conversation immediately put on his mask." P1, whose first swab for COVID-19 was positive, revealed his awkward encounter with his resident surgeon. He recounted that he just came from the emergency room for second swabbing and his way to their dormitory when the incident happened. "While on my way to my dorm, I saw our resident surgeon coming near to where I came from and as we get closer to each other, he wore his mask and just greeted 'hello' without any other words. Thinking that I used to assist him in the operating room during his surgical operation, I assumed that he avoided me." He also shared a mocking experience: "When I met my costaff in the operating room, she laughingly reminded me of my COVID-19 condition and even emphasized that I am the talk of the dormitory." P2, on his part, enumerated his stressful feeling of being disregarded, which, "on the first day I reported in my work, my male co-staff sarcastically joking asked if I am already negative while mocking with a body language that I should go away."

Unsupportive environment
The participants experienced various disgraces and mockery in their workplace and even outside the clinical setting. Most of them perceived that they acquired COVID-19 from the hospital. Two of the participants were assigned to patients with moderate to severe symptoms of COVID-19. When they became COVID-19 positive, they were the ones that experienced the worst symptoms of COVID-19.
An unsupportive environment is a theme for the negative experiences of participants from their workplace. They felt that the irregularities, inconsistencies, and lack of support from the administration had led them to acquire COVID-19 and prevent them from experiencing social disgrace.
In this theme, participants were asked about the supports provided to them by the hospital administration before and after infection from COVID-19 to lessen or minimize the social stigma experienced by frontline nurses. Some of them revealed that they received text messages from their colleagues and even their nursing administration staff. However, they expressed that staff nurses' problems and social stigmas associated with COVID-19 would have been prevented or minimized if guidelines or appropriate measures on implementing necessary health protocols have been in place, created, modified, or strictly followed.
P8 stated, "when I was COVID-19 positive, I got depressed because of the possible worrisome symptoms that may appear to me. During that time, I did not receive any psychological support from our hospital since there is no available mental health unit." P9 also said, "Now and then, the Ministry of Health changes the guidelines for COVID-19. Sometimes we were not being updated because of the leaflet that was distributed in our ward or through our email, infection control officers never oriented or provided seminars on COVID-19." P6 handled the COVID-19 patients in the ward and after two months, she turned out COVID-19 positive. "I already handled many patients with COVID-19. The disease may not have infected me if the hospital has provided complete Personal Protective Equipment (PPE). There were times when we reused some of our PPEs because the hospital was out of stock. When I was back to work, I requested another swabbing test. However, I was not allowed because accordingly, I was asymptomatic." In the case of P7, he recalled his experience and narrated, "when I learned that my co-staff became positive, I went to our emergency room and also requested for swabbing test, but the doctor in charge did not allow me to have it because I do not have any symptoms of COVID-19. I was disappointed then, so I went to a private hospital for a swabbing test and the result was COVID-19 positive." As narrated by P5, the lack of understanding from administrative personnel aggravates the lack of necessary personal protective equipment that the administration is supposed to provide. P1 described their work area, "our operating room is not spacious. Social distancing is not observed." P9 meanwhile recalled, "some of my colleagues panicked when we had COVID-19 patient."

Discussion
This research's primary objective is to explore the social stigma experienced by the hospital nurse who tested positive with COVID-19 but recovered after undergoing the necessary treatment and quarantine. The thematic analysis of the participants' narratives resulted in identifying three themes: personal sentiment, pessimistic image, and unsupportive environment.
In the personal sentiment theme, some of the respondent staff nurses perceived that they were judged by the people around them as COVID-19 carriers and thought their co-staff nurses had abandoned them in time of need. Such notion is understandably emanated from their observations that some of their colleagues avoided them with no communication since they were tested positive with coronavirus. This result is congruent to Taylor et al. (2020) statement, which revealed that 32% of the 3551 respondents avoided HCWs because they believed they were infectious. Therefore, the participants' stigmatization and stereotyping are not isolated because it happened almost everywhere globally while the pandemic rages. Researchers discussed that since COVID-19 is a new disease, health institutions were not prepared for its impact in the health care setting which resulted in health workers' psychological and emotional devastation leading to mental instability (Serafini et al., 2020;Alkhamees et al., 2020;Jimeno, 2020). With this finding, it is recommended for health institutions to formulate a comprehensive plan on mental health awareness among hospital workers so that in cases of emerging or remerging contagious diseases, no one will experience mental problems. Another health personnel quarantined should have a way of connecting to immediate relatives or friends for emotional or psychological support to reduce the impacts of work-related health problems. According to Tomlin et al. (2020), social and family connection during the time of emotional stress or in isolation stage due to pandemic plays a vital role in maintaining mental strength.
Under the pessimistic image theme, most of the respondents also narrated what they considered negative experiences and horrible encounters with their colleagues after recovering and completing the mandatory quarantine period. They expected to be warmly welcomed back by their co-health care workers to their workstations after full recovery from COVID-19, but it was not the case. Despite being back to normal health, the respondents observed some colleagues staying away from them as if they are still infectious. This result conforms with the study of Dye et al. (2020), that not only those patients diagnosed with COVID-19 and who recovered experienced stigma, health workers too were discriminated against in the community. It is highly recommended then for concerned governments and health institutions to revitalize mental health awareness for all ages to ensure a well-informed citizenry and reduce health-related social stigma.
In the unsupported environment theme, researchers expected nurses to be feeling stigmatized only outside of the hospital setting. However, it was discovered in this study that social stigma could be experienced even at the hospital where, supposedly, the place of healthy environments, healthy habits, and healthy human interactions. The respondents here also experienced a lack of moral support from the administrations of the hospitals. They believed that the lack of personal protective equipment and lack of guidelines and information on infection control has rendered them susceptible, so they got infected with the COVID-19. Being front-liners who are highly exposed to possible COVID-19, the participants also experienced bullying from their communities. Similar cases of physical and emotional abuse in the community setting were experienced by health care workers worldwide as reported by various international media because people judge them as carriers of COVID-19 (Bagcchi, 2020;Fernandez et al., 2020;Taylor et al., 2020;Nyblade et al., 2019). The case of COVID-19 poses an enormous challenge to the health sector, and so it is suggested that health care institutions ensure professionalism among HCWs to reduce or eradicate stigma within their ranks. Hospital administrations should create a support system that will be readily available for all staff that might experience any emotional burden related to their work. In such cases, nurses will always have good mental health that may lead to high-quality health care. Therefore, a study on the resilience of COVID-19 survivors is recommended, and further studies also dealing with the public's views and perceptions of COVID-19 survivors will likely be very useful.

Conclusion
All the nine (9) respondent-nurses of this study suffered and survived the dreaded COVID-19 while enduring social stigmas classified under three themes; personal sentiment, pessimistic image, and unsupportive environment. As front liners, they are very much exposed and vulnerable to any forms of contagious diseases such as COVID-19. Participants experienced social stigmas in the community and their work areas where personnel should be more accommodating and understanding concerning infectious conditions. Since this research is limited only to nurses diagnosed with COVID19, a parallel investigation is recommended for other health care workers to identify if they also experienced similar sentiments both in the hospital and in the neighborhood.

Acknowledgment
The research investigators would like to express their gratitude toward the University of Hail for funding this study and we are indebted to all the nurses who freely gave their time to participate in this study.

Ethical considerations
The research study's importance and other considerations such as the freedom to withdraw anytime during the interview session were explained to the potential participants. Before any interview proceeded, the prospective respondent signed a free and prior informed consent, who willingly and voluntarily participates. It was also clear that any information collected from participants and their identities are kept anonymous and confidential. The researchers established protocols and procedures in conducting the study. The data collected were checked by the respondents ensuring the credibility of the results. It assured that the description of the participant's situation was completely transcribed, after which the authors analyzed the results.