The Immediate and Short-term Impact of COVID 19 Infections on Nurses in a UAE Hospital

Background/Aims Nurses were on the front line against the COVID 19 pandemic, fighting to save human lives. Many nurses sacrificed their well-being and social life to win the battle. In consequence, many nurses have been infected with the virus around the Globe. This study aims to determine the immediate and short-term physical, psychological, and social impact of COVID 19 infection on nurses and midwives retrospectively. On the other hand, it aims to find the effect of COVID 19 stigma on the self-esteem of the infected nurses. Methods To achieve this goal, the authors used an exploratory, mixed-method design with a sample of nurses and midwives working in a tertiary hospital in UAE who has been infected with the COVID 19 virus and recovered. The authors have used the qualitative results to explain and interpret the findings of the quantitative findings. The data were collected through distributing the quantitative survey to participants and then it was followed by conducting semi-structured interviews. Results The careful exploration of the experiences of nurses infected with the COVID 19 virus suggested a simple model that manages the patients in hospitals and at homes, including improving self-efficacy and patient coping, providing the basic nursing skills to patients and families, providing continuous psychological support, and providing high standards of health care. Conclusion The new suggested model will maintain a positive status of wellbeing amongst infected patients during the infection time and in 3–6 months after the infection.

WHO's Information Network for Epidemics (EPI-WIN) (2020) mentioned that people usually recover from COVID 19 in 2 to 6 weeks. For some people, some symptoms may linger or recur for weeks or months following initial recovery in people with mild disease. Those symptoms include fatigue, cough, congestion or shortness of breath, loss of taste or smell, headache, body aches, diarrhea, nausea, chest or abdominal pain, and confusion. However, people are not infectious during this time.
The International Council of Nurses (ICN) (2021) reported that the total number of the reported COVID 19 deaths was increased to 2,262 in nurses in 59 countries, and COVID 19 infections were reached more than 1.6 million among healthcare workers in 34 countries as of 31 December 2020. The ICN estimated that around 10% of all con rmed COVID-19 infections are among healthcare workers. Al Maskari, Al Blushi, Khamis, Al Tai, Al Salmi, Al Harthi, Al Saadi, Al Mughairy, Gutierrez, and Al Blushi (2021) found in a cross-sectional study in health care workers in Oman that more than three-quarters of the infected health care workers had no chronic diseases or risk factors for severe COVID-19, while 7% had hypertension, 11% had diabetes mellitus, and 3% had other chronic diseases. The study also found that the most common acquisition of COVID-19 among health care workers was from the community (61.3%), by hospital acquisition (25.5%), and no clear source was identi ed for the rest (13.2%) of cases. Among those who acquired COVID-19 in the hospital, around one quarter (35%) acquired the infection from a con rmed positive colleague and around two quarters (65%) from exposure to infected patients. An internal unpublished report from Tawam hospital (the study location) presented that a total of 113 nurses were infected with COVID 19 viruses and the number of deaths was zero (Tawam hospital, 2020).
Gheysarzadeh, Sadeghifard, Safari, Balavandi, Falahi, Kenarkoohi, Tavan (2020) highlighted that despite nurses having enough skill and knowledge, they can be infected quickly as the result of their exposures to infected patients. However, the study showed that receiving the necessary care and treatment at home was a good experience for nurses and can be used for some cases.
On the other hand, Literature highlighted several impacts of the COVID 19 pandemic on people, including psychological, social, well-being, self-esteem, and others. For example, a report by Simetrica-Jacobs (2020) from the UK about the wellbeing costs of COVID19 in April 2020 compared to March and April 2019 concluded that the health, social and economic impacts of COVID-19 and social distancing are associated with large reductions in a range of wellbeing in terms of life satisfaction, happiness, sense of worthwhile, and anxiety and increases in psychological distress, with some evidence that the impacts are more severe for women and ethnic minority groups. Dagnino, Anguita, Escobar, Cifuentes (2020) found several psychological impacts of the quarantine, including various concerns (67%) and anxiety (60%), and concerns about the future, including concerns about general health (55.3%), employment (53.1%), and nances (49.8%). More, Ripon, Mim, Puente, Hossain, Babor, Sohan, and Islam (2020) claimed that the prevalence of depression and post-traumatic stress disorder (PTSD) is 85.4% among those who had home quarantine and 94% among those who had institutional quarantine in Bangladesh Nevertheless, Out, Charles, and Yaya (2020) pointed out in a literature review that the mental health care of patients, health professionals, and communities is likely under-addressed during COVID 19 pandemic, which could raise the major medium and long-term consequences and, accordingly, a proactive longer-term strategy rather than short-term crisis responses is desirable. Also, Dagnino, Anguita, Escobar, Cifuentes (2020) found that almost half of the participants (43.8%) felt they would need emotional support after this pandemic.
In sequence, Literature highlighted a new phenomenon COVID 19 stigma and discrimination. The Merriam-Webster dictionary (n.d.) de nes stigma as a mark of shame or discredit. CDC (2020) pointed out that stigma related to COVID 19 is associated with the lack of knowledge about how the virus spreads, a need to blame someone, fears about disease and death, and common rumors and myths about the disease. The CDC (2020) highlighted several groups of people who may experience stigma during the COVID-19 pandemic, including 1) certain racial and ethnic minority groups, 2) people who infected and recovered, 3) emergency responders or healthcare providers, 4) other frontline workers, such as grocery store clerks and delivery drivers, 5) people having disabilities or developmental or behavioral disorders that make them unable to follow the protection instructions, 6) people who have underlying health conditions that cause a cough, and 7) people living in groups. Therefore, those groups of people could experience discrimination in form of rejection by other people, denying providing speci c services to them, such as healthcare, education, housing, or employment, verbal abuse, and physical violence (CDC, 2020).
Ramaci, Barattucci, Ledda, and Rapisarda (2020) found that stigma positively predicted burnout and fatigue and negatively predicted satisfaction among frontline care providers working with patients infected with the COVID-19 in a large hospital in Italy. In India, Yadav, Laskar, and Rasania (2020) reported that 70% of a sample of health care provider perceived some kind of stigma, 50% perceived some form of stigma in their residential colony, 46% observed change in behaviour of their neighbours, and round 20% experienced rude behaviour or harassment from neighbour/landlord. Additionally, Munson (1992) claimed that the positive experience leads to high self-esteem, while the experience of failure or rejection leads to low self-esteem. However, Dimitriadou-Panteka, Koukourikos, and Pizirtzidou (2014) reported that self-esteem correlates perfectly with the way one experiences reality, no matter true or false perceptions.
In 2020 and 2021, academics published a large number of articles. Most of these articles were relevant to the impact of the COVID 19 pandemic on people and health care providers. Nevertheless, the number of articles that addressed the experience of people and health care providers, who were infected with the COVID 19 virus, was less.

Study Questions
This study aims to answer two main questions as follows: 1. What are the immediate and short-term physical, psychological, and social impacts of COVID 19 infection on the infected nurses and midwives at Tawam Hospital?
2. What is the effect of the COVID-19 stigma on the self-esteem of the infected nurses?
4. Study Objectives 1. To determine the immediate and short-term impacts of the COVID-19 infection on the physical, psychological, and social impact of the nurses and midwives.

2.
To nd the effect of COVID-19 stigma on the self-esteem of the infected nurses.

Signi cance Of The Study
As COVID 19 crisis is still ongoing, a second stronger wave is currently beating the world. The number of cases was dramatically increased and exceeded 38,000,000 until the moment of writing this paper. Experts are becoming more certain that the crisis will last for longer periods and will cause more harm to people, including deaths.
Hence, understanding nurse's experience with the COVID 19 infection could help other nurses and health care providers in the eld to gain the courage and the con dence to continue ghting the disease until we have a great victory. Also, the study could help nurses and other healthcare providers in other similar crises in the future.
This study will provide important information about the immediate and short-term physical, psychological, and social impact of COVID 19 infection on nurses and midwives and about the effect of COVID 19 stigma on the self-esteem of the infected nurses since it is the rst study, at least in the MENA area, to explore this concept.

Methods, Study design
The authors will use an exploratory, mixed methods research design. According to Creswell (2006), the mixed methods research design focuses on collecting, analysing, and mixing both quantitative and qualitative data through using all the available tools to provide a better understanding of the research problem. Bryman (2006) suggested that the combining of both quantitative and qualitative research allows the researcher to offset the weaknesses of each design and draw on the strengths of both. Also, Bryman (2006) suggested using qualitative data to illustrate quantitative ndings, often referred to as putting meat on the bones of dry quantitative ndings to improve the usefulness of ndings.
In this study, the authors will use the sequential explanatory approach to mixed methodology guided by Creswell (2013), where the quantitative phase is conducted rst and then followed by the qualitative phase. The authors will use the qualitative results to explain and interpret the ndings of the quantitative ndings.
The data will be collected through distributing the quantitative survey to participants and then will be followed by conducting semi-structured interviews.

The Sample
The authors will adopt the whole sampling techniques to collect the required data for the rst quantitative phase of the study. The authors will target all Tawam Hospital nurses who infected and recovered from COVID-19 between February and July 2020.
For the second qualitative phase, the authors will conduct semi-structured interviews with an extreme case sample of nurses who were affected negatively by the COVID 19 infection and included in the primary sample. According to Creswell (1998), 5 -25 cases are required for phenomenological (lived experiences) studies. Therefore, the authors will interview a sample of 10 nurses or less if saturation is reached earlier, and no new concepts are still emerging.

Inclusion and Exclusion Criteria
The authors will include nurses working at Tawam Hospital who were infected with COVID-19 and recovered. The authors will exclude those who infected after June 2020.

Data Collection Tool
The study included two surveys: the rst is quantitative, and the second one is qualitative.
The rst survey included several parts that collect information about the respondents, the physical symptoms, emotions, coping, and social status during COVID 19 infection period and 3-6 months after. The study used a Likert scale to rate the participant's responses for selected statements on scales that vary from 1 (did not experience at all) to 5 (the experience was extremely strong). Furthermore, the survey explores the impact of COVID-19 infection on the physical, psychological, and social status of infected nurses at two points of time; rst during the infection period (immediate) and after 3-6 months (short-term).

Analysis of the Quantitative Part
The quantitative part of the study is analysed using the Statistical Package for the Social Sciences V. 23. Thematic analysis will be used for the qualitative part.

Results
For the rst part of the study, the authors received responses from 22 nurses out of 113 infected nurses in November and December 2020. The analysis of the demographic data shows that the majority of the respondents were between the ages of 31 and 40 years, females, staff nurses, holding bachelor degrees, and working in in-patient's units. See Table 1 for details. To assess the reliability of the data collection tool, Cronbach's alpha was calculated and presented in Table 2. The Cronbach's alpha for the scales is above 6.0 (the acceptable value for the Cronbach's alpha) except for one subscale.
However, the value of Cronbach's alpha for the entire tool, including all subscales, is 0.945.  (2012), of the individual items that make up one scale that is more reliable than the individual items and then presented those averages in a bar chart. This calculation is repeated for the rest of the scales (Fig. 1, 2 Regarding the physical symptoms, Fig. 1 shows that tiredness, fever, and loss of smell and taste were reported moderately, dry cough, headache, joint pain, sore throat, chest pain, and di culty of breathing were low, and the other symptoms, including severe breathing problems, heart symptoms, and loss of movement were very low among the respondents during the infection time. See also the responses 3-6 months after the COVID 19 infection. Regarding the respondent's emotions during the COVID 19 infection, the worry was high; frustration, sadness, stress, loneliness, and boredom were moderate; depression was low; anger was very low (Fig. 2). See also the responses 3-6 months after the COVID 19 infection.
About the social status, isolation and spending a hard time were reported moderately, while the other items were low to very low (Fig. 3). See also the responses 3-6 months after the COVID 19 infection.
Regarding daily activities, respondents reported watching TV and praying moderately, while the other activities were low to very low. Some activities such as smoking and drinking alcohol were not reported at all (Fig. 4). See also the responses 3-6 months after the COVID 19 infection.
The in uence of COVID 19 on the respondent's self-esteem was low to very low, as presented in Fig. 5. See also the responses 3-6 months after the COVID 19 infection.

Inferential Statistics
This study ended with two data sets; one data set presents the means and standard deviations for all variables, including the physical symptoms, emotions, social status, daily activities, and self-esteem during the COVID 19 infection and the second set presents the same variables 3-6 months after the infection. Table 3 presents the means and standard deviations of all variables (scales) before and 3-6 months after the infection. As the sample of the study is less than 30, the normality test, speci cally the Shapiro-Wilk test that is more appropriate when the sample size is less than 50, is a prerequisite before going further. If the sample is normally distributed, then the paired t-test could be used for the comparative analysis. Otherwise, the paired samples Wilcoxon test could be an alternative. To test the normality, the two data sets, which presents the total scores of all variables for each participant during and 3-6 months after the infection, are reduced to one new data set by subtracting the second data set from the rst one. Then, the new data set is analyzed to nd the results of the Shapiro-Wilk tests (Table 4). In reference to the above table, the Sig. value of the Shapiro-Wilk test is .145 (> 0.05), which indicates that the data is very close to the normal distribution. Accordingly, the authors conducted the comparative analysis using the paired ttest, which usually measures the difference between two variables for the same sample separated by time.
The SPSS software also performs correlation analysis when comparing two sets of data for the same variables to nd how strongly the two variables are associated with one another. Table 5 presents a moderate positive correlation between all pairs.  Furthermore, Table 6 shows that the t-value and p-value for the pair of variables as follows: the physical symptoms (4.68, 0.00), emotions (7.37, 0.00), social status (6.86, 0.00), daily activities (2.66, 0.015), and self-esteem (3.40, 0.003). The results re ect a reduction of all means of the second data set, which re ects improvements in the nurse's conditions after 3-6 months after the COVID 19 infection except the daily activities, which increased in 3-6 months after the infection due to increasing of some activities, such as walking, exercises, and staying with family.

Analysis of the Qualitative Part
The authors conducted semi-structured interviews with a sample of 5 nurses who infected with the COVID 19 virus to explore their experience and main concerns during the infection time and after that, and explore the effect of the COVID 19 infection on their attitude, including emotions, beliefs, and behaviours toward a particular thing and future goals. The authors interviewed 5 nurses and stooped after reaching the state of data saturation.
The nurses like other people expressed tough experiences during the COVID 19 infection time. However, they mostly suffered psychologically. For example, one nurse expressed psychological stress when she saw her husband suffering to manage the house, shopping, taking care of 5 children, including food and schools. Another nurse stressed as she tried to avoid breastfeeding and care of her new-born baby; she said that my baby also got the infection from me. A third nurse said that "my fear was great since I was one of the rst people contacted COVID 19 infection and no certain information was known about the disease at that time" and a fourth nurse said that "I was psychologically destroyed and terri ed, it's a challenge to suffer the extreme symptoms of the infection and at the same time worried about the kids in which you are helpless and can do nothing".
On the other hand, three nurses reported a perceived stigma; one nurse said "I felt the social stigma, and as a nurse, the stigma against me was stronger". Another nurse said "I felt the stigma, people were afraid to contact us to avoid the infection" and she also added that "I was worried about not be accepted between my colleagues at work and also between my friends in the community even after I tested negative". Furthermore, a nurse suffered from stigma at home; she said "I felt a stigma in my house and between my immediate family members, and my co-workers avoided me after recovery as I had bad cough".
Two nurses reported suffering from physical symptoms. Three nurses con rmed receiving support from managers, and Abu Dhabi Health Services Company (SEHA). Also, one nurse received support from some people who had been infected with the virus before and they shared their experiences and knowledge about the disease, how to manage symptoms with her.
Regarding lessons learned and future goals, one nurse pointed out that nurses should be careful and take COVID 19 seriously by adhering to all policies and procedures. Another said she bene ted from the isolation to think about her life and review her objectives and plans. Another nurse also said she thinks more about herself and the family. Two nurses did not address any impact of the COVID 19 infection period on their future goals. Lastly, one nurse pointed out that "inside me, I was enlightened that I have the power, the courage to beat COVID 19 infection. My beliefs, deep spiritual strengths, family support, and prayers helped me to cope with COVID 19 infection, and another nurse blamed herself for being infected.

Discussion
During the COVID 19 crisis, nurses had in some situations two roles; rst health care providers and secondly, patients infected with COVID 19 virus. Accordingly, their experiences could be unique and rich. Therefore, this study aimed to determine the immediate and short-term physical, psychological, and social impact of COVID 19 infection on nurses and midwives retrospectively and nd the effect of COVID 19 stigma on the self-esteem of the infected nurses.
In general, the majority of respondents rated most of the items in the physical, emotional, social, daily activities, and self-esteem scales very low, low, or moderate during the infection time. The symptoms improved signi cantly in 3-6 months after the infection. The results of the paired t-test con rmed a reduction of the means of the second data set of the physical, emotional, social, and self-esteem scales. Although the reduction in the mean of the second data set of the daily activities scale was insigni cant, the authors still consider that a signi cant improvement in the symptoms as the second mean of the daily activities affected by contradicting effects of the increased level of some healthy activities, such as walking, exercises, and staying with family against unhealthy daily activities such as oversleeping, insomnia, and loss of appetite.
The results of the qualitative part of the study aimed to shed light on the result of the quantitative part. The nurses expressed that they suffered emotionally due to the separation from the family members, concerns about their safety, and inability to do their role as mothers toward their children. Also, the nurses felt stigma against them from people, colleagues, and some family members due to being infected with COVID 19 virus. However, the stigma did not affect signi cantly the items of the self-esteem scale. Thus, the stigma was not a concern among Tawam hospital infected nurses. On the other hand, the nurses highlighted some lessons they learned during the infection time, such as being careful and adhering to all safety and protection policies and procedures, reviewing life objectives and plans, and focusing more on self and the family.
The study identi ed several factors that could be interacted to give positive outcomes in people infected with COVID 19 virus. Those factors included high self-e cacy, which was identi ed by Ramaci, Barattucci, Ledda, and Rapisarda (2020), as a factor that could lead to less fatigue and burnout, and more satisfaction amongst health care workers during COVID 19 crisis. The self-e cacy is re ected by using more positive coping mechanisms, such as praying, watching TV, staying with family, and practicing hobbies, and using less negative coping mechanisms, such as oversleeping, insomnia, smoking, or drinking alcohol. Furthermore, nursing knowledge and skills were an important factor in dealing with COVID 19 symptoms. On the other hand, psychological support from managers, families, and colleagues, as well as the high standards of care and treatment provided in UAE to patients infected with the COVID 19 virus, either in hospitals or at homes, are key factors for achieving such outcomes.

Recommendation
We encourage governments to adopt the above-suggested model for all patients infected with COVID 19 virus. This model could be useful, especially for those who cannot provide enough beds to patients. This could be achieved by introducing this model to the communities, providing enough teaching about the required nursing care, and assign special telephone numbers to answer patient's concerns, and give them directions.
Al last, the authors believe that nurse's experiences are unique and rich. Therefore, the authors encourage conducting more quantitative and qualitative researches to explore these experiences.

Conclusion
The No personal identifying information was collected for the patients, both subject privacy and patient data con dentiality was strictly adhered to in accordance with the international and national guidelines.
Availability of data and material: The raw data generated and/or analysed during the current study ae not publicly available due to the institution policy to code and archive data in a central repository of the hospital, but data are available from the corresponding author on reasonable request by the editor.  Figure 1 Description of the physical symptoms among participants during and 3-6 months after the COVID 19 infection.

Figure 2
Description of the emotions among participants during and 3-6 months after the COVID 19 infection.

Figure 3
Description of the social status of participants during and 3-6 months after the COVID 19 infection.

Figure 4
Description of the daily activities of participants during and 3-6 months after the COVID 19 infection.

Figure 5
Description of the self-esteem of participants during and 3-6 months after the COVID 19 infection.