DOI: https://doi.org/10.21203/rs.3.rs-2335250/v1
Healthcare professionals around the globe suffered a lot during the COVID-19 pandemic. The present study aims to explore the lived experiences of nurses caring for COVID-19 patients in Pakistan.
The study is qualitative in nature to explore the lived experiences caring for the patients with Covid-19 in Pakistan. This research was conducted in two government hospitals of Pakistan. Face to face in-depth interviews were conducted among 30 nurses who were selected for face-to-face in-depth interviews by using purposive sampling technique. Thematic analysis was applied to extract the themes out respondent’s answers.
By using the thematic analysis, social response, impact on physical and mental health, and experience of handling COVID-19 patients were extracted as major themes.
The findings of this research are of immense importance to show the impact of COVID-19 on mental and physical health, along with social and personal consequences of nurses who provide care to COVID-19 patients.
Healthcare professionals around the globe suffered a lot during the COVID-19 pandemic [1, 2]. They suffered not only from mental effects such as anxiety [3, 4], depression [5], anger [6] and exhaustion [7], but also faced social and economic problems [8, 9]. Nurses are a significant part of healthcare delivery, also because of their devotion to work and the quantity of time they spend while providing care to COVID-19 patients [10]. Nurses have played a tremendous role not only in caring for COVID-19 patients, but also in curtailing the pandemic [11, 12]. Healthcare providers, especially nurses, who are working in the frontline have worthy experiences of handling and caring COVID-19 patients [13, 14]. In Pakistan, since a longer period of time, it a common norm the majority of the nurses are females [15, 16]. The common career choice among females is nursing [17, 18]. The most importantly, female nurses played a very significant in effectively managing COVID-19. To gain an insight and in-depth information regarding lived experiences of nurses working with the patients of COVID-19, the present study aimed an exploratory analysis to answer the questions like, how nurses managed the situation (psychosocially)? How community and their social circle respond them and how the handled the contagious disease?
The main reason behind conducting this research was to explore what sort of problems and issues nurses who were providing care to COVID-19 patients were confronted with. Lived experiences are basically explored and understood through qualitative research. Lived experiences are, in fact, a representation and understanding of a researcher related to human choices, experiences, and options and provide insights how all these factors impact individual’s perception of knowledge [19]. According to Honey et al. [20], study designs investigating lived experiences try to answer questions on “How?”, “What?”, and “Why?”. Therefore, the meaning or theory can be extracted from the context in which people lived the phenomenon [21]. This study was specifically designed to inquire about the lived experiences of nurses who provided care to COVID-19 patients in two government hospitals of Pakistan.
This study was conducted in the two government hospitals of Islamabad and Rawalpindi. Both cities were among the hardest-hit districts in the second and third wave of the COVID-19 pandemic in Pakistan.
We adopted a purposive sampling technique while conducting this study. Participants were selected in terms of the inclusion criteria: Information was collected from those female nurses who worked in specially allotted treatment and isolation centers for COVID-19 patients and cared for them. The sample size was not fixed a priori; instead, sampling could be continued until the data saturation point was reached. Prior to the interview, approval was taken from the hospital’s concerned authorities for conducting the research and participants’ informed consent was also taken. Despite heavy workload, a total of 30 nurses participated in this study. They were informed about the reason and significance of the investigation and their written consent for participation was taken.
Qualitative data was collected with the help of an interview guide. Face-to-face interviews were conducted in order to acquire the desired data from the participants.
The study received an ethical approval by the Institutional Ethical Review Board of Shaheed Zulfikar Ali Bhutto Institute of Science and Technology, Islamabad, Pakistan (Ref. No. IERB(7)/SZABIST-ISL(SS)/1890102/200175).
The procedure used to analyze data was thematic analysis, which is one of the most frequently used procedures of analyzing data in the domain of qualitative research. Thematic analysis is performed through coding the acquired dataset in six different steps in order to create sub-themes and themes. All six phases are important and come in sequence; each phase builds on the previous one [22]. These six phases applied in this study are the following:
1) Familiarization with the data (transcription of data)
The collected data was first transcribed into written form because it was collected through face-to-face interviews. Moreover, this phase involved reading and re-reading of the entire transcribed data.
2) Generating initial codes
On the basis of all the important features of the data, we generated codes by keeping in view their relevance to the research question. Coding was done on the entire dataset. All relevant codes were kept for further stages of data analysis by extracting the unnecessary ones.
3) Generating themes
This phase was highly important because the extracted codes were investigated. Major, significant and broader sub-themes and themes were generated on the basis of these codes.
4) Reviewing themes
Themes were reviewed to ensure authenticity and proper utilization according to the data. We also checked, whether the themes answered the research question and in how far they were relevant to the generated codes. Moreover, proposed theories were reviewed in accordance to their support of the refined themes, which led to few changes in the generated themes.
5) Defining and naming themes
Themes were defined and named accordingly. Scope and focus of each theme were kept in consideration.
6) Producing the final report
After defining and reviewing the themes we weaved together the analytical narrative. The final report was written after conducting the analysis of the entire findings in relation to the existing literature.
The characteristics of the respondents are presented in the Table 1. Almost all respondents in the sample belong to the age group 25–35 years. The minimum age was 25 years and the maximum 55 years. Nurses had an experience of providing healthcare services from one to eight years, with one respondent having even 30 years of experience. The majority of nurses were married and living in nuclear families. All of them were female and performed their duties for COVID-19 patients for one to four months.
| ID | Age (in years) | Marital status | Designation | Family type | Shift | Work experience (in years) | COVID-19 duty duration (in months) |
|---|---|---|---|---|---|---|---|
| P1 | 30 | Married | Nurse | Nuclear | Morning | 4 | 2 |
| P2 | 27 | Unmarried | Nurse | Nuclear | Morning | 2 | 3 |
| P3 | 30 | Married | Nurse | Nuclear | Morning | 5 | 2 |
| P4 | 26 | Unmarried | Nurse | Nuclear | Morning | 1 | 1 |
| P5 | 30 | Married | Nurse | Nuclear | Morning | 5 | 4 |
| P6 | 28 | Married | Nurse | Nuclear | Morning | 3 | 3 |
| P7 | 26 | Unmarried | Nurse | Nuclear | Evening | 1 | 1 |
| P8 | 27 | Unmarried | Nurse | Nuclear | Morning | 2 | 2 |
| P9 | 28 | Married | Nurse | Nuclear | Morning | 3 | 2 |
| P10 | 28 | Unmarried | Nurse | Joint | Morning | 3 | 3 |
| P11 | 27 | Unmarried | Nurse | Joint | Evening | 2 | 2 |
| P12 | 27 | Unmarried | Nurse | Nuclear | Morning | 2 | 2 |
| P13 | 55 | Married | Head nurse | Joint | Morning | 30 | 1 |
| P14 | 30 | Married | Nurse | Nuclear | Morning | 5 | 4 |
| P15 | 26 | Married | Nurse | Joint | Morning | 1 | 1 |
| P16 | 34 | Married | Nurse | Joint | Morning | 7 | 1 |
| P17 | 30 | Married | Nurse | Joint | Morning | 5 | 5 |
| P18 | 25 | Unmarried | Nurse | Nuclear | Evening | 1 | 1 |
| P19 | 26 | Unmarried | Nurse | Nuclear | Morning | 1 | 1 |
| P20 | 28 | Unmarried | Nurse | Nuclear | Evening | 2 | 2 |
| P21 | 28 | Unmarried | Nurse | Nuclear | Evening | 2 | 2 |
| P22 | 32 | Married | Nurse | Nuclear | Morning | 6 | 1 |
| P23 | 32 | Married | Nurse | Nuclear | Morning | 6 | 2 |
| P24 | 30 | Married | Nurse | Nuclear | Morning | 5 | 2 |
| P25 | 30 | Married | Nurse | Nuclear | Morning | 5 | 1 |
| P26 | 30 | Married | Nurse | Nuclear | Evening | 5 | 1 |
| P27 | 36 | Married | Nurse | Nuclear | Morning | 8 | 2 |
| P28 | 35 | Married | Nurse | Nuclear | Morning | 8 | 2 |
| P29 | 32 | Married | Nurse | Nuclear | Morning | 6 | 2 |
| P30 | 30 | Married | Nurse | Nuclear | Evening | 5 | 1 |
The themes and sub-themes extracted while applying thematic analysis are presented in Table 2 and described in the following.
| Themes | Sub-themes | Codes |
|---|---|---|
| Social response | Strong support system Strong social bonding | Family support, appreciation by the society, encouraging attitude, supportive spouse, cooperative colleagues, motivation |
| Impact on mental health | Fear Anxiety Depression | In the beginning, anxiety, depressive thoughts, fear of the disease, stress of carrying germs of the disease (family concern) |
| Impact on physical health | COVID-19 positive Fatigue Breathing issues | Fatigue, weakness, increased workload, sleeplessness, fever, difficulty in breathing, lack of appetite |
| Experience of handling contagious diseases | Professional requirements Serving the humanity | Professional requirement, sympathetic attitude, honest to duty, sense of serving the humanity, proud to be a nurse |
The most important component of this study was to inquire the respondents about the responses of the society, friends and family towards them during this pandemic. Healthcare workers suffered the most from the COVID-19 pandemic because they sacrificed their personal lives and responsibilities, own health and preferences to serve the masses and to be available for handling patients with COVID-19 during this pandemic. The responses of the nurses who participated in this research regarding social response and attitudes towards them are discussed in further two sub themes, which relate to a strong support system and strong social bonding.
This study aimed to explore how people react towards nurses when they knew that these nurses are consecutively exposed to a contagious disease. The majority had positive experiences regarding societal response towards them, despite different impacts of the pandemic on individuals:
“I tested positive with COVID-19, home quarantined for one month, during all this my family supported me a lot. Now I am performing my duty with the full-time support and assistance of my family. My family is side by side with me. They did not leave me alone in this battle to fight with. We still cannot overcome the crisis and win this battle without constant support of our families.” (P13)
“I was pregnant last year and tested positive with COVID-19. Although it could be unmanageable for me to handle the situation but, I must say, my husband, in-laws and all my family supported me a lot. So, I managed everything well and fulfilled all my personal responsibilities with the support of my husband. Even at work my fellow nurses and all other staff helped me to manage my things while I was on duty in COVID-19 units.” (P16)
The responses of the participant nurses clearly indicate that they received full support from family members when they were performing tough duties in the hospital. Nurses mentioned that it was not an easy thing to manage their responsibilities during the worst crisis of their career. Not only their family members encouraged them, but their colleagues also proved to be a great source of assistance and support to handle the unforeseen situations.
Although the situation might differ compared to other countries or even to nurses from other hospitals, we explored from the experiences of the study participants that they had a strong support system and strong social bonding. The spouses of married nurses supported them to manage their duties and it happened because of their strong bonding. However, there were some people who avoided interacting with them, but it was all because of the fear of contracting the virus. Respondents of the study were also concerned about the health, protection and safety of their family members. Therefore, they tried not to visit them for a longer period of time:
“I myself avoided frequent social interaction in order to keep people safe if I carry the virus. My husband helped me a lot to remain honest with my profession. On both sides I had my own people to care for.” (P14)
Participants mentioned that they received support from the hospital to be able to limit social interactions:
“I received full cooperation while I was serving in COVID-19 intensive care unit. I stayed in a nursing hostel to limit my interaction with people just to keep them safe. I avoided visiting my family for a long time. […] When I am on duty in Corona units, I prefer to stay in a nursing hostel because I assume it is better for my family.” (P21)
Any stressful situation impacts on mental health and well-being. This has been particularly visible during the COVID-19 pandemic. All participants of this study took maximum safety measures while interacting with their families and other people around them. There was little known about the disease/virus in the beginning so that ambiguity caused initial upset and stress among them, but later on they managed to cope with the situation. However, the early situation impacted their mental health and they faced some psychological problems such as fear, anxiety and depression to manage.
Nurses were fearful of COVID-19, particularly in the initial stages of the pandemic. Mostly, nurses were more concerned about their families than themselves, because they tried to avoid contracting the disease and transferring it to their children and other family members:
“If I say that I wasn’t fearful of the disease, I must be lying to you. Yes, I had fears.” (P17)
“Being an active participant of the medical field and exposed to COVID-19 patients, I didn’t want to become a source of transmitting the disease to my family and other people around me.” (P26)
Fear was common among many respondents in the very beginning of the pandemic.
“Initially, I was concerned about my performance and I literally wanted to overcome my fear because I didn’t want to compromise on my duties.” (P28)
“Sometime when I had symptoms of normal fever, I thought what happen if I test positive for this disease? Who would take care of my kids even if I die?” (P27)
The responses of the nurse clearly indicate that they experience fear while performing their duties in the initial stages of the pandemic. These fears might have badly impacted their mental health. Nurses had gone through such experiences in the very beginning of the outbreak of COVID-19 when there was uncertainty and ambiguity. Later on, they not only controlled their own fear but also helped and guided others to behave properly.
From the experiences of nurses, it is revealed that they were aware of the impacts of their mental condition on their job and quality of care they provided to the patients. Furthermore, they were fully aware and understood the severity of these conditions while they were handling COVID-19 patients.
Respondents described various factors behind their anxiety and stressful conditions, including restless routine, haziness about the treatment and nature of the disease (at initial stages), severity of the disease, stress for the event of a grievous circumstances, and overall a restless and questioning environment. There was an initial feeling of sudden emergency and consecutive stress of an unfortunate environment. The majority of nurses narrated that they faced anxiety because in the initial stages of the outbreak there was no clarity of the existence and treatment of the disease even among healthcare providers:
“We didn’t know much about the disease. How could we stay calm while witnessing people dying with corona virus when the cases were on their peak in the country… Even the attendants of patients were unable to bid them last farewell. It was so heart wrenching and emotional thing to see and pay focus on performing our duties.” (P 18)
“I won’t deny the fact that I was panicked… I used to get panic… I still remember… Although, we see people dying every day, the situation in the case of the corona virus was entirely different. People should not treat it as a joke.” (P4)
It was highly difficult for the nurses to see people dying without having their loved ones with them in their last moment. Witnessing these worse situations made nurses emotional and more empathetic towards their COVID-19 patients:
“We are used to handle situations of emergency. However, this pandemic made us experience many worst things. We see people dying of it and their loved ones cannot be with them! It is difficult to handle such emotional situations sometimes.” (P21)
COVID-19 has changed the lifestyle of many people. When nurses were asked to explain the situation of the pandemic, they frequently managed the psychological impact and their experiences related to it. Nurses, more specifically married ones, were quite worried about their kids. They did not want to bring them an undesirable situation:
“My family was my biggest concern and I did not want to become the cause of their pain if they might get the disease. Even now, every time when I go home, I don’t interact with my family unless I change my uniform, take proper bath and proper sanitization.” (P20)
“Being a mother, I had so much to do for my kids and I thought what will happen if I die soon. These thoughts were enough to put me under depression. I have little kids to look after. I cannot rely on anyone in this matter. This was my biggest worry while handling patients in COVID-19 special units.” (P30)
The experiences of nurses handling patients with a contagious disease have highlighted the impacts of this ongoing pandemic on their lives, responsibilities and mental wellbeing.
Nurses are frequently called as “Superheroes” or “Life Savers” by the public as a result of the tasks they have successfully fulfilled during the COVID-19 pandemic. Appreciation by the people added much worth and appeasement in the healthcare professions. However, at the same time, it put more pressure on healthcare workers, by leaving no chance of mistake from their end. Furthermore, fulfilling the tasks puts pressure on them and negatively impacts on their physical health.
In the case of Pakistan, many healthcare workers sacrificed their lives while handling COVID-19 patients. All respondents of this study performed their duties in specially allocated COVID-19 units. A few nurses even got COVID-19 positive themselves. Responses of the nurses related to their contraction of the disease are described below:
“I was tested positive with Corona virus last year and home quarantined myself for 15 days. I not only recovered from it but I am absolutely fine. Although I belong to the upper age group, still I don’t have major complications after contracting the virus – except for a few ones.” (P13)
“I tested positive last year while I was pregnant and I was really upset about how to manage this toughest routine while expecting a baby.” (P16)
Furthermore, the study participants also mentioned that a few of their staff members sacrificed their lives in the line of duty.
When nurses were asked about the impact of COVID-19 on their physical health, almost all of them spoke on it and narrated their experiences related. The pandemic has altered the life of every individual. Due to heavy workload and excessive precautionary measures to handle the patients along with standardized operating procedures (SOPs), the lives of nurses also got hectic: They had to wear protective gears (like face masks, gloves, protective gowns), sanitization of everything was necessary, and nurses had to change their dress everyday as soon as they reached their hostels or homes. Initially, nurses had to perform excessive work that became a cause of their sleeplessness. Heavy workload in hospitals and tough routines by following SOPs may lead to extreme fatigue. All nurses – particularly those who were infected with COVID-19 themselves – experienced weakness:
“I felt extreme weakness and fatigue while I was performing my duties in COVID-19 wards.” (P30)
“I did not focus on my diet while I was serving in a COVID-19 unit. That was also the reason behind my weakness. Actually, because of extensive sanitization and safety protocols, I got so much exhausted and had no desire to do anything but relax.” (P29)
Furthermore, study participants mentioned that due to the work burden they could not focus on their own health and had fatigue. Carrying personal protective equipment enhanced their work and made them exhausted:
“Although I was not fearful, but yes… I had fatigue while I was serving in COVID-19 units because of following SOPs and excessive precautionary measures which is even today mandatory to follow by every nurse who handles patients with COVID-19 in the hospital. Moreover, I do not take proper care of me, but now I realized that self-care is highly important in order to handle this situation. Otherwise, I would be of no use. And I don’t want that to happen.” (P2)
In fact, the respondent nurses mentioned that excessive protective measures and adopting COVID-19 SOPs increased their work. Body fatigue was normal in emergencies, but the prolonged duration of COVID-19 actually brought negative impacts on the health of nurses:
“Body fatigue is a normal thing for us in situations of emergencies and workload. But this time it was a mental fatigue as well. Initial uncertainty, misinformation and myths played a huge role in increasing our duty, because it took us a lot of energy and time to educate people that their lack of care could further spread the disease. Sometimes, even now it becomes really difficult to handle attendants of the patients in terms of following safety protocols and implementing social distancing.” (P10)
When nurses were asked about their experience of handling patients with a contagious disease like COVID-19, two themes emerged from data which relate to professional requirements and (nurses’) intensions to serve the humanity.
All study respondents had experiences of handling contagious diseases caused e.g. by the Human Immunodeficiency Virus (HIV), Hepatitis (A, B and C), dengue and then most importantly COVID-19:
“We became used to this situation because it is our profession. For me, my profession is more than anything else. I have no regrets to join this. At least I am satisfied with what I am doing.” (P4)
The participants of this study highlighted the fact that they encountered initial fear because of the uncertainty and misconceptions about the virus. But, later on, they became familiar with the situation and took it as their professional responsibility:
“We came in this profession to serve people. I even handled patients who were suffering from AIDS and cancer in my entire career. I have seen the pain and misery of people. However, this time it was not only for us, but the entire world was battling hard with it. Even though few countries have got some hold on it. But we can clearly see the all-time worst situation of Corona virus in India. It is a requirement of our profession and we are always here to serve in any situation.” (P13)
“Even having suffered from this COVID-19 pandemic by myself I am still motivated and good to perform my duty without any fear.” (P13)
Nurses showed that they were motivated to cope with the crisis because it was their duty to do it:
“Yes, when there is some uncertainty about the disease like this pandemic in the very beginning we had some fearful thoughts, but we know that it is our profession and we have to do our job no matter what happens.” (P25)
The nurses were motivated to manage their work and family life along with battling COVID-19 in the frontline.
Nurses join this profession by knowing its hardness and in case of pandemics and emergencies they know that they have to work wholeheartedly and provide their serves to the public. Almost all nurses responded that no matter how fearful and restless they get in the beginning of any emergency, they have to work to manage themselves and overcome their fear to serve the people in need of care:
“We took oath to serve humanity so we know it is the requirement of our profession and we came into this profession by knowing the severity and demands of it. Neither we can run away from this situation nor should we!” (P24)
The nurses participating in this study were all ready to serve humanity. They were passionate to work during the pandemic and motivated enough to beat it:
“I was not at all fearful. Not even in the beginning of the pandemic in Pakistan. I worked in COVID-19 special units. My only concern was the pain and misery of the people who were dying of it. I was very sympathetic towards them. I do my best to serve my people. Even if I have to devote my entire life to serve humanity, I would literally love to do that! It might be surprising for you but, I am like this. I feel the pain of my patients.” (P2)
Irrespective of initial fear and anxiety, nurses were more concerned about their profession performance and providing their best services to the patient than anything else.
The present study has highlighted the experiences of nurses who cared for patients with COVID-19 in Pakistan. Nurses served wholeheartedly and with full devotion throughout the pandemic while standing in the frontline in terms of patient care, COVID-19 service handling, and management of the crisis. Nurses stood firmly against the pandemic and scarified their lives in the line of duty. They faced extreme workload due to the pandemic and have been through severe anxiety, mental and physical fatigue.
The findings of this research clearly show that nurses have gone through fear and anxiety at the beginning of the pandemic. In addition to this, consecutive exposure of healthcare workers to stressful situations like seeing the suffering and pain of patient who were dying with the disease amplified anxiety and fear [23].
It is evident in many studies that COVID-19 significantly affected the psychological and mental health of general population but more especially the nurse [24]. The frontline health providers, particularly nurses were more vulnerable to the mental health deterioration [25, 26]. As previous research of [27, 28] explored the fear among health care providers. It has also been seen by N Sakib, T Akter, F Zohra, A Bhuiyan, MA Mamun and MD Griffiths [29] that pandemic had significantly created fear and depression among health care workers, the study explored that the participants of this study also experienced the same (i.e. the fear of being quarantined, the fear of losing family and friends and more importantly the fear of being socially rejected or stigmatized) but at the same time, the participants experienced a strong social bonding and overwhelming social support from their family and community members.
Among all healthcare providers, nurses had most exposure and closest contact to patients. According to the statement of study participants, they were not much concerned about their own lives but their families were their main concern. Another main finding was that nursed did not want to compromise on the care they provided to their patients. This leads to adverse impacts on physical and mental health [30]. Therefore, nurses nead resilience to encounter the additional responsibilities and challenges going along with the COVID-19 pandemic [31]. Nurses showed extreme resilience and professionalism to tackle these difficulties.
Globally, it has been witnessed that healthcare professionals sacrifised their lives while fighting in the frontline against COVID-19 [32, 33]. One of the most important findings of this study was the willingness of nurses to serve humanity. Although they suffered from stress and sort of fear in the initial stages of the disease, they adapted themselves to the situation later on. Nurses experience a sense of accomplishment and felt better as soon as they accepted the situation. Despite all that difficulty and uncertainty, they were concerned about the health of their patients. This led to the attribution of being a “superhero” [34].
The research only focused on nurses who were providing care for patients with COVID-19 and the study area was limited to one hospital each in Islamabad and Rawalpindi. It was highly difficult to conduct the interviews because of the surge in cases of COVID-19 in Pakistan, more specifically in its third wave. The situation of the lockdown also put a barrier and limitation to initiate the data collection process. It took a lot of time and efforts just to conduct the interviews and collect data because the possibility of interaction with nurses was limited due to the workload and safety issues.
Globally, the COVID-19 pandemic put the entire healthcare systems under extreme burden. Healthcare professional were more prone to COVID-19, because they served in the frontline against this devastating pandemic and sacrificed their lives as well as developed several mental, physical and psychological issues. Social responses, impact of COVID-19 on mental as well as physical health, and the experiences of nurses of handling contagious diseases were the main themes of this research. During the COVID-19 pandemic, nurses performed tough duties. Intense working environment and workload can be a source of insomnia for healthcare professionals specially nurses. So, management of concerned hospitals should sort out such situations timely in order to prevent the core segment of medical field from becoming a prey to insomnia and professional stress. Safety and wellbeing of nurses should be given priority. The well-being of healthcare providers should be government’s most important priority because their well-being ensures their best performance at work.
COVID-19 Coronavirus disease 2019
SOP Standardized operating procedure
Ethics approval and consent to participate
The study received an ethical approval by the Institutional Ethical Review Board of Shaheed Zulfikar Ali Bhutto Institute of Science and Technology, Islamabad, Pakistan (Ref. No. IERB(7)/SZABIST-ISL(SS)/1890102/200175).
All procedures were taken in respect of the Declaration of Helsinki. The study participants were informed about the reason and significance of the investigation and their written consent for participation was taken.
Consent for publication
Not applicable
Availability of data and materials
In this qualitative study, the raw data cannot be made publicly available for data safety reasons. However, data is available from corresponding author upon reasonable request.
Competing interests
The authors declare no conflict of interest. FF serves on the Editorial Board of BMC Public Health as Associate Editor.
Funding
This research received no supporting funds from any funding agency in the public, commercial, or not-for-profit sector.
Authors’ contributions
MA and MAuHR conceptualized the study. MA led the analysis, interpretation of the study findings, and manuscript writing. MAuHR contributed to data collection. MAuHR and FF revised the manuscript critically for important intellectual content. All authors read and approved the final version of the manuscript.
Acknowledgments
Not applicable.