Fear and Challenging behavior: A Phenomenological-Hermeneutic Study of people with public mass shooting attacks during the COVID-19 pandemic in Thailand

doi:10.21203/rs.3.rs-3884455/v1

Background Public mass shooting attacks during the COVID-19 pandemic have had a significant impact on victims. Understanding and realizing the biological, psychological, and social impact of the problem and the individual's needs may help the nurse design the nursing intervention to meet the individual needs of the victims, which can reduce mortality and disability rates.

Aim This phenomenological-hermeneutic study aims to describe and interpret the perspectives of people with public mass shooting attacks during the COVID-19 pandemic.

Methods Data were collected in dialogical conversations with 15 people who were involved in a mass shooting during the COVID-19 attack using a random sampling method: purposive sampling and snowball techniques. Analyze by using thematic analysis. The COREQ guidelines for reporting qualitative studies were performed.

Results A group of people who have been involved in a mass shooting during the COVID-19 outbreak revealed five main themes, which are fear, being in the same boat, impact, coping, and intervention.

Conclusion The fear and challenge behavior will have implications for health care providers, including prioritizing validating interactions and adopting a relational approach to practice.

COVID-19

Fear

Challenging behavior

Phenomenological-Hermeneutic

mass shooting attacks

Coping

Public mass shooting is a Global public health concern, and injuries are one of the top five leading causes of death for all ages. Moreover, the coronavirus disease 2019 (COVID-19) is a global public health emergency that started in 2020 [1]. Both have affected the global population, especially the health status, mental health state, risk perception, and coping strategies, and it was the sixth leading cause of public health emergencies worldwide [2, 3]. These situations were stressful life events for the people who participated. The impact was significant in physical, mental, and societal aspects at the individual, family, and global levels.

Public mass shooting attacks are a well-known and long-standing public health crisis in Thailand. COVID-19 and public mass shootings are global public health concerns and multifaceted ones. In Thailand, the Ministry of Mental Health set up the team Mental Health Crisis Assessment and Treatment to provide care for those victims a) comprising relatives of the deceased, the injured, relatives of the injured, and hostages; b), comprising those involved in the incident, including eyewitnesses such as traders/entrepreneurs who were present at the incident, those stranded at the scene, and officers who work on the job site; and c), involving general people who receive information on violence through various channels, such as people who may have been psychologically impacted from receiving information on social media. Public mass shootings, albeit unusual and uncommon in the country, caused 57 injuries and 29 deaths in Thailand in 2021 and have had a severe physical, mental, and economic impact on individuals and communities [4]. Moreover, in north-east Thailand, the ex-policeman killed at least 37 people, most children, in a gun and knife attack at a childcare center [5]. In recent events, a 14-year-old boy went on a shooting rampage inside the Siam Paragon shopping mall, killing two people and injuring five others — two of them critically [6]. Another event is a Palestinian gunman killed at least seven civilians in the Israeli settlement [7].

A public mass shooting is an event in which one or more individuals are “actively engaged in killing or attempting to kill people in a populated area as three or more people being killed in a single incident [8, 9] that impacts the daily lives and mental health of people in the Community and was a life-threatening, stressful event that affects lives of people [10].

Mass shootings result in widespread biological and psychological trauma and social for survivors and members of the affected Community. Knowledge of the broader effects of indirect exposure to mass shooting victims may give insight into the way to save people in the Community in the following events. Our focus in this study is on illuminating the lived experiences of participants in a public mass shooting during the COVID-19 Pandemic to design a supporting system of nursing intervention and the process of remaking a life in the provision of nursing care.

Aim of the Study

This study explores people's perceptions regarding mass shooting attacks during the COVID-19 pandemic.

Research question

What are people's experiences with public mass shooting attacks during the COVID-19 pandemic's experiences?

Ethics and consent

The study was approved by the Human Research Ethics Committee of Thammasat

University (Science), Thailand (COA No. 119/2563), in October 2020. The study's scope, risks, and benefits were explained to all participants. Before data collection, informed consent was obtained from all the participants. The author conducted a study following the guidelines and regulations such as declared by the Declaration of Helsinki. Participation was voluntary, and participant anonymity and confidentiality were ensured. The interview duration was determined based on the participants' desire, patience, and experience. Interview sessions were recorded by Microsoft Teams recording software, and the original video interviews were automatically permanently deleted from the Microsoft Teams system after a month. The transcription has been retained in the principal investigator's secure computer hard drive since the completion of the study. After three years, a secure deletion program for Windows called Secure Deletion Shredder Window 10 permanently deletes the files and folders only.

Design

This phenomenological-hermeneutic research [11] used narrative-based data collection procedures. Narrative-based data collection [12] allows researchers to grasp the human experience through listening and understanding and contributes to delivering care based on a recovery-oriented paradigm.

The Participants

The 16 participants were selected by purposive sampling. The inclusion criteria were people in the Nakorn Ratchasima province in Thailand who had experienced public mass shooting attacks during the COVID-19 pandemic and were willing to participate in the study. The exclusion criteria included stress or mental health problems, making informed consent and participation impossible. Individuals who refused to participate were excluded from this study, and no participant was excluded.

Procedures

The phenomenological-hermeneutic approach was operationalized through dialogical discussions as they allow for examining and interpreting nurses' lived experiences and perceptions in the age of mass shootings and the COVID-19 pandemic [11, 13, 14]. Dialogical conversations were conducted with participants who were in a vulnerable situation. During the interviews with the principal investigator, a checklist was used to help the author report essential aspects of the research team, study methods, study context, findings, analysis, and interpretations [15].

Data collection

Data were collected using a semi-structured individual interview guide [16] that was developed for this study in December 2020 to explore nurses' perceptions of mass shooting events during the COVID-19 pandemic. A Ph.D. holding female principal investigator—with more than 15 years of experience in psychiatric and mental health nursing—and research team members trained in the data collection processes conducted the interviews. The author contacted nurses in different health settings in Thailand's Nakorn Ratchasima province to obtain participants' contact details. The participants were contacted by phone and asked about their potential participation in the study. Information about assumptions and personal interests in the research topic was provided to the participants by the research team. Participants were then contacted during their day off. Written and verbal consent was obtained directly from the participants before the interview process. A semi-structured individual interview was conducted in the Thai language via Microsoft Teams, and Microsoft Teams recording software was used to record all the interviews. Only the interviewer and participant were present during the interviews. The sampling continued until data saturation, and the interviewer maintained a professional relationship with the participants. The duration of the interviews was between 20 and 60 minutes. The data were anonymized. Finally, the transcripts were returned to the participants for comment and correction.

Data analysis

Data analysis was conducted using the phenomenological-hermeneutic method [11], and a voice was given to the participants and their understanding of their experience. After the first readings, the authors constructed the narrative, condensed all the participants' experiences, and secured data anonymity. Then, general themes were constructed, named, and interpreted as overarching. Microsoft Excel Spreadsheet Software was used to create the transcription and conduct the analysis.

Trustworthiness of the study

The procedures to maximize trustworthiness to ensure the data trustworthiness of this study were reflexivity, member checking, and auditing. They were used on the parts of member reflections instead of traditional member checking and incorporating peer debriefing to ensure rigor in interpretative qualitative research. Validation of results and an opportunity for further elaboration of findings from participants in the co-construction of the phenomenon with the authors were feedback and reflections of the participants [17, 18]. The reflections were primarily incorporated upon completion of the study analysis. Phone contact and a Microsoft Teams discussion were conducted for a results summary. The peer debriefing process included data collection or analysis and aided in probing the thinking around the research process and analysis construction of knowledge through critical feedback that encouraged reflection upon and investigation of alternative interpretations emerging from the data [19, 20] as weekly during data collection and monthly during data analysis and interpretation. The trail of the audit was established as initial notes; step-by-step methods for recruitment, data collection, and analysis; annotated transcripts; tables of themes that developed; the final report; and all field notes [21, 22, 23].

1. Demographic data of the participants

The sample group of people who experienced mass shootings consisted of 15 people, almost all of them aged between 41–50 years, accounting for 46.67 percent, followed by those aged between 31–40 years, accounting for 26.66 percent, and most of them were female. Accounting for 66.67 percent and one in three have single status. Accounting for 33.33%, more than half of the sample graduated with a bachelor's degree. Accounting for 66.67%, almost half of the sample had a career. Serving as a government employee/state enterprise employee accounted for 40 percent, followed by trading or running a personal business and 26.67 percent, with almost half of the sample using civil service/state enterprise rights. Universal health insurance cards Account for the same 40 percent, followed by social security rights. Accounting for 20 percent, almost half of the sample had no chronic diseases. Representing 46.66%, 26.67% had congenital diseases such as depression, diabetes, and high blood pressure. Most of them lived with their mother and father, 66.67% and 60%, respectively (Table 1).

2. Main Themes

The results of in-depth interviews with groups that experienced mass shootings during the COVID-19 outbreak can be summarized in five main themes as follows:

Theme 1: Fear

Fear refers to a feeling or emotion resulting from the perception that something is a threat, which can be identified as the cause of fear and affect daily activities.

"I was terrified." "Frightened, afraid, not prepared at all. I went to work as usual, but this happened. Well, I went to see the doctor at the hospital. He told me not to be afraid. He always consoled me. Coincidentally, we were lucky in one way. Find someone to trust and ventilate to relieve fear" (Cl.MS 1)

"I did not think there would be any severe events happening there. At that time, I was frightened, fear, and so scared. I want to go home" (Cl.MS 2).

"We have never met. Why does it happen? Many people have died easily during the days when there should not have been such an event. I do not know what it is." (Cl.MS 7)

"I was shocked, but the place was a 10x10 room, and they had a steel ball. I hear gunshots. I thought I had to do something, so I went to take down both wheels and lock the room. He held the gun and walked past the room where we were hiding. I feel severe fear and terrible" (Cl.MS 6)

We still have fear. However, I do not want to express much. Try to be patient. I have to survive no matter what. It gets better. I felt reassured that my father and mother were still beside me. These reduce our fear" (Cl.MS 2)

Theme 2: Be in the same boat

Being in the same boat means being in an unavoidable shooting situation.

"As soon as I heard the gunshot, I ran to the women's restroom. There is also a maid. She took the key to lock it. There were more than 20 people here, including children. They feared the children would cry and the culprit would walk up. Our luck was that he did not come to the 2nd floor. At first, the culprit would livestream where he was right now. At that time, they signed out of Facebook and stopped live streaming. I never thought I would encounter a situation like this" (Cl.MS 1)

"My husband ran into the mall. I called him because I was in the bathroom when the incident happened. I opened the bathroom door and met him. So I hid in the bathroom and felt like it was okay. Our lives are safe" (Cl.MS 2)

"We communicate via the Line application. Ask if you are hungry or anything. If you are thirsty, turn on the tap water and drink it. My cell phone's battery will run out, and the housekeeper was charged it and turn on silent mode, check the news, tell the worried kids, and tell them they do not have to listen to the outside news. The more we listen, the more it hurts us. Because people outside do not know what is going on inside. Anyway, we have to escape from here and encourage each other" (Cl.MS 2)

"Why do we have to be in this kind of situation? Were we surviving or dying? When I was depressed, I had a severe depression; I did not want to live. However, when we encountered this incident, it made me see many truths: I don't want to die. When I was in the bathroom, the person who worried about me was my husband. He was afraid that I would fall out because of depression. Now, I realize that 21 people are living together in that room. Everyone has a family and a future as well. "There are good friends, and we are be in the same boat. (Cl.MS 4)

"Around 5 p.m., a gunshot was heard. I thought it was a funeral at the temple that set off fireworks and firecrackers. After that, the noise increased by another 2–3 shots—people running in front of the street where the person died by gunshot. The police officer shouted, "Everyone runs away...now there is a shooting incident". I did not know which way to run. Some people are still shopping, still walking, they only see us running. The security guards said everyone was prohibited from running out of this door and should hide inside the mall. So, we went up as high as possible. There is an intersection leading to the parking lot. There were 4 of us. She said the parking was not safe. If the shopping section has four floors and stops on the 2nd floor because the escalator stops there and we want to run up, then do not take it and try it. I hid in the bathroom on the 2nd floor for almost 5 hours. There were about 20 people, and the terminal bathroom was quite large. We started to feel that it was time to relax, and we came to sit together. Listen to the situation from outside and contact the police outside. The mobile battery will run out. Then, one older person turned it on social media and let everyone see it. At that moment, I was in shock. There had been a shooting incident, and they had already shot and killed many people. The shooter is a soldier;

that moment made my heart flutter. Will I survive? After a while, there was a gas canister shot. Furthermore, they sent news to each other and kept staying here. Whoever is there stays there, and there is a power outage, and the air conditioner is cut off. If a shopping mall explodes, they probably will not survive. The gunman shot a gas tank, and a fire broke out in front of the mall" (Cl.MS. 7).

"I thought finding my boyfriend. Finally, we met and hid together" (Cl.MS. 11).

Theme 3: Impact

Impact refers to anything that results from a shooting incident that results in the victims' daily lives being changed physically, mentally, socially, and economically.

"When I sleep, I am frightened when I hear something. I cannot sleep. It is a flashback, and I always hear a gun sound" (Cl.MS. 1).

"I cannot go to Foodland alone. I must go with friends. I was dizzy. The smell of blood was overwhelming. I was an employee who had a house next to the terminal" (Cl.MS. 1)

"After the incident occurred around February, the sound sounded like a bang; It startled all the time" (Cl.MS. 6)

Theme 4: Coping

Coping refers to how people who experience a mass shooting situation choose to use coping methods and problems in various forms to deal with things that control themselves to a balanced level.

"I do not sleep well. When I sleep, I am frightened. I woke up and went into the garden to do some embossing. Being close to brothers and sisters is better" (Cl.M S.1)

"Watch movies, reduce your media consumption. Breathe in and out. Know your consciousness" (Cl.MS. 2)

"Exercise, watch movies, listen to music, watch series" (Cl.MS. 6)

Theme 5: Assistance from Healthcare provider (Intervention)

Assistance from Healthcare providers refers to various activities in which shooting victims receive assistance from the health team, including physical, mental, social, and economic assistance.

"The team from the hospital took us to do activities. Draw a picture you like in your imagination and ask why you drew it. Then, draw again. How did you feel when the incident happened at the terminal? And after the incident, how do you feel? Let us explain it in pictures. Then he would ask us why it was like this. Choose one musical instrument to sit in a group, depending on what you're getting. Then he will have you tap in rhythm." (Cl.MS.1)

"About a week after the incident happened, MCat Teams went to ask for information and provide an activity, which is to sit in a group and do the activity of writing down our feelings. What we want" (Cl.M S.6)

" I went to the hospital to consult with what to do. The doctor recommended it and got some medicine as well. The medicine was similar. It makes us sleep well. Just take seven pills. Small pills. If not, don't take them. I cannot remember the doctor's name. It has been many months since the incident." (Cl.M S.1)

"Encouragement from colleagues and also groups from the network of monks that we work with Most will have support from their families" (Cl.MS. 7)

"The medical team that day, I thought that the medical personnel of Maharaj Hospital in this province were already burdened with a heavy burden. Both the military and police units that came to help him were shot and injured. Furthermore, other people were injured. He provided full service there. I do not want him to help me. Let him help those who are hurt more than us" (Cl.MS. 2)

The present study showed that the experience of people with public mass shooting attacks during the COVID-19 pandemic in Thailand was associated with a variety of experiences. An analysis of the experiences revealed five main themes: fear, being in the same boat, impact, coping, and intervention. This section discusses these themes:

The participants felt fear, were very afraid and frightened, and were utterly unprepared. I did not think there would be a serious incident. This feeling is consistent with the studies [10, 25] that found that survivors of mass shooting attacks are more likely to be in shock. Moreover, The group of victims had adverse effects from the shooting incident, such as sleeping in fear and not daring to go to the mall again. If the victims talk about shooting events, the flashback occurs again and again, which is related to the incident after a shooting, and victims will experience déjà vu [26]. The participants are easily startled, and loud noises, such as bangs, interfere with them. People shouting and talking always startled the participants. This result is consistent with many studies, which found that survivors of mass shootings are more likely to be sensitive, easily startled, insecure, and shocked [10, 24].

The participants felt they were in the same boat because they all were in the event of a mass shooting and all impacted together. This situation is supported by the study of the participants, who felt that impact is a big deal and happens physically, mentally, and socially. In an extensive systematic review, along with the exposure to stressors that people are life event, evidence shows that people are at risk of psychological effects such as stress, anxiety, sleep disturbances, maladjustments, relationship issues, uncertainty, psychological distress and clinically significant elevations in posttraumatic stress, depression, and anxiety symptoms with an increase in the degree of physical exposure and social proximity to the incident [27, 28, 29].

Public mass shooting event in Thailand not only kills and leave physical wounds, but it also harms loved ones beneath the surface by impeding mental wellness from this event. The participants show the impact that results from a shooting being changed physically, mentally, and socially. The impact that they face, such as sleeping pattern disturbance, attention impairment, depression, and fear of going out, is threatening them. Additionally, the participant had a problem with the cost and treatment burden they and their families incur and, in fact, the nation. The results of this study are related to the study of Smith and teams, The impact of exposure to gun violence fatality on mental health outcomes. The study indicated significantly higher levels of psychological distress, depression, suicidal ideation, and psychotic experiences compared to those not exposed [18].

The participants felt coping is the way of life to heal their life. Some participants have mental health problems and psychiatric disorders. However, the group of participants in this study were depressive patients in ongoing treatment. They use many methods to relieve the negative feelings and impact, including gardening and activities with family members. Watch series online and watch movies. Reduce media consumption. Using techniques to relieve stress by breathing in and out, mindfulness, and exercising related to the regular events of "grief" issue tags showed a significant increase in proportion in the week following the shooting [30]. In contrast, there is extant existing knowledge demonstrating that public mass shooting attacks produce a high occurrence of posttraumatic stress and depression that leads to suicidal ideas and showed a significant decrease in proportions the week following the shooting [18, 28, 31, 32].

The participants felt the Assistance model (intervention); the group of informants received included therapy activities such as talking, drawing pictures, and writing down feelings that make them get better, which is consistent with the study of Efodzi, Potash, & Moore [33] that provides an arts-based narrative engagement/art therapy to supporting Gun Violence Survivors ventilation to facilitate them ventilation about the events and can relieve their pain. In addition, Counseling, drug therapy such as anti-anxiety medication, sleeping pills, and encouragement from colleagues and a network of monks. Encouragement from family, most of whom are getting better and able to live their everyday lives, was excellent to support their feeling from fear and impact, and they can adapt to stressful life events to everyday life [33]).

This study showed that participants experienced public mass shooting attacks during the COVID-19 pandemic. They faced many challenges, including fear, negative impact from the events, psychological problems, physical problems, and social problems. To overcome these challenges, they used strategies such as solving the root cause of stress by participating in recreational, religious, and spiritual activities. They also spend their time with family. Thus, some strategies can be adopted to reduce these challenges and provide better conditions for them, including providing adequate psychological strengthening, a suitable environment, financial and social support, effective management of occupational, paying attention to their physical and mental health after the event to prevent suicidal idea, and developing long term appropriate communicate with their families, and the Community around them. These need intervention and policy to help them in the future.

Implications for nursing and health

Policy implications

• Protecting the multidisciplinary healthcare teams

In light of the challenges associated with responding to public mass shooting attacks during the COVID-19 pandemic, there are plentiful directions for future responses to protect multidisciplinary healthcare teams. First and foremost, in line with public health recommendations, law enforcement agencies should work to provide more and special training for all personnel on health, primarily mental health and psychiatric and safety actions of gun shooting during a pandemic, including modes of escape from the situation, how to call for help, finding the shelter, negotiation skill. Relatedly, to prepare for future public mass shootings, it is critical for agencies to constantly maintain their inventories of self-protect action, including negotiation skills, running away from emergency events, finding a safe place, and protecting the ones who love to ensure that all people stay safe. Finally, to limit exposure for officers and the public during a public mass shooting, agencies should consider setting up alternative virtual formats for traditional in-person activities, such as in-service training, roll calls, and community engagement initiatives.

• Protecting the Community

We should focus on reducing community concerns and anxieties to protect the Community effectively by training people to create Self-defense or active shooter training and a "Run, hide, fight protocol." Finally, the victims need support from the government to receive the care they need to reduce disability and morbidity.

Nursing interventions

The victim is experiencing their symptoms. Often, they hide, ignore, or dismiss their symptoms. Or they may delay, refuse, or never seek help. Their willingness — and readiness — to get help can take time. The nursing intervention should be friendly, short, effective, and low-cost.
The findings can be applied to guide the construction of more robust healthcare systems against and responsive to external and internal pressures of healthcare providers, especially nurses.

Nursing research

Negative feelings such as fear, isolation, and loneliness related to depression showed a significant decrease in proportions the week following the shooting. This area needs to be investigated more.
Fear, coping, and intervention from healthcare providers are the significant perceived factors for the victims and need further study of brief innovation to decrease and relieve fear and promote coping quickly to help victims get adequate activity and daily living as usual. Future research in this area is needed.
To overcome these challenges, the participants used strategies such as solving the root cause of stress by participating in recreational, religious, and spiritual activities and spending time with family. Thus, some strategies can be adopted to reduce these challenges and provide better conditions for victims, including adding religious and spiritual activities in the intervention design and providing a suitable room environment to help them do activities. This needs intervention and policy to help them in the future.

Data availability

The Data available are demographic questions, field notes, participant information, and raw data at Figshare [34]. Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Supplementary Material: Semi-structured Interview guide are available at Figshare [16].

Consent

The authors obtained written and verbal informed consent from all participants to use their data in this study.

Acknowledgments

This research was supported by the Thammasat University Research Unit in the Innovation of Mental Health and Behavioral Healthcare and funded by the Faculty of Nursing, Thammasat University. The authors thankfully acknowledge those participants who shared their valuable experiences. Special thanks to Mr. Benjamin Ivry, University Expert in English language and International Exchange, Thammasat University Library, for proofreading support. Thank you for the academic writing support workshop by Alicia K. Matthews, Ph.D. Professor and Clinical Psychologist Columbia University School of Nursing.

Competing interests

No competing interests were disclosed.

Grant information

This study was funded by the Faculty of Nursing, Thammasat University contract No. 4/2563, and the Thammasat University Research Unit in the Innovation of Mental Health and Behavioral Healthcare.

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Imkome, Ekuma (2024). Fear and Challenging behavior: A Phenomenological- Hermeneutic Study of people with public mass shooting attacks during the COVID- 19 pandemic in Thailand. figshare. Dataset. https://doi.org/10.6084/m9.figshare. 25018022.v1

Table 1 Demographic of participants experiencing public mass shooting attacks during the COVID-19 pandemic (N=15)

Demographic data		N (15)	%
1. Age
	1. < 30 years	3	20
	2. 31-40 years	4	26.66
	3. 41-50 years	7	46.67
	4. 51-60 years	1	6.67
2. Gender
	Female	5	33.33
	Male	10	66.67
3. Marital status
	1. Single	5	33.34
	2. Couple	4	26.66
	3. Widow	3	20
	4. Divorced/Separated	2	13.33
	5. Separate	1	6.67
4. Level Education
	1. Primary school	2	13.33
	2. Secondary education	2	13.33
	3. Vocational Certificate/Higher Vocational Certificate/ Diploma	1	6.67
	4. Bachelor's degree or higher	10	66.67

5. Career
	1. Government service/state enterprise employee	6	40
	2. Trading or running a personal business	4	26.67
	3. Unemployed	3	20
	4. Employed	2	13.33
6. National Health Security
	1. Universal Health Insurance (Gold Card)	6	40
	2. Social Security Scheme	3	20
	3. Government or State Enterprise Officer	6	40
7. Congenital disease
	1. No	7	46.66
	2. Yes
	depression	4	26.67
	Diabetes and hypertension	4	26.67
8. Family member
	1. Father	9	60
	2. Mother	10	66.67
	3. Elder sibling	4	26.67
	4. Sibling	2	13.33
	5. Friend	2	13.33

No competing interests reported.

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Fear and Challenging behavior: A Phenomenological-Hermeneutic Study of people with public mass shooting attacks during the COVID-19 pandemic in Thailand

Status:

Version 1

Abstract

Introduction

Aim of the Study

Research question

Methods

Data analysis

Trustworthiness of the study

Results

1. Demographic data of the participants

2. Main Themes

Theme 1: Fear

Theme 2: Be in the same boat

Theme 3: Impact

Theme 4: Coping

Theme 5: Assistance from Healthcare provider (Intervention)

Discussion

Conclusions

Implications for nursing and health

Policy implications

• Protecting the multidisciplinary healthcare teams

• Protecting the Community

Nursing interventions

Nursing research

Declarations

References

Table 1

Additional Declarations

Supplementary Files

Status:

Version 1