Authors: Tiziana Ramaci, Massimiliano Barattucci, Caterina Ledda, and Venerando Rapisarda
[This article is republished under an open access Creative Common CC BY license. Sustainability 2020, 12(9), 3834; https://doi.org/10.3390/su12093834.]
The outbreak of COVID-19 in Italy is a unique historical event that will need to be investigated more extensively and with more refined methodologies. Our findings suggest that stigma has a high impact on workers’ outcomes. Stigma may influence worker compliance and can guide management strategies relating to pandemic risk for healthcare workers.
Stigma has a variety of negative consequences that inhibit recovery, such as shame, embarrassment, and the “why try” phenomenon. Stigma is such a pressing issue for the national health system, that it has been identified as a health crisis that clinicians must combat.
In the specific case of healthcare workers, coming into contact with patients is an emotional stressor that can pose a threat to well-being and have an impact on quality of professional life. Human resourced management can positively support efforts to reduce the job stress that is generated by increased workload and assignment to unfamiliar tasks.gh
The COVID-19 emergency has significantly transformed the working environment and job demands. Providing care was emotionally difficult for healthcare workers. Uncertainty, stigmatization, and potentially exposing their families to infection were prominent themes for healthcare workers during the crisis, which first broke out in China at the end of 2019, and then in Italy in early 2020.
This study examined the effects of stigma, job demands, and self-esteem, and the consequences of working as a “frontline care provider” with patients infected with the coronavirus. A correlational design study involved 260 healthcare workers working in a large hospital in southern Italy. The following questionnaires were administered: (1) the Job Content Questionnaire, for assessing psychological and physical demands; (2) the Professional Quality of Life Scale to measure the quality individuals feel in relation to their work as “frontline care providers”, through three dimensions: compassion fatigue, burnout, and compassion satisfaction; (3) the Rosenberg Self-Esteem Scale, for evaluating individual self-esteem; (4) a self-administered multiple-choice questionnaire developed by See et al. about attitudes of discrimination, acceptance, and fear towards healthcare workers exposed to COVID-19.
The findings suggest that stigma has a high impact on workers’ outcomes. Stigma may influence worker compliance and can guide management communication strategies relating to pandemic risk for healthcare workers.
The COVID-19 pandemic first struck Italy in January 2020, when two Chinese tourists tested positive for SARS-CoV-2 in Rome. An outbreak of infections was subsequently detected, beginning with 16 confirmed cases in Lombardy on 21 February, rising to 60 cases the following day, with the first deaths were reported. At the time of writing, there are over one million 300 thousand people infected with the coronavirus worldwide and the number of deaths stands at almost 75 thousand, almost 85% of which have been registered in Italy, Spain, France, and the United Kingdom.
The pandemic crisis has significantly transformed the working environment and job demands (e.g., high-pressure work, an unfavorable physical environment, and emotionally demanding interactions). Providing care was emotionally difficult for healthcare workers, with stress, uncertainty, and stigmatization being dominant themes for healthcare workers. They often had complex and conflicting thoughts and feelings about balancing their roles as healthcare providers and parents, feeling professional responsibility but also fear of this new disease, associated coronavirus patients, and guilt about potentially exposing their families to infection by working during the COVID-19 emergency [2,3,4,5].
Working with potentially highly infectious patients led to considerable stigmatization [6,7]. Contagion brings out a whole range of attitudes, beliefs, prejudices, stereotypes, and stigmas. Under these conditions, emotions play a key role by distorting planned choices or those based on facts. There is a contradiction between the duty owed by doctors, nurses, and healthcare workers to their patients and the underlying attitudes caused by the contagion. In some cases, this can lead to prejudice against those who are seen as modern day “plague spreaders”. The overriding fear is that of becoming infected, making the management of contact with infected individuals or those waiting for diagnostic test results difficult .
One of the most typical reactions in these cases is to experience fear, a primary emotion, which is crucial to our self-defense and survival. It is this fear that can lead healthcare workers to provide treatment that is less precise or careful than that which they would provide under normal circumstances .
The implications of working with potentially highly infectious patients should be recognized and acknowledged.
In this context, it is therefore essential to understand the effects of stigma, related to the intensity and frequency of exposure to the ongoing pandemic, job demands, and self-esteem, and its impact on healthcare workers outcomes. In particular, it is essential to investigate whether these variables are potentially capable of producing changes to the quality of professional life, including compassion satisfaction, burnout, and compassion fatigue for healthcare workers; in addition, it is also possible to hypothesize on the contribution of contextual variables, such as organizational type, position, years of experience, and role.
Stigma and discrimination tend to persist in the long term, even after quarantine has ended and the epidemic has been contained. Human Resourced Management can positively support efforts to reduce stigma among healthcare workers and the related stress generated by increased workloads and being assigned to unfamiliar tasks. Both systematic training and specific network meetings, as well as the possibility to access counselling seem to be very important tools to fight burnout and social stigmas .
Social Stigma with Coronavirus Patients
Stigma can be defined as a mark of disgrace that sets a person apart from others . Social stigma (e.g., discrimination and devaluation by others) has a variety of negative consequences that inhibit recovery, such as shame, embarrassment, and the “why try” phenomenon [12,13].
Social stigma, in the context of health, is the negative association related to people or a group who have a specific disease in common. In an epidemic, this may mean that people are labelled, stereotyped, and discriminated against because of a perceived link to the epidemic. This is even more true when dealing with a highly contagious disease. This can have a negative effect on those affected by the virus and on the work of healthcare workers [14,15].
Firstly, stigmatization can substantially increase the suffering of people with the disease. Secondly, people with the disease or those at risk of catching it may avoid seeking health care, making it much harder for public health authorities to control the disease. Thirdly, professionals and volunteers working in the field may also become stigmatized, leading to higher rates of stress and burnout [16,17,18,19,20].
Familiarity (e.g., knowing a friend or family member who has tested positive) is well-established as a factor that positively impacts stigma . Specifically, familiarity has been associated with lower levels of perceived dangerousness and fear  and less desire for social distance [23,24], as well as increased sympathy and prosocial attitudes .
Discrimination towards patients is the behavioral response of prejudice [26,27] and can be understood in terms of social processes of power and domination with some groups, which serve to devalue the stigmatized .
Evidence clearly shows that stigma and fear of infectious diseases hinder healthcare workers of different roles and responsibilities from responding correctly. They are facing an unprecedented emergency and insidious invisible danger, which has pushed the national health service to its limits, increasing workloads and physical and mental stress. At the individual level, stigma has been associated with insufficient levels of knowledge  and fear of casual transmission in the workplace [30,31].
Further examination of the factors relating to stigma has resulted in associations between stress and satisfaction [32,33]. For all these reasons, the acute stress of working with potentially highly infectious patients should be recognized and acknowledged.
A number of models have been put forward by the literature for the study of workplace health that investigate the relationship between stress perceived by the worker  and available resources. The starting point for these studies is the perceived level of stress, seen as a result of an imbalance between the demands imposed by the situation and the individual personal resources available .
Individual resources are also very important in protecting healthcare workers against the negative effects of infection . In fact, O’Keefe  found that strong self-esteem was the strongest predictor of hopefulness among healthcare workers with patients affected by virus . Additionally, [39,40,41] suggested that after an individual experienced adversity, a higher sense of self-esteem was identified as one of the personal characteristics contributing to resilient psychosocial outcomes. On the contrary, low self-esteem may be a risk factor contributing to negative psychological outcomes [42,43].
Less attention has been paid by researchers to the pandemic situation and life satisfaction, and how these may impact on attitudes toward healthcare workers. Stigma-related stress is not a diagnosable concern, but it can lead to more serious direct consequences for workers’ outcomes and their performance . It could be that when workers experience increased stigma-related stress, they feel more inclined to assist with patients’ health concerns.
The opposite may be true for those experiencing high levels of stigma-related stress, where stigma may inhibit an individual from providing treatment. Similarly, satisfaction with life may be inversely related—with treatment provided and good performance outcomes when the individual feels satisfied with their current professional life circumstances, and perhaps more likely to provide support when satisfaction levels are higher. In a study with counselling professionals [45,46], help counsellors who reported higher self-stigma also had less help behaviors. This lack of behaviors then contributed to higher levels of stress and burnout and lower satisfaction.
In general, people who had higher levels of stigma were less satisfied. This finding suggests that when a person feels stressed, levels of satisfaction decrease [45,47,48,49]. Another study found that doctors who carried out abortions faced significant workplace stigma, resulting in reluctance due to workplace strain .
In such a context, an increase in job demands (e.g., psychological overload) exposes the individual to a tangible risk of burnout with cognitive, behavioral, emotional, and physical consequences, such as tiredness, pervasive detachment from others, anxiety, irritability, insomnia, poor concentration and indecision, degradation of performance levels, and reluctance to carry out one’s work [51,52,53].
Literature on psychological consequences of exposure to the COVID-19 emergency reported emotional strain, burnout, and physical symptoms, such as shortness of breath and headaches, which were attributed to continually wearing protective masks, while fear and anxiety associated with the risk of contracting COVID-19 was prominent in their minds [54,55,56,57]. Authors found that although healthcare workers carried out their duties, the dual role of healthcare worker and family member caused conflict. Respondents were particularly concerned about infecting family and friends who they considered vulnerable.
Other studies on the emergency found that healthcare workers were worried about expected overtime hours if other staff were quarantined, as well as the stigma of the illness and the health of their families and themselves , indicating general emotional distress [59,60,61]. Several studies have investigated the attitudes, knowledge, and practices of healthcare workers towards patients with the virus and underlined that healthcare workers still fear the disease and behave prejudicially toward infected patients [62,63,64].
Factors that influence these attitudes include fear of contagion associated with the uncertainty of care and the awareness of feeling useless in providing care for patients with a potentially fatal disease . The focus of institutions and the scientific community on occupational health and safety is progressively increasing, leading to a continuous regulatory evolution and the development of good practices in safety and prevention. Easily accessible practical advice on coping strategies and stress management at work may be a most challenging task and useful to significantly improve and guarantee their quality of life and work, and to avoid burnout.
Study Aim and Results
Therefore, after considering these research findings, the specific objective of the present preliminary analysis was to identify direct and indirect relationships between stigma, job demand, and quality of professional life, including compassion satisfaction, burnout, and compassion fatigue, in a group of healthcare workers working in a large hospital in the south of Italy with a COVID-19 ward.
In this hypothesis-generating study supported by a convenience sample drawn in close temporal proximity to the period of lockdown, imposed on the entire country by the government in an attempt to flatten the curve the pandemic (range time from 17 March to 2 April), we examined whether the relationships between these constructs existed for workers and to what extent. The data are still being constantly updated to provide additional support for the model presented in this paper.
In summary, according to the literature, stigma clearly influences work outcomes . Moreover, some working environment variables (perceived job demands) [35,51] and personal variables (self-efficacy) [38,42] could have a role in possibly mediating/moderating stigma and outcomes. Self-efficacy could influence the perception of stigma, increasing discrimination and fear of COVID-19. However, this study was only intended to verify the first step of the theoretical framework. Stigma, job demands, and self-efficacy have the role of antecedents in relation to the outcomes of healthcare workers, overall making a joint contribution to the experience of work.
Based on this simple rationale, and with a view to further exploratory research, this paper intended to verify the following hypotheses:
- Hypothesis 1: Social stigma (discrimination, acceptation, and fear) predicts outcomes: stigma discrimination, and fear negatively predict compassion fatigue and burnout, and positively predict compassion satisfaction. On the contrary, stigma acceptance positively predicts fatigue and burnout, and negatively predicts satisfaction.
- Hypothesis 2: Job demands (mental and physical overload) predict outcomes, such as professional quality of life. More specifically, job demands positively predict compassion fatigue and burnout, and negatively predict compassion satisfaction.
- Hypothesis 3: Self-esteem negatively predicts negative outcomes (fatigue and burnout) and positively predicts satisfaction levels.
Other contextual variables such as gender, age, role, length of service, and working hours were considered as control variables.
Gender differences emerged for fatigue and burnout: women reported higher scores of compassion fatigue and burnout than men. Age was significantly positively related only to burnout levels and satisfaction, as was length of service.
No profile differences (doctors vs. nurses) were found for any of the measured variables, nor for shift presence/absence. Furthermore, weekly working hours were not significantly related to any of the variables. Nevertheless, differences between temporary and long-term workers emerged for job demands, fatigue, and burnout—unexpectedly, permanent workers showed higher levels of perceived psychological job demands, fatigue, and burnout, compared with temporary workers.
Measuring the effect of pandemic factor stigma on workers’ performance is of extreme importance [55,56,73]. To this end, the research sought to provide preliminary indications on the relationship between stigma and work outcomes, and on the role of job demands and self-efficacy. The results undoubtedly show that stigma positively impacts fatigue and burnout, and negatively impacts satisfaction. The role of job demands, although having an effect on negative outcomes, appears to be reduced compared to the interaction with stigma perceptions. Self-efficacy also appears to relate more to the processes of discrimination and satisfaction than to those of emotional reaction (fear) and negative outcomes.
Stigma is such a pressing issue for the national health system, it has been identified as a health crisis that clinicians must take action against . Healthcare worker stigmatization is associated with psychological and physical health. Healthcare workers who expected to experience higher levels of stigmatization reported increased psychological distress, and this predicted increased somatic symptoms .
There are some major pathways for studying stigma in healthcare facilities, namely stigma related to discrimination and fear of contracting the virus and its outcomes [76,77,78]. Where healthcare workers are not aware of potentially stigmatizing attitudes and behaviors, the impact of stigma is serious. The practical reason for exploring stigmatized attitudes and behaviors, and reducing related stigma, is the negative effect stigma has on a person’s self-concept [79,80], life satisfaction [81,82], and professional quality of life, stress, burnout, and self-engagement [81,83].
It is no surprise then, that stigma toward healthcare workers has been a topic of focus in the literature [26,84,85,86,87].
There are several potential mechanisms by which stigma could affect healthcare workers outcomes [88,89]. Many research studies have been conducted to study the ways in which stigma impacts help behaviors [90,91,92]. The importance of stigma to quality of life is well-recognized in HIV research and care: Stigma is included as a domain in the World Health Organization’s HIV-specific measure of quality of life .
Caring for people living with a virus requires ongoing health care services, as they are potentially at increased risk of developing disorders, including cardiovascular and liver disease, accelerated bone loss, metabolic disorders, etc. [94,95]. Taking care of infected patients requires healthcare workers to have good knowledge of their unique issues. Cultural differences in healthcare workers, combined with professional ethics and personal beliefs, could also result in conflicting attitudes, which may lead to difficulties related to care [65,96]. Although most workers rationalized this as a lack of understanding about the illness or the risks involved, all described feeling angry and hurt, acutely aware of others’ reactions.
Overall, on one hand, the results of this research seem to provide indications in line with cited literature and with the proposed theoretical model (Figure 1), but on the other, the range of relationships and the sample size do not allow for causal inferences or hasty conclusions to be drawn.
Indeed, the limited size of the sample can only provide preliminary indications and does not allow results to be generalized for all healthcare workers. Moreover, the very low response rate of the nurses was certainly caused by the lower temporal availability compared to doctors, and it can certainly represent an important source of bias and a loss of important information.
The outbreak of COVID-19 in Italy is a unique historical event that will need to be investigated more extensively and with more refined methodologies [54,55,56]. What is certain is that it is essential to study workers’ stigma in the face of pandemics and the training and information provided for healthcare workers to ensure adequate levels of satisfaction can be maintained and prevent phenomena such as fatigue and burnout.
Research relating to the set of different antecedents of workers’ outcomes in pandemics seems crucial since stigma risk may influence the general compliance of workers and results can provide useful information for management communication strategies.
There is now a greater focus than ever on studying stigma in relation to healthcare workers. Where healthcare workers are not aware of potentially stigmatizing attitudes and behaviors, the impact of stigma is serious. Healthcare workers who expected to experience higher levels of stigma reported increased psychological distress, stressors which may be important in predicting impact on healthcare workers’ outcomes [75,76,77]. Working with potentially highly infectious patients generates considerable stigmatization [6,7].
Our findings underline that stigma is an important predictor of compassion satisfaction, burnout, and compassion fatigue among healthcare workers. Therefore, strengthening human resources for frontline care providers requires measures to reduce stigma.
This appears particularly relevant for healthcare workers in this specific situation, whose contact with patients during the COVID-19 emergency is emotionally difficult and where stigma can jeopardize outcomes and affect work performance. [2,3,4,5,54,55]. In line with the broader literature, our findings also suggest that studying the stigmatization of COVID-19 may provide us with insight into the stigma associated with emerging infectious diseases and the potential consequences of such stigmatization.
In the specific case of healthcare workers, coming into contact with patients is an emotional stressor that can pose a threat to well-being outcomes and have an impact on quality of professional life.
Human Resourced Management can positively support efforts to reduce the job stress that is generated by increased workload and assignment to unfamiliar tasks. Systematic training and specific network meetings, as well as the possibility to access counselling, are very important tools to fight burnout and social stigma  in order to prevent them or avoid their harmful effects.
Despite the contribution made by this study to the understanding of the topic, there are limits which provide direction for future research. Firstly, the methods used to examine “causal” hypotheses and data collected were cross-sectional and, therefore, cannot offer evidence of actual causation. In future research, using a structural equation longitudinal method would be useful. Secondly, self-reported measures were used to assess the dimensions of this study.
Future studies should at least consider different methods to reduce the influence of self-report bias. In this hypothesis-generating study carried out in close temporal proximity to the lockdown period, imposed by the government to attempt to flatten the curve of the pandemic, we used a convenient sample. The data are still being constantly updated to provide additional support for the model presented in this paper.
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