This study is part of a research project titled “Exploration of Stigma Towards Nurses in Indonesia During the COVID-19 Pandemic,” conducted 1.5 years after the pandemic onset. The study used a qualitative descriptive approach to understand how people interpret, construct, and derive meaning from their world and experiences [29]. A semi-structured interview method was employed to gain insight into how nurses describe the intensity of stigma in the context of the prolonged COVID-19 pandemic in Indonesia.

To better picture the condition of Indonesia, the urban area of Jakarta province and the rural side of West Borneo province was chosen to gain richer data [30]. The purposive sampling method was used to recruit registered nurses actively working at healthcare facilities in the selected provinces who had experienced stigmatizing behavior during the pandemic. Invitations to participate were sent through various channels with the help of social media. To support the sampling process, a brief questionnaire was used to collect data related to socio-demographic information, work-related profiles, and stigma-related experiences. The sampling ended after theoretical saturation was reached [31].

Thirty-three (33) informants participated in this study. The average age of the participants was 32 years, with the youngest being 24 years old and the oldest 45 years old. Most participants were female (n=25; 76%), married (n=18; 55%) and worked at the secondary and tertiary healthcare levels (n=24; 73%). The number of participants working in urban areas (n = 16; 48%) and rural areas (n = 17; 52%) was nearly equal (Table 1).

Semi-structured interviews in the Indonesian language were conducted from September 2021 to the initial week of January 2022. Before conducting the interviews, the questions were tested by two nurses who have backgrounds in West Borneo and Jakarta. At the beginning of the interview, the study objective and interview mechanism were re-introduced to the participants, followed by a casual conversation to enhance trust and rapport between the researcher and the participant. Furthermore, questions associated with the study objective were presented. Samples of the main open-ended questions were provided: “What are the stigmatizing attitudes and treatment you have experienced during this pandemic?”; “Are there any differences in these attitudes of treatment from the beginning of the pandemic until now, and if so, why?”. Researchers conducted the interviews in an exploratory manner. Probing on the answers given by the participants was addressed during the interview.

All interviews were conducted synchronously online [32] using the Zoom platform. The justification for using Zoom was due to the COVID-19 pandemic situation, which had limited face-to-face data collection. Using technology was helpful in capturing visual data. Nurses in both urban and rural areas also had familiarity with the necessary devices and internet connections, as well as familiarity with the Zoom platform [33]. Researchers conducted the interviews individually with each participant to ensure confidentiality and comfort. The average time of the interview was 60 minutes. After the interviews, participants were compensated for their internet usage.

All in-depth interview recordings with informants were transcribed. The transcribing process was carried out immediately after each interview. Three trained students helped with the process. Further steps of analysis only began after approvals of transcripts had been obtained through a member-checking process for participants. All the transcripts were in the Indonesian language.

Researchers used a Framework Method approach to generate themes [34]. This method consists of seven steps of analysis. The analysis process began with a thorough reading of transcripts written in the original language to familiarize researchers with the data. Six transcripts that have the depth of phenomena being explored were selected for this step. The decision to determine which transcripts to read was made through discussion among researchers. The researchers then took notes and conducted coding procedures on these transcripts. All researchers contributed as the coders. The next steps were categorizing and developing an analytical framework. All the codes generated in the previous step were categorized and organized to an analytical framework, which was then applied to all datasets. After all datasets were coded, researchers created framework matrices, charted data into matrices, and developed themes. Finally, an interpretation memo was developed to conclude the findings. The researchers employed the traditional way of handling the data. The analysis process used paper, pen, and Microsoft Excel.

The trustworthiness of the study was maintained based on Korstjens and Moser [35], which includes credibility, transferability, dependability, confirmability, and reflexi- vity. Credibility was ensured by using multiple data sources from both urban and rural settings, as well as from nurses in different settings (i.e., primary and secondary/tertiary health settings). Member-checking was also conducted, where participants were asked to review the interview transcriptions. Transferability was addressed by providing clear context in the method, including who the participants were, when and where the data was collected, and how it was collected, allowing others to apply the results to their own setting. Purposive sampling was also used to support transferability. Dependability and confirmability were ensured with regular meetings among the researchers to discuss the data, the coding and theme compilation that were collaboratively conducted, and the member-checking process, which helped to increase objectivity and reduce subjective biases. Finally, all researchers were aware that their background in public health, nursing, and healthcare management might influence their positionality or the reflexivity process of the analysis. Therefore, to improve the validity and integrity of the data, the bracketing was carried out in the data collection phase.

This study obtained ethical clearance from the local institutional review board (Reference number: 1090/SLKE-IM/UKKW/FKIK/KE/VII/2021). Prior to data collection, informed consent was obtained from all participants. Researchers also maintained confidentiality throughout the research process and reporting.

Almost all participants agreed that the stigma towards nurses was strongly felt and experienced by nurses at the start of the COVID-19 pandemic. It then continued to decline gradually as the pandemic progressed. “During the early days of Covid, I was avoided by friends, family, and co-workers, but now I am not.”–P1, 24 years old.

A participant shared her fears at the beginning of the pandemic as she faced the reaction of neighbors, noting that the feeling subsided after a period. “Maybe at first it was scary when I was first asked to work in the COVID unit, it was a bit scary. When I came back home, I was like, oh my God, I'm afraid of neighbors. But the more the time passed by, it seems that people are getting used to it too”–P2, 26 years old.

Another participant also mentioned that avoidance from co-workers was reduced after the pandemic had lasted for some time. “(In the beginning) they were more afraid. When we walked down to the area of management (hospital), it must be like ‘Ugh, stay away, don't come near you guys to this room’. Why did they do so? I'm in the ICU, not in the COVID room. They seemed to generalize. I think now it's okay, it's normal”–P16, 31 years old.

The stigma manifestations associated with this pattern were primarily behaviors linked to the threat of COVID-19. Many participants felt shunned, avoided, rejected, fearful and worried in this period as compared to later periods.

Although participants generally reported a decline in stigma intensity over the course of the pandemic, stigma had not completely disappeared by the end of 2021, when the study was conducted. Stigma was still experienced on some occasions, although not as strongly as before.

When the incidence increased, demeaning words from patients and their families were often experienced due to unmet expectations regarding the quality of services provided by nurses. “In the second wave, (…) the hospital was full, and we couldn’t accept patients. I was treated badly at that time, with several patients with stigma they brought to us. That was a month ago that I experienced. We were crammed with patients, and the oxygen supply was low. So, we said, ‘Madam, we were out of oxygen, and the facility and staff were both completely occupied. Please visit a different hospital.’ Immediately they said, ‘Eh, you're a nurse, huh! You were sworn in to do this and serve. Then you?!’ She said to me, ‘You know, I could pay your wages for an entire year!’ It was very disparaging to me. She said, ‘I could pay your salary and bonuses directly for a year. If that is how you serve, you won't enter heaven’–P15, 24 years old.

As the incidence of COVID-19 decreased, some participants felt more vulnerable to stigma. In this context, they felt that society viewed them as a major source of COVID-19 transmission compared to the general population. One participant revealed that the decreasing number of new COVID-19 cases caused people around her to accuse her of transmitting COVID-19 to family members, even though transmission may have had an unrelated source.“Around November, my family and I got COVID-19. We had seven people in our house, and all of us got it. (…) Since I am a health worker, I took an isolation period in the hospital. At that time, the case was going down when we were hit. The response from the neighbors was not nice. When I arrived home, the rumors were like I brought it to my family.”–P2, 26 years old.

Another form of stigma revolved around the issue of health workers making profits during the COVID-19 period. Some believed that health workers were faking COVID-19 test results in order to gain benefits from the COVID-19-related funding. When new cases had already declined, nurses’ requests to carry out COVID-19 screening procedures at health facilities were suspected of fraud. “In August or September, while the number of cases was declining, we continued to operate a polyclinic for acute respiratory illnesses. There, a PCR swab must be performed on a patient who has had symptoms for a week. However, there was a patient refusing to be PCR-tested (for Coronavirus). “I don’t want to undertake it because currently, there are fewer COVID cases. Why must I perform PCR? There’s no such thing as Covid. I don’t want it to be positive when it is tested by PCR. All of you, health workers, you are all to make the result positive for COVID.”–P22, 29 years old.

Participants often explained the intensity of stigma they experienced during the prolonged pandemic by taking into account both the frequency of stigmatizing behaviors and the intensity of emotions they felt about it. The most frequently mentioned behaviors used to describe this intensity were avoidance behaviors from family members, friends, and colleagues in healthcare facilities. Other points of reference they used included the frequency and emotions associated with nurses’ expulsion from their residences, rumors and accusations of nurses being the main source of COVID-19 transmission or falsifying COVID-19 test results for financial gain, and how often they observed patients or individuals still hiding when being visited. Participants also discussed the intensity of stigma when non-COVID clients questioned them during service about whether they were nurses who also handle COVID-19 and when clients used negative labeling towards them.

In addition to the behaviors mentioned above, the intensity of stigma throughout the pandemic was also associated with the extent to which participants felt negative about their level of acceptance in their residential community. It was often found that participants felt the stigma had subsided when they were no longer afraid to go home, be expelled, or be asked to move. In other words, the intensity of the stigma decreases when they feel safe living close to the community.

Following these expressions, researchers attempted to structure the point of references nurses repeatedly used to evaluate the intensity of stigma in a protracted pandemic;

(a) The frequency of avoidance behavior.

(b) The frequency of expulsion from their home/ residence.

(c) The frequency of witnessing people being suspi-cious or accusing them of faking COVID-19 test results.

(d) The frequency of hearing negative rumors about themselves/their profession.

(e) The frequency of meeting clients who are suspicious or worried if they are nurses who handle COVID-19.

(f) The frequency of verbal conflicts that demean nurses occurs in health services.

(g) The intensity of fear or anxiety regarding each of the above situations.

Several factors influenced the intensity of stigma against nurses during the pandemic (Fig. 1). These included aspects related to communication, the image of nurses, burden distribution, fatigue and familiarity with the pandemic, inability to meet community needs, and incentive policies.

Fig. (1). Factors influencing stigma intensity towards nurses during the prolonged COVID-19 pandemic.

To the best of the researcher’s knowledge, the nature of this study, which discusses stigma in the long term fills a gap of many previous stigma studies. This study suggests that future programs and policies aimed at preventing stigma towards Indonesian nurses in extraordinary events like the pandemic must consider the prolonged nature of stigma. Such efforts to anticipate and reduce stigma towards nurses should be made at the onset of the outbreak and continue along the trajectory of an epidemic. Attention should be given to avoid more complexity in disease control efforts during the challenging situation, because nurses play a critical role as frontliners. Factors contributing to stigma intensity listed in this study can be used in the development of strategies for anti-stigma intervention in the future.

The possible weakness of this research is that data collection (i.e., interview) was performed online, which might have reduced the openness and comfort of participants to some degree even though researchers had performed ways to establish confidentiality, trust, and comfort throughout the study. In addition, the transferability of the findings to other settings may be limited to places that have similarities with the sociodemographic and cultural profile of Indonesia. Indonesia itself has a multiethnic and multireligious society and is considered to be in the low-socioeconomic country group at the time this study was conducted.