Grounded Theory analysis of these results permitted the understanding of social identity importance and how there are significant psychological implications when this is under threat (Cruwys et al., 2014). Social Identity Theory (SIT) (Tajfel, 1974; Tajfel & Turner, 1979, as cited in, Hogg & Vaughan, 2014) is best suited to explain this phenomenon and will be referred to throughout this discussion.
Social identity is prevalent for individuals to maintain a sense of belonging and to furnish a sense of self (Cruwys et al., 2014). Being a member of a group which we associate with is how this achievement is accomplished (Baron & Branscombe, 2014). Individuals categorise themselves into groups that make them feel good about themselves, defined by SIT as the in-group. As a result of community nurses shielding, separation between them and the nurses who remained patient facing inadvertently created an out-group, one that does not comply with the culture and norms real nursing (Hogg & Vaughan, 2014). Being a member of the out-group puts social identity at risk, resulting in adverse psychological health and well-being implications (Crabtree et al., 2010).
Themes one and two (Nurses are people-people, and, Hands-on care is better care) are closely interlinked, focusing on what it means to be a nurse. The results demonstrate how people are at the heart of everything nurses do.
“To me being a nurse, it’s always been people focused and patient focused. I like to be out there interacting with people, erm, a lot of the reason why I love this job is because I get to meet new people every day.” (Jane).
The need to provide hands-on care is perceived as a fundamental part of nursing. Without this ability, the shielders’' social identity as a nurse was jeopardised.
“I missed that physical contact; missed being with that person and touching their hand for reassurance.” (Megan).
Very early in nurse training, the four themes of the NMC Code (2018) are preached to student nurses and infused into the behaviours and beliefs, embedding the nursing culture from day one. The first theme outlined in the NMC Code is to "Prioritise People" (NMC Code, 2018, p. 6), a belief that was evident during data analysis. In order to meet the professional standards of expertise which allow entry to the nursing register, student nurses must outwardly demonstrate and uphold their understanding of the NMC Code and exhibit the desired behaviours.
"So for me, a nurse is somebody that cares for people and looks after them, and that's what it means to me, just helping people in need." (Sally).
Comments similar to this one were verbalised by almost every participant. Some expanded to explain how nursing is a vocation and more than just a job, sentiments echoed by HCPs participating in support groups led by Doctors in Distress (2021). Nurses are accountable for their actions and invest time, energy, and emotion into their patients, which cannot be switched off at the end of a shift.
The second theme relates to how hands-on care is better care. Physical interaction with patients is necessary for a nurse to feel like a nurse. The power of touch should not be underestimated, and when physical care is removed, nurses feel that a part of their identity is lost.
"Nursing is about being hands-on, which might be considered old-fashioned these days. Nursing is about being face to face, not at the end of a phone. Nursing had gone, could no longer see patients. Virtual technology such as Apps is not the same. I need to physically see and look at something close up." (Jane).
As a result of shielding nurses no longer seeing patients face-to-face, social categorisation occurred, leading to an out-group formation of shielders’. The in-group was nurses who could continue hands-on nursing duties and were considered the real nurses, superior to the newly formed out-group. Social comparisons led to the out-group feeling substandard, less of a nurse, and guilty for letting their profession, teammates, and patients down.
This innate desire for physical support may be linked to self-esteem enhancement, closely linked with social identity (Baron & Branscombe, 2014). If the groups we identify with carry high status and respect, adhesion to the individual's perception of themselves occur, thus enhancing self-esteem (Hogg & Vaughan, 2014). Consequently, involuntary social mobility to an out-group may lower self-esteem, reinforcing feelings of being disposable and increasing inter-group tension.
The third theme coded during analysis is dedicated to guilt and secret relief. Guilt is an emotion experienced when we view ourselves behaving in ways that are not consistent with our usual self, either physically or morally (Signs of Guilt, 2020). Participants felt highly guilty for not providing physical support during the height of the pandemic. The excessive media coverage of frontline nurses working in ICU with images of bruised faces and wearing PPE in demanding environments reinforced this guilt (Chattopadhyay et al., 2020). Even though most participants could work from home and support their teams remotely, many reported that this did not ease the guilt, moral injury or prevent social identity loss.
“Even though I worked from home, I didn’t feel like a nurse anymore. Just talking to people on the phone. My daughter even said I’d turned into a receptionist.” (Naomi).
Shame and guilt often come hand-in-hand, resulting in a meta-emotion whereby feeling guilty is not always associated with negative emotions; positive emotions such as relief can be equally prevalent (Signs of Guilt, 2020). Hiding the relief could suggest that shame is felt for having this emotion; however, it could also be a considerate action. Being openly relieved around colleagues who are donning and doffing PPE numerous times a day and working in dangerous conditions may be immoral, unkind, and perceived as gloating. Non-disclosure of relief forms a dual purpose; prevention of colleagues becoming dismayed and prevention of shielders’ being frowned upon and ostracised by in-group members. This behaviour may be perceived as prototypical as not sharing emotive differences may help maintain an in-group association and reduce animosity (Hogg & Vaughan, 2014).
In addition to guilt and shame, many other complex and varied emotions were uncovered during data analysis and formed the fourth theme. The majority of emotions were negative, ranging from fear, loneliness, anger, and depression. One participant shared how their General Practitioner (GP) instilled them with panic and trepidation during a routine telephone review.
"They asked if I became unwell with Covid would I want admitting to intensive care. I was only 39; of course I would want to be admitted; I'm not old enough to die. Then asked if I would want intubating, and if the worst-case should happen, did I want resuscitating! This phone call from the GP was the worst bit out of all the pandemic. Being asked if I wanted resuscitating sticks with me the most." (Suzanne).
Following this phone call, the fear of dying from COVID-19 became very real, and the media's daily reports of climbing death rates and images of overcrowded ICUs reinforced this. Many people suffering this turmoil would benefit from the support of friends, families, or groups with which they identify. With social networks not readily accessible due to the shielding regulations, individuals like ’Suzanne’ were left with high anxiety and reduced psychological support. Research undertaken during previous pandemics has determined that isolation increases loneliness, depression, anxiety, and even triggers psychosis in those susceptible to such mental health disorders (Rettie & Daniels, 2021). This is unsurprising considering the lack of psychological support and resources available during such unprecedented circumstances.
Not all emotions were negative in connotation. Relief was a complex emotion due to the aforementioned association with shame; however, less compound emotions were also disclosed, such as feeling protected, safe and grateful for having the opportunity to continue working from home.
Humans are social animals who live and work in social groups, and a shared sense of social identity is essential for good mental health (Hogg & Vaughan, 2014). Physical interaction is crucial as it helps build trust and connectedness, both essential elements of social identity. When positive social identity is compromised, good mental health is under threat leading to disconnection and feelings of alienation (Cruwys et al., 2014).
Feeling trapped, claustrophobic, and having no control over the situation were frequently discussed. One participant described this feeling as being in a prison without bars and formed the fifth theme of analysis. Having freedom taken away felt like a punishment for having a LTHC. However, prisoners have cellmates, social interaction, visitation rights, and time spent each day outdoors; therefore, in this respect, shielding restrictions might be considered more punitive than being incarcerated when it comes to an individual’s own perception of the psychological impact it has on them. Shielding was more atone to an innocent victim in homely solitary confinement. One participant who lived alone was so traumatised by this experience that a decision was made to break the shielding regulations and escape, regardless of how severe the consequences might have been.
“I remember sitting here towards the end of the three months and just getting in the car, drove to the supermarket; I just wanted to do something normal. I didn't know what I was supposed to do, the rules. I didn't realise I had to line up outside; I had to ask for help. Something simple, walking round a supermarket, it was like being on holiday. It was absolutely lovely; it just boosted me up. A prison without bars, it was horrible." (Megan).
Haney (2003) states that when prisoners in solitary confinement are deprived of human contact, they often lose their minds, as relationships with other people are vital in the creation and maintenance of social identity and a sense of self. Whilst shielding nurses’ realities are not quite identical to prisoners in solitary confinement, data from this study suggests that the feeling of isolation that can result from shielding could have similar effects.
The sixth theme highlights that shielding was an unpleasant experience; however, it was not bad all the time. Many challenges mirror those of the general population, such as missing families, boredom, and loneliness (Matias, Dominski & Marks, 2020). Participants expressed how they grieved their career, their social identity and were concerned about the future.
“Uncertainty of how long it is going to last. Is this now life forever? Is my nursing career as I knew it over? Not knowing when they would let me back out. A long 11 weeks!” (Jane).
and
“Scared, a lot of unknown. How will I stay up to date? NMC revalidation…it did bring my career into question.” (Asha).
Shielding was predominantly a negative experience for participants involved in this study; however, there were some positive affirmations of being lucky compared to others. Associations with those in worse situations may be considered self-serving bias and self-esteem enhancing (Hogg & Vaughan, 2014), but it is also a form of social change/creativity, as portrayed in SIT literature, an element important for positive distinctiveness. Direct comparison with those in a worse situation makes people feel better about themselves, and acknowledging the positive things in life helps build mental assets and improve well-being (Positive Psychology Centre, 2022). This comparison and positive distinctiveness may go some way towards explaining why for some, shielding was not all bad.
The community spirit and Thursday night clapping were considered a positive aspect of shielding; however, some participants felt that this was NHS-focused and private nurses were unacknowledged. In addition, many felt undeserving of any appreciation as they did not associate the support they provided remotely as the frontline.
“I remember the first Thursday I went outside, didn't think anyone would be out there, but everyone was out clapping. This choked me up. People bonded; it was nice." (Megan).
and
“All the love being shown to frontline workers, I didn’t feel like I was one of them because I wasn’t out there in the thick of it.” (Melanie).
The seventh theme was formulated around virtual technology and how this enhanced the participants' remote working experience. Technology such as VAs was considered fundamental for continuing an element of nursing duties. By performing VAs, participants felt they had delivered an aspect of nurse care, and seeing a patient at the other end of a video call enhanced morale and self-esteem, making them feel more like a nurse and closer to the in-group.
"Luckily, we had the App for virtual visits. I still felt useful, would have hated being at home not being able to do anything to help. I was able to do part of my role because of the App; I could do virtual training and things like that, training patients.” (Megan).
and
“It was brilliant when you actually spoke to a patient and helped them; it felt like I’d done an actual visit. The App enabled me to still feel like I was doing something nursey. The App probably stopped me from going mad” (Naomi).
Virtual technology was the closest thing to physical contact and became a lifeline to the outside world. Numerous studies on the effectiveness of this technology have been conducted throughout the pandemic (Maffoni et al., 2021). Although some felt VAs were less personal, and some patients missed the reassurance of a physical examination, the benefits of contact-free consultations during the pandemic were appreciated (Parkinson et al., 2021). Virtual appointments have increased accessibility to HCPs, reduced travelling times, and protected CEV patients due to less exposure to others (Maffoni et al., 2021). Participants in this study felt VAs were not a form of real nursing but it was better than nothing. Research suggests that patients have valued the option; many felt that care was not negatively impacted, and for some, it even improved (Ervin, Weller-Newton & Phillips, 2021).
Support from managers and teammates were reassuringly positive overall and formed the eighth theme during analysis. Many participants felt included due to their managers and teammates keeping in regular contact. This contact was considered mental health support (albeit indirectly) for many participants and was imperative to prevent loneliness and maintain a connection with the in-group.
“The team were locking me up if needed. My manager was a good support, always there to support when things got too much.” (Beth).
However, there was scepticism around this support, and some regarded it as inauthentic. The following excerpt is from a participant who decided to return to working in the community after a short time shielding.
“Do you have any advice how I feel less negative about people that actually shielded and let everybody down in my eyes? When you consider that you have very limited specialist team who can do what we do, considering the effect it can have.” (Phoebe).
This statement demonstrates that the out-group feelings of subordination were, to some extent, valid. The attitude toward “people that actually shielded” highlights the self-esteem hypothesis and the positive distinctiveness of SIT (Li, Xu, Fan, Zhang, & Yang, 2021). Pre-judgments are being made that all shielders’ are the same and not viewed as favourably as those who continued their regular duties. Shielders’ are stereotyped as selfish and traitors, putting themselves before patients and breaking the norm of the nursing culture. Here the out-group is perceived as letting the nursing profession and patients down, negatively impacting the already limited resources. This participant may have an increased sense of self-esteem, deeming themselves superior and viewing their in-group more favourably than the out-group, thus reinforcing positive distinctiveness (Baron & Branscombe, 2014). In addition, the advice is requested from the participant, for the participant and the statement fuels in-group bias, ethnocentrism, prejudice, and discrimination (Hogg & Vaughan, 2014). The out-group homogeneity effect is also evident in this statement. People that shielded are generalised, suggesting a negative association with all people who shielded. Upon further probing of this question, it was determined that the participant was referring to only one person they felt let down by. However, this overgeneralisation suggests a more profound resentment to all shielders’; the out-group.
This participants' perception that shielders’ have let the nursing profession down reinforces the guilt and shame felt by many. Knowing that colleagues have these stigmatised judgements, whether inwardly or outwardly, helps explain why guilt is so profound. For this participant, the need for self-esteem enhancement and belonging to a group that psychologically matters (Cruwys et al., 2014) outweighed the risks of severe illness or death should they contract COVID-19. It is striking to learn that the need to belong to the in-group is so extreme that for this participant, the risk of death by COVID-19 (which may be considered suicide) was not enough to deter them from social mobility (Hogg & Vaughan).
With regards to the employer, feelings of being forgotten, judged, devalued, and fraudulent were prominent during data analysis and formed the ninth theme of this study. These statements are echoed by NHS nurses and HCPs who were required to shield, therefore, are not directly associated with nurses in the private sector (Nolan, 2021). The following statement is an example of how the perceived lack of recognition from the employer fuelled inter-group conflict and a sense of us and them. Recognition is required to boost morale, self-esteem, and motivation, and when this is not received in ways that are meaningful to the individual, feelings of resentment will transpire (Hogg & Vaughan, 2014).
"I just think that everything was so focused on the nurses in the field that were doing such an amazing job, which they always do, that they kind of just dismissed, you know, the good ones are out in the field, and they left the bad ones behind cos they had no use for them cos they were working from home.” (Lizzie).
Not all participants felt animosity towards their employer. Some were grateful for the protection and option to work from home. Performing an element of nursing care was better than doing nothing and staying safe outweighed any other incentives. Those that were able to adapt their roles appeared to have better experiences of shielding than those who were furloughed. Furloughed nurses felt significantly devalued however they were not in direct competition with an in-group of other nurses. Being furloughed may have resulted in less pressure to be part of the in-group, and arguably, furloughed nurses may have had a better experience of shielding than those working from home.
A repetitious response formed the tenth theme of future suggestions when asked what could be done differently to support community nurses should they ever need to shield again. Many participants were unaware of whom the other shielders’’ were, resulting in a fragmented out-group. Weekly virtual gatherings for those who were shielding would have provided solidarity, psychological support, and a platform on which they could have their say.
“A group of everyone who was shielding getting together may have helped. Support for each other all going through the same thing. Informal support and a coffee together.” (Suzanne)
and
"It would have been nice to have a drop-in where you could chat. I wouldn't have been the only one feeling guilty, guilty for not being able to support your team. It would have been nice to chat with others, to support each other when we were struggling.” (Naomi).
Participants also suggested that shielders’’ should be recognised for their efforts if shielding is ever enforced again. The lack of recognition had significant psychological effects on participants, and many were passionate that this should not re-occur. Not only recognition for individual nurses working from home but the entire nursing cohort who are in the same situation.
“Those more able bodied, or don’t have anything autoimmune or anything like that, who were going out and doing their regular job, you know were getting more recognition that what, you know, than us and that was that was quite difficult I’ve got to admit.” (Lizzie).
This would go some way towards raising the out-group profile, make them feel valued, boost self-esteem, increase motivation, and feel like they are still a part of the wider team. Doctors in Distress (2021) launched virtual support groups for shielding nurses (amongst other HCPs); however, they are aimed at NHS employees. The inter-group conflict between NHS and private sector staff warrants further discussion than word count allows; however private nursing companies should follow this example.
The final theme concentrated on the lasting psychological effects of shielding, most of which were considered non-problematic. Many participants shared how they remain paranoid, continuing to wear face masks and practice enhanced hygiene techniques; however, this was considered a personal choice rather than a psychological effect. This is debatable as choosing to continue these behaviours suggest that fear has remained prevalent and is likely to increase anxiety; therefore, the psychological effects cannot be fully dismissed (Matias et al., 2020).
"I still wipe things down, erm, especially when I go round the shops and see like loads of people not wearing masks and coughing all over the place and that. Yeah, I'll just wipe it all down when I get in, yeah, so we've never stopped, never stopped doing that, erm, and I've never been anywhere without a mask." (Jane).
For one participant, the lasting psychological effects have been more severe as they continue to suffer from social anxiety, OCD behaviours, and coming to terms with a diagnosis of BD.
"It is one of the things I really struggled with, after shielding; I could no longer do some of the things I used to like doing. Like, I could not walk into a cinema at all, don't know why… big dark room with loads of people, it's not my idea… even things like going to shopping centres, going into town, even going into a supermarket on a weekend when it's busy, sometimes I walk in and I've got to walk straight back out again, and that's one thing I haven't got over since shielding. It's funny how something can change in the space of three months, you know, three months of just being in the same house, and all of a sudden you can't do anything anymore. It’s just crazy.” (Lizzie).
Research to date suggests that shielding has resulted in mental health deterioration, with many reporting this to be severe (Rettie & Daniels, 2021). This participant felt that shielding-induced isolation was the trigger for these psychological issues, and the diagnosis of BD would not have been reached so soon if shielding did not occur.
Limitations
The findings of this study are interesting; however, some limitations exist. Participants were all female, which may cause bias in the results. The perception of male participants would have enriched the data and should be considered in future research. Virtual interviews were a necessity due to COVID-19 restrictions, and although they were successful, there is the potential for missing non-verbal cues, misreading body language, and feeling less personal. Occasionally, the internet connection would fail, causing brief disruption, resulting in potential frustration for the participant and missing important sentences mid-flow the conversation. Finally, some participants stated how time has been a healer, and had they been interviewed nearer to the time they were shielding; their answers may have been more emotive. Where possible, further research should be performed as close to the event as possible to ensure the data is raw and as authentic as possible.