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Mental Health of Nurses in Mexico during COVID-19:

Aggression, Rejection, and its Impact on Health

Salud mental de enfermeras en México durante el COVID-19:

Agresión, rechazo y su impacto en la salud

Leivy Patricia González-Ramírez

Nancy Evelyn Navarro Ruiz

Reyna Jazmín Martínez Arriaga

José María De la Roca Chiapas

ABSTRACT

Aims: Our study aims to measure Nurses’ perception of aggression and violence during the COVID-19

pandemic in Mexico. Background: The COVID-19 pandemic has generated physical and emotional strain in

all health workers, such as rejection, maltreatment, stress, and anxiety among health workers. Methods:

Analytical cross-sectional study, applied virtually through a Google form, to collect sociodemographic,

occupational, and clinical details of workers. We applied the Goldberg General Health Questionnaire (GHQ-

28), the sample size was 560 nurses from universities, hospitals, and nursing colleges across Mexico. Results:

The principal source of aggression against nurses were strangers, increasing symptoms of anxiety and

insomnia. Conclusions: The COVID-19 pandemic has exacerbated violence towards and discrimination

against health professionals. This work investigated the perception of aggression and rejection towards

nursing staff during the pandemic. Implications for Nursing Management: Nursing students, technicians and

graduates perceived more aggression than specialist nurses or those with a post-graduate qualification.

Among our respondents, we found that younger nurses, who lived in the East of the country, worked in the

public sector in clinical or hospital settings, and had contact with COVID-19 patients or had been diagnosed

with the virus were more susceptive to this type of violence.

Keywords: COVID-19, psychosocial, violence, discrimination, health personnel.

Tecnológico de Monterrey, School of Medicine and Health Sciences. Monterrey, Nuevo León, Mexico. PhD

in Psychology. Email: leivy@tec.mx ORCID: https://orcid.org/0000-0002-2952-2836

Independent. Lic. in Nursing. Guadalajara, Mexico. Email: nancynavarro.ruiz@gmail.com

ORCID: https://orcid.org/0000-0002-2910-5557

Department of Population Health, Tonalá University Centre, University of Guadalajara, Guadalajara,

Mexico. PhD in Psychology. Email: reyna.martinez@academicos.udg.mx ORCID: https://orcid.org/0000-

0002-0146-7660

Department of Psychology, University of Guanajuato, Guanajuato, Mexico. PhD in Medical Sciences.

josema_delaroca@yahoo.com.mx ORCID: https://orcid.org/0000-0002-2563-403X

DOI: https://doi.org/10.15517/wl.v18i1.55625

Recepción: 15/09/2023 Aceptación: 07/05/2023

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RESUMEN

Objetivo: Medir la percepción de las enfermeras sobre la agresión y violencia durante la pandemia de

COVID-19 en México. Antecedentes: La pandemia de COVID-19 ha generado tensión física y emocional en

todos los trabajadores de la salud, como rechazo, maltrato, estrés y ansiedad. Métodos: Estudio transversal

analítico, aplicado virtualmente a través de un formulario de Google, para recolectar datos sociodemográficos,

ocupacionales y clínicos de los trabajadores. Se aplicó el Cuestionario de Salud General de Goldberg (GHQ-

28), el tamaño de la muestra fue de 560 enfermeras de universidades, hospitales y colegios de enfermería de

México. Resultados: La principal fuente de agresión contra las enfermeras, fueron los extraños, aumentando

los síntomas de ansiedad e insomnio. Conclusiones: La pandemia de COVID-19 ha exacerbado la violencia y

discriminación hacia los profesionales de la salud. Se investigó la percepción de agresión y rechazo hacia el

personal de enfermería durante la pandemia. Los estudiantes, técnicos y egresados de enfermería perciben

más agresiones que enfermeros especialistas o con posgrado. Encontramos que las enfermeras más jóvenes,

que vivían en el este del país, trabajaban en sector público en entornos clínicos u hospitalarios y tenían

contacto con pacientes con COVID-19, o fueron diagnosticadas positivas, eran más susceptibles a violencia.

Palabras clave: COVID-19, psicosocial, violencia, discriminación, salud personal.

Background

The COVID-19 pandemic has generated physical and emotional strain for all health

workers, added to the many existing stressors in the daily work and activities of nurses.

However, the most common stressors may be divided into three categories: difficulty

relating to patients, lack of resources, and workload. The COVID-19 pandemic has

generated more stress than the three main stressors combined, due to the rejection,

maltreatment, stress, and anxiety it has caused for health workers. However, nurses still

provide their services daily to a significant number of patients who are sick with the virus.

On the other hand, social distancing has consequences for workers' psychological

wellbeing, now considered a vulnerable population (Acosta et al., 2002).

It is inescapable that nurses have a duty of care, in other words, they protect life by

ensuring the satisfaction of needs, and they are the only permanent carer in the healthcare

system. Nurses' steadfastness in the care of the patient subjects them to stressful situations,

and they are vulnerable to suffering physical and psychological afflictions. Moreover, when

work is predictable, aggressive behaviour from patients and their family members influence

the perception of aggression and maltreatment of that health worker (Flores et al., 2010;

Kumari et al., 2022).

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On the other hand, we can trace the consequences of aggression to the physical and

psychological health of the worker. Health workers can present with psychosomatic

diseases, lower performance in providing their services, and absenteeism. This is reflected

in an observable deterioration in the quality of care a patient receives (Animal Politico,

2020).

Although frequently the aggressive behaviours by patients may harm their recovery

process, the nursing staff may be reluctant to commit to these patients due to the anxiety

from being hurt physically or psychologically (Ansoleaga, 2015).

The Health Professional is immersed in the context of risk at work, as they pass

most of the day subject to occupational hazards, considered by many of them to be "part of

the job". Health personnel have put their own and their families’ lives at risk. If this

challenge were not enough, the increase in acts of aggression and discrimination towards

health staff is evident (Avendaño, 2020). Aggression, maltreatment, rejection, and

discrimination towards health workers creates a harmful effect at the individual, social, and

occupational levels, affecting performance when attending to patients, besides creating

stress, injuries, and sometimes even death (Needham et al., 2005; Pollock et al.,2020).

Painfully, over time, these behaviours towards health workers have been

normalised, discrimination has occurred in public spaces, streets, workers' homes and even

in treatment centres for COVID-19 patients. Health workers around the world have

contracted the coronavirus and, hence, have been viewed as a risk for public health (Madrid

Franco et al., 2011). This has generated discrimination towards health workers. Another

facet of this psychological attack by members of the public is rejection; refusing to

maintain contact with health staff outside of the hospital because they suspect they are

infectious. Avoidance gradually transformed into more direct actions such as prohibiting

hospital staff from entering supermarkets, grocery stores, lifts or common areas in buildings

and health professionals were asked to abandon their apartments (El Tiempo, 2020).

In cities such as New York, the psychological threat posed by health workers as

potential vectors of the virus forced doctors and nurses to sleep in their vehicles and not

return home. This persecutory and discriminatory attitude and is highly contrasted with the

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applause and ovations promoted by the community for a few minutes to signal support for

health workers (González, 2020).

Another form of discrimination was evident when medical staff or nurses in surgical

scrubs were denied access to public transport towards the hospital. Although the health

worker quickly explained that casual clothes were changed for hospital clothes once inside

the hospital, the public maintained their rejection, which forced some cities to make

exclusive transport or routes available to ensure the mobility of health workers (Galián

Muñoz, 2012).

Collecting data published in the Latin-American press, we can see that cases of

discrimination or violence against health workers have been recorded in many countries,

registering at least 111 cases: Mexico, 40; Columbia, 20; Argentina, 10; Venezuela, 9;

Paraguay, 8; Honduras, 4; Panama, 4; Peru, 2; Costa Rica, 1; El Salvador, 1. Almost half

(45%) of the cases of discrimination or violence have occurred against women, and 28%

against men; 40% against doctors, 40% against nurses and nursing assistants, and 11%

against various members of the health team simultaneously (Idoiaga, 2016).

Regarding psychological aggression, it seems that the fear of contracting or

transmitting the disease, coexisting with the frontline workers during the pandemic,

developed from different elements. The unknown about a new virus, erratic symptoms that

to date do not have proven therapeutic strategies. On the other hand, the uncertainty

generated by the indeterminate closure of business and the duration of the quarantine

measures.

Finally, the permanent threat with acts of anguish through the media and social

networks, in some cases with broadcasting indeterminate investigations, have a negative

impact on health workers who are already frustrated and consumed by the situation (Jojoa,

2020).

There is also the possibility of contracting infection and/or transmitting it to loved

ones, especially in places with irregular availability of the protective equipment necessary

to face their care; and at the same time, the anguish of health personnel responsible for

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other people, mothers, heads of household, only children, regarding who would be called

for their loved ones in case they succumb to the illness (United Nations, 2020).

Emphatically, the representative for the United Nations (UN) in Mexico lamented

the increase in aggression towards health personnel who combated the COVID-19

pandemic and drew attention to the vital work that they do. In a press communication, the

UN in Mexico calls on the whole population to respect the work of the health professionals

and condemns any expression of “hate, intolerance, stigmatisation, and discrimination

against those who are today are the front-line responders of pandemic” (United Nations,

2020).

Regarding the psychological impact wrought by the pandemic, isolation may

worsen anxiety and mental anguish. Those in quarantine may perceive fatigue, loneliness,

anger, shame, guilt, or stigma, motivated in part by the media. Psychological anxiety has

been associated with symptoms of post-traumatic stress, financial losses and the risk of

unemployment, and negative emotions were intensified further still (Maguire et al., 2018).

Although health staff are familiar with death, witnessing several deaths daily may

provoke anxiety and anguish within any human being. Being alongside these patients,

accompanying them in their final moments, just as much as it could be a profoundly human

moment, can also be exhausting and frustrating (Guerra, 2020).

The deaths of health professionals have been a hard knock to families, as well as

health institutions, whose most valuable resources are the healthcare workers themselves

that every country is counting on to combat the illness, and it should be the first universal

principle to support them in these moments of social risk (González, 2020).

All the above is highly important, considering that while the primary strategy

around the world has been to situate people within their homes, health staff prepared for the

opposite; that is to say, they prepared for commuting to treatment centres to attend to

patients carrying a virus with a very high capacity for transmission (Semana, 2020).

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Methods

Cross-sectional analytic study to understand the perception of aggression and

violence among Mexican nurses. The study was conducted online through a Google form.

The participants were professional nurses or trainee nurses. Nurses were found through

Universities, hospitals, and nursing colleges across the country. A total of 560 nurses

responded to the call, and four were excluded for answering that they did not want their

data used for research purposes. A survey was undertaken to capture sociodemographic,

work, and clinical variables, such as: age, sex, civil status, education, workplace, and if the

sector was public or private, the state where they lived if they were in contact with COVID-

19 patients, or if they had been diagnosed with COVID-19. Additionally, we investigated

the perception of aggression or rejection by direct family, colleagues, neighbours, patients,

or family members of patients and/or by strangers. The study was conducted during the

months of April 2020 to October 2020. Inclusion criteria: Nursing professionals or

students, workers, practitioners or social service providers who practice nursing in Mexico

and who complete the form; Exclusion criteria: Health professionals from other areas;

Elimination criteria: Participants with incomplete questionnaires.

It is important to note that the state where the participant lived was later grouped

into 8 regions that divide Mexico: the Northeast (Baja California, Chihuahua, Durango,

Sinaloa, Sonora), Northeast (Coahuila, Nuevo Leon, Tamaulipas), West Mexico (Colima,

Jalisco, Michoacan, Nayarit), East Mexico (Hidalgo, Puebla, Tlaxcala, Veracruz), North

Central (Aguascalientes, Guanajuato, Queretaro, San Luis Potosi, Zacatecas), South Central

Mexico (Mexico City, the State of Mexico, Morelos), Southwest (Chiapas, Guerrero,

Oaxaca) and Southeast (Campeche, Quintana Roo, Tabasco, Yucatan).

Furthermore, we applied the Goldberg General Health Survey (GHQ-28), validated

in Mexico, obtaining an α=0.91. There are four subscales with seven items each: somatic

symptoms (α=0.86), anxiety and insomnia (α=0.86), social dysfunction (α=0.86), and

depression (α=0.80). The GHQ-28 evaluates the general level of health, tries to differentiate

probable psychiatric patients from those considered as potentially normal. It has been

employed in epidemiological screening studies to assess mental health at the population

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level, young students, older people, pregnant and post-natal women, relatives, and carers of

the chronically ill, among others (Solís Camara et al., 2016).

Informed consent and the Goldberg General Health Survey were transcribed to a

Google Form and distributed virtually. Answer time did not exceed 10 minutes. We used

the Statistical Package for the Social Sciences v21 for the data analysis. To describe the

population's sociodemographic characteristics, we obtained frequencies and percentages

and median and standard deviation according to the variable type. To find any existing

differences between nurses exposed to aggression or violence by others, concerning

somatic symptoms, anxiety and insomnia, social dysfunction, and depression, we used the

Chi2 or Fisher's Exact test in case of more than 25% of the boxes having a frequency below

Additionally, those had statistically significant differences with a value p < 0.05.

We calculated the Odds Ratio (OR). To contrast the sociodemographic characteristics, we

used the Student's t-test for independent samples and the Chi2 or Fisher's Exact test, in this

case, realising a post-hoc pair-wise analysis to find precisely where there are differences in

tables greater than 2x2 and in this second analysis we calculated the odds ratio (OR).

Regarding ethical considerations, the project was approved by the Committee of

Ethics and Research with an approval number of R-2020-1001-078. By answering the

survey online, the participants read the informed consent and gave their express permission

for their data to be used for research purposes. For this investigation, we followed the basic

principles established in the Helsinki Declaration and the General Law on Health

Regulations as Relates to Health Research in Mexico [Ley General de Salud en Materia de

Investigación para la Salud, MEX-1986-L-3369].

Results

The sociodemographic characteristics of the 556 participants are shown in Table 1.

The number of nurses that have perceived aggression or rejection due to COVID-19 from

family members were 17 (3.1%), from colleagues 23 (4.1%), neighbours (7.6%), patients or

patient's family members 20 (3.6%), and/or by strangers 202 (36.3%). Regarding the result

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of Goldberg's General Health Questionnaire (GHQ), 47 (8.5%) of nurses obtained

significant scores in the dissemination of somatic symptoms, 117 (21%) in anxiety-

insomnia, 27 (4.9%) in social disfunction and 14 (2.5%) in depression.

Table 1. Sociodemographic and clinical characteristics of the sample

n (%)

M±DE

Sex

Female

Male

445 (80)

111 (20)

Age

30.47±9.6

Civil Status

Married/ Free Union

Divorced/ Separated

Single

Widowed

181 (32.6)

34 (6.1)

338 (60.8)

3 (0.5)

Education (Nursing)

Technician/ auxiliary

Post-technical specialism

Student

Undergraduate

Postgraduate

114 (20.5)

65 (11.7)

101 (18.2)

209 (37.6)

67 (12.1)

Type of work

Hospital/ Clinical

Other

226 (44.5)

282 (55.5)

Work sector

Public

Private

296 (68.2)

138 (31.8)

Residence (in Mexico)

Northwest

Northeast

West

East

Central North

Central South

Southwest

Southeast

19 (3.4)

14 (2.5)

363 (65.3)

28 (5)

36 (6.5)

58 (10.4)

20 (3.6)

18 (3.2)

In contact with COVID-19 patients

Yes

218 (39.2)

338 (60.8)

Diagnosed with COVID-19

Yes

5 (0.9)

551 (99.1)

Note: n (%) = frequency (percent); M±DE= Mean ± Standard deviation.

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When comparing the GHQ dimensions with the results of the concurrent survey for

the perception of aggression or rejection among nurses in Mexico, we found statistically

significant differences in somatic symptoms, where the source of aggression or rejection

was close family and strangers. Furthermore, in the subscale of anxiety and insomnia,

aggression or rejection by strangers was the source of stress and insomnia (Table 2).

Table 2. Aggression or rejection perceived by nurses in Mexico and its impact on health,

measured by the Goldberg Health Questionnaire

Somatic Symptoms

Anxiety and

Insomnia

Social Dysfunction

Depression

Aggression or

Rejection by:

Case

n(%)

No case

n(%)

Case

n(%)

No case

n(%)

Case

n(%)

No case

n(%)

Case

n(%)

No case

n(%)

Close Family

Yes

4 (8.5)

43 (91.5)

13 (2.6)

496 (97.4)

6 (5.1)

111

(94.9)

11 (2.5)

428 (97.5)

1 (3.7)

(96.3)

16 (3.0)

513 (97)

0 (0)

(100)

17 (3.1)

525 (96.9)

p=0.047; OR=3.55

p=0.142

p=0.576

p=1.00

Colleagues

3 (6.4)

20 (3.9)

5 (4.3)

18 (4.1)

1 (3.7)

22 (4.2)

0 (0)

23 (519)

44 (93.6)

489 (96.1)

112

(95.7)

421 (95.9)

(96.3)

507 (95.8)

(100)

519 (95.8)

p=0.432

p=1.00

p= 1.00

p=1.00

Neighbours

3 (6.4)

44 (93.6)

39 (7.7)

470 (92.3)

9 (7.7)

108

(92.3)

33 (7.5)

406 (92.5)

(14.8)

(85.2)

38 (7.2)

491 (92.8)

2 (14.3)

(85.7)

40 (7.4)

502 (92.6)

p=1.0

p=1.00

p=0.138

p=0.286

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Patients or

their family

members

Yes

4 (8.5)

43 (91.5)

16 (3.1)

493 (96.9)

6 (5.1)

111

(94.9)

14 (3.2)

425 (96.8)

1 (3.7)

(96.3)

19 (3.6)

510 (96.4)

0 (0)

(100)

20 (3.7)

522 (96.3)

p=0.079

p=0.399

p=1.00

Strangers

Yes

26 (55.3)

21 (44.7)

176 (34.6)

333 (65.4)

56 (47.9)

61 (52.1)

146 (33.3)

293 (66.7)

(33.3)

(66.7)

193 (36.5)

336 (63.5)

5 (35.7)

9 (64.3)

197 (36.3)

345 (63.7)

p=0.005; OR=2.34

p=0.004; OR=1.84

p=0.740

p=1.00

Nota: n(%)= frequency and percent; p= p value; OR= Odds Ratio

With respect to the sociodemographic characteristics, we did not find differences by

sex or civil status. We did find statistically significant differences by education, age,

location, and sector, residence, nurses in contact with COVID-19 patients and diagnosed

with COVID-19 (Table 3).

Table 3. Comparison of the perception of aggression or rejection by sociodemographic

characteristics

Aggression and rejection by

Close Family

Colleagues

Neighbours

Patients or

Patient’s

Family

Strangers

Yes

n (%) / M±DE

Sex

Male

2 (1.8)

109

(98.2)

7 (6.3)

104

(93.7)

8 (7.2)

103

(92.8)

5 (4.5)

106

(95.5)

(39.6)

(60.4)

Female

(3.4)

430

(96.6)

(3.6)

429

(96.4)

(7.6)

411

(92.4)

(3.4)

430

(96.6)

158

(35.5)

287

(64.5)

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p=0.545

p=0.191

p=0.877

p=0.570

p=0.418

Civil

Status

Married/

Free Union

2 (1.1)

179

(98.8)

9 (5)

172

(95)

(5.5)

171

(94.5)

4 (2.2)

177

(97.8)

(33.7)

120

(66.3)

Divorced/

Separated

2 (5.9)

(94.1)

1 (2.9)

(97.1)

(11.8)

(88.2)

1 (2.9)

(97.1)

(41.2)

(58.8)

Single

(3.8)

325

(96.2)

(3.8)

325

(96.2)

(8.3)

310

(91.7)

(4.4)

323

(95.6)

126

(37.3)

212

(62.7)

Widowed

0 (0)

(100)

0 (0)

(100)

0 (0)

(100)

0 (0)

(100)

(33.3)

2 (66.7)

p=0.176

p=0.890

p=0.457

p=0.466

p=0.817

Education

Technical/

auxiliary

(CTA)

1 (0.9)

113

(99.1)

1 (0.9)

113

(99.1)

8 (7)

106

(93)

3 (2.6)

111

(94.4)

(45.6)

(54.4)

Specialism

and post-

technical

(EPT)

3 (4.6)

(95.4)

3 (4.6)

(95.4)

1 (1.5)

(98.5)

1 (1.5)

(98.5)

(46.2)

(53.8)

Student

(E)

2 (2)

(98)

5 (5)

(95)

(11.9)

(88.1)

3 (3)

(97)

(30.7)

(69.3)

Undergrad

uate (L)

(4.8)

199

(95.2)

(5.7)

197

(94.3)

(9.6)

189

(90.4)

(4.8)

199

(95.2)

(34.4)

137

(65.5)

Postgradua

te(P)

1 (1.5)

(98.5)

2 (3)

(97)

1 (1.5)

(98.5)

3 (4.5)

(95.5)

(25.4)

(74.6)

p=0.263

p=0.249

p=0.028

Post hoc: EPT vs

E (p=0.015,

OR=8.629); EPT

vs L (p=0.033,

OR=6.772); E vs

P (p=0.014,

OR=0.112); L. vs

P (p=0.030,

OR=0.143).

p=0.772

p=0.016

Post hoc: CTA vs

E (p=0.025,

OR=0.528); CTA

vs L (p=0.049,

OR=0.627); CTA

vs P (p=0.007,

OR=0.405); EPT

vs E (p=0.044,

OR=0.517); EPT

vs P (p=0.013,

OR=0.397).

Work

Hospital/

Clinic

(5.8)

213

(94.2)

(6.6)

211

(93.4)

(9.3)

205

(90.7)

(4.9)

215

(95.1)

102

(45.1)

124

(54.9)

Other

4 (1.4)

278

(98.6)

6 (2.1)

276

(97.9)

(6.4)

264

(93.6)

8 (2.8)

274

(97.2)

(31.9)

192

(68.1)

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p=0.007;

OR=0.236

p=0.011;

OR=0.306

p=0.221

p=0.231

p=0.002;

OR=0.570

Work

sector

Public

(4.7)

282

(95.3)

(6.1)

278

(93.9)

(8.1)

272

(91.9)

(3.7)

285

(96.3)

117

(39.5)

179

(60.5)

Private

1 (0.7)

137

(99.3)

2 (1.4)

136

(98.6)

(7.2)

128

(92.8)

6 (4.3)

132

(95.7)

(44.2)

(55.8)

p=0.045;

OR=0.147

p=0.032;

OR=0.227

p=0.756

p=0.752

p=0.356

Residence

Northwest

1 (5.3)

(94.7)

1 (5.3)

(94.7)

1 (5.3)

(94.7)

0 (0)

(100)

(36.8)

(63.2)

Northeast

0 (0)

(100)

1 (7.1)

(92.9)

0 (0)

(100)

0 (0)

(100)

(21.4)

(78.6)

West

9 (2.5)

354

(97.5)

11 (3)

352

(97)

(7.2)

337

(92.8)

7 (1.9)

356

(98.1)

124

(34.2)

239

(65.8)

East

0 (0)

(100)

2 (7.1)

(92.9)

(14.3)

(85.7)

(10.7)

(89.3)

(46.4)

(53.6)

North

Central

2 (5.6)

(94.4)

2 (5.6)

(94.4)

2 (5.6)

(94.4)

3 (8.3)

(91.7)

(30.6)

(69.4)

South

Central

2 (3.4)

(96.6)

3 (5.2)

(94.8)

5 (8.6)

(91.4)

4 (6.9)

(93.1)

(53.4)

(46.6)

Southwest

2 (10)

(90)

2 (10)

(90)

2 (10)

(90)

2 (10)

(90)

6 (30)

14 (70)

Southeast

1 (5.6)

(94.4)

1 (5.6)

(94.4)

(11.1)

(88.9)

1 (5.6)

(94.4)

(38.9)

(61.1)

p=0.265

p=0.274

p=0.751

p=0.016

Post hoc: West

vs East(p=0.028,

OR=6.103)

p=0.115

Contact

with

COVID-19

patients

Yes

11 (5)

207

(95)

(7.8)

201

(92.2)

(10.1)

196

(89.9)

(6.4)

204

(93.6)

101

(46.3)

117

(53.7)

6 (1.8)

332

(98.2)

6 (1.8)

332

(98.2)

(5.9)

318

(94.1)

6 (1.8)

332

(98.2)

101

(29.9)

237

(70.1)

p=0.029;

OR=0.34

p≤0.001;

OR=0.214

p=0.069

p=0.004;

OR=0.263

p≤0.001;

OR=0.494

Diagnosed

with

COVID-19

Yes

1 (20)

4 (80)

1 (20)

4 (80)

0 (0)

(100)

1 (20)

4 (80)

(100)

0 (0)

(2.9)

535

(97.1)

22 (4)

529

(96)

509

(92.4)

(7.6)

(3.4)

532

(96.6)

197

(35.8)

354

(64.2)

p=0.144

p=0.191

p=1.00

p=0.168

p=0.006;

OR=2.797

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141

Age

26.65±

4.3

30.59±

9.6

30.09±

8.4

30.35±

9.6

28.07±

7.9

30.66±

9.7

29.45±

6.8

30.5±

9.7

28.74±

7.2

31.45±

10.6

p=0.002

p=0.180

p=0.092

P=0.629

p≤0.001

Note: n(%) = frequency (percent), M±DE= Median ± standard deviation, p= p value, OR= Odds Ratio,

CTA= technician/auxiliary, EPT = post-technical specialist, E= Student, L= Undergraduate, P=

Postgraduate.

In terms of the post-hoc analysis by education, students, and those with a degree in

nursing were those who presented had a greater risk for the perception of violence and/or

rejection by neighbours. For the perception of violence and/or rejection by strangers the at-

risk-groups were those with a technical or auxiliary background, and nurses with a post-

technical specialism. In terms of location and the perception of violence and rejection by

patients and their family members, differences were found between the West and East, with

the East having greater risk.

Discussion

Violence and discrimination towards health professionals is a sad reality that has

become more acute since the COVID-19 pandemic began. Our aim in this study was to

investigate the perception of aggression and rejection towards nursing staff due to the

pandemic, finding that it was mainly from strangers, impacting mental health, mainly

through symptoms of anxiety and insomnia. Nursing students, both technical and degree

level, presented with a greater perception of rejection or aggression than those with a

specialism or post-graduate degree. Younger people, those who were in the East of the

country, public sector workers in clinics and hospital, those that had contact with COVID-

19 patients, or had also been diagnosed were more sensitive to this type of violence.

Discrimination, stigmatisation, and/or violence that is externalised with health

workers presents a new situation, with multiple challenges. Where preceding situations

exist, New ones arise, connected to the historical moment that the world is going through,

and forcing us to think of new approaches and strategies to reach the greatest number of

people possibly sick with COVID-19. It has been shown that healthcare professionals, as

part of their own work, are at high risk of contamination from COVID-19 (Senuzun Ergün

& Karadakovan, 2005; Hernández-Hernández et al., 2023).

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142

In Mexico, it is estimated that up to 20% of cases are health professionals. In this

context, and accompanied with uncertainty and misinformation, there has been an increase

in fear and violence towards these professionals. Therefore, the excessive workload due to

the rise in infections in the population and the need for social isolation to avoid infecting

family members are not the only stressors on these professionals. Rejection and social

discrimination, even physical violence against healthcare workers has made them prone to

physical exhaustion, fear, anxiety, depression, post-traumatic stress disorders, sleep

problems, among other negative health impacts (Agredo, 2020; Bitencourt et al., 2021).

At the Nanfang Hospital in the Medical University of South China, researchers

found a depression prevalence of 50.7%, anxiety 44.7%, insomnia 36.1%, and symptoms

related with stress in 73.4% of a sample of doctors.

Considering that not all respondents work in clinical or hospital environments, nor

had they perceived aggression or rejection, the percentages are not as high as those reported

in the literature. However, filtering out only those who had perceived aggression,

specifically by strangers, physical symptoms reach up to 55.3%, anxiety and insomnia

47.9%, social disfunction 33.3%, and depression 35.7%, evidencing the psychological

impact that these acts generate among nurses.

Regardless of the function that the professional performs, be that doctor, nurse,

technician, the lived experiences of discrimination in their daily lives are the same: on

public transport, in supermarkets, and even in their places of residence they are victims of

intense stigmatisation, that on various occasions has materialised as physical and verbal

aggression. Cases of violence and discrimination of healthcare worker victims may be

caused by the public's fear of contagion (Animal Politico, 2020).

Regrettably, this type of behaviour, are often not denounced, the rhetoric revolves

around highlighting that there is a general acceptance that workplace violence exists and

that it forms an intrinsic part of the work of professionals in the healthcare system, as

mentioned previously. Unfortunately, the psychological consequences for health workers is

a topic of great impact, at both the national and global levels, that generates traumas as the

biopsychosocial level of the victim.

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143

Violence at work is all those incidents in which personnel suffer abuse, threats, or

attacks in the circumstances related to their work, that implicitly or explicitly puts security,

wellbeing, or the worker's health at risk. The World Health Organization (WHO) reported

that almost 25% of all the incidents of violence discussed here occur in the healthcare

system. It is evident that there have always been aggressions that violate the rights of

healthcare workers; a situation that has intensified in COVID-19 pandemic times; which is

why in response, the UN made a statement calling for respect and condemnation of the

situation (WHO, 2006).

Typically, the family is considered the principal source of social support.

Unfortunately, intrafamily violence has increased globally due to the COVID-19 pandemic

(International Labor Organization [ILO], 2002). In our study, only a small percentage of

nurses reported having perceived rejection or discrimination by a family member, with

significant differences in somatic symptoms. Some authors have argued that the family

could perceive professionals as a health risk. We should consider that the mental health of

the family is also affected, increasing the stress, fear, and exhaustion response (WHO,

2002).

In this sense, our findings show that those nurses that work in clinical or hospital

environments, principally in the public sector, and that have been in contact with COVID-

19 patients, perceive more aggression or rejection from their family. On the other hand,

various studies have indicated that the mental health of younger or student participants has

been more severely impacted (ILO, 1998). Additionally, teenagers and young adults have

been considered a vulnerable group for acts of intrafamilial violence during the pandemic

for COVID-19 (Estryn-Behar et al., 2008).

However, we did not find any study that indicated that younger health professionals

or students in health are more likely targets of aggression or rejection than older

participants, and much less that this type of acts are within the family or generated by some

other specific sources. There is a gap in the research that needs to be explored. Based on

our findings, strangers are the principal source of aggression and rejection perceived by

nurses in Mexico, generating somatic anxiety-insomnia symptoms. In accordance with

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other studies (United Nations, 2020), hospital workers are most affected, especially those

who are in contact with COVID-19 patients or have been diagnosed (Farrel et al., 2005).

Healthcare professionals may be a target of greater stigmatisation, and that mass enforced

quarantine may cause mass hysteria, anxiety, and anguish, due to factors such as the sense

of being trapped and the loss of control, intensified if there are financial losses, greater

perception of risk, and of course disinformation (Jackson et al., 2002).

In the case of students, psychological impact linked to themes such as source of

income, future employment, or their place of residence or compared against those that

already have a job has been reported. We hypothesise that these hierarchical and economic

disadvantages, such as uncertainty towards the future and lack of experience could make

student nurses a target for discrimination and assault in Mexico, as many of them are

economically dependent, travelling on public transport, and are subordinate or restricted in

clinical areas. Again, this is a research and intervention gap during the pandemic (Kackin et

al., 2020).

On the other hand, the nurses evaluated have also perceived discrimination or

rejection from work colleagues, patients, and family members of patients. The variables

that have been significant by relating them with this source of violence is that they work in

the public sector, they work directly with COVID-19 patients, and we found differences by

a residential area, being those that live in the East of the country the most affected in this

respect (Kang et al., 2020).

It has been reported that some healthcare workers, not involved with COVID-19

patients, have been discriminatory towards providers of frontline medical staff and if they

are, through behaviours such as talking negatively about them or disapproval of eating in

the same cafeterias. They also reported that nurses who care for other colleagues during the

pandemic may increase the anxiety of personnel in the hospital with respect to their

competency and abilities, making them more vulnerable mentally. The fear of finding

oneself in situations such as these, adding to the misinformation and the social panic that it

has generated, could explain the discriminatory and rejection behaviours between

colleagues (Labrague & De los Santos, 2020).

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145

In the case of violence by patients and family members has been studied for several

years pointing to patients and visitors as principal instigators. During the SARS pandemic,

health professionals were more prone to stigmatisation, it was reported that 54% of nurses

evaluated in their study affirmed that they had been exposed to non-physical violence, and

20% had been exposed to acts of physical violence in the workplace. Something similar

was reported, where 12.8% of nurses in their sample experienced discrimination in the

workplace, and 28.3% of nurses experienced harassment by patients or members of the

public. Furthermore, it has been argued that healthcare workers may find it extremely

difficult to treat alarmed, uncooperative, panicked, and stigmatised COVID-19 patients,

possibly generating apathy and abstinence among healthcare professionals (Pappa et al.,

2020).

This study did not find differences between the perception of discrimination and

violence by sex or civil status, despite the UN (2020) having included a gender perspective

on the prevention measures and security during the pandemic, or, both characteristics are a

risk factor for psychological malaise.

Furthermore, it has been indicated that we should consider the economic burden due

to the costs related with increased rotation, absenteeism, medical and psychological

attention, low labour satisfaction, and a decrease in morale and the resulting quality of care

that arises when nurses admit that they tend to avoid patients who have been or could be

violent.

Conclusions

The COVID-19 pandemic has exacerbated violence towards and discrimination

against health professionals.

The nurses evaluated have also perceived discrimination or rejection from

colleagues, patients, and the family members of patients.

We corroborated an existing relationship between violence and perceived

discrimination by workers in the public sector, who work directly with COVID-19 patients,

or who live in East Mexico.

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146

Nurses perceived some form of violence or discrimination from direct family,

colleagues, neighbours, patients, or family members, but above all from strangers.

Based on the Goldberg General Health Survey, nurses expressed a greater number

of somatic symptoms, reflected in an increase in anxiety, insomnia, social dysfunction, and

depression.

There is a lack of programs oriented towards mental health for professionals and

students in the field of health.

Implications for Nursing Management

Nursing students, technicians and graduates perceived more aggression than

specialist nurses or those with a post-graduate qualification. Among our respondents, we

found that younger nurses, who lived in the East of the country, worked in the public sector

in clinical or hospital settings, and had contact with COVID-19 patients or had been

diagnosed with the virus were more susceptive to this type of violence.

Strategies should be developed to improve the mental health of nurses and students

in the field of health that are attending to COVID-19 patients; as well as managing,

teaching, and support staff that work in public hospitals and clinics in Mexico, such as the

Mexican Institute of Social Security as well as private hospitals and clinics.

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Corresponding author:

José María de la Roca Chiapas, PhD

Department of Psychology, University of Guanajuato, Blvd. Puente Milenio 1001, Fracción

del Predio San Carlos, C.P. 37670, León Guanajuato. Email:

josema_delaroca@yahoo.com.mx Telephone: +52-477-2674900 ext. 3664.

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