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COVID-19 Stigma and Nurses’ Professional Quality of Life, Self-esteem and Performance

Magda Atiya Gaber Atiya*, Wafaa Mostafa Mohamed Sliman, Safia Ragab Elsebaie

Department of Nursing Administration, Faculty of Nursing, Zagazig University, Egypt

Abstract: Background: The COVID-19 pandemic has risen to the top of the public's concentration. Epidemics generate societal stigma. Contagion stimulates numerous preconceptions, views, emotional states, labels, stereotypes, and stigmas. Emotions play a crucial role in these situations, affecting planned or fact-based decisions. Today amid COVID-19, nurses in a challenge for caring for patients. There is a conflict between the professional obligation due by nurses to their patients and the contagion-induced tacit attitudes. A fear begins during outbreaks as a result of concern about an unidentified reason disease with a potentially lethal end, particularly when infection control procedures such as quarantine and strict isolation are executed to safeguard the public. Methods: The exploratory correlational design was used to achieve the objectives of the present study. This study was conducted at Zagazig University Hospitals (ZUH’s), Egypt. A stratified proportionate random sample (n=326) from different categories of nurses, and a Jury committee (n=7). 4 Questionnaires format and 4 opinionnaire sheets were utilized for data collection. Results: 56.1% of study subjects have a high level of social stigma. there were statistically significant differences between COVID-19 social stigma and nurses’ performance (task dimension at p-value 0.004, Contextual dimension at p-value 0.0001 and Counterproductive dimension at p-value 0.0001), nurses’ self-esteem at p-value 0.001, and nurses' professional quality of life (satisfaction at p-value 0.002, nurses' burnout at p -value 0.0001, and nurses' fatigue at p -value 0.0001). Conclusion and recommendations: nurses have a high level of stigma. COVID-19 stigma was associated with nurses’ performance, self-esteem, and professional quality of life. Nurses’ self-esteem and professional quality of life were associated with nurses’ performance. Stigma predicts performance (contextual dimension), Self-esteem predicts performance (task and counterproductive dimension), satisfaction predicts performance dimensions, burnout predicts task, contextual dimensions, and stigma, and finally, fatigue predicts counterproductive dimension. Thus, strategies and measures should be taken, to promote nurses’ quality of life, self-esteem, and performance; keep nurses away from fatigue, burnout, and stigmas; enforce positive public attitudes toward nurses; continuing education and training sessions; and support.

Keywords: stigma, COVID-19, nurses’ performance, professional quality of life, self-esteem

Received November 01, 2021; Revised December 03, 2021; Accepted December 12, 2021

Citation: Magda Atiya Gaber Atiya, Wafaa Mostafa Mohamed Sliman, Safia Ragab Elsebaie, COVID-19 Stigma and Nurses’ Professional Quality of Life, Self-esteem and Performance. American Journal of Nursing Research, 9 (6). 206-215. January 2021. doi:10.12691/ajnr-9-6-4

1. Introduction

The COVID-19 pandemic demonstrated how health affects all parts of life, forcing decision-makers to prioritize important decisions. [1]. Furthermore, [2] emphasized that even with frequent warnings of a likely pandemic, healthcare organizations were not prepared to manage it, according to the report. Additionally, [3] declared that health care providers are now functioning beneath a lot of pressures incorporating a lack of resources, such as a shortage of staff.

COVID-19 is a health disorder with enormous community effects. Healthcare workers (HCWs) are fronting an extraordinary crisis and treacherous unseen threat [4]. HCWs in Africa belong to the high-risk category for COVID-19, [5]. So HCWs must be cautious because they are at a critically greater danger of infection [6]. Nurses are recognized to be the biggest group of HCWs [7]. Nursing performs 73% of medical services for patients in hospitals, meaning that it represents the backbone of the health system along with the rest of the medical team [8]. Nurses are at the forefront of this epidemic [9]. The spirit of labor to endure committed to the public is one method for nurses to sustain their performance in delivering heartfelt service and caring for COVID-19 victims even with increasing job burden and inadequate personal protective equipment. [10]

Nurses are now powerfully integrated into COVID-19 doings, and they will stay the key contributor in inhibiting and controlling the epidemic. So, they must be supported, given the opportunity to work, and empowered with a healthy work setting. The environment has to be a judgment-free atmosphere, where they will be permitted to record happenings as exposure to threats, or reports of allegations, maltreating, or abuse, and to take required act as providing of counseling. Occupational safety is critical to nurses' work during COVID-19 [11].

The research questions were:

1. What is the perceived level of COVID-19 stigma, nurses’ performance, professional quality of life, and self-esteem among nurses at Zagazig University Hospitals?

2. Is there a relationship between stigma in the context of COVID-19 and nurses’ performance, professional quality of life, and self-esteem at Zagazig University Hospitals?

3. Is there a relation between nurses’ self-esteem and professional quality of life with their performance?

1.1. Hypotheses

The following hypotheses are formulated to achieve the objectives of the present study:

• Hypothesis 1. There will be a negative association between perceived Stigma during COVID-19 and nurses’ professional quality of life and vice versa

• Hypothesis 2. There will be a negative relationship between perceived Stigma throughout COVID-19 and nurses’ self-esteem and vice versa

• Hypothesis 3. There will be a significant relationship between perceived Stigma throughout COVID-19 and nurses’ performance and vice versa

• Hypothesis 4. There will be a positive relationship between nurses’ self-esteem and improved nurses’ performance and vice versa

• Hypothesis 5. There will be a significant positive relationship between nurses’ professional quality of life and better-quality nurses’ performance and vice versa

1.2. Background

Outbreaks, as in the COVID-19 create stigma [12], in the same line the WHO reported that the COVID19 occurrence produced stigma and provided suggestions on how to deal with it (13). This stigma formed mainly when accompanied with various fears and worries related to impressive strange actions to save people's health, incorrect knowing of ways of spread, lack of resources, and contradictory dispatches from experts are reasons that directed to community terror and worry throughout the COVID-19 contagion [14]. Working with possibly extremely communicable cases directed to substantial stigmatization [15].

Stigma can be defined as a sign of shame that puts somebody away from others [16]. In the past, stigma has been allied with altered transferable illnesses [17] and produced discrimination which caused destructive impacts for the persons and the community [18]. Discrimination is the behavioral reply of bias [19] and can be comprehended as community-based practices of power, authority, and supremacy with specific groups [20].

Community stigma has a diversity of bad effects as discomfiture and shame [21]. Individuals are classified, stereotyped, and distinguished when dealing with a very infectious illness. This can have an adverse outcome on patients and the work of HCWs [22].

The process of health-regarding stigma is composed of interaction of driving and facilitating forces [23]. In COVID-19-concerning stigma among HCWs, driving forces include fright of contagion, worries about the public ruling, and self-censure or reprehend to others for being a cause of contagion or for the resulting opposing results [24]. Facilitating forces contain the accessibility of job-related security standards and protective tools for HCWs [25]. Stigma performance included labeling (tenet related to being an HCW), bias (underestimation of HCWs), stigmatizing demeanor (societal evasion in daily actions), and discriminatory stance (persuasion that HCWs should be forbidden from civic contribution) [26].

COVID-19-related stigma has several impacts among HCWs. HCWs are exposed to social separation, public abuses, pestering invectives or annoyance, rejecting to utilize transportation means, and house exclusion. a deficit of counseling and emotional bolster, stigma, worry of infecting their kids, and dread of family stigmatization and the adverse impacts on their children's public and learning life [27].

Stigma has resulted in links between pressure and satisfaction [28]. Generally, individuals who had higher levels of stigma were less satisfied. [29]. Burnout is one of the most widespread somatic and psychical health complaints noticed in nurses [30]. Moreover, workers as nurses working in the field become stigmatized, resulting in higher rates of stress and burnout [31]. In the same context, Health care providers are exposed to a threat of infection, emotional suffering, burnout, working extended shifts, and stigma [32].

Furthermore, stigma is a matter that influences the quality of life and should be identified among HCWs associated with a communicable disease [33]. HCWs felt not only ambiguity and stigmatization but also anticipated quitting their work. In addition, the HCWs suffer from distress, nervousness, and a lower quality of life. In the COVID-19 epidemic, altering functioning and living circumstances (isolation and separation from family), feeling of stigma, and psychosomatic health disorders can affect HCWs quality of life. Generally, various altered work allied tensions undesirably upset the quality of life in hospital nursing staff. [34]

Low self-esteem may be a hazardous aspect leading to bad mental results [35], As well as stigma and fear of contagious diseases, hamper HCWs as nurses of diverse duties and roles from reacting appropriately, rising workloads, and bodily and psychological pressure. Stigma has been connected with lack of knowledge [4] and fear of occasional spread in the work [36]. Delivering care was emotionally hard for nurses, with strain, doubt, and stigmatization. They predominately had multifaceted and contradictory beliefs and emotions about harmonizing their roles as caregivers and parents, sense occupational duty, and at the same time worry from infection and guilt about possibly transmit the infection to their families [37].

Stigma-allied pressure can lead to critical impacts on nurses' results and their performance [38]. Performance is a series of actions, [39]. Job performance is the final following variable in nursing human resource management, and its appraisal is the main concern [40]. Job performance measuring and investigation is crucial for diverse institutional processes, as staffs selection, reward, and payments, or training. Organizations want precise assessments of the act [41]. Job performance has three key dimensions task, contextual, and counterproductive work behavior) [40]. These dimensions deliver a complete and close approach to whole job performance [42].

The performance of nurses through COVID-19 includes giving information, guidance, instruction, and communication, about health to the public; prompt investigation while quick finding and separating of patients with COVID-19 infection must be carried out and direct service to victims which is the key task performed by nurses. Victims or families often practice fear, concern, and sadness. These situations are risky and impede the curing of cases. Immunity will decline and it influences one's power to battle viruses. Patients frequently have numerous health problems; consequently worse patient prognosis may happen and even hurrying death. Patients with COVID-19 had the probability to suffer from a mental interruption and that is where the humanitarian responsibility of a nurse was verified [43].

Chen et al. [44] specified the roles of nurses in five areas for the COVID-19 pandemic. The first one is health education and providing support for high-risk sets. The second arena is the discovery and control of hospital infections. The third domain is the planning and safety protection implementation in nursing care. The fourth domain is the keeping of individuals with immune deficits or chronic obstructive pulmonary disease and cancer. The last area is promoting care to COVID-19 patients. Nurses should have adequate knowledge about COVID-19 to accomplish their roles and tasks in these five domains [45]. Most of the work for patients who need care is carried out by nurses. Nurses must not only ensure a good job in handling patients, but also in daily life care, fundamental care, and psychosocial care [46].

Nurses now are greatly involved in COVID-19 initiatives, and they will endure being a key player in the pandemic's prevention and containment. Consequently, they must be allowed to work in a healthy environment. This environment must be devoid of judgment, where they will be able to record incidences such as infection control risks or claims of maltreatment or mismanagement and make prompt decisions. The primary accountability of nurse leadership will be to ensure that appropriate preventative and safety measures are implemented to reduce workplace dangers. [11]. Nurses should be safeguarded against any potential risks. Furthermore, if a nurse contracts COVID-19, they should be entitled to medical treatment, counseling, reimbursement, and psychotherapy [47].

The Egyptian nursing syndicate confirmed that the number of its members reaches 300,000 thousand nurses and they are working at the governorate level, in all hospitals and health care institutions, pointing out that nursing performs more than 70% of the patient’s health services within the medical facilities [48]. COVID-19 in Egypt. HCWs are on the front line amongst vulnerable people, Egypt and other countries have reported fear of communicating with them in various ways. e.g., there are reports that taxi drivers refuse to bring doctors, restaurants refuse to supply food to hospitals, and citizens reject to let health professionals become neighbors [49]. Jointly, these separate occurrences indicate a likely invisible danger, which may be lead to no reporting of cases, fear to ask therapeutic care, and a negative consequence on the psychological and emotional health of stigmatized sets [50].

1.3. Significance

Working with possibly extremely infective cases produced substantial stigmatization. There were features of stigma documented in Egypt. Reports about residents rejecting to bury the body of dead individuals from COVID-19 have been published as it might be a cause of contagion those events signaled the fear for the stigma, an Additional risky feature of stigma is the one toward healthcare professionals. More than three-quarters of Egyptian doctors consider that stigmatization of HCWs and harassment of families of patients with varying degrees of burnout and fatigue are related [51]. According to the latest actual count of the number of deaths due to the Coronavirus from the nursing staff was reached more than 270 [52]. Nurses are soldiers in COVID-19 pandemic. Thus, if we need to control and prevent this epidemic, we have to fight against stigmatization toward nurses concurrently. COVID-19-related stigma and its relation among nurses have not been studied. There was no scale for assessing COVID-19 stigmatization for nurses that affect nurses. Up till now, numerous knowledge gaps found. So this study aims to explore the relationship between COVID-19 stigma and nurses' professional quality of life, self-esteem and performance may aid administrators to detect this problem effectively and take corrective actions and required measures to protect nurses' professional quality of life and self-esteem, raising the self-esteem of nurses is of great relevance to stabilizing the nursing team and improving the quality of clinical services, that consequently enable nursing staff to carry out their roles, accomplish their performance effectively.

2. Methods

2.1. The Study Aim

This study aimed to explore the relationship between COVID-19 stigma and nurses’ professional quality of life, self-esteem, and performance. The objectives were to assess the level of COVID-19 stigma, nurses' professional quality of life, self-esteem, and performance, and examine correlations among all variables.

2.2. The Study Design

An exploratory correlational design was used to achieve the objectives of the present study

2.3. Ethical Considerations

Managerial arrangements, official permission was obtained from the chairman of the board of trustees at Zagazig University Hospitals to conduct the study and to collect the data. The researchers explained the aim of the study to participants. Nurses were fully informed about the research aim and then, agreed to join the research process. All of them voluntarily responded to the questionnaire. The research was employed through the principles of the Declaration of Helsinki.

2.4. Setting

The research was carried out at Egypt's Zagazig University Hospitals. There are two sectors with eight hospitals having a capacity of around 2168 beds.

2.5. Sample

A stratified proportionate random sample (n=326) giving a response rate of 86.9% from various classes of nursing staff. Exclusion criteria contain staff nurses with less than one year of experience and jury group (n=7). They were (5) professors from the faculty of nursing, Zagazig University, and 2 nursing staff at Zagazig University Hospitals.

2.6. Instruments

The following tools were used to gather data for this research:

a. Questionnaires

The Professional Quality of Life Scale (ProQOL) developed by Stamm 2009 [53,54] was adopted to measure the professional quality of life of accident and emergency workers based on three dimensions (fatigue, satisfaction, and burnout) with 22 items. Items were rated on a 5-point response scale, ranging from 1 = never, 2 = rarely, 3 = sometimes, 4 = often, and 5 = very often. The coefficient alpha for satisfaction was .088, burnout 0. 75, and for fatigue, 0. 81.

The COVID-19 stigma was assessed with Adapted a self-administered multiple-choice questionnaire developed by See et al [55] contains 15 items. Items were assessed on a 4-point response scale, ranging from: strongly to strongly agree. (The coefficient alpha was 0.83).

The Rosenberg Self-Esteem Scale [56,57] was adapted to measure nurses’ self-esteem. A 10-item scale was answered using a 4-point Likert scale format ranging from strongly agree to strongly disagree. (the coefficient alpha was 0.89).

The Individual Work Performance Questionnaire (Koopmans, 2015) [58] is an 18-item scale developed to measure the three main dimensions of job performance: task performance, contextual performance, and counterproductive work behavior. All items have a 5-point rating scale (0 = seldom to 4 = always for the task and contextual performance, and 0 = never to 4 = often for counterproductive work behavior). Reliability were (α = .72, α = .82, and α = .86 for task performance, contextual performance, and counterproductive work behavior dimensions, respectively).

b. 4 opinionnaire sheets

2.7. Data Collection

The current study had two phases: a preparation phase in which the researchers prepared the assessment questionnaire tools, tested their content and face validity, conducted a pilot study, and examined the questionnaires' reliability, and a data collection phase in which data was collected over two months. The time it took to complete the questionnaire sheet ranged from 35 to 45 minutes. Some participants' data were collected by the distribution of questionnaire sheets to the subjects, which was then returned to the researchers once completed.

2.8. Data Analysis

All data were collected, tabulated, and statistically analyzed using SPSS 20.0 for windows (SPSS Inc., Chicago, IL, USA 2011). Quantitative data were expressed as the mean ± SD & (range), and qualitative data were expressed as number & relative frequencies (percentage). A t-test was used to compare two groups of normally distributed variables. Pearson correlation coefficient was calculated to assess the relationship between various study variables, (+) sign indicate direct correlation & (-) sign indicate inverse correlation, also values near to 1 indicate strong correlation & values near 0 indicate weak correlation. All tests were two-sided. p-value < 0.05 was considered statistically significant , p-value < and p-value ≥ 0.05 was considered statistically insignificant.

Multilinear regression:

Situations frequently occur in which we are interested in the dependency of a dependent variable on the independent variable. Formally, the model for multiple linear regression, given n observations, is

Y= the variable that we are trying to predict

X = the variable that is using to predict

a= the intercept (Constant)

β = coefficient of x represents the mean change in the dependent variable) for one unit of change in the predictor variable (independent) t-test =test of significant.

3. Results

3.1. Demographic Characteristics of the Study Sample

Table 1. According to the results, it was found that the mean age of nursing staff in the sample was (33.57±5.8) SD years; the mean of the years of nurses’ experience was (13.86±5.76) SD years. The study sample was composed of females (92.3%). 41.7% of the subjects have technical institute qualifications while 87.7% of the study sample did not receive training about the corona pandemic.

Table 1. Demographic characteristics of studied nurses (n.326)

Table 2. Clarified that the majority of study sample has a moderate level of self-esteem (76.4%), moderate level of performance regarding task dimension (73.6%) contextual dimension (80.0%), and counterproductive dimension (71.8%). 56.1% of study subjects have a high level of stigma. 88.7% of them moderately satisfied, however, 73.9% have burnout and 75.2% have fatigue.

Table 2. Mean, standard deviation, frequency and percentage distribution of following parameters level: Self-esteem, Task dimension, Contextual dimension, counterproductive dimension, Stigma, Satisfaction, Burnout, Fatigue among studied nurses (n.326)

Table 3. It was found that COVID-19 stigma was negatively associated with task dimension at p-value 0.004, contextual dimension at p-value 0.0001, Self-esteem at p-value 0.001, satisfaction at p-value 0.002, nurses' burnout at p value 0.0001, nurses' fatigue at p value 0.0001, and positively associated with counterproductive dimension at p-value 0.0001. Moreover, nurses' self-esteem was positively associated with task dimension at p-value 0.0001, contextual dimension at p-value 0.008, satisfaction at p-value 0.0001, while negatively associated with counterproductive dimension at p-value 0.0001, burnout at p-value 0.0001, fatigue at p-value 0.003, and nurses age at p-value 0.019. As well as nurses' satisfaction was positively associated with task dimension at p value 0.0001, contextual dimension at p-value 0.0001, and negatively associated with counterproductive dimension at p-value 0.0001. Besides nurses' burnout was negatively associated with task dimension at p value 0.0001, contextual dimension at p-value 0.0001, satisfaction at p-value 0.0001, but was positively associated with counterproductive dimension at p-value 0.0001. Along with nurses' fatigue was negatively associated with task dimension at p value 0.014, contextual dimension at p-value 0.005, satisfaction at p-value 0.045, on the other hand, was positively associated with counterproductive dimension at p-value 0.0001, and burnout at p-value 0.0001.

Table 3. Correlation matrix between Self-esteem, Task dimension, Contextual dimension, counterproductive dimension, Stigma, Satisfaction, Burnout, Fatigue (n.326)

Table 4. This shows that self-esteem positively predicts task dimension and negatively predicts counterproductive dimension. While stigma negatively predicts contextual dimension. However, satisfaction positively predicts task and contextual dimensions and negatively predicts counterproductive dimensions. Whereas Burnout negatively predicts task and contextual dimensions. Finally, fatigue negatively predicts the counterproductive dimension.

Table 4. Multiple linear regression model for predict Task dimension score, Contextual dimension score, Counterproductive dimension among studied nurses (n.326)

Table 5. Demonstrated that predictors are; self-esteem, satisfaction, burnout, and fatigue. It was noticed that burnout positively predicts stigma.

Table 5. Multiple linear regression model for predict Stigma among studied nurses (n.326)

4. Discussions

Nursing naturally has long been thought to be hard and challenging work [59]. What is more, in epidemics, nurses are prone to threats and hazards [60]. In the face of the COVID-19 epidemic, nurses are under extraordinary work heaviness, causing numerous psychosomatic disorders [61]. In addition, nurses confronted incidences regarding COVID-19-stigma as house deportation, disallowing to ride public transportations, societal segregation, mistreatments, or annoyance [62]

According to the current study results, most of the studied sample reported that they did not receive training about the corona pandemic. That might be due to: the COVID-19 was not anticipated, the hospitals were unprepared to manage this crisis, there was not a proactive strategy for training and making drills regularly for handling probable disasters or catastrophes, heavy workload, and limited time. This was consistent with [63] who found that HCWs had no definite training allied to coronavirus. Similarly, [64] revealed that, about training at zagazig university hospitals, nursing leaders did not know that there was training carried out before the epidemic. On the other hand, staff nurses were not trained to work with infectious cases. Thus, it was recommended that workshops and training sessions about COVID-19 should be conducted for nurses, furthermore. [65] suggested that simulation should be utilized for COVID-19. The simulation reflects a chance and an important aspect for the delivery of nursing care. Besides, [66] directed that nursing staff should create WhatsApp groups to share, disseminate and communicate messages and information. In the same context [67] clarified that remote or telecommunication facilities could aid professionals to provide consultations, guidance, helpless- competent persons, and decline patient contacts and accordingly possibilities for infection.

The results of the present study showed that the majority of the studied sample had a moderate level of self-esteem, a moderate level of performance dimensions (task, contextual, and counterproductive), moderately satisfied, had burnout and fatigue, had a high level of stigma and felt stigmatized. That could be due to nurses exposed to emotional tiredness, increasing workload, depersonalization, stress, and lack of personal accomplishment, incidents, and reports about social stigma, believing that they are prone to fatal disease, fear from infection, lack information, doubts, rumors and still no treatment available for COVID-19.

This was harmonious with [68] who proved that numerous healthcare providers in the Ebola and SARS waves suffered from stigmatization, and isolation. In the same way, [63] evidenced that HCWs considerably felt stigmatized, COVID-19 symptoms were experienced, and endured from health syndromes. Also, [62] emphasized that most Egyptian physicians had been stigmatized because of COVID-19, primarily from their neighbors and others with who they have interacted in society.

Congruently, [69] underlined that nurses as forefront workers be subjected to psychological effects, as well they have a lower quality of life for a long time following the beginning of the outbreak. Likewise, [70] recognized that stimulatingly, nurses had a greater danger of burnout and stress. However [71] most of the staff demonstrated high self-esteem.

Therefore, recommended that authorities, administrators, and nurse executives should take the required measures, strategies, and actions to protect nurses from stigmatization, burnout, and fatigue; enhance professional quality of life, raise their self-esteem, satisfaction, and as a result nurses' performance will be improved. Furthermore, [72] specified that working in the COVID-19 epidemic was closely linked to nurses’ community-based and ethical duty. Hospital administrators must recognize and reward nurses with bonuses. Moreover, [73] added that leaders should also work to boost the self-esteem of nurses in all areas, keenly reinforce nurses' self-esteem, control all issues that lead to burnout, this will lead to decline professional burnout, and consequently, this will help to enhance their health, the stability of workforce, and performance.

According to the present study, it was discovered that COVID-19 stigma was negatively associated with task dimension, contextual dimension, self-esteem, satisfaction, nurses' burnout, nurses' fatigue, and positively associated with the counterproductive dimension. Moreover, nurses' self-esteem was positively associated with task dimension, contextual dimension, and satisfaction, while negatively associated with counterproductive dimension, burnout, fatigue, and nurses' age. As well as nurses' satisfaction was positively associated with task dimension, contextual dimension, and negatively associated with the counterproductive dimension. Besides nurses' burnout was negatively associated with task dimension, contextual dimension, satisfaction, but was positively associated with the counterproductive dimension. Along with nurses' fatigue was negatively associated with task dimension, contextual dimension, satisfaction, on the other hand, was positively associated with counterproductive dimension, and burnout. that might be due to COVID-19 pandemic and its related stigma, shortage of nursing staff and nurses have a heavy workload, nurses experienced tension and stigma behaviors, low social status, and low welfare, most of the nurses are females and married and fear to get an infection or transmit this infection to their families, lack of knowledge related COVID-19, work schedules, lack of motivation, incentives and low financial income

This was in agreement with [37] who declared that stigma has a great effect on nurses' performance, impacts staff's obedience, and can direct controlling communication policies concerning nurses' exposure to danger. Furthermore, [63] wrote that stigmatization was negatively associated with the professional quality of life. As well as [59] added that for the period of COVID-19 crisis, nurses’ professional quality of life is in great danger. Also, [37] manifested that stigma positively influences fatigue and burnout, and negatively affects satisfaction.

In the same line [74] assured that burnout will affect performance. In addition, [75] indicated that there was burnout in nurses. When nurses saw so numerous patients with COVID-19 who were under their observation, they were burned out, where nurses had feelings of high-threat occupation during the pandemic, the thinking of their children, and the possibility of transmitting infection for them.

Besides [76] who assumed that negative awareness associated with much effort and heaviness can produce fatigue. As well as, [75] presented that there has been fatigue in the nurses who handled Covid-19 patients. Heavy workload leads to nurses' pressure and fatigue. Emotional fatigue is the principal cause of burnout, the feeling of fatigue leads to a feeling of running out of energy at work so which stimulates the feeling of unenthusiastic to perform work and to act together with others.

Moreover, [77] said that low self-esteem causes substantial communication problems with coworkers and patients. Compassion and effectiveness have both been lowered. Nurses with strong self-esteem, on the other hand, cooperate well with workmates and patients, and as a result, perform better at work. Furthermore, [78] revealed that there is a significant positive correlation between nurses’ self-esteem and satisfaction. Besides [71] self-esteem may jeopardize nurses' bodily and emotional health, quality of life, and performance. Additionally, [73] self-esteem plays a complete mediating role between bullying and job performance. Similarly, [75] referred that, individuals with low self-esteem feel unenthusiastic so that each task is considered an extreme load.

Therefore, the hospital needs to keep the nurses away from fatigue, burnout, and stigmas. Provision of protective equipment, recognition, and compensation for nurses, enforce positive public attitudes toward nurses, public health education and raising community and media awareness about the importance of public support for nurses, counseling, advocating and psychological support, social and moral responsibilities were a major empowering force to nurses during COVID-19. Measures should be taken to promote quality of life and work, through continuing education. Additionally, [79] training and precise network conferences, plus the likelihood to entrance psychotherapy look to be significant implements to combat burnout and stigmas. Also, [73] suggested, that nursing directors should enhance nurses' self-esteem through carrying out psychological training courses and offering learning chances for self-esteem, to stimulate higher job satisfaction and decrease turnover.

The current study findings underline that self-esteem positively predicts task dimension and negatively predicts counterproductive dimension. While stigma negatively predicts contextual dimension. However, satisfaction positively predicts task and contextual dimensions and negatively predicts counterproductive dimensions. Whereas Burnout negatively predicts task and contextual dimensions. Finally, fatigue negatively predicts the counterproductive dimension.

This was proportionate with [80] who mentioned that high self-esteem predicted improved work environments and performance, self-esteem is accompanying to well professional operational, less discourteous and abnormal behavior, higher job satisfaction, and further work accomplishment. Moreover, [73] identified that self-esteem predicts individual job satisfaction. Nurses with high levels of self-esteem are more probable to have higher job satisfaction.

As well as, [81] said that Job performance was positively predicted by job satisfaction. In addition [82] showed that contextual performance is closely connected with burnout. Also, [83] illuminated that burnout was associated with a lower task and contextual performance, and the direct negative influence of exhaustion with contextual performance. Besides, [84] indicated that acute and chronic fatigued nurses reported lower physical performance and felt less attentive and unable to concentrate in delivering patient care. HCWs who anticipated higher levels of stigma showed higher levels of psychological suffering, pressures that may be predicting the effect on HCWs' performance.

As a result, throughout the pandemic, interventions focused on raising self-esteem will be beneficial to nurses’ well-being and performance. To safeguard nurses’ mental health and improve their quality of life, it is vital to avoid stigmatizing them and to strengthen coping mechanisms. Empowering and supporting nurses requires measures to reduce stigma.

The findings of the current study verified that burnout positively predicts stigma that could be due to heavy workload, pressures, fatigue, less achievement, emotional tiredness, and suffering. This was consistent with [85] who evidenced that burnout was predicted stigma and was linked with higher levels of stigma, and particularly, for persons with lower emotional immutability and lower levels of personal accomplishment. Additionally, burnout can upsurge stigma. Thus nurse managers should apply all strategies, procedures, and activities to protect nurses from burnout

5. Conclusion, Recommendations

It was concluded that nurses have a high level of stigma. COVID-19 stigma was associated with nurses’ performance, self-esteem, and professional quality of life. Nurses' self-esteem and professional quality of life were associated with nurses' performance. Stigma predicts performance (contextual dimension), Self-esteem predicts performance (task and counterproductive dimension), satisfaction predicts performance dimensions, burnout predicts task, contextual dimensions, and stigma, and finally, fatigue predicts counterproductive dimension. Therefore, strategies and measures should be taken, to promote nurses' quality of life, self-esteem, and performance; keep nurses away from fatigue, burnout, and stigmas; enforce positive public attitudes toward nurses; continuing education and training sessions; and support.

6. Implications

For nursing practice:

Facilitate the work of nursing leaders in decision - making process through the pandemic, nursing leaders can use these results to create policies, schemes and dealings and actions to stimulate and improve nurses' quality of life, self-esteem, and performance; keep nurses away from fatigue, burnout, and stigmas; enforce positive public attitudes toward nurses; continuing education and training sessions; and support. Protect the nursing staff, improving nurses’ performance, and consequently will positively and consequently, nurses will provide effective and high-quality nursing care.

For nursing education:

The bulk of knowledge added to the nursing knowledge.

For nursing research:

Replicate the study at other sites.

7. Limitations

Some limitations help to direct future research. Because the study sample was limited to ZUHs, the generalizability of the results to other healthcare organizations and the entire country may have been influenced, future replication and expansion of this study to larger work contexts are required. We had to use a scale developed to measure another health-related stigma because there was no dedicated tool to test COVID-19-related stigma. Because of the lack of a definite instrument to assess COVID-19-accompanying stigma, we adapted a scale developed to measure another health-related stigma. Furthermore, because the study relied on participants' self-reports and used a cross-sectional study design, usual way bias may have occurred; as a result, other methods of assessment should be carried out to obtain objective data to lessen the influence of self-report bias, and an intervention study design is required in future studies, as well as using a longitudinal method.'

Acknowledgments

The authors wish to thank all of the staff nurses for their cooperation and everyone had been participate in the conduction of this study

Conflicts of Interest Disclosure

The authors declare that there is no conflict of interest statement.

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