Unprecedented numbers of migrant people transiting through the Darién Gap at the Panama-Colombia border were recorded in 2021 and 2022. Data on sexual and reproductive health (SRH) needs and service provision among migrant people in transit is generally extremely sparse. This study aimed to collect personal accounts of sexual behaviours and SRH needs and access to services among migrant people in transit through Panama.We conducted a rapid-assessment qualitative study using semi-structured interviews during June-July 2022. Participants were migrant people in transit at three locations across Panama: (i) at the Migrant Reception Station (MRS) in Darién province at the Panama-Colombia border, (ii) in the city of David near the Costa Rica-Panama border, and (iii) at the Costa Rica-Panama border. Migrant peoples (>18 years) were invited to participate using purposive sampling.Overall, 26 adult migrant people  across the three sites participated in the study. We identified three overarching themes from the interviews: (1) increased need for SRH service provision, (2) experiences of sex, relationships, and transactional sex, and (3) vulnerability to exploitation and sexual violence. All accounts reported that no formal SRH care was present during the journey through the Gap and described as inconsistent at the MRS in Darién. Provision of gynaecological or genital examinations, laboratory testing for urinary tract or STI, and prenatal care were mentioned to be the most pressing needs. Participants reported a change in their sexual behaviour while travelling, whether a decline in sexual libido or preference towards short-term partners. Most female participants recounted constantly fearing sexual violence during the journey through the Gap and several respondents reported witnessing incidents of sexual and other forms of violence.There are significant unmet needs regarding SRH care during the journey of migrant people transiting through the Darién Gap, at the MRS in the Darién province, and across Panama. Provision of antenatal care, rapid testing for HIV/STI, condom distribution, and care for victims of sexual violence would significantly reduce adverse SRH outcomes and improve the well-being of migrant people, even when in transit. Achieving a state of physical, emotional, mental, and social well-being in relation to sexuality and reproduction relies on the realisation of sexual and reproductive rights, based on the human rights of an individual. Thus, the definition of sexual and reproductive health has been expanded at the 1994 International Conference on Population and Development (ICPD) to address the full range of people's needs and the services required for the maintenance of sexual and reproductive health . A comprThere are major gaps in the literature on SRHR of migrant people—most of the available information pertains to specific SRHR barriers faced by migrant people after their settlement in the destination country, while the needs and experiences of those in transit remain largely undocumented. Lack of available research may be explained by the difficulty of data collection due to the temporary nature of transit, requirement for international cooperation and research funding across multiple countries, and unreliable nature of quantitative data related to migrant people's interceptions at borders , 5.The term “migrant in transit” has no universal definition and does not refer to a legal category of individual; “transit migration” is commonly viewed as a process rather than a migration status, an umbrella term for various migrant categories that includes both irregular and regular migration and that may lead to vastly different migration outcomes , 6. DespA particular scenario has developed in Panama, where border authorities receive migrant people in transit emerging from the Darién Gap—a 66-mile region along the border between Panama and Colombia that serves as a recently established migration route for those travelling North to Mexico, United States, and Canada , 10. AccDespite the large number of migrant people passing through Panama, access to relevant preventative and therapeutic services is extremely limited. Pre-existing SRH conditions may be exacerbated during the journey through the Gap due to delays in accessing care, malnutrition, dehydration, poor hygiene, and pervasive sexual violence . Timely The risks of sexual assault and other forms of gender-based violence (GBV) are known to increase when unsafe or irregular migration routes are used; while GBV can be experienced by members of any gender, it disproportionately affects women, girls, and those of diverse gender identity or diverse sexual orientation , 20. DatBoth the characterisation of migrant people's sexual and reproductive health and an increased understanding of their needs align with the goals of Panama's Ministry of Health (MINSA) and the Pan American Health Organization (PAHO) in offering better healthcare and support to people in transit through Panama. Gabster et al’s team conducted a rapid epidemiological assessment of SRH needs and access among migrant people in transit through Panama, the results of which indicated a total lack of access to SRH care . This foThe aims of this study were to obtain accounts of sexual behaviours, SRH needs and access to relevant services experienced by the population of migrant people in transit, both prior to and during the journey through Darién Gap, and throughout Panama. We focused on describing the individual, social, and institutional factors that may act as barriers to health-seeking behaviour and influence migrant people's SRH outcomes.We conducted a cross-sectional rapid-assessment qualitative study using semi-structured interviews at three different locations in Panama, with a sample of adult (≥18 years) migrant people in transit across the country.The study was conducted at three locations on the migrants' journey across Panama: (i) at an MRS in Darién province on the southern Panama border with Colombia; (ii) at the main bus terminal in David, Chiriquí province, near the Costa Rica border; (iii) and at the Panama-Costa Rica border, Chiriquí province. To facilitate their travels onwards, migrant people are then transported to David and the Panama-Costa Rica border following their stay in the Darién MRS. The settings were chosen due to being at opposite sides of the country, which allowed the co-authors to see if migrant people's experiences with SRH and behaviours were different after leaving the Gap but before leaving Panama.While at the time of the study, most migrant people travelled via the same route from Darién MRS to the Panama-Costa Rica border, all three locations were utilised due to the large density of migrant people residing at and passing through the MRS, creating a more suitable environment for purposive sampling.There is no access to healthcare within the Darién Gap due to a complete lack of infrastructure. At the Darién MRS, the only access to a health professional is provided through visits from NGOs such as the Panamanian Red Cross and Doctors Without Borders (MSF). Two health centres in the communities of Metetí and Santa Fe, Darién province, can provide health services to migrant people in transit in case of medical emergencies. However, these care visits require authorised transport by the National Migration Service and the National Border Service of Panama (SENAFRONT) .Participants were selected using non-randomised, purposive sampling. Recruitment was undertaken based on participants' ability to communicate experiences in an expressive and reflective manner, and their availability and willingness to participate.Purposive sampling was used to include a representative sample of men and women who were interested in speaking about their SRH experiences. Quota sampling was used to produce an approximate 60/40 percent ratio of male to female participants to represent the total number of migrant people in transit; the ratio was based on the 2021 data provided by the National Migration Service of Panama . AdditioSampling took place in communal areas of the MRS, around the bus station and in the streets of the Panama-Costa Rica border. Co-authors approached potential participants and asked if they would be willing to hear about a study in a private location, out of earshot of others. The purpose of the study was verbally described to potential participants; those eligible and willing to participate were invited to sign a written informed consent. The interviews were undertaken in a location chosen by the participant for its privacy.a priori sample size determination apart from aiming to obtain data saturation with regard to the themes and objectives of the study.Languages used in the interviews were selected based on prior observation of these native language speakers in transit through Panama. There was no A semi-structured interview guide was designed to capture diverse personal experiences regarding (i) participants' journey to and through Panama, (ii) their romantic and sexual relationships, (iii) prevention, testing, and care needs related to HIV and STIs, (iv) reproductive healthcare experience, needs and access, (v) and prevention and reporting needs of experiences of violence.Data collection was performed over 7 days, from June 30-July 7, 2022. Semi-structured interviews were conducted by trained field workers and lasted between 30 and 60 min. Participant pseudonyms and details are shown in a priori determined themes and any emerging ones, with the coding frame being constantly revisited to refine emerging themes.Interviews were analysed using a mixture of deductive and inductive approaches to thematic analysis developed by Braun and Clarke . InitialLocal approval was granted by the Research Bioethics Committee of the Gorgas Memorial Institute for Health Studies, Panama (ref: N221/CBI/ICGES/22). The study was also approved by the London School of Hygiene and Tropical Medicine Ethics Committee (ref: 27587). All participants signed written informed consent forms in a private location and were interviewed in a private location by a single interviewer, with a translator present where appropriate. Participants were told that if they wished to discuss any physical violence or sexual assault committed against them on Panamanian territory, the research team would help them report it to the relevant authorities. Participants who reported the need for healthcare or social services during the interview were linked by an interviewer to an NGO National Ministry that was providing relevant care.n = 20) originated from Venezuela. Median age of all participants was 28.5 years, ranging between 18 and 50 years old; 23 interviews were conducted in Spanish, 2 in French, and 1 in English. 14 interviews were conducted at the Darién MRS, 9 in the city of David, and 3 at the Costa Rican border.Overall, 26 adults aged >18 years (16 men and 10 women) participated in this study. Their sociodemographic characteristics are summarised in Our analysis identified three overarching themes: (1) increased need for SRH service provision, (2) experiences of sex, relationships, and transactional sex, and (3) vulnerability to exploitation and sexual violence.NGOs such as MSF and the Panamanian Red Cross provide general health services, including basic SRH care at the Darién MRS during day hours. Five participants  said that they were suffering from a possible urinary tract or reproductive tract infection (UTI/RTI) at the time of interview, which they believed was acquired due to poor hygiene conditions while crossing the forest, but could not receive adequate care at the NGO stations that had been set up. Gynaecological examinations in particular were emphasised as an urgent need for migrant women as symptoms of UTIs/RTIs upon arrival to the MRS were said to be commonplace:“We were all sitting on the floor [of the boat] and there were a lot of children. And many women, and they all urinated there […] And since we were all sitting like that, we felt that all of it got into our private parts […] When we urinated, it was horrible, it burned.” Isabel, 18SRH service provision at the Panamanian MRS and throughout the route across Panama was highlighted as a neglected issue among the migrant peoples—being in an environment where sexual and reproductive care is consistently deprioritised in favour of issues that are deemed more immediate can lead to long-term consequences to both physical and mental health:“You’re the first person to ask me how I feel sexually [how my sexual health is], how everything is functioning for me. The first. And I’ve been to all the medical centres [throughout Panama], and this is the first time that anyone asked me” Beatriz, 40When asked about where the SRH services should be provided many agreed that the Darién MRS and the city of David would be the best locations since most, if not all, migrant people in transit pass through them.“taking care of yourself”, being “selective with all [sexual] partners”, and “using protection”. Some participants connected their lack of worry to the fact that they “didn't notice anything unusual on [their] body” , i.e., being asymptomatic.Being equipped with information about prevention of HIV/STI transmission and maintaining personal hygiene was considered by most as a crucial component of sexual health maintenance. Sixteen participants identified HIV as either one of, or the only, sexually transmitted infection. Human papillomavirus (HPV), syphilis, and gonorrhoea were also commonly named. Most female participants felt that it was very important for them to know their health status regarding HIV and STIs for their own benefit and to protect others while in transit. Some, however, did not seem to worry, especially those in exclusive sexual relationships, as the way to reduce the risk of HIV/STIs was commonly believed to be “in contact with the rim [of a glass/container] that has this disease”  or “through saliva” . In one case, language that implied personal judgement about casual sexual relationships seemed to be linked to HIV stigma:There appeared to be an increased need for health promotion surrounding HIV/STIs, which was highlighted by the use of stigmatising language among some participants, as well as general misinformation. A few interviewees demonstrated erroneous knowledge of HIV/STI transmission by saying, for instance, that HIV can be transmitted by being “That gay guy was giving us water from his pot where he drinks the water from and sticks his mouth in, and how many things did he do to the other one [sexual partner] there?” Beatriz, 40“don't discriminate against people who have this type of illness” and “want to learn more about these diseases” .On the other hand, those who had a personal experience with an STI  or were friends with people living with HIV could correctly describe the routes of HIV/STI transmission when prompted to, and noted that they “to take care of [one]self” in relation to using birth control methods, preventing HIV/STI acquisition, and maintaining personal hygiene. Both male and female participants were able to name a variety of contraception methods that exist, such as contraceptive injections, implant, intrauterine device (often referred to as “T” due to its characteristic shape), the pill, and spermicides, either from using it themselves, from their friends, or their partners. When asked to discuss their reason for using hormonal contraception at the time of the interview, female participants said that it allows them to gain more control of their reproductive health by making a conscious choice to not become pregnant during or shortly after their journey .Many participants used the expression All female participants recognised the need to bring contraception with them if they wished to be protected from pregnancy during their journey due to complete lack of SRH services within the Darién. Some emphasised the need for birth control provision at Darién MRS and other health services while in transit, specifically for sexually active adolescent girls:“There are also many children who come here, who are 16, 14, who are not yet young ladies, but they get with someone […] and they are not taken care of either.” Maria, 32“[giving out condoms] should be a benefit to any camp” , both for current and future use. An overwhelming number of testimonies recognised the lack of HIV/STI prevention and care services throughout the journey and the essential nature of them, as “it never hurts to offer health [services]” .All respondents agreed that it was not possible to obtain condoms anywhere during the journey through the Darién Gap—many felt it was important for condoms to be provided at the MRS on Panamanian territory and at the camps within the forest, saying that One participant also gave an account of SENAFRONT personnel confiscating condoms upon arrival at the Darién MRS, making it difficult to practice safer sex:“A girl who was right next to me, when we arrived at the camp they check your things, and she had condoms, and [the police] took the condoms away.” Carolina, 29“in very large quantities” . Similar to other health service provision within the Gap, there were “no doctors helping [pregnant] women [along the way]” . Pregnant women must bring their own medicines or supplements with them on the journey, and they often get lost, damaged or stolen along with other possessions. While the three female participants who were pregnant at the time of interview seemed to be fully conscious of the risks, they expressed feelings of acute anxiety, guilt, and the overwhelming weight of maternal responsibility.Both first- and second-hand accounts of pregnancy in the Darién Gap were recorded. Most interviewees said that they saw at least one visibly pregnant woman along the journey, with one participant mentioning that pregnant women travel through the Darién Gap Gabriel, 26, recounted witnessing a migrant woman give birth in the forest who received emergency help:“Gabriel: There was a girl who gave birth there, gave birth […] a truck arrived and took her.Interviewer: Took her where, sorry?Gabriel: They took her to the hospital, to the labour ward, she had pains in the forest.”However, Beatriz's story of seeing a pregnant woman who also started giving birth along the way showed a different angle:“She was pregnant, her water broke, you could see from her belly. She lifted her robe […] and you could see the baby moving […] Having a paramedic, someone to help her there in the jungle, there, maybe that could have saved the baby, I don't know if they saved it or not.” Beatriz, 40This disparity may point to a potential inconsistency in emergency service response, alongside the absence of regular health service provision in the Gap. This was highlighted by Carolina's care experience at the Darién MRS:“I felt that I had [the foetus] very low, I couldn't close my legs and I was very worried. I talked to the people [at the Darién MRS] and there was no medical attention until 3 in the afternoon […] I told them that I felt very poor, and they asked me “Are you bleeding?” I told him “No”. He responded that [the problem] doesn't count as essential.” Carolina, 29“wouldn't have received the same support, nor the same attention” in Panama if it wasn't for her pregnancy.The other two pregnant participants, Ana and Sonia, gave a somewhat positive account of their experience at the MRS—both women said they were given vitamins and folic acid at the MRS and were overall satisfied with the services. Ana mentioned that she “dirty mentalities” and are “unhygienic”, saying that “in all those places it smells of everything except love”. Sex along the way was viewed by most as “energy that is wasted”  and that, even with existing partners, there is often “no intimacy” . However, many have also told stories of seeing couples get together in the Darién Gap:Many participants, such as Mauricio and Jesus, believed that migrant people who have sex on their journey through the Gap have “There is something called ‘love in the mud’ here […] There are people who meet on this journey and get into relationships. They become a couple! Man with man or woman with woman, and vice versa […] They meet and suddenly they are together. I met a couple and I thought they’ve been together for ages, turns out that they met about 5 days ago […] I was shocked, and they told me “No, this is ‘mud love’”. Jesus, 37“one-night stand”, which happened just before entering the forest in Colombia:One of the participants recounted his own “It [one-night stand] was there, in Necocli, where I spent 4 days camping on the beach and it was good, that's where the opportunity arose […] I only met her in those 4 days that I was there, the last two days. The girl's name was [name redacted], a very pretty little thing, she was also going, she was going there [through the Gap].” Simon, 29Such wide range of attitudes surrounding sexual relationships in transit through the Darién Gap suggests that individual experiences of sex and relationships, as well as the reasons for engaging in them, can be profoundly heterogenous. While the brutal conditions of the journey can have a significant effect on mental and physical health, it would be misguided to describe all sexual and romantic relationships that are formed on the way as wholly negative. The patterns of sexual behaviour during migration, although often significantly influenced by migration itself, appeared to reflect participant's pre-existing views on sexual norms.Regarding sexual activity in exchange for money, participants gave direct and indirect witness accounts of migrant women providing sexual services in the Gap for food or cash to continue their journey:“The men offer the money. And since the girl doesn't have money to keep going and they have children, then they sacrifice themselves for the children, […] because they need the money to, to continue the journey.” Jaime, 29“the situation lends itself” to the exchange .Some said that the financial power imbalance between migrant women travelling through the Gap and the men who are soliciting sex means that Second-hand accounts of transactional sex within the Gap were not described by participants as sexually exploitative or non-consensual. Both male and female participants acknowledged that transactional sex is often a commonplace solution to a dire economic situation, and the need for HIV/STI prevention and testing provisions for female sex workers was highlighted:“They [those exchanging sex for something] also have to take care of themselves, if that is their job, if that is what they are going to live on. They have to take pills, take good care of themselves.” Isabel, 18“organised armed groups”  and “bandits”  within the Darién Gap picking out women from travel groups to rape during or after the robbery.Constant fear of sexual violence could be traced across most of the interviews with female participants. There was a shared agreement that travelling as a woman comes with perceivable risks, even where it wasn't spoken about directly. Many participants gave accounts of the “put together”  as a group by the armed men and robbed, with some participants also mentioning that they “could see what they [the armed men] were doing”:Participants described how during the incident they were “They started choosing the girls. They chose two young girls whom they’ve gone to rape. They came again for the two more. They raped them again. When I asked what happened before we came, [a friend] said they raped other girls before that. We couldn't see them, because they told us to turn our heads, to lie flat on our stomachs. There, they raped little girls in front of their dad, in front of their parents.” Francisco, 26“I don't want to travel here with her, because she's a woman”. This may suggest that even though there is a shared sentiment among the participants of not knowing “what I was getting myself into” , the ubiquity of sexual violence in the Gap is largely recognised.When discussing the dangers encountered on the journey, Mauricio mentioned that he chose to travel on his own instead of bringing his female partner—Participants who discussed incidents of sexual assault in the Gap also discussed the lack of support from the local authorities in regards to reporting cases of sexual violence. Crimes committed on Panamanian territory are the responsibility of the Public Ministry, to whom SENAFRONT typically report all cases of rape. Some participants, like Alvaro, said they felt that the opportunities to file a sexual assault report were limited:Interviewer: “They reported that they were raped to the police, or did you report it?”Alvaro: “Yes, but they don’t say anything. We told the soldiers, but they didn’t tell us anything. They said “Yes, we are after them, but what can we do? The jungle is huge, so what can we do?”.“out of fear” and “because of what happened to them”. Alvaro said that women who were raped within the forest “mostly ke[pt] it to themselves, they [were] ashamed to talk about it”. He mentioned that when a woman in his travel group was raped “the husband told her not to speak [about it]”. In one case, participant Teresa talked about a woman whom she witnessed was “reporting [the rape]” at the Darién MRS, “a girl who was bleeding”, and that “[local authorities] took her to the doctors”.The feelings of shame, guilt, and fear were mentioned as the primary reasons for not reporting cases of rape, suggesting that women did not report Some participants expressed the view that emergency contraception should be provided along the journey to mitigate the unintended consequences of rape:“[Armed men] are raping [the women], imagine that they get pregnant, it's not their fault,” said Mauricio. Maria said that a young woman travelling in her group “told her mom to stay calm [about the rape], as long as she doesn't get pregnant”. Similar to regular contraception, participants considered it necessary “to bring stuff [emergency contraception] with you” , although did not know how or where the contraception was acquired. This may point to the fact that women who were preparing to travel through the Darién may have been aware of the likelihood of sexual violence and so had planned to acquire the emergency contraception before the start of the journey.“business” between both lone and state actors. However, whilst participants knew that they were a commodity to human traffickers, they believed that travelling through the Darién was their only option to reach North America.Migrants transiting through the Darién Gap between Colombia and Panama gave accounts of their gruelling journey, which often manifested in fear, anxiety, anger, and the feeling of being at the mercy of not only the difficult conditions of the terrain but also of the individuals involved in the migratory process. Many expressed an opinion that every part of the journey, from being taken through the forest by “coyote” guides, to being left near the Costa Rican border by the National Migration Service, was an inter-connected n = 21) of men and 54.8% (n = 23) of women felt somewhat or completely unsafe from sexual assault while traveling through the Gap  of women and 5.7% (n = 4/70) of men reported a current reproductive tract or genital infection symptom, with abnormal vaginal discharge being the most common symptom among the women screened (40.0%)  of men and 80.0% (n = 8/10) of women reported not using a condom; whilst 32.7% (n = 18/55) of men and 18.2% (n = 8/44) of women reported never having an HIV test prior to the study  for Sexual and Reproductive Health in Crises, supported by the Woman Refugee Commission under the UNHCR , 41. MISBased on the WHO data, approximately 15% of women pregnant at the time of displacement will experience obstetric complications, including “obstructed or prolonged labour, pre-eclampsia/eclampsia, sepsis, ectopic pregnancy or complications of abortion”, many of which will not manifest in external bleeding , 42. Obsn = 20/26) of interviewees originated from Venezuela, which limited the diversity of participant background. During participant recruitment, every effort was made to diversify the participant sample to reflect the range of personal experiences, views, and beliefs; however, the selection process was based on ascertaining the most information-rich cases and the suitability of participants based on the pre-determined inclusion/exclusion criteria– at the time of data collection, limited number of migrant people in transit from countries outside of Venezuela were deemed to fit the above conditions. Six participants who originated from countries outside of Latin America were also all male, which may have further affected representativity of the sample, however the fact that nearly all individuals originating from extracontinental countries are male; therefore, this is in line with what Toller-Erausquin et al’s article also found. Nevertheless, participant interviews provided a sufficient range of information to reach data saturation regarding all four a-priori defined themes. Second, the externality of one of the interviewers being a white, English-speaking woman may have introduced respondent bias into participants' responses, but was minimised by employment of well-trained, Spanish-speaking local staff where required. Thirdly, given the small participant sample of our study, the findings cannot be generalisable to all migrants in transit through Panama or Latin America; further longitudinal research across several countries is required in the future to help build a picture of SRH services needs and outcomes associated with the migrant people's journey. Fourthly, non-response bias could have occurred; those who were at greatest risk or those who were survivors of assault may not have accepted to participate in the study.This study had a number of strengths and limitations. The use of semi-structured interviews as the main instrument for this qualitative study was a suitable approach for giving participants a voice in the collection of their experiences, feelings, and opinions. The approach enabled a more relaxed, trusting interview environment, and helped achieve data saturation. This study had three main limitations. First, an overwhelming majority (In conclusion, this study has captured crucial insights into the experience and unmet needs regarding SRH care and access to services within the Darién Gap, at Darién reception centre, and while travelling across Panama. Lack of appropriate risk-prevention information, reduced access to contraception, HIV/STI testing, and antenatal care pertains to the erosion of bodily autonomy and changes in sexual behaviour, both of which are intensified by the gruelling migration process. Local SRH interventions at the Panamanian reception centres and mobilisation of personnel are required to mitigate adverse health outcomes for migrant people in transit through the country. Many survivors are reluctant to report sexual and other GBV to authorities due to the bureaucracy of referral process. Therefore, integration of SRH services with GBV programmes is key—safe and confidential spaces within Panamanian MRS should be available to provide survivors with appropriate clinical care, and fast-tracked health referrals. On a larger scale, improved cooperation between governmental and non-governmental agencies, and provision of a minimal package of SRH preventative and care services throughout the migration route, are required to address the needs of highly vulnerable migrant populations.


The immigrant population across Europe is ageing rapidly. Nurses will likely encounter an increasing number of patients who are older adult immigrants. Moreover, access to and equal provision of healthcare is a key issue for several European countries. The relationship between nurses and patients is asymmetrical with unequal power relations; however, the way nurses construct the patient through language and discourse can help maintain or change the balance of power. Unequal power relations can affect access and be a hindrance to equal healthcare delivery. Hence, the aim of this study is to explore how older adult immigrants are discursively constructed as patients by nurses.An exploratory qualitative design was used. Data were collected through in-depth interviews with a purposive sample of eight nurses from two hospitals. The nurses’ narratives were analysed using critical discourse analysis (CDA) as described by Fairclough.The analysis identified an overarching, stable, and dominant discursive practice; ‘The discourse of the other’, with three interdiscursive practices: (1) ‘The discourse on the immigrant patient versus an ideal patient’; (2) ‘The expert discourse’; and (3) ‘The discourse of adaption’. Older immigrant adults were constructed as ‘othered’ patients, they were different, alienated, and ‘they’ were not like ‘us’.The way nurses construct older adult immigrants as patients can be an obstacle to equitable health care. The discursive practice indicates a social practice in which paternalism overrides the patient’s autonomy and generalization is more prevalent than a person-centred approach. Furthermore, the discursive practice points to a social practice wherein the nurses’ norms form the basis for normal; normality is presumed and desirable. Older adult immigrants do not conform to these norms; hence, they are constructed as ‘othered’, have limited agency, and may be considered rather powerless as patients. However, there are some examples of negotiated power relations where more power is transferred to the patient. The discourse of adaptation refers to a social practice in which nurses challenge their own existing norms to best adapt a caring relationship to the patient’s wishes.The online version contains supplementary material available at 10.1186/s12913-023-09590-6. Worldwide, many people live in a country outside their country of birth. Europe is the region that hosts the largest number of international immigrants; in 2020 this amounted to 87 million people, of whom about 40 million are non-European . In the The immigrant population across Europe is aging, but significant differences exist between countries in terms of age composition . Most imThis paper focuses on immigrants from countries outside Europe who are aged 65 years and above, and how nurses talk about them as patients in hospitals.Health is considered a human right; however, there are differences in access and the way health services are organized in European countries, both for immigrants and the majority population . A revieThough immigrants in Norway have the same legal rights to health and care services as the rest of the population, they use the services somewhat differently. Previous studies have revealed that older immigrant adults in Norway do not consult primary health services as often as the majority population does . FurtherDifferences in the use of healthcare services for older immigrants may be attributable to different access barriers . Care prTraditionally, healthcare service has been dominated by a paternalistic ideology. Paternalism refers to intentionally overriding another individual’s preferences or actions and, therefore, contrasts with individual autonomy characterized by one’s freedom to act in accordance with a self-chosen plan . Hence, In recent decades, there has been widespread acceptance, in political and policy declarations, that patients should be more involved in care, the treatment process, and decision-making . The comin and behind discourses. Thus, language can lead to the domination of some people over others [Critical discourse analysis (CDA), which forms this study’s theoretical background, is used to study how language creates meaning and informs social practice . Discourr others .Language is essential for nurse-patient interactions, as discourses construct our perceptions of relationships, identity, knowledge, and power . DiscourDiscourses are essential in the asymmetric nurse-patient relationship, as the nurses’ construct of the patient can help maintain or change the unequal balance of power . UnequalAlthough communication behaviour among professionals is referred to as a healthcare barrier , there iThis study aims to explore how older adult immigrants are discursively constructed as patients by nurses.An exploratory qualitative study was employed, based on nurses’ narratives of older immigrant patients. CDA was applied as a theoretical framework and a method of analysis . CDA is Purposive sampling  was usedFour hospitals in Norway were invited to participate in the study; two of them accepted. Both of these hospitals offer emergency care for approximately 200 000 inhabitants and are located in cities with a large immigrant population. One medical ward in each hospital was chosen to participate by the respective heads of research. The nurses were notified about the project and asked to participate by the charge nurse in each ward. The charge nurses were informed that variation and diversity in age, work experience, ethnicity, and gender were desirable. In total, eight participants were recruited Table ; no infoThe study data were collected via eight individual face-to-face interviews using open-ended questions in a narrative interview format. The narrative form of communication is appropriate for organizing events, actions, feelings, or thoughts regarding others . The intdescription of text; (2) interpretation of discursive practice, and (3) explanation of the social practice. Prior to the analysis, the first author listened to the audio recordings and then transcribed them. All interviews were then read thoroughly and repeatedly, to receive an impression of the content of the text. Paragraphs and sentences wherein the nurses spoke about older adult immigrants were subsequently selected for analysis. Examples of selected sentences are: ‘They can be tiresome; they call a lot and ask about minor matters’ (Nurse 1), and ‘It makes it a bit wrong that they… when I think that you should be able to do this’ (Nurse 8). The NVIVO software was used to keep track of the selected sections, and the subsequent text descriptions.The nurses’ narratives were analysed using CDA and Fairclough’s three-dimensional model of discourse analysis , 38. ThiThis was a detailed linguistic examination of the selected text, focusing on the words employed . The folGrammatical level expresses a range of modalities  yieldingInterdiscursivity is the expression and combination of different types of discourse in the text ; in thisThe third dimension is an explanation of the social practice where the discourse is embedded and of which the nurses are a part. This dimension emphasizes how power relations are created through language and its effect on clinical and social practice. The relationship between text, discursive practice, and social practice is elucidated in the Eight nurses from two different hospitals working in 24-hour internal medicine wards were interviewed. Both hospitals are located in cities with a large immigrant population, and all respondents had extensive experience with older adult immigrant patients. Table The analysis of the nurses’ narratives identified an overarching discursive practice, ‘The discourse of the other,’ with three interdiscursive practices as follows: 1) ‘The discourse on the immigrant patient versus an ideal patient’; (2) ‘The expert discourse’; and (3) ‘The discourse of adaption’. The discursive practice, including examples from the linguistic description, is detailed below .In Norway, the jungle represents the most foreign and unknown place imaginable. Hence, the nurse indicated that the hospital setting in Norway was as unfamiliar to immigrants as a hospital in the jungle would be to herself. This highlighted the nurse’s perception of older adult immigrants, and the nurse constructed a patient who was considered foreign and without knowledge of the Norwegian health care system.we and they. The pronoun we was never used to refer to the nurse-patient relationship; the immigrants belonged to one group, the others, which was different from we, the group to which the nurses belonged. The quote, ‘They view illness completely differently than we do’ (Nurse 3), reveals the presentation of we and they as a dichotomy with asymmetric value and mutually exclusive categories.Older immigrants were rarely referred to as individuals; they were defined as ‘the others’ through the nurses’ use of the plural personal pronouns everybody, nobody, often, and rarely, leading to generalization; the nurses appeared to view and manage ‘the others’ as a homogeneous group.The nurses categorized the others based on recognizable similarities, such as language skills, family size, or country of origin, and subsequently, attributed stereotypical characteristics to the patients, such as being passive, not adhering to the nurses’ recommendations, and having a different understanding of illness. The construct of the others as ‘non-Norwegian’ was the most noticeable categorization. One nurse mentioned many family members visiting and said: ‘I think we might have reacted if a Norwegian family had taken up so much space’ (Nurse 6), implying that the family was not Norwegian. Additionally, the nurses used words such as The discourse of the other revealed how the nurses constructed and defined older adult immigrants as patients who were ‘different’ and alienated; ‘they’ were not like ‘us’. However, the choice of words also indicates that the nurses occasionally felt alienated, especially when many family members visited the patient.I almost said that I’ll stand by the door then (laughs). You just don’t want to disturb. (Nurse 1); When you enter a room, and there are… (…) … if there are very many people in the room, the communication is sort of… you feel that they are watching what you are doing. In a way, you feel that you are intruding… (Nurse 6).disturb, they are watching you, and you are intruding) indicates that the nurses apparently felt uncomfortable, like an intruder, and outside the norm.In this case, the nurses were in the minority, and the choice of words . It was for just a few hours… but my goodness, they turned the whole ward on its head, so to speak (Nurse 3).some things about immigrants were so far from her assumption of normal. Abnormal is the antonym of normal; this was negatively presented using the word problem. Turning the ward on its head generates a chaotic image. This is an orientation metaphor wherein the body indicates space, direction, and the normal and sensible. Thus, the nurse expressed that the choices of the patient and their family were contrary to her ideal of the normal.In this case, the nurse communicated that The nurses expressed a perceived expectation, from the patient and their families, that the patient needed rest. This was described as follows.They lie down under the covers and are very sick… they should be on their feet, but they lie down anyway because they are sick (Nurse 3). Very many of them often want us to do everything for them. No, I’m not here to… it isn’t really a hotel. And if they resist completely, I think… well, I’ll just get their food. But, you feel a bit disheartened. You have many other patients, and we are rushing through the corridors here (Nurse 7).lie down and on their feet can be interpreted literally and metaphorically. Metaphorically, on their feet indicates resourcefulness, independent thinking, and sensible choices. This quality is positively valued in Norwegian culture. Thus, the metaphor implies that older immigrants did not make sensible choices or know what was good for them. Additionally, these patients were compared to hotel guests. They were unmotivated and not participative, and the statement, if they resist completely, I think… well, I’ll just go get their food implies that they did not always follow the nurse’s recommendations. The negative word disheartened and the metaphor we are rushing through the corridors here reveal the nurse’s opinions.The expressions The nurses used words highlighting a gender disparity.Naturally, there are challenges, because especially older women who have lived in Norway for 20 years… can’t speak a smidgen of Norwegian. And they cling to their culture, I mean… They cling… yes, and they can’t speak a smidgen of Norwegian (Nurse 3).cling and can’t speak a smidgen of Norwegian highlighted the additional challenges associated with older adult women immigrants. The expression cling to their culture creates a distance and contrast between the women’s culture versus the nurse’s culture. The nurses implied that these patients were inflexible and un-adapted to Norwegian culture. However, the issue with women was not just mutual linguistic comprehension; the nurses expressed that these patients were more likely to let others make decisions and not express their own thoughts. A nurse opined:Repetitive usage of I rarely feel that older women… I rarely feel that they want to take action and try to communicate (…) I feel that they are a bit secluded (Nurse 6).rarely.Thus, the nurse generalized older adult women immigrants as passive patients by repeating the word The nurses used words, including auxiliary verbs, indicating that they knew the patient’s best interests. This was justified as follows:In terms of the profession, you (i.e. the nurse) must just be strict, you must just do it… you (i.e. the patient) must understand now. You (the patient) can’t do what you are doing, in a way (…). Sometimes we just have to whip them up, so to speak (Nurse 3).strict is often associated with an authority figure, particularly, a parent. This indicates that the patient did not follow the nurse’s orders if she expressed herself more mildly. The modal auxiliary verbs must and can were repeatedly used. Must implies an instruction and a lack of choice for the patient. The nurse’s statement you can’t do what you are doing, can be understood as a prohibition wherein the patient was prevented from making their own assessments or choices. This was reinforced through the metaphor whipping them up, conventionally associated with slaves, or domesticated animals. The nurse’s expression we just have to whip them up, indicated that she alone knew the patient’s best interests and that there were no other options. Another nurse spoke about a patient who sought assistance:The word It makes it a bit wrong that they… when I think that you should be able to do this… (…)… it’s hard to accept, that I have to do it this way (Nurse 8).wrong referred to the patient’s wish for assistance, implying that the nurse’s understanding would have been more correct. Moreover, if the patient’s actions were contrary to the nurse’s ideal of ‘right’, negatively charged words, such as hard to accept, were used.The word In the expert discourse, nurses expressed that they knew the patient’s best interests and behaved accordingly. Hence, older adult immigrants were constructed as patients who were unable to assess or comprehend their own best interests, and, had limited opportunity to involve themselves in decision-making.a need to adapt, adjust, and be creative. Thus, older adult immigrants were constructed as patients who needed a different approach. Most nurses clarified that they had little or no professional knowledge about older adult immigrants and their need for adaptation. Nonetheless, they rarely discussed these issues with colleagues. An area where the nurses indicated a need to think differently was communication and interaction. This resulted in a ‘creative’ nurse:The nurses desired to treat immigrants in a caring relationship, even though they differed from the regular patients. The discourse of adaption describes the nurses’ approach to this aspect. Their narratives comprised words such as You become a kind of… MacGyver nurse… How do I do this, what do I do in this case? (Nurse 5).The nurse compared herself to the fictional television action-hero MacGyver, who uses creative solutions and simple items to aid him in impossible situations. As for impossible communication, the nurses stated that different approaches were attempted to get the patient to understand and be understood. For example, they simplified their language, avoided irony and humour, spoke more slowly, used fewer words, and expressed themselves using body language, drawing, or Google Translate.In addition, they allowed adjustments contradictory to professional recommendations. One nurse opined, based on her professional knowledge, that the patient should have been more active; nonetheless, she allowed the patient to remain in bed because: ‘it’s a balancing act. I don’t want to be disrespectful’ (Nurse 2).flexible and open and had to adapt and adjust. However, such statements were partially followed by a but.The nurses expressed that they chose to be but… (Nurse 6); Well… I sort of respect it, but… (Nurse 7).Well, we… we want to be open, but introduces a break in the context and expresses a limitation and contradiction to the earlier statement. Another nurse spoke about the number of visiting family members and used the term tolerance limit (Nurse 6). Tolerance is permitting something one dislikes or disagrees with, and the term tolerance limit indicates the limit to which the nurses were willing to endure, in the context of alienness and difference.The conjunction Table This study aimed to explore the discursive construction of older immigrant adults as patients in hospitals, by analysing the nurses’ narratives Fig. ; Table 2Fairclough  highlighOthering is probably not a deliberate act by the nurses; it could be seen as the result of norms that have become naturalized to the extent that nurses simply take them for granted, without reflecting on the consequences for social practice or care delivery. Nurses will, regardless of well-intentioned practice, be influenced by factors, such as societal norms, dominant ideologies, and frameworks for what is perceived as normal in the hospital as an institution. First, the meeting between older adult immigrants and nurses is a meeting between generations, as well as a meeting between the minority and majority societies, respectively. The majority possesses power and can set the premises and define, influence, and identify norms and values that marginalize those who fall outside these norms . AdditioOthering puts older adult immigrant patients at risk for suboptimal care  and inflNursing is based on respect for human rights and the humanist ideal that all people are unique, irreplaceable, and have inherent dignity . ConversIn the adaption discourse, the nurses expressed that they had to adapt and adjust. Thus far, this is in line with recommendations emphasizing that care shall be adapted to the individual’s background to achieve equality in health services . HoweverIn this study, the discourse on the immigrant patient versus an ideal patient points to a social practice where an active and participative patient is considered ideal by the nurses and immigrants are constructed in relation to such a patient. Nurses’ norms regarding patients are influenced by several factors, including the legislative framework. In recent years, the evolving patient role has expected patients to be more involved ; patientWhile participation potentially influences and changes power relations , the nurNevertheless, the discursive practice in this study points to a social practice where nurses directed more attention to what they perceived as deviations from the norm, rather than reflecting on and questioning the basis for their own norms. This may be because the interests and perspectives of the majority are presumed natural and universal for the nurses.This study aims to explore discursive constructions; hence, CDA was chosen. Discussion on quality criteria within CDA is limited. Thus, in this study, aspects of credibility, transferability, dependability, and confirmability are used to ensure trustworthiness .credibility. The present study has a social constructivist approach; the nurses’ narratives are constructed in dialogue with the researcher and, hence, cannot be seen as an accurate representation of the real world. The small sample size of eight could be a limitation; however, the study aims to explore how older adult immigrants are discursively constructed as patients by these nurses, at this given time and in this context. The nurses who participated had extensive experience with older adult immigrant patients and were, thus, able to provide detailed narratives; therefore, the sample was considered large enough. The nurses were asked to describe their experiences with older immigrant patients who were born and raised in countries outside Europe, and we trust that the provided narratives were about those patients. However, the nurses comprised only ethnic Norwegian women, although variation and diversity within gender and ethnicity were desirable. Other nurses  may have constructed different discourses about older adult immigrant patients.A purposive sample based on certain inclusion criteria was used to gain transferability, we cannot conclude that the findings are transferable to other contexts; however, the authors have tried to provide clear descriptions of context, sample, data collection, analysis, and interpretation process. In addition, choices made throughout the research process are described to strengthen dependability and create transparent research. COREQ, a checklist for qualitative studies [confirmability, the authors applied a reflexive approach to all parts of the manuscript as we are co-constructors of the narratives, interpretations, and discourses. The first author, who conducted the interviews, tried to bridle her preunderstanding by adapting a self-reflexive approach. The interviewer’s professional experience as a nurse was both a weakness and a strength. It was a strength because of field-based knowledge and familiarity with the ‘language’ of the nurses, but also a weakness because feedback from the interviewer might have influenced the narratives. The analysis was a collaborative effort by the authors, where reflexivity was central. The researchers’ work experience regarding older adult immigrant patients ranged from little to no experience. However, as beliefs and ideologies are embedded within the researcher, the analysis is inevitably guided by the researcher’s preconceptions. Therefore, the analysis and interpretation of discursive practices have been extensively discussed by the authors to pause, reflect, and challenge personal experiences and preconceptions.Regarding  studies , was useOlder adult immigrants are constructed by nurses as ‘othered’ and different patients. The examples discussed show how the language and discourses of caregivers contribute to a social practice with unequal power relations and how discursive practices can have a major impact in a care context. Discursive practice indicates a social practice where paternalism overrides patient autonomy and generalization is more prevalent than a person-centred approach. Furthermore, discursive practice indicates a social practice where nurses’ norms are the basis for normal. Belonging to the norm confers power; normality is presumed and desirable. Older immigrants as ‘othered’ patients do not conform to the nurses’ norm. This contributes to unequal power relations in an otherwise asymmetrical patient-professional relationship wherein the nurse possesses the power to decide the normal, define the other, and determine the extent of adaptation and tolerance. However, there are a few examples where power relations are negotiated, and more power is transferred to the patient. In the discourse of adaptation, the nurses showed counter-behaviour and challenged their own existing norms to adapt a caring relationship in the best possible way as per the patient’s wishes.Nevertheless, it can be assumed that older adult immigrant patients have a reduced opportunity to participate, they have restricted agency, and are rather powerless in the care relationship. Hence, the language and discourses used by nurses may pose a threat to equal healthcare delivery.This study is important for nurses at the individual level, nursing managers, and nurse educators. The findings reveal how discourses influence social practice and can be an obstacle to providing equal healthcare delivery to older immigrant adults. Moreover, the findings can raise awareness of attitudes, and hopefully interrupt the forces that promote the process of other-directedness in the nurse-patient interaction.Finally, the study findings have implications for further research. The analysis in this study is based on interviews with nurses, and it will be of interest to explore the immigrant patient’s perspective. Furthermore, it will be of interest to explore and compare any similarities and differences in the way nurses construct older adults as patients, whether they are ethnic Norwegians or immigrants. Future research could also explore adaptation in the nurse-patient interaction when the patient is an older adult immigrant.Below is the link to the electronic supplementary material.Supplementary Material 1


N = 7) employed within a Canadian provincial healthcare system who have attempted workplace reintegration after being off of work with an OSI. Methods: Nurses were recruited via social media, unit emails, and word of mouth. Data were collected through recorded semi-structured interviews conducted over videoconferencing. Once transcribed, the data were thematically analyzed using an inductive approach. Results: The resulting themes included (1) heroes to zeros, (2) changing the status quo, (3) connection is key, and (4) post-traumatic growth: advocacy and altruism. Study participants indicated both that nursing culture and a cumulation of events contributed to a need for a leave of absence from work and that a formalized process was desired by nurses to assist in returning to work. Conclusions: The development, implementation, and exploration of innovative policies, procedures, and initiatives to bridge the gap from clinical interventions to workplace reintegration are needed for nurses experiencing OSI. Further research is also needed regarding mental health impacts and appropriate resources to support nurses in their workplace reintegration process after experiencing psychological and/or physical injury.Background: Nurses are engaged in an unpredictable and dynamic work environment where they are exposed to events that may cause or contribute to physical and/or psychological injuries. Operational stress injury (OSI) may lead to an extended time away from work or nurses leaving the profession altogether. A deliberate focus on the workplace reintegration phase of the mental health recovery process may lead to the increased retention of nurses in their profession. Prior to the creation and implementation of potential solutions to address workplace reintegration, it is imperative to explore the experiences and perceptions of nurses affected by OSI. This qualitative study aims to investigate the experiences and perceptions of nurses ( Nurses routinely work in environments that are fast-paced and unpredictable. Their dynamic work environment is constantly time-pressured, and laden with decreasing resources, staffing, shortages, ethical dilemmas, and increasingly complex caseloads . Nurses Workplace reintegration after an OSI can be challenging for nurses and other HCPs. Repeated exposures to potentially psychologically traumatic situations and the physically and mentally demanding nature of a healthcare environment can contribute to career-ending challenges. An unsuccessful post-injury workplace reintegration process may impact the individual, their family, and the wider community, while further contributing to nursing shortages within healthcare systems. Further, decisions on policies, programs, and initiatives regarding workplace reintegration for nurses have not always been evidence-based, nor included perspectives of nurses with the lived experience of returning to work after injury or illness . There is a paucity of research regarding essential post-clinical treatment when nurses are reintegrated into adverse environments and still expected to perform their occupational duties. The limited literature focusing on the return to work of nurses with mental health challenges has largely focused on military or civilian nurses experiencing substance use disorders in the United States ,10,11. NThe current qualitative thematic analysis was part of a larger mixed-methods study (QUAL quan)  initiatiParticipants included Registered Nurses, Registered Psychiatric Nurses, Licensed Practical Nurses, or Nurse Practitioners working in urban centers in Alberta, Canada, and who were employed within a major provincial health organization. Recruitment was conducted through social media, such as Twitter and Facebook, as well as snowball and purposeful sampling. Key contacts within nursing organizations, such as peer support groups, assisted with dissemination of study flyers through their networks. Care managers of the targeted units were also asked to spread recruitment emails widely and post hardcopy flyers. Potential participants were asked to contact the research team directly and screened for inclusion before consenting to study participation. Some participants from a separate component within the larger mixed-methods study were invited by the research team to participate in the additional study. Invited participants had self-identified through an online demographic questionnaire as having required time off of work due to psychological traumatic events in the workplace and experiencing an OSI.Data were collected between August and December 2022. This extended length of time was needed due to the staggered access to operational approval of study sites and the specificity of the participant inclusion criteria. Consent and demographic questionnaires were administered via REDCap (Research Electronic Data Capture) which is a secure, web-based software platform  . QuestioThe demographic and qualitative data were analyzed using Microsoft Excel software. Audio and video-recorded interviews were thematically analyzed following an iterative inductive and deductive process . InitialN = 7) are presented in n = 2) reported involvement or utilization of formal processes for workplace reintegration. At the time of data analysis, four participants had returned to work in their previous capacity, two had returned to nursing in a new role or different capacity, and one had not reintegrated back to work. It was also noted through the interviews that the time away from work varied widely amongst the participants from a period of weeks to years. The time from injury to participation in the interview also varied from a period of approximately one to seven years prior to engaging with the current study.Demographic details of study participants , heroes to zeros, (2) changing the status quo, (3) connection is key, and (4) post-traumatic growth: advocacy and altruism . ThreadsNurses reported being profoundly impacted by the shift in public perception from initially being hailed as “Healthcare Heroes” at the beginning of the pandemic, to being vilified as the pandemic continued. “And that was when the dialogue was shifting from us being healthcare heroes to you know, that was just when the flavor really changed.”(P1)The changes in public perception exacerbated the impact of exposure to potentially psychologically traumatic events, potentially morally injurious events, environmental stressors, self-stigma, and stigma from others. An under-acknowledgement of psychologically injurious events within the nursing profession by the profession, stakeholders, and the public was noted to have caused additional strain. A visual metaphor emerged through the dialogue, involving a strong and confident superhero watching pieces of their costume falling off until they are isolated and powerless.An accumulation of distressing events over a period of time was reported to contribute to OSI. A single recent event was often cited as causing a “tipping point” that precipitated the need to take leave from work. Participants recognized that the dynamics of their workplace created the “perfect storm” and exposed them to both potentially psychologically traumatic events and potentially morally injurious events. Some expressed feeling a sense of helplessness and lack of control over their ability to advocate for and provide safe, competent, and ethical care to their patients, which was also a cumulative stressor. “… what they were doing was torturing this man. And I really felt like I was part of it. And I had, I had to take like, some time off work I just called in sick for, I don’t know, maybe maybe just like a set, but it made it so that I had like, over a week off work. Just to kind of like deal with that, because I found it really upsetting to even be like near even like the thought of going to work made me like so anxious.”(P3)Subsequent care pathways utilized by the nurses did not acknowledge physical and/or mental health injuries in a holistic manner once psychological distress or an OSI was identified and reported. Participants commented that only a single psychologically traumatic event or injury was addressed at a time within the designated workers’ compensation procedures. Cumulative events were not viewed as relevant and intertwined, or compounded physical and psychological injuries were dismissed. “The paperwork says, well, what’s the one specific event or injury and in my mind, it’s a dozen events that are just right. And it’s not just one, it’s not just this…and it’s difficult to articulate on most forms because those forms are very regimented. For one problem, one injury, one solution done. That is not how complex psychological injuries work.”(P7)Responsibility for the potentially psychologically traumatic events or potentially morally injurious events was at times (mis)placed by the organization upon the nurses who had experienced an OSI. This contributed to secondary or sanctuary/organizational trauma. Shame and guilt were experienced by some participants who felt they ought to have been able to prevent specific events from occurring. “I think I felt really, like I did something and it was my fault. Like, what could I have done to make this not happen? Because clearly it happens in our workplace, but you just always think, like, it’ll never happen to me kind of thing. So I’m like, What did I do? Because we were always told, like, have exits, like, keep the curtains open. And I was like, I feel like I did that. Like he was on the other side of the structure. So it was a lot of replaying, and what did I do wrong? And I think I felt kind of embarrassed about it.”(P2)Stressful and unpredictable work environments were described by all of the participants. Staffing shortages, combined with an increasingly complex, vulnerable, and distressed caseload, were frequently cited as an overarching contributor to worsening working conditions. “There’s a lot of, I think, stress within the healthcare scenario. And lots of things that I find challenging when you can’t do your work properly. You’re short staffed, I feel like I’m not caring about doing the job to the best, not because of myself, but because of the scenarios around.”(P4)Immense pressure to forgo time off of work including vacation, sick, and personal time was notable. Constant text messages on days off reminding them of the staffing shortages and encouraging them to pick up shifts caused participants to feel guilt when not working, even while they were at home recovering from an OSI or other injuries related to the traumatic event(s).“But I also, there’s also that history there of being guilted to come into work, and that, you know, ignoring of concerns, our manager came to triage desk, and took off all the signs that were posted, saying like ‘this is a respectful workplace—violence and verbal abuse will not be tolerated.’ …she took down all those signs. And she said, this sends the wrong message to our patients. It’s not welcoming. And I said, ‘Well, what about when people are swearing at me, and I point to the sign saying, you can’t talk to me that way.’ And she’s like, ‘nothing bad ever happens at *site*.’”(P7)A healthy work/life balance was reportedly challenging to maintain in such a stressful and highly pressured environment. Consequently, participants were left feeling under-appreciated, invalidated, disrespected, and oppressed by leadership, which led to distrust of the organization as a whole. During shifts, even their basic needs, such as eating, drinking, and using the washroom, may go unmet in such a stressful work environment.“… in terms of trauma, and it’s like that’s what it felt like going in there. It’s like you didn’t have any idea how you were gonna make it through this shift, like, and how you were gonna be able to physically care for two people who were actively dying, you know, in trying to make sure they’re both okay. And plus, like, take care of yourself in any way like getting a break… and it’s, it is simple stuff like knowing that you can, you will be able to use the washroom when you need to use the washroom knowing like when you need water, you can get water.”(P3)Stigma often made it difficult for participants to acknowledge they were experiencing an OSI in the first place, or that they were continuing to feel its effects. As a result, they either denied to themselves and others that they were affected by the OSI, which often led to delays in taking time off, or premature return to work. “I think that really primed the pump for the PTSD. And just pretending and the denial. It’s not here. It’s not real. And kind of dissociating from what was happening. And then, the longer I stayed sick, the more angry I felt that it had happened, because I had done everything right. And I had done everything to prevent it and it still happened.”(P1)By returning to work early, participants hoped for fewer questions and conversations from peers and leadership about their injury and return to work. Participants felt they had to justify their actions and decisions to all levels of the organization and all timepoints from the point of going on leave throughout their workplace reintegration. Self-stigma contributed to higher distress and emotional responses when participants had to engage in discussions or tasks regarding their workplace reintegration.Participants discussed the guilt/pressure they felt to take medication to assist with their mental health, especially since this was not required prior to the OSI. Despite this feeling and self-stigma, some of the participants understood that medication was needed to enable them to reintegrate into the workplace. Stigma and discrimination in the workplace after disclosing an OSI were also experienced by some participants. “I’ve been in meetings where I’ve openly shared and been treated differently. I’ve been asked if I was well enough to do the work that I’m doing now by another nurse, and not in a way that was caring. Or it was in another way, that did not feel very nice.”(P5)Despite internal and external mental health stigma being a reality, some participants indicated having witnessed improvements in this within the workplace in recent years. Indications of change toward healthy work environments offered some participants hope in the face of stigma.“It was just the thing to do. You just truck(ed) on, like, you know, like given 12 years ago, often people didn’t even want to admit if they had to take medications for depression or anything. And now that’s changing, and people are much more open about talking about it. But 12 years ago, there was still a fair bit of stigma regarding it.”(P4)Several immediate and intermediate needs and desired changes regarding responses to potentially psychologically traumatic events and the workplace reintegration process were identified by the participants. This included recommended changes to existing policies, practices, and procedures from a point of stress through to workplace reintegration. Education at all levels of the organization related to mental health, trauma-sensitive practice, coping strategies, and profession-specific mental health resources was specifically identified as being needed both immediately after a traumatic event, and intermediately for the affected staff, their peers, family units, and leadership. Increased education was cited as potentially leading to enhanced validation of nurses ‘experiences, understanding of their injury, and hope for successful work re-entry. “Education or mental health resiliency, and all these things that we’re lacking, are more important than taking care of our patients. If we’re not healthy, our patients aren’t going to be well either.”(P7)Compassionate, empathetic, respectful, engaged, and supportive leadership, as well as non-judgemental colleagues, was also identified as integral to recovery and reintegration both immediately and intermediately.A standardized process and protocol for acknowledging and responding to potentially psychologically traumatic events or potentially morally injurious events was desired by participants as a means of addressing gaps in the current processes, structures, and supports. “I think there is no clear process for acknowledging when somebody has had a psychological injury. Yeah, so not the same way as if I’ve had a back injury. There’s a very clear return-to-work process .”(P1)Acknowledgement by the healthcare organization of the risk to nurses of experiencing psychologically traumatic and morally injurious events was strongly desired by the participants. Debriefing immediately after the injurious event was proposed to facilitate the processing of the event and learning about both signs of mental health challenges and nursing-specific mental health resources. “I don’t think anybody ever talked about anything. Except my co-workers were very upset because, they were like, this could happen to anybody in our department. And I think they wanted to hear something from managers, they wanted to have some sort of debriefing or some sort of ability to talk about kind of what happened.”(P2)A formalized individually tailored return-to-work process was desired by the participants. Current systems for navigating return to work after an OSI required participants to be action-oriented at a vulnerable time, leaving them to navigate complex systems with limited, if any, assistance. “I wouldn’t kind of just work myself so hard. And that’s what I felt that I needed to do last time. But I’m sitting here as you ask these questions, I’m like ‘Why? Why did I have no idea but there wasn’t anyone directing the kind of time off or the comeback other than me so I was the one making those decisions?”(P6)An interdisciplinary workplace reintegration program that was individualized, paced, and led by the reintegrating individual was envisioned by participants. Personalized programming was seen as essential to facilitating safe return to work. Reintegration at the right time was also seen as critical to minimizing retraumatization and reducing delay to overall recovery and re-entry into the workplace. “But I think had I been offered, like, some kind of a slower, like, reintroduction to work, which I know would have been really hard to support, especially like last summer. But that would have been helpful, I think, because it was… it was really tough to go back to, like, full time caring for it.”(P3)Access to financial support to compensate for lost wages and sick time benefits would also enable those with OSIs the time they need to recover and prevent premature workplace reintegration. The development of policies and procedures regarding workplace reintegration was desired by participants. They felt this may reduce duplication of services and inadequate communication between the services, organization’s clinicians, and OSI-affected nurses. Presumptive legislation for nurses affected by OSI was also strongly advocated for by the participants so as to reduce the distress caused by the need to “prove” that an OSI was, in fact, a result of their work.“… * the province* not having presumptive PTSD legislation I had to go through an extensive process. I had to go through a comprehensive psychological assessment. But of course, it was five months after the fact.”(P7)Connection with self, the profession, peers, chosen family, and community were identified by participants as all being necessary for recovery from the OSI and subsequent workplace reintegration. A team-driven and collaborative workplace nurtures healthy working relationships, but this was not what many of the participants experienced. Many participants lamented the lack of healthy workplace relationships and commented that having these relationships was and would be central to workplace reintegration and recovery from OSI.A loss of self-identity and purpose contributed to participants becoming overly entrenched in their work roles once they were injured and could no longer engage in professional activities. “When you’re in the darkest moments of this…there’s an identity crisis, there’s like, “am I ever going to nurse again?” and “what the hell is happening to me”, like you just, it feels like, just a cloud, you’ve lost a piece of yourself, you don’t know who you are anymore.”(P5)“My guilt for being home was crippling. And I don’t say that lightly. But it was because here I am. I’m like ‘here, I’m an emergency nurse. This is my passion, my profession. This is what I’ve been trained for. And here I am at home crying when my coworkers are suffering’.”(P7)After recovery, the participants could acknowledge that stepping away from work allowed them to gain insight into themselves, their personal identities, and their work environments. A central realization was that they had a right and responsibility to care for themselves, and there was more to who they were than their role and profession as a nurse. “And I guess taking that time off. And like, losing touch with that, I guess, like not not being able to consider that kind of like my primary, a primary part of my identity or having to think like, will I be able to stay in ICU? Like, do I need to take a different type of job and like, this is what I love. I guess I kind of realized that maybe I need to, like take a step back and kind of take, you know, I can care about what I do. But it’s also… it is just a job. And I need to, like, prioritize myself over any of this.”(P3)Connection within the profession was cited by participants as being important to facilitate a compassionate, respectful, validating culture, and environment. A lack of connection between peers, leadership, and workers’ compensation organizations resulted in them experiencing additional distress, distrust, and isolation. Participants felt that dismantling silos between the union, leadership, workers’ compensation organization, and staff would be beneficial to addressing OSI-related concerns.“And no one even, from management or anything, even like checked on me, which I really felt, like, annoyed and upset about at the time. But now I’m kind of like, ‘I don’t know’. If they…don’t know what they’re kind of, like, allowed to do in terms of like, not overstepping boundaries, but it felt kind of like, insensitive, like, no one really said, like, “Oh, how are you feeling? Are you okay?” Or whatever. It’s just like…I didn’t even leave…my work friends, the people I work with were really good…they were really supportive.”(P6)“My manager, who had just come in, I had never met her before you emailed me and said, I know what happened to you. I’m really sorry, I’m here. These are some mental health resources. I’m a big proponent of it. She was great. Rather than the previous cadre who had just kind of slid the brochure across the table, you know.”(P1)Formal or informal peer support with nurses who understand the turbulent workplace demands were also cited by participants as helpful. “And she (colleague) checks on me like she, we kind of check on each other. She’s someone that like, seems to cope really well with all this stuff. But she’s someone I can definitely, like, count on. And then I know that like, if I were to ever just tell my friends like I’m having a really bad day or whatever…they would be there for me.”(P3)Positive support outside the workplace was emphasized by the participants as important to recovery and workplace reintegration; nevertheless, some participants reported feeling responsible for keeping family and friends unburdened by their mental health challenges. Friends and family may have been the first to identify behavioral changes within the participants, which helped them identify their own mental health challenges and seek help. In some cases, participants reported their closest relations were unavailable or incapable of providing support, which created additional barriers to recovery and reintegration.“I told my parents, my parents don’t live here. And from *province* my dad, and my mom. And my brother is my only family who lives here. And he said, “You know, I don’t know if this job is the best for you.” I’ve always had lots of family and friends around me, so I’m blessed in that way. And, they also noticed that I was isolating. So my husband, you know, we were just keeping it together…I said to him, finally, I’m like, you got to go and talk to someone because, like, I know, this was hard on you.”(P5)“[M]y partner unfortunately wasn’t…I don’t think he really even had the capacity to be and then like, also, you know, living with someone that’s depressed and anxious and stuff, and not knowing how to deal with that is probably not easy either. So yeah, that, that I ended up ending that relationship.”(P3)Close relations further assisted participants with navigating and accessing assistance before or after leaving work. “I think having somebody there to be able to talk to you, that’s a safe person. Yeah. And I would say, like, really reach out to your support system, because I don’t know what I would do without them. Yeah. I genuinely, like, that sounds very scary, but I don’t think I would still be here without them. I think I would have, like, I think I really would have collapsed in the darkness.”(P2)Post-traumatic growth was a common theme identified by participants. Despite the challenges nurses experienced during their OSI recovery and subsequent workplace reintegration efforts, it helped them to recognize their personal strengths and resilience, engage in new opportunities, and find a new appreciation in their profession and personal lives. Many participants wanted to altruistically assist other nurses in their recovery from OSI, through formal and informal peer support, and advocate for change within systems and organizations.Coping and emotional regulation skills were strengths that participants identified as having increased during their recovery. The importance of self-advocacy skills and stronger boundary settings was also emphasized, with the goal of protecting and enhancing their mental health and wellness at work and home.“Some of the differences is that I will realize when I’m getting low, that I will necessarily take a mental health day versus…not. Not having a clue that there’s days when I just know, mentally I need to do that. And I would say there was definitely days when I was redeployed to ICU that I did take more mental health days last fall… I just, I knew I’m like, that’s it. I can’t come back to this scenario tonight. I have realized that sometimes there’s things that I’m just like, need some time out?”(P4)Participants acknowledged and accepted the importance of addressing mental health challenges by developing self-awareness, education, and engagement with mental health treatments. Participants also described enhanced compassion and empathy for others experiencing mental health challenges as having being bolstered during their recovery. “So working on that with people and just kind of being an advocate for workplace safety. And helping some of my co-workers and another co-worker got punched in the face by a kid. And just like helping with like, K, you need to do this*workers compensation organization*, you need to go get checked out by a doctor and just kind of being somebody there for support and the department.”(P2)“I have a lot more empathy. For everybody with every mental health concern, I always did. But man…”(P1)Some participant experiences with OSI and workplace reintegration proffered new opportunities for growth; for example, gaining new knowledge, pursuing education, moving into alternate nursing positions, finding new leisure activities, making new connections, and engaging in other paid, volunteer, or informal roles that assist others in the community. Participants identified a sense of peacefulness with regard to finding their voices and cumulatively advocating for support for one another.“I don’t have to continue in emergency if I don’t want to. I don’t need to be a trauma nurse. I really wanted to be a trauma nurse… But now I’m kind of like, I don’t want that stress in my life. And I will be okay. Without that I don’t need that; I will kind of do the work that makes me happy.”(P2)“I am now driven and very passionate for supporting mental health for nurses. And I have a lot of experience and knowledge that I want to share with other nurses because there is a substantial gap of knowledge within our profession, and that needs to be addressed, and it’s not in a negative way.”(P7)Participants reported shifts in their personal priorities and enhanced self-determination after being away from work and experiencing an OSI. Participants also reported renewed appreciation of life and time spent with family and friends. Engaging in purposeful activities became clearer and prioritized among participants as a result of their recovery journey. “… [I]t almost kind of feels like I don’t owe *healthcare organization* my life anymore. Yeah, I feel like I’ve kind of gotten into being a nurse is not my whole life. There are other things to life that matter. So now I will take my personal days if I need to.”(P2)Having a sense of purpose beyond their nursing career resulted in participants feeling less guilt when taking time off of work. “I can happily say that I am very grateful for the experiences that I’ve had, because I have this new knowledge I would have never had. And that’s, you know, someone who’s talking that’s done a lot, a lot of work and healing. And, you know, so there’s a lot of gratitude there.”(P5)N = 7) employed within a Canadian provincial healthcare system who have attempted workplace reintegration after being off of work with an OSI. The current study appears to be the first to specifically address the topic of workplace reintegration among nurses with OSI. Participant engagement helped to contextualize the current nursing context, factors that contribute to OSI, and facilitators, barriers, and changes needed for workplace reintegration among Canadian nurses. The current study was designed to explore the experiences and perceptions of nurses , starting with an acknowledgement that a potentially psychologically injurious event has taken place. Consistent policies and procedures for providing support to staff during and after these events were desired by participants, together with compassionate leadership and non-judgement from peers. Some participants felt abandoned by their health organization to navigate their workplace reintegration independently without standardized policies, programs, support, or resources, which may have contributed to poorer return-to-work outcomes. Only two participants had engaged in a formalized workplace reintegration effort. The need for education on mental health through a trauma-sensitive lens at all levels of the organization as well as for those nurses who experience OSI was noted as a prominent need, which is consistent with recommendations from the literature ,16. CritThe third theme identified and emphasized the importance of finding and leveraging connections within self, the profession, family, and friends during their recovery journey and workplace reintegration. Social support has been shown in the literature to be an important aspect of resilience and recovery after psychologically injurious events or psychological distress via a number of psychological and behavioral mechanisms. These include motivation to adopt healthy lifestyle behaviors and reduce risky behaviors, feelings of being understood, appraisal of potentially stressful events as being less threatening, enhanced sense of control or mastery, increased self-esteem, use of active coping strategies, and impact of social influence and social comparison . ParticiFor the fourth theme, post-traumatic growth was identified in three of the five domains of the formal definition of this construct . These iThe study results informed several recommendations regarding the workplace reintegration of nurses who have sustained an OSI. The recommendations were related to addressing OSIs, policy, initiatives and implementation related to workplace reintegration, and future research.The nursing profession, educators, leadership, healthcare organizations, government agencies, workers’ compensation organizations, and the public at large need to acknowledge that nurses experience potentially psychologically traumatic events. Without such acknowledgement, nurses will continue to have invalidating experiences that cause additional, unwarranted distress and bureaucratic burden after sustaining an OSI. Unions, healthcare organizations, mental health advocates, and governments could educate stakeholders and the public and advocate for global awareness and acceptance that nurses experience potentially psychologically traumatic events. The proposed psychoeducation may help reduce the secondary and sanctuary/organizational traumas experienced by injured nurses. The reductions may also help to reduce injury severity, shorten workplace reintegration processes, and increase retention.Additional education related to profession-specific mental health, including a focus on trauma and moral injury, wellness, and coping strategies for all levels of the healthcare organization, is recommended. This would assist nurses and their networks to increase mental health literacy and reduce stigma ,10,23,24The revision and creation of evidence-guided policies, programs, practices and initiatives are needed to further support nurses in workplace reintegration after an OSI, and to bridge the gap from clinical interventions for OSI to a full workplace reintegration. Setting the stage through education on the challenges and importance of workplace reintegration after clinical interventions may be an initial step in this process. Such education would be appropriately aimed at stakeholders, such as nurses, nursing students, nurse educators, leadership, administrators and policymakers, workers’ compensation organizations, varying levels of government, unions, and HCPs engaged in the care and rehabilitation of nurses. Novel policies, programs, practices, and initiatives will require context-specific development, design, implementation, fidelity, and evaluation efforts to ensure effectiveness. Initiatives must involve a formalized, well-communicated process that can be individually tailored to be person and profession-specific. Individuals must be provided with the space and time needed to recover and engage with a clinical intervention addressing the OSI without pressure to return to work too early. Allowing the individuals to have control and choice is imperative for a successful workplace reintegration, enabling the nurses to feel empowered. The incorporation of formal peer support into such efforts is also recommended based on the results of this and other studies ,23,24,25Workplace reintegration and return-to-duty initiatives by PSP and military organizations may provide a template that could be contextualized and adapted to a healthcare environment . HealthcPresumptive legislation adoption and implementation by governments and healthcare systems is strongly recommended. Presumptive legislation “accepts disease or disorder claims from a worker, such as PSP, without the worker having to prove that the physical or psychological disease or disorder resulted from the job” . This leResearch is needed in multiple areas related to workplace reintegration and OSI among nurses and HCPs. First, more research and advocacy are recommended regarding the healthcare settings as the effects of chronically stressful environments are modifiable risk factors for OSI in HCPs and nurses. Secondly, listening to and researching the perspectives and experiences of nurses and HCPs who have experienced OSI and engaged in workplace reintegration are critical to developing interventions that are effective, co-designed, and population-specific. The existing literature also advocates for research to consider gender more carefully. This is particularly important given that nursing is a woman-dominated profession resulting in research that is biased by the homogeneous nature of participants ,30. GendAs mentioned, workplace reintegration initiatives will need to be visioned, developed, implemented, and scaled to address this issue. Once initiatives are started, high-quality studies need to explore the effectiveness, efficacy, safety, and fidelity of novel policies, procedures, or programs . When reThe current study acknowledged, listened to, and amplified the voices of nurses with lived experience of OSI and workplace reintegration. The results included identifying barriers, facilitators, and recommendations for return to work to be identified. The current study also captured a glimpse into the COVID-19 pandemic experiences of nurses, which will be retrospectively viewed as an important point in the history of healthcare systems as a whole. There were several limitations to the current study that can inform future research. Recruitment for the current study was lower than expected, likely due to the sensitive nature of the topic and the demands currently placed on healthcare professionals and systems as a result of the COVID-19 pandemic. Interviews were commonly rescheduled or cancelled completely as potential participants attempted to accommodate shift changes, overtime, and other demands. The scheduling challenges resulted in a smaller-than-expected sample size, limiting generalizability. Additionally, gender bias is notable in this study. Although efforts to recruit all genders were made, nursing remains a profession of mostly women and this was reflected in the data . FinallyNurses and other HCPs are frequently exposed to potentially psychologically traumatic events and potentially morally injurious events. Profession-specific and tailored policies, practices, initiatives, and support are needed to assist HCPs in OSI recovery and subsequent workplace reintegration. HCPs should not be compelled to return to work in a nondescript capacity, but should be enabled to reintegrate with purpose into their desired roles and capacities and be retained long term. Listening to and amplifying the voices of nurses with lived experience of OSI and workplace reintegration allowed for barriers, facilitators, and recommendations for return to work to be identified. The current results can assist in setting the stage for subsequent work on the development and evaluation of novel approaches to best serve nurses reintegrating into the workplace. Development, implementation, research and exploration of innovative policies, procedures, and initiatives can help bridge the gap from clinical interventions to workplace reintegration for nurses experiencing OSI.