The COVID-19 pandemic has forced rapid and widespread change to standards ofpatient care and nursing practice, inevitably leading to unprecedentedshifts in the moral conditions of nursing work. Less is known about howthese challenges have affected nurses’ capacity to meet their ethicalresponsibilities and what has helped to sustain their efforts to continue tocare.1) To explore nurses’ experiences of striving to fulfill their ethicalresponsibilities of care during the COVID-19 pandemic and 2) to explore whathas fostered nurses’ capacity to fulfill these responsibilities.A generic qualitative approach was used incorporating concepts coming fromfundamental features of care.Twenty-four Canadian Registered Nurses from a variety of practice settingswere interviewed.After receiving ethics approval, signed informed consent was obtained beforeparticipants were interviewed.Four themes were identified. 1) Challenges providing good care in response tosudden changes in practice. 2) Tensions in juggling the responsibility toprevent COVID-19 infections with other competing moral responsibilities. 3)Supports to foster nurses’ capacity to meet their caring responsibilities.4) The preservation of nurses’ moral identity through expressions ofgratitude and health improvement.Infection control measures and priorities set in response to the pandemicmade at distant population and organizational levels impacted nurses whocontinued to try to meet the ideals of care in close proximity to patientsand their families. Despite the challenges that nurses encountered, the carethey received themselves enabled them to continue to care for others. Nursesbenefited most from the moral communities they had with their colleagues andoccasionally nurse leaders, especially when they were supported in aface-to-face manner.Conclusion: Moral community can only be sustained if nurses are afforded theworking conditions that make it possible for them to support each other. Several studies have explored the ethical implications of theCOVID-19 pandemic on nurses’ work. Iheduru-Anderson1 and Rezaee2 et al. foundthat nurses have expressed ethical concern with the standard of care that has beenprovided during the pandemic. In particular, Rezaee2 et al. described how spiritual,compassionate, and family-centered care has been poor because of the shift inclinical priorities. Similarly, Sperling3 reported on nurses’perspectives regarding the allocation of scarce resources, with nurses expressingconcern for the lack of organizational support. Other studies have focused more onnurses’ emotional responses to these issues, in particular the lack of support forpatients because of restrictive visitation policies5 and the frequent witnessing ofsuffering and death6 of COVID patients.The COVID-19 pandemic has forced rapid and widespread change to standards of patientcare and nursing practice, with nurses having had little opportunity to have theirvoices heard.7 More evidence is needed todetermine the contexts and types of strategies that are beneficial to support andcare for nurses. This understanding is not only essential during the pandemic, butalso for future circumstances, so that nurses can continue to provide care at thehighest possible standards.Less is known, however, about how these challenges are understood through the lens ofethically good care and how they have affected nurses’ capacity to meet theirethical responsibilities. Moreover, little is known about what has helped to sustainnurses’ efforts to continue to care. Without resources and opportunities toadequately care for themselves, nurses will be unable to focus on the needs ofothers and manage the ethical demands of practice.The overall purposes of this research were: 1) to explore nurses’ experiences ofstriving to fulfill their ethical responsibilities of care during the COVID-19pandemic and 2) to explore what has fostered nurses’ capacity to fulfill theseresponsibilities.8 was used as a theoretical lens.They stipulate four fundamental features of care drawing on related work in virtue,care, nursing, and feminist ethics which are described below:8(1) “Care is simultaneously a way of life and an ethical task”(p.16)The work of Vanlaere and Gastmans8 As an ethical task or responsibility, care must beother-regarding in that attention and involvement must turn to the needs of others.The goal of nursing activity is “the promotion of the well-being of the patient byproviding good care in the wider meaning of the word—that is, on the physical aswell as the psychological, relational, social, moral, and spiritual levels”(p.45).7 In doing so, nurses enable patients to maintain a sense ofidentity by preserving their association to the social and cultural world despitethe depersonalization of illness and the routinization of institutionalwork.9 Nurses’ ethicaltask of caring for persons is not only necessary for those who are in closeproximity but is also required for unknown and future others through healthpolicy.8 When patients are immediate, however, the closeness to pain,suffering, and vulnerability generates strong normative intuitions in nurses to careand attend to their needs.108(2) “Care is a practice by which attitude and activity go hand-in-hand”(p.20)As a way of life, care is fundamental, often considered instinctual or natural,involving all human activities that better the human condition, includingself-care.8 Attentivenessrequires that caregivers have had their own needs sufficiently met so that they canput aside their own concerns and goals to recognize others’ needs.11 The activity of care involves“face-to-face interactions between both persons”(p.21),9 that is, in order to be considered good care, must be competentand recognized by the care recipient as effective.118(3) “Care is reciprocal” (p.24)Care involves an attitude of “caring about” which refers to the emotions andattentiveness of the caregiver along with taking responsibility for caringactivities in response to another’s needs, that is, “caring for.”10 In nursing, when patients express gratitude, displayimprovement or confidence, or show signs of being physically comforted, they providenurses with a sense that they are good nurses.10 In this way, “patients cancomplete the caring presence of the nurse” (p. 51).7Not only are care recipients dependent on caregivers to have their needs met,caregivers also are dependent on care recipients to maintain their moralidentity.84) “Care is meaning-giving” (p.27)8Ultimately, with reciprocity, nurses can find life fulfillment and meaning inproviding care. However, nurses can experience stress and meaninglessness withlimited personal contact with patients is possible because under these circumstancesthey cannot receive patients’ responses.12 to integrate ethical theorythroughout the research process to clearly conceptualize nurses’ ethicalresponsibilities. This methodology encourages flexibility to tailor methods and theuse of appropriate techniques from existing qualitative methodologies to best answerresearch questions.12 To maintain coherence, we chose to locate this work withinan interpretivist paradigm where meanings are understood to be generated throughsocial interaction.13 Vanlaere and Gastmans’8 work is consistent with thecharacteristics of this paradigm because of its emphasis on nurse-patientrelationships and the meaning of care.We chose a generic qualitative approach because established methodologies could notprovide us with the flexibility needed14After receiving ethics approval from the University of Toronto’s Health SciencesResearch Ethics Board, participants were recruited using purposive sampling throughthe Lawrence S. Bloomberg Faculty of Nursing’s graduate student list serves andFacebook groups, the university’s web-based learning management system, and snowballsampling. Inclusion criteria included: (1) Registered Nurse (RN); (2) experienceproviding direct clinical care to someone with, or suspicion of, COVID-19 infection;and (3) English fluency because of the language skills of the researchers. Oneexclusion criterion included: (1) a current student of any of the researchers.Because we used passive recruitment strategies, we do not have insight into why somenurses chose not to participate. To obtain a balanced appreciation of the contextualinfluences on care, we recruited a heterogeneous sample of 24 participants from 12hospitals and three community/public health organizations from six cities in theprovince of Ontario and from one city in the province of Nova Scotia, Canada. SeeWe conducted semi-structured, audio-recorded interviews of approximately one-houreach using Microsoft Teams because of COVID-19 restrictions during the spring andsummer of 2020. Interviews were a suitable form of data collection because theyelicited participants’ reflections of their care during the pandemic. Participantswere asked about their work and educational background; how the pandemic wasaffecting their care; the ethical challenges and sources of stress they wereencountering; what helped or would help them cope; the influence of colleagues,managers, and the public. The audiotapes were transcribed by a professionaltranscriptionist, de-identified, and then stored on a secure server.An informed consent document was signed by the participants, which described thestudy, the risks and benefits, the opportunity to withdraw, data security, andmeasures to maintain confidentiality, including the use of participant numbers asopposed to names. All recruited participants completed the study. As a form ofappreciation, participants received a $30 electronic gift card of their choice atthree different businesses after their interviews. Because this amount is less thanthe hourly rate for nurses in Canada, it was not considered coercive.16 Tentative themes wereidentified and then we went back and forth between these themes, care ethics, andthe research questions until there was coherence and agreement regarding the namingand key analytical characteristics of the themes.Data analysis was a collaborative and iterative process which occurred independentlyand collaboratively during regular research team meetings of the first four authors.Nvivo was used to manage the data and facilitate the analysis. Initially, codes wereidentified in an iterative fashion using constant comparison and staying close tothe words of the participants. Later deductive techniques employing the fourfundamental features of care ethics to add depth, contextualization, andtheorization to the analysis.17 We engaged in reflexivity bybeing aware of the influence we had on our interactions with participants and ourprocess of analysis.18 We kept reflexive notes of our reactions, assumptions, andinsights that reflected our own identities as nurses, faculty members, researchers,and people impacted by COVID-19.17Trustworthiness was maintained by being attuned to the interrelationships between theperspectives of the participants and our interpretations of them. To further promotetrustworthiness, we closely followed the data collection strategies, ethicalguidelines, and analytical procedures.(1) Challenges providing good care in response to sudden changes inpractice.Our analysis yielded four themes that conceptualize the experiences of nursesstriving to fulfill their ethical responsibilities of care and describe whatfostered their capacity to fulfill their ethical responsibilities.To manage the rapidly evolving COVID-19 crisis, changes to nursing staffing modelswere instituted very quickly and hospital beds were emptied to accommodate patients.These changes to practice reflect organizational and governmental decisions thatwere made at a distance and generally without nurses’ involvement but had greatimpact on their frontline work in close proximity to patients. These changespresented barriers to good care from the perspective of nurses in several ways.Everything kept changing so rapidly, there was no time to acclimatize to anykind of new norm. And that invisible labour of constantly renegotiating,adjusting, moving in that capacity of resilience sits differently for a lotof people, but I think it’s part of that spectrum of invisible labour thatreally isn’t qualified.One nurse described the impact of the sudden changes this way:Due to changes to nurse staffing models, such as the redeployment of nurses to theintensive care unit (ICU) to accommodate the influx of COVID-19 patients, nurses hadto contend with working in new areas of practice without sufficient staffing orclinical resources. As a result, not all nurses believed they were adequatelycompetent to care for these patients.Because I’m not an ICU Nurse I’m not supposed to be caring for these patientsindependently, but I’ve had agency nurses that didn’t look over everythingthat I was doing, which – I don’t mean like in an intense way, but I’m notan ICU nurse, so I think that you should review my rhythm strip, or justtake a peek at the patient to make sure they look okay to you.One participant said:The hospital system is trying to get people out…So now that everyone is kindof mass dumped into the shelter system, so just trying to figure that out.Because it is challenging dealing with the influx, and I’m only one person.I can only do so much.Freeing hospital beds to accommodate COVID patients had implications for nurses inthe community and in ICUs. A community nurse identified the distress theyexperienced when the shelter system was overwhelmed with people rapidly dischargedfrom acute care, reflecting the further marginalization of people in need of shelters:The people who have been here for like months and months, they were verystrongly pushed for the withdrawal, and they’ve contacted their families,and over the weekend, just like, people started going, and I couldn’tbelieve that... It seemed like there was a handful that they kind of justdecided, okay, we’re supporting this person, but we need the beds…Thenursing culture, I think, is very happy to keep a chronic patient. Like,there’s no harm in him being here, or them being there.In addition to quick discharge from hospital, participants described their concernsregarding the withdrawal of non-COVID related treatment from vulnerable patients tomake room for COVID patients:(2) Tensions in juggling the responsibility to prevent COVID-19infections with other competing moral responsibilitiesThrough this excerpt, this nurse reveals that the usual attentiveness along with theextensive involvement with the family when treatment withdrawal is performed wasforgone to make beds available in a rapidly evolving crisis.Nurses experienced the tension between needing to meet their usual caringresponsibilities and simultaneously needing to prevent the spread of COVID-19. Themost common way nurses experienced this tension was in relation to visitationpolicies, the requirement to don and doff PPE, the responsibility to ensure thatpatients adhered to infection control measures, and the reduction of communityservices.She had had five previous losses. And she was having, like, had finallycarried a baby to term and developed a fever. And I had to ask her husbandto leave. Can you imagine?.. It’s just awful. Just awful. And I thinkeverybody was really horrified of having to be put in those positions ofasking people to leave, or people come into triage, and you have to tellthem that their husband can’t come with them.Because of policies that restricted the presence of family in hospitals, nurses couldnot reach their ideals of family-centered care and beyond this, often held theresponsibility of enforcing these policies, despite not having participated in theircreation. A nurse, referring to a laboring patient, stated:Usually when a patient is imminently dying, the family would be able to atleast hold their hand, even if the patients themselves weren’t conscious,just that physical touch I feel like was immensely comforting to the family.But that’s not possible now.Nurses’ proximity to their patients generated a strong caring attitude when COVIDmeasures disrupted patients’ face-to-face contact with others. They spoke ofpatients’ lonelinessand how Nevertheless, nurses did their best to facilitate patients’ relationships with theirfamilies, despite the visitation policies. Some found ways to have family presentwhen patients were imminently dying, and many provided tablets and other virtualmeans for families to connect. For example, one participant said: “We have tried tointroduce iPad communication, daily video chats, anything we can to let that facetime happen between patients and their family members. And I think it helps quite alot.”The patient is coding and rapidly de-sating, but you have people gowning upoutside, and it takes a while to put on all your PPE, right? So, you’ll bewatching the sat drifting down, and you’re trying to put on your N95 as fastas humanly possible.Although PPE was necessary, and nurses understood the importance of it, it acted as abarrier to nurses’ moral actions by inhibiting nurse–patient relationships andslowing down their ability to care for patients. Nurses spoke of the time-consumingnature of donning PPE even in emergent situations, such as the one described below:I feel like a robot and very distant from my patients. That whole, you know,‘treat the patient holistically, person-mind-soul-spirit’ I think that’sgone by the wayside. I feel like that important aspect of providing careand, you know, touching a patient’s shoulder with a bare hand, you know,that human touch is lost…And I feel terrible because the patients can’t seemy face because I’ve got a face mask on, a face shield on, a yellow gown,scrubs, gloves, and… it sort of removes yourself from the patient, you know?And then you always have to say to yourself, “this is a human being and nota body.Others spoke of PPE interfering with face-to-face relationships with patients. Forexample, one participant said:To mitigate risk while also doing the least restraint, we’ve had to locksomeone’s door essentially to mitigate them coming out, because they’re justnot in a place where they can cognitively understand the risk that isimposed upon them, other people, the staff. At some points, we’ve had to dochemical restraints as well until we’re able to safely ensure that thatperson is not COVID positive.In mental health settings, unique circumstances arose in which nurses were requiredto restrain patients to prevent them from spreading COVID-19 which resulted inpatients not being able to freely move about and a disruption in nurses’ caringrelationships with their patients. One participant stated:If you look at the homeless community here in X, for example, all of theservices that our homeless community would typically access from a drop-inbasis are gone. And so now, I mean, I am literally the only street outreachnurse in X at the moment. And it’s a huge amount of pressure…I feel likethere’s a huge need and I feel like I can’t provide the kind of care that Iwant to be providing because there’s only one of me and because the need isjust so high.(3) Supports to foster nurses’ capacity to meet their caringresponsibilities.Community services were also reduced to stem the spread of COVID-19 resulting innurses not having face-to-face contact or the resources they required to meetclients’ needs. One nurse described the challenge of not being able to conduct wellbaby visits andanotParticipants shared a range of experiences with respect to supports offered to nursesby their clinical organization. Some participants described an oppressiveorganizational context that they perceived to be characterized by a lack of trust,concern, and transparency which contributed to their sense of being unsupported,while others provided examples in which organizational leaders demonstrated care andsupport.All of us were pretty blindsided by this decision. And I think also there wasno input from frontline staff whatsoever when they made this choice. Andthat was difficult too…I didn’t come to this work to be told “You have nochoice. You’re now doing something that is so far from what you wouldnormally be doing.One participant described nurses having no input into the decision to make their unita COVID unit, leaving them unprepared, and potentially lacking in competence, tocare for this patient population. They said:I perhaps feel a bit more disposable than I did at the beginning of this. Ichose the COVID unit because I thought that’d be the safest place, but inthe end, I still got COVID…I just feel like they didn’t care as much as Iwish they would have is the issue. In the end, at the end of the day, thenurses were still the ones showing up for every shift, every night shift,every weekend; when everyone else went home, no one else were in those roomswhen those aerosol-generating procedures were happening. Or when there was aCOVID positive patient, the APN (Advanced Practice Nurse) would never stepin the room, the manager never needed to go in the room.A lack of care and concern for nurses also manifested itself through administration’streatment of nurses who were sick with COVID-19 and through their limited in-personcontact. One nurse expressed feeling devalued by the organization:The director for that (nursing) governing body never even set foot really ona unit – any unit... I was struggling with just being on a COVID unit andworking alongside others every day, trying to support them and lead themthrough, you know, what everyone’s been calling an unprecedented time.Meanwhile, this large body that represents nursing and nursing professionalpractice was absent and disconnected, not on the same page. That was very,very upsetting and frustrating for me.The lack of face-to-face interaction by management further created an atmosphere thatbred a sense of a lack of support and care for nurses. For example, one participant said:So, having that reflective practice has been a really good support becauseI’m able to kind of dump everything out during that hour and get a lot offeedback and support back, too. My supervisor is really good at filling upour cup.In contrast, others spoke of their managers in very positive ways with respect totheir support, openness, and presence:I actually felt as though the relationship (between frontline staff andleadership) was quite good because we felt very supported. We always had aleadership team member pretty much there every day, even on weekends, whenit was really bad. So, then we felt super supported.Another said,The organization offered, the psychologists were offering one-on-one supportthrough over the phone, virtually, as well as EAP (Employee AssistanceProgram). But staff were very reluctant, and, again, it felt like that wholelayer of disconnect. Like, I don’t want to talk to someone on the phone whocan’t possibly appreciate what I am going through and what I am livingthrough right now.Receiving professional therapy, which was occasionally provided by the organization,was met with mixed responses. Some described this support as valuable, whereasothers expressed hesitation because the therapists were too far away from therealities of their work. For example, one participant said:... your colleagues really are there for you. That kind of stuff has been agreat source of support for myself, and I hope for my colleagues… that havebeen directly involved in the most distressing situations. I feel likespeaking to that person and just kind of validating, “yeah, that wasterrible. Yeah, that was an awful situation.” Having those feelingsvalidated I think has been probably one thing that has assisted me.The strongest and most common source of support recognized by nurses was throughtheir nursing colleagues, particularly in the context of face-to-face interactions.Participants found it particularly helpful if their colleagues had similarexperiences and could recognize and validate their painful experiences. Oneparticipant noted:Another said: “Having that camaraderie and leveraging that camaraderie with mycolleagues who understand and are in similar shoes has been very helpful.”Strangely, since COVID the level of just being collegial it feels like it’sgone up. Because I feel like people need to support each other more… Butrealistically we’re a unit that is fairly tight-knit and we need to cometogether to help each other out a lot. And we hug each other, and we pateach other on the back, and we show each other – we’re like a large group ofwomen who are all kinds of ages, and it’s not uncommon for someone to comeand rub your shoulders while you’re on the computer or for someone to giveyou a hug. Some of the older nurses will come and just pat you on thehead.Another spoke of physical touch that was offered by their colleagues in response totheir distress. They said:I feel that there’s a good, strong sense of the team, that it’s imperativethat we work together, that we are all facing these risks. I think there’s arecognition of the type of specific risk and difficulties for eachprofession that their inter-professional colleagues are recognizing.Similarly, but less common, participants spoke of the importance of theinterprofessional team who also offered support and recognized the difficulties theywere facing. One participant said:Underscoring the importance of proximity in offering support, another said: “theclinical lead actually came inside the room with me at that time.”(4) The preservation of nurses’ moral identity through expressions ofgratitude and health improvementNurses also relied on self-care activities to help sustain their capacity to continueto meet their caring responsibilities. These included, “binge watching a lot of TV,playing video games, online shopping,” “exercisAnd then when she woke up, all of a sudden, and I was the nurse. Oh my God, Iwas jumping! So happy that the tears were coming out of my eyes. She wasnodding appropriately. She was squeezing my hand… I need some happiness frommy patients, from my work. It’s not that I just need happiness from myfamily or from my personal life. I work half of the time here. Twelve hoursI work here, right?Patients’ responses either through the improvement of their health or expressions ofgratitude completed the caring process, thereby helping to sustain nurses’ moralidentity as illustrated in the following quotes:Another stated: “We had one patient who told me, “Oh, you’re making me feel so calm…”He was like, “Oh, I’m so glad you’re here.” ParticipI have the same patient ratio, I’m doing the same work, and I’m giving thesame care that I do every day of the year… and when this is all over, I’mgoing to be doing the same kind of care when all the hero stuff goes away.I’m still going to be working this hard.Although nurses valued the gratitude of patients, the public’s response, such as potbanging, cheering outside hospitals, and statements of thanks, was received withmixed reactions. At times, it was appreciated, but other times, it was met withskepticism. For example, for many nurses being called a hero by the public was notsuitable as an ideal to internalize as constitutive of their moral identity and notrepresentative of their work during the pandemic. One participant said that the heroworship would do little to yield long-standing change:And all over the radio when you listen to it, it’s like, “nurses and doctors,thank you so much. You’re the heroes.” And I’m like, no one’s ever called methat! No one’s ever – I feel like any time I say that I’m a nurse, there’salways a handful of people who are like, “oh, you’re just a nurse?” Orsomething like that. And now it’s like, “oh my gosh, you’re the hero!” I’mlike, huh there you go.In contrast, another said:I personally started to feel like it became a bit more of a performativeaction, like a virtue signaling of companies just kind of jumping in to saythat they did something for nurses or frontline heroes to make their companykind of look better.With respect to corporate contributions, participants expressed ambivalence becauseit was not always seen as an authentic expression of gratitude. For example, onenurse said:The results of this research point to less commonly identified ways that theprovision of good care has been compromised during the COVID-19 pandemic. Nursesexperienced challenges in fulfilling their moral responsibilities and enacting theirmoral identities because of public health measures that led to restrictions inpractice, such as visitation policies. The diminishing of nurses’ moral agency intheir caring work and their perception of not being supported were sustained byorganizational cultures that lacked transparency and provided few opportunities forfrontline nurses to participate in decision-making in relation to public healthmeasures and new organizational priorities. Nevertheless, some organizational,collegial, and personal strategies helped nurses to provide good care.19 In thecontext of a pandemic, these measures, along with prioritization decisions, are usedto maximize the number of lives saved and protect the public from harm.19Many of the challenges nurses in our study experienced were a result of public healthmeasures that were translated into organizational policies by senior administrativeleaders. These powerful measures, which often take the form of government policies,frequently impede personal liberties. Typically, they are understood to createethical tensions or dilemmas between the collective good and the rights ofindividuals, yet they are not necessarily without ethical justification.8 ourparticipants were not in a position to make choices about how these measures would,or would not, be imposed. Instead, most our participants experienced the moralimpact of these policies in close proximity to patients and their families, not atthe level of an organization or the distant level of population health. Insightsfrom the enduring work of Gilligan20 and Nortvedt10 on the ethicof care speak to how the moral world can be encountered differently when people comeacross ethical concerns that involve people in close proximity versus those at adistance, such as members of the public we have not met. Concerns involving those inclose proximity generally create strong moral motivations to respond in thosenearby10 with the unique characteristics and circumstances of peopleinvolved often being viewed as more important than abstract rules andprinciples,20 such as those articulated in policies. While public healthmeasures can be ethically justifiable in the context of a pandemic and theparticipants in our study adhered to them as best as they could, overall, theyexperienced them as challenging when the immediate situations they found themselvesin demanded caring responses they could not fully provide.While one of the ethical tasks of caring is understood to involve health policiesthat address the needs of people who are not in close proximity,9 often with the inclusion offamily, the participants’ inability to be adequately present with dying patients wasthreatening to their moral identities.21Therefore, it is not surprising that participants found visitor restrictions to be asource of ethical concern given both their lack of input into organizationaldecisions and their proximity to patients. The witnessing of patients dying withoutfamily present was viewed as a compromising good care given the centrality offamily-focused care, which highlights the importance of family present at death tohumanize and support the dying. Because nurses’ moral identities are sustained byholding the identities of vulnerable people,19 Some participants explicitly expressed concern that there waslittle transparency or requests for their input into how decisions were being madewith respect to the pandemic response in their organizations, contributing to theirexperience of restricted moral agency. Nurses frequently found themselves withoutthe needed expertise and resources to practice in a way that supported the provisionof good care. While our findings are novel because they pertain mainly to nurses’frequent lack of input into infection control measures and organizational prioritiesduring a pandemic, the organizational context in which they found themselves in isvery familiar, harkening back to Jameton’s identification of the “institutionalconstraints” (p.6)22 that frequently shape nurses’ moral lives.In addition, ethical decision-making during a pandemic should be guided by proceduralvalues, such as transparency and inclusiveness, so that decision-making is open toscrutiny, and stakeholders have opportunities to be engaged in the decision-makingprocess.24 They consistently spoke of the importance of engaging in dialogwith their colleagues, especially when these conversations occurred with those whoshared their own experiences and concerns. Moral communities are places where peoplecan speak openly, and critically reflect on, their responsibilities, values, andconcerns as members of a particular community. They encourage open and respectfulmoral discourse from all their members.24 These participants emphasizedthe significance of validation, reflection, collegiality, and occasionally physicaltouch, all attributes of a moral community in which people are cared about and caredfor. Face-to-face discussions with colleagues who shared their experiences wereviewed very positively, as opposed to those with managers or therapists who wouldnot, or could not, make themselves available in person and, therefore, could notfully demonstrate attentiveness and understanding. Moral communities were thereforelinked to the notion of proximity to mitigate the effects of a work environmentwhere physical barriers, isolation, and distance were required to curbtransmission.In terms of fostering nurses’ capacity to meet their caring responsibilities, ourparticipants pointed to several organizational, collegial, and self-care strategies.Participants found that a supportive moral community, that is, one that fostersmoral dialog, reflection, mutual respect, and collective moral support, to behelpful.9 In essence, these patients completed the caringprocess.7 It is essential, that this finding is viewed with caution,however, because not all patients improve and not all patients can, or should beexpected to, express gratitude.9 Moreover, in contrast to otherstudies,26 we did not find that these nurses spoke of finding meaning intheir work.Other strategies were also identified to have a positive impact on fostering nurses’capacity to care. For example, self-care strategies including exercise, meditation,and distraction were found to be helpful to participants. In addition, participantsfound that seeing patient improvement and expressions of gratitude from patients washelpful. Witnessing or receiving messages about patients’ recovery has the potentialto bolster nurses’ moral identity as good people who can make a difference inpeoples’ lives.27 and ultimately their moral agency.The responses of the public and corporate support were met with ambivalence. Whilesome nurses experienced a sense of being valued and empowered, others were quiteskeptical suggesting this adulation might be short-lived, a form of virtuesignaling, and no substitute for good working conditions and remuneration. The nurseas hero discourse was also questioned as a positive response because heroes, likeangels and saints, are expected to engage in supererogatory acts. Hero worship mayspawn a kind of moral ideal that is impossibly high and potentially oppressive,particularly during a pandemic with a shortage of resources. The hero discourse isalso problematic because it normalizes nurses’ exposure to risk, enforces modelcitizenship, and preserves power relationships that curtail nurses’ capacity to havecontrol over their workSeveral limitations are present in our study. The theoretical lens used was helpfulin adding depth to the study, but this lens could be strengthened with more explicitelements attending to the sociopolitical conditions of nurses’ work that make carepossible. In addition, this research was conducted in a Canada, a high-incomecountry, and mainly in Ontario during the first wave of the pandemic, limiting thetransferability of the findings. In comparison to many other places, resources wereless scarce and case counts were lower likely having an impact on our participants’experiences. Canada later experienced much higher waves of COVID-19 during 2021.While nurses may have gained confidence in their skills to provide care to patients,we speculate that nurses likely experienced even greater difficulties in theircapacity to fulfill their ethical responsibilities of care over time given highernumbers of COVID-19 patients and growing fatigue.The pandemic has exacerbated the challenges nurses experience in providing good careto their patients. We discovered that infection control measures and priorities setin response to the pandemic made at distant population and organizational levelsimpacted nurses who continued to try to meet the ideals of care in close proximityto patients and their families. Despite the challenges that nurses encountered, thecare they received themselves enabled them to continue to care for others. Nursesbenefited most from the moral communities they had with their colleagues andoccasionally nurse leaders, especially when they were supported in a face-to-facemanner. We stress, however, that moral communities can only be sustained if nursesare afforded the working conditions that make it possible for them to support eachother. Without care for nurses, care for patients will not be possible.


People use numerous metaphors to describe God. God is seen as a bearded man, light, and love. Based on metaphor theories, the metaphors people use to refer to God reflect how people think about God and could, in turn, reflect their worldview. However, little work has explored the common metaphors for God. This was the purpose of the current investigation. Four trained raters coded open-ended responses from predominantly Christian U.S. undergraduates  describing God for the presence or absence of numerous metaphoric categories. We then assessed the frequency of each of the metaphor categories. We identified 16 metaphor categories that were present in more than 1% of the responses. The top categories were “GOD IS POWER,” “GOD IS HUMAN,” and “GOD IS MALE.” These findings were similar across religious affiliations. We attempted to support our coding analysis using top-down and bottom-up automated language analysis. Results from these analyses provided added confidence to our conclusions. We discuss the implications of our findings and the potential for future studies investigating important psychological and behavioral outcomes of using different metaphors for God. God is conceptualized in many ways, even within religions. Religion researchers have spent considerable time exploring these conceptualizations and the outcomes of individual differences in their endorsement. Most of this work has focused on the character of God. Researchers reason that if we know a person’s conceptualization of God’s character, then we can predict important psychological outcomes, and ample evidence supports this idea. Researchers have adopted various methods to extract or measure conceptualizations of God. However, little work has looked at the common metaphors or metonymies used to conceptualize God. This lack of work is important because metaphor and metonymy are quite relevant for these conceptual purposes . TherefoThere are many ways people conceptualize God. One key insight involves the self. For example, Epley et al.  found stPrior work has also focused on various personality characteristics of God. Common characteristics analyzed in the literature focus on anthropomorphic God concepts , benevolis. In this case, DesCamp and Sweetser [is metaphoric, because, theologically, God is omnipresent and omniscient , at least in most Abrahamic traditions. Even so, humans are limited in their ability to comprehend such non-natural entities and must conceptualize God within their physical boundaries [Johnson et al.  focused Sweetser  analyzedundaries . Specifiundaries , 11. ThiMetaphors consist of a “source” and a “target” . The “taliterally think God is human, but they use humanness (the source) to ground or concretize the God concept (the target). This is the purpose of metaphors as they are studied in the broader literature [Of course, people do not offer up metaphors for God in such a clear SOURCE-TARGET mapping . They mostly provide descriptors and images. However, these descriptors and images can provide key insights into the metaphoric conceptualizations of God. For example, if people use human-like descriptors for God, we can infer that they understand the concept of God through their existing knowledge about humans. This maps well with Barrett and Keil’s  theory oterature .In sum, we define metaphor, in line with the broader metaphor literature, as the non-literal use of a source domain to refer to a relatively abstract concept , 12–14. The Simpsons or the film Dogma) and such images are instantiations of metaphoric processes. The way people report their relationships with God is similar to their relationships with other humans [Given the bodily and experiential limits on human cognition, the easiest way to think metaphorically about a supernatural entity, like God, is by giving it human-like characteristics . Indeed, the imagery of God as a human is apparent in art and media . Further, at least in Christian religions, God is referred to as “Father” . Even in Judaism, while God is not considered gendered, the Hebrew Bible uses the masculine gender form. DesCamp and Sweetser [Beyond these more human-like conceptualizations of God, religious teachings provide additional source categories for God metaphors. Nearly every religion depicts God as the “CREATOR,” or by using “POWER” terms. For example, note Jeremiah 32:17: “Ah Lord GOD! Behold, Thou hast made the heavens and the earth by Thy great power and by Thine outstretched arm! Nothing is too difficult for Thee.” Of course, describing God as “powerful” is barely metaphorical. It is yet another adjective to describe God’s attributes. Even so, there seems to be a consistent theme of metaphors or, in this case, metonymies that would fall under a “GOD IS POWER” category. For example, God is THE Creator . Further, many Gods are depicted as forces of power or nature . DesCamp and Sweetser  further The human, male, and power metaphoric source categories are likely to be most common, especially if our results follow the religious texts  of our pIn sum, there are numerous ways to conceptualize God metaphorically. Our ultimate goal, here, was to identify the most common metaphors and metonymies used to refer to God using a methodological triangulation approach . SpecifiMage = 19.10, SDage = 1.80; Minage = 18, Maxage = 51) participants responded to the focal item after providing demographic information, including their religious affiliation. The study was approved by the Case Western University Institutional Review Board. Informed consent was in written form.We collected data from 3,071 undergraduates attending three universities in the United States. Participants completed a large questionnaire on their religious beliefs and demographics and described God. Of the original sample, 2,923 . We were also interested in briefly exploring the consistencies between these responses based on religious affiliation . Following the recommendations of Fetterman et al.  and the Overall, the raters read the response and then decided whether each word in the description was being used metaphorically. If it was, they located the category and gave it a “1,” indicating that the category was present. The categories that were not present received a “0.” For example, if a participant wrote, “He is the universe,” the coders might have given the response a “1” for the male category and a “1” for the cosmos category.To ensure that one rater did not have too much influence over the coding results, we gave the source category a “1” if more than one rater applied a code to any particular response. If only one rater applied the code, we gave the response a “0” for that source category. Therefore, each response could have a “1” (present) or “0” (absent) for each source category.The second approach we used to identify metaphoric source categories was top-down automated language analysis. Specifically, we used the Linguistic Inquiry and Word Count (LIWC) software . LIWC auWe put all responses into a single file and analyzed it as a whole, instead of analyzing each participant’s response separately because writing samples were short and uneven in length. Analyzing the responses separately would result in language categories being over-weighted. For example, if one participant’s response is simply “power,” the power category receives a score of 100%. Compare that to the participant who writes “God is power.” For this person, the power category receives ~33%. However, qualitatively, the participants have written the same thing. As such, compiling all responses into one file allows us to avoid undue influence by word count.While automated language analyses are not optimal for identifying metaphors for psychological purposes , in combThe third approach we used to identify metaphoric source categories was a word frequency analysis using word clouds. This is a more bottom-up approach to automated language analysis, relative to the LIWC. To do so, we used the Meaning Extraction Helper . SpecifThe results from the metaphor source category coding procedure are shown in Tables The frequencies of the source categories are in The next two most common metaphor source categories were “GOD IS HUMAN” and “GOD IS MALE.” Though their prevalence is not equal, they likely came together . These two themes being highly prevalent make sense and fit our general predictions. When people are picturing God, they are likely seeing some sort of human and male figure, based on their embodied cognitive limitations , 11 and The next most common source category was “GOD IS A CONCRETE ENTITY.” This was a catch-all category for descriptions of “some physical being” that was not necessarily human. This theme was relatively less common for Christians of all sorts, including Catholics. It was more common for Muslim and Buddhist participants, compared to the other affiliations.After the concrete entity source category, there was a dramatic drop in prevalence. The next most prevalent source category, “GOD IS SUPERNATURAL,” was less than half as prevalent as the prior one. However, those who identified as Eastern Orthodox and Buddhist used this category more frequently than the other affiliations. For the former, this appears to be driven by the common mention of a “spirit,” and for the latter, “divine” was a frequently used word.The remaining source categories were relatively less frequent in all Abrahamic faiths, with one notable exception. For Jewish participants, “GOD IS UP” was relatively common. This might be because they used fewer human source categories and the next most prevalent source category was “up.” The same can be said for the prevalence of “GOD IS UP” for those who identified as spiritual and those who responded “unsure” to the religious affiliation question.Those who identified as spiritual also used source categories of “GOD IS EMOTION,” “GOD IS LOVE,” “GOD IS THE COSMOS,” and “GOD IS NATURAL PROCESS” with relatively more frequency than the other affiliations. However, there were relatively few of these participants and they indicated that they just believe in “something.” Atheists used “GOD IS COGNITIVE PROCESS” sources, which was driven by their descriptions of God as “an idea.”Overall, we identified 16 metaphorical source categories that people use when describing God at a frequency of at least 1% or higher. The most common were power-related and human-like in their imagery and this somewhat transcends religious affiliation. These source categories will be useful for understanding how people conceptualize God and differences in these conceptualizations will be informative for understanding psychological and behavioral outcomes.The results of the language analysis using the LIWC 2015 dictionary are in Figs In In In In all, the findings of the common linguistic dimensions and the higher- and lower-order psychological processes from the LIWC analysis support our coding results. While this method requires more qualitative interpretation, it was worthwhile to examine how automatic language might reflect our coding . God appIn We often read and hear God being described in numerous metaphors and metonymies . These metaphors represent how people understand God, and perhaps the world. However, a systematic examination of the actual metaphors used in people’s descriptions of God does not exist. Therefore, we sought to identify the most commonly used metaphoric source categories for God. To do so, we analyzed thousands of open-ended descriptions of God, using hand-coding procedures as well as top-down and bottom-up automated language analyses. The results were consistent across methods and with an analysis of religious texts . People Our investigation is informative for numerous literatures related to religious cognition. Particularly, the results support prior research and provide numerous avenues for future work on God conceptualization and the outcomes of such conceptualizations. Furthermore, the current work informs coding and analysis procedures when applied to a unique topic like God. We discuss each of these implications and corresponding future directions related to them, in turn.The results of the current investigation support prior work on the conceptualization of God. Particularly, the frequency of power imagery reflects DesCamp and Sweetser’s  analysisNearly all prior work on God conceptualizations has an anthropomorphic theme , 9, 21. Broadly, future work should investigate how people who are more likely to use “GOD IS HUMAN” metaphors differ compared to those who are less likely to do so. For example, human source domain endorsement might be positively associated with authoritarian/benevolent God beliefs. Further, it might be positively associated with religious behavior, such as praying to God for decision-making advice, as one would seek with a parent, and attachment to God . We see relatively more concrete than God for some. If God is ineffable, love is at least a little more effable. People have multiple physical and emotional experiences they associate with love that they can then use to ground the God concept. Even so, because the purpose of metaphors is to provide meaning to relatively abstract concepts by making them more concrete [The “GOD IS HUMAN” metaphor is highly concrete, which likely explains its ubiquity. However, some of the more frequent categories were less concrete. For example, “GOD IS LOVE” is the mapping of an abstract concept (“God”) with another relatively abstract concept (“love”). On the other hand, love is concrete , less coconcrete . TherefoConsequently, if people are trying to find the meaning of God, or meaning in life through God , then usIn addition to supporting prior work and inspiring new lines of research, our procedures provide some insights for future explorations of God metaphors and metonymies. Here, we used a triangulation approach  involvinUsing the coding procedures to identify metaphors for God proved challenging. Specifically, it required us to train raters to focus on descriptions of what God is, rather than what God does or God’s personality. This differs from other metaphor identification studies in that those studies tend to focus on the conceptualization of non-agentic target domains, like an orgasm  or tourisuggests that the person thinks of God as a male human (or entity). The use of power-related words suggests that a person conceptualizes God as a powerful force . The LIWC results enhance and support the results of our coding procedure.The top-down language analysis procedures  added confidence to the hand-coding procedures. While the LIWC, and other automatic language analysis techniques, are not directly useful for identifying metaphors , they caUsing a bottom-up or data-driven language frequency analysis procedures we identified common single words from the corpus we analyzed. Here, we opted for a word cloud. This allowed us to visualize the specific words used and to make inferences. Again, we were able to confirm the results from the coding and LIWC procedures, providing added confidence to our conclusions. For example, the words “creator” and “father” stand out in the word cloud and are easily represented in the “GOD IS POWER” and “GOD IS HUMAN/MALE” source categories. Of course, there are a lot of words that are not useful for metaphor identification and are also descriptors of God’s attributes. Furthermore, for both automated language analysis processes, we cannot determine if the words were used in negation . But, even then, negating that God is x somewhat suggests that people are using x to think about the God concept. Overall, though, our triangulation approach makes up for the limitations and difficulties of each method.Finally, we have used a number of terms in describing our theory, procedures, and implications  and labeled source categories  under which raters coded participants’ descriptions of God. We want to be clear that participants did not necessarily use these words. Most participants did not write “God is human,” for example. Therefore, our analyses were necessarily qualitative in the sense that we had to “translate” participants’ descriptions into the probable metaphoric source categories we perceived them as reflecting. As a result, different researchers may have coded some descriptors into different categories or felt that they were not metaphoric. Such issues of subjectivity are a limitation of most hand-coding procedures and their reproducibility , 40. We,Aside from the limitations of our analysis procedures, there are additional issues to consider. Primarily, our sample was decidedly non-representative, as it consisted of mostly Christian participants in the U.S. This limits our ability to make broad conclusions or to generalize to universal God conceptualizations. Even so, some researchers suggest that religiosity and God-belief might stem from evolutionary pressures, which could explain the near-universal belief in the supernatural, the existence of creation myths, the performance of religious rituals, and the similarity of anthropomorphic Gods across religions . FurtherAttempts to understand life have plagued humans likely since the beginning of consciousness. To find meaning in life is to reduce ultimate uncertainty, a state that humans universally hope to avoid . One comThe current investigation represents an exploration of the most common metaphors people use to describe the God concept in a predominantly Christian sample. We identified 16 relatively common source categories that our sample used to refer to God. With these findings, future work can start to explore the consequences of individual differences in God metaphor endorsement. Indeed, understanding God in one way over another may reflect fundamental differences in how one understands the world. Metaphors for God may be one way to discern these differences.


This paper explores how Australian gay men experience gender and sexuality in relation to heteronormative gender norms, specifically masculinity. A sample of 32 gay men 22–72 years of age participated in an online interview, using a videoconferencing software, on masculinity and homosexuality. Thematic analyses revealed that gay men experience gender and sexuality-related strain across all levels of their socioecological environment through social regulation, homophobic discrimination/harassment, and anti-effeminacy prejudice. The gay men expressed feelings of self-loathing, shame, internalized homonegativity, and isolation as a result. In examining interactions at each level of the socioecological environment, future research and practice may gain understanding in the social phenomena and how to ameliorate such strain. Beginning from the microsystem, family and close social networks, and extending to the macrosystem, broader social structures and ideologies, the socioecological environment of an individual includes a complex network of formal and informal structures which progressively exist and take shape according to the individuals inhabiting them ,2,3,4. MGender expression encompasses an individual’s conformity (or transgression) of societal gender norms, masculinity and femininity, where in traditional heteronormative and western societies, men are expected to be aggressive, brave, and stoic while women are expected to be emotive, passive, and sentimental ,13. AddiIn the lack of behavioral and verbal cues to signify an individual’s sexual orientation, gender expression is often used as a determinate . Extant The strain gay men may experience in their efforts to be as heteronormatively masculine as possible is perpetuated by prejudice and discrimination in all areas of life that serve to govern socially acceptable expressions of masculinity. Minority stress theory argues that people of minority groups are at risk of negative physical and mental health disparities as a result of such stigma and discrimination . MasculiThe socioecological environment of non-heteronormative and, particularly, sexual minority groups, within a western context, is argued to be a rapidly evolving environment . HoweverPrior to this, discrimination against sexual minority groups was common, with arguments of gay relationships being unnatural . SimilarThis study draws on socio-ecological theory ,2 which The microsystem, family and close social networks;The mesosystem, major settings ;The exosystem, other social structures that, although do not contain the individual, encompass their immediate setting, and;The macrosystem, broader social structures and ideologies.The socio-ecological environment of a gay man includes a complex network of structures which progressively exist and take shape according to those who traverse through them ,2,3. SocBased on extant literature , Figure The role of heteronormative masculinity within a gay man’s life should be examined as a complete system of variables contributing to and manufacturing internalized experiences of homonegativity . As suchThis paper is a part of a larger body of research exploring masculinity and internalized homonegativity amongst gay men. Limited research explicitly focuses on masculinity and internalized homonegativity ,25,45,46Our study asks: how do heteronormative ideals of gender and sexuality impact Australian gay men’s experiences? It is anticipated that the findings will assist in identifying the underlying issues surrounding internalized homonegativity  and epistemological gaps for further exploration. This paper is one in a series of forthcoming papers exploring masculinity and internalized homonegativity amongst gay men.This paper is part of a larger body of research, titled “It’s a Man’s World”, exploring masculinity and internalized homonegativity amongst gay men. Participants were recruited into the “It’s a Man’s World” study via advertisements through LGBTI networks , social media , dating applications , flyers placed across Western Sydney University campuses, and word of mouth. Advertisements included the researcher’s contact details in order to express interest in the study. Participants from the “It’s a Man’s World” study were provided the option to also express interest in the current research and provide their contact details. A pool of 253 individuals self-identifying as gay men were contacted through email after expressing interest and, from which, only 32 individuals followed up by arranging an interview. No interviews were cancelled or turned down and no participants withdrew from the study.Using a sample of 32 self-identified gay men 22–72 years of age  living in Australia , online interviews focusing on masculinity and homosexuality were conducted between March and July 2017, several months prior to the legalization of same-sex marriage in Australia and during the period in which discussion and contention was high. Among the sample, 3.13% identified as Aboriginal, 6.25% as East Asian, 6.25% as Southeast Asian, and the remainder as Caucasian (85.38%). Additionally, most of the sample identified with No Religion (68.75%), followed by those identifying as Christian (18.75%), Buddhist (6.25%), and Other (6.25%). Gay men are argued to be most adversely affected by heteronormative gender norms and prone to resultant health and wellbeing complications compared with lesbian women . TherefoFew studies have examined masculinity and internalized homonegativity qualitatively . This stInterviews were facilitated via the Zoom online videoconferencing software which needed to be installed by participants prior to the interview. This software was utilized for two reasons: (a) it enabled the audio-recording of interviews without additional software or equipment and (b) it did not require the researcher to add participants to their contacts, a common requirement in other online conferencing and social media. This allowed for the inclusion of samples from underrepresented, geographically and/or socially isolated populations, and individuals who are unable or prefer not to attend in person ,49,50. TFollowing initial contact, the first author (J.T.) forwarded details of the study to the participants, including a participant information sheet, a participant consent form, instructions on how to install and use Zoom, and the time of the scheduled interview. On the day of the interview, participants were required to click on the link included in the email correspondence which automatically prompts the participant to agree to installation of the software. Upon completion of the software installation, Zoom automatically opens the appropriate videoconference session. The researcher then enabled audio-recording on Zoom once consent was provided and commenced a semi-structured interview using the interview guide to facilitate conversation with the participant. All interviews were facilitated by J.T.Following data collection, interviews were transcribed verbatim and uploaded into Quirkos. Quirkos is a visually intuitive data management software that assists researchers in the coding and analyses of qualitative data . QuirkosTo maintain participant anonymity, pseudonyms were assigned to participants where direct quotes were used. Several themes and subthemes emerged from the gay men’s stories, namely: Gay Men and Homonegativity, Gay Men and Identity, and Personal Responses to Homonegativity. The gay men were asked to recount experiences of homonegativity. In telling their stories, gay men described experiences where both known  and unknown (strangers) individuals within their micro and mesosystems were perpetrators of homonegativity.The gay men often recounted stories of experiencing homophobic harassment whilst in public. For instance, Tyler  recounted “I remember one occasion where I was walking down a street, I had a carload of four guys go past, leaning out the window, calling me a fag”. Tyler’s story highlights an instance of public homophobic harassment from unknown individuals within one’s mesosystem. Aaron  shared a similar story: “Someone threatened to knife me. … It was late at night and I was heading home with a friend and some guys came along and thought they would start harassing us. They actually said specifically, ‘When did you choose to be gay?’”Both Tyler’s and Aaron’s stories share similarities. Despite being from quite different age brackets, they were both harassed by unknown individuals within a public environment. This was a common theme among the stories the gay men shared and, such as these two cases, they were often perpetrated by multiple individuals.Similarly, Ernest  recounts a story of returning to his regional hometown after moving to a capital city: “I think I counted two heterosexist jokes in the space of the first 30 min I arrived. People have just said stuff without even realizing that that may upset me or something. It’s just so ingrained that they don’t even realize that they’re being insensitive or ignorant or whatever”.Similar to Ernest, other gay men also described experiencing more homonegativity in regional areas compared with larger metropolitan cities. Melvin  describes an aversion to regional areas as a result of past homophobic experiences: “I don’t live in rural areas anymore. I now stick to cities because people are much more closed minded in rural areas in my experience”. The heteronormative and homophobic experiences described in participants’ stories highlight the culture embodied within these individuals’ exosystem, notably, differences between regional and metropolitan Australia. When describing changes in acceptance of diverse genders and sexualities, Cooper  eloquently stated: “we’re out of the closet now but we’re locked in the bedroom, and I think that we haven’t really yet left the house”. This highlights the limited acceptance of diverse identities within the greater exosystem, which in this context, is Australian society.Additionally, homonegativity was also experienced and perpetrated from known individuals within gay men’s micro and mesosystems. Finn  recounts an experience whereby his friends reacted negatively to his gender presentation: “his exact words were, ‘Finn, I knew you told me you were gay, but I didn’t realize you were going to go full blown poofter’. I remember it so vividly. It was shit”. Additionally, Ernest  stated: “it’s hard to go, ‘My friends really helped me’, when they kind of embody some of those things”.Parents, notably fathers, and other family members were also often described as perpetrators of homophobic remarks. Cooper  shared this story: “I remember vividly, my dad was driving me to a high school swimming carnival. It was Year 7 or Year 8 or something like that. He basically said to me ‘Dude, you’re not a cat. Cut your goddamn fingernails’. I was really embarrassed … there’s an undertone there. It’s dad saying ‘Cut your fingernails because they’re too long’ but what he’s not saying in words … ‘Stop looking so gay’. … I think my mum has probably said ‘Those jeans are too tight’ or comments about hair”.Cooper’s story highlights the subtle nuances in homophobic experiences and their ability to become ingrained in individual experiences of internalized homonegativity. A commonality in Cooper and many other participants’ stories is that these experiences can often be recalled vividly and many years after they occurred. This demonstrates the effect interactions with others within one’s microsystem have longitudinally.Furthermore, the gay men often expressed experiencing negative affects when receiving homonegativity from others within their microsystem. For example, “when my parents found out that I was gay … my parents didn’t speak to me for a year. … That was hard. That was really hard. … It made me feel rejected and unloved” . Similarly, Harry , expressed: “I want my brother to be proud of me and I want to feel love from my family”. He further explained: “probably my brother was the most impacting one. … More than anyone pegging fruit or yelling things [at me] … that doesn’t matter. Having him say that to me. I was like that was probably the roughest I’ve had”. The gay men often stated that homonegativity expressed from people within their microsystem were more impactful and negative than homonegativity expressed from individuals in other systems of their socioecological environment.Gay men were asked to share experiences of self-identity in relation to their sexual and/or gender identities. Their stories often described experiences whereby pressure and regulation of heteronormative ideals were exerted from within their micro, meso, exo, and macrosystems.Participants described experiences of homonegativity and heteronormative regulation of individuals’ gender and sexual expressions. When asked to recount previous homophobic and heteronormative experiences, Ernest  described an overarching account of the social regulation enforced throughout his life: “We grow up in a world where from the minute a child is born, they’re told that they must behave in a certain way and, if they step outside of those rules, they’re punished. From such an early age, they’re told non-normative genders, non-normative sexualities are bad things”.Additionally, the gay men who identified as masculine often expressed an incongruence between their gender and sexual identities. Participants expressed receiving pressure to enact stereotypical and caricaturized presentations of gayness (effeminacy) and masculinity from their micro , meso , and exosystems . For example: “Gay men in film and television is purely the high camp version, effeminate version of gay men. So therefore, if I didn’t identify with that but I felt attracted to guys there’s a serious disjuncture going on” . When experiencing this incongruence, gay men often expressed feelings of self-loathing, isolation, and confusion. For example: “That expectation in a way that society sort of projects okay, you’re gay, so you’re probably going to be more [effeminate]. … Do I hang out with my friends who are all girls and go shopping, or do I go to the gym by myself and be lonely” .Due to the heteronormative pressures exerted from various systems of a gay man’s socioecological environment, gay men experience various states of self, identity incongruence, pressure to conform, self-loathing, isolation, confusion, and internalized homonegativity, for instance.When asked about how others in their micro and mesosystem react to effeminate behavior and presentation, the gay men tended to describe receiving negative reactions from other men, notably other gay men: “it’s sometimes considered more negatively, often more by gay guys … because of the whole no femmes, masc tops, all that bullshit” . They continued to highlight that: “with straight people, it’s not so much a thing. … some guys might find it a little bit confusing and off-putting, but I feel like gay guys are kind of worse about it than a lot of other people”.Similarly, the gay men reported experiencing discrimination and segregation from other gay men who identify as straight acting; “Rather than pointing and calling names… now we simply exclude them. You’re not behaving straight enough for me and therefore I’m going to exclude you out and I only want to meet straight acting men. It’s not portrayed as a personal preference; it’s portrayed as somehow being better than the alternative” .A hierarchy and valuation of masculinity was often mentioned when describing straight-acting culture, that is, passing as heterosexual was coveted and being noticeably gay was shunned.The gay men often described experiencing fear or anxiety as a result of both experienced and anticipated homophobic harassment. Thomas  shared his story of how his experiences of homonegativity affected how he has lived his life: “I didn’t do any of those sorts of things. I think perhaps that was a fear. There was a fear that I’d lose my job as a schoolteacher. … some people may not accept gay people as being normal and, therefore, will not allow them to do certain jobs, like some churches and organizations who have this sort of attitude”.Another commonality among gay men’s stories of homonegativity was that they did not perceive themselves as being visibly gay. For example: “I wasn’t doing anything particularly gay”  and “the only instances where I’ve felt threatened or intimidated is when I haven’t been camp or effeminate” . The gay men often expressed fear, confusion, and anxiety around how they present themselves in public and how perpetrators discriminate them from other individuals: “It wasn’t like I was running around with a rainbow flag over my shoulder. … Did they see me as being someone that they could pick on and make themselves feel good by enhancing their own masculinity, or did they actually identify something in the way I was walking down the street that made me stand out?” .In response to homophobic experiences, the gay men may often present themselves as straight and/or masculine in order to avoid homophobic harassment, which is known as passing. However, this form of self-regulation is described to be a consumption of one’s internal resources: “passing is something that requires a lot of energy” .When asked about their experiences of homonegativity and heteronormative ideals, participants often described feelings of shame, self-loathing, isolation, and internalized homonegativity. Ernest  explained: “Being a faggot was the worst thing you could be, really”. Similarly: “I went through a certain period probably when I was about 17/18 of quite significant self-loathing around my sexuality” .These gay men’s stories highlight the pervasive nature of heterosexism and homonegativity and emphasizes the internalization of such ideals within a gay man’s psyche. This was articulated in other participants stories, including: “queer people still embody the same attitudes of heterosexism and shame”  and “you can drown in [self-loathing] all day” .This paper examined gay men’s stories of being both gay and a man. From their experiences of homonegativity and internalized homonegativity, we identified areas within their socioecological environments which exert influence over their sense of gender, sexuality, experiences of gender norms, and the impact it may have on their health and wellbeing. In examining gay men’s stories, it was ascertained that gay men experience gender and sexuality strain from all levels of their socioecological environment. Beginning from their family/friends in their microsystem; colleagues and unknown individuals in their mesosystem; film, media, and geo-specific cultures  in their exosystem; and broad societal ideals and norms within the macrosystem. These strains may manifest in the form of social regulation, homophobic discrimination and harassment, and anti-effeminacy prejudice. As such, gay men experience feelings of self-loathing, shame, internalized homonegativity, and isolation. This is similar to previous literature which highlight gay men’s experience of depression, poor wellbeing and quality of life, sexual discrimination, shame, body dissatisfaction, eating disorders, suicidal ideation, and results in more extreme and unbearable states of mind ,24,25,26Gay men within the present study expressed experiences of identity incongruence, self-loathing, and internalized homonegativity. Homonegativity and heterosexism have historically been integral components in the conception and reproduction of hegemonic masculinity . So muchAdditionally, Diefendorf and Bridges  maintainFurthermore, the stories shared by the gay men within this study depict anti-effeminacy and social-regulation of gender expression among other gay men within their micro and mesosystems, notably straight-acting gay men. It is suggested that gay men who conform more to masculine norms, as well as self-identify as straight-acting, possess higher degrees of internalized homonegativity ,55. ThepLimitations of the present study may include the lack of ethnic diversity (mostly Caucasian), age, and sexual identities (only examined gay men). Future studies may wish to examine other non-heteronormative identities, ethnicities, and age groups in order to ascertain the broader spectrum of how gendered norms impact non-heteronormative individuals and whether these impacts are unique to particular identities or are a shared experience.Additionally, the minority stress model may not be without fault. Bailey  providedSparse are current researches explicitly examining masculinity and internalized homonegativity ,25,45,46


Dyspraxia, otherwise known as Developmental Coordination Disorder (DCD), is a specific learning difficulty (SpLD). Its main difficulties manifest as problems with motor coordination, organisation, academic and social difficulties. There are now more students arriving at university with SpLDs, and, therefore, a similar rise may be expected within medical education. There has been no previous research focusing on dyspraxia in doctors. An interpretive phenomenological approach was used. Six UK foundation schools disseminated the announcements. Three participants took part in loosely structured telephone interviews regarding their experiences of undertaking medical school and foundation school with dyspraxia. These were transcribed verbatim and then thematically analysed. The themes could be split into two main categories: “Weakness and Coping Strategies” and “Perspectives of Dyspraxia”. “Weakness” included: clumsiness, organisation and needing extra time. The participants focused on their “Coping Strategies” that included: Ensuring safety, adapted learning preferences and external support. “Perspectives of Dyspraxia” included: diagnosis, career choice, stigma, “normalisation” and the “difference view” or “medical deficit” view of dyspraxia. Doctors with dyspraxia often mask their difficulties through sophisticated coping strategies. These were determined and hardworking individuals who believe that their dyspraxia was a positive aspect of their identity, adopting a “difference view”. They felt further education is needed about dyspraxia to change the perceived stigma. There is now a need for further research in this area.The online version contains supplementary material available at 10.1007/s10459-021-10029-y. Dyspraxia is one of a family of Specific Learning Difficulties (SpLDs) that includes dyslexia, dyscalculia and dysgraphia  is increasing, and we might expect a similar increase within medical education , and he subsequently has a special interest in interpretive phenomenological and autoethnographic research approaches—each of which he has engaged with for multiple previous studies. He also currently teaches postgraduate workshops on qualitative interview skills and qualitative data analysis in health research.MR is Dean of Brighton and Sussex Medical School, co-chair of the UK Medical Schools Council and chair of the MSC Education Subcommittee. A practising breast surgeon his main area of focus in education relates to assessment and associated policies concerning adjustments for candidates with dyspraxia and related conditions.JA is a medical sociologist by training. He is a Principal Lecturer in Postgraduate Medicine at Brighton and Sussex Medical School. He has extensive experience and publications in both qualitative and quantitative methods. He has taught about qualitative methods, skills data analysis to postgraduate students or many years and has previously been the lead for research in the Department of Medical Education.A research methodology encapsulates one’s approach to a given research question Kothari, . It alloDescriptive phenomenology stems from the work of Edmund Husserl—a German philosopher . As such, she would be considered an insider researcher in this area. Interpretive phenomenology helps us to embrace this, and to use her own experiences as a strength to guide the planning, conduct, and interpretation of the overall study  Research Governance and Ethics Committee granted approval for this study.Six UK Foundation Schools disseminated an announcement inviting junior doctors with dyspraxia (JDWD) to participate during the Spring of 2017. Foundation schools are UK training bodies that train junior doctors for the two years between their graduation from medical school and advanced training in their chosen specialities. Foundation doctors with a diagnosis of dyspraxia by an educational psychologist or a doctor were eligible. Those with only self-reported dyspraxia were excluded. Interested JDWD were contacted and the study was explained to them. They were also sent a participant information sheet to read. Mutually agreeable times were then agreed for informed consenting and the interviews.Loosely structured telephone interviews were conducted by EW with each JDWD during Spring 2017. At the beginning of each phone call, EW again explained the aims of the study and received participants’ informed consent. The voluntary and confidential nature of their participation was stressed. The process included explicitly asking for a positive response to each section in the consent form. Only after informed consent was formally recorded did the interview begin. Each lasted for about an hour. Our interview topic guide can be found as a supplement to this paper.The interview audio-recordings were transcribed verbatim by EW, allowing for improved immersion in the data  and a “difference view”  of SpLDs  they considered themselves to live similarly to those who are not “disabled.” All three of these are in keeping with the social model of disability.It is important to note that these attributions are not permanent, and it is possible to change over time. This is likely to have happened to all the participants in this study with them progressing from a “medical/deficit view” to a “difference view”. Missiuna et al. found that, as her participants entered adulthood, they underwent a “reframing of the diagnosis” and became more comfortable with their condition Below is the link to the electronic supplementary material.