Nurses’ Actions to Protect Their Families from COVID-19: A Descriptive Qualitative Study

Participants and Research Locations

Nurses who worked in government COVID-19 referral hospitals and nine private hospitals in Indonesia were recruited for this study using snowball sampling. This technique is used for research with a limited number of potential participants because of accessibility issues or constraints (Cresswel, 2013). In this study, snowball sampling was used, starting from the research team’s personal networks, to recruit a sample of nurses currently working in hospitals in a variety of clinical contexts. The study participants were asked to provide recommendations for additional participants. Seventeen nurses participated in the study. The participants came from 17 hospitals on the islands of Java and Sumatra. Java Island was chosen because 70% of Indonesia’s population lives on this island, and most COVID-19 cases have occurred in the Java provinces. In addition, Sumatra Island is the closest island to Java and has a low number of COVID-19 cases. The participants were grouped into two categories: group 1 included nurses who worked in hospital wards with direct contact with COVID-19 patients, such as emergency rooms, intensive care units, and COVID-19 isolation wards (n = 9). Group 2 consisted of nurses who worked in low-risk areas for COVID-19 transmission, such as women’s and pediatric wards and outpatient services (n = 8).

Data Collection

The study protocol was approved by the Human Ethics Committee in the School of Health Science UNJANI, West Java, Indonesia (approval # 02/KEPK/III/2020). Data were collected using semi structured individual interviews between June and August 2020 to explore nurses’ actions to protect their families from COVID-19 transmission. The principal investigator and three research team members trained in the data collection processes conducted the interviews. One interview was conducted as a face-to-face interview with social distancing, and the other interviews were conducted via telephone or video conferencing. The participants provided informed consent prior to the interviews. Each interview began with an opening question to build trust between the participant and the interviewer; this question asked about nurses’ personal expectations regarding maintaining health during the pandemic. The interviews continued with an exploration of nurses’ actions to protect their families from COVID-19. All interviews were conducted in Bahasa (an Indonesian language) and recorded. The duration of the interviews was between 20 and 45 minutes.

Data Analysis

The researchers transcribed the interview data in Microsoft Word. The researchers analyzed the data using a combination of qualitative analysis approaches suggested by Widiasih and Nelson (2018). This approach drew on the sequential process of qualitative analysis described by Dierckx de Casterlé et al. (2012), with an emphasis on a phase of preparatory work with the data, followed by constant comparative and coding processes to identify themes. The data analysis was also informed by the qualitative content analysis strategies described by Graneheim and Lundman (2004), including identifying and labeling meaning units and sorting codes into categories to formulate themes. The combined approach consisted of four phases: precoding, coding, formulating themes and presenting the themes. The first phase, precoding, involved reading the 17 transcripts multiple times, selecting meaning units based on text describing important aspects of the participants’ experiences (e.g., “keeping a distance from our kids,”) writing a narrative of each interview reflecting the key components of the participant’s story, drawing on this narrative to develop conceptual interview schemes and verifying these schemes against the interview data. The second phase of analysis focused on using the codes (labels) for the meaning units to code the data using NVivo software (version 12) and exploring similarities and differences in the data, grouping the codes into subcategories and categories. The third phase involved formulating themes based on the categories and conducting comparisons between participant groups 1 and 2 (those at high and low risk of COVID-19 transmission). Finally, a presentation of the themes was prepared and supported by relevant quotes from participant interviews. Based on the analysis, four main themes were identified.

Trustworthiness

Trustworthiness was supported in this study by using the guidelines developed by Lincoln and Guba (Lincoln & Guba, 1985; Polit & Beck, 2017) related to credibility, dependability, confirmability, and transferability. Credibility refers to demonstrating internal consistency, ensuring the rigor of the research process, and communicating the actions taken. Credibility was supported by reviewing the data collection two times, including the perceptions between the research and the enumerators. Each interviewer wrote notes on the interview process to ensure that each aspect was appropriate according to the interview guidelines and conducted a briefing before each data collected. Dependability involves evidence of and reasoning for the accuracy, relevance, or meaning of the data. Dependability was ensured by congruence between two or more independent people. It indicates that the findings of qualitative inquiry would be repeatable if the inquiry were to be conducted again within the same cohort of participants, with the same coders and within the same context. Dependability was ensured by defining clear study stages, keeping research diaries, having regular weekly coordination, and ensuring accurate data coding. Confirmability refers to establishing and communicating a link between the data, analytic processes, and findings so that the reader can confirm the adequacy of the findings. Confirmability was ensured by evaluating the research process during meetings and the reading and analysis of the data together as a team. Transferability provides reasoning and evidence that findings can be generalized or transferred to other empirical settings or points of time. Strategies to support transferability included purposefully sampling according to the study criteria and objectives to obtain a range of experiences, and by providing a description of the context of nurses’ experiences.

Theme 1: Nurses Modified Their Behavior and Environments to Prevent the Transmission of COVID-19 to Their Families

The analysis results showed that nurses engaged in various behavioral modifications and actions to prevent the transmission of COVID-19 to their families. Several nurses said that they limited their interactions with their families and modified their home environments to prevent their families from contracting the virus, as disclosed by the following participant:

“I chose not to go to the dormitory because many nurses from different wards also stay there. On the other hand, my father-in-law has a second house, so I stay there to rest after work for about eight hours. When I feel refreshed, I am ready to see my kids; I return to my own home. I always wear a mask when I have contact with my kids. I also keep a distance from my kids at home.” (P15)

Other nurses also described other types of modifications they made to protect their families, including sleeping in a separate room away from their children. For example, one nurse reported that before the pandemic she slept with children, but that she stopped doing that during the pandemic. The nurses rarely hugged and kissed their children. Another nurse reported that she and her family agreed to enter the house from the back door, which was rarely used before. The back door became the main door for her to enter the house after work. She immediately put her dirty clothes in the washing machine and took a shower before seeing her children. Before the COVID-19 pandemic, her children and husband dropped her off and picked her up from work. However, they could no longer do those activities. This nurse did not work in a COVID-19 ward; however, she realized that she still worked in the hospital, which is one of the potential places where COVID-19 can be transmitted.

Theme 2: Nurses Provided Supplements and Nutritious Food for Their Families

Almost all participants conveyed the importance of consuming vitamins, supplements, and nutritious foods to prevent them from getting COVID-19. They provided additional vitamins and nutritious food for their families. The participants believed that nutritious food could increase their stamina and prevent them from getting COVID-19.

“Personally, I provide multivitamins to increase immunity, Ma’am, I do it for illness prevention to my family. On the other hand, food is needed for our body, which I learned from pathophysiology.” (P7)

The nurses provided additional chemical and natural supplements to their families. The natural supplements they gave to their families, especially children, included honey, dates, and Habatussauda. They believed that these supplements increased body immunity.

Theme 3: Nurses Enhanced Their Families’ Knowledge and Awareness of COVID-19

The nurses said that they explained information related to COVID-19 to their families, including how the virus is transmitted and how to avoid contracting the virus. The family members who obtained the information included husbands and wives, children, and parents. For example, the information on the prevention of COVID-19 transmission provided by nurses was related to washing hands, using masks, and maintaining social distancing, as conveyed by the following nurse:

“Our family and I must prepare due to the relatively easy spread of the COVID-19 virus. We have to keep clean, clean the environment, keep our bodies clean, and we also have to limit interactions with our friends. Don’t leave the house if it is not for something important. To our families, we must also teach and allow frequent hand washing because the COVID-19 virus can be transmitted from our hands; it is important that children wash their hands.” (P2)

The nurses conveyed the latest information about COVID-19, especially on the importance of preventing transmission, to their parents and children. One of the nurses reported the challenge of explaining the current condition to children under five, expressed as follows:

“Explaining a pandemic situation to children has difficulties. As it happens, today, my son is whining and wants to play outside because he knows that a tourist spot is open. In this case, we need to provide information that this place is at risk for COVID-19 transmission, and in the end, he is willing to accept my orders.” (P9)

The nurses realized that their family members were at high risk for COVID-19 infection, and by sharing knowledge about COVID-19 and prevention actions, they believed that their family members would have a better understanding and awareness about the disease. Different opinions were reported by nurses whose husbands or wives were also nurses; they did not have challenges related to COVID-19 knowledge and awareness because both spouses knew about the disease.

Theme 4: Nurses Protected Their Families from Social Stigma

The interviews with the nurses showed that they were aware of maintaining personal and family health behavior to avoid stigmatization from the community as a source of COVID-19 transmission because they worked in hospitals. One of the nurses who worked at the COVID-19 national referral hospital conferred with family members about this topic:

“My husband often follows and is involved in social activities at the mosque and the neighborhood. However, since this pandemic, he never went to the mosque again. The people around us see that we work as nurses in hospitals with COVID-19 patients. We feel that other people around us are uncomfortable with our presence.” (P15)

The same experience was also reported by a nurse who worked at a COVID-19 referral hospital at the district level; she and her family decided to limit interactions with the surrounding community. They conveyed that extended families were recommended not to visit them because they work in the hospital, for the convenience of all parties.

Strengths and Limitations

The results of this study provide information about the actions of nurses to protect their families from COVID-19. The results of this research can be used as information and reference for nurses and the government to determine policies to prevent the spread of COVID-19. Increased knowledge about COVID-19, behavior changes, adequate nutritional and supplement intake, and psychological strengthening through the prevention of stigma are important to prevent the spread of COVID-19 in families and communities. However, this study was limited to a descriptive qualitative approach that provided a general overview of the research results. This study applied more than one method of interview. We have used the mode of interviewing by phone, online meeting, and face to face. Each method has characteristics; for example, when interviewing by phone researcher could not observe the participant’s expression. While online meetings sometimes challenge with the internet signal. Those could be the limitation of this research. Further development of the methods and analysis could provide more specific results.