A total of 22 nurses were interviewed, consisting of 14 females and 8 males. All participants had an educational background in nursing either diploma III or undergraduate and worked at the hospital where COVID-19 patients were treated. All participants were involved in healthcare service delivery to COVID-19 patients. The details of the participants are presented in Table 1.
The findings were categorized into several themes: (i) fear of being infected and infecting loved ones, (ii) fear of early death, (iii) psychological distress related to the conflict between the lack of PPE and professionality and moral responsibility for patients, (iv) stress and worried due to public indifference and lack of role models, (v) negative impact of community doubt and distrust around COVID-19 and (vi) distress due to stigma and discrimination towards nurses caring for COVID-19 patients and their families.
Table 1
Characteristics of the participants
Respondent No.
|
Age, years
|
Gender
|
Work experience, years
|
R1
|
27
|
Female
|
5
|
R2
|
32
|
Female
|
7
|
R3
|
37
|
Male
|
8
|
R4
|
28
|
Female
|
3
|
R5
|
30
|
Female
|
7
|
R6
|
34
|
Male
|
8
|
R7
|
35
|
Male
|
6
|
R8
|
29
|
Female
|
4
|
R9
|
41
|
Female
|
13
|
R10
|
39
|
Female
|
12
|
R11
|
33
|
Male
|
7
|
R12
|
27
|
Male
|
4
|
R13
|
29
|
Female
|
3
|
R14
|
36
|
Female
|
12
|
R15
|
36
|
Female
|
8
|
R16
|
29
|
Female
|
4
|
R17
|
33
|
Male
|
7
|
R18
|
28
|
Female
|
4
|
R19
|
30
|
Female
|
5
|
R20
|
45
|
Female
|
15
|
R21
|
34
|
Male
|
7
|
R22
|
37
|
Male
|
9
|
Fear of being infected and infecting loved ones
The increased number of people and healthcare workers infected with COVID-19 seemed to have put nurses under unprecedented strain. Participants described experiencing fear of being infected and transmitting the virus to their loved ones. Such fear was influenced by their awareness of the quick and easy spread of the virus and the close contact they had with COVID-19 patients due to the nature of their work. Participants’ understanding of not being fully protected by PPE they used and their awareness of failing to follow the instructions to properly use PPE were also factors that contributed to the heightened fear of contracting the virus. The following quote highlights the fear of getting infected, mainly because of the likely outcome they would also infect their family. Even though this nurse expected to get COVID-19, they felt that they needed to hide their fear from their families, in an attempt to try to shield or protect them:
“I already feared being infected when there were no COVID-19 patients in the hospital and I felt more scared when the number of patients with COVID-19 in the hospital increased. I thought, it is just a matter of time being infected because the virus spread so quickly and I am a nurse caring for COVID-19 patients. But you know, I did not want to show my fear to my family. I am scared, if I am infected then I may spread it to my family members” (R2: 32 years old).
The next quote also shows that even though the nurse talked about the availability of PPE and appropriate procedures to wear and take off PPE they admitted to not always following the procedures, thereby increasing their chances of getting infected and spreading the virus:
“I am a nurse and there is no guarantee I will not be infected although I wear gloves, facemask and apron. You know, when we deal with a highly contagious disease, we (nurses) need to wear facemasks, gloves, aprons and face shields correctly and properly. It is the same when we take off all the stuff. We need to remove gloves first, gown and then masks. However, in practice, I tended to forget the sequence. Some also may not understand the infection control procedure leading them to easily get infected” (R9: 41 years old).
Similarly, their stories showed that their understanding and awareness of asymptomatic carriers was also a contributor to their fear of contracting the virus, which made them often feel worried and suspicious about the possibility of contracting the virus. The next quote highlights the constant worry that nurses felt because asymptomatic people with COVID-19 often “felt or looked healthy” and as such, were less likely to wear facemasks. For this nurse, that increased her worry because the risk of transmission from such patients was higher, which increased her risk of getting COVID-19 and passing it to her family:
“What made more scared was people without COVID-19 symptoms who could spread the virus. We might think they were healthy because they did not have any symptoms like coughing or fever. Because they felt or looked healthy, they were less likely to be wearing facemasks or quarantining. So, I could get the virus from them and I may transmit it to my parents and other family members. I often feel worried and suspicious about myself contracting the virus every time I feel tired or a bit unwell” (R15: 36 years old).
The participants’ sub-optimal home living situations seemed to also exacerbate their fear and worry about the possibility of the virus spreading among their family members. The lack of rooms at home for proper quarantine after interacting or having close contact with COVID-19 patients in the hospital led them to easily have contact with other family members. Nurses also talked about sharing a variety of household utensils and equipment, increasing the chances of viral transmission. Similarly, those renting a room in shared house had to share a bathroom and toilet with other tenants, which not only caused inconvenience to other tenants during self-quarantine but also increased the fear of transmission of COVID-19. Such situations were acknowledged as affecting their mental health or causing them stress and anxiety. Such experiences are described by the following statements:
“I quarantined myself at home when one of the nurses tested positive. My home is small with three bedrooms and six people were living in the house. Normally, we shared rooms. But when I was in quarantine, I used one bedroom and the others had to share the two bedrooms remaining. In the evening, some slept with me in the living room, I was so worried. So, you know, I was in quarantine but still had contact with other family members and shared a bathroom, toilet and corridor. It was a very stressful situation…” (R11: 33 years old).
“It was a bit hard for those who lived in kost (renting a room). You know, not all kost have a bathroom directly connected to the bedroom. Toilet and bathroom were built separately from the bedroom. This means, they had to share bathroom and toilet with other tenants, and other tenants might not be happy” (R12: 27 years old).
Fear of early death
Facts and news about the death of young people including nurses and doctors due to COVID-19 were reported as supporting factors for the fear of early death among participants. A few participants commented that they were still young, responsible for raising and preparing the future of their children and responsible for the family. Some nurses talked about planning to start a family and others had only recently embarked on careers in nursing. These had led the majority of nurses in our study to talk about excessive fear of death. The quote below not only links the fear of early death to their role as a parent of young children, but also that doctors and nurses were dying in “reputable hospitals” even though they were wearing PPE, increasing the fear that they themselves could also die from COVID-19:
“I felt anxious and a bit stressed any time I read news on Facebook about young nurses and doctors who worked in national and reputable hospitals dying due to COVID-19 infection although they wore gloves, facemasks and aprons. That was really scary. You know, I did not want to die early because I am still young and I have kids. They really needed me and, of course, I have responsibilities for their future” (R 10: 39 years old).
In the next quote, the nurse made specific reference to young nurses dying of COVID-19, which made it feel “close”. This particular nurse is also young and was in the process of planning a wedding, and the fear that ensued impacted her mental health:
“Knowing young people died due to COVID-19, I felt like death was so close to me. You know, I was not married yet and I plan to get married next year. I prayed to God to protect me from the virus. To be honest, sometimes, the fear of early death affected me” (R5: 30 years old).
The fear of early death and the potential impact on their lives and the lives of others (e.g. their young children, their future spouse etc) had led some of our participants to consider switching jobs (to move out of nursing completely) or moving to other departments within the hospital that had low risks of COVID-19 infection. However, the nature of their particular nursing qualification meant that moving to other parts of the hospital was difficult because they did not have the appropriate specialization. In addition, the unavailability of other job opportunities outside of nursing made it very difficult to have a career change, partly due to the economic implications of the pandemic due to lockdowns, provincial and international border closures and shrinking of many industries within Indonesia. This was explained by several nurses as follows:
“I am a civil servant nurse (a nurse who works for the government. She is a government employee and can only work for the government hospital or community health centre or health department). I never felt scared like today because of this deadly virus. If there is a chance to move to other departments other than health or hospital, I would take it because I did not want to risk myself and my family. It was hard to move to other departments such as education and tourism because my educational background is nurse or health only” (R6: 34 years old).
“I am a casual worker nurse in the hospital. I discussed with my husband about finding another job that has low risks of getting infected with the deadly virus. However, you know, in this current situation it is hard to get another job in this district” (R1: 27 years old).
Psychological distress: conflicts between the lack of PPE and professional/moral responsibilities
Lack of adequate PPE in the hospital where the participants worked was reported as a contributing factor to their stress. This seemed to also encourage their decision not to engage in the work under the condition where PPE was unavailable, which was considered a strategy to avoid putting their lives at risk. Such an action was supported by the perception that the availability of PPE and other safety equipment to support healthcare service delivery to COVID-19 patients was the responsibility of the healthcare facilities (the hospital). Difficulty in obtaining facemasks in stores and sudden increase in facemasks price were also reported as factors affecting their mental health. Quotes below described such experiences:
“When one or two patients with COVID-19 were quarantined in the hospital, we (nurses) were panicked and stressed. We (nurses) went to the hospital but we did not want to work because of a lack of adequate facemasks, gloves and aprons. It was kind of our protest. It was covered in the news. You know, we did not want to risk our life” (R11: 33 years old).
“It was hard to find facemasks in pharmacies or stores at the beginning of the COVID-19 case here (Belu). If there was, the price was more expensive than before the pandemic. This was a very stressful situation because I think the hospital is responsible for providing facemasks for us” (R7: 35 years old).
However, refusing to work due to the lack of PPE was acknowledged as putting the participants in a difficult situation and dilemma due to their awareness of negative health consequences for COVID-19 patients and their moral obligation to the patient safety. On the one hand, patient safety is part of a nurse’s duty of care, but on the other hand, nurses care about their health and have embodied obligations to their families. This difficult and almost intractable situation for nurses impacted their mental health and their sense of self – for the first time, nurses in our study were forced to choose between the safety of their patients (i.e. the reason why they went into nursing), their own safety and the safety of their families. The COVID-19 pandemic had caused psychological distress for nurses, who felt the need to make difficult choices in short periods of time, with little moral or professional guidance. The conflict between professional and moral responsibilities and personal safety was described by participants as follows:
“My friends and I refused to work because there were no facemasks and aprons. However, you know, we were in dilemma. We could not let patients stay in the hospital without care. They (patients) might wonder why nurses did not visit or provide them with medicines. They might die easily” (R10: 39 years old).
“It was not easy. As a nurse, I have a commitment to providing care for patients. I refused to work due to the lack of PPE, but my heart went to the patients. I refused because I have kids and family who rely on me” (R14: 36 years old).
A few participants acknowledged that the long waiting period to know the result of the COVID-19 tests contributed to their stress. This was due to the lack of a COVID-19 swab test laboratory services in the district. As the consequence, all samples were sent to the provincial laboratory, which took 2–3 weeks to provide results. This long waiting period was also reported to provide space for additional spread of the virus in the community. Participants provided examples of patients being impatient whilst waiting for their results, assuming they were negative (until they received results) and concomitantly engaging with the community. Nurses suggested that the lack of local laboratory services and the resulting long waiting times may have increases COVID-19 community transmission. The following quotes illustrate these points:
“The hospital did not have a swab laboratory. All the samples have to be sent to Kupang (provincial laboratory), and the results are informed in two or three weeks. You know, patients will keep asking about the result. We (nurses) always said to them to just wait but we do not know how long they would be patient enough to wait” (R2: 32 years old).
“It takes time to know the result of the swab test. Some patients who are quarantined at home are impatient and they might have engaged with other family members in a normal situation because they think they are okay or healthy or have no symptoms anymore. This situation makes us stressed and worried about the virus spread in the community” (R8: 29 years old).
Stress and anxiety due to public indifference to COVID-19 and lack of role models
Some participants mentioned a lack of public awareness and public indifference reflected in hosting and attending non-COVID-adjusted parties. These were described to be out of their control and make them worried and stressed out during the pandemic due to the awareness of the possibility of rapid community transmission of the infection through such events:
“We have a very limited number of medical doctors and lack health infrastructures and COVID test tools. But you know, there are still wedding parties and many people attend those parties. They gather, chat and dance together. They are not scared of the increasing number of infected patients and deaths due to the virus. Some do not care about the warnings. These kinds of events make me worried and stressed” (R9: 41 years old).
“I thought those hosting wedding parties and guests attending the parties were not afraid of the disease or they might not care at all. My friends and I working in the hospital were struggling to look after infected patients, we were worried because the number of patients with COVID increased every day” (R4: 28 years old).
In addition to public nonadherence related to social events, political events were also reported to contribute to nurses’ stress and worry. Participants mentioned that they were worried because crowds gathered without wearing facemasks, standing close to others and shouting to support political leaders during political campaigns. Such nonadherence was acknowledged to be supported by a lack of role models from local leaders and politicians who gathered crowd without considering COVID-19 protocols and a lack of health resources in the district. The following quotations describe how such challenges occurred and caused mental health challenges to nurses:
“Many people did not care about COVID-19 protocols during political campaigns. In the crowd, they just gathered, shouted, sang, stood close to each other and hugged. You know, they did not care about health and death, but we (nurses) were really worried and sometimes felt stressed” (R4: 28 years old).
“Sometimes I felt stressed with political campaigns. They (politicians) campaigned about people’s health and asked people to stay healthy. But you know, they (politicians) continued to gather lots of people during their campaigns and they did not provide facemasks” (R15: 36 years old).
Negative impact on nurses due to community doubt and distrust around COVID-19
Nurses provided numerous examples of patients, patient’s families, and indeed their own families of questioning whether people were ’really’ getting COVID-19 and dying of COVID-19. This needs to be set within the context of post-Trump ‘Fake news’ and the huge social media presence of conspiracy theories and mis-information about COVID-19. Nurses fully accepted that family members would and should be entitled to question them about their death of their relative – that was part of the role of being a nurse. However, nurses acknowledged feeling overwhelmed and negatively impacted when family members and friends consistently questioned the diagnosis of patients with COVID-19 and doubted COVID-19 as the cause of the death of patients who died in hospital quarantine. Nurses in our study assumed that such questions and doubt stemmed from community assumptions that healthcare professionals and hospitals too easily blamed COVID-19 as the main reason for patients’ death and used it as a strategy to make people adhere to COVID-19 protocols. Such feelings were explained by several participants:
“My friends texted me asking whether the patients died due to COVID-19 or due to other diseases. I explained that the patients had COVID-19 symptoms and had been quarantined in the hospital for several days. But, again, they still doubted it. You know, sometimes I felt annoyed with their questions. They should have known that many people around the world died due to this deadly virus” (R13: 29 years old).
“Some did not believe that their family members died because of COVID-19. They thought that the hospitals just made up the reason so their family members became afraid and could not come in large numbers to mourn in the hospital. I really felt annoyed with this assumption. People thought that this was a strategy from the hospital so that people do not ignore the COVID-19 protocols” (R14: 36 years old).
These quotes highlight that nurses perceive a level of community distrust in healthcare professionals and the hospital system regarding the management and treatment of COVID-19.
Stigma and discrimination towards nurses caring for COVID-19 patients and their families
The stigmatising attitude of community members against nurses working in the hospital was reported contributing factors to nurses’ stress and anxiety. The suspicion towards these nurses as the carriers of COVID-19 in the community due to their close contact with COVID-19 patients they treated was the main reason for the stigma against them by other community members. This was reflected in the dissemination of information to the community to avoid healthcare professionals working in the hospital. This also caused difficulty for them to convince people about their negative status of COVID-19 as reflected in the following narratives:
“There was a message spread in the community (mouth to mouth news) to not to be close to nurses or healthcare workers because we (nurses) might bring the virus and would infect people. That made me a bit stress and anxious at the beginning of COVID-19 pandemic. This happened when some patients with COVID-19 were quarantined in the hospital (R13: 29 years old).
“After several days being quarantined at home, I tested and the result was negative. But you know, it was hard to convince people. People thought that I still had corona because I work in hospital” (R2: 32 years old).
Being socially excluded was reported as a miserable experience. Participants reported losing valuable social experiences such as chatting and incidental social interactions with families, neighbours or other community members. This was reflected in the avoidance of physical contact with them due to the suspicion of their COVID-19 status and the fear of the transmission:
“I was in quarantine because I had a fever and runny nose. But I was grateful because the result of the COVID-19 test was negative. However, you know, my relatives kept their distance from me when they visited my home. They stood away from me. They did not chat with me. I felt a bit excluded but then I realized it was OK because they did not want to get infected or they followed the COVID-19 protocol. I didn’t like and sometimes felt angry and stressed because of their attitudes and behaviours” (R6: 34 years old).
“Some family members and neighbours were afraid to sit next to me even though there was no COVID-19 patient in the hospital and we finished quarantine and tested negative. I knew it was good during the pandemic but sometimes it is uncomfortable and stressed me out. It seemed as if people did not like us” (R15: 36 years old).
Furthermore, as echoed by some participants, stigma attributed to nurses’ family members, reflected in labeling nurses’ whole families as COVID-19 carriers, was also reported as contributing factors for stress and worry among the nurses. Participants described how their work in delivering COVID-19-related care and treatment for patients led to suspicion towards their families as virus carriers in the community which made them more stressed as elucidated in the following statement:
“My neighbours suspected my family because I worked in hospital and had close contact with COVID-19 patients. So you know, I also felt a bit stressed with the stigma against my whole family” (R14: 36 years old)