A phenomenological study of the lived experience of nurses in the battle of COVID-19.

BACKGROUND: Roles and responsibilities of nurses are crucial in the battle of Coronavirus disease 2019 (COVID-19), but nursing duties also put them at risk for infections.
PURPOSE: The purpose of this study was to explore the lived experience of nurses in combatting COVID-19 in Belitung, Indonesia.
METHODS: This study employed a phenomenological study design. Online interviews and chatting were conducted among 17 clinical nurses who were purposively selected from March to June 2020. Data were audio-recorded, transcribed, and validated among researchers. The thematic approach was used for data analysis.
FINDINGS: Seven themes emerged (1) feeling "nano-nano", (2) lack of N95 masks, (3) we are just pawns, (4) being rejected, (5) please do not spread our identity, (6) we miss home, and (7) feeling betrayed by regulation. DISCUSSION: Findings of this study should be used by government agencies, nurses, and the general population in combatting COVID-19.

Background

Coronavirus disease 2019 (COVID-19), detected in Wuhan, China, was first reported to the WHO Country Office in China on December 31, 2019. It has been spread through 218 countries and territories around the world and two international conveyances (Worldometers, 2020). As of January 8, 2021, there are 216 countries and areas involved, with 88,499,863 confirmed cases. This includes 1,906,693 deaths and 63,610,686 recovered patients (World Health Organization, 2020). Indonesia is one of the affected countries, and as of January 8, 2021, there are 797,723 confirmed cases. There are 659,437 recovered patients and 23,520 confirmed deaths (Ministry of Health of Indonesia, 2020).

The biggest challenge is the excessive number of cases, and our health care systems are being challenged. Lack of hospital capacity, insufficient numbers of facial masks and personal protective equipment, lack of ventilators, caregiver fatigue, and challenges with rapid and diagnostic tests have become the issues among the affected countries (Djalante et al., 2020; Gunawan, Aungsuroch, & Fisher, 2020; Tanne et al., 2020). Leaders’ are dealing with complexity, ambiguity, and uncertainty in decision making (Djalante et al., 2020)—due to the rapidly evolving situation, lack of expert knowledge of the evolving novel disease and the constant additional information that is made available locally and globally as it is discovered.

Long before the COVID-19 pandemic, the WHO had designated 2020 the year of the nurse. The year of the nurse is apropos as nurses are the main heroes fighting COVID-19 as they play critical roles in the testing, treatment, and containment of the virus (Visagie, 2020). In responding to the outbreak, nurses are at the front line sacrificing their lives to care for others. As of October 28, 2020, the International Council of Nurses confirms 1,500 nurses have died from COVID-19 in 44 countries (ICN, 2020). The works of nurses across the globe and in Indonesia are invaluable, and the response to COVID-19 would not continue without the crucial role nurses fill in addressing testing, treatment, and containment.

Indonesia Health Care System

The Republic of Indonesia is geographically located between the Pacific and Indian Oceans (Central Intelligence Agency, 2018). Indonesia consists of 17,508 islands with 300 ethnic groups, 700 local languages, and multiple religions (Central Intelligence Agency, 2018). As of April 8, 2020, the total population in Indonesia is 267.7 million (World Bank, 2020). The majority of people are Muslim, but Pancasila and the Indonesian language unite them. Pancasila is Indonesia's national philosophy with pillars of a belief in God, humanism, unity, democracy, and justice (Gunawan et al., 2020).

The Indonesian health care system became decentralized in 2001 to gain greater control and management of local resources (Paramita et al., 2018). Decentralization is a transfer of power by the central government to regional governments, which indicates that each hospital in the city government, provincial and district government can build their own health system (Mahendradhata et al., 2017). In response to the COVID-19 pandemic, each hospital in all regions in Indonesia has control in managing the cases and performing rapid testing for their community. However, swab tests and the results of examinations can only be issued by the COVID-19 National Referral Laboratory of the Ministry of Health of Indonesia.

Long before the announcement of the first case in Indonesia on March 2, 2020, there were conflicts regarding lockdown or quarantine policies in the country. Considering multiple aspects of the economy and business, the government of Indonesia did not make any decisions until the number of cases increased rapidly. Sadly, all 34 provinces in Indonesia have been infected, which causes both economic and health risks. As of January 7, 2021, there were 9,321 new cases in Indonesia (Ministry of Health of Indonesia, 2020). While COVID-19 has rapidly spread, the government of Indonesia with its decentralized system must make efforts to prevent further transmission and reduce the outbreak's impacts.

Given the importance of the roles of nurses in the battle of COVID-19, this study aimed to explore the lived experience of nurses in the battle of the virus, inclusive of providing care to both positive and suspected cases. There is currently no research available that illuminates the lived experience of nurses providing care for COVID-19 patients, so this study will provide crucial information needed to optimally support nurses and recognize the hard efforts of nurses in this battle.

Methods

Design

This study employed a phenomenological design as outlined by van Manen's phenomenology of practice (Van Manen, 2015) to explore the lived experience of nurses in the battle of COVID-19. Hermeneutic phenomenology is a human science and philosophical method that allows studying a phenomenon through lived experience (Errasti‐Ibarrondo et al., 2019; Van Manen, 2015). Phenomenology is fundamentally practical in human contexts of practice, specifically to nursing associated with human sciences as they always present unique situations (interactions, reactions, and lived experiences) (Errasti‐Ibarrondo et al., 2019). Phenomenology is a theory of the unique that helps us give a competent and adaptive response to each individual in each particular time, place, and context (Errasti‐Ibarrondo et al., 2019; Van Manen, 2015).

The phenomenon is described in terms of phenomenological themes (Van Manen, 2015). Formulating thematic knowledge means interpreting the meaning of a lived experience represented in the phenomenological text as approachable in terms of meaning units, structures of meaning, or themes (Van Manen, 2015). In short, a theme is a conceptual formulation or a categorical statement that has phenomenological power when it allows for the development of phenomenological description.

Sample and Setting

During the pandemic, it is understandable that nurses are working under stressful conditions. In the setting of this study, the nurses are staying in quarantine after their shifts, unable to go back to their homes to see their families. Sharing or online interviews is one strategy to support them and understand how they live their lives daily. Therefore, it is not that hard to encourage them to participate in this study. In this study setting, there are three isolation rooms for COVID-19 with a total of 31 nurses (Room A 10 nurses; Room B 11 nurses, and Room C 10 nurses). For the purpose of this study, 17 nurses were selected using purposive sampling (Room A 5 nurses; Room B 7 nurses, and Room C 5 nurses) based on their availability and willingness to participate.

The inclusion criteria of the participants included registered nurses providing direct care to patients with COVID-19. In Indonesia, nurses' educational level consists of Diploma III, Diploma IV, Bachelor degree, Master degree/specialist, and Doctoral degree. Diploma III refers to a 3-year nursing program at the college/university level focusing on clinical or bedside nursing without conducting any research. Diploma IV is a 1-year diploma program after Diploma III that focuses on one of the clinical areas of nursing. Bachelor/Ners degree refers to a 5-year program that consists of 3.5 years of the academic program and 1.5 years of profession program. Master degree refers to a 2-year nursing educational program followed by a 1-year specialty program in nursing based on an area of interest of each nurse. Doctoral degree refers to a 3-year nursing program that is more likely to focus on research (President of Indonesia, 2014).

Data Collection

This study was conducted from March to June 2020 in a public hospital in Belitung, Bangka Belitung Province, Indonesia. This area is considered a red zone for COVID-19 (Ministry of Health of Indonesia, 2020). Data were collected after ethical approval and study permission from the hospital had been obtained. Head nurses of the isolation rooms facilitated the researchers to contact their nurses by providing their names and phone numbers. Thus, the participants were approached through short message service (SMS) and phone call, and the head nurses also contacted some nurses to join the study. Once they accepted the invitation, an appointment was scheduled for an online interview and chat (SMS) using WhatsApp.

The semistructured online interview and chat were conducted using the Indonesian language. The rationale of using an online interview was that a face-to-face interview was not possible due to nurses being sequestered, and a semistructured interview was used to guide the questions within the designed context. The rationale of using chatting was to reduce the formal manner of asking questions to reduce boundaries for the nurses to share their experiences. The principal investigators conducted each interview that lasted approximately 30 to 60 minutes, while chatting was done every time the researchers had questions based on the answers from the participants.

The participants were also provided with a list of interview questions in paper format that they could answer independently. The papers were returned within 1 week. Considering their busy work, the participants were expected to need some time to write and further share their experiences on paper. The interview guideline was developed and prepared by the researchers prior to data collection (Table 1 ); however, additional questions were asked based on the participants’ answers until data were saturated or when the researchers listened to the same comments repeatedly. There was no repeated interview in this study, and only chats were done for clarification. The online interviews and chats were recorded, transcribed verbatim, and validated by re-listening to the recording and re-read by the researchers. All researchers analyzed, reviewed, and discussed each interview and transcript collaboratively.

Table 1

Interview Questions

Interview questions
1. Could you please tell us how do you feel today?
2. Do you feel afraid, worried, stress, and depressed in caring for patients with COVID-19? Why?
3. Could you describe how you deal with your life as a nurse taking care of patients with COVID-19 every day?
4. How many hours of your shift? Do you think it is harmful to your health? Why?
5. Does this hospital support what you need? Could you tell us about the guidelines, facilities, and personal protective equipment?
6. Could you tell us how do you feel about staying in quarantine and unable to go back home?
7. How people react towards you when they know you are a nurse in the hospital? How do you feel? Could you describe it?
8. What do you think the government and the community have done so far in dealing with the COVID-19 pandemic? Why?

Data Analysis

In this study, we followed six steps of van Manen's approach (Van Manen, 2015), namely (1) turning the nature of lived experience by formulating the research question of this study (‘what is the lived experience of nurses in the battle of COVID-19?’), (2) investigating the experience of the participants by semi-structured interviews and chats, (3) reflecting on the essential themes by reading carefully and repeatedly the whole interview transcripts (statements, words, and phrases) line-by-line to develop initial themes, (4) describing the phenomena in the art of writing and rewriting by re-reading the initial themes and constant revising and refining thought, (5) maintaining a strong and oriented relation to the phenomenon by reflecting back the themes with the research question, and (6) balancing the research context by considering the parts and the whole themes by isolating thematic statements to develop final themes that represent the lived experience. All of the themes or findings were then translated from the Indonesian language into English in the text. During the analysis, J.G., N.N., and A.S used both Indonesia and English to discuss and translate the findings with the other researchers. The translation decisions were guided by the framework of Abfalter et al. (2020).

Ethical Consideration

The study approval was obtained from the Local Research Ethics Committee of Department of Health of Indonesia in Tanjung Pandan, Belitung District, Bangka Belitung Province, Indonesia (No. 440/672/Dinkes/2020). Prior to data collection, the authors ensured that all participants had signed the written informed consent and understood the aim and procedures of the study correctly. The researchers in this study confirmed that each respondent had obtained appropriate informed consent. The researchers guaranteed their data confidentiality and ensured them that their information would be published anonymously.

Trustworthiness

To ensure the trustworthiness of this study, peer review was done by experienced researchers and experts to ensure that there was no bias or preconceived notion in analyzing and developing the themes. Audits and notes of methodological issues and decisions were made to ensure dependability. Member checking was also done, where the findings of the study were sent to the participants for validation. As a result, there were no changes in the findings. All researchers agreed with the findings.

Findings

The participants consisted of 12 females and five males. All participants were married and have a diploma III nursing. The average age of the participant is 34 years old, with a minimum age of 25 and a maximum of 40. All nurses provided direct nursing care to patients with COVID-19 in the isolation units.

Seven themes developed from the data, including feeling “nano-nano,” lack of N95 masks, we are just pawns, being rejected, please do not spread our identity, we miss home, and feeling betrayed by regulation. These themes are illustrated by the respondents below.

Feeling “Nano-Nano”

The term “nano-nano” is often used by people in Indonesia to describe mixed things. Nano-nano is a type of candy with mixed flavors. Various feelings were expressed by the participants, including the feelings of being scared, stressed, sad, fearful, nervous, and proud. This is described in the following statements:

At first, yes, I was so scared, fearful, and stressed because I knew this virus has no medicine yet. I could not describe my feeling. (N1)

I saw the cases most likely on television, and now it's at our hospital. It's being real. Can we handle this? I don't know. Too scary and sad to imagine. (N2)

I am so proud to be in this phenomenon, taking care of patients with coronavirus. It will be the history of my life. (N5)

The first time, I was scared and stressed because I wasn't sure we made it. In fact, the lack of facilities we have. Today it's just the case we usually handle, but yeah I still feel nervous sometimes. Just give everything to God. (N6)

Lack of N95 Masks

The majority of the respondents agreed that the facial masks, specifically N95 masks, are limited. The N95 mask is a respiratory device to protect health practitioners against airborne particles. As indicated in this study, a nurse only gets one N95 mask and must reuse it, as the respondents said:

We lack face masks, like N95 masks. We sometimes wash and dry it (N11)

Each nurse has limited facial masks. Like one nurse with one N95 mask only, and use it until the new stock comes. That's dangerous. However, protective clothes are many, just N95 masks (N9)

Sometimes, I just spray my mask with disinfectant and dry it. Even sometimes I don't want to work if there are no stocks of N95 masks (N12)

We Are Just Pawns

Most of the respondents said that they are more like pawns in the battle of COVID-19. It is described in the following statements:

Whatever the condition, we just follow what the director told us to do (N3)

We are just pawns, the first persons to face all situations at front whether the facilities are enough or not. Nothing else we can do, otherwise we will not get our salary (N4)

If the leader said go, we go; if the leader stops, we stop (N5)

Being Rejected

The majority of the respondents agreed that they have a difficult situation today. Their family members, friends, nurses, colleagues, and community reject them and are afraid to talk with them because they might be infected by the virus. The respondents describe this:

It really hurts sometimes, we did everything to save the lives of the people in the hospital, but now we are being rejected in the community because they think we bring the virus (N2)

Some people try to avoid and stare at me outside like they feel scared of me. That's sad (N6)

Now I understand how the feeling of being rejected. I thought I am a hero (N1)

Not only the community reject us, but health practitioners, family members, and nurses who do not work closely with COVID-19 as well. It really hurts (N11)

Please Do Not Spread Our Identity

The majority of the respondents emphasized they did not want to spread their identity to the public. They do not want people around them to reject their existence. The respondents described this in the following statement:

For the sake of our goodness, please don't spread my identity. People and my neighbors will reject me and my family members (N8)

Don't tell people where I live; they will keep an eye on me (N6)

A bit scared if people know my identity, I don't know what will happen to me and my family (N9)

We Miss Home

All nurses are quarantined during the pandemic. They cannot go back to their home as a precaution to prevent the spread of the virus. Therefore, they miss their home and family. This is described in the following statement:

It has been 3 months since I was quarantined; I miss my home and family (N4)

No one would be happy staying far from their beloved ones. I miss my wife and son (N3)

After my shift, I am back to the quarantine place. I cannot go home, afraid to spread the virus to my family (N10)

Feeling Betrayed by Regulation

A majority of the respondents felt betrayed by the regulations, especially when the airport was re-opened during the height of the pandemic. The respondents also voiced feeling betrayed by the violation of physical and social distancing. The respondents described this:

Not only me, but most health practitioners in Indonesia also gave up. We thought social and physical distancing worked well, but the majority of people didn't care. As a consequence, many people get infected (N3)

I was feeling betrayed. I thought we won at Eid ul-Fitr because no more cases in our hospital and we could celebrate with our family. After one hour, five additional positive cases directly came here. My goodness! (N4)

Regulation just the regulation; not all people can follow that. That's why there are tags #IndonesiaTerserah, #IndonesiaWhatever, and #whateverIndoensia

Discussion

The theme feeling “nano-nano” indicates the initial stage of the process of acceptance of nurses in taking care of patients with COVID-19, which begins with feeling scared, anxious, and stressed due to new threats on their lives from COVID-19. This persists until time passes, and they become de-sensitized and accept the situation. This process is somehow considered normal if the stages of change are understood, which allows the movement from comfort until the new normal is embraced (Hussain et al., 2018). Some nurses even feel proud of being in this pandemic to create such a history for their lives. However, these nurses most likely have a strong coping mechanism, such as a belief in a greater good or a higher power, such as surrendering to God with the belief that life or death is in God's hand. Surrender does not mean one is weak, but rather, it means there is a combination of effort and prayer.

The theme lack of N95 masks reveals the unacceptable conditions of the facilities that the hospital provides for the nurses, specifically for providing N95 facial masks. The WHO has specific guidelines for health care professionals, but the distribution of N95 masks to nurses has seen facilities struggle to provide sufficient N95 masks. When each nurse only has access to one N95 mask for days at a time, this creates concerns regarding the integrity of the mask as we know that the N95 facial masks are labeled as disposable and for single-use only. With the current supply and demand, the shortage of masks has forced nurses to wear the mask for the duration of the shift and reuse it for days at a time. We have seen many nurses fall in this pandemic (Gunawan, Juthamanee, et al., 2020). As of December 15, 2020, 146 nurses in Indonesia have lost their lives and died in the battle (Indonesian National Nurses Association, 2020). This supports the theme that nurses lack the facial masks they need to provide nursing care to their patients without becoming a patient, too.

Under the theme we are just pawns, nurses feel that instead of being a hero, they are pawns in a chess game, or the ones smallest in size and value. This theme is closely related to a lack of N95 masks in the second theme, and they may think that it does not matter if the nurses live or die. There is no one to care nor advocate for nurses in the highest levels of the government and facilities. Nurses feel they cannot speak up about their marginalization nor fight back for fear they would lose their livelihood and be terminated by their employer.

The theme being rejected reflects the current situation that the nurses received after what they did to save the lives of the people. Nurses are often considered a source of viral transmission (Gunawan, 2020), and they are rejected by their community, peers, family members, other nurses, and health practitioners. This creates a terrible environment for front-line nurses, and it is often the worst situation that the nurses have experienced in their lives. Their feelings of isolation and rejection lead to a poor state of mental health. Therefore, many nurses have started to develop signs and symptoms of depression, stress, and other mental health issues today (Gunawan, Juthamanee, et al., 2020). This rejection occurs due to misinformation the society may not be able to validate.

The theme please don't spread our identity exists due to the rejection and discrimination of nurses expressed in the previous theme. When the community identifies where a nurse lives, persecution and harassment efforts target the nurse and their family and homes. People are afraid of COVID-19, and they are paranoid about transmission resulting in selfish and callous actions (Gunawan, Juthamanee, et al., 2020). Therefore, nurses in this study wish that their identities should be kept confidential.

Under the theme we miss home, nurses miss their homes after being quarantined for such a long time during the pandemic. The quarantine is to prevent the local transmission to the family members. One nurse reported being unable to go home because two elderly parents and two teenage daughters live at home (Marsiela, 2020). Since the transmission is possible, nurses are isolated from their families for long periods, and the sacrifice should be acknowledged. Nurses are the heroes we need today.

The last theme feeling betrayed by regulation is raised due to the changeable rules in place from the government. At first, all individuals were required to stay at home, and the airport was closed to stop the transmission. All nurses were happy because all positive patients medically recovered. However, with the amended regulation to open the airport, an increased incidence of COVID-19 occurred, which made the nurses feel betrayed by the regulations. This should not have happened if the government was consistent and steadfast with the implementation of the rules. The changing regulations offered hope to some nurses that the dream to join their family members suddenly appeared a reality. However, this is not happening in the setting of this study or other regions in Indonesia. Therefore, tag #IndonesiaTerserah, #IndonesiaWhatever, and #whateverIndonesia were a trending topic at that time. This reflects fatigue by health practitioners as they were too tired with the changing rules and regulations, and the nurses were fatigued by the community violating the physical distancing policies (Fachriansyah, 2020).

The implications of this study include the need for hospital managers to add self-protection equipment, specifically N95 facial masks for nurses who make direct contact with patients. In addition, it is also necessary to reduce the rejection and discrimination of nurses both in the community and by the hospital itself. This study also has implications for nurse turnover, burnout, and mental health. The hospital managers, nurse managers, and staff nurses are needed to motivate the nurses in charge, especially by acknowledging the sacrifices made by front-line nurses, providing mental health support and early vaccines to protect them.

As human beings, we are meant to help each other. There is no other way to combat COVID-19 without the same direction and full cooperation. Nurses have a professional obligation to save lives and do public education. The government is encouraged to provide strict rules and regulations to stop the transmission of COVID-19, and the community is encouraged to remain at home. It is also essential that community members become educated about COVID-19. The community should be reminded to consult the WHO and reputable journals, which will prevent misinformation that can create stigma and discrimination.

Findings from this study provide new knowledge in understanding the lived experience of nurses in combatting COVID-19. However, the results might not represent all nurses in Indonesia. It is recommended that future studies validate the findings in other hospital settings in other parts of Indonesia.

Conclusion

This study explored the lived experience of Indonesian nurses in battling COVID-19. The results provided the holistic perspectives describing the nurse's feelings and the current state of phenomena in the hospital and community setting. The emotions that nurses perceived are mixed from negative to positive feelings with the change. However, most developed themes are considered negative, which is related to the lack of N95 masks, the rejection and discrimination of nurses, being only pawns in the battle, and feeling betrayed by the regulation. These results are the reflection of the situation today and can help motivate nurses in the pandemic. It is expected that we could appreciate the nurses as the real heroes in the battle of COVID-19 instead of labeling them as the source of viral transmission. We should support all nurses in the world to keep their smiles no matter the condition. Nightingale (2018) stated that nursing has to put the patient in the best situation for nature to act upon, and nurses empower and enable this on a daily basis.

Credit Statement

Joko Gunawan, Yupin Aungsuroch, Colleen Marzilli, Mary L Fisher, Nazliansyah: Made substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data.

Joko Gunawan, Yupin Aungsuroch, Colleen Marzilli, Mary L Fisher, Nazliansyah, Ade Sukarna: Involved in drafting the manuscript or revising it critically for important intellectual content.

Joko Gunawan, Yupin Aungsuroch, Colleen Marzilli, Mary L Fisher, Nazliansyah, Ade Sukarna: Given final approval of the version to be published. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content.

Joko Gunawan, Yupin Aungsuroch, Colleen Marzilli, Mary L Fisher, Nazliansyah, Ade Sukarna: Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.