Family relationship of nurses in COVID-19 pandemic: A qualitative study

Melike Yavas Celik,Meryem kilic

Abstract

Key Words: COVID-19; Nurses; Family relationship; Coping; Role performance

lNTRODUCTlON

Nursing is a profession with a scientific basis. Among the components of the scientificness and professionalism of nursing profession are ethics, philosophy, theory, and nursing models[1]. With these qualifications, nurses plan the steps of the nursing process by examining the patients and help the patients return to normal conditions by giving them care[2,3]. According to Roy[4], a person has four modes of adaptation: Physiologic, self-concept, role function, and inter-dependence. The physiologic mode contains the person’s physiologic responses to environmental stimuli[4,5]. Reactions to environmental stimuli aim to protect the physiologic integrity of the body. Roy suggested that the physiologic mode comprises nine requirements. They are oxygenation, nutrition, elimination, activity and rest, protection, senses, fluid-electrolyte and acid-base balance, neurologic function, and endocrine function[6]. The self-concept mode is associated with the person’s body and sense of self, spiritual and moral values, and basic needs about her/his emotions[7]. The role function mode is associated with the person’s roles in society and indicates her/his social integrity. The responsibilities that the person takes in her/his lifetime and all the roles that she/he fulfills are evaluated in this mode. The interdependence mode includes the person’s all interactions with the environment and other people[8]. According to Roy, these four modes of adaptation are connected to each other and are affected from one another. The solution of a problem perceived in any of the modes of adaptation depends on the person’s adaptation effort. The person’s positive response to problems perceived in the modes of adaptation keeps her/him in balance[4]. The coronavirus disease 2019 (COVID-19) outbreak has upset this balance in nurses. Most nurses are struggling against COVID-19. They work harder than ever and have had to give up many physiological needs such as sleep and nutrition, their self-concept, their roles, and the individuals that they depend on. They are also concerned about transmitting COVID-19 to people and harming them. For this reason, they had to leave their families to which they were attached and had difficulties in meeting their needs[9-12].

Interruption of the family relationship is the breakdown of continuity in functioning effectively due to situational crises in a family, which is supportive and functions effectively under normal circumstances, and the disruption in the process of coping with stressors. This condition might be caused by a disease, breakdown of family routines, alteration in family function, loss of a family member, abandoning, separation, divorce, economic problems, and emotional changes in members due to treatments. These individuals may fail in adapting to the disease or crisis, show non-functional responses, may not be able to communicate openly, and may not able to meet, help, or want to meet the (physical, mental, social, and moral) needs of family members and not express their emotions[13].

COVID-19 was first seen in Wuhan, China in December 2019, and has affected the whole world and left individuals from all sections in a difficult situation[14,15]. Involved are among the virus groups causing severe acute respiratory syndrome (SARS) and middle east respiratory syndrome (MERS). COVID-19 may be asymptomatic or cause mild or severe symptoms[14].

The World Health Organization (WHO) declared COVID-19 as a pandemic in March 2019 (WHO, 2020). According to the recent data of the WHO, it has been reported that COVID-19 has been seen in all countries[15]. In Turkey, it was first seen in March 2019 and has been very common so far[12]. In this pandemic process, nurses have always been in the forefront and have been faced with vital risks to fulfil their task. Nurses who have a close contact with COVID-19 patients have been vulnerable to the infection and have been faced with the situation of infecting their colleagues and family members with the virus[16,17].

The International Council of Nurses (ICN) recognized the passing of a large number of healthcare professionals including nursing staff[18]. In addition, according to the Turkish Nurses Association COVID-19 analysis report, 55.7% of the nurses work in 24-h shifts, 58.6% work 40-48 h a week, and 35.3% give care to ten and more patients. It has been determined that the rate of nurses giving care to patients diagnosed with COVID-19 in their unit is 82.1%. Additionally, 50.1% of the nurses indicated that their institution did not provide sufficient food for adequate and balanced nutrition[19]. In the pandemic process, the female partner is given the right of using administrative leave in case that both partners are healthcare professionals; the leave has to be approved by executive supervisors, and if not approved, it will lead to serious problems in child care. Consequently, 48.6% of the nurses face problems in child or elderly care[19]. Nurses are unable to return home due to the COVID-19 pandemic, and lead a life separated from their family members, rendering them powerless in meeting the needs of the family members that they were responsible for. Therefore, this study was planned to examine family relationship of nurses in the COVID-19 pandemic.

MATERlALS AND METHODS

Qualitative approach and research paradigm

We used Corbin and Strauss (2014) grounded theory methodology to understand the process of clinic nurses’ change in family relationship during the COVID-19 pandemic. Grounded theory is an inductive method of creating a theory of data[20], where researchers foster critical reflection throughout the process by asking questions, seeking clarifications, and actively listening to participant’s stories. Researchers also draw on personal experiences to facilitate theoretical development, as active agents in the research process[20,21].

Symbolic interactionism

Our ground theory methodology was rooted in symbolic interactionism[22]. The symbolic interactionism framework has three major assumptions: Culture influences how people live and learn, experiences through culture determine how people make meaning from their interactions, and everyone creates meaning at an individual level and acts according to this meaning[22]. The use of grounded theory methodology inherently acknowledges that the context of a theory is inseparable from the theory itself[21]. In this study, the understanding of nurses’ change in family relationships is based on the context of COVID-19.

Researcher characteristics and reflexivity

Type of the study:This is a phenomenological qualitative study. The research had a descriptive qualitative design. In this design, an event or phenomenon is defined directly.

Population and sample of the study: Sample calculation was not made, and considering the general sample number used in qualitative studies, the participants that we could reach and who volunteered to participate in the study constituted the sample. The snowball method was used in sample selection. Participants (n= 18) were included in the sample according to the adequacy of the outcomes of 27 participants from whom adequate information was collected. Participation in the study was voluntary. Interviews were conducted with nurses who had to live separated from their family and had obligation to a relative to take care of (child or other family members). All of our participants were women, were preferably married, and could be reachedviasocial media (Figure 1).

Inclusion criteria

(1) Obligation to live separated from their family; (2) taking care of (child or other family members); (3) being women; (4) being married; (5) using social media; and (6) living in the provinces of Istanbul, Ankara, and Gaziantep where the number of COVID-19 cases was high.

Exclusion criteria

(1) Having a psychological illness; (2) being addicted to substance; and (3) getting psychiatric counseling and participating in counseling groups.

Data collection

The interview form comprised two sections. The first section included closed-ended questions about the nurses’ demographic characteristics (age, family type, number of children, care need of children, caregiver of children, and state of living separated from family) and working conditions (service worked, weekly working time, manner of work, and province where they worked). The second section included two questions about the effects of interrupted family relationship of the nurses during the COVID-19 pandemic on themselves, their children, and partner.

Figure 1 Sample selection. COVID-19: Coronavirus disease 2019.

Interview questions

(1) Can you explain the effects of the COVID-19 pandemic on your relations with your family? and (2) How does the COVID-19 pandemic affect you?

Context and researchers

The members of our research team have background in healthcare and nursing, with expertise in qualitative research. This study was conducted in three cities with a high number of COVID-19 cases in Turkey between May and June 2020. These three cities were chosen for the reason that they are big cities. There were no prior relationships between participants and researchers. Participants were aware of the purpose of the study and were encouraged to share their views freely.

Implementation of the study

The data were collected by the researcher in charge by phone due to the pandemic (the researcher has worked as an intensive care nurse in the past and has previously conducted qualitative studies). The interviews were made by phone call. First of all, the participant was informed about the study and approval was obtained from the participant to participate in the study. An individual in-depth interview technique was used while the participants were away. Reaching the participant through a nurse that she knew provided a safer and more comfortable interview. Participants freely expressed themselves. An hour outside of working hours was scheduled for the interview, and nurses were allowed to answer questions freely. The interviews were planned not to be too long, considering the busy working hours of the nurses. The interviews were terminated when repetitions began in the responses of the participants. In-depth interviews were made with a total of 27 nurses. Nine of these nurses were excluded from the study due to communication problems and device problems during the interview.

Evaluation of data

The Statistical Package for the Social Sciences (SPSS) version 25 program was used to analyze the nurses' input characteristics. Descriptive analysis was performed to analyze the interview data. The responses of the participants were analyzed immediately after the research in order not to forget the data in the interview. The data were written down word for word immediately after each interview. Subsequently, the texts prepared were read many times and the first codes were extracted. Later, the relevant codes were combined in a frame to form main and sub-categories according to their similarities and differences. With this framework, the themes under which the data will be organized were determined. Then the data obtained were read, categorized, defined, and coded logically according to the frame. The responsible and assistant researcher evaluated the explanations separately. The texts that came together were compared and the results were evaluated. As a result of the analysis of the interviews, three main themes and two sub-themes were formed. Themes were created with the data obtained from the participants.

Themes

(1) Breakdown in continuity of intrafamilial relationship; (2) ineffectiveness in role performance; and (3) ineffective individual coping.

Ethical considerations

In order to conduct the study, approval was obtained from the Ethics Committee of Kilis 7 Aral?k University (2020/25 decision number). The study was planned and conducted in accordance with the principles of the Helsinki Declaration.

RESULTS

The nurses participating in the study were chosen from the provinces of Istanbul, Ankara, and Gaziantep, where the number of COVID-19 cases is higher. The majority (70.4%) of the nurses were aged 30-41 years (mean: 31.11 ± 11.11 years); 38.9% were working in the intensive care unit, 27.8% in the COVID-19 service, and 33.3% in other services (internal medicine, surgery, and emergency services); 38.9% worked in shifts, and 72.2% worked for 46-72 h a week; 66.7% had only one child, 72.2% had a child with care needs, 83.3% had to leave home in the pandemic relationship, and 77.4% were not able to meet the needs of their family (Table 1). When examining the qualitative responses of the nurses, it was determined that they suffered from breakdown in continuity of intrafamilial relationship, ineffectiveness in role performance, and ineffective individual coping (Table 2). Also, it was seen that the nurses in the present study were also subjected to intense working conditions in the pandemic process (Table 1).

Theme 1: Breakdown in continuity of intrafamilial relationship

When examining the qualitative responses of the nurses, it was determined that they suffered from breakdown in continuity of intrafamilial relationship (Table 2). This theme is given under two subthemes involving partner and child relationships.

Mother-child relationship:Statements of the participants regarding their relations with their children are given below.

”At first I video chatted with my child on the phone. She/he wanted me to cuddle her/him. Then, she/he refused to talk to me because I could not cuddle her/him. She/he said: “Turn off the mom on the video”. I try to fulfill my longing with video chat but it doesn’t work because I can’t hug my children.” (Participant 1)

“I hesitate about going home. If I went, I would infect them. If I didn’t, we would miss each other, which may cause an emotional burden for both us and our children. I always feel restless and guilty whenever I am around my child.” (Participant 3)

“My son is growing up and has started walking. I can only video chat with him.” (Participant 5)

“Lifestyle change and my longing for my children have really beaten me. Lonely in a small apartment, I am waiting for the day I would see them again.” (Participant 6)

“If I were asked whether I would leave my child one day, I would say never. But now we are separated and I haven’t seen her/him for days.” (Participant 8)

“It turns out my child doesn’t ask about me anymore. She/he cries for her/his mother no more. You have no idea how painful this is.” (Participant 9)

“My children have become more aggressive in this pandemic period. They can’t stand that I have left them.” (Participant 7)

“My children have forgotten my face. Even I have forgotten myself. I used to have a family. We would sing, have breakfast and sleep together with my daughter. Now it is all in the past.” (Participant 10)

“I miss being a family. I miss spending time with my children. My son looks at me like a stranger on the phone. I don’t know how much I can stand it.” (Participant 11)

“Whenever I call my children, she/he says: “I don’t want to see you. You left me”. She/he couldn’t sleep without me. Now she/he sleeps alone.” (Participant 13)

“Do you know how it feels to miss your child’s smell?” (Participant 14)

“I want to hug my son so bad. He wants it, too. It breaks my heart to reject him due to the fear of infecting him.” (Participant 15)

“I think about them more than myself. I feel like I am stricken with plague. The idea of making them sick shatters me.” (Participant 16)

“Our family balances have been destroyed. The children have developed behavioral disorders like pettishness and getting bored easily. I have great difficulty in communicating with them.” (Participant 18)

Relationship between the partners:Statements of the participants regarding their relations with their partner are given below.

“I unavoidably reflect my restlessness and concerns on my husband. We start fighting so easily now.” (Participant 1)

“My greatest support in this process is my husband. He has always been there for me. I wouldn’t make it without him.” (Participant 3)

Table 1 Demographic data of the participants (n = 18)

“In this period the work stress affects our relationships, which naturally causes conflicts and disagreements between us. We try to overcome this by being tolerant toward each other.” (Participant 14)

“Being at home all the time means more fights. The situation is sure annoying. We fight a lot. I think we will get a divorce in the end.” (Participant 4)

“We can’t approach each other. It’s too hard.” (Participant 10)

“This COVID-19 has destroyed our life.” (Participant 18)

“We can’t have distance within the family. We are so close. Even if we try to stay away from each other, we just can’t. As they are too young, they need me. I can’t leave them. But I’m so scared. I fear that I might make them sick. I even hesitate about breastfeeding. I don’t know what to do.” (Participant 12)

Theme 2: Ineffectiveness in role performance

The nurses complained about not being able to fulfill their family roles outside of their professional roles. The views of the nurses on this issue are as follows.“I can’t fulfill motherhood.” (Participant 1)

Table 2 Analysis results of interviews conducted with nurses

“I feel insufficient for my children due to the uneasiness and tension I have faced in this process.” (Participant 3)

“We used to go somewhere, spend time together, and relieve our stress on holidays. Now they are at home and we are at work. We are really bored. But there is nothing to do. We have given up on motherhood for a while. Our priority is nursing.” (Participant 4)

“As her/his mother, I want to be with her/him all the time. The other day she/he made a toy with play dough. It was so pretty. She/he invents, plays, grows up and I’m not even there.” (Participant 12)

“I haven’t enjoyed motherhood. I had to leave my little child.” (Participant 13)

“As a mother, I can’t cook for my children. I can’t dress them. I can’t take them anywhere.” (Participant 14)

“I can’t even fulfill motherhood. I’m just a nurse right now. Someone else is their mother now. Unfortunately our supervisors don’t consider that we are a mother, a wife, a child and our loved ones need us.” (Participant 15)

“I have forgotten that I’m a mother. Our families have forgotten us, as well. We are literally broken.” (Participant 17)

“I want to fulfill motherhood. I want to spend time with my family at home. Sometimes I think that this is all a nightmare and try to wake up.” (Participant 18)

Theme 3: Ineffective individual coping

Nurses expressed that they cannot manage this process, that their individual coping methods are insufficient, and that they are in a great lack of care. The statements of the participants on this issue are given below.

“Actually, I can’t say that I’m able to cope. This is a crisis and it has really beaten me. I’ve cried a lot. Finally, I have decided to receive psychological treatment.” (Participant 2)

“I suffer from a great sleep disorder due to excessive stress. I’ve become really upset and feel insufficient.” (Participant 5)

“This issue has really beaten me. I can’t cope with anything. Even my slightest mistake may make someone sick or die and it’s just too hard to live with this responsibility. They force us to become more careful and obsessive. I feel like a murderer. Lifestyle change and my longing for my children have really beaten me. I don’t want to work. I don’t want to do this job.” (Participant 6)

“There is a great gap inside me. It’s a bit hard to explain that feeling. You can’t even resign your job. You have to work and there is no one else to take care of your children. So you hire a nanny. A woman you don’t even know looks after your child. You won’t be able to see or smell your child for a while. This is unbearable and too painful.” (Participant 7)

“We are patient because we believe that this will be over. But I feel less powerful now.” (Participant 10)

“We have to be patient. We have to do it for job ethics, career, belief, whatever you name it, for the sake of humanity. We have to do it both for our children and our family.” (Participant 11)

“Even though I get scared and sad when I look at patients and see what they go through, I continue. I try to stand it.” (Participant 12)

“I am depressed. If I go to a psychologist, they would definitely diagnose me with depression. But I have to work. I have to control my psychology and emotions. Indeed we can’t get permission unless we are diagnosed with COVID-19. There is nothing to do.” (Participant 13)

Limitations of the research

The study has a few limitations. One of them is that the information could not be collected face to face due to the COVID-19 pandemic. In addition, in order to participate in the study and fill out the questionnaire, the participant must have a device that supports the program, an internet connection, and the ability to fill in the questionnaire. People with these limitations had to be excluded from the study. Also, the study had a small sample from only three cities.

DlSCUSSlON

During the pandemic, nurses had to work in long shifts and in harsh conditions[23]. According to the COVID-19 current situation analysis report by the Turkish Nurses Association, 55.7% of nurses work in 24-h shifts, 58.6% work for 40-48 h a week, and 35.3% give care to ten and more patients[19]. Similar to these results, our study showed that nurses work in long shift systems. Also, this study was planned to examine family relationship situation of nurses in the COVID-19 pandemic. For this purpose, the themes determined in the research are discussed below.

Theme 1: Breakdown in continuity of intrafamilial relationship

Mother-child relationship:In this process, children have also been affected like other family members. One of the reasons for the breakdown in parent-infant/child bonds is the interruption of the parentinfant/child relationship which is based on trust, love, and care[24]. During the study time, the nurses had to leave their children with someone else to protect them. In addition, children were too young to understand why their mother had to leave them. These children thought that their mother had left them completely, refused to communicate with her, and began to display behavioral problems (Theme 1). In previous studies, it was determined that children who were deprived of their mother were more aggressive than other children[25,26]. Suzukiet al[27] determined that parents’ skills and mental health and the relationship between the parents had an effect on children to develop behavioral problems. Also, the nurses stated that besides the inability of fulfilling the motherhood roles, they suffer an indescribable pain because they cannot hold their children and show them love (Theme 1).

Relationship between partners:One of the situations causing breakdown in continuity of intrafamilial relationship is the breakdown of the communication with partners during this pandemic. The fact that partners started a fight for minor things and were not able to approach each other has made this process harder. The nurses stated that the partners tried to support each other despite all these (Theme 1). Family and occupation are the two important areas in a person’s life. The person’s life is basically a whole and only one. Job and family roles are intertwined in the person’s life. These roles continuously interact. A positive or negative situation in any one of them may affect the other positively or negatively and cause the working mother to experience a role conflict[28]. According to the data acquired from the study, the nurses experienced ineffectiveness in role performance in the COVID-19 pandemic. The nurses stated that they had to hand the motherhood role down to someone else because they were separated from their family in this process, could not stand being away from their children and meeting their needs, and their intrafamilial trust was shattered due to conflicts with their husband.

Theme 2: Ineffectiveness in role performance

Many reasons such as illness, personal problems, and psychological problems can negatively affect our roles[7]. Today, COVID-19 has led to changes in nurses’ family roles due to its severe course, rate of contagion, and lethality. While nurses assumed their primary role, they had to abandon their roles within the family. He/she had to be away from his/her children, parents, and spouses[29,30]. For this reason, it should not be forgotten that the relationship that nurses establish with their families is important in terms of child health and maternal health, and the safe maintenance of this relationship should be supported. Alternative practices should be created for nurses to spend time with family members.

Theme 3: Ineffective individual coping

As is understood from the statements in the study, it was determined that the nurses were sad, exhausted, tired, and unhappy mothers who missed their family and were not able to cope with the current situation (Theme 3). In the pandemic processes, fear of getting infected is greater for healthcare professionals than the entire society. On the other hand, healthcare professionals fear infecting their family and other people in their immediate surroundings rather than being exposed to the virus themselves. Thus, they have to live separated from their family for a long time. Besides, intense working hours in a stressful environment and healthcare professionals’ deprivation of psychosocial support from their family make this process unbearable[31]. In pandemics, healthcare professionals have higher levels of psychiatric disorders such as anxiety, depression, and posttraumatic stress disorder and symptoms like burnout, compared to the entire society. According to the studies examining psychosocial aspects of pandemics, women and nurses are affected more[32-34]. In a descriptive study to determine the anxiety level of nurses in the COVID-19 process (n= 206), it was found that the nurses had a higher general anxiety level, and those who were female, were married and had children, contacted COVID-19 patients, and contacted patients for a longer time also had a higher anxiety level. In the present study, the nurses stated that they had great difficulty in managing the COVID-19 process, feared dying or infecting other people, could not cope with their longing for their family and all these emotions, and wanted to receive psychological support (Theme 3).

CONCLUSlON

This study discusses the difficulties faced by nurses, who are in the forefront in the war against this disease that everyone fears, with their family. It was determined that as mothers, nurses experienced emotions such as sadness, unhappiness, anxiety, and fear due to the inability of fulfilling their motherhood roles. Nurses felt anxious about themselves, their children and family and were not able to cope with the situations caused by these anxieties.

ARTlCLE HlGHLlGHTS

FOOTNOTES

Author contributions:?elik MY and Kili? M completed the manuscript and gave their final approval of the version to be published.

lnstitutional review board statement:The study was reviewed and approved by the Ethics Committee of Kilis 7 Aral?k University (2020/25 decision number).

lnformed consent statement:All study participants, or their legal guardian, provided informed written consent prior to study enrollment.

Conflict-of-interest statement:There are no conflicts of interest to report.

Data sharing statement:The identities of the participants are confidential, data can be shared without personal information when requested.

STROBE statement:The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.

Open-Access:This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

Country/Territory of origin:Turkey

ORClD number:Melike Yava? ?elik 0000-0002-1155-1022; Melike Kili? 0000-0003-4807-5346.

S-Editor:Chen YL

L-Editor:Wang TQ

P-Editor:Chen YL