Background
COVID-19, as a pandemic infection, quickly emerged as a health problem around the world. As of November 30, 2023, 772,052,752 confirmed COVID-19 cases and 6,985,278 deaths have been reported to WHO [1]. In Iran, from January 3, 2020, to November 30, 2023, 7,624,407 confirmed COVID-19 cases with 146,705 deaths were reported to WHO [2]. The probability of frontline healthcare workers contracting COVID-19 in one study was reported at least three times [3] and in another study ten times [4] more than the general population, and a significant number of healthcare workers, especially doctors and nurses, have lost their lives [5]. The multiple effects of COVID-19 on the personal, family, and professional lives of nurses are significant [6‐9]. Iranian nurses, like nurses in other countries, are always at a higher risk of infection during an epidemic, which endangers their health due to the nature of their profession and long-term contact with infected patients [10‐12]. Several studies reported the infection of nurses with COVID-19 with or without admission to hospital wards [13, 14]. In any case, the care of patients with COVID-19 at home is the responsibility of family caregivers [15]. Various studies have reported the experiences of family caregivers of patients with COVID-19 and the consequences of care on family caregivers [16‐18]. The findings of studies on the effects of the pandemic on the health of family caregivers indicated that they are more frequently exposed to stress, high workload, social isolation, anxiety, disability, insecurity, fear, worry, and sadness [19, 20]; however, little attention has been paid to the experiences of family caregivers of nurses with COVID-19 and its effects on caregivers.
Nevertheless, nurses may experience more difficult conditions during their illness due to the nature of their job and direct and continuous contact with COVID-19 patients [11, 21‐23]. Exploring the views of family caregivers of nurses who have recovered from COVID-19 can reveal common aspects and experiences, as well as specific or differentiating aspects of their care with caregivers of COVID-19 patients in the general population. To date, no study has addressed the experiences or needs of family caregivers of nurses with COVID-19 [20]. The present study aimed to explore the experiences of family caregivers of nurses who recovered from COVID-19.
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Methods
Design and participants
This study was conducted in 2022 using the conventional content analysis method on 12 family caregivers of nurses who recovered from COVID-19. The caregivers were selected through purposive sampling who had rich experiences regarding the study subject and were willing to participate in the study. One of the researchers was responsible for the sampling. In the next steps, the primary analysis moved toward the selection of participants. The participants were selected with maximum variation in terms of age, education level, job, and relationship with the nurse. The sampling process continued until data saturation. The caregivers of nurses working in different hospital wards who had a history of contracting COVID-19 at least once during the last 6 months and had recovered were included in the study as participants.
Data collection
Data were collected through in-depth individual semi-structured interviews to understand the experiences of the main caregivers of nurses with COVID-19, which were conducted by the same researcher. Interview questions were designed based on the purpose of the study. Each interview began with two questions: “How was your experience of caring for a nurse infected with COVID-19?” and “How did you feel the day you got COVID-19?” followed by probing questions (e.g., Could you tell me more about this? ). Subsequent questions were designed based on the information provided by the participant. Interviews were conducted at home or in a location that was most convenient for the participants. The next participants were selected based on interview analysis and data guidance. The average duration of each interview was 40 min. All interviews were developed for this study and have not previously been published elsewhere.
Ethical considerations
The protocol for this study was approved with the code of ethics IR.ZAUMS.REC.1400.118 by the ethics committee of Zahedan University of Medical Sciences, Iran. Informed written consent was obtained from the participants to indicate their willingness to participate in the study and confirm the recording of the interviews. The participants were assured of the confidentially of their data and their right to leave the study. They were also told at the beginning of the session that their participation would be voluntary, and they could stop, postpone, or terminate the interview.
Data analysis
The collected data were analyzed through the steps proposed by Lundman and Graneheim [24]. Qualitative content analysis reduces the data and gives them structure and order. It is also a way to explore the symbolic meanings of the messages. For this purpose, the interviews were first converted from audio file format to text. The interviewer then listened to the recorded interviews several times while reading the transcript to gain a better understanding of them. Then, the recorded interviews were transcribed and read several times to get a general impression of the data. In the next step, the meaning units were specified, and primary codes were extracted. The primary categorization started from the second interview, and primary codes, categories, and subcategories were extracted by comparing them based on similarities and differences. Finally, the core theme was extracted. All authors reviewed the final categories and theme to ensure a clear distinction between categories and subcategories and fit the data within each category.
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Rigor
The rigor of the findings was checked using Lincoln and Guba’s four criteria [25]. The credibility of the data was ensured through prolonged engagement with the research process. The transferability of the findings was evaluated by selecting participants with very diverse backgrounds and by accurately describing the details of the research procedure. Participants reviewed the text of the coded interviews to evaluate their compatibility with their experiences (member check). In addition, the extracted codes, subcategories, categories and theme were reviewed by external observers (external check). Moreover, several experts coded the text of some interviews and reviewed the resulting categories, and the inter-rater agreement was specified.
Results
The findings showed that the average age of caregivers was 27.41 ± 5.71 years. Moreover, 75% of caregivers were female, and 66% of them were nurses’ spouses. The average job experience of the nurses was 6.25 ± 6.60 years, and the average frequency of COVID-19 infection was 2.66 ± 1.66 times. Other characteristics of the caregivers and nurses are shown in Table 1.
Table 1
The participants’ demographic characteristics
Caregivers | Nurses | |||||||
|---|---|---|---|---|---|---|---|---|
Row | Age (year) | Gender | Education | Occupation | Relationship with the nurse | Workplace | Job experience (year) | Number of COVID-19 infections |
1 | 30 | Male | Bachelor’s degree | Military staff | Husband | Pulmonary ward | 5 | 3 |
2 | 25 | Female | Bachelor’s degree | Housewife | Wife | COVID-19 | 2 | 7 |
3 | 34 | Female | Bachelor’s degree | Nurse | Brother | ICU | 3 | 2 |
4 | 22 | Female | Student | - | Sister | COVID-19 | 4 | 4 |
5 | 24 | Female | Bachelor’s degree | Nurse | Sister | PICU | 2 | 2 |
6 | 22 | Female | Bachelor’s degree | Housewife | Wife | COVID-19 | 2 | 3 |
7 | 24 | Female | Bachelor’s degree | Nurse | Wife | Surgical ward | 2 | 1 |
8 | 27 | Female | Bachelor’s degree | Housewife | Wife | Emergency department | 5 | 3 |
9 | 21 | Female | Student | - | Daughter | CICU | 25 | 1 |
10 | 32 | Male | Bachelor’s degree | Self-employed | Husband | Pediatric ward | 5 | 2 |
11 | 28 | Female | Ph.D. | Physician | Wife | Emergency department | 8 | 3 |
12 | 40 | Male | Diploma | Self-employed | Husband | Internal ward | 12 | 1 |
One theme, three categories, and nine subcategories were revealed through data analysis. (Table 2).
Table 2
Theme, categories, subcategories and codes extracted from the data
Theme | Categories | Subcategories | Codes | ||
|---|---|---|---|---|---|
Psychosocial consequences | Negative emotions and attitudes | Fear of deterioration/death | News of nurses’ deaths due to COVID Absence of definitive treatment Exacerbation of the disease | ||
Fear of frequent infection | The possibility of loved one getting infected more than others Reinfection of loved one after sick leave | ||||
Fear of transmitting infection to others | Worried about my family Family caregiver worried about parents getting sick | ||||
Despair of recovery | Frequent infection with COVID after recovery Continued worry even after recovery due to working in hospital | ||||
Changing attitudes toward the nursing profession | Vague future of living with a nurse Concerns of family members about the work condition of loved one Increasing tension in life with a nurse because of his/her profession Regret of marrying a nurse | ||||
Caregiver burden | Role conflict | Multiple roles and responsibilities Stress caused by work pressure at home and outside | |||
Economic pressure | Lack of insurance coverage for treatment costs Not paying proper overtime High costs of medicine and treatment | ||||
Lack of support, ineffective interactions, and isolation | Lack of support from nursing managers and colleagues | Heavy workload despite no recovery from COVID Disagreement of nursing managers with sick leave Forced working conditions even with the risk of illness and death | |||
Ineffective interactions and isolation | Reduced family relationship due to work condition of loved one Lack of relatives’ relationships | ||||
Psychosocial consequences
All participants had experienced various negative emotions, including fear, worry, frustration, economic pressure, burden of caregiving, lack of social support and isolation, which ultimately led to a change in their attitude to the nursing profession.
Negative emotions and attitudes
Given the dangerous and progressive nature of COVID-19, many caregivers experienced negative emotions such as the feeling of fear of the deterioration of their family members’ condition/death, the fear of the patient getting infected frequently, the fear of other family members getting infected with COVID-19, and despair of recovery:
Fear of deterioration/death
Most of the participants stated that since nurses were in contact with COVID-19 patients or the news they received about the illness and death of nurses, they were greatly afraid of the aggravation of the disease or the death of their family members.
“Because my wife was a nurse, we were more stressed. We thought that something terrible was going to happen or that she would not be alive” (Participant #1).“I saw on TV that all the nurses were dying. It was really scary for us too. My husband was working in the hospital during the COVID-19 peak. I was very worried about him, fearing that something bad would happen to my husband” (Participant #2).“Since we were working in the hospital, we were much more worried than others. We had seen different types of people who had got COVID1-19. I also knew about the incidence and death statistics. This made us worry more” (Participant #11).“She thought everything would be over, and we got very stressed” (Participant #5).
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Fear of frequent infections
The caregivers in this study reported their fear of nurses frequently contracting COVID-19 due to the nature of their jobs, which made the situation even more difficult for caregivers.
“Once he recovered from the disease, he went to the COVID-19 ward and got infected again, and this was repeated over and again. I was very scared” (Participant #2).“She got the disease several times within a short period, and every time I was completely afraid. When she got better, I was always afraid that she would be infected again in the ward and her condition would get worse” (Participant #4).
Fear of transmitting infection to others
Most of the caregivers stated that nurses increase the possibility of infection transmission to other family members due to direct contact with patients, and this issue intensified their fear.
“My wife is a nurse. So, we should not go anywhere because if they ever got COVID-19, they would think we had transmitted it. They say she goes to the hospital and makes us infected” (Participant #10).“She was always afraid that nothing would happen to her child and family members. That is why we experienced more fear. We were very careful, but we were still afraid because we had someone in the family who was more in touch with COVID-19 patients” (Participant #1).
Despair of recovery
Most of the caregivers stated that they received the news and statistics from the mass media and online platforms about the increasing spread of COVID-19 throughout the world and Iran, as well as the growing number of deaths. Thus, they were disappointed with the recovery of their family members.
“When I heard the news on TV and online, I felt very terrible. I was very disappointed, and I had no hope” (Participant #6).“I was always worried that if she got really bad and died one day, what I should do with these three children and how I should continue my life. I had no hope that she would get better” (Participant #12).
Changing of attitudes toward the nursing profession
The family caregivers reported that they changed their attitudes toward the nursing profession. They believed that the nursing profession made nurses experience additional fear and stress caused by the probability of developing COVID-19 and even death, as compared to the general population. Most of the participants had a negative assessment of the nursing profession:
“At that time, we were really unhappy. We were wondering why the hospital where my sister works should be a COVID-19 treatment center. Even my father asked my sister not to go to work anymore because the causes of COVID-19 were still unknown, but my sister had to go to the hospital because of her job and future” (Participant #6).“If I could go back to the past, I would never marry a nurse. If he had another job, we wouldn’t have had much stress due to COVID-19” (Participant #2).“Maybe if my husband had another job, he would never have transferred COVID-19 to the family members” (Participant #11).“It would be better if my wife wasn’t a nurse. At least she could handle the housework and life and she wouldn’t get sick, and we wouldn’t have so much stress during the COVID-19 pandemic” (Participant #12).
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Caregiver burden
The family caregivers in this study reported that they were exposed to much pressure when caring for the patients, and subsequently, they experienced a lot of anxiety and stress. The increase in the burden of responsibilities at home, patient care, job responsibilities, and early return of the patient to work due to the lack of nursing staff in the ward were some problems reported by the caregivers:
Role conflict
The participants reported a conflict in their roles and the responsibility of taking care of patients at home.
“When he took a few days off to rest at home, I was involved in taking medicine and cooking. Also, I had to do shopping and do outdoor chores. My work pressure was too much” (Participant #8).“We had much stress because my wife and I had many things that were left undone. Our life was a real mess. Her supervisor was constantly calling and asking her to go to the hospital if she got better, as they had a shortage of medical staff. My boss also called me and asked me to go to work. To make things worse, the house was a real mess. And I was the only one who had to do everything” (Participant #10).“My responsibilities had increased a hundred times. I had to be at home all the time and take care of the house, my sick wife, and the children. I was in great trouble because I had never been in such a tough situation” (Participant #12).“The number of shifts had increased and there was a shortage of staff during the COVID-19 pandemic and thus we experienced a high workload, making it very difficult for us” (Participant #1).
Economic pressure
High treatment expenses and reduced income due to the inability to go to work imposed a lot of economic pressure on the caregivers. The monthly income of the nurses infected with COVID-19 was also reduced due to their failure to work.
“I couldn’t go to work. I am a paid employee. I don’t receive a fixed salary. I used to get a total of 2 million tomans. But I could not afford medication or food with little money. I didn’t know what to do at all” (Participant #10).“She was struggling with COVID-19 for half a month and didn’t attend all her shifts in the hospital. So, she was paid less. The financial pressure was also very severe. She had also to pay a high cost for booster and supplemental drugs or the drugs that were recommended for her disease (Participant #5).“Unfortunately, I had to close the shop for 10 days and not open it, and thus I had many financial problems. The medication costs were also high. I had to pay the rental for the house and shop and other installments. So, I was under financial pressure” (Participant #12).
Lack of support, ineffective interactions, and isolation
The third category extracted from the data analysis was the perception of lack of support, ineffective interactions of colleagues and nursing managers from nurses with COVID-19, and isolation.
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Lack of support from nursing managers and colleagues
Most caregivers in this study reported that medical staff and managers of the hospital did not support nurses infected with COVID-19 during their illness and recovery periods. Intensive work schedules, no shift changes on sick days, returning to work before full recovery, and short-term sick leave were some of the problems faced by nurses.
“The hospital manager did not cooperate with nurses, and he had to work on consecutive shifts. He also did not receive any support from his colleagues. For instance, once he was sick, no one was willing to work on his shift and he was forced to go to the hospital” (Participant #6).”My sister had to work on long and tough shifts because of the shortage of nursing staff. A person who is sick and returns to work without full recovery should not bear such high work pressure. The hospital managers expected her to keep working like a healthy nurse, but it was very hard for her” (Participant #5).“The hospital managers didn’t cooperate with us either. He had to work tough shifts. I tried to take sick leave for him, but they did not agree with it. During this time, both the work pressure and illness made the recovery process slower” (Participant #7).
Ineffective interactions and isolation
The participants in this study reported that ineffective interactions with the public led to the nurses’ isolation. The low quality and quantity of relationships and family support, ineffective interactions of people with nurses outside the hospital, and the possibility of COVID-19 transmission were other problems reported by the family caregivers.
“Unfortunately, all relatives stopped visiting us because my husband was working as a nurse in the COVID-19 ward. Whenever one of the relatives had a positive PCR, they thought he/she might have been in contact with us. Well, this had a terrible impact on us” (Participant #2).“The relatives had little or no relationship with us as my wife was working in the hospital and caring for COVID-19 patients” (Participant #1).“All relatives stopped having any contact with us for a long time because my husband and I were working in the hospital, and they were afraid of contracting COVID-19. We were rejected by the relatives” (Participant #5).“Because we were both nurses working in the COVID-19 ward, people avoided having any contact with us. Even taxi drivers were afraid of us and did not pick up us. They kind of ran away from us” (Participant #3).
Discussion
The findings of the present study showed that like other caregivers, family caregivers of nurses recovered from COVID-19 experienced psychological consequences and a heavy burden of responsibility. Some of these experiences were like the experiences of family caregivers of patients with COVID-19 in the general population, and some of them were unique experiences reported by the caregivers when taking care of the nurses due to the nature of the nursing profession.
The participants reported fear and despair including fear of deterioration/death, fear of frequent infections, fear of transmitting infection to others, and losing hope in recovery when taking care of nurses with COVID-19. The fear of the disease worsening and the patient becoming unwell was one of the most common feelings reported by most of the family caregivers of patients with COVID-19 in numerous studies [26‐28]. However, this fear is more intense in the caregivers of nurses with COVID-19; Because nurses are in direct and long-term contact with infected patients, and personal protection or isolation like normal patients is not possible for them due to the nature of their profession. Many participants stated that the nurses cared by them had not fully recovered from COVID-19, but they had to return to work immediately or after recovery because of the shortage of medical staff and they were infected with COVID-19 again. Other studies have also confirmed nurses’ fear of transmitting COVID-19 to other family members [29‐31]. However, this fear was more frequently experienced by the nurses in the present study because they were directly caring for COVID-19 patients and were afraid of transmitting the disease to their family members. The constant presence of nurses in the hospital to care for COVID-19 patients and the possibility of contracting the coronavirus, especially the dangerous and severe strains of the disease, made the caregivers feel hopeless about the nurses’ recovery. This feeling of hopelessness has been reported in many patients and their caregivers due to the pandemic, the unknown and complex behavior of coronavirus, the absence of effective treatment protocols, and the uncertainty of the disease [26, 32, 33]. However, due to the reasons detailed above, the caregivers of nurses with COVID-19 reported a more complicated and deeper form of despair and helplessness.
The caregivers in this study reported that they changed their attitudes toward the nursing profession and regretted choosing a nurse as their spouse. The work pressure of nurses, the possibility of their family members frequently contracting COVID-19 and even death, the possibility of transmitting coronavirus to others, the lack of support and failure to understand the nurse’s condition, family and social isolation, and the burden of care perceived by the caregivers led to the development of negative attitudes toward the nursing profession. Studies have reported changes in attitudes toward the nursing profession after the COVID-19 pandemic, especially among nurses and nursing students. However, no study has yet examined the attitudes of family caregivers of nurses with COVID-19. Nevertheless, some studies reported that nursing students developed a positive attitude toward the nursing profession after the COVID-19 pandemic [34]. However, in line with the present study, numerous studies have reported negative attitudes of students, nurses, and their families after the COVID-19 pandemic [35‐37]. Thus, this issue can be considered a serious warning and threat to the future of the nursing profession. Accordingly, the formulation of effective strategies to solve the challenges affecting different aspects of the personal, family, professional, and social lives of nurses is necessary.
The participants also complained about caregiver burden that involved role conflict and economic pressure. The burden of responsibility for patient care, job duties, fear and worry, and early return of the patient to the hospital due to the shortage of nursing staff were factors that intensified caregiver burden. Tekin et al. (2022) examined the experiences of family members of frontline healthcare workers during the COVID-19 pandemic in England and reported that they experienced increased domestic and emotional responsibilities due to anxiety about their family members’ work [20]. This study described the lived experiences of frontline healthcare workers caring for patients with COVID-19, while the current study explored the experiences of family caregivers in caring for nurses who have recovered from COVID-19. No study has yet addressed this issue. In another study in Iran, Faghani et al. (2023) reported that caregivers tried hard to balance the needs of healthy and sick family members due to challenges in caring for patients with COVID-19 and they experienced caregiver burden due to the lack of support from others [38].
The participants in the present study also reported that they experienced higher levels of stress due to economic pressure caused by the patient’s medical expenses and job loss or reduced income during the epidemic, as evident in the literature [39, 40]. Accordingly, social support from governments to reduce treatment costs, workplace support, and support from family members and relatives can reduce the economic burden of the disease.
Lack of support, ineffective interactions, and isolation were other problems reported by the caregivers in the present study. A majority of the participants believed that during the COVID-19 pandemic, not only did they not receive enough support and effective interaction from the public, managers, their colleagues, family members, and friends, but because the patients were nurses, they experienced isolation and rejection, and the people around them cut off or reduced their communication with them due to the fear of contracting and transmitting coronavirus. The caregivers also reported that they experienced great suffering and stress caused by the nurses’ quick return to work due to the shortage of nursing staff before full recovery and the lack of support from the hospital managers, as confirmed in several studies [41‐43]. The support of nursing managers to nurses during epidemics will bring positive effects and consequences not only for nurses but also for their family caregivers [44].
Limitations of the study
This study has several limitations. One of the limitations was the recall bias because the caregivers were asked to share their past experiences. In addition, the caregivers might have refused to accurately share their experiences of caring for nurses with COVID-19 due to their concerns about presenting the findings to hospital managers. Thus, the researcher assured the participants of the confidentiality of their information and the findings. Another limitation of this study was that the participants were selected from among volunteers and thus family caregivers who were not willing to participate in the study might have different caregiving experiences that were missed. In addition, the experiences of family caregivers caring for nurses with COVID-19 who were hospitalized or died in the intensive care unit were not addressed in this study.
Conclusion
The present study examined the perceptions of family caregivers of nurses with COVID-19. The participants experienced numerous psychosocial consequences such as the fear of the patient’s condition deteriorating, their frequent infections, the transmission of the coronavirus to other family members, and their disappointment about the nurse’s recovery due to the risks associated with the nursing profession. Family caregivers of nurses who recovered from COVID-19, like other caregivers, complained about the caregiving burden caused by role conflict and high treatment expenses. The lack of support from colleagues and managers for nurses with COVID-19, poor interactions, and family and social isolation led to a change in the caregivers’ attitudes toward the nursing profession and regret for their family members being a nurse. All these challenges put additional stress on caregivers and can expose them to many risks. Thus, caregivers of nurses who are infected with a pandemic and are exposed to health risks in similar circumstances need more attention and support; an issue that seems to have been neglected during the COVID-19 pandemic.
Implication for practice
The findings of this study can help health managers and policymakers formulate some strategies to support and care for families and family caregivers of healthcare workers who are on the front line of treatment.
Acknowledgements
The authors are thankful to the participants who shared their experiences in this study.
Declarations
Ethics approval and consent to participate
All participants in this study gave full informed consent to participate. The study adhered to the principles of the Declaration of Helsinki and has ethics approval from the ethics committee of Zahedan University of Medical Sciences with the code IR.ZAUMS.REC.1400.118.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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