1. Introduction

COVID-19 pandemic was and is still the worldwide pandemic, a fatal infection that affects all races young and old.  Globally people lost their lives because of this unforeseen pandemic called COVID-19 both rich and poor. With regard to its control and infection propagation, the COVID-19 pandemic has caused a rise in general public concern and panic.  The coronavirus disease of 2019 (COVID-19) first appeared in Wuhan, China. Respiratory symptoms mostly dominate clinical manifestations related to COVID-19 [1].  The most common complications are acute respiratory disease syndrome (ARDS) and systemic inflammatory response Syndrome (SIRS). This article describes the support provided by the family members of the COVID-19 patients admitted to public hospitals in South Africa (SA). Family members were not visiting the patients who were admitted to the hospitals due to the National COVID-19 pandemic Disaster Management Act 2002 in place [2].

When most patients are admitted to hospitals, family members provide some level of care and support. Findings from the study by [3] revealed that having enough social support was essential for patients to combat the COVID-19 virus. The expectation was that comprehensive patients care is to be given. However, during the COVID-19 pandemic, it was not allowed to visit the patients admitted with COVID-19. Objective of the study was to explore and describe the support of patients admitted with COVID-19 at public hospitals in SA by their family members

2. Literature Review

The COVID-19 pandemic has led to extraordinary global morbidity and mortality rate, with population health impacts as a growing concern. The increased morbidity and mortality profoundly interrupted the systems and structures that previously operated to support the patient’s health and well-being individuals and families [4]. Wuhan Red Cross Hospital in China was turned into an infectious disease treatment center on the 21^st of January 2020 [5]. The study by [5] showed that the number of COVID-19 patients was far beyond the bed capacity of respiratory departments in Wuhan. Every hospital was designated to exclusively admit and treat such flooding-in new patients. As the number of COVID-19 cases raised, hospitalization also increased. African countries including SA were admitting patients diagnosed with COVID-19 [2], and a departmental circular was put in place to restrict visitors to the hospitals to prevent the spread of the virus. In SA the status was that visitors were prohibited to enter the hospitals' premises, which denied the support of the patients during their difficult times in the hospitals.

Hospitalisations were extremely challenging for patients, due to uncertainty about recovery hence, support from family members was most significant.  All patients were screened as they enter the hospital gates for the clinical manifestations of COVID-19 virus. The study conducted in Spain by [6] showed that patients with COVID-19 symptoms were treated in isolated infectious hospitals This was due to social isolation, perceived danger, and physical discomfort. Patients with the virus can experience loneliness, anger, anxiety, depression, and post-traumatic disorders [7]; [8] and [9]. According to [3], most patients claim that having adequate social support helped them cope with the COVID-19 pandemic. They needed to have the support of friends and family members at all levels if they were to successfully battle the illness. The study aimed to answer questions from the patients: A central question was used “Kindly share your experiences when admitted to the hospital during the COVID-19 pandemic”, Followed by probing questions such as;

1. Tell me your coping mechanisms while hospitalised with no visitation by family members,
2. How best do you think you could have been supported while hospitalised with COVID-19?

Most of the patients reported going through multiple negative emotional states, including shock and disbelief.  According to [10], when patients were asked to rate the thoughts of "going to die", upon hearing the news about the diagnosis of COVID-19, they experienced anxiety, fear, stress, and social stigma. Almost all of the patients reported an increase in 'faith in God, 'respect for doctors and other health professionals, and a decrease in 'the power of money.  Patients admitted with covid-19 infections experienced psychological stress as they witnessed co-admitted patients dying in the same unit [12].

2.1 Problem statement

When patients are admitted to the hospital, support from their loved ones and friends is essential. Visiting hospitalised patients by family members was encouraged for social interaction and emotional support prior to the COVID-19 epidemic, but during the pandemic, visiting a patient who is hospitalized was prohibited. Due to the COVID-19 circular, which forbids visits to stop the transmission of infection, they were not permitted to have visitors during the admittance time. Since their family members did not visit them while they were in the hospital, all the patients experienced stress. The COVID-19 pandemic is an adversary that has triggered a burden on all aspects of life for both the patients and their family members.  Every citizen's health is impacted, whether they are healthy or ill, whether they have COVID-19 or not.

Despite the precautions taken, the COVID-19 pandemic infections were growing. Patients with COVID-19 reported feeling angry, lonely, anxious, depressed, and unable to sleep. Owing to stressful circumstances and feelings of abandonment or being put at the hospital, a patient's condition deteriorated due to a lack of emotional support and interaction with loved ones. Therefore, the researchers were interested in learning more about how patients felt about support when they were hospitalized with COVID-19 at public hospitals in South Africa without a family member's presence.

2.2 Objectives of the study

The objective of this study was:

To explore and describe the support of patients admitted with COVID-19 at public hospitals in South Africa by their family members.

3. Material and Research Methodology

3.1 Study context and setting

Data was conducted from May 2021 to June 2022 at Vhembe district hospitals in four municipalities which were Makhado, Musina, Thulamela, and Collin Chavani in SA. The selected hospitals were Donald Fraser, Elim, Malamulele, Messina, and Siloam. The researchers chose these hospitals because they were admitting patients suffering from COVID-19 [13].

3.2 Study design

A phenomenological design was conducted with 12 participants from five hospitals in the Vhembe district in Limpopo Province [14; 15]. Researchers collected data telephonically using a semi-structured interview guide and analysed the qualitative data.

3.3 Study Population

The population for the study comprised all patients who were suffering from COVID-19 and admitted during the COVID-19 pandemic in the selected Vhembe district hospitals.

3.4 Sampling Method and Sample Size

Non-probability purposive sampling was used to select five Vhembe District hospitals from four sub-districts. The hospitals selected were admitting patients diagnosed with the COVID-19 pandemic. Purposive sampling was used to select 12 participants according to the researchers' judgment because those were relevant participants with experience of the phenomenon. 

3.5 Recruitment procedure 

Using the list provided by the nursing service managers of the chosen hospitals, the researchers found potential volunteers. Random sampling was employed, and individuals who answered the call and indicated a willingness to participate were verbally requested to provide consent.

3.6 Data Collection and Analysis

To prevent the spread of Infection, the researchers used unstructured interviews telephonically to elicit detailed information from the volunteers who had been discharged. The participants' native tongues, both Venda and Xitsonga speaking, were used by the researchers during participant interviews. The interviews took place between April and July 2021 at the interviewees' convenience and lasted between 30 and 45 minutes. The language specialists translated from the regional tongues. Utilizing quotes from the participants, manual data analysis was carried out utilizing Tesch's eight processes [16]. The researchers assembled the data that had been gathered, defined the unit of analysis, developed categories, coded all the text, examined consistency, and made judgments [16].

3.7 Ethical Considerations

To conduct research on participants, clearance was obtained from the University high degree committee, and the research ethics committee (PROJECT NO: SHS/20/PDC/19/0608),  Permission was requested from the Department of Health, the District Health Office of the Vhembe district, The researchers had to request permission to obtain approval from the hospital executive officers and nurse managers of the chosen institutions in order to follow all established procedures, avoid misunderstandings, and prevent delays in data collecting. The rights of the participants were upheld throughout the study; these rights included the right to secrecy, the right to privacy and dignity, the right to voluntary participation, and the right to withdraw from the study at any time.

3.8 Demographic profile

The participants whose ages were ranging between 26-60 years, out of 12 participants, seven were males and five were females.

Table 1: Summary of theme and sub-themes

Theme 1: Lack of support 

The findings revealed that participants experienced various challenges of loneliness and distress, social stigma, and isolation, and most of them expressed a lack of support from their family members as they were restricted to enter the hospital premises. The following are the sub-themes to describe the support as expressed by the participants.

Sub-theme 1.1: Family support

All the hospitals did not allow visitors to visit the admitted patients. Participants were not comfortable with the issue of relatives not visiting them. The following quotes illustrated that:

Participant 1 male “You know doctor that issue of not allowing visitors to come to the hospital! no no no! I don’t like that! As participants, we need support from our relatives, their presence means a lot!!!”

Participant 5 male: our relatives are not allowed to bring anything from home I have a problem, I have been here for 2 months nobody from home to see who can comfort you”

Participant 12, a female “My mother was hospitalized and died in January 2021 from the COVID-19 virus. A few days later, my husband and I became sick and tested positive, and were hospitalised for three weeks and my husband died too. I was very scared, thinking I am next in line to die. It feels like a death sentence on my entire family in the name of COVID. The sadness, distress, and pain that I feel daily are beyond human imagination. I feel very naked, empty, cold, and dark inside”.

Participant 7 male: “It would also be better if the hospital allows one family member to come and visit as one patient died and was asking to see his eldest son, but it was denied, He was heartbroken. I felt bad about the situation”

Sub-theme 1. 2: Spiritual support

During the COVID-19 pandemic while patients suffering from COVID-19 were admitted to the hospital the patients and their relatives were very distressed due to the uncertainty of the patient’s condition. Hospital visits were not allowed. Social distancing and wearing of masks were followed to comply with the health guidelines. The telephone has become a greater tool of pastoral support used by almost all pastors to communicate with patients and their relatives.

Participant 2, female “The family pastor used to call pray with us over the phone, The support from the pastor was so much needed during the admission period.

Calling and talking to someone suffering from COVID-19 was the only means to reach patients admitted and their relatives to pray for them and give words of comfort. Nevertheless, even during a pandemic, pastors and other church leaders should continue providing pastoral care for all their members infected and affected. This was a very difficult period ever because previously the pastors used to visit patients in the hospital for support. However, it is an awkward time that needs everyone to protect self-first before taking care of another person.

Participant 9, female. I was anxious because even the pastors could not physically visit me when admitted to the hospital as no one was allowed. Possibly the pastors were also afraid of the transmission of the disease

Pastors also protected themselves by not visiting patients’ family members at their homes, and the patients suffering from COVID-19. Calling someone and talking to someone has become a significant method of ministering to all because of social distancing. Voices over the telephone were used to comfort, encourage and sometimes WhatsApp, zoom counselling sessions, SMS, and emails to those who were able to use them.  Pastors found the COVID-19 pandemic to be a surge that disturbed their pastoral duties.

Sub-theme 1.3:  Psychological support

Some patients indicated that they were isolated from their family members as they were denied the right to visit them. The family members were eager to see their hospitalised patients to an extent that they would visit the hospital though they knew that they will not be allowed to enter through the gates. This denial of hospital entrance further made them feel alienated and separated from the important support they needed during their stay at the hospital. This was evidenced by the following quotes:

Participant 6, male: Ok nurse, I don’t want to go to the hospital again. This thing is trouble, is like you are in jail. On the other hand, it was good for protecting my family but on the other hand, it was not good for the family and myself. To tell you the truth, I was stressed. I kept on wondering about what is happening in my family, and how they feel when I’m seriously ill and I cannot see them. Sometimes my wife and the children will come to the hospital and pack their car and call me to tell me that they are at the gate but none of them can come and see me. Loneliness was too much. I think one can heal fast with the support of the family”

4. Discussions

In this study, one theme which is lack of support emerged: family relationships were under pressure, and families were concerned about their loved ones.  Patients and family members missed each other. The findings of this study revealed that the patients diagnosed with COVID-19 admitted to the hospitals have a distressing story that entails dealing with the news of their diagnosis all by themselves. Since visitation by their relatives was prohibited to prevent the spread of the COVID-19 virus, some patients showed that they felt like COVID-19 was a death sentence for their entire family because of social distancing and fear of death. The sadness, distress, and pain that they experienced daily were beyond human imagination

Family support

The findings of the study showed that patients and their relatives understood the guidelines of no visitation to the hospital during the COVID-19 pandemic. However, the study has shown that patients with the COVID-19 pandemic were experiencing loneliness, anger, anxiety, depression, and insomnia. The study findings were similar to the study conducted by [17] which showed that the Covid-19 pandemic brought a shift in many aspects of healthcare facilities.

Patient recovery is based on moral support from relatives however, due to COVID-19 the visiting hours are restricted or limited. The same applies to this study, family members were not allowed to visit their loved ones, and this impacted them negatively.  The study conducted by [18; 17] supported the theme by indicating that restricted visiting hours in hospitals resulted in a refit between family members and admitted patients. Some patients viewed this as a life sentence and separation from their loved ones. The situation was not palatable to both patients and family as this has resulted in loneliness and resentment. Similarly, the study by [19] supported that there were no family support teams recognised or established. Family members were not able to phone or visit their patients in critical care units in some hospitals. However, some of the family members were saddened by the death notification of their patients. In support of the findings [20] patients experienced anxiety and depression because of visitors’ restrictions guidelines.

This was a dilemma as mental health wellness was supposed to be part of the nursing care for patients even during covid-19 the pandemic. The isolation and restricted hours of visiting patients were overwhelming and added emotional and psychological stress. This also made the patient feel resented and unsupported by the people closest to them. In addition, [19] indicated that family support is a core and critical to patients, this was a prestigious opportunity that patients were deprived of during the time of COVID -19 pandemic. A study conducted by [ 21] argued that mental health and family support are crucial during any outbreak or pandemic. Family support also ensures adherence to medical and hospital treatment. People with support turn out to be more compliant with the treatment regime. This was distorted due to restrictions and limitations of visitors during hospitalisation of patients during the COVID -19 pandemic.

Spiritual support

The COVID-19 pandemic has led the country into a dilemma, the spiritual support is very difficult to display as social distancing is a must [22] Visiting the patients required authorization and coordination. Gone are the days when pastors could visit a patient at any time of day or night. If hospitals now allow visitors, patients stated that they must follow processes to obtain authorization and protect everyone from COVID-19 [23].   Rapid response to COVID-19: health informatics support for outbreak management in an academic health system.  Hence, the telephone has become a greater tool of ministry. Calling and talking to someone has become a much more significant approach to ministering to people including patients and their family members.  Voices over the telephone can be more comforting, encouraging, and motivating than email or texts.  Personal visits are far less common, and they often take place in socially isolated chairs in a driveway and are somehow not permitted at all due to COVID-19.

The study conducted by [24], showed that the psychological support from pastors and other church members for admitted patients is more likely to be from family members and friends than from healthcare workers.  According to [10] showed that a lack of support was also seen in patients when they stated that they were insecure, panicking, and unsafe during their hospital stay. This was because the diagnosis of COVID -19 brought a feeling of shock, disbelief, and fear of death. Before COVID -19 pandemic counselling was conducted on the spot in churches that offer a "come forward" response period at the end of the service. However, social distancing made it difficult for pastors to lay hands on members and pray for them. Due to the current situation, new ways should be devised to respond to spiritual needs at the moment. The findings concur with the study by [17], who indicated that the COVID -19 pandemic also affected church gatherings which negatively impacted the admitted patients. Those admitted did not have a chance to get prayers from their spiritual pastors as they were not allowed to visit them. The same applies to the relatives who did not have a chance to consult their pastors for guidance and spiritual support.

Psychological support

According to [18]; [3] the COVID-19 pandemic came with many healthcare changes that affected many systems of care including family support and social interactions of admitted patients. The patients experienced distress and anxiety as they were displaced from their normal hospital routine. This is because family members were no longer allowed to participate in the holistic care of their loved ones.  Family members were not able to follow the care and also not sure that their patients were receiving care as was expected. Besides, [17], indicated that patients were overwhelmed by the diagnosis of COVID-19 and psychological depression with the belief that they have a life sentence and are going to die. Patients were also fearful and guilty of infecting their loved ones. In addition, [25] showed that the COVID-19 pandemic caused stress for both patients and family members. Stressors included uncertain prognosis and the imposition of public unfamiliar health measures. Furthermore, [25;26] contended that if participants have enough rest and consistency with family and friends stress can be minimized.

5. Conclusion

The findings showed that patients’ understanding was that the policy in place was appropriate, even, though there was no support shown through visitation by their family members. To them, it was a system to prevent the spread of COVID -19 infection from their family members. Albeit some of the participants were considering it as a good system to curb the infection. Some family members showed that for them not to visit the patients in the hospital was just like abandoning them and felt not supporting them enough through calling and communicating telephonically as to whether they are being well catered for in the hospital.

Recommendations

The Department of Health should strengthen community education through awareness campaigns and roadshows to conscientize them about policy compliance and its benefits. The hospital to put mechanisms in place to update the family members about patients’ progress to ally anxiety. The department should have an app for use of social media to update family members about patients’ conditions.

Recommendations for further study

Further studies may be conducted to assess the impact of stressors experienced by both patients and family members during the COVID-19 Pandemic.

Acknowledgments

The researchers acknowledge the following institutions and participants:

The university funding the study ethics number (PROJECT NO: SHS/20/PDC/19/0608). The hospital management, patients, and their family members for the cooperation shown during telephonic data collection.

Funding

The study was funded by the University of Venda and is the Advanced Nursing Science Project.

Conflict of Interest

The authors declared that there is no conflict of interest.

Authors’ Contributions

The University Research and Publication Committee (RPC) funded the project. The project leader was Dr RT Luhalima who was involved in the conceptualization and researchers T.R. L, T.M, N.D.N conducted data collection, analysis, T.R.L, M.T and N.D.N participated in report writing. All authors contributed to the literature search, drafting, revising, and finalisation of the article. In addition, all authors read and approved the final manuscript.

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