The emotional neglect potentials of nurses working in the COVID-19 service towards their children: A qualitative study

Abstract

Purpose

This study aims to examine in depth the potential child emotional neglect behaviors of nurses working in the COVID-19 service, and their feelings, thoughts, and experiences regarding the causes and effects on their children.

Design and methods

The study was designed as a qualitative study based on a descriptive phenomenological approach. A purposeful sample of service providers (N = 22) in the COVID-19 clinics of the region's largest hospital in northeast Turkey in terms of education and patient care were recruited for the study. The data were collected through semi-structured interviews using the individual in-depth face-to-face interview method. The interviews were audio-recorded, transcribed verbatim, and analyzed with Braun and Clarke's thematic analysis method. The research was reported by following Consolidated criteria for reporting qualitative research-COREQ.

Results

The findings enabled the identification of four unique themes expressed by the participants: parent-child interaction, social impact, physiological impact, and psychological impact. The first theme consists of adversely affected time nurses spent with their children, decreased physical contact, and communication problems; the second theme includes nurses' and their children's social isolation and social stigma; the third theme includes a change in eating habits and daily activities; the fourth theme includes fear of losing parents and emotional change.

Conclusions and practice implications

To prevent the increased emotional neglect potential due to the COVID-19 pandemic, it is necessary to regulate the working conditions of parents who are nursing professionals and support the parent/child emotionally and psychologically.

Introduction

Children witnessing domestic violence, not receiving adequate care and affection from their parents, and no parental intervention in inappropriate behaviors, etc. are defined as childhood emotional neglect (Lavi et al., 2019; Stoltenborgh et al., 2013). Open to interpretation by nature, emotional neglect is hard to assess, unlike more easily detectable physical neglect (Fung et al., 2020). Neglect continues to receive less attention in research than other forms of maltreatment (Lavi et al., 2019; Logan-Greene & Semanchin Jones, 2018). Emotional neglect is often questioned along with other types of abuse and neglect, but it is estimated that 184 out of every 1000 people are exposed to emotional neglect (Stoltenborgh et al., 2013). The prevalence of emotional neglect is reported to vary between 45 and 74%, and 16.8% of children aged 13–18 are exposed to moderate and severe emotional neglect (Musetti et al., 2021; Tingberg & Nilsson, 2020). Çalgı and Saydam (2020) evaluated the potential neglect behaviors of mothers with children aged 0–11 and stated that 60% of mothers allowed their children to watch TV for more than two hours a day, and 42% allowed their children to spend time outside without an adult (Çalgı & Saydam, 2020).

Child and parent-related factors that cause emotional neglect need to be adequately evaluated (Debowska et al., 2017). Risk factors associated with a child that may cause emotional neglect include being an unwanted child, chronic illness, disability, dangerous behavior problems, difficult temperament, constant crying, and being a stepchild (T.R. Ministry of Health, 2021; WHO, 2020). Parent-related risk factors include being young, living alone, not having knowledge and awareness about child development, using alcohol and/or drugs, having a physical or psychiatric illness, having anger control problems, and increased stress and anxiety levels (T. R. Ministry of Health, 2021; WHO, 2020). These factors can be considered risk factors for the parent to exhibit emotional neglect behavior (Debowska et al., 2017; T. R. Ministry of Health, 2021; WHO, 2020). Therefore, it is pivotal to evaluate the impacts of the COVID-19 pandemic as a factor that triggers the risk factors for the emergence of emotional neglect behavior (Adams et al., 2021; Brown et al., 2020; Lee et al., 2021; Marchetti et al., 2020). The measures taken during the COVID-19 pandemic have caused children/parents to stay at home longer, increased childcare burden, inadequate social support systems for working parents, job loss of parents, the need for technological devices in the distance education process, and economic problems in the family, resulting in increased anxiety and stress in the parents (Brown et al., 2020; Griffith, 2020; Lee et al., 2021). It is argued that the loss of a job and the symptoms of depression in the parents during the COVID-19 pandemic increase the possibility of psychological maltreatment towards their children, and the social isolation perceived by the parents and the change in employment are associated with the possibility of increased emotional neglect (Lawson et al., 2020; Lee et al., 2021). Parents' job loss in this period causes an increase in anxiety and stress levels, inadequacy in parenting roles, and disruptions in the execution of family processes (Griffith, 2020; Kovler et al., 2021).

Literature has citations that nurses who are healthcare professionals are more exposed to these risk factors during the COVID-19 pandemic (Kisely et al., 2020; Lai et al., 2020; Özdemir & Kerse, 2020; Söğütlü & Göktaş, 2021; Tengilimoğlu et al., 2021). A study examining the optimism, job stress, and emotional exhaustion of healthcare professionals during the COVID-19 period revealed that healthcare professionals experience stress and emotional exhaustion but try to remain optimistic (Özdemir & Kerse, 2020). Various studies have shown that health workers experience depression (50.4%), anxiety (44.6%), insomnia (34%), stress (71.5%), and fear of transmitting the virus to their immediate circle of people (Lai et al., 2020), increased state anxiety (50.5%), trait anger (34.8%), insomnia (35.4%) and difficulty in emotion regulation (36.1%) (Söğütlü & Göktaş, 2021), and increased workload and emotional load (Kisely et al., 2020; Lai et al., 2020; Özdemir & Kerse, 2020; Söğütlü & Göktaş, 2021) during the COVID-19 pandemic.

The people affected by the COVID-19 period are not only the nurses themselves, but their family members and especially their children (Chen et al., 2020; Gray et al., 2021; Riguzzi & Gashi, 2021). Health workers isolated themselves from their families because of the fear and anxiety of transmitting the virus to the family, as they were more concerned about the health of the individuals in their families than their health (Chen et al., 2020; Gray et al., 2021; Maraqa et al., 2020; Tengilimoğlu et al., 2021). During COVID-19, decreased time nurses spent with their children (Chen et al., 2020; Gray et al., 2021), increased childcare burdens (Adams et al., 2021; Brown et al., 2020; Griffith, 2020; Marchetti et al., 2020), and inadequate social support systems in the care of their children (Gray et al., 2021; Zheng et al., 2021) may lead them to potential emotional neglect towards their children. In addition, due to the burden of care for the child and work stress/burden (Maraqa et al., 2020; Riguzzi & Gashi, 2021; Tengilimoğlu et al., 2021), nurses' spending productive time with their children may be adversely affected. The psychological and behavioral effects of emotional neglect on the child can last a lifetime (Cohen & Thakur, 2021; Yang et al., 2021). Based on these considerations, it is important to identify and prevent the behaviors and causes of potential emotional neglect that nurses unconsciously exhibit towards their children during the COVID-19 period.

Contribution of the present study

Despite the current scientific studies on emotional neglect in children, there is a lack of data to gain insights into nurses' potential emotional neglect behaviors during COVID-19, their causes, and their effects on their children. To the best of our knowledge, there is no study in the literature on this subject, which constitutes the strength of this study and will provide basic data for further relevant studies. The study aims to examine in depth the potential childhood emotional neglect behaviors of nurses working in the COVID-19 service, and their feelings, thoughts, and experiences regarding the causes and effects on their children. We addressed the following research questions: What are the potential emotional neglect behaviors of nurses working in the COVID-19 service towards their children?, What are the causes of childhood emotional neglect during the COVID-19 pandemic?, What are the effects of nurses' working in the COVID-19 service on childhood emotional neglect? This study will provide an empirical and qualitative reflection of emotional neglect in children of nurses during the COVID-19 period.

Material and methods

Design

This research has a qualitative research design. Qualitative research is the process of revealing the perspectives and experiences of individuals or groups and making sense of the contexts in which these perspectives and experiences are acquired in a multidimensional way (Creswell & Poth, 2017). In this study, which aims to reveal the views and thoughts of nurses working in COVID-19 clinics on childhood emotional neglect during the pandemic, a descriptive phenomenological approach, one of the qualitative research designs, was used. The descriptive phenomenological pattern is recommended for researchers who aim to investigate situation-specific factors and comprehensively evaluate the impact of factors on nurses (Creswell & Poth, 2017). The main purpose of the phenomenological approach, which focuses on the life experiences of individuals and the meaning of these experiences, is to define and group personal experiences and reveal conceptual perceptions. In this type of research, the source of data is embedded in in-depth interviews between the researcher and the participant (Creswell & Poth, 2017; Willis et al., 2016). Consolidated criteria for reporting qualitative research-COREQ checklist standards were considered in the reporting of the study data to increase the reliability and quality of the study (supplementary material).

Participants

The research was carried out in a hospital located in northeast Turkey. This hospital was chosen because it is the largest hospital in the region in terms of education and patient care, it is a center where patients diagnosed with COVID-19 are treated, and it serves as a pandemic hospital at regular intervals.

In the hospital, 138 nurses provide care to patients diagnosed with COVID-19 in 11 clinics, five of which are in the intensive care unit. Therefore, the population of the study consisted of 138 nurses working in these COVID-19 clinics. The sample of the study was determined by using the criterion sampling method, one of the purposive sampling methods. The criteria of the study were set by the researchers using the literature data (Griffith, 2020; Kovler et al., 2021). Inclusion criteria were (a) having been working at the COVID-19 clinic for at least 6 months, (b) having at least one child, (c) being a volunteer to participate in the study, and (d) being over 18. The exclusion criteria were the termination of the interview due to nurses' getting sick during data collection and their preferences to quit the study. Four nurses refused to participate in the study because the interviews were audio-recorded. In qualitative research, sample size depends on what researchers want to know, what they want to do, their purpose, what will be useful and reliable, and their time and resources. There is no specific rule about sample size. One of the suggested approaches in deciding the sample size in qualitative studies is the “saturation point” (Polit & Beck, 2018). In this study, data saturation was reached after interviews with 22 nurses.

Data collection tools

Face-to-face interviews, the most frequently used method in research with a phenomenological approach, were conducted with the participants (Creswell & Poth, 2017). In the interviews, the “Nurse Identification Form” and the “Semi-structured Interview Form” prepared by the researchers in line with the literature were used (Griffith, 2020; Kovler et al., 2021). The Nurse Identification Form consists of main questions and subsidiary questions, including information about nurses' sociodemographic characteristics, profession, and children. The Semi-Structured Interview Form, created within the framework of the research topic, includes open-ended main questions and subsidiary questions asked when the participants could not recall their experiences (Table 1 ). Two experts in the field of nursing were consulted to evaluate the questions in the form in terms of purpose, meaning, and scope. In addition, a pilot study was conducted with three nurses to evaluate the intelligibility of the form, and then the form was finalized. Those involved in the pilot study were excluded from the sample.

Table 1.

Semi-structured interview form.

1. What do you think about the term and scope of childhood emotional neglect? Can you please explain your thoughts?

2. What does working in the COVID-19 service mean to you in terms of emotional neglect? Could you please give an example? What are the factors that influence your thoughts?

3. Do you think there has been any change in your and your child(ren)’s life after working in the COVID-19 service? a)If your answer is yes, how was it affected, can you please share the changes? b)How do you think it will be affected in the future, could you please share? c)Can you give an example? Can you explain in more detail? How did you think/feel?

4. Do you think that your behavior towards your child(ren) has changed during working in the COVID-19 service? a)If your answer is yes, how was your behavior towards your child/children affected? b)If your answer is yes, please explain why, what are the influencing factors? c)Can you explain in more detail? How did you think/feel?

5. What did you do to protect your child/children from emotional neglect during this period? Could you please give an example?, Could you please explain in more detail?

6. Finally, is there anything you would like to add?

Data collection

Individual face-to-face interviews were conducted with each participant by the researcher (EB) between December 2021 and January 2022. Due to some busy clinics, lack of suitable environment, and the COVID-19 pandemic, interviews were conducted in an interview room. The interview room was arranged to be quiet, calm, suitably lit, ventilated, and not distracting before the interview. Since the interviews were face-to-face, extra precautions were taken due to COVID-19 (using an N95 mask, visor, overalls, and social distance). For the participants to express themselves comfortably, behave sincerely, and give accurate information, they were given detailed information about the content of the interview and time to read the interview form. Before the interviews, they were informed that the interviews would be recorded on an electronic voice recorder to be used only for this research purpose and that they could withdraw from the research at any time. Then, semi-structured in-depth individual interviews were conducted. All the interviews were recorded on the electronic recorder by obtaining written consent from the nurses to avoid data loss, make quality data analysis, and use time effectively. Nikon brand voice recorder with good sound quality was used for recording and no video was recorded. In addition, the researcher took notes on body language such as tone of voice, gesture, and posture to better understand the participants' experiences of the interviews with the note-taking method. The length of the interviews varied between 20 and 60 min but lasted an average of 40 min. The interviews continued until the researchers were sure that no new data could be added to any data code related to the questions. After the interview, a summary of the information obtained was presented to the nurses for comment and revision. All nurses confirmed that the summary matched their statements.

Data analysis

In the analysis of the data, the thematic analysis approach was used to obtain a rich and unique description of the interview content (Clarke & Braun, 2014). Thematic analysis is one of the types of qualitative data analysis that allows the data to be examined and explained in more depth (Vaismoradi et al., 2013). Based on this approach, the data were analyzed in six stages (Fig. 1 ) (Clarke & Braun, 2014). Before proceeding to the six stages, the audio recordings obtained from the interviews and the observation notes kept were written down by the researcher, and 188 pages of written text were obtained. In the first stage, familiarization with the data set was ensured by repeated reading and taking notes. In the second stage, codes related to the data obtained from the interviews were created by following a systematic way. One of the most common ways of coding is that researchers prepare a set of code lists (suggested by current theories) and organize the entire coding process according to the ready-made codes in the list. This provides great convenience to the researcher, but it may also cause the researcher to move away from the basic philosophy of qualitative research, that is, not to see the data-specific codes coming from the data itself (Creswell & Poth, 2017). Therefore, a codebook with a ready-made code list was not used in order not to deviate from the philosophy of the research. In the third stage, as a result of a detailed examination of the obtained initial codes and data set, comprehensive potential themes were created. In the fourth stage, the themes created by the researchers and the codes embedded in the themes were reviewed to ensure that the data corresponding to the research questions. In the fifth stage, the names, scope, and explanations of the themes were checked, and a detailed analysis was made. In the last stage, the findings were reported by the researchers. The COREQ followed throughout the reporting was reviewed at the end of the research.

Fig. 1.

Stages of thematic analysis.

Rigor and trustworthiness

To ensure the validity and reliability of the research, credibility, transferability, dependability, and confirmability criteria should be considered (Marshall & Rossman, 2015). A researcher diary was used, and the COREQ guideline was followed to improve reflexivity and reduce bias in the study. More than one data collection method (individual interview, observation notes) was used to increase the construct validity of the study. To increase the internal validity (credibility) of the research, an interview form was developed, and a conceptual framework was created by scanning the relevant literature. The interview form was finalized in line with the opinions of the experts. For transferability, inclusion criteria of criterion sampling were specified in sample selection, the purposive sampling method was used, and homogeneity was taken into account. To increase credibility, professional communication was established with the nurses and the interviews were held in a quiet room away from external factors. Before the interview, the nurses were given the necessary information about the research, they were told that they could withdraw from the study whenever they wanted, and their verbal and written consent was obtained. The researcher was not guiding during the interview and observation.

To increase dependability, all data obtained from the recording and observation were directly transcribed by the researcher. The relationships between all created themes and sub-themes were checked for integrity. After the final versions of the codes and themes were created, two experts, independent of the research, were consulted for the intercoder consistency ratio (Kappa) analysis. Cohen's Kappa analysis and independent expert opinion ensured dependability for the study. Kappa value was calculated based on expert opinion and found to be 0.869. A Kappa value between 0.81 and 1.00 is interpreted as a perfect fit. For confirmability, the form created for the in-depth interview and the final version of the data, made into themes, were evaluated by the expert. To increase the external validity (transferability) of the research, an external expert was consulted about the data collection tools, raw data, coding and observation notes, writings, and inferences that form the basis of the report. The researcher and other researchers interviewing patients are trained in pediatric nursing and qualitative research.

Ethical considerations

Institutional permission was obtained from the Ministry of Health (Date: 03.05.2021), the General Directorate of Health Services (Date: 01.06.2021), and the hospital (Date: 04.06.2021). Ethics committee approval (Number: 2021/124, Date: 01.12.2021) was obtained from the scientific research ethics committee of the hospital where the study was conducted. Before the data collection, the participants were informed about the purpose of the study, how it would be conducted, that the interviews would be recorded on an electronic voice recorder, that they could withdraw from the study at any time, and their verbal and written consent was obtained. The principles of the Declaration of Helsinki were followed in the study.

Results

Characteristics of nurses

22 nurses caring for hospitalized COVID-19 patients were involved in the study. The mean age of the nurses was 34 (SD 6.80), 3 nurses were male, 19 were female, and 21 were married. 7 were high school graduates, 5 had an associate degree, 9 had an undergraduate degree, and 1 had a postgraduate degree. The work experience of nurses was 12.82 (SD 6.07) years, and the work experience in the COVID-19 service was 13.32 (SD 4.35) months. 4 of them had 3 children, 8 had 2 children, and 10 had 1 child. During the COVID-19 pandemic, 23 of these children received hybrid education (online + face-to-face), 5 received face-to-face education, and 10 did not go to any educational institution. The age range of nurses' children is between 1 and 18 years old. 10 children are younger than 3 years old and did not attend any educational institution.

Themes

Child potential emotional neglect behaviors of nurses working in the COVID-19 service, their causes, and their impacts on their children are explained under four themes and nine sub-themes. The main themes are: (first theme) parent-child interaction, (second theme) social impact, (third theme) physiological impact, and (fourth theme) psychological impact (Table 2 ).

Table 2.

Data analysis samples of themes and subthemes.

Main themes	Sub-themes	Codes	Meaning unit analysis
Parent-child interaction	Adversely affected time nurses spent with their children	Working hard	N 1. ‘I think the reason for the emotional neglect in children may be that we spend less time at home due to our working conditions. If there is a problem at home, it will reflect on the child. Ummm…’
			N 7. ‘I haven't been able to spare time for my daughter for a year and a half because of the workload (she sighed).’
			N 9. ‘While we were working in the COVID-19 service, the number of shifts increased, annual leaves were canceled, and the time I allocated to my children automatically decreased. We worked a lot of overtime…’
		Living in separate houses	N 2. ‘My daughter is not with me, she is a high school student, she needed me a lot, but I sent her to her grandmother. Because her school is important… If she were with me now, if she got sick, she would not be able to study, so we are not even in the same house anymore.’
			N 3. ‘At first, they opened the state dormitory across this hospital for us, I don't know if you know or not, we barely stayed there for two weeks during that time, so we had a two-week break.’
			N 17. ‘You know, people don't believe when they see it on TV, we lived in separate places, there was the talk of going and seeing through the door, for example, I did it. I was going through the door, I knew my daughter's favorite things, and I bought them for her. Here is the neglect…’
		Feeling tired	N 9. ‘Physically, my son was 2 years old at the beginning of the epidemic, I was feeling very tired even though I was at home, so I couldn't be very alert.’
			N 13. ‘Yes, yes, this period definitely affected it. Well, you go home more worn out, scattered, tired, finished… I don't even see the child…’
	Decreased physical contact	Not hugging and kissing	N 2. ‘I have not hugged my children since I started working in the COVID service, of course, I am afraid that something will happen to them.’
			N 4. ‘As a father who loves to hug, love, and kiss my children, of course, I was extremely influenced during this period. So, no matter how much we brush our teeth or take a shower all the time, I abstain from kissing, (sigh) hugging.’
			N 8. ‘This period affected me touching the child… (stopped for a few seconds)’
			N 3. ‘I was scared… it is not clear how it affects people, no study on the child or us for now. I mean, as a mother, it would be a great shame if I infected her/him and caused a bad effect. You know, because as I said, no one knew at that time what it does, you know, there is news about the child in the hospital that the 13-year-old child was intubated from COVID and so on. When we saw such examples, as I said, I was avoiding my child, I couldn't hug, I couldn't kiss… I mean, God forbids. if she gets infected or something (sighing)’.
			N 19. ‘(sighing) my daughter's birthday was in May, she told me something that day, ‘Mommy, today is my birthday, aren't you going to hug me today? It's really one of the saddest things you can hear as a mother.’
			N 7. ‘I used to kiss her cheeks a lot, I stopped it, I just smell her, I never kiss anywhere on her face.’
		Not sleeping together	N 3. ‘Um, for example, I never put him/her to sleep next to me, his father always put him/her to sleep. So, in this way, there was emotional neglect, we experienced it …’
	Communication problems	Communicating on the phone	N 10. ‘I talked to my child from a distance or on the phone all the time. Of course, it was very difficult, but I had to.’
			N 6. ‘My communication is only on the phone and something like that, from a distance …’
		Decreased communication	N 4. ‘There was really no communication with our children. It didn't even happen during our busy periods.’
		Yelling	N 7. ‘Especially when I was trying to establish a new order again, I shouted and yelled. That is not your house, this is your house, because she wanted to go for a while, she never listened to me, I couldn't accept it, I shouted.’
Social impact	Social isolation	Staying away from people outside the family	N 3. ‘As the simplest example, now I have neighbors on the site where I live, those neighbors and my children are the same age as those of my neighbors, let me tell you…. that we haven't met for a year, for example.’
		Not going to social areas	N 5. ‘They couldn't go out, they couldn't participate in social activities, we haven't even been to the park for months.’
	Social stigma	Having a mother working in the COVID service	N2. ‘Families don't want it either, mmmm how can I say? Her/his mother is a nurse, stigma happens, so it definitely does.’
			N 17. “Something happened because she was a nurse's child. I mean to my daughter… I was freer, when she went out, they said that her mother is a nurse and they moved away from my daughter, there were those who said, ‘Oops, be careful, please. Your mother a nurse?’ The child did not understand what was happening, so I pulled her away from there, my daughter did not understand.”
		Being a COVID nurse	N 3. ‘Because I work in COVID, you know, people's perspectives towards you change, of course. This situation is frustrating.’
Physiological impact	Changes in eating habits	Consuming ready-made food	N 4. ‘Well, when we are tired at home, we always have ready meals, sometimes you can't cook, you order ready-made food, either you can't actually trust ready meals or you don't know what the food is like’
		Changing mealtimes	N 12. ‘Regarding their diet, while I regularly fed them at a certain time, mealtimes shifted towards later hours in this period. This situation has changed the children's diet a lot..’
	Changes in daily activities	Increased use of TV/phone/tablet	N 5. ‘Children have become much more addicted to television, they watch the cartoons they want all day long. I think they will wear glasses in the future.’
			N 16. ‘They play for a long time with the tablet, the computer. Sometimes when we go home, we look them. Well obviously, they looked at the computer until the evening.’
		Decreased movement	N 2. ‘Nothing has happened to my two children at home right now, they are fine. Um… maybe I can say (pause) that they always sit, it's okay for now, but they will be weak in the future because they are too inactive, maybe they will gain weight...’
Psychological impact	Fear	Fear of losing parents	N 8. “The child, for example, knew, for example, that I was in contact with those patients. For example, when we got on the elevator, ‘Mom, Don't be afraid, COVID will not see us here.’ for example, he was trying to hug me …”
		Fear of being COVID-19 positive	N 13. ‘For example, when I was working on COVID, my daughter was very afraid of COVID.’
	Emotional change	Crying	N 12. ‘When we were apart, they cried a lot when we broke up with them at first, of course, they got used to it over time. My little girl was crying on the phone all the time, asking when I would go.’
		Being unhappy	N 19. ‘My child was already unhappy because her routine was broken. I am afraid of the future.’
		Exhibiting aggressive behavior	N 8. “During this period, my child naturally became aggressive, became aggressive all the time, started hitting here and there, picked a fight with friends.’

Theme 1. Parent-child interaction

Parent-child interaction is the first main theme and includes the sub-themes of adversely affected time nurses spent with their children, decreased physical contact, and communication problems.

Subtheme 1. Adversely affected time nurses spent with their children.

Most of the nurses stated that the time they spent with their children was adversely affected and decreased due to their intense work in the COVID-19 services. Nurses stated that before the COVID-19 pandemic, they worked normal monthly working hours, they did not have to work overtime, and the overtime was not more than 8 or 16 h. However, with the onset of the COVID-19 epidemic, the working hours of nurses increased due to the interruption of the work of nurses who have chronic diseases, who are pregnant, and who use immunosuppressive drugs, and the nurses stated that they worked an average of 56–80 h per month. They could not spend time with their children, which could cause emotional neglect in their children. Many nurses stated that since they lived in separate homes from their children during this COVID period, the time they spent together decreased, and thus neglect occurred. In addition, some nurses expressed that they spent less time with their children due to the fatigue caused by working in the COVID wards.

N 3. ‘I mean, when I think about it, even just being a nurse's child is already very difficult. I think now, for example, my child is away from me ten full days a month, it's really sad (sigh), I don't like 24 hours shift, but unfortunately, we have to work... overtime...’.

N 4. ‘In the early days of COVID-19, we sent the children to my mother's village, and we were separated for a month. I mean, the child was calling us from there, asking when we would go. At that time, there was neglect (with a worried expression) …’.

N 7. ‘Our children have always had to live in a house separate from us, we have deprived them of their mother's love, their home, and their food to protect them. I get so angry...’

N 4. ‘There is really extreme tiredness, and no one can come and spend time with their child when they are tired. In our case, this is very possible. When you are really tired, you come and just take a shower and go to bed…’.

Subtheme 2. Decreased physical contact

Almost all the nurses reported that they could not hug or kiss their children due to working in the COVID services, which they thought decreased physical contact and lead to a potential behavior of emotional neglect. Nurses stated that they could not hug their children because they were afraid. In addition, some nurses stated that they could not sleep with their children during this period.

N 1. ‘We have already been alert since the emergence of COVID-19, and when I started working in service, we hugged each other less and touched our children less. Or when I came home from work, they didn't hug me directly, they waited for me to wash my hands first, or be completely clean. They said, ‘Can I hug you now? which is something my children like a lot when I lay them on my lap and caress their hair. Don't you think this is a kind of neglect? (she swallowed and waited for a few seconds), I think so (with a sad expression)’.

Statement by a male nurse about not being able to hug his baby: N 6. ‘For example, my baby was born. I haven't seen him for a very long time, you think about his well-being, but, his father's voice, we were rarely together. Well, he hardly heard my voice, I couldn't touch my baby (he took a deep breath). Do I want to neglect my child? Sometimes there are obligations. My baby may not understand right now and doesn't know me yet, hardly held my hand. Now, how does he know about his father, how can he be connected to me? Oh, this is my personal preference, (in a bittersweet tone) …’.

N 12. ‘Of course, my children want to sleep with me at night. Especially my little girl was calling me a lot during the day, well… at bedtime.’

Subtheme 3. Communication problems

Nurses expressed that they were able to communicate with their children via telephone during the COVID-19 period, and their communication decreased. In this section, five nurses stated that they or their spouses shouted at their children while communicating with them, as an emotional neglect behavior.

N 12. ‘When I was away, I always video chatted so that my child would not be affected. I called, and we talked for hours. Our communication was adversely affected.’ N 7. ‘Our communication with my daughter was affected a lot and even shortened (she got upset and stopped for a few seconds).’

N 9. ‘I am not normally a mother who yells a lot, I became a mother a little late. Once my daughter cried a lot at the door, I couldn't stand it because I was going out, whatever I said didn't work. As a rule, I told her to stay in her room so that she should be a little scared, I told her to cry in her room, I shouted to her to stay there (pausing for a few seconds).’

N 13. ‘So, I yell even more at my children in this period (with a sad expression). When this happens, I feel sad, then, for example, after shouting at children, it becomes very sad and painful.’

Theme 2. Social impact

Social impact is the second main theme and includes sub-themes of social isolation and the social stigma of nurses and their children.

Subtheme 1. Social isolation

Some nurses stated that both they and their children distanced themselves from people outside the family during this period. Most nurses could not go to social areas with their children during this period, and they banned their children from doing it.

N 1. ‘Children have already distanced themselves from people outside the family. Because they were watching many things during the day, then we warned them to be careful. They never talked to anyone without asking me.’

N 7. ‘I used to meet with two of my neighbors on the site, they both have children close to my daughter's age, but we haven't seen each other since COVID started, maybe we can infect each other, and it was not clear what kind of effect it has on children.’

N 11. ‘Both of my sons loved to play outside and ride bikes, but of course, I couldn't allow them during this period. They were locked in the house.’ N 9. ‘There were already a lot of bans. At first, the children could not go out at all, we generally withdrew into our shells.’

N 22. ‘Um…I always had a thought in my mind, I wonder if I got this disease as a carrier, but it didn't affect me and I always thought about whether I could infect someone else or if I had it, so we didn't go out in any social area.’

Subtheme 2. Social stigma

Nurses reported that their children were exposed to a stigma in the society or their close circle of friends since their mother was a nurse in the COVID service, and they were excluded. Some of the nurses emphasized that they were also exposed to a stigma in society due to their work in the COVID-19 service.

N 8. ‘My house is somewhere in the middle of the street like this, so the children are walking out of the door, and people say ‘his mother is working in COVID…. My child is excluded!’

N 12. ‘Since the mother of the child is a nurse, that is me, families kept their children away.’ A nurse stated that her caregiver stopped taking care of her child because she was working in the COVID-19 service.

N 15. ‘When I returned from unpaid leave, I worked in a service for about a month. Then they appointed me to the COVID-19 service. Earlier, we had found a caregiver, but since I am a nurse, her husband didn't approve of it. Then we convinced her that I was not working in COVID. But then, when I switched to the COVID-19 service, she quit. In that period, I had to look for a caregiver again.’

A nurse could not even use the elevator in the apartment she lived in. N 12. ‘It was even written on the elevator that there was a health worker in the apartment, and it was written that they should use a certain elevator and that they should stay away from people in the building.’

Theme 3. Physiological impact

The physiological impact is the third main theme and includes discussions on sub-themes of changes in eating habits and daily activities.

Subtheme 1. Changes in eating habits

Many nurses stated that their children's consumption of ready-to-eat food increased because they were left alone at home in this period, and their children's meal times changed.

N 16. ‘Children were left alone then. I mean, when they are on their own, they either don't eat even if there is food at home, or they always order ready-made burgers, wraps, pizza... Well, they eat unhealthy foods.’ Two nurses expressed that their children's eating times changed.

N 2. ‘Since I was not at home, everyone ate whenever they wanted (laughs). They may become obese in the future’.

Subtheme 2. Changes in daily activities

All nurses explained that children's activities of daily living changed during this period, and they spent most of their days using TV/phone/tablet. In addition, nurses emphasized that their children moved less during this period, which could result in health problems.

N 13. ‘Using a tablet has become an addiction in children. Well, there is already COVID, we were already in the mode of letting them play, for example, we could not take the tablet from them because we had no other alternative. Well, this time the tablet became an addiction for them, something else… (she breathed out deeply) something else… They were addicted to cartoons, so they embraced technology during the day.’

A nurse said that her child did not use to have a phone, but she had to get a phone call during this period so that she could talk to him more while at work but then regretted it:

N 8. ‘Okay, I bought the phone myself for the child (in a tone like saying sorry, how can I do it)… For example, firstly, I am a very anti-phone person … But… right now, the habit is extremely common, and I can't get over it, I mean, I can't stop.’ Some nurses' children's daily activities decreased or even disappeared.

N 4. ‘Well, there is no activity in the house anymore except going from one room to the other. No movement at all.’

Theme 4. Psychological impact

The psychological impact is the fourth main theme and consists of the fear of losing a parent and emotional change sub-themes.

Subtheme 1. Fear of losing parents

Many nurses reported that their children were afraid of losing their parents during this period, and they expressed this fear. In addition, some children were afraid of being COVID in this period.

N 13. ‘My child seems to have more fear of losing, he wants to hug me all the time, he doesn't leave my side, he watches me all the time, I don't know if he is afraid of losing but this is the case.’

N 22. “We say it doesn't affect my son much, but once he lined up our shoes in front of the door, then put a barrier in front of them and said, ‘Mom! no, no going’. I think he thought that if I went to the hospital, I would never come back… because that was something he had never done before.”

N 20. ‘My son, that is, 11 years old, since I work in the COVID service, asked us such questions as ‘Mom, will the disease come home in this way, what will it be like if we get sick, what will they do to us?’

Subtheme 2. Emotional change

Most of the nurses stated that their children experienced emotional changes for different reasons during this period, and therefore they cried and felt unhappy. In addition, some nurses expressed regret that their children exhibited aggressive behavior because of this mood change.

N 14. ‘I could not transfer my prenatal leave, I started working when my baby was two and a half months old. He cried a lot on the first day I started work... (Her eyes filled with tears and stopped for a few seconds)’.

N 21. ‘Sometimes in our games, she played a mother who went to the hospital, then the child was always alone, unhappy or something…’.

N 17. ‘There was that period when everywhere was closed at first, then when I was talking to my daughter on video chatting, I saw that my daughter's face fell, she was getting upset.’

N 21. ‘He started to like violent games more, he punched us sometimes during the game, I think he got angry about this situation, so we are always at home (with a sad expression). He hurt himself once or twice with his toys, but I can't say that something else happened.’

Discussion

The current study contributes to the field of child maltreatment and emotional neglect by gaining insight into the potential emotional neglect behaviors of nurses working in the COVID-19 service towards their children, its causes, and how it affects their children. The fact that no studies have been found in the existing literature on the qualitative research of emotional neglect towards children in the COVID-19 period is the innovative and robust aspect of this current research and provides the literature with a new perspective. Childhood emotional neglect in nurses working in the COVID-19 service was explained with four unique themes: (a) parent-child interaction, (b) social impact, (c) physiological impact, and (d) psychological impact.

In the first main theme, many nurses stated that the time they spent with their children was adversely affected and decreased due to their busy work in the COVID-19 wards or living in separate homes. In addition, some nurses could not interact with their children because of their fatigue. Shortly before the COVID-19 pandemic emerged, a serious patient density started in hospitals and continued throughout the period (Riguzzi & Gashi, 2021). Due to the pandemic, the workload of nurses, the number of patients they care for, and their working hours have increased. For this reason, the working conditions of nurses became even more difficult than before the pandemic (Maraqa et al., 2020; Tan et al., 2020; Fernández-Castillo et al., 2021; Malinowska‐Lipień et al., 2022; Riguzzi & Gashi, 2021; Tengilimoğlu et al., 2021). These challenges caused nurses to become overtired and burnt out, which increased employee tension, anxiety, stress disorders, and sleep problems during the COVID-19 pandemic (Maraqa et al., 2020; Lipien et al., 2021; Lai et al., 2020; Zheng et al., 2021).

Nursing is a professional occupation with a predominantly female gender group of workers (World Health Organization, 2020). In this study, only 3 of 21 nurses were male. Therefore, it can be concluded that the majority of those who continue to bear the burden of the nursing profession in the COVID-19 period are women. On the other hand, the roles imposed on women by society, such as childcare and housework, caused the second shift of female nurses to continue at home. (Llop-Gironés et al., 2021; Maraqa et al., 2020). Considering all these conditions and the increasing workload and difficult living conditions of nurses, fatigue, burnout, high stress, and anxiety levels are inevitable. All these burdens are considered an obstacle to the desired level of childcare and a risk factor for exposure to emotional neglect (Debowska et al., 2017; Stoltenborgh et al., 2013; WHO, 2020). Nurses isolated themselves, especially in the early stages of the pandemic due to the fear of infecting family members with viruses (Chen et al., 2020; Gray et al., 2021; Maraqa et al., 2020). Similarly, in this study, some nurses were afraid of infecting others and therefore isolated themselves. These conditions, which negatively affect the parent-child relationship, paved the way for emotional neglect. To reduce these risk factors, new adjustments to the number of nurses, daytime hours, overtime, and inadequate equipment are required.

Touching, which is one of the ways of showing love for a healthy neurodevelopmental process in children, contributes to the child's cognitive and emotional development (Orben et al., 2020). In this study, all the nurses reported that they could not have physical contact with their children during this period. Parents have a significant role in their children's emotion regulation, meeting their emotional needs, and personality development (Spinelli et al., 2021; Yang et al., 2021). Fear of transmitting the COVID-19 virus to others has led to the isolation of healthcare workers and a reduction in their physical interactions (Chen et al., 2020; Maraqa et al., 2020; Orben et al., 2020; Gray et al., 2021). In a study conducted in Turkey, it was reported that 20.8% of health workers could not see their families in the current situation (Tengilimoğlu et al., 2021). Nurses with children may be inadequate in meeting their emotional needs due to difficult working conditions (Maraqa et al., 2020; Tan et al., 2020; Fernández-Castillo et al., 2021; Lipien et al., 2021; Riguzzi & Gashi, 2021; Tengilimoğlu et al., 2021) and mandatory isolation (Chen et al., 2020; Gray et al., 2021; Maraqa et al., 2020; Tengilimoğlu et al., 2021; Zheng et al., 2021). In this respect, a vicious circle may occur between inadequate family support, nurses' psychological problems, and potential emotional neglect towards the child.

Nurses emphasized that they had communication problems with their children in this period, and the interruption of communication may cause the child to experience mental, emotional, and social problems (Orben et al., 2020). In addition, some nurses reported yelling at their children during this period. Increasing childcare burdens of parents due to COVID-19 and changing family routines cause burnout in parents (Adams et al., 2021; Brown et al., 2020; Griffith, 2020; Marchetti et al., 2020). Regardless of the reason, yelling at a child is emotional abuse and this experience in childhood can lead to behaviors such as affective disorders and aggression in adulthood (Schwarzer et al., 2021). Considering that potential emotional neglect and emotional abuse behaviors are due to changeable causes, social and psychological support for nurses working under difficult conditions and whose lives have changed with COVID-19 will be a significant step.

Since the beginning of the COVID-19 pandemic, nurses have been declared heroes in Turkey and many other countries (Einboden, 2020; Karasu & Çopur, 2020; Boulton et al., 2022; Mohammed et al., 2021; Halberg et al., 2021). This outstanding performance of nurses and health workers was evaluated as self-sacrificing behavior as well as heroism (Boulton et al., 2022). The term “heroic nurse”, emphasized by both politicians and the public, especially on social media, has positively affected the image of nursing (Boulton et al., 2022; Mohammed et al., 2021). However, even this attitude did not prevent nurses from being stigmatized due to the high risk of COVID-19 (Halberg et al., 2021; Kisely et al., 2020; Maraqa et al., 2020). Another remarkable finding of this study was that nurses stated that children with mothers working in these services were excluded by other people and were exposed to social stigma and labeled by society. Various studies have shown that when healthcare professionals declare that they work in the COVID-19 clinic, other people automatically move away from them (Halberg et al., 2021; Maraqa et al., 2020). Inhibition of social interaction can have lasting negative consequences on a child's physical and mental health (Orben et al., 2020). It is essential to reduce this potential emotional neglect behavior of the society that influences children as well. By making use of the widespread influence of the media, awareness training should be organized (Halberg et al., 2021).

In this study, nurses stated that their children's nutritional habits and daily activities have changed physiologically because they work in the COVID-19 services. Studies have emphasized that with the onset of COVID-19, family meal routines have changed, they eat more junk food (Carroll et al., 2020), and the consumption of potato chips, red meat, fried foods, and sugary drinks in children increased significantly (Pietrobelli et al., 2020). Studies evaluating daily activities highlight that 52% of children's physical activities (Carroll et al., 2020) and movement in all physical areas except housework (Moore et al., 2020) decreased. The nurses in the study stated that their children's consumption of ready-made food increased, and their daily movements decreased. The weight gain that occurred during the quarantine period is reported not to be easily reversed and causes excessive body fat in adulthood (Pietrobelli et al., 2020). In addition, most nurses in this study stated that their children spent most of their days using TV/phones/tablets. The time spent by children looking at the screen has increased due to the measures taken during the pandemic and the switching of schools to distance education (Carroll et al., 2020; McCormack et al., 2020). Ness et al. (2021) suggested that children's homeschooling and physical activity routines have changed (Ness et al., 2021). As part of COVID-19, restrictions on social interaction and the use of playgrounds and parks have been imposed (McCormack et al., 2020; Moore et al., 2020). In this study, some nurses stated that the use of TV/tablets increased because their children could not go to social areas. These changes, directly influencing the health of children, can also be considered negligence. Therefore, parent and child-based training and activities can be planned to reduce such habits.

Many nurses in our study expressed that their children were afraid of losing their parents, and some expressed their fear of their children getting infected with COVID-19. Children's direct exposure to negative information about COVID-19 from their teachers, friends, and the media has had a direct impact on children's fear levels (Radanović et al., 2021). Children need to see that their parents can manage the fear and cope with stress during crisis periods such as the COVID-19 pandemic (Duan & Zhu, 2020). As parents' levels of fear of COVID-19 increase, the children's levels of fear increase (Radanović et al., 2021), and the high-stress levels of parents struggling with challenging conditions during the quarantine period increase the stress levels of their children (Spinelli et al., 2021). It is also expected that a child whose parent is afraid of COVID-19 will focus more on negative news (Radanović et al., 2021). Family dynamics and intra-family communication are effective in preventing all these negativities (Prime et al., 2020). Nurses should inform their children about the difficulties of their working conditions, their requirements to go to work, and the ways to protect themselves from the virus without frightening them. Within the scope of emotional changes, nurses in our study stated that their children were crying, unhappy, and exhibiting aggressive behavior. The sudden change in school, social life, and daily routines caused by COVID-19 caused aggression in some children (Pavone et al., 2020). To identify parents' maltreatment behaviors early, it is important to have knowledge of their emotional roles and risk factors for emotional maltreatment (Lavi et al., 2019). Therefore, following up and psychologically supporting parent nurses and children at risk and understanding these emotional processes of nurse parents will be beneficial in determining psychological interventions for them and their children.

Practice implications

The emergence of the COVID-19 pandemic has led to an increase in the working hours and workload of nurses, negatively affecting them psychologically and disrupting their family processes. The measures taken to prevent the spread of the virus and social restrictions have also caused some changes in parenting roles. To reduce the negative effects, it is critical to increase the number of nurses per patient and make new adjustments to ensure nurse recruitment. The adverse effects of emotional neglect in childhood can last a lifetime. Therefore, it is necessary to determine the risk factors and plan the necessary interventions. It is recommended to evaluate the nurses and their children emotionally and psychologically and follow and support those in risk groups.

Limitations

This study has some identified limitations. Using a single clinic for recruitment could limit the transferability of the findings, so the experiences and perspectives of the nurse sample in this study cannot be superimposed on nurses from different backgrounds and experiences. That most of the samples were female may also be a limitation. Conducting the interviews in an interview room determined by the researchers can be considered a research limitation. In addition, another limitation of the external validity of the study may be that the participants did not review their transcripts. Nevertheless, the results of this study provide new and powerful information to the literature on child emotional neglect behaviors in nurses working in COVID-19 wards, their causes, and how they affect their children.

Conclusions

No study has been found on emotional neglect in children of nurses during the COVID-19, and in this study, conducted with a qualitative approach, the feelings, thoughts, and experiences of nurses regarding potential emotional neglect behaviors, causative factors, and their effects on their children during the COVID-19 were explained under four themes. Main themes are parent-child interaction, social impact, physiological impact, and psychological impact and include sub-themes of adversely affected time nurses spent with their children, decreased physical contact, and communication problems, nurses' and their children's social isolation and social stigma, a change in eating habits and daily activities, fear of losing parents and emotional change.

Ethical approval

Institutional permission was obtained from the Ministry of Health (Date:03.05.2021), the General Directorate of Health Services (Date:01.06.2021), and the hospital (Date:04.06.2021). In order to conduct the study, ethics committee approval was obtained from T.R. Ministry of Health Health Sciences University Trabzon Kanuni Training and Research Hospital Clinical Research Ethics Committee (Number:2021/124, Date:01.12.2021). This study was performed according to the Helsinki Declaration.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Credit authorship contribution statement

Vildan Apaydin Cirik: Conceptualization, Data curation, Investigation, Formal analysis, Methodology, Supervision, Visualization, Writing – original draft, Writing – review & editing. Elif Bulut: Investigation, Data curation, Writing – original draft. İlknur Kahriman: Conceptualization, Methodology, Supervision, Writing – review & editing.

Declaration of Competing Interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Appendix A. Supplementary data

Supplementary material