The experiences of nurses who were involved in the COVID-19 contact tracing and tracking activities in Bulawayo, Zimbabwe

Setting and participants

The study was conducted in Bulawayo, the second largest city in Zimbabwe. Bulawayo City has 19 city health clinics and three central hospitals, one of which is a mental health institution. Zimbabwe has a very fragile healthcare system, characterised by a perennial shortage of medicines and a manpower shortage owing to a brain drain (Makoni 2020). Therefore, with the emergence of COVID-19, the health institutions in Bulawayo re-assigned staff to work on COVID-19 response activities. The local authority was responsible for coordinating COVID-19 contact-tracing activities. The City Health department was also responsible for quarantine centres. The two central hospitals and Bulawayo City Health re-allocated some of their nurses to work in the COVID-19 centre, the pre-investigation ward and quarantine centres, thus joining the COVID-19 Rapid Response Team. The inclusion criteria for this study were nurses designated specifically for COVID-19 contact tracing, line listing (an organized, detailed table that contains key information about each COVID-19 contact) and the testing of contacts in the Metropolitan Province of Bulawayo, and who were willing to participate in the study. There was no deliberate effort made to recruit any gender to participate in the study, however only two participants were males.

As part of the COVID-19 response activities, these nurses were re-assigned to the new role of conducting contact-tracing activities for the whole city of Bulawayo. The majority belonged to the Bulawayo City Health department, while some were seconded nurses from the two central hospitals. The scope of work for these nurses encompassed following up all contacts of all indices that had tested positive for COVID-19 and providing testing and support services to all of them. In addition to the contact-tracing activities, the city health department manned COVID-19 quarantine centres. On the other hand, one central hospital had a COVID-19 centre whilst the other had a COVID-19 pre-investigating ward.

Data collection

To facilitate the recruitment of study participants, the managers responsible for coordinating the contact-tracing activities, on behalf of the researcher, distributed the information sheets about the study as well as screening questionnaires which were sent to potential study participants. This was meant enable the recruitment process of study participants by managers on behalf of the researcher. Contact details were then availed by those who were willing to participate in the study and met the inclusion criteria. The researcher then collected these forms, The researcher then made a follow up by calling them and arranging convenient dates and times for the in-depth interviews. Data was collected telephonically by the first author, in keeping with the then COVID-19 guidance, whose focus was to limit physical contact. The researcher contacted participants when they were ready to be interviewed at their own convenient time and space. The first author conducted interviews in English. The author is an experienced female qualitative researcher working as a research fellow in a South African university and a holder of PhD. Prior to commencement of the study, potential study participants had access to the information sheet that detailed the nature and aims of the study as well as the credentials of the researcher. Because COVID-19 was novel and so it stimulated interest in the researcher, who has a passion for public health issues.

A pilot study was conducted, involving two nurses who shared similar characteristics as the participants of this study, not part of the study participants and who worked in a COVID-19 quarantine centre in the city. This process assisted the researchers in refining the interview guide and minor adjustments were instituted. It was established that the participants understood the questions in the interview guide. Few probes were adjusted in the tool as the participants clearly responded to the main question. Other probes followed the participants verbal cues. The findings from the pilot were not used for the study findings.

As indicated, data collection was guided by the use of an interview guide. The interview guide was developed guided by the research question and the literature and the expertise of the researchers as qualitative researchers holding PhD. A copy of the interview guide is shared as an Extended data in the Figshare (Moyo et al. 2022b). To prevent the potential risk of contracting or spreading COVID-19, all the interviews were conducted virtually, through a cell phone call that was audio-recorded. The interviews were conducted through individual interviews virtually between 28 December 2020 and 25 February 2021. The interview guide had a central question that was used to guide the interviews: “What have been your experiences in conducting COVID-19 contact tracing?” Thereafter, open-ended probing questions based on the participants’ responses were used to obtain more detailed descriptions of the participants’ experiences. This is in tandem with Polit and Beck (2021), who posit that open-ended probes enable the researcher to delve deeper into personal and sensitive issues. Each individual interview lasted 45 to 60 minutes.

The sample size of twelve participants was determined by saturation, which refers to the point at which the data-collection process fails to yield new information relevant to the study, as highlighted by Korstjens and Moser (2018). Data saturation was attained (at participant number ten) when no new information emerged and there was only repetition of previously collected data. Two more participants were interviewed before closure was reached at participant number twelve. At the end of the interviews the researcher set a reminder for second contact to discuss the study findings to ascertain study findings reflected the participants experiences (member-checking).

Ethics statement

In complying with the ethics of research, all the rights of participants, as well as the ethical principles governing research, were adhered to (Gray, Grove & Sutherland, 2020). Prior to conducting the study, the full research protocol was reviewed and approved by the University of South Africa’s College of Human Sciences Research Ethics Review Committee (NHREC Registration #: Rec-240816-052) on the 30^th September 2020 and the Medical Research Council of Zimbabwe (MRCZ/A/268) on the 14^th December 2020. An overarching project covered the experiences of health workers who were affected or infected by COVID-19 (Moyo et al., 2022a). These were nurses who either contracted COVID-19 and or provided care to confirmed COVID-19 cases or those still under investigation in different healthcare settings. This manuscript, however, covers one of the other objectives of the main study and targets different participants, namely the experiences of nurses involved with COVID-19 contact tracing and tracking activities in the community. Permission to conduct the study was also obtained from the Director of Health Services of the City of Bulawayo.

Information leaflets stating the purpose of the study, the rights of participants and the objectives of the study were given and explained to participants during recruitment. Those who agreed to participate were given consent forms that were signed before the interviews were conducted. Aspects covered by the consent form included among other issues: permission to voluntarily take part in the study and that the study findings will be used for academic purposes. Participants had been informed about the publication of the study findings on the information leaflet provided prior signing the consent form. The consent form assured participants of anonymity and confidentiality throughout the study and the publication process. The participants were told that participation was voluntary and that there would be audio-recording of the data to capture all that would be said during the interviews. The interviews were conducted telephonically, in line with the COVID-19 pandemic guidelines that emphasised limited contact. Confidentiality, anonymity, and privacy were ensured during the interviews. Pseudonyms were used instead of real names and the data was stored with an encrypted password on a computer.

Data analysis

The data analysis followed the seven steps of Colaizzi (1978) strategy, as outlined in Beck (2019). No software was used to analyse the data but the strategies by Collaizi was followed step by step to ensure every experience shared was captured. Colaizzi’s steps were chosen for their ability to generate a dense description of the experiences of participants, as they capture the essential aspects of those experiences. All the three authors were involved with data analysis. In step one: Familiarisation was done by repeatedly reading the transcripts of participants’ experiences of the phenomenon of the study. The 3^rd author who is an established researcher was responsible for doing independent coding to ascertain we reach consensus over the themes and subthemes. Step two: The researchers identified the significant statements that were directly relevant to the phenomenon of the study. In step three: The researchers formulated meaning relevant to the phenomenon of the study from significant statements. In step four: The researchers clustered themes by identifying meanings in themes that were common across all accounts. In step five: the researchers developed a full and inclusive description of the phenomenon, incorporating all themes produced in step four. In step six: The researchers produced a fundamental structure by condensing the exhaustive description into a short, dense statement that captured essential aspects of the structure of the phenomenon. In step seven: In seeking verification of the structure of the phenomenon, the researchers returned the fundamental structure to the participants to check whether the experiences were captured as verbalised by them. After summarising the findings, the first author conducted telephone conversations with eight of the participants whom she collected data from, to ascertain whether what was captured was a true reflection of what had transpired (whether it was their voice or not). Feedback received from participants confirmed the collected data was a true reflection of what was voiced out during the interviews. After confirmation from the participants, the results were captured as themes and sub-themes. The results yielded by the analysis are displayed in Table 2 as themes and sub-themes.

Rigour

Rigour in this study was ensured through the four criteria of Lincoln and Guba (1985), as cited in De Vos et al. (2016). Credibility, dependability, transferability, and confirmability were ensured in this study in the following manner:

Credibility was ensured by engaging participants for a substantial amount of time during the interviews, and by using an independent coder to analyse data separately from the researchers who collected and transcribed the data. Participant checking was done through a telephone call, as explained in 2.4 above, and as guided by a study of Williams and Kimmons (2022). The researchers ensured dependability and confirmability by thoroughly describing the steps taken from the start of this research project to the development and reporting of the findings. The reporting of the research journey in steps was maintained throughout the study. Transferability was ensured through the detailed description of behaviours and experiences, as well as the context of the study, to allow someone to replicate what was done (Korstjens & Moser, 2017, 2018). Member checking which was done through the telephonic calls with participants was to verify if the transcripts reflected their insights. The participants confirmed that the transcripts accurately captured their experiences during COVID-19 contact tracing. This is in keeping with insights from Carlson (2010) and Harvey (2015), who emphasise the importance of discussing the contents of each transcript with each study participant.

Follow-up and contact-tracing activities

Negative perceptions of the re-assigned roles

Perceptions of the re-assigned nurses’ roles were negative. Some participants felt that working in the COVID-19 Rapid Response Team was not an easy task, but it had to be done since it was the prevailing situation. Participants also thought that the exercise was unfairly done, as the following excerpts show:

Some participants were allocated from the central hospitals to join the contact-tracing activities and had this to say:

Unintended outcomes

Whilst the initial intention of contact tracing was to identify COVID-19 exposed individuals, test them and link them to appropriate service, several issues emerged as the following extracts illustrate:

Delayed COVID-19 test results

According to the study participants, efforts were made to test all the contacts. However, there was a challenge in accessing all the test results.

Another challenging experience cited by participants was delayed turnaround times for COVID-19 test results, as the following excerpt shows:

Increased workload

The nurses indicated that the workload was overwhelming because of the contact-tracing activities at hand, as reflected below:

The participants pointed out that they were not happy with the incentives they received compared to the workload, as shown below:

Support system

In this study, the participants appreciated the support they received from the health management teams in terms of availing PPE, conducting training, and providing meals.

Provision of personal protective equipment

In this study, the participants indicated that they were happy that they had been provided with adequate PPE as the following excerpt show:

The participants indicated that they attended some training (workshop) on COVID-19 which prepared them for their new roles. However, they also felt that the training was inadequate, as illustrated below.

Training and orientation on COVID-19

The participants said that they had some training on COVID-19 and infection prevention and control:

Meals for providers involved in contact tracing

The participants appreciated the gesture associated with getting meals while they were in the field. The following extract demonstrates that:

We want to be heard and listened to

On the other hand, participants also felt they would have benefitted from a listening ear from management, for them to express themselves, to explain the challenges they encountered and their emotions during the course of duty. Some participants had this to say:

Psychosocial implications

Some of the psychosocial effects experienced by nurses during contact tracing included anxiety and fear, stress and discomfort.

Anxiety and fear

The participant lived in fear of contracting the virus and infecting their family members, since they were in contact with both confirmed COVID-19 patients and their contacts.

Stress

Witnessed patients’ experiences

Providers experienced emotional pain when they met clients in the community after the loss of relatives to COVID-19, or after testing positive or being told they were a contact of someone who has COVID-19.

Emotionally challenging moments

Participants expressed emotionally challenging moments as follows:

The participants also indicated that they witnessed clients being emotional in the community. The following excerpts demonstrate their experiences.

Unable to provide a service

Witnessed discomfort

Participants indicated that they witnessed a lot of discomfort on the part of the community on seeing either the vehicle with the Rapid Response Team or the ambulance. This is evident from the following extracts:

A person who tested positive for COVID-19 had to be transported by ambulance to an isolation centre:

Experiences of stigma and discrimination

Participants indicated that they noticed that the community was either afraid or uncomfortable in their presence. One participant had this to say:

Follow-up and contact-tracing activities

Healthcare leaders play a critical role in supporting healthcare workers, particularly during moments of crisis (O’ Donovan & McAulife, 2020). The importance of utilising a framework for best leadership practices during public health crises that encompasses listening to people, being truthful and honest, and maintaining frank and open communication with compassion, cannot be overemphasised (O’ Donovan & McAulife, 2020). The participants that were involved in the COVID-19 Rapid Response activities were both from the local authority and public health facilities. These healthcare workers felt they were not prepared for the task, that they were simply assigned to the work, and they perceived it as some form of punishment. To enhance efficiency and ensure continuity of care during COVID-19 and other such pandemics, scholars have advocated for the provision of proper mental health support for the healthcare providers involved (Ho, Chee & Ho, 2020; Elkholy et al., 2021). This is further corroborated by Tomlin et al. (2020) and Cabarkapa et al. (2020), who emphasise the importance of organisational leaders to understand the needs of and provide support to their workforce. The researchers are of the opinion that these frontline healthcare workers should have been consulted, informed about the proposed move, and psychologically prepared before deployment to the COVID-19 Rapid Response Team.

The study participants also felt that that the workload involved in COVID-19 contact tracing was overwhelming, while incentives lacked. Many countries have adjusted their provider payment systems in response to pandemics such as COVID-19 (Waitzberg et al., 2020). In Tanzania, both financial and non-financial incentives were found to be effective motivators for healthcare providers (Mpembeni et al., 2015). According to the study findings of Bhaumik et al. (2020), the provision of incentives to healthcare workers during COVID-19 (such as transport and housing allowances, equal training opportunities, and improved salaries) was found to be an effective strategy for staff retention.

Another stumbling block that was cited by healthcare providers (the contact tracers) was the long turnaround period for COVID-19 test results. This had a negative effect on the affected families and meant that the clients were kept in suspense, with some never getting their test results. This state of affairs made the clients and their relatives anxious, and they would constantly ask the Rapid Response Team about the results, whenever they met them. This echoed the findings of a study conducted in Ethiopia by Mulu et al. (2021), where delays in the COVID-19 test results were attributed to human resource challenges. Similarly, Kobia and Gitaka (2020) attributed delays in Africa to the fact that there were very few testing centres that had the capacity to do COVID-19 testing.

Support system

Preparedness

During any public health emergence, the support system forms the basis for motivating teams in the frontline involved in public health emergencies. This is a point that is further buttressed by Chapman and Veras-Estévez (2021) who argue that investment in training ahead of public health emergencies pays dividends by strengthening the health system resilience. In the COVID-19 context, a study by Williams et al. (2020) found that different governments provided different types of support to boost the morale of health workers during COVID-19.

According to Tessema and Nkengasong (2021), the health systems in Africa were inadequately prepared for the COVID-19 pandemic, and the impact was significant, particularly on frontline healthcare workers. A study by Desalegn et al. (2021) that assessed COVID-19 knowledge and the preparedness of healthcare workers found that there was sub-optimal preparation of healthcare workers involved in COVID-19 activities, which was evidenced by a lack of knowledge. Contrary to the findings of this study, the participants (COVID-19 contact tracers) in the current study indicated that they received some form of training that prepared them for the new role, although they felt that the training was inadequate. For example, the participants indicated that they polished their knowledge of some infection prevention and control practices (e.g., donning and doffing) while in the field.

The training of healthcare providers plays a critical role during an emergency such as COVID-19. Evidence has demonstrated that supportive conversations and clear guidance on the existing recommendations could minimise misinformation and help reduce anxiety (Adams & Walls, 2020). To ensure uniformity and standardisation regarding COVID-19 (and other pandemic) management, regular refresher training and debriefings should be conducted.

Provision of personal protective equipment

The evidence cited by Moyo et al. (2021) in South Africa and Bajaria et al. (2021) in Tanzania has demonstrated that healthcare facilities had limited availability of some COVID-19 precaution products, such as medical masks, disinfectants, hand sanitisers, and even access to running water (particularly in public healthcare facilities). In this study, the findings were different, as the participants indicated that they had sufficient supplies of personal protective equipment and that they appreciated this support that was provided by institutional managers. In contrast, in a study in Ethiopia by Deressa et al. (2021) found that the inadequacy of PPE during emergencies left the healthcare providers dissatisfied. That adequate training, proper use and uninterrupted availability of adequate PPE provide nurses with a minimal risk of infection when providing care to suspected or confirmed COVID-19 cases is emphasised in several studies (Adams & Walls, 2020; Karlsson Fraenkel, 2020).

The healthcare workers in this study who were involved in contact tracing indicated that the work environment was busy and challenging and that they were emotionally drained. The participants also expressed the need for a listening ear from management, which was absent at the time. Similar findings were noted in a study by Shanafelt, Ripp and Trockel (2020), which established that healthcare providers were grateful for the visit management made to COVID-19 units, as well as the support provided (Shanafelt et al., 2020). In addition, the World Health Organization (2020b) calls for the provision of an adequate supportive supervision structure for all health workers assigned to COVID-19 activities. In this study, the participants appreciated the meals that were provided to them as they conducted COVID-19 contact tracing in the community, but unfortunately these were only provided for a short period of time by a donor during the initial days of the pandemic. Related to this, Zhang et al. (2020), in a study in China, found that a significant proportion of frontline healthcare workers had unbalanced diets throughout the COVID-19 response. Maffoni, Kalmpourtzidou and Cena (2021) highlight the important role played by nutrition during periods of stress and how it may affect healthcare professionals involved in COVID-19 activities. The authors argue that it is critical that strategies be put in place to enhance the nutritional status of frontline healthcare workers during public health crisis.

Psychological implications

The evidence shows that the COVID-19 pandemic has had a huge psychological impact on frontline healthcare workers. This is attributed to the excessive workload and long working hours, and the psychological strain emanating from the fear of contracting the virus, as well as the fear of spreading the disease to their families (Shanafelt et al., 2020; Cullen et al., 2020; Kisely et al., 2020).

The participants in this study experienced anxiety and stress as they executed their contact-tracing duties. They feared contracting the virus, as well as spreading it to their families. In addition, the work environment was characterised by overwhelming workloads, resulting in stress. As per findings by Adams and Walls (2020) and Liu et al. (2020), this study found that healthcare workers were afraid they transmit the COVID-19 virus to their families. These findings concurred with those by Buselli et al. (2020) and Chersich et al. (2020) who also found a similar concern among healthcare workers.

The provision of psychosocial support to healthcare workers during an epidemic can have a positive impact on their mental health as studies in China have demonstrated (Wang et al., 2020; Chen et al., 2020; Zaka et al., 2020). In that vein, the researchers would recommend that Zimbabwe provides such support to healthcare providers engaged in the fight against COVID-19 and other epidemics.

The healthcare providers experienced emotional pain or distress when they met clients in the community after the loss of relatives to COVID-19, or after testing positive or being told that they were a contact of someone who has COVID-19. According to the study participants, these clients were emotional and required psychosocial counselling, but the healthcare workers were not able to provide this service because of time constraints. The authors recommend a structured support system for healthcare workers during COVID-19 and other pandemics. Healthcare leaders play a critical role in supporting healthcare workers, particularly during moments of crisis (O’Donovan & McAulife, 2020). The authors further emphasise the importance of utilising a framework for best leadership practices during public health crises that encompass listening to people with compassion, being truthful and honest, and maintaining frank and open communication (O’Donovan & McAulife, 2020). According to Shanafelt et al. (2020), the evidence shows that healthcare workers appreciate hospital leaders regularly visiting hospital units that are caring for patients with COVID-19, to provide reassurance and support.

Witnessed patient experiences

In the present study, healthcare workers who were part of the Rapid Response Team and who were involved in COVID-19 contact-tracing activities experienced emotionally challenging moments, for example when they came across people who had just lost a relative to COVID-19, or who were in distress because of being told that they were a contact. In some instances, they felt discomfort because of being unable to provide counselling to those in need, because of a lack of time. In a related study, Liu et al. (2020) pointed out that quantitative studies have shown that frontline healthcare workers who had provided care to COVID-19 patients have greater risks of mental health problems, such as stress, anxiety, depression and insomnia. Similar findings were noted during the Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks, when healthcare workers experienced severe stress owing to fear of contracting the disease, and stigma and discrimination (Lee et al., 2018; Maunder et al., 2003). In addition, the healthcare workers in the current study also stated that they witnessed some discomfort on the part of the community on seeing either the vehicle with the Rapid Response Team, or the ambulance. Such instances of stigma and discrimination were noted in some studies. There is indeed evidence of stigma and discrimination against frontline healthcare workers (WHO, 2019; Poudel & Subedi 2020).

Limitations

Firstly, the study was limited to nurses who were involved in contact-tracing activities, working in a particular city and in one specific province (Bulawayo) in Zimbabwe. Still, the study was critical in that it provided the researchers with an opportunity to gain in-depth insights into the experiences of nurses who conducted contact tracing during the COVID-19 pandemic. Secondly, the study utilised telephone interviews as a data-collection method, which was convenient because of the COVID-19 situation. However, this meant that the interviewer was not able to observe and record the facial expressions/nonverbal cues of the study participants, and some non-verbal information might have been missed.