“We are Tired but Do Not Give Up” the Dilemma and Challenges of Primary Nurses Facing the Omicron Variant: Qualitative Research

Introduction

There is an immediate threat to public health around the world due to the emergence of the Omicron version of the acute respiratory syndrome coronavirus 2 (SARS-CoV-2).^1,2 In February of 2022, it was identified as the most recent VOC. Since December 2021, the Delta variety has been the most prevalent strain circulating globally, while Omicron is spreading faster. On January 7, 2020, in Wuhan City, Hubei Province, Chinese officials successfully isolated and identified COVID-19 virus. Both respiratory droplets and direct touch can spread the COVID-19 virus.^3,4 Direct contact with an infected individual is the most reliable means of transmission, but indirect contact with infected surfaces or objects (like a thermometer or stethoscope) can also be a factor in the spread of infection.^5,6 As of October 6, 2021, 4,223,095 people in Indonesia have positive test results for Covid-19. Four million, five hundred and two people have recovered completely from Covid-19, another 28,381 are undergoing medical care in hospitals or in isolation, and 142,413 have died from the virus. As of the 6th of October in 2021, the number of confirmed cases of Covid-19 in Indonesia was 4,223,092. 1 Out of the total number of people infected with Covid-19, 4,052,300 have recovered completely, 28,381 are still receiving medical care in hospitals or in isolation, and 142,413 have died. An isolation facility in a rural area will assist manage the anticipated influx of COVID-19 cases and keep hospitals from nearing capacity. This is supported by a number of studies.⁷

A Transmission of COVID-19 is more likely to occur at the primary departments in the healthcare sector. The primary care clinic is the initial point of contact between a patient and a healthcare provider, therefore the risk of infection for both the patients and the staff is significant.⁸ Nurses are particularly at risk for contracting COVID-19 because they deal directly with patients in the primary care setting.^9,10 In the emergency room, nurses have a significant risk of contracting the COVID-19 virus.¹¹

Inadequate protection, prolonged exposure to directly infected patients, job pressure, and the lack of personal protective equipment (PPE) are some of the variables previously found to contribute to the spread of COVID-19 among healthcare personnel.^12–15 In spite of the widespread use of PPE, many healthcare workers remain at risk of getting COVID-19. In addition to the virus’s inherent ease of spread, the primary management structure put in place during the pandemic is largely to blame for the spread of COVID-19 among healthcare professionals. During the present pandemic, the health care system requires a suitable main management system.^10,15–17

Primary care delivery in Indonesia is complicated by the country’s size and the widespread nature of its rural and remote regions. Behaviors linked to worse health outcomes¹⁸ are more common among those living in rural and remote areas of Indonesia. When patients are admitted to or while going to one of the numerous smaller hospitals in rural and non-existent distant locations, they are sometimes moved to larger hospitals because of a lack of medical staff. In both circumstances, patients in serious condition typically have to wait for medical help to arrive at the hospital.¹⁹ Nurses often make up the bulk of hospital staff at smaller facilities located in more distant areas. Often times, when doctors are not available, it’s up to registered nurses to provide primary care management on the front lines.²⁰

The approach of health workers to the community to carry out tests and close contact tracing is often hampered by strong resistance from the community. There are also many people who are dishonest when they come to primary health care, so the risks we face are quite high.²¹ By exploring the perspectives of rural primary care nurses in Indonesia during the omicron variant pandemic, this study aims to fill in the gaps in the literature that does not specifically address this issue. This study specifically targets RNs working in a primary care setting because they will get the most out of it.

Methods

Study Design

Semi-structured interviews with primary nurses were conducted as part of the study’s qualitative explorative descriptive design. For investigating and comprehending the experiences of nurses working in primary care clinics in rural regions during the omicron variant pandemic, the qualitative technique is appropriate. In a way that the quantitative approach cannot do, the qualitative approach offers the most explanation possible.²² The completeness and validity of the analysis were assessed using the Consolidated Criteria for Qualitative Research Reporting (COREQ).²³

Setting, Sampling, and Participant

To conduct this research, a purposive sample strategy was used. Unique instances are picked based on judgment for the special traits that these cases offer in solving a research topic, and purposeful sampling is most commonly utilized in exploratory research or field research.²⁴ The nurses were gathered using a purposeful sample strategy from several public health institutions in the Malang area of East Java, Indonesia. Only nurses with extensive expertise in the field (ie, more than a year’s worth), who are actively receiving patients and caring for patients in main departments during the COVID-19 epidemic, and who are also willing to engage in this study, were considered for inclusion.

Data Collection

The researchers that performed the online interviews (using Zoom) were all equally skilled in carrying out qualitative research. master’s degrees, doctorates, and professorial credentials. includes one lady and four guys, As lecturers, they undertake research, Participants are aware of the study’s goal, and researchers and participants do not have any familial or other connections. This study does not interest the researcher in any way. The specifics of the interview procedure were provided to the participants after making contact with them and presenting the researcher to them. Participants were guaranteed that their identities would remain anonymous and that all personal information and interviews would be kept private. Data was gathered from February to March 2022 for a single month. Due of the tight constraints, the semi-structured interviews were conducted via Zoom on an individual basis. Digital voice recorders were used to capture every interview. Open-ended questions that let participant and interviewer to follow any fascinating or pertinent experience of inquiry directed the semi-structured interview. One broad inquiry regarding their experiences in the main department during the omicron variant pandemic was the first thing the researcher asked the interviewees. The probing questions for the co-construction of the following interview were amended in light of the findings of the interview data. To preserve data integrity and lessen researcher bias, the interview audio recordings were verbatim transcribed as soon as possible following each interview. Depending on the circumstances and the participants’ interests, experiences, and perspectives, the interview lasts anywhere between 30 and 65 minutes (on average 47 minutes). 20 interviews later, data saturation had been reached. No subjects withdraw from the study before the investigation is finished.

Interview Questions

Using guidelines, semi-structured interviews were done to promote conversation about the problems and emotions faced by nurses in rural areas during the delivery of care during a pandemic. Based on the Theory Base Rural Nursing, which consists of job beliefs and health beliefs; isolation and distance; independence; lack of anonymity; outsiders/insiders; and elderly people/newcomers, the question guideline was produced.

The primary concerns are as follows:

• How was your experience as a nurse at the village’s primary care facility?
• How do you feel about caring for this individual?
• What lessons can you learn from this experience?
• Which circumstances cannot be predicted?
• During the omicron variant epidemic, what challenges have you encountered in treating for rural patients?

Data Analysis

After verbatim transcription, the interview data were examined with a typical method to content analysis. Accordingly, data analysis begins with frequent reading of all transcripts in order to comprehend the entire and accomplish dyeing. Following this, the data were reviewed in their entirety, and a text expressing the nurse’s experience was gathered and included into the text, which served as the unit of analysis. Later on, condensed “meaning units” were developed. The writers summarized the “units of meaning” and took notes on initial thoughts, feelings, and early analyses (open coding). Then, using axial coding, the various codes are classified into subcategories based on their interconnections and relationships. To reach consensus across writers on how to divide code into subcategories, a procedure including debate and introspection was devised. Depending on the relationship between the subcategories that emerge, fewer categories are formed to arrange and organize the subcategories into meaningful categories in order to provide actual content. The category’s hidden meaning or latent content is defined as a single theme. Themes and categories of unprocessed data were thoroughly analyzed and amended using methods of continual comparison. For the purpose of reporting findings, examples for each category are extracted from the data. The author includes the following elements to enhance believability. The interview data were examined by the study team following transcription and codification. In addition, the whole text of the transcribed interview together with the Nvivo 12 code (words used by the patient in the interview) was made available to two participants so that they could assess the compatibility of the conversation transcript with their own experiences. Then, three specialists in qualitative research were requested to review the interviews, the codes, subcategories, categories, and themes were extracted, and if required, revisions were made to the synthesis and interpretation of the data based on their ideas.

Result

We conducted 20 semi-structured interviews with primary care nurses. Persons gave their written informed consent and participated in present study. The participants informed consent included publication of anonymized responses. As can be seen in Table 1, the participants’ ages ranged from 28 to 43 years old, with 8 (40%) being male and 12 (60%) being female (average age 36.4 years). The bulk (75%) had some sort of technical training, and they all had years of experience (5–15). (average 11 years).

Table 1 Interviewees’ Socio-Demographic and Professional Characteristics

Participants were asked to explain or describe their experiences working as a primary care nurse in a public health facility during the omicron variant pandemic in this semi-structured interview. Table 2 describes the findings of five themes and nineteen sub-themes. The five themes are: The Dilemma of Nursing Clinical Practice, School cluster, Virus Type Confusion, Indigenous peoples do not believe in covid, Must be Excited and Alert.

Table 2 Themes and Sub-Themes Derived from Analysis of Interviews

Theme 1: The Dilemma of Nursing Clinical Practice

Nurses who care in the era of a pandemic have a big problem. One of them is the dilemma of how nurses deal with internal and external problems. Many things make them confused what they will do. Dilemma is always a problem in the field for many reasons.

Sub Theme: Less Than Optimal Vaccination

Primary care faced by Vaccination that is less than optimal due to the lack of operators, vaccinators and so on compared to the number of patients who are vaccinated. However, some people in rural area have bad mind about vaccinated. Optimally vaccination is the front line against covid, if this has problems then control will be hampered.

Vaccinator can’t handle people who have different mind about vaccinated (P4, P8)

Patients who are vaccinated more high than volunteer in primary care (P10, P12)

Sub Theme: Reporting of Covid is Not Optimal

Less than optimal was reporting vaccinated in primary health care how are problem in private data. However, other problem about technician in primary health care are bad signal, broken device, miscommunication with volunteer.

….we were working on network eror suddenly…(P2, P5, P6)

….The computer being used has an eror and lights are off so that administrators are hampered from collecting data(P8, P11, P12)

Sub Theme: Patient is Given a Normal Mask

Masks are very important, so all are required to wear masks, because the local government rules are very strict. But this is loose when in the country side, Because they are not usually used to wearing masks. Covid case reporting is the basis for determining policy.

…….We are actually afraid of the rules, but most people don’t wear masks….(P2, P5)

……we didn’t usually used to masks, so that important is we aren’t punished for not wearing masks….(P8, P11, P12)

Sub Theme: Only Serve Circumcision and Birth Control

Everyone is afraid to go to hospital, so that health worker who practice independently only serve circumcision, control pregnant women, prepare pregnant women for healthy and normal births. Only basic services are carried out, if the services are advanced, the nurses do not want to accept them because they are at risk.

….We have not been serve more patients because it is still a risk for to family and neighbor’s, especially the issue of stigma…(P1, P3, P12)

……We only serve circumcision and controlled pregnant women for their birth………(P13, P18, P19)

Sub Theme: Regardless of Omicron or Delta

Confusion between omicron or delta type is common in the countryside, due to we lack of equipment. We only rely on government regulation and patient symptoms. Whatever the type of covid, we still serve patients with wholeheartedly.

….When we were asked by our patient, we were confused, what the type of covid they had. So we advised them to refer for hospital in the city…(P3, P5)

….We recommend drugs that suit the symptoms, without knowing whether it is omicron type or delta type covid, we still serve them…(P9, P13, P17)

Sub Theme: Afraid of the Swab Test

Health workers are traumatized because they often do swab tests, sometimes they are also afraid when a swab test is done, not only because of pain when taking specimens, but afraid because they are afraid that the results will be positive and have an impact on their families.

I’m afraid to take a specimen in my nose, even though I’ve done swab tests many times (P5, P8)

We are afraid of the impact on the family, our swab test results (P9, P16, P20)

Theme 2: School Cluster

Schools are the initial place for the spread, because in shopping centers and government institutions there are already rules for restrictions on gathering, but in schools where the majority of children are less obedient to the rules, making it difficult to regulate in schools, besides traders, parents who take students increasingly creating clusters of covid 19 transmission.

Sub Theme: Transmission from the School Drop off Group

The transmission of covid from schools became dominant because students who were not controlled and introductory students crowded together waiting for students and snack vendors who were selling there.

…we can’t control the school cluster because most of the children and delivery students…(P6, P9)

the school’s dilemma is that they are allowed to teach offline, because they don’t fully control the spread of covid. (P10, P11, P12)

Sub Theme: Nausea, Hot Vomiting, Cough Symptoms in Children

Children have symptoms of vomiting, fever, and cough when they come to health services, so we immediately recommend symptomatic treatment. We do not dare to make a decision that their child has Covid, we only suggest increasing their immunity.

….We receive a lot of children with symptoms of vomiting, fever, accompanied by cough….(P1, P3, P15)

….Don’t dare if we make a decision that their child has covid….(P18)

….Good immunity is important for children….(P19, P20)

Sub Theme: Dominant Psychological Problems

Children have symptoms of vomiting, fever, and cough when they come to health services, so we immediately recommend symptomatic treatment. We do not dare to make a decision that their child has Covid, we only suggest increasing their immunity.

….We receive a lot of children with symptoms of vomiting, fever, accompanied by cough…(P3, P4, P7)

….Don’t dare if we make a decision that their child has covid…(P8, P11, P12)

….Good immunity is important for children.(P10, P14, P17)

Theme 3: Virus Type Confusion

Covid have some problem about type in Indonesia, because they are can not detection that minimal technology. So that health worker in rural area have problem about people who denial to covid spread.

Sub Theme: Most of the Covid Verdicts are Only from Symptoms

The different symptoms of each virus are the basis for health workers to conclude the type of virus. Because in rural areas there is a lack of tools to distinguish the types of viruses based on RNA.

We were confused when asked about the type of covid that attacked them (P5, P7)

inadequate tools so we differentiate by symptoms alone (P8, P16, P17)

Sub Theme: Have Been Vaccinated so Symptoms are Mild

People who have been vaccinated show a milder condition than those who have not been vaccinated. So, vaccines are the government’s way to fight the pandemic.

Incessantly carrying out vaccines because government programs must be carried out (P7, P10)

People often complain because it is mandatory to have vaccines (P11, P12)

Sub Theme: The Verdict of the Type of Covid Depends on the One That is Pandemic

The decision on the type of covid, when the patient’s symptoms are not clear, but the government has informed that the wave experienced by the country is omicron, then most types of covid virus are omicron. Sometimes there are also previous types of viruses.

When the patient has a cough and cold, but there is no typical sign of omicron, then we tend to suspect that the type of covid is omicron (P9, P14)

When we were asked by the patient, we only talked about being suspected of having the omicron virus type (P18)

Sub Theme: Medication Only Treats Symptoms

The focus of care in rural areas when there are people affected by Covid is to focus on treating and reducing symptoms. Most of them are only outpatient, and rarely hospitalized, because of many considerations.

Many people come to us asking for covid medicine, but we can only provide snacks to reduce it (P4, P7)

We already have a protocol for handling covid from the government that focuses on reducing patient symptoms (P8, P11, P12)

Sub Theme: Symptoms of Omicron (Digestive and Respiratory)

The symptom that distinguishes between the delta and omicron types of covid virus is that omicron has additional digestive symptoms in the form of diarrhea, cough, runny nose and shortness of breath. So that we can decide that the patient is suspected of being infected with the omicron type of covid.

dominant community with complaints of cough, cold and diarrhea (P1, P5)

What is typical is the presence of diarrhea (P12)

Theme 4: Indigenous Peoples Do Not Believe in Covid

The culture in the countryside is that the symptoms of COVID-19 are similar to previous outbreaks, so they do not think it’s a dangerous thing. So, they do not believe it and think it’s just an issue.

Sub Theme: Village Community Culture (Pagebluk/ Common Disease)

The countryside has a culture that is still strong, the signs and symptoms of covid have been there based on historical stories. So they consider it normal and do not obey the rules of the command. A culture that is still followed today.

they believe that this is a common thing that happened in the past (P11, P12)

We are having problems with public trust (P8, P11)

Sub Theme: Do Not Dare to Speak Out for Covid, Because You are Afraid of the Masses

People are already fed up with the Covid condition, because of restrictions on gathering so they cannot make a living, so if someone is exposed to Covid, they automatically cannot make a living and their needs. Misrepresentation about covid so that people are afraid and stigmatized. Because of this impact, people will be angry if one of their families is sentenced to covid and feels slandered.

They can’t believe their family has Covid (P12)

In fact we are a bit risky if we convict someone of covid, so we don’t say but still we recommend treatment (P8, P11, P12)

Sub Theme: Afraid to Go to the Hospital for Fear of Being Infected with Covid

The hospital is a place that villagers will never approach, because there is an issue that if you go to the hospital, even if you have a cold, you will be infected, so that when you are sick, people never go to the hospital.

They choose to be treated at home instead of having to go to the hospital (P3, P4)

They chose to call us home instead of taking the family to the hospital (P17, P19)

Theme 5: Must Be Excited and Alert

It’s been almost a year since this pandemic has haunted me, the fear has not gone away. As the front line fighters against Covid-19, these health workers are the most vulnerable group to get infected. It’s very hard to avoid. They can only take care and not infect other people or families. Nurses really have to be in good shape. They cannot be in a state of drop. If there are complaints of pain even though it is mild, it must be reported immediately.

Sub Theme: Case Addition Data

Since Covid-19 hit, every day there are always increasing positive cases. From dozens of cases, to a million cases. Some of the Covid-19 patients are in severe and critical condition. Nurses must be strong, and are required to reduce that number.

…we must fight with increasing positive case….(P9, P19, P20)

…people who have positive covid always increasing every day….(P8, P11, P12)

Sub Theme: Because We are at the Forefront

Community nurses are the first door in preventing covid 19. The failure of community nurses will have an impact on the number of patients in hospitals increasing and the government budget will also increase. Even though we work focused on prevention, we are very important in handling omicron cases.

Everything we have to face, because we are at the forefront (P1, P4, P7)

It has become our risk if we face more complex cases because we are at the forefront (P11, P12)

The government and hospitals really depend on us (P18, P19, P20)

Sub Theme: Raise People’s Spirits

Health workers, especially nurses, have to show and give their best, if they see us tired or giving up, they will become even more hopeless. No matter how tired the nursing staff are, they must always appear happy and enthusiastic in order to awaken the community.

We don’t want to look tired or tired in front of the community, so they can keep their spirits up (P8, P13, P15)

We humans feel tired and tired, but seeing people who are in a slumped condition doesn’t seem able to complain about it (P18, P20)

Discussion

The impact of the Covid-19 pandemic is felt in various aspects of human life, including for nurses who are the largest health profession in the world. The description of nurses’ experiences during the Covid-19 pandemic, especially for nurses who work in primary department in rural areas of Indonesia, is illustrated by 4 (four) themes which have answered the objectives of this study. The themes that emerged included the dilemma of nursing clinical practice, school clusters, confusion about the type of virus, and community leaders who do not believe in the Covid-19 virus.²⁵

Nurses as the front line in handling patients in the midst of the Covid-19 pandemic are a vulnerable population to exposure to Covid-19, causing feelings of fear, stress, uncertainty, confusion, and difficulty.²⁶ This finding is also reflected in the first theme in this study which describes the feelings of nurses’ dilemmas in conducting nursing clinical practice. This can be caused by heavy workloads, risk of infection, lack of Personal Protective Equipment (PPE), fears of transmitting the virus to family members, and long working hours.²⁷ Nurses’ concerns in carrying out clinical practice described in this theme are also caused by low vaccination coverage and incomplete reporting of Covid-19 cases.²⁸ stated that distrust of vaccine effectiveness and low perception of seriousness of Covid-19 infection were the main determinants of individuals reluctant to get vaccines. This situation triggers the emotional state of nurses who have close contact with Covid-19 patients prone to experiencing feelings of fear of being infected, falling sick, to fear of death.^29,30 Encouragement and education from various elements including government, health professionals, and community leaders is needed to reduce public concerns and increase vaccine acceptance.

Another dilemma felt by nurses in conducting clinical practice is that the patient’s willingness to perform swab diagnostic tests is still low. Analyzed several obstacles why patients with symptoms that lead to COVID-19 were afraid to take a swab test, including the threat of stigma from the community, misinformation, to economic factors that required patients diagnosed with Covid-19 to be isolated so that they could be isolated. unable to work. Another concern that arises is related to the emergence of a new sub-variant of SARS-Cov-2, namely the Omicron variant which has different clinical features from the previous variant, namely the Delta variant. Although the delta variant has more severe clinical symptoms, longer disease duration, and higher hospitalization rates, the omicron variant is faster in terms of transmission. Some nurses in considering some of the things above decided not to do clinical practice and chose to provide limited services such as providing family planning and circumcision only. For this reason, it is important for nurses to have good knowledge and understanding of the clinical symptoms that arise so that they are able to treat patients with proper management.³¹

Another theme in this study reports about the majority of cases of Covid-19 transmission that occurred in school clusters. Although some research evidence suggests that school-age children are less likely to be infected with Covid-19,^32,33 and a case study by³⁴ also reports that no there is transmission from a child infected with Covid-19 despite contact with more than a hundred children at school, but the prognosis is different for children who are infected with Covid-19 and have a history of comorbid diseases. Children with comorbid diseases have an increased risk of admission to the PICU, increased mortality, and have more serious disease manifestations.³⁵ This study also reported that nurses during the assessment found symptoms that they often complained about such as fever, nausea, vomiting, and coughing.³⁶ The CDC (2019) states that fever and cough are the most common symptoms that child Covid-19 patients often complain about, but other symptoms may arise such as nausea and vomiting that are not specific to COVID-19 symptoms. This requires accurate diagnostic tests. However, this often encounters obstacles including inadequate diagnostic test facilities, especially in remote areas, limited costs, incompetent professional staff, so that many cases are suspected of leading to Covid-19 but are not diagnosed.³⁷

In addition to the physical symptoms that arise, the dominant psychological problem is also a complaint that is often reported. Symptoms of anxiety, fear, uncertainty, social phobia due to stigmatization, to xenophobia are individual symptoms that need attention.³⁸ For this reason, it is necessary to plan short-term interventions that specifically deal with psychological problems arising from the Covid-19 pandemic.

All viruses, including SARS-CoV-2, have characteristics that change over time. So far hundreds of variants of this virus have been identified worldwide.³⁹ Nurses involved in this study expressed a sense of confusion regarding the type of virus that continues to mutate. In 2021, the delta and omicron variants are the most dominant. Detected for the first time in Botswana, the omicron variant was identified as having a higher infectivity rate than the previous variant. In contrast to omicron, which has a lower risk of infection in people who have received complete vaccination, the delta variant is actually capable of significantly infecting people even though they have been completely vaccinated or commonly known as breakthrough infections.²¹ In line with this, in this study it was also reported that from several cases handled by nurses in the primary department, most of the patients who received complete vaccinations complained of mild symptoms such as cough, runny nose, dizziness, and an increase in body temperature.⁴⁰ Specific to the symptoms caused by the Omicron variant, in this study it was stated that the complaints did not only include the symptoms as previously mentioned, but also the presence of digestive complaints such as nausea and vomiting.

Most COVID-19 patients have mild to moderate symptoms, but about 15% develop severe pneumonia and about 5% develop acute respiratory distress syndrome (ARDS), septic shock, and/or multiple organ failure.^41,42 The therapy given consisted of symptomatic management and oxygen therapy. Although several antiviral drugs are being actively tested, none are specifically aimed at treating COVID-19.⁴³ This finding explains some of the statements that emerged in this qualitative study that the drugs given in the health care facility setting are only drugs to treat symptoms.⁴⁴ Education and explanations are needed for the public to understand the type and purpose of therapy given for Covid-19 so that there are no misunderstandings that result in issues of trust in health professionals and the government, including awareness to get vaccines that are proven effective in overcoming the spread of Covid-19.

The final theme in this qualitative research describes one of the obstacles that are often found among health professionals, namely unscrupulous public figures who do not believe in Covid-19. This has an impact on people who have an incorrect understanding due to misinformation and disinformation. There are several statements obtained, one of which is the culture of the village community who believes in the existence of pagebluk from a mythical point of view. People believe that Covid-19 is a common disease and there is no need to be too vigilant. (Sahoo et al, 2020) mentions that in essence myths or inaccurate information are widely published, in a very short time, and people tend to follow them without questioning their authenticity or looking for evidence. This can increase the stigma of society in dealing with the Covid-19 pandemic. As is the case with the statement obtained in this study which states that there is a reluctance to access health services despite experiencing health complaints for fear of being diagnosed with Covid-19. This supports another statement which states that there is a fear of reporting Covid-19 cases because of the poor response from the public. Patients tend to be dishonest in reporting their medical history. This has resulted in difficulties for nurses in the primary department to obtain accurate data from patients and families during the Covid-19 screening. As a result of this, the diagnosis is inaccurate and there is a high risk of transmission for both nurses, patient families, and other patients. Therefore, WHO (2020) recommends accurate information, and the broadcasting sector has a big role in influencing the public so that people perceive that what is conveyed by the broadcasting sector is the truth. In addition, evidence-based information needs to be encouraged to change people’s perceptions that are not correct regarding Covid-19. The ultimate goal is for the public to understand and support various government programs in handling Covid-10 so as to reduce morbidity and mortality.

This research will become input for health services that are more alert, anticipatory, responsive and resilient in facing the threat of health problems that occur now and in the future. Nursing professional organizations always promote Nurses with the People, Towards a Healthy Nation, Free of Covid-19. Nurses as the front line always experience many problems but they will never give up. The implication of this research is that it becomes the basis for policy holders to give appreciation for their services, educational institutions must improve adaptation-based education so that they always make a contribution. As well as professional organizations that are always there for nurses.

Limitations of the Study

The sample included in this study may not represent the entire context of primary care nurses in Indonesia. In addition, the use of stratified random sampling, especially related to geographic areas, is needed to generalize the findings in future studies.

Conclusion

This research reveals that The Dilemma of Nursing Clinical Practice, School cluster, Virus Type Confusion, Indigenous peoples do not believe in covid, Must be Excited and Alert are the main theme identified in this study. Making innovations to increase motivation thereby reducing mental and physical fatigue are the implications of the results of this study. Further exploration of the readiness of nurses to treat patients in the main department is believed to be beneficial for the results of this study.