Intimate care is one of the significant elements of the nursing profession that makes it different from other healthcare professionals, as nurses spend more time with their patients and provide safe, individualised, holistic and comprehensive care (Jordan et al. 2022). Caring is a core attribute of nursing, including physical, mental and emotional care (Shin & Yoo 2022). Much literature has been dedicated to describing the COVID-19 pandemic and its progress, with the main concern being the direct or indirect transmission through contact with infected individuals and contaminated objects (Garba, Lubuma & Tsanou 2020).

Many countries adopted strategies to minimise and control the spread of the COVID-19 pandemic. ‘Social or physical distancing’ aimed to reduce clustering and interactions among individuals and communities (Mbunge 2020; Shah et al. 2021). It is an umbrella term for the limitation and restriction of personal interactions and movement (Feldman et al. 2022), which led to limiting health workers’ interactions with patients and minimising the hospitalisation of patients to prevent respiratory droplet transmission (Jamaludin et al. 2020). Regarding hygiene, the focus was on good hand hygiene practices, as this was considered an important measure of risk reduction practices to prevent the transmission of pathogens in healthcare facilities (Moore et al. 2021). Therefore, nurses wore personal protective equipment (PPE), such as gowns, face masks, goggles, face shields and gloves, while working with patients (Deliktas Demirci, Oruc & Kabukcuoglu 2021). The South African Nursing Council (SANC) provided a directive for the mandatory provision of PPE to protect nurses and patients while rendering nursing care (SANC 2021).

Patients’ hygiene related to bodily cleanliness and excretion (i.e. urination and defaecation) is essential to maintaining the patient’s dignity and integrity. Intimate care is classified as the closeness of a patient and nurse at a physical, psychological and spiritual level where touch cannot be avoided (Shakwane & Mokoboto-Zwane 2020b). Thompson et al. (2021) emphasised that intimate care is person-centred and requires creating and maintaining a relational space that promotes integrity. Intimate care is task-oriented touch to areas of patients’ bodies that might cause them discomfort, anxiety and fear (O’Lynn, Cooper & Blackwell 2017). Nurses need to touch patients to provide bodily care; the body plays a role in assigning meaning to experiences of illness and guides what action needs to be performed (Ohajunwa & Mji 2018). Touch is essential in nursing as it communicates care (Pedrazza et al. 2018) and is a medium to connect with the patient to achieve nursing goals (Mainey et al. 2018). During basic nursing care provision, intimate care conflict can be experienced by both the provider of care and the recipient. The Model of Shakwane and Mokoboto-Zwane (2020b) for facilitating the teaching of intimate care suggests that intimate care conflict exists through diversity such as age, gender, religion and cultural beliefs of a nurse and a patient. As the tasks are hands-on, a patient’s physical and social space is invaded (Thompson et al. 2021). Therefore, a therapeutic nurse-patient relationship should be created through negotiating and establishing trust, respect and dignity during intimate care execution. Understanding patients’ cultural and religious beliefs and social norms is essential when providing culturally acceptable intimate care and touch (Shakwane & Mokoboto-Zwane 2020a).

During hospitalisation, the power rests with the healthcare provider, and touch can be perceived as a manifestation of that power, causing the patients to interpret it negatively (Gleeson & Timmins 2005). During the COVID-19 pandemic lockdown, nurses could not provide basic nursing care that involved touch owing to the changing clinical practice guidelines on isolation, physical distancing and wearing of PPE (Moore et al. 2021). This situation caused exhaustion and discomfort for nurses (Gordon, Magbee & Yoder 2021). A bed bath is a form of therapeutic care that allows for close relationships between the nurse and patients (Avilar et al. 2021). The patients had to put aside their embarrassment and allow their bodies to be exposed to professionals of both sexes, without being given any options to alleviate their discomfort. A lack of patient-centred care led to an absence of intimate care and touch during the pandemic because of nurses’ increased workload and their inability to provide standard nursing care (Bergman et al. 2021). The prevention and control of the COVID-19 pandemic also led to the breach of patients’ confidentiality, privacy and integrity (Sun et al. 2021). During admission, patients experienced a loss of relationship, personal control, identity and privacy (Jordan et al. 2022). Intimate care and hygiene care had to be provided following prescribed guidelines for the pandemic to avoid the risk of contamination and promote patient safety (Avilar et al. 2021).

Patients’ human dignity was infringed, as they were isolated from both their families and the nurses caring for them; so when a patient died, the individual was separated from other humans, without any consideration of their beliefs about death and what happens to them after death. Many individuals believe that certain bodily rituals need to be performed before or shortly after a patient dies (Lobar, Youngblut & Brooten 2006; Qian & Jiang 2022). Unfortunately, patients who died in the hospital during the height of the pandemic were simply placed in a sealed plastic bag, which was never opened by the family members. Consequently, the relatives never got a chance to bid their loved ones farewell or conduct their cleansing rituals before burial. The World Health Organization (WHO) speaks of maintaining the dead person’s dignity, and this should include respecting the cultural and religious traditions of the family (WHO 2020). However, the amendments to the South African National Health Act 61 of 2003 under the Disaster Management Act 57 of 2002 added stipulations on the viewing of human remains. According to section 28(1), no person was allowed to contact or touch the human remains; in subsection (2), the families were not allowed to wash or prepare the human remains of their loved ones (Republic of South Africa 2020). In traditional African society, death is attached to sacredness; however, the eruption of COVID-19 pandemic influenced the ritual practices (Okechi 2017). Healthcare providers should create space for ideas on African culture regarding clinical interventions and acknowledge the African cultural knowledge system (Singh, Bhagwan & Bhagwan 2020). Creating this space will assist in their preparedness for future disasters and pandemics.

The literature has focused on nurses’ experiences during COVID-19 (Bergman et al. 2021; Gordon et al. 2021; Shah et al. 2021), and, sadly, the patient’s hygiene and touch-based care were neglected in favour of risk prevention and curing measures. Thus, the aim of this study was to explore and describe the experiences of intimate care and touch during the COVID-19 pandemic lockdown in two selected hospitals in South Africa.

Three main themes emerged from the findings: (1) Keeping away from the body; (2) Who is touching my body? and (3) Fear of dying dirty – a sense of losing bodily dignity. The participants’ codes present the gender and age of the participant: M (Male), F (Female) and O (Other) non-classified gender. For example, M-25 means a 25-year-old male.

This study presents the participants’ experiences of intimate care and touch during the COVID-19 pandemic lockdown. The cleanliness of the human body offers a person a sense of self-respect and dignity. However, the participants experienced isolation and loneliness as the nurses tried to keep themselves safe from contracting the virus. Social distancing meant that the nurses had to keep away from the patients’ bodies by avoiding close contact and touch. Unfortunately, this action compromised the primary care provided to vulnerable patients. This was in line with the WHO’s (2020) recommendation for social distancing between individuals to prevent respiratory droplet transmission during human interaction (Jamaludin et al. 2020; Shah et al. 2021). In Bergman et al. (2021), registered nurses expressed the challenges of ensuring physical distancing as they could not provide the best standard of care. The participants acknowledged the importance of PPE to prevent the virus’ spread, but such equipment concealed the caregiver’s identity and prevented communication with the patient. In terms of section 28 of the Disaster Management Act (Republic of South Africa 2020), no person was allowed to contact or touch the human body of a patient without wearing the appropriate PPE. The South African Nursing Council (2021) provided a directive for the mandatory provision of PPE for frontline workers. Clearly, nurses should not have risked their lives by working without the appropriate PPE during the COVID-19 pandemic. However, physical distancing led to incomplete care (Deliktas Demirci et al. 2021), creating fear within the nursing profession, as most were infected with the virus, and some even died (Akkuş et al. 2022).

The question, ‘Who is touching my body?’ calls for reflection on the importance of identifying the person providing nursing care and showing respect for the patient’s body. When nurses wore PPE, such as gloves, gowns and goggles, it restricted their communication and interaction with patients; thus, there was less nursing engagement (Deliktas Demirci et al. 2021). The provision of intimate care involves hands-on work, which infringes on a patient’s personal and social space (Thompson et al. 2021). Patients had to submit to embarrassing situations during intimate care procedures, such as bed baths, by exposing their bodies to professionals without being able to make choices that could alleviate their discomfort (Avilar et al. 2021). Furthermore, the participants were not informed about how and where they would be touched. Arcadi et al. (2021) attested that the meaning of care changed during the pandemic; the physical distancing diminished the care that consisted of closeness, communication and patient protection. The studies of Gordon et al. (2021) and Wittenberg et al. (2021) confirmed that using PPE challenged the clinical care of patients and decreased patient-centred care. When providing care requiring touch, the patients ought to be treated with respect by the nurses, thereby acknowledging their value as a person (Bridges et al. 2021) and the meaning they attach to their bodies. Most nursing care requires the patient’s body to be touched; therefore, a nurse must inform the patient of what procedure they need to perform and ask for the patient’s permission to uphold the ethical principle of autonomy. This allows the patient to make an informed choice and exercise control over their body (Dowdell & Speck 2022). Open and effective communication about touch is necessary to avoid misinterpretation (Kelly et al. 2018) and assist the patient in feeling physically and emotionally safe (Kokokyi, Klest & Anstey 2021).

The COVID-19 pandemic lockdown led to nurses’ neglecting intimate care procedures that promote patient cleanliness and respect for the human body. The participants’ greatest fear ‘was not to die, but to die dirty’ in the hospital. The WHO recommendation of social distancing and personal hygiene focused on cleaning hands with soap and water and limiting healthcare professional engagements with patients to decrease the spread of the COVID-19 pandemic (Jamaludin et al. 2020). The cultural and religious values in African societies define the position and role of individuals, thus presenting challenges to gender equality. The African human personhood is influenced in its formation and development by cultural and socialisation processes within local traditions and customs (Nwoye 2017). A person means that the self has meaning when it is in a creative relationship with others and the rest of creation (Klaasen 2017). In Africa, becoming an ancestor after death is a desire for individuals and can be achieved through living a meaningful life (Ekore & Lanre-Abass 2016). This includes having an acceptable or good death, which allows for social adjustments and personal preparation (Gire 2014). Ancestors are the living-dead compassionate spirits who are blood-related to people who believe in them; they act as mediators between the living and the dead (Mokgobi 2014). Avoiding engaging in things that provoke their ancestors’ anger is important; therefore, people control themselves by fear and anticipatory consequences of acting contrary to the prescriptions sanctioned by their ancestors and spiritual agencies (Nwoye 2017). Dying clean for the 60-year participant refutes the idea that the response to one’s death is fear (Gire 2014) and affirms that death is associated with the sacredness of life after death. The focus on curing and the pharmaceutical treatment of COVID-19 left nurses unprepared for intimate care and touch while promoting and advocating for patient safety. Social distancing and hygiene must be redefined in terms of the unprecedented COVID-19 pandemic.

Various rituals are performed on the body after death to assist in the smooth passage to a new life as an ancestor; this includes closing the eyes and washing the body in preparation for burial (Martin et al. 2013). Death indicates the physical separation of the individual from other humans. The funeral and ceremonies focus on this permanent separation and avoid causing undue offence to the dead (Ekore & Lanre-Abass 2016). Death changes the identity of the person (Gire 2014). The study indicates that the family must wash the body for the last time after a person dies. The WHO (2020) provided critical considerations for the safety and well-being of those who tend to dead bodies. It emphasised the dignity of the deceased’s body, including cultural and religious traditions. It asserted that the families of the deceased should be respected and protected throughout the process (WHO 2020). The prohibition of the family from washing or preparing the human violated the bodily dignity of the deceased. The South African Constitution of 1996 provided hope and fundamental rights for all its people. In South Africa, culture is regarded as a way of acting, thinking and doing things unique to a particular group (Mubangizi 2012). Protection of cultural rights is stipulated in sections 30 and 31 of the Constitution. In terms of section 30, cultural rights are protected to provide individuals with cultural and language rights. In contrast, section 31 refers to a collective dimension, emphasising belonging to a group and community. Therefore, a person does not exist in isolation; each person grows up in a specific social and cultural setting, which influences the individual’s behaviour in the world (Kpanake 2018). The COVID-19 pandemic has limited these rights in terms of a general clause in section 36, which permits limitations that are ‘reasonable and justifiable in an open and democratic society, based on human dignity, equality and freedom’. Therefore, the inability to prepare the body adequately for burial and to maintain the body of the deceased in a dignified manner has been a challenging experience for many. African bereavement rituals render death a broadly dialectical process of shepherding the deceased’s soul through a series of embodied practices performed and involving the bodies of the deceased and the bereaved; the rituals steward the deceased’s soul to an ancestral spiritual realm (Martin et al. 2013). For the majority of African people, conducting proper rituals on the dead body eases the passage to the next life. In this study, the greatest desire of the participants’ relatives was to advocate for bodily hygiene for the participants who were awaiting their turn to be released from their earthly journey. Therefore, the healthcare system must recommit to upholding social, cultural and just practices that respect each person’s humanity and dignity.

Being isolated from their family undoubtedly caused enormous stress for the hospitalised patients during the lockdown. Using defensive care to avoid contracting and spreading COVID-19 left patients feeling unwanted, as they were seen as the source of the virus, with the result that the nurses tried their best to avoid touching them. It goes without saying that nurses were faced with ethical dilemmas created by the COVID-19 preventive measures, such as physical distancing and wearing PPE, which led to communication difficulties and possibly even misunderstandings. As the profession prepares for future outbreaks, nurses must be ready to deal with and respect the patient’s physical, cultural and religious needs to maintain patient dignity.