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Determining Nursing Education Needs During a Rapidly Changing COVID-19 Environment

Prior, Michele MSN, MEd, RN; Delac, Kathy MSN, RN, CNS; Laux, Lori MSN, CRNP, RN-BC; Melone, Debbie MSN, CCNS, RNFA

Author Information
doi: 10.1097/CNQ.0000000000000328
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THE EMERGENCE of the COVID-19 coronavirus has become the biggest challenge to the health care industry to date. What began as a novel virus similar to influenza in December of 2019 emerged as a pandemic by March of 2020. The World Health Organization and the Centers for Disease Control and Prevention (CDC) in the United States were continually investigating a virus that the world knew little about. Standard treatments were not effective and guidelines for the management of COVID-19 changed daily if not hourly.1 Within this institution, meetings and classes were cancelled. Everything that seemed routine was disrupted and reorganized to adhere to the CDC guidelines for social distancing. These guidelines impacted nursing education as onboarding of new staff continued throughout this crisis. The Department of Nursing Practice and Education needed to find innovative ways to orient new staff. Adding to this disruption was the realization that training on the management of the patient with COVID-19 needed to occur quickly and efficiently. This article addresses how education was implemented during a crisis when resources and time was of an essence.


This particular hospital was designated as an Ebola Center; subsequently, there were policies and procedures in existence that provided a foundation for the plans to manage the expected surge of patients with COVID-19. An oversight committee was quickly established. New policies and procedures were developed, the need for supplies identified, and most importantly, the committee directed the resources needed to accomplish the essentials. The chief nurse officer pulled together the resources in her departments to address many directives including staffing, COVID-19 unit designation, and the support of the Department of Professional Practice and Education. The first directive delegated to the Department was the need for nursing staff training on personal protection. There was a sense of urgency requiring the department to initiate education on several key topics over a short period of time. Educators soon realized that every day brought additional challenges as more information about COVID-19 became available. This article addresses one hospital's methodologies employed to provide extensive training during a crisis for approximately 1100 nursing staff at a large urban teaching hospital, in an integrated delivery system, with more than 600 licensed beds.


The first goal was to develop and implement education on infection prevention and personal protection. Topics included what personal protective equipment (PPE) needed to be used and how to apply it; how to safely obtain and transport laboratory specimens; and how to manage linen and trash to prevent contamination and aerosolization. Second, as the care and management of the COVID-19 patient changed, additional training was developed and implemented over the next 3 weeks. Topics included PPE conservation, proning, QT interval monitoring for patients treated with antimalarial medications, and practice changes to minimize health care worker exposure.


The Department of Professional Practice and Education at this hospital is unique in its structure. There are several different types of professionals: clinical education specialists,2 Lean quality coaches,3 a wound care specialist, and a department director. Each professional has different job responsibilities but when it came to providing urgent training, every team member played a role in accomplishing the education. In fact, it was the teamwork within the department that enabled priorities and education plans to be quickly identified. The most important tasks to providing rapid real-time training were to (1) identify education priorities, (2) increase the amount of time needed to provide training by identifying programs within the department that were considered noncritical and could be suspended (eg, charge nurse workshop, preceptor workshop), and (3) identify multiple educational strategies. In addition, the establishment of a small subgroup of nursing educators provided concentrated efforts in the design of additional training that occurred over the next few weeks.

When training nursing staff on new procedures and processes, it is important to provide didactic information with demonstration and competency. However, during a crisis, different methods have to be deployed.4 Not only was there a short time interval to accomplish the training, there were also limited supplies and resources. For instance, donning and doffing of PPE could not be demonstrated because of the shortage of PPE. Therefore, other strategies were employed to supplement training. Essential training was provided face-to-face with a goal of reaching 70% of the nursing staff while some training lent itself to daily huddle announcements. In addition, tip sheets, scripts, visuals, and videos were designed to supplement the education.5 Each topic in the article will provide more detailed explanation of the educational resources implemented.



The data from the CDC suggested that the mode of transmission for COVID-19 was from person to person in the form of respiratory droplets. As a result, the immediate management for this contagion was to reduce exposure and transmission by the use of droplet isolation and protection of health care personnel.3,6 For the safety of employees, initial training focused on the correct use of isolation and PPE in the treatment of the patient with COVID-19.


The objectives of the education included reviewing the correct PPE to be used, hand hygiene, how to properly don and doff to prevent contamination, and how to dispose of or disinfect PPE. An additional objective was to provide information on the correct procedure for sending laboratory specimens, as well as the management of linen and trash to avoid aerosolization of the virus.


The first hurdle was trying to determine how quickly the training for approximately 1100 unit staff could be accomplished. The education department requested the assistance of the Lean quality coaches in the design of training materials and in providing education. It was decided at a team meeting that not only face-to-face education would be provided but also visuals would be placed outside each patient room as an immediate reference. The visuals included photographs along with a step-by-step list for donning and doffing (see Figure 1).

Figure 1.
Figure 1.:
Posters demonstrate 2 types of COVID-19 isolation.

The photographs of the PPE needed to enter a droplet or airborne room were created using the visual management tenets of Lean methodology. The goal was to make anyone who entered a room successful even if there were literacy issues among the staff. “Visual controls are mechanisms that give workers visual cues about how to perform their work effectively, efficiently, and without errors.”7 The visual tool placed on the outer door of the affected patient's room also included the standard work required, in the appropriate sequence, to be protected and safe to enter and exit the room to care for the patient. “Standard work establishes the best way to do the work and/or provide a service.”8 This was the basis for the Lean process of creating the donning and doffing education tools.

A goal was set to teach approximately 70% of the staff over the next 6 days. Training initially started on the COVID-19 designated units. Realizing that nursing staff would be pulled, all units were provided the PPE and personal protection training. The plan included the use of superusers along with concentrated efforts to cover the day shift and the night shift during the week and the weekend. To accomplish this, 6 superuser training sessions were conducted over a 2-day period for the supervisors and charge nurses of each unit. The educators and coaches paired off and arranged a schedule of unit in-services covering all shifts and the superusers provided additional training.


A script was designed to provide a standard for the education and covered the topics of donning, doffing, laboratory collection, and linen/trash management (see Table 1). Included in the didactic portion of the presentation was an explanation of the difference between aerosolized and nonaerosolized PPE procedures and identification of the procedures and equipment that could cause aerosolization.

Table 1. - Allegheny General Hospital, Pittsburgh, Pennsylvania: COVID-19 Training
The objective of this training is to provide staff with the following information regarding the management of COVID-19 isolation based on the AHN policy and the CDC:
  1. Donning and doffing of PPE for the COVID-19 and rule out COVID-19 patient

    1. Aerosolized

    2. Nonaerosolized

  2. Procedures for the management of laboratory specimens, linen, and garbage for the COVID-19 and rule out COVID-19 patient

COVID-19 training script
  1. Donning and doffing

    1. Introduction

      Explain to staff that the purpose of the training is to clarify the PPE process for both the COVID-19 and the R/O COVID-19 patient and for the safety of our staff.

    2. Aerosolized vs nonaerosolized

      1. There are 2 procedures, 1 for aerosolized and 1 for nonaerosolized.

      2. Aerosolized by definition is any process or procedure that causes the airborne particles to become tiny liquid droplets containing infectious virus or bacteria such as with mechanical ventilation. More details will be provided later in the presentation.

      3. When working with a patient who has aerosolized COVID-19, the N95 or PAPR is used for protection.

      4. With nonaerosolized, the regular mask is used for protection.

    3. Nonaerosolized procedure used for the COVID-19 or rule out COVID-19 (show the handout demonstrating proper nonaerosolized attire)

      1. Donning

        1. Hand hygiene

        2. Apply gown, tied in the back only (tying the gown in the front makes it more difficult to remove)

        3. Apply regular mask and then eye protection (goggles or mask with eye shield)

        4. Apply gloves

      2. Doffing

        1. Hand hygiene while wearing gloves (this is used with contagions such as Ebola and COVID-19)

        2. Remove gown from front rolling down and away from the body removing the gloves with the inside of the gown

        3. Hand hygiene

        4. Step outside of room

        5. Remove eye protection (goggles and face shields are reusable; masks and masks with eye shields are disposed of)

        6. Hand hygiene

        7. Remove mask

        8. Hand hygiene; apply new set of clean gloves if sanitizing goggles/face shield

        9. Wipe goggles/face shield with germicidal wipes; place in bag with users name; goggles stay with nurse and can be reused with other patient isolation; face shield in bag is hung outside patient's room and can be reused by that nurse for 1 patient; follow PPE conservation guidelines

    4. Aerosolized procedure for COVID-19 or R/O COVID-19 patient (requires use of N95 mask or PAPR)

      The aerosolized procedure is used in the presence of high-flow oxygen (any device delivering O2 >30 L/min) including: Optiflow (humidifies O2 via NC at 31-81/Lmp), BiPap, and mechanical ventilation; other procedures that aerosolize COVID-19 include intubation, extubation, bronchoscopy, AMBU use, suctioning, nebulizer treatment, and CPR.

      N95 or PAPR would be required in all the above instances.

      However, high-flow nasal cannula does not fall under the definition of high-flow oxygen as it delivers only O2 at 15/Lpm

      1. Donning with N95

        1. Hand hygiene

        2. Gown, tied in the back only

        3. Apply N95

        4. Apply eye protection

        5. Apply gloves

      2. Doffing with N95

        1. Hand hygiene with gloves on

        2. Remove gown from front, rolling down the body removing gloves with inside of gown

        3. Hand hygiene

        4. Step outside room

        5. Remove eye protection

          1. If using a mask or mask with shield, bend over garbage can to dispose of mask

          2. See PPE conservation recommendations

          3. If using goggles or face shield:

            Apply clean gloves. Wipe goggles/face shield with germicidal wipes; place in bag with users name; goggles stay with nurse and can be reused with other patients in isolation; and face shield is single-patient use, it is placed in a bag and hung outside patient room, and dispose once foam is deteriorated. Follow PPE conservation chart

        6. Hand hygiene

        7. Remove mask

        8. Hand hygiene

      3. Donning with PAPR use

        1. Hand hygiene

        2. Apply PAPR

        3. Apply gown over PAPR tied in back only (if small build, make sure that the gown is not covering the air inlet)

        4. Apply hood

        5. Apply gloves

      4. Doffing with PAPR use

        1. Hand hygiene with gloves on

        2. Remove gown from front rolling down the body removing gloves with inside of gown

        3. Hand hygiene

        4. Step outside room

        5. Apply clean gloves

        6. Remove hood; clean inside and outside with wipes; store in plastic bag; and follow PPE conservation guidelines

        7. Remove PAPR; clean with germicidal wipe; disengage battery; and clean with wipe

        8. Hand hygiene

          There will be a number of resources available in the next few days including tip sheets, a COVID-19 binder, and QR codes that will take you to videos for donning, doffing, and NP swabbing.

          In addition, bedside nurses have asked us to share the following tips:

          • Do not wear jackets or long sleeves when entering the isolation room

          • Keep your hair pulled back

          • If possible, use secure chat while in the room to alert another staff member when you need help. This will conserve our isolation equipment

    5. Guidelines for the management of laboratory specimens, linen, and trash with COVID-19 isolation

      As per staff request, I will now review the proper management of laboratory specimens, linen, and trash in COVID-19 isolation.

      Lab specimens (blood tubes and swab specimen):

      When sending specimens from an isolation room, perform the following steps:

      • Take supplies into the room including patient labels, biohazard bag, and orange PUI (person under investigation) sticker

      • Once the specimen is obtained, label the tubes and place them in the biohazard bag

      • Place orange PUI sticker onto the outside of the specimen bag

      • A second staff member should be gloved and outside the room with another biohazard bag

      • The RN in isolation places the bagged specimens into the second biohazard bag being held by the staff member outside the room

      • The second staff member secures the outer bag

      • The specimens are then walked down to the laboratory (2nd floor ST)


      When removing dirty linen from isolation rooms, perform the following steps:

      • Linen is placed in the designated blue bag

      • The linen bag should be changed when no more than ¾ full

      • Wearing gloves, tie off the bag without compressing the contents and place outside of the isolation room

      • PPE for standard precautions should be followed to carry the linen from the unit


      When removing trash from isolation rooms, perform the following steps:

      • Place the trash in the proper bag (clear—regular trash red bag—contaminated trash)

      • The trash bag should be changed when no more than ¾ full

      • Wearing gloves, tie off the bag without compressing the contents and place outside the isolation room

      • PPE for standard precautions should be followed to carry the trash from the unit

Once outside the room, linen and trash bags are not considered contaminated.

Abbreviations: AHN, Allegheny Health Network; CDC, Centers for Disease Control and Prevention; CPR, cardiopulmonary resuscitation; PAPR, powered air purifying respirator; PPE, personal protective equipment.

Since the management of the patient with COVID-19 changed on almost a daily basis, it was important to continue to review the hospital oversight committee updates daily. It was no surprise to learn the morning of our first superuser training session that the use of PPE equipment had changed. There was a detailed outline on the conservation of equipment that now needed to be added to the PPE training. Additional educational needs were identified: specimen collection for patients with COVID-19, N95 and N100 fit testing, and proning of the ventilated patient. The team formulated a plan to consolidate efforts. The PPE training would proceed as designed while the subgroup of educators would begin developing the proning training.

The outcome of the PPE training was achieved. Sixty to seventy percent of the staff received training over the 6 days. Immediately afterward, the quality coaches continued the efforts for the PPE training and then shifted to fit testing while the educators immediately began training on proning the ventilated and nonventilated patient with COVID-19.



With the threat of the possible increasing influx of hospitalized patients presenting with symptoms related to COVID-19 and requiring isolation, there were increasing educational needs identified related to specimen collection, labeling, packaging, and delivering. These needs were immediate and required reaching large numbers of staff in a short period of time. Nasopharyngeal (NP) swab collection was one of the initial educational needs due to the increasing numbers being ordered for COVID-19 testing. Faced with the international shortage of COVID-19 test kits, the network employees created an innovative solution to create the kits on-site. Social distancing specifications were followed and volunteers included staff from all disciplines. This endeavor allowed for continued excellent service to the patients as well as the health of the entire region. Numerous kits were assembled on site and they included two biohazard bags, labels, a NP swab, an instructional sheet, and a tube with transfer media. The kits were made with the CDC specifications by the Network's Research Institute. Collecting NP swabs was an important tool in the diagnosis of a variety of upper and lower respiratory tract infections including influenza, respiratory syncytial virus, and SARS-CoV-2. The quality of the specimen collection was critical and the correct collection of the specimen was directly linked to the sensitivity of the test. Coordination of this education was done utilizing the education specialists and quality Lean coaches.


The objectives of the education included training on the proper technique for obtaining a nasal swab and educating the staff on the process for sending all COVID-19–related specimen to the laboratory to protect unnecessary staff exposure. The training was provided to the nursing staff on the units designated to receive COVID-19 rule out and positive patients, which accounted for approximately 500 employees.


Step-by-step procedures were developed for the collection of NP swabs. The units were assigned to one education specialist and one Lean quality coach who determined designated times to visit the units during the week being sure to reach day shift, night shift, and weekend staff. Educational material was provided during unit huddles as well as face-to-face discussion with staff members. Each unit made its own COVID-19 binder that included the education provided.

Other laboratory collection for patients with COVID-19 needed to be addressed since the process differed from isolated patients for non-COVID-19. Proper labeling and packaging were addressed as well as the technique to deliver the specimen.


  • Ensure that all infection prevention and control steps are followed including the following:
    1. Hand hygiene before and after the procedure and before and after the patient encounter.
    2. Follow isolation status of the patient and utilize appropriate PPE.
  • Tilt the patient's head back slightly and ask him or her to close his or her eyes, if possible.
  • Insert the flexible flocked swab into the nostril parallel to the palate until resistance is met by contact with the nasopharynx.
  • Leave swab in place for 2 to 3 seconds and then rotate completely around for 10 to 15 seconds.
  • Remove swab and repeat the same process in the other nostril with the same swab.
  • After the second swab is completed, immediately place into the sterile vial containing the universal transport media.
  • Apply the patient label following hospital policy.

Other laboratory collection for patients with COVID-19 needed to be addressed since the process differed from isolated patients for non-COVID-19. Proper labeling and packaging were addressed as well as the technique to deliver the specimen.

When sending specimens from an isolated room, perform the following steps:

  • Take appropriate laboratory collection supplies into the patient's room.
  • Once the specimen is obtained, label the tubes and place them in the biohazard bag—do not roll this bag up.
  • Place orange PUI (person under investigation) sticker on the outside of the specimen bag.
  • A second staff member should be gloved and outside the room with another biohazard bag.
  • The RN in isolation places the bagged specimens into the second biohazard bag being held by the staff member outside the room.
  • The second staff member secures the outer bag and the specimens are then walked to the laboratory as the specimens could not be sent through the pneumatic tube station.



Most recently, the American Thoracic Society led an international task force of clinicians from academic medical centers active in COVID-19 and strongly recommended that patients with refractory hypoxemia (defined as a Spo2 consistently less than 90%) be proned for at least 12 hours a day.2 The rationale for their decision was that patients with COVID-19 may develop viral pneumonia, which can progress to acute respiratory distress syndrome (ARDS) that is similar to other disease states for which the advantages of prone ventilation are well established. Prone positioning was first researched and recognized in the 1970s for its ability to improve oxygenation and gas exchange in patients with ARDS.9 Acute respiratory distress syndrome is a clinical diagnosis that has been associated with severe hypoxemia and high mortality rates. Research completed by Froese and Bryan9 confirmed their hypothesis that placing patients in a prone position would result in better expansion of the dorsal lung fields with consistent improvement in oxygenation in critically ill ventilated patients. For more than 45 years, prone positioning has been used as a rescue treatment for refractory hypoxemia. When placing patients in a prone position versus supine position, there is improved pulmonary perfusion to ventilation matching, a reduction in the pleural pressure gradients, and a more homogeneous aeration of the lungs. The outcome is often improved oxygenation, decreased severity of lung injury, and subsequently a mortality benefit.

Prone positioning for patients with ARDS has evidence-based support, and additional studies10,11 have demonstrated the effect of the prone positioning on improving the oxygenation of patients with ARDS and the effects on increasing patient survival.

The Proning Severe ARDS Patients (PROSEVA) trial completed in 2013 demonstrated a significant reduction in mortality in a subgroup of patients who were proned for at least 16 hours a day until there was sustained oxygenation improvement for at least 4 hours after the patient was returned to a supine position.10 A subsequent meta-analysis also made a persuasive case that prone positing in patients with severe ARDS early in their course improved survival.11 The 2017 joint clinical practice guidelines from the American Thoracic Society/the European Society of Intensive Care Medicine/the Society of Critical Care Medicine formed evidence-based strategies for patients with ARDS. One of their strong recommendations was that ventilated patients with moderate to severe ARDS should be proned for greater than 12 hours per day.12

Although prone positioning is primarily used in critically ill ventilated patients with hypoxemic respiratory failure, Scaravilli and colleagues13 studied the feasibility and efficacy of utilizing the prone position in 15 awake and spontaneously breathing patients with respiratory failure. They found that this was a safe practice and was associated with significant benefit on oxygenation. Recent experience from the Jiangsu Providence in China also showed impressive improvements in oxygenation when awake and nonventilated patients with coronavirus utilized the prone position.14

At the Network, an interdisciplinary team comprising pulmonary critical care medicine intensivists, intensive care unit nurse managers, advanced practice nurses, and the director of the professional practice department was established at the onset of the COVID-19 crisis to develop a policy for prone positioning. This group made the decision to use prone positioning as an early treatment option for critically ill patients with COVID-19. A policy was developed and implemented. Although both manual maneuvers and automated beds can be utilized to achieve the prone position, the team made the decision to use manual positioning as it was felt to be a safer option with less risk of aerosolized secretions. It was also the team's belief that there would not be sufficient automated beds to meet the possible threat of a “surge” of patients with COVID-19 presenting with respiratory difficulties who would require proning. Prior to this epidemic, the facility utilized automated beds for proning. Therefore, a robust education program was developed and implemented to instruct nurses on the policy and the technique of manually proning patients. This education also included proning on the nonventilated patient.


Objectives for the education included reviewing the newly developed policy, teaching proper techniques in manual proning of the ventilated patient, and reviewing proning of the nonventilated awake patient. This education was provided to nurses in all of the intensive care units.


A designated area was set up with a mannequin that was intubated and had central line, arterial line, and urinary catheter. Staff were required to schedule an education session, limiting the number of staff to 6. At least 1 education specialist was present along with one of the nurses who had been trained as a super user. There were 35 sessions and more than 200 participants. The session consisted of hands-on proning activity as well as verbal instruction. One goal was to ensure that sufficient staff were educated so that every shift would have a staff member who could lead other staff on proning technique. A tip sheet was provided to the staff as well (see Table 2).

Table 2. - Allegheny General Hospital, Pittsburgh, Pennsylvania: Prone Procedure Tip Sheet
Patients with severe ARDS as defined as a PF ratio ≤150 mm Hg with an Fio 2 > 0.6, PEEP > 5 cm H2O, and tidal volume of 4-6 mL/kg of ideal body weight.
  1. Gather supplies—flat sheets × 3-4, cardiac electrodes attached to second cable pillows × 3-6, other head support device such as the Z-flo Fluidized Positioner

  2. Turn off tube feedings

  3. Be sure that tubes are secured and positioned properly: ones located above the patient's waist, go up toward the head of the bed and ones below the waist, go down toward the foot of the bed

  4. IV poles need to be positioned on opposite side of the bed (IV fluid infusing in the right arm—pole goes on the left side—once proned, the arm and the IV pole will be on the left side) (if IV poles not outside the room)

  5. If tongue is protruding or swollen, you may need to insert bite block or oral airway (endotracheal tube may have built-in bite block)

  6. Empty collection bags (ileostomy, colostomy, Foley, etc)

  7. Remove Stat Lock for Foley and apply tape to secure Foley tubing—keep Foley at the bottom of the bed

  8. Change any dressings that are due to be changed prior to pronation therapy

  9. If the patient is on low air-loss surface, inflate it to the maximum level (to make turning easier)

  10. Assess the patient's level of paralysis, sedation, and pain, and medicate as necessary

  11. Apply Aquacel to areas of increased pressure: shoulders—large pads, elbows—medium pads, knees—small pads

  12. Apply ophthalmologic ointment

  13. Suction patient, if needed

  14. Have 1-L bag of IV fluids or sand bag in the room in case of cardiac arrest (used under the chest during CPR)

Gather team:
  1. Intensivist/fellow present (in or outside the room)

  2. Respiratory therapist at the head of bed

  3. At least 2 up to 3 (if possible) people on each side of the patient

Perform hand hygiene before entering the room
Don appropriate PPE
Turn the patient onto his or her side and place a flat sheet under the patient. While the patient is on his or her side, apply cardiac electrodes to the back. Next turn the patient to the opposite side and pull the flat sheet through. Then return the patient to his or her back.
Remove cardiac cable attached to chest electrodes and plug in cable attached to back electrodes
Remove electrodes from chest
Cover patients with flat sheet and remove their gown
Tuck arms to side and under hips—palms up
Avoid wrinkles in sheets
Place 1-2 pillows/pads at axillary line, ileac crest, and shins
Place flat sheet over pillows
Roll all 3 sheets toward the patient:
  1. Down and under on side of ventilator; over and up on side away from ventilator

Remove pillow from under head
Slide/lift patient to the side of the bed away from ventilator
Turn the patient on his or her side toward the ventilator
Hand off the rolled sheets to staff on opposite side of bed
Do not let go of sheets until person on the opposite side has hold with 1 hand
Turn patient onto stomach
Remove top sheet and make sure that the patient is in neutral position—if not, adjust the pillows
Assist respiratory therapist in getting the Z-flo Fluidized Positioner under the head by lifting up the shoulders
Always use a pillowcase over the positioner. You can easily mold a space to protect the ears and to create channels for medical devices such as the endotube. These are for single-patient use and should be cleaned with disinfecting wipes.
Place arms in swimmer's position. The arm closest to the ventilator tubing is placed up toward face; arm away from the ventilator is at the patient's side with palm up
Ensure that ears are not bent
Be sure that NG tube and ETT are not pressed against the mouth or the nose
Place pillow under shins to allow feet to float free from the bed
If the patient is on a low air-loss surface, adjust the inflation as appropriate
Place the patient in 30° reverse Trendelenburg position
After positioned prone:
  • Check position of tubes, drains, and lines to ensure that there are no kinks

  • Rotate head and arms at least every 4 h

  • Continue prone position for at least 16 h as deemed by the provider (unless there is an urgent or emergent condition listed later)

In case of cardiopulmonary arrest:
  1. If possible, turn the patient supine (to be done quickly but safely if possible)

  2. If not possible to turn supine, then CPR is performed in prone position

  3. Roll the patient to side and place IV bag or sand bag under the patient's sternum to providecounter pressure, roll back to prone, and place hands over the spine at the T7 level, whichis the border of the inferior scapula. Compressions can be performed in one of two handpositions: (1) two hands over the T7 level or (2) one hand on each side of the spine at the T7level.

  4. Use the same depth and rate (100-120 and 2”)

  5. Provide asynchronized ventilation every 6 s if advanced airway is in place

Turning supine:
  1. Roll sheets up to the patients' side: Down and under on opposite side of ventilator and up over on side of the ventilator

  2. On respiratory therapist's count, pull the patient to the side of the bed toward the ventilator

  3. On RT count, turn the patient on the side away from the ventilator, being sure to keep hands on rolled up sheet until the person on the other side grabs the rolled sheet

  4. On RT count, turn the patient back to supine position

  5. Place electrodes on chest, plug cable into monitor (unplugging other cable)

  6. Put gown back on the patient

  1. Check to be sure that all lines are secure and free from kinks

  2. Roll the patient on side to remove flat sheet from under the patient, and while the patient is on his or her side, remove the electrodes from the back (you may place lift sheet or pad under the patient). Roll the patient to remove flat sheet and pull through the lift sheet or pad.

  3. Leave the Z flow pillow under the patient's head (better protection from skin breakdown)

  • Unexplained extubation

  • ETT obstruction

  • Loss of vascular access (venous and arterial)

  • Facial and airway edema

  • Pressure ulcers

  • Hypotension

  • Arrhythmias

  • Cardiac arrest/death

Abbreviations: ARDS, acute respiratory distress syndrome; CPR, cardiopulmonary resuscitation; ETT, endotracheal tube; PEEP, positive end-expiratory pressure; PF, PaO2/FiO2; PPE, personal protective equipment; IV, intravenous; NG, nasogastric; RT, respiratory therapist.


To begin the sessions, the reason for proning was discussed so that the staff could better understand the rationale. Contraindications were reviewed. Questions were encouraged throughout the session. The number of staff and the supplies that were needed, the steps to take prior to proning the patient regarding lines and drains, and the need to pad bony areas of the patient were reviewed, and step-by-step directions were given on the safe proning of the patient with the staff engaging in the procedure. Instructions on techniques for cardiopulmonary resuscitation were reviewed. The participants were then given instructions on how to place patients back in the supine position. Then the positioning of awake patients was reviewed and tip sheets were given (see Table 3).

Table 3. - Allegheny General Hospital, Pittsburgh, Pennsylvania: Proning for the Awake Nonventilated Patient
  • Lying prone may improve the oxygen levels in the blood and possibly prevent the need for a ventilator

  • It is recommended that patients lay face down for as much of the day as they can tolerate

Inclusion criteria:
  • All confirmed/suspected COVID-19

Exclusion criteria:
  • Recent abdominal surgery requiring ongoing wound care (could potentially still lay on sides)

  • Pregnancy (could still lay on sides)

  • Spine fracture/limb fracture requiring hard brace

  • High aspiration risk

  • Patients in restraints

  • Encephalopathy: unable to follow simple commands

  • Have the patient lay prone on his or her abdomen for as long as possible

  • If unable to lay prone, rotate between L lateral decubitus and R lateral decubitus position every 4 h

  • If the patient needs position change, have the patient utilize lateral decubitus positions until able to lay prone again

  • Avoid lying supine between 6 am and 10 pm excluding meals (avoid lying down until 1 h after meals)

  • From 10 pm to 6 am encourage patient to sleep on abdomen/sides without scheduled turning

Document patient position in vitals flow sheet



During the COVID-19 crisis, attempts to reduce nursing and multidisciplinary health team members' exposure to airborne/droplet isolation rooms while also trying to conserve protective personal equipment become high priorities. Creative approaches were required to ensure that safe quality care continued to be provided. The Institute for Safe Medical Practices and the Infusion Nurses Society both cited multiple issues that might arise with consolidation of care especially with regard to externalization of intravenous (IV) pumps outside of patients' rooms.15–17 At the time of this publication, no evidence-based practice or research studies were completed on the consolidation of care due to the unprecedented nature of this pandemic.

Therefore, at the Network a multidisciplinary team was formed to establish guidelines for consolidating care of intensive care unit patients with both suspected and confirmed COVID-19. This team comprised intensive care unit physicians, intensive care nurse managers, advanced practice nurses, the director of the regulatory department, and pharmacists on the medication safety committee.


Objectives for the education included reviewing the room setup and design, presenting the challenges of externalization the IV pumps and poles outside of patients' rooms, communicating the process and documentation for meeting The Joint Commission patient safety goals for patient identification and double checks of high-alert medications, and discussing the proposed schedule for bundling of nursing care. This education was primarily provided to nurses who worked in the medical intensive care unit, which was designated as the COVID-19 Unit.


For this just in time learning, a tip sheet was developed. This information was reviewed as a timely topic during daily huddles and as mini face-to-face in-services. Pictures of the patient room setup design, externalization of IV pumps outside the room, IV extension tubing, and securement devices were obtained and also utilized when providing the education (see Figure 2).

Figure 2.
Figure 2.:
Consolidation of nursing care.


  • Room setup and design.
    • Intravenous pumps to be placed outside of the room.
    • Ventilator, PRISMA Continuous Renal Replacement Therapy Machine to be placed near the door so that the parameters could be easily seen through the glass.
  • Externalization of IV pumps/poles outside of the patient room.
    • Length of microbore extension tubing to be utilized, linking the extension sets and applying Curos caps.
    • Priming, labeling, and dating IV tubing (during the COVID-19 crisis, the network changed the frequency of tubing change from 96 hours to 7 days).
    • Fluid boluses to ensure that IV push medications reached the patient.
    • Possibility of titrations being delayed because of the length of the extension tubing.
    • Ensuring rate accuracy.
    • Tube securement to keep the tubing off of the floor to prevent contamination and also avoid a tripping hazard.
  • Patient identification.
    • Identification band placed on the patient's arm/leg.
    • An additional identification band placed on the patient's IV pole, ensuring that the patient's confidentiality was not compromised.
    • Two nurses assess and document that the information on the identification bands matches at the beginning of each shift and with the administration of high-alert medications requiring a cosignature (see Figure 2).
  • Consolidating nursing care.
    • Nurses enter the room routinely every 4 hours instead of the standard of care, which is every 2 hours for intensive care unit patients. (Because of regulatory standards, if the patient is in nonviolent restraints, the nurse must still assess and document restraints every 2 hours.)
    • During every 4-hour assessment, a physical examination of the patient; assessment of lines, tubes, and drains; and nursing standards of care would be performed (eg, mouth care, urethral catheter care, intake, and output). In addition, any physician orders and blood draws would be completed.
    • Shift report would occur outside of the room where the patient, IV pumps, and ventilator could easily be seen.



The COVID-19 pandemic has led to efforts for rapid investigation of medications, which may improve survival but for which there is little established safety and efficacy. Two of the medications that have been promoted as a treatment combination for patients with COVID-19 are hydroxychloroquine (HCQ) and azithromycin (AZM). However, a risk associated with each of these medications is a prolonged QT/QTc (corrected for heart rate) interval. A lengthening of this interval can cause polymorphic tachycardia (Torsades de pointes [TdP]) and sudden cardiac arrest in patient with or without a prolonged baseline/QTc interval.18

There are rare case reports of HCQ lengthening the QT interval and causing TdP when used to treat patients with lupus, and a recent case was reported in a patient diagnosed with COVID-19.18,19 The widely used antibiotic, AZM, has also been recognized as a rare cause of QT prolongation. The QT interval prolongation may be more common in critically ill patients with impaired renal and/or liver function, electrolyte abnormalities, and other medical conditions such as COVID-19. Therefore, continuous cardiac monitoring is required with repeated QT/QTc interval assessments with consideration of consequent withdrawal of the medication if the interval exceeds a present threshold.18

Both HCQ and AZM are on the Network treatment algorithm for patients with confirmed COVID-19. At the onset of the pandemic, the division of cardiology within the Network reached out to the department of nursing and professional practice to request that the intensive care and telemetry units' nurses and monitor technicians receive education on the importance of monitoring and documenting QT intervals for patients receiving HCQ and/or AZM.


Objectives for the education included discussing the risk of QT interval prolongation that is associated with HCQ and AZM and when to notify the physician, presenting the treatment plan for a patient who develops episodic or sustained TdP and reviewing the Network “Bedside and Telemetry Monitoring System” policy. This was a widespread education initiative as the information needed to reach intensive care unit and telemetry unit RNs and monitor technicians.


For this education, a tip sheet was developed for just in time training (see Table 4). The information was reviewed as a timely topic during daily huddles and as mini face-to-face in-services. This tip sheet was also sent out electronically as an announcement in the learning management system. The RNs and monitor technicians were asked to acknowledge that they read and reviewed the information. The nurse educators were able to track completion compliance and also could perform random audits to ensure that the QT interval was documented per policy.

Table 4. - Allegheny General Hospital, Pittsburgh, Pennsylvania: Measurement and Documentation of the QT Intervals
Hydroxychloroquine may be prescribed in the treatment of COVID-19. One of the complications is prolongation of the QT interval placing the patient at a risk to develop Torsades de pointes. A much higher risk for Torsades de pointes develops if the patient is also prescribed an additional medication that prolongs the QT.
Commonly prescribed examples include:
  • Azithromycin

  • Antipsychotics, eg, haloperidol (Haldol), ziprasidone (Geodon)

  • Propofol

  • ondansetron (Zofran)

  • Quinilone antibiotics (eg, Cipro, Levaquin)

Nursing Intervention:
According to our policy, interpretation of the patient's rhythm is completed every 12 h; change in condition and with change in caregiver.
Included in the documentation standard is the measurement of the QT interval.
  • Documentation is found in the cardiac complex assessment in electronic medical record:

    No Title

  • QT intervals are measured from the beginning of the QRS complex to the end of the T wave (see insert). Measure with e-calipers or manually.

    No Title

    Reference: QT interval-Wikipedia

  • Normal range ≤0.46 ms

  • Notify MD if the QT interval is longer than 0.46 ms and also inform MD of heart rate

  • As a result of prolongation, the medication may be discontinued or the dose decreased

  • In the event of

    • Episodic Torsades de pointes, notify physician

    • Sustained Torsades de pointes, call a COVID-19 code

      If wearing appropriate PPE, begin CPR and defibrillate (either with AED or manually if ACLS certified)

      • Patient will be treated with intravenous magnesium sulfate

Abbreviations: ACLS, advanced cardiac life support; AED, automatic external defibrillator; CPR, cardiopulmonary resuscitation; PPE, personal protective equipment.

A recent American College of Cardiology document on coronavirus suggested monitoring the QTc interval during treatment.5 This measurement is not a nursing standard. The clinical engineering department was able to set the central stations to automatically calculate the QTc interval, and it was the physician's responsibility to asses, monitor, and record this value. In the future, there may be exploration to see whether the QTc interval can be added to the nursing documentation in the electronic medical record. Applicable nursing education about the QTc interval would then be developed and implemented.


  • Recognize the medications that have the potential to cause a prolonged QT interval that may result in TdP.
  • Interpret and document the patient's rhythm, including time, lead, heart rate, PR interval, QRS duration, and QT interval in the electronic medical record every 12 hours, with change in patient's condition and with change in caregiver. A rhythm strip is also to be printed and placed in the chart at these times.
  • Measure the QT interval from the beginning of the QRS complex to the end of the T wave using manually or using e-calipers.
  • Notify the physician if the interval is longer than 0.46 seconds (heart rate also to be reported).
  • In the event of episodic TdP, notify the physician. If sustained TdP, call a COVID-19 code (see section “Mock Codes With Patients With COVID-19”) and be prepared to treat the patient with magnesium sulfate (see Table 4).



There were many challenges with educating staff on the specific needs of patients with COVID-19. As an institution, it became clear that there were many areas of needed education. The code and resuscitation committee recognized that due to this unique population, resuscitative procedures needed to be determined, standardized, and communicated across the institution. Many of the current resuscitative procedures such as chest compressions and intubation needed to be modified for patient and staff safety. Each step of resuscitation needed to be investigated and modified. A subset of the code and resuscitation committee took on the task of examining each step and modifying the processes from beginning to end starting with team arrival through transportation to higher level of care.

This became evident shortly after the institution began receiving rule out and positive COVID-19 patients. Within a day of receiving patients with COVID-19, a situation arose that left staff unclear on how to respond to a cardiac arrest or rapid response. For a code or rapid response on a COVID-19 rule out or positive patient, the goal was to prevent staff exposure to COVID-19 while avoiding patient care delays. Many times aerosolizing procedures such as chest compressions, intubation, or suctioning occur during a code or rapid response, which can expose staff to COVID-19 if not adequately protected. Staff needed direction on how to prevent exposure.


The code resuscitation response team realized that an institution-wide approach to emergency response processes should be taken to provide the best patient care and protect the staff members. The institution-based code and rapid response team set an objective to outline resuscitation procedures and put measures in place to optimize patient care and staff safety. In addition to the institution-specific objective, the group also shared the procedures system-wide to standardize emergency care practice. To achieve this objective, all members who participate in codes were involved in the development of these standards.


To set the institution and hospital system standards, representatives from all disciplines who responded to codes and rapid responses needed to be involved. Because of social distancing, a system-wide conference call was scheduled to discuss the standards and processes for COVID-19 resuscitation. This needed to be done in a timely manner and was set up within 1 day. From the meeting, several action items were determined such as developing a tip sheet that could be communicated to staff quickly with information that would be consistent throughout the hospital system to go through emergency procedures one by one on each unit (see Table 5). The emergency procedures that were reviewed were rapid responses and codes. To ensure the success of this educational endeavor, all levels of administration in all departments were informed of the action items and were asked to support the education. This support was communicated to all levels and departments from the chief operating officer of the hospital.

Table 5. - Allegheny General Hospital, Pittsburgh, Pennsylvania: Code/RRT/Stat Intubation in Patient With Known or Suspected COVID-19
  1. Staff call code/RRT/stat intubation. State to operator patient COVID-19 suspected or confirmed. If information is provided, the following information will display on pagers/devices

    1. Codes will be “Code 19”

    2. RRT will be “rapid response 19”

    3. Stat intubation will be “stat intubation 19”

  2. When arrive to code/RRT

    1. confirm code status with bedside nurse

    2. see whether the patient is in droplet/contact precautions or airborne-COVID-19 suspected/confirmed

      1. Droplet/contact—don PPE including gown, mask with face shield (or goggles), gloves, and eye protection

      2. airborne—don PPE including gown, face shield, or goggles, PAPR or N95, eye protection

  3. Team leader of code/RRT (hospitalist or PCCM) to limit number of people in room. People may remain outside the room and if additional help is needed, they can enter the room once they are garbed in PPE

    1. Code-in room—1 RIC nurse, 1 ICU nurse, 2 anesthesia personnel (1 CRNA, 1 anesthesiologist), 1 respiratory therapist, hospitalist, or PCCM leader. Resident (if present in room when code called) and 2 RN to do CPR (bedside nurse and 1 other floor nurse or resident in room and bedside RN). Nurse to take monitor into the room from the code cart

    2. RRT-in room—hospitalist, 1 RIC nurse, 1 respiratory therapist, bedside nurse

  4. Outside room

    1. Arrest cart (house, floor) N95 masks stocked on house arrest cart.

    2. Anesthesia bag

    3. Other ICU nurse to hand cart items and anesthesia items

    4. Documenter outside the room

    5. MHO to be the “outside team leader”

    6. Resident responders to remain outside the room

    7. Radiology and portable x-ray machine. If used, clean with Saniwipes

    8. ECG machine (to remain outside the room and if needed, ECG can be taken in and done by persons in the room). If used, clean with Saniwipes

  5. Care of patient as normal

    1. If patient needs intubated and not in ICU, call code blue. All personnel in room don N95 masks and close door

    2. If patient in droplet/contact arrests during an RRT, staff to change to airborne PPE

  6. Transfer patient (if needed) to higher level of care by utilizing elevator O (sign on door)

    1. Shut down hallway and close all doors—MHO to ensure that hallway is clear. If MHO is not available, a resident can ensure that this occurs.

    2. Health care personal to wear PPE during transport. Prior to transport, transporters change gown and gloves and keep same face protection unless visibly soiled

    3. If the patient moving from floor to MICU—MICU to take an MICU bed up to the room and transport the patient in an MICU bed

    4. If the patient is on nonrebreather, transport the patient through the hallway by covering mouth and nose with an ear loop mask (yellow mask).

    5. If the patient is on high-flow nasal cannula, change to nonrebreather and transport as above.

    6. If the patient is intubated, transport through hallway with an ear loop mask (yellow) covering the nose. Utilize portable ventilator to ventilate the patient (respiratory therapy to provide). Anesthesia and respiratory have a HEPA filter that can be attached to the AMBU bag, which can also be used.

    7. Do not transport the patient on BiPAP or Optiflow

    8. Contact Ext 5 EVS(ext 5387) after each elevator transport to clean elevator

    9. Unit secretary or floor personnel to contact EVS for room cleaning after the patient is transferred. Equipment can be left in the room to be cleaned by EVS or if removed, should be cleaned with Saniwipes.

  7. All personnel in the room must sign the personnel log outside room

Abbreviations: CPR, cardiopulmonary resuscitation; EVS, environmental services; HEPA, high efficiency particulate air; ICU, intensive care unit; MHO, Manager of Hospital Operations; MICU, medical intensive care unit; PAPR, positive airway pressure respirator; PCCM, pulmonary critical care medicine; PPE, personal protective equipment; RIC, resource intensive care nurse; RRT, rapid response team.


  • The emergency response group decided that the quickest way to get information out to staff was to develop a tip sheet that was standardized across the system since several groups of health care workers travel to multiple hospitals. A tip sheet was developed covering the actions to take prior to the response team arrival. The tip sheet pointed out very specific steps: (1) establish code status on team arrival, (2) PPE to wear, (3) resuscitation steps, (4) items that can and cannot be placed in the room, and (5) transportation of the patient to a higher level of care. This tip sheet was then disseminated to the system hospitals so that each institution could individualize as needed (see Table 5).
  • As the tip sheet was developed, it became clear that additional steps were needed to be taken to ensure that the emergency response was conducted to avoid unnecessary staff exposure and delays in patient care. The additional processes that were needed involved the operator calling the response and alerting the team of possible or definite COVID-19 diagnosis. Another process item involved communicating to ancillary departments that respond to codes and rapid responses the expectations and the cleaning processes posttransport. The process items needed to be decided and communicated to staff who would be responding to the emergency situation. The tip sheet was revised and was sent to nursing management for discussion during huddles and posted on the huddle board. The tip sheet was also disseminated to all departments in the hospital in the event that a code or RRT occurred in that area.
  • An institution-specific intervention that was suggested and implemented was the utilization of mock codes/rapid responses (RRT) on the units that were receiving the COVID-19 positive and rule out patients. Various team members were committed to providing this education. A team of intensivists, hospitalists, anesthesia personnel, residents, advance practice nurse, off shift nursing managers, and respiratory therapists convened to determine the best way to approach the mock codes. The group decided to conduct the first mock code/rapid response on a unit that currently had positive COVID-19 patients. Initially, the group had considered calling either a code or a rapid response and conducting the mock code as a real code situation. This would involve having all emergency response team members go into the room and conduct the code or rapid response. The team quickly realized that by doing this, staff were outside the room and could not hear what was occurring inside the room. For the next nursing unit, the mock code was held outside the room by discussing step-by-step each team member's role in the rapid response. The next situation that was discussed was rapid response that transitioned to a code. The hospitalist physicians lead the rapid response discussion since that group of physicians are the physician leads when a rapid response occurs. The next scenario to be discussed was a code. When the code scenario is discussed, the intensivists lead the discussion of the step-by-step process emphasizing each team member's role during the code response. The intensivist is the physician leader of a code response and so leads the scenario discussion. During the mock codes staff from any discipline could ask questions or offer suggestions of what process to follow. This also gave the team the opportunity to share ideas for practice. The discussion piece made the unit staff feel not threatened as no one felt that they were put “on the spot.”
  • Initially, the group had done mock codes on the units that were to receive the patients with COVID-19 but then realized that rule out COVID-19 cases were also being admitted to other areas of the hospital. The group expanded the focus of the mock codes to include every floor of the hospital and in most of the procedural areas. In total, the code rapid response group did 17 mock codes within 1 week. The nursing units with the most patients with COVID-19 had multiple mock codes to educate as many staff members as possible. The group continued to check on the units with many patients with COVID-19 to determine whether additional in-services were needed. The mock codes and rapid responses involved a commitment from multiple disciplines and departments. The hospitalist and critical care intensivist staff were very involved and at every mock response. Since the physician attendance was so important, this also caused service lines to adapt physician coverage so that the hospitalists and the intensivists could do the in-servicing. The anesthesia department also adjusted its coverage since anesthesia department was very active in participating with anesthesiologists and nurse anesthetists attending every mock response. The respiratory therapy department also adjusted coverage so that bedside therapists could attend every session. Nursing management was very involved and supported the mock responses, and in most cases, every staff member on the unit attended the mock codes and rapid responses including nurses, nurse aides, and unit secretaries. This became a multidisciplinary event where everyone felt very comfortable in asking questions and giving feedback.
  • There were some struggles during the process and changes did occur. Initially, the group struggled with distributing supplies of PPE and how to keep the staff safe. The group was able to keep its focus on emergency procedures while other education sessions covered donning and doffing PPE, fit testing, and prone positioning. The overall goal was to keep staff and patients safe. As the mock codes progressed, the emergency response group realized the need to revise the tip sheet again to include very specific items for the regular and telemetry units (see Table 6). Although additional mock codes were not done, the group did check in daily with staff to address questions and concerns and routed the concerns and needs to nursing and hospital management. A very difficult struggle that was encountered was the culture change of emergency response. The staff were accustomed to responding quickly to an emergency situation. In the COVID-19 code or rapid response, it was emphasized that staff had to be adequately protected prior to responding to the emergency. This was a very difficult concept for health care providers to accept and many discussions were held with staff members.
  • The staff were very receptive to the mock codes since the attendance was supported by the managers. The participation in mock codes in ancillary areas was overwhelming. The mock codes/rapid response sessions were not limited by time, so the staff were free to ask questions and discuss solutions. This experience demonstrated how to truly work as a team in order to get the work accomplished and make everyone feel that they were an equal part of the team. It really evolved into a team-building exercise where everyone understood the other's role.
Table 6. - Allegheny General Hospital, Pittsburgh, Pennsylvania: COVID-19 Code/RRT/Stat Intubation
What to do before code team arrives:
  1. Protect self—If someone is not in the room, 1 staff member with appropriate droplet precautions should enter the room

  2. Pull emergency cord from wall, if available

  3. Shout help is needed

  4. Call RRT/Code—Tell operator COVID-19 and location

  5. Another staff member—Bring code cart to the room/area and leave outside the room. Take monitor from top of the code cart and hand into the room. Person in room can apply pads and turn to AED mode and follow prompts. If ACLS-certified area, apply pads and follow ACLS guidelines

  6. Person in room can

    1. Apply nasal cannula and increase the oxygen and place AMBU bag and mask over face and turn up oxygen flow. Do not bag

    2. Can do CPR if airborne PPE is available. Do not do compressions without proper PPE equipment

    3. Set up suction. Do not suction the patient without airborne appropriate PPE equipment

    4. If the patient requires BiPAP, Optiflow, bagging, or oropharyngeal suction, apply airborne PPE

  7. If airborne precautions are available, another staff member should don gown, face shield or goggles, N95 or PAPR, and gloves and go into room. Other staff member can leave. Close door

  8. Limit personnel in room. Additional staff members to remain outside of room. If staff in room calls out for help, second person to put on protective gear and go in. Maximum 2 RNs in room

  9. Charge or supervisor (if not in room) act as “gatekeeper “outside of room until MHO arrives. Can be delegated to other floor personnel as needed. One attending in room (no residents), 1 respiratory therapist in room

  10. If RRT change to code—Staff to come out and put on airborne garb if not already garbed

  11. When code team arrives, follow next page.

Abbreviations: ACLS, advanced cardiac life support; AED, automatic external defibrillator; CPR, cardiopulmonary resuscitation; MHO, Manager of Hospital Operations; PPE, personal protective equipment; RRT, rapid response team.


The nursing educators, with assistance from the Lean quality coaches, developed a robust education program to train nurses on multiple COVID-19–related topics.

During the rapid implementation of the education, several strategies were used to meet the needs of the staff including face-to-face education sessions, easy-to-use tip sheets, announcements in the learning management system, a proning video production, and simulated mock codes. Feedback on the education indicated that it helped minimize the nurses' anxieties and added to their comfort and confidence levels during a time of crisis. In the future, the department of nursing practice and education will evaluate which components of the education will be added to orientation or will be a part of annual competencies for the nurses.


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COVID-19; nursing education; personal protection; resuscitation

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