HEALTH CARE systems are going through unprecedented disruption following the coronavirus pandemic, straining under the volume of patients, and struggling with a lack of resources. The pandemic is increasing the need for team-based and person-centered care, infection control, and other skills that really address the strengths of nurses. We are in unknown territory, in response to the scale of the pandemic; it is a time of great stress and uncertainty, and nurses are rising through the challenge. Nurses in every role are impacted. They are being asked to work in areas of the hospital that are not their normal specialty. They are being redeployed to learn new skills, take new roles and taking care of critically ill patients. They are making triage plans operational. Our nurses continue to care with compassion, skill, and dignity. The fact that they come to work each day to provide nursing care to those in need has not changed, but the circumstances they provide that care in have changed significantly. Some of them have volunteered to be part of the core team that care for coronavirus disease-2019 (COVID-19) patients. Our hospital employs more than 60 head nurses, 1200 nurses, and roughly 500 support staff. Nurses have a strong vocation for clinical research and they are closely integrated with the university with the bachelor of science in nursing, postdegree certificates (clinical areas, management, and clinical research) and, starting this year, the master's degree in nursing and midwifery. The Chief of Nursing Staff Office is organized with 6 main areas related to nursing specialties: surgical, intensive care, and emergency area; medical areas; oncologic areas; operating rooms; outpatients and diagnostics; and maternal area. Each area is led by one nurse manager, cooperating with head nurses and staff of the different units. This kind of organization has proven to be extremely effective in the management of the emergency. The rapid change in the hospital's organizational structure to deal with the COVID-19 emergency has allowed us to face the situation by anticipating its critical issues. The creation of departments for the management of COVID-19 patients and the increase in intensive care beds have posed a challenge for nursing staff from different points of view.
In this article, we explore the experiences faced following the COVID-19 outbreak and analyze take-home messages at organizational, clinical, and interpersonal level.
PREPARING STAFF AND COORDINATING A RESPONSE
One big concern was the necessity to create nursing teams in short time, recruiting staff from outside the hospital and from other areas within the hospital. In the first case, an important effort was made to recruit and select resources with an acceleration on all the required procedures, so as to have a minimum time between interview and hiring. An example of acceleration is the time between the signing of the contract and the beginning of the work. During the pandemic, the nurse started working the same day of the signing of the contract. In this way, there were no critical issues related to staff shortages. The recruitment procedures involved job posting through recruitment agencies, professional journals, and nursing registry, consultation of past job applications in the hospital database.
The reallocation of resources from other areas of the hospital went hand in hand with the progressive reduction of ordinary and contextual opening of COVID-19 units. Nursing managers had to support professionals during this transition. The situation has been complex due to a lack time for reorganization, the need for reallocation of wards and areas, and certain degree of uncertainty between professionals. Operating room nursing staff have been selected to work in intensive care units (ICUs), given their expertise with patients on invasive ventilation; they joined nursing staff already present in ICUs, redeployed to a greater number of wards. The number of ICU beds has in fact gone from 33 to 67 within a month. In nonintensive COVID-19 departments, nursing staff was increased in number so to guarantee a nurse/patient ratio of 1 to 6, given the characteristics of these patients, often with noninvasive ventilation. The inflow of patients with COVID-19 symptoms required more health care providers than usual, due to the high fraction of hospitalized COVID-19 patients requiring critical care and the time-consuming regimen of donning and working in personal protective equipment (PPE). The acuity of the patient linked to the total absence of family members has increased the time that the nurse has dedicated to the individual patient, even just for simple social interaction. A total of 13 head nurses, 475 nurses, and 140 support staff were redeployed. During the months of March and April 2020, 60 nurses and 18 support workers were hired. In order to deal with the management of an extremely heterogeneous group of staff, it was decided to manage the selection of resources for the opening operating units and the planning of their shifts directly in the Chief of Nursing Staff Office, so to give head nurses time for organizing in-ward activities and mentoring of the staff assigned to them. The sudden opening of highly complex wards required an effort to find resources and medical equipment (in particular ventilators, monitors, and infusion pumps), which took place thanks to the simultaneous closure of ordinary wards. From the onset, differentiated pathways were defined between positive and non-COVID-19 patients within the hospital, to ensure the safety of staff and other patients. We set dedicated elevators for patients, clean and dirty staff, and accurate segregation of contaminated material; routes from COVID-19 departments to diagnostics or from the emergency department to other wards have been defined in detail. Communication in emergency situations is a critical issue that has also been addressed in this case with a centralization in the governance of the activities, integrating the Chief of Nursing Staff Office into the coordination group created at central level. The multidisciplinary integration of all staff has been achieved in the operating units dedicated to COVID-19 patients: doctors (belonging to different specialties), nurses, physiotherapists, support staff, and technicians.
Safety is an enormous concern, as hospitals face occasional shortages of PPE. Infection prevention is a top priority of any caregiver at all times. An event like this is a strong reminder of the constant, high-level attention necessary throughout the entire day, to keep patients and colleagues safe. Something as simple as pushing an elevator button makes you stop and think about the number of people coming and going within the hospital on a daily basis. Protecting staff, as well as being an ethical duty for health care providers, is also essential to prevent reductions in skilled staff due to illness when they are needed more than ever.1 Shortness of PPE impacted Italian national health system and as a consequence, also our hospital. At the beginning of the outbreak, health care providers were frightened and information from international institutions was scarce. The response was a clear communication about PPE real availability and the education about their proper utilization, hand hygiene, ward disinfection, waste management, and sterilization of patient care devices.
A training course about the appropriate use of PPE, in collaboration with the Scientific Direction of the University, was realized and then made available for all Italian nurses, thanks to the collaboration with the Federazione Nazionale Ordini Professioni Infermieristiche—FNOPI. Stocking and distribution of PPE was closely monitored. Maintaining high level of protection during time was one of the challenges for head nurses of COVID-19 units, because fatigue and lack of confidence tend to lower the level of attention. Head nurses have been working to support staff to increase the level of confidence. Some strategies have been implemented, such as coaching during donning and doffing procedures, provision of different kinds of PPE (face masks, goggles) to allow the staff to choose the most comfortable one. Through their work, head nurses have emerged as positive models toward the staff.
ORGANIZATION OF CARE
Setting “crisis care” standards, rather than “usual care” ones, helps to shift from patient-centered care to community-centered care. This could be very frustrating in particular for expert nurses with high competence level, used to ensure the very best nursing care to patients. The organization provided a mix of qualified and less qualified staff, while providing training to the latter and maintaining an adequate level of care. A constant and open communication with the clinicians led to map the competencies of all the nursing staff, to set safe and realistic crisis care standards and to modulate staff mix and education interventions. Nonexpert nurses have been trained to upgrade their competencies, to obtain a skilled staff, not knowing real characteristics and extension over time of the pandemic. Among the competencies, nontechnical skills are the first to detect in crisis situation, such as a pandemic. In critical care areas, situation awareness, decision-making, leadership, communication, teamwork, and coping with stress and fatigue are considered as important as scientific knowledge. Situation awareness, for example, including gathering information, comprehension, and anticipation, was a fundamental skill we worked on, to improve nursing care in new ICU staff. One difficulty was the great variety of background experiences of the members of the new nursing staffs. In one of the new ICUs dedicated to COVID-19 patients for example, we have nurses from the operating theater, neonatal ICU, neurology ward, hematology unit, neurosurgery, emergency medical team, urology, and vascular surgery unit. Online educational sessions, posters with flowcharts and algorithms about common procedures were realized to standardize the nursing practice of the teams and shared between similar units. Training on the job was carried out by expert nurses and head nurses.
A healthy work environment is the target for every institution in every time, but in crisis situation it becomes mandatory. Health care workers were frightened, concerned, and tired, conditions that can be the substrate of clinical mistakes and adverse events. They need a comfortable environment to work in, with organized breaks, food, and drink available to restore and manage physical needs. The right management of the communication led to limit confusion and misunderstanding in information exchanges. Head nurses have to, better than ever, stay tuned to the staff, listening and looking for stress alarm bells. New staffs often were composed by nurses not confident with suffering, pain, end-of-life care, and death, such as operating theater nurses. On the other hand, expert nurses felt the responsibility of caring for patients with characteristics they have never seen and at the same time to lead novice colleagues. They are all at high risk of posttraumatic stress disorder. Frequently, they told about sleep disturbs with night awakenings and nightmares. A psychologist was present 24/7 for online or telephone support. The team often made up the place of outburst, of sharing emotions like fear or frustration, the place to understand that you are not alone and you are not the only one suffering. Listening, talking, and teaching them risks and strategies to face high level of stress is a never-ending work. We need to encourage staff to speak up when they are facing experiences that are distressing them, care situations or ethical concerns. Even in a well-staffed hospital with a supportive professional environment, aspects of COVID-19 disease confront health care providers with unique risks and emotional strain. Because the virus is highly contagious, health care providers face constant worry for themselves and their family members of contracting the virus. The visitor restrictions in hospital make the health care providers the only people available to offer emotional support and comfort to all hospitalized patients during their illness and, for those who do not survive, while dying. The spread of COVID-19 has revealed excellent collaboration and integration between nurses, especially those from different operating units. The creation of a team composed by experts and novices helped the consolidation of teamwork, improving outcomes on patients. Most of the expert staff involved has shown great willingness and enthusiasm especially in the training of novices, thus reinforcing the sense of belonging to the profession and the institution.
Head nurses played a pivotal role and, despite a firm and decisive style, were really able to welcome and support new staff in a situation of uncertainty. All head nurses, even those not directly involved in the implementation of COVID-19 units, participated directly, helping colleagues to open new wards as well as suggesting nurses with a relevant profile who could be deployed in COVID-19 areas, a distinctive sign of a deep knowledge of the nursing workforce.
Distancing measures required of COVID-19 are posing unique challenges to care. Family members cannot visit. Routine interactions have to be set aside, and comfort given from a distance. That is the hardest—not to have the connection in the hospital, not to bring families in. Nurses are making many efforts to connect patients with loved ones through technology, even if it is as simple as a phone call. The current circumstances have led to innovative uses of technology to assist with communication. Tablets and other devices are being used to reduce the number of times caregivers need to enter individual patient rooms. This not only reduces the risk of exposure and transmission of the virus, it also helps conserve PPE, so that we always have it available when needed. Technology is also being used to help patients connect with the family and loved ones during this time of restricted visitation.
Physical and social distancing are the main mitigation strategies used to reduce transmission in the COVID-19 pandemic. The organization of care has provided for a limitation of family presence for all patients to protect the health of patients, family members, and workers.2 The limitations of the hospital visit policy do not allow caregivers to be close to their loved ones, with the risk of leaving them without any form of representation and advocacy.3,4 Many studies have shown that communication between health care professionals, patients, and families has been identified as one of the most valued aspects of care.5,6 Receiving honest, understandable, and timely information is among the main concerns of patients' families.3,5,6 The physical presence of family members at the patient's bedside promotes trust, support, comfort, proximity, reassurance, communication, involvement in care, and decision-making.3 Two essential ways of contact are between the family and the patients and between the family and the clinical team.4
The coronavirus pandemic is already radically changing human relationships and how they are manifest in health care. Health care professionals are alone, without the support of family members, which means that communication between nurses, physicians, and patients is much more difficult, exacerbated by all the protective clothing and equipment they have to wear.4,6 Patients also need to communicate and know what happens to their families who are outside the hospital. Despite this situation, the aims of patient care remain the same and are focused on facilitating respect for the role of family members as care partners, collaboration between family members and the health care team, and maintenance of family integrity. However, new ways of communication need to be redefined.6 Health professionals are faced with new communication tasks that no one has ever faced before, having to deal with the worst news imaginable in some cases.6 The clinical team should aim to establish a primary contact with the family, document the technologies available to the patient and family for communication, and identify and mitigate any barriers to communication engagement. Communication with families should occur daily, unless otherwise requested, using strategies to support family presence during physical distance.4,6
Every possible means available could be used to facilitate communication: blackboards, post-it notes, sheets of paper, cards, smartphones, tablets, and computers. Video conferencing is preferable to phone calls because it improves emotional connection through facial expressions and nonverbal communication. Using a checklist could be a support and guide for the professional during the call (Figure).4 It provides support during the conduction, standardizes the conversation, and ensures information.4,6 At a time when families can only hear by phone a voice that often gives them bad news, the opportunity to “meet” health professionals who care for their loved ones seems to be an opportunity to give something more. This requires the team's integration skills and provides family members with complete information about their loved ones. The time dedicated to the family for communication, involving the patient as well, guarantees excellent care and allows the exchange of information and the sharing of the care path. The information must be prepared in advance and the way in which it is communicated must be taken care of. This suggests for operators the need to prepare and dedicate time, and it also requires greater synergy and integration between professionals. This seems to be better cared for now than before the pandemic. Health professionals are required to have the skills of flexibility, integration, and problem-solving. Tackling barriers to facilitate better communication in this time of emergency is a priority area to improve patient safety and promote optimal interaction and patient satisfaction. In the future it is recommended to study and explore the use of all possible means—be it special protective devices for relatives or the availability of improved audio-video communication devices available for all hospitalized patients.
Nursing research demonstrates that care settings that value professional nursing knowledge and skill achieve better patient outcomes.7,8 In these settings, nurses are expected and supported to fully utilize their knowledge and skill, to coordinate care within the health care team, including physicians, respiratory therapists, assistive personnel, and to be partners in planning for disaster response. A key institutional metric is the staffing level of nurses. The research evidence is consistent that better staffed hospitals achieve superior patient outcomes.7,8 Multiple, rigorous studies have documented lower patient mortality in hospitals with better educated nurses. Therefore, hospitals can best prepare for a pandemic-related surge by establishing safe staffing levels, professional environments, and high educational expectations for their nurses.
Research is one of the most important aspects for health care professionals, as they build their daily practice on it, but at the same time it is the last aspect taken into consideration in emergency time. It is hard to try to spend time thinking “outside the box” and talk with expert researchers, who could help us in shaping the most useful research protocols. Clinicians and researchers must create an alliance to best manage the amount of available data and translate them into information to better care for patients. During the emergency period we perceived the importance of the research but we were not able to define study protocols because of time. We would like to investigate the perception of the professionals satisfaction with reorganization of care, the patient satisfaction for the care received, and the family satisfaction for the information received. Unfortunately, we did not have time to measure all. Many researchers in our university hospital dedicated time to the study of the COVID-19 in order to identify treatments for our patients. We had the opportunity toward the end of the pandemic to begin a study of the moral distress perceived by health care professionals during the pandemic. We hope this will be a small contribution to return to our colleagues.
At the moment, we are getting back to a situation of cautious normality, with 3 main lessons learned. First of all, we had a positive feedback on the outstanding level our nurses reached at organizational, clinical, and interpersonal level. The integration between hospital, university, and research has proven to be a distinctive feature for nurses in our institution too. As stated at the beginning, the coordination of nursing activities at central level, in close cooperation with the management of the hospital, has been really effective in achieving positive results and relevant outcomes. Finally, our patients and their families have changed their view on nursing care, as this pandemic has shown the whole country the value of nurses performing care.9 As stated by Dr Tedros Adhanom Ghebreyesus, World Health Organization Director General, presenting the latest state of the world's nursing 202010: “Nurses are the backbone of any health system. Today, many nurses find themselves on the frontline in the battle against COVID-19. This report is a stark reminder of the unique role they play, and a wakeup call to ensure they get the support they need to keep the world healthy.”
1. Bagnasco A, Zanini M, Hayter M, Catania G, Sasso L. COVID 19—a message from Italy to the global nursing community. J Adv Nurs. 2020;76(9):2212–2214. doi:10.1111/jan.14407.
2. Lewnard JA, Lo NC. Scientific and ethical basis for social-distancing interventions against COVID-19. Lancet Infect Dis. 2020;20(6):631–633. doi:10.1016/S1473-3099(20)30190-0.
3. Bowman BA, Back AL, Esch AE, Marshall N. Crisis symptom management and patient communication protocols are important tools for all clinicians responding to COVID-19. J Pain Symptom Manage. 2020;60(2):e98–e100. doi:10.1016/j.jpainsymman.2020.03.028.
4. Negro A, Mucci M, Beccaria P, et al. Introducing the video call to facilitate the communication between health care providers and families of patients in the intensive care unit during COVID-19 pandemia. Intensive Crit Care Nurs. 2020;60:102893. doi:10.1016/j.iccn.2020.102893.
5. Kleinpell RM. Improving communication in the ICU. Heart Lung. 2014;43(2):87. doi:10.1016/j.hrtlng.2014.01.008.
6. Mistraletti G, Gristina G, Mascarin S, et al. How to communicate with families living in complete isolation [published online ahead of print October 15, 2020]. BMJ Support Palliat Care. doi:10.1136/bmjspcare-2020-002633.
7. Aiken LH, Cimiotti JP, Sloane DM, Smith HL, Flynn L, Neff DF. Effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments. Med Care. 2011;49(12):1047–1053. doi:10.1097/MLR.0b013e3182330b6e.
8. Lake ET, Sanders J, Duan R, Riman KA, Schoenauer KM, Chen Y. A meta-analysis of the associations between the nurse work environment in hospitals and 4 sets of outcomes. Med Care. 2019;57(5):353–361. doi:10.1097/MLR.0000000000001109.
9. Manara DF, Giannetta N, Villa G. Violence versus gratitude: courses of recognition in caring situations. Nurs Philos. 2020;21(3):e12312. doi:10.1111/nup.12312
10. World Health Organization. State of the World's Nursing 2020: Investing in Education, Jobs and Leadership. Geneva, Switzerland: World Health Organization; 2020.