key: cord-265666-27ckjl7w authors: Kang, Hee Sun; Son, Ye Dong; Chae, Sun‐Mi; Corte, Colleen title: Working experiences of nurses during the Middle East respiratory syndrome outbreak date: 2018-05-30 journal: Int J Nurs Pract DOI: 10.1111/ijn.12664 sha: doc_id: 265666 cord_uid: 27ckjl7w AIMS: To explore working experiences of nurses during Middle East respiratory syndrome outbreak. BACKGROUND: Since the first case of Middle East respiratory syndrome was reported on May 20, 2015 in South Korea, 186 people, including health care workers, were infected, and 36 died. DESIGN: A qualitative descriptive study. METHODS: Seven focus groups and 3 individual in‐depth interviews were conducted from August to December 2015. Content analysis was used. RESULTS: The following 4 major themes emerged: “experiencing burnout owing to the heavy workload,” “relying on personal protective equipment for safety,” “being busy with catching up with the new guidelines related to Middle East respiratory syndrome,” and “caring for suspected or infected patients with caution.” Participants experienced burnout because of the high volume of work and expressed safety concerns about being infected. Unclear and frequently changing guidelines were 1 of the common causes of confusion. Participants expressed that they need to be supported while caring for suspected or infected patients. CONCLUSION: This study showed that creating a supportive and safe work environment is essential by ensuring adequate nurse staffing, supplying best‐quality personal protective equipment, and improving communication to provide the quality of care during infection outbreak. information on the new guidelines and job-related information via text messages using smartphones was helpful for the nurses. • Creating a supportive work environment and providing adequate training for nurses is essential. The implications of this paper: • Nurse managers and hospital administrators should establish strategies to prevent nurses from burnout and to ensure their safety during the outbreak of infectious diseases. • Clear and consistent practice guidelines and effective communication methods among nurses should be developed. • Increasing awareness of health care workers about infectious diseases to enhance emergency preparedness is essential. with MERS on May 20, 2015, which was 9 days after his first visit (Lee & Ki, 2015; Yang et al., 2015) . A MERS outbreak in Korea was caused by hospital-to-hospital transmission because patients were moved to other hospitals without appropriate quarantine (Ki, 2015; Kim et al., 2016) . It was exacerbated by overcrowding in the emergency room, delayed diagnosis, and lack of self-protection (Balkhy, Perl, & Arabi, 2016; Xia, Zhang, Xue, Sun, & Jin, 2015) . As more and more MERS cases were reported, hospitals restricted the visitors and checked all visitors and employees for the presence of fever. Additionally, for the temporary screening of MERS-suspected cases, triage was set up to screen the infected or suspicious patients and to block the cross-transmission in and outside hospitals. Furthermore, the government adopted the National Safe Hospital Program to control MERS infections within hospitals (Korea Centers for Disease Control and Prevention, 2015 Along with high risk of being infected, studies reported that health care personnel experienced occupational risks, distress, and the fear of contacting and transmitting the disease during epidemics of H1N1, severe acute respiratory syndrome (SARS), and Ebola virus (Bukhari et al., 2016; Chou et al., 2010; Corley, Hammond, & Fraser, 2010; Koh, Hegney, & Drury, 2012; Speroni, Seibert, & Mallinson, 2015) . Nurses also reported positive experiences of becoming more confident, mature, and broad-minded while caring for SARS patients (Liu & Liehr, 2009) and positive feelings about their experience of caring for H1N1 patients (Honey & Wang, 2013) . However, few studies have been conducted on nurses' working experiences during the MERS outbreak. The aim of the study was to explore the working experiences of nurses during the MERS outbreak. Data were collected using 7 focus group interviews and 3 individual in-depth interviews from August to December 2015 until the data were saturated. Focus group questions were developed based on a literature review (Chou et al., 2010; Corley et al., 2010) . Each focus group was comprised of 2 to 5 participants. Individual in-depth interviews were conducted for those who were not able to meet in focus groups because of time conflicts. Prior to the interview, participants were informed about the reasons for doing this study and the goals of the study. The first author (HSK), who has experience with qualitative research, conducted the focus groups and the individual in-depth interviews. The focus group discussions and individual interviews were conducted in a private room at a site with convenient participant access. Each session lasted for 1 to 2 hours. No one was present besides the participants and the researchers during the interviews. A semistructured interview guide was used. We conducted a pilot test with 2 nurses caring for the patients with MERS and refined the interview questions. The following questions guided the interviews: • What are your working experiences of caring for suspected or infected patients with MERS during the outbreak? • What are the challenges of working during the MERS outbreak? To ensure consistency and accuracy of our data, interviews were audio-taped with the participants' permission and transcribed verbatim. The researchers made field notes during and right after the • It's so sweaty and hard to breathe with it. It is hard to work and see clearly while wearing it (protective measures) and I feel dizzy when wearing it for long hours. • (We were) sweating, (find it) hard to breathe; it was difficult to work wearing personal protective equipment. Being busy with catching up with the new guidelines for MERS Frequently changing guidelines • MERS guidelines kept changing. At first, (we were told to) do thing this way and this is the guideline. We needed time to understand and practice a new guideline; however, guidelines kept changing without considering our adjustment to a new one. • The most difficult thing was that protocols were changed daily. Working along with memorizing new protocols was very difficult. While workload increased, (we) were told this has been changed this way and that has been changed that way in shift change meetings. Sharing the new information • We promptly communicated and shared updated information among nurses within the unit, through Kakao Talk (a free mobile instant messaging application for smartphones with free texting). • We had a notice note summarized about new information on MERS. When changing shifts, we read the note and were also told what we have to be cautious because of what has been changed and it helped. It helped because we never had MERS before and didn't know how we have to send the specimens and did not know how to cope with it. It worked as basic guidelines. Lack of support • Why do you have to do it, and what if you are infected? Why? Why does it have to be you? • When the patients' condition was bad and when we were having a hard time, no one showed appreciation of our hard work. Identifying the best way to care for patients • After spending many days in the isolated room, we started using a messenger. We supported each other and shared information. It was very helpful for me to ask my colleagues when I was unsure about patient care. • We made a package for MERS patients, a package for MERS. At first, we brought water bottles to patients because they cannot come out a negative pressure room and we complained regarding this matter. Next thing, we agreed to make a package for the patients in the isolation room. When a patient comes, we give this package that has water, sleeper, and disposable products that patients need. (Continues) interviews to help understand the interviews. There were no repeat interviews carried out. The study was approved by the institutional review board (1041078-201506-HRSB-099-01). All participants were informed about the purpose of this study and participants' right to withdraw from the study at any time, without penalty. Confidentiality of participants was ensured, and written informed consent was obtained from each participant. The responses from the participants were analysed, using qualitative content analysis (Krueger & Casey, 2009 ). Data collection was conducted concurrently with data analysis and continued until no new information emerged from the responses. The researchers read each verbatim transcript several times to obtain an overall understanding of the content and to gain a sense of the whole. The meaning units (words, sentence, and paragraphs) in the interviews related to nurses' work experiences were identified and coded. The codes were sorted into similar things together and grouped into categories based on similarities and differences. After assessing themes across groups, overarching themes were derived. Two of the investigators independently coded each transcript. When discrepancies in coding occurred, the investigators discussed and resolved them by consensus. Trustworthiness of the study was maintained following criteria by Lincoln and Guba (1985) . The study participants included 25 female and 2 male nurses. Their mean age was 29.5 (4.7) years, ranging from 20 to 24 years, and their work experience ranged from 3 months to 17 years. The following 4 major themes emerged: "experiencing burnout owing to the heavy workload," "relying on personal protective equip- Participants reported discomfort in wearing PPE all day on duty. The amount of time of wearing PPE varied according to their work and the severity of the patients' condition. Participants said that they preferred a mask that led to less breathing difficulties. One participant said, "I prefer the mask made by A company because it has a space that helps me to breathe easily. Many nurses prefer to use it." The patterns of staying in the isolation room wearing a PAPR differed. Nurses from one hospital stated that they stayed in the isolation room for a maximum of 2 hours while wearing their PAPR and then came out; they stayed in the anteroom (a room in front of the negative pressure isolation room) and went back into the isolation room when needed. Contrary to this, nurses from another hospital stayed in the isolation room for their entire shift, except for the lunch hour. Meanwhile, nurses who wore a PAPR said that they felt like wearing a space suit. They had a backache from wearing heavy equipment. "I had put the battery of the PAPR on a side Participants communicated with others by writing on paper. They reported that it was easy to hear the intercom sound in the room, but it was difficult to talk back because the head shield of the PAPR blocked out sounds. Permission to use computers or smartphones in the isolation room varied across hospitals. In one hospital, nurses working in an isolated intensive unit communicated with other nurses in another isolated room using a smartphone messenger application. They said it helped them to know how others in isolation rooms were doing and to ask them when they were unsure about patient care. Participants said that they gradually returned to normal life. The hospitals rewarded working with MERS patients differently. These included participating in healing programs, receiving financial incentives, eating out in teams, or receiving several days off for resting. A participant said "I enjoyed participating in the healing camp. The post-trauma prevention education was also helpful. I was relieved to hear that we could seek psychiatric counselling if necessary." After completing their volunteered job with the MERS patients, participants stated that they had learned on site while caring for infected patients and that it was very rewarding and worthwhile. They expressed that they felt being matured and gained a lot of confidence from these experiences. Participants also said that when they returned to their work unit, they often heard "You did a good job" from their peers, and that "It felt supportive and healing." This study explored the nurses' work experience during the MERS outbreak. Our participants reported that their workload increased with time. This result indicates that, as part of emergency planning, nurse managers and hospital administrators should prepare for the extra workload during the emergency of an infection outbreak and to ensure quality of care. Participants reported that restricting unauthorized access of visitors was one of the main issues. Restricting visitors was one of the strategies used for controlling further outbreak during the Norovirus outbreak (Danial et al., 2016) . Visiting hospitalized patients in a group is a part of the Korean culture, as it is a way of expressing support and wishing for a quick recovery. Rather than just restricting the visitors, it would be helpful to suggest alternative ways of expressing support for patients, such as sending a message through a phone or social networking service. Participants expressed their concerns about the possibility of being infected. In fact, health care personnel who had close contact with MERS patients were at a high risk for infection (Alraddadi et al., 2016) . Previous studies support our results. During the MERS epidemic, health care workers felt fearful about being infected; however, they continued to work during the epidemic as it was their professional and ethical duty (Al-Dorzi et al., 2016; Khalid, Khalid, Qabajah, Barnard, & Qushmaq, 2016) . Emergency room nurses working during the outbreak of MERS also expressed high concerns about being infected, and that they would have like to avoid caring for patients with MERS if there was a choice (Choi & Kim, 2016) . These fears of nurses could be reduced by sharing the correct information about the quality of the protection devices they wear and appropriate ways to use them to prevent the transmission of infection (Speroni et al., 2015) . In addition, hospitals experiencing MERS epidemic suggested that institutional plans be made in advance to provide personal safety equipment when there is a rapid increase in its demand (Al-Dorzi et al., 2016; Stirling, Hatcher, & Harmston, 2017) . However, our participants mentioned discomfort in wearing PPE. Likewise, a study on a simulation exercise for health care workers wearing PPE in a hospital in the UK reported that they found the PPE uncomfortable, and even basic tasks took longer than usual while wearing it (Phin et al., 2009) . Thus, feedback from nurses on protection devices would help medical equipment companies design more comfortable medical protection equipment. Our participants complained of having to continuously catch up with the frequently updated guidelines. Likewise, it was reported that one of challenges for hospitals was the changing and conflicting guidelines and the overwhelming amount of information that required sifting through during the H1N1 influenza pandemic (Rebmann, 2010 Regarding going back to routines, our participants felt supported when they received positive responses from peers when they went back to their unit after taking care of patients at risk. Additionally, hospitals implemented various programs for health care professionals to reward or appreciate their hard work during the outbreak. The common response of participants on these was very positive. In a study, nurses who took care of H1N1 high-risk infected patients and who worked in an isolated area in Taiwan said that nurses needed counselling services (Honey & Wang, 2013) . After any outbreak, it may be important to offer a healing program for nurses, to help them share their experiences and feelings with others. A limitation of this study was that all participants were staff nurses. Further research is needed to explore the MERS experiences of patients, nurse managers, and other health care workers. Because of variations in nurses' work schedule, the focus groups were quite small. The disadvantage of a small group is that it limits generating a rich diversity in views and the total range of experiences, although the advantage of smaller groups is that they are easier to recruit and allow everyone to have a greater opportunity to share experiences. Another limitation was that this was a cross-sectional study. Longitudinal studies are needed to examine the impact of any changes in hospital regulations or policies on nursing care. These study results suggest that nurse managers and administrative personnel should understand that overload of nurses' work during the outbreak may lead them burned out, which may negatively affect quality of care to patients. Furthermore, establishing consistent and solid practice guidelines and efficiently disseminating them and training health care workers to deliver them could lead to less confusion during an infection outbreak. It is important to acknowledge nurses' work as valuable and to create a supportive environment in workplace of nurses. These efforts will empower nurses to work as an expert and will positively influence the quality of care. Finally, it is essential to raise awareness about infection control among health care workers and people in general to strengthen emergency preparedness. The critical care response to a hospital outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) infection: An observational study Risk factors for Middle East respiratory syndrome coronavirus infection among healthcare personnel Middle East respiratory syndrome coronavirus: Current situation and travel-associated concerns Preventing healthcareassociated transmission of the Middle East Respiratory Syndrome (MERS): Our Achilles heel Middle East respiratory syndrome: A new global threat Middle East respiratory syndrome coronavirus (MERS-CoV) outbreak perceptions of risk and stress evaluation in nurses Factors influencing emergency nurses' ethical problems during the outbreak of MERS-CoV Uniformed service nurses' experiences with the severe acute respiratory syndrome outbreak and response in Taiwan The experiences of health care workers employed in an Australian intensive care unit during the H1N1 Influenza pandemic of 2009: A phenomenological study Lessons learned from a prolonged and costly norovirus outbreak at a Scottish medicine of the elderly hospital: Case study New Zealand nurses perceptions of caring for patients with influenza A (H1N1) Healthcare workers emotions, perceived stressors and coping strategies during a MERS-CoV outbreak 2015 MERS outbreak in Korea: Hospital-to-hospital transmission The characteristics of Middle Eastern respiratory syndrome coronavirus transmission dynamics in South Korea Nurses' perceptions of risk from emerging respiratory infectious diseases: A Singapore study Middle East respiratory syndrome coronavirus outbreak in the Republic of Korea Focus groups: A practical guide for applied research Strengthening epidemiologic investigation of infectious diseases in Korea: Lessons from the Middle East Respiratory Syndrome outbreak Naturalistic inquiry Instructive messages from Chinese nurses' stories of caring for SARS patients Personal protective equipment in an influenza pandemic: A UK simulation exercise Pandemic preparedness: Implementation of infection prevention emergency plans Worry experienced during the 2015 Middle East Respiratory Syndrome (MERS) pandemic in Korea Nurses' perceptions on ebola care in the United States, part 2: A qualitative analysis Communicating the changing role of a nurse in an epidemic: The example of the MERS-CoV outbreak in Saudi Arabia Consolidated criteria for reporting qualitative research (COREQ): A 32-item checklist for interviews and focus groups Modeling the transmission of Middle East respirator syndrome corona virus in the Republic of Korea Middle East respiratory syndrome in 3 persons, South Korea Working experiences of nurses during the Middle East respiratory syndrome outbreak None. The authors declare no conflict of interest. All listed authors meet the authorship criteria and all authors are in agreement with the content of the manuscript. Sun-Mi Chae http://orcid.org/0000-0002-3010-2265