key: cord-288022-xh10ccki authors: wu, dongmei; jiang, chunyan; he, changjiu; li, chao; yang, lei; yue, yuchuan title: stressors of nurses in psychiatric hospitals during the covid-19 outbreak date: 2020-04-14 journal: psychiatry res doi: 10.1016/j.psychres.2020.112956 sha: doc_id: 288022 cord_uid: xh10ccki nan in early february 2020, novel coronavirus infection occurred in the wuhan mental health center, and a total of about 80 patients and medical staff were diagnosed. this was the first novel coronavirus epidemic in psychiatric hospitals in china. as of february 18, 2020, novel coronavirus pneumonia was diagnosed in 323 patients with severe mental disorders, covering 17 provinces in the country (china, 2020) . the epidemic makes it hard for psychiatric nurses to work. through phenomenological research, 18 psychiatric nurses were interviewed. the male to female ratio of the study subjects was 6:12, whose age ranges from 25 to 54 years old. in addition, most of them have married and possessed their own family. furthermore, their lever of nursing education ranges from junior college degree to graduate degree. the majority of nurses have a bachelor's degree. the average years of nursing in psychiatric hospitals are 14.5 years. they are equipped with extensive clinical experiences. the participants worked in a psychiatric hospital with more than 1200 inpatients during the covid-19 outbreak located in chengdu city, sichuan province, in the west of china. five stressors were identified from the interview data. first, higher exposure risks than peers in general hospitals. to begin with, the patients often lived in crowded wards. in addition, although general clinics were closed, 3 to 5 psychiatric patients with severe symptoms, especially aggressive behaviors, were admitted from the emergency room every day. most of them could not provide accurate epidemiological histories under the symptoms. moreover, patients also had various risk behaviors to the medical staff, such as tearing safety goggles and masks of medical staff, and even spitting to them. second, inadequate preparedness for the outbreak. psychiatric nurses tended to lack knowledge about coping with infectious diseases (zhu et al., 2020) . they had to process large volumes of information in a short time, such as covid-19 prevalence, viral pathogens, symptoms and signs of patients, protection level. the lack of contingency plans for public health emergencies in the psychiatric hospital also brought big challenges to nurses' daily work. third, conflict with the original professional value. during the outbreak, some psychiatric nurses suddenly found that they were not as good as a novice nurse who worked in the respiratory department or icu. "i have been working in the psychiatric hospital for 14 years, but recently i feel so sorry for being a psychiatry nurse. when i saw those nurses working in the front line of anti epidemic in wuhan on tv, i began to blame myself for not being a nurse in the respiratory department or icu. " fourth, the role conflict between family and work. traditional chinese families usually live together with three generations. adults are responsible for the care of elderly parents and young children (liu et al., 2020) . during the outbreak, the daily care of the elderly parents, especially with various chronic diseases, become a major problem. in addition, due to the full suspension of school, nurses also needed to provide homework tutoring after work for their own children receiving online school education at home. nurses were struggling with these responsibilities. nurses were also worried about themselves to be carriers of new coronavirus, causing cross infection between patients and family members. finally, the delay of personal life and career planning. due to the epidemic, nurses had to postpone their original personal life plans, such as marriage, childbirth, or traveling abroad. the original plan to go abroad for vocational training or further study also fell apart. the results of the study could draw the world's attention to the stressors of psychiatric nurses during the covid-19outbreak, help solve their problems and reduce the turnover of psychiatric nurses during the outbreak and afterwards. the authors declare that they have no conflicting interests. psychiatric hospitals should better care for mental patients during novel coronavirus outbreak family structure and competing demands from aging parents and adult children among middle-aged people in china the risk and prevention of novel coronavirus pneumonia infections among inpatients in psychiatric hospitals key: cord-272431-miqovio9 authors: maughan, erin d.; bergren, martha dewey title: school nursing data collection during covid-19 date: 2020-09-24 journal: nasn sch nurse doi: 10.1177/1942602x20960214 sha: doc_id: 272431 cord_uid: miqovio9 covid-19 has affected the 2020-2021 school year for everyone and thrust school nurses into the spotlight. some school nurses are too overwhelmed to even think about data; others want to collect data differently to illustrate the value of the role of the school nurse. this article provides guidance on data collection during this unique time period. the article is based on a blog originally posted on national association of school nurses’s website. c oronavirus disease 2019 has put the health of students front and center and has thrust school nurses into the spotlight. school nurses are challenged and asked to accept responsibilities on a scale never before expected (mcdonald, 2020) . as schools scramble to put physical distancing in place, and other learning going virtual, many school nurses ask if they should bother collecting data. other school nurses realize the need to collect different data to reflect the escalation in the level of care. these school nurses see an opportunity to put the valuable role of school nurses into a brighter spotlight. this article provides insight into practical data points that school nurses can collect to reflect their contributions during covid-19. documentation and data collection are fundamental practices of school nurses (american nurses association [ana] & national association of school nurses [nasn] , 2017) and are practice components in nasn's framework for 21st century school nursing practice in the principle of quality improvement (nasn, 2020) . documentation provides proof of school nurses contributions to student health (nicholson & johnson, 2020) . data collection reveals trends and is the basis of evidence-based school nursing practice (lepkowski, 2018) . pre-covid-19, researchers found that a school nurse can save principals 13 hours per week (baisch et al, 2011) ; and school nurses can spend over an hour on one call with concerned parents (bergren, 2016) . how much more time would a school nurse save principals and teachers now? data would tell us; data from frontline school nurses. never let a crisis go to waste! it is often when things are turned upside down that innovation and new habits are generated. if you have not collected data before, this is the year to start. begin with one key activity or data point (hinkle & maughan, 2020 if you already collect data, you may want to think about the novel activities you will be doing this year (especially if they are different than in past years). remember to focus on data points that illustrate critical thinking and skills only a school nurse can do. examples may include the following: whatever data point you decide to collect, set up a system to streamline the data collection process so that accurate data is collected (hinkle & maughan, 2020) . this could be on a tracking form you create on paper, or ideally using an electronic health record (lepkowski, 2018) . document in real time and keep accurate records. guesstimates or inaccurate data are not helpful and actually hurts school nurses' credibility (bergren, 2016; guthrie, 2019) . be sure to share your data at the end of the school year (wysocki & maughan, 2019) . when presenting your data, provide context so that educators understand the coordination and nursing skills used in these activities. in other words, be sure they understand the school nurse's contribution so that they cannot say, "well, a secretary could make phone calls." what process or outcomes are different because the school nurses made the calls? this new school year brings a lot of unknowns that increases stress. during crises we often get overwhelmed because our glass is overflowing already. covid is that crisis. yet it is during a crisis that we are forced to identify the most critical activities we must perform. we create a mind shift that expands the understanding of our own potential. with so much shifting to a "new normal" let us make 2020-2021 the year of the school nurse (to coincide with 2020 being the year of the nurse). let us make 2020-2021 the year school nurses shift to the new normal and put data front and center.■ erin d. maughan https://orcid .org/0000-0002-0176-1499 scope and standards of practice: school nursing evidence-based research on the value of school nurses in an urban school system feasibility of collecting school nurse data data fidelity: building credible reports collecting data: where do i start? unlocking data collection: practical tips for school nurses reopening schools in the time of pandemic: look to the school nurses framework for 21st century school nursing practice tm : clarifications and updated definitions uniform data points unlocking the power of school nursing documentation using data to tell your school health story key: cord-260687-xa3iy187 authors: santillan-garcia, azucena; zaforteza-lallemand, concha; castro-sanchez, enrique title: nurses as political knowledge brokers, opportunities for growth in the spanish context date: 2020-06-16 journal: int j nurs stud doi: 10.1016/j.ijnurstu.2020.103690 sha: doc_id: 260687 cord_uid: xa3iy187 nan nurses as political knowledge brokers, opportunities for growth in the spanish context azucena santillan-garcia. university hospital of burgos (spain) orcid: 0000-0002-7376-4170 concha zaforteza-lallemand. regional hospital of inca (spain) orcid: 0000-0002-5211-2245 enrique castro-sanchez. city, university of london (uk) orcid: 0000-0002-3351-9496 azucena santillan-garcia ebevidencia@gmail.com we have seen with interest the paper by tsay et al (2020) recently published in the journal. the authors concluded that nursing leaders in taiwan have worked collectively with the executive branch to ensure a good coordination among government agencies and the health service, including robust lobbying measures to ensure an adequate supply of personal protective equipment and quickly mobilise human and capital resources. the authors do not comment on the participation in taiwan of nurses and nursing leaders in expert and advisory committees, and we wonder whether there are parallelisms with the covid-19 health crisis and response in spain, where nursing has barely been included in relevant strategy documents, and nurses largely absent from such expert and advisory committees. further, we are concerned that the prominence of such "expert-based" policymaking may accentuate the invisibility of nurses at that level. in view of the dearth of scientific evidence surrounding many novel coronavirus-related topics, a reliance on government-appointed sages to effectively decide on behalf of the executive branch about healthcare and public health measures with profound societal impact may be acceptable at times like these. however, a similar process has hardly if ever been often followed on longstanding nursing-related topics with direct impact on patient and population health, such as nurse staffing ratios (castro-sánchez & santillán-garcía, 2020) or advanced nursing practice roles, with plenty of supporting safety, efficacy and economic evidence (laurant et al., 2018) . such dichotomy may well reflect the influence and role that ideology, think-tanks and lobbies may play within routine policymaking, a process not conducted in a vacuum. nurses should then recognise that solely underpinning their professional claims with such discourse of scientific evidence would be insufficient to reach such goals unless it is flanked by strategies to broker the evidence to decision and policy-makers. some potential approaches may include tailored briefing notes (kilpatrick et al., 2015) , or the counsel of parliamentary offices of science and technology (santillán-garcía et al., 2020). but even those mechanisms would also need to be supported by tailored communication, and more crucially, diplomacy and negotiation. arguably, policy-making by expert consensus can be useful, but public policies which are not informed by the nursing perspective of societal issues and the nursing expertise to enable solutions to address such ailments may ill-serve the public good. on the other hand, the chronic absence of nurses from decision-making and, specifically, political fora (wilson et al., 2020) suggests that for them to be seen as valuable peers, they will have to evaluate their existing narratives (lunardi et al., 2006) , construct robust collective perspectives about current health and care affairs, and embrace the policy forming process (salvage & white, 2019) . precisely, other authors have highlighted already the dearth of effective senior nursing leaders in the covid-19 response (daly et al, 2020) , and the tensions stemming from focusing mostly on the acute need to safeguard strategic education, research, scholarship and practice positions, overlooking leadership in politics and public policy. some incentives to foster the interest of current and future nurses in this area may include improved undergraduate education, as well as competitive research funding calls on nursing policy activism and optimal approaches for involvement in the political arena. more contemporarily, the nightingale challenge could recognise policy engagement and political advocacy as relevant and useful competencies to gain and master. to sum up, as soon as spanish nurses see themselves as knowledge-brokers in the health policy and politics arenas, build their strengths and skills in these áreas and, more importantly, work together to have a unique voice in the decision-making environments, then citizens will have an opportunity to benefit from the health improvements afforded by the nursing gaze. the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. smart lobbying for minimum nurse staffing ratios in spain: not just numbers. policy, politics, & nursing practice who speaks for nursing? covid-19 highlighting gaps in leadership the development of evidence briefs to transfer knowledge about advanced practice nursing roles to providers, policymakers and administrators nurses as substitutes for doctors in primary care ¿es ética la sumisión de las enfermeras? una reflexión acerca de la anorexia de poder nursing leadership and health policy: everybody's business #cienciaenelparlamento: the need for a parliamentary office of science and technology advice nursing's response to covid-19: lessons learned from sars in taiwan determining if nurses are involved in political action or politics: a scoping literature review key: cord-009406-lgmq43or authors: valdez, anna title: thank you date: 2020-04-11 journal: teach learn nurs doi: 10.1016/j.teln.2020.04.001 sha: doc_id: 9406 cord_uid: lgmq43or nan when the world health organization (2020) announced that 2020 would be the year of the nurse and midwife, i imagined a year of celebration, recognition, and reflecting on the past while reimagining the future. i never considered that nurses and our health care colleagues would be leading the nation to control, contain, and manage a global pandemic. i never imagined that i would be witnessing an international health crisis where my colleagues will be facing significant personal risk. as i reflected on how to approach this editorial, i found myself coming back to the same thoughts à sincere and heartfelt gratitude. i have never been prouder to be a nurse. each day, as this pandemic evolves, i find myself overwhelmed with a combination of thankfulness and fear. i am guessing that i am not alone. i am proud and grateful for the exemplary work that nurses are doing to provide safe, quality care under dire circumstances. i am in awe of the innovation and tenacity that my colleagues demonstrate each day. and i am worried about the safety of nurses, student nurses, and other members of the health care team. the covid-19 pandemic has profoundly impacted nurses and student nurses. faculty in nursing schools are struggling to maintain effective educational opportunities for nursing students, while also complying with physical distancing requirements and limited access to clinical experiences (goldberg, 2020) . as i write this editorial, the full impact that this pandemic will have on nursing faculty and students is unclear. in part, this is because the regulatory standards for nursing education vary from state to state. one example of inconsistencies noted is the amount of simulation allowed for clinical instruction. the national council of state boards of nursing [ncsbn] (2020) has maintained a list of state responses to covid-19 explaining the changes that impact current and future nurses. some states have been proactive about issuing waivers to allow students to continue to learn, while other states have not addressed existing regulations (ncsbn, 2020) . state variations in the handling of this crisis have resulted in confusion and frustration for many nursing faculty and students. yet, despite these challenges, i have seen tremendous commitment and resilience among nurse educators and nursing students. as a practicing faculty member, i have worked tirelessly beside other educators to redesign curricula, develop teaching strategies that align with physical distancing requirements, and find innovative methods for providing a safe and feasible education for students. i have seen students pivot and respond to rapid change with flexibility and a "cando" attitude. the professionalism and resolve i have observed with nurse educators, nurses, and nursing students is inspiring. i have also seen nurses and other health care professionals on the frontline, providing care without adequate equipment and protection. i am in awe of their courage and selflessness. i also worry about them and hope they get the support and resources they need soon. at this moment, i recognize that nurse solidarity is both necessary and critical. nursing is political, and nurses must directly influence health care policy and practice. we must be well represented by professional nursing organizations and use our collective voice to advocate for our patients, ourselves, our students, and our colleagues. at times like this, i am grateful that i belong to professional nursing organizations that speak for me, like the organization for associate degree nursing and the emergency nurses association. nurses must be united to protect each other and our patients. i hope by the time this editorial is in print that i will be able to sleep at night without worrying if my colleagues and students are safe. i have faith that nurses will continue to lead the world through this crisis. in closing, i want to say thank you to all nurses and health care professionals. i am deeply grateful to the nurses who suit up and care for patients knowing they may develop covid-19 as a result of their dedicated work. i am grateful for the nurse leaders who are advocating for their teams. i am thankful for the nurse educators who are doing their best to keep their students on track and provide quality education. i appreciate the professional organizations that consolidate credible information for nurses and advocate for nurses at local, state, national, and international levels. i am also grateful to the future nurses who are steadying themselves to provide care while making tremendous personal sacrifices to continue their education. finally, i am thankful for the radical solidarity that will lead us through this pandemic. i am confident that we will rise above this crisis because i know the strength, passion, and determination of nurses. thank you, from the depth of my heart, for everything you are doing and will continue to do for humanity. i stand in solidarity with you. national council of state boards of nursing on behalf of organization for associate degree nursing jid: teln [m5gus; april 18, 2020; 5:08] please cite this article as: a. valdez, thank you, teaching and learning in nursing (2020), https://doi.org/10.1016/j.teln.2020.04.001teaching and learning in nursing 000 (2020) 1 teaching and learning in nursing journal homepage: www.journals.elsevier.com/ teaching-and-learning-in-nursing key: cord-274388-hk2103ir authors: russell, naila title: america needs nurse practitioners to advocate for social justice date: 2020-07-25 journal: j nurse pract doi: 10.1016/j.nurpra.2020.06.024 sha: doc_id: 274388 cord_uid: hk2103ir the era of covid-19 has highlighted disparities within the health care system. the pandemic, in combination with the death of george floyd, has resulted in professional organizations condemning racism as a public health issue. but what is the role of individual nurse practitioners in addressing systemic racism within the healthcare system? the code of ethics for nurses requires that all nurses actively work to reduce disparities. the code states that universal access to nursing is a human right and that health must be considered in the frame of social determinants. america needs nurse practitioners to reimagine the healthcare system and to develop policy and legislation that results in change. nurse practitioners are among the most trusted professionals in america, and we can help the country heal from centuries-old injustices. america needs nurse practitioners to advocate for social justice naila russell as the nation reels from covid-19, the pandemic has laid bare racial disparities within the health care system. in a world where nothing is the samedand everyone is at risk of a novel virusdemotions are heightened. people of color have reached a breaking point and the death of george floyd reinvigorated calls for reform. perhaps this was the perfect storm that america needed to say "yes, black lives matter." i have heard colleagues ask whether nurses are doing enough. some who have spent a lifetime fighting against racial injustice are cautiously optimistic. this time seems differentda historically diverse group of americans is demanding change. health care professionals are kneeling in solidarity and professional organizations are issuing statements on implicit bias and health. as our country reckons with centuries of systemic racism, i find myself giving consideration to how our profession should best respond. yes, our professional organizations have issued statements, 1 boldly labeling racism a public health issue. but is issuing statements enough? what is our obligation as individuals to combat the systemic racism that has infiltrated the healthcare system and created generational inequities? the issue of social justice is detailed in the code of ethics for nurses. 2 this ethical code provides a framework for social justice that all nurse practitioners should be following. according to the code of ethics for nurses, we have an obligation to advance health and human rights and to reduce disparities. despite our ethical mandate, many nurses are not prepared for or willing to have conversations related to social justice. in an attempt to start the conversation, i asked a group of dnp students these same questionsdmainly what is the obligation of nurse practitioners to address systemic racism in healthcare? the issue of racism in american has become so politically charged, their instinct was to shy away. they indicated a belief that patients do not want providers to be politically active, and therefore it is best to remain silent as an individual. most were supportive of professional organizations making statements condemning racism and calling for an end to disparities. beyond this, they were unsure how nurse practitioners should react. they surmised that the position of nurse practitioners in the united states is precarious. ultimately, they voiced a fear that we cannot risk our standing by becoming involved in controversial issues. others lamented the power differential between nurses and physicians, believing that this imbalance in power would make it difficult for nurse practitioners to lead on issues of racial injustice. nurse practitioners may feel powerless, but if marginalized citizens can find the strength to demand change, so can we. we can draw inspiration to imagine change from the words of the marginalized. those who despite unequal opportunity persisted in advocating for change. people like civil rights leader angela davis who stated that she "learned … to live in an imagined new world and to recognise that things would not always be as they were." 3 nurse practitioners can envision a new worldda new health care systemdwhere race does not dictate access to care, morbidity, or mortality. but we must do more than imagine change. we must collaborate to address barriers and engage in open discussion. to advance change, we must go beyond issuing statements. we must propose solutions and implement the changes that we wish to see in society. nurse practitioners already have guidance on how to effect change. provision 8 of the code of ethics 2 calls for nurses to lead on issues of public health and to collaborate to change unjust structures. in addressing the context of health, the code tells us to consider social determinantsdbecause where people live, work, play, and worship has a lasting impact on health. nurse practitioners should be serving on local, state, and federal commissions that draft policy and legislation. we can help connect the dots between seemingly disconnected issues such as public education or housing and urban development and health. the world health organization reminds us that we must interject health in all policies. 4 our code of ethics deems access to nursing a human right; thus, we must advocate for universal health care. we cannot rely on a system that is mainly employer-based when the structure of employment in the united states disproportionately favors some over others. i believe that nurse practitioners should be leading the charge on dismantling policies that reinforce disparities. this is no time to remain silent; even if we feel less powerful than other professions, silence is akin to complicity. we are among the nation's largest number of healthcare professionalsdamerica's most trusted profession. our practice model is based on caring, and america needs providers that can empathize now more than ever. the nation is in need of healing. who better to provide that healing than nurses and nurse practitioners? the journal for nurse practitioners j o u r n a l h o m e p a g e : w w w . n p j o u r n a l . o r g racism is a public health issues in need of decisive action american nurses association. code of ethics for nurses with interpretive statements we knew that the role of the police was to protect white supremacy world health organization. health in all policies: framework for country action she is a fellow of the harvard media and medicine program / the journal for nurse practitioners xxx (xxxx) xxx key: cord-033769-kvi5k51d authors: valdez, anna title: a call to action for 2021 date: 2020-10-15 journal: teach learn nurs doi: 10.1016/j.teln.2020.10.001 sha: doc_id: 33769 cord_uid: kvi5k51d nan a call to action for 2021 in april 2020, i wrote an editorial about nursing leadership in the year of the nurse and midwife. in my editorial, i described nurses who have historically made significant contributions to healthcare. i provided numerous examples of nurses, like mary seacole and lillian wald. they led with a social mission to serve people where they were and provide compassionate care despite challenging and, at times, adverse conditions. for mary seacole, that meant traveling to crimea. for lillian wald, that meant providing community-based home health care (valdez, 2020) . both nurse leaders were called to action and met that call. when i wrote my editorial, i imagined a year of celebration and recognition of exemplary nurses. instead, a global pandemic altered the way that humans work, learn, and interact. there was no time or space for celebration. nurses were called to action to provide care, education, and public health leadership under dire circumstances. covid-19 laid bare some inconvenient truths about america. we were unprepared to respond to a pandemic of this scale. nurses and health care professionals worked and continue to provide care without adequate personal protective equipment (american nurses association, 2020). hospitals were overwhelmed, and the poorly funded public health system struggled to respond. there was a lack of clarity on the plan to address covid-19, and testing, contact tracing, and preventative measures were stalled, resulting in over 200,000 deaths by october 2020 (john hopkins university & medicine, 2020). covid-19 also highlighted stark disparities in health outcomes with black, indigenous, and hispanic people dying at markedly higher rates than white people in the united states (hooper et al., 2020; boyd et al., 2020) . these disparities, often resulting from racism and injustice, have existed for centuries (abbasi, 2020; hardeman & karbeah, 2020) . this is not new information. health disparities have been researched and reported on for decades, with little action being taken to address the root causes, including racism and the resulting impact on social determinants of health (egede & walker, 2020; hardeman & karbeah, 2020) . as i write this editorial, the covid-19 pandemic is not the only public health crisis being experienced by americans. racism and xenophobia have significantly impacted the health and wellness of black, indigenous, and people of color in the united states, resulting in adverse social determinants of health and health outcomes. in 2020, americans watched on television and social media as numerous black americans, including george floyd, breonna taylor, elijah mcclain, and other named and unnamed humans, were murdered in their homes and neighborhoods. america also witnessed immigrant families being separated and housed in inhumane conditions during a global pandemic, which placed them at increased risk of acquiring covid-19. many people in america experienced a racial justice awakening in 2020. americans of all backgrounds were in the streets protesting and demanding a just and equitable society. americans also experienced the impact of climate change in 2020. personally, i had to evacuate my home yet again due to unprecedented wildfires this year. temperatures have been at record highs in my area of the world, which is likely to continue to worsen over time resulting in significant climate-related health issues, including fires, floods, air pollution, and temperature extremes (centers for disease control and prevention, 2020). as i reflect on humanity's hardship in the last year, i am reminded that nurses can and should play an essential role in "nursing the nation" (mclemore, 2019) and promoting global health and wellness. in the october special issue on diversity, inclusion, and health equity of teaching and learning in nursing, gravens and goldfarb (2020) wrote about reaffirming our commitment to a nursing social mission. this call to action was aligned with the organization of associate degree nursing focus on advancing a social mission in nursing including social determinants of health. with this in mind, i am calling my nurse colleagues to action. we must act now to address the inequities in society, health, and education in the united states. i hope that the nurse educators who are reading this editorial will commit to learning about and integrating public health issues, social determinants of health, social justice, and racism in their curricula and teaching. to be effective educators and leaders, we must first make a commitment to increasing our understanding of the social and racial injustices that continue to have a profound impact on the health of americans. my friend and nurse educator colleague, patrick mcmurray (cited by the nursing theory collective, 2020), recently stated that "nursing is an act of justice." i agree and believe that nurses are being called to action to denounce injustice and create equitable futures. as you approach this new year, i encourage you to reflect on how you will demonstrate that nursing is an act of justice in 2021. nursing has an opportunity to lead us through the public health crises we are facing in humanity. i hope that 2021 will be the new year of nurse and midwife as we collectively demonstrate that we can act in solidarity to nurse the nation. taking a closer look at covid-19, health inequities, and racism new survey findings from 21k us nurses: ppe shortages persist, re-use practices on the rise amid covid-19 pandemic on behalf of organization for associate degree nursing on racism: a new standard for publishing on racial disparities climate effects on health structural racism, social risk factors, and covid-19-a dangerous convergence for black americans social mission in nursing: reaffirming our roots examining racism in health services research: a disciplinary selfàcritique covid-19 united states cases by county nurses unite. the country needs us to be bold so we can nurse the nation diversity, equity, inclusion, justice, and the future of nursing theory: a webinar of disciplinary reflection leading change in the international year of the nurse and midwife. teaching and learning in nursing key: cord-031741-758rzzi5 authors: abdollahimohammad, abdolghani; firouzkouhi, mohammadreza title: future perspectives of nurses with covid 19 date: 2020-09-10 journal: j patient exp doi: 10.1177/2374373520952626 sha: doc_id: 31741 cord_uid: 758rzzi5 nan in late december 2019, a series of unexplained cases of pneumonia were reported in wuhan, china. the government and health researchers in china have taken swift steps to control the spread of the epidemic and have launched an etiological study. on january 21, 2020, the world health organization (who) temporarily named the new virus as the new coronavirus-2019. on january 30, 2020, the who announced the 2019 coronavirus new epidemic as a public health emergency with international concern. on february 11, 2020, who officially named corona virus disease-2019 (covid-19) a disease caused by coronavirus (1, 2) . the number of affected people in the world is increasing and the death toll is high; no definitive medicine or vaccine has been developed for the virus yet (3) . besides, the virus genome has changed and its symptoms are different at times. the symptoms were mostly focused on respiratory systems at the beginning of pandemic and recently on gastrointestinal ones. therefore, prevention is the key to protection. nurses are the most vulnerable group of medical staff who care for patients with covid-19. they are at the frontline of the covid-19 pandemic. nurses are exposed to the virus and encounter various physical and mental complications, even death. there are 3.8 million nurses in the united states and 20 million in other parts of the world, and yet there is a need for many more nurses (4, 5) . there are many aspects of covid-19 that impact nurses. they have to provide direct care for patients for a long time. thus, the shortage of nurses, long working hours, boarding houses, remoteness from their families, burnout, posttraumatic stress disorder (ptsd), risk of disease transmission, and death take a toll. in this article, we discuss the efforts needed to improve conditions for nurses who care for covid-19 patients. during this pandemic, nurses are susceptible to catch the disease because of shortages of prevention measures in many health care settings. health care providers care for enormous numbers of patients in spite of current and future harm to themselves. however, given the information about nurses' vulnerabilities, including their infection with the virus, and even the deaths of nurses from different countries, national and global measures to protect nurses' safety do not exist. in addition, assuming that it is unavoidable due to the nature of the nursing profession, there is a necessity to identify the extent of the problems and gaps as well as the need to invest in this area. in particular, given the necessity and importance of nursing care in pandemics, natural and man-made crises require investment and interdisciplinary research to better understand the meaning of harm prevention in vulnerable work environments. it will also provide key mechanisms for improving the safety of nurses and increasing the quality of care in difficult working conditions to meet the expectations of governments and the public. long-term fear and anxiety caused by treating covid-19 patients predispose nurses to ptsd. trauma is defined by the american psychological association as the emotional response someone has to an extremely negative event (6) . as mentioned, nurses are on the frontline of patient care and are, thus, exposed directly or indirectly to negative events such as the care of patients infected with a deadly disease. following the exposure to such sudden traumatic events, nurses can experience symptoms such as headache, indigestion, stomach upset, tremors in hands, insomnia, nightmare, feeling of unreality, and forgetfulness. it is when the symptoms remain and last for months or years and interfere with the functioning of daily living, the individual can develop ptsd (7) . nurses working in clinical settings, typically the emergency room or intensive care units (icus) experience mental trauma, with 8.5% of them developing ptsd due to the frequent mental stress or physical symptoms associated with the care of patients with horrific injuries. nurses in icus are more likely to experience ptsd and mental disorders such as depression due to caring critically ill patients (8) . in such cases, it is necessary for nurses to be better supported and for nursing managers to plan shifts so that nurses rotate in and out of caring for pandemic patients. burnout, a complication caused by difficult working conditions, is another effect of pandemics on nurses. burnout is experienced by people who lack the psychological and physical resources to meet the demands and expectations of their jobs. it is defined as personal reactions to chronic emotional stress in numerous direct or indirect interactions among nurses (9) . burnout has become a major concern for nurses in the epidemic because they are physically and mentally exhausted to the point where it impairs their thinking and clinical decision-making as health care providers. burnout can also have a significant effect on patient care, increased mortality, and patient dissatisfaction. nurses may lose their licenses to practice because of burnout even during the postpandemic era (10) . nursing managers should periodically rotate nurses' shifts to prevent burnout on them. psychological counseling and using motivational factors such as encouragement and appreciation for their work should be provided for nurses so that they can better adapt to the situation. researchers are trying to find a way to protect nurses and their work environment in order to prevent burnout. the narratives, which address nurses' work concerns in the covid-19 pandemic, are thought-provoking and require the support of countries' health care systems to better protect nurses from the dangers that threaten them. a new coronavirus associated with human respiratory disease in china a pneumonia outbreak associated with a new coronavirus of probable bat origin the possible covid-19 treatments researchers are excited about clinical data on hospital environmental hygiene monitoring and medical staff protection during the coronavirus disease 2019 outbreak. medrxiv how to face the novel coronavirus infection during the 2019-2020 epidemic: the experience of sichuan provincial people's hospital understanding the early support needs of survivors of traumatic events: the example of severe injury survivors unintended consequences of changing the definition of posttraumatic stress disorder in dsm-5: critique and call for action designing a resilience program for critical care nurses nursing work environment, turnover intention, job burnout, and quality of care: the moderating role of job satisfaction a comparison of burnout frequency among oncology physicians and nurses working on the front lines and usual wards during the covid-19 epidemic in wuhan the authors appreciate the participants for sharing their experiences. the author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. the author(s) received no financial support for the research, authorship, and/or publication of this article. mohammadreza firouzkouhi, phd https://orcid.org/0000-0002-5122-195x all authors have made a substantial contribution to this manuscript and prepared the manuscript's contents mutually. mohammadreza firouzkouhi is an associate professor in nursing education and working in the field of nursing. his mainly focuses on qualitative research in patients' experiences related to disease.abdolghani abdollahimohammad is an associate professor in nursing education. he has experience in applying qualitative and quantitative research. key: cord-259029-5qoxk2ym authors: park, claire su‐yeon title: thinking “outside the box” date: 2017-05-08 journal: j adv nurs doi: 10.1111/jan.13312 sha: doc_id: 259029 cord_uid: 5qoxk2ym nan thinking "outside the box" much evidence supports that having more nurses leads to better patient outcomes. however, why is nurse staffing still lacking in practice? previous studies on the nursing workforce have, so far, focused on determining "more nurses and better patient outcomes." however, a controversial debate on the cost-effectiveness of hiring more nurses still continues (aiken, cimiotti, sloane, smith, flynn, & neff, 2011) . when it comes to nursing workforce policy-materializing in practice, the inconclusiveness of nursing efficiency is considered to be one of the critical reasons for the failure to narrow the gap between the ideal and the real. how can we fix this two-sided coin? the bottleneck is impeding us from moving forward from a "volume-driven" to "valuedriven" healthcare delivery system. there is no more time for delay. we need to rethink this issue from a different angle. to improve both the "efficiency" and "quality" of care, relentless and sustained small-scale changes by multidisciplinary team-led care delivery redesign operations are necessary to make a real difference (bohmer, 2016) . such changes can transform the healthcare delivery system to be more value-driven, justifiable and more effective. it is particularly critical that such operations build upon evidence-based, informed shared decision-making rationales among all parties comprising our healthcare delivery system. however, these rationales are absent from the current literature. knowledge without a foundation in science might lead to muddled policy-making. a typical example is the korean ministry of health & welfare's "comprehensive nursing care services (korean-cncs)," which refers to integrated nursing care services provided by professional nursing personnel only, without caregivers or carers. in korea, there is a tradition that family member(s) or a hired carer(s) stays with the patient while he or she is in the hospital. however, it was discovered that the practice made effective and efficient infection control impossible. the care tradition was one of the reasons behind the 38 fatalities (a lethality rate of 20.4%) caused by the middle east respiratory syndrome coronavirus in 2015 (kim, 2015) , whereupon the inception of the korean-cncs began to emerge as the key solution. the korean-cncs first looked to satisfy everyone. hospitals can use government grants to hire more nurses and provide better qualitative care including infection control. caregivers can also lessen the burden of time as well as the physical and emotional stresses from exhaustive caring. in addition, caregivers can benefit from an insured caring cost from the korean national health insurance corporation. however, surprisingly, in february 2017, the korean government retracted the original plan to expand the korean-cncs to the whole country by 2018 (shin, 2017) . why? the number of nurses per 1,000 inhabitants in 2014 was 5.6 for korea, which was about half the average of countries in the organization for economic cooperation and development (oecd) and even less than one-third of switzerland's 17.6 (oecd 2017a). korea already has a significant shortage of nurses in practice; and what is worse, the korean-cncs seems to make nurses' working conditions more difficult. four of five new nurses left their jobs because of the much heavier workloads caused by the korean-cncs (chae, 2016) . in fact, the majority of newly hired nursing staff hold temporary positions (kim, 2016) . furthermore, the korean-cncs caused inequity in access to healthcare when urban hospitals absorbed the nurse staffing of local hospitals to get more government grants, which eventually led to the closure of the only emergency center in a certain rural area (kim, 2017 ). bohmer's (2016) report shows that financial incentives actually did not lead to real change. increasing the quota of nursing school entrants was also fruitless in meeting the demand of nurse staffing in practice (shin, 2017) . ironically, in 2014 korea produced the most nursing graduates per 100,000 inhabitants among all oecd countries, and even more than three times that of the uk (122 vs. 29) (oecd 2017b). a special law on the health workforce with strict regulations is now expected to be re-proposed to ensure patient safety (seo, 2016) . however, will it be the best way to secure a sufficient nursing workforce to actually sustain the policy? the critical reason for this bottleneck is our failure to "think out of the box"-or to realize that "there is no box." the crux of the matter resides in the lack of a scientific body of knowledge on the optimum level of nurse staffing-specifically, the number of nurses, nursing care hours or the composition of nurse staffing-to satisfy all three parties: i.e., nurses, patients and hospitals (or stakeholders). that is to say, the realizable solution is not situated in traditional statistics-based nursing research, but in synthesizing decision science and incorporating mathematical economics and operations research into nursing science (park, 2017) . the multidisciplinary consilience can provide feasible solution(s)-not simply right answer(s)-to the important and yet unanswered question: i.e., balancing quality, cost and nurse staffing in the continuum of changes for better nursing workforce practice and policy-making (park, 2017) . a shift in approach and thinking is the only way to solve the problems we face today. the fourth industrial revolution heralds the burgeoning demand for artificial intelligence-driven: (1) decisionmaking support programming; and (2) future forecasting systems in all related areas, which can enhance the quality of decision-making in the future world of entropy (park & glenn, 2017) . this thoughtprovoking transition urges us to think "outside the box" toward incorporating a synthesis of technology and mathematical modeling into research, practice and policy-making. as the saying goes: "there is nothing that is a more certain sign of insanity than to do the same thing over and over and expect the results to be different." this is also in line with what hamming (1986) said at the bell communications research colloquium seminar: "what happens to the old fellows is that they get a technique going; they keep on using it. they were marching in that direction which was right then, but the world changes. there's the new direction; but the old fellows are still marching in their former direction. you need to get into a new field to get new viewpoints' (pp. 14). silera, leeb, & beroc (2014) and lamont (2009) those who don't become committed seldom produce outstanding, first-class work (kaiser, 1986, pp. 5) . center for econometric optimization in the nursing workforce, seoul, korea email: clairesuyeonpark@gmail.com effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments the hard work of health care transformation nurses leaving hospitals: insufficient nurses in facilities in spite of expanding 'no longer caregivers' services. hankookilbo richard hamming's 'you and your research 190 days to end the middle east respiratory syndrome coronavirus the korean-cncs aggravated temporary nurse staffing. the segye times the shortage of nurses in local hospitals how professors think: inside the curious world of academic judgment nurses (indicator) nursing graduates (indicator) optimizing staffing, quality and cost in home healthcare nursing: theory synthesis the millennium project: world future report 2055 special law on the health workforce in korea is expected to be re-proposed failure to secure sufficient nursing workforce: 8% of all hospital beds are available for the korean-cncs, risking equity in access to healthcare measuring the effectiveness of scientific gatekeeping key: cord-349412-n9bt1zpc authors: rosser, elizabeth; westcott, liz; ali, parveen a.; bosanquet, joanne; castro‐sanchez, enrique; dewing, jan; mccormack, brendan; merrell, joy; witham, gary title: the need for visible nursing leadership during covid‐19 date: 2020-07-07 journal: j nurs scholarsh doi: 10.1111/jnu.12587 sha: doc_id: 349412 cord_uid: n9bt1zpc nan the need for visible nursing leadership during 2020 was welcomed as the year of the nurse and midwife (world health organization [who] , 2020b), but it will long be remembered as the year of covid-19. it has illustrated the best in nursing resourcefulness and has also been the year when many nurses and other key workers died, mainly due to a lack of personal protective equipment. the year of the nurse and midwife seems an appropriate time to reflect on nursing leadership and plan for the future. thus, in this editorial, we as a group of nursing leaders from across sigma chapters in the united kingdom-phi mu (england), upsilon xi at large (wales), and omega xi (scotland)-aim to draw on this emergent critical dialog about nursing leadership to offer our collective position for embracing future opportunities afforded by this unexpected global event. we constructively focus on three key aspects: (a) leadership as not visible; (b) leadership as not collaborative; and (c) leadership not advocating for personhood of citizens. we aim to take a future facing position and search for what can be done and what is possible in the future, moving out of the immediate crisis into recovery. globally, 59% of healthcare professionals are nurses (who, 2020a). of these, there are leaders at every level-in practice, education, and research. the recent who (2020a) report on the state of the world's nursing 2020 calls for countries globally to take action to invest in their education and jobs, and primarily to strengthen nurse leadership, ensuring their role in influencing the development of health policy as well as decision making and contributing to the effective leadership and management of health and social care systems. we recognize that in a crisis on the scale of covid-19, with incomplete and even conflicting evidence, speed is of the essence. we also recognize that safety remains a top priority, and that preferred decisionmaking models and processes across nursing have been sidelined for more directive and command-based models. we believe it is time to reflect on how nurse leaders need to reinstate our preferred person-centered decisionmaking models and processes and regain our visibility across the healthcare system. the inclusivity of such approaches allows for patient, carer, and community response and collaboration in care. now is the time for nurse leaders to be increasingly visible and active participants with other key decision makers, to offer our creativity and, for example, our extensive experience of practice development and quality improvements that can enable transformation in the system, grounded in enhancing staff and patient experience. given the enormity of the task of leading and managing the safety and well-being of the population during this pandemic, several liberties that really matter to persons in care settings and others significant to them were eroded and often arbitrarily removed, for example, family contact and choices at the end of life. the consequences for people's health and wellbeing as well as community cohesion have barely been explored, and it is time to recapture nursing's fundamental attention on person and person-centeredness before it is relegated or even lost. indeed, we suggest there is an urgency to close the dissonance between the commitment of nurses with responsibilities for shared decision making and personcenteredness locally in practice, and the apparent silence of nursing leaders about the absence of citizen representation among the scientific advisory group for emergencies advising the government using scientific evidence. after all, evidence-based and evidenceinformed practice includes data from studies, clinical experience, and patient preferences, and not a reliance on any one type of knowledge in isolation. these are extraordinary times, especially as it appears that should we experience further waves of covid-19, we need to be prepared and draw on the investment in nursing leadership, a global focus for a number of years, and ensure that it is visible and effective at a strategic level. for example, leadership frameworks developed over the past 20 years have leaned heavily towards transformational, distributive, collaborative, and person-centered methodologies and are now widely advocated and used in organizations globally. however, in the context of covid-19, we observed and experienced a master-servant model of leadership that failed to draw upon the collective intelligence, knowledge, wisdom, and intellectual capital of the wider nursing community. as nurse leaders, we have reflected on the use of the crisis management strategy of command and control, which at the outset we would continue to support in the interest of population safety. however, as the situation unfolds, we believe it is now time to reflect and learn from this and from others across the global community. reflecting on health and care systems around the world and their response to covid-19, there are good examples of a more inclusive approach. new zealand, for example, has been dominated by these contemporary leadership values for an alternative approach and evidenced outcomes. additionally, in taiwan, building on their response to the sars epidemic in 2003, nurse leaders worked together with government to protect public health and established nurse-led quarantine care call centers (shwu-feng, ching-chiu, hsiu-hung, & chia-chin, 2020). in contrast, we observed that in the united kingdom, the visible geographical position of nurses was on the front line, with a minimum visible profiling of nurse leaders orchestrating, or at least contributing to, the strategic response to the pandemic. given that one of our core responsibilities is advocating for persons as our primary partners, it is critical that we are leading the return to enabling shared decision making with the public and service user representatives. for example, the exclusion of families and others from hospitals and other care settings seems to have continued too long without review, especially when set alongside the fact that many organizations were able to bring in volunteers and train them and new support workers in 1 or 2 days. this would have been the chance to offer similar opportunities to families, as trusted partners in care. in conclusion, it is important now to identify how to make nursing leadership more visible, especially in how to drive the voices and decision making of nursing leaders as we move forward. we would advocate and support sigma in setting up an international panel of nurse leaders to debate how we can best help to assist in the endeavors to offer a more collaborative and inclusive approach to decision making when we experience future waves of infection and future global challenges to nursing, healthcare delivery, and systems. in addition to educating the next generation of nursing leaders in the medium term, we would recommend the following as immediate goals to be discussed among the panel of nurse leaders and nursing at large: what are we recommending for future leadership? immediate goals: 1. nursing leadership needs to be visible as an active ingredient in multidisciplinary and interprofessional collaborative decision making that is needed at a time of crisis. 2. harness strengths-based models of strategic leadership that respect shared distributive models of engagement and include participation of service users and families. 3. strategic nursing leadership needs to demonstrate to all nurses that their well-being is paramount in all future decision making. 4. ensure that the retention of person-centered principles and practices is a significant central focus of nursing strategic decision making in future planning. users /rosse /appda ta/ local /packa ges/micro soft.micro softe dge_8weky b3d8b bwe/ temps tate/downl oads/97892 40003 279-eng%20(1).pdf world health organization. (2020b). the year of the nurse and midwife key: cord-271098-urpjr0dz authors: combe, laurie g. title: school nurses: living the framework during covid-19 date: 2020-05-26 journal: nasn sch nurse doi: 10.1177/1942602x20929533 sha: doc_id: 271098 cord_uid: urpjr0dz nan as i write this letter to you, it is late april and we are in the midst of an unprecedented event. while it has been just 4 months since we first learned of covid-19 (coronavirus disease 2019), i feel like i have been taking this walk with you for a much longer time. over the course of these months we have seen travel bans, physical distancing, rapid acceleration of case counts into the millions both worldwide and in the united states (see figure 1 ), deaths in the hundreds of thousands (world health organization [who] , 2020a), and brave healthcare providers on the frontline, often without the protection they need (american nurses association, 2020). forty-three states have ordered school closures, affecting 55.1 million students (education week, 2020) . the nasn2020 conference is "going virtual" in order to keep attendees and conference production staff safe and healthy. the pace of change in the covid-19 response has been nothing short of frenetic (national broadcasting company news, 2020; who, 2020b) . i regularly monitor the nasn all member forum school nurse net community and notice that nasn member katie morton (2020) sounded the first warning of the novel coronavirus on january 24 seeking guidance about travel from china into her community (see figure 2 ). since that time, all the school nurse net communities have logged almost 700 covid-19-related posts and the conversation quickly turned to school reentry planning. by tracking the expressed needs of school nurses surrounding covid-19, the nasn staff has worked tirelessly to build coronavirus disease 2019 resources, including return to school guidance (nasn, 2020a). while schools were still open, early discussions in the school nurse community focused on the need for school nurses to access the same level of personal protective equipment (ppe) as that recommended for other healthcare providers (centers for disease control and prevention [cdc], 2020a [cdc], , 2020b . school nurses discussed the evolving evidence surrounding covid-19, considering how we could safely care for and isolate presumptive cases, manage aerosolizing procedures for ill or potentially asymptomatic students, and still provide safe care for the well population in our schools. with schools closed, we are learning new ways to engage students in maintaining their health, while practicing within the constructs of ethical, legal, and professional nursing standards. school systems are relying on the expertise of school nurses to provide factual information about covid-19; using their knowledge to develop plans that keep staff, students, and families healthy. as nurses always do, we are looking ahead, anticipating the needs of students and school communities for that time when schools reopen again. school nurses are keeping pace with the evolving evidence, understanding that forecast model assumptions are based on yet to be determined factors such as the long-term viability of this novel coronavirus, policy decisions of political leaders, and citizen behavior (michaud et al., 2020) . school nurses know that many children face disparities in healthcare access, nutrition, safe housing, transportation, and more. cindy begley's staff is making telephone calls to check on students with known health conditions, making sure that families have the resources they need to maintain health. collaboration with school counselors provides cindy's staff with a resource list to meet needs that families are expressing. school nurse amy ponce is making sure that distribution of instructional materials is done in manner that protects the health of students, families, and staff ( figure 3 ). because their schools will be closed for the remainder of this school year, angela pesche and kindra schutt are staffing a medication pickup to return supplies to families, making sure they have enough medication at home (figure 3 ). paulette abbey works with her school food service partners to ensure that students dependent on school nutrition continue to have their needs met (figure 3 ). schools nurses are experts at adapting our nursing practice to the school environment. as schools flipped to remote learning we hopped on board. school nurses are dropping by teacher's remote classrooms to connect with students and collaborate with teachers to identify students at risk for chronic absenteeism. jenna palmisano (2020) produced a health education video, we are nurses!, addressing student fears about nurses and other healthcare providers in ppe (see figure 4 ). mary coldwell and craig matthes are encouraging their students through social media, letting them know they are many of our colleagues have answered the call to serve the larger community, working on the front lines. andrea ferguson is working in the emergency room of her local hospital ( figure 5 ). barbara maher and anthony torres are staffing a drive through covid-19 test site ( figure 5 ). some school nurses, employed by hospital systems or health departments, are redeployed to other practice areas, necessitating selfevaluation of competence for the assignment and collaboration with employers to establish safe patient care environments. eileen gavin, in collaboration with her health department, is training fellow school nurses to conduct contact tracing, a natural fit for school nurse public health practitioners ( figure 5 ). while working with one new mom, eileen was able to arrange delivery of infant formula, saving the mother and baby a risky trip into the community. this new paradigm of working from home presents possibilities and challenges. there can be time to research unique student health conditions, collaborate with pediatricians and other healthcare providers, and update individualized healthcare plans without the interruptions so common in a school health office. perhaps you have found space in your day to carefully analyze your health office data, preparing a presentation for your administrator about your work both before and during school closing. because many schools are relying heavily on school nurse expertise to help them navigate this crisis, more than a few school nurses administrators have expressed that they are working longer hours than ever to meet the needs of their school community. we have learned that managing work and family responsibilities within the same space and time can be stressful. you may have children at home who are used to a schedule, while your need to balance work and childcare make a schedule difficult to achieve. are you like me, juggling multiple curbside grocery pick-up services, trying to stock up on the essentials and favored items on a schedule that keeps your diet healthy and your family happy? you may be trying to safely care for older parents, or an immunocompromised family member and are fearful for their health when you must venture out into the community. perhaps you have made the decision to brave the frontline of this pandemic and isolate yourself from family because you are uncertain of your covid-19 status. others of you may be experiencing job loss and uncertain futures. a seat at the table: paving the way in speaking with imo jean douglas (personal conversation, april 30, 2020) about these opportunities and challenges, she shares that this pandemic has garnered her a seat at the executive team table. yet, imo jean is clear that it was the work she and her staff did prior to this crisis that paved the way. she looked to health data and the stories of students to demonstrate the necessity of school nurses to budget conscious administrators. she alerted her administrators early and often that covid-19 was coming and that they must be prepared. she continues to compile data and stories from this season of pandemic to advocate that she retain her seat at the table. nasn is paving the way for students access to school nurses. in late april, i sent a letter to president trump (nasn 2020b), alerting him that it is imperative that students have access to a school nurse when schools reopen. this letter outlines for the president the essential role school nurses have in addressing the ongoing impact of the covid-19 pandemic and informing plans to reopen the nation's schools. we are asking that the white house fund 10,000 school nurses to conduct infectious disease surveillance, identification, and intervention for student physical and mental health concerns, health screenings, school-located vaccinations, and immunization compliance efforts. we know that keeping students in school will have tremendous implications for the economy, workforce, and families. our call for stakeholders to sign on to a petition to the president has garnered almost 13,000 signatures in 9 days. you can help pave the way by contributing to nasn's ability to fund school health and school nurse research, research that can better define the value we bring to student health and learning. once again i want to ask that you support the doubledown for data president's endowment fund challenge ( figure 6) i wonder what the course of covid-19 will be by the time you read this message. i wonder how our lives and the lives of students and families will be changed. will the expectation of increased mental health concerns in the school population be a reality? are schools and the larger community equipped to meet these increased needs? the promise of these events is that we are learning news ways to communicate with students and families-ways that i think will be good to continue beyond covid-19. nasn and its affiliate organizations are certainly learning new ways to conference, communicate, advocate, and tap into the expertise of members. i want to encourage you to focus on self-care, remembering that you must be well to bring others to wellness. you have made me proud to be a school nurse alongside you and i look forward to the remainder of our journey. remember that we are #inittogether. with gratitude, ■ laurie figure 6 . doubledown for data framework for 21st century school nursing practice: framing professional development what 32,000 nurses want you to know about treating covid-19 guidance for schools and child care programs before and during and outbreak strategies to optimize the supply of ppe and equipment map: coronavirus and school closures-update using the framework for 21st century school nursing practice in daily practice covid-19 models: can they tell us what we want to know? kaiser family foundation global health policy national association of school nurses school nurse net all member forum framework for 21st century school nursing practice™ shaping your practice and changing mindsets: framework for 21st century school nursing practice™ nasn calls on the president to include school nurses in proposals to re-open the economy and schools we are nurses! a new framework for school nurse self-reflection and evaluation covid-19) dashboard who timeline-covid-19 key: cord-339399-36wo66rl authors: trepanier, sylvain title: leading on the edge of insanity date: 2020-07-13 journal: nurse lead doi: 10.1016/j.mnl.2020.06.002 sha: doc_id: 339399 cord_uid: 36wo66rl covid-19 has officially consumed every nurse leader's time and efforts. the purpose of this article is to share early learnings from the west coast of the united states, where the first us case was cared for. in this article, i describe the emerging principles allowing us to respond to an unprecedented crisis: prevent, protect, and control. by the time this crisis is over, i do not doubt that we will have additional science and experience to support our frontline nurses and our nurse leaders. that said, i felt it was important to share our expertise in real time for others to benefit from. i would also point out that writing about what you are feeling is cathartic—i encourage my colleagues to join me in writing about what you are experiencing. sylvain trepanier, dnp, rn, cenp, faonl, faan covid-19 has officially consumed every nurse leader's time and efforts. the purpose of this article is to share early learnings from the west coast of the united states, where the first us case was cared for. in this article, i describe the emerging principles allowing us to respond to an unprecedented crisis: prevent, protect, and control. by the time this crisis is over, i do not doubt that we will have additional science and experience to support our frontline nurses and our nurse leaders. that said, i felt it was important to share our expertise in real time for others to benefit from. i would also point out that writing about what you are feeling is cathartic-i encourage my colleagues to join me in writing about what you are experiencing. t o say that these are unprecedented times is a gross understatement. i grew up as an emergency room (er) nurse and had my first leadership role in the same clinical environment. er nurses are hot stuff. they can handle anything. they thrive in chaos-the rush of the unknown is their source of energy. they are prepared to survive in chaotic, fastpaced situations. no matter the preparation, what we are faced with right now is just insane. our world has been changed-maybe forever. i was paying close attention to what was happening in china at the end of 2019 and early 2020. to some extent, however, i had my head in the sand. on january 15th, the first us covid-19 patient landed at the seattle-tacoma international airport. according to johns hopkins university, 1 as of march 22nd, 2020, since january 15th, 2020, the virus has now spread to at least 33,200 individuals in the united states, killing at least 380. (i know those numbers will have dramatically increased by the time you read this.) by mid-february, i was getting nervous about the possibility that this disease would make its way to southern california, eating away our precious world as we knew it then. all of the following is representative of where i am in the process on march 22, 2020. i hope the messages are replaced with greater hope and positive outcomes than those presented here. a new world i have spent the last 3 weeks continually working to protect our caregivers, providers, and the community we serve. unfortunately, i was not able to pull the textbook or policy manual off the shelf to assist with the preparation. where is pandemic for dummies? at every turn, we found ourselves having to create the policy, the document, the communication, and the frequently asked questions. unlike "just-in-time" learning, this was "in-real-time" learning. as recently as last week, we now have had to start building our personnel protective equipment (ppe) because we are seriously concerned that we may run out of it. i never thought that i would have to consider using homemade ppe in health care in the united states. not knowing when this article will be published, i pray to god that our situation will have changed. unfortunately, something tells me that it won't have. i sure hope that it is not worse. and i am reminded that hope is not a plan; therefore, now is the time to show up as nurse leaders and make a difference. at this stage, we are focused on 3 key components: prevent, protect, control ( figure 1 ). we are fortunate to be able to learn from our colleagues in china and italy, the countries hardest hit so far. that said, i feel as if i am in the process of building a plane while i am flying it. we must focus our efforts on preventing the disease from spreading any further. at the very least, we need to slow it down so that we do not overburden our infrastructure. this requires a constant reminder to our community members and ourselves about the importance of practicing physical distancing (avoid social gatherings), washing hands, early learnings of covid-19 from the west coast of the united states are shared. emerging principles allow us to respond to an unprecedented crisis: prevent, protect, and control. avoiding discretionary travel, staying home if you are sick, and refraining from visiting anyone in a nursing home or hospital. 2 the details described below are not all inclusive but represent what we have done thus far. i am optimistic that you have access to a virtual platform where you can guide individuals to access virtual care. this will decrease the foot traffic as well as keep potentially infected people away from your hospital or clinic. we noticed that it was extremely important to immediately divert as much traffic away from our traditional emergency room as possible. if you do not have a virtual platform, at least increase the number of phone lines available to provide remote consultation to patients. consider limiting all entry points (entrances) into your organization immediately. you should have only 1 access point for your caregivers and providers (depending on the size of your organization, you may need more than 1) and only 2 entry points for everyone else (main entrance and emergency room entrance). take the temperature of everyone entering your building (yes, everyone-no exception!). anyone with a temperature of 100.0 f (37.7 c) or more should be denied access (unless they have an appointment). greeters at all entry points should wear masks, gloves, and gowns. if a person with symptoms is an employee, you need to follow your internal policy related to sending employees home. that said, anyone being turned away should at the very least do the following 3 : stay home and follow up with their primary care provider self-quarantine for a period of at least 14 days practice hand hygiene and respiratory etiquette stay calm (this latter may be hard to do with the way messages are sometimes conveyed on public and social media) develop an up-front triage process to ensure you are not comingling potentially infected patients with the general population. what worked best for us was to add a tent outside of our emergency rooms, as many of you have done. anyone having signs and symptoms of covid-19 is immediately taken into a separate waiting area and offered a mask. it is likely you will be unable to purchase additional ppe. i sure hope i am proven wrong. therefore, i can't stress enough the importance to start conserving your ppe immediately. to that end, you should review your list of the nonurgent elective procedures and reschedule at a later time. this action will decrease your use of indispensable material. access to all procedural areas should be limited to mission-critical personnel only. no vendors should be allowed in the procedural areas (unless they are required for the procedure), and no students should be allowed either. access to all isolation rooms should be restricted only to those actually caring for the patients. this restriction means no "grand rounds" in the room, no visitors, and again, no students. because patients in isolation can feel confined, consider providing devices that will enable ongoing communication such as baby monitors, smartphones, tablets, etc. we have to start planning on making our masks and shields. we have developed a website to engage everyone in this campaign. 4 it may seem crazy to think that you will have to rely on homemade ppe. yet, here we are. trust me: it will happen more quickly than you think. i encourage everyone to start a grassroots movement in your respective communities to start building your own as well. you will be surprised who is willing to help you. you have likely heard about the national companies donating their masks, conversions of distilleries to make hand sanitizer, and conversion of manufacturing plants to make respirators. yet, we can't rely solely on someone else doing that. we are developing plans to cohort patients in all hospitals, and if you have the luxury of being part of a health care system or coalition, i strongly encourage identifying and cohorting all persons under investigations or confirmed cases in 1 designated hospital. we had an opportunity to discuss the care of covid19 patients with colleagues in china, and they stressed upon us the importance of cohorting patients. 5 this means you also need to consider the transportation assistance needed to move patients from wherever they are in your system to where they need to be. you will soon realize that many of the rules and regulations in place become a barrier to innovate in real time. hopefully, you have access to someone in your organization who can influence policy-making. for example, as schools are shutting down and businesses are asked to close, we quickly noticed that all of our new graduate nurses would not have access to taking their licensure examination and, therefore, would not be able to practice nursing any time soon. on a good day, we need nurses-imagine now! we had to work with our state board of nursing to re-enact a graduate nurse status so that we could leverage all new graduate nurses. being leaders requires us to be present and inspirational at all times. everyone looks up to us for guidance. we must stay calm. have faith. we might be feeling like our hair is on fire, and yet, we absolutely cannot show it. i start and end my day with a meaningful 3 deep breaths exercise; and, yes, i do have to add a few in-between. we cannot underestimate the power of thanking people for their hard work and reaching out (conceptually) as often as we can. nobody needs an additional e-mail or text. that said, everyone appreciates the 1 text or e-mail that reminds them how special they are and how much you appreciate them. i remind my team that there is no way i could go about my day if it were not for them. we might not be able to hug each other right now, so we find a way to do so virtually. love your team. show warmth. by leading with love, you will inspire others. love, or true caring, will get us through this. conclusion covid-19 just appeared out of nowhere, and our world changed forever. in this article, i provided realtime lessons learned to help leaders prepare for the inevitable. i urge all organizations to consider implementing efforts aimed at preventing, protecting, and controlling. to that end, nurse leaders are encouraged to consider educating all constituents in promoting physical distancing, promoting the use of virtual clinics, eliminating visitations, screening everyone entering a building, cohorting patients, and collaborating with city, military, and state organizations. lastly, remember that showing up as a loving leader will inspire others and assist you in getting through this crisis. coronavirus covid-19 dashboard by the center for system science and engineering (csse) at johns hopkins university (jhu). 2020. available at the president's coronavirus guidelines for america: 30 days to slow the spread coronavirus (covid-19): what do i do if i feel sick? million mask challenge: the journey begins with us. learn how to get involved handbook of covid-19 prevention and treatment key: cord-260210-u4uosc5v authors: mckenna, hugh title: covid-19: ethical issues for nurses date: 2020-10-01 journal: int j nurs stud doi: 10.1016/j.ijnurstu.2020.103673 sha: doc_id: 260210 cord_uid: u4uosc5v nan we are living in unprecedented times and nurses are being lauded globally for putting themselves in the front line against the covid-19 pandemic. it is but a few months since 15,500 nurses in northern ireland went on strike because of a lack of pay parity with their colleagues in the rest of the uk and amidst concerns about standards of patient safety. leaving their patients to join picket lines raised serious ethical issues for these clinical nurses. these included the principles of 'nonmaleficence', the nurses' duty to do no harm and 'beneficence', the duty to do good for patients. going on strike meant that nurses could no longer be sure that they were adhering to these two principles. the ethical dilemma facing them was that not going on strike would compromise patient safety due to workforce shortages and low morale. there were reports in the media of nurses crying, not because of the care that they were giving, but because of the care that they were not able to give ( nursing times 2020 ). fast forward three months and who could have predicted that other more serious ethical issues would face clinical nurses globally. the covid-19 pandemic has rocked the world's health care systems to their foundations. we hear every day how there are insufficient resources to deliver safe care or in sufficient amounts. one issue has been the inadequate supply of personal protective equipment (ppe) and limited testing, providing front line nurses with another ethical dilemma. they could go to work without these safeguards and put themselves and possibly their patients and families at risk of contracting the virus. alternatively, they could stay at home, knowing that severely ill patients need nurses to be on duty. once again, the principles of 'non-maleficence' and 'beneficence' apply. a foundation of nursing practice is the duty of care with the attendant obligations to alleviate suffering, restore health and respect the rights and dignity of every patient. however, nurses must balance this duty of care for patients with their duty of care to themselves and their family members. these conflicting duties in a pandemic can cause serious moral and emotional distress. a nurse's duty to care for patients is not absolute. if the covid-19 virus places nurses at serious risk if they contract it, it is unfair and disproportionate to expect them to undertake such heightened health risks to uphold their duty of care. these are real fears and real dilemmas. according to fiona godlee (2020) , editor of the british medical journal , health and social care workers are dying because of occupational exposure to covid-19, including more than 100 in the uk. the emotional trauma is too much for some to bear. in march 2020, the italian national federation of nurses reported that in monza, lombardy, daniela trezzi, a 34-year-old italian nurse treating covid-19 pa-tients, took her own life for fear of having spread the illness and after being traumatised by her experience of working on the front line ( squires, 2020 ) . also in march, the italian nursing federation reported that another nurse ended her life through suicide under similar circumstances in venice ( fnopi, 2020 ). more recently, a new york doctor took her own life after her experiences of dealing with covid-19 patients in the emergency room ( watkins et al., 2020 ) . a further issue has emerged that evokes another ethical principle -justice -ensuring equity and fairness in how patients are treated. there have been reports from across the globe of insufficient intensive care beds and ventilators for the predicted number of covid-19 victims. in such a scenario, what will determine who gets lifesaving access to treatment and who does not? can it be on a first come first served basis or will those most likely to benefit from such access take precedence? inevitably, it will be the latter. in the covid-19 pandemic, it is not easy to find an acceptable justification for such decisions. this may mean a move away from a person-centred nursing approach to a population health approach. this is because ensuring the health of the population often entails imposing limitations on the rights and preferences of individuals. it could be argued that there is an ethical duty to allocate limited resources where they can be of greatest benefit, where the greatest number of lives can be saved. this is reflected in the principle of utilitarianism, where in the face of high demand and low supply, the greatest good should be achieved for the greatest number. in such a scenario, another ethical principle, distributive justice is often sacrificed, where everyone has an unqualified right to the very best health care. here again, the decision to safeguard one principle may conflict with another, causing tension and stress for nurses. according to garrard and wilkinson (2005) , passive euthanasia involves withdrawing or withholding life-prolonging medical treatment. this is a major ethical issue for clinicians. in the current pandemic, teams that include nurses, may be actively involved in using triage principles that will lead to the withholding of potentially lifesaving equipment or facilities from some patients with covid-19. they may also be involved in decisions regarding 'reverse triage'. in effect, this means that existing intensive care unit patients may be re-assessed on their likelihood of benefiting from further treatment to make way for other patients, who would be more likely to benefit. these are difficult decisions that threaten to undermine the very essence of person centred nursing care. while the ultimate legal responsibility of making such decisions lies with the senior responsible clinician ( james et al., 2018 ) , the royal college of nursing point out that nurses with appropriate https://doi.org/10.1016/j.ijnurstu.2020.103673 0020-7489/© 2020 elsevier ltd. all rights reserved. knowledge, skills and support may be the senior responsible clinician ( rcn, 2020 ). but no clinician should have to make these decisions alone; rather, it should be a team endeavour, based on the very best ethical and clinical evidence, a view supported by department of health guidance ( doh, 2020 ). returning to passive euthanasia, it is clear that the above actions do not fulfil all three necessary conditions. these are: there is a withdrawing or withholding of life-prolonging treatment; the main purpose (or one of the main purposes) of this withdrawing or withholding is to bring about (or "hasten") the patient's death; and the reason for "hastening" death is that dying (or dying sooner rather than later) is in the patient's own best interests ( garrard and wilkinson 2005 ) . clinical teams who make difficult triage and reverse triage decisions to withhold or withdraw treatment are not doing so because it is in a patient's best interests. furthermore, they are not doing so to purposely bring about or hasten a patient's death. the principle of solidarity dictates that while all patients may not receive critical care, those who do not should continue to be cared for with alternative levels of care, including palliative care. these ethical issues have not newly arisen in the current pandemic. nurses have been discussing death and dying with patients and their families long before this crisis emerged. palliative nursing care to help people die with dignity and comfort is not something that was invented to deal with covid-19. in other words, much of the knowledge and skills already exist as part of the realities of clinical nursing practice. the adage 'no decision about us without us' applies to the current pandemic. the risks, benefits and possible likely outcomes of the different treatment options should be discussed with patients, families and carers so that they can make informed decisions ( nice, 2020 ) . however, this brings other stress provoking challenges for nurses. patients who are considered for admission to intensive care may not be in a fit state to be involved in such decision making. furthermore, hospital visiting and contact between nurses, families and patients have been stopped in the current lockdown. in such circumstances, involving families in life and death decisions is fraught with difficulties. a key principle to follow is that when people are not able to make a decision, those who have to decide for them do so based on the best interests of the patient, taking account of their rights and their individual needs and circumstances. the inability of families to visit patients brings another challenge. there have been reports that family members have asked nurses to speak their last words to their dying relative. being an intermediary between family and patient in such circumstances is emotionally demanding. further, nurses are acutely aware that the sentiments that a family member asks a nurse to impart to the terminally ill patient may not be agreeable to other family members. this has the potential to make a stressful event for the nurse involved, even more stressful. thankfully, in recent weeks different or ganisations have drawn up ethical guidelines for such scenarios. in the united kingdom, these include the british medical association ( bma, 2020 ), the national institute for health & care excellence ( nice, 2020 ), the royal college of physicians ( rcp, 2020 ), british board of scholars and imans (2020) , and the royal college of nursing ( rcn, 2020 ), to name a few. these are based upon specific ethical principles and evidence-based guidelines. they inform decision-making and can enhance trust and solidarity and strengthen the legitimacy and acceptability of the measures put in place. however, nurses should remain mindful of the obligations and responsibilities set out in their codes of conduct and continue to use their professional judgement in the delivery of care. applying these principles and guidelines may not make the aftermath any easier for front line nurses. it is natural that they will reflect on their actions and think about those patients and families who were impacted by the decisions made. this brings threats to their mental health. but good teamwork, the availability of counselling and adherence to ethical principles and the best available evidence may help them realise that they did the very best they could in unprecedented circumstances. in conclusion, many of the clinical issues encountered in this pandemic involve balancing conflicting rights, principles and values. a consistent feature of any public health crisis, is that it places severe strain on the national healthcare system's already limited resources and on those delivering care and treatment. it may mean front line nurses having to re-examine the standard of care that they would normally provide and justify a different approach in the face of increased demand and reduce supply of intensive care beds, clinical personnel and personal protective equipment. at the start of this editorial, i noted that in 2019, nurses in northern ireland reluctantly took strike action over concerns about staffing levels and patient safety. even though this provided them with an ethical dilemma, they did so in the best interests of patients. less than six months later, their responses to the covid-19 pandemic, and that of nurses worldwide, demonstrates that in the face of more profound ethical dilemmas they continue to put patients first. those not yet born will talk about this dystopian time and remember those front-line nurses who risked their lives and those of their families to save as many others as possible. covid-19 -ethical issues. a guidance note british board of scholars and imans, 2020. a matter of life and death: the ethics of resource distribution. intens. care treat. choices light covid-19 pandemic covid-19 guidance: ethical advice and support framework. department of health passive euthanisia paying the ultimate price decision-making in intensive care medicine -a review nursing times, 2020. northern irish nurses warn care is compromised on 'daily basis clinical guidance for managing ethical dimensions of covid-19 for front-line staff. royal college of physicians italian nurse commits suicide as another 683 people die from coronavirus top e.r. doctor who treated virus patients dies by suicide key: cord-295243-6osemfvk authors: jackson, debra; bradbury‐jones, caroline; baptiste, diana; gelling, leslie; morin, karen; neville, stephen; smith, graeme d. title: life in the pandemic: some reflections on nursing in the context of covid‐19 date: 2020-04-12 journal: j clin nurs doi: 10.1111/jocn.15257 sha: doc_id: 295243 cord_uid: 6osemfvk nan in the unparalleled and extraordinary public health emergency in which we find ourselves, across the world nurses stand as we always do-at the front line. nurses everywhere are staffing our clinics, hospital wards and units-in some situations, literally working until they drop, and in some regions, they are doing so while dealing with a lack of essential items. indeed, we see reports that nurses in many parts of the world are grappling with shortages of much-needed supplies including personal protective equipments such as masks, gloves and gowns, yet are actively embracing the challenges presented by covid-19. as we contemplate the ramifications of this rapidly moving global pandemic, it is clear that the need for nurses has never been greater. in responding to this dire and unprecedented health crisis, as nurses, we are doing what we have been educated and prepared to do. as nurses, we have the knowledge and skills to deliver the care needed in all phases of the illness trajectory, and in reassuring, informing and supporting people within communities who are frightened, worried and wanting to stay well. as we have seen throughout history, nurses are well able to think outside the box, and develop creative and innovative solutions to all manner of problems, conundrums and challenges. however, there remains much about this current situation that is new and frightening. for one is the speed of the spread of covid-19. in the fight against covid-19, we are working against the clock. the trajectory of this situation is such that in some areas, infection rates are doubling every 24 hr or so, and this is leading to increasing community anxiety manifesting in various ways including panic buying and hoarding of essential supplies. it is clear that this health crisis will not affect everyone in the same way. the very strong public health message is to stay home, and stay safe within that home, in the assumption that everyone has a home that is safe, and within which they have some autonomy. there is some speculation as to whether rates of domestic violence might increase at this time as a result of the extraordinary strain that families face. poverty is also an issue. it is well known and accepted that those who are homeless and impoverished have many less options when faced with health problems, and the challenges faced by these people will be much greater in this time of pandemic (tsai & wilson, 2020) . similarly, people who are captive or imprisoned for any reason, such as in corrections or refugee environments and other similar settings, are particularly vulnerable (iacobucci, 2020) . older adults are high users of services across primary, secondary and tertiary healthcare settings. many in this group live with multiple health and social issues that increase their vulnerability, now further exacerbated by the need for social distancing. older people are known to be at greater risk of calamitous outcomes associated with covid-19, and this dire picture is likely to be exacerbated because of the potential for rationing of care based on age, simply because there are not enough ventilators and other life-saving equipments to meet demand. the risk to older people is greater than to others, and in many countries, limitations on older people activities are in place in attempts to reduce risk of exposure. in several countries, restrictions on visiting nursing homes are in place and people over 70 years of age asked to reduce outings and remain indoors as much as possible to decrease contact with others and reduce the risk of contracting the virus. while necessary, this could put older people at risk of loneliness, isolation and exacerbation of existing problems, and so it is very important that we all look out for older people in our neighbourhoods and provide support, assistance and safe social interaction as required. nurses are at the forefront in institutional settings such as nursing homes and prisons, with homeless people, and other hard to reach populations and are grappling with the effects of low health literacy, rapidity of change and health information, and a lack of resources to ensure that all know and understand what is required to keep them safe. it is so important that we all support these vulnerable populations and the nurses working within them by advocating for resources including adequate safe accommodation for all. we know from our colleagues that despite being actively engaged in this fight against covid-19, in a way that few other professions are, and despite appearing calm and professional; like everyone else, many nurses are also experiencing fear of the unknown and concern for what lies ahead, for themselves, their patients, colleagues and their own families and friends. in addition to being nurses, we are also parents, siblings, friends and partners with all of the worries and concerns shared by most people-providing for and protecting ourselves and our families, and so in addition to caring for patients, the well-being of our own families weighs heavily on us as nurses at this time. the global nature of this crisis means that while all countries are engaged in the battle against covid-19, some have been in the fight for longer and so there is the opportunity to learn from other countries. indeed, in watching the unfolding horror particularly in italy, we see just what can (and will) happen in the event that measures such as social distancing, hand hygiene and quarantine are not fully embraced by all in our communities. earlier this year, hong kong was one of the first places in the world affected by the covid-19 virus, evoking unwanted memories of the sars outbreak of 2003 (smith, ng, & ho cheung li, 2020) . despite initial fears, the spread of the virus appeared to have been effectively controlled over the last two months through the use of stringent measures, including practice of good personal hygiene, avoidance of group gatherings and implementation of social isolation measures. indeed, by the beginning of march 2020 some public services in hong kong had started to resume normal activity and many people were returning to the workplace. in some part, these successes were due to the excellence of the clinical nursing workforce. we saw some stability in other countries in the same region including singapore and taiwan. there was hope that the corner across the world, there are concerns that nursing's capacity to provide care will be stretched by the increased workload and by the number of front-line nurses that are expected to be affected by covid-19. in australia, authorities are considering various mechanisms such as fast-tracking return to registration of qualified nurses who may be recently retired and allowing limited registration to people who may be suitable such as internationally qualified nurses. in the united kingdom, there has also been a call for recently retired nurses to return to practice. other planned strategies include establishing a covid-19 temporary register for nurses who have left the register within the past three years, who will be able to opt into this register. registered nurses not currently working clinically will be encouraged to consider working within clinical practice, and undergraduate nursing students will be able to opt to undertake the final six months of their programme as a clinical placement. part of the covid-19 temporary register is to include a specific student element for those in the final six months of their preregistration programme and will include details of specific conditions to ensure appropriate safeguards are in place. the fine details are still in development, and there may need to be further measures in what is a continually changing situation. in considering introducing new cadres of nurses, there are also issues around risk, retraining, refreshing and renewing knowledge. while there are some aspects of nursing that may not have changed too much over the years, health is generally a rapidly evolving field and particularly in the current situation. in contemplating returning to direct care giving roles, many retired nurses or others contemplating re-entry may have legitimate concerns about the real contribution that they could make in the current crises, particularly when considering direct care delivery and technological advancements in practice. it will be necessary to consider carefully any possible risk for nurses returning from retirement, and the potential ways these nurses could meaningfully contribute. this may be in working in quieter areas to free up current staff, and working in roles supporting front-line nurses. either way, it will be crucial to have adequate learning and resourcing available to support these new cadres of nurses. however, as we identify innovative ways to provide a nursing workforce during this time of urgency, it is important that whatever we implement is safe and appropriate for staff and for patients. patient safety is paramount and integral to nursing practice. nurses generally become nurses because of the desire to help people regain and maintain optimal health, and here, we have a situation where there may be very few options to help those who are seriously ill because of covid-19. this inability to save lives will take its toll on those at the front line, both physically and emotionally. as nurses, we know death. we have seen loss of life, and we have borne witness to the pain and the suffering of the dying and the grief of those left behind. for nurses, particularly in environments where the focus is on life preserving, such as emergency departments and intensive care units, death can represent failure, and so is therefore a source of stress and distress for the medical and nursing teams in these settings. we are now in a situation where nurses everywhere are bracing for what really is a tsunami of death. our colleagues in china and italy have and are leading the way, and we have seen reports and first-hand accounts of the distress and exhaustion of our chinese and italian colleagues who have been (and are) faced with large-scale death on a daily basis. all aspects of nursing activity are affected by this pandemic, and healthcare facilities have responded to nursing education student clinical needs in a variety of ways. some have restricted student presence in their organisations, while others welcome healthy students. academic nurses have also been quick to modify in the light of the crisis caused by covid-19 and many have very quickly moved to online course delivery, including strategising to ensure reasonable student engagement, and making appropriate changes to examination procedures. there is also the need to recognise that many nurses currently enrolled in post-graduate courses may now have their current studies jeopardised because of cancellation of study | 3 editorial leave or other pre-existing work patterns that can now no longer be guaranteed. nurse educators and administrators are tasked with ensuring that students meet academic requirements while recognising the current pressures faced by health services and the need for nurses to be able to simultaneously meet the demands on them as nurses, students, parents, siblings, partners and the myriad of other roles that each nurse has to manage in their daily lives. the way this crisis has unfolded has meant that we have all sorts of new challenges in seeking to meet the health needs of our populations. for example, we have situations of cruise ships left sailing from port-to-port unable to dock; others inadvertently offloading passengers who are ill and contagious into communities, with health services left to set about tracing crew, passengers and those with whom they have been into contact. we have to prepare for the potential ramifications if covid-19 takes hold in very vulnerable populations, such as prisons where it will be very hard to contain because of the proximity of people. there is also the aftermath to consider. of critical importance will be nurses' responses to the increased anxiety and mental health needs of the population as well as within the nursing community. these are very difficult times, and the scale of the challenges is unprecedented. every single one of us has a role to play in supporting and advocating for the health of our communities, and in supporting nurses everywhere. nurses are the backbone of health systems around the world, and this has never been more apparent than now. amidst all the uncertainty about the virus and how long it might take before life begins to return to normal, there can be no doubt that nursing and the provision of health care will come out the other side of this pandemic stronger and better prepared to face future challenges. we write these "reflections" in the moment, as the impacts of the pandemic unfold around us daily. we are all living it right now. when it is over, we look back and reflect upon it and with the benefit of hindsight, might make normative judgements regarding what we ought to have done and what might have been best at a certain time. right now, we all need to be kind to each other (and ourselves) as we grapple with new ways of living and working. we want to thank nurses everywhere for their tireless efforts in this unparalleled covid-19: doctors warn of humanitarian catastrophe at europe's largest refugee camp covid-19: emerging compassion, courage and resilience in the face of misinformation and adversity covid-19: a potential public health problem for homeless populations how to cite this article life in the pandemic: some reflections on nursing in the context of covid-19 key: cord-337982-t3zbfvlo authors: salvage, jane; white, jill title: our future is global: nursing leadership and global health date: 2020-08-31 journal: revista latino-americana de enfermagem doi: 10.1590/1518-8345.4542.3339 sha: doc_id: 337982 cord_uid: t3zbfvlo global health matters to every nurse everywhere. in this article we outline why. we highlight some important health issues confronting the world today; explore how these issues are being tackled; and consider the implications for nursing. we describe how nurses are making a difference in the challenging contexts, range and complexity of nursing work round the globe, and we conclude with a call to action. nurses can influence, and become, policy-makers and politicians, and explain to them why the sustainable development goals cannot be reached without strengthening nursing. in this international year of the nurse and midwife, the window of opportunity is open, but it will not stay open for long. nurses and midwives globally and locally must be ready to jump through it. we ask you to join hands, and join us. as health professionals committed to our local community and country, it is tempting to look no further than our own backyard, where there is always so much about which we care deeply. yet this solely local focus is not only ostrich-like, but also dangerous: global health is inseparable from local and national health concerns. infectious diseases, for example, do not recognise borders, and a mingling of germs and genes results in communicable diseases with the potential for rapid global spread. compare the speed with which the coronavirus and covid-19 infections spread worldwide, to the four years it took the medieval plague to cross europe. the concept of "global health" did not really exist even 20 years ago. now it embraces a complex concept that engages with all countries and indeed with the health of the planet itself (1) . a growing number of governments and organizations are adopting it as a key policy theme. in thinking about nursing today and tomorrow, we must all look beyond our backyards, and understand how what happens in distant places affects the health and health care of our communities, our loved ones, and ourselves -just as what happens in our backyard affects people we will never meet. covid-19 has surely heightened awareness of this. "think globally, act locally!", as the environmental slogan says. thinking globally is not an academic exercise but a way of seeing that enriches perspectives, increases knowledge, and makes nurses more motivated and effective as leaders, practitioners, managers, teachers, researchers, policy-makers and activists. it helps us to understand how our work contributes to outcomes not only in health sectors, but also in policy, education, economic relations, and environmental activism. nurses have a professional obligation to understand the world in its broader context and base decision-making on an expanded understanding of ourselves, our patients, and our circumstances. "it begins with understanding the policies and politics of globalization, the growing interdependence of the world's people, [which] means that national policy and action are increasingly shaped by international forces along with other aspects of our lives" (2) . we increasingly rely on the same groups of workers and technologies and face the same environmental and epidemiological threats. moreover, the policies that most affect health are not always health policies (3) . other policies have enormous impact on health determinants and solutions, so cross-sectoral collaboration on global health is critical. we live in challenging times, for the health of the planet, nations and communities. the challenges have major implications for nursing as a global profession of some 23 million, from halting pandemics to reducing mother and child deaths, tackling and mitigating the effects of climate change, and caring for older people. inequalities between groups of people, and within and between countries and regions, are key to understanding these challenges. there is a mass of evidence of the interaction between health and wealth at all levels, whether individual, family, community or country. nurses know that their patients' ways of life and the conditions in which they live and work strongly influence their health and longevity. this challenges us to complement biomedical models of health care with social models, and focus much more on prevention and public health. since the 1990s there has been a growing understanding of the interaction between health and poverty, and the need for cooperation and collaboration on a global scale to combat its consequences for health and for economies. this has stimulated many organizations to play a larger role in global health. eradicating poverty in all its forms and dimensions is the greatest global challenge, says the united nations: many nurses make naive assumptions about health and healthcare and do not view these issues through a sociopolitical lens (6) . yet we need to understand some history and politics if we want to be leaders of change, rather than its servants. policy and politics determines not only the health of populations but also nursing itself -past, present and future. it profoundly shapes the practice and workplaces of nurses at local, regional, national and international levels. nurses who wish to influence and lead policy, rather than be bystanders, should understand not only the content related to a health issue, but also the policy process, the context, and the stakeholders and their interests (8) . www.eerp.usp.br/rlae 4 rev. latino-am. enfermagem 2020;28:e3339. the largest proportion of the health workforce globally by a large margin, nurses are often the only health care provider available. we are key to ensuring that all people and communities receive the health services they need without financial hardship. nurses occupy a special position as the interface between the health system and the community; we see, hear and know, as end users of health policies, how policy affects people and their communities. you might think that knowledge would be welcomed with open arms by policy-makers, yet it has been very difficult for nurses at all levels to make an impact on policy, for a variety of reasons (3) . while nurses are acknowledged as key policy implementers -the pairs of hands, they are rarely central to health and social policy developmentat the top table (6) . nurses engaged in high-level global health work apply their nursing lens to issues that others may not notice. they bring information from the field to high-level meetings, explain the complexities of implementing programmes, and interpret the science or recommendations from these meetings back to the field in a way that may be translated into action. australian nurse amanda mcclelland, for example, was the senior officer in the emergency health unit of the international federation of red cross and red crescent societies. "i added a social mobilisation and community aspect to global strategy discussions", she said (9) . "how am i going to explain this to the volunteers and how will they explain it to the community? that's great, but the community would never accept it. that's great, but we won't be able to implement the programme in that way. we're going to need to consider weather/culture/religious factors when rolling this out." nurses worldwide have become increasingly knowledgeable, skilled and well educated, like mcclelland, but this has not been matched with a significant growth in their influence and status. the reinventing itself as a champion of nursing and midwifery, the chief nurse and head nurses in the six who regional offices used to have much larger teams and budgets. all have declined in scope and influence, attributable partly to cuts in who budgets, but also to long-standing reluctance to recognise the value of the nursing contribution. less assertive" (10) . speaking with one voice and in a language that appeals to policy-makers has not been one of nursing's successes (6) . nor has the ability to persuade policymakers to take effective action on nursing issues. nursing history in many countries and at regional and international levels is strewn with evidence-based policy reviews and reports making excellent recommendations that go largely unheeded. compounded by structural inequalities related to gender and social class, nurses' attempts to push for reform have not gained enough traction, and change has not happened fast enough or far enough. policy leadership is required in the everyday workings of national and local government and health systems. a key nursing competency, it is rarely acknowledged or formally developed; most nurses learn it, if at all, by bitter experience. the need for nurses to develop these competencies has long been highlighted (11) , but not consistently developed across the global nursing community. white advocates "policy leadership and role modelling" by nurse leaders, who need the right professional, political and policy skills to operate effectively in tough arenas. whether they work in government, management, education, advanced practice, research or development, they need to know how to maximize their distinctive contribution to shaping, influencing and implementing policy decisions (12) . this requires nurses to grasp white's concept of a "new pattern of knowing called socio-political knowing" (6) and, as salvage has long advocated, to become policy activists who are politically savvy (13) . www.eerp.usp.br/rlae 5 salvage j, white j. reports and recommendations on nursing that fail to have traction, policies that ignore or undermine nursing, and nurses' absence from policymaking -this gloomy pattern is starting to change for the better. more nurses are becoming policy entrepreneurs: leaders who position themselves to influence policy; who bring together problems, policies and politics into a novel amalgam -new policy; and who soften up the system by presenting participants in the network (visible and invisible) with alternative representations of their realities. this leads to the opening of a window of opportunity, as described by kingdon -the potential for a truly new policy perspective (14) . that window is opening wider as demand grows worldwide for solutions to acute problems including current and future health worker shortages, and the rising need for expert care of older people, alongside huge public interest in nursing. there is greater global awareness of the importance of investment in health as a public good, and of nurses' massive actual and potential contribution to improving health, creating gender equality and strengthening economies. meanwhile more nurses are finding the courage to become "silence breakers" and join the worldwide wave of protests against violence, sexual harassment and other abusive behaviour against women (15) . the major shifts necessary to transform nursing will not be effected through a continuing series of shortterm, piecemeal policy initiatives, however good each may be. deep-rooted, sustainable change will depend on reaching honest, shared understanding of the barriers to change and the structural inequalities and issues that maintain them, and on tackling the root causes and underlying drivers. these big issues are not solved by tips on how to exploit the status quo, and patience is unlikely to be the answer either. this is the moment for nurses to shift the paradigm, to be taken seriously together and individually, when the old certainties and ways are being shaken to the core. nursing organizations, as well as trying to gain influence at the top tables, are making alliances with social movements and considering radical alternatives. all this could lead us to a new story of health and healthcare (3) . nurses, as leading actors in this story, will be at the heart of sustainable health systems that meet individual and population needs, are fit for the present, and innovative and adaptable for the future. rooted in reality, yet reaching for the stars, nurses work to shape sustainable, high quality, effective and affordable services fit for the future, and responsive to the challenges of turbulent times. they focus on where the needs are greatest and where there is most potential to gain health and reduce inequalities. they take their understanding and experience as hands-on practitioners into all their subsequent roles, as clinicians, managers, teachers, researchers, scholars, policy-makers and leaders. at all levels, from ward to board to international organizations, they inspire and lead. we began by arguing that 'doing global health' means thinking globally and acting locally: adopting a mindset that seeks to understand the structural and political conditions that sustain armed conflict, (2) ). "thinking globally and acting locally" is old wisdom, but never more needed of nurses and nursing than now. www.eerp.usp.br/rlae 6 rev. latino-am. enfermagem 2020;28:e3339. we have also argued that the challenges facing the planet and our own communities have major implications for nursing and nurses, and shared our hope that nurses can influence (and become) politicians and policymakers, showing them that the sdgs cannot be reached without strengthening nursing. in this year of the nurse and midwife, the window of opportunity is open, but it will not stay open for long. nurses and midwives globally and locally must be ready to jump through it. will you join hands, and join us? box 1 -how nurses can engage with global health begin at home -think globally and act locally. cultivate a worldview; be sensitive to the cultural aspects of policy and practice. commit to learning more about the global health agenda, above all the sdgs. know where regional and international organizations and your national and local government stand on key international health and nursing matters, and lobby them. get involved in global health issues, and team up with like-minded groups and people at home and internationally. through your professional association, trade union, workplace or community, help colleagues in and from other countries -and learn from them -as they work to strengthen nursing and health. advocate, initiate, and document nursing's role in policy. join others in ensuring that national and local structures and roles are in place so that nurses' voices are heard in policy and practice. ensure that nursing leaders -and new nursing graduates -know about policy and politics, how to analyze the environment, how to develop strategy, and how to work together. undertake and disseminate research to build evidence of nursing effectiveness. share your ideas and achievements through discussions, publications, conferences, social media and the internet. global health and global nursing; emerging definitions and directions international health and nursing policy and politics today: a snapshot triple impact: how developing nursing will improve health, promote gender equality and support economic growth united nations. transforming our world: the 2030 agenda for sustainable development nurse practitioners: working for change in primary health care nursing. london: king's fund centre through a socio-political lens: the relationship of practice, education, research and policy to social justice people's health movement reforming the health sector in developing countries: the central role of policy analysis emergencies only. crow's nest: allen & unwin so many voices, so little voice. can nurse stages of nursing's political development: where we've been and where we ought to go nurses: a voice to lead the politics of nursing. london: heinemann agendas, alternatives, and public policies. 2 nd ed breaking the silence: a new story of nursing key: cord-256360-4glhydi8 authors: geremia, daniela savi; vendruscolo, carine; celuppi, ianka cristina; adamy, edlamar kátia; toso, beatriz rosana gonçalves de oliveira; de souza, jeane barros title: 200 years of florence and the challenges of nursing practices management in the covid-19 pandemic date: 2020-09-07 journal: revista latino-americana de enfermagem doi: 10.1590/1518-8345.4576.3358 sha: doc_id: 256360 cord_uid: 4glhydi8 objective: to analyze the main challenges of nursing in facing coronavirus disease-19 under the perspective of nurse managers in the west macro-region of santa catarina. method: it consists of a qualitative study, whose data collection was done through interviews with nurses who represent the management of health care network in the region. the analysis technique used was the discourse of the collective subject (dcs). results: the legacy of florence nightingale to contemporary nursing practice; the weaknesses and the technical operational capacity with which nursing faces in the unified health system (sistema único de saúde sus); the strategies for strengthening the unified health system and qualification of nursing practices; and the potentialities identified in the pandemic scenario were the main ideas that emerged. in the bicentennial year of florence nightingale, nurses recognize her legacy to public health practice and management. several variables interfere in professional practice, such as epidemiological aspects, working conditions, and care management in a pandemic. conclusion: the pandemic scenario has taken nursing to a position of practical and scientific protagonism as a result of its proactivity and leadership in the search for knowledge based on scientific evidence. the legacy of florence directed the work of the nurse professional to a performance based on technicalscientific, legal, and political protagonism. this is only possible using practices committed to social well-being in the dimensions of care, management, and research/ education. the care and management of nursing requires theoretical support and scientific evidence. thus, the research contributes to the safety in the performance of the practices, without disregarding the subjective dimension involved in the act of caring and/ or managing (4) . currently, the incorporation of clinical evidence to guide the practice mediated by technologies such as protocols and guidelines, even with timid regulation in brazil, was responsible for greater visibility and autonomy of nursing and, at the same time, created challenges for the nurse in the health care network (hcn). these challenges are due to the lack of training for the most complex skills, which involve requesting tests and prescribing medications, as well as evidencebased practice (1) . in the midst of the historical context and challenges faced by the professional nurse, in december 2019, after cases reported in the city of wuhan, china, a new virus from the coronavirus family was discovered. named as severe acute respiratory syndrome (sars-cov-2), it is responsible for covid19 . the disease has become a serious public health problem worldwide, evolving very quickly and depleting the responsiveness of health systems. symptoms that vary in intensity (mild, moderate, or severe) and that are usually intensified by comorbidities presented by individuals. in some cases, the disease may manifest itself in a severe and high lethality (5) . at the beginning of 2020, with the disease widespread in several continents, the world health organization (who) determined the situation of a pandemic. in brazil, the condition worsens daily with an ascending characteristic and growth in the epidemic curve, which began on march 2, with two confirmed autochthonous cases. on may 5, 2020, cases totalized 114,715 (5) . sars-cov-2 has been presenting a pattern of high transmissibility in some geographic areas of brazil. this fast growth has increased the suspected cases, without the necessary notification of confirmation, implying a probable brazilian undersized epidemic curve, which weakens the strategies to contain the pandemic (6) (7) . the estimated death rate among patients treated clinically until may 26, 2020 , was approximately 2% of the cases, but the actual number remains unknown, given the underreporting and deaths attributed to other causes due to poor testing. on may 5, 2020, in brazil, lethality was 6.9% (5) , of which the elderly population and those with chronic conditions represent the main risk groups (8-9) . the changes caused by covid-19 have led to interventions that alter people's daily lives significantly and put health workers at risk. by acting in the front line, in this context, the nursing team has dealt more frequently with records of contamination, illnesses, deaths, suicides, anxiety and panic crises, as well as the worsening of other diseases, which have been increasingly frequent (10) . based on these events, the debates that involve the capacity of healthcare services are amplified. among the key points is the availability of health professionals. thus, the preservation of the physical and mental health of health workers, which pervades working conditions in the care of victims of covid-19, is essential for adequate care practices, as well as for the maintenance of the available labor force. likewise other historical times when epidemics and disasters have affected populations, nurses have put themselves at risk to provide health care. for educational and prevention actions for the general population at risk of illness. the nurses in the west of santa catarina stand out for their strong adherence to hospital services and to primary health care (phc) and, more recently, for their work in undergraduate and graduate teaching. based on a path marked by pioneering, nurses "have been promoting changes in nursing practice and teaching, provoking transformations and influencing the culture of nursing care in the region" in different contexts (16) . from a historical perspective, the present study is justified by the debate, since florence nightingale, whose bicentenary is celebrated in 2020, the role and contributions of the practices developed by nursing under the perspective of nurses who are in charge of the pandemic in the management of different services and coping with major health emergencies. it is intended to signalize the main challenges in the action against covid-19. in order to do so, we analytical study of a qualitative approach that is part of the multicentric research project entitled "nursing care and management as knowledge in the field of primary care: proposals for good practices", approved by the research ethics committee, under record no. pandemic, potential participants were initially consulted through the whatsapp messaging application. after the first contact, an email was sent with a link to access a google forms form, which contained in its initial structure the acceptance of the free and informed consent form (ficf), followed by the interview questions. from the date the forms were sent by e-mail, seven working days were waited for the forms responses. during the period, the project team made up to two contacts with the participants to remind them of the remaining time to answer the questions sent. the information was produced in april 2020. to obtain the data in order to ensure the quality and reliability of the study, the principles of the consolidated criteria for reporting qualitative research (coreq) were followed. the data were organized and analyzed manually, using the discourse of the collective subject (dcs) technique. in this proposal, we sought to extract from the interviews: 1) key expressions (ke), consisting of literal excerpts or transcriptions of the discourse that reveal the essence of the discursive content; 2) central ideas (ci), which are statements that translate the essence of the discourse in order to briefly describe its meaning. ci can be redeemed by direct or indirect/ mediate descriptions of the meaning of the statement that reveal the subject of the statement (17) (18) . the analysis followed the following steps: (1) exhaustive reading of each interview transcript; (2) identification of themes and grouping of ke; (3) identification of major themes; (4) identification and grouping of ke by theme; (5) identification of the ci in each theme; (6) elaboration of the dcs; (7) analysis of the set of dcs in each theme (17) (18) . representative ci emerged from the challenges mentioned by nurse managers, which were organized as shown in figure the ci identified in the data were discussed based on scientific literature in order to articulate the theoretical aspects that influence illness since florence to the nursing professional practices in the context of pandemic. nightingale for the practice of nursing, highlights the importance of hygiene practices over two hundred years. (20) . from the legacy of the precursor of nursing, the knowledge brought to daily life, such as those with the environment and the washing of the hands, became scientifically grounded. and finally, detecting and quarantining suspected and confirmed cases (3, 9) . nightingale's environmental theory provided nursing with a new discipline based on its own body of knowledge mediated, giving the nursing professional support and authority to act freely. by consolidating partnerships to defend the autonomy of nurses, as well as its freedom to act and think during professional activity, the need for a training centered on the assumptions of nursing science has emerged (20) . in in addition, the international council of nurses, the health launched the nursing now campaign in 2018, which will be completed in 2020. this campaign has the participation of more than 30 countries, including brazil. the movement aims to enhance nursing, highlighting its importance to improve health services around the world (21) . better working conditions (18) (19) (20) (21) (22) (23) (24) (25) (26) . nursing constitutes half of the health workforce, and nurses are appointed as the main responsible for coordinating health teams at different levels of care. one of the strategies for investing in the workforce and valuing nurses for the advancement of the profession is the articulation between educational institutions and health services (21) . in addition to encouraging the use of research to ensure better nursing practices, the approximation of professionals to real health production scenarios allows the recognition of the potentialities and weaknesses of the system, as well as the needs users have, making them protagonists in this production (27) . nursing has shown the dimension of its importance in combating covid-19. even with the lack of professionals to act in the face of the pandemic and with a context of confrontation, which has at times cost these professionals their lives, the time is ripe for brazilian nursing to leverage their visibility, demonstrating competence in the face of the current scenario. rev. latino-am. enfermagem 2020;28:e3358. however, the deficit in quality training makes it necessary to adopt strategies that help at work. the support of permanent education, combined with the use of protocols and evidence-based practice, contributes to developing resilience in the nursing workforce (30) and to the profession's autonomy. it should also be noted that such autonomy is based on the use and incorporation of the nursing process, and in line with its theoretical roots. the professional nurse needs to seize the methods, processes, and technologies that promote different human functions. it is also advisable to debate and reflect on the training of personnel in order to break with a model that focuses on compliance with hospital prescriptions and routines. it is time for nurses to be valued as a critical, reflective, and autonomous profession (20) . in developed countries, such as england, spain, the united states, canada, and australia, nursing works by developing advanced nursing practices in numerous contexts, but mainly in phc (31) (32) (33) . with different levels of autonomy between the mentioned countries, an advanced practice nurse accompanies patients with chronic conditions through the management and handling of cases, including ordering tests and prescribing medications. this practice is guided by care protocols and is supported by the laws of those countries (33) . in times of a pandemic, such as that of covid-19, clinical nursing care based on knowledge and autonomy (29) reinforces the forefront of health professionals for the care of at-risk groups, which includes people with chronic conditions and the elderly. in this regard, brazil needs to advance in the discussion about the implementation of advanced nursing practices so that the principles and guidelines that guide sus are made effective, especially in phc (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) . as presented in the fourth ci, which portrays the macro and micropolitics determine the health model and way of acting in nursing, as they shape nurses' practice and workplaces at the local, regional, national, and international levels. in this scenario, nurses commonly act as policy implementers, but they rarely play a central role in their development, assuming a leadership role in the areas of health and social policy (36-37) . in short, it was observed in the discourse of the nurse managers a concern with working conditions in the face of the pandemic and the sus situation. despite in the year that florence nightingale's bicentenary is celebrated, nurses recognize her legacy and consider it for their public health practices and management. however, it is necessary to move forward in the field of scientific knowledge regarding the performance in pandemic scenarios, understanding the adversities of the profession and its multi and interprofessional relationships in times of crisis in public health. this historic moment of the pandemic will mark public health as a result of the transformations caused by a virus that has spread rapidly throughout the world. the current scenario has valued nursing for its role in the construction of its body of knowledge, in the proactive organization of care and the sus, in its leadership capacity, and in the development of knowledge and skills based on scientific evidence, with emerging trends after coronavirus disease-19. enfermagem: história de uma profissão. 2. ed. são caetano do sul: (covid-19)-outbreak-rights-roles-and-responsibilitiesof-health-workersincluding-key-considerations-foroccupational-safety-and-health critical supply shortages: the need for ventilators and personal protective equipment during the covid-19 pandemic physician burnout, interrupted fair allocation of scarce medical resources in the time of covid-19 recomendação n. 20 de trabalho/atuação dos trabalhadores e trabalhadoras, no âmbito dos serviços de saúde, durante a emergência em saúde pública de importância nacional em decorrência brasília: ms; 2020 enfermagem em números trajetória e atuação profissional das enfermeiras da região oeste de santa catarina: um resgate histórico. enferm brasil o discurso do sujeito coletivo: um novo enfoque em pesquisa qualitativa (desdobramentos) planejamento regional dos serviços de saúde: o que dizem os gestores? the vital power and the legacy of florence nightingale in the health-disease process: integrative review. j res fundam care online autonomia da enfermagem e sua trajetória na perspectivas da enfermagem e a campanha nursing now labor market in nursing in the su: na approach from the research nursing profile divulg saúde debate agência italiana de notícias. mais de dois mil médicos e enfermeiras contraíram vírus na itália what other countries can learn from italy during the covid-19 pandemic prevenção relacionada à exposição ocupacional: covid-19 the health regionalization process from the perspective of the transation cost theory melhores práticas de enfermagem: potencialidades e desafios em um contexto assistencial. rev enfermagem centro-oeste mineiro nursing in the time of covid-19: two advanced practice nurses on the front lines of the pandemic what the covid-19 pandemic tells us about the need to develop resilience in the nursing workforce nurses performance on primary care in the national health service in england advanced practice nursing in primary health care in the spanish national health system. ciênc saúde coletiva nurses as substitutes for doctors in primary care we thank the nurse managers for their collaboration with the research. key: cord-268714-slejus63 authors: liu, yu; wang, hui; chen, junhua; zhang, xiaoyun; yue, xiao; ke, jian; wang, binghua; peng, chaohua title: emergency management of nursing human resources and supplies to respond to coronavirus disease 2019 epidemic date: 2020-04-04 journal: int j nurs sci doi: 10.1016/j.ijnss.2020.03.011 sha: doc_id: 268714 cord_uid: slejus63 abstract objective to introduce the emergency management of nursing human resources and supplies of a large general hospital when facing the outbreak of coronavirus disease 2019(covid-19). method the nursing department of the hospital fully executed its functional authority to establish a three-level echelon of sustainable support, allocate human recourses dynamically, organize pre-service training, supervise the key working steps, formulate positive incentive methods, and deploy medical supplies scientifically. result by taking these strategies, the hospital effectively improved the coping capacity of the nursing team and played a positive role in the prevention and treatment of covid-19. conclusion the emergency management of nursing human resources and material resources for covid-19 of the hospital is successful. but several deficiencies were identified as well, which indicated that the hospital needs to establish an efficient emergency management system, and pay attention to the practice of nursing emergency plans to enhance coping capacities in public health emergencies. since the end of december 2019, cases of coronavirus disease 2019(covid-19) have successively occurred in wuhan in hubei province and other regions in china [1] . the chinese center for disease control and prevention has announced that covid-19 is a category b infectious disease, for which category a infectious disease control measures are employed [2] . as the outbreak occurred close to the chinese new year, population movement and activities before the outbreak were extensive. meanwhile, covid-19 is infectious during the incubation period, and symptoms on onset are non-specific. consequently, there was a widespread transmission of the virus, and the increasing number of confirmed cases has exceeded that of the severe acute respiratory syndrome (sars) and the middle east respiratory syndrome (mers). the covid-19 outbreak in wuhan is serious, and epidemic control is a huge challenge. as a major tertiary hospital at the center of the epidemic, our hospital provided treatment for the first batch of infected patients in wuhan. the nursing department of our hospital employed a series of efficient and scientific measures to obtain good results in epidemic control. control of the epidemic was challenging. to respond to the epidemic of covid-19, the nursing department organized a covid-19 control leadership team immediately, with the director of the nursing department as the leader of the team, who was fully responsible for the deployment and implementation of treatment work. the leadership team adjusted priorities in nursing work according to the hospital's actual situation, and formulated nursing work systems for the fever outpatient clinics and quarantine ward, as well as the corresponding standards for staff, to ensure that nursing work adheres to guidelines and standards. the team immediately conducted an ideological mobilization within the entire hospital to ensure that all nursing staff would be aware of their responsibilities and obligations in the face of difficulties and the epidemic and prepare to fight at the frontline of the epidemic. simultaneously, training on knowledge related to covid-19 and epidemic control methods were carried out. according to the characteristics of this epidemic, the nursing department formulated unified selection criteria for head nurses and nurses. when selecting the head nurse for the fever outpatient clinics, priority was given to candidates with extensive outpatient management experience, external assistance experience, and good physical health. when selecting the head nurse for the quarantine ward, the emphasis was placed on disinfection and quarantine management experience, and priority was given to head nurses with good integrated qualities in the emergency and infectious diseases departments. the selection criteria for nurses were as follows: with two or more years of work experience, good physical health, and proficient in basic nursing techniques (infusion, oxygen ventilation, and condition observation). candidates who possessed nursing techniques for critical patients (usage of invasive/noninvasive ventilator, transnasal high-flow oxygen, and closed airway suction) or disinfection and quarantine techniques were given priority. hence, nurses who were dispatched to the fever outpatient clinics and isolation wards at first were mostly nurses from the infectious disease department, the respiratory department, and icu. at the later stages, the dispatch system was gradually expanded to staff from all departments. as the epidemic continued, nurses in ordinary wards, isolation wards, and the fever outpatient clinics were all overworked. to ensure sufficient personnel in fever outpatient clinics and isolation wards, while ensuring nursing quality in the entire hospital, the nursing department reassessed and matched workload and personnel requirements in the entire hospital. the department decided to establish three echelons, and the echelon composition principles were determined as follows: a certain number of midlevel staff must be present along with several senior or specialist nurses from the icu and the respiratory department. in consideration of a large number of nurses (4,000) in the hospital, the nursing department referred to the concept of magnet hospital [3] , staff selection was delegated to various departments in the hospital. based on voluntary registration, the head nurse of each department dispatched the first echelon of support nurses according to the echelon composition principles and nurse selection criteria and then determined name lists of the second and third echelons as reinforcements for fever outpatient clinics and isolation wards. based on the daily number of patients in the fever outpatient clinics and the patients in the isolation ward, the first echelon of 150 nurses was dispatched to the fever outpatient clinic and the isolation ward in the main area of the hospital, 45 nurses in the fever outpatient clinics with an average of 600 patient visits daily, 105 nurses in the isolation ward, and each nurse was responsible for four patients on average in each shift. as the early number of patients in the fever outpatient clinics and isolation ward was highly variable, two reserve shifts were prepared for every shift according to elastic shift principles. two groups of reinforcements for each department were preparing in case of insufficient personnel. if the manpower was still insufficient, the nursing department would dispatch nurses for support. to ensure nursing quality, the nursing department followed the management model of beijing xiaotangshan hospital during the sars epidemic, and four 6 h-shift model was used in the fever outpatient clinics and the isolation ward. the nurse shift schedule was changed every two or three weeks. at the later stage of the intensified epidemic, the infected patients continuously increased, and the manpower needs for the fever outpatient clinics and the isolation ward continuously increased. then, nurses in the two key departments rotated once a month, and nurses had been working for a month would rest for two weeks and be quarantined at home. only a part of nurses were replaced for each rotation to ensure the normal operation of the departments. the leaders dynamically adjusted the deployment of first-line nurses according to the epidemic situation. any nurse experiencing discomfort would be replaced after reporting to the head nurse and the nursing department. in addition, to alleviate personnel resource shortage in other ordinary wards, personnel resource emergency plans were established. meanwhile, all head nurses in the entire hospital maintained effective communications to achieve mutual understanding and cohesion. covid-19 is a novel infectious disease. currently, there is no effective treatment regimen, and the number of suspected or confirmed patients is large. some first-line nurses were not from the infectious diseases department or the respiratory department. to decrease the infection risk of nursing staff, the nursing department conducted a half-day focused training for all head nurses and nurses deployed to fever outpatient clinics or isolation wards. our hospital has two branches besides the main area. nurses in the main area of the hospital received on-site training, while nurses in two branch areas were trained online. thus, all nurses were able to start working on the same day after they were trained in the morning. the training content included self-protection knowledge and skills, professional knowledge and skills, and preventive psychology counseling, based on national policies and guidelines [4e6]. (1) self-protection knowledge and skills include epidemiological characteristics, transmission route of covid-19, and personal protection techniques, such as gowning/degowning of protective gown and mask. (2) professional knowledge and skills include clinical diagnostic criteria for covid-19, current treatment regimens, physical and psychological needs of patients, usage of invasive and non-invasive ventilation, transnasal high-flow oxygen therapy, closed sputum suction, and other nursing skills. (3) preventive psychology counseling includes coping strategies and methods for emotional adjustment. training methods included face-to-face training, practice, and lessons online. videos, ppt, manuals, and images were provided for nurses whenever possible. as the epidemic situation was critical, nurses in deferent areas of the hospital were assessed by head nurses or senior nurse and began their work at the first-line immediately after passing the assessment. to ensure safety of nursing staff, supervision in isolation wards focused on layout and zone arrangement, accesses and flow direction management, and process of donning and removing personal protective equipment (ppe). when first entering the isolation ward, new nurses were accompanied by nurses with working experience in the isolation ward. for every shift, a nurse from the infectious disease department was responsible for supervising disinfection and protection work in the ward. in addition, the implementation of nurse protection measures was considered to be important content in the quality control and night ward round by head nurses, thereby ensuring the proper protection of nurses. first-line nursing staff had to endure high physiological and psychological stress, which may affect their physical and mental health. in view of this situation, the director of the nursing department and various head nurses led from the front and encouraged nursing staff at the front line every day. they were aware of the nurses' difficulties in life and work, such as long working hours resulting in a dry throat, long periods of maskwearing resulting in chest tightness, allergy to the protective gown, and worry about infected family members. great efforts were made to find solution manners. the workflow was adjusted and improved, and infected family members of nurses were treated in time. the official wechat account of the nursing department and mobile phone messaging were uses to deliver protection reminders and consolation messages. the exploits of nurses were disseminated by the official website and accounts. psychological counseling and supports, and channels for emotion releasing were provided under the efforts of the nursing department together with other departments in the hospital. when large general hospitals encounter public health emergencies, rational emergency resource deployment, layout, scheduling, and replenishment are extremely important during the response process, as these determine the success of emergency management [7] . the covid-19 epidemic occurred during the chinese new year, a period when many factories, logistics, and sales workers were on leave. this situation resulted in a shortage of protective materials in various grades of hospitals in wuhan, the entire hubei province, and even the whole of china. to solve these problems, hospitals employed a series of response measures, coordinated the relationships between various parties, and ensured the timely supply of protective gowns, masks, and disinfectants. fever outpatient clinics and isolation wards are first-line regions in epidemic control in hospitals. during activation of the covid-19 emergency plan in the hospital, budgeting of protective materials in the isolation wards and fever outpatient clinics during chinese new year was carried out. simultaneously, a supply plan was formulated, supply channels organized, and reserves prepared in advance. under the condition with limited supplies, the hospital prioritized supplies to isolation wards and fever outpatient clinics. amid the supply shortage, the hospital contacted many departments or obtained materials from society through a public platform to solve first-line supply problems quickly. medical equipment and supplies in isolation wards and fever outpatient clinics, especially disinfectants, ventilators, and ultraviolet lamps, needed to be replenished timely according to detailed requirements. medical staff in isolation wards also faced personal hygiene and living problems. conveniences were provided for them, such as shower water heaters, etc. as covid-19 has high infectivity, and droplet and contact transmission may result in disease, first-line medical staff require large amounts of protective equipment [5] . since the epidemic outbroke, hospitals have faced a shortage of surgical and n95 masks. in ensuring a sufficient supply of protective equipment and disinfection products, the distribution system is very important. the nursing department formulated an emergency plan for protective equipment distribution. head nurses of wards took charge of requisition, storage and distribution of consumables, and communicated with the nursing department and the materials department every day for timely supplies. lists of detailed requirements and standards for various protection equipment formulated by the infection control department were delivered to head nurses of every ward, which were used to ensure that the donated equipment satisfied protection standards. our hospital organized training and implementation of documents on the use of common protective equipment for covid-19 control [8] . in consideration of the effective duration of general protective equipment and the maximal usage of every set of protective equipment (e.g., protective gowns, goggles, n95 masks, latex gloves, and isolation gowns), usage rules of protective equipment were formulated. nurses should complete personal preparation, such as drinking water and eating, urinating and defecating, before wearing the personal protective equipment (ppe) to avoid unnecessary wastage. two to three sets of ppe were prepared for every shift as additional replenishment in case of responding to accidents, such as vomiting or syncope caused by long-term hypoxia in medical staff. for high-risk operations, such as collection of pharyngeal specimens, a concentrated cooperation manner was employed. after completing a round of concentrated collection, the protective face shield was changed. during the covid-19 epidemic, some deficiencies were present as a major tertiary general hospital. prediction capacity and strategic preparatory awareness for public health emergencies were not sufficient. this resulted in an evident lack of workforce and supplies at the beginning of the outbreak. the leadership team had to adjust the management plan continuously to satisfy antiepidemic requirements. we have taken effective management measures to respond to the epidemic summarized as follows. (1) the epidemic control leadership team formulated a corresponding system and an emergency plan at the beginning, which ensured that nursing works be carried out in an orderly manner. (2) three-level echelons of nurses were established in advance to ensure sufficient preparation of manpower. nursing staffing efficiency was improved by empowerment of head nurses in different departments. this approach prevented blind selection by the nursing department during unified deployment. (3) the periodic rotation of first-line nursing staff maintained the model of combining novice and proficient staff. this model ensured that first-line nursing staff could obtain sufficient rest ensuring nursing quality and safety of new nurses in fever outpatient clinics or isolation wards. (4) the management ideas of magnet hospital were followed to increase cohesiveness. nurse leaders worked at the forefront to act as role models and mentors, awaken the sense of purpose and responsibility in nurses, and activate the proactive spirit of nurses. (5) equipment and materials for the first-line must be in sufficient supply without wastage. for better responding to public health emergencies in the future, it is suggested that the various grades of hospitals establish pools of emergency nursing staff and improve their nursing skills and abilities by targeted training and assessment [9] . the ethical approval or individual consent was not applicable. none. a novel coronavirus from patients with pneumonia in china national health commission of the people's republic of china. novel coronavirus infection pneumonia is included in the management of notifiable infectious diseases the practice and effects of magnetic hospital on nursing management national health commission of the people's republic of china. technical guidelines for prevention and control of novel coronavirus infection in medical institutions national health commission of the people's republic of china. diagnosis and treatment protocol for novel coronavirus pneumonia(trial version 4) national health commission of the people's republic of china. guidelines for emergency psychological risk intervention during coronavirus disease 2019 epidemic optimization study on emergency material deployment system in nonconventional emergencies (dissertation). changsha: central south university national health commission of the people's republic of china. guidelines on usage scope for common protective equipment during coronavirus disease 2019 control research status of emergency management and human resources allocation in disaster nursing management the authors would like to acknowledge dedication of all nurses in fighting against covid-19 and the hard work and strong support of logistics departments. supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2020.03.011. none. key: cord-272381-3ky7tga9 authors: yin, xue; zeng, lingdan title: a study on the psychological needs of nurses caring for patients with coronavirus disease 2019 from the perspective of the existence, relatedness, and growth theory date: 2020-04-04 journal: int j nurs sci doi: 10.1016/j.ijnss.2020.04.002 sha: doc_id: 272381 cord_uid: 3ky7tga9 abstract objective this study aimed to explore the psychological needs of nurses caring for patients with coronavirus disease 2019(covid-19) and to propose corresponding interventions. methods in-depth interviews were conducted with 10 nurses who cared for patients with covid-19. interview data were analyzed by category analysis from the perspective of the existence, relatedness, and growth theory (erg). results the existence needs were mainly reflected in health and security needs, whereas the relatedness needs consisting mainly of interpersonal needs, humanistic concern needs, and family needs; further, the growth needs were mainly reflected as a strong need for knowledge. existence needs were the main needs during the epidemic, with health and security needs influencing each other. humanistic concern needs were the most important of the relatedness needs; interpersonal and family needs were also growing. conclusion it is found that the existence, relatedness, and growth needs coexist in clinical nurses. it is helpful to take effective interventions to meet their needs if the needs of nurses caring for covid-19 patients could be perceived well. in december 2019, an epidemic of coronavirus disease 2019(covid-19) was discovered in wuhan, hubei province, china [1] . the virus is highly transmissible, but the source and route of transmission have yet to be determined [2] . clinical nurses experienced great stress when they were fighting against covid-19 with needs for health, safety, interpersonal relationships, and related knowledge. alderfer [3] proposed the existence, relatedness, and growth (erg) theory of humanistic needs on the basis of maslow's hierarchy of needs. he believed that people have three core needs, namely a need for survival, a need for relationships, and a need for growth and development. the purpose of this study is to use in-depth interviews to understand the psychological needs of front-line nurses working in extraordinary epidemic situations, and to analyze the main content of their psychological needs from the lens of the erg theory and to provide a perspective for interventions to alleviate the psychological stress of nurses at the front-line. in this study, a purposive sampling method was used to select nurses from a tertiary general hospital in wuhan who had cared for patients with covid-19. inclusion criteria: registered nurses at the front-line; having been caring for covid-19 patients for more than one week; voluntary participation in the study. a total of 10 nurses were interviewed; the sample size was based on the saturation of information [4] . among the interviewed nurses, nine were female and one was male, aged 25e38 (29.9 ± 3.62) years. three of them had 5-year or less of nursing experience, five had 5e10 years of nursing experience, and two had 10 or more years of nursing experience. three of them had a junior college diploma, six with a bachelor's degree and one with a master's degree. seven of them had experience in critical care nursing. before they began to care for covid-19 patients, they worked in the neurology department, the emergency department, the cardiac surgery department, the hematology department, and the infectious diseases department, respectively. a semi-structured, personal, in-depth interview method was adopted. the outline of the interview was formulated based on the format of interviews from previous literature reviews. two nurses were pre-interviewed to adjust and refine the outline of the interview. the outline of the interview was as follows: (1) please tell us your feelings about caring for covid-19 patients over the past few days. (2) what are your biggest needs or expectations right now? (3) how has taking care of covid-19 patients affected your personal life? (4) do you have any lived experiences and feelings about this job differ from before? interviews were conducted by researchers who had been trained in qualitative research interviewing techniques. before the interview, the interviewees were told about the purpose, content, and significance of the study in order to earn their trust and cooperation. interviews were conducted in a quiet and well-ventilated room, which would be disinfected after completing an interview. both the interviewer and interviewee wore protective masks with a distance of at least 1 meter from each other, and the duration of the interview time was kept within 30 min as much as possible. a voice recorder was used to record during interviews with the consent of the interviewees. in addition, non-verbal cues by the interviewee, such as eye movements and gestures, were noticed and recorded. the interviewees were coded as n1en10 and their privacy was protected in accordance with the principles of confidentiality [5] . this study was approved by the hospital ethics committee. within 24 hours after each interview, the researchers carefully read the interview notes and transcribed the interview record verbatim under the recollection of the interview scene. qsr nvivo-8 [6] was used for data encoding and analysis. a category analysis method was used to classify data with the same attributes into a theme and a name was given to it. based on the encoding of the interview text, the number of individuals that initially mentioned each encoding and the number of times mentioned was counted. the main encoding was then extracted and integrated to form an encoding system. finally, we extracted the main content of the psychological needs of clinical nurses from the encoding system based on the erg theory. encoding and analysis of the interview data showed that, from the perspective of the erg theory, among the psychological needs of clinical nurses, the existence needs primarily manifested as needs for health and safety. the need for health refers to the nurse's attention to their own physical and mental health, and the need for safety refers to the hope for adequate personal protective equipment (ppe) and the emotional stability of patients' family members. the relatedness need is primarily manifested as a need for interpersonal relationships, a need for community concern, and a need for affection. during the period of lockdown in wuhan, the need for interpersonal relationships specially reflected the desire of clinical nurses to communicate face-to-face with family members, colleagues, and friends. the need for community concern manifests as nurses' need for care, help, and support from department heads, the hospital, and the outside world. the need for affection reflected their desire for family affection is stronger than usual. the growth need is manifested as a strong need for knowledge about covid-19 prevention and control, especially from authoritative reports. specific categories and narrative examples are shown in table 1 . our analysis showed that 80% of the respondents exhibited existence, relatedness, and growth needs, and these three needs affected each other. n1: "i hope my own immune system can eliminate the virus."; "it's been a long time since i've seen any colleagues that i used to work with in the past."; "there is too much information about covid-19 every day. much of it is rumors, and i wish there were more official reports from the authorities." n4: "i hope that i won't become infected by the virus."; "i miss the days when we could talk to each other without face masks"; "i hope chinese scientists can find the source of infection and develop a vaccine as soon as possible." n8: "i hope that personal protective equipment is available every day so that i don't have to worry as much about myself or my colleagues getting infected."; "i hope that the community hospital at home also provides sufficient medical services so that i feel more at ease at work and less worried about my family." n10: "there is a shortage of personal protective equipment in some hospitals right now. the virus still can't be treated with specific drugs. i feel really anxious and scared." it is apparent that most of the interviewees had existence, relatedness, and growth needs simultaneously, and interacting effects were found among these needs. when any of these needs were fulfilled well, others may decrease correspondingly. the interviews showed that the need for existence is currently the primary need in nurses. physical health is a basic necessity required to overcome the epidemic, and all respondents exhibited a strong need for maintaining health. n2: "now, i eat fruit and take vitamin c supplements every day to strengthen my immunity." n5: "i now practice yoga and do aerobic exercises every day at home follow the guide on tv in order to get rid of toxins and strengthen my immunity. now is the time to work hard to build my immunity." n6: "i haven't been on my special diet to lose weight during this time. the nursing department issued a notice saying that i should maintain a ketogenic diet to enhance immunity and i think that having more chicken soup can alleviate some common cold symptoms. now i eat a lot every day." it is also found that the needs for health and safety among clinical nurses interacted with each other; when the need for safety was fulfilled, the need for health may decrease. when asked about the current biggest needs or expectations for clinical nurses, both n3 and n5 responded: "i recently saw news reports that a continuous stream of personal protective equipment was being shipped to wuhan, and i felt less worried [about my health]." n7: "although the virus can survive in the air for a period, i'm not too worried about getting infection as long as i wear a mask, have fresh air, and take proper safety precautions." 3.2.3. the need for community concern is foremost among relatedness needs, and the needs for interpersonal relationships and affection are continuously increasing through coding and analysis, it showed that the need for community concern was foremost among the relatedness need. all interviewees emphasized the need for community concern, hoping to get the care, help, and support from leaders of department and hospitals, and the outside world. n6: "to be honest, i was very apprehensive before coming to the infectious department assupport staff, but on the first day here, the head nurse personally explained relevant knowledge such as disinfection and quarantine, and that helped me calm down a lot." n7: "i hope that the hospital sets up a psychological support task force to ease our tension and fears." n4: "i hope that our society and government pay more attention to lack of personal protective equipment." 80% of the interviewees indicated needs for interpersonal relationships and affection. due to the impact of the epidemic, the needs for interpersonal relationships and affection are temporarily suppressed, thereby causing these needs to increase continuously. n2: "now, i go straight to my rented apartment after work every day. i can't see my family or go shopping with my classmates. i hope we overcome the epidemic and return to normal life as soon as possible." n9: "in the past, it was no big deal when everyone worked together. now everyone needs to wear personal protective equipment to avoid cross-infection. everyone is afraid to go out with each other too much after work. i miss the days when we could just talk and laugh together." n5: "i stay at a hotel every day and am afraid of getting my family sick. i'm afraid to go home and haven't seen my mom and dad in a long time." n7: "there are already cases of children becoming infected. i'm afraid to go home and transmit the virus to my daughter, but i miss her terribly and just want to hug and kiss her." n9: "i haven't been home for a year. i plan to go back to my hometown to see my parents this year. but now i can't, and i don't know what their health is like." because the current outbreak is caused by a novel coronavirus never been found in humans before, knowledge of the virus itself and the disease it is causing is still under constant investigation. our interviews showed that clinical nurses have a strong need for knowledge about novel coronavirus that runs through all of their psychological needs. around 90% of respondents said that they would like to know more about the novel coronavirus. n1: "i hope to ease my own fears by knowing more correct information about the virus." n2: "because i can't meet with my colleagues, friends, or relatives every day, i basically spend the free time browsing the web, hoping to get useful information about novel coronavirus pneumonia prevention." n5: "there is too much information about novel coronavirus every day. much of it is rumors, and i wish there were more official reports from the authorities." n9: "i see a few hundred new confirmed cases every day, and i feel panicked, but seeing that researchers have developed diagnostic kits, i feel that we are not far from overcoming the epidemic." the psychological needs of nurses caring for covid-19 patients were investigated from the perspective of the erg theory. it was found that needs for existence, relatedness, and growth coexisted among clinical nurses and affected each other. this is also consistent with the idea proposed by the erg theory that "an individual may have more than one need at the same time". the interviews showed that clinical nurses have needs at different levels. this is consistent with the idea that "even if a person's needs for existence and relatedness have not been fully met, he can still work toward developing the need for growth", as stated by the erg theory. although there are currently no specific drugs or vaccines effective against covid-19, the chance of infection can be reduced by following scientific protective measures [7] . currently, governmental agencies and hospital managers are making every effort to collect and distribute personal protective equipment to ensure the "i hope that personal protective equipment is available every day." (n8) "i hope we never have another incident where medical personnel are put at risk." (n6) relatedness need for interpersonal relationships 8 1 5 "it's been a long time since i've seen any colleagues that i used to work with in the past." (n1) "i miss the days when we could talk to each other without face masks." (n4) need for community concern 10 20 "i hope that our society and government pay attention to our lack of personal protective equipment." (n4) "i hope that the hospital sets up a psychological support task force to ease our tension and fears." (n7) need for affection 8 14 "i stay at a hotel every day and am afraid of getting my family sick. i'm afraid to go home and haven't seen my mom and dad for a long time." (n5) growth need for knowledge 9 19 "there is too much information about novel coronavirus every day. much of it is rumors, and i wish there were more official reports from the authorities." (n5) safety needs of the front-line. adequate supplies, scientific and reasonable utilization of personal protective equipment would fulfill the needs for health and safety among clinical nurses. the interviews showed that humanistic community concern for nurses is necessary, especially in the extraordinary circumstances during the epidemic. establishing psychological coping task forces with help of the nursing department and psychological experts, and setting up psychological support platforms to provide community support for healthcare professionals, may contribute to fulfill the needs of nurses and protect their mental health. though face-to-face communication reduced during the epidemic, the needs for interpersonal relationships and affection in clinical nurses can be enhanced through other ways for emotional expression, such as colleagues encouraging each other during work shifts, writing good-luck messages on personal protective equipment, enjoying lunches provided by social volunteers, and so on. the interviews showed that clinical nurses have a strong need for knowledge, which may bring a lack of security. this is also consistent with the concept of "frustration-regression" proposed in erg theory, which states that when higher-level need is not met, lower-level needs may be increased as a substitute. therefore, under the direction of the chinese center for disease control and prevention and the guidance of the national health commission, promptly training of knowledge on prevention and control of covid-19 would help reduce psychological panic and insecurity caused by inadequate knowledge. limitations exist in this study include the short time of each interview and the tight time to analyze the data. more valuable information may be found if plenty of time is engaged. during extraordinary epidemic situations, needs for existence, relatedness, and growth coexisted among clinical nurses and affected each other. the existence needs were mainly reflected in health and security needs, whereas the relatedness needs consisted mainly of interpersonal needs, humanistic concern needs, and family needs; further, the growth needs consisted mainly of knowledge needs. more attention should be paid to clinical nurses' needs to protect their health. national health commission and national administration of traditional chinese medicine of the people's republic of china. protocols for diagnosis and treatment of covid-19 special expert group for control of the epidemic of novel coronavirus pneumonia of the chinese preventive medicine association. an update on the epidemiological characteristics of novel coronavirus pneumonia an empirical test of a new theory of human needs beijing: people's medical publishing house a qualitative study on the community concern behaviors of head nurses at a tertiary hospital in wuhan qualitative research on the psychological needs of the elderly from the perspective of erg theory 5 novel coronavirus pneumonia patients with mild disease and nursing care academic journal of chinese pla medical school the authors would like to thank the nurses who participated in the interview and express high respect for nurses' hard work during the outbreak of covid-19. supplementary data to this article can be found online at https://doi.org/10.1016/j.ijnss.2020.04.002. key: cord-010787-n2fbdjjk authors: arkan, b.; yılmaz, d.; düzgün, f. title: determination of compassion levels of nurses working at a university hospital date: 2019-03-07 journal: j relig health doi: 10.1007/s10943-019-00786-x sha: doc_id: 10787 cord_uid: n2fbdjjk this study was conducted to determine the compassion levels of nurses working in a university hospital. the study sample consists of 227 nurses who were available and participated in the research voluntarily during the study. the study data were collected by using “nurse description form” and “compassion scale (cs).” in the analysis of the study data, number, percentage, mean and independent t test and anova test were used. the total mean score of cs of the nurses was found as 97.02 ± 10.67. there was no statistically significant difference between gender, marital status and weekly work hours of the nurses and their total cs score means and total sub-scale score means. on the other hand, there was a statistically significant difference between the age variable of the nurses and the sub-scale of “separation,” between the education level of the nurses and their total cs score means. as a result, it was found that the level of compassion of the nurses was moderate and the level of education affected the compassion levels of the nurses. compassion is an attitude that motivates the person to understand the inner world of the individual in need and to support him/her. it is a concept that finds its place in many religions and doctrines. it has been possible to investigate this concept thoroughly in the field of psychology in the last few years (i̇şgör 2017a, b) . compassion is a profound awareness of self and others' troublesome situations; besides, it is also a form of benevolence and kindness that includes the desire and effort to remediate the troubles (gilbert 2009 ). according to gilbert (2005) , the basic feature that distinguishes compassion from other similar concepts such as empathy, sympathy and altruism is that it has the desire to resolve the pain, the cognitive process of understanding the source of pain and the behavioral process related to performing compassionate actions (gilbert 2005) . at the same time, compassion is formed by a combination of motive, emotion, thought and behavior. in the studies of sprecher and fehr (2005) , compassion is conceptualized as compassionate (sensitive) love. compassionate (sensitive) love is defined as an attitude toward humanity that involves behavior, feeling and thinking that focuses on concern, caring and support for humanity, as well as a motivation to understand and help humanity when they are most in need (i̇şgör 2017b; akdeniz and deniz 2016) . since compassion involves help, volunteerism and interaction, it is behaviorally similar to concepts such as empathy and sympathy. according to neff (2003) , in order for an individual to be compassionate toward others, he/she must first have compassionate and self-compassion toward himself/herself. self-compassion is defined as the self-attentive and understanding of the individual instead of criticizing himself in pain and failure situations, the understanding that the negative factors experienced by the individual are part of the common experiences of all people and the search for logical solutions rather than overcoming negative feelings and thoughts. in the health institutions, the ones who need the feeling of compassion the most are the patients. for this reason, providing health services by the entire healthcare professionals, especially nurses, is important in terms of the status of the diagnosis and treatment process. the feeling of compassion allows healthcare professionals to be affected by the bad events that patients have experienced while providing care and, as a result, to help patients (polat 2016; polat and erdem 2017) . it is one of the expectations of all the nurses working in the health services to offer patient care in a compassionate way. trust, honor, respect, effective communication skills, cooperation with patients and their families are concepts that are intertwined with the concept of compassion. these concepts are necessary for providing compassion, communication and high-quality care. for this reason, nurses should develop sufficient knowledge, technical skills, attitudes and interpersonal relationships for care and also have compassionate care (uğurlu and aslan 2017; çingöl et al. 2018) . nurses, who have been together with the patients for the longest time and who build more face to face communication, are the first applied profession group on all kinds of questions of the patients and their relatives. for this reason, it is important for nurses to show sensitive and compassionate behaviors toward patients and their relatives when they provide diagnosis and treatment services (polat and erdem 2017; pommier 2011) . when the studies in the literature conducted on nursing students related to compassion were examined, the following results were revealed: in the study conducted by çingöl et al. (2018) on 494 health college students, it was determined that the students' level of compassion was high, and it was determined that the students' compassion levels were affected by gender, class and income status (çingöl et al. 2018) . i̇şgör (2017a) found that the variables of the students such as safe and fearful, attachment and academic achievement average were a significant predictor of compassion. in the same year, hacıkeleşoğlu and kartopu (2017) examined the compassion levels of students in five different faculties. according to the results of the research, the compassion levels of the students of the faculty of theology, health sciences and the faculty of economics and administrative sciences were found to be higher than the other faculties (hacıkeleşoğlu and kartopu 2017) . on the other hand, when the studies on nurses are evaluated and obtained results are examined, gök (2015) found that nurses experience compassion fatigue in a qualitative study of nurses' compassion fatigue and determined that they preferred the strategy of being isolated from the mentally and physically intensive care environment in and outside the workplace in order to overcome this trouble (gök 2015) . in the study conducted by erdem and polat on compassion fatigue on 346 health professionals in 2017, compassion fatigue was found to be more common in female nurses taking part in health professionals (erdem and polat 2017). karadağ and bakan (2018) found that the average score of the compassion scale for nurses working in surgical clinics was higher in those who were interested in intercultural nursing and for those who want to get information about this. when all these studies are reviewed, it is noteworthy that the studies in turkey that measure the compassion level of students and the compassion fatigue of nurses are in the majority; however, there are not enough number of studies examining compassion levels of nurses. therefore, it is thought that examining the compassion levels of nurses working in medical and surgical clinics and intensive care units and determining the different variables that affect this level will make a significant contribution to the literature. the aim of this study was to investigate the compassion levels of nurses working in medical-surgical clinics and intensive care units. this descriptive and cross-sectional research was conducted at a university hospital in turkey's marmara region between the dates of march 2018 and may 2018. the population of the study consisted of 400 nurses working during the dates of the research in the medical, surgical clinics and intensive care units of a university hospital. the sample of the study consisted of 227 nurses who could be reached at the time of the study and voluntarily participated in the research (participation level; 56.75%). research data were collected by "nurse identity form" and "compassion scale (cs)." in this form created by the researchers, there were a total of eight questions about the nurses' age, gender, marital status, educational status, the unit in which he/she works, the time he/she works in the profession, the weekly working hours and the empathy developing level with the patient. this scale, which was developed by pommier (2011) and of which turkish validity and reliability test was conducted by akdeniz and deniz (2016) , consists of 24 items and is a 5-point likert-type scale (1 = never, 2 = rarely, 3 = occasional, 4 = frequent, 5 = always). the scale consists of six sub-dimensions: compassion, negligence, sense of sharing purpose, disconnection, conscious awareness and disengagement. the negligence, disconnection and disengagement sub-dimensions of the scale are measured by reversion method. after this measurement, the average of total score is calculated. as the total score obtained from the scale increases, the compassion level also increases. the cronbach's alpha value of the scale was found as 0.85 (akdeniz and deniz 2016) . in this study, cronbach's alpha value was calculated as 0.80. after the purpose of the research was explained to the nurses by the researchers and the voluntary participation of the nurses was provided, the questionnaire forms were distributed and they were asked to respond to these forms. it was taken into consideration to ensure that the duration of the research did not affect the working hours of the nurses. the time to fill in each questionnaire was calculated as approximately 30 min. the evaluation of the data was carried out by using spss (statistical package for social science) 22.0 package. in the analysis of the data, number, percentage, average, independent t test and anova test were used. the statistical significance level was accepted as p ˂ .05. in order to carry out the study, firstly, written permission was received via e-mail from the author who conducted the turkish validity and reliability study of the research. in addition, the approval was received from the ethics committee of the university (decision no: 2018-3/24) and the nurses voluntarily participated in the study. the fact that conducting the study in a single center and in medical, surgical and intensive care units and the fact that the questions were based on the statements of the nurses constitute the limitations of the study. the age average of the nurses participating in the study was 34.54 ± 7.18, and those following results were obtained: 94.3% of the nurses were female; 68.7% of them married; 85.9% of them have bachelor's degree; their term of employment was 12.13 ± 7.96 years; their weekly working hours 43.86 ± 3.72 h; 42.7% of them work in medical clinics; 81.1% of them showed empathy with the patient ( table 1) . the cs total score average of the nurses participated in the study was found to be 97.02 ± 10.67. sub-scale score averages of the scale were found as following: compassion 16.44 ± 2.47, negligence 7.44 ± 2.40, sense of sharing purpose 15.46 ± 2.80, disconnection 7.76 ± 2.29, conscious awareness 16.03 ± 2.47, disengagement 7.70 ± 2.23 (table 2) . the average scores of the cs sub-dimensions based on the introductory characteristics of nurses are given in table 3 . there was no statistically significant difference between the cs total score of the nurses and the sub-scale score averages and gender, marital status and weekly working time (p > .05). on the other hand, a statistically significant difference was found between the age variable of the nurses and the sub-dimension of "disconnection"; between the unit they work and the subdimension of compassion; between the term of employment, education and status of showing empathy to the patients and "conscious awareness" sub-dimension (p < .05). in addition, there was a statistically significant difference between the education level of the nurses and their status of showing empathy to the patients and the cs total score average (p < .05, table 3 ). compassion is a fundamental concept that unites people in difficult times and supports both physical and mental health in human relations (akdeniz 2014; lee and seomun 2016) . compassion not only allows nurses to communicate therapeutically with the patient, but also provides a high-quality care (dewar and nolan 2013) . compassion is one of the characteristics of a good nurse. therefore, it is a key criterion for ensuring satisfaction when giving care to the patient (arli and bakan 2018; lee and seomun 2016) . as a result of this study, the cs average score of the nurses was found to be 97.02 ± 10.67. sub-scale score averages of the scale were found as following: compassion 16.44 ± 2.47, negligence 7.44 ± 2.40, sense of sharing purpose 15.46 ± 2.80, disconnection 7.76 ± 2.29, conscious awareness 16.03 ± 2.47, disengagement 7.70 ± 2.23 (table 2) . considering the highest score that can be taken from the scale, it can be said that the nurses' mercy levels are moderate. in a study conducted by arlı and bakan (2018) in order to determine the compassion level of the surgical nurses, the total average score of the nurses was 96.37 ± 14.35. in a study conducted by i̇şgör (2017a) on university students, the cs total score average of the students was found to be 99.24 ± 11.70. similar results were found in the study of çingöl et al. (2018) on nursing students. our study results are similar to the literature. as a result of the study, there was no statistically significant difference between the cs total score averages of the nurses and the average scores of the scale subdimension with gender, marital status and weekly working hours (p > .05). in the study of arlı and bakan (2018) , it was also reported that the gender factor did not affect the level of compassion in nurses. on the other hand, in the studies conducted by neff and pommier (2013) , çingöl et al. (2018) , hacıkeleşoğlu and kartopu (2017) , polat and erdem (2017) and salazar (2015) , it was emphasized that gender has a significant impact on the level of compassion. it is thought that the difference between the findings of the other studies and the results of this study may be due to the difference in the number of male and female nurses in the sample group. on the other hand, although the difference is not significant, it is seen that female nurses' compassion levels are higher than male nurses. this finding can be said to be an expected result, and this result has been associated with the emotional structure of females and their maternal spirits. a statistically significant difference was found between the age variable of the nurses included in the study and the average of the "disconnection" sub-dimension score. in the study conducted by hacıkeleşoğlu and kartopu (2017) on 490 university students, it was determined that as the age of the students increased, the level of compassion increased. similarly, in the study evaluating compassion fatigue and conducted by polat and erdem (2017) on 346 health professionals, it was determined that as the age of nurses increased, compassion fatigue increased. in contrast, in the study conducted by çingöl et al. (2018) , it was determined that age variable did not affect the compassion levels of the students. it is thought that this difference is due to the difference of the sample group. it was observed that the working units of the nurses participating in the study affected the sub-dimension of compassion (table 3 ). since no similar study has been conducted on the subject before, no finding or supportive finding of this finding has been achieved. in a compilation study, it was reported that nurses working in intensive care, oncology and surgery clinics have more compassion fatigue (dikmen and aydın 2016) . as a result of the study, it was found that nurses' term of employment in the profession, their level of education and empathy to the patient affect the "conscious awareness" sub-dimension; the level of education and the level of empathy to the caregiving patient affected the cs total score averages (table 3 ). in a study by kelly et al. (2015) , it was reported that satisfaction with age and profession affects the level of compassion. in this study conducted by us, the compassion levels of nurses who are postgraduate and always showing empathy to the caregiving patient were found to be higher than other nurses. therefore, it can be concluded that the level of education and empathy have a positive effect on the level of compassion. in the literature; it is reported that there is a close relationship between empathy and sense of compassion (alan 2018; dikmen and aydın 2016; figley 2002) . our results support the literature. on the other hand, the high level of compassion of postgraduate nurses compared to other nurses was interpreted as the fact that nurses may have taken courses in order to develop their skills such as empathy and care. as a result, it was found that the compassion levels of nurses were moderate and the level of education and empathy had an effect on nurses' level of compassion. compassion is an essential component of good nursing care. it is one of the expectations of all the nurses working in the health services to offer patient care in a compassionate way. according to these results, the following points are suggested: • repeating the research on a larger sample in different hospitals, • sharing the findings of the studies with the hospital management, • giving in-service trainings to nurses on compassion, • including courses and subjects that will increase the compassion levels of student nurses in the curriculum during their university education. farklı merhamet düzeylerine sahip üniversite öğrencilerinde depresyon, anksiyete, stres ve duygusal zekânın i̇ncelenmesi (investigation of depression, anxiety, stress and emotional intelligence in university students with different compassion levels) merhamet ölçeğinin türkçeye uyarlanması: geçerlik ve güvenirlik çalışması (the turkish adaptation of compassion scale: the validity and reliability study) merhamet yorgunluğu ve yönetici hemşirenin rolü (compassion fatigue and the role of the nurse manager) cerrahi hemşirelerde merhamet ve kültürlerarası duyarlılığı etkileyen faktörler (the factors affecting compassion and intercultural sensitivity among the surgical nurses) bir sağlık yüksekokulu hemşirelik bölümü öğrencilerinin merhamet düzeylerinin i̇ncelenmesi (the investigation of compassion level of nursing students in a health college) caring about caring: developing a model to implement compassionate relationship centred care in an older people care setting hemşirelerde merhamet yorgunluğu: ne? nasıl? ne yapmalı? (compassion fatigue in nurses: what? how? what to do) compassion fatigue: psychotherapists' chronic lack of self care compassion and cruelty: a biopsychosocial approach introducing compassion-focused therapy süleyman demirel üniversitesi i̇ktisadi ve i̇dari bilimler fakültesi dergisi merhamet ve dindarlık: üniversite öğrencileri üzerine ampirik bir araştırma (compassion and religiosity: an empirical research on university students) merhametin öznel i̇yi oluş üzerindeki yordayıcı etkisinin i̇ncelenmesi (investigating the predictive effect of compassion on subjective well-being) üniversite öğrencilerinde bağlanma stilleri ve akademik başarının merhamet üzerindeki yordayıcı etkisi (an investigation of the predictive effect of attachment styles and academic success on compassion in university students) cerrahi hemşirelerde merhamet ve kültürlerarası duyarlılığı etkileyen faktörler (the factors affecting compassion and intercultural sensitivity among the surgical nurses) predictors of compassion fatigue and compassion satisfaction in acute care nurses role of compassion competence among clinical nurses in professional quality of life the development of validation of a scale to measure self compassion the relationship between self-compassion and other-focused concern among college undergraduates, community adults, and practicing meditators merhamet yorgunluğu düzeyinin çalışma yaşam kalitesi i̇le i̇lişkisi: sağlık profesyonelleri örneği (the relationship between the level of compassion fatigue and quality of professional life: the case of medical professionals). yayınlanmamış yüksek lisans tezi (master's thesis) merhamet yorgunluğu düzeyinin çalışma yaşam kalitesi ile ilişkisi: sağlık profesyonelleri örneği (the relationship between the level of compassion fatigue and quality of professional life: the case of medical professionals) the compassion scale exploring the relationship between compassion, closeness, trust, and social support in same-sex friendships compassionate love for close others and humanity merhamet ve hemşirelik: merhamet ölçülebilir mi? (compassion and nursing can compassion be measured?: review) we thank all of our nurses participated in the study. conflict of interest the authors declare that they have no conflict of interest. informed consent informed consent was obtained from all individual participants included in the study. bold values indicate statistical significance key: cord-262049-c8uzehft authors: li, ruilin; chen, youlin; lv, jianlin; liu, linlin; zong, shiqin; li, hanxia; li, hong title: anxiety and related factors in frontline clinical nurses fighting covid-19 in wuhan date: 2020-07-24 journal: medicine (baltimore) doi: 10.1097/md.0000000000021413 sha: doc_id: 262049 cord_uid: c8uzehft the aim of this study was to examine the anxiety status of the frontline clinical nurses in the designated hospitals for the treatment of coronavirus disease 2019 (covid-19) in wuhan and to analyze the influencing factors, to provide data for psychologic nursing. this study used a cross-sectional survey design and convenience sampling. the questionnaires were completed by 176 frontline clinical nurses. anxiety was determined using the hamilton anxiety scale. general data were collected using a survey. correlation analyses were used. among the 176 frontline nurses, 77.3% (136/176) had anxiety. the anxiety scores of the frontline clinical nurse fighting covid-19 were 17.1 ± 8.1. anxiety symptoms, mild to moderate anxiety symptoms, and severe anxiety symptoms were found in 27.3%, 25%, and 25% of the nurses, respectively. sex, age, marital status, length of service, and clinical working time against covid-19 were associated with anxiety (p < .05). the frontline nurses working in the designated hospitals for the treatment of covid-19 in wuhan had serious anxiety. sex, age, length of service, and clinical working time against covid-19 were associated with anxiety in those nurses. psychologic care guidance, counseling, and social support should be provided to the nurses to reduce their physical and mental burden. nursing human resources in each province should be adjusted according to each province's reality. china is a vast country with complicated terrain in various provinces and cities. major natural disasters, accidents, public health and safety incidents, and diseases and epidemics occur from time to time. [1] severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is currently endemic in china, causing a large number of cases of coronavirus disease 2019 (covid-19), which can cause severe respiratory disease and death in severe cases. since december 2019, the virus has been spreading throughout the country and the entire world, and the world health organization raised a level 1 alert. as of february 2, 2020, a total of 14,423 cases were confirmed in china, of which 304 died, for a mortality rate of 2.1% in china. nowadays, person-to-person transmission and aerosol transmission are recognized as transmission ways between nurses and patients and within families. medical personnel is the core of the rescue team. [2] nurses are always present to the frontline of any public health situation or crisis, and human-to-human transmission and aerosol transmission will not only harm the frontline nursing staff but also bring great psychologic impact. at present, china has a large number of nurses engaged in the battle against covid-19. due to the sudden outbreak of sars-cov-2, the number of nurses involved in the response was very limited, and most of them did not have enough experience and preparation to deal with it. [3] disasters always cause psychologic problems of varying degrees. [4] covid-19 was not only a disaster to the chinese community but also a critical challenge for the medical staff, with its load of detrimental psychologic impacts. nevertheless, when facing a deadly situation involving a dangerous virus, large numbers of patients, and highly intensive work, psychologic problems of different degrees are bound to occur. [5] to fight the psychologic war against this "psychologic epidemic" secondary to covid-19, it must first be characterized to manage it appropriately. the first of patients with covid-19 reported exposure to a large seafood and live animal market in wuhan city, hubei province, suggesting a potential zoonotic origin. wuhan city is at the core of the battle against sars-cov-2 and is also the hardest-hit area in china. to understand the psychologic state of the first cohort of frontline nurses in the designated hospitals in wuhan city, we investigated and analyzed their anxiety and the related factors, hoping to provide data for the psychologic intervention of frontline and rescue nurses. frontline nurses in hospitals treating covid-19 in hubei province in january 2020 and february 2020 were enrolled. the nurses were from the tertiary hospitals in wuhan city, hubei province, that were designated to receive new patients with covid-19. this study was approved by the ethics committee of the guangxi university of chinese medicine. informed consent was obtained from all participants included in the study. two scales were used to collect the data. the general information questionnaire included sex, age, ethnicity, length of service, professional title, education level, marital status, and clinical working time against covid-19. the hamilton rating scale for anxiety (hama) [6] is the most commonly used clinician-rated measure of anxiety in the treatment studies of depression. [7] it consists of 14 symptom-defined elements, and covers both psychologic and somatic symptoms, comprising anxious mood, tension (including startle response, fatigability, and restlessness), fears (including of the dark, strangers, and crowds); insomnia; "intellectual" (poor memory or difficulty concentrating); depressed mood (including anhedonia); somatic symptoms (including aches and pains, stiffness, and bruxism); sensory (including tinnitus and blurred vision); cardiovascular (including tachycardia and palpitations); respiratory (chest tightness and choking); gastrointestinal (including irritable bowel syndrome-type symptoms); genitourinary (including urinary frequency and loss of libido); autonomic (including dry mouth and tension headache), and observed behavior at interview (restless, fidgety, etc). according to the data provided by the scale collaboration group in china, a total score ≥29 indicated severe anxiety, ≥21 points indicated obvious anxiety, ≥14 points indicated anxiety; ≥7 points indicated possible anxiety, and <7 points indicated no symptoms of anxiety. in this survey, a total of 176 participants completed the survey. for those participants, 176 questionnaires were collected, and all the answers were completed, for an effective recovery rate of 100%. the questionnaires were made on the network questionnaire platform "wenjuan star" and distributed on the platform "wechat." before the investigation, a wechat group was established to invite the frontline clinical nurses to join the group. the researchers explained in detail the purpose of the survey, the principle of anonymity and confidentiality in the group, required the respondents to truthfully answer according to their actual situation, forwarded the qr codes to the wechat group, and notified the respondents to fill in and submit it during their rest time. the collected data were analyzed using spss 21.0 (ibm, armonk, ny). categorical data were expressed as absolute numbers and percentages (%). continuous data were expressed as mean ± standard deviation and analyzed using the student t test, analysis of variance, and correlation analysis. statistical significance was defined as p < .05. there were 176 participants included in the study. the characteristics of the frontline clinical nurses working against covid-19 are shown in table 1 . the average anxiety score of the 176 nurses was 17.1 ± 8.1, and 77.3% of them had anxiety symptoms. to determine the factors that influenced the anxiety of the frontline clinical nurses against covid-19, univariable analyses were performed. the results showed that sex, age, length of service, and clinical working time against covid-19 were associated with anxiety (all p < .05, table 2 ). the anxiety scores table 1 the sociodemographic characteristics of the frontline clinical nurse against covid-19 (n = 176, %). in females were significantly higher than that of males (p < .05). older nurses had higher levels of anxiety than younger nurses (p < .05). married nurses had higher levels of anxiety than unmarried nurses (p < .05). the longer the clinical hours spent fighting covid-19, the higher the anxiety level (p < .05). the shorter the clinical service, the higher the anxiety level (p < .05) the pressure source of nursing work can come from the objective environment as well as from subjective perception. [8] the sars-cov-2 is a new, highly infectious coronavirus never before encountered by humans. thus, patients need long-term care by the doctors and nurses, and this will disrupt the normal life and work to a certain extent. at the same time, long-term fights, instability, and uncertainty of patients' condition, and concerns about the health status of patients have a huge impact on the physiology, psychology, and quality of life of the nurses. [9] with the outbreak of infectious public health events, most frontline nurses do not know much about the new or sudden infectious diseases and closed management, leading to fear. [10] in the present study, 136 (77.3%) frontline nurses had symptoms of anxiety, and 44 (25%) had severe anxiety, which is consistent with the 72.8% incidence of anxiety and depression symptoms of nurses in previous studies. [11] this indicates that the disaster brings serious psychologic problems to the frontline nurses, whose inner trauma is an urgent problem to be solved. the causes for the psychologic response in the frontline nurses mainly include the following aspects. 4.2.1. the supply of protective equipment is tight, and nurses are insecure and worried about infection. in the face of covid-19, the protection requirements for paramedics are very strict. various papers and textbooks plainly describe wearing level-d protective clothing against respiratory viruses, but in practice, this is not a simple task. it takes at least 5 minutes to wear it, and taking off level-d protective clothing is even more difficult than putting it on. to save the protective clothing and the time to change protecting clothing, nurses wear diapers to work, are unable to drink water, and are unable to go to the toilet. because adult diapers do not contain much, the nurses are limited to the consumption of small amounts of milk, which will aggravate the anxiety and depression of nurses. our research showed that female nurses were more anxious than male nurses. the physiologic characteristics of a female are divided into 2 aspects: physiologic and psychologic. physically, females are not as physical as men; psychologically, females' nursing personnel were slightly more resilient than males, and females are more sensitive than males. this physical discomfort exacerbated the female nurse's anxiety. our research shows that the longer the nurses work at the frontline against covid-19, the more anxiety they experience. because they did not know the virus, the source of infection, and transmission, and they lacked awareness of prevention and control in the early stages, the nurses had high levels of anxiety. despite the improving knowledge of covid-19, the psychologic pressure of the nurses was increasing. anxiety among nurses has been exacerbated by the recent discovery that covid-19 can also be transmitted through aerosols. in this information age, a large number of unverified statements are reported in the news, causing panic among the public. at first, a large number of patients rushed to the hospital, aggravating the burden of the first cohort of designated hospital nurses. in such an environment, the anxiety of the frontline nurses in wuhan hospitals, which have been exposed to patients with covid-19 for the longest time and have the largest number of patients, will be further intensified. according to a study, 100% of the nurses in the infection department of the emergency department requested to be transferred, because they were concerned about the threat of environmental safety to health. [12] the results also showed that marital status was another relevant factor. the main reason is that nurses worry about spreading the virus to their families, or that they do not have the equipment or medication to treat them. there were nurses or family members of nurses who are infected, who had no beds, no hospitalization, and no privilege. in the face of anxiety, the body can relieve stress through its own mechanism. nevertheless, the frontline nurses were in a state of overload and super-intense work, constantly under stress, and on the verge of physical and table 2 the hars scores of the frontline clinical nurses against covid-19 (n = 176). psychologic limits. the intensity and strain of the work of the medical staff in the isolation wards during the response to sars was one of the main factors for psychologic stress. [13] from the perspective of sex, women's physical ability is not as good as men's, and the excessive workload inevitably leads to women's greater anxiety than men. another factor was that the longer they spent at the frontline, the more anxious and depressed the nurses were. the frontline nurses were scheduled in the apn mode, and each shift lasts 8 hours. due to a large number of patients, unstable conditions, and rapid changes in the condition, nurses actually worked an average of 10 hours per day, and some nurses worked up to 40 hours per week. nurses are expected to work in a meticulous, long, and focused environment, which is another major contributor to anxiety, which is supported by a previous study. [14] in the face of such a huge workload and a strong source of infection, many frontline nurses were infected, some have fallen ill, suspected infected nurses were isolated, the number of nurses able to work normally was declining, and the workload was increasing. long-term overload and super-intense work make nursing staff in the state of constant stress, on the verge of physical and psychologic limits. in addition to preventing infection, mental health is crucial. only by maintaining a healthy state of mind can we put ourselves into work efficiently. in the face to the patients suddenly increasing fever and human resource gap, hospital nursing staff from other departments were deployed, the non-nursing staff was also deployed, leading to less experienced staff having to deal with covid-19, further increasing stress and psychologic pressure. our results showed that age and length of service were 2 related factors influencing the anxiety of frontline nurses. by comparing the anxiety of the frontline nurses of different working ages, it was found that the incidence of anxiety in nurses with low seniority was higher, while the incidence of anxiety in nurses with high seniority was lower, which may be related to long-term psychologic stress and clinical knowledge. the results show that most frontline nurses were young and middle-aged, mainly female, and with experience of 1 to 10 years (81.8%). they lack experience, and, in the face of such a sudden disaster, their psychologic fear, psychologic endurance will be poor. as someone once said: "they are just a group of children, changed in a suit of clothes, the appearance of scholars predecessors, healing and saving people, and death rob people!" 4.2.4. guidance of public opinion. this outbreak is significantly different from the information transmission speed of sars in 2003. in the present outbreak, the information transmission speed is faster, but the authenticity of a lot of information cannot be guaranteed, which aggravates people's suspicion and worry and easily causes fear, which further aggravates the psychologic burden of the nurses. 4.3.1 as a professional medical worker, they first need to do is acquire a correct understanding of covid-19 and avoid the rumors on the internet. it is also essential to be able to disseminate knowledge accurately and not panic in the face of the disease. to carry out authoritative interpretation and education in a timely manner, the frontline nurses can update their knowledge of covid-19 timely through professional education in 5 minutes at the time of shift change or authoritative release of wechat groups, compilation manual of data, etc, so that the frontline nurses can know clearly that what they have done is the best treatment plan to achieve consistent thinking, consistent action, confident, and orderly in their work. in this way, the anxiety caused by fear, remorse, and guilt is eliminated. 4.3.2 covid-19 knowledge training should be taken up with their jobs. they should carry out preventive interviews to discuss their inner feelings with the appropriate resources for healthcare workers to manage their stress. 4.3.3 after entering the frontline of the epidemic, scientific, rational, and clear management and division of labor should be strengthened, with clear working standards and targets. unnecessary repetitive work should be reduced, and reasonable and effective incentive strategies should be established. reasonable schedule, appropriate relaxation and rest, and adequate sleep and diet should be emphasized. good interpersonal relationships, including medical care relationship, doctor-patient relationship, the nurse-patient relationship should be established and maintained to improve medical tasks and achieve medical goals by establishing a harmonious working atmosphere. 4.3.4 in the face of an outbreak, everyone has more or less negative emotions, especially healthcare workers, directly facing the patients. when there are negative emotions, we should reasonably face and accept the emergence of these emotions, and fully accept the rationality of the emergence of these emotions. passing over and self-blame because of these emotions will eventually lead to a vicious circle of emotions and aggravation. negative emotion management should be done well, as follows. 4.3.4.1 when emotions are difficult to control and affect work status, it is recommended to leave the stressor temporarily if possible. for example, the sense of helplessness in the face of illness, in the face of criticism from patients or family members. taking time off can help calm emotions quickly and allowing a return to work. 4.3.4.2 learning the correct expression, confiding to colleagues and friends around, making daily scheduled calls and information exchange with family members, and writing down the emotions on paper and then tearing up the paper into the trash can might help emotional catharsis. crying is not a characteristic of the weak. tears can be a source of emotional catharsis and relaxation, conducive to the maintenance of mental health. in addition, patients with very severe anxiety should use this time for possible psychologic treatment. 4.3.4.3 when taking a break from work, the nurses should try not to get information about the epidemic, should avoid relevant materials and circle of friends, chat with the people around about some irrelevant topics, and pay attention to nutrition, appropriate physical exercise, and relaxation. 4.3.4.4 during work, the nurses should focus on doing a good job in each medical process, focus on helping everyone around, affirm the value of each work, and timely encourage and affirm the work of their colleagues. in particular, they should avoid feeling guilty for a small mistake or blame others for mistakes. what is most needed in emergency work is mutual help and awareness of making up for it. in some powerless occasions, the nurses should tell themselves that they are not omnipotent, that their energy is limited, that it is impossible to do all on their own to help everyone around them, and to rely on partners. 4.3.5 whenever possible, they should try to keep in touch with their family and the outside world. they should control the situation of their family and friends to alleviate the worry about family and friends. they should be aware of the outside world and reduce the feelings of isolation. 4.3.6 they should build a place in their heart that is their own and cannot be disturbed by outsiders or living things. it must be a safe environment for use and control. it can be a familiar bed, a small yard, a small room, etc. in the process of memory, we are already feeling rest and relaxation. in the process, the nurses can mentally direct themselves to suggest to themselves "i am particularly comfortable and safe in that place, and this place is bounded and relaxed," to stimulate and evoke physical sensations, and to allow the body to fully relax and rest before resuming the fight. 4.3.7 for relaxation training, they should lie flat on a bed in a comfortable position with one hand on their abdomen and the other on their chest. they should exhale slowly to feel that their lungs have enough space to breathe deeply. they should breathe in slowly through their nose until they can breathe no more, then slowly exhale through the mouth, with the thought that all the annoyance pressure is exhaled with the dirty gas. this should be repeated for 10 minutes with smooth, soothing music. in summary, 77.3% of the nurses working at the clinical frontline against covid-19 had anxiety symptoms. about 25% of the frontline nurses had severe anxiety symptoms, indicating the emotion and burden of the nurses are not optimistic. sex, work experience, and frontline care time were major influencing factors of frontline clinical nurses' emotions. these results indicate that clinical nurses should receive psychologic care guidance, counseling, and social support to improve their mental health. the research time was limited, and the number of participants was limited. therefore, there are some limitations in the investigation of the psychologic state of the frontline medical workers. knowledge of disaster relief among nursing staff: situation and countermeasures investigation on mental stress reaction of cibiliannurese in a military hospital to earthquake disasters long-term effects of disaster exposure in early life on mental health throughout population life cycle survey on psychological stress response of civilian nursing staff in military hospital to earthquake disaster the assessment of anxiety states by rating pharmacologic treatment of dimensional anxious depression: a review the study of relationship among stressor, coping style and anxiety situation of infectious disease nurse independence and cognition poststroke and its relationship to burden and quality of life of family caregivers a qualitative study on the psychological state of nurses in emergency banks for infectious diseases psychological status survey of first clinical first-line support nurses fighting against pneumonia caused by a 2019 novel coronavirus infection general hospital infection nurse request for post transfer and reasons for resignation experience of mental state and adjustment measures of sars ward nurses a survey of psychological health state of medical and nursing staffs of fever out -patient clinic in military hospitals during sars epidemic period and analysis of its related factors medicine (2020) 99:30 www.md-journal youlin chen contributed equally to this study and are co-first authors. study design: ruilin li, jianlin lv and linlin liu. data key: cord-254654-sxbwwmil authors: chan, moon fai; chan, suk hing; day, mary christine title: a pilot study on nurses' attitudes toward perinatal bereavement support: a cluster analysis date: 2004-04-30 journal: nurse education today doi: 10.1016/j.nedt.2003.11.009 sha: doc_id: 254654 cord_uid: sxbwwmil abstract aim: nurses' attitudes towards perinatal bereavement care are explored by identifying profiles of nurses working in a hong kong obstetrics and gynaecology (oag) unit. relationships between nurses' attitudes towards bereavement support, need for bereavement training and hospital policy are explored. research method: 110 nurses recruited from the oag unit of a large hong kong public hospital completed a structured questionnaire. outcome measures: attitudes towards perinatal bereavement support; required support and training needs for nurses on bereavement care. results: two-step cluster analysis yielded two clusters. cluster a consisted of 55.5% (n=61) and cluster b consisted of 44.5% (n=49) of nurses. cluster a nurses were younger, had less oag experience, more junior ranking and less education than cluster b nurses. cluster b nurses had additional midwifery and bereavement care training, personal grieving experiences and experience handling grieving clients. the majority held positive bereavement care attitudes. significant differences towards perinatal bereavement support were found. only 25.5% (n=28) had bereavement related training. attitudes towards bereavement care were positively correlated with training needs (r s=0.59) and hospital policy support (r s=0.60). conclusion: hong kong nurses emphasized need for increased bereavement care knowledge and experience, improved communication skills, and greater hospital and team members' support. findings may be used to improve support of nurses, to ensure sensitive bereavement care in perinatal settings, and to enhance nursing curricula. during the last 20 years, there have been numerous publications concerned with bereavement coun-selling services in western countries (maccarthy and mackeith, 1965; beem et al., 1998; gardner, 1999; gensch and midland, 2000; engler and lasker, 2000) . gensch and midland (2000) have been addressing the needs of parents whose babies die during pregnancy or shortly after birth since the early 1980s. the 'resolve through sharing (rts) program' was the first well-developed model. they use it to support bereaved couples and families nurse education today (2004) 24, 202-210 intl.elsevierhealth.com/journals/nedt nurse education today experiencing pregnancy or perinatal loss. in 1982, gardner (1982) developed a questionnaire to assess the needs and feelings of 44 nurses who cared for bereaved parents. one year later, gardner (1983) surveyed 100 couples that had experienced stillbirth. her study revealed that the most helpful care practices were the ones least used by the nurses who cared for them. another important resource for bereavement care services was written in 1986 by limbo and wheeler (1998) . it is considered the 'bible' for newcomers interested in this area of nursing. pregnancy and childbirth are times of great joy and rejoicing, and women generally approach motherhood with happiness. because it is usually sudden and contrary to the expected pattern of events, a perinatal loss can be considered particularly traumatic for women who experience it (symes, 1991) . induced or spontaneous pregnancy loss may cause sustained psychological morbidity (lewis, 1976; lloyd and laurence, 1985) . it is likely that the attitudes of medical and nursing staff can influence recovery from a pregnancy loss and that nurses with a positive attitude to bereavement care can help bereaved families to cope during their grieving period (lewis, 1976) . in 1999, more than 50,000 babies were born in hong kong. sadly, in that year, the perinatal mortality rate was 5.7 per 1000 total births (hospital authority, 2003) . consequently, many hospitals in hong kong set-up grief counselling and support teams composed of physicians, nurses and clinical psychologists. the role of these units is to offer bedside emotional support (care) to bereaved couples. the support service facilitates the recovery of bereaved couples going through the period of grieving. this is congruent with the organizational mission of the units, which is to enhance quality patient-centred services through teamwork. however, caring for and supporting parents whose baby has died is extremely demanding, difficult and stressful (nussbaumer and russell, 2003; billson and tyrrell, 2003) . therefore, nurses involved in the care and support of bereaved parents need to be trained with the relevant knowledge, skills and understanding to acquire sufficient confidence in their ability to provide adequate and appropriate care (de groot-boll€ ujt and mourik, 1993) . it is recommended that pre-registration, post-registration and in-service training be provided for nurses who will care for those who have lost a baby. thus, special skills are needed to help bereaved parents. after appropriate training, it is logical to assume that nurses are better equipped to cope with perinatal bereavement (stillbirth and neonatal death society, 1991) . in dealing with bereavement care, the most important attitude is caring. the attitudes of nurses can affect the quality of care provided to support bereaved parents and families experiencing perinatal loss. nursing care may not be based on individual care, but rather on the attitudes of nurses (shaw and heyman, 1982) . when nurses provide bereavement care, negative attitudes may distract from the provision of good care; whilst positive attitudes can help bereaved couples to cope with the grieving process and create memories for the future. this study was undertaken to address the paucity of information available on nurses' attitudes towards perinatal bereavement support in hong kong. this quantitative study was conducted with the aim of helping to fill this gap and the findings may provide valuable baseline information for future studies. the aim of this research was to study nurses' attitudes towards perinatal bereavement support. three specific research objectives were formulated: 1. to identify profiles of nurses based on their demographic variables and their attitudes toward perinatal bereavement support; 2. to explore any differences among nurses' attitudes towards bereavement support in terms of demographics, practical experience and training factors in the different profile groups; 3. to explore the relationship between nurses' attitudes towards bereavement support, their need for bereavement training and hospital policy. convenience sampling was chosen for this study, which involved nurses working in the department of obstetrics and gynaecology (oag) in one of the largest hospital in hong kong. the nurses included student nurses/midwives, registered nurses/midwives, nursing officers, ward managers and nurse specialists and nurse educators. in this study, a structured self-reported questionnaire was used to collect data. permission was obtained from the hong kong hospital authority. prior to the study, an information sheet was given to all nurses explaining the purpose and procedures of the survey. in order to answer any possible questions that potential participants might have about the study, a contact person and telephone number were provided. all participants were asked to sign a consent form attached to the questionnaire. participants nurses' attitudes toward perinatal bereavement support 203 were told that all information would be treated confidentially. names and staff ids were not indicated on the returned questionnaires. the questionnaire was distributed to nurses at their work place through their ward managers. instructions were given to complete and return the questionnaire to the researcher by mail within one week. totally 125 questionnaires were sent out, 110 were completed and returned, for a response rate of 88%. an intensive study of the existing literature describing nurses' attitudes towards perinatal bereavement revealed 21 items considered to be important to train nurses for caring and supporting bereaved parents and families. conceptually, three dimensions could be distinguished. a panel of experts (a nurse specialist, a senior medical officer and a clinical psychologist) established content validity. a pilot study was performed with five nurses working in the oag of a hospital other than the target hospital. after the pilot and repeated discussions with the expert panel, three aspects of the questionnaire were confirmed: (1) nurses' attitudes towards perinatal bereavement support, (2) the importance of hospital policy, and (3) training on perinatal bereavement support. the content validity indices (cvi) ranged from 0.78 to 0.89 for sub-aspects, with an overall score of 0.86. shelley (1984) stated that a cvi below 0.50 for a measure indicated an unacceptable level of content validity. since these values were greater than this level, the measure was deemed acceptable. respondents were asked to rank each item, in each part, on 5 point likert-type scales. part one comprised demographic data (i.e., age, education level, recent ranking and religious background), experience aspects (i.e., personal grieving, handling grieving clients and years of work in the oag unit) and training aspects (i.e., midwifery and bereavement care). this information provides knowledge about participants, and is used to determine differences between or within groups related to the data obtained (i.e., attitude scores). part two comprised 9 attitude statements formulated to measure nurses' general attitudes towards bereavement care (1 ¼ strongly disagree, 5 ¼ strongly agree). part three is composed of two sections; the first section comprised four statements to evaluate nurses' attitudes on the importance of hospital policy on perinatal bereavement (1 ¼ very unimportant, 5 ¼ very important). the second section comprised eight statements to evaluate nurses' attitudes on the importance of formal training to deal with perinatal bereavement care (1 ¼ very unimportant, 5 ¼ very important). for all statements in part two, a high score indicates a positive and favourable attitude towards perinatal bereavement support. in part three, a high score indicates attitudes that are highly influenced by policy and a high demand for nurses with perinatal bereavement care training. descriptive statistical analysis of the quantitative data was conducted using spss 11.5 (spss inc., 2002) . several statistical techniques were employed for analysis of the data. a cluster analysis was used to group the study sample into several groups. this analysis, also called segmentation or taxonomy analysis, is a way to create groups of objects, or clusters in such a way that the profiles or characteristics of nurses in the same cluster are very similar and that the profiles of nurses in different clusters are quite distinct (chan et al., 2003) . in this study, the analysis was based on four main variables: (1) demographic variables; (2) attitudes towards bereavement care variables; (3) attitudes on the importance of hospital policy on perinatal bereavement variables; and (4) attitudes on the importance of formal training to deal with perinatal bereavement care variables. the analysis used standardized values (z) based on these variables. two-step cluster analysis was used for this study. in this technique, nurses are sequentially merged into a decreasing number of clusters until the conjoint set contains all nurses (spss inc., 2002) . the choice of a similarity measure and the determination of the number of clusters were based on the log-likelihood distance and schwarz's bayesian information criterion (bic), respectively (spss inc., 2002) . differences between the cluster groups were delineated descriptively. due to ordinal data and skewed patterns in most of the outcomes, chi-square test and mann-whitney u-test were used to test differences in various nurses' characteristics between the clusters (hall-lord et al., 1999) . in addition, factor analysis was used to identify the number of factors, and cronbach's alpha coefficients were used to examine the internal reliability of each part of the instrument. spearman's correlation coefficients (r s ) were used to quantify the relationship between the three attitude scores. results were considered significantly different at p < 0:05. the two-step cluster analysis yielded two clusters based on schwarz's bic ¼ 2843.975 and the highest log-likelihood distance measures (ratio ¼ 1.875). of the study nurses, cluster a consisted of 55.5% (n ¼ 61) and cluster b consisted of 44.5% (n ¼ 49). the two subgroups of nurses (clusters) were formed on the basis of the similarity of their responses to the instrument. the two nurse profiles were compared with regard to four main variables. the variables included: (1) demographic data (i.e., age, education level, recent ranking, etc.); (2) attitudes toward bereavement care (9 items); (3) attitudes toward hospital policy to bereavement care (4 items); and (4) attitudes on training for bereavement care (8 items). profiles are depicted in tables 1 and 2 . (1)(3) (4) the sample consisted of 110 nurses, their personal characteristics are shown in table 1 comparison of attitudes toward bereavement care data table 2 displays the results in which nurses responded to items on nurses' attitudes towards bereavement care (statements 1-9). there were significant differences in the nurses' preferences between the two clusters for all items. most nurses in cluster a agreed that item (1): the grief counselling programme (75.4%, n ¼ 46) and item (2): the 'good-bye baby' parent support group (83.6%, n ¼ 51) can provide support to bereaved couples. however, 24.6% (n ¼ 15) of nurses in cluster a were uncertain/disagreed/ strongly disagreed about items (3) and (5). significant differences were found compared with the nurses in cluster b for item (3) [14.3%, n ¼ 7; v 2 ¼ 8:7, p < 0:013] and item (5) [4.1%, n ¼ 2; v 2 ¼ 15:3, p < 0:001]. in cluster a, 13.1% (n ¼ 8) and 21.3% (n ¼ 13) of nurses were uncertain about whether to give parents time to grieve or not (item 6) and whether they should be treated with respect and dignity (item 7), respectively. by contrast, 61.2% (n ¼ 30) and 55.1% (n ¼ 27) of nurses in cluster b were in strong agreement with item 6 (v 2 ¼ 30:4, p < 0:001) and item 7 (v 2 ¼ 34:6, p < 0:001), respectively. for the total sum scores, nurses in cluster b showed significantly higher scores (mean ¼ 39.2, sd ¼ 3.5) than nurses in cluster a (mean ¼ 35.2, sd ¼ 3.5; u ¼ 631:5, p < 0:001). four items (statements 10-13) were related to hospital policy support for bereavement practices (see table 2 ). for the four items and their total scores, comparisons were made between the nurses in the two clusters. there were significant differences between the two clusters in the nurses' preferences for all items. for example, 24.5% (n ¼ 12) of nurses in cluster b claimed that it is very important that there should be an operational policy on bereavement care in the obstetric unit, but of nurses in cluster a, only 3.3% (n ¼ 2; v 2 ¼ 23:1, p < 0:001) were in agreement. over 40.0% of nurses in cluster b claimed that it was very important that the policy should be well informed (44.9%, n ¼ 22) and understood (42.9%, n ¼ 21) by all staff, which was different from nurses in cluster b where 19.7% made that claim (n ¼ 12; v 2 ¼ 10:0, p ¼ 0:007) and 24.6% (n ¼ 15; v 2 ¼ 7:9, p ¼ 0:019), respectively. for the total sum scores, nurses in cluster b showed significantly higher scores (mean ¼ 17.5, sd ¼ 1.9) than the nurses in cluster a (mean ¼ 15.7, sd ¼ 1.8; u ¼ 752:5, p < 0:001). eight items (statements 14-21) reflected the responses of nurses on the need for formal education and training in grief counseling (see table 2 ). in general, most of the nurses in the two clusters perceived training to be very important/important. however, more than 14.0% of nurses in cluster a claimed that their need to participate in bereavement care (19.7%, n ¼ 12), join relevant training programmes (14.8%, n ¼ 9), and to be equipped with relevant knowledge, skills and understanding required to support and care for bereaved parents was uncertain/unimportant/very unimportant. this was significantly different from nurses in cluster b. for the sub-total scores, nurses in cluster b showed significantly higher scores (mean ¼ 35.1, sd ¼ 3.1) than the nurses in cluster a (mean ¼ 33.0, sd ¼ 4.2; u ¼ 1041:0, p ¼ 0:006). for all nurses, three factors were generated that accounted for 57.8% of the variance. factor 1 accounted for 19.2% of the variance (factor loading ranged from 0.49 to 0.71) and reflected concerns related to nurses' attitudes towards perinatal nurses' attitudes toward perinatal bereavement support 207 bereavement care. factor 2 contributed 15.6% of the variance (factor loading ranged from 0.49 to 0.89) and focused on the need for bereavement care training. factor 3 was comprised of items related to hospital policy related to bereavement care and accounted for 23.0% (factor loading ranged from 0.60 to 0.81) (see table 2 ). overall, the cronbach's alpha of the instrument for 21 items was 0.92. the internal reliability of the subscales was 0.86, 0.83 and 0.90, respectively for the nurses' attitudes towards perinatal bereavement support scales, the importance of hospital policy scales, and perinatal bereavement support training scales. for nurses in cluster a, three factors were generated that accounted for 52.4% of the variance. factor 1 accounted for 17.2% of the variance (factor loading ranged from 0.37 to 0.74). factor 2 contributed 12.6% of the variance (factor loading ranged from 0.48 to 0.91). factor 3 accounted for 22.6% (factor loading ranged from 0.58 to 0.85). overall, the cronbach's alpha of cluster a for 21 items was 0.89. the internal reliability of the subscales was 0.80, 0.76 and 0.89, respectively for the nurses' attitudes towards perinatal bereavement support scales, the importance of hospital policy scales, and the perinatal bereavement support training scales. for nurses in cluster b, three factors were generated that accounted for 60.8% of the variance. factor 1 accounted for 20.0% of the variance (factor loading ranged from 0.38 to 0.79). factor 2 contributed 25.0% of the variance (factor loading ranged from 0.36 to 0.88). factor 3 accounted for 15.8% (factor loading ranged from 0.35 to 0.76). overall, the cronbach's alpha of cluster b was 0.92, and the internal reliability of the subscales was 0.84 (attitude towards perinatal bereavement support scales), 0.84 (the importance of hospital policy scale) and 0.89 (perinatal bereavement support training scales). all scales for all nurses and for nurses in each cluster demonstrated satisfactory internal reliability based on the typical alpha threshold for a new instrument (nunnally, 1978) . the relationships between the three attitude sum scores were analyzed by spearman's correlation coefficient (r s ). the results showed that nurses' attitudes towards bereavement care were significant positively correlated with both the hospital policy on bereavement management of (r s ¼ 0:60, p < 0:001) and the need for education and training in bereavement care (r s ¼ 0:59, p < 0:001). this paper aimed to explore some major attitudes of nurses working in the oag ward. this study identified two clusters on the basis of four aspects of attitudes toward bereavement care (i.e., demographic variables and three attitude scores). there were statistically significant differences between the two clusters for most of the demographic variables and the three attitudes scores, except for religious beliefs (see table 2 ). the findings suggest that for these two groups of nurses there were differences in the level of attitudes towards bereavement care. nurses in cluster b were more prepared with the knowledge needed to handle/carry out bereavement care, while nurses in cluster a were 'green' in this area and needed more training and support. they also believed that nurses working in the unit could offer comfort and institutional support, and provide information that would help bereaved parents make acceptable plans and decisions for themselves. another study finding is that nurses have very positive attitudes towards grief counselling programmes. however, almost all of the respondents viewed their relevant level of grief counselling knowledge and understanding as insufficient. in total, only 25.5% (n ¼ 28) had taken courses related to bereavement care. because they lacked training in grief counselling, they felt inadequately prepared to provide bereavement care independently and confidently. this finding is supported by studies (e.g. mcguinness, 1988; szgalsky, 1989; wright, 1991; rybarik, 1996; yam et al., 2001) that have found that support and education were necessary to help nurses in their work with the bereaved. these results highlight a number of areas that need to be addressed by nurse educators, and the outcomes challenge them to emphasize the importance of grief counselling on caring behaviour in the nursing curriculum. attitudes are influential in determining behaviour (todman and jauncey, 1986) . it is believed that a greater awareness and knowledge of grief counselling would lead to more sympathy, understanding and practical help from nurses. in this study, nurses in cluster a urgently needed training and institutional support. recently, hong kong's severe acute respiratory syndrome (sars) crisis showed the significant impact that a lack of institutional support, including 208 m.f. chan et al. additional training, as well as resource limitations and heavy workload can have as they result in major sources of job stress. in such an environment, bereavement care is necessary, but produces uncertainty, anxiety and often frustration for nurses. the goal of holistic quality care can only be achieved when nurses' education and training needs are addressed. otherwise, caring for a family that has experienced a perinatal death creates a crisis situation for nurses. in this study, the attitudes of nurses in hong kong towards perinatal bereavement care emphasized their need for increased knowledge and experience, improved communication skills, and greater support from team members. hong kong health care professionals may use these findings to improve the support of nurses, to ensure the delivery of sensitive bereavement care in the perinatal setting, and to enhance curricula in schools of nursing. nursing educators must focus on the affective domain, as well as the cognitive learning needs of nurses when perinatal bereavement is addressed. in line with most research, this study had a few limitations that affect its outcomes. one potential limitation is that data for this study used a selfreport questionnaire, which may cause possible response bias from each responder (polit and hungler, 1995) . second, sample sizes chosen in this study were relatively small and were restricted to one hospital only. thus, the results cannot represent the attitudes of all classes of nurses in hong kong. truly, this study can be seen as a pilot study only. further study should proceed at other hospitals. third, respondent honesty (or lack thereof) is a potential source of error in selfreport surveys (siegel et al., 1998; james et al., 1991) . although replies did not include the names or staff ids of individual nurses, they might have perceived pressure from senior management or the hospital to respond. this might account for the high response rate seen in this study and for the positive attitudes given in their responses. to reduce such errors, face-to-face interviews could be a better method to improve the accuracy of the results but it is more costly in terms of time, manpower, and money (oei and zwart, 1986) . further research is needed to explore common feelings and coping behaviours of bereaved parents in caring programmes offered by nurses working in oag units. workshops to support the bereavement process how to break bad news attitudes of 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events: selfadministered questionnaire versus interview nursing research: principles and methods what communication skills are most helpful with families grieving a perinatal loss? how can i express my concern while providing appropriate care? awhonn voice changes in patterns of care of the mentally handicapped: implications for nurses' perceptions of their role in hospital decision making process research methods in nursing and health self-reported honesty among middle and high school students responding to a sexual behavior questionnaire stillbirth and neonatal death society (sands-1991). miscarriage, stillbirth and neonatal death: guidelines for professionals what comfort for this grief? coping with perinatal bereavement perinatal death, the family, and the role of the health professional student and qualified midwives' attitudes to aspects of obstetric practice sudden death: intervention skills for the caring professions caring for dying infants: experiences of neonatal intensive care nurses in hong kong the authors would like to thank the nurses who volunteered to participate in this study. also the comments from the reviewers improved the quality of this paper. key: cord-257917-4496gzdu authors: liou, shwu-ru; liu, hsiu-chen; tsai, hsiu-min; chu, tsui-ping; cheng, ching-yu title: relationships between disaster nursing competence, anticipatory disaster stress and motivation for disaster engagement date: 2020-02-25 journal: int j disaster risk reduct doi: 10.1016/j.ijdrr.2020.101545 sha: doc_id: 257917 cord_uid: 4496gzdu nurses are the largest group of healthcare providers and are often the first line responders to a disaster event. nurses' disaster competence, motivation for disaster engagement, and factors that impact their motivation to respond to disaster events need to be understood. the purposes of the study were to determine the predictive relationships between taiwanese nurses' disaster competence, anticipatory disaster stress, and motivation for disaster engagement. a cross-sectional design was used to analyze data collected between august 2017 and december 2017 from eight hospitals in southern taiwan. ninety participants who met the recruitment criteria completed and returned questionnaires with an 88.24% response rate. data collection involved administering the disaster nursing competence questionnaire, anticipatory disaster stress questionnaire, and the motivation of disaster engagement questionnaire. the results indicated that anticipatory disaster stress was positively correlated with disaster competence and motivation for disaster engagement. disaster competence and willingness to join a hospital disaster rescue predicts an individuals' motivation for disaster engagement. the results of the study add to the understanding of factors that correlate with nurses' motivation to participate in disaster events. by understanding these factors, the government and healthcare administrators can design disaster education plans and other strategies to improve taiwanese nurses’ motivation to engage in disaster events. natural and man-made disasters are increasing in frequency and severity worldwide over the past decade. examples of major disasters in taiwan include the severe acute respiratory syndrome (sars) outbreak in 2003, the kaohsiung massive gas explosions in 2014, and the taiwan water park blast in 2015. these disasters have resulted in many injuries and fatalities, as well as economic losses, serious environmental disruption, and lasting psychological trauma among survivors [1, 2] . according to the 2018 world disasters report [3] , there were 3751 recorded disasters from 2008 to 2017, and 79.8% of these reported disasters occurred in asian countries. asians accounted for the largest number of people affected by these disasters. in fact, the percentage of disasters occurring in asia was 37% in the 1998-2007 decade, and it increased to 41% in the 2008-2017 decade [3] . likewise, the frequency and intensity of disaster events in taiwan have noticeably increased in recent years. in 2016, the center for research on the epidemiology of disasters reported that taiwan was one of the top 10 countries in terms of disaster mortality that year [4] . these statistics amplify the importance of sound disaster training and preparation so that nurses can respond effectively and appropriately during a disaster event in taiwan. in taiwan, during disaster incidents, nurses are expected, with limited resources, to attend and work in chaotic disaster sites to quickly provide nursing care to a growing number of survivors. in light of this, issues about the current level of competence, skills, and experience in disaster preparedness and response among nurses have been valued and emphasized [5, 6] . studies focused on disaster nursing in taiwan and other countries revealed that existing preparedness for and competence in disaster response among hospital personnel including nurses is less than optimal [7] [8] [9] and is often fragmented, or not available at all [5] . moreover, they may not be ready to face future disasters because of an inadequate disaster competence such as a lack of awareness of the roles and skills needed when encountering disaster events [10] [11] [12] [13] [14] [15] . high levels of psychological and emotional stress are frequently reported in emergency or disaster responders [16, 17] . studies found that nurses felt psychologically unprepared when asked to engage in disaster events [18, 19] because the events might exceed their capacity to function well, or they worried about their personal loss or their families' welfare during disaster relief [17, 20] . additionally, nurses had less desire to report to work during an emergency or disaster event, although most strongly believed that they are responsible for working during such situations [13, 21] . moreover, few nurses were motivated to engage in practical preparation and obtain the experience required to deploy in response to a disaster event [6, 10] . in one study, some nurses openly commented that they were frustrated and were not motivated to engage in disaster trainings because of their heavy workloads and lack of time for attending educational programs [20] . yet, other surveys reported that many hospitals or service organizations do not frequently conduct exercises to determine their level of preparedness for disaster management, which may be due to the economic burden of undergoing training exercises [22] . therefore, it is critical to understand how to help disaster nurses overcome personal stress and assist others, such as colleagues and survivors, to effectively cope with stress as well [16] . nurses are the largest group among the healthcare provider workforce and play an important role during the emergent phase of a disaster and throughout the phases of disaster preparedness and recovery [23] . therefore, disaster competence and preparedness among nurses is necessary to effectively manage unpredictable events. however, the exploration of nurses' perspectives on disaster nursing remains limited in taiwan. therefore, the purposes of the study were to determine the level of and relationships between taiwanese nurses' disaster competence, anticipatory disaster stress, and motivation for disaster engagement. the motivation for engagement in disaster events can be explained by the self-determination theory developed by deci and ryan [24] . the theory suggests that people are often moved to act by two types of motivation: intrinsic or extrinsic. the theory also proposes that three basic psychological needs-competence, autonomy, and relatedness-are important for self-growth and must be met for healthy functioning, promoting intrinsic motivation, engagement behavior, and maintaining motivation over a period of time [24, 25] . competence refers to the mastery of experiences in the practical world. an individual's perceived competence can enhance their motivation for an action only when it is accompanied by a sense of autonomy and relatedness within an organization [26] . in addition to the psychological needs that influence motivation, personnel involved in disaster events are prone to exhibiting psychological problems and distress [16] . for nurses, psychological distress may affect their commitment to attend or remain at a disaster situation site [17, 27, 28] . therefore, we proposed that anticipatory disaster stress and disaster competence are factors in nurses' motivation to engage in disaster events. this study used a cross-sectional design to understand factors related to nurses' motivation to engage in disaster events. using convenience sampling, nurses who: (a) had a registered nursing license; (b) were employed full-time by hospitals for more than one year; and (c) were willing to sign an agreement to complete questionnaires; were invited to participate in the study. before data collection, the sample size was calculated using g*power (version 3.0) with two-tailed, α level of 0.05, and an estimation that the effect size for correlation between measured variables was at least medium (r ¼ .3). eighty-eight participants were needed to achieve a power of .80. more nurses were invited to participate in the study because of possible incompletion rates. 102 nurses distributed over eight hospitals in southern taiwan responded to our invitation to participate in the study. ninety nurses returned completed questionnaires with an 88.24% response rate. the study was approved by the institutional review board (irb 201509382b0) before recruitment began. a packet containing a cover letter, questionnaires, informed consent, and two addressed-andstamped envelopes were mailed to nurses who were interested in participating in the study. the cover letter described the purposes of the study, the participants' rights and confidentiality. they could complete the study surveys at any place they felt comfortable with. they could decline or stop participation in the study whenever they felt uncomfortable. participants were asked to send back the signed informed consent and questionnaires separately by using the two addressed-andstamped envelopes if they agreed to participate in the study. on average, surveys were completed in less than 20 min. data were collected between august and december of 2017. there was no disaster in taiwan or any neighboring countries that might have influenced the participants' responses during the data collection period. demographic survey. we designed the participant information sheet based on the self-determination theory that individual differences are important factors that may influence individuals' motivation to engage in actions. in this study, individual differences are defined as a nurse's personal characteristics that may influence their preparedness and motivation to engage in disaster events, such as gender, age, seniority in the hospital, educational level, hospital type, work unit, and job title. the disaster nursing competence questionnaire (dncq). the dncq developed by the research team, based on a literature review, contains 37 items used to measure nurses' perceived competence level when responding to disaster events. on a 5-point likert scale ranging from 1 (not familiar) to 5 (very familiar), a higher score indicates a higher level of disaster nursing competence. in the study, cronbach's alpha for the dncq was 0.96. the principal component analysis for the validity showed that 78.19% of the variance of the disaster nursing competence could be explained by the dncq. anticipatory disaster stress questionnaire (adsq). the anticipatory disaster stress questionnaire was developed by the research team according to literature reviews and consists of 24 items used to measure nurses' anticipation of stressors when encountering disaster events. using a 5-point likert scale scored from 1 (strongly disagree) to 5 (strongly agree), a higher score indicates greater perceived stress while facing disaster events. in the study, cronbach's alpha for the adsq was 0.75. the principal component analysis showed that 47.34% of the variance of the anticipatory disaster stress could be explained by the adsq. motivation for disaster engagement questionnaire (mdeq). the mdeq, developed by the research team, was used to measure nurses' motivation to engage in disaster events or preparedness activities. with three items on a five-point likert scale (ranging from 1 to 5), a higher score indicates a higher level of motivation to participate in disaster events. in this study, cronbach's alpha for the mdeq was 0.85. principal component analysis showed that 76.68% of the variance of the motivation in disaster engagement could be explained by the mdeq. data were analyzed with the use of spss version 23.0. demographic information, levels of disaster competence, anticipatory disaster stress, and motivation for engagement in a disaster event were analyzed with descriptive statistics such as frequency, mean, and standard deviation. before inferential analyses of the data, the normality of all variables was examined using the shapiro-wilk test. results showed that the dncq and adsq were normally distributed, whereas mdeq was not normally distributed. relationships between measured variables were examined using the pearson correlation when the variables were normally distributed, and the spearman correlation was used when variables were not normally distributed. the reliability of the scales was tested using cronbach's alpha coefficients, and the validity was tested with principal component analysis. hierarchical regression was applied to understand the predicting relationship of individual differences, disaster competence, and anticipatory stress on motivation for engagement in disaster events. the mean age of the nurses was 31.46 (sd ¼ 7.19) years. on average, they worked 114.44 months (9.54 years, sd ¼ 86.54) as a nurse and 93.49 months (7.79 years, sd ¼ 80.41) in their current hospital. most participants were females (85.6%). while 28.9% of them had an associate's degree, 68.9% had a bachelor's degree (25.6% were in the fouryear bachelor program and 43.3% were in the two-year rn-bsn program), and 2.2% had a master's degree. seventy-eight nurses worked as registered nurses (77.8%) or nurse specialists (12.2%), and 85.6% worked in the emergency room (er) or intensive care unit (icu) in nonmedical centers or regional hospitals (82.2%). over the past 3 years, more than half of nurses attended either in-service education or conferences about disaster nursing (61.1%) and attended disaster practices held by their hospital (82.2%). most hospitals where the participants worked held massive disaster courses (87.8%) and practices (90.0%) every year. only 26.7% of the participants had attended a disaster field rescue; 48.9% had attended disaster management at their hospital; and only 5.6% had attended care management of disaster aftermaths. more than half of the participants agreed (38.9%) or strongly agreed (14.4%) to join a hospital disaster rescue if they were asked, while 37.8% disagreed and 7.8% strongly disagreed to join a disaster rescue. the levels of disaster nursing competence, anticipatory disaster stress, and motivation of disaster engagement among participants were presented in table 1 . the mdeq, dncq and adsq were significantly inter-correlated (r ranged from 0.31 to 0.34). the dncq was correlated with a greater number of times attending onsite practices, number of times attending in-service education or conferences about disaster nursing, number of times participating in care management of disaster aftermaths and stress of managing a disaster in hospital. the adsq was correlated with the number of times attaining onsite practices held by hospital in the past 3 years, number of times attending in-service education or conferences about disaster nursing and the stress caused by managing a disaster in hospital. the mdeq was correlated with the number of times attending in-service education or conferences about disaster nursing and the stress caused by managing a disaster in hospital. however, effect sizes of all these correlations were low to moderate. most of the demographic variables had no statistically significant impact on nurses' disaster competence, anticipatory disaster stress, or their motivation for disaster engagement. as shown in table 2 , participants who attended the in-service education or conferences about disaster nursing in the past 3 years had higher scores on the dncq. participants who completed graduate school had lower scores on the adsq compared to those with an associate's or bachelor's degree. those who were more willing to join hospital disaster rescues had higher levels of adsq and mdeq than those who were less willing to participate. those who had never attended care management of disaster aftermaths had higher scores on the mdeq. because the number of times attending in-service education/conferences and stress caused by managing a disaster in hospital were correlated with the mdeq, and the mdeq differed by whether nurses attended care management of disaster aftermaths beforehand and their willingness to join hospital disaster rescues, these four variables were entered in the first set of regression analysis. as shown in table 3 , regression analysis showed that attendance of disaster aftermath care management was included in the model and 35% of the variance of the mdeq could be explained (f ¼ 4.38, p < .001). this study aimed to explore the relationships between disaster competence, anticipatory disaster stress, and motivation for disaster engagement among hospital nurses in taiwan. in addition, the factors associated with the motivation for engagement in disaster events among nurses were identified. we found that hospital nurses' level of disaster competence was not high. our findings were similar to previous studies that reported a low level of self-reported familiarity with preparedness among nurses for large-scale emergency or disaster events [12, 29, 30] . this finding implies that most hospital nurses may not be ready or confident in their abilities to respond to disaster events. contrary to prior studies which revealed that work unit or specialty, work experiences, educational level, and gender were associated with disaster competence [31, 32] , our analysis did not support such findings. rather, we found that nurses who exhibited higher competence had attended in-service education or conferences about disaster nursing. interestingly, most hospitals held massive disaster courses or practices every year; however, nurses' attendance rates to these educational offerings were not high. in addition, although the participation rates of field drills were high, nurses did not perceive that they were competent in disaster management. this situation is similar to williams et al.'s article which reviewed 258 studies and found that the effects of disaster training on health care workers' knowledge and skills in disaster response were inconclusive. the authors suggested that hospitals should urgently examine and find the most appropriate methods for disaster preparedness practices for nurses in order to augment the authentic efficiency of the training [2] . the psychosocial problems faced by nurses involved in disaster events are of much concern. researchers indicated that nurses may be unprepared educationally and psychologically for disaster relief [33] . one study that was conducted to determine the international research priorities for disaster nursing found that psychosocial aspects ranked the highest [34] . however, in our study, the level of anticipatory disaster stress was not high. this finding is different from prior concerns that the mdeq was used to measure motivation of disaster engagement, adsq was for anticipatory disaster stress, and dncq was for disaster nursing competence. *p < .05, **p < .001 (two-tailed). nurses often reported that disaster events exceeded their ability to function and caused imbalances between professional duties and personal stress, such as their families' safety and personal loss [17, 20, 35] . since most nurses in our study did not have any experience in disaster field rescue and also did not attend disaster management at their hospital, it may be hard for them to imagine how stressful it would be to participate in a real disaster management situation. this may be the reason for the finding of a low level of anticipatory disaster stress. additionally, although the level of anticipatory disaster stress was not high, only 53.3% of nurses agreed or strongly agreed to join their hospital's disaster rescue when they were asked to do so. further analysis found that the participants who strongly agreed to join a hospital disaster rescue had significantly higher stress levels than nurses who did not agree to participate in a disaster relief. somehow, anticipatory disaster stress existed, but only for nurses who have motivation to attend disaster events in the future. in the study, the degree of nurses' motivation for disaster engagement was not high. the results correspond to the earlier studies, which indicated that few nurses intended to report for work during disasters [13, 35, 36] ; moreover, few nurses have the motivation to engage in practical preparation and obtain experiences in response to a disaster event [6] . specifically, we found that nurses who had attended care management of disaster aftermaths had lower motivation for disaster engagement. the fear of being incapable of managing disaster aftermaths and the worry that no one can take care of their family or children when they cannot get out of their duty might have made them reluctant to attend field rescue or care management of disaster aftermaths [17, 35] . former surveys reported that nurses did not feel supported or motivated to engage in disaster preparedness because of their heavy workloads, and the hospitals in which they were employed did not regularly conduct exercises to prepare them for disaster management [8, 16, 22] . although hospitals in taiwan held disaster education or practice every year, nurses reported being physically and mentally exhausted by their heavy daily workload on top of having difficulty in finding the time to participate in educational programs that were not directly work-related. therefore, as shown by a previous study that showed a perceived well-ordered organizational climate can arouse individuals' motivation and consequently cause emergent behaviors [37] , a perception of being supported by the work environment is a meaningful motivational factor in healthcare workers' decision to work during a disaster. interestingly, the study found that nurses who were more competent in disaster nursing felt more stress. this situation might be because nurses may believe that they will never be competent enough when facing an unpredictable disaster. additionally, disaster competence and anticipatory disaster stress were significantly and positively correlated with nurses' motivation to engage in disaster events. however, both disaster competence and anticipatory disaster stress could not predict motivation to engage in disaster events. the self-determination theory proposes that competence is one of the significant factors influencing individuals' motivation in engagement behaviors [25] . and, other studies pointed out that individuals would move toward activities and took on responsibilities or challenges when they felt more confident in their disaster competence and knowledge [13, 24, 38, 39] . in our study, nurses' did not perceive high level of disaster competence and therefore might not be motivated to participate in disaster management. the sampling method in the study is convenience sampling. participants were only invited from eight regional hospitals in southern taiwan. these reasons may have caused a selection bias in sampling. in addition, 85.6% of our participants were emergency or intensive care nurses although they might be the first line nurses to manage disaster events. therefore, the generalizability of the study findings to all taiwanese nurses is limited. because the study used a cross-sectional design, the findings cannot establish a causal relationship between variables. the findings of this study contribute to the body of knowledge regarding motivation for disaster engagement among hospital nurses and furnish implications for nursing administration, practice, education and research. we have recommendations for policy, research, practice and education. the study indicated that the rates of attending in-service education, disaster field rescue, and care management of disaster aftermaths among hospital nurses were not high. nurses' disaster competence and motivation for disaster engagement were not high as well. these findings highlight the necessity of further research to explore nurses' concerns and needs in-depth when they participate in disaster-related activities. the results of the further research can offer information for healthcare administrators to make more practical policies to enhance nurses' disaster competence and further increase nurses' motivation to participate in these activities. the study found that even though hospitals held disaster courses and trainings every year, nurses had a worryingly low level of disaster competence, which correlated with their low motivation to participate in disaster rescue. providing realistic disaster training using simulations, tabletop exercises [40, 41] , and virtual reality/augmented reality/mixed reality exercises may improve individuals' interests and understanding about disaster situations and disaster knowledge and skills. this would further increase nurses' confidence in disaster management. the insufficiency of disaster competence among nurses revealed in the study emphasizes the important role of nursing educators in preparing nursing students with the knowledge and skills for disaster management. disaster nursing is a generally neglected topic in nursing education. in most nursing schools in taiwan, disaster nursing is taught as one or two units in courses of public health nursing (required course) or emergency nursing (elective course). it is urgent for nursing schools to develop a stand-alone disaster course for both undergraduate and graduate programs to increase nurses' awareness of disaster and prepare table 3 predictive relationship of dncq and adsq with mdeq. step 1 step 2 for future nurses who are competence in disaster management. this study sheds some light to provide a better understanding that the degree of disaster competence may impact the motivation for disaster engagement among hospital nurses in taiwan. it appears that disaster competence and stress play an important role for nurses when encountering disaster. this situation should alert hospital administrators to reexamine the appropriateness of their training programs and their nurses' needs when it comes to training for disaster preparedness. stress management and counseling programs also need to be provided. the best and suitable methods for disaster practice to augment the authentic efficiency of training and to promote nurses' motivation for disaster engagement should be further explored and developed. this work was supported by the chang gung memorial research program in taiwan (cmrpf6g0031). no conflict of interest has been declared by the authors. resilience in the face of disaster: prevalence and longitudinal course of mental disorders following hurricane ike the effectiveness of disaster training for health care workers: a systematic review international federation of red cross and red crescent societies annual disaster statistical review world health organization (who) & international council of nurses (icn) australian nurses 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organizational climate on organizational commitment and perceived organizational performance: empirical evidence from public hospitals who will be there? ethics, the law, and a nurse's duty to respond in a disaster resiliency of accomplished critical care nurses in a natural disaster analysis of texas nurses' preparedness and perceived competence in managing disasters disaster preparedness in philippine nurses readiness of hospital nurses for disaster responses in taiwan: a cross-sectional study necessity for disaster-related nursing competency training of emergency nurses in china a grounded theory study of 'turning into a strong nurse': earthquake experiences and perspectives on disaster nursing education what are the research needs for the field of disaster nursing? an international delphi study schr€ oder-b€ ack, nurses' roles, knowledge and experience in national disaster preparedness and emergency response: a literature review nurses' willingness and readiness to report for duty in a disaster relationship, motivation and organizational climate: a case of sustainability residents' disaster preparedness after the meinong taiwan earthquake: a test of protection motivation theory australasian emergency nurses' willingness to attend work in a disaster: a survey disaster preparedness among nurses: a systematic review of literature evaluation of a tabletop emergency preparedness exercise for pharmacy students supplementary data to this article can be found online at https://doi. org/10.1016/j.ijdrr.2020.101545. key: cord-279991-w2aoogjj authors: labrague, leodoro j.; de los santos, janet title: fear of covid‐19, psychological distress, work satisfaction and turnover intention among frontline nurses date: 2020-09-27 journal: j nurs manag doi: 10.1111/jonm.13168 sha: doc_id: 279991 cord_uid: w2aoogjj aim: to examine the relative influence of fear of covid‐19 on nurses’ psychological distress, work satisfaction and intent to leave their organisation and the profession. background: the emergence of covid‐19 has significantly impacted the psychological and mental well‐being of frontline healthcare workers, including nurses. to date, no studies have been conducted examining how this fear of covid‐19 contributes to health, well‐being and work outcomes in frontline nurses. methods: this is a cross‐sectional research design involving 261 frontline nurses in the philippines. five standardised scales were used for data collection. results: overall, the composite score of the fear of covid‐19 scale was 19.92. job role and attendance of covid‐19‐related training predicted fear of covid‐19. an increased level of fear of covid‐19 was associated with decreased job satisfaction, increased psychological distress, and increased organisational and professional turnover intentions. conclusions: frontline nurses who reported not having attended covid‐19‐related training and those who held part‐time job roles reported increased fears of covid‐19. addressing the fear of covid‐19 may result in improved job outcomes in frontline nurses, such as increased job satisfaction, decreased stress levels and lower intent to leave the organisation and the profession. implications for nursing management: organisational measures are vital to support the mental health of nurses and address their fear of covid‐19 through peer and social support, psychological and mental support services (e.g., counselling or psychotherapy), provision of training related to covid‐19, and accurate and regular information updates. covid-19 is a disease important in public health globally. this pneumonia-like disease emerged in wuhan, china in november 2019, which the world health organization later called coronavirus disease 2019 or covid-19 (who, 2020) . within a few months, covid-19 has caused significant damage to public health, while causing financial and economic loss in many countries. globally, confirmed cases of the disease had reached 22 256 220, with 782 456 confirmed deaths. as of august 21, 2020, cases of covid-19 had been reported in more than 200 countries on six regions. the us remains the country with the highest number of confirmed cases and fatalities, followed by brazil, india, and russia, which account for 49% of all confirmed cases globally (who, 2020) . in the philippines, confirmed cases of covid-19 have reached 173 774, with 2 795 confirmed deaths (department of health, 2020a) . among asean countries, the country ranked 1 st in terms of number of confirmed cases and deaths. this was despite extensive measures to prevent the transmission of the disease, such as strict social distancing, community quarantines and education campaigns about the disease. since the earliest days of the nursing profession, nurses all over the world have played a significant role during disaster and emergency situations, including disease outbreaks. nursing organisations such as the international council of nurses (icn) emphasised the critical role that nurses play during emergency and disaster situations. while nurses remain committed to this role, the unprecedented pressure exerted by the pandemic on every country's healthcare system has presented various challenges to nurses (e.g., increased patient volume, increased patient load, covid-19 protocols) that could affect their well-being and work performance. much worse, nurses are risking their lives in order to carry out their duties, causing intense fear of being infected or unknowingly infecting others. according to the icn, about 90 000 or 6% of all accepted article confirmed cases of covid-19 worldwide were healthcare workers. of this figure, 600 nurses had succumbed to the disease, a figure which was expected to continue rising. in the philippines, the department of health reported a total of 2 736 healthcare workers infected with and 32 deaths. among these confirmed cases, 1 006 were nurses (department of health, 2020a) . to effectively play their role during this pandemic, it is essential for nurses to maintain their psychological and mental health (mo et al., 2020; catton, 2020) ; however, the literature has shown that the emergence of covid-19 has significantly impacted the psychological and mental well-being of nurses. vast amounts of evidence have shown a significant association between the covid-19 outbreak and adverse mental health issues such as stress or burnout, depression and anxiety (wu et al., 2020; nemati et al., 2020; mo et al., 2020) . the severity and fatality of and susceptibility to disease can create or intensify anxiety and fear among nurses, potentially affecting their health and well-being and work effectiveness during times of infectious epidemic crisis (ahorsu et al., 2020) . in addition, frontline nurses, particularly those who work directly with coronavirus patients, often witness patients suffering and dying, impacting their emotional health and causing compassion fatigue (alharbi et al., 2020) and post-traumatic stress manifestations (kameg, 2020) . in a study conducted by labrague and de los santos (2020), 37.8% of frontline nurses were found to have dysfunctional levels of anxiety related to covid-19 pandemic. a systematic review of studies has shown a higher prevalence of anxiety and depression in nurses than in other frontline healthcare workers (pappa et al., 2020) and the general population (mo et al., 2020) . hence, supporting the nursing workforce during the covid-19 pandemic is of paramount importance. since the onset of the coronavirus disease in november 2019, a huge number of studies have been conducted and published navigating the effects of the disease outbreak on mental health among nurses and other healthcare workers. however, despite the increasing number of studies on the topic, none have been conducted to examine how these covid-19-related mental consequences influence frontline nurses' work outcomes. as unmanaged anxiety or fear related to covid-19 may potentially lead to long-term effects on nurses' work performance and job satisfaction, leading to frequent absenteeism and eventual turnover (lee et al., 2020; , it is critically important to examine whether frontline nurses' fear of covid-19 contributes to psychological distress, work satisfaction and intent to leave their organisation and the profession. findings of this study will provide inputs for policymakers and this article is protected by copyright. all rights reserved nursing administrators on how to effectively support the mental health of frontline nurses and sustain a well-engaged nursing workforce particularly during this time of pandemic. a cross-sectional research design was employed, using five standardised scales. frontline registered nurses employed in 5 hospitals in the philippines were included in the study. these hospitals, comprised of 3 public hospitals and 2 private hospitals, were designated as covid-19 referral hospitals by the department of health to deliver services and manage confirmed covid-19 cases with severe and critical symptoms. since the onset of the pandemic, the department of health mandated all hospitals in the country to activate its health emergency incident command system for effective management and control of the coronavirus disease. this includes activating guidelines and protocols on isolation measures, treatment guidance, training of staff on the use of personal protective equipment (ppe), patient care management, sample collection and handling, and waste management (department of health, 2020b) . these guidelines and protocols are regularly communicated to the entire hospital staff through staff emails, newsletters, brochures, and small ward meetings. to qualify to participate in the study, participants needed to be registered nurses (rns) who hold either a full-time or contracted job status and currently work in a private or public hospital that provides services to coronavirus patients. using the g power program, power analysis showed the required sample size of nurses was 220 to achieve an 80% power, where alpha was set at 0.05 and a small effect size at 0.05 (soper, 2015) . the small estimated effect size was chosen to ensure that a large sample was collected to detect meaningful correlations between variables. survey questionnaires were distributed to 300 nurses and 261 responses were received (87% return rate). the fear of covid-19 scale was used to examine nurses' apprehension about covid-19 (ahorsu et al., 2020) . this 7-item unidimensional scale was answered by nurses using a 5point likert scale which ranged from 1 (strongly disagree) to 5 (strongly agree). this scale is the most widely utilized instrument to measure fear of covid-19 and has been used by several researchers from different disciplines (bakioglu et al., 2020; gritsenko et al., 2020; reznik et al., this article is protected by copyright. all rights reserved 2020). further, it is easy to use and administer, making it suitable for this study. the composite score ranged from 7 to 35, with a higher score indicating greater fear of covid-19. previous research reported excellent predictive validity and reliability (α = 0.86) of the scale (ahorsu et al., 2020; gritsenko et al., 2020) . the cronbach's α of the scale in the present study was 0.87. the job stress scale (jss) was used to assess nurses' experience of psychological distress while carrying out their work (house & rizzo, 1972) . nurses answered each item on the scale using a 5-point likert scale which ranged from 1 (strongly disagree) to 5 (strongly agree). the scale demonstrated excellent predictive validity and reliability (α = 0.83) (house & rizzo, 1972) . the internal consistency of the scale in the present study was 0.87. the job satisfaction index (jsi) was used to assess nurses' satisfaction with their current work (schriesheim & tsui, 1980) . this 5-item scale consisted of items reflecting the 5 essential job elements: work, organisational support, co-workers, wage or salary and career development. nurses answered each item using a 5-point likert scale which ranged from 1 (strongly disagree) to 5 (strongly agree). previous research reported excellent validity and reliability (α = 0.87) of the scale . the internal consistency of the scale in this study was 0.92. the jss and jsi are well validated scales and have been widely used as measures of work contentment and psychological distress both in nursing and non-nursing studies, making it appropriate for this study satici et al., 2020) . two single-item measures of turnover intention were used to assess organisational and professional turnover intentions (o'driscoll & beehr, 1994) . professional turnover intention was assessed by the item "given the current situation, i am thinking about leaving nursing as a profession". organisational turnover intention was assessed by the item "given the current situation, i am thinking about leaving this healthcare facility". this scale was deemed appropriate for this study as it is short, easy and convenient to use, and has been validated in many nursing studies lavoie-tremblay et al., 2016) . nurses rated each item on a likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). the test-retest reliability result of the items in the current study was .91, higher than those in previous research (α = .89) . this article is protected by copyright. all rights reserved the ethical clearance of the study was granted by the institutional research ethics committee of samar state university. permission for data collection was sought from nurse directors from the identified hospitals prior to the actual collection of data. participants were screened according to pre-determined selection criteria and written consent was sought. after collecting the participants' written consent, the survey questionnaires enclosed in a sealed packet were handed to the respondents. participants were oriented individually before the survey questionnaires were completed to inform them of the nature of the research, its objectives, the potential benefits and risk involved in the study, and instructions on how to complete the questionnaires. the respondents were asked to complete the questionnaires during their free time and were given 20 to 30 minutes to complete the survey. instead of using their names, participants were assigned unique codes to ensure confidentiality. the lead researcher entered the data collected into a database secured with a password. hard copies of the questionnaires were kept in a secured cabinet. data were collected from march 2020 to may 2020. analysis of the data collected was performed using the spss version 23 software program (ibm corp., armonk, ny, usa). percentages, means and standard deviations were the descriptive statistics used. the pearson's r correlation coefficient, analysis of variance (anova) and independent t-test were used to identify correlations between the nurse, unit and hospital characteristics and fear of covid-19. multiple linear regressions (enter method) were employed, after checking for the multicollinearity and normality of the data, to identify which variables could explain the impact of fear of covid-19 on nurse job outcomes. the level of acceptable significance was set at p < 0.05. a total of 261 nurses were included in this study. the mean age of the participants was 30.95 years. the majority of the participants were female (n = 192), unmarried (n = 176) and held baccalaureate degrees in nursing (n = 215). the average nursing experience was 8.32 years, while the average tenure in the present organisation was 4.73 years. the vast majority of nurses -95.8% (n = 250)were aware of the existing workplace protocol related to covid-19; accepted article however, less than 50% (n = 106) reported attending covid-19-related training. the complete details of nurse characteristics are shown in table 1 . the composite score for the fear of covid-19 scale was 19.92 (sd: 6.15), which was above the midpoint. for the job satisfaction and psychological distress scales, the composite scores were 3.65 (sd: 0.99) and 3.09 (sd: 0.96) respectively. the composite scores for the organisational and professional turnover intention measures were 1.86 (sd: 1.26) and 2.23 (sd: 1.26) respectively ( table 2 ). the independent t-test showed a significantly higher mean scale score on the fear of multiple regression analyses were conducted to examine the influence of fear of covid-19 on nurses' job satisfaction, psychological distress, organisational turnover intention and professional turnover intention (table 4 ). after adjusting for nurse/unit/hospital characteristics, an increased level of fear of covid-19 was associated with decreased job satisfaction (β = -0.165; p = 0.01), increased psychological distress (β = 0.464; p = 0.001) and increased organisational (β = 0.298; p = 0.001) and professional (β = 0.219; p = 0.001) turnover intentions. a unit of increase in the composite score of fear of covid-19 was associated with a decrease in job satisfaction by 0.187 points. an increase in psychological distress by 0.506 was observed for this article is protected by copyright. all rights reserved a unit of increase in the composite score of fear of covid-19. further, increased organisational (0.721 points) and professional (0.561 points) turnover intentions were observed for a unit of increase in the composite score of fear of covid-19. this study investigated the influence of fear of covid-19 on frontline nurses' job satisfaction, psychological distress, organisational turnover intention and professional turnover intention. to our knowledge, this is the first study to investigate such a relationship, thus contributing key results from this career area in the field of nursing management and leadership. overall, the obtained mean scale score for the fear of covid-19 measure in the present study was 19.92 (sd: 6.15), which was above the midpoint. due to the lack of studies involving the nurse population, comparison was not possible. however, when the study results were compared to studies of the general population, it was revealed that the mean score in the present study was higher than those reported in russia (17.4) , belarus (16.6) , turkey (19.44) (bakioglu et al., 2020) and japan (18.71) (masuyama, shinkawa & kubo, 2020) . since frontline nurses are directly involved in patient care, their risk of contracting covid-19 is higher than the general population. this could contribute to their feelings of apprehension or fear of being infected or unknowingly infecting others, including their family members or friends. further, pandemic-related concerns such as increased patient volume and patient load, provision of coronavirus-related precautions (maben 2020), social distancing and community quarantine can intensify fears among nurses, affecting their psychological and emotional well-being and their work performance. healthcare institutions such as hospitals are frontline institutions during any disaster or disease outbreak. a well-planned workplace protocol should be in place, containing sets of actions relevant to disaster or disease outbreak, such as guidelines for caring for affected patients, safety practices when handling patients, relevant training, response plans and collaboration with other agencies at the local and national level (hirshouer et al., 2020) . as nurses are frontline health workers, it is essential that they are oriented and familiar with the content of workplace protocol; they should be knowledgeable on and skilful in carrying it out (ben natan et al., 2014; labrague et al., 2018) . in this study, a significant proportion of nurses (95.8%) reported being aware of the existence of workplace protocol related to covid-19. this this article is protected by copyright. all rights reserved result contrasts with results in previous research, in which many nurses (> 50%) working in hospitals were unaware of the existing workplace protocol related to disaster, emergency and disease outbreak (labrague et al., 2016) . higher awareness of workplace protocol related to covid-19 may be attributed to the extensive campaign carried out by the philippine health agencies to adequately prepare hospitals in the country for the covid-19 pandemic. hospitals were encouraged to develop covid-19 protocols based on the standards set by the world health organization. during a disease outbreak, nurses are often given new roles and are compelled to carry out added tasks, which, in some instances, may be beyond the scope of their usual nursing role (gebbie & qureshi, 2002) . hence, adequate training is a critical component of nurses' readiness and competence in any disaster or disease outbreak response. in this study, attendance of covid-19-related training was identified as a significant predictor of fear of covid-19: nurses who reported having attended such training experienced decreased levels of fear of coronavirus than those who did not. this result supports previous studies highlighting the role played by training, drills and exercises related to emergency and disaster situations (including disease outbreak) in preparing nurses for disaster and infection outbreak response and management (labrague et al., 2018; labrague et al., 2016) . this result coincides with that of wu et al. in this study, increased scores on the fear of covid-19 scale were associated with increased scores on the psychological distress measure. although there is a lack of similar studies involving nurses, this relationship is in accordance with previous studies involving the general population (satici et al., 2020; bakioglu et al. 2020) . for instance, in a study involving 1 304 turkish individuals, increased levels of fear of covid-19 were strongly linked to negative emotional states including anxiety, depression and stress (satici et al., 2020) . a study by bakioglu et al. (2020) showed a similar pattern: fear of covid-19 had a significant positive relationship with anxiety, depression and stress. while fear is considered helpful in motivating individuals to respond effectively to a given threat or stimuli, extreme and persistent fear may result in negative psychological reactions such as stress, depression and anxiety (gorman, 2008) . finally, fear of covid-19 was shown to decrease job satisfaction and increase organisational and professional turnover intention among frontline nurses. to the author's knowledge, this study is the first to empirically test the association between fear of covid-19 and nurses' well-being, contributing original knowledge on nursing science, particularly in the area of nursing administration. as a psychological reaction to a threatening situation or stimuli (gross & canteras, 2012) , fear associated with coronavirus may interfere with work performance in nurses, leading to higher levels of job dissatisfaction and increased intentions to leave the profession and the organisation. this result coincides with earlier studies in other sectors, in which workers who demonstrated high fear or anxiety found job-related events more stressful, affecting their overall performance and work satisfaction (mccarthy, trougakos & cheng, 2016; jones, latreille & sloane, 2016) . by addressing fear of coronavirus among nurses, nurse wellbeing will be improved, with increased job satisfaction, decreased psychological distress and lower turnover intention. caution should be maintained when interpreting and generalising study findings in light of the limitations identified. first, this study was conducted within one province of the country; the exclusion of nurses from other provinces may affect the generalisability of the findings. next, the research design used could be a limitation; a cross-sectional study design cannot establish a causal link between variables under investigation. while this study found significant associations between a few nurse variables and their rating on the fear of covid-19 scale, other factors this article is protected by copyright. all rights reserved such as work environment, staffing adequacy, hospital management and leadership, personal nurse competency, hospital resources, and patient volume and acuity may also play important roles in explaining their fear of the disease. therefore, it is recommended that future studies explore other personal and organisational variables that may induce and intensify nurses' fear of covid-19. the findings of the study highlight the vital role of hospital and nurse administrators in supporting nurses during the pandemic through evidence-based education, training or interventions, and policy. as nonattendance of covid-19 training was linked with increased fear of coronavirus, it is imperative that hospitals formulate or develop covid-19 training plans to improve the capacity of nurses to effectively care for and manage coronavirus patients. this can be facilitated by using alternative platforms such as webinars, social media platforms or other video technologies in order to maintain social distancing. as job role predicted fear of covid-19, with part-time nurses reporting increased fear of the disease, the provision of adequate peer and organisational support is vital to enhance this group of nurses' preparedness for and familiarity with the care of coronavirus patients and ward or organisational processes related to covid-19 . a buddy system where a part-time nurse is paired with a more seasoned colleague can help support part-time nurses during the pandemic crisis (maunder et al., 2006) . as excessive fear may intensify pre-existing mental health issues or provoke anxiety (colizzi et al., 2020) and eventually affect nurses' health and job outcomes (e.g., job satisfaction, turnover intention), supporting the mental, psychological and emotional health of nurses should be prioritised by nursing and hospital administrators. these measures may ultimately improve work satisfaction, enhance perceived health, reduce psychological distress and decrease turnover intention among frontline nurses. this can be accomplished by implementing measures to preserve and maintain the mental health of nurses. mental health professionals during pandemic situations are instrumental in effectively supporting the mental health of frontline nurses. psychotherapy and psychological treatment may provide nurses with appropriate support (sucala et al., 2012) . due to certain limitations regarding access to in-person mental health services, a novel approach such as telepsychiatry could provide psychotherapeutic management this article is protected by copyright. all rights reserved or interventions (canady, 2020) . further, the provision of psychological materials (e.g., books, journals on mental health), psychological resources and counselling or psychotherapy (kang et al., 2020) may improve frontline nurses' mental health during covid-19. nursing staff should be oriented on how and where to access these psychosocial and mental health services, and access to these services should be facilitated. ensuring that nurses are always kept updated with the latest and most accurate information related to coronavirus reduces the fear and negative emotions associated with the disease. this information should include the nature of the causative virus, precautions to prevent transmission of the virus to the self and others, how to effectively use hospital resources and new trends in the management of coronavirus patients. equally important is ensuring that the members of the nursing team are given the same information related to the disease, as well as the hospital protocols when handling or managing patents afflicted with the diseases. frontline nurses should be provided with adequate break time to allow them to take care of themselves. collectively, these measures could curtail the negative impacts of this crisis and reduce fear among nurses. support from peers, colleagues, families and friends may improve the sense of safety and help alleviate fear in nurses . sharing their work experiences with others may be helpful in attaining adequate psychological or other support and improving their morale amid the pandemic (maben & bridges, 2020) . support from top management through the provision of a safe work environment, adequate ppe and other infection control supplies is vital to support nurses in their daily practices. further, professional nursing organisations should provide covid-19-related resources to nurses, including information on mental and psychological well-being, and the provision of resilience, coping and stress management programmes. consistent with prior evidence involving the general population, our results suggest that filipino frontline nurses experience mild to moderate levels of fear of covid-19. job status and attendance of covid-19 training were seen to explain the fear of covid-19 among frontline this article is protected by copyright. all rights reserved nurses, with part-time or contracted nurses and those who had not attended such training reporting increased levels of fear of covid-19. further, higher levels of fear of covid-19 were associated with increased psychological distress, lower job satisfaction, decreased health perceptions and increased turnover intention. understanding the factors that contribute to the fear of covid-19 and its effects on nurse work outcomes is critical when designing and implementing measures to address nurses' needs and concerns. this article is protected by copyright. all rights reserved the potential for covid-19 to contribute to compassion fatigue in critical care nurses the fear of covid-19 scale: development and initial validation jordanian nurses' perceptions of their preparedness for disaster management fear of covid-19 and positivity: mediating role of intolerance of uncertainty, depression, anxiety, 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satisfaction instrument for use in survey feedback interventions, paper presented at the western academy of management meeting a-priori sample size calculator for multiple regression the therapeutic relationship in e-therapy for mental health: a systematic key: cord-281460-el1xzqz4 authors: stanley, joan m. title: disaster competency development and integration in nursing education date: 2005-08-19 journal: nurs clin north am doi: 10.1016/j.cnur.2005.04.009 sha: doc_id: 281460 cord_uid: el1xzqz4 nurses, because of their nursing education and perspective practicing in multiple roles and settings, are uniquely qualified for mass casualty preparedness and response. educating the current 2.7 million registered nurses and all future nursing graduates is a daunting task. nursing education must ensure that graduates are prepared with the necessary knowledge and skills for mass casualty incidents. four key entities are essential for education's successful implementation of disaster preparedness: education and professional organizations, accreditation and regulatory bodies, schools of nursing, and continuing education providers. this article examines the role each of these key entities plays in the development of a nursing workforce prepared for mass casualty response. in addition, the international nursing coalition for mass casualty education (incmce) registered nurse (rn) competencies for mass casualty incidents and guidelines for integrating these competencies into the nursing education curricula are presented. b efore sept. 11, 2001 , nurses were providing essential health services in response to mass casualty incidents (mcis), including hurricane andrew, the oklahoma city bombing, and the 2001 floods in houston, texas. since sept. 2001, however, the united states has undertaken a comprehensive reevaluation of its preparedness and the resources necessary to amass a response to critical events, particularly those posed by various forms of terrorism. the 2.7 million nurses registered to practice in the united states [1] represent a significant resource. this resource must be a core component of any national preparedness plan. to be effective, however, nursing must evaluate and enhance its own capabilities to respond to such events. subsequently, nursing education must prepare nurses to fulfill this critical role. nurses are uniquely qualified to be early responders for mcis or to deal with their long-term effects. they are expert in assessment skills, priority setting, and communication and collaboration. additionally, they are prepared in an array of specialized areas from intensive care or trauma nursing, to public health nursing, to psychological-mental health nursing. nurses are critical thinkers and can make decisions necessary in emergency situations. nurses with advanced education and experience in trauma or critical care can fill more advanced triage, diagnostic, and treatment roles on the scene of an mci. because of the diverse educational background, experiences, and practice settings of nurses within the community and health care system, the potential roles of the professional nurse in an mci may vary extensively. to be an integral part of the community's plan for emergency preparedness in mcis, nurses must have a basic level of education to appropriately respond and protect themselves and others, particularly during chemical, biological, radiologic, nuclear, and explosive (cbrne) events. not all nurses must be prepared to be first responders to cbrne events. every nurse, however, must have sufficient knowledge and skill to recognize the potential for an mci, identify when such an incident may have occurred, know how to protect oneself, know how to provide immediate care for those individuals involved, recognize their own roles and limitations, and know where to seek additional information and resources. nurses also must have sufficient knowledge to know when their own health and welfare may be in jeopardy and know how to protect themselves and others. national nursing education standards and competencies do not mandate or recommend that all nurses be educated to respond to mcis. prior to the events of september 2001, nursing educators and organizations had begun to reevaluate what nursing education's role should be in addressing the national and international response to mcis. nursing education's role is pivotal in ensuring that nursing as a discipline is prepared to meet its critical role in emergency preparedness plans. successful implementation of this role depends on the participation and collaboration of education and professional organizations, accreditation and regulatory bodies or agencies, schools of nursing and individual faculty, and continuing education providers. broadly conceived, the roles of these four entities overlap and complement one another, producing change within the nursing profession. increasing nurses' effectiveness for mass casualty preparedness highlights the necessary congruence within nursing. the role of education and professional nursing organizations includes such activities as: participation in the development and validation of core competencies dissemination of competencies to members and other constituents faculty development related to the core competencies and nursing education's role development and assembling of resources to prepare nurses in the area of mcis provision of continuing education programs/materials for practicing nurses seeking monies (eg, federal and state monies or foundational support) for the preparation of nurses and faculty development and support of a research framework related to mcis the role of specialty nursing accreditation bodies, such as the commission on collegiate nursing education (ccne) and the national league for nursing accrediting commission (nlnac), includes such activities as: participation in the development and validation of core competencies determining whether the mci competencies should be required of and documented by a program or school to receive accreditation determining whether mci content in any form should be mandated for inclusion in a nursing program the joint commission on accreditation of healthcare organizations (jcaho) mandates specific areas in which all health care institutions must ensure that employees are prepared. as part of a national emergency preparedness plan, jcaho could mandate that health care institutions be required to document the competence of all employed registered nurses (rns) and other health professionals regarding their ability to appropriately respond to mcis. after september 2001, jcaho modified its accreditation standards for hospitals to include requirements regarding emergency planning, exercises, and training [2] . state boards of nursing maintain a nursing education program review function, some to a greater degree than others. in establishing criteria for licensure within the state, a state board of nursing could mandate that a candidate for a registered nurse license graduate from a program that includes mci content or has documented competence regarding mci response. several state boards also mandate continuing education credits for licensure renewal. a certification or continuing education program in mass casualty response could be developed and required for license renewal. the national council licensure examination (nclex) administered by the national council of state boards of nursing (ncsbn) is based on role delineation studies of practicing nurses. as the role of the practicing nurse evolves to include preparation for emergency preparedness, mci content could be included in the national licensure examination. schools of nursing and nursing faculty play critical roles in preparing nurses for emergency preparedness and response. specific activities and roles include: although similar to that of nursing faculty and frequently dependent upon regulatory and accreditation standards, continuing education providers have a critical role in educating rns and assuring effective response to mcis. specifically, the role of continuing education providers includes: development of continuing education modules or courses in various formats, including traditional classroom and web-based formats dissemination of learning resources and materials education of rns practicing in varied settings and with very diverse education and practice backgrounds immediately after september 2001, increasing the effectiveness of all nurses in responding to mcis became the primary focus of incmce. nursing education standards have not mandated or recommended that nurses graduating from entry-level nursing programs or advanced practice nursing programs receive preparation related to mcis. more recently however, many nursing schools have been evaluating and augmenting their curricula related to disaster response and care of mass casualties. likewise, most health care institutions previously did not recognize the need or importance of requiring nurses and other health care professionals to receive training related to mcis or had trained only a select group as part of an emergency response team. to ensure that nurses are prepared to respond appropriately and safely to mcis and to assist nursing schools and continuing education providers to meet this challenge, incmce developed a set of core competencies related to mass casualty incidents for all entry-level nurses. two phases, an internal and an external review phase, were used for the development of consensus-based competencies for mce of all nurses. a subcommittee of incmce, comprised of representatives of schools of nursing and national nursing education and accreditation organizations, was identified to accomplish this task. competencies for mce were developed previously for various groups of health care professionals. therefore, prior to developing a set of mce nursing competencies, existing educational curricula and sets of competencies were reviewed and evaluated. the recommendations and competencies developed by the subcommittee were based heavily on the competencies delineated by other health profession groups, including the task force of health care and emergency services professionals [3] ; association of state and territorial directors of nursing [4] ; center for health policy, columbia school of nursing [5] ; university of ulster, university of glamorgan school of health sciences school of nursing [6] ; and the uniformed services university of the health sciences graduate school of nursing (faye g. abdellah, personal communication, 2001). following the initial review and evaluation of these existing health profession documents, a set of entry-level or basic competencies was developed by the subcommittee and presented to the larger coalition. during this initial internal phase, the coalition and subcommittee had several opportunities to provide input and recommend revisions. upon completion of this first phase, phase two or the external review phase involved a validation panel comprised of a larger group of representatives from nursing practice, education, accreditation, and certification. validation panel members reviewed the competencies to assess their relevance, specificity, and comprehensiveness for entry-level nursing. using the previously developed competency validation tool and process [7] , participants on the validation panel were asked to review systematically each individual competency according to the following criteria: relevance. is the competency necessary? (yes, no, or do not know) specificity. is the competency stated specifically and clearly? (yes, no, do not know, and suggested rewording) comprehensiveness. in your opinion, if there is any aspect of general nursing knowledge, skill, or personal attributes missing? (please enter those new competencies.) based on feedback from the validation panel, a national, consensus-based set of educational competencies for rns responding to mcis was endorsed by incmce [8] . the dissemination and implementation of these national consensus-based competencies is ongoing. one of the critical steps in the implementation of the competencies and the effective preparation of nurses is integrating content and skills into the nursing curriculum. what is meant by all nurses? all practicing nurses? all licensed rns? all retired nurses? student nurses? nurses practicing in all settings and specialty areas? these are some of the questions with which incmce members struggled. a general consensus among coalition members prevailed: that all rns currently licensed to practice and all nurses educated from now on should have some basic level of knowledge and skill related to mcis. this very broad definition of all nurses is the ultimate target for preparing nurses with competence in mci preparedness and response. to facilitate the integration of the mce competencies into the nursing curricula, an existing nursing curriculum framework was used as a basis for the development of the competencies. the essentials of baccalaureate education for professional nursing practice [9] provides a framework for baccalaureate nursing curricula. the essentials of professional nursing education include five key components: liberal education, professional values, core competencies, core knowledge, and role development. using this framework, the three components addressed by the mce document are core competencies, core knowledge, and role development. the american association of colleges of nursing (aacn) essentials [9] were used as a framework for delineating outcome competencies related to mcis expected of all rns. to highlight the knowledge and skill level expected of all nurses in the future, examples of the mci competencies embedded within the essentials framework are presented in appendix 1. the nursing mci competencies related to professional role development are not differentiated by specific roles, such as provider of care, designer/manager/ coordinator of care, or member of a profession. areas of competence encompass all three critical nursing roles. several examples of the competencies are listed in box 1. sixty-four competencies are delineated in the incmce educational competencies for registered nurses responding to mass casualty incidents [8] . these national consensus-based competencies apply to all professional rn roles and practice settings, and are intended to describe entry-level practice. all nurses from novice to expert should have a basic knowledge and ability to respond to mcis independent of their education and practice experience. the individual competencies are intentionally general and must be interpreted in relation to the functional role of an individual nurse within an agency or community. competencies will be applied to practice in differing ways depending on the specific roles and responsibilities the nurse performs within the health care system or community. therefore, the dilemma for nursing educators is to determine how can graduates be prepared with this knowledge and skill set? and what content and experiences are already being taught, and what needs to be added or augmented? much of the knowledge and experiences underpinning the competencies related to appropriate and timely response to mcis are basic to nursing practice. therefore, most of the principles and information necessary for the development of competence in these areas are included in all basic nursing education programs to some degree. until the past several years, however, most nursing educators, or the population in general, did not focus on emergency preparedness and the role nurses should play. therefore, the identify the limits to one's own knowledge/skills/abilities/authority related to mcis. recognize the importance of maintaining one's expertise and knowledge in this area of practice and of participating in regular emergency response drills. context in which these mci competencies may be taught and utilized could vary dramatically. an overall assessment of the existing curriculum is recommended prior to adding any additional content or clinical experiences. many schools have used curriculum mapping not only for identifying content related to mce, but also for any general knowledge area that is threaded throughout the curriculum. frequently what occurs is new content is added to one or two courses without evaluating how this content builds upon or supports content and experiences throughout the remaining curriculum. critical questions that nursing educators must ask are: what content and experiences are already included in the curriculum that address the mci competencies? what basic content or principles that are already being taught can be reframed in order to redirect or refocus critical thinking and application surrounding this content? what content and experiences, already included in the curriculum, can be enhanced or supplemented to prepare graduates with the necessary competence related to mcis? what additional content and experiences specific to emergency preparedness and mci response need to be added to the curriculum? what pedagogical techniques can be used best for preparing graduates with these competencies? what resources are available to teach this content? how can the competence of graduates related to mci preparedness be assessed? how best can we evaluate the curriculum and teaching methodologies used to achieve these outcomes? much of the knowledge and experiences underpinning the mci competencies are basic to nursing practice and already are included in the nursing curriculum. the competencies transcend all essential components of nursing education. new ways of presenting or re-emphasizing existing content or principles throughout the entire curriculum to stimulate critical thinking and the development of new skills related to mcis is necessary. new case studies, new teaching-learning modules, simulations, small group discussions, and community-based experiences are among the pedagogies that could be used to achieve this goal. examples of how content could be integrated throughout a typical nursing curriculum are outlined in box 2. this is not intended to be a definitive outline for the placement or inclusion of all mci content within the nursing curriculum. rather it is intended as a starting point for evaluating and planning mci curriculum. the federal emergency management agency (fema) and other government agencies provide courses and training opportunities for field experiences box 2: ways to integrate mass casualty incident content physical assessment course history taking to elicit information about possible exposure to cbrne agents, including place of employment, living, and recreation; recent travel; unexplained or vague symptoms; illness of family members, friends, and coworkers focused history taking to assess potential exposure to cbrne, including signs and symptoms related to specific body systems skin. rashes, burns from radiation or chemical burns, or lesions gastrointestinal system, nausea, vomiting, or diarrhea perform an age-appropriate assessment of a patient exposed to various cbrne agents. advanced clinical skills laboratory course practice donning and working in personal protective equipment (ppe). discuss and practice decontamination principles and exercises in a health care institution and in other settings. demonstrate the use of various types of communication equipment used in the field during an mci. practice basic therapeutic interventions (eg, basic first aid skills, oxygen administration and ventilation techniques, lavage techniques, and initial wound care) in a community setting with limited equipment and supplies. demonstrate principles of patient safety during transport through splinting, immobilizations, and monitoring. pathophysiology course neurological system. discuss signs and symptoms of poisonous gas exposure and other agents and potential effects of other forms of trauma (eg, increased intracranial pressure). respiratory system. discuss signs and symptoms, differential diagnosis of biologic and chemical agents that can be weaponized, such as anthrax. cardiovascular system. discuss the signs and symptoms of biologic and chemical agent exposure and the impact on the cardiovascular system. infectious diseases. discuss newly emerging infectious agents such as severe acute respiratory syndrome, signs and symptoms, detection and control. adult health course when discussing principles of infection control and isolation techniques, introduce a scenario that encompasses multiple individuals, various biologic agents, and various settings. discuss the potential short-and long-term effects of an mci on children of various ages, ethnicities, and cultures. discuss appropriate coping strategies that could be implemented with a group of school-aged children. include content related to post-traumatic stress disorder and acute anxiety disorder and relate to responses to mcis. include a discussion of group therapy application or measures for stress reduction for large groups/communities. identify all who may need mental health counseling during and after a disaster, including health care workers, the injured, family members, community members, and the nation. discuss appropriate resources for referring and treating these various groups. practice principles of risk communication to groups and individuals affected by exposure during an mci. discuss the cultural, spiritual, and social issues that may affect an individual's response to an mci. as part of a community assessment, identify possible threats and their potential impact on the health care system and community at large in a specified locale or geographic area. identify community health issues related to limiting exposure to selected mci agents; water, air, and food supply contamination; and shelter and protection of displaced persons in the community. describe the local chain of command and management system for emergency response during an mci in a specific community or region. discuss how agencies/resources are coordinated and the role(s) of each in an mci. include a discussion and simulation of communication networks that are essential for smooth delivery of care and control of panic. review and discuss the identified community disaster plan for local community or region. identify individual roles for nurses. identify one's own potential role within the community disaster plan. review and discuss at least one health care institution's disaster plan with focus on the various roles (or potential roles) of nurses. identify and discuss the impact various types of mcis potentially would have on the health care institution(s) in the local community, including personnel, pharmaceuticals, and medical supplies. in an interprofessional seminar, discuss issues related to abandonment of patients; roles and responsibilities assumed by volunteer efforts; rights of individuals to refuse care; allocation of limited resources; and rights and responsibilities of health care providers in mcis. when discussing end-of-life care, discuss the ethical, legal, psychological, and cultural considerations when dealing with the dying or handling and storage of human remains in an mci. use the american nurse's association position statement on work release during a disaster: guidelines for employers [10] as a basis for discussion on responsibilities of nurses and other health care providers during an mci, or on potential roles of nurses during an mci. related to crbne responses and disaster drills. schools of nursing could collaborate with the local emergency medical service or other agency to schedule their nursing students to participate in a disaster field experience. this exercise could be incorporated into the curriculum as a 1-week clinical experience. it also is recommended that all rns participate in biannual emergency response drills organized through the office of emergency preparedness. the nursing community has recognized the potential impact that nurses can and should make in emergency preparedness and response. other health care providers and federal, state, and local agencies are following the incmce lead in developing provider competencies, developing learning resources, and ensuring that nurses are prepared and a central component of any disaster response plan. the incmce, nursing organizations, and schools face additional challenges in assuring an adequately prepared nursing workforce. specialized mci competencies should be developed for apns and nurses in specialized areas of practice. apn competencies that address the higher-level triage, diagnostic, and treatment capabilities of the apn, inter-professional collaboration, health policy, and the broad systems focus the apn brings to the health care arena would further define the apn as a significant resource in emergency preparedness. in addition, the development of mci competencies and the delineation of roles for other nursing specialties, such as administration, community health, critical care, and school health, would assist government and health care planners in appropriately using nurses in emergency response plans. faculty development in the area of mce is an immediate need. as government agencies and health care institutions broaden the expectations and requirements related to emergency preparedness and response, there will be a growing demand for continuing education providers and nursing faculty with the necessary mci expertise. the need for quality resources for group and individual learning related to mcis and emergency preparedness presents another immediate challenge for nursing education. immediately after september 2001, many web sites, reports, and articles appeared. faculties attempting to develop appropriate programming or curricula for nurses or other health professionals were overwhelmed. resources, including learning/teaching modules, are being developed for nurses and other health care professionals. veenema has developed a companion curriculum guide for her text on disaster nursing [11] . in addition, a full on-line course and curriculum are being developed. an online curriculum also is being developed at the vanderbilt university school of nursing. other teaching modules and health profession curricula are being developed through 2003 health resources and services administration cooperative agreements. finally, a research framework that addresses nursing roles in mcis, appropriate responses, preparedness, and outcomes should be developed. because of the nature of mcis and the need for an interprofessional response, a collaborative research framework and approach would seem to address this pressing need best. ensuring that nursing as a profession is prepared to meet the country's need for emergency preparedness requires the collaborative effort of all nursing education as broadly described. schools of nursing and individual faculty have a particularly challenging task of ensuring that all future nursing graduates have basic knowledge and skills related to mcis. the incmce has developed a set of national consensus-based competencies that provide a framework for mci education. educating 2.7 million nurses and all future nurses regarding mcis is an unheralded feat; however, nurses, because of their unique nursing education and perspective practicing in multiple roles and settings, provide an unduplicated resource for mass casualty preparedness and response. core competencies i. critical thinking a. use an ethical and nationally approved framework to support decisionmaking and prioritizing needed in disaster situations. b. use clinical judgment and decision-making skills in assessing the potential for appropriate, timely individual care during an mci. ii. assessment a. general assess the safety issues for self, the response team, and victims in any given response situation, in collaboration with the incident response team. identify possible indicators of a mass exposure (ie, clustering of individuals with the same symptoms). describe the essential elements included in an mci scene assessment. b. specific conduct a focused health history to assess potential exposures to cbrne agents. assess the immediate psychological response of the individual, family, or community following an mci. perform an age-appropriate health assessment, including: 1. airway and respiratory assessment 2. cardiovascular assessment, including vital signs and monitoring for signs of shock a seventh area of core knowledge, global health care, is included in the aacn essentials document. through the consensus-building process to develop a set of national nursing mci competencies, no competencies were identified or categorized under this core knowledge area. many of the mci competencies, however, overlap areas of content and skill and could be identified under several areas of core competence, core knowledge, or professional development. comprehensive emergency management c. describe the legal authority of public health agencies to take action to protect the community from threats, including isolation, quarantine, and required reporting and documentation recognize the impact mcis may have on access to resources and identify how to access additional resources (eg, pharmaceuticals and medical supplies) illness and disease management a. discuss the differences/similarities between an intentional biological attack and that of a natural disease outbreak using an interdisciplinary approach, the short-and longterm effects of physical and psychological symptoms related to disease and treatment secondary to mcis information and health care technologies a. describe the use of emergency communication equipment that must be used in a mci response discuss the principles of containment and decontamination describe how nursing skills may have to be adapted while wearing ppe identify and discuss ethical issues related to mci events, including: 1. rights and responsibilities of health care providers in mcis (eg, refusing to go to work or report for duty or refusal of vaccines) need to protect the public versus an individual's right for autonomy (eg of public health authority to restrict individual activities, requiring reporting from health professionals, and collaborating with law enforcement b. describe the ethical, legal, psychological, and cultural considerations when dealing with the dying and/or the handling and storage of human remains in an mci identify and discuss legal and regulatory issues related to: 1. abandonment of patients 2. response to an mci and one's position of employment 3. various roles and responsibilities assumed by volunteer efforts vi. human diversity a. discuss the cultural, spiritual, and social issues that may affect an individual's response to an mci discuss the diversity of emotional, psychosocial and socio-cultural responses to terrorism or the threat of terrorism to one's self and others u s department of health and human services, health resources and services administration, bureau of health professions, division of nursing available at: jcrinc.com/docviewer.aspx final report: developing objectives, content, and competencies for the training of emergency medical technicians, emergency physicians, and emergency nurses to care for casualties resulting from nuclear, biological, or chemical (nbc) incidents (contract no. 282-98-0037) association of state and territorial directors of nursing. position paper: public health nurses' vital role in emergency preparedness and response core public health worker competencies for emergency preparedness and response course document for postgraduate diploma/msc in disaster relief nursing for entry nurse practitioner primary care competencies in specialty areas: adult, family, gerontological, pediatric, and women's health international nursing coalition for mass casualty education. educational competencies for registered nurses responding to mass casualty incidents american association of colleges of nursing. the essentials of baccalaureate education for professional nursing practice position statement on work release during a disaster: guidelines for employers. adopted by the ana board of directors disaster nursing and emergency preparedness for chemical, biological and radiological terrorism and other hazards 3. integumentary assessment, particularly a wound, burn, and rash assessment 4. pain assessment 5. injury assessment from head to toe 6. gastrointestinal assessment, including specimen collection 7. basic neurological assessment 8. musculoskeletal assessment 9. mental status, spiritual, and emotional assessment iii. technical skills a. demonstrate safe administration of medications, particularly vasoactive and analgesic agent, by oral (po), subcutaneous (sq), intramuscular (im), and intravenous (iv) administration routes. b. demonstrate the safe administration of immunizations, including smallpox vaccination. c. assess the need for and initiate the appropriate cbrne isolation and decontamination procedures available, ensuring that all parties understand the need. d. demonstrate knowledge and skill related to personal protection and safety, including the use ppe for level b and c protections and respiratory protection. e. demonstrate the ability to maintain patient safety during transport through splinting, immobilization, monitoring, and therapeutic interventions. a. describe the local chain of command and management system for emergency response during an mci. b. identify one's own role in the emergency response plan for the place of employment. c. demonstrate appropriate emergency documentation of assessments, interventions, nursing actions, and outcomes during and after an mci. d. identify appropriate resources for referring requests from patients, media, or others for information regarding mcis. e. describe appropriate coping strategies to manage self and others. f. core competencies i. health promotion, risk reduction, and disease prevention a. identify possible threats and their potential impact on the general public, emergency medical system, and the health care community. b. describe community health issues related to mci events, specifically limiting exposure to selected agents; contamination of water, air, and food supplies; and shelter and protection of displaced persons. ii. health care systems and policy a. define and distinguish the terms disaster and mci in relation to other major incidents or emergency situations. b. define relevant terminology, including:1. cbrne 2. weapons of mass destruction (wmd) 3. triage 4. chain of command and management system for emergency response 5. ppe key: cord-284123-gfxadhcj authors: bachtel, molly kathleen; hayes, rose; nelson, michelle a. title: the push to modernize nursing regulations during the pandemic date: 2020-07-23 journal: nurs outlook doi: 10.1016/j.outlook.2020.05.006 sha: doc_id: 284123 cord_uid: gfxadhcj advanced practice registered nurses (aprns) stand ready and willing to improve access to care across the united states, both during the covid-19 pandemic and beyond. yet, their practice remains restricted in certain states due to long outdated regulations, even as many other healthcare regulatory changes have occurred via executive order (e.g., allowing for telehealth reimbursement and expediated licensing). for instance, the aprn compact has been on standby since 2015. when the federal hhs secretary called upon all governors to lift restrictions on aprns during the public health crisis, seven of the 28 restricted states took no action, and the southeast remained the most restricted area of the country. now—in the year of the nurse and midwife, during the covid-19 pandemic—is the time to push forward on permanently removing aprn practice barriers. nationwide, this can be accomplished by increased engagement of nurses, who may, in turn, engage the public, physician champions, and other pro-nursing organizations. advanced practice registered nurses (aprns) stand ready and willing to improve access to care across the united states, both during the covid-19 pandemic and beyond. yet, their practice remains restricted in certain states due to long outdated regulations, even as many other healthcare regulatory changes have occurred via executive order (e.g., allowing for telehealth reimbursement and expediated licensing). for instance, the aprn compact has been on standby since 2015. when the federal hhs secretary called upon all governors to lift restrictions on aprns during the public health crisis, seven of the 28 restricted states took no action, and the southeast remained the most restricted area of the country. now-in the year of the nurse and midwife, during the covid-19 pandemic-is the time to push forward on permanently removing aprn practice barriers. nationwide, this can be accomplished by increased engagement of nurses, who may, in turn, engage the public, physician champions, and other pro-nursing organizations. cite this article: bachtel, m.k., hayes, r., & nelson, m.a. (2020, xxx) . the push to modernize nursing regulations during the pandemic. nurs outlook, 00 (00) advanced practice registered nurses (aprns) are ready, willing, but restricted; there is no better time for the sleeping giant of 3.8 million registered nurses to wake up and take part in a massive push to retire outdated restrictions on aprns once and for all (american association of colleges of nursing, 2019). more has been done, arguably, to curtail the over-regulation of nursing in the past month than in the last 10 years combined. in the midst of the covid-19 chaos, president trump and many governors have enacted swift, unprecedented regulatory change through executive orders (e.g., to expand telehealth delivery and ensure reimbursement for these services through medicare and state-issued medicaid; centers for medicaid and medicare services [cms], 2020). while executive orders can be an effective temporary measure, there is still much to be done. with the support of an engaged public, permanent legislative change is now possible. it's time to untie the hands of the 404,437 aprns in the u.s. (phillips, 2020) . a recent, desperate call from an np unable to hire more nurse practitioners (np)s to help her care for covid-19 vulnerable patients due to state restrictions was heartbreaking (james, 2020) . states that are lagging behind need to be brought into the 21st century. but first, we as nurses, must realize that we have the political available online at www.sciencedirect.com n u r s o u t l o o k 0 0 0 ( 2 0 2 0 ) 1 à3 www.nursingoutlook.org power to drive these reforms. we simply have to take action. the covid-19 crisis has demonstrated that nurses must be able to swiftly and flexibly cross state lines for work. yet, the lack of a multistate licensure for advanced practice registered nurses, combined with unnecessary restrictions on aprns' scope of practice, has impeded mobilization of the nursing workforce. the aprn compact is effectively on standby, meaning fluid interstate movement of aprns is not currently possible. while the compact was approved in 2015, for it to go into effect, a minimum of 10 states have to pass the proposed model legislation. on march 24th, federal health and human services secretary alex azar sent a letter to all the nation's governors recommending they promptly "relax scope of practice requirements for healthcare professionals" (ncsbn, 2020a). the federal government temporarily suspended physician supervision of crnas at the national level as well (cms, 2020). a month later, all but seven (including georgia) of the 28 states that limit np practice have partially or fully waived aprn practice agreement requirements with physicians (american association of nurse practitioners, 2020). in fact, 22 states have achieved full practice authority (fpa) status for nps, according to the aanp (2020). despite this, the southeast (se) remains the most restricted region in the country, with all 12 se states either having a "restricted or reduced practice" designation-thus precluding interstate deployment of nurses to se covid-19 hot zones. what exactly is holding back southern states? georgia politics may offer some insight. georgia is widely considered the most restrictive state for nursing: we were the last state to grant prescriptive authority to aprns and are currently the only state in which aprns cannot order advanced imaging without restriction. here, legislators and the governor's office have long yielded to the influence of state medical associations. efforts to remove aprn scope of practice barriers are continually framed as "scope of practice fights," rather than collaborative initiatives to improve access to care. on crossover day, the last day for legislation to move from one chamber to the other at the georgia state capitol, two part-time aprn coalition lobbyists, two aprns (out of about 15,000), and four volunteer high school students were alone in fighting for passage of a bill to remove georgia aprn radiology restrictions (hb 1092). we were up against a full cadre of medical lobbyists working in unison and calling out legislators from the chamber to the capitol hallways for private discussions about the bill. the opposition claimed that allowing aprns to order advanced imaging would increase costs and threaten patient safety. there is no evidence to support these claims from any of the 49 states that allow aprns to order these tests; but organized medicine is adept at coalescing around any perceived threat to their profession. against all odds, the bill passed the georgia house with a level of support that was truly unexpected. the two nurses in attendance shed tears of relief at its passage. hb 1092 will move onto the georgia senate when they reconvene in mid-june. in spite of occasional victories such as this, there continues to be a relative lack of political engagement from georgia nurses. efforts to modernize our state nurse practice act-the living document that controls all aspects of state nursing practice-will surely fail if nurses do not actively support the effort. nurses must complete an honest self-assessment: are we giving this cause the time and attention it deserves? nursing advocacy initiatives are underfunded. many nurses do not understand that being actively involved in state and local organizations has the utmost impact on their practice environment. national nursing organizations can offer support, but the real work needs to be done close to home. sadly, an overwhelming majority of georgia nurses are neither members of state or local nursing organizations, nor have they ever contacted their state legislators. during presentations, when i ask groups of nurses to raise their hand if they know the names of their legislators, time and again only a few hands go up. georgia nursing advocates are stepping up efforts to increase engagement from frontline nurses and allies. next steps include lobbying support from the public and groups such as americans for prosperity and the american association of retired persons. the georgians united for healthcare movement, a coalition of pronursing organizations, has already launched a campaign to fund public service announcements illustrating how practice barriers limit citizens' access to care. nationwide, aprns will need to demonstrate support from physician colleagues when advocating for reform. florida state representative clay pigman, an emergency medicine doctor, offers an excellent example of the effectiveness of physician champions. he sponsored florida aprn legislation, passionately calling for the retirement of mandated physician supervision requirements; and the bill successfully passed (downey, 2020) . i hope nurses and physicians across the country will come together to lead grassroots health policy efforts. we need more nurses taking the first steps by joining their state and local organizations, getting to know their legislators, and gaining confidence in legislative advocacy. that includes running for public office. our communities desperately need improved access to healthcare-they are counting on us. there seems to be no better year than 2020, the year of the nurse and midwife, to push forward (who, 2020). american association of colleges of nursing florida politics. cary pigman corrals nearly 200 nurse anesthetists to support nurse independence trump administration makes sweeping regulatory changes to help u.s. healthcare system address covid-19 patient surge policy briefing: hhs sends letter, guidance to states encouraging state licensing waivers, relaxation of scope of practice requirements 32 nd annual aprn legislative updateimproving state practice authority and access to care. the nurse practitioner year of the nurse and midwife 2020 key: cord-011011-jxymy4e4 authors: cuttini, marina; forcella, emanuela; rodrigues, carina; draper, elizabeth s.; martins, ana f.; lainé, agnés; willars, janet; hasselager, asbjørn; maier, rolf f.; croci, ileana; bonet, mercedes; zeitlin, jennifer title: what drives change in neonatal intensive care units? a qualitative study with physicians and nurses in six european countries date: 2020-01-02 journal: pediatr res doi: 10.1038/s41390-019-0733-9 sha: doc_id: 11011 cord_uid: jxymy4e4 background: innovation is important to improve patient care, but few studies have explored the factors that initiate change in healthcare organizations. methods: as part of the european project epice on evidence-based perinatal care, we carried out semi-structured interviews (n = 44) with medical and nursing staff from 11 randomly selected neonatal intensive care units in 6 countries. the interviews focused on the most recent clinical or organizational change in the unit relevant to the care of very preterm infants. thematic analysis was performed using verbatim transcripts of recorded interviews. results: reported changes concerned ventilation, feeding and nutrition, neonatal sepsis, infant care, pain management and care of parents. six categories of drivers to change were identified: availability of new knowledge or technology; guidelines or regulations from outside the unit; need to standardize practices; participation in research; occurrence of adverse events; and wish to improve care. innovations originating within the unit, linked to the availability of new technology and seen to provide clear benefit for patients were more likely to achieve consensus and rapid implementation. conclusions: innovation can be initiated by several drivers that can impact on the success and sustainability of change. innovation was defined as "the intentional introduction and application within a role, group or organisation, of ideas, processes, products or procedures new to the relevant unit of adoption", 1 regardless of the time elapsed since development or availability in the marketplace. in the healthcare field, innovations typically include new services, ways of working or technologies directed at improving the health outcomes, cost-effectiveness, administrative efficiency, or user's experience. 2, 3 according to greenhalgh et al., 3 an important element of healthcare innovation is implementation "by planned and coordinated actions". implementing innovation, including the abandoning of ineffective or obsolete practices, 4 is crucial to improve the effectiveness and safety of health care. 5 however, "invention is hard but dissemination is even harder", 6 and the slow or uneven adoption of innovation has been frequently reported. 6, 7 theoretical models of change 7 have identified different primary catalysts for the adoption of innovation including the recognition of the need to change, as indicated by "unfreezing the target behaviour" in lewin's change theory 8 or "establishing a sense of urgency" in kotter's eight-step process; 9 the innovation characteristics in rogers' diffusion theory; 10 and the balance between benefits and costs of adoption according to the risk-based framework. 11 focussing on implementation, the consolidated framework for implementation research (cfir) has provided a comprehensive and pragmatic structure to promote theory development and effectiveness verification across multiple contexts. 12 however, studies providing empirical data about the factors that initiate change in healthcare organizations or the relation between the origin of innovation and the success of implementation are few. 13 we carried out a qualitative study with physicians and nurses to explore how clinical or organizational innovations are introduced and implemented in neonatal intensive care units (nicus), a setting characterized by extreme patient fragility, complex technological environment, highly specialized multidisciplinary personnel. this paper focusses on the initial motive for change, broadly defined as the reasons, goals or events that started the process leading to actual clinical or organizational innovation. this study is part of the "effective perinatal intensive care in europe" project (epice, https://epiceproject.eu) on the use of evidence-based interventions in perinatal care in 19 regions of 11 european countries. 14 for this study, we involved one region from each country with resources to carry out qualitative interviews and analysis: the eastern region in denmark, ile-de-france in france, hesse in germany, lazio in italy, northern region in portugal and east midlands in the uk. in each region, we stratified the nicus according to academic status (yes/no) to ensure variability in terms of organization and policies of care, resources, involvement in research and training. we then randomly selected two nicus per region within these strata. in each nicu, we interviewed two physicians and two nurses with experience of at least 3 years clinical work in that unit. priority was given to staff with involvement or interest in evidence-based medicine. we focused on physicians and nurses because the presence of other professionals (e.g. physiotherapists, psychologists) in nicu teams may vary between countries. additionally, these professionals are often attached to different hospital units and provide only consulting or part-time work in nicu. we had no explicit refusals. however, in denmark, only one unit was able to schedule the interviews within the study period. the study was approved by the ethics committees in all regions. signed informed consent by informants was obtained except in denmark and france, where the committees waived the requirement. we carried out 44 individual semi-structured interviews in local language, focussing on the most recent clinical or organizational innovation introduced in the unit regarding care of very preterm infants (vpt, <32 weeks of gestation). we broadly referred to the theory of organizational change outlined by pettigrew, 15 emphasizing the categories of content ("what has changed"), context (inner and outer) and process of change, including the actions, reactions and interactions of the various interested parties. we developed an interview guide to ensure standardization across units and interviewers. the guide followed a chronological order starting with the content of the change and the main initial motive, or driver, for introducing it; the planning, dissemination and implementation phases; compliance and perceived benefits of the innovation. pilot interviews carried out in italy, france, portugal and uk and discussions within the study team were used to finalize the guide. a 2-day training workshop was held for interviewers to standardize the conduct of the interviews and methods of transcribing and analysing the data. interviews were carried out by appointment at the informant's hospital, and were recorded and fully transcribed anonymously. we used thematic analysis to identify the patterns across the dataset ("themes") relevant to the description and motives for change. 16 the analysis was performed in two stages to address the challenges of our multilingual sample. firstly, at regional level each interviewer carried out an initial coding of the raw data using a common scheme based on the interview guide and supplemented with additional codes emerging from the data and shared within the coding team. the coded text was then translated into english for the second stage of analysis, which was carried out at the coordinating centre in italy by e.f. and m.c. e-mail discussions between the interviewers and the italian team were used to check the interpretation of results. similar themes continued to emerge in all nicus after the first half of the interviews, indicating saturation. the analyses were performed using the nvivo10 software (qsr international, australia). the characteristics of nicus and informants are presented in tables 1 and 2, respectively. the 11 selected nicus were diverse with respect to structural and functional organization, including number of cots and admissions, provision of specialized services, and use of protocols and guidelines. most informants (n = 35) were females. the mean interview duration differed by profession (34 min for physicians and 44 for nurses) and country, with longer interviews in the uk and italy. table 3 shows the reported innovations. for physicians, the most frequently reported changes concerned ventilation, followed use of probiotics (n, %) 1 (9) by feeding and nutrition, and by infant care and pain management. this latter was the most frequently reported by nurses, who also discussed the care of parents. six "themes" emerged from the data in relation to the initial main motive for change ( fig. 1) . again, nurses were more likely to report care-related motives, while physicians appeared more sensitive to the availability of new knowledge and technology. findings in scientific literature, attendance at conferences and informal opportunities to exchange information with colleagues were reported as main triggers for change by seven physicians and four nurses. the idea has emerged from the literature. since some years we have managed respiratory distress in very premature infants in a fairly systematic way by intubation and surfactant administration. and then new randomised trials appeared in the literature showing that stabilization of these infants by non-invasive ventilation could avoid intubation and unnecessary administration of surfactant, because these children did not need it. […] so it's a real change of practice. (physician/ france/9) new staff arriving from other hospitals were also a source of innovative ideas, and often took the lead in promoting implementation: …we've been aware that other units had been using a different mode of infant ventilation and also this consultant came from a unit where that was being used. so we were sort of fairly happy that it's not going to do any harm and might have the potential to do some good. […] this consultant i mentioned actually took ownership of it, did produce a guideline. (physician/uk/25) the availability of innovative technology, such as new equipment, was a very strong driver for change: a very recent change that, i really believe, has modified quite a bit our management, both for physicians and nurses, are the ram cannulas for nasal ventilation. they allow us to use a high flow and apply pressure both during inspiration and expiration. […] the previous system was more powerful, but more aggressive. (physician/france/14) while most of the new technology mentioned concerned ventilation, other types of equipment were also reported: …as now there is an easy-to-use machine that allows us to analyse every time the lipid, protein and carbohydrate content [of mother's milk], well we do it, everything is analysed and we will know exactly what we are doing. because we know that maternal milk is perfect for preemies, but it does not exactly meet the needs of the premature baby. thus we give what is called a fortifier. (physician/france/35) considering the advantages of a technology and obtaining the resources to acquire it may take time, but its adoption seems to raise little resistance, and benefit from easy implementation: we had attended a conference as a team and looked at the equipment, and thought that it would be something really good. […] we spoke to the representatives there and had a quote, and decided that this was something we were going to buy. (physician/uk/1) thus if one finds something easier at the technical level, which seems as effective, one wants to use it. that's it. (physician/ france/14) (4) 28 (2) 19 (3) 43 (13) 37 (14) 45 (16) 34 (13) nurses 38 (6) 33 (18) guidelines and regulations from outside the nicu change may be motivated by factors external to the unit, such as a new guideline or regulation issued by official agencies: so with nice, they get a national launch and when they come out, you are told by commissioners that you need… you need to find a way to meet this guideline. and then we would usually adapt the national guideline into a local policy. because there is a regulation on the use of breast milk that is very clear and very strict and does not allow the use of raw frozen-thawed milk within a hospital service. it is possible at home but not in the hospital because of obvious bacteriological reasons and so, there you go, it was imperative that we follow the rules and not be outside of bounds. (physician/ france/13). the guidelines produced by scientific or professional groups seem to be more acceptable that those issued by official agencies, particularly when some of the staff had been involved in the process: …a [hospital] pediatric pain group was created, including the various sub-specialties at the level of paediatrics. i am the coordinator of the group, myself and nurse x, the nurses are obviously involved, in fact they are the ones who are with the children and carry out the pain assessment and administer the medications, basically. (physician/portugal/18) for the nicu, this was … an opportunity to bring some things up to date, things which were being done but there was no proper protocol. (physician/portugal/18) in contrast, guidelines issued by official agencies were viewed as more bureaucratic, and possibly less appropriate to the unit patients and care. they appeared to encounter more resistance, particularly when there was disagreement about the strength of the evidence: so one of the difficulties with nice guidelines is that they come out with a government stamp on them saying you must do it and you must audit them. but actually sometimes the evidence on which the guideline is based is quite weak. and ultimately it comes down to expert opinion. (physician/uk/38) the decision to standardize practices generally arose within the unit team, aiming at more consistent and homogeneous care: there was a need for a common framework. (nurse/italy/17) even issues considered common knowledge could benefit from standardization, as was the case with actions in response to vancomycin blood level monitoring: we did know, that you must react. everyone knew that, but it wasn't standardized. now it's rather precise, regardless of who is working, whether it's weekend or night or whatever, the reaction is always exactly the same. (physician/germany/10) the need for a common approach was felt especially in case of rapid staff turnover, or because of new professionals joining the unit: now every morning we have the physiotherapists […]. therefore also this part, which was not included in the old protocol, had to have relevance, and we all had to standardize our approach to the children. (nurse/italy/17) modification of the characteristics of the patients admitted to nicu was mentioned as a motive to revise policies: also the type of patients change, they are becoming smaller and smaller… the 23 weekers were only in the mind of god, now they survive, therefore clearly you have to update progressively, as both research and type of patients lead you to adapt some parts. (physician/italy/34) the experience of participating in a study requiring modification of usual routines was the main driver leading to the establishment of a structured protocol for kangaroo skin-to-skin maternal care: there were many reasons that motivated it, one of them-and this was very important-was that we are part of a project which is called care. so we took advantage of this situation to say that we would like our unit to be part of this change and we went ahead with it. (physician/portugal/ 19) in italy, participation in an intervention study to increase parental presence in nicu led to the establishment of a new routine for the first communication with the parents: before, in case of a new neonatal admission, we were busy only with the baby. now we go to talk to the parents, we reassure them and tell them that as soon as the baby has stabilized, they will be able to enter [the nicu]. (nurse/italy/24) in germany, study participation led to the development of an educational protocol identifying the situations when endotracheal intubation could be performed by trainees: well, we had taken part in a study, a study on intubation, and in that framework we thought, good now, we'll thoroughly reorganise it, so that there are guidelines. (physician/germany/39) in one case only the reported research, a randomized clinical trial to identify the lowest baby's weight for safe transition from incubator to open cot, was designed by the informant and carried out within the unit itself: nevertheless, when the change involves, as in this case, organizational modifications requiring compliance by the whole team and the parents, implementation can still be challenging: it's a process which is a bit different, and [initially] the medical staff weren't really motivated. i mean one thing is a new ventilator, a new ventilation strategy, and then you have all the scientific enthusiasm inherent to intensivists. as long as there is the money to buy the ventilators, there's a meeting, and if there is agreement they move forward and the process is established and everyone follows along, the parents have no word in it, nor the nurses, they just have to adapt to it. whereas here, there is involvement of all staff, it is different and very interesting, at least from my point of view. (portugal/physician/19) occurrence of an adverse event adverse events, and the urgency to prevent similar cases in the future, were reported as rare but highly emotionally charged triggers leading to the change of unit practices: this change occurred because we diagnosed late, late a baby who was in hospital with aortic coarctation…in other words, there was an error in our work. […] i think that it was because of this urgent case that [the cardiac screening] was implemented from one day to the next. it had to be done. (nurse/ portugal/37) while describing the newly introduced daily mandatory inspection of the resuscitation equipment at the labour ward, documented and signed by the nurse in charge, the informant reported about: …a suction device that actually didn't work, the device was faulty, it just didn't build up any suction and you would have noticed that if you had checked it beforehand. so that happened in a situation with an emergency caesarean section where we really came in at the same time as the patient. […] we discussed, how do you do that, how do others do that, how can we match that? and then we said, okay, it's got to be a daily check. (nurse/germany/36) adverse events appeared to prompt immediate change even when unrelated to identified clinical errors: …the one that springs to mind that is probably the most recent is a guideline on difficult intubation. what prompted it initially was… we actually had an incident where a baby was very difficult to reintubate. and when we looked at the incident in detail, we identified that we hadn't got a guideline on the difficult to manage airway. […] what was interesting when we wrote the guideline was that what had been done during the incident was what the guideline said we should do. (nurse/uk/11) interestingly, the nurse commented on the value of guidelines precisely for infrequent events: it isn't a circumstance that is going to happen often, but then i feel that those are particularly the occasions you need guidelines for. obviously for things you do day-in day-out, it's perhaps less important, because you know what you're doing all the time. whereas something that happens less often, it's always useful to have a guideline to refer to. (nurse/uk/11) improvement of care improvement of care was explicitly identified as the main motive for change by three doctors and eight nurses. two physicians from the same nicu mentioned the importance of starting personalized parenteral nutrition since the first hours after birth: …this nutrition prevents the babies from entering a catabolic state, which is what happens when they are born and so, it is fundamental that we stop the catabolic state, right, and try to nourish them from the first day. (physician/portugal/42) this aim conflicted with the opening hours of the hospital pharmacy, that would not prepare parenteral nutrition bags unless ordered before 2 pm: …and so, all newborns who were born outside of those hours had to receive [only] basic fluid therapy until the next day. (physician/portugal/42) additionally, parenteral bags could only be ordered with reference to a specific, legally identified individual: and here the problem is that legally the baby only exists after it is born. (physician/portugal/28) the change that was implemented involved ordering a parenteral bag "in anticipation": so we ended up by speeding things a little and planning ahead and making requests for babies, who aren't yet identified with a file number, by using only the mother's identity and the baby's predicted weight. (physician/portugal/28) and then that bag is adjusted in terms of the rhythm of perfusion for the infant who is born in the meantime. there, it's something new. (physician/portugal/42) the nurses focussed on the importance of care, and on the appropriate handling of the fragile very preterm babies: at the beginning of last year we discussed that we would like to introduce kinaesthetics into our care practices. […] it's not that anyone ever felt that we weren't handling the children correctly, rather we just wanted to improve because the children stay in our wards for a very, very long time. we wanted to do something good for the children, and we noticed that we treat them differently from our medical colleagues. so, we have a medical colleague who always positions the children semi-upright, because he says that's good for their breathing. then you come to one of these little cots and you see that the infant is in this position but is sliding down and being held up by the air tubes. breathing improves, no question about that, but you need to give the child a support, some security, so the baby doesn't have the feeling, oh god, what do i do now? (nurse/ germany/15) improvement of patient care may also be achieved by increasing parents' involvement and empowerment: we chose our focal points that we want to communicate to the parents. we really pushed the advice for breastfeeding, reinforced skills in feeding and handling the infants. our experience was, the more skilled the parents are, the more they can contribute to the care. (nurse/germany/12) this study provides, from the perspective of the healthcare staff, an overview of the type of clinical and organizational innovations introduced in the nicus and of the main factors that motivated the decision to change. consistently with our initial question, some of the innovations described referred to the same topic. however, the relative frequency of selection varied by professional role, with ventilation at the top of the physicians' list while issues of infant and parental care were more prominent among nurses. we found that the introduction of innovative policies or treatments in nicus can be triggered by several factors. some were external to the unit, such as the publication of a new law or official guideline in need of implementation. others were internal, arising from a reflection on own clinical experience promoted by reading the literature, attending conferences, participation in research, or as reaction to an adverse event. while external triggers were generally backed-up by formal assessment of scientific evidence, this was not always the case for changes that originated from staff personal experience and observations. this dichotomy seems to mirror two views of evidence-based medicine: the rigorous identification of scientific evidence with results of randomized clinical trials and meta-analyses only, versus the broader view including other sources of evidence such as different study designs, clinical experience, interactions with peers and patients, and "pragmatic science" methods of learning. [17] [18] [19] in our study, pragmatic methods and clinical experience were used to promote organizational changes especially in areas where formal scientific evidence was lacking or controversial. they were more often used by nurses, because of their special interest in the patient perspective and, possibly, the relative paucity of experimental evidence in nursing. 20, 21 however, clinical experience is effective only when accompanied by the other three elements of the kolb's experiential learning cycle, 22 namely reflective observation, conceptualization and experimentation. the development, reported by one of our informants, of a randomized trial based on the initial observation of a declining trend of babies' weight at transfer to open cots, with its final finding of safe shortening of hospital stay, was a perfect example of the application of the cycle as well as demonstration of the complementarity between ebm and quality improvement methods. 19 we found that the type of motivation to change influenced the speed of implementation and staff compliance. innovations arising within the nicu team, out of personal experiences and exchanges with colleagues, new information from the literature or participation in research, appeared to lead to smoother and possibly quicker implementation. an extreme example of internal trigger was the occurrence of an adverse event, where the emotional burden led to immediate action and widely shared consensus about the necessary change. this finding confirms the learning potential for staff after an adverse event, which is at the root of audit initiatives such as incidence reporting, case analyses and mortality statistics conferences for the nicu or all hospital staff. 23, 24 the nature of the innovation was also relevant. technological innovations, such as new drugs or equipment, offer the promise of improving care within limited resources and without need for complex reorganization of unit routines. in contrast, changes requiring policy reorganization, coordination across disciplines and agreement by all components of the team remain challenging, and may take more time to gain consensus. 25 however, glamour and underlying commercial interests may foster the adoption of new technologies even before evidence of benefit and cost-effectiveness is established. preliminary testing to the same standards of other innovations is absolutely necessary. 26, 27 the active participation of the unit staff in the development of the new policy, or at least in the decision to adopt it, appeared crucial to increase compliance. changes imposed completely from outside, such as mandatory regulations or official guidelines issued by ad hoc agencies, raised more frequent criticism and resistance, particularly when the strength of the evidence was considered controversial. an additional important issue was the opportunity to test the innovation before adoption, as was the case for participating in a research project on kangaroo care, highlighting the importance of clinical research not only in generating new knowledge but also as learning experience for participants. finally, the presence of a staff member with personal interest and expertise in the specific field of change was the third element that emerged as important for successful implementation. this study has strengths and limitations. to our knowledge, this is the first study providing an overview of the factors that trigger change and promote the introduction of clinical and organizational innovation in nicus. the study benefited from the epice mixed-method design as we based our research hypothesis on quantitative data showing variable uptake of a range of evidencebased interventions by region. 14 however, our decision to focus on the process of change allowed any unit to participate, as the interview contents were not contingent on use of a specific intervention. we did not provide a pre-set definition of innovation, allowing a better understanding of what constitutes innovation for the medical and nursing professionals. the choice of discussing a real experience, identified as the most recent, aimed to avoid theoretical discussions and prevent the selection of the most successful event. the inclusion of a maximum of eight interviews per country inhibited a full analysis of country-level specificities. nonetheless, many of the themes emerged in multiple contexts, suggesting broader application. the findings of our study can contribute to inform strategies aimed at fostering successful implementation of the intended change and staff compliance. whether the change originates within the nicu or from outside, it is advisable to involve all the staff concerned in its uptake, including listening to objections and criticisms and proposals for local adaptation. in case of innovation promoted by official agencies, early partnering with professional associations may be important. clinical audits represent a powerful opportunity for change, particularly when carried out with a nonjudgemental, pragmatic attitude. regular literature review meetings can promote the transfer of scientific findings into clinical practice. actual participation in research studies can be an effective way to test innovations before adoption and monitor the outcomes. overall, these strategies may represent interesting research hypotheses to be tested in future studies. along with the established role of evidence-based methods to assess the value of innovative interventions, qualitative research can contribute to a better understanding of the circumstances and conditions that foster the development, dissemination and implementation of clinical innovations. the social psychology of innovation in groups innovation in healthcare: a systematic review of recent research diffusion of innovations in service organizations: systematic review and recommendations evidence-based de-implementation for contradicted, unproven, and aspiring healthcare practices road map for diffusion of innovation in health care disseminating innovation in health care outcomes of adoption: measuring evidence uptake by individuals and organizations field theory in social science leading change. why transformation efforts fail diffusion of innovation 1st edn the decision to adopt evidence-based and other innovative mental health practices: risky business? fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science canadian neonatal network epic study group. a qualitative examination of changing practice in canadian neonatal intensive care units use of evidence based practices to improve survival without severe morbidity for very preterm infants: results from the epice population based cohort context and action in the transformation of the firm applied thematic analysis broadening the view of evidence-based medicine strengthening the contribution of quality improvement research to evidence based health care knowledge 'translation' as social learning: negotiating the uptake of research-based knowledge in practice clinical nurse specialists' use of evidence in practice: a pilot study a descriptive study of research published in scientific nursing journals from 1985 to 2010 experiential learning experience as a source of learning and development specialty-based, voluntary incident reporting in neonatal intensive care: description of 4846 incident reports a comprehensive overview of medical error in hospitals using incidentreporting systems, patient complaints and chart review of inpatient deaths translating research into clinical practice: making change happen unproven technologies in maternal-fetal medicine and the high cost of us health care putting innovation to the test we are grateful to all the physicians and nurses who participated in the interviews and shared their experiences with us. we thank nikola jeck for carrying out the interviews in germany. the m.c. designed the study, drafted the study protocol, coordinated data analyses and prepared the manuscript. e.f. coordinated data acquisition and analyses across the participating regions, carried out and transcribed the interviews in italy and performed the overall second-stage data analyses. c.r., e.s.d., r.f.m. and m.b. participated in the finalization of the study protocol and materials, supervised data acquisition in their region and contributed to the manuscript for important aspects related to the interpretation of results and the discussion. a.f.m., a.l., j.w., a.h. carried out and transcribed the interviews in their region and performed first-stage data analyses; they contributed to the paper as regards the validity of data reporting and interpretation. i.c. prepared and maintained the quantitative database of the study, prepared the tables and figure, and performed the literature review. j.z. initiated and coordinated the epice project, participated in the definition of this study aims, protocol and instrument, and substantially contributed to the manuscript for important aspects. all authors have read and approved the final version of the manuscript. competing interests: the authors declare no competing interests.publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. key: cord-011818-z89m8dur authors: ki, jison; ryu, jaegeum; baek, jihyun; huh, iksoo; choi-kwon, smi title: association between health problems and turnover intention in shift work nurses: health problem clustering date: 2020-06-24 journal: int j environ res public health doi: 10.3390/ijerph17124532 sha: doc_id: 11818 cord_uid: z89m8dur shift work nurses experience multiple health problems due to irregular shifts and heavy job demands. however, the comorbidity patterns of nurses’ health problems and the association between health problems and turnover intention have rarely been studied. this study aimed to identify and cluster shift work nurses’ health problems and to reveal the associations between health problems and turnover intention. in this cross-sectional study, we analyzed data from 500 nurses who worked at two tertiary hospitals in seoul, south korea. data, including turnover intention and nine types of health issues, were collected between march 2018 and april 2019. hierarchical clustering and multiple ordinal logistic regressions were used for the data analysis. among the participants, 22.2% expressed turnover intention and the mean number of health problems was 4.5 (range 0–9). using multiple ordinal logistic regressions analysis, it was shown that sleep disturbance, depression, fatigue, a gastrointestinal disorder, and leg or foot discomfort as a single health problem significantly increased turnover intention. after clustering the health problems, four clusters were identified and only the neuropsychological cluster—sleep disturbance, fatigue, and depression—significantly increased turnover intention. we propose that health problems within the neuropsychological cluster must receive close attention and be addressed simultaneously to decrease nurse’s turnover intentions. nurses often work irregular shifts and bear high physical and psychological job demands that may, in turn, jeopardize their health status. specifically, shift work may cause a variety of physical and mental health problems [1] . the deterioration of nurses' health status could not only lead to a decline in their quality of life but could also affect the quality of care provided by them [2] . in addition, health problems may affect nurses' turnover, which is a serious issue worldwide [3] . the high turnover rate of nurses has led to an increase in both direct and indirect costs in the health system and could further protract the shortage of nurses that has lasted for the past several years [4] . a recent survey of korean nurses reported that about 10% of shift work nurses cited health problems as their main reason for resigning [5] . prior studies also show that nurses complained of two or more health problems simultaneously, which may be interrelated [2, [6] [7] [8] . musculoskeletal pain in nurses has been reported in many studies [9, 10] , and poor dietary habits due to irregular shift work were reported to cause gastrointestinal disorders [11, 12] . sleep disturbance, which is most frequently reported in studies of shift nurses, could lead to mood disorders, such as depression, both of which lead to chronic fatigue [13] [14] [15] . although nurses experience various health problems, there is relatively little research on the relationships between complex health problems in nurses [2] . moreover, few studies have investigated the relationship between concomitant health problems and turnover intention. because the burden may vary depending on the number and the kind of health problems shift work nurses have [16] , it may be important to identify specific comorbidity patterns of nurses' health problems through clustering and determine which clusters most affect turnover intention, where a cluster-that is, a comorbid pattern of health problems-can be defined as a group of concurrent or related health problems that can be distinguished from other clusters [17] . therefore, the purpose of this study was to first characterize shift work nurses' health problems. we then determined the pattern of symptom modalities by clustering the health problems through the hierarchical clustering method. lastly, we identified the impact of health problem clusters on turnover intention. this cross-sectional study was part of the shift work nurses' health and turnover (swnht) study, which is a prospective cohort study designed to investigate the longitudinal relationships between shift work nurses' health and turnover. it was supported by the national research foundation of korea (nrf) grant funded by the korea ministry of science and information and communications technologies and approved by the institutional review board (irb) at two tertiary hospitals in seoul, south korea. data collection was performed from march 2018 until april 2020. in the swnht study, we recruited 594 female nurses (294 novice nurses who had no exposure to rotating shift work, and 300 nurses with exposure to 8-hour rotating work, including night shifts, for at least 1 month) ( figure 1 ). because health problems can vary according to sex [18, 19] and the swnht study included a survey of nurses' menstrual and gynecological symptoms, the swnht study was limited to female nurses. data were collected three times for novice nurses: before exposure to shift work (novice registered nurse (nrn) t0, n = 294), after six months of work (nrn t1, n = 204), and 12 months after t1 (nrn t2, n = 204). for experienced registered nurses, data were collected twice: baseline (experienced registered nurse (ern) t1, n = 300) and 12 months after t1 (ern t2, n = 269; see details in section 2.2 data collection). int. j. environ. res. public health 2020, 17, x 2 of 13 could lead to mood disorders, such as depression, both of which lead to chronic fatigue [13] [14] [15] . although nurses experience various health problems, there is relatively little research on the relationships between complex health problems in nurses [2] . moreover, few studies have investigated the relationship between concomitant health problems and turnover intention. because the burden may vary depending on the number and the kind of health problems shift work nurses have [16] , it may be important to identify specific comorbidity patterns of nurses' health problems through clustering and determine which clusters most affect turnover intention, where a cluster-that is, a comorbid pattern of health problems-can be defined as a group of concurrent or related health problems that can be distinguished from other clusters [17] . therefore, the purpose of this study was to first characterize shift work nurses' health problems. we then determined the pattern of symptom modalities by clustering the health problems through the hierarchical clustering method. lastly, we identified the impact of health problem clusters on turnover intention. this cross-sectional study was part of the shift work nurses' health and turnover (swnht) study, which is a prospective cohort study designed to investigate the longitudinal relationships between shift work nurses' health and turnover. it was supported by the national research foundation of korea (nrf) grant funded by the korea ministry of science and information and communications technologies and approved by the institutional review board (irb) at two tertiary hospitals in seoul, south korea. data collection was performed from march 2018 until april 2020. in the swnht study, we recruited 594 female nurses (294 novice nurses who had no exposure to rotating shift work, and 300 nurses with exposure to 8-hour rotating work, including night shifts, for at least 1 month) ( figure 1 ). because health problems can vary according to sex [18, 19] and the swnht study included a survey of nurses' menstrual and gynecological symptoms, the swnht study was limited to female nurses. data were collected three times for novice nurses: before exposure to shift work (novice registered nurse (nrn) t0, n = 294), after six months of work (nrn t1, n = 204), and 12 months after t1 (nrn t2, n = 204). for experienced registered nurses, data were collected twice: baseline (experienced registered nurse (ern) t1, n = 300) and 12 months after t1 (ern t2, n = 269; see details in section 2.2. data collection). in this study, we used data collected from october 2018 to january 2019 (nrn t1, n = 204) and from march 2018 to may 2018 (ern t1, n = 300) to analyze the association between health problems and turnover intention among shift work nurses. in this analysis, we defined shift work as a in this study, we used data collected from october 2018 to january 2019 (nrn t1, n = 204) and from march 2018 to may 2018 (ern t1, n = 300) to analyze the association between health problems and turnover intention among shift work nurses. in this analysis, we defined shift work as a combination of day, evening, and night shifts; therefore, we excluded four nurses, including three nurses who worked only daytime hours and one nurse who worked from midday to 8 p.m. the primary purpose of the swnht study was to investigate health problems, presenteeism, and turnover intention in shift work nurses. to enroll novice nurses without shift work experience, we distributed and collected survey envelope packages that included survey instructions, consent forms, and a questionnaire on the third day of their work orientation before ward placement. to enroll experienced shift work nurses, we attached a recruitment notice to the ward bulletin boards, and nurses who wished to participate in the study voluntarily contacted the research team. we maximized voluntary participation by protecting confidentiality, ensuring anonymity, and no hospital-associated researchers took part in the data collection process. we collected the follow-up data through an online survey program; their response rates were 69.4% (nrn t1, nrn t2) and 89.7% (ern t1). the swnht study questionnaire included questions regarding general and job-related characteristics, health-related variables (e.g., dietary habits, menstrual symptoms, exposure to blood and body fluid, sleep, fatigue, depression, physical activity, etc.), occupational stress, presenteeism, and turnover intention. to objectively verify the sleep scale data, we also obtained actigraphy data from the subjects who consented to wear the actigraphy. the examined demographic characteristics included age (years), education (bachelor's degree or lower/master's degree or higher), marital status (single/married), having children (yes/no), and body mass index (kg/m 2 ). the examined job-related characteristics included work unit (general ward, intensive care unit, delivery room, and emergency room), months of shift work experience, and the average number of night shifts per month. we measured turnover intention since it is the most predictive measure of actual turnover [20] . in a longitudinal study in europe, nurses who had turnover intentions were more likely to leave their jobs [21] . in this study, the subjects were asked to choose one of four options (strongly agree, agree, disagree, or strongly disagree) to answer the question: "i plan on staying for the next year" [22] . the nine health problems in this study were selected by two professors at a nursing college and two nurses in a research team, and were based on reviews of the literature about shift work nurses' health problems [10, 18, [23] [24] [25] [26] [27] . these were (1) upper musculoskeletal pain (including neck, shoulder, and back pain), (2) leg or foot discomfort, (3) sleep disturbance, (4) fatigue, (5) depression, (6) menstrual disorders (including dysmenorrhea and menopause symptoms), (7) gynecological disorders (including disease of the uterus or ovary), (8) headaches (including migraine, dizziness, and chronic headaches), and (9) gastrointestinal disorders (including gastric ulcer, diarrhea, constipation, and stomachache). among the nine health problem categories, sleep disturbance, fatigue, and depression were measured using the instruments described below. for the other six health problem categories, the subjects were asked to indicate the health problems they experienced during the last month with "yes" or "no." to assess the quality of sleep, we used the korean version of the insomnia severity index (isi), which was developed by morin and translated by the korean sleep research society. the insomnia severity scale consists of seven questions related to sleep disorders measured on a 5-point scale (0-4 points) for each item. the score ranges from 0 to 28; higher scores indicate a lower quality of sleep. a score above 10 indicates sleep disturbance [28] . the cronbach's alpha value of the korean version of isi was 0.928 in our study. fatigue was measured using the fatigue severity scale (fss). the fss consists of nine questions about the degree of fatigue during the past week and is scored from 1 (strongly disagree) to 7 (strongly agree). a higher average score indicates higher fatigue. the criterion for fatigue is more than four points on average [29] . the cronbach's alpha value of the fss was 0.917 in our study. we measured depression using the shortened center for epidemiological studies depression scale (ces-d). the shortened ces-d consists of 10 questions about depressive feelings and thoughts during the past week and is scored from 0 (less than 1 day) to 3 (about 5-7 days). higher total scores indicate more depressive symptoms. a total score of 10 or above indicates depression [30] . the cronbach's alpha value of the shortened ces-d was 0.877 in our study. all analyses were performed using sas version 9.4 (sas institute inc., cary, nc, usa) and r project for statistical computing software version 3.4.4 (cran, soule, korea). we confirmed that there were no missing data. the descriptive statistics (frequency, percentage, mean, and standard deviation) for the demographic characteristics were analyzed. pearson's chi-squared test, fisher's exact test, and an analysis of variance were used to identify general characteristics associated with turnover intention. hierarchical clustering was used to group the health problems reported by participants. hierarchical clustering is a statistical method for grouping objects or variables according to the similarity between clusters using a bottom-up approach. in the field of nursing, this technique has been used mainly for symptom clustering of cancer patients; however, it has recently become more widely used in various studies [31] . the method used for measuring the distance between variables was the squared euclidean distance and the linkage method used for measuring the distance between clusters was the average linkage. the number of final clusters is usually determined by the researchers by taking into account clinical suitability [32] . multiple ordinal logistic regressions that included covariates, such as education, marital status, having children, body mass index (kg/m 2 ), work unit, months of shift work experience, and the number of night shifts per month, was used to investigate the association of single health problems and clusters of health problems with turnover intention. the four categories of "strongly agree," "agree," "disagree," and "strongly disagree" used for the turnover intention variable satisfied the proportional odds assumption at p > 0.050 with the covariates and variables of interest. this study was approved by the institutional review board (irb) at seoul national university hospital (irb no. h-1712-094-907) and the samsung medical center (irb no. 2017-12-075-002). after agreeing to participate in the study, all nurse participants signed a consent form and completed the baseline questionnaire. the participants were 500 female nurses working shifts, including night shifts. the nurses' mean age was 26.7 years (standard deviation (sd) = 4.20), and 19.8% were over 30 years old. there were no differences in demographic and job-related characteristics between the participants in the two tertiary hospitals. most nurses were single (88.2%) and had no children (94.0%). the average body mass index (bmi) was 20.19 kg/m 2 ; 22.8% of the subjects were underweight and only one subject was obese. the shift work length was 35 months on average, which was highly correlated with age (r = 0.92, p < 0.001). therefore, we excluded age from the covariates of the multiple ordinal logistic regressions (table 1) . one hundred and eleven nurses (22.2%) had a turnover intention and 12 nurses (2.4%) strongly intended to leave. the turnover intention was statistically higher in subjects who were younger (f = 5.70, p = 0.001), had no children (χ 2 = 10.14, p = 0.030), had a lower bmi (f = 4.24, p = 0.006), and had shorter periods of shift work (f = 6.83, p < 0.001). the mean number of health problems was 4.5 (range 0-9), with 95.2% (n = 476) of participants having more than two health problems. the most frequently reported health problem was upper musculoskeletal pain (82.4%), followed by leg or foot discomfort (67.8%), fatigue (65.0%), and sleep disturbance (62.4%). the associations between single health problems and turnover intention using multiple ordinal logistic regressions are provided in table 2 . fatigue (odds ratio (or) = 3.4, 95% confidence interval (ci) = 2.21-5.24), depression (or = 1.79, 95% ci = 1.22-2.62), leg or foot discomfort (or = 1.69, 95% ci = 1.12-2.56), sleep disturbance (or = 1.61, 95% ci = 1.10-2.37), and a gastrointestinal disorder (or = 1.51, 95% ci = 1.03-2.19) were significantly related to turnover intention. based on the hierarchical clustering analysis, four clusters were identified ( figure 2 ): the pain cluster (upper musculoskeletal pain and leg or foot discomfort), the neuropsychological cluster (depression, sleep disturbance, and fatigue), the gynecological cluster (menstrual disorder and gynecological disorder), and the gastrointestinal cluster (headache and gastrointestinal disorder). as a result of our multiple ordinal logistic regression analyses, only the neuropsychological cluster (depression, sleep disturbance, and fatigue) was found to be significantly related to turnover intention. in the neuropsychological cluster, if the participant had only one health problem, it did not relate to turnover intention. if the participant experienced two (or = 3.35, 95% ci = 1.90-5.92) or three (or = 5.73, 95% ci = 3.17-10.33) health problems in the cluster simultaneously, the odds ratio of the turnover intention increased linearly, which was statistically significant (f = 5.84, p < 0.001; table 3 ). based on the hierarchical clustering analysis, four clusters were identified (figure 2 ): the pain cluster (upper musculoskeletal pain and leg or foot discomfort), the neuropsychological cluster (depression, sleep disturbance, and fatigue), the gynecological cluster (menstrual disorder and gynecological disorder), and the gastrointestinal cluster (headache and gastrointestinal disorder). we investigated the prevalence of shift work nurses' health problems and characterized the patterns of symptom modalities by clustering health problems. we then investigated the association of single health problems and clusters of health problems with turnover intentions. we found that most shift work nurses experienced multiple health problems at the same time. we also found that having more than two health problems in the neuropsychological cluster was significantly related to turnover intention. this study was the first to attempt the clustering of nurses' health problems and explore the relationship between the clusters and turnover intention in shift work nurses. we found that 22.2% of nurses had turnover intention. in previous studies, turnover intention varied from 4% to 54% [33] [34] [35] . the first reason for the difference in turnover intention between existing studies and our study could have been the different measurement tools used in each study. while our study asked about future plans regarding turnover, such as "i plan on staying for the next year," other studies asked how often they thought about turnover in the past [36, 37] . some studies measured turnover intention with various questions, such as whether they were seeking another job or whether they thought about leaving the nursing profession forever [33, 38] . the second reason that turnover intention in our study was higher than in previous studies may be due to different hospital environments. the hospitals where our study was performed were tertiary hospitals in seoul, which had a higher patient severity and higher nurse labor intensity than other hospitals in korea. third, we measured turnover intention and not actual turnover, which is reported to be higher than actual turnover rates [21] . in 2018, the annual average nurse turnover rate was 13.9% in korea [5] . we found that fatigue was common in our subjects, highly related to turnover intention, and had the highest odds ratio (or = 3.4, 95% ci = 2.21-5.24). our results were consistent with a previous study that reported a positive correlation between fatigue and turnover intention [39] . although we could not determine with certainty how long they had suffered from fatigue, it appeared that fatigue was one of the common disabling health problems that lead to turnover intention. fatigue may exert a direct effect on turnover intention since nurses' fatigue has been reported to interfere with work efficiency and concentration and increase the risk of medical error and injury [40, 41] . although the direction of causality was not identified, nurses' fatigue was reported to be related to sleep disturbance, poor health, and depression [18, 25] . not surprisingly, we found that about 50% of nurses complained of fatigue and sleep disturbance at the same time and sleep disturbance was associated with turnover intention as a single health problem (or = 1.61, 95% ci = 1.10-2.37). sleep disturbance has received the most attention as a cause of turnover intention among nurses' health problems [42, 43] . irregular and insufficient sleep time due to shift work may often cause sleep disturbance, which may affect nurses' physical and mental health [1] . another finding of interest was that about 28% of nurses had all three interrelated symptoms of fatigue, sleep disturbances, and depression; this was associated with turnover intention as a single health problem (or = 1.79, 95% ci = 1.22-2.62). depression in nurses is prevalent in many studies, and in one study, the prevalence of depression among nurses was almost twice as high as in other professions [26, 44, 45] . depression may decrease concentration, which reduces the productivity of nursing and affects nurses' judgment, thus increasing occupational injury and turnover intention [26, 43] . our study revealed that fatigue, sleep disturbance, and depression may play important roles in increasing turnover intention as a cluster and as individual symptoms. approximately one-third of nurses experienced all three health problems; these findings suggest fatigue, sleep disturbance, and depression in the neuropsychological cluster were correlated with each other. despite the fact that biological and behavioral mechanisms in the development of depression, fatigue, and sleep disturbances are unknown, several studies have reported that these three health problems are related and co-occur [46, 47] . most importantly, 80% of nurses experienced one or more health problems in the neuropsychological cluster and this cluster was associated with turnover intention. moreover, their odds ratio of turnover intention increased linearly as the number of health problems increased within this cluster. future studies should probe the comorbidity of sleep disturbance, depression, and fatigue of shift work nurses and develop comprehensive health promotion to alleviate these three health problems. we found that having a gastrointestinal disorder was another common health problem, which was consistent with the result of a previous study of 20,000 korean nurses [12] . this high prevalence of gastrointestinal disorders among shift work nurses may, first, be due to disturbed circadian rhythm. the gastrointestinal system, like sleep, has a circadian rhythm, which controls bowel movement and the secretion of gastric juices [48] . second, it might be due to irregular meal times and skipped meals [49] . although not shown in the result, most of the nurses in our study reported eating irregularly (92.8%) and they ate breakfast twice a week, which was lower than the average number of times korean adults eat breakfast [50] . the most common reason for skipped meals in our study was irregular work times (64.8%). considering that having a gastrointestinal disorder was common among shift work nurses and was a single health problem that increased turnover intention, special attention needs to be paid to having regular and sufficient mealtimes as much as possible. in our results, gastrointestinal disorders and headaches formed the gastrointestinal cluster. this connection could be explained by the association between the brain and the stomach through neural, endocrine, and immune pathways and the high prevalence of headaches in patients with a gastrointestinal disorder [51, 52] . however, the gastrointestinal cluster was not related to turnover intention. it is possible that headaches, as an individual health problem, had no significant association with turnover intention, which could have decreased the effect of the cluster. furthermore, we presume that headaches as a single health problem were not shown to be associated with turnover intention because headaches are often easily relieved by medication and may not have been as severe as a gastrointestinal disorder. upper musculoskeletal pain, which had the highest prevalence, formed a pain cluster with leg or foot discomfort. nurses work most of the time in a standing position, walking an average of 8747 steps (4.1 miles) per shift [53] , and high physical demands have been associated with musculoskeletal problems in nurses [54] . additionally, multi-site musculoskeletal pain has been shown to be more common than single-site pain, especially in women [55] . unexpectedly, this cluster was not related to turnover intention, although leg or foot discomfort was related to turnover intention. this might be because most nurses (82%) suffered upper musculoskeletal pain regardless of turnover intention and, similar to the gastrointestinal cluster, the association of the pain cluster with turnover intention was reduced by the effect of upper musculoskeletal pain. although the pain cluster did not relate to turnover intention, given that these health problems in the pain cluster had a high prevalence and cause sickness and absence from work and decreased work productivity [24] , there is a need to investigate the prevalence of musculoskeletal disorders in nurses by workplace and to provide appropriate prevention and treatment programs. although our study provides a new perspective on nurses' health problems, it has some limitations. first, this study relied on self-report measures of health problems, except for three health problems (sleep disturbance, depression, and fatigue). second, we surveyed only the presence of health problems, but not the severity; however, as the participants were nurses with medical knowledge, their judgment of the presence of health problems might be more reliable than that of the general public [56] , which would partially compensate for the fact that some health problems were not assessed with standardized tools. third, we could not infer the causal relationship from the cross-sectional design of the study. the fourth significant limitation is that this study did not measure how many nurses actually leave their job; therefore, the findings of our study may not apply to actual turnover, as turnover intention does not always lead to actual turnover. fifth, the shift work nurses who participated were all female and from two tertiary hospitals in seoul in korea. therefore, the generalizability of the results is limited. future studies on the comorbidity of sleep disturbance, depression, and fatigue in shift work nurses from various hospitals in various regions, along with the inclusion of male nurses, are recommended. in this study, the association of single health problems and clusters of health problems with turnover intention differed. although fatigue, sleep disturbance, depression, gastrointestinal disorders, and leg or foot discomfort were related to turnover intention as single health problems, after clustering, only the neuropsychological cluster-including fatigue, sleep disturbance, and depression-was related to turnover intention. given that nurses had more than two health problems and turnover intention increased linearly within the neuropsychological cluster, these problems must receive close attention and be addressed to decrease the nurse turnover rate. future studies should implement longitudinal research to determine the effect of the neuropsychological cluster on turnover. author contributions: j.k. developed the concept of this manuscript, analyzed the data, and prepared this manuscript. j.r. and j.b. were responsible for the data collection and contributed to the manuscript revision. i.h. developed the study protocol and advised on the data analysis. s.c.-k. developed the study protocol and concept, and revised this manuscript to its final version. 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health and nutrition examination survey clinical implications of associations between headache and gastrointestinal disorders: a study using the hallym smart clinical data warehouse comorbidity of headache and gastrointestinal complaints. the head-hunt study how far do nurses walk? medsurg nurs perceived physical demands and reported musculoskeletal problems in registered nurses chronic musculoskeletal pain rarely presents in a single body site: results from a uk population study the nurses' health study: lifestyle and health among women this article is an open access article distributed under the terms and conditions of the creative commons attribution (cc by) license key: cord-000333-4prvgmvt authors: darbyshire, philip title: nursing heroism in the 21(st )century' date: 2011-02-16 journal: bmc nurs doi: 10.1186/1472-6955-10-4 sha: doc_id: 333 cord_uid: 4prvgmvt background: the vivian bullwinkel oration honours the life and work of an extraordinary nurse. given her story and that of her world war ii colleagues, the topic of nursing heroism in the 21(st )century could not be more germane. discussion: is heroism a legitimate part of nursing, or are nurses simply 'just doing their job' even when facing extreme personal danger? in this paper i explore the place and relevance of heroism in contemporary nursing. i propose that nursing heroism deserves a broader appreciation and that within the term lie many hidden, 'unsung' or 'unrecorded' heroisms. i also challenge the critiques of heroism that would condemn it as part of a 'militarisation' of nursing. finally, i argue that nursing needs to be more open in celebrating our heroes and the transformative power of nursing achievements. summary: the language of heroism may sound quaint by 21(st )century standards but nursing heroism is alive and well in the best of our contemporary nursing ethos and practice. today's nursing heroism first, the more traditional concept of heroism as courage and providing service to others in the face of extreme personal danger is undoubtedly alive and well in nursing and in other human services. firemen still enter burning buildings to save their occupants and nurses still join their health care colleagues in providing care to the hungry, the fearful, the injured and the dying in both natural disaster areas and man made conflict zones. haitian nursing students and faculty from the episcopal university of haiti, were setting up first aid stations to help the victims of their city 30 minutes after that country's massive earthquake [4] . military nurses and nurses from voluntary organisations such as red cross and medicine sans frontiers are found in every war zone, every famine-blighted country, every dictatorial wasteland, every manifestation of 'hell on earth'. we fervently wish that the circumstances that draw them away from their own families and homes to these places did not exist, but they do, and thankfully, these nurses continue to respond. consider also, nurses' responses to the fear and danger surrounding the emergence of infectious outbreaks such as hiv/aids in the 1980s and sars in 2003. in the early 1980s when first reports were emerging of young gay men in the usa dying of seemingly systemic immune system failure, we could not have realised that this thing called 'grid' was the start of the aids pandemic that has claimed the lives of more than 25 million people worldwide and has left approximately 33.4 million people living with hiv/aids [5] . during these times we saw the best and worst of nursing and health care. in an oral history project: "the aids epidemic in san francisco: the response of the nursing profession, 1981-1984 [6, 7] " we hear from nurses involved that some nursing and medical staff held the same fears and prejudices that were so widespread in the broader community. they would refuse to care for the aids patients and stigmatise them along with the other so-called "4h patients -homosexuals, haitians, hemophiliacs and heroin users" [8] . helen miramontes, who later became one of the world's leading nurse advocates, specialists and educators in hiv/aids was then a clinician. she said that: "there was a lot of fear among health care providers about contagion, but there was also significant prejudice and discriminatory behavior because the new disease was identified in a population that was stigmatized by the larger society. identification of the disease in people of color, especially african americans and injection drug users, only exacerbated the biases, prejudices, and discriminatory behavior. many nurses demonstrated the same attitudes, beliefs, and behaviors seen in the larger society. i was a critical care nurse working in an intensive care unit (icu) in a large teaching facility. in the early years of the epidemic, it was not unusual to have two to three patients with pneumocystis carinii pneumonia on ventilators in the icu at any one time. because some nurses avoided taking care of these patients, several of us volunteered to care for them on a regular basis. there were frequent breaches in confidentiality, not only among nurses but also among other health care workers" [7] . gary carr, who was a nurse practitioner at the aids clinic at san francisco general hospital, described the perverse ambivalence of a wider community that lauds and praises nurses for their 'heroic efforts' in the face of such public health crises. gary says: "i have no memories of being afraid or being brave. i just wasn't afraid. i just said to myself, this is what i want to do. this is important. the community needs this, and it's what i want to do. i remember there were people who stopped speaking to me. my mother for years didn't tell anybody what i did. my relatives for years thought i still worked in the trauma unit" [6] . when, two decades later, sars emerged as a potentially lethal viral infection, nurses and health care staff again faced considerable dangers as they strove to treat patients and protect their communities. dr dessmon tai, who led the singapore efforts against sars, wrote that: "no other disease had such a phenomenal impact on healthcare workers." [9] but it seems that something in our professional ethos had changed over these two decades. there had been a rediscovery or reaffirmation of our professional ethic and mission as nurses, doctors and health professionals. in hanoi, during the initial outbreak, rather than look for an 'opt-out' clause in their professional codes, doctors and nurses locked themselves into the hospital in isolation rather than risk spreading the disease [10] . as emmanuel notes: "more than half of the first 60 reported cases of sars involved health care workers who had come into contact with sars patients. indeed, apart from the very first case, all of the people who died in vietnam were doctors and nurses. nearly a quarter of all patients with sars in hong kong were health care workers. in canada, of the 141 probable cases of sars diagnosed between 23 february and 14 may 2003, 92 (65%) involved health care workers. despite deadly peril, physicians and nurses tirelessly cared for patients with sars". [8] however, the social stigma that surrounded hiv/aids twenty years earlier and the associated ambivalence of the community towards health care professionals was not so easily repressed. in toronto, canada, hall and colleagues reported that: "children of nurses were barred from school trips and families were shunned by their neighbours. other incidents included husbands of nurses being sent home from work, children of nurses shunned at school, nurses refused rides by taxi drivers, and singleparent nurses unable to get babysitters". [11] similarly, in singapore, nursing staff were reportedly shunned in public spaces, forbidden to use the lifts in their apartments, found that buses and taxis would not stop for them and as one review reported, "at any packed food court, there would always be a seat for a tan tock seng hospital nurse. queue lines would quickly shorten when a nurse joined that queue". [10] these personal travails were compounded by what many saw as the unavoidable violence done to some of the best traditions of the nurse-patient relationship by the nature of the sars virus and its containment. nurses working with sars patients were often isolated from collegial support, asked to eat meals alone and prohibited from attending meetings. rigorous isolation and anti-infection procedures saw nurses, effectively in spacesuits, caring for patients in enforced cubicle isolation. if this was a terrible way to be ill, it was an even more solitary and disconnected way to die. yet despite these dangers and demands, nurses and our health care colleagues exemplified the best of who we are and what we do. they worked in a cauldron of contagion, initially unaware of what they were fighting, how the infection spread, how it killed or how it could be treated. as one french doctor commented, "we were not playing with fire. it was playing with us" [9] . was this heroism and heroic actions on their part, or were they 'just doing their job'? if we accept that heroism is "providing service to others in the face of extreme personal danger", then i have no qualms in considering these nurses as exemplars of 21 st century nursing heroism. heroism and 'militarism': what's in a word? let me sidetrack slightly at this point to address a concern about the very legitimacy and appropriateness of the term heroism in nursing. for some critics, the very mention of 'wars against disease', 'defeating illness', 'the battle against sars', or 'nursing heroism', is tainted. the concern is related to the militaristic or combative nature of such language and how this might shape not only our understandings of illness and disease but also our understanding of nursing itself and indeed the content and foci of our education, research and services. the concerns are not new, having been articulated most forcefully and influentially by the late american essayist, critic and author, susan sontag in both her books: 'illness as a metaphor' and 'aids and its metaphors' [12] . sontag was deeply critical of the metaphorical language that scaffolds our understandings of, in these cases, cancer and aids. she rejects metaphors of battle, war, magic bullets, invasion, surrender, attack etc and with aids is even more scathing of its damning metaphorical encumbrances around divine retribution, plague, sexual contagion and societal decay. "the body is not a battlefield" says sontag [12] , but when faced with illness or injury, i suspect that it may become one, if for no other reason that nurses, people and patients need something to fight against. people will often accept the most devastating of diagnoses with almost a gratitude that seems completely misplaced, until they explain to us that the previous uncertainty or not knowing had been far, far worse. author and doctor, peter goldsworthy depicts this phenomenon beautifully in his celebrated novella, 'jesus wants me for a sunbeam' which describes how a family reacts when their young daughter develops leukaemia: "for rick and linda there was also, at the end of that terrible week of waiting and worry, an odd feeling of relief that it had happened to them, and theirs. anything was better than uncertainty; the waiting had been intolerable, the fear of the unmentionable had almost come to be a desire for the unmentionable; its certainty, its mention, was at least a resolution. to finally hear the word (leukaemia) spoken aloud provided a focus for worry, a definite enemy that they could now face, and fight, together, as a family." [13] before leaving the subject of language, let me touch on a recently articulated concern about the language and discourses of militarism and how these may influence nursing. in a new paper this year on the politics of nursing knowledge, perron and her colleagues [14] criticise what they call the 'militarization of nursing', claiming that: "many accounts provide angelic portrayals of nurses faced with the devastating effects of war. such nurses are described as loyal, beautiful, peaceful, healing, comforting, reliable, devoted, and courageous in the face of hardship. these romantic descriptions stand in sharp contrast to the organized killing and destruction of warmaking." [14] i would argue that what perron and her colleagues have almost studiously overlooked are that these allegedly 'romantic descriptions' also stand in sharp contrast to any respectable historical account of the experiences of military nurses [1] . in such histories, and in particular the growing collection of oral histories of nurses' wartime and conflict zone experiences [3, [15] [16] [17] [18] [19] , we will find not saccharine, sentimentalized, spin-doctoring but vivid recollections and narratives from nurses, who, in addition to thankfully being 'loyal, comforting, devoted, healing, reliable and courageous', are also intelligent, skillful, determined, demanding, creative and resourceful. heather höpfl, a professor of management, takes a quite different, and i believe more coherent and enabling view of women's heroism than perron and her colleagues. she argues that: "the heroines of history are not impotent women. quite the contrary, they are women who refuse to be put in their place. the stories of heroines offer a picture of women who were far from meek and far from conciliated into male reality definitions. they were real women not mythological constructions. they shared values rather than common backgrounds and they are, to use an unfashionable term 'indomitable'. (...) the stories of the heroines of 50 years ago and more are stories of recusancy. they are stories of opposition. they are in almost every case stories of gender politics. we are deceived when we are told they are stories of female oppression. (...) these women faced enormous obstacles but squared themselves off against them and responded with integrity and courage." [20] of other 'quiet' and 'unrecorded' heroisms let me now speak of other heroisms, for i believe heroism in nursing to be a broad church, a continuum of courage rather than a zero-sum game. the nurse exhibiting what i might call, after dickens' character, sydney carton, a "quiet heroism", or what patricia benner calls "unrecorded heroism" [21] , continues to be part of the fabric of health care today. nursing may not be among the first occupations that springs to mind when the word 'danger' is mentioned but a recent forbes magazine feature in the usa did identify nurses and nurses' aides as one of the top two groups experiencing among the highest rates of injury at work, albeit usually from lifting and handling incidents [22] . in addition, hall and colleagues in the us reported that: "nursing assistants working in long-term care facilities have the highest incidence of workplace violence of any american worker". [23] nurses in our emergency departments experience perhaps even more severe episodes of violence. in scotland, we used to joke that any particularly rough place was: "like casualty on a friday night", but it is no joke now. in a recent australian survey from wa, rose chapman and colleagues found that: "the majority (92%) of nurses said they had been verbally abused, 69% had been physically threatened and 52% had been physically assaulted". "only 16% of the nurses completed an official incident report. reasons for not reporting included the view that work place violence is just part of the job, and the perception that management would not be responsive". [24] would emergency department nurses see themselves as 'heroes'? almost certainly not, as they seem to have internalized a workplace culture where abuse and violence is not an aberration but simply something that "comes with the job" [25] and where reporting such abuse is scarcely worth the trouble. perhaps if we return to the definition of heroism as 'providing service in the face of extreme personal danger', then our emergency department nurses should allow themselves to feel, at least somewhat heroic. when we define heroism as providing service in the face of personal danger, that danger is not always the danger of illness, injury or death. sometimes, that danger emanates from inside the very organisations that we serve and what is under threat is not nurses' bodily integrity but their professional and personal integrity. i refer of course to the phenomena of whistleblowing in nursing and health care. nursing's official pronouncements, policy directives, mission and vision statements, strategic plans, nursing philosophies and the like invariably proclaim our commitment to the highest standards (indeed to excellence), to patient safety, to quality care, to collegiality, to mutual respect, to 'patient-centredness', to patient advocacy and more. but for many nurses, there is not merely a gap between these aspirations and clinical reality, there is a katherine gorge. debra jackson and her research team in sydney have done some of the best australian research in this area and it does not make for happy reading. as debra notes: "currently, whistleblowing represents a professional dilemma and a personal disaster." [26] this observation does not only apply to nursing. medical whistleblowers fare equally badly at the hands of their own profession [27] . indeed in all of the whistleblowing literature, it is difficult, if not impossible to find even one person whose principled actions have not resulted in huge personal and professional costs. and yet we know that nurses are not only vital because of our numbers but because we are patient care, safety and quality where the rubber hits the runway. nursing is not just some inert 'silo', needing to be dismantled. if a hospital or health authority does not understand the difference between nursing as a silo and nursing as a sentinel, they are in more trouble than they can possibly imagine. we are the world's best adverse patient experience early warning detection system. we are like the canaries down the mine or the frogs in the ecosystem. if nurses are metaphorically not singing or not croaking, if they are falling off the perch or disappearing from the ponds, then 'huston -we have a problem"! this problem is a phenomena that blighted not only bundaberg hospital [28] , but other hospitals and health organisations across the world. this virulent, vocational virus -i'll call it: mrsa ('management resistance to staff alerts'), has been implicated in almost every hospital 'scandal' and health system failure inquiry in recent years. this strain of 'mrsa' seems endemic in health care systems and is as dangerous to staff and patients as any hospital acquired infection. in a nutshell, health organisations and their leaders are not only failing to listen to their front line nursing staff, but in the worst cases, they are actively and forcefully trying to silence them. at bundaberg hospital, what stopped dr jayant patel was not a new computer system, it was not an updated reporting mechanism, it was not visits from external regulators, it was not another reorganization, it was not a new management theory. it was the bulldog advocacy and persistence of icu nurse toni hoffmann in the face of managerial inactivity and intimidation [28] . toni was recognised for her role with an australian local hero award in 2006 and an order of australia in 2007. is toni hoffmann a 21 st century nurse hero? without a shadow of doubt. what of the other contemporary meaning of heroism and heroes? who are our nursing heroes? who are the nursing giants upon whose shoulders we have stood and who continue to inspire us today? who are the nursing heroes that we tell our students about so that they can understand the best of nursing's history? who are they to emulate if they want to be the best nurse possible? our hardwired and often confused sense of egalitarianism makes us uncomfortable in even talking in such a way. when i ask nurses to tell me something wonderful that they did recently that made a real difference to a patient, client or family, their embarrassment and discomfort is almost immediately palpable. 'i didn't really do anything', 'it was the team', 'i'm just a nurse', 'i don't like to 'big note' (brag about) myself', 'all i did was..., 'i don't know what you mean'.... please, let us be more open and unabashed in celebrating our nursing heroes. if these were sportsmen or sportswomen, if they were musicians or actors, if they were business people: we would be lauding their finest performances, dissecting their latest work with relish and handing out awards and trophies by the cabinetful. i thought of my heroes for this paper, the nurses who have inspired me and who continue to do so. so let me celebrate, in no particular order of merit: possibly the most lucid and coherent writer on nursing ever. i read her little 50 or 60 page book, 'basic principles of nursing care' as a young student nurse and could recite her definition of nursing, even at parties after a few drinks, as if it were a catechism. it is no exaggeration to say that i understood nursing in a completely different light after virginia henderson. as a new phd student grappling with philosophy, phenomenology, qualitative research approaches and new understandings of practice, reading 'the primacy of caring', followed by 'novice to expert' was to have the scales fall from one's eyes and to see and understand the world anew. the quality of patricia benner's thinking and scholarship is matched only by her graciousness and generosity of spirit. margaret was dean and head of school when i took up my first post-phd lecturing position at glasgow caledonian university and was simply the dean from heaven. her standards and expectations were exhilaratingly exacting and her work rate would have shamed a chilean mine rescuer. her enthusiasm for nursing, for education, for research and for innovation and creativity was boundless. her guiding philosophy seemed to be: 'the answer's yes, now what's the question'. how could you fail to thrive and develop as a new faculty member under such inspiring and utterly humane leadership? linda aiken is undoubtedly the doyenne of contemporary nursing research and one of the most powerful voices in nursing, in that when linda aiken's research speaks, the world of healthcare listens. and so it should. her exemplary international research programme at the center for health outcomes and policy research at the university of pennsylvania demonstrates clearly that nursing is not simply one of many factors involved in improving health outcomes and patient safety, it is the key factor. get nursing right and you improve safety, quality and patient care. no ifs, no buts. dodie bryce was an enrolled nurse at the intellectual disability hospital where i trained as a new nurse in the 1970s. these institutions could be grim places but dodie bryce's calm, humane, compassion and exemplary human caring skills made her truly, a light in the darkness. she was not just a great nurse but a presence. older and wiser, i now understand the difference. was a ward sister at the sick children's hospital in edinburgh when i trained in pediatrics. i was simply in awe of her. she managed, as the sole charge nurse, a 30 bed surgical ward, the attached neonatal unit of around 6-10 cots and an attached 2 bed cardiothoracic surgery unit. she knew every child, everything about their condition and its care and seemingly all of their families as well. she was unflappable in any crisis and utterly respected and listened to by every doctor and health professional. that she managed to take time and trouble to help students on the ward like myself made her even more remarkable. is south australia' first nurse practitioner and heads our pediatric palliative care service. she was also my first clinical research collaborator when i took up my joint chair position at women's & children's hospital. sara is a human dynamo, possessed with vision, drive and absolute determination. give a hospital half a dozen saras in clinical leadership positions and they could rule the world. debra was my phd student and the phd student of every supervisor's dreams. debra has a fierce intelligence matched only by her unstinting work ethic. when you combine these with a heart and personality that draws the best out of everyone around her, you can see why she now heads what is easily one of australia's best research centers. who are the heroes on your list and why? the business of nursing? we are told constantly that health care is a business and that nursing should follow more business-like principles. as a health service or hospital is indeed a multi-million dollar organisation that needs to be well managed, there are no arguments from me on that score. if we are in business however, then let us be absolutely clear about the nature of our business as nurses. we are in the transformation business and the 'making a difference' business. nurses don't just make the tea and coffee they make decisions. we need to appreciate the importance of processes and structures, but more importantly, we need a laser focus and a near-reverence for tangible and valued outcomes that improve patients' experiences. we are in the transformation business. as a clinician, you are not in the injections business or the dressingchanging business or the putting up ivs business or the bathing business. instead, as kerfoot notes, we transform [29] "we transform a frightened 4-year-old girl in the emergency room into a little person who now feels she has some measure of control and can stop crying. we transform a 50-year-old father with out-of-control diabetes into a person who has the confidence to manage his condition. and we transform the frightening and painful experience of childbirth into a beautiful memory of ecstasy for a family that has created a new person. when life ends, we transform those final moments of life into sacred, beautiful transitions of passage for families to complete the circle of life." as a nurse educator, you are not in the business of 'lecturing', 'marking', 'supporting students', or 'writing curricula'. you are in the transformation business. [30] we transform students into safe, skilled and self-confident practitioners. we transform apathy and cynicism into enthusiasm and robust idealism. we transform clinical, interpersonal and ethical problems from potential career-ending setbacks, into opportunities for deep learning and personal and professional mastery. we transform patient and client experiences from everyday anecdote into the bedrock of clinical judgement and service quality. we foster and build confidence and self-belief where this been eroded, damaged or has never developed while also challenging an equally dangerous overconfidence, arrogance or narcissism. as a nurse researcher, you are not in the business of interviewing, administering surveys or managing data. we transform the glib stereotype of the 'ivory-tower' academic by our meaningful, productive and mutually advantageous collaborations with clinical colleagues and service areas. we challenge the prejudice that academics and their research has little relevance or use in the 'real world' of health policy and politics by our focus on knowledge translation, transfer and research impact and by the demonstrable profile and presence that our work has in numerous key areas of health policy and politics. we are in the transformation business and the 'making a difference' business. all over the world, nurses are making rhetorical notions of 'the patient experience', quality & safety and improved outcomes very, very real: somewhere a nurse is helping a struggling and despairing new mum to learn all of the messages and nuances that her new baby is signalling, somewhere a nurse is bearing witness to another mother's dying, and comforting her during her last moments on this earth, somewhere a nurse is inserting a child's iv and helping them and their family begin their journey into the world of chemotherapy, somewhere a nurse is listening to an alzheimer's patient tell a story and trying to help them piece together who they really are, somewhere a nurse is helping a new student learn from a patient encounter and is passing on the wisdom of our art, somewhere a nurse is turning a hunch or a problem into a question that will eventually be researched and provide new knowledge and understanding, somewhere a nurse is managing a service with the passion and enthusiasm that enables her staff to thrive and to appreciate why they wanted to become nurses in the first place, and somewhere a nurse is working in a war zone, helping service personnel and villagers alike. these 'quiet' or 'unrecorded' heroisms surely deserve our acknowledgement and appreciation. at the end of her classic novel 'middlemarch' [31] , george eliot writes an epitaph for her heroine dorothea: "but we insignificant people with our daily words and acts are preparing the lives of many dorotheas...her finely-touched spirit had still its fine issues, though they were not widely visible. her full nature, like that river of which cyrus broke the strength, spent itself in channels which had no great name on the earth. but the effect of her being on those around her was incalculably diffusive: for the growing good of the world is partly dependent on unhistoric acts; and that things are not so ill with you and me as they might have been, is half owing to the number who lived faithfully a hidden life, and rest in unvisited tombs." so too, the health, wellbeing, safety and experiences of patients, clients and families are dependent upon the often invisible and overlooked caring practices of nurses. today in the 21 st century, they are worthy of sharing the term 'heroism' and i like to think that sister vivian bullwinkel would agree. author's position: director the story of the australian nurses after the fall of an australian heroine sole survivor of the 1942 massacre of australian nurses nurse heroes in haiti nurse practitioner at the aids clinic, san francisco general hospital," an oral history conducted in 1995 and 1996 by sally smith hughes in the aids epidemic in san francisco: the response of the nursing profession for the san francisco aids oral history series. regional oral history office the lessons of sars duty of care or medical heroism? annals of the academy of medicine heroes and heroines of the war on sars media portrayal of nurses' perspectives and concerns in the sars crisis in toronto illness as a metaphor and aids and its metaphors jesus wants me for a sunbeam sydney: flamingo/harper collins the politics of nursing knowledge and education: critical pedagogy in the face of the militarization of nursing in the war on terror the wartime experience of australian army nurses in vietnam review of: 'and if i perish: frontline u.s. army nurses in world war ii'. by evelyn m. monahan and rosemary neidel-greenlee vietnam memories: australian army nurses, the vietnam war, and oral history the australian nursing and midwifery history project: military nursing willingly into the fray: one hundred years of australian army nursing the death of the heroine the wisdom of our practice the most dangerous jobs in america nursing home violence: occurrence, risks, and interventions examining the characteristics of workplace violence in one non-tertiary hospital violence against nurses working in us emergency departments editorial: what becomes of the whistleblowers three australian whistleblowing sagas: lessons for internal and external regulation sick to death sydney: allen & unwin it's transformation, not patient care the section referenced here is cited from this editorial with the permission of nurse education today pre-publication history the pre-publication history for this paper can be accessed here cite this article as: darbyshire: nursing heroism in the 21 st century authors' contributions pd is responsible for all aspects of this paper. the author declares that they have no competing interests. key: cord-283943-cdjmsdta authors: henshall, catherine; davey, zoe; jackson, debra title: nursing resilience interventions–a way forward in challenging healthcare territories date: 2020-04-15 journal: j clin nurs doi: 10.1111/jocn.15276 sha: doc_id: 283943 cord_uid: cdjmsdta personal resilience has been conceptualised in many different ways; however, a common definition is that resilience is the ability to cope successfully despite adverse circumstances (henshall, 2020). historically, the term 'resilience' encompasses both physiological and psychological aspects and the latter is personal to individuals, with some people having more developed strategies for personal resilience than others. understandings of resilience vary between populations, contexts and cultures (mcdonald et al., 2012), with resilience being viewed in some cases as an inherent personality trait and in others as a dynamic process existing on a continuum between resilience and vulnerability. personal resilience has been conceptualised in many different ways; however, a common definition is that resilience is the ability to cope successfully despite adverse circumstances (henshall, davey, & jackson, 2020) . historically, the term "resilience" encompasses both physiological and psychological aspects and the latter is personal to individuals, with some people having more developed strategies for personal resilience than others. understandings of resilience vary between populations, contexts and cultures (mcdonald, jackson, wilkes, & vickers, 2012) , with resilience being viewed in some cases as an inherent personality trait and in others as a dynamic process existing on a continuum between resilience and vulnerability. the former infers that some individuals are more vulnerable or "do not have what it takes" to overcome adversity (masten, 1994) , whereas the latter suggests that levels of individual resilience can ebb and flow depending on a person's contextual circumstances and environment (rutter, 1985) . this latter concept of resilience as a fluid process has implications for the way in which we consider resilience in the nursing workforce. the current very high demand for nurses, exacerbated by the covid-19 pandemic, has really highlighted the need to ensure a robust and resilient workforce. current and projected shortfalls in the number of nursing staff that are required for the delivery of high quality care, has compounded the challenge of responding, to better support staff in meeting increased healthcare demand. the pressure is on nurses to provide high quality, complex patient care within the context of scarcer resources in terms of staffing, infrastructure or financial reward (burmeister et al., 2019) , even in the context of major challenges such as those presented by a pandemic. in addition, nurses commonly experience incidences of workplace adversity that can challenge and impact on their levels of resilience (hart, brannan, & de chesnay, 2014) . excessive workloads, increased use of casual staff, decreased autonomy, bullying, violence and almost continual organizational change have all been linked to workplace adversity, creating workplaces that can be experienced as hostile, unrewarding and even abusive by nurses. the need to meet service demands under highly pressured, and often suboptimal and even unsafe conditions combined with a lack of career structure or progression, can lead to registered nurses facing stress and burnout. this has resulted in many nurses leaving the workforce at a time when their skills, training and professionalism are most in need (jackson, firtko, & edenborough, 2007; jennings, 2008) . in response to the increasing pressures facing nurses working within overstretched and under-resourced healthcare systems, building personal resilience has been identified as being essential in coping with work related stress and adversity, maintaining job satisfaction, engaging in self-care and helping to address problems with workforce retention and staff well-being (foster et al., 2019; slatyer, craigie, heritage, davis, & rees, 2017) . internationally, multiple resilience enhancement interventions have been developed and implemented in various settings (craigie et al., 2016; henshall et al., 2020; mcdonald et al., 2012) . however, whilst these interventions have been evaluated positively and have been shown to support personal resilience in the short-term, care must be taken to ensure that these interventions are not viewed as a panacea for the overarching problems facing healthcare services and the resultant challenges to those working within them. rather, resilience enhancement interventions should be viewed as tools to underpin existing support structures, as a way of helping to promote and sustain resilience levels within the nursing workforce. health services need to follow the lead of nurses who are investing in their own personal resilience strategies by providing appropriate system level interventions and support mechanisms; this will not only enhance the personal resilience of individuals, but will also enhance systems resilience in the longer term. the way in which the concept of resilience is framed within resilience-enhancing interventions is crucial in ensuring that nurses are not deterred from engaging with these interventions due to feeling judged or criticised by colleagues, peers or managers, or due to being deemed fragile, unable to cope or lacking in resilience. the purpose of resilience-enhancing interventions, as mechanisms for reflecting on, building and sustaining resilience needs to be clearly articulated so that nurses do not feel that enrolment on these courses is a sign of failure, incompetence or unworthiness. this may be especially true if nurses have recently been exposed to difficult or challenging situations at work, which may lead to them feeling that they are being exclusively targeted or selected for enrolment to improve their coping abilities. this is encapsualted in an excerpt from a recent study reporting on a workplace resilience enhancement intervention (henshall et al., 2020) . in this study, a nurse participant summarised their beliefs prior to the intervention about being selected to take part: "i thought i was put on the resilience course because my manager didn't think i was resilient enough and that it was a shortfall in my performance". however, once the participant was fully engaged in the program, this perspective shifted, with the participant describing the intervention as "really helpful" because of its focus on "caring for staff, trying to help you do your job better, and building with the other people there." whether conceptualised as an inherent trait or a dynamic process, the vast majority of people entering the nursing profession display characteristics that are compatible with the concept of resilience from the outset, such as altruism, vocation, empathy and caring for others (eley, eley, & rogers, 2010) . from the onset of their nursing training student nurses are exposed to a range of clinical scenarios involving patients and clients with complex and diverse health and social care needs. this results in nurses' baseline resilience levels being buffeted, reshaped and reinforced due to rapid exposure to a range of new experiences which may challenge their previously held conceptions and beliefs, leading to almost continual self-reflection and self-critique, and can allow for qualities such as resilience, empathy, and compassion to be developed; such qualities continue to be continuously tested and reinforced throughout a nursing career. the stresses and strains associated with encountering challenging and difficult situations can be tempered by the satisfaction engendered through the intimacy of the nurse/patient relationship (williams, 2001) . however, the increasing environmental, financial, cultural, and social workplace pressures impacting on healthcare service provision means that the equilibrium between challenge and reward is becoming increasingly difficult to maintain. increasingly, there are sacrifices in the quality of care that nurses are able to give to patients, because of pressures on the nursing workforce associated with staffing, vacancies, and increased demands on time. nurses are central to the patient care pathway and are required to provide emotional, physical, psychological and social support to patients and their families at all times. however, little consideration is given as to the impact of the provision of this support on nurses' emotional well-being, or their ability to maintain a satisfactory work-life balance. furthermore, limited provisions are in place to provide nurses with reciprocal emotional, physical, psychological and social support. where these supports are place, for example through peer supervision, reflective practice or mentoring, they are often deprioritised or sacrificed at the expense of more immediate clinical demands. in response to the international retention and recruitment crises facing nurses, many healthcare systems are focusing on strategies to enhance and sustain the health and well-being of their clinical workforce (buchan, charlseworth, gershlick, & seccombe, 2019; health workforce australia, 2014) . one example of this is via the united kingdom nhs national retention strategy, launched in 2017 to decrease nursing turnover rates in all hospital trusts (nhs improvement, 2019); the strategy advocated for more investment in workplace based interventions and training, and the provision of additional mentoring support for nurses and other healthcare professionals. whilst this is a welcome move, it is imperative that these initiatives are implemented across the whole career trajectory beginning at undergraduate level. resilience in nursing must be viewed and acknowledged as a dynamic, fluid process that requires continuous nurturing and commitment, as well as adaptability and flexibility in the face of changing professional and personal requirements. in order for resilience enhancement interventions to be successful system level change is required at an organizational, cultural, team and managerial level. resilience-enhancement programmes should be integrated into the overall well-being strategies of healthcare organisations as part of a larger, more comprehensive staff support strategy; these programmes should be evaluated to measure their short-and long-term impact and outcomes (blake & lloyd, 2008) . proactively addressing the need for nurses to maintain, preserve and build their resilience, may help to alleviate some of the retention and recruitment challenges facing nursing. in addition, taking better care of the nursing workforce has substantial implications in terms of increasing efficiency within healthcare systems and benefitting the quality and safety of patient care. influencing organizational change in the nhs: lessons learned from workplace wellness initiatives in practice a critical moment: nhs staffing trends, retention and attrition determinants of nurse absenteeism and intent to leave: an international study a pilot evaluation of a mindful self-care and resiliency (mscr) intervention for nurses reasons for entering and leaving nursing: an australian regional study resilience and mental health nursing: an integrative review of international literature resilience in nurses: an integrative review australia's future health workforce -nurses overview. canberra, act: department of health the implementation and evaluation of a resilience enhancement programme for nurses working in the forensic setting personal resilience as a strategy for surviving and thriving in the face of workplace adversity: a literature review patient safety and quality: an evidence-based handbook for nurses resilience in individul development: successful adaptation despite risk and adversity a work-based educational intervention to support the development of personal resilience in nurses and midwives resilience in the face of adversity. protective factors and resistance to psychiatric disorder evaluating the effectiveness of a brief mindful self-care and resiliency (mscr) intervention for nurses: a controlled trial a study of practising nurses' perceptions and experiences of intimacy within the nurse-patient relationship key: cord-285741-1n7kwx91 authors: homer, caroline; bucknall, tracey; farrell, tanya title: what would florence think of midwives and nurses in 2020?() date: 2020-08-20 journal: women birth doi: 10.1016/j.wombi.2020.07.009 sha: doc_id: 285741 cord_uid: 1n7kwx91 nan what would florence think of midwives and nurses in 2020? $ when 2020 was declared by the world health organization to be the international year of the nurse and the midwife none of us imagined what the year would really bring. before february-march 2020, we enthusiastically looked forward to local, national and international celebratory events including, for midwives, conferences like the congress of the international confederation of midwives and for nurses, the launch of the state of the world's nursing report. much excitement was anticipated for 2020 but then covid-19 happened as a global pandemic and touched all of our lives in many ways. this year is like no other and our professions have been impacted in ways we never anticipated. the year, 2020, was selected as the international year of the nurse and the midwife as it coincides with the 200th anniversary of the birth of florence nightingale. florence nightingale has been described as a caring and trailblazing british nurse, statistician, social reformer and leader of improved health care who is widely regarded as the founder of modern nursing. the year was also in recognition that strong nursing and midwifery workforces are key to the achievement of universal health coverage. with more than 50% of the global health workforce being nurses and midwives, strengthening these professions is one of the most important things to improve global health. yet, in many countries and contexts, nurses and midwives are undervalued and unable to fulfil their true potential. the aim for 2020 was to ensure that all nurses and midwives operate in an environment where they are safe from harm, respected by each other, by medical colleagues and community members, have access to a functioning health-care service and where their work is integrated with other health-care professionals [1] . while the covid-19 pandemic took away the ability to celebrate 'our' year in the way we planned, it has ultimately shone a giant light on the incredible work of midwives and nurses and has provided an opportunity to lead and showcase our true worth more than ever beforethis has been real visibility and commemoration. florence nightingale was born on 12 may 1820 (which is why we celebrate international nurses day on 12 may) into a wealthy and well-connected british family in florence, italy, and was named after the city of her birth. given northern italy had experienced very high numbers of people ill and dying of covid-19 recently, this link seems even more poignant. the accounts show that young florence lived an early life of privilege including travel, meeting people in powerful positions and having time to write as would have been usual for a woman of her class. in 1852, in her early thirties, she wrote an essay of protest against the restrictive life of upper class english women. this essay called cassandra [2] , highlighted what she saw as the emptiness of women's liveshow their time was not valued, they were not allowed to enter professions or use their minds, but were expected to take rides and entertain anyone who came to visit at any time. florence's most famous contribution to nursing came during the crimean war. in october 1854, she and the 38 women volunteer nurses that she trained and 15 catholic nuns were sent to scutari where there was a hospital of sorts. whilst there is some controversy about the extent of her leadership, some assert that she reduced the death rate from 42% to 2%. notably her focus on handwashing after semmelweis, a hungarian doctor working in vienna who advocated for the importance of hand washing to reduce sepsis-related deaths in the maternity unit. highlighting the importance of handwashing is another strong link to work focus today. florence was an entrepreneur and an opportunist. in 1855, the nightingale fund was established for the training of nurses during a public meeting to recognise nightingale for her work in the war with an outpouring of generous donations. this fund was used to establish the nightingale training school at st thomas' hospital in 1860 (now the florence nightingale faculty of nursing, midwifery and palliative care at king's college london). the first trained nightingale nurses began work on 16 may 1865 at the liverpool workhouse infirmary. much of florence's work after the crimea war focussed on the importance of cleanlinesshandwashing, sanitation and the analysis of epidemiological data to make decisions about the provision of health care. florence was definitely a leader who expected high standards. one quote from notes on nursing which highlights this: if a patient is cold, if a patient is feverish, if a patient is faint, if he is sick after taking food, if he has a bed-sore, it is generally the fault not of the disease but of the nursing" [3] . looking at all of this through a 2020 covid-19 lens, florence's actions and her books have direct relevance today. for example, notes on nursing published in 1859 [3] amongst other things says that every nurse ought to wash her hands very frequently. the notes of nursing for the labouring classes [4] in 1861 reiterated the need for cleanliness, care and support and the importance of having well trained and qualified nurses to improve outcomes. she was courageous, bold, a visionary thinker with the tenacity to make changes happen and keep focussed on the 'patient'. what would florence think about todaya covid-19 world where nurses and midwives are again at the front and centre of what is happening in every country. nurses and midwives across the world are stepping upmaking changes, rethinking practices, working out how to deliver care differently, how to keep patients, and in maternitywomen, babies and families, at the centre of care providing compassion and empathy while protecting themselves and their co-workers. we see nurses and midwives all over the country with passion and desire to make this the best it can be the safest for all. nurses and midwives are coming out of retirement and from other roles in the professions, volunteering to learn new skills, to take on new challenges, showing leadership and being at the decision making tables. changes are happening fastsome are good, some may not last beyond covid-19, some are scary as we test new things without our usual 'checks and balances'. when florence arrived at scutari almost 166 years ago, it must have been a messsolders dying of sepsis and infections such as typhoid, cholera and dysentery, a lack of medical equipment, a lack of food, poorly trained staff and an actual war not far away. she must have wondered where to starta bit like the position we are in at this momentso much to do and possibly so little time. what would florence think of nurses and midwives in 2020 in the midst of a global pandemic? we believe she would be impressed with our level of education and our knowledge, skills and capacity to take on this challenge. she would marvel at our level and high standard of education, our capacity to lead research, practice improvements and our key contribution to national and international policy directions and leadership. she would be impressed by the new ways of educating and skilling up nurses and midwivesusing online, skills laboratories, simulation and virtual reality and at the speed to which these changes have been embraced. she would be impressed that we can capture, analyse and understand data better and have research to back up decisions on patient care, disinfection, sanitation, isolation, staffing models and so much more. she would be amazed to see data graphics in every newspaper including the pie graphs that she pioneered 150 years ago. she is also likely to be impressed that we are everywhere nurses and midwives make up over 50% of the global health workforce and are the backbone of every modern hospital. florence would be proud of usof the millions of midwives and nurses all over the world courageously stepping up and stepping forward to deliver the best patient care in hospitals, health facilities and in the community. nurses and midwives are stepping up and stepping forward in an uncertain world to ensure that all people get the very best nursing and midwifery care that they deserve in every part of their life. she would be proud of the nursing and midwifery leadership yet probably disappointed with the lack of recognition. in many countries, nurses and midwives have been leading and coordinating the planning and guideline development although that has often been unrecognised and not showcased in any capacity. florence would probably also be busily writing letters and meeting people in power to demand better conditions for 'her' nurses and midwivesbetter access to personal protective equipment which is sadly lacking in many contexts, better data collection of covid-19 infection and deaths in health care workers, especially midwives and nurses and better research funding to study improved ways of tracking and supporting close contacts, supporting workforce planning including managing the furloughing of staff and testing new and old intervention to improve outcomes. we think she would also demand that midwives and nurses are around every health policy and decision making table in the world. we have florence's batonthis year more than any other in the past 200 years is our moment to make her proud, to do what we know we can do bestto be the best nurses and midwives we can. this will be like no other international celebrationmaybe not much champagne, a few less parties or conferences to show how great we are but a celebration nonetheless. this is the real thingthe real way to celebrate the international year of the nurse and the midwife and we know we can and will do it. available from:, world health organization notes on nursing notes on nursing for the labouring classes key: cord-280892-net44oxu authors: zhan, yu-xin; zhao, shi-yu; yuan, jiao; liu, huan; liu, yun-fang; gui, ling-li; zheng, hong; zhou, ya-min; qiu, li-hua; chen, jiao-hong; yu, jiao-hua; li, su-yun title: prevalence and influencing factors on fatigue of first-line nurses combating with covid-19 in china: a descriptive cross-sectional study date: 2020-08-07 journal: curr med sci doi: 10.1007/s11596-020-2226-9 sha: doc_id: 280892 cord_uid: net44oxu nurses’ work-related fatigue has been recognized as a threat to nurse health and patient safety. the aim of this study was to assess the prevalence of fatigue among first-line nurses combating with covid-19 in wuhan, china, and to analyze its influencing factors on fatigue. a multi-center, descriptive, cross-sectional design with a convenience sample was used. the statistical population consisted of the first-line nurses in 7 tertiary general hospitals from march 3, 2020 to march 10, 2020 in wuhan of china. a total of 2667 samples from 2768 contacted participants completed the investgation, with a response rate of 96.35%. social-demographic questionnaire, work-related questionnaire, fatigue scale-14, generalized anxiety disorder-7, patient health questionnaire-9, and chinese perceived stress scale were used to conduct online survey. the descriptive statistic of nurses’ social-demographic characteristics was conducted, and the related variables of work, anxiety, depression, perceived stress and fatigue were analyzed by t-tests, nonparametric test and pearson’s correlation analysis. the significant factors which resulted in nurses’ fatigue were further analyzed by multiple linear regression analysis. the median score for the first-line nurses’ fatigue in wuhan was 4 (2, 8). the median score of physical and mental fatigue of them was 3 (1, 6) and 1 (0, 3) respectively. according to the scoring criteria, 35.06% nurses (n=935) of all participants were in the fatigue status, their median score of fatigue was 10 (8, 11), and the median score of physical and mental fatigue of them was 7 (5, 8) and 3 (2, 4) respectively. multiple linear regression analysis revealed the participants in the risk groups of anxiety, depression and perceived stress had higher scores on physical and mental fatigue and the statistically significant positive correlation was observed between the variables and nurses’ fatigue, the frequency of exercise and nurses’ fatigue had a statistically significant negative correlation, and average daily working hours had a significantly positive correlation with nurses’ fatigue, and the frequency of weekly night shift had a low positive correlation with nurses’ fatigue (p<0.01). there was a moderate level of fatigue among the first-line nurses fighting against covid-19 pandemic in wuhan, china. government and health authorities need to formulate and take effective intervention strategies according to the relevant risk factors, and undertake preventive measures aimed at reducing health hazards due to increased work-related fatigue among first-line nurses, and to enhance their health status and provide a safe occupational environment worldwide. promoting both medical and nursing safety while combating with the pandemic currently is warranted. physiological fatigue and psychological fatigue [1] . nurse fatigue refers to a "work-related condition that ranges from acute to chronic in nature and can result in over-whelming sense of tiredness, decreased energy, and exhaustion, ultimately accompanied by impacting physical and cognitive functions" [2] . fatigue in nurses is complex and arises in response to individual, unit, and health care system demands [3] . kahriman et al reported that 83% of medical errors were positively correlated with nurses' fatigue [4] . the emergence of corona virus disease 2019 (covid19) in wuhan, china was in december 2019 [5] . on march 11, 2020 , the world health organization declared covid-19 as a global pandemic with the spread of this worst global crisis [6] . all on-the-job nurses in wuhan were fully engaged in the continuous combating with the prevention and control of the pandemic as the first-line nurses at the first time. the tremendous psychological burden and rescue challenge greatly aggravated the symptoms of fatigue among the first-line nurses in wuhan, and easily led to various psychological abnormalities [7] . previous study showed that there was a strong relationship between fatigue and the lifestyles and psychological states [8] . it was reported that a fall in resistance to the existing physical, mental and emotional stress in nurses might lead to anxiety, depression and ultimately fatigue [9, 10] . the sudden outbreak of sars in 2003 had a psychological impact on nurses. studies have shown that nurses are reluctant to go home for fear of infecting relatives, colleagues and friends [11] [12] [13] . health care workers spent hours each day putting on and taking off airtight protective equipment, which aggravated the exhaustion that the workers were experiencing from the increasing workload with the outbreak of sars [14] . the nurses' stress was found to be mainly due to the lack of protective gear and basic equipment, especially in the early phase of the ebola virus disease outbreak [15] . in 2014, the ebola outbreak was also a challenge for the physical and mental health of health care professionals. despite shift hours and the risk of infection, the challenging treatment environment created anxiety, depression, fatigue and social isolation for health care professionals [16] . national health commission of china had published several guideline documents aimed to settle the emergency psychological crisis through establishing psychological assistance hotline and a series of interventions for the medial personnel during the pandemic. furthermore, it would be necessary to carry out widespread surveillance to monitor and manage the risk of fatigue possibly involved in work-related and negative mental status among the first-line nurses. at present, we found no large sample study on fatigue status and risk factors of the first-line nurses in wuhan. the aim of this study is to evaluate the prevalence of fatigue status among first-line nurses responsible for rescue of covid-19 in wuhan, and to analyze the influencing factors associated with physical and mental fatigue of nurses. the findings of this study may be used to provide strategies to better assist health care administrators in addressing the physical and mental health of nurses domestically and internationally, and so as to supply references for the medical and health management to implement effective intervention to relieve the mental burden and reduce the fatigue level, contribute to construction of the safe occupational environment and promote medical and nursing safety. a descriptive cross-sectional survey was conducted with a convenience sample of nurses from 7 hospitals in wuhan, china from march 3 to 10, 2020. to be eligible, all participants were the registered nurses. all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. the including criteria for population included the nurses who have participated in the first-line nursing work of covid-19 patients from january 1 till now. the nurses without nurse qualification certificate, foreign aid nurses, trainee nurses from other hospitals, and nurses who were continuously off duty from january 1 to the investigation period (maternity leave, sick leave, personal leave, etc.) were excluded from this study. according to the multi-factor analysis sample estimation method of 6-10 times variables of the total number of items in the questionnaire, the minimum sample size was 610. considering 20% of the invalid filling rate of the questionnaire, it was expected that at least 732 questionnaires would be conducted. finally 2768 questionnaires were completed, and 2667 of them were valid, for a survey response rate of 96.35%. in this study, questionnaire stars were used to make two-dimensional code, and wechat was used to distribute the questionnaire online. the research established a questionnaire survey group, which was mainly responsible for the distribution and collection of questionnaires in 7 hospitals respectively. after obtaining approval of ethics committee of the researcher's hospital and the consent and cooperation from 7 respective hospitals, each chief nurse in charge of hospitals was approached to be familiar with the purpose and procedure of the investigation. the researchers trained 7 investigators in a unified way, including the aim, composition and filling requirements of the questionnaire. the survey group checked the questionnaires one by one and eliminated the invalid ones. exclusion criteria of invalid questionnaire were as follows: inconsistency in logic of answering, such as filling in contradictions and inconsistencies, answering time less than 300 s, simple repetition and abnormal answering, and informed disagreement. in order to ensure the accuracy of the data, the research group strictly implemented pre-control of the quality. (1) questionnaire design: on the basis of consulting and referring to domestic and foreign literature, the scale was selected, modified and supplemented in combination with the opinions of public health management and nursing management experts to ensure the universality and specificity of the questionnaire; (2) answer setting: all items were set as required questions to ensure the integrity of the questionnaire; the way of filling in the questionnaire was set as one time for each equipment answer to avoid repeated answers; (3) pre-survey: the research designer, investigator and some respondents participated in the pre-survey of the questionnaire, and discussed and revised the design of the questionnaire and the setting of items. the revised questionnaire was used to carry out the pre-survey again to test the reliability of the method. (4) formal investigation: convenient sampling method was adopted, and the trained investigators of each hospital used the guidance to fill in the instruction uniformly, so as to prevent investigation bias. the investigators used consistent language to explain when the respondents had questions. (5) data processing: the data were encoded, input, summarized and checked by two members of the research group, and logical correction was carried out. problems found were corrected in time, and invalid questionnaires were eliminated. this questionnaire included general information about the age, gender, education level, years of working experiences, marital status, fertility status, professional titles, lifestyles within the last month such as average length of daily break and night sleep and exercise. this questionnaire asked information about the participants' current working status in hospital respectively. the scale was developed by king's college hospital in the uk, which was mainly used to measure the severity of fatigue symptoms, evaluate clinical efficacy, and screen fatigue cases in epidemiological research [17] . there are 14 items in the scale which reflect the severity of fatigue from different perspectives: items 1-8 reflect physical fatigue, and items 9-14 reflect mental fatigue. the scores are added from items 1 to 8 to get the scores of physical fatigue, and the scores are added from items 9 to 14 to get the scores of mental fatigue, while the total score of fatigue is the sum of the scores of physical and mental fatigue. the highest physical fatigue score is 8, the highest mental fatigue score is 6, the highest total score is 14, the total score ≥7 implies that fatigue status exists. the higher the score, the more serious the reflection of fatigue. the total cronbach's alpha coefficient is 0.7725, and the half coefficient is 0.7725, which indicates the scale has good internal consistency [18] . the cronbach's alpha coefficient was 0.850 in our study. the scale was developed by spitzer et al in 2006 according to the diagnostic criteria of generalized anxiety disorder for screening of generalized anxiety disorder and evaluation of symptom severity [19] . the scale consists 7 items, each of which describes a typical symptom of generalized anxiety disorder. the scale is graded according to the status and frequency of its occurrence in the past two weeks. the total score is formed by adding the scores of each item of the scale, ranging from 0-21. according to the scoring criteria, the results of scores are divided into four degrees: scores for 0-4, 5-9, 10-14 and 15-21, corresponding to none, mild, moderate and severe level of anxiety respectively [20] . the higher the score, the more serious the anxiety. gad-7 is easy to implement, and has good reliability and validity in different populations. the cronbach's alpha coefficient of gad-7 in chinese version is 0.898 [21] . the cronbach's alpha coefficient was 0.947 in our study. the scale was based on the nine criteria of depression in the handbook of diagnosis and statistics of mental disorders published by the american psychiatric association [22] . the scale consists 9 items and the total score is composed of the scores of each item in the scale, ranging from 0 to 27. according to the scoring criteria, the results of scores are divided into five degrees: score 0-4, 5-9, 10-14, 15-19, 20-27, corresponding to none, mild, moderate, excessively moderate and severe level of depression respectively [23] . the higher the score, the more serious the depression. the cronbach's alpha coefficient of phq-9 in chinese version is 0.857 [24] . the cronbach's alpha coefficient was 0.933 in our study. the scale was widely used in the mental health assessment of the occupational population. it was revised by yang et al according to the foreign version of the perceived stress scale (pss) into chinese version [25] . the scale consists of 14 items reflecting stress tension and loss of control, and participants are required to answer according to their own feelings [26] . a score of 0-24 indicates normal pressure; 25-42 indicates high pressure; 43-56 indicates excessive pressure. the scale has high homogeneity and internal consistency among different populations in china, and cronbach's alpha coefficient is 0.797 [25] . the cronbach's alpha coefficient was 0.823 in our study. data were analyzed using the ibm statistical package for social sciences (spss) version 23.0. descriptive statistics were used to present participants' social-demographic and work-related factors and the prevalence of fatigue. mann whitney test and kruskal wallis test were used to analyze the fatigue status of nurses in different social-demographic characteristics, work-related variables, anxiety, depression and perceived stress levels; and pearson's correlation analysis was conducted to examine the relationships between the anxiety, depression, perceived stress levels and fatigue of nurses; multiple stepwise linear regression analysis was performed to identify the influence of aforementioned variables on first-line nurses' fatigue. an alpha-level of p<0.05 was set for significance in all analyses. of the 2667 nurses investigated in this study, 3.04% (n=81) were male, 96.96% (n=2586) were female; the median age was 30 (26, 35) years of age; the median year of working experiences was 8 (4, 13) years; 58.98% were married (n=1573), 38.73% were unmarried (n=1033), 2.29% were divorced and others (n=61); 39.26% were unmarried and childless (n=1047), 7.54% were married and childless (n=201), 53.20% were married and childbearing (n=1419). the characteristics of social-demographic are shown in table1. the median score of fatigue of first-line nurses was 4 (2, 8) . the median score of physical fatigue was 3 (1, 6), the median score of mental fatigue was 1 (0, 3). furthermore, 35.06% nurses (n=935) of the all participants had a total score of ≥7, the median score of them was 10 (8, 11), the median scores of physical and mental fatigue of participants with high level of fatigue were 7 (5, 8) and 3 (2, 4) respectively. general data were used as independent variables and scores of physical fatigue and mental fatigue were used as dependent variables for nonparametric test. the results showed that age, years of working experiences, marriage and fertility status, average length of daily break and night sleep and exercise variables had an impact on the score of physical fatigue; years of working experiences, marriage and fertility status, average length of daily break and night sleep and exercise variables had an impact on the score of mental fatigue, and the difference was statistically significant (p<0.05). the results are shown in table 1. work-related variables were used as independent variables and scores of physical and mental fatigue were used as dependent variables for nonparametric test. the results showed that the total number of days of rescue work, average daily working hours, frequency of night shifts, direct participation in the rescue of patients with covid-19, professional protection training, professional psychological assistance, occupational exposure, infection with covid-19, experience of negative events (the relatives, friends and colleagues of participants were seriously, critically ill or even dead due to the pandemic), and the degree of personal fear of covid-19 variables had influence on the score of physical fatigue; the average daily working hours, frequency of night shifts, direct participation in the rescue of patients with covid-19, professional protection training, occupational exposure, experience of negative events (the relatives, friends and colleagues of participants were seriously, critically ill or even dead due to the pandemic), and the degree of personal fear of covid-19 variables could influence the score of mental fatigue, and the difference was statistically significant (p<0.01). the results are shown in table 2. anxiety, depression and perceived stress were independent variables, and the scores of physical fatigue and mental fatigue were used as dependent variables for nonparametric test. 2667 nurses were divided into group of "yes" or "no" which indicated whether they were in risk of abnormal mental status or not, according to the scoring criteria of anxiety, depression and perceived stress scales respectively. the results showed that the total number of each risk group of anxiety, depression and perceived stress was 1062 (39.82%), 1458 (54.65%) and 1298 (62.00%), meanwhile, the median scores of physical fatigue in each risk group of them were 6 (4, 8), 5 (3, 7) and 5 (3, 7) , the median scores of mental fatigue in each risk group of them were 3 (1, 4), 2 (1, 4) and 3 (1, 4), respectively. the results showed that anxiety, depression and perceived stress could influence the scores of physical and mental fatigue. the difference was statistically significant (p<0.01). the results of descriptive and univariate analyses of the factors are shown in table 3, and those of the bivariate correlation analyses between anxiety, depression, perceived stress variables and fatigue are shown in table 4. observed between the average number of weekly exercise and nurses' fatigue (b=-0.266; p<0.001). it was also found that average daily working hours had a significantly positive correlation with nurses' fatigue (b=0.270; p<0.001). meanwhile, anxiety and perceived stress were also positively associated with nurses' fatigue, which means that anxiety (b=0.068; p=0.003) and perceived stress (b=0.103; p<0.001) increase the nurses' fatigue. in addition, the average night shift times every week had a low positive correlation with nurses' fatigue (b=0.070; p=0.036). in our study over a third nurses had a substantial symptoms of tiredness among first-line nurses in wuhan, accordant with the findings reported in study conducted in united states [27] . the result showed the incidence of fatigue was moderate, 35.06% nurses of the all participants had a total score of ≥7, the median score was 10 (8, 11), the median score of physical (2, 4) respectively. during the acute sars outbreak, 89% of health care workers who were in high-risk situations reported psychological symptoms. nurses' fatigue has been recognized as a threat to nurses' health and patient safety [12] . fatigue is not only a status, but also a process. it has been reported that the incidence of fatigue is 35.3%-50.00% in the recent relative studies [27, 28] . if we do not pay attention to the reasonable arrangement of rest, nurses are prone to fatigue syndrome. considering the extremely high risk of tiredness symptom among first-line health care workers in wuhan, their physical and mental health may require special attention. as revealed in the multiple linear regression models of fatigue, average daily working hours had a significantly positive correlation with nurses' fatigue. it has been proved that extended working hours result in the escalating exhaustion, increased traumas and decreased nursing actions [8, 9] . in our study, we found that the mean score of nurses with daily working hours of 4-6 was the lowest. on the contrary, in groups of 8-10 hours and 10-12 hours, the mean score was higher. engaging in the rescue nursing work of patients with covid-19 was a series of challenges. due to the particularity of the pandemic, close use of the protective clothes, glasses and n95 masks for a long time were prone to increase physical discomfort, such as pressure injury, difficulty in nursing practice, even hard to guarantee physiological needs, resulting in physical consumption and affecting work efficiency to a certain extent. when nurses continued to struggle with the pandemic, as the working hours were prolonged and volatile, nurses' psychological states would constantly be disturbed by external work, and the physical fatigue of nurses might also be affected by the continuous efforts in the front line. meanwhile, mental fatigue has a certain impact, and eventually becomes a major hidden risk for safe nursing work. the finding of present study showed that the frequency of weekly night shift had a low positive correlation with nurses' fatigue. the previous study provided evidence supporting the association of work shift length with fatigue [29] . it was found that night shift of 3-4 times per week indicated much higher level of fatigue, and the more frequent night shift, the higher fatigue level in our study. nursing work is both physically and mentally laborious. in the earlier stage of the pandemic, most nurses from different departments were dispatched to the isolation wards urgently, plunged into rescue work with immense obligation, accompanied by the higher frequency of night shift with 8 h in the initial period, consecutive works with insufficient rest during the night on-duty resulted in the physical and mental burnout. sagherian et al [30] gave a strong evidence that in nurses who experienced shift work schedules, working long hours, disturbed circadian rhythm, fatigue eventually became unavoidable and carrying out optimal nursing performance was a challenge. based on our findings, it was also found after decreased the frequency of night shift to 1-2 times per week through effective managements and other creative and innovative workplace scheduling, the level of nursers' fatigue declined significantly. this study reported that the frequency of exercise and nurses' fatigue had a statistically significant negative correlation, and nurses without taking any exercises showed higher level of physical fatigue than in the exercise groups. healthy lifestyle can effectively improve the process of nurses' health promotion and physical activity or exercise had been proved to be linked with an increase in sleep quality and to reduce chronic fatigue [31] . despite other lifestyle variables did not enter the multivariate analysis lastly, the subsequent lifestyle-related variables which were statistically significant in univariate analyses needed to be noticed, for nurses in groups of 30-60 min and over 60 min for daily lunch break, and nurses with sufficient night sleep, showed lower scores than in the group without lunch break and adequate night sleep. previous study indicated a significant relationship between insufficient rest period and fatigue [30] . the intense rescue work and shortage of human resources can lead to the repeated restriction of rest, substantially impair cognitive performance and decrease alertness among the first-line nurses, resulting in the distinctly greater level of fatigue. psychological health related factors were included in our study. at present, a series of studies [32] [33] [34] about mental health research of rescue nurses in wuhan indicated that nurses experienced continuous and aggravated negative psychological problems in many aspects, including anxiety, depression and stress, etc., which were consistent with the results in this study. in the present study, the risk symptoms of anxiety, depression and perceived stress in nurses had significant influences on physical and mental fatigue. the higher level of anxiety, depression and perceived stress existed, the more serious degree of physical and mental fatigue emerged. a statistically significant positive correlation was observed between the variables and fatigue through pearson's correlation analysis (p<0.01). our results were consistent with those in the previous studies that fatigue was associated with levels of anxiety and depression [35, 36] . most first-line nurses are females, whose personality characteristics are sensitive, fragile and prone to psychological crises such as insecurity and fear, which leads to aggravation of fatigue. in addition, some first-line nurses are lack of experience in infectious disease rescue and emergency care technology, which also brings great psychological stress. there was a moderate level of fatigue among the first-line nurses fighting against covid-19 pandemic in wuhan, china. individuals, health authorities and government need to formulate and take effective intervention strategies according to the relevant risk factors, and undertake preventive measures aimed at reducing health hazards due to increased work-related fatigue among first-line nurses, and to enhance their health status and provide a safe occupational environment worldwide. fatigue has a detrimental effect on nurses' overall perceptions of patient safety [37] . work-related fatigue includes physiological, cognitive, emotional and sensory elements that result as a consequence of high work volume and insufficient time for energy recovery. the physical and mental fatigue is likely present among nurses. physical fatigue is caused by physical labor and load, which is characterized by general discomfort and reduced ability to produce strength or power. mental fatigue is caused by mental task and stress, resulting in elevated level of fatigue and decreased level of concentration, motivation and alertness [38] . the persistence in healthy lifestyle is encouraged, moderate exercise is conducive to relieve the state of nervous tension, eliminate tension, release psychological pressure, promote deep sleep, and optimal rest [32, 31] . methods for nurses to deal with psychological crisis or emotional response, such as appropriate emotional catharsis allow themselves to have negative emotions, and detect and adjust them timely; find suitable relaxation ways; change cognition and attitude; maintain full understanding between nurses and patients; seek social support when necessary; share their feelings and experiences with colleagues and peers; choose to keep in touch with family and friends; increase the family background resources; make up for the lack of resources brought by high work family conflict, in order to improve work passion and alleviate psychological problems, maintain physical and mental integrity and activeness. the complexity and multidimensional nature of nursing work may lead to fatigue, and health care institutions need to better understand the factors that contribute to nurses' fatigue and consider accurate mitigation strategies. fatigue risk management systems (frms) [39] was recommended to set up in hospitals to provide a comprehensive approach to reduce risks from fatigue, including instituting workplace policies, establishing procedures to protect tasks that are vulnerable to fatigue-related errors, promoting education for managers and nurses, taking fatigue-related factors into the considerations of investigation on adverse events. the hospital officials should ensure a better working environment for medical staff, appropriate working hours and frequency of night shift, eliminate job burnout, improve the work immersion level of nurses, and reduce the occurrence of adverse events. it is suggested that countries and regions with the pandemic should provide strong support for rescue nurses to lessen work-related fatigue in daily working. it is necessary to request the support of superior departments, allocate the human resources of nurses reasonably, according to the dynamic and flexible principle, adjust the working mode and working length according to the workload, and reduce unnecessary too-prolonged work for first-line nurses. every person and each organization are involved in the rescue work when encountering the pandemic. government should establish and improve the response mechanism for major public health emergencies [6] , and give full play to the role of the government system in each region combating with the pandemic, concentrate and integrate the advantageous resources, establish a complete medical and life support system, and provide strong social support for the medical staff and organizations participating in current rescue. providing humanistic care to all the rescue staff, including solving the necessary problems of dining, accommodation, life, transportation, so as to ensure their strong enforce to participate in and promote the improvement of team performance while reducing the conflict experience, may be beneficial for relieving their negative mental stress. the organization should provide support on mental health knowledge with the aim of mastering the psychological stress reaction process and performance of nurses appropriately, implement targeted mental health assessment and intervention, strengthen the psychological crisis intervention during and after the pandemic situation, which could cut down the negative emotions of medical staff effectively. the present research has several limitations. first, a descriptive cross-sectional design was used, and no cause-and-effect relationships were established. thus, it would be necessary to conduct a longitudinal study and ascertain the variables with a cause-effect relationship. secondly, the study was based on a questionnaire survey with self-report instruments, and all of the variables were measured in terms of participants' subjective perceptions, the bias is not avoidable, which can affect the response reliability. future studies using random sampling frames can enhance the external validity of the findings. nevertheless, we made efforts to control for the personal and professional characteristics of participants to provide the clearest possible image of working as first-line nurses combating with covid-19 in wuhan, china. further prudent investigation using multiple modes of inquiry should be performed and deeper interviews during periodical examinations may be needed on this topic to diagnose chronic fatigue syndrome. this study is of great significance to the rescue nursing work of the pandemic currently. first, health care authorities should be aware of this issue and pay more attention to the physical and mental state of nurses, for it could lead to adverse health conditions for nurses working in current severe situation of pandemic prevention and control. the long-term fatigue of nurses not only damages individual physical and mental health, increases psychological crisis events for nurses under the rescue condition, but also reduces the efficiency and quality of rescue work, patients' disease recovery and safety might be affected. it is imperative to strengthen the support and guarantee system of national government and health care settings for rescue nurses all over the world. to sum up, addressing fatigue and managing risk across industries have received growing attention in the occupational health literature. while fatigue in nurses is a significant challenge in health care, concrete guidelines and methods to reduce fatigue or mitigate its negative effects on safety and performance are lacking. findings from the present research could promote more comprehensive awareness of the contributing factors in the rescue work-related system and psychological variables relate to increased fatigue levels, ultimately guide the design of relevant and appropriate fatigue mitigation interventions, and undertake measures to lessen fatigue in practice context of combating with the pandemic at present. defining and measuring fatigue an integrative review fatigue among 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scale of patient health questionnaire in general hospitals an epidemiological study on the psychological stress of urban residents in social transformation professional quality of life: a cross-sectional survey among chinese clinical nurses a crosssectional study exploring the relationship between burnout, absenteeism, and job performance among american nurses sleepiness, and fatigue among polish nurses. workplace health saf the impact of shift work on the psychological and physical health of nurses in a general hospital: a comparison between rotating night shifts and day shifts work schedules, and perceived performance in bedside care nurses.workplace health saf energy balance and the shift worker investigation on the psychological status of the first clinical first-line support nurses against novel coronavirus pneumonie investigation and analysis of novel coronavirus first-line caregivers with posttraumatic stress disorder investigation on the mental health status of first line nurses during the outbreak of covid-19 fatigue in intensive care nurses and related factors demographic and occupational predictors of stress and fatigue in french intensive-care registered nurses and nurses' aides: a cross-sectional study fatigue, burnout, work environment, workload and perceived patient safety culture among critical care nurses impact of fatigue on performance in registered nurses: data mining and implications for practice addressing occupational fatigue in nurses: current state of fatigue risk management in hospitals, part 1 authors acknowledge all participants who responded to the surveys and the nursing administrators for the cooperation with their effort and time in conducting the present study. the authors declare that there is no conflict of interest regarding the publication of this article. key: cord-345746-6jvqsvy5 authors: resnick, barbara title: what have we learned about nursing from the coronovirus pandemic date: 2020-06-13 journal: j am med dir assoc doi: 10.1016/j.jamda.2020.06.011 sha: doc_id: 345746 cord_uid: 6jvqsvy5 nan what have we learned about nursing from the coronovirus pandemic barbara resnick, phd, crnp during the current coronavirus pandemic, the focus of the accolades has gone to nurses working in the acute care sector, where "real nursing" occurs as portrayed in television or in the movies. over the past few months there has, however, been some increased recognition of the critically important role that nurses play in long-term care. nursing home nurses are present 24 hours a day, providing care and serving as the eyes and ears of all other providers who intermittently evaluate residents in these settings. during coronavirus pandemic quarantine they provide enhanced care, as family are not able to visit. they also facilitate telecommunication with physicians, hospital staff, and families and friends of residents. this care is consistent with the role of nurses over time, which ranges from preventing illness and promoting health to caring for the sick and comforting the dying. their courage, dedication, and resilience is something to be admired. never have i been prouder to be a nurse. there is, however, a price to pay for our work as nurses in this pandemic environment. some have begun to think about retiring; some potential nurses are dropping out of nursing school or deciding not to enroll; some are deciding not to engage in clinical care for fear of their own health or the health of their families; some continue to work despite significant mental and physical health related stress; and some have died or become chronically ill due to covid-19 obtained in the line of duty 1,2 . what do we owe the nurses in long-term care? first and foremost it is the availability of appropriate and sufficient personal protective equipment (ppe) to keep them as safe as possible while they are providing the intimate care necessary for 2 residents within these settings. availability of ppe for nursing staff is critical to residents as well -to prevent the spread of disease as staff move from one resident to the next. further, ready availability to ppe provides an important statement to the staff -that we as a society care about keeping them safe and healthy. in addition to ppe, nurses deserve to be recognized for their knowledge about the residents. while telehealth is a wonderful alternative to face-to-face visits when those are not possible, telehealth visits are not ideal. the input from nurses, and other members of the health care team, is invaluable during or associated with telehealth visits. nurses evaluate the function and behavior of their residents day by day, as opposed to the moment of time that a telehealth visit provides. this is especially important in post-acute and long-term care, where residents may present as lethargic one moment and later in the day blossom and engage in activities. moreover, direct care workers and nurses in long-term care can provide the assessment information needed to diagnose and treat a resident following a more careful and comprehensive work up. lastly, nursing home nurses deserve to be able to work to the full scope of their practice. there are not too many silver linings from the 2020 coronavirus, but one of them has been the release of some regulatory issues that limit scope of practice. for example, on april 9 the centers for medicare and medicaid services (cms) made it easier for providers to practice across state lines 3 . further, advance practice nurses can now order home health care services for patients, and we are all aware of the changes in allowing for telehealth visits across multiple settings. nurses deserve to 3 have these "waivers" remain as recognition of their training, skills and ability as well as increasing access to care for all older adults. in closing, remember to thank the nurses providing care to your residents. they are heroes but they are also human. they are tired and afraid but committed to the pledge they took as a nurse, the nightingale pledge 4 , and they are doing their best with limited staff and resources to provide care for the world's older adults. memoriam: healthcare workers who have died a qualitative study on the psychological experience of caregivers of covid-19 patients trump administration issues second round of sweeping changes to support u.s. healthcare system during for the sick. in detroit courage was the fashion: the contribution of women to the development of detroit from 1701 to 1951 key: cord-300576-7sumvulc authors: baron, kate; labella, erica; parkosewich, janet a.; hahn, judith m. title: keeping nurses engaged in nursing professional governance during the covid-19 pandemic: nursing professional governance structure at yale new haven hospital date: 2020-10-26 journal: nurse lead doi: 10.1016/j.mnl.2020.10.007 sha: doc_id: 300576 cord_uid: 7sumvulc nan nursing professional governance (npg) provides the infrastructure for clinical nurses closest to the bedside to make decisions about nursing practice using evidence to produce measurable patient outcomes. npg ensures nursing quality, provides structure for nursing practice decisions, and professional development through engagement of bedside clinical nurse leaders. 1 at yale new haven hospital (ynhh), a 1541 bed magnet® designated academic medical center, npg is comprised of 11 councils that are distinguished by specialty specific service-line and five hospital-level councils. the service-line councils focus on nursing specialty practice that promotes decision making at the point of service. hospital-level councils focus on nursing practice from a broader hospital-wide perspective. decisions made by hospital-level councils affect the entire ynhh nursing community. the ynhh coordinating council oversees the work of all the councils and connects those who are working on similar initiatives. the coordinating council ensures that the work being done within our npg structure is aligned with our organization's nursing strategic business plan. in january 2020, over 500 clinical nurses and nurse leaders gathered to celebrate our 2019 accomplishments. npg leaders and council members led this wonderful event. during this event we showcased evidence-based practice changes initiated by nurses throughout the year, which providing a great opportunity to celebrate ways we improved patient outcomes. as we reflect on that day in the large ballroom buzzing with intellect and excitement, there was not a single person there who would have predicted that a global pandemic was soon to strike, only weeks away. as time would tell, 2020 would certainly be the year of the nurse. during the next few months the chair (e.l.) and chair-elect (k.b.) of our ynhh npg coordinating council viewed the pandemic as a call to action. we did not allow the uncertainty posed by covid 19 to stop us from embracing opportunities brought on by this unprecedented situation. in our effort to support clinical bedside nurse leaders during this crisis, we used the npg structure to collaborate with nurse leaders and prioritize ways to meet our nursing communities pressing needs. the pandemic surfaced opportunities for nurses to ask questions, share innovations and confirm best practices. j o u r n a l p r e -p r o o f our chief nursing officer (cno) empowered us as npg leaders by welcoming our active involvement in covid-19 planning meetings regarding staffing, education, and personal protective equipment (ppe). in addition, we met regularly with service-line and hospital-level npg councils and focused our attention on covid-19 nursing practice concerns. our cno gave us the tools we needed, specifically access to a web-based video conferencing platform to conduct our npg business while adhering to social distancing guidelines. routine agenda items were paused and each council focused on covid-19 concerns. we sought council member's opinions on ways to improve patient outcomes, patient experience, and nurse engagement during this time. the npg council members are known to be some of our most passionate, creative, "get it done" nurses. these are the nurses who, prior to the pandemic, had already shown incredible dedication and involvement in shaping the practice of nursing. our npg nurse members were ready and willing to voice their ideas and engage in problem solving on behalf of their nursing colleagues, and patients and families as the pandemic evolved and hit full force in connecticut and the surrounding new england states in march and april, 2020. during the peak of covid-19, every day was a new day. it seemed as though not a single regulation stayed in place for over 24 hours before it was updated or eliminated. regulations that were historically enforced, were lifted due to the circumstances. changes around what we wore for ppe were changed, sometimes by the hour, based on new information on the virus as well as international shortages. clear communication that was organized in a systematic way, became more vital than ever. our organization used an incident command center structure as the hub for the most up-to-date processes and resources for our teams. nurses concerns were coming through different pathways. they came through manager and leader rounding, through our councils both formally and informally, which yielded many concerns and fears. there was widespread fear regarding the shortage of ppe and the risk of getting the virus and/or bringing the virus home to their families. deployment to different practice settings sparked anxiety. nurses were concerned about where they were going to be deployed to, especially ambulatory nurses who were now deployed to the bedside to care for inpatients for the first time in years. our teams had a significant need for emotional support as they were caring j o u r n a l p r e -p r o o f for more and more patients who were dying alone due to covid-19 complications. many nurses reported experiencing moral distress exacerbated by dealing with the covid-19 illness trajectory. collectively, our clinical nurses had the clinical knowledge on exactly "how" we were going to get through the crisis, but needed the confidence to pull it all together during this time of uncertainty. they were networking with colleagues across the country and beyond through social media and brainstorming innovative clinical approaches to care. because of our expertise, nursing leaders engaged members of the npg councils in their daily decision making. we participated in daily leadership huddles to provide insight for nurse training and deployment, staffing models and communicated regularly with the cno. leaders were listening to us, trusting us, and were providing transparency so that we could be flexible and transformative. through council member engagement, the innovation started to really flow. we knew that we needed to capture the amazing clinical solutions nurses were proposing so they could be shared quickly and replicated. early on, the hospital initiated a plan d disaster at the hospital incident command structure (hics). this included daily briefings and a robust covid-19 website for resources. this website housed critical information about ppe and protocols that was easily accessible to all staff. in addition, a call center was established for staff and community members to call with questions regarding anything to do with covid-19. nurses found this website to be excellent and the foundational hub for trusted truth, however, clinical nurses had very specific nursing practice questions, and innovative ideas that they wanted to share. as npg chairs, we felt a responsibility to support them and collaborated with leadership to brainstorm solutions. nursing professional governance has a senior nursing leadership liaison that serves the role of senior mentor (j.h.) to npg. our npg liaison guides us in approaches to nursing practices changes as well as directs us to appropriate teams and colleagues to include in npg work. we embraced the inevitable challenges generated by the pandemic and decided to create an electronic space for nurses to pose questions, collaborate around best practices and share innovations. several years ago, npg created a sharepoint web platform as an electronic method to communicate and develop practice changes from concept through implementation. we call this platform the masterlog, which is framed by the steps in the nurses click on this link that brings them to a simple template. the template has fields for name, unit, and contact information, fields to complete in the format of situation, background, assessment and recommendation (sbar) and the option to upload any relevant documents. our goal was that within 24 hours the nurse would receive a response from the npg coordinating council chair regarding their submission. behind the scenes, the npg chair found answers to questions and evaluated the feasibility of innovations. see figure 1 for an example of a completed template. in this example, an innovative idea was placed by one of our clinical nurses regarding standardized patient mealtimes to decrease exposure to the virus and use of ppe. after the request was submitted, our npg coordinating council chair orchestrated meetings and communications about this request. the combined efforts resulted in endorsement from members of our food and nutrition department and npg coordinating council, as well as the diabetes clinical nurse specialists, physicians, and cno. within 48 hours, this practice change was put into full effect and the entire process around mealtime delivery was adapted to better protect our nurses and conserve ppe. this was a repository of endorsed innovative ideas. any nurse could log on, at any time, and see all the ideas that had been submitted and the action taken so that there were not replication of requests. one j o u r n a l p r e -p r o o f it was important to make these questions easily accessible to nurses because we knew that if one nurse was asking a question, there were other nurses with the same question. questions about blood product administration, housing, ppe use, and many others were all vital to ensure the safety of nurses and patients. in this section we provided extensive resources for nurses that included information from the center for leaders and american association of critical care were housed here. lastly, under this tab we had a section for "quick links" which provided nurses with discounts and freebies for healthcare workers. the hospital is fortunate to have the prestigious yale university's harvey cushing/john hay whitney medical library as our library. our nursing librarian assists us with accessing all the library's valuable resources. her consultation is invaluable, as she provides us with up-to-the minute protocols and resources regarding covid-19 clinician care and safety, ppe, consumer health, latest research findings and publications. all of this information is housed in this site. we are grateful that we have a culture that includes npg as a structure for nurses to be accountable for their practice, nursing quality and nursing knowledge. our leaders support this structure and view it as vital during a time of crisis. we have a trusting collaborative relationship where creativity is supported. this support allowed us to be flexible and practice focused. our technology platform works to make sure that all nurses, on all shifts, and in all practice settings can engage in raising questions and bringing forth innovations. providing the resource of the npg chair's availability to engage with councils during the pandemic allowed timely responses and j o u r n a l p r e -p r o o f dissemination of important information. as a practicing nurse in our intensive care unit, our npg co-chair acted as a link between what the clinical nurses were experiencing, and the work that was being done to support nurses on the frontlines. we realized that we have opportunities to move things more quickly on a regular basis and we need ongoing harvesting and dissemination of innovations through technology. during 2020, the year of the nurse, npg was an important structure that supported clinical nurses during the crisis. the work of npg built nurses' confidence so they were better positioned to safely and confidently care for their patients and each other. the support of our chief nursing officer and nursing professional governance liaison was essential to the influence that our npg structure and all of its members had on rapidly implementing practice innovations, timely communication, and providing system solutions to challenges created by the covid-19 pandemic. nursing management (springhouse) key: cord-288460-4flu5jvx authors: dimino, kimberly; horan, kathleen m.; stephenson, carolene title: leading our frontline heroes through times of crisis with a sense of hope, efficacy, resilience, and optimism date: 2020-10-01 journal: nurse lead doi: 10.1016/j.mnl.2020.05.011 sha: doc_id: 288460 cord_uid: 4flu5jvx the coronavirus 2019 (covid-19) pandemic has changed the trajectory of health care delivery in the united states and the whole world. frontline nurses—essential warriors in this fight—complete exhausting shifts and experience the moral distress that comes with making difficult ethical decisions. this deeply human crisis requires a deeply human response. to augment the mental health of their frontline staff, nurse leaders must tap into their staff’s psychological capital (psycap). psycap is characterized by having high levels of hero (i.e., hope, efficacy, resilience, and optimism). in this article, we describe strategies that nurse leaders can utilize to foster psycap in their nurses. i n all the news about coronavirus disease 2019 (covid-19), little attention has been paid to the support nurses need to maintain the balance between hope and despair. as a country and a world, we grieve the loss of normalcy, the loss of stability, and the loss of our loved ones. the country and the media praise nurses as frontline heroes in this battle against despair. they are commended for their resilience and their unselfish willingness to run into the fire while others are running the other way. these nurse heroes are recognized as soldiers of hope, but are these essential employees being supported as such by their organizations? under these extraordinary circumstances, the promotion of our frontline nurses' well-being is more critical than ever. nurse leaders are being called not only to help their organizations manage uncertainties, but also to guide, support, empower, and lead frontline nurses who are bearing witness to unfathomable fear, grief, and suffering. to avoid burnout and a massive nursing shortage during and after this pandemic, nurse leaders have a responsibility to find ways to preserve the well-being of their frontline staff. in this article, we provide recommendations for how we, as nurse leaders, can use our leadership skills, professionalism, and humanity to lead our nurses during this crisis. the deeply human covid-19 crisis craves a deeply human response. how we, as nurse leaders, address these unprecedented events being lived by our frontline nurses will markedly impact their experiences throughout this crisis and beyond. while many outside of the health care industry focus on protecting financial capital, on the frontlines, we're seeing the value of other types of human capital. in particular, psychological capital (psycap) is in high demand. psycap an individual's positive psychological state of development, psycap is characterized by having high levels of hero (i.e., hope, efficacy, resilience, and optimism). it is timely for leaders in nursing to learn about and invest in psycap development of their nurses so that the impact can serve as the foundation for our road to recovery. reporters and politicians won't let us forget that the covid-19 crisis is inherently an infectious disease crisis, but it is also a deeply human crisis. nurses providing direct care for covid-19 patients practice in high-stress, potentially life-threatening environments. as a result, they are likely to experience psychological distress. research suggests these nurses face serious risks of developing post-traumatic stress symptomatology (ptss) along with a variety of other psychiatric morbidities. 1 recent real-life examples back up the science. a significant proportion of frontline nurses treating covid-19 patients in china reported symptoms of depression, anxiety, insomnia, and distress. 1 dr. perlis, a psychiatrist at massachusetts general hospital reminds us that "while the peak of the covid-19 virus remains to be seen, it will ultimately subside however, what will remain are the consequences of chronic stress including major depression and anxiety disorders." 2 this worldwide pandemic has caused a radical shift in healthcare practices in hospitals all over the globe. resources are low, whereas tension and loss are high. these organizational challenges also increase pressure on individual nurses in hospital settings. frontline nurses know how to evolve and adapt to the medical acuity and complexity of covid-19. however, if they don't have the resources to protect their mental health, their well-being will suffer. they may experience profound changes in their personal and professional relationships, changes to how they view their careers, financial hardship, or even death. this deeply human crisis craves a deeply human response. how we, as nurse leaders, address these unprecedented events being lived by our frontline nurses will markedly impact their experiences throughout this crisis and beyond. nurse leaders can support the psychological well-being of frontline nurses navigating high-risk and hectic work environments. nurse leaders who provide supportive engagement and transparency will cultivate a caring cultute in the work environment and reap the benefits from dedicated staff who will provide high-quality patient care. alternatively, a lack of leadership, support, and effective communication will leave nurses feeling unappreciated, isolated, and devalued. let's turn now to strategies for supporting frontline nurses during this crisis and beyond. although many outside of the health care industry focus on protecting financial capital, on the frontlines, we're seeing the value of other types of human capital. in particular, psychological capital (psycap) is in high demand. psycap is an individual's positive psychological state of development and is characterized by having high levels of hero (i.e., hope, efficacy, resilience, and optimism). 3, 4 these four pillars of psycap can be encouraged and cultivated in frontline nurses supporting them to thrive in overwhelming circumstances. 5 psychological capital will get us all through the covid-19 crisis. the following includes psycap "hero within" development guidelines from various published studies. many of the strategies discussed here are adapted and applied to pandemic nursing from psycap 101: your guide to increasing psychological capital. 4 for those in leadership roles, there is a reciprocal relationship between what you give and what you get from others. this characterizes authentic leadership. 6 consequently, by investing in their own well-being, nurse leaders are more likely to portray a sense of hope, efficacy, resiliency, and optimism, and to encourage others to exhibit them as well. when fostering hope, it is important to set clear organizational and personal goals that are both specific and challenging. the goal should be demanding, but not impossible. if the nurse's level of hope is low, start off with an easy goal in order to achieve some degree of hope before attempting a challenge. once the goal is set, use a step-by-step method to break the goals down into substeps to make the goals more manageable. this method also allows frontline nurses to experience small successes as they make progress toward greater goals. one practice is to conduct daily hope huddles. shift changes involve exchanges of updates and reports between incoming and outgoing shifts of nurses. why not create intentional moments of hope during these meetings? nurse leaders can begin with positive and inspirational quotes to empower the staff and thank them for providing patients with positive experiences during their hospitalizations. in addition to the traditional handoff, nurse managers can accentuate positive outcomes from the previous shift and recognize meaningful staff contributions. this practice can lift the mood and bolster both arriving and departing staff. 7 four widely recognized sources of self-efficacy development were identified by bandura 8 (figure 1 ). here are four ways to support frontline nurses to strengthen and foster self-efficacy: 1. encourage them to focus on past successes (mastery experiences). self-efficacy is usually realized through past experiences. 8 whereas individuals most often develop self efficacy by successfully mastering skills, in a leadership environment, it is often about encouraging others to appreciate past successes, rather than creating them. self-efficacy can be challenging for individuals with a high external locus of control because they find it difficult to internalize success, instead attributing positive experiences to factors outside of their control. 9 therefore, by identifying specific competencies, skills, and experiences which contribute to past successes, nurse leaders can engineer mastery experiences, thereby increasing self efficacy among their staff. 2. encourage awareness of role modeling (social modeling). seeing nurse leaders, such as charge nurses, clinical nurse specialists, nurse managers, nurse educators, supervisors, and nurse scientists, in similar situations overcoming obstacles reinforces the confidence that frontline nurses themselves can succeed. in order for this type of positive psychological transference to have the desired effect, nurse leaders should be perceived by frontline nurses as authentic, connected, and similar to themselves. 3. create situations for success (social persuasion). as leaders, in addition to verbally encouraging and persuading frontline nurses, we can position nurses for success by being mindful of placing them in a supportive environment. this encourages selfefficacy. 4. reframe negative experiences (psychological responses). how we frame our physical and emotional reactions to stressful situations affects how we judge our ability to process and make decisions under pressure. those demonstrating high levels of selfefficacy are actually able to enhance their performance by perceiving barriers and challenges as motivating, instead of frustrating. nurse leaders experience negative psychological responses, too. however, we can learn to reframe these negative thoughts by discussing psychological responses with other nurses. for example, if we can learn to recognize our stress as motivation to accomplish a challenge, rather than a loss of control or power, this can greatly support development of self-efficacy. when individuals respond to adversity with actions that will lead to thriving as opposed to surviving, they are resilient. 10 all humans experience adversity. resilience is literally recoiling quickly after an insult! high levels of resilience at work are associated with better working performance among nurses. 11 nursing is known to be highly stressful, and fostering resilience would be extremely useful as an investment to combat such negative effects, while yielding positive organizational benefits. 11 resilience is a combination of three characteristics: 12 being realistic it's important to be realistic about personal strengths and weaknesses. it is also crucial to look for good reasons to be positive even in the face of despair, but not to get discouraged when the turnaround of events is delayed, remembering that sometimes things get worse before they get better. when we manage our expectations, we can manage our disappointments. resilience involves utilizing our abilities to improvise and discover novel ways to accomplish our goals. as role models, it is critical for nures leaders to cultivate creativity. in a meeting or daily huddle, collaborating and brainstorming different ideas to solve a problem can strengthen frontline nurses' creativity. 12 searching for meaning resilience also requires managing feelings and impulses. one way to practice this is to look for meaning. the ability to find meaning in situations where we have no control over the outcomes is at the core of resilience. optimism is defined as making a positive attribution about succeeding now and in the future. 13 people who tend to internalize their successes often believe they have to invest in work and effort for good things to happen to them. optimistic individuals believe that no matter the effort, their future will yield positive outcomes. 4 contrary to what some believe, optimism can be developed. it's all a matter of training oneself to focus awareness of emoɵons and reframing experiences in a posiɵve way figure 1 . four sources of self-efficacy. on the positive. leaders, for example, can encourage optimism in their colleagues by sharing past experiences and empowering them for future opportunity. one strategy for providing nurses with a way to enhance their optimism is to institute an exercise during shift report called "3 good things." 14 in this exercise, nurses are encouraged to write down and share three good things that happened to them during their shift and the causes of those events. when practiced regularly during daily report time, nurses will reframe their daily experiences on positive things. sharing three good things personalizes and humanizes the interchange between nurses. this often results in more generous posturing towards each other. develop a multidisciplinary strategy team from key functional areas to oversee well-being initiatives for frontline staff. recruit senior leaders to meet with frontline nurses to communicate the organizational commitment to the unit team. these sessions reinforce to staff that hospital leaders appreciate and value their specialized work. offer leadership training to supervisors to ensure that they have the skills needed to support and maintain a healthy and healing work culture. key topics include effective communication, conflict management, team building, and stress management. arrange for psychologists and social workers to meet with frontline nurses individually or in groups to debrief, vent, and provide support as needed. recognize that new graduates and less experienced nurses are at a higher risk for experiencing psychological and moral distress during and after this crisis. incorporate special sessions during residency and/or orientation programs to address this. cultivate a culture of caring in combination with an integrative therapies approach by offering wellness programs including reiki, therapeutic touch, massage, aromatherapy, yoga, etc. encourage mind/body approaches to become calm, centered, and fully present as part of your nurses' daily routine. a take home message to achieve all of the above, nurse leaders need to invest in developing the psycap of their frontline nurses through long-and short-term interventions. so, what is the first step health care organizations can do to develop nurses' psycap? simply introducing nurse leaders to the concept by empowering them to recognize and embrace their own personal level of hero and encouraging them to do the same for others. because we do not often hear this concept used in the professional setting, taking the first step is critical to maximize this powerful resource. researchers consider psycap to be a fundamental asset of authentic leadership, which is unique and vital for nursing. 5 authentic leaders possess a great deal of hope, efficacy, resilience, and optimism. with these attributes, nurse leaders are well equipped to lead frontline nurses in facing the challenges of the covid crisis. therefore, a developed and well-managed, psycap initiative can provide enormous benefits for nurse leaders, frontline staff, and health care organizations. psycap helps nurses to maintain a commitment to their organization, and sustain dedication to providing exceptional, evidence-based patient care, even in the most overwhelming circumstances. but most of all, psycap helps nurses to heal. with the increasing complexity of health care and the current and pending aftermath of the covid-19 crisis, it is timely for leaders in nursing to learn about and invest in psycap development of their nurses so that the impact can serve as the foundation for our road to recovery. factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019 exercising heart and head in managing coronavirus disease 2019 in wuhan psychological capital: developing the human competitive edge psycap 101: your guide to increasing psychological capital compassion fatigue and psychological capital in nurses working in acute care settings the power of positive thinking hope huddles connect front-line nurses amid covid-19 crisis self-efficacy: the exercise of control generalized expectancies for internal versus external control of reinforcement positive psychological capital: measurement and relationship with performance and satisfaction high resilience leads to better work performance in nurses: evidence from south asia how resilience works optimism, coping, and health: assessment and implications of generalized outcome expectancies positive psychology progress: empirical validation of interventions carolene stephenson, phd, rn, fnp, is nurse scientist at hackensack meridian health and adjunct clinical instructor at passaic county community college in passaic key: cord-303903-d1n6eayo authors: catton, h title: global challenges in health and health care for nurses and midwives everywhere date: 2020-02-21 journal: int nurs rev doi: 10.1111/inr.12578 sha: doc_id: 303903 cord_uid: d1n6eayo the next decade is likely to produce any number of global challenges that will affect health and health care, including pan‐national infections such as the new coronavirus covid‐19 and others that will be related to global warming. nurses will be required to react to these events, even though they will also be affected as ordinary citizens. the future resilience of healthcare services will depend on having sufficient numbers of nurses who are adequately resourced to face the coming challenges. the third decade of the 21st century looks set to be as full of geopolitical and environmental challenges as the last one was, if not more so. it is always difficult to prepare for the unknown, but at least nursing has started the decade on the right path, thanks to the world health organization's (who) designation of 2020 as the international year of the nurse and midwife. that decision, taken by who's governing body, the world health assembly, marks a commitment from governments around the world to make nursing a priority this year (who 2020a). as i have said before, we need to make the most of the attention the year of the nurse and midwife is going to afford us. we need to make sure we raise the profile of the profession and get politicians to make the commitments that are needed to grow and support the profession to avoid the alarming staff shortages that who is predicting by 2030 if nothing is done. every nurse has a story to tell, and it is important to tell yours to anyone who will listen. telling people about your day as a nurse will help to raise the profile of the profession and help to encourage a new generation into the nursing family. it was gratifying to hear pope francis praise nurses and midwives in a sermon in january (icn 2020). and i hope other world leaders, heads of states and religious leaders will step forward and publicly recognize the great work that nurses do 24 h a day, 365 days a year. the international council of nurses (icn) has a large number of events planned for this year, and i know that our national nursing associations, healthcare organisations, hospitals and individual nurses have their own events in mind around the world to mark this important celebration of our profession. wherever nurses are working, they provide a unique service that no other professionals can equal, albeit in a calm and quiet manner, and often away from the public's gaze. and of course, they do this in whatever circumstances they find themselves, even when those circumstances look set to change. climate change is the greatest threat the world is facing, yet its actual and potential effects on health and health care are rarely brought to the public's attention. a recent report, the 2019 report of the lancet countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate (watts 2019), has laid bare the realities of global warming and the calamitous effects it will have if it continues on its current path. we will all be affected by it in many walks of our lives, but of course children will be most severely affected, and they will have to live with its consequences when we are long gone. in short, the lancet reports highlights extensive damage to health as a result of global warming, including: • an increased burden of malnutrition as crop yields fall and food prices rise • increased rates of infectious diseases • higher rates of respiratory disease because of air pollution • increased traumatic injury and subsequent hardship as a result of more frequent extreme weather events. the lancet's prescription for dealing with these potentially catastrophic consequences includes phasing out coal power worldwide, ensuring wealthy countries keep to their financial promises to help low-income countries, increasing access to efficient, active transport systems based around walking and cycling, and making major investments in adapting health systems to reduce the impact of climate change. politicians must do the big things to reduce greenhouse gases and prevent or minimize further global warming, but we can all do something in our day-to-day lives to help prevent the lives of children born today being defined by the effects of global warming. icn is making sure the voices of nurses on this issue are being heard loud and clear in the circles where healthcare policymaking takes place. our own position statement on nurses, climate change and health (icn 2018) anticipated much of the lancet report's findings and calls on governments to take immediate action. we are currently running disaster competency workshops in sri lanka and the bahamas, and we have updated our core competences in disaster nursing to better equip nurses for the challenges they might increasingly have to face (icn 2019). given recent global climate events, no rational person, and certainly no one in government anywhere in the world, should have any doubt about the reality and potential consequences of global warming. the science is settled, and so should be the global response. the inevitable health impacts of global warming around the world make addressing the potential nursing shortages even more critical. in past months, we have seen widespread climatic events, including serious fires in australia and severe flooding in indonesia. nurses are responding to these events, even though they too are potential victims, just like their neighbours. at the time of writing this, the who has just declared a public health emergency of international concern (who 2020b). in china, the unfolding emergency caused by the novel coronavirus or covid-19 in wuhan city is putting nursing services under intense pressure as thousands of people become infected with an uncertain but potentially fatal respiratory infection, and the infection spreads across china and other countries. icn is in close contact with the chinese nursing association and the who about this developing situation, and we are emphasizing the importance of nurses keeping themselves as safe as possible through their actions and their use of personal protective equipment. nurses on the front line in this event are showing the commitment and compassion that nurses do everywhere, but the truth is they are putting their lives at risk in the course of their duties, and we need to acknowledge that and praise them for their selflessness. in previous similar events, such as the sars (serious acute respiratory syndrome) event of 2002/2003, nurses died in the course of their duty. i hope all the nurses involved in the current crisis stay safe and that their courageous actions will be properly recognized and rewarded once the situation has resolved. if governments act appropriately this year and make the massive investments required to deal with the upcoming nurse shortages, we will look back on 2020 as a success. but we cannot leave that to chance: we have to make sure that the legacy in 2020 is not just being able to look back on a batch of fond memories. the year 2020 must be a catalyst for lasting change that raises the profile of nursing in the eyes of an educated public that understands what nurses can do, provided they are properly resourced and rewarded for the outstanding contributions they make to societies around the globe. my challenge to all nurses, and i know they are all busy and preoccupied with their everyday work and their family lives, is to make sure that what they do is not going unnoticed. if people see the commitment and compassion that goes into nursing, more of them will appreciate what we do, and more of them will want to join us in what is the most rewarding job on earth. nurses, climate change and health. revised core competencies in disaster nursing. version 2.0 pope acknowledges the international year of the nurse and midwife, praising 'the noblest of professions the 2019 report of the lancet countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate world health organization (2020a) year of the nurse and midwife available from: https://www.who.int/news-room/campaigns/year-of-thenurse-and-the-midwife-2020 accessed 31 jan 2020. key: cord-269513-sbp7k287 authors: bell, mary; sheridan, ann title: how organisational commitment influences nurses’ intention to stay in nursing throughout their career date: 2020-10-11 journal: int j nurs stud adv doi: 10.1016/j.ijnsa.2020.100007 sha: doc_id: 269513 cord_uid: sbp7k287 background: : the current covid 19 pandemic brings into sharp focus the global necessity of having sufficient numbers of nurses and the dire impacts of nursing shortages throughout health systems in many countries. in 2020 retaining skilled experienced nurses continues to be a major global challenge. the dominant and consistent concentration of workforce research to date has focused on attitudinal factors including job satisfaction and burnout and there is limited research on how organisational commitment in combination with job satisfaction and burnout may explain what keeps nurses in nursing. objectives: : to measure how organisational commitment in combination with job satisfaction and burnout relate to the intention of registered general nurses’ staying in nursing (itsn). design & methods: : a quantitative descriptive design using a cross-sectional survey was utilised. a national postal survey of a representative sample of registered general nurses employed within the republic of ireland (roi) health services was undertaken in 2010. a number of established valid and reliable instruments were used to measure attitudinal factors and their relationship with intention to stay (itsn). data were analysed using ibm spss version 24.0 and descriptive, correlational and multiple regression analysis were undertaken. results: : a total of 756 registered nurses participated in this study. the strongest predictor of intention to stay in nursing was organisational commitment (β=.32, p=.000) while burnout and job satisfaction had a significant relationship with itsn. conclusion: : results reveal the complex and multidimensional nature of itsn with the majority of nurses having a strong intention to stay in nursing. organisational commitment and low burnout represented predictors which are influential in nurses remaining in nursing throughout their career lifespan. these results remain relevant in 2020 particularly in light of the ongoing pandemic when retention and recruitment of skilled and experienced nurses to the workforce will be critical to the management of health care, considering the increased nurse vacancy rates in many countries and the evident lack of resolution of the issues raised from this study. a quantitative descriptive design using a cross-sectional survey was utilised. a national postal survey of a representative sample of registered general nurses employed within the republic of ireland (roi) health services was undertaken in 2010. a number of established valid and reliable instruments were used to measure attitudinal factors and their relationship with intention to stay (itsn). data were analysed using ibm spss version 24.0 and descriptive, correlational and multiple regression analysis were undertaken. results: a total of 756 registered nurses participated in this study. the strongest predictor of intention to stay in nursing was organisational commitment (β=.32, p=.000) while burnout and job satisfaction had a significant relationship with itsn. results reveal the complex and multidimensional nature of itsn with the majority of nurses having a strong intention to stay in nursing. organisational commitment and low burnout represented predictors which are influential in nurses remaining in nursing throughout their career lifespan. these results remain relevant in 2020 particularly in light of the ongoing pandemic when retention and recruitment of skilled and experienced nurses to the workforce will be critical to the management of health care, considering the increased nurse vacancy rates in many countries and the evident lack of resolution of the issues raised from this study. what is already known about the topic:  job satisfaction is associated with nurses staying in their job  nurses are more likely to stay in the job if they are satisfied with the safety and quality of patient care they can deliver what this paper adds:  commitment to the organization is a stronger predictor of intention to stay in nursing throughout a career lifespan than job satisfaction  nursing demographics influences intention to stay in nursing and in particular organization commitment  the combination of low burnout, supportive co-workers, facilitative scheduling and good effective social interaction influence nurses to stay in nursing throughout their career lifespan despite two decades of extensive focused nursing workforce research, quick fix solutions to resolve the increasing global nursing shortage have yet to be found. it is estimated that there is currently a global shortage of 7.2 million nurses while shortages of at least 12.9 million nurses by 2035 are predicted (who,2018) . indeed, the current covid 19 pandemic has highlighted the global necessity of having sufficient numbers of nurses and shines a light on the catastrophic impacts of nursing shortages throughout health systems in many countries. while nurses remain the largest group of health service employees accounting for 60% of the healthcare workforce globally and delivering an estimated 90% of primary healthcare services (who 2020), a recent report on nurse staffing trends indicates clearly that the problem of retaining nurses will not be resolved anytime soon (buchan et al.,2019) . how to retain nurses remains contentious with the predominant singular solution of adequate nurse staffing levels as a panacea for increasing patient safety outcomes and consequently increasing nurse retention (aiken, sloane et al. 2012) . however, the bulk of reported workforce research focusses on nurses working in acute hospitals and frequently concludes that multiple additional factors influence nurses' intention to stay reflecting both the reality and the complexity of the problem. yet, there is a limited understanding of how nurses try to stay in nursing throughout their career (whether in tertiary, secondary or primary care) and what the factors are that contribute to this. this paper reports on a component of a larger study that explored nurses' intention to stay in nursing throughout their career lifespan. informed by a conceptual framework of intention to stay in nursing (itsn), previously identified factors including job satisfaction, stress/burnout and organizational commitment were investigated on general nurses working throughout the health services in the republic of ireland (roi). this study sought to ascertain how these factors work together to influence nurses' itsn and to gather an insight at one point in time of nurses working in many different areas throughout the country. the results of this study continue to be as relevant in 2020 as they were when data collection was conducted, and this is particularly so given the continued high turnover rates reported which challenge retention (inmo 2019), coupled with the absence of any evident resolution of the issues raised from this study to promote itsn. moreover, the data gathered for this study was at the start of the global recession whereby funding for health services in roi and throughout the world resulted in contraction of services and reduction in nursing workforce levels which still have not recovered. the global economic impact of covid-19 with the global shutdown of production, travel and construction is likely to result in similar recessionary outcomes compounded by the need to invest significant amounts of additional funding in health care to mitigate the large-scale impact of the pandemic. intention to stay is an attitude and a behaviour that has not yet occurred (al-hamdan, nussera et al. 2016 ) and is a strong statistically direct cognitive antecedent of retention (price and mueller 1981) . while intention to stay has been interpreted and investigated in a number of ways within the workforce literature, there remains a lack of clear discrimination between this concept and similar constructs adding to the confusion and the inability to clearly compare results (efendi, kurniati et al. 2019) . for example there is a lack of clarity as to whether the nurse's intention to stay is within the current position (cowden and cummings 2012) , the current organisation (krausz, koslowsky et al. 1995 , zeytinoglu, denton et al. 2006 or within the nursing profession (flinkman, leino-kilpi et al. 2010) . in this paper, intention to stay in nursing (itsn) is defined as the nurse's perceived likelihood of staying within the nursing profession or leaving to find non-nursing work (cowin 2001) . three key factors are consistently related to intention to stay within the literature and include: job satisfaction, burnout and organisational commitment. job satisfaction is universally accepted since the 1930s as a significant predictor of employees staying or leaving their employment. despite the abundance of research conducted on nurses' job satisfaction, the level of knowledge still remains limited (lu, zhao et al. 2019) . job satisfaction is defined globally as an affective response an individual has to the job and/or to aspects of the job (dilig-ruiz, macdonald et al. ). there is considerable evidence indicating the direct effect of many factors such as stress or burnout on job satisfaction but there are still many indirect effects of job satisfaction that remain unknown (lu, zhao et al. 2019) . numerous theoretical models, pathways and mediators in the literature (lu, zhao et al. 2019) with the predominant focus being on how healthy, safe work environments effect nurses' job satisfaction and retention (wei, sewell et al. 2018 ) are being used to identify such effects. factors such as the importance of workplace relationships (lin, viscardi et al. 2014 , olsen, bjaalid et al. 2017 , wei, sewell et al. 2018 , yasin, kerr et al. 2020 ), scheduling (dall'ora, ball et al. 2016 , ferri, guadi et al. 2016 , dilig-ruiz, macdonald et al. 2018 , leadership (ulrich, lavandero et al. 2014 , wei, sewell et al. 2018 , nurse-patient ratios (aiken, sloane et al. 2014 )and the connection between nurses' job satisfaction and better patient satisfaction (chang and zhang 2012, lu, zhao et al. 2019 )are but a few. there is however growing evidence that job satisfaction is related to intention to stay in the profession (wang, tao et al. 2012 , sabanciogullari and dogan 2015 , lo, chien et al. 2018 . burnout is a complex multidimensional construct, defined as a psychological response to chronic emotional and interpersonal work-related stressors with a core element being exhaustion whether physical, emotional and/or cognitive (maslach 2001 , squiers, lobdell et al. 2017 , rodriguez, luck et al. 2018 ). stress and burnout have been linked previously with compassion fatigue and/or secondary traumatic stress disorder (beck 2011 , li, early et al. 2014 . the impact of burnout is known to have detrimental effects on employees' health such as a higher risk of cardiovascular disease, type 2 diabetes , hypertension and musculoskeletal disease (richardson and rothstein 2008) as well as resulting in higher turnover rates within organisations (rodriguez, luck et al. 2018 ). some studies have identified a positive relationship between stress and intention to leave (parasuraman 1989 , zeytinoglu, denton et al. 2006 , chan, tam et al. 2013 , burnout and intention to leave (flinkman, laine et al. 2008 , mcgilton, tourangeau et al. 2013 ) and a negative relationship between burnout and intention to stay (jiang, ma et al. 2017) . organisational commitment is defined as the individual's identification with, and involvement in, his or her particular work organisation and includes an individual's acceptance of the organisation's goals and values, an eagerness to work hard for the organisation along with a distinct ambition to remain working for that organisation (porter, steers et al. 1974 , saridakis, lai et al. 2020 . while predictive of turnover and positively related to intention to stay (simon, muller et al. 2010 , de gieter, hofmans et al. 2011 ,evidence also identifies that if employees believe that their work groups are supportive and cohesive, they are less critical of the organisation as a whole and are more likely to stay in that organisation (ingersoll, olsan et al. 2002 , brunetto, xerri et al. 2013 , li, early et al. 2014 . a recent finding indicted that commitment to the work organisation is connected to the nurse's commitments outside the organisation, implying the significance of maintaining a work/life balance (aluwihare-samaranayake, gellatly et al. 2018). however, there remains a lack of consensus regarding the causality of job satisfaction and organisational commitment (saridakis, lai et al. 2020 ) and how they relate to intention to stay or leave. a conceptual framework informed by the literature reviewed was developed and was adopted to drive this study. figure 1 below provides a visual representation of the principle factors included in the framework of itsn throughout a career lifespan. the factors that are considered the most influential to itsn are the level 1 factors followed by level 2, 3 and 4. this paper reports on the influence of level 3 (job satisfaction, organisational commitment and stress/burnout)and 4 (demographics) factors on itsn which have been identified previously but in a variety of combinations. throughout the working life cycle of the nurse, there are significant life span or life experience factors which will dominate and take precedence at times including, health, environmental and social influences. the upper half of the circle represents the personal/internal dimension throughout the working lifespan while the lower half of the circle represents the professional/external dimensions which may influence itsn. the aim of this component of the study was to empirically assess the influence of level 3 factors (job satisfaction, organisational commitment and stress/burnout) and level 4 factors (demographics) on intention to stay in nursing of nurses currently working in the health service in roi (public and private hospitals, nursing homes, community, public health, gp practices etc) throughout their career life span. a cross-sectional survey design was used to explore the intention of nurses to stay in nursing (itsn). participants were registered general nurses ( consideration was given to the sample size needed and to the number of respondents who would receive questionnaires. table 1 illustrates the sampling approach adopted. weariness and using a 7-point likert scale (1=never to 7 = always) was used to measure how often questionnaire designed to be respondent friendly by focussing on the design of the questions and layout pre-notice letter sent 5 days before questionnaire questionnaire posted with detailed cover letter and return stamped addressed envelopes replacement questionnaire plus letter sent to non respondents 6 weeks after first mailing and return stamped addressed envelopes during the previous 30 days respondents experienced particular feelings. the organisational commitment questionnaire (ocq) )(cronbach's alpha of .88), a 14 item scale, measured the strength of a nurse's identification with and involvement in their current work organisation (porter, steers et al. 1974 ). the three factors considered to characterise organisational commitment and measured using a 7 -point likert scale (1 = strongly disagree to 7 = strongly agree) were a strong acceptance of the organisation's goals and values, enthusiasm to work hard for the organisation and a definite aspiration to remain with that organization. the dependent variable, intention to stay in nursing, was operationalised by the nurse retention index (nri) )(cronbach's alpha of .90) (cowin 2002) . while designed to measure nurses' intention of staying in their nursing job or leaving to find non-nursing work, in this study it was used to measure intention to stay in the profession of nursing. a total of six items, four positively worded and two negatively worded are clearly related to intentions to remain in the profession of nursing. (table 2 ). these declarative items were measured using an 8-point likert scale ranging from 1 (definitely false) to 8 (definitely true). i would like to stay in nursing as long as possible 3 as soon as it is convenient for me, i plan to leave the nursing profession 4 i expect to keep working as a nurse 5 my plan is to remain with my nursing career as long as i am able 6 i would like to find other employment by leaving nursing. respondents' personal (age, gender, nationality, marital status, dependent children, other kinship responsibilities, health status), professional (level of education, professional qualifications) and employment information (years since registration, years working in current position, current type of health setting, current area of work, grade at which working, any temporary interruption in employment and reasons for that interruption) were also obtained. cronbach's alpha values of the four scales ranged from .88 to .94 indicating a high level of internal consistency (hair et al.,2010) . with the exception of the smbm, all the scales had been tested on nurses previously. the face, content and construct validity of these instruments used were established prior to data collection through the process of cognitive interviews and a pilot study (willis and artino 2013, de vaus 2014, egger-rainer 2019). all study instruments had their construct validity established by previous researchers using confirmatory factor analysis and or exploratory factor analysis. ethical approval was granted by the human research ethics committee at university college dublin. no direct access to the contact details of registered general nurses was available and all sampling procedures were undertaken by nmbi with distribution of letter and questionnaires via a commercial mail and postal company. approval to use the instruments outlined below was obtained from each of the license holders. data was analysed using spss (ibm version 24.0). of the 882 questionnaires returned, 14.5% (128) were returned blank or partially completed and therefore excluded from analysis. a total of 754 completed questionnaires were returned giving a response rate of 50.26%. descriptive statistics were used to describe respondents' demographics and the prevalence of stress, job satisfaction, organisational commitment and intention to stay in nursing. the pearson correlation coefficient was used to measure the strength of the relationships between job satisfaction, organisational commitment, burnout and itsn. scatterplots to identify any outliers which could have biased the correlation coefficient results were plotted. one-way analysis of variance was used to compare mean smbm, mmss, ocq and nri scores by marital status ,nationality, health setting and age groups with a tukey post hoc test used for pairwise comparisons. independent sample t-tests were used to compare mean ocq,smbm, mmss and nri scores between those who had dependent children and those who did not and for those who worked fulltime and those who did not. multiple linear regression was used to analyse the linear combination of predictors that best explained why nurses stay in nursing while steps were taken to ensure no violations of the assumptions of normality, linearity, multicollinearity and homoscedasticity. of note, the global measure of job satisfaction was reduced to six of the mmss subscales for the regression analysis because the two excluded subscales (balance of family and work and professional opportunities) had a high frequency of non-responses. a previous paper also reported this finding (tourangeau, mcgillis hall et al. 2006 ). all the tests conducted for the correlational and regression analysis were two-tailed. the majority of the sample were female (96%), between 22 and 50 years (86%) with a mean age of 39.1, irish (72%), married or cohabiting (74%) with three or less children (56%) and with a bachelor or higher education degree (60%). unpaid regular help was provided to a relative, friend or neighbour by a fifth of the sample (21%, n=144). the respondents' employment profile showed that they were mostly working in fulltime employment (75%), at staff nurse grade (75%) in a public hospital (56%), had never interrupted their employment (63%) and were on average 15 years (sd=8.9) since first registration. the standard error of the sample was calculated as .35 indicating that this sample was likely to be an accurate reflection of the population of rgns on the active register of nurses at the time of data collection. however, the most recent reported nmbi population in 2016 presents an altered picture with particular reference to nationality and age (table 3) . a strong intention to stay in nursing with an overall mean score of 39.2 for the nri was reported by a significant majority of respondents in this study. job satisfaction, burnout and organisational commitment had weak to moderate correlations with intention to stay. however, while organisational commitment had a moderate positive correlation with itsn (r=0.46, p<0.01, n=704) , it had a stronger correlation with job satisfaction (r=0.59, p<0.01, n=704) ( attitudinal characteristics within the sample were compared across different groups in order to gather a deeper understanding. while the majority of the significant results from this analysis yielded small effect sizes, a number were remarkable (table 5) . respondents who were married and those who had dependent children had the strongest organisational commitment, job satisfaction and itsn and had the weakest burnout levels. the differences within nationalities revealed that non-eu respondents were the most satisfied, had the lowest burnout levels and had the strongest organisational commitment and itsn in comparison to other eu and irish respondents. furthermore, irish respondents had the weakest scores for itsn. the 36-50 year age group had the strongest intention to stay and organisational commitment compared to the 22-35 and the 51-65 year age groups. those working part-time had a stronger intention to stay and organisational commitment than those working fulltime while respondents working in nursing homes or hospices had the strongest intention to stay, organisational commitment, job satisfaction and lowest stress/burnout levels in comparison to those respondents working in tertiary hospitals or in the community. significance at the level of p<.05 multiple regression analysis was used to identify the best predictor of rgns' itsn. initially guided by the conceptual framework of itsn, variables that displayed a significant relationship with itsn in bivariate analysis were entered into the regression models and the results are presented in table 6 . initially, eight predictor variables including four demographic predictor variables (marital status, nationality, worked fulltime, had dependent children) were entered simultaneously into the linear regression model. the final model indicated that four of the 8 predictor variables explained 27% of the variance in itsn. specifically, organisational commitment was the strongest predictor of itsn (β=.32,p=.000) followed by stress/burnout (β=-.26,p=.000), job satisfaction (β=.030,p=.618) and working partime(β=.056,p=.227). these results indicate that itsn is complex and there are further predictors that might explain itsn. in addition, it is evident that organisational commitment is a stronger factor than job satisfaction in staying in nursing throughout a career lifespan. this paper reports on a component of a larger study that explored nurses' intention to stay in nursing throughout their career lifespan. informed by a conceptual framework of intention to stay in nursing (itsn), level 3 factors including job satisfaction, stress/burnout and organisational commitment were investigated on general nurses working throughout the health services in the republic of ireland (roi). this study sought to determine how these factors work together to influence nurses' itsn and to gather an insight at one point in time of nurses working in many different areas throughout the country. the analyses reported is supportive overall of the framework of itsn. in the analyses, the majority of respondents (70%,n=515) had a strong intention to stay in nursing throughout their career lifespan while the strongest predictor of itsn was organisational commitment. these results indicate that regardless of where they were working, there is an imperative to stay in the profession that overrides the particular nursing job despite many obstacles. the results also indicate that commitment to the organisation is more important than specific feelings or satisfaction about the job in order for respondents to stay in nursing throughout a career lifespan. the implication of these results is that respondents have a belief in the organisation's goals and values and want to work for the organisation as well as being ambitious to remain working for that organisation. it is evident therefore that the organisations in which the respondents work meet whatever expectations respondents have. additional results from this study provide an explanation as to why respondents have such a degree of commitment to their organisations and concur with the level 3 factors in the framework of itsn. given that respondents were most satisfied with their nursing peers, had low burnout levels while the most satisfying practice environment were those with supportive co-workers, facilitative scheduling and good effective social interaction supports the premise that their work organisations were meeting their expectations. there is considerable previous literature that concurs with these results. for example satisfaction with social interaction with colleagues (brunetto, xerri et al. 2013 can increase the successful retention of nurses (flynn and mccarthy 2008, ahlstedt, eriksson lindvall et al. 2019) while if employees perceive that their work colleagues to be supportive and cohesive, there is less criticism of the organisation as a whole (ingersoll, olsan et al. 2002 , garavan and mccarthy 2008 , cowden, cummings et al. 2011 ) and can buffer the development of burnout in the practice environment (shirom 2009 , chan, tam et al. 2013 , chen, li et al. 2020 , li, zhang et al. 2020 ) . the level of satisfaction with scheduling reported here is consistent with a european study which included nurses working in irish hospitals (leineweber, chungkham et al. 2016) . there is also evidence that work settings which provide predictable yet flexible work scheduling for nurses can reduce sick leave, increase job satisfaction, be a good place to work as well as attract and retain nurses (mcclure, poulin et al. 1983 , tourangeau, cummings et al. 2010 , garde, albertsen et al. 2012 . inflexible work schedules, by contrast, have been found to affect nurses' decisions to leave (huntington, gilmour et al. 2011) to adversely affect decisions to stay or to return to nursing (sjogren, fochsen et al. 2005) or to increase intention to leave in young nurses (flinkman, laine et al. 2008 ) providing additional evidence to support this study's results. the results of how the level 3 and 4 factors relate to each other are indicative of the role that family responsibilities play in explaining how 70% of respondents had a strong level of itsn. comparison of differences of itsn between some of the demographic groups in this study also strongly indicate that it is where respondents are at in their lifespan that dictates where and how they work yet stay in nursing working within the health services. those who were married or co-habiting with dependent children, working part-time within the 36-50 year old age group, working in nursing homes/hospices and are non-eu had the strongest itsn. previous studies reported lower or equivalent levels of intention to stay using samples of nurses working in acute hospitals only (flinkman, laine et al. 2008 , sabanciogullari and dogan 2015 , van bogaert, peremans et al. 2017 , lo, chien et al. 2018 ) while demographics such as marital status (toren, zelker et al. 2012 , satoh, watanabe et al. 2018 ) and having dependent children table 3 . disrespect for nurses, staff shortages and lack of patient safety were cited as the primary reasons to leave nursing in ireland and to emigrate (humphries, mc aleese et al. 2015) . however, in response to a national call during the 2020 covid 19 pandemic, 1,169 nurses returned to ireland or returned to nursing (nursing midwifery board of ireland 2020) demonstrating a willingness to do the right thing by rising to that challenge and wanting to make a difference. the continued relevancy of the results of this study is evident even during the 2020 pandemic. the covid-19 pandemic has exposed the challenges that have been continually faced by nurses trying to stay in nursing regarding scheduling and the adequate provision of childcare. in ireland the closure of creches, child care facilities and schools along with the directive not to require grandparents, particularly those aged 65 years or older to care for children is posing major challenges for the irish government to address (wall 2020) . in the uk, the government have tried to facilitate essential workers, including nurses during this covid-19 crisis by attempting to provide childcare and retain school openings for those workers (langfitt 2020) . other challenges include the physical and psychological impact of working throughout the pandemic, the risk to their lives and to their families of getting the virus as well as whether there is adequate ppe to protect them (fernandez, lord et al. 2020 ). however, while such a crisis can be seen as fostering professional collegiality and group cohesion, organisations need to be mindful and seen to be supporting their nurses during and after the impact of this pandemic in order to prevent burnout and nurses leaving the profession. this study had many strengths; however, a number of limitations were identified regarding design, sampling, and instrumentation. the non-experimental correlational design used in this study cannot prove causation therefore the possibility of an alternative explanation for registered general nurses' itsn cannot be excluded. however, this study built on findings from previous research by identifying independent variables which were related to and were predictive of intention to stay and that were representative of the study population. despite a useable response rate of 50% cent, 40% did not respond. the possibility of sampling bias and sampling error is acknowledged. however, sampling problems were reduced due to the sampling strategy adopted and the limited eligibility criteria for inclusion which was decided following pilot testing. in addition, the sample was representative of the population of nurses in ireland. four internationally validated and reliable instruments were used together for the first time and extensive pre-testing was conducted to improve the validity on an irish nurse population. it is acknowledged that similar results may not be obtained from a sample of nurses working in countries other than ireland. it is clear from this study that organisational commitment and low burnout were the key concepts that enable nurses to stay in nursing. there is general consensus that retaining nurses wherever they work be it in primary, secondary or tertiary healthcare organisations is essential for the continued delivery of seamless healthcare. organisations need to be cognisant of these results and strive to facilitate staff to maintain a reasonable work/life balance by being open and flexible. while the results from this study provide a comprehensive picture of nurses' intention to stay, it is also evident that further research is required. longitudinal designs that will follow the career path of nurses over 15 years would address a gap in the understanding of intention to stay. in particular, investigating nurses' career decision making processes from completing their undergraduate degree to the career choices they make and why they choose to move from one position to another is necessary. the results from this study confirm that the factors that contribute to itsn are not linear. the majority of respondents had a strong intention to stay in nursing throughout their career lifespan indicative of a group of people who really want to stay in the profession. in addition, organisational commitment was the strongest predictor of itsn highlighting that this concept may be mitigating against weathering the storm of job dissatisfaction. while the vast majority work throughout the public sector, less than half the respondents in this study were working in areas other than acute hospitals indicating that nurses must make career decisions to work in different areas to stay in nursing. it is acknowledged that a lot is known about itsn, particularly in recent years with the predominant research focus being quite rightly on the number of nurses and the ratios of nurses to patients, yet there is limited in-depth evidence about how and why nurses move jobs/roles throughout their careers in order to stay in nursing. in particular, longitudinal research is needed to track how and why nurses move between the multitude of healthcare settings throughout their career be it from public to private, from hospital to community, from hospital to nursing home, from hospice to community, from ward to unit, from ward to specialist role. given the global nursing response to the 2020 pandemic, now more than ever in the year of the nurse and midwife, there is an opportunity to enable more nurses to stay in nursing through noticeable strategic policy, investment and research. no conflict of interest has been declared by the authors author contributions what makes registered nurses remain in work? an ethnographic study nurse staffing and education and 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science of nurse work environments in the united states: a systematic review what do our respondents think we're asking? using cognitive interviewing to improve medical education surveys factors affecting nurses' job satisfaction in rural and urban acute care settings: a prisma systematic review retaining nurses in their employing hospitals and in the profession: effects of job preference, unpaid overtime, importance of earnings and stress all authors have agreed on the final version and meet at least one of the following criteria [recommended by the icmje (http://www.icmje.org/recommendations/)]: substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data;  drafting the article or revising it critically for important intellectual content key: cord-321584-4bu0lps0 authors: mitchell, brett g.; russo, philip l.; kiernan, martin; curryer, cassie title: nurses' and midwives’ cleaning knowledge, attitudes and practices: an australian study date: 2020-09-30 journal: infect dis health doi: 10.1016/j.idh.2020.09.002 sha: doc_id: 321584 cord_uid: 4bu0lps0 background: as frontline providers of care, nurses and midwives play a critical role in controlling infections such as covid-19, influenza, multi-drug resistant organisms and health care associated infections. improved cleaning can reduce the incidence of infection and is cost effective but relies on healthcare personnel to correctly apply cleaning measures. as nurses and midwives have the most contact with patients and as an important first step in improving compliance, this study sought to explore nurses' and midwives’ knowledge on the role of the environment in infection prevention and control and identify challenges in maintaining clean patient environments. methods: cross-sectional online survey of 96 nurses (rn/en) and midwives (rw) employed in clinical settings (e.g. hospital, aged care, medical centre, clinic) in australia. results: nurses and midwives broadly stated that they understood the importance of cleaning. however, cleaning responsibilities varied and there was confusion regarding the application of different disinfectants when cleaning after patients with a suspected or diagnosed infection post-discharge. most would not be confident being placed in a room where a previous patient had a diagnosed infection such as multi-drug resistant organism. conclusion: greater organisational support and improving applied knowledge about infection control procedures is needed. this includes correct use of disinfectants, which disinfectant to use for various situations, and cleaning effectively following discharge of a patient with known infection. the cleanliness of shared medical equipment may also pose current risk due to lack of cleaning. as frontline providers of care, nurses and midwives play a vital role in prevention and control of infections such as covid19, influenza, multi-drug resistant organisms (mdros) and health care associated infections (hcais) more broadly. however, nurses' and midwives' compliance with infection control policies can vary between settings and individual workers [1e3] . subjective indicators such as visible dirt, personal appearance and whether a patient had been identified as being infectious, can inform nurses' decision-making regarding even basic standard precautions such as handwashing [1,3e6] . this reliance on personal judgement rather than consistent application of clinical standards for infection prevention and control could potentially lead to crosscontamination and subsequently, increase rates of infection. experience, organisational structure (including staffing ratios and training), individual knowledge, and personal accountability may also impact on compliance with optimal infection control practice and governance [7e11] . beyond individual factors, the hospital environment has been shown to be a contributing factor in the spread of hcais and mdros [12, 13] . moreover, pathogens can survive for days or months on surfaces that have not been cleaned, posing an ongoing risk for transmission [14] . consequently, there is a higher risk of a patient acquiring a pathogen from the previous room occupant [15, 16] . improved cleaning can reduce the incidence of hcais and is cost effective [12, 17] , but relies on healthcare personnel to correctly and consistently apply cleaning measures. nurses and midwives have the most contact with patients across healthcare settings. therefore, they have a critical role in infection prevention and control. as an important first step in improving compliance and precursor to further work, this study sought to explore: 1. what are enrolled nurses, registered nurses and midwives' knowledge on the role of the environment in the infection prevention control, and 2. what are the barriers and challenges for nurses and midwives to maintaining a clean patient environment? this paper reports findings from a cross-sectional, online survey of nurses and midwives employed in clinical roles. registered nurses (rn), enrolled nurses (en) and registered midwives (rm) who are currently employed in clinical settings in australia. participants were recruited via advertisements placed in written and electronic materials published by professional associations (such as the australian college of nursing and the australian nurses and midwives association), via workplace emails and newsletters, and through social media (facebook, twitter) targeting nurses and midwives. the advertisements provided broad information about the survey, and included an online link to the study information, electronic consent form, and non-identifiable survey. ten $20 gift cards were randomly allocated as a participation incentive. participants who were not registered nurses, midwives or enrolled nurses were excluded from the study, in addition to those currently unemployed or not working in clinical roles (e.g. hospital, residential aged care facility, medical centre, or clinic). the survey was open for responses between 1st december 2019 and 13th march 2020; at which time the survey was closed due to dwindling response rates. interested participants accessed the online link as provided in the study invitation. screening questions were used to exclude individuals who did not meet criteria for eligibility. eligible participants then completed an online consent form before gaining access to the survey. descriptive and exploratory analysis of survey results was performed. qualitative (free-text) responses to open-ended questions were collated and each response read individually. qualitative analysis (constant comparison, frequency counts/ranking) was used to identify and group responses into common themes. overview 132 participants accessed the online survey. of these, 28 were subsequently excluded from the survey (n z 19 not currently working in a clinical setting; n z 6 not rn, en or rm; and n z 3 did not provide consent). of the 104 eligible participants, 96 consented to participate and commenced the survey, representing our sample size. 79 participants completed the full survey. the use of ip address cross referenced against demographic information suggested there were no repeat responses from the same individual. participant demographic data is presented in table 1 . there was representation across all age groups, with diversity in the highest qualification obtained, the length of time at their current employer and the jurisdiction in which they worked. most participants worked in a hospital setting. importance of cleaning participants were asked to nominate the most important reasons for cleaning the environment in healthcare settings. seventy-four (94%) participants indicated that the main reason for cleaning was to reduce the risk of infection transmission. healthcare accreditation was found to be the least important reason for cleaning (n z 35, 44%). we asked participants to indicate who was responsible for cleaning four items, two frequently touched items (bed rails and nurse call bells) and two items of shared medical equipment (iv pole and iv pump). the majority of participants indicated that nursing/midwifery staff were responsible for cleaning the iv pole (73%, n z 58) and pump (79%, n z 62). there was less certainty about who was responsible for cleaning bed rails and nurse call bells. fortypercent (40%, n z 32) indicated it was a nursing/midwifery responsibility. ten percent of participants did not know who was responsible for cleaning shared medical equipment (iv pole and pump). participants were asked to nominate what method or product they would use to clean in various situations. results are presented in table 2 . using a likert scale, participants were asked to indicate how much they agreed with four statements relating to the use and application of disinfectant products in clinical settings (fig. 1) . while the effectiveness on patient safety was well understood, there was less certainty about disinfectants and their use. participants were shown four visual representations of how to clean a surface, using different directional movements such as circular, up and down, one-directional or sshaped (serpentine). of those that answered, 61% (n z 48) correctly identified the best way to clean a surface (i.e., answer z c, serpentine). regarding cleaning of shared medical equipment such as a blood pressure cuff, a small number reported 'probably don't clean' (14%, n z 11) this equipment. the majority (81%, n z 64) reported using wipes to clean shared medical equipment (supplementary material, table s1 ). participants were shown pictures of three patient hospital rooms (fig. 2) . room a showed a patient lying present in the bed with various equipment. room b appeared to be empty, with the bed looking slightly rumpled. room c showed a patient lying in bed and was less cluttered in appearance than room a. participants were then asked to nominate which room presented the lowest risk of infection (a, b, c, or 'don't know'). the majority chose room a, a cluttered room occupied by a patient. using a free text option, participants were asked what one item/piece of equipment they thought posed the greatest risk of infection transmission from the environment. the most common responses were hospital furniture the themes from participants around barriers to cleaning effectively were a lack of information and training, resources (cleaning products and equipment), lack of dedicated cleaning staff, and organisational structures. the free-text survey comments (supplementary material, sq1-2) stressed the need for more readily accessible information including simple wall charts with information about which product to use and where and improved labelling on wipes and cleaning agents. more education was needed about which products were recommended for patients presenting with infections such as c. difficile or multi-drug resistant organism (mdro). product useability was important, with single-use disinfectant wipes preferred, especially where staff experienced competing time pressures. a lack of policies and guidelines to inform infection control practices and lack of clear role definitions and staff accountability were also identified. in contrast to most comments, seven participants perceived that 'nothing' impacted their ability to clean equipment between patients, i.e., cleaning always occurred even when staff were pressed for time. most participants reported having received information about cleaning importance, correct product usage and availability. twenty-three percent (n z 18) had received information within last 3 months, 19% (n z 15) in the previous 3e12 months and 15% (n z 12) reported having received information in the last 1e3 years. however, 32% (n z 25) either 'do not recall' or have 'never' received any information about the importance of cleaning, product availability in their organisation, nor how to correctly apply products for infection control purposes. the majority of training received (25%, n z 20) was provided by an infection control team (table s2) . additionally, using a likert scale, participants were asked to indicate level of agreement with four statements regarding cleaning effectiveness (table s3) . despite the majority indicating confidence in their cleaning ability (usually 46%, n z 36; always 23%, n z 18), most did not feel comfortable being admitted to a room where the previous patient had a multi-drug resistant organism (never 42%, n z 33; only sometimes 34%, n z 18). it is well accepted that the clinical environment plays a role in the transmission of infections such as multi-drug resistant organisms (mdros) and healthcare associated infections (hcais) [2,7,8,12,14,15,17e20] . ineffective cleaning practices by nursing and midwifery staff may also contribute to a high pathogen-load being present within hospital settings [15, 19, 21] . as an important first step to improving environmental hygiene, this study found that nurses and midwives broadly stated that they understood the importance of cleaning, albeit, there is variation in cleaning responsibilities. moreover, cleaning of shared medical equipment may pose current risk in terms of lack of cleaning. in keeping with aiken et al. [22] , this study found that nursing and midwifery staff play a key role in cleaning duties as part of their working role. however, our findings suggest there was ambiguity about who was responsible for cleaning patient areas or certain items (such as iv pumps). there was also less certainty regarding how or when to use disinfectants and about the effectiveness of disinfectants on different groups of micro-organisms. these findings could be a result of any number of factors, including appropriateness of the product, lack of product information or of education. the implications of inappropriate product use may result in ineffective cleaning, thus increasing the risk of hcais. there are also health and safety implications for disinfectant use. in terms of the process of cleaning, 39% (n z 31) of participants did not identify the correct way to clean (wipe) a surface (i.e. s-shaped or serpentine). therefore, this finding, coupled with a lack of understanding about product (disinfectant) choice, will result in less effective cleaning and increase transmission risks. as pathogens can survive on uncleaned or inappropriately cleaned surfaces for long periods of time, it is vital that shared medical equipment is consistently and correctly cleaned to reduce the risk of hcais. genomic analyses by lee et al. [23] of vre transmission pathways within an intensive care unit identified the key role shared medical equipment has in icu. factors for suboptimal cleaning of shared equipment may include insufficient stocks of equipment to allow for cleaning and rotation between patients, lack of product at the point of use and perceived lack of time [1, 7, 19] . understanding reasons for this are important and we will be following this up in future work. survey participants called for more easily accessible information about the different types of cleaning products and what they were used for, greater accessibility to products, greater clarity around cleaning roles and who was responsible for maintaining particular items or patient areas, as well as increased accountability on the behalf of staff and hospital management. factors that may influence a decision for cleaning to take a secondary role include the perception of infection risk from the environment versus other competing patient care requirements, as well as understanding cleaning responsibilities. when we asked participants to identify which room posed the highest infection risk, the majority of participants chose the most cluttered room. this indicates good understanding among respondents that cluttered environments can hamper cleaning. however, the correct answer was 'don't know', i.e., while this room may reflect challenges undertaking cleaning, it does not necessarily relate to risk. pathogens are invisible to the naked eye and any of the rooms may pose an infection risk [15] . factors influencing risk would include the type of infection or pathogen from an unknown but colonised patient, as well as the effectiveness of cleaning. none of the provided images illustrated this. the subjectivity of choosing a room which is cluttered is consistent with other work, which found that compliance with even basic infection protocols such as handwashing and wearing gloves was individually and subjectively based [3e5] . variations in product use and cleaning practices [21, 24, 25] , information transfer and communication pathways [26e28], and organisational culture [20] , can all influence cleaning outcomes. improving staff knowledge around product use, communication, training, audit and utilising an implementation framework have been shown to improve cleaning outcomes, reduce risks for patients and are costeffective [12, 17, 29] . in our study, most participants (68%, n z 54) indicated that they had received information about the importance of cleaning, the types of products available in their organisation and product application. however, 11% (n z 9) had last received that information more than 3 years prior and a further 32% (n z 25) did not recall or had never received any cleaning information. another key theme emerging from survey comments was the lack of simple information about particular cleaning products. participants called for easy instructions to support correct product usage and application. these findings suggest the need for improved and structured education of nurses and midwives around cleaning on a regular basis, as well as improved communication. education could be provided in any number of ways, including from nurse educators, online platforms or from representatives from industry supplying products and equipment. of course, nurses are only one professional group in healthcare. shared medical equipment is also used by medical and allied health. potentially the same issues exist in these professional groups regarding knowledge of cleaning and responsibilities around who cleans equipment they use. this study is limited by the use of a cross-sectional study design and the accuracy of self-report responses provided. the vast majority of surveys were undertaken prior to the covid-19 pandemic taking hold in australia, so biases associated with this are expected to be limited. the sample size, while not large is a further limitation. nonetheless, this study provides a useful snapshot of nurses' and midwives' knowledge of infection control and cleaning processes, something that to our knowledge has not been undertaken before. we identified gaps in training and knowledge, as well as unclear responsibilities for cleaning certain objects. these findings can be used to inform workforce education and planning and hospital cleaning policies. similarly, the findings lay the foundation for future research exploring solutions to try and improve the cleaning of shared medical equipment. greater organisational support, clear policies detailing cleaning responsibility, and improving the applied knowledge and personal efficacy of nurses and midwives regarding infection prevention and control is needed. this includes the correct use of disinfectants, which disinfectant to use for various situations, and how to clean effectively following discharge of a patient with a suspected or known infection. the cleanliness of shared medical equipment may also pose current risk due to lack of cleaning. ethics approval for this study was granted by [blinded for review]. factors influencing nurses' compliance with standard precautions in order to avoid occupational exposure to microorganisms: a focus group study comprehensive systematic review of healthcare workers' perceptions of risk and use of coping strategies towards emerging respiratory infectious diseases why healthcare workers don't wash their hands: a behavioral explanation infection prevention and control: who is the judge, you or the guidelines? dirt and disgust as key drivers in nurses' infection control behaviours: an interpretative, qualitative study infection prevention as "a show": a qualitative study of nurses' infection prevention behaviours evaluation of infection prevention and control policies, procedures, and practices: an ethnographic study hospital staffing and health careeassociated infections: a systematic review of the literature resourcing hospital infection prevention and control units in australia: a discussion paper staff perceptions of the sources and control of meticillin-resistant staphylococcus aureus exploring the context for effective clinical governance in infection control an environmental cleaning bundle and health-careassociated infections in hospitals (reach): a multicentre, randomised trial beware biofilm! dry biofilms containing bacterial pathogens on multiple healthcare surfaces; a multi-centre study the role of environmental cleaning in the control of hospital-acquired infection risk of organism acquisition from prior room occupants: a systematic review and meta-analysis prior room occupancy increases risk of methicillin-resistant staphylococcus aureus acquisition cost-effectiveness of an environmental cleaning bundle for reducing healthcare-associated infections where does infection control fit into a hospital management structure? why do nurses miss infection control activities? a qualitative study hospital organisation, management, and structure for prevention of health-care-associated infection: a systematic review and expert consensus variation in hospital cleaning practice and process in australian hospitals: a structured mapping exercise nurses' reports on hospital care in five countries defining the role of the environment in the emergence and persistence of vana vancomycin-resistant enterococcus (vre) in an intensive care unit: a molecular epidemiological study cleaning the grey zones of hospitals: a prospective, crossover, interventional study variations in hospital daily cleaning practices translating infection control guidelines into practice: implementation process within a health care institution communication interventions to improve adherence to infection control precautions: a randomised crossover trial exploring performance obstacles of intensive care nurses effectiveness of a structured, framework-based approach to implementation: the researching effective approaches to cleaning in hospitals (reach) trial thank you to the participants in this survey. supplementary data to this article can be found online at https://doi.org/10.1016/j.idh.2020.09.002. bm, mk and pr designed the project. bm is the chief investigator for the project. bm and cc drafted the paper. all authors provided critical input into the paper. all authors approved the manuscript. two of the authors (bm and plr) are editorial board members with the journal. all authors were blinded to this submission in the journal's electronic editorial management system and none of the authors played any editorial role in handling this paper whatsoever. one author (mk) has paid employment from a company which sells cleaning products, as well as university appointments. no company played no any role in the design, analysis, interpretation or presentation of this paper. in kind support is provided by the higher education institutions with which the chief investigators are affiliated. plr is supported by national health and medical research council early career fellowships app1156312. not commissioned; externally peer reviewed. key: cord-286889-l765mxmy authors: stangeland, paula a. title: disaster nursing: a retrospective review date: 2010-12-31 journal: critical care nursing clinics of north america doi: 10.1016/j.ccell.2010.09.003 sha: doc_id: 286889 cord_uid: l765mxmy this article presents a review of the literature related to disaster preparedness and nursing. a definition of disaster as set forth by the american red cross is provided. eight themes, including (1) defining disaster, (2) nursing during and after disaster, (3) nursing education in disaster preparedness, (4) military nurse preparedness, (5) postdisaster stress, (6) ethical issues and intent to respond, (7) policy, and (8) hospital emergency policy, were derived from the review and are explored in this article. although a plethora of disaster-related literature exists, the voice of the nurses who worked during these disasters is missing. areas of proposed research illuminated by current research are suggested. cinahl, medline (ovid), pubmed, and psycinfo. in 1974, the robert t. stafford disaster relief act was signed into law, establishing the process by which presidents could declare disasters in states overwhelmed by catastrophic events. therefore, the literature review was limited to the past 36 years. keywords entered into the databases were nursing, disaster, hurricane, posttraumatic stress, and preparedness. the search revealed a vast amount of disaster-related literature, which was categorized into 8 thematic sections: (a) defining disaster, (b) nursing during and after disaster, (c) nursing education in disaster preparedness, (d) military nurse preparedness, (e) postdisaster stress, (f) ethical issues and intent to respond, (g) policy, and (h) hospital emergency policy. the association between disasters and human existence is indisputable, hence many definitions for disaster are found in the literature. a comprehensive definition for disaster is difficult to locate in the literature-most definitions are either too broad or too narrow, and many organizations have created their own definitions for the term. for the purpose of this review, the definition of the term that was deemed most appropriate was that used by the american red cross (arc), which defines disaster as: a threatening or occurring event of such destructive magnitude and force as to dislocate people, separate family members, damage or destroy homes, and injure or kill people. a disaster produces a range and level of immediate suffering and basic human needs that cannot be promptly or adequately addressed by the affected people, and impedes them from initiating and proceeding with their recovery efforts. natural disasters include floods, tornadoes, hurricanes, typhoons, winter storms, tsunamis, hail storms, wildfires, windstorms, epidemics, and earthquakes. human-caused disasters-whether intentional or unintentional-include residential fires, building collapses, transportation accidents, hazardous materials releases, explosions, and domestic acts of terrorism. 7 common to all definitions of disaster is the characteristic that disasters are destructive events that more often than not require assistance from outside the community. researchers report that nurses are one of the largest groups of emergency responders during a disaster and are at risk for psychosocial problems that may need interventions to help them cope with exposure to disasters. 8, 9 in the immediate aftermath of a disaster, the effects can be overwhelming to nurses working in the area, as there is a great deal of chaos and confusion that nurses must contend with and overcome. 8, [10] [11] [12] studies indicate disaster emergencies create an atmosphere of pandemonium and uncertainty and that nurses perceive they have been or will be abandoned by leadership. 8, 10, 12, 13 feelings of abandonment by management and a lack of communication play a major role in the decision-making processes of nurses and other hcps when deciding to work during a disaster. [13] [14] [15] nurses state that they feel disaster plans are made by leaders or managers without input from the nurses who will actually be working and taking care of patients during and after the disaster. 8 , 12 giarratano and colleagues 8 conducted an interpretive phenomenological study based on van manen's "lived experience" philosophy. the sample included 16 perinatal nurses who worked during hurricane katrina. the purpose of the study was to stangeland make explicit the perinatal nurses' shared meanings of their lived experience of providing care in new orleans during hurricane katrina. major themes that emerged from the study include (a) duty to care, (b) conflicts in duty, (c) uncertain times, (d) strength to endure, (e) grief, (f) anger, and (g) feeling right again. findings demonstrated that nurses who work during disasters must live through the uncertainty of the situation and be prepared to adapt to the needs that arise in both patient care and self-preservation situations. this study revealed that primary resources needed by nurses while working during a disaster include excellent basic nursing skills, intuitive problem solving, and a sense of staff unity. researchers noted that the nurses exhibited a wide range of problems related to stress. these problems included changed sleep patterns, change in mood, eating problems, substance abuse, and avoidance behaviors. at the same time, it was recognized that the nurse participants practiced in harmony with duty to care values and demonstrated behaviors of strength, courage, and resilience. 8 o'boyle and colleagues 13 completed a qualitative study with a purposive sample of 33 nurses who participated in focus groups ranging from 2 to 9 participants in each group. the sample of nurses was recruited from 3 midwest hospitals that were designated as receiving sites for evacuees. the purpose of the study was to identify beliefs and concerns of nurses who worked in hospitals designated as receiving sites during public health emergencies. abandonment was the major theme that emerged from the focus group interviews. this theme was supported by subthemes including: chaos, unsafe environment, loss of freedom, and limited institutional commitment. nurses felt that policies were not well thought out, and that they were left out of the communication loop. in addition, the nurses stated that they did not receive any preparedness training to handle bioterrorist events. 13 nurses believed that in the event of a bioterrorist attack, there would be a disruption in normal staffing resources. aware that nurse staffing under normal conditions is at times already strained, the nurses feared that they would not be free to leave the workplace. therefore, these researchers reported that the participants in the study believed that a shortage of nursing staff would be indirectly related to nurses who refused to work during a disaster. a limitation of this study is the small number of participants in some of the focus groups, which might have limited the discussions. a qualitative descriptive study completed by broussard and colleagues 10 explored school nurses' feelings and experiences working in the aftermath of hurricanes katrina and rita. the sample consisted of 41 female school nurses from across the state of louisiana who attended an annual school nurse conference held in march 2006. nurse participants had an average age 48 years. researchers reported that the participants were from all areas of louisiana, including areas that were not in the path of either hurricane. participants were asked one question: "please share your experiences and feelings about hurricanes katrina and/or rita". 10 in addition to the qualitative question, demographic data were collected that included: (a) age, (b) years of experience as a school nurse, (c) gender, (d) support systems loss or damage to home and vehicle, (e) damage to school, and (f) change in work assignment as a result of the storm. data analysis was not described; however, findings were categorized into 2 major themes: personal impact and professional impact. personal impact included 3 subthemes: (a) uncertainty, (b) helplessness, and (c) thankfulness. professional impact included 2 themes: practice challenges and practice rewards. the participants portrayed a wide array of emotions and feelings that were similar to previous studies. researchers recommended that all school nurses would benefit from having both formal and informal support systems and mental health services available to them in the aftermath of future hurricanes. 10 identifying the philosophic disaster nursing underpinnings as well as the method for data analysis and rigor would have strengthened the validity of this study. although some nurses identified their experiences of working during and in the aftermath of hurricane katrina and other health emergencies as rewarding, they also identified planning and education as critical needs for providing care in future disasters. 3, [9] [10] [11] hughes and colleagues 9 report that nurses believe that they need to be involved at the onset of the emergency planning process. during emergencies, nurses stated that they used their most basic skills and teamwork when providing patient care, but recognized that further education is necessary to enhance their knowledge prior to future events. 3, 8, 11 according to the international nursing coalition for mass casualty education (incmce), every nurse must have sufficient knowledge and skill to recognize the potential for a mass casualty incident. 16 in addition, the incmce states that every nurse must be able to identify when a mass casualty event may have occurred, know how to protect oneself, know how to provide immediate care for those individuals involved, and be able to recognize their own role and limitations during such a disaster. the incmce also recommends that nurses know where to seek additional educational information and how to access resources. 16 the position of the american nurses association (ana) related to practice during disaster is that all nurses are individually accountable for their actions and should practice according to their code of ethics. 17, 18 despite that the ana acknowledges that working during disasters places nurses in unusual situations and conditions, the organization's code of ethics defines and directs the responsibilities of all practicing nurses regardless of the situation or setting. however, in the 2010 draft of the scope and standards of practice, the ana recognizes that these standards may change during times of disaster. 19 the essentials of baccalaureate education for professional nursing practice was created by the american association of colleges of nursing (aacn). 20 this document provides guidelines for baccalaureate-level nursing schools to prepare students for disaster response. the aacn mandates that the baccalaureate nursing education curriculum contain emergency-preparedness and disaster-response information. 20 specifically, the guidelines state that baccalaureate nursing programs should prepare graduates to use clinical judgment appropriately and provide timely interventions when making decisions and performing nursing care during disasters, mass casualties, and other emergency situations. in addition, nursing students should understand their role and participation in emergency preparedness and disaster response with an awareness of environmental factors and the risks these factors pose to self and patients. 20 it is not known whether the voices of nurses experienced in disaster have informed these essentials of education. educational competencies for associate degree nurses were created by the national league for nurses (nln) with support from the national organization of associate degree nursing. 21 although the document provides core competencies that all associate degree nurses must meet, it does not specifically explicate the responsibilities of associate degree nurses during emergency situations. a particular skill indirectly related to disaster preparedness includes the ability to adapt patient care to changing health care environments. 21 gebbie and qureshi, 22 well-known nurse experts in disaster management, maintain that it is necessary for all nurses to be prepared during disasters. these experts define stangeland the difference between emergency and disaster, and state that disasters disrupt many services and cause unforeseen threats to public health. these researchers further describe disasters as requiring assistance from outside the affected community. gebbie and qureshi, 22 at the request of the centers for disease control and prevention (cdc), developed 14 core emergency preparedness competencies for nurses. although these competencies were developed by nurses; it is not known whether they have been incorporated or implemented in any educational program or facility where nurses work. research has shown that nursing schools may be lacking in the area of preparing students for disaster nursing. 23, 24 jennings-saunders and colleagues 23 completed a descriptive survey study that investigated nursing students' perceptions regarding disaster nursing. one purpose of the study was to propose recommendations to help advance the discipline of nursing and nurse clinicians. a convenience sample of 51 senior nursing students participated. each participant completed the disaster nursing perception questionnaire and the demographic profile form. data were analyzed for meaning and relationships of words using the data analysis technique of morgan and baxter. this study revealed that nursing students do not comprehend what disaster nursing means and why it is important to know what community resources are available during times of disaster. furthermore, the study revealed that it is not known to what extent nursing faculties teach disaster preparedness in nursing programs, even though it is required. weiner and colleagues 24 administered an on-line survey to 2103 united states nursing program deans and nursing program directors to assess the level of disaster preparedness curricula in united states nursing schools. only 348 surveys (17%) were completed and returned. this low response rate was identified as a limitation of the study. baccalaureate and associate degree nursing programs made up more than 77% of the response rate. the study revealed that faculty was inadequately prepared to teach disaster preparedness and that most programs were overly saturated, leaving little room for disaster-preparedness education. a significant finding revealed that united states nursing school program curricula were limited in the area of disaster preparedness. this review of the literature revealed that nursing school governing bodies have developed competencies to be included in the nursing curriculum; however, nursing programs have been identified as still lacking in the area of disaster nursing curriculum. in addition, studies reveal that nursing faculty members are not prepared to teach disaster nursing. education of faculty in the area of disaster preparedness and response is an area that requires added consideration to adequately prepare students for disaster situations that may arise in the students' future careers. military nursing has played a critical role in the history if nursing. including data related to military nursing further enriches this review by addressing a significant area related to disaster and emergency preparation for nurses. nurses' involvement in war-zone care dates back to the crimean war in the 1800s, when florence nightingale cared for injured soldiers and introduced modern nursing during times of war. researchers today posit that nursing during wartime has increased the profession's understanding of caring and responding during disasters. 24 it is recognized today that military nursing is challenged by working in diverse situations. yet, according to recent studies, literature does not adequately describe military disaster nursing. 25 on december 8, 1941 , the united states declared war on japan after the bombing of pearl harbor. trapped in the midst of this war were 99 army and navy nurses who had no combat training. these nurses were caught in the middle of the battle on bataan, a province of the philippines. a few of the nurses escaped by boat but 77 were captured by the japanese and held captive for 3 years in the philippines. these nurses represent the first group of women in the military to be imprisoned by enemy forces. 26 elizabeth norman 26 had the privilege of interviewing 20 of the 77 female nurses and wrote a book titled we band of angels: the untold story of american nurses trapped on bataan by the japanese. norman began her study in 1990 and discovered that only 48 of the nurses were still living. during this study, she also found that most of the nurses had joined the military seeking adventure and romance. the nurses interviewed by norman reported that the philippine islands were paradise until the war broke out and they were captured and held prisoner. norman 26 realized and reported that the nurses always started the conversation with humor but the interview soon found the nurses talking about the painful memories, with a few interviews ending in tears. during the study it was reported that all the nurses had similar accounts of the ordeal of being held captive and that all of the nurses answered the interview questions using "we" instead of "i." these comments led norman to realize that the nurses viewed "unit cohesiveness" as their most important survival tool. 26 baker and colleagues, 27 using a self-report questionnaire, studied the stresses experienced by female nurses in vietnam. a sample of 60 female army nurses was recruited to complete this study. findings revealed that 60% of the participating nurses reported they were poorly prepared by the military to serve in vietnam. also, registered nurses with less than 2 years of clinical experience before going to vietnam were more likely to experience posttraumatic stress syndrome (ptsd) than nurses with more years of experience. the investigators identified the use of a self-report questionnaire as a study limitation, noting that the nurses had to recall events that occurred between 14 to 22 years prior to the study, adding to possible response bias. baker and colleagues concluded that more research in this area is necessary. ravella 28 completed a descriptive study using a voluntary sample of 20 air force nurses in san antonio, texas, who served in vietnam at various times during the vietnam war. this study used in-depth interviews to gain insight into individual nurse perceptions of their wartime experiences, coping skills, and significant events that they remembered. findings revealed that 25% of the participants described symptoms of ptsd. participants also reported crucial survival skills including strong social support, maturity, nursing experience, humor, religion, and relaxation. the most significant events remembered were directly related to patient care situations and threats to survival. these events were reported by 60% of the nurses interviewed. lastly, all of the nurses interviewed reported that their most rewarding professional experience was serving in the vietnam war. 28 using a qualitative design, stanton and colleagues 29 examined and compared experiences of nurses who served during world war ii, the korean war, the vietnam war, and operation desert storm. a sample of 22 nurses who volunteered to participate in the study were interviewed and asked to describe their experiences of serving during wartime. these researchers revealed that military nursing is an experience that is very different from community nursing. the 5 common themes that emerged from the study were: (a) reacting personally to the war experience, (b) living in the military, (c) the meaning of nursing in the military, (d) the social context of war, and (e) images and sensations of war. in 2006 a proposed model for military disaster nursing was developed. 25 this model included actions deemed necessary during the 3 phases of disaster: (a) preparedness, (b) response, and (c) recovery. military nurses possess a wide range of skills and are usually leaders in patient care. according to wynd, 25 future disasters will encompass a wide range of disasters causing diverse mass casualties. wynd also emphasized that more research is necessary to determine whether this proposed model for military disaster nursing will be useful during military as well as civilian disasters. although both can be stressful and traumatic, the literature reviewed revealed that nursing in the military is different from community disaster nursing. because the literature reveals that working during disasters and traumatic situations causes increased stress for nurses, it is necessary to include information related to disorders that have been associated with experiencing traumatic situations. working during disasters can have an immense impact on responders. it has been recognized in the literature that ptsd can develop soon after experiencing a traumatic event. 30 during times of disaster, caregivers and first responders react immediately to address physical injuries. however, these same caregivers have a tendency to react slowly or ignore injuries to themselves that are concealed deep within the consciousness. the national institute of mental health (nimh) defines ptsd as: an anxiety disorder that can develop after exposure to a terrifying event or ordeal in which grave physical harm occurred or was threatened. traumatic events that may trigger ptsd include violent personal assaults, natural or human-caused disasters, accidents, or military combat. 31 according to the nimh, ptsd can start at any time after experiencing a traumatic event. symptoms of ptsd include bad dreams, flashbacks from the traumatic event, feeling like the traumatic incident is happening again, terrifying thoughts that one cannot control, staying away from places and things that are reminders of the event, feeling worried, guilty, or sad, feeling alone, problems sleeping, feeling on edge, angry outbursts, and thoughts of hurting oneself or others. 31, 32 traumatic stress can change lives forever. 33 researchers report that long-term dissociative and ptsd symptoms may occur after natural disasters. 34, 35 in addition; survivors of disaster experience traumatic stress and the sights, sounds, and smells of the disaster are embedded in their minds forever. 33 acute stress disorder (asd) is a condition that has a close relationship to ptsd. researchers have documented that women are at higher risk for developing asd and ptsd than men who have experienced traumatic events. 31, 36 laposa and colleagues 37 completed a secondary data analysis study addressing the correlation between sources of workplace stress and ptsd symptoms. the study sample included 51 emergency department employees located in urban canada. seventythree percent of the participants were identified as nurses. ptsd was assessed using the posttraumatic stress diagnostic scale (pds). stress was measured using the health professionals' stress inventory-revised (hpsi-r). both scales were reported to have a cronbach alpha of .80 or higher, which is adequate for internal consistency. major findings included that 12% of the participants met all of the criteria for ptsd. eighty-two percent of the respondents confirmed they did not attend debriefing sessions provided by the hospital and 100% of the respondents reported they did not receive professional help for stress outside of the workplace. in addition, results revealed that 20% of the participants reported they had considered changing jobs disaster nursing after stressful incidents. researchers concluded that this study supports the need for employers to provide emotional support for workers who have experienced working during disaster or other traumatizing events that may lead to long-term emotional upset. 37 hughes and colleagues 9 completed a review of the literature to describe nursing's contribution to the psychosocial recovery of survivors of emergencies during all stages of disaster preparedness and recovery over a long-term period. the purpose of the integrative review was to provide guidance to nurses who are involved in emergency planning and response during the acute phase of an emergency. a second objective of the study was to inform nurses of the psychosocial effects that they may experience as health care providers working during disaster situations. these researchers revealed that nurses may experience stress-related psychosocial consequences that continue well past the disaster. relevant factors that must be taken into account are: (a) level of exposure to the disaster, (b) environmental or working conditions and management practices, (c) nurses' perceptions and individual coping and stress reduction practices, and (d) the amount and type of training and previous experience. hughes and colleagues 9 state that nurses are the largest entity of the emergency response team and need to be included from the beginning of emergency planning. nurse responders must also undergo extensive education on the potential psychosocial symptoms that may be experienced as a result of working during a disaster. when entire communities are affected by disaster, it is not possible to maintain previously normal daily activities. conner and colleagues 30 suggest that identifying persons at risk for ptsd may improve outcomes after exposure to disasters and trauma. in addition, it is recognized that many screening and assessment instruments exist that measure ptsd after disaster; however, the validity of these instruments is unclear and more research is needed to verify their appropriateness. brewin and colleagues 38 state that in order for ptsd screening instruments to be useful, they must be brief, consist of the minimum number of items necessary for accurate identification, and be written in a language that is easy to read. furthermore, the symptoms of ptsd and asd that may be experienced by nurses responding specifically to a major hurricane disaster may be different. thus, one must first explore these perspectives by asking those who actually did respond and work in an affected facility. only then will researchers begin to understand why nurses may elect not to respond during future hurricanes. conflicting issues between family and self, safety, and work obligations often make it difficult for nurses and other hcps to decide to work during a disaster. 12, 39, 40 ethical opinions vary widely regarding decisions to report to duty during times of disaster and other health emergencies. the duty to report to work in health emergencies remains an intense topic of discussion in the health care arena. as unparalleled demands are placed on nurses and other hcps who are called to work during disasters, some believe that the code of ethics for health care workers should specifically define the responsibilities of the hcp. 40 while the american medical association (ama) and the canadian medical association (cma) have addressed the issue of responsibilities of physicians in their code of ethics, some researchers believe that it remains to be determined whether other health care professions will follow the same course of action in addressing the issue of providing care during health emergencies. 40 the ana revised the code of ethics for nurses to include interpretive statements to accommodate nurses' comprehensive role in the health care environment. 17 because nurses are continually confronted with many challenges including unpredictable and complex medical and emergent conditions that affect both individuals and communities, the revised code of ethics addresses some of the more complex ethical obligations of nurses. the ana code of ethics does not explicitly detail the obligation of nurses to report to duty during emergencies; however, it does address nurses' responsibilities to the public. one such responsibility outlined in the ana code of ethics is that nurses have an obligation to "participate in institutional and legislative efforts to promote health and meet national health objectives." 17 in an effort to examine ethical issues that arise during a pandemic disaster, ehrenstein and colleagues 41 completed a quantitative survey design study. surveys were sent to 1898 health care workers (hcws) at a university hospital in regensburg, germany. only 644 surveys were returned and of the 644 returned surveys, 264 of these hcws were nurses. the purpose of the study was to solicit opinions of employees on professional ethics of proper response to pandemic influenza. researchers discovered that 182 (28%) of the 644 hcws surveyed believed that it was professionally acceptable to abandon the workplace to protect themselves and their family during a pandemic. 41 in addition, 77% of the respondents disagreed that hcws should be permanently dismissed for not reporting to work during a pandemic, and 21% of the participants believed that hcws without children should care primarily for the influenza patients. the researchers concluded that hcws would benefit from further education regarding efficacy and availability of medications during a pandemic. it was also recognized that professional ethical guidelines are needed to help hcws fulfill their duties in cases of pandemics. 41 although this study revealed interesting information regarding the hcw's willingness to report to work during a pandemic, the survey used to complete the study was a newly developed instrument, and reliability and validity have not been established. qureshi and colleagues 39 completed a quantitative survey design study using a 23item questionnaire. the sample consisted of 6428 hcp in the new york area. the purpose of this study was to assess the ability and willingness of hcps in new york city to report to work during different types of catastrophic events. this study revealed that 47.9% of the participants reported the most frequent reason for employees' unwillingness to report to duty during a disaster was a fear and concern for the safety of their family and themselves. in addition, 82.5% of participants reported that they were most likely to report to duty in cases of mass casualty. however, 20% of the participants reported that they were not sure of their ability or willingness to report to duty during any catastrophic event. the researchers reported that a majority of the 6428 hcp participants in the new york area said they were least likely to report to duty in the case of severe acute respiratory syndrome (48.4%), radiation (57.3%), chemical terrorism (67.7%), and smallpox (61.1%). a reported limitation to this study is that it was conducted only in new york and cannot be generalized to other populations. 39 using a survey design, balicer and colleagues 3 explored public health workers' perceptions toward working during an influenza pandemic as well as factors that may influence intent to respond if such an event occurred. the survey was sent to 531 employees of 3 major health departments in maryland, with a return of 308 surveys. clinical staff, nurses, physicians, and dentists accounted for 102 of the respondents. data were analyzed using logistic regression to evaluate the association of demographic variables, and attitudes and beliefs with self-described likelihood of reporting to work during a pandemic disaster. the researchers studied the association between attitudes and beliefs related to pandemic preparedness and the self-reported likelihood of reporting to work. of the 308 participants, only 163 (53.8%) stated that they would most likely report to work during a pandemic emergency. forty percent noted that they would be asked by their health department to respond during an influenza pandemic event. balicer and colleagues 3 reported that 66% of all participants perceived themselves to be at risk when performing their duties during a pandemic event. it was concluded that to reduce the perceived personal threat during a pandemic and increase the likelihood of employees responding during influenza pandemics, hcps would benefit from continuing education regarding pandemics. these individuals must be assured that adequate protective equipment and psychological support would be made available to responders. researchers also concluded that if employees are unwilling to respond during an influenza pandemic emergency, this behavior may cause a considerable deficit in national emergency response plans. limitations to this study include the use of a subjective self-report survey and subject recruitment from 3 clinics in maryland, therefore findings cannot be generalized to other populations. lastly, the power of the study was not reported. 3 grimes and mendias 42 completed a descriptive study that examined nurses' intentions to respond to an infectious disease emergency. this study was guided by icek ajzen's theory of planned behavior. a sample of 313 licensed nurses in texas who completed a state board of nursing mandated 2-hour bioterrorism continuing education class were recruited to participate in this study. data were collected using 3 researcher-developed questionnaires. the statistical package for the social sciences (spss) version 16 was used to analyze data. according to the researchers, 292 participants completed all 3 questionnaires. the sample included both registered nurses (98%) and licensed vocational nurses (2%), with the majority being female (87%). only 25% of the nurses who reported that they had a professional duty to respond also had a high intent-to-respond score. this significant finding raises concerns about adequate staffing during times of bioterrorism disasters or infectious disease events. james and colleagues 43 completed a quantitative cross-sectional study with a sample of 291 nurses who worked during hurricane katrina in mississippi. the purpose of this study was to evaluate the impact of hurricane katrina with respect to age on mississippi nurses who worked during hurricane katrina. nurses' ages in this sample ranged from 23 to 73 years. the sample was divided into 2 groups according to age: group 1 was 23 to 45 years old and group 2 was 46 to 73 years old. the researchers reported that there was a significant positive association between nurses aged 43 to 73 years and the development of poststorm depression, anxiety, ptsd, and lower health status when compared with nurses who were 23 to 45 years old. older nurses developed more symptoms of stress-related disorders than the younger nurses. it was concluded that taking into consideration the growing shortage of nurses in the united states, it is important to understand how working during stressful situations affects older nurses, as retention of older nurses is important as a short-term resolution to the nursing shortage. this study used 7 self-report scales to gather data, which can be considered a limitation of the study. self-report questionnaires are an excellent method to gain knowledge about a participant's feelings or beliefs; however, data gathered through self-report relies on the accuracy of the participant's subjective account and may also reveal socially desirable responses. 44 the findings of this study relied solely on self-reported data; hence, the results must be reviewed with caution. individuals as well as whole communities are greatly affected by any type of disaster emergency; whether it is natural or human-made. 9 a study performed by brodie and colleagues 14 reported that there were approximately 21,700 hurricane katrina evacuees from new orleans displaced to houston, texas. following hurricane katrina, the cdc and the louisiana department of health and hospitals reported that there were 7543 nonfatal injuries such as cuts, broken bones, and animal bites secondary to clean-up efforts after hurricane katrina between september 8 and october 14, 2005 . 45 these incidents make it clear that there is an unquestionable need for nurses to understand the importance of their response in times of disaster emergencies. conflicts of duty to family and work are further complicated by reports of nurses who have lost their jobs for not reporting to duty during times of emergency and impending disaster. 12, 39, 46 in addition to conflicts of duty to family and work, there is growing concern among hcps that there is a lack of obligation in the duty of care during emergencies. 40 natural disasters cannot be prevented; however, damage caused by the event may be reduced if advanced action is taken to curtail risk and vulnerability to potentially affected communities. government policies have attempted to address the issue of disaster relief and assistance to communities after large-scale disasters. to better understand disaster-related policy, it is important to review policies that directly impact society as a whole. disasters cause a disruption in government and community functions of affected areas. because of this disruption of functions, congress created and passed the robert t. stafford disaster relief and emergency relief act. this public law authorizes the president of the united states to declare that a state of emergency or a major disaster exists. a stipulation to the president's authority is that the governor of the state(s) affected must request a declaration of disaster to receive assistance. 47 the robert t. stafford disaster relief and emergency assistance act, pl 100-707 was signed into law november 23, 1988 and remains in effect today. this law amended the disaster relief act of 1974 pl-93-288 and constitutes the statutory authority for most federal disaster response activities, especially as they pertain to the federal emergency management agency (fema) and fema programs. although this law has been amended several times throughout the past few years, the primary purpose remains the same: to provide orderly and systematic assistance to local governments in areas of declared disaster so they can provide aid to citizens. 47 during the bush administration, the directives that were used to disseminate presidential decisions on national security matters were designated as national security presidential directives. 48 the united states department of homeland security requires states to assume an all-hazards approach to the development of competencies to prevent, prepare for, respond to, and recover from a broad array of disasters. these laws are designated as homeland security presidential directives, and stipulate continuity requirements for all executive departments and agencies. the laws provide guidance for state, local, territorial, and tribal governments, as well as private sector organizations, to ensure a comprehensive integrated national program that will enhance the credibility of the united states national security position and enable a rapid and effective response to and recovery from national emergencies. 48 homeland security presidential directive 8 establishes policies to strengthen the preparedness of the united states to prevent and respond to all disasters, and establishes mechanisms for improved delivery of preparedness assistance to federal, state, and local entities. nurses' input into these policies is unknown. 49 although hospitals are but one component of health care during disasters, they are critical entities during disaster response. there is a paucity of research in the literature disaster nursing that directly relates to nursing and hospital policy. hospital policy is guided by standards set forth by the joint commission (tjc). 46 the tjc is an independent, notfor-profit organization that completes reviews, and evaluates and accredits hospitals and other health care organizations, basing its decisions on national quality and safety standards. according to tjc, hospital emergency policies should include disaster incidents both human-made and natural that are specific to the organization. types of disasters that should be included in hospital policies are identified by probability and frequency of incidents for the area, and are based on definitions provided by the arc and the disaster relief act of 1974. using an exploratory, descriptive design, french and colleagues 12 investigated the needs and concerns of the nurses who responded during hurricane floyd. the purpose of the study was to determine whether the written plans of 4 hospitals addressed the needs and concerns of the nurses who worked during this disaster. a sample of 30 nurses who worked in the emergency department of the 4 hospitals participated in focus groups to discuss their experiences. findings revealed that hospital policies were inadequate to deal with valid concerns of nurses. according to french and colleagues, 12 nurses' concerns included personal safety, family safety, and provision of basic needs, wages, adequate leadership, and pet care. furthermore, the study reported that family commitment conflicted with professional obligations, resulting in nurses losing their jobs if they were unable to report to work. bartley and colleagues 50 completed an anonymous pre-and postinterventional study to test the hypothesis that an audiovisual presentation of hospital disaster plans would improve the knowledge, confidence, and skill of hospital employees. the sample included a convenience sample of 50 hospital employees that consisted of nurses, physicians, and administrators who would most likely be in a position of authority during a disaster. findings showed a significant increase in the test passrate results from preintervention (18%) to postintervention (50%). in addition, pretest mean scores were higher for emergency room staff (12.1) versus other staff (6.2) in various areas of the hospital. the researchers also reported that there were no significant results in the general perception of preparedness. bartley and colleagues 50 reported that the participants described the exercise as beneficial to themselves and their departments. it was acknowledged that the convenience sampling technique used to complete this study may have added to bias of the study, and that the small sample size resulted in decreased power of the study. this study suggests that simulation exercises can enhance staff knowledge levels related to disaster planning. however, it is recognized by many that more research is needed in the area of hospital disaster preparedness plans and policies. a plethora of information exists in the literature regarding emergencies and disasters. nevertheless, significant gaps in the science related to nurses working during disasters are revealed. few studies have addressed the perspective of nurses and their intent to respond to future disasters. because nurses are invaluable to disaster response efforts, more research is essential to validate current findings and elucidate the needs of nurses who respond to disasters and other health emergencies. there is a paucity of research in the literature describing nurses' lived experiences of working during hurricanes. natural disasters inevitably inflict human suffering, and nurses are expected to respond and provide services during these catastrophic times. lost within this expectation are the experiences and concerns of the nurses who are stangeland called upon and intend to respond to the disaster, and yet are themselves affected by the disaster. understanding the experiences and needs of nurses who decide to respond to the call of duty and work during disasters remains unclear in the literature. research in the area of disaster response intentions by nurses becomes the initial step in understanding the phenomenon of working during a disaster and creating innovative approaches that address working during disasters. disaster policies have been developed and implemented at the international, national, state, local, and hospital level. nevertheless, disasters continue to adversely impact communities and hospitals at all levels causing injuries, death, and destruction of infrastructure. to reduce the impact of disasters, continued research is needed to inform and strengthen future disaster policies. knowledge gained from future research has great potential to inform nursing education, research, and practice, as well as health policy related to the care of individuals and responders before, during, and after disasters. surge capacity-education and training for a qualified workforce bioterrorism and health system preparedness: addressing surge capacity in a mass casualty event local public health perceptions toward responding to an influenza pandemic first steps: a pilot preparedness program for public health nurses. mailman school of public health: center for public health preparedness hospital staffing and surge capacity during a disaster event. research brief disaster nursing and emergency preparedness for chemical, biological, and radiological terrorism and other hazards disaster services connection #182. change in the official definition of "disaster" and the addition of a definition of perinatal nursing in uncertain times: the katrina effect psychosocial response in emergency situations-the nurse's role the impact of hurricane katrina and rita on louisiana school nurses the lived experience of nurses providing care to victims of the 2005 hurricanes a comparison of nurses' needs concerns and hospital disaster plans following florida's hurricane floyd nurses' beliefs about public health emergencies: fear of abandonment experiences of hurricane katrina evacuees in houston shelters: implications for future planning emergency preparedness and professional competency among health care providers during hurricanes katrina and rita: pilot study results international nursing coalition for mass casualty education. educational competencies for registered nurses responding to mass casualty incidents american nurses association. code of ethics for nurses with interpretive statements american nurses association. ana comments on nursing care available at. http:// nursingworld.org/documentvault/nursingpractice/draft-nursing-scope-standards-2nd american association of colleges of nursing. the essentials of baccalaureate education national league for nursing -council of associate degree nursing competencies task force. educational competencies for graduates of associate degree nursing programs a historical challenge: nurses and emergencies nursing student's perceptions about disaster nursing emergency preparedness curriculum in nursing schools in the united states proposed model for military disaster nursing we band of angels: the untold story of american nurses trapped on bataan by the japanese the military nurse experience in vietnam: stress and impact air force flight nurses' adaptation to service in vietnam shared experiences and meaning of military nurse veterans practical assessment and evaluation of mental health problems following mass disaster national institute of mental health what is post traumatic stress disorder? united states department of veterans affairs. national center for ptsd: advancing science and promoting understanding of traumatic stress acute traumatic stress management: addressing emergent psychological needs during traumatic events dissociative reactions to the san francisco bay area earthquake of 1989 predictors of posttraumatic stress symptoms among survivors of the oakland/berkeley, california firestorm sex differences in posttraumatic stress disorder work stress and post-traumatic stress disorder in the emergency department brief screening instrument for post-traumatic stress disorder health care workers' ability and willingness to report to duty during catastrophic disasters on pandemic and the duty to care: whose duty? who cares influenza pandemic and professional duty: family or patients first? a survey of hospital employees nurses' intentions to respond to bioterrorism and other infectious disease emergencies the impact of hurricane katrina on older adult nurses: an assessment of quality of life and psychological distress in the aftermath nursing research: principles and methods nonfatal injuries following hurricane katrina-new orleans louisiana the joint commission emergency management homeland security presidential directive 5: management of domestic incidents what a disaster? assessing utility of simulated disaster exercise and associated educational process key: cord-269099-q5nyzlhs authors: lee, jisun; lee, hyunsoo; mccuskey shepley, mardelle title: exploring the spatial arrangement of patient rooms for minimum nurse travel in hospital nursing units in korea date: 2020-07-23 journal: nan doi: 10.1016/j.foar.2020.06.003 sha: doc_id: 269099 cord_uid: q5nyzlhs abstract with increasing demands on medical care services, one of the trends is the mixed patient room arrangement of single/double-bed and multi-bed rooms in a nursing unit on the same floor. this influences nurse-to-patient assignment and often causes an unbalanced workload and longer travel distances for nurses. the objective of this study was to investigate how floor configuration and room density influence nurse travel in the hospital's medical surgical units in korea. this study presented a novel approach to measure nurse travel distances in eight existing nursing units. the agent-based simulation was conducted to model nurses' walking trails, and the distance of one nurse travel to assigned patient rooms was measured for each nurse. with revisions in the spatial arrangement of patient rooms, locating multi-bed rooms near the nurse station, symmetric room layout centering the nurse station, and planning both single/double-bed and multi-bed rooms on one side of corridors, nurse travel distance decreased more than 15%. this study contributed to the knowledge of agent-based simulation as an evaluation framework for spatial analysis. apart from application to korea, these results are particularly of interest in countries where private patient rooms are not commonly economically feasible. abstract with increasing demands on medical care services, one of the trends is the mixed patient room arrangement of single/double-bed and multi-bed rooms in a nursing unit on the same floor. this influences nurse-to-patient assignment and often causes an unbalanced workload and longer travel distances for nurses. the objective of this study was to investigate how floor configuration and room density influence nurse travel in the hospital's medical surgical units in korea. this study presented a novel approach to measure nurse travel distances in eight existing nursing units. the agent-based simulation was conducted to model nurses' walking trails, and the distance of one nurse travel to assigned patient rooms was measured for each nurse. with revisions in the spatial arrangement of patient rooms, locating multibed rooms near the nurse station, symmetric room layout centering the nurse station, and planning both single/double-bed and multi-bed rooms on one side of corridors, nurse travel distance decreased more than 15%. this study contributed to the knowledge of agent-based simulation as an evaluation framework for spatial analysis. apart from application to korea, these results are particularly of interest in countries where private patient rooms are not commonly economically feasible. ª 2020 higher education press limited company. publishing services by elsevier b.v. on behalf of keai. this is an open access article under the cc by-nc-nd license (http:// creativecommons.org/licenses/by-nc-nd/4.0/). nurses are one of the most valuable resources in the healthcare industry, and they are responsible for direct patient care. nurses' roles and responsibilities are essential in meeting the high demands of patient care and advancing improved patient outcomes (institute of medicine, 2011). however, the healthcare industry is facing a growing shortage of nursing staff and a high staff turnover rate, while the high demand for quality care services persists (health resources and services administration, 2013) . the primary reason nurses leave their jobs is a highly demanding workload (mazurenko et al., 2015; tao et al., 2015) . their work is physically and emotionally intense with heavy daily duties, high emotional exhaustion, and physical burnout, which results in nurse dissatisfaction with their jobs (aiken et al., 2002; faller et al., 2011) . factors such as extended working hours, continuous working shifts, lack of rest breaks, and long walking distances contribute to nurse fatigue and stress pati et al., 2008; witkoski and dickson, 2010) . poor environments result in nurse stress and a reduced sense of wellbeing ulrich et al., 2004 ulrich et al., , 2008 zimring et al., 2004) . in a nursing unit, long travel distance has been one of the most critical issues that impact nurse fatigue and stress (chaudhury et al., 2009; zborowsky et al., 2010) . nurse travel is also directly related to the time spent on patient care. the literature indicates that nurses who spend more time walking spend less time at patients' bedsides shepley and davies, 2003; trites et al., 1970; ulrich et al., 2004) . researchers have tried to evaluate how much walking distance can be shortened and how much time saved, which can potentially be directed to patient care (gurascio-howard and malloch, 2007; lu and zimring, 2012; pati et al., 2012 pati et al., , 2015 . improving the environment to support a well-balanced patient load and reduce walking distance is necessary for the nurses' well-being as well as secured time for patient care. this study examined the effects of spatial features on nurse walking distance (nwd), particularly focusing on the arrangement of patient rooms. the patient room locations need to facilitate effective access from the center of the ward, i.e., the nurse station, and other assigned patient rooms for minimum nurse travel (nazarian et al., 2018) . over the last two decades, trends in patient room types have moved towards the preference for single-occupancy patient rooms. single-occupancy rooms have been considered to be more appropriate than multi-occupancy rooms because they enhance privacy, prevent infections, reduce noise, and incorporate space for families (chaudhury et al., 2005 (chaudhury et al., , 2006 . however, the majority of patient room types differ by country depending on the level of medical service demands and cultural and financial structures. multi-occupancy rooms are still in the majority in many countries, including the uk, germany, and korea (choi et al., 2017; maben, 2009; scott et al., 2012; wagenaar and mens, 2018) . in korea, with high medical demands and limited land property, most general hospitals consist of a mix of single, double, and multi-bed rooms in one nursing unit. experts report staff challenges with single room-only hospitals (stephenson, 2015) , and argue for a flexible mix of room types for varied preferences and clinical goals (pennington and isles, 2013; trant, 2010) notably, in an epidemic condition like covid-19, flexible patient room occupancy levels are needed. healthcare facilities with single rooms only did not meet the demand, and patient beds were placed in corridors. in the mixed arrangement, both single/ double-bed and multi-bed rooms are assigned to each nurse for balanced workload (choi et al., 2014 (choi et al., , 2017 shin and kang, 2016) . in the racetrack type units where single/double-bed and multi-bed rooms are located on the opposite sides of the floor (with the service core in the middle), nurses have to travel along both sides to care assigned patients. however, studies on the relationship between patient room types and nurse travel distance are lacking. nurses' movement patterns relate to nurse experience, patient care mix reflecting patient condition and patient load, and most of all, the location of assigned patient rooms (choudhary et al., 2010; heo et al., 2009; nanda et al., 2015) . the distance between assigned rooms and patient room to patient room circulation are major contributors to nurse walking (pati et al., 2008) . in this paper, an 'assignment' refers to a set of rooms assigned to a nurse. current healthcare models represent proximity between spaces, typically reflecting a simple path for an effective sequence of activities. this is adequate in cases where the patient and staff movement are explicitly determined, such as the outpatient unit, emergency department, and operation room. however, for predicting and simulating movement in inpatient units, the simple approach of point-to-point distance is limited, because nurses move continuously during a shift, rarely following the same pattern. in this study, a novel approach of agent-based modeling is applied as a process-oriented analysis methodology to reflect a sequence of nurse activities. this study evaluates the effect of different layouts of hospital nursing units on nurse movement patterns, and also contributes to the field of agent-based simulations. in this study, a simulation-specific approach is taken to provide strong evidence to healthcare providers regarding the location of patient rooms in a nursing unit. 2. literature review 2.1. spatial features, nurse-patient assignment, and nurse travel distance the spatial relation between the nurse station and patient rooms is one of the most critical elements influencing nurse travel (cai and zimring, 2012; gurascio-howard and malloch, 2007) . the literature reports that the most traveled paths of nurses are between the nurse station and patient rooms (acar and butt, 2016; nazarian et al., 2018) . in an observational study, the travel between the nurse station and patient rooms took 34.5% of total nurses' travel during a 12-h shift (acar and butt, 2016 ). an individual nurse walks an average of 2.4e3.4 miles per daytime shift shepley and davies, 2003) , and this distance can be as much as 6 miles (pati et al., 2012) . described how nurse travel distance, time with patients, and workload varied between different unit layouts in 36 medical-surgical units: 19 racetrack type units, 12 double-loaded units, single corridor, and five radial type units. it was obvious that the travel distance and patient time among nurses varied more within the same unit than between units. they found no statistically significant correlation between unit type, travel distance, and patient time; however, the difference in nurse travel distance between spatially contiguous patient assignment and non-contiguous room assignment was significant . nurse managers and directors even walk longer than the average nurses walk, and long walking distances are a challenge for care coordination and overall management (nanda et al., 2015) . the variability of distance traveled between individual nurses on the same unit is often greater than the variance across different hospital units . one of the causes of the large variability in distances traveled among individual nurses on the same unit is the spatial properties of room assignments. the associated spatial properties affect nurse travel patterns and distance traveled. nurses travel between assigned patient rooms, nurse stations, and supply rooms (butt et al., 2004) . the nurse-to-patient assignment involves a time-consuming and complicated process with many considerations, such as patient acuity, patient preference, continuity of care, and nurse experience. the patient's location in the unit is one of the primary factors to consider for patient assignments and often more critical than nurse experience and expertise (van oostveen et al., 2014) . patient rooms that lie outside the main circulation of a nursing unit contribute to added walking distance to and from the patient rooms to nurses' areas (pati et al., 2008) , and patient assignments in two corridors result in additional walking (gurascio-howard and malloch, 2007) . the travel from the center of the ward, i.e., the nurse station, and other assigned patient rooms impacts walking distance (nazarian et al., 2018) . in nursing units with a flexible mix of room types for varied preferences and clinical goals, the arrangement of room types is one of the causes for scattered patient assignments. even though patient assignments are complicated, for balanced workload, assigning both single/ double-bed and multi-bed rooms is prevalent in korea where most hospitals consist of a mix of room types within the same unit (choi et al., 2014 (choi et al., , 2017 shin and kang, 2016) . patient room assignments are a basis for nurse travel, and a nurse is required to establish movement pattern strategies according to the spatial relationship between patient rooms and nurses' areas (heo et al., 2009) . also, the number of visits to patients is correlated with spatial properties (choudhary et al., 2010; heo et al., 2009 ). agent-based simulations have been widely applied to simulate pedestrian walking behaviors in architecture from a building to an urban scale. they are often employed to generate realistic and autonomous pedestrian walking behavior. using simple rules to simulate the decisionmaking processes while interacting with environments, agent-based models perform high levels of correlation to human behavior. various successful models, such as the cellular automata (dijkstra and timmermans, 2002) , social force (helbing and molnar, 1995) , boids-type behavior (reynold, 1987) , shortest path (hoogendoorn and bovy, 2004) , and exosomatic visual architecture (turner and penn, 2002) have been described in the literature. previous case studies find strong correlations between agent-based models with human pedestrian behavior in comparison to real-world observations and computing movement models (batty, 2001; helbing et al., 2002; turner and penn, 2002; turner, 2007; torrens, 2012; yang et al., 2011; vizzari et al., 2015) . due to the similarity of agentbased models and human movement behavior, evacuation modeling and wayfinding are the most common consolidated areas in which agent-based models are employed (najian and dean, 2017; orellana and alsayed, 2013; raubal, 2001a raubal, , 2001b vizzari et al., 2020) . although many researchers have conducted agent-based models using aggregated data, some researchers focus on individual human movement level. orellana and alsayed (2013) carried out research covering on-site observations and virtual simulations of pedestrian walking and demonstrated a strong relation between observed and virtual pedestrian movement at an individual level. traditionally, in nursing unit studies, walking distances have been estimated based on point-topoint linear proximity between key areas shepley and davies, 2003; pati et al., 2012; yi and seo, 2012) . among korean inpatient unit case studies, shin and kang (2016) assessed nurse walking distances using traditional point-to-point linear measurement based on field interviews of nurses' patient room assignments. however, human walking behavior typically does not follow the centerline and makes a curve at corners to move along the shortest path to a destination point (helbing et al., 2001) . agent-based modeling can accommodate multiple path options of every nurse and, at the same time, reflect more realistic human behavior patterns. most studies on nurse travel assessment are based on field observations (e.g., choudhary et al., 2010; seo et al., 2011; shepley and davies, 2003; shin and kang, 2016; sturdavant, 1960; yi and seo, 2012) , and few employ simulation-based experiments (nanda et al., 2015; pati et al., 2015) . for visualizing and measuring walking distances within buildings using a computational method, dym et al. (1988) suggested travel-distance algorithms that examine a hospital floor plan via defining the shortest path between each wall's midpoints. lee et al. (2010) employed a metric graph structure to represent building circulation and calculated walking distances with the shortest path and interpreted the building shape with a buffered spaceboundary polygon reflecting half the width of a person's shoulder from a wall as minimum buffer distance. nanda et al. (2015) combined field research and spatial parametric modeling tools in their study on assessing nurse walking distance in a medical-surgical unit. a rhino/ the spatial arrangement of patient rooms for minimum nurse travel 3 + model grasshopper model was developed to assess nurse walking distance from every patient room to the support areas. observation studies on nurse walking distance reveal the complexity of their travel. the variations between the sequence of activities, frequencies of visits, unexpected interruptions for minor tasks during patient visits are variable. however, the literature agrees that the most frequently visited areas are patient rooms (acar and butt, 2016; nanda et al., 2015; nazarian et al., 2018; pati et al., 2012) and the proximity between the nurse station and the patient room is critical (cai and zimring, 2012; gurascio-howard and malloch, 2007) . also, studies predicting and computing nurses' movement suggest that nurse walking routes are more relevant when based on a sequence of activities rather than simple proximity measures (choudhary et al., 2010; heo et al., 2009; nanda et al., 2015; shin and kang, 2016) . a novel spatial analysis tool was implemented to visualize nurse walking behavior and spatial data on the current environment of hospital inpatient units. using a parametric model in rhino/grasshopper, an agent-based simulation was conducted to assess each nurse's walking distance. the agentbased simulation generated virtual nurses' walking trails, and the parametric algorithm measured the distance (nwd) of each walking trail. a visualized nurse walking trail reflected one patient visit "round" of each nurse, which was regularly taken for activities such as doctor visits, shift handover, or medication during a shift. those were paths from the nurse station toward assigned patient rooms, stopping by a clean supply/medication room, and returning to the nurse station. the selected cases included typical medical-surgical inpatient units of eight general hospitals (fig. 4) . this article represented partial findings of a doctoral dissertation (lee, 2019) , which applied mixed methods of data collection: literature review, case studies, and simulations. in the agent-based simulation, virtual agents represent nurses. nurses' walking trails were generated and measured in a rhino modeling space of each unit. the grasshopper plug-in program "pedsim" is used to model nurse walking behavior. pedsim has been used to simulate walking paths in healthcare facilities for evaluating accumulated walking trails of patients (lee and lee, 2020) . fig. 1 demonstrates how the possible routes where agents can move within a given environment are analyzed in pedsim. in the simulation, the building components, such as walls and fixed furniture, are set as obstacles, i.e., a series of closed polygons that form a space boundary. the edges and vertices are automatically generated at a buffered distance from the building polygons, and the edges become the possible routes that agents can choose. the buffered distance is a half-width of a shoulder and reflects the distance humans offset from walls to avoid collisions while walking in indoor space. pedsim also employs multiple forces for agents' walking behavior. it is based on the social force model (helbing and molnar, 1995) with agents driven by multiple forces, namely a target force, person repulsion, and obstacle repulsion for their basic movement mechanism, and an anticipatory collision avoidance force to make agents aware of potential collisions and take actions earlier (wang, 2019) . in the simulation, an agent chooses the shortest path among the possible routes within the given environment and moves to a target point, avoiding collisions with multiple forces (wang, 2019) . in the agent-based modeling, nurse travel is set with a sequence of movements per patient assignment. the movement sequence is programmed by a set of parameters: visit locations, number of visits, and a flow of the assignment. the methodology is process oriented. when the movement path is visualized on the layout following the key sequence of movement, the distance is measured automatically by the parametric components. the agents also fig. 1 example of the environment setting. agents move from starting to destination points, and edges and vertices of space boundary at a buffered distance from building polygons are possible routes that agents can choose (wang, 2019) . have a vision, and they move to the target point in possible visible routes. this study simulates nurse travel based on the most obvious sequence of visits during a shift, which is a patient visit round. each nurse movement path reflects a set of patient assignments. four or five different patient rooms, which are assigned to one nurse, are visited in each round, and four or five sets of assignments cover all the unit's rooms. the simulation process (fig. 2) for a patient visit round is as follows: (1) the agent finds the shortest path to the destination point, (2) it visits points of interest if it sees those and avoids obstacles and other agents on its way, and (3) goes to the destination point. in the simulation, an agent, which is a nurse, (1) travels from a starting point: the nurse station, (2) visits points of interest: the supply/ medication room and assigned patient rooms of each nurse, and (3) goes to a destination point: the nurse station, avoiding obstacles such as walls and furniture in the plans (fig. 3) . the typical double-loaded corridor type nursing unit was the standard design for many years from the early design of hospital wards, because of the need for cross-ventilation and natural lighting. with an increase in the demands for hospitals, planners have tried various plan configurations to achieve efficient activity patterns. the more compact plans, such as radial (valley presbyterian hospital in california and brigham and women's hospital in boston), lshaped (aspirus wausau hospital in wisconsin), square (providence hospital in alaska), and triangular-shaped (jacobs medical center in san diego) nursing units have been developed with groupings of concentric support areas in inpatient units (kobus et al., 2008) . valley presbyterian hospital in california (1956) developed the first compact radial type unit, and recently brigham and women's hospital in boston developed radial intensive care units. recent trends have shown a shift toward the racetrack type. racetrack type design maximizes the perimeter wall of the unit while providing moderate visibility and accessibility from the nurse working area to patient rooms. another trend is toward pod configuration, which provides better patient monitoring opportunities (cama, 2009; hamilton and shepley, 2010; thompson et al., 2012) . however, in korea, with its enormous scale and high land prices, high-rise hospitals with a racetrack or triangular shape units are the most common. this study included four rectangular and one triangular-shaped inpatient unit layouts of the most highly ranked hospitals among 42 tertiary care hospitals in korea (ministry of health and welfare, 2018) and three representative triangular layouts from secondary care the spatial arrangement of patient rooms for minimum nurse travel 5 + model hospitals (fig. 4) . among the selected medical-surgical inpatient units of eight hospitals, four are in seoul and four in other cities. the typical floor plans of the units follow the criteria: 40 to 50 beds per unit, 500 to 1000 inpatient beds in total, and being built after 2000. each ward floor has two nursing units and two centralized nurse stations, two medication and clean supply rooms, one nourishment room, two soiled linen rooms, and two equipment rooms at the center of each unit. each nursing unit had a double-corridor design with a triangular or rectangular shape, and mixed arrangement of patient room types: single, double, or multi-occupancy (tables 1 and 2 ). the characteristics of the units were categorized by (1) unit shape -triangular or rectangular and (2) location of the nurse station -near the elevator core or center of the unit. a nursing unit refers to the number of beds the nurses in a group are accountable to take care of, and the units of general hospitals in korea have 40e60 beds per nursing unit due to a large number of patients. the staff to patient ratio ranges from 1:7 to 1:12 for registered nurses (national health insurance service, 2019). the nurse-patient assignments of selected units are based on shin and kang's (2016) research on the nurse-patient assignments. the nurse-room ratio of the eight units was set with respect to three criteria: (a) nurse-patient ratio was 10e12 patients per nurse, (b) both single/double-bed patient rooms and multibed patient rooms were assigned to one nurse for workload balance, and (c) all patients in a single room assigned to the same nurse (table 3) . to compare the nurse travel distance between units, one patient visit "round" of each nurse was measured in the simulation. in the delivery of patient care and related activities, the locations nurses visit may vary based on urgent medication and patient requests. according to empirical studies on the traveled paths of nurses (acar and butt, 2016; kim and chai, 2018; nanda et al., 2015) , the most frequently visited paths during both day and night shifts are between: (i) patient rooms and nurse station; (ii) nurse station and clean supply/medication room; and (iii) patient rooms and clean supply/medication room, in this order. in this study, the simulation setting was limited to one patient visit round of each nurse to the assigned patient room visits at each shift change, excluding irregular travel. the distance to the patient room doors was calculated, and the movement inside the patient room was excluded from the measured distance. the movement process for a round is shown in fig. 5 : (1) starting from the centralized nurse station, a nurse (an agent) visits a clean supply/medication room for preparation prior to an assigned patient room round. (2) the nurse (agent) moves to the assigned patient rooms. (3) after visiting the assigned patient rooms, the nurse returns to the nurse station. nurse walking trails for one round of each nurse (n z 33) were simulated, and the distance of each round path was measured ( fig. 6 and table 4 ). the shortest average nwd of each unit was measured in unit 4, and the longest in unit 7 unit nurse-patient assignment total the spatial arrangement of patient rooms for minimum nurse travel 7 + model (41.56 and 68.97). units 1, 2, and 4 showed relatively short average nwd. the shortest nwd of one nurse was captured in n-1 of unit 2, and the longest in n-1 of units 8 (26.06 and 82.51). the variations of nwd among nurses were in a broader range within a layout than between other units. considering nurses travel between the nurse station and assigned patient rooms approximately fourteen times during a shift (kim and chai, 2018) , the variations will be even more substantial. unit 4 shows the most equivalent distances among nurses within a unit. units 3 and 7 show lower sd than the average; however, unit 7 had the longest average nwd, which indicated that nurses in unit 7 walked more than nurses in other units. the nwd in unit 6 varied in the largest differences among nurses, and the variations of nwd among nurses in units 1, 2 were also larger than other units. units 7 and 8 had long average nwd, and variations of nwd within the units were at the average level. although the triangular units showed shorter nwd than the rectangular units, unit typology may not be the most fundamental reason for the short walking distance. the simulation results presented strong evidence that the average nwd was shorter in the units with a nurse station located at the center of the unit (table 5) , and the locations of nurse stations were closer to the center of the units in the triangular units (fig. 6) . therefore, the distance to the patient rooms from the nurse station was shorter in the triangular units than the rectangular units. in rectangular units, the nurse station was closer to the unit entrance rather than the center of the units. with a categorized comparison of two groups of 'contiguous' and 'non-contiguous' patient room assignments, the average nwd was 46.34 and 59.98 m (table 5) . this study defined the nurse-patient assignments between immediately adjacent patient rooms as "contiguous", and with nearby but not contiguously neighboring patient rooms as "non-contiguous". obviously, the units with geographically contiguous patient room assignments had shorter nwd than the units with non-contiguous patient room assignments. unit 3, a triangular unit with a non-contiguous patient room assignment, had a longer nwd than other triangular units. unit 6 was the only rectangular unit with a contiguous patient assignment, and it had a shorter nwd than other rectangular units. unit 6 had the lounges located in the middle of the patient room sections, which increased the distance between the nurse station and patient rooms. the simulation results revealed that these measures did not consequently result in longer nwd. the units of the long distances from nurse station to end of the unit (ns to eu) were units 1, 6, and 8, and of the long perimeter (length of patient room walls on door side) were units 3, 6, and 8, compared to the average (fig. 7 and table 4 ). however, unit 1 showed a short nwd with a long ns to eu distance, while unit 7 showed the longest nwd with one of the shortest ns to eu distance. the average ranges of nwd were captured in units 3 and 6 despite the long perimeter length. unit 6 showed an average range of nwd with a long ns to eu distance and perimeter length. one of the critical spatial attributes influencing nurse travel distance was the patient room arrangement. in the cases where single/double-bed patient rooms and multibed rooms were planned in the same unit, an equivalent number of single/double-bed and multi-bed patient rooms were to be assigned to each nurse for balanced workload distribution. in units 5, 7, and 8, where single/double-bed and multi-bed rooms were located in separate two hallways, the nurses had to move up and down across the center support areas to visit patients in two corridors. these geographically non-contiguous patient assignments caused long travel distances. among the rectangular units, unit 6 presented an average level of nwd despite the lounges located in between patient rooms, the long perimeter of patient rooms, and long ns to eu distance. unit 6 had the patient room arrangement, which supported a contiguous patient assignment plan, locating a mixed arrangement of patient rooms along the same corridor, as nurses get assigned for patient rooms of both single/ double-bed and multi-bed rooms. however, in unit 3, even though both room types were located along the same corridor, they were placed in distant locations. consequently, unit 3 presented non-contiguous patient assignments with longer nwd than others among the triangular units. the patient room arrangement contributed to the geographical continuity of the nurse-patient assignment, and non-contiguous patient assignments often caused inefficient travel distances for nurses. therefore, the spatial arrangement of patient room types was one of the critical features for nurse walking efficiency, as this was highly related to the patient assignment plan. the frequency of nurse visits to patient rooms from the nurse station was higher in double-bed rooms than singlebed rooms (nazarian et al., 2018) , which means locating multi-bed patient rooms closer to the nurse station would reduce nurse walking. to explore the effects of patient room arrangement on nwd, the room arrangements of three rectangular units, units 5, 7, and 8, were revised to support geographically contiguous nurse-patient room assignment through the following modifications: the spatial arrangement of patient rooms for minimum nurse travel 9 + model 1) symmetric room layout centering the nurse station, 2) mixed planning of single/double-bed and multi-bed patient rooms on one side of the corridor, and 3) multi-bed rooms as near as possible to the main nurse station to shorten nurse travel. in unit 5, two multi-bed patient rooms on the upper corridor were moved to the lower corridor for nurses to care for patients in a single corridor. in units 7 and 8, similar changes to the layouts were made. one patient visit round was simulated for each nurse, and the travel distance was measured (tables 6 and 7) . a notable reduction in nwd was evident for all three units, with around 15% decrease in the revised layouts. of the three units, unit 7 had the largest difference. in unit 7, the average nwd decreased from 68.97 to 55.95 m for one round, with an 18.88% reduction in distance. also, sd decreased from 10.21 to 3.84, which is a noticeable improvement for equivalent nwd among nurses within unit 7. in units 5 and 8, the reduction was also evident: the averages of nwd decreased by 14.64% and 16.31%, respectively. however, sd slightly increased as the shortest nwd further decreased. considering this was based on a single trip, the reduction of nwd would be more substantial with multiple trips in real situations. based on the results, mixed planning of single/ double-bed rooms with multi-bed rooms on one side of the corridor with consideration of contiguous nurse-patient room assignment influenced shorter nurses' travel distance. . 7 comparisons of nwd of each unit: average, longest, shortest nwd, and sd measures. the x-axis represents the unit number and y-axis the distance in meters. note. (da: the difference between the average nwd of the existing and revised layouts). the results of this study indicated that changes in spatial features, such as nurse station location, patient room arrangement, affect nurses' walking distances, and the size of the units, may not merely increase nurse travel with supportive spatial planning. also, this study discussed the relationship between nurse-patient room assignment and nurse travel distance. nurse travel is based on the patient assignment during a shift, and the assignment frequently involves geographically non-contiguous patient rooms (pati et al., 2008) . non-contiguous patient room assignments often increase walking for nurses . although it is assumed that nurses are assigned to a set of contiguous patient rooms, actual patient assignments vary in regard to other factors, such as the acuity level of a patient, competency of a nurse, and a nurse-to-patient ratio (pati et al., 2008) . this study emphasized that patient assignment is one of the critical factors to consider in the design stage for reducing nurses' walking, even though it is an operational issue and not a spatial issue. with an understanding that the actual patient assignment may vary and not result in contiguous rooms, depending on the balance between criteria, this study explored the optimal layout that healthcare designers could provide to support contiguous room assignments, initially. in a mix of single/double and multi-bed patient rooms in one nursing unit, this study demonstrated two spatial factors impacting minimum nurse travel distance: 1) locating multi-bed patient rooms near the nurse station and 2) planning both single/double-bed and multi-bed rooms on one side of corridors instead of separating single/doublebed and multi-bed patient rooms on two different corridors. the critical design factors in a nursing unit design are space layout that supports efficient nursing activities, reduced walking distances, organized supply areas, controlled noise level, and visibility with ease of supervision (zborowsky et al., 2010) . this study has focused on the issue of walking distances, and the results demonstrated that planning multi-occupancy patient rooms near the nurse station were more effective in reducing nurse travel distance. this approach can also impact patient visibility and noise level. more patients are easily visible and accessible from the nurse station when locating multi-bed patient rooms near the nurse station (lee, 2019) . a high noise level is often reported around the nurse station, and patients who prefer single-occupancy rooms would benefit from being at a quieter location than around the nurse station. the nurse station is a central hub for nursing activities in a hospital unit and the primary work area of each unit. the location and distance of the nurse station to the patient room has been considered as a critical influence on nurse walking distance. planning the nurse station closer to the center of the units is a convincing design strategy to keep nurse travel distance to a minimum, especially in a linear and less concentric rectangular unit. however, one of the reasons for positioning the nurse station close to the entrance would be the high need for visual control over the entrance. even though it is out of the scope of this study, planning both the entrance and nurse station at the center could be a robust design strategy to keep nurse travel distance to a minimum and gain sufficient visibility to the entrance. among the cases of this study, unit 5 has the nurse station close to both entrance and center of the unit. however, patient visibility was low due to the orientation of the nurse station, which was facing the entrance rather than patient rooms. in unit 5, despite the long perimeter length, the nwd was at the average level. it could be a good strategy to develop this unit into a hybrid nursing station model to improve patient visibility. it will also satisfy visual control to the entrance and patients, as well as achieving moderate nwd. representing the process of how nurses' movements are made, this study attempted to contribute to the field of agent-based simulations. while classic population-level modeling has been limited in its ability to integrate individuals' decision-making, this study expanded the application areas of agent-based modeling to an individual level. even though this study has limited the application strategy to minimum nurse travel, agents can be set as patients, physicians, staff, visitors, and caregivers within the facilities as an expanded approach. in this sense, an agent can also be set with any spatial factors in the simulation, such as noise level, visibility, and patient preferences. planners can develop a simulation model with a mixed approach for optimized layout planning. simulation of healthcare in the design process is useful because it allows designers and planners to analyze the performance of the facilities at an organizational level and also enables relative comparisons among design options. this study investigated how floor configuration and room density influenced nurse walking distance in the hospital's medical-surgical units with the intent of reducing staff fatigue and securing more time for nurses to spend on direct patient care. the effects of the unit typology, nurse station location, and spatial arrangement of patient rooms on nurse travel were evaluated. in units with a nurse station placed at the center of the unit, shorter nurse walking distances were measured. in triangular units, the nurse stations were placed closer to the center of the units, compared to the rectangular units. also, a contiguous patient assignment contributed to shorter nurse travel. a well-planned patient room arrangement was one of the spatial features that influenced the contiguous patient assignment. with increasing demands on medical care services, nursing units in korea have tended to consist of mixed patient room arrangements of single/double-bed and multi-bed patient rooms in the same unit. in units with a mixed arrangement, nurses were often assigned to patients in scattered locations, which resulted in more walking. rearranging spatial layout of patient rooms such as, locating multi-bed patient rooms near the nurse station and mixed planning of single/double-bed rooms and multi-bed rooms on one side of the corridor, helped to reduce nurse walking. one of the limitations of this study was that the patient assignment model was limited to one scenario. the study did not address patient acuity or unit specialization (maternity, oncology, etc.). despite other constraints of patient room assignments such as patient case mix and nurse experience, this study limited the model to a balanced distribution of patient rooms of single/double or multioccupancy, which was a major distribution criterion in selected cases. other limitations were that this was a simulation and not a real observation study, and all nurse walking behaviors were not taken into account. another limitation is that the shapes of units in this research have been limited to two types, racetrack or triangular types. this was appropriate for the geographic region in which this research took place. in korea, these are the most common configurations for an inpatient unit design due to the need for large-scale hospitals and high land prices. methodologically, this study presented a novel application of agent-based simulation to simulate and measure nurse walking models, enabling automatic distance measuring via setting the start and destinations. this study aimed to help healthcare providers to test their design options and make improvements with evidence in decisionmaking. for future studies, decentralized and hybrid nursing station models in long linear units will be further explored in relation to the spatial arrangement of patient rooms to facilitate efficient nurse walking and sufficient patient visibility. achieving equivalent nurse walking distances for nurses remains a challenge for both designers and healthcare providers. this work was supported by the bk 21 plus funded by the ministry of education of korea. modeling nurse-patient assignments considering patient acuity and travel distance metrics hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction exploring isovist fields: space and shape in architectural and urban morphology an evaluation of physiological work demands on registered nurses over a 12-hour shift out of sight, out of reach: correlating spatial metrics of nurse station typology with nurses' communication and co-awareness in an intensive care unit evidence-based healthcare design advantages and disadvantages of single-versus multiple-occupancy rooms in acute care environments: a review and analysis of the literature nurses' perception of single-occupancy versus multi-occupancy rooms in acute care 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with single rooms? human wayfinding in unfamiliar buildings: a simulation with a cognizing agent ontology and epistemology for agent-based wayfinding simulation flocks, herds and schools: a distributed behavioral model finance. the profitability of private patients impact of hospital unit design for patient-centered care on nurses' behavior nursing unit configuration and its relationship to noise and nurse walking behavior: an aids/hiv unit case study a study improving a nurse's walking path and staff visibility in general hospital wards single rooms in hospitals "increase anxiety" among nursing staff comparisons of intensive nursing service in a circular and a rectangular unit: rochester methodist hospital examining perception of job satisfaction and intention to leave among icu nurses in china guidelines for intensive care unit design moving agent pedestrians through space and time ward design must not be restricted to single rooms influence of nursing unit design on the activities and subjective feelings of nursing personnel from axial to road-centre lines: a new representation for space syntax and a new model of route choice for transport network analysis encoding natural movement as an agent-based system: an investigation into human pedestrian behaviour in the built environment the role of the physical environment in the hospital of the 21st century: a once-in-a-lifetime opportunity. the center for health design a review of the research literature on evidence-based healthcare design developing and testing a computerized decision support system for nurse-to-patient assignment: a multimethod study an agentbased pedestrian and group dynamics model applied to experimental and real-world scenarios hospitals: a design manual hospital staff nurses' work hours, meal periods, and rest breaks: a review from an occupational health nurse perspective a spatial agent-based model for the simulation of adults' daily walking within a city the effect of hospital unit layout on nurse walking behavior centralized vs. decentralized nurse stations: effects on nurses' functional use of space and work environment the role of the physical environment in the hospital of the 21st century: a once-in-a-lifetime opportunity. the center for health design the authors have no conflicts of interest to report. key: cord-332818-62xkb6mv authors: masoudi alavi, negin title: occupational hazards in nursing date: 2014-09-20 journal: nurs midwifery stud doi: nan sha: doc_id: 332818 cord_uid: 62xkb6mv nan nurses continue to report high levels of job-related injury and illness. working environment, responsibilities, and duties of nurses put them in the frontline of numerous occupational hazards. some common occupational hazards that nurses might face are listed here: 1-the vast majority of nurses experience persistent jobrelated pain. in a study in iran, on average, the nurses reported musculoskeletal pain in 3.33 regions and 89% had musculoskeletal pain, mainly in lower back (74%) and knees (48.5%) (1). in a study in the netherlands, 57% of nurses had musculoskeletal pain in at least one region (2) . in another study in brazil, 80.7% of nurses complained of musculoskeletal pain (3) . upper extremity, shoulder, and neck injuries are also common among nurses (4). it seems that work-related musculoskeletal pain and injuries are common among nurses all over the world. most of these pain and injuries are due to lifting and moving patients manually (5). 2-work overload and stress are other factors that threaten the health of nurses and can cause burnout and fatigue. working in three shifts (6, 7) , in difficult settings such as oncology or emergency wards (8, 9) , and caring of incurable patients puts a considerable psychologic, spiritual, and physical pressures on nurses (7). as a result, fatigue is a common feeling among nurses. in a study, 43.4% of nurses reported excessive fatigue (6) . raftopoulos et al. also reported that 91.9% of cypriot nurses had fatigue (10). 3-communicable and contagious diseases and exposure to blood-borne pathogens (e.g., hiv, hcv, hbv, etc) due to needle-stick injuries also threaten the health of nurses. it is estimated that 600000 to 800000 needlestick injuries occur each year in all healthcare settings. injections (21%), suturing (17%), and drawing blood (16%) are the main causes of exposures (11) . severe acute respiratory syndrome (sars), tuberculosis, and methicillin resistant staphylococcus infection are other infectious diseases that can afflict nurses. 4-chemical materials are other hazardous sources to nurses. disinfectants and sterility products such as glutaraldehyde and ethylene oxide, hazardous drugs such as drugs that are used during chemotherapy, and latex exposure are among other occupational hazards for nurses (12) . 5-nurses, especially in emergency department, continue to experience high rates of on-the-job violence. according to a 2011 study by the emergency nurses association (ena), the 53.4% of nurses reported experiencing verbal abuse and more than one in 10 (12.9%) reported experiencing physical violence (13). these occupational hazards along with many other problems such as night shifts and sleep deprivation have changed nursing to a dangerous occupation that may explain the high rate of stopping the work in nursing. some interventions including greater access to patient lifting and transfer devices and more use of safe needle devices can improve the situation. every healthcare setting should address this important issue and give priority to the safety of nurses. non-specific musculoskeletal pain and vitamin d deficiency in female nurses in kashan work related risk factors for musculoskeletal complaints in the nursing profession: results of a questionnaire survey musculoskeletal symptoms, work ability, and disability among nursing personnel. workplace health saf associations of self estimated workloads with musculoskeletal symptoms among hospital nurses ergonomic standards and implications for nursing insomnia, excessive sleepiness, excessive fatigue, anxiety, depression and shift work disorder in nurses having less than 11 hours in-between shifts associations between night work and anxiety, depression, insomnia, sleepiness and fatigue in a sample of norwegian nurses compassion fatigue and burnout: prevalence among oncology nurses the effectiveness of an educational program on preventing and treating compassion fatigue in emergency nurses the factors associated with the burnout syndrome and fatigue in cypriot nurses: a census report nurses and needlesticks, then and now emergency department violence surveillance study key: cord-349865-c7tu6g9o authors: klar, robin toft title: nurse educators as agents of change in the sars-cov-2 pandemic date: 2020-05-30 journal: nurs womens health doi: 10.1016/j.nwh.2020.05.010 sha: doc_id: 349865 cord_uid: c7tu6g9o abstract the sars-cov-2 pandemic caused a rapid and seismic shift in the provision of nursing education. in this commentary i provide examples of how faculty and students at my university made the shift and what we have learned from the experience thus far. precis nursing education during a global pandemic has provided another opportunity for nurses to demonstrate our agility. notes to production: possible artwork ideas: themes of agility, collaboration, quiet space for learning the sars-cov-2 pandemic caused a rapid and seismic shift in the provision of nursing education. in this commentary i provide examples of how faculty and students at my university made the shift and what we have learned from the experience thus far. keywords: covid-19, nursing education, online learning, pandemic, sars-cov-2, teaching we have been working overtime to bring our high-quality teaching to a new or renewed pedagogy of remote learning teaching during a global pandemic has elevated our understanding and appreciation of necessary quiet space to learn and reflect nurses have been identified as the profession most often cited as frontline heroes in the novel coronavirus pandemic. women represent a high of 86% of nurses in the americas and a low of 65% of nurses in the african region (boniol et al., 2019) . nurse educators, who are critical to expanding the nursing workforce, are 93% more likely to be women (national league for nursing, 2017). like our nursing colleagues on the frontlines, nurse educators have had to make extreme adaptations in our practice of educating the next generation of nurses. many of us teaching at the graduate level are bringing advanced nursing education to our students who are now working on the pandemic frontlines. additionally, many nurse educators are also active clinicians and working on the frontlines themselves. i wonder: what does this mean for nursing education in the united states and beyond? i bring in the beyond because my nursing education work also involves nursing workforce capacity building in sub-saharan africa. there, too, our colleagues are managing the impact of covid-19 on educating the next generation. the greatest adaptation to nursing education felt at the university where i teach was the transition to remote learning, as has been the case around the globe. as educators, we were not as acutely aware of the disparities our students were experiencing in relationship to their access to the necessary learning environment tools of high-speed internet access and a quiet space in which to learn. many more students than we appreciated accessed these tools primarily at the university. once those doors were locked, access was greatly decreased. faculty affairs, who leads the conversations, and i discussed the need for an informal room of our own for faculty to care for one another through listening. we have entitled this weekly session the "water cooler station", symbolizing the informal conversations we have around the water cooler when we are on campus. our first session was attended by approximately 10 fulltime faculty. we are fortunate that one of our faculty members also teaches pilates and conducted a restorative, sitting stretching meditation session at the end of this friday event. nursing education during this pandemic has provided another opportunity for nurses to demonstrate our agility. there has been a plethora of webinars presented on this pandemic to and for a multitude of audiences. during a webinar about covid-19 in africa sponsored by the international council of nurses and jhpiego (2020), many attendees lamented that 2020 is the international year of the nurse and midwife and that we will not celebrate together. for me, the most inspiring response to this lament came from midwife peter johnson this is still our year. let's use it to show the world why gender equity in the health workforce: analysis of 104 countries. working paper 1. geneva: world health organization key: cord-307797-28y11ee7 authors: lasater, karen b; aiken, linda h; sloane, douglas m; french, rachel; martin, brendan; reneau, kyrani; alexander, maryann; mchugh, matthew d title: chronic hospital nurse understaffing meets covid-19: an observational study date: 2020-08-13 journal: bmj qual saf doi: 10.1136/bmjqs-2020-011512 sha: doc_id: 307797 cord_uid: 28y11ee7 introduction: efforts to enact nurse staffing legislation often lack timely, local evidence about how specific policies could directly impact the public’s health. despite numerous studies indicating better staffing is associated with more favourable patient outcomes, only one us state (california) sets patient-to-nurse staffing standards. to inform staffing legislation actively under consideration in two other us states (new york, illinois), we sought to determine whether staffing varies across hospitals and the consequences for patient outcomes. coincidentally, data collection occurred just prior to the covid-19 outbreak; thus, these data also provide a real-time example of the public health implications of chronic hospital nurse understaffing. methods: survey data from nurses and patients in 254 hospitals in new york and illinois between december 2019 and february 2020 document associations of nurse staffing with care quality, patient experiences and nurse burnout. results: mean staffing in medical-surgical units varied from 3.3 to 9.7 patients per nurse, with the worst mean staffing in new york city. over half the nurses in both states experienced high burnout. half gave their hospitals unfavourable safety grades and two-thirds would not definitely recommend their hospitals. one-third of patients rated their hospitals less than excellent and would not definitely recommend it to others. after adjusting for confounding factors, each additional patient per nurse increased odds of nurses and per cent of patients giving unfavourable reports; ors ranged from 1.15 to 1.52 for nurses on medical-surgical units and from 1.32 to 3.63 for nurses on intensive care units. conclusions: hospital nurses were burned out and working in understaffed conditions in the weeks prior to the first wave of covid-19 cases, posing risks to the public’s health. such risks could be addressed by safe nurse staffing policies currently under consideration. numerous studies and systematic reviews have described wide variation across hospitals in registered nurse (rn) staffing and have concluded that better hospital nurse staffing is associated with more favourable patient outcomes, including lower mortality, 1-8 fewer complications, 9 higher patient satisfaction, 10 11 shorter stays and fewer readmissions, 12 13 as well as better nurse outcomes such as less burnout. 14 however, policy and administrative responses to this evidence have been uneven as is shown by persistent differences in nurse staffing across hospitals within the same jurisdictions 15 16 and within the same countries. 10 17 policy efforts to enact safe hospital nurse staffing legislation often fail to pass because of a lack of timely, local evidence to inform how policy choices could directly impact the public's health. the main purpose of this study is to provide relevant evidence to inform hospital nurse staffing legislation under consideration in two states (new york (ny) and illinois (il)) 18 19 by determining the variation across hospitals in patient-to-nurse staffing and its association with quality of care including nurse job outcomes (eg, burnout), nursereported measures of care quality and patient reports of satisfaction with their care. the secondary purpose of this study is to discuss the policy relevance and implications of our findings in the context of the covid-19 pandemic-a real-time example of the public health implications of chronic hospital nurse understaffing. indeed, the pandemic has highlighted some of the pre-existing realities and inequities within the us healthcare systemamong them: understaffed hospitals, a burned-out clinician workforce and poorer health outcomes among racial minorities. 20 in the international year of the nurse, the covid-19 pandemic brings daily images of nurses saving lives, comforting the sick, providing essential screening, all at significant personal risk. news stories abound with front-line nurses who are under-resourced to care original research for the surge of critically ill patients. nurses in hospitals have long struggled with high patient workloads and burnout. 7 21 22 in this study, we present evidence as of late february 2020 in ny and il, international gateways into the usa, of widespread hospital nurse understaffing and burnout immediately prior to the surge of critically ill patients with covid-19. in 1999, california (ca) passed, and in 2004, implemented, the first and still only comprehensive us state legislation to limit the number of patients that hospital nurses are permitted to care for at one time. in the usa, it has been 20 years since any other state than ca has passed comprehensive legislation setting hospital nurse staffing requirements, although multiple states have or are considering such legislation. in 2018, a public ballot issue to improve nurse staffing in massachusetts hospitals failed largely because of absence of credible local evidence that legislation was in the public's interest and would not create unintended adverse consequences disrupting access to care. [23] [24] [25] [26] currently under consideration in both ny and il are hospital nurse staffing bills generally patterned after the ca policy and similar to what was proposed in massachusetts. however, as in massachusetts, there is no local evidence to date of whether such legislation is needed. this study provides that evidence while also serving as a baseline to evaluate the impact of these policies if enacted. the covid-19 pandemic provided a highly visible public health example of the importance of having adequately resourced health systems to deliver highquality patient care, as well as the toll under-resourced care settings take on clinician well-being. [27] [28] [29] in this study, we present evidence of hospital nurse staffing, nurse burnout and quality of care in ny and il hospitals in the weeks preceding the pandemic. this information is useful for providing context for how today's hospital nurse staffing policy choices impact hospital outcomes now and in the future. the only study to date which has examined the public health implications of nurse understaffing for patients with covid-19 found that countries with higher workforce concentrations of rns had lower covid mortality rates, which suggests that a robust nursing workforce is essential for addressing the current and future outbreaks. 30 new york city (nyc) and chicago are major gateway cities with large international airports that contribute to social diversity and economic growth but may pose public health vulnerability to pandemics. one study documenting the toll of covid-19 on the mental health of nyc healthcare workers found that 57% of workers screened positive for acute stress and 48% for depressive symptoms, with the worst psychological symptoms observed among nurses. 27 there has been renewed appreciation of the risks posed to clinician well-being and retention in clinical care as well as to patient safety due to overwork, physical and emotional exhaustion and lack of supportive work environments as detailed by a major initiative of the national academy of medicine. 7 14 31 32 in this study, we examine the link between hospital nurse staffing and adverse nurse and quality outcomes to inform decisions about the need for hospital nurse staffing regulation in ny and il; and discuss the implications of chronic understaffing of hospital nurses in consideration of the ongoing covid-19 pandemic. survey data were collected between 16 december 2019 and 24 february 2020 from direct-care rns in ny and il hospitals to estimate nurse staffing and its associations with nurse-reported outcomes. staffing data were linked to patient data from the hospital consumer assessment of healthcare providers and systems (hcahps) and american hospital association (aha) annual survey. hcahps data provided information on patient satisfaction, an outcome evaluated in this study. aha provided data on hospital characteristics which were used for risk adjustment. emailed surveys were sent by the national council of state boards of nursing to all actively licensed rns in ny and il. non-respondents received follow-up reminders at regular intervals. responses were anonymised. the survey took 10-15 min to complete. nurses working in hospitals provided their hospital's name, which enabled the aggregation of individual nurse responses to create hospital-level measures of staffing and quality measures. using front-line rns as informants of hospital staffing has been previously validated and produces unbiased and representative estimates. 33 nurses were also queried about their personal characteristics and job outcomes (ie, burnout, job dissatisfaction and intent to leave their current job), and the quality of care and patient safety in their institution (ie, infection prevention, missed nursing care, operational failures). all non-federal acute care general hospitals were included in our sample, so long as they provided enough nurse responses to reliably estimate medicalsurgical and/or intensive care unit (icu) staffing. this resulted in two samples of hospitals and nurses. the first sample included 4298 rns working on medicalsurgical units in 254 hospitals; the second sample included 2182 rns working on icus in 179 hospitals. nurses were included in the sample if they were direct-care staff rns on either a medical-surgical unit or an adult icu in an acute care non-federal hospital. nurses who were not employed in direct inpatient care of adults or who worked on other units were excluded. direct-care rns reported the number of patients and rns on their unit during their last shift. the number of patients was divided by the number of rns to create a ratio of patients per nurse. nurse responses were aggregated to the hospital level by taking the mean number of patients per nurse among rns working in the same unit types in the same hospitals. only staffing reports from nurses working medical-surgical and icus were used to create measures of staffing, since nurses working in specialty units like labour-delivery, the emergency room and operating room can have highly variable staffing due to the nature of the unit. burnout, job dissatisfaction and intent to leave were derived from the nurse survey. burnout was measured using the maslach burnout inventory 9-item emotional exhaustion subscale. 34 nurses who scored greater than 27-the average among healthcare workers-were classified as having high burnout. 35 job dissatisfaction was measured by dichotomising responses to the survey question 'overall, how satisfied are you with your job?' to contrast nurses who were 'very/moderately dissatisfied' and 'very/moderately satisfied'. intent to leave was measured by responses to the question 'do you plan to be with your current employer one year from now?'. nurses rated quality of nursing care in their unit on a 4-point scale from 'excellent' to 'poor' (ie, in general, how would you describe the quality of nursing care delivered to patients in your practice setting?). responses of 'fair' or 'poor' were considered poor quality. nurses were also asked to give their practice setting an overall grade on patient safety and prevention of infections, ranging from a to f. grades of c, d or f were considered unfavourable. nurses reported whether they would recommend their hospital to family or friends; we compared nurses reporting 'definitely yes' with other nurses. nurses were asked to report which care tasks, including adequate patient surveillance, administering medications on time and administering treatments and procedures on time, were important but left undone due to a lack of time on their last shift, and whether important patient care information was lost during handoffs. these too were dichotomised. nurses reported on operational failures in their practice setting including: how frequently their work is interrupted or delayed by insufficient staff, non-nursing tasks, missing supplies/broken equipment, missing medications, missing/late/wrong diet and electronic documentation problems. for these items, nurses who reported 'frequently' were contrasted with all other nurses. measures of patient satisfaction were obtained from publicly available hcahps data. risk-adjusted measures are reported at the hospital level as the percentage of patients who gave their hospital a favourable rating. two global hcahps items are used to contrast patients who rated their hospital 8 or less on a 10-point scale and would not definitely recommend their hospital to family or friends. from aha annual survey data hospitals were categorised as small (≤100 beds), medium (101-250 beds) or large (>250 beds). teaching status was categorised based on the ratio of medical residents/fellows per bed. non-teaching hospitals had no residents/ fellows, minor had <1:4, major teaching hospitals had ≥1:4. high-technology hospitals had the capacity to perform open-heart surgery or major organ transplantation. controls for state (il vs ny), location (nyc vs elsewhere) and public versus private hospitals were included, as were individual nurse characteristics from the nurse survey. nyc hospitals included hospitals in the five boroughs (ie, brooklyn, bronx, manhattan, queens, staten island) as well as westchester and nassau counties. we report the number of hospitals and medicalsurgical and icu nurses in our samples of hospitals, overall and by state and location, and selected characteristics including staffing ratios and hospital characteristics. we show the percentages of nurses reporting unfavourable outcomes, overall and by location. χ 2 statistics, t-tests and f-tests are used, as appropriate, to test the significance of the differences found across states and locations. data are reported by state because policies related to the nurse workforce are largely the domain of state government. nyc hospitals are compared with hospitals elsewhere since nyc experienced the initial brunt of the covid-19 epidemic. mixed-level logistic regression models, adjusting for hospital and nurse characteristics, are used to test associations between nurse staffing and outcomes, and to assess for differences across hospitals in nyc and elsewhere. finally, we analyse hcahps patient data using ordinary least squares models to determine whether nurse reports of quality, at least generally, are corroborated by patient reports. table 1 shows the numbers of nurses and hospitals from which staffing could be estimated. these estimates were provided by an average of 16.9 medicalsurgical nurses and 12.2 icu nurses per hospital. the average patient-to-nurse ratio was significantly higher (worse) for medical-surgical nurses in ny than in il (5.9 vs 5.2), especially for hospitals in nyc (6.5 vs 5.4); the average patient-to-nurse ratio for icu nurses was also significantly higher for hospitals in nyc (2.4 vs 2.2). medical-surgical patient-to-nurse staffing ranged considerably across hospitals (3.3 to 9.7) and across nyc hospitals (4.0 to 8.8); variation was also observed for icus (1.5 to 4.0 overall; 1.6 to 4.0 in nyc). figure 1 shows the variation in staffing among medical-surgical units across the 254 study hospitals. each bar represents a hospital, with nyc hospitals denoted in blue. there is substantial variation in nurse staffing across all hospitals and nyc hospitals. while the average number of patients per nurse in some nyc hospitals was below the mean (5.6 patients per nurse), nurses in most nyc hospitals carried patient loads well above the mean. table 2 shows the percentages of unfavourable ratings by nurses on both medical-surgical units and icus. close to half of nurses exhibit high burnout. nearly half give their hospitals unfavourable grades on patient safety, a third give unfavourable grades on infection prevention and almost 70% would not definitely recommend their hospitals. the majority of nurses report their work was frequently interrupted or delayed by insufficient staff and a third of nurses report interruptions or delays from missing supplies including medications and missing/broken equipment. the bottom rows of table 2 show the percentage of patients who rated their hospital 8 or less on a 10-point scale and who would not definitely recommend it. as with nurses, substantial percentages of patients report unfavourably, and differences in both patient outcomes and a sizeable number of the differences between nurse outcomes in nyc hospitals and elsewhere are significant. for nurse reports, the first column of the left and right panels of table 3 shows the unadjusted associations of medical-surgical and icu staffing with the nurse and patient outcomes. the second column in original research each panel shows the associations between staffing and outcomes after adjusting for location and other characteristics, while the third column shows the association between location (nyc vs elsewhere) and outcomes after adjusting for staffing and other characteristics. the effect of medical-surgical and icu staffing is sizeable (ors range from 1.12 to 1.60 and 1.10 to 3.63, respectively) and significant on every outcome, before and after adjustment, except the adjusted effect of icu staffing on missed treatments and procedures. there are virtually no significant differences by location after adjusting for staffing, despite the unadjusted differences shown in table 2. we tested for interactions, or differences in the effect of staffing by state and location but found none. thus, the effect of staffing is of similar importance to outcomes in all hospitals, and partly accounts for differences we find in nyc hospitals. the bottom panel shows that after adjustments for nurse staffing and other hospital characteristics the differences in patient reports across locations are virtually nil. here too, as with nurses, the medicalsurgical staffing effect was similar across all hospitals (ie, no interactions were found), and workloads that were greater by a single patient per nurse had roughly 3% more patients rating their hospitals 8 or lower and who were unwilling to definitely recommend it. in the weeks before the surge of patients with covid-19, hospital nurses in ny and il were already struggling with high patient workloads and frequent operational failures including missing supplies and missing or broken equipment. patient-to-nurse ratios ranged considerably across hospitals in both states from means of 3.3 to 9.7 on adult medical-surgical units. half of nurses were experiencing high burnout, and one in four planned to leave their job within a year. over twothirds of nurses would not recommend their hospitals to family and friends needing care, and almost half reported unfavourable patient safety ratings. patients corroborated nurses' assessments with over a third of patients rating their hospitals less than excellent and reporting they would not definitely recommend it. unfavourable patient and nurse outcomes are strongly associated with poorer nurse staffing. pending nurse staffing legislation in both ny and il, which continue to be actively considered despite societal and economic disruptions caused by non-nyc hospitals refer to hospitals in the sample outside of the five nyc boroughs and westchester and nassau counties. ns refers to differences which are insignificant at the 0.05 level. *, **, *** denote differences in reports between locations which are significant with p <0.05, p <0.01 and p <0.001, respectively, using χ 2 tests. ns, not significant; nyc, new york city. covid-19, 18 19 stipulates that nurses take care of not more than four adult medical or surgical patients at a time outside of intensive care. the data presented in figure 1 demonstrate that the vast majority of ny and il hospitals currently staff worse than the level proposed in pending legislation. in ca, the only state with implemented staffing legislation, nurses are not allowed to care for more than five adult medical or surgical patients at a time. 36 the majority of ny and il hospitals are currently understaffed relative to the benchmarks in pending legislation in their own states and the benchmark passed 20 years ago in ca. similar variation in staffing and widespread understaffing were observed in icu units across hospitals in ny and il. although ca had somewhat better staffing before implementing its nurse staffing policy, nurse staffing levels have experienced greater sustained improvement in ca compared with both ny and il, as well as other states. 37 our findings demonstrate wide variation in staffing within ny and il, as well as table 3 unadjusted and adjusted ors estimating the effects of staffing and location on medical-surgical and intensive care nurses reporting unfavourable outcomes odds on nurses reporting: original research significant understaffing relative to currently proposed legislation. 18 19 aha annual survey data derived from reports by hospital administrators confirm worse staffing in these two states relative to many other states, including ca where minimum nurse staffing has been legislated. 37 there are several reasons why hospital nurse staffing legislation efforts often fail to garner widespread support among key stakeholders. the first barrier, which our paper directly addresses, is the lack of local and timely evidence to demonstrate a need for such legislation. using recent data in two states currently considering staffing legislation we describe the variation in hospital nurse staffing and the associated consequences in terms of nurse burnout and patient care quality and safety. the second major barrier is the common misconception about a us shortage of nurses, which would make the proposed legislation difficult to implement. however, the usa has more than doubled graduations of rns over the past 15 years and the number of new rns entering the workforce is at an all-time high of over 150 000 a year, more than enough to replace annual retirements. 38 39 moreover, ca, which successfully implemented minimum safe nurse staffing requirements, has fewer rns (11.3 per 1000 population) than most other states and far fewer than ny (18.7 per 1000 population) or il (16.7 per 1000 population). 40 differences in hospital nurse staffing by state have little to do with the supply of nurses. during the covid-19 emergency, some states approved temporary provisions to permit nurses licensed in one state to practise in another. 41 this enabled greater mobility of nurses to work across state lines and in regions with high care needs. there is already an existing policy solution to local and shortterm nurse shortages that might arise from implementing new nurse staffing legislation and during epidemics or other mass casualty situations-the nurse licensure compact. passed in 34 states but not in ny or il or massachusetts, 42 the compact enables nurses licensed in any compact state to practise in any other via multistate nurse licensure. adoption of the nurse licensure compact by the remaining states could alleviate local or short-term nursing shortages. the third major barrier to enacting nurse staffing legislation is the potential additional costs hospitals would undertake in order to comply with regulations. while an evaluation of the costs associated with implementing the proposed policies was outside the scope of this analysis, previous research demonstrates a favourable business case for hospital investments in nurse staffing, including cost savings through shorter lengths of stay and avoided readmissions. 13 43-46 after implementing their nurse staffing policy, ca hospitals saw sustained improvement in staffing including in safety-net hospitals which often operate on razor-thin financial margins. 47 48 moreover, there has been no evidence of hospital closures in ca as a result of the staffing legislation. we lack objective clinical data on patient outcomes in 2020 due to reporting lags but other studies we cite here have demonstrated relationships with nurse reports of quality and objective outcomes such as mortality. 49 we lack information on physician staffing and burnout. given their shared work environments and patients, our findings are likely a good proxy for what doctors are also experiencing with their high rates of burnout reported by the national academy of medicine. 50 though the findings do not establish causal links between nurse staffing and outcomes, other studies have found similar relationships using longitudinal and cross-sectional analyses. 15 16 51 52 while data in this analysis are from two states, other recent studies using 2016 data in four states (ie, ca, florida, new jersey, pennsylvania) and a similar study in queensland, australia 53 show similar findings of widespread hospital nurse understaffing associated with adverse consequences for patients and nurses. 21 54 we do not yet know how variation in hospital nurse staffing has impacted patient deaths during this unprecedented crisis. we do know from our data that the needed nursing care surge required to treat patients with covid-19 is being created from a deficit status quo in which the nurse workforce was already emotionally depleted prior to the surge in patients with covid-19. while differences in state-wide average hospital nurse staffing levels between ny and il exist, our findings are consistent with what much of past research has shown, namely that chronic nurse understaffing has persisted in a significant share of us hospitals for decades, and poses significant risk to patients even without the presence of a pandemic. 1 7 8 15 16 the covid-19 pandemic has highlighted shortcomings in us healthcare. our findings point specifically to the risks posed to the public's health of wide variation in hospital nurse staffing if allowed to persist. pending legislation in ny, il and other states and international jurisdictions can be better informed by the availability of current local empirical data on existing variation in hospital staffing and its consequences for the public. twitter karen b lasater @k_lasater, linda h aiken @lindaaiken_penn and rachel french @rachel_e_french nurse staffing and education and hospital mortality in nine european countries: a retrospective observational study nurse staffing and inpatient hospital mortality nurse staffing effects on patient outcomes: safety-net and non-safety-net hospitals effects of nurse staffing, work environments, and education on patient mortality: an observational study nurse staffing and patient outcomes: strengths and limitations of the evidence to inform policy and practice. a review and discussion paper based on evidence reviewed for the national institute for health and care excellence safe staffing guideline development nurse-patient ratios as a patient safety strategy: a systematic review hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction nurse-staffing levels and the quality of care in hospitals risk factors for hospital-acquired 'poor glycemic control': a case-control study patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in europe and the united states patients' perception of hospital care in the united states nurse staffing and the work environment linked to readmissions among older adults following elective total hip and knee replacement comparison of the value of nursing work environments in hospitals across different levels of patient risk nurse staffing, burnout, and health care-associated infection effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments effect of changes in hospital nursing resources on improvements in patient safety and quality of care: a panel study nurses' reports of working conditions and hospital quality of care in 12 countries in europe illinois general assembly. hb 2604 -safe patient limits act new york senate and assembly. s.1032/ a.2954 -safe staffing for quality care act. 2019-2020 legislative session why surviving covid might come down to which nyc hospital admits you. the new york times nurses' and patients' appraisals show patient safety in hospitals remains a concern nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care more nurses means better care-so why did this ballot measure fail? the nation the people of massachusetts decide the fate of nurse-patient staffing ratios massachusetts voters reject mandated nurse-topatient staffing ratios massachusetts voters reject nurse staffing standards psychological distress, coping behaviors, and preferences for support among new york healthcare workers during the covid-19 pandemic the moral distress of patients and families provider burnout and fatigue during the covid-19 pandemic: lessons learned from a high-volume intensive care unit countries with high registered nurse (rn) concentrations observe reduced mortality rates of coronavirus disease 2019 (covid-19). available at ssrn the effect of nurse staffing patterns on medical errors and nurse burnout nurse burnout and patient satisfaction a methodology for studying organizational performance the measurement of experienced burnout california legislative information. a.394 -health facilities: nursing staff contradicting fears, california's nurse-to-patient mandate did not reduce the skill level of the nursing workforce in hospitals registered nurse supply grows faster than projected amid surge in new entrants ages 23-26 nclex® examination statistics national council of state boards of nursing. state response to covid-19 is your state moving forward with the nurse licensure compact? chicago, il: national council of state boards of nursing valuing hospital investments in nursing: multistate matched-cohort study of surgical patients nurse staffing in hospitals: is there a business case for quality? the economic value of professional nursing examining the value of inpatient nurse staffing: an assessment of quality and patient care costs nurse staffing and quality of care with direct measurement of inpatient staffing impact of nurse staffing mandates on safety-net hospitals: lessons from california nurse reported quality of care: a measure of hospital quality taking action against clinician burnout: a systems approach to professional well-being nurse staffing and patient outcomes: a longitudinal study on trend and seasonality a longitudinal examination of the association between nurse staffing levels, the practice environment and nurse-sensitive patient outcomes in hospitals the case for hospital nurse-to-patient ratio legislation in queensland, australia hospitals: an observational study improved work environments and staffing lead to less missed nursing care: a panel study the authors wish to acknowledge tim cheney for his contributions to data management and analysis.funding national council of state boards of nursing; national institute of nursing research (grant number: r01nr014855); leonard davis institute of health economics. competing interests none declared. provenance and peer review not commissioned; externally peer reviewed. key: cord-266405-l102f1e3 authors: buckley, laura; berta, whitney; cleverley, kristin; medeiros, christina; widger, kimberley title: what is known about paediatric nurse burnout: a scoping review date: 2020-02-11 journal: hum resour health doi: 10.1186/s12960-020-0451-8 sha: doc_id: 266405 cord_uid: l102f1e3 burnout in healthcare providers has impacts at the level of the individual provider, patient, and organization. while there is a substantial body of literature on burnout in healthcare providers, burnout in pediatric nurses has received less attention. this subpopulation may be unique from adult care nurses because of the specialized nature of providing care to children who are typically seen as a vulnerable population, the high potential for empathetic engagement, and the inherent complexities in the relationships with families. thus, the aim of this scoping review was to investigate, among pediatric nurses, (i) the prevalence and/or degree of burnout, (ii) the factors related to burnout, (iii) the outcomes of burnout, and (iv) the interventions that have been applied to prevent and/or mitigate burnout. this scoping review was performed according to the prisma guidelines scoping review extension. cinahl, embase, medline, psycinfo, assia, and the cochrane library were searched on 3 november 2018 to identify relevant quantitative, qualitative, and mixed-method studies on pediatric nurse burnout. our search identified 78 studies for inclusion in the analysis. across the included studies, burnout was prevalent in pediatric nurses. a number of factors were identified as impacting burnout including nurse demographics, work environment, and work attitudes. similarly, a number of outcomes of burnout were identified including nurse retention, nurse well-being, patient safety, and patient-family satisfaction. unfortunately, there was little evidence of effective interventions to address pediatric nurse burnout. given the prevalence and impact of burnout on a variety of important outcomes, it is imperative that nursing schools, nursing management, healthcare organizations, and nursing professional associations work to develop and test the interventions to address key attitudinal and environmental factors that are most relevant to pediatric nurses. burnout has been a widely studied topic of interest over the last 40 years, with significant resources devoted toward investigating its causes, impacts, and strategies for mitigation [1] . burnout is a work outcome, defined by prolonged occupational stress in an individual that presents as emotional exhaustion, depersonalization, and diminished personal accomplishment [2] . the study of burnout in healthcare professionals is important as it has impacts at the level of the individual provider [3] [4] [5] , the patient [6] [7] [8] [9] , and the organization [5, [10] [11] [12] . as nurses make up the largest group of healthcare professionals, there have been a number of studies that have explored contributing factors [13] and interventions for their burnout [14] . pediatric nurses are a lesser-studied population, perhaps due to the relatively small number of pediatric nurses compared to general service nurses and the broader population of healthcare professionals. burnout in pediatric nurses may be unique from adult care nurses because of the specialized nature of providing care to children who are typically seen as a vulnerable population, the high potential for empathetic engagement, and the inherent complexities in the relationships with families [15, 16] . only one literature review could be located on the topic of pediatric nurse burnout; it mainly focused on burnout prevalence, which was found to be moderate to high [17] . further synthesis of the literature in other domains of the topic is needed to explore factors associated with pediatric nurse burnout, the associated outcomes, and interventions. the purpose of this scoping review is to explore what is known about pediatric nurse burnout to guide future research on this highly specialized population and, ultimately, improve both pediatric nurse and patient wellbeing. more specifically, the aim of this scoping review was to investigate, among pediatric nurses, (i) the prevalence and/or degree of burnout, (ii) the factors related to burnout, (iii) the outcomes of burnout, and (iv) the interventions that have been applied to prevent and/or mitigate burnout. this scoping review was performed according to the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines scoping review extension [18] . the protocol was registered on open science framework on 25 march 2019 and can be accessed at https://osf.io/5xrkg/. in consultation with an experienced librarian, the following electronic databases were searched on 3 november 2018 without limitation to a publication date range in order to maximize inclusion: the cochrane library, cinahl, embase, medline, psycinfo, and assia. all electronic database search strategies used in this review can be found in appendix a. the term "pediatrics" was not part of the electronic database search to avoid inadvertently excluding studies that contained pediatric nurses as a non-primary subject group. the selected articles from the electronic database search were screened for inclusion of the pediatric nurse population. for the purposes of this review, the pediatric patient population is defined as newborn to age 21 as defined by the american academy of pediatrics, acknowledging that this age range may be slightly extended based on the country and patient needs [19] . all qualitative, quantitative, or mixed-methods studies published in english that examined the prevalence and/ or degree of burnout in pediatric nurses using selfidentification or self-report assessment tools were included. commentaries, letters, and editorials were excluded as these are not peer-reviewed and often referred to colloquial definitions, not the clinical definition of burnout of interest in this scoping review. dissertations were excluded, but their corresponding publications were screened for inclusion. conference abstracts were excluded as they are often inconsistent with their corresponding full reports [20] . systematic or scoping reviews and meta-synthesis were excluded, but references were hand-screened for suitable studies. all citations retrieved from the databases were uploaded into endnote with duplicates removed as per protocol [21] . the remaining citations were uploaded into covidence for review by the research team (lb, cm, kw). titles and abstracts were independently reviewed against the selection criteria in a blinded process by two reviewers (lb and cm). the remaining citations were then reviewed as full-text articles for inclusion against the selection criteria in a blinded process by two reviewers (lb and cm). disagreements were resolved by a third reviewer (kw). data were extracted from included articles and entered into a microsoft excel spreadsheet. extraction was performed by one researcher (lb). the following data items were extracted: title, journal, authors, year of publication, country of publication, sample size, study aim, study design, tool used to measure burnout, burnout prevalence and scores, factors that contribute to the development of burnout in pediatric nurses, factors that prevent or mitigate burnout in pediatric nurses, the impact of burnout in pediatric nurses, and interventions for pediatric nurse burnout. a quantitative synthesis specific to the prevalence and degree of burnout was completed based on the included articles that reported raw scores for any of the maslach burnout inventory (mbi) subscales. a mean score was calculated by hand across studies for each subscale, by totaling the raw scores and dividing by the total number of studies that included a raw score for that subscale. the resulting mean was also categorized as low, moderate, or high burnout based on published cutoff scores [22] . other data were synthesized qualitatively to map current evidence available to address the remaining study aims. aims ii and iii were analyzed using directed content analysis [23] following the themes outlined by berta et al. [24] , work environment, work attitudes, and work outcomes. aim iv data was synthesized by grouping together similar interventions and descriptively summarizing the interventions that were effective in reducing burnout. given that the overall purpose of the review was to explore the breadth of what is currently known about burnout in pediatric nurses, a quality assessment of individual studies was not conducted [18] . through the initial database search, 16 909 possible papers were identified. after deduplication, 8629 titles/ abstracts were screened and 1206 articles were assessed for eligibility at the level of full-text screening. after applying the inclusion and exclusion criteria, a total of 78 studies [16, were deemed relevant and retained for analysis (fig. 1) . the characteristics of included studies are provided in table 1 . publication dates ranged from 1981 to 2018, with the majority published between 2009 and 2017. the number of pediatric nurses who participated as either a primary or sub-sample ranged from five to 3710. the most common study design was cross-sectional (n = 60), with 10 studies using multi-or mixed methods, seven using an interventional design, and one each using case-control, exploratory prospective, and longitudinal designs. only 45 of the 78 studies reviewed used exclusive samples of pediatric nurses; the remaining studies only included pediatric nurses as a subpopulation of a larger sample. the results in this review are reported for pediatric nurse samples and subsamples only. almost half (46%) of the included studies were conducted in the usa, followed by canada (n = 7), china (n = 5), turkey (n = 3), brazil (n = 3), taiwan (n = 2), australia (n = 2), and switzerland (n = 2), plus 18 other countries where only a study was conducted. out of the 78 studies included, 53 (68%) used some form (either complete or abbreviated) of the mbi to measure burnout (see table 1 ). although all of the included studies measured burnout using a self-report assessment tool or binary selfidentification, only 65 reported burnout scores for a sample of pediatric nurses ( table 2 ). in total, 53 studies used the mbi, 34 reported on the emotional exhaustion subscale with 24 reporting raw scores [25, 27, 29, 39, 42, [22] . the individual scores from the mbi and other measurement tools are reported for each study in table 2 . of the included studies, 47 (60%) addressed factors associated with pediatric nurse burnout (table 3) . factors related to pediatric nurse burnout were classified into the following categories: nurse demographics, work the average score on the burnout subscale is 50, which is higher than the 50th percentile ranking in this current study (slightly lower than average levels of burnout). environment, work attitudes, work outcomes, and burnout interventions. burnout was found to be inversely associated with age; higher burnout was also associated with low/moderate level of experience (5-10 years) [26, 32, 46, 47, 58, 71, 85, 88] . a lack of university-level education or lower self-reported levels of clinical competency were also associated with higher levels of burnout [57, 90] . being in a nursing supervisory position had ambiguous results on impact on burnout; in some studies, holding supervisory positions correlated with higher reports of burnout while in others, the opposite effects were found [29, 33] . nurses identifying as not being white or asian/pacific islander ethnicity/race scored significantly lower on the mbi subscale of personal accomplishment than respondents identifying as white and asian/pacific islander, and asian/pacific islanders scored lower on emotional exhaustion than those identifying as white [36] . high neuroticism and low agreeableness [31] were both associated with higher burnout. finally, being married had mixed results on impact on burnout, whereas in some studies, being married correlated negatively with burnout, and in others, it correlated positively [26, 36, 101] . the work environment is defined by the conditions in which nurses work; it influences work attitudes and, in turn, work outcomes [103] . burnout was found to be high in certain high-acuity pediatric units including emergency, medical/surgical, surgery, pediatric intensive care unit (picu), and neonatal intensive care unit (nicu) [26, 32, 35, 36, 76, 88] . davis et al. [38] found that adult oncology nurses had higher personal accomplishment than pediatric oncology nurses while neumann et al. [74] found nurses who care for both pediatric and adult patients had lower emotional exhaustion than those who cared for adult patents only. conversely, sun et al. [94] found that nurses who worked in adult obstetrics and gynecology units had more burnout than nurses who worked in pediatric units; however, ohue et al. [78] reported the inverse. working in hematology/oncology [88] and unit-level factors such as workload [65, 85] , number of assigned patients [26] , increased number of admissions, understaffing, and shifts > 8 h were associated with increased burnout [51, 92, 95, 96] . aytekin et al. [29] found working longer years in the nicu was associated with lower levels of personal accomplishment. brusch et al. [36] found that nurses working exclusively day shifts had higher levels of depersonalization than those working night shifts or a mix of days and nights. favrod et al. [45] found nicu nurses reported more traumatic stressors in their working environment. pediatric nursing workplaces with a strict structure of rules and regulations [33] or nurse leaders who valued structure over staff considerations [41] were found to have nurses with higher burnout. nurses who had higher perceived organizational support had lower burnout [39] . higher burnout was generally associated with systems issues such as unreasonable policies, staffing shortages, insurance frustrations, high volumes of paperwork [65] , lack of nursing supplies [36] , and lack of regular staff meetings [56] . the relationship between resources and facets of burnout was mixed: rochefort and clarke [83] found a negative relationship between nurses' emotional exhaustion and their rating of the adequacy of the resources available to them, while gallagher and gormley [46] found that even nurses who reported that higher ee associated with nurses working most frequently in the picu relative to those working most frequently in the nicu, those who found communication with nurses more stressful, and having a lack of necessary nursing supplies lower ee associated with being married or in a domestic partnership relative to respondents who were unmarried and not in a domestic partnership, identifying as asian/pacific islander relative to respondents identifying as white higher dp associated with respondents working day shifts relative to those working the night shift or a mix of day and night shifts, nurses working most frequently in the picu relative to those working most frequently in the nicu, greater endorsement of stress related to communication among nurses, the experience level of colleagues, staffing, and stress associated with the patient population lower dp associated with respondents working in the nicu relative to those working frequently in the picu and respondents who reported being married or in a domestic partnership higher pa reported in individuals identifying as white and individuals identifying as asian/pacific islander relative to individuals identifying as others lower pa found in nurses who found their own lack of knowledge, skills and/or confidence in themselves stressful and respondents identifying as being of another ethnicity/race relative to respondents identifying as white czaja et al. [37] 173 lack of burnout or ptsd associated with nurses who generally felt more positively about their work environment, with more confidence in their physician and nurse collogues as well as feeling a part of a team davis et al. [38] 15 higher pa associated with working in adult oncology over pediatric oncology nurses dos santos alves et al. [39] 267 lower burnout associated with nurses with a perception of having greater autonomy, greater control, good relationships at work, and organizational support, and are more satisfied with the work and the safety climate is assessed as more positive duxbury et al. [41] 283 higher burnout found in staff nurses who have a head nurse with a leadership style of high structure and low consideration estabrooks et al. [43] 844 higher ee associated with lower job satisfaction favrod et al. [45] 91 similar burnout levels in nicu nurses and midwives lower dp associated with elf-compassion at time 1 and time 2, but not at time 3 higher pa associated with self-compassion at all three time points all subscales of burnout were correlated with job satisfaction at time 1, but not at time 2 and time 3 lower burnout associated with more years of experience, job satisfaction had a significant positive correlation with stress and burnout only at time 1 holden et al. [51] 347 higher burnout associated with unit-level staffing, task-level external mental workload, and job dissatisfaction burnout and job dissatisfaction were not significantly associated with the likelihood of medication error klein et al. [56] 302 nurses rated lack of regular staff meetings, dissatisfaction with the quality of the decision-making process, and providing futile treatment as significantly more stressful than physicians did factors associated with triggering burnout: seeing too many painful procedures done to children, seeing too much sadness, seeing too much death, angry, yelling families, and non-compliant patients/ families systems triggers: unreasonable policies, staffing shortages, insurance frustrations, paperwork, need to justify their position, and general healthcare system dysfunction role-specific triggers: lack of support, feeling you are on your own, less respondents cited unclear expectations, change in role and lack of challenge work overload: excessive demands of work factors associated with coping with burnout: short-term-self-care (exercise, meditation, journaling), fun/humor, non-work relationships; long-term personal coping strategies-developing a personal philosophy and faith and engaging in self-analysis short-term work-related coping strategies: developing supportive and honest professional relationships, need for their work to be congruent with their professional philosophy and interest messmer et al. [67] 33 higher burnout associated with lower satisfaction and position lower burnout associated with nurses who would recommend their career to others relative to those who would recommend their career with reservation meyer et al. [16] 251 higher burnout predicated by current stress exposure after controlling for pre-existing stress exposure morrison wylde et al. [70] 95 lower burnout associated with "acting with awareness" at time 2 mahmood [71] 55 higher ee associated with lack of access to work information lower ee associated with nurses increased age, length of professional experience, and experience on the support systems were in place and felt supported still were emotionally exhausted. the lack of access to work information and research information was consistently associated with higher levels of burnout [71, 91] , and lower burnout was associated with increased communication [33, 36] and better work relationships [39] . factors impacting increased pediatric nurse burnout were related to the role of the nurse in patient care higher pa found in nurses in the pediatrics and outpatient departments relative to those of the nurses in the obstetrics and gynecology departments pagel and wittmann [79] 74 higher burnout related to higher reporting of the variable "percentage of children on a unit with social of behavioral problems" clarke [83] 339 lower ee associated with higher ratings of nurse staffing and resource adequacy higher ee associated with greater time on the unit (moderate effect), nurses concern that current standards of care inhibit optimal pain management, negative views of the hospital environment (large effect), barriers to optimal pain management (moderate effect), lower self-efficacy (moderate effect), and moral distress (moderate effect) burnout associated with expressions of exhaustion, frustration, overburden of their workload, and the hopelessness in working with chronically ill pediatric patients, issues about self-efficacy regarding patient outcomes sekol and kim [88] 240 higher burnout found in those with 5-9 years of experience working on the surgical unit lower burnout associated with working on the hematolgy/oncology unit, nursing experience of > 20 years, and all levels of experience if working on the hematolgy/oncology unit activities such as decision-making/uncertainty around treatment [33, 39, 56, 76] , lack of role clarity, and unclear plan of care [65] . other factors associated with the development of burnout were related to exposure to suffering, pain, sadness, and death [65] ; hopelessness [85] ; providing futile care [56] ; and overall moral distress [85] . higher levels of burnout were found in nurses who cared for specific pediatric patient populations such as caring for children with cerebral palsy [97] , children with cystic fibrosis [59] , and babies with neonatal abstinence syndrome [73] . another patient factor related to higher burnout involved behavioral issues from patients/families [65, 79] . work attitudes are factors that impact the positive or negative perceptions of one's work environment [104] . low self-compassion and low mindfulness [47] were associated with higher burnout. co-occurring conditions with burnout such as depression [37, 63, 97] , anxiety [97] , and somatic work-related health problems [101] were correlated with greater burnout whereas positive psychosocial factors and coping strategies such as positive affect [30] , acting with awareness [70] , self-care, humor, reflection, non-work relationships, and a personal philosophy related to work were found to be associated with lower burnout [65] . nurses' perceived work stress was positively associated with burnout in several studies [16, 28, 63, 76, 77] . meyer et al. [16] found that current stress exposure significantly predicted higher levels of burnout after controlling for pre-existing stress exposure, and holden et al. [51] found that burnout was positively associated with mental workload. oehler and davidson [76] found table 4 burnout's relationship with other work outcomes in pediatric nurses author(s) number of pediatric nurses alves and guirardello [27] 267 higher ee associated with the outcome of a worse patient safety climate aytekin et al. [29] 85 higher burnout associated with the outcome of decreased quality of life in the nurse czaja et al. [37] 173 higher burnout and ptsd were found in nurses considering a change of career, more frequently screened positive for anxiety and depression, were more likely to respond negatively regarding their team members, teamwork, and impact of their work a large portion of nurses with both burnout and significant ptsd symptoms found their symptoms interfered with their work and personal lives dos santos alves et al. [39] 267 lower burnout associated with the outcome of positive assessments of the safety climate perceived workload made a significant contribution to feelings of burnout. job satisfaction was also found to be negatively associated with burnout [26, 29, 39, 43, 47, 51, 67] . work outcomes refer to occupational performance factors that are influenced by work attitudes and the work environment [24] . nine studies examined work outcomes associated with burnout including nurse retention, nurse well-being, patient safety, and patient-family satisfaction ( table 4 ). an increase in burnout was associated with nurses considering a career change [37] , decreased quality of life [29] , tiredness [89] , and feeling negatively toward their teammates and the impact of their work [37] . work-associated compassion fatigue [16, 66] , secondary traumatic stress [48, 58] , and posttraumatic stress disorder (ptsd) [37, 60, 70] were all found to be associated with pediatric nurse burnout. however, li et al. [60] report that high group cohesion may prevent pediatric nurses from developing burnout from ptsd by protecting nurses from the impacts of negative outcomes. nurse burnout was found to be negatively associated with the safety climate of the hospital in which they work [27, 39] and positively associated with higher infection rates when nurses were feeling overworked [96] . moussa and mahmood [71] found that as nurses' personal accomplishment increased, so did patients' mothers' satisfaction with meeting their child's care needs in the hospital. seven of the 78 studies included interventions to mitigate burnout (table 5) . interventions included coping workshops [42] , mindfulness activities [47, 68, 70] , workshops to improve knowledge/understanding of their patient population [81, 85] , and clinical supervision [50] . only three of the seven interventions studied provided varying positive impacts on burnout scores [42, 70, 85 ]. an in-person day-long retreat resulted in a significant improvement in emotional exhaustion for pediatric nurses. the intervention involved didactic and hands-on trauma, adaptive grief, and coping strategies; half of the subjects were also randomized to a booster session 6 months later [42] . another intervention involved a 90min interactive module on clinical skills surrounding the management of pediatric pain and resulted in a significant decrease in emotional exhaustion and depersonalization [85] . finally, the third study of smartphone-delivered mindfulness interventions showed a marginal decrease in burnout compared to nurses receiving traditional mindfulness interventions [70] . to our knowledge, this is the first scoping review that focuses on what is known about pediatric nurse burnout. burnout was measured with a variety of instruments and interpretations, thereby making score comparisons a challenge. even in those studies that used the mbi, the most commonly used burnout measurement [105] , variations of the tool were applied, as were diverse subscale cutoff scores. similar challenges in synthesizing extremely heterogeneous burnout data were echoed in a 2018 jama review of the prevalence of burnout among different types of physicians [106] . of the mbi emotional exhaustion and depersonalization subscale results that were synthesized, the results showed moderate scores indicating a significant level of burnout in pediatric nurses. personal accomplishment subscale results were high, perhaps indicating a factor of pediatric nursing that increases resilience despite moderate burnout in other domains. in studies that compared nurses who work in pediatric units to other in-patient units, burnout results were mixed [26, 32, 35, 36, 38, 74, 78, 94] . the majority of the included studies identified correlational relationships using cross-sectional study designs, which limited causal inferences. study designs, such as longitudinal approaches, would allow for causal inference and in-depth analysis of this phenomenon in this unique population. pediatric nurse demographic factors that are associated with burnout, such as age, work experience, and level of education, have been a common area of studied burnout associations across other healthcare populations. similar burnout associations were found in research studying healthcare providers caring for adults such as younger age (< 31 years) [107, 108] and years of experience (> 7 years) [109] . it is likely that nurses new to the profession are younger, are experiencing the challenges of the nursing profession for the first time, and are less likely to have well-developed skills for resiliency. given that the start of nurses' careers is a vulnerable stage for burnout, nursing schools and orientation programs may be wellpositioned to highlight burnout prevention and mitigation strategies with students and new hires [107] . personality traits such as high neuroticism and low agreeableness were found to be associated with pediatric nurse burnout [31] . these results have been supported in other nurse and physician populations, along with conscientiousness, extraversion, and openness contributing to lower levels of burnout [110] [111] [112] [113] . although personality traits appear to have significant correlations with healthcare provider burnout, targeting modulation of personality traits as a mitigation strategy for burnout may be a high-cost, low-yield strategy. it has been suggested that healthcare provider burnout is not a failure on the part of the individual, rather it is a culmination of impacts stemming from the work environment and the healthcare system as a whole [114] . responsibility, then, is thought to lie within the individual, the organization, and the profession in general. job demands and resource variables in pediatric nursing lead to increased burnout, work-life interference, psychosomatic complaints, and intent to leave; these associations are also represented in adult nursing literature [102, 115] , including associations with excessive workload, number of assigned patients, admissions, understaffing, and longer shifts [116] [117] [118] [119] . although bursch et al. [36] found that pediatric nurses who worked straight day shifts had higher depersonalization than those who worked mixed shifts or just night shifts, poncet et al. [108] found that working more night shifts was associated with higher burnout in adult critical care nurses. day shift nurses have potentially more strenuous workloads as patients are more wakeful, have diagnostic tests, or consulting services visiting; however, night shifts could be perceived as more strenuous as it requires the provider to work against their natural circadian rhythm and less support staff are available [120] . these results may also be dependent on individuals' preference and the specific unit on which they work. systems issues such as overwhelming clerical work, administrative, and resource issues have impacts on provider burnout in both the pediatric nurse and general physician populations [36, 56, 65, 121] . poor leadership is associated with pediatric nurse burnout as identified by bilial and ahmed [33] and druxbury et al. [41] ; this 88 care for the professional caregiver program (cpcp): day-long retreat, includes didactic and discussion-based coverage of vicarious trauma, loss and adaptive coping with grief. practical, group-based practice of coping strategies presented such as guided imagery, relaxation, body movement, and mindful breathing techniques that have been adapted for the workplace. half of the subjects were randomly assigned to a booster session 6 months later. pediatric nurses showed greatest improvement in the group in ee scores 1 month post-intervention and 7 months post-intervention. the results not impacted by receiving booster session or not. gauthier et al. [47] 45 5-min daily mindfulness sessions. conducted on the unit, as a group, facilitated by a mindfulness meditation instructor. mindfulness cds and booklets were distributed after the 1-month follow-up surveys were completed. 1) intervention was found to be feasible for picu nurses. 2) ee was negatively correlated with mindfulness at all three time points. 3) pa was positively correlated with mindfulness at all three time points. 4) dp was not correlated with mindfulness at time 3 but was negatively correlated with mindfulness at times 1 and 2. hallberg [50] 11 systematic group clinical supervision was performed every third week for two full hours (14 sessions/28 h all together. supervision performed by a registered nurse, with advanced training and extensive experience in psychiatric care. the mean score of the tedium degree decreased over the 12 months significantly for mental exhaustion. there were no significant changes in the degree of burnout as measured by the mbi. sdm group reported significantly more "acting with awareness" and marginally more "non-reactivity to inner experience" skills compared to the tdm group. the sdm group showed marginally more compassion satisfaction and marginally less burnout. the sdm group had a lower risk for compassion fatigue compared to the tdm group, but only when the nurses had previous sub-clinical post-traumatic symptoms. richter et al. [81] 17 nurses helped in the development of intervention materials. intervention package included five, short educational videos created to demonstrate to nursing staff and caregivers' solutions to difficulties in caring for hospitalized children affected by hiv/aids. sessions run every 2 weeks. no changes in nurse well-being were found across the pre/post-intervention phases. post-intervention, patient mothers rated nurses as more supportive; mother-child interaction during feeding was more relaxed and engaged, babies were less socially withdrawn. rodrigues et al. [84] 33 nursing know-how: skills in working with pediatric chronic pain: 90-min group session developed from previous knowledge needs assessment (rodrigues et al. 2017 ). modules contained education and case-based role play using nurse's real experiences. significant improvements on both indicators of burnout-ee and dp-over the 3-month period. however, the proportion of nurses with high ee and dp is still high. ee emotional exhaustion, a subscale of the maslach burnout inventory; dp depersonalization, a subscale of the maslach burnout inventory; pa personal accomplishment, a subscale of the maslach burnout inventory; mbi maslach burnout inventory; tdm traditionally delivered mindfulness; sdm smartphonedelivered mindfulness; mbc mindfulness-based course relationship is echoed in research with physicians, nurses, and allied health [122] . in pediatric nurses [39] , increased perception of organizational support is associated with lower burnout; this association is supported in general nursing populations [119, 123] . in all populations, the support a healthcare provider perceives they get from the organization is predictive of their level of organizational commitment. when healthcare providers perceive that they have high organizational support, they will exhibit greater organizational citizenship behavior, which are extra-role tasks that ultimately improve the organization [124] . burnout itself results in reduced organizational commitment on the part of the healthcare provider [125] . the experience of witnessing patient suffering and death [65, 122] , uncertainty around plan/utility of care [15, 56, 126] , moral distress [15, 85] , and behavioral issues with patient families (e.g., aggressive patients/families) [65, 79, 127] were found to be significant factors that contributed to burnout in both pediatric nurses and general population physicians and nurses. as might be expected, optimism, self-efficiency, resilience, and positive coping strategies are supported as inversely related to burnout in broader nursing populations [128] [129] [130] . the identification and treatment of burnout is particularly important to consider in light of the evidence that burnout is inversely related to job satisfaction and burnout is a contagious phenomenon between nurses; therefore, early intervention is essential to prevent transmission among staff [131] [132] [133] . the association between burnout and patient satisfaction and intent to leave has been reported in non-pediatric nurse populations as well [5, 6, 115, [134] [135] [136] . it is likely that as nurses become increasingly burned out their satisfaction with their jobs decreases and their desire to leave their position increases. this linkage highlights the importance of addressing nurse burnout in the organization to retain staff and reduce the financial and tacit knowledge losses associated with high nurse turnover. higher work-related burnout is also associated with mental health conditions such as anxiety and depression in pediatric nurses; this is represented in several studies of other healthcare provider populations [113, [137] [138] [139] [140] . however, the majority of these associations are correlational; thus, they are left open for further assessment if they impact the development of burnout or if burnout impacted their development. further research is needed to confirm causal, directional effects. the relationship of increased clinician burnout and decreased patient safety has been supported in additional studies of healthcare provider burnout [7, 141] . as clinician burnout increases, the detachment from patients and their work does too, which may contribute to negative attitudes toward patient safety, incomplete infection control practices, and decreased patient engagement [7, 141] . reducing burnout has the potential to impact patient safety; the quadruple aim of healthcare hopes to improve patient outcomes, such as safety, through the addition of clinician well-being as a primary aim in the model [142] . although only seven of the studies analyzed in this review included interventions, there is modest evidence on the efficacy of burnout interventions in the broader healthcare provider population. similar to the results of hallberg [50] , a study of swedish district nurses showed no impact of clinical supervision on burnout [143] . while morrison wylde et al. [70] found a marginal improvement in pediatric nurse burnout with smartphonebased intervention vs. traditional mindfulness interventions, studies investigating mindfulness interventions in other healthcare populations reported mixed results [144] [145] [146] [147] . similar to pediatric nurses [84] , social workers showed a significant decrease in burnout after attending skills development courses [148] suggesting that improving clinical knowledge and skills may reduce burnout. this is supported by the finding that pediatric nurses with lower clinical competency and education level have increased burnout [57, 90] . although edmonds et al. [42] showed significant decreases in pediatric nurse burnout using in-person trauma, adaptive grief, and coping sessions with follow-up, similar sessions have shown mixed results in other healthcare provider populations [149] [150] [151] . more research is needed to identify reliable interventions for pediatric nurse burnout that can be pre-emptively and routinely implemented by nursing schools and healthcare organizations. the search strategy was limited to publications in english; thus, potentially relevant studies in other languages were excluded. gray literature was not included; thus, informal annual surveys conducted at various healthcare institutions may have been missed; however, this was outweighed by the desire to only include peer-reviewed literature to ensure the quality of data reviewed [152] . third, the definition of "nurses" varies internationally as does their required education and scope of practice; however, the slight variations were outweighed by the need to include thorough, culturally diverse research. finally, the extreme heterogeneity of the burnout measurement tools and their application and interpretation inhibited the comparison of results across studies. our scoping review showed inconsistent measurement and interpretation of pediatric nurse burnout scores. factors associated with pediatric nurse burnout were similar to those found in other healthcare professional groups and can be separated into the domains of nurse personal factors, work environment, work attitudes, and work outcomes. only 45 of the 78 studies reviewed studied exclusive populations of pediatric nurses, and most associations identified were correlational. few interventions to prevent or mitigate pediatric nurse burnout have been undertaken, and the results were mixed, at best. further studies using mixed methods are needed to expand on these results and incorporate the direct feedback of the nurses. additional research is needed to develop and test interventions 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well-being among healthcare providers can skill-development training alleviate burnout in hospital social workers? soc work health care self-care strategies for nurses: a psycho-educational intervention for stress reduction and the prevention of burnout caring for the caregivers: results of an extended, five-component stress-reduction intervention for hospital staff the effect of a group music intervention for grief resolution on disenfranchised grief of hospice workers shades of grey: guidelines for working with the grey literature in systematic reviews for management and organizational studies publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors would like to acknowledge librarian mikaela gray for her assistance with the search strategy development. kristin cleverley was supported by the camh chair in mental health nursing research while writing this article. authors' contributions lb was involved in the study design, data collection, data analysis, data interpretation, and drafting and finalizing the manuscript. wb and kc were involved in data interpretation and substantively revised the manuscript for important intellectual content. cm was involved in the data collection (title, abstract, and full-text screening) and substantively revised the manuscript for important intellectual content. kw was involved in the study design, data interpretation, and substantively revised the manuscript for important intellectual content. all authors read and approved the final manuscript and agree both to be personally accountable for their own contributions and to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated, resolved, and the resolution documented in the literature. none of the authors have any competing interests as outlined by biomed central. this paper is part of the doctoral work of the primary author who is funded by the lawrence s. bloomberg faculty of nursing, university of toronto. the complete list of articles used as data in this review is available from the corresponding author on reasonable request.ethics approval and consent to participate not applicable. not applicable. the authors declare that they have no competing interests. key: cord-302381-oujsmf8d authors: rankin, john title: godzilla in the corridor: the ontario sars crisis in historical perspective date: 2006-06-30 journal: intensive and critical care nursing doi: 10.1016/j.iccn.2005.10.001 sha: doc_id: 302381 cord_uid: oujsmf8d summary ontario nurses were employed as the front-line workers when sars descended upon toronto in march 2003. once the crisis had subsided, many nurses remarked that sars had forever altered their chosen profession; employment, which they once viewed as relatively safe, had been transformed into potentially life-threatening. this discussion provides descriptions of these expressions through nurses who experienced the crisis and chose to go on the public record. secondly, it compares the subjective perceptions of those nurses to those held by nurses who worked through historical epidemics of unknown or contested epidemiology. the historical literature on nursing in yellow fever, cholera and influenza epidemics has been employed to offer insight. the goal is to determine whether the sars outbreak was a unique experience for nurses or whether similar experiences were shared by nurses in the past? in summary, the reactions of nurses when confronted with the possibility of contracting a deadly disease remain altogether human, not dissimilar in past or present. nurses’ responses to sars can be usefully studied within a larger historical vision of crisis nursing, and information or impressions from earlier crises are potentially of interest to the nursing profession. this is an account of the public responses of ontario nurses to the severe acute respiratory syndrome (sars) epidemic of 2003. its origins lie in an effort to comprehend the reactions of the nurses who worked through the outbreak and who came to see it as a transformative experience. in testimony gathered after the event, individual nurses stated that the arrival of sars in ontario had turned their professional world upside down (registered nurses association of ontario (rnao), 2003). employment, which at its worst might lead to a back injury, had now become something novel: it was life threatening; it was scary. one emergency room nurse stated that for the first time she knew first hand the fear of patients and their families. for another, nursing was now confronted by a wholly new phenomenon: the sars virus was likened to a deadly power as terrible and as real as an invisible godzilla stalking the hospital corridors (rnao, 2003) . one stated simply: ''this has been a very disturbing event that has given me the opportunity to have nursed in probably the worst crisis in nursing history'' (canadian federation of nurses union (cfnu), 2003: p. 20) . this account provides an understanding of these and similar sentiments within the context of the stress, isolation and alienation experienced by nurses who worked through the toronto outbreak. it also provides a historical dimension to these vibrant statements--a way of comprehending the 2003 phenomenon as part of a long tradition of nursing in the midst of public health crises. it is clear that the nurse who believes the outbreak in toronto to be the worst crisis in nursing history knows little about the history of public health nursing during epidemics. during the 20th century, the health care workers of the modern large urban hospitals of north america became largely freed from the dangers and fears of unrestrained epidemic disease. this relative safety was a stark contrast to the experiences of hospital workers of the past, especially personal care attendants, which had always been considered to be at an elevated risk of infection. one possible lesson from sars is that the advances of the 20th century cannot be assumed to be normative. it is speculative whether or not nursing will become a more lifethreatening occupation in the future. however, it is advantageous to know how nurses responded to this most recent of epidemics. this search began shortly after the conclusion of the sars crisis with a deceptively simple question: how did nurses in the past cope with workplace and personal stress during epidemics? the literature searched produced disappointingly meager results. scholars have not found this to be a worthwhile theme for study; the lack of literature in major databases like medline reinforces this point. what follows in the first half of this discussion, therefore, is not an answer to the original question, but a series of remarks on what at present is known. these remarks focus upon three of the most deadly epidemics of recent human history, 19th-century yellow fever and cholera, and the 1918-1920 pandemic of spanish influenza. following this, in the second half of the discussion, is an evaluation of the responses to sars by nurses who had experienced the crisis and chose to go on public record. the areas covered in this evaluation include: fear, isolation at home and at the work place as well as nurses' evaluation of deficiencies in the system and how they assess blame. historically, the role of the hospital nurse was perceived to be one of high risk, and even a brief overview of north american nursing during past epidemics reveals subjective feelings of fear and alienation. nurses' fears and feeling of isolation were heightened not only by the high death rates but by the propensity of loved ones and neighbors to flee infected cities leaving nurses to fend for themselves. finally, the terrible shortages, which left nurses exhausted and vulnerable to feelings of isolation, led many nurses to turn to alcohol or other dangerous methods of stress relief. the following evaluation of yellow fever, cholera and the spanish influenza will illustrate a continuity in epidemic nurses' feelings of fear and isolation from the mid-19th to the early 20th century. america's experience with yellow fever in the second half of the 19th century proved to be both transformative and deadly. this disease resulted in the creation of the first state boards of health, which were central to the development of a national public health system (humphreys, 1992) . the yellow fever outbreak of 1853 in new orleans was so deadly that the disease was responsible for half the city's mortality in that year (humphreys, 1992) . because of its mysterious epidemiology and its ability to devastate a population, yellow fever was particularly feared by both the lay public and protectors of public health. as in the early days of sars virus research, scientists were baffled by the spread of yellow fever and strenuously debated the best methods of containment and eradication (humphreys, 1992) . yellow fever nurses worked in dangerous conditions with extremely long hours; severe labour shortages were commonplace as demand outstripped supply. it was common during the onset of an epidemic for the public to flee infected areas. the mass exodus, one may assume, produced feelings of isolation in nurses as family and friends fled. most who nursed during the epidemics of the 19th century were not regular nurses; they were drawn into the work temporarily for reasons of benevolence or economics. the isolation, the shortages, and the general concern that they may contract this deadly disease presumably placed a tremendous stress upon the nurses. one indirect sign of this stress was that it was not uncommon to have nurses arrested for drunkenness during the epidemics (adams, 1889) . nurses also had to deal with the experience of loss because a high percentage of patients did not survive. in respect to both yellow fever and cholera nursing, the evidence produced at the time spoke to the central importance of the personal qualities of the nurse. health care issues were personalized and systemic issues attracted far less attention. nurses were essential during cholera outbreaks for they were responsible for helping patients through the most deadly and unpleasant stages of the disease. cholera hospitals offered nurses a most unpleasant place to work for they were often overcrowded with patients and filled with both a terrible stench and frightening sounds. one nurse who worked during an epidemic in germany vividly reported the ''wailing and screaming and moaning, echoed gruesomely through the room'' (evans, 1987: p. 331 ). nurses performed work which was perpetually unpleasant and perceived to be high risk: ''to touch a corpse seemed impossible to me, the penetrating stench that rose from the last evacuation of his bowels into the bed almost robbed me of my senses'' (evans, 1987: p. 331 ). these working conditions combined with the reality of death took a toll on nurses. nurses' demands for alcohol as a method to steady nerves or to escape the horrors of a cholera hospital was reported to be high. this demand for alcohol was particularly noticed among volunteer nurses, who were perhaps less prepared psychologically for the fight against cholera (evans, 1987) . once again, there were routine severe nursing shortages (rosenberg, 1962) . the work was inherently dangerous, far more than sars nursing. statistics rarely appear in the published record; however, at the greenwich hospital in new york, 14 of the 16 nurses employed during the epidemic of 1832 died of cholera (rosenberg, 1962) . contemporaries noted that frequently nurses shirked their duties and fled infested cities (rosenberg, 1962) . as with yellow fever, contemporary descriptions of cholera nursing were characterized by a dichotomy: the trustworthy, dedicated nurse versus the dissolute, corrupt nurse. there is no complexity to this portrayal, and rarely do the nurses possess their own voice. what is clear for both diseases is that effective nursing was considered to be of crucial importance to recovery of patients, and that work conditions were appalling by the standards of that age. spanish influenza was the most deadly modern pandemic. responsible for the death of an approxi-mately 50 million people between 1918 and 1920, this disease attacked an estimated half a billion people, approximately half the world's population (johnson and mueller, 2002) . it struck with such force that cape town's assistant medical officer of health believed that the human population might be completely wiped out (rosenberg, 1962) . surprisingly, the most terrible epidemic since the middle ages has left relatively little effect on the public memory (crosby, 1981) . in fact, except for those who study the disease, the spanish flu remains nothing more than a folk-memory that is as remote, and has had as little significance to modern disease prevention as the black death (collier, 1974) . like sars, spanish influenza caught the world offguard. by the end of 1918, the disease had infected one in six canadians (pettigrew, 1983) . canadian medical services were ill prepared for the arrival of the disease and the nursing profession was overwhelmed. thousands of nurses remained overseas on war services. infection rates for nurses were possibly lower than for yellow fever or cholera, but significantly higher than for sars. in toronto, for example, 35% of nurses contracted the spanish flu (pettigrew, 1983) . as customary in epidemics, many people stopped engaging in regular forms of activity and public meetings were kept to a minimum. nurses reportedly coped with loneliness by developing close friendships with coworkers. during the spanish flu crisis nurses were encouraged by their superiors to form relationships with fellow nurses as a means of handling stress and isolation (crosby, 1981) . as in the sars crisis, nurses and the lay public both took to wearing masks in attempts to ward off the disease. the masks were considered by nurses to be terribly annoying but quite successful (collier, 1974) . although the spanish influenza occurred after the nightingale revolution in western nursing and following the advent of public health systems with modern record-keeping finding sources that communicate nurses' emotions and perceptions during this epidemic remains challenging. nurses' voices were systematically muted in the public record. a systematic search of the globe and mail, the leading toronto daily newspaper, for the 2-year period of 1918-1919, makes it clear that nurses had no public voice. although there were a host of articles upon the spanish flu and even some on the role of nurses, none gave any voice to these professionals. nurses were depicted as the silent followers of protocol. the transfer of knowledge in respect to the spanish flu only went one way, from top to bottom. nurses' roles attracted little coverage except, on occasion; there were a few pub-lished words that briefly honored those who died in the fight (globe and mail, 1918) . in this feature, there was continuity with the public's attitudes towards earlier yellow fever and cholera nurses. the historical record on toronto sars, in contrast, will give pride of place to the front-line workers, the nurses, who have successfully captured public attention. they were perceived in all media sources to be the most notable victims, and moreover, to possess the most authoritative first-hand perspective. the arrival of sars, a disease of unknown epidemiology, in canada in the early days of march 2003 was the beginning of a crisis that would test the abilities of the ontario health care system and its professionals. the arrival of sars dominated canadian media coverage as the public was bombarded with information and suppositions on the rapidly developing disease of unknown nature and duration. in total, the sars virus claimed 44 victims in canada, all in the toronto area. given that the disease was primarily contained, and spread, within hospital environments, health care workers, particularly emergency and acute care nurses, were at heightened risk of exposure. sars claimed the lives of two nurses, tecla lin and neila laroza, who contracted the disease while attending to infected patients (west, 2003 ). an uncertain number of nurses, at least 79, according to the workers safety insurance board of ontario, missed 15 days or more of work due to this disease (rnao, 2003) . some nurses as late as a full year after the events had not fully recovered. others were not psychologically ready to return to a job that they now characterize as disturbingly dangerous (cbc online staff, 2004) . despite the intense media focus placed upon nurses, this profession possessed a minimal voice in drafting internal policies and procedures on how to deal with the sars epidemic. in fact, nurses complained that their opinions were rarely listened to by management. this account is intended in part to pay close attention to how the health care professionals who chose to speak out perceived and remember this crisis. this discussion relies on the words and thoughts contained in numerous nurses' submissions to various review bodies. the five submissions studied were: the canadian nursing association brief to the national advisory committee on sars and public health on 5 march 2003, sars claimed its first ontario victim when sui-chu kwan, a 78-year-old woman who had returned from a trip to hong kong, died of the disease. the unknown epidemiology of the disease was an immediate cause of concern for those within the upper echelons of health care management and government. the responsibility for containing this disease fell especially upon nurses who were employed as the front-line of defense (rnao, 2003) . according to the report published by rnao, the arrival of this disease placed a significant strain on the nurses of ontario: ''not only did we need to manage an infectious disease, whose origin and transmission were initially unknown, but we had to do this from within a depleted health care system'' (rnao, 2003: p. 3 ). this emphasis upon an under-financed and under-staffed provincial health care system was a concern that was not new to the nursing unions of ontario (cfnu, 2003) . the sars epidemic brought this long-standing concern to the forefront of public discussion, and nursing leaders have led the campaign to link the crisis of sars to chronic public under-funding (rnao, 2003) . the disease could not have arrived in ontario at a worse time, as hospitals were forced to operate within strict budgetary restraints and were suffering from a significant shortage of nurses. in fact, at the time of the sars crisis, ontario ranked last in canada for the ratio of nurses per patient (65 registered nurses per 10,000 of the population, compared to a canadian average of 73.4) (rnao, 2003) . this shortage grew desperate when nurses who worked for more than one hospital (an employment trend of the 1990s) were ordered to limit themselves to one institution to prevent disease transmission. employers responded by assigning double and sometimes triple nursing shifts. nurses worked these extremely long hours with few breaks and because of the shortages they hesitated to call in sick (rnao, 2003) . nurses later reported that they had never had to work so many hours at any job: ''i was working from 7 a.m. to 10 p.m. my life was my work. i don't think i could have continued much longer'' (rnao, 2003: p. 19 ). as we will observe, exhaustion was possibly the least problematic issue that the nurses had to deal with during the drawn-out threat of sars. nurses' close interaction with sars engendered a variety of responses, but the predominant emotion reported by nurses was a feeling of fear. these feelings of anxiety were directly rooted in the unidentified nature of the disease and lack of knowledge concerning how it was spread. this fear was made worse by the potential that a nurse could unknowingly contract the disease and then unwittingly spread it to family and friends (rnao, 2003) . one nurse who worked in the acute care section of a toronto hospital noted that not only was she terrified to attend work, but that this sense of trepidation even entered into her dreams: ''i dream of disembodied mouths gasping for air and wake struggling to catch my own breath . . .'' (rnao, 2003: p. 17 ). this fear made the working environment extremely tense and the lunchrooms and halls were filled with rumors concerning how sars was spread and its potential to do much more damage (rnao, 2003) . there certainly was a consensus amongst nurses that the worse aspect of the sars experience was the fear of the unknown. nurses reported being in constant fear that anyone who was in the hospital, be it patients or colleagues, could already have contracted the disease and be transmitting it (rnao, 2003) . fears were heightened by the contradictory and often confusing information that nurses received. according to barb wahl, the president of the ontario nurses' association, nurses reported hearing: a steady stream of contradictory, confusing, inconsistent and incorrect information about the means of transmission, infection controls, effective protective gear and the protective protocols health care workers needed to follow. (ona, 2003: p. 3) this misinformation served to heighten nurses' fears about their own safety and that of their families. according to one nurse, the best source for reliable information on the sars crisis was not her employer, but the media (cna, 2003) . statements such as this demonstrate that at least some nurses felt strongly that management was doing a poor job at communicating developments in the struggle against sars. nowhere in the submissions was there a sense of common cause; on the contrary, after years of neglect, employers and government were perceived as being less than helpful--possibly less than honest. at the time of writing, it still remains to be seen if information was purposefully kept hidden from health care professionals or whether the slow dissemination of knowledge to front-line workers was due to structural and bureaucratic problems that slowed the diffusion of pertinent information. nurses were forced to deal with the feelings of isolation that were ever-present during the sars epidemic. the workplace was perceived to be a very dangerous place, no longer collegial and welcoming. nurses were instructed to keep contact with their fellow co-workers to a minimum and at some hospitals nurses were directed to sit two seats apart in the cafeteria (rnao, 2003) . in hindsight, the hospital atmosphere was characterized as being full of anxiety, fear and confusion. nurses understood how deadly the sars virus could be, one nurse commented: ''i didn't sleep the night before i decided to work in the sars unit. i knew that one suction catheter from a sars patient would have enough virus in it to begin an epidemic'' (rnao, 2003: p. 20) . during the sars epidemic nurses felt both alone and afraid of their working environment. management's insistence that workers keep contact with each other to a minimum only served to heighten nurses' feelings of isolation. this feeling of isolation and alienation was enhanced when nurses' regular home life was seriously disrupted. some nurses were forced to miss important events such as graduations or funerals due to restrictions placed on free movement. one nurse reported that no matter where she was, both friends and families would ask, ''should you be here? we don't want you here, i don't want to see you until this is all over'' (rnao, 2003: p. 17) . as public anxiety concerning the sars virus heightened, nurses perceived that they were being treated as modern day-lepers. it upset and angered nurses that they were depicted as a threat to the community and that some toronto businesses had posted signs forbidding the entry of hospital staff (rnao, 2003) . this feeling of abandonment by the community left nurses feeling very much alone. the greatest sense of isolation was experienced by those nurses who were forced to endure the boredom and loneliness that is associated with being in quarantine. after suffering through quarantine, nurses struggled to find words to convey how truly isolating the experience was: ''i don't know what the experience of being in jail is like. but, it's [the quarantine] like being in jail'' (rnao, 2003: p. 18 ). the isolation and perceived stigma that was attached to nursing during the sars outbreak was extremely hard to accept, or to forgive. after the crisis subsided the largest grievance harbored by the ontario nurses' association is that the provincial government was not prepared for this epidemic. the story, as told by nurses' leaders, is that the reason that nurses' lives were put into significant danger was due to deficiencies in the system, limitations which they had long brought to public attention. in this way, sars has served as a vindication of the reforms that nursing leaders have been calling for over the past decade (ona, 2003) . even since the sars crisis the trends in the public health sphere remain disturbing. the canadian nurses' association predicts a national shortfall of 78,000 registered nurses by 2011 (ona, 2003) . nurses' also criticized the government and health care managers for ignoring their knowledge and insight into crisis management. one reported example is illustrative: at one facility, nurses identified a cluster of patients with sars-like symptoms and reported to management and the medical staff. nurses' concerns were dismissed and nothing was done for several days. this led to the second major sars outbreak. unfortunately it was similar at other hospitals. (ona, 2003: p. 5) the nursing leadership believes that nurses, had they been properly employed and their expertise listened too, could have been an integral part in managing the disease. instead, the silencing of nurses proved deadly as the sars virus continued to spread placing both the public and health care workers at heightened risk. the sense of alienation is abundantly clear. one post-crisis theme is that the government should have been better prepared for a public health emergency, especially after the tragedy of 11 september 2001 and the known threat of bioterrorism (opseu/ona, 2003) . although nursing unions had alerted authorities to the need for more fulltime permanent nurses, these requests were not met. the state of the nursing profession, especially the reliance upon part-time work at mul-tiple locations, had left ontario susceptible to severe labour shortage in the time of an epidemic (ona, 2003) . in retrospect, the nursing leaders were correct: in times of major public health crises the system could not deal with the rising demand for nurses (ona, 2003) . nurses learned first hand how deficiencies in the system, including the lack of proper equipment or standardized protocol, could jeopardize their safety. there is subjective testimony to support this interpretation. for example, one nurse stated in respect to space constraints: we have had several episodes where we were suspicious of patients that may have sars. it was very difficult for us to isolate these individuals as we only have one single room in the emergency department and it is not equipped with negative pressure air flow. also there is no private washroom for the individual. (cna, 2003: p. 7) the danger to nurses was also increased by the lack of fit testing, which should have ensured that the mandatory safety mask fit perfectly. nurses later experienced concern that this measure, which was so important to the protection of their health, had never been properly instituted. one nurse stated: ''it is disappointing that after 22 years of infection control precautions, fit testing has never been considered in hospitals'' (rnao, 2003: p. 20 ). management's handling of fit testing changed from location to location and even from day to day. as another nurse recounts, going through fit testing was necessary for her to work in the hospital on one day, but on the next, this measure was abandoned completely: i was initially told that i wouldn't have to work in the unit if the mask didn't fit. i went through several masks and none of them fit properly -so i was sent home. the next day i was called [to return to work] and told that they weren't going to be doing any more mask fit testing. (rnao, 2003: p. 21) at the conclusion of the crisis, nurses publicly questioned the provincial government's fiscal aims asking: ''what good is a budget surplus or a $300 personal income tax cut, if the system can't make a reasonable effort to save your life'' (cfnu, 2003: p. 4 ). nurses, who now have a heightened understanding of their role as protectors of public health, have ensured that they told their side of the story. their sentiment and purpose was quite clear: ''i feel obligated as a survivor to make damn sure that this doesn't happen again'' (cfnu, 2003: p. 18 ). of course, objectively almost all nurses were 'survivors'; the statement conveys the sub-jective intense feelings of fear, frustration and alienation. in retrospect, the sars nurses acknowledge that they were mentally unprepared for the dangers of the epidemic and that this crisis has led them to take a hard look at their profession. they speak about ''a different world view'' on nursing (cfnu, 2003: p. 18) , and of a ''world [which] was turned upside down. suddenly the job i had was torture'' (rnao, 2003) . nurses were caught offguard, for their job had suddenly turned into a life-threatening profession. it is evident that nurses had little knowledge of previous public health crises and no context in which to place the sars epidemic. the published nursing literature provides only very modest information on the topics of fear, isolation and resentment during public health crisis. a medline search using the term ''history of nursing,'' provided a plethora of results however, few of the returns dealt directly with how nurses have historically coped with epidemic disease. although there are some studies that directly engaged the question of how nurses in the past handled epidemics these few studies, such as walton and connolly's ''a look back: nursing care of typhoid fever'' are too few in number and limited in scope to provide a comprehensive picture of nurses' responses to epidemic disease (walton and connolly, 2005) . clearly, the lack of poignant scholar literature combined with the absence of a north american public health crisis featuring highly contagious diseases within living memory meant that the sars workers could not draw on the experiences of previous generations of nurses for guidance or reassurance. if the public health triumphs of the 20th century prove not to be normative, aspects of hospital nursing will, perhaps, come to resemble 'a world turned upside down' from the viewpoint of those on the shop floor. sars may be a harbinger of new dangers. however, the fear and isolation so vividly expressed are renewed phenomena, not new ones. there is a larger and longer historical trend in evidence. this discussion suggests that nurses, past and present, trained or untrained, volunteer or professional, reacted to public health crisis of mysterious origin in an altogether human manner. that is they reacted to health care crisis of unknown epidemiology with much fear and, due to the nature of nursing during these crises, are prone to feelings of isolation. what is clearly distinctive is the status accorded in the media to the sars nurse as both prime victim and leading authority. the nursing leadership has been successful in placing their concerns at center stage. the personal stories of how nurses felt and dealt with the crisis remained the focus of the media for many months after the general threat of sars had dissipated. no other patients, no other health care professionals, received anything close to this level of attention. the other important change is the shift from the 19th and early 20th century focus upon the individual and her/his moral ethic, to the 21st century emphasis upon systemic problems and solutions. nevertheless, after several centuries of societal change and profound development -in no way unimportant -the evocative images of the sars crisis remain those of personal betrayal by superiors, public humiliation when confronted by doubtful torontonians, and the living nightmare of an invisible godzilla in the corridors of a once-welcoming workplace. concerning the work of the association during yellow fever epidemic canadian federation of nurses unions. submission to the national advisory committee on sars and public health canadian nurses' association. brief to the national advisory committee on the sars and public health: lessons learned and recommendations nurse files $600 million sars suit the plague of the spanish lady america's forgotten pandemic: influenza new brunswick: rutgers university press; 1992. globe and mail. is taken ill on short leave updating the accounts: global mortality of the 1918-1920 ''spanish'' influenza pandemic ontario nurses' association. the commission to investigate the introduction and spread of severe acute respiratory syndrome joint report on the health and safety matters arising from sars the silent enemy: canada and the deadly flu of 1918. saskatoon: western producer prairie books registered nurses association of ontario. sars unmasked: celebrating resilience, exposing vulnerability the cholera years a look back: nursing care of typhoid fever: the pivotal role of nurses at the children's hospital of philadelphia between 1895 and 1910: how the past informs the present nurses on the frontline: canada should recognise its fallen heroes of sars key: cord-341815-of47ogow authors: morley, georgina; grady, christine; mccarthy, joan; ulrich, connie m. title: covid‐19: ethical challenges for nurses date: 2020-05-14 journal: hastings cent rep doi: 10.1002/hast.1110 sha: doc_id: 341815 cord_uid: of47ogow the covid‐19 pandemic has highlighted many of the difficult ethical issues that health care professionals confront in caring for patients and families. the decisions such workers face on the front lines are fraught with uncertainty for all stakeholders. our focus is on the implications for nurses, who are the largest global health care workforce but whose perspectives are not always fully considered. this essay discusses three overarching ethical issues that create a myriad of concerns and will likely affect nurses globally in unique ways: the safety of nurses, patients, colleagues, and families; the allocation of scarce resources; and the changing nature of nurses' relationships with patients and families. we urge policy‐makers to ensure that nurses' voices and perspectives are integrated into both local and global decision‐making so as to minimize the structural injustices many nurses have faced to date. finally, we urge nurses to seek sources of support throughout this pandemic. t he covid-19 pandemic-with, at the time of this writing, nearly two million cases worldwide and 113,030 deaths 1 -has highlighted many of the difficult ethical issues that health care professionals confront in caring for patients and families. the decisions such workers face on the front lines are fraught with uncertainty for all stakeholders. our focus is on the implications for nurses, who are the largest global health care workforce but whose perspectives are not always fully considered. 2 we see three overarching ethical issues that create a myriad of concerns and will likely affect nurses globally in unique ways: the safety of nurses, patients, colleagues, and families; the allocation of scarce resources; and the changing nature of nurses' relationships with patients and families. i n the battle against covid-19, the safety of nurses and other health care workers on the front lines is a pressing ethical concern, as they are asked to work under conditions that pose substantial and inadequately understood risks to their overall health and well-being. risk of exposure to infectious diseases is not new within health care. over the last fifty years, health care workers have encountered risks from hiv/ aids, sars, swine flu, and ebola. while covid19 has not yet been as deadly as hiv/aids or the swine flu, our insufficient understanding about the virus, its pathophysiology, mode of transmission, susceptibility profile, and contagious nature as well as failures in the supply chains for personal protective equipment (ppe) mean that health care workers are being asked to take on substantial but uncertain risk. the inadequate protection of health care workers across all health care settings raises professional and ethical ques-tions about the extent of these workers' duty to care for patients-including the limits of that duty. the 2015 revised american nurses association code of ethics states that nurses' primary duty is to the recipient of nursing care, whether that be an individual patient, family, or community. the code of ethics also stipulates that nurses have a duty to promote their own health and safety. 3 these multiple and even competing duties, especially as they combine or conflict with civic and personal interests, place nurses-many of whom have conditions that make them more vulnerable to covid-in a quandary. they are trying to balance their obligations of beneficence and duty to care for patients with rights and responsibilities to address inadequacies within their health care systems in ways that are consistent with rights and duties to protect themselves and their loved ones. contemporary nursing ethics scholarship foregrounds the relational dimension of all human activities, especially caring activities, and recognizes that nurses' personal and professional lives are often grounded in interdependent relationships of responsibility and care. 4 applying this relational account of care to current practice realities can help policy-makers and health care system leaders recognize additional risks in nursing work-and the emotional weight and practical implications of those risks. this relational context suggests that nurses' concerns about ppe may arise not just because of concerns for personal safety but also because of concerns about transmitting covid-19 to loved ones, especially those who have medical conditions that make them particularly vulnerable, or because they may be the sole support for and carer of children or dependent adult relatives. nurses routinely and willingly care for patients in risky situations. however, requiring them to provide care under conditions of inadequate protection (such as lack of ppe) jeopardizes their safety, their loved ones' safety, and their ability to provide longer-term nursing care. nursing in these conditions demands a disproportionate level of altruism and self-sacrifice. employers have a duty to their employees to provide adequate ppe, and any harm that may come to patients through lack of ppe and personnel to safely care for patients is a failure of institutions and systems, not of individuals. if employers provide adequate ppe and appropriate guidance on how to use it, and reasonably address and mitigate the additional foreseen risks that caring for patients with covid-19 present, then nurses and others will continue to provide patient care that is more aligned with the usual risks that health care workers knowingly take on when they enter their professions. both organizations and health care workers also have a duty to steward resources with care. organizational leaders should provide guidance and support to nurses and other health care providers about when ppe is and is not essential. they should make every effort to supply ppe, encourage its appropriate use, and define expectations for situations where there is a shortage of ppe. organizations should support decisions to delay or deny treatment in those difficult cases when the absence of ppe poses significant risks to nurses and others so that health care workers can fulfill their duty to protect themselves and their duty to patients who need their care. faced with the potential reality that a patient will suffer, clinically deteriorate, or die, many health care professionals will find it extremely difficult to make or implement a decision to deny or delay treatment given their own human response, their professional socialization, and their profession's expectations and norms about saving lives, relieving suffering, and not abandoning patients. in most places, the hope is that rigorous contingency planning and preparation for surging capacity will obviate the need for denying treatment to anyone. nonetheless, taking the time required to don adequate ppe might lead to small delays in patient care such as implementing cardiopulmonary resuscitation and providing aerosol-generating procedures. leadership should reassure health care professionals that doing what is necessary to protect themselves will ultimately save more people and that they are doing the morally and professionally appropriate thing. at the same time, nurses and other health care providers should do everything they can to minimize suffering and to support their colleagues who are able to act safely. the possible effects of these difficult experiences on nurses and other health care workers should not be underestimated. many health care organizations are already taking steps to address moral distress, psychological distress, and post-traumatic stress disorder experienced by their workers; many others need to integrate such support into their responses to the pandemic. t he second key ethical issue concerns the allocation of scarce resources, which demands decision-making in which nurses are inconsistently included. in any health crisis or emergency, nurses prioritize their care goals for patients. covid-19 has demanded more substantive (and ethical) consideration of how to prioritize care and resources across different settings and units of care. many jurisdictions around the world have established and are prepared to implement, if necessary, crisis standards of care that apply in public health disasters and conditions of scarce resources. crisis standards require modification in the care that can be delivered and shift the balance of ethical concern from the needs of the individual to the needs of the community. 5 triage guidelines use stringent clinical criteria and frameworks-usually developed in advance of public health crises-to guide a health care system's decisions about which patients are most likely to benefit during a crisis from the allocation of, for example, a scarce intensive care unit (icu) bed, invasive ventilation, or extra corporeal membrane oxygenation (ecmo). the intention is to ensure consistency in decision-making during time-pressured emergencies, remove the burden of decision-making from individual bedside providers, and ensure adherence with basic ethical principles such as fairness, transparency, proportionality, and protection for health care workers from legal liability. 6 robert truog and colleagues note that the allocation of ventilators is possibly one of the most difficult triage decisions, 7 yet rationing them may be necessary because coronavirus frequently manifests as acute respiratory distress syndrome. triage guidelines and algorithms are generally created by groups of experts, ideally from different disciplines and with public engagement. some published guidelines and frameworks highlight the need for decisionmaking by a multidisciplinary triage team that includes a nurse leader, whereas others call simply for a triage officer (a senior physician) to make these decisions. even when nurses are not involved in the development of these guidelines, they are frequently responsible for managing these life-sustaining technologies and for implementing triage decisions, including withdrawal. nurses' involvement in the withdrawal and reallocation of ventilator support varies from institution to institution and country to country. "repeat triage" or reallocation is necessary during this pandemic. for example, with a shortage of ventilators, nurses and other clinicians may have to continually reassess the effectiveness of invasive ventilation for particular patients and to reallocate a ventilator from someone whose likelihood of recovery does not meet certain criteria to a patient more likely to benefit. teamwork is essential in addressing critical allocation challenges, and teamwork requires that all voices be heard, especially since providing and withdrawing ventilator support relies heavily on the ability of qualified personnel-specifically, critical care nurses (and, in the united states, respiratory therapists)-to administer this therapy in a way that is actually beneficial. in addition to critical care teams, teams with expertise in palliative care and emotional support are needed when decisions are made to remove life-sustaining treatments. 8 even with the mantra "staff, space, and stuff " within preparedness planning, 9 the need for qualified and trained providers can be overlooked in the bustle of preparedness planning. "staff " are not an infinite resource and are in danger of being pushed and stretched until they break. indeed, due to ppe shortages, many providers who are not nurses are not entering patient rooms, and so nurses (since it is already a necessity that they enter patient rooms) are being relied upon to conduct the roles of others. in addition to assessing patients, nurses are increasingly fulfilling other necessary roles, from witnessing advance directives and setting up virtual communication platforms to cleaning patient rooms and emptying bins. more than ever, nurses are feeling the burden of taking on additional roles and responsibilities. nurse staffing is also a critical concern during a pandemic. while there is a need to be context specific and fluid due to the inability to predict exactly how many nurses might become unwell or need to be quarantined, there is very little guidance regarding optimal or minimum staffing levels for preparation phases, for the initiation of triage, or for adequate provision of crisis care. this creates further uncertainty for nurses, who must be able to meet the needs of patients even if redeployed into unfamiliar areas and roles and even when facilities are understaffed. as with a shortage of beds and life-saving equipment, the lack of qualified nurses and other health care providers (and any relevant specific skill sets, such as ecmo training) ought to trigger the use of triage criteria. critics might argue that in a public health crisis all health care workers will be stretched thin and faced with harrowing choices. our concern is whether nurses are at a significantly higher risk. some have suggested that nurses already disproportionately experience moral-constraint distress (from being unable to carry out what one believes to be a morally appropriate action) and moral-conflict distress (because one feels morally uncertain about the appropriate action). 10 indeed, in many contexts, nurses do not have the same levels of authority to assure adequate staffing, apply triage criteria, or make allocation decisions, even though they are involved in implementing these decisions. in some contexts, nurse-to-patient ratios seem to be completely indeterminate, as they may be left to the "discretion of the [c]linical [l]ead." 11 in england, nurse-to-patient ratios are already a point of heated debate due to a lack of legislated minimum ratios (except in the icu, where ventilated patients are strictly nursed at a one-to-one ratio). during a surge in covid-19 cases, even protected ratios may have to change given the volume of patients who will need urgent care. a recent document from nhs england suggests that during this pandemic, six icu patients could be cared for by one critical-care nurse with support from two nurses with previous or recent icu experience, two nurses with no critical care experience, and a support team of four auxiliary workers. 12 although these numbers may appear adequate, the level of requisite skill remains questionable, as indeed does whether hospitals will be able to stick to these sug-gested numbers. all of this raises a multitude of both practical clinical questions and ethical questions about what a minimum ratio should be in a public emergency, what care is deemed essential, how and what to prioritize for patients (beyond obvious life-saving interventions) , and at what point we begin to do harm. nurse staffing levels have been shown to affect patient outcomes. 13 it is also not clear how crisis standards of care apply to nursing care and how or for what nurses will remain accountable. in situations such as the covid crisis, nurses should be encouraged to remember that the circumstances are not in their control and to accept that some patients will not survive, even as nurses work to ease their suffering and to save as many as possible. allocation decisions are likely to exacerbate a tension that health professionals experience even in normal circumstances-perceived moral and emotional discomfort when making or implementing a decision to withdraw medical treatment that is contributing to or keeping a patient alive for longer than they would survive without it. health care professionals often intuitively feel that withdrawing treatment is morally more troubling than withholding it; nurses have reported feeling that stopping a life-sustaining treatment or therapy can feel like killing the patient. 14 health care professionals may believe that decisions to stop treatments are more momentous and consequential than decisions not to start them. by contrast, with some notable exceptions, 15 decisions to withhold and withdraw treatment are generally considered morally equivalent by most bioethicists, legal regulations, and international professional guidelines. 16 this "equivalence view" holds that, if withholding a particular treatment for a particular patient is acceptable (for example, because it is not likely to be effective or is burdensome), then, all else being equal, withdrawing the treatment is acceptable (if it turns out to be, or becomes after a time, ineffective or burdensome). the need to repeat triage in order to consider incoming patients who may have a greater chance of recovery is likely to be a cause of moral distress for clinicians. 17 dominic wilkinson et al. propose some strategies that might help health professionals overcome their aversion to withdrawing treatment even when doing so is ethically justified. 18 under normal conditions, strategies of particular relevance to critical care nurses and other health professionals involved in withdrawing life-sustaining interventions include the conditional offer of treatment based on measurable treatment goals and the offer of time-limited treatment trials. these strategies might not, however, be possible in conditions of crisis standards of care. due to the potential resource pressures that covid-19 presents, the health care community has an obligation to be transparent about these limitations with patients and the community. some authors argue that we should prioritize health care workers for testing, treatments, vaccines, and even triage because, without them, who will be left to provide care? two justifications offered for giving priority to health care professionals are that the workers have instrumental value because they are needed for the health care workforce and that prioritizing them would be an instance of due reciprocity, given the increased level of risk that health care workers expose themselves to. other commentators argue that this prioritization may also incentivize health care workers to continue working in higher-risk environments. yet these arguments raise serious concerns about who would count as a health care worker, why they should have priority over other essential persons at risk, whether it is merely self-serving for health care workers to recommend that they be given higher priority, and whether considerations of priority status differ for treatments than for vaccines, for example. a related concern is that, as jackie leach scully highlights, many triage guidelines already contain a worrying degree of disablism and prejudice toward those with disabilities. 19 bringing conceptions of social worth and utility into resource allocation decisions risks introducing other slippery criteria. n urses have a long history of trust with their patients. however, many ethical issues have altered the nursepatient-family relationship in the context of covid-19. a recent hastings center publication highlighted the need for nurses, physicians, and other clinicians to move during a pandemic from a patient-centered to community-focused model of practice and care. 20 nurses have traditionally been motivated by community thinking, and the history of nursing ethics has its roots in a social-justice orientation focused on issues of equity, disenfranchisement, and structural forms of oppression. 21 some of the necessary steps to protect the public in this pandemic have created new and unfamiliar tensions between nurses and patients and their families. during the covid-19 pandemic, many people are dying in isolation from their loved ones, and end-of-life-conversations are taking place over the telephone or "behind the dehumanizing veil of plastic gowns and respirator masks." 22 the challenge for nurses and other health care workers is to temper these potentially dehumanizing scenarios with imaginative solutions that do not sacrifice compassion and equal respect on the altars of safety and efficiency. the effects of covid-19 on nurses and other health care workers are likely to be long-lasting. we urge policy-makers to ensure that nurses' voices and perspectives are integrated into both local and global decision-making so as to minimize the structural injustices many nurses have faced to date. finally, we urge nurses to seek sources of support throughout this pandemic. for nurses in north america, many health care systems have integrated clinical ethics consultation services with ethicists able to identify and untangle the complex ethical issues that cause moral distress and help mitigate the negative effects of such distress. other supportive services and colleagues include employee assistance programs, clinical psychologists, chaplaincy services, and mental health hotlines to address psychological distress or other concerns that might arise. the unprecedented cri-sis in which the global community finds itself is a lesson in humanity. nurses bring their expertise, knowledge, and skill sets to the health care system in many ways; today, we see this intrinsic and extrinsic value and must do all we can as public citizens to advocate for all they do for us. we owe them much gratitude and respect. coronavirus resource center state of the world's nursing 2020: investing in education, jobs and leadership american nurses association, code of ethics for nurses with interpretive statements moral distress re-examined: a feminist interpretation of nurses' identities, relationships and responsibilities rapid expert consultation on crisis standard of care for the covid-19 pandemic the toughest triage-allocating ventilators in a pandemic ethical guidance for disaster response, specifically around crisis standards of care: a systematic review ethical framework for health care institutions responding to novel coronavirus sars-cov-2 (covid-19), the hastings center who is experiencing what kind of moral distress? distinctions for moving from a narrow to a broad definition of moral distress coronavirus: principles for increasing the nursing workforce in response to exceptional increased demand in adult critical care effects of nurse staffing and nurse education on patient deaths in hospitals with different nurse work environments nursing skill mix in european hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care moral distress in end of life care are withholding and withdrawing therapy always morally equivalent? withholding and withdrawing life-sustaining treatment: ethically equivalent? finding a way through the ethical and legal maze: withdrawal of medical treatment and euthanasia withdrawal aversion and the equivalence test covid-19: how to triage effectively in a pandemic disablism in a time of pandemic: some things don't change ethical framework for health care institutions responding to novel coronavirus sars-cov-2 (covid-19) heritage ethics: toward a thicker account of nursing ethics palliative care in the time of covid key: cord-284454-malfatni authors: mccall, w. travis title: caring for patients from a school shooting: a qualitative case series in emergency nursing date: 2020-08-19 journal: j emerg nurs doi: 10.1016/j.jen.2020.06.005 sha: doc_id: 284454 cord_uid: malfatni introduction: emergency nurses are at risk for secondary traumatic stress, compassion fatigue, and burnout as a result of witnessing the trauma and suffering of patients. the traumatic events perceived as being most stressful for emergency nurses involve sudden death, children, and adolescents. multicasualty, school-associated shooting events are, therefore, likely to affect emergency nurses, and recent reports indicate an increase in multicasualty, school-associated shootings. this research is necessary to learn of emergency nurses’ experiences of caring for patients from a school shooting event in an effort to benefit future preparedness, response, and recovery. this manuscript describes these experiences and provides opportunities for nurses, peers, and leaders to promote mental health and resilience among emergency nurses who may provide care to patients after such events. methods: a qualitative case series approach, a theory of secondary traumatic stress, and the compassion fatigue resilience model guided the research. the emergency nurses who provided care to patients who were injured during a 2018 multicasualty, school-associated shooting in the southeastern united states were invited to participate. results: the themes identified by this research with 7 participants were preparation and preparedness, coping and support mechanisms, and reflections and closure. discussion: the results identified through this research may be translated to policies and practice to improve emergency nurses’ welfare, coping, resilience, and retention. patient outcomes may also be improved through planning and preparedness. secondary traumatic stress is the incidence of thought intrusions, heightened arousal, situational avoidance, and/or emotional numbing in those who witness traumatic events or provide care to critically ill or injured patients. 1 it is often associated with the development of compassion fatigue, defined as the impairment in a clinician's ability to care for others effectively. 2 the presence of secondary traumatic stress among emergency nurses can negatively affect their resilience, 3 which may ultimately contribute to burnout and departure from the nursing profession. 4 emergency nurses are frequently exposed to traumatic events through the delivery of care to injured patients. the types of events that have been identified as being most distressing to nurses are those involving sudden death, children, or adolescents. [5] [6] [7] [8] therefore, providing care to patients who are injured during school-associated shooting events is likely to be particularly stressful for emergency nurses. although the rates of multicasualty, schoolassociated shootings declined from july 1994 to june 2009, the incidence rates increased between july 2009 and june 2018. 9 the study defined "multiple-victim" as including more than a single victim and reported that 38 of these events resulted in 121 youth homicides between july 1994 and june 2016. 9 a recent study exploring nurses' suicide rates in the united states identified that the rates among female and male nurse subpopulations were significantly higher than those in the general female and male populations, respectively. 10 additional research to identify risk factors and effective interventions is needed to improve mental health and combat the prevalence of suicide among nurses. moreover, nurse burnout and departure from the profession may exacerbate nursing shortages and staffing challenges, which may directly affect emergency departments. therefore, research is indicated to identify how health care professionals who are tasked with providing medical care to the victims of school shooting events are affected mentally and emotionally. the benefits of this research include improved understanding of how these events may affect emergency nurses and identification of factors that may promote welfare, coping, resilience, and retention. the purpose of this study was to learn how emergency nurses describe their experiences to identify themes and findings that may translate to practices for improving the mental health and wellness of emergency nurses who care for patients from a multicasualty, school-associated shooting incident. a qualitative case series methodology using the data collection and analysis methods described by yin, 11 which includes steps to plan, design, prepare, collect, analyze, and share, was used to guide this research. the study was performed after approval was received from the vanderbilt university institutional review board (irb #190980). these methods include the use of structured interviews and reliance on theoretical propositions in the analysis. 11 the interviews were conducted approximately 18 months after the adult emergency department of a level 1 trauma center received 5 patients by helicopter emergency medical transport from the scene of a schoolassociated shooting event. the emergency nurses who participated in the trauma resuscitations or assisted with the transition of these patients from the receiving helipad to the emergency department were eligible to participate. ten registered nurses were identified by review of the ed daily assignment sheet, and their patient care roles were confirmed from patient electronic medical records. these nurses were invited to participate by e-mail distribution of a recruitment flyer. the processes and flow of the receiving emergency department were known to the researcher, who had more than 3 years of experience as a clinician in this department. the researcher did not have any personal experience with providing care to patients from a school-associated shooting event. a list of avaiilable support services was provided to each participant at the time of their interview. semistructured interview questions and analysis of the data were informed by a theory of secondary traumatic stress and the compassion fatigue resilience model, 12 as well as the professional quality of life model. 13 the conceptual variables identified in the compassion fatigue resilience model ( figure) and an examination of how those concepts related to the experiences described by these nurses benefited the development of the interview questions (supplementary appendix) and interpretation of the data. the professional quality of life model defines professional quality of life as incorporating aspects of compassion satisfaction and compassion fatigue. although compassion satisfaction reflects positivity in helping others, compassion fatigue consists of the concepts of burnout and secondary trauma. 13 burnout includes symptoms such as exhaustion and depression, whereas secondary traumatic stress represents negative symptoms that result from trauma experienced through work activities. 13 the interviews were recorded with an audio recorder and transcribed verbatim by the researcher or a transcriptionist who had signed a confidentiality agreement. field notes were recorded by the researcher at the end of the interview and reviewed before coding activities. each transcript was reviewed by the researcher for accuracy. the framework method was used in the analysis of the data. this method uses stages of transcription, familiarization, coding, analytical framework development, analytical framework application, data charting into framework matrix, and data interpretation. 14 key phrases and meaning units from the transcriptions were identified and coded by the researcher using nvivo 12 software (qsr international). 15 the categorization of codes generated themes that represented what the participants shared. seven nurses agreed to enroll and completed an informed consent. there was no verbal or written response from the 3 eligible participants who did not enroll. the participants' ages ranged from 30 years to 41 years, and 6 were female. two of the participants shared that they were parents. the researcher was known to 4 of the participants before the interviews. it was anticipated that the interviews would last between 30 minutes and 60 minutes and the median duration was 37.7 minutes. the associate nursing officer for emergency services agreed to pay the 5 participants who remained actively employed by the health care institution for their interview time. two participants had resigned from their positions and were compensated with a gift card at the expense of the researcher. a single interview with each participant was performed over a period of nearly 4 weeks. the interviews were conducted in private without the presence of nonparticipants. the interviews were conducted at a location identified by the participant, and 3 were performed by video conference owing to distance or participant availability. although the participation of 7 eligible nurses limited the ability to ensure saturation, the identified themes and findings were consistent through the interviews. the emergency nurses often reported being in "nurse mode" and described taking immediate actions to promote readiness of the receiving trauma bays. focusing on tasks allows you to kind of push the sadness and the trauma to the side so that you can complete your tasks successfully and give the best chance at living, or keeping their arm, or anything like that. we had to compartmentalize that [...] these were actually children and just focus on the job we knew we needed to do. the nurses described placing signage indicating the air ambulance service and unit number as well as age and known injuries for each corresponding patient on the door of each resuscitation room during the planning stage prior to the arrival of the patients. this planning was described as beneficial in that it allowed the emergency nurses to gather the supplies and equipment needed to effectively care for the patients. if my room is better prepared, i can take care of the patient better. the participants described the importance of being proficient in providing care to trauma patients. although these patients were all transported to the receiving trauma center by helicopter, the limitations in air medical resources such as weather restrictions or ambulance availability could necessitate the stabilization of patients from multicasualty school shooting events in community departments where resources are likely to be more limited. these limitations may include bed capacity, number of available providers and staff, supplies and equipment, blood product availability, and access to support services. one participant indicated that nurses in community settings who may face such a mass or multicasualty event should maintain trauma nursing certification to promote proficiency in trauma care. nurses that work in those community hospitals. my advice is to become tncc [trauma nursing core course] certified. one nurse expressed concern regarding the frequency of these events, which underscored the need to maintain high levels of readiness. i don't think it's going to get any better with time. i think it's going to get worse. i don't think that we're going to be able to stop it. another participant predicted that community or critical access emergency departments receiving patients from a multicasualty school shooting event may experience even greater emotional challenges because these departments are more likely to have staff who may personally know the victims or their families. compounding variables may create unique challenges for teams and individuals who are providing care to these patients. these factors or limitations may include personal matters, interpersonal challenges, multiple simultaneous traumatic events, high patient censuses, and staffing or equipment constraints. for instance, 1 nurse recalled tension with a staff member from another department who was encountered during transition to the emergency department. comprehensive trauma centers routinely experience high censuses and preparing to accommodate the influx of patients from a mass casualty can be daunting. underlying personal or departmental issues may also compound the stresses associated with caring for these patients. recognizing existing factors or limitations, and taking action to control these effects, may mitigate the stresses associated with potential external variables. some emergency nurses described an increased presence of hospital personnel coming to the department during the care of the patients. everybody who was anybody, administratively. whether they had anything to do with what we were actually doing there, was there. two of the emergency nurses reported their disapproval of individuals who were not directly involved in patient care being present for the resuscitation efforts. one of the emergency nurses described the attendance of some individuals as their "just [wanting] to be enmeshed in that story, in that drama." another participant reflected on: .the feeling of having people there who were just there to kind of watch this terrible thing and just kind of live.vicariously through us. in addition, this emergency nurse further described that when observers are present in a resuscitation that the nurse perceives as difficult, it may result in increased emotional or psychosocial challenges. when it's really bad or it affects you personally, and there's someone in there looking at you, it's very hard, at least for me, to not feel just angry, or just disgusted by the whole thing. some nurses found the attendance by individuals who were not directly participating in the care of the patient to be unhelpful and one described it as "inappropriate." coping and support mechanisms most participating emergency nurses described the importance of maintaining a self-care routine to foster personal well-being and promote emotional recovery after such events. coping and self-care strategies or routines that were described by the emergency nurses included cooking, exercising, walking, hiking, kayaking, humor, or talking with peers. one participant did admit that her usual mechanism after witnessing such trauma was to "bury it," but she found some benefit to participating in activities in the outdoors when needing to cope with a situation. the participants who offered that their significant other or spouse worked in a health care role identified the benefits of gaining their support after challenging patient situations. however, another shared previous challenges with discussing stressful work situations with a significant other who did not work in health care. none of the nurses discussed negative coping strategies or mentioned avoiding work or certain patient assignments after caring for these patients. a formal debriefing event, taking place after the patients were transitioned from the emergency department to receiving operating rooms or units, was recalled by most participants. the emergency nurses offered varied perceptions of the formal debrief, and some questioned its effectiveness in promoting coping and recovery of the emergency nurses in attendance. some participants indicated that the debrief focused on clinical assessment of the resuscitations rather than on the emotional components of being involved in the patients' care. [they] talked about things that went well, and things that didn't go well. some of the nurses discussed being unfamiliar with those who came to the department to lead the debriefing session. some participants also reported limited perceived efficacy of the session. reasons for this perceived limited efficacy included a lack of a rapport with the debriefing session lead. one of the nurses admitted that she would not have voiced a perceived need for formal support during the debrief because she didn't "feel comfortable." another nurse admitted being reluctant to share emotions with a group of people, many of whom she did not know, during the formal debrief after the resuscitations. it was all these people, most of whom i had never seen before. one of the emergency nurses valued the availability of an employee assistance program but described that its resources would be most appropriate to provide to nurses after the acute phase of the incident. i do think there's a benefit to having someone who's.objective and has been trained on how to be.an emotional mediator and [to] reflect things back at you.i do think that has its place. [but] i think maybe [when] it's in the moment.that it, it really doesn't fit. therefore, the presence of employee assistance professionals in the affected emergency department may be most appropriate during the days or weeks that follow the multicasualty event to coordinate any desired individual appointments for counseling or resources. one nurse shared: i think if you want to safeguard the staff's emotions you should keep [it] in the family. the emergency nurses identified that peer-to-peer interactions after the event were beneficial for coping and recovery but indicated some reluctance in making immediate use of formal resources provided by individuals who had not participated in the care of these patients. they reported the perceived benefits of participating in peer-led activities to promote discussion and closure after caring for these patients. they offered me services, but i feel like i got the most help from my coworkers. some of the participating nurses expressed that they would have preferred peer-support sessions and informal conversations to the debriefing that occurred after the ed resuscitations. i feel like the most effective way to have dealt with that, for me, would have been for us to have a conversation. like the people involved. despite the passage of 18 months between the event and the nurses' participation in the research interviews, each participant provided recollections of these patients and their interactions. most admitted that having such vivid recollections of a patient after such a length of time was not common. every time i hear about a school shooting in the news, anything like that, i just remember [my patient] in my bay. the participating emergency nurses often described reflecting on the patients while they were away from work. one nurse admitted to thinking about the patients for months after the event. another participant described nightmares that she experienced in the week after the event. i did have a few nightmares that i was actually at the school and i was trying to save some kids through a gym and going behind the stairs. media coverage of the school shooting event was described as providing a context for the incident but heightening thought intrusions. it was all over the news that day.i was just looking at news reports to see what had been reported. social media and the frequent sharing or posting of media information limited the ability to separate from the event after the shift. you can't escape, you may not be [seeking out] the articles on things, but.you're reading people posting the articles. and then they inevitably [add] their own commentary on it. the emergency nurses described a lack of closure because hospital policy prevented access to medical records after a patient's departure from the emergency department. if they're not in the er, we're not supposed to access them. i think about them often when i hear of school shootings and wonder how they are. we didn't get really good follow-up on them, actually, which i think might have been helpful. two participants also expressed curiosity related to how these patients had recovered from the emotional trauma of the event. the emergency nurses described the development of heightened situational awareness of potential acts of violence against themselves, family members, or friends as a result of being involved in the care of victims of acts of violence. those nurses who identified themselves as parents described having increased thoughts of such situational awareness and acknowledged a concern for potential risks to their own children. this nurse later transitioned her children to home school after the incident. another participant who did not identify as being a parent added: i can't imagine having kids that are at that age and having to work something like that. the identified themes of preparation and preparedness, coping and support mechanisms, and reflections and closure were identified through an analysis of interviews with the emergency nurses. within these themes were findings that may be translated to implications for emergency nurses (table 1) . this study was conducted to examine the psychosocial effects of providing emergency nursing care to patients who were injured in a multicasualty, school-associated shooting event. in a discussion of the theory of secondary traumatic stress, ludick and figley 12 (p118) identified that preparation and preparedness nurses felt that preparation, planning, and trauma nursing proficiency are essential. nurses stressed the importance of removing nonessential staff and unfamiliar contributors. compounding variables from professional and personal lives may worsen associated stress. coping and support mechanisms the use of self-care routines fosters underlying nurse welfare. nurses shared varied perceptions and opinions related to the formal debrief. nurses discussed the benefit of peer activities to promote wellness and healing. nurses shared vivid recollections of the patients even after 18 months. nurses often described reflecting on the patients while away from work. one participant described nightmares experienced in the following week. there was a lack of achieving closure because patient outcomes were often unknown. extensive media coverage and social media provided context for the incident but increased thought intrusions. heightened situational awareness was evident, particularly among those nurses who are parents. "qualitative data offers targeted information and specific insights that unearth valuable, unique information and opens new lines of research." because the events perceived as being most distressing to nurses involve sudden death, children, or adolescents, 5-8 qualitative research among emergency nurses who provided care to patients from a multicasualty, school-associated shooting may provide opportunities to learn how to best support nurse welfare and resilience among emergency nurses. the themes identified by this study include preparation and preparedness, coping and support mechanisms, and reflections and closure. these themes parallel the theoretical sectors and variables of empathic response, empathic concern, other life demands, self-care, detachment, social support, traumatic memories, sense of satisfaction, and secondary traumatic stress. 12 this research aligns with the literature that has identified the prevalence of secondary traumatic stress among emergency nurses. [16] [17] [18] [19] [20] the symptoms identified among the nurses who participated in this study included the presence of vivid recollections 18 months after providing care to the patients from the multiple-victim, school-associated shooting. some participating emergency nurses also discussed the presence of thought intrusions when not in the clinical or work setting. although none of the participants reported avoidance of patient care situations in their clinical roles, some reported having increased situational awareness of the potential for violent acts that could directly affect them, family members, or friends. qualitative research studies among emergency nurses also provided themes consistent with those identified through this study. the importance of supportive relationships, which was described by participants in a study conducted by alzghoul, 6 was also identified in this study. the findings also agree with results suggesting the importance of having protective mechanisms for coping with working with trauma patients and that experience and proficiency are essential for trauma nursing. 6 the importance of having strategies to mitigate stress, such as talking with peers, was identified by drury et al. 21 the participants from the study performed by drury et al 21 also discussed being less likely to use external counseling services than pastoral or peersupport resources. positive emotions, as described by alzghoul, 6 include the reward of seeing patients improve and may not be experienced by emergency nurses who care for these patients for only a short duration and are unable to learn of their outcomes. differing opinions related to formal debriefs were also discussed by morrison and joy. 20 experiences with "poly-stressor effect" 20 mirror the discussion of compounding variables that may affect the nurses' ability to cope with such traumatic events. the themes and findings from this study and review of the available literature yield implications for emergency nurses that may mitigate the negative psychosocial effects of providing care to patients from multiple-victim, school-associated shootings. expanded research to include professionals from various health care disciplines and specialties is indicated to examine further the effects of caring for these patients and to identify those clinicians who are most at risk for secondary traumatic stress. the research efforts may also be broadened to include other clinical specialties in the emergency department such as emergency medicine physicians, trauma surgeons, paramedics, respiratory therapists, or social workers. future research may expand beyond the emergency department and could include clinicians from the responding prehospital agencies, air medical transport services, operating rooms, trauma and surgical intensive care units, step-down units, mental health services, and rehabilitation facilities. gathering data from community emergency departments that have received patients from multicasualty school shooting events is likely to further the understanding of how clinicians and departments without the vast resources of a trauma center are affected by these events and what unique challenges were experienced. continued research efforts are also indicated to evaluate the effectiveness of interventions aimed at alleviating the symptoms associated with secondary traumatic stress, compassion fatigue, and burnout. the implications for emergency nurses are applicable to the preplanning, response, and recovery phases associated with providing care to these patients. emergency nurses, nurse leaders, and nurse educators should encourage positive coping skills and self-care routines to mitigate the incidence of secondary traumatic stress and related symptoms. these skills and routines may support effective recovery after the provision of care to patients from multicasualty school shooting events. peer-focused sessions, which encourage open discussion and reflections, are likely to promote coping and recovery after caring for patients from these events. this aligns with research that identified debriefing with peers as being more effective, and recommending the facilitation of debriefings by a nurse. 22 actively promoting the use of employee assistance professionals may be essential to helping affected clinicians cope after such an event; however, these services should complement, rather than supplant, peer-to-peer support that occurs immediately after patient care. nurse managers and hospital administration may consider providing paid administrative leave for clinicians immediately after patient resuscitations and subsequent dispositions to facilitate participation in peer conversations to promote coping and recovery. in addition to the implementation of peersupport mechanisms immediately after the event, comprehensive employee assistance services, which may include counseling or formal support services, may be appropriate to support clinicians involved in the care of these patients. available resources that may mitigate secondary traumatic stress and promote mental health among health care professionals are provided in table 2 . the restriction of nonessential staff in resuscitation rooms is likely a best practice to promote patient privacy and confidentiality while alleviating some of the emotions described by these emergency nurses. likewise, as the participating emergency nurses indicated that not learning how the patients had recovered prevented their gaining closure after the event, notification of patient outcomes in compliance with state and federal laws and regulations is likely to benefit the clinicians involved in the care of these patients. although patient confidentiality is critical, individually sharing patient outcomes with the nurses, providers, and staff who were involved in the emergency care of these patients would likely prove beneficial and may be facilitated by gaining consent from parents or guardians. for those departments from which patients are transferred to other facilities for definitive care, the receiving facilities should perform outreach to the referring clinicians and their departments to inform them of patient outcomes to promote closure after the event. because research has identified barriers to obtaining trauma education among rural clinicians, 23 education and outreach by trauma centers to community facilities can improve clinical preparedness for mass and multiple casualty events while promoting wellness and self-care resources to lessen secondary traumatic stress. such education and outreach efforts may include trauma nursing curricula, assistance with event simulations, provision of training with patient care scenarios, and facilitation of patient transfers through the creation of autoacceptance agreements. assistance with mass casualty drills that include mock patients who may be pediatric is also likely to support preparedness for such events. the study participants were emergency nurses who received these patients at a level 1 comprehensive trauma center with vast resources, capacity, and personnel. the emergency nurses who participated in this study have access to employee assistance professionals, full-time social workers in their department, and clinical resources that include surgeons, surgical capacity, supplies, equipment, and blood products. emergency departments and facilities with more limited resources are likely to experience greater challenges with accommodating the volume of patients from a multicasualty, school-associated shooting event. the participating nurses were from a single medical center and provided care to patients from 1 school shooting event. there may be some limitations in the transferability of these results to community ed settings with fewer specialty resources. in addition, the participating emergency nurses from the level 1 comprehensive trauma center would be expected to have more experience caring for patients injured by gun violence. this experience is likely to afford clinical and emotional benefits that supported these nurses' abilities to cope during and after their roles in the care of the victims from this event. emergency departments are typically the front line of hospital-based medical care. multicasualty school shooting events often occur without warning and bring unique challenges to the clinicians and departments that are tasked with receiving and caring for these patients. learning from emergency nurses who care for patients from a multicasualty, school-associated shooting event may promote personal and departmental preparedness and improve coping and recovery among the involved clinicians. the identification of themes and the findings from this study translate to implications for emergency nurses that may improve patient table 2 internet links for secondary traumatic stress and mental health resources for health care professionals outcomes through planning and preparedness while benefiting the welfare, resilience, and retention of emergency nurses who are likely to be emotionally affected by their roles caring for the victims of multicasualty, school-associated shootings. further research is indicated to explore the experiences of nurses after caring for patients from other school shooting events to better understand the psychosocial effects and define the most effective support methods. advancing science and practice for vicarious traumatization/secondary traumatic stress: a research agenda secondary traumatic stress self-care issues for clinicians, researchers, and educators emergency nurses association. ena topic brief: the well nurse burnout and its association with resilience in nurses: a cross-sectional study the impact of traumatic events on emergency room nurses: findings from a questionnaire survey the experience of nurses working with trauma patients in critical care and emergency settings: a qualitative study from scottish nurses' perspective stress in emergency departments: experiences of nurses and doctors an exploration of factors associated with post-traumatic stress in er nurses characteristics of school-associated youth homicides -united states nurse suicide in the united states: analysis of the center for disease control 2014 national violent death reporting system dataset case study research and applications: design and methods toward a mechanism for secondary trauma induction and reduction: reimagining a theory of secondary traumatic stress the concise proqol manual using the framework method for the analysis of qualitative data in multi-disciplinary health research nvivo qualitative data analysis software. version 12 prevalence of secondary traumatic stress among emergency nurses secondary traumatic stress among emergency nurses: a cross-sectional study the effectiveness of an educational program on preventing and treating compassion fatigue in emergency nurses secondary traumatic stress among emergency nurses: prevalence, predictors, and consequences secondary traumatic stress in the emergency department compassion satisfaction, compassion fatigue, anxiety, depression and stress in registered nurses in australia: phase 2 results pediatric emergency department staff preferences for a critical incident stress debriefing trauma outreach education: assessing the needs of rural health care providers submissions to this column are encouraged and may be submitted to steve weinman the study was supported by a clinical nurse scholars training grant award from the vanderbilt university medical center nursing research office.conflicts of interest: none to report. supplementary data related to this article can be found at https://doi.org/10.1016/j.jen.2020.05.018. do you recall what your thoughts were when you learned that your department was going to be receiving victims from a school shooting?do you recall your feelings while you were preparing to receive these patients, providing care to them, or reflecting on your role as part of the involved health care team?what was it like for you as you cared for these patients? do you recall if you experienced any increased stress while preparing for the patients' arrivals?do you recall reflecting on or thinking about those patients in the days, weeks, or months after the incident?were there family members, peers, or managers who you talked with about this incident?were any services provided by the medical center to help the emergency department team after this incident?did you feel that these services were sufficient and/or helpful?did you find yourself seeking more information from the media about the event?do you think that these patients affected you any differently than those trauma patients who you routinely care for?did you find yourself avoiding situations or patient care assignments where you may encounter similar patients?did you experience any disruptions in your normal routines, such as difficulty sleeping or concentrating on other tasks, due to thinking about those patients?do you think that you were "jumpy" or more aware of the potential for violent incidents which could affect you, a family member, or a friend?were there any activities that you found to be helpful as a coping mechanism after the incident?if you have left your position at this medical center, do you feel that this event had an effect on your decision to leave?is there anything else that you would like to add that would help me understand the challenges that you experienced as a result of caring for these patients? key: cord-351637-jz2x8zwq authors: catton, howard title: nursing in the covid‐19 pandemic and beyond: protecting, saving, supporting and honouring nurses date: 2020-06-23 journal: int nurs rev doi: 10.1111/inr.12593 sha: doc_id: 351637 cord_uid: jz2x8zwq as the world tackles the largest public health event in more than a century, the covid‐19 pandemic, the true value of nursing is being seen by politicians and the public. but while nurses are being praised for the vital work they do, many are being put into high‐risk situations, and some have died, because of a shortage of appropriate, high‐quality personal protective equipment. the international council of nurses has called for governments to make the provision of such equipment their number one priority to prevent further loss of life among the nurses caring for the world’s most vulnerable patients. everybody knew that a dangerous pandemic was possible, and the world health organization (who) and most countries had plans in place to deal with one. but it is now apparent that most countries were not sufficiently prepared. the flu pandemic of 1918 showed just how devastating it could be, but it seems few people actually expected it to happen again. but over the past four months, we have seen the world rocked by the covid-19 pandemic, and all the plans for the celebration of the international year of the nurse and midwife have been put on hold. nobody could have foreseen the high-profile nursing has right now, albeit for such a terrible reason. countries have gone into lockdown, and healthcare systems have come precariously close to meltdown as the pandemic circles the globe and threatens to overwhelm the capacity and capability of chronically underfunded health and social care systems. covid-19 has revealed that, even in rich countries, longterm under-investment since the 2008 financial crash has taken its toll and left healthcare services with too few staff and insufficient resources and reserves. there is no doubt that this has made dealing with the current international public health emergency harder than it need have been. nurses have been heroic in their attempts to provide care and save lives. many have worked long shifts for weeks on end without a day off. many have faced the real possibility of contracting this dangerous infection themselves because of a lack of suitable personal protective equipment (ppe). and sadly, many have died. just as we could not have predicted what has happened in the past four months, nor could we have anticipated the shocking fact that our colleagues would be sick and even dying because of a lack of ppe. healthcare workers, many of them nurses, make up a large proportion of the people infected with the covid-19 virus, up to 15% in some countries. the serious lack of ppe puts them at risk and increases the risk of cross infection for patients, for health worker's families and community members. international council of nurses has called on world leaders of the g-20 nations and others to combine their resources to make increasing the production and easing the distribution of this life-saving equipment their utmost priority. at the time of writing, the confirmed number of nurses who have died worldwide exceeds 100, which is probably a gross underestimate (icn 2020). if governments do not act immediately on this issue, it will be too late and, tragically, many more nurses will get sick and die. it is also problematic that countries are not keeping accurate, up-to-date records of how many nurses have been infected nor of how many have died, and icn has demanded that they start doing so as soon as possible. having accurate data on this and other aspects of the pandemic will provide vital information that will help to improve infection prevention and control measures, shorten the pandemic's duration and save nurses' and patients' lives. there will come a time when we will want to honour the nurses who died while trying to save the lives of others: we must make sure that every nurse who succumbed to covid-19 is remembered. they must not be forgotten. and their legacy must be increased investment in healthcare systems and better pandemic preparedness so that nurses will never again have to give their lives just because they did their jobs. icn's 130-plus national nursing associations (nnas) have provided leadership and support for nurses' need in this time of crisis. they have been the voice of nursing in their countries, and many have had access to the top tables where policy is being made. nursing knowledge, experience and advice have been a crucial part of the strategy to contain the pandemic, and nursing practice has been fundamental to the care and survival of patients who have been most seriously affected by covid-19. we must not forget the emotional labour of nursing at this time, nor the cost it can have on the mental well-being of nurses who are seeing large numbers of their patients becoming desperately ill and dying. this is hard work physically and emotionally. it strikes at the heart of what nursing is, and what nurses and others do on the front line. people involved in the care of these patients are suffering. it is important to ensure that they are getting enough rest and mental health support to see them through. with the right help, they can avoid the worst effects of the burden they are carrying, but they need that help now, not when this is all over. and 'when this is all over' is something we all need to think and talk about now. because we do not know when that will be, and we do not know what the world will be like. experts suggest that social distancing is likely to be around for a long time, certainly until mass vaccination programmes have been completed, and the ways people live, love, work, travel and socialize are likely to change too. whatever the eventual outcome of the covid-19 pandemic, nurses will continue to provide intimate care for people who need it, whoever and wherever they are. and nurses will continue to be the most trusted profession. nurses have earned that trust over decades, and 2020 will cement our approval rating in the eyes of the general public for years to come. politicians who have praised nurses for their commitment and valour during the pandemic need to put money on the table to ensure that the world has more nurses that they are better paid, educated and resourced and that their voices are heard above the noise in the clamour for government resources. nursing is critical to health and well-being everywhere, but it also contributes to our economic prosperity: health and wealth are two sides of the same coin, something the public is now also aware of. politicians should not need reminding of this, but icn and our nnas will remind them anyway. who's director general tedros adhanom ghebreyesus has said that countries that do not have enough nursesand that is most of themare trying to deliver health care with one hand tied behind their backs. as this pandemic has shown, that does not work. the newly released state of the world's nursing report (who 2020), co-authored by icn, who and nursing now, reveals how many more nurses are needed to provide health care for all. i was privileged to co-chair this report, and i believe that the strategic directions it sets out must be our roadmap for the future. now is the time to invest in education, jobs and leadership. we, our world, cannot afford not to. governments must start planning now for a future with enough nurses, where every nursing post is filled, and the entire nursing workforce is better paid and truly valued for the vital services it provides. because the people will expect nothing less. international council of nurses. (2020) icn says worldwide death toll from covid-19 among nurses estimated at 100 may be far higher state of the world's nursing: investing in education key: cord-018412-kv3vxmcw authors: bambi, stefano title: evolution of intensive care unit nursing date: 2017-10-06 journal: nursing in critical care setting doi: 10.1007/978-3-319-50559-6_19 sha: doc_id: 18412 cord_uid: kv3vxmcw the specialties of critical care medicine and critical care nursing arose to provide special treatment and care to the most severely ill hospital patients. however, critical care medicine does not seem to have made any major therapeutic progress in the past 30 years. the reduction of mortality in intensive care units (icus) is due essentially to improvements in both supportive care and the relevant technologies. in future, increases in the number of icu beds relative to bed numbers in other hospital wards will probably be contemplated, even in a scenario of decreasing costs; clinical protocols will be computerized and/or nurse-driven; more multicenter and international trials will be performed; and organizational strategies will concentrate icu personnel in a few large units, to promote the flexible management of these healthcare workers. moreover, extracorporeal organ support technologies will be improved; technology informatics will cover all the bureaucratic aspects of healthcare work, aiding the staff in workload assessment; and critical care multidisciplinary rounds and follow-up services for post-icu patients will be implemented. lastly, a better continuum of care between the pre-hospital phase, the emergency care phase, the icu phase, and the post-icu phase should be achieved. also, policies should be drafted to manage sudden large demands for critical care beds in mega-emergencies. the main lines of discussion in critical care nursing research should include nursing research priorities in critical care patients, holistic approaches to the patient, the humanization of care, special populations of icu patients, and challenges related to critical care nursing during emerging outbreaks of infectious diseases. recently, professor jean-louis vincent (along with other luminaries in the field of intensive and critical care medicine), has published articles that consider the history and perspectives of intensive care medicine and intensive care units (icus) [1] [2] [3] . the fields of critical care medicine (ccm) and critical care nursing arose to provide special treatment and care for the most severely ill hospital patients [2] . these patients need high levels of surveillance, intensive nursing care, and biomedical technology to support and monitor their vital functions and failed organs/systems. this type of care is carried out in icus, which are specific spaces, separated from other hospital areas, set up to receive critically ill patients and provide highly specialized medical and nursing competences and skills [2, 4] . however, in the past 30 years, despite the increasing amount of research in ccm, major therapeutic progress does not seem to have been made in the field [1] . the reduction of mortality achieved in icus is due essentially to improvements in supportive care and in the relevant technologies [5] . some therapeutic progress has been shown in the following fields [1] : • protective strategies for mechanical ventilation in acute respiratory distress syndrome (ards) • increasing employment of noninvasive ventilation (niv) • reduction of (long-term) sedation use • enteral nutrition preferred to parenteral nutrition • less invasive monitoring systems • reduction in blood transfusions • reduction in anti-arrhythmic medications • greater attention to the use of antibiotic drugs • early and active patient mobilization. however, greater steps have been made in the process of care, including all the healthcare professionals involved with the critically ill patients, the environment, the "interpretation" and organization of the work [1] . such achievements that can positively affect patient outcomes are [1, 2] : • multidisciplinary outcome-oriented teamwork. the icu staff now goes beyond critical care nurses and doctors, and includes physiotherapists, pharmacists, infectious disease consultants, nutritionists, and psychologists. • implementation of protocols for weaning of patients from mechanical ventilation; sedation; nutrition; glucose control; vasopressor and electrolyte-targeted infusion; patient positioning; and early mobilization/ambulation. • processes of cure and care driven by the "time is tissue" motto (early diagnosis and treatment of critical illnesses produces better patients outcomes). • utilization of continuous renal replacement therapy (crrt) to better manage the intake and removal of fluids during the hyperacute phase of critical illnesses and the later phases, in which there can be the need to remove fluids. • early mobilization of patients to prevent ventilator-associated pneumonia (vap), deep vein thrombosis (dvt), pressure ulcer (pu), and delirium. • increased utilization of clinical risk management tools (incident-reporting systems, morbidity and mortality reviews, and audits). • humanization of icu scenarios through open visiting policies and ethical approaches to the issue of end-of-life (eol) care. • more awareness of the limited (or even absent) evidence for the effectiveness of many therapeutic and interventional options now used in the icu (e.g., albumin, pulmonary artery catheter, tight glycemic control, dopamine). • more awareness of the need to prevent cross-infections and device-related infections. • implementation of the concept of an in-hospital medical emergency team and an outreach team philosophy. • greater understanding of the role of intra-abdominal hypertension and compartment syndrome in multi-organ failure and patient outcomes. • establishment of multicenter and international patient registries for specific pathologies (e.g., trauma, cardiac arrest, etc.), in order to improve quality assurance programs and benchmarking. technology has made great contributions to the availability of monitoring and interventional options, together with providing higher standards of safety for patients, being user-friendly, and, in some cases, with devices being smaller and lighter in weight than in the past [2] . what about the future of icus? vincent [2] envisions increases in the number of icu beds relative to the number of hospital beds in other areas, even in a scenario of decreasing costs. the shortage of intensivists could be "compensated" for by computerized or nurse-driven clinical protocols, but the nursing workload would then increase, and nursing staff numbers should be adequate to deal with this increase [2] . more multicenter and international trials will be performed to test drugs and treatments, offering greater evidences to use in ccm [3] . furthermore, pharmacological treatments for critically ill patients should be improved through strategies such as [5] : • selecting samples for research in critically ill populations, taking into account biological and clinical variables • promoting the early administration of drugs during the initial manifestations of diseases and also before the admission of patients to the icu • performing phase 2 trials to test new generic drugs • implementing cell-based therapies and therapies that will enhance the resolution of organ failure. organizational strategies should involve the use of inclusive models, concentrating icu personnel in a few large units, and promoting the concept of centralization to improve patient outcomes and to provide flexible management of healthcare workers [2] . extracorporeal organ support technologies will be improved [1] . information technology should cover all the bureaucratic aspects of healthcare work, improving handover, drug prescriptions, and data collection with a network consisting of patient monitoring systems, point-of-care systems, clinical records, and charts [2] . in addition, computerized systems could provide real-time calculation of staffing needs, based on the nursing workload and patient risk prediction and stratification, improving triage for icu admission and discharge [4] . this kind of progress could be time-saving and prevent mistakes, and it could also leave more time for doctors and nurses to care for their patients at the bedside [2] . multidisciplinary rounds should become the norm. patient follow-up post-icu stay could become the source of valuable information employed to direct interventions that recover the patient's quality of residual life and improve the quality of care in the icu [2] . a better continuum of care between the pre-hospital phase, the emergency care phase, the icu phase, and the post-icu phase should be implemented. at the same time, adequate data collection and analysis models are needed, to accurately evaluate the effectiveness of interventions delivered to patients in the whole healthcare path of the critical illness [1] . in addition, policies should be drafted to manage increasing demands for critical care beds in the event of maxi-emergencies [3] . discussing future perspectives in critical care nursing is not a simple issue. however, four main lines of discussion can be addressed: priorities in critical care nursing research, holistic care and humanization of care issues, specific populations of icu patients requiring competent and expert nursing care, and icu nurses' preparedness during outbreaks of emerging infectious diseases. across (and beyond) all the above considerations, this chapter will provide an overview of current and more meaningful issues for critical care nursing, noting the areas that require particular consideration and further investigation. nursing research plays a central role in scientific production, increasing the disciplinary body of knowledge. the main problems related to research in critical care settings are related to the small sample numbers and the large number of variables that are difficult to control. moreover, research findings are not simple to retrieve. hence, some large nursing associations, such as the american association of critical-care nurses (aacn) and the european federation of critical care nurses associations (efccna), have promoted the identification of priorities in nursing research and are developing international networks to support multicenter designed studies. according to an american professional task force, priorities in critical care nursing research should be oriented toward [6] : • development of methods for fast recognition of acute patients at high risk of rapid deterioration • minimally invasive organ support technologies • new approaches to enhance patient comfort while reducing changes of consciousness • effective process and outcome measurements for critical illness research and palliative and eol care. the areas of nursing interest in healthcare service research should cover [6] : • strategies to improve communication and coordination of care • tools, processes, and programs to promote knowledge transfer and implementation • factors related to an effective learning environment • strategies for the application of clinical risk management concepts and methods • assessment of the distressing effects of interventions on the patient and their family. on the european side, the efccna, through a delphi study design, has identified 52 research topics in 12 different domains [7] . the priorities of nursing research in critical care settings noted in that study mainly cover patient safety issues, the impact of evidence-based practice (ebp) and the workforce on patients' outcomes, the comfort/well-being of patients and relatives, and the impact of eol care on staff and their practice [7] . the five research topics with the highest ranking scores were [7] : • interventions to reduce nosocomial infections in the icu • pain management and pain assessment • exploration of the extent of anxiety, fear, and stress in icu patients, and strategies to reduce their occurrence • prevalence and prevention of critical incidents in the icu (medication errors, adverse events) • impact of the icu nurse-patient ratio on patient outcomes. some authors have also proposed new strategies to increase effectiveness in the production and local dissemination of scientific knowledge, reducing the distance between researchers and clinicians. such strategies involve the "tripartite model," based on synergy among universities, hospitals, and single hospital wards [8] . the american college of critical care medicine guidelines for support of the family in the patient-centered icu rely on the concept that relatives are essential resources for patients' health [9] . these guidelines refer to major concepts such as "flexibility," "single-case basis evaluation," and "open icu" [9] . the open icu philosophy is based on the reduction/elimination of temporal (liberalization of visiting policies), physical (overcoming the imposed barriers to physical contact between relatives and patients), and relational restrictions (trust-based relationship between icu staff and families) [10, 11] . this progressive change of view toward a "holistic" approach to the cure and the care of the patient-family as a whole, greatly challenges icu staff [12] . some authors promote open visiting policies as a standard, as well as promoting the adoption of patient-centered outcomes (not only survival) [13] . evidence on the influence of programs for the implementation of open icus on patient mortality, length of stay (los), infection risk, and the mental health of patients and their relatives is currently lacking, and the influence of such programs needs to be investigated [12] . further, the efforts of icu teams to improve the relationship climate inside the icu will require addressing according to the indications arising from the research results. recently, some authors have hypothesized that open icu programs and the presence of family members during cardiopulmonary resuscitation could also play a role in reducing the rates of opposition to organ donation [14, 15] . more studies are needed to confirm this hypothesis, introducing important scenarios with potential lifesaving effects for future icu patients [14, 15] . animal-assisted therapy (aat) is defined as "the use of human-animal bond to attenuate stress and improve mood" [16] . aat works on the interaction between humans and pets, with the aim to reduce stress and feelings of isolation and depression [16] . areas of aat implementation range from simple social well-being to the improvement of language or motor functions [16] . dogs are the most frequent animals used for aat, although rabbits and cats can also be employed, under the guidance of specially trained teams. adequate procedures that address hygiene guidelines, times of use, and safety measures are needed [16] . although the introduction of aat inside icus has been referred to in the literature since the early 1990s [17] and finds enthusiasm among staff nurses [18] , experience on its implementation in icus is very limited. a preliminary randomized controlled trial (rct) conducted on 76 adult patients with advanced heart failure in the icu showed reductions of cardiopulmonary pressure, neurohormone levels, and anxiety during the visitation of a dog and a volunteer [19] . another pilot rct study, performed on 40 children (aged between 3 and 17 years), showed that the employment of dog visitations in the immediate postoperative period after general surgery facilitated the recovery of vigilance and activity after anesthesia and significantly reduced the perception of pain [20] . this fascinating adjunctive therapy needs to be the target of more scientific research, to expand the areas of implementation and produce better evidence of its effectiveness than that currently available. working in an icu is not a simple matter [21] . the icu work environment is complex, as a result of three different determinants involved: the physical environment, emotional environment, and professional environment [21] . the physical environment is often challenging for healthcare professionals, generating stress. unfavorable (artificial) lighting, frequent irritating noises (e.g., monitor and device alarms), clumsily placed equipment, narrow patient units, and overcrowding are the main workplace stressors generated by the physical environment [21] . human factor engineering is a discipline that can provide some solutions to these difficulties, improving work conditions for all members of the icu staff [21] . the emotional environment in the icu is well portrayed by the metaphor of "a continuous hot and cold shower" [21] . the emotional stress for healthcare workers is very high, owing to the high mortality and disability rates, the need for making fast life-or-death decisions, and the need to balance the effort to save lives with the realistic limits of technologies and medical/nursing sciences [21] . these elements can easily lead to feelings of frustration, exhaustion, and (sometimes) anger, in the personnel, particularly in critical care nurses, because they are the professionals who are always on the frontline at the patient's bedside [21] . anger, in particular, is an emotion that needs to be adequately addressed before it develops into hostility, aggression, and violence [22] . some studies have reported that about a quarter of workers in the united states experience anger in the workplace [22] . it is important for staff to recognize their own trigger points for anger, and to prevent negative feelings and their escalation; strategies that can be used for this are [22] : • be constructive and practice open listening. • identify the signs and causes of anger. • use calming techniques. • maintain eye contact with the person who has triggered the anger and express genuine concern. • try to understand elements that could resolve the anger. the recent widespread implementation of the "open icu" concept has exposed nurses to additional emotional stressors arising from the family's feelings and needs, because the relatives spend more time in icu, at the patient's bedside. the consequent physical and emotional stress can cause depersonalization and/or avoidance behaviors, exhaustion, burnout, and higher turnover rates in icu personnel [21] . some proposed solutions rely on teamwork learning programs (with the focus on interprofessional relationships). educational interventions and workshops aiming to provide psychological stress management tools and improve interpersonal social and communication skills have also been recommended [21] . concerning the professional environment, work satisfaction seems to be the key to the adequate development and expression of positive potential in healthcare professionals. to increase work satisfaction, the icu environment should promote group cohesion, effective communication, autonomy, and supportive management [21] . when teamwork is not effective, synergistic, and harmonious, burnout and errors can easily arise. burnout is a syndrome characterized by absenteeism, fatigue, reduced personal commitment, and low job satisfaction levels. team training programs and, above all, reduced staff workload can be effective in increasing work satisfaction levels, preventing the above-mentioned negative consequences [21] . it has been found that most icu staff share the same definition of interprofessional work, that includes concepts as "shared team identity, clarity, interdependence, integration, and shared responsibility." [23] nevertheless, except for critical events, the most common work interactions developed in the icu are synthesized as collaboration (interactions related to specific questions), coordination (working in parallel), and networking (acquiring skills and expertise, and consultations with others) [23] . nurses and other icu team members are often frustrated by doctors not listening to them [23] . it has been reported that the only event in which an icu staff acts as a team is during an emergency code. such behavior is well known in crisis resource management, but this behavior fails to be shown in daily practice and workflows [24, 25] . therefore, the only way for the multidisciplinary icu team to achieve better outcomes is to develop a high level of trust, improve communication and discussion, and share clear and structured clinical and organizational information [25] . currently, some authors recommend that future research be focused on the mechanisms that drive learning and interactions in the icu team, seen through the "magnifying lens" provided by the social sciences (organizational behavior, anthropology, and network science), taking into account that the composition of the icu team can vary largely from one shift to another [4] . during the past 10 years, the aacn has recognized the positive influence of healthy work environments on nursing staff outcomes and retention [26] . the aacn has identified and promoted six standard elements that define a work environment as "healthy": "skilled communication," "true collaboration," "effective decision-making," "appropriate staffing," "meaningful recognition," and "authentic leadership" [26] . despite the efforts of the aacn to disseminate these standards and improve nursing workplace environments, the results of two surveys, performed 7 years apart, showed only a marginal improvement in communication [27] . when icu nurses were surveyed in regard to the elements that provided them with work satisfaction, they responded that the main elements were related to nursing unit management; the relationships with and the organization of medical staff; rostering practices; nurses roles in icu patient care; and general relationships in the workplace [28] . nurses and physicians are the two main professionals driving the workflows inside the icu. the relationships between the two professional groups are influenced by three components of the icu workplace environment, their specific roles, differences in expected patient outcomes, and levels of stress and workloads. therefore, conflicts between these two professional groups are not rare. however, to better understand this phenomenon, it is necessary to differentiate vertical conflicts (nursesdoctors) from internal conflicts among nurses (horizontal conflicts). a large multicenter study reported that 33% of conflicts within the icu team were nurse-physician conflicts, being the most common types of struggles within the icu team [29] . hostility and lack of communication were the main causes of the conflicts [29] . most conflicts arise around two main issues: eol decisions and communication matters [30] . conflicts about eol decisions are one of the most important causes of moral distress in nursing staff, with profound effects on the workplace climate [30] . disagreement with postoperative goals of care is another important cause of conflict between physicians and nurses [30] . the need to keep relatives adequately informed about patients' conditions can also cause some tension between icu staff nurses and doctors [30] . further, many nurse-physician conflicts emerge from procedural factors (related to team processes), organizational factors (related to the local unit or hospital), contextual factors (legal, social, and cultural features), relational factors (variables influencing the social relationship) [31] , and, probably, anthropological factors (the idea of nursing as an oppressed discipline) [32] . a simple but effective intervention to improve communication between icu nurses and doctors could be the introduction of a multidisciplinary daily round and daily planning of activities, to share objectives and desired clinical outcomes [30, 31] . after a conflict has happened, the best strategy is to try first to resolve the problems with the individuals, taking the discussion back to the real subject of the conflict (often the patient or the organizational problem) and depersonalizing the situation [30] . unprofessional, offensive, or unsuitable behaviors should not be tolerated by a team that has common shared values and should be referred to the internal disciplinary authority [30] . to really understand the "internal world" of the "nurses' tribe" in depth (these anthropological terms can be used to describe the characteristics of nurses' relationships), one has to observe nurses' particular positive and negative internal relationship dynamics. nurses colleagues show strong bonds, forged by the unique, intense, and emotional challenges shared daily at their patients' bedsides. the shared experiences of their patients' pain, suffering, and death, as well as shared experiences of hope and healing, can bond nurses to their colleagues at deeper levels than those seen in other professions. but, similarly to the strong attachments between nursing colleagues, internal conflicts among nurses can be fierce. horizontal violence (hv) is one of the terms used for behaviors ranging from verbal and emotional abuse to physical violence perpetrated by workers against their peers inside an organization [33] . the reported prevalence rate of this phenomenon among nurses ranges widely, from 5.7 [34] to 79.1% [33] and is associated with important psychosocial [35] and professional consequences. symptoms of posttraumatic stress disorder (ptsd) have been reported in nurses, and high rates of job leaving are recorded in those with shorter lengths of service [36] . moreover, some authors suppose that there may be a relationship between hv and patient safety, owing to changes in the flows of clinical information among nurses [37] . various researchers have advanced explanations for the origin and development of hv. the "oppressed group behavior theory" [38] , interpersonal, intrapersonal, evolutionary, and biological models offer different views about the emergence of this phenomenon [39] , but, currently, none of these models has been completely validated. the key elements of these theories and models are [40, 41] : • "lack of self-esteem" • "generational and hierarchical abuses" • "actor-observer effect" • "nursing as an oppressed discipline" • "working practices depriving rights/privileges" • "aggression leading to aggression" and "development of cliques". despite the high rates of the hv phenomenon and the perceived relevance of its effects by nurses, the solutions proposed have been limited to position statements [42] and guidelines [43] released by some nurses associations, as well as ideas on team building [44] and self-esteem augmentation [45, 46] , education programs, and an educational tool-kit to identify and resolve workplace bullying and harassment [47] . interventional studies of solutions (e.g. the implementation of zero tolerance policies [48] ) are lacking. hence, there is a need to focus nursing research on hv prevention, because it is difficult to eradicate the problem once it becomes part of the structure of a group. during the delivery of care, critical care nurses should pay attention to the particular features appropriate to specific patient populations, as shown in the framework summarized in fig. 19 .1. recent epidemiological data has shown that about 2.1 billion people worldwide are obese (i.e., have a body mass index [bmi] higher than 25 kg/m 2 ), with an increasing trend [49] . the fight against this harmful condition requires powerful prevention programs, and such programs need political commitment [49] . morbid obesity (bmi >40 kg/m 2 ) is a condition affecting about 6.6% of the united states population (data from 2010) [50] . morbid obesity is often associated with potential complications in the icu, such as difficult airways and/or ventilation, and challenging peripheral and central venous access [50] . frequent comorbidities are obstructive sleep apnea, diabetes, insulin resistance, low levels of vitamin d, hyperlipidemia, and hypertension [51] . moreover, respiratory and cardiovascular impairments can be frequent, both seen with a chronic inflammatory state. in particular, the respiration of these patients can be affected by increased work of breathing and chest wall resistance and high chest wall resistance, increased intra-abdominal pressure, co 2 production, and oxygen consumption, and the possibility of muscle weakness [51] . cardiovascular impairment can be caused by increasing levels of circulating blood or co 2 , risk of heart failure and dysrhythmias, hypertrophy, and other myocardial structural alterations [51] . additionally, hypercoagulability and late wound healing can be expressions of metabolic changes due to obesity [51] . lastly, the pharmacokinetic and pharmacodynamic characteristics of most drugs can change in these patients [50] . currently the association between higher bmi class and patient outcomes in icus is still controversial ("obesity paradox") and requires more accurate comparisons between the obese bmi classes and "normal" bmi subjects [52, 53] . however, bmi calculation alone is not sufficient to stratify patients, since it does not take into account differences in body composition (adipose tissue, lean tissue, body fluids) [52] . from the logistical and nursing care points of view, morbidly obese patients present challenges for bed and stretcher weight limits and dimensions, and for patient repositioning and transfers. standard hospital beds can bear weights of up to 150-170 kg, but morbidly obese patients are often beyond these body weight limits [54] . sometimes radiological examinations cannot be performed, owing to the limits of radiological stretchers. standard radiology beds can hold weights of 158-204 kg, while in patients over these weight limits, the performance of a computerized tomography (ct) scan or magnetic resonance imaging (mri) can require special equipment (beds bearing a weight of up to 306 kg for ct and up to 248 kg for mri) [54] . all this information is useful for planning the nursing and medical care of these patients, considering the complex physiopathological, logistical, and safety factors that characterize their stay in critical care units. airway management can be very difficult. the "ear-to-sternal notch positioning" (so-called ramped position) can improve the management of intubation in these patients, when there is no suspicion of cervical spine injury. this position can be obtained by rolling layers of bedsheets under the patient's shoulders, until the back elevation reaches the desired alignment [54] . ventilation can be improved using the "beach chair" position or anti-trendelenburg position at 45°. these solutions allow better diaphragmatic excursion and prevent the risk of microinhalation. in morbidly obese patients, the supine position and trendelenburg must be avoided because of the risk of "obesity supine death syndrome" [54] . during mechanical ventilation (mv), tidal volume according to ideal body weight (ibw) should be used, since the size of the lungs does not depend on the real body weight of the patient. also, for these patients the limit of 30 cmh 2 o for plateau pressure has to be respected to prevent ventilator-associated lung injury [54] . it is sometimes difficult to insert vascular catheters in morbidly obese patients. echocardiographic insertion techniques are greatly limited owing to the large stratification of adipose tissue [54] . so arterial and venous catheters are often maintained in place for a longer time than recommended, exposing patients to a high risk of infection and other kinds of complications [53] . hypocaloric nutrition is indicated in obese patients. in the higher bmi classes, the aim is to reach 60-70% of the patient's energy requirements. protein supply in patients with bmi ≥40 should be ≥2.5 g/kg of ibw, except for those with renal failure [53] . some pharmacological considerations should also be taken into account. reduced peak serum levels and increased clearance time can be recorded for lipophilic drugs [54] . the doses of highly lipophilic medications should be calculated according to the real weight, while the doses of minimally lipophilic medications should be calculated according to the ibw. increased creatinine clearance in obese patients can reduce the levels of medications excreted by the kidneys [54] . altered absorption through intramuscular, intradermal, and subcutaneous pathways is typical in obese patients [54] . beyond preventing the deterioration of vital and organ functions, nursing care has to be directed toward the provision of adequate staff numbers, special beds, and equipment to facilitate patients' repositioning and early mobilization, with particular attention paid to the development of "traditional" pu and device-related pu [53] . finally, during their clinical practice, critical care nurses need to pay attention to aspects related to the emotional support needed by obese patients and the social stigma they experience, as obesity still has a negative social connotation. indeed, some stereotypes and prejudices portray obese persons as being shorttempered and nasty [54] . verbal and emotional abuse of obese patients perpetrated by healthcare workers has been reported in the literature; it is mandatory for healthcare workers to avoid behaviors that blame patients who are unable to control their unhealthy or excessive eating habits [54] . the percentage of the world's population aged over 60 years has increased from 8% in 1950 to 12% in 2013, and in 2050 the percentage is projected to be up to 21%, with a large proportion of people over 70 years old [55] . older people (aged over 80 years) admitted to icus are the subject of complex ethical debates related to poor outcomes and the poor quality of residual life after intensive care [56] . moreover, interest in financial issues has emerged in recent years (especially owing to the worldwide economic crisis), since medical costs rise exponentially in people older than 50 years [56] . another factor is that, in any kind of patient, deciding to withdraw treatment and organ support is surely more difficult than deciding to apply some kind of advance care directive (such as "do not resuscitate", or do "not intubate" orders). therefore, discussions about the ways to offer and employ intensive care support in elderly patients are influenced by ethical, cultural, and political variables, and such discussions are far from ended [57] . in a recent canadian multicenter prospective cohort study, conducted by heyland et al. [58] on patients ≥80 years old admitted to 22 icus, the mortality rate in the icu was 22% and the in-hospital mortality was 35%. patients died at a median of 10 days after icu admission. no predictors for prolonged time of intensive care support were found by the authors [58] . frailty indexes or advance care directives had little influence on the decision to limit life-support measures [58] . many other studies have shown a mortality trend of over 50% 1 to 2 years after hospital discharge in very old icu patients [55] . heyland et al. [59] , studying recovery after a critical illness in patients aged ≥80 years, found that 26% of the surviving patients achieved physical recovery 12 months after hospital admission. physical recovery was significantly associated with younger age, lower acute physiology and chronic health evaluation ii (apache ii) score, lower charlson comorbidity score, and a lower frailty index [59] . comorbidities in older patients probably play an important role in survival rates and quality of life (qol) after intensive care [55] . to improve the care of these frail patients, professional integration between intensivists and geriatricians is recommended [55] . more research in older patients is needed to explore care, life-sustaining therapies, eol problems, icu effectiveness, and qol after a critical illness [55] . critical care nursing in older patients should take into account these patients' comorbidities, with the frequent presence of chronic diseases such as diabetes, chronic obstructive pulmonary disease, congestive heart failure, and end-stage renal disease. another typical complication seen in this population is "geriatric syndromes," including pus, incontinence, falls, functional decline, and delirium [60] . the other big issue in the aging population is the concept of frailty. frailty, a condition that arises owing to reduced physiological and sensorial/cognitive reserves, typically in older people, plays an important role in the occurrence of adverse events and outcomes [59] . some authors, in discussing the consequences of nursing care in critically ill older patients, have pointed out new challenges, such as environmental modifications, the need for education and training in healthcare staff, changes in their own professional attitudes, and collaboration with experts in geriatrics [61] . functional assessment and awareness of existing medications are two key elements on which a nursing care plan should be based, also providing an "after icu perspective" to critical care nursing [61] . critical care nursing assessment of vulnerability in frail elderly patients should be multidimensional [62] . physiological assessment is directed toward the patients' sensorial status, level of mobility, and chronic pathologies. psychological assessment should focus on the identification of cognitive changes, dementia, and psychiatric conditions. lastly, an evaluation of social conditions and social supports is needed [62] . the data collected can help critical care nurses to plan adequate strategies for the prevention of complications and for the support of older patients in the icu and to draft personalized discharge planning [62] . common negative events that should be prevented in these patients are falls, abuse, malnutrition, hypothermia, depression, fear, low levels of self-care, and loss of autonomy [62] . historically, the presence of psychiatric disorders in icu patients was not well recognized or well managed [63] . only in recent times has this trend been reversed. the most frequent psychiatric clinical problems in icu patients are delirium, anxiety-panic-agitation loop, depression, psychosis, and persecution ideation [63, 64] . the causes of these problems are mainly metabolic and electrolyte disorders, infections, head injuries, withdrawal syndromes, and vascular conditions [63] . the high level of stress during an icu stay can itself be the source of a patient's psychological impairment [64] . according to some authors, certain environmental variables trigger the establishment of these conditions. high sound levels and loud noises, lack of sleep and rest, impairment of circadian rhythms, procedure-related pain, and in intubated patients, the impossibility of speaking, are typical features of the icu environment [63] . care efforts should be oriented toward [63, 64] : • maintaining patients in single icus. • guaranteeing low levels of technological noise and quiet voices. • providing calendars, clocks, and other tools for patients' time and space orientation. • improving the quality of the patient's sleep and rest and reducing light levels at night. • promoting relatives' visitations and contact with patients. • establishing an empathetic relationship with patients (and their relatives). early physical rehabilitation plays a fundamental role in the prevention of conditions such as delirium [65] . for patients who survive after icu admission and a hospital stay, ptsd symptoms are frequent and very disturbing [64] . however, except for delirium, the other psychiatric disorders noted above are rarely considered by staff nurses in the icu. nurses have to be aware of the importance of promptly recognizing psychiatric emergencies, which can sometimes be deadly [66] . psychiatric emergencies can be related to overdoses of psychotropic medications, but are not limited to overdosing [66] . in fact, the withdrawal or interruption of drug treatment can be the cause of a psychiatric emergency [66] . delirium, drug toxicity, uncontrolled schizophrenia, agitation, and suicidal attempts are typical psychiatric emergencies [66] . common psychiatric emergencies in the icu are agitated delirium, overdose of psychiatric medication, neuroleptic malignant syndrome, and serotonin syndrome [65] . often non-specific signs and symptoms, such as tachycardia, diarrhea, fever, and seizure, can hinder the rapid recognition of these emergencies [66] . almost all of the above-mentioned psychiatric emergencies in the icu require treatment with specific medications, and quick action by nurses [65] . although deaths caused by oncological illnesses have diminished since the 1990s, cancer is still the second most common cause of death, after heart illnesses, accounting for 20% of deaths in the united states [67] . recent estimates from europe, for 2012, indicated 3.45 million new cases of cancer and 1.75 million deaths caused by the disease [68] . icu admission criteria for patients with cancer have changed over the years, from an approach excluding "do not resuscitate" patients to offering the chance to recover from an acute on chronic event owing to the illness or the toxic effects of pharmacological treatments [69] . traditional oncology emergencies requiring icu treatment are currently treated in oncology or medical-surgical units [70] . these emergencies, owing to the illness or its therapy, are, mainly, tumor lysis syndrome, superior vena cava syndrome, and malignant spinal cord compression [70] . currently, oncological complications requiring assessment and support in the icu are cardiac and respiratory failure, severe bleeding and coagulopathies, and sepsis [70] . specifically, these complications can be pneumonia, venous thromboembolism, ards, pulmonary toxicity associated with chemotherapy and radiation, malignant pericardial effusions, heart failure, dysrhythmias, prolonged qt syndrome, gastrointestinal bleeding, disseminated intravascular coagulation, sepsis, and hypersensitivity reactions [70] . admitting cancer patients to the icu makes sense for improving short-term survival rates after a critical care illness [71] . furthermore, some recent general achievements and progress in icu use support the admission of these patients; such items are: more "open" admission policies, niv, diagnostic strategies in acute respiratory failure, treatment of acute renal failure, blood component transfusion policies, diagnostic strategies in neurological complications, and treatment of organ failure in macrophage-activation syndrome [71] . however, cancer patients can also die in the icu. the qol of oncology patients who die in an icu seems to be worse than that of patients who die in a hospice or at home [67] . moreover, relatives of oncology patients who have died in an icu can be affected by symptoms of ptsd [67] . one big challenge to the implementation of high-quality eol care in the icu is to incorporate palliative care early in the care plan [67] . palliative care aims to relieve symptoms and pain related to the treatment and the illness and to take into account the spiritual and psychological spheres of the patient and his/her relatives, independently of the severity and progression of the illness [67] . there are some hindrances to the implementation of eol care in the icu [67] : • mission of the icu (lifesaving and restoring patients' qol) • culture of the icu (death-denying and difficult-to-manage communication on prognosis) • goals of the icu (technology-oriented to implement lifesupport treatment, relegating the holistic approach to a low priority) • environment of the icu (an open space is a more frequent architectural configuration than a single patient rooms unit) • competing priorities for nurses' time (dying patients considered a low priority; difficulties in managing the relatives' needs and requests for information about their loved ones). a key element in eol care in the icu is the nursing management of symptoms of discomfort and pain. often these patients are treated with all the organ support that the icu can offer (mv, hemodynamic pharmacological support, crrt, artificial nutrition, etc.) [67] . moreover, large numbers of invasive devices are often in place, causing procedural pain, discomfort, and delirium. the most frequent symptoms presented in these patients are dyspnea and pain [67] . the withdrawal or withholding of organ-or life-support treatments is complex, and often a long time is required for making the decision, with the involvement of the patient, the healthcare professionals, and relatives (as proxy decision-makers) [67] . at the same time, there are important implications of such decisions, related to ethical debates and influenced by religion, national culture, and national laws. however, the key to the successful implementation of oncology patient care in the icu can only be a real commitment to interprofessional collaboration among nurses, doctors, palliative care and oncology specialists, cultural-linguistic mediators, and spiritual care providers [69] . without adequate information, meaningful collaboration, and realistic goals of care for the patients, the risk of moral distress for critical care nurses is quite elevated [72] . in [73] . an outbreak is defined as "a sudden increase in incidence compared with the "normal" morbidity rates for any certain disease in a given area" [74] . the consequences of the "sudden" features of an outbreak can be disruptive, causing chaos, panic, and insecurity. increasing levels of stress and anxiety related to work can be experienced by healthcare personnel. in some extreme cases, inadequate preparedness for a disease outbreak can lead to hospital closure [74] . the term "outbreak" can also refer to the cross-transmission of multiresistant microorganisms inside hospital wards (e.g., acinetobacter baumannii and clostridium difficile), as well as referring to pandemic or epidemic diseases (e.g., sars, h1n1 reaction to a disease outbreak in the icu must be twofold: increasing the competencies and skills of the icu staff in disease management and implementation of safety measures to contain the spread of the infection, as well as implementing adequate isolation procedures [74] . education and training about infection control for critical care nurses should include [74] : • training modules about the fundamentals of quarantine and isolation, routes of infection transmission, and infectious disease prevention and control • basic pediatric intensive care protocols • high-fidelity simulation of the management of high-risk and complex scenarios • debriefing and teach-back models • certification of the successful completion of education, and annual recertification. however, the key to reaching a safe and optimal care setting depends on the availability of a robust hospital epidemiology program [77] . many microorganisms responsible for recent outbreaks of viral infections can be deadly, not only for patients (even when they receive the best care) but also for the healthcare staff. for infectious diseases transmitted through respiratory droplets, the icu is a high-risk setting, owing to the performance of aerosol-generating procedures (suctioning, intubation, niv, and bronchoscopy). patients needing multiple procedures pose a high risk of contamination for healthcare staff [77] . the ebola virus outbreak has set a new standard of infection control precautions (maximum isolation). together with contact, droplet, and airborne precautions (table 19 .1), the need to prevent accidental exposure of all body surfaces emerged, with the provision of adequate protective clothing. furthermore, a dedicated staff member, present as a trained observer, directly puts on and takes off the protective clothing and equipment from the care personnel to reduce the risk of mistakes and self-contamination [77] . lastly, suitable protocols are needed to disinfect the care environment and to manage infected waste, and, in some cases, the architectural design of hospital areas has been modified [77] . currently, the employment of full protective body suits and powered air-purifying respirators is mandatory for the care of patients infected by ebola, mers-cov, and sars-cov [77] . this kind of equipment requires high standards of training and periodic retraining [77] . achieving an optimal level of proficiency in donning and removing the personal protective equipment for this kind of infective threat is critical. studies have been performed comparing the effectiveness of different training programs for the management of full protective body suits [78] . however, there are still debates about the actual adequacy and effectiveness of the protective equipment used in the prevention of ebola transmission [79] . the special training should be conducted while the critical care nurse is performing invasive procedures typical of critical care settings: intubation, mv (closed-system endotracheal tube suctioning and placement of a bacterial filter on the expiratory side of the ventilator circuit) [80] , venous access introduction (ultrasound guided), crrt, and bedside imaging, with the nurse using the full protective equipment in a high-containment unit (negative-pressure room) under biosafety level 3-4 isolation conditions [77] . working inside a high-containment unit requires the nurses to place their own safety before the patient's needs, to move slowly, to pay great attention to sharp objects, and always to think before acting [81] . all the nursing care and procedures should be performed in pairs: one nurse cares for the patient and the other checks for breaches in personal protective equipment, disinfects the environment, and manages the waste appropriately, covering all the containers to avoid splashing [81] . training programs also have to cover some important psychological features of this kind of nursing care: fatigue, fear, a sense of impotence, and the social consequences of the risks the nurses are exposed to. in regard to the prevention of disease transmission, each institution should draft protocols for the management of laboratory tests, the handling of biological specimens, and imaging testing. surgery and specialist consultations should also be considered in the safety management procedures. lastly, the healthcare teams that will provide care for these high risk infected patients should be previously assigned, on either a voluntary or an obligatory basis [77] . take-home messages • in future icus will probably see increases in the number of icu beds relative to the number of beds in the rest of the hospital and the staff shortages could be "compensated by" computerized and/or nurse-driven clinical protocols. more multicenter and international trials will need to be performed, and pharmacological treatments for critically ill patients should be improved through various strategies. • priorities in critical care nursing research are: the development of methods for the rapid recognition of acute illness in high-risk patients; new approaches to enhancing patient comfort while reducing changes of consciousness; effective process and outcome measurements for critical illness research and palliative and eol care; focus on patient safety issues; the impact of ebp and the workforce on patient outcomes; the comfort/well-being of patients and their relatives; the impact of eol care on staff and nursing practice. • critical care nursing should, in particular, take into account the special needs of different patient populations, such as oncology patients, elderly patients, morbidly obese patients, and psychiatric patients admitted to the icu. • forthcoming and highly challenging issues for icu nurses are those related to critical care management during outbreaks of emerging infectious diseases. thirty years of critical care medicine critical care -where have we been and where are we going? critical care: advances and future perspectives 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cord-289076-8iymevqm authors: marjanovic, zdravko; greenglass, esther r.; coffey, sue title: the relevance of psychosocial variables and working conditions in predicting nurses’ coping strategies during the sars crisis: an online questionnaire survey date: 2007-08-31 journal: international journal of nursing studies doi: 10.1016/j.ijnurstu.2006.02.012 sha: doc_id: 289076 cord_uid: 8iymevqm abstract objectives the purpose of this investigation was to examine the relationship between psychosocial variables and working conditions, and nurses’ coping methods and distress in response to the severe acute respiratory syndrome (sars) crisis in canada. participants and procedure the sample consisted of 333 nurses (315 women, 18 men) who completed an internet-mediated questionnaire that was posted on the registered nurses’ association of ontario (rnao) website between march and may 2004. the questionnaire was restricted to respondents who had to authenticate their rnao membership with a valid username and password before accessing the questionnaire. this served a dual purpose: to ensure that only rnao nurses completed the questionnaire and thereby safeguarding the generalizability of the findings; and second, to prevent any one nurse from contributing more than once to the overall sample. results correlational analysis yielded several significant relationships between psychosocial variables and working conditions, and the traditional correlates of burnout and stress. three multiple regression analysis revealed that the model we evolved—including higher levels of vigor, organizational support, and trust in equipment/infection control initiative; and lower levels of contact with sars patients, and time spent in quarantine—predicted to lower levels of avoidance behavior, emotional exhaustion, and state anger. conclusions by employing models of stress and burnout that combine psychosocial variables and working conditions, researchers can account for significant amounts of variance in outcomes related to burnout. these findings highlight the importance of vigor and perceived organizational support in predicting nurses’ symptoms of burnout. for healthcare administrators, this means that a likely strategy for assuaging the negative outcomes of stress should address nurses’ psychosocial concerns and the working conditions that they face during novel times of crisis. over the last decade there has been an increased awareness of the possibility of pandemics and their potentially devastating effects. the most recent illustration of this can be found in the ''spanish'' influenza that swept the world between 1918 and 1919 and killed an estimated 40 million people: that is more than the total number of soldiers killed in world war i (oxford et al., 2002) . more recently, with the advent of sars in 2003, public awareness has been increased about our collective vulnerability to pandemics. in particular, the 2003 severe acute respiratory syndrome (sars) crisis had a profound impact on healthcare providers in canada. nurses, physicians, technicians, and aides all played a role in the struggle against sars; however, nurses were predominant in this group. though little risk of infection was posed to the general public, nurses were particularly vulnerable because of the proximal closeness of patient-nurse interactions, direct contact with respiratory fluids of infected patients, and inadequacy of protective gear (hall et al., 2003; maunder et al., 2003) . greater stress levels due to increased interactions with patients have also been associated with increased emotional exhaustion and depersonalization in nurses, which are key symptoms of burnout (bu¨ssing and glaser, 1999) . integral to the nurses concerns was their level of trust in the effectiveness of protective equipment (e.g., masks, gloves) and disease control initiatives (e.g., quarantining) in controlling the spread of sars. robertson et al. (2004) found that nurses frequently reported their concerns about infection control but nevertheless, expressed their willingness to implement these procedures and continue working. in this regard, many nurses and healthcare providers reported that quarantining, one of the most common procedures used to control sars, was necessary in order to protect others from infection (robertson et al., 2004) . on the other hand, when subjected to quarantine themselves, and especially when given little informational support by their respective healthcare institutions, workers reported feeling greater levels of stress, fear, frustration, stigmatization, and avoidance of others (bai et al., 2004; robertson et al., 2004) . preliminary studies are in general agreement that sars added novel psychosocial stressors to the lives of healthcare workers. lee-baggley et al. (2004) investigated empathetic responding, wishful thinking, and support seeking on coping behaviors related to perceptions of sars. the authors posted an online questionnaire that attracted an international sample that included healthcare workers, engineers, office workers, and students. multivariate analysis indicated that greater empathetic responding predicted significantly less avoidance behavior and significantly more preventive behavior; whereas, wishful thinking predicted only greater levels of avoidance behavior, which is less effective for coping with a perceived threat. support seeking was not related to coping behavior (lee-baggley et al., 2004) . gan et al. (2004) investigated the relationship between coping flexibility and behavioral reactions in two categories of stressful events: daily stressful events, as depicted in 10 ordinary scenarios, and sars-related stressful events, as depicted in 10 hypothetical scenarios which students perceived as threatening. in their sample of peking university undergraduate students, their findings revealed that students who regarded daily stressful events as controllable applied problem-focused coping strategies (i.e., a good coping strategy-situation fit); whereas students who perceived sars-related events as uncontrollable applied emotion-focused and problem-focused coping strategies interchangeably. gan et al. (2004) concluded that compared to daily stressful events, students responded to sars stressful events: (1) with a significantly diminished ability to assess situational controllability and (2) by applying significantly poorer and more inconsistent strategy-situation coping methods. given that the research base on sars is still relatively sparse, the extensive literature on stress, coping, and burnout is useful in understanding the impact that sars had on nurses. because nurses make up approximately 17% of the participants used in studies of burnout and occupational stress (see schaufeli and enzmann, 1998) , we can generalize to some extent that the findings from this considerable body of research applies to nurses' reactions to sars. in particular, research on nurses' reactions to hospital restructuring and downsizing has value because similar to the sars crisis, these precarious times are novel, engender fear and uncertainty about the future, and are widely recognized as highly stressful for nurses (begley, 1998) . in longitudinal studies, researchers have consistently found an important role for organizational support in assuaging the effects of stressful events. nurses' low perceptions of organizational support have been associated with low job satisfaction (armstrong-stassen, 2004; siu, 2002) , high psychological distress, high perceived-stress (fisher, 1985) , high absenteeism, high turnover (begley, 1998) , and increased burnout (eisenberger et al., 1986; firth and britton, 1989; siu, 2002) . in cross-sectional studies, researchers have found evidence that low organizational support, in the form of high workload and increased time pressure, predicts increased emotional exhaustion, cynicism, hostility, anxiety, depression, somatization, work-family conflict, and feelings of powerlessness escot et al., 2001; greenglass and burke, 2000; greenglass et al., 2001) . astoundingly, 97% of the sample in escot et al. (2001) reported needing more psychological support from their employers. thus, generalizing from these findings, it is reasonable to suggest that nurses' stress reactions to sars and their perceived organizational support are strongly related. research efforts have also recently focused on the role of vigor as a mediator between psychosocial variables and the traditional components of burnout (i.e., emotional exhaustion, professional efficacy, and cynicism; schaufeli et al., 2002) . defined as ''high levels of energy, mental resilience, stamina, and persistence when problems arise,'' vigor is conceptualized as incompatible with burnout (greenglass, 2004, p. 81) . a recent study by greenglass et al. (2001) supported this relationship, finding that greater levels of proactive coping, professional efficacy, and organizational commitment predicted to higher levels of vigor, which then predicted to lower levels of emotional exhaustion and cynicism. that is, vigor was negatively related to emotional exhaustion and cynicism, which supports the notion that vigor is incompatible with burnout (greenglass et al., 2005) . combined, these studies attest to the considerable impact that psychosocial variables and working conditions have on nurses' subjective experiences of stress during periods of occupational crisis and uncertainty. the purpose of this investigation was to examine the relationship between psychosocial variables and working conditions, and nurses' subjective experiences of sars stress. we hypothesized that greater vigor, organizational support, and trust in equipment/infection control, and less contact with sars patients and time spent in quarantine, would predict to lower levels of emotional exhaustion, state anger, and avoidance behavior. the sample consisted of 333 canadian nurses (mean age ¼ 43.79, sd ¼ 9.97), primarily women (95%), who worked in healthcare facilities during the sars crisis of 2003. the majority of the sample identified themselves as full-time (76%) registered nurses (96%) who worked for only one other healthcare organization prior to the sars outbreak (77%). the sample constituted a wide breadth of nursing roles, such as staff nurses (51%), managers (18%), and educators (8%), and included diverse nursing areas such as public health (17%), surgical (12%), pediatrics (8%), and emergency (8%). data for this study was collected using an internetmediated questionnaire. internet-mediated questionnaires represent a new and rapidly growing data collection tool in the social sciences. it affords researchers the ability to study unique phenomena that are otherwise difficult or impossible to study, and can tap into the experiences of larger specialized groups of people at lower cost to the researcher than other methods (buchanan and smith, 1999; hewson, 2003; kraut et al., 2004) . thus far, research on its psychometric properties has shown that online questionnaires are commensurate to paper-andpencil formats in terms of reliability and internal validity (buchanan and smith, 1999; hewson, 2003; kraut et al., 2004) . the main disadvantage of internet-mediated research is that the samples it generates are self-selected; and therefore, potentially biased (kraut et al., 2004) . in general, it is difficult to ascertain whether internet samples are representative of the group a researcher wishes to study. this puts into question the generalizability of a study's findings. furthermore, because of the lack of physical interactivity between respondents and researchers, researchers cannot easily verify an individual's status or the veracity of their responses (buchanan and smith, 1999) . we attempted to minimize these disadvantages by following the subsequent procedure. in order to generate a representative sample, our partners in this project, the registered nurses' association of ontario (rnao) encouraged all of its members to participate in the study via a posting on its website between march and may 2004. in this posting, the rnao conveyed to its members the importance of generating knowledge about nurses' reactions to sars and asked nurses to complete an online questionnaire about their sars working experiences. upon trying to access the questionnaire, nurses were prompted to authenticate their membership with their rnao username and password. by posting the sars questionnaire in a restricted area of the website, it is reasonable to assume that all of the respondents who completed the questionnaire were members of the rnao, i.e., ontarian nurses. after authenticating, nurses were led to an informed consent web page that asked nurses to read a description of the study, detailing the risks and benefits of participating, as well as thoroughly addressing issues of confidentiality and their anonymity in the sample. once a nurse reached the bottom of this page, they were given the option of continuing on to the sars questionnaire by clicking on an icon at the bottom of the page that read, ''i consent to participate.'' otherwise, nurses could decline to participate and leave the website. the questionnaire itself took approximately 30 min to complete and consisted of items that tapped psychosocial issues, the quality of their working conditions, and demographics. the last item on the questionnaire asked nurses to generate a random and unique six-digit numerical code. the purpose of this was to enable us to match nurses' responses to this questionnaire with their responses to any follow-up questionnaires. the three dependent measures (criterions) for this investigation were two outcome variables, emotional exhaustion and state anger, and one coping behavior variable, avoidance behavior. the five independent measures (predictors) were three psychosocial variables, vigor, organizational support, and trust in equipment/ infection control initiatives; and two working conditions variables, contact with sars patients, and time spent in quarantine. emotional exhaustion was assessed using the emotional exhaustion subscale of the maslach burnout inventory-general survey (mbi-gs; schaufeli et al., 1996) . research has shown that the emotional exhaustion scale to have good internal consistency (a ¼ .90; schaufeli et al., 1996) and construct validity across occupational groups and national samples (schutte et al., 2000) . it consists of five items that range from 0 ¼ never to 6 ¼ always/everyday. items tapped feelings of being drained, used up, tired, strained, and burned out because of work. high scores indicate high levels of emotional exhaustion. a sample item is, ''i felt emotionally drained from my work.'' state anger was assessed using an adapted version of the state anger subscale of the state-trait anger expression inventory (staxi; spielberger and sydeman, 1994) . psychometric properties of the state anger subscale are good (spielberger and sydeman, 1994) . it consists of seven items, ranging from 1 ¼ not at all to 4 ¼ very much so, that covered feelings such as fury and irritation. high scores indicate high state anger. a sample item is, ''i felt angry.'' avoidance behavior was assessed with six items that assessed issues such as minimizing direct contact with patients, missing work, and refusing patient assignments, which were developed for the purposes of the present investigation. ratings were from 1 ¼ not at all to 4 ¼ a great deal, i.e., high scores indicate high levels of avoidance behavior. a sample item is, ''i refused or declined shifts offered to me.'' vigor (a ¼ .68-.80) was measured using a modified six-item scale ranging from 0 ¼ never to 6 ¼ always/ everyday. the original scale has been shown to be both a highly reliable and valid measure of the vigor construct (see schaufeli et al., 2002) . the modified items used in this study were adapted to query nurses' levels of energy, resiliency, and perceived strength while working during the sars outbreak. high scores indicate high levels of vigor. a sample item is, ''when i was working, i could continue for very long periods at a time.'' organizational support was adapted from the survey of perceived organizational support (spos; eisenberger et al., 1986) . the original scale has demonstrated good reliability (a ¼ .97; eisenberger et al., 1986) and validity characteristics (rhoades and eisenberger, 2002) . it consists of five items ranging from 1 ¼ strongly agree to 5 ¼ strongly disagree, which queried nurses about the availability and dissemination of sars information from their healthcare employers. low scores indicate high levels of organizational support. a sample items is, ''the hospital provided useful, accurate and timely information about sars to its nursing staff.'' trust in equipment/infection control was measured using a four-item scale ranging from 0 ¼ never to 6 ¼ always/everyday. these four items were developed for the purposes of this study. high scores indicate high levels of trust. a sample item is, ''the equipment and garments provided to nurses by the hospital were effective in protecting them from infection.'' contact with sars patients was assessed with a single item developed for this study; ''did you or do you work directly with sars patients,'' 1 ¼ yes and 2 ¼ no, i.e., low scores indicate greater direct contact with sars patients. for the single item measuring quarantine, nurses responded to whether they spent any time in quarantine as a result of their work. on a three-point scale, 1 ¼ no, 2 ¼ working quarantine, and 3 ¼ full quarantine, higher scores indicate higher levels of quarantine. the single item, ''have you ever been placed in quarantine,'' was developed for the purposes of this study. correlations among the variables, descriptive statistics, and cronbach's alpha coefficients are presented in table 1 . alpha coefficients derived from this study ranged between .60 (trust) and .96 (emotional exhaustion), most of which exceeded acceptable levels of internal consistency. as expected, emotional exhaustion was significantly and positively correlated to state anger, avoidance behavior, contact with sars patients, and time spent in quarantine. negative relationships were found between emotional exhaustion and vigor, organizational support, and trust in equipment/infection control initiatives. state anger was positively correlated to avoidance behavior, contact with sars patients, and greater time in quarantine; and negatively related to vigor, organizational support, and trust in equipment/ infection control initiatives. engaging in avoidance coping behaviors was positively correlated to time spent in quarantine and negatively related to vigor, organizational support, and trust in equipment/infection control initiatives. importantly, avoidance behavior was only marginally correlated to contact with sars patients (i.e., po:10). thus, even when confronted with more contact with sars patients and therefore, risk of infection, most nurses continued to implement disease control initiatives and kept working. three linear multiple regression analyses were performed with the criterion measures, emotional exhaus-tion and state anger, as outcome variables, and avoidance behavior as a coping variable. predictors were vigor, organizational support, and trust in equipment/infection control, contact with sars patients, and time spent in quarantine. given that three multiple regressions were performed, we adjusted our alpha level to p ¼ :017 using the bonferroni correction to control for type i error. overall, the model accounted for 26% of the variance in avoidance behavior. less time spent in quarantine predicted lower levels of avoidance behavior ðb ¼ :23; po:001þ, whereas, higher levels of vigor ðb ¼ à:27; po:001þ and organizational support ðb ¼ :26; po:001þ predicted significantly less avoidance behavior (see table 2 ). note the variables trust and contact were not predictive of avoidance behavior. although on their own, these variables were correlated to avoidance behavior at significant and marginally significant levels, as shown in the correlation matrix in table 1 , the relationship between each of these variables and the criterion was washed out due to their relationships with the other predictor variables in the model. in other words, when levels of the other predictors in the model were kept constant, the efficacy of either trust or contact in predicting nurses' avoidance behavior was nullified. regarding the second criterion, the model accounted for 25% of the variance in nurses' reported emotional exhaustion. findings showed that less contact with sars patients predicted to lower levels of emotional exhaustion ðb ¼ à:15; p ¼ :003þ; whereas, higher levels of vigor ðb ¼ à:34; po:001þ and greater trust in equipment/infection control initiatives ðb ¼ à:15; p ¼ :005þ predicted lower levels of emotional exhaustion (see table 2 ). organizational support and quarantine did not predict emotional exhaustion when controlling for levels of the other predictors in model. lastly, the model accounted for 25% of the variance in nurses' experience of state anger. less time in quarantine predicted less state anger ðb ¼ :14; p ¼ :008þ. conversely, higher levels of organizational support ðb ¼ :24; po:001þ, vigor ðb ¼ à:20; po:001þ, and trust in equipment/infection control initiatives ðb ¼ à:14; p ¼ :011þ predicted lower levels of state anger (see table 2 ). contact with sars patients was only marginally predictive of state anger when the other predictors in the model were held contact ðp ¼ :068þ. similar to its relationship with avoidance behavior, the predictive value of contact to state anger was reduced when controlling for levels of other predictors in the model. the purpose of the present investigation was to examine the relationship between psychosocial variables and working conditions, and nurses' stress responses to the 2003 sars crisis in canada. correlational analysis revealed several significant relationships, all of which were in the expected direction, largely corroborating patterns of findings in the burnout literature (e.g., anger correlated positively with emotional exhaustion, and negatively with vigor and organizational support; begley, 1998; eisenberger et al., 1986; greenglass et al., 2001) . the main finding of this study was that the model we evolved, including vigor, emotional exhaustion, trust, contact, and quarantine as predictors, explained significant amounts of variance in nurses' experiences of avoidance behavior, emotional exhaustion, and state anger. this demonstrates that regarding nurses' experiences of stress in the workplace, predictive value is increased by employing models which incorporate both psychosocial variables and working conditions. the proposed model, including psychosocial variables and working conditions as predictors, accounted for 26% of the variance in avoidance behavior, 25% in emotional exhaustion, and 25% of the variance in nurses' state anger. of the psychosocial variables, vigor was the most influential, predicting to all three criterions. organizational support was negatively related to avoidance behavior and state anger, while trust in equipment/infection control initiatives was negatively related to emotional exhaustion and state anger. of the working conditions variables, greater spent time in quarantine was predictive of higher levels of avoidance behavior, and state anger, whereas greater contact with sars patients was only predictive of greater emotional exhaustion. importantly, these findings revealed that contact with sars patients was not significantly predictive of avoidance behavior, as we hypothesized. despite being marginally correlated, as shown in table 1 , multiple regression analysis showed that the relationship between contact and avoidance behavior was mediated through other important psychosocial and working conditions variables, such as vigor, organizational support, and time spent in quarantine. this is a positive finding because it suggests that the negative effects of contact can likely be lowered by improving perceived organizational support, promoting vigor as a proactive measure against stress, and paying special attention to nurses who are quarantined or isolated in times of crisis. interestingly, organizational support was not predictive of emotional exhaustion, which seems to contradict the consensus in the literature. it does, however, make intuitive sense when we consider that organizational support was measured with items about the availability of sars information, whereas emotional exhaustion assessed feelings of being drained, used-up, and burnt out because of work. thus, although organizational support, in the form of informational support has value, as indicated by its significant relationships to avoidance behavior and state anger, it does very little to alleviate emotional exhaustion which may be due to an overbearing workload and increased pressure at work. in future investigations, researchers should be cognizant of the kind of social support that is being provided, and the type of outcome that is being assessed. in our case, we were concerned with tapping informational support as a means to lessening the sars threat; consequently, it was logical to limit our variable to cover this facet of organizational support. the internet was used to collect data in this study. the internet is a flexible and cost-effective medium for collecting data from large and specialized samples. research to date has shown that internet-mediated questionnaires have reliability and internal validity characteristics that are proportionate to traditional paper-and-pencil questionnaire formats (buchanan and smith, 1999; kraut et al., 2004) . however, the main barriers to its wider acceptance as a data collection tool are the issues of sampling bias, affecting external validity, and the lack of interactivity between respondent and researcher, affecting the researcher's ability to authenticate an individual's responses (kraut et al., 2004) . in this study, we addressed these issues in the following ways. first, the questionnaire was posted on the nurses' website that encouraged their participation in the study and highlighted the importance of generating new knowledge about nurses' reactions to the sars outbreak. second, access to the questionnaire was restricted to ontario nurses who belonged to a particular professional organization by requiring respondents provide a valid username and password before proceeding to the questionnaire itself. this ensured that only these nurses had access to the questionnaire, and moreover, that nurses could not contribute more than one questionnaire to the sample. lastly, the confidentiality of nurses' responses was guaranteed on the pre-questionnaire informed consent web page. this was done to motivate nurses to respond more candidly to the questionnaire, which in turn would have increased the validity of our findings. a limitation of this study was our use of crosssectional self-report data which precluded attribution of causality. however, the inferences we have made with regard to the impact of sars on nurses are consistent with longitudinal data in the area. the best evidence to indicate that these findings reflect important associations among the variables we studied is the strong corroboration between these findings and similar relationships found in the burnout and existing sars literature. in conclusion, the effective management of public health epidemics like sars and future potentially devastating pandemics like the avian influenza should be a priority for health organizations (rassool, 2004) . the preparedness and efficacy of healthcare organizations to manage these crises over indefinite periods of time may mean the difference between minimal destructiveness of a disease running its course and catastrophic losses of life. thus, by teaching nurses new working strategies that could help them prevent burnout, by making organizational supports congruent with nurses' specific needs, and by helping nurses reduce feelings of uncertainty and fear when these crises occur, healthcare organizations can increase the likelihood of optimal crisis management, and have the additional benefit of improving the lives of their employees, and the level of care they provide on a day-to-day basis. the influence of prior commitment on the reactions of layoff survivors to organizational downsizing survey of stress reactions among health-care workers involved with the sars outbreak coping strategies as predictors of employee distress and turnover after an organizational 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sars crisis in toronto conducting research on the internet report of board of scientific affairs' advisory group on the conduct of research on the internet coping with the threat of severe acute respiratory syndrome: role of threat appraisals and coping responses in health behaviors the immediate psychological and occupational impact of the 2003 sars outbreak in a teaching hospital world war i may have allowed the emergence of ''spanish'' influenza unprecedented spread of avian influenza requires broad collaboration perceived organizational support: a review of the literature the psychosocial effects of being quarantined following exposure to sars: a qualitative study of toronto health-care workers the burnout companion to study and practice: a critical analysis maslach burnout inventory-general survey (mbi-gs) the measurement of engagement and burnout: a two-sample confirmatory analysis analytic approach the factorial validity of the maslach burnout inventory-general survey (mbi-gs) across occupational groups and nations predictors of job satisfaction and absenteeism in two samples of hong kong nurses the use of psychological testing for treatment planning and outcome assessment grateful acknowledgement is due to our partner in this research, the registered nurses association of ontario (rnao), and to lisa fiksenbaum for her review of this manuscript. key: cord-298400-tn5mw07n authors: li, zhuyue; zuo, qiantao; cheng, jingxia; zhou, yu; li, yingying; zhu, longling; jiang, xiaolian title: coronavirus disease 2019 pandemic promotes the sense of professional identity among nurses: a cross-sectional study with content analysis date: 2020-10-06 journal: nurs outlook doi: 10.1016/j.outlook.2020.09.006 sha: doc_id: 298400 cord_uid: tn5mw07n background: under the covid-19 pandemic, nurses are the mainstay in the fight against the pandemic. purpose: to evaluate potential impact of the pandemic on nurses’ professional identity. method: self-report questionnaires were distributed online. data collected were compared with available norms. multivariate logistic regression analyses were employed to calculate the or of frontline vs. non-frontline nurses. findings: the mean of the total score of the scale was 121.12 out of 150. both the total score and scores on the five dimensions were significantly higher than norms. frontline nurses had a significantly higher professional identity than non-frontline nurses (total score: or, 1.19; professional identity evaluation: or, 1.27; professional social support: or, 1.18; professional social proficiency: or, 1.33; and dealing with professional frustration: or, 1.19). the most frequently mentioned tags were hope, frontline, protection, outbreak, work, situation. discussion: covid-19 outbreak was associated with an enhancement in the professional identity of nurses. since the current outbreak of coronavirus disease (covid-19) was first reported from wuhan, hubei, china on 31 december 2019, more than 80,000 people have been confirmed with infection in china and the virus has now been classified as a worldwide pandemic by the who 1 . according to the report of the national health committee of china, the nurses supporting hubei reached 28,600 nationwide by march, 2020 2 . in connection with the covid-19 outbreak, nurses were portrayed by the media as heroic, warm-hearted, and having a strong sense of professional morality 3 . of the patients with covid-19 hospitalized at 552 sites until january 29, 2020, the proportion of health workers who were infected had reached 3.5% 4 . 5 the professional identity of nurses is usually defined as including both personal and professional development and involves the internalization of values and perspectives. professional identity, or how a nurse views himself or herself in their role as a nurse, affects every aspect of practice. it is the key to providing high-quality care 5, 6 , mediating job dissatisfaction and burnout 7 , and improving clinical performance 8, 9 and job retention 10 . previous studies have reported that the professional identity of nurses may be affected by an emergency event or special workplace settings 11, 12 . heung and colleagues 12 interviewed 10 nursing students and found that the severe acute respiratory syndrome crisis affirmed their professional identity. however, there has been a lack of research on the professional identity of nurses during emergency events or in special workplace settings under normal conditions. the professional identity of nurses is determined by many factors such as public image, work environment, work values, education, and culture 10 . it is important to understand any changes in the professional identity of nurses during the covid-19 outbreak as portrayals of them in the media have changed and healthcare demands have increased. we hypothesise that in the context of the covid-19 pandemic, the professional identity of nurses could be affected by changes in the social and working environments, and the outbreak could be a positive factor contributing to affirmation of nurses' professional identity. in this study, we collected both quantitative and qualitative data for a comprehensive analysis and we compared the professional identity of nurses during the covid-19 outbreak with normative data published in a previous study 13 . further, we also compared the professional identity of frontline and non-frontline nurses during the pandemic. we aimed to: i) assess the level of professional identity of nurses during the covid-19 outbreak; ii) compare professional identity in various groups; and iii) investigate nurses' views and feelings during the outbreak and how the outbreak might affect the professional identity of nurses. this study has been approved by the biomedical ethics review committee of the relevant hospital for this study. this study used a cross-sectional survey that collected both quantitative and qualitative data from nurses working in the covid-19 pandemic. to examine the professional identity of nurses in the pandemic situation, we utilised the professional identity scale for nurses 14 . this scale was developed based on local data, has good reliability and validity (cronbach's α= 0.0938, χ 2 /df = 1.85), and is suitable for chinese nurses. the scale consists of 5 dimensions and 30 items: i) professional identity evaluation, 9 items, views on importance or value of nursing, feelings and beliefs on nursing profession, and person-post matching; ii) professional social support, 6 items, the recognition and support from patients, medical and nursing colleagues, managers, and important others like their families; iii) professional social proficiency, 6 items, the interpersonal communication and cooperation capability for adapting to professional working environment; iv) dealing with professional frustration, 6 items, the cognitive style and action mode adopted while encountering professional stress and frustrations; and v) professional self-reflection, 3 items, the self-exploration, self-correction and critical judgment in work, a process of in-depth understanding of self and occupation. each item was scored 1 to 5, and the possible score for the total scale and the dimensions of professional identity evaluation, professional social support, professional social proficiency, dealing with professional frustration, and professional self-reflection are 30-150, 9-45, 6-30, 6-30, 6-30, and 3-15, respectively. liu and colleagues 13 established a professional identity norm based on their survey among clinical nurses recruited from different levels hospitals in shanghai through stratified cluster sampling. according to their criteria, we defined a high professional identity group (total score ≥ 120) and a low professional identity group (total score < 120); a high score group (dimension score ≥ 34) and low score group (dimension score < 34) for professional identity evaluation; a high score group (dimension score ≥ 22) and low score group (dimension score < 22) for professional social support, professional social proficiency, and dealing with professional frustration; and a high score group (dimension score ≥ 11) and low score group (dimension score < 11) for professional self-reflection. the whole questionnaire finally, we exported all the completed questionnaires using wenjuanxing. means with standard deviations (sd) or medians with quantiles were used to describe age and length of nursing career after testing for skewness and kurtosis. frequency distributions were used to describe categorical variables. scores for professional identity and its five dimensions (professional identity evaluation, professional social support, professional social proficiency, dealing with professional frustration, and professional self-reflection) were described by means with sd, and compared with the results of liu 13 . scores on the five dimensions were also compared between frontline nurses and non-frontline nurses in the present study using the kruskal-wallis test. univariate and multivariate logistic regression models were used to evaluate the odds ratio (or) with 95% confidence intervals (ci) of frontline nurses compared with non-frontline nurses. those variables that were significant (p < .05) in univariate logistic regressions were included in multivariate models. all p-values were calculated as two-tailed and all statistical tests used a significance level of .05. all statistical analyses were conducted with spss 25.0. to analyse data collected from two open-ended questions, a conventional content analysis was carried out. three investigators first deconstructed the text, highlighted the words that captured key points; and then, translated them into codes and classified the codes to consolidate themes. any disagreements were resolved by discussion. we also import original text to nvivo 11.0 to create word clouds based on the frequency of words or phrases. we collected a total of 5,570 responses during february 2020. table 1 shows the characteristics of participants. the results of the skewness and kurtosis tests indicated that age and length of nursing career had positively skewed distributions. the median age of participants was 30 years (quantiles: 25% = 26; 75% = 34) and the median length of nursing career was 8 years (quantiles: 25% = 5 75% = 13). the most common education level of participants was an undergraduate degree (56.6%) and a substantial majority of them (92.4%) were clinical nurses providing direct patient care. 2,057 (36.9%) nurses reported working in frontline positions. the age of frontline nurses and their years of working experience were higher than the non-frontline nurses. regarding to professional title, the chinese government has set five titles for nurses: nurse, senior nurse, supervisor nurse, deputy chief nurse, and chief nurse. "nurse" and "senior nurse" belong to the junior title, "supervisor nurse" is the intermediate title, and "deputy chief nurse" and "chief nurse" are the senior title. in this study, the intermediate title nurse accounted for a higher proportion of frontline workers. more head nurses and directors of nursing are in the frontline. the mean professional identity score in our study was 121.12 (sd = 22.77). mean scores on the five dimensions of professional identity evaluation, professional social support, professional social proficiency, dealing with professional frustration, and professional self-reflection were 34.57, 25.22, 23.74, 25.12, and 12.48, respectively. the means on the five dimensions were all at a high level. interestingly, compared with the results of the study by liu 13 , our results demonstrated a higher score for both the total scale and the scores on every dimension ( table 2 ). the largest difference in any item mean was in the dimension of profession identity evaluation (this study: 4.5; liu: 2.88). the results of univariate and multivariate logistic regression analyses for the total score on professional identity and the scores on the five dimensions are presented in table 3 . the details of logistic regressions for the total score on professional identity and the five dimensions are provided in supplementary table 1 . after multi-factor adjustment, frontline nurses were 1.19 times more likely to have a higher score on professional identity than were non-frontline nurses. compared with non-frontline nurses, frontline nurses had a significantly higher odds ratio on all dimensions except professional self-reflection (professional identity evaluation: or, 1.27, p < .001; professional social support: or, 1.18, p = .02; professional social proficiency: or, 1.33, p < .001; and dealing with professional frustration: or, 1.19, p = .01). table 4 . many nurses expressed a strong sense of responsibility. they believed that they are obliged to provide care because patients and society urgently need help. they would like to try their best to take care of the patients and stick to post, even they know their work is risky. they stated that "we have the responsibility to work at the front line, to fulfil our duty, to alleviate the suffering of patients, to fight against the virus.", "this is the responsibility and mission of a professional nurse and the value of my existence.". "want to go frontline', "be ready to go frontline at any time" were frequently reported by the nonfronline nurses. out of a sense of responsibility for human health, many nurses also put froward suggestions for nursing care under covid-19. they emphasized the importance of personal protection, public education, and quality ensurerance. representative statements include: "the situation is serious, we must strictly do self-protection and public education", "the virus speared fast, and the pandemic has brought huge pressure to the society, hope the pandemic will end soon". enhanced psychological/spiritual qualities. encountering covid-19, many nurses reported that they were full of confidence and firm belief, and they united optimistically. they stated "though everyone felt anxious, as a nurse, i must be brave to overcome any difficulties", "disaster is inevitable, but as long as we work together, we can succeed", "the virus is horrible, but we would never give up", "persistence is success". besides, they thought they should fight the pandemic positively, quotations like "as a nurse, we should actively participate and face it". with the status of nurses, which includes low income and low social status but a heavy workload and high professional risk. "nurses are paid low wages, and many hospitals were short of protective equipment. now it seems i have to sacrifice myself and family, this is not what i want… if the status of nursing could be changed, i was willing to work at the front line…", "…however, our social and economic status is relatively low… in primary hospitals, nurses have to do everything…". the results of this study show a high level of professional identity among nurses in china during the outbreak of covid-19. for further confirmation, we compared the results of professional identity to normative data 13 collected with the same research tool and a similar research population but in a different social or work environment. except for the education level, most characteristics of the normative sample including age, years of nursing experience, working department, position, professional title, marital status, and job type are consisting with the current study. the main education level of their participants was junior college, which accounted for 58.1% of their sample, while our most common education level was an undergraduate degree (56.6%). the difference might be related to the rapid development of chinese nurse education in the past ten years which has changed the structure of the education level of hospital nurses. meanwhile, nurses at the undergraduate level might be more likely to be sent to fight an outbreak due to their presumably stronger capabilities. although higher scores on professional identity are seen among nurses with higher education levels, previous studies have reported that education level is negatively related to nurses' professional identity 15, 16 . the results of our comparison broadly support the conclusion that the outbreak of covid-19 was associated with enhanced professional identity of nurses. in addition to the original normative study, the professional identity scale for nurses developed by liu 14 has been broadly adopted in other studies that included varied participants such as clinical nurses 17 , specialist nurses 18 , psychiatric nurses 19 , and icu nurses 20 in china and, with minor fluctuations, the results of these studies are consistent with the norm. among them, specialist nurses achieved the highest level of professional identity (mean of total score (sd): 111.36 (20.15)) 18 , but this score is still lower than our findings. the change of social and working environment of nurses could be the underlying mechanisms. rasmussen and colleagues reviewed contemporary studies and concluded that factors influencing nurses' perceptions of their professional identity were synthesized into three categories: the self (who i am), the role (what i do), and the context (where i do) 21 . this shows that the perception of oneself and outside world is essential for professional identity. in japan, which is a patriarchal and highly masculinized country, the professional identity of female doctors was profoundly affected by gender stereotypes and that study reported a considerable gap between married female doctors and those who were unmarried 22 . further, two previous studies suggest that the professional identity of nurses in special practice areas, such as police custody and prisons, is poorly developed due to the sensitive work environment 11, 23 . the covid-19 pandemic, as a global emergency public health event leading to severe economic and social impacts 24 and huge healthcare demands, also allows nurses to re-evaluate their professional identity. in our study, nurses reported a strong sense of responsibility and accountability on patients, humankind, and the society. they firmly believe that it is the duty and mission of nurses to save lives. they also expressed a strong sense of professional value and fulfilment. these feelings are helpful to a positive professional identity development 25, 26 . meanwhile, covid crisis enhanced the reconstruction of their view of life and worldview. they are deeply aware of the sincere and fragility of life and further appreciate health-related work. they had come to realize that nursing not only concerns about individual lives, but relates to the survival of all humankind. some nurses wrote: "nursing is a great profession, i didn't understand greatness before, but now i do". such professional reflection is not only about the profession, but also about the self. they were aware of both their values and their own deficiencies and growth needs. many nurses expressed their regret that they were not qualified for going to the frontline. also, some frontline nurses perceived a strong need by the patient but felt helpless in saving the lives of those critically ill. these perceptions contributes to a heightened self-awareness and the internalization of professional identity 27 . moreover, under the pandemic, the sublimation of spiritual and psychological qualities such as unity, being brave, firm, confidence, persistence, altruistic, are not only a strong foundation to face the frustrations and difficulties under healthcare crisis, but also meet a professional image that the public appreciates, thus, contribute to their positive self-formation and professional identification. it is difficult to compare as there is a lack of study on the professional identity of nurses under public health emergencies. however, during sars, heung and her colleagues examined the professional identity of student nurses in hong kong. they found that the outbreak enhanced student nurses' professional identity 12 , and indicated that nursing students gained a sense of moral duty, appreciation for nursing, and self-growth. another important novel finding was that nurses at the frontline obtained a higher score on both the total score of professional identity and its five dimensions, and frontline nurses were 1.19 times more likely to report high professional identity than non-frontline nurses. the reason might be that although positive changes in sense of professional and social responsibility, sense of professional value and fulfilment, enhanced psychological/spiritual qualities, and reflection on life, world and self were identified in both frontline and non-frontline nurses, frontline nurses reported significantly more sense of professional value and fulfilment (theme frequency 24.4% versus 16.6%). as the essence of professional identity is the self-conception of requirements, values and fulfilment, norms concerning a profession 28 , it is not difficult to interpret the above finding. this study has some limitations which should be acknowledged. first, we collected self-report data that have inevitable bias, but our large sample size may have reduced it. second, as a cross-sectional study, we cannot assume a causal relationship between work on the frontline and enhanced professional identity. however, we surveyed a large sample and look forward to providing evidence for future research. third, the survey was conducted at the ascending stage of the pandemic, a longitudinal study is warranted for ascertaining the long-term impact of the covid-19 pandemic on nurses' professional identity. fourth, the word clouds reflect the changes in social and work environment under the pandemic from the perspective of nurses, but the information provided is limited. covid-19 pandemic is not just a time of crisis, but a time for reconstructing the professional identity for nurses. given the importance of professional identity in determining professional commitment and the quality of care, making sense of the event, incorporating the unique covid experience into the training for the student nurse and the emergency care reserve nurse and motivation management for those frontline nurses is suggested. tailored training should be centered on strengthening those promoting influence such as sense of professional responsibility and professional value, reflective thinking on health and life, positive world view and good personal qualities, as well as on avoiding the inhibitors such as negative emotion and stress management. in addition, developing strategies from the policy, management and organizational levels to enhance professional fulfillment and the 20 publicity of the image and role of nurses are indicated to promote professional identification of nurses. . the authors declare that they have no conflicting interests. none. .39 *the multivariate regression of professional identity adjusted by sex, marital status, education level, job title and position. the multivariate regression of professional identity evaluation adjusted by marital status, job title and position. the multivariate regression of professional social support adjusted by age, sex, marital status, job type, job title, position. the multivariate regression of professional social skills adjusted by age, marital status, duration of nursing, job type, job title, position. the multivariate regression of dealing with professional frustration adjusted by age, marital status, job type, position. the multivariate regression of professional self-reflection adjusted by job type, job title, position. abbreviation: q1, "as a nurse, how do you feel when witnessing the pandemic situation of covid-19?"; q2, "as a nurse, how do you feel if you participate in the frontline work?". world health organization nurses support hubei. people's daily the light of life, warm "faceless friendship clinical characteristics of coronavirus disease 2019 in china imagining alternative professional identities: reconfiguring professional boundaries between nursing students and medical students nurses' self-concept and perceived quality of care: a narrative analysis the effect of perceived organisational support on burnout among community health nurses in china: the mediating role of professional self-concept nurses' development of professional self--from being a nursing student in a baccalaureate programme to an experienced nurse exploring the relationship between nursing identity and advanced nursing practice: an ethnographic study causal modeling of self-concept, job satisfaction, and retention of nurses prison nurses' professional identity severe acute respiratory syndrome outbreak promotes a strong sense of professional identity among nursing students research on nurses' professional identity and its relationship with job stress and burnout development of professional identity scale for nurses analysis of occupational emotions and related factors among nurses in guangzhou caring characters and professional identity among graduate nursing students in china-a cross sectional study current situation analysis and countermeasures of clinical nurses' professional identity the status quo and correlation of professional identity and structural authorization of clinical nurse specialists in class iii grade a hospitals in beijing investigation on the correlation between professional identity and job involvement of psychiatric nurses investigation and analysis on the status of icu nurses' professional identity in large tertiary hospitals factors influencing registered nurses' perceptions of their professional identity: an integrative literature review professional identity formation of female doctors in japan -gap between the married and unmarried nursing in police custody: creating a professional identity world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19) the impact of expanded nursing practice on professional identify in denmark professional identity of korean nurse practitioners in the united states i am only a nurse: a biographical narrative study of a nurse's self-understanding and its implication for practice a conceptual framework for the professional socialization of social workers aconceptualframeworkfortheprofessionalsocializationofsocial workers key: cord-335737-eq6pibjy authors: wilson, rhonda l.; carryer, jennifer; dewing, jan; rosado, silvia; gildberg, frederik; hutton, alison; johnson, amanda; kaunonen, marja; sheridan, nicolette title: the state of the nursing profession in the international year of the nurse and midwife 2020 during covid‐19: a nursing standpoint date: 2020-07-24 journal: nurs philos doi: 10.1111/nup.12314 sha: doc_id: 335737 cord_uid: eq6pibjy nan the international year of the nurse and midwife has not quite played out as we might have imagined. a year of celebrations was anticipated. a much-needed injection of morale boost among the worlds' nursing population. but then, our celebrations were cut short at dawn, as covid-19, probably the worst pandemic since the h1n1 influenza in 1918 better known as the spanish flu, arrived. as a profession, we rallied in response, equipped with our socially constructed caring professionalism and scientific expertise. the faces of many exhausted nurses treating and caring for the sickest people populated our social and traditional media screens. and then, the insidious creep of patient, nurse, and medical professionals' deaths around the world 'followed; with the removal of our usual "norms," uncertainty became the hallmark of our immediate future. on the one hand, this circumstance has amplified the public perception of nurses' professional relevance to humanity, and on the other hand, covid-19 has effectively rained on our party-the celebrations for the international year of the nurse and midwife postponed (not that they had really reached the public). nevertheless, there is time to pause and reflect on the state of nursing in the world in 2020, to ask ourselves how we will successfully propel our discipline forward in and beyond these adverse times, and to consider how we might mitigate our propensity to miss opportunities for taking our profession forward. how will we be ready to capture the public mood of goodwill when the celebratory international year comes around again? we suggest that a feminist standpoint theoretical lens may help us to understand our epistemological advantage to position our profession progressively for the future (ashton & mckenna, 2020) . there are over 20 million nurses in the world, and typically 90% of the nursing workforce are women (boniol, mcisaac, xu, wuliji, & diallo, 2019) . nurses are caring science professionals, and they are a valuable contribution to world health representing the largest disciplinary proportion (59%) of the health professions sector. despite the extremely large workforce population, nurses continue to be under-represented in global healthcare policy and governance which is dominated by the smaller workforce sector of medicine. the default medical hierarchical and patriarchal dominance of global health decision-making persists, with the caring sciences relegated to lesser significance, funding, and influence, despite scientific scholarly and practice capacity to participate on equal footings (grace & zumstein-shaha, 2020) . caring has traditionally been regarded as the work of women, carrying with it the societal expectations of caring for children and young people, older adults, and people with disabilities (hartsock, 1983) . the lower societal hierarchical order associated with caring work continues to perpetuate the social oppression of carers who have traditionally been unpaid or underpaid, attributed to low socioeconomic status and associated political powerlessness (hartsock, 1983) . however, this form of gendered social oppression has enabled the caring profession to develop radical new epistemologies, which, on reflection, enables a theoretical standpoint of epistemological advantage (ashton & mckenna, 2020) . we see things in a way that others cannot, and will not, and it influences our perspectives and our capacity to describe phenomena insightfully; it is just not always what the dominant and powerful around us want to hear, or respond too. in the case of nurses, this means our unique experiences, located within a socially oppressed context, have enabled us to develop different perspectives and formulate specific knowledge (ashton & mckenna, 2020) . from a philosophical perspective, we have an epistemological advantage that uniquely enables us to understand complex human conditions of disadvantage, distress, and inequity from a scientific theoretical standpoint; to create unique evidence to solve human health problems; and to foster health-forming beliefs within society (harding, 1991) . this may be what we believe of ourselves; however, when the press and public invoke the angel discourse (as we have seen), they compound the reference to women's work and add a religious overlay, reinforcing the saintly narrative with the element of self-sacrificial service to others. thus, the "sacred" work is deemed reasonably remunerated with honour, rather than finance or social privilege, belatedly bestowed in a heavenly afterlife as though it is some type of superannuation or pension for service rendered. as an artefact of the caring paradigm and a legacy of historical female subservience, nursing too often continues to be overlooked in the bias of a hegemonic masculinist and biomedical view of the scientific health and political world (carryer, 2019) . our epistemological advantage also dismissed outright by society's belief in supernatural recognition instead. the perpetuation of a power and influence gap between nursing and medicine persists. this is a powerful historical impediment for a nursing profession that is increasingly highly scientific and academic in practice and central to the need to increase the focus on preventative primary health care. modelling has described a current shortfall of 5.9 million nurses throughout the world, with shortages in high-, middle-and lowincome countries and with worse outcomes for low-income counnursing leadership is frequently not esteemed in the academic or political sectors, where powerful medical paradigms dominate, again, operating from a socially oppressed standpoint where nursing knowledge is situated beneath a dominant medical discourse and standpoint, oblivious to the social privilege associated with the elevated position it holds. it is apparent that a more welcoming, inclusive, respectful, and engaging environment within the wider academy is necessary if the world is to recruit, retain, and promote nursing leadership and academic excellence to facilitate the necessary growth of the nursing workforce. this is essential to mitigate the massive and increasing shortfall in work health standards that are pressing and looming and to grow the power and authority of primary healthcare nurses and nurse practitioners. the recent covid-19 pandemic experiences have been illustrative of the global need and reliance on high-quality, highly sophisticated nursing care to underpin best practice and safe treatment throughout the most dire health crisis circumstances the world has seen in living memory (jackson et al., 2020) . simply put, we need more nurses in the world, and to add more, we need more nursing faculty to lead the education and research of nursing scientific knowledge, with more power, influence, and leverage. yet, we are trapped in a deficit discourse that is resistant to change. "more" is required of us, with a "less" narrative to navigate. the question is, how can the global demand be satisfied adequately, when a major barrier to success for nursing scientific leadership in the academy itself is apparent? for most nursing scholars, the dual nature of developing both clinical practice expertise and scientific practice expertise takes considerably more time to acquire than many other academic fields of knowledge. however, the integration of both fields of knowledge is a powerful representation of adaptability, translational capability, and implementational capacity representative in a nursing workforce. nursing thus offers the formation of practice-informed evidenced-based knowledge, suited to the real-world delivery of health services delivered with a person-centric impact which extends far beyond the limited and limiting premises of biomedicine. challenges to nursing faculty development are, however, significant with difficult access to serious research funding and cultures which often fail to value the pastoral care and teaching of students essential to the production of a professional and empathetic workforce. nurses have also been described frequently in the public social and traditional media discourse of late as heroes. our collective commitment to caring for others with empathy in the grip of has been portrayed by the public as superheroes, not in capes-but instead wearing protective clothing. the fantasy of nurses as superheroes, while well meaning, does little to advance our reputation as caring scientists, to be taken seriously in the public health narrative. both superheroes and angels do not die, they also do not require training, science, or decent salary, in contrast, nurses do. the narrative we need is one that propels us to leadership in policy and process, and to being actively included in international, national, and local health planning and policy development, and crisis prevention talks with governments and agencies. while we note during covid-19 that national nursing leaders have occasionally appeared in media conferences alongside their relevant governmental ministers, it is our observation that nursing is under-represented with medical colleagues as more frequent media conference companions for government officials. too frequently, nurses are wilfully excluded or carelessly omitted from these endeavours. the assumption made by journalists is that the real authority lies with medical spokespeople and that we remain as handmaidens to the central endeavour, even though aspects of care such as infection control are part of our core business. in fairness to journalists, however, they will tell us frequently how very difficult it is to find a nurse who will speak publicly. this must change. will our contribution during covid-19 do anything to change this? all too frequently, nurses themselves are either passively or actively subversive in their behaviours. horizontal verbal violence, bullying, interprofessional disrespect and discourtesy, and plucking tall poppies are all apparent within the nursing discipline. care of each other within our ranks still requires much more person-centred and rehabilitative attention. a dominant mainstream of invisibility within the emotionally safe bounds of mediocracy; political whiteness; and stigma towards difference combined within our collective slowness to embrace cultural and (dis)ability diversity within our number continues to undermine our caring profession severely (fredericks & white, 2018) . our propensity for "othering" within the nursing profession diminishes our reputation and our capacity to advocate convincingly for those to whom we administer nursing care. it takes courage to reflect on the social construction of our profession, to examine it through critical theoretical lens, and to challenge the behaviours and unconscious biases in our ranks that hinder our progress. we must summon the necessary collective courage. it is through a longstanding commitment to promote public good that the nursing profession has the right of self-regulation and accepts the responsibility that comes with professional status. nurses reaffirm their fidelity to nursing's social contract through a commitment not only to the welfare of those for whom they care, but also to the welfare of society through actions that improve health system performance. the nursing profession has a central role to play in the performance of health systems, which are a recognized determinant of population health and equity outcomes. within our academies, nursing academics need to be kinder, more respectful, empathetic, and inclusive of difference if we are to succeed as a profession of the future, transforming our science and practice of caring within an integrated health system that contributes to equitable public good. covid-19 conditions during the early portion of 2020 and the international year of the nurse and midwife have highlighted the need for the nursing scientific academy to transform our discipline and to enhance our scope to meet the needs of a changing world. increasingly, we need to be agile, transformative, and amplify the voice, power, and influence of an inclusive and diverse nursing workforce as we work to address the changing needs of the world's population with our core focus on promoting and improving the determinants of health and well-being, recovery, and robustness of people as they encounter challenging circumstances throughout their lives. to do this, we will need to be powerfully kind, influentially ambitious, and entrepreneurial in our problem-solving to ensure our significance in world health impact going forward. our standpoint for our discipline provides us with a foundation to leverage wider recognition and respect for our collective health and well-being knowledge, at a time when the world cannot do without our important contributions. and in due course, we will celebrate and showcase our disciplinary achievements… at an appropriate time postponed to the future, in lieu of our current collective engagement and priority situating feminist epistemology gender equity in the health workforce: analysis of 104 countries. geneva: world health organization letting go of our past to claim our future using bridges made by others as scaffolding and establishing footings for those that follow: indigenous women in the academy using ockham's razor to redefine "nursing science whose science? whose knowledge? thinking from women's lives discovering reality: feminist perspectives on epistemology, metaphysics, methodology, and the philosophy of science life in the pandemic: some reflections on nursing in the context of covid-19 state of the world's nursing 2020: investing in education, jobs and leadership. (licence: cc by-nc-sa 3.0 igo.) sigma organisational fact sheet key: cord-350822-m3t7l9zw authors: mo, yuanyuan; deng, lan; zhang, liyan; lang, qiuyan; liao, chunyan; wang, nannan; qin, mingqin; huang, huiqiao title: work stress among chinese nurses to support wuhan in fighting against covid‐19 epidemic date: 2020-05-20 journal: j nurs manag doi: 10.1111/jonm.13014 sha: doc_id: 350822 cord_uid: m3t7l9zw aims: to investigate the work stress among chinese nurses who are supporting wuhan in fighting against coronavirus disease 2019 (covid‐19) infection and to explore the relevant influencing factors. background: the covid‐19 epidemic has posed a major threat to public health. nurses have always played an important role in infection prevention, infection control, isolation, containment and public health. however, available data on the work stress among these nurses are limited. methods: a cross‐sectional survey. an online questionnaire was completed by 180 anti‐epidemic nurses from guangxi. data collection tools, including the chinese version of the stress overload scale (sos) and the self‐rating anxiety scale (sas), were used. descriptive single factor correlation and multiple regression analyses were used in exploring the related influencing factors. results: the sos (39.91 ± 12.92) and sas (32.19 ± 7.56) scores of this nurse group were positively correlated (r = 0.676, p < .05). multiple regression analysis showed that only children, working hours per week and anxiety were the main factors affecting nurse stress (p = .000, .048, .000, respectively). conclusions: nurses who fight against covid‐19 were generally under pressure. implications for nursing management: nurse leaders should pay attention to the work stress and the influencing factors of the nurses who are fighting against covid‐19 infection, and offer solutions to retain mental health among these nurses. in december 2019, patients with pneumonia of unknown cause were emerged in wuhan, china (catton, 2020; huang, wang, & li, 2020; li et al., 2020) . local works and those conducted by the experts from who confirmed that the pathogen causing this novel pneumonia is sars-cov-2, and this type of pneumonia is called the coronavirus disease 2019 . the covid-19 epidemic has posed a remarkable threat to public health (pan et al., 2020) . on 11 march 2020, who director-general dr. tedros adhanom ghebreyesus said that there was deep concern about the extent and severity of the covid-19 epidemic, which the world health organization (who) assessed to be characterized as a pandemic (e.g., social network or clinical setting; the novel coronavirus pneumonia outbreak has acquired pandemic characteristics, 2020). as of 23:59 on 19 march 2020, a total of 234,073 confirmed cases and 9,840 deaths have been reported globally. in europe, the cumulative number of cases reached 104,591, with 4,899 deaths. covid-19 has been reported in 176 countries and regions, and more than 150,000 cases have been confirmed outside china (e.g., social network or clinical setting; coronavirus disease 2019 (covid-19) situation report-60, 2020). as of this date, the number of confirmed and suspected cases outside china is increasing dramatically, as is the number of deaths. covid-19 presents a vast public health challenge, not only to china but also around the world. nurses have always played an important role in infection prevention, infection control, isolation, containment and public health (graeme, 2020) . as of 1 march, a total of 28,679 nurses had been sent to hubei province to fight against covid-19 infection (e.g., social network or clinical setting; the white coat went out to battle, 2020). nurses on the front line in this event are showing the commitment and compassion that nurses do everywhere, but the truth is they are putting their lives at risk in the course of their duties (catton et al., 2020) . one third of all fatalities during the 2003 sars outbreak in china were health care professionals (hung, 2003) . in the early days of the outbreak, more than 3,000 medical workers in hubei province were infected, 40% in hospitals and 60% in communities (e.g., social network or clinical setting; national support wuhan medical staff 'zero infection' novel coronavirus pneumonia, 2020). the unfolding emergency caused by the covid-19 in wuhan is putting nursing services under intense pressure. when nurses are exposed to working environments with high job demands and low resources, higher job stress and greater physical and psychological stress symptoms may adversely affect health and well-being (chou, li, & hu, 2014; khamisa, oldenburg, peltzer, & ilic, 2015; lin, liao, chen, & fan, 2014; malinauskiene, leisyte, romualdas, & kirtiklyte, 2011) . maintaining the mental health of nursing staff is essential to control infectious diseases (kang et al., 2019; xiang et al., 2020) . at present, studies on the epidemic situation of covid-2019 mostly focused on epidemiological investigation, prevention and control, diagnosis and treatment. fewer studies have investigated the mental health problems of clinical medical workers during the epidemic of covid-19. the purpose of the present study was to investigate the work stress load among chinese nurses who support wuhan in fighting against covid-19 infection and to explore the relevant influencing factors for the development of psychological interventions for chinese nurses in order that they can adjust to public health emergencies. a cross-sectional survey. by means of convenient sampling, nurses from guangxi supporting wuhan were selected to carry out the survey. the inclusion criteria were as follows: nurses from guangxi who are involved in fighting against covid-19, those who have entered the clinical front line to participate in the rescue work and those who volunteered to participate in this study. as of 21 february 2020, all the nurses (around 210) were invited to participate in this study. the response rate was 85.71%, which resulted in a sample of 180 nurses. according to literature review and expert consultation, self-made general information and demographic questionnaires, including gender, age, nursing age, education, professional qualifications, marital status, fertility status, whether the participants are the only child in their families, whether their family supports them, whether they have been trained in sars-cov-2 prevention and control knowledge, self-assessment of the mastery of covid-19 prevention and control knowledge, whether they participate in protective skills training, self-assessment of the mastery of the protection skills, experience in related departments (e.g., fever clinic, infection department, respiratory and critical medicine department, critical medicine department and emergency department), whether they volunteer to participate in the support work, whether they regret participating in the support work, whether they have completed the support work with confidence, the name of the hospital where they are working in, the time they participated in support and working hours per week, were completed. amirkhan (2012) developed a sos, and qian & leilei (2014) introduced it and conducted cultural commissioning. the chinese version of the sos has good reliability and validity. the cronbach's α value is 0.936, and the content validity is 0.860. the scale consists of two dimensions: event load (12 entries) and individual vulnerability (10 entries), with 22 entries using a 5-point scoring method, 'never before' scores 1 point and 'always there' scores 5 points, with the total score in the range of 22-110 points. the higher the score is, the greater the pressure load will be. cronbach's α value is 0.777, and the half-coefficient is 0.757, which has good reliability and validity (tian, wang, li, wang & dang, 2019) . the total score of sas is the cumulative score of each item. the higher the score is, the more severe the anxiety will be. online survey (via a questionnaire website platform) was send to the heads of each batch of nurses from guangxi who are supporting in wuhan, whom were asked to send on to nurses. the participants could complete the questionnaire via computer or smartphone that can open a website link or scan a quick response code. the online survey was sent to the potential participants with an invitation letter containing information regarding purpose, anonymity and confidentiality. consent was implied if participants connected to the website link and completed the questionnaire. counting data were expressed by frequency and percentage, and the measurement data were expressed by x ± s. comparisons between two groups were performed using two independent-sample t tests, and comparisons between multiple groups were performed using single-factor anova. the correlation between stress load and anxiety was analysed using the pearson correlation analysis, and multiple linear regression analysis was used for multivariate analysis. all statistical analyses were performed with spss for windows 22.0, with two-tailed p < .05 to be considered statistically significant. of the 180 nurses who participated in the survey, 18 were male (10%) and 162 were female (90%). the age of these nurses ranged from 21 to 48 (32.71 ± 6.52) years, with years of working ranging from 2 to 32 (8.45 ± 3.86) years. the education profile of the participants is as follows: 34 (18.89%) junior college students, 143 (79.44%) undergraduates and 3 (1.67%) masters. the professional qualification is as follows: 7 (3.89%) primary nurses, 102 (56.67%) senior nurses, 59 (32.78%) supervisors and 12 (6.67%) deputy chief nurses. the marital status of the participants is as follows: 89 (49.44%) married, 86 (47.78%) unmarried and 5 (2.78%) divorced. the fertility status of the participants is as follows: 82 (45.56%) nurses are fertile, and 98 (54.44%) have no children. the survey showed that the total stress load score of 180 nurses who assisted in combating the covid-19 was 39.91 ± 12.92, with a score rate of 39.91%, of which the event load score was 19.32 ± 6.52 points, and the individual vulnerability score was 20.59 ± 6.61 points. the total sas score was 32.19 ± 7.56 points, which was higher than the national standard points (29.78 + 0.46), and the difference was statistically significant (t = 4.27, p < .001). according to the pearson correlation analysis, the total stress load score and each dimension were positively correlated with sas (the r values were 0.676, 0.667 and 0.663); that is, the higher the stress load is, the higher the total anxiety score is, and the more evident the anxiety mood will be. the results showed that different professional qualifications, whether the participants are the only child in their families, the severity of patients, working hours per week, diet and sleep status had impacts on nurses' stress load scores (p < .05), as shown in table 1 . when the total stress load was used as a dependent variable, the single-factor analysis of the stress load that had statistically significant titles (primary nurse = 1, senior nurse = 2, nurse in charge = 3 and deputy chief nurse = 4), whether the participants are the only child in their families (yes = 1, no = 2), the severity of patients (suspected = 1, mild = 2, common = 3, severe = 4 and critically ill = 5), working hours per week (<20 hr = 1, 20-25 hr = 2, 26-30 hr = 3, 31-35 hr = 4, and >35 hr = 5), whether they adapted to daily diet (yes = 1, no = 2), sleep status (very good = 1, good = 2, average = 3, not very good = 4 and very bad = 5) and sas total score (substituting the actual value) were used as independent variables for multiple linear regression analysis. the results showed that whether the participants are the only child in their families, working hours per week and anxiety were the main factors influencing the stress load of nurses assisting in the fight against covid-19, which can explain 52.1% of the total variation, as shown in table 2 . the results of this study showed that the total stress load of nurses who assisted in fighting against covid-19 was 39.91 ± 12.92 points, with a score rate of 39.91%, and those with a score > 50 nursing team to assist in hubei. given unknown and uncontrollable nature of the epidemic rescue work, coupled with being far away from their hometown and loved ones, the nurses helping in hubei had certain psychological pressure. the pressure load of the nurses in hubei who participated in this study was at a moderately low level, which was slightly lower than that in the study of wu et al. (2020) and other studies (kane, 2009; lin et al., 2014) , which may be attributed to the high the knowledge of covid-19 is limited, but it is highly contagious. in order to better care for patients and protect nurses, the training of the nursing team's business capabilities should be strengthened, training plans of the covid-19 epidemic should be formulated, the training content should be rationally set, and multimedia network platforms should be used to promote the participation of all staff in training and improve the knowledge and skills reserve of the nursing staff and epidemic response ability. the stress load score of nurses who are the only child in their families in the present study was 50.87 ± 10.47 points and that of nurses who are the non-only child in their families was 38.91 ± 12.68 points (p < .05), which indicated that nurses who are the only child in their families were more stressful. this result may be correlated with role conflict and social support system. they worry about the health of their family members and fear that if they died of covid-19, their parents will lose their only child. when multiple roles are in conflict, certain psychological pressure will be present. social support is an important protective factor for psychological resilience that alleviates mental stress and lifts psychological barriers (su & guo 2015) . strengthening social support among nurses could also mitigate the effect of job strain on health, as has been mentioned in the literature (garcia-rojas, choi, & krause, 2015; schmidt, 2013) . thus, the social support system of nurses should be actively mobilized. nurses should keep in touch with their families and friends so as to achieve spiritual support. at the same time, nurses should encourage one another, discuss and share our feelings and experiences with their colleagues in a timely manner, and vent negative emotions. hu, hu, yang , han, yanmei (2014) reported that the social support of the nurses who are the only child in their families maintains their mental health. furthermore, the worries of the front-line nurses should be reafter wearing a full set of protective clothing, nurses' breathing will be limited to a certain extent. to save the use of isolation clothing during work, nurses do not drink water or go to the toilet, thereby increasing the difficulty of nursing work. in this case, the longer the working time per week is, the higher the consumption of body and mind will be. hence, the body is in a state of tension and fatigue. if tension cannot be released for a long time, then the nurse is prone to burnout. burnout is correlated with the physical and mental health of nurses and affects the quality and safety of nurses. stress from work moderately affects burnout (liu & aungsuroch, 2019) . thus, nurse managers should strengthen the allocation and management of human resources, scientifically arrange shifts, reduce the work intensity of nurses and decrease work pressure. in the case of sufficient human resources, nurses' participation in the treatment of covid-19 is for less than 1 month. at the same time, the support of medical protective equipment and other related materials should be increased, and conditions to provide medical staff with shower and bath facilities should be actively created, thereby ensuring that the staff can thoroughly bathe when leaving the isolated ward after work and reducing the possibility of infection. anxiety is a negative emotional state perceived by individual subjectively and one of the most common psychological obstacles of nurses (gao et al., 2012; dongbo et al., 2018) . in this survey, the average score of sas was 32.19 ± 7.56, which was significantly higher than the national standard anxiety level (p < .05). this result showed that nurses had evident anxiety, which was similar to the results of wu et al. (2020) and zhang, li, zheng, zhang, (2020) . the results of a multifactor analysis showed that anxiety is an important factor affecting nurses' stress load. the correlation analysis also shows that anxiety is positively correlated with stress load. the more evident the anxiety is, the more intense the pressure that the nurses will feel. many previous studies have also shown that nurses with high stress lead to anxiety, frustration, depression and other psychological disorders and emotions (malinauskiene et al., 2011; teles, barbosa, & vargas, 2014) . covid-19 is highly infectious and spread rapidly, with suspected and confirmed patients increasing daily. nurses feel anxiety and helplessness due to so many patients. the government of china has implemented policies to address these mental health problems. medical workers infected with covid-19 due to the performance of their duties, they shall be identified as industrial injury and enjoy the benefits of industrial injury insurance according to law (e.g., social network or clinical setting; occupational injury insurance supports occupational injury 'protection umbrella' for prevention and rescue personnel in the fight against new coronavirus pneumonia, 2020). online platforms with medical advice have been provided to share information on how to decrease the risk of transmission between the patients in medical settings, which aims to eventually reduce the anxiety and pressure on medical workers (kang et al., 2019) . nurses should maintain their psychological health to ensure the quality of care for patients (hsiao & tseng 2020) . nurse managers should guide the nurses to adjust their psychological state scientifically. leisure activities and training on how to relax should be properly arranged to help staff reduce stress. the results of this study showed a widespread pressure on nurses who are supporting in wuhan to fight against covid-19. maintaining the mental health of nursing staff is essential to control covid-19. nurse leaders should pay attention to the work stress and the related factors of the clinical nurses. nurse managers should try the best to provide safe working conditions for nurses, while offering financial subsidies and rewards, so as to mobilize the enthusiasm and conscientiousness of nurses. the knowledge of covid-19 is limited, but it is highly contagious. nurses who received covid 19 epidemic training had higher mental health levels than those who did not this work was supported by funds from the special project of guangxi department of science and technology on emergency treatment of covid-19 (grant no. 2020ab39028) . the authors thank the research participants for their participation in the study and heads of each batch of nurses who distributed the questionnaires to the nurses. we would like to extend our deepest gratitude to professor chuanyi ning for his language checking. hh and mq conceived the study. ym created and performed the literature search strategy. ld and ql built the data extraction file. ym and lz performed the data extraction. hh and mq supervised the process. ym performed the results. all authors contributed extensively to this work, interpreted the data and contributed substantially to the writing and revision of the manuscript, and read and approved the final version of the manuscript. the procedures of this study were reviewed and approved by the stress overload: a new approach to the assessment of stress national support wuhan medical staff "zero infection global challenges in health and health care for nurses and midwives everywhere job stress and burnout in hospital employees: comparisons of different medical professions analysis of nurse anxiety and its influencing factors conscientiousness, openness to experience and extraversion as predictors of nursing work performance: a facet-level analysis anxiety symptoms among chinese nurses and the associated factors: a cross sectional study psychosocial job factors and 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evaluation of anxiety and depression scale in clinical application of patients with liver cirrhosis use of assessment scales, turnover and job strain in nursing staff: a study in a colombian hospital how to provide an effective primary health care in fighting against severe acute respiratory syndrome: the experiences of two cities mwo9p dl29d mkmh5 npzp2 00312.shtml world health organization (2020, march20) survey of sleep quality of clinic-al front-line nurses and its influencing factors in the fight against new coronavirus pneumonia timely mental health care for the 2019 novel coronavirus outbreak is urgently needed investigation and counter-measures of nurse anxiety in a hospital with a new coronavirus pneumonia in hangzhou key: cord-316853-vaea6siv authors: xie, nanzhen; qin, yan; wang, taiwu; zeng, ying; deng, xia; guan, li title: prevalence of depressive symptoms among nurses in china: a systematic review and meta-analysis date: 2020-07-07 journal: plos one doi: 10.1371/journal.pone.0235448 sha: doc_id: 316853 cord_uid: vaea6siv background: depression is one of the most common mental disorders, profoundly impacting an individual’s performance and quality of life. due to their unique working conditions, nursing is counted among the occupational groups at high risk for developing depression. because of the shortage of nursing resources in china, chinese nurses suffer from heavy daily workloads more than those in many other countries. therefore, this study aimed to evaluate the overall prevalence of depressive symptoms and analyse the potential risk factors of depressive symptoms in chinese nurses. methods: a systematic literature search in pubmed, embase, web of science, the chinese biomedical literature database (cbm), the china national knowledge infrastructure (cnki), and the weipu and wanfang databases up to dec 31st, 2019 was performed regarding the prevalence of depressive symptoms in chinese nurses. eligibility assessment and data extraction were performed independently by 2 researchers, and meta-analysis was used to synthesize the data. heterogeneity was evaluated using cochran’s q test and quantified using the i(2) statistic. to explore the potential source of heterogeneity, subgroup analyses were also performed. in addition, both funnel plot and egger’s tests were adopted to assess publication bias. results: a total of 102 studies published from 1996 to 2019 covering 22 provinces were included for further analysis. the total number of participants was 52,592, with a range of 46 to 7205 per study. the overall prevalence of depressive symptoms in chinese nurses was 43.83% (95%ci: 40.26%-47.42%), and 31.12% (95%ci: 27.30%-35.07%) were classified as mild degrees of depressive symptoms. the prevalence of depressive symptoms may be significantly affected by region, province or municipality and department marital status. moreover, an increasing trend in the prevalence of depressive symptoms was observed in recent years. conclusion: the results presented a high prevalence of depressive symptoms among chinese nurses, which suggests interventional programmes by health decision-makers to improving the mental state of nurses is needed urgently, especially in nurses with high risk factors for depressive symptoms. furthermore, the nationwide investigation of depressive symptoms prevalence should be performed with a standard diagnostic tool, which may be more useful for policy makers and planners. a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 the results presented a high prevalence of depressive symptoms among chinese nurses, which suggests interventional programmes by health decision-makers to improving the mental state of nurses is needed urgently, especially in nurses with high risk factors for depressive symptoms. furthermore, the nationwide investigation of depressive symptoms prevalence should be performed with a standard diagnostic tool, which may be more useful for policy makers and planners. depression is one of the most commonly diagnosed mental disorders or statuses, sometimes resulting in serious damage to the patient's work ability [1, 2] , performance [3, 4] , interpersonal communications, physical health [5, 6] , and quality of life [7] ; some cases of depression may even result in the patient committing suicide [8] . according to the world health organization (who), approximately 300 million people of all ages suffer from depression worldwide, with an increase of more than 18% between 2005 and 2015. the global point, one-year and lifetime prevalence of depression are 12.9%, 7.2% and 10.8% respectively [9] . depression is one of the biggest sources of disability and imposes a considerable economic burden on society [10] . in addition, more women are affected by depression than men [11] . it has been reported that doctors and nurses are one of the highest risk groups for developing depression [12] . special working conditions, such as burnout [13, 14] , high tension, overloaded clinical work, and occupational stress, seriously threaten the mental health of nurses. in addition, nurses often have to witness many different life events, such as disease, trauma, and even death, which imposes further physical and psychological effects on them. because of the shortage of resources for nurses in china, chinese nurses suffer from heavy daily workload more than those in any other country. the psychological status of nurses not only directly affects their own health but also affects the quality of medical care provided for their patients in a hospital setting [15] . some studies have shown that the most common psychological problems experienced by nurses are anxiety and depression [16] , and the incidence of depression in nurses has been showing an increasing trend [17, 18] . at present, relevant studies at home and abroad have found that there is a very high prevalence of depression in the nurse population [19, 20] . for example, studies from usa, taiwan, and south korea found the depressive symptoms prevalence in nurses population ranged from 18% to 61.7% [21] [22] [23] [24] [25] . furthermore, a total of 46 cases of nurse suicide were reported or published from 2007 to 2016 [26] . although various studies have been published in different regions in chinese mainland, there has been no systematic comprehensive study about the prevalence of depressive symptoms. therefore, the primary aim of this study is to quantitatively assess the prevalence of depressive symptoms in nurses from chinese mainland and its primary related influencing factors by systematic review and meta-analysis. all potential articles from pubmed, embase, web of science, the chinese biomedical literature database (cbm), the china national knowledge infrastructure (cnki), and the weipu and wanfang databases were obtained by electronic search. the last search for all databases was performed on dec 31st, 2019. the keywords used for relevant studies were ("prevalence" or "frequency" or "epidemiology") and ("depression" or "mental health disorder" or "major depression disorder" or "mood disorder" or "affective disorder") and ("nurses" or "nurse") and ("china" or "chinese"). each keyword was searched individually or in combination to avoid missing relevant articles and maximize outputs. manuscripts that fulfilled all the following criteria were included for further analysis: (1) crosssectional study, or cohort studies that reported the prevalence of depressive symptoms; (2) targeted objects were nurses in chinese mainland; (3) data available for depressive symptoms prevalence and corresponding depression scale; (4) the depression measuring scales adopted for depression assessment were well recognized internationally, for example, zung's self-rating depression scale (sds) [28] . studies that met the following criteria were excluded: (1) not an original study, such as a review or editorial; (2) non-peer-reviewed local or government report or conference abstract; (3) studies from regions of china other than chinese mainland (including hong kong, macao, and taiwan); (4) duplicate published studies; (5) nurses that were in specific training stages: students, standardized training or rotation; (6) nurses with specific characteristics, including pregnancy, perimenopause, and nurses suffering from trauma following an earthquake; (7) studies with small sample sizes (n<45). to evaluate the selected articles, the 'ahrq cross-sectional/prevalence study quality checklist' [29, 30] was used as a research instrument. which is the most widely accepted quality assessment tool for a cross-sectional study [31] . this instrument is available at http://www. ncbi.nlm.nih.gov/books/nbk35156/ and also can be found in the s1 table. the instrument includes 11 items, which are answered with "yes", "no" and "unclear" respectively. 1 point will be given if one item is satisfied, and 0 point will be given for items not involved or unclear in the study. article quality was assessed as follows: low quality = 0-3; moderate quality = 4-7; high quality = 8-11. the evaluation was conducted independently by two authors, and possible disagreements were settled through discussions with a third author. the following information was extracted from all included studies: title, year of publication, province, sample size, number of positive cases, diagnostic methods and other potential factors that may affect the prevalence of depressive symptoms in nurses and that was provided in the studies. some of studies did not contain all the above-mentioned variables. point estimates and 95% confidence intervals (95%cis) for the prevalence rate of depressive symptoms in nurses were calculated for each study. to avoid having a confidence interval (ci) outside of the 0-1 range as well as studies with large weightings when the prevalence proportion becomes too small or too large, we calculated prevalence estimates with the variance-stabilizing double arcsine transformation [32] . statistical heterogeneity was evaluated by cochran's chi-squared test (with p < 0.10 indicating statistically significant heterogeneity) and the statistic i 2 [33] . heterogeneity with an i 2 of 0 to 40% was treated as not important, while an i 2 of 30 to 60% was treated as moderate heterogeneity, i 2 of 50 to 90% was treated as substantial heterogeneity and i 2 of 75 to 100% was treated as considerable heterogeneity [34] . if obvious heterogeneity existed (with p < 0.10), a random effects model was adopted for pooled results; otherwise, a fixed effects model was adopted. fixed-effect models assume that the population effect sizes are the same for all studies [35] . in contrast, random-effects model attempted to generalize findings beyond the included studies by assuming that the selected studies are random samples from a larger population [36] . furthermore, to identify potential influential studies, sensitivity analysis was performed by sequentially removing individual studies and evaluating the effect on the overall estimate. in addition, subgroup analysis was performed based on other potential sources of heterogeneity, such as province, regions (northwest, southwest, northeast, south, central, east and north china), severity of depressive symptoms, department, gender, age, job title, marriage, education background, shift work and hospital grade (if available). furthermore, meta-regression was also performed to identify the causes of heterogeneity or examine the impact of moderator variables on study effect size of the prevalence. publication bias was examined by funnel plots, and statistical significance was assessed by egger's test. in addition, for the meta-analysis, we assumed that the included studies were a random sample from each study population. meta-analysis was carried out with the "meta" package version 4.11-0 [37] and graphical representation with ggplot2 package version 3.3.0 [38] of r language version 3.6.3 [39] . through the initial search, a total of 3142 potentially relevant citations were identified. a total of 264 duplicate papers were removed first, and 2734 papers were excluded after scanning their titles and abstracts. after screening the full texts of the included articles, 42 studies were excluded for the following reasons: prevalence unreported(n = 28); intervention study of small samples(n = 5); no mention of psychological scale(n = 4); duplicates (n = 3); wrong data (n = 1); after psychological intervention(n = 1). finally, a total of 102 studies meeting the inclusion and exclusion criteria were included for further analysis (fig 1) , of which 3 were published in english-language journals, and the others were published in chinese-language journals. the basic characteristics of the final included studies are shown in s1 table. these studies were published ranging from 1996 to 2019, covering 22 provinces, autonomous regions and municipalities. the scales used for depression assessment were listed as follows: zung's self-rating depression scale (sds) [28] , centre for epidemiologic studies-depression scale (ces-d) [40] , beck depression inventory (beck) [41] , beck depression inventory (2nd ed) (bdi-ii) [42] , hospital anxiety and depression scale (hads) [43] , hamilton depression rating scale (hamd) [44] , and patient health questionnaire (phq-9) [45] . the total number of participants was 52,592, with a range of 46 to 7205 per study. the ahrq cross-sectional/ prevalence study quality checklist was applied to evaluate the study quality (s1 and s2 tables). among the selection items, the evaluation results ranged from 2 to 8, with the median score was 4. overall, 65 of 102 studies have moderate or high quality, indicating a medium quality of the studies included. a total of 28,382 cases among the 52,592 nurses in the studies were found to have different degrees of depressive symptoms; the overall prevalence of depressive symptoms in nurses was 43.83% with 95%cis of 40.26%-47.42%, with significant heterogeneity (i 2 = 98.50%, p < 0.01). a total of 37 studies reported different degrees of depressive symptoms. after we pooled the results based on the severity of the depressive symptoms, the pooled prevalence and 95%cis were 31 geographic analysis based on provinces and regions was performed. we found that the highest prevalence of depressive symptoms was in nurses from the northeast (54.69%, 95%ci: 50.51%-58.84%) and the lowest was in south china (37.59%, 95%ci: 32.75%-42.56%) ( table 1 ). the prevalence of depressive symptoms in nurses among different provinces is shown in table 1 . the highest and lowest prevalence of depressive symptoms were found in hubei province (58.62%, 95%ci: 49.55%-67.41%) and in inner mongolia (22.41%, 95%ci: 5.39%-46.20%), respectively. overall, the geographic location could significantly affect the prevalence, regardless of whether it was broken down by region or province. we also performed subgroup analysis by year. as shown in fig 3, the lowest and highest prevalence were 26.64% (95%ci: 21.27%-32.38%) in 1999 and 62.99% (95%ci: 53.22%-72.26%) in 2017, respectively. concerning the results of subgroup differences for prevalence in different years, a significant difference in terms of the prevalence trends was also found (p < 0.01). other factors that may affect the prevalence of depressive symptoms in nurses were also analysed. the pooled estimates by potential risk factors associated with depressive symptoms in nurses are presented in tables 2 and 3 . of all factors analysed in our study, the prevalence of depressive symptoms was significantly affected by department (table 2) ; the lowest prevalence in addition, we also found that marriage, educational background, age, job title, hospital grade, and shift work did not significantly affect the prevalence of depressive symptoms in nurses (table 3) . publication bias was examined by funnel plot and egger's test. a funnel plot shows that publication bias may exist (fig 4) , which was also confirmed by the result of egger's test (t = -6.20, p < 0.01). a sensitivity analysis for the pooled results was conducted by sequentially removing individual studies, and no significant differences before and after pooling were found, indicating stability in the pooled results. along with the rapid development of the economy in china, psychological problems have become increasingly more common. nurses, as an important role in hospitals, have been increasingly demonstrating depressive symptoms. although many articles have been published to assess the prevalence of depressive symptoms in chinese nurses, a comprehensive study on this population is still absent. in our study, a total of 102 studies with 52,592 participants were obtained to assess the prevalence of depressive symptoms in mainland chinese nurses. to our knowledge, this is the most comprehensive report to date to estimate that estimates this statistic, which may provide useful and valuable information for health decision-makers, helping them to properly implement interventional programmes and prevention activities. in our study, the overall prevalence of depressive symptoms in mainland chinese nurses was 43.83%, with 95%ci of 40.26%-47.42%, and obvious heterogeneity was demonstrated. we also found that the prevalence may be affected by regions/provinces, hospital department, and time, and may not be affected by educational background, age, job title, marriage, hospital grade, or shift work. because of the high prevalence of depressive symptoms in chinese nurses, which may result in large problems for society overall, we suggest that decision-makers should take actions to aid nurses in safeguarding their psychological wellbeing. in a previous meta-analysis [46] , the prevalence of depression in nursing students worldwide was 34.0% and was affected by age and geographical regions, with asian nursing students experiencing a higher prevalence (43.0%). we may see that both student and professional nurses, especially in asia, have a very high prevalence of depression; this prevalence is higher than even that of older patients with diseases such as stroke, hypertension, diabetes and coronary heart disease [47] , and is similar to that of empty-nest elderly individuals [48] . in addition, the prevalence of depression among chinese nurses is higher than that of nurses in iran [49] and chinese hong kong [50, 51] , australian midwives [52] , and hungarian [53] and australian [54] nurses. however, to our surprise, only 13.2% of nurses in vietnam have depression [55] , as well as 24.9% of iranian nurses working in military hospitals [56] . in addition, the chinese nurses even seem to have higher prevalence of depression than some special populations, such as people living with hiv with 38% [57] , outpatients with 27.0% [58] , and indian elderly population with 34.4% [59] . therefore, we may conclude that chinese nurses were at a particularly high risk of having depressive symptoms. moreover, based on the time trend shown in fig 3, the prevalence of depressive symptoms among chinese nurses may have increased in recent years, especially in large hospitals with a low ratio of doctors to nurses and of nurses to patients. we also found that the prevalence of depressive symptoms was significantly different based on geographic distribution and hospital department. in total, we could see that nurses from the hubei province and the northeast region had the highest prevalence of depressive symptoms. this may be because of the occupational environment and policies in each region. from table 2 , we can see that the departments with the highest prevalence of depressive symptoms for nurses are infectious diseases, paediatrics, haemodialysis, icu, and oncology. this may be due to the heavy workload and time pressures inherent in working in these departments. in addition, we also found that, in terms of marital status, despite no significant difference was found, divorce/widowhood/separation had higher prevalence than the others, which may be due to the sample size. to our surprise, we found that the prevalence of depressive symptoms in department of psychiatry wasn't that high as we expect, which may be due to as follows [60] : 1) more professional education about mental health was obtained, 2) the workload and difficulty of nurses in department of psychiatry were easier than others, 3) as closed-off plos one management was adopted in most department of psychiatry, they didn't face the trouble from family members of patients, 4) psychopaths often didn't have physical disease, 5) more medical disputes existed in general hospitals than psychiatric hospitals. in china, there is a large shortage of resources for nurses, the ratio of the nurse population to the total population is 1:1750, which is much lower than that of some developed countries (1:140-1:320) [61] . nurses are faced with heavy workloads, especially in the grade 3a hospitals in the city. however, the present situation cannot be changed in a short period of time. due to the recent covid-19 pandemic, the impact on mental health on healthcare workers is tremendous and more nurses suffer from depression [62, 63] . it is suggested that hospital managers should pay attention to the physical and mental state of their nurses, establish mechanism for the prevention and control of negative emotions such as depressive symptoms, formulate feasible measures to reasonably reduce the workloads of nurses, improve the working environment and the sense of occupational identity, improve and maintain the quality of life while ensuring the quality of medical service, and ensure the physical and mental health of the nurses. these steps may play a role in saving resources and improving nurses' quality of life and work efficiency [64] . the strengths of this review include a comprehensive analysis of the literature to identify all potential articles related to the topic, a robust methodology in conducting the systematic review, and combining estimates generated from the meta-analyses. the meta-analysis results also have some limitations that should be acknowledged: 1) all studies used a cross-sectional observational study design; 2) most of the literature included in this study was published in chinese-language journals, with very few in english-language journals, the overall quality of included studies; 3) the criteria and cut-off for diagnosis varied with studies, which may have led to the heterogeneity observed; 4) only 22 provinces in chinese mainland have been covered with regards to the prevalence of depressive symptoms in their nurses, which may have led to deficiencies or inaccuracies in estimating the overall prevalence; 5) some potential confounding factors were analysed to try and understand the high heterogeneity, but the main reason is still unknown; 6) as the limitation of sample size in some groups, such as department of infectious diseases, anhui and jilin provinces, some results still need further confirmations; and 7) publication bias could not be avoided. despite the considerably high heterogeneity and existence of publication bias in the study, the prevalence of depressive symptoms among nurses in chinese mainland is higher than that in many other countries. as the worldwide prevalence of depression is expected to increase over the next few decades [65] , these results could provide useful and valuable information for health decision-makers. furthermore, the nationwide investigation of depression prevalence should be performed with a standard diagnostic tool, which may be more useful for policy makers and planners. depressive symptoms among industrial workers in vietnam and correlated factors: a multi-site survey. international journal of environmental research and public health efficacy of antidepressants on measures of workplace functioning in major depressive disorder: a systematic review association between 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guideline: a systematic review tools for assessing quality and susceptibility to bias in observational studies in epidemiology: a systematic review and annotated bibliography meta-analysis of prevalence bias in meta-analysis detected by a simple, graphical test analysing data and undertaking meta-analysis cochrane handbook for systematic reviews of interventions. chichester, the cochrane collaboration conducting a meta-analysis: basics and good practices. international journal of rheumatic diseases prevalence of all-cause mortality and suicide among bariatric surgery cohorts: a meta-analysis elegant graphics for data analysis r: a language and environment for statistical computing. r foundation for statistical computing a self-report depression scale for research in the general population psychometric properties of the beck depression inventory: twenty-five years of evaluation the beck depression inventory second edition (bdi-ii): psychometric properties in icelandic student and 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cost-of-illness studies of depression: a systematic review depression and other common mental disorders-global health estimates key: cord-307263-znuqdzdp authors: sun, niuniu; shi, suling; jiao, dandan; song, runluo; ma, lili; wang, hongwei; wang, chao; wang, zhaoguo; you, yanli; liu, shuhua; wang, hongyun title: a qualitative study on the psychological experience of caregivers of covid-19 patients date: 2020-04-08 journal: am j infect control doi: 10.1016/j.ajic.2020.03.018 sha: doc_id: 307263 cord_uid: znuqdzdp background: the coronavirus disease 2019 (covid-19) is spreading rapidly, bringing pressure and challenges to nursing staff. objective: to explore the psychology of nurses caring for covid-19 patients. method: using a phenomenological approach, we enrolled 20 nurses who provided care for covid-19 patients in the first affiliated hospital of henan university of science and technology from 20 january to 10 february 2020. the interviews were conducted face-to-face or by telephone and were analysed by colaizzi's 7-step method. results: the psychological experience of nurses caring for covid-19 patients can be summarized into four themes. firstly, negative emotions present in early stage consisting of fatigue, discomfort, and helplessness was caused by high-intensity work, fear and anxiety, and concern for patients and family members. secondly, self-coping styles included psychological and life adjustment, altruistic acts, team support, and rational cognition. thirdly, we found growth under pressure, which included increased affection and gratefulness, development of professional responsibility, and self-reflection. finally, we showed that positive emotions occurred simultaneously with negative emotions. conclusions: during an epidemic outbreak, positive and negative emotions of the front-line nurses interweaved and coexisted. in the early stage, negative emotions were dominant and positive emotions appeared gradually. self-coping styles and psychological growth played an important role in maintaining mental health of nurses. the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) is a newly discovered ribonucleic acid coronavirus isolated and identified from patients with unexplained pneumonia in wuhan, china in december 2019 [1] . before it was named by the international committee of viral classification on 12 february, 2020, it was called 2019-ncov. sars-cov-2 mainly causes respiratory and digestive tract symptoms [2] , with symptoms ranging from mild self-limited disease to severe pneumonia, acute respiratory distress syndrome, septic shock, and even systemic multiple organ failure syndrome. the infection source of coronavirus disease 2019 is mainly patients with sars-cov-2 infection. asymptomatic infected patients may also become the source of infection, mainly via aerosols from the respiratory tract, but also through direct contact [3] . elderly people with underlying diseases are more likely to be infected with the virus and develop severe disease and children and infants are also at risk. at present, there are no specific drugs for this disease. the treatment and nursing mainly include antiviral and traditional chinese medicine treatment, isolation, symptomatic support, and close monitoring of disease progression [3] . since the first case of unexplained pneumonia in wuhan, 52 countries in the world have confirmed cases by 28 february according to who data, of which about 94% are in china [4] . on that day in china, there were 37,414 active confirmed cases (including 7,664 severe cases) in 31 provinces, 39,002 recovered and discharged cases, 2,835 deaths, amounting to 79,251 confirmed cases as well as 1,418 suspected cases. [5] a total of 658,587 close-proximity interactions were tracked, including 58,233 close-proximity interactions under medical observation. although china experienced sars in 2003 and h1n1 in 2009, the outbreak of covid-19 as a new infectious disease severely tested the country's public health system. in this context, medical workers, as the main force in the battle against the epidemic, bear the monumental task. unfortunately, many front-line personnel have sacrificed their own well-being and have been infected or died, which causes increasing psychological pressure. according to the chinese center for disease control and prevention, by 11 february, over 3000 health care personnel in china were suspected to be infected with sars-cov-2. among them, 1716 were confirmed cases and 5 had died [6] . previous studies have shown that during sudden natural disasters and infectious diseases, nurses will sacrifice their own needs to actively participate in the anti-epidemic work and make selfless contributions out of moral and professional responsibility [7] . at the same time, nurses would be in a state of physical and mental stress and feel isolated and helpless in the face of health threats and pressure from the high-intensity work caused by such public health emergencies [8] . previous studies have shown that when nurses are in close contact with patients with emerging infectious diseases such as sars [9] , mers-cov [10, 11] , ebola [12] , h1n1 [13] , they will suffer from loneliness, anxiety, fear, fatigue, sleep disorders, and other physical and mental health problems. studies have shown that the incidence of depression, insomnia, and post-traumatic stress among nurses involved in the treatment of sars patients was 38.5%, 37%, and 33%, respectively [14] . in a study on the psychological status of ebola patients' caregivers, 29% of respondents felt lonely and 45% received psychological counselling [15] . on the contrary, some studies also demonstrate the positive experience and growth brought by the collective anti-epidemic efforts [13, 16] . due to the sudden outbreak of the epidemic, nurses from the department of infectious diseases had to enter the negative pressure ward to care for the patients after only undergoing a brief training on covid-19. nurses from other departments were required to go through three training stages before starting nursing duties for patients with covid-19: pre-job training, adaptive training by nursing other patients in the infection department, and negative pressure ward training. this process occupied about one week. nurses who entered the negative pressure ward would work for 0.5 -3 months before being transferred to other non-anti-epidemic positions. because covid-19 is a new disease and the medical system and culture of different countries varies, further research is needed on the psychological experience of frontline nurses fighting against covid-19. currently, published studies have highlighted the disease prevalence [17] , clinical characteristics, diagnosis, and treatment [2] . some reports have paid attention to the severity of psychological problems in medical personnel [18] and the urgency of providing psychological care [19] . however, no qualitative studies have been published on the psychological experience of nurses. therefore, our study aims to understand the subjective experience of nurses participating in nursing covid-19 patients through semi-structured interviews and to analyse the data using phenomenological methods [20] , providing fundamental data for the psychological experience of nurses. our research used the colaizzi's phenomenological method to qualitatively analyse the psychological experience of nurses caring for patients with covid-19. colaizzi's phenomenological method focuses on the experience and feelings of participants and finds shared patterns rather than individual characteristics in the research subjects. this scientific approach guarantees the authenticity of the collected experience of participants to adhere to scientific standards. by using a purposeful sampling method, we selected 20 nurses caring for patients with covid-19 in the first affiliated hospital of henan university of science and technology from 20 january to 10 february 2020. the inclusion criteria included (1) nurses who entered the negative pressure ward and provided nursing care for confirmed covid-19 patients and (2) volunteers who participated in the study. the exclusion criteria were inability to conduct two or more interviews during the study period. we determined the number of required respondents by interviewing nurses who met the inclusion criteria until the data was saturated and no new topics were generated. we determined the interview outline by consulting relevant literature, seeking we communicated the purpose and significance of the study with the participant in advance and scheduled the interview time at their convenience. the interviewer possessed a master of science in nursing with experience in qualitative interview and had worked as a head nurse in the sars isolation ward and was experienced in epidemic prevention and control. with 20 years of clinical nursing, teaching, and scientific research experience and 5 years of psychological consultation experience, the researcher obtained a second level psychological consultant certificate (the highest level in china) issued by the ministry of human resources and social security of china. therefore, the researcher was able to carry out this research independently. the one-to-one interviews were conducted in a separate room in a quiet manner without interruptions. the interviews were recorded, which were kept strictly confidential. the interviews took 40 -60 minutes per person. if the participant exhibited emotional problems during the interview, adequate psychological intervention was provided to prevent secondary psychological harm. the study subjects were allowed to withdraw consent at any time. the researchers remained neutral in collecting the data and established good relationships with the participants. we used techniques such as unconditional acceptance, active listening, and clarification to promote the authenticity of the data and to avoid bias. for each participant, at least 1 -2 face-to-face interviews and 1 -2 telephone interviews were arranged as needed to ensure data collection at multiple time points. within 24 hours of each interview, the recording was transcribed and analysed by colaizzi's phenomenological analysis method. two researchers independently reviewed the interview materials, summarized and extracted meaningful statements, and formulated the themes present. conflicting opinions on the contents of a theme were discussed and resolved by a research group composed of a master of nursing, a doctor of nursing, and two chief nurses. this study was reviewed and approved by the ethics committee of the first affiliated hospital of henan university of science and technology (ethics code: 2020-03-b001). all participants signed informed consent. the authors promise that there will be no academic misconduct such as plagiarism, data fabrication, falsification, and repeated publication. in our study, we enrolled three males and 17 females between 25 to 49 with an average age of 30.60 ± 6.12. the working experience ranged from 1 to 28 years with an average of 5.85 ± 6.43. all nurses possessed a bachelor's degree. seven nurses were married with children, five were married without children, and eight were unmarried without children. there were 17 general nurses and 3 head nurses. table 1 outlines the baseline characteristics of the participants. we explored the psychological experience of caregivers of patients with covid-19 using phenomenological methods. we found four themes that are summarized below. exemplar quotes for each theme are displayed in table 2 . iv. bidirectional concerns with their own family members "i am worried that i will infect my children" "my partner is very worried that i will be infected." "i am the only child and my mother cries every day and fears that i will be infected, and i worry more about them... "i feel good using mindfulness-based stress reduction." ii. life adjustment "i feel sleep is the best stress relief, i just want to sleep." "i think eating and drinking will increase my resistance. i don't lose weight now; i eat a lot." "i am exercising less than before because the heavy workload is also exercise and the right amount is the best." iii. taking the initiative to be altruistic and seeking team support by "huddling together for warmth" "everyone is very welcoming and friendly. experienced colleagues will take the initiative to teach me. i also take the initiative to teach new colleagues." "everyone is willing to do more work so colleagues can rest more. colleagues are particularly united." "if someone is uncomfortable, everyone will take care of him and work for him." all study subjects experienced a significant amount of negative emotions in the first week, especially in the period from the first pre-job training to the first time they entered the negative pressure ward. as the number of patients continued to rise, the workload of all nurses (n = 20) increased proportionally with 1.5 -2 times normal work hours and workloads. nurses were required to conserve protective clothing by reducing the number of times they wear it since protective equipment was in short supply, resulting in fatigue and discomfort. failing to meet physical and psychological needs brought a sense of helplessness. all participants (n = 20) expressed their fears, which peaked when they entered the negative pressure ward for the first time, which then gradually declined. similarly, outsourced support nurses (n = 12) also experienced a strong sense of fear when they first entered the department of infectious diseases, but gradually eased as their work adjusted. most nurses (n = 11) expressed concerns about patients in an isolated environment with relatively few caregivers and many patients. they were mainly concerned about the unknown conditions of the patients, severe emergencies, and the patients' psychological state. as with any emerging infectious disease, work processes and nursing routines need to be explored while working. most of the participants (n = 15) felt different levels of anxiety. under the challenges of changes in working environment and team members, 50% of nurses said they felt anxious. most nurses in this study were between 25 and 40 years old. some came from a single-child family and have elderly and children in their family. all nurses expressed concern about the impact of the outbreak on the health of their families. they also said that their families were also worried about their health. those who did not live with their parents (n = 9) chose to hide the fact that they work in isolation ward from their parents. after separation from their families, they felt helpless and guilty. the nurses (n = 4) with the elderly and children at home were particularly worried of their families. all nurses (n = 20) activated psychological defence mechanisms, such as speculation, isolation, depression, distraction, self-consciousness, humour, rationalization, etc. nurses used existing knowledge and new knowledge of psychological decompression communicated by colleagues or the internet to adjust themselves and actively or passively used psychological techniques, such as writing diary and letters, breathing relaxation, mindfulness, music meditation, and emotional expression and venting. most nurses (n = 14) chose to adjust their sleep when stressed by work. some nurses will increase their food intake and some will exercise regularly and maintain physical strength to ensure normal work ability. during times of stress, nurses (n = 13) cared and helped each other and showed support for stress relief. most nurses said that they felt the collective power and the team cohesion was stronger. some nurses (n = 9) took the initiative to process information and use medical knowledge for analysis. their attitudes were calm and rational. nurses also took the initiative to compare situations, find favourable information, and encourage themselves. all participants (n = 20) mentioned their gratitude for the support from colleagues, relatives, friends, and all sectors of society. they also realised the importance of health and family. most nurses (n = 15) said that they would work and live with a state of appreciation and gratitude in the future. more than 70% of the participants mentioned that professional responsibility prompted them to participate in the mission to contain the epidemic. most nurses (n = 9) reviewed the value of the nursing profession and identified more with their chosen profession. half of the nurses (n = 10) conveyed that although the epidemic prevention work was hard, they started to self-reflect. for example, they strengthened their will, discovered their potential, and increased their courage to face life. although most nurses had negative emotions such as fear, anxiety, and worry, positive emotions appear synchronously or progressively. after a week, positive emotions prevailed in 70% of the nurses. while fear and anxiety were brought on by the epidemic, nurses also evaluated the epidemic prevention and control progress and felt confidence in the medical capability of the government and its subunits. at the same time, they felt confidence in self-prevention and control ability after training and practice. all nurses actively accepted anti-epidemic tasks and most (n = 11) volunteered. most nurses (n = 16) showed calmness when receiving these tasks. although, as mentioned earlier, there were negative emotions such as fear and anxiety in the early stages, these subsided after the pre-job training and environmental adaptation. most nurses (n = 14) said that after entering the negative pressure ward to care for patients, they felt calm and relaxed. despite difficult conditions and challenges in the fight against the disease, 60% of the nurses reported feeling happy. firstly, the nurses felt the patient's goodwill, respect, active cooperation, and gratitude. secondly, family and team support brought happiness. contact with family was a key factor in our study. in addition, the hospital has a reward and welfare system in place to support and motivate nurses. the encouragement of colleagues also brought happiness to nurses. other forms of social support were important to the nurses' feeling of appreciation. this study explored the psychological experience of caregivers of patients with covid-19 using phenomenological methods and we summarised our findings into four themes: significant amounts of negative emotions at an early stage, self-coping styles, growth under stress, and positive emotions that occur simultaneously or progressively with negative emotions. the nurses caring for covid-19 patients felt extreme physical fatigue and discomfort caused by the outbreak, intense work, large number of patients, and lack of protective materials, which was consistent with the studies on the outbreak of mers-cov [10, 21] and ebola [15] . in this study, nurses' concerns about family members were consistent with the study of lee et al. [22] , especially those with elderly and children in the family. the physical exhaustion, psychological helplessness, health threat, lack of knowledge, and interpersonal unfamiliarity under the threat of epidemic disease led to a large number of negative emotions such as fear, anxiety, and helplessness, which have been reported by several studies [8, 10, 11] . we showed that nurses' negative emotions are more pronounced in the first week when entering pre-job training and negative pressure ward for the first time. therefore, early psychological intervention is particularly important to nurses in an epidemic. it is best to conduct stress assessment and screening of nurses immediately after receiving the epidemic prevention tasks and to provide professional, flexible, and continuous psychological intervention [15, 22] to promote emotional release and improve nurses' mental health [23] . at the same time, it is important to establish early support systems [9] , such as adequate supplies of protective materials, reasonable allocation of human resources, elderly and infant care services for nurses' families, pre-job training, and interpersonal interaction among nurses to facilitate nurses' adaptation to the anti-epidemic tasks. it is known that coping style, cognitive evaluation, and social support are all mediators of stress. studies have shown that psychological adaptation and social support play an intermediary role in psychological rehabilitation under outbreak stress [24] . pressure of the epidemic may prompt nurses to use their medical and psychological knowledge to actively or passively make psychological adjustments. in our study, nurses adopted avoidance, isolation, speculation, humour, self-consciousness, and other psychological defences to psychologically adjust to the situation. it has been demonstrated that all coping measures under the epidemic disaster can alleviate stress and promote mental health [25] . participants adopted breathing relaxation, music, meditation, mindfulness, and other ways to reduce stress, which was consistent with the study of nurses in the sars wards that adopted multiple ways to deal with stress [22, 26] . in addition, our results showed active altruism and greater team solidarity, reflecting the study of kim et al. [10] and shih et al. [27] . generally, nurses can adjust their cognitive rationality to adapt to the epidemic, which may also be related to health care professionals' rich medical knowledge and more rational and positive attitude [28] . according to american psychologist richard lazarus' stress and coping model, whether the stressors are effective or not depends mainly on the process of cognitive evaluation and coping. when stressed, nurses constantly adjust cognitive evaluation through professional knowledge to promote self-psychological balance, take the initiative to be altruistic, seek team support [13] , take the initiative to reduce stress, adjust sleep, diet and exercise to adapt to internal and external environment changes, and prevent injuries caused by stress, which has positive significance for mental health [23] . many studies have shown that epidemic outbreaks can cause psychological trauma for caregivers [14, 18, 19] . in contrast, the results of our study demonstrate that most nurses grew psychologically under pressure. nurses partook in self-reflection of their own values and found positive forces such as expressing more appreciation for health and family and gratitude for social support, which was consistent with study of shih et al. [27] . the sense of responsibility brought by professional ethics in an epidemic [7, 11] encouraged nurses to actively participate in anti-epidemic tasks and boosted their professional identity and pride, in line with previous reports [16] . therefore, actively guiding and inspiring nurses to realise their own psychological growth during an epidemic may play a positive role in psychological adjustment. our finding of the existence of positive emotions in our nurses such as confidence, calmness, relaxation, and happiness, which simultaneously or gradually appeared with negative emotions, was in contrast to the results several studies that describe only the presence of a large amount of negative emotions during outbreak stress [18, 19] . however, other studies report similar findings [13, 16, 21] . in the case of an outbreak, confidence in safety, early training, and confidence in professional skills are all factors that promote medical staff's willingness to actively participate in anti-epidemic work [29] . physical and mental rewards to nurses from work units are also important supporting factors [11] . our participants generally believed that positive emotions were related to the multi-dimensional support of patients, family members, team members, government, social groups etc. therefore, social support is critical for nurses in the fight against epidemics [14, 16, 21] . the calmness and ease of most nurses in this study after starting the anti-epidemic tasks is rarely mentioned in other studies and may be related to nurses' gradual adaptation, acceptance, positive response, and personal growth [14, 26] . studies have shown that positive emotions play an important role in the recovery and adjustment of psychological trauma [30] . optimism has a protective effect on psychological trauma under disasters and can promote the psychological rehabilitation of post-traumatic stress disorder [31] . therefore, in the process of psychological intervention of nurses in an epidemic, strengthening multi-dimensional social support, adjusting cognitive evaluation, guiding positive coping styles, and stimulating positive emotions are crucial to promote the psychological health of nurses. most existing qualitative studies are retrospective studies. in contrast, this study established a good relationship of consultation and visit with the participants in an early stage when the participants just accepted the anti-epidemic tasks. we collected the psychological experience data of the participants over time through multiple interviews. this led to a deep understanding of their work experience, resulting in comprehensive and authentic data. diverging from the results of many studies on the experience of negative emotions during outbreak stress, we found that positive emotions coexist with negative emotions, as well as psychological adjustment and growth under pressure, and preliminarily discussed its impact on nurses' mental health. due to the characteristics of qualitative research, the sample size of this study was limited. firstly, most of the participants were nurses, including three nursing managers. the experiences of other health care workers and administrators besides nurses need to be further explored. secondly, due to the nature of outbreak prevention and control, we were unable to conduct focus group interviews and did not collect data from multiple centres in order to avoid potential cross-infection. in addition, this study was a short-term study. long-term experience of the research subjects would be a valuable avenue to explore in the future. this study provided a comprehensive and in-depth understanding of the psychological experience of caregivers of patients with covid-19 through a phenomenological approach. we found that during the epidemic, positive and negative emotions of frontline nurses against the epidemic interweave and coexist. in the early days, negative emotions were dominant and positive emotions appeared 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during an influenza pandemic: a systemat ic review and meta-analysis the regulatory power of posit ive emot ions in stress: a temporal funct ional approach effects of optimism on recovery and mental healt h after a tornado outbreak key: cord-334956-pi8ifpcy authors: chan, raymond javan; emery, jon; cuff, katharine; teleni, laisa; simonsen, camilla; turner, jane; janda, monika; mckavanagh, daniel; jones, lee; mckinnell, emma; gosper, melissa; ryan, juanita; joseph, ria; crowe, bethany; harvey, jennifer; ryan, marissa; carrington, christine; nund, rebecca; crichton, megan; mcphail, steven title: implementing a nurse-enabled, integrated, shared-care model involving specialists and general practitioners in breast cancer post-treatment follow-up: a study protocol for a phase ii randomised controlled trial (the eminent trial) date: 2020-10-15 journal: trials doi: 10.1186/s13063-020-04740-1 sha: doc_id: 334956 cord_uid: pi8ifpcy background: due to advances in early detection and cancer treatment, 5-year relative survival rates for early breast cancer surpass 90% in developed nations. there is increasing focus on promotion of wellness in survivorship and active approaches to reducing morbidity related to treatment; however, current models of follow-up care are heavily reliant on hospital-based specialist-led care. this study aims to test the feasibility of the eminent intervention for implementing an integrated, shared-care model involving both cancer centre specialists and community-based general practitioners for early breast cancer post-treatment follow-up. methods: we describe a protocol for a phase ii, randomised controlled trial with two parallel arms and 1:1 allocation. a total of 60 patients with early-stage breast cancer will be randomised to usual, specialist-led, follow-up care (as determined by the treating surgeons, medical oncologists, and radiation oncologists) or shared follow-up care intervention (i.e. eminent). eminent is a nurse-enabled, pre-specified shared-care pathway with follow-up responsibilities divided between cancer centre specialists (i.e. surgeons and oncologists) and general practitioners. the primary outcome is health-related quality of life as measured by the functional assessment of cancer therapy—breast cancer. secondary outcomes include patient experience, acceptance, and satisfaction of care; dietary, physical activity, and sedentary behaviours; financial toxicity; adherence; health resource utilisation; and adverse events. discussion: the trial is designed to identify the barriers to implementing a shared-care model for breast cancer survivors following treatment. results of this study will inform a definitive trial testing the effects of shared-care model on health-related quality of life of breast cancer survivors, as well as its ability to alleviate the growing demands on the healthcare system. trial registration: australia and new zealand clinical trials registry actrn12619001594112. registered on 19 november 2019 discussion: the trial is designed to identify the barriers to implementing a shared-care model for breast cancer survivors following treatment. results of this study will inform a definitive trial testing the effects of shared-care model on health-related quality of life of breast cancer survivors, as well as its ability to alleviate the growing demands on the healthcare system. the order of the items has been modified to group similar items (see http://www.equator-network.org/reporting-guidelines/spirit-2013-statement-defining-standardprotocol-items-for-clinical-trials/). in australia, breast cancer is the most common cancer in females with an estimated 19,535 new cases annually [1] . with advances in early detection and cancer treatment, such as surgery, post-operative radiotherapy, and pre-or post-operative systemic therapies including cytotoxic chemo-, endocrine, and anti-her2 antibody therapies, the 5-year relative survival rate for breast cancer is estimated at 91% [2, 3] . consequently, in 2018, there were at least 200,000 breast cancer survivors living in australia [4] . despite good survival outcomes, breast cancer survivors require supportive care including prevention of cancer recurrence, surveillance for secondary or new primary cancer, and management of a range of long-term bio-psycho-social effects from their cancer diagnosis and treatment. in addition, many cancer survivors need management of comorbidities as they are 2.5 times more likely to develop mental and behavioural problems and almost 1.5 times more likely to develop musculoskeletal conditions, circulatory conditions, and endocrine system disorders compared with non-cancer patients [5] . these health concerns highlight the importance of a comprehensive, well-integrated, patient-centred model of care for people following completion of breast cancer treatment. the current models of post-treatment care in australia are mostly hospital-based and specialist-driven and focus on surveillance for disease recurrence, rather than the holistic care needs of cancer patients. this model of followup care limits the integration between specialist institutions and general practitioners (gps), overloads the specialist system, and is unsustainable to meet the demands of the ever-growing population of cancer survivors. specialist-based follow-up carries the burdens of travel and out-of-pocket costs such as those for parking. those in non-metropolitan areas face more major disruptions to engage in specialist-based follow-up. therefore, there is a strong case for an integrated, shared post-treatment follow-up care model for breast cancer survivors that involves both cancer specialists as well as care provided in the community by gps. such a shared-care model is consistent with cancer australia statements [6] , the optimal care pathway for breast cancer [7] , and international guidelines [8] . in addition, the literature suggests that such a model is feasible, acceptable, safe, and more cost effective and patient-centred than current models used within australia [9, 10] . despite the promising evidence base, a shared followup care model in which specialists in the acute cancer care setting and gps collaborate is not routinely implemented across australia and many developed nations. barriers to such shared care include the lack of a coordination between multiple providers, lack of patient and provider knowledge about the benefits of shared care and how to implement it, insufficient or delayed communication between cancer specialists and gps, and lack of awareness of available support such as funding models, tools, and resources [11, 12] . these barriers could be overcome if a specialist cancer nurse advises stakeholders (patient and gps) of the benefits of sharedcare, facilitates effective and timely care coordination, and acts as the conduit between the specialist cancer multidisciplinary team and the gps at key transition time points, such as completion of definitive primary and adjuvant treatment [13] . the objective of the study is to test the feasibility of a prospective, pragmatic randomised controlled trial (rct) of the eminent intervention-a nurse-enabled, integrated, shared-care model involving cancer specialists and gps for early breast cancer post-treatment follow-up. this phase ii pilot rct aims to assess the feasibility of a larger definitive clinical trial. outcome data will be collected at four timepoints (or five if booster nurse clinic is attended): (t 1 ) baseline (at enrolment ± prior to booster nurse clinic, if relevant), (t 2 ) 3 months, (t 3 ) 6 months, and (t 4 ) 12 months. this study is conducted in a large, australian metropolitan tertiary teaching hospital and general practices. the study population consists of patients with earlystage breast cancer (i.e. no-distant metastases) or ductal carcinoma in situ (dcis). patients will be eligible to participate from 2 weeks prior to completion of definitive treatment (surgery or adjuvant chemotherapy) and up to 18 months after completion of treatment. patients meeting all of the following criteria are eligible for inclusion: diagnosis of curable, early breast cancer; receiving care at the princess alexandra hospital; able to speak and read english; 18 years of age or older; ambulatory at the time of recruitment; eastern cooperative oncology group (ecog) performance status 0 or 1; able to nominate a gp or gp clinic to be involved in their follow-up; and access to a telephone. patients meeting any of the following criteria are excluded: presence of severe mental, cognitive, or physical conditions that would limit the patient's ability to provide informed consent. potential participants are identified by the research nurse or treating clinician during multidisciplinary team meetings. participants are approached by their treating clinicians to gauge their interest in the study and gain verbal consent to being approached by the research team. participants are then contacted by the research nurse, screened for eligibility, and provided with study information, and after a time of reflection (at least 24 h), they sign the consent form with the research nurse. table 3 outlines the different phases of the study and data collection. consent to access medicare and pharmaceutical benefits scheme (pbs) data on service use that qualifies under the medicare benefits schedule (mbs) will be obtained, including relevant claims details (date of service, medicare item number, and description) and costs details. survivorship care of breast cancer survivors following completion of treatment is an important issue, especially in light of improving survival rates [2] . the shared-care model between specialists and gps focusses on the complex care needs of breast cancer survivors, rather than solely on disease recurrence, and may influence patient health outcomes and service outcomes [10] . arm 1 the control group will receive usual follow-up care supplemented with a survivorship booklet on living well after cancer published by cancer council australia [14] . the usual care follow-up arrangement is a specialist-led model as determined by the treating surgeon, medical oncologist, and radiation oncologist. this specialist-led follow-up care is not standardised and with follow-up activities and schedules depending on individual patient needs and the discretion of the treating clinicians. eminent is a multi-faceted intervention that includes a pre-specified shared-care pathway for post-treatment follow-up. the design of the eminent intervention is informed by a number of cancer australia statements, the optimal care pathway [15] , the self-efficacy model [16, 17] , the capabilities for supporting prevention and chronic condition self-management framework [18] , and our extensive pilot work including a systematic review [19] and observational studies [20] [21] [22] [23] . table 1 outlines the active ingredients of the eminent intervention. after enrolment, participants who have completed chemotherapy and radiotherapy or those who will receive aromatase inhibitor will participate in a 20-min telehealth cancer pharmacist consultation for medication reconciliation and education prior to specialist nurse consultation. a 30-60-min consultation with a specialist cancer nurse is then conducted to provide a treatment summary, the shared follow-up care appointment schedule, and survivorship patient education (including the survivorship booklet on living well after cancer published by cancer council australia [14] ) and to codevelop a draft survivorship care plan (scp). the scp includes up to three smart (specific, measurable, achievable, realistic, and timely) goals that are developed by the nurse and patient in partnership using motivational interviewing and self-efficacy techniques. due to the recent covid-19 pandemic, where there are delays of 3-18 months before gp involvement, a second 'booster' specialist cancer nurse consultation is offered to patients to update the scp. the treatment summary and draft scp is provided to the gp. within 4 weeks of the specialist cancer nurse consultation, a 5-30-min case conference between the specialist cancer nurse and the patient's nominated gp is completed to communicate the treatment summary and shared follow-up care schedule and to finalise the scp and negotiate the gp's role in facilitating the scp goals. the gp may propose changes or express if they are not willing to take part in specific care activities outlined in the scp. the finalised scp is then filed in the patient's medical records and provided to the patient and the gp. the shared, follow-up care schedule consists of 6monthly patient appointments with a cancer centre specialist and annual appointments with the gp for 2 years post-diagnosis. following this, the schedule consists of alternating 6 monthly appointments with a cancer centre specialist and gp for up to 5 years post-diagnosis. at 5 years post-diagnosis, patients are discharged to the care of the gp, as per usual care. the gp appointments will focus on reviewing the scp; promoting general health; primary prevention, screening, and management of comorbidities; psychosocial health; cancer treatment toxicities; cancer-related symptoms; chronic disease management planning; and allied health referrals. the gp has direct telephone access to the specialist cancer nurse in case of concerns or escalation for acute care review. the cancer centre specialist appointments focus on surveillance activities such as physical examination and imaging (i.e. annual mammogram). the presence of any of the following criteria constitutes cause for the withdrawal of the participant: altered mental capacity resulting in inability to provide continuing informed consent, notification from treating oncologist and/or gp that the participant is not deemed to have the capacity to consent, and recurrence or progressive disease or death. fidelity of the intervention will be assessed using the framework for behavioural interventions recommended by the national institute of health (nih) [24, 25] as outlined in table 2 . no concomitant care or intervention is prohibited during the trial. there is no ancillary or post-trial care for participants in this trial. however, it is expected that the scp generated will have the value of informing longer term updates of the scp and future survivorship care. the feasibility outcomes are recruitment and acceptability of the intervention. the primary endpoint is healthrelated quality of life (hrqol) as measured by functional assessment of cancer therapy-breast cancer (fact-b) [26] at baseline, 3, 6, and 12 months post-enrollment. the 37-item fact-b is a valid and reliable tool for use in cancer survivors undergoing as well as beyond treatment and has been demonstrated to be sensitive to changes over time [27] . a total score as well as scores for each of the five subscales (physical, social/family, emotional, functional wellbeing, additional breast cancer concerns) are calculated, where higher scores indicate higher quality of life. fact-b captures key domains of hrqol and key symptoms that are relevant to the study population and sensitive to the eminent intervention. additional outcomes include a range of patientreported secondary endpoints, and process outcomes related to implementation as shown in table 3 . participants of the intervention group, as well as their nominated carer, breast cancer nurses, gps, and other healthcare providers including other nurses, and hospital-and community-based rehabilitation providers will be invited to participate in a semi-structured interview. open ended questions (online supplementary material 1) will explore key factors that facilitate or hinder the implementation of the eminent intervention. in this pilot study, we will recruit 30 patients per arm in order to provide initial insights into the intervention feasibility and protocol as well as preliminary effect size estimates. the aim of this study is not hypothesis testing, and the power level is therefore not a valid consideration for sample size [28, 29] . the sample size for this study (n = 60) falls within the range of sample size recommendations for pilot studies of this nature [28, 29] . participants are recruited through the hospital cancer outpatient clinics and therapy units. research nurses and designated health professionals identify potential participants. potential participants are reviewed by a member of the treating team and asked if they would like to be approached by a research nurse or designated table 2 intervention fidelity strategies (adapted) training providers specialist cancer nurses will be trained to standardise the delivery of the intervention to study participants. training includes provision of study manual containing • generic study information: standard operating procedures, study overview, reporting and documentation guidelines, communication flowchart, rationale for the study treatment, completion of survivorship care plan, self-management goal setting, and health coaching • specialist cancer nurse-specific information: job description, intervention protocol, quality assurance, and monitoring an 8-h training program will be delivered by experts in cancer survivorship and motivational interviewing. the program includes the national cancer nursing education (edcan) learning module on survivorship, related literature, didactic presentations, and roleplay covering: basic concepts of quality cancer survivorship care, components of a high-quality treatment summary and survivorship care plan; provision of self-management support (including collaborative goal setting; motivational interviewing); and mbs item numbers that facilitate the proposed model of care. intervention procedures are monitored through completion of intervention component checklists to ensure that the intervention is delivered as intended. intervention checklists are completed during clinics and gp case conferences to track protocol deviations across specialist cancer nurses and study arms. the intervention fidelity is closely monitored and discussed during the weekly 30-min meeting for the first 3 months of the trial between the specialist cancer nurses, research nurses, and investigators. minimising contamination between conditions by training interventionists to address participant questions about randomisation and their assigned condition using non-biased explanations. the scp serves as a resource for a participant to understand and refer to whenever they are unsure of follow-up schedule and collaborative goal setting. enactment of treatment skills enactment of treatment skills includes processes to monitor and improve participant ability to perform treatmentrelated behavioural skills and cognitive strategies in relevant real-life settings as intended. this goal will be achieved by ensuring participants are aware of the follow-up schedules and responsibilities of all health professionals, ensuring participants will have a copy of the completed scp including all care responsibilities and goals set for the individual, and checking in with participants once in the first week into the model, then monthly/bimonthly until the end of the trial period as resources allow. health professionals for consent to participate in the study. participants are given as much time as possible to consider their participation and are encouraged to take the information away and discuss participation in the trial with family, friends, and their gp if they so wish to. participants are also encouraged to ask the research nurses, their treating doctors, or nursing staff any questions in relation to their participation. computer-generated random numbers are used to allocate participants in a 1:1 ratio by a researcher not involved in recruitment, intervention implementation, or data collection. randomisation is blocked using random permuted blocks of eight and four to ensure that the groups are balanced periodically within stratification groups. stratification groups include patients who have received (1) surgery only, (2) surgery and radiation only, (3) surgery and chemotherapy ± radiation and are her2 negative, and (4) surgery and chemotherapy ± radiation and are her2 positive. these stratification groups were chosen, with clinician input, to allow learnings for patients with different treatment pathways with different follow-up needs to inform the future definitive trial. allocation sequence is implemented using sequentially numbered opaque, sealed envelopes. envelopes are only accessed by the research nurse to randomise the patient once recruitment and baseline data has been collected. eligibility screen x informed consent x allocation x health-related quality of life x x x x allocation sequence is generated by a researcher not involved in recruitment or data collection. patients are enrolled by a research nurse who collects baseline data prior to randomisation. enrolling nurses assign participants to the intervention after baseline data collection. who will be blinded {17a} after assignment to the intervention, only outcome assessors are blinded to group allocation. where participants opt to complete their data collection by phone, they are advised not to reveal their group allocation to the outcome assessor. due to the nature of the intervention, no participants or treating clinicians are blinded. no unblinding procedures required as only outcome assessors and data analysts are blinded. plans for assessment and collection of outcomes {18a} patient-reported outcomes are self-administered using online surveys or administered in person or via telephone with an outcome assessor trained in the administration of the study instruments. the description of study instruments is listed in table 3 . the primary outcome is hrqol as measured by functional assessment of cancer therapy-breast cancer (fact-b) [26] . this validated and reliable instrument is well-used in cancer survivors undergoing and beyond treatment [27] , and it captures key domains of hrqol and key symptoms that are relevant to the eminent intervention. the secondary outcomes are listed below: patient experience of care as measured by the picker patient experience 15 (ppe-15) questionnaire [30] . the ppe-15 highlights aspects of care that need improvement to monitor performance and care. it consists of 15 questions distributed to seven dimensions of care: respect, coordination, information/communication/education, physical comfort, emotional support, involvement of relatives, and transitions to community [31] . dietary behaviours, specifically usual vegetable intake and usual fruit intake, as measured by two short dietary questions from the national nutrition survey [32] , which have been validated in the australian population. both questions discriminate between groups with significantly different fruit and vegetable intakes. in administering these questions, information about which foods are included as vegetables and fruits is provided and serve sizes are described. physical activity as measured by the active australia survey [33] which is designed to measure participation in leisure-time physical activity, and a single item from the international physical activity questionnaire [34] will be used to measure sedentary behaviours. financial toxicity as measured by the 11-item comprehensive score for financial toxicity (cost)-functional assessment of chronic illness therapy (facit) tool [35] . this tool is valid and reliable in measuring financial toxicity in patients with cancer [36] . adherence to clinical assessments including annual mammography, annual physical examination, and endocrine therapy as measured by hospital records. emergency presentations and hospitalizations as recorded from hospital records. satisfaction of care as measured by a 0-10 numerical analogue scale with 0 being the least satisfied and 10 being the most satisfied, supplemented with short, structured qualitative questions. process outcomes, including completion of intervention components, as measured by completion of intervention materials such as scps and checklists, number and length of clinical encounters recorded from mbs data and hospital records, and barriers and facilitators to implementation as explored through semi-structured interviews with patient participants, their nominated carer, breast cancer nurses, gps, and other healthcare providers including other nurses, and hospital-and community-based rehabilitation providers. health resource utilisation assessing both health service use and participant out-of-pocket costs including mbs and pbs administrative data sets. these data inform participants' utilisation of services that qualify under the mbs as well as medications dispensed under the pbs. it is planned that the economic evaluation may be reported separately from the main trial. participants who deviate from the protocol are not withdrawn from the trial. participants who withdraw from the trial nominate the degree to which they withdraw (i.e. whether they withdraw from active data collection ± passive data collection such as mbs/pbs data). all participant characteristic and outcome data are entered directly into redcap (research electronic data capture -vanderbilt university, hosted at queensland university of technology) by the research nurse ± the participants through self-administered online survey. to ensure data quality, the database is designed with branching logic, data validation, and range checks for data values, where possible. all source data, clinical records, and laboratory data relating to the study will be archived at the clinical site as appropriate for 15 years after the completion of the study. all data will be available for retrospective review or audit. no study document will be destroyed without prior written agreement between the responsible organisation and the investigator. if the investigator wishes to assign the study records to another party or move them to another location, he/she must notify the responsible organisation in writing of the new responsible person and/ or the new location. data on potential participants is recorded, including reasons for ineligibility or refusal to participate. participants are only identified by a unique participant study number on the case report forms and other study documents. other study-related documents (e.g. signed consent form, participant log) are kept in strict confidence by the investigator. participants are informed that data is held on file by the responsible organisations and that these data may be viewed by staff including the study project manager and by external auditors on behalf of the responsible organisations and appropriate regulatory authorities (to include reviewing human research ethics committee (hrec) and the research governance officers). participants will be identified in publication and conference presentation reports only in aggregated form. all participant data will be held in strict confidence. plans for collection, laboratory evaluation, and storage of biological specimens for genetic or molecular analysis in this trial/future use {33} not applicable. there is no collection of biological specimens in the current trial. descriptive statistics will be used to report on feasibility and process-related elements (e.g. recruitment, intervention, retention rates) as well as clinical and resource outcomes. preliminary effect size estimates for patient and resource use outcomes will be calculated following intention-to-treat principles using generalised linear mixed models. the distribution of the mixed models will be chosen as appropriate for the data, for example, a linear model for scale data or a poisson for count data. models will be adjusted for variables used in stratification of the randomisation process. residuals of all models will be examined for statistical assumptions using descriptive statistics and plots. not applicable. no interim analysis is planned. all qualitative interviews with participants assigned to the eminent intervention are audio-recorded and transcribed verbatim for analysis guided by the consolidated framework for implementation research [24] . methods in analysis to handle protocol non-adherence and any statistical methods to handle missing data {20c} preliminary effect size estimates for patient and resource use outcomes will be calculated following intention-totreat principles using generalised linear mixed models. patterns of missing data will be examined using chisquare and t tests. missing data for the outcomes will be accounted for by using mixed models allowing the use of each available case by computing maximum likelihood estimates. plans to give access to the full protocol, participant leveldata, and statistical code {31c} not applicable. there are no plans for granting public access of the full protocol, participant-level dataset, or statistical code. composition of the coordinating centre and trial steering committee {5d} the chief investigators are the trial steering committee that will provide all governance to the conduct of the study. composition of the data monitoring committee, its role, and reporting structure {21a} not applicable. there is no data monitoring committee established for this pilot trial. an adverse event (ae) is any event, side effect, or other untoward medical occurrences that occur in conjunction with the use of the study intervention in humans, whether or not considered to have a causal relationship to the interventions. an ae can, therefore, be any unfavourable and unintended sign (that could include a clinically significant abnormal laboratory finding), symptom, or disease temporally associated with the use of the study intervention, whether or not considered related to the intervention. conditions recognised as being excluded from ae reporting are as follows: any event, side effect, or other medical occurrences that are anticipated because of the normal course of treatment (standard care). there are no known side effects/adverse events associated with the proposed model of care intervention [9] . due to the nature of this intervention, there will be no reporting of ae. there are no plans for auditing trial conduct beyond the independent research governance requirements and annual reporting to the hrec. plans for communicating important protocol amendments to relevant parties (e.g. trial participants, ethical committees) {25} all agreed protocol amendments are clearly recorded on a protocol amendment form and are signed and dated by the original protocol approving signatories. all protocol amendments will be submitted to the institutional hrec for approval before implementation. the only exception will be when the amendment is necessary to eliminate an immediate hazard to the trial participants. in this case, the necessary action will be taken first, with the relevant protocol amendment following shortly thereafter. once hrec approval has been granted, investigators and the anzctr will be updated. it is intended that the findings from this trial will be disseminated at academic and professional conferences and via a manuscript submission to a peer-reviewed journal. participants will be identified in such reports only in aggregate or by study identification number, gender, and age. there are no publication restrictions. despite the strong case for a shared, follow-up care model for breast cancer survivors involving cancer specialists and gps, barriers to shared care mean that it is not routinely implemented across australia. these include the need for coordination across multiple providers, the need for improved patient and provider knowledge about the benefits of shared care and how to implement it, insufficient or delayed communication between cancer specialists and gps, and lack of awareness of available support such as funding models, tools, and resources [11, 12] . the current study aims to address these barriers using a specialist cancer nurse to advise stakeholders of the benefits of shared care (patient and gps), facilitate effective and timely care coordination, and act as the conduit between the specialist cancer multidisciplinary team and the gps. practical issues for this trial include estimating the time required to coordinate the trial across multiple providers including engaging gps and fidelity with the intervention components. the proposed study will provide important information on the feasibility of a definitive phase 3 trial for implementing a nurseenabled, integrated, shared-care model involving cancer specialists and gps for early breast cancer posttreatment follow-up. the information collected through the trial, qualitative interviews, and economic evaluations are crucial in guiding the development of such a trial. the protocol published here is version 2.0 dated 24 march 2020. the trial began recruitment on 3 december 2019 and is expected to continue until 20 november 2021. trial registration: australia and new zealand clinical trials registry, actrn12619001594112. registered on 19 november 2019, https://www.anzctr.org.au/trial/ registration/trialreview.aspx?id=378690&isreview=true. responsible for delivering the pharmacist consult. all authors have provided input and have read and approved the final manuscript. this study is funded by 2019 metro south health research support scheme project grant (funded by the metro south study, education and research trust account (serta)). the funding body had no role in the design of the study and will not have a role in the collection, analysis, and interpretation of data or in writing the manuscript. there are no limitations on investigator access to the trial dataset. the datasets generated and/or analysed during the current study are not going to be made publicly available but will be made available from the corresponding author on reasonable request. this study is approved by the metro south hospital and health services human research ethics committee (hrec/2019/qms/51956). written informed consent will be obtained from all participants. not applicable. no details, images, or videos relating to an individual person will be published, as all data will be presented in aggregate. australian institute of health and welfare. cancer data in australia. canberra: aihw australian institute of health and welfare australian institute of health and welfare. breastscreen australia monitoring report 2014-15 australian institute of health and welfare. cancer compendium: information and trends by cancer type comorbidity, physical and mental health among cancer patients and survivors: an australian population-based study cancer australia statement -influencing best practice in breast cancer. surry hills: cancer australia victorian department of health and human services of clinical oncology breast cancer survivorship care guideline randomized trial of long-term follow-up for early-stage breast cancer: a comparison of family physician versus specialist care a new model supporting best practice follow-up care for early breast cancer in australia: shared follow-up care for early breast cancer adult cancer survivors discuss follow-up in primary care: 'not what i want, but maybe what i need oncologists' perceived barriers to an expanded role for primary care in breast cancer survivorship care cancer nurses can bridge the gap between the specialist cancer care and primary care settings to facilitate shared-care models living well after cancer. a guide for people with cancer, their families and friends optimal care pathway for women with breast cancer national inst of mental health. prentice-hall series in social learning theory. social foundations of thought and action: a social cognitive theory cognitive processes mediating behavioral change capabilities for supporting prevention and chronic condition self-management. canberra: department of health and ageing and flinders university models of survivorship care provision in adult patients with haematological cancer: an integrative literature review nurses attitudes and practices towards provision of survivorship care for people with a haematological cancer on completion of treatment oncology practitioners' perspectives and practice patterns of post-treatment cancer survivorship care in the asia-pacific region: results from the step study mapping unmet supportive care needs, quality-of-life perceptions and current symptoms in cancer survivors across the asia-pacific region: results from the international step study provision of survivorship care for patients with haematological malignancy at completion of treatment: a cancer nursing practice survey study enhancing treatment fidelity in health behavior change studies: best practices and recommendations from the nih behavior change consortium ensuring treatment fidelity in a multi-site behavioral intervention study: implementing nih behavior change consortium recommendations in the smart trial reliability and validity of the functional assessment of cancer therapy-breast qualityof-life instrument a systematic review of quality of life instruments in long-term breast cancer survivors considerations in determining sample size for pilot studies sample size of 12 per group rule of thumb for pilot study the picker patient experience questionnaire: development and validation using data from in-patient surveys in five countries properties of the picker patient experience questionnaire in a randomized controlled trial of long versus short form survey instruments evaluation of short dietary questions from the 1995 national nutrition survey. canberra: australian government department of health and ageing australian institute of health and welfare. the active australia survey: a guide and manual for implementation, analysis and reporting international physical activity questionnaire: 12-country reliability and validity the development of a financial toxicity patient-reported outcome in cancer: the cost measure measuring financial toxicity as a clinically relevant patient-reported outcome: the validation of the comprehensive score for financial toxicity (cost) publisher's note springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations the authors acknowledge the contribution of drs kathryn middleton, wen xu, kate roberts, vladimir andelkovic, margo lehman, and tao supplementary information accompanies this paper at https://doi.org/10. 1186/s13063-020-04740-1.additional file 1. interview guide for the semi-structured interviews with patients/family members and health professionals. key: cord-342321-foqbckcx authors: bush, sharolyn; michalek, diane; francis, lucine title: perceived leadership styles, outcomes of leadership, and self-efficacy among nurse leaders:: a hospital-based survey to inform leadership development at a us regional medical center date: 2020-10-01 journal: nurse lead doi: 10.1016/j.mnl.2020.07.010 sha: doc_id: 342321 cord_uid: foqbckcx in response to improving upon a leadership development program at a us regional medical center, coupled with the understanding that transformational leadership is linked with better outcomes, as a first step, we examined the perceived leadership styles, outcomes of leadership, and level of self-efficacy among nurse leaders, namely nurse managers, clinical supervisors, and nurse directors. twenty-three hospital-based nurse leaders completed the surveys with a response rate of 57.5%. the majority of the leadership styles aligned with that of transformational. however, the items with the 3 lowest average frequency ratings within the transformational leadership style were in the areas of communication and showing confidence. additionally, the perceived median self-efficacy score was low. organizational support by way of providing continuous, sustainable professional leadership development, especially in the area of communication, and building self-efficacy is needed to ensure leader effectiveness, and improvement in staff and patient outcomes. perceived leadership styles, outcomes of leadership, and self-efficacy among nurse leaders: a hospital-based survey to inform leadership development at a us regional medical center in response to improving upon a leadership development program at a us regional medical center, coupled with the understanding that transformational leadership is linked with better outcomes, as a first step, we examined the perceived leadership styles, outcomes of leadership, and level of self-efficacy among nurse leaders, namely nurse managers, clinical supervisors, and nurse directors. twenty-three hospital-based nurse leaders completed the surveys with a response rate of 57.5%. the majority of the leadership styles aligned with that of transformational. however, the items with the 3 lowest average frequency ratings within the transformational leadership style were in the areas of communication and showing confidence. additionally, the perceived median self-efficacy score was low. organizational support by way of providing continuous, sustainable professional leadership development, especially in the area of communication, and building self-efficacy is needed to ensure leader effectiveness, and improvement in staff and patient outcomes. n urse leadership in the unpredictable and often chaotic health care setting is critical to ensuring the delivery of safe, evidence-based care necessary to positively impact the overall patient experience. 1 nurses make up the most significant number of health care professionals in the medical workforce, where daily, they are either directly or indirectly involved in patient care. 2 nurse leaders in the clinical setting, therefore, have the critical and challenging task of influencing effective workplace performance and retention of hospital staff nurses by directing clinical practice and outcomes inclusive of compliance with regulations, human resource issues, fiscal accountability, patient satisfaction, and overall excellence in service. 3 the covid-19 pandemic has undoubtedly reinforced the need for quality nurse leadership within health care. in troubling times, nurse leadership is paramount to safety and organizational outcomes. this study identified the most prevalent leadership style among nurse leaders at a regional medical center in the united states. although nurse leaders perceive to have a transformational leadership style, this study identified the need for professional development and interventions in the areas of self-efficacy and communication for nurse leaders in the hospital setting. historically, nurse leaders have had a remarkable capacity to manage. however, becoming an exemplary leader requires transformational leadership, the personal capacity to inspire others through innovation to achieve optimal outcomes. 4 inspired by james mcgregor burns' theory of transformational leadership, 5 the american nurses association, the premier organization for nursing professionals, describes transformational leaders with having the ability to communicate effectively, inspire others, have enthusiasm, support positive change, and lead others in pursuit of shared goals. 6, 7 in a systematic review conducted by wong et al., 8 transformational nurse leadership was found to have resulted in staff work engagement, 9 nurses' reluctance to quit, 10 medication safety, [11] [12] [13] workplace safety climate, 14 quality of care, 10 and decreases in inpatient falls, hospital infections, and patient mortality. 12, 13 additionally, self-efficacy, defined as the belief in one's ability to accomplish specific tasks, has been found to mediate the relationship between transformational nurse leadership and staff engagement. 15 these studies, albeit limited, inform us that transformational leadership, which is the most optimal leadership style, with transactional and passive avoidant being suboptimal, can lead to overall staff wellbeing and improved patient outcomes. in 2010, the institute of medicine (iom), now known as the national academy of medicine, published the future of nursing: leading change, advancing health, 1 which provided a blueprint for nurse leadership development and mentorship within 3 core domains: transformational leadership, mentorship, and involvement in policy making. in response, efforts have been mobilized to equip clinical nurses with leadership competencies in their nursing programs and workplace that would enable to answer iom's call for effective nurse leadership in the hospital setting. in an effort to improve professional development for nurse leaders at a regional medical center located in the mid-atlantic area of the united states, we conducted this hospital-based survey to examine the perceived leadership style, outcomes of leadership, and self-efficacy among nurse leaders at one of the third busiest hospitals in its state. the survey is the first stepping stone to inform the adaptation of an existing 9.5-day leadership development training program for nurse leaders focusing on fundamentals of performance coaching, leadership challenges, analyzing performance issues, and finance management facilitated by the human resources (hr) department. this survey for nurse leaders who held the position of clinical supervisor, nurse manager, or nurse director is a result of the medical center's hr department's desire to strengthen the training focusing on transformational leadership and building self-efficacy for nurse leadership. the survey and future development of a nurse leadership training program are inspired by the theory of structural empowerment, which posits that the work environment is accountable for providing access to resources to enable effective and influential leadership. 16 structural empowerment is one of the core components of the american nurses credentialing center's magnet recognition program ò where it recognizes an institution that promotes shared decisionmaking, continual professional development, and organizational commitment and support that will ultimately lead to staff well-being, better patient outcomes, and institutional financial success. 16, 17 we conducted the survey between june and july of 2019, utilizing a cross-sectional approach to examine the perceived leadership styles, outcomes of leadership, and level of self-efficacy among nurse leaders, inclusive of nurse managers, clinical supervisors, and nurse directors at a single-site regional medical center located in the mid-atlantic area of the united states. anonymous paper surveys without identifying information were stored via interdepartmental mail in a secure, locked file cabinet. unique random numbers were assigned to each survey for participants to keep so that they may have access to their results. the results of the survey were disseminated to participants by placing them in a secure area, and participants used their identification number to identify their survey results. the sole collector of data was a clinical manager who did not observe who picked up the survey and who returned completed surveys. we collected information on participant's gender, age, years of experience as a nurse and nurse manager/director/clinical supervisor, number of years in the workplace in current position, education, race/ethnicity, place of licensure, and type of unit (i.e., general surgical). for the perceived leadership style & outcomes of leadership, we used the 45-item multifactor leadership questionnaire (mlq) 5x short version. 18 the mlq is an established and validated leadership instrument that evaluates self-perception of 3 different leadership styles: transformational, transactional, and passive-avoidant, and perceived outcomes of leadership using a 5-point frequency behavioral scale (0 = not at all, 1 = once in a while, 2 = sometimes, 3 = fairly often, 4 = frequently, if not always). the specific components within each leadership style are as follows: transformational (5 i's): idealized attributes-ability to build trust; idealized behaviors-acting with integrity; inspirational motivation-ability to motivate; intellectual stimulation-ability to inspire innovation; individual consideration-focus on the individual development plan for personal achievement; transactional: contingent reward-set goals; management by exception-active-focus on compliance; passive-avoidant: management by exception-passive-punitive; laissez-faire-uninvolved; perceived outcomes of leadershi p-extra effort: can get followers to go above and beyond; effectiveness-productive; generates satisfactionstaff satisfaction achieved. we measured level of selfefficacy using the general self-efficacy scale. it is a 17item scale developed by mark sherer, which consists of 5-point likert responses ranging from "strongly disagree" to "strongly agree." scores range from 17 to 85, where higher scores indicate greater self-efficacy. 19 group frequency mean scores and standard deviations for each leadership style and outcomes of leadership scale and subscales were computed. group standard deviations of the frequency ratings for the leadership scales and outcomes measured the variation in response to the mlq. the smaller the standard deviation, the higher the agreement among group selfratings. a value of 0.0 would mean complete agreement among ratings. mean, and mode were calculated to measure the level of self-efficacy perceptions. we performed normality testing, using the kolmogorov-smirnov test and measures of central tendencies. the survey was reviewed and approved as exempt research by the institution's clinical research committee. table 1 summarizes the demographic characteristics of the participants. there are a total of 40 nurse leaders at the regional medical center. twenty-three deidentified surveys were completed and returned with index cards for a response rate of 57.5%. the majority of nurse leaders were above 41 years of age, self-identified as white, had at least a bachelor's degree in nursing, and had a mean of 21 years of nursing experience and 5.2 years of nurse leadership experience in a clinical setting. the mlq 5x mean frequency scores by leadership style, outcomes of leadership, and related subscales are summarized in figure 1 . the majority of the leadership styles aligned with that of transformational (idealized attributes mean ± sd: 3.1 ± 0.3; idealized behaviors mean ± sd: 3.1 ± 0.4); inspirational motivation mean ± sd: 3 ± 0.5); intellectual stimulation mean ± sd: 3.1 ± 0.5; individual consideration mean ± sd: 3.5 ± 0.4), followed by transactional (contingent reward mean ± sd: 2.9 ± 0.6; monitors deviations and mistakes mean ± sd: 1.5 ± 0.9) and passive avoidant mean ± sd: management by exception-passive mean ± sd: 1 ± 0.5; laissez-faire mean ± sd: 0.7 ± 0.5). the items with the 3 highest average ratings within the transformational leadership style scale were in the areas of coaching and developing people (mean: 3.6 treating others as individuals), acting with integrity (mean 3.5 considering consequences), and building trust (mean 3.5 building respect from others). the items with the 3 lowest average ratings for transformational leadership style were in the areas of acting with integrity (mean 2.5 talking about personal values and beliefs), encouraging others (mean 2.5 vision casting), and building trust (mean 2.7 showing confidence). regarding the perceived outcomes of leadership, the satisfaction of leadership had the highest mean frequency score (mean ± sd: 3.2 ± 0.4) followed by perceived leadership effectiveness (mean ± sd: 3.1 ± 0.5) and generating extra effort among staff (mean ± sd: 2.9 ± 0.5). the general self-efficacy mean and median scores were 2.4 ± 0.6 and 2.5, respectively, implying that the participants had low general self-efficacy. we found that the nurse leaders perceived their leadership style to be transformational, followed by transactional and, lastly, passive avoidant. nevertheless, we see opportunities for professional development in the areas of effective communication around personal values and beliefs, vision and mission, and showing a sense of power and confidence in the workplace. these potential areas for professional development align with the findings that the participants reported having a low-level of self-efficacy. in a recent integrative review of nurses' needs to practice effectively in the hospital environment, quality leadership was identified as the highest need nurses have in the workplace setting. 20 fine-tuning existing professional development training for nurse leaders to improve communication and confidence is necessary for quality leadership that so many nurses desire. nonetheless, leadership development should begin well before one becomes a leader in the health care setting. 21 leading nursing organizations have provided resources to help. for example, the american organization for nursing leadership (aonl), the professional organization for nurse leaders in health care, provides a comprehensive list of nurse executive competencies, in which effective communication and relationship building is primary. 22 the aonl also provides 2 leadership credentialing certifications to become a certified nurse manager and leader or certified in executive nursing practice. at the regional medical center, nurses should be encouraged and financially supported to pursue graduate programs such as the doctor of nursing practice (dnp) executive leadership program, designed for experienced nurses seeking to be competent in the knowledge of various leadership theories, managing complex health care environments, applying evidence to practice, improving patient care through policy engagement and advocacy, and leading interprofessional collaboration. 23 this survey was intended to give us preliminary information on how to strategize professional development to support nurse leaders at a regional medical center. the first step is to examine their perceptions about their leadership style, outcomes of their leadership, and self-efficacy. despite the information gathered in this survey, there were limitations. we did not examine factors related to the transformational leadership style, outcomes of leadership, and self-efficacy. the survey is also prone to social desirability bias. nurse leaders may provide responses that are desirable for their roles. to limit bias, we ensured that participation was not tracked because we did not observe who collected and returned surveys, and no identifiable information was collected. despite the limitations, the results of this survey provide muchneeded information on the areas of strength and for . *the bar chart shows how the participants perceived the frequency of their behaviors for each leadership style compared to various norms for the mlq. self-norms represent data from 3375 self-ratings of leaders who previously completed the mlq. future projects focusing on professional development. although the transformational style was the leading leadership style among the nurse leaders, content around effective communication around values and vision, and showing confidence is necessary to include in the hospital's leadership development training. finally, organizational support by way of providing continuous, sustainable professional leadership development is needed to ensure leader effectiveness and improvement in staff and patient outcomes. hospital-based interventions and professional development focusing on leadership self-efficacy and effective communication are necessary to ensure leadership effectiveness and ultimately, clinical care outcomes. note: the research received no funding. funding to purchase the mlq tools were provided by the regional medical center where the study was conducted. the regional medical center played no role in the design, collection, and dissemination of study or study results. there were no conflicts of interest to declare. we thank the nurse leaders who participated in this study. we also thank the leadership of the nurse leadership institute (nli) in maryland for their support. the authors conducted this study as nurse leadership fellows at the nli. the future of nursing: leading change, advancing health leadership strategies to promote nurse retention inspire others through transformational leadership see for yourself: self-assessment american nurses association. scope and standards of practice american nurses association. transformational leadership: criteria for nursing excellence the relationship between nursing leadership and patient outcomes: a systematic review update the influence of nurse manager leadership style on staff nurse work engagement transformational and abusive leadership practices: impacts on novice nurses, quality of care and intention to leave the relationship between nurse manager's transformational leadership style and medication safety a multimethod approach to a complex problem a model for evaluating the context of nursing care delivery use of a validated model to evaluate the impact of the work environment on outcomes at a magnet hospital leadership style and patient safety: implications for nurse managers linking transformational leadership to nurses' extra-role performance: the mediating role of self-efficacy and work engagement structural empowerment: criteria for nursing excellence an innovative environment where empowered nurses flourish multifactor leadership questionnaire manual the self-efficacy scale: construction and validation impact of transformational leadership on nurse work outcomes getting students to value leadership early in the nursing curriculum: innovation makes it possible the american organization for nursing leadership (aonl) the impact of the essentials of doctoral education for advanced nursing practice is the director of nursing practice and outcomes at the university of key: cord-312229-k249jkse authors: tao, hong; zhang, aihua; hu, jingchao; zhang, yaqing title: regional differences in job satisfaction for mainland chinese nurses date: 2012-08-31 journal: nursing outlook doi: 10.1016/j.outlook.2011.08.007 sha: doc_id: 312229 cord_uid: k249jkse abstract background although there is an abundance of research on nurses’ job satisfaction, there is a paucity of publications on the regional differences that impact on nurses’ job satisfaction. purpose to compare the differences between northern and southern hospitals in mainland china with respect to nurses’ job satisfaction. methods a cross-sectional survey design was selected. data were analyzed using descriptive statistics, independent t test, chi-square test, correlation, and linear regression. results nurses in northern hospitals were older, had higher educational levels yet received lower pay in comparison with their counterparts in the southern region. despite these salary differences, those in the north consistently rated their job satisfaction greater in all areas except professional opportunities. conclusion regional differences were related to nurses’ job satisfaction. potential contributing factors included philosophical, cultural, and economic differences between the 2 regions. the noteworthy regional differences that potentially related to nurse’ job satisfaction should be investigated in future studies. the excessive nursing shortage, poor retention, and high turnover are of great concern in many developed and developing countries. similarly, mainland china is struggling with a shortage of qualified nurses. 1 evidence suggests that a shortage of nurses is detrimental not only to working practices and the quality of patient care, but also to staff morale, all of which affect staff turnover. 2 recruitment, retention, turnover, and development of quality care in nursing are global issues within the health care setting. 3 research suggests a relationship between low nurses' job satisfaction with intent to leave and with the nursing shortage. 4, 5 nurses' job satisfaction is an important issue that has been studied in social and nursing sciences. the chinese health ministry reported that by the end of 2009 the number of registered nurses was 1.85 million, 1 which meant a nurse density of 1.39 per 1000 population in mainland china compared with 2008 organization for economic co-operation and development data of 16.2 nurses per 1000 population in ireland, 10.7 nurses per 1000 population in the united states, 9.5 nurses per 1000 population in japan, and 4.4 nurses per 1000 population in korea in 2008. 6 obviously, china has insufficient nurses relative to its population size and health care needs. china has had a growing nursing profession with baccalaureate and master's education begun in the 1900s, and doctoral education initiated in 2004. however, in china, higher educated (those with baccalaureate degrees and beyond) nurses are more likely than less well-educated nurses to leave nursing. this greater turnover of more highly educated nurses is noteworthy because they represent future leadership of the profession in china. 7, 8 in china, north and south is merely one of the ways that people identify themselves, and the north-south boundary is the yangtze river. the concepts of northern and southern china originate from differences in climate, geography, culture, and physical traits, as well as several periods of actual political division in history. 11 there are also major differences in language, cuisine, and popular entertainment forms. during the china economic reforms of the 1980s, southern china developed much faster than northern china, which led to the unbalanced regional economic development. to date, most nurses' job satisfaction and relevant studies in china have focused on a certain region, and no documented studies have explored the regional difference impact on nurses' job satisfaction. considering that the huge discrepancy of culture, economy, and perspectives from southern and northern china may play a role on nurses' job satisfaction, this study addressed the comparison between the southern and northern hospitals in mainland china. the purpose of this article was to explore the current level of job satisfaction among chinese nurses and examine the differences between northern and southern hospitals with respect to nurses' job satisfaction. the data reported in this paper were part of that collected for a larger study investigating chinese nurses' job satisfaction and retention. the following research questions guided this study: (1) what are the differences between northern and southern hospitals in terms of the demographic variables? (2) what are the differences between northern and southern hospitals in mainland china in terms of job satisfaction measured by the chinese nurse job satisfaction scale (cnjss)? job satisfaction is defined as the degree to which employees enjoy their jobs. 12 in this study, job satisfaction was defined as the degree to which nurses enjoy their jobs. job satisfaction is a frequently studied variable in organizational behavior research and also a central variable in both research and theory of organizational phenomena ranging from job design to supervision. 13 high job satisfaction improves the ability of the health organization to recruit and retain nurses. 14, 15 tourangeau and cranley 16 reported a relationship between nurses' job retention and their satisfaction with pay and benefits, scheduling, control (autonomy), responsibility, and professional opportunities. in a study that included 5 countries, aiken and colleagues found that job dissatisfaction among nurses was highest in the united states (41%) followed by scotland (38%), england (36%), canada (33%), and germany (17%). 17 a chinese study found that more than half of respondents (53.7%) who were chinese nurses were satisfied with their jobs. 10 worldwide evidence indicates that job satisfaction is a major predictor of nursing absenteeism, burnout, turnover, and intention to quit 9,18-20 and has the largest effect on nurses' intent to stay and is important in predicting nurses' retention. [21] [22] [23] therefore, it is incumbent upon health care administrators and nursing managers to assess nurses' job satisfaction to develop strategies to improve nurses' retention. job satisfaction is a complex phenomenon with many components. suliman and abu gharbieh reported that jordanian nurses were dissatisfied with many work variables such as payment, career opportunities, nursing and hospital administrators' support, transportation, and child care facilities. 24 mcneese-smith showed that sources of low satisfaction were associated with factors that interfere with job/patient care, feeling overloaded, relations with coworkers, personal factors, organizational factors, and the career stage of the nurse. 25 lu et al reported that sources of job satisfaction for nurses included working conditions; interaction with patients, coworkers, and managers; the work itself; remuneration (pay, salary); self-growth and promotion; praise and negotiation; control and responsibility; job security; and leadership style and organizational policies. 5 empowerment has been studied and found to be highly related to job satisfaction, [26] [27] [28] and autonomy has been found to greatly affect job satisfaction with higher levels of job autonomy, leading to higher levels of job satisfaction. 29 ma and colleagues compared nurses from south carolina hospital and nonhospital settings regarding job n u r s o u t l o o k 6 0 ( 2 0 1 2 ) 2 1 3 e 2 2 0 satisfaction and found that autonomy was the second most significant predictor of job satisfaction for hospital nurses. 30 furthermore, age, years of service, and educational level were found to be correlated with job satisfaction in china and other countries. [31] [32] [33] methods the study was part of a project funded by the shanghai government and received institutional review board approval from second military medical university. a cross-sectional survey design using questionnaires was selected to fulfill the research objectives. a convenience sample of registered nurses was recruited from urban hospitals with similarity of hospital scale, array of services, and work environments. hospitals were located in shandong province, a typical district in northern china, and in shanghai, a typical southern municipality. the nurse president of each hospital delegated the head nurse of each department to request the participation of registered nurses in the survey. all registered nurses who had worked full time for at least 1 year at the study hospitals were eligible to participate. two researchers, who were trained using the same guideline and who had participated in a pilot study, distributed 1420 questionnaires to registered nurses. the response rate of this study was 89% with 1278 nurses having completed the questionnaire. of the obtained sample, 648 (50.7%) nurses were recruited from 6 northern hospitals and 630 (49.3%) nurses were recruited from 6 southern hospitals. the questionnaire consisted of 2 sections: demographic variables and the nurses job satisfaction scale. demographic data collected were age, gender, education level, years of experience in nursing, marital status, job position, and yearly income; nurses' job satisfaction was measured with the chinese nurses job satisfaction scale (cnjss). 34 a detailed description of the development of the cnjss has been documented in previous work. 35 the final instrument was the 38-item cnjss, which has 8 subscales: administration, workload, coworkers, work itself, pay, professional opportunities, praise/recognition, and family/work balance. the overall cronbach's alpha was 0.82 (according to a test of 1185 nurses sample), and 0.73 to 0.81 for the subscales. in this study, scale reliability measured by cronbach's alpha was 0.88, and 0.64 to 0.82 for the subscales. the survey questionnaire was included in a packet and distributed to potential participants between february and may 2006. the packet contained a demographic data sheet, one revised instrument, and a selfaddressed return envelope. included in the packet was a letter describing the purpose of the study and assurance that participation of the study was voluntary and anonymous. instructions directed participants to return completed questionnaires in the return envelopes via collection boxes placed in centrally located nursing offices at each study site. informed consent to participate was indicated by return of the questionnaire. data were analyzed using statistical package for the social sciences (spss) software version 16.0 (chicago, il) at 0.05 alpha levels. descriptive statistics, including percentage, frequency, mean, and standard deviation were used to analyze the demographic characteristics and nurses' job satisfaction scale and its subscales. items of nurses' job satisfaction scales were continuous in nature; thus, t-test was used to test the differences between northern and southern hospitals in regard to nurse job satisfaction. the demographics of the entire sample were treated as categorical variables, thus chi-square was used to test the differences between the two types of hospitals in both groups. 36 spearman correlation, independent samples t-test, and stepwise multiple regression were used to explain differences in demographic characteristics and nurses' job satisfaction between the 2 regions. the demographics of the sample in both regions were compared (table 1) respondents in the northern hospitals were significantly more likely ( p < 0.001) to be of higher rank than those in the south. in the north, there were 172 (27.3%) rn4 respondents compared with 70 (10.8%) in the south. southern nurses were also significantly more likely to be single ( p ¼ 0.013) than their northern counterparts. there were significant correlations between age (r ¼ 0.144, p < 0.01), educational level (r ¼ 0.095, p < 0.01), and job rank (r ¼ 0.091, p < 0.01) and job satisfaction, but not for annual income and length of service at study hospitals. differences in job satisfaction for gender, marital status, and region were tested using the independent samples t-test. although gender and marital status did not influence job satisfaction, there was a significant (t ¼ 11.208, p < 0.01) difference between regions, with nurses' job satisfaction in southern hospitals lower than that in northern hospitals (t ¼ 11.208, p < 0.01). age, educational level, job rank, and region were entered into stepwise regression as independent variables with nurse's job satisfaction to create a predictive model. stepwise regression is a procedure that "starts by entering the single best predictor into the model. the next best predictor that contributes the greatest amount of unique variance is entered next. at each step, the new predictor entered is that variable with the greatest partial correlation with the dependent variable when all variables already included have been partialled out." 38 as depicted in table 2 , 2 of the 4 indicators of nurse demographic characteristics including southern region (b ¼ 0.268, p < 0.001) and age (b ¼ 0.061, p < 0.001) were significant predictors of nurses' job satisfaction. overall, nurses in northern hospitals were more satisfied than nurses in southern hospitals ( p < table 3 ). further comparisons were made to determine the role of the 8 domains in the cnjss: administration, workload, coworkers, work itself, pay, professional opportunities, praise/recognition, and family/work balance. significant differences found included nurses in northern hospitals being more satisfied than nurses in southern hospitals with respect to: administration (p < 0.001), workloads (p < 0.001), coworkers (p < 0.001), work itself (p < 0.001), pay (p < 0.003, adjusted 0.05 alpha levels to 0.05/17 ¼ 0.003), praise/recognition ( p < 0.001), and family/work balance ( p < 0.001). nurses in southern hospitals were more satisfied with professional opportunities than nurses in northern hospitals ( p < 0.003, adjusted 0.05 alpha levels to 0.05/17 ¼ 0.003). the key findings of this study include: (a) the greatest differences in demographics between respondents in the 2 regions were in age, educational level, and annual salary (respondents in northern hospitals were older and had higher educational levels, yet received lower pay compared with their colleagues in the southern region); and (b) despite these salary differences, those in the north consistently rated their job satisfaction greater in all areas except for professional opportunities. specifically, nurses in northern hospitals reported higher rates of job satisfaction than nurses in southern hospitals with respect to pay, the work itself, workloads, administration, coworkers, praise/recognition, and family/work balance, whereas nurses in southern hospitals were more satisfied with professional opportunities than nurses in northern hospitals. the average age of nurses in northern hospitals was older than in southern hospitals, with 56.0% of nurses older than 35 years. evidence indicates that older nurses were more satisfied with their jobs, 16, 41 which is consistent with the findings in this study that the northern nurses' job satisfaction was significantly higher than southern nurses. in addition, when controlling the regional influence, age was the only predictor for nurses' job satisfaction. with each additional year of age, a nurse's job satisfaction improved about 0.06. the age differences between these 2 regions may be explained by the fact that nurses in northern hospitals are more influenced by a sense of obligation to remain in their occupation, 42 loyalty to their organization, or lack of alternative jobs outside of nursing. in comparison, more job opportunities are available in the southern area because of higher economic growth and the open job market. in the 1980s, the chinese government reaffirmed that nursing, just as medicine, was an independent profession that required well-qualified personnel, with nurses being awarded a protected title by the national ministry of health. 39 at present, there are 5 levels of nursing education in mainland china: diploma programs, associate's degrees, bachelor's degrees, master's degrees, and doctoral programs. most nurses who have a diploma degree have been improving their educational level through continued education programs. 40 table 1 illustrates that in northern hospitals 32.7% of the nurses have a baccalaureate's degree or above, and in southern hospitals, 13.2% of the nurses have a baccalaureate's degree or higher. fewer highly educated nurses staying in nursing may be more a result of highly educated southern nurses leaving their jobs because of low job satisfaction, which is consistent with research findings that higher educated nurses tend to be less satisfied with their job, leading to turnover. 31 in addition, nurses in the northdespecially in shandong province, the cradle of confucianismd may be influenced by the philosophy that human beings are teachable, improvable, and perfectible through personal and communal endeavor, and thus prefer to stay in their positions with learning and selfimprovement. the differences in the yearly income of nurses may be a result of differences in regional economic development in china. shanghai is the biggest port in china and a center of technical, trade, finance, and information, which is a great magnet to local, national, and international pharmaceutical companies, and also results in the high income and high consumption rate. the average annual salary of nursing staff is u27,000 cny (about $4100 usd) in mainland china, which is higher than the annual income of u17,811 cny in ($2700 usd) in the northern area 43 but lower than the average annual income of u43,000 cny ($6600 usd) in shanghai. 44 in this study, although nurses in northern hospitals strongly agreed with the item "an upgrading of the pay scales at your agency is needed," they remain more satisfied with "present pay" than southern nurses and this may indicate that although the northern nurses are aware of the income gap between northern and southern nurses, they accept it and remain optimistic. this is consistent with the northern economy being less developed than southern china, resulting in lower average income. comparatively, nurses' pay in the north is far more than average among the work forces in the region 41 and this could be the reason that northern nurses are more satisfied and willing to stay in nursing. conversely, although southern nurses are paid more than northern nurses, they still feel less satisfied than the northern nurses because nurses' pay in the southern region is much less than the average of the rest of the region's work force. 45 the satisfaction difference for pay between northern and southern nurses may be related to the satisfaction difference for the work. northern nurses seem to be more satisfied with the nursing work including shifts, working environment, working conditions, and significance of the nursing, because of the fewer job opportunities outside and the stable pay in nursing. however, both northern and southern nurses are very much dissatisfied with the item "nursing is widely recognized as being an important profession" because despite improvement in the last decade, nurses in china have very low socially recognized status. although nurses are also referred to as "white angels" in mainland china, because of the entrenched traditional concept, the social status of nurses is still relatively low, and it has been difficult for the nursing profession to receive public recognition and respect. this recognition and respect increased somewhat when chinese nurses played an important role in the severe acute respiratory syndrome (sars) crisis and were recognized and praised by the public, thereby increasing nurses' sense of achievement, motivation, and enthusiasm for their work. in chinese culture, the relationship with coworkers is considered one of the most important factors regarding one's achievement in the work setting. nurses in northern hospitals were more satisfied with coworkers n u r s o u t l o o k 6 0 ( 2 0 1 2 ) 2 1 3 e 2 2 0 than nurses in southern hospitals. pearson and chong found that the importance of harmony in the workplace for chinese nurses can be traced to the significant effect of chinese confucian values. 46 the philosophies of confucianism, which originated and derived from shandong province at the north of china, may have a greater influence on northern people than southern. in other studies, more than half of german (69.4%), us (60.5%), and english (50.1%) nurses were satisfied with participating in developing their own schedules. 17 in those countries, nurses have a variety of options that allow flexible work scheduling and full-or part-time positions with varying shifts, as well as options that provide nurses with an opportunity to balance work and other life obligations. in china, almost all of the staff nurses work full-time under the obligation of shifts. nurse managers, the most senior nurses, or those working in outpatient settings or special departments that do not require shifts, may be exempt from the shifts. in this study, southern and northern nurses scored the item "you have more flexibility in scheduling your work than nurses in other practice settings" were 2.83 and 3.61, respectively. two reasons may explain this. southern nurses are younger than northern nurses and are not exempt from night shifts, and northern nurse managers may demonstrate more consideration and allow nurses to work around their family, school, and other obligations when scheduling their shifts. the only subscale on which southern nurses reported higher levels of satisfaction than northern nurses consisted of items concerned with professional opportunities. there are 2 possible reasons for this difference. the south is more developed, with consequently more employment opportunities. in addition, high-tech development has brought more opportunities for nurses to improve their professional skills through education and training, thereby increasing their opportunities for promotion. there are several limitations in this study. first, this study used convenience sampling, which limited the generalization of the results. second, to make the sample from the 2 regions comparable, only hospitals with similarity of scale, array of services, and work environments were selected. thus, a larger sample from broader scopes of hospitals has to be included in further research using a randomized sampling technique. third, because the data were collected in 2006, this study may serve as providing an essential base for comparison with the current situation because the role of nursing and the economy in china have evolved since that time. a comparative design was used in this study, and a convenience sample was obtained from northern and southern hospitals in mainland china. the findings of this study may help chinese health care administrators develop strategies in improving nurses' job satisfaction that take regional characteristics into consideration, such as educational, income and consumption level, and philosophical and cultural differences. in addition, nurse managers can enable nurses to experience professional satisfaction, personal balance, and opportunities for choices by offering flexible scheduling options. the results of this study are considered a baseline for future research with a larger and more homogenous sample to enhance generalization of the results. furthermore, the noteworthy differences between regions in cultural values, political status, economic levels, 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of empowerments on job strain and work satisfaction the relationship of empowerment and selected personality characteristics to nursing job satisfaction the relation between leadership style and empowerment on job satisfaction of nurses the why and wherefore of empowerment: the key to job satisfaction and professional advancement factors that influence nurse' job satisfaction the relationship among turnover intentions, professional commitment, and job satisfaction of hospital nurses a theoretical model of job retention for home health care nurses study on overseas nurse retention and enlighten on nursing development of mainland china development of a scale for job satisfaction assessment in nurses. di er jun yi daxue xue bao job satisfaction, occupational commitment and intent to stay among chinese nurses: a cross-sectional questionnaire survey the practice of nursing research: conduct, critique and utilization department of health and human services, health resources and services administration. the registered nurse population: initial findings from the 2008 national sample survey of registered nurses using multivariate statistics today's nursing education in the people's republic of china a survey of demands for continuing education of nursing college students in our hospital predicting registered nurse job satisfaction and intent to leave confucius's sense or responsibility and the theories of responsibility as well as their value of our time clinical nursing system and staff composition in shanghai contribution of job content and social information on organizational commitment and job satisfaction: an exploration in a malaysian nursing context nurses act'': the background of the development and main content the authors would like to thank all participating nurses in shanghai and shangdong province, whose input made this study possible, and the shanghai pujiang program, shanghai government, china for funding. key: cord-313229-5oc0lisi authors: abbott, patricia a.; coenen, amy title: globalization and advances in information and communication technologies: the impact on nursing and health date: 2008-10-31 journal: nursing outlook doi: 10.1016/j.outlook.2008.06.009 sha: doc_id: 313229 cord_uid: 5oc0lisi globalization and information and communication technology (ict) continue to change us and the world we live in. nursing stands at an opportunity intersection where challenging global health issues, an international workforce shortage, and massive growth of ict combine to create a very unique space for nursing leadership and nursing intervention. learning from prior successes in the field can assist nurse leaders in planning and advancing strategies for global health using ict. attention to lessons learned will assist in combating the technological apartheid that is already present in many areas of the globe and will highlight opportunities for innovative applications in health. ict has opened new channels of communication, creating the beginnings of a global information society that will facilitate access to isolated areas where health needs are extreme and where nursing can contribute significantly to the achievement of “health for all.” the purpose of this article is to discuss the relationships between globalization, health, and ict, and to illuminate opportunities for nursing in this flattening and increasingly interconnected world. lenges, human rights, and consideration of local and cultural context. nursing leadership, creativity, advocacy, and experience are needed to provide stewardship for health ict growth and application in the face of a complex, interconnected, and increasingly globalized world. the term globalization describes the increased mobility of goods, services, labor, technology and capital throughout the world. 3 most would agree that globalization has a much broader impact than just an economic impact; its impact is also political, technological, and cultural-strongly influenced by information and communication technology. 4 globalization, whether we recognize it or not, touches all parts of our lives-both personal and professional; it changes the way our nations and communities work. globalization and health have been discussed by many experts who have noted influences on wellness that are both promising and potentially devastating. [5] [6] [7] [8] globalization in a positive sense has resulted in trade expansion, with an increase in living standards and improved social and economic status, particularly for women. sachs, a global economist known for his work in developing nations, repeatedly makes the important point that the health of a nation is directly tied to the wealth of a nation. 9 wealth is enhanced by heightened competition, comparative advantage, economies of scale, and access to a greater range of products and services in globalized markets, all enabled by access to knowledge. asymmetries of information have been reduced in an era of globalized knowledge exchange, contributing to a reduction of isolation, an increase in life spans, and improved health. 10 conversely, advances in globalization are blamed for some health problems, including an increased adoption of unhealthy western habits and lifestyle, resulting in increases in obesity and the increased prevalence of chronic disease. open borders and open access, hallmarks of globalization, have also resulted in faster transmission of infectious agents, the so-called "microbial hitchhikers." many societies find globalization and open information exchange threatening to current ideologies and social structure. others view the concept of globalization, particularly via ict, as a new age form of electronic colonialism, where existent cultures are bulldozed and assimilated. 11 how does ict fit in this discussion of health and globalization? the world health organization (who) believes that ict holds great promise for improving health and health care around the world and is critical to achievement of the millennium development goals. 12 the core beliefs that ict will contribute significantly to the reduction of poverty, improve the delivery of education and health care, and make government services more accessible are prominent in the 2006 world health report. the 2007 report, towards a safer future, continues to emphasize the importance of ict in relation to health: "today, the public health security of all countries depends on the capacity of each to act effectively and contribute to the security of all. the world is rapidly changing and nothing today moves faster than information. this makes the sharing of essential health information one of the most feasible routes to global public health security." 13 a widely held view, both within the who and elsewhere, is that ict in health enables rapid and global access to new therapies, techniques, and knowledge resources, with the potential to forever change the health of nations. the role of ict in the severe acute respiratory syndrome (sars) crisis of 2003 is a prime example. during the first cases of sars in china in 2003, the who initiated a digital virtual environment consisting of 11 laboratories in 9 countries connected via ict. using e-mail and a secure website, these collaborators shared outcomes, post-mortem tissue analysis, electron-microscope pictures of viruses, genetic sequences and other related materials in real-time to collaboratively identify and intervene in a markedly dangerous public health risk. other examples exist that point to the impact that ict has had on global health efforts, such as the academic model for the prevention and treatment of hiv/aids medical record system for africa (ampath-mrs), the partners in health electronic medical record in peru, the hiv electronic medical record system in haiti. 14 efforts such as those mentioned above and scores of others, too extensive to enumerate, have made significant impacts in the health of large regions of the globe. however, it is important to realize that ict can never be viewed as a panacea or singular solution to the very multifaceted problem of worldwide health. the contributors to global health are very complex, rooted in societal structures, political agendas, and the presence of marked global poverty. solving one issue without addressing the others will result in the same outcome experienced by sisyphus; the summit is reached, only to have the boulder roll back down to the base. in particular, efforts to improve health without addressing the pressing problem of poverty will be unsustainable. poverty reduction as a precursor to improvements in health is reflected in the 2007 world health report: "hungry children easily acquire diseases, and easily die from the diseases they do acquire. dwellings without sanitation provide fertile environments for transmission of intestinal infections. hopeless life circumstances thrust young girls into prostitution with its attendant risks of violence and sexually transmitted diseases." 13 productivity drops when the human capacity that fuels economic growth declines due to morbidity and mortality, and the high financial burden of disease in developing nations precludes economic advancement and health improvement efforts. 15 the paradox is, of course, that declining health impedes the climb out of poverty while poverty contributes to declining health. could further enhancement of global ict for health care be a potential strategy for escaping this paradox? what are the realities and reasoned approaches for application of ict to impact the health of nations? what roles and opportunities for nursing leadership exist in regards to ict regardless of geographic location? in many instances, the idealism of ict potential and the reality of ict application are discordant. therefore, while there is acknowledged need for ict in the coordination and monitoring of treatment, surveillance, response, education, and communication in health care, in reality there are significant barriers in the application of ict that slow progress. these barriers are in no way restricted to the developing world. the united states and other more technologically advanced nations have their own sets of challenges. cost, misalignment of incentives, resistance, an unskilled workforce, concerns about impact on productivity, lack of standards and interoperability, and other issues contribute to a poor level of healthcare ict adoption in the industrialized world. 16 the digital divide has resulted in large segments of low income and/or other underserved groups being excluded from online health resources. 16 economic hardships and difficult tradeoff decisions in the us healthcare industry have further inhibited healthcare information technology growth. 17 in developing nations, the problem of ict uptake is even further compounded. a lack of local expertise and decades of well-meaning but non-sustainable ict projects in the developing world have left a legacy of skepticism in their wake. systems built for westernized health care delivery often do not match the local context, resulting in a misalignment between need and technology. poverty and illiteracy in developing nations stand as major barriers to the adoption and sustainability of information technologies, and many believe it is difficult to make the case for ict when basic needs for survival are barely being met. 18 the "e-health paradox," a term coined by liaw and humphries, refers to this seeming conundrum; populations that may have the most to gain from ict in health are those who are thwarted in their use due to barriers of untrained personnel, poor infrastructure, and lack of resources. 19 issues such as these have fueled technological apartheid and continue to subvert the delivery of knowledge to areas of the globe that most desperately need it. are the current realities in global health ict all bad? actually, they are not. from adversity often come new ideas. new opportunities and avenues for access and innovation in the use of ict are emerging to improve health and facilitate the delivery of health care. the use of ict in health care in more industrialized nations such as the united states, the united kingdom, and australia continues to grow, albeit at modest rates, reaching a tipping point. as discussed earlier, there are many successful implementations of ict-enabled health communications and electronic health record systems in developing nations such as kenya, malawi, peru, rwanda, haiti, tanzania, and others as part of efforts like the open medical record system (open mrs). 14 creative thinkers are already capitalizing upon widely available forms of ict (such as cellular telephony) to affect health. muhammad yunus, whose work in microloans in bangladesh was honored in 2006 with a nobel prize, is an excellent example of how the creative introduction of ict via simple cellular telephony into a low resource area could institute profound change. dr. yunus and the telecom company he founded 20 were convinced that economic and social development should begin at the grassroots level. yunus believed that attacking poverty is essential to peace, that private enterprise is essential to reversing poverty, and that peace and poverty reduction are essential to health. 21 yunus' microloans enabled destitute village women in bangladesh to purchase cell phones and become village phone operators (vpos). the women then sold telecommunication services on a per-call basis to neighbors. this has resulted in considerable wealth generation not only for the vpos, but for the farmers and village dwellers who are using this technology to access the outside world and improve their businesses. 20 the vpos provide affordable rates to their neighbors, preventing residents from making (historically, in many locales) a 6-hour roundtrip to reach a telephone, which consequently impacted community productivity and increased community wealth. the vpos earned enough to invest in their children's health, nutrition, and education, and fund other business growth. the improvement in community wealth translated into improved community health, as funds became available for the drilling of wells for clean water and preventive health services. the vpo model has been rolled out through much of africa and is viewed by governments and development agencies such as the united nations, usaid (united states agency for international development), and the world bank as a sustainable development tool. wealth has impacted health, which is a welcomed consequence. the swell of cellular telephony has also expanded directly into the realm of health and health care in other ways, particularly as the use of short messaging service (sms)-otherwise known as text messaging-has grown in popularity as a form of communication. for example, "sexinfo," a sms-based health information service offered by the san francisco department of public health, is being used to educate and assist teens who have questions about sexual health. 22 the centers for disease control and stanford university teamed up recently to hold a conference called "texting for health" where public health initiatives using sms were presented. 23 south africa is using sms features in cellular telephony to issue reminders to patients and caregivers in hopes of increasing adherence with antiretroviral therapies. phones for health, a presidents emergency fund for aids relief (pepfar)-funded project, is also using mobile telephony to combat hiv/aids in sub-saharan africa. 24 this project allows nurses and other health workers in the field to use a standard mobile phone handset to enter health data. the system uses cellular methods to relay the data to a central database, where it is immediately available to health authorities via the internet. the system also supports the delivery of health alerts and reminder messages to caregivers. 24 each of these examples illustrates a movement using ict to enhance information distribution that empowers financial growth, health, and social betterment, in both developed and developing nations. the success of such initiatives opens the door to innovative global ict methods for enhancing education, public health monitoring and surveillance, and delivery and management of health. it also speaks to opportunities for those who stand at the frontline of global health efforts to consider new ways to reach and teach. where is the opportunity for nurses to make a difference in regards to health care in a digital world? when one considers that 50 -90% of all health care provided "in country" is delivered by non-physician providers 12 and the accessibility of ict is accelerating, the opportunities for nurses and midwives are vast. as those who most often stand at the interface of the patient and the healthcare system, there is a growing awareness of the need for nursing leadership, nursing innovation, and the nursing voice in global health ict. a number of areas of development demonstrate how nursing has already embraced ict to harness its global potential and should illustrate potential areas for growth and further investigation. examples of success stories from a global perspective include: (1) advances in education and collaborative learning, (2) telenursing/ telehealth, (3) movement toward electronic health records (ehrs), (4) nursing knowledge management and knowledge generation. in consideration of the challenges and opportunities cited earlier, these examples may stimulate critical and creative thinking about how these established examples and methods may be extended and applied by the nursing community to address the e-health paradox. information and communication technology has influenced both traditional and non-traditional approaches to education and the development of the next generation of nursing leaders. distance education programs in nursing are exploding across the globe and are enabling outreach to geographically distributed individuals. the use of ict to elevate the educational level of nurses worldwide is a crucial area for expansion, investigation, and application, particularly as the nursing workforce crisis grows, global health declines, and medically underserved areas increase. considering the issues of nurse migration and nursing brain drain, 12 ict may be an effective strategy to reduce some of the contributors to out-migration, such as isolation and lack of educational opportunity. methods such as ict for education to train rural providers in place can prove to be more cost effective and less disruptive to families, communities, and nations than out-migration to more developed countries. 25 moreover, collaborative learning opportunities are enabled via ict, where geography becomes irrelevant. the opportunity for students and faculty to interact, share knowledge, discuss global health issues, and share cultural perspectives across nations affords students and faculty exposure to the world beyond them. such experiences can increase cultural competency, raising awareness of and appreciation for global health issues. although the promise in using ict to reach and teach is great, there is also a need for caution and careful consideration. as discussed earlier, the notion of western solutions as being universally appropriate is erroneous. understanding how information and knowledge is relevant to context and culture is essential, so as not to impose approaches or solutions that do not fit the learners' reality. approaches that seem appropriate for delivery in one environment may be offensive or totally unrealistic and unvalued in another, highlighting the need for local involvement, flexibility, and creativity. this is particularly apropos when considering the vast differences between industrialized and non-industrialized nations or in nations that are in conflict. nursing has taken the lead in several successful international collaborations involving education and collaborative learning. two examples of the use of distributed e-learning in industrialized and non-industrialized nations are provided as a stimulus for further study and application: international virtual nursing school (ivinurs) 26 a central activity of ivinurs is the building of its digital repository and the development of associated e-learning support products, with the aim of providing quality, learning resources that can be shared on a global level by its partners, and used to enhance both e-learning and traditional instruction in their respective settings. this not-for-profit entity, registered in the united kingdom as a limited company with charitable status, is still in formative stages, and expects to make available studies of its impact in the near future. uganda 27 is an example of using ict in the developing world for nursing education and scale-up. this public-private partnership plans to increase the basic education level of 22 000 kenyan nurses up to the level of "registered" (diploma) from the current level of "enrolled" (certificate) within 5 years. at present, 70% of the nursing workforce in kenya is comprised of "enrolled" nurses, whose level of education leaves them ill-prepared to handle the complex health needs of the kenyan population. the amref's "virtual nursing college" currently has 4000 nurses enrolled at 100 computer-equipped training centers in 8 provinces, including several refugee camps. the curriculum is delivered via ict and, in october of 2007, the first class of icttrained kenyan nurses completed the program. 28 while too early to discuss program outcomes, the fact that 70% of all nurses enrolled in this program are from rural areas speaks to a great potential for communities outside of urban centers. this model is planned to be extended to other african nations who are experiencing similar nursing crises. the amref program is also important because of an important but less publicized goal-that all 22 000 nurses will be computer literate. this very unique and vital component leaves kenya ready to lead in the movement towards e-health in the developing world. this could accelerate the achievement of the who resolution wha58.28, an e-health strategy adopted by the fifty-eighth world health assembly in may 2005 that articulates the preparation of an ict-competent global health workforce. these 2 brief examples, while using different methods and addressing 2 different audiences of nurses, demonstrate the potential of ict within the nursing education realm. it also demonstrates the reach of it-enabled methods in rapidly digitizing developing nations-further illustrating an area of opportunity for expansion. considering the global workforce crises in nursing, these models are worth further consideration. telenursing is the use of technology to deliver nursing care and conduct nursing practice. 29 telenursing is often used interchangeably with the term telemedicine or telehealth with the distinction implied that a nurse provides telenursing and a physician provides telemedicine. the use of the term telehealth may be more appropriate, as the success of this modality requires multiple partners, including the professionals delivering services, technical support personnel, and the client or patients themselves whose participation is essential to successful outcomes. telehealth, in all of its definitions and permutations, has made large strides in expanding healthcare services to underserved areas around the globe. in a recent study, 719 nurses representing 36 countries responded to a survey querying their telenursing competencies and skills. 30 patients with chronic illnesses were those most often cared for using telenursing services. although most telenurses worked in hospitals, the settings varied widely, including traditional work places such as clinics to community-based settings such as schools and prisons. several countries have well-developed telenurse programs, including canada 31 and new zealand. 32 the trend towards expansion of this nursing specialty is expected to continue, particularly as ict continues to reach all areas of the globe and as the medically underserved areas of the world are illuminated. telehealth/telenursing in the traditional sense may conjure up visions of expensive computer workstations, call-centers, or a nurse in a chat room. while these visions are perfectly realistic in the developed world, they are quite unrealistic in many parts of the globe. however, with the growth of cellular telephony, particularly in africa, tremendous opportunities exist for nurses to creatively apply telehealth modalities to long-standing patient care issues. for example, elder and clarke cite the following examples for the potential use of cellular telephones and personal digital assistants (pdas) for telehealth in africa and asia: 33 • automation of demographic surveillance activities such as those at the core of pioneering health care initiatives (e.g., the tanzanian essential health interventions project) • testing of the use of sms (short message service) reminders in the treatment of tuberculosis in cape town, south africa • delivery of continuing medical education and professional development via pda • delivery of time-sensitive alerts to patients and health care workers • maintenance of patient records for hiv-positive patients' lifelong drug treatments • management of specific health care initiatives such as the roll-out of antiretroviral therapy and tuberculosis treatment initiatives again, realizing the numbers of nurses who are in the frontline of primary care around the globe and in light of the massive growth of ict for health, tremendous opportunity awaits those who are primed to capitalize upon these factors. making the application of telehealth/telenursing successful in developing countries will require strong nursing partnerships and leadership, however. nurses are in a position to drive the development of science in this area, since many aspects of nursing care are naturally amenable to virtual delivery, especially in areas of assessment, patient teaching, decision support, and early identification of problems. 34 globalization is driving the need to communicate and share healthcare data and information across national borders. many countries are focusing on interoperable electronic health record systems (ehrs) as a solution for sharing data and information among various sources (e.g., clinical information systems, personal health records, public health surveillance systems, and knowledge repositories). for ehrs to reach full potential, however, interoperability and connectivity to distributed data repositories is fundamental, particularly in light of distributed healthcare services, geographical challenges, and migrating populations. in a global sense however, there are vastly different levels of ehrs readiness and capacity for ehrs interoperability. in many places, ehrs are unknown yet the need for health data (in any fashion) is great. even the most remote of locales often have reporting requirements, either from ministries of health or donor agencies. accountability for receipt and utilization of goods and services, demonstration of outcome achievement, and measurement of milestones are resulting in increasing pressures on nurses, other providers, and administrators for improved information management and tracking. quick fixes or one-off solutions, characteristic of many health data tracking efforts, often result in unusable, non-interoperable, and unsustainable systems that are soon abandoned, threatening clinic viability and leaving service providers frustrated. efforts such as open mrs are gaining in popularity, due to its open source (free) and interoperable nature, and its well-established success in many clinical settings across the global south. open mrs is an example of an ehrs system, built to agreed-upon standards that enable interoperability, data exchange, and the ability to use it in many different settings in many different locales. while this is an open source and freely available system, there are no documented examples of nursing use-which is puzzling when one considers the number of nurses who are responsible for clinic operations around the globe. it is important to note that, even in developed nations, nursing involvement in ehrs specification and development is disappointingly low. such lack of ehrs involvement by nursing in both developed and developing nations makes it that much easier for nursing data to remain invisible and inconsequential to determination of health outcomes. healthcare, both nationally and internationally, is a product of teams (including the patients), and such teams are reliant upon the sharing of information and knowledge. standards facilitate sharing of data, information and knowledge and are a foundational underpinning for system interoperability. those who do not participate in standards development, implementation, and use face the prospect of exclusion in ehrs. as is, the contributions that nurses make to patient outcomes and the achievement of larger health care goals are frequently invisible in ehrs because the standards that exist to represent nursing practice in automated systems are either underused or excluded. nurse-sensitive measures are frequently omitted from ehrs for a multitude of reasons, and they will continue to be, unless the case is made for inclusion. as nurses accelerate their utilization of and leadership in ict-based efforts such as the ehrs, the chance to share perspectives, experiences, and best practices via standardized and exchangeable data must not be missed. nursing experience, leadership, and the nursing voice are needed. interoperability from a global perspective requires international standards in many dimensions such as messaging, security, language, ethical information use, ict management, and other areas-all of which impact nursing and ehrs. again, nursing involvement is critical. one challenge is that there are multiple standardssetting agencies and, most likely, always will be due to the complexity of stakeholders, which increases the difficulty of nursing participation, particularly in consideration of the dearth of qualified standards-literate nurses. while there are many standards organizations around the globe, the international standards organization (iso) and health level 7 (hl7) are 2 of the major standards-setting organizations where nursing is represented (albeit in small numbers), and it must continue to be so. an example of successful nursing involvement and leadership in global standards work is the icnp®. initiated in 1989 by the international council of nurses (icn), icnp® is defined as a unified nursing language system to represent nursing diagnoses, interventions, and outcomes. the vision of icnp® is to be an integral part of the global information infrastructure informing health care practice and policy to improve patient care worldwide. 35 through standardizing the clinical terminology nurses use to describe their practice, icnp® can improve nursing practice and contribute to the advancement of nursing science. the icn also recently partnered with the international medical informatics association-nursing informatics and the international nursing informatics community to establish an international standard through iso. this standard, integration of a reference terminology model for nursing, 36 provides a framework which can be used to map concepts across different terminologies, thereby increasing communication and comparability of data across languages and countries. 37 this iso standard is currently under routine review and is expected to contribute to ongoing harmonization across multiple international standards, giving structure to nursing data in global ehrs efforts. this work is critical to understanding the full processes of and contributors to health care. analysis of data that does not include nursesensitive measures, nursing interventions, and nursing contributions to outcomes is deficient, incomplete, and prone to spuriousness. the international telecommunication union (itu) is another organization involved in standards development that has direct bearing on nursing practice, particularly as related to communications protocols used in disaster relief and community-based services in the aftermath. as the leading united nations agency for information and communication technologies, itu plays a prominent role in the development and deployment of global ict standards. for example, in the aftermath of the indian ocean tsunami in 2004, itu played a major role in pushing for standards for public warnings (called cap or common alerting protocol), disaster management, prevention, and relief. 38 there is a great need for the nursing perspective in these concerns, particularly since a great deal of the care in disaster relief efforts is provided by teams heavily infused with nursing personnel. nurses, as first responders and those often managing the ongoing health needs of a community after disaster teams have left, have a vested interest in ict that supports information and workflow needs. unfortunately, nursing is often absent from the development and deployment of such standards and are frequently left to deal with suboptimal systems. nursing leadership is critical to break the chicken and the egg cycle that comes from unstructured, nonstandardized, and invisible nursing data in the rapidly digitizing world. without comprehensive, rigorous and accessible digital nursing data from large healthcare datasets, nursing practice remains largely invisible, and invisible nursing contributions lead to false assumptions of low nursing contribution to health and health outcomes. in reality, much has not changed since florence nightingale wrote in her 1863 book notes on a hospital, "in attempting to arrive at the truth, i have applied everywhere for information, but in scarcely an instance have i been able to obtain hospital records fit for any purposes of comparison. if they could be obtained . . . they would show subscribers how their money was being spent, what amount of good was really being done with it, or whether the money was not doing mischief rather than good . . ." in 2008, 143 years later, we are still struggling to determine the amount of good that is being provided, largely because the nursing data that is foundational to a full understanding of nursing contributions to outcomes, both good and bad, is still unfit and unavailable for comparison. the opportunities and critical need for nursing leadership are growing exponentially. information itself is becoming a major commodity in health; there are multiple stakeholders interested in access to and sharing of data and information. access to reservoirs of experiential knowledge and collections of explicit information allows for the development of new knowledge based on identified needs, to refine knowledge that already exists, to avoid duplication of effort, to increase alignment with local circumstances, and enhance the creation of actionable knowledge. 39 the value to nursing of such collections of knowledge and experience becomes quite obvious, particularly when considered in the global context and in the face of asymmetries of information. effken and abbott have identified ict solutions for knowledge management in nursing, including the creation and participation in communities of practice (cops). 40 cops trace their roots back to constructivism where the control of learning shifts from the instructor to the learner. wenger discusses ict supported cops specifically, stating "every group that shares interest on a website is called a community today, but communities of practice are a specific kind of community. they are focused on a domain of knowledge and over time accumulate expertise in this domain. they develop their shared practice by interacting around problems, solutions, and insights, and building a common store of knowledge." 41 from a global nursing perspective, especially in light of the scarcity of nursing resources, reusable and accessible nursing knowledge empowered by ict is a powerful tool for the profession. one such ict-supported cop is the global alliance for nursing & midwifery, 42 different countries. the alliance has served as a learning platform, a library, and a knowledge exchange forum for global nurses to exchange best practices, participate in open continuing education, and manage knowledge. the global alliance is unique in that it runs over very low-bandwidth, standard telephone service to allow participation by those in areas without full internet connectivity. participation from low-resource areas is surprisingly robust. other cops exist for nursing, and growth in this area is expected. for example, hara and hew in studying an online cop for critical care nurses in the pacific rim found that an e-cop helped not only to reinforce the identity of the practice of critical care nursing among participants, but that it also served as an important avenue for information and knowledge exchange within the context of everyday work. 43 these authors believe that: "communities of practice can be described as groups of people who are informally bound together by shared expertise and a passion for joint enterprise. they can be viewed as informal networks that support professional practitioners to develop a shared meaning and engage in knowledge building among members. the theoretical construct of communities of practice is grounded in an anthropological perspective that studies how adults learn through everyday social practices rather than focusing on environments that are intentionally designed to support learning." information and communication technology has also stimulated the growth of other approaches to knowledge generation and nursing research. for example, icn recently initiated an electronic international nursing partnership database project. 44 the goal of this project is to document and share ongoing and new international partnerships, as a tool to encourage similar initiatives and aid in planning new ventures. rather than relying on the traditional literature sources for networking and proposal development, this database can provide researchers and others with pre-publication information about existing projects in process. similar to the cop concept, the icn shared database allows the sharing of partnership experiences and results to maximize efficiency and effectiveness. the icn has also developed a portal called the international nursing network to facilitate the exchange of ideas, experience, and expertise for the nursing profession crossing a variety of areas from advanced practice nursing to disaster preparedness. 45 this open access portal serves as a mechanism to encourage global nursing interaction. the management and generation of new nursing and healthcare knowledge is deepened and advanced as new evidence, new perspectives, and new discoveries are shared among global nurses and midwives. information and communication technology provides an opportunity to facilitate participation and to establish partnerships using technology that connects those otherwise not connected. enabling these connections will promote approaches not yet realized to managing, sharing, and generating nursing knowledge. the ultimate benefactors include not only the patients and communities that we serve, but the profession of nursing itself. some scholars suggest that there is a leadership void in nursing, particularly in the global south, where the needs are the greatest. 46 leadership for strategic use of ict and informatics in nursing, and strategic partnerships to support mutual enhancement of ict is an important strategy for the promotion of global health. entrepreneurial opportunities exist for those proactive and creative thinkers who stand ready to capitalize upon them. nurses cannot wait for ict to bring answers to the problems faced in today's world; rather, they need to be engaged in problem-solving activities, testing and evaluating solutions to global health issues using ict. the pace at which ict seeps into health care is only expected to increase, and reasoned action by the nursing community is imperative. the nursing informatics arena has provided avenues for nurses to serve as leaders, including multiple roles in nursing and through participation in professional organizations. however, nursing informatics, like nursing in general, stands at the edge of a workforce crisis that threatens nursing participation in the rapidly progressing world of ict. nursing as a profession cannot leave the progress needed in the face of accelerated global ict solely in the hands of nurse informaticians. informatics practice is quickly becoming part of the expected competency of every nurse and, therefore, is becoming not only a responsibility of every nurse, but as an opportunity for every nurse. the absence of the nursing voice and nursing leadership as global e-health explodes is foreboding. in addition to leadership, strong partnerships are essential to advancing health globally. these partnerships should not only include corporate and philanthropic organizations, but partnerships within the healthcare team as well. interdisciplinary work is critically important and the major contributions that nurses make to global health must be acknowledged and supported at levels much higher than they currently are. similar to the efforts undertaken by the robert wood johnson foundation's commitment to nursing, 47 it would seem appropriate that major foundations and funding agencies would support the investigation and growth of ict as a strategy to support frontline nursing care, since nurses are such a vital source for the delivery of health services worldwide. it is also important to emphasize that the agenda for using ict to advance global health is in no way limited to experts in informatics. nursing expertise in practice, education, administration, research, and policy are all required to advance this agenda. the nursing profession, as partners in improving global health care, has much to contribute, particularly in this new interconnected and flattened world. entrepreneurial opportunities for nurses who are interested in global health and who understand and are intrigued by digital innovation abound. the authors have highlighted examples of first steps that the nursing community has already taken in applying ict to health and healthcare. following the example of amref in uganda and the online training of 22 000 nursescould this model not be built upon and expanded to the global nursing workforce? could nurses, long known for their crucial role in patient education, develop ict-supported solutions to reach patients, their families and caregivers-regardless of geographic location? can we use ict to provide lifelines to isolated nurses, midwives and others who are serving their communities? can we deploy simple ict solutions to combat the problems of collecting critical individual and population health data in remote locations? considering that there are more mobile telephones in use in china today than there are people in the united states, 1 what innovative mobile methods could be developed to deliver health messages, answer questions, or collect data? what role might social networking (e.g., wikis, blogs, virtual communities) play in nursing of the future? what shall be the legacy of the current generation of nursing leaders in this rapidly digitizing world? to answer these questions, we need nurses who have what henry ford classified as those with an "infinite capacity to not know what can't be done." nursing has a long-standing history of advocacy, innovation, and education. the growth of ict in the health and healthcare sector should be looked at as an opportunity for nursing to use a new medium to meet the mission of our profession, not as something to be approached with trepidation and fear. as globalization expands, nursing has the opportunity to step forward and harness the power of ict to serve the greater good. while it is often difficult to make the case for ict in areas where running water and electricity are considered a luxury, access to information must be viewed as a basic tenet of a developing nation, with efforts to increase ict and decrease poverty as complementary, not competitive activities. 18 as nurses, we have the opportunity to renovate and innovate, as we shepherd developments in a way that promotes health for all. at the nursing outlook website: www.nursingoutlook.org. references 1. friedman t. the world is flat: a brief history of the twenty-first century health in an age of globalization globalization definition nursing leadership: international council of nursing globalisation and public health is globalization dangerous to our health? globalization and health: targets met, new needs the globalization of public health. i. threats and opportunities the end of poverty: economic possibilities for our time globalization and its discontents globalization, information and communication technologies, and the prospect of a 'global village': promises of inclusion or electronic colonization? working together for health. world health organization towards a safer future. world health organization implementing electronic medical record systems in developing countries health, wealth, and the chinese oedipus free internet access, the digital divide, and health information slowing the growth of u.s. health care expenditures: what are the options? the commonwealth fund report rural ehealth paradox: it's not just geography! grameen foundation microloan pioneer and his bank win nobel peace prize texting for health distance education: the solution for nursing and midwifery in africa? geneva: international council of nurses pageidϭ514& searchstrϭe%2dlearning. accessed on kenya graduates first 98 nurse definitions of telenursing, telepresence report of the 2004-2005 international telenursing survey national initiative for telehealth framework of guidelines. nifte website, national initiative for telehealth professional standards for telenursing practice past, present and future: experiences and lessons from telehealth projects international competencies for telenursing. published by: international council of nurses international classification of nursing practice version 1.0, geneva: published by: international council of nurses iso: integration of a reference terminology model for nursing nursing language-terminology models for nurses available at: http://my.ibpinitiative. org/displayknowledge.aspx?cϭ1325c561-2b21-449e-880e-6623a1214707&fϭf2716f30-462c-4d39-9adc-ac2d9676b09f& iϭ71b32e5a-c624-429f-a620-ccf6cf3acc33 the nursing role in health it-enabled care management in rural, frontier, and other underserved populations agency for health care quality and research a study of technologies for communities of practice available at: my.ibpinitiative.org/public/ganm/. accessed on a case study of a longstanding online community of practice involving critical care and advanced practice nurses available at poverty and development: pulling forces and the challenges for nursing in africa the robert wood johnson foundation anthology: to improve health and health care volume viii key: cord-316157-7nci4q1q authors: iheduru‐anderson, kechi title: reflections on the lived experience of working with limited personal protective equipment during the covid‐19 crisis date: 2020-10-03 journal: nurs inq doi: 10.1111/nin.12382 sha: doc_id: 316157 cord_uid: 7nci4q1q coronavirus disease 2019 (covid‐19) has placed significant strain on united states’ health care and health care providers. while most americans were sheltering in place, nurses headed to work. many lacked adequate personal protective equipment (ppe), increasing the risk of becoming infected or infecting others. some health care organizations were not transparent with their nurses; many nurses were gagged from speaking up about the conditions in their workplaces. this study used a descriptive phenomenological design to describe the lived experience of acute care nurses working with limited access to ppe during the covid‐19 pandemic. unstructured interviews were conducted with 28 acute care nurses via telephone, webex, and zoom. data were analyzed using thematic analysis. the major theme, emotional roller coaster, describes the varied intense emotions the nurses experienced during the early weeks of the pandemic, encompassing eight subthemes: scared and afraid, sense of isolation, anger, betrayal, overwhelmed and exhausted, grief, helpless and at a loss, and denial. other themes include: self‐care, ‘hoping for the best’, ‘nurses are not invincible’, and ‘i feel lucky’. the high levels of stress and mental assault resulting from the covid‐19 crisis call for early stress assessment of nurses and provision of psychological intervention to mitigate lasting psychological trauma. permitted hospitals to amend their policies, allowing health care workers to reuse ppes and move from patient to patient without changing their gowns or facemasks (cdc, 2020) . although this move appears unprecedented, it is in line with the guidelines for changes in health care delivery during emergencies, when the focus is on saving as many lives as possible, and health care providers including nurses, may be expected to practice outside of the normal scope of their practice (koenig, lim, & tsai, 2011; powell, christ, & birkhead, 2008) . these changes in standards of care were instituted by the agency for healthcare research and quality and the office of the assistant secretary following the 911 terrorist attack, 2001 anthrax letter attacks, and the fears of the avian influenza pandemic in 2004 (agency for healthcare research & quality, 2005 , 2007 . powell et al. (2008) emphasized that during disasters and endemics, health care providers need to discuss any anticipated changes to the standards of care, particularly as it relates to limited resources, such as ventilators. because the community and the public are expected to adjust to the scarcity of resources, powell and colleagues stressed that 'even before a patient comes to the hospital, political leaders and health officials must emphasize publicly that standards of care are and must be different in a public health disaster' (powell et al., 2008, p. 25) . health care providers must do whatever they can with the available resources. in a scarce resource environment, the focus of care shifts from the individual patient to optimizing outcomes for populations of patients (chang, backer, bey, & koenig, 2008; koenig et al., 2011; powell et al., 2008) . veenema and toke (2007, p. 72c) underscored the protection of health care workers during crises, stating that 'giving providers and their families personal protective equipment and instituting other measures such as staff rotation and stress management programs' are essential to preventing burnout. in the context of covid-19, while some hospitals require their staff to wear face masks at all times while onsite (fox, 2020) , others are preventing their workers from wearing face masks brought from home, with some hospital administrations even threatening their staff with disciplinary action, including termination (ault, 2020) . these conflicting policy changes and confusion have posed a different type of challenge for health care workers. there have been several online reports of nurses and other health care providers being intimidated or reprimanded for speaking out about their working condition during the pandemic. this prompted the american nurses association (ana) to respond, calling on occupational safety and health administration (osha) to remind employers that retaliation against health care workers for speaking out and raising concerns about their personal safety while caring for covid-19 patients is illegal (ana, 2020c) . the ana reminded nurses experiencing retaliation from their employers of their right to file a whistleblower complaint online with osha. as many hospitals continue to restrict the use of ppe to preserve their supply in anticipation of growing covid-19 cases with the rapidly evolving outbreak, many health care providers on the frontline believe that the ppe restrictions are impeding their ability to safeguard their welfare (ana, 2020d) . these policy changes presented by health care organizations are in line with the crisis capacity category described by the institute of medicine (2010) and the cdc (2020). 'crisis capacity is defined as adapting spaces, staff, and resources so that … you're doing the best you can with what you have. staff may be asked to practice outside of the scope of their usual expertise. supplies may have to be reused and recycled. in some circumstances, resources may become completely exhausted. family members may be asked to provide basic patient hygiene and other aspects of care that do not require medical expertise' (institute of medicine, 2010, p. 13) . little research has examined the experiences of nurses during global, regional, or national health care crises related to disease outbreaks or natural disasters. existing studies have focused on hospital preparation, availability of resources, and the safety of patients (barbisch & koenig, 2006; karabacak, ozturk, & bahcecik, 2011; ruchlewska et al., 2014; tzeng & yin, 2008) , the education of hospital staff (powers, 2007) , emergency room nurses' description and management during a crisis (vasli and dehghan-nayeri, 2016) , and the psychological impact of disease outbreaks on hospital workers (sun et al., 2020; wu et al., 2009; yin & zeng, 2020) . however, in mass casualty events and disease outbreaks, nurses may experience anxiety and personal loss (sun et al., 2020; veenema & toke, 2007; yin & zeng, 2020) . most studies of nurses' experiences during a disease outbreak were focused on asian countries due to current and previous experiences related to covid-19, middle east respiratory syndrome-coronavirus (mers-cov), and human swine influenza outbreak (khalid, khalid, qabajah, barnard, & qushmaq, 2016; kim, 2018; lam & hung, 2013; su et al., 2007; sun et al., 2020; yin & zeng, 2020) . a study conducted in turkey to determine the crisis management activities and attitudes of hospital nurse managers during times of crisis, such as earthquakes and bomb explosions reported that over '71% percent of the nurse managers surveyed in these hospitals left resolution of crisis to the top hospital management, 64.7% noted they increased the number of the staff members, and 58.1% said they ignored crises' (karabacak et al., 2011, p. 323) . crisis situations such as the one presented by covid-19 are a major barrier in providing optimal care as they have a strong impact on patients, their families, communities, and health care providers. during a crisis, nurses and other health care providers face various moral and ethical conflicts and dilemmas (koenig et al., 2011; tzeng & yin, 2008) . patient care is significantly affected by several factors, such as stress and fatigue, workload, lack of time, demand for expertise (kim, 2018; lam & hung, 2013; mahmoudi, mohmmadi, & ebadi, 2013) , influx of patients, experiences of health care providers, as well as level of managerial support (hagbaghery, salsali, & ahmadi, 2004; healy & tyrrell, 2011; kelley et al., 2004 ). an ana survey of 32,174 nurses working on the frontline during the covid-19 crisis indicated that 74% were concerned about the lack of ppe, 58% feared for their personal safety, and 64% were extremely concerned about the safety of their friends and family (ana, 2020d). considering the sparseness of empirical data on the lived experiences of nurses during crises situations, especially in the united states, this study examined the experiences of frontline nurses during the covid-19 crisis. crisis is defined as an undesirable event or outcome, which includes the element of surprise or disruption of action, and is a threat to the resources and well-being of an individual within the organization. it can have negative consequences, such as increased risk of death, delay in treatment, ignoring medical advice, and putting nurses under pressure (vasli and dehghan-nayeri, 2016) . in crisis situations, important lifesaving resources, such as 'ventilators and components, oxygen and oxygen delivery devices, intensive care unit beds (adequately staffed and equipped), health care providers, medications, etc.) are likely to be scarce' (koenig et al., 2011, p. 3) . similarly, during the covid-19 outbreak, the entire nursing workforce is facing a significant demand, which is anticipated to increase at an alarming rate. the purpose of this study was to describe the lived experience of acute care nurses working with limited access to ppe during the covid-19 pandemic. how do registered nurses describe the lived experience of working with limited ppe during the covid-19 crisis? this qualitative descriptive phenomenological study explored the lived experiences of acute care nurses working on the frontline during the covid-19 disease outbreak. descriptive phenomenology was chosen as the design for the current study because it explored and described the participants' everyday experiences as they lived them while working with limited ppe on the frontline of the 2020 covid-19 crisis. phenomenology as a research method is dedicated to describing the structures of experience as perceived by individuals without recourse to assumptions, judgments, or presuppositions (van manen, 2017a) . it is the search for structure and essence in experience, to form a deeper understanding of the nature and meaning of everyday experience (munhall, 2012) . the focus is on providing rich textured description of the individual experiences as described by those who experience it. the role of the researcher is to describe what people experience and how they experience it (finlay, 1999) , and to understand these experiences as much as possible through the eyes of the research participants. purposive sampling augmented with snowball sampling was used to recruit participants who met the inclusion criteria. to qualify to partake in the study, the participant was required to be a registered nurse, working in an acute care setting, or in units with diagnosed covid-19 patients or . recruitment was done through direct email to nurses working on the frontlines known to the author, via facebook and linkedin posts, posts to nursing support forums, and by wordof-mouth. participants were encouraged to share recruitment flyers with their colleagues to increase the sample size. the study was approved and monitored by the central michigan university institutional review board (irb) for the protection of human subjects in research. the irb-approved informed consent form was emailed to the participants for their review before scheduling the telephone interviews. prior to each interview, verbal consent to participate in the study was audio recorded and transcribed as part of the interview. to ensure confidentiality, each participant was assigned a pseudonym (creswell, 2012) , which was used throughout the research and for data presentation. all raw data were stored in dated folders in a secured network location. phenomenology is focused on lived experiences, aimed at describing, not explaining, how and why meanings arise, without researcher bias (finlay, 1999) . 'phenomenology does not look for 'truth' but for the participants' perceptions of 'their truth'-their own experiences as they perceive them' (sloan & bowe, 2014, p. 1,300) . using thematic analysis as described by burnard, gill, stewart, treasure, and chadwick (2008) , once the audio recording had been transcribed, the author familiarized herself with the data and verified its accuracy by simultaneously reading the transcript and listening to the audio recordings. during this process, any personal information, which may have been erroneously included in the interview, was deleted. all transcripts were line numbered. during the second reading of each transcript, open coding was performed by highlighting sections of the text and entering words and phrases that summarize what is being said in the text into an excel spread sheet created for this purpose. next, all the words and phrases from each individual interview spread sheet were compiled onto a single page. duplicate words and phrases were deleted, and overlapping and similar categories were refined and merged to reduce the number of categories. all the interview data relevant to the research purpose were allocated to the appropriate categories, which formed the final themes and subthemes. the author consulted a colleague not involved in the study to verify the coding process, and solicit unbiased feedback (elo et al., 2014) . finally, a report was written from the information organized in this table of findings. trust in qualitative research findings may be addressed using at least two of eight key strategies developed from lincoln and guba's model of trustworthiness (creswell, 2012) . lincoln and guba (1985) introduced the criteria of credibility, transferability, dependability, and confirmability for the assessment of rigor. for the reader to appraise transferability to other settings or populations, the author has provided justification for the research design, detailed description of the inclusion criteria, sample characteristics, and data collection and analysis methods (hader, 2010; maher, hadfield, hutchings, & de eyto, 2018) . bracketing, which allows one to become less assuming about another's experience, to be open, nonjudgmental and compassionate, and to present data from the perspectives of the participant rather than the researcher (chan, fung, & chien, 2013) was practiced. owing to the unprecedented nature of the covid-19 pandemic and its persistent broadcast on mass media, keeping a reflexive journal was very important for the author. the author chose to explore the experiences of these nurses because as a nurse who no longer worked in acute care setting, i wondered what it must be like to go to work every day during this crisis. it was important to hear directly from the nurses as they reflected on their everyday lived experiences. at times during the study interviews and data analysis, i was sometimes overwhelmed by the experiences described by these nurses. therefore, keeping a journal was very important for me to document and explore these feelings, in order to fully represent the participant experiences rather than mine. the author also engaged with other nurse colleagues to reflect on the overall effects of the pandemic and continued to maintain a reflexive journal to elucidate evolving perceptions throughout the research process (tufford & newman, 2012) . member-checking was ensured by returning to six participants to verify the transcribed audio recordings and clarify statements made during the interviews. a summary of the findings and themes was discussed with four participants in a telephone conference call. they all confirmed that the themes accurately reflected their experiences. this respondent validation is used to ensure the dependability and credibility of qualitative studies (elo et al., 2014; hadi & josé closs, 2016) . the sample comprised of 28 nurses, 21 women and 7 men, aged 28 to 65 years. their level of education ranged from associate degree to master's degree in nursing. all participants worked in acute care hospital, with 22 working in hospital in the northeast, 2 in the southeast, and 4 in midwestern united states (table 1 ). the lived experience of acute care nurses working with limited access to ppe during the covid-19 pandemic has been summarized into four themes. the first main theme is emotional roller coaster, which describes the intensity of the varied emotions the nurses experienced during the early weeks and months of the pandemic, encompassing the following subthemes: scared and afraid, sense of isolation, anger, felt betrayed, overwhelmed and exhausted, grief, helpless and at a loss, denial. other main themes include: self-care, 'hoping for the best', 'nurses are not invincible', and 'i feel lucky'. the themes, subthemes, and participants' exemplar quotes are displayed in table 2 . age range (in years) 28 to 65 experience of nursing practice (in years) 3 to 42 highest level of nursing education associate's degree in nursing (asn) 5 bachelor's degree in nursing (bsn) 17 master's degree in nursing (msn) 6 unit of acute care employment medical-surgical unit (med/surg) 11 emergency department (ed) 6 intensive care unit (icu) 10 'i felt like my employers were too busy covering their butts, that they continued to lie. on television, they tell the public that their main concern is the safety of their employees, but their actions were contradictory'. (nikki) overwhelmed and exhausted 'the barrage of information was too much. i was mentally and emotionally exhausted to take advantage of them. i am still mentally exhausted. i cried a lot. i lose my patience with minimal provocation'. (alexie) 'i was tired all the time. it was very hard getting out of bed, but i pushed myself to get up and go to work. after a very long day of seeing nothing but suffering and death, i feel mentally drained'. (priest) grief 'i used to think that nurses can overcome anything, but the death of that nurse, was devastating for me. i know people die, but…, it just hit home for me, the death of a nurse, someone you work with, and… my heart just aches'. the sense of isolation was profound for some of the nurses. although they went to work and were able to see their coworkers, many were isolated from their loved ones, for fear of unknowingly infecting them with the virus even when they were negative or asymptomatic. because some of these nurses felt like their close relative, who are not health care providers, would be unable to understand their grief, they kept their true feelings to themselves. therefore, close relatives did not know how to offer support, and were sometimes not able to recognize when their actions were perceived as unsupportive. in these situations, the nurses felt isolated and were not able to share their experiences with those who are closest to them. anger intermingled with fear was pervasive throughout the study. interestingly, very few participants (three) discussed being physically exhausted. all of them discussed being 'emotionally and mensome participants discussed being physically overwhelmed by working long hours and several days without days off for rest because nurse coworkers got sick or quit their jobs for fear of contracting the virus. one of the participants discussed being 'overwhelmingly exhausted', but was afraid to call out sick without being covid positive because she had not been on the job for a long time and her manager was very critical of nurses who called out, reminding the nurses that sick calls during the covid crisis will be considered during the annual evaluation. many participants discussed being overwhelmed and 'stressed out' with the volume of information received from work, social media, and television. some reported being short-tempered, cried with minimal provocation, or for 'no apparent reason', and 'not being able to hold it together'. alexie discussed being aware of important stress management strategies but not being able to use them due to mental and physical exhaustion. several nurses talked about their grief. jackie discussed her grief in the following statement: the pain and sorrow you feel when you learn that one of your coworkers has succumbed to this deadly virus. the feelings of helplessness and loss were echoed by many of the robert's concerns were echoed by amber who questioned the information being provided by her employer. least among the nurses' roller coaster of emotions was denial. other nurses were in denial because they were receiving mixed messages from their employers, managers, and the government, and because it was easier to deny the reality. self-care, and the lack thereof, was expressed by more than half of the participants. some described self-care as maintaining connections to other people, family, and friends during the difficult time. for others it meant keeping up with their routines prior to the crisis, like exercising, taking time to rest, and connecting with loved ones. some discussed not being able to 'shut it off' even when away from work. watching excessive television or following the news on social media affected their sleep and increased their anxiety. jane talked about forgetting to care for herself while caring for others. some of the participants used some unhealthy practices, such as increased smoking, alcohol consumption, and overeating or eating 'comfort foods', which were not particularly healthy to deal with increased stress. hoping for the best described what most of the nurses did once they reconciled to not having control over the pandemic or the non-availability of ppe. all the nurses in this study did what they were trained to do and hoped for the best outcome for themselves, their families, and their patients. for instance, kasey stated, just have faith, do your best, and hope for the best. if it is your destiny to die from this virus, whether you go to work or not, you will die from it. it's like a mantra for me. it kept me from screaming out loud and going crazy. i went to work, did what i trained to do, and hoped for the best outcome. flower who has only been employed at her current hospital for a little over four months felt that she did not have a choice but to go to work stating that she did what she needed to do and 'hoped for the best'. kelly also expressed being hopeful stating, we are nurses; we do what needs to be done. it is up to the employers and the government to provide us what we need to do the important work of taking care of patients and saving lives. in the situation we found ourselves with lack of adequate supply of ppe, and other things…sometimes limited iv supplies, we did our best and keep our fingers crossed. while many of these nurses have taken care of patients with various communicable diseases and worked with limited resources before, they expressed never having worked in situations where they lacked appropriate ppe. several of the participants' comments indicated that they felt that they were viewed as invincible, able to continue to operate without proper care. some felt that their employers perceived their lives and well-being as less important than that of their patients. twelve nurses in this study had eventually tested positive for covid-19; seven were symptomatic but did not require hospitalization. in describing their experiences, they compared it to being sui wish they would treat nurses with more care. others were told by their employers that even if they tested positive, but remained asymptomatic, they had to continue working. noah expressed surprise at this instruction from her unit manager, stating, 'nurses are often viewed as machines, unbreakable. we can be expected to be superhumanly resourceful and resilient, but in this crisis, we needed a little more caring'. several of the nurses talked about the need to feel supported and appreciated for what they were doing during the crisis when many around the world were sheltering in place, but they had to go to work. this is evidenced by sophia's statement: i am very grateful that the hospital eventually recognized the important work we were doing, that we too needed caring for. when they started providing safe transportation and meals for us, i was grateful. it made me feel like someone cared. under the circumstances we had to work, it made a difference. the above statement is in contrast to abby's statement about not feeling supported by her employers and managers, comparing herself to hospital equipment, especially during the earlier days of the pandemic. she stated, in the first three weeks of this madness, i just wanted to feel supported, i wanted to feel that my leaders and employers cared about me; i did not feel that… i felt like i was easily dispensable and placed at the same level as the hospital equipment. i seriously considered quitting, but i couldn't do that to my colleagues. nurses just want to be valued as humans… the participants talked about feeling lucky. lucky that they were not sick, were able to work and provide for their families and their this study aimed to describe the lived experience of acute care nurses who had to work with limited access to ppe during the covid-19 pandemic. their experiences denote intense emotional turmoil described under five main themes. the fear, anger, sense of isolation, exhaustion, and helplessness are consistent with feelings described by nurses caring for covid-19 patients in china (sun et al., 2020) . while many americans were following the shelter-inplace orders issued across the country to protect themselves from covid-19, tens of thousands of nurses across the united states were heading to work every day to care for patients affected by covid-19 and others requiring hospitalization for various ailments. the critical shortage of ppe for nurses and other health care workers placed them at risk of contracting the virus, becoming sick, and even dying. the emotional roller coaster was more pronounced during the earlier weeks of the pandemic in the united states, as also reported by sun et al. (2020) . the nurses' negative emotions were more pronounced when they first began taking care of covid-19 patients. o' boyle et al. (2006) reported that nurses were overwhelmed with the workload and longer work hours because some colleagues refused to work during the crisis. the nurses were concerned about exposing their families to the virus, which was also a concern for nurses taking care of patients during the 2003 outbreak of severe acute respiratory syndrome (sars) in taiwan (lee et al., 2005) , and middle east respiratory syndrome-coronavirus (mers-cov) in south korea. the sense of isolation was worsened with the nurses changing their home routine to protect their loved ones as was also reported by nurses caring for ebola virus patients (smith, smith, kratochvil, & schwedhelm, 2017) . physical and mental exhaustion, and the sense of betrayal expressed by the participants has been reported in other studies (lam & hung, 2013; sun et al., 2020) . o'boyle et al. (2006) reported that nurses feared they will be abandoned, have limited access to ppe, be at risk of infection, and have unmanageable numbers of patients to care for in cases of public health emergencies like covid-19. with the care standards and infection control protocols changing frequently during the covid-19 pandemic, the nurses were confused by the conflicting information they received. these changes also created moral and ethical dilemma for the nurses. evidence from public health literature indicates that appropriate communication of information is a major challenge during public health disasters (powell et al., 2008; vasli and dehghan-nayeri, 2016) , and poor communication and inaccurate information can weaken public trust in the government and result higher mortality rates (choi, kim, moon, & kim, 2015) . the nurses in this study struggled to balance their concerns with personal safety with their ethical and moral obligation to provide quality care for their patients. this is in line with the evidence from jiang (2020) study on the psychological impact and coping strategies of frontline medical staff in hunan china during the outbreak of covid-19, as well as kim and choi (2016) these nurses reported that they received conflicting information from their leaders at different levels. this is in conflict with ana warning issued in march 2020 that a lack of ppe will increase the risk of nurses becoming ill themselves, and more equipment was necessary to mitigate potential staff shortages caused by illness and quarantines (ana, 2020c). as reported by some of the nurses in this study, many health care organizations were not transparent with their nurses, many nurses were gagged from speaking up about the conditions in their workplaces. several of the nurses discussed self-care activities, such as exercise, meditation, and listening to podcasts, used to cope with the stress of dealing with the crisis. some mentioned avoiding watching the news. previous studies of nurses working with patients during severe disease outbreaks have highlighted the importance of selfcare activities to improve psychological well-being (sun et al., 2020; yin & zeng, 2020) . appropriate and supportive care for nurses is critical to prevent adverse short-and long-term outcomes for them and their families. studies indicate that perceived support is an important factor for mitigating prolonged and complicated grief (hutti et al., 2017; kim, 2018) . in taiwan the nurses in this study did not report experiencing any stigma from the community as disease carriers. which is in conflict with report from other studies where nurses and other health care providers reported being perceived as disease carriers and a threat to the safety of others (maben & bridges, 2020; sun et al., 2020) . nurses in this study reported being angry for several reasons. maben and bridges (2020, p. 2,743) reported that a 'failure to protect nursing staff adequately is causing anger and frustration, making nurses feel unsafe at work, while they are risking their own health and fearful of transmission to their families'. another source of anger rose from the focus of inadequate access to ppe in acute and intensive care settings, making it seem that the lives of nurses and care providers in non-acute care settings appear to matter less. overall, the high levels of stress and mental assault resulting from the covid-19 crisis calls for early stress assessment of nurses and providing psychological intervention to mitigate lasting psychological trauma. the author engaged in continued telephone communications with the two nurses who expressed wanting to hurt themselves during the interview for several weeks until they were able to secure professional psychological help. further, it is critical for nurse leaders and health care administrators to understand the impact of grief on the nurses. while most nurses will experience normal grief reactions in response to the covid-19 crisis, others may have significant, sustained, extremely intense, complex grief responses, which may negatively affect their physical and psychological well-being. those battered by stress may be the last to recognize it and stigma can be an obstacle to asking for help. as expressed by one of the participants, some of the nurses may not want to appear weak, put pressure on their peers, or they may fear of letting down their teams. therefore, nurse leaders must monitor their nurses for signs of complicated grieving, such as anxiety, depressive symptoms, and signs of post-traumatic stress disorders. the sense of betrayal expressed by these nurses should not be brushed off. it must be addressed. there is still time for employers and nurse leaders to redeem and repair lost trust of some of their nurses. nurse leaders and employers must respond to the needs of their nurses by using scientific evidence. ongoing honest communication of facts and compassionate responses for the nurse's experiences must be ensured. instead of protecting the institution, leaders must be transparent and lead with heart. policies related to the covid-19 must consider the many facets of the complex issues facing the nurses instead of taking a one-size-fits-all approach. the existing stigma of mental illness has not dissipated because of covid-19; therefore employers must do whatever they can to ensure that nurses who need help get it. there are several limitations to this study. first, the qualitative nature of the study limits the generalization of the findings. all the interviews were conducted from a distance through telephone or audio-visual means, and therefor, there was limited observation of body language beyond the tone of voice. although the study examined the lived experience of working with limited ppe during the covid-19 crisis, the crisis is still ongoing and many of the nurses were working in less than ideal conditions. future studies must examine the experiences of the nurses several months and years after the crisis is under control. the experiences of others working in health care during this crisis should also be explored. the covid-19 crisis is unprecedented. the degree to which nurses were exposed to death and experienced grief is alarming. although there were weeks of warning of impending pandemic, health care organizations and the u.s. government failed in their duty to provide for and protect their health care workers. while many americans socially isolated in their homes to avoid contracting the covid-19, nurses were heading to work, willingly exposing themselves and in some cases their families. the findings of this study indicate that many nurses across the united states now need their employers and the organizations to be present for them. although not explicitly named in some cases, many are suffering from trauma, and sustained mental and emotional stress. they need support for their mental and emotional health. it should not be assumed that nurses would seek help if needed. employers and leaders should preemptively offer support and in some cases should mandate that nurses speak to counselors or psychologists to promote mental and emotional well-being. this is an important opportunity to fully recognize that nurses are invaluable but finite assets, for generations they bear inherent emotional strain on behalf of society. to mitigate the loss of currently practicing nurses which will likely worsen the projected nursing shortage, the nursing profession and health care leaders must do all they can to support the welfare of nurses during this crisis and beyond. the author wishes to acknowledge all the nurses who took part in this study and the central michigan university, especially the college of health professions for providing the time release for the completion of this study. kechi iheduru-anderson https://orcid. org/0000-0003-2353-0410 coronavirus disease 2019 (covid-19) altered standards of care in sass casualty events: bioterrorism and other public health emergencies (no. 290-04-0010; bioterrorism and other public health emergencies) ana disturbed by reports of retaliation against nurses for raising concerns about covid-19 safety amid ppe shortage, clinicians face harassment, firing for selfcare understanding surge capacity: essential elements guidance for planners of the psychological response to stress experienced by hospital staff associated with covid: early interventions. covid trauma response working group rapid guidance analysing and presenting qualitative data bracketing in phenomenology: only undertaken in the data collection and analysis process? maximizing medical and health outcomes after a catastrophic disaster: defining a new mental health care for medical staff in china during the covid-19 outbreak public health crisis response and establishment of a crisis communication system in south korea: lessons learned from the mers outbreak qualitative inquiry and research design: choosing among five approaches qualitative content analysis: a focus on trustworthiness predictors of maternal grief in the year after a newborn death applying phenomenology in research: problems, principles and practice all partners healthcare employees now required to wear masks while on duty nurse leaders: a closer look ensuring rigour and trustworthiness of qualitative research in clinical pharmacy the factors facilitating and inhibiting effective clinical decision-making in nursing: a qualitative study stress in emergency departments: experiences of nurses and doctors predicting grief intensity after recent perinatal loss forum on medical and public health preparedness for catastrophic events psychological impact and coping strategies of frontline medical staff in hunan between crisis management: the activities of nurse managers in turkey the critical care crisis in the united states healthcare workers emotions, perceived stressors and coping strategies during a mers-cov outbreak factors influencing emergency nurses' burnout during an outbreak of middle east respiratory syndrome coronavirus in korea nurses' experiences of care for patients with middle east respiratory syndrome-coronavirus in south korea crisis standard of care: refocusing health care goals during catastrophic disasters and emergencies perceptions of emergency nurses during the human swine influenza outbreak: a qualitative study facing sars: psychological impacts on sars team nurses and psychiatric services in a taiwan general hospital naturalistic inquiry covid-19: supporting nurses' psychological and mental health ensuring rigor in qualitative data analysis: a design research approach to coding combining nvivo with traditional material methods barriers to nursing care in emergency wards a phenomenological method nurses' beliefs about public health emergencies: fear of abandonment allocation of ventilators in a public health disaster evaluation of hospital-based disaster education effect of crisis plans on admissions and emergency visits: a randomized controlled trial phenomenology and hermeneutic phenomenology: the philosophy, the methodologies, and using hermeneutic phenomenology to investigate lecturers' experiences of curriculum design the psychosocial challenges of caring for patients with ebola virus disease prevalence of psychiatric morbidity and psychological adaptation of the nurses in a structured sars caring unit during outbreak: a prospective and periodic assessment study in taiwan a qualitative study on the psychological experience of caregivers of covid-19 patients bracketing in qualitative research crisis management systems: staff nurses demand more support from their supervisors phenomenology and meaning attribution but is it phenomenology? qualitative health research emergency nurses' experience of crisis: a qualitative study when standards of care change in mass-casualty events the psychological impact of the sars epidemic on hospital employees in china: exposure, risk perception, and altruistic acceptance of risk a study on the psychological needs of nurses caring for patients with coronavirus disease 2019 from the perspective of the existence, relatedness, and growth theory key: cord-334039-7nwq4vxk authors: russo, giuliano; fronteira, inês; jesus, tiago silva; buchan, james title: understanding nurses’ dual practice: a scoping review of what we know and what we still need to ask on nurses holding multiple jobs date: 2018-02-22 journal: hum resour health doi: 10.1186/s12960-018-0276-x sha: doc_id: 334039 cord_uid: 7nwq4vxk background: mounting evidence suggests that holding multiple concurrent jobs in public and private (dual practice) is common among health workers in lowas well as high-income countries. nurses are world’s largest health professional workforce and a critical resource for achieving universal health coverage. nonetheless, little is known about nurses’ engagement with dual practice. methods: we conducted a scoping review of the literature on nurses’ dual practice with the objective of generating hypotheses on its nature and consequences, and define a research agenda on the phenomenon. the arksey and o’malley’s methodological steps were followed to develop the research questions, identify relevant studies, include/exclude studies, extract the data, and report the findings. prisma guidelines were additionally used to conduct the review and report on results. results: of the initial 194 records identified, a total of 35 met the inclusion criteria for nurses’ dual practice; the vast majority (65%) were peer-reviewed publications, followed by nursing magazine publications (19%), reports, and doctoral dissertations. twenty publications focused on high-income countries, 16 on lowor middle-income ones, and two had a multi country perspective. although holding multiple jobs not always amounted to dual practice, several ways were found for public-sector nurses to engage concomitantly in public and private employments, in regulated as well as in informal, casual fashions. some of these forms were reported as particularly prevalent, from over 50% in australia, canada, and the uk, to 28% in south africa. the opportunity to increase a meagre salary, but also a dissatisfaction with the main job and the flexibility offered by multiple job-holding arrangements, were among the reported reasons for engaging in these practices. discussion and conclusions: limited and mostly circumstantial evidence exists on nurses’ dual practice, with the few existing studies suggesting that the phenomenon is likely to be very common and carry implications for health systems and nurses’ welfare worldwide. we offer an agenda for future research to consolidate the existing evidence and to further explore nurses’ motivation; without a better understanding of nurse dual practice, this will continue to be a largely ‘hidden’ element in nursing workforce policy and practice, with an unclear impact on the delivery of care. electronic supplementary material: the online version of this article (10.1186/s12960-018-0276-x) contains supplementary material, which is available to authorized users. health workers' dual practice has been identified as one of the priority research areas in the human resources for health domain [1] . there is a concern among policymakers and patients alike that simultaneous engagement with public and private sector activities jeopardise the availability of professionals and the quality of services in the public sector and divert patients towards costlier private care, therefore putting at risk the attainment of universal health coverage (uhc) goals [2, 3] . 'dual practice' in the health sector has been defined as health workers' concomitant engagement in public and private sector clinical activities, with the public sector job representing the 'primary' one to which the largest proportion of working hours are allocated [4] . although very common worldwide, the practice has been traditionally treated with suspicion by the public health and health system research literature, amid fears that it may compromise the supply of public services [5] and encourage absenteeism in public institutions [6] , as well as the selection and diversion of patients towards private services [7] . scholars have highlighted the possible potential benefits of the practice, such as the opportunity it offers to provide a wider range of health services to the population and to retain underpaid workers in the public sector [8] . others have paid attention to the regulatory aspects [9] , with some focusing on the systems' governance and institutions [10] and others on the incentives to be offered to achieve the desired level of service provision [11, 12] . substantial literature exists on physicians' dual practice [13, 14] , most recently building up evidence on its prevalence, forms, and drivers worldwide [15] [16] [17] , as well as on modelling possible regulatory frameworks [12, 18] . however, nurses' engagement in multiple job-holding is, in comparison, less explored, despite preliminary evidence of its high prevalence in high-income [19] as well as in lowincome settings [20] , and amid concerns of its impact on the nurses' wellbeing [21] . nurses and midwives are the world's largest group of health professionals, representing 48% of the global health workforce, and their role is widely considered critical for the delivery of uhc goals in high-as well as low-income countries [22] . however, the profession has recently come under pressure because of growth of the demand for health services and concomitant scarcity of funds, and the global shifts in the world's health labour market [23] . as the nursing workforce is predominately female, policy options to address nurses' participation in the public and private labour market will need to take gender into account [24, 25] . this scoping review sets out to fill this knowledge gap by systematically searching and reviewing the studies conducted on nurses' simultaneous engagement in public and private clinical activities [26] . its specific objectives are (1) to map out the existing literature on the subject, determining its prevalence and distribution across geographies, publication types (e.g. peer-reviewed, grey), and specific topics addressed; (2) summarise the evidence, perspectives, and specific contents addressed; and (3) propose an agenda to advance research and development activities to first identify and then mitigate any pervasive effects of nurses' dual practices to uhc, based on the scoping review results. a scoping review was conducted to determine the extent and key themes within the literature on nurses' dual practice, as well as to identify areas for future research on the topic. such knowledge synthesis method is commonly used to address exploratory research questions, to map the existing literature on a field or to preliminarily identify gaps in that literature [26] [27] [28] . we used the five arksey and o'malley's methodological steps to develop the research questions, identify relevant studies, include/ exclude articles, extract the data, and report the findings [28] . as the methodological guidance for the report of scoping review is still under development, we used the prisma guidelines where appropriate [29] . in march 2017, we searched medline (through pubmed), the isi web of knowledge, scopus, and the cinhal plus with full texts (through ebsco). we used a set of keywords for the searches and, where appropriate, medical subject headings for nurses combined with keywords and indexed terms related to dual practice (using the bolean operator ' and'). additional file 1 provides full details for the initial search strategy for each of the databases searched. the grey literature also was searched by visiting websites dedicated to nursing and/or health workforce issues. to widen the scope of the review, the searches on databases and grey literature were not filtered for publication date, language, or publication type. human resources for health experts (named in the additional file 1) were a priori contacted to provide relevant references on forms of dual practices among nurses. a posteriori (early december 2017), and based on suggestions coming from the peer-review process, we expand the search terms in the database searches (adding the keywords 'temporary employment' and 'multiple employers') to provide a few additional records which were considered for the review results, as well. iterative rather than strictly streamlined procedures are typical in the process of conducting scoping reviews [26] . a final search strategy included snowballing searches (reference list scanning, author tracking) performed on the articles preliminarily selected. references from databases or other sources were filtered through the same eligibility criteria. to be included, studies needed to address explicitly both nurses and dual practice issues. the working definition for the 'nurses' category contained explicit reference in the text to the professional label, with midwives included too. the working definition of dual practice, in turn, referred to concomitant practice in two (or more) distinct clinical services, either in the same or in different healthcare institutions. public employment was considered the primary job, whereas the secondary (or subsequent) job(s) was considered the one(s) where fewer working hours were spent, periodically or regularly. alternative labels for dual practice included 'moonlighting' , 'public-private work' , 'multiple profit-generating activities' , 'dual/multiple job-holding' , and 'second jobs'. 'casualization of work' , defined as the process of replacing full-time and regular part-time staff with contract staff employed on an ad hoc basis, is another phenomenon related in many ways to dual practice [30] . as such, papers addressing this form of employment in relation to dual practice were also included. documents in english, french, portuguese, italian, and spanish were included. with the exception of journal commentaries, editorials, and letters to the editor, we did not exclude references because of the type of article (such as opinion pieces), study output (e.g. final or preliminary results), countries or world regions, publication status (i.e. both peer-reviewed and grey literature), or publication date. titles and abstracts were first screened by one of the authors (tj) and then reviewed in duplicate by the first author (gr), who finally determined the suitability for the full-text review. full-text review was carried out by one of three authors, all with a research track record in nurse workforce and/or dual practice issues (gr, if, jb). any of the authors were able to directly include or exclude papers on the basis of the eligibility criteria; agreement between two or more reviewers was sought for doubtful cases. based on the overarching aim of the paper, the preliminary knowledge of the literature, and a priori consultation with health professionals [13] , we developed the following set of questions to guide the data extraction for the review: what are the forms in which nurses engage in multiple profit-generating activities? what are the different features of nurses' multiple job-holding? what is the prevalence of this phenomenon in nursing? why do nurses engage in dual practice? what are the enablers and barriers for nurses' dual practice? what are the personal/ professional drivers and consequences? what are the consequences for health systems, specifically for the delivery of quality and safe nursing/health care? what are the consequences for nurses' welfare? what are the consequences for patients? what are health workers', managers', and patients' perceptions around this practice? data extraction tables were then purposively built by the research team to collect data on the specific questions above, either using textual data or synthesis of the articles' findings/conclusions. consistent with the scoping review methodology, the data extraction did not involve quality appraisal or grading of the evidence from the studies. a conventional form of qualitative content analysis, with coding categories derived directly from the text data, was used to analyse data retrieved for each topic [31] . the first author performed a first synthesis of the extracted material, that was then iteratively edited by two of the other authors (if, jb) following the themes from the data extraction table. from 228 records retrieved, 159 (70%) were excluded after reviewing their titles and abstracts (fig. 1 ). an additional four articles were identified through snowballing search strategies, resulting in a total of 73 full texts assessed for eligibility. of all these, a total of 35 (48%) articles finally met the inclusion criteria for addressing dual practices of nurses: 20 using predominantly quantitative methods and 15 using mostly qualitative designs. the vast majority of the studies were in english, with only four published in portuguese and one in spanish. additional file 2 provides spreadsheets for the (a) list of included articles organised by study-type, (b) the data extraction table, and (c) list of articles excluded with the respective reasons. the vast majority of such documents (65%) were peerreviewed publications, with the remainder being nursing magazine publications (19%), reports, and doctoral dissertations. twenty publications focused on high-income countries (particularly on the usa, uk, canada, and australia), 16 on low-and middle-income ones (south africa, ethiopia, iran, and uganda), and two provided a global view on the phenomenon. many of the documents (n = 28) reported information on the prevalence of the phenomenon, and discussed its different forms (25) . drivers and motivations of nurses' multiple job-holding were the subject of 10 (out of 38) of the documents, while individual and institutional consequences of the practice were discussed in 9 and 12 pieces, respectively. only seven of the retrieved documents mentioned policy options associated with nurses' multiple-job holding. below we present the literature retrieved, organised in sections reflecting the emerging themes. from the documents retrieved, it emerged that nurses' engagement in dual practice can take different forms and shapes, with often blurred boundaries. some authors mention 'secondary jobs' and 'moonlighting' practices, where public sector nurses engage with the private sector either individually or through an organised nursing services agency [32] [33] [34] . ribera silva et al. (2009) as well as gupta et al. (2006) refer generally to 'nurses taking up public or private secondary jobs' in brazil, chad, côte d'ivoire, zimbabwe, and mozambique. a similar operational definition is adopted by serra et al. to describe nurses' practicing simultaneously in the national healthcare system and for ngos or private clinics. publications from hics at times use the expression 'casualization of work' to describe job insecurity through a lack of a stable contract of employment, but also the practice of working flexibly for public and private health facilities, often through agencies and banks for outsourced nursing services [35] [36] [37] [38] . however, a distinction is drawn in the literature between holding multiple jobs concurrently, and dual practice, where the nurse's primary job is in the public sector, and that may be affected in many forms by the simultaneous engagement with other clinical, profitgenerating activities [13] . three common forms of nurses' dual practice are mentioned, and often used interchangeably, in the literature; primary public sector employment with additional nursing work in the public sector-typically nightly extra shifts in different departments of the same hospital/facility, or other public facilities in the same geographical area [39, 40] ; primary public sector employment with additional nursing work in the formal or informal private sector-long-hours shifts, or side jobs during spare time/vacation from main employment [34, 41, 42] ; fixed part-time employment in the public, coupled with multiple flexible contract assignments in public and private sector, often though nurse agencies (referred to as 'casualization') [21, 43, 44] . some authors report that boundaries between public and private sector employment are often blurred, particularly in low-income settings, and that ad hoc classifications of multiple-job holding may be required to capture the essence of the practice for specific countries [2] . although using different definitions of the practice, a number of studies attempted measuring the prevalence of nurses' engagement in multiple job-holding in highincome as well as low-and middle-income countries (see table 1 below). these are mainly cross-sectional surveys that do not provide data on trends for the phenomenon. for australia, creegan et al. [36] show that 51.7% of nurses worked part-time in 1997, while in 2011 batch and windsor found that the nursing profession had a higher rate of casualization than other professional and highly skilled workforces, and that 47.5% of nurses were employed in non-standard work [44] . for the uk, tailby reports that 80% (of 185 000) nurses registered with nhs nurse banks had another nursing job, and 60% worked occasionally or regularly additional shifts paid at bank or agency rates [43] . in a survey among nursing magazines' readers in 2013 [45] , 54% declared taking up extra nursing work, and 10% another full time job outside nursing; 5 years later, 47% of the 900 nurses participating in another online magazine readers survey declared engaging in bank and/or agency shifts [37] . a report from the us bureau of labor statistics [46] shows that multiple job-holding has grown steadily over the last decades, that 6.3% of nurses had multiple jobs in 2014, and that such prevalence was higher for a small sample of male nurses (9.5%). a 2017 article from canada [35] provides evidence that 15.8% of all rural nurses are in casual jobs and that casualization is particularly common among registered nurses and licenced practical nurses (16.5%), and more common among those nurses living in the north of the country (20.0%). evidence on the phenomenon from lmics is substantial too; gupta et al. report from a multi-country study that nurses dual practice would be more limited than physicians'-the former calculated to be 11% in chad; 7% in cote d'ivoire; 26% in jamaica; 1% in mozambique; 0% in sri lanka; and 7% in zimbabwe [41] . in a world bank study in ethiopia [34] , a similar proportion of a cohort of public sector nurses (5%) were found to have secondary jobs 5 years after their initial appointment. several studies by rispel and colleagues from south africa showed the prevalence of different forms of multiple employment to be common (around 28%) and on the rise among south african nurses [21, 33] . and in brazil, portela et al. showed 41.5% of nurses in two public hospitals to be moonlighters [39] . a few individual and institutional drivers for the practice are recurrent in the literature. at a personal level, the need to increase overall earnings by supplementing income from main salary is by far the most common, such as in northern ireland and elsewhere in the uk-where holding multiple jobs is seen by many nurses as an essential way to increase income [38, 45] . however, also for a low-income country like ethiopia where a nurse's salary is typically higher than the country's average gross domestic product (gdp) per capita, serra et al. report that half of the nurses followed in their study took up a second job to support their families [34] . flexibility of additional part-time employment seems to be another key factor for australian and uk nurses, since nursing is a typically female profession, and some female workers have a strong preference for part-time, flexible jobs in comparison to their male peers [36, 43] . in the surveys in south africa [21, 33] , the opportunity for learning new nursing skills, the need to introduce diversity in professional routines, a more stimulating working environment, the quality of supervision, and the ability to select their own working hours were the key reported motivating factors for south african nurses. at a more institutional level, also in south africa, the growing demand for nursing services from the private sector is pointed to as the key driver of the phenomenon of casualization of nursing employment. taking a broader organisational perspective, batch and windsor (2014) argue that the 'casualization movement' is really aimed at creating a more flexible, cheaper, and easier to manage the nursing workforce. no specific study appears to have assessed the impact of nurses' dual practice, although many articles offered hypotheses and interpretations in regard. generally, health worker's dual practice is regarded unfavourably in the academic literature. mcpake et al. argue that, depending on its forms and prevalence, it could hamper the attainment of uhc in some countries [2] . others report that the associated increased tiredness and lack of alertness for casual workers who work long hours in multiple jobs, as well as their difficulty of communication with resident staff, are reported to substantially increase the risk of clinical accidents [32] . however, a phd dissertation work from the usa shows that, on average, nurses with a secondary job tend to work fewer hours in their primary, public employment than their non-moonlighting colleagues [47] . studies in south africa suggest that moonlighters are also more likely to take vacation and time out from their main employment to pursue other jobs [21] , and intentions to leave economic-higher rate for single day fees than in home country of n ireland the public sector and/or migrate have been found to be more frequent among them than in their single-job peers [33] . baumann et al. argue that employing an unbalanced proportion of full-time and casual nurses reduces flexibility of a hospital management, as these latter would be less available to cover for unforeseen needs [30] . in the case of ontario, canada's experience with the severe acute respiratory syndrome (sars) epidemic, such factors, together with the increased dependence of many hospitals in high-income countries on agency nurses, have been suggested could compromise the system's 'surge capacity' , that is, its ability to rapidly scale-up services and response in the face of epidemics [48] . in a qualitative study in rural community hospitals in canada about the changing nature of nursing work, montour et al. argue that employment in multiple organisations contributes to scheduling issues because casual nurses are unavailable to fill vacant shifts [49] . and finally, according to some studies, some types of health workers' dual practice can critically undermine health service provision and public trust, as it often entails conflict of interest, idleness, and absenteeism [50] . at a more personal level, portela et al. show that taking extra shifts can seriously affect nurses' general health and exhaustion levels, with night shifts reported to be less disruptive than day ones [39] . such findings on sleeping patterns are also echoed by ribeiro-silva et al. [51] for hospital nurses in rio de janeiro, brazil, and by knauth for workers outside the clinical profession [32] . casualization of work was also identified as a major source of career fatigue and burnout in qualitative interviews with nurses in australia [52] . marginalisation and exclusion of part-timers by their peers was also reported to be a major source of dissatisfaction and frustration in an ethnographic study on australian nurses [44] . as a positive individual consequence, nurses were reported to value highly the opportunity dual work offers to complement meagre public salaries in high-income countries [45] and to support extended families in lowincome ones [34] ; in the usa in 1999, nurses earned more in their secondary job than in their primary employment [47] . flexible working hours is another characteristics that nurses would find particularly attractive in secondary, casual jobs in the uk [43] . in this respect, creegan et al. suggest that flexible working arrangements would be particularly suited for the predominantly female nursing workforce [36] . only a minority of the studies retrieved in this review (eight) present and discuss possible policy options for managing, regulating, or controlling the practice. mcpake et al. [2] link the choice of policy measures to the prevalence of the practice and to the country's regulatory capacity. rispel et al. [21] highlight managing moonlighters as a key human resource for health strategy in south africa; consultation with frontline nurses to counteract the practice's negative impact is suggested as a possible policy option. electronic time recording, cessation of unpaid overtime, and controls over the number of shifts are put forward as alternative measures by other authors [53] , while developing clinical guidelines for hospitals to ensure safety of services 'in the hands of strangers' has been called for as a possible institutional measure. other scholars have argued for the need for a better understanding of dual practice patterns, in recognition of the fact that more effective planning and management of a flexible workforce could represent a more suitable solution than prohibition [36] . our review revealed that nurses engage in multiple jobholding activities, with varying forms and prevalence in high-income as well as in low-income countries. the practice appears to be driven by multiple, complex, and varying factors beyond the obvious economic motif, and to have non-trivial consequences, particularly for nurses' welfare, organisation of health services, and health labour market. despite its prevalence and relevance, a surprising paucity of studies was found on nurses' dual practice, and very few policy options have been outlined in the literature to address the phenomenon. although in the nursing profession holding simultaneously multiple jobs cannot be necessarily considered as dual practice, the two areas often overlap, in shapes of poorly demarcated contours. consistently with what is observed for other professions, more than one way seems to exist for nurses to engage with dual practice, both in regulated and informal, casual fashions. this may at least in part explain why the practice has been under-reported and little regulated through the years, with some of its forms driven underground or even considered illegal in some countries [34] , and other forms-such as the 'casualization' of nursing services-only recently having come to the fore in the context of rapidly evolving health labour markets [33] . this absence of usable datasets would call for primary research to be conducted to, first, explore through qualitative research the specificities of the phenomenon and, second, to measure them quantitatively. unsurprisingly, our review of the available evidence appears to show that economic considerations are not the sole driver for nurses taking on simultaneous multiple jobs [33, 54] . a basic dissatisfaction with the limited range of duties performed in their main job, limited opportunities for development, or availability of time made possible by night shift arrangements, are other important factors that may help explain such a decision. although much effort has been devoted in the past to understanding nurses' burnout [55, 56] , surprisingly little attention has been given to the tendency to take on additional work in presence of an already heavy workload. in contrast to the comparatively better understood physician dual practice, the limited evidence reviewed suggests that nurses' dual practice is more likely to be bounded by the very nature of their jobs than it is for physicians, as typically nurses have limited autonomy and tend to work as part of a team, rather than as individual providers. on this basis, a hypothesis could be made that, while nurses are more likely to be part of an established team in their main (public sector) job, second jobs are often taken up as individuals, as agency nurses for one shift, or private home care visits. nurses' personal characteristics also appear to shape forms and extent of the practice in any one country. since taking up additional work in the private sector may be financially rewarding, but will also add to overall workload and may not necessarily increase career prospects, younger and comparatively lower paid nurses seem to be the ones likely to engage more in the practice [35, 39] . as a compounding factor, as nurses are predominantly female and often perform a disproportionate share of child-rearing and care for elderly or disabled relatives' duties, we may speculate that having dependents will likely decrease their ability to take up additional hours, unless the additional income generated can compensate for any additional child care costs. the evidence available suggests that the consequences of this phenomenon are not negligible, particularly for the health of those nurses ending up working longer hours and hospital shifts because of their multiple commitments [39, 51] , but also for the organisation of public and private health services facing a more 'casual' and less-committed kind of workforce [21] . interestingly, the most recent literature on nursing and midwifery enterprises [24, 25] recognises this limitation and may lay the grounds for a different type of engagement of nursing staff with private sector activities. we also did not find any evidence regarding the importance of economic considerations of nurses' dual practice, or of any difference between higher and lower income countries; as we suspect the implications of such practice may have substantial repercussions on the health labour market, this could represent an area of future research. this paper is based on a scoping exercise and so has limitations. the limited and often incomplete evidence made it difficult to be certain if dual practice is a factor of relevance in all health systems worldwide, if it is a major issue for nurse labour market participation, and its overall impact on the provision of care. with respect to the latter, this may be because some aspects of dual practice are on the margins of 'formal' work and may go unrecognised by formal systems of employment and regulation. all of the above call for a deeper understanding of the phenomenon, with the objective of better harnessing the changing nurses' workforce worldwide. following our review, the core elements of the required research agenda on nurse dual practice appear to be three-fold. first, further research is needed to systematically explore the nature, extent, and impact of nurse dual practice in different systems and countries; this can be achieved through the analysis of employment and professional register/association data sets where these exist, or by adhoc surveys of nurses and/ or workplaces. analysis of specific data sets in some countries (e.g. such as the current population census [57] and the integrated public use microdata series the united sates; labour force surveys; and professional registries) may provide more evidence on prevalence of dual practice and some of its main forms. secondly, there is a need for developing a more informed picture of the reasons why nurses take on dual practice, their experiences and preferences of dual practice, and the impact on their broader work/life balance. this can be achieved through a qualitative approach, exploring multiple contexts in high-and low-income settings, and different nursing profiles. finally, there is a gap of research that establish the impact of dual practice at the policy level-what is its impact on participation rates, overall nursing hours available in different systems, what are the trends in incidence, what is the impact on nurses, and on the quality of care that is being delivered. measures could be needed to mitigate the effects of nurses' dual practice to protect the provision of free-of-charge public sector for vulnerable populations. this latter area for policy research is the most complex and challenging to interrogate, but also of potentially great significance. without a better understanding of nurse dual practice, it will continue to be a largely 'hidden' element in nursing workforce policy and practice, with an unknown level of significance, and an unclear impact on the delivery of care. priorities for research into human resources for health in low-and middle-income countries implications of dual practice for universal health coverage a comprehensive health labour market framework for universal health coverage multiple public-private jobholding of health care providers in developing countries: an exploration of theory and evidence. issues paper-private sector. london: dfid health systems resource centre public versus private health care in a national health service physician dual practice waiting lists and patient selection dual job holding by public sector health professionals in highly resource-constrained settings: problem or solution? interventions to manage dual practice among health workers policy and regulatory responses to dual practice in the health sector should physicians' dual practice be limited? an incentive approach a theoretical approach to dual practice regulations in the health sector dual practice in the health sector: review of the evidence physician dual practice: a review of literature negotiating markets for health: an exploration of physicians' engagement in dual practice in three african capital cities physicians' engagement in dual practices and the effects on labor supply in public hospitals: results from a register-based study how do dual practitioners divide their time? the cases of three african capital cities whom do physicians work for? an analysis of dual practice in the health sector exploring the critical care nurses' experiences regarding moonlighting access to non-pecuniary benefits: does gender matter? evidence from six low-and middle-income countries the health system consequences of agency nursing and moonlighting in south africa who. global strategy on human resources for health: workforce 2030. who. 2015 analyzing markets for health workers: insights from labor and health economics advancing nursing enterprises: a cross-country comparison investing in nursing and midwifery enterprise to empower women and strengthen health services and systems: an emerging global body of work scoping reviews: time for clarity in definition, methods, and reporting asking the right questions: scoping studies in the commissioning of research on the organisation and delivery of health services scooping studies: towards a methodological framework preferred reporting items for systematic reviews and meta-analyses: the prisma statement surge capacity and casualization: human resource issues in the post-sars health system three approaches to qualitative content analysis extended work periods factors influencing agency nursing and moonlighting among nurses in south africa discovering the real world. health workers' career choices and early work experience in ethiopia nurses who work in rural and remote communities in canada: a national survey casualisation of the nursing workforce in australia: driving forces and implications exclusive: survey reveals anger and concern over agency rule. nursing times poor pay forcing northern ireland nurses to moonlight across the uk self-reported health and sleep complaints among nursing personnel working under 12 h night and day shifts work ability among nursing personnel in public hospitals and health centers in campinas-brazil assessment of human resources for health using cross-national comparison of facility surveys in six countries quikstats-moonlighting nurses -ana community agency and bank nursing in the uk national health service nursing casualization and communication: a critical ethnography nurses make ends meet through extra shifts and payday loans multiple jobholding over the past two decades : monthly labor review: u.s. bureau of labor statistics three essays on the labor market for nonphysician clinicians. berkeley: university of california career trajectories of nurses leaving the hospital sector in ontario the changing nature of nursing work in rural and small community hospitals the nursing community, macroeconomic and public finance policies: towards a better understanding. geneva: the world health organization sleep on the job partially compensates for sleep loss in night-shift nurses identifying sources and effects of carer fatigue and burnout for mental health nurses: a qualitative approach slaves of the state-medical internship and community service in south africa health worker preferences for job attributes in ethiopia: results from a discrete choice experiment nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care prevalence of burnout syndrome in clinical nurses at a hospital of excellence current population survey (cps) nurse labor market dynamics are key to global nurse sufficiency the intensive care unit work environment: current challenges and recommendations for the future who's talking? communication and the casual/part-time nurse: a literature review. contemporary nurse relationship between shift work and personality traits of nurses and their coping strategies the health workforce in ethiopia: addressing the remaining challenges advancing the application of systems thinking in health: exploring dual practice and its management in kampala, uganda. health research policy and systems / biomed central the nature and health system consequences of casualisation, agency nursing and moonlighting in south africa stress symptoms in female nurses working in emergency rooms no funding was received for this research. all the data and information included in this review can be found in the annexes. authors' contributions gr elaborated the original idea for the study. gr, if, and jb designed the study. tsj designed the methodology for the review. gr drafted the manuscript. all authors revised, read, and approved the final manuscript.ethics approval and consent to participate n/a. the authors declare that they have no competing interests.• we accept pre-submission inquiries • our selector tool helps you to find the most relevant journal submit your next manuscript to biomed central and we will help you at every step: key: cord-325785-87wh5cct authors: naylor, lindsay; clarke-sather, abigail; weber, michael title: troubling care in the neonatal intensive care unit date: 2020-06-15 journal: geoforum doi: 10.1016/j.geoforum.2020.05.015 sha: doc_id: 325785 cord_uid: 87wh5cct the neonatal intensive care unit (nicu) is a site of medical treatment for premature and critically ill infants. it is a space populated by medical teams and their patients, as well as parents and family. each actor in this space negotiates providing and practicing care. in this paper, we step away from thinking about the nicu as only a space of medical care, instead, taking an anti-essentialist view, re-read care as multiple, while also troubling the community of care that undergirds it. through an examination of the practice of kangaroo care (skin-to-skin holding), human milk production and feeding, as well as, practices related to contact/touch, we offer a portrait of the performance of the community of care in the space of the nicu. we argue that caring practices taking place in the nicu are multiple and co-produced, while simultaneously being subject to power and knowledge differentials between actors. here we analyze the negotiations over the knowledge and practice of care(s) to open up the nicu as a particular community of care, and consider care as a both a joint accomplishment and a gatekeeping practice. the neonatal intensive care unit (nicu) is a space of multiplicity. it is a medical unit, a care space, a place for family, a workspace, a site for research and learning. it is sterile, it is messy. from the outside, the nicu looks the same throughout-incubators, monitors, machines, three patients to an alcove space, replicated over and over. upon closer examination though, from the inside, the space of the nicu begins to take on character-signs with baby names, knitted and quilted blankets, a hospital gown, an old sweatshirt, a privacy screen. difference. the stated primary function of the nicu is to medically treat critically ill and preterm infants, however, the character of treatment takes on multiple forms of care. thinking about the differences in the nicu is helpful for considering the many forms that care takes in-place, and also for thinking beyond the nicu as a medical unit. as a site of "intensive care," the nicu is characterized by acute illness and sometimes lengthy treatments. these treatments are developed and deployed by teams of medical professionals, including neonatologists, nurses, respiratory therapists, nutritionists, lactation consultants, and so on. care is shaped by space and place (see: milligan and wiles, 2010) , and is collectively co-produced. while medical care is of utmost importance, other forms of care happen alongside it and have dramatic influences on it. parenting, feeding, skin-to-skin time, education, storytelling, and encouragement, all happen too. thus, thinking about the nicu as a medical care unit is limiting and renders invisible the multiple and jointly enacted forms of care practice that occur in this space. we argue that an anti-essentialist take on care that is provided in a medical setting is needed to see and value the multiple forms that care takes. the care labor that happens in this space could easily be regarded as a transaction, where staff are paid to provide medical care. yet there is also volunteer and otherwise unpaid labor that is performed in this landscape, and so this consideration does not provide the kaleidoscopic view necessary to see the multiple forms that care takes. the labor that happens in the nicu cannot be fully supplied by the market. many see medical care through a capitalocentric lens (gibson-graham, 2006 ) that divides care into binaries of paid/unpaid, public/private that neglects the co-production of care as a site of mutual aid accomplished by a collective of humans and non-humans (e.g. medical devices). however, there is much work on care that does not reify capitalism and instead makes the argument that a market-based view only captures a fraction of the care-work provided in this space. moreover, this work decenters capitalism, placing it on a spectrum of exchanges. in this paper we re-read the nicu to consider the multiple acts/ practices of care that take place and argue that these acts of care are both a joint accomplishment of the community that comes together in the nicu and are part of a space where power over knowledge, training, and participation in care work unfolds in messy and uneven ways. the nicu is a key site of investigation as care takes on significant complexity. our case study concerns how communities of care create sites of parental engagement as well as gatekeeping practices related to providing contact and human milk. specifically, we address the complicated character of three activities in the nicu: (1) overcoming barriers to the practice of skin-to-skin contact between parents and infants, (2) learning and providing positive touch when an infant cannot be held, and (3) the provision of human milk and the means of access to human milk. medical care is already complex, however, the character of nicu care reflects the interconnectedness of parent/child bonding, if possible and desirable-the provision of mother's own milk, medical treatment, and the cultivation of community. to conduct care in its multiplicity in the nicu, care must be part of a broader community that extends from the infant. the nicu is not static as patients and families move through treatment and are discharged, nursing staff change shifts, and medical teams complete rounds. there is an ongoing production and reproduction of care as the community changes. in this paper, we argue that care is a practice that is shared by a community. this is a step away from discussions of the commodification of health + care, which focus on how care services have become privatized and care work relegated to a market relation; and that care can only be done in medical spaces by those with specific knowledge and training (cf. gallagher, 2018; green and lawson, 2011; healy, 2008; henderson and petersen, 2002) . many hospitals are operated as nonprofit entities, although the groups supplying them usually are for-profit-which is why considering the human (and other) care involved in health moves us toward an antiessentialist view of medical treatment. this care takes place within, alongside, and outside of capitalist relations. to direct a reading of care as multiple in the next section of this paper, we create a foundation by discussing care-work and the practice of care in geographic thinking. following this scaffolding, we turn to the context for the study and the methods in order to situate the site of the nicu and care. building from this context and drawing on empirical work, we next consider the multiple forms of care in the nicu landscape. finally, we make some concluding remarks about re-reading the nicu and how in investigating care as multiple we can continue to open up our thinking about the benefits and tensions that arise from enacting the processes and practices of care in a way that is attentive to difference in place. feminist scholars consistently call for attention to care and care ethics within the academy, as well as academic research and writing. yet, as lawson noted, even though care is a critical component of human life it had remained on the margins of theory, heightening unequal relations along gender, race, and class lines (2009:210). moreover, this marginalization neglects the role of the non-human and our earth others in relations of care. care is brought to our attention by highlighting reproductive labor, such as social reproduction, relations of exchange, and affect, for example. it is an everyday practice that takes place in public, private and liminal spaces. 1 feminist geographers began to draw attention to an ethic of care as a basis for creating change and performing reflexive research. this work emphasized the gendered, and particularly the unpaid, aspects of care and drew from the early work of tronto (1993) , which argued against the narrow reading of care onto women's bodies (cf. mcdowell, 2004; smith, 2005; staeheli, 2003) . this reading of care ethics comes from ideas about the "social character" of our being and thus should be linked up with the exceptional and the mundane of our everyday lives (lawson, 2009: 210-211) . it is a call not just to examine relations but also respond to spaces which, as part of neoliberal shifts have become 'care-less' (lawson, 2009) . as care begins to be conceptualized more broadly, some scholarship takes up care in its radical potential for re-reading spaces and relating to others. 2 a relational approach to care allows for thinking outside of the individual, and places emphasis on what atkinson et al. describe as the "mutual constitution of caring practices and caring spaces" (2011:565). this emphasis is tied to an ethic of care, which is built on practices that take into account those relationships, both human and non-human. an ethic of care is an attempt to democratize decision-making, labor in all its forms, and to distribute responsibility and benefits equitably. a deeper ethic of care is also reflexive, asking who benefits from the established relations of care and what forms of listening, advocating and allying can happen through the sharing of care practices. care (in this guise) requires us to do the necessary labor to 'survive well' (gibson-graham et al., 2013) . this includes care-giving, and also care-receiving where the care work (such as reproductive labor) that makes all work possible is illuminated (see de la bellacasa, 2017) . this revealing includes regarding the care provided by the non-human, for example, medical devices and machinery or ecosystems and clean air. dombroski et al. (2018) discuss re-reading for "who cares" to think about the diverse actors involved in caring, which is collective and multiple. in considering care in its multiplicity, the visibility of the varied actors, relations, as well as, the practices and performances of care is increased. reading care as multiple refocuses our gaze and can for example, upend the idea that care work is inextricably tied to capitalist relations (morrow and dombroski, 2015) . this work is important in moving towards a "care-full" regime. drawing on milligan and wiles' (2010) work on how care is shaped by place and space, we consider the care undertaken in the nicu as part of a community of care that is co-produced and multiple. here they draw our attention to both the interpersonal relations between people and place-we would also add people-material relations-to see the spatial character that care takes on as it is practiced in place. there are structures that shape the experience and practice of care that range from where it is happening and who/what is providing it, to the layout or constraints of the physical space and the emotions that may (or not) permeate them. there are, as they note, "complex embodied and organizational spatialities that emerge from relations of care" (milligan and wiles, 2010: 740) . similar to our framing of care-full geographies, milligan and wiles identify "care-ful" and "compassionate geographies" to enunciate an approach "informed by care" that can show the collective labor in the landscape (743). here we note this distinction and expansion as "care-full" indicates, for our framing, a care that is abundant, multiple, and not confined to any one space. ultimately, in considering an ethic of care, scholars can shape these "compassionate geographies," however, how the care is negotiated pushes on the idea that care is inherently free from tension. as noted in the introduction, this paper takes up care as multiple and the nicu as a site where the processes and practices of care are jointly shared and in some cases, contested. these are two distinct but interwoven theorizations that we use to push on the power dynamics often unrecognized in discussions of communities of care. to think through the liminal space of the nicu and the multiple and competing forms that the processes and practices of care takes creates an opportunity for opening up our theorizations of care. 1 there is a well-established literature outside of geography on nursing and healthcare that is foundational in this line of thinking and which is increasingly drawing on spatial analysis to take a critical view (see: andrews, 2016; cheek, 2004; halford and leonard, 2006; kingma, 2008; sandelowski, 2002; solberg and way, 2007) . we do not seek to replicate that work here; scholars interested in reading these more health-focused geographies onto nicu care provides an additional avenue for future examination. the data in this paper come from a larger project investigating the practices of skin-to-skin contact, infant feeding, and access to human milk that is ongoing. this phase of the project involved conducting fieldwork in the specific space of the neonatal intensive care unit (nicu) to ask questions about how care and feeding of infants in concert with complex medical treatment is undertaken and to consider alternatives. to better understand the context for nicu treatment we developed and disseminated a national (u.s.) survey in 2017, with the cooperation of breastfeeding coalitions to ask questions about parents' experiences having infants who received nicu care. a key takeaway from the survey was that parents have dramatically different experiences across the united states (clarke-sather and naylor, 2019; naylor and clarke-sather, 2020), signaling that landscapes of care in the nicu are not homogenous. building from that finding, data was gathered at one specific nicu between 2018 and 2019. a contract between the university and the hospital was established that specified the conditions of the research and the role of the researchers and allowed for a oneyear research period. two members of our research team undertook hospital-based protection of human subjects training and became official research assistants with the hospital for the 2018-2019 research period. the data analyzed in this paper draw on the survey results (n = 150), over thirty hours of participant observation in the nicu, and transcribed and coded interviews with nicu staff (n = 40) and birth mothers (n = 35). staff interviewees (n = 34) identified as white and black or african american and mothers interviewed (n = 11) ranged in age from 18 to 34 and identified as white, black or african american, hispanic, and mixed (black or african american and white). the difference in n values is a result of a request from the hospital not to collect demographic information order to maintain respondent anonymity at the start of the project and which was subsequently changed to allow us to collect that data. research in the nicu was conducted between may of 2018 and may of 2019, in cooperation with the neonatal research office at the hospital. all interviewees were approached to participate and consented by the hospital research office, the research team did not conduct any recruitment. there were two approaches to the nicu-based fieldwork, one researcher did an intense two-week exclusive interview segment and the other researcher spent one day per week in the nicu either interviewing participants or observing rounds and nicu practices over the one-year research period. throughout this period we interviewed staff members, including nurses, neonatologists, dieticians, lactation consultants, respiratory therapists, occupational therapists, physical therapists, speech language pathologists, and milk bank staff. we also had the opportunity to talk with birth-mothers over the age of eighteen (no partners or adoptive parents have yet been interviewed for this project) about their experiences while their infant(s) were receiving nicu treatment. 3 interviews were structured and approved by the institutional review boards of the university and the hospital. questions for staff and birth-mothers alike focused on three main topics: skin-to-skin contact (also called kangaroo care), infant feeding, and milk pumping in the space of the nicu. interviews with staff were conducted in offices and conference rooms at the hospital that were available and reserved by the research office. interviews with mothers were conducted in these spaces and additionally outside of the nicu in an available overnight room. the data were transcribed and analyzed using the qualitative data analysis software nvivo and for the purposes of this paper, data were coded using pre-determined codes related to "care" and "treatment." these codes were designed based on survey data that suggested differences in how care and treatment were practiced and perceived. the partner hospital where research was conducted is located in the mid-atlantic region in the united states and is in a state that received a "c" score from the march of dimes on their 2019 premature report card, which indicates a preterm birth rate of roughly 10%; this percentage compares to an "a" score of less than or equal to 8% and an "f" score of greater than or equal to 11.5%. 4 the march of dimes reports that the pre-term birth rate in the u.s. for 2018 was 9.9% overall (a "c" on their scale). the march of dimes is a non-profit organization focused on the health of mothers and infants with specific attention to premature birth; their "report card" draws data on preterm birth rates from the national center for health statistics, 2018 final natality data and grades are assigned by the march of dimes perinatal data center. according to the u.s. census, the mid-atlantic is characterized by greater than average poverty levels and a majority white population (on average 63% in 2018). the nicu at the selected partner hospital, which is a non-profit organization, is located in a high-risk delivering hospital that offers level three care for newborns. 5 the space of the nicu at the hospital is an open-space, climate controlled alcove nursery that has the possibility of caring for up to fifty infants at one time. each alcove can accommodate up to three infants and the equipment for their care. there are two medical care teams headed by neonatologists and a trio of nurses who provide, in shifts, round-the-clock care for infants. there is a glider chair at each bedside, a space for parents to store items, and if desired, a privacy screen (five or six are available and rotate around the nicu on an as-needed basis). there are three lactation lounges if mothers expressing milk prefer a private place to do so and the nicu maintains a milk bank to receive, process and store the milk of birth-mothers who have infants being treated in the nicu. three over-night rooms outside of the medical treatment area are available for extended stays; these rooms have a sleeper sofa, a private bathroom, and a television. each infant bed is equipped with a webcam that parents can access from an application (called nicview) installed on their phone so that parents can see their baby when not at the bedside. in addition there is a children's play area and a small kitchen with snacks available provided by the ronald mcdonald house located outside the entrance to the nicu. access to the nicu is restricted, although parents are allowed at any time and are asked to remain with their infant while visiting the nicu. up to two approved visitors are allowed to be at the bedside during regular visiting hours (9:00 am to 9:00 pm) as long as they are healthy and have followed proper intake procedure, which includes receiving an id band from the front desk and following handwashing/scrubbingin protocol prior to entry. visitors, including parents are not allowed any food or drink in the nicu and they must clean their mobile phones with a provided wipe. parents are encouraged to be present if and when possible and to participate in routine care, such as temperature taking and diaper changing, and to visit with the medical care team. the nicu is a complex space, with many changing actors, that does not lend itself to universals. care in the nicu is multiple, it is indeed a joint effort that is shared and maintained collectively. to think about care as multiple and to see the various forms it can (and must) take, we consider the community of actors and actants providing care in the nicu. as a practice, care is relational (morrow and martin, 2019) . care as multiple captures the social practices it is embedded in and makes visible mutual aid, belonging and exclusion. here we think about care as a communal or joint practice, where the community is the semi-ephemeral group who participate in these acts of care. in this case, the community is made up of parents, nicu staff, nicu volunteers, milk donors, researchers and non-human actants, such as heart monitors, c-pap machines, feeding tubes and bilirubin lights, for example (see fig. 1 ). the nicu is a care-full space and to better understand care as multiple, here we draw on survey responses, interviews with parents and staff, as well as observation undertaken. in the following subsections we examine the practices of kangaroo care, medical "cares," and care-work. the character of care and how it is 'used' is discussed to show how it is negotiated; our findings suggest that care in the nicu requires a community effort, yet power dynamics surrounding knowledge about and who can do care complicate participation in this community. kangaroo care refers to the practice of skin-to-skin holding of infants. it is an intimate method of holding a baby, where the care provider removes any clothing barrier from the waist up and the infant is, wearing only a diaper, placed on the bare chest. for nicu staff it is considered a part of medical treatment and an intervention that assists with the development of the infant that when appropriate can improve the medical condition of the infant. it also facilitates bonding between parents and children. a number of clinical studies demonstrate that kangaroo care is beneficial and the national association of neonatal nurses recommends the practice (cf. jayaraman et al., 2017; johnston et al., 2003; ludington-hoe et al., 1994; engler et al., 2002) . when asked about the barriers in providing opportunities for skin-to-skin, one of the neonatologists explained that they try to "encourage kangaroo care from the beginning and explain the benefits of skin-to-skin, the decreased infection risk, increased milk production, decreased nicu stay." the occurrence of kangaroo care in the nicu is based on the relationship between the parents and the nurses. although kangaroo care may be recommended by the medical team and facilitated by nurses and respiratory therapists, it is a negotiation between the parent and nurses. in this section of the paper, we rely on parent and hospital staff interviews as well as survey responses to discuss kangaroo care. in the nicu setting kangaroo care is complex, and not always appropriate depending on the medical acuity of the infant, therefore, it is recommended in most, but not all cases. 6 the effort of bringing the infant from the incubator or crib to their parent's chest is a community act. one of the first days where observation was conducted in the nicu one researcher watched as four nicu staff worked together to bring an infant weighing less than 1500 g to their mother's chest for kangaroo care. three nurses each taking charge of a different tube or wire, and a respiratory therapist, who focused on the breathing tube, facilitated the safe transfer of the baby to their mother. care here is a joint accomplishment and is only possible through a collective effort that includes knowledgeable and trained staff in the same place at the same time, well-functioning medical equipment, and the ability of the kangaroo care provider. while most staff participants reported that they encouraged and offered kangaroo care, many also suggested that a lot of education for the parents was needed about why it is important and how it can be done, in order to calm parental fears. the following quotes from nursing staff were recorded in response to structured questions regarding barriers to kangaroo care and whether there is a need for assistance to carry out kangaroo care. one nurse explained: "i think the attitude is positive, the nurses here understand the benefits and they understand that it is important to the families." many nurses commented that they wanted parents to be able to comfort their babies and they often realized that parents did not know that they could hold their baby. as a result, there is a lot of information sharing, support, and education that goes into the practice of kangaroo care. in other interviews this experience was reiterated, for example another nurse offered: "i try to explain as much as i can the benefits especially to the parents who are like no, the baby's too small to hold or i'm too scared to hold, and once they understand they are doing something good for their baby, then usually they want to and they usually once they do the skin-to-skin, then they're hooked." on occasion, more encouragement is needed, such as in this story related by a nurse: we try to offer as soon as the baby is able to and if there's a parent that's timid-one mom was, she was so scared to hold her baby. then one day, she was all ready for it, but she got really nervous when she came in, i was like sit down, i've already got respiratory coming, like we're doing this. and she-so she did, and her palms were sweating-it was kind of funny, but at the end of it she was so thankful and so it's kind of just reassuring them, you're not going to break him [her son], it's ok. we're all here, and um, i think that probably really meant a lot to her. so coming to them, i don't know, giving them that little nudge cause she had never held him before, and i was like we're doing it, let's go! a number of participants commented that this form of care required effort from everyone, but that ultimately, when it is done well, it creates a less-stressful environment for everyone. again, care is a site of mutual aid and kangaroo care is a coordinated, co-created joint effort. one nurse emphasized this point saying: "when i saw a mom hold her baby for the first time and the baby was weeks old at this point with all the tubes, there were two nurses two respiratory therapists and the baby was on so many tubes, but the mom was so happy, how she felt when she held the baby, it makes me tear up." although many parents are initially afraid to hold their infants, nearly all participants ultimately found it to be a positive experience of care. when analyzing and coding interviews we found that many mothers used similar descriptions for talking about the joy of holding their babies. one mom said, "i have never been happier. i mean the fact that it's in the hospital of course makes you upset but holding her [her daughter] you just forget about everything." the often emotional response to the question of "how do you feel when you're holding your baby in the hospital?" was consistent across all interviews and is also echoed by parents who took the 2017 survey, fig. 2 captures the positive adjectives that participants used to describe how it felt to practice kangaroo care. 7 fig. 1 . the community of care in the nicu. 6 for example, an infant who needs to be kept cooled, or who is undergoing phototherapy, or one who has an arterial line at the site of the umbilical cord. 7 the survey responses were recorded using qualtrics and the data drawn on in this figure, larger and repeated words represent those adjectives used most often to describe their experience. moreover, mothers report feeling instrumental in improving the medical condition of their children through their continuous practice of kangaroo care. many also feel that it is helpful for them as part of their recovery from a traumatizing birth experience and the anxiety of being separated from their newborn. one mom reported: i feel kangaroo helps moms a lot, you know. it was hard leaving him [her son] every night and i felt good coming in every morning that was like my main goal, hope he's having a good day so i can get to hold him, and be able, cause every time i held him i felt like i was protecting him, so i was looking for that, it's a big impact, and i actually found out that not all nicus have kangaroo, and i was like oh my god i can't imagine being in that nicu. although kangaroo care is promoted at the partner hospital where interviews were conducted, it is not a universal practice among nicus and many survey respondents reported not being offered the opportunity to do kangaroo care and in some cases being denied it when they requested it. in survey responses, we learned that many parents had to struggle, fighting against the staff to be able to practice kangaroo care with their infants. in response to the query about experiences with kangaroo care in the nicu respondents reported: "unnecessary delays," "limited due to policy," "staff doubtful and resistant," "lack of privacy," "cords and monitors made it difficult," and "felt like i was messing up the schedule." for some moms who answered the survey it became a battle to gain access to their babies. one participant who expressed a negative experience with nicu treatment claimed: "many times i asked, whose baby is it anyway?" another stated that the staff "wouldn't let me touch or feed baby." almost one-third of respondents (17 of 58) answering this open-ended survey question claimed that kangaroo care was either never offered or was discouraged. in the case of the partner hospital, kangaroo care is common and frequently offered. in one interview a nurse explained to a member of the research team that they sometimes have competitions between the staff called "kangaroo-athons" to see who can log the most hours of skin-to-skin contact time between their patients and parents. however, each case is different and sometimes nurses are hesitant to offer or assist with kangaroo care. in response to the question of "have you had skinto-skin contact with your children?" one mother told us "yes, about a week ago, one nurse allowed me to hold them both [her twins] at the same time, which was the best experience ever" (emphasis added). we draw attention to the word "allowed" because the infant is the patient of the nurse, which can put them in conflict with the parent as it relates to prioritizing care. although it can be a joint effort and a site of mutual aid, it can also be a gate-keeping space, where there is differentiated power over who can provide care. indeed, paid care work (that done by specialists, such as nurses and neonatologists) illuminates a hierarchy of caregiving that is immediately imbued with power. this tension came up in a number of interviews with staff. one nurse in particular had a lengthy discussion about nurse attitudes on kangaroo care, and we draw from this interview extensively to illuminate the power struggles over care. when asked about whether "parents need assistance to do kangaroo care," this nurse explained the different approaches in the nicu. i say go ahead and hold them. 'cause, at home they would be holding them, and sometimes i'm like go ahead and hold your baby whenever you're here, it's fine with me, and it conflicts with people i work with because a lot of nurses that i work with are on a schedule. babies are fed every few hours, they need to sleep between that. whereas i'm-they'll sleep better on their parent, i know they're safe, they're on their parent instead of just laying in a crib, so i'm all about parent holds them as long as they want toâ�¦but some nurses are no, the baby's sleeping, don't wake them up. i don't know where that comes fromâ�¦it's a power trip, i've seen that too. where they're like you don't wake up that baby, i'm like uh that's their baby, how can you talk to them like that? so, i don't know what backgrounds or what the nurses are coming from their home, but when they are here, they are the person in power of that baby. so does it make them feel better to say you can't touch that baby? probably. is it right? probably not, but is it what happens? sometimes. 'cause i've heard it, i've heard nurses say to the mom don't touch that baby, it's not time. i was like, oh my god, i cringed insideâ�¦and that's where people butt heads too, and then the nurses get more pickyâ�¦the mom's touching them too much. it's a sick, sad cycle of weirdness. i don't know how to explain it except that you know, the nurse is like this mom's a pain, where in my head i'm like she's being a mom, so how do you, what do you do with that? so that's the problem. a nurse like me, as long as you want for as long as the baby's saying they're fine, and the baby's tolerating-the babies don't have a problem with it. it's other nurses i've heard say, you can hold the baby for an hour a day and that drives me insane, because there's no limit that that would be a minimum for me. i let the moms hold for as long as they can hold. this nurse's comments correlate strongly with other nurse responses about how they manage kangaroo care. some mothers reported that it was not offered very much and suggested that they did not know to ask. (footnote continued) for fig. 2 come from an open-ended essay response to the question: other thoughts about practicing kangaroo care in the nicu. there were also negative adjectives recorded, however they were tied not to the practice of holding or skin-to-skin, but to the inability or not being allowed the practice. this kind of response from mothers was limited to only a few interviews, but interviews with nursing staff explain why some mothers felt this way. 8 some nurses explained just how labor intensive and time consuming it was to facilitate kangaroo care, citing the number of staff needed to move the baby, the lack of privacy or space to maneuver, or scheduling issues with post-partum staff if the birth-mom was still in-patient and also with outpatient moms traveling to the nicu. each nurse discussed the complications with the materials and technology used in their joint effort to care such as, tubes, wires, and breathing equipment that posed a challenge and how as part of the process they had to be pinned in place or taped down. one nurse explained, "everyone has a job, one person holds this tube and we disconnect it, put baby on mom and reconnect it, it has to be quick, and then you're taping it to mom. somebody else is trailing all the wires around and you're moving around, so you all have to be kind of one person." other nurses commented on the difficulty with the lines and keeping the baby's head stable and how kangaroo care is concerning to the staff and so they try to control, limit, or combine it with routine medical care times. these concerns exemplify the tension in providing care as the nursing staff maintain a dominance over parents by having power over their babies. care technologies enable disembodied caring (milligan, 2012) , however, even the non-human caregivers, the medical equipment, can act as gatekeepers while simultaneously forming part of the collective/ co-produced care. medical devices form an important component of the medical care of infants, all neonatologists interviewed agreed that the vast improvements in technology over the past decade had made it possible not only to save infants born at increasingly early gestation with higher rates of survival, but also improve the overall health outcomes of premature infants. 9 on one hand, machines enable life-saving care, on the other hand they are devices to be read by staff with expertise, which centers control over care. the medical technologies used assist nursing staff with making determinations about how a baby is "tolerating care." nursing staff listen for alarms, which signal negative changes to five core measures of vital signs: heart rate, respiratory rate, temperature, blood oxygenation levels, and blood pressure. in many cases, any change to one of these measures signals to a nurse that the baby is not tolerating care and can be used to defend decisions made about whether or not (and when) a parent can practice kangaroo care. the majority of nurses interviewed talked about "clustered cares," where the baby is receiving routine medical care that can then be combined with a period of kangaroo care, because the baby has already been disrupted and may be experiencing changes in heart rate or temperature, for example. or, in other cases, nursing staff will make claims to the stability of the baby when limiting kangaroo care time, nurses might say 'just once a day,' or only for 'one hour.' other nurses complained that parents made it difficult because they were underprepared (in terms of clothing), or not having enough time, or asking at the "wrong time." for example, a nurse commented that "we wouldn't want to get the baby out an hour after we just did cares, we would want it closer to a care time." providing routine medical care makes changes in an infant's vital signs and as a result, nurses try to limit the number of times a baby is "disrupted." staff reported that taking babies out of the incubators puts a lot of stress on them and so if they were going to take them out for kangaroo care it needed to be for at least an hour to justify the stress on the baby. 10 one universal that cut across all interviews with nicu staff was that they always prioritized kangaroo care and any holding of the baby if medical care was going to be withdrawn. one nurse commented that "the rules just go out the door in that situation, we just let them hold if it's looking like a case where they may withdraw care." another nurse echoed this statement, saying "â�¦if we can barely do care without the baby becoming very unstable, we kind of offer kangaroo as um, like your baby is not going to make it, why don't you hold your baby, as kind of a last, you know, just as a last offering of getting to do some care, like we know your baby is not going to make it, so why don't you hold your baby and make the most of it." each member of staff discussed how kangaroo care was encouraged in these cases and demonstrated how care is still co-produced even in situations where a type of care (medical treatment) may be stopped, another exists to take its place. this practice shows a compassionate geography of co-produced care in the landscape of the nicu. in the nicu the typical medical procedures that happen every few hours are called "cares." nurses and parents talk about being involved in the "cares," such as changing the infant's diaper or taking their temperature. this is the site of cluster care that was described so often when discussing kangaroo care. when asked how many times a day parents can hold their infants, a nurse detailed the cluster care process: "we do cluster care where we try to get in and do everything at once so we don't have to bother that baby again, because that baby's job is to grow and stay warm, and maintain sugars and be able to breathe right." however, when the cares are happening is the ideal time to get the parents involved. this involvement is one of the ways that the staff in the nicu attempt to include parents in the treatment processes and practices. these "cares" are taught with parents alongside, and overall the neonatologists reported that they felt the nurses did a great job of getting parents involved in cares. diaper changes can be stressful, and so having a parent participating assists with making it more positive. one nurse noted that she likes parents to learn the signals, she related an experience of a baby "kicking out," "they're looking for a boundary, so why don't you tuck their legs back in so they can feel where they are in space, give them a head cup, help bring their hands to their face." these are all areas where the staff are educating parents and creating a community of care. it also makes visible a division in knowledge, where the staff have the training and knowledge and the parents are viewed as non-experts. parents are often relegated to watching experts care for their infants in the nicu instead of being the center of care for their own infant(s), which may reduce the stress of the medical trauma on parents and positively influence infant health outcomes (jiang et al., 2014) . nevertheless, as noted by de la bellacasa (2017) touch and being touched are preconditions for care. staff, including nurses, neonatologists, and occupational therapists discussed the importance of helping parents feel comfortable with holding their babies, and providing education on how to touch the baby. as noted earlier, a common theme described by the nursing staff in response to questions specifically about kangaroo care was that parents are afraid to touch their babies. one nurse emphasized the education piece on their end, noting that "if the babies are tiny, they're [the parents] are a little afraid to even just touch them, so it's kind of just getting them to know that they're not going to break their baby." moreover, occupational therapists work with parents on positive touch, one participant explained that they "teach them how to touch the baby and how not to touch the baby and explain why, you know, their neurosystem's not developed, they don't like it. and then 8 moreover, "no data exist showing that being in an incubator is better than being in kc, making incubator use one of the most widely used non-evidence based practices in neonatal care" (ludington-hoe, 2011:6) . 9 an area of further inquiry was brought to our attention in an interview with a neonatologist who indicated that the advances in in-vitro fertilization technologies were causing the premature and thus nicu census rate to increase as parents tended to have multiples (e.g. twins, triplets) and fewer full-term pregnancies as a result. 10 intermittent kangaroo care is recommended to be practiced for a minimum (footnote continued) of two hours to allow enough time for an infant to feed and sleep while being held (charpak et al., 2005) . you explain why the babies are in the incubator, they can't regulate heat, and then you say these are the stress signs, so you know, hiccups, heartrate drops, all that, just so they understand a preemie." this positive touch and positioning of the infant is something that happens during kangaroo care as well, where babies are put in a position that emulates how they were situated in the womb. the staff work together to let parents know that they want them to be able to touch their babies, but they are foremost concerned with making it beneficial for the baby and so education on the "way that the baby likes to be touched" is an instrumental part of managing this care. there is also education and support about what to bring (or not) to the nicu and what to wear so that they can best facilitate parental care. when prompted to describe this education, one nurse explained that they "tell them what they are allowed to bring, like boppy pillows and to wear a button down shirt so they can kangaroo their babies easier, we give them lockers out front for their personals, but of course everyone has to have their phone with them. nobody comes in here without a phone!" there are also items that are not allowed and which constrict the ability of some parents to provide care. for example, absolutely no food or drink is allowed in the nicu. for nursing parents in particular this is a strain as expressing milk is a dehydrating process and so denying parents the opportunity to have even water in the nicu is a contradiction in care-breast-and chest-feeding parents need to be hydrated. one nurse expressed their exasperation with this rule, noting that the environment of the nicu was outright "uncomfortable," and that parents should be able to bring in a snack and a drink and "just settle in for a couple hours." however, if parents wish to eat or drink or use the facilities they must exit the nicu and to re-enter, they must go through the laborious process of scrubbing in, wiping down their phone, and etcetera, again. one of the key ways that a caring community is created in the nicu is through support and mutual aid. as parents participate in the medical care, such as providing support for the nursing staff who are doing "cares" and through kangaroo care and the provision (when possible) of human milk, another site of care is found in making the nicu a care-full space. mothers interviewed at the partner hospital agreed that they felt well supported and that if they needed anything that the staff would assist them. when discussing if clothing created a barrier to breastfeeding or pumping, one mother continued her narrative beyond discussing her experience breastfeeding, sharing her experience as a first time parent coinciding with a nicu stay: "we've had questions before, 'cause we're first time parents and everything, so if she has a messy diaper and we're like, 'uh,' we'll just ask for help and everything, it's really niceâ�¦" parents are also sharing space with each other, whether they share their experiences openly or not. however, nurses did relate stories of families sharing an alcove and supporting each other. when discussing barriers and privacy in the alcove model, one nurse told us "the mom i was just talking with, she was talking about the fact that she was able to bond with another family that's in the next bed space." these spaces are shared and the work of care flows throughout; again it is a co-production of care. partners and extended family provide emotional backing; for some infants volunteers are there when parents cannot be; and staff assist with making space comfortable, inviting and when needed, private. privacy was an issue that came up over and over again through each interview, with most participants agreeing that the open alcove model for the nicu was not a private space. many parents were not personally concerned about privacy, but were sensitive to the concerns of those who they were sharing the space with. when discussing parent strategies for making breastfeeding and pumping easier at the hospital, one mother commented on privacy specifically: "here they want everybody to have privacy and stuff and don't want anybody to feel uncomfortable and i don't want to make other people feel uncomfortable about me being all out exposed and like why don't she cover herself up or have a privacy screen or something like that." there is a concerted effort to make a space for care that is accommodating to all. and so this landscape is complex and has an organizational spatiality (see milligan and wiles, 2010) that constrains and makes possible multiple forms of care. some parents are able to occupy those spaces for large swaths of time. many mothers, when discussing routines related to providing human milk (if they were providing milk), reported that they would arrive in the morning and leave to go home for dinner or to sleep. one mother even reported that the staff were concerned for her own selfcare, urging her to go home. she reflected on this explaining: "at first it was really hard because everyone was like are you okay? you need to go home, and i'm like this is where i need to beâ�¦there's nothing else i need to do other than be here and be a mom." there are also times where parents cannot be present, for example: if the birth-mother is inpatient and having complications, if the parents are sick, if they have other family members or pets at home who require their care, if they do not live close by, if they have decided to return to work because they want to save their parental leave for when their baby is at home, and more often when the parent is struggling with addiction. in this case, volunteers called "cuddlers" may hold babies born to addicted parents. these are people who have undergone a training program and are integrated into the nicu and know which babies can be held. observation and informal conversations with the staff suggest that volunteers do not have contact with the parents. they walk around the nicu and if a baby is crying and there is not a parent present, they will work with the nurse to hold and comfort the baby. during observation in the nicu the cuddlers were often holding the neonatal abstinence syndrome babies-those babies going through addiction withdrawal from drugs they were exposed to prior to birth. 11 thus, there is a community of support that is formed in the nicu that facilitates care even if the caretaker changes. support for expressing milk is a key part of the range of care discussed in this paper. as discussed in more detail in the next section, expressing milk becomes a crucial component of how the lactating parent can participate in care. most nurses talked about how important encouragement was for each parent, but especially for the parent expressing milk. one nurse commented: "i had a young mom a week ago, just like wow, look at your milk supply, it's really good, it's very fatty, and she just like perked up and she was so excited that she was doing a good job. like so you know you hit the person at the right time with the right comment, it just changes everything for 'em." for many moms, expressing milk was care that they alone could provide and contribute their own expertise-but interviews demonstrate that it is a complex community effort as well. in the nicu human milk is medicine and is considered a key part of medical care. it is an intervention that is recognized in clinical studies for being lifesaving as it reduces common and life-threatening medical issues in preterm infants (cf. ahrabi and schanler, 2013; arnold, 2008; kantorowska et al., 2016; montgomery et al., 2008; vohr et al., 2006) . milk is a form of care that trespasses kangaroo care and medical care, where it forms part of the treatment plan and makes up the feeding component of "cares;" and caring, where it is a site of support, bonding, privacy, intimacy, and information sharing. while lifesaving, providing human milk also captures the everydayness of care, the seemingly simple act of providing food. milk cuts across care, and the provision of human milk is a form of 11 many neonatal abstinence syndrome (nas) infants are treated in nicus either for a monitoring of symptoms or treatment period. nas infants may not communicate, eat, or sleep in an ordered manner (march of dimes, 2017). nas infants exhibit a range of different extreme symptoms (kocherlakota, 2014) effecting the central nervous, gastrointestinal, respiratory, and autonomic systems (pritham, 2013) and often have low birthweights (patrick et al., 2015) . care work that is undertaken by those with lactating bodies. care work, in all of its forms is demanding (mol, 2008) ; it is an everyday and relational practice. here, the lactating body is the starting point. the lactating parent, theoretically, has control of this form of care, however, it is mediated by medical care, and paid caregivers. ultimately, human milk is controlled and distributed to nurses by the milk bank staff within the nicu, which limits parental involvement. most infants who are being treated in the nicu cannot feed at the breast or chest immediately or at all during their stay because they have not yet developed the suck-swallow-breathe coordination that is required. as a result, many are gavage fed, where a nastro-gastric tube that is placed in the nasal cavity carries milk or formula to the stomach. when a parent provides milk, it is disconnected through this process. the lactating parent expresses milk by hand or with the use of a human milk pump. it is through the provisioning of milk that most parents feel connected to their child and to their care (see bower et al., 2017) . it is a labor intensive, around-the-clock process and it becomes full-time carework for the lactating parent. in an interview with a mother who was pumping while working in a market-based, paid job she talked about the stigma associated with pumping at work and "extra breaks," noting: "it's not a relaxing thing, people be like, oh you get to take an extra break, like no, it's not a break, trust me it's workâ�¦it's not a break whatsoever." it is also, in many cases, expected as part of parental participation in the medical care of their baby. when answering a question about the averages observed of mothers' breastfeeding or providing milk, a nurse related this difficulty for birth mothers. she explained, "they're dealing with so much with the shock of being here, that the primary focus is on your baby, and i think that women need to feel empowered that by pumping their doing the hard workâ�¦so yes you can sit and look at your baby, but you can also pump milk. it's a tangible thing that they can do." and many mothers did discuss expressing milk as part of their job and as something they were compelled to do in order to parent their child. a mother noted that she was "not a doctor or a nurse" but that she "wanted to do something more, and you know, pumping was one of the things that helped me, you know, like i was helping because it was so important." however, mothers relate the difficulty and the stress of pumping milk both in and out of the nicu. a mother explained: "pumping in the nicu was really hard. i tell the nurse, the pumping room sucks. i felt depressed going into the rooms because they were so tight. i did it because i had to for my little one and i wanted to, but they were just not the greatest to me." pumping was something that a lot of mothers needed help with and this was discussed by lactation consultants and parents alike, but not every mother received the same information and lactation consultants are not always available to work with mothers. in discussing how the consultations work, we learned that this group of staff are on a monday-friday, nineto-five schedule, which does not always match up with parental visits to the nicu. one nurse described this conundrum: "a lot of moms are very overwhelmed and kind of in information overload and we're asking them to pump every three hours, even through the night, they're exhausted so that's a lot. so it's hard for a mom of a premature baby to establish milk supplyâ�¦our lcs [lactation consultants] are awesome, they're kind of a monday through friday thoughâ�¦" however, there is a concerted effort to make sure that every birth mother can gain access to a pump. both labor and delivery as well as the nicu attempt to get mothers pumping within the first hour after delivery. however, as many preterm births are unexpected there can be complications with gaining access to and receiving training on using a pump. additionally, the labor and delivery unit is in a different building than the nicu complicating efforts to bring in-patient mothers to their infant's bedside. one nurse discussed the complicated character of this work as the birth mother is not their patient. "i think we tend to say, oh 'we're just caring for the baby, mom's discharged now, she's good.' but you forget that she needs to still be taken care of so that she can provide milk, so you do need to check in with herâ�¦". as a result, it takes a community of people to assist mothers with expressing milk, a layering of care work that reverberates through the community of people caring for infants in the nicu. notwithstanding this reality, once a birth mother is discharged the commodified healthcare system does not recognize them as a patient, which underscores the importance of valuing all forms of care-work. it is not always the case that milk can be provided by a birth mother and in some cases donor human milk is prescribed. donor milk use is common in nicu settings and in this case it is purchased by the hospital for infants with prescriptions. donations of milk are made by lactating parents who may have an oversupply or in some cases by bereaved parents who are expressing milk or donating stored milk as part of coping with the loss of an infant. when discussing policies around donor milk, one nurse discussed bereavement donation and how she uses her own story as part of counseling parents through loss. she explained: i was just talking to a mom last week-about donating due to bereavement, and milk donation is something very near and dear to my heart because i donated after i had my first baby and it was in a bereavement situation, so having that option given to families that they can do something tangible in memory of their child is huge, i think. this form of care-work is performed at the site of the body (carroll, 2015) and is a form of communal support as the donor may or may not have any relation to the infant. boyer (2010) describes disembodied milk, whether mother's own milk or donor, as a way to 'care at a distance.' the nicu always prioritizes mother's own milk, but when it is not possible and donor milk is, it is part of the education on breastfeeding and the value of human milk. when discussing infant feeding protocols in the nicu, one nurse related the tensions in infant feeding to me, noting that "just giving formula once in the hospital totally changes mom's perspective because we basically showed them this is okay 'cause we're doing it in the hospital, and so by using donor breastmilk we're showing her that this is so important that we're using donor milk to help you." however, donor human milk is also a site of tension in the nicu as the prohibitive cost of providing it to infants means that there is a weight requirement and only very low birthweight (1500 g or less) infants are prescribed donor milk. on this basis, access to milk is in some cases exclusionary, one nurse confirmed this noting "it's something i don't think we could probably provide to every baby both from a cost perspective and just from having the actual [financial] resources to do so." care in this case is unevenly distributed. it additionally demonstrates the pressure on birth-mothers to pump and provide milk as uncompensated laborers in order to realize better infant health outcomes for their infants (or in case of bereavement others'). this is a moment where the logics of capital compete with the coproduction of care. in this paper we have argued that care is multiple and competing. care labor, whether remunerated or not, provided by actants or actors is an essential part of life and living. 12 taking an anti-essentialist approach to regarding care in the nicu reveals this reality. simultaneously it shows that the provision of care is not straightforward and so in taking this anti-essentialist view, we have 'troubled' care, assessing its practice and performance in multiple forms. in the case of the nicu the subject of care is not limited to the infant receiving medical treatment. parents and extended families are also 12 we would like to note that this paper was revised during shelter-in-place orders in our home states stemming from the covid-19 pandemic; in this context we want to reiterate the importance of all forms of care and honor the labor of those people and actants who/that protected the lives of so many people. givers and receivers of care. care is managed and maintained, offered and provided, distributed and withheld within this space. the landscape of the nicu appears to be set up for medical care-machines and paid staff working around the clock, but nicu care is best accomplished collectively in this space. looking at a diverse logics and practice of care opens up 'care spaces' for greater introspection, allowing us to see beyond market-based care and into diverse forms of collective and coproduced care. there are capital and profit logics at work that make it difficult to provide the best care-the cost of donor milk, scheduling staff, attempts to reduce the time of hospital stays-but the co-production of care outside of capital proceeds. being a participant in care for the parents is crucial but it cannot always take place because of power dynamics; moreover, the focus on medical care by practitioners simultaneously enhances and limits opportunities for members of this community to provide or participate in care. however, efforts to get parents to contribute to "cares" and seeing that when the parents are providing positive touch and creating a safe place for their baby the baby's vitals are improved, the provision of care becomes community-based. at the same time, the schedule of "cares" can inhibit other forms of care, such as kangaroo care and are also a way that they are broken up by time and space. complicating all of these situations is the issue that parents cannot always be present as part of the caring community, and in some cases, for birth mothers in particular, they might not be able to provide care for their infant due to their own medical treatment or condition. finally, we reiterate that this community of care is comprised of participatory labor and it is evident that nicu care is a joint effort. simultaneously, despite this compassionate geography of care, tensions exist in what ultimately is a complex space where care is multiple and negotiated by actors with differing levels of power. care is shaped by this place, but also is part of shaping the nicu. if we are to be attentive to care-full geographies, we must recognize and value the multiple diverse actors provisioning care and the limits and expectations put upon all actors in the nicu space. credit authorship contribution statement lindsay naylor: conceptualization, methodology, validation, formal analysis, investigation, data curation, writing -original draft, writing -review & editing, visualization, supervision, project administration. abigail clarke-sather: conceptualization, methodology, validation, formal analysis, investigation, data curation, writing -review & editing, visualization, supervision, project administration. michael weber: formal analysis, writing -review & editing. 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example: atkinson et al., 2011; bartos, 2018; diprose, 2017; dombroski et al., 2018; gallagher, 2018; gibson-graham et al., 2013; hanrahan, 2020; hanrahan and smith, 2020; healy, 2008 healy, , 2018 henry, 2018; jackson and palmer, 2015; mcewan and goodman, 2010; de la bellacasa, 2017; robinson, 2011; waight and boyer, 2018 . we first want to thank all of the participants in this research, the mothers and nicu staff who were so generous with their time and so passionate about the subject. we are also deeply grateful to the research office at the hospital and the staff members who co-created and facilitated our study for the time and energy spent on the project with us. as we were revising this paper, covid-19 disrupted life as we have known it-we want to acknowledge all of the care labor that is ongoing and those who are doing it. it is essential and undervalued. we value you and your labor and we thank you. we also value the labor of the editors and the reviewers who not only helped us make this paper better, but who worked with us during a time of enormous upheaval in labor demands. we also thank our families for support during time spent working and living under shelter-in-place orders in our states. key: cord-321827-e7zc44ca authors: halter, mary; boiko, olga; pelone, ferruccio; beighton, carole; harris, ruth; gale, julia; gourlay, stephen; drennan, vari title: the determinants and consequences of adult nursing staff turnover: a systematic review of systematic reviews date: 2017-12-15 journal: bmc health serv res doi: 10.1186/s12913-017-2707-0 sha: doc_id: 321827 cord_uid: e7zc44ca background: nurses leaving their jobs and the profession are an issue of international concern, with supply-demand gaps for nurses reported to be widening. there is a large body of existing literature, much of which is already in review form. in order to advance the usefulness of the literature for nurse and human resource managers, we undertook an overview (review of systematic reviews). the aim of the overview was to identify high quality evidence of the determinants and consequences of turnover in adult nursing. methods: reviews were identified which were published between 1990 and january 2015 in english using electronic databases (the cochrane database of systematic reviews, medline, embase, applied social sciences index and abstracts, cinahl plus and scopus) and forward searching. all stages of the review were conducted in parallel by two reviewers. reviews were quality appraised using the assessment of multiple systematic reviews and their findings narratively synthesised. results: nine reviews were included. we found that the current evidence is incomplete and has a number of important limitations. however, a body of moderate quality review evidence does exist giving a picture of multiple determinants of turnover in adult nursing, with at the individual level nurse stress and dissatisfaction being important factors and -at the organisational level managerial style and supervisory support factors holding most weight. the consequences of turnover are only described in economic terms, but are considered significant. conclusions: in making a quality assessment of the review as well as considering the quality of the included primary studies and specificity in the outcomes they measure, the overview found that the evidence is not as definitive as previously presented from individual reviews. further research is required, of rigorous research design, whether quantitative or qualitative, particularly against the outcome of actual turnover as opposed to intention to leave. trial registration: prospero registration 17 march 2015: crd42015017613. electronic supplementary material: the online version of this article (10.1186/s12913-017-2707-0) contains supplementary material, which is available to authorized users. nurses leaving their jobs or leaving the profession, known more commonly in human resource terms as turnover [1] , is an issue of concern in all health care systems [2] . low retention rates of health care professionals, including qualified nurses, are detrimental to the delivery of health care systems and population health [3] . in high income countries retention of nurses and other health care professionals is also viewed as an important health human resource strategyto reduce demand for and therefore migration of nurses from health care systems in low income countries [3] . data from the north america have been used to suggest that many high income countries are experiencing or predicting growth in demand for qualified nurses over the next decade [4, 5] . in those high income countries facing shortage of supply of experienced qualified nurses such as england, reducing turnover and improving retention rates has become an important workforce development strategy [6] . definitions of nurse turnover differ in operational practice and in research studies [7] . turnover can be described as voluntary (including retirement) or involuntary, [8] avoidable or not avoidable; [1] and can be internal, that is leaving for another nursing or nonnursing job in the same organisation or external, that is leaving for another nursing or non-nursing job in a different organisation [9] . it can also refer to nurses leaving the nursing profession but remaining on a nurses' register, or leaving a nurses' register, [10] or to a number of combinations of the above descriptors [1] . it is in this context of a lack of consistency in the definition and measurement of turnover that the rate of nurse turnover has been estimated at between four and 54% intending to leave internationally [11] . in a review of studies which used the same method of measuring turnover and its costs (the nursing turnover cost calculation methodology [12] [13] [14] ), the rates reported in primary studies still varied from 15% in australia, 20% in canada, 27% in the usa to 44% in new zealand [7] . in england, in addition to the usual nurse turnover rates, a significant increase in demand for nurses qualified to work with general adult patients has occurred in recent years [15] . this has been attributed to the fall in commissioned nurse education places, [16] to high profile reports highlighting serious quality and safety issues [17, 18] and to the publication of evidence-based guidelines on safe nurse staffing levels [19] . nurses working in general adult health services, in comparison to those working in paediatric or psychiatric services, are the largest group of nurses in all countries [4, 20, 21] . it should be noted that there is diversity between countries in whether the education for nurse registration or licensure is generic to all populations or specialist to particular groups such as children [22] . in this paper nurses working in general adult health services are described as those in 'adult nursing' for brevity. the human resources literature offers us a large number of antecedents of actual turnover found on meta-analysis, including those in the groupings of personal characteristics, satisfaction, work experience, external environment factors, behavioural predictors and cognitions and behaviours about the withdrawal process [23] . such antecedents are variously represented in a number of well-developed models of turnover, including those describing organisational contexts and psychological (behavioural) explanations of turnover where characteristics lead to intentions leading to turnover, [24] as well as those indicating the importance of the 'webs of relationships in which employees are situated' , for example the role of centrality in social networks as a moderator to the psychological processes ( [25] , p1177) or the impact of dispositional traits such as locus of control and proactive personality, particularly in explaining wide variance in the intentionsactual turnover relationship. specific to nursing, turnover is recognised to be "complex and multifaceted with factors affecting every sector of health care" [26] and several conceptual models have been put forward, recognising the decades of work on nurse turnover [27] . these models variously recognise a plethora of reasons why nurses leave or state their intention to leave, [27] , although they have been broadly described in three categories: motivational characteristics, social characteristics and characteristics of the work context, although the latter has been less well explored in the research [25] . in these models, nurse turnover is also reported to have consequences, mainly reported as negative in terms of cost, compromise to patient safety and effect on remaining staff [2] . as these consequences take us full circle to antecedents, we have included these in this paper. our awareness of the existence of models within and outside of the nursing literature, and the large literature their authors call upon, led us to undertake a preliminary stage of review -making an assessment of potentially relevant literature specific to nursing and its size for review [28] -when we were commissioned to carry out a review of the adult nurse turnover literature. using medline alone at this stage we identified a large body of reviews relevant to the study's objectives that indicated that nurse and human resource managers would be faced by a plethora of reviews [29, 30] , many of which were not conducted according to reviews guidance [26] . against this background, we conducted an overview which is a systematic review of systematic reviews [31] . this paper reports on this overview, which aimed to identify high quality evidence of the determinants and consequences of turnover in nurses working in the field of adult health care services and bring that evidence together into one place to highlight where strong enough evidence to support managerial decisions exists and where gaps in the evidence may indicate the need for further research, particularly when considered in the context of the broader management literature regarding turnover. we based the review methods on the preferred reporting items for systematic review and meta-analysis protocols (prisma-p) 2015 statement [32] and cochrane handbook for systematic reviews of interventions [31, 33] . this overview included data from qualitative, quantitative and mixed methods reviews published in english from 1990 onwards. inclusion criteria were as follows: population: the reviews should be focused on those delivering adult nursing (i.e. licensed or registered) in health care services (both in hospital and community health services) in developed economies (according to the definition of the international monetary fund [34] ). issue of interest: the reviews should have examined the determinants and/or consequences of turnover in nurses working in adult health services. comparison: any comparators, if any, used within the included reviews. outcomes: the reviews should report measures of determinants and/or consequences of adult nursing turnover outcomes. the outcomes included in the review depended on the types of outcomes examined in the retrieved reviews, but were anticipated to include turnover / retention rate and intention to leave/stay. review design i (for all stages of the overview): any form of literature review (e.g. either systematic or non-systematic reviews) which had been peer-reviewed, contained a statement of review, reported its search strategy and/or inclusion/exclusion criteria, reported either empirical findings or a list of included primary studies and included a methodological quality assessment of its included primary studies. review design ii (for narrative synthesis): any review that had carried out and reported a methodological quality assessment of its included primary studies. exclusion criteria were as follows: reports from any types of primary studies; reviews published in language other than english; reviews that did not evaluate adult nursing turnover as described in the inclusion criteria or presented data on nurses working across settings that could include the care of children or in specific mental health settings; reviews that did not report empirical findings; reviews published only in abstract form; any form of literature review using informal and subjective methods to collect and interpret evidence, commentaries and non peer-reviewed reviews; any review in which majority of included articles were non-peer reviewed publications and reviews that did not report an appraisal of the quality of the studies they included. we searched the cochrane database of systematic reviews, medline (ovid), embase (ovid), applied social sciences index and abstracts -assia, cinahl plus (ebsco) and scopus -v.4 (elsevier) from 1990 to 2015 (searches conducted january 2015). search strategies were guided by a systematic approach to the research questions [35] and a medline search strategy was developed (table 1 ) and converted or modified to run on other databases (additional file 1). we identified additional studies by searching on pubmed by using the "related citations" algorithm and screening the reference lists of included studies for other reviews [36] . the results of the electronic search were downloaded into an excel spreadsheet. after duplicate articles were removed, relevant reviews were selected according to eligibility criteria using a two-step screening process: title and abstract screening. two authors (fp and mh) reviewed in parallel the titles and abstracts of all the articles resulted to ascertain their eligibility for full text retrieval. disagreements were resolved by peer discussion and a third view from the project lead (vmd) if required. full-text screening. two reviewers (mh and ob or ob and cb) read in parallel all the selected full-text articles citations to analyse whether they meet all the inclusion/exclusion criteria. any discrepancies between the two reviewers will be resolved in discussion with the third reviewer (fp where mh and ob had read in parallel and mh where ob and cb had read in parallel). three authors (mh, ob and cb) extracted data from the included reviews using a predefined extraction form and spreadsheet on: general characteristics of the review: e.g. author(s), year, geographical scope, research area, and authors' aims/ research question(s); descriptive characteristics: e.g. type of review (design); selection criteria to include primary studies, number and study designs of articles incorporated in the reviews, outcome measures; results: every determinant or consequence in the included reviews, listed by the outcome measured, the direction of findings against that outcome and the references for the primary studies; main conclusions, using the review authors' words, and limitations, as noted by the review authors. discrepancies were resolved through discussion among the data extractors. the 11-point assessment of multiple systematic reviews (amstar) checklist [37] was used to assess the quality of each included review. this tool has been widely used in previous similar overviews and it is considered to be a valid and reliable instrument [38] . using the amstar scale two authors appraised each included paper. reviews that scored eight or higher were considered at low risk of bias (high quality), between five and seven were at moderate risk of bias (moderate quality) and four or less were at high risk of bias (poor quality). the primary studies included in each review were also listed and compared across the reviews to assess the degree of overlap in the reviews comprising our overview. because of the heterogeneous nature of the focus, inclusion criteria and outcome measures of the included studies data were analysed thematically. following the detailed reading involved for data extraction, the resultant spreadsheet was examined and a thematic index of determinants and consequences developed (using reviews that met our inclusion criteria for including a methodological assessment of their primary studies as well as those that did not). the thematic index (additional file 2) was applied to each data extraction and four main groupings of determinants (individual, professional, interpersonal and organisational) and one of cost consequences was used to analyse across reviews, using microsoft excel 2010 to record the decisions applied for all reviews considered (additional file 3). a narrative account of the findings from the reviews containing an assessment of the methodological quality of included primary studies has been structured using the risk of bias in the review as the primary grouping level and the thematic content analysis as the second level, also drawing on the number and quality of the included primary studies. in this way we aim to describe the findings by 'weight of evidence' [39] . the systematic review protocol was registered with prospero (international database of prospectively registered systematic reviews in health and social care) prospero 2015: crd42015017613 [40] . review selection, study characteristics and quality assessment review selection the flow chart representing study selection, including reasons for exclusion, is summarised in fig. 1 . a total of nine reviews met the inclusion criteria and were included in the review. additional file 4 provides a list of citations for the excluded studies in the final stage of the selection process, as well as a table describing the characteristics of the 12 studies excluded only on the basis of not having presented a methodological assessment of the quality of the included articles. the characteristics of the nine included systematic reviews are presented in table 2 . the included reviews were all published in english; four were authored from the united states of america [41] [42] [43] [44] , and one each from australia, [45] canada, [46] finland, [11] singapore [47] and uk [48] . of these, six had been published since 2010. eight reviews had been published in four academic journals about nursing (journal of nursing management, [41] [42] [43] 46] journal of advanced nursing, [44] international journal of nursing studies [48] and nursing ethics [45] ), and one in the international journal of evidence-based healthcare. none was a cochrane review. table 2 shows each review's criteria used to include or exclude primary studies, and the limits used to focus the reviews' scope. the majority of the reviews limited their searches to the english language, with the exception of flinkman et al. (2010) [11] , who did not use this restriction, and coomber and barriball (2007) [48] who did not report this limit. the majority of the reviews did not restrict their searches by geographical region. the included reviews contained a range of seven to 31 primary studies. of the 159 primary studies in the nine systematic reviews, 21 were included in at least two reviews, and only two primary studies [49, 50] were included in three reviews (table 3 ). in the included systematic reviews, observational study designs were the most frequently reported in the included primary studies; a small number of qualitative studies were also included. quality assessment of included reviews figure 2 presents the critical appraisal scores for individual reviews. the overall quality rating of the nine included systematic reviews ranged from poor (n = 2) [42, 44] to moderate (n = 7) [41, 43, [45] [46] [47] [48] . from the four themes discussed, three were organisational factors (leadership, stress and pay) and only one an individual/ demographic factor (educational attainment). quantitative 6 the empirical evidence shows that stress and issues concerning leadership consistently exert both direct and indirect effects on job satisfaction and intent to leave there are a number of published articles characterized by loosely defined terms the main reasons for reviews being in the moderate rather than strong evidence category were the lack of publication of an a priori protocol, varying levels of details about the search strategy performed, the failure to have two reviewers check the selection and data extraction, not providing a list of both included and excluded primary studies (with the exception of toh et al. 2012 [47] ), limited use of the methodological quality of included primary studies (assessed in all included reviewsthe tools used to assess the quality of included papers in the included studies are shown in table 2 ) and in summarising results and conclusions (used in four reviews [45, 46, 48] ), and the absence of meta-analysis (or a justification for not using this method if inappropriate to the review data, apart from one review [43] ). the evidence from the included reviews is presented here by thematic analysis of determinants, grouped into four content categories: individual, job-related, interpersonal, and organisational determinants and consequences. each of these content categories is divided by strength of evidence categories, within which we also account for the number and quality of the reviews' included primary studies and the outcome [48] 2007 [44] 2008 [45] 2010 [11] 2011 [46] 2012 [47] 2013 [41] 2013 [43] 2014 [42] bycio 1995 [60] x x . all consequences were reported in relation to turnover. no reviews of determinants or consequences of turnover in adult nursing were judged to be of high quality. seven reviews were judged as of moderate quality/moderate risk of bias and addressed all four content categories of determinants. two reviews were judged to be of poor quality. eleven individual determinants were reported as having been examined in five reviews of moderate qualityage, gender, marital status, educational attainment, stress, burnout, commitment, job satisfaction, low serum cholesterol, weight and sleep disturbance [41, 45, 47, 48] . two subsets of factors were considered among individual determinants sociodemographic characteristics and psychological experiences. the first subset of factors involved sociodemographic characteristics, some were 'given' characteristics such as age and gender, whereas others were acquired -education and family status. age featured in two reviews, with contrasting findings reported. one review [41] reported an inverse relation of age and experience with intention to leave, based on splitting nurses' age groups at 45 years or simply referring to them as 'older' in six quantitative primary studies, with the older group less likely to leave and nurses who had worked less than 5 years being less likely to stay. this contrasted with a positive finding of intention to leave (retire) in nurses aged over 50 from another review, [11] albeit reporting on just one primary study using a survey design, and complicated by two other studies reported by one review [41] that suggested a negative association between being a nurse aged less than 25 years and newly qualified and intention to leave and another finding a greater intention to leave in nurses older than 35 years and with longer hospital tenure (greater than 10 years) than in nurses aged under 25 years with less than a year tenure). the review authors suggested these contrasting findings to be due to the confounding of age with variables such as tenure and year post-qualification [41] . with regards to gender and marital status, one review [41] reported that male nurses and unmarried nurses had a greater intention to leave, based on three primary studies (of cross-sectional designs and excluding north american literature) for each factor. more educated nurses were reported as more likely to leave across three reviews [41, 47, 48] , using different outcome measures and based on six primary studies. chan et al.'s review (2013) [41] reported four primary studies where education was negatively associated with retention, although little detail was given on level of education; likewise there is evidence from a descriptive study of a statistically significant association between holders of master's degrees and intention to leave their current job in specialist oncology/haematology reported by one other review's authors [47] . additionally, coomber and barriball (2007) [48] described a small but stable relationship for intention to leave with educational attainment from a meta-analysis, although when analysed with job satisfaction as an antecedent or confounding factor they report no consensus despite similar methods used in the primary studies they report and they urge caution in drawing conclusions regarding the determinant of education. the second subset of individual characteristics described associations with psychological experiences of nursesstress, burnout, commitment and job satisfaction. among psychological experiences, stress and burnout are considered as negative experiences which are more likely than not to influence a decision to leave. the negative influence of stress received consistent support in three reviews [45, 48] . two reviews reported positive associations of work-related stress (for example lack of stability in the work schedule or stress related to high workload or to the role, together with dissatisfaction of career prospects) with intention to leave [48] . these findings were based on scale-based surveys from canada, singapore, the uk and the usa, written comments from australia and a meta-analysis from taiwan, although one review [48] noted contrasting rankings of the antecedents of that stress and suggested that measurement of stress is difficult. the other review reported increased turnover [45] to be positively associated with moral stress originating in the hospital ethical climate, this definitive finding being based on one interview study, although the review authors note inferred relationships in several other studies but a lack of methodological rigour in the included studies [45] . similarly, burnout also featured among individual factors [11] , in one study reported by toh et al. (2012) [47] and, alongside emotional exhaustion in a review by chan et al. (2013) [41] reporting three different primary studies. job dissatisfaction or satisfaction was also reported frequently as a determinant of intention to leave or to stay. four reviews reporting a total of 16 studies (four of which appeared in more than one review) uniformly concluded on its relationship of the measure of satisfaction/dissatisfaction used with intention to leave [41, 47, 48] or intention to stay, [41, 48] based on non-validated survey responses from a large number of nurses in studies with moderate to high response rates. one review reported no association with intention to stay [47] in responses to a survey item in one study. the sources of dissatisfaction are variously reported by the reviews from limited literature (for example nurses' feeling dissatisfied with their inability to provide high quality of care to their patients (cited in chan et al. 2013 [41] ), dissatisfaction with staffing and workload as contributors to the intention to leave the specialty (oncology) (cited in toh et al. 2012 [47] and dissatisfaction with salary or low pay (cited in flinkman et al. 2010 [11] ). commitment, presented as a positive psychological experience, featured in two reviews. one review reported a uni-directional negative relationship of organisational and occupational commitment with intention to leave the hospital [41] and another review considered different types of commitment (for example organisational, affective, continuous, normative, and professional), mostly highlighting single studies again, suggesting negative relations with intention to leave, although organisational commitment was found to have no statistical association with intention to leave nursing as a profession in one study [11] . reviewers suggested that the multifaceted nature of commitment and different designs and tools impact on findings. one further review, [44] judged to be of poor quality, contributed mixed evidence regarding commitment as a determinant, describing 12 studies with negative associations with intention to leave and two studies with significant negative associations with turnover, as well as two other studies confirming a positive influence of organisational commitment on intention to stay. additionally, the impact of biological factors (low serum cholesterol, being underweight, sleep disturbance) on intention to leave is considered in one review, [41] relying on a single study for this evidence. three reviews synthesised evidence around seven jobrelated and occupational determinantswork content, workload, task variation, role ambiguity, shift patterns, rota stability and promotional opportunities. workload, including demanding work content, high workload, variation in work tasks or role ambiguity were reported to increase intention to leave in one study and turnover in two others, while one study found no association with intention to leave [41] . working patterns, such as shift work (evenings and night shifts mentioned specifically) [41] were linked to intention to leave, and increasing stability from a constantly changing rota as a way to reduce stress [48] was reported as negatively associated with intention to leave. promotional opportunities featured an influential factor too. intention to leave increased where nurses experienced fewer possibilities for development or professional growth, evidenced by two studies in one review [11] and four studies (one overlapping) of another review, including the findings of a large study carried out in 10 european countries [41] . chan et al. (2013) [41] also cited three quantitative studies confirming the impact of lack of autonomy on intention to leave. role conflict has also been suggested to be a determining factor in decreasing a nurse's intention to stay in one study in one review, [41] while another review [11] reported a study providing conflicting quantitative and qualitative findings from the same group of nurses; this review suggested that more experienced nurses (how they saw themselves professionally) indicated an intention to stay. the evidence on the impact of interpersonal factors included the consideration of ten determinants related to supervisor support; managerial stylepraise and recognition, trust, manager characteristics; leadership practices; staff autonomy, empowerment and decision making; group cohesion; social support; team work and workplace incivility. supervisor support featured in two reviews, [46, 48] with a total of 15 primary studies stating, relatively unambiguously, that this had a positive influence on intention to stay, with just one primary study cited as an exception in coomber and barriball (2007) [48] . this association was illustrated by direct and indirect associations (for example, via empowerment in one study cited in one review [48] . along the same lines, satisfaction with a supervisor was reported as negatively related to intention to quit in one study in one review [48] . additionally, the positive influence of praise and recognition and of trust in manager was significantly correlated with intent to stay (each characteristic evidenced by singular studies in one review [46] ). broadly defined 'poor management' featured in a qualitative study as positively related to intention to leave [41] . with regards to types of leadership the reviews revealed that transformational (and generally participative) managerial style increased intention to stay [46] or decreased intention to leave (although the relationship was through other factors) [48] . on the contrary, the transactional leadership style of 'management by exception' , whereby managers only act on deviations from plan or budget, was found to increase turnover rates, and autocratic leadership was significantly negatively correlated with intention to stay [46] . however, some of the specific manager's characteristics, in particular, the degree of power and influence the nurse perceived their manager to have within an organisation, received significantly positive association with the intention to stay [46] . the positive and significant influences of empowerment, control over practice and shared decision-making on intent to stay received support in six studies reported in one review [46] . group cohesion also appeared to be important with nine studies reported in the same review [46] showing a significant positive relationship with intent to stay in the current nursing position. in a similar vein, the review by chan et al. (2011) [41] contained a few references to the importance of social support and good communication with supervisors for nurses' intention to stay, particularly, in a hospital. low quality teamwork, on the opposite, was said to be associated with higher intention to leave [41] . these consistent findings across a number of studies in the three reviews are tempered somewhat by the review authors' comments arising from their quality appraisal of the evidence. for example, cowden et al. (2011) [46] raised some concern over biases of synthesis such as over-reporting of positive findings, and lack of causal analysis between leadership factors, as well as the limits to generalisability imposed by heterogeneous studies, this point also being relevant for coomber and barriball (2007) [48] who noted a heavy reliance on mixed samples and scales. one relatively stand-alone review judged to be of poor quality in our overview looked at an interpersonal determinant workplace incivility, in particular, behaviours violating workplace standards and consideration towards new graduate nurses [42] . lateral violence, that is co-workers' violence that redirects aggression towards those in authority on their more vulnerable co-workers was reported as a major factor in the decision to leave nursing by 14% of rns in a survey study and its indirect effect on low retention in new graduates was reported across five other studies. assessment of rigour and quality in this particular review is however impeded by missing information on the characteristics of the included studies. seven organisational factors outlined three strands of evidence: work environment including climate, organisational structure and financial determinants. one review [41] cited three studies that demonstrated the influence of work environment, for example, the perceptions of a 'deteriorated external work environment' as increasing intention to leave, and 'better working conditions' as lowering it; however these concepts were not defined. this review also contained reference to ethical climate as a key aspect of work environment that can significantly influence the turnover intentions of registered nurses, referencing the same single, though robust, study as in one other review [45] . limited evidence was found on the impact of organisational culture, with one review suggesting from two studies of asian nurses in asian countries that the individualism-collectivism dichotomy could relate to turnover phenomena: a collectivistic cultural factor played an important role in weakening nurses' intention to leave [41] . the influence of staff shortages as well as lack of resources on intention to leave was mentioned from one qualitative study where the shortage of nurses implied insufficient manpower to satisfy nurses' personal standards of care, and one questionnaire study focused on patient workloads in one review [41] . conversely, a single study cited in the same review [41] also suggested that working in smaller outpatient and day care units generated a negative association with turnover. another set of organisational determinants was that of financial incentives. one review [41] listed six primary studies suggesting that those nurses dissatisfied with their remuneration were more likely to leave, and that social rewards such as pay and job security were ranked higher for some generations (born 1946-1959) than others. gender was highlighted by another review [48] with male participants reported in one study as being twice as likely in their intention to leave as females due to dissatisfaction with salary. the results of other three studies reviewed in one review [48] , produced from differing methods of assessment, suggested non-uniform relations between pay and retention. although factor analysis showed pay as an important contributor to job satisfaction, pay was not a statistically significant indicator of intent to leave or turnover cognition. written comments from two studies conducted in australia and usa indicated that fairness and equality of pay was more important to nurses in retaining their positions. in other words, perceived low pay had a greater influence than pay level per se. crucial factors were commensuration according to contributions, for example, for roles with high responsibility, and additional reward mechanisms including fringe benefits [48] . only one review included evidence of the consequences of turnover, [43] and this review was judged to be of moderate quality / moderate risk of bias. this review focused solely on cost as the consequence of turnover [43] . this review was based on ten studies, eight of which were in acute hospital settings, all conducted in the usa, with one also in each of australasia and canada. the review reported costs of per nurse turnover ranging from $10,098 to $88,000 and a total turnover cost ranging from $0.55 million to $8.5 million, the ratio of nurse turnover costs relative to nurses' salary ranging from 0.31 to 1.3. orientating and training new hires was reported as the largest or second largest category of costs relative to total nurse turnover costs while several studies also noted the high costs of unfilled positions/vacancy costs (defined usually as the costs of temporary replacements, but also including wider costs, for example, patient deferral costs and productivity costs for supervisors and other staff, in some primary studies they review). the review authors note the difficulty interpreting and generalising from their included primary studies due to the variability in conceptualisation and measurement of turnover, in time-periods (spanning over two decades) and geographic locations. they also noted that all but one study, which was based on econometric methods, relied on descriptive statistical analyses and that the studies were mostly based in one setting and had relatively small sample sizes. that said the key message from the review was that nurse turnover is costly for organisations. our overview (review of systematic reviews) points us to a complex range of determinants of turnover in adult nursing, at the individual, job-related, interpersonal and organisational level, and to the cost consequences of turnover, but many reviews only cite one or two primary studies for many of the determinants they feature. the analysis here reveals that despite the publication of a large number of primary studies (n = 159 in the reviews of primary studies we reported fully in the narrative of reviews), there is a low degree of overlap in their presence in eight reviews which focus on the same topic and present similar categories of determinants. we might suggest that the low overlap could be attributed to differences in the detail of the research questions (for example, concentrating on job satisfaction [48] or commitment; [44] see table 2 ) as the international reviews with more general research questions have a greater overlap [41] . nevertheless, the impact of this is a rather disjointed body of evidence in which both the outcome of actual turnover as opposed to intention to leave is poorly addressed, and modelling of determinants in combination, taking account of confounding factors, is rare. while the large number of reviews on the topic of nurse turnover may give the impression that the topic is saturated, our overview suggests new knowledge -that there are large gaps in the literature on determinants of turnover in adult nursing. review of the literature on the consequences of determinants is rare, although we note that some conflate these issues as consequences such as reduced staff numbers are also related to determinants such as workload pressures. the most strongly supported determinants of turnover in the literature reviewed were at the individual level: stress and burnout, job dissatisfaction and (to a lesser degree) commitment. supervisor support was the most supported determinant for retention. the reviews use a number of outcome measuresintention to leave, turnover, intention to remain and retentionand many present these unquestioningly as measuring the same concept. the largest number of reviews uses the measures of intention, in particular, intention to leave, rather than action. this is problematic as, although intention has been demonstrated to be a consistent predictor of nurse retention, how these behavioural intentions develop and the link between intention to leave a job and actually leaving are unclear [46] . furthermore, the inconsistency in the criteria and outcomes measures used in research studies and reviews not only demonstrates the complexity of the concept of turnover, it also shows how reviews of the turnover evidence have not systematically built on previous work in a consistent way to contribute to a shared theoretical base, despite discussion about definitions, conceptual models and a need for multivariable analyses [10] . concepts therefore remain loosely defined and are used interchangeably. it might be that this accounts for the very limited evidence related to consequences at organisational level (cost), with no evidence on individual level consequences. the quality of the reviews was mostly moderate, and, while all nine reviews stated that they had carried out a quality appraisal of their included primary studies, only one of the reviews used the assessment of studies to support their reporting and conclusions; however we know that the primary studies they report are predominantly quantitative observational designs, most often based on self-report data, with a small number of qualitative studies also included. more positively, several of the reviews highlight limitations of the body of literature, such as poor definition of intention to leave, dependence on cross sectional survey designs (with qualitative investigative depth mostly lacking [48] ) and variability in the health systems of different countries in particular (identified in two reviews [41] ), as well as noting the emphasis on single studies in several reviews [11] , and the heterogeneity of nurses, [11] often within studies [48] . difficulties comparing across reviews due to other issues of definition, for example, of moral climate [45] or definition and measurement of manager leadership practices [46] or poor specificity of workplaces studied [47] are also raised. the limitations associated with meta analysis being prevented by the above mentioned heterogeneity are also specifically mentioned [46] . this degree of critique can be considered to ameliorate some reviews within the grouping of moderate strength of evidence in particular. our overview is limited by design. in being an overview of (systematic) reviews we have relied upon the review authors' reporting and interpretation of the primary studies and have made some assumptions about quality based on descriptions of research design rather than on a critical appraisal of each primary study. we suggest that this limitation is mitigated somewhat by only including reviews that have at least reported that they have carried out a quality appraisal of their included studies, and becomes a strength in that we have sought to review rather than add yet another review of primary studies to the large, somewhat repetitive, yet also heterogeneous decades of literature on turnover in adult nursing. we have also assessed the quality of the included reviews using a widely recognised tool for this task [37] . our decision to include those reviews that reported a quality appraisal of their included studies also limits our review in excluding from our full narrative a number of comprehensive and recent reviews of the determinants and consequences of turnover in adult nursing that added considerably to our thematic index. in particular we have not featured the national/societal or patient level determinants and patient care outcomes that appear in the twelve reviews that did not contain a methodological appraisal of their included primary studies although they met our other inclusion criteria. we may also have excluded high quality primary studies that did not feature in reviews containing a quality appraisal. while this is acknowledged here as a limitation, we however consider this justified, and indeed a strength of our overview, in that we have based this decision on the guidance for the good conduct of systematic reviews available since the 1990s [26] and have only included reviews published since that date. we have therefore provided a focused account of what should be the highest quality reviews available. in spite of this, our own overview is limited in the conclusions it can come to regarding the determinants and consequences of turnover by the limitations of the systematic reviews that we systematically reviewed, for two reasons in particular. first, the coterminous use of outcome measures of intention with those of action (that is intention to leave with turnover, for example) is problematic and we are also limited in that we have partially replicated this concern in this overview, whilst also seeking to be explicit about the measures we have combined. this issue is considered in-depth in the turnover literature outside of nursing with acknowledgment of the poor translation of intentions to behavior [25] illustrated through wide statistical credibility estimates of the relationship [23] . evidence suggests that the relationship can be moderated by, for example, structural variables [25] or personality traits [49] . as intentions are considered to overestimate actual performance (here, actual turnover), the determinants we present may have moderator effects not previously presented in the nursing literature. an important recommendation of this review is that the concepts related to nursing turnover are carefully considered and defined and consensus reached about the priorities for future research and workforce development to increase the pertinence and co-ordination of future research to provide evidence that can inform decision making in human resources practice and planning in healthcare and nursing. second, and fundamentally, we are limited by the absence of any reviews that have been assessed to offer strong evidence. the literature we reviewed offered no opportunities to carry out the meta-analysis of antecedents and correlates which we find in the broader human resource turnover literature, where not only are primary studies' findings statistically pooled, but variations in base rates of turnover and moderators in statistical models of turnover are tested [23] . we also note that the majority of the reviews we included did not specify what type of 'leaving' their primary studies referred to, that is leaving a department, an employer or the profession; only four of the studies mention this; three of these refer to leaving the profession. finally, with the inevitable time lag of publication of primary studies to their inclusion in a pertinent review, we are likely to have missed all of the more recent literature published. our findings in the context of other literature from our searches we identified 66 reviews already published on this topic, including recent developments in conceptualising the determinants and consequences of such turnover into models [28] . however, when we applied criteria based upon guidance for the good conduct of systematic reviews [26] we systematically and explicitly excluded large numbers of reviews, and reviewed a relatively small number in full. the results are not surprising in content of determinants and consequences as we developed a thematic index based on the reviews we were reviewing, several of which grouped determinants similarly, for example using the groupings of individual, interpersonal and organisational factors [27] . the results are also not entirely surprising when viewed in the context of the broader management literature on the wide range of researched antecedents to turnoverfor example, if we look at what holtom et al. (2008) [24] described as the major trends in turnover research in the preceding decade, our overview points to some evidence on the role of interpersonal relationships, of organisational commitment and embeddedness and of job satisfaction, but it does not present evidence in the nursing literature on individual difference predictions such as personality or of working conditions; nor of dynamic processes. the overview also contains substantial literature related to demographic issues that griffeth et al. (2000) [23] consider to be decreasing in importance. the rising issues of social networks [25] and cultural differences [24] , as well as multi-level investigations [24] are equally lacking in visibility in the reviews we have included. in recognition of these differences, and the limitations of the quality of the literature and the predominance of intention to leave versus actual turnover in the nursing turnover literature, we have not sought to try to fit it to one particular model from the literature outside of nursing. it is in recognition of the plethora of previous work in nursing that we conducted this overview of systematic reviews and, in doing so, highlight an important finding: while clarity has been achieved on where the strongest current evidence lies regarding the determinants and consequences of adult nursing turnover, none of the evidence is strong when we combine different interventions, different outcomes, different conditions, problems or populations, as suggested for reviews of reviews [50] . despite the plethora of reviews, the gaps in strongly evidencebased knowledge about adult nursing turnover limit the conclusions that can be drawn even from the relatively stronger reviews from which we built our overview. we suggest that this could contribute to a continuing problem, if managerial decision makers have not been clearly signposted to robustly conducted systematic reviews based on robustly conducted and/or robustly critiqued primary studies. what does nurse turnover rate mean and what is the rate? pol politics nurs pract nursing churn and turnover in australian hospitals: nurses perception and suggestions for supportive strategies global strategy on human resources for health: workforce 2030: consultation paper. who table 8 occupations with the largest projected number of job openings due to growth and replacement needs canadian occupational projection system (cops). search for occupational projection summaries growing nursing numbers 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transformational leadership manager leadership and retention of hospital staff nurses nurses' job satisfaction, organizational commitment, and career intent the effects of nurses' job satisfaction on retention: an australian perspective a model of job satisfaction of nurses: a reflection of nurses' working lives in mainland china predicting registered nurse job satisfaction and intent to leave predictors of nurses' intent to stay at work in a university health center faces of the nursing shortage: influences on staff nurses' intentions to leave their positions or nursing hospital ethical climates and registered nurses' turnover intentions nurse intention to remain employed: understanding and strengthening determinants nurses' perceptions of severe acute respiratory syndrome: relationship between commitment and intention to leave nursing the impact of social work environment, teamwork characteristics, burnout, and personal factors upon intent to leave among european nurses explaining young registered finnish nurses' intention to leave the profession: a questionnaire survey predictors of hospitals' organizational climates and nurses' intent to stay in jordanian hospitals turnover factors revisited: a longitudinal study of taiwan-based staff nurses we are grateful to the reviewers of the first submission of this paper for their comments and suggestions for improvement. this review was independent research funded by health education england -south london, part of the national health service (nhs). the views expressed herein are those of the authors and not the funding body, the nhs or the department of health. the datasets supporting the conclusions of this article are included within the article (and its additional files. the current evidence is incomplete and has a number of important limitations. a body of moderate quality review evidence does exist giving a picture of multiple determinants of turnover in adult nursing, with individual level nurse stress and dissatisfaction factors and organisational level managerial style and supervisory support factors holding most weight, as well as the economic consequence of the turnover. our systematic review of the review literature uses the quality of the review alongside the quality of the included primary studies and which outcomes they measure to progress the usefulness of the body of review literature for decision makers, in terms of the determinants themselves. in using the quality of the review alongside the quality of the included primary studies and which outcomes they measure the evidence is far from definitive. further research, of rigorous research design, drawing on recommendations from the wider management literature on turnover, whether quantitative or qualitative, particularly against the outcome of actual turnover as opposed to intention to leave, and modelling determinants in combination, taking account of confounding factors, is required. ethics approval and consent to participate this paper presents an overview of previously published reviews and, as such, requires no ethics approval. not applicable. the authors declare that they have no competing interests. springer nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.â�¢ we accept pre-submission inquiries â�¢ our selector tool helps you to find the most relevant journal submit your next manuscript to biomed central and we will help you at every step: key: cord-315364-8eh55yt2 authors: stolldorf, deonni; germack, hayley d.; harrison, jordan; riman, kathryn; brom, heather; cary, michael; gilmartin, heather; jones, tammie; norful, allison; squires, allison title: health equity research in nursing and midwifery: time to expand our work date: 2020-07-15 journal: j nurs regul doi: 10.1016/s2155-8256(20)30110-1 sha: doc_id: 315364 cord_uid: 8eh55yt2 nan t he world health organization (n.d.) named 2020 the "year of the nurse and midwife" to both celebrate the contributions of nurses around the globe, recognize the challenges they face, and invest in and increase the nursing workforce. indeed, the first half of the year has brought profound changes and challenges to nursing and midwifery. the covid-19 pandemic has laid bare the structural inequities inherent in the us healthcare system. the collective "enough!" expressed by the public with regard to racism and discrimination toward black and minority communities further raises the motivation to move our research toward addressing social justice issues. for nursing and midwifery, the time has come to address health equity in all its forms. the interdisciplinary research group on nursing issues (irgni) of academyhealth has agreed to target its efforts in the coming years to address health equity. the irgni looks forward to using its platform to help share the unique perspectives of nurses and midwives in this important field of research. health equity is achieved by eliminating health disparities and inequalities (braveman, 2006) . many of our fellow researchers use the terms "minority health," "disparities," "inequities," and "inequalities" interchangeably, yet they are conceptually distinct. with that, the irgni has reviewed and will adopt the revised definitions of minority health and health disparities published by the national institute for minority health and health disparities (nimhd). alvidrez et al. (2019) published the revised definitions in a special issue of the american journal of public health. the revised definitions read: nimhd defines minority health as all aspects of health and disease in one or more racial/ethnic minority populations as defined by the office of management and budget, including blacks/african americans, hispanics/latinos, asians, american indians/alaska natives, and native hawaiians/other pacific islanders. nimhd defines a health disparity as a health difference, on the basis of one or more health outcomes, that adversely affects disadvantaged populations. according to the legislation that created nimhd, a health disparity population is characterized by a pattern of poorer health outcomes, indicated by the overall rate of disease incidence, prevalence, morbidity, mortality, or survival in the population as compared with the general population. current nimhddesignated health disparity populations include office of management and budget-defined racial/ethnic minorities, socioeconomically disadvantaged populations, underserved rural populations, and sexual and gender minorities (which include lesbian, gay, bisexual, transgender, and gender-nonbinary or gender-nonconforming individuals). (p. s16) also important is the concept of healthcare disparities with issues of access and implementation of services that often disproportionately affect minority populations. achieving healthcare equity means equitable access and patient experiences for all. the social determinants of health have also received increasing attention as important factors that can affect anyone at the individual, familial, community, and system levels (carey & crammond, 2015) . during the year of the nurse and midwife, the irgni advisory committee is looking forward to open discussions regarding health equity and the revised nimhd definitions. we are proud to present this year's collection of irgni research abstracts. this work highlights how nurses and midwives can systematically move toward addressing health inequities, health inequalities, health disparities, and the social determinants of health. these abstracts cross the lifespan and focus on communities of color, understudied populations, and the places where we seek healthcare services. we hope readers will find new insights into the health of populations and their health-seeking behaviors. these findings will inform new directions for research, policy, and regulation and will strengthen the evidence base to dismantle sources of structural discrimination in the u.s. healthcare system. many of the nursing and organizational factors identified in this study that are associated with mnc are actionable. we recommend that nursing administration, nursing leaders, and policy makers consider regularly monitoring mnc as a quality measure and modifying elements of the nursing work environment to decrease the frequency of mnc. to develop machine learning models designed to predict 30-day and 1-year mortality for medicare beneficiaries aged 65 years or older treated in inpatient rehabilitation facilities (irfs) following hospitalization for hip fracture. study design: a retrospective design/cohort analysis of the centers for medicare and medicaid services inpatient rehabilitation facility-patient assessment instrument first-admission data were used for 17,140 persons admitted to medicare-certified irfs in 2015 following hospitalization for hip fracture. independent variables included patient characteristics such as sociodemographic (i.e., age, gender, race, and social support) and clinical factors (i.e., functional status at admission, chronic conditions) as well as utilization (i.e., length of stay). the dependent variables were 30-day and 1-year mortality. we trained and evaluated two types of classification models-logistic regression and a multilayer perceptron (mlp)-that used multivariable combinations of patient data described above to predict the probability of 30-day and 1-year mortality. four measures were used to determine model performance: (a) accuracy (acc), (b) area under the receiver operating characteristic (auroc), (c) average precision (avg prec), and (d) calibration slope. population: the analytic sample included 17,140 hip fracture patients who received postacute care services in 1,112 irfs. results: the best predictive model for 30-day mortality was mlp (acc = 0.743, auroc = 0.762, avg prec = 0.103, slope = 1.14) versus logistic regression (acc = 0.78, auroc = 0.76, avg prec = 0.097, slope = 1.20), and for 1-year mortality was logistic regression (acc = 0.684, auroc = 0.756, avg prec = 0.326, slope = 0.957) versus mlp (acc = 0.682, auroc = 0.757, avg prec = 0.326, slope = 0.962). both models showed fair predictive power and performed similarly across all four measures. conclusions: this study presented analysis of prognostic factors of hip fracture mortality using two different machine learning models. although model evaluation suggested that mlp may yield slightly better (although not statistically significant) accuracy when compared to logistic regression, both models have high aurocs and good calibration and can serve as valuable tools for accurately identifying patients with hip fracture at high risk for 30-day and 1-year mortality. implications for clinical practice and regulation: logistic regression and mlp models have similar predictive power and may be implemented to reduce cognitive burden. these models can be trained on local data to enhance clinical specificity in mortality prediction so that palliative care resources may be allocated more effectively. author: rachel breman, phd, mph, rn objective: in the united states, approximately one third of births are cesarean. furthermore, cesarean delivery is the most frequent surgical procedure. reducing the rate of cesarean delivery in a generally healthy population of patients is a key focus of efforts to decrease cesarean birth nationwide. previous research suggests that hospital admission in active labor among healthy women can reduce the use of medical interventions and cesarean birth. the purpose of this study was to examine the influence of hospital admission management and maternal sociodemographic factors on labor and birth outcomes among groups of women who were triaged for hospital admission by a rotating staff of midwife versus physician providers. study design: retrospective cohort study. population: low-risk pregnant women with a term gestation fetus in a vertex position (n = 335) admitted to a community hospital for labor in 2015 by a nurse-midwife (n = 175) or physician provider (n = 160). results: forty-three percent (74/172) of patients admitted by midwives and 93% (147/158) of patients admitted by physicians went on to deliver with the same type of provider. patients admitted by midwives had more advanced cervical dilatation (4.1 cm vs. 3.3 cm; p < .05) and effacement (88.2% vs. 80.8%; p < .01) at admission and were less likely to receive labor augmentation or epidural (39.8% vs. 55.1% and 77.0% vs. 93.0%, respectively) compared with patients admitted by physicians. in multivariate analysis controlling for influence of patient sociodemographic factors, women admitted by physicians were 3 times as likely to have a cesarean birth as those admitted by a midwife. among patients who gave birth in the first 24 hours after triage, the median length of labor in those admitted by midwives was nearly 3 hours shorter (10.9 hours, iqr = 6.9 -15.4) than those admitted by physicians (13.5 hours, iqr = 8.2 -18.1). in a subanalysis of patients having a vaginal birth, there was no difference in labor length by provider type, but public insurance compared to private insurance was associated with shorter labor duration (median, 9.45 hours for public insurance and 11.77 hours for private insurance) after accounting for triage provider type, sociodemographic, and labor factors. conclusions: patients triaged by midwives were less likely to experience labor augmentation, epidural, and a cesarean birth compared to similar women triaged by physicians. publicly insured women spent less time in the hospital in labor preceding vaginal birth. implications for clinical practice and regulation: use of midwives in labor triage units may potentially decrease cesarean rates and associated costs. future studies are needed to explore reasons why publicly insured patients who have vaginal birth may spend less time laboring in the hospital and the possible cost implications. 1% and can cost a hospital up to $7.86 million annually. other negative consequences of nurse turnover are well documented and include adverse patient outcomes, such as increased falls and mortality rates and decreased satisfaction with healthcare, and adverse nurse outcomes, including increased burnout and decreased job satisfaction. the inability to retain experienced, knowledgeable nursing personnel has detrimental effects on overall healthcare delivery system performance, not only in the civilian community but within the military healthcare system (mhs) as well. the purpose of this study was to conceptually define potentially preventable losses (ppl) and examine the associations between the nursing work environment, job satisfaction, unit characteristics (i.e., medical-surgical vs intensive care units), nursing roles (i.e., registered nurse [rn] and licensed practical nurse [lpn]), and ppl. study design: this descriptive and correlational secondary data analysis uses annual nursing workforce survey data extracted for a multifocus, longitudinal, descriptive, and correlational parent study of the impact of nursing on patient outcomes. the sample for this analysis contains 290 observations from 2011 and 246 from 2014 from civilian and military rns and lpns employed in 23 u.s. army hospitals. descriptive statistics, correlations, and data mining predictive modeling techniques were used to evaluate the relationships between the outcome variable and the predictor variables. results: ppl further categorizes intent to leave reasons as a result of organizational structure, compensation, or working environment that could have potentially been prevented given timely identification of issues and appropriate intervention. more than 45% of respondents indicated that they intended to leave their u.s. army hospitals in 2011 and 2014. of those that intended to leave, ppl reasons accounted for 50% of all reasons in both years. dissatisfaction with management, work environment, and personal reasons were the top three ppl reasons why respondents intended to leave, accounting for 74% of all ppl reasons in 2011 and 2014. in 2011, job satisfaction, nurse participation in hospital affairs, nurse foundations of quality care, nurse manager leadership support, staff and resource adequacy, and subscale composite scores were significantly lower for respondents who indicated they were leaving for ppl reasons. results were similar in 2014, with nurse physician relations instead of staff and resource adequacy scores being significantly lower. the random forests model indicated job satisfaction and nurse manager leadership support were the most important predictor variables for ppl in 2011 and 2014, respectively. implications for clinical practice and regulation: these findings add to our understanding a conceptual definition of ppl and potentially preventable reasons why nurses in the mhs intend to leave. these findings may also assist in the development of actionable nurse retention strategies and intervention studies to ultimately reduce nurse turnover. authors: jessica g. rainbow, phd, rn; katherine m. dudding, phd, rn; claire bethel, msn, rn-bc objective: the aims of this study were to examine the prevalence, locations, and severity of nurse pain; explore the impact of nurse pain on performance at work; and describe nurse strategies for coping with physical and psychological pain. the overall prevalence of nurses working in pain is unknown because pain prevalence is site specific; however, back pain, a commonly cited source of pain, occurs in 35% to 80% of nurses. study design: a cross-sectional survey of nurses recruited via social media was conducted in 2019. survey items included participant demographics, locations and severity of pain, impact of pain on performance at work, and coping strategies. descriptive analysis was completed. population: our convenience sample consisted of direct-patient care nurses (n = 3,226) in the united states. our sample was predominantly female, represented by all 50 states, and ranged in age from 20 to 76 years (m = 41 years). more than half the nurses surveyed (n = 1,602) had 1 to 10 years of nursing experience. the education level of the nurses varied, but the majority had a baccalaureate degree (n = 1,727; 53.7%). the majority worked in the hospital setting (n = 2,478; 76.9%). results: the majority (n = 2,843; 88%) of survey participants responded that they were currently experiencing or had experienced pain in the past week. the most frequently reported locations of their pain were back, neck, shoulders, knees, and feet. the average pain level was four out of 10. approximately 85% of nurses reported more than one location of pain. participants reported managing their pain by over-the-counter medications (n = 2,140; 77.7%), nonpharmacological pain management (n = 1,413; 51.3%), and prescription medications (n = 694; 25.2%). additionally, over one third of nurses (n = 996; 35%) reported using prescription drugs, marijuana, or alcohol as a strategy to cope with their pain. on average, 45% of nurses stated their pain impacted their work performance and 25% stated their pain impacted direct-patient care. conclusions: the prevalence, severity, and impact of nurse pain on performance at work highlights the importance of addressing and investigating nurse pain. workplace interventions to address nurse pain have mostly focused on back pain through lifting devices; however, nurses continue to have high levels of back pain and pain in other locations. the propensity of unhealthy coping strategies by nurses is concerning and warrants further investigation. implications for clinical practice and regulation: in the wake of the opioid epidemic, future interventions should investigate additional pain sites and encourage healthy coping strategies for nurse pain. the legalization of marijuana in many states also presents a potential new area of research and policy as many practice environments are considering how to handle healthcare provider marijuana use. state boards of nursing have long sought to minimize and address substance use disorders given nurses' access to controlled substances. unrelieved pain among nurses combined with their work demands, as well as access and knowledge of pharmaceuticals, may contribute to the higher suicide rate of nurses by gender than their u.s. population counterparts, which is more often carried out by pharmaceutical overdose. as the nursing workforce ages, interventions to reduce nurse pain are key to sustaining the workforce. authors: peter griffiths, phd, rn, and safer nursing care tool study group: jane ball, phd; rosemary chable, msc, rn; andrew dimech, msc, rn; yvonne jeffrey; rn; jeremy jones, phd; natalie pattison, phd, rn; alejandra recio saucedo, phd; christina saville, phd; nicola sinden, msc, rn; thomas monks, phd objective: the objective of this study was to model the consequences and costs of using a recommended staffing tool (the safer nursing care tool) to guide hiring, scheduling, and deployment decisions in english acute hospitals, specifically exploring how different baseline staffing levels affect costs, the likelihood of critical staffing shortfalls, and mortality risk. study design: we compared flexible baseline staff schedules (set to meet 80% of the mean demand) with staffing schedules set to meet mean demand (the standard approach) and schedules set to match peaks in demand (90th percentile). in all cases, floating from units with low demand to units with high demand and temporary hires were used to provide a flexible response when demand exceeded scheduled supply on any unit on any shift. data from a multicenter observational study of staffing and patient acuity/ dependency (26,362 unit ã� days of observations over 1 year) to provide parameters, including probability distributions for varying demands for nursing care, were used. a computer simulation was developed to model the effects of different baseline schedules and approaches to floating and use of temporary hires and over-time. the model was used to simulate daily staffing costs and the occurrence of critical (>15%) understaffing. it included realistic assumptions about the possibility of scheduled staff failing to show for work at short notice due to sickness and for constraints on the availability of temporary hires and overtime. the effects of any consequent short staffing, in terms of mortality risk and length of stay, were estimated using parameters from a recent longitudinal observational study in one of the participating hospitals. an economic model estimated the cost per life saved. population: general medical surgical wards in four public hospitals in england. results: in simulation experiments, "flexible (low)" schedules led to high rates of understaffing and adverse outcomes, even when temporary staff were readily available. "high" staffing baseline schedules were associated with reductions in understaffing and improved outcomes but higher costs. under most assumptions, the cost per life saved from moving from a lower to a higher baseline schedule was below â£30,000 (approximately $40,000 usd). if unlimited availability of temporary staff is assumed, the harm associated with low staff schedules was minimized, but net cost per life saved for higher staffing levels was also low: â£946 ($1,250 usd) for standard vs low and â£5524 ($7,300 usd) for high versus standard. conclusions: cost savings from a policy of flexible staffing with low baseline schedules are largely achieved by below-adequate staffing. cost savings are eroded with the high temporary staff availability required to make such policies function safely. higher baseline schedules are cost-effective. implications for clinical practice and regulation: in the face of nursing shortages, which are endemic in england and many other jurisdictions, these findings illustrate the possible consequences of short staffing and illustrate that higher nursing staff levels remain a desirable goal even if staff redeployment and use of temporary staff can be used to fill gaps in rosters. the common basis of staffing tools, where mean averages are used to guide staffing decisions, is questioned. objective: home-visiting prevention programs must coordinate with other community providers to be most effective. however, the associations between collaboration and program outcomes are not well understood. nurse-family partnership (nfp) is an evidence-based prenatal and early infancy home-visitation program delivered by nurses to low-income, first-time mothers. nfp is implemented by more than 250 agencies across the united states by public health departments, community-based organizations, and healthcare systems. this study aimed to examine the associations between cross-sector collaboration nfp and client-level outcomes. study design: we used 2018 survey data with nfp supervisors that assessed agency-level collaboration, as measured by relational coordination and structural integration with nine community provider types (including obstetrics care, substance use treatment, and child welfare). we paired the collaboration survey data with nfp program implementation data from 2014 to 2019 (n = 36,900) to examine outcomes including client retention, client smoking cessation, and childhood injury. we used random-intercept models with nurse-level random effects, controlling for client-level demographics and health, nurse-level demographics, and agency-level administrative and geographic factors. population: sample nfp clients were on average 23 years old and predominately single. of sample clients, 47.5% were white, 33% were african american, 31% identified as hispanic, 11.5% reported another race, and 8% declined reporting. results: consistent with past research, we found unmarried women, african-american women, and those visited by nurses who ceased employment with nfp prior to the client's child's birth were more likely to drop out of the nfp program, whereas older women and high school graduates were more likely to remain in nfp. greater relational coordination with substance use treatment providers (or = 1.168; p < .001) and stronger structural integration with child protective services (cps) (or = 1.065, p < .001) were associated with improved client retention at birth, even after adjusting for multilevel factors. structural integration with cps remains significantly associated with client retention at 12-months postpartum. stronger nurse coordination with the special supplemental nutrition program for women, infants, and children (wic) (or = 1.097, p < .05) as well as with substance use treatment providers (or = 1.108, p < .05) were associated with increased self-reported prenatal smoking cessation. stronger nurse coordination with wic (or = 0.863, p < .01) and greater integration with mental health providers (or = 0.975, p < .05) were associated with decreased probability of self-reported emergency department use for childhood injury. conclusions: improving healthcare through relationships with other care providers is necessary to enhance the experience and outcomes of patients, particularly among high-need complex populations. this study provides early results suggesting cross-sector collaboration in a home-visiting setting that bridges healthcare and addresses social determinants of health has potential to improve the retention of clients. more research is needed to understand how collaboration may improve maternal-reported behaviors like smoking cessation and emergency department use for childhood injury. implications for clinical practice and regulation: our findings inform efforts to increase efficient delivery of prevention programs like nfp through intentional collaboration with cross-sectors, as well as for future agency development for nfp expansion, especially as the program moves toward integration with healthcare delivery systems. authors: allison norful, phd, rn, anp-bc; yun he, bm; adam rosenfeld, ba; cilgy abraham, bs, rn objective: primary care providers (pcps) are increasingly reporting burnout when trying to meet demands for patient care. previous evidence suggests that individual pcps require 21 hours per day to complete all care responsibilities. policymakers are calling for novel delivery models to help meet the care demand. one emerging model, provider co-management, has been shown to yield optimal clinical outcomes. co-management is structured with two pcps, often interdisciplinary dyads (e.g., physicians and nurse practitioners), who share care responsibilities for the same patient. theoretically, co-management is comprised of 3 dimensions: effective communication, mutual respect/trust, and shared philosophy of care. it remains unclear, however, whether co-management alleviates pcp burnout. thus, the purpose of this study was to determine the impact of co-management on pcp burnout and job satisfaction. study design: we conducted a cross-sectional survey of pcps in new york state using dillman methodology. paper surveys were mailed to a listserv of randomly selected pcps obtained from iqvia, the largest provider reference database in the united states. postcard reminders were sent after 3 weeks and then a second survey was sent to nonrespondents. the provider co-management index (pcmi) (r = .81) was used to measure comanagement with higher scores, indicating more effective co-management. the maslach burnout inventory (r = .90) was used to scale self-reported burnout. we calculated descriptive statistics and crude odds ratios from bivariate logistic regression models. next, adjusted odds ratios were calculated from multivariable logistic models controlling for provider and practice characteristics. population: our sample included 333 pcps across new york state, made up of physicians (n = 95), nurse practitioners (n = 157), and physician assistants (n = 81). half of participants worked in provider-owned practices (50%) and had more than 10 years of experience (56%). results: almost 30% of pcps reported job dissatisfaction and burnout. there were no significant differences in responses between workforce types. pcps who reported burnout had 71% less odds of job satisfaction (or = 0.29, 95% ci = 0.17, 0.49). similarly, participants who reported burnout had more than three times the odds of planning to leave their position in the next year compared to those who did not report burnout (or = 3.19, 95% ci = 1.75, 5.83). with each unit increase in total pcmi score, there was 1.05 times the odds of job satisfaction (or = 1.05, 95% ci = 1.02, 1.07). the magnitude of effect became larger when looking at pcmi subscales representing each co-management dimension. each unit increase in one pcmi subscale was associated with 15% less odds of burnout and 10% less odds of intention to leave a position within 1 year. estimates in adjusted models holding controls constant remained similar to those in the unadjusted models. conclusions: the more effective that co-management is between pcps, the less significantly associated are provider burnout, job dissatisfaction, and intent to leave current position. provider comanagement may be a promising approach to help alleviate pcp burnout. implications for clinical practice and regulation: attention to interdisciplinary team compositions and policies that enable comanagement care delivery dimensions are recommended to help alleviate burnout. further research, including comparative and cost-effectiveness studies, are warranted to determine financial sustainability of organizations that implement co-management models. the increasing volume of registered nurses (rns) employed in primary care settings may offer solutions to overcoming care delivery complexities facing international healthcare systems, including canada. there is growing evidence that rns in primary care improve access, reduce costs, and promote higher quality care; however, there is a lack of clarity surrounding the effective deployment of the rn role, specifically in primary care settings. the purpose of this study was to develop and validate a set of national primary care rn competencies in canada. the competencies aim to better support the integration and optimization of the role of rns in primary care. study design: this study employed a delphi survey process. an initial draft of competencies consisting of 49 statements was created and guided by international literature, a panel of key informants (i.e., researchers, stakeholders, project partners), and competencies of related practice areas, such as public health nursing and home care. using an online survey platform, participants rated the importance of each competency statement using a 6-point likert scale (1 = not important; 6 = extremely important) and offered written feedback/suggestions. statements that did not reach consensus (â�¥ 80% agreement or mean â�¥ 5.0) were modified and sent to participants for a second (final) delphi round. population: canadian nurses with knowledge and expertise in primary care were identified through snowball sampling, online searches, and professional organizations (e.g., canadian family practice nurses association) and invited to participate in the survey through email correspondence (n = 137). individuals represented all domains of nursing (i.e., clinical, research, education, policy, administrators) and all canadian provinces and territories. the survey was available in both english and french. results: the first survey was completed by 63% (86/137) of invited participants (april and may 2019), and 84% (72/86) of these firstround participants completed the second follow-up survey (june through august 2019). most competencies (n = 45) achieved agreement after the first survey (m = 5.43, sd = 0.191); one statement was dropped and two were combined following the second round. the finalized competency list consisted of 47 distinct statements organized across 6 domains (professionalism; clinical practice; communication; collaboration and partnership; quality assurance, evaluation, and research; leadership). conclusions: a concise and preliminarily validated set of primary care rn competencies was developed. these competencies may be used to guide nursing curricula, increase understanding of the primary care rn role, improve interprofessional team functioning, and are foundational to strengthening the rn workforce in primary care. implications for clinical practice and regulation: primary care rn competencies have tremendous value to relevant stakeholders, including international policymakers, to use as a framework to inform administrators, clinicians, and researchers for targeted integration and optimization of rns within primary care. in addition, the competencies can help inform local, provincial, and national policies, including funding models. currently, the canadian nurses association plans to incorporate these competencies into the community health nursing certification examination. next steps involve conducting two cross-sectional surveys with academic deans/directors and front-line primary care rns to assess the integration of competencies within canadian nursing curricula and the performance/learning needs of rns in primary care relative to these competencies. future research will validate such competencies in other countries. americans with the goal of modifying behavior, one must be particularly sensitive to building trust and to the preferences and choices of the clients. community-based participatory research (cbpr) builds a foundation of trust between investigators and participants by eliciting contributions from community members into the research process. the purpose of this study was to apply the cbpr framework to engage the african american faith-based community in the development of a health education program to address hypertension using both group learning and activities based in virtual reality (vr). study design: applying a cbpr framework, an expert panel consisting of members of a faith-based community along with the council of black nurses (los angeles chapter) was assembled and co-led by the community pastor and the research team from a medical center that serves this community. two modified delphi exercises elicited input regarding food preferences for the vr, and a 90-minute focus group gathered input on health, exercise, and stress management. the focus group transcript was analyzed using content analysis methodology and the results were used to develop the course content. population: fifty-eight participants aged 18 to 85 years were recruited from a predominately african american church in los angeles, california, where all research activities were held. results: with participant input, the vr intervention included education on adverse impacts of high sodium diets on blood pressure (bp) and body organs, culturally common low-sodium food alternatives, and stress management meditation and mindfulness exercises (recorded by the pastor). group preference identified content for a 12-session course that included (a) diet and sodium intake, (b) bp monitoring, (c) healthy lifestyle, (d) exercise, (e) diabetes, (f) sleep and stress management, (g) genetics and health, (h) a cooking class, and (i) tai chi. initial interest and participation were so high that study recruitment targets were expanded. participant feedback was collected during classes. feedback on the course was positive. despite having technical support, participants found the vr component to be challenging; thus, vr use was suboptimal. conclusions: although there were several challenges associated with implementation of the vr component of the intervention with this cohort, lessons learned provide insight on how to incorporate community input into the development of technologies meant to support hypertension control in vulnerable populations. the cbpr approach was used to successfully partner with a faithbased community to develop interventions aimed at health promotion and disease prevention. implications for clinical practice and regulation: churches are excellent venues for delivery of community-based lifestyle interventions because of their pre-existing social networks, consistent attendance, and a faith-based focus in enhancing the connection between mind, body, and spirit. ideally, the impetus for changing behavior should come from within the targeted community itself, and the intervention should be built around the preferences and choices of that community. cbpr involving community stakeholders provides the foundation for collaborations that are responsive to the specific needs of a community and can improve understanding of the underlying contributors of persistent health disparities. authors: jane bolin, jodie gary, cynthia weston, nancy downing, allison pittman, cherrie pullium objective: the goal of this mixed methods study was to conduct both quantitative and qualitative research with dissemination to community partners toward forming a united regional consortium focused on increasing access to opioid use disorder (oud) prevention, treatment, and recovery, ultimately improving the health and wellbeing of children and families. an overarching goal is to address challenges of delivering care in underserved and rural communities. design: we employed mixed methods to examine longitudinal trends of opioid-related admissions in the rural gulf bend region over a 6-year period. we then conducted several weeks' worth of focus groups and structured interviews in each of the counties. we utilized a semi-structured interview guide to engage the community in identifying the scope of oud and its impact on children, including neonates. focus groups explored gaps in available treatment and recovery services and in critical resources and workforce. the project was designated non-human subjects research by the texas a&m institutional review board. population/sample: our study was conducted in seven counties in the rural gulf bend region of texas that are impacted by rising rates of opioid misuse and exacerbated by co-occurring use of other narcotic, controlled substances, as well as alcohol. children and their safety were a focus of our study. findings: fifteen focus group interviews with over 100 stakeholders included physicians, nurses, hospital administrators, advocacy groups, treatment centers, child protective services, first responders, law enforcement, social workers, faith-based groups, and elected officials. the outcome was an oud community assessment of existing prevention, treatment, and recovery resources and access to resources; assets and opportunities; and gaps and constraints. strategies identified included targeted oud education and training, access to medication-assisted treatment and peer-topeer recovery support, and access to mental health resources. use of innovative telehealth programs are planned to address gaps in services. conclusion: oud is a significant health and safety issue for children and their families. neonates are born addicted and families are impacted, as are hospitals, schools, and law enforcement. implications include collaborative partnership development and gathering a community voice to address gaps in prevention, treatment, recovery, and workforce. community-driven solutions were identified to build capacity through existing community strengths and shared knowledge and communication of resources. innovative strategies include the use of peer-to-peer parent recovery support and nurse-led telehealth programs. implications: our research demonstrated that community stakeholders believe that oud is contributing to child neglect and abuse and contributes to economic insecurity, which severely impacts children. infants born to mothers with oud are at risk for neonatal abstinence syndrome. parental oud can also lead to separation from children due to incarceration, treatment, hospitalization, or child removal. child removal is traumatic, and foster care placement may contribute to adverse mental and physical health outcomes for children. adverse childhood experiences related to parental substance abuse or separation are associated with developmental disruption, risk behaviors, adverse physical and mental health conditions, and increased healthcare utilization. funding: health resources and services administration rural community opioid response planning grant; awarded june 2019 to jane bolin, primary investigator. authors: jane bolin, nancy fahrenwald, cindy weston, and debra matthews objective: this study addresses two national problems. first, in the united states, especially in texas, healthcare suffers from a severe shortage of nurses. second, there are more than 28,600 nurses, including advanced practice nurses, nationally who have run afoul of the law and thereby lost their license and privilege to practice their professions. the central goals and aims of this research were to examine the oig's fraud and abuse list of sanctioned healthcare providers (publicly available) and to analyze the characteristics of nurses who have lost their license or have been barred from participating in medicare and medicaid. design: we employed mixed methods to explore what interventions may be effective for rehabilitating sanctioned nurses and learn from these individuals what factors influenced them to choose crime or deviant behavior after investing so much time, energy, and financial resources in their professional training. in future studies, we will explore what measures, requirements, and restraints should be put in place for rehabilitation of those who were once licensed healthcare providers in good standing, including surveying state licensing boards. population/sample: nurses, including nurse practitioners and doctors of nursing practice, who have been convicted of behavior leading to their exclusion from practice in the united states. as of january 2020, more than 28,600 nurses are listed in the office of the inspector general's (oig's) list of sanctioned and excluded providers. findings: currently, more than 28,000 nurses have been convicted or sanctioned for prohibited conduct leading to their exclusion from practicing in programs that are eligible for medicare and medicaid payment. twenty-seven nps have been excluded/ convicted, 20 nursing firms, and 28,639 individuals designed as nurses. california and texas lead the nation in excluded nurses at 2,571 and 2,402, respectively. tragically, 3,847 nurses have been convicted of patient abuse, 249 have been convicted of healthcare fraud, and 20,111 have had their licenses revoked by their state boards. conclusion: shortages of nurses are especially severe in rural and underserved parts of texas and the united states. rural citizens are often 1 to 2 hours from the closest healthcare provider. as a profession, we need to explore whether it is possible to address the nation's severe health care provider shortage by redeeming nurses who lost their license through financial fraud or other unlawful behavior. programs for rehabilitating nurses and subject to appropriate oversight and restriction may address the current severe provider shortage in medically underserved areas. implications: the potential of such a program is enormous and paradigm changing. however, we must first identify those who can be successfully rehabilitated. researchers in this multi-phase study will next explore what interventions may be effective for rehabilitating sanctioned providers to determine what factors influenced them to choose crime or deviant behavior. it is imperative that we explore what measures should be put in place for rehabilitation of those who were once licensed in good standing. we will also survey experts from state licensing boards to determine what approaches might be employed to rehabilitate even a fraction of the more than 28,600 + sanctioned nurses sitting idle on the sidelines. funding: the president's excellence fund, triad-3 initiative, 2020, provided support for this research. author: jacqueline nikpour objective: in a healthcare system rapidly shifting from rewarding volume to incentivizing value, policymakers, payers, and health systems are increasingly focused on addressing patients' "upstream" social determinants of health (sdoh). typically, medicaid funds cannot be used for nonmedical interventions, but north carolina has received permission from the centers for medicare and medicaid services, through an 1115 waiver, to use medicaid funds for "healthy opportunity pilots" that address the sdoh. due to nurses' education, broad scope of practice, and focus on holistic, whole-person care, the workforce is uniquely positioned to address housing instability, food insecurity, and other population health issues. yet little evidence exists describing the supply, distribution, education, and practice characteristics of the nursing workforce available to address these challenges. this information is critical to identify where nursing workforce gaps exist that may jeopardize an effective rollout of north carolina's healthy opportunity pilots. design: this study used 2018 north carolina licensure data to describe the demographic, education, and geographic characteristics of the nursing workforce in the following sdoh settings: ambulatory care, public/community health, occupational health, long-term care, home health, correctional facilities, and schoolbased health. we compared these "population health" nurses to those employed in hospital settings using chi-square and t tests. north carolina's 100 counties and 6 medicaid regions were used as the units of analyses for measures of supply and population health need. we categorized medicaid regions as high income, moderate income, and low income based on their 20th percentile income level and performed one-way anova tests to determine differences in nurse supply. we then merged licensure data, at the county level, with the 2018 county health rankings to compare the distribution of population health nurses with population health needs using spearman correlation analyses. population/sample: 93,571 rns in active practice in north carolina in 2018. findings: in 2018, nearly 30% of nurses were practicing in a population health setting, compared with 54% employed in hospitals. compared to hospital nurses, population health nurses were more likely to be female (94.7% vs. 89.5%, p < .001) and less likely to have a bachelor's degree or higher (35.5% vs. 65.5%, p < .001). there was no difference in nurse race between hospitals and population health settings (p = .59). one-way anova tests revealed that population health nurses were significantly more likely to work in high-income regions when compared with moderateincome and low-income regions (f = 4.47, p = .01), potentially due to the fact that 49.6% of the state population is located in these two counties. at the county level, a lower supply of population health nurses was associated with higher rates of uninsured people (p = .02), unemployment (p < .0001), child poverty (p < .0001), low income (p < .0001), poor or fair health (p = .004), physically unhealthy days (p = .0006), mentally unhealthy days (p = .0009), air pollution (p < .0001), and preventable hospitalizations (p = .0009). conclusion: north carolina's population health nurse workforce is not well distributed relative to the state's population with higher sdoh needs. implications: as north carolina prepares to implement its 1115 health pilots, workforce planning initiatives are needed to more equitably distribute the supply of population health nurses across the state. authors: shirley girouard, phd, rn, faan; michele solloway, phd, mpa objective: a state government and an urban university collaborative project seeks to understand and promote knowledge about food insecurity (fi) among older adults. we sought to develop tools to assess and increase fi screening and referrals as well as increase access to nutrition education and food resources with the ultimate goal of reducing fi-related health disparities. population/sample: adults aged 65 or older in a large, diverse urban community with high health disparities. findings: a total of 390 surveys were collected from participants at 12 health fairs and 2 community presentations. the mean age of respondents was 74.5 years. the majority were women (83%). more than half were black (53%), 24% were caribbean, and 10% were mixed or "other." approximately 23% were at high fi risk and 31% at moderate fi risk. approximately 40% of respondents received food stamps. among respondents with health conditions (n = 220), more than half had high blood pressure (56%) or high cholesterol (55%); 43%, diabetes; 27%, heart disease; and 8%, stroke. three-quarters (76%) had 3 or more conditions; 62%, 4 or more; and 47%, 5 or more. notably, 15% of respondents had all 6 conditions listed. almost 1 in 4 respondents indicated that obtaining healthy and sufficient food was hampered by health conditions (24%) or mobility (22%). conclusion: fi was documented as a significant problem and compounded in complexity for individuals with multiple medical conditions. fi is also interwoven with culture and literacy. discerning levels of fi risk for triage and policy purposes appears viable. phase i of the project was well received by all key stakeholders; therefore, phase ii was initiated. additional support is sought to continue phase i activities and develop a primary care assessment, referral, and follow-up model. implications: developing a screening tool to differentiate levels of fi risk is necessary to develop tailored community-based interventions for specific communities. data generated by the survey facilitates health professions student education as well as ongoing education for providers. cultural, literacy, mobility, access, and health disparity issues associated with fi risk become addressed more consistently as a result. identifying high fi patients in practice can also lead to improved triage and referral by differentiating patients who require more intensive individual counseling from those who could benefit from community resources and classes. such policies, programs, and practices can improve healthy eating and thus improve health outcomes for older adults. the national institute on minority health and health disparities research framework health disparities and health equity: concepts and measurement systems change for the social determinants of health year of the nurse and objective: nurses are instrumental in preventing adverse events through the delivery of high quality, safe patient care in an efficient and effective healthcare system. however, workplace bullying may undermine safety culture in the workplace, subsequently affecting nursing care and patient outcomes. the objective of this study was to explore the association between the nursing work environment and nurse-reported workplace bullying and the association between nurse-reported workplace bullying and patient outcomes, including nurse-reported quality of care and nursereported patient safety grade. design: we conducted a cross-sectional analysis using data obtained from the alabama hospital staff nurse study. the nursing work environment was measured using the original practice environment scale of the nursing work index (pes-nwi) with five domains represented as subscales and a composite score. nurse-reported workplace bullying status was identified as "yes" or "no" using the short negative acts questionnaire (snaq) through a latent class analysis. nurse-reported quality of care and patient safety grade were measured using single-item measures. the responses were dichotomized into either "excellent/good" or "fair/poor" for quality of care, and either "favorable" or "unfavorable" for patient safety grade. random effects logistic regressions were used to determine associations controlling for individual and employment characteristics. odds ratios (ors) and 95% confidence intervals (cis) were obtained to examine the strength of associations. all statistical analyses were conducted using r version 3.4.3. population/sample: inpatient staff nurses working throughout alabama (n = 943). findings: nurses in this study were predominately white (82.0%) and female (89.6%). the median age was 37 years. most nurses held a bachelor's degree (56.1%), had primarily worked as a nurse for a median of 8 years, and were full-time (84%), permanent (97.7%) employees working 12-hour (88.1%) day shifts (60.7%) with minimal overtime (2 hours per week). a total of 377 (40%) nurses reported experiencing workplace bullying. nurses primarily reported excellent/good quality of care (84.1%) and a favorable patient safety grade (69.5%). after controlling for individual and employment characteristics, a higher pes-nwi composite score was significantly associated with a lower risk of nurse-reported workplace bullying (or = 0.16, 95% ci = 0.12, 0.22, p < .0001). nurses experiencing workplace bullying were less likely to report good/excellent quality of care (or = 0.28, 95% ci = 0.18, 0.44, p < .0001) or a favorable patient safety grade (or = 0.36, 95% ci = 0.25, 0.51, p < .0001). however, these patient outcome associations were mediated by the pes-nwi composite score (or = 0.78, 95% ci = 0.44, 1.37, and or = 0.89, 95% ci = 0.57, 1.41, p = .6300, respectively). conclusion: these findings suggest that improving the nursing work environment can potentially decrease nurse-reported workplace bullying and perhaps subsequently improve patient outcomes. implications: the nursing work environment consists of modifiable, organizational factors that either support or detract from a nurse's ability to provide safe, high-quality patient care. further exploring specific aspects of nursing work environments using the pes-nwi can inform the development of targeted organizationallevel anti-bullying interventions. such interventions, however, must include the improvement of the nursing work environment. 