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Introduction to COVID-19: methods for detection, prevention, response and control
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Coronaviruses are a large family of viruses that are known to cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS).
A novel coronavirus (COVID-19) was identified in 2019 in Wuhan, China. This is a new coronavirus that has not been previously identified in humans.
This course provides a general introduction to COVID-19 and emerging respiratory viruses and is intended for public health professionals, incident managers and personnel working for the United Nations, international organizations and NGOs.
As the official disease name was established after material creation, any mention of nCoV refers to COVID-19, the infectious disease caused by the most recently discovered coronavirus.
Please note that the content of this course is currently being revised to reflect the most recent guidance. You can find updated information on certain COVID-19-related topics in the following courses: Vaccination: COVID-19 vaccines channel IPC measures: IPC for COVID-19 Antigen rapid diagnostic testing: 1) SARS-CoV-2 antigen rapid diagnostic testing ; 2) Key considerations for SARS-CoV-2 antigen RDT implementation
Please note: These materials were last updated on 16/12/2020.
Course contents
Emerging respiratory viruses, including covid-19: introduction:, module 1: introduction to emerging respiratory viruses, including covid-19:, module 2: detecting emerging respiratory viruses, including covid-19: surveillance:, module 3: detecting emerging respiratory viruses, including covid-19: laboratory investigations:, module 4: risk communication :, module 5 : community engagement:, module 6: preventing and responding to an emerging respiratory virus, including covid-19:, enroll me for this course, certificate requirements.
- Gain a Record of Achievement by earning at least 80% of the maximum number of points from all graded assignments.
- Gain an Open Badge by completing the course.
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Coronavirus Tips PowerPoint Template
Mar 28, 2020 | Data Dashboards , DataPoint , DataPoint Real-time Screens , Healthcare
To help with the current coronavirus emergency, we have put together these free coronavirus tips Powerpoint slide templates for you to use. The slides include coronavirus prevention tips, symptoms and instructions on what to do if you have symptoms.
Feel free to adjust the templates based on your local health authority instructions and contact information. Download the templates by providing your name and email address below.
Coronavirus Tips – Symptoms
This slide shows the common coronavirus symptoms and gives patients instructions on what to do if they have symptoms so that they don’t go to the hospital or doctor in a panic and overload the local health system. You can edit this slide or add additional slides to add local phone numbers, websites or other resource information.
nice template
I would like to download and amend the COVID slides please.
Solved over chat. Now you can use the presentation. Good luck with it!
I would like to download the template as well.
Did you sign up Nicole? That should be working. Check your spam folder maybe.
Excellent template , I will use for professional and public presentations.
Great to read. Thanks.
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Key strategies for managing nursing care under the COVID‐19 pandemic: A multiple‐case study of nursing directors
Yukie takemura.
1 Nursing Department, The University of Tokyo Hospital, Tokyo Japan
2 Department of Nursing Administration, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo Japan
Naoko Ichikawa
Ryohei kida, hiroe koyanagi.
3 Research Center for Implementation Nursing Science Initiative, School of Health Sciences, Fujita Health University, Toyoake Japan
Sumie Ikezaki
4 Department of Health Promotion in Nursing and Midwifery, Graduate School of Nursing, Chiba University, Chiba Japan
5 Department of Family Nursing, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo Japan
Associated Data
Research data are not shared.
We aim to identify measures implemented by hospital nursing directors early in the COVID‐19 pandemic and enabling factors.
Managerial factors affect nurses' physical and mental health and willingness to work, especially early in a pandemic.
We used multiple‐case study of 15 hospitals, comparing management approaches by interviewing 28 nursing directors and their assistants from August to December 2020.
Hospitals that accepted COVID‐19 patients and hospitals that unexpectedly experienced clusters underwent a nursing provision system organization phase, followed by an adjustment phase to maintain nursing organization function. Two factors aided measure implementation: an emergency system and staff protection policies.
Early epidemic management strategies apply across contexts. The hospital's basic attitude is key to effective implementation of the strategies.
Implications for Nursing Management
The results suggest that hospitals, nursing directors and nurses can each prepare for future emerging infectious disease epidemics.
1. INTRODUCTION
In the early stages of an epidemic, prevention and treatment methods are not yet established, and health care workers must care for patients while facing the risks of infection, severe complications and death (Gómez‐Ochoa et al., 2021 ). Bedside nurses are especially at risk for adverse mental health outcomes (De Kock et al., 2021 ), and fear of COVID‐19 increases psychological distress and turnover intention (Labrague & de Los Santos, 2021 ). Managerial support and attitudes affect workers' mental and physical health and work intentions (Hendy et al., 2021 ; Yıldırım et al., 2021 ), and nursing management urgently requires knowledge to control an emerging epidemic.
Studies of nursing managers reported that they performed the tasks of prioritizing staff well‐being and preserving humanized care while continually adapting to change (Vázquez‐Calatayud et al., 2022 ) and that they experienced stress and fatigue (White, 2021 ), considered leaving (Middleton et al., 2021 ) and sought organizational support (Jackson & Nowel, 2021 ). However, there is limited knowledge regarding how nursing directors managed the overall n u rsing organization and how they continued providing care to COVID‐19 and non‐COVID‐19 patients while supporting nurses and nurse managers. Although some case studies reported initial nursing department responses to the COVID‐19 pandemic (organizing support teams, reallocating nurses with intensive care skills etc.) (Gupta & Federman, 2020 ; Liu et al., 2020 ), single‐case studies may only reflect the unique conditions surrounding the case. In contrast, multi‐case analyses can identify commonalities while retaining processes, leading to more robust and generalizable results (Yin, 2018 ). A multi‐case study on management practices on entire nursing organizations in the COVID‐19 context is required.
Ministry of Health, Labour and Welfare ( 2022 ) data show that Japan experienced its first COVID‐19 wave from March to May 2020, wherein 5.3% of the cumulative infected patients died. Nurses who treated COVID‐19 patients in the first wave are assumed to have felt strong fear. As of October 2020, only 19% of hospitals had accepted COVID‐19 patients (Ministry of Health, Labour and Welfare, 2020a ), and this discrepancy in patient admission across hospitals likely made it harder for nurses at hospitals that accepted COVID‐19 patients to accept their fate. In addition, unexpected cluster infections (defined in Japan as 5+ people infected simultaneously in the same department) occurred in a few hospitals not accepting COVID‐19 patients (Ministry of Health, Labour and Welfare, 2020b ), and nurses had to unexpectedly care for COVID‐19 patients without being prepared. Hence, nursing directors of hospitals that accepted COVID‐19 patients or those that experienced clusters in the early stages of the pandemic in Japan had to manage their nursing organizations while supporting nurses who experienced strong anxieties.
The purpose of this multi‐case study was to clarify how nursing directors of hospitals that accepted COVID‐19 patients in the early stage of the pandemic in Japan and those that experienced clusters managed their nursing organizations while supporting highly anxious nurses. Did managerial processes differ across the two hospital groups? What factors determined effective management? Answers to these questions obtained in our study can help nursing directors implement effective strategies in the early stages of future epidemics.
2.1. Research design
A multiple‐case study design was adopted to examine nursing management practices and factors affecting their success. This article has been prepared in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist.
2.2. Settings and participants
To identify management practices in the early pandemic, hospitals in Japan that began accepting COVID‐19 patients by April 2020 or experienced a COVID‐19 cluster by August 2020 were included. The Japan Nursing Association provided us with 18 hospitals accepting patients and 13 hospitals that had experienced clusters as of 31 July 2020.
For the former group, we confirmed on each hospital's home page that hospitals had begun accepting COVID‐19 patients by April. Hospitals were selected from the list and asked to participate in the study, while attempting to maintain diversity in the size, establishment entity and region of the hospitals selected. Five hospitals refused to participate, nine agreed and two were unreachable and dropped after ensuring theoretical saturation.
In the latter group, we requested eight hospitals whose clusters occurred when they were not accepting COVID‐19 patients to participate: three refused, three (two in the April cluster and one in the July cluster) agreed and two were unreachable; they were augmented by a hospital that experienced the August cluster and two that were accepting COVID‐19 patients in other wards at the time of the cluster outbreak. Six hospitals were considered to constitute theoretical saturation, and sampling was terminated.
Each hospital's interviewee was its director of nursing or equivalent; directors could bring other nursing managers to provide additional information if desired. Ultimately, 28 nursing directors and other nursing managers from 15 hospitals participated in the interviews, as shown in Table 1 .
Characteristics of participating hospitals
| Categorization | ID no | Number of beds | Establisher | Availability of ICU | Region | Participants other than the nursing director |
|---|---|---|---|---|---|---|
| Hospitals accepting severe and moderate COVID‐19 cases | 1 | 300–399 | Social welfare service corporation | Yes | Kinki | None |
| 2 | 300–399 | Social medical corporation | Yes | Kanto | General nursing director, deputy nursing director | |
| 3 | 500–599 | Incorporated educational institution | Yes | Kanto | None | |
| 4 | 500–599 | Japanese Red Cross Society | Yes | Hokkaido | Deputy nursing director, nurse manager, infection control nurse | |
| 5 | 600–699 | Japanese Red Cross Society | Yes | Kanto | None | |
| 6 | 1000– | Incorporated educational institution | Yes | Chubu | Infection control nurse | |
| Hospitals accepting moderate COVID‐19 patients | 7 | 300–399 | Local government | No | Kanto | Deputy nursing director, nurse manager |
| 8 | 400–499 | Social insurance organizations | Yes | Kanto | Infection control nurse | |
| 9 | 600–699 | Medical corporation | Yes | Kanto | None | |
| Hospitals with COVID‐19 cluster | 10 | 100–199 | Medical corporation | No | Kanto | None |
| 11 | 200–299 | Social welfare service corporation | No | Kanto | None | |
| 12 | 200–299 | Medical corporation | No | Chubu | Infection control nurse | |
| 13 | 300–399 | Public‐service corporation | Yes | Kanto | Nurse manager of COVID‐19 ward | |
| 14 | 500–599 | Local government | Yes | Kinki | Deputy nursing director | |
| 15 | 700– | Local government | Yes | Kanto | Deputy nursing director |
2.3. Data collection
All interviews were conducted in September–December 2020 by two or three of the seven researchers. The research team consisted of six members with PhDs and experienced in qualitative research and one PhD graduate student. Before the interviews, we gathered information from press materials and hospital websites to add specific questions to a common interview guide.
The group treating COVID‐19 patients was asked about the hospital's series of pandemic responses. Average interview time was 68 min. The cluster group were asked about circumstances after the first infected patient was identified and outlined the hospital's COVID‐19 responses and measures they found helpful. Average interview time was 72 min. The interviews were recorded with permission and transcribed verbatim.
2.4. Data analysis
Using Yin's ( 2018 ) method, we coded each case in terms of approach and progress patterns, focusing on the ‘hows’ and ‘whys’ in hospitals' strategy choices and outcomes, management difficulties and challenges. Coding was performed independently by the first and second authors for the patient‐accepting hospitals and by the first, second and third authors for the cluster hospitals using Microsoft Excel. This was followed by a cross‐verification by the three researchers to refine the initial 671 codes. Other researchers then joined the analysis meetings to compare the codes for each hospital and identify commonalities and differences, which were then categorized.
Despite differences in implementation difficulties between hospitals accepting COVID‐19 patients and those that experienced clusters, we found no differences in practice or process categories, and no new categories were generated by adding hospitals. Therefore, theoretical saturation was determined to have been achieved at 15 hospitals: nine of the former and six of the latter.
2.5. Ethical considerations
This study was approved by the Research Ethics Committee of the Graduate School of Medicine, The University of Tokyo (2020130NI). Participants were informed that participation was voluntary and identifiable information was not disclosed.
Analysis of commonalities in management strategies indicated that all hospitals experienced a nursing system reorganization phase followed by an adjustment phase to maintain the organization's functioning. Many measures implemented in each phase were similar between groups.
3.1. Organizing the nursing provision system
In the ‘organizing nursing provision system’ phase, directors designated COVID‐19 wards and selected nursing staff for them. In hospitals where clusters occurred, rapid responses were required, complicating staff assignment as nurses became infected.
3.1.1. Designating COVID‐19 ward nurse managers
All hospitals defined COVID‐19 wards, cancelled nonurgent surgeries and closed some other wards to reassign staff to COVID‐19 wards. Directors chose nurse managers to lead COVID‐19 wards and other nurses to lead care manual development and to do care work.
3.1.2. Reassigning nurses based on physical and mental condition and skills
Nurses were selected for COVID‐19 wards based on three criteria: physical health (lack of underlying diseases), mental disposition (especially, willingness to work in a COVID‐19 ward and family opposition) and skills (infection control knowledge and years of experience).
Hospitals that reassigned already existing nursing teams to COVID‐19 wards reported handling difficulties through teamwork. Simultaneously, hospitals that constructed new teams with nurses from multiple departments reported greater sense of involvement in COVID‐19 among nurse managers and nurses across departments.
COVID‐19 ward assignment had to be expedited in hospitals that experienced outbreaks, and directors faced great difficulties. However, most managed to reassign nurses based on the three criteria. For example, despite a shortage of nurses, those with insufficient PPE‐wearing skills were not assigned to COVID‐19 wards. In contrast, hospitals that reassigned nurses without considering their concerns reported that some nurses worked in tears, no longer came to work or expressed distrust and anger toward managers.
In small hospitals, enough nurses contracted COVID‐19 that maintaining full shift complements was impossible; nurses were dispatched from other facilities or corporate job placement services, as well as disaster relief nurses from the Nurses Association. In general, nurses were allowed to opt out of COVID‐19 care.
3.2. Maintaining nursing organizations functioning while taking special measures
Once the nursing provision system for the COVID‐19 wards was built, directors entered the phase of ‘adjustments to maintain the organization's functioning as a whole’: providing medical care, maintaining nurses' willingness to work in all wards and departments and fostering a sense of unity.
3.2.1. Protecting COVID‐19 ward nurses' physical and mental health
Meticulous infection protection.
Nurses' willingness to work was affected by anxieties about becoming infected/infecting their families. Directors took various protective measures (Table 2 ).
Meticulous infection protection measures implemented by the participating hospitals
| Categories | Representative narratives [ID no.] |
|---|---|
| Procuring PPE | We did not have enough masks and other personal protective equipment. I tried to make sure that the staff who needed them were able to use them. ICT (infection control team) told members of the administrative department and managers, including myself, who were not directly involved with patients to prepare their own handmade masks instead of the hospital's masks. Although there was a mask shortage, the staff members directly in contact with COVID‐19 patients were told not to reuse masks but change them at the appropriate time as usual. [5] |
| Creating zones | (When the cluster occurred), the hospital was almost full, and there was no infection ward, so patients who tested positive could not be moved to other wards. Therefore, we gathered the positive patients in some rooms in the ward and zoned those using partitioning screens. We were not sure if this approach was appropriate, but an infection specialist from outside the hospital came in to check the site and gave us some advice. Following the advice, the rooms of the positive patients were divided into a red zone, the rooms of the negative patients who had shared the same room with the positive patients, which was almost all of the remaining patients, into a yellow zone, and the staff station into a green zone. [12] |
| Implementing necessary facility renovations | When I mentioned that part of the ICU could be partitioned off so that nurses could have a place to take a break from their N95 masks, the maintenance staff immediately went to Home Depot and bought the materials and built it. It did not take long. It was very helpful for the staff. [3] |
| Updating infection control measures around new information | The ICT was functioning, and they made manuals on what to do in such cases, for example, regarding what to do with students, what to do with patient families, how to examine patients, what supplies to use and everything else. The COVID manual was available on the hospital's intranet and was updated frequently. [5] |
| Identifying high‐risk care situations | Surgeries that were not urgent were postponed. [omitted] Since infection control measures for aerosols and others generated during surgery had not yet been determined, the implication was to wait until the proper measures were in place. [7] |
| Educating and guiding staff | We took a video of the DMATs who came in to assist us on how to put on and take off the PPE, printed it out frame by frame and posted it in all departments. It is important to know how to remove the PPE and in what order to remove it so as not to contaminate the surroundings or expose oneself. [omitted] Staff members first watched the video for self‐study, then practiced PPE donning and doffing in pairs and finally took the test one by one. They were graded on four ranks: pass, not good enough, fail and ‘excellent’ to be an instructor. Only staff who passed were allowed to enter the red zone. [10] |
| Consulting infection control experts | When transferring a COVID‐19 patient whose condition had changed to another ward, the certified infection control nurse worked with the staff to determine what transportation procedures would be safe and reliable. The staff felt very safe having the certified nurse actually accompany the patient and confirm the transfer. [6] |
| Securing rest periods and holidays through adequate staffing | We increased the number of days off and breaks. When we did a workload survey, only the nurse managers in the ICU (COVID‐19 ward) indicated that their workload had either stayed the same or gotten a little easier. [3] |
| Conducting regular physical examinations | We continue to conduct daily health checks of all hospital employees. The nurses immediately report to the nurse manager any fever in a family member or changes in their own health condition. So, in addition to the health checks, information from the nurses was shared with the certified infection control nurses to enable early action such as having the nurses undergo testing, if necessary. [1] |
| Introducing information and communication technology equipment and robots to enable noncontact communication and observation | Nurses in the red zone used iPads to tell nurses in the green zone which medical supplies they needed. We also have robots that work remotely. Nurses were able to reduce the number of red zone entries by having a robot with a camera take a round of the entire ward. But it wasn't as good as a person, so the robot wasn't able to play such a big role. [9] |
Appreciation from hospital executives
Directors stressed the importance of hospital executives making rounds in COVID‐19 wards or at least visiting wards to thank frontline personnel. They noted that executives' direct understanding of ground realities enabled prompt decisions and support for nurses.
Psychological support
Recognizing mental burdens related to infection anxiety, conflicts due to family opposition, shock from discrimination and distress due to inability to provide routine care, nursing directors arranged various types of psychological care for nurses (Table 3 ). In hospitals where clusters occurred, nurses felt responsible for causing nosocomial infection, especially if they became infected or were asked to isolate.
Psychological support provided by the participating hospitals
| Categories | Representative narratives [ID no.] |
|---|---|
| Arrange for support by psychology‐related professionals (clinical psychologists, industrial physicians, psychiatrists, liaison nurses, psychiatric nurses, university faculty in psychology and psychiatric nursing etc.) | We had a psychiatric nurse specialist immediately set up a mental health response team. A system for consultation with industrial physicians was also set up. [8] |
| Assessing and following up on the psychological status of nurses | Once a month, the staff members were individually communicated with based on a brief questionnaire that included the degree of fatigue, workload burden, level of stress and experience of discrimination in the community. [2] |
| Identification of high‐risk nurses through stress checks and assessment of depression and burnout | The Japanese Red Cross stress checklist was used to identify those with follow‐up concerns. The results were notified to the nurse managers, and individual consideration was requested. Individual interviews with a clinical psychologist were also arranged. [7] |
| Careful observation by nurse managers during each shift | The nurse managers were watching the staff's expressions and communicated with them daily. They tried to talk to nurses who were concerned. [7] |
| Individual interviews by nurse managers or nursing directors | I also make a conscious effort to interview nurses and listen to them individually. When I asked, ‘What do your family members say?’ some nurse told me, ‘To tell you the truth, my husband does not want me to work at the hospital,’ or ‘To be honest, I have a lot of anxiety’. [omitted] I asked ‘How are you?’ and some nurses confided their feelings all at once. [4] |
| Allow mentally unstable nurses to take leave | A few nurses worked with tears in their eyes, and some could not get into the wards, so I sent those nurses home and let them rest.[13] |
| Reassignment of mentally unstable nurses to other departments | A few nurses were reassigned from a COVID‐19 ward to another department because their children were discriminated against in the community. [8] |
| Create opportunities for nurses to express their feelings | The liaison nurses frequently rounded each ward and consulted with the nurses at that time. There were about five nurses who visited the liaison nurse's room on their own. The liaison nurses told the nurses, ‘Let us rest your mind, we will consult with you’. [5] |
| A clinical psychologist set up a meeting in the COVID‐19 ward every 2 weeks. When a patient died, the nurses were in tears because they could not take care of the patient as usual. They had been told to go to the bedside but were conflicted about being told to go as little as possible and wondered if this was really the right thing to do. The nurses expressed these feelings. [2] | |
| Care conferences were held in the wards, and liaison nurses were invited to join in to encourage nurses to reflect on themselves and discover something applicable to the next nursing situation. [1] | |
| The clinical psychologist opened a refreshment room for staff. Staff members could visit whenever they wanted and talk to the clinical psychologist at any time; snacks and tea were provided. A total of 62 staff members visited the room over a period of about a month. They had tea, talked and received hand massages. [4] | |
| Support for nurse managers | I felt that the nurse manager of the COVID‐19 ward was under a lot of stress, so I asked a clinical psychologist to make her a priority and meet with her regularly. [7] |
| At nurse managers' meetings, I asked each of them to share their thoughts and feelings. Some confided that it was really hard, whereas others said they did not know what to do. [Omited] Some nurse managers said that listening to the COVID‐19 ward nurse manager helped them to know that taking care of COVID‐19 patients is much harder than they had imagined. Mutual understanding was promoted. [2] | |
| A group meeting of nurse managers was held where, with the intervention of a clinical psychologist, they expressed their feelings. They gained experience of having the clinical psychologist listen to them and what it feels like to express their feelings. Then, the nurse managers themselves worked on similar involvement with their staff. [7] | |
| Sharing small thoughts and events among nurses through a messaging application | COVID‐19 ward nurses said that it was great that the doctors created a social networking group where they frequently shared new findings, information and little things such as a word of the day. [3] |
Directors anticipated the psychological problems; nurses would face and worked with hospital mental health experts to support them. Some hospitals conducted stress checks and assessments of depression and burnout to identify high‐risk individuals and created spaces where nurses could share their experiences and feelings.
Finding ways to provide nursing care as nurses wish
Nurses were distressed about being unable to provide quality care, such as allowing end‐of‐life patients to see their families. Directors tried to alleviate this distress by enabling the desired care and discussing care priorities with nurses.
Health check
Many hospitals used checklists to assess nurses' physical and mental symptoms, ensuring they rested immediately upon presenting symptoms. Some nurses reported that they refrained from reporting symptoms to their managers; therefore, directors noted that managers needed to inquire.
Most hospitals provided hazard pay, subsidized by the government.
3.2.2. Support for nurses in other departments
Nurses in non‐COVID‐19 wards experienced the same stressors, such as fearing infection and performing unfamiliar work tasks with unfamiliar colleagues and also needed support.
Understanding and expressing appreciation for the burden nurses carried
COVID‐19 wards absorbed more experienced nurses, leaving other wards understaffed, with more inexperienced nurses. Additionally, several general wards were closed, and their patients were transferred to other wards, increasing the number and variety of diseases treated by fewer nurses. As nonurgent surgeries were postponed, operating room nurses supported general wards, working in unfamiliar departments doing unfamiliar tasks. When disease outbreaks reduced staff availability, these problems were exacerbated.
Support to reduce the burden
Directors tried to retain sufficient nurses in other wards to operate safely. They stated the necessity of explaining the changes to doctors and soliciting their support preparing a concise working manual of supporting nurses' tasks to enable collaboration across departments or facilities. Directors also arranged expert mental health support for nurses across departments.
3.2.3. Preventing discrimination and fostering sense of unity
Directors tried to protect emotions and foster an atmosphere of unity and support.
Stop avoiding COVID‐19 ward workers
Several directors reported that nurses in other departments other than the COVID‐19 wards were also worried about infection, and alienated nurses in COVID‐19 wards by insisting that they do not use common staff spaces. Directors acknowledged this fear as natural and attempted to explain the mechanism of infection and the hospital's efforts to protect staff and to reduce anxiety.
Fostering a sense of unity
Directors worked to foster a sense of unity in the hospital, unify attitudes across departments and reduce dissatisfaction among staff. They asked all departments to send nurses to support COVID‐19 wards and acknowledged that all departments were working hard under greater burden than usual. They also created opportunities for nurses to express their gratitude to each other using the hospital information network and bulletin boards. One effective approach was having nurse managers gather to confide their hardships and thoughts and understand each other's difficulties.
Non‐blaming atmosphere
Although all hospitals told staff to take preventive measures even in their private time, several nursing directors considered that emphasizing compliance could lead to blaming infected staff or avoiding staff working in COVID‐19 wards. They informed staff members in advance that, despite prevention efforts, infections among staff members or patients could not be completely avoided but needed to be controlled.
Activities to protest discrimination
Discrimination against nurses' family members was reported in all hospitals. Hospitals tried to raise awareness through lectures and gain support from local governments and medical associations to spread knowledge toward reducing discrimination and to support personnel.
3.2.4. Proactive information‐sharing
Participants emphasized the importance of controlling information.
Official information‐sharing
Because nurses received a variety of information from outside the hospital, it was important to avoid confusion with direct communication from hospital executives. In hospitals when clusters occurred, executives had to describe the situation: extent of outbreak control, how it would progress and resumption of medical services. Many hospitals frequently updated information on their hospital networks and bulletin boards.
Casual information exchange
Directors reported that in COVID‐19 wards, staff supported each other by sharing information such as happy events.
3.3. Factors affecting implementation of effective and rapid management measures
Although all hospitals experienced similar phases and similar measures, there were differences in policies and approaches between hospitals that were quick to implement comprehensive, multifaceted measures and those that were not (Table 4 ).
Factors affecting implementation of effective and rapid management measures
| Categories | Narratives from hospitals where measures were effectively implemented [ID no.] | Narratives from hospitals where measures were not effectively implemented [ID no.] |
|---|---|---|
| Declaring emergencies and establishing systems of an organized concerted effort | An emergency system was put in place, and meetings were held almost every day with the participation of the hospital director, two deputy hospital directors, the director of the nursing department, each section chief of the administrative department, a physician from the infectious disease department, key figures from each medical profession and not only directors but also practical leaders. Every morning, detailed information was shared, decisions were made on the spot on matters that needed to be resolved immediately and important information was sent out via e‐mail. If necessary, the deputy hospital directors explained to the physicians in each department. This system allowed us to make timely decisions at upper management and communicate the information well. [15] | Multidisciplinary meetings were held, but they were only one‐way communication from the hospital director about what had already been decided. So we had to ask the hospital director individually before the meeting. I only knew about nursing, and the administrative director only knew about administration, so each of us made requests to the hospital director. There was no horizontal cooperation. The department directors could not participate in the decision‐making process because they did not know where in the hospital organization decisions were made. [omitted] Even if I informed the hospital director of the problem, its details were not conveyed to other departments. [omitted] I did not know how to get support for nurses in this organization. [omitted] Since relationships had been established, I asked the rehabilitation director, without going through the meetings, if therapists could clean the COVID‐19 ward to help nurses. [12] |
| Declaring organizational protection of all employees | What really helped was the leadership of the hospital director. It was the hospital director who suggested that we close one more ward to create a backup system because the nurses were having a hard time. [omitted] They permitted us to do what we could for the staff right away. So we were able to immediately prepare water servers for the nurses. When the number of patients decreased, the hospital director told me to take the nurses off in shifts of a week or 10 days each. However, the nurses were more than happy to get water servers, scrubs and other amenities to make their work environment more comfortable than long vacations. [omitted] Looking back, I believe that the hospital director's leadership, the early decision to downsize and rebuild the medical care system, keeping the staff safe and promoting community collaboration were extremely important. [8] | (Regarding the decisions told by the hospital director at the meeting,) it was as if the rest was left up to us, and we were told to move the site as instructed. We were treated as if we had no will. [omitted] The hospital director sometimes said to us, ‘Cannot you do this kind of thing?’ I asked the hospital director not to say anything to break our motivation when we were all trying to work together to do something little by little as staff gathered for the first time. [omitted] When the staff and their families were being discriminated against in the community and the staff was under increasing stress, I asked the hospital director to convey a direct message to the staff. The hospital director apologized to the staff. [omitted] I did not think the apology was appropriate. There was something sad about the apology because I thought nurses were willing to do their best in times like this. [12] |
3.3.1. Declaring emergency and establishing systems of organized effort
Hospitals that effectively implemented measures declared an emergency and set up a temporary network of managers from every department to consolidate information, discuss issues, make prompt decisions on reducing medical services, coordinate departments, allocate resources and implement decisions. These meetings enabled hospitals to effectively gather and move resources.
3.3.2. Declaring organizational protection of employees
Some hospital executives declared commitment to employees' physical and mental health, which reflected in their decision‐making, leading to improved management. In these hospitals, PPE was secured in COVID‐19 wards, and the rest was ensured through adequate staffing. In response to nurses' concerns, accommodation and water servers were provided, and nursing assistance tasks were shifted to other professionals. In other hospitals, nurses were exhausted by the enormous amount of peripheral work, with no operational support from other professionals. Some nurses in charge of infection control were assigned administrative duties, leaving them unable to provide guidance/support to COVID‐19 ward nurses and relieve confusion.
3.4. Future needs for nursing directors
Participants reported common challenges in preparing for future epidemics.
3.4.1. Ability to continue to plan ahead and make choices during uncertainty
Many participants stated the importance of being able to make their own decisions on priorities with incomplete information, explain their thinking, gain cooperation and explain their thinking without losing focus amid uncertainty.
3.4.2. Ability to obtain information
Many participants noted that although infection control teams had obtained information about infection control measures and physicians had obtained information about practice guidelines from academic societies and the government, they were not provided with any nursing management information from outside the hospital. Nor were they aware of how to seek this information, but now recognize that they can seek it from the Japanese Nursing Association and the government.
3.4.3. Preparing for future epidemics
Many participants mentioned the importance of preparation for future epidemics and reported that hospitals should teach staff about the hospital's role in an epidemic and provide regular training on infectious diseases and infection control.
3.4.4. Networking among local medical and welfare facilities
Participants spoke about the need for regional resource‐sharing, such as for local, medical and welfare facilities to visit each other regularly to strengthen infection control, clarify division of roles among facilities during an epidemic and establish an inter‐facility system for accepting and transferring patients. The participants said that because small hospitals and welfare facilities are severely short of nurses in an outbreak, building relationships among facilities and promoting understanding of each other's patients and facilities may lead to speedier dispatch of external nurses and care workers to smaller facilities.
4. DISCUSSION
Both hospitals that accepted COVID‐19 patients and hospitals where cluster infections occurred first underwent an ‘organizing a nursing provision system phase,’ and then a ‘maintaining the nursing organization's functioning as a whole’ phase; many measures implemented during each phase were also the same across hospitals, though with differing effectiveness. Basic approaches that were key to effective nursing management and challenges to combat future outbreaks were also suggested.
4.1. Important basic management approaches
Measures commonly implemented by participants in this study included those reported in qualitative and quantitative studies in various countries as effective in alleviating stress and maintaining nurses' willingness to work during the influenza (Devnani, 2012 ) and COVID‐19 pandemics (De Kock et al., 2021 ; Hendy et al., 2021 ; Labrague & De Los Santos, 2020 ). The measures identified by this study are common and effective across contexts to maintain hospital functions while protecting the physical and mental health of nurses.
A novel discovery of this study was that hospitals that promptly implemented multifaceted measures shared two basic approaches: The first was that hospital executives declared an emergency and held a multidisciplinary decision‐making meeting based on information gathered from various departments. The second was that the hospital executives clearly declared a policy to protect all employees' safety and made decisions according to that policy.
The former approach enabled the consolidation of varied information, review by multiple departments, rapid decision‐making and the communication of decisions. It further enabled management decisions on reducing medical care levels, reassigning tasks among departments and taking budgetary measures. It also enabled staff in each department to share a common understanding that it was an emergency and that a switch from normal operations was necessary, allowing the entire hospital to respond in a coordinated manner. All this made it possible to deploy all resources effectively and efficiently and to demonstrate to the staff through the actual implementation of the measures the attitude of ‘protecting the physical and mental safety of staff,’ as declared in the latter approach.
For staff to continue working during an emerging epidemic, they need to have confidence in the employer (Devnani, 2012 ) and feel that they are receiving the utmost attention and protection of institution managers (Yıldırım et al., 2021 ). The hospital's declaration to protect employees and to take every possible measure may support their willingness to work in the face of risk. The two basic management approaches identified in this study will allow multiple disciplines to share issues and make decisions on how to deploy resources flexibly, quickly and effectively under the broad policy of fulfilling the hospital's role while protecting employees during a crisis.
4.2. Reassigning nurses and ensuring their physical, psychological and technical suitability
This study found that most hospitals, including those with a severe shortage of nurses due to the outbreak, had ascertained nurses' willingness to work in COVID‐19 wards and assigned them based on their physical, psychological and technical suitability for nursing in COVID‐19 wards. The hospitals' policy of respecting nurses' willingness to work made it essential to implement all measures to alleviate nurses' concerns. Due to a shortage of nurses, one hospital placed nurses who were not psychologically prepared in the COVID‐19 ward, where mental health problems arose, leading to nurses being unable to come to work and showing distrust and anger toward hospital managers. Nursing directors need to make decisions to secure nurses for the mid to long term, rather than on an ad hoc basis.
The nursing directors in this study stated that to secure nurses, it is effective to prepare for epidemics on a daily basis. By learning about infectious diseases and training in infection control techniques, it is expected that more nurses will be able to cope psychologically and technically during an epidemic (De Kock et al., 2021 ; Devnani, 2012 ). Although some hospitals were able to respond promptly to outbreaks because they created a list of nurses to be assigned to the COVID‐19 ward, it would be useful to periodically check with nurses their willingness to engage in emerging infectious disease response teams and create a list of interested nurses. Using such a list, nursing directors could ascertain the number of nurses available for assignment to infectious disease wards. If the number is low, they could consider measures such as creating a sense of security by strengthening infection control measures, providing special allowances or hiring additional nurses temporarily. For the nurses, confirming their intentions allows them to discuss the situation with their families and prepare themselves.
Another new finding of this study is that the nursing directors were concerned about the anxiety and burden felt by nurses who did not work directly with COVID‐19 patients and made efforts to prevent discrimination within the hospital and to foster a sense of unity in the hospital. When the Fukushima nuclear accident occurred as a result of the 2011 Great East Japan Earthquake, the relationship between nurses who worked under uncertain risks and those who temporarily left their workplaces to avoid risks for reasons such as having young children reportedly changed, and their teamwork deteriorated (Takahashi et al., 2021 ). To maintain a sense of unity as a team, it is necessary to understand and alleviate nurses' respective anxieties and appreciate their respective burdens and contributions.
4.3. Preparing for future epidemics
This study found that the basic response processes and measures were the same for hospitals accepting infected patients and hospitals where unexpected cluster infections occurred, although there were differences in the amount of time they could spend preparing. This indicates that preparing to accept infected patients is a good way to prepare for a future epidemic. In fact, one participating hospital reported that while preparing to accept COVID‐19 patients, an outbreak occurred in one of their wards, and the preparation proved helpful in managing the outbreak. It is expected that infectious disease outbreaks will be incorporated into business continuity plans.
Participants in this study stated that it is important for local medical and welfare facilities to build relationships to mutually support each other in an emergency. Understanding the characteristics of each facility's patients and nursing services would lead to the smooth implementation of support, such as dispatching nurses or transferring patients between facilities. This is especially important when an outbreak occurs at smaller hospitals or welfare facilities with fewer nurses. The participants expressed the hope that mutual visits and information exchange among medical and welfare facilities will promote the implementation of appropriate infection control measures in smaller hospitals and welfare facilities. This study also indicated that nursing directors need the ability to withstand decision‐making and to keep everyone hopeful in the face of novel and uncertain situations.
4.4. Limitations
First, only the hospitals recruited through convenience sampling and which agreed to participate were included in the study. Therefore, it is possible that many successful cases that overcame difficulties, rather than representative cases, were included. Second, the purpose of this study was to identify management measures for supporting nursing staff during the early stages of a pandemic; it is unclear whether the findings can be directly applied to nursing management when the pandemic extends beyond 1 year. Third, it should be noted that because this study analysed hospital management, it did not identify management measures beyond hospitals, such as in regional or wide‐area collaboration.
5. CONCLUSIONS
This study revealed that appropriate management strategies to support nurses in the early stages of an emerging infectious disease epidemic are common regardless of context. Hospitals that implemented these measures quickly, effectively and comprehensively had one thing in common: They had established an emergency system and declared a policy to protect all employees. It is important for hospitals, nursing managers and nurses to apply these lessons to prepare for future emerging infectious disease epidemics.
6. IMPLICATIONS FOR NURSING MANAGEMENT
In the event of an emerging infectious disease epidemic, hospitals need to establish a system that allows them to share issues among multiple disciplines and to make decisions on how to deploy resources flexibly, quickly and effectively, based on a policy of promptly switching to an emergency system and fulfilling their role as a medical institution while protecting their employees. In addition, it is necessary to work continuously to establish and maintain a relationship with local medical and welfare facilities and to provide mutual support in emergencies.
Nursing directors and managers need to assign physically, psychologically and technically suitable nurses to infectious disease wards, and they need to regularly update a list of candidates to promote skill acquisition and mental preparedness. In addition, to maintain a sense of team unity, it is necessary to understand and alleviate the anxieties of both nurses in the infectious disease ward and those outside of it and to show appreciation for the burdens and contributions of each group.
Nurses should consider the role they can play in an emerging infectious disease outbreak by acquiring knowledge and skills related to infectious diseases and by discussing with family members their work caring for patients with infectious diseases.
CONFLICTS OF INTEREST
The authors have declared that there are no competing interests.
ETHICS STATEMENT
This study was approved by the Research Ethics Committee of the Graduate School of Medicine, The University of Tokyo (2020130NI). Participants were informed that participation is voluntary and identifiable information was not disclosed.
ACKNOWLEDGEMENTS
We would like to express our appreciation to all the participants. This study was funded by the Health, Labour and Welfare Sciences Research Grants: Special Research (20CA2029).
Takemura, Y. , Inoue, M. , Ichikawa, N. , Kida, R. , Koyanagi, H. , Ikezaki, S. , & Ikeda, M. (2022). Key strategies for managing nursing care under the COVID‐19 pandemic: A multiple‐case study of nursing directors . Journal of Nursing Management , 30 ( 8 ), 4042–4053. 10.1111/jonm.13844 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
This study was conducted when the corresponding author was an Associate Professor at Department of Nursing Administration, Division of Health Sciences and Nursing, Graduate School of Medicine, The University of Tokyo.
Funding information This study was supported by the Health, Labour and Welfare Sciences Research Grants: Special Research (20CA2029).
DATA AVAILABILITY STATEMENT
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IMAGES
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Six coronaviruses (CoVs) are known to infect humans: 229E, OC43, SARS-CoV, NL63, HKU1, and MERS-CoV. Many CoVs are simultaneously maintained in nature, allowing for genetic recombination, resulting in novel viruses. SARS-CoV-2 is the third pathogenic novel coronavirus to emerge over the past two decades.
FDA recommends. If symptomatic, test at least twice 48 hours apart. A third test might be needed if the patient is concerned they have COVID-19. If asymptomatic, but believe they have been exposed, test with RAT at least 3 times, each 48 hours apart to be considered truly negative. Consider reflex testing to NAAT.
Cohort study to examine factors associated with COVID-19-related death 17,278,392 adults in England 10,926 COVID-19 related deaths Adjusted cox proportional hazard model -Age, sex, race -Underlying conditions Williamson EJ, et al. Factors associated with COVID-19-related death using OpenSAFELY. Nature. 2020;584(7821):430-436.
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