Nurses in the pandemic: ‘Everyone was confused. . . communication was the biggest problem’

“I felt no one wanted to touch me, it makes you feel like you’re dirty”. This was a comment made by one woman who recently attended an Irish hospital for surgery.

A man, who underwent a knee replacement during the summer, also spoke about the lack of human contact and touch, saying: “The care was very good, but the heart wasn’t in it; it all felt very remote.”

These feelings speak of what it may be like to receive treatment during the ongoing coronavirus pandemic; and they mirror the concerns of healthcare workers wearing personal protective equipment (PPE) at this time.

Healthcare workers in Ireland report that wearing PPE, such as masks, makes communication more difficult and they worry that patients may feel frightened or stigmatised. Yet, both patients speaking here recognise that the use of PPE and reduced physical contact is part of the crucial role of our healthcare workers in caring for, and ensuring the safety of, the public.

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These feelings and anxieties reflect findings from a recent review published in the Cochrane Database of Systematic Reviews, supported by Evidence Synthesis Ireland (an all-Ireland non-profit organisation). I was lead author on the review.

Qualitative evidence synthesis

Infection prevention and control guidelines, are vital to protect healthcare workers, their patients and, indeed, their families and friends. The guidelines include the use of PPE; such as masks, face shields, gloves and gowns; separating patients with respiratory infections from others; and stricter cleaning routines.

Using an approach called qualitative evidence synthesis, our group looked at what helps or hinders healthcare workers when using these guidelines to work with respiratory infectious diseases. "Qualitative evidence synthesis" is a type of research that brings together the findings of separate studies in a way that captures "real world" views. We looked at 20 studies; 10 were from Asia, four from Africa, four from central and North America, and two from Australia.

So, what were the views and experiences of nurses, doctors, allied health professionals and other healthcare workers caring for patients with respiratory infectious diseases?

Healthcare workers find it difficult to follow guidance because of rapidly changing guidelines, lack of training, inadequate resources, and challenging working environments.

We found several important factors that influenced healthcare workers’ ability to comply with infection prevention and control (IPC) guidelines. Support from management was needed to help healthcare workers, particularly in recognition of the extra workload and burden of working with PPE. On top of this, healthcare workers were concerned about the lack of appropriate PPE; especially at the height of an outbreak.

Staff found it confusing when guidelines were too long or if they were different to national and international guidance. Guidelines change frequently and so how busy staff are informed of these changes is critical.

In the current Covid-19 pandemic, one senior nurse working in an acute Irish hospital said: “We were informed of policies in a fragmented way over several meetings so everyone was confused about what we should do. Communication was the biggest problem particularly when policies changed. For myself and other staff, this is one of the most stressful parts of working during the pandemic.”

Implications

Healthcare workers highlighted the need for training about the infection itself and about how to use PPE. This training was important for all staff, including cleaners, porters and kitchen staff. The physical environment was also a problem. To fully adhere to IPC guidelines, there needs to be enough space to isolate patients. Physical structures are needed to minimise overcrowding, fast-track infectious patients and provide easy access to handwashing facilities.

What are the implications of this review for Irish healthcare?

Qualitative evidence synthesis is a systematic and rigorous approach to examining the evidence. This means that our findings are applicable to many settings in many contexts, including primary, secondary and community healthcare settings. These findings need to be utilised in the planning, resourcing and delivery of Irish healthcare amid the Covid-19 pandemic. Government funding and support is needed to ensure healthcare systems can provide training, resources, physical spaces and, ultimately, the culture that healthcare workers need and deserve to provide safe care that will protect patients, the public and themselves.

These conclusions are echoed by Dr Michael Ryan, executive director, WHO Health Emergencies Programme, in a recent address: "Frontline workers are working under immense pressure, under immense strain and they are extremely courageous. The least we can do is give them the tools, the training and the environments in which they can do that work at the safest possible level . . .

“That’s what we want, highly performant, highly skilled health workers, operating in an environment where they can turn all of their knowledge into solutions for their patients.”

Catherine Houghton is a Senior Lecturer in the School of Nursing and Midwifery, National University of Ireland Galway